Margins
45 YO M who presents with a 1 cm pearly rolled lesion on the forehead. What is the treatment and margin?
Excision of the lesion with 0.5 cm margin
24 YO F with abdominal pain, diarrhea, and weight loss. Endoscopy shows coble stoning, aphtous ulcers, and transmural involvement. When would you recommend screening colonoscopy?
8 years after diagnosis.
A 45-year-old woman presents with a 1-cm estrogen receptor-positive ductal carcinoma in situ. What is the management and margin?
Lumpectomy + XRT+ 2 mm margins
59 YO F who was recently diagnosed with stage 2 right colon CA s/p RHC. Discuss post-op surveillance
1. H/P + CEA every 3-6 months
2. colonoscopy after 1 year
3. CT chest/abd/pelvis 6-12 months
30 YO M presents to the trauma bay with multiple GSW to the chest and abdomen. HR: 130 BP: 70/40. What is the class of hemorrhagic shock and estimated blood loss in cc and percentage?
Class III: 1500-2000 cc, 30-40 %
60 YO F with a history of kidney transplant, presents with an ulcerated lesion with adherent crust on the back. What is the management and margin?
Excision of the lesion.
Low risk: 4 mm margin
High risk : 10 mm margin
in patients with Lynch syndrome or HNPCC, colonoscopy should be performed?
Age 20 to 25 years or 10 years before the age of the youngest person in the family received a colorectal cancer diagnosis
65 YO F presents with a palpable mass in her left breast. Imaging studies are done and confirm the mass. A biopsy shows vimentin and actin. What is the treatment and margin?
Wide local excision with 1-2 cm margin.
46 YO F with stage 1 right thigh sarcoma s/p excision, presents to the office for a post-op visit. He would like to discuss his post-op surveillance.
H/P every 3-6 months for 2-3 years and then annually with periodic imaging
20 YO M s/p GSW to the right chest. R chest tube is placed. What are the indications for ED thoracotomy and ED thoracotomy?
ED: Penetrating thoracic trauma in patients who are pulseless with less than 15 minutes of CPR. Blunt trauma in patients who lose vital signs en route or in the ED with less than 10 minutes of CPR or patients
OR: Initial output of 1500 mL of blood from a chest tube, or 200 to 300 mL/hour for 2 to 4 hours. Ongoing hemodynamic instability despite adequate fluid/blood resuscitation
55 YO M who presents with a cecal adenocarcinoma, no distant metastasis. What is surgical management? How many lymph nodes? What is the margin?
RHC, 12 lymph nodes, 5 cm margin
20 YO F with a significant family history of BRAC mutation. At what age she should start breast cancer screening? What diagnostic test?
MRI at age 25
Mammogram at 30
61 YO F who presents with refractory peptic ulcer disease and diarrhea, was found to have a 3 cm mass in the body of the pancreas. Discuss diagnostic tests and values.
1. Serum Gastrin: 1000
2. Gastrin > 200 and basal acid output> 15
3. Secretin stimulation test: Gastrin > 120 at 10 minute
A 52 YO F is undergoing a screening colonoscopy. During the procedure, a 21-mm polyp is seen in the descending colon. The polyp is completely removed. Pathology report reveals a 21-mm tubular adenoma. What is the next step in the management of this patient's colonoscopy findings?
Repeat colonoscopy in 3 years
You are seeing a 60 YO F who is s/p LUE AV fistula creation in the clinic. The Vascular attending wants you to discuss the rule of six.
Within 6 weeks:
Flow volume >600 mL/min; vein diameter >6 mm; vein depth <6 mm
Patient presents with a forearm lesion. The lesion has increased in size, color variation, and ulcerated border. Discuss the different possible surgical margins and indications for SLNBx.
< 1mm: 1 cm margin. 1-4 mm: 2 cm margin. >4 mm: 2-3 cm margin
SLNBx:
1. Lesion > 0.75 mm. Lesion < 0.75 mm with high-risk features (ulceration, high mitotic rate, lymphovascular invasion)
65 YO who was found to have a 2.2 cm rectal carcinoid on screening colonoscopy. Staging workup is negative. What is the management?
Proctectomy with mesorectal excision
61 YO F who was recently diagnosed with right liver hepatoma. He undergoes further workup and is deemed to be a fit surgical candidate. Review the different future liver remnant (FLR) values.
20%: Normal liver
30%: Patients on chemo
40%: Cirrhosis
55 YO M with a recent diagnosis of stage II gastric cancer s/p resection and adjuvant chemotherapy. What is an appropriate surveillance follow-up plan for this patient?
H/P every 3 to 6 months for 1 to 2 years, every 6 to 12 months for 3 to 5 years, and annually.
CT of the chest, abdomen, and pelvis every 6 to 12 months for 2 years and then annually for up to 5 year
40 YO M who was recently treated for pneumonia, now presenting with multiple episodes of watery diarrhea, and abdominal pain. The diagnosis is confirmed with the diagnostic test. What is the treatment (dose, frequency, and length, give 2 different treatments)
Vancomycin 125 mg QID for 10 days.
Fidaxomicin 200 mg BID for 10 days.
65 M with a history of liver transplant, presents with a 1.5 cm reddish-purple nodule with rapid growth on the arm. staging workup shows no metastasis. Biopsy showed small round, blue cells. What is the management?
Excision with 2 cm margin, SLNBx, and post-op radiation
23 YO with a history of radiation therapy to the abdomen, presents for screening colonoscopy evaluation. What do you recommend?
5 years after radiation therapy or at age 30
70 YO M who presents with dysphagia and odynophagia. He is found to have the most common benign tumor of the esophagus on further evaluation. What is the treatment based on the size of the tumor?
< 5 cm: endoscopic enucleation
> 5 cm VATS and enucleation
65 YO M presents for screening colonoscopy and was found to have a 25 mm tubular adenoma polyp in the transverse colon. The polyp is fractured during hot snare polypectomy but is completely removed. When do you recommend repeating his colonoscopy?
Repeat colonoscopy in 6 months to ensure complete excision
A 30-year-old man is caught in a car fire and severely burned. The burns include 20% second-degree to his abdomen and legs and 5% third-degree to his back. He weighs 60 kg. What is his daily caloric requirement?
kcal needed per day equals 25 kcal x kg bodyweight + 40 kcal x %TBSA (in whole numbers).
For this patient, the calculation is (25 kcal x 60 kg) + 40 kcal x 25% TBSA (20% second-degree and 5% third-degree burns) = 2500 kcal/day.