Clinical questions - Surgery Flashcards by Autumn Brubaker

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

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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

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Indications for emergent cholecystectomy

generalized peritonitis

emphysematous cholecystitis - concern for gangrene/performation

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Best choice in management for clavicular fracture

sling or figure 8 bandage

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Best choice in management for colles fracture

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

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Best choice in management for scaphoid fracture

fall on outstretched hand

-thumb spica cast

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Best choice in management for femoral neck fracture

femoral head replacement - high risk for avascular necrosis

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Best choice in management for intertrochanteric fracture

ORIF with pin

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Best choice in management for femoral shaft fracture

intramedullary rod fixation

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Best choice in management for trigger finger and de Quervain tenosynovitis

steroid injection

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Compartment syndrome

crush injury with prolonged ischemia followed by reprofusion

Classic sign: severe pain with passive movement

Tx: emergency fasciotomy

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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

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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

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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

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Nonsurgical management of achilles tendon rupture

casting in equines position

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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