General Surgery

Question 1

Define the acute abdomen. What physical exam signs suggest its presence?

Answer 1

Inflamed peritoneum (peritonitis), which is often due to a surgically correctable problem. Best physical exam confirmations are rebound tenderness (letting go quickly after deep palpation of abdomen causes acute pain) and involuntary guarding (abdominal wall muscle spasms that cannot be controlled). Voluntary guarding and tenderness to palpation are softer signs often present in benign diseases.

Question 2

What should you do if you are not sure whether a stable patient has an acute abdomen?

Answer 2

Use minimal as needed pain medications (to avoid masking symptoms), perform serial abdominal exams, and consider CT scan.

Question 3

Name a few causes of peritonitis that do not require laparotomy or laparoscopy.

Answer 3

Pancreatitis, many causes of diverticulitis, spontaneous bacterial peritonitis

Question 4

Which condition is associated with pain and peritonitis in the upper right abdominal quadrant?

Answer 4

Gallbladder/biliary (cholecystitis, cholangitis) or liver (abscess)

Question 5

Which condition is associated with pain and peritonitis in the upper left abdominal quadrant?

Answer 5

Spleen (rupture with blunt trauma)

Question 6

Which condition is associated with pain and peritonitis in the lower right abdominal quadrant?

Answer 6

Appendix (appendicitis), pelvic inflammatory disease

Question 7

Which condition is associated with pain and peritonitis in the lower left abdominal quadrant?

Answer 7

Sigmoid colon (diverticulitis), pelvic inflammatory disease

Question 8

Which condition is associated with pain and peritonitis in the epigastric area?

Answer 8

Stomach (peptic ulcer) or pancreas (pancreatitis)

Question 9

What are the classic symptoms and signs of gallstone disease?

Answer 9

Postprandial, colicky pain in the RUQ with bloating and/or nausea and vomiting. Pain usually begins 15-60 minutes after a meal (esp. fatty meal). Look for Murphy sign (palpation of RUQ under rib cage causes arrest of inspiration 2/2 pain) in cholecystitis.

Question 10

What are the six Fs of cholecystitis? How are the demographics of patients with pigment stones different from those with cholesterol stones?

Answer 10

Fat, Forty, Fertile, Female, Flatulent, Feather
Pts with pigment (i.e. calcium bilirubinate) stones are classically young with hemolytic anemia (e.g. sickle cell disease, hereditary spherocytosis).

Question 11

How is a clinical suspicion of cholecystitis confirmed and treated?

Answer 11

Ultrasound is the best first imaging study for gallbladder disease. May show gallstones, thin layer of fluid around gallbladder, and/or thickened gallbladder wall. Nuclear hepatobiliary scintigraphic study (e.g. hepato-iminodiacetic acid [HIDA] scan) clinches the diagnosis with nonvisualization of gallbladder. Tx is cholecystectomy.

Question 12

Define cholangitis. How does it differ from cholecystitis?

Answer 12

Cholangitis is inflammation of the bile ducts, whereas cholecystitis is inflammation of the gallbladder. Cholangitis is classically due to biliary obstruction with subsequent bile stasis and infection. Autoimmune cholangitis (e.g. sclerosing cholangitis) and primary infection (e.g. Clonorchis sinensis) are other causes.

Question 13

How does cholangitis classically present? How is it treated?

Answer 13

Charcot triad: (1) RUQ pain, (2) fever or shaking chills, and (3) jaundice
Tx: broad-spectrum antibiotics to cover bowel flora (e.g. piperacillin with tazobactam); then definitive management with cholecystectomy or biliary stent placement

Question 14

Describe the classic presentation appendicitis. How is it treated?

Answer 14

10-30 year-old with a history of crampy, poorly localized periumbilical pain followed by nausea and vomiting. Then pain localizes to RLQ, and peritoneal signs develop with worsening nausea and vomiting. “Hamburger” sign - pt who is hungry and asking for food does NOT have appendicitis. Rovsing sign - palpate a different quadrant then release hand, pt feels pain at McBurney point.
Tx: appendectomy

Question 15

What is the cause of left lower quadrant pain and fever in a patient over 50 years old until proven otherwise? How is it treated?

