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00Step 2 > Surgery UWorld > Flashcards

Surgery UWorld Flashcards

1
Q

some studies show that ALT >150 has a 95% PPV for diagnosing _____

A

gallstone pancreatitis

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2
Q

how do you treat gallstone pancreatitis

A

EARLY cholecystectomy

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3
Q

what’s the next step after placing a central venous catheter

A

CXR prior to catheter use to confirm catheter tip placement

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4
Q

ideal placement of central catheter

A

lower SVC

tip is “just proximal to the angle between the trachea and right mainstream bronchus”

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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

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6
Q

what is the risk of using succinylcholine

A

efflux of K ions,

leading to severe hyperkalemia and arrhythmias

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7
Q

what pathology is most likely to develop in a chronic non-healing wound

A

squamous cell carcinoma

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8
Q

squamous cell carcinoma arising within a burn wound is called ___

A

Marjolin ulcer

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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)

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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)

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11
Q

what’s the most sensitive test for soft tissue injuries

A

MRI

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12
Q

how do you treat uncomplicated MCL tear

A

non operatively, with RICE

rest, ice, compression, elevation

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13
Q

which injury is characterized by a small joint effusion with crepitus, locking, or catching with range of motion

A

medial meniscus tear

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14
Q

which injury occurs with chronic overuse, anterior knee pain, and tenderness

A

patellar tendonitis

“Jumper’s knee”

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15
Q

what is most likely diagnosis of a nontender hard mass in hard palate of mouth, present for many years?

A

Torus Palatinus

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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

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17
Q

when is IV atropine indicated

A

symptomatic bradycardia

lightheadedness, presyncope, syncope

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18
Q

which antibiotic is commonly given prophylactically before surgery

A

IV cefazolin

usually within 60min of procedure

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19
Q

what is indicative of free intraperitoneal air, and what is the next step in management

A

bowel perforation

immediate exploratory laparotomy

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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

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21
Q

which bowel segment is most likely to perforate in mesenteric ischemia

A

jejunum

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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

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23
Q

what is dx in pt who is hypotensive, abdominal pain, and CT scan showing enlarged aortic silhouette

A

rupture abdominal aortic aneurysm

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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

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25
Q

what is immediate next step once a bowel perforation is identified

A

urgent exploratory laparotomy

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26
Q

what is dx in pt with fever, tachy, hypotension, and poor urine output

A

septic shock

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27
Q

what is your goal of managing septic shock

A

restoring adequate tissue perfusion through IV 0.9% saline (crystalloid) and identifying the underlying infection

aggressive volume resuscitation!!

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28
Q

why is crystalloid the fluid of choice to quickly restore volume

A

it is as effective as albumin in terms of survival but less costly and easier to acquire

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29
Q

what is a common crystalloid fluid

A

0.9% Saline

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30
Q

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

A

give vasopressors (dopamine) to improve perfusion if pt is not responding to your volume resuscitation efforts

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31
Q

what are these scenarios indications for:
major electrolyte abnormalities
uremia
volume overload

A

indications to start urgent hemodialysis

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32
Q

when is the use of bicarbonate clearly indicated

A

in a pt who has severe acute acidosis (pH <7.2)

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33
Q

when is transfusion indicated in pts with septic shock

A

to keep hemoglobin > 7; or perhaps a higher hemoglobin and showing clear indications (active bleeding)

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34
Q

what noninvasive test is highly sensitive and specific for peripheral artery disease in symptomatic pts

A

ankle-brachial index

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35
Q

how do you calculate and interpret ankle-brachial index to diagnose peripheral artery disease

A

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

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36
Q

what is suspected dx in pt with intermittent claudication

A

Peripheral artery disease

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37
Q

which injury includes lucid interval

A

epidural hematoma

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38
Q

what is dx in pt with trauma to sphenoid bone with tearing of Middle meningeal artery

A

epidural hematoma

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39
Q

what is ipsilateral CN3 palsy and hemiparesis indicative of

A

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)

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40
Q

what are symptoms of elevated intracranial pressure

A

nausea/vomiting

headache

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41
Q

how do you manage epidural hematoma

A

emergent craniotomy in pts w/ focal neuro deficits to prevent brain herniation and death

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42
Q

what is dx in pt with traumatic acceleration/deceleration shearing forces that causes diffuse damage

