Surgery Flashcards
Amyand’s hernia
Inguinal hernia with appendix
Littre’s hernia
Meckel’s diverticulum hernia
Maydl’s hernia
2 small bowel loops in one sac
Morgangni hernia
abd contents in thorax
Pantaloon hernia
direct + indirect hernia
Richter’s hernia
sidewall of bowel
increased strangulation
Spigelian hernia
lat ventral wall hernia
Levels of axillary LNs
1- lat to pec minor
2- deep to pec minor
3- medial to pec minor
Systemic therapy for breast cancer
trastuzumab if HER2 +
docetaxel, adriamycin and cyclophosphamide
Presentation of Boerhave syndrome
L sided pleural effusion
subq emphysema
c/p and leukocytosis
Dx of Boerhave syndrome
water soluble contrast esophagogram
Staging for Melanoma
Clark method by level of invasion into dermal layers
Breslow method dept of invasion (better)
Causes of obstructions in adults (5)
adhesions hernia Crohns gallstone ileus tumor
Causes of carpal tunnel (5)
DM hyperthyroid acromegaly pregnancy myxedema
Tx for carpal tunnel
splint
NSAIDs
steroid injections q4 mo
Indication for cholecystectomy with acalculous gallbladder
<35% emptying of gallbladder
US findings with choledocholithiasis
common bile duct > 5mm
Dieulafoy erosions
bleeding from aberrant submucosal arteries in stomach
can cause significant bleeding
Upper GI bleeding causes
Variceal veins (most common) duodenal/gastric ulcers Mallyr Weiss neoplasm AV malformation
Causes of acute lower GI bleeds
Diverticulosis angiogysplasia neoplasm hemorrhoids IBD ischemic bowel
Dx of lower GI bleed
colonoscopy if stable
mesenteric angiography
labeled RBC scan
Asscs with GI angiodysplasia
over 50 yrs
cardiac disease hx
aortic stenosis
Lobular carcinoma of breast risk
not seen well on mammography
resembles fibrocystic changes
Mgt of head trauma
Intubation
fluid/blood resuscitation
hyperventilation and mannitol for ICP decrease
Lucid interval assc
Epidural hematoma
Mgt of burns
airway/intubation
IV fluid resuscitation
4mL/kg/%burn in 24 hrs, half within 8hrs
PVD classification
- ABI 0.8-1.0
- ABI 0.41-0.8 (claudication)
- ABI 0.2-0.4 (rest pain)
4-6. ABI < 0.2 with ulceration/gangrene
Stab wound mgt
primary assessment
upright CXR
FAST exam
dx laparoscopy for diaphragm injury
Dx methods for stab wounds
local wound exploration
diagnostic peritoneal lavage
CT with contrast
dx laparoscopy
Use of FAST exam
pericardial blood
abd injury
CT vs US in dx
CT better for abd pathology
US better for pelvic pathology
CRC chemo regimen
FOLFOX4 is name
5FU, leucorovin, oxaliplatin
Presentation of soft tissue sarcoma
lg nontender mass in extremity
DDx of acute abd (8)
AAA mesenteric ischemia GI perforation bowel obstruction volvulus ectopic pregnancy MI splenic rupture
Medullary thyroid carcinoma assc
MEN2
Types of thyroid malignancies
Follicular-iodine uptake, Hurthle cells
Papillary-common, Psammoma bodies, Orphan Annie eyes
Medullary-calcitonin, MEN2, CEA marker
MEN2A neoplasms
Medullary thyroid parathyroid Pheochromocytoma Lichen planus amyloidosis Hirschsprungs
MEN2B neoplasms
Medullary thyroid pheochromocytoma Mucosal neuromas ganglioneuromatosis of GI Marfan habitus
Dx of thyroid nodule
Fine needle aspiration
Risks for spontaneous pneumothorax
subpleural blebs
COPD
TB/malignancy
Phases of wound healing
Inflammatory- secretion of growth factors (0-3 days)
Proliferative- collagen/fibrin deposition (3-28 days)
Remodeling- capillary regression (3wks to 1yr)
Nutrition important in wound healing
Vit C increases collagen
Vit A increases epithelialization
B6 increases cross linking
Abx for intraabdominal infections
standard=aminoglycoside +metronidazole/clindamycin
single agent options=ceftriazone, ampicillin-sulbactam, piperacillin-tazobactam, imipenem-cilastin
Fever within 24hrs post op
atelectasis
Causes of short bowel syndrome
Crohns
mesenteric infarction
necrotizing entercolitis (infants)
volvulus
Assc with hepatic adenoma
OCPs
hemorrhage
Focal nodular hyperplasia
central scar pattern on CT