Answer 15

Diverticulitis. Treat medically with broad-spectrum antibiotics, avoidance of eating, and an NG tube if nausea and vomiting are present. For disease that recurs or is refractory to medical therapy, consider sigmoid colon resection.

Question 16

What tests should and should not be done to confirm possible cases of diverticulitis? What test does every patient need after a treated episode of diverticulitis?

Answer 16

Colonoscopy should NOT be performed in the acute setting because colon rupture may occur. Barium enema is also avoided for the same reason. However, one of these tests should be done in every patient after tx to exclude colon CA. Order a CT scan, if necessary, to confirm the diagnosis.

Question 17

Describe the typical history, physical exam, and lab findings of pancreatitis. How is it treated?

Answer 17

Epigastric pain that radiates to the back in an alcohol abuser or pt with history of gallstones. Serum amylase and/or lipase should be elevated. Also decreased bowel sounds, localized ileus (“sentinel” loop of bowel on abd radiograph) and nausea, vomiting, and/or anorexia.
Tx: SUPPORTIVE! Narcotics for pain control (meperidine favored over morphine b/c sphincter of Oddi spasm; fentanyl), NG tube for n/v, IV fluids

Question 18

Describe the usual history of a perforated ulcer. How is it treated?

Answer 18

Usually no history of alcohol abuse or gallstones but history of peptic ulcer disease. Abdominal radiographs show free air under diaphragm. Perforated bowel can cause an increased amylase level! Treat surgically.

Question 19

What are the hallmarks of small bowel obstruction? How is it treated?

Answer 19

Bilious vomiting (early symptom), abdominal distention, constipation, hyperactive bowel sounds (high-pitched, rushing sounds), and usually poorly localized abdominal pain. Radiographs show multiple air-fluid levels. Pts often have history of previous surgery.
Tx: withold food, place NG tube, give IV fluids. If obstruction does not resolve or peritoneal signs develop, laparotomy is usually needed.

Question 20

What are the common causes of small bowel obstruction?

Answer 20

In adults, most common cause is adhesions (usually from prior surgery). Incarcerated hernias and Crohn’s disease are other common causes. Other causes include Meckel diverticulum and intussusception (both typically seen in children).

Question 21

Describe the signs and symptoms of large bowel obstruction. What causes it? How is it treated?

Answer 21

Gradually increasing abdominal pain, distention, constipation, and feculent vomiting (late symptom). In older adults, most common causes are diverticulitis, colon CA, and volvulus. In children, watch for Hirschsprung disease.
Tx: withhold food and place NG tube for n/v. Sigmoid volvulus can often be decompressed with endoscope. Other refractory causes require surgery to relieve obstruction.

Question 22

Describe an indirect hernia

Answer 22

Most common type in both sexes and all age groups. Hernia sac travels through inner and outer inguinal rings (protrusion begins lateral to inferior epigastric vessels) and into scrotum or labia because of patent processus vaginalis (congenital defect).

Question 23

Describe a direct hernia

Answer 23

No sac. Hernia protrudes medial to inferior epigastric vessels because of weakness in abdominal musculature of Hesselbach’s triangle.

Question 24

Describe a femoral hernia

Answer 24

More common in women. Hernia (no sac) goes through femoral ring onto anterior thigh (located below inguinal ring).

Question 25

Which type of hernia is most susceptible to incarceration and strangulation?

Answer 25

Femoral hernia

Question 26

Define incarcerated and strangulated hernias.

Answer 26

Incarcerated - herniated organ is trapped and becomes swollen and edematous; most common cause of small bowel obstruction in pts without history of previous abdominal surgery
Strangulated - occurs after incarceration when entrapment becomes so severe that blood supply is cut off; can lead to necrosis (can present with small bowel obstruction and shock) - surgical emergency

Question 27

True or false: Generally, patients should not eat or drink for 8 or more hours before surgery.

