Surgery Rotation 2 Flashcards
What percent is normal saline?
0.9%
Next steps in a patient with signs of GERD
Upper GI endoscopy
Causes of post-operative atelectasis
♣ Accumulation of pharyngeal secretions
♣ Tongue prolapsing posteriorly into the pharynx
♣ Airway tissue edema
♣ Residual anesthetic effects
What are the ways in which head trauma can cause problems
- Damage of the initial blow
- Intracranial bleed displacing brain structures
- Intracranial hemorrhage
What is the difference between an epidural and subdural hematoma (on XR and clinically)
Epidural = lens shaped; can occur from less serious trauma; longer lucid interval
Subdural = crescent shaped; can be acute with severe trauma, or chronic
What type of brain bleed can easily occur the elderly and alcoholics and why
Subdural
Their brains have shrunk but cranial cavity is the same size so it is easy for the brain to be “rattled” and to tear bridging veins
How do you manage head trauma in a patient with no bleed
Prepare for edema
Mannitol, furosimide, hyperventilation
Describe Cushing reaction (Triad of hypertension, bradycardia, and respiratory depression in response to increased intracranial pressure)
Increased ICP = pressure constricts arterioles in brain = cerebral ischemia = sympathetic response increases peripheral vasoconstriction, thus increasing BP = aortic baroreceptors sense increased BP = respond with reflex bradycardia and respiratory depression
How does hyperventilation help with cerebral edema
A drop in PaCO2 due to hyperventilation causes vasoconstriction = decreased cerebral blood flow = decreased ICP
Which way will the trachea deviate in tension pneumothorax
Away from side of lesion
Air enters the pleural space but cannot exit, and air continues to build up with each breath
What is a pleural effusion
Build up of fluid around the lung
Trachea deviates away from side of lesion
Where is the damage in initial hematuria (blood only at beginning of voiding)
Urethral damage
Where is the problem in terminal hematuria (blood at end of voiding)
Bladder, prostate, or posterior urethra
Where is the problem in total hematuria (blood throughout entire voiding)
Kidney or ureters
What is the “psoas sign”
Abd pain with hip extension
Damage to what part of the bladder may cause peritonitis (diffuse abdominal pain and guarding)
Dome of the bladder (superior and lateral surfaces of the bladder which are bordered by the peritoneal cavity)
Rupture can cause the spilling of urine into the peritoneum
Irritation of what structure causes referred pain to the shoulder
Diaphragm
Can be irritated by many things (e.g. peritonitis or pericarditis)
What would be the clinical presentation of rupture to anterior bladder wall or bladder neck?
Usually caused by pelvic fracture
Causes extraperitoneal leakage of urine, leading to localized lower abdominal pain; signs of peritonitis should not be present
What are the retroperitoneal structures?
o SAD PUCKER ♣ S Suprarenal (adrenal gland) ♣ A Aorta and IVC ♣ D Duodenum (2nd through 4th parts) ♣ P Pancreas (except tail) ♣ U Ureters ♣ C Colon (descending and ascending) ♣ K Kidneys ♣ E Esophagus (thoracic portion) ♣ R Rectum (partially)
Signs of basilar skull fracture
- Hematoma of the mastoid process or periauricular hematoma (Battle’s sign)
- Bilateral peri-orbital hematoma (raccoon eyes)
- Hemotympanum
- CSF fluid otorrhea
- Cranial nerve palsies (resulting in anosmia, vertigo, tinnitus, or hearing loss)
Potential complication of thoracic aortic aneurysm surgery that causes bilateral flaccid paralysis and loss of pain/temp in lower extremities
Spinal cord infarction (due to aortic cross-clamping) leading to anterior spinal cord syndrome
What do hyperactive bowel sounds suggest?
Diarrhea, malabsorption (e.g. Celiac or lactose intolerance), incomplete mechanical bowel obstruction
Most common cause of bowel obstruction
Adhesions
Presentation of syringomyelia
• Anterior white commissure:
o Loss of pain and temp with sparing of fine touch and position “cape-like” distribution
• Anterior horn involvement can occur with progression of disease
o Lower motor neuron effects
• Lateral horn of hypothalamospinal tract
o Horner syndrome
Presentation of ALS
UM and LMN deficits (twitching, muscle weakness, cramping)
NO loss of sensory function
Presentation of multiple sclerosis
Due to autoimmune demyelination of CNS ♣ Charcot triad of symptoms SIN: • Scanning speech • Intention tremor, Incontinence, Internuclear ophthalmoplegia • Nystagmus ♣ Hemiparesis, hemisensory symptoms
Causes of syringomyelia
• Arnold Chiari I malformation
• Prior spinal cord injury
o Clasically an MVC with whiplash
o Symptoms develop months or years after the initial injury and progress gradually
What are the 3 components of Glasgow coma scale (GCS)
Eye opening
Verbal response
Motor response
What is a furunculosis
Deep infection of the hair follicle leading to abscess formation and accumulation of pus and necrotic tissue
How do you differentiate between compartment syndrome and DVT
CS = swelling + excruciating pain worse with passive movement; presence of neuro sx; diagnosed with compartment pressure
DVT = pain and swelling with less insidious onset and less severe; diagnosed with doppler US
What are the 2 main complications caused by rib fractures
What is the most important part of management
Pain leads to hypoventilation which may cause atelectasis and pneumonia
Pain control is the most important part of management
When is surgical repair of rib fracture indicated?
