Surgery Shelf Flashcards
Ischemic Colitis: RF Clinical picture Diagnosis Management
RF: older than 60yo, Renal disease/ hemodialysis, Athersclerotic vascular disease, AAA repair/ vascular procedure, MI
Clinical picture: mild pain and tenderness, hematochezia, diarrhea, metabolic acidosis
Diagnosis: CT: thickened bowel wall, double halo sign, pneumatosis coli.
Colonoscopy: mucosal pallor/cyanosis, petechia, hemorrhage, ulcers
Management: supportive care: IVF, bowel rest, IV abx, Colon resection (bowel infarct)
Dumping Syndrome:
symptoms:
- Abdominal pain, diarrhea, nausea.
- Hypotension/tachycardia
- Dizziness/confusion, fatigue, diaphoresis
- rapid emptying of a carbohydrate load from the stomach into the small bowel casues vasomotor and hormonal changes
Management of dumping syndrome:
- Small/ frequent meals
- Replace simple sugars with complex carbohydrates
- Incorporate high-fiber and rich protein-rich foods
Twisting of the knee with the foot fixed is a high risk factor for what kind of ligament tear?
Medial meniscus
What is the test for medial meniscus tear:
McMurray’s sign: palpable or audible snap occurring while slowly extending the leg at the knee from full flexion while simultaneously applying tibial torsion.
Pilonidal disease/ piloniial cyst
young males
sweating and friction of the skin overlying the coccyx within the superior gluteal cleft. Infection of hair follicles in this region may spread subcutaneously forming an abscess that then ruptures forming a pilonidal sinus tract.
- sinus tract may collect hair and debris = recurrent infections and foreign body reactions.
- If infection= drainage from midline postsacral interfluteal region.
Tx: I/D
signs of posterior urethra injury
How do you assess?
- blood at urethreal meatus
- inability to void
- high-riding prostate on digital rectal exam
- assess with retrograde urethrogram prior to insertion of a foley.
- associated with pelvic fractures
34yr Pt was in a high-speed highway motor vehicle collision. Hypotension, subcutaneous emphysema of chest + bruises in same area. S/p Chest tube –hours later on CXR: pneumomediastinum.
What is diagnosis?
Bronchial rupture
Persistent pneumothorax despite chest tube placement and pneumomediastinum.
Right main bronchus is most commonly injured in these cases.
Tx: surgery
what is a pneumoperitoneum
air underneath the diaphragm and above the liver
= perforation
Tx: surgery
what is a Marjolin ulcer?
SCC arising from a non-healing burn wound.
SCC can be seen within the skin overlying a focus of osteomyelitis, radiotherapy scars, and venous ulcers.
SCC arising from chronic wounds tends to be more aggressive
Definition of massive hemoptysis?
greater than 600mL in 24hrs
- secure airway and go to surgery if bleeding does not stop.
- move patient so that he/she is placed with bleeding lung in the dependent position (lateral position) to avoid blood collection in the airways of the opposite lung.
Tx: bronchoscopy is initial procedure of choice– embolization or resection. localize site of bleeding, suction availability to improve visualization before other therapeutic interventions.
When do you use a diagnostic peritoneal lavage?
hemodynamically unstable with an equivocal or inconclusive FAST examination.
DPL determine presence of intraperitoneal hemorrhage.
Blunt trauma causes a diaphragmatic hernia how?
increase intraabdominal pressure overcomes muscular strength of diaphragm. Leads to large radial tears in muscle. Intraabdominal contents leak into chest.
- tears more common on left side 2/2 liver
NGT found in chest.
Pts have respiratory distress
presentation of hypocalcemia
- asymptomatic
- nonspecific symptoms: fatigue, anxiety depression
- Involuntary contractions (tetany) of lips, face, and extremities
- seizures (severe hypocalcemia)
- prolonged QT interval
- periorbital tingling
- Chvostek’s sign: muscle spasm when tap jaw (facial n.)
