Surgery Flashcards

Question

Causes of dysphagia

Answer 1

Causes of Dysphagia 1. Systemic CVA, MS, Polio, Parkinson's, Guillian-Barre, Neuropathy, Myasthenia gravis 2. Extramural Tracheo-oesophageal fistula, large pharyngeal pouch, arch aortic aneurysm, **carcinoma of bronchus, mediastinal lymphadenopathy**, left atrial dilation, retrosternal goitre 3. Intramural - Scleroderma, Chagas' disease, Diffuse esophageal spasm, **achalasia, carcinoma of esophagus, GORD scarring**, caustic stricture, presbyoesophagus (dysmotility associated w/ old age) 4. Intraluminal Food bolus, foreign body (child and phychiatric patient), polypoid tumour, esophagitism candidiasis

Answer 2

Esophagus Esophageal carinoma, Acute reflux esophagitis, Mallory-Weiss syndrome, **Oseophagel varices ** ``` Stomach Erosive gastritis (NSAIDs, alcohol), **gastric ulce**r, gastric cancer, gastric leiomyoma (rare), Dieulafoy's disease (rare), **acute gastritis** ``` Duodenum Duodenal ulcer, aortoduodenal fistula

Answer 3

Risk factors for malignant change in colonic polyps Large size (\> 2 cm 40% risk) - most important factor Villous architecture - high risk in adenomas with villous adenomas \> 4 cm Multiple polyps Dysplasia

Answer 4

General: 90% of epithelial polyps in large intestine Found 1/2 over 60 Types 1) Hyperplastic polyps: 90% of epithelial polpys in large intestine. 30-50% \> 60 yo 2) Hamartomas Types: Juvenile retension polyps; Peutz-Jegher Polyposis

Answer 5

**Airway Disease** Acute or Chronic Bronchitis, Bronchiectasis, Bronchogenic CA, Bronchial carinoid tumour **Parenchymal Disease** Pneumonia, TB, Lung abscess, Miscellaneous (Goodpasture's, idiopathic pulmonary hemosiderosis, **Vascular disease** PE, elevated pulmonary venous pressure (LVF, mitral stenosis), vascular malformation **MIscellaneous** Imparied coagulation, pulmonary endometriosis

Answer 6

**Abscess**: localized collection of pus and necrotic tissue anywhere in the body, surrounded and walled off by damaged and inflammed tissues. **Empyema** (pyothorax): pus in pleural cavity, usually secondary to infection in the lun or in the space below the diaphragam. An empyema is a collection of pus within a naturally existing anatomical cavity, such as the lung pleura. It must be differentiated from an abscess, which is a collection of pus in a newly formed cavity (due to an infectious/inflammatory state).

Answer 7

Children: acute anal fissure, Meckel's diverticulum, intussusception, ilieal tumours Young adults Colitis, Meckel's diverticulum, anal fissure, hemorrhoids Elderly Neoplasia, diverticular disease, angiodysplasia

Answer 8

1. **Subcostal/Kocher's**: Choleocystectomy 2. **Right Paramedian**: Laparotomy 3. **Midline**: Laparotomy 4: **Nephrectomy/Loin:** Renal surgery 5. **Gridiron**: Appendectomy 6. **Laparoscopic**: Choleocystectomy, Appendectomy, Colectomies 7. **Left Paramedian**: Anterior rectal resection 8. **Transverse suprapubic/Pfannenstiel**: Hysterectomy, Other pelvic surgery 9. **Inguinal hernia**: Hernia repair

Answer 9

Rule of 2s for Meckel's Diverticulum: 2% of population Symptomatic in 2% of cases Found within 2 feet (10-90 cm) of the ileocecal valve 2 inches in length Often present by 2 years of age (50% present by this age) Can contain 2 types of epithelium (gastic and pancreatic) \*Remnant of the embryonic vitelline duct

Answer 10

Intraluminal: Intussusception, Gallstones Intramural: Crohn's, Radiation stricture, adenocarcinoma Extramural: adhesions, incarcerated hernia, peritoneal carcinomatosis **Top Causes in Order: ABC** Adhesions Buldge (Hernias) Cancer (Neoplasm)

Answer 11

Intraluminal: constipation Intramural: Adenocarinoma, Diverticulitis, IBD stricture, Radiation stricture Extramural: Volvulus **Top 3 Causes (in order)** Cancer Diverticulitis Volvulus

Answer 12

**pain out of proportion to clinical findings and beyond border of erythema**, edema, tenderness, ±crepitus (subcutaneous gas from anaerobes) ±fever Late Findings: skin turns dusky blue and black (secondary to thrombosis and necrosis); induration, formation of bullae; ○ cutaneous gangrene, subcutaneous emphysema Ix: a clinical diagnosis

Answer 13

**_Think 3,6,9_** Normal = ≥ 1 Claudication = 0.6-0.9 Rest Pain = 0.3-0.6 Impending gangrene ≤ 0.3 Beware of fasely high results due to incompressible vessels (calcification) as seen in upwards of 40% of diabetics. Think of this when ABPI \> 1.2

Answer 14

a sac formed by the dilatation of the wall of an artery, a vein, or the heart

Answer 15

a condition characterized by hyperbilirubinemia and deposition of bile pigments in the skin, mucous membranes, and sclera, with resulting yellow appearance of the patient

Answer 16

Break into Generalized and Specific Hematoma (wound or scrotal) Acute urinary retention Wound infection Chronic Pain Testicular Pain and swelling leading ot testicular atrophy Hernia recurrance (2%)

Answer 17

An aching pain in the leg muslces, usually the calf, that is precipitated by walking and relieved by rest

Answer 18

Streptococcal pharyngitis Viral pharyngitis Infectious Mononucleosis Tonsilitis Peritonsiliar abscess Foreign body/trauma Leukemia Hodgkin's disease

