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Clerkship (CC3) > Surgery > Flashcards

Surgery Flashcards

1
Q

When considering someone that may be a candidate for surgery, what sorts of questions do you want to explore pre-op?

A

Consider contraindications to surgery e.g. anaesthesia.

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2
Q

When you have a murmur, what are the 4 possible valve pathologies? How do you differentiate?

A

Systolic - aortic stenosis or mitral regurg
Diastolic - aortic regurg or mitral stenosis

Sternal pattern (right = A, left = M)

Crescendo vs decrescendo (think blood flow)

Radiation (direction of flow / jet)

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3
Q

What are the high-risk features for aortic dissection?

A

Cardiac involvement

  • > Ischemia + new onset regurg
  • > pericardial effusion

End-organ involvement
->leg ischemia

Brain / carotid invovement

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4
Q

Why do people die of aortic dissection ?complications

A

Heart failure
Rupture / tamponade
End-organ ischemia
Paraplegia (involvement of artery of Adamkiewicz)

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5
Q

What is the DeBakey classification for aortic dissection?

A

I -> Ascending AND descending aorta
II -> Ascending only
III -> descending only after origin of left subclavian artery

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6
Q

What are the risk factors to ask about on history in vascular surgery patients?

A

Stroke
HTN
Diabetes
Dyslipidemia

Smoking
FH - cardiovascular disease

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7
Q

What physical exam is relevant in vascular surgery?

A

Don’t forget to inspect limbs, check pulses, feel temp etc.

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8
Q

What investigations would you order for AAA?

A

Bloodwork: CBC, lytes, Cr, LFTs lipase (ABG lactate if sick)

ECG/trop if C/P

CXR for cough or dyspnea or to assess free air

CT abdo / pelvis with contrast

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9
Q

How do you diagnose a AAA?

A

Any imaging modality (usually CT, but can do U/S or MRI)

Aneurysm = 1.5x normal size

abdominal aorta normally 2cm; thus 3cm+ is aneurysm.

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10
Q

What is the threshold for surgical intervention in AAA? What are the options for surgical repair?

A

> =5cm in women
5.5 cm in men (rupture risk = 10%

Growth >1cm / yr
Symptomatic or ruptured

Open vs endovascular (similar outcomes, but endo is faster recovery time).

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11
Q

What is f/u for AAA?

A

2-3 years if 3-3.9cm
4-4.9 1 year repeat u/s
5 cm -> time for a CT, repeat u/s in 6 mos

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12
Q

What are the medical management options for AAA?

A

Smoking cession
Control HTN (140/90; 130/80)
diabetes <7% A1C
dyslipidemia LDL < 2 statin

Avoid fluoroquinolones

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13
Q

What is the criteria for a symptomatic AAA?

A

Pulsatile mass that is tender on palpation.

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14
Q

What is the triad for AAA?

A

Severe abdo pain, pulsatile abdo mass, hypotension

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15
Q

When do you bypass CT for symptomatic AAA?

A

If they are unstable / hypotensive, then you go straight to the OR

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16
Q

What are some signs of compartment syndrome?

A

Pain out of proportion that is exacerbated by muscle stretch.

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16
Q

What are some signs of compartment syndrome?

A

Pain out of proportion that is exacerbated by muscle stretch.

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17
Q

How do you manage acute limb ischemia?

A
  1. CT to confirm diagnosis

2. OR for embolectomy

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18
Q

How do you manage compartment syndrome?

A

OR for 4-compartment fasciotomy

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19
Q

If you have a laceration near a fracture, is it open?

A

Yes until proven otherwise

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20
Q

How do you check the nerves of the upper extremity?

A

Axillary (lateral deltoid)
Musculocutaneous (biceps, lateral forearm)
Radial (wrist extension, triceps, (PIN) thumb extension, sensory to 1st webspace)
Median (lateral 1st digit, AOK sign)
Ulnar (medial pinky cross/spread fingers.

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21
Q

Suppose someone has a distal radius fracture with D1 and D2 numbness but motor still intact; where is the lesion?

A

Likely carpal tunnel compression - median nerve proper runs through the carpal tunnel.

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22
Q

Name the fracture pattern

A
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23
Q

Name the deformity

A
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24
Q

What is the ATLS protocol for burns?

A 
Airway
Breathing
Circulation (fluids)
Escharotomy (full-thickness burns)
Wound management
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25
Q

What are some signs of inhalation injury?

A 
Facial soot
Sooty sputum
Singed nasal hair
Oropharyngeal burns
Stridor / air hunger (resp obstruction)
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26
Q

What investigations would you do for burns?

A

ABGs / VBGs
Carboxyhemoglobin +cyanide
Bronch

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27
Q

when you have a burn patient what you should also consider?

A

Trauma!

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28
Q

In a burns patient with an airway injury, what should you consider?

