Surgery Flashcards
Next step if FAST reveals free intraperitnoeal fluid in abdomen of hemodynamically unstable Pt?
Urgent laparotomy
Management of hemodynamically unstable Pt with suspected intraabdominal trauma.
IV fluid resuscitation and FAST exam. If positive for intraabdominal hemorrhage, then laparotomy. If negative, then stabilize and look for signs of extra-abdominal hemorrhage (i.e. CT scan of abd).
FAST acronym?
Focused assessment with sonography for trauma.
Labs in Gilbert syndrome?
Elevated unconjugated bili (UDP glucuronosyltranferase enzeme deficient)
Normal liver ATs, etc.
Name MC organisms to infect a new prosthetic joint (knee) under 3 months, 3-12 months, or >12 months after surgery.
<3 mo: Staph. Aureus or Pseudomonas
3-12: Coag negative staph (epidermidus) or propionibacterium
>12: Staph. Aureus (often hematogenous spread from distant infxn)
A common postop complication resulting from shallow breathing and weak cough due to pain is?
Atelectasis. Most commonly shows up 2-3 days posop after abd surgery or thoracoabdominal surgery.
Preoperative evaluation of what is required for a patient on long term steroid use (>5mg/day)?
Early-morning cortisol level. Study the risk of Addisonian crisis after surgery.
Management of blunt abdominal trauma in hemodynamically stable patient?
If Alert and talking, do FAST exam. If not go right to CT. If Fast positive or negative gonna end up doing CT anyway.
First step in dangerous hemorrhage?
2 large bore IVs.
Management in suspected variceal hemorrhage in alcoholic?
2 large bore IVs. Fluids, IV octreotide, antibiotics (if cirrhotic). Urgent endoscopic therapy for varices.
Fever, CP, leukocytosis, and mediastinal widening on chest Xray after cardiac surgery may indicate?
Acute mediastinitis. Requires drainage, surgical debridement, and prolonged antibiotic Rx.
Epidural hematoma presentation on CT of head?
Hyperdense biconvex lesion that does not cross suture lines. Requires emergent hematoma evacuation.
How is clavicle fracture managed?
Fractures of the middle third of the clavicle, which are the MC type of clavicle Fx, are treated nonoperatively with a brace, rest, and ice. If Fx occurs in the distal third it may require open reduction and niternal fixation to prevent nonunion. Careful neurovascular exam is required also and if damage to vasculature under the clavicle suspected then angiogram required.
Management of umbilical hernia vs gastroschisis or omphalocele.
Hernia can be monitored for spontaneous resolution by age 5. Immediate surgery for the others.
Contusion or rupture of the neck, anterior wall, or anterolateral wall of the bladder are considered what kind of bladder injury?
Extraperitoneal bladder injury. Often associated with pelvic Fx. Gross hematuria usually present and urinary retention may occur. Injury does not involve leakage of urine into peritoneal space (vs intraperitoneal bladder injury).
Rupture of the dome of the bladder abutting the peritoneum is called what?
Intraperitoneal bladder injury. The dome of the bladder is composed of the superior and lateral bladde walls and directly abuts the peritoneal space. This results in intraperitoneal urine leakage and presents with chemical peritonitis.
In what case are imaging studies needed in acute appendicitis?
Only in nonclassic cases. Otherwise, a classic clinical diagnosis (umbilical pain the moves to RLQ, sharp peritoneual pain, anorexia, NV, mild fever) can be made and laparoscopic surgery performed without need for imaging.
What assessment must be made in a patient with penile fracture first, before surgery?
Urethral injury 2° to retrograde urethrogram. Evidence of urethral injury (blood at meatus, dysurea, retention), need urethrogram.
Duodenal hematoma Rx?
Decompression via NG tube and parenteral nutrition for ~1-2 wks. until resolution.
Placement of a central venous catheter must be confirmed immediately afterward with what method of imaging?
Chest Xray. Observation of tip placement proximal to angle between trachea and right mainstem bronchus confirms proper placement.
Name 5 ways to decrease ICP in head trauma Pt.
Head elevation Sedation Mannitol Hyperventilation Remove CSF
Stress fractures management of metatarsal 2-4 vs 5?
2-4: Requires rest and simple analgesia.
5: May require casting or internal fixation due to nonunion risk.
What common risk presents after burn injury?
