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Uworld Step 2 > Surgery > Flashcards

Surgery Flashcards

1
Q

What are the best predictors of post op outcome following lung resection surgery?

A

FEV1

DLCO (diffusion capacity of the lung for carbon monoxide)

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2
Q

Clinical presentation of traumatic carotid injuries

A

gradual onset hemiplegia
aphasia
neck pain
“thunderclap” HA

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3
Q

Mechanism of injury for traumatic carotid injuries

A

penetrating trauma
fall with object in mouth
neck manipulation

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4
Q

Etiology of Ogilvie syndrome

A

Major surgery
electrolyte derangement
medication (opiates, anti-ACh)
neurologic disorders

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5
Q

Management of Ogilvie syndrome

A

NPO, nasogastric/rectal tube decompression

Neostigmine if no improvement within 48 hours

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6
Q

What imaging should be performed in hemodynamically unstable pt following blunt chest trauma?

A

eFAST
chest CT
EKG

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7
Q

What imaging should be performed to diagnose toxic megacolon?

A

CT of the abdomen

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8
Q

How is blunt thoracic aortic injury diagnosed?

A

CT angio in stable pts

TEE for unstable pts

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9
Q

What is the initial diagnostic test in pts with suspected PE?

A

CT pulmonary angiography

Ventilation-perfusion scan if pts unable to receive IV contrast

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10
Q

What drug is preferred for treatment of acute PE in pts with cancer?

A

therapeutic-dose low molecular weight heparin

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11
Q

What is the most concerning feature in a pt with a parotid gland neoplasm?

A

facial droop or facial numbness which suggests neural invasion due to malignant disease

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12
Q

Work up for diabetic pt with foot ulcer

A

Probe to bone test should be performed to measure the extent of infection. If positive bone biopsy with culture should be performed before starting pt on antibiotics

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13
Q

Treatment for acute hyponatremia (present for <48 hours)

A

Pts with sodium <130 and any symptoms of elevated intracranial pressure should be treated with hypertonic 3% saline boluses

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14
Q

Risk factors for bleeding in pts with angiodysplasias

A 
end-stage renal disease
aortic stenosis (due to destruction of VWF multimers when they pass through the valve)
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15
Q

How are hydatid cysts described on CT scan?

A

“eggshell” calcification

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16
Q

Definitive hose of E. granuloses

A

dogs

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17
Q

Treatment of hydatid cyst

A

surgical resection under the cover of albendazole

Aspiration usually should not be performed as worms can spill out of cyst causing anaphylaxis

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18
Q

What imaging should be performed for testicular torsion?

A

US with doppler

If positive will show no blood flow to testicle

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19
Q

Pts with new onset ascites should have what imaging performed initially?

A

Abdominal US

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20
Q

Management of pt with clenched-fist bite injury

A

urgent surgical irrigation and debridement

antibiotics (ampicillin/sulbactam [IV], amoxicillin/clavulanate [PO])

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21
Q

Clinical features of perianal abscess

A

indurated, erythematous mass near the anal orifice associated with severe, constant anal pain and a low-grade fever

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22
Q

What causes a perianal abscess?

A

due to occlusion of an anal crypt gland, which allows for bacterial infection

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23
Q

Physical exam findings of pes anserinus pain syndrome

A

well-defined area of tenderness over the medial tibial condyle just below the joint line

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24
Q

Management of pes anserinus pain syndrome

A

quadricep strengthening exercises and NSAIDs

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25
Q

Clinical presentation of renal abscess

A

Pt recently had UTI now with several days of unilateral flank pain, weight loss, fever, and leukocytosis, with no UTI symptoms or bacteriuria

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26
Q

Risk factors for renal abscess formation

A

anatomic abnormalities
nephrolithiasis
uncontrolled DM
tobacco use

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27
Q

Pts with Crohn disease or other disorder resulting in fat malabsorption are predisposed to what?

A

hyperoxaluria (excess fats binds calcium which would normally bind to oxalate)

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28
Q

Clinical presentation of suppurative parotitis

A

firm, erythematous pre/postauricular swelling
exquisite tenderness exacerbated by chewing and palpation
trismus, systemic findings
elevated serum amylase without pancreatitis

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29
Q

Typical pt who gets suppurative parotitis

A

elderly postoperative patients, particularly those with dementia whoa are at risk of inadequate fluid hydration and poor oral hygiene (leads to salivary stasis and retrograde seeding of bacteria)

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30
Q

Persistently bloody ascites found on multiple paracenteses is suggestive of what cancer

A

hepatocellular carcinoma (these pts should go on to have abdominal imaging, measurement of alpha-fetoprotein, and cytologic analysis of the ascitic fluid to identify primary tumor)

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31
Q

Which antibiotics can be used in pts with sepsis due to diabetic foot infection?

