Surgery Flashcards
Best initial step when suspecting pancreatic cancer
Spiral CT Scan→mass, dilated pancreas, local spread, and dilated bile ducts
- Endoscopic retrograde cholangiopancreatography (ERCP) locates tumors not seen with CT→too invasive to be initial
- Endoscopic US→helpful for staging and to guide fine-needle aspiration biopsy (suspicion of periampullary neoplasm, small tumors, nodal and major vascular involvement)
How do you see the liver adenoma in a technetium-99 sulfur colloid scan? Why?
Majority of liver adenoma don’t have Kupffer cells→don’t take up sulfur colloid→cold spots in the scan
Treatment for iridocyclitis
Immediate ophthalmology referral
- Cyclopegics→block nerve impulses to the pupillary sphincter and ciliary muscles (easing pain and photophobia) [muscarinic receptor blockers: atropine, tropicamide]
- Topical steroids →↓inflammation (only initiated after consultation with ophthalmology)
Mainstay treatment for osteoarthritis
- Exercise→muscle strength and resistance training
- Weight loss
Hospital admission criteria in a colic pain by renal stone?
- Patient can not tolerate oral hydration
- Pain is uncontrolled with oral medications
- Infection
- One kidney
- Significant renal impairment
What are the recommendations if a renal stone fails to pass spontaneously?
- Stones <1cm at proximal ureter→Extracorporeal shock wave lithotripsy (ESWL)
- Stones >1cm at proximal ureter→percutaneous nephrolithotomy, ureteroscopia
- Stones at distal ureter→ESWL or ureteroscopia
How do you differentiate Lumbar spinal stenosis vs Lumbar disc herniation at physical exam?
- Lumbar spinal stenosis→Flexion of the spine relieves the pain
- Lumbar disc herniation→Flexion of the spine worst the pain
What is the purpose to measure the postvoid residual (PVR)?
Rule out overflow incontinence or urinary retention
- Men normal < or same 50 mL
- Women normal < or same 150 mL
What is the next step when you suspect foreign body in the eye and don’t see it with slit lamp?
Fluorescein application→abrasion or foreign body may be present although not seen on gross examination
Surgery time after supportive treatment of a complicated gallstones disease (acute cholecystitis, choledocholitiasis, gallstone pancreatitis)
Early cholecystectomy (within 72 hours)
*Reduces disease duration, duration of hospitalization and mortality compared to delayed cholecystectomy (>7 days after hospitalization)
Treatment of choice in acalculous cholecystitis
- Antibiotics
- Percutaneous cholecystostomy
*Cholecystectomy when medical condition stabilizes
Radiologic signs of acalculous cholecystitis
- Gallbladder wall thickening and distension
- Pericholecystic fluid
Next steps in a hemodynamically stable patient with blunt abdominal trauma without peritonitis
*If Alert/normal mental status
- FAST:
(+) CT scan of abdomen→Determine need of laparotomy
(-) Serial abdominal exams +/- CT scan
*If NO normal/alert mental status→Serial abdominal exams +/- CT scan
Next steps in a hemodynamically unstable patient with blunt abdominal trauma without peritonitis
- FAST (+) Laparotomy Inconclusive: Diagnostic Peritoneal Lavage [(+) Lapratomy, (-): (-) Signs of extra-abdominal hemorrhage: Yes→Stabilize (ex, angiography, splint) No→Stabilize and CT of abdomen
Physiopathology and treatment of urinary urgency incontinence
- Overactive bladder→detrusor instability
- Tx: Kegel exercises, bladder training (timed voiding, distraction or relaxation techniques), antimuscarinics
(eg, oxybutynin), B-agonists (eg, Mirabregon)
Which is the most appropriate next step when suspect an obstructive jaundice caused by tumor?
