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Surgery Flashcards

1
Q

Normal Bile Composition (3)

  • Why ileal resection increase risk for stone?
  • Why TPN patients increase risk for stone?
A

Bile = Cholesterol, Bile Salts, Phosphatidylcholine
- Ileal Resection = xBile Salt Reabsorption = supersaturated Chol bile = Chol Stones PPT

  • TPN: lack of proteins/FFA in duodenum = xCCK stimulation = increase risk for stones
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2
Q

Chemo Tx Definitions

  • Adjuvant/NeoAdjuvant
  • Induction, Consolidation, Maintenance
  • Salvage
A 
Adjuvant = treatment given in addition to Sx
NeoAdjuvant = treatment given just before surgery

Induction (initial dose killing to ≤5% tumor burden) –> Consolidation (further decrease burden) –> Maintenance (kill residual tumor to keep in remission)

Salvage: tx for disease after above standard regimens fail

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3
Q

MCC Syrinx (2)

A
  1. Congenital = 2/2 Arnold Chiari Malformation (herniation of cerbellar tonsils in FM; type I = +Syrinx, II = +Lumbar Myelocele)
  2. Spinal Trauma = CSF retention in central canal = Syrinx
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4
Q

Paralytic Ileus: 2 MCC

  • vs. SBO
  • vs. Ogivle’s?
A

Paralytic Ileus: complete distention of SI and LI (no bowel sounds)

  1. Intestinal Surgery (touching GI tract)
  2. Retroperitoneal Hemorrhage

vs. SBO: just distention of SI (think hyperactive bowel sounds)
vs. Ogilve’s: just large intestine

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5
Q

CAE Indications (2)

What to do for patients with stenosis who don’t meet criteria?

A

CAE in:

  1. Symptomatic patients 70-99% Stenosis
  2. Asymptomatic patients 60-99% Stenosis

If less, start ASA + Statin

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6
Q

4 Complications of PUD, Indicate MC*

A

Hemorrhage*
Perforation
Obstruction (Gastric Outlet)
Penetration

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7
Q

MC Thyroid Nodule

5 Thyroid Malignancies (MC –> LC)

A

Colloid

Papillary, Follicular, Medullary, Anaplastic, Lymphoma

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8
Q

MCCOD in Burn Patient

  • with adequate resuscitation
  • with inadequate resuscitation
A
  • with adequate resuscitation = Septic Shock

- with inadequate resuscitation = Hypovolemic Shock

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9
Q

2x Reasons Ventilation hastens death in hypovolemic shock?

A
  1. PPV = increase thoracic pressure = decrease volume = decrease VR
  2. Anesthesia given dilates capacitance vessels = decrease VR
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10
Q

DPA+ (2)

DPL+ (2)

A 
DPA+ = 10cc gross blood + feculent matter
DPL+ = ≥100K RBC, ≥500 WBC
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11
Q

FAST shows fluid around spleen. Next step based on ___.

A

HDS

  • If unstable –> EXLAP
  • if stable –> CT

The reason is to try and avoid splenectomy at all costs for immune function, especially in kids.

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12
Q

Erectile Dysfunction s/p Trauma (2)

A

Neurogenic: a/w urethral injuries
Venogenic: a/w penile fracture (b/c tunica albuginea, where veins are, are damaged)

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13
Q

Early vs. Late Prosthetic Infection

  • Timing
  • Bug
  • Tx
A
  1. Timing
    Replacement
    - Late = Replacement
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14
Q

Pt with breast cancer, wanting to start traztuzamab. Before doing so, need ____.

