S01E07: HIGH YIELD GENERAL SURGERY

Check out the full transcript and all of the cited resources used for the show below.

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Hello and welcome to PASPAC Podcast, your Audio passport from Physician Assistant Student to Certified – and beyond – with your host, Rebecca Harrell, MPA, PA-C. Today, our destination is a high yield review of General Surgery based on the EOR topic blueprint. Sit back, relax, and lets get to it

Hey Everyone, It’s Becca and today will be like other days where we do an in-depth overview with case vignettes and wrapping up with our rapid review. As usual, we’ll be going in descending order of content covered on the EOR starting with…

GI/Nutrition (50%)

First, I want to start with a few pointers going about studying for this EOR. Because there is such a heavy focus on GI/Nutrition, I recommend doing as many questions as you can that cover GI on Rosh Review or SmartyPANCE if you have trouble finding a specific question bank dedicated to General Surgery.

Don’t necessarily focus only on surgical intervention techniques and names of specific procedures themselves, but more so indications for certain general or common procedures, pre-op, post-op and historical presentations of surgical emergencies, and so forth. Look at the bigger picture and not just the surgery itself.

That being said, let’s start with our first vignette:

Your adult female patient with history of cirrhosis arrives to the ER with fever, chills, and abdominal pain. Physical exam reveals ascites with shifting dullness. Culture of the ascitic fluid reveals a granulocyte count over 500 and neutrophil count > 250. Given your top differential, what is your initial treatment option?

• Immediate IV Cefotaxime, or 3rd gen Cephalosporin will be your first line treatment for Spontaneous Bacterial Peritonitis

• This is an acute bacterial infection of ascitic fluid that usually occurs in patients who have advanced stages of liver disease, like cirrhosis.

• The pathogenesis behind this infection begins with portal hypertension which leads to to bowel edema that allows the bacteria to migrate to the ascites from the GI tract.

  • This pathogenesis can probably lead you to the most common offending organism in this diagnosis, which is E. Coli.

  • Treat empirically with 3rd gen cephalosporin prior to obtaining culture results.

Your patient with history of atrial fibrillation presents with acute abdominal pain that is out of proportion with his exam. Based on clinical picture, what is the gold standard for diagnosing suspected embolic cause of his acute pain?

Mesenteric Angiography is the gold standard for a patient with suspected Mesenteric Ischemia or Infarction.

• In patients with a history of A-Fib who present with sudden onset of abdominal pain that is out of proportion of their exam, immediately suspect acute mesenteric ischemia.

• The most common cause of acute mesenteric ischemia is from an embolism, which is why atrial fibrillation is a high risk factor.

• Abdominal X-Ray may show “thumbprinting” due to submucosal bleeding

• These patients require immediate surgical evaluation for emergent revascularization and/or resection of necrotic bowel if present.

Your patient is a 55 year old male patient with history of chronic alcohol use who presents with intermittent abdominal pain that radiates to his back with steatorrhea. Physical exam reveals mild jaundice and diffuse abdominal tenderness. Labs reveal normal amylase and lipase and CT of the abdomen reveals pancreatic calcifications. What diagnosis do you suspect?

Chronic Pancreatitis

• This due to chronic, excessive alcohol use 90% of the time and can lead to necrosis and fibrosis of the pancreas, which decreases its overall function resulting in normal or mild elevations of amylase and lipase (which is different than the elevations you see with acute pancreatitis)

• The initial step in treatment is abstaining from alcohol, then patient should be given replacement pancreatic enzymes, pain management, and consider surgery as last measure if requirement for denervation, decompression, and/or resection warranted

• These patients are at increased risk for pancreatic carcinoma and also may present with diabetes due to the destruction of beta and alpha cells

While working in the ER, your 50 year old male patient with 30 Pack-Year-History presents due to epigastric pain, nausea, and darkened color to her urine. Physical reveals a thin patient with generalized weakness and palpable non-tender mass at the right costal margin and palpable, fixed, hard left supraclavicular lymph node. What diagnosis do you most suspect at this time?

Pancreatic Carcinoma

• This is a highly lethal cancer and remains 4th cause of cancer-related death in the US with the most common type also carrying the worst prognosis – which is Ductal Adenocarcinoma

• Suspect this in a patient with family history or other risk factors, such as cigarette smoking

• Patients can present with the symptoms in our vignette or even just painless jaundice

• Courvoisier’s Sign is a high yield physical finding which is the palpation of the distended, nontender gallbladder at the right coastal margin

  • Other HY findings include Virchow’s Node (Left Supraclavicular Node), Sister Mary Joseph Sign (palpable nodule under umbilicus) and Trousseau Syndrome (migratory thrombophlebitis 2/2 hypercoagulability accompanying many cancerous etiologies)

• Mets are most commonly found in the liver, but can also quickly travel to the peritoneum and lungs

• The 1st line imaging for identification is CT, but if patient has jaundice or high suspicion for pancreatic cancer, then TAUS is preferred as first line.

  • Diagnosis and staging can be done with a contrast enhanced CT.

  • The tumor marker to watch for these patients is CA19-9

• The only potential curative modality in these patients is complete surgical resection, such as conventional pancreaticoduodenectomy (Whipple) but most commonly, patient’s present with unresectable disease at time of diagnosis, leading to need for Chemo and/or radiation.

Your 30 year old male patient with BMI 30 presents with chronic pain at the upper midline region of his buttocks. Physical reveals a painful, fluctuant area at the sacrococcygeal cleft. What should be done for acute management at this time?

I & D for acute presentation of Pilonidal Abscess

• Only definitive treatment is surgical excision of all sinus tracts

• If they are asymptomatic and no signs of system infection, manage with patient education for maintaining hygiene and monitor closely for signs and symptoms of developing infection

What acute complication is most associated with the most common bariatric surgery in the US?

