ROSH General surgery Flashcards by Karina Borges

African-American woman
Labs will show hypercalcemia and elevated serum ACE
CXR will show bilateral hilar adenopathy
Biopsy will show noncaseating granulomas

Sarcoidosis

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Patient will be older, usually male
With a history of HTN, Marfan syndrome
Complaining of sudden “ripping” _or“tearing” CP radiating to back

Aortic Dissection

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PE will show:

asymmetric pulses/BP

Aortic Dissection

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CXR will show:

widened mediastinum

Aortic Dissection

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Aortic Dissection

treatment:

reduce BP/HR
surgery (depending on dissection type)

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complaining of:

headaches
diaphoresis
tremors
vision changes

PE will show:

hypertension

Pheochromocytoma

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Diagnosis is made by:

Assay of urinary catecholamines and metanephrines
plasma metanephrine levels

Pheochromocytoma

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MCC by:

catecholamine-secreting tumor located in the adrenal glands

Pheochromocytoma

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Pheochromocytoma

Treatment:

Treatment is surgery
α-blocker (ie phentolamine, phenoxybenzamine) prior to β-blockade to prevent unopposed alpha agonism

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PE will show:

Pitting Edema

Labs will show:

Proteinuria > 3.5 g/24 hr
Hyperlipidemia
Hypercoagulability (renal vein thrombosis)
Fatty casts

Nephrotic Syndrome

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Normal ABG values

pH: 7.35 – 7.45

PaCO2: 35 – 45

HCO3: 22 – 26

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pH: < 7.35

PaCO2: > 45

HCO3: Normal

Respiratory Acidosis

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pH: > 7.45

PaCO2: < 35

HCO3: Normal

Respiratory Alkalosis

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pH: < 7.35

PaCO2: Normal

HCO3: < 22

Metabolic Acidosis

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pH: > 7.45

PaCO2: Normal

HCO3: > 26

Metabolic Alkalosis

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generalized weakness
fatigue
facial swelling
constipation
cold intolerance
weight gain

Hypothyroidism

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PE will show:

Periorbital Edema
Dry Skin
Coarse Brittle Hair

Hypothyroidism

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Labs will show:

high TSH
low free T4
antithyroid peroxidase
antithyroglobulin autoantibodies

Hypothyroidism

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Most commonly caused by Hashimoto’s thyroiditis

Hypothyroidism

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Hypothyroidism

treatment:

Treatment is levothyroxine

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History of prior abdominal/pelvic surgery
Complaining of bilious vomiting
PE will show high pitched bowel sounds

Small Bowel Obstruction

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X-ray will show:

dilated bowel
air fluid levels
Stack of Coins or String of Pearls Sign

Small Bowel Obstruction

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Small Bowel Obstruction

treatment:

NGT
surgery

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Patient will be complaining of:

chronic nonbloody diarrhea
crampy abdominal pain
weight loss

Crohn Disease

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PE will show: * aphthous ulcers * anal fissures * perirectal abscesses * anorectal fistulas

Crohn Disease

Labs will show: * ASCA positive * p-ANCA negative

Crohn Disease

Crohn Disease Diagnosis is made by

colonoscopy

Colonoscopy will show: * **skip lesions** * **cobblestone mucosa** * **transmural inflammation**

Crohn Disease

* Patient will be **2–8 weeks** of age * Complaining of nonbilious **projectile vomiting** after feeding and early satiety

Pyloric Stenosis

PE will show: * **RUQ olive-like mass** (hypertrophied pylorus)

Pyloric Stenosis

* Labs will show hypochloremic hypokalemic metabolic alkalosis * Diagnosis is made by ultrasound or UGI series **(string sign)**

Pyloric Stenosis

Pyloric Stenosis Treatment:

surgery

* Chest pain/pressure on exertion/stress that is **relieved by rest** * Consider non-cardiac causes

Angina

Angina treatment:

* lifestyle modifications * beta blockers * calcium channel blockers * nitrates

Patient with a history of smoking, long-distance travel, surgery, oral contraceptives use

Deep Vein Thrombosis (DVT)

* Complaining of unilateral leg edema, leg pain, tenderness, and warmth * Physical exam may show a positive **Homans sign**

Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT) diagnosis:

ultrasound; Gold standard is venography

Most commonly caused by stasis, hypercoagulable state, trauma **(Virchow triad)**

Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis (DVT) Treatment is

anticoagulation

Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs)

Cholecystitis

Complaining of: * colicky * steadily increasing RUQ or epigastric pain after eating fatty foods

Cholecystitis

PE will show Murphy sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula)