Answer 27

True. This reduces the chance of aspiration and subsequent pneumonia.

Question 28

What is the best test (other than a good history) for preoperative evaluation of pulmonary function?

Answer 28

Spirometry, which gives functional vital capacity, forced expiratory volumes, and maximal voluntary ventilation

Question 29

What measures help to prevent intraoperative and postoperative deep venous thrombosis and pulmonary embolus?

Answer 29

Compressive/elastic stockings, early ambulation, and/or low-dose heparins (unfractionated or low molecular weight)

Question 30

What is the most common cause of fever in the first 24 hrs after surgery?

Answer 30

Atelectasis. Prevent and treat with early ambulation, chest physiotherapy/percussion, incentive spirometry, and proper pain control. Both too much pain and too many narcotics (decrease respiratory effort) increase the risk.

Question 31

What are the other common causes of postoperative fever?

Answer 31

Water - UTI
Wind - atelectasis and pneumonia
Walk - DVT
Wound - surgical wound infection
Weird - drug fever
In pts with daily fever spikes that do not respond to antibiotics, think about an intraabdominal abscess

Question 32

Define fascial or wound dehiscence. How do you recognize it?

Answer 32

Occurs when the surgical wound opens spontaneously, usually 5-10 days postoperatively. Look for leakage of serosanguineous fluid from the wound, particularly after the pt coughs or strains. Frequently the wound is infected. Surgical reclosure of the wound and treatment of infection are required.

Question 33

Explain the ABCDEs of trauma. How are they used?

Answer 33

Airway, Breathing, Circulation, Disability, and Exposure

Keys to the initial management of trauma patients. Follow them in order if simultaneous management is not possible.

Question 34

What is the different between airway and breathing in trauma protocol?

Answer 34

Airway - provision, protection, and maintenance of an adequate airway at all times (may require intubation or cricothyroidotomy)
Breathing - similar to airway but even pts with an open airway may not be breathing spontaneously (may require intubation or cricothyroidotomy)

Question 35

Explain circulation, disability, and exposure in trauma protocol.

Answer 35

Circulation - circulating blood volume; if pt seems hypovolemic give IV fluids (lactated Ringers or NS) and/or blood products
Disability - neurologic function (Glasgow coma scale)
Exposure - expose and examine the entire body; remove all clothes and “put a finger in every orifice”

Question 36

What imaging films are routinely ordered for most patients with at least moderately severe trauma?

Answer 36

Cervical spine, chest, and pelvic radiographs

Question 37

What is the imaging study of choice for head trauma?

Answer 37

Noncontrast CT (better than MRI for acute trauma)

Question 38

How do you manage a patient with blunt abdominal trauma?

Answer 38

If awake, stable, and examination is “benign”, observe patient and repeat abdominal exam later. If patient is hemodynamically unstable, proceed directly to laparotomy

Question 39

How is penetrating abdominal trauma managed?

Answer 39

With any gunshot wound that may have violated the peritoneal cavity, proceed directly to laparotomy. Stab wounds management is controversial. Either proceed directly to laparotomy (esp. if unstable) or perform CT scan.

Question 40

Which six thoracic injuries can be rapidly fatal?

Answer 40

1. Airway obstruction 2. Open pneumothorax 3. Tension pneumothorax 4. Cardiac tamponade 5. Massive hemothorax 6. Flail chest

Question 41

How do you recognize and treat airway obstruction?

Answer 41

No audible breath sounds, cannot answer questions even if awake, and may be gurgling. Treat with intubation. If this fails, do cricothyroidotomy (or a tracheostomy in OR if time allows).

Question 42

How do you recognize and treat an open pneumothorax?

Answer 42

Present with an open defect in the chest wall and decreased or absent breath sounds on the affected side. Causes poor ventilation and oxygenation. Treat with intubation, positive-pressure ventilation, and closure of the defect in the chest wall (gauze and tape it on 3 sides only - allows excessive pressure to escape so that you do not convert into a tension pneumothorax)

Question 43

How do you recognize and treat a tension pneumothorax?