Roux-en-Y Gastric Bypass is the most common bariatric surgery which can lead to the complication of dumping syndrome

• Dumping syndrome can present with severe nausea, abdominal pain, and light headedness about 30 minutes following initiation of normal diet after surgery

• The most common late complication of Roux-En-Y is anemia, especially megaloblastic due to B12 deficiency but deficiencies can be seen in all water AND fat soluble vitamins and minerals, like iron

• Management consists of lifelong micronutrient supplementation

Your patient is a 40 year old G2P2 female with BMI 38 who presents to the ER due to intermittent, cramping right upper quadrant pain that radiates to the inferior right scapula. History reveals no sick contacts, but she believes she may have gotten food poisoning from eating at a fast food restraint right before the pain began. Physical exam is unremarkable and labs are unremarkable. What diagnosis do you suspect at this time?

Symptomatic Cholelithiasis, also known as Biliary Colic

• This is most commonly seen with a series of F’ words - fertile female patients in their forties with high BMI following a fatty meal.

• Differentiate from choledocholithiasis which will present slightly more severely with elevated LFTs, ALK PHOS, and typically jaundice.

• Cholecystitis is when a blocked stone in the cystic duct leads to inflammation and infection. Suspect this in a patient with similar risk factors as our vignette that presents with steady and unremitting RUQ pain in addition to a fever. High yield findings for these patients will be positive murphy sign.

• Once a patient develops Cholangitis, you will see an even more severe presentation with Charcot’s Triad, which is RUQ, Jaundice, and fever or Reynold’s Pentad which is the same but with Hypotension and AMS, as we’ve discussed in a few episodes before

• For all your GB differentials, first line imaging is going to be with ultrasound and ERCP as the gold standard for diagnosis/therapeutic intervention with the exception of Cholecystitis which is preferably confirmed using a HIDA scan that would reveal in a gallbladder failing to fill due to obstruction

What should be suspected in a patient with chronic diarrhea and abdominal pain that relieves with defecation?

Irritable Bowel Syndrome

• This is due to an intestinal motility disorder that can lead to change in bowel habits with no identifiable organic cause. Can present with constipation, diarrhea, or mix of both back-and-forth

• This is a diagnosis of exclusion and can be supported by the Rome III Diagnostic Criteria

• Management depends on the predominating symptom – either pain, constipation, or diarrhea

  • Remember conservative lifestyle modifications first like FODMAP diet initiation or behavioral changes are usually initiated first

• For pain, you can try an antispasmodic like dicyclomine but SSRIs, TCAs, and even motility reducing antibiotics can also be considered

• Constipation responds to osmotic laxatives and Lubiprostone or Linaclotide

• Diarrhea can improve with antidiarrheal agents, like loperamide (aka Imodium, peripheral opioid antagonist), bile acid sequestrants, and even Serotonin 3 Receptor Antagonist like Alosetron are also approved

(you might be asking, "Why are you talking about IBS in a general surgery episode?" Well, remember what I said before. The big picture should be looked at when studying for general surgery - and this includes knowing when surgery IS and IS NOT warranted. For example, surgery may be warranted in a patient with IBD or acute abdomen, which might be a differential given the IBS presentation, and you need to know that the condition is likely non-surgical and how to treat instead)

Your patient is a 66 year old female who presents with acute left lower quadrant pain, fever, nausea, and vomiting. Physical exam is notable for rebound tenderness in the LLQ with guarding and abdominal rigidity. Abdominopelvic CTA shows colonic bowel wall thickening > 4mm with fat stranding and colonic pouching. With exception to fever and slight tachycardia, vital signs are other wise normal and she appears hemodynamically stable. What is the treatment recommended at this time?

For acute, uncomplicated diverticulitis you can prescribe short course of antibiotics like Pip-Tazo inpatient or if really, really mild presentation can consider 7-10 day course of Ciprofloxacin with metronidazole.

• Patients should be instructed to decrease fiber during acute period and after resolution, should be instructed to begin long-term increased fiber

• If patient has complicated diverticulitis, such as severe and persistent symptoms despite antibiotics or hemodynamic compromise, initiate bowel rest and consider surgery for possible perforation or abscess

• Don't forget, colonoscopy is contraindicated in suspected diverticulitis

While working on your gastroenterological surgical rotation, you are consulted to evaluate a 45 year old male patient in the ER who presented with persistent abdominal pain, history of progressive dysphagia, and weight loss. History reveals progressive early satiety and recurrent post-prandial vomiting. You are able to palpate a left supraclavicular node and a fixed, hardened mass at the epigastrium and deep to left anterior costal margin. His skin exam reveals acanthosis nigricans. What should you do to establish diagnosis?

EGD with biopsy

• Histology for Gastric Carcinoma commonly shows Signet-Ring Cells

• 95% Gastric Carcinomas are adenocarcinomas and risks include h. pylori infections, smoking, and excessive salt diet.

• As with pancreatic cancers and other metastatic lymph infiltration, you may palpate Virchow’s Node or other palpable lymph nodes.

• Gastric Carcinoma is associated with paraneoplastic syndromes, such as Acanthosis Nigricans, Seborrheic Keratosis, and Hypercoagulability resulting in Trousseau-Migratory Thrombophlebitis

  • Differentiate with pancreatic carcinoma with historical findings of dysphagia and early satiety +/- presence of linitis plastica (rigidity of the stomach due to malignancy) because physical exam may appear similar to pancreatic carcinoma. If patient has jaundice, suspicion should move toward pancreatic carcinoma.

• Gastric carcinomas are associate with a high yield metastasis to ovary, known as Krukenburg’s Tumor

• Surgery is the only curative option in gastric carcinoma, but once hepatic artery or other vasculature is infiltrated, the malignancy is considered unresectable.

Your patient is a 23 year old female who presents with scant hematemesis following a night of excessive vomiting after going to a party. Considering her stability, EGD is performed following acquisition of IV access and visualization of longitudinal, non-penetrating mucosal tears are visualized at the GEJ. Should bleeding persist, what treatment options should be considered?

While condition is normally self-limited, if the tear does not heal spontaneously – consider endoscopic hemostatic therapy – Like Epinephrine, and/or cauterization + acid suppression therapy

• Can also give patients with Malloy-Weiss Tears antiemetics to prevent re-bleed

• Most cases will resolve on their own by 72 hours

• Regardless of etiology for upper GI bleed, ensure patient is stable and get your IV access right away

Your 57 year old patient with a PMHx notable for Hepatitis C arrives to the ER due to rapidly accumulating ascites. Physical reveals hepatomegaly. He has no fever and aspiration reveals sanguineous fluid. liver. What tumor marker do you suspect is elevated in this patient?

