2 Surgery Flashcards
When is surgery indicated for an abdominal aortic aneurysm?
More than 5 cm in size or growth >4 mm/year or if symptomatic
What is the classic triad of ruptured abdominal aortic aneurysm
Abdominal pain, hypotension, pulsatile abdominal mass
What is the name and treatment of the fracture of the fifth metacarpal that occurs after striking an object with a fist?
Boxer fracture; treat with closed reduction and ulnar splint. If skin broken, débride and give amoxicillin/clavulanate (Augmentin), cefuroxime (Ceftin) or doxycycline for human oral pathogens
What is the name and treatment of the fracture of the carpal bone that causes tenderness in the anatomical snuffbox?
Scaphoid fracture. Treatment is thumb Spica cast.
What is the most common fracture of the wrist that results from a fall on an outstretched hand and causes fracture of the distal radius with dorsal displacement of the distal fragment?
Colles’ fracture. Treat with closed reduction and cast.
What is the name and treatment of ulnar diaphyseal fracture and dislocation of the radial head?
Monteggia fracture (?nightstick fracture?). Treatment is closed reduction of the radial head and open reduction, internal fixation of ulna.
What is the name and treatment of radial head subluxation caused by forceful pulling by the hand?
Nursemaid elbow. Treatment is manual reduction by supination at 90 elbow flexion.
What is the name and treatment of the most common shoulder dislocation (95%)?
Anterior shoulder dislocation. Treatment is closed reduction, sling, rehabilitation.
What is the name and treatment of the most common fracture in school–aged children, which may also threaten the brachial artery?
Supracondylar fracture of the humerus. Treatment is closed reduction and pinning.
8 year old boy with involuntary tics, such as eye blinking, coughing, throat clearing, sniffing, and facial movements; coprolalia. What is the diagnosis?
Tourette’s syndrome
What are the signs of basilar skull fracture?
Hemotympanum, clear otorrhea/rhinorrhea, raccoon eyes, Battle sign (mastoid ecchymosis)
Ecchymosis of the lower abdomen from a seatbelt is a sign of what injury?
Small bowel perforation
What is Beck’s triad, which is seen in cardiac tamponade and tension pneumothorax?
Hypotension, jugular venous distension, decreased heart sounds
What are the signs of tension pneumothorax?
Unilateral absence of breath sounds, jugular venous distension, mediastinal shift
Difficulty swallowing liquids which is greater than difficulty with solids suggests what type of disorder?
Oropharyngeal dysphagia
Difficulty swallowing both liquids and solids occurs in what disorder?
Esophageal dysphagia
How does mechanical obstruction affect the ability to swallow solids and liquids?
Difficulty swallowing solids is greater than difficulty swallowing liquids when mechanical obstruction is the cause
How is Zenker’s diverticulum treated?
Myomectomy and excision of diverticulum
What are the causes of esophageal dysphagia?
Achalasia, esophageal stricture, esophageal web, scleroderma, esophageal cancer
What is achalasia?
Ganglionic loss causing inability of the lower esophageal sphincter to relax and loss of peristalsis; ?bird beak? appearance on barium swallow and increased pressure of lower esophageal sphincter.
What is Plummer–Vinson syndrome?
Iron–deficiency anemia, dysphagia, esophageal web, atrophic glossitis
What is Barrett’s esophagus?
Columnar metaplasia of squamous epithelium of distal esophagus, occurring because of acid injury from gastroesophageal reflux disease
What is the complication of Barrett’s esophagus?
Esophageal cancer
Which esophageal cancer is associated with alcohol and tobacco use?
Squamous cell cancer
What is the surgical term for esophageal perforation caused by severe vomiting?
Boerhaave’s syndrome
What are the signs of gastroesophageal reflux disease?
Substernal chest pain, heartburn, regurgitation, which are worse after meals and in the supine position
How is Barrett’s esophagus treated?
