Surgery Step 2 12-16-2015 GI TRACT and GI BLEED

ruhland1's version from 2015-12-16 15:37

Section 1

Question Answer
54 M hx of retrosternal pain, onset yrs agoGERD
GERD tx1st= PPI, if no improve get Endoscope w bx
hx of GERD, scope shoes peptic esophagitis and Barrettsget Nissen
62 M severe epig pain, (-)EKGGet Acid Perfusion (Bernstein) to r/o if pain is due to reflux or not
44 M prog Dysphag 3 mo, lost 30 lbCx Esph (dx= Barium->scope and bx-> CT)
47 F dysphagia many years, Lquids are more difficult to swallow than solidsmeans problem of peristalsis, achalasia, manometry studies
night of ETOH, V repeatedly, soon bright red bllodMallory Weiss tear at GastEsph Junc
Mallory Weiss MxNG lavage then scope, photocoag if up bleeding
severe V and one very severe wrenching epig and low sternal pain of sudden onset, F and up WBCBoerhaves, dx gastrographin (avoid barium it damges mediastinal tissues), get surgery
55 M post scope for ulcer, severe retrosternal pain constant, RR 30, Tmep 104instrument perf, get srx
72 M dn 40lb in 3 mo. vauge epig discomfortstomach cx, dx with scope/bx`
54 M colicky abdominal pain, V for several days, abd dist, 0 BM/flatus 5 days, AXR shows distended loops of sm bowel and air-fluid levels, hx of abd srx1st get AXR dx= SBO to adhesions Mx: NGT LIS, IVF
SBO with F, up WBC, abd/rebound tenderstangulatation, get emergency laporotaomy
reducible hernia is now notincarcerated potientially strangulated hernia, need IVF first then URGENT srx
55 F protracted diarrhea, flushing, expiratory wheeze, prominent JVP on neckcarcinoid syndroma, dx 5-HIAA
22 M vauge periumbilical pain, then goes to RLQ, up PMN bandsacute appendicitis, ex-lap-appy
59 M syncope, pale, Hgb 5, occult blood stoolCx right colon, Get C-scope and bx, Tx is B transfuse and R hemicolectomy
56 Y M blood coats outside BM, narrow caliberCx of distal left colon Dx= 1st=flexible sigmoidoscopy, do C-scope and Bx after.
villous adenomapre cx
FAPpre cx
GardnersSebaceous Cyst/Osteoma/Desmoid tmx,
Adenomatous Polyppre cx
Juvinile Polypbenign
Peutz JegerBenign
Inflamm Polypbenign
hyperplastic Polypbenign
chronic UC, appears "toxic", temp 104, up wbcToxic Megacolon, Have to remove involved colon and ALWAYS include rectum
clindamycin/tobramycin now h20 rrhea crampy abd pain, F, up WBCC Diff Pseudomembranous Colitis (dx 1st with C. Diff toxin Assay then stool culture, quicker dx is proctosigmoidoscopy
CDiff due to abxStop Clinda, Give vanco/metro, avoid LOMOTIL
Anorectal ruleMUST r/o Cancer!
60 M + hx hemorrhoids + painless bright red toilet paperinternal hem, BUT must r/o cx so get proctosigmoidoscopic exam
ext hemm presentation (anal itich perianal pain when sitting down)must R/O cx 1st
23 F pain with BM and blood streaks on outside of stools, very pain ful anusanal fissure, pain so must examine under anesthesia tx= lateral internal sphincterotomy
28 M hx of recurring perianal fistulathink Chrons (Must r/o cx with bx)
44 M perianal pain, fever, hot tender red fluctuant mass between anus and ischial tuberosityischiorectal abscess Tx: Rule out cancer and examine under anesthesia w I and D
62 M perianal disc, streaks of fecal soiling in underwear, cord like tract going opening towards inside of anal canal, brownish pusfistula-in-ano, 1st ro cx with rpoctsigmoidoscope then schedule elective fistulotomy

