surgery Flashcards
most common cause of lower extremity edema
venous valve incompetence.
ischemia-reprefusion injury can commonly lead to what critical condition
Compartment syndrome
vomitting and abdominal pain after blunt abdominal trauma in a kiddo
Duodenal Hematoma
abdominal succusion splash
ausc a splashing at epigastrium when rocking pt back and forth
suggesting retained gastric material.
seen often in pyloric stenosis/stricture
what is Flail Chest
> /= 3 rib fractures in >2 places
Marjolin Ulcer
burn injury with resulting SCC
fluid resucitation in burn victims
LR
treatment for complicated diverticulitis with >3 cm fluid
CT guided drainage
prosthetic joint infection, whats the bug?
w/in 3 months of surgery- virulent organism ie S Aureus or P Auerginosa
3 mo- 1 yr- low virulence organism ie S.Epi
1 yr+- post op infection ie S.aureus from hematogenous spread
testicular mass that increases with valsalva and doesnt transilluminate
varicocele- dilated pampiniform plexus
FOOSH with hyperextended arm can cause
supracodylar fracture
Median N and brachial A at risk
shin splints vs stress fractures
shin splints: diffuse anterior leg pain, in overweights
stress fracture: pointed pain, in underweights
blunt trauma pt who is unstable with signs of peritonitis? whats the next step?
diagnostic peritoneal lavage
penetrating trauma pt who is unstable with signs of peritonitis?
exploratory lap
penetrating trauma pt who is STABLE with signs of peritonitis?
CT
Gilbert’s Syndrome
inherited disorder of bilirubin glucoronidase precipitated by stressors.
jaundice in the setting of normal CBC, normal ALP, and liver enzymes
how to transport an amputated limb
saline gauze in bag, on ice
what is torus palatinus?
a fleshy hard mass midline on the hard palate
the cause is congenital NOT traumatic
how to differentiate an intra-peritoneal and extra-peritoneal rupture?
intra-peritoneal: injury to the dome (superior/lateral) portion of the bladder. this can cause chemical peritonitis (burning abdominal pain) because urine may enter the peritoneum
etra-peritoneal: injury to the anterior bladder, usually secondary to a pelvic fracture. can cause hematuria
what diaphragm is more prone to tear?
L side following trauma b/c no liver to reinforce it
Small Bowel Obstruction management
- fluids, NG tube, bowel rest
- small bowel follow through series if stable
- surgical exploration if unstable
when to transfuse platelets before surgery
if under 50k
how to reverse warfarin before surgery
FFP (even if the INR is therapeutic! you need to give FFP before surgery)
fat embolism syndrome
usually following a long bone fracture
- petechiae
- respiratory distress
- neuro/cognitive changes
McBurney sign
appendicitis
pain in RLQ
Rosving sign
appendicitis
pain in RLQ when LLQ palpated
perianal abscess
caused by obstruction of crypt gland related to receptive intercourse and constipation
fluctuant painful
fever, leukocytosis,
how does succinylcholine work?
depolarizing NMJ blockade at Ach receptors. More Na influx and K+ outflux. Can be used rapidly bc it takes <1 min to onset and 10 mins to offset.
cardiac arrhythmia 2ndary to hyperkalemia is a a.e.
nasopharyngeal carcinoma
think eastern china, with EBV
what is emphysematous cholycystitis
an infection of the GB with a gas producing organism like clostridium, causing gas in the GB.
this is a surgical emergency
for BAT w/ suspected splenic lac whats the next step
FAST US if SBP >90, if this is normal but pt is anemic do a f/up CT.
if pt is unstable go to lap
pneumobilia, air in sm bowel, hyperactive bowel sounds
gallstone ileus picture
spontaneous pneumothorax management
spontaneous (NOT tension) and small(<2cm) witnessed clinically by being well oxygenated and hemostable can be managed with just oxygen supp and observatin
anterior mediastinal mass diff dx
the 4 T's thymoma thyroid cancer teratoma and other germ cell tumors(AFP and bHCG high) terrible lymphoma
malignancies in young men
testicular cancer, lymphoma, leukemia
in a penetrating abdominal injury what are indications for ex lap
signs of urgent ex lap: peritonitis, blood per rectum or NG, hemo unstable, evisceration
pilonidal disease
a blocked hair follicle develops an abscess in the intergluteal cleft
scaphoid fracture and imaging
will not show up on an Xray immediately following trauma. two options- get CT/MRI or put in thumb spica splint and Xray in 7-10days
what are the 3 components of GCS
eye opening
verbal response
motor response
purpose of GCS
prognosis of coma, NOT diagnosis of coma
normal ROM but positive impingement test (Neer, Hawkins)
rotator cuff tendinopathy
decreased ROM of shoulder with pos impingement test
adhesive capsulitis, frozen shoulder
how to manage a DVT
warfarin with a heparin bridge
avoid LMWH and rivaroxaban if pt has ESRD
when to do surgery on asymptomatic umbilical hernia (congenital)
age 5 if persistent
whistling after rhinoplastry
nasal septum perf
central line placement in the subclavian v can go wrong in what way?
