Surgery Flashcards
Bladder Cancer 65 yo smoker @ trigone, expected finding?
Bilateral Hydronephrosis via prolonged urinary retention
Beaten up in the face, decreased facial sensation over lower chin and jaw
Mandibular fracture distal to inferior alveolar nerve (3rd branch of trigeminal n.)
Hypovolemic/ hypotensive post surgery, decreased urine outflow
3rd spacing vs. renal failure -> bolus fluid challenge -> improve BP vs no improvement / or urinary Na ( 40 renal)
Signs of vascular injury requiring immediate surgery
absent pulses, bruit, thrill, active hemmorrhage/hematoma expanding, distal ischemia (cold/pale, paresthesia, pain, paralysis)
Signs of stable vascular injury but require vessel imaging
hx of hemmorrhage at scene, stable hematoma, decreased pulses / asymetric, proximal to major vessel, associated nerve deficit, ABI
Steroid use, pneumoperitoneum (air under diaphram)
Ulcer hx, perforated, immediate abdominal laparotomy
Age >40, hematochezia, constipation, weight loss, stool caliber change
Colon cx, Left side
Pt w glass eye, or missing toe (surgical), presents w liver mets
Melanoma: marker Tyrosinase
Pneumoturia
Colovesicular fistula (via crohns, diverticulitis, iatrogenic, foreign body, cancer) -> CT abdomen/pelvis
Pringle Maneuver: clams portal triad… still bleeding?
triad (portal vein, hepatic artery, common bile duct) yet Hepatic veins (to IVC) is not blocked and bleeds
Nausea Vomiting, Abd distention? –> SBO workup? Mng?
Abd Xray: dilated loops of bowl. NPO, NG tube decompression. Surg for severe/ worrisome ischemia
hypotensive /pale 28yof on birth control w vomiting and distended/ tender abdomen
Rutpured hepatic adenoma, benign, a/w OCP use, glycogen storage dz 1, bleed into abdomen
Painless obstructive jaundice (dilated biliary duct/ high alk phos). Dilated thin walled gallbladder w/o stones
Malignancy ie. Cancer of the head of the pancreas -> CT Scan
Flank pain, radiating to thigh and scrotum, Hematuria
Nephrolithiasis -> CT non contrast
RUQ pain, cholecystites w/ stones, 1 week later: bilious vomiting, air in biliary tree, dilated bowel loops
Gallstone Ileus -> Fistula between biliary tract and bowel-> Pneumobilia
Fat, Female, Forty, Fertile, colicky abd pain a/w fatty foods
Gallstones: confirm w/ R upper abd ultrasound, Rx: Antibiotics, IVF for cholecystitis (+fever, leukocytosis)
Post op abd pain / distended, nausea, constipation, dilated large bowel
Oglivie syndrome - colonic pseudo obstruction: Rx IV Neostigmine 2m over 10min
High spinal anesthetic -> hypotense / flushed, 0 central venous pressure
Sympathetic block -> vasodilation -> vasomotor shock Rx. Peripheral vasoconstrictor alpha agonists and IVF
Intra-op tachycardia, hypotensive, low urine output, decreased cardiac output, increased vascular resistance
Cardiogenic shock -> Rx Dobutamine (beta1 agonist) -> increased contractility and output
Pituitary adenoma resection -> lethargic, confused, comatosed, increased urine, dry mucosa
Central diabetes insipitus -> hypernatremia -> CNS pathology, Rx: IVF, Desmopressin
Hx chronic hepatitis B/C, cirrhosis, hepatotoxins + sx wt loss, RUQ discomfort
Hepatocellular carcinoma (HCC) -> monitro AFP (alpha feto- protein)
Inspiratory arrest w/ palpation of RUQ abd
Murphy’s sign: acute cholecystitis
Shortened leg, externally rotated -> displaced fx neck of R femur Mx?
