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Step 2 UWORLD > Surgery > Flashcards

Surgery Flashcards

1
Q

most common cause of LE edema

A

venous insufficiency (valvular incompetence)…NOT arterial occlusion

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2
Q

Sxs of arterial occlusion

A 
6 P's of PVD: 
Pallor
Pain 
Pulselessness
Paresthesias
Poikolothermia (cold)
Paralysis
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3
Q

How to test for PVD?

A

ABI via Doppler studies: Ankle-Brachial Index:
Normal = 0.9-1.3
1.3 = calcified incompressible vessels, needs more studies

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4
Q

Unilateral LE edema that worsens in dependent position (moving around) and better with elevation (sleeping)

A

Venous insufficiency secondary to valvular incompetence

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5
Q

Findings suggestive of aortic injury after MVC

A

Widened mediastinum, left-sided hemothorax, rightward mediastinum deviation, disruption of normal aortic contour. Sxs = Anxiety, HYPERtension, TACHYcardia

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6
Q

Tx of aortic injury after MVC

A

beta-blockers (anti-hypertensive) and immediate operative repair

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7
Q

widened mediastinum and left-side hemothorax

A

Aortic injury post high force blunt trauma (MVC)

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8
Q

T/F: High energy, blunt, rapid deceleration injury i.e. MVC commonly results in aortic injury, which usually results in death unless contained

A

True

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9
Q

Shock characterized by:

Increased/upper normal PCWP

A

Cardiogenic –> Myocardial contusion

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10
Q

Infusion of saline increases patients PCWP, does not increase SBP. Type of shock?

A

Cardiogenic –> Myocardial contusion

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11
Q

Who gets screened for AAA?

A

Men 65-75 with a hx of smoking get a one time screening. Not surgically repaired until >5cm or >1cm growth/year.

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12
Q

common peripheral artery aneurysms

A

Popliteal and then femoral. Commonly associated with AAA. Cause ischemia and pain (compression of nerve)

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13
Q

Aortoiliac artery occlusion (Leriche syndrome) triad

A
  1. thigh/hip/buttock claudication
  2. impotence
  3. symmetric atrophy b/l LE
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14
Q

Hemodynamic instability/ipsilateral flank or back pain after cardiac catheterization

A

Retroperitoneal hematoma –> need to get a non-contrast CT abdomen/pelvis or US

*note: will have flat jugular veins (vs tamponade will have distended)

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15
Q

Where is ischemic colitis most likely to occur?

A

Watershed areas: Splenic flexure and rectosigmoid. Is Non-Occlusive, so either due to hypotension or underlying atherosclerotic disease

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16
Q

What is a watershed area?

A

area between the territory of two arteries, i.e. splenic flexure (SMA and IMA) and rectosigmoid (Sigmoid and superior rectal). This is where ischemic colitis is most likely to occur

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17
Q

Whats the difference between ischemic colitis and mesenteric ischemia?

A

Ischemic colitis: Colon. Usually occurs due to hypotension in watershed areas (splenic flexure/rectosigmoid)

Mesenteric Ischemia: Due to thromboembolic (afib) or atheroembolic (endovascular procedures) events, pain is severe but is poorly localized and OUT OF PROPORTION

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18
Q

Management of ischemic colitis

A

Occurs in watershed after hypotension or atherosclerotic disease

  • immediate CT with contrast to identify need for surgical intervention –> colectomy (perf/extensive damage).
  • IV fluids + ABx + Colonoscopy to confirm dx
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19
Q

T/F: Patient with classic signs of appendicitis (pain over McBurneys point, +Rovsing’s sign, leukocytosis and fever) needs CT before appe

A

False. If signs are classic then go to OR to avoid complications like perforation. Only need imaging if not convinced clinically

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20
Q

Patients with appendicitis for >5 days have probably developed what?

