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SURGERY ORAL EXAMINATION REVIEWS Rectal Examination

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					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 RF’s 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
            --Serum Ca2+ / AlkPhos for bone mets                --LFTs looking for liver 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 RF’s 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 pt’s 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 patient’s 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 patient’s 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 ABC’s 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 pt’s 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 RF’s 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 Dx’d 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, Meckel’s?
        --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. Pt’s 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                        --Amylase—not 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 D5½NS +20-40mEq KCl)
          --Place Foley; ideal u/o = 0.5-1.0 ml/kg/hr
   • Objective parameters which lower the threshold to operate in pt’s 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
          --Pt’s 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
          --Pt’s w/ complete SBO should be managed operatively at first UNLESS h/o previous SBO’s
          --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 RF’s 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 0.5–1.0 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. LFT’s 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:
            --Duke’s  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
     --Duke’s 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 Duke’s 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 RF’s 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)    --Pletal—phosphodiesterase inhibitor
           --Exercise—stimulate collateral vessel growth       --Trental—rheologic 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 RF’s 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 RF’s 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 Murphy’s 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 output—foley
           --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 possibilities—get 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.

				
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Description: SURGERY ORAL EXAMINATION REVIEWS Rectal Examination