Surgery Flashcards
when should you suspect traumatic aortic injury and how is it diagnosed?
Suspect when there are fractures of bones that are hard to break: sternum, first rib, scapula. Or if there is a widened mediastinum.
Dx with spiral CT/CT angio
What does subperiosteal bone resorption suggest?
Hyperparathyroidism
Type of diverticuli
True: mucosa, submucosa, muscularis
Ex. Meckel diverticulum
False: no muscularis
Ex. diverticulosis
Where does colon cancer metastasize to?
Liver
Most common fistula seen in diverticulitis
Colovesicular fistula
(Between colon and bladder)
Presentation: pneumaturia (air in urine), fecaluria (stool in urine), or recurrent urinary infections
If patient has a medullary thyroid carcinoma what should you screen them for?
Pheochromocytoma
Treatment of PE
Heparin
Most common site of diverticulitis
Sigmoid colon
What is the only absolute contraindication to oral intubation?
Massive facial trauma
What kind of fluid loss occurs in SBO?
Third space fluid losses
What study is used to diagnose esophageal rupture
Water soluble contrast esophagram
Median Nerve
Ulnar nerve
Radial nerve
Median: make fist
Ulnar: finger abduction/adduction
Radial: wrist extension
Dumping syndrome
N/V/D and abdominal cramps with palpitations and diaphoresis that is a common postgastrectomy complication
Caused by loss of the normal action of the pyloric sphincter due to injury or surgical bypass
Manage patients with dietary modifications
Most common cause of esophageal perforation
Iatrogenic: instrument perforation of the esophagus
Why do patients with Zollinger Ellison get steatorrhea?
The increase in gastric acid inactivates the pancreatic enzymes
What deficiency is seen in carcinoid syndrome?
Niacin deficiency due to inc production of serotonin (niacin is a precursor)
Abdominal CT for SBO… with or without contrast?
With contrast
Need to assess intestinal distribution and intestinal wall perfusion
What is the most common cause of fever within the first day of surgery?
Atelectasis
Emphasize the importance of incentive spirometry
What part of the GI tract are retroperitoneal
Duodenum
Ascending and descending colon
Pancreas
Preservation of which of the following, ileum or jejunum, is associated with better nutritional outcomes?
Ileum: absorption of B12 and bile salts
What muscle makes the inguinal ligament?
The external oblique
What fracture is associated with a calcaneous fracture?
T or L spine (usually from a fall)
Where can there never be diverticuli? Why?
Rectum: two layers of muscle
Child with an abdominal mass in the right abdomen that moves up and down with respiration
Malignant liver tumor (hepatoblastoma or hepatocellular carcinoma)
Tension pneumothorax causes what effect on the heart?
Dec in venous return to the heart –> hypotension and cardiac arrest
Presentation of right sided colon cancer vs left sided
Right sided = bleeding (anemia)
Left sided = obstruction (because the lumen is smallest in the left sided colon)
Difference between esophagus and rest of the GI tract?
Esophagus does not have serosa
MEN2A
MEN 2A: 2 P’s
- Parathyroid
- Pheochromocytoma
- Medullary thyroid carcinoma
Gastrectomy causes what deficiency?
Vitamin B12 (loss of intrinsic factor)
Diameter of the large intestine
Ascending: 9 cm
Transverse: 6 cm
Descending: 3 cm
Vomiting causes what electrolyte abnormality
Hypokalemic hypochloremic metabolic alkalosis
Hypokalemia occurs because of the loss of HCl causes K+ to enter cells when H+ exits cells
What electrolyte abnormality causes ileus?
Hypokalemia
What is the lethal triad?
- Acidosis
- Coagulopathy
- Hypothermia
Where are the blood vessels on a rib?
Vein, Artery, Nerve (VAN)
Underneath a rib (thus, need to place chest tubes and thoracentesis needles above the rib)
Skin manifestations of ulcerative colitis
Erythema nodosum
Pyoderma gangrenosum
Patient with worsening jaundice with an US that shows a thin walled, dilated gallbladder and has with lab evidence of obstruction (inc alk phos, liver enzymes, direct bilirubin) suggests….
Courvoisier-Terrier sign
Obstructive jaundice caused by tumor (adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of Vater, cholangiocarcinoma of the common bile duct)
Hemorrhoid locations
Right anterior
Right posterior
Left lateral
Patient with worsening jaundice with evidence of obstruction on labs (inc alk phos) and who has a nondilated gallbladder on US suggests…
Obstructive jaundice caused by stones
ERCP used to confirm diagnosis and to remove stone, followed by cholecystectomy
Trauma patient has subcutaneous emphysema in the upper chest… what do you suspect?
Traumatic rupture of the trachea or major bronchus
Dx with bronchoscopy
Electrolyte abnormality associated with SBO
Hypokalemia
Need to give them IV fluids with K+ added
Electrolyte abnormalities associated with refeeding syndrome
Hypokalemia
Hypomagnesemia
Hypophosphatemia
Management of penetrating extremity injuries
- No major vessels in vicinity: clean wound and give tetanus
- Near major vessels but pt is asymptomatic: doppler or CT angio
- Obvious vascular injury (absent distal pulses, expanding hematoma): surgical exploration and repair
Signs of pathologic nipple discharge
Spontaneous
Unilateral
From a single duct
What is the medical management for a patient with a prolactinoma?