AFP – nonspecific but is the tumor marker associated with Hepatocellular Carcinoma

• The most common cause of HCC is Cirrhosis of all etiologies but most commonly due to Viral Hepatitis (both B & C) with alcoholic cirrhosis trailing behind

• Hepatocellular carcinoma is the most common cause of primary malignancy in the liver, but this remains rare in the US where we usually see liver malignancy as a result from distant mets

Your patient is a 22 year old male presenting with pain in the left lower quadrant following progressively worsening loose stools intermixed with with mucous and blood. He has decreased bowel sounds, fever, tachycardia, and abdominal distension. Abdominal radiograph is notable for colonic dilation > 6 cm and labs note neutrophilic leukocytosis. His blood pressure is dropping and he’s becoming increasingly altered. What is the first step in treating this patient?

Fluid Resuscitation and decompression of the colon via bowel rest and NGT

• Emergent surgical consult is required at admission in a patient with suspected Toxic Megacolon, which is a life-threatening complication of Ulcerative Colitis

• Suspect in a patient with history or clinical presentation of UC who presents hemodynamically unstable and/or has severe bloody diarrhea that is resistant to treatment

• In patients with hypotension, first line includes fluid resuscitation, once medically stable – colectomy is considered curative for UC

Your patient with history of alcoholic liver disease presents with weakness, fatigue, and weight loss. Physical reveals spider angiomas, palmar erythema, and muscle atrophy. Hepatomegaly and ascites is noted as well. What medication could be provided to the patient to reverse the sodium retention and conserve potassium to diuresis his ascites?

Spironolactone, which is an aldosterone antagonist

• Also advise salt restriction and consider paracentesis

• This patient has signs and symptoms of Cirrhosis which is most commonly caused by alcoholic liver disease in the US and can present with signs/symptoms of portal hypertension, ascites, hepatorenal syndrome, spontaneous bacterial peritonitis, and/or HCC

Your 2 month old patient presents with her parents due to nonbilious projectile vomiting immediately after eating with persistent signs of hunger. There is a small, palpable mass at lateral edge of rectus abdominis and ultrasound reveals a thickened pyloric muscle. What would you expect ABG to show?

Metabolic Alkalosis secondary to hypochloremia and hypokalemia due to progressive vomiting

• This diagnosis is Pyloric Stenosis which is most commonly idiopathic and should be suspected in any young infant with projectile vomiting immediately after eating.

  • Because the pyloric sphincter is thickened, there will be no bile in the vomit because it will not be able to get through from the duodenum, just like the food can’t get through from the stomach.

• Treatment should focus on electrolyte imbalances first with subsequent pyloromyotomy

We’ll touch on a lot high yields for GI in the rapid review, but lets move onto Preoperative and Postoperative Care which makes up 12% of the EOR

PRE-OP/POST-OP CARE (12%)

Your patient with history of CAD is a possible surgical candidate for an elective procedure. 12 lead EKG is normal, but what should be done prior to surgery to rule out possible cardiac ischemia?

Stress Test

• Nuclear ST can be done prior to noncardiac operations for those with active cardiac comorbidities or risk factors

• In patients with significant CAD, including unstable angina, coronary revascularization should be performed prior to any noncardiac operations and elective surgeries should be avoided

• In patients with history of prior cardiac infarct, there is a 5-10% risk increase for post-operative MI

Your patient is a 45 year old male with PMHx HTN and CAD who presents to the ER with fatigue, shortness or breath, and dizziness on and off for a few weeks that has progressed and now has been persistent for the past 2 days with a feeling of fluttering and skipped heart beats. EKG reveals irregularly irregular rhythm with no identifiable P waves. His vitals are within normal limits at this time and rate control is achieved with diltiazem. What additional diagnostic imaging is warranted before additional procedures are pursued?

Echocardiogram

• Echocardiogram is indicated for patients with atrial fibrillation in order to rule out valvular heart disease and evaluate heart size, function, and identification of possible thrombus.

• TEE is additionally required if the patient has been in Afib > 48 hours

• CHAD2DS2-Vasc Score should be used to determine risk of anticoagulation bleed vs. stroke in a patient with Afib.

• If the patient presents with paroxysmal a-fib within 48 hours of onset, consider TEE to rule out thrombus and perform a cardioversion at presentation.

• If warranted by CHADVASC - Anticoagulation should be onboarded for at least 21 days before scheduling patient for synchronized cardioversion

• However, if the patient is unstable the first line treatment is cardioversion ("unstable gets the cable")

Your patient with PMHx of diabetes and advanced renal failure is admitted inpatient after surgical amputation and revascularization of his lower extremity. While running post-operative rounds, you note new onset muscle weakness and flaccid paralysis in his upper extremities. Telemetry monitor shows bradycardia with peaked ST-segment elevations. What diagnosis do you most suspect?

Hyperkalemia

• Hyperkalemia is the most dangerous acute electrolyte abnormality.

  • Patients with renal failure, in particular, are at increased risk, especially with administration of a potassium sparing diuretic, such as Spironolactone.

• Other causes of post-operative hyperkalemia include malpositioning leading to rhabdomyolysis, vascular procedures in the setting of tissue ischemia, hypovolemia, acidosis – just to name a few.

  • Additionally, patients may develop post-operative hyperkalemia during or within 24 hours of stopping IVF due to intravascular/cellular fluid shifting.

• In patients hyperkalemia in the setting of renal failure or acidosis, symptomatic, or ekg changes, AND/OR, even asymptomatic with extreme elevations of potassium, aka > 6.5 mEq/L urgent treatment is indicated.

  • However, if there is a strangely elevated potassium in an asymptomatic and extremely low risk patient, consider repeat of blood work to rule out hemolyzed sample due to lab/retrieval error.

• If urgent treatment IS indicated, administer IV calcium gluconate which will stabilize myocardial conduction.

  • Remember, this has no effect on the actual potassium level itself. To do this, you need to give insulin +/- glucose to shift excess extracellular potassium back into the intracellular space.