Antacids, H2 blockers or proton pump inhibitors; surveillance EGD and biopsies
List the complications of gastroesophageal reflux disease
Ulceration, strictures, Barrett’s esophagus, bleeding, aspiration
What are the common causes of epigastric pain?
Peptic ulcer disease, gastritis, pancreatitis, cholecystitis, coronary ischemia, gastroesophageal reflux disease
What is priapism?
Intractable, painful erection; caused by venous thrombosis, trazodone, sickle cell disease
What is balanitis?
Inflammation of the glans caused by poor hygiene
What is testicular torsion?
Twisting of the vasculature of the testicle; spontaneous or caused by trauma; usually rotates medial; therefore, detorsion is usually accomplished by twisting the testicle laterally.
What is a hydrocele testes?
Collection of fluid in the tunica vaginalis
What is a varicocele?
Palpable, ?bag of worms? dilation of veins of the spermatic cord
What are the complications of cryptorchidism?
5–10 times increased risk of germ cell tumors; atrophy, sterility, and inguinal hernias
What is the treatment for cryptorchidism?
Orchiopexy; will decrease the risk of sterility, but not decrease the risk of malignancy
What is the most common cause of orchitis?
Mumps virus; orchitis occurs 1 week after parotiditis
What organisms are the most likely cause of epididymitis in children?
Gram–negative rods
What is the cause of squamous cell carcinoma of the penis?
Human papilloma virus types 16, 18, 31, and 33
What category of testicular tumors accounts for 95% of all cases?
Germ cell tumors; peak incidence of 15–34 years of age
What is a seminoma of the testes?
Malignant, painless enlargement of testis; most common germ cell tumor, radiosensitive
What grading system is used to stage prostatic carcinoma?
Gleason system
Which prostate disorder commonly affects the peripheral zone?
Prostatic carcinoma
Which prostate disorder commonly affects the central zone?
Nodular hyperplasia
Which prostate disorder causes an increase in total prostate–specific antigen, with a decreased fraction fo free prostate specific antigen?
Prostatic carcinoma
Which prostate disorder causes an increase in total prostate–specific antigen, with a proportionate increase in the fraction of free prostate specific antigen?
Nodular hyperplasia
A patient with prostate cancer and an increased prostatic acid phosphatase is likely to have what complication?
Penetration of the prostate capsule by the prostate cancer
A patient with prostate cancer and an increased alkaline phosphatase is likely to have what complication?
Osteoblastic lesions from bony metastasis of the prostate cancer
What is the primary arterial supply to the gonads?
The testicular or ovarian arteries supply the gonads, which branch from the abdominal aorta
What is the primary venous drainage of the gonads?
The gonads on the left drain to the left testicular/ovarian vein, which drains to the left renal vein. The gonads on the right drain to the right testicular/ovarian vein, which drains into inferior vena cava
What is the lymph drainage of the gonads?
Deep lumbar nodes
What are the contents of the spermatic cord?
Genitofemoral nerve, ductus deferens, ductus deferens artery, pampiniform venous plexus, autonomic nerves (sympathetic and parasympathetic), cremasteric muscle and vessels, testicular artery, lymphatics.
What structures are found in the transverse cervical (cardinal) ligament of the uterus?
Uterine vessels
What structures are found in the suspensory ligament of the ovaries?
Ovarian vessels, lymphatics, autonomic nerves
What structures are found in the broad ligament?
Round ligaments of the uterus, ovarian ligament, ureters, uterine tubes, and uterine vessels
What is the anatomic relationship of the ureter and the uterine artery?
Ureter lies posterior and inferior to uterine artery. ?Water under the bridge?
What is an intestinal intussusception?
Telescoping of the intestines, resulting in intestinal obstruction
What is the most common location for volvulus?
Sigmoid colon; occurs most frequently in middle–aged and elderly men
What section of the colon is most frequently affected by diverticulosis?
Sigmoid colon
What type of neoplastic colonic polyp is the most common?
