BOObies
Bari Scary
Freaky Fluids
Graveyard gallbladders
Trick or Trauma
100

A 27yo pregnant F (27 weeks) presents w/ 2-cm breast mass. She undergoes appropriate imaging and core needle biopsy confirming an invasive ductal carcinoma.  She has no palpable axillary adenopathy. She desires breast conservation, and you plan to proceed to surgery. This is the appropriate axillary staging:

Sentinel node biopsy with technetium-99

100

A 43yoF w/ a history of morbid obesity underwent a Roux-en-Y gastric bypass 3 months ago. She now presents with symptoms of nausea, dizziness, and diaphoresis about 2 hours after eating a meal. This is the likely diagnosis

late dumping syndrome

1-3 hrs after eating, secondary to inappropriate insulin release and resulting hypoglycemia

100

An 82-year-old patient with a history of HTN, paroxysmal atrial fibrillation, and hyperlipidemia presents with severe, acute-onset abdominal pain that is out of proportion to her exam. Lab studies show an anion gap metabolic acidosis, and an ECG obtained in the ED reveals peaked T waves and widened QRS complexes. this is the best next step in management of these ECG changes

IV calcium gluconate

100

A 55-year-old woman with HTN and type 2 DM presents with painless jaundice and a 6-kg weight loss over 3 months. Workup reveals obstruction of the distal common bile duct with no evidence of metastatic disease. ERCP with stent placement and bile duct brushings show cholangiocarcinoma. this is the most appropriate surgical treatment

 Pancreaticoduodenectomy

100

A 57-year-old patient involved in an MVC has BP of 90/50 mm Hg and HR of 116 beats/min. After 2 L of crystalloid, BP is 115/70 mm Hg, and HR is 105 beats/min. A left femur fracture is splinted. CXR, pelvic x-ray, and FAST are otherwise normal. Fifteen minutes later, BP drops to 80/50 mm Hg, and HR increases to 134 beats/min. In addition to 2 units of PRBCs, this is the next step in management

repeat FAST exam

200

A 42-year-old female presents to your office with breast asymmetry as seen in the pic below. Biopsy is performed revealing both epithelial and stromal components staining positive for vimentin and actin. This is the most likely diagnosis:

phyllodes tumor

200

A 46yoF presents to theED w/ abd pain, N/V. She is tachycardic and febrile, with leukocytosis, but hemodynamically stable. Her surgical history is signif for a vertical sleeve gastrectomy for morbid obesity 20 days ago. This would be the next step in diagnosing postoperative leak and this is the most common site for a concomitant stricture

Oral and IV contrast-enhanced CT; incisura angularis

200

A 32yoF w/ bipolar disorder w/ schizophrenic features is found to have Na level of 124 mEq/L and presents to your office w/ confusion. 2 months ago, the pt's Na level was normal. Your working diagnosis is psychogenic polydipsia versus syndrome of inappropriate antidiuretic hormone (SIADH). These 3 labs/ studies will differentiate between these 2 conditions

Urine sodium, serum osmolarity, and urine osmolarity

SIADH:urine osm & urine Na will be elevated, as ADH will inappropriately work on the distal collecting system. 

In psychogenic polydipsia:urine Na and urine osm will be maximally low as the body appropriately tries to keep sodium.

200

A 64yoF w/ a history of cholecystectomy complicated by complete transection of the CBD requiring hepaticojejunostomy for definitive repair 3 years ago now presents with 4 days of progressively worsening RUQ pain, fevers, and chills. Her husband reports new yellowing of her skin and eyes. Examination is notable for fever 101.6 °F, HR in the 110s, BP 94/55, and ttp in RUQ with positive Murphy sign. Labs reveal leukocytosis, hyperbilirubinemia, and transaminitis. this is the most likely etiology of her acute cholangitis

 Biliary-enteric stricture

The most common late complication of bile duct resection and reconstruction is bile duct stricture formation, reported at a rate of 10% to 30%. Patients who develop a stricture are susceptible to biliary sepsis and cholangitis, which this patient has, and this condition may require urgent percutaneous transhepatic cholangiography to decompress.

