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Exam – 2019 # Thyroglossal duct Cyct : near medline ,

below hyoid

> Abscess ; ABXs , I&D then Sistrunk .
# Branchial duct cyct : MC type 2 inferior
1- Infected lesion anterior to sternocleidomastoid: Angle of mandible, Ant to SCM
> Abscess ; ABXS , I&D then Excision
- Branchial cyst (see the types in puzzle, pediatric chapter)

2- PTC 1.2 cm (in histopathology report status) post
hemithyroidectomy, what is the next step: (Micro PTC management
in Schwartz)
- total thyroidectomy Hemithyroidectomy : 1-4 cm or <5foci ( each 8-9mm)
- hemithyroidectomy is sufficient no contralateral lobe , no previous radiation , no
Extrathyroid extension or LN metz .
- radio iodine ablation

3- PTC invading internal jugular vein:
- Ligation
If unilateral ligate ( collateral ) , if B/L bypass .
- Graft

4- PPTH post right parathyroid adenoma excision, preop PTH level is
180, then it dropped 50% at 10 min minutes, what is your next step:
- Repeat test Drop. 50% fro highest pre op indicate successful removal .
- Bilateral neck dissection
- Terminated the procedure

5- Bethesda ll thyroid lesion with BRAF gene tested positive, what is
your next step:
BRAF : MC mutation in PTC/anaplastic > aggresive/prognostic .
- True cut biopsy RAS/PRAF suggest malignancy .
- Left hemithyroidectomy
- Repeat US in 6 months

6- PHPT, intraop failed to drop PTH level, what is your next step:
- Bilateral exploration If intra-op PTH or other localization study N/A .
- Bilateral venous sampling

7- MTC, what defines local invasion or distant metastasis:
- Calcitonin level Labs : calcitonin , FNA , Ca

8- Patient with Grave’s disease, he is not tolerating medical treatment,
what is your next step:
- total thyroidectomy
- Subtotal thyroidectomy (shwartz)
Leaving 4 g or total thyroidectomy .
- Near total thyroidectomy Recurrance after thyroidectomy
managed by RAI
 9- Adrenalectomy for aldosteronism will improve:
- Aldosterone/Renin ratio 90% improving hypokalemia , 70% correcting HTn
- HTN
- Potassium (shwartz/puzzel)

10- Bilateral adrenal adenomas (1.5cm/1 cm) :
- Venous sampling 1- selective Venous Sampling for Ald/cortisol . 2- NP-95 .
- Bilateral adrenalectomy Ifmanagment
Unilateral > adrenalectomy. if B/L or fail to localize > medical
.

11- Anaplastic thyroid cancer (small lesion detected by PET scan):
- Chemoradiotherapy
Intrathyroid : Total Thyroidectomy & LND + adj Radiotherapy ( for Good
- Thyroidectomy + BCND PS , no metz )
- Treacheostomy Extrathyroid : en Block

12- Post fibroadenoma excision, found in the report to have LCIS at the
edge of the specimen, what is the next step : ADH or LCIS +ve margin is not
- Reexcsion indication for Re- excision .

- Risk reduction strategy * LCIS : observe , chemoprevention , b/l Total mastectomy .

Discharge High risk : bloody , clear , serous .
Others :spontenous , unilateral , single duct, >40yr , +mass .
13- Nipple ulcer with serous discharge: Excisional biopsy to R/O cancer .
- Nipple biopsy (Schwartz: nipple discharge and managment )

14- 70 year old female, with 3.5 cm IDC, ER,PR positive , what is the next
step: BCS : Stage I/II early
- Lumpectomy + radiotherapy+SLNB+ hormonal therapy breast cancer with
unifocal non BRCA .
Size up to 5 cm ( NCI )
15- Female with hx of lymphoma treated with Rx , what is the
recommended breast cancer screening : >25 yr : CBE + Mamo + MRI annually ,
- Mammogram + MRI annually (Cameron table) start 10 yr after RT .
< 25 yr : CBE , start 10 yr after RT .

16- Induced Green nipple discharge, what is the appropriate next step:
- Stop squeezing , and annual mammogram Bening discharge : no further evaluation , stop
manipulation .

