Clinical questions - Surgery

Question 1

Small bowel obstruction

Answer 1

abdominal distention
hyperactive, high pitched bowel sounds
air fluid levels on abd XR

MC cause - adhesions

Tx:
Initially: NPO, NGT + intermittent suction, IVF
If develop peritoneal signs -> laparotomy

Question 2

Epidural hematoma

Answer 2

Head injury with LOC then lucid interval

CT head: lens-shaped (biconvex) hematoma with midline deviation

Tx:
EMERGENT CRANIOTOMY

Fatal within hours if untreated

Question 3

Indications for emergent cholecystectomy

Answer 3

generalized peritonitis

emphysematous cholecystitis - concern for gangrene/performation

Question 4

Best choice in management for clavicular fracture

Answer 4

sling or figure 8 bandage

Question 5

Best choice in management for colles fracture

Answer 5

• fall on outstretched hand, radial fx with distal radius segment pointing upwards
  tx: closed reduction and casting

Question 6

Best choice in management for scaphoid fracture

Answer 6

fall on outstretched hand

-thumb spica cast

Question 7

Best choice in management for femoral neck fracture

Answer 7

femoral head replacement - high risk for avascular necrosis

Question 8

Best choice in management for intertrochanteric fracture

Answer 8

ORIF with pin

Question 9

Best choice in management for femoral shaft fracture

Answer 9

intramedullary rod fixation

Question 10

Best choice in management for trigger finger and de Quervain tenosynovitis

Answer 10

steroid injection

Question 11

Compartment syndrome

Answer 11

crush injury with prolonged ischemia followed by reprofusion

Classic sign: severe pain with passive movement

Tx: emergency fasciotomy

Question 12

Epididymitis

Answer 12

scrotal pain, fever, chills, likely new sexual partner

PE:
prinz sign: pain relieved with scrotal content manually elevated
cremasteric reflex present

US: normal testicular blood flow

Lab: UA + UCx
Cx discharge

Tx:
cover GC and chlamydia
-Cipro
-doxy

Question 13

management of AAA and risk factor modification

Answer 13

asymptomatic and AAA less than 5.5 cm - observe with serial u/s
asymptomatic and AAA 5.5 cm or more - surgical repair
If symptomatic -> surgical repair

Risk factor modification: Stop smoking! #1 risk factor for development and progression of a AAA

Question 14

Acute cholangitis

Answer 14

obstructed CBD with proximal infection
S/S: fever, RUQ pain, leukocytosis, elevated ALP, elevated Bili

Within 24 hr - IV abx, ESRP to decompress

If septic or life threatening:
-emergent ERCP to decompression CBD
IV abx: zosyn or ceftriaxone + flagyl
-> cholecystectomy

Question 15

Nonsurgical management of achilles tendon rupture

Answer 15

casting in equines position

Question 16

Presentation, Diagnosis and management of esophageal perforation

Answer 16

Presentation: pain in chest/upper abd, dysphagia, odynophagia, subQ emphysema after endoscopy

MC causes: iatrogenic (EGD), Boerhaave sn (excessive V), chest trauma

Dx:
CT chest OR gastrografin contrast esophagram

NO barium- can lead to mediastinal/pleural cavity inflammation

Question 17

Subclavian steal syndrome

Answer 17

narrowing of subclavian a. proximal to origin of the vertebral artery -> arm claudication
Neurologic sxs d/t brainstem ischemia -> disequilibrium, diplopia, ataxia

Dx:
Doppler US
MRA or CTA

Tx:
bypass surgery to bypass atherosclerotic lesion causing stenosis

Question 18

thoracic outlet syndrome

Answer 18

compression of brachial plexus or subclavian vessels d/t anatomic problem -> arm claudication
No brain stem symptoms

Question 19

Acute mesenteric ischemia

Answer 19

acute onset n/v and severe periumbilical abdominal pain - 10/10.
Known history (MI, CAD) or significant risk factor for atherosclerosis

PE: pain out of proportion to exam, mild tenderness to palpation, no guarding

W/U: CTA abdomen - lock for arterial embolus or thrombosis

Consult surgery - sooner on cases

Question 20

Management of a patient with head trauma with CT showing cerebral edema and concern for impending herniation

Answer 20

Goal - preserve brain perfusion

Venticulostomy to relieve pressure
Elevate HOB 30 degrees
IV mannitol - cautiously - can decrease cerebral perfusion

2nd line:

• hyperventilation
• sedation
• hypothermia

Question 21

Bone(s) involved in monteggia fracture

Answer 21

proximal ulna with dislocation of head of radius - fall on pronated arm

Question 22

Bone(s) involved in galeazzi fracture

Answer 22

radius with dislocation of radial/ulnar joint

Question 23

Bone(s) involved in boxer’s fracture

Answer 23

5th metacarpal

Question 24

Bone(s) involved in Jones fracture

Answer 24

5th metatarsal

Question 25

Bone(s) involved in Greenstick fracture

Answer 25

long bone fracture - incomplete
Result of bending that breaks one side of the cortex
suspect child abuse

Question 26

Plantar fasciitis

Answer 26

Pain with first steps that gradually improves with continued walking
Risk: obesity, flat feet, runners

PE: decreased dorsiflexion, point tenderness near medial process of calcanea tuberosity

Tx:
Self limited - lasts 12-15 months
Sxs tx: stretching exercises, avoid flat shoes and walking barefoot, shoe insert, NSAIDs
if no improvement within 6-12 months, local glucocorticoid injection
Surgical release

Question 27

Testicular torsion

Answer 27

sudden onset of severe groin pain with radiation to lower abdomen

PE: affected testicle oriented horizontally(transversely) in scrotum
Absent cremasteric reflex

Doppler US scrotum to evaluate

Tx: emergent surgery

Question 28

Diagnosis and management of claudication due to PVD

Answer 28

Confirm with ABI and doppler US to identify location of disease

ABI: ankle BP/arm BP - 0.9 or less = PVD

Tx:
exercise
angioplasty
surgical revascularization

Meds:
cilostazol - improve pain free walking distance

Question 29

Basillar skull fracture

Answer 29

trauma with resulting raccoon eye bruising

PE: ecchymosis around both eyes and behind ears
Continuous leakage of clear, watery fluid from nose - CSF

Mgmt:
Admit for obs
CSF leak self limited
CT head w/o con if AMS to r/o intracranial hemorrhage

if ICH -> NSx consult

Question 30

Esophageal atresia

Answer 30

1 day old neonate with choking when feeding, excessive drooling

NGT coiled in upper chest on XR

Tx:
Sx repair
-if Sx delayed - gastrostomy to protect lungs from acid refluxing via tracheoesophgeal fistula

Question 31

Knee injury associated with positive anterior drawer test and positive Lachman’s test

Answer 31

ACL - forced hyperextension of knee

Anterior force -> hyperextension -> ACL inj

Question 32

Knee injury associated with positive posterior drawer test

Answer 32

PCL - forced hyper flexion of knee

Posterior force -> hyper flexion -> PCL injury

Question 33

Knee injury associated with tibial joint line tenderness with clicking or locking and positive McMurray’s test

Answer 33

Meniscal tear