Cholecystitis

Cholecystitis diagnosis:

* Initial - US * Gold standard - HIDA

Cholecystitis Most commonly caused by

obstruction by a gallstone

Cholecystitis Treatment

cholecystectomy

* Patient will be complaining of **pain, redness, swelling** * PE will show tenderness, **erythema with poorly demarcated borders**, lymphedema * Most commonly caused by group A Streptococcus, Streptococcus pyogenes, or Staph aureus

Cellulitis

Patient will be complaining of: * weakness * dizziness * fatigue PE will show: * pallor * tachycardia * atrophic glossitis or koilonychia (spoon nails)

Iron Deficiency Anemia

Labs will show: * microcytic * hypochromic red blood cells * **Decreased** serum iron level * an **increase** in the total iron binding capacity (TIBC) * **decreased** serum ferritin levels

Iron Deficiency Anemia

Patient will be complaining of: * abrupt onset of **"worst headache of their life"** or * **"thunderclap"** headache

Subarachnoid Hemorrhage

Subarachnoid Hemorrhage Diagnosis:

* Diagnosis is made by noncontrast CT scan. Blood will appear white in color on the CT * If CT negative, and suspicion high, lumbar puncture

**_Subarachnoid Hemorrhage_** Most commonly caused by a\_\_\_\_\_\_\_\_

ruptured aneurysm

Most common cause: GERD

Esophageal Stricture

* Progressive dysphagia * Barium swallow (initial), endoscopy * Surgery, high-dose PPIs

Esophageal Stricture

* Patient will be complaining of **headaches, diaphoresis, tremors**, and **vision changes** * PE will show ***_hypertension_***

Pheochromocytoma

* Diagnosis is made by assay of **urinary catecholamines _andmetanephrines, _andplasma metanephrine levels** * Most commonly caused by ***_catecholamine-secreting tumor_*** located in the adrenal glands

Pheochromocytoma

Pheochromocytoma treatment:

* surgery * α-blocker (ie phentolamine, phenoxybenzamine) prior to β-blockade to prevent unopposed alpha agonism

Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting

Acute Pancreatitis

* PE will show flank ecchymosis **(Grey Turner sign)**, umbilical ecchymosis **(Cullen sign)** * Labs will show elevated **lipase** (best) and amylase

Acute Pancreatitis

**_Acute Pancreatitis_** **Etiology_:_**

Most commonly caused by gallstones \> alcohol

PE will show **^↓breath sounds ₊ dull percussion ₊ ^↓ tactile fremitus**

Pleural Effusion

CXR will show blunting of the costophrenic angle

Pleural Effusion

* Patient will be a young, tall, thin, man * PE will show decreased breath sounds, decreased fremitus, hyperresonance to percussion

Spontaneous Pneumothorax

Spontaneous Pneumothorax \> 20%

chest tube thoracostomy

CXR will show the absence of lung markings along lung periphery

Spontaneous Pneumothorax

* weakness, dizziness, and fatigue * PE will show pallor, tachycardia, atrophic glossitis or koilonychia (spoon nails)

Iron Deficiency Anemia

* Labs will show **microcytic**, **hypochromic red blood cells**. **Decreased** serum iron level, an **increase** in the total iron binding capacity (TIBC), and **decreased** serum ferritin levels

Iron Deficiency Anemia

* obese woman **40 - 50-years-old** * Complaining of slowly resolving **right upper quadrant pain** that begins **suddenly after eating** a **fatty or large meal**

Cholelithiasis/Choledocholithiasis

Post-procedure Nausea/Vomiting Risk Factors

* Expected use of post procedure opioids * Female Gender * Non-smoker * Patient age * Previous history of post-procedure nausea/vomiting * Previous history of motion sickness * Type of anesthesia * Type and duration of surgery

* history of smoking * Complaining of abdominal/epigastric pain, **painless jaundice, depression**, and weight loss * PE will show palpable nontender gallbladder **(Courvoisier sign),** migratory thrombophlebitis **(Trousseaus syndrome)**

Pancreatic Cancer

Labs will show **CA 19-9** serum marker

Pancreatic Cancer

Patient will be complaining of flank pain radiating to groin

Nephrolithiasis

PE will show a patient that **won't lay** **still** and hematuria

Nephrolithiasis

Nephrolithiasis Most commonly caused by\_\_\_\_\_\_\_\_

calcium oxalate

Nephrolithiasis Most common location is the

ureterovesiclular junction (UVJ)

Nephrolithiasis treatment:

