✅Surgery Flashcards
1
Q
1st and 2nd steps for treating acute variceal bleeding
A
1st: 2 Large bore IV needles vs. central line for IVF
2nd: Endoscopic sclerotherapy vs. band ligation
2
Q
Postop Cholestasis develops after surgerys that involve ⬜, ⬜ and ⬜ .
________________
Why is this?(3)
A
hypOtension | [massive blood loss] | [massive blood transfusion]
________________
- hypOtension ➜ [⬇︎ Liver function] ➜ [⬇︎bilirubin excretion]
- [massive blood loss] ➜ [renal ischemic tubular necrosis] ➜ [⬇︎ bilirubin urine excretion]
- [massive blood transfusion] ➜ [⬆︎ pigment load] ➜ [⬆︎ bilirubin to excrete]
3
Q
Surgical repair for hip fractures may be delayed up to ⬜ hours.
________________
Why?
A
72 hours
________________
address unstable medical comorbidity first
4
Q
How does SBO present (3)?
________________
What’s most common cause?
A
- [NV –> hypOkalemia]
- [Bloating - Hyperactive “tinkling” Bowel Sounds]
- [Dilated Bowel Loops X-ray]
________________
Adhesions! (operations)
5
Q
Etx for [Isolated Duodenal Hematoma] occur?
________________
1st line tx? -2
________________
2nd line tx?
A
[Abd trauma to children]–>blood between mucosa and submucosa –> resolves spontaneously in 1-2 weeks
________________
Tx =
1st: [NG suction + Parenteral nutrition]
2nd: [Laparascopic hematoma removal]
6
Q
Describe Varicoceles
________________
Etiology?
A
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
7
Q
[Retropharyngeal Abscess] presentation (5)
Why does this have to be treated STAT?
A
Odynophagia / [Painful Neck Extension] / Fever / Sore throat / [Trismus (inability to open mouth)]
Abscess infection may spread into mediastinum!
8
Q
[Retropharyngeal Abscess]
Dx -2
________________
Tx -2
A
Dx = CT neck vs. Lateral Radiographs–>Demonstrates cervical spine Lordosis
________________
Tx = [Abx IV] + [I&D]
9
Q
Complications of SBO (2)?
Management (2)
A
Strangulation vs. Perforation
Mgmt = [Surgical Exploration] vs. [NPO & IVF –> NG tube suction]
10
Q
Diverticulitis Abscess Tx
A
CT guided-percutaneous (alternative surgical) abscess I&D
Diverticulitis = Soft tissue stranding & colonic wall thickening
11
Q
INR for normal people
A
0.8 - 1.2
12
Q
Therapeutic INR range for pts on warfarin
A
2 - 3
13
Q
Acute GI perforation requires emergent _____
A
Laparotomy (surgical incision thru abd wall)
14
Q
MOD of [AMBIC- Acute Mesenteric Bowel ischemic colitis] post AAA repair
A
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
15
Q
Step-wise process for [Blunt Abd Trauma in hemodynamically unstable pts]. Any Caveat?
A
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)
16
Q
Staph Aureus and Staph Epidermidis both affect prosthetic joints. What is the difference?
A
[Staph Aureus = Acute ( < 3 mo. onset)] & may only require debridement
[Staph Epidermidis] = Delayed > 3 mo. onset and must be replaced
17
Q
PrePatellar bursitis is often due to ⬜, but other causes include ⬜ or ⬜
A
S.Aureus (infects bursa via extension of local cellulitis after trauma)
________________
[Gout Crystalline Arthropathy] / [Rheumatoid Arthritis]
18
Q
CT scan shows ⬜ which indicates what diagnosis?
________________
. What causes this?
________________
Tx(2)?
A
[air in DEEP tissue]; Necrotizing Fasciitis
________________
[Polymicrobial > GASP] spreads rapidly thru SubQ & deep fascia after minor trauma –>
PAIN OUT OF PROPORTION WITH EXAM
________________
Tx = Debridement + Broad Abx
19
Q
What is the first sign of hypOvolemia
A
INC HR
20
Q
Massive Hemoptysis is defined as ⬜ or ⬜ . The greatest danger with this is ⬜ .
A
[>600 mL expectorated blood over 24 hours] vs. [Bleeding > 100 mL/hour] –> Asphyxiation from blood in airway
21
Q
What is the management for [Massive Hemoptysis] -4
A
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
________________
[>600 mL expectorated blood over 24 hours] vs. [Bleeding > 100 mL/hour]
22
Q
On which PostOp Day is atelectasis most common? Explain how this causes Respiratory Alkalosis
A
POD2! ; PostOp pain vs. Residual anesthesia vs. tongue prolapse —> hypOxemia and INC work of breathing –> Hyperventilation —> Respiratory Alkalosis
Acute PE may present similarly
23
Q
Femoral n. Function (2)
A
[Hip flexion]
[Knee extension]
24
Q
Femoral n. innervation (2)
A
[ANT thigh] & [Medial leg via saphenous branch]
25
Obturator n. function
Thigh ADDuction
26
Obturator n. innervation
medial thigh
27
[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
28
Flail Chest presentation (3)
Pt with recently fractured ribs who has..
1. **paradoxic thoracic wall movements** (inverted chest wall w/inspiration, correted when on positive pressure)
2. [shallow tachypneic breathing]
3. Respiratory distress **despite chest tubes**
29
A pt with pneumobilia, [hyperactive bowel sounds] and Dilated loops of the bowel probably has ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Cholecystitis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dx = CT
Tx = Surgery
30
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]
31
*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*
32
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)
33
Acute Mediastinitis
MOD -2
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
cp -2
[cardiothoracic SSI] vs [Retropharyngeal Abscess spread] ➜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. [purulent sternal wound drainage]
2. [widened mediastinum]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*SSI = Surgical Site Infection*
34
Tx for Acute Mediastinitis (3)
1. Broad Abx
2. [I&D]
3. Debridement
35
Mngmt for [Gallstones **without** sx]
NOTHING
36
Mngmt for [Gallstones with biliary colic] (2)
[Elective Lap Chole] vs. [UrsoDeoxycholic acid in poor surgical candidates]
37
Mngmt for **Complicated** Gallstones (Acute cholecystitis vs. CholeDocholithiasis vs. Gallstone pancreatitis)
Cholecystectomy within 72 hours!
## Footnote
*Acute Cholecystitis = inflammation & distension of gallbladder from [cystic duct obstruction]*
38
MCL tear
Dx?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx -2
MRI (surgical candidates only)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Surgery vs. [RICE in uncomplicated MCL tears]
39
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
40
[Aortic injury 2/2 to rapid deceleration]
Dx(2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Mngmt(3)
Dx = [**Upright CXR** showing (widened mediastinum/hemothorax/interrupted aortic contour)] ➜ [**CT** confirmation]
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
Mngmt = [ABC] --\> AntiHypertensives --\> Surgery
41
[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
42
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**\*\*
43
Pt with Fever [100 F ( \>38 C)].
