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Master the Boards Step 3 > MTB - Surgery > Flashcards

MTB - Surgery Flashcards

1
Q

How do you secure the airway in trauma pt with cervical spine injury

A
  1. Orotracheal intubation with manual cervical immobilization
  2. Best answer - flexible sigmoidoscopy
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2
Q

Best way to secure airway in pt with extensive facial trauma and bleeding into airway

A

Cricothyroidotomy

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3
Q

In a patient with hemorrhagic shock - what next steps should you take in management?

A

Prep for surgery

  • 2 large bore IVs
  • fluids, blood, type and screen
  • insert Foley catheter
  • administer IV abs
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4
Q

Initial bolus of fluids for children

A

20 ml/kg of Ringers lactate

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5
Q

Signs to make you think of vasomotor shock

A

Hypotension
Tachycardia
Warm and flushed skin
History of medication, spinal anesthesia or allergen exposure

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6
Q

First step in management of vasomotor shock

A

Vasoconstrictors and fluids

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7
Q

Asymptomatic head injury with closed skull fracture - management

A

No surgery is needed

Next step - clean any lacerations

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8
Q

Tx. Depressed or comminuted skull fractures

A

Surgery - repair or craniotomy

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9
Q

First step - head trauma and LOC

A

CT of the head and neck without contrast

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10
Q

What should be given to all patients with open skull fractures

A

Tetanus toxoid

Prophylactic antibiotics

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11
Q

Management of a CSF leak due to skull fracture

A

CT scan of head and neck
No treatment of CSF leak - it will stop on its own
Prophylactic antibiotics are not necessary

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12
Q

Management of all patients with epidural hematoma

A

Emergency craniotomy

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13
Q

Management of subdural hematoma

A

Emergency craniotomy only if there are lateralizing signs or midline displacement

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14
Q

Management of diffuse axonal injury

A

No surgery

Therapy aimed at preventing more damage from raised ICP

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15
Q

How does hyperventilation help with lowering ICP

A

Causes vasoconstriction and thus, decreased blood volume in the brain and therefore, lowers ICP

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16
Q

First line measures in elevated ICP

A
  1. Head elevation
  2. Hyperventilation
  3. Avoid fluid overload
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17
Q

Second line measures for lowering ICP

A
  1. mannitol - use very cautiously

2. Sedation and /or hypothermia (lower oxygen demand)

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18
Q

What causes of acute abdomen are treated with surgery? (4)

A
  1. Peritonitis
  2. Abdo pain plus signs of sepsis
  3. Acute intestinal ischemia
  4. Pneumoperitoneum
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19
Q

Primary peritonitis

A

Spontaneous inflammation in children with nephrosis

Adult with ascites and mild abdominal pain

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20
Q

Three things that can mimic acute abdomen

A

Lower lobe pneumonia
Myocardial ischemia
Pulmonary embolism

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21
Q

CF: GI perforation

A

Acute abdo pain that is sudden, severe, constant and generalized. It is excruciating with any form of movement

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22
Q

MCC of GI perforation

A

Diverticulitis
Perforated peptic ulcer
Crohn’s disease

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23
Q

Best dx test - GI perforation

A

Supine and erect CXR

- will show free air under the diaphragm or falciform ligament

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24
Q

Management - GI perforation

A

NPO and IVF
IV antibiotics
Emergency surgery

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25
Q

Preferred method of securing airway in trauma patient

A

Orotracheal intubation

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26
Q

Study of choice for suspected esophageal perforation

A

Gastrograffin contrast esophagogram

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27
Q

Baby is born and it is excessively salivating and has had multiple choking spells with feeding - dx?

A

esophageal atresia

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28
Q

first step - esophageal atresia?

A

NG tube - coils in upper chest on XR

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29
Q

Tx. esophageal atresia

A

primary surgical repair

- if delayed, do gastrostomy to prevent acid reflux into lungs

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30
Q

Tx. Anal Atresia

A

if a fistula is present - repair can be delayed until further growth; if no fistula - colostomy

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31
Q

VACTERL

A 
Vertebral Anomalies
Anal atresia
Cardiovascular anomalies
TE fistula
Renal and/or radial anomalies
Limb defects
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32
Q

Management - Congenital Diaphragmatic Hernia

A
  1. Endotracheal intubation
  2. Low pressure ventilation
  3. Sedation
  4. NG Suction
  5. Repair in 3-5 days
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33
Q

Management - Gastroschisis or Omphalocele

A

if large –> Silastic Silo and manual replacement of bowel daily
1. supplement with TPN

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34
Q

Tx. Exstrophy of the Bladder

A

Transfer to specialized center with repair in 1-2 days!

