Surgery 5 Flashcards
1
Q
Bacterial pneumonia often causes a pleural effusion - what kind, typically?
A
Uncomplicated parapneumonic effusion that is small, sterile, free-flowing, and resolves with ABX
2
Q
Presentation of complicated parapneumonic effusion or empyema?
A
Continued symptoms (fever, pleuritic pain) despite adequate ABX
CXR with loculation (walled-off pleural fluid)
Thoracentesis with exudative effusion
3
Q
Compare the etiology of uncomplicated vs. complicated parapneumonic effusion.
A
Sterile exudate in pleural space vs. bacterial invasion of pleural space
4
Q
Compare pleural fluid analysis of uncomplicated vs. complicated parapneumonic effusions.
A
pH 7.2+, glucose 60+, WBC 50k or less
vs.
pH<7.2, glucose <60, WBC>50k
5
Q
Compare pleural fluid gram stain and culture of uncomplicated vs. complicated parapneumonic effusions.
A
Negative vs. negative (false negative due to low bacterial cont, both positive in empyema)
6
Q
Rx uncomplicated vs. complicated parapneumonic effusions
A
ABX vs. ABX + drainage
7
Q
Features of transudative effusions (protein, glucose, pH)
A
Low protein, normal glucose and pH
8
Q
Presentation of acute hypocalcemia?
A
Muscle cramps Chvostek and Trousseau signs Paresthesias Hyperreflexia/tetany Seizures
9
Q
Causes of acute hypocalcemia?
A
Neck surgery (parathyroidectomy) Pancreatitis Sepsis Tumor lysis syndrome Acute alkalosis Chelation - blood (citrate) transfusion, EDTA, foscarnet
10
Q
Rx acute hypocalcemia?
A
IV calcium gluconate/chloride
11
Q
How does high-volume blood transfusion lead to hypocalcemia?
A
Citrate in transfused blood binds ionized calcium, which is the biologically active fraction (total calcium levels will not be significantly affected); uncommon in patients with normal liver function (citrate rapidly metabolized by the liver)
12
Q
Rx varicocele?
A
Gonadal vein ligation (boys and young men with testicular atrophy)
Scrotal support and NSAIDs (older men who do not desire additional children)
13
Q
Why should varicoceles be treated in young patients?
A
Decrease risk for infertility
14
Q
Causes of esophageal perforation?
A
Instrumentation (eg, endoscopy -> most common overall cause), trauma Effort rupture (Boerhaave syndrome) Esophagitis (infectious/pills/caustic)
15
Q
Rx esophageal perf?
A
NPO, IV ABX, PPIs
Emergency surgery consultation
16
Q
Presentation of ganglion cysts?
A
Mobile, non-tender swelling, most common at the wrist
Generally harmless
Common in patients with underlying joint disorder or prior joint injury
Filled with mucinous fluid and often communicate with the underlying joint via a hollow pedicle
17
Q
Dx ganglion cyst
A
Inspection, can be confirmed on transillumination of the mass
18
Q
Management of ganglion cyst?
A
Most resolve spontaneously
If painful/persistent symptoms, options include aspiration and surgical excision
19
Q
___ are small (<1 cm), freely mobile nodules, typically with a central punctum; they develop most commonly on the palmar surface of the digits.
A
Epidermoid cysts
20
Q
___ are soft, fleshy masses found in subcutaneous tissues; they are found on the trunk or shoulders.
A
Lipomas
21
Q
Walk through the management of blunt abdominal trauma in hemodynamically stable patients.
A
- Assess mental status. If abnormal, complete serial abdominal exams +/- CT scan
- If normal, complete a FAST exam. If positive, get CT abdomen
- If negative, serial abdominal exams +/- CT scans
If positive and hemodynamically unstable -> ex-lap
22
Q
If FAST is limited or equivocal, what can be done to evaluate for hemoperitoneum?
A
Diagnostic peritoneal lavage (DPL)
23
Q
Compare the pathophysiology of aspiration syndromes - pneumonia vs. pneumonitis
A
Pneumonia - lung parenchyma infection, aspiration of upper airway or stomach microbes (anaerobes)
Pneumonitis - lung parenchyma inflammation, aspiration of gastric acid with direct tissue injury
24
Q
Compare the clinical features of aspiration syndromes - pneumonia vs. pneumonitis
A
Pneumonia - presents days after aspiration event with fever, cough, increased sputum. CXR infiltrate in dependent lung segment (classically RLL). Can progress to abscess
Pneumonitis - presents hours after aspiration event. Range from no symptoms to non-productive cough, decreased O2, respiratory distress. CXR infiltrates (one or both lower lobes), resolve with ABX
25
Rx aspiration syndromes - pneumonia vs. pneumonitis
Pneumonia - ABX (clinda or beta-lactam + beta-lactamase inhibitor)
Pneumonitis - supportive
26
Presentation of cutaneous squamous cell carcinoma?