Causes if it happens **0 - 2 Hours** PostOp (4)
44
Pt with Fever [100 F ( \>38 C)].
Causes if it happens **1 Day - 1 Week** PostOp (3)
45
Pt with Fever [100 F ( \>38 C)].
Causes if it happens **1 Week - 1 Month** PostOp (5)
46
Pt with Fever [100 F ( \>38 C)].
Causes if it happens **More than 1 month** PostOp (2)
47
Syringomyelia etx
[**Whiplash** **Spinal Cord Injury**] vs. [Arnold Chiari Malformation] --\> disrupted CSF drainage in central canal --\> compression of STT and CST
48
[Pulmonary Contusion] is ⬜ of the lung that occurs within ⬜ days of injury
Parenchymal bruising
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**1-2**
49
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]!
## Footnote
*Cushing's Reflex = **HBO** (**H**TN / **B**radycardia / sl**O**w breathing) and indicates INC ICP*
50
All trauma pts should receive ⬜ stability and ⬜ immobility until ⬜ injury has been ruled out
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
List Trauma Mgmt in order (4)
[ABC cardiopulm]; spine; spinal cord injury
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1st: [ABC/FAST]
2nd: SPINE IMMOBILITY
3rd: [Bladder protection (urinary catheter for urinary retention/bladder injury)]
4th: spine imaging
51
Dumping Syndrome MOD
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dumping Syndrome Sx(5)
rapid emptying of **hyper**tonic stomach contents into Duodenum & small intestine (usually after gastrectomy or RYGB) --\> **DDUMP**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
**D**iarrhea
**D**iaphoresis
[**U**mbilical ABD Pain]
**M** (N)ausea
**P**alpitations
*worst after eating and better at night*
52
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
## Footnote
*If pt responds to fluids (SBP \> 100) and doesn't require blood*
53
Definition of Shock
Any state that causes perfusion inadquate to meet O2 and nutritional demands of tissue
54
An elevated [**P**ulmonary **C**apillary **W**edge **P**ressure] following MVA suggest what diagnosis?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you confirm this?
Myocardial Contusion
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Giving Saline will worsen PCWP but not change systemic BP
*damage to L Vt during MVA --\> INC intracardiac filling pressures*
55
During a Tension PTX, what 2 anatomic sites are best for needle thoracostomy?
1st: [MidClavicular 2nd ICS (InterCostal Space)]
2nd: [MidAxillary 5th ICS]
56
Which part of the airway is usually perforated during blunt thoracic trauma
R Main Bronchus
## Footnote
*Tracheobronchial perforation*
57
What is a [Marjolin Ulcer]
SQC arising within a Burn wound
## Footnote
*Note: SQC arising within chronic skin wounds are more aggressive!*
58
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
59
Which pts are most at risk for [Acute S.Aureus Parotiditis]?(2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you prevent this(2)?
[Dehydrated PostOp pts] & Elderly
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Fluid Hydration] & [Oral Hygiene]
60
Name the Rotator Cuff Muscles (4). List each of their function.
Supraspinatus(**most commonly injured**) = initiates Arm ABduction
61
Describe the "Empty-Can" test and which muscle it test for?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What is the [Drop arm sign]?
[ABduction of arm] + [30°flexion of arm forward] + [thumbs pointed toward floor] --\> Pain = [**Supraspinatus** Rotator cuff injury]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Arm passively ABducted passed 90° that drops when released = no ADDuction which = Rototar cuff injury
62
Describe [Popeye sign] and what causes it?
[Bicep m. belly] *pops* up out of mid upper arm; [Bicep long head tendon rupture]
63
Classic sx of [Pancreatic ADC] (5)
**F**at **G**uys **C**an **S**mell **T**erribly
1. [**Gnawing** Epigastric pain-worst at night-not relieved w/AntiAcids or food]
2. \*\*[**C**ourvoisier Palpable Gallbladder w/Painless Jaundice]\*\*
3. **FFAW** CA signs (**F**ever, **F**atigue, **A**norexia, **W**eakness)
4. [**T**rousseau Migratory Thrombophlebitis]
5. **S**teatorrhea
64
After arterial catheterization how long should you stay vigilant for hematoma formation?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Which vascular site is highest risk?
12 hours
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Arterial puncture site above inguinal ligament --\> retroperitoneal hematoma
65
Retroperitoneal Hematoma/Hemorrhage
Dx?
Tx?
Dx = [CT **Abd/Pelvis**]
Tx = [Fluid & Blood Resuscitation]
66
Describe how [Anterior Shoulder Dislocation] occurs?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What neurovasucular bundle does it damage?
[Forceful ABduction + External Rotation] @ Glenohumeral joint --\>
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
[Axillary n. and artery] damage
67
[AMBIC - Acute Mesenteric Bowel ischemic colitis]
Sx (5)
1. **POOP** periumbilical
2. Bloody Diarrhea
3. Rebound
4. Guarding
5. [NV ➜ hypOkalemia]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
* POOP = Pain Out Of Proportion*
* CT revealing air & edema in bowel wall--\>thickening = MBIC*
68
[Pancreatic Retroperitoenal abscess] MOD
Blunt abd trauma compresses [Pancreas neck vs. body] against vertebral column --\> contusion --\>
## Footnote
**devitalized tissue ➜** [pancreatic pseudocyst] ➜ [pancreatic retroperitoneal abscess] ➜ DEATH (if not diagnosed)
69
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]
70
**GCS**(**G**lasgow **C**oma **S**cale) predicts Prognosis of what 4 things?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
The 3 components are **EVM** (**E**yes/**V**erbal/**M**otor)
Describe the [**M**otor] component (6)
* GCS prognosis'* *Brain **CHIT***
1. **C**oma
2. **H**emorrhage (SAH)
3. **I**nfection (bacterial meningitis)
4. **T**rauma
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**EVM** = **E**yes / **V**erbal / **M**otor
71
**GCS**(**G**lasgow **C**oma **S**cale) predicts Prognosis of what 4 things?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
The 3 components are **EVM** (**E**yes/**V**erbal/**M**otor)
Describe the [**E**yes] component (4)
* GCS prognosis'* *Brain **CHIT***
1. **C**oma
2. **H**emorrhage (SAH)
3. **I**nfection (bacterial meningitis)
4. **T**rauma
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**EVM** = **E**yes / **V**erbal / **M**otor
72
**GCS**(**G**lasgow **C**oma **S**cale) predicts Prognosis of what 4 things?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
The 3 components are **EVM** (**E**yes/**V**erbal/**M**otor)
Describe the [**V**erbal Response] component (5)
* GCS prognosis'* *Brain **CHIT***
1. **C**oma
2. **H**emorrhage (SAH)
3. **I**nfection (bacterial meningitis)
4. **T**rauma
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
**EVM** = **E**yes / **V**erbal / **M**otor
73
DDx for Anterior Mediastinal Mass (4)
4 T's
## Footnote
[**T**eratoma Germ cell tumor (Seminomatous vs. NonSeminomatous)]
**T**hymoma
**T**hyroid CA
**T**errible lymphoma
74
Diagnosis?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Composition?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Complications (5)?