• If the patient has life-threatening hyperkalemia and is not responding to medication or advanced renal failure is present, hemodialysis is indicated

• If urgent treatment is not indicated, you may be able to achieve lowering total body potassium by initiating exchange resin like Kayexalate, loop diuretics in those with ok renal function, and stopping all potassium-containing fluids like lactated ringers, discontinuing any potassium sparing diuretics or other medications that can raise serum potassium like ACES/ARBs and initiate a low sodium diet.

(Alternatively, When we think about Hypokalemia following surgery, which is the most common electrolyte abnormality, the #1 complication to remember is the development post-op ileus)

On Post-Op-Day 1, following a long surgery, your patient develops extreme nausea and recurrent vomiting. Should the post op nausea and vomiting remain severe and uncontrolled, what acid-base complication is she at risk for?

Metabolic Alkalosis

• Remember how I remember it – vomiting out all your stomach acid leads to an overall alkalotic state

• Post op N/V is common on POD1, especially with history of easy GI upset like those with motion sickness or hx chemo-induced n/v

• Prior to discharge, the N/V should be controlled which can usually be accomplished with antiemetics like scopolamine, ondansetron, etc.

Following a prolonged surgery, your 65 year old female patient with BMI 30 develops unilateral lower leg edema with overlying warmth, tenderness, and calf pain with passive dorsiflexion. What is the preferred first line imaging modality to evaluate for your top differential?

Ultrasound with Doppler compression is preferred modality for those with high pretest probability of DVT using Well’s Criteria.

• If there is low suspicion for DVT, screening can be done with D-Dimer, but any suspicion at all should indicate Ultrasound.

• If asked for the gold standard modality, the answer would be venography – however, this is invasive and generally not performed.

• ¼ of patients without VTE prophylaxis will develop DVT post-operatively

• Proximal DVT can occur in the peripheral femoral or iliac veins leading to signs affecting entire limb vs Isolated Distal DVT may be only symptomatic below the knee.

• This diagnosis should be suspected in a patient with history of immobilization, recent surgery, prior VTE events, malignancy, increased estrogen therapy like OCP/HRT or pregnancy/postpartum.

• High yield physical maneuver includes the Homan’s Sign which is calf pain with passive dorsiflexion, however the absence of this does not rule out DVT.

• Prophylaxis for DVT includes pre-op LMWH or LDUH, intraoperative sequential compression devises (aka SCD’s) or intermittent pneumatic compression (IPC), early ambulation postoperatively and use of compression stockings.

• In patients with confirmed proximal DVT, treatment with anticoagulation is warranted.

  • In those with distal DVTs, only treat symptomatic patients if bleeding risk is low.

  • In patients with high risk of bleeding leading to anticoagulation contraindication, such as active bleed (including GI bleed), platelet count < 50k, major trauma, or history of intracranial bleed, use of an IVC filter should be utilized over anticoagulation

Your 75 year old male patient is 4 hours s/p anorectal surgery and has been unable to urinate. Ultrasound of the bladder detects 600 mL of fluid in the bladder. After indwelling cath removal, there is still 300 mL retention. What should be done at this time?

Intermittent catheterization

• Patients at risk of post operative urinary retention are older men with history of urinary retention, neurological disease, pelvic or anorectal surgery, prolonged anesthesia, etc.

• There will typically be symptoms related to bladder fullness leading to lower abdominal discomfort

• First line and preferred method of diagnosis is with Bladder Ultrasound and bladder catheterization should be done if still unable to void 4 hours post-op and >600 mL retained urine is visualized on ultrasound.

• You can leave the catheter in place if it drains 400 or more mL and then remove before discharge or switch to intermittent cath if there is still retention < 600 mL

• In patients with operations over 3 hours or high risk due to intravenous fluid administration, prophylactic catheterization should be done

Your diabetic patient returns to your clinic post-operatively after ORIF on his tibia 12 days ago. He is complaining of increasing pain and you visualize purulent drainage through his incision in the setting over overlying erythema and localized warmth. What is the first line treatment for top differential?

Utilize primary source control by removing sutures and inspecting SSI

• Pain is the most sensitive indicator for SSI, especially when considering risk factors for diabetes/immunosuppression, smoking, etc.

• While similar, don’t confuse SSI with wound dehiscence which results in partial or total disruption of the operative wound.

  • The most important risk factor for this is inadequate closure.

Alright, we’ll get into more pre/post op later but lets keep it moving with Cardio, accounting for 9% of the EOR

CARDIOVASCULAR(9%)

Your 43 year old male with PMHx HTN presents with sudden “knife-like” pain immediately behind his sternum which seems to radiate all the way to his back. Physical reveals a decrescendo murmur along his right sternal border. Pulse pressure is widened and you note asymmetry of both pulse strength and blood pressure. What imaging modality will confirm your suspicion for top differential?

CT-Angiogram is the confirmatory imaging of choice for Thoracic Aortic Dissection, additionally this can be used to identify between ascending vs. descending origin.

• CTA will reveal dissection by visualizing the intimal flap separating the true aortic lumen from the false lumen.

  • Other modalities, that are typically quicker and may be used initially if waiting on CTA includes CXR which reveals widened mediastinum and transesophageal ultrasound.

• Hypertension is the most important risk factor for this life-threatening cardiac differential.

  • Other risk factors to remember are collagen disorders, like Marfan Syndrome and Ehlers-Danlos Syndrome, turner syndrome, bicuspid aortic valve, pregnancy, and family history of thoracic aortic dissection.

• In patients found to have a Stanford type A (A=ASCENDING) thoracic aortic dissection, this is a surgical emergency due to risk of aortic regurgitation, cardiac tamponade, frank rupture, stroke, MI, and death.

• Descending dissections (Type B) can be treated with blood pressure control, imaging monitoring, and/or endovascular repair.

  • Blood pressure should be reduced to the LOWEST tolerable level, and HR should be reduced as well.

  • You can use IV BBs for rate control FIRST and then nitroprusside for bp reduction after. Don’t forget pain control measures as well.

Your 72 year old male patient with 40 pack-year-history and BMI of 33 arrives to the ER due to dull pain in lower extremities with crusting and weeping irregularly bordered ulcerations on his medial malleoli. Physical reveals the ulcer wound bed is beefy red, granulated and there is surrounding. Anterior shins also exhibit brown hyperpigmentation with dermatitis. What diagnosis do you suspect?

