Surgery Flashcards
1
Q
Recommendations for lung cancer screening
A
Annual chest CT for all current & former smokers who:
- Are age 55-79
- Quit <15 years ago
- Have >30 pack years
2
Q
Histologic type for Pancoast tumor
A
Squamous cell CA
3
Q
DDx: Adult, jaundice, elevated LFT’s vs Adult, jaundice, elevated Alk Phos
A
LFT: Hepatitis; Hemochromatosis
ALK PHOS: Cancer; PBC/PSC; Gallstones
4
Q
Hearing loss:
TM with red blush vs with white horseshoe
A
Red blush = otosclerosis (AD)
White horseshoe = tympanosclerosis (chronic OM)
5
Q
Interpretation of Weber/Rinne tests
A
Weber –> + is conductive (ips) or sensory (cont)
Rinne –> + is normal or sensory, - is conductive
6
Q
Difference between Dix Hallpike and Epley
A
DH = diagnostic Epley = treatment
7
Q
Mutation, Wilsons disease
A
ATP7B
8
Q
ENT complication of gout
A
Higher incidence of salivary stones
9
Q
Acute vs chronic management of gout
A
Acute: NSAIDS or colchicine (if no NSAID)
Chronic: Allopurinol – will trigger acute attack!
10
Q
Best imaging for toxic megacolon
A
AXR – no Barium!
11
Q
Treatment for toxic megacolon
A
NGT, IVF
Steroids if IBD e/o
12
Q
Presentation of toxic megacolon
A
- Hx of abx use or IBD
- bloody diarrhea
- peritonitis with SIRS criteria
13
Q
Appropriate workup for primary lung cancer
A
- CXR & CCT
- Small nodule <8mm : follow serial CCT
- Likely malignancy: Bx and/or VATS
14
Q
Appropriate imaging for aspiration foreign body
A
- XR
2. CT if XR is neg (non radio opaque objects)
15
Q
4 drug classes most likely to cause pill esophagitis
A
- Tetracyclines
- NSAID’s
- Bisphosphonates
- Vitamin supplements (Fe esp)
16
Q
Treatment for bony mets from prostate primary
A
– If SC compression –> emergency steroids
External beam radiation
17
Q
Best Antibiotics for bacterial prostatitis
A
Bactrim or Keflex
18
Q
Treatment: infantile hemangioma
A
Watchful waiting
If ulcerated –> propranolol
19
Q
Required vax in burn patients
A
Tetanus
20
Q
Appropriate tetanus prophylaxis:
Clean wound, up to date on shots (3 or more) vs dirty wound, up to date on shots
A
Clean: TT only if last dose >10 years
Dirty: TT only if last dose >5 years
21
Q
Appropriate tetanus prophylaxis:
Clean vs dirty wound, <3 prior shots (inadequate)
A
Clean: TT
Dirty: TT & TG
22
Q
CA-125 vs CEA?
A
CA-125 = ovary CEA = colon
23
Q
Best imaging to assess for metastatic disease
A
CT
24
Q
Treatment: giant cell arteritis
A
Steroids
25
Treatment: Buergers disease
Quit smoking
26
Predisposing conditions for SIBO
Gastric motility impairment -- diabetes, IBD
27
Workup for dyspepsia in young vs old patient
Young?
1. Trial PPI
2. ? H. pylori testing
3. Barium swallow if no improvement
Old/alarm symptoms?
1. UGI w Bx
2. CT if Bx +
28
E/o : popliteal Baker cyst
DJD
29
Treatment: hypertensive emergency in pregnant and non pregnant adult
Pregnant? Hydralazine
| Not pregnant? Sodium nitroprusside
30
Diagnosis? Infant with weak abdominal muscles, dilated ureters, undescended testes
Most likely COD?
```
Dx = prune belly (Eagle Barrett syndrome)
COD = pulmonary hypoplasia
```
31
Best imaging for bone mets
Technetium 99 bone scan
32
Contraindications for immunomodulators:
Prednisone?
Azathioprine?
Cyclosporine?
P - diabetes
A - cirrhosis
C - renal dz
33
Crypt abscesses are seen in
UC
34
What is IRIS?