A

Intubation to protect the airway

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29
Q

Describe the rule of 9s for adults and children

A

Adults head, arms 9% each
Chest back and each leg 18%
1% perineum

For kids
Head is 18, legs are 13.5%

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30
Q

What are the different depths of burn injuries

A

Superficial - a sunburn that doesn’t blister (no epi/dermal jct disruption)
Partial thickness - superficial de-epithelialization or deep. Superficial if epidermis is intact.
Deep thickness / full thickness (all the way down through the epidermis into the dermis, white-leathery.

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31
Q

what is the Parkland formula for burns & how do you calculate it for 82kg person with 18% TBSA involved.

A

4ml x TBSA (%) x body weight (kg);
50% given in first eight hours;
50% given in next 16 hours.
Total is about 6L

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32
Q

What is the minimum urine output that you want

A

0.5-1 cc/kg/hr

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33
Q

When do we transfer someone to a burn unit?

A 
partial-thickness+ burns >10% TBSA
Burns involving face/hands/feet/genitalia/perineum major joint
ANY 3rd degree burn
Electrical, chemical burns
Inhalation injury
Co-morbidity patient
Burns + trauma
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34
Q

What is a potential complication that can arise in burn patients after receiving resuscitation?

A

Abdominal compartment syndrome / intraabdominal hypertension

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35
Q

If you suspect increased ICP from a tumor with deteriorating GCS, what are your options?

A

Mannitol (1g/kg), hypertonic saline, intubation if needed, hyperventilation, raise head of bed.

If cancer = give dexamethasone

Anticonvulsants if needed

36
Q

Where is the lesion?

A

R cerebellum (note bony prominencies and the tentorium)

37
Q

What questions on history do you want to know for back pain?

A

Back vs leg pain - distribution esp if leg pain
OPQRST
Ambulation, Bowel/bladder dysfunction, saddle anaesthesia, weakness, constitutional symptoms
What do you do for work / how is it affecting you?

38
Q

What are the important points on history to ask about headache?

A 
N/V
Associated symptoms / focal neuro signs /visual symptoms
Positional - intracranial hyper/hypotension
Hx CA
Trauma?
Previous headaches?
Seizure, syncope
Balance, coordination, gait, vertigo
39
Q

Describe the movements of the screening upper extremity motor exam

A 
Basketball shot:
C5 (biceps)
C6 (wrist extension)
C7 (elbow extension wrist flexion)
C8 (metacarpal flexion, thumb extension)
T1 (finger ABduction or ADduction)
40
Q

What is the DDx for back pain Nonradiculopathy

A 
Annular tear
Discogenic
Compression fracture
Lumbar stenosis
Facet arthropathy
41
Q

What is the Ddx for back pain that produces radicular symptoms

A

Disc herniation
Spinal stenosis
Tumors
Zoster

42
Q

What about if you have back pain with systemic symptoms?

A

Ankylosing spondylitis
Infection
etc.

43
Q

What systems can cause referred back pain?

A 
AAA
Vascular disease
Visceral disease (abdo)
Infection
UTI
PID
Hip arthritis
44
Q

What is the non-operative management of radicular back pain?

A

at least 3 months of physio, NSAIDs, pain killers. Must encourage movement.

45
Q

What are some operative techniques that can treat back pain?

A

(micro) Discectomy, laminectomy / laminotomy.

46
Q

Which nerve root exits between L5 and S1?

A

L5

Note L5 is the “exiting” root and S1 at that level is still “traversing”.

47
Q

Why is cauda equina an emergency?

A

Because the incontinence becomes permanent.

48
Q

What special tests can you do for appendicitis?

A

Tenderness at McBurney’s Point
Rovsing (LLQ palpation -> RLQ tenderness)
Psoas / obdurator signs.

49
Q

What investigations are useful in the context of the acute abdomen?

A 
CBC, lytes, Cr
Beta HCG if female
blood type cross / match
Abdo panel: LFTs, amylase, lipase
U/S or CT (if older, unsure, large body habitus)
50
Q

What is the management of appendicitis?

A

Medical: with active observation, ceftriaxone + metronidazole (about 63%

Surgical: lap appy

51
Q

A patient with previous history of exploratory laporotomy presents with 4 hours of severe abdo pain and signs of acute small bowel obstruction. AVSS. What is the first step in management?

A

Place NG tube and suction. Admit for observation.

52
Q

What is the diagnosis? How would this present?

A

Coffee bean sign - sigmoid volvulus

large bowel obstruction, insidious progression of continuous + colicky pain and constipation + distention.

53
Q

Patient presents with right seminoma which is removed by radical orchiectomy. A staging CT is performed and there is spread to a retroperitoneal lymph node. How is this managed?

