Clinical questions - Surgery Flashcards
Small bowel obstruction
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
Epidural hematoma
Head injury with LOC then lucid interval
CT head: lens-shaped (biconvex) hematoma with midline deviation
Tx:
EMERGENT CRANIOTOMY
Fatal within hours if untreated
Indications for emergent cholecystectomy
generalized peritonitis
emphysematous cholecystitis - concern for gangrene/performation
Best choice in management for clavicular fracture
sling or figure 8 bandage
Best choice in management for colles fracture
- fall on outstretched hand, radial fx with distal radius segment pointing upwards
tx: closed reduction and casting
Best choice in management for scaphoid fracture
fall on outstretched hand
-thumb spica cast
Best choice in management for femoral neck fracture
femoral head replacement - high risk for avascular necrosis
Best choice in management for intertrochanteric fracture
ORIF with pin
Best choice in management for femoral shaft fracture
intramedullary rod fixation
Best choice in management for trigger finger and de Quervain tenosynovitis
steroid injection
Compartment syndrome
crush injury with prolonged ischemia followed by reprofusion
Classic sign: severe pain with passive movement
Tx: emergency fasciotomy
Epididymitis
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
management of AAA and risk factor modification
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
Acute cholangitis
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
Nonsurgical management of achilles tendon rupture
casting in equines position
Presentation, Diagnosis and management of esophageal perforation
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
Subclavian steal syndrome
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
thoracic outlet syndrome
compression of brachial plexus or subclavian vessels d/t anatomic problem -> arm claudication
No brain stem symptoms
Acute mesenteric ischemia
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
Management of a patient with head trauma with CT showing cerebral edema and concern for impending herniation
Goal - preserve brain perfusion
Venticulostomy to relieve pressure
Elevate HOB 30 degrees
IV mannitol - cautiously - can decrease cerebral perfusion
2nd line:
- hyperventilation
- sedation
- hypothermia
Bone(s) involved in monteggia fracture
proximal ulna with dislocation of head of radius - fall on pronated arm
Bone(s) involved in galeazzi fracture
radius with dislocation of radial/ulnar joint
Bone(s) involved in boxer’s fracture
5th metacarpal
Bone(s) involved in Jones fracture
5th metatarsal
Bone(s) involved in Greenstick fracture
long bone fracture - incomplete
Result of bending that breaks one side of the cortex
suspect child abuse
Plantar fasciitis
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
Testicular torsion
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
Diagnosis and management of claudication due to PVD
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
Basillar skull fracture
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
Esophageal atresia
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
Knee injury associated with positive anterior drawer test and positive Lachman’s test
ACL - forced hyperextension of knee
Anterior force -> hyperextension -> ACL inj
Knee injury associated with positive posterior drawer test
PCL - forced hyper flexion of knee
Posterior force -> hyper flexion -> PCL injury
Knee injury associated with tibial joint line tenderness with clicking or locking and positive McMurray’s test
Meniscal tear