Pt comes in with subacute fever, abdominal/flank pain that radiates to groin. Anorexia, weightloss, and abdominal pain w/hip extension. Also had a hx of a skin infection.
Psoas abscess
Psoas sign: abd pain with hip extension
How do you diagnose and treat a psoas abscess?
CT scan, leukocytosis, elevated inflammatory markers, blood and abscess cultures.
Tx: drainage, broad spectrum abx
How do you calculate the ankle-brachial index and what is it used for?
Peripheral vascular disease (PVD)
90% sensitivity; 95% specificity
systolic pressure LE/ systolic pressure Brachial artery
less than/equal to 0.9 abnormal
0.91-1.30 normal
More than 1.30: calcified and incompressible vessels; additional vascular studies should be considered.
A pulsatile groin mass below the inguinal ligament?
Femoral artery aneurysm.
Can also have anterior thigh pain due to compression of the femoral nerve that runs LATERALLY to artery. (NAVEL).
** Popliteal aneurysm and femoral artery aneurysm are assocaited with an ABDOMINAL AORTIC ANEURYSM
Kehr sign
irritation of the diaphragm –> shoulder pain, sob
Phrenic nerve: C3-C5
what part of the bladder is covered by peritoneum?
Dome of the bladder. Injury here would permit leakage of urine into the peritoneum.
Also prone to rupture with sudden increases in intravesical pressure.
What are the 5 intervensions for lowering intracranial pressure?
What are their mechanisms
- head elevation – increase venous outflow from the brain
- Sedation – decreased metabolic demand and control of hypertension.
- IV mannitol– edxtraction of free water from brain tissue — osmotic diuresis
- Hyperventilation – CO2 washout — cerebral vasoconstriction
- Removal of CSF – reduce CSF pressure/volume
How can you increase FRC in a hospitalized patient POD3
Elevation of head of the bed — prevent a pickwickian-like syndrome.
- reduces abdominal pressure under the diaphragm
Pickwickian syndrome
Obese patients – severely overweight people fail to breathe rapidly enough or deeply enough, resulting in low blood oxygen levels and high blood carbon dioxide (CO2) levels.
Ludwig’s angina
An infection of the submandibular space – flloor of the mouth and extends through the submandibular and sublingual space into the tissues surrounding the airway.
Why is an infection in the retropharyngeal space so worrisome?
Clinical symptoms?
spread to the mediastinum — anterior and posterior portions of the superior mediastinum as well as the entire length of the posterior mediastinum.
= acute necrotizing mediastinitis.
- early diagnosis and debridement of teh mediastinum is essential!
Clinical symptoms: neck pain, trismus (inability to open mouth normally), limited cervical extension.
What is an important step in managing a patient with a possible spinal cord injury?
- especially if a patient has abdominal discomfort
In the absence of obvious pelvic injury and blood at the urethral meatus, patients should be catherized to asses for urinary retention and prevent possible bladder injury from acute distention)
43 year old male falls on outstretched hand. Physician passively abducts arm above head. The right arm drops rapidly at the midpoint of its descent.
What is the diagnosis?
Rotator cuff tear
Muscles of the rotator cuffs:
- supraspinatus - abductor
- infraspinatous
- Teres minor
- subscapular
Supraspinatus is the most commonly injured 2/2 bouts of ischemia.
Leriche syndrome
triad of bilateral hip, thigh, and buttock claudiication, impotence and symmetric atrophy of the b/L LE due to chronic ischemia
Treatment of septic shock?
underlying low tissue perfusion
IV NS is 1st line treatment for maintenance of intravascular pressure while antibiotics are given to correct the underlying infection
Paralytic Ileus
cause?
Management?
exaggerated intestinal reaction after abdominal surgery but can also seen in other conditions such as retroperitoneal hemorrhage associated with vertebral fractures.