Pancreatic Pseudocyst
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Walled off [amylase-rich fluid] surrounded by a fibrous **capsule --**-\>
[Infection / [Biliary obstruction] / [Psuedoaneurysm (digestion of adjacent vessels)] / ascities / [Pleural Effusion]
75
Mngmt (2)
Pancreatic Pseudocyst
[Embolize pseudoaneurysm if present] --\> [Endoscopic drainage of Pancreatic Pseudocyst]
76
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
77
Diagnosis?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Complications?
*Image shows L arm*
[Supracondylar Humeral FOOSA] fracture --\>
Entrapement of **Brachial A.** or **Median Nerve**
78
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)]
79
Mngmt for suspected [Scaphoid fracture] (2).
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What should be used if you need immediate diagnosis(2)?
\< [Wrist immobilization with thumb spica cast x 7-10 days] --\> [Repeat X-Rays] \>
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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!***
80
WHERE do Stress fractures occur in pts involved in...
A: Jumping sports
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
B: Runners
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the X-ray findings?
A: Jumping sports = [**TIBIA** Anterior middle third]
B: Runners = [**TIBIA** Posteromedial Distal third]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
X-rays = normal initially!
81
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
82
**SIRS** (Systemic Inflammatory Repsonse Syndrome) is defined as ⬜ cause (vs. Sepsis which is an ⬜ cause)
of ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
List Criteria for SIRS
[SIRS = **NONinfectious**] vs. [Sepsis = **Infectious**] cause of massive proinflammatory release --\> extensive tissue damage
83
Common causes of SIRS (4).
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is this related to Sepsis?
[**BVAP**: **B**urns / **V**asculitis / **A**utoimmune / **P**ancreatitis] --\> SIRS
--(can lead to) ---\> [Concomitant infection] = Sepsis
84
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]
85
Sx of [Leriche Syndrome] (3)
Arterial Dz --\> "Leriche was in the **CIA**!"
1. [**C**laudication bilaterally of Hip, Butt, Thigh]
2. \*\*\* **I**mpotence \*\*\*\* (Key sign)
3. **A**trophy bilaterally of LE
86
[Leriche Syndrome] MOD
"Leriche was in the **CIA**"
Arterial Dz (from smoking, atherosclerosis) --\>Occlusion at Bifurcation of Aorta into the common iLiac arteries --\> **CIA**
87
Causes of Compartment Syndrome (3)
1. Trauma
2. [Prolonged Compression]
3. [**REVASCULARIZATION OF ISCHEMIC LIMB** (Fx with closed reduction)]
➜
[⬆︎ swelling pressure] ➜ [⬇︎ venous blood flow] and eventually [⬇︎ arterial blood flow]
88
What's the most important prognostic indicator for Compartment Syndrome
Time it takes to do a Fasciotomy
89
Compartment Syndrome Sx (6)
The 6 **P**'s!
1. **P**OOP (*Pain Out Of Proportion*)
2. [**P**aresthesia - EARLY finding]
3. [**P**ulselessness - LATE finding]
4. **P**allor
5. **P**oikilothermia *(inability to regulate body temp)*
6. **P**aralysis
90
Tears of the [⬜ meniscus] are more common than tears of the [⬜ meniscus]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What causes meniscus tears?
MEDIAL meniscus \> lateral meniscus
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Twisting force against a fixed foot --\> **popping sound followed by acute pain**
91
What's the Initial test for diagnosing Meniscus tears (2)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How do you confirm this? -2
Initial test = [McMurray (palpable locking/catching when joint is rotated)] vs. [Thessaly]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Confirmatory = MRI vs. arthroscopy
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*etx: Twisting force against a fixed foot --\> popping sound followed by acute pain*
92
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
93
Describe [Torus Palatinus]
Congenital benign **NonTender** bony growth on midline of hard palate that can INC throughout life and ulcerate w/trauma
94
Adrenal Gland crisis Tx (2)
[Hydrocortisone IV vs. Dexamethasone IV]
+
IVF
*Adrenal Crisis = Loss of Adrenal gland function*
95
Pts taking Prednisone[ ≥ ⬜ mg/day] or taking Prednisone [ > ⬜ weeks] are at risk for Adrenal Gland crisis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How is this related to "Stress Doses"?
≥ [**20**mg/day prednisone] ; [ > **3** weeks] --\> Adrenal Gland Crisis
## Footnote
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Give these pts Stress Doses of [Glucocorticoid CTS] during an acute stressor (i.e. surgery) since they won't have functioning Adrenal Glands
96
Name the **1ST MOST COMMON** peripheral artery aneurysm
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2nd most common?
**1ST MOST COMMON = POPLITEAL**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
2nd = Femoral (may compress Femoral n. --\> Thigh claudication)
97
Pelvis fractures are often associated with ⬜ urethral injury
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
What are the sx(3)?
**Posterior (prostatic and membranous)**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
1. Urethral meatus Bleeding
2. High riding prostate (prostate displacement by pelvic hematoma)
3. Scrotal Hematoma
98
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**
99
What 2 injuries cause Clavicle fractures?
FOOSA vs. Directly Shoulder blow
100
[(AMBIC) Acute Mesenteric Bowel ischemic colitis]
Labs (4)
* AMBIC* ⇪ **WAHL** *products!*
1. **W**BC ⇪
2. **A**mylase ⇪
3. **H**gb ⇪
4. [**L**ACTASE ⇪ ➜ metabolic acidosis]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*CT revealing air & edema in bowel wall --\> thickening = MBIC*
101
s/p rhinoplasty, Pt now has a new whistling noise during respiration
Diagnosis?
[Septal perforation] 2/2 septal hematoma
102
Tx for Metatarsal Stress Fracture (2)
Demographic(2)?
Rest + Analgesics
Athletes & Military
103
Terminal Hematuria (blood at end of peeing) suggest bleeding from where(3)?
[Bladder Neck/Trigone]
Prostate
[Posterior Urethra (prostatic urethra & membranous urethra)]
104
Initial Hematuria (bleeding at beginning of peeing) suggest what?
Urethral damage
105
Total Hematuria (blood all throughout peeing) suggest damge to what(2)?
