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)
2
Q
Clinical presentation of traumatic carotid injuries
A
gradual onset hemiplegia
aphasia
neck pain
“thunderclap” HA
3
Q
Mechanism of injury for traumatic carotid injuries
A
penetrating trauma
fall with object in mouth
neck manipulation
4
Q
Etiology of Ogilvie syndrome
A
Major surgery
electrolyte derangement
medication (opiates, anti-ACh)
neurologic disorders
5
Q
Management of Ogilvie syndrome
A
NPO, nasogastric/rectal tube decompression
Neostigmine if no improvement within 48 hours
6
Q
What imaging should be performed in hemodynamically unstable pt following blunt chest trauma?
A
eFAST
chest CT
EKG
7
Q
What imaging should be performed to diagnose toxic megacolon?
A
CT of the abdomen
8
Q
How is blunt thoracic aortic injury diagnosed?
A
CT angio in stable pts
TEE for unstable pts
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
10
Q
What drug is preferred for treatment of acute PE in pts with cancer?
A
therapeutic-dose low molecular weight heparin
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
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
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
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)
15
Q
How are hydatid cysts described on CT scan?
A
“eggshell” calcification
16
Q
Definitive hose of E. granuloses
A
dogs
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
18
Q
What imaging should be performed for testicular torsion?
A
US with doppler
If positive will show no blood flow to testicle
19
Q
Pts with new onset ascites should have what imaging performed initially?
A
Abdominal US
20
Q
Management of pt with clenched-fist bite injury
A
urgent surgical irrigation and debridement
antibiotics (ampicillin/sulbactam [IV], amoxicillin/clavulanate [PO])
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
22
Q
What causes a perianal abscess?
A
due to occlusion of an anal crypt gland, which allows for bacterial infection
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
24
Q
Management of pes anserinus pain syndrome
A
quadricep strengthening exercises and NSAIDs
25
Clinical presentation of renal abscess
Pt recently had UTI now with several days of unilateral flank pain, weight loss, fever, and leukocytosis, with no UTI symptoms or bacteriuria
26
Risk factors for renal abscess formation
anatomic abnormalities
nephrolithiasis
uncontrolled DM
tobacco use
27
Pts with Crohn disease or other disorder resulting in fat malabsorption are predisposed to what?
hyperoxaluria (excess fats binds calcium which would normally bind to oxalate)
28
Clinical presentation of suppurative parotitis
firm, erythematous pre/postauricular swelling
exquisite tenderness exacerbated by chewing and palpation
trismus, systemic findings
elevated serum amylase without pancreatitis
29
Typical pt who gets suppurative parotitis
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)
30
Persistently bloody ascites found on multiple paracenteses is suggestive of what cancer
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)
31
Which antibiotics can be used in pts with sepsis due to diabetic foot infection?
piperacillin-tazobactam
carbapenem
fourth-gen cephalosporin (cefepime)
32
Pain management in pts with opioid use disorder
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)
33
What imaging should be performed in a pt with lower rib fractures
CT of the abdomen and FAST scan
34
When is open reduction and surgical exploration indicated in humeral shaft fractures?
1. open fractures
2. significant displacement
3. neurovascular compromise
4. polytrauma
5. pathologic fractures
35
When to suspect tracheobronchial injury
despite pt having appropriate tube thoracostomy, repeat CXR shows rapid pneumothorax re-accumulation and increased subcutaneous emphysema
36
Diagnostic steps for psoas abscess
1. CT scan of abdomen and pelvis
2. leukocytes, elevated inflammatory markers
3. blood and abscess cultures
37
When should wet-to-dry dressings being used?
wounds that are infected or have devitalized tissue or slough. As the dressing dries it will adhere and then pull off the dead skin
38
When should nonadherent, moisture-retaining dressings be used?
once healthy granulation tissue appears
39
What imaging should be performed in pts with concerning findings but without frank peritonitis?
abdominal CT (oral contrast can help finds sites of leakage due to injury in surgery)
40
What imaging should be performed if the pancreas is not visualized well on US?