- both small and large bowels indicates a paralytic ileus.
symptoms: no flatus/BM, abd distention, N/V, tympany, decreased/absent BS
Diagnosis: Abd X-ray: air-fluid levels and distended gas-filled loops of bowel (small and large intestines)
Management: conservative, bowel rest, supportive care, tx of secondary causes.
gunshot wound/penetrating injury in 6th intercostal space anteriorly lateral to midclavicular line with hypotension, obtunded, and not responding to 3L normal saline. Bedside U/S limited 2/2 body habitus. What is the appropriate next step?
Any penetrating injury in the thorax below the level of the nipples has potential to also involve the abd through the diaphragm and is assumed to involve both compartments until proven otherwise.
- Exploratory laparotomy
Athelete falls on outstretched hand. Bruising on clavicle area. Palpable gap in the middle of the clavicle. Bruit just underneath clavicle. What is the next step?
if bruit is heard, then an angiogram is needed because of proximity to subclavian artery and brachial plexus.
r/o injury to underlying vessel
how does positive pressure mechanical ventilation decrease venous return to heart?
Positive pressure increases the intrathoracic pressure = decreases venous return; decrease in preload.
* in patients with hypovolemic shock, this effect may cause circulatory collapse if the patient’s intravascular volume is not replaced before mechanical ventilation is attempted.
Patient has a whistling noise after rhinoplasty. What is the cause and why?
Septal perforation
Septum is made up of cartilage and has poor blood supply. Underlying cartilage depends on overlying mucosa for nourishment via diffusion.
Typically the result of septal hematoma through a septal abscess. Also nose-picking/syphilis, TB and intranasal cocain use, sarcoidosis, and granulomatosis with polyangiitis.
Signs of strangulation of SBO?
- fever
- tachycardia
- leukocytosis
- metabolic acidosis
- failure to improve with conservative measures (bowel rest, NGT, pain control, fluid resuscitation, and correction of metabolic acidosis)
Differential diagnosis for unilateral hip pain in a middle aged adult
- infection
- trauma
- arthritis
- bursitis
- radiculopathy
Trochanteric bursitis
inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur’s greater trochanter.
-hip pain exacerbated when pressure is applied (sleeping) and with external rotation or resisted abduction.
2/2 to overuse, trauma, joint crystals or infection
Management of cervical spine trauma pre-hospital
- spinal immobilization (backboard, rigid cervical collar, lateral head supports)
- careful helmet removal (motorcycle)
- airway oxygenation
Management of cervical spine trauma emergency department
- orotracheal intubation unless significant facial trauma present
- rapid-sequence intubation added for unconcious patients who are breathing but need ventilatory support
- in- line cervical stabilization suggested unless it interferes with intubation
- CT of entire cervical spine
- Monitoring for neurogenic shock from spinal cord injury
differential diagnosis for an anterior medialstinal mass:
“4- Ts”
- Thymoma
- teratoma + germ cell tumors
- Thyroid neoplams
- Terrible lymphoma
What is the respiratory quotient (RQ)?
CO2: O2 consumed per unit time.
Ratio depends on major fuel being oxidized for ATP production.
RQ= 1 -- carbohydrate RQ = 0.7-0.8 -- protein and lipids
normal is around 0.8
*Overfeeding (carbohydrates) can cause excessive CO2 production and make weaning off ventilation more challenging.
Patient had thoracic artery aneurysm repair. Now he presents with weakness in both lower extremities and urinary retention. Flaccid paraplegia and loss of pain sensation over the lower extremities. Vibratory sensation still intact. UE no issues. What is the cause of this neurologic dysfunction?
Spinal cord infarction of anterior spinal cord syndrome.
- anterior corticospinal tract, spinothalamic tract.