tension pneumothorax with tracheal deviation, decreased breath sounds, and distension of neck veins bc SVC is compressed
which metatarsal stress fracture do you cast or internally fixate
5th bc it is more likely to have non-unionization
what is Kehr sign?
referred pain to the shoulder due to peritoneal irritation leading to diaphragmatic irritations as the phrenic N is inn by the same roots as the shoulder
what is Leriche syndrome?
aortico-iliac occlusion causing
- buttock/groin/thigh pain
- absent or diminished FP,PP, DP
- impotence
management of anal fissure
(often accompanied by a skin tag, do not worry!)
- sitz bath
stool softener and dietary mod
topical anesthetics and vasodilators to increase blood flow/healing to anus
if you suspect urethral injury do?
retrograde urethrogram
peritonsillar abscess looks like?
uvula deviated, trismus, hot potato voice, anterior lymphadenopathy,
ear pain and throat pain
atelectasis abg’s
happens on day 2-3 after surgery
shallow breathing, low alveolar recruitment, so low pO2, then this stimulates increased RR, causing low pCO2 and basic pH
how to deal with massive hemoptysis ?
first secure airway (ABCs)
then if bleed continues, do bronchoscopic intervention
if after intervention and pulmonary artery embolization bleeding continues do thoracotomy
acute mediastinitis
can occur after sternotomy. proof: discharge from surgical site. often has widened mediastinum as well. fever, leukocytosis common.
tx: surgical debridement, and long course of antibiotics.
afib after CABG
very normal for the first 24 hours.
if over 24 hours, can consider Anticoagulation therapy.
what is a marjolin ulcer
SCC arising from wound or burn, usually has higher mets rate
pre-patellar bursitis
- housemaid knee
when do you give bicarbonate
severe acidosis pH<7.2
what should you do after placing a central catheter?
portable xray. correct placement is in lower SVC, can cause pneumothorax/venous perf and other complications if in the wrong spot
what are hints of a medial meniscus tear
twisting on a planted foot
‘popping’
pulmonary contusion vs hemothorax on cxray
pulmonary contusion shows intra-alveolar hemorrhage
hemothorax shows pulmonary effusion
what does ankle brachial index show?
high specificity and sensitivity for PAD.
if <0.9
psoas abscess signs
psoas sign +
hip/flank/abdominal pain
hx of recent infection nearby
who is affected by slipped capital femoral epiphysis
obese kiddos, male, early adolescence
low CI and high PCWP is
MI
air under diaphragm vs air fluid levels in bowel
- air under diaphragm- perforation
2. air fluid levels- SBO
whats the McMurray test?
external and internal rotation of the knee
whats the Thessaly test?
external and internal rotation of the hip while keeping knee stable
terminal hematuria
bladder/prostate
initial hematuria
urethra
total hematuria
kidneys
patellar dislocation
<20 yo, lateral mass which is patella that has dislocated, medial pain
what is Ludwig’s angina
rapidly progressive cellulitis in submandibular and submental region due to infected molar
what is dumping syndrome?
pyloric sphincter looseness after gastric surgery
sx are diarrhea, abdominal pain, as well as vasomotor sx of palpitations and lightheadedness
suspicious of testicular cancer? whats next?
do NOT do FNA or biopsy, this can cause spillage and seeding
a mass+ US findings is enough for orchioectomy
based on pathology from this you can decide on chemo
sliding hernia
hernial sack has a thickened posterior wall formed by a retroperitoneal organ, usually left sided indirect inguinal and descended into scrotum
is either colon or bladder, so you cannot dissect or divide it due to risk of injury
whats the most common type of hernia? in women?
indirect inguinal hernia is the most common type in both
surgery on an asymptomatic femoral hernia?
YES, the chance of strangulation is too high.
what is management of post-op ileus?
switch pain meds from opiates to NSAIDs
if symptomatic with vomitting consider bowel decompression with NG tube
what is a richter hernia?
when only one wall of the bowel is in the hernial sac, so it isnt visible on imaging, and sometimes classic sx are missing. and so is often missed as being strangulated.