17- Female with family history for breast cancer :

- Screening +ve Family hx : , annual Mamo and CBE every 6-12 month, annual MRI , start 10yr
before youngest Family member but not less than 30 yr , Genetic counseling.
+ve BRCA : annual MRI starting at 25yr , CBE semiannual .
18- Chronic constipation, manometry was normal, defecography: unable
to expel the content :
- Increase the angel of the anorectal (see cameron chart OPDS,low
transiet )


 19- Ulcerative colitis , the patient is not tolerating medical treatment:
- Subtotal colectomy + AR anastomosis
- Total proctocolectomy + IPAA elective : TAC+IPAA ( intact sphincter )
Emergency : TPC + End Ileostomy .

20- Simple sigmoid volvulus :

- Reduction If Stable , sigmoid is viable .

21- Sigmoid polyp. 3 cm (what indicate local excision):
- Size (table in shwartz) High risk indicating resection post polypectomy :
LVI , poor diff , budding , margin < 1mm .
Malignant Sessile polyp ( invade SM level 2/3 ) >> resection .
Malignant Pedunculated polyp ( head/ no stalk ) otherwise >>resection
22- Case of abdominal pain, diarrhea, image showed lead pipe sign:
- Ulcerative colitis Colon foreshortened and lack hustral marking .

23- Case of SMA syndrome, what is the mamngemtn:
- Duodenojejunostomy Conservative and nutrition first then DJ .

24- Jejunal cyst:
- Resection and anastomosis Bening mesentric cyct : enucleation
Malignant cyct : lap/open resection with clear margin .
Fenestration/aspiration : high reccurance .

25- FAP with 2 cm duodenal polyp which was excised and showed
adenomatous polyp, what is the next step:
- Whipple > 1cm , HGD , villous , Spigelman > IV : consider
- Pylorus preserving polyp whipple | small <1 cm , tubular , LGD consider :
EGD and F/U

26- Carcinoid syndrome with multiple liver lesion, what is the primary:
- Ileum
- Appendix 1- ileum 2- appendix
* CAMERON

27- Chron’s stricture 9 cm in length : < 12 cm : H-M
- Henick Mechklicks stricturoplasty 12-25 cm : Finney
longer : side to side

28- Post appendectomy, diarrhea, what is the next step:

- US ? Collection or ? C diff infection .
- CT

29- Post colon surgery, brown discharge (fistula):
- TPN If Low output ECF , conservative for 5 days then consider TPN .

30- Post ileal resection , risk increase for :
- Renal stones Megaloblastic : b12 def and folate , decrease bile salt uptake :
- Microcystic anemia gallstone & dirrhea , increase Oxalate binding to ca : renal stone

- Peripheral numbness
 31- Indeterminate IBD : If final histopath UC : IPAA , if unclear :
proctectomy with end ileostomy .
- Colectomy with end ileostomy

32- C. diff diagnostic test :
- A,B toxins * Immunoassay and cytotoxic assay are sensetive and rapid , A
- Stool culture enterotoxin B cytotoxin .

33- Duodenal ulcer :
- Graham’s patch If unstable . If stable + perforation ( while on PPI ) > need + HSV or TV+D

Anchhovy paste , By CT : well def , low density , round , wall
34- Case of liver amebic abscess: enhanced and peripheral edema .
- Metronidazole 750 mg TID 7-10days ( aspiration only if super infection or unclear Dx )

35- Rupture HCC:
If unstable > OR
- Angioembolization

36- HCC 4 cm , with elevated LFTs , and ascites:
- Transplant Resection for no Cirrhosis / child A / single / no metz . Transplant for 1 lesion
<5 cm/ 3 <3cm / Child A,B,C / no gross Vas Inv / no metz

37- Desmoid tumor attached to the abdominal wall and to the left lobe of
the liver: High recurrance , No metz potential .
- Encapsulated from the liver Can be observed , Systemic therapy : tamoxifen
If progress/ fail : Function sparing operation is the goal even
- Wedge liver resection with +ve margin .
- Left hepatectomy Adjuvant / Unresectable : Radiation .

38- Fibrolamellar HCC: Young , better prognosis, well circumscribed, >50% resectable , often
comtain central scar . Fibeolamellar HCC Not produce AFP but high
- Will have high neurotensin neurotensin level .