Arthroplasty (prosthetic replacement) given the risk of avascular necrosis, tenuos blood supply to femoral head
Kid falls on outstretched arm -> supracondylar humeral fx -> closed reduction -> pain/palor/cold forearm -> ?
Compartment sx -> untreated (faschiotomy) -> ischemic injury: Volkman’s contracture: necrosed muscle replaced by fibrotic tissue
Boy 4-10 hip/groin/knee pain + antalgic gait
Legg-Calve-Perthes Avascular necrosis of femoral head
Boy 10-15 groin knee pain, chubby, hip flexed/thigh external rotated, internal rotation difficult
Slipped capital femoral epiphysis (SCFE) - Rx. pin femoral head
Hypotension w pulsatile abdominal mass
Ruptured AAA -> emergent laparotomy / surgical repair
MVC midshaft femoral fx Mx?
Closed intramedullary fixation of the femoral shaft
Airway for apneic pt w head n neck injury
Orotracheal intubation or cricothyroidectomy
AAA repair, next day febrile, LLQ pain, bloody diarrhea, leukocytosis
Ischemic Bowel: CT: thickening of bowel wall, colonoscopy cyanotic mucosa w hemorrhagic ulceration; surgical rx colon resx colostomy
Palpable crepitus at mediastinum, protracted vomiting
Pneumomediastinum, perforated esophagus (Boerhaave’s sd.)
Valgus stress test: increased laxity, tender medial knee
Medial Collateral Ligament tear
Varus stress test: increased laxity, tender lateral knee
Lateral Collateral Ligament tear
Sudden onset diffuse abdominal pain, air under diaphragm
Perforated gastric ulcer
Unilateral hip pain, middle aged adult, exacerbated by external pressure to upper lateral thigh
Trochanter bursitis
Abdominal trauma, adolescent, duodenal hematoma with obstruction Mx?
NG suction + parenteral nutrition (isolated hematoma)
Pt febrile RLQ pain, 5 days post appendicitis sx presentation
Perforated / complicated appendicites: Rx IVF + Cefotetan (enteric G-, anaerobes)
Abd trauma, epigastric pain, N&V, air in retroperitoneum
Duodenal Rupture: CT w contrast
Popping sound on passive flexion/extension of knee joint
Meniscal tear -> MRI / arthroscopy
MVC Deceleration chest trauma, decreased breath sounds, palpable mediastinal crepitus (subQ emphesyma), pneumothorax despite chest tube
Tracheobroncial injury / rupture -> high resolution CT -> surgical repair
Post trauma, decreased breathing / chest pain / discomfort, lower, mediastinal deviation, lower lobe atelectasis
CXR: mediastinal deviation, hemidiaphrag, bowel gas above L diaphragm -> CT contrast / barium swallow : perforated diaphragm w herniation -> surgical repair
Grand-mal seizure, shoulder pain, arm adducted and internally rotated
Posterior dislocated shoulder
Bone pain, diabetic, elevated ESR and leukocytosis
Chronic osteomyelitis
Teen, bone pain, afebrile, joint swelling erythema, normal ESR, elevated AlkPhos, metaphysis of long bones
Osteogenic sarcoma (osteosarcoma), destructive lesions w periosteal formation & elevation (Codman’s triangle), sunburst pattern
Teen, bone pain, systemic fever/wt loss, diaphysis of long bones (spine, pelvis)
Ewing sarcoma: small round blue cell malignancy, osteolytic onion skin pattern
Excess hair/easy bruisablitiy, elevated cortisol, High dose dexamethasone -> ACTH still elevated
Small Cell Cancer of the Lung -> chemo / radiation
Infiltrating ductal cx breast mass >4cm
Mastectomy w axillary sampling
Herniation felt in the lateral aspect w examiner’s finger in the external inguinal ring
Direct inguinal hernia: direct through floor/posterior wall of inguinal (Hesselbach’s) triangle (inferior epigastric laterally, rectus abdominis medially, inguinal ligament inferiorly)
Herniation felt by examiner’s finger in the external inguinal ring
Indirect inguinal hernia: defect in deep inguinal ring, incomplete closure of processus vaginalis, contents into scrotum/labia
Progressive dysphagia solids&liquids, bird’s beak barium study
Achalasia: loss of inhibitory neurons in LES -> fail to relax: endoscopic pneumatic dilation, surgical myotomy / fundoplication
Ranson’s criteria
WBC>16000, Glu>200, AST>25, LDH>350, Age>55
Alcoholic, steatorrhea, intermittent intense epigastric pain, diabetes
Chronic pancreatitis! most accurate test: Secretin -> bicarb rich pancreatic secretion (- test) if functional; CT best initial
Male w trauma to perineum / unstable pelvis (fx), unable to void, possible blood at meatus/ penile/ scrotum, high riding prostate
Trauma to urethra: must get retrograde urethrogram before foley!