Venus Stasis Ulcers and Stasis dermatitis from chronic venous insufficiency.

• These signs and symptoms should make you suspicious of venous involvement more than arterial involvement.

• In venous ulcers, borders are typically irregular and can occur on either medial or lateral malleoli, but medial is more common.

  • Other symptoms of Chronic Venous Insufficiency can include pruritis, edema, and history of varicose veins or other VTE.

• Diagnosis is clinical, but ultrasound should be ordered to rule out DVT or D-Dimer to rule out if low DVT suspicion.

• Treatment for venous insufficiency is compression first and foremost, with compression socks/stockings.

  • Also, leg elevation and exercises should be advised.

  • Wound care management as needed for venous ulcers should be implemented, along with compressive stockings/bandages.

  • In those with stasis dermatitis, topical medium potency corticosteroids, like Triamcinolone cream, can be beneficial.

• In arterial ulcers from PAD/PVD, ulcer borders are typically regular and/or rolled in / look “punched out” and are most commonly located on lateral malleoli and on the tops of the feet/ toes.

  • There will also be signs and symptoms more consistent with peripheral arterial disease, such as LE pallor and claudication.

• Had the patient had peripheral arterial disease, ankle-brachial index can be utilized to compare upper and lower extremity blood pressure using doppler ultrasound flow.

  • ABI < 0.9 indicates PAD and <0.4 indicates limb-threatening ischemia.

  • In patients with diabetes, especially, be weary of false ABI readings due to calcified arteries.

  • If asked for gold standard diagnostic modality for PAD, the answer would be angiography.

We’ll touch on more cardio HY in rapid review, but now lets move onto Endocrine which makes up 8% of the Gen Surgery EOR

ENDOCRINE (8%)

Your 33 year old female patient presents with unintentional weight loss, increased anxiety, and diarrhea. She states she feels she is constantly hot and sweating and feels jittery and tremulous all the time now. Physical reveals proptosis, brittle nails, and tachycardia. Labs reveal a low TSH and high T3/T4. Aside from elevated heart rate, her vitals are stable and she does not appear hemodynamically compromised. What treatment do you recommend for this patient’s symptom management?

Symptoms, resulting from the increased adrenergic tone, are typically improved using Beta-Blockers, like atenolol.

• To treat disease process itself, Antithyroid trugs like methimazole or propylthiouracil should be started in patients with Hyperthyroidism.

  • In those with multinodular goiter or benign thyroid tumor leading to hyperthyroidism, consider radioactive iodine ablation in adult patients that are non-pregnant without a suspicious nodule.

  • If those exist or patient is generally noncompliant or refractor to medications, surgical thyroidectomy should be performed.

• In surgery, be sure to avoid damaging the recurrent laryngeal nerve, which can lead to hoarse voice if unilateral nerve damage occurs but can occlude the airway from vocal cord paralysis if both are damaged.

• In addition to initial TSH/T4 labs, Ultrasound is useful for visualization of nodules/cysts

  • Radioactive iodine uptake testing can be used to determine underlying etiology of hyperthyroidism, such as Graves’ disease or thyrotoxicosis with diffuse uptake, Multinodular Goiter with heterogenous uptake, or “Hot” Nodule in hyperfunction adenoma. However, ensure the patient is not pregnant in the stem before choosing that answer.

• The most common cause of hyperthyroidism is Graves’ Disease, which is due to autoimmune anti-thyrotropin antibodies that stimulate the TSH receptors, leading to hyperactive synthesis and secretion of thyroxine from thyroid

  • The negative feedback loop of elevated thyroid hormones will cause TSH to be low, but because the receptors are constantly turned on by the autoimmunity, the thyroid will continue to produce and secrete thyroxine, leading to this hyperactive metabolic state which results in a lot of the symptoms we see.

• Whenever you see a stem that has a female with proptosis/exophthalmos, you should have a high suspicion the answer is going to be something primary hyperthyroid related.

  • Other findings that might be included in the stem include irritability, increased appetite, hyperreflexia, pretibial myxedema, and enlarged thyroid gland.

• Ensure the patient is hemodynamically stable.

  • If the same patient came into the ER with fever, weakness, restlessness, confusion, NVD, jaundice, and/or hemodynamic compromise - you should be highly suspicious of Thyroid Storm which is a life-threatening, acute hyperthyroidism from untreated or undertreated hyperthyroidism, regardless of the etiology.

Your 42 year old female patient presents with dysphagia and progressive hoarseness. Physical exam reveals a palpable unilateral thyroid nodule. Ultrasound is notable for a hypoechoic mass with irregular margins and microcalcifications that is 2cm tall and 1cm wide. FNA reveals psammoma bodies following a cold thyroid uptake scan. What is your top differential?

Papillary Thyroid Carcinoma

• This is the most common and least aggressive thyroid carcinoma.

• Suspect this in patients with risk factors including assigned female at birth between 40-60 years old, history of radiation to the head/neck, or familial tumor syndromes like MEN-2.

• Ultrasound is the initial imaging modality of choice in a patient with palpable thyroid nodule.

  • Suspicious findings were outlined in our stem, especially with a nodule that is taller > wider.

  • In the setting of normal/elevated TSH and thyroid scan revealing a cold (non-functioning) nodule, you need a fine needle aspiration.

    • Alternatively, If the TSH is decreased then perform radio nucleotide thyroid scan to evaluate for any functioning.

• Surgical resection for papillary thyroid carcinoma is the preferred treatment, with either total thyroidectomy or thyroid lobectomy.

  • Radioiodine therapy can be considered for non-surgical candidates.

• High yield surgical complications for any surgical resection of the thyroid includes hypocalcemia from iatrogenic parathyroidectomy in process of thyroid resection and/or recurrent laryngeal injury as we have already discussed.

Okay, lets move onto our last vignette sections before our mixed rapid review, which will be one vignette each for Dermatology, Neurology, Urology / Renal which make up 5% of the EOR each. We will mix the remaining sections of Hematology, Pulmonology, and some OBGYN in with our rapid review at the end.

