✅Surgery Flashcards
1st and 2nd steps for treating acute variceal bleeding
1st: 2 Large bore IV needles vs. central line for IVF
2nd: Endoscopic sclerotherapy vs. band ligation
Postop Cholestasis develops after surgerys that involve ⬜, ⬜ and ⬜ .
________________
Why is this?(3)
hypOtension | [massive blood loss] | [massive blood transfusion]
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- hypOtension ➜ [⬇︎ Liver function] ➜ [⬇︎bilirubin excretion]
- [massive blood loss] ➜ [renal ischemic tubular necrosis] ➜ [⬇︎ bilirubin urine excretion]
- [massive blood transfusion] ➜ [⬆︎ pigment load] ➜ [⬆︎ bilirubin to excrete]
Surgical repair for hip fractures may be delayed up to ⬜ hours.
________________
Why?
72 hours
________________
address unstable medical comorbidity first
How does SBO present (3)?
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What’s most common cause?
- [NV –> hypOkalemia]
- [Bloating - Hyperactive “tinkling” Bowel Sounds]
- [Dilated Bowel Loops X-ray]
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Adhesions! (operations)
Etx for [Isolated Duodenal Hematoma] occur?
________________
1st line tx? -2
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2nd line tx?
[Abd trauma to children]–>blood between mucosa and submucosa –> resolves spontaneously in 1-2 weeks
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Tx =
1st: [NG suction + Parenteral nutrition]
2nd: [Laparascopic hematoma removal]
Describe Varicoceles
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Etiology?
Tortuous Dilation of Pampiniform Venous Plexus surrounding spermatic cord & testis within scrotum
________________
L renal vein compression (from Aorta and SMA or thrombosis) –>L side scrotal bag of worms worst with standing/valsalva and better when supine
[Retropharyngeal Abscess] presentation (5)
Why does this have to be treated STAT?
Odynophagia / [Painful Neck Extension] / Fever / Sore throat / [Trismus (inability to open mouth)]
Abscess infection may spread into mediastinum!
[Retropharyngeal Abscess]
Dx -2
________________
Tx -2
Dx = CT neck vs. Lateral Radiographs–>Demonstrates cervical spine Lordosis
________________
Tx = [Abx IV] + [I&D]
Complications of SBO (2)?
Management (2)
Strangulation vs. Perforation
Mgmt = [Surgical Exploration] vs. [NPO & IVF –> NG tube suction]
Diverticulitis Abscess Tx
CT guided-percutaneous (alternative surgical) abscess I&D
Diverticulitis = Soft tissue stranding & colonic wall thickening
INR for normal people
0.8 - 1.2
Therapeutic INR range for pts on warfarin
2 - 3
Acute GI perforation requires emergent _____
Laparotomy (surgical incision thru abd wall)
MOD of [AMBIC- Acute Mesenteric Bowel ischemic colitis] post AAA repair
inadequate [Left Descending Colon] and [Sigmoid Colon] arterial perfusion from IMA during aortic graft placement –> Ischemia
CT revealing air & edema in bowel wall –> thickening = AMBIC
Step-wise process for [Blunt Abd Trauma in hemodynamically unstable pts]. Any Caveat?
DPL = Diagnostic Peritoneal Lavage = aspiration of 10 mL of peritoneal fluid with blood = intraperitoneal injury
Caveat = PENETRATING ABD TRAUMA (GUNSHOT/STAB) = SKIP DIRECTLY TO XLAP (Xploratory LAPARATOMY W/REPAIR)
Staph Aureus and Staph Epidermidis both affect prosthetic joints. What is the difference?
[Staph Aureus = Acute ( < 3 mo. onset)] & may only require debridement
[Staph Epidermidis] = Delayed > 3 mo. onset and must be replaced
PrePatellar bursitis is often due to ⬜, but other causes include ⬜ or ⬜
S.Aureus (infects bursa via extension of local cellulitis after trauma)
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[Gout Crystalline Arthropathy] / [Rheumatoid Arthritis]
CT scan shows ⬜ which indicates what diagnosis?
________________
. What causes this?
________________
Tx(2)?