Immune Reconstitution Inflammatory Syndrome -- the reason not to start (or restart) HAART in an acutely ill AIDS patient
35
A deformity in which body system causes oligohydramnios vs polyhydramnios?
Oligo -- renal (can't produce urine)
| Poly -- GI (can't swallow)
36
Leslar-Trélat sign
Acute eruption of sebhorreic keratoses; suggestive of gastric cancer
Justifies ordering an ACT
37
Treatment for keratoacanthoma
A low grade SCC; should be excised completely
38
Anatomic site for foreign body impaction in infants vs children
Baby: larynx
Kid: R main bronchus or trachea
39
Is blood hyper or hypo dense on CT?
Hyper
40
Diagnosis: head CT shows hyperdense fluid in ventricles
SAH
41
#1 most common brain tumor
Metastatic lung cancer
42
Most likely diagnosis: newborn with difficulty breathing and CXR showing diffuse interstitial/alveolar edema
What's the treatment?
Transient tachypnea of the newborn
Self resolving
43
What is a normal value for CVP? Which values would suggest fluid overload?
Normal: 0-5
| Fluid overload: >12
44
Under which criteria can a pregnant trauma patient be d/c home?
If they can't be d/c home, what test should you order?
1. Fetal nonstress test shows no acute distress
2. No contractions > q10m
3. No abdominal pain
4. Normal fetal heart tracing
First test if patient fails these criteria: Biophysical profiling
45
Treatment: Warthin tumor
Superficial parotidectomy
46
Biggest risk factor: Warthin tumor
Smoking
47
Best imaging: renal artery stenosis
Renal arteriogrhaphy
48
Screening guidelines: AAA
Men >age 50 with significant smoking history
US
49
Most common location of a peripheral aneurysm
Popliteal; often b/l
50
Imaging for intact vs stable ruptured AAA
Intact: US
Ruptured: CT
51
Treatment: ruptured AAA
Morphine and propranolol
52
Prenatal US finding (and its significance): Gastroschisis
Polyhydramnios (concomitant intestinal atresia)
53
Infants with omphalocele should be screened for these three genetic syndromes
1. Trisomy 13
2. Trisomy 18
3. Beckwith-Wiedemann (macroglossia, microcephaly)
54
Treatment, according to Cobb angle: Scoliosis
>20 needs a brace
| >50 needs surgery
55
Workup for dysphagia
1. Barium swallow to r/o Zenker
2. Manometry to r/o achalasia
No UGI until Zenker has been r/o (risk of perf)
56
MOA of these drugs for acute angle closure glaucoma:
PO Carbonic anhydrase inhibitors
Topical beta blockers and alpha 2 agonists
CAI: decreases intraocular pressure
Symps: induces pupil constriction (miosis)
57
Treatment: acute adrenal insufficiency
Corticosteroids and IVF
58
Pharmaceutical treatment for anal fissure -- what are they and why do they work? Side effects?
Vasodilators -- nifedipine, nitroglycerin
Increased bloodflow improves healing
Nitro can cause headaches
59
Imaging for aortic dissection stable vs unstable
Stable: CT
Unstableish: TEE
Unstable: emergent thoracotomy
60
When would a dissection of the descending aorta necessitate surgical repair?
Signs of end organ or limb ischemia
61
Best drug treatment for dissection of descending aorta?
Labetalol
62
Aortic transection: finding on CXR
Left hemothorax with widened mediastinum and deviation of trachea to the right
63
3 diseases that predispose to angiodysplasia
1. Renal disease
2. Aortic stenosis esp when associated w VWD
3. VWD alone
64
Preferred drug treatment for:
Dog bite
Black widow bite
Brown recluse bite
Dog: Amox/Clav
Black widow: Calcium gluconate
Brown recluse: Dapsone
65
Deadliest animal injury
Bee sting
66
Prophylaxis for post op atelectasis in smokers
Stop smoking at least 8 weeks prior to surgery
67
Common e/o organism: bacterial parotitis
MRSA
68
Common e/o organism: Septic arthritis
MRSA
69
Most common appendiceal tumor
Mucinous adenocarcinoma
70
Diagnosis: "lead pipe" appearance of colon on AXR
UC
71
Initial imaging: basilar skull fracture
Head CT
72
Treatment: Bell's palsy
PO corticosteroids
73
Definitive diagnostic test for biliary atresia
HIDA scan with Phenobarbital
74
Imaging: Bladder dome rupture
Retrograde cystogram
75
What is the clinical indication for aminocaproic acid? How does it work?