Answer 19

Major: smoking, DM, hyperhomocysteinemia Minor: HTN, hyperlipidemia, family Hx,obsesity, sedentary lifestyle, male gender

Answer 20

○ Pain: absent in 20% of cases due to prompt onset of anesthesia and paralysis ○ Pallor: within a few hours becomes mottled cyanosis ○ Paresthesia: light touch (small fibres) lost first then sensory modalities (large fibres) ○ Paralysis/Power loss: most important, heralds impending gangrene ○ Polar (cold) ○ Pulselessness: not reliable

Answer 21

Conservative: Risk factor modification (smoking cessation, treatment HTN, hyperlipdemia, and/or DM) Exercise program (develops collateral circulation, improves exercise tolerance) Foot care (especially DM) Pharmacotherapy Anti-platelet (clopidogrel) Cilostazol (cAMP-phosphodiesterase inhibitor with anti-platelet and vasodilatory effects) ``` Pain Relief Opiate analgesia (morphine), supplemented by NSAIDs ``` Surgical Indications: cladication interfering w/ lifestyle, rest pain. Pre-gangrene, gangrene Options: stents, arterial bypass grafts (aortofemoral, axillofemoral, femoropoliteal)

Answer 22

FAT CAB F - Fluids A - Antiobiotics T - TPN C - Chemotherapy A - Administration of Blood B - Blood sampling

Answer 23

**percutaneous transhepatic cholangiography** complications: bile peritonitis, chylothorax, pneumothorax, sepsis, hemobllla

Answer 24

Check Name, Date, AP or supine A- Airway B - Bones C - Cardiomegaly/Cardiac shadow D - Diaphragm E - Effusion F - Lung Fields H - Hilium

Answer 25

A - Ariway w/ c-spine control B- Breath sounds, chest expansion, sounds, percussion, ascultation, tracheal deviation C - pulse, Beck's triad AP pelvis, Lateral C-spine, CXR

Answer 26

Clubbing, leuconychia, koilonychia, palmar erythema, Dupuytren's contracture, spider naevi, purpura

Answer 27

Cirrhosis of liver, UC, Crohn's disase, Celiac disease

Answer 28

Cirrhosis of liver and nephrotic syndrome

Answer 29

Chronic liver disease, pregnancy, the contraceptive pill, rheumatoid arthritis For first 3, due to increased levels of circulating estrogens. Chronic liver disease there is gonadal atrophy and depressed testosterone production. A larger proportion of testosterone is rapidly metabolised to estrogen

Answer 30

1-2 can be found in normal people in pregnancy, and in thyrotoxicosis. However, if more than 5 can indicate chronic liver disease

Answer 31

Vitamin B deficiences, Iron deficiency anemia

Answer 32

**_DISCO _** Digitalis Isoniazid Spirnolactone Cimetidine Oestrogen (extra: methyldopa, anti-androgens (cyproterone acetate), gonadrolein analogue)

Answer 33

Transudate less than 30 g/L. Exudate greater than 30 g/L Causes of ascites Transudate: Congestive Heart Failure Chronic Liver Disease Nephrotic Syndrome Constrictive pericarditis Hypoproteinaemia Exudate Intra-abdominal malignancy Bacterial peritonitis Tuberculous peritonitis

Answer 34

* *1. Primary hyperparathyroidism 2. Malignancy: hematological, humoral, skeletal metastases (\>90% 1 & 2)** 3. Renal disease: tertiary hyperparathyrodism 4. Drugs: calcium carbonate, milk-alkali syndrome, thiazide, lithium, theophylline, vitamin A/D intoxication 5. Familial hypocalciuric hypercalcemia 6. Granulomatous disease: sarcoidosis, TB 7. Thyroid disease: thyrotoxicosis 8. Adrenal disease: adrenal insufficiency, pheochromocytoma 9. Immobilization

Answer 35

A blind-ending tract, typically lined by epithelial or granulation tissue, whihc oipens to an epithelial surface

Answer 36

Primary - excessive secretion of PTH by either an adenoma (~80% cases), hyperplasia (~20%), or rarely a carinoma (\<1%) of the parathyroids Secondary - Excess secretion and hyperplasia of PTH by the parathyroid glands in reponse to persistant hypocalcemia (e.g. chronic renal disase, vitamin D deficiency, or intestinal malabsorption syndromes) Tertiary - autonomous secretion of PTH when the secondary stimulus has been removed (e.g. after renal transplant)

Answer 37

**"Bones, stones, psychosis-based moans, and abdominal groans"** Bones Osteitis fibrosa cystica Osteoporosis Chondrocalcinosis (can cause pseudogout) ``` Stones Renal stones (nephrolithiasis) ; polyuria ``` Moans Psychosis, confusion, anxiety, coma Abdominal groans PUD, acute pancreatiis (Ca2+ stimulates phospholipase), constipation **Note: 50% are asymptomatic (esp in prolonged disease)**

Answer 38

- treatment depends on the Ca level and the symptoms; treat acute, symptomatic hypercalcemia aggressively ## Footnote Increase Urinary Ca excretion (isotonic saine + furosemide (only if hypervolemic) Dimish bone resorption (Bisphosphonates; cinacelet if not working) Decrease gut absorption (corticosteriods in hypervitaminosis D and hematological malignancies) Dialysis Chelation: EDTA or IV phosphate (rarelty used) If causes is primary/tertiary hyperparathyroidism - removal of glands!

Answer 39

Hypomagnesemia: Magnesium is a cofactor for adenylate cyclase. Cyclic adenosine monophosphate (cAMP) is required for PTH activation.