\< 5 mm: likely to pass spontaneously \> 8 mm: unlikely to pass, lithotripsy

Protrudes **directly** through Hesselbach's triangle and medial to the inferior epigastric artery (IEA) Bulge decreases upon reclining

Direct Inguinal Hernias

what type of inguinal hernia? * Most common type * Protrudes through internal ring, lateral to IEA

Indirect

* Patient will be complaining of **heat intolerance**, palpitations, weight loss, tachycardia, and anxiety

Hyperthyroidism

PE will show: * **hyperreflexia** * **goiter** * **exophthalmos** * **pretibial edema**

Hyperthyroidism

Labs will show **low TSH** and **high freeT4**

Hyperthyroidism

Most commonly caused by **Graves disease** _{(autoimmune against TSH receptor)}

Hyperthyroidism

Hyperthyroidism treatment:

* methimazole * PTU

* Patient with a history of prior **abdominal/pelvic surgery** * Complaining of **bilious vomiting** * PE will show **high pitched bowel sounds**

Small Bowel Obstruction

X-ray will show: * **dilated bowel** * **air fluid levels** * **stack of coins or string of pearls sign**

Small Bowel Obstruction

* Visual sx (**bitemporal hemianopia** (or hemianopsia)) * Prolactinoma: (most common), amenorrhea, impotence * Growth hormone tumor: gigantism (children), acromegaly (adults) * ACTH secreting * TSH secreting * Nonfunctioning

Pituitary Tumors

Patient with a history of a head injury with a **loss of consciousness** followed by a **lucid interval**

Epidural Hematoma

* CT will show a **biconvex opacity**

Epidural Hematoma

Most common artery ruptured is the **middle meningeal artery**

Epidural Hematoma

* history of a parent with similar symptoms * Complaining of **mucosal hemorrhage or bleeding that is difficult to control**

von Willebrand Disease

Labs will show: * decreased factor VIII * **prolonged bleeding time**

von Willebrand Disease

von Willebrand Disease treatment:

desmopressin (DDAVP)

Most common **inherited bleeding disorder**, autosomal dominant

von Willebrand Disease

* Patient will be complaining of discomfort and **itching in the anal region** * If thrombosed may also complain of pain

Hemorrhoids

what kind of hemorrhoids? * proximal to the dentate line

Internal

what kind of hemorrhoids? * distal to the dentate line

External

Hemorrhoids treatment:

* lifestyle modifications * sitz baths * analgesic creams, or surgical excision

* Patient will be obese, pregnant or older * With a history of prolonged standing, family history of venous insufficiency * Complaining of leg edema * PE will show skin changes, ulceration, edema, varicose veins * Imaging will show valvular abnormalities

Venous Insufficiency

**_Venous Insufficiency_** treatment:

* leg elevation * compression therapy * ulcer care * ablation

* Patient will be a man younger than 40 * Complaining of a painful area by his buttocks * PE will show painful, fluctuant area at the sacrococcygeal cleft

Pilonidal Cyst

Pilonidal Cyst treatment:

surgical drainage

* Patient with a history of high dietary consumption of red meat, low dietary fiber, sedentary lifestyle, BMI \> 25 kg/m2, and cigarette smoking * Complaining of **painless hematochezia**

Diverticulosis

MC cause of significant lower gastrointestinal bleeding

Diverticulosis

Patient will be complaining of fever, pain that began **periumbilical then moved to RLQ**, nausea, and anorexia

Appendicitis

PE will show: * **Psoas sign** (RLQ pain on extension of right hip) * **Obturator sign** (RLQ pain on internal rotation of flexed right hip) * **Rovsing sign** (right lower quadrant pain when the left lower quadrant is palpated)

Appendicitis

Patient will be complaining of pain in the affected extremity **related to activity** (intermittent claudication)

Peripheral Artery Disease

PE will show: * cool extremity with absent or diminished pulses

Peripheral Artery Disease

Patient will be complaining of gnawing epigastric pain

Peptic Ulcer Disease

what type of ulcer? ## Footnote Pain is **alleviated by ingesting food** (mnemonic: DUDe give me food)

Duodenal ulcer

what type of ulcer? ## Footnote pain is exacerbated by ingesting food

Gastric ulcer

Peptic Ulcer Disease Most commonly caused by

* H. pylori infection * nonsteroidal anti-inflammatory use

MCC of **upper GI bleed**

Peptic Ulcer Disease

* Decrease in systolic blood pressure 20 * Decrease in diastolic blood pressure 10 * Inadequate physiologic response to postural changes

Orthostatic Hypotension

* Patient will be older, usually male * With a history of HTN, Marfan syndrome * Complaining of sudden **"ripping" _or "tearing"** CP radiating to back