200

A 32-year-old man was working on his car when the jack gave out and the car landed on his bilateral lower extremities. Extrication time was ~1 hour. When he arrives at the trauma bay, he is lethargic with a GCS score of 7, HR of 120 beats/min, and BP of 80/50 mm Hg. this is the best combination for induction prior to intubation of this patient

Etomidate and rocuronium

300

A healthy 75yoF w/ history of DCIS treated w/ breast-conserving surgery, whole-breast radiotherapy, and 5 yrs of aromatase inhibitor, which she completed 2 yrs ago. On surveillance, she is found to have an ipsilateral recurrence of DCIS measuring 1.5 cm. This is the most appropriate treatment option for this patient

mastectomy with sentinel node biopsy

300

67yo F presents to the ED w/ acute onset of nausea, epigastric abdominal pain, and fever. She has a rigid abdominal exam and an elevated wbc. She reports a history of Roux-en-Y gastric bypass, poor f/u w/ a bariatric specialist, current tobacco use, occasional ibuprofen use for chronic low back pain, and no prior similar symptoms. You eval the pt immediately and discuss emergent operation with her based upon this bariatric surgical complication:

perforated marginal ulcer

300

A 67-year-old woman underwent total thyroidectomy yesterday for a large goiter compressing her airway. On morning rounds, she complains of perioral numbness and tingling. Her vital signs are T 37.5°C, HR 84 beats/min, BP 116/85 mm Hg, RR 14 breaths/min, O2 sat 97% on room air. these three signs of this electrolyte abnormality would be present on physical exam

facial muscle spasm with percussion of facial nerve (Chvostek sign)

Trousseau sign (carpal spasm with occlusion of brachial artery)

hyperactive deep tendon reflexes.

300

A 27yoF is referred to your clinic w/RUQ pain. Her pain persists despite having a lap chole for gallstones the previous year. MRCP is obtained. This is the treatment for the depicted pathology

Resection of biliary diverticulum

300

A 74-year-old man tripped on a broken sidewalk and fell. He is awake, alert, and able to provide a clear history. He hit his head and did not lose consciousness. His ABCDs are intact. He has an abrasion over his left eye and on his left palm, with no other obvious injury. Notably, he has no neck pain, tenderness to palpation of his cervical spine at the midline, or neurologic deficit. this is the next step in the evaluation of this patient for a cervical spine injury

Obtain CT of the cervical spine.

he most commonly used tools are the NEXUS criteria and the Canadian Cervical Spine Rule. However, both studies from which these rules were derived excluded patients over the age of 65 and should be interpreted with caution in this patient population. Older adults are more likely to have a cervical spine injury with low-energy mechanisms such as falls from standing, and they are more likely to have clinically significant injuries not apparent on physical examination.

400

A 57yoF presents after an abnormal screening mammo & denies any palpable masses, skin changes, nipple discharge, or inversion. Diagnostic mammo reveals heterogeneous calcifications in the R. breast at 10 o'clock, 3 cm from the nipple w/no assoc mass. Stereotactic biopsy reveals atypical ductal hyperplasia. This is the next step in management:

Surgical Excision in OR

When ADH is found on core needle biopsy, the patient should undergo excisional biopsy for wider tissue sampling. There is an up to 20% rate of upgrade to malignancy on excisional biopsy after a diagnosis of ADH on core needle biopsy. Typically, the upgrade is to ductal carcinoma in situ or early invasive carcinoma

400

A 36yoF presents to ED, complaining of sharp abd pain that radiates to her back with no other symptoms. She underwent a laparoscopic Roux-en-Y gastric bypass 2 yrs ago, resulting in a 125 lb. weight loss. Her labs are: WBC 7.4, Hgb 12.7,LA 1.0. and Cr 0.7. CT is shown below. This is the best step in management of this patient:

Diagnostic laparoscopy and repair of mesenteric defect

400

A 78-year-old man is brought to the emergency department via ambulance after his wife found him obtunded. He has stage 4 chronic kidney disease and has been complaining of constipation lately. He has been using over-the-counter magnesium hydroxide (Milk of Magnesia), yet has had no relief. Vital signs are blood pressure 90/50 mm Hg, temperature 98.9ºF, heart rate 93 beats/min, and respiratory rate 8 breaths/min. The man appears flushed and has decreased reflexes.This classic EKG finding will be present

1st degree AV block

400

A 46yoF presents with RUQ pain and nausea. Labs are notable for elevated ALT and AST, with bili of 3.2 mg/dL. US demonstrates a dilated CBD of 12 mm. You take the patient for a lap chole with IOC. The cholangiogram demonstrates a filling defect in the distal CBD. You administer glucagon and flush the duct, but the stones do not clear. You elect to perform a transcystic laparoscopic CBD exploration. This is the most important initial step of this procedure

Insert a wire through the cholangiocatheter and confirm wire position in the duodenum using fluoroscopy. Insert the choledochoscope over the wire.