Answer 40

**ECF Ringer's Lactate 0.9 NS ** **Na ** 142 130 154 **K ** 4 4 - **Ca **4 3 - **Mg ** 3 - - **Cl ** 103 109 154 **HCO₃ **27 28 - * *Total **280- 273 308 * *(mOsm/L)** 310

Answer 41

Look A) Inspect (shape, colour) B) Measure (distance from nearest bony prominence; dimensions) Feel ASK IF LUMP IS TENDER/PAINFUL A) Temperature (run back of fingers along lump) B) Surface (smooth, bosselated, rough) C) Edge (clearly/poorly defined) D) Consistency (stony-hard, rubbery, soft, spongy) E) Surrounding (indurated, invaded, colour change) PRESS A) Pulsatility (expansive vs pulsatile) B) Compressibility/reducibility C) Percussion (dull, resonant) MOVE Try to move skin over lump (fixation?) Try to move lymp in 2 planes at right angles (mobility) Ask patient to tense underlying muscle (attached to muscle or beneath it) LISTEN Bruit, bowel soudns TRANSLUMINATE Press pen torch and an opaque tube on opposite sides of the lump EXAMINE SURROUNDING TISSUES Limbs/trunk - axilla Head/neck -cervical

Answer 42

Hyperthyroidism Grave's (younger patients, goitre diffusely enlarged w/ bruit), Multinodular goitre (older patients), Functioning adenoma (rare, most non-functioning) Hypothyroidism Primary myxoedema (autoimmune, no goitre) ; Hashimoto's thyroiditiis (autoimmune, younger patients, rubbery goitre, early may present hyperthryoid)

Answer 43

**1) When and how did you first notice it?** **2) Has it changed since you first noticed it (bigger, smaller, same size, come and gone - does its appearance or consistency change over a period)?** **3) What symptoms does it cause you (pain, nipple discharge)?** **4) Have you got any more lumps or have you had this before? - does it come on periodically (menstrual) ** **5) What do you think it is?**

Answer 44

Common: Thyroid swelling, Thyroglossal cyst Uncommon Lymph nodes, sublingual dermoid cyst, plunging ranula, pharyngeal pouch, subhyoid bursa, carinoma of the larynx/trachea/esophagus

Answer 45

Mid-inguinal point: midway ASIS and pubic symphysis; location of femoral artery) Midpoint of the inguinal ligament (midway ASIS and pubic tuercle: location of the deep ring)

Answer 46

**Fibrocystic change Breast Ca** Often Bilateral Often unilateral May have multiple nodes Usually single Menstrual variation No menstrual variation Cyclic pain & engorgement No CP or engorgement May regress during pregnancy Does not regress

Answer 47

DDx for Breast Mass - Breast Ca - Fibrocytic changes - Fat necrosis - Papilloma/papilloatosis - Galactocele - Duct ectlasia - Ductal/lobular hyperplasia - Sclerosing adenosis - Lipoma - Neurofibroma - Granulomatous mastitis (TB, Wegner's, sarcoidosis) - Abscess - Silicone implant

Answer 48

General Specific Urinary retention Bruising - ~30% Pain - chronic groin pain persists in ~5% Hematoma - 10% Infection - 1% Ischemic orchitis - 0.5% - thrombosis of pampiniform plexus Recurrance \<0.5%

Answer 49

Post-surgical complications of appendectomy (Bailey's and Love's): - **Wound infection** (5-10%). Most common post-operative complication. Rx wound drainage and antibiotics as required - **Intra-abdominal abscess** - relatively rare. CT and abdo U/S diagnose and allow percutaneous drainage. Laparotomy in patients with intra-abdominal sepsis - **Ileus** - expected after surgery. May last numebr of days. If 4-5 days think intra-abdominal sepsis - **Portal pyaemia (pylephebilits**): rare but serious complication of gangrenous appendicitis (high fever, rigors, jaundice. Caused by septacemia of portal venous system and leads to intrahepatic abscess. Tx: systemic Ab and percutaneous drainage of hepatic abscesses - **Adhesive intestinal obstruction**: most common late complication

Answer 50

Most commonly affects boys aged 2–8 weeks ■ Characterised by projectile vomiting after feeds ■ Gastric peristalsis can be seen and a lump felt ■ Fluid and electrolyte disturbances must be corrected before surgery ■ Pyloromyotomy splits the hypertrophied muscle leaving the mucosa intact 3 Ps - Palpable mass (70% - "olive") - Peristalsis visible Projectile vomiting (2-4 weeks after birth)

Answer 51

Indicator of superior vena cava compression Pemberton's sign is the development of facial flushing,[1] distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising of the patient's both arms above his/her head simultaneously, as high as possible (Pemberton's maneuver).

Answer 52

_MEN 1 (Werner's syndrome)_ **- 3 P's**: ○ Parathyroid tumours (80-95%) ○ Pituitary tumours ○ Pancreatic endocrine tumours - Zollinger-Ellison syndrome, insulinomas, VIPomas, glucagonomas (rare) ○ Note: commonly presents with kidney stones and stomach ulcers - 2 per 100,000 - Mutation is in a tumour suppressor gene _MEN 2A (Sipple's syndrome)_ **- 2Ps** ○ Parathyroid ○ Pheochromocytoma ○ Medullary thyroid carcinoma (secretes calcitonin) - 100% patients _MEN 2B_ **- 1 Ps** ○ Pheochromocytoma ○ Medullary thyroid carinoma (secretes calcitonin) ○ Oral/intestinal ganglioneuromatosis (associated with marfanoid habitus)

Answer 53

NO CAST N - nonunion O - open fracture C - neurovascular compromise A - intra-articular fracture S - Salter-Harris 3,4,5 T - polytrauma

Answer 54

Local Early Compartment syndrome Neurological injury Vascular injury Infection Implant failure Frature blisters (formation of vesicles or bullae that occur on edematous skin overlying a fractured bone) Systemic Early DVT Sepsis PE Fat emoblism ARDS Hemorrhagic shock Local Late Mal/non-union AVN Osteomyelitits Heterotropic ossification (formation of bone in abnormal locations (e.g muscle), secondary to pathology Post-traumatic arthritis/joint stiffness Chronic regional pain syndrome type 1

