Surgery Flashcards

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1
Q

Best initial step when suspecting pancreatic cancer

A

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)
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2
Q

How do you see the liver adenoma in a technetium-99 sulfur colloid scan? Why?

A

Majority of liver adenoma don’t have Kupffer cells→don’t take up sulfur colloid→cold spots in the scan

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3
Q

Treatment for iridocyclitis

A

Immediate ophthalmology referral

  1. Cyclopegics→block nerve impulses to the pupillary sphincter and ciliary muscles (easing pain and photophobia) [muscarinic receptor blockers: atropine, tropicamide]
  2. Topical steroids →↓inflammation (only initiated after consultation with ophthalmology)
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4
Q

Mainstay treatment for osteoarthritis

A
  • Exercise→muscle strength and resistance training

- Weight loss

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5
Q

Hospital admission criteria in a colic pain by renal stone?

A
  • Patient can not tolerate oral hydration
  • Pain is uncontrolled with oral medications
  • Infection
  • One kidney
  • Significant renal impairment
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6
Q

What are the recommendations if a renal stone fails to pass spontaneously?

A
  • 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
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7
Q

How do you differentiate Lumbar spinal stenosis vs Lumbar disc herniation at physical exam?

A
  • Lumbar spinal stenosis→Flexion of the spine relieves the pain
  • Lumbar disc herniation→Flexion of the spine worst the pain
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8
Q

What is the purpose to measure the postvoid residual (PVR)?

A

Rule out overflow incontinence or urinary retention

  • Men normal < or same 50 mL
  • Women normal < or same 150 mL
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9
Q

What is the next step when you suspect foreign body in the eye and don’t see it with slit lamp?

A

Fluorescein application→abrasion or foreign body may be present although not seen on gross examination

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10
Q

Surgery time after supportive treatment of a complicated gallstones disease (acute cholecystitis, choledocholitiasis, gallstone pancreatitis)

A

Early cholecystectomy (within 72 hours)

*Reduces disease duration, duration of hospitalization and mortality compared to delayed cholecystectomy (>7 days after hospitalization)

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11
Q

Treatment of choice in acalculous cholecystitis

A
  • Antibiotics
  • Percutaneous cholecystostomy

*Cholecystectomy when medical condition stabilizes

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12
Q

Radiologic signs of acalculous cholecystitis

A
  • Gallbladder wall thickening and distension

- Pericholecystic fluid

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13
Q

Next steps in a hemodynamically stable patient with blunt abdominal trauma without peritonitis

A

*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

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14
Q

Next steps in a hemodynamically unstable patient with blunt abdominal trauma without peritonitis

A
- FAST
(+) Laparotomy
Inconclusive: Diagnostic Peritoneal Lavage [(+) Lapratomy, (-):
(-) Signs of extra-abdominal hemorrhage:
Yes→Stabilize (ex, angiography, splint)
No→Stabilize and CT of abdomen
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15
Q

Physiopathology and treatment of urinary urgency incontinence

A
  • Overactive bladder→detrusor instability
  • Tx: Kegel exercises, bladder training (timed voiding, distraction or relaxation techniques), antimuscarinics
    (eg, oxybutynin), B-agonists (eg, Mirabregon)
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16
Q

Which is the most appropriate next step when suspect an obstructive jaundice caused by tumor?

A

CT Scan of the abdomen

*Usually ultrasonography is done first

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17
Q

Most common tumors that can cause obstructive jaundice

A
  • Adenocarcinoma at the head of the pancreas
  • Adenocarcinoma of the ampulla of Vater
  • Cholangiocarcinoma arising in the common duct itself
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18
Q

Most appropriate first step in management trauma of the urethra

A

Retrograde urethrography or urethrogram

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19
Q

Most appropriate next step when diagnosed basal cell carcinoma on the face

A

Mohs Micrographic Surgery➡sequential removal of thin skin layers with microscopic inspection to confirm the margins cleared of malignant tissue

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20
Q

How do you explain hematuria in a Abdominal Aortic Aneurysm rupture?

A

Rupture into the retroperitoneum→create aortocaval fistula with inferior cava vena→venous congestion in retroperitoneal structures (bladder)→fragile and distended veins rupture►gross hematuria

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21
Q

Triad to suspect biliary cyst

A

Abdominal pain, jaundice (obstructive cholestasis) and palpable mass

*Normal gallbladder on sonography

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22
Q

Treatment for biliary cyst. What do you want to avoid?

