General Surgery Flashcards
1
Q
Define rebound tenderness
A
Pain upon releasing the palpating hand pushing on the abdomen
2
Q
Define voluntary guarding
A
Abdominal muscle contraction with palpation of the abdomen
3
Q
Define involuntary guarding
A
Rigid abdomen as the muscle “guard” involuntarily
4
Q
Define colic
A
Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction
5
Q
What conditions can mask abdominal pain?
A
Steroids, diabetes, paraplegia
6
Q
What is the classic position of a patient with peritonitis?
A
Motionless, often with knees flexed
7
Q
What is the classic position of a patient with a kidney stone?
A
Cannot sit still, restless, writhing in pain
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
9
Q
What is a left shift?
A
Sign of inflammatory response: Immature neutrophils (bands)
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)
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
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
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)
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
15
Q
What is the differential diagnosis of epigastric pain?
A
Peptic ulcer disease Gastritis MI Pancreatitis Biliary colic Gastric volvulus Mallory-Weiss
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
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
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
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
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
21
Q
What is the classic location of referred pain in cholecystitis?
A
Right subscapular
Epigastric
22
Q
What is the classic location of referred pain in appendicitis?
A
Early: periumbilical
Rarely: testicular
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)
24
Q
What is the classic location of referred pain in pancreatitis, pancreatic cancer?
A
Back pain
25
What is the classic location of referred pain in rectal disease?
Pain in the small of the back
26
What is the classic location of referred pain in nephrolithiasis?
Testicular pain, flank pain
27
What is the classic location of referred pain in small bowl stuff?
Periumbilical pain
28
What is the classic location of referred uterine pain?
Midline small of the back
29
What is the classic diagnosis associated with abdominal pain out of proportion to the exam?
Mesenteric ischemia
30
What is the classic diagnosis associated with hypotension and pulsatile abdominal mass?
Ruptured AAA - GO TO THE OR
31
What is the classic diagnosis associated with fever, LLQ pain, change in bowel habits?
Diverticulitis
32
Give the test of choice for cholelithiasis
Ultrasound
33
Give the test of choice for bile duct obstruction
Ultrasound
34
Give the test of choice for mesenteric ishemia
Mesenteric angiogram
35
Give the test of choice for AAA
Abdominal CT or U/S
36
Give the test of choice for abdominal abscess
Abdominal CT
37
Give the test of choice for severe diverticulitis
Abdominal CT
38
What are the most common endocrine problems that cause abdominal pain?
Addisonian crisis
| DKA
39
What is a sliding hernia?
Hernia sac partially formed by the wall of a viscus ie bladder, cecum
40
What is a Littre's hernia?
Hernia involving a Meckel's diverticulum
41
What is a Spigelian hernia?
Hernia through the linea semilunaris or spigelian fascia, aka spontaneous lateral ventral hernia
42
What is an internal hernia?
Hernia into or involving intra-abdominal structure
43
What is a Petersen's hernia?
Seen after bariatric gastric bypass--internal herniation of small bowel through the mesenteric defect from the Roux limb
44
What is an obdurator hernia?
Hernia through the obdurator canal (females > males)
45
What is a lumbar hernia?
Petit's hernia or Grynfeltt's hernia (below latissimus dorsi muscle and above iliac crest on backside)
46
What is a Grynfeltt's hernia?
Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)
47
What is a pantaloon hernia?
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
What is a sciatic hernia?
A hernia through the sciatic foramen
49
What is a Richter's hernia?
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
What is an epigastric hernia?
A hernia through the linea alba above the umbilicus
51
What is an umbilical hernia?
A hernia through the umbilical ring -- ascites, pregnancy, obesity
52
What is an intraparietal hernia?
Hernia in which abdominal contents migrate between the layers of the abdominal wall
53
What is a femoral hernia?
A hernia medial to femoral vessels, under the inguinal ligament
54
What is a Hesselbach's hernia?
