Uworld Surgery Flashcards
Nasopharyngeal carcinoma is associated with what virus
EBV
Nasopharyngeal carcinoma is endemic to where
sourthern china (and parts of Africa and the Middle East)
Aflatoxin B1 is a mycotoxin that often contaminates agricultural products and is associated with an increased risk of what?
hepatocellular carcinoma
Recent cardiac cath, anticoagulation with heparin, sudden onset of hypotension, tachycardia, flat neck veins, and back pain is consistent with what?
-retroperitoneal hematoma due to bleeding from the arterial access site (with retroperitoneal extension . . . . .Non contrast CT scan of abdomen and pelvis or abdominal US confirms . . . treatment supportive
This causes chronic anterior knee pain and is most common in women. It presents with peripatellar pain worsened by activity or prolonged sitting
Patellofemoral pain syndrome
Patient in MVA with persistent pneumothorax despite chest tube placement and pneumomediastinum, and has subcutaneous emphysema on PE . . cause?
- Tracheobronchial perforation secondary to blunt thoracic trauma (bronchial rupture)
- The right main bronchus is most commonly injured in these cases. Dx confirmed with high-resolution CT scanning, bronchoscopy, or surgical exploration
This is a common complication of vascular surgery, as patients are often older and have extensive underlying atherosclerosis. CT imaging can show thickening of the bowel wall. Colonoscopy shows cyanotic mucosa and hemorrhagic ulcerations
Ischemic colitis
In burn victims, clinical indicators of thermal inhalation injury to the upper airway and/or smoke inhalation injury to the lungs include burns on the face, singing of the eyebrows, oropharyngeal inflammation/blistering, oropharyngeal carbon deposits, carbonaceous sputum, stridor, carboxyhemoglobin level >10%, or history of confinement in a burning building. The presence of one or ore of these indicators warrants what?
early intubation to prevent upper airway obstruction by edema
Stress fractures of the 2nd, 3rd, and 4th metatarsals are managed how and why?
- conservatively . . initial interventions include rest and simple analgesics (e.g. acetaminophen)
- The surrounding metatarsals act as splints and nonunion is uncommon
Stress fractures of the 5th metatarsals are at increased risk for nonunion and are usually managed how?
with casting or internal fixation
A patient with stuttering episodes of nausea and vomiting, pneumobilia (air in the biliary tree), hyperactive bowel sounds, and dilated loops of bowels likely has what?
A gallstone ileus, a form of mechanical small bowel obstruction
Gallstone ileus occurs when what happens
A gallstone passes through a biliary enteric fistula into the small bowel. As the stone advances it may cause intermittent “tumbling” obstruction with diffuse abdominal pain and vomiting until finally lodging in the ileum
Dislocation of this carpal bone following a fall on an outstretched hand can cause compressive neuropathy of the median nerve?
Lunate
Describe the extension and complications potentially of a retropharyngeal abscess
- drains inferiorly to the superior mediastinum
- Spread to the carotid sheath can cause thrombosis of the internal jugular vein and deficits in cranial nerves IX, X, XI, and XII
- Extension through the alar fascia into the “danger space” (between the alar and prevertebral fascia) can rapidly transmit infection into the posterior mediastinum to the level of the diaphragm
- Acute necrotizing mediastinitis is a life-threatening complication characterized by fever, chest pain, dyspnea, and odynophagia, and requires urgen surgical intervention
Ludwig angina is a rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces, most often arising from what?
an infected mandibular molar
Acalcujlous cholecystitis is a serious condition that can lead to sepsis and death if undetected. Most often seen in SEVERELY ILL patients in the ICU with multiorgan failure, severe trauma, surgery, burns, sepsis, or prolonged. The immediate treatment in critically ill patients includes what?
-antibiotics followed by percutaneous cholecystostomy under radiologic guidance
Sphincter of Oddi dysfunction is a functional biliary disorder due to dyskinesia or stenosis of the sphincter of Oddi. Patients experience recurrent, episodic pain in the RUQ or epigastric region, with corresponding elevations in aminotransferases and alk phos. What meds may cause sphincter contraction and precipitate symptoms?
-Opioid analgesics (e.g. morphine)
most common cause of primary hypoparathyroidism
post surgical
All trauma patients should be triaged using the Glasgow coma scale, which can predict the severity and prognosis of coma, during the primary survey. The GCS assesses what?
