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Uworld Step 2 > Surgery > Flashcards

Surgery Flashcards

1
Q

What is the most appropriate management of a patient with provoked DVT (i.e. after major surgery) and with end stage renal disease?

A

Anti-coagulation for 3 months starting with unfractionated heparin followed by warfarin (bridging since wafarin takes days to have effect and can be pro-coagulative in that time due to proteins C/S suppression).

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2
Q

When are IVC filters used for DVT?

A

Patients with contraindications to anti-coagulation (massive GI bleed, hemorrhagic stroke, ect).

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3
Q

What is the size threshold for urology consult for nephrolithiasis?

A

A stone greater than 10 mm.

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4
Q

What is the next best step for suspected rotator cuff tendinopathy/tear? (i.e. limited abduction and external rotation)

A

Shoulder MRI

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5
Q

What is the preferred agent for volume resuscitation in burn patients?

A

Lactated ringers.

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6
Q

What two organisms are responsible for most deep tissue infections (osteomyelitis, ect) following puncture wounds?

A

S. aureus and Pseudomonas aeruginosa.

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7
Q

What is the most likely cause of a middle mediastinal mass?

A

Bronchogenic cyst. (anterior would be thymoma and posterior would be neurogenic tumors).

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8
Q

What is the acute onset of severe periumbilical pain suggestive of?

A

Acute mesenteric ischemia (patient had acute bacterial endocarditis which is a risk factor for emboli).

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9
Q

What is a potential life threatening complication of a retropharyngeal abscess?

A

Acute necrotizing mediastinitis (retropharyngeal space drains to superior mediastinum plus infection can spread to the danger space between alar fascia and prevertebral fascia leading to drainage to middle mediastinum).

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10
Q

What are the causes of immediate post-op fever? (i.e. withing first couple of hours)

A

Prior infection/trauma, inflammation due to surgery, malignant hyperthermia, medications (anesthetics), transfusion reaction.

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11
Q

What are the causes of acute post-op fever? (i.e. within first week)

A

Nosocomial infections (pneumonia, UTI), PE, atelectasis

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12
Q

What are the causes of subacute post-op fever? (i.e. after the first week)

A

Drug fever, surgical site infection, PE

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13
Q

What are the causes of delayed post-op fever? (i.e. 1 month out)

A

Infection (viral infection from blood products, infective endocarditis).

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14
Q

What are the findings with avascular necrosis of the femoral head?

A

Pain with hip abduction and internal rotation, normal WBC and ESR/CRP, normal imaging for months (advanced will show crescent sign).

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15
Q

Can burn wound sepsis present without fever?

A

Yes. Consider gram negative sepsis in a burn wound patient who develops hypotension and necrotic wound edges.

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16
Q

What characterizes gastric outlet obstruction?

A

Early satiety, nausea, weight loss, non-bilious vomiting. Caused by many disease processes (pyloric stricture, malignancy, PUD, Crohn’s).

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17
Q

What is an atypical presentation of testicular cancer?

A

Metastasis (chronic cough from pulmonary spread, back pain from retroperitoneal LN involvement, ect).

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18
Q

What is pulmonary contusion?

A

Tachypnea, tachycardia, and hypoxia that occurs within 24 hours of blunt thoracic trauma.

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19
Q

How is pulmonary contusion diagnosed?

A

Rales or decreased breath sounds and CT scan or CXR showing patchy alveolar infiltrates not restricted by anatomical borders.

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20
Q

What is the treatment for pulmonary contusion?

A

Pain control, pulmonary hygiene (nebulizer, chest PT), supplemental O2/ventilation support.

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21
Q

What should be suspected in anyone who develops fever and abdominal signs (pain, vomiting, ect) several days following an abdominal operation?

A

An intra-abdominal abscess. A sub-phrenic abscess would also have pulmonary signs (SOB, pleural effusion).

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22
Q

What is a potential complication of cardiac surgery related to intra-operative wound infection?

