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MS3 Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Define rebound tenderness

A

Pain upon releasing the palpating hand pushing on the abdomen

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2
Q

Define voluntary guarding

A

Abdominal muscle contraction with palpation of the abdomen

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3
Q

Define involuntary guarding

A

Rigid abdomen as the muscle “guard” involuntarily

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4
Q

Define colic

A

Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction

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5
Q

What conditions can mask abdominal pain?

A

Steroids, diabetes, paraplegia

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6
Q

What is the classic position of a patient with peritonitis?

A

Motionless, often with knees flexed

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7
Q

What is the classic position of a patient with a kidney stone?

A

Cannot sit still, restless, writhing in pain

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8
Q

What lab tests are used to evaluate a patient with an acute abdomen?

A

CBC with differential, Chem-10, amylase, type and screen, urinalysis, LFTs

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9
Q

What is a left shift?

A

Sign of inflammatory response: Immature neutrophils (bands)

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10
Q

Which x-rays are used to evaluate a patient with an acute abdomen?

A

Upright chest x-ray, upright abdominal x-ray, supine abdominal x-ray (if patient cannot stand, left lateral decubitus abdominal film)

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11
Q

What are the differential diagnoses by quadrant? RUQ

A 
Cholecystitis
Hepatitis
Peptic Ulcer Disease
Perforated ulcer
Pancreatitis
Liver tumors
Gastritis
Hepatic Abscess
Choledocholithiasis
Cholangitis
Pyelonephritis
Nephrolithiasis
Appendicitis - esp during pregnancy
Thoracic causes ie pleurisy, pneumonia
PE
pericarditis
MI, esp inferior MI
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12
Q

What are the differential diagnoses by quadrant? LUQ

A 
Peptic Ulcer Disease
Perforated ulcer
Splenic injury
Abscess
Reflux
Dissecting AA
Thoracic causes ie pleurisy, pneumonia
Pyelonephritis
Nephrolithiasis
Hiatal hernia (strangulated paraesophagel hernia)
Boerhaave's syndrome
Mallory-Weiss tear
Splenic artery aneurysm
Colon disease
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13
Q

What are the differential diagnoses by quadrant? LLQ

A 
Diverticulitis
Sigmoid volvulus
Perforated colon
Colon cancer
UTI
SBO
IBD
Pyelonephritis
Nephrolithiasis
Fluid accumulation from aneurysm or perforation
Referred hip pain
Gynecologic causes
Appendicitis (rare)
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14
Q

What are the differential diagnoses by quadrant? RLQ

A 
Appendicitis
Cecal Diverticulitis
Sigmoid volvulus
Perforated colon
Colon cancer
UTI
SBO
IBD
Pyelonephritis
Nephrolithiasis
Fluid accumulation from aneurysm or perforation
Referred hip pain
Gynecologic causes
Mesenteric lymphadenitis
Meckel's diverticulum
Intussusception
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15
Q

What is the differential diagnosis of epigastric pain?

A 
Peptic ulcer disease
Gastritis
MI
Pancreatitis
Biliary colic
Gastric volvulus
Mallory-Weiss
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16
Q

What is the differential of gynecologic pain?

A 
Ovarian cyst
Ovarian torsion
PID
Mittelschmerz (ovulation pain)
Tubo-ovarian abscess
Uterine fibroid
Necrotic fibroid
Pregnancy
Ectopic pregnancy
Endometriosis
Cancer of the cervix/uterus/ovary
Endometrioma
Gynecologic tumor
Torsion of cyst or fallopian tube
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17
Q

What is the differential of thoracic causes of abdominal pain?

A 
MI, especially inferior
Pneumonia
Dissecting aorta
AA
Empyema
Esophageal rupture/tear
Esophageal foreign body
Persistent pneumothorax
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18
Q

What is the differential of scrotal causes of abdominal pain?

A 
Testicular torsion
Epididyimitis
Orchitis
Inguinal Hernia
Referred pain from nephrolithiasis or appendicitis
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19
Q

What are nonsurgical causes of abdominal pain?

A 
Gastroenteritis
DKA
sickle cell crisis
PID
rectus sheath hematoma
acute porphyria
kidney stone
pylonephritis
pancreatitis
pneumonia
MI
C. diff colitis
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20
Q

What is the unique differential diagnosis for patients with AIDS and abdominal pain?