Tubular adenoma (75%); benign and pedunculated
What type of neoplastic colonic polyp is highly malignant?
Villous adenoma; sessile tumor >4 cm with finger–like projections
What are the signs of a mass in the head of the pancreas?
Courvoisier sign: Painless jaundice, malabsorption and an enlarged, palpable gallbladder
What type of hyperbilirubinemia results from cholestasis?
Conjugated hyperbilirubinemia
How does hepatic failure affect the brain?
Coma, hepatic encephalopathy, characterized by asterixis, hyperreflexia, behavioral changes
The portal vein is formed by the confluence of what two vessels?
Splenic vein and superior mesenteric veins
What nerve must be avoided during parotid gland surgery because it traverses the parotid gland?
Facial nerve (CN VII)
Posterior perforation of an ulcer in the first part of the duodenum can rupture what blood vessel?
Gastroduodenal artery; rupture can cause massive hemorrhage.
What two structures merge to form the hepatopancreatic ampulla of Vater?
The common bile duct and pancreatic duct drain into the duodenum through the ampulla of Vater
The hepatic artery, portal vein, and common bile duct comprise what structure?
The porta hepatis
What is the suspensory ligament of Treitz?
Supports the duodenum at the duodenojejunal flexure
What is the function of the puborectalis muscle?
Maintains the rectum in a 90º flexure
What is the venous drainage of internal hemorrhoids?
Superior rectal vein, which drains to portal circulation
What is the innervation of internal hemorrhoids?
Visceral innervation; ligation is not painful
What is the venous drainage of external hemorrhoids?
Inferior rectal vein, which drains to systemic circulation and IVC
What is the innervation of external hemorrhoids?
Somatic innervation; ligation of external hemorrhoids is painful
The external anal sphincter consists of what type of muscle?
The external anal sphincter consists of striated muscle under voluntary control by the pudendal nerve. The internal anal sphincter consists of smooth muscle under involuntary control.
What are the boundaries of Hesselbach’s triangle?
Hesselbach’s triangle is bounded by the inferior epigastric artery, inguinal ligament, lateral border of rectus abdominus muscle
What factors regulate the secretion of gastric acid?
Secretion is stimulated by histamine, acetylcholine, gastrin; secretion is inhibited by prostaglandin, somatostatin, gastric inhibitory peptide
What factors regulate the secretion of somatostatin?
Secretion is stimulated by acid; secretion is inhibited by vagal stimulation.
What is the purpose of intrinsic factor?
Binds vitamin B12 for uptake in terminal ileum
What is the purpose of somatostatin?
Inhibits the secretion of acid and pepsinogen; inhibits the production of pancreatic and small intestine secretions. Inhibits gallbladder contraction; decreases release of insulin and glucagon.
Which chemical potentiates the actions of acetylcholine and gastrin in stimulating parietal cell H+ secretion?
Histamine; H2 blockers block the actions of histamine.
Which drug blocks the effects of histamine on parietal cells?
Cimetidine (H2 receptor blocker)
Parasympathetic innervation of the gastrointestinal tract occurs via which nerves?
Vagus nerve and pelvic nerve. Parasympathetic innervation is usually stimulatory.
Which pancreatic enzymes are responsible for fat digestion?
Lipase, phospholipase A, and colipase
What is the cause of steatorrhea after ileal resection?
Ileal resection prevents bile acid reabsorption and recirculation, resulting in depletion of the bile acid pool, resulting in fat malabsorption
What is the dumping syndrome?
Rapid delivery of large amounts hypertonic food to the small intestine after vagotomy, resulting in distention and diarrhea.
What is the most common salivary gland tumor?
Pleomorphic adenoma, consisting of epithelial and mesenchymal elements.
What is oral hairy leukoplakia?
Irregular white mucosal patches in the mouth, associated with AIDS; caused by Epstein–Barr virus.