A

An phlegmon with an abscess that has walled off. Mnage with IV Abx, bowel rest and a delayed appendectomy weeks later

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21
Q

RUQ pain, fever, nausea/vomiting and gas in the gallbladder wall/crepitus

A

Emphysematous cholecystitis…life-threatening form of actue chole due to infection with Clostridium or e coli. Risk factors = Diabetes, vascular compromise, immunosuppression

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22
Q

Imaging for patient with blunt genitourinary trauma (i.e renal lac)

A
  • All get UA
  • Hematuria –> Contrast-enhanced CT (most common)
  • Gross hematuria, difficulty urinating, and blood @ meatus (urethral injury)/suprapubic pain (bladder rupture) –> Retrograde Cystourethrograms (so not most common test to get)
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23
Q

CT scan findings in ischemic colitis

A

bowel wall thickening

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24
Q

partial vs complete SBO (imaging)

A

Partial: air in colon
Complete: transition point, no air in colon

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25
Q

colicky abdominal pain, vomiting, inability to pass flatus or stool, abdominal distension and diffuse tenderness

A

SBO

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26
Q

Mgmt of SBO (small bowel obstruction)

A
  • Normal: Bowel rest, NG tube, correct metabolic deragnements
  • Complicated (fever, hypotension/tachycardia, guarding, keukocytosis, metabolic acidosis (low bicarb): Urgent ex lap before perforation n
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27
Q

T/F: Atelectasis is a common post-op pulmonary complication, esp after abdominal

A

True…pain and changes in lung compliance can cause impaired cough and shallow breathing, limiting recruitment of alveoli @lung bases and weak cough predisposes o small-airway mucus plugging. Get hypoxia, which increase resp rate = low CO2

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28
Q

Why is there respiratory alkalosis during atelectasis?

A

Get small airway mucus plugging/shallow breathing…results in low pO2, which stimulates respiratory drive = hyperventilation = low pCO2

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29
Q

How do we decrease risk of atelectasis post-op?

A

Incentive spirometry! Also, pain control and early mobilization

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30
Q

T/F: We use prophylactic antibiotics to reduce risk of post-op pneumonia

A
  • False, these are only used if pre-existing infection. -INCENTIVE SPIROMETRY = BEST
  • can use deep breathing exercises, CPAP, and intermittent positive pressure breathing
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31
Q

define flail chest

A

> 3 contiguous ribs fractured in 2 or more location. Will see paradoxical chest wall motion with inspiration (i.e. moves inward) + chest pain/rapid shallow breaths

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32
Q

lower GI bleed + abdominal tenderness

A

highly suggestive of colitis (IBD, ischemic colitis, infectious diarrhea)

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33
Q

lower GI bleed + iron deficiency anemia

A

suggestive of malignancy (CRC)

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34
Q

left side abdominal pain and bloody diarrhea in old person with dehydration/heart failure/shock/trauma

A

ischemic colitis

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35
Q

most common cause of lower GI bleed

A

diverticulosis

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36
Q

T/F: Left colonic diverticula are more likely to be source of lower GI bleed than right

A

False. Most diverticula are left sided, but most that bleed are from the right side

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37
Q

T/F: 60% of people over 60 have diverticula

A

true

38
Q

most common site of diverticula

A

95% in sigmoid colon (b/c harder stool b/c water reabsorbed and dec lumen diameter)

39
Q

T/F: Diverticulosis and diverticulitis both bleed

A

False, typically diverticulosis bleeds.

40
Q

CT scan findings of mesenteric ischemia

A

small bowel thickening, occlusion of SMA and gas in bowel wall (pneumatosis)

41
Q

Initial steps in management of a lower GI bleed

A
  • Place 2 large-bore IV
  • send lab tests for cross and match, CBC, INR
  • if sig blood loss, resusc with crystalloid and possibly PRBCs
  • place NG tube (to r/o upper GI bleed…NG aspirates bile without blood)
42
Q

first diagnostic step of choice in hemodynamically unstable patient with lower GI bleed (NG already done)?

A
  1. Colonoscopy done urgently w/o bowel prep (unless they can wait a day)
    -if this doesnt help localize bleeding, 2 more options:
    2A. Diagnostic arteriography
    2B. Nuclear scintography (tagged rbc scan, nuclear med)
43
Q

What are the two types of spontaneous pneumothorax?

