Surgery Flashcards
________ presents with mid-systolic, crescendo-decrescrendo right 2nd intercostal+ left sternal border
Aortic stenosis
Aortic stenosis radiates to _________
carotid
______ increases the murmur of aortic stenosis
squatting
_______ decreases the murmur of aortic stenosis
valsalva
when is the valve replaced in aortic stenosis
if symptomatic, gradient > 50 or CHF
________ presents with Holosystolic murmur with click at the apex radiating to axilla
mitral regurgitation
Most common cause of mirtal regurgitation
MVP (Marfans)
Early peaking systolic ejection murmur increased by Valsalva,
decreased by squatting/handgrip
HOCM
if pt with HOCM present with syncope, arrhythmia or FH of HOCM
place an Implantable Cardioverter Defibrillator
Acute: young person with endocarditis & sudden CHF with
loud diastolic murmur at right 2nd intercostal space
Acute Aortic Regurgitation/Insufficiency
blowing high-pitched diastolic at 2nd intercostal space
+ left lower sternal border assoc’d with wide pulse pressure.
Chronic Aortic Regurgitation/Insufficiency
what is the first line treatment of chronic aortic regurgitation
medical therapy with vasodilators
Low pitched rumbling diastolic at apex with opening snap
mitral stenosis
complication of mitral stenosis
atrial fibrillation
extreme drop in platelets + clots in post-op patient who has received
heparin within 5-14 days
Heparin Induced Thrombocytopenia
treatment of heparin Induced Thrmbocytopenia includes _________
STOP HEPARIN, give lepirudin or argatroban
Lidocaine + epinephrine should not be given in the following places: ______, _______, _______ and _____
fingers, nose, penis and toes
A patient takes amlodipine for hypertension. When should
this patient discontinue this medication prior to surgery?
Hold morning dose
For how long should an active smoker be told to quit before surgery?
8 weeks
why are patients with nephrotic syndrome at increased risk of clotting?
loss of antithrombin III in urine
symptoms of malignant hyperthermia
high fever (>104 degrees celcius), muscle rigidity, metabolic acidosis, hyperkalemia
treatment of malignant hyperthermia
IV dantrolene, 100% oxygen, Cooling blankets, correct acidosis
patient presents with fever less than 24hrs of surgical operation. most likely cause?
malignant hyperthermia
patient presents with fever within 24hrs of surgical operation. most likely causes?
atelectasis, necrotizing fasciitis
management of atelectasis
incentive spirometry, mobilization
symptoms of atelectasis
low-grade fever, non productive cough
CXR findings for atelectasis
bilateral fluffy lower lobe infiltrates without consolidation
management of necrotizing fasciitis
surgical debridement, antibiotics
symptoms of necrotizing fasciitis post operatively
high fever, ill, rash
findings for necrotizing fasciitis
gas in tissue
post operative fever Day 2-5. Most likely causes?
Pneumonia
UTI
Thrombophlebitis
post operative fever Day 7. Most likely causes?
central line infection cellulitis wound infection dehiscence pulmonary embolus
post operative fever Day 10-15. Most likely cause?
abscess
prevention of decubitus (pressure) ulcers
change position every two hours
light criteria
LDH> 200
LDH effusion/LDH serum > 0.6
Protein effusion/protein serum >0.5
what stage of pressure ulcer- intact skin, red, blanches with pressure
Stage 1
what stage of pressure ulcer- break in dermis, blister
Stage 2
what stage of pressure ulcer -into subcutaneous tissue and muscle?
Stage 3
what stage of pressure ulcer- involvement of bone?
Stage 4
what makes an exudative effusion complicated?
flank pus, +gram/culture, pH <7.2
diagnostic criteria of ARDS
- PaCO2/ FiO2 < 200 (< 300=acute lung injury)
- Bilateral alveolar infiltrates
- PCWP < 18 (Rules out cardiogenic cause of pulmonary edema)
when should 3% Normal saline be used
severe hyponatremia (<110), seizures
rapid correction of hyponatremia could lead to ____
central pontine myelinosis
rapid correction of hypernatremia could lead to _____
cerebral edema
Pain/dysphagia worse with liquids, chest pain, no regurgitation. Suspect?
Diffuse esophageal spasm
Confirmatory diagnosis of diffuse esophageal spasm
Manometry
Management of diffuse esophageal spasm
CCB or nitrates
Barium swallow done at the time of pain showing “corkscrew esophagus” is suspicious of
Diffuse esophageal spasm
Usually idiopathic, can be associated with Chagas’ disease and patient presents with dysphagia to liquids and solids. Suspect?
Achalasia
Barium swallow for achalasia shows?
Bird’s beak
Management of achalasia
CCB; Nitrates; Botox; Dilation; heller myotomy
Terrible breath, regurgitation of dinner in the morning. Suspect?
Zenker diverticulum
False diverticulum, only contains mucosa
Progressive dysphagia, weight loos with h/o smoking or alcoholism . Suspect?
Squamous cell esophageal carcinoma
Progressive dysphagia, weight loos with h/o GERD/ Barrett’s. Suspect?
Adenocarcinoma of the esophagus
Management of early stage esophageal carcinoma
Esophagectomy
Management of advanced esophageal carcinoma
Chemo + RT and then surgery
Management of metastatic esophageal carcinoma
Chemotherapy
Epigastric pain worse after eating or laying down with h/o hiatal hernia. Suspect?
