surgery Flashcards
* remember clinical correlation
history of intense epigastric pain and longstanding heavy alcohol with steatorrhea and diabetes are suspicious for …………
chronic pancreatitis
what do you see on plain film in acute pancreatitis
“colon cut-off sign” ( gaseous distension seen in proximal colon associated with narrowing of the splenic flexure)
what is the most accurate test for chronic pancreatitis?
secretin stimulation (90% specificity)
the best initial tests for chronic pancreatitis are …
abdominal x-ray film and abdominal CT scan
what is the appropriate treatment for symptomatic acute epidural hematoma?
craniotomy and burr hole hematoma evacuation
what is the correct course of action for acute epidural hematoma with stable neurologic exam and no ICP
observation with interval repeat of CT scan
what conservative measure can be done for a stable patient with epidural hematoma to reduce ICP?
hyperventilation on mechanical ventilation
in what way does follicular cancer usually metastasize
hematogenously
follicular cancer usually metastasize to the …., …., ……, or…..
liver, lung, brain or bone
what is the treatment of choice for follicular cancer?
total thyroidectomy and radioactive iodine therapy
when is iodine therapy ineffective and why?
if there is residual thyroid tissue as it will preferentially absorb the iodine.
for how long should the radioactive iodine therapy continue
until there is no further uptake noted
peripheral vascular injuries from a penetrating trauma are initially evaluated with ……………. ……………….
physical exam
a clear vascular injury should be……………
promptly explored
in a patient older than 50 years with the combination of red blood coating stool, change in bowel habits and stool caliber, there should be a high suspicion of …….. ……
rectal cancer
in a patient suspected of cancer of the rectum what is the diagnostic test after physical exam
endoscopic evaluation
what is fistula-in-ano
this is a chronic form of perianal abscess that is spontaneously or surgically drained but the abscess does not heal completely leading to partial tract epithelization .
a fistula-in-ano results as a complication of …………..or ………….. in the ………………..area
perirectal abscess or surgical procedures; anorectal area
how does fistula-in ano present?
constant drainage
on PE a small opening on the anus with granulation tissue and a fistulous tract is visible.
treatment of fistula-in-ano
fistulotomy
before treatment of fistula-in-ano , what do you rule out and how?
necrotic and draining anorectal malignancy via proctoscopy or sigmoidoscopy
a patient with history of mitral stenosis and an irregular pulse point towards a diagnosis of ……. ………………
atrial fibrillation
Atrial fibrillation is a common cause of ……………………… (GI)
mesenteric thromboembolism
abdominal tenderness with metabolic acidosis is highly concerning for …… ……
bowel necrosis
concern for bowel ischemia warrants what intervention?
surgical exploration
Graft-versus-host Disease presents with …… ……… ………….. ……………….
rash, jaundice, diarrhea, intestinal bleeding, death
graft-versus-host disease (GVHD) is mediated by ………..
donor T lymphocytes
the most severely affected organs in graft-versus-host disease are
the immune system, GIT, liver, skin and lungs
a frequent fatal complication in the acute stage of graft-versus-host disease is
CMV pneumonia
surgical resection of pituitary adenoma with dramatic increase in urine output and altered mental status is highly suggestive of ………………. caused by …………….
hypernatremia caused by central diabetes insipidus
central diabetes insipidus can be treated with
IVF hydration and desmopressin
Patient >60 years with h/o smoking, urinary obstruction (which can lead to hydronephrosis) and/or hematuria is highly suggestive of …………………
bladder cancer
what is the initial treatment of choice for severe hyponatremia (<110 mEq/L)? and rate shouldn’t exceed ………..
hypertonic 3% saline
0.5-1 mEq/L/hr
Cushing triad comprises of an is indication of?
- bradycardia
- hypertension
- irregular respiratory patterns.