Distended, diffusely tender abd, mitral stenosis + irregular pulse, acidotic
Afib -> mesenteric thromboembolism -> bowel ischemia -> metabolic acidosis: emergent exploratory laparotomy, (mesenteric angio if stable w/o signs of ischemic bowel)
Tender painful spot in 3rd interspace of foot between 3rd/4th toes
Morton’s neuroma, avoid high heels, surgical removal
Obese old man, blood in stool, anemic, increased AlkPhos & bilirubin, dilated intra & extra -hepatic ducts
Duodenal cx obstructing common bile duct @ ampulla of Vater -> abd US -> endoscopy w/ biopsy
Crushing injury, months later intense constant burning pain
Causalgia: reflex sympathetic dystrophy - sympathetic block relieves sx/ dx -> sympathectomy
Incidental finding: dilated distal ureter
Megaureter: more common in males -> asymptomatic / hydronephrosis -> kidney failure
Increased parathyroid hormone in postmenopausal femal, increased Ca
Parathyroid adenoma, Rx. Surgical removal, or Estrogen/progesterone, Raloxifen, Bisphosphonates -> decreased Ca
Postsurgical sx hypothyroid w low T4
Potential adrenal insufficiency, give Steroids, before T4. ACTH if pituitary insufficiency is the cause
Jaundiced, pruritis, wt loss, RUQ pain, conjugated hyperbilli, transaminases, hx sclerosing cholangitis, hepatomegaly
Obstructive jaundice 2/2 cholangiocarcinoma @confluence of hepatic ducts: US inconclusive-> CT or MRCP: ductal dilation/ small gallbladder -> ERCP cytologic dx
Asymptomatic Bacteriuria, pregnant, E Coli
Nitrofurantoin, Cephalosporin (cefpodoxime), Sulfisoxazole, Amoxicillin, Amoxicillin-Clavulanate, Fosfomycin
8 yo w/ melena, RLQ pain, intussusception, volvulus, or obstruction near the terminal ileum
Meckel’s Diverticulum: dx: Techtenium Pertechtinate, sx: 2 inches long., 2 feet from the ileocecal valve., 2% of population, first 2 years of life. 2 types of epithelia (gastric/pancreatic).