A

piperacillin-tazobactam
carbapenem
fourth-gen cephalosporin (cefepime)

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32
Q

Pain management in pts with opioid use disorder

A
  1. Maximize non-opioid medications
  2. Use regional anesthesia when possible
  3. Add opioids only as needed (if there is sustained pain and then try to taper them off as quickly as possible)
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33
Q

What imaging should be performed in a pt with lower rib fractures

A

CT of the abdomen and FAST scan

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34
Q

When is open reduction and surgical exploration indicated in humeral shaft fractures?

A
  1. open fractures
  2. significant displacement
  3. neurovascular compromise
  4. polytrauma
  5. pathologic fractures
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35
Q

When to suspect tracheobronchial injury

A

despite pt having appropriate tube thoracostomy, repeat CXR shows rapid pneumothorax re-accumulation and increased subcutaneous emphysema

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36
Q

Diagnostic steps for psoas abscess

A
  1. CT scan of abdomen and pelvis
  2. leukocytes, elevated inflammatory markers
  3. blood and abscess cultures
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37
Q

When should wet-to-dry dressings being used?

A

wounds that are infected or have devitalized tissue or slough. As the dressing dries it will adhere and then pull off the dead skin

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38
Q

When should nonadherent, moisture-retaining dressings be used?

A

once healthy granulation tissue appears

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39
Q

What imaging should be performed in pts with concerning findings but without frank peritonitis?

A

abdominal CT (oral contrast can help finds sites of leakage due to injury in surgery)

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40
Q

What imaging should be performed if the pancreas is not visualized well on US?

A

CT of the abdomen

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41
Q

Signs of necrotizing surgical site infection

A

> pain, edema, erythema
systemic signs like fever, tachycardia, hypotension
paresthesia or anesthesia at edges of wound
purulent, cloudy-gray discharge
subcutaneous gas or crepitus

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42
Q

Young or middle aged pt with osteoporosis. What GI issue can lead to this?

A

celiac disease due to malabsorption of vit D

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43
Q

What is the usual source of infection in Ludwig angina?

A

dental infections

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44
Q

Phases of wound healing

A
  1. hemostasis (0 hours- 1 day)
  2. inflammation (3 hours-5 days)
  3. proliferation (3 days-5 weeks)
  4. remodeling (3 weeks-2 years)
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45
Q

Complications of high myopia (>6 diopters of correction)

A

> retinal detachment

>macular degeneration

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46
Q

Management of diverticulitis complicated by abscess

A
  1. <3cm treated with IV antibiotics and observation, surgery if it worsens
  2. > 3cm needs CT-guided percutaneous drainage, if does not work then surgery
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47
Q

Which nerve can be damaged following anterior shoulder dislocation?

A

Axillary nerve

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48
Q

When are massive transfusion protocols required?

A 
if 2 of the following are present
>penetrating mechanism of injury
>positive FAST scan
>systolic <90 mmHg
>pulse >120bpm
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49
Q

How should blood products be given in massive transfusion protocol?

A

1:1:1 ratio

FFP/packed RBCs/platelets

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50
Q

What masses are found in the anterior mediastinal compartment?

A

> thymic neoplasms
lymphoma
germ cell tumors
thyroid tissue

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51
Q

What masses are found in the middle mediastinal compartment?

A

> lymphadenopathy, lymphoma
benign cystic masses (pericardial cyst, bronchogenic cyst)
vascular masses
esophageal tumors

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52
Q

What masses are found in the posterior mediastinal compartment?

A

> neurogenic tumors, meningocele
spinal masses
lymphoma

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53
Q

What type of feeding is recommended for burn victims?

A

Early enteral nutrition

> maintains gut integrity and decreases bacterial translocation
reduced rates of sepsis
decreased mortality

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54
Q

What is the preferred screening test to evaluate cervical spine injury?

A

CT scan

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55
Q

Indications for cervical spine imaging? (5)

A
  1. neurologic deficit
  2. spinal tenderness
  3. altered mental status
  4. intoxication
  5. distracting injury
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56
Q

What imaging should be performed following primary survey of trauma?