Answer 55

bone \> lungs \> pleura \> liver \> brain

Answer 56

NO CAST * *N**onunion * *O**pen Fracture * *C**ompromise of Blood Supply * *A**rticular surface malalignment * *S**atler-Harris grade III-IV fracture * *T**rauma patients who need early ambulation

Answer 57

Symptoms: pain, paresthesia, and paralysis Signs: pain on passive movement (out of proportion to injury), cyanosis or pallor, hypoesthesia (decreased sensation, decreased two point discrimination), firm compartment Complications: muscle necrosis, nerve damage, contractures, myoglobinuria Initial Rx: bivalve and split casts, remove constricting clothes/dressing, place extremity at heart level Definitive Ix: Fasciotomy within 6 hours (6-8 max) if at all possible

Answer 58

Breast Lump When did you notice the lump How did you notice it Has the lump changed since you first noticed it? How? Is it painful Have you had any breast lumps in the past Has anyone in your family had any lumps Hormonal Factors Does the lump change with your menstrual cycle or at different times in the month When did you start your periods? menarche If relevant - when did you stop your periods (menopause)

Answer 59

Percussion Breath S Vocal R Added S Consol Dull Bronchial Increased Crackles Effusion Stoney Dull Vesicular Reduced/ Absent reduced or Absent absent

Answer 60

Contracture of the forearm flexors secondary to **forearm compartment syndrome** Causes: brachial artery injury, **supracondylar humerus fracture,** radius/ulnar fracture, crush injury, etc

Answer 61

Marjolin's ulcer refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized, chronically inflamed, or scarred skin. They are commonly present in the context of chronic wounds including burn injuries, venous ulcers, ulcers from osteomyelitis, and post radiotherapy scars. Appearance Slow growth, painlessness (as the ulcer is usually not associated with nerve tissue), and absence of lymphatic spread due to local destruction of lymphatic channels

Answer 62

Lateral: axillary lymph nodes Medial: parasternal nodes that run with the internal mammary artery

Answer 63

1. Prophylactic Ab to include IV gram +ve +/- anerobic coverage (cefazolin, cefoxitin/gentamicin) 2. Surgical debridement 3. Inoculation against tetanus 4. Lavage wound \< 6 hours postincident w/ high-pressure sterile irrigation 5. Open reduction of fracture and stabilization (e.g. use of external fixation)

Answer 64

1) Infiltrating ductal carcinoma 2) Lymph nodes (most common), lung/pleura, liver, bone, brain 3) Intraductal papilloma 4) Fibroadenoma

Answer 65

Breast tissue undergoes fatty replacement with age, making masses more visible. Younger women have more fibrous tissue, which makes mamograms harder to interpret

Answer 66

TKO Ewing ``` Twenty years old or younger Knee joint Onion skinning (X-ray - lytic lesion with periosteal reaction, calcified layering) ``` 5 yr survival rate 50%

Answer 67

1) Breast ultrasound 2) Spiculated mass

Answer 68

Bilateral mammogram (contralateral breast met) CXR (lung met) LFTs (liver meg) Serum Ca2+, ALP (bone met/"bone pain" --\> if +ve bone scan) Other tests based on signs (e.g. head CT for focal neurological deficity (brain met))

Answer 69

Ipsilateral arm lymphedema Infection Injury to nerves (long thoracic nerve, thoracodorsal nerve, medial pectoral nerve, lateral pectoral nerve) Skin flap necrosis Hematoma/seroma Phantom Breast syndrome Modified radical mastectomy Indications: \> 4 lymph nodes, plus chest wall involvement of tumour Proceudre: Breast, axillary nodes (level II, 1), nipple removed. Pec major and minor spared (hence modified)

Answer 70

HAM Hydration with IV fluids Alkalization of urine with IV bicarbonate Mannitol diureisis

Answer 71

Secure airway and supply O2 Treat the cause of the Shock Control external bleeding Infusion of 1-2 L of NS/RL as rapidly as possible (2 large bore (14 gauge) IVs die open - give bolus until HR decreases, urine output picks up, and patient stabilizes. Maintenance 4-2-1 Rule. Replace lost blood volume ar 3:1 with crystalloid

Answer 72

Battle's sign: bruised mastoid process Hemotympanum Raccoon eyes (periorbital brusing) CSF rhinorrhea/otorrhea

Answer 73

Elevate head of bed (up to 20 degrees if stable) Intubate and hyperventilate (100% O2) to a PCO2 of 30-35 mmHg Mannitol consider paralysing meds if agitated/high airway pressures

Answer 74

**HOT and FAT** **H**emothorax massive (\> 1500 mL in chest cavity) CXR. Restore blood volume. Thoracotomy if: \> 1500 mL blood loss, \> 200 ml/hr continued drainage **O**pen pneumothorax. Hole \> 2/3 tracheal diameter. Unequal breath sounds. Air-tight dressing sealed on 3 sides, chest tube, surgery. **T**ension pneumothorax: clinical diagnosis. Respiratory distress, tachycardia, distended neck veins; Tracheal deviation away from pneumothorax; percussion hyperresonance; unilateral absence of breath sounds. Management: needle thracostomy - large bore needle (12G) cannula into 2nd ICS mid-clavicular line, followed by chest tube in 5th ICS, anterior axillary line **F**lail chest: Free-floating segment of chest wall due to \> 2 rib fractures, each at 2 sites. Paradoxical movement of flail segment. Decreased air entry on affected side. O2 + fluid therapy + pain control. Positive pressure ventilation. +- intubation and ventilation **A**irway Obstruction: Anxiety, stridor, hoarseness, alterned mental status, apnea, cyanosis Management: definitive airway management, intubate early **T**amponade (cardiac): clinical diagnosis. Beck's triad, tachycardia, tachypnea, pulsus paradoxus, kussmaul's sign (raise JVP on inspiration). IV fluids, pericardiocentesis, open thoracotomy