women of reproductive years
benign
Hemangioma of liver
most common benign liver tumor
do not bx due to hemorrhage
AFP tumor marker
HCC
CA 50 tumor marker
pancreatic
Neuron-specific enolase tumor marker
SCLC
CA 15-3 tumor marker
Breast cancer
Ferritin tumor marker
HCC
Tx for hepatic adenoma
excision due to hemorrhage risk
Indications for colon resection with diverticulitis
> 4 recurrent episodes
Most common area for AAA
infrarenal
Risk reduction for AAA
beta blocker
statin therapy
smoking cessation
Surgical tx indication for AAA
> 5.5cm diameter in women
>5.0cm diameter in men
Dx of AAA
US or CT
Tx for shock
fluids 1st
vasopressors (NE, DA, epi)
correct underlying problem
Definition of aneurysm
> 2x normal vessel diameter
Definition of ectasia
< 2x normal vessel diameter
Contents of triangle of Calot
Lund’s node/Mascagni’s node
cystic artery
Ann Arbor Staging
for lymphoma
4 stages
Sloan Kettering LN classification
for LN of the head/neck
6 stages
Dx of pancreatitis
CT scan
Tx for necrotizing pancreatitis
imipenem-cilastatin
Most common cause of unilateral bloody discharge of breast
intraductal papilloma
ductal ectasia is #2
DDx for nipple discharge (7)
pregnancy abscess galactorrhea fibrocystic changes intraductal papilloma diffuse papillomatosis (increased cancer risk) carcinoma
Tx for TIA due to carotid stenosis
tx side of TIA irregardless of stenosis %
Paraneoplastic syndromes with SCLC
Lambert-Eaton ACTH/Cushings Hypercalcemia SIADH paraneoplastic cerebellar degeneration
Courvoisier Sign
from biliary obstruction due to malignancy
painless jaundice
palpable gallbladder
nontender
DDx for hypercalcemia (7)
hyperparathyroid malignancy (mets or PTHrP) milk alkali syndrome thiazides Pagets Familial hypocalciuric hypercalcemia granulomatous diseases
Tx for hyperparathyroid
parathyroidectomy
Sx of chronic mesenteric ischemia
postprandial pain
wt loss
Revised Cardiac Risk Index
risk statification for peri-op carid morbidity 1) ischemia heart disease 2) CHF 3) Cerebral vascular disease 4) High risk surgery 5) Insulin dependent DM 6) Cr >2mg/dL If RCRI >2, use beta blocker
Types of gastric ulcers
I) Lesser curvature, (70% of ulcers)
2) Assc with duodenal ulcer
3) Prepyloric region
4) High on lesser curvature
5) NSAIDs caused
FAST exam
ultrasound four views (subxiphoid, R&LUQ, pelvic) for ID of intraperitoneal fluid or pericardial fluid
Assc with myasthenis gravis
thymoma
Dx of MG
Edrophonium Tensilon test
Acute exacerbation tx of MG
plasmapheresis
Mediastinal tumors and location
ant-thymoma
middle-lymphoma
post-neurogenic tumors
Risk for testicular cancer
cryptorchidism
DDx for anal pain
anal fissure (post midline)
hemorrhoids
fistula-in-ano
perirectal abscess
DDx for adrenal mass
adrenal adenoma pheochromocytoma mets ganglioneuroma carcinoma
Indications for adrenal tumor surgery
> 4cm
<4cm but enlarging
solitary adrenal met
Dx of pheochromocytoma
24hr urine VMA/metanephrines
plasma free metanephrines
confirm with iodine-131 metaiodobenzylguanidine scan (MIBG)
Femoral hernia boundaries
Inguinal ligament superiorly
Femoral vein laterally
Piriformis/pubic ramus medially
Spigelian hernia
lateral to rectus sheath
along lower post rectus sheath
Obturator hernia
Mass on medial thigh
Necrotizing soft tissue infections
beta-hemolytic strep commonly
no skin abnormalities
edema and pain beyond erythema
Fournier gangrene
scrotal gangrene/perineum and groin
anaerobic strep and gram negative bugs
Wilm’s tumor
peak age 1-5 years
abd or flank mass
hematuria
Abd mass with calcifications on XR in children
cystic meconium ileus
neuroblastoma
1 renal mass in neonate
hydronephrosis
1 renal mass in children >1yr
neuroblastoma
Complications of gastric bypass surgery
B12/iron/folate deficiency
osteoporosis
anemia
Dx of ITP
hypercellular megakaryocyte in marrow
peripheral Plt destruction
assc with IgG antiplatelet by spleen
Indications for splenectomy