CT of the abdomen
41
Signs of necrotizing surgical site infection
>pain, edema, erythema
>systemic signs like fever, tachycardia, hypotension
>paresthesia or anesthesia at edges of wound
>purulent, cloudy-gray discharge
>subcutaneous gas or crepitus
42
Young or middle aged pt with osteoporosis. What GI issue can lead to this?
celiac disease due to malabsorption of vit D
43
What is the usual source of infection in Ludwig angina?
dental infections
44
Phases of wound healing
1. hemostasis (0 hours- 1 day)
2. inflammation (3 hours-5 days)
3. proliferation (3 days-5 weeks)
4. remodeling (3 weeks-2 years)
45
Complications of high myopia (>6 diopters of correction)
>retinal detachment
| >macular degeneration
46
Management of diverticulitis complicated by abscess
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
47
Which nerve can be damaged following anterior shoulder dislocation?
Axillary nerve
48
When are massive transfusion protocols required?
```
if 2 of the following are present
>penetrating mechanism of injury
>positive FAST scan
>systolic <90 mmHg
>pulse >120bpm
```
49
How should blood products be given in massive transfusion protocol?
1:1:1 ratio
| FFP/packed RBCs/platelets
50
What masses are found in the anterior mediastinal compartment?
>thymic neoplasms
>lymphoma
>germ cell tumors
>thyroid tissue
51
What masses are found in the middle mediastinal compartment?
>lymphadenopathy, lymphoma
>benign cystic masses (pericardial cyst, bronchogenic cyst)
>vascular masses
>esophageal tumors
52
What masses are found in the posterior mediastinal compartment?
>neurogenic tumors, meningocele
>spinal masses
>lymphoma
53
What type of feeding is recommended for burn victims?
Early enteral nutrition
>maintains gut integrity and decreases bacterial translocation
>reduced rates of sepsis
>decreased mortality
54
What is the preferred screening test to evaluate cervical spine injury?
CT scan
55
Indications for cervical spine imaging? (5)
1. neurologic deficit
2. spinal tenderness
3. altered mental status
4. intoxication
5. distracting injury
56
What imaging should be performed following primary survey of trauma?
1. chest and pelvic XR
2. FAST scan
3. cervical spine CT
57
Clinical features of open globe injury (5)
```
>extrusion of vitreous
>eccentric or teardrop pupil
>decreased visual acuity
>relative afferent pupillary defect
>decreased intraocular pressure
```
58
Hard signs of extremity vascular trauma (4)
>observed pulsatile bleeding
>presence of bruit/thrill over injury
>expanding hematoma
>signs of distal ischemia
59
Soft signs of extremity vascular trauma (4)
>history of hemorrhage
>diminished pulses
>bony injury
>neurologic abnormality
60
Treatment of priapism in sickle cell disease
>aspiration of blood from corpora cavernosa
| >intracavernous injection of phenylephrine
61
What is test of choice in pt where PE is likely?
CT angio of chest
62
What disease is Paget disease of bone associated with?
osteosarcoma
63
Diagnosis and treatment of upper extremity DVT
>doppler or duplex US
| >3 months of anticoagulation
64
Epidemiology of upper extremity DVT
>central catheter or PICC line
>young, athletic male (spontaneous)
>thoracic outlet syndrome
65
How to differentiate Factor V from Sickle Cell
Sickle cell will have evidence of hemolysis
66
Physical exam findings of adhesive capsulitis
>decreased passive and active range of motion
| >stiffness +/- pain
67
When is emergency thoracotomy required in a pt with trauma?
* initial blood output >1500ml
| * persistent hemorrhage:>200ml/hr for >2 hours, or continuous need for blood transfusion
68
Treatment for septic arthritis
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
Complications of ankylosing spondylitis (3)
1. osteoporosis/vertebral fractures
2. aortic regurgitation
3. cauda equina syndrome
70
Imaging for ankylosing spondylitis
>XR of sacroiliac joints
| >MRI of sacroiliac joints
71
Diagnosis and treatment of sphincter of Oddi dysfunction
Dx: manometry
Tx: sphincterotomy
72
What drug class can worsen the symptoms of sphincter of Oddi dysfunction
opioids by causing sphincter contraction
73
tumor markers for cholangiocarcinoma
increased CEA
increased CA-19
normal AFP
74
What should be regularly checked in a pt who had removal of medullary thyroid cancer
Calcitonin
the tumor arises from calcitonin-secreting parafollicular C cells
75
Eye findings for uncal herniation
ipsilateral fixed and dilated pupil due to compression of the ipsilateral oculomotor nerve and accompanying parasympathetic fibers
76
Eye findings for tonsillar herniation
fixed, mid-position pupils due to disruption of both sympathetic and parasympathetic innervation
77
Diagnostic work up should include what in pts with suspected acute lung transplant rejection
bronchoalveolar lavage and lung biopsy
78
Treatment for malignant pericardial effusion
acute management: pericardiocentesis, cytologic fluid analysis
prevention of recurrence: prolonged drainage (catheter, pericardial window)
79
treatment of hepatic adenoma
* Asymptomatic and <5cm: stop oral contraception
| * Symptomatic and >5cm: surgical resection
80
Clinical manifestations of acute graft vs host disease
>Occurs within 100 days (common in those receiving hematopoietic stem cell transplantation)
>profuse, watery diarrhea that has a secretory pattern
>liver inflammation
81
What type of immune reaction is graft vs host disease?
