SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

BREAST MASSES

SAMPLE QUESTION

A 42 year-old woman comes into your office with the chief complaint of
feeling a mass in her left breast while showering. Describe your workup.
Take a history designed to flush out HPI and identify any RFs for breast CA.
--When mass first noticed?
--Age of first menarche?
--Has it enlarged, and how fast?
--Age of menopause?
--Noticed any nipple discharge?
--Prior h/o breast CA in self?
--Associated w/ any pain/swelling?
--Family h/o breast CA?
--Do Sx change w/ menstruation?
--Personal h/o radiation exposure?
Perform physical exam looking for:
--Character of the mass (smooth, mobile, firm) --Dimpling of skin
--Local edema
--Overall symmetry
--Nipple retraction
--Nipple discharge
--Lymph nodes (axillary, cervical, clavicular)
Perform mammography or ultrasound next. (can perform FNA prior to imaging but only for
aspiration, NOT for biopsy, as aspiration alone will not interfere with imaging, but FNA Bx will)
Perform FNA of the breast mass AFTER imaging Discard fluid if non-bloody; no cytology
Perform incisional, excisional, or core biopsy if:
--PE bloody nipple d/c or nipple ulceration
--2nd cyst recurrence
--Mammographic suspicion (micro-Ca, spiculated) --Pt's concern of breast abnormality
--FNA bloody fluid, solid mass, or palpable mass after aspiration

The biopsy or FNA results return a diagnosis of infiltrating ductal carcinoma, how do you proceed now?
Pay attention to the question, as it may ask specifically how to Tx the mass, and not the whole disease
Treatment for the primay lesion, the breast mass, includes:
--Identification of Estrogen and Progesterone receptors in all biopsy / FNA specimens
--Modified Radical Mastectomy +/- Reconstruction
--Lumpectomy + Radiation (tumors < 5cm)
Both treatments have similar local recurrence and survival rates
Both can be bolstered with adjuvant chemotherapy and/or Tamoxifen depending on receptors
Regional treatment, the axillary region, along with the primary excision, allows for staging:
--Axillary node dissection, levels I and II (lateral and deep to pectoral minor)
Stage the patient's disease
IIIA = tumor >5cm, mobile nodes
--I = tumor < 2cm, no nodes
any size tumor, fixed nodes
--IIA = tumor <2cm, mobile nodes
IIIB = any size tumor, ipsilat int mamm nodes
tumor 2-5cm, no nodes
Peau d'orange, chest wall invasion,
--IIB = tumor 2-5cm, mobile nodes
inflammatory CA, skin ulceration
tumor >5cm, no nodes
IV = mets (including ipsilat supraclavic node)
Evaulate for signs of systemic disease:
--Bilateral mammogram (contralateral breast) --CXR looking for lung mets
--LFTs looking for liver mets
--Serum Ca2+ / AlkPhos for bone mets
--Provide chemotherapy based on systemic findings OR positive nodes / est/prog receptors
The biopsy or FNA results return a diagnosis of DCIS, how do you proceed now?
Treatment for the primary lesion, the breast mass, includes:
--If < 5mm, remove with clear margins and f/u
--If 5mm - 2cm, lumpectomy with 1 cm margins and radiation
--If > 2cm or diffuse breast involvement, Total (simple) mastectomy
Axillary node dissection has no role in true DCIS if there is no microinvasion
Major risk with DCIS is development of infiltrating ductal CA in same breast
Suspect DCIS if diffuse microcalcifications are seen on mammorgraphy

SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

UPPER GI BLEED

SAMPLE QUESTION A 55 year-old man calls your answering service on a Saturday c/o burning
pain in his upper abdomen, nausea, dark brown vomit & appetite. How do you proceed:
Take a history designed to flush out HPI and identify any RFs for GI bleeding.
--How long have these Sx occurred?
--EtOH and smoking history
--Have you had similar episodes in the past?
--Current meds, especially NSAIDS?
--"COLD-REARS" of pain (esp Referred)
--Is there a history of liver disease?
--Blood in the stool--BRBPR vs melena?
--Ever been Dx with an ulcer?
--Any assoc syncope, MS, fatigue, thirst?
--Ever undergo AAA repair?
Perform physical exam looking for:
--Heart Rate tachycardia?
--Epigastric or Lower Quadrant tenderness?
--Blood pressure hypotensive?
--Abdom distention with air or fluid?
--Resp Rate tachypnic?
--Any periotneal signs / guarding / rebound?
--Focus on abdominal exam:
--Rectal exam / guiac stools
Insert large peripheral IV lines for resuscitation purposes and Foley to monitor fluid status
--Blood should be sent for Type & Xmatch, as well as CBC/Lytes/Coags/LFTs/Amylase
Perform NGT placement and aspiration
--Determine rate & amount of blood lost; warm H2O lavage to remove clots and allow EGD
Send for an upright KUB if pt is stable enough
--Look for free air under diaphragm
--Evaluate for signs of obstruction
Perform EGD examination of esophagus and stomach
--Biopsy only if mass associated with duodenal ulcer
--Biopsy ALL gastric ulcers, obtaining multiple specimens
--Look for stigmata of ulcer hemorrhage visible vessel, clot over ulcer, necrotic base
If EGD fails to Dx source of UGI bleed, & blood persists in NGT mesenteric angiography.
EGD reports a 1.5cm ulcer on the posterior aspect of the duodenal bulb, 2 cm from the gastric pylorus,
with no evidence of active bleeding, but a clot covers the ulcer. EGD sclerotherapy is performed. What
is your biggest concern with this ulcer location and how would you proceed with managing this patient?
Ulcer of the posterior duodenum may erode gastroduodenal A bleeding & pancreatitis
Ulcer of the anterior duodenum perforation more common than posterior free air
If pt is stable with no evidence of bleeding, proceed with medical management:
--H2 Receptor Antagoinists heal 70% of ulcers by 4-6wks
--Proton-Pump Inhibitors heal 95% of ulcers by 4-6wks
--Adjunctive antacids and sucralfate
--Advise pt to avoid ASA, EtOH, and cigarettes
Pt presents to the ER 2 weeks later with acute upper abdominal pain, hypotensive, and appearing acutely
ill. After IV fluids and NGT lavage, EGD reveals an actively bleeding ulcer in the posterior wall of the
duodenum. What are the indications and the options for surgical management?
Indications for surgical intervention in duodenal / peptic ulcer disease:
--Intractability
--Obstruction
--Hemorrhage
--Perforation
("I-HOP")
--Goals of surgery in PUD are to correct the above indication AND decrease acid secretion
Physiology behind decreasing gastric acid secretion via truncal vagotomy:
--G-cells in antrum of stomach release gastrin, which is one stimulus for the parietal cells of
the stomach fundus to secrete acid. AcH also directly stimulates acid secretion, as well as
stimulates histamine secretion from ECL cells. By removing AcH stimulus, there is no
stimulation of the G-cells in the antrum (especially if antrum is removed), no direct
stimulation of the parietal cells, and no stimulation of H2 release from the ECL cells.

 Types of surgery for PUD depend on pt's clinical presentation and goals of treatment:

--Graham Patch omental patch over duodenal perf in unstable pt / poor op candidate.
--Truncal Vagotomy and Pyloroplasty resect 1-2cm of each vagal trunk at distal esoph,
thereby decreasing gastric acid secretion and emptying, and
thus requires pylorplasty to facilitate gastric emptying
**Not good procedure for OBSTRUCTION
--Truncal Vagotomy and Antrectomy remove antrum in addition to vagotomy, reconstruct
with Billroth I (gastroduodenostomy) or II (gastrojejunostomy)
**Good procedure for Perforation, Obstruction, or Intractability
**Procedure with LOWEST RECURRENCE rate and HIGHEST DUMPING rate
**Procedure with the HIGHEST MORTALITY
--Proximal Gastric Vagotomy (Highly Selective) no drainage procedure needed; fibers to
pylorus are preserved
**Ideal procedure in setting of INTRACTABILITY
**Contraindicated in concomitant pyloric / prepyloric ulcer
**Procedure with HIGHEST RECURRENCE rate and LOWEST DUMPING rate
**Procedure with the LOWEST MORTALITY

SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

TRAUMA

SAMPLE QUESTION A 23 year old male is brought to the ER after receiving multiple injuries in
a MVA. EMS reports a BP of 80/palp, pulse of 130, and an RR of 36. What do you do?
Evaluate airway-breathing-circulation. Regarding airway:
--Consider spinal immobilization when evaluating airway integrity (backboard + collar)
--Patient speaking? If yes, airway is intact
--Be extra concerned about pts with maxillofacial fractures or crushed trachea.
--1st maneuver to establish airway chin-lift / jaw-thrust; if success oral / nasal airway
--Nasotracheal intubation is CONTRAINDICATED in maxillofacial fractures or apnea
Assess the patients breathing:
--Inspect Breathing RR, cyanosis, tracheal shift, open chest wound, assymmetry
--Auscultate, Percuss, and Palpate Chest
--Attempt to rule out airway obstruction
flail chest
tamponade
tension pneumothorax
pulmonary contusion
open pneumothorax
massive hemothorax
subcutaneous emphysema (ptx until proven otherwise)
Evaluate the integrity of the patients circulation:
--Obtain HR
peripheral perfusion
mental status
skin exam
BP
urinary output
capillary refill
--Place 2 large-bore IVs in upper extremities & infuse LR (total volume = 3X what was lost)
Assess the presence of any disability in the patient after ABCs are secure.
--Evaluate Mental Status, Pupils, Motor/Sensory status
--GCS, 3-15, scores eye opening (4), motor response (6), verbal response (5), T if intubated
--Blown pupil present? ipsilateral CN III
--Check movement at all extremeties and test for presence of any gross sensation defect
Obtain adequate exposure and environment for the patient.
--Completely disrobe patient
--Thorough exploration and palpation of pateint during 2o survey
--Keep a warm environment (Hypothermia acidosis, arrhythmia, and coagulopathy)
You manage to secure an airway in the patient via endotracheal intubation, he appears to have no
breathing abnormalities, and two large bore IVs have been placed w/ LR flowing free. The pts GCS is
9T and he has been completely disrobed in the trauma suite. What do you do next?
Proceed with secondary survey of the patient: Peform head-to-toe physical exam:
--Continue to obtain vital signs as resuscitation continues
--Examine ears hemotympanum or otorrhea = basilar skull fracture
--Examine eyes traumatic hyphema of the anterior chamber; raccoon eyes
--Examine nose nasal septal hematoma
--Examine back logroll, exit wounds from gunshots
--Examine jaw mandibular malocclusion evaluated by asking pt to bite down
--Evaluate ribs lateral and anterior-posterior compression of thorax
--Evaluate abdomen peritoneal signs; should decompress w/ NGT
--Evaluate rectum
sphincter tone, blood, rigid sigmoidoscope
--Evaluate pelvis r/o fractures via lateral and anterior-posterior compression
--Evaluate extremities r/o compartment syndrome, fractures (especially hip dislocation)
Obtain an AMPLE history from the patient or from friends/family members:
--A = allergies
--L = time of last meal
--M = medications
--E = events surrounding the injury
--P = past medical / surgial Hx