A

ECHO; cardiotoxic

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15
Q

Suspected Melanoma

  • 1st step?
  • Take margins @1st step?
  • Margins for different thickness?
  • When to get sentinel node study?
A
  • 1st step? = Excisional Biopsy
  • Take margins @1st step? NO!!! May interfere with lymph flow, difficult to ID sentinel node
  • Margins for different thickness?
  • 4mm = 3cm
  • When to get sentinel node study? Depth >1mm
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16
Q

2 Fx of CO on O2-Dissociation Curve

5 Things that Shift Curve to Right

A

CO: Left Shift (b/c CO increase Hb affinity for CO AND for O2) and ∆Curve Shape
*Both decrease O2 delivery to tissue

Shift Curve Right = CBEAT

  • CO2
  • 2,3 BPG
  • Exercise
  • Acidosis/Altitude
  • Temperature

**All things increase pO2 requirement to saturate Hb, making it easier to deliver O2 to tissues

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17
Q

Respiratory Quotient

  • Define + Normal Value
  • Value for Fats, Proteins, Carbs
  • What if >1.0
A
  • Define: ratio of CO2 production to O2 consumption, normally around 0.8.
  • Represents average oxidation (O2 consumption) of fats (0.7), proteins (0.8) and carbs (1.0).
  • If >1.0 = Mainly utilizing carbs

*guide nutrition in ICU patients

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18
Q

Acute Mediastinitis

  • MCC (2)
  • P/w
  • CXR Finding
  • Tx (3)
A

MCC = intraop infection of sternotomy wound + s/p esophageal rupture

P/w = purulent drainage from sternum

CXR finding = wide anterior mediastinum

Tx = Immediate Debridement + WOUND CLOSURE + Long term antibiotics

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19
Q

3 Signs of Tracheobronchial Performation + Management

A
  1. SubQ Emphysema
  2. Pneumomediastinum on CXR
  3. Persistent pneumothorax despite chest tube

Management = ABCs —> Bronch to locate injury —> repair

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20
Q

Uncomplicated vs. Complicated Diverticulitis Def + Management

When is colonic resection indicated? (4)

A
  1. Uncomplicated:
    - LLQ Pain, Fever, CT with thickened colon +/- soft tissue stranding.
    - Manage outpt with bowel rest, abx, pain rx
  2. Complicated: IHOP (Infection, Hemorrhage, Obstruction, Perf)
    - P/w above findings + IHOP (HOP managed as below)
    - Abscess
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21
Q

Central Cord Syndrome

  • Who gets it and how?
  • Presentation?
A
  • Think older patients with cervical DJD with hyperextension injury
  • P/w damage to xCST&raquo_space;> decussating spinothalamic tract

xMotor in arms, ok in legs (b/c morphology of fibers in CST with arms being more central)

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22
Q

Esophageal Varices

  • Who needs screening?
  • ASx Management
  • Syx Management
A
  • Screen ALL Cirrhotics
  • ASx Management = Propranolol
  • Sx Management = Octreotide / Endoscopic Scleropathy
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23
Q

Insulinoma (3) vs. Glucagonoma (4) Presentation. Tx of inoperable glucagonoma (2)?

A

Insulinoma = Whipple Triad

  • Fasting HypoGluc
  • Neurohypoglycemic Symptoms
  • Resolve with Glucose

Glucagonoma = 4Ds

  • Diabetes (mild)
  • Dermatitis (NME)
  • DVT
  • Diarrhea

Tx

  1. Somatostatin
  2. Streptozocin
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24
Q

Early vs. Late Dumping Syndrome

  • Timing
  • Paph
  • Management
A

Early

  • Timing: Minutes after meal
  • Paph: increase osmotic load to SI –> increase vasoactive peptides
  • Tx: reassurance (will resolve), small meals, octreotide

Late

  • Timing: hours later
  • Paph: increase duodenal load = increase insulin release
  • Tx: as above (except octreotide)
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25
Q

Timing of 4 Tx Reactions

A

Immediate: Anaphylaxis (IgA Deficiency; should’ve WASHED RBC)

1 hr: Febrile non-hemolytic (2/2 Residual leuks releasing cytokines; should’ve LUEKOREDUCED) + ARDS (TRALI)

> 1 day: Delayed Hemolytic

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26
Q

What trauma causes anterior cord syndrome?