Answer 75

BLT w/ Kosher Pickle Breast Lung Thyroid Kidney Prostate Breast & Prostate make up 2/3rds of bone mets

Answer 76

POSSET Physio Occupational therapy Specialists (e.g. stoma care, breast care, speech therapist) social workers Education Terminal acrea

Answer 77

1) Increased Sweating (hyperthyroidism) 2) Palmar erythema (hyperthyroidism) 3) Thyroid acropachy (aka pseudoclubbing - seen in Graves) 4) Onycholysis (Plummer's nails - detachment of the nail from the nail bed) 5) Areas of vitiligo (Grave's) 6) Pulse - tachycardia or a fib (hyperthryoid), bradycardia (hypothyroid) 7) Fine Tremour

Answer 78

Obstructive symptoms Suspicion of malignancy Cosmetic reasons Thyrotoxicosis Increasing size despite adequate thyroxine therapy Retrosternal extension

Answer 79

Obesity Persistant postoperative cough postoperative abdominal distension

Answer 80

Malnutrition (obesity, weight loss) Metabolic disease (diabetes, uremia, jaundice) Immunosuppresion (cancer, AIDS, steriods,chemotherapy, radiotherapy) Colonisation and translocation in GI tract Poor perfusion (systemic shock or local ischemia) Foreign body material Poor surgical technique (dead space, hematoma) Infection rates based on type of surgery Clean (no viscus opened): 1-2% Clean-contaminated (viscus opened, minimal spillage): \<10% Contaminated (open viscus w/ spillage or inflammatory disease): 15-20% Dirty (pus or perforation, or incision through abscess): \<40%

Answer 81

Establish Tissue Diagnosis then look for: Local Invasion Local Regional Spread (lymphatics) Systemic spread Establish whether can achieve Oncologic Clearance - exicision w/ margins Adjuvant Rx - if applicable

Answer 82

** Hematological disorders**: iron deficiency and hemolytic anemia, leukocytosis, thrombocytosis, DVT **Skin**: erythema nodosum, pyoderma gangrenosum, apthous ulcers, drug reactions of erythema multiforme and finger clubbing) **Ocular**: iritis (CD \> UC), uvetiis, episcleritis, superficial keratitis, blepharitis, retrobulbar neuritis ``` **Hepatic Disease** sclerosing cholangitis (UC 3-10%\> CD ~1%), pericholangitis, fatty infiltration ``` **Renal ** nephrolithiasis, glomerular nephritis, hypokalemic nephritis **Arthopathy ** anklyosing spondylitis, sacroilitis, migratory monoarthropathy, peripheral arthritis in children

Answer 83

Urine Volume Average adult 1-2 L per day. □ Excess of 2L is called polyuria □ Oliguria = less than 500 mL/day □ Anuria = 0-100 mL/day

Answer 84

** Superficial**: epidermis only (e.g. sunburn) (1st degree) Present: dry, red areas that do not form blisters Tx: keep clean, neosporin, pain meds Healing time 3-6 days **Partial thickness**: 1. Superfical: painful, blanches with pressures, blisters Healing time 7-21/days 2. Deep: painless (preceptive to pressure only), blisters, does not blanch Healing TIme \> 21 days (usually requires surgical treament) Rx: Remove blisters, apply antibiotic and dressing, pain meds. Silverlon (silver ion dressing - new treatment). Tend to heal w/ conservative management ** Full thickness**: all layers of the skin (3rd degree) Painless, insensate, swollen, dry, mottled, white, and charred areas; often described as dry leather Tx: early excision of eschar (within 1st wk burn) and split thickness skin grafting **Deep (fourth degree)**: to fat, muscle, even bone

Answer 85

Volume = TBSA (%) x Weight (kg) x 4ml Used to estimate volume of crystalloid necessary for initial resuscitation of burn patient; half of calculated volume is given in first 8 hours (SINCE INITATION OF BURN), the rest in the next 16

Answer 86

2nd degree burns to \> 20% BSA (10% TBSA in children and elderly) 3rd degree: \>5% TBSA Any burns involving face, hands, feet, perineum Any burns with inhalation injury look for carboxyhemoblobin (\>60% has 50% mortality) - Rx 100% O2 Any burns with associated trauma Any electrical burns

Answer 87

1. Vasomotor 2. Cardiac 3. CNS 4. Metabolic 5. Psychogenic HEAD, HEART, VeSSELS * *H**ypoxia/Hypoglycemia * *E**pilepsy * *A**nxiety * *D**ysfunctional brainstem **H**eart attack **E**mbolism (PE) Aortic obstruction Rhythm disturbance Tachycardia Vasovagal Situational Subclavian Steal ENT (glossopharyngeal neurlagia) Low systemic vascular resistance Sensitive carotid sinus

Answer 88

Acute Treatment of Pulmonary Edema • treat acute precipitating factors (e.g. ischemia. arrhythmias) • **L** - Lasix (furosemide) 40-500 mg IV • M -morphine 2-4 mg IV- decreases anxiety and preload (venodilation) • **N**- nitroglycerin- topical/IV/SL (decreases preload) • 0-oxygen • **P**- positive airway pressure (CPAP/BiPAP)- decreases preload and need for ventilation • **P** - position - sit patient up with legs hanging down unless patient is hypotensive

Answer 89

ACE inhibitors\* Beta Blockers\* +/- Aldosterone antagonists\* (if severe CHF) Diuretic +/- Inotrope +/- Antiarrythmic +/- Anticoagulant \* = mortality benefit

Answer 90

1. Coronary Artery Disease (60-70%) 2. HTN 3. Idiopathic (often in the form of dilated cardiomyopathy) 4. Valvular (e.g. AS, AR, MR) 5. Alcohol (may cause dilated cardiomyopathy)