DERMATOLOGY (5%)

Your patient is a 43 year old female who presents with an itchy and growing mole on left calf that is asymmetrical with irregular borders, mixed colors of black and brown, and measures ~7 mm in diameter. What is the preferred diagnostic and treatment modality for suspected diagnosis?

Excisional Biopsy

• Excisional Biopsy is preferred when you find a lesion that is highly suspicious of Melanoma due to its deadly prognosis.

  • While melanoma is the least common skin cancer, it carries the highest mortality if missed.

• If the melanoma is >1mm thick, wide excision with 2cm margin is indicated, whereas melanomas < 1mm thick are indicated for 1cm margins.

• Depth is your most important prognostic factor in melanoma, which is why, if excisional biopsy is not performed or a choice in the answers, the next option choice for biopsy should be punch biopsy. If both are included as answer choices, choose excisional.

• The ABCDEs of melanoma are useful when both evaluating suspicious nevi and also educating your patients when discussing self-skin exams.

  • This acronym stands for Asymmetry, Borders (irregular), Colors (mixed), Diameter (> 6mm or the diameter of a pencil eraser), and Evolving (growing)

NEUROLOGY (5%)

Your 61 year old female patient with PMHx PCKD and 15 PYH presents to the ER with a severe headache that began suddenly while she was running this morning and has been unrelenting. Physical reveals stiff neck and she is extremely sensitive to the light. She denies any head trauma or known cause. What diagnostic study should be pursued first?

Non-contrast CT of the head

• In a patient with subarachnoid hemorrhage, non-contrast CT should be used to diagnosis which will reveal blood that involves the sulci.

  • If the CT is non diagnostic and you still have a high suspicion of SAH, LP should be performed which will reveal xanthochromia (yellowish CSF due to hemoglobin degradation products) and an increased opening pressure due to ICP

• The most common cause of SAH is a ruptured saccular (berry) aneurysm and the most common location is at the bifurcation site of the anterior communicating artery in the circle of Willis.

• Patients will classically present with “the worst HA of their life” that is non-traumatic in nature.

  • There can occasionally be mention of comorbid polycystic kidney disease, turner’s syndrome, or cocaine use – which are all risk factors for intracranial aneurysms and rupture.

• These patients should be given nimodipine, which is a CCB, that will prevent vasospasm and decrease hypertension, which has been proven to reduce mortality.

  • Be careful not to reduce BP too much or you risk cerebral hypoperfusion.

  • Additionally, the patient should be considered for surgical management such as clipping / occluding aneurysms +/- embolization or resection of AV malformations.

• Subarachnoid hemorrhages should be differentiated from other high yield intracranial hemorrhages, like epidural hematoma and subdural hematoma – which are both usually associated with traumatic etiology.

  • The presentation of epidural hematoma is unique due to the lucid interval that is sandwiched between an initial LOC following trauma to the temporal bone/middle meningeal artery and progressive neurological deterioration.

    • Non-contrast CT will reveal lens-shaped or “lemon” shaped bleed due to hemorrhage being contained within the suture lines.

  • Alternatively, Subdural Hematoma, which is more common than epidural hematoma – will uniquely present after a traumatic injury or, if chronic, due to a non-traumatic or slow bleed.

    • Patients are usually older, or alcoholics, with history of recent fall that have a progressive headache with slow neurological deterioration due to rupture of bridging veins.

    • Non-Contrast CT will show a crescent shaped or “banana” appearance of the bleed due to extension beyond suture lines.

UROLOGY/RENAL (5%)

Your 23 year old male patient presents with severe left lower flank pain that is radiating to the groin, nausea, and vomiting. He is writing in pain and states he has been “bleeding blood”. Helical CT scan without contrast confirms suspected diagnosis of Nephrolithiasis with acute ureter obstruction at the uterovesical junction. The obstructive stone measures 8.2 mm. What is the treatment of choice?

Lithotripsy for stones > 8mm or emergent decompression in patients with high risk factors like solitary kidney, complete obstruction, or sepsis

• In patients with non-obstructive stones that are < 5mm in diameter, discharging home with analgesics is warranted with outpatient follow up as these will likely pass spontaneously

• Urologic consultation with possible admission should be considered if any complicating features are present, such as uncontrollable pain, fever, history of transplant, or any significant comorbidities.

Okay, we have made it to our rapid review which will cover a mix from all the sections plus some HY from the topics we have not covered yet, including hematology, pulmonology, and OBGYN.

RAPID REVIEW

1. What is the most common underlying conditions increasing risk for Atrial Fibrillation?

a. Hypertension and Coronary Artery Disease

b. Other risk factors include binge drinking (“holiday heart”), age, and rheumatic HD

2. What are surgical indications for PUD?

a. Perforation

b. Ulcer over 3 cm

c. Refractor Ulcers

d. UGI Bleed

e. GOO

3. What should you suspect with a teenage male presenting with scrotal pain and swelling with an absence of cremasteric reflex?

a. Testicular Torsion

4. What are the “Six Ps” for Acute Arterial Occlusion

a. Paresthesia, Pallor, Pain, Pulselessness, Paralysis, Poikilothermic

b. Paralysis and loss of sensation are both late findings, along with gangrene

5. What electrolyte disorder should be suspected in a patient with fatigue, diffuse myalgias, abdominal pain with GI upset, anxiety, and hallucinations?

a. Hypercalcemia

b. Memory Aid: Aching bones, renal stones, abdominal moans, & psychic overtones

6. What are the features of a 2nd degree (partial thickness) burn?

a. Tender, red skin, and blistered

b. In first degree, presentation may be similar but the skin will blanch with pressure and no blisters are present. 3rd degree is typically non tender with burned tough/leathery skin. 4th degree should be diagnosed when burn extends into muscle and bone.