A

Acute mediastinitis (tachycardia, chest pain, leukocytosis, fever, purulent drainage). Shows mediastinal widening on CXR.

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23
Q

What is the management of acute mediastinitis following cardiac surgery?

A

Surgical debridement and antibiotic therapy.

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24
Q

What are the symptoms of a massive post-op PE?

A

Sudden onset hypotension and right heart dysfunction (JVD and right bundle branch block). Will progress to left heart dysfunction (dyspnea, bibasilar crackles, ect). Also remember that massive PE is one of the few causes of sudden cardiac death.

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25
Q

What is the management of complicated gallstones ( cholecystitis, gallstone pancreatitis, ect)?

A

Cholecystectomy (patient had gallstone pancreatitis and improved but that gallbladder still needs to come out. No need for HIDA scan).

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26
Q

What is the prophylactic agent of choice for animal bite wounds?

A

Amoxicilin/clavulanate (the amoxicillin provides Pasturella coverage while the clavulanate provides oral anaerobes coverage).

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27
Q

Is imaging testing needed if there is a high clinical suspicion for appendicitis?

A

No. Go straight to laproscopic appendectomy (no need to wait for CT scan)

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28
Q

Are those with appendicieal abscesses (presentation delayed by several days allowing for rupture and abscess formation. May not have abdominal signs so do psoas sign) candidates for immediate surgery?

A

No, due to risk of complications. Manage with IV hydration, antibiotics, bowel rest, and interval appendectomy weeks later.

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29
Q

What should be suspected in a child who presents with epigastric pain and bilious vomiting 24-48 hours after blunt abdominal trauma?

A

An obstructing duodenal hematoma.

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30
Q

What is the ugly duckling sign for melanoma?

A

If a patient has multiple pigmented lesions (freckles, ect) a melanoma will be different in character from the others. This combined with nodularity (vertical growth) is concerning for melanoma even if there are no ABCDE signs and requires an excisional biopsy.

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31
Q

What does imaging show with atelectasis?

A

Opacification of the affected lung fields with shifting of mediastinal structures toward the atelectasis.

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32
Q

What are some signs of dumping syndrome following bariatric surgery?

A

Abdominal pain, diarrhea, and vasomotor symptoms (diaphoresis, palpitations).

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33
Q

What is the initial management of dumping syndrome?

A

Dietary modifications (high fiber, high protein, replacing simple sugars with complex carbohydrates, ect.)

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34
Q

What is the work-up for suspected testicular cancer?

A

Radical inguinal orchiectomy, scrotal ultrasound, tumor markers (AFP, b-hCG, LDH).

35
Q

What is the next best step if initial x-rays are negative for a suspected scaphoid fracture? (pain at base of first metacarpal fallowing fall on hand)

A

Either perform CT/MRI or immobilize wrist with a thumb spica splint and repeat radiographs after 7-10 days.

36
Q

In addition to tearing back pain what is a clinical sign of aortic dissection?

A

Variation in systolic blood pressure between arms (can occur in absence of back pain).

37
Q

What is the imaging modality of choice for hemodynamically stable patients with suspected aortic dissection?

A

CT angiography.

38
Q

In addition to Beck’s triad (hypotension, JVD, muffled heart sounds), what can be seen with cardiac tamponade?

A

Elevation and equalization of intracardiac diastolic pressures (elevated RA, RV, and pulmonary capillary wedge pressures) on pulmonary artery catherization.

39
Q

What is required for definitive diagnosis of cardiac tamponade?

A

Echocardiography.

40
Q

What is the first step in management of acute upper GI bleeding?

A

Establishing vascular access with 2 large bore IV catheters to initiate resuscitation with iV fluids.

41
Q

What is the next best step for a foot ulcer through which bone can be palpated/probed?

A

Bone biopsy (due to increased risk of osteomyelitis).

42
Q

What can positive pressure mechanical ventilation precipitate in a severely hypovolemic patient?

A

Acute cardiac arrest due to decreased RV preload (increased intrathoracic pressure from mechanical ventilation).