Answer 91

History of immobilization or prolonged hospitalization/bed rest Recent surgery Obesity Prior episode(s) of venous thromboembolism Lower extremity trauma Malignancy Use of oral contraceptives or hormone replacement therapy Pregnancy or postpartum status Stroke

Answer 92

1) Weight gain, cataracts/glaucoma, hyperglycemia, osteoporosis, avascular necrosis, PUD, infection susceptibility , easy infection, acne, hypokalemia, hypertension 2) active infection, osteoporosis, hypertension, gastric ulcer, diabetes, TB

Answer 93

**_Intraoperative_** 1. Bleeding 2. Thyrotoxic storm * Occurs if thyrotoxic patient has been inadequately prepared for thyroidectomy (extremely rare) * Dehydration (IV fluids), hyperpyrexia (cooling with ice packs 1. Laryngeal edema * Most important cause: tension hematoma * Trauma to larynx during anesthetic intubation and sugrical manipulation are important contributing factors (particularly if goiter highly vascular 1. Pneumothorax **_- Early_** 1. Hypoparathyroidism leading to hypocalcemia * Parathyroid insufficiency: * \< 1% of thyroidectomies. Present dramatically 2-5 days after surgery 1. Hematoma * Decompression. If fail intubate 1. Recurrent layrngeal nerve palsy * 1.8% at 1 month, declining to 0.5% at 3 months post-op * Permanent paralysis of external branch of superior laryngeal nerve more common because of proximity to superior thyroid artery 1. Wound Infection: cellulitis **_Late_** 1. Hypothyroidism * After subtotal thyroidectomy: usually occurs within 2 years (20-40% at 10 years) 1. Hypertrophic scarring 2. Recurrence of thyroid disease

Answer 94

Chronic, reversible inflammatory disorder of airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough (particularly at night and/or early morning) Triad 1) **Airway obstuction**: intermittent and reversible airway obstruction 2) **Chronic inflammation**: chronic bronchial inflammation and esosinophils 3) **Hyperreactivity**: bronchial smooth muscle hypertrophy and hyperreactivity

Answer 95

1) Aspirin - NSAIDs (COX-1). PGE2 drops which increases leukotrienes. Interestingly, COX-2 is not a problem 2) Beta-blockers (B1 component causing bronchial smooth muscle contraction) 3) ACEI: increases bradykinin

Answer 96

Exenatide: long-acting glucagon-like peptide (GLP-1) agonist. GLP augments glucose-dependent insulin secretion Sitagliptin: inhibits dipeptidyl peptidase (DPP-4) which breaks down GLP-1

Answer 97

Galactorrhea, visual changes, headache

Answer 98

**Imipramine, clomipramine, amitriptyline** Presynpatic NT reuptake: tremour, insomnia Cardiac fast Na channels: conduction defects, arrhythmias, hypotension Central/Peripheral AChM: hyperthermia, flushing, dilated pupils intestinal ileus, urinary retension, sinus tachycardia Peripheral alpha receptors: peripheral vasodilation (orthostatic hypotension) Histamine 1 receptors: sedation **_Toxicity: coma, convulsions, cardiotoxicity (3Cs)_**

Answer 99

Asthmatics are to warm up 2x as long as others and take β2 agonist 10 min prior

Answer 100

Menstrual irregularities - Oligomenorrhea is the most common complaint. ## Footnote Hirsutism, infertility, obesity (40-50%) Lab FIndings § (1) LH:FSH ratio \> 2 § (2) Increased serum testosterone (free and total) and androstenedione (derived from adipose conversion of estrogen) § (3) Increased serum estrogen § Test to determine whether hypothalamic/pituitary or ovarian PCO □ Give 5 day treatment with oral progesterone (e.g. Medroxyprogesterone acetate 10 mg 12-hourly) ® If PCOs, then progesterone will cause menstruation after treatment stopped If Hypogonadotrophic hypogonadism, menstruation will not occur after withdrawal of treatment because endometrium is atrophic as a result of estrogen deficiency.

Answer 101

Serotonin Syndrome: Symptoms: neuromuscular excitation (hyper-reflexia, myoclonus, rigidity), ANS stimulation (hyperthermia, tachycardia, diaphoresis, tremour), altered mental status (agitation and confusion). Can be associated with SSRIs & TCAs, meperidine (opiate with metabolite SSRI), ephedrine (cold meds), amphetamine= Hypertensive Crisis: Symptoms: high BP, arrhythmia, exciation, hyperthermia. Associated with MAO. Drugs that can worsen: tyramine, TCA, alpha-1 agonists, levodopa

Answer 102

§ Deep vein thrombosis — 32 percent § Thrombocytopenia — 22 percent § Livedo reticularis (L. Livedo = "bluish") — 20 percent § Stroke — 13 percent § Superficial thrombophlebitis — 9 percent § Pulmonary embolism — 9 percent § Fetal loss — 8 percent □ Due to thrombosis of placental bed vessels § Transient ischemic attack — 7 percent § Hemolytic anemia — 7 percent

Answer 103

Both characteristic of cholangitis Charcot's Triad: fever, RUQ pain (biliary colic), jaundice (50-70%) Reynold's Pentad in patients with suppurative (severe) cholangitis: Charcot's Triad + altered mental status and hypotension

Answer 104

1) procainamide, phenothiazides, TCAs, disopyramide 2) MgSO4

Answer 105

SLUDGE : (ie, salivation, lacrimation, urinary incontinence, diarrhea, GI upset and hypermotility, emesis (vomiting)

Answer 106

Quinolones

Answer 107

1 day - pneumonia or atelectasis 3 days - UTI 5 days - wound infection 7 days - DVT Mnemonic: Wind, Water, Wound and Walk