A

Vertebral burst factures

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27
Q

ZES/Gastrinoma

  • 2 EGD Findings
  • 3 Steps in Protocol
A

EGD

  • Prominent gastric folds
  • Ulcers in beyond duodenal bul

W/U

  1. Gastrin >1000 diagnostic, or
  2. Secretin Stimulation increasing gastrin, or
  3. Ca Stimulation
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28
Q

Management of

  • Mild Claudication (4)
  • Severe (2)
A

Mild = ASA, STatin, Smoking Cessation and Supervised Execise

SEvere = Cilastozol (PDEI) and Surgery

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29
Q

Duodenal Hematoma

  • P/w
  • Management (2)
A

P/w SBO s/p abdominal injury

Management = NGT + TPN

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30
Q

ABI Intepretation

A 
>0.91 = Normal
≤0.9 = Diagnostic of PAD
>1.3 = DM with Calcified Vessels --> FURTHER STUDIES NEEDED
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31
Q

Next step in HDS patient s/p abdominal trauma who p/w LUQ tenderness, Kerr Shoulder sign and drop in BP?

A

CT scan with contrast for splenic trauma. If unstable –> EXLAP

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32
Q

Next best step for post-chole syndrome?

A

ERCP/MRCP

**Just like in severe cholangitis, you have to remove whatever is in the bile duct. If ERCP fails, use T tube for decompression

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33
Q

Can medical students practice procedures on newly deceased patients?

A

YES, if the patient or patient’s family gives permission

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34
Q

Bacterial Parotitis

  • 2 populations of patients
  • MC Bug
  • Prevention
A
  • Common in OLD and DEHYDRATED post-op patients
  • Bug = Staph Aureus
  • Prevention = IVF + oral hygiene
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35
Q

Next step in patient with Direct HyperBili, normal LFTs and elevated Alk Phos?

A

Abd USG

  • If LFTs were up, think hepatitis –> serology would be next
  • If no LFTs or Alk Phos ∆ –> Dubin Johns/Rotor
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36
Q

Cystinuria

  • Paph
  • Diagnostic Study (2)
A

Paph = poor dibasic AA transport across tubular cells (Cystine, Ornithine, Lysine and Arginine = COLA); cystine poorly soluble in water = PPT

Diagnostic Study (2)

  • UA = hexagonal crystals
  • Urine Cyanide Nitroprusside test: detects elevated cystine levels
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37
Q

Esophageal Perforation

  • MCC
  • 2 PE Findings
  • CXR Findings (3)
  • Dx Procedure
  • Tx (3)
A
  • MCC: Esophageal instrumentation (dilation for achalasia)&raquo_space;> Boerhave’s Syndrome
  • 2 PE Findings: Hamman’s sign (crunching auscultation) + subQ emphysema
  • CXR Findings (3): Wide Mediastinum, Air in Mediastinum, Pleural Effusion (Left sided)
  • Dx Procedure: Water Soluble Contrast (Gasrografin Swallow)
  • Tx (3): TPN, Broad Spectrum ABx and Surgery (don’t forget TPN, b/c even after management they ain’t gonna be eating!)
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38
Q

1 week S/p Blunt Upper Abdominal Trauma pt has fever, chills and “deep abdominal pains”. Initial CT scans negative.

A

Missed pancreatic injury (pancreas crushed against vertebral bodies); normal CTs initially so have to f/u with serial CT scans; pt now probably has retroperitoneal abscess

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39
Q

6 Stages (0-5) Diabetic Foot Ulcers

6 Components to Management

A

Stage 0: high risk foot, no ulcer
Stage 1: full thickness, no subQ tissue involvement
Stage 2: deep ulcer penetrating into muscle/ligament, no bone
Stage 3: deep ulcer penetrating to bone / osteo
Stage 4: Local Gangrene
Stage 5: Extensive gangrene

Management

  1. Off-loading
  2. Debridement (stage 2)
  3. Wound Care (all)
  4. Abx (stage 3)
  5. Revascularize
  6. Amputate (for stage 3 + 4)
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40
Q

Penile Fracture

  • When does it occur?
  • Presentation
  • Paph
  • Management (2)
A
  • Occurs when penis is erect = Sex
  • Presentation: woman on top, snapping sensation
  • Paph: breaking of tunica albuiguina (encasing corpus) –> hematoma
  • Mgmt = Retrograde Urethrogram –> Surgical evacuation of hematoma
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41
Q

80 y/o man with usual nl ADL managed by himself has suddenly gotten senile/demented over last 2 weeks. Fell down 2 weeks ago. Dx and management?

