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Elaina: Surgery > Blessington lecture > Flashcards

Blessington lecture Flashcards

1
Q

patient presents with periumbilical pain migrating to the RLQ with low-grade fever and nausea, vomiting

A

appendicitis

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2
Q

what is the single most important sign for diagnosing appendicitis?

A

RLQ pain on palpation

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3
Q

what 5 signs may be positive in your patient with appendicitis?

A

1) guarding
2) psoas
3) obturator
4) rovsings
5) dunphy’s (increased pain w/ coughing)

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4
Q

in what position will a patient with appendicitis lay in for comfort?

A

hip flexion with knees drawn up

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5
Q

diagnosis of appendicitis?

A

CT with contrast if stable

without contrast if unstable

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6
Q

treatment of appendicitis?

A

NPO then appendectomy

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7
Q

what meds will we give as part of our treatment for appendicitis?

A

flagyl (metronidazole) and unasyn?

fentanyl and zofran on PRN schedules

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8
Q

a bloated, distended, “taunt” abdomen and increased pain in the LLQ should make you think what?

A

diverticulitis

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9
Q

what other symptoms, aside from pain, may your patient with diverticulitis present with?

A

nausea
maybe loose stools with blood
fever

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10
Q

will a patient with diverticulitis pain be improved while lying down or standing up?

A

improved lying down

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11
Q

where is the most common area in the abdomen for diverticulitis?

A

left sided/sigmoid lesions

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12
Q

what genetic disease increases risk for diverticulitis?

A

familial polyposis

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13
Q

patients with diverticula and polyposis are at increased risk for what?

A

colon cancer

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14
Q

how do we diagnose diverticulitis?

A

CT! will see diverticula in rectosigmoid, focal wall thickening in sigmoid colon with adjacent fat stranding

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15
Q

pneumoperitoneum on CT indicates what?

A

perforation!

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16
Q

fluid collection adjacent to the area of inflammation and diverticulitis indicates what?

A

abscess

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17
Q

management of uncomplicated diverticulitis?

A

1) NPO initially, then gastric and bowel rest (clear liquids)
2) IV hydration
3) analgesic medications
4) antibiotics
5) discharge home
6) return if worsening symptoms

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18
Q

what are the antibiotics of choice for managing diverticulitis?

A

cipro and flagyl

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19
Q

when is diverticulitis considered “complicated”?

A

presence of perforation, bowel obstruction, abscess or fistula seen on CT, high fever, sepsis, vomiting

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20
Q

if your patient with diverticulitis is vomiting, what do they need?

A

NG tube!

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21
Q

management of complicated diverticulitis?

A

1) NPO
2) IV cipro + flagyl
3) IV analgesics
4) surgical intervention

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22
Q

what are the two surgical procedures used for complicated, emergent diverticulitis?

A

primary or secondary anastomosis*

colectomy (hartman procedure) – use is limited to emergency surgery when immediate anastomosis is not possible

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23
Q

what are recommendations you can give your patient with a hx of diverticulitis/diverticulosis?

A

increase fiber

avoid seed containing products (popcorn, tomatoes, nuts)

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24
Q

following a bout of diverticulitis, when should your patient go in for a colonoscopy?

A

1 month

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25
Q

what is the recurrent rate of diverticulitis?

A

30-50 percent

26
Q

what is charcot’s triad of cholangitis?

A

1) abdominal pain
2) fever
3) jaundice

27
Q

what is reynold’s pentad of cholangitis?

A

1) abdominal pain
2) fever
3) jaundice
4) confusion
5) septic shock

28
Q

what may a patient with cholangitis complain of during their history intake?

A

diffuse itching

29
Q

what is the most common cause of cholangitis?

A

bile duct obstruction by gallstones or cancer

30
Q

imaging modality of choice for ruling out carcinoma as the cause of patient’s cholangitis?

A

MRI

31
Q

what should the first diagnostic modality of suspected cholangitis always be?

A

ultrasound!

32
Q

what might ultrasound of cholangitis show?

A

dilation of the bile duct; identification of a percentage of bile duct stones

relatively poor at identifying stones further down the bile duct

33
Q

when do we choose ERCP in patient with suspected cholangitis?

A

only used first-line in critically ill patients in whom delay for diagnostic tests is not acceptable

34
Q

if the index of suspicion for cholangitis is high, what do we do?