Pt w/ (infection/surgery/trauma/stroke/tumor) sx. Hyponatremia, increased FENa, hypo-osmolality; fluid restriction ineffective
SIADH: if can’t tolerate loop diuretics, sodium tablets, give ADH antagonist: Demecocycline or Lithium
Pt (critically ill/ post op/ hypovolemic/ sedated) abd pain, vomiting, leukocytosis, fever
Acalculous cholecystitis via bile stasis; US: distended gallbladde, thickened wall; Percutaneous Cholecystostomy, or if possible/stable Cholecystectomy
High fever, jaundice, RUQ pain (charcot’s triad), high AlkPhos, mental status changes
Acute Cholangitis: Choledocholithiasis (stone in common bile duct), distended C bile D. on US; ERCP dx & rx
Intermittent crampy abd pain/ bloody diarrhea; US: dilated intra/extra hepatic ducts, high AlkPhos, jaundice
Primary Sclerosing Cholangitis, a/w: IBD, Ulcerative Colitis, increased risk of colonic cx and cholangio cx
Urinary frequency, dribbling, hesitancy, large prostate, distended bladder
Overflow incontinence: alpha antagonist (tamsulosin, doxazosin, terazosin), 5alpha-reductase inhibitor (finasteride) for BPH
Pain, edematous arm, worst with raising arm above head, recent hx weight lifting
Thoracic Outlet Sd: venous->edematous; neuro TOS->paresthesia, muscular atrophy, Arterial TOS-> pulseless, ischemic
Cold tingling muscle pain, visual & equilibrium rpoblems, maybe syncope
Subclavian steal sx
LLQ abd mass, neuro deficits in L leg, increased urine epi/norepi metabolites, café au lait lesions
Adrenal gland pheochromocytoma -> MRI confirms (Type 1 Neurofibromatosis) v. Extra-adrenal pheo: only epi metabolite in urine
Gunshot wound bellow 4th intercostal / nipple
Exploratory Laparotomy
Post-op CABG day 10: Chest pain, fever, leukocytosis, widened mediastinum
Acute mediastinitis: throacotomy for drainage/debridement, antibiotics
MVC LE weakness (ant corticospinal), loss of pain/temp (spinothalamic), proprioception/vibration is intact (dorsal column)
Anterior cord sx: immediate rx w/ methylprednisone. Confrimed on CT. Also post aortic aneurism repair
MVC blunt chest trauma, increased PCWP, hypotensive, tachycardic
Cardiogenic shock (MI, arrhythmia, contusion, compression) -> IVF to increase PCWP to 15-20, Ionotropics Dobutamine / Dopamine
MVC deceleration, hypertense UE, hoarse voice
Aortic rupture -> hematoma -> compressing: vessels - pseudocoarction & L recurrent laryngeal
MVC blow to pelvis, full bladder, abd pain referred to L shoulder
Intraperitoneal rupture of bladder dome -> peritonitis -> irritating diaphragm w shoulder pain (Kehr’s sign)
Blunt trauma to abdomen, intial CT negative. 1 week later: chills, fever, deep abd pain
Pancreatic laceration/contusion/crush injury -> pseudocyst -> retroperitoneal abcess -> percutaneous drainage/culture -> surgical debridement
Mexican w atraumatic severe hemoptysis, cxr opacity in R lower lobe
M. Tuberculosis -> rigid bronchoscopy -> control bleeding / airway
Chest trauma, JVD, tachy, hypotensive despite fluids
Pericardial Tamponade -> cardiogenic shock; rx. Pericardiocentesis / pericardiotomy
Swollen painful calf post femoral artery embolectomy
Ischemic-Reperfusion sx -> interstitial/ intracellular edema -> tissue swelling -> compartment sx (pain, pallor, pulseness, paresthesia, paralysis); fasciotomy
MVC, hours later develops tachycardia, tachypnia, hypoxia; cxr patchy uni/bilateral alvolar infiltrates
Pulmonary contusion; tachypnea, decreased CO2 & alkalosis; monitor, intubation /ventilation if severe
Senior w cervical spondylosis post MVC hyperextension injury, w/ UE weakness
Central cord sx: damage to central portions of corticospinal pathway
Petechia in upper body, dyspnea, confusion, fracture of long bones
Fat Embolism: petechial rash, dyspnea, tachypnea, severe respiratory distress, subconjuctival hemorrhage, fever, pulmonary infiltrates on cxr
Severe onset substernal pain, widened mediastinum, medistinal air / crepitus, taking K/Cl, hx HIV
Esophageal perforation: Gastrograffin (H2O sol contast) study; Hamman’s sign - crunching sound on heart auscultation (pneumomediastinum); atibiotics, surgery
MVC, pelvic, rib fx, hypotense 80/40 post fluids, FAST/ peritoneal lavage: no intraperitoneal blood/ organ damage
Pelvic Angiography: for dx and repair of retroperitoneal bleeds
MVC, hypotense, distended abd, no bowel sounds
Hemorrhagic abdomen -> exploratory laparotomy
Colicky/periodic abd pain/ constipation 3 days, N&V 6h, episodic high pitched bowel sounds, increased amylase, mildly acidotic
Complete SBO: requires surgical corrections; metabolic acidosis: ischemic strangulated bowel loop -> lactic acidosis
Acute flank pain, hematuria, vomiting, hx Crohn’s dz, abd pain
Nephrolithiasis - Calcium Oxylate stones; fat malabsorption - Ca binds fat in lumen, increased unbound Oxalate absorption in blood -> stones
Asian w recent neck swelling, mass on posterior nasal cavity, undiff cx.