Dopamine agonists (Bromocriptine)
Dopamine blocks prolactin
If you suspect diaphragmatic rupture, what do you do?
Laparoscopy!
Resuscitation for massive trauma and massive blood loss
1:1:1 ratio
PRBCs
FFP
Platelets
Maintenance fluid for an adult
mass in kg + 40 = X ml/hour
How to determine a patient’s airway is intact?
If they can talk, airway is intact
Normal urinary output
1-2 ml/kg/hour
Treatment of hypercalcemia
Normal saline (and calcitonin)
What is the strongest layer of the bowel?
Submucosa
Posterior knee dislocation can cause what?
Injury to the popliteal artery
What does every patient with diverticulitis need?
A colonoscopy to rule out colon cancer
Refeeding syndrome
Hypophophatemia
Hypomagnesemia
Hypokalemia
PTH site of action and effects
The kidney –
- inc calcium reabsorption in the DCT
- dec phosphate reabsorption in the PCT
- inc activation of vitamin D
What antibiotic is given to patients with variceal bleeding?
IV ceftriaxone
Gerota’s fascia
Fascia surrounding the kidney
Hesselbach’s triangle
Inferior epigastric vessels
Inguinal ligament
Lateral border of the rectus sheath
Floor consists of the internal oblique and the transversus abdominis muscle
MEN2B
MEN2B: 1 P
- Pheochromocytoma
- Medullary thyroid carcinoma
- Marfinoid body habitus
- Mucosal neuromas
Air embolism management
Put patient in trendelenburg position
At what GCS should a person be intubated?
GCS of 8 or lower
Nonoperative management of small bowel obstruction
NPO
NG tube
Intravenous fluid resuscitation
3 most common causes of SBO
- Adhesions
- Hernia
- CA
Portal triad
portal vein, hepatic artery, common hepatic bile duct (splits into left and right)
Which thyroid tumor produces calcitonin?
Medullary carcinoma (arises from the parafollicular C cells)
Causes of post-op fever (sequentially)
Atelectasis (1 day), pneumonia (1-3 days), UTI (3), DVT (5), wound infection (day 7)
MEN1
MEN1: 3 P’s
- parathyroid (hypercalcemia)
- pituitary (prolactinoma)
- pancreatic endocrine tumors (Zollinger Ellison, Glucagonoma)
Liver mass with central scar
Focal nodular hyperplasia (benign tumor of the liver)
Workup for esophageal motility problems
Barium swallow esophagram
Manometry
Calot’s triangle
Cystic duct
Common hepatic duct
Liver edge
(Cystic artery/Calot’s lymph node are within the triangle)
Lab diagnosis of carcinoid syndrome
24 hour urine 5-HIAA (serotonin metabolite)
What is the classic triad in renal cell carcinoma?
Flank pain
Hematuria
Palpable renal mass
Mets to the liver are most commonly seen in….
colorectal cancers
Medical management of anal fissures
Nifedipine
Nitroglycerin (has more systemic effects)
Botox
Myotomy
Upper GI bleed workup and treatment
Upper GI endoscopy
Fluid resuscitation
Endoscopic hemostasis: epinephrine injections, thermal application techniques, and clip applications
Antibiotic treatment of intra-abdominal infections
Dual agent
3rd generation cephalosporin + flagyl or clindamycin
Fluoroquinolone + flagyl or clindamycin
Single agent
Ceftriaxone or Ampicillin-Silbactam
What paraneoplastic syndromes is RCC associated with?
PTHrP (hypercalcemia)
EPO (inc hemoglobin)
Hepatic risk (Child Pugh)
Bilirubin Albumin INR Encephalopathy Ascites
Patient reports mucous like discharge in his underwear. What do you suspect?
Fistula in ano
Best method of determining fluid status in a post op patient
Urine output
Pyloric stenosis electrolyte abnormality
Hypokalemic
Hypochloremic
Metabolic alkalosis
Dx of urethral injury
Retrograde urethrogram
Parkland formula
Fluid resuscitation for burn victims
4 x mass in kg x %of body burned = mL given in first 24 hours
Ogilvie syndrome
o Paralytic ileus of the colon: colon dilation without a mechanical obstruction
o Classically seen in elderly sedentary patients who have become further immbolized owing to surgery elsewhere (broken hip, prostatic surgery, etc)
o Tx
• Colonoscopy to suck out the air and to place a rectal tube
• IV neostigmine: stimulates colon motility but has a lot of side effects and can be lethal if inadvertently given to someone whose colon is actually mechanically obstructed
Liver manifestation of ulcerative colitis
Primary sclerosing cholangitis
Diagnosis of Zollinger Ellison
Lab
Histo
Highly elevated gastrin levels, positive secretin stimulation test
Histo: parietal cell hyperplasia and enlargement of the gastric folds
Colon mets vs lower rectal mets
Colon/upper rectum– portal circulation, mets to liver
Lower rectum- vena cava, lung mets
What drug should a patient with esophageal varices be placed on?
Non cardioselective beta blocker (propranolol)