Enlarging nodule in sun-exposed areas. Often becomes keratinized (thickened, rough surface) or ulcerates with crusting and bleeding
Can display early perineural invasion, causing regional neuro symptoms (numbness, paresthesias, etc.)
27
Risk factors for SCC?
Sun exposure, fair skin, chronic inflammation or scar formation, ionizing exposure, chronic immunosuppression
28
Presentation of basal cell carcinoma?
Pearly, flesh- or pink-colored nodule with telangiectatic vessels, usually found on the head or neck
29
Describe the pathophysiology of febrile non-hemolytic transfusion reaction.
When red cells and plasma are separated from whole blood, small amounts of residual plasma and/or leukocyte debris may remain in the red cell concentrate. During blood storage, these leukocytes release cytokines that when transfused can cause transient fevers, chills, and malaise (without hemolysis) within 1-6 hours of transfusion
30
Management of febrile non-hemolytic transfusion reaction?
Stop the transfusion to rule out other serious causes of fever
Antipyretics (avoid aspirin in thrombocytopenic patients)
31
Presentation of massive PE in a post-operative patient?
Hypotension, syncope, JVD, new-onset RBBB
32
Dx massive PE?
CT pulmonary angiography
Echocardiogram (only for massive PE - visible abnormalities not seen in segmental PE)
33
Rx massive PE?
Fibrinolysis
34
An ulcerated tonsillar lesion in a patient with a long smoking history is highly suspicious for ___.
Oropharyngeal squamous cell carcinoma
35
Presentation of oropharyngeal SCC?
Sore throat, odynophagia, ulcerated/friable lesions, referred otalagia, isolated neck mass
36
Risk factors for oropharyngeal SCC?
Age >40, tobacco use, alcohol use, immunocompromised status, HPV
37
Work-up for suspected oropharyngeal SqCC?
```
Biopsy lesion with evaluation of HPV status
Neck imaging (CT) to characterize the lesion and any associated nodal mets
```
38
3 main causes of acute arterial occlusion?
Embolus from a cardiac or arterial source
Arterial thrombosis
Iatrogenic or direct blunt trauma to the artery
39
Drugs with anticholinergic properties can cause acute urinary retention - how?
Prevent detrusor muscle contraction and urinary sphincter relaxation
40
When should a lesion be worked up for melanoma despite not having any of the ABCDE characteristics?
1. Patient who has multiple pigmented lesions and a lesion with an appearance that is substantially different from the others -> ugly duckling sign (90% sensitivity)
2. Vertical growth -> palpable nodularity
3. Moles hat itch or bleed
41
What is the most important prognostic indicator in malignant melanoma?
Breslow depth (distance from the epidermal granular cell layer to the deepest visible melanoma cells)
42
Next step if melanoma is suspected?
Excisional biopsy with initial margins of 1-3 mm of normal tissue
43
__ are indistinct, roughened papules that are most common in sun-exposed areas such as the face and dorsal hands.
Actinic keratoses
44
Rx actinic keratoses?
Destruction in situ with cryotherapy or topical fluorouracil
45
Clinical presentation of acute aortic dissection?
Hx HTN, genetic disorder (Marfan, etc.)
Severe, sharp, tearing chest or back pain
>20 mm Hg difference in SBP between arms
Possible hypotension and aortic regurgitation
46
Dx acute aortic dissection?
EKG - normal or non-specific ST and T-wave changes
CXR - mediastinal widening
CT angio or TEE for definitive diagnosis
47
Type A vs. Type B dissections?
Type A - involve the ascending aorta
| Type B - originate in the descending aorta
48
Complications of type A dissections?
Syncope, stroke, MI, heart failure
49
Management of Type A dissection?
Very high mortality rate -> immediate surgical intervention +/- intraoperative TEE
50
Why is early identification of aortic dissection so essential?
Because therapies for similar presenting conditions (eg, aspirin and heparin for MI, thrombolytics for PE or ischemic stroke) worsen outcomes and are contraindicated
51
Management of type B dissections?
If they do not result in malperfusion to thoracic or abdominal organs -> medical management with pain and BP control
If malperfusion -> urgent surgical or endovascular repair
52
What is endophthalmitis and how does it present?
Bacterial or fungal infection within the eye, particularly the vitreous
Present with pain, decreased visual acuity. On exam, swollen eyelids and conjunctiva, hypopyon, corneal edema, infection
53
Work-up and management of post-operative endopththalmitis?