Pre-operative for severe (transfusion-dependent) Hemophilia A
Decreases fibrinolysis by binding to plasminogen
76
Mechanism of action for each of these anticoagulants?
```
Fondaparinux (Arixtra)
Bivalrudin
Argatroban
Rivaroxaban (Xarelto)
Apixaban
```
Direct thrombin inhibitors:
- Bivalrudin
- Argatroban
Direct Xa inhibitors:
- Rivaroxaban
- Apixaban
Indirect Xa inhibitors (anti-thrombin binding)
- Fondaparinux
77
Mechanism of action for each of these anti-platelet agents?
```
Aspirin
Clopidogrel (Plavix)
Cilostazole
Dipyridamole
Abciximab (Reopro)
```
ADP receptor blockers:
- Clopidogrel
PDE inhibtors:
- Cilostazole
- Dipyridamole
Platelet GP receptor blockers:
- Abciximab
78
Presentation for Blount's disease
Persistent bowleggedness (genu varum) in an older child; requires surgical correction
79
Brachial plexus: nerve roots for superior vs inferior trunk
Superior: C5-C6
Inferior: C8-T1
80
Best imaging: brain abscess
Head CT
81
Appropriate management for bronchial rupture
Intubation with fiberoptic bronchoscopy followed by urgent surgical repair
82
Best imaging: breast abscess
US
83
Paget's disease of the breast is most commonly associated with this pathologic diagnosis
DCIS
84
Most common bacteria to infect burn patients:
- First 5 days
- >5 days
- Overall
- First: MRSA and Group B Strep
- >5 days: Gram negative
- Overall: Pseudomonas
85
What is the rule of 9's? How is it different in babies?
Adults -
Head and each arm 9%
Front, back, and each leg 18%
Babies -
Head, front, and back 18%
Each arm 9%
Each leg 14%
86
Which imaging study would be most appropriate to order in a patient with severe burn injuries?
Endotracheal fiberoptic bronchoscopy
87
Appropriate treatment for a burn patient with carboxyhemoglobin > 10%
100% O2
88
What is the Parkland Formula for calculation of IVF in a burn patient?
TBSA % (2nd and 3rd degree) * Weight kg * 4
| usually ~1,000mL/hr in adults or 20mL/hr in babies
89
Which IVF is absolutely contraindicated in a burn patient, and why?
Anything with dextrose -- sugar can induce osmotic diuresis
90
What are the side effects of silver sulfadiazene and mafenide acetate?
Silver --> thrombocytopenia
| Mafenide --> severe pain with application; metabolic acidosis
91
Which lab test is fastest for diagnosis of C. diff colitis?
Stool toxin
92
What is the antibiotic of choice in C. diff colitis?
Vancomycin PO
93
Which vessel is most commonly transplanted to the heart in a CABG?
Internal mammary artery
94
What is the most common complication of CABG and which imaging is appropriate to identify it? How is it treated?
Retroperitoneal hematoma, less than 12 hrs
A/P CT without contrast
Treatment = supportive only
95
What is the appropriate management for multi-vessel heart disease in patients who are poor surgical candidates for CABG?
Balloon angioplasty with stent placement
96
If a patient with recent history of CABG presents with SIRS criteria, what should be your first differential? What's the treatment?
What is Hamman's sign?
Acute mediastinitis
Tx = surgical debridement and antibiotics
Hamman's sign = systolic crepitus over mediastinum
97
This finding on cardiac echo justifies performing a CABG
EF < 50%
98
Contraindications specific for CABG
- Poor ventricular function
| - No distal vessels sufficient for graft
99
CP manifestations of carcinoid syndrome
Right valvular disease (ie tricuspid) 2/2 increased JVP
100
Which vitamin deficiency is associated with carcinoid syndrome and why?