Answer 43

May occur after blunt or penetrating trauma to the chest. Air forced into the pleural space cannot escape and collapses the affect lung, then shifts the mediastinum and trachea to the opposite side. Findings include absent breath sounds on affected side and a hypertympanic percussion sound. Hypotension and/or distended neck veins may result from impaired cardiac filling. Treat with needle thoracentesis, followed by chest tube insertion.

Question 44

Describe the usual presentation of cardiac tamponade. How is it diagnosed and treated?

Answer 44

Classically associated with penetrating trauma to the left chest. Presents with hypotension (2/2 impaired cardiac filling), distended neck veins, muffled heart sounds, pulsus paradoxus (exaggerated fall in BP on inspiration), and normal breath sounds. If pt is unstable, treat with pericardiocentesis. If pt is stable, do echocardiogram to confirm diagnosis.

Question 45

Define massive hemothorax. How is it diagnosed and treated?

Answer 45

Loss of more than 1 L of blood into the thoracic cavity. Pts have decreased (not absent) breath sounds in affected area, dull note on percussion, hypotension, collapsed neck veins (from blood leaving vascular tree), and tachycardia. Placement of chest tube allows blood to come out. Give IV fluids and/or blood before placing chest tube if diagnosis is known in advance. If bleeding stops after initial outflow, order CXR or CT to check for remaining blood or pathology. Treat supportively. If bleeding does not stop, do emergent thoracotomy.

Question 46

How do you recognize and treat flail chest?

Answer 46

Several adjacent ribs are broken in multiple places, causing affected part of chest wall to move paradoxically during respiration (inward during inspiration, outward during expiration). Almost all pts have associated pulmonary contusion, which, combined with pain, may make respiration inadequate. When you are in doubt or the pt is not doing well, intubate and give positive pressure ventilation.

Question 47

What is the most common cause of immediate death after an automobile accident or a fall from a great height?

Answer 47

Aortic rupture. Look for widened mediastinum on CXR and an appropriate history of trauma. Order CT scan or angiogram if a contained aortic rupture is suspected. Aortic laceration, traumatic aortic injury, and traumatic pseudoaneurysm all describe the phenomenon seen in initial survivors: an aortic rupture contained by a hematoma or an inadequate amount of surrounding tissue (e.g. adventitia only). Treat with immediate surgical repair.

Question 48

What is the most commonly injured organ in blunt trauma?

Answer 48

Spleen

Question 49

How does splenic rupture present?

Answer 49

History of blunt abdominal trauma, hypotension, tachycardia, shock, and/or Kehr sign (referred pain in left shoulder). Pts with EBV or infectious mononucleosis should avoid contact sports to prevent rupture. Make sure pts needing splenectomy have received the pneumococcal, meningococcal, and H. influenzae vaccines.

Question 50

What clues suggest a diagnosis of diaphragmatic rupture? How is it treated?

Answer 50

Diaphragm rupture usually occurs after blunt trauma and on the left side (liver protects the right side). May hear bowel sounds when listening to chest or see bowel that has herniated into chest on CXR. Treat with surgical repair.

Question 51

What are the 3 zones of the neck? How is trauma in each of the different zones managed?

Answer 51

Zone I - base of neck from 2 cm above clavicles to level of clavicles
Zone II - midcervical region from 2 cm above clavicle to angle of mandible
Zone III - top of neck from angle of mandible to base of skull
With zone I and III, order arteriogram before going to OR. With zone II, proceed to OR for surgical exploration. In pts with obvious bleeding or rapidly expanding hematoma in the neck, proceed directly to OR no matter where the injury is.

Question 52

How should a choking victim be managed?

Answer 52

Always leave them alone if they are speaking, coughing, or breathing. Otherwise, do Heimlich maneuver.

Question 53

What should you do if a tooth is knocked out?

Answer 53

Put the tooth back in place with no cleaning (or only saline to rinse it off) and stabilize the tooth in place. The sooner this is done, the better the prognosis for salvage of the tooth.