Surgery Flashcards
Icp tx (3)
Elevate head
Hyperventilate to pco2 35
Meds
Blown pupil with contralateral hemiparesis
Epidural hematoma on side of pupil.
Dx for gsw to upper neck
Arteriographic studies
2 sx of brown-sequard
Paralysis on same side distal
Loss of pain on distal contralateral side
Lost (2) and preserved (1) of anterior cord syndrome
Loss motor and pain
Preserved proprioception
Syndrome with hyper extension of neck in elderly and sx
Central cord syndrome
Paralysis and burnning of UE only
Rib fracture tx in elderly (2)
Local nerve block and epidural
Indication for surgery after chest tube in hemothorax
1500 mL from chest tube
Tx flail chest
Restrict fluids and diurese
Monitor ABGs
Most common site of metastasis crc
Liver
Sequence of 3 cr polyps. Increasing to more dangerous
Tubular, tubulovillous, villous
Type of pain relief for biliary dz
Demerol (meperidine)
asymtomatic dz to suspect in severe deceleration injury w/ chest bones difficult to break (sternum, scapula, or first rib)
ruptured aorta
3 locations where 1500 mL of blood can “hide”
pelvis, thighs, abdomen
3 tx for possible renal failure in sever electrical burns
fluids
mannitol
alkalinize urine
legs in rule of 9’s
each leg is 2 9’s
trunk of person in rule of 9’s
4 units
target with rehydration after burn (2, 1 target, 1 to monitor)
hourly urinary output of 1-2 mL/kg
avoiding CVP over 15 mmHg
SA (surface area) threshold for treating burns with ringer lactate
> 20% of body surface
bolus in babies
20 mL/kg
2 changes in rule of 9 in babies
head = 2 9’s
2 legs = 3 9’s (instead of 4)
prophylaxis to burn patients
tetanus
3 oitments for burns (shallow, deep, near eyes)
silver sulfadiazine
mafenide acetate
triple abx ointment
tx(2) for all bites
tetanus
wound care
black widow antidote
IV calcium gluconate
helpful drug for brown recluse
dapsone
chubby 13 yo w/ groin or knee pain
legs dangling, affected side points in
slipped capital femoral epiphysis
little kid w/ fever
severe localized pain in bone
-XR
condition, test, and tx
acute hematogenous osteomyelitis
MRI
abx
dz = consistent varus beyond age 3
blount dz
inward turned feet w/ plantar flexion, inversion
seen at birth
talipes equinovarus (club foot)
monteggia fracture vs galeazzi fracture
mont: fracture of proximal 1/3 ulna
gale: distal radius
Mount Ulna and Gale-adius
tx of scaphoid fracture
thumb spica cast
(remember XR show fx 3 weeks later!
apearance of hip fracture (2)
shortened and externally rotated leg
tx for postop of intertrochanteric fx of hip
anticoagulation
describing fractures (5)
LD PAU
Location Displaced Pattern (transverse vs oblique vs comminuted) Angulation/Rotation Unusual Circumstance
most reliable sign of compartment syndrome
excruciating pain w/passive extension
tx and dx of De Quervain tenosynovitis
thumb in fist, and ulnar deviation = pain
steroid injection
tx of felon
surgical drainage
PEx finding w/ disc dz
straight leg testing gives excruciating pain
amaurosis fugax
transient visual loss one eye
carbuncle
collection boils (furuncles)
furuncle
boil (small subcu staph infection of follicle)
inspissated
hard
lieno-
denoting spleen
obstipation
failure to pass flatus or stool
-pexy vs. -raphe
pexy = fixation (pexation)
raphe=repair
phlegmon
soft tissue inflammation (commonly pancreatic)
succus
fluid
ballance’s sign
dullness to percussion L flank, resonance on R.