A

Radiation! GCTs are very sensitive to radiation. Chemotherapy can be used with more extensive lymph mets.

54
Q

What is the differential for breast mass

A

Fibroadenoma, lipioma, ductal ectasia, DCIS, Breast CA, Phylloides tumor.

55
Q

If SLNB comes back positive for 1-2 lymph nodes after partial mastectomy, what is the appropriate management?

A

Whole breast radiation + chemo, as axillary dissection is not shown to improve outcomes.

56
Q

If a person presents with unilateral sudden onset breast tenderness, swelling and skin changes (non-lactating), what should be at the top of your differential?

A

Inflammatory breast CA

57
Q

What BIRADS indicates suspiscion for malignancy requiring biopsy?

A

4

58
Q

What is the top risk factor for adénocarcinomes of the esophagus?

A

GERD (eg Barrett’s eso)

59
Q

What are signs of complicated small bowel obstruction?

A

Persistent pain, fever, tachycardia, focal abdo tenderness, amylase, low bicarbonate.

60
Q

What is the appropriate follow-up for someone with a noncancerous polyp on colonoscopy? What about cancerous polyp?

A

Noncancerous - repeat colonoscopy in 5y

Cancerous - repeat colonoscopy in 1y, then can go to 5 years depending on findings

61
Q

What pattern of inflammation is associated with Crohn rather than UC?

A

Transmural inflammation with sparing of rectum

62
Q

What are the major risk factors for CRC?

A

personal history of polyps
IBD
Family history (esp. FAP, Lynch)

63
Q

Does amylase or lipase correlate witb the progression of pancreatitis?

A

No

64
Q

Can you do watchful waiting with a femoral hermia?

A

No. These types of hernias are associated with high rates of incarceration and complications

65
Q

What is the managment for an incarcerated scrotal hernia

A

Urgent repair + groin exploration

66
Q

What is the most common cause of morbidity after lung transplant (late)

A

bronchiolitis obliterans

67
Q

What is triple therapy for h pylori

A

Amoxicillin, clarithromycin, ppi

68
Q

What is quadruple therapy for h pylori and when do you use it

A

Bismuth metronidazole tetracycline ppi

If recently exposed to macrolide or resistance locally to triple therapy

69
Q

What is the best imaging modality for acute limb ischaemia

A

CT angiogram

70
Q

In the patient presenting with sah and meningeal signs but negative CT what is the next step?

A

LP for xanthrochromia

71
Q

What surgical approach is best for adrenal malignancy ?

A

Open transabdoninal

72
Q

What is the characteristic presentation concerning for VIPoma

A

WDHA
Watery diarrhea
Hypokalemia
Acidosis / achlorhydria

73
Q

How does dysautonomia present?

A

Unopposed sympathetic tone (eg due to bladder retension after spinal cord injury)

74
Q

What medixation is first line for dysautonomia?

A

Nifedipine

75
Q

After mastectomy, what is the appropriate followup?

A

No need for mammography as breast tissue has been removed; annual breast exam

76
Q

What ids the difference between type A and type B lactic acidosis

A 
A = hypoperfusion
B = every thing else eg DKA
77
Q

What is the next step for a young patient with a 6 month history of conatitutional symptoms and cervical lymphadenopathy

A

Surgical excision biopsy (needs to preserve tissue arch for biopsy, FNA not recommended)

78
Q

When is CaCl2 indicated for hyperkalemia?

A

When K is 6.5 or more regardless of ECG changes

79
Q

What is a Spigelian hernia?

A

Protrudes between linea semilunaris and rectus abdo

80
Q

What are the most common causes of acquired hydronephrosis?

A

Tumours stones and strictures

81
Q

When is perc nephrostomy ordered over retrograde stent for treatment of complicated hydronephrosis?

A

Pregnant - due to reduced radiation to fetus

82
Q

What is the treatment for idiopathic intracranial hypertension?

A

Acetazolamide or topiramate (better for migraine)

Ventricular shunt if refractory to medical therapy

83
Q

What cancer occurs in the setting of Barrett esophagus?

A

Esophageal ademocarcinoma

84
Q

What compartment pressure is associated with compartment syndrome?

A

> 30 mmHg

85
Q

This young patient presents with hemoptysis after an episode pofnretching. What is the diagnosis?

A

Boerhaave’s syndrome (esophageal rupture, note free air in mediastinum)

86
Q

In an elderly patient that is hemodynamically unstable presenting with copious bright red blood per rectum, what is the next best step for management after establishing ABCs?

A

NG aspiration or upper endoscopy to r/o massive upper bleed

87
Q

Patient presents with facial trauma, maxillary and mandibular fracture after MVA and is satting 78 on O2 by face mask. What is the next step in management?

A

Cricothyroidectomy, as intubation is contraindicated when there is facial trauma

Clerkship (CC3) (12 decks)

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