Surgery UWorld Flashcards
1
Q
some studies show that ALT >150 has a 95% PPV for diagnosing _____
A
gallstone pancreatitis
2
Q
how do you treat gallstone pancreatitis
A
EARLY cholecystectomy
3
Q
what’s the next step after placing a central venous catheter
A
CXR prior to catheter use to confirm catheter tip placement
4
Q
ideal placement of central catheter
A
lower SVC
tip is “just proximal to the angle between the trachea and right mainstream bronchus”
5
Q
what are 3 common risks of an improperly placed central venous catheter
A
venous perforation (tip placement in smaller veins)
pneumothorax
pericardial tamponade
6
Q
what is the risk of using succinylcholine
A
efflux of K ions,
leading to severe hyperkalemia and arrhythmias
7
Q
what pathology is most likely to develop in a chronic non-healing wound
A
squamous cell carcinoma
8
Q
squamous cell carcinoma arising within a burn wound is called ___
A
Marjolin ulcer
9
Q
what type of injury is caused by severe valgus stress on knee
A
MCL
blow to lateral knee
(if they mention pain with abduction, think of the foot abducting while holding the lateral knee)
10
Q
what type of injury is caused by severe varus stress on knee
A
LCL
blow to medial knee
(these injuries are rather uncommon)
11
Q
what’s the most sensitive test for soft tissue injuries
A
MRI
12
Q
how do you treat uncomplicated MCL tear
A
non operatively, with RICE
rest, ice, compression, elevation
13
Q
which injury is characterized by a small joint effusion with crepitus, locking, or catching with range of motion
A
medial meniscus tear
14
Q
which injury occurs with chronic overuse, anterior knee pain, and tenderness
A
patellar tendonitis
“Jumper’s knee”
15
Q
what is most likely diagnosis of a nontender hard mass in hard palate of mouth, present for many years?
A
Torus Palatinus
16
Q
what is an immediate step needed in pts with traumatic spinal cord injuries
A
urinary catheter placement to assess for urinary retention and prevent acute bladder distention/damage
17
Q
when is IV atropine indicated
A
symptomatic bradycardia
lightheadedness, presyncope, syncope
18
Q
which antibiotic is commonly given prophylactically before surgery
A
IV cefazolin
usually within 60min of procedure
19
Q
what is indicative of free intraperitoneal air, and what is the next step in management
A
bowel perforation
immediate exploratory laparotomy
20
Q
what “unusual” injury do you have to worry about with blunt abdominal trauma and damage to mesenteric blood supply
A
bowel perforation
may take several days to present
21
Q
which bowel segment is most likely to perforate in mesenteric ischemia
A
jejunum
22
Q
when is a diagnostic peritoneal lavage warranted? (buzzword?)
A
pts who are HEMODYNAMICALLY UNSTABLE with questionable beside ultrasound results,
or where emergency ultrasound or CT is unavailable
23
Q
what is dx in pt who is hypotensive, abdominal pain, and CT scan showing enlarged aortic silhouette
A
rupture abdominal aortic aneurysm
24
Q
how do you manage ruptured abdominal aortic aneurysm
A
immediate surgery
CT scanning is only done in stable pts;
–if you must confirm aneurysm presence, use bedside ultrasound
25
what is immediate next step once a bowel perforation is identified
urgent exploratory laparotomy
26
what is dx in pt with fever, tachy, hypotension, and poor urine output
septic shock
27
what is your goal of managing septic shock
restoring adequate tissue perfusion through IV 0.9% saline (crystalloid) and identifying the underlying infection
aggressive volume resuscitation!!