A

jump to the ERCP

35
Q

what are the most common bacteria linked to ascending cholangitis?

A

1) gram neg = e. coli, klebsiella
2) gram pos = enterococcus
3) anaerobic = c. diff and bacterioides (MC in elderly)

36
Q

treatment of cholangitis?

A

1) IV fluids
2) ABX
3) fix underlying problem (ERCP)

37
Q

what should we do following ERCP if patient’s cholangitis was due to gallstones?

A

cholecystectomy

wait until all symptoms have resolved and ERCP has confirmed that bile duct is clear of gallstones!

38
Q

what causes the abdominal pain associated with ectopic pregnancy?

A

prostaglandins are released at implantation site and free blood is in the peritoneal cavity

39
Q

what causes the vaginal bleeding seen in ectopic pregnancy?

A

falling progesterone levels

40
Q

shoulder pain is an ominous sign in the face of ectopic pregnancy, why?

A

often due to free blood tracking up the abdominal cavity and irritating the diaphragm

41
Q

where do most ectopic pregnancies occur?

A

the fallopian tubes (tubal pregnancies)

42
Q

true or false, an ectopic pregnancy can occur anywhere in the abdomen?

A

true

43
Q

6 risk factors for ectopic PG?

A

1) PID
2) IUD
3) tubal surgery (ligation)
4) intrauterine surgery (ie D and C)
5) smoking/alcohol abuse
6) previous ectopic

44
Q

sharp, lower abdominal pain and intermittent bleeding is classic of ectopic pregnancy. how else may they present?

A

1) bladder and rectal pressure

2) pain radiating to loer back

45
Q

when is pain the worst with ectopic pregnancy?

A

when walking; car ride in can be very difficult

46
Q

on palpation of a patient with an ectopic pregnancy’s abdomen, what will you appreciate?

A

1) firmness
2) diffuse rigidity
3) guarding

47
Q

will a patient with an ectopic pregnancy have rebound tenderness?

A

yes

48
Q

what other signs will be positive on abdominal/pelvic exam of an ectopic pregnancy?

A

positive psoas, obturator

acute cervical motion tenderness, bilateral tenderness to both adnexa

49
Q

what my you see on inspection of a patient’s cervix with an ectopic pregnancy?

A

bright red blood per cervix

50
Q

at what level of beta-quantitative HCG will an intrauterine pregnancy, if present, be apparent on ultrasound?

A

2,000 mIU

51
Q

what if you don’t see an intrauterine pregnancy on ultrasound in a patient with an HCG level of 2,000?

A

high suspicion for ectopic

52
Q

if levels are around 1500 and there is no evidence of an intrauterine pregnancy, what should you do?

A

it may be too small to see

do repeat in 2-3 days

53
Q

an ultrasound showing a gestational sac with a fetal heart in the fallopian tube is what?

A

ectopic

54
Q

if a large amount of free fluid exists throughout the abdominal cavity with pooling in the cul de sac, what should we worry about?

A

perforated ectopic pregnancy

55
Q

you aren’t sure if your patients abdominal pain and cervical motion tenderness is due to PID or an ectopic pregnancy. what should you do?

A

get PG test!

the presence of a positive PG test virtually rules out pelvic infection as it is rare to find pregnancy with active PID

56
Q

what is the most common misdiagnosis assigned to early ectopic pregnancy?

A

PID!

57
Q

how can stable patients with an ectopic pregnancy be treated?

A

methotrexate injection (reduces need for surgery)

58
Q

unstable patients with an ectopic pregnancy need what?

A

surgery

59
Q

what happens if there is no intrauterine OR ectopic pregnancy found in a STABLE patient with a positive beta-HCG? what should you do?

A

manage expectantly with follow-up quantitative beta-HCG levels and ultrasound within 2-3 days

60
Q

if left untreated, what percentage of ectopics will resolve without treatment?

A

half

tubal abortions

61
Q

shoulder pain, lower back pain, cramping on one side of the pelvis mean what?

A

more severe internal bleeding may have occurred

62
Q

an ectopic pregnancy should be considered as the cause of ______ or ______ in EVERY woman who has a positive pregnancy test

A

abdominal pain or vaginal bleeding

Elaina: Surgery (6 decks)

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