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35
Q

Conditions presenting with “double bubble” sign

A

Annular pancreas
Duodenal atresia
Intestinal Malrotation

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36
Q

XR - multiple air-fluid levels throughout the abdomen (dx?)

A

Intestinal Atresia

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37
Q

CF: Necrotizing Enterocolitis

A

Feeding intolerance in preemie
Abdominal distention
Dropping platelet count

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38
Q

Tx. Necrotizing Enterocolitis

A
  1. Stop feeds
  2. Broad spec. abx
  3. IVF and TPN
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39
Q

When do you do surgery for NEc?

A

Signs of necrosis or perforation

  • abdominal wall erythema
  • portal vein gas
  • gas in bowel wall
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40
Q

Dx. Meconium Ileus

A

XR –> multiple dilated loops of bowel and ground glass appearance in lower abdomen

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41
Q

Management of Meconium Ileus

A

Gastrograffin enema

- both diagnostic and therapeutic

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42
Q

Management of Hypertrophic Pyloric Stenosis

A
  1. correct dehydration and electrolyte abnormalities

2. Ramstedt pyloromyotomy

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43
Q

CF: biliary atresia

A

progressive rise in bilirubin (CB) in a 6-8 week old baby

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44
Q

Dx. biliary atresia

A

Give baby 1 week of phenobarbital then do a HIDA scan; if no bile reaches duodenum –> will need surgical exploration

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45
Q

A patient presents with chronic constipation; A rectal exam causes explosive expulsion of stool and flatus w/ relief of distention - dx?

A

Hirschsprung dz

Dx. with full thickness biopsy of rectal mucosa

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46
Q

Management - Intussusception

A

Barium or Air enema

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47
Q

Dx. of Meckel Diverticulum

A

Radioisotope scan

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48
Q

Tx. Meckel Diverticulum

A

Surgical Resection

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49
Q

diagnostic testing for intestinal obstruction

A

CBC and lactate level (elevated)

supine/erect AXR

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50
Q

initial management of intestinal obstruction

A

NPO
IVF
NG suction

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51
Q

Tx. volvulus

A

proctosigmoidoscopy with rigid tube - leave rectal tube in place

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52
Q

What two hernia types do NOT require surgical repair?

A

umbilical hernias in children < 2 yo

esophageal sliding hiatal hernia

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53
Q

Diagnostic test for acute diverticulitis

A

CT w/ contrast

- fat stranding of inflamed bowel

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54
Q

Management of acute diverticulitis

A

No peritoneal signs? outpt abx

Peritoneal signs and abscess -> admission, IVF, NPO, IV abx

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55
Q

warning signs for acute hemorrhagic pancreatitis

A

dropping Hct
very high WBC, glucose and BUN
very low Ca

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56
Q

tx. pancreatic pseudocyst

A

if painless - do not drain

if painful and > 6 cm and > 6 weeks - percutaneous or endoscopic drainage

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57
Q

Dx of appendicitis

A

clinical picture and physical exam

- only do CT scan if those are not clear

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58
Q

What IV abx can be given in acute appendicitis

A

Cipro + Metro
Ampicillin/sulbactam
Levofloxacin + Clindamycin
Cefoxitin or Cefotetan

59
Q

Abdominal pain that is out of proportion to exam - next step?

A

Surgery consult

Order angiography

60
Q

Tx. of mesenteric ischemia if diagnosis is made in (1) surgery and (2) angiography

A
  1. Embolectomy and revascularization

2. Vasodilators and thrombolysis

61
Q

Diagnostic testing for suspected intra abdominal abscess

A

CBC

Contrast CT of abdomen and pelvis

62
Q

Tx. Intra abdominal abscess

A

drainage

Antibiotics

63
Q

Diagnostic testing for obstructive jaundice

A

USG

Confirm with EUS or MRCO

64
Q

Treatment of obstructive jaundice due to stones

A

ERCP with sphincterectomy

Cholecystectomy should follow

65
Q

Dx. Obstructive jaundice due to tumor

A

USG

Ct scan

66
Q

Treatment of acute Cholecystitis

A

NG suction, NPO, IVF, antibiotics

67
Q

When do you do an emergency cholecystectomy for acute Cholecystitis

A
  1. Generalized peritonitis

2. Emphysematous Cholecystitis (perforation or gangrene)

68
Q

Reynolds Pentad

A 
Jaundice
Fever
Abdominal pain 
Altered mental status
Shock
69
Q

Clinical findings in acute ascending cholangitis

A 
High fever
Very high WBC count
High ALP
High total bilirubin and direct bilirubin
Mild elevation of LFTS
70
Q