A

Primary (thin young men)

Secondary (to underlying lung dz…COPD)

44
Q

signs and sxs of spontaneous vs tension pneumo

A

Spontaneous: chest pain, dyspnea, dec breath sounds/chest movement, ipsi hyper resonance

Tension= all of that + hemodynamic instability + tracheal deviation across from normal side

45
Q

management of pneumothorax

A

Spontaneous: Small (<2cm) = observe and O2
rest = needle aspiration or chest tube

Tension: urgent needle decompression or chest tube

46
Q

where is needle placed from decompressiong a large pneumothorax?

A

2nd-3rd MCL or “%th interfost space

47
Q

hx of blunt trauma/MVC, abnormal CXR and lower lung , mediastinal shift

A

diaphragmatic rupture. get a CT

48
Q

NG tube in the pleural cavity

A

diaphragmatic hernia

49
Q

blunt abdominal trauma, i.e. MVC, leading to respiratory distress and decreased breath sounds on the left side

A

Diaphragmatic hernia…sudden increase in intra-abdominal P leads to tear in diaphragmatic musculature…left more susceptible b/c not protected by liver…compression of lungs and mediastinal shift

50
Q

T/F: Mediastinal shift and respiratory distress after MVC = pneumothorax always

A

False. Blunt abdominal trauma = diaphgramatic rupture = diaphragmatic hernia

51
Q

Adducted and internally rotated leg following trauma suggests:

A

Acetabular fracture with posterior dislocation

52
Q

high-riding prostate after trauma on DRE

A

worry about urethral/bladder injury. If blood at urethral meatus, need retrograde urethrogram, and then retrograde cystogram (esp if hematuria/not voiding)

53
Q

Initial hematuria vs terminal hematuria vs total hematuria

A

Initial: Urethra (Urethritis, injury/trauma)

Terminal: Bladder (cystitis, urothelial cancer), Stone or Prostate (cancer or BPH)

Total: Kidney (stone, mass, GN, PKD, pyelo, cancer, trauma)

54
Q

Risk of mechanical ventilation in hypovolemic shock

A

Already have low CVP. Vent causes increase in intrathoracic P which = collapse of venous capacitance vessels = no venous return to RA = no CO = cardiac arrest

55
Q

Trauma patient with hypotension, tachycardia and tracheal deviation: decreased breath sounds, hyperresonance to percussion

A

Tension pneumo

56
Q

Trauma patient hypotension, tachycardia and tracheal deviation: absent breath sounds, dullness to percussion

A

Hemothorax

57
Q

T/F: All burn victims should initially get tx with high flow O2 via non-rebreather mask

A

True! And low threshold for intubation, because can get supraglottic airway compromise (it exchanges heat with air and susceptible to thermal injury…edema = resp block). ABCs!!

58
Q

tx if you suspect tension pneumothorax

A

immediate needle thoracostomy in hemodynamically unstable pt (2nd intercostal space in MCL. alt: 5th intercostal in midaxillary). Followed by emergency tube thoracostomy

59
Q

Rapid onset of tachycardia, hypotension, tachypnea, distention of neck veins due to compression of _____ = _____

A

superior vena cava. Tension pneumothorax

60
Q

most common cause of urethral injury

A

Iatrogenic –> during abdominal surgery

61
Q

T/F: Ability to pass a foley catheter makes urethral injury unlikely

A

True

62
Q

tachypnea, tachycardia and hypoxia <24 hours after blunt trauma/MVC

A

Pulmonary contusion

63
Q

hypoxia and CXR/CT showing patchy, alveolar infiltrate following MVC/blunt trauma with decreased breath sounds on one side

A
  • Pulmonary contusion within 24 hours

- ARDS = complication of PC, 24-48 hour out and bilateral patchy alveolar infiltrates

64
Q

Mgmt of pulmonary contusion (occurs <24 hours after trauma)

A

Pain control
Pulm toilet (nebs, PT)
Oxygen

65
Q

Bladder injury causing chemical peritonitis (spillage of urine causing guarding/pain and referred pain to shoulder)

A

Bladder dome rupture!