A

Subdural Hematoma –> CT Scan Dx –> Surgical Decompression = Cure

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42
Q

Base of Skull Fx:

  • How do you diagnose?
  • How do you manage? (3)
A 
Dx = CT Scan (> Plain film)
Manage = NSG for repair + ANTIBIOTICS + CSpine Clearance
43
Q

Resonant/tympanitic to percussion vs. dull to percussion s/p stab to chest?

A

PT vs. Hemothorax

44
Q

Mgmt of hemothorax?

A
  • Most just need chest tube as low pressure lung bleeding stops spontaneously
  • If putting out >1L / >400 cc/hr —> thoracatomy b/c systemic vessel is involved
45
Q

Pt in accident has sternal fracture. 2 Concerns with tests?

A
  1. Myocardial Contusion: EKG/Enzymes

2. Aortic Injury: CT/ TEE (—NOT AORTOGRAPHY)

46
Q

4 Places bleeding can cause hypovolemia?

A
  1. Abdominal Viscera
  2. Pelvic Fx
  3. Upper Thighs
  4. Scalp Lac
47
Q

Management of anterior vs. posterior urethral injury?

A
  • Note determined b/c both get retrograde urethrogram
  • Anterior = Immediate Surgery
  • Posterior = Suprapubic cath with delayed repair
48
Q

S/p pelvic fracture, patient has foley put in with gross hematuria. Retrograde cystogram is NORMAL. Dx?

A

Nl retrograde cystogram R/o bladder injury, bleeding is coming from kidneys –> CT Scan

49
Q

Microscopic hematuria in adults vs. kids?

A

Adults = microscopic does not always need investigation (gross does)

Kids = microscopic always does because it could signify renal abnormalities (renal USG)

50
Q

S/p kicked in the nuts, patient has scrotal hematoma. Next step?

A

Sonogram; if ruptured testes –> surgery. If not –> symptomatic

51
Q

Management of chemical burn?

A

Esp alkali > acid, regardless of location = COPIUS IRRIGATION x30 minutes BEFORE rushing to ED

52
Q

Management of patient s/p electricution/electric burns?

A

BURNS ARE ALWAYS DEEPER = debridement, look out for posterior shoulder dislocation, bone and nerve problems. Myoglobinuria too

53
Q

Script + Management of Respiratory Burn

A

Pt in burning building has dark soot around mouth and inside mouth. Dx with Bronchoscopy.

Remember, have low threshold for intubating these patients!

54
Q

Parkland Formula

A

4xWTxTBSA %Burned = cc/24 hr

55
Q

What to do for a 3rd degree burn (white leathery, vs. second degree = blistery, moist)

A

Early excision with grafting

56
Q

Patient has multiple small tumors in heart. Or in duodenum?

A

Metastatic Melanoma, recall it goes weird places

57
Q

32 y/o woman with h/o multiple painful breast swellings during menses now has 2cm cyst for 6 weeks. Dx + Management?

A
  • Dx is likely still persistent cyst

- F/u regular protocol FNA if cystic vs. core biopsy if solid

58
Q

Woman with breast abscess; after I&D + ABx, what needs to be done?

A

Have to biopsy the abscess wall!

59
Q

How do you w/u Paget’s disease of breast?

A

It’s still a cancer! Use same 35 protocol —> Tissue needed!

60
Q

Old lady with normal PE is found to have mammogram findings suspicious of cancer. Next step?

A

Follow protocol Nik! >35 –> CBE with Diagnostic Mammogram (done in this case) —> Need Tissue

**Because she has mammogram with discrete lesion and a normal PE, STEREOTACTIC GUIDED BIOPSY is option

61
Q

Management of ductal carcinoma without palpable axillary nodes in:

  • Patient with normal breast size and 2 cm tumor
  • Patient with small breast and 4 cm tumor
A
  • Patient with normal breast size and 2 cm tumor
  • Lumpectomy with radiation
  • Axillary node dissection needed
  • Patient with small breast and 4 cm tumor
  • Modified radical mastectomy
  • Axillary node dissection needed
62
Q

Treatment for +nodes in pre- vs. post-menopausal woman?