A
  1. chest and pelvic XR
  2. FAST scan
  3. cervical spine CT
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57
Q

Clinical features of open globe injury (5)

A 
>extrusion of vitreous
>eccentric or teardrop pupil
>decreased visual acuity
>relative afferent pupillary defect
>decreased intraocular pressure
58
Q

Hard signs of extremity vascular trauma (4)

A

> observed pulsatile bleeding
presence of bruit/thrill over injury
expanding hematoma
signs of distal ischemia

59
Q

Soft signs of extremity vascular trauma (4)

A

> history of hemorrhage
diminished pulses
bony injury
neurologic abnormality

60
Q

Treatment of priapism in sickle cell disease

A

> aspiration of blood from corpora cavernosa

>intracavernous injection of phenylephrine

61
Q

What is test of choice in pt where PE is likely?

A

CT angio of chest

62
Q

What disease is Paget disease of bone associated with?

A

osteosarcoma

63
Q

Diagnosis and treatment of upper extremity DVT

A

> doppler or duplex US

>3 months of anticoagulation

64
Q

Epidemiology of upper extremity DVT

A

> central catheter or PICC line
young, athletic male (spontaneous)
thoracic outlet syndrome

65
Q

How to differentiate Factor V from Sickle Cell

A

Sickle cell will have evidence of hemolysis

66
Q

Physical exam findings of adhesive capsulitis

A

> decreased passive and active range of motion

>stiffness +/- pain

67
Q

When is emergency thoracotomy required in a pt with trauma?

A
  • initial blood output >1500ml

* persistent hemorrhage:>200ml/hr for >2 hours, or continuous need for blood transfusion

68
Q

Treatment for septic arthritis

A
  1. vancomycin is first line and is to cover S. aureus

2. if continue to have symptoms then third gen cephalosporin to cover aerobic gram-negative pathogens

69
Q

Complications of ankylosing spondylitis (3)

A
  1. osteoporosis/vertebral fractures
  2. aortic regurgitation
  3. cauda equina syndrome
70
Q

Imaging for ankylosing spondylitis

A

> XR of sacroiliac joints

>MRI of sacroiliac joints

71
Q

Diagnosis and treatment of sphincter of Oddi dysfunction

A

Dx: manometry
Tx: sphincterotomy

72
Q

What drug class can worsen the symptoms of sphincter of Oddi dysfunction

A

opioids by causing sphincter contraction

73
Q

tumor markers for cholangiocarcinoma

A

increased CEA
increased CA-19
normal AFP

74
Q

What should be regularly checked in a pt who had removal of medullary thyroid cancer

A

Calcitonin

the tumor arises from calcitonin-secreting parafollicular C cells

75
Q

Eye findings for uncal herniation

A

ipsilateral fixed and dilated pupil due to compression of the ipsilateral oculomotor nerve and accompanying parasympathetic fibers

76
Q

Eye findings for tonsillar herniation

A

fixed, mid-position pupils due to disruption of both sympathetic and parasympathetic innervation

77
Q

Diagnostic work up should include what in pts with suspected acute lung transplant rejection

A

bronchoalveolar lavage and lung biopsy

78
Q

Treatment for malignant pericardial effusion

A

acute management: pericardiocentesis, cytologic fluid analysis
prevention of recurrence: prolonged drainage (catheter, pericardial window)

79
Q

treatment of hepatic adenoma

A
  • Asymptomatic and <5cm: stop oral contraception

* Symptomatic and >5cm: surgical resection

80
Q

Clinical manifestations of acute graft vs host disease

A

> Occurs within 100 days (common in those receiving hematopoietic stem cell transplantation)
profuse, watery diarrhea that has a secretory pattern
liver inflammation

81
Q

What type of immune reaction is graft vs host disease?

A

CD8+ T-lymphocyte mediated injury

82
Q

Risk factors for sigmoid volvulus

A

> sigmoid colon redundancy (dilation/elongation from chronic constipation)
colonic dysmotility (underlying neurologic disorder)

83
Q

Treatment of C diff (non-severe, severe, and fulminant)

A

non-severe: oral fidaxomicin or vancomycin

severe: oral fidaxomicin or vancomycin
fulminant: oral vancomycin, IV metronidazole

84
Q

What will liver biopsy show in a pt with primary sclerosing cholangitis?

A

fibrous obliteration of small bile ducts, with concentric replacement by connective tissue in onion-skin pattern

85
Q

At what glucose level is there increased mortality in a trauma pt?

A

> 180 and they should be treated with short-acting insulin

86
Q

What cardiac issue is associated with splenic abscess?