splenic rupture
carcinoid triad
FDR
flushing, diarrhea, R. sided heart failure
blue coloration of periumbilical area
cullen’s sign = retroperitoneal hemorrhage cought be hemmhoragic pancreatitis
obturator sign
passive internal rotation of leg
pheochromocytoma (3)
PhD
palps, HA, episodic diaphoresis
psoas sign
keep knee extended, and passively extend hip (on side)
Fitz-Hugh-Curtis syndrome
perihepatic gonorrhea
3 things (besides GI polyps in Gardner’s syndrome)
Gardeners plant SOD
sebaceous cysts
osteoma
desmoid tumors
most common indication for surgery w/ Crohn’s
SBO : small bowel obstruction
most common bacteria in stool
Bacteroides fragilis
Upright AXR finding w/SBO
air-fluid levels
position of anal fissure
posterior
most common benign tumor of liver
hemangioma
monocryl
absorbable monofilament
postop ordering
VAN DISL
Vital signs and monitoring Activity Nutrition Drugs IV Special orders Labs, XR
normal time period for wound tensile strength
6 weeks
increased complications after what time period with ileus
3-5 days
IV maintenance
4-2-1 rule
4 cc/kg for the first 10 kgs of a patient’s weight
2 cc/kg for the next 10 kgs of a patient’s weight
1 cc/kg for the rest of the patient’s weight
60 kg person = 100 mL/hr
when do you look at bandage?
after 48 hours (daily)
2 labs if concerned about shock/resuscitation
ABG and lactate
contents seroma
lymph
serum
2 most common causes acute pancreatitis
Gallstones and etoh
Boundaries of axilla for ln dissection (4)
Axillary vein, superior
Long thoracic nerve, posterior
Latissimus Dorsi, lateral
Pectoral minor
4 nerves at risk Axillary ln dissection
Long thoracic
Thoracodorsal
Medial and lateral pectorals
Ltn innervates
Serratus anterior
Thoracodorsal innervates
Latissimus dorsi
Course of medial and lateral pectoral nerves
Opposite of one another!
Cutaneous nerve that crosses axilla
Intercostobrachial nerve
Levels 1,2,3 of Axillary lymph nodes
Lateral, deep, and medial to pectoral minor
Rotter’s nodes
Between pec major and minor
Tail of spence
Tail of breast tissue into axilla
Breast cancer risk (5)
NAACP
Nulliparity
Age menarche 55
Ca breast, self or family
Pregnancy 1st, >30
3 major blood sources to breast
Lateral and internal thoracic arteries
Intercostal
Dermatome of knee
L3 is the knee
FENa =
yoU Need Pee
UNa * Plasma creatinine
For numerator
Denominator is reversed
Prerenal FENa
<1.0
Melanoma on Palm or sole of African american
Acral lentiginous
Two findings with chronic anal fissure
Sentinel pile
Hypertrophied Anal papilla
Surgical tx anal fissure
LIS lateral internal sphincterotomy
indirect vs direct hernia location
indirect = lateral to inferior epigastrics
position inguinal hernias usually resolve
recumbency
indirect v direct etiology
indirect = patent processus vaginalis direct = weakness of transversolis fascia
vague aching low back pain
sudden onset severe neurogenic pain
excruciating pain on straight leg test
disc dz
ulcer w/o pressure gradient on doppler
microvascular dz (no amenable to surgery)
SCC from chronic leg ulcer
Marjolin ulcer
inflammation at digital nerve at between 3rd, 4th toe
morton neuroma
EF cutoff for +surgery risk
35%
fever over 104, 30-45 minutes after surgery
bacteremia
if wound pain, consider gas gangrene
therapy for atelectasis if no imrpovement w/deep breathing, cough and postural draining
bronchoscopy
most common fever POD>3
UTI
fever on POD 5
thrombophlebitis
fever days 7 vs 9
7 = wound infection
9=abscess
ABG w/PE (2)
hypoxemia
hypocapnia
FENa significance, 1, >4
1 = intrinsic AKI >4 = postrenal
FENa =
(PCr * UNa ) / (PNa x UCr) %
ileus not resolving after 7 days
mechanical ileus (adhesions)
paralytic ileus in immobilization
+abd distension, dilated colon
mechanical obstruction ruled out
Ogilvie syndrome
tx Ogilvie syndrome (2, 1 is a consideration)
Decompress w/ sigmoidoscopy or colonoscopy and rectal tube IV neostigmine (consider)
typical day for wound dehiscence
day 5
hypernatremia, how much dehydration for every 3 meg above 140?