Nasopharyngeal carcinoma; strong a/w EBV (epsteinbarvirus), smoking, nitrosamines
Supracondylar fx Humerus, post reduction -> forarm pain, palor, cold
Acute compartment sx needs fasciotomy, may progress to Volkman’s ischemic contracture - dead muscle replaced by fibrous tissue
Values suggesting post op-hypovolemia
FENa500, UNa/Cr>20, UBUN/Cr>20
Hyer-reflexia, paresthesia, muscle spasm, tetany, prolonged QT, T-wave inversion; chovstek (facial nerve spasm), Trousseau (pressure cuff, forarm spasm)
Hypocalcemia; adjust Ca for low Albumin (add 0.8 for each 1.0 decrease in albumin); IV Ca Gluconate
Hyer-reflexia, paresthesia, muscle spasm, tetany, prolonged QT/PR, ST depression, flat/inverted P, torsades
Hypomagnesemia
Pt with Von Willebrands, preop treatment?
DDAVP (vasopressin analogue) releases vWB factor, shortens bleed time; cryoprecipitate
Severe weight loss from cx, parenteral nutrition side effects
Refeeding syndrome: insulin increase, electrolyte shift: decreased phosphate, magnesium, potassium, hyperglycemia, hyperchloremic acidosis
Hemophelia A pre-op treatment?
DDAVP with Aminocaproic acid (inhibitor of fibrinolysis)
Hemolytic transfusion reaction
Give mannitol and fluids: clear hemolyzed redcells (from clumping at glomeruli), hypotensive resuscitation; alkalinize urine w NaBicarb
Hypoglycemia, weakness, lasstitude, hyperkalemia, hyponatremia, fever, wt loss, vomiting, dehydration
Adrenocortical insufficiency, Addisons, chronic steroid use, acute stress (surgery); U Na decreased, no response to ACTH
Acute renal failure post aortic angiography, increased ESR, proteinuria, FENa>1
Cholesterol atheroembolism to renal artery, intra-renal acute renal failure
Extubation criteria
Minute ventilation 20
Factors shifting O2 dissociation curve to the right
Acidosis, increased PCO2, increased temperature; (2,3 DPG shifts left)
mnemonic for postoperative fever is the “6 W’s”
Wind (pneumonia and atelectasis), Water (UTI), Wound, Wonder drugs (i.e., erythromycin, isoniazid, penicillin, captopril, aspirin, allopurinol, heparin), Walking (DVT), and “What happened” (medical interventions).
Pt recovering from acute pancreatitis, secondary to gallstones; management?
Once stable perform cholecystectomy
Post op fever, decreased UO, tachypnea, hypotension, AG metabolic acidosis; dx, rx?
Lactic acidosis septic shock; normal saline IVF 1st, add broadspectrum antibiotics
Post op pt develops hypotension, tachypnea, initial tachycardia then bradycardia, new onset RBBB, JVD; dx; complications?
Massive thromboembolism; RBBB - RHF - decreased preload -LHF - decreased CO - cardiogenic shock and bradycardia - CNS unresponsive, dilated pupil, death