A
  • Pre = Chemotherapy

- Post = Hormonal Therapy (including Aromataes inhibitors)

63
Q

Baby has huge shining eyes?

A

Congenital glaucoma + tearing = shiny eyes; optho immediately or else blind

64
Q

Suspect mallory weiss tear. Next step + management?

A

Next step = endoscopy

Mgmt = usually will resolve on its own (but have to do the EGD)

65
Q
  • R Sided CRC findings

- L Sided CRC findings

A
  • R Sided CRC findings: Anemic with +FOBT

- L Sided CRC findings: Blood coating stools + narrow stools

66
Q

4 Pre-malignant
4 Benign

POLYPS

A

Pre-Malignant

  1. FAP
  2. HNPCC
  3. Villous Adenoma
  4. Tubular Adenoma

Non

  1. Juvenile
  2. Peutz (Harmatomas)
  3. Hyperplastic
  4. Inflammatory
67
Q

Patient with known hemorrhoids reports BRBPR?

A

STILL NEED COLONOSCOPY

Compare this to question about young patient with anal fissure and no other GI symptoms and has obvious anal fissure on PE –> no colonoscpy

68
Q

HIV patient has fungating mass just inside anal verge

  • Dx
  • Management
A
  • Dx = Squamous cell carcinoma of anus

- Mgmt = still need full colonoscopy

69
Q

Patient with signs of intestinal obstruction has plain film showing distention of small and large bowel from RUQ –> LLQ. Dx and next step?

A

Sigmoid Volvulus –> Proctosigmoidosocpy for relief

70
Q

Which hepatic abscess does not need surgical excision/drainage?

A

Amebic –> Flagyl will take care of it!

71
Q

Pt with obstructive jaundice has normal CT other than dilated bile ducts. Pancreatic duct not dilated. Next step + DDx (2)?

A

ERCP

DDx = Cholangiocarcinoma vs. Sphincter of Odi Dysfunction

72
Q

Tx for acute cholangitis?

A

Need immediate decompression of CBD = ERCP; if ERCP fails that’s when you do the T Tube

73
Q

Management of hemorrhagic pancreatitis?

A

Serial CT scans to monitor for formation of MCCOD = pancreatic abscess

74
Q

Two weeks after any surgery a patient develops fever and leukocytosis? Next best step?

A

Think ABSCESS –> CT Scan

75
Q

Next step in baby with TE Fistula?

A

Screen for other VACTERL associations before surgery:

  • Vertebral / limb - XRAY
  • Anal atresia - PE
  • Cardiac = ECHO
  • GU = Renal USG
76
Q

Best ppx/treatment for fight bite / dog bite / cat bite?

A

Augmentin (≠Amoxicillin and ≠Clinda)

77
Q

What does atelectasis affect? 3 ways to comabat?

A

Atelectasis decreases FRC

  1. Elevated HOB
  2. Incentive Spirometry
  3. Cough
78
Q

Gradual vs. Sudden Onset Bell’s Palsy

A
  • Gradual = suggests neoplastic process (MRI)

- Acute = suggestions Lyme, Sarcoid, etc (Will resolve / start antivirals)

79
Q

Management of Ludwig’s Angina? (2)

A
  1. Tracheostomy

2. Then InD

80
Q

Girl picks her nose all the time gets severe epistaxis. Management (2)

A

Control bleeding from the anterior septal plexus

  • Phenylephrine Spray
  • Pressure
81
Q

Which cancer if found in lung is NOT treated with surgery?

Which cancer in lung IS SURGICALLY removed?

A

No Surgery = Small Cell (use platinum chemo)

Surgery = Non-small cell

82
Q

What WBC count on synovial analysis for GC arthritis?

A

75K (lax with the 10^5)

83
Q

Patient has arm claudication + vertigo, ∆vision and ∆speech. Dx and next step?

A

Likely subclavian steal syndrome

Get angiography showing retrograde flow through the vertebral artery

84
Q

Patient with history of Cushing’s syndrome treated with b/l adrenalectomy now has bitemporal hemanopia and low BP?