SBO management
- bowel rest
- IV fluids
- NG tube
consider surgery based on pain, leukocytosis, acidosis
can self resolve
pediatric umbilical hernia guidelines
do not operate until 4 yo greater than 2cm (likely to close spontaneously), growing defect, or evidence of strangulation
rarely incarcerates.
testicular pain with decreased or absent doppler flow? following surgery?
IF following surgery , likely due to ischemic orchitis secondary to vascular injury of pampiniform plexus (more likely than test A).
(otherwise testicular torsion is also likely, but less likely than vasc cause following sx)
most common cause of bloody nipple discharge
intraductal papilloma
appropriate followup for inflammatory breast cancer suspicion
punch biopsy of skin
MRI
what type of breast finding is an indicator for cancer in either breast
LCIS
following an MI no elective surgery for how long?
min 4 wks.
6 mos is preferred, but if pt passess stress test its ok
post op STEMI vs NSTEMI management
NSTEMI- medical management no PCI indicated f/up with stress test in 6 wks
STEMI- PCI
HOCM signs
increase with valsalva
decrease with squatting
remember not laterally displaced PMI bc its just a hypertrophied septum
pericarditis signs
worse pain on inspiration, lessened by leaning forward
friction rub on auscultation
global ST elevation PR depression
Dressler syndrome
pericarditis following MI,weeks to months after
first 48 hrs after MI death is likely due to
arrhythmia
4-5 days after MI death is likely due to
myocardial rupture, free wall or septal
most accurate way to measure EF?
MUGA scan
Stanford A vs Standord B dissection
A- ascending aorta and aortic arch- complications are deadly need immediate surgery
B - descending aorta, can be medically managed unless malperfusion
stroke sx following MI
most likely ventricular thromboembolism
R sided MI management?
IV fluids to increase preload
Hammam’s sign?
crunching heard in systole, most likely acute mediastinitis
what are the three signs of severe aortic stenosis and what causes the worst outcomes
angina, syncope, CHF
CHF is indicative of 2 yr max prognosis
pulsus bispherens
2 systolic peaks with a dip/divot
most commonly seen in AR
IV thrombolytics following an MI is contraindicated in what condition?
aortic dissection
primary parathyroidism leads to what bone disorder?
osteitis fibrosa cystica
adrenal incidentalomas smaller than what size are unlikley to be malignant
<6 cm
what are the symptoms of a glucagonoma?
- new onset diabetes, polyuria polydypsia
- migrating rash, (necrolytic migratory erythema)
MEN1 symptoms
3P’s (pancreatic, parathyroid, pituitary)
MEN 2 findings
Parathyroid, Pheo, and Medullary Thyroid Ca (check calcitonin)
suspected thyroglossal duct cyst, next step?
if in an adult, must remove because high infection and malignancy risk
no need to FNA.
what elevated in pheo
chromagraninA, metanephrine, VMA
following adrenalectomy what is a complication
addisonian crisis, check cortisol levels- BPs will tank
presents as abdominal pain, nausea, vom, hyponatremia, and hyperkalemia
polycythemia vera as a paraneoplastic syndrome is associated with?
HCC, RCC, hemangioblastoma, pheo
paragangliomas vs pheos
look exactly like pheos but are outside the adrenals, but most common place is the abdomen.
more likely to be malignant, more likely to have heriditary causes
can be missed on CT/MRI, use a functional scan.
superior laryngeal n transection,
high pitch deficit , runs with superior thyroid A and V
recurrent laryngeal N transection
hoarseness
primary hyperparathyroidism w/ 4 enlarged glands
remove 3.5
in the case of biopsied laryngeal cancer what kind of imaging do you need to check for more cancer
chest xray , lung cancer
what is otomycosis
grey discharge, intense pruiritus and fullness,
tympanic membrane unaffected.
usually seen in AML and diabetes
Aspergillus Niger most common cause
what n traverses through the parotid?
Facial N
most common aspiration site?
child <1 larynx
older children trachea, r main stem bronchus
most common salivary gland tumor is?
pleiomorphic adenoma
in smokers its warthrin’s
suspicious of Plummer Vinson syndrome? whats the next step in diagnosis?
esophaGRAM to visualize the webs
indirect vs direct laryngoscopy?
indirect done in the office to visualize vocal cord (uses a mirror so considered indirect)
direct done in the OR
Courvoisier’s sign
palpable non-tender gallbladder distended due to obstruction, most likely pancreatic adenocarcinoma,
can be accompanied by jaundice etc.