Pellagra (niacin deficiency) 2/2 depletion of tryptophan
101
Dermatologic manifestation of carcinoid syndrome
Cutaneous telangiectasias
102
What is the best imaging test for metastatic carcinoid tumors?
OctreoScan (and A/P CT)
103
What is the standard treatment for symptomatic carcinoid tumor?
Pre-operative octreotide followed by surgical resection of liver mets
104
Best imaging for cauda equina syndrome
MRI
105
Which part of the hand is affected in carpal tunnel?
Thumb, 2, 3, and half of 4
| NOT THE PALM (palmar cutaneous comes off before the carpal tunnel)
106
Best imaging for carotid artery dissection?
MR Angiogram (and usually head CT to r/o stroke in cases of Horner syndrome)
107
Most feared complication of carotid artery dissection?
SAH
108
Appropriate management for carotid artery dissection
Medical anticoagulation
Stenting increases stroke risk and is therefore reserved for special cases
109
Appropriate management for carotid artery stenosis
>60% and symptomatic (or >80% and asymptomatic): endarterectomy
110
Best initial imaging in C-spine injury
CT -- then MRI if CT is negative
111
Treatment for cholangitis
Decompressive ERCP with elective chole to follow
112
Neoplastic association of porcelain gallbladder
Gallbladder cancer
113
Appropriate treatment for chronic symptomatic cholelithiasis in a poor surgical candidate. What is the most common side effect
Oral ursodeoxycholic acid; diarrhea
114
Why does Crohn's disease predispose to cholecystitis?
Terminal ileum resection --> loss of bile salts
115
A gallbladder wall beyond a thickness of ___ cm is suggestive of acute cholecystitis
4 cm
116
Which organism is usually responsible for emphysematous cholecystitis, and which characteristic laboratory finding does it cause?
Clostridium
| + Unconjugated bilirubin (hemolysis)
117
Best antibiotic for clostridial species
PCN or Clinda
118
HIDA scan results in acalculous cholecystitis
Gallbladder is not visualized at all (may be false +)
119
Appropriate workup and treatment for acute bile duct leak
1. CT --> determines drain placement
2. HIDA --> tracer in the abdomen is justification for ex lap with hepaticojejunostomy; if tracer is contained, can do an ERCP with stent placement instead
120
What is Mirizzi's syndrome?
A gallstone in the cystic duct compressing the common hepatic duct
121
Appropriate treatment for benign gallbladder cyst
Cholecystectomy. Cysts can be premalignant; and they can predispose to cholangitis (especially if the involve the hepatic ducts, as in Caroli's syndrome)
122
Best pain relieving medication for gallbladder disease
Anti-cholinergics
123
Which two vessels are at highest risk for injury in a clavicle fracture?
Axillary artery, subclavian artery
124
How does the location of a clavicular fracture change the treatment? Which location is most common?
Mid-shaft (most common): ice, rest, bracing
| Distal shaft: open reduction and internal fixation
125
How does a person with a clavicle fracture hold the affected arm?
Posterior & inferior
126
Which chemotherapeutic agent is most standard in CNS lymphoma?
Intrathecal methotrexate
127
What is the appropriate treatment for a cocaine overdose with EKG changes? Which treatment is absolutely contraindicated?
PCI!
| Never give BB!
128
What are the treatment for acute and chronic cluster headaches?
Acute -- sumatriptan (5HT agonist) and O2
| Chronic -- verapamil prophylaxis
129
Which genetic syndrome predisposes to coarctation of the aorta?
Turner syndrome
130
Which condition presents with "scalloping" or "notching" of the ribs on CXR? Why?
Coarctation of the aorta (erosion from collateral enlargement of intercostal vessels)
131
How is coarctation of the aorta managed in a neonate?
Prostaglandin E --> opens the DA
132
What is a Colles fracture, how does it present, and how is it treated?