[air in DEEP tissue]; Necrotizing Fasciitis
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[Polymicrobial > GASP] spreads rapidly thru SubQ & deep fascia after minor trauma –>
PAIN OUT OF PROPORTION WITH EXAM
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Tx = Debridement + Broad Abx
What is the first sign of hypOvolemia
INC HR
Massive Hemoptysis is defined as ⬜ or ⬜ . The greatest danger with this is ⬜ .
[>600 mL expectorated blood over 24 hours] vs. [Bleeding > 100 mL/hour] –> Asphyxiation from blood in airway
What is the management for [Massive Hemoptysis] -4
1st: Intubate
2nd: Place bleeding lung in lateral decubitius to prevent bleeding from going to other lung
3rd: Bronchoscopy to localize & cauterize bleeding site
4th: Thoractomy if bleeding persist despite bronchoscopy or if uL bleeding
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[>600 mL expectorated blood over 24 hours] vs. [Bleeding > 100 mL/hour]
On which PostOp Day is atelectasis most common? Explain how this causes Respiratory Alkalosis
POD2! ; PostOp pain vs. Residual anesthesia vs. tongue prolapse —> hypOxemia and INC work of breathing –> Hyperventilation —> Respiratory Alkalosis
Acute PE may present similarly
Femoral n. Function (2)
[Hip flexion]
[Knee extension]
Femoral n. innervation (2)
[ANT thigh] & [Medial leg via saphenous branch]
Obturator n. function
Thigh ADDuction
Obturator n. innervation
medial thigh
[PiloNidal Dz] MOD
sweating/friction of coccyx skin in young males with body hair –> Hair follicle infection–>spreads SubQ –> Abscess that ruptures to form [piloNidal sinus tract]
Tx = I&D + Sinus tract excision
Flail Chest presentation (3)
Pt with recently fractured ribs who has..
- paradoxic thoracic wall movements (inverted chest wall w/inspiration, correted when on positive pressure)
- [shallow tachypneic breathing]
- Respiratory distress despite chest tubes
A pt with pneumobilia, [hyperactive bowel sounds] and Dilated loops of the bowel probably has ⬜
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What’s biggest Risk Factor for this?
________________
Dx? | Tx?
Gallstone iLeus (gallstone passes thru biliary enteric fistula into small intestine)–>air in biliary tree (pneumobilia)
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Cholecystitis
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Dx = CT
Tx = Surgery
Flail Chest etiology and tx(3)
Multiple ribs fractured in GOE 2 locations –> segment of ribs losing continuity with thoracic wall –> Rib collapse with inspiration –> shallow breahs –> Hyperventilation
Tx = Pain control + supplemental O2 + [Intubation w/CPAP]
Pt with suspected Claudication 2° to [Peripheral Artery Disease]
Dx test? Describe the test
ABI (Ankle Brachial Index) = inexpensive/noninvasive measurement of systolic BP Ankle:Brachial
[Peripheral Artery Dz] < [0.90 - 1.3] < [Calcified Vessels]
Alternative is Arterial Duplex US but this is less specific & sensitive
Clinical presentation for [Paralytic iLeus] (4)
[Abd pain following trauma or abd surgery]
+
[Xray with Dilated loops of STOMACH, SMALL & LARGE intestine]
+
[hypOactive bowel sounds]
+
Obstipation (can’t pass flatus/stool)
Acute Mediastinitis
MOD -2
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cp -2
[cardiothoracic SSI] vs [Retropharyngeal Abscess spread] ➜
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- [purulent sternal wound drainage]
- [widened mediastinum]
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SSI = Surgical Site Infection
Tx for Acute Mediastinitis (3)
- Broad Abx
- [I&D]
- Debridement
Mngmt for [Gallstones without sx]
NOTHING
Mngmt for [Gallstones with biliary colic] (2)
[Elective Lap Chole] vs. [UrsoDeoxycholic acid in poor surgical candidates]
Mngmt for Complicated Gallstones (Acute cholecystitis vs. CholeDocholithiasis vs. Gallstone pancreatitis)
Cholecystectomy within 72 hours!
Acute Cholecystitis = inflammation & distension of gallbladder from [cystic duct obstruction]
MCL tear
Dx?