A 
infective endocarditis
(should be suspected in pt who has MVP, fever with systemic manifestations, and splenic abscess)
87
Q

Management of gallstones

A

> without symptoms: no treatment
with biliary colic symptoms: elective surgery or Urso deoxycholic acid if poor surgical candidate
complicated: cholecystectomy within 72 hours

88
Q

What type of fluid is used for fluid resuscitation in burn victims?

A

isotonic crystalloid solution (normal saline, lactated Ringer solution)

lactated better since it is a balanced fluid

89
Q

How does Lactated ringers solution maintain normal blood pH?

A

Contains sodium lactate which is hepatically metabolized to bicarbonate

90
Q

Potential complication with using normal saline

A

hyperchloremic metabolic acidosis due to its supraphysiologic chloride concentration

91
Q

Clinical presentation of pt with hemobilia?

A 
melena
RUQ pain
jaundice
anemia
hyperbilirubinemia
recent liver biopsy
92
Q

What is the most reliable physical exam maneuver for checking for complete Achilles tendon rupture?

A

calf squeeze test (Thompson test)

If there is no passive plantarflexion then it is a complete rupture

93
Q

What will LFTs be in a pt with ischemic hepatitis?

A

Aminotransferase levels ?1000 U/L shortly after inciting event

94
Q

Treatment for radial head subluxation

A

> hyper pronation of forearm

> supination of forearm and flexion of elbow

95
Q

How does excess normal saline lead to non-anion gap metabolic acidosis?

A

infusion increases intravascular Cl-, which drive intracellular shifting of HCO3- -> loss of HCO3- in the bloodstream–> decrease in blood pH

96
Q

Management of pt with venous air embolism

A

> left lateral decubitus position to trap the air bubble on the lateral wall of the right ventricle
high flow or hyperbaric oxygen (helps to shrink the bubble)

97
Q

Etiologies of venous air embolism (3)

A
  1. trauma, certain surgeries
  2. central venous catheter manipulation
  3. barotrauma
98
Q

What should be done to prevent further bleeding in a pt with a severe pelvic frature?

A

pelvic binder should be placed immediately

99
Q

What are the next steps following application of pelvic binder in a pt with severe pelvic fracture?

A
  1. CT of abdomen and pelvis

2. retrograde cystourethrogram to assess for urethral injury

100
Q

Best imaging for hemodynamically stable pt with splenic laceration?

A

CT abdomen/pelvis with IV contrast

101
Q

Variceal hemorrhage bleed algorithm (3 steps)

A
  1. Place 2 large-bore IV catheters
  2. Volume resuscitation, IV octreotide, antibiotics
  3. Urgent EGD
102
Q

Clinical manifestation of Candida endophthalmitis

A

> unilateral decreased vision
floaters in vision
fluffy, yellow-white chorioretinal lesions

103
Q

Besides EKG and physical exam findings what else is suggestive of cardiac tamponade?

A

elevation and equalization of intracardiac diastolic pressures

104
Q

Stage II and III colon cancer require what screening tests?

A
  1. colonoscopy in 1 year and then q3-5 years
  2. periodic CEA testing
  3. annual CT scan of the chest and abdomen to check for metastasis
105
Q

How differentiate compartment syndrome from DVT

A

Compartment syndrome is more likely to have severe pain and sensory or motor deficits

106
Q

Pathogenesis of Gilbert syndrome

A

decreased hepatic UDP-GT which leads to an increased unconjugated bilirubin

107
Q

Staging of gastric adenocarcinoma

A
  1. initial EGD w/biopsy positive for adenocarcinoma
  2. CT abdomen and pelvis
  3. PET/CT, endo US, laparoscopy
  4. Limited stage=surgical resection, advanced stage=chem +/-palliative surgery
108
Q

Adverse effects of aggressive crystalloid resuscitation

A
  1. coagulopathy due to dilution
  2. hypothermia
  3. acidosis due to Cl- driving HCO3- intracellularly
  4. increased mortality due to causing the previous three things
109
Q

Imaging used to diagnose bladder rupture

A

retrograde cystography

110
Q

Clinical presentation of idiopathic pulmonary fibrosis (3)

A
  1. chronic progressive dyspnea, nonproductive cough, fatigue
  2. fine “velcro” inspiratory crackles, digital clubbing
  3. high res CT: UIP (subpleural honeycombing, reticular opacities); PFTs: restrictive pattern
111
Q