Fracture of the distal radius
Most commonly presents in a little old lady with osteoporosis and a FOOSH injury with a "dinner fork" deformity (the fractured end of the radius is displaced dorsally)
Treated with casting
133
A patient with colon cancer and colonization by Clostridium septicum is at increased risk for these
hematologic malignancy; myositis
134
How does R-sided colon cancer present?
+FOBT, asymptomatic
135
First site of metastasis for rectal cancer
Lungs
136
Which of these polyposis syndromes are benign?
Peutz-Jeghers
Juvenile polyposis
Gardner syndrome
Peutz-Jeghers and Juvenile polyposis
137
A patient with UC needs increased screening for colon cancer at 20 years after diagnosis. How often should they get a colonoscopy?
Every 1-2 years
138
Which non-malignant etiology can cause false elevations in CEA?
Smoking
139
Patients with FAP can usually wait to undergo a total proctocolectomy until their early 20's, unless ...
They have HG dysplasia or are symptomatic
140
Children who test positive for the APC (FAP) mutation should undergo this test every year
Flexible sigmoidoscopy (since polyps arise on the left)
141
Colon cancer screening protocol in patients with Lynch syndrome
Annual flex sig or colonoscopy starting at age 25
142
Female patients with Lynch syndrome need this non-GI screening test
Annual endometrial biopsy (or prophylactic hysterectomy)
143
What is the purpose of the GCS? What does a GCS < 8 indicate?
PROGNOSTIC rather than diagnostic
| <8 justifies intubation
144
What are the three components of the GCS?
Eye opening (4), verbal (5), motor (6)
145
Which chemotherapy regimens are most appropriate in colon cancer?
FOLFOX (5FU and folinic acid)
or
FOLFIRI (5FU, folinic acid, and irinotecan)
146
Which test can be used to diagnose abdominal compartment syndrome?
Bladder pressure test
147
How is abdominal compartment syndrome treated, and how does that vary by etiology?
Post-surgical (most common): surgical opening of the wound with placement of temporary cover
Pancreatitis: NG tube placement and paracentesis
148
What is the time scale at which irreversable damage occurs to these structures in a case of limb ischemia?
- Muscle
- Nerve
- Fat
- Skin
- Bone
```
Muscle 4h
Nerve 8h
Fat 13h
Skin 24h
Bone 5d`
```
149
Which surgical procedure is most likely to lead to extremity compartment syndrome?
Femoral artery embolectomy
150
Which vascular symptoms do you expect to see in compartment syndrome of the extremity?
NONE. Pulses should be normal
151
Most likely diagnosis in a post-surgical patient with a warm, exquisitely tender limb
Warm = fairly specific for cellulitis
152
Top 4 complications of an electrical burn injury
1- hyperkalemia
2- compartment syndrome
3- cataracts
4- demyelination syndromes
153
Localizing corticotropic tumors using the 8mg dexamethasone suppression test: After suppression:
High ACTH, low cortisol = ?
High ACTH, high cortisol = ?
Low ACTH, high cortisol = ?
High ACTH, low cortisol -- pituitary
High ACTH, high cortisol -- ectopic (ie lung)
Low ACTH, high cortisol -- adrenal
154
DIagnosis: ascites and "square root sign" on Swann Ganz catheter
Chronic constrictive pericarditis
155
Treatment for DeQuervain tenosynovitis vs DePuytren contracture
DeQuervain: Steroid injections
DePuytren: Surgery eventually
156
A scaphoid ("sucked in") abdomen may portend this abnormality
Diaphragmatic hernia -- the abdomen is empty because its contents are in the chest
157
Diaphragmatic hernias may occur in children weeks or months after a BAT, in which case they undergo immediate surgical repair to prevent bowel strangulation. How are they treated differently in infants with congenital disease?
Provide ECMO respiratory support and delay surgery until 3-4 days old to allow the displaced little lungs to mature
158
A patient presents with a dislocated shoulder. Explain how you would treat them and how imaging would factor in .
1 - start with XR
2 - reduce
3 - re-XR
(4 - concern for vascular injury -- CT angio post reduction)
159
How does a patient with an anterior shoulder dislocation hold their arm?
AD and ER (like shaking hands)
160
What is the primary long term concern in a patient with anterior shoulder dislocation and how would it manifest?