Note: anterior bladder wall and bladder neck = extraperitoneal…usually injured from pelvic fracture…get extraperitoneal leakage of urine = localized lower abdominal pain

66
Q

In the trauma setting, subcutaneous emphysema (crepitus) is caused by ________ until proven otherwise

A

Pneumothorax

67
Q

Cushings reflex that indicates elevated ICP (3)

A

hypertension, bradycardia, respiratory depression

68
Q

loss of pain and temp in UE following whiplash MVC

A

syringomyelia ( can have delayed presentation years later)

69
Q

5 or 6 yo kid who is cyanotic, small for his age, clubbing

A

Tetralogy of Fallot

R->L shunts = cyanosis, 5 T’s…Tet is most common and children can grow into infancy

70
Q

1 or 2 day old child with cyanosis who is in deep trouble

A

Get an ECHO…most likely Transposition of the Great Vessels. Req ASD, VSD, or PDA to survive but will die soon if not corrected.

71
Q

Harsh mid-systolic murmur, angina and exertional syncope

A

Aortic Stenosis

72
Q

Blowing, high pitched diastolic heart murmur best heard at 2nd lower LSB

A

Aortic Regurg

73
Q

Why would a young person develop acute aortic regurg?

A

Drug addict gets endocarditis. Will develop CHF and new, loud diastolic murmur @ right 2nd intercostal space

74
Q

Mitral stenosis is caused by:

A

Rheumatic fever

75
Q

Sxs of mitral stenosis

A 
Dyspnea on exertion
Orthopnea
PND
Cough
Hemoptysis 
Afib
76
Q

First thing to do in a patient with hx of smoking that shows Coin Lesion on CXR

A

find an old xray to compare

77
Q

most common intracranial tumor

A

metastatic from Lung>Breast>Melanoma

78
Q

most common primary brain tumor

A

Gliomas and then meningiomas

79
Q

most malignant brain tumor

A

GBM

80
Q

how can you tell if a stroke/vascular problem is ischemic vs hemorrhagic

A

+HA: Hemorrhagic

-HA: Occlusive/Ischemic

81
Q

Patient is awaiting surgical removal of brain tumor. What do you use to treat the increased ICP?

A

High-dose steroids (dexamethasone)

82
Q

Testicular Torsion vs Acute Epididymitis: surgical emergency?

A

Torsion

83
Q

Testicular Torsion vs Acute Epididymitis: Fever and pyuria

A

Epididymitis only

84
Q

Testicular Torsion vs Acute Epididymitis: Tender cord

A

Epididymitis only

85
Q

Testicular Torsion vs Acute Epididymitis: Ages

A

Torsion: young adolescent
Epidy: young man, sexually active age

86
Q

Testicular Torsion vs Acute Epididymitis: Acute onset severe testicular pain

A

both!

87
Q

How do you tx acute epididymitis?

A

First get an US to r/o testicular torsion (surg emergency). Then antibiotics

88
Q

Patient is being allowed to pass ureteral stone but develops high fevers, chills and flank pain. Dx?

A

Obstruction and infection of the urinary tract –> Dire emergency!!!

89
Q

Why is a combined obstruction and infection of the urinary tract a dire emergency?

A

Can lead to destruction of kidney in few hours and death from sepsis. Give IV antibiotics and immediate decompression (ureteral stent or percutaneous nephrostomy)

90
Q

Urologic workup: Sonogram, CT scan, Cystoscopy. When are these used?

A

US: Dilation/obstruction
CT: Renal tumors
Cystoscopy: Bladder cancer

IV pyelogram is the probs wrong answer (nephrotoxic, allergic)

91
Q

old man with chills, fever, dysuria, frequency, low back pain and tender prostate

A

Acute bacterial prostatitis. Give IV antibiotics, avoid doing any more rectal exams (sepsis risk)

92
Q

who gets bladder cancer?

A

Smokers

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