Questions

1. How do you treat DCIS ?

2. How do you treat an incidentally-found ovarian/adnexal mass ?

3. How do you treat a tubo-ovarian abscess ?

4. How does IABP (intra-aortic balloon pump) improve hemodynamics ?

5. When is IABP contraindicated ?

6. What syndrome includes a necrloytic migratory erythema ?

7. How do you confirm the diagnosis of carcinoid syndrome ?

8. What criteria meet “critical” aortic stenosis ?

9. What criteria meet “critical” mitral stenosis ?

10. What is the most common cause of a solid renal mass in an adult ?

11. How do you treat an intra-caval renal cell cancer ?

12. How do you treat a testicular mass ?

13. What are the serum markers in testicular cancer ?

14. What is the BIRADS Classification ?

15. What is the first test for a palpable breast mass ?

16. What is the most effective treatment for an aspiration episode ?

17. How do you treat clear, serous discharge from a single duct in the female breast ?

18. What is the most common palpable breast mass in a pregnant female ?

19. What is the operative approach to a thoracic duct leak ?

20. What causes most bloody nipple discharge ?

21. What chromosome is responsible for Gardner's syndrome ?

22. What are the “Amsterdam Criteria” ?

23. When do you see a bird's beak esophagus ?

24. What is the most common cause of lower GI bleeding ?

25. What is the most common cause of Massive lower GI bleeding ?

26. What is the most common cause of Massive lower GI bleeding in patients > age 70 ?

27. How do you treat an infected urachal cyst ?

28. What level differentiates colon cancer from rectal cancer ?

29. How do you approach a BIRADS 0 classification ?

30. What is a Stage III colon cancer ?

31. When do you administer preoperative neoadjuvant therapy for esophageal cancer ?

32. Where is iron absorbed ?

33. What is the most common cause of Portal HTN in the United States ?

34. What is the Budd-Chiari Syndrome ?

35. What is the best way to prevent a first bleed in a portal HTN patient ?

36. What is the preferred treatment of Ascites ?

37. What is the preferred treatment for Grave's Disease ?

38. How do you treat a 3 cm. Appendiceal Carcinoid ?

39. What are the two main risk factors for Papillary Thyroid CA ?

40. How does follicular thyroid cancer spread ?

41. What do C-cells produce ?

42. What is the origin of the Superior Thyroid Artery ?

43. How do you treat a duodenal diverticulum ?

44. What is the most common manifestation of the Carcinoid Syndrome ?

45. What are 3 extra-colonic manifestations associated with Ulcerative Colitis ?

46. What is the half-life of Parathyroid Hormone ?

47. What is the best diagnostic screen for a “lost parathyroid” ?

48. What is the most common cause of a “cushing's picture” ?

49. What is the most common cause of primary hyperparathyroidism ?

50. How do you treat a 100 % occlusion of the internal carotid artery ?

Answers

1. DCIS: wide local excision to negative margins, followed by XRT to the ipsilateral breast

2. The “Incidental Ovarian Mass”

1. First, always perform the operation that you went there to perform

2. Remember, you can always come back

3. Then, describe fully what you see

4. 1. i.e. peritoneal studding, omental caking...

   2. never do a wedge biopsy of the mass or ovary

   3. 1. never do a TAH-BSO, at the time of initial discovery

3. Antibiotics, antibiotics, antibiotics....

When you find a tubo-ovarian abscess, you are likely exploring for suspected appendicitis; perform the appendectomy and describe the relevant findings. Unless the ovary is necrotic or gangrenous, do not proceed with resection (especially in the pre-menopausal female). If the abscess progresses or begins to lead to septic complications, you can always go back and resect.

4. 2 effects of IABP:
a. Increases coronary blood flow
b. decreases afterload

5. IABP is contraindicated in:
a. Aortic regurgitation
b. Lower limb ischemia

6. Glucagonoma

7. Carcinoid Diagnosis: Check Urinary 5-HIAA level**

8. Critical aortic stenosis: Area < 1 cm ² P > 50 mmHg

9. Critical mitral stenosis: Area < 1.5 cm ² P > 15 mmHg

10. Renal Cell CA

11. Resection; intracaval spread does not preclude a full and complete resection, i.e. a radical nephrectomy without previous biosy.

12. A testicular mass is cancer till proven otherwise and should be treated with an inguinal orchiectomy. Do not violate the median raphe or perform a scrotal biopsy.

13. Serum markers in testicular cancer: AFPB-HCG LDH

14. BIRADS Classification: “0” - inadequate mammogram
“I” - normal mammogram
“II” - radiographic abnormality present, likely benign
“III” - undetermined lesion, low suspicion for carcinoma
“IV” - suspicious lesion present
“V” - malignancy strongly suspected
(i.e. a solid mass with calcifications)

15. FNA

16. Aggressive suctioning – consider endotracheal intubation and formal bronchoscopy

17. Ductogram followed by complete ductal excision

18. Lactating adenoma

19. Right Thoracoctomy – with ligation of the duct just above the diaphragm (VATS if available)

20. Papilloma

21. Chromosome 5q

22. Amsterdam Criteria: the Lynch Syndromes, 3 relatives, in 2 or more generations, where at least 1 is a first-degree relative

23. Achalasia

24. Colonic neoplasia

25. Diverticulosis

26. A-V Malformations

27. Antibiotics, followed by complete excision (including the associated cuff of bladder)

28. 12 cm. from the dentate line – above is condidered “colon” & below is “rectum”

29. You must repeat the mammogram, and may require cone-views

30. Duke's Colon Ca: A - Limited to the Bowel Wall
B - Extension through the Bowel Wall with Negative Nodes
C - Regional Node Metastasis
Duke's Modification: C 1 - Regional Node Metastasis C 2 - Node Involvement at the Point of Vessel Ligation

31. Stage II or Stage III Esophageal CA

32. Duodenum

33. Alcoholic cirrhosis

34. Budd-Chiari Syndrome: hepatic vein thrombosis leading to post-sinusoidal

portal hypertension

35. Beta-blockade is the only proven method to prevent a FIRST bleed

36. Medical management: fluid & salt restriction spironolactonesurgery carries a minimal role in the direct treatment of ascites

37. I ¹³¹ Ablation, followed by supplemental replacement

38. Right hemicolectomy with ileocolic anastamosis, and remember to take the regional nodes.

39. Risk Factors – Papillary CA:
Childhood exposure to Radiation
Positive family history

40. Follicular cancer does not spread through the lymphatics; it spreads hematogenously to bone and lung

41. Calcitonin

42. The external carotid artery

43. Resect the diverticulum

44. Diarrhea

45. Erythema nodosum, erythema multiforme, & pyoderma gangrensum (just to name a few)

46. 8 minutes, this is why on-table PTH levels are helpful in parathyroid surgery

47. Sestamibi scan

48. Exogenous steroid use

49. A single adenoma

50. Observation – you do not treat a 100 % occlusion. Place on ASA qd and follow the contralateral carotid with surveillance duplex sreening

Correspondence to

Bradley J. Phillips, MD Dept. of Trauma & Critical Care Medicine Boston Medical Center Boston University School of Medicine CCM 2707 One Boston Medical Center Place Boston, MA 02118 Phone: (617) 638-6406 Fax: (617) 638-6452 Email: bjpmd2@aol.com