1 liter
safe speed limit of potassium admin
10 meq/hr
colicky abd pain w/ high pitched bowel sounds
then silence and loops of bowels w/air-fluid levels
mechanical obstruction
main tx of SCC of anus
chemoradiation
rate of active Gi bleed caught on angiogram
2 mL/minute (1 unit blood q4 hrs)
blood er rectum child
meckel diverticulum
dx meckel
technetium scan
parrot’s beak on axr
volvulus of sigmoid
large thin-walled distended gallbladder
Courvoisier-Terrier sign (malignant obstructive jaundice)
acute pancreatitis w/+ Ht or -Ht
\+Ht = edematous pancreatitis -Ht = hemhorrhagic pancreatitis
size of pancreatic pseudocyst likely to rupture or have prob
6 cm
bloody nipple discharge
intraductal papilloma
breast cancer patient w/ backache or persistent headache
metastasis to brain or vertebral pedicles
hypersecretion of insulin in newborn
nesidioblastosis (devastating = 95% pancreatic resection)
patient w/DM
migratory necrotic dermatitis
mild anemia, glossitis, stomatitis
glucagonoma
newborn first fed;
feeding intolerance, abd. distension, rapidly developing thrombocytopenia
necrotizing enterocolitis
person w/mono gets L. shoulder pain
Kehr sign
ruptured spleen
physical findings (2) in hemorrhagic pancreatitis
cullen sign; bruising around umbilicus
bruising on flanks
electric alternans on EKG
pericardial tamponade
abdominal pain 10/10 but no physical findings
acute mesenteric ischemia
acute abd pain out of proportion.
best first test?
most accurate test?
CT scan of abdomen
angiography
subcutaneous emphysema upon palpation of thorax or clavicles
esophogeal perf
histology of boerhaave vs mallory-weiss
boerhaave = full thickness tear mallory-weiss = mucosa only
3rd vs 4th degree burn
3rd = subcu 4th = muscle
front of torso = what percent?
18
% more calories w/major burns
40%
IV access for all burns over
20% (NG tube too)
2 tests to order with 20 yo F w/ RLQ pain
B-HCG
pelvic sonogram
most accurate test for cholecystitis
HIDA scan (delayed emptying of gallbladder)
high pitched tinkling bowel sounds
+lactate and acidosis
dx?
bowel obstruction
open reduction and internal fixation fractures
displacement or misalignment of bones
close fracture vs open fracture
closed = mild w/o displacement open = skin punctured
fracture w/several pieces
comminuted fracture
most common stress fracture
metatarsals
tx scaphoid fracture
thumb spica cast
unhappy triad knee (3)
ACL
MCL
Lateral meniscus
surgery indicated on AAA when……
5 cm
5 causes, in order of post-operative fever
WIND: 1-2 water: 3-5 walking: 5-7 WOund: 7 WOnder/abscess: 8-15
infant first few months
failure to thrive
pansystolic murmur at USB
VSD
gradient where surgery indicated for aortic stenosis
50 mmHg
or CHF, angina or syncope
square root sign on EKG
pericarditis
FEV1 required for surgery in lung cancer
minimum 800 mL
management tender AAA
surgery
medical term lazy eye
amblyopia
medical term crossed eyes
strabismus
abscess of floor of mouth, often due to bad tooth infection
ludwig angina
diplopia with person with sinutisitis
cavernous sinus thrombosis
a medical emergency
therapy for prolactinoma
bromocriptine
several months after crush injury
pain
reflex sympathetic dystrophy (causalgia)
reflex sympathetic dystrophy
dx and tx
dx = successful sympathetic block tx = sympathectomy
absolute contraindication to surgery
DKA
Assist-control on vent
patient takes a breath, vent gives volume
vent setting for weaning
pressure support
patient rules rate
with high paCO2, adjustment on vent
tidal volume
rate also acceptable
acidosis vs alkalosis
check what 2 values after pH?
HCO3, pCO2
anion gap equation
include normal
Na - (Cl + HCO3)
8-12
Na correction rate
12-24 meq/24 hours
maintenance daily
1-10 kg?
10-20?
20+?