A

Surgical resection►relieves the obstruction and reduces the risk of malignancy➡cholangiocarcinoma, gallbladder cancer, pancreatic cancer

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23
Q

Pneumobilia + Hyperactive bowel sounds + Nausea, Vomiting + Dilated loops of bowel + Diffuse abdominal pain in several days. Disease and mechanism.

A

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

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24
Q

Potential cause and explanation of splenic abscess

A

Complication of bacteremia from a distant infection (infective endocarditis, cholecystitis)

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25
Q

Risk factors of splenic abscess

A

Immunosupression from HIV, diabetes mellitus, hematologic malignancy

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26
Q

Most common cause of referred otalgia

A
  1. Dental disease and Temporomandibular joint disorders
  2. 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
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27
Q

How may you distinguish a cardiogenic from a hypovolemic shock?

A
  • Both are pale/cool
  • Cardiogenic: ↑Left ventricular end diastolic pressure (LVEDP) or Pulmonary capillary wedge pressure (PCWP)
  • Hypovolemic: ↓LVEDP or PCWP
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28
Q

Warm and flushed types of shock, How do you differentiate them?

A
  • Neurogenic shock: ↓Cardiac output

- Septic shock: ↑Cardiac output

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29
Q

Warm/flushed type of shock with elevated cardiac output and decreased PCWP?

A

Anaphylactic shock

*No change PCWP and ↑CO→Septic shock

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30
Q

Best management in an unstable patient with pelvic fracture

A

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

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31
Q

Types of bladder injuries in a pelvic fracture and management

A
  • Extraperitoneal bladder injury (bladder neck/trigone rupture)→ place Foley catheter
  • Intraperitoneal bladder injury (bladder dome rupture)→surgical correction
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32
Q

Malignancies to think in young men (15-35)

A

Testicular cancer, Lymphoma, Leukemia

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33
Q

Metastatic process of testicular cancer and associated symptoms

A
  • Retroperitoneal lymph nodes→compression adjacent structures [nerves roots, psoas muscle]►Lumbar back pain
  • Lung and liver mestastasis
  • Lung→nodules►cough or dyspnea
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34
Q

Symptoms and signs of schwannoma and why are they caused?

A
  • 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
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35
Q

Sensorineural hearing loss

A

Air conduction>Bone conduction, lateralization to the unaffected ear

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36
Q

Conductive hearing loss

A

Bone conduction>air conduction, lateralization to the affected ear

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37
Q

What might suggest a bruising on the flank after trauma? Which is the sign?

A

Grey Turner sign➡Retroperitoneal hemorrhage

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38
Q

Most accurate test for acute and chronic mesenteric ischemia and ischemic colitis

A

Angiography

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39
Q

How may you distinguish by risk factors acute mesenteric ischemia vs colitis ischemia or chronic mesenteric ischemia?

A
  • AMI➡#1 risk factor Atrial Fibrillation

- Ischemic colitis or CMI➡#1 risk factor Atherosclerotic disease (prior MI, PAD or Stroke)

40
Q

What is the Median Arcuate Ligament Syndrome (MALS) or Celiac compression syndrome? Symptoms.

A
  • External compression of the celiac trunk by the median arcuate ligament
  • Severe postprandial abdominal pain, nausea, and weight loss
41
Q

Important sign of Boerhaave syndrome during physical examination at the thorax

A

Hamman sign➡crunching heard upon palpation of the thorax➡subcutaneous emphysema

42
Q

Most common complication after diverticulitis.

A

Abscess formation

43
Q

For which symptom you must ask that is highly correlated with diverticulitis?