Answer 108

Hypoglycemic and Anti-coagulant effect of Ginseng requires that it needs to be stopped before surgery

Answer 109

Diabetic, Calcified gallbladder (risk of malignancy), bariatic surgery, immunosuppressed, pediatric patient, sickle cell disease

Answer 110

**_Complications of burns_** **Immediate** Compartment syndrome from circumferential burns **Early** Hyperkalemia. Rx insulin or dextrose -Acute Renal failure . Prevent by aggressive early resuscitation, ensuring high GFR wit fluid loading and diuretics, treat sepsis Infection (beware of streptococcus). Rx infections Stress ucler (Curling's ulcer) prevent with H2 blocker of PPI prophylaxis) **Late** Contractures

Answer 111

Chest pain, friction rub, ECG Changes ECG changes: initially ST elevation +/- depressed PR segment. 2-5 days later ST isoelectric with T wave flattening and inversion

Answer 112

**Clinical Diagnosis**: Becks Triad (hypotension, increased JVP, distant (muffled) heart sounds) **+** pulsus paradoxus

Answer 113

Constrictive percarditis Severe obstructive pulmonary disease (e.g. asthma) Tension pneumothorax PE Cardiogenic shock

Answer 114

1) Ventolin = albuterol (onset 5-15 min; duration 3-5 hrs) Acute bronchospasm: 2 puffs inhaled PO q 4-6 hrs Severe bronchospasm: nebulized Exercise: 2 puffs inhaled 15-30 min before; up to 12 puffs/2 hours 2) Spiriva = tiotropium Long-acting anticholinergic (\>24 hours) 1 capsule per day. 3) Flovent = fluticasone (corticosteroid) Asthma treatment: either inhaler or diskus. Though dosages vary between inhaler/diskus, both are 2 puffs PO BID 4) Serevent = long-acting B2 agonist (\>12 hrs) Asthma/COPD/Bronchospasm: 1 inhalation BID

Answer 115

Tumours: renal cell carinomas, bladder transititional cell carinomcas, prostate adenocarcinoma Trauma: post insertion of FOley catheter, after cystoscopy or after urethral injury in pelvic fractures Infection: cystitis, prostatitis Inflammation: nephritic syndrome Mechanical: urinary stones Medical: coagulopathies Red herrings: ingestion of beetroot, jaundice causing dark urine

Answer 116

1) Type 1 DM 2) Type II DM 3) Other: Genetic defects (beta-cell function or insulin action) DIseaes of pancreas (pancreatitis) Endocrinopathies (acromegaly, Cushing syndrome) Drugs (glucocorticoids, thiazides) 4) Gestational DM

Answer 117

Pitting: 1) intrasvascular hydrostatic pressure (CHF, portal hypertension) 2) decreased plasma oncotic pressure (nephrotic syndome, malnutrition, cirrhosis) 3) increased capillary leak (burns, trauma, infection) Non-pitting 1) lymphatic obstruction 2) increased interstital oncotic pressure, albumin etc (e.g. myxedema seen in hyperthyroidism)

Answer 118

• gallbladder mucocele (hydrops) -long term cystic duct obstruction results in mucous accumulation in gallbladder (clear fluid) • gangrene, perforation - result in abscess formation or peritonitis • empyema of gallbladder - suppurative cholecystitis, pus in gallbladder + sick patient • cholecystoenteric fistula, from repeated attacks of cholecystitis, can lead to gallstone ileus • emphysematous cholecystitis - bacterial gas present in gallbladder lumen, wall or pericholecystic space (risk in diabetic patient) § Gas forming bacteria: clostridium, eschersia, staphylococcus, streptococcus, pseudeomonas, klebsiella § Typically males 50-70 yrs § Risk factors □ Vascular compromise (obstruciton or stenosis of cystic artery (sole artery to gallbladde) □ Gallstones □ Immunosuppreion (diabetics) □ Infection gas-producing bacteria • Mirrizzi's syndrome- extra-luminal compression of CBD/CHD due to large stone in cystic duct

Answer 119

- Intraoperative § Bleeding § Thyrotoxic storm § Occurs if thyrotoxic patient has been inadequately prepared for thyroidectomy (extremely rare) § Dehydration (IV fluids), hyperpyrexia (cooling with ice packs § Laryngeal edema § Most important cause: tension hematoma □ Trauma to larynx during anesthetic intubation and sugrical manipulation are important contributing factors (particularly if goiter highly vascular § Pneumothorax - Early § Hypoparathyroidism leading to hypocalcemia § Parathyroid insufficiency: § \< 1% of thyroidectomies. Present dramatically 2-5 days after surgery § Hematoma § Decompression. If fail intubate § Recurrent layrngeal nerve palsy § 1.8% at 1 month, declining to 0.5% at 3 months post-op § Permanent paralysis of external branch of superior laryngeal nerve more common because of proximity to superior thyroid artery § Wound Infection: cellulitis - Late § Hypothyroidism § After subtotal thyroidectomy: usually occurs within 2 years (20-40% at 10 years) § Hypertrophic scarring § Recurrence of thyroid disease

Answer 120

= signs of hypercalcemia constipation, abdo pain, weight loss, polyuria, polydipsia

Answer 121

Anteriorly: Inguinal ligament Medially: Lacunar ligament Laterally: Femoral vein Posteriorly: Pectineal ligament

Answer 122

Superiorly: Inguinal ligament Laterally: Medial border of sartarious muscle Medially: Medial border of adductor longus Floor: Iliacus, psoas, pectineus, adductor longus Roof: Superficial fascia, great saphenous vein ## Footnote

Answer 123

Most common - Mets, CCF, Cirrhosis and Infection Infection (Hepatitis, IM, Hydatid Cysts, Ameoba, Schistomomiasis, Bacteria abscess, cholangitis, portal pyaemia) Cellular Proliferation (Polycythemia, Leukemia, Lymphoma) Cellular infiltrates (Amyloid, Sarcoid) Metabolic (Hemochromatosis, Wilsons, galactosemia) Neoplasm (Mets, Cholangiocarcinoma, Abscess, cysts, syphilltic gumma) Congestive