________________
Tx -2
MRI (surgical candidates only)
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Surgery vs. [RICE in uncomplicated MCL tears]
Both Hemothroax and Tension PTX produce hypOtension, tachycardia and tracheal deviation.
What’s the difference in Physical Exam?
Hemithorax = DULLNESS to percussion
vs.
Tension PTX = HYPERRESONANCE TO Percussion
[Aortic injury 2/2 to rapid deceleration]
Dx(2)
________________
Mngmt(3)
Dx = [Upright CXR showing (widened mediastinum/hemothorax/interrupted aortic contour)] ➜ [CT confirmation]
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Mngmt = [ABC] –> AntiHypertensives –> Surgery
[Diaphragmatic Hernia] MOD
INC intraabd pressure from Blunt Abd trauma causes radial tears in diaphragm muscle –> leakage of abd contents into LEFT chest (R protected by Liver) –>Lung compression & bowel strangulation –> FAST DEATH
Image showing NG tube in the upper chest
Tx = Surgical Repair
Umbilica hernia is most commonly associated with (⬜4)
________________
Umbilical hernias may contain ⬜ or ⬜
Blacks
Prematurity
[Beckwith Widemann]
hypOthyroidism
**Umbilical hernias may contain omentum vs. small intestine**
Pt with Fever [100 F ( >38 C)].
Causes if it happens 0 - 2 Hours PostOp (4)
Pt with Fever [100 F ( >38 C)].
Causes if it happens 1 Day - 1 Week PostOp (3)
Pt with Fever [100 F ( >38 C)].
Causes if it happens 1 Week - 1 Month PostOp (5)
Pt with Fever [100 F ( >38 C)].
Causes if it happens More than 1 month PostOp (2)
Syringomyelia etx
[Whiplash Spinal Cord Injury] vs. [Arnold Chiari Malformation] –> disrupted CSF drainage in central canal –> compression of STT and CST
[Pulmonary Contusion] is ⬜ of the lung that occurs within ⬜ days of injury
Parenchymal bruising
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1-2
How is Epidural Hematoma (think blunt head trauma) associated with Cushing’s Reflex?
Epi Hematoma –> INC elevated ICP –(can)–> [TUMTL herniation (COPPR)] & [Cushing’s Reflex]!
Cushing’s Reflex = HBO (HTN / Bradycardia / slOw breathing) and indicates INC ICP
All trauma pts should receive ⬜ stability and ⬜ immobility until ⬜ injury has been ruled out
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List Trauma Mgmt in order (4)
[ABC cardiopulm]; spine; spinal cord injury
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1st: [ABC/FAST]
2nd: SPINE IMMOBILITY
3rd: [Bladder protection (urinary catheter for urinary retention/bladder injury)]
4th: spine imaging
Dumping Syndrome MOD
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Dumping Syndrome Sx(5)
rapid emptying of hypertonic stomach contents into Duodenum & small intestine (usually after gastrectomy or RYGB) –> DDUMP
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Diarrhea
Diaphoresis
[Umbilical ABD Pain]
M (N)ausea
Palpitations
worst after eating and better at night
Pt with Blunt Abd Trauma shows spleen hemorrhage on FAST but is hemodynamically stable: Next 2 steps?
[CT Abdomen w/contrast] –> Repair spleen –> Remove if necessary with immunization against encapsulated bacteria
If pt responds to fluids (SBP > 100) and doesn’t require blood
Definition of Shock
Any state that causes perfusion inadquate to meet O2 and nutritional demands of tissue
An elevated [Pulmonary Capillary Wedge Pressure] following MVA suggest what diagnosis?
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How do you confirm this?
Myocardial Contusion
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Giving Saline will worsen PCWP but not change systemic BP
damage to L Vt during MVA –> INC intracardiac filling pressures
During a Tension PTX, what 2 anatomic sites are best for needle thoracostomy?
1st: [MidClavicular 2nd ICS (InterCostal Space)]
2nd: [MidAxillary 5th ICS]
Which part of the airway is usually perforated during blunt thoracic trauma
R Main Bronchus
Tracheobronchial perforation
What is a [Marjolin Ulcer]
SQC arising within a Burn wound
Note: SQC arising within chronic skin wounds are more aggressive!