A

Constipation

44
Q

Most accurate test for cholecystitis

A

HIDA scan: Hepatobiliary iminodiacetic acid gammagraphy or cholescintigraphy

45
Q

Treatment for bowel obstruction from stool impaction by chronic opioid use

A

Methylnaltrexone (Relistor)

46
Q

Treatment options for fecal incontinence

A
  • Bulking agents➡fiber
  • Biofeedback➡control exercises and muscle-strengthening exercises
  • Dextranomer/hyaluronic acid (Solesta) injection➡⬇50% incontinence episodes

*If all fails, colorectal surgery

47
Q

Most common knee ligament injury

A

Anterior cruciate ligament (ACL)

48
Q

Management of aortic abdominal aneurysm (AAA)

A
  • 3-4 cm➡US/2-3 years
  • 4-5,4 cm➡CT or US/6-12 months
  • > 5,5 cm➡even asymptomatic, surgery
49
Q

Most likely cause of postoperative fever at day 3-5?

A

Urinary tract infection

50
Q

What is the Klatskin tumor?

A

Hilar cholangiocarcinoma➡at the confluence of the right and left hepatic bile ducts

51
Q

Treatment for urinary stress incontinence that does not respond to measures

A

Duloxetine

52
Q

Types of priapism and how do you distinguish them?

A
  • Ischemic➡ABG➡hypoxemia, black blood, hypercarbia, acidemia
  • Nonischemic➡ABG➡red blood, normal pO2, pCO2 and pH

*Blood aspirated from corpora carvenosa

53
Q

Which sign on physical examination you should explore to assess thoracic outlet syndrome?

A

Adson sign➡loss of radial pulse upon rotating the head to the ipsilateral side with neck extended and taking deep inspiration

54
Q

Most common cause of thoracic outlet syndrome

A

Congenital cervical rib➡extra rib that arises from 7th cervical vertebra

55
Q

What is the early dumping syndrome?

A

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

56
Q

What is the late dumping syndrome?

A

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

57
Q

Etiology of each cause of priapism

A
  • Ischemic➡⬇venous flow

- Nonischemic➡fistula between cavernosal artery and corporal tissue (associated with trauma to the perineum)

58
Q

Most common complication of the anterior shoulder dislocation

A

Axillary nerve injury

  • Teres minor, deltoid innervation➡weakened shoulder abduction
  • Sensory lateral shoulder➡⬇sensation
59
Q

Treatment for acute angle-closure glaucoma

A
  • 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

60
Q

Treatment for Herpes keratitis. Which medication you must avoid?

A
  • Oral acyclovir, famciclovir, or valacyclovir
  • Topical antiherpetic: trifluridine and idoxuridine.
  • Steroids make the condition worse
61
Q

How do you identify Herpes keratitis?

A

Fluorescein staining➡dendritic pattern

62
Q

How may you differentiate retinal artery vs vein occlusion?

A
  • Retinal artery occlusion➡pale retina (swelling), dark macula (cherry-red macula), bloodless arteries
  • Retinal vein occlusion➡venous stasis▶extravasation of blood (hemorrhages)
63
Q

What is the Lemierre syndrome?

A

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

64
Q

What is the Tolosa-Hunt syndrome? Treatment.

A
  • Granulomatous inflammation of the cavernous sinus with ophthalmoplegia (paralysis III, IV, VI CN)
  • Steroids
65
Q

Why should you do close cardiac monitoring during laparoscopic surgery?

A

Insufflation of CO2 into abdominal cavity➡peritoneal stretch receptors➡⬆vagal tone➡severe bradycardia, AV block, asystole

*Also mechanical ⬆ in systemic vascular resistance➡⬆blood pressure

66
Q

Cause of gallstones formation in a patient with total parental nutrition

A

TPN or prolonged fasting➡⬇cholecystokinin➡❌gallbladder contraction➡ Gallbladder stasis

67
Q

Why chron disease and small bowel resection are associated with gallstones formation?

A

Decreased enterohepatic circulation of bile acids➡altered hepatic bile composition➡supersaturated of cholesterol▶gallstones

68
Q

What is sympathetic ophthalmia?

A

“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

69
Q

What is a postcholecystectomy syndrome? Causes.

A

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
70
Q

What liver function test is associated with pancreatitis?

A

ALT>150➡95% positive predictive value for diagnosing gallstone pancreatitis

71
Q

Best next test after reduction of knee dislocation

A
  1. Palpation pulses distal and popliteal
  2. Rule out popliteal artery injury➡Measure ankle-brachial index▶ABI<=0.9➡emergency CT angiogram, vascular consultation
  3. Duplex ultrasonography
72
Q

Next steps when scaphoid fracture is suspected and initials x-rays are negative

A
  • 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.
73
Q

When do you suspect scaphoid fracture?