Answer 124

3 fascia: external, cremastic and internal fascia 3 arteries: gonadal (from aorta), artery to vas deferens (inferior vesical artery), cremastic arter (inferior epigastric artery) 3 veins: testicular vein, vein of vas deferens, cremasteric veins 3 nerves:ilioinguinal (outside cord), sympathetic from t10-t11, gento branch of genitofemoral nerve 3 contents: vas deferens, lymph nodes and if present a patent processus vaginalis

Answer 125

Tamoxifene - VTE, endometrial ca Trastuzumab - cardiotoxicity

Answer 126

DEAFEST PAIL Diabetes Epilepsy Age Family Hisotry/Fibromatosis Epileptic Medications Smoking Trauma Peyronie's - fibrosis of corpus callosum AIDS Idiopathic (most common) Liver Disease 2 to EtOH

Answer 127

Physiological - Puberty Pathological - Decreased androgens - reduced androgen production (hypogonadism), testicular atrophy (bilateral crytoorchidism, orchitis or bilateral torsion), Kleinfelters syndrome, hyperprolactenemia and renal failure - Increased estrogens - increased secretion (lung and testicular ca.) and increased peripheral aromatization (liver, adrenal disease and thyrotoxicosis) Portions - marijuana, amphetamines, diazepam, GI (cimetidine, ranitidine), antibiotics (metronidazole. ketoconazole, isoniazid), Cardiac (Verapamil, nifedipine, Spironolactone, ACEI, digoxin)

Answer 128

**End colostomy** (single lumen, flush with skin, firm brown contents) Resection of part of colon, e.g.: due to carcinoma, diverticulitis, perforation E.g.: Hartmann's procedure - in emergency cases where primary anastomosis cannot be obtained - this can be reversed at a later date E.g. Abdominoperineal resection for sigmoid carcinoma **Loop colostomy** (two lumens, flush with skin, firm brown contents) To allow the bowel to rest Diverticulitis Or rectal carcinoma which cannot be resected (so colostomy formed to prevent obstruction) Or to defunction a healing anastomosis (e.g. following an anterior resection of the sigmoid and creation of a primary colo-rectal anastomosis) This has largely been replaced by loop ileostomy (because it is easier to site, less bulky, and easier to surgically close) **End ileostomy** (single lumen, spouted, liquid green/yellow contents) Total colectomy E.g.: due to Ulcerative Colitis or Familial Adenomatous Polyposis **Loop ileostomy** (two lumens, spouted, liquid green/yellow contents) Usually formed to allow the bowel to rest Acute severe Diverticulitis Rectal carcinoma which cannot be resected (to prevent obstruction) Defunctioning of rectal/anal disease in a flare up of Crohn's disease **Double barreled colostomy** (two lumens not joined by tissue, flush with skin, firm brown contents) Resection of bowel e.g.: due to carcinoma Usually resection of caecum **Urostomy** This is a general term for the surgical diversion of the urinary tract. The main reasons for a urostomy are cancer of the bladder, neuropathic bladder, and resistant urinary incontinence The bladder is usually removed, but this may depend on the underlying condition. Formation of an ileal conduit is the most common procedure, which constitutes isolation of a segment of ileum. One end of the ileum is closed and the two ureters are anastomosed to it. Finally, the open end of ileum is brought out onto the skin as an everted spout and will look similar to an end ileostomy. Urine drains almost constantly from the kidneys through the ureters and ileal conduit into a stoma bag

Answer 129

Specific Psychological Lymphedema SHoulder pain Sensory loss over inner aspect of lower arm (intercostal brachial nerve) risk of local recurrence

Answer 130

- Pancreatic ○ Pancreatitis, pseudocyst, tumor, abscess, pancreatic duct obstruction, ascites, cancer - Non-pancreatic ○ Biliary tract disease, bowel obstruction/ishcemia, perforated or penetrating ulcer, ectopic pregnancy, chronic liver disease, aneurysm, peritonitis - Non-abdominal ○ Cancer (lung, esophagus), salivary gland lesions, renal transplant/insufficiency, burns, ketoacidosis ○ Macroamylasemia

Answer 131

Perforation leading to peritonotinits Appendix Abscess Appendix Mass (inflamed appendix becomes covered wiht omentum - diagnosed on CT - treat with surgery)

Answer 132

Gastro-duodenal - duodenal ulcer Large bowerl - CRC, diverticulitus, appendicits

Answer 133

Gas on either side of the bowel - sign of perforation

Answer 134

**Immediate** Compartment syndrome from circumferential burns **Early** Hyperkalemia. Rx insulin or dextrose Acute Renal failure . Prevent by aggressive early resuscitation, ensuring high GFR wit fluid loading and diuretics, treat sepsis Infection (beware of streptococcus). Rx infections Stress ucler (Curling's ulcer) prevent with H2 blocker of PPI prophylaxis) **Late** Contractures Psychological problems

Answer 135

TBSA that is burned estimated by rule of nines as follows Each upper limb: 9% (front and back 4.5% each) Each lower limb: 18% (front and back 9% each) Anterior and posterior trunk = 18% each Head and neck: 9% (front and back 4.5% each) Perineum and genitalia = 1%

Answer 136

Na 70-100 mmol K 60-70mmol Ca 20 mmol

Answer 137

**Physiological** Fibroadenosis **Neoplastic** Benign: Fibroadenoma, Duct papilloma, Phylloides tumour Malignant: Primary Carcinoma, Secondary carcinoma **Trauma** Far necrosis **Infective** Cellulitis, Abscess

Answer 138

a focal area of stromal hyperplasia with epithelial proliferation