- Increased Intracranial pressure (ICP)
mention six strategies that can be used to decrease ICP
- raising the head of the bed
- mechanical ventilation
- sedation with propofol
- hyperventilation (PaCO2 btw 30-35 mmHg)
- administration of mannitol
- surgical decompression with a burr hole or craniotomy
how do one distinguish ABO-compatible transfusion vs ABO-incompatible transfusion?
on basis of hematocrit. It is unchanged in the compatible one and decreased in the incompatible transfusion
the most common transfusion reaction is ………….
a febrile non-heamolytic transfusion reaction
what causes a febrile non-hemolytic transfusion in compatible donors?
the recipient antibodies targeting donor WBC
the most common cause of death by transfusion reaction due to
ABO incompatibility due to a clerical error
what is the most common complication of the ventriculo-peritoneal (VP) shunts? and how is it treated?
- mechanical obstruction
- replacement of the device
visceral artery aneurysms most often involve the …………..
splenic artery
what is carpal tunnel syndrome?
It is an entrapment neuropathy of the median nerve as it passes through the carpal tunnel at the wrist
symptoms of carpal tunnel often begins with ………………. and ………..
paresthesia and numbness
when does symptoms of carpal tunnel syndrome get worse?
at night
what is the initial treatment of carpal tunnel syndrome?
splinting and anti-inflammatory agents
in the case of carpal tunnel syndrome, what can be done to rule other etiologies and confirm the diagnosis
wrist x-rays and electromyelography
risk factors for carpal tunnel syndrome?
DM, thyroid disease, occupation and pregnancy
what do you suspect when facing sudden dyspnea
pneumothorax
how is pneumotorax on chest radiograph identified
by lack of pulmonary markings
what are the most common causes of early functional deterioration following a liver transplantation
technical problems with biliary and vascular anastomoses
what happens following a liver transplantation if biliary and vascular anastomoses appear normal
appropriate liver biopsy to confirm diagnosis of organ rejection
abdominal pain and distention, nausea, constipation and dilated large bowel typically in post operative period is highly suggestive of
colonic pseudo-obstruction or Ogilvie syndrome
management of Ogilvie syndrome
mechanical or pharmacological decompression
in a patient with deep epigastric blunt tauma with elevated amylase and lipase levels, what type of injury will you suspect?
pancreatic injuries
what are the “hard” signs of vascular injury to an extremity?
- active hemorrhage
- expanding hematoma
- absent pulse
- bruit or thrills
- distal ischemia
how are “hard” signs of vascular injury to an extremity managed?
immediate surgical exploration
what are the “soft” signs of vascular injury to an extremity
- h/o hemorrhage at the scene
- stable, non-expanding hematoma
- proximity to a major vessel
- anatomically related nerve deficit
- ankle-brachial index <0.9
- unequal pulses
how are “soft” signs of vascular injury to an extremity managed?
further evaluation of affected vessels e.g. CT angiography of the extremity
describe the onset of neurological symptoms in intracerebral hemorrhage
it is not abrupt and it progresses slowly
describe the onset of neurological symptom in intracerebellar hematoma
abrupt onset
mention some of the characteristics presented in cerebellar hemorrhage
inability to walk due to lose of balance, vomiting, headache, neck stiffness, gaze palsy and facial weakness
what kind of injuries are supracondylar fratures specifically prone to ?
brachial artery and median nerve damage
reversal of an elevated INR is best done with administration of ………
fresh frozen plasma
Progressive dysphagia from solids to liquids is ………. until proven otherwise.
Esophageal cancer
Smoking and drinking are strong risk factors for the development of ………… (GI)
Squamous cell carcinoma
Longstanding GERD and Barrett esophagus are associated with
Adenocarcinoma of the esophagus
Class 1 according to wound classification and the risk for infection is
Clean wound: 1-1.5%
Class 2 according to wound classification and the risk for infection is
Clean- contaminated (sterile environment but involves entry into the respiratory, GI or genitourinary system): 3-5%
what is the mainstay treatment for primary biliary cirrhosis
ursodeoxycholic acid
porcelain gallbladder (intramural calcification) is associated with high risk for progression to
gallbladder cancer
a prostate specific antigen (PSA) level of 4nm/ml with a palpable nodule on DRE should raise suspicion of ……………..
prostate cancer
the most effective method for early detection of prostate cancer is …………………….
the combined use of DRE and PSA level
what is the most appropriate step to rule out adenocarcinoma of the prostate?
