Surgery Flashcards
Patient post infrarenal AAA repair surgery presents with abdominal pain and bloody diarrhea should make you think of what pathology?
bowel ischemia due to loss of IMA in grafting procedure and low collateral circulation of colon
hypocalcemia results in a _____ QT while hypercalcemia results in a ______ QT
hypo: prolonged QT
hyper: shortened QT
Patients with acute cholecystitis should be treated with?
laparoscopic cholecystectomy within 72 hours
When would you use a HIDA scan?
Evaluate for cholecystitis when ultrasound findings are indeterminate
most common intra-abdominal organ injuries due to BAT are?
hepatic and splenic lacerations
how might a AAA lead to hematuria?
AAA can rupture into retroperitoneum leading to an Aortocaval fistula with the Inferior vena cava leadig to venous congestion in retroperitoneal structures like the bladder. distended veins in bladder may rupture.
MOA of succinylcholine
depolarizing neuromuscular blocker. binds to post-synaptic ach receptors and causes influx of sodium and efflux of potassium. This can lead to life threatening hyperkalemia
What patients are at a particular risk for life threatening hyperkalemia with succinylcholine use?
Patients with extenseive skeletal muscle cell injury (rhabdo). Also because skeletal muscle injury leads to upregulation of post-synaptic ach receptors
What type of neuromuscular blocking agents should be used in patients with crush, burn, muscle atrophy, denervation injuries or diseases?
nondepolarizing NMB agents like vecuronium and rocuronium
Side effect of halothane that makes it uncommonly used?
acute liver failure due to production of hepatotoxic intermediary compounds
severe hypotension due to myocardial depression is a severe side effect of what anesthetic agent?
propofol
subacute shoulder pain on abduction with full range of motion?
rotator cuff tendinopathy
Impingement syndrome?
occurs with rotator cuff tendinopathy -> space between humoral head and acromion is reduced which puts pressure on supraspinatus tendon
untreated rotator cuff tendinopathy can increase the risk for?
rotator cuff tear
adhesive capsulitis “frozen shoulder”
fibrosis and contracture of glenohumoral joint capsule. persistent pain and decreased range of motion in many planes
INR > ____ should suspect coagulopathy
1.5
When should pulmonary arteriography be used in the case of hemoptysis?
If bronchoscopy is not successful in identifying area of blood loss
Patient with acute onset severe abd pain, fever, tachy, abd gaurding and rigidity with history of NSAID and alcohol use likely has?
perforated viscus related to peptic ulcer disease
rupture of which part of the bladder can lead to peritonitis?
dome of bladder
Treatment for acute adrenal insufficiency?
hydrocortisone
dexamethasone
Adrenal insufficency is more likely to occur after a major illness or an acute stressor like surgery in a patient with?
primary adrenal insufficiency (addison disease) or suppression of HPA axis due to chronic glucocorticoid use
A patient with migratory thrombophlebitis and weight loss and fatigue. think of?
pancreatic cancer
Triad: resp distress, neuro dysfunction (confusion), petechial rash should make you think of?
fat embolism
neck pain, odynophagia, fever should make you think of?
retropharyngeal abscess
urgent additional surgical complication of retropharyngeal
abscess that causes fever chest pain, shortness of breath
acute necrotizing mediastinitis
stress fracture treatment in metatarsal? which metatarsal requires more aggressive treatment?
stress and pain control
5th metatarsal (due to increased risk for non-union) also anterior tibial cortex
Evaluation of hemodynamically stable patient with suspected splenic laceration includes?
- FAST
- If negative fast, CT scan
- If stable with altered mental status- go directly to CT
When is urgent exploratory laparotomy appropriate?