A

diffuse axonal injury

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43
Q

what 2 things tell you that you have a concussion vs an epidural hematoma

A

concussions don’t usually have elevated intracranial pressure or focal neuro deficits
imaging is usually normal

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44
Q

what is dx in pt who has traumatic head injury then develops headache and confusion gradually over 1-2 days

A

subdural hematoma

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45
Q

what is ripped in subdural hematoma

A

tearing of bridging veins

46
Q

what is dx in pt w/ recent h/o skin infection who presents with fever and abdominal pain radiating to the groin

A

psoas abscess

47
Q

what does PE of pain with hip extension indicate

A

psoas sign- psoas abscess

48
Q

what is required to confirm dx of psoas abscess

A

CT scan

will show enlarged/inflammed psoas muscle just lateral to vertebrae

49
Q

what is management of psoas abscess

A

drainage with antibiotics

50
Q

what must you have high suspicion for in pts involved in MVCs or falls >10 ft

A

blunt aortic injury

51
Q

what is most sensitive image finding for blunt aortic injury

A

mediastinal widening

enlarged, widened aortic arch contour obscuring the pulmonary artery

52
Q

what commonly causes myocardial contusion in blunt trauma

A

rib fractures

53
Q

what is dx in CXR with prominent bulge along the L heart border

A

LV aneurysm

54
Q

how is LV aneurysm most commonly seen

A

LV aneurysm is most commonly seen as a complication of transmural myocardial infarction

  • -not associated with trauma
  • -best diagnosed w/ echocardiogram
55
Q

what is dx in pt with fever, RUP pain, N/V, and crepitus in abdominal wall near gallbladder

A

emphysematous cholecystitis

56
Q

what are 2 common gas-forming bacteria that may cause crepitus

A

Clostridium

E coli

57
Q

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)

A

emphysematous cholecystitis

58
Q

what is tx for emphysematous cholecystitis

A

emergent cholecystectomy

broad spectrum Abx with clostridium coverage (ampicillin-sulbactam)

59
Q

what is dx in pt with whistling noise during respiration following rhinoplasty

A

nasal septal perforation,

likely resulting from a septal hematoma

60
Q

what is next step when pt presents with “classic” appendicitis

A

laparoscopic appendectomy

don’t wait for further imaging tests- not necessary, and appendix may rupture in the meantime

61
Q

what is a known complication of abdominal aortic aneurysm repair

A

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
Q

what fracture presents with pain at radial wrist proximal to the base of the thumb

A

scaphoid fractures

most commonly fractured carpal bone

63
Q

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”

A

scaphoid fracture

64
Q

what is the concern in scaphoid fracture

A

osteonecrosis

because blood supply enters at the distal pole and flows proximally, which can be disrupted by the fracture

65
Q

what tx can be considered for non displaced scaphoid fractures

A

wrist immobilization

but pts should be monitored with serial XRs to r/o osteonecrosis and non-union of the fracture

66
Q

what FOOSH injury can cause compressive neuropathy of median nerve

A

lunate dislocation

67
Q

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

A

Sphincter of Oddi dysfunction

due to dyskinesia or stenosis of Sphincter of Oddi

68
Q

why do opioids make Sphincter of Oddi dysfunction worse

A

sphincter contraction, which precipitates symptoms

69
Q

what is gold standard for dx of sphincter of oddi dysfunction and tx

A

sphincter of oddi manometry

tx w/ sphincterectomy

70
Q

what is dx in pt with recent cardiac catheterization, anticoagulation with Heparin, sudden onset hypotension, tachy, flat neck veins, and back pain

A

retroperitoneal hematoma due to bleeding from arterial access site

71
Q

when do most hemorrhage or hematoma formations occur after a catheterization

A

within 12 hours

72
Q

how do you confirm dx of retroperitoneal hematoma

A

non-contrast CT of abdomen and pelvis

or abdominal ultrasonography

73
Q

how do you tx retroperitoneal hematoma

A

usually supportive with bed rest, intensive monitoring, and IV fluids +/- blood transfusion

surgery is rarely needed

74
Q

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

A

Pilonidal disease

75
Q

what is pathogenesis of pilonidal disease

A

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
Q

what is tx of pilonidal disease

A

drainage of intergluteal abscess and excision of sinus tracts

open closure is preferred due to decreased recurrence rates

77
Q

what are 5 interventions for lowering ICP

A

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
Q

what is “pain on passive movement” and paresthesias buzzwords for

A

compartment syndrome

79
Q

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

A

tracheobronchial injury

80
Q

what is dx in pt with tachy, BBB, arrhythmia, and sternal fracture

A

myocardial contusion

81
Q

what is dx in pt with tamponade (muffled heart sounds), hypotension, distended neck veins