How does shallow breathing and weak cough contribute to PostOp (POD2-5) atelectasis?
shallow breathing –> DEC alveoli recruitment at lung bases
weak cough –> INC small airway mucus plugs
Which pts are most at risk for [Acute S.Aureus Parotiditis]?(2)
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How do you prevent this(2)?
[Dehydrated PostOp pts] & Elderly
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[Fluid Hydration] & [Oral Hygiene]
Name the Rotator Cuff Muscles (4). List each of their function.
Supraspinatus(most commonly injured) = initiates Arm ABduction
Describe the “Empty-Can” test and which muscle it test for?
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What is the [Drop arm sign]?
[ABduction of arm] + [30°flexion of arm forward] + [thumbs pointed toward floor] –> Pain = [Supraspinatus Rotator cuff injury]
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Arm passively ABducted passed 90° that drops when released = no ADDuction which = Rototar cuff injury
Describe [Popeye sign] and what causes it?
[Bicep m. belly] pops up out of mid upper arm; [Bicep long head tendon rupture]
Classic sx of [Pancreatic ADC] (5)
Fat Guys Can Smell Terribly
- [Gnawing Epigastric pain-worst at night-not relieved w/AntiAcids or food]
- **[Courvoisier Palpable Gallbladder w/Painless Jaundice]**
- FFAW CA signs (Fever, Fatigue, Anorexia, Weakness)
- [Trousseau Migratory Thrombophlebitis]
- Steatorrhea
After arterial catheterization how long should you stay vigilant for hematoma formation?
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Which vascular site is highest risk?
12 hours
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Arterial puncture site above inguinal ligament –> retroperitoneal hematoma
Retroperitoneal Hematoma/Hemorrhage
Dx?
Tx?
Dx = [CT Abd/Pelvis]
Tx = [Fluid & Blood Resuscitation]
Describe how [Anterior Shoulder Dislocation] occurs?
________________
What neurovasucular bundle does it damage?
[Forceful ABduction + External Rotation] @ Glenohumeral joint –>
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[Axillary n. and artery] damage
[AMBIC - Acute Mesenteric Bowel ischemic colitis]
Sx (5)
- POOP periumbilical
- Bloody Diarrhea
- Rebound
- Guarding
- [NV ➜ hypOkalemia]
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- POOP = Pain Out Of Proportion*
- CT revealing air & edema in bowel wall–>thickening = MBIC*
[Pancreatic Retroperitoenal abscess] MOD
Blunt abd trauma compresses [Pancreas neck vs. body] against vertebral column –> contusion –>
devitalized tissue ➜ [pancreatic pseudocyst] ➜ [pancreatic retroperitoneal abscess] ➜ DEATH (if not diagnosed)
Explain why appendicitis pts have periumbilical pain that radiates to RLQ and then LLQ TTP
[Appendiceal wall stretching = periumbilical pain] and when [periTOneum becomes inflammaed = RLQ radiation].
[Rovsing sign = LLQ TTP can also occur]
GCS(Glasgow Coma Scale) predicts Prognosis of what 4 things?
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The 3 components are EVM (Eyes/Verbal/Motor)
Describe the [Motor] component (6)
- GCS prognosis’* Brain CHIT
1. Coma
2. Hemorrhage (SAH)
3. Infection (bacterial meningitis)
4. Trauma
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EVM = Eyes / Verbal / Motor
GCS(Glasgow Coma Scale) predicts Prognosis of what 4 things?
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The 3 components are EVM (Eyes/Verbal/Motor)
Describe the [Eyes] component (4)
- GCS prognosis’* Brain CHIT
1. Coma
2. Hemorrhage (SAH)
3. Infection (bacterial meningitis)
4. Trauma
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EVM = Eyes / Verbal / Motor
GCS(Glasgow Coma Scale) predicts Prognosis of what 4 things?
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The 3 components are EVM (Eyes/Verbal/Motor)
Describe the [Verbal Response] component (5)
- GCS prognosis’* Brain CHIT
1. Coma
2. Hemorrhage (SAH)
3. Infection (bacterial meningitis)
4. Trauma
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EVM = Eyes / Verbal / Motor
DDx for Anterior Mediastinal Mass (4)
4 T’s
[Teratoma Germ cell tumor (Seminomatous vs. NonSeminomatous)]
Thymoma
Thyroid CA
Terrible lymphoma
Diagnosis?