- hemodynamically unstable patients with + FAST
- hemodynamially stable patietns with + CT
What is the significant risk associated with scaphoid fractures?
osteonecrosis because blood supply can be interrupted by the fracture
lunate dislocation following fall on an outstretched hand can cause ______
compressive neuropathy of median nerve
acute shoulder pain after forceful abduction and external rotation at glenohumeral joint suggests?
anterior shoulder dislocation
anterior shoulder dislocation causes injury to?
axillary nerve (causing sensory issues of lateral shoulder and abducted
anterior dislocations are caused by?
blow to externally rotated or abducted arm
C5-C6 spinal nerves mediate what reflex?
biceps reflex
long thoracic nerve injury with deep lacerations to axilla or axillary lymphadenopahty will cause?
scapular wingning
prepatellar bursitis is often caused by what organism
staph aureus
how do you confirm prepatellar bursitis diagnosis?
aspiration of bursal fluid for cell count and gram stain
Tic douloureux
trigeminal neuralgia
how can you prevent acute bacterial parotitis after a surgery?
adequate fluid hydration and oral hygeine- commonly caused by staph aureus
A patient on warfarin with INR of 2.1 who needs surgery after GI perforation needs to be given _____ pre-op?
FFP to reverse warfarin affect to reduce intraop and postop bleeding issues
smoking cessation should take place at least _____ weeks prior to surgery
8
anserine bursitis is characterized by pain at?
anterior medial knee distal to the joint line
Presentation of factor XI deficiency?
Usually no increased bleeding. Prolonged PTT. Can have increased bleeding after surgery
Presentation of factor XII deficiency?
no increased bleeding. prolonged PTT. no therapy needed.
How to confirm diagnosis of HIT?
confirmed with ELISA for platelet factor 4 or serotonin release assay
What drug is safe to use with HIT?
fondaparinux
Best initial test to confirm antiphospholipid antibody?
mixing study. PTT will remain elevated after the mix.
diagnosis for sphincter of Oddi dysfunction?
SOO manometry
why might a patient have anterior thigh pain when they present with femoral artery aneurysm?
compression of femoral nerve
preferred long term anticoagulant in end stage renal disease patients?
Warfarin
What anticoagulants are contraindicated in end stage renal disease?
LMWH and direct factor 10 inhibitor (Rivaroxiban)
Ischemic colitis most commonly affects what areas of bowel?
watershed areas: splenic flexure. rectosigmoid junction.
Imaging of choice to diagnose Psoas abscess
CT scan
subacute fever, abdominal pain radiating to flank, anorexia, weight loss, pain with hip extension =
psoas abscess
how to differentiate retrocecal appendicitis from psoas abscess?
retrocecal appendicitis is more likely to cause pain on rectal exam
what infection should you suspect after a CABG in a patient who has fever, chest pain, leukocytosis and mediastinal widening on cxray?
Acute mediastinitis
Treatment for acute mediastinitis?
drainage, surgical debridement, prolonged antibiotic therapy
when should you anticoagulate or cardiovert someone who has afib postop?
after 24 hours of symptoms
a failed drop arm test confirms a diagnosis of?
rotator cuff tear
Treatment for diverticulitis?
bowel rest, PO abx, observation
Treatment for complicated diverticulitis with abscess > 3cm?
CT guided drainage
treatment for complicated diverticulitis with abscess < 3cm?
IV abx and obs
Management of hemodynamically stable patients who experienced blunt GU trauma with evidence of hematuria on urinalysis?
CT scan of abdomen
hemodynamically unstable patients with evidence of renal trauma should have what test done?
IV pyelography
when would you use a diagnostic peritoneal lavage?
unstable patient with equivocal fast exam
thoracic aortic aneurysm repair resulting in loss of movement, pain + temp sensation, but still able to feel position, vibration and touch?
anterior spinal cord syndrome
scaly, puritic, patches and plaques - cancer
cutaneous T cell lymphoma (mycosis fungoides)
young individual with a fleshy immobile mass on midline hard palate- most likely diagnosis?
torus palatinus (bony growth, benign, midline of hard palate)
Pilonidal disease affects who and presents how?
males age 15-30, particularly obese, sedentary, occupations and those with deep gluteal clefts. painful, fluctuant mass 4-5cm with purulent, mucoid, bloody drainage.
is the heart contour abnormal in cardiac tamponade?