Aortic Dissection

PE will show asymmetric pulses/BP

Aortic Dissection

CXR will show **widened mediastinum**

Aortic Dissection

Aortic Dissection Treatment:

* reduce BP/HR * surgery (depending on dissection type)

* Patient will have a history of **drinking alcohol** **_and forceful vomiting** * Complaining of **hematemesis**

Mallory-Weiss Syndrome

Mallory-Weiss Syndrome diagnosis:

Diagnosis is made by **upper endoscopy**

* Caused by an **incomplete tear in the esophagus mucosa and proximal stomach**

Mallory-Weiss Syndrome

Complaining of: * **sudden onset of pain** * **pallor, paresthesias** * **pulselessness, paralysis** * **pain out of proportion to exam** * **(6 P's)** Patient with a history of: * **recent MI _or atrial fibrillation**

Arterial Embolism

Blood Transfusions - Hospitalized patient

* Goal Hb 7-8 g/dL * Use the least amount of blood products necessary * Consider transfusing one unit at a time * Follow the patient clinically and monitor for response and possible transfusion reactions

* history of **renal failure, DKA, rhabdomyolysis, tumor lysis** * Complaining of **lethargy, weakness, paralysis**

Hyperkalemia

ECG will show: * **peaked T waves** * **prolonged PR** * **wide QRS**

Hyperkalemia

**Hyperkalemia** ## Footnote tx:

* calcium gluconate * insulin * albuterol * bicarbonate

Which approach is preferred in cases of a bilateral adrenalectomy?

Posterior retroperitoneoscopic.

**airway inflammation₊bronchial hyperresponsiveness ₊reversible airflow obstruction**

Asthma

PEF \< 50%: severe exacerbation

Asthma

Asthma treatment:

* O2: maintain SpO2 \> 88% * Beta-agonists: increase cAMP resulting in bronchodilation * Anticholinergics: decrease bronchoconstriction * Corticosteroids: decrease inflammation, administer early * Mg: severe exacerbations * Non-invasive ventilation: decrease work of breathing

* Patient will be **elderly _or alcoholic** * With a history of a fall or traumatic head injury * Complaining of **headache, mental status changes, seizures,_orfocal deficits**

Subdural Hematoma

Diagnosis is made by **non-contrast CT**, will appear as **crescent-shaped hematoma**

Subdural Hematoma

Most commonly caused by **rupture of the bridging veins**

Subdural Hematoma

* Older Patient Complaining of: * **Hesitancy** * **Intermittence/Incontinence** * **Frequency/Fullness** * **Urgency** * **Nocturia** * **(HI FUN)**

Benign Prostatic Hyperplasia (BPH)

PE will show: * **smooth** * **firm and mobile prostate without any nodules or indurations**

Benign Prostatic Hyperplasia (BPH)

Most commonly caused by stromal and epithelial cell growth in the transitional zone of the prostate

Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) treatment:

* alpha-blockers * 5-reductase inhibitors * surgery (TURP)

* Patient will be a woman * Complaining of a **dull ache in her legs after prolonged standing**

Varicose Veins

PE will show: * **dilated** * **elongated subcutaneous veins**

Varicose Veins

Varicose Veins treatment:

* leg elevation * compression stockings

* Patient will be a man * With a history of H. pylori infection * Complaining of **loss of appetite, unintentional weight loss**

Gastric Carcinoma

PE will show: * left supraclavicular node **(Virchow’s node)** * left axillary node **(Irish node)** * periumbilical node **(Sister Mary Joseph’s node)**

Gastric Carcinoma

Patient will be complaining of: * **right upper quadrant pain** * **jaundice** * **fever** * **(CHARCOT TRIAD)**

Acute Cholangitis

Acute Cholangitis treatment:

* **antibiotics** * definitive treatment is **ERCP** with antibiotics typically an adjunct

Charcot triad + **hypotension _and AMS** = ***_Reynolds pentad, acute obstruction_***

Acute Cholangitis

Hemoptysis Diastolic murmur=

mitral stenosis

Hemoptysis Sudden SOB, CP=

Hemoptysis Trauma=

pulmonary contusion

**_Hemoptysis_** Immunodeficiency, immigrant=

Hemoptysis Hx of TB or sarcoidosis=

aspergilloma

**_Hemoptysis_** Renal dysfunction=

Goodpasture’s syndrome or Granulomatosis with Polyangiitis (GPA, Wegener’s)

**_Hemoptysis_** Hx of tobacco use, weight loss=

malignancy

* Patient **will be a woman** * With a history of **constipation alternating with diarrhea** *