- recall dorsal column is NOT affected
ASA depend on blood supply from the radicular arteries that originate from the thoracic aorta (artery Adamkiewicz)
Systemic inflammatory response syndrome (SIRS) – 4 qualifications
- Temperature greater than: 100.4 less than: 96.5
- Pulse greater than 90
- Respirations greater than 20
- WBC greater than 12, 000 or less than 4,000 or greater than 10% bands
Why is bowel ischemia one of the complications from abdominal aortic aneurysm repair?
- inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of the inferior mesenteric artery during aortic graft placement.
what is the treatment for a non-displaced scaphoid fracture (fractures with less than 2mm of displacement and no angulation)?
wrist immobilization.
Open reduction and internal fixation is required if initial x-ray shows fracture displacement
73 y/o male s/p laparotomy now p/w pain and swelling of the left angle of his jaw.
T: 102.0 BP: 150/80 P: 90 RR: 16
PE: swelling, erythema, and tenderness in the region of the left partoid gland.
wbc: 15,600
What does he have? What could have prevented this?
Bacterial parotitis.
- dehydration post-op and elderly are most prone.
- pain aggravated by chewing.
- most common infectious agen is Staph aureus.
Adequate hydration and oral hygiene both pre- and post-op can prevent this complication
Compartment syndrome causes:
Symptoms:
- trauma
- prolonged compression
- revascularization of an acutely ischemic limb
Symptoms:
- excruciating pain on passive motion
- paresthesias (early)
- UNCOMMON to LOOSE PULSES
Patient presents with a tension pneumothorax. Mediastinal shift present. He is unstable. What are the two steps in management:
- urgent needle decompression ( 2nd intercostal space)
2. Chest tube placement (5th intercostal space)
what is the Cushing’s reflex?
- hypertension
- bradycardia
- respiratory depression
all indicates elevated intracranial pressure
If you suspect primary hyperthyroidism what is the first test you do?
- Thyroid U/S to evaluate size number and presence of nodules.
80 year old male comes in because of hypercalcemia Calcium is slightly elevated, phosphorus is normal. Everything is normal except amount of PTH. Daughter is also in because of hypercalcemia.
What test do you want to do? Why?
24 hour urine calcium test.
R/o: familial hypercalcemia hypocalciuria
What is the treatment for secondary hyperparathyroidism?
- renal failure or low vit D.
tx: Cinacalcet – calcimimetic. increases sensitivity of Ca-sensing receptors.
Hungry Bone syndrome?
constellation of hypocalcemia, hypophosphatemia, and hypomagnesemia after successful parathyroidectomy due to the sudden withdrawal of excess PTH.
Parathyroidectomy for hyperparathyroidism may result in an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption that results in rapid absorption of calcium, phosphate, and magnesium into the bones.
what causes Parathyromatosis
caused by the rupture and/or spillage of hyperfunctioning parathyroid cells into the operative bed during an initial operation. If the cells remain hyperfunctioning they cause recurrent hyperparathyroidism and present as multiple random nodules within the original operative field.
Syringomyelia
CSF drainage from the central canal of the spinal cord is disrupted, leading to a fluid filled cavity that compresses surrounding neural tissue.
Caused by Arnold Chiari malformation and prior spinal cord injuries. 3-4% of spinal cord injuries go on to develop syringomyelia.
Complications from an aortic dissection:
- stroke (carotid arteries)
- Acute aortic regurgitation
- Horner’s syndrome
- Acute MI
- Pericardial effusion/ cardiac tamponade
- Hemothorax
- Lower-extremity weakness or ischemia (spinal or common iliac arteries)
- Abdominal pain (mesenteric artery)
Duodenal obstruction s/p blunt abdominal trauma 2/2 to duodenal hematoma in children. Management?
Duodenal hematomas most commonly occur following direct blunt abdominal trauma and are more commonly seen in children.
Most hematomas resolve spontaneously in 1-2 weeks and the intervention of choice is nasogastric suction and parenteral nutrition. Surgery may be considered to evacuate the hematoma if the more conservative methods fail.