Onset and management of chemical pneumonitis

A

> sudden: within minutes to hours

>supportive care, oropharyngeal suction if event is witnessed

112
Q

Onset and management of chemical pneumonitis

A

> indolent: a few days to weeks

> antibiotics (ceftriaxone + azithromycin)

113
Q

Things to do to reduce risk of ventilator associated pneumonia (4)

A
  1. head of bed elevation at 30-45 degrees
  2. suction of subglottic secretions
  3. minimize pt movement
  4. limited use of gastric acid inhibitors
114
Q

Treatment for emphysematous cholecystitis

A

> emergency cholecystectomy

> piperacillin-tazobactam to cover Clostridium

115
Q

MOA of tranexamic acid

A

antifibrinolytic

helps prevent acute traumatic coagulopathy following significant trauma

116
Q

treatment for acute bacterial prostatitis

A

prolonged treatment (6 weeks) with:
>fluoroquinolone
>trimethoprim-sulfamethoxazole

117
Q

Management of postoperative mediastinitis

A

> drainage, surgical debridement with immediate closure

>prolonged antibiotic therapy

118
Q

treatment of hidradenitis suppurativa

A

Mild: topical clindamycin
Moderate: oral tetracycline
Severe: tumor necrosis factor-alpha inhibitor, surgical excision

119
Q

Indications for retrograde urethrography in pts with penile fracture (4)

A
  1. blood at the meatus
  2. hematuria
  3. dysuria
  4. urinary retention
120
Q

Treatment for penile fracture

A

surgical repair of the tunica albuginea

121
Q

Indication for surgery in pts with chronic mitral valve regurgitation

A

surgery if LVEF <60%

122
Q

ALT > what has 95% positive predictive value for diagnosing gallstone pancreatitis?

A

ALT>150 U/L

these pts should have cholecystectomy once medically stable.

123
Q

Best diagnostic test for diverticulitis?

A

Abdominal CT

sigmoid or colonoscopy are contraindicated in acute setting

124
Q

Next step in pt who’s frostbite has not improved with rewarming measures

A

angiography or technetium-99m scintigraphy to assess for perfusion

125
Q

Diagnosis of left ventricular aneurysm

A

> EKG: persistent ST elevation, deep Q waves

>Echo: thin and dyskinetic myocardial wall

126
Q

Best way to perform biliary drainage in the setting of acute cholangitis

A

> ERCP with sphincterotomy and/or a biliary stent

127
Q

Pts with biliary cysts are at an increased risk of what cancer?

A

cholangiocarcinoma

128
Q

What drugs can cause acquired methemoglobinemia?

A

> topical anesthetics (benzocaine)
dapsone
nitrates (in infants)

129
Q

What blood gas value should you suspect in a pt with acquired methemoglobinemia?

A

Pt has a significant difference between the oxygen saturation value estimated on blood gas analysis and that obtained on pulse oximetry

130
Q

Alarming features of constipation

A

> acute onset at an older age (>50 y/o)
weight loss
hematochezia

131
Q

Clinical manifestations of pyoderma gangrenosum (3)

A
  1. begins with small papule or ulcer
  2. rapidly progressive, painful ulcer with purulent base and violaceous border
  3. precipitation of ulceration at site of injury
132
Q

Pyoderma gangrenosum is associated with what diseases?

A

IBD, inflammatory arthritis, malignancy

133
Q

Abrupt upward shifting of the prostate can cause damage at what part of the urethra?

A

bulbomembranous junction

134
Q

Ankle-brachial index numbers and their meaning (3)

A

<0.9 = PAD
>1.3 = calcified and uncompressible vessels
anywhere between those two values is normal

135
Q

Treatment for lung abscess

A

First line: ampicillin-sulbactam

Second line: clindamycin for those with beta-lactam allergy

136
Q

Features that distinguish biliary colin from cholecystitis

A

Pain resolution within 4-6 hours and absence of abdominal tenderness, fever, and leukocytosis

137
Q

Management of femoral hernias

A

Referred for elective surgical repair as they pass through a smaller hole and are more likely to become incarcerated or strangulated

138
Q

Imaging for suspected aortic dissection

A

stable: CT angiography

unstable or bad kidneys: transesophageal echo

139
Q

Clinical manifestations of copper deficiency (5)

A
  1. brittle hair
  2. skin depigmentation
  3. neurologic dysfunction
  4. anemia
  5. osteoporosis
140
Q

What antibiotics should be given empirically in pts with catheter-related bloodstream infection?

A

vancomycin + ceftazidime to cover common skin pathogens

Uworld Step 2 (2 decks)

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