A

NELSON SYNDROME

  • original cushing disease was not a problem with adrenals, but the pituitary
  • adenoma continued to grow, low BP b/c no adrenals
85
Q

Foster-Kennedy Syndrome

A

Brain Tumor of Frontal Lobe

  • Personality ∆
  • Optic Nerve Atrophy on ipsilateral side (compare to papilldema on opposite side)
  • Anosmia
86
Q

60 y/o woman with soft tissue mass in thigh located deep and fixed to surrounding tissue? Dx and Next Step?

A
  • Sarcoma

- MRI (≠biopsy)

87
Q

Open fractures ned repair within _______.

A

6 hours of injury

Don’t confuse with femoral neck fractures which need repair in 72 hours (b/c need to w/u underlying condition)

88
Q

(T/F) Posterior shoulder dislocations can be missed on AP/lateral xrays?

A

True, get axillary and scapular views; remember always get two views 90 degrees away from each other

89
Q

Runner has tibial stress fracture. Management? Compare this to metatarsal fracture?

A

Don’t image right away, wont’ show up. Manage with casting and repeat imaging in 2 weeks.

With metatarsal fracture, don’t need to cast b/c the other metatarsals act like splints. You can just do rest and analgesia.

90
Q

Patient with stone develops pyelo. Managemetn?

A

ABx + Surgical Decompression with Stent/percutaneous nephrostomy

91
Q

(T/F) Patient found to have Porcelain gallbladder needs it removed?

A

True increase risk for adenocarcinoma of gallbladder

92
Q

(T/F) Medical therapy with bromo or cabergoline is indicated for both MICRO AND MACRO adenomas.

(T/F) Vision ∆ 2/2 pituitary adenoma is reason for surgery.

A

True = Rx for both micro and macro adenomas

False = vision change does NOT immediately = surgery, still try bromo/cabergoline

93
Q

High amylase in pleural fluid?

A

Effusion 2/2 esophageal perforation

94
Q

Anastrazole + Exemestane = when used?

A

These aromatase inhibitors are used in POST-MENOPAUSAL women with breast cancer

95
Q

(T/F) Mastectomy and BCS are equally effective.

A

Mastectomy = BCS AND RADIATION (can’t not radiate).

96
Q

Cell of Origin for Pancreatic Cancer?

A

Ductal Epithelium

*Recall depression is almost = PNP for Pancreatic Cancer

97
Q

Management of acalculous cholecystitis? (2)

A
  1. Emergent Percutaneous Cholecystostomy

2. Once stable, chole

98
Q

MC laceration / visceral injury after blunt abdominal trauma?!!!!!!!

A

SPLEEN SPLEEN SPLEEN SPLEEN

99
Q

How long do you have to fix a femoral neck fracture in old person and why does this matter?

A

72 hours; this matters b/c (in older persons especially), it is important to investigate the cause of the (likely) original fall that caused the fracture (CXR, EKG, ECHO)

100
Q

Patient with OBVIOUS anal fissure and no signs/symptoms of CRC who is 35 y/o. Do you need a colonoscopy?

101
Q

Patient with Charcot’s triad is on broad spectrum ABx but becomes persistently confused and febrile. Next step?

A

ERCP!!! (not T Tube, do T tube if ERCP is not working). Point is, patient needs immediate decompression of CBD, and ERCP is best to do this!

102
Q

How is the management of hairline fracture of the metatarsals different from other stress fractures?

A

Usually stress fractures needed splinting / casting, but the adjacent metatarsals act as splint so management of these = Rest, Analgesia

103
Q

Head Trauma Definition + Management

  • Minor
  • Mild
  • Moderate/Severe
A
  • Minor: GCS 15, normal neuro exam, no h/o LOC
  • No head imaging, send home with reliable individual
  • Mild: GCS 13-15 with brief LOC / vomiting / HA
  • CTH –> D/C home if normal with reliable individual
  • Moderate / Severe: anything greater than above = Head imaging and admit for neuro checks

Step 2 CK (8 decks)

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