transrectal ultrasound-guided biopsy
dyspnea on exertion, rales and jugular venous distension are all markers of
congestive heart failure
medical optimization of congestive heart failure includes medical therapy with
ACE-inhibitors, beta-blockers and diuretics
why is estrogen-progestin therapy beneficial in post menopausal women with primary hyperparathyroidism?
ability to reduce bone resorption, increase bone density and decrease serum calcium concentration
what is the first line therapy for erectile dysfunction (ED)?
phosphodiesterase inhibitors e.g sildenafil
when are phosphodiesterase inhibitors contrandicated?
contraindicated with nitrate use
what is the second-line therapy for erectile dysfunction?
vacuum device
what is used as a last resort for ED patients who fail all other conventional therapy?
penile implant surgery
Class 3 according to wound classification and the risk for infection is
Contaminated wound ( there is gross spillage from respiratory, GI or genitourinary system, result of recent trauma or an outright violation of sterile techniques in the OR) 10-15%
Class 4 according to wound classification and the risk for infection is
Dirty wound (result of trauma that contains devitalized tissue or is in the presence of established infection). 30-35%
What are the criteria for proceeding with thoracotomy in a patient with chest trauma
- recovering >20mL/kg on placement of the chest tube
- shock and persistent and substantial bleeding of > 3mL/kg/h
What are the indications for intubation in a burn patient?
- dyspnea
- stridor
- wheezing or coughing
- hoarseness
- burn or soot inside pt’s mouth or nose
Nondisplaced fractures of the carpal navicular (scaphoid bone) are often not visualized on X-ray. True/False
True
Management of nondisplaced fractures of the carpal navicular (scaphoid bone) includes
Thumb spica cast
the most common cause of colovesical fistulas is …..
diverticulitis
the most sensitive test for detecting a colovesical fistula is
contrast CT scan
flank pain radiating to the groin or suprapubic region is highly suspicious of
nephrolitiasis
what is the diagsnostic modality of nephrolithiasis?
plain x-ray after which CT scan without IV contrast
why is there a higher incidence of calcium oxalate and uric acid nephrolithiasis in Crohn disease pt?
it is because of fat malabsorption and excess oxalate
abdominal distention, obstipation and radiographic bowel distention is consistent with ………………….
a small bowel obstruction
diagnosis of small bowel obstruction caused by adhesion is by …………..
CT scan
management of all gunshot wound of the abdomen requires …………………..
exploratory lapatomy
when is a gunshot wound considered to involve the abdomen?
below the nipples and above the pubic symphysis
Meckler triad includes and is suggestive of ……
- vomiting
- chest pain
- subcutaneous emphysema
- boerhaave syndrome
painless masses in the neck in an older patient are considered to be ………. until proven otherwise
cancer
workup for diagnosis of an unknown cancer in the neck includes
- direct visualization of the oropharynx with panendoscopy
- Fine needle aspirate (FNA)
- imaging with CT and/or MRI scan
direct inguinal protrudes ……………
directly through the defect in the floor of the inguinal canal
where is a direct hernia felt when an examiner’s finger is placed in the external inguinal ring?
the hernia is is felt along the lateral aspect of the examiner’s finger
what produces indirect hernia
a defect in the deep inguinal ring
what happens when an examiner’s finger is placed in the external inguinal ring?
the examiner feels the herniation on the tip of the finger
drainage of pink or “salmon-colored” fluid following abdominal surgery is diagnostic for …………………..
fascial dehiscence
pancreatic abscess typically occurs when and after what
10-14 days after the onset of acute pancreatitis
how is the diagnosis of pancreatic abscess made?