Kidneys vs. Ureters
106
Which 2 organs are most frequently injured during Blunt **Abdominal** Trauma?
**Spleen** and Liver
## Footnote
*BE ON THE LOOK OUT FOR SPLENIC LACERATIONS!!*
107
In a pt with **any** Urethral injury, what's first step in mngmt?
Assess and determine damage with **Retrograde Urethrogram**
## Footnote
*Contrast retrogradely injected into urethra*
108
Diagnosis? Explain findings (3)
Diaphragmatic Hernia
[L lower lobe opacity] + [Elevated Hemidiaphragm] + [Mediastinal shift]
**Confirmed via CT Abd**
109
Mngmt for [Small PTX in clinically stable pt]
[supplemental O2 (⇪ resorption)]
110
Mngmt for [LARGE PTX in clinically stable pt]
Large bore (14 - 18 gauge) needle thoracostomy
111
Mngmt for [LARGE PTX in clinically UNSTABLE pt]
Chest Tube thoracostomy
112
PostOp PNA can develop ➜ Septic shock which➜ ⬜ that ➜ Lactic Acidosis
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Mngmt (2)?
tissue hypOperfusion
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Abx + IVF
113
5 signs of [Necrotizing Surgical Site]
1. Dishwater Drainage (cloudy gray)
2. SubQ crepitus
3. Systemic signs (fever/hypOtension/tachycardia)
4. Wound edge paresthesia
5. **PAIN out of proportion with PE**
*Develops into Necrotizing Facititis*
114
What's the most important step in managing Necrotizing Surgical Site/Fascitis
Surgical exploration Debridement
115
What part of the bladder can cause Kehr sign?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
why?
Dome of Bladder
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
it's covered by peritoneum and allows leakage of urine into peritoneum--\> Peritonitis--\> Kehr sign since hemidiaphragm undersurface is covered by parietal peritoneum
116
Kehr sign
[**referred** **L SHOULDER PAIN**] from [diaphragm irritation] or [periTOnitis abd pain]
117
Overall lifetime dose of [Tetanus Toxoid vaccine] is ⬜ with a booster every ⬜ years.
[**6** **throughout childhood]**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
[booster **q****10y starting at age** 19]
*This is for USA*
118
Tetanus Px in a pt who has
[≥3 Lifetime Tetanus Toxoid Vaccine (TTV)]
+
[Booster 13 years ago]
+
[Clean minor wound]
TTV with **NO** [**Tetanus Ig**]
119
Tetanus Px in a pt who has
[Uncertain/ LOE 3 Lifetime Tetanus Toxoid Vaccines(TTV)]
+
[Clean minor wound]
TTV with **NO** [**Tetanus Ig**]
120
Tetanus Px in a pt who has
[DIRTY SEVERE WOUND]
+
[≥3 Lifetime TTV (Tetanus Toxoid Vaccine)]
+
[booster 7 years ago]
TTV with **NO** [**Tetanus Ig**]
121
Tetanus Px in a pt who has
[Uncertain/ LOE 3 Lifetime Tetanus Toxoid Vaccines(TTV)]
+
[DIRTY SEVERE WOUND]
TTV + [**Tetanus Ig**]
122
Normal range for Phosphorous
**C1288 N3045**
3.0 - 4.5
123
CRITICAL range for Phosphorous
**C1288 N3045**
1.2 \> x \> 8.8
124
Normal range for Mg
**C1148 N1722**
1.7 - 2.2
125
CRITICAL range for Mg
**C1148 N1722**
1.1 \> x \> 4.8
126
CRITICAL Range for [Total Ca+]
**6 - 13**
6.0 \> x \> 13.0
127
4 signs of hypOcalcemia *( total Ca+ \< 6)*
1. Prolonged QT
2. PeriOral tingling
3. Muscle Cramps
4. Seizures
128
CRITICAL Range for [ionized Ca+]
0.76 \> x \> 1.49
129
Tx for Anal Fissures (7)
[**SNF x 2 +** **L**idocaine]
1. **S**tool softeners
2. **S**itz Baths
3. **N**ifedipine *(relaxes sphincter to ⇪ blood to fissure for healing)*
4. **N**TG *(relaxes sphincter to ⇪ blood to fissure for healing)*
5. **F**luid intake
6. **F**iber
7. **L**idocaine
130
Causes of Anal Fissures (5)
**SNF x 2** w/ **L**idocaine
## Footnote
- Constipation
- Prolonged Diarrhea
- Anal Sex
- Crohn Dz
- CA
131
Penile fracture MOD
Tunica Albuginea (wraps the corpus cavernosum) tears from bending while erect --\> **SNAP** --\>hematoma --\>MORE bending
132
Penile Fracture Mngmt (2)
Retrograde Urethrogram --\> Surgical Repair
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*image:* *RUG of penis fracture*
133
[(AAA) Abdominal Aortic Aneurysm] = Aorta \>⬜ cm at (⬜location)
**3**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
[renal arteries L1-L2]
*RF = Smokers / Men / CAD*
134
Presentation for AAA (4)
1. Back Pain
2. [hypOtension --\> Syncope]
3. [Umbilical Pulsatile Mass]
4. Gross Hematuria *(AAA ruptures into retroperitoneum and creates aortocaval fistula with IVC --\>Venous congestion in retroperitoneal structures --\> vein ruptures)*
135
Psoas Abscess presentation (3)
1. Psoas Sign (Pain with Hip Extension)
2. [RLQ **DEEP** TTP w/radiation to R Groin]
3. Subacute Fever
136
Psoas Abscess Dx
CT Abd/Pelvis
137
Trochanteric Bursitis presents as ⬜ worsened by (⬜3)
[Mid Adult Unilateral Hip Pain]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Pressure / External Rotation / Resisted ABduction
138
Risk Factors for Trochanteric Bursitis -4
Overuse
Trauma
Joint Crystals
Infection
139
Eschar formation can compress blood & lymph circulation --\> distal swelling --\> Compartment Syndrome
When should an Escharotomy be performed?
When compartment pressure is within [25-40 mmHg]
140
Explain why [Positive Pressure Mechanical Ventilation] is relatively contraindicated in hypOvolemic shock pts.
How do we circumvent this?
