Surgery UWorld Facts

Question 1

management of c-spine trauma

Answer 1

• prehospital
  
  • spinal immobilization
  • careful helmet removal if present
  • airway oxygenation
• ED
  
  • Orotracheal intubation (unless significant facial trauma)
  • rapid-sequence intubation for unconscious patients who are breathing but need ventilatory support
  • CT c-spine
  • monitoring for neurogenic from spinal cord injury

Question 2

Causes of RUQ post-chole pain

Answer 2

1. common bile duct stones
   
   1. RUQ pain + elevation of liver enzymes
   2. r/o w/US and ERCP
2. sphincter of Oddi dysfunction
   
   1. RUQ pain + elevation of liver enzymes
   2. dx of exclusion if US/ERCP does not show stones
   3. tx = ERCP sphincterotomy

Question 3

Clinical presentation of tension pneumo

Answer 3

• Tracheal deviation to opposite side
• hyper-expanded chest w/decreased movement with respiration
• increased percussion
• elevated CVP

Question 4

Management of tension pneumo

Answer 4

• emergency needle thoracostomy in the 2nd intercostal space @ mid-clavicular line
  
  • 14-16G IV cannula

Question 5

Ankle-brachial index measurement and use

Answer 5

• higher ankle systolic pressure/higher brachial systolic pressure
  
  • <0.90 = abnormal ==> occulsive PAD
  • .91 - 1.30 = normal
  • >1.30 = suggests calcified and uncompressible vessel; consider other vascular studies
• used in work-up for claudication/presence of peripheral arterial disease

Question 6

Types of pediatric abdominal wall defects + characteristics

Answer 6

• umbilical hernia
  
  • defect @ linea alba; covered by skin
  • may contain bowel
  • umbilical cord inserts @ apex of defect
• gastroschisis
  
  • defect to right of cord insertion; not covered by membrane or skin
  • contains bowel
• omphalocele
  
  • midline abd. wall defect; covered by peritoneum
  • contains multiple abdominal organs
  • cord inserts @ apex of defect

Question 7

Pediatric/newborn umbilical hernia associations/risk factors

Answer 7

• african-american
• premature birth
• Ehlers-Danlos
• Beckwith-Wiedemann
• hypothyroidism

Question 8

Common result/management of pediatric umbilical hernia

Answer 8

• most close spontaneously (concentric fibrosis and scar tissue formation)
• spontaneously closure less likely in large (>1.5 cm) defect or those w/underlying medical problems
• surgery @ age 5 if not closed

Question 9

SBO cause and presentation

Answer 9

• adhesions = most common cause
  
  • congenital vs. abdominal surgery/inflammation
• complete proximal obstruction ==>
  
  • early vomiting, abdominal discomfort, abnormal contrast filling of xray
• mid/distal obstruction ==>
  
  • colicky abdominal pain
  • delayed vomiting
  • prominent abdominal distension
  • hyperactive bowel sounds
  • dilated loops of bowel on xray

Question 10

Common cause and consequences of blunt abdominal trauma

Answer 10

• MVC ==> BAT
• most common solid organs injured =
  
  • liver
  • spleen

Question 11

Aortic dissection presentation + most common risk factor

Answer 11

• Chest pain that is sudden, tearing, radiating to back
• Decrescendo diastolic murmur = aortic regurg in dissection of aortic root
• widened mediastinum on xray
• HTN = most common risk factor

Question 12

Causes of aortic dissection

Answer 12

• HTN = 75% of cases
  
  • older patient
• Connective tissue disease ==> aortic dissection @ younger patient
  
  • Marfan’s
  • Ehlers-Danlos

Question 13

Intermittent bloody nipple discharge w/out masses/lymph nodes ==> dx?

