Surgery 5 Flashcards
Bacterial pneumonia often causes a pleural effusion - what kind, typically?
Uncomplicated parapneumonic effusion that is small, sterile, free-flowing, and resolves with ABX
Presentation of complicated parapneumonic effusion or empyema?
Continued symptoms (fever, pleuritic pain) despite adequate ABX
CXR with loculation (walled-off pleural fluid)
Thoracentesis with exudative effusion
Compare the etiology of uncomplicated vs. complicated parapneumonic effusion.
Sterile exudate in pleural space vs. bacterial invasion of pleural space
Compare pleural fluid analysis of uncomplicated vs. complicated parapneumonic effusions.
pH 7.2+, glucose 60+, WBC 50k or less
vs.
pH<7.2, glucose <60, WBC>50k
Compare pleural fluid gram stain and culture of uncomplicated vs. complicated parapneumonic effusions.
Negative vs. negative (false negative due to low bacterial cont, both positive in empyema)
Rx uncomplicated vs. complicated parapneumonic effusions
ABX vs. ABX + drainage
Features of transudative effusions (protein, glucose, pH)
Low protein, normal glucose and pH
Presentation of acute hypocalcemia?
Muscle cramps Chvostek and Trousseau signs Paresthesias Hyperreflexia/tetany Seizures
Causes of acute hypocalcemia?
Neck surgery (parathyroidectomy) Pancreatitis Sepsis Tumor lysis syndrome Acute alkalosis Chelation - blood (citrate) transfusion, EDTA, foscarnet
Rx acute hypocalcemia?
IV calcium gluconate/chloride
How does high-volume blood transfusion lead to hypocalcemia?
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)
Rx varicocele?
Gonadal vein ligation (boys and young men with testicular atrophy)
Scrotal support and NSAIDs (older men who do not desire additional children)
Why should varicoceles be treated in young patients?
Decrease risk for infertility
Causes of esophageal perforation?
Instrumentation (eg, endoscopy -> most common overall cause), trauma Effort rupture (Boerhaave syndrome) Esophagitis (infectious/pills/caustic)
Rx esophageal perf?
NPO, IV ABX, PPIs
Emergency surgery consultation
Presentation of ganglion cysts?
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
Dx ganglion cyst
Inspection, can be confirmed on transillumination of the mass
Management of ganglion cyst?
Most resolve spontaneously
If painful/persistent symptoms, options include aspiration and surgical excision
___ are small (<1 cm), freely mobile nodules, typically with a central punctum; they develop most commonly on the palmar surface of the digits.
Epidermoid cysts
___ are soft, fleshy masses found in subcutaneous tissues; they are found on the trunk or shoulders.
Lipomas
Walk through the management of blunt abdominal trauma in hemodynamically stable patients.
- 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
If FAST is limited or equivocal, what can be done to evaluate for hemoperitoneum?
Diagnostic peritoneal lavage (DPL)
Compare the pathophysiology of aspiration syndromes - pneumonia vs. pneumonitis
Pneumonia - lung parenchyma infection, aspiration of upper airway or stomach microbes (anaerobes)
Pneumonitis - lung parenchyma inflammation, aspiration of gastric acid with direct tissue injury
Compare the clinical features of aspiration syndromes - pneumonia vs. pneumonitis
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
Rx aspiration syndromes - pneumonia vs. pneumonitis
Pneumonia - ABX (clinda or beta-lactam + beta-lactamase inhibitor)
Pneumonitis - supportive
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.)
Risk factors for SCC?
Sun exposure, fair skin, chronic inflammation or scar formation, ionizing exposure, chronic immunosuppression
Presentation of basal cell carcinoma?
Pearly, flesh- or pink-colored nodule with telangiectatic vessels, usually found on the head or neck
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
Management of febrile non-hemolytic transfusion reaction?
Stop the transfusion to rule out other serious causes of fever
Antipyretics (avoid aspirin in thrombocytopenic patients)
Presentation of massive PE in a post-operative patient?
Hypotension, syncope, JVD, new-onset RBBB
Dx massive PE?
CT pulmonary angiography
Echocardiogram (only for massive PE - visible abnormalities not seen in segmental PE)
Rx massive PE?
Fibrinolysis
An ulcerated tonsillar lesion in a patient with a long smoking history is highly suspicious for ___.
Oropharyngeal squamous cell carcinoma
Presentation of oropharyngeal SCC?
Sore throat, odynophagia, ulcerated/friable lesions, referred otalagia, isolated neck mass
Risk factors for oropharyngeal SCC?
Age >40, tobacco use, alcohol use, immunocompromised status, HPV
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
3 main causes of acute arterial occlusion?
Embolus from a cardiac or arterial source
Arterial thrombosis
Iatrogenic or direct blunt trauma to the artery
Drugs with anticholinergic properties can cause acute urinary retention - how?
Prevent detrusor muscle contraction and urinary sphincter relaxation
When should a lesion be worked up for melanoma despite not having any of the ABCDE characteristics?
- Patient who has multiple pigmented lesions and a lesion with an appearance that is substantially different from the others -> ugly duckling sign (90% sensitivity)
- Vertical growth -> palpable nodularity
- Moles hat itch or bleed
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)
Next step if melanoma is suspected?
Excisional biopsy with initial margins of 1-3 mm of normal tissue