congenital hemolytic anemias (thalassemia/spherocytosis) Myeloproliferative disorders ITP Hodgkins Lymphoma Splenic injury
Complications with splenectomy
abscesses
postsplenectomy sepsis (in children <4yrs)
encapsulated bug infections (need pneumovax)
Cauda equina syndrome
compression of sacral nerve bundle
bladder/bowel dysfxn
saddle paresthesias
pain/weakness in legs
Mgt of herniated disc
bed rest heat/ice NSAIDs muscle relaxants PT
DDx for neonatal jaundice
hepatitis TORCH infections A1AT deficiency CF choledochal cyst/biliary atresia
Neonatal jaundice workup if over 2 weeks
abd US
HIDA scan
Percutaneous liver bx
Unconjugated hyperbilirubinemia in neonates
hemolytic disease
Crigler-Najjar
Gilberts
Physiologic (resolved by 1 week)
Conjugated hyperbilirubinemia in neonates
biliary atresia
insipissated bile syndrome
TORCH infection/sepsis
Complications of biliary atresia surgery
Will develop portal HTN eventually
CKD stages
1- >90 GFR 2- 60 to 90 GFR 3- 30 to 60 GFR 4- 15 to 30 GFR 5- <15 GFR
Common causes of CKD
DM #1
HTN
glomerulonephritis
Transplant rejection meds
corticosteroids cyclosporin tacrolimus sirolimus mycophenolate mofetil/AZA
Infections post-transplant
CMV (especially)
Pneumocystis carinii
toxoplasmosis
aspergillosis
Maligancies post-transplant
Lymphomas #1 SCC and cervical (HPV) Kaposi sarcoma NHL HCC
Empiric therapy for diabetic foot ulcer
Amoxicillin-clavulanic acid
ciprofloxacin
vancomycin
long term IV 4-6 weeks
Charcot neuroarthropathy
destruction of well perfused and insensate foot
extensive bone/joint remodeling
similar presentation as diabetic foot ulcer
Wagner ulcer classification
1-superficial 2-involves ligament, tendon or fascia 3- abscess or osteomyelitis 4-gangrene of distal foot 5-extensive gangrene
Lucid interval assc
epidural hematoma
Sx of chronic subdural hematoma
change mental status worsening over 1-4 weeks
due to trauma
Basilar skull fracture presentation
raccoon eyes
fluid dripping from nose/ears
ecchymosis behind ears
Mgt of hypovolemic shock from gunshot
Lg bore IV lines
exploratory lap to control bleeding
IV fluids after lap
Mgt of tension pneumothorax
chest tube placement prior to CXR
Lg bore IV
Vessels causing excess blood with hemothorax
intercostal arteries
tx with thoracotomy for ligation
Mgt of flail chest
fluid restriction/diuretics
respiratory support
r/o other causes
Presentation of diaphragmatic rupture
no breath sound on L side
Presentation of Aortic rupture
widened mediastinum
dx with arteriogram
Dx of intra-abd bleeding
periotneal lavage
sonogram
CT if stable
Mgt of bladder/urethral blood in trauma
retrograde urethrogram
Sx of fractured tunica albuginea
lg penile shaft hematoma
surgical emergency
Mgt of electrical burns
IV fluids and diuretics for myoglobinuria
surgical debridement
Complications of circumferential burns
circulatory compression/compromise
escharotomy needed
Mgt of 2nd degree burns
silvadene (silver sulphadiazine)
Fluids for burn pts
4cc/kg/% burned (up to 50%)
1/2 in first 8 hrs
rest in remaining 16 hrs
urinary output goal 1cc/kg/hr
Lg breast mass with slow growth
cystosarcoma phyllodes
bx and resection for mgt
Leukocoria in kids
retinoblastoma
cataracts
Mgt of acute glaucoma
mannitol
pilocarpine
acetazolamide
Mgt of Barrett’s esophagus
Nissen fundoplication
Mgt of Boerhave Syndrome
gastrographin swallow to confirm
emergency surgery
Mgt of small bowel obstruction
NG tube and suction
IV fluids
observation
Dx of carcinoid syndrome
5-hydroxy-indoleacetic acid
Mgt of melena in unstable/hypotensive pt
NG tube, if no blood then emergency angiogram
Bloody stool in children
#1 Meckel's diverticulum dx with technetium scan
Acute abd and free air under diaphragm
most likely duodenal perforation
tx with exploratory lap
Dx of ureteral colic
KUB xray of abd
sonogram or IV pyelogram
Acute abd with elderly Afib pts
mesenteric artery occlusion
blood in stool and acidosis seen
Mgt of CRC mets to liver
one lobe-resection
both lobes-chemo
Amebic abscess mgt
tx with metronidazole
