Surgery Flashcards
If a child has a septic hip, what position do they normally hold their hip in?
a. abducted and internally rotated
b. abducted and externally rotated
c. adducted and internally rotated
d. adducted and externally rotated
b. abducted and externally rotated
A mother comes to you with her 2.5 year old son who she says is intoeing. On exam, you find evidence of metatarsus adductus. What do you suggest?
a. Reassure
b. Avoid W sitting
c. Refer to orthopedics
reassure
torsional deformities, such as meta-tarsus abductus, intoeing secondary to tibial torsion, and femoral torsion resolve spontaneously by adulthood.
Which is the most sensitive test for early detection of Legg-Calve-Perthes?
a. Bone scan
b. Bone densitometry
c. Ultrasound
d. AP and frog leg Xrays
bone scan
AP and frog leg Xrays -this would be the first test, but is often negative in early disease therefore not most sensitive
Child has insidious onset testicular pain. On exam there is a Blue dot, management?
a) reassure
b) Ultrasound testes
reassure
Septic joint next step?
a) Aspirate
b) Urgent consult to Ortho - I would consult ortho because this is a surgical emergency
c) Admit and start IV antibiotics
urgent ortho consult
- A 12 year old was in an MVC that resulted in severe splenic laceration requiring splenectomy. What does she need now?
a. Penicillin prophylaxis
b. Penicillin prophylaxis and meningococcal and pneumococcal vaccines
c. Meningococcal and pneumococcal vaccines
d. Nothing required
penicillin prophylaxis
All children with these conditions, regardless of age, should receive vaccines to protect against S pneumoniae, N meningitidis, Hib and seasonal influenza.
49. When should repair for a persistent hydrocele occur? 6 months 12 months 18 months 24 months
12 months
A 10 year old boy presents with 12 hours of scrotal pain. He has focal tenderness at the upper pole of the testis with a focal blue discolouration, and there is some edema. What is the best next step?
a. Ultrasound
b. Analgesia and scrotal support
C. Urology consult
b. Analgesia and scrotal support
Torsion of the appendix testis - management is reassure, bedrest and analgesia
Adolescent girl with scoliosis has undergone spinal surgery. She present with bilious vomiting for the last few days. What is the etiology?
a. bowel adhesions
b. superior mesenteric artery syndrome
c. malrotation with volvulus
d. Pancreatitis
SMA syndrome
5 mo Kid flexion of arms and legs, and with associated vomiting and abdo distention, sleepy after episodes. What will give diagnosis?
a) EEG
b) US abdomen
US abdo
Kid with abdo pain; describes kid with malrotation and intermittent volvulus; what investigation?
a. AXR 2 views
b. U/S
c. UGI
d. Barium enema
UGI
A 3 month old male infant presents to the emergency department with a 1 month history of “spit ups” and 2 day history of projectile vomiting. His last two vomits were bilious. On exam, he looks dehydrated and unwell. His abdomen is distended, non tender, with no palpable masses. What diagnostic test would MOST likely reveal the underlying abnormality?
a. Abdominal ultrasound
b. Barium enema
c. Upper GI series
d. Abdominal X ray (anterioposterior and lateral)
c. Upper GI series
New born baby born with refractory hypoglycemia and attached photo. What is he most at risk for?
Hirschprung’s disease
Wilm’s tumour
Hypothyroid
wilms tumor
This is an omphalocele; baby likely has beckwith wiedeman syndrome and is thus at risk of Wilm’s tumor :(
The majority (≈75%) of infants with omphalocele have associated congenital anomalies/syndromes, including Beckwith-Wiedemann syndrome (omphalocele, macrosomia, hypoglycemia), and other chromosomal (29%, including trisomies 13 and 18) and nonchromosomal (45%) multiple and isolated congenital anomalies (musculoskeletal, 24%; urogenital, 20%; cardiovascular, 15%; and central nervous system, 9%).