28
why is crystalloid the fluid of choice to quickly restore volume
it is as effective as albumin in terms of survival but less costly and easier to acquire
29
what is a common crystalloid fluid
0.9% Saline
30
what should you give to pt who fails to respond to crystalloid fluid, or who develops evidence of vol overload w/o improvement in blood pressure
give vasopressors (dopamine) to improve perfusion if pt is not responding to your volume resuscitation efforts
31
what are these scenarios indications for:
major electrolyte abnormalities
uremia
volume overload
indications to start urgent hemodialysis
32
when is the use of bicarbonate clearly indicated
in a pt who has severe acute acidosis (pH <7.2)
33
when is transfusion indicated in pts with septic shock
to keep hemoglobin > 7; or perhaps a higher hemoglobin and showing clear indications (active bleeding)
34
what noninvasive test is highly sensitive and specific for peripheral artery disease in symptomatic pts
ankle-brachial index
35
how do you calculate and interpret ankle-brachial index to diagnose peripheral artery disease
ABI is calculated by dividing the higher ankle (dorsals pedis or posterior tibial) systolic pressure in each lower extremity by the higher brachial artery (left or right) systolic pressure
ABI <0.9 = abnormal (diagnostic of occlusive PAD)
ABI 0.91-1.30 = normal
ABI >=1.30 = suggestive of calcified and incompressible vessels; additional vascular studies should be considered
36
what is suspected dx in pt with intermittent claudication
Peripheral artery disease
37
which injury includes lucid interval
epidural hematoma
38
what is dx in pt with trauma to sphenoid bone with tearing of Middle meningeal artery
epidural hematoma
39
what is ipsilateral CN3 palsy and hemiparesis indicative of
uncal herniation in an epidural hematoma
(dilation of pupil on ipsilateral side of lesion 2/2 compression of oculomotor nerve; and ipsilateral hemiparesis 2/2 contralateral crus cerebri compression)
40
what are symptoms of elevated intracranial pressure
nausea/vomiting
| headache
41
how do you manage epidural hematoma
emergent craniotomy in pts w/ focal neuro deficits to prevent brain herniation and death
42
what is dx in pt with traumatic acceleration/deceleration shearing forces that causes diffuse damage
diffuse axonal injury
43
what 2 things tell you that you have a concussion vs an epidural hematoma
concussions don't usually have elevated intracranial pressure or focal neuro deficits
imaging is usually normal
44
what is dx in pt who has traumatic head injury then develops headache and confusion gradually over 1-2 days
subdural hematoma
45
what is ripped in subdural hematoma
tearing of bridging veins
46
what is dx in pt w/ recent h/o skin infection who presents with fever and abdominal pain radiating to the groin
psoas abscess
47
what does PE of pain with hip extension indicate
psoas sign- psoas abscess
48
what is required to confirm dx of psoas abscess
CT scan
will show enlarged/inflammed psoas muscle just lateral to vertebrae
49
what is management of psoas abscess
drainage with antibiotics
50
what must you have high suspicion for in pts involved in MVCs or falls >10 ft
blunt aortic injury
51
what is most sensitive image finding for blunt aortic injury
mediastinal widening
| enlarged, widened aortic arch contour obscuring the pulmonary artery
52
what commonly causes myocardial contusion in blunt trauma
rib fractures
53
what is dx in CXR with prominent bulge along the L heart border
LV aneurysm
54
how is LV aneurysm most commonly seen
LV aneurysm is most commonly seen as a complication of transmural myocardial infarction
- -not associated with trauma
- -best diagnosed w/ echocardiogram
55
what is dx in pt with fever, RUP pain, N/V, and crepitus in abdominal wall near gallbladder
emphysematous cholecystitis
56
what are 2 common gas-forming bacteria that may cause crepitus
Clostridium
E coli
57
what is dx in pt with air-fluid levels in gallbladder, gas in gallbladder wall,
unconugated hyperbilirubinemia,
mildly elevated aminotransferases
gas-forming bacteria (clostridium, E coli)
emphysematous cholecystitis
58
what is tx for emphysematous cholecystitis
emergent cholecystectomy
broad spectrum Abx with clostridium coverage (ampicillin-sulbactam)
59
what is dx in pt with whistling noise during respiration following rhinoplasty
nasal septal perforation,
likely resulting from a septal hematoma
60
what is next step when pt presents with "classic" appendicitis
laparoscopic appendectomy
don't wait for further imaging tests- not necessary, and appendix may rupture in the meantime
61
what is a known complication of abdominal aortic aneurysm repair