A 
CMV (most common)
Kaposi's sarcoma
Lymphoma
TB
MAI
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21
Q

What is the classic location of referred pain in cholecystitis?

A

Right subscapular

Epigastric

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22
Q

What is the classic location of referred pain in appendicitis?

A

Early: periumbilical
Rarely: testicular

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23
Q

What is the classic location of referred pain in diaphragmatic irritation (from spleen, perforated ulcer, abscess)?

A

Shoulder pain, + Kehr’s sign on the left (acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr’s sign in the left shoulder is considered a classic symptom of a ruptured spleen)

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24
Q

What is the classic location of referred pain in pancreatitis, pancreatic cancer?

A

Back pain

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25
Q

What is the classic location of referred pain in rectal disease?

A

Pain in the small of the back

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26
Q

What is the classic location of referred pain in nephrolithiasis?

A

Testicular pain, flank pain

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27
Q

What is the classic location of referred pain in small bowl stuff?

A

Periumbilical pain

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28
Q

What is the classic location of referred uterine pain?

A

Midline small of the back

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29
Q

What is the classic diagnosis associated with abdominal pain out of proportion to the exam?

A

Mesenteric ischemia

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30
Q

What is the classic diagnosis associated with hypotension and pulsatile abdominal mass?

A

Ruptured AAA - GO TO THE OR

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31
Q

What is the classic diagnosis associated with fever, LLQ pain, change in bowel habits?

A

Diverticulitis

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32
Q

Give the test of choice for cholelithiasis

A

Ultrasound

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33
Q

Give the test of choice for bile duct obstruction

A

Ultrasound

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34
Q

Give the test of choice for mesenteric ishemia

A

Mesenteric angiogram

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35
Q

Give the test of choice for AAA

A

Abdominal CT or U/S

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36
Q

Give the test of choice for abdominal abscess

A

Abdominal CT

37
Q

Give the test of choice for severe diverticulitis

A

Abdominal CT

38
Q

What are the most common endocrine problems that cause abdominal pain?

A

Addisonian crisis

DKA

39
Q

What is a sliding hernia?

A

Hernia sac partially formed by the wall of a viscus ie bladder, cecum

40
Q

What is a Littre’s hernia?

A

Hernia involving a Meckel’s diverticulum

41
Q

What is a Spigelian hernia?

A

Hernia through the linea semilunaris or spigelian fascia, aka spontaneous lateral ventral hernia

42
Q

What is an internal hernia?

A

Hernia into or involving intra-abdominal structure

43
Q

What is a Petersen’s hernia?

A

Seen after bariatric gastric bypass–internal herniation of small bowel through the mesenteric defect from the Roux limb

44
Q

What is an obdurator hernia?

A

Hernia through the obdurator canal (females > males)

45
Q

What is a lumbar hernia?

A

Petit’s hernia or Grynfeltt’s hernia (below latissimus dorsi muscle and above iliac crest on backside)

46
Q

What is a Grynfeltt’s hernia?

A

Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)

47
Q

What is a pantaloon hernia?

A

A hernia sac that exists as both a direct and indirect hernia straddling the inferior epigastric vessels and protruding through the floor of the canal as well as the internal ring

48
Q

What is a sciatic hernia?

A

A hernia through the sciatic foramen

49
Q

What is a Richter’s hernia?

A

Incarcerated or strangulated hernia involving only one sidewall of the bowel, which can spontaneously reduce, resulting in gangrenous bowel and perforation within the abdomen without signs of obstruction

50
Q

What is an epigastric hernia?

A

A hernia through the linea alba above the umbilicus

51
Q

What is an umbilical hernia?

A

A hernia through the umbilical ring – ascites, pregnancy, obesity

52
Q

What is an intraparietal hernia?

A

Hernia in which abdominal contents migrate between the layers of the abdominal wall

53
Q

What is a femoral hernia?

A

A hernia medial to femoral vessels, under the inguinal ligament

54
Q

What is a Hesselbach’s hernia?

A

Hernia under the inguinal ligament lateral to the femoral vessels

55
Q

What is a Bochdaleck’s hernia?

A

Hernia through the posterior diaphragm usually on the left

56
Q

What is a Morgagni’s hernia?

A

Anterior parasternal diaphragmatic hernia

57
Q

What is a properitoneal hernia?

A

Intraparietal hernia between the peritoneum and the transversalis fascia

58
Q

What is a Cooper’s hernia?