4-2-1 rule
1-10 = 4 mL/kg/hr 10-20 = +2 mg/kg/ hr 20+= +1 mL/kg/hr
clotting
edema, htn
foamy pee
nephrotic syndrome
bleeding with isolated thrombocytopenia
ITP
parkland formula for burn resuscitation
kgX BSA X 4 ml
Over 24 hrs. 1/2 over 1st 8
side effect silver sulfadiazene
leukopenia
burn topical that penetrates
mafenide
burn topical that causes hypoK and hypoNa
silver nitrate
electrolyte to check if rhabdo
potassium
pressure of compartment syndrome
> 30 mmHg
normal CVP w/flat neck veins’what type of shock?
hypovolemic
GCS scoring
eyes 4
motor 6
verbal 5
GSW or stab to zone 3 workup (2)
aortography and triple endoscopy
zone 3 of neck
above mandible
zone 2 of neck
angle of mandible to cric
GSW or stab wound to zone 2 of neck workup
2D doppler +/- surgery
zone 1 of neck
below cricoid
zone 1 of neck penetrating workup
aortography
handlebar sign
pancreatic rupture
4 phases wound healing
In every fresh cut
Inflammation
Epitheliazation
Fibroplasia
Contraction
effusion characteristic of lung adenocarcinom
exudative w/ high hyalurondase
PCWP cutoffs for ards vs cardiogenic
Less than 12 is ards
More than 15 is cardiogenic
valsalva or squatting with systolic murmurs(2)
softer = aortic stenosis louder = HOCM
mentrier’s
protein losing gastropathy
if duodenal ulcers persist, consider
ZE syndrome
best test for ZE syndrome
secretin stimulation test (high gastrin)
chronic pancreatitis causes thrombosis of
splenic veins (gives gastric varices)
hyperglycemia
diarrhea
weight loss
dark rash
glucagonoma
tumor that looks like carcinoid
VIPoma
choledochal cysts
type 1 v 4
1 = fusiform dilation Biliary duct = excision
4=caroli’s dz = intrahepatic ducts =liver transplantation
RUQ pain fever jaundice -BP AMS
ascending cholangitis
RUQ pain
+bili
+alk phos
choledocholithiasis
+AST, ALT
s/p hemorrhage, surg, or sepsis
shock liver (from hypotension)
TIPS relieves portal HTN, but
worsens hepatic encephalopathy
3 most common bugs for liver abscess
EBE
E.coli
Bacteroides
enterococcus
RUQ pain in traveler
sweating, rigors, palpable liver
ENTAMOEBA HISTOLYTICA
TX entamoeba histolytica
metronidazole
do not drain it
from mexico
RUQ pain
large liver cysts on US
echinococcus
thrombocytosis post splenectomy
tx?
asa
ITP tx
1st, 2nd
1st= steroids 2nd = splenectomy
carcinoid tumor #1 site
appendix
when sx of carcinoid
mets to liver
vitamin deficiency with carcinoid
niacin (Diarrhea, dementia, dermatitis)
postop ileus vs ogilvie’s syndrome on XR
postop ileus = dilated loops of small bowel w/air-fluid livels
ogilvie = colonic distension
tx of ogilvie syndrome (2)
> 10 cm decompression w/NG tube
neostigmine
sigmoid vs cecal volvulus on AXR
sigmoid = coffee bean sign cecal = bird beak
direct vs indirect inguinal hernias anatomy
Indirect Inguinal-MC through inguinal ring (lat to epigastric vessles) in spermatic cord. R>L, more often congenital (patent proc vaginals)
•Direct Inguinal-through Hasselbeck’s triangle (med to epigastric vessles), more often acquired weakness.