Section 2

Question Answer
UGI bleednose to Lig of Treitz Mx= Start w NG lavage then endoscope
3 large dark red BM, diaphoretic, up HR, dn BPbleed could be anywhere 1st place NGT
NGT returns copious bloodafter NG lavage get E-scope
NGT clear fluid wo bilenose to pylorus
NGT bile aspiratenose to Lig of Treitz
bleeding more than 0.5 cc minemergency angiogram
GI Bleed3/4 from UGI all LGI are from polyps,cx, angiodysplasias.
Slow GI bleedboth upper and lower GI E-scope
7 M lg bloody BMMeckels Divert (Tc-99=dx)
ICU for 2 weeks and shitload of preocedures, now vomits lg amount bright bloodstress ulcer, Mx= Keep pH of stomach above 4 with H2/PPI, once bleeding takes place make dx with e-scope. Tx= angiographic emboloization of L gastric a.
59 M adb pain 1 hour ago, rigid, guarding, rebound all 4 quardgeneric picture of acture abdomen (generalized acutre peritonitis) must have emergency exploratory lap
acute abodmenmust rule out LLobe Pneumonia and MI with CXR and EKG
cirrosis + ascites and generalized abdpain recent, rebound, mild F, up WBCprimary perionitis=no Srx or acute peritonitis secondary to ...
dx peritonitisparacentesis >250 WBC and SBP and Culture of ascitic fluid
43 M excruating abd pain T 0 and rigid and lies motionless T 30, no bowel sounds, AXR show free air under diaphragmacute abd + perf viscus most likely due to duod ulcer Mx= Emergency ex-lap
44 M ETOH with severe epig pain after heavy ETOH rad straight to backacute pancreatitis dx=Amylase/Lipase -> CT is unclear Mx= NPO,NGT, IVF, pain mx
43 F Obese Multiparrous severe RUQ pain, colicky now constant, 101F and WBC 16KAcute Cholecystitis dx= U/S -> HIDA Mx= surgery
52 M right flank colick sudden, rad into scrtum and micro hematuriaUreteral Colic
Uro EVALget KUB then U/S then IV pyelorgam
59 F 3 episodes LLQ pain, now F and up WBCAcute Diverticultis, DX with CT scan
Diverticultis txacute= ABX/NPO, Recurrent: elective sigmoid resection, non-respond to tx * get emergent resection/colostomy
82 M Abd Dist, N/V, colick. Tympainc bowel hyperactive B sounds, Parrot Beak X-raySigmoid volvulus, get proctosigmoidoscopy or rectal tube
79 M A FIB diffuse tender, acidoticEmbolic mesenteric isch, get eemergent Lap to remove any dead bowel
cirrosisSpironolactone is diuretic of choice
Liver Cirr + vauge RUQ pain and dn lb. up Alpha Feto ProteinHepatocell cx. Get CT and if in one lobe only resect.
RUQ pain, 20lb loss, Palp liver w nodularity, CEA wnl right after his hemicolectomy now it is elevatedmeta from colon to liver, Mx= CT Tx= 1 lobe * resect, otherwise chemo.

Section 3

Question Answer
24 F sudden abd pain, faints, pale tachy dn BPruptured hepatic adenoma 2ndary to OCP, MX: CT scan -> surgery
44 F post acute ascending cholangitis 2nd to choledocolith, now F, up WBC and RUQ pain, U/S show liver abscesspyogenic absesess, IR drains percutaneious
Mexico, F, up WBC, tender liver, jaun, up Alk Phos, Absces liverAmebic Abscess, Mx= Flagyl + amberic serology, do not aspirate pus
42 F jaundic Tbili 6 IndBili 6 DBili0hemolytic jaundice
19yo mexico, maliase weak anorexia jaundic TB 7 IDB 7 DB 5, up up AST/ALThepatocelluar jaundice due to hepatitis, get serology
4 wk progress jaundic TB 22 IDB 6 DB 16, 6x up Alk phosObstructive jaundice, get U/S
40 F Multiparous prog Jaun 4 wk TB 22 INDB 6 DB 16, up alk phos, RUQ colicky pain w fatty foodobstructive jaun due to stone, 1st = US 2nd= ERCP to remove stone from CBD 3rd= cholescystectomy
66 M prog jaundice 6 wk TB 22 DB 16 IDB 6, up alk phose, lost 10 lb 2 mo, dilated bili tree on US and thin walled GBMalignant detructive jaundice, got US now get CT and ERCP
gallbalder is thick walled and non-pliableassoc w stones
66 M 6 wk jaun. TB 22 DB 16 IDB 6, up alk phos. US show thin GB and dil bili tree. CT is negative. ERCP shows a narrow area in the distal common ductcholangio carcinoma of lower end of common ductm get cytological brushings and do a pancreatoduodectomy/
64 F up TB up DB up IDB, up alk phos, anemia, slight poop blood, US dil intraheop duct, thin GBslow GI bleed + obstructive jaundice think Ampullary Carcinoma, Get E-scope with BX then radical srx
56 M up Bilis, UD LFT, lost 20 lb 2 mo, persistent nagging mild pain deep in epigastrumCx of head of panc, get CT and then ERCP. (obstruction of both panc and CBD)
Female Fat Multip 40, repated episodes of RUQ with fatty food, colicky, N and vomitgallstones w bili colic Mx= US and elective cholexcystectomty
43 F obese multip RUQ pain temp 101 WBC 16k, past 2 hours been constantacute cholecystitis
43 F obese, multip, severe RUQ for 3 day, colicky->constant, temp 105. WBC 22k bili is 5 alk phos 20X normalAcute ascending cholangitis. Get US but need emergency decompression of bili tract with ERCP or 2nd due Percutaneous transhepatic cholangiogram
57 M ETOH tx'd for hemorrhagic panc, in ICU 1 wk. Now he spikes fever and has leukocytosisPanc Absess, dx CT, tx drain
49 M ETOH ill defined upper abd disc and ealy satiety. Palp lage epig mass. recent hx of acute pancreatitispancreatic psuedogout, Get CT > U/s Tx= IR darin

Section 4

Question Answer
Post op day 1 open cholesectomy, has 101 Fatelectasis
Post op day 3 open cholesectomy. has 101 FUTI
Post op day 4 open cholesectomy, has 101 F and tender calfDVT, Get Duplex US and put on Anticoag
Post op day 7 ing hernia, has F and wound is red hot tenderwound inf, drain pus, pack open let heal by secondary intention
post op 14 day open cholesectomy, up F up WBC, wound non-infxthink subphrenic or subhepatic absecess, Get CT and do IR percutaneous Drain
Post op day 5 R hemicolec for cx, dressing covered in pink fluidwound dehiscence,