NO- its normal. (normal with acute cardiac tamponade in trauma) chronic processes like malignancy can expand the pericardial sac
hematuria at start of urine stream suggests?
urethral damage
terminal hematuria (end of urine stream) indicates?
bladder or prostate damage
NSAIDs constrict the?
afferent
12 year old hits abdomen against handle bars, presents 24 hours later with epigastric pain, colicky and bilious vomiting. likely cause?
duodenal hematomas
management of duodenal hematoma?
gastric decompression
parenteral nutrition
head trauma and development of ipsilateral hemiparesis, ipsilateral mydiasis, strabismus, contralateral hemianopsia, altered mentation indicates?
transtentorial herniation of the parahippocampal uncus
hypertension, bradycardia and resp depression =
cushings triad
what nerve what an uncal herniation interfere with?
oculomotor
emphysematous cholecystitis presents more commonly in who?
immunosuppressed patients and patients with diabetes
vascular congestion of cystic artery
gallstones
what is emphysematous cholecystitis
life threatening. infection of gallbladder wall with gas forming bacteria. requires emergent cholecystectomy
crepitus in abdominal wall adjacent to gall bladder might suggest?
emphysematous cholecystitis
why do you see unconjugated hyper bili in emphysematous cholecystitis?
Clostridium induced hemolysis
complications of emphysematous cholecystitis?
gangrene and perforation
Next step in management when clavicle bone is fractured?
angiogram to evaluate neurovascular structures due to close proximity to subclavian artery and brachial plexus
which clavicular fractures might require open reduction and internal fixation?
distal
most common complications of cardiac catheterization?
bleeding, hematoma (localized or retroperitoneal), arterial dissection, acute thrombossi, pseudoaneurysm, AV fistula
Varicocele?
tortuous dilation of pampiniform plexus of veins surrounding spermatic cord and testis.
soft, irregular mass “bag of worms” that increases in size with standing and Valsalva?
Varicocele
Risks of varicoceles?
elevated teste temperature leading to atrophy and infertility
What is more common left sided varicoceles or right sided?
left sided
when you see a right sided varicocele you should think of?
malignant compression (RCC, thrombosis)
Spermatocele
fluid filled cyst of the head of the epididymis presenting as a painless mass (differentiate from cancer as cancer would be a firm mass)
peritoneal fluid collection between parietal and visceral layer of tunica vaginalis?
hydrocele
the fluid of a ________ is easily transilluminated
hydrocele
Treatment for varicocele?
gonadal vein ligation (in boys young men with testicular atrophy to preserve fertility)
Scrotal support and NSAIDs (older men who do not desire additional children)
febrile hemolytic transfusion reactions are caused by?
cytokine accumulation during blood storage
acute hemolytic reaction is caused by?
ABO incompatibility
Delayed hemolytic reaction is caused by?
anamnestic antibody response
anaphylactic transfusion reaction caused by?
recipient IgA antibodies
TRALI is caused by?
donor anti-leukocyte antibodies
when should you suspect appendiceal rupture with a contained abscess?
when patient presents >5 days after onset of appendicitis symptoms
how should appendiceal rupture with contained abscess be managed?
if patient is stable, bowel rest, IV abx, perc drainage possibly. Return in 6-8 weeks for appendectomy on elective basis
fever, pharyngeal pain and earache should make you think of?
peritonsillar abscess
treatment of peritonsillar abscess?
needle aspiration or I/D + Abx therapy
When should you suspect gallstones as cause of pancreatitis?
elevated AST/ALT, gallstones seen in gallbladder
ALT > 150 has a ____ % PPV for gallstone panc
150
In patients with traumatic spinal cord injuries, what is an important step in management after they have been completely stabilized with ABCs?