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Composition?
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Complications (5)?
Pancreatic Pseudocyst
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Walled off [amylase-rich fluid] surrounded by a fibrous capsule –->
[Infection / [Biliary obstruction] / [Psuedoaneurysm (digestion of adjacent vessels)] / ascities / [Pleural Effusion]
Mngmt (2)
Pancreatic Pseudocyst
[Embolize pseudoaneurysm if present] –> [Endoscopic drainage of Pancreatic Pseudocyst]
How is an [abd succussion splash] performed? What does it indicate?
With stethoscope over upper Abd, pt is rocked back and forth at hips –> [meals in stomach > 3 hours] make “splash” sound
=
Gastric Outlet Obstruction
Diagnosis?
________________
Complications?
Image shows L arm
[Supracondylar Humeral FOOSA] fracture –>
Entrapement of Brachial A. or Median Nerve
Initial mngmt of Burn pts is similar to Truama in that ABC is done first
Why is this(2)? What are the 2 options?
Supraglottic airway is susceptible to direct thermal injury and obstruction by edema or blistering;
Use NonRebreather Mask –> [Intubation if PE shows thermal damage to airway(Face burns/Oropharyngeal blisters/GOE 10% CarboxyHgB/Eye Singing)]
Mngmt for suspected [Scaphoid fracture] (2).
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What should be used if you need immediate diagnosis(2)?
< [Wrist immobilization with thumb spica cast x 7-10 days] –> [Repeat X-Rays] >
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Use CT or MRI for immediate diagnosis
DO THIS EVEN IF INITIAL X-RAY IS NEGATIVE. CAN TAKE UP TO 10 DAYS FOR ABNORMALITIES TO SHOW!
WHERE do Stress fractures occur in pts involved in…
A: Jumping sports
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B: Runners
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What are the X-ray findings?
A: Jumping sports = [TIBIA Anterior middle third]
B: Runners = [TIBIA Posteromedial Distal third]
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X-rays = normal initially!
In regards to sx presentation, what is difference between Arterial Embolism and Thrombosis?
Arterial Embolism = Abrupt Pain
vs.
Arterial Thrombosis = [insidious gradual pain] from progressive narrowing of vascular lumen
SIRS (Systemic Inflammatory Repsonse Syndrome) is defined as ⬜ cause (vs. Sepsis which is an ⬜ cause)
of ⬜
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List Criteria for SIRS
[SIRS = NONinfectious] vs. [Sepsis = Infectious] cause of massive proinflammatory release –> extensive tissue damage
Common causes of SIRS (4).
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How is this related to Sepsis?
[BVAP: Burns / Vasculitis / Autoimmune / Pancreatitis] –> SIRS
–(can lead to) —> [Concomitant infection] = Sepsis
How is AAA Repair of the ____ region related to [Anterior Spinal Cord Syndrome]
Thoracic AAA Repair –> [⬇︎Adamkiewicz radicular artery flow] –> [⬇︎ ANT Spinal Artery flow] —> [infarction of CST and STT areas]
Sx of [Leriche Syndrome] (3)
Arterial Dz –> “Leriche was in the CIA!”
- [Claudication bilaterally of Hip, Butt, Thigh]
- *** Impotence **** (Key sign)
- Atrophy bilaterally of LE
[Leriche Syndrome] MOD
“Leriche was in the CIA”
Arterial Dz (from smoking, atherosclerosis) –>Occlusion at Bifurcation of Aorta into the common iLiac arteries –> CIA
Causes of Compartment Syndrome (3)
- Trauma
- [Prolonged Compression]
- [REVASCULARIZATION OF ISCHEMIC LIMB (Fx with closed reduction)]
➜
[⬆︎ swelling pressure] ➜ [⬇︎ venous blood flow] and eventually [⬇︎ arterial blood flow]
What’s the most important prognostic indicator for Compartment Syndrome
Time it takes to do a Fasciotomy
Compartment Syndrome Sx (6)
The 6 P’s!