What type of cancer accounts for 95% of oral cancers?
Squamous cell carcinoma
What is the most common esophageal cancer?
Squamous cell carcinoma; proximal two–thirds of esophagus.
What are the risk factors for esophageal cancer?
Alcohol and tobacco use
What part of the esophagus is the most common location for adenocarcinoma?
Distal one–third of the esophagus; adenocarcinoma is a mucin–producing glandular tumor.
What are the risk factors for gastric carcinoma?
Chronic gastritis, Helicobacter pylori infection, blood type A, nitrosamines; men > 50 years old; low–fiber diet.
What are the risk factors for esophageal carcinoma?
Achalasia, Barrett esophagus, corrosive esophagitis, diverticula, esophageal webs, family history
What are the risk factors for nephrolithiasis?
Low fluid intake, hypercalcemia, gout, enzyme deficiency, renal tubular acidosis, allopurinol, chemotherapy, loop diuretics, inflammatory bowel disease, family history
What tests are used to evaluate for nephrolithiasis?
Urinalysis (hematuria, pH, crystals), x–ray (90% of stones are radiopaque); helical CT scan without contrast is the best test for nephrolithiasis
What is the initial treatment of kidney stones?
Hydration and analgesia
What is the most common urinary tract malignancy?
Bladder (transitional cell) cancer
What is the strongest risk factor for bladder cancer?
Smoking
How does bladder cancer usually present?
Painless hematuria
What is the best diagnostic test for bladder cancer?
Cystoscopy
What is the most common cancer in men?
Prostate cancer. Lung cancer causes more deaths than prostate cancer.
Prostate cancer presents with metastatic disease in what percentage of patients?
40% of patients with prostate cancer have metastatic disease at presentation
What are the most common complications of prostatectomy?
Impotence and incontinence
What are the recommendations for screening for prostate cancer?
Digital rectal examination and prostate specific antigen every year >50 years old (or >40 years old if African American or a positive family history of prostate cancer)
Injury to the upper trunk of the brachial plexus will result in what finding?
Erb–Duchenne palsy or Waiter’s tip (C5, C6)
The lower trunk of the brachial plexus can be damage by what type of injury?
Klumpke injury due to sudden upward jerk of the arm (C8, T1); associated with Horner’s syndrome
Injury to the ulnar nerve will result in what finding?
Claw hand (impaired wrist flexion and adduction)
Injury to the radial nerve will result in what finding?
Wrist drop
Pain with wrist flexion caused by repetitive motion injury is indicative of injury to what nerve?
Median nerve (carpal tunnel syndrome)
Injury to the axillary nerve will result in paralysis of what muscle?
Deltoid paralysis
Injury to the long thoracic nerve during a mastectomy will result in what finding?
Winged scapula
Injury to the musculocutaneous nerve will result in what findings?
Decreased elbow flexion and loss of biceps reflex
A patient with foot drop has an injury to which nerve?
Common peroneal nerve
Loss of ability to plantarflex is a sign of what lesion?
Injury to the tibial nerve
Loss of ability to make a fist is a sign of what lesion?
Injury to the median nerve at elbow
Injury to the median nerve at wrist will result in what sign?
Inability to form an ?O? with the thumb and index finger because of damage to the anterior interosseous nerve branch
Anterior shoulder dislocation may injure which nerve?
Axillary nerve; resulting in impaired abduction of the shoulder and loss of sensation over lateral upper arm.
What maneuvers are useful for evaluating the median nerve at the wrist?
Tinel’s sign: tapping over the median nerve to elicit tingling. Phalen’s test: Patient pushes the hands together – tingling or numbness over the thumb, index, middle and ring fingers confirms carpal tunnel syndrome.
Loss of knee jerk reflex (quadriceps) and loss of sensation over anterior thigh suggests injury to what nerve?
Femoral nerve
What are the signs of obturator nerve injury?