CT scan
how is pancreatic abscess managed?
management is percutaneous or surgical drainage
tumors with evidence of metastasis require …………
chemotherapy
what type of abscess responds to antimicrobial therapy
amebic abscess
liver abscess caused by superinfection from the biliary tree are termed
pyogenic abscess
what is the management of pyogenic liver abscess
drainage: percutaneous more favored over surgical drainage
what do you do with potential sources of infection in relation to altered mental status
evaluate and treat
in the elderly with a h/o frequent falls and rapid mental deterioration, what should one think of?
subdural hematoma
what is pathognomonic for colovesical fistulas
pneumaturia
what is the initial management of colovesical fistulas
NPO and IV antibiotics
in a situation of pneumothorax and there is a large amount of air draining continuously through chest tube with failure of lungs to re-expand suspect ……….
bronchial tear
epidural hematoma results from
tearing of the middle meningeal artery
how is an amputated digit preserved
wrap the digit in moist gauze,
put it in a plastic bag and
place the bag on a bed of ice
in preserving an amputated digit, the digit must be kept from drying out and must not be injured with any chemical agents. True/ False
True
in the preservation of an amputated digit, the digit should be placed in direct contact with ice but must not be allowed to freeze. True/ false
False
what is the fastest and least invasive management of an unstable patient with pelvic fracture?
external fixation
charcot’s triad is characteristic for …….. and is consist of ……………………
cholangitis
RUQ pain
fever
jaundice
what is the management that is both diagnostic and therapeutic for cholangitis
Endoscopic retrograde cholangiopancreatography (ERCP)
what is recommended when foley urinary catheter cannot be placed in a pt with BPH?
bladder decompression with a suprapubic tube
what is the number one cause of subarachnoid blood
trauma
blowout fracture of the orbit is an ophthalmologic emergency. True/False
True
what is the consequence of blowout fracture of the orbit?
inferior rectus entrapment and enophthalmos
a patient that presents with rapidly progressive erythema and edema with pain and tenderness significantly out of proportion to the physical finding is highly suspicious of what?
necrotizing fasciitis
necrotizing fasciitis is a surgical emergency. True/False
true
aneurysms >5cm or with a rapid growth have a higher risk of ………….. and are recommended for ………….
- rupture
- open or endovascular repair
features seen in rupturing abdominal aortic aneurysm include:
- severe, tearing back pain
- h/o high bp
- pulsatile abdominal mass
describe the pain of bony metastasis
constant, dull,low-grade and worse at night
describe the pain from a herniated disc
pain runs down the leg and is exacerbated by sneezing and coughing
describe the pain from dissecting thoracic aortic aneurysm
excruciating back pain that starts retrosternally and migrates inferiorly
what is the most common congenital cystic midline neck mass?
thyroglossal duct cyst
how does thyroglossal duct cyst present?
a mobile nontender midline mass at the level of the thyroid cartilage and can fluctuate in size
how is thyroglossal duct cyst managed?
surgical excision via the Sistrunk Procedure
oral contraceptives increase the risk of hepatic adenoma. True/False
true
actively bleeding adenomas present with
abdominal pain, hypotension, tahycardia and anemia
what is the first-line for diagnosing osteomyelitis in the early post-operative period
bone scan
clinical suspicion for a pancreatic head mass should be evaluated with
CT scan
what is the locked-in syndrome?
this is the complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement
causes of locked-in syndrome
- stroke in the base of the pons
- traumatic brain injury
- demyelinating diseases
what neurological condition is associated with rapid correction of chronic hyponatremia
central pontine myelinolysis
what is seen on MRI scan in central pontine myelinolysis?
white patches within the central basis of the pons
what are the characteristic features o pericardial tamponade?
- low blood pressure
- distended neck veins (high CVP)
- muffled heart sounds
treatment for pericardial tamponade includes ……
a pericardial window or a pericardiocentesis
what is essential in treating burn patients?
fluid resuscitation
what are the first-line fluids used in resuscitation?
normal saline or ringer’s lactate
isolated, acute meniscal tears are initially managed with
physical therapy and NSAIDs
failure of conservative management or the presence of chronic symptoms warrants
surgical intervention with either arthroscopic partial meniscectomy or repair
fever that starts approximately 10 to 15 days after a contaminated abdominal surgical procedure is most likely caused by a ……….
deep pelvic or subphrenic abscess
how can pelvic abscess be ruled out ?
by rectal examination
how can diagnosis of subphrenic abscess be confirmed?