17 year old female present with a small firm lump in her breast. What is the MOST likely cause
Fibrocystic changes
Fibroadenoma
fibroadenoma
5 month old with vomiting for 6 hours intermittently, has had 3 or 4 episodes of flexion and extension of arms and legs, drowsy after, abdomen is distended, which test would reveal diagnosis? A. EEG B. CT abdomen C. Ultrasound abdomen D. Abdominal x-ray
abdo u/s
Adolescent girl with scoliosis has undergone spinal surgery. She present with bilious vomiting for the last few days. What is the etiology?
a. bowel adhesions
b. superior mesenteric artery syndrome
c. malrotation with volvulus
d. pancreatitis
SMA
5 mo Kid flexion of arms and legs, and with associated vomiting and abdo distention, sleepy after episodes. What will give diagnosis?
a) EEG
b) US abdomen
b) US abdomen
The success rate of radiologic hydrostatic reduction under fluoroscopic or ultrasonic guidance is approximately 80-95% in patients with ileocolic intussusception
The recurrence rate after reduction of intussusceptions is approximately 10%, and after surgical reduction it is 2-5%; usually within 72 hr
In patients with multiple ileal–colonic recurrences, a lead point should be suspected and laparoscopic surgery considered
Photo of G tube site as below. What would you do?
(this exact photo shown, brought to you by googling granulation tissues)
a. Oral antibiotics
b. Consult surgery
c. Silver nitrite cautery
d. Reassure
reassure
Teen with large firm symmetrically enlarged thyroid. Negative for thyroid antibodies. What next?
a. f/u in 6 mo
b. do ultrasound
c. Biopsy
fu in 6 months
Peritonitis, what to do next?
a. Bolus & analgesics
a. Bolus & analgesics
Would like an answer that includes antibiotics. If secondary peritonitis then this answer makes sense + Abx
2 year old umbilical hernia
a. Reassure
b. refer to surg
reassure
Most umbilical hernias that appear before the age of 6 months disappear spontaneously before 1 year of age. Even large hernias (5-6 cm) have been known to close spontaneously by 5-6 years of age. Strangulation is extremely rare. Surgery is not advised unless the hernia persists until 4-5 years old, causes symptoms, becomes strangulated or becomes progressively larger after 1-2 years.
A 1 month old boy is diagnosed with pyloric stenosis. He has a severe metabolic alkalosis, bicarbonate 34. What do you do:
a. Operate immediately
b. Give HCl
c. Give K bolus
d. Give large amounts of chlorinated fluid IV
d. Give large amounts of chlorinated fluid IV
correct before surgrey d/t post op APNEA
get paradoxical aciduria
NEED TO REPLENISH CHLORIDE TO ALLOW EXCHANGE BY KIDNEYS - REABSORB CL AND EXCRETE HCO3
hypochloremic, hypokalemic, metabolic alkalosis due to the loss of large amounts of gastric hydrochloric acid
olume deficit triggers an expansion of the extracellular volume rather than maintenance of pH → RAAS activated and aldosterone effects begin. Na is resorbed, but K is lost via an aldosterone mediated mechanism and this leads to excretion of H ion
Picture of gastroschisis (still same poor picture). Most common associated anomaly?
a. Intestinal atresia
Gastroschisis (R of umbilicus)
Picture of gastroschisis. What is this associated with:
a. intestinal atresia
b. cardiac defect
c. renal defects
IA
cardiac- omphalocele
Description of baby pulling legs up, well between. What investigation should you do?
a. EEG
b. Abdominal ultrasound
u/s
1 year old with rectal abscess. Mgt?
a. Systemic abx
b. Excision by surgery
c. I and D
I and D
If 3 months of age or older:
Low grade/no fever and no systemic sx = observe after drainage; Abx only if no improvement or culture grows something other than staph
Significant cellulitis or low grade fever with no systemic sx = PO TMP/SMX + Cephalexin pending cultures
Systemic symptoms = IV abx
Unwell boy, tense abdomen. What do you do after calling surgery?
a. Bolus and analgesia
b. Bolus and CT scan
c. IV antibiotics
a and C
6 month old with umbilical hernia. Mother wants to know what should be done. You tell her:
a. arrange elective repair
b. surgery at 2 years old
c. place a coin over the hernia
d. reassure
reassure
An 8 month old child is admitted for viral gastroenteritis. The child has intermittent episodes of screaming and vomiting. On exam, the child is pale and lethargic. Which of the following investigations is most useful in diagnosis of this patient?
