High Yield Surgery

Question 1

Blunt Abdominal trauma

Answer 1

1. Gunshot to abdomen = anything below nipples = Ex-Lap
2. Blunt abdominal trauma + guarding + rigidity + rebound tenderness + peritonitis = Ex-lap
3. Blunt abdominal trauma + hypotensive + no signs for peritonitis = FAST (you can’t do Ex-lap yet because you don’t know where they are bleeding yet)
4. Blunt abdominal trauma (stabbed/gunshot) + hemodynamically stable = CT-abdomen
5. Blunt abdominal trauma (stabbed/gunshot) + hemodynamically unstable/ or signs of peritonitis = EX-lap

Question 2

Cardiac tamponade

Answer 2

1. Classified by beck’s triad: (hypotension + JVD + Distend (muffled) heart sound) + no signs for respiratory distress
2. Initially: insert venous fluid (two large bores IV-lines 16 gauge needle)
3. Diagnosed: clinically or FAST or Echo
4. Treated: pericardiocenthesis

Question 3

(Tension) Pneumothorax

Answer 3

1. Classified as: hypotension + JVD + signs of respiratory distress/ or absent of breath sound at affected side + tracheal deviation + diaphragm pushed down + compression atelectasis ( collapsed lung because it cannot dilate)
2. Pneu-mediastinum can lead to pneumothorax or vice-versa
3. Diagnosis: clinically

Treat tension pneumothorax :

1. needle decompression (needle thoracenthesis ) = mid-clavicle at 2nd intercostal space (between 2/3 ribs)
2. thoracostomy tube ( chest tube) = anterior-axillary line at the 5th intercostal space

Treat pneumothorax:
1. Only chest tube

Question 4

Widened mediastinum

Answer 4

1. Anthrax ( bacteria inhalation)
2. Aortic ( aneurysm, rupture, unfolding. Dissection)
3. Cardiac ( cardiac tamponade, pericardial effusion)
4. Esophageal rupture
5. Mediastinum ( teratoma, thymoma, thyroid mass, lymphoma) or mediastinitis
6. Thoracic Vertebral fracture (trauma)

Question 5

Head trauma

Answer 5

1. Head trauma + loss of consciousness = head CT without contrast
   * note = negative CT scan & patient is awake/alert/oriented (time 3; place, person, time) = patient can go home

Question 6

Epidural hematoma

Answer 6

1. Lucid interval: get knocked out, then wake up, then pass out again (blood take so much space, it displaces medulla)
2. On CT-scan of head shows: lens shape
3. Treat: emergency craniotomy

Question 7

Increase ICP

Answer 7

Treat with:

1. Elevating the head
2. Hyperventilating
3. Mannitol (osmotic diuretic, helps draw fluid into the vessels to alleviate edema in the brain)

Question 8

Hemothorax

Answer 8

1. Usually resolves by its own
2. Decide if it needs OR intervention:
   * if there is >1.5 L increase in blood
   * > 200 mL/ hour for 4 hours
3. If these criteria presents, then there is an intercostal artery injury ( rather than lung laceration) & surgical procedure is required ( video assisted thorascopic surgery = VATS)

Question 9

Blunt trauma to the chest

Answer 9

Causes:

1. Pulmonary contusion = occurs 24 hours after blunt chest trauma, associated with flail chest = Chest X-ray shows white outline = treated supportively.
2. Myocardial contusion = trauma to the sternum, associated with sternal fracture = diagnosed by EKG & Troponin.
3. Traumatic aortic transection (aortic rupture) = associated with high fall & MVC (sudden deceleration) (fracture of the 1st rib, scapula, sternum) = imprint of steering wheel= chest X-ray shows widened mediastinum = CT with angiography (two types: 1. Incomplete rupture = higher survival; 2. Complete rupture= death prior to arrival to hospital) (hemorrhagic shock= hypotension, tachycardia, pale/cool extremities, collapsed neck vein/flat), signs: 1. Widened mediastinum; 2. Abnormal aortic contour; 3. Left-sided effusion due to hemothorax; diagnosis: 1. Stable pt: CT angio; 2. Unstable pt: TEE (operating room)