7. What triad of symptoms should be indicative of renal cell carcinoma?

a. Flank pain, hematuria, flank mass – remember renal ultrasound or CT followed by Biopsy is the gold standard for diagnosis of this cancer

8. What vitamin deficiency is commonly seen in alcoholics presenting with confusion and potentially confabulation?

a. Vitamin B1 (Thiamine)

9. What tumor marker is associated with Medullary Thyroid Carcinoma?

a. Calcitonin

10. What should you suspect in a patient with COPD who presents with ABG of pH 7.32, PCO2 42, and HCO3 of 29?

a. Compensated Respiratory Acidosis

11. What should be suspected in a patient following trauma surgery resulting in significant blood loss who develops tachycardia and hypotension?

a. Hypovolemic Shock

b. Look to Hgb to determine if hypovolemic shock is due to blood loss vs. fluid loss. High/Normal Hgb = Fluid Loss; Decreased Hgb = Blood Loss

12. What is the most common location for a pressure ulcer?

a. Sacrum; MCC = Immobility

13. What tumor marker is associated with Colorectal Carcinoma?

a. CEA

14. What post-operative complications in patients with hepatic disease can be related to ascites?

a. Wound dehiscence and hernias

b. In those with hepatic encephalopathy, clinical deterioration can occur from sedatives and analgesics

15. What is the definitive treatment for primary hyperparathyroidism?

a. Parathyroidectomy

16. When is transurethral resection warranted for a patient with Benign Prostatic Hyperplasia?

a. After 2 failed voiding trials

17. What is the most common cause of an incisional hernia?

a. Wound Infection

18. What is the treatment for a pt with transient visual disturbances who is found to have carotid stenosis > 70%?

a. Carotid Endarterectomy indicated for symptomatic carotid disease > 70%. If asymptomatic, carotid endarterectomy is indicated at 80+ % stenosis.

19. What diagnosis is suggested by pneumatosis intestinalis on abdominal imaging?

a. This is indicative of Ischemic colitis as evidenced by gas in the bowel wall, a sign of ischemia

20. What is the most common cause of cellulitis?

a. Staph Aureus

21. What is the first line treatment for a male patient with painless, hard, fixed scrotal mass that is found to be a stage I seminoma?

a. Orchiectomy

22. What should be suspected in a teenager with history of menorrhagia who presents with pagophagia, koilonychia, and low serum ferratin?

a. Iron Deficiency Anemia

23. What signs and symptoms are suggestive of hypocalcemia?

a. Tetany, muscle cramping, and perioral/paresthesias of fingers

b. Don’t forget your high yield signs like Chvostek’s (facial contraction with tapping facial nerve) and trousseaus sign (carpal spasm w compression)

24. What diagnostic test should be done on a patient with inflammation and erosion of the gastric mucosa without response to standard GERD therapies?

a. EGD with Biopsy

b. Urea Breath Test in clinic for H. Pylori if available

c. Also, the gold standard for diagnosis celiac disease – blunting of microvilli (aka villous atrophy)

25. What is considered first line therapy for coronary artery vasospasm in a patient without ASC?

26 Nitrates during acute event and CCBs like Amlodipine and/or long acting nitrates for long term therapy

27. What is the first line treatment for patient with area of the skin that is red, edematous, warm, and fluctuant with/without spontaneous drainage and fever?

a. I&D for cutaneous abscess is first line

28. What is considered gold standard for diagnosis of Pulmonary Embolism?

a. CT Pulmonary Angiogram

b. In those with low clinical suspicion, can get D-Dimer to rule out

c. High clinical suspicion, but less invasive than CTPA, can get Helical CT scan WITH contrast

29. What diagnosis should be suspected in a middle aged adult male patient with abdominal pain, diarrhea, and heartburn in the setting of an elevated serum gastrin level despite PPI and H2 blocking therapy?

a. Zollinger-Ellison Syndrome

b. Gastrin-producing endocrine tumor

30. What diagnosis presents with history of menorrhagia, easy bleeding from gums, and labs revealing normal platelet count, PT, and aPTT with prolonged bleeding time?

a. Von Willebrand Disease – Most common inherited bleeding disorder (AD)

31. What are some unique clinical characteristics of epididymitis?

a. Gradual scrotal pain with positive Prehn sign (pain relief with elevating testicle), and normal cremasteric reflex

32. What does post op hyperglycemia increase risk for?

a. Surgical Site infection

33. When should you suspect Pancoast Syndrome?

a. Horner’s Syndrome (Ptosis, Miosis, Anhidrosis) with shoulder pain from lung cancer at the apex

b. Don’t confuse with Superior Vena Cava Syndrome which is when the tumor pushes on the SVC leading to facial and arm swelling/redness

34. What should you suspect in a patient with multiple painful genital ulcers with painful inguinal LAD?

a. Chancroid, 2/2 Haemophiles ducreyi

35. What is the best marker for nutritional status, especially in a patient with suspected preoperative malnutrition?

a. Albumin/ Pre-Albumin

b. Malnutrition prior to surgery increases risk of refeeding syndrome, an electrolyte derangement due to huge intracellular shifting of electrolytes when normal diet is resumed leading to hypophosphatemia, hypokalemia, and hypocalcemia

36. How is breast cancer definitively diagnosed?

a. Core needle biopsy following diagnostic mammography

37. What treatment should be given to a patient with history of chronic liver disease and new onset mild cognitive impairment with asterixis?

a. Lactulose

b. Treatment of hepatic encephalopathy which results from build up of ammonia which crosses the BBB leading to cerebral dysfunction and can be acutely worsened by constipation

38. What are some associated complications from Acute Pancreatitis?

a. Pancreatic Pseudocysts and infectious pancreatic necrosis

39. What should be suspected in a middle aged patient with hearing loss, tinnitus, and vertigo?

a. Acoustic Neuroma (aka Vestibular Schwannoma)

40. What is considered first line pharmacotherapy for gastroparesis?

a. Metoclopramide

41. Which location of an anal fissure should raise suspicion for Crohn’s Disease or another systemic pathology?

a. Lateral

42. What preoperative antibiotics provide pseudomonas coverage in patients undergoing surgery to the small intestine?

a. 3-4th gen cephalosporins like ceftazidime or cefepime

43. What physical findings are associated with hypomagnesemia?

a. Hyperreflexia, weakness, risk of torsades – so you’ll see that prolonged QT with widened QRS and possible VT

44. What is the most common swallowed foreign body?

a. Coin

b. Usually in pediatrics

c. CXR can reveal location – if AP/PA shows flat side, then esophageal – if lateral view shows flat side of coin – then in trachea

d. If battery is swallowed and stuck in the esophagus, immediate endoscopic removal is warranted to prevent corrosive perforation