a. AXR
b. serum lactate
c. air enema
- ————–
air enema
If “diagnostic modality of choice”/”next step” - U/S (if option)
But most “useful”/”best test” - air enema (both diagnostic and therapeutic - as long as well with no signs of shock/peritonitis)
What is the most common complication after gastroschisis repair?
a. Bowel obstruction
b. Abdominal compartment syndrome
b. Abdominal compartment syndrome
What is the most likely complication of a ruptured appendicitis?
a. Bowel obstruction
b. Abscess in the abdomen -
c. Wound infection
d. Enterocutaneous fistula
ABSCESS- if they did not go to the OR
WOUND INFXN- if they did go to the OR (as per lecture/JELD)
3w old brought to ER because of repeated projectile vomiting after each feed. What to find on lab work:
a. hyponatremia
b. hyperkalemia
c. hypochloremia
c. hypochloremia
1 m baby irritable, not feeding well, vomited once, distended abdomen. On exam VSS except mild tachycardia. There is a mass in the right scrotal, firm and non reducible. Does not transilluminate. What is the next step?
a. Ultrasound
b. Urgent surgical consultation
c. Nuclear scan
d. Testicular Doppler
b. Urgent surgical consultation
10 mo irritable. Acute onset of red scrotal swelling. Parents had noted on + off swelling in the past few days. Today irritable, VSS mild tachycardia. On exam Rt red swollen and transilluminates well. What is the diagnosis?
a. Epididimytis
b. Testicular torsion
c. Acute hydrocele
d. Incarcerated hernia
d. Incarcerated hernia -
Photo of baby with gastroschisis (I think). Most likely ass’n?
a. Intestinal atresias
b. Heart defect
c. Renal defect
a. Intestinal atresias
Gastroschisis - BAD GUT, GOOD BABY (To the right)
Associated gastrointestinal anomalies and problems (eg, malrotation, atresia, stenosis, perforation, necrosis, volvulus) occur in up to 25 percent of cases. Meckel’s diverticulum and gallbladder atresia also occur, but are less common. Bladder herniation has been reported in 6 percent of cases.
-Most cases have no extraintestinal abnormalities.
-Other: Meckel’s diverticulum, gallbladder atresia, bladder herniation (less common).
-Intestinal atresia occurs in 10%
6 year old boy presents with severe abdominal pain, 8/10. HR 150, BP 120/80, abdomen is rigid. You immediately call the surgeons; what is your next step?
a. Culture and start IV antibiotics
b. IV bolus 20cc/kg NS and arrange for urgent CT abdomen
c. Ultrasound abdomen
d. IV bolus 20cc/kg NS and analgesia
cx and start IV abx PLUS bolus
do bolus!!
needs culture, antibiotics (amp/gent/clinda), fluid resuscitation, general surgery.
JELD picked both
A 2 month old baby is diagnosed with pyloric stenosis and a HCO3 of 34. What would you do?
a. OR immediately
b. Give hydrochloric acid
c. Give large bolus of hyperchloremic solution
d. Give potassium bolus 5mmol/kg
Give large bolus of hyperchloremic solution
3-week old baby presents with gastroenteritis and intermittent abdominal pain and severe irritability. Best investigation to reveal the diagnosis?
a. abdominal x-ray
b. abdominal ultrasound
c. air enema
d. EEG
abdo u/s
adhesions, Necrotizing enterocolitis, Volvulus*, Colic, Dietary protein allergy, Testicular torsion
r/o volvulus
What is true about intussusception?
a. Meckel’s diverticulum is the most common lead point
b. 75% of cases are idiopathic
c. most patients present with red currant jelly stools
b. 75% of cases are idiopathic
2 week old girl with rectal bleeding. HR 220, BP 60/35, abdomen tense and sensitive. What is the next step in your diagnostic approach:
a. Call general surgery
b. Abdominal ultrasound
c. IV antibiotics
d. Abdominal x-ray
e. Ba meal with small bowel follow through
Abdominal x-ray
15 y/o status post therapeutic abortion. Sudden onset of respiratory distress, chest pain. On exam, bilateral crackles. She is coughing blood. What is the best test:
a. ECG
b. Pulmonary angiography
c. CXR
d. Pulmonary V/Q scan
e. Leg dopplers
f. CT scan
b. Pulmonary angiography
now pick CT angio
Omphalocele. What do you tell nurse to do?