 Draw a blood sample to obtain (1) Type and Crossmatch, (2) ABG, and (3) Hematocrit
Place a Foley Catheter to monitor urine output. Contraindications to immediate Foley:
--High-riding ballotable prostate on DRE
--Scrotal or perineal ecchymosis
--Blood at the urethral meatus
--Obvious GU trauma
Consider retrograde urethrogram if urethral disruption suspected
Order any necessary imaging studies:
--AP-CXR r/o great vessel injury (wide mediastinum, loss of knob)
--Lateral Cervical spine film
--AP-Pelvis Film
--AP-KUB
Consider performing DPL, FAST, or CT Scan if abdominal injury suspected
You successfully complete your primary and secondary surveys, having stabilized the patient to a BP of
120/90 and a HR of 85. Blood is drawn & imaging studies are ordered. When the studies return, you
discover a ______ injury. How do you treat this injury and what are the indications to operate?
Subcutaneous emphysema no Tx unless upper airway compression; r/o PTX
Tension pneumothorax tube thoracostomy in midaxillary line, 4th intercostal space
Open pneumothorax
intubate w/ pos pressure vent, chest tube, and 3-sided dressing
Massive hemothorax IV fluids, chest tube; Operate if bleeding continues at > 200cc/hr
Flail chest
intubate with pos pressure vent and PEEP prn
Cardiac tamponade IV fluid bolus, pericardiocentesis, mandatory surgical exploration
Compartment syndrome four-compartment fasciotomy of the lower extremity
Zone I Penetrating Neck Injury arteriogram before exploration
Zone II Penetrating Neck Injury surgical exploration first
Zone III Penetrating Neck Injury arteriogram before exploration
Penetrating Neck Injury Superficial to Platysma no surgical exploration needed
Gunshot to Abdomen exploratory laporotomy
Stabbing to Abdomen exploratory laporotomy IF peritoneal signs, bleeding, visible bowel
Penetrating Colon Injury Stable w/ minimal fecal spill: primary repair =/- resection
Unstable w/ major fecal spill: colostomy and resection
Small Bowel Injury primary closure or resection and primary anastamosis
Penetrating Rectal Injury diverting proximal colostomy, close perforation, presacral drainage
Extraperitoneal or Minor Bladder Rupture Foley and observe
Intraperitoneal or Major Bladder Rupture Operative closure in three layers
Pelvic Fracture external fixators, IVF/blood, supraumbilical DPL, A-gram w/ embolization
Do not enter pelvic hematoma in OR for (+) DPL unless major arterial injury
Irreparable Duodenal and Pancreatic Head injury Whipple
Minor Pancreatic Injury drainage