43
Q

What is the pathophysiology behind post-op atelectasis? (most common on post-op days 2-3)

A

Pain from the surgery causes shallow breathing and impaired cough, resulting in limited recruitment of alveoli at the lung bases and small airway mucus plugging respectively.

44
Q

What are the ABG findings with post-op atelectasisl?

A

Hypoxia (low pO2) with low pCO2 (respiratory alkalosis) from compensatory increase in respiration rate.

45
Q

What does hypocalcemia with hyperphosphatemia and no other signs (renal disease, nutritional deficiency, ect) suggest?

A

Primary hypoparathyroidism (autoimmune, ect).

46
Q

What is the next best step for postcholecystectomy syndrome?

A

ERCP for both definitive diagnosis and possible treatment.

47
Q

What is the best initial step in management of suspected acute arterial occlusion? (decreased peripheral pulses in limb, ect)

A

Anti-coagulation (heparin) while further diagnostic studies are performed (arterial doppler ultrasonography, ect).

48
Q

What is the most likely diagnosis for a patient with a 3rd degree burn who presents days later with localized tense edema, pain out of proportion to injury, and a circumferential eschar around the burn wound?

A

Acute compartment syndrome due to vascular compromise.

49
Q

What is a potential complication of thoracic aorta aneurysm repair?

A

Anterior spinal cord syndrome (b/l loss of motor and pain/temperature sensation with preserved proprioception) due to anterior spinal artery infarction.

50
Q

What is the next best step for a trauma patient with signs of spinal cord injury and no sings of pelvic fracture or urethral injury?

A

Bladder catherization for assessment of neurogenic incontinence.

51
Q

What is a potential neurological complication of polycythemia?

A

Stroke. Requires further evaluation (primary vs secondary, EPO levels, hypoxic secondary or secondary due to tumor {CT scan for RCC}, ect).

52
Q

What is first line for papillary thyroid carcinoma?

A

Surgical resection. Adjuvant radioiodine ablation is after.

53
Q

What is the best initial test for SCC following a negative CT scan?

A

Panendoscopy (esophagoscopy, bronchoscopy, and laryngoscopy).

54
Q

What are the x-ray findings for a traumatic diaphragmatic rupture in a trauma patient?

A

NG tube in the left hemithorax due to resultant diaphragmatic hernia.

55
Q

What are potential complications of a posteriorly displaced supracondylar humerus fracture?

A

Impingement of the brachial artery/median nerve (anterior displacement can affect the ulnar nerve).

56
Q

What areas are assessed by the Glasgow Coma Scale?

A

Ability to open eyes, verbal response, and motor response.

57
Q

What is the diagnostic work-up for suspected renal trauma? (blunt genitourinary trauma)

A

Urinalysis and abdominal/pelvic CT with contrast if hemodynamically stable. If unstable IV pyelography prior to surgical evaluation.

58
Q

What should be performed on those with a clavicular fracture?

A

Angiogram to rule out subclavian artery injury. Also assess for brachial plexus injury.

59
Q

What are the treatments for clavicular fractures?

A

If midclavicular then it is managed non-surgically. Distal clavicular fractures may require open reduction and internal fixation to prevent non-union.

60
Q

What are potential complications of cardiac catherization through the femoral artery?

A

Hematoma (non-pulsatile mass), pseudoaneurysm (pulsatile mass with systolic bruit), and AV fistula (continuous bruit).

61
Q

In addition to NG tube and IV fluids, what should be done for suspected complicated small bowel obstruction? (i.e. leukocytosis, fever, and metabolic acidosis indicating ischemia)

A

Urgent surgical exploration.

62
Q

What is the most likely diagnosis for signs of peritonitis (guarding with rebound tenderness) following blunt pelvic trauma?

A

Ruptured dome of the bladder.

63
Q

What is the best initial step for suspected epidural spinal cord compression? (lower limb UMN signs, neurogenic incontinence, ect)

A

IV glucocorticoids followed by MRI for diagnosis.