Hernia under the inguinal ligament lateral to the femoral vessels
55
What is a Bochdaleck's hernia?
Hernia through the posterior diaphragm usually on the left
56
What is a Morgagni's hernia?
Anterior parasternal diaphragmatic hernia
57
What is a properitoneal hernia?
Intraparietal hernia between the peritoneum and the transversalis fascia
58
What is a Cooper's hernia?
hernia through the femoral canal and tracking into the scrotum or labia majus
59
What is an indirect inguinal hernia?
Inguinal hernia lateral to Hesselbach's triangle (borders are inferior epigastric vessels, lateral border of rectus abdominus and inguinal ligament)
60
What is a direct inguinal hernia?
Inguinal hernia within Hesselbach's triangle
61
What is an Amyand's hernia?
Hernia sac containing a ruptured appendix
62
What is the differential for a healed C-section incision mass?
Hernia
| Endometrioma
63
What are the classic findings with a CO2 gas embolus?
Hypotension
Decreased end tidal CO2 (low flow to lung)
Mill-wheel murmur
64
What is the safest time for laparoscopy during pregnancy?
Second trimester
65
In an alert patient, what is the quickest way to test for an adequate airway?
Ask a question: if the patient can speak, the airway is patent
66
What is the definitive airway, if endotracheal intubation is unsuccessful?
Cricothyroidotomy - incise the cricothyroid membrane between the cricothyroid cartilage inferiorly and the thyroid cartilage superiorly
67
What are the life-threatening conditions that MUST be diagnosed and treated during the breathing step?
Tension pneumothorax, open pneumothorax, massive hemothorax
68
What are the layers of the abdominal wall?
```
Skin
Subq fat
Scarpa's fascia
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia
Preperitoneal fat
Peritoneum
```
69
What is the risk of strangulation of a hernia?
Higher with indirect than direct inguinal hernia, highest in femoral hernia
70
What is Nissen fundoplication?
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
What are the cardiovascular effects of a pneumoperitoneum?
Increased afterload and decreased preload (CVP and PCWP are deceivingly elevated)
72
What is the cause of post-laparascopic shoulder pain?
Referred pain from CO2 stretch on diaphragm
73
What comprises adequate assessment of breathing?
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
How is a diagnosis of tension pneumothorax made?
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
Where is the needle placed in a needle thoracostomy to treat tension pneumo?
second intercostal space midclavicular line (immediate decompression)
76
What is the medical term for a sucking chest wound?
Open pneumothorax
77
Where is the tube placed in tube thoracostomy to treat pneumo?
Anterior/midaxillary line at the fourth intercostal space (level of nipple in men)
78
What is flail chest?
Two separate fractures in three or more consecutive ribs
Chest wall moves paradoxically
Treat with Intubation PEEP PRN
79
What is Beck's triad?
1. Hypotension
2. Muffled heart sounds
3. JVD
seen in cardiac tamponade
80
What is Kussmaul's sign?
JVD with inspiration
| seen in cardiac tamponade
81
What is pulsus paradoxus?
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
How is cardiac tamponade diagnosed?
U/S (Echo)
83
Who can be hypovolemic with normal BP?
Young patients - autonomic tone can maintain BP until cardiovascular collapse is imminent
84
For a femoral vein catheter, how can the anatomy of the right groin be remembered?
```
Lateral to medial, "NAVEL"
Nerve
Artery
Vein (venous close to the penis)
Empty Space
Lymphatics
```
85
A blown pupil suggests
An ipsilateral brain mass (ie blood) as herniation of the brain compresses CN III
86
What is the GCS indication for intubation?
Less than or equal to 8
87
A hypothermic patient can become...
coagulopathic
88
Otorrhea and hemotympanum are signs of
basilar skull fracture
89
What are typical signs of basilar skull fracture?
Racoon eyes
Battle's sign
clear otorrhea and rhinorrhea
Hemotympanum