39- FNH , symptomatic , right lobe , 10 cm in size :
- Eneculation * Well circumscribed with central scar , no rupture or malignant risk
- Right hepatectomy Reassure and observe , stop OCP
Resection if +symptoms or cant R/O HCC

Anal SCC : Chemo- Rad , if recurrence APR .
40- Anal cancer, SCC : Anal melanoma : local excision
- Nigro protocol Anal Adenocarcinoma : chemo-Rad then APR .

5FU/mito-C+Radiation ( evaluation in 8-12weeks ) consider persistent after 6m AFTER COMPLETION
41- Pancreatic head mass with jaundice , alcoholic patient:
- EUS and FNA
- Whipple Inflammatory mass

42- Pancreatic head cyst , with honey comb appearance:
- EUS and FNA * (char in cameron)
- Whipple
Cystadenoma : low CEA & CA19-9 , NO commniucation with the duct , appears as honeycomb (
polycyctic microcyctic ) . + Sunburst sign ( central calcified scar ) . Ground glass of gapes .
 43- Pancreatic body large mass: Any suspicious mass , take the spleen ( Prof said )
- Distal pancreatectomy
- Distal pancreatectomy with splenectomy
Acute infected psudocyct : external drainage
> 6cm/>6weeks/ symptomatic : internal drainage ( transgastric or surgical )
44- Pancreatic pseudocyst:
- Endoscopic driange

45- Post sever pancreatitis and hematemesis and lesser sac cyst :
- Angio * Splenic artery psuedoaneurysm : IR embolization
- Endoscopic driange then manage the psudocyct .

46- Pancreatic cyst with itching, necrolytic skin lesion :
- Gluconoma +DM , necrolytic migratory erythema Site: body/tail

47- Case of mild pancreatitis, start to deteriorate:
- CT scan Early CT scan ( less than 48 hrs ) indicated in the following :
Indication : deterioration with high CRP, ? local complications , ? Bowel ischemia , acute bleeding , ACS .
48- Post splenectomy with ascites :
- Fluid analysis Pancreatic ascites : High fluid lipase > conservative , octeriotide , PC drainage .
Pancreatic fistula : conservative and if not close > ERCP+stent

49- Case of pancreatic leak:
- Pancreatic stent Pancreatic fistula managed conservative.
NPO / NJF for High output .
IVF , octeriotide , ERCP+stent , PC drainage .
50- For colon cancer , poor prognostic factor:
- APC High risk Stage II : <12LN , T4 , poor diff , perforation .
Hepatic CR metz prognostic : extrahepatic metz , short term , bipolar
,large >5 , CEA >200 , +ve margin
51- Gallbladder mass :
- Open chole
- Lap chole Polyp >1cm high risk , Open to avoid perforation .

- Biopsy
- Observation

52- Acute cholecystic in ICU patient: Acalcular in stable pt : lap chole
Critically ill : PC chole tube
- Tube cholecystostomy After recovery : lap chole can be done or not

53- case of mirrizi syndrome, what to do preop:
- ERCP and stent
- MRCP Mirrizi Type I lap chole , others : Open
- PTC

54- Post lap chole collection:
- Percutaneous drainage
Biloma : R/O leak .
 55- Post lap chole collection with intrahepatic dilation:
- PTD In biliary injury : 1st decopmress biliary pre-operative , define anatomy , control sepsis .
Wait at least 6 weeks to 3 months .

56- Abdominal hernia anterior to …….. Incomplete

57- Mysthenia gravis with big thymus:
- Extended thymectomy
- Simple thymectomy (puzzle thoracic)

58- Aortic dissection : BBs, BP control | Complicated DAD ( malperfusion/rupture ) :
endovascular or open repair .
- Endovasculat stent
- Observation Dissection > 5.5 : surgery
(table in shwartz, according to the type) survillance : 3-3.9 Q3yr , 4-4.9 Q1yr , 5-5.4 Q6m

59- AAA 3.5 cm:
- Beta blocker 3.5-4.4 cm : reexam in 1 yr | 4.5-5.4cm : reexam in 6 months .