45. What is the initial medication of choice in patient with pheochromocytoma that is not in an acute crisis?

a. Phenoxybenzamine > Phentolamine (alpha-blockade) first. Then beta blockage.

b. You can use phenoxybenzamine for 10-14 days prior to surgical resection of this adrenal neuroendocrine tumor

46. What confirms diagnosis of Achalasia?

a. Esophageal Manometry

b. Upper endoscopy should be performed prior to medical or surgical management as the gold standard for ruling out malignancy

47. What should be considered to give pre-operatively in a mild-moderate persistent asthmatic patient to prevent post-operative exacerbation of bronchospasms?

a. Add ICS to SABA preoperatively

48. What is the imaging modality of choice for evaluating an acute stroke?

a. Non-Contrast CT – differentiates hemorrhagic stroke from ischemic stroke

49. What is the most common cause of upper GI bleeding overall?

a. Peptic Ulcer Disease

b. MC secondary to H. Pylori > NSAIDS

c. Suspect in patient that has deep, gnawing pain after eating (if gastric) or relieved with eating (if duodenal)

50. What is commonly used as treatment for neuropathic pain?

a. Gabapentin and pregabalin

51. What laboratory findings are associated with DIC?

a. Decreased plasma fibrinogen and platelets with elevated D-Dimer, PT, and PTT

52. What is the mainstay of symptomatic therapy for anorectal fistula?

a. Surgery goal of surgery is to eradicate fistula while preserving fecal continence

53. What treatment should be considered in a patient with esophageal spasms?

a. CCBs

54. Which sign of acute appendicitis presents with right lower quadrant pain when passively flexing/rotating hip?

a. Obturator

b. Don’t confuse with psoas sign with is RLQ pain on hip extension or Rosving’s which is pain in RLQ when LLQ is palpated

55. What diagnosis should be suspected in a patient with obstipation and intolerance of PO intake following abdominal surgery?

a. Post-operative Paralytic ileus

56. What type of hernia travels under the inguinal ligament medial to femoral vessels?

a. Femoral Hernia

57. When should patients with tobacco use, disorder be encouraged to quit smoking preoperatively?

a. 4 weeks pre-op

58. What is usually the first manifestation of Myasthenia Gravis?

a. Ocular symptoms like ptosis, diplopia, and blurred vision

59. What is the most common cause of hypothyroidism?

a. Hashimoto’s Autoimmune Thyroiditis

b. Suspect in patient with cold intolerance and weight gain, generalized weakness, periorbital edema, and fatigue.

60. What is the difference between incarcerated hernia and strangulated hernia?

a. Incarcerated is irreducible

b. Strangulated is incarcerated with s/sx ischemia and/or obstruction – suspect when there is overlying erythema, fever, and abdominal distension or even peritonitis

61. How can claudication be treated?

a. Platelet inhibitors like ASA, Plavix for PDA plus Cilostazol (PDE inhibitor) can treat claudication pain. Statin therapy should initiate and revascularization should be considered. In patients with significant PAD, surgical bypass can offer relief

b. Beta Blockers are contraindicated in patients with PAD because they can actually worsen claudication

62. How can Addisonian Crisis be avoided in those with chronic steroid use undergoing surgery?

a. Increase perioperative “stress” steroid administration 5-10 fold from normal

b. Adrenals regulate cortisol and aldosterone which can lead to sodium and potassium balance and water retention. Removing cortisol “crutch” or not accounting for perioperative increase in cortisol to account for stress of surgery in these patients leads to a sudden drop that can cause hypotension and hemodynamic instability/death

c. This concept applies for those with adrenal insufficiency and Cushing’s as well as well

63. What are the 5 W’s of Post Op Fever?

a. Wind, Water, Walking, Wound, Wonder Drugs

b. This rhyme helps you remember the acute causes of post-op fever in 1st week in their order of occurrence

c. Wind POD1-2 (pneumonia, atelectasis), Water POD3-5 (UTI), Walking POD4-6 (DVT/PE), Wound POD 5-7 SSI, Wonder Drugs POD 7+ (drug fever, line infection, transfusion reaction, etc.)

d. Most common postop complication has been largely attributed to atelectasis, which should be suspected in fever on POD 1-2, increased work of breathing, scattered rales, dullness to percussion, and a CXR + for plate-like hyper attenuations

Alright, that wraps up today’s episode. As always, you can go to www.paspacpodcast.com for a full transcript and also all of the resources I used for making these questions. Please head over to Instagram and follow the pod @paspac_passport for near daily questions, quizzes on the story, and updates in healthcare.

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as always, safe travels.

REFERENCES

• https://smartypance.com/courses/general-surgery-end-rotation-exam/ref/ixemn/

• https://www.uptodate.com/contents/postoperative-ileus?search=paralytic%20ileus&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

• https://www.uptodate.com/contents/treatment-of-irritable-bowel-syndrome-in-adults?search=ibs&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H106781221

• https://www.nursebuff.com/nursing-mnemonics-and-acronyms-acid-base-fluids-and-electrolytes/

• https://emedicine.medscape.com/article/240681-clinical#:~:text=Follow%2Dup-,History,symptoms%20and%20signs%20of%20hypercalcemia.

• https://www.dynamed.com/approach-to/postoperative-electrolyte-abnormalities-in-adults#GUID-17B76DD4-DFEB-4131-92BC-F80ED419FE49

• https://www.dynamed.com/condition/thoracic-aortic-dissection#GUID-BF623A4F-D0CF-482B-BA25-6AFB6EB68F49

• https://smartypance.com/lessons/vascular-disease/peripheral-artery-disease/ref/ixemn/

• https://smartypance.com/lessons/vascular-disease/venous-insufficiency-reeldx304/ref/ixemn/

• https://www.dynamed.com/condition/peripheral-artery-disease-pad-of-lower-extremities#GUID-FE303A65-2795-4745-BA41-2155319C3520

• https://smartypance.com/lessons/endocrinology/hyperthyroidism-reeldx042/ref/ixemn/

• https://smartypance.com/lessons/neurology-and-neurosurgery/subarachnoid-hemorrhage/ref/ixemn/