CT Scan of the abdomen
*Usually ultrasonography is done first
Most common tumors that can cause obstructive jaundice
- Adenocarcinoma at the head of the pancreas
- Adenocarcinoma of the ampulla of Vater
- Cholangiocarcinoma arising in the common duct itself
Most appropriate first step in management trauma of the urethra
Retrograde urethrography or urethrogram
Most appropriate next step when diagnosed basal cell carcinoma on the face
Mohs Micrographic Surgery➡sequential removal of thin skin layers with microscopic inspection to confirm the margins cleared of malignant tissue
How do you explain hematuria in a Abdominal Aortic Aneurysm rupture?
Rupture into the retroperitoneum→create aortocaval fistula with inferior cava vena→venous congestion in retroperitoneal structures (bladder)→fragile and distended veins rupture►gross hematuria
Triad to suspect biliary cyst
Abdominal pain, jaundice (obstructive cholestasis) and palpable mass
*Normal gallbladder on sonography
Treatment for biliary cyst. What do you want to avoid?
Surgical resection►relieves the obstruction and reduces the risk of malignancy➡cholangiocarcinoma, gallbladder cancer, pancreatic cancer
Pneumobilia + Hyperactive bowel sounds + Nausea, Vomiting + Dilated loops of bowel + Diffuse abdominal pain in several days. Disease and mechanism.
Gallstone ileus→stones pass through a biliary-enteric fistula and advances by the intestinal tract (usually lodges in ileum, also stomach, colon, jejunum)
*Mechanical obstruction
Potential cause and explanation of splenic abscess
Complication of bacteremia from a distant infection (infective endocarditis, cholecystitis)
Risk factors of splenic abscess
Immunosupression from HIV, diabetes mellitus, hematologic malignancy
Most common cause of referred otalgia
- Dental disease and Temporomandibular joint disorders
- Common presentation of mucosa head and neck squamous cell carcinoma (HNSCC)→IX CN (base of tongue, external auditory canal), X CN (larynx, hypopharynx, external auditory canal)►Tumor at base of tongue or larynx/hypopharynx
How may you distinguish a cardiogenic from a hypovolemic shock?
- Both are pale/cool
- Cardiogenic: ↑Left ventricular end diastolic pressure (LVEDP) or Pulmonary capillary wedge pressure (PCWP)
- Hypovolemic: ↓LVEDP or PCWP
Warm and flushed types of shock, How do you differentiate them?
- Neurogenic shock: ↓Cardiac output
- Septic shock: ↑Cardiac output
Warm/flushed type of shock with elevated cardiac output and decreased PCWP?
Anaphylactic shock
*No change PCWP and ↑CO→Septic shock
Best management in an unstable patient with pelvic fracture
External pelvic binder (provides stability and tamponade effect) and angiographic embolization
*External and internal pelvic fixation if pelvic binder is not an option, but surgery on a bleeding pelvis is risky
Types of bladder injuries in a pelvic fracture and management
- Extraperitoneal bladder injury (bladder neck/trigone rupture)→ place Foley catheter
- Intraperitoneal bladder injury (bladder dome rupture)→surgical correction
Malignancies to think in young men (15-35)
Testicular cancer, Lymphoma, Leukemia
Metastatic process of testicular cancer and associated symptoms
- Retroperitoneal lymph nodes→compression adjacent structures [nerves roots, psoas muscle]►Lumbar back pain
- Lung and liver mestastasis
- Lung→nodules►cough or dyspnea
Symptoms and signs of schwannoma and why are they caused?
- Cochlear nerve compression→unilateral sensorineural hearing loss
- Vestibular nerve damage→Imbalance, most when depriving visual input (Ex, walking at night)
- Extension from internal auditory canal into the cerebellopontine angle
- CN V compression→facial numbness
- CN VII compression→facial weakness
Sensorineural hearing loss
Air conduction>Bone conduction, lateralization to the unaffected ear
Conductive hearing loss
Bone conduction>air conduction, lateralization to the affected ear
What might suggest a bruising on the flank after trauma? Which is the sign?
Grey Turner sign➡Retroperitoneal hemorrhage
Most accurate test for acute and chronic mesenteric ischemia and ischemic colitis
Angiography
How may you distinguish by risk factors acute mesenteric ischemia vs colitis ischemia or chronic mesenteric ischemia?