Flail chest with failure to wean from ventilator, refractory pain, significant chest wall deformity
Not indicated in single, uncomplicated rib fractures
What will be the BUN:Cr ratio in Pre-renal, intrinsic, and post-renal azotemia
Pre-renal = BUN:Cr > 20 (BUN is reabsorbed and Cr is not)
Intrinsic = BUN:Cr < 15 (damage to tubules)
Post-renal = > 20 early on and < 15 later stage when tubular damage occurs
What form of diagnosis is needed for appendectomy
Classic clinical and lab findings of appendicitis
Imaging (US or CT) is not needed unless patient has atypical presentation or other possible causes of RLQ pain
Presentation of Toxic shock syndrome
Fever, hypotension, diffuse rash
What are the ABCs of melanoma
A = asymmetry B = irregular border C = color variability D = diameter > 6 mm E = evolution of size/appearance
What is the difference between conductive and sensorineural hearing loss
Conductive
• Obstruction of external sound to inner ear
Sensorineural
• Involves the inner ear, cochlea, or auditory nerve
Describe Rinne test and how results differ in conductive vs. sensorineural hearing loss
♣ Vibrating tuning fork placed on mastoid bone until patient can’t hear it
♣ Still-vibrating fork then held outside auditory canal until patient can’t hear it
♣ Results:
• Normal = Air-conducted (AC) sound should be heard twice as long as bone-conducted (BC) sound
• Conductive hearing loss = BC > AC in affected ear; AC > BC in unaffected ear
• Sensorineural hearing loss = AC > BC in both ears
Describe Weber test and how results differ in conductive vs. sensorineural hearing loss
♣ Vibrating tuning fork placed on middle of head or forehead equidistant from both ears
♣ Results:
• Normal:
o Midline
• Conductive hearing loss:
o Lateralizes to the affected ear because that ear cannot hear ambient noise of the room
• Sensorineural hearing loss:
o Lateralize to the unaffected ear because the inner ear of the affected ear cannot sense the vibration
What is otosclerosis
Abnormal remodeling of the otic capsule though to be a possible autoimmune process; the stapes footplate becomes fixed to the oval window
Causes conductive hearing loss
What type of hearing loss is caused by ototoxic antibiotics
Sensorineural
What is Meniere disease
• Increased pressure and volume of endolymph • Features: o Recurrent vertigo o Ear fullness/pain o Unilateral sensorineural hearing loss o Tinnitus
Affected areas in rheumatic heart disease
Early disease = mitral regurg
Late disease = mitral stenosis
Cause of secondary hyperparathyroidism
Due to decreased calcium, usually secondary to renal disease
Cause and content of transudative pleural effusion
Low protein content (Think: TRANSudate = TRANSparent)
Due to increased hydrostatic pressure (e.g. CHF) or decreased oncotic pressure (e.g. cirrhosis or nephrotic syndrome)
Cause and content of exudative pleural effusion
High protein content, cloudy
Due to pleural and lung inflammation resulting in increased capillary and pleural membrane permeability (e.g. malignancy, pneumonia, trauma, connective tissue disease)
What is atrioventricular nodal reentry tachycardia
Subtype of SVT
Caused by a reentrant circuit formed by 2 separate conducting pathways (one fast and the other slow) within the AV node
Characterized by sudden onset and termination, rapid (140-250/min) regular rhythm, narrow QRS complexes, and absence of definite P waves
Most common cause of atrial fibrillation
Ectopic foci within the the pulmonary veins
Treatment of Prinzmetal / Vasospastic angina
- Calcium channel blocker (preventive)
- Sublingual nitroglycerin (abortive)
What are the dihydropyridine CCBs?
“-dipine” suffix
Nifedipine, Nimodipine
What are the non-dihydropyridine CCBs?
Verapamil
Diltiazem
Management of healthy patient with a thyroid nodule
Measurement of TSH + thyroid US