Note:
1. Pulmonary contusion = decreasing perfusion/ ventilation gradient by increasing the pulmonary vascular resistance and decreasing pulmonary compliance

Question 10

Blunt Bladder injury

Answer 10

1. Diagnosed with retrograde cystogram
2. If leakage into the peritoneal space = intra-peritoneal bladder injury = treat with surgery & close it with supra-pubic cystostomy tube
3. If leakage is extra-peritoneal space, below peritoneum = treat with foley catheter
4. Complications of untreated bladder injury: ileus, urinary ascites, intra-abdominal abscess, peritonitis, sepsis, vesicovaginal fistula

Question 11

Renal injury

Answer 11

1. Associated with lower rib fracture (11/12th rib which overlay the kidney)
2. present with gross hematuria
3. diagnoses: CT
4. Treatment: self-resolving (leave it alone)

Question 12

Urethral injury

Answer 12

1. Present with blood at meatus, scrotal hematoma, inability to void, high-riding prostate
2. Diagnosis: retrograde urethrogram
3. Avoid applying foley catheter because this can worsen injury

Question 13

Extremity injury (major concern is artery injury)

Answer 13

1. Differentiate between hard signs vs. soft signs:
   * Hard signs (absent pulse, bruits/thrills, active hemorrhage, expanding hematoma, distal limb ischemia)
   * soft signs (no-expanding hematoma, history of hemorrhage, unexplained hypotension, peripheral nerve deficit)
2. Diagnoses:
   * hard signs= go straight to OR
   * soft signs: MDCT angiography or duplex/doppler US

Question 14

Developmental dysplasia of the hip

Answer 14

1. Malformation of the acetabulum
2. Present with clunking sound when moving the babies’s hip , asymmetric gluteal or thigh fold
3. Diagnose: US
4. Treat: Pavlik harness

Question 15

Slipped capital femoral epiphysis

Answer 15

1. Present in obese teenage (11 years old) with slippage of epiphysis
2. Diagnosis: X-ray
3. Treatment: surgery to stabilize the growth plate that slipped (screw fixation)

Question 16

Genu varum vs genu valgum

Answer 16

1. Reassurance of patient
2. genu valrum = normal till 3 years old
3. Genu valgum = normal till 8 years old

Question 17

Legg-Calve-Perthes

Answer 17

1. Avascular necrosis of femoral head
2. Present in 6 year old kid, who is skinny
3. Treated supportively

Question 18

Osgood-schlatters disease

Answer 18

1. Tibial tuberosity inflammation with little micro fracture
2. Present with tenderness over tibial tuberosity in athletic kid
3. Treat: conservatively

Question 19

Tibial stress fracture

Answer 19

1. Present in a kid, with low BMI who is athletic
2. Present with point tenderness over the shin
3. Diagnosis: X-ray is normal
4. Treat: cast + no weight bearing + repeat x-ray in few weeks

Question 20

Compartment syndrome

Answer 20

1. Associated with fracture (supra-condylar/distal humerus), re-vascularization, and compression due to cast
2. Present with: pain, pallor, pulselessness, hypothermia, paresthesis, paralysis
3. (Excruciating) Pain out of proportion with passive movement
4. Diagnose with: clinically or needle manometry
5. Treat: fasciotomy

Question 21

Blackberry thumb (De Quervain’s tenosynovitis)

Answer 21

1. Repetitive thumb movement lead to inflammation/swelling of extensor pollicis
2. Diagnose: put thumb and cover with rest of finger & ulnar deviate = positive, if illicit pain
3. Treat: NSAIDs (Iv)

Question 22

Game-keeper thumb

Answer 22

1. Ulnar collateral ligament (UCL) tear around MCP joint of the thumb
2. Treat: casting

Question 23

Jersey finger

Answer 23

1. Hyperextend of DIP at the flexor digitorum profundus

Question 24

Mallet finger

Answer 24

1. When a ball hit the finger (index) & lead to tear in tendon

Question 25

Cuada equina syndrome

Answer 25

1. Caused by disc herniation 2. Present with LMN symptoms, urinary & bowel incontinence, decrease anal sphincter tone, perianal saddle anesthesia (can’t feel butt), paralysis 3. Diagnosis: MRI & EMERGENCY