60- Left thigh stab wound in unstable patient:
- Gloved hand compression
- Ligate the vessel Then to walk with the pt to OR for definitive repair .
- Deep suture
- Angio

61- Left thigh tender hematoma:
- Angio Soft sign : non expanding hematoma , injury proximal
- Surgical exploration , significal bleeding , diminished pulse , unexplained
hypotension .
- Local exploration

62- Left thigh large SCC:
- Excision with skin graft In General Skin SCC : WLE with 4-6 mm margin +/-
SLNB +/- adj radiotherapy

63- Gluteal sarcoma, incision will be :
- Oblique STS :
- Verical - core needle is the best
- bx incision should be longitudinal to be included in definite surgical incscion.
- Horizontal - >3cm or enlarging need imaging
- Cimcircum* - WLE 1-2 cm margin

64- Post trauma, skin infection, unstable patient:
- Strept pyrogen
- Clostridium

Necrtozing fascitis :
1- polymicrobial : gm + , gm -rods , cols perf .
2- mono : b hemolytic strepto or staph
Clindamycin , vancomycin , tazo or carbapenem .
 65- Epidural anesthesia, low HR, low blood pressure, what you should
you give:
- Atropine Sympathetic block cause vasodilation and decrease venous return >
- Epinephrine hypotension after epidural .
IVF + small dose of epinephrine.
- IVF

66- Malignant hyperthermia: AD disorder ( RYR1 )
- Dantroline Stop Volatile and given Dantrolene 2.5 mg / kg IV

67- Causes of shock in sepsis:
Endothelium dysfunction and vasculture
- Increase endothelial permeability secondary to circulating mediators

68- ECG with flat T wave:
- Hypokalemia Others : U wave , T wave faltten , ST segment change .

69- Description of DES (eosphagus): Stimulaneous spontenous repeatitive mutlipeaked
contarctions . 30% or more out of 10 wet swallows .
- Shwartz and rush (table)

70- GIST negative margin should be:
- 1 cm R0 is the goal , but R1 is not an indication for Re-Excsion .
- 5 cm
- 1 mm

71- Stomach cancer, (lantis plastica), young female:
- Diffuse type Diffuse : familial , young , poor diff , proximal
- Intestinal type Intestinal : Enviromental , Chronic gastritis , less aggressive
(lauren classification)

72- Best procedure to decrease gastric ulcer recurrence:
- Antrectomy and truncal vagotomy For type 2 and 3 ulcers , Low recurrance but
(shwartz - table) high mortalitiy , billroth recon .

73- Abdominal compartment Sx, 28, RTA, low urine out put :
- Laparotomy
- CT without contrast
High IAP + organ dysfunction
- Bolus IVF
Decreased :renal blood flow , UOP , CO , VR , SV
- DPL Increased : SVR , airway pressure

74- Adult intersussption:
- Resection and anastomosis
R&A of the lead point to R/O
malignancy

 75- Meckel’s diverticulum, adult , 3 cm , long , 1 cm base , with umbilical
band:
Non complicated : diverticulectomy + Band connected to abdominal wall
- Diverticulectomy .
- RBC scan If indicated for bleeding : R&A or segmental resection .
- Segmental resection

76- Pediatric diaphragmatic hernia, cause of instability:
- Cardiac compression CDH : 1- air filled bowel compress mediastinum
- Bowel ischemia compreomise air exchange on contralateral lung
2- Pulm HTN 3-ipsilateral hypoplastic lung
77- Imperforated anus + RLQ ground glass appearance:
- Stoma creation ? Could be imperforate anus with high fistula into membranous
urethra/ cloaca : colostomy followed by Pull through .
Or low fistula to the perineum : Perineal
78- Spleen found in LLQ:
Embryo anomaly > floats in abdomen > torsion, infarction :
- Wandering spleen need splenopexy or splenectomy

79- Biliary atresia management: Hepato-porto-enterostomy
- Kasai procedure

80- Lung resection contraindication:
- EF < 40% FEV1: >2L : tolerate pneuoonectomy | >1.5L : tolerate lobectomy .
< 0.8 or 30% of predicted are high risk