[PPMV ⇪ intraThoracic pressure] --\> [DEC venous return/preload] --\> circulatory collapse
## Footnote
**Fluid Resuscitate BEFORE PPMV in these pts**
141
Signs of Emphysematous Cholecystitis (6)
1. [Air Fluid gas] in **GallBladder WALL & LUMEN**
2. Crepitus in Abd wall next to GB
3. Fever
4. RUQ pain
5. Leukocytosis
6. NV
*THIS IS LIFE THREATNING!*
142
Causes of Emphysematous Cholecystitis (2)
[Gas-forming [**Clostridium** vs. **E.Coli**]] GB infection
*THIS IS LIFE THREATNING!*
143
Emphysematous Cholecystitis Mngmt (2)
[Ampicillin-Sulbactam] + [Emergent Chole]
*THIS IS LIFE THREATNING!*
144
Emphysematous Cholecystitis RF (4)
1. Gallstone hx
2. DM
3. [cystic artery ischemia]
4. immunosuppressio
*THIS IS LIFE THREATNING!*
145
Earliest sign of HYPERMagnesemia
Loss of Deep Tendon Reflexes
## Footnote
* eventually --\> Resp depression*
* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*
**1148 1722**
146
Why can bypassing or losing the iLeum --\> Kidney stones
Fatty Acids are normally absorbed @ terminal iLeum.
No Terminal iLeum = intestinal Fatty acids combine with Ca+ --\> [⇪ Free Oxaluria absorption] --\>[⇪ retangular (Ca+Oxalate renal stone) excretion]
147
How should you volume replete hypovolemic shock in NON-urban setting?
[2L Lactated Ringer w/NO sugar] ---\> [Packed RBC] until
Urinary Output = [(0.5-2 cc/kg) /hr]
but not exceeding 15 mmHg CVP
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
*Urban setting = Take directly to Trauma Center*
148
What causes [Neurocardiogenic Vasomotor] shock? (2)
1. Spinal Cord Injury
2. Anesthesia
149
**Subdural Hematoma**
Mngmt if midline is deviated?
Mngmt if midline structures are fine?
**Subdural Hematoma**
Craniotomy ONLY if midline is deviated
[Monitor/Prevent further ICP] if no midline deviation(elevate head/hyperventilate/mannitol/furosemide)
150
Key signs of Pulmonary Contusion? (3)
Chest wall bruising
[DEC breath sounds on affected side]
[CXR: Patchy irregular alveolar infiltrate]
151
Pt develops Coagulopathy (*can NOT coagulate*) during prolonged abd surgery for trauma.
Next Step? (2)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When would you terminate the surgery?
[10U Fresh Frozen Plasma 10U] + [10U Platelet Packs]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TERMINATE IF PT DEVELOPS [hypOthermia & acidosis]
152
Gunshot to upper anterolateral thigh away from vessels. 1st step in mngmt? (2)
TTV (Tetanus Toxoid Vaccine) + Wound Cleaning
## Footnote
*Doppler vs. [Spiral CT angio] if near vessels*
153
Why is it important to monitor Peripheral pulses & Cap Refill in Circumferential Burns?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Mngmt?
Circumferential Burns eventually ---\> Eschar which allows underlying edema to cutoff perfusion ➜ compartment syndrome (at \>30 mmHg)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Escharotomy
154
signs of [Developmental Dysplasia of Hip] (2)
Congenital Hip dysplasia --\>
## Footnote
1. Easy Posterior Hip dislocation with a click & then snap when returned
2. Uneven Gluteal Folds
155
[Developmental Dysplasia of Hip] Dx? Tx?
Dx = **US**
Tx = [ABduction splinting with Pavlik harness x 6 mo.]
156
Why is angulation of a fractured bone in kids ok, but not ok in adults?
Kids have **accelerated bone Remodeling** and as long as the fracture is reduced & immobilized, they're fine
157
How are Clavicular fractures managed?
Arm Sling
## Footnote
*Clavicular fractures occur at junction of mid & distal third*
158
Classic presentation for Hip fracture (3)
[**Elderly** **post fall**] with affected Leg being **shortened** and **rotated** (internal vs. external)
159
Tx for Intertrochanteric Fractures (2)
[Open reduction + internal fixation] --\> [PostOp AntiCoags]
160
Tx for Femoral Neck fractures
Replace femoral head with prosthesis
161
Dx for Compartment Syndrome (2)
Dx = [Clinical in Revascularization pts] vs.
[Compartment pressures \> 30 mmHg]
162
pts who've fallen from high heights will have foot fractures, leg fractures AND **possibly** ⬜ fractures as well
[Thoracolumbar spine]
163
Pt with triad of
1. Digoxin
2. Diuretics
3. Abdominal Pain
..should make you suspect what dz?
MBIC! (Mesenteric Bowel ischemic colitis)
## Footnote
Digoxin = aFib
Diuretics = HF
Abd pain occurs after SMA or IMA are occluded
164
[(AMBIC) Acute Mesenteric Bowel ischemic colitis]
Mngmt (6)
1. O2
2. IVF
3. [Abx: CefTriaxone vs. (Levoflox + flagyl)]
4. Pain control
5. Heparin (if clot present)
6. Laparatomy
## Footnote
*CT revealing air & edema in bowel wall --\> thickening = MBIC*
165
Causes of SBO in Kids (3)
Intussuception
Intestinal Atresia
Volvulus
166
PE findings for Appendicitis (5)
**PMR PD**
1. Peritoneal signs (Rebound, Guarding)
2. McBurney's point TTP
3. [Rovsing's LLQ TTP]
4. [Psoas & Obturator sign]
5. DEC bowel sounds
167
DDx for SBO (14)
**GIVES BAD CRAMPS**
## Footnote
**G**allstone iLeus
**I**ntussuception (kids)
**V**olvulus (kids)
**E**xternal compression (CA)
**S**MA syndrome
**B**owel wall hematoma
**A**bscess
**D**iverticulitis
**C**rohn's Dz
**R**adiation Enteritis
**A**nnular Pancreas
**M**eckles Diverticulum
**P**eritoneal adhesion
**S**tricture
168
Labs for SBO (3)
[⬇︎ **K** / **H+**(alkalosis) / **C**l]
169
Appendicitis DDx (8)
1. Ectopic Pregnancy
2. Ovarian Cyst/Torsion
3. PID
4. Crohn's
5. Pyelo
6. Gastroenteritis
7. Perforated ulcer
8. Pancreatitis
170
Acute Appendicitis mnmgt (3 steps)
**LAS**
## Footnote
1st: **L**R
2nd: [**A**bx: **FUCCC= F**lagyl, **U**nasyn, **C**ipro, **C**efoxitin, **C**efotetan]
3rd: **S**urgery? [Nonperf = Appy within 24 hours] vs. [Perf = Prompt appy with postop abx for 1 week] vs. [Abscess = perQ drainage + abx + interval appy]
171
[(AMBIC) Acute Mesenteric Bowel ischemic colitis]
Dx (2)
Dx = [CT contrast] vs. [Mesenteric Angiogram]
*CT revealing air & edema in bowel wall --\> thickening = MBIC*
172
Mngmt for Diverticulitis (4)
- Colonic Bacterial Abx
- NPO
- IVF
- rule out colon CA
173
Diveriticulitis Dx
**CT** showing [bowel wall FREE AIR & edema]
174
Acute Pancreatitis Mngmt (5)
- NPO
- IVF
- Pain control
- [NG decompression if emesis]
- Possibly: [Postpyloric TF vs. TPN]
175
Difference between [Jersey and Mallet finger]
Tx
Jersey = flexed finger is forcefully extended--\>flexor tendon damage --\> Distal phalanx won't flex
Mallet = (THINK VOLLEYBALL) = EXTENDED finger is forcefully flexed --\> extensor tendon rupture --\> Distal phalanx won't extend
Tx = Splint
176
How can nutritional depletion be circumvented in surgical candidates?