GERD
Risk factors for GERD
Hiatal hernia Obesity Pregnancy EtOH/ smoking Acidic, spicy foods/caffeine Certain meds
Best diagnostic test for GERD
24-hr pH monitoring
What can be used to treat GERD if incompetent LES or symptoms persists after maximum dose of PPI
A Nissen fundoplication
Alcoholic presents with bright red blood in emesis after severe vomiting. Suspect?
Mallory-Weiss tear
To confirm diagnosis of Mallory-Weiss tear do?
Endoscopy
Hematemesis after vomiting, subcutaneous emphysema, severe pain, fever leukocytosis and ill appearing. Suspect?
Boerhaave syndrome
Full thickness esophageal rupture
Diagnostic test when you suspect full thickness esophageal rupture
Gastrografin swallow
Management of boerhaave syndrome
Surgical repair
Management of varices
Octreotide/SST Balloon tamponade Endoscopic sclerotherapy Banding Beta blocker if asymptomatic
Risk factors of gastric ulcers
H. Pylori
NSAIDS use
Steroids
When is the pain from gastric ulcer worse
Worse with eating
Treatment of H.pylori cause of gastric ulcer
Clarithromycin
Amoxicillin/metronidazole
PPI
Complications of partial/total gastrectomy
Gastric dumping
Pernicious anemia
Fe-deficiency anemia
Management of H.pylori gastric lymphoma
Treat H.pylori with triple therapy
Epigastric pain of duodenal ulcer improves with
Eating
Management of Duodenal ulcer
Triple therapy for 14 days then test for eradication
Unremitting peptic ulcers + watery diarrhea. Suspect?
Zollinger-Ellison syndrome
Diagnostic test for Zollinger-Ellison Syndrome
Secretin stimulation test (inappropriately high gastrin)
CT
Management of Zollinger-Ellison Syndrome
Surgery
Check for MEN syndrome
Omeprazole for metastases
Epigastric pain, nausea, vomiting with increased amylase + lipase. Diagnosis?
Acute pancreatitis
Complications of acute pancreatitis
Pseudo cyst Hemorrhage Abscess Sepsis ARDS
Complication of chronic pancreatitis
Splenic vein thrombosis which leads to gastric varices
Large, non-tender gallbladder, itching, jaundice - what sign?
Courvoiser’s sign of pancreatic cancer
Migratory thrombophlebitis- what sign
Trousseau’s sign of pancreatic cancer
Which endocrine pancreatic tumor presents with malabsorption and steatorrhea
Somatostatinoma
Complications of gallbladder
Rupture
Fistula formation
Gallstone ileus
RUQ pain, elevated bilirubin + alkaline phosphatase
Suspect?
Choledocholithiasis
RUQ pain, fever, jaundice, hypotension, AMS
Suspect?
Reynolds pentad
Ascending cholangitis
Which hematoma does not cross the suture lines
Epidural hematoma
Which hematoma shows biconvex lens on non-contrast CT scan
Epidural hematoma
What vessel is responsible for epidural hematoma?
Middle meningeal artery
Semilunar, crescent shaped on CT. What hematoma?
Subdural hematoma
What vessel is responsible for subdural hematoma?
Bridging vein
Raccoon eyes, CSF rhinorrhea/otorrhea, ecchymosis behind the ear is suggestive of?
Basilar skull fracture
Management of ICP
Elevation of head of bed
Hyperventilating to PCO2 35
Mannitol/ furosemide & avoid excess IVF
Maintain adequate CPP (MAP- ICP)
What zone of penetrating neck injury warrants surgical exploration?
Zone 2
Forced neck hyperextension (whiplash); paralysis & burning pain in the upper extremities. Suspect?
Central cord syndrome
Vertebral body burst fractures; loss of motor, pain and temperature distal to injury on both sides. Suspect?
Anterior cord syndrome
Gun shot wounds or stab cutting the cord at one level; paralysis & loss of proprioception distal to injury on the same side; loss of pain & temperature sensation on opposite side. Diagnosis?
Brown-Sequard syndrome
Flail chest symptom to watch out for
Inward movement of chest with inspiration
Complication to watch out for with flail chest
Aortic transection
Management of rib fracture
Pain control w/ aggressive respiratory therapy
What do you see on CXR 48 hours after for the diagnosis of pulmonary contusion
White out of lungs on CXR
Difference between pneumothorax and hemothorax
Dullness to percussion for hemothorax
Difference between tension pneumothorax and hemothorax
Trachea deviates toward the side of injury
What injuries increases the suspicion of aortic rupture
- scapular
- 1st rib
- Sternal fracture
How do you intubate a patient with tracheal rupture?
Fiber optic bronchoscopy
The four spaces FAST exam checks
Perihepatic
Perisplenic
Pericardium
Pelvis
Next step in a stable patient who had an abdominal trauma
CT scan
Lower rib + abdominal bleed
Splenic/ liver laceration
Lower rib fracture + hematuria
Kidney laceration
Kher sign + viscera in the left thorax on XR
Diaphragmatic rupture
Handlebar sign
Pancreatic rupture
Retro peritoneal fluid + epigastric pain
Duodenal rupture
Seizure/electric burn; arm is internally rotated and addicted on exam. ?
Posterior shoulder dislocation
Fall on outstretched hand; arm externally rotated and abducted arm
Anterior shoulder dislocation
Direct blow to proximal ulna, anterior dislocation of radial head
Monteggia fracture
Direct blow to distal radius, dorsal dislocation of radioulnar joint
Galeazzi fracture
Shortened and externally rotated leg
Hip fracture
Parkland formula:
kg x BSA% x 4
Management of circumferential burns
Escharotomy