Charcot triad vs Reynaud’s pentad
charcot triad- RUQ pain, jaudice, fever
pentad: + hypotension, altered mental status
acute cholangitis, often secondary to gallstone obstruction
Cullen’s sign
red-blue around umbilicus
suggestive of retroperitoneal bleeding
may be seen in hemorrhagic pancreatitis too
when to entereal feed in pancreatitis
around hospital day 5-7 if pancreatitis not resolving
gallbladder polyps management
<10 cm- monitor with US
>10 cm- lap choly
management of isolated GASTRIC varices
due to splenic vein thrombosis, often secondary to pancreatitis
banding, sclerotherapy, etc do not work
not a prob with the liver so no point in TIPS
do splenectomy to treat
after a whipple, or any pancreatic procedure, there is a leak? whats the next step in working this up
get the amylase of the drain fluid
if high in amylase go NPO to decrease secretion
when to do cholecystectomy for gallstone pancreatitis
immediately (w/in 48 hrs) if pancreatitis is mild, no need to wait for labs to normalize
if severe or necrotizing, do not operate yet
common complication after AAA leading to abdominal pain and bloody stools? dx and management?
ischemic colitis
flexible sigmoidoscopy- NPO and fluids
screening for child with APC+
flexible sigmoidoscopy from 10 yo, removal of colon if polyps seen
UC and colon cancer, when to screen?
- risk for colon cancer goes up after 8 yrs, so after 8 yr from diagnosis can start yearly colonoscopies and biopsies.
Ogilvie’s syndrome?
markedly distended colon, with no notable obstruction of the colon.
:pseudo obstruction
most common site of perforation
- cecum
what prevents fistulas from closing
HIS FRIENDS H- high output I- IBD S-short fistula F-foreign body R- radiation I- infections E- epithelialization N neoplams D- distal obstruction
whats an alternative to colonoscopy for screening
flexible sigmoidoscopy and FOBT
“bent inner tube” or “coffee bean sign” mean?
sigmoid volvulus
carcinoid in the appendix, how to manage?
<1 cm , appendectomy is fine
>1 cm, need R hemicolectomy
what can falsely elevate CEA
smoking 4 hrs before the lab
most common cause of appendicitis
fecalith in adults
lympoid aggregation in kiddos
melanosis coli
uniformly darkened colon, secondary to laxative abuse.
recurrent diverticulitis increases risk for what?
stricture
endocarditis associated with what bugs is associated with colon cancer
S.bovis and clostridium septicum
most common primary malignant brain tumor in adults
GBM, astrocytoma IV
what does it mean when a brain MRI shows blurring of grey and white junction
a rapid deceleration trauma causing diffuse axonal injury, shearing forces,
next step if ring enhacing brain lesion found in HIV
tmp/smx if no response get stereotactic biopsy to prove lymphoma
what would the aspiration of a septic joint show?
green/brown fluid
WBC>2.0x10
glucose <25
carpal tunnel syndrome, is the palm affected or no?
NO, it is not affected. it is supplied by the median recurrent nerve. which does not travel through the tunnel
drop arm test is for what nerve?
supraspinatus
Legg Calves Perthes?
osteonecrosis of the hip in kiddos. sometimes the complaint will be knee pain bc kids cannot express
fist bite injury, most common bug?
eikenella corrodoris
DDH?
developmental dysplasiaof the hip
dx by ortalani and barlow manuevers, then US (bones not ossified in babies)
tx: get ortho! might use Pavlik harness
what are the types of shoulder dislocations?
anterior: most common
Posterior: not common, can be caused by seizures and electrocution.
McMurray’s sign?
meniscus tear. when applying tibial torsion and extending foot from flexion position
sunburst vs onion peel
sunburst- osteosarcoma
onion peel- ewings
unhappy triad
medial meniscus tear
medial collateral ligament tear
ACL
duodenal atresia sign and factors?
double bubble
risks: Down syndrome, polyhydramnios,
what is tracheomalacia?
softness of the tracheal cartilage causes collapse, especially when supine. can notice whistling and cyanosis
Mohs surgery is not recommended forwhat cancer type
melanoma
what type of melanoma has the worst prognosis
nodular
berry colored lesion, extensive vertical growth before radial growth
hampton hump
a wedge shaped opacity usually near the costo-phrenic angle that RARELY occurs in setting of PE
Westermark’s sign
dilation of pulmonary vessels with a sudden cut off where its no longer able to be seen
rarely occurs in the setting of a PE
S1Q3T3
rarely seen on EKG in PE (remember most common finding is sinus tach)
S wave in lead 1, Q wave in lead 3, inverted T wave in lead 3
most common DVT location
L common iliac V
most common cause of intrinsic renal AKI
ATN> AIN
what are the 4 types of wounds?
clean- not involving organ or cavity
clean contaminated- aseptic incision into organ or cavity
contaminated- secondary to trauma
dirty infected- ex: an abscess or perforated viscera
septic shock managemetn
IV fluids
NE