7-10 day PreOp nutritional support directly to gut
177
Parameters for Nutritional Depletion (4)
* Albumin \< 3
* Transferrin \< 200
* [GOE 20% wt. loss over prior 2 months]
* Skin Antigen Anergy
*NUTRITIONAL DEPLETION ⇪ OPERATIVE RISK*
178
Green fluid draining from hemigastrectomy wound likely indicates ⬜
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Mngmt?-3
Fistula(bowel --\>wound)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
1. Abd Wall protection
2. fluid
3. nutrition
179
Name one of the key lab differences between
Acute Hemorrhagic Pancreatitis vs. Acute Edematous Pancreatitis
Hemorrhagic = lower Hematocrit
Edematous = HIGHER Hematocrit
180
What is Ranson's Criteria and what does it refer to?
chUG
[⬇︎ca+/ ⬇︎hct / ⇪︎WBC / ⇪︎ Glucose]
Indicates Acute Hemorrhagic Pancreatitis
181
[Ground Glass appearance of lower abd] is pathognomonic for \_\_\_\_\_
Meconium iLeus
## Footnote
*MOTHER WILL HAVE CYSTIC FIBROSIS!*
182
Why is Gastrografin used as both diagnostic and therapy for Meconium iLeus
Diagnostic = it'll show inspissated pellets of meconium in terminal iLeum
Therapeutic = Gastrografin draws fluid in and dissolves pellets
183
Signs of Congenital Vascular Rings
1. Stridor
2. Crowing Respiration with positional hyperextension
3. Dysphagia
184
Vascular Rings MOD
Two Aortic Arches wrap around Trachea & Esophagus --\> Segmental tracheal compression on Bronchoscopy
185
Amblyopia MOD
Infants who don't have Vision impairment (such as [Strabismus CrossEye]) fixed within first 6 years of life --\> Permanent Cortical Blindness in affected eye since Brain eventually suppresses 1 of the overlapping images
186
Demographic for SQC of Head & Neck
Old Men who smoke, drink, rotten teeth
187
Dx for SQC of Head & Neck (2)
[Triple Panendoscopy to look for 1° tumor] --\> CT to demonstrate extent
188
Tx for [Mitral Stenosis s/p Rheumatic Fever] (2)
Surgical Commissurotomy vs. Balloon Valvuloplasty
189
Pt with Frontal or Ethmoid Sinusitis is at risk for what serious complication?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Tx?-2
Cavernous Sinus Thrombosis!
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Drain affected sinuses + IV Abx
190
What is the classic presentation for [Ureteropelvic Junction Obstruction]?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
why?
**16 yom on a beer-binge for first time w/colicky flank pain**
**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**
Large diuresis in a narrow area will produce flank colicky pain
191
What should **first** be assessed in a deteriorating \>5 day old Liver after transplant-2? Why?
[**Biliary Obstruction** via US] & [**Thrombosis** via Doppler]; Technical problems are more common than rejection in Liver transplants!
192
In a compromised airway pt, what is the next option if intubation can not be done?
Cricothyrotomy
193
What are 2 scenarios that predispose to Air Embolism
1. Trauma pt intubated and on respirator
2. Subclavian vein opened to air (Central venous line placement,supraclavicular node biopsies)
## Footnote
*Air Embolism --\> Sudden Death from Cardiac Arrest!*
194
[Trauma pt intubated and on respirator] develops air embolism!
Mngmt?
Cardiac Massage w/pt L side down
195
Mngmt for pts with trace hematuria post trauma
NONE! This is normal
196
Method for biopsing breast masses
Mammographically/Sonographically-guided Multiple Core Biopsy
197
Examples of Alkaline burns-2? Mngmt?
Liquid Plumer vs. Drano; H20 Irrigation for GOE 30 min --\> ER
198
[Knock Knee Valgus] is normal between what ages?
4 - 8 (No tx needed)
199
[Bowlegged Varus] is normal between what ages?
birth - 3
## Footnote
[Bowlegged Varus] beyond 3 = Blount Dz which needs surgery
200
Demographic for Dupuytren Contracture
Older Norwegian Men
201
What are the Hepatic predictors of mortality during a surgery-4?
**BAPE**
(GOE 3 = 85% Mortality)
1. **B**ilirubin \> 2 *(* *\> 4 alone = 85% Mortality )*
2. **A**lbumin \< 3 *( \< 2 alone = 85% Mortality)*
3. **P**T time \> 16
4. **E**ncephalopathy *(Ammonia alone \> 150 = 85% Mortality**)*
202
Wound Dehiscence
Description of draining fluid?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Onset?
[Pink Salmon Peritoneal fluid]
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
POD**5**
203
Wound Dehiscence Mngmt-3?
1st: Tape Wounds
2nd: Bind Abd
3rd: Schedule Operation to prevent Evisceration vs. Ventral hernia
204
[Zollinger Ellison Gastrinoma] Dx
[Measure Gastrin] --\> [If Gastrin is equivocal Measure Secretin*(normally ⬇︎ Gastrin secretion = would be HIGH because of feedback)*] --\> [Locate Pancreatic Tumor with CT] ---\> Remove tumor
205
What conditions cause this-3?
**[Newborn Green Emesis] + DOUBLE BUBBLE SIGN = DAM!**
**D**uodenal Atresia
**A**nnular Pancreas
**M**alrotation *(Most dangerous)*
206
Cardiac Catheterization showing [**Square Root Sign**] and [**Equilization of Pressures**] indicates what dx?
Constrictive Pericarditis
207
Sx for Retinal Detachment-3
**THIS IS AN EMERGENCY!**
1. Flashes of light
2. Floaters (⇪# = ⇪ Severity)
3. [Dark Cloud vs. Snow storm vs. MANY floaters] in upper visual field = Extreme Retinal Detachment!
208
Tx for Retinal Detachment
Laser spot welding
209
What is Cushing's Reflex?
Cushing's Reflex = **HBO** Compensatory response to ⬆︎ ICP that preserves perfusion of the brainstem
## Footnote
***HBO** (**H**TN / **B**radycardia / sl**O**w breathing)*
210
Kidney stones of what size are eligible for invasive intervention?