MEN syndromes
names and shapes (3)
diamond
square
triangle
MEN syndromes
mnemonics
PPP
MPP
MMP
MEN 1 syndrome (3)
pituitary
parathyroid
pancreas
MEN2a syndrome (3)
medullary thyroid Ca
parathyroid
pheo
MEN2b syndrome
medullary thyroid Ca
marfan
oral
pheo
tx for fibrocystic change of breast (3)
restrict caffeine
vitamin E
supportive bra
ped umbilical hernia association
and big tongue
hypothyroidism
ddx (2) of 3 day old newborn has still not passed meconium
meconium ileus (CF) Hirschprung's
4-5 yo w/painless limp and avascular necrosis
leg-calve-perthes’s dz
caution rocuronium
allergic rxn if asthmatic
caution meperidine
lower seizure threshold, esp if renal failure
problem with succinylcholine if burn/crush victim
hyperK
Varus memory tool
Varus = airus. Air between knees
normal urinary output
.5 cc/kg
paralytic ileus on AXR
everything is dilated
paralytic ileus of entire large colon in elderly
Ogilvie’s
tx Ogilvie’s (2)
rectal tube
colonoscopy
etiology of dehiscence vs evisceration
failure of fascia
failure of fascia and skin
tx wound evisceration prior to surgery (2)
saline towel
strict bed rest
never push back in!
borborygmi
high pitched sounds of bowel obstruction
on test, if person has appendicitis sx, next step
OR!! (CT not necessary)
String of pearls sign
SBO
initial tx of sigmoid volvulus
sigmoid scope for decompression
crohn’s dz most commonly effects
terminal ileum
bezoar
chunk of food; commonly a gastrolith
pancreatic tumor Copious Watery Diarrhea, Hypokalemia, and Achlorhydria (WDHA syndrome).
VIPoma
amt and fluid to give 75 kg person with burns in 24 hrs.
15 L of LR
most common lung cancer
adenocarcinoma
if necrotizing pancreatiti, ICU, daily CTs, and what abx?
carbepenem
weeks after pancreatitis
early satiety, +/- ascities, dyspnea
pseudocyst
pseudocyst >6 weeks or >6 cm
complicated pseudocyst
drainage necessary
soot on their nostrils/mouth
respiratory burn; evaluated w/bronchoscopy
electrical burn, what labs
CK-MB
tx rhabdo
IVF and mannitol
parkland formula for burns
%BSA * kg * 4cc
+2000 D5W
50% in 8 hours
50% in 16 hours
PCWP in CHF vs ARDS
normal (10) in ARDS
+ (25) in CHF
O2 rate of face/venti mask vs NRB
face/venti = 6-10
NRB is 10-15
FiO2 of NC vs face/venti mask
to 40%
40-80%
after NRB,
NIPPV - 3 types
high flow NC
CPAP
BiPAP
NIPPV if AMS or vomiting
high flow NC
bipap 10/5 means
10 = pressure support 5 = PEEP
bipap used in ventilation support for unloading CO2 for COPD NOT
asthma
ventilation changes
CO2
2 components of ventilation
Tidal volume
Respiratory rate
+PS/PEEP increases
ventilation
monitoring vents
CO2 method
O2 method
CO2 method = ABG
O2 method = O2sat
2 components of oxygenation
FiO2
PEEP
normal pCO2
40
normal pO2 range
75-105
lab to check if suspecting inhalation burn
carboxyhemoglobin
autograft vs allograft
autograft = patient's own skin allograft = cadaveric skin
SCC ulceration in burn rissue
marjolin’s ulcer
before chemo/surgery with lung Ca (3) but after bx
stage
PET CT
PFT
stable pulmonary nodule size to watch only
<2 cm
tx of small cell Ca
chemo only!
never operate
lung mass
flushing, diarrhea
dx, and side of heart affected
carcinoid
LEFT! (unlike GI which is right)
dx of +PTHism
sestamibi scan
migratory necrolytic dermatitis
mild DM
glucagonoma
calcium and phos levels in 1 vs 2nd degree hyper PTH
exact opposites!
Ca+, Ph- in 1
Ca-, Ph+ in 2
chalazion
like a stye, but painless, and inside the lid (rather than on edge
Hyphema
blood in anterior chamber of eye
iridocyclitis
uveitis
Ratio of NS or LR to replace blood lost
3:1
PaO2/ FiO2 indicative of ARDS
Less than 200
Dx of ventilator associated pneumonia
Greater than 10K cfu/ml
Tx of urine if myoglobinuria
Alkalize the urine
Mafenide side effect
Metabolic acidosis
Flap
Vascularized tissue for skin graft
2 types coag - staph
Epidermidis and saprophyticus
+ diagnostic peritoneal lavage
100 k/uL