bowel ischemia
it results from inadequate colonic collateral arterial perfusion to the L and sigmoid colon after loss of the IMA during aortic graft placement
62
what fracture presents with pain at radial wrist proximal to the base of the thumb
scaphoid fractures
| most commonly fractured carpal bone
63
what is dx in PE of tenderness in the shallow depression at the dorsoradial wrist bounded medially by the tendon of the extensor pollicis longs and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis "anatomic snuff box"
scaphoid fracture
64
what is the concern in scaphoid fracture
osteonecrosis
| because blood supply enters at the distal pole and flows proximally, which can be disrupted by the fracture
65
what tx can be considered for non displaced scaphoid fractures
wrist immobilization
but pts should be monitored with serial XRs to r/o osteonecrosis and non-union of the fracture
66
what FOOSH injury can cause compressive neuropathy of median nerve
lunate dislocation
67
what is dx in pt with recurrent, episodic pain in RUQ or epigastric region w/ corresponding elevations in aminotransferases and alk phos; dilated common bile duct in absence of stones; made worse by opioid analgesics
Sphincter of Oddi dysfunction
due to dyskinesia or stenosis of Sphincter of Oddi
68
why do opioids make Sphincter of Oddi dysfunction worse
sphincter contraction, which precipitates symptoms
69
what is gold standard for dx of sphincter of oddi dysfunction and tx
sphincter of oddi manometry
tx w/ sphincterectomy
70
what is dx in pt with recent cardiac catheterization, anticoagulation with Heparin, sudden onset hypotension, tachy, flat neck veins, and back pain
retroperitoneal hematoma due to bleeding from arterial access site
71
when do most hemorrhage or hematoma formations occur after a catheterization
within 12 hours
72
how do you confirm dx of retroperitoneal hematoma
non-contrast CT of abdomen and pelvis
| or abdominal ultrasonography
73
how do you tx retroperitoneal hematoma
usually supportive with bed rest, intensive monitoring, and IV fluids +/- blood transfusion
surgery is rarely needed
74
what is dx in pt with subacute pain over the midline sacrococygeal (intergluteal, cephalic to anus) with mucoid and bloody drainage.
Most commonly affects young adult M, obese, sedentary
Pilonidal disease
75
what is pathogenesis of pilonidal disease
edematous, infected hair follicle in intergluteal region becomes occluded
infection spreads subcutaneously, forms an abscess, which can rupture and create a pilonidal sinus tract
as pt moves around, hair and debris are forced into sinus tract,
causing recurrent infections and foreign-body rxns
76
what is tx of pilonidal disease
drainage of intergluteal abscess and excision of sinus tracts
open closure is preferred due to decreased recurrence rates
77
what are 5 interventions for lowering ICP
head elevation
-increased venous outflow from brain
sedation
-decreased metabolic demand and control of HTN
IV mannitol
-extraction of free water from brain tissue --> osmotic diuresis
hyperventilation
-CO₂ washout --> cerebral vasoconstriction
removal of CSF
-reduction of CSF volume/pressure
78
what is "pain on passive movement" and paresthesias buzzwords for
compartment syndrome
79
what is dx in pt with persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma; other findings of pneumomediastinum and subcutaneous emphysema
tracheobronchial injury
80
what is dx in pt with tachy, BBB, arrhythmia, and sternal fracture
myocardial contusion
81
what is dx in pt with tamponade (muffled heart sounds), hypotension, distended neck veins
myocardial rupture
82
what are some signs/symptoms that would warrant intubation in a burn pt
```
burns on face
singing of eyebrows
oropharyngeal inflammation/blistering
oropharyngeal carbon deposits
carbonaceous sputum
stridor
carboxyhemoglobin level >10%
h/o confinement in a burning building
```
presence of >=1 of these warrants early intubation to prevent airway obstruction by edema
83
what are the hard signs of vascular injury, therefore indicating the need for surgical intervention
observed pulsatile bleeding
presence of bruit/thrill over injury
expanding hematoma
signs of distal ischemia (absent pulses, cool extremities)
in the presence of a penetrating injury, these signs are almost always predictive of the need for urgent surgical repair
84
what are the 3 things in an initial evaluation of a severe extremity injury
hemorrhage control
radiography of skeletal injuries
evaluation of neurovascular bundle
85
what is an immigrant pt with foamy red sputum w/ significant blood a buzzword for?