CD8+ T-lymphocyte mediated injury
82
Risk factors for sigmoid volvulus
>sigmoid colon redundancy (dilation/elongation from chronic constipation)
>colonic dysmotility (underlying neurologic disorder)
83
Treatment of C diff (non-severe, severe, and fulminant)
non-severe: oral fidaxomicin or vancomycin
severe: oral fidaxomicin or vancomycin
fulminant: oral vancomycin, IV metronidazole
84
What will liver biopsy show in a pt with primary sclerosing cholangitis?
fibrous obliteration of small bile ducts, with concentric replacement by connective tissue in onion-skin pattern
85
At what glucose level is there increased mortality in a trauma pt?
>180 and they should be treated with short-acting insulin
86
What cardiac issue is associated with splenic abscess?
```
infective endocarditis
(should be suspected in pt who has MVP, fever with systemic manifestations, and splenic abscess)
```
87
Management of gallstones
>without symptoms: no treatment
>with biliary colic symptoms: elective surgery or Urso deoxycholic acid if poor surgical candidate
>complicated: cholecystectomy within 72 hours
88
What type of fluid is used for fluid resuscitation in burn victims?
isotonic crystalloid solution (normal saline, lactated Ringer solution)
lactated better since it is a balanced fluid
89
How does Lactated ringers solution maintain normal blood pH?
Contains sodium lactate which is hepatically metabolized to bicarbonate
90
Potential complication with using normal saline
hyperchloremic metabolic acidosis due to its supraphysiologic chloride concentration
91
Clinical presentation of pt with hemobilia?
```
melena
RUQ pain
jaundice
anemia
hyperbilirubinemia
recent liver biopsy
```
92
What is the most reliable physical exam maneuver for checking for complete Achilles tendon rupture?
calf squeeze test (Thompson test)
| If there is no passive plantarflexion then it is a complete rupture
93
What will LFTs be in a pt with ischemic hepatitis?
Aminotransferase levels ?1000 U/L shortly after inciting event
94
Treatment for radial head subluxation
> hyper pronation of forearm
| > supination of forearm and flexion of elbow
95
How does excess normal saline lead to non-anion gap metabolic acidosis?
infusion increases intravascular Cl-, which drive intracellular shifting of HCO3- -> loss of HCO3- in the bloodstream--> decrease in blood pH
96
Management of pt with venous air embolism
> 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
Etiologies of venous air embolism (3)
1. trauma, certain surgeries
2. central venous catheter manipulation
3. barotrauma
98
What should be done to prevent further bleeding in a pt with a severe pelvic frature?
pelvic binder should be placed immediately
99
What are the next steps following application of pelvic binder in a pt with severe pelvic fracture?
1. CT of abdomen and pelvis
| 2. retrograde cystourethrogram to assess for urethral injury
100
Best imaging for hemodynamically stable pt with splenic laceration?
CT abdomen/pelvis with IV contrast
101
Variceal hemorrhage bleed algorithm (3 steps)
1. Place 2 large-bore IV catheters
2. Volume resuscitation, IV octreotide, antibiotics
3. Urgent EGD
102
Clinical manifestation of Candida endophthalmitis
>unilateral decreased vision
>floaters in vision
> fluffy, yellow-white chorioretinal lesions
103
Besides EKG and physical exam findings what else is suggestive of cardiac tamponade?
elevation and equalization of intracardiac diastolic pressures
104
Stage II and III colon cancer require what screening tests?