Gram+ infxn immediately after injury and gram- infxn more commonly occur after 5 days. A change in wound appearance or loss of graft often indicates infxn of burn wound. Hyperkalemia (EKG required and tele if abnormal) and compartment syndrome also possible (5Ps).
Hypocalcemia and hyperphosphatemia in the presence of normal renal fxn indicates?
Hypoparathyroidism. Often due to post-surgery, autoimmune or non-autoimmune parayhroid destruction or defective calcium-sensing receptors (pseudohypoparathyroidism).
Causes of sphincter of Oddi dysfxn?
Dyskinesia and stenosis are more common. Appears as episodic colicky RUQ pain with AT and alk phos elevations. Opioids exacerbate problems.
Typical imaging and evaluation of a patient with blunt genitourinary trauma in stable/unstable Pt.
Focused Gu exam
Urinalysis –> hematuria and stable need contrast-enhanced CT of abd/pelvis to stage renal trauma. If unstable with renal trauma, then IV pyelograph.
Pt is post-op for partial distal gastrectomy and has intermittent cramping/diarrhea. Nausea, weakness, palpitations, dizziness, and diaphoresis occur about 25-30 minutes after eating. Dx?
Dumping syndrome. Characterized by GI symptoms and vasomotor symptoms, dumping syndrome is common after gastrectomy in about 50% of cases. Loss of pyloric sphincter results in hypertonic gastric content dumping into duodenum and fluid shift into intestine. This causes autonomic reflexes and intestinal vasoactive polypeptide release. Rx is dietary management including small meals/eating slowly/increase fiber/protein and stop eating sugar. VIP fxn includes “Its role in the intestine is to greatly stimulate secretion of water and electrolytes,[8] as well as relaxation of enteric smooth muscle, dilating peripheral blood vessels, stimulating pancreatic bicarbonate secretion, and inhibiting gastrin-stimulated gastric acid secretion.”
Petechiae, follicular bleeding, gum bleeding/carries, arthralgias, weakness, impaired wound healing in a patient with poor nutritional risks. Dx?
Scurvy. Vitamin C is needed in healing (necessary for scarring).
Definitive Rx of perforated viscus suspicion (intrabdominal air on ray)?
Urgent exploratory lap.
MC organisms in necrotizing fasciitis?
Strep pyogenes Staph aureus C. perfringens Polymicrobial Bacteria spread under subQ/deep fascia, undermining skin leading to redness, swelling, edema, and pain out of proportion to exam findings.
Pt presents with acute-onset abdominal pain that is 9/10 in the midabdomen with few PE findings. She has A.fib. and found to have an elevated lactate. Dx?
Likely acute mesenteric ischemia. Rapid onset abd pain that is out of proportion to exam findings with an Hx of embolic risk (A. fib., IE, etc.) are classic. Metabolic acidosis, leukocytosis, elevated amylase or phosphate are lab findings that may be present.
Post operative day 2 with hyperventilation. Dx?
Atelectasis or PE likely. pH will be high, PO2 low, and PCO2 low in both. Atelectasis is ostruction due to retained airway secretions, decreased lung compliance, pain, or meds that interfere with deep breathing.
Subacute infxn with fever and lower right abdominal/flank pain. Pain is only present with deep abdominal palpation and extension of the leg with the Pt. in lateral recumbent position elicits pain. High WBCs and elevated platelets are present. Dx?
Psoas abscess. These are all classic signs of PA. Pain sometimes radiates to the groin, differentiating it from appendicitis. Psoas sign in appendicitis is generally rare, unless it is retrocecal. Appendicitis is also usually very acute with only low grade fever.
Time period in which C. diff will develop after antibiotics?
4-5 days.
Voluminous watery diarrhea at 4-5 POD with abdominal pain and fever. Dx?
C. diff.
Aneurysm of an infrarenal aorta and subsequent repair followed by abd. pain, tachycardia, mild distention of abd. Dx?
Ischemia of bowel. Sometimes pain is localized to LLQ, as in inferior mesenteric artery damage. Risk to the bowel is possible in AAA repair.
Penetrating trauma at or below the nipples requires what management?
Exploratory laparotomy in unstable patients. The diaphragm can reach up to the 4th IS on the right and 5th IS on the left on expiration and down to the 12th IS on inspiration. Any penetration below the nipples has potential to involve the abdomen.
3 components of the Glascow Coma Scale?
Eye opening (4 points) - Spontaneous 4 - Verbal 3 - Pain 2 - None 1 Verbal response (5) - Oriented - Confused - Inappropriate words - Incomprehensible - None Motor response (6) - Obeys commands - Localizes - Withdraws - Flexion - Extension - None
What is an abdominal succession splash?