- AMI➡#1 risk factor Atrial Fibrillation
- Ischemic colitis or CMI➡#1 risk factor Atherosclerotic disease (prior MI, PAD or Stroke)
What is the Median Arcuate Ligament Syndrome (MALS) or Celiac compression syndrome? Symptoms.
- External compression of the celiac trunk by the median arcuate ligament
- Severe postprandial abdominal pain, nausea, and weight loss
Important sign of Boerhaave syndrome during physical examination at the thorax
Hamman sign➡crunching heard upon palpation of the thorax➡subcutaneous emphysema
Most common complication after diverticulitis.
Abscess formation
For which symptom you must ask that is highly correlated with diverticulitis?
Constipation
Most accurate test for cholecystitis
HIDA scan: Hepatobiliary iminodiacetic acid gammagraphy or cholescintigraphy
Treatment for bowel obstruction from stool impaction by chronic opioid use
Methylnaltrexone (Relistor)
Treatment options for fecal incontinence
- Bulking agents➡fiber
- Biofeedback➡control exercises and muscle-strengthening exercises
- Dextranomer/hyaluronic acid (Solesta) injection➡⬇50% incontinence episodes
*If all fails, colorectal surgery
Most common knee ligament injury
Anterior cruciate ligament (ACL)
Management of aortic abdominal aneurysm (AAA)
- 3-4 cm➡US/2-3 years
- 4-5,4 cm➡CT or US/6-12 months
- > 5,5 cm➡even asymptomatic, surgery
Most likely cause of postoperative fever at day 3-5?
Urinary tract infection
What is the Klatskin tumor?
Hilar cholangiocarcinoma➡at the confluence of the right and left hepatic bile ducts
Treatment for urinary stress incontinence that does not respond to measures
Duloxetine
Types of priapism and how do you distinguish them?
- Ischemic➡ABG➡hypoxemia, black blood, hypercarbia, acidemia
- Nonischemic➡ABG➡red blood, normal pO2, pCO2 and pH
*Blood aspirated from corpora carvenosa
Which sign on physical examination you should explore to assess thoracic outlet syndrome?
Adson sign➡loss of radial pulse upon rotating the head to the ipsilateral side with neck extended and taking deep inspiration
Most common cause of thoracic outlet syndrome
Congenital cervical rib➡extra rib that arises from 7th cervical vertebra
What is the early dumping syndrome?
Complication of gastric bypass (Roux-en-Y) and sleeve gastrectomy➡Rapid emptying of hyperosmolar food➡fluid shifts from plasma into the bowel
*Hypotension, flushing, tachycardia, syncope
What is the late dumping syndrome?
Complication most commonly Roux-en-Y occurring several months after surgery➡postprandial hyperinsulinemic hypoglycemia (PHH)➡1-3 hrs after CHOS-rich meal
*Hypoglycemia, dizziness, fatigue, diaphoresis, weakness
Etiology of each cause of priapism
- Ischemic➡⬇venous flow
- Nonischemic➡fistula between cavernosal artery and corporal tissue (associated with trauma to the perineum)
Most common complication of the anterior shoulder dislocation
Axillary nerve injury
- Teres minor, deltoid innervation➡weakened shoulder abduction
- Sensory lateral shoulder➡⬇sensation
Treatment for acute angle-closure glaucoma
- Oral or IV Acetazolamide➡⬇aqueous humor
- IV Mannitol➡ osmotic draw of fluid out of the eye
- Beta-blockers (Timolol), Apraclonidine (alpha-2)➡⬇aqueous humor [may cause miosis as well)
- Pilocarpine (M3)➡miosis➡⬆aqueous humor drainage
- Laser iridotomy➡hole in the peripheral iris (curative and prophylactic)
*DO NOT use mydriatic medications: Atropine or Epinephrine
Treatment for Herpes keratitis. Which medication you must avoid?
- Oral acyclovir, famciclovir, or valacyclovir
- Topical antiherpetic: trifluridine and idoxuridine.
- Steroids make the condition worse
How do you identify Herpes keratitis?
Fluorescein staining➡dendritic pattern
How may you differentiate retinal artery vs vein occlusion?