Question 26

Marginal ulcer

Answer 26

1. Non-healing wound (that heal, break down, heal….) over many year 2. Can progress to squamous cell carcinoma 3. Need to do biopsy

Question 27

Acute gout

Answer 27

1. Main location: metatarsal phalangeal joint of big toe 2. Present with redness & inflammation 3. Investigation: aspirate & analyze the fluid (shows: negatively birefringent crystal; yellow/needle shape) 2. Treated with indomethacin (NSAID) or colchicine. 3. Colchicine is contraindicated in patients with kidney diseases, instead use intra-articular steroid

Question 28

Chronic gout

Answer 28

1. Treat with allopurinol or probenecid

Question 29

Meniscal injury

Answer 29

1. Present with popping sound when someone extend the knee

Question 30

ACL injury

Answer 30

1. Present with knee injury that gets swollen immediately | 2. Diagnosis: anterior drawer test (tibia extend anteriorly more than it should)

Question 31

Contraindication to surgery

Answer 31

1. EF < 30% 2. Diabetic coma 3. DKA

Question 32

If someone had recent MI, you should wait ?

Answer 32

6 months before any surgery

Question 33

When do you stop smoking before any surgery

Answer 33

1. At least 2 months ( 8 weeks) | 2. Smoking is bad for wound healing & act as vasoconstrictor

Question 34

Malignant hyperthermia

Answer 34

1. Caused by general anesthesia 2. Present with fever & rigidity 3. Treat: supportively with dantrolene

Question 35

Neuroleptic malignant syndrome

Answer 35

1. Caused by anti-psychotic use 2. Present with fever & rigidity 3. Treat: supportively with dantrolene

Question 36

Serotonin syndrome

Answer 36

1. Caused by anti-depressant use (SSRI) 2. Present with fever & rigidity 3. Treat: benzodiazepines or cyproheptadine

Question 37

If PE or DVT patient on anti-coagulant

Answer 37

1. drugs not working or increase bleeding | 2. Second line treatment: install IVC filter (catch any ascending thrombus that might embolize to the lung)

Question 38

If a patient is confused or disoriented

Answer 38

1. First: oxygen supplementation, to rule out hypoxia | 2.

Question 39

Metabolic acidosis (low PH, low Bicarb, low CO2)

Answer 39

Elevated anionic gap: 1. Poor tissue perfusion (lactic acidosis; sepsis) 2. Diabetic ketoacidosis (DKA) 3. Renal failure (uremia) 4. Toxicities (methanol, ethylene glycol) Normal anionic gap: 1. Severe diarrhea 2. Renal tubular acidosis (RTA) 3. Excess normal saline infusion (chloride-bicarbonate ionic shift)

Question 40

Metabolic alkalosis (high pH, High Bicarb, High CO2)

Answer 40

1. Nasogastric suctioning or severe vomiting (hypokalemia, hypochloremic, low urine Cl-/Na+ , low serum Cl-) 2. Diuretic overdose 3. Primary hyperaldosteronism ( HTN, Hypokalemia, high bicarb)

Question 41

Respiratory acidosis (hypoventilation, low PH, high bicarb, high CO2)

Answer 41

1. Central respiratory depression (opioids overuse) 2. Obesity hypoventilation syndrome, neuromuscular disease 3. Chronic obstructive pulmonary disease (COPD)

Question 42

Respiratory alkalosis (hyperventilation, high PH, low bicarb, low CO2)

Answer 42

1. Acute V/Q mismatch (PE, pneumonia) 2. Anxiety, inadequate pain control 3. High altitude, pregnancy

Question 43

Nephrolithiasis

Answer 43

1. Flank pain, hematuria, vomiting | 2. Caused by increase absorption of oxalate in the gut, due to fat malabsorption syndromes (Crohn’s disease)

Question 44

Urinary tract infection

Answer 44

1. Caused by proteus —> struvite stones in renal pelvis —> staghorn calculi

Question 45

Crohn’s disease

Answer 45

1. Increase absorption of oxalate in the gut (form oxalate stones) 2. Decrease bile salt recycling & fatty acid absorption

Question 46

Renal cell carcinoma

Answer 46

1. Weight loss, fever, anemia, hematoma, flank pain/mass