A

Fall onto an outstretched hand and tenderness in the anatomic snuffbox

*Avascular necrosis and nonunion

74
Q

Best next steps after strongly caustic solution ingestion

A
  • 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
75
Q

Earliest findings of macular degeneration. Risk factors.

A
  • 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
76
Q

Signs and symptoms of malignant hyperthermia

A
  • Hypercarbia (↑cell metabolism)→Tachypnea
  • Sinus tachycardia
  • Masseter/generalized muscle rigidity
  • Myoglobinuria (rhabdomyolysis)
  • Hyperthermia→later manifestation, not usually present initially
77
Q

Cause of malignant hyperthermia

A

Autosomal dominant or sporadic skeletal muscle receptor disorder→excessive calcium release→sustained muscle contraction

*Triggered by volatile anesthetics, succinylcholine, excessive heat

78
Q

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

A

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

79
Q

Uncorrectable causes of pancreatitis

A
  • Hypotension
  • Ischemia
  • Viruses
  • Atheroembolism (eg, cholesterol embolism after cardiac catheterization)
80
Q

Clinical presentation of cholesterol emboli after vascular procedure (eg, cardiac catheterization)

A
  • Skin: Livedo reticularis, blue toe syndrome
  • Kidney: AKI
  • GI: Pancreatitis, mesenteric ischemia
81
Q

Reynolds pentad, and what does it suggest?

A

Acute cholangitis

  • Fever
  • Upper quadrant pain
  • Altered mental status
  • Jaundice
  • Hypotension
82
Q

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?

A
  • Acute cholangitis
  • After strenous IV fluid resucitation and antibiotics, Endoscopic retrograde cholangiopancreatography➡relieve the biliary obstruction
83
Q

Important difference in clinical presentation between paralytic ileus and bowel obstruction

A
  • Paralytic ileus: hypoactive bowel sounds

- Bowel obstruction: hyperactive “tinkling” bowel sounds. Peristaltic waves on the abdominal wall

84
Q

Management of small spontaneous pneumothorax

A
  • Observation

- Supplemental oxygen (regardless of oxygen saturation)➡⬆speed of resorption

85
Q

Treatment of triglyceride-induced pancreatitis

A
  • 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

86
Q

How do you confirm benign paroxysmal positional vertigo (BPPV)?

A

Dix-Hallpike maneuver➡vertigo and nystagmus on quickly lying back into a supine position with the head rotated 45 degrees

87
Q

Most common cause of blindness in the US in the elderly and its treatment

A
  • Macular Degeneration [Dry (80%)>Wet]
  • Dry: No treatment
  • Wet: VEGF Inhibitors➡Bevacizumab, Ranibizumab
88
Q

How do you test for rotator cuff tear?

A

Drop arm test➡arm abducted over the head, patient is unable to lower the arm smoothly

*Complete supraspinatus tear

89
Q

Most common complications of ERPC

A
  1. Pancreatitis (10%), and prevalent in sphincter of Oddi dysfunction
  2. Infection (ascending cholangitis)
  3. Perforation
90
Q

Most likely diagnosis in an adult with knee pain and instability without joint effusion and tenderness along the patella

A

Chondromalacia patella

91
Q

Steps in management when suspect blunt cardiac injury after blunt chest trauma

A
  • Continuous cardiac monitoring 24-48 hours
  • ECG
  • If significant cardiac findings (arrhythmia, hypotension, heart failure)➡Echocardiography
92
Q

Indication of Massive Transfusion Protocol

A

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
93
Q

What suggests persistent large air leak after appropriate pneumothorax treatment with tube thoracostomy? Best diagnosis test.

A
  • Tracheobronchial injury

- Dx: Bronchoscopy

94
Q

Most common cause of postoperative hematoma in patients with no personal or family history of easy bleeding or bruising

A

Insufficient hemostasis

95
Q

Most common risk factor for sigmoid volvuvlus

A
  • Chronic constipation

- Colonic dysmotility (neurologic disorder)

96
Q

Most effective management for palliative symptom control in a patient with nonresectable metastatic pancreatic cancer with elevated total bilirubin and pruritus

A

Endoscopic stent placement➡relieves common bile duct obstruction