Axillary nerve injury
- Can't ABduct (teres minor & deltoid weakness)
- Numbness in lateral shoulder (deltoid)
161
Posterior shoulder dislocations are rare. Which imaging to they require, and how is that different from an anterior shoulder dislocation?
Posterior needs both lateral and axillary views (more than anterior)
162
Is it ever appropriate to order a CT in a shoulder dislocation?
Only if the XR is equivocal
163
What is the FIRST test to order in a case of bacterial endocarditis?
Blood culture
| *Not echo*
164
A patient has a suspected colovesical fistula which needs to be evaluated by contrast CT. How should the contrast be administered?
Rectal or oral -- NOT IV
165
What is the pathogenesis of Dumping Syndrome s/p gastric bypass and how is it treated?
Excessive release of post-prandial insulin
| Dietary modifications & octreotide
166
Appropriate initial imaging in a case of acute diverticulitis
ACT with contrast
*not colonoscopy -- could perforate if you pump air into it*
NEVER DO A COLONOSCOPY ON AN ACUTELY ANGRY COLON
167
When does a diverticulitis patient need to be admitted to the hospital? When do they need emergent (non-elective) surgery?
Any abscess at all on ACT should be admitted
If the abscess is >3cm it needs to be drained
If it persists after drainage colectomy is required
168
You should have a high index of suspicion for this injury in a child with a recent fall onto their bicycle handlebars
Duodenal hematoma
169
Does duodenal hematoma with perforation commonly present with peritonitis?
NO -- injuries are usually retroperitoneal
170
What is the appropriate treatment for duodenal hematoma with and without extravasation of contrast on CT?
With -- emergent ex lap
| Without -- NG decompression, may need I/D if doesn't improve
171
Treatment: epidural hematoma
Emergent craniotomy
172
Neurologic exam findings in epidural hematoma
Ipsilateral fixed and dilated pupil
| Contralateral hemiparesis
173
Patients with otomycosis (or malignant otitis media) 2/2 aspergillus need to undergo this test
Head CT
174
The most common complication of acute otitis media is what? What test is required? What's the treatment?
Mastoiditis
CT
Surgical mastoidectomy with ear tube placement
175
3 most appropriate tests in a baby with esophageal atresia
Renal US
Limb (radius) XR
Echo
(for VACTERL)
176
Best pharmacotherapy for esophageal spasms
Diltiazem
177
Esophageal varices are treated with vasopressin, nadalol, and this drug, which decreases portal bloodflow
Octreotide
178
Patient's s/P TIPS procedure should limit this in their diets
protein
179
The preferred beta blocker in esophageal varicies
Nadalol
180
Patients with Plummer Vinson Syndrome need to undergo this screening test
annual UGI (high risk of SCC)
181
Appropriate management for empyema
thoracentesis, and chest tube
182
CBC finding characteristic of fat embolism syndrome
thrombocytopenia
183
What causes a felon, how does it present, and how is it treated?
Cause: neglect of penetrating wound
Presentation: abscess in fingertip with fever and severe pain, sometimes meeting SIRS criteria
Treatment: I/D terminal joint space
184
Injury to this nerve causes numbness in the anterior thigh and an inability to extend the knee
femoral nerve
185
Injury to this structure needs to be ruled out in cases of flail chest
thoracic aorta
186
What is Foster Kennedy syndrome? What are its symptoms?
Frontal brain tumor -- bizarre behavior, anosmia, C/L papilledema, vomiting
187
Which test is considered definitive for gastroparesis?
Scintigraphic emptying study
188
Gamekeeper's (skiier's) thumb, jersey finger, and mallet finger are all treated with casting. What is the difference between them?
Gamekeeper/skier -- forced hyperextension of thumb
- ulnar collateral ligament
Jersey finger -- forced hyperextension of finger
- flexor tendon
Mallet finger -- forced hyperflexion of finger
- extensor tendon
189
Appropriate treatment for GERD with HG dysplasia
NIssen with radiofrequency ablation
190
What is the #1 risk factor for gastric cancer?
H pylori