Numbness and pain radiating to the inner thigh; loss of thigh adduction
Inability to rise from a seated position or climb stairs due to loss of gluteus maximus function is a sign of injury to which nerve?
Inferior gluteal nerve
Injury to the superior gluteal nerve will result in what sign?
Positive Trendelenburg sign; when standing on one leg, the pelvis drops on the side opposite to the stance leg. The weakness is present on the side of the stance leg because of paralysis of the gluteus medius and minimus muscles.
Posterior hip dislocation in a motor vehicle accident may injure what nerve?
Sciatic nerve
Fracture of fibular neck may cause injury to what nerve?
Common peroneal nerve, causing foot drop
After a motor vehicle accident, a patient presents with leg in external rotation, appearing shorter than the contralateral leg. What fracture is likely?
Fracture of the femoral neck
Landing on a foot after a large drop may cause fracture of what bone in the foot?
Calcaneus
Hyperextension of the neck may cause what type of fracture?
Hangman fracture, characterized by anterior subluxation of C2, bilateral fracture of C2 pars interarticularis
Hyperflexion of the neck may cause what fracture?
Teardrop fracture caused by subluxation of vertebrae; spinal cord injury
What artery passes through the anatomic snuffbox?
Radial artery
Radial or ulnar artery patency is evaluated by what test?
Allen test is used before arterial blood sampling from the wrist.
What are the steps in the Allen test?
1) The patient clenches fist. 2) Pressure is applied over the ulnar and the radial arteries. 3) Ulnar pressure is released and the color should return in 7 seconds.
Lateral impact to the knee damages what structures?
Anterior cruciate ligament, medial collateral ligament, and medial meniscus
A torn anterior cruciate ligament is indicated by what sign?
Positive anterior drawer sign
What sign suggests a torn medial collateral ligament?
Abnormal passive abduction of the leg
What is the most common site for a clavicular fracture?
Middle one–third
What is the term for increased pressure within a fascial compartment that causes damage to muscles and neurovascular structures?
Compartment syndrome
What ligament can be stretched or torn by inversion of the ankle?
Anterior talofibular ligament (ankle sprain)
What common carpal bone fracture can lead to avascular necrosis?
Scaphoid fracture
What are the muscles of the rotator cuff?
Supraspinatus, infraspinatus, teres minor, subscapularis muscles
What is tennis elbow (lateral epicondylitis)?
Syndrome of pain on extension of the wrist and supination on of the forearm. Overuse injury; microscopic tearing in extensor carpi radialis brevis muscle.
What are the signs of thoracic outlet syndrome?
Sensory loss of the medial forearm and hand, disappearance of radial pulse on turning head away from affected side, atrophy of thenar, hypothenar, and interosseous muscles; cervical accessory rib is often present.
What traumatic injury is suggested by an internally rotated and adducted leg appearing shorter than the contralateral leg?
Posterior dislocation of the hip
What traumatic injury presents with an externally rotated and abducted leg?
Anterior dislocation of the hip
What is bone avascular necrosis?
Infarction of osteocytes, leading to joint pain, osteoarthritis
What is Legg–Calve–Perthes disease?
Idiopathic avascular necrosis of the head of the femur
What is Osgood–Schlatter disease?
Traction phenomenon resulting from repetitive quadriceps contraction upon the immature tibial tubercle. Most frequent cause of self–limiting knee pain in children aged 10–15 years.
What conditions delay wound healing?
Poor circulation, infection, necrotic tissue debris, foreign bodies, nutritional deficiencies, diabetes
What is the most common thyroid carcinoma?
Papillary carcinoma
What is the best diagnostic test to evaluate a thyroid nodule?
Fine needle aspiration
What parathyroid disorder is caused by chronic renal failure or deficiency of vitamin D?
Secondary hyperparathyroidism
What is the normal flora of the colon?
Bacteroides fragilis, E. coli
Which bacteria is associated with nosocomial wound infections?
Staphylococcus aureus