Send vitreous for Gram stain and culture
Based on severity, intravitreal antibiotic injection or vitrectomy is done
54
Approximately 25% of ___ is heralded by a recent (<2 years) dx of DM.
Pancreatic cancer
55
Although screening for pancreatic cancer is not recommended for patients with new-onset DM, those who have symptoms (eg, constant abdominal pain, weight loss) of pancreatic cancer should undergo ___.
Abdominal CT scan
56
List 3 major risk factors for pancreatic cancer.
1. Cigarette smoking
2. Chronic pancreatitis
3. Disorders of glucose metabolism (insulin resistance and DM)
57
Abdominal U/S is used in the initial evaluation of suspected pancreatic cancer in patients with painless jaundice, anorexia, or weight loss. What patient presentation indicates the need for CT abdomen instead and why?
Those who have abdominal pain WITHOUT jaundice; U/S often misses smaller potentially resectable tumors
58
A nuclear gastric emptying scan can diagnose ___.
Gastroparesis
59
Presentation of central cord syndrome (incomplete acute spinal cord injury)?
Common after whiplash-type injuries in older adults with underlying cervical spondylosis
Upper extremity motor, sensory, and reflex abnormalities; sacral and lower extremity function generally preserved
60
How does central cord syndrome occur?
In older individuals with a stenotic cervical spinal canal, hyperextension injury to the neck compresses the spinal cord between a hypertrophied ligamentum flavum posteriorly and a bulging disc/osteophyte complex anteriorly, leading to damage to the central spinal cord (gray matter)
61
Why do patients develop upper extremity manifestations in central cord syndrome?
1. Weakness 2/2 damage to the alpha motor neuron cell bodies in the anterior horn of the SC
2. Pain/temp/sensory loss in dermatomes at and around the level of injury 2/2 damage to the posterior grey column
3. Reflex loss at the level of injury 2/2 damage to fibers as they cross from the dorsal to ventral horn
4. Lateral spinal tracts running to the sacrum and lower limbs are generally spared 2/2 the central location nof the lesion
62
Work-up for suspected central cord syndrome?
Spinal imaging - XR often normal, but may show cervical spondylosis
Cervical myelogram generally diagnostic (persistent cord compression)
63
Rx central cord syndrome?
Glucocorticoids, surgery
64
Presentation of brachial plexus injury (nerve roots C5-T1)?
Shoulder or arm pain, upper extremity muscle weakness, atrophy (after weeks), and sensory loss; most cases are unilateral
Usually occurs in the setting of downward traction on the shoulder, neck forced to contralateral side
65
Presentation of toxic megacolon?
```
Total or segmental non-obstructive colonic dilation
Severe bloody diarrhea
Systemic findings (fever, tachycardia)
```
66
Confirm diagnosis of toxic megacolon?
Plain abdominal XR (dilated R or transverse colon >6cm, possible multiple air fluid levels, thick haustrel markings that do not extend across entire lumen) + 3 or more of the following:
1. Fever >38 C (100.4 F)
2. Pulse >120
3. WBC >10.5
4. Anemia
67
Rx toxic megacolon?
Prompt IV steroids (preferred for IBD-induced)
NG decompression, bowel rest
ABX (broad-spectrum)
Fluid management
Emergency surgery (sub-total colectomy with end-ileostomy) if colitis does not resolve
68
Causes of toxic megacolon?
```
IBD (highest risk early in disease, within 3 years dx)
Ischemic colitis
Volvulus
Diverticulitis
Infections (C. diff, etc.)
Obstructive colon cancer (less common)
```
69
___-sided colon cancer tends to present with anemia, whereas ___-sided colon cancer present with bowel obstruction.
Right; left
70
List the steps in management of OA.
1. Non-pharmacologic treatment (exercise, weight loss, etc.)
2. NSAIDs (or acetaminophen) PRN
3. Topical agents (NSAIDs, capsaicin, etc.), intrarticular glucocorticoids, intrarticular hyaluronic acid
4. Surgery (if possible); chronic pain management (non-surgical candidates)
71
Typical findings of OA?
Narrowing of the joint space (most notable in the medial compartment)
Periarticular osteophyte formation
72
Rx symptomatic tears of the meniscus?
Arthroscopic meniscectomy
73
Risk factors for OA?
Obesity
prior joint injury
Abnormal joint alignment
74
Presentation of pes anserinus pain syndrome (aka anserine bursitis)?
tenderness of the medial aspect of the knee just distal to the joint line, pain worse with pressure from contralateral knee while lying on side
75
Pes anserinus location?
Insertion of Sartorius, gracilis, semitendinosus tendons
76
Manage anserine bursitis?