pulmonary tuberculosis
86
what is the initial step of management in a pt suspicious for pulmonary tuberculosis
respiratory isolation
to prevent the spread of infection before further diagnostic evaluation and tx
87
what is the initial management in a pt with massive hemoptysis (>600mL/24hrs or 100mL/hr)
secure airway, breathing, and circulation
pt should be placed in dependent position of the bleeding lung
bronchoscopy is initial procedure to localize the bleeding site
88
what is dx in pt with extra-axial well-circumscribed or round homogeneously enhancing dural-based mass on MRI; usually undergoes calcification and can appear hyper dense;
usually in middle-aged to elderly F with neuro symptoms (headache, seizure, focal weakness/numbness) from mass effect
meningioma (benign)
89
what is tx of choice for pts with symptomatic meningioma
complete resection in OR
| typically leads to cure in most pts
90
what is dx in pt with multiple ring-enhancing lesions at the grey-white junction in brain (intra-axial)
brain metastasis
91
what is dx in pt with hypocalcemia and hyperphosphatemia
hypoparathyroidism
92
what are 3 causes of hypoparathyroidism
post-surgical
autoimmune /non-autoimmune PTH destruction
defective calcium-sensing receptor
93
what is most common dx in pt with unilateral LE edema that worsens when leg is dependent and improves with leg elevation/sleeping.
venous valve insufficiency
94
what is pathology of venous valve insufficiency
failure of venous valves
blood pooling in dependent areas
increased capillary hydrostatic pressure
favors increased filtration of fluid out of the capillaries into the interstitial fluid
causes a decrease in intravascular volume,
so kidneys are stimulated to retain water and salt
ultimately leading to more edema
95
what is classic dx in pt who falls then presents with pain and immobility of affected arm, holding it with the contralateral hand
clavicle fracture
96
what should be done in all cases of clavicle fracture
a careful neurovascular exam,
due to proximity to subclavian artery and brachial plexus
this could include PE of hand/arm and angiogram
97
what is dx in pt who chronically uses NSAIDs that has frequent postprandial pain --> constant; with XR showing pneumoperitoneum
perforated peptic ulcer
98
how do you tx perforated peptic ulcer
urgent exploratory laparotomy
99
what do Q waves on an EKG indicate
old myocardial infarction
100
what is the 4 T ddx for an anterior mediastinal mass
thymoma
teratoma
thyroid neoplasm
terrible lymphoma
101
what are beta-hCG and AFP levels in pts with a seminoma vs nonseminomatous germ cell tumor
Seminoma:
- -serum beta-hCG can be elevated in 1/3 of pts with seminoma
- -AFP is essentially always normal
Non-seminomatous germ cell tumor:
- -most pts have an elevated AFP
- -considerable amount also have elevated beta-hCG
102
what type of tumor is also included in the category of teratoma; and how do you distinguish
germ cell tumors
teratomas can often be distinguished from other germ cell tumors on imaging by the presence of fat or calcium,
esp in the form of a tooth
103
what are the 3 forms of nonseminomatous germ cell tumors
yolk sac tumor
choriocarcinoma
embryonal carcinoma
104
what is dx in pt with abdominal pain, diarrhea, nausea, hypotension, tachy, dizziness/confusion, fatigue, diaphoresis with a recent gastrectomy
dumping syndrome
105
what causes dumping syndrome
loss of normal action of pyloric sphincter due to injury or surgical bypass
leads to rapid emptying of hypertonic gastric contents into duodenum and small intestine
causes fluid shifts from intravascular space to small intestine,
leading to hypotension, stimulation of autonomic reflexes, and release of intestinal vasoactive polypeptides
106
what does dietary modification look like in a pt with dumping syndrome
consume small, frequent meals and eat slowly
avoid simple sugars
increase fiber and protein
drink fluids between, rather than during, meals
107
what is dx in pt with:
1- distended veins; normal breathing
2- distended veins; respiratory distress
3- flat veins
1- pericardial tamponade
2- tension pneumothorax
3- hemorrhagic/hypovolemia
108
what's the difference between primary vs secondary spontaneous pneumothorax
primary:
no preceding event or lung disease; typically thin young men
secondary:
underlying lung disease (COPD)
109
what is immediate treatment for tension pneumothorax
needle thoracostomy
110
what is the clinical triad of fat embolism syndrome
respiratory distress
neurologic dysfunction (confusion)
petechial rash