a. elective surgery
b. dry dressing
c. wet dressing
d. topical flamazine
c. wet dressing
1month old has progressive non-bilious vomiting. On exam has a small palpable olive in the RUQ. Most likely lab abnormality:
a. Metabolic acidosis
b. Respiratory acidosis
c. Hypokalemia
d. Alkalotic urine hypernatremia
c. Hypokalemia
Umbilical hernia, what to do?
a. Take a coin and strap it down
b. May resolve in 24m
c. Do surgery right now or else the hernia will incarcerate
b. May resolve in 24m
A previously healthy 15y old boy has cramping periumbilical pain. After several hours, the pain shifts to the right lower quadrant and becomes constant. He vomits several times and is brought to the emergency department. The abdomen is tender on deep palpation of the right lower quadrant. Findings on chest and abdominal xray films are normal. Leukocyte count is 15,000mm which of the following is the most appropriate initial management?
a. A CT scan of the abdomen
b. IV hydration
c. Surgical exploration of the abdomen
d. U/S of the abdomen
iv hydration
A 1-month-old has progressive non-bilious vomiting. He appears hungry. On exam there is a small palpable olive in the right upper quadrant. What would be the most likely lab abnormality:
a. metabolic acidosis
b. respiratory acidosis
c. alkalotic urine
d. hypokalemia
e. hypernatremia
hypokalemia
A 12 year old boy has been having trouble playing soccer lately due to pain in his feet. You see him and diagnose flat feet.
What are 3 categories of flat feet?
flexible flatfoot
What are 2 indications for referral in flat feet?
flexible flatfoot with a tendo-Achilles contracture
rigid flatfoot
Rigid flatfoot
Patients with collagen, vascular or neuromuscular conditions contributing to painful flat feet (i.e. down syndrome or ehlers danlos)
Symptomatic
A 2 month old boy has an inguinal hernia.
What is the pathophysiology of this condition?
What are 2 complications of an unrepaired inguinal hernia?
What is ONE post-operative complication that would affect the TIMING of the surgery?
Failure of obliteration of the processus vaginalis - permits fluid or abdominal viscera to escape the peritoneal cavity into the extraabdominal inguinal canal
Incarcerated and strangulated hernia
Intestinal obstruction
(I think they mean pre-operative)
Intestinal obstruction
You are seeing a 1 or 2 year old with an umbilical hernia, what would you tell parents?
When would you repair it?
Majority spontaneously resolve by 5-6 years of age without surgery
“Strapping” is ineffective
Strangulation is rare
Persists past the age of 4-5 yr
Symptomatic
Strangulation
Becomes larger after the age of 1-2 yr
Child with CP and G-tube for 2 years, who has been growing well with it, now comes with acute abdominal pain. Name 4 “complications” (they used this wording) of indwelling enteral tubes that could explain this presentation.
Peritonitis (tube cracked with leakage into peritoneal cavity)
Irritation to gastric wall from balloon
Pyloric outlet obstruction from tube migration
Cellulitis +/- abscess
If GJ tube: intussusception
List 3 indications for urgent surgical referral for endoscopic removal of an esophageal foreign body
1-When the ingested object is sharp, long (>5 cm), or a superabsorbent polymer, and is in the esophagus or stomach.
2-When the ingested object is a high-powered magnet or magnets
3-When a disk battery is in the esophagus (and in some cases in the stomach if >24-48h in there)
4-When the patient shows signs of airway compromise.
5-When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions).
Kid with abdo pain; describes kid with malrotation and intermittent volvulus; what investigation?
a. AXR 2 views
b. U/S
c. UGI
d. Barium enema
UGI
Photo of G tube site as below. What would you do?