Place a pillow between the knees during sleep
77
Presentation of patellar dislocation?
Quick, twisting motion around a flexed knee
Feeling of knee giving way, severe pain, popping noise
Lateral dislocation of patella, decreased extension
78
Risk factors for patellar dislocation?
```
Joint laxity
Misaligned lower extremity
Tight iliotibial band
Patellar subluxation
Competitive sports, dance, military training
Age <20
```
79
Most common type of patellar dislocation?
Lateral displacement with associated tear of the medial patellofemoral ligament
80
Rx patellar dislocation?
Often reduce spontaneously
If not, closed reduction
F/u care with splinting and rehab for muscle strengthening
81
Injury typically due to rapid deceleration or pivoting at the knee with the foot planted
ACL tear
82
Injury caused by severe valgus stress or twisting injury?
MCL tear
83
How can an MCL tear be differentiated from patellar dislocation if the ligamentous laxity is masked by swelling/muscle spasm?
ROM is preserved in MCL tear
| Patella not displaced
84
Injury typically occurring from pivoting on a flexed knee while the foot is planted?
Meniscal tear
85
Presentation of meniscal tear?
Joint line tenderness, small joint effusion, crepitus, locking, or catching with ROM
86
What should be done in all patients with oliguria and acute renal failure 2/2 suspected bladder outlet obstruction in the post-op setting?
Urgent bladder scan and catheterization
87
Define oliguria.
<250 mL urine in 12 hours
88
In the setting of acute oliguria, what are the first 2 steps?
1. H&P (BPH, etc.)
| 2. Bedside bladder scan to assess urinary retention
89
If there is significant urinary retention on bladder scan, what should be done?
Urethral catheter to decompress bladder
Serum and urine biochemistry +/- imaging
Rx underlying cause (eg, BPH, malignancy) w/urologic consultation
90
If there is no significant urine retention on bladder scan, what should be done?
Serum and urine biochem +/- imaging
Pre-renal causes - hypovolemia, sepsis, low CO -> fluid administration if appropriate, Rx underlying cause
Renal causes - ATN, interstitial nephritis, glomerular disease -> Rx underlying cause
91
Patients with heart failure can have volume overload but low CO (ie, cardiorenal syndrome). How can renal perfusion be improved?
IV loop diuretics
92
After blunt chest trauma, hemorrhagic shock associated with decreased breath sounds and dullness to percussion over one hemithorax and contralateral tracheal deviation is most likely due to what?
Large ipsilateral hemothorax
93
Each hemithorax is capable of holding up to ___% of the circulating blood volume. Massive hemothorax is defined as ___.
50; >1.5 L
94
The most common causes of massive hemothorax are traumatic laceration of the ___ or damage to ___.
Lung parenchyma; intercostal or internal mammary artery
95
Major physical exam difference between tension pneumothorax vs. hemothorax?
Tension pneumo - hyperresonance to percussion
Hemo - dullness to percussion
96
What is Echinococcus granulosus, how is it transmitted, and where is it found?
```
Dog tapeworm (sheep intermediate host, humans incidental hosts)
Egg ingestion (eggs hatch in small intestine, penetrate intestinal wall, travel to the liver) where 1+ hydatid cysts form
Rural, developing countries (eg, South America, Middle East)
```
97
Presentation of Echinococcus granulosus?
```
Initially asymptomatic (often for years)
Liver cyst (most common) -> mass effect (RUQ pain, N/V, hepatomegaly), rupture (fever, eosinophilia)
Lung cyst (cough, chest pain, hemoptysis)
```
98
Dx Echinococcus granulosus?
Imaging (U/S has excellent sensitivity) - Large, smooth hydatid cyst often with internal septations
IgG E granulosus serology
99
Rx Echinococcus granulosus?
Albendazole (small cysts <5 cm)
Percutaneous therapy (>5 cm or septations)
Surgery (if rupture)
100
Eating contaminated pork may result in a ___ infection.
Taenia solium GI tapeworm
101
What does infection with T. solium cause?
Cysticercosis (usually affects the brain -> seizures or cerebral ventricular system -> intracranial HTN)
102
What does E. histolytica cuase?
Dysentery/colitis and liver abscess
103
Presentation of amebic abscess?
Fever, RUQ pain, smooth, cystic, subcapsular liver mass
104
What is torus palatinus?
Benign bony growth (exostosis) located at the midline suture of the hard palate that can be congenital or develop later in life
Chronic, asymptomatic
105
Rx torus palatinus?
Surgery only if mass becomes symptomatic, interferes with speech or eating, or causes problems with denture fitting
106
Presentation of oral cancer?
Progressive ulcerating lesion located eccentrically on soft structures rather than the center of the hard palate