serology titers
DO NOT drain
assc with Mexico
Mgt of hemorrhagic pancreatitis
serial CT for abscesses
drainage of abscesses
support
Thyroid mass with normal histology
no such thing
metastatic follicular carcinoma
thyroid scan to look for primary
Mgt of Cushing’s
AM and PM cortisols
dexamethasone suppression test
MRI
removal of adenoma
Mgt of gastrinoma
serum gastrin
CT of pancreas
removal of tumor
Sx of glucagonoma
stomatitis
DM
migratory necrolytic dermatitis
Borchardt’s triad
epigastric pain
retching w/o vomiting
inability to pass NG tube
for gastric volvulus
ASA classification
American Society of Anesthesiologists 1) Healthy 2) Mild systemic disease 3) Severe systemic disease 4) Extreme systemic disease 5) Emergency that is 1 or 2 6) Emergency that is 3 or 4 For surgery risk
Revised cardia risk index interpretation
0= 0.4% cardiac death, MI during surgery
1= 0.9%
2=6.6%
3>or = 11%
HTN unresponsive to meds
fibromuscular dysplasia
tx with balloon dilitation
DDx for bilary emesis in newborn
duodenal atresia
annular pancreas
malrotation
Cause of intestinal atresia in neonates
vascular accident in utero
Mgt of meconium ileus
gastrografin enema
surgery if enema ineffective
Mgt of intussusception
barium enema
lap if enema ineffective
Midline neck mass mgt
Likely thyroglossal duct
Sistrunk operation
Lateral neck mass mgt
Likely branchial cleft cyst
surgical removal
Fluid filled mass at base of neck
likely cystic hygroma
CT of neck and surgical removal
Mgt of enlarged LN
reschedule in 3 weeks and reassess
if resolved-infection
if persistent-workup and bx
Mgt of metastatic SCC of head/neck
triple endoscopy
FNA
Ludwig’s angina
abscess of floor of the mouth
tracheostomy and drainage
CN VII palsy after trauma
if immediate-temporal bone transection
if gradual-edema from trauma (no tx)
Indications for aortic valve replacement
gradient over 50mmHg
CHF from AS
angina/syncope
Murmur echoing to axilla
mitral regurg
Lung surgery qualifications
need FEV1 at least over 800
Subclavian steal syndrome presentation
claudication of nondominant arm
post brain neuro sx
mgt with angiography and surgery
Mgt of aortic dissection
beta blockers and IV nitrates for BP control
surgery for ascending AD
ICU medical mgt for descending
Sx of brain tumors
progressive neuro sx
emesis from increased ICP
morning HA’s
tx=mannitol/hyperventilation/steroids/surgery
Bitemporal hemianopsia in children
Craniopharyngioma with calcifications
dx with MRI
Foster Kennedy syndrome
from frontal lobe tumors
optic atrophy/papilledema
central scotoma
anosmia
Mgt of spinal cord syndromes
high dose corticosteroids
Sx of disc herniation
Positive straight leg raise
muscle spasm
pain down leg
Causalgia
reflex sympathetic dystrophy
follows crush injury
cold/cyanotic/moist extremity
tx with surgical sympathectomy
Mgt of congenital hip dysplasia
abduction splinting
Leggs-Perthes disease
avascular necrosis of capital femoral epiphysis
lat and AP XR for dx
tx with casting and crunches
Slipped capital femoral epiphysis
ortho surgery needed
groin pain/limp
Post shoulder dislocation
easily missed on XR
axillary and scapular lat XR view needed
Risk with post hip dislocation
avascular necrosis of femoral head
Mgt of femur fractures
femoral neck-metal prosthesis (due to blood supply)
intertrochanteric-pinned together
Mgt of stress fractures
not seen on XR for 2 weeks
return in 2 weeks and repeat XR and cast
Mgt of priapism
alpha agonist injection into corpora
Low implantation of ureter
seen in females
ureter empties into vagina
IVP and surgery for mgt
Mgt of painless, gross hematuria
IV pyelopgram first
cystoscopy
possible CT afterwards
Mgt of prostate mass
trans-rectal needle bx
surgical resection
Mgt of prostate mets
LH agonist
flutamide
orchiectomy
Mgt of prostate cancer over 75yrs
if asymptomatic, no tx
Mgt of testicular mass
radical orchiectomy (rarely benign)
LN dissection
Platinum based chemo
AFP and beta-hCG for monitoring