400

A 16-year-old unrestrained passenger is involved in a high-speed motor vehicle accident. He is taken to the operating room for exploration. He is found to have a left renal laceration that involves the deep renal cortex, the medulla and collecting system with a small contained hematoma at the renal hilum. this grade injury is being described:

IV

Grade I involves contusions with an intact renal capsule.

Grade II involves minor lacerations to the renal parenchyma extending to the superficial renal cortex, but does not involve the medulla or collecting system.

Grade III involves major parenchymal lacerations that involve the renal cortex and medulla, but does not involve the collecting system.

Grade IV involves major parenchymal laceration extending through the cortex and medulla as well as the collecting system, and involves the renal vasculature with locally contained hemorrhage.

500

A 34-year-old woman is diagnosed with triple negative (ER/PR and HER2-negative) right breast cancer during the 28th week of her first pregnancy. The tumor is 7 cm in diameter, and she has several palpable axillary lymph nodes. Her breast size is an A cup. this is the appropriate next step in management:

Primary systemic chemotherapy

Chemotherapy is increasingly being administered to women during their second and third trimesters of pregnancy with minimal risk to the fetus. HER2-targeted therapies, not necessary in this case as the tumor is HER2 negative, are not approved in pregnancy. For this patient, chemotherapy may decrease the size of the tumor, thus allowing for breast conservation and postpartum external-beam radiation therapy

500

You are performing a robo-assisted Roux-en-Y gastric bypass on a 52yoM for morbid obesity. You insufflate the abdomen to 15 mm Hg to achieve pneumoperitoneum. To obtain more working space, you increase the pressure to 18 mm Hg. At the end of the procedure, you notice that his Foley bag only contains 20 cc of urine after the 2½ hour case. The pt received 1800 cc of fluid intraope. this hormone level finding is associated with his urine output:

 Increased antidiuretic hormone

Pneumoperitoneum can result in decreased urine output by direct compression of splanchnic vessels, which results in decreased renal blood flow.

  • Decreased renal blood flow → decreased glomerular filtration rate → decreased urine output
  • Decreased renal blood flow → decreased glomerular filtration rate → activation of the renin-angiotensin system → increased levels of renin, angiotensin II, aldosterone, antidiuretic hormone → decreased urine output
500

A 32-year-old man is admitted to the ICU after sustaining multiple long bone fractures, rib fractures and moderate traumatic brain injury (GCS = 10) with multiple craniofacial fractures. His vital signs are as follows: T 36.9°C, HR 102 beats/min, BP 134/74 mm Hg, RR 14 breaths/min, 96% on 2L nasal cannula, and his weight is 83 kg. His serum Na is 153 mEq/dL, up from 147 mEq/dL 2 days ago. calculated free water deficit in this patient

4.6

 free water deficit = % total body water (fraction) × weight (kg) × (current Na/ideal Na – 1).

500

A 58yoF is admitted w/ choledocholithiasis, jaundice, and leukocytosis. MRCP confirms a large stone in the distal CBD. She undergoes attempted ERCP, but the stone is unable to be extracted or fragmented. You take her to the OR for an open CBD exploration. Despite kocherization of the duodenum, you are unable to extract the stone and decide to perform a transduodenal sphincteroplasty. this is where the incision should be made on the sphincter

11 o’clock

A small longitudinal duodenotomy is made over the ampulla, and two stay sutures are placed on each side of the ampulla to elevate it. A small incision is made at the 11 o'clock position in the sphincter, taking care to avoid the pancreatic duct, which is usually found at the 5 o'clock position. The sphincterotomy is extended through the sphincter (approximately 1.5 cm), and the impacted stone is removed. The bile duct and duodenal mucosa are then reapproximated with interrupted 4-0 absorbable sutures

500

A 47-year-old woman is the victim of several stab wounds to the right and left chest. She is being evaluated in the trauma bay. A chest x-ray shows bilateral pneumothoraces for which bilateral chest tubes have been placed. Air leaks are present in both chest tubes, and a bronchoscopy is performed to evaluate for tracheobronchial injury. A 50% circumference laceration is discovered at the carina extending into the left proximal mainstem bronchus. This is the ideal operative approach to repair this injury?

Right posterolateral thoracotomy

gets you to the carina 

Devitalized tissue should be debrided and the bronchus repaired with interrupted absorbable suture.

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