- Ability to open his/her eye
- motor response
- Verbal response
The most rapid means of normalizing the prothrombin time (INR) is restoration of the vitamin K-dependent clotting factors through what?
an infusion of FFP
This is given pre-operatively to patients with mild hemophilia A in order to prevent excessive bleeding. It directly increases factor VIII levels by causing vWF release from endothelial cells
Desmopressin (DDAVP)
Medial tibial stress syndrome (shin splints) causes anterior leg pain resembling that of a stress fracture. It is usually seen in casual runners and is characterized by what?
- diffuse area of tenderness (not point tenderness, as seen in stress fracture)
- Shin splints are more common in overweight than underweight individuals
Gastric outlet obstruction can be caused by many disease processes and is characterized by early satiety, nausea, nonbilious vomiting, and weight loss. In a patient with a history of acid ingestion, what is the most likely cause?
Pyloric stricture
A patient with blunt abdominal trauma, hypotension, right chest/abdominal wall injury, and free intraperitoneal fluid most likely has what?
A hepatic laceration, one of the most common solid organ injuries, along with splenic lacerations
What are other manifestations of hepatic laceration?
-RUQ pain and right shoulder pain due to irritation of the phrenic nerve from hemorrhage
Major surgery is a significant risk factor for DVT. Describe the anticoagulation in a provoked DVT?
- At least 3 months of anticoagulation is recommended for provoked DVT
- Stable patients can be treated wit hanticoagulation as early as 48-72 hours after surgery
- Patients started on warfarin must be started on an additional anticoagulant (e.g. heparin) at the same time because warfarin temporarilty causes a prothrombotic state
- Low molecular weight heparin in NOT recommended in end-stage renal disease
A varicocele is a tortuous dilation of the pampiniform plexus of veins surrounding the spermatic cord and testis. It occurs in nearly 20% of postpubertal males and presents how?
-a soft, irregular mass (“bag of worms”) that increases in size with standing and valsalva
This is a fluid filled cyst of the head of the epididymis that presents as a painless mass at the superior pole of the testis. Would NOT changed in size with position or valsalva
Spermatocele
This would typically present as a painless, firm testicular mass that would NOT change in size with position or valsalva
Testicular cancer
These are peritoneal fluid collection between the parietal and visceral layers of the tunica vaginalis. They can change in size with position but the fluid is easily tranilluminated
Hydrocele
Patients with a contained appendiceal abscess have a very high complication rate from immediate surgery due to the mass of inflamed, infected, and friable debris and adhesions. How should they be managed?
- If they are otherwise clinically stable, should be managed with IV antibiotics
- bowel rest
- possibly percutaneous drainage of the abscess
- They can return in 6-8 weeks for appendectomy on an elective basis (“interval appendectomy”)
Patients who present with appendicitis >5 days after the onset of symptoms have a high incidence of perforation with abscess formation . . what physical exam maneuvers would be positive?
- Psoas sign
- Obturator sign
- pain on rectal exam
physical exam findings in Meniscal tears?
- Joint line tenderness
- Pain or catching in Provocative tests (Thessaly, McMurray)
After a snowmobile accident, patient has Costovertebral pain and hematuria concerning for what?
Blunt genitourinary trauma
All patients with blunt genitourinary trauma should undergo urinalysis, and hemodynamically stable patients with evidence of hematuria should undergo further imaging with what?
a contrast-enhanced CT scan of the abdomen and pelvis
Hemodynamically UNstable patients with evidence of renal trauma should undergo what?
IV pyelography prior to surgical evaluation
The leukocyte count in the synovial fluid in prosthetic joint infection is usually elevated to what?
> 1000 but is often lower than in septic native joints (usually >50k)
The most common causes of syringomyelia are what?
Arnold Chiari malformations and prior spinal cord injuries
3-4% of patients with spinal cord injuries will develop post-traumatic syringomyelia. Whiplash is often the inciting injury. Symptoms develop months to years later. The condition involves enlargement of the central canal of the spinal cord due to CSF retention, resulting in what physical exam findings?