81- Patient post drug eluting PCI, when can do elective surgery:
- 12 months (puzzle) 14 days after ballon angio , 30days after bare metallic stent , 1 year
after DES (180days in semi-elective )

82- Liver lesion with dilated duct around it in US , next :
- Look for primary
- Biopsy
- Resection

83- Simple hemothorax :
- Chest tube

eFAST
84- Blunt chest trauma, best method to check for cardiac injury:
- US US is the best To R/O cardiac tamponade . If stable and ? Contusion : 24h telemtry .
- Beck’s triad If unstable : ECHO
- CT

85- Best modality for PE:
- ECHO*
- Chest x ray
- CT
 86- Electrical burn, escharotomy done, not improving:
- Fasciotomy Decrease perfusion indicate compartment .
- Brachial exploration
87- -
88- -
89- Case of 6 days abdominal pain , RLQ, tender, CT scan showed thick
around duodenum, collection 10*15 cm RLQ :
- Drainage Sealed perforated DU approved by radiology without
- Barium with contrast periotnitis managed with conservative

90- During Hip surgery , the patient became unstable:
- PE (fat embolism*)
- Cardiac shock
- MI High risk long bone fracture and trauma or intramudally surgery .

91- Bypass length: BMI 40 > 80-120cm
- 150 cm BMI 50 > 150 cm
R limb At least 75 cm

92- Anal wartz, with positive acetic acid test:
- Condyloma accuminata Anogenenital wart by HPV

93- Pediatric spleen injury with minimal fluid around the spleen:
- Observation*
- Angio If stable manage conservative
- Spleenoraphy
- Splenectomy

94- Right colonic injury 75%, contamination:
- Resection and anastomosis More than 50% Right hemi if stable

95- Rectal injury:
- Colostomy Extraperitineal injury : diversion only
Presacral drain : not use ex selected post/ lateral injuries .

96- Man inject himself with paint:

- X ray
- CT
- MRI

97- Baby chocking with feeding :
- TEF


 98- NEC (pediatric) when to operate on:
- Abdominal distention
- Skin erythema

99- Pain post inguinal hernia repair, suprapubic lower inner thigh, which
nerve:
- Ilioinguinal nerve Nerve distribution

100- Male post bypass surgery, have pain lower abdomen, improve with
thigh flexion: Howship romberg sign ( compression of obturator nerve ) relive by thigh flexion .
- Obturator hernia

101- Post kidney transplant collection:
- Nephrostomy US then aspiration ( to see nature )
Urinoma : early post op > stent
- Reoperation Lymphocele : more than 2wk > PC drain

102- How to diagnose transplant rejection for pancreatic transplant:
- Biopsy
In kidney and pancreas to R/o rejection .

103- Kidney transplant rejection medicated by:
- T cell Acute rejection mediated by cell mediated ( mononuclear Macrophage and T lymphocyte )

104- Doudenal ulcer bleeding, controlled with EGD, then rebleed again,
next step:
- Surgery 2 attempts endoscopy then OR if stable .
- Re- endoscopy *

105- Submucosal bleeding (stomach):
- Deilafoy’s lesion > congenital AV malformation ( large submucosal artery )
- Water melon > Gastric antral Vascula ectasia ( GAVE) : dilated blood vessele contain thrombi
- Angiodysplasia
(shwartz)

106- Choledocal cyst pathology: Congenital dilatation of Intra/extra hepatic biliary ducts .
- Pancreto-biliary reflux Pancreatic
>1.5cm )
duct joins CBD outside Dudenal wall ( long channel

107- Distal CBD stricture:
- Whipple Stricture : Percutenous/ ERCP +stent
Persistent /complex : sugrical resection and recon with R en Y choledocho-J or H-J .
Distal 1/3 : choledocho- D. If tension free
108- FAP surveillance:
- UGI endoscopy every 1-2 years
(summary in shwartz- table)
Start at 10 yr with annual F. Sigmoidoscopy
EGD every1-3 yrs
 109- During whipple you found vessel posterior to the pancreatic head
going post. Lateral to CBD:
- Replaced right hepatic artery Anterior
(10-15%)
In hepatodeudenal ligment to the left of CBD

110- Hand lesion (solid) dorsal aspect of the index:
- Excision!