- Retinal artery occlusion➡pale retina (swelling), dark macula (cherry-red macula), bloodless arteries
- Retinal vein occlusion➡venous stasis▶extravasation of blood (hemorrhages)
What is the Lemierre syndrome?
Fusobacterium necrophorum from pharyngitis, peritonsillar abscess, mastoiditis or parotiditis expands beyond the mouth to the neurovascular bundle around jugular vein➡spread locally and bloodstream▶septic jugular thrombophlebitis
What is the Tolosa-Hunt syndrome? Treatment.
- Granulomatous inflammation of the cavernous sinus with ophthalmoplegia (paralysis III, IV, VI CN)
- Steroids
Why should you do close cardiac monitoring during laparoscopic surgery?
Insufflation of CO2 into abdominal cavity➡peritoneal stretch receptors➡⬆vagal tone➡severe bradycardia, AV block, asystole
*Also mechanical ⬆ in systemic vascular resistance➡⬆blood pressure
Cause of gallstones formation in a patient with total parental nutrition
TPN or prolonged fasting➡⬇cholecystokinin➡❌gallbladder contraction➡ Gallbladder stasis
Why chron disease and small bowel resection are associated with gallstones formation?
Decreased enterohepatic circulation of bile acids➡altered hepatic bile composition➡supersaturated of cholesterol▶gallstones
What is sympathetic ophthalmia?
“Spared eye injury”➡immune-mediated inflammation of one eye (the sympathetic eye) after a penetrating trauma to the other eye▶anterior uveitis, panuveitis, papillary edema, blindness
*Break barriers protecting some antigens from immunologic recognition▶uncovering of hidden antigens
What is a postcholecystectomy syndrome? Causes.
Persistent abdominal pain or dyspepsia either postoperatively (early) or months or years (late) after cholecystectomy
- Biliary: retained common bile duct or cystic bile duct stone, biliary dyskinesia
- Extrabiliary: pancreatitis, peptic ulcer disease, CAD
What liver function test is associated with pancreatitis?
ALT>150➡95% positive predictive value for diagnosing gallstone pancreatitis
Best next test after reduction of knee dislocation
- Palpation pulses distal and popliteal
- Rule out popliteal artery injury➡Measure ankle-brachial index▶ABI<=0.9➡emergency CT angiogram, vascular consultation
- Duplex ultrasonography
Next steps when scaphoid fracture is suspected and initials x-rays are negative
- Wrist immobilization with a thumb spica splint➡repeat x-rays in 7-10 days
or
- CT scan or MRI of the wrist
- Initial x-rays have low sensitivity for scaphoid fracture.
When do you suspect scaphoid fracture?
Fall onto an outstretched hand and tenderness in the anatomic snuffbox
*Avascular necrosis and nonunion
Best next steps after strongly caustic solution ingestion
- Assessment and stabilization of the airway, breathing and circulation
- Serial chest and abdominal x-rays➡Rule out perforation (pneumomediastinum, pleural effusions, subdiaphragmatic air)
- Upper GI x-ray study with water-soluble contrast if perforation suspected
- If no perforation suspected➡endoscopy within first 24 hours to assess severity
Earliest findings of macular degeneration. Risk factors.
- Distortion of straight lines (look wavy)→Grid test to screen
- Driving and reading first activities affected
- Ophtalmologic exam: drusen deposits in macula
- Increase age, smoking
Signs and symptoms of malignant hyperthermia
- Hypercarbia (↑cell metabolism)→Tachypnea
- Sinus tachycardia
- Masseter/generalized muscle rigidity
- Myoglobinuria (rhabdomyolysis)
- Hyperthermia→later manifestation, not usually present initially
Cause of malignant hyperthermia
Autosomal dominant or sporadic skeletal muscle receptor disorder→excessive calcium release→sustained muscle contraction
*Triggered by volatile anesthetics, succinylcholine, excessive heat
Most likely diagnosis in a patient with history of head trauma, episodic vertigo with nystagmus triggered by sudden pressure changes (valsalva maneuvers) or loud noises
Perilymphatic fistula→leakage of endolymph from the semicircular canals and cochlea into surrounding tissues►progressive sensorineural hearing loss (cochlear hair cells damage) and episodic vertigo with nystagmus
*Tullio phenomenon→pressure change due to sound conduction through the ossicles (loud noise, loud clap)►nystagmus
Uncorrectable causes of pancreatitis
- Hypotension
- Ischemia
- Viruses
- Atheroembolism (eg, cholesterol embolism after cardiac catheterization)
Clinical presentation of cholesterol emboli after vascular procedure (eg, cardiac catheterization)
- Skin: Livedo reticularis, blue toe syndrome
- Kidney: AKI
- GI: Pancreatitis, mesenteric ischemia
Reynolds pentad, and what does it suggest?