SURGERY ORAL EXAM REVIEWS, JASON FISHER

SMALL BOWEL OBSTRUCT

SAMPLE QUESTION A 42 year old man presents to the ER with a 3-day history of crampy
abdominal pain, nausea, and vomiting. He has not had a bowel movement in 3 days.
Describe your work-up and initial treatment of this patient.
Take a history designed to flush out the HPI and identify any RFs for small bowel obstruction:
--How long have these Sx occurred?
--Any history of abdominal surgery?
--Have you had similar episodes in the past?
--Ever been Dxd with a hernia?
--COLD-REARS of abdominal pain
--Is there FH of cancer? Recent wt loss?
--Any blood in stool or the emesis?
--Any history of radiation Tx?
--Meds (coumadin, anti-AcH, diuretics, narcotics)? --Any h/o IBD, volvulus, Meckels?
--History of gallstones, colic, or endometriosis?
--Any h/o of atherosclerosis/CAD?
o
Paralytic ileus commonly mimicks SBO, often 2 to post-op, hypoK, meds, inflammation,
retroperitoneal hemorrhage, sepsis/shock, or SCI. Pts usually have NO bowel sounds.
Want to rule out colonic obstruciton and ischemic bowel / mesenteric ischemia
Perform a physical exam looking for:
--HR, BP, Orthostatics, RR Hypovolemia?
--Peritoneal signs guarding, percusion
--Temperature, Tachycardia, Tachypnea ?OR
--Presence of surgical scars?
--Abdominal distention and tenderness
--Palpable masses in abdomen or groin?
--High pitched vs absent bowel sounds
--Rectal exam impaction, mass, blood
Draw blood to perform laboratory evaluation, including Lytes, CBC, Type and Cross, and U/A
--Leukocytosis ?OR
--HypoCl, hypoK metabolic alkalosis
--Mildly elevated Hct dehydration
--Metabolic acidosis LATE in SBO
--Mildly depressed Hct cancer
--Amylasenot specific
--Prerenal azotemia dehydration
--Low UNa and low FeNa prerenal
Perform routine imaging studies of the abdomen:
--Upright CXR free air?
--Flat and Upright KUB dilated bowel loops presence of colonic air or stool
air-fluid levels
ground-glass appearance of small bowel
stack-of-coins
signs of intussusception or volvulus
--If Dx uncertain, perform barium enema BEFORE performing UGI w/ small bowel f/t
UGI series with small bowel follow-thru has NO ROLE in a known complete SBO
On exam, the pt is tachycardic, normotensive, and normothermic, with hyperactive bowel sounds.
Rectal exam is negative and there is no abdominal mass present. KUB reveals distended loops of small
bowel with air fluid levels and scant air in the colon. Labs are pending. How do you proceed?
Initial treatment is conservative nonoperative therapy:
--Nasogastric decompression
--IV Fluids (LR or D5NS +20-40mEq KCl)
--Place Foley; ideal u/o = 0.5-1.0 ml/kg/hr
Objective parameters which lower the threshold to operate in pts w/ SBO:
--Leukocytosis
--Tachycardia or Tachypnea
--Fever
--Evidence of complete SBO
Based on radiographic and clinical findings, determine if SBO is partial vs. complete
--Partial presence of flatus, BM, colonic air; not specific
--Pts w/ partial SBO should be managed nonoperatively at first UNLESS peritoneal signs
--80% of partial SBO will resolve with conservative management
--Complete no flatus or BM, no colonic air; presence of these Sx does NOT r/o complete
--Pts w/ complete SBO should be managed operatively at first UNLESS h/o previous SBOs
--80% of complete SBO will not resolve with conservative management

SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

COLON CANCER

SAMPLE QUESTION A 66 year old man arrives at the ER with c/o light-headedness. He
describes passing dark tarry stools 3-4x in the past week. He does not smoke or drink.
Take a history designed to flush out the HPI and identify any RFs for lower-GI bleeding:
--How long have these Sx occurred?
--Any associated BRBPR or tenesmus?
--Fam Hx of colon CA? Diet, Smoke, EtOH?
--Hx of vascular dz or chemoradiation?
--Any recent weight loss, anorexia, bowel habits? --Hx of hemorrhoids or diverticulosis?
--Any N/V +/- blood, abd pain?
--Hx of IBD or abdominal surgery?
Perform a physical exam looking for:
--HR, BP, Orthostatics, RR Hypovolemia?
--Peritoneal signs guarding, percusion
--Temperature, Tachycardia, Tachypnea
--Presence of surgical scars?
--Abdominal distention, tenderness, masses?
--Presence of hemorrhoids?
--High pitched bowel sounds?
--Rectal exam mass, HEMOCCULT
Insert large peripheral IV lines for resuscitation purposes and Foley to monitor fluid status
Draw blood to perform laboratory evaluation, including Lytes, CBC w/ MCV, Type/Cross
Perform imaging to localize the source of bleeding:
--Place NG Tube to r/o UGI bleed (look for bile) --Angiography (bleeds 0.51.0 ml/min)
--Colonoscopy or Gastrograffin Enema
--Tagged RBC Scan (bleeds 0.1 ml/min)
The pt is normotensive with a HR = 104. Abdomen is soft, nt/nd, with normal BS. Rectal exam reveals
heme-positive melenotic stool in the rectal vault. Hgb is 8.1 with an MCV of 72. LFTs are normal.
Colonoscopy reveals sessile fungating mass proximal to hepatic flex, not ammenable to endoscopic tx.
The lesion is biopsied and reveals adenocarcinoma. How do you now proceed?
What are some of the types of polyps typically found on colonoscopy?
* = ca risk
--Neoplastic tubular*, villous*
--Hyperplastic areas of neoplastic
--Hamartomatous Peutz Jegher*, juvenile
--Inflammatory IBD
Which symptoms of colon CA are more common with the side of the lesion?
--Right Sided colon CA large diameter: anemia, melena > BRBPR
--Left Sided colon CA
small diameter: change in bowel habits, obstruction,scant blood
Preoperative preparation for colon CA resection
--CBC, Chem10, PT/PTT, T&C, LFT, CEA, U/A --CXR and Abdominal CT
--Pelvic CT if suspect rectal CA
--Bowel preparation: Golytely until clear, PO Abx (1g neo + 1g erythro +/- flagyl x 3doses)
IV Abx (cefoxitin or cefotetan;clinda+aztreonam at least 30min preop)
Want to rule out any distant metastases before proceeding to surgical treatment
Rectal cancers should have Preoperative Staging via transrectal ultrasound
Treatment is surgical excision with the following parameters:
--Segmental surgical excision of lesion
--LAR if tumor >8cm from anal verge
--Remove regional lymphatics +/- sentinal node
--APR if tumor <8cm from anal verge
--Margins of AT LEAST 2cm, >5cm desirable
--Excise mesorectum if rectal CA
--Liver Mets resect with 1-2cm margins
Attempt to stage the cancer after resection to decide definitive therapy:
--Dukes A = limited to mucosa
90% 5yr survival
B1 = limited to muscularis propria 80% 5yr survival
B2 = penetrate muscularis propria 70% 5yr survival
B3 = involves adjacent tissues
70% 5yr survival
C1-3 = B classes with nodes
40% 5yr survival
D = distant metastases
5% 5yr survival