Irritable Bowel Syndrome

Complaining of **abdominal discomfort which is relieved with bowel movements**

Irritable Bowel Syndrome

Patient will be complaining of: **pain** **redness** **swelling**

Cellulitis

PE will show: * tenderness * **Erythema _with Poorly Demarcated Borders** * lymphedema

Cellulitis

Cellulitis Most commonly caused by:

* Group A Streptococcus * Streptococcus pyogenes * Staph aureus

* Patient will be a man 20 - 35-years-old * Complaining of a testicular lump

Testicular Cancer

PE will show**:** * **Painless** * **Hard** * **Fixed** **mass**

Testicular Cancer

Labs will show: * **Increased beta-hCG** * **Alpha-fetoprotein (AFP)** * **Lactate dehydrogenase (LDH)**

Testicular Cancer

* Patient with a history of **smoking, long-distance travel, surgery, oral contraceptives use** * Complaining of unilateral leg edema, leg pain, tenderness, and warmth

Deep Vein Thrombosis (DVT)

* Physical exam may show a **positive** **Homans sign**

Deep Vein Thrombosis (DVT)

Most commonly caused by: * **stasis** * **hypercoagulable state** * **trauma (Virchow triad)**

Deep Vein Thrombosis (DVT)

PE will show transient blanching, edematous papules, and plaques

Urticaria

Urticaria treatment:

* supportive care * antihistamines * glucocorticoids (if associated with angioedema)

* Patient with a history of prior abdominal/pelvic surgery * Complaining of bilious vomiting * PE will show high pitched bowel sounds

Small Bowel Obstruction

X-ray will show: * dilated bowel * air fluid levels * **stack of coins or string of pearls sign**

Small Bowel Obstruction

Patient will be complaining of: * **rectal pain _and bleeding which occurs with _or shortly after defecation**

Anal Fissure

PE will show fissure located in the **posterior midline**

Anal Fissure

Anal Fissure treatment:

stool softeners, protective ointments, sitz baths

Patient will be complaining of: * abdominal pain that is localized to the **left lower quadrant** * fever * nausea * vomiting * **change in bowel habits**

Diverticulitis

* Transient episode of neurological dysfunction without acute infarction * 10% of TIA patients will have a stroke within 90 days

Transient Ischemic Attack

* Patient will be a child * Complaining of easy bruising or hemarthroses * Labs will show increased PTT * Most commonly caused by **X-linked recessive factor VIII (8)** deficiency

Hemophilia A

* Patient will be **2–8 weeks of age** * Complaining of nonbilious **projectile vomiting** after feeding and early satiety

Pyloric Stenosis

* PE will show **RUQ olive-like mass** (hypertrophied pylorus)

Pyloric Stenosis

* Patient will be complaining of a **painless slow growing lesion on the face, ears, _or neck** * PE will show **pearly papule _withrolled borders _andtelangiectasia**

Basal Cell Carcinoma (BCC)

* Patient with a history of **chronic reflux** * Diagnosis is made by upper endoscopy, biopsy * Biopsy will show **squamous to columnar epithelium** and proximal shift in the squamocolumnar junction

Barrett Esophagus

Barrett Esophagus treatment:

proton pump inhibitors

Barrett Esophagus can lead to an Increased risk for \_\_\_\_\_\_\_\_\_\_

adenocarcinoma

Cardiac output is the product of what?

Heart rate multiplied by stroke volume

Patient will be complaining of: * **weakness** * **Dizziness** * **fatigue** PE will show: * **Pallor** * **Tachycardia** * **Atrophic glossitis** * **Koilonychia (spoon nails)**

Iron Deficiency Anemia

Labs will show: * microcytic red blood cells * hypochromic red blood cells * ***_Decreased_*** serum iron level * **Increase** in the total iron binding capacity (TIBC) * ***_Decreased_*** serum ferritin levels

Iron Deficiency Anemia

* **Rate** will be **irregular** * **Rhythm** will be **irregular** * _{No defined P waves}

Atrial Fibrillation

**_Atrial Fibrillation_** **_treatment:_**

Unstable: cardioversion Stable: rate control is mainstay

* Patient will have fair skin * With a history of severe blistering sunburns, a family history of melanoma, dysplastic nevus syndrome * Complaining of an itching, tender lesion that ***_won't heal_***

Melanoma

* Most common cause: GERD * Progressive dysphagia * Barium swallow (initial), endoscopy * Surgery, high-dose PPIs

Esophageal Stricture

* ↑ PTH * ↑ Ca * ↓ phosphorus

Primary Hyperparathyroidism