Surgery 6 Flashcards
Presentation - painful swelling of the parotid gland that is aggravated by chewing; high fever, tender/swollen/erythematous parotid gland, purulent saliva expressed from the duct; leukocytosis
Acute bacterial parotitis
What can be done to prevent acute bacterial parotitis in the post-op setting?
Adequate fluid hydration and oral hygiene in the pre- and post-operative setting
Most common infectious agent in acute bacterial parotitis?
S. aureus
___ has been shown to reduce post-operative pulmonary complications by 50%.
Incentive spirometry
Perioperative use of ___ in patients with CAD decreases the likelihood of MI.
Beta-blockers
Perioperative ABX should routinely be given to patients undergoing ___ surgery.
Abdominal
___ is one of many proven methods of preventing post-operative complications, particularly DVT.
Early ambulation
Presentation - preceding violent muscle contractions; arm held in adduction and internal rotation, impaired external rotation, flattening of the anterior aspect of the shoulder, prominence of the coracoid process
Posterior shoudler dislocation
X-ray appearance of posterior shoulder dislocation?
Loss of the normal relation/overlap between the humeral head and glenoid; internal rotation of the humeral head (circular appearance -> light bulb sign), widened joint space (>6 mm) = rim sign, 2 parallel cortical bone lines on the medial aspect of the humeral head (trough line sign)
Management of posterior dislocation?
Closed reduction
Potential complications of posterior shoulder dislocation?
Fractures of the proximal humerus, labral injuries, tears to the rotator cuff system
Most common form of shoulder dislocation? Most common injury causing this?
Anterior dislocation; direct blow or fall on an outstreched arm
How does an anterior dislocation present (appearance of arm)?
Slightly abducted and externally rotated
What is Todd paralysis?
Transient unilateral weakness following a tonic-clonic seizure, resolves spontaneously
What is this maneuver and what is it looking for - the physician places the stethosocope over the upper abdomen and rocks the patient back and forth at the hips?
Abdominal succussion splash
Retained gastric material >3 hours after a meal will generate a splash sound, indicating the presence of a hollow viscus filled with fluid and gas
Modest sensitivity and specificity for diagnosing gastric outlet obstruction
Initial managemnet of gastric outlet obstruction?
NG suctioning to decompress the stomach
IV hydration
Endoscopy for definitive diagnosis
Presentation - pain and weakness in the shoulder; with the arm abducted over the head, the patient may be unable to lower the arm smoothly (drop arm test)
Rotator cuff tear
Components of the rotator cuff?
Tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles
Which part of the rotator cuff is most commonly injured and why?
Supraspinatus, due to degeneration of the tendon with age and repeated ischemia induced by impingement between the humerus and the acromion during abduction
Dx and Rx rotator cuff tear?
MRI; surgery
Presentation - injury caused by forceful flexion of the arm; sudden pain with an audible pop and a visible bulge (Popeye sign)
Biceps tendon tear
Presentation - paralysis of the deltoid and teres minor muscles, sensory loss over the lateral upper arm; bony tenderness, swelling, ecchymosis, or crepitus over the site of injury
Fracture of the surgical neck of the humerus -> axillary nerve injury
Although the deltoid is responsible for shoulder abduction between 15-90 degrees, deltoid weakness is best appreciated with what maneuver?
At extreme extension rather than abduction
Presentation - weak serratus anterior with impairment at extreme abduction (>90 degrees) due to inability to rotate scapular upward, caused by penetrating trauma or procedures
Long thoracic nerve injury
Presentation - weakness and atrophy of the hypothenar and interosseous muscles, claw hand deformity, caused by injury with sudden upward traction on the arm
Injury to the lower (inferior) trunk of the brachial plexus (orginates from C8 and T1 cervical roots); affects muscles supplied by the ulnar nerve
Distinguish between rotator cuff impingement or tendinopathy vs. rotator cuff tear.
PAIN with abduction and external rotation vs. WEAKNESS with abduction and external rotation
Impingement/tendinopathy -> normal ROM with positive impingement
Management of amputation injury?
Amputated parts should be wrapped in saline-moistened sterile gauze, sealed in a plastic bag, placed on ice, and brought to the ED with patient
Who are the best candidates for amputation reimplantation?
Younger patients suffering sharp amputations with no crush injury or avulsion
Presentation - new-onset watery diarrhea, fever, leukocytosis, mild abdominal tenderness, recent ABX use
May present as fulminant colitis/toxic megacolon
C. difficile colitis
Risk factors for C. difficile colitis?