- POOP (Pain Out Of Proportion)
- [Paresthesia - EARLY finding]
- [Pulselessness - LATE finding]
- Pallor
- Poikilothermia (inability to regulate body temp)
- Paralysis
Tears of the [⬜ meniscus] are more common than tears of the [⬜ meniscus]
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What causes meniscus tears?
MEDIAL meniscus > lateral meniscus
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Twisting force against a fixed foot –> popping sound followed by acute pain
What’s the Initial test for diagnosing Meniscus tears (2)?
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How do you confirm this? -2
Initial test = [McMurray (palpable locking/catching when joint is rotated)] vs. [Thessaly]
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Confirmatory = MRI vs. arthroscopy
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etx: Twisting force against a fixed foot –> popping sound followed by acute pain
3 common signs of [Blunt Aortic injury]?
________________
What are 2 major causes?
________________
Initial dx?
Tachycardia / HTN / [CXR Widened Mediastinum]
________________
MVA vs. (Falls > 10 ft.)
________________
CXR = Initial screening
Describe [Torus Palatinus]
Congenital benign NonTender bony growth on midline of hard palate that can INC throughout life and ulcerate w/trauma
Adrenal Gland crisis Tx (2)
[Hydrocortisone IV vs. Dexamethasone IV]
+
IVF
Adrenal Crisis = Loss of Adrenal gland function
Pts taking Prednisone ≥ ⬜ mg/day are at risk for Adrenal Gland crisis
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How is this related to “Stress Doses”?
≥ 20mg/day prednisone –> Adrenal Gland Crisis
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Give these pts Stress Doses of [Glucocorticoid CTS] during an acute stressor (i.e. surgery) since they won’t have functioning Adrenal Glands
Name the 1ST MOST COMMON peripheral artery aneurysm
________________
2nd most common?
1ST MOST COMMON = POPLITEAL
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2nd = Femoral (may compress Femoral n. –> Thigh claudication)
Pelvis fractures are often associated with ⬜ urethral injury
________________
What are the sx(3)?
Posterior (prostatic and membranous)
________________
- Urethral meatus Bleeding
- High riding prostate (prostate displacement by pelvic hematoma)
- Scrotal Hematoma
In Clavicle fractures the shoulder is displaced ⬜ and ⬜
________________
Why should a careful neurovasulcar exam be done?
Inferiorly and Posteriorly (pushed down and back)
________________
Clavicle is very close to Subclavian a. and Brachial plexus
What 2 injuries cause Clavicle fractures?
FOOSA vs. Directly Shoulder blow
[(AMBIC) Acute Mesenteric Bowel ischemic colitis]
Labs (4)
- AMBIC* ⇪ WAHL products!
1. WBC ⇪
2. Amylase ⇪
3. Hgb ⇪
4. [LACTASE ⇪ ➜ metabolic acidosis]
________________
CT revealing air & edema in bowel wall –> thickening = MBIC
s/p rhinoplasty, Pt now has a new whistling noise during respiration
Diagnosis?
[Septal perforation] 2/2 septal hematoma
Tx for Metatarsal Stress Fracture (2)
Demographic(2)?
Rest + Analgesics
Athletes & Military
Terminal Hematuria (blood at end of peeing) suggest bleeding from where(3)?
[Bladder Neck/Trigone]
Prostate
[Posterior Urethra (prostatic urethra & membranous urethra)]
Initial Hematuria (bleeding at beginning of peeing) suggest what?
Urethral damage
Total Hematuria (blood all throughout peeing) suggest damge to what(2)?
Kidneys vs. Ureters
Which 2 organs are most frequently injured during Blunt Abdominal Trauma?
Spleen and Liver
BE ON THE LOOK OUT FOR SPLENIC LACERATIONS!!
In a pt with any Urethral injury, what’s first step in mngmt?
Assess and determine damage with Retrograde Urethrogram
Contrast retrogradely injected into urethra
Diagnosis? Explain findings (3)
Diaphragmatic Hernia
[L lower lobe opacity] + [Elevated Hemidiaphragm] + [Mediastinal shift]
Confirmed via CT Abd
Mngmt for [Small PTX in clinically stable pt]
[supplemental O2 (⇪ resorption)]
Mngmt for [LARGE PTX in clinically stable pt]
Large bore (14 - 18 gauge) needle thoracostomy