--TMN T1:submucosa, T2:muscularis propria, T3:thru propria no serosa, T4: thru serosa
N1: 1-3 nodes, N2: 4+ nodes,
N3: central nodes positive
Decide on any adjuvant therapy after surgical resection
--Dukes C / Stage III
adjuvant chemotherapy with 5-FU and leucovorin
--Liver metastasis resection adjuvant chemotherapy
--T4 or Positive Margins adjuvant radiation therapy
--No role for radiation therapy in Dukes Class C
--T3 Rectal Cancer
adjuvant radiation therapy
--Neoadjuvant still controversial in T2/T3 Rectal CA 5-FU acts as radiosensitizer
Provide follow-up screening of this patient post-op
--3 month follow-up for 1st 2 years PE, guiac, CEA every 3mos x 3yrs/6mos x 2yrs
--90% of colorectal recurrences occur within 3 years after surgery
--Routine colonoscopy at 1 year, 3 years, and 5 years post-op, and then q3 years
Normal recommendations for screening:
1) Annual DRE with guiac at age 50, if positive colonoscopy
2) Colonoscopy surveillance every 10 years after age 50 or
Flexible Sigmoidoscopy every 5 years after age 50 or
Flexible Sig plus Barium enema every 10 years after age 50
Recommendations for CRC screening if pos FH
1) Annual DRE with guiac at 10 yrs prior to when family member was diagnosed
2) Colonoscopy surveillance every 5 years after that

SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

VASCULAR DISEASE

SAMPLE QUESTION A 68 year-old man comes to you for his annual physical and complains of
cramps and leg pain in the right calf after walking. How would you work this up?
Take a history designed to flush out the HPI and identify any RFs for peripheral vascular dz:
--Does pain occur consistently at certain distances? --Do you smoke? Are you sedentery?
--Is the pain relieved by rest? Is it reproducable? --PMHx of CAD, HTN, DM, ESRD,
--Does the pain begin in the calf or lower back?
TIA/CVA, high cholest, obesity?
--Is there any pain at rest / during the night?
--Is there family Hx of vascular disease?
Perform a physical exam looking for:
--Pulses: DP, PT, Pop, Fem, Radial, Carotid
--Decreased hair, shiny skin, thick nails
--Doppler the pulses above as well as palpate
--Muscular atrophy or ulcers
--Listen for bruits at same points and abdomen
--Ankle-Brachial Index w/ Doppler
--Palor on elevation and rubor on dependency
--Pulse Volume Recordings
The patient describes his symptoms as occuring always when he walks 4 blocks, but denies rest pain.
He has a h/o significant CAD and a 40pack year smoking history. Diminished pulses are detected in the
right DP and PT, but no ulcers or atrophy present. ABI = 0.6 and PVRs are diminished below the knee.
What is the differential for lower extremity pain and how would you treat this patient initially?
The differential for lower extremity pain includes:
--Acute arterial embolism
--Arthritis / Musculoskeletal disorders
--Occlusive atherosclerotic disease
--Coarctation of the Aorta
--Chronic venous disease
--Popliteal Artery syndrome
--Deep vein thrombosis
--Chronic compartment syndrome
--Neurogenic pain from disc/nerve root
--Neuromas
--Diabetic neuropathy pain
--Anemia
Appropriate initial treatment for claudication involves:
--RFs (smoking, BP, cholest, diet, weight loss)
--Pletalphosphodiesterase inhibitor
--Exercisestimulate collateral vessel growth
--Trentalrheologic agent
--Only about 20% of patients with PVD will fail medical management
What are indications and options for sugical treatment of this disease?
Indications for surgical intervention in arterial occlusive disease
--Rest Pain
--Tissue Necrosis
--Infection
--Disabling refractory claudication
Different surgical options for PVD treatment
--Angiogram of the affected limb should be obtained preoperatively
--Surgical graft bypass
--Angioplasty
--Endarterectomy
--Patch Angioplasty
Determinants of bypass graft patency include several factors
--Inflow to the graft
--Type of graft used
--Infection
--Outflow from the graft
--Presence of technical error
--Cessation of smoking
--Distal runoff of the limb
--Presence of underlying ESRD --Intimal hyperplasia at anast

SAMPLE QUESTION A 77 year-old man presents to the ER complaining of brief loss of vision
in his right eye, occuring several times over the past 2 weeks. How do you assess him?
Take a history designed to flush out the HPI and identify any RFs for cartoid vascular disease:
--Is the vision loss in a shade-like pattern ?
--Personal or family h/o CAD or PVD?
--Any associated loss of consciousness?
--Do you smoke? Are you sedentery?
--Any other associated neuro deficits?
--PMHx of HTN, DM, cholest, obesity?
--Any history of stroke, TIA, or syncope?
--Any headache or pain assoc w/ vision?
Perform a physical exam looking for:
--Pulses: DP, PT, Pop, Fem, Radial, Carotid
--Evidence of PVD (hair, nails, ulcer))
--Doppler the pulses above as well as palpate
--Current medications (ASA, warfarin)
--Listen for bruits at same points and abdomen
--Carotid duplex ultrasound
--Full neurologic exam w/ cranial nerves as well
The patient does not associate any other problems with his vision loss, and describes the temporary
blindness like a shade coming down over his eyes. He describes an extensive smoking history as well as
recent CABG surgery, but no PMHx of stroke. Bruits are present bilaterally and your neurologic exam
is normal. Cartoid duplex ultrasound reveals 75% stenosis on the left and 50% stenosis on the right.
How do you proceed from here?
Indications to perform carotid endarterectomy include:
--NASCET Trial Stenosis of 60% or more in an asymptomatic patient
--ACAS Trial
Stenosis of 70% or more in a symptomatic patient
Stenosis of 50% or more in symptomatic patient with multiple TIAs
The preoperative work-up of any patient undergoing CEA
--EKG
--Agram / MRA (but not always)
--Cardiac Echo
--Head CT if symptomatic patient
Surgical considerations during endarterectomy:
--Use of shunt depends on surgeon; pt can tolerate 20-30min carotid occlusion; shunts
carry small but some risk of embolizaiton; all results equal
--Monitor for cerebral hypoperfusion MS, distal stump pressure, EEG, near-infrared spec
--Dacron patch closure
--Structures encountered during dissection Platysma, facial vein, superior thyroid A,
Omohyoid (prox) and digastric (dist) muscles,
Hypoglossal nerve, Facial nerve, Vagus nerve
Postoperative follow-up and complications after CEA include:
--Follow-up duplex studies are valuable to track progression of contralateral disease
--Ipsilateral recurrence after CEA is rare
--Stroke (1-5% depending on if Sx)
--CN XII injury
--Death (1%)
--Intracranial hemorrhage
--MI
--Hypo/Hypertension
--CN X injury
--Infection and hemorrhage
--Thrombosis ASA should be given postoperatively