Recent ABX use (mostly commonly FQs, PCN, cephalosporins, clindamycin)
Hospitalization
PPI use
Advanced age
Dx C. difficile colitis?
Stool PCR for toxin (high sensitivity, specificity)
Rx C. difficile colitis?
Oral metronidazole
Vancomycin
Initial management of patient with septic shock?
- Secure an airway if necessary
- Restore adequate tissue perfusion through IV 0.9% saline (crystalloid) -> IV boluses (500-1000 mL) to improve systolic BP >90 mmHg
- Identify and Rx the underlying infection
Why is crystalloid the fluid of choice to restore volume quickly vs. albumin?
It is just as effective as albumin in terms of survival, but less costly and easier to acquire
When should vasopressors be started to improve perfusion in a patient with septic shock?
If a patient fails to respond to adequate IV fluid resuscitation or develops evidence of volume overload without improvement in blood pressure
When is IV hydrocortisone used in septic shock?
In patients who do not respond to volume resuscitation and initiation of vasopressors
Rx malignant hyperthermia?
Dantrolene (skeletal muscle relaxant)
Cooling measures
X-ray of the ankle is required in what situations based on the Ottawa ankle rules?
Pain at the malleolar zone AND:
- Tender at posterior margin/tip of medial malleolus or
- Tender at posterior margin/tip of lateral malleolus or
- Unable to bear weight 4 steps (2 on each foot)
X-ray of the foot is required in what situations based on the Ottawa ankle rules?
Pain at the midfoot zone AND:
- Tender at the navicular or
- Tender at the base of the 5th metatarsal or
- Unable to bear weight 4 steps (2 on each foot)
Presentation - injury caused by forceful inversion of the foot during running, walking on even surfaces, or a fall from a height; swelling of the lateral ankle, tenderness over the ligaments. Range from stable/weightbearing to ecchymosis, anterior or inversion laxity, and impaired weightbearing
Lateral ankle sprain
Most commonly injured ligament in a lateral ankle sprain
Anterior talofibular ligament
Management of lateral ankle sprain?
If tenderness only over the ligaments distal to the lateral malleoli + bear weight -> conservative management (compression bandage or brace, ice packs, crutches, etc.) without imaging
If Ottowa rules met -> X-ray to rule out a distal fibular fracture
Classic presentation - insidious onset of constant/gnawing epigastric pain, frequently worse at night, anorexia with weight loss, jaundice due to extrahepatic biliary obstruction
Pancreatic cancer
Risk factors for pancreatic adenocarcinoma
Smoking
Hereditary pancreatitis
Non-hereditary chronic pancreatitis
Obesity and lack of physical activity
Clinical presentation of pancreatic adenocarcinoma
Systemic symptoms (>85%) Abdominal pain/back pain (80%) Jaundice (56%) Recent-onset atypical diabetes mellitus Unexplained migratory superficial thrombophelbitis (Trousseau sign) Hepatomegaly and ascites with mets
Lab findings in pancreatic adenocarcinoma
Cholestasis (increased alk phos and Dbili)
Increased CA 19-9 (not a screening test)
Abdominal U/S (if jaundiced) or CT (if no jaundice)
What is a hiatal hernia?
Common disorder that occurs when the contents of the abdominal cavity herniate through the diaphragm into the thoracic cavity at the esophageal hiatus
Appearance of hiatal hernia on plain radiography?
Retrocardiac opacity (often with an air/fluid level) within the thoracic cavity
Management of asymptomatic sliding hiatal hernia?
Observation
Management of symptomatic sliding hiatal hernia (reflux symptoms vs refractory GERD symptoms)
Reflux - medical management (PPIs, etc.)
Refractory - consider anti-reflux surgery (Nissen fundoplication)
What does 24-hour esophageal pH monitoring evaluate?
GERD
What does esophageal manometry evaluate?
Suspected esophageal motility diorders
What is the cause of acquired methemoglobinemia?
Oxidization of iron in hemoglobin to methemoglobin, which cannot bind oxygen; the remaining normal hemoglobin has an increased affinity for oxygen, resulting in less deelivery to tissues; most commonly due to topical anesthetic agents or dapsone (and nitrates in infants)
Presentation - hypoxia, characteristic pulse oximetry reading of ~85%, large oxygen saturation gap (false elevation on ABG)
Acquired methemoglobinemia