Answer 13

• intraductal papilloma = benign breast disease in perimenopausal women
• situated beneath the areola; small size (<2mm) and soft

Question 14

Presentation of compartment syndrome

Answer 14

• common features
  
  • pain out of proportion to injury
  • increased pain on passive stretch
  • rapidly increaseing and tense swelling
  • paresthesia
• uncommon features
  
  • decreased sensation
  • motor weakness (w/in hours)
  • paralysis (late)
  • decreased distal pulses (rare)

Question 15

Risks for compartment syndrome

Answer 15

• long operative/ischemic time
• limb revascularization

Question 16

Blunt trauma @ upper abdomen ==>

Answer 16

• pancreatic trauma
• early abdominal CT may fail to detect pancreatic injury
• presentation = upper abdominal trauma, nothing on CT, return with ~ 1wk later with abdominal pain, poor appetite +/- fever and chills
  
  • injured tissue/pseudocyst from injury can become infection
• tx of pancreastic abscess = placement of percutaneous drain catheter, culture of drained fluid, immeadiate surgical debridement

Question 17

Common traumatic causes of small bowel injury

Answer 17

• more likely injured in penetrating (instead of blunt) trauma
• duodenum may be crushed in blunt tauma ==> duodenal hematoma and obstruction

Question 18

DDx for unilateral hip pain in adult

Answer 18

• infection
• trauma
• arthritis
• bursitis
• radiculopathy

Question 19

Presentation of trochanteric bursitis

Answer 19

• troch bursitis = inflamation of bursa surrounding insertion of gluteus medius onto femur’s greather trochanter
• caused by excessive frictional forces from overuse, trauma, joint crystals, or infection
• hip pain w/applied pressure, external rotation or resisted abductions

Question 20

Paget’s disease of bone characteristics

Answer 20

• bone turnover is accelerated in localized areas ==> focal bony hypertrophy
• affected bone is weak and prone to fx
• usually @ elderly pts, 75% asymptomatic

Question 21

Characteristics of aortoiliac peripheral vascular disease

Answer 21

• ==> buttok, thigh, hip pain and claudication
• may lead to erectile dysfuction
• pain is exercise-induced, relieved by rest

Question 22

Management of SBO

Answer 22

1. if hemodynamically stable, w/out signs of strangulation:
   
   1. NPO
   2. NG tube
   3. pain control
   4. fluid resuscitation
2. if signs of strangulation/hemodynamically unstable or failure of conservative measure
   
   1. urgent/emergent surgery

Question 23

Clavicular fx mechanism, presentation, and complications

Answer 23

• usually fx @ middle third of bone
• mechanism:
  
  • athletic events
  • fall on an outstretched arm vs. direct blow to shoulder
• presentation:
  
  • opposite hand supports arm
  • shoulder is posteriorly and inferiorly displaced
• complications:
  
  • injury to subclavian artery
    
    • bruit ==> angiogram
  • injury to brachial plexus nerves
  • **careful neurovascular exam

Question 24

Interventions for lowering ICP

Answer 24

• Head elevation ==> increased venous outflow from brain
• Sedation ==> decreased metabolic demand & control of hypertension
• IV mannitol ==> extraction of free water from brain tissue/osmotic diuresis
• hyperventilation ==> CO2 washout ==> cerebral vasoconstriction
• Removal of CSF ==> reduction of CSF volume and pressure

Question 25

Steroid doses ==> adrenal insufficiency

Answer 25

• daily prednisone >20mg for >3weeks can lead to suppression of HPA axis
• Cushingoid features = increased risk for HPA suppression
• Patients w/HPA axis suppression need higher “stress” doses of glucocorticoids in acute stress such as surgery, infection, bleeding, MI
• pt.s on lower doses (<5mg of prednisone) have no risk of HPA suppresion and do not need stress-dose steroids

Question 26

Presentation of post-traumatic syringomyelia

Answer 26

• 3-4% of spinal cord injuries ==> post-trauma syringomyelia
• whiplash = common cause
• sx develop months to years later
• CSF retention ==> impaired strength and pain/temp sensation in upper extremities
• final dx with MRI

Question 27

Causes of post-operative fever

Answer 27

• PO hours 0-2:
  
  • prior trauma/infection
  • blood products
  • malignant hyperthermia
• POD#1-7:
  