111- Post bypass leak, first sign:
- Tachycardia

112- Obese patient:
- Hypoventilation syndrome

113- Post MI 2 months, mortality risk:
- 5 %
- 10 %* (puzzle)
- 20%
Duodenal switch
114- Obese for 2 stage procedure which one first:
- Bypass
- Gastric sleeve

115- Calculate corrected Na : Every 100 mg/dl increase plasma Na , 1.6 mEq/L decrease in Na
- Equation Sodium deficit = TBW x ( 140-Na )
TBW 0.6 x weigh : male , 0.5 x weight female

116- Thyroid lesion hypoechoic when to do FNA:
- If > 2.5 (table, US features) US gauid FNA : Cyctic vs solid , MNG .

117- Thyroid lesion + LN enlargement, LN biopsy showed follicular
lesion:
- PTC*
- FTC
- MTC Aberrant Lymph node ( follicular cell in LN indicate PTC )

118- How H pylori cause gastric ulcer:
- Submucosal histamine release
- Submucosal HCL
- Hypergastremina And decrease mucosal defense by low bicarb .




 Low - mod : Rectal advancment flap +/-
shincteroplasty .
119- Rectovaginal fistula, 4 cm from anal verge: High : abdominal ( resection and fistula closure )
- Advancement flap .

120- Upper GI bleeding, not controlled with EGD:
- Minnesota tube

121- Pancreatitis indicated increased mortality:
- Hypoxia *? APACH II score
- Amylase
- ALP

122- For pancreatitis monitoring:
- CRP Sensetive
After 2 days

123- Ventral hernia in obese patient:

- Do bariatric surgery, delay hernia repair
- Do them both at the same time

124- In trauma patient, monitoring the end point tissue perfusion with:
- Lactate level
Quick and reliable
- Svo2
- Urine output

125- Borehave syndrome, where is the location of the tear:
- Left lower esophagus Most perforation above GEJ or left lateral wall
- Cardia
Tri 1: discuss TOP or mastectomy + Axilla
staging
126- Pregnant breast cancer lady, 2nd trimester: Tri2 : mastectomy or BCS + Axilla staging | or :
- Neoadjuvant then surgery pre-op chemo then mastectomy or BCS + Axilla
staging .
- Surgery then post partum radiotherapy Tri3 : mastectomy or BCS + Axilla staging
(explained indetails in shwartz and puzzle) Note : Radiation in BCS given post partum .

127- Breast mammo result showed microcalcification:
- Steroitactic localization Non palpable mass ( microcalcification or architecture
distirtion )

128- Urology case

129- --
130- Consultant write wrong prescritption:
- Inform the head

131- Nurse refuse to deal with HIV patient:
- Ask other nurse

132- Nurse got needle brick, refused to write OVR:
- Write OVR

133- Colleague uses fake data:
- Inform his consultant

134- The instrument you use broken:
- Inform the administration

135- Neurological issue post bariatric surgery:
- Vit B 6 deficiency
- Vit B 1 deficiency Vomiting > Wernicke encephalopathy > Thiamine (vit B1 )
- Zinc deficiency
(Fiser)

136- Anal fissure with low anal tone: Chronic fissue can be treated with
- Advancement flap Advancment flap VY +/- sphincterotomy

137- Old female with rectal prolapse:
- Altmaier procedure High risk/ elderly : Perineal rectosigmoidectomy . ( high recurrance )
Young and Fit : abdominal .

138- Retroperiotenal mass:

- ( Review Approach and DDX ) Abdominal CT + IV/PO contrast , Biopsy
MC retroperitoneal malignancy : Lymphoma

139- Face lesion , biopsy showed sulfar granule, what abx:
- Penicillin Actenomysis : cutenous swelling in cervicofascial area

140- Mesenteric mass, pushing mesenteric vessels, how to Dx:
- True cut biopsy
- FNA
- Excision

141- Dumping syndrome, 3 hours , caused by:
- High osomalr volume Early 15-30 m : hyperosmolar load to intestine
- Hypoglasemia Late 2 hr : hypoglucemia relive by sugar

142- Retroperiotoneal mass DDX: Liposarcoma ( MC retroperitoneal sarcoma )
CT gauuided core needle bx

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