≥7mm
211
Tx for [Kidney stone ≥ 7 mm]
What are the Contraindications to this-3?
[ExtraCorporeal Shockwave Lithotripsy]
Cx = Pregnancy, [Coagulopathic Bleeding Diathesis], [Size \> 1 **centi**meter]
212
Demographic for Chronic Subdural hematomas-2 and why this is?
Old and Alcoholics; **Shrunken Brain** has EASY venous sinus tearing
213
Hemothorax Mngmt. When is more invasive intervention indicated-2?
[**Chest Tube Thoracostomy]** ; Surgery only indicated if [\> 1500 mL total] or [\> 600 in 6 hours] is recovered
214
Normally [Penetrating Abd Stab wounds require XLap]
In what situations is digital exploration of Abd stab wounds sufficient-3?
1. **NO** evisceration (*protruding viscera*)
2. **NO** peritoneal signs
3. **NO** HemoDynamic instability
215
Mngmt for Abd wound that can't be closed due to tension-2
[Temporary Abd Cover *(absorbable mesh vs. plastic)*] --\> [Graft over mesh vs. Remove Plastic] Later
216
Dx for Bladder Injuries post trauma
[Retrograde Cystogram **with** Postvoid films]
## Footnote
*Postvoid films needed to see xtraperitoneal leaks @ bladder base that are hidden by dyed bladder*
217
What determines Rabies px-2
[If animal is alive = Examine Animal Brain] vs. [**Mandatory** if animal n/a]
## Footnote
*rabies px = IgG AND Vaccine*
218
Presentation of [**SCFE** - Slipped Capital Femoral Epiphysis] -4
1. 13 yom with
2. [Knee / Groin Pain + Limping]
3. **sole of affected foot pointed toward other foot**
4. **Thigh can NOT be rotated internally during hip flex**
## Footnote
***Tx= immediate Surgery to avoid AVN***
219
What determines closed vs. open reduction in fractures involving growth plates?
Fractures involving [epiphysis and growth plate displaced laterally from metaphysis **but in 1 piece** = Closed Reduction]
but if fractures crosses epiphysis vs. involves joint = OPEN REDUCTION
220
What bone pathology is associated with uncoordinated muscle contractions (seizure)? How do pts present?
Posterior Shoulder Dislocation; Internally rotated (arm held clsoe to body)
221
Posterior Shoulder Dislocation Dx-2
**Axillary** vs. **Scapular Lateral** Xray
222
Ankle fractures occur when _________ and leads to breakage of \_\_\_\_\_\_. Mngmt?
Falling on inverted OR everted foot --\> BOTH malleoli breakage; [Open Reduction + internal fixation]
223
Where does Lumbar disk herniation occur-2?
(L4-5) vs. (L5-S1)
224
What is Morton Neuroma and what causes it?
**tender** inflammation of [Common Digital n.] between 3rd and 4th toe; High-heel shoes *(forces toes to be bunched)*
225
Which drugs cause Malignant Hyperthermia-2?
Halothane vs. Succinylcholine
226
Sx of Malignant Hyperthermia-3
**MM**alignant Hyperthermia
1. **M**uscle contraction from Hypercalcemia
2. **M**etabolic Acidosis
3. Hyperthermia (Fever)
227
Mngmt of Malignant Hyperthermia-4 and what should you be watching for?
1. IV Dantrolene
2. 100% O2
3. Metabolic Acidosis Correction
4. Cooling Blankets
## Footnote
**BE ON THE LOOKOUT FOR MYOGLOBINURIA!**
228
Although ___ is gold standard for PE dx, ____ is more commonly used
Pulmonary Angiogram; [**Spiral CT angiogram**]
## Footnote
*Image: Spiral CT Angio showing [R Pulm artery clot]*
229
PE Tx-2
Heparin --\> [IVC filter if recurrence or Heparin contraindicated]
230
Other than Free water changes, which fluid is HYPERnatremia corrected with?
D5 1/2NS *(HYPERtonic)*
231
Other than Free water changes, which fluid is hypOnatremia corrected with-2?
NS vs. LR (*both isotonic**)*
232
Mngmt for pt with [Long standing GERD + Barretts and peptic esophagitis]? Tx if there are SEVERE dysplatic changes?
Nissen Fundoplication; Resection
233
[Obstructive Jaundice 2° to tumor] often has _____ on US. What is the dx w/u-3
[**C**ourvoisier Palpable Gallbladder w/Painless Jaundice]
## Footnote
1st: US (did that) - shows distended GB
2nd: CT upper abd
3rd: ERCP
234
Fever and Leukocytosis develops 10 days after onset of Pancreatitis. Diagnosis?
Acute Suppurative Pancreatic **Abscess**
235
[Fibroademona] and [Cystosarcoma Phyllodes] are both [*Firm, rubbery Breast masses, that occur in young women*]
Name 3 things that make Cystosarcoma Phyllodes different from Firbroademona?
1. CP has malignant potential! Removal **MANDATORY**
2. CP grows over many years, distorting breast
3. CP requires Core (Not FNA or US) Biopsy
236
in [*Congenital* *intra-utero* Diaphragmatic Hernia], what's the biggest issue? How is this addressed-2?
Lung hypOplasia in-utero; [Extracorporeal membrane oxygenation] --\> Repair after 3 days postpartum
237
Necrotizing Enterocolitis Presentation-3
Premature infant who just started feeding and develops [RAPID PLATELET DROP(sign of neonatal sepsis)], feeding intolerance, abd distension
238
Necrotizing Enterocolitis Mngmt-5
1. STOP FEEDINGS
2. Broad Abx
3. IVF
4. IV nutrition
5. Surgery *(if abd wall erythema/portal vein air/pneumatosis/pneumoperitoneum develops)*
239
When is Surgical intervention indicated in Necrotizing Enterocolitis-4?
* Abd Wall Erythema
* Portal Vein air
* Intestinal Pneumatosis (intestinal wall gas)
* Pneumoperitoneum
240
What is Foster Kennedy Syndrome-4
Tumor at [Base of Frontal Lobe] that makes u **BOAP**
1. **B**ehavior inappropriate
2. [**O**ptic n. atrophy *ipsilateral to tumor*]
3. **A**nosmia
4. [**P**apilledema *CONTRAlateral to tumor*]
241
What's the most common Postop maintenance fluid
D5 1/2NS (Hypertonic)
242
When does Acute organ rejection occur and how do you manage it-2?
[5 Days - 3 mo. post op]; [Steroid Boluses and AntiThymocyte serum]
243
Pt with a ureteral stone suddenly develops fever and flank pain. What's Diagnosis and what needs to be done-2?