Management of acute ascending cholangitis

A
  1. Blood cultures
  2. Antibiotics
  3. Emergency decompression with ERCP
71
Q

Antibiotics used in acute ascending cholangitis

A

Amp + gent

Monotherapy with either imipinem or levofloxacin

72
Q

Hepatic risk factors with increased morbidity and mortality for surgery

A
  1. Bilirubin > 2
  2. Albumin below 3
  3. Prothrombin time > 16
  4. Encephalopathy (altered mental status)
73
Q

Can you operate on someone with EF < 35%?

A

No

74
Q

When can you do surgery on a patient with recent myocardial infarction?

A

Defer surgery for 6 months

75
Q

Preop assessment: patient with severe progressive angina

A

Perform cardiac cath to eval for possible revascularization

76
Q

Pre op assessment of pt who smokes

A

Order PFTs to evaluate fev1: if high pco2 or fev1 < 1.5 (at increased risk of pneumonia) other smoker pts should stop smoking 8 weeks prior to surgery

77
Q

Post op fever day 1

A

Atelectasis

- incentive spirometry

78
Q

Post op fever day 3

A

Pneumonia

  • CXR infiltrate
  • sputum culture and antibiotics
79
Q

Post op fever day 3

A

UTI

  • urinalysis and urinary culture
  • antibiotics
80
Q

Post op fever day 5

A

DVT

  • get Doppler of LE and pelvis
  • give anti coagulation
81
Q

Post op disorientation

A

Always consider hypoxia first and get an ABG

82
Q

when is open reduction and internal fixation appropriate for fracture?

A

severely displaced or angulated fractures that cannot be aligned

83
Q

tx. open fractures

A

cleaning in the OR and reduction w/in 6 hours

84
Q

what test should you always order in anyone with facial fracture?

A

spinal XR

85
Q

Tx. gas gangrene

A

IV penicillin and hyperbaric oxygen

86
Q

what do you suspect in pt with shoulder pain and inability to move arm who recently had a seizure (or got an electrical burn)?

A

posterior shoulder dislocation

- arm held close to body, forearm internally rotated

87
Q

Dx. posterior shoulder dislocation

A

axillary or scapular views of the spine

88
Q

patient comes in with arm held close to the body, externally rotated forearm and numbness over the deltoid muscle

A

anterior shoulder dislocation

89
Q

Tx. clavicular fracture

A

figure 8 sling

90
Q

Monteggia vs. Galeazzi fracture

A

direct blow to either ulna (monteggia) or radius (galeazzi) –> diaphyseal fracture and displaced dislocation of nearby joint

91
Q

Tx. monteggia/galeazzi fracture

A

ORIF - diaphyseal fracture

closed reduction - dislocation

92
Q

tx. femoral neck fractures

A

femoral head replacement - high risk of avascular necrosis

93
Q

tx. intertrochanteric femoral fractures

A

Open reduction and pinning

94
Q

Tx. femoral shaft fractures

A

intramedullary rod fixation

95
Q

best initial therapy: trigger finger

A

steroid injection

96
Q

best initial therapy: deQuervain’s tenosynovitis

A

steroid injection

97
Q

Dupuytren’s contracture - tx

A

surgery

98
Q

how do you differentiate between a hip fracture and posterior dislocation of the hip?

A

posterior dislocation - internally rotated leg

hip fracture - externally rotated leg

99
Q

tx. rupture of achilles tendon

A

casting in equinis position or surgical repair

100
Q

first step in management of compartment syndrome

A

emergency fasciotomy

101
Q

neurovascular complication of oblique distal humerus fracture

A

radial nerve damage –> unable to extend the wrist; function is usually regained after reduction, if not - surgery

102
Q

neurovascular complication of posterior dislocation of the knee

A

popliteal artery injury –> decreased distal pulses; order doppler studies or arteriogram; prophylactic fasciotomy if reduction is delayed

103
Q

characteristic feature of lumbar spinal stenosis

A

increased pain with extension of the spine that improves with sitting or bending forward`

104
Q

dx. lumbar spinal stenosis

A

MRI of the spine

105
Q

Tx. lumbar disc herniation (acute)

A

ibuprofen and bed rest

do not need to get an MRI at first

106
Q

when do you need immediate surgical decompression in lumbar disc herniation?