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
How differentiate compartment syndrome from DVT
Compartment syndrome is more likely to have severe pain and sensory or motor deficits
106
Pathogenesis of Gilbert syndrome
decreased hepatic UDP-GT which leads to an increased unconjugated bilirubin
107
Staging of gastric adenocarcinoma
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
Adverse effects of aggressive crystalloid resuscitation
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
Imaging used to diagnose bladder rupture
retrograde cystography
110
Clinical presentation of idiopathic pulmonary fibrosis (3)
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
Onset and management of chemical pneumonitis
>sudden: within minutes to hours
| >supportive care, oropharyngeal suction if event is witnessed
112
Onset and management of chemical pneumonitis
>indolent: a few days to weeks
| > antibiotics (ceftriaxone + azithromycin)
113
Things to do to reduce risk of ventilator associated pneumonia (4)
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
Treatment for emphysematous cholecystitis
>emergency cholecystectomy
| > piperacillin-tazobactam to cover Clostridium
115
MOA of tranexamic acid
antifibrinolytic
helps prevent acute traumatic coagulopathy following significant trauma
116
treatment for acute bacterial prostatitis
prolonged treatment (6 weeks) with:
>fluoroquinolone
>trimethoprim-sulfamethoxazole
117
Management of postoperative mediastinitis
>drainage, surgical debridement with immediate closure
| >prolonged antibiotic therapy
118
treatment of hidradenitis suppurativa
Mild: topical clindamycin
Moderate: oral tetracycline
Severe: tumor necrosis factor-alpha inhibitor, surgical excision
119
Indications for retrograde urethrography in pts with penile fracture (4)
1. blood at the meatus
2. hematuria
3. dysuria
4. urinary retention
120
Treatment for penile fracture
surgical repair of the tunica albuginea
121
Indication for surgery in pts with chronic mitral valve regurgitation
surgery if LVEF <60%
122
ALT > what has 95% positive predictive value for diagnosing gallstone pancreatitis?
ALT>150 U/L
these pts should have cholecystectomy once medically stable.
123
Best diagnostic test for diverticulitis?
Abdominal CT
| sigmoid or colonoscopy are contraindicated in acute setting
124
Next step in pt who's frostbite has not improved with rewarming measures
angiography or technetium-99m scintigraphy to assess for perfusion
125
Diagnosis of left ventricular aneurysm
>EKG: persistent ST elevation, deep Q waves
| >Echo: thin and dyskinetic myocardial wall
126
Best way to perform biliary drainage in the setting of acute cholangitis
>ERCP with sphincterotomy and/or a biliary stent
127
Pts with biliary cysts are at an increased risk of what cancer?
cholangiocarcinoma
128
What drugs can cause acquired methemoglobinemia?
>topical anesthetics (benzocaine)
>dapsone
>nitrates (in infants)
129
What blood gas value should you suspect in a pt with acquired methemoglobinemia?
Pt has a significant difference between the oxygen saturation value estimated on blood gas analysis and that obtained on pulse oximetry
130
Alarming features of constipation
>acute onset at an older age (>50 y/o)
>weight loss
>hematochezia
131
Clinical manifestations of pyoderma gangrenosum (3)
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
Pyoderma gangrenosum is associated with what diseases?
IBD, inflammatory arthritis, malignancy
133
Abrupt upward shifting of the prostate can cause damage at what part of the urethra?
bulbomembranous junction
134
Ankle-brachial index numbers and their meaning (3)
<0.9 = PAD
>1.3 = calcified and uncompressible vessels
anywhere between those two values is normal
135
Treatment for lung abscess
First line: ampicillin-sulbactam
| Second line: clindamycin for those with beta-lactam allergy
136
Features that distinguish biliary colin from cholecystitis
Pain resolution within 4-6 hours and absence of abdominal tenderness, fever, and leukocytosis
137
Management of femoral hernias
Referred for elective surgical repair as they pass through a smaller hole and are more likely to become incarcerated or strangulated
138
Imaging for suspected aortic dissection
stable: CT angiography
| unstable or bad kidneys: transesophageal echo
139
Clinical manifestations of copper deficiency (5)
1. brittle hair
2. skin depigmentation
3. neurologic dysfunction
4. anemia
5. osteoporosis
140
What antibiotics should be given empirically in pts with catheter-related bloodstream infection?
vancomycin + ceftazidime to cover common skin pathogens