  • Nosocomial infection
  • SSI (GAS or clostridium perfringens)
  • Noninfectious: MI, PE< DVT
• POD#7-30:
  
  • SSI (not GAS or C. perfringens)
  • Catheter site infection
  • C. diff
  • Drug fever
  • PE/DVT

Question 28

Common complication after gastrectomy procedures

Answer 28

• early dumping syndrome = rapid emptying of hypertonic gastric content into duodenum/small intestine
• ==> abdominal cramps, weakness, lightheadedness, diaphoresis

Question 29

Management of patients w/suspected spinal cord injury

Answer 29

• decreased sensation +/- decreased strength below a certain level of body bilaterally, e.g. @ legs ==> suspicion of spinal cord injury
• as long as no obvious trauma to urethra, foley catheter should be placed to avoid bladder distention

Question 30

Tetanus prophylaxis for wounds

Answer 30

• Clean or minor wound
  
  • if >3 tetanus vaccines: give tetanus vaccine only if last dose was >10y ago; no TIG
  • if unimmunized/unsure/<3 vaccines: give tetanus vaccine; no TIG
• Dirty or severe wound
  
  • if >3 tetanus vaccines: give tetanus vaccine only if last dose was >5y ago; no TIG
  • if unimmunized/unsure/<3 vaccines: give tetanus vaccine AND TIG

Question 31

Dx and management?

Answer 31

• pneumoperitoneum
• exploratory surgery

Question 32

“response to fluids” = ?

Answer 32

SBP > 100mmHg

Question 33

Pulsatile mass @ groin ==> dx?

Answer 33

• pulsatile mass below inguinal ligament = femoral artery aneurysm
• ==> anterior thigh pain
• second most common after popliteal aneurysm

Question 34

Indirect vs. direct inguinal hernia

Answer 34

• indirect can ==> scrotum

Question 35

Presentation of ischemic bowel

Answer 35

abdominal pain + hematochezia

Question 36

Pulmonary contusion presentation

Answer 36

• pulm cont = brusingo fl ung parenchyma
• may or may not be associated with rib fx
• usually w/in 24h of trauma (may develop within a few minutes):
  
  • tachypnea
  • tachycardia
  • hypoxia
  • chest wall bruising
  • decreased breath sounds
  • CXR: patchy, irregular alveolar infiltrate and CT scan
  • ABG: hypoxemia

Question 37

Pulmonary contusion vs. ARDS

Answer 37

• Pulmonary contusion =
  
  • associated with trauma to lung
  • w/in 24h of trauma
• ARDS
  
  • 24-48h after trauma
  • bilateral

Question 38

Common presentation of postop cholestasis

Answer 38

• benign condition that develops after major surgery w/hypotension, high blood loss, massive blood replacement
• ==> jaundice by POD2-3; bilirubin peaks @ 10-40 by POD10; alk phos possibly elevated; AST/ALT normal
  
  • jaundice 2/2 increased pigment load (transfusion), decreased liver fxn (hypotension), decreased renal tubular excretion (ATN)

Question 39

Lab results in Paget Disease of bone

Answer 39

• elevated alk phos
• normal Ca
• normal phos

Question 40

Common presentation & possible consequences of Paget’s disease of bone

Answer 40

• bowing or fx of long bones ==> secondary OA of hip or knee
• skull bone enlargement ==> frontal bossing, increased head size (hats no longer fit), HA, cranial n. palsy, **hearing loss due to damage to cohlear nerve

Question 41

Tx of penile fx

Answer 41

1. emergent urethrogram
2. emergent surgery to evacuate hematoma and mend torn tunica albuginea

Question 42

Bladder portion covered in peritoneum

Answer 42

• bladder dome = only portion covered by peritoneum ==> spillage of urine into peritoneum in setting of trauma
• segment most prone to rupture in setting of sudden increase in intravesical pressure

Question 43

Hypoparathyroidism presentation

Answer 43

• low Ca + elevated phosphorous w/normal renal fxn
• causes:
  
  • post-surgical
    
    • parathyroidectomy
    • thyroidectomy
    • autoimmune destruction