64
Q

What is a potential adverse complication of pacemaker placement?

A

Tricuspid regurgitation (signs of right heart failure and holosystolic murmur at lower left sternal border).

65
Q

What is the ultrasound appearance of a hepatic adenoma? (woman on OCP)

A

Well-demarcated hyperechoic lesion

66
Q

What should be done for suspected peripheral artery disease?

A

Ankle brachial index

67
Q

When is surgery indicated for chronic primary mitral valve regurgitation? (i.e. primary = due to defect in valve, not secondary due to MI, ect).

A

If symptomatic and/or if EF is under 60% (EF tends to overestimate actual LV function in these patients).

68
Q

What is the management for secondary mitral regurgitation (i.e. MV stretched due to dilated LV but valve itself is normal, not prolapsed, ect)

A

ACEI and beta-blockers. Rarely does secondary MR need surgery (primary MR such as prolapse does though).

69
Q

What are the clinical and imaging findings of necrotizing fasciitis?

A

Antecedent history of minor trauma, erythema of overlying skin, edema, pain out of proportion to exam, and systemic symptoms (fever, hypotension). Imaging such as CT may reveal air in deep tissue. Treatment is urgent surgical debridement and broad spectrum antibiotics.

70
Q

What are the x-ray findings with a tibial stress fracture? (anterior leg pain, history of repeated running, ect)

A

X-rays are often normal. Treatment is reduced weight bearing for 4-6 weeks.

71
Q

What does recurrent UTI’s, pain with ejaculation, and pyuria/bacteruria suggest?

A

Chronic bacterial prostatitis.

72
Q

What is suggestive of chronic osteomyelitis?

A

A sinus tract with a persistently draining wound over the affected site. If causing a fracture non-union (i.e. fracture not healing after weeks to months) then the fracture will show irregular fracture lines. Requires bone biopsy and surgical debridement.

73
Q

What is a good diagnostic choice for suspected compartment syndrome? (patient had a crush injury and although there was no sensory loss/diminished pulses, pain with passive motion of foot should raise suspicion of CS)

A

Measurement of compartment pressures (needle manometry).

74
Q

What can be seen with the cardiac contours on CXR with cardiac tamponade?

A

They can appear normal due to the small amount of fluid needed to be symptomatic (around 100 mL). Would show JVD, hypotension, and/or muffled heart sounds.

75
Q

What is Charcot joint?

A

Neurogenic arthropathy seen with various neuropathies (most commonly diabetic). Because of repeated trauma to weight bearing joints they develop severe ostophytes and appear unstable on x-ray (joint effusion).

76
Q

What are the signs of a splenic abscess?

A

Fever, leukocytosis, and LUQ pain (with or without left pleural effusion). Most common cause is infective endocartditis (patient had MVP) and treatment is splenectomy.

77
Q

What does plural fluid analysis show with esophageal rupture? (remember to always suspect with vomiting and alcohol abuse).

A

Low pH and high amylase (due to saliva).

78
Q

What is the next best step for complicated diverticulitis with abscess formation?

A

CT guided percutaneous drainage.

79
Q

What imaging study should be performed following acute scrotal trauma?

A

Doppler ultrasound to assess for testicular torsion.

80
Q

What should be administered to a patient on warfarin who needs emergent laparotomy?

A

Fresh frozen plasma.

81
Q

What is the main objective in management of rib fractures?

A

Adequate pain control (allows for better inspiration which combats risk of atelectasis/pneumonia).

82
Q

How does short-term hyperventilation assist in the management of increased intracranial pressure?

A

Lowers PaCO2, thus causing cerebral vasoconstriction.

83
Q

In addition to MVA, what kind of trauma should raise suspicion for blunt aortic trauma?

A

Falls from higher than 10 feet (sudden deceleration). May show hypertension, tachycardia, and a widened mediastinum on CXR.

Uworld Step 2 (6 decks)

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