CT scan
what is the most undifferentiated form of germ cell tumor?
embryonal carcinoma
describe the histologic features of embryonal carcinoma
sheets of undifferntiated cells with scant cytoplasm,
indistinct cell borders,
crowded nuclei,
numerous mitoses and necrosis
embryonal carcinoma is aggressive with early metastasis. True/False
True
serum alpha-fetoprotein level is elevated in embryonal carcinoma. true/false
true
what is the tumor marker for seminoma?
placental alkaline phosphatase (PLAP)
ischemic colitis is a known complication of AAA repair secondary to ……………….
occlusion of the inferior mesentric artery
how is ischemic colitis diagnosed?
colonoscopy
what is the management for ishemic colitis?
resection of the colon with a colostomy
bariatric surgical procedures are indicated in the following conditions:
- motivated patient
- BMI >40kg/m2
- BMI> 35kg/m2 with serious comorbidities
- reasonable sugrical risk
- failure of previous weight-loss regimens
combination lidocaine with epinephrine should be avoided in areas prone to ischemia without redundant blood flow. True/ False
True
a non-diagnostic FNA of a suspicious parotid mass is an indication for ………………………. to function as an excisional biopsy.
superficial parotidectomy
what are the classic clinical symptoms of anal fissure
equisite pain and minimal bright red bleeding seen on toilet paper with defecation as well as pain with coughing and sitting
On examination, 90% of fissures are seen at the …………………..
posterior midline, distal to the dentate line
in trauma cases with significant volume infusion, what can be done prophylactically to prevent abdominal compartment syndrome?
leave the abdomen open with a negative pressure therapy system
what is the management of abdominal compartment syndrome?
- paralysis
- GI decompression
- decompressive laparotomy
intraoperative development of coagulopathy during prolonged abdominal surgery for multiple trauma with multiple transfusions is treated empirically with …………….
platelet packs and fresh-frozen plasma
what is the next step in management in a situation of coagulopathy, hypothermia and acidosis during a laparotomy?
pack the bleeding surfaces and close the abdomen temporarily with towel clips
what is the typical presentation of femoral fractures?
hip pain and limited range of motion often abduction and external rotation and sometimes limb shortening
how is femoral fracture diagnosed?
plain x-ray films
what is the definitive treatment of femoral fracture
surgical fixation
what management is indicated in a situation of intrinsic cardiogenic shock?
Inotropic drugs like dobutamine and milrinone
what are the presenting symptoms of papillary muscle rupture?
pansystolic murmur radiating to the axilla, sudden drop in blood pressure and acute heart failure
what is the management of acute papillary muscle rupture?
emergent surgical intervention
In a patient whose symptoms of GERD are not resolved with medical therapy if is unable to tolerate medical therapy, what is the best step in management?
Nissen fundoplication
What is the best next step in a stable child with a femur fracture
Skeletal survey
What is a common complication of pancreatitis which is often the cause of death?
Pancreatic abscess
Large volume fluid and blood product resuscitation in trauma cases requires ……..……… catheter namely……….. which varies from ……to …… gauge.
Larger-bore catheter
Introducer
10 to 16 gauge
If IV access cannot be obtained, ………….. can be performed.
Intraosseous cannulation
Examples of inhaled corticosteroids
- Fluticaeone
- Budesonide
- Mometasone
- Beclomethasone
- Ciclesonide
The signature of septic shock in the normovolemic patient is ……. cardiac output and ………..
High cardiac output and low peripheral resistance
The signature of hypovolemic shock is …….. cardiac output and ……..central venous pressure
Low
Low
The signature of neurogenic shock is ……. cardiac output and ………CVP with ……
Low
Low
High spinal cord transection
The signature of cardiogenic shock is …….. cardiac output and ………CVP
Low
High
Signs and symptoms of alcohol withdrawal delirium (6)
- autonomic hyperreactivity
- perceptual disturbances
- diaphoresis
- agitation
- hyperreflexia
- seizures
What is the treatment of choice for alcohol withdrawal delirium?
Benzodiazepines such as lorazepam
………….. presents with abdominal distention, obstipation, vomiting, and hyperactive bowel sounds
Small bowel obstructions
The most common cause of bowel obstruction is ……….. from a ……..
- adhesion
- previous surgery
The most common cause of small bowel obstruction in a patient with no history of previous surgery is ……….
Hernia