Acute cholangitis
- Fever
- Upper quadrant pain
- Altered mental status
- Jaundice
- Hypotension
What is the most likely diagnosis in a patient with gallstone pancreatitis and fever, RUQ pain, jaundice altered mental status and hypotension? What should be the management?
- Acute cholangitis
- After strenous IV fluid resucitation and antibiotics, Endoscopic retrograde cholangiopancreatography➡relieve the biliary obstruction
Important difference in clinical presentation between paralytic ileus and bowel obstruction
- Paralytic ileus: hypoactive bowel sounds
- Bowel obstruction: hyperactive “tinkling” bowel sounds. Peristaltic waves on the abdominal wall
Management of small spontaneous pneumothorax
- Observation
- Supplemental oxygen (regardless of oxygen saturation)➡⬆speed of resorption
Treatment of triglyceride-induced pancreatitis
- If Glucose≥500 mg/dL: consider insulin infusion▶limits fatty-acid release from adipocytes)
- If Glucose≥1000 mg/dL or severe pancreatitis (lactic acidosis, hypocalcemia, etc): apheresis▶removes triglyceride-rich plasma
*Always IV fluids and pain control
How do you confirm benign paroxysmal positional vertigo (BPPV)?
Dix-Hallpike maneuver➡vertigo and nystagmus on quickly lying back into a supine position with the head rotated 45 degrees
Most common cause of blindness in the US in the elderly and its treatment
- Macular Degeneration [Dry (80%)>Wet]
- Dry: No treatment
- Wet: VEGF Inhibitors➡Bevacizumab, Ranibizumab
How do you test for rotator cuff tear?
Drop arm test➡arm abducted over the head, patient is unable to lower the arm smoothly
*Complete supraspinatus tear
Most common complications of ERPC
- Pancreatitis (10%), and prevalent in sphincter of Oddi dysfunction
- Infection (ascending cholangitis)
- Perforation
Most likely diagnosis in an adult with knee pain and instability without joint effusion and tenderness along the patella
Chondromalacia patella
Steps in management when suspect blunt cardiac injury after blunt chest trauma
- Continuous cardiac monitoring 24-48 hours
- ECG
- If significant cardiac findings (arrhythmia, hypotension, heart failure)➡Echocardiography
Indication of Massive Transfusion Protocol
Patients with ≥2:
- Penetrating mechanism of injury
- Positive focused assessment with sonography
- SBP ≤90 mmHg
- Pulse ≥120/min
- 1:1:1 ratio of FFP/pRBC/Platelets - mitigates coagulopathy. Alternative is whole blood
- Adjunct therapy: Tranexamic acid, topical hemostatic agents
What suggests persistent large air leak after appropriate pneumothorax treatment with tube thoracostomy? Best diagnosis test.
- Tracheobronchial injury
- Dx: Bronchoscopy
Most common cause of postoperative hematoma in patients with no personal or family history of easy bleeding or bruising
Insufficient hemostasis
Most common risk factor for sigmoid volvuvlus
- Chronic constipation
- Colonic dysmotility (neurologic disorder)
Most effective management for palliative symptom control in a patient with nonresectable metastatic pancreatic cancer with elevated total bilirubin and pruritus
Endoscopic stent placement➡relieves common bile duct obstruction