SURGERY ORAL EXAMINATION REVIEWS, JASON FISHER

HEPATOBILIARY DZ

SAMPLE QUESTION A 73 year old man goes to the ER complaining of RUQ pain of 3 days
duration. He has had a fever and felt chills intermittently. How do you proceed.
Take a history designed to flush out the HPI and identify any RFs for acute cholangitis:
--Pain assoc with meals or relieved by antacids?
--Noticed any changes in skin/sclera?
--History of gallstones or cholecystectomy
--Any history of IBD or pancreatic CA
--Noticed any changes in the color of his urine?
--Any recent travel?
Perform a physical exam looking for:
--Tachycardia / Hypotension
--Ellicit a Murphys sign
--Evidence of jaundice?
--Rectal exam with hemoccult
--Abdominal RUQ tenderness or mass?
--Quick assessment of mental status
--Peritoneal signs present?
--Other signs of sepsis
Provide IV Fluids for resuscitation and IV antibiotics if suspecting acute cholangitis
--Should ascertain adquate urine outputfoley
--Antibiotics should have gram negative coverage Ecoli, Klebsiella, Pseudo, Enterobact
--75-80% with cholangitis respond to fluid and ABx alone
--Less than 50% with cholangitis 2o to CA will respond to fluid and ABx alone
Laboratory evaluation is often helpful, and blood should be drawn during initial resuscitation
--Leukocytosis
--Type Cross, CBC, Chem7, LFT
--Elevated TB and Alk Phos
--Send for blood cultures (prior to ABx ideally)pos in 25%
The diagnosis of acute cholangitis is made based on history, physical and labs. Fluids and antibiotics
were begun, and laboratory values showed leukocytosis with markedly elevated TB and AlkPhos and
mildly elevated transaminases. The patient appears stable presently. How do you now proceed?
Perform imaging to help identify source of CBD obstruction after pt has received resuscitation:
--Ultrasound detects CBD dilatation, less good for CBD stones
--ERCP/PTC diagnostic and therapeutic possibilitiesget brushings if possible
--PTC better radiographic procedure for prox dz, strictures, and malignancy
--ERCP better radiographic procedure for distal dz,
--CT Scan good for detecting cholangitis secondary to malignancy
Common causes of common bile duct obstruction leading to cholangitis include:
--Choledocholithiasis
--Extrinsic Compression (pancreatitis / psuedocyst)
--Stricutre (post-op)
--Instrumentation of bile ducts (ERCP / PTC)
--Neoplasm
--Biliary stent
--Sclerosing cholangitis
--Parasites
Determine whether disease process is suppurative vs nonsuppurative
--Nonsuppurative Dz generally incomplete obstruction, responds to ABx, milder Sx
Tx IVF and ABx with definitive treatment later
--Suppurative Dz generally complete obstruction, less responsive ABx, Reynolds pentad
Tx IVF and ABx with decompression via ERCP, PTC, or surgery
The various modalities of emergency biliary duct decompression include:
--ERCP Indications Distal CBD Stones, Proximal CA, Nondilated bile ducts
--PTC Indications
Proximal Obstruction, Altered biliary anatomy, Dilated bile ducts
--Surgical Indications ERCP/PTC fail, Recurrent CBD Stones, 1o CBD Stones,
Multiple large stones, Stones in the Hepatic ducts
--Definitive treatment for benign strictures and for intrahepatic stones with recurrent
cholangitis involves ERCP.