urinary catheter placement
What should you be careful with in the setting of hypovolemic shock when a patient needs to be intubated?
mechanical ventilation increases intrathoracic pressure. it can cause acute loss of right ventricular preload, loss of CO, cardiac arrest
persistent pneumothorax and air leak following chest tube placement in a patient who sustained blunt chest trauma suggests?
tracheobronchial rupture
extra-axial well-circumscribed dural-based mass that is partially calcified on neuroimaging is suggestive of?
meningioma (benign) - should be surgically removed if causing mass effect
recurrent mild, unilateral mid-cycle pain prior to ovulation lasting hours-days?
mittelschmerz
amenorrhea, abdominal/pelvic pain, vaginal bleeding, positive B-hCG?
Ectopic
Sudden onset, severe, unilateral, lower abd pain, nausea and vomiting, unilateral tender adnexal mass on exam?
ovarian torsion
sudden onset, severe, unilateral abd pain following strenous or sexual activity with abd rigidity (sometimes)?
ruptured ovarian cyst
fever, chills, vag discharge, lower abd pain, cervical motion tenderness?
PID
After clinical diagnosis of penile fracture, what imaging test is required with certain presentations? why?
retrograde urethrogram to evaluate for uretheral injury
what are the indications for retrograde urethrogram with penile fracture?
blood at meatus, dysuria, urinary retention
any penetrating wound below the 4th intercostal space (level of the nipples) in unstable patients- requires?
exploratory laparotomy
widened mediastinum and left-sided hemothorax point to?
aortic injury
2 options for suspected scaphoid fracture if x-ray comes back negative?
order CT/MRI to confirm
wait 7-10 days in a spica splint and x-ray again
differential diagnosis for anterior mediastinal mass (4 T’s)
thymoma, teratoma (and other germ cell tumors), thyroid, terrible lymphoma
acalculous cholecystitis occurs in?
severely ill patients in ICU. due to cholestasis and gallbladder ischemia which predisposes to infection (life threatening)
treatment for acalculous cholecystitis?
antibiotics followed by percutaneous cholecystostomy
whistling noise during respiration following rhinoplasty, suspect?
nasal septal perforation as a result of septal hematoma
treatment for pancreatic pseudocyst?
- expectant management if asymptomatic
- endoscopic drainage procedure reserved for patients with significant symptoms
adducted and internally rotated lower extremity?
acetabular fracture with posterior hip dislocation
nasopharyngeal carcinoma is associated with the reactivation of?
Epstein Barr virus
nasopharyngeal carcinoma is endemic to?
southern china and parts of africa and middle east
aflatoxin B1 contaminates agricultural products and is associated with an increased risk of?
hepatocellular carcinoma
femoral nerve provides sensation to the?
anterior thigh and medial leg via saphenous branch
motor function femoral nerve?
flexion at hip. knee extension (anterior compartment of thigh functions)
tibial nerve provides sensation to?
posterior leg (except medial side) and plantar foot
tibial motor function?
plantar flexion and knee flexion and toe flexion
obturator motor and sensory function?
medial compartment of thigh. (adduction of thigh and sensation over medial thigh)
superficial peroneal nerve motor and sensory?
foot eversion and sensory of lateral leg and foot
deep peroneal nerve sensory and motor
sensory: between big toe and 1st toe
motor: foot dorsiflexion and toe extension
Young Patients with symptoms >3-4 weeks who have normal findings on exam for suspected meniscal tear. what is your next step?
order MRI
patchy alveolar infiltrate presenting 20 hours after BAT?
pulmonary contusion
management of pulm contusion?
supportive: pain control, nebs, chest physiotherapy
acute pain and parasthesias following lower extremity embolectomy are suspicious for?
reperfusion syndrome. compartment syndrome
a patient has full thickness burns to distal extremities. what should you always be concerned about?
compartment syndrome