Placing the stethescope ober the upper abdomen and rocking the hips back and forth elicits a spalshing sound if gastric material is in the stomach. Retained material >3 hrs after a meal may indicate pyloric stenosis.
How are gallstones found incidentally without symptoms managed?
No treatment typically.
How are gallstones with typical biliary colic symptoms managed?
Elective lap chole. Could do ursodeoxycholic acid in poor surgical candidate.
How are gallstones with symptoms of acute cholecystitis, choledocholithiasis, gallstone pancreatitis managed?
Cholecystectomy within 72 hrs.
AC: US is best initial test. CT can find stones too, but also can find complications of stones. HIDA (hepatoiminodiacetic acid) scan is used if US inconclusive.
Choledocho: Labs show total/direct hyperbilirubinemia and elevated Alkphos. RUQ US usually initial study, though not very sensitive (~50%). ERCP is gold standard and follows US. ERCP is diagnostic and therapeutic.
Pancreatitis: ERCP is indicated if pancreatitis from stone. NPO, fluids, pain control, NG tube, TPN if it doesn’t resolve.
Acute RUQ pain, tenderness, fever, and leukocytosis. Likely Dx?
Acute cholecystitis. Characterized by inflammation and distention of the GB due to obstruction of the cystic duct by a stone.
CT of patient shows round, well-circumscribed, encapsulated fluid collection in upper, mid abdomen. He has abdominal distention, nausea, and vomiting, with an Hx of alcohol use. Dx?
Pancreatic pseudocyst. Can leak amylase-rich fluid into circulation and increase levels. Infxn, duodenal or biliary obstruction, pancreatic ascites, and pleural effusion are possible. This may require drainage, but may require only expectant management if not symptomatic.
A post op Pt with pain, and erythema spreading beyond the surgical site and paresthesia at the edges of the wound with cloudy-gray discharge and mild crepitus in the surrounding area. Dx?
Necrotizing surgical site infxn. Requires ABx and debridement.
Men with pelvic fracture are at risk of injury to which portion of the urethra?
Posterior portion (prostatic urethra and membranous urethra, which both sit above the bulbomembranous jxn). An abrupt motion of the bladder and prostate can cause tearing of the urethra usually at the bulbomembranous jxn (separation point between the anterior and posterior urethra). Blood at urethral meatus, inability to void, scrotal/perineal hematoma, and high riding prostate on DRE indicate posterior urethral injury. Do Retrograde urethrogram to establish Dx before surgery to look for extravasation of contrast.
Blood at the beginning (initial hematuria) of voiding indicates?
Anterior urethral bleeding (urethritis, trauma).
Blood at the end of voiding (terminal hematuria) indicates?
Bladder problem (infxn, stone, cancer, BPH, prostate cancer). Eval with cystoscopy.
Blood throughout urination indicates?
Renal issue. Mass (benign/malig), glomerulonephritis, stone, PKD, pyelo, cancer, trauma. Needs cystoscopy. Clots usually not seen in renal causes.
A patient with chest trauma and signs of acute heart failure and shock requires what imaging modality immediately?
Echocardiogram.
Femoral nerve fxn and dermatomal pattern
Leg flexion at hip, extension at knee. Medial lower thigh and lower leg (via saphenous nerve) sensation.
Obturator nerve fxn and dermatomal pattern
Adduction of the thigh. Mid-thigh medial skin sensation.
Superficial peroneal nerve fxn and dermatomal pattern
Foot eversion. Anterolateral leg and dorsum of lateral foot from big toe.
Deep peroneal nerve fxn and dermatomal pattern.
Foot dorsiflexion, toe extension. Sensation on dorsum of foot webbing between big toe and 2nd metatarsal.
Appearance of pulmonary contusion on CXR?
Patchy, irregular alveolar infiltrate <24 hrs after chest insult.
A burn victim receives skin grafting, but has significant scarring. During Rx he has chronic draining at the wound site. Staff notice an enlarging nodule at the lesion site associated with pain and drainage. Biopsy will reveal?
Squamous cell carcinoma or a Marjolin ulcer (SCC 2° to burns).
Man presents with RUQ pain and imaging reveals gas in the gallbladder. Dx?
Emphysematous cholecystitis. Gas forming species (Clostridium, some E. coli) infect the GB resulting.