A

cauda equina –> bowel bladder incontinence, flaccid anal sphincter and saddle anesthesia

107
Q

Tx. ankylosing spondylitis

A

anti-inflammatory agents

physical therapy

108
Q

which ca. cause blastic bone mets?

A

prostate ca and breast ca

109
Q

first test to order in suspected metastatic bone malignancy

A

XR

110
Q

heel pain that is worse in the morning, resolves with walking and is accompanied by tenderness to palpation of the heel

A

plantar fasciitis

- bony spur on heel

111
Q

tx. plantar fasciitis

A

symptomatic - resolves w/in 12-18 months on its own

112
Q

inflammation of common digital nerve at 3rd interspace between 3rd and 4th toes; very tender to palpation in that area

A

Morton’s neuroma

113
Q

Tx. mortons neuroma

A

analgesics, appropriate footwear

114
Q

male pt presents with severe, sudden onset testicular pain. on exam, cremasteric reflex is absent and testis is high riding. - dx? next step?

A

R/O testicular torsion

- order testicular USG

115
Q

Tx. testicular torsion

A

immediate surgery with bilateral orchiopexy

- do not delay surgery for diagnostic tests

116
Q

male pt comes in with acute scrotal pain, urinary symptoms and fever - dx? next step?

A

dx - acute epididymitis

next step - urinalysis and culture

117
Q

Tx. epididymitis

A
  1. males < 35 yo: ceftriaxone and doxycycline

2. older males: tx. as UTI - levofloxacin

118
Q

management of urologic obstruction + infection

A
  1. decompression of urinary tract above obstruction (ureteral stent or percutaneous nephrostomy)
  2. IV Abx
119
Q

MCC for newborn boy not to urinate in first DOL

A

posterior urethral valves

120
Q

management: posterior urethral valves

A
  1. catheterize bladder

2. voiding cystourethrogram

121
Q

child with hematuria from trivial trauma

A

congenital anomaly until proven otherwise

122
Q

child with UTI

A

undiagnosed congenital anomaly ex. vesicoureteral reflux

123
Q

dx. vesicoureteral reflux

A

voiding cystogram

- give long term abx

124
Q

young girl who voids appropriately but her underwear are constantly wet with urine

A

low implantation of ureter (into vagina)

125
Q

ureteropelvic junction obstruction

A

only sx if diuresis occurs - ex. teenager who drinks large volumes of beer and develops colicky flank pain

126
Q

48 year old man comes in c/o coldness and tingling in L hand as well as pain when he does strenuous work. These episodes are accompanied by dizziness and blurred vision. Dx?

A

Subclavian steal syndrome

127
Q

Dx. subclavian steal syndrome

A

angiography

128
Q

Tx. subclavian steal syndrome

A

bypass surgery

129
Q

Tx. symptomatic AAA (abdominal pain, hypotension)

A

urgent surgery w/in the next day

130
Q

Tx. asymptomatic AAA

A

ASA + Statins
4-5.4 cm: USG q6-12 mo
< 4cm: USG q2-3 years

131
Q

most impt modifiable RF for AAA

A

smoking

132
Q

Elective repair for AAA

A
  1. if > 5.5 cm
  2. rapidly enlarging (>0.5 cm in 6 mo)
  3. AAA assoc. with PAD or aneurysm
133
Q

MC location of AAA

A

infrarenal aorta

134
Q

most important intervention to prevent progression of thoracic aortic aneurysm

A

BP control

135
Q

MC complication post AAA repair

A

spinal cord infarction - ASA occlusion

- get immediate neuro consult

136
Q

management of intermittent claudication (if not interfering significantly with lifestyle)

A

cessation of smoking

cilastazol and ASA

137
Q

dx. intermittent claudication

A

doppler studies - ABI <0.9

138
Q

When do you consider surgery stenting or angioplasty for intermittent claudication?

A

disabling symptoms or impending ischemia to extremity

139
Q

preferred intubation method in pt with multiple facial fractures

A

oral laryngoscopy

- blind nasal intubation is C/I

140
Q

CF: patellar tendon rupture

A

excrucitating pain
joint swelling of anterior knee
difficulty bearing weight
unable to perform active extension of leg
unable to maintain passively extended knee against gravity

141
Q

CF: ACL tear

A

lots of pain
inability to ambulate
popping sensation/sound at time time of injury
positive anterior drawer test

142
Q

mechanism of meniscal injury

A

twisting force with the foot fixed on the ground

143
Q

what test do you use to test meniscal injury

A

McMurray’s maneuver

- audible or palpable click or popping sensation during extension of involved knee

144
Q

Tx. ruptured patellar tendon

A

early surgical repair

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