A

myocardial rupture

82
Q

what are some signs/symptoms that would warrant intubation in a burn pt

A 
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
Q

what are the hard signs of vascular injury, therefore indicating the need for surgical intervention

A

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
Q

what are the 3 things in an initial evaluation of a severe extremity injury

A

hemorrhage control

radiography of skeletal injuries

evaluation of neurovascular bundle

85
Q

what is an immigrant pt with foamy red sputum w/ significant blood a buzzword for?

A

pulmonary tuberculosis

86
Q

what is the initial step of management in a pt suspicious for pulmonary tuberculosis

A

respiratory isolation

to prevent the spread of infection before further diagnostic evaluation and tx

87
Q

what is the initial management in a pt with massive hemoptysis (>600mL/24hrs or 100mL/hr)

A

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
Q

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

A

meningioma (benign)

89
Q

what is tx of choice for pts with symptomatic meningioma

A

complete resection in OR

typically leads to cure in most pts

90
Q

what is dx in pt with multiple ring-enhancing lesions at the grey-white junction in brain (intra-axial)

A

brain metastasis

91
Q

what is dx in pt with hypocalcemia and hyperphosphatemia

A

hypoparathyroidism

92
Q

what are 3 causes of hypoparathyroidism

A

post-surgical

autoimmune /non-autoimmune PTH destruction

defective calcium-sensing receptor

93
Q

what is most common dx in pt with unilateral LE edema that worsens when leg is dependent and improves with leg elevation/sleeping.

A

venous valve insufficiency

94
Q

what is pathology of venous valve insufficiency

A

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
Q

what is classic dx in pt who falls then presents with pain and immobility of affected arm, holding it with the contralateral hand

A

clavicle fracture

96
Q

what should be done in all cases of clavicle fracture

A

a careful neurovascular exam,
due to proximity to subclavian artery and brachial plexus

this could include PE of hand/arm and angiogram

97
Q

what is dx in pt who chronically uses NSAIDs that has frequent postprandial pain –> constant; with XR showing pneumoperitoneum

A

perforated peptic ulcer

98
Q

how do you tx perforated peptic ulcer

A

urgent exploratory laparotomy

99
Q

what do Q waves on an EKG indicate

A

old myocardial infarction

100
Q

what is the 4 T ddx for an anterior mediastinal mass

A

thymoma
teratoma
thyroid neoplasm
terrible lymphoma

101
Q

what are beta-hCG and AFP levels in pts with a seminoma vs nonseminomatous germ cell tumor

A

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
Q

what type of tumor is also included in the category of teratoma; and how do you distinguish

A

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
Q

what are the 3 forms of nonseminomatous germ cell tumors

A

yolk sac tumor
choriocarcinoma
embryonal carcinoma

104
Q

what is dx in pt with abdominal pain, diarrhea, nausea, hypotension, tachy, dizziness/confusion, fatigue, diaphoresis with a recent gastrectomy

A

dumping syndrome

105
Q

what causes dumping syndrome

A

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
Q

what does dietary modification look like in a pt with dumping syndrome

A

consume small, frequent meals and eat slowly
avoid simple sugars
increase fiber and protein
drink fluids between, rather than during, meals

107
Q

what is dx in pt with:

1- distended veins; normal breathing

2- distended veins; respiratory distress

3- flat veins

A

1- pericardial tamponade

2- tension pneumothorax

3- hemorrhagic/hypovolemia

108
Q

what’s the difference between primary vs secondary spontaneous pneumothorax

A

primary:
no preceding event or lung disease; typically thin young men

secondary:
underlying lung disease (COPD)

109
Q

what is immediate treatment for tension pneumothorax

A

needle thoracostomy

110
Q

what is the clinical triad of fat embolism syndrome

A

respiratory distress

neurologic dysfunction (confusion)

petechial rash

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