**OBSTRUCTIVE PYELONEPHRITIS**
## Footnote
1st: IV Abx
2nd: **IMMEDIATE PROXIMAL TO STONE DECOMPRESSION** (via Ureteral stent vs. PerQNephrostomy)
244
Diagnosis? Describe-4
Venous Stasis Ulcer
Above Medial Malleolus
Chronically Edematous
Indurated (Hard)
Hyperpigmented
245
How would you confirm this diagnosis? Tx-2?
Duplex Scan;
Tx = [Keep Veins empty (compression stockings/Unna boot)] vs. [Surgery(vein stripping/ulcer graft)]
246
Hypernatremia and hypOnatremia both manifest with ____ and \_\_\_\_. What sx differentiates them?
BOTH = Confusion & Possible Coma
[HYPER = Lethargy] vs. [hypO = seizures]
247
Paralytic iLeus is prolonged by which metabolic abnormality?
low K+
248
Demographic-2 for Primary Peritonitis and tx
Demographic = [Child w/Ascites and nephrosis] vs. [Adult w/Ascites]
Tx = Abx only
*Primary Peritonitis = Mild Generalized Acute Abd*
249
What are Hepatic Adenomas a complication of and why are they dangerous?
OCP; They can rupture and bleed into abd
250
What class of drugs can be given to temporarily alleviate Biliary Colic
Anti-Cholinergics
251
HTN in BUE + [Normal-to-No Pulses] in BLE typically indicates \_\_\_\_\_\_. What would CXR reveal?
Coarctation of Aorta; [**Scalloping of lower edge of Ribs***(from Dilated collateral intercostal a.)*]
252
Coarctation of Aorta Dx
Spiral CT Angio
253
*Pt with hemoptysis comes in with [Coin lesion on CXR]*
What determines whether or not he needs w/u?
**1ST: LOCATE PREVIOUS (At least 1 year prior or older) CXR!** If lesion unchanged = NO CA
## Footnote
*Coin lesions = 80% chance malignancy*
254
Brain tumors in kids are mostly located where? How does this manifest-2?
Posterior Fossa; Cerebellar Dysfunction + [Knee-chest position to relieve HA]
255
Pt with Human Bite on knuckle: Mngmt-2?
Extensive irrigation and Debridement in OR
## Footnote
*Human Bites are the DIRTIEST Bites!!*
256
Pt who's been vomiting now has metabolic **aLKalosis** and needs fluid resuscitation: What do you give?
NS **with added KCl**
257
[Osgood Schlatter Dz] MOD
Osteochondrosis of Tibial Tubercle --\> Persistent *Teenager* Pain
258
[Osgood Schlatter Dz] Tx-2
RICE ---\> [Cylinder cast x 4-6 weeks]
259
What is the abx px for elective surgery? What about Complex prolonged procedures?
A = **single** dose abx [no more than 1 hour prior] to surgery;
Prolonged procedures = A + Redose abx during procedure
260
What are the 4 main causes of somnolence?
He's totally somnolent and **GONE**
## Footnote
*Abnormalities with...*
**G**lucose
**O**xygenation
**N**arcotics
**E**lectrolytes
261
Pt on POD4 develops PNA and septic shock
What *two* tx are most important right now?
1. IV NS to maintain intravascular pressure
2. Abx
262
What modality is necessary to **confirm** Diaphragmatic Hernia?
**CT Abd**
263
When is it ok for pts concerning for appendicitis to skip CT and go directly to Lap appy?
Pts can skip CT if they have **classic appendicitis signs** (PMR PD)
## Footnote
*Appendicitis can be based on lab and clinical findings!*
264
Syringomyelia presentation - 2
[Whiplash Spinal Cord Injury] vs. [Arnold Chiari Malformation] --\>
[Cape distributed Loss of Pain & Temp] --\> **Burning** and eventually Muscle Weakness
265
Tubocurarine and Atracurium MOA ; Indication
Non-Depolarizing Nicotinic R Blockers; **Muscle paralysis** for endotracheal intubation and Surgery
266
How do you evaluate a pt with mild TBI (concussion)?-2 ; When is it ok to discharge them?
NonContrast Head CT vs [5 hr observation period]; Pts can be DC'd with **reliable guarden** if the above is negative
267
When should you do endovascular repair on an AAA? - 3
1. Aneurysm \> 5.5 cm
2. Expansion rate is \>1/2 cm in 6 months or \>1 cm in 1 year
3. Classic s/s present (abd/back pain, gross hematuria)
268
In Vascular extremity trauma, when HARD signs of injury are present _____ is warranted immediately
What are the HARD signs of vascular injury?- 4
XLap
269
In Vascular extremity trauma, when HARD signs of injury are present _____ is warranted immediately
What are the soft signs of vascular injury?- 4
XLap
## Footnote
*Soft signs in image*
270
Legg Calve Perthes disease etx ;demographic
idiopathic Avascular Necrosis of the hip ; boys 5-7 yo
271
Developmental Hip Dysplasia etx
abnml development of hip during utero --\> leg length discrepancy and poorly formed femoral head
272
Hydrocele etx ; Tx?-2
**transilluminative fluid** accompanies testis during scrotal descent and/or if processus vaginalis fails to obliterate this --. communicating hydrocele ;
Self Limited to 1 year old --\> surgery if it doesn't
273
MOD for Cryptorchidism ; What are the 2 biggest complications for this disorder?; tx?
failure of testicular descent that can --\> Torsion uncorrected and [**⬇︎Fertility** even if corrected].
Tx = if not naturally descended by 6 months --\> Orchiopexy BEFORE 1 year old
274
cp of Chronic Prostatis Pelvic pain syndrome - 4; Dx?
1. chronic **perineal** pelvic pain worst with ejaculation
2. chronic **testicular** pelvic pain worst with ejactulation
3. Urinary Urgency with NO dysuria
4. Urinary Frequency with NO dysuria
Dx = Clinical symptoms with Sterile urine cx
*Dont confuse this with BPH which should NOT have back/pelvic pain*
275
tx for Chronic Prostatis Pelvic pain syndrome - 3
1. Tamsulosin
2. Abx if UTI hx present
3. Finasteride
Dx = Clinical symptoms with Sterile urine cx
*Dont confuse this with BPH which should NOT have back/pelvic pain*
276
cp for Acute Bacterial Prostatitis
UTI sx **PLUS PERINEAL PAIN**
277
What are the 5 steps to appropriately transport an amputated extremity?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
How long will this sustain viability?
"**SPLIT** extremity!? wrap in... "
**S**aline moistened gauze. THEN put in-
**P**lastic bag.
**L**id seal bag shut before putting it on
**I**ce bed. to keep
**T**emperature ideal (33.8 - 50 F) as to NOT FREEZE extremity
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
24 hours