(this exact photo shown, brought to you by googling granulation tissues)
a. Oral antibiotics
b. Consult surgery
c. Silver nitrite cautery
d. Reassure
reassure
Teen with large firm symmetrically enlarged thyroid. Negative for thyroid antibodies. What next?
a. f/u in 6 mo
b. do ultrasound
c. Biopsy
6 month
. 6 month old with umbilicical hernia. Mother wants to know what should be done. You tell her:
a. arrange elective repair
b. surgery at 2 years old
c. place a coin over the hernia
d. reassure
- ————–
arrange ELECTIVE repair
due to imperfect closure or weakness of the umbilical ring
consists of omentum or portions of the small intestines
most umbilical hernias that appear before 6 mos disappear spontaneously by 1 year
even large hernias up to 5-6cm have been known to disappear spontaneously by 5-6 yrs of age
defects over 2 cm are less likely to close spontaneously
strangulation is rare
surgery is not advised unless the hernia persists until age 4-5, causes symptoms, becomes strangulated, or becomes progressively larger after 1-2 years of age
Umbilical hernia, what to do?
a. Take a coin and strap it down
b. May resolve in 24m
c. Do surgery right now or else the hernia will incarcerate
b. May resolve in 24m
→ Most resolve by 1 year (some up to 5 years)
→ Only repair if not resolved by 4-5 years, symptomatic, strangulated (rare), increased in size after 2 yrs
A previously healthy 15y old boy has cramping periumbilical pain. After several hours, the pain shifts to the right lower quadrant and becomes constant. He vomits several times and is brought to the emergency department. The abdomen is tender on deep palpation of the right lower quadrant. Findings on chest and abdominal xray films are normal. Leukocyte count is 15,000mm which of the following is the most appropriate initial management?
a. A CT scan of the abdomen
b. IV hydration
c. Surgical exploration of the abdomen
d. U/S of the abdomen
b. IV hydration
you see a violacious mass tender growing pre auricuclar afebrile diagnosis 1- salivary gland neopalsms mycobacteriam avium adenitis hemangioma branchial cleft
mycobacterium avium adenitis
tx biaxin 7-10d
I and D
and excise if not improved
what test would u do in a babe with hyperbili
a) acoutistic auditory brain stem AABR
b) otoacoustic emission (OAE)
c) visually reinfored audiometry
Goal to rehab by 6 months of age.
if tx before 2yo, most normal education
AABR - then if they pass that, but an at risk baby - do the VRA (done at 8-12 months corrected)
also if they fail they do a diagnostic ABR at 6w corrected
** intense surveillence if CMV or mengiigits
without surveillance- detected usually 18months to 30months. always treat even if unilateral - cochealr implants (vaccinate as if immunocomrpomised)
baby with severe SNHL
what is workup at 2 weeks, or at 3 months
when to image?
CMV urine culture <3w, if older then blood spot from NBS do PCR
with severe/profound would do a CT to r/o cochlearvestibular anomalies, consider EKG (lange nielson) and urinalsys with renal u/s for brahciootorenal sx
what is the diagnostic criteria for sinusitis and treatment
persistant - nasal discharge and/or daytime cough more then 10 d without improvement
worsening course- after initial improvement
severe onset >39 deg AND purulsent d/c x 3 consencutive days
tx- amox/clav, r/a72 hours.
ddx - allergic, FB, viral urti
complciations- orbital or intracranial infection, osteo of frontal bone (potts puffy tumor), mucocel
What is samter triad
Asthma, ASA sensitivity and polyps
DDx polyps: CF, PCD, wegneners granulomatosis
Patient presents with saddle nose after bar fight
what to do
management
its septal hematoma ,
elevates perichondrum and can create abscess and cartilage necoris
urgent Iand D, nasal ack and biaxin then refer to ENT
what causes severe unilateral recurrent epistatxis in a male
juvenile angiofibroma
if bleeding alot >30min, or <2yo, >2-3x/week (and not angiofirbomaa) do coag, CBC, Pplatlet function assay and VWF) usually its VWf
can use silver nigrate if otirivin and packing not working - but ONLY caudarize ONE side (as can cause septal perforation)
Differenitating factors of GAS pharingitis vs viral
complications of GAS,
acute rheumatic fever
GN
parapharyngeal abscess
1) petichae in soft palate
2) rapid onset
3) no cough
4) prominent sore throat
ensure to treat to prevent rheumatic fever
treat wihtout culture if - scarlet fever, prev hx ARF, recent ARF in family or if symptomatic and positive rapid test
treat iwth penicillin 250mg bid x 10 days (500 if >27kg), could also use keflex
TandA if GAS >7/year or >5 in two years