A

hernia through the femoral canal and tracking into the scrotum or labia majus

59
Q

What is an indirect inguinal hernia?

A

Inguinal hernia lateral to Hesselbach’s triangle (borders are inferior epigastric vessels, lateral border of rectus abdominus and inguinal ligament)

60
Q

What is a direct inguinal hernia?

A

Inguinal hernia within Hesselbach’s triangle

61
Q

What is an Amyand’s hernia?

A

Hernia sac containing a ruptured appendix

62
Q

What is the differential for a healed C-section incision mass?

A

Hernia

Endometrioma

63
Q

What are the classic findings with a CO2 gas embolus?

A

Hypotension
Decreased end tidal CO2 (low flow to lung)
Mill-wheel murmur

64
Q

What is the safest time for laparoscopy during pregnancy?

A

Second trimester

65
Q

In an alert patient, what is the quickest way to test for an adequate airway?

A

Ask a question: if the patient can speak, the airway is patent

66
Q

What is the definitive airway, if endotracheal intubation is unsuccessful?

A

Cricothyroidotomy - incise the cricothyroid membrane between the cricothyroid cartilage inferiorly and the thyroid cartilage superiorly

67
Q

What are the life-threatening conditions that MUST be diagnosed and treated during the breathing step?

A

Tension pneumothorax, open pneumothorax, massive hemothorax

68
Q

What are the layers of the abdominal wall?

A 
Skin
Subq fat
Scarpa's fascia
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum
69
Q

What is the risk of strangulation of a hernia?

A

Higher with indirect than direct inguinal hernia, highest in femoral hernia

70
Q

What is Nissen fundoplication?

A

Wrapping the fundus around the LES and suturing it in place to treat sliding esophageal hiatial hernia that was not responsive to more conservative treatments

71
Q

What are the cardiovascular effects of a pneumoperitoneum?

A

Increased afterload and decreased preload (CVP and PCWP are deceivingly elevated)

72
Q

What is the cause of post-laparascopic shoulder pain?

A

Referred pain from CO2 stretch on diaphragm

73
Q

What comprises adequate assessment of breathing?

A

Inspection - for air movement, respiratory rate, cyanosis, tracheal shift, jugular venous distention, assymetric chest expansion, use of accessory muscles of respiration, open chest wounds
Auscultation
Percussion - for hyperresonance or dullness over either lung field
Palpation - for presence of subcutaneous emphysema, flail segments

74
Q

How is a diagnosis of tension pneumothorax made?

A

Clinically - dyspnea, JVD, distention, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from the affected side, hyperresonance on the affected side

75
Q

Where is the needle placed in a needle thoracostomy to treat tension pneumo?

A

second intercostal space midclavicular line (immediate decompression)

76
Q

What is the medical term for a sucking chest wound?

A

Open pneumothorax

77
Q

Where is the tube placed in tube thoracostomy to treat pneumo?

A

Anterior/midaxillary line at the fourth intercostal space (level of nipple in men)

78
Q

What is flail chest?

A

Two separate fractures in three or more consecutive ribs
Chest wall moves paradoxically
Treat with Intubation PEEP PRN

79
Q

What is Beck’s triad?

A
  1. Hypotension
  2. Muffled heart sounds
  3. JVD
    seen in cardiac tamponade
80
Q

What is Kussmaul’s sign?

A

JVD with inspiration

seen in cardiac tamponade

81
Q

What is pulsus paradoxus?

A

Pulsus paradoxus is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg.

82
Q

How is cardiac tamponade diagnosed?

A

U/S (Echo)

83
Q

Who can be hypovolemic with normal BP?

A

Young patients - autonomic tone can maintain BP until cardiovascular collapse is imminent

84
Q

For a femoral vein catheter, how can the anatomy of the right groin be remembered?

A 
Lateral to medial, "NAVEL"
Nerve
Artery
Vein (venous close to the penis)
Empty Space
Lymphatics
85
Q

A blown pupil suggests

A

An ipsilateral brain mass (ie blood) as herniation of the brain compresses CN III

86
Q

What is the GCS indication for intubation?

A

Less than or equal to 8

87
Q

A hypothermic patient can become…

A

coagulopathic

88
Q

Otorrhea and hemotympanum are signs of

A

basilar skull fracture

89
Q

What are typical signs of basilar skull fracture?

A

Racoon eyes
Battle’s sign
clear otorrhea and rhinorrhea
Hemotympanum

MS3 Surgery (3 decks)

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