-impaired strength and pain/temp sensation in the upper extremities . . MRI is used for definitive diagnosis
typical colonoscopy findings in colonic ischmemia
- pale mucosa with petechial bleeding
- bluish hemorrhagic nodules
- cyanotic mucosa with hemorrhage
The differential diagnosis for an anterior mediastinal mass includes the “4 T’s”: . . . what are they
- Thymoma
- Teratoma (and other germ cell tumors)
- Thyroid neoplasm
- Terrible lymhoma
In a penile fracture, diagnosis is usually clinical, and surgical management, a urological emergency, is the mainstay of treatment. The only imaging test commonly used in evaluation is what?
Why is this used and what are the indications?
- Retrograde urethrogram
- employed in cases of suspected urethral injury, a common complication
- indications: blood at meatus, hematuria, dysuria, urinary retention
Patient has acute pain and paresthesias following a lower extremity embolectomy; these are suspicious features for what?
Ischemia-reperfusion syndrome, a form of compartment syndrome
Reperfusion of a limb following arterio-occlusive ischemia for longer than 4-6 hours can lead to intracellular and interstitial edema. compartment syndrome may occur when edema causes the pressure within a muscular facial compartment to rise above what?
above 30 mm Hg, leading to further ischemic injury
Describe how a AAA can lead to hematuria?
-AAA can rupture into the retroperitoneum and create an aortocaval fistula with the inferior vena cava, leading to venous congestion in retroperitoneal structures. The fragile distended veins in the bladder can rupture and cause gross hematuriea
Complications due to inappropriate central venous catheter placement are common. With the exception of select cases, appropriate catheter tip placement should be confirmed by what?
Chest x-ray prior to catheter use
In case of amputation injury, describe how you should manage it in the field?
- amputated parts should be wrapped in saline-moistened gauze
- sealed in a plastic bag
- placed on ice and brought to the emergency department
Patient is experiencing unilateral lower extremity edema that worsens when the leg is dependent (i.e. while the patient is at work) and improves with leg elevation (i.e. when the patient is sleeping). most likely cause?
venous valve incompetence
This is a chronic growth on the hard palate. it is a benign bony growth located on the midline suture of the hard palate. It is thought to be due to both genetic and environmental factors and is more common in younger patients, women, and Asians
Torus Palatinus
This is a depolarizing neuromuscular blocker that can cause life-threatening hyperkalemia in patients with a condition leading to upregulation of postsynaptic acetylcholine receptors (e.g. skeletal muscle trauma, burn injury, stroke)?
Succinylcholine
In skeletal muscle trauma, burn injury, and stroke, nondepolarizing neuromuscular blocking agents such as what should be used?
- Vecuronium
- rocuronium
Severe Hypotension due to myocardial depression is a common adverse effect of this anesthesia med and it should be avoided or used with extreme caution in patients with ventricular systolic dysfunction?
Propofol
This anesthesia med can lead to acute liver failure due to production of hepatoxic intermediary compounds, therefore it is now rarely used. Adult women are at greatest risk
halothane
This anesthesia med inhibits 11-beta-hydroxylase and can lead to adrenal insufficiency. The elderly and patients with critical illness (e.g. sepsis) are typically susceptible
Etomidate
This anesthesia med inactivated vitamin B12, leading to inhibition of methionine synthase activity; subsequent neurotoxicity (e.g. peripheral neuropathy) can result in patients with preexisting vitamin B12 deficiency
Nitrous oxide
This is another name for Aortoiliac occlusion which is characterized by the triad of bilateral hip, thigh, and buttock claudication, impotence and symmetric atrophy of the bilateral lower extremities due to chronic ischemia
Leriche syndrome
What surgery would put one at at risk for injury to the hypoglossal nerve leading to tongue palsy
surgery below the mandible (tumor of submandibular gland)
A winged scapula can result from injury of the long thoracic nerve. This most commonly occurs during what operation
axillary lymphadenectomy for the treatment of breast cancer
In flail chest, what improves oxygenation and causes the flail segment to move normally?
Positive pressure mechanical ventilation
What is the clinical presentation of Fat embolism?
- 24-72 hours following inciting event
- Clinical triad of: Respiratory distress, neurologic dysfunction (e.g. confusion), petechial rash
- Low grade fever and subconjunctival hemorrhage may also be present
This can occur following cardiac surgery and presents with fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray?
-What management does it require?
- Acute mediastinitis
- Drainage, surgical debridement, and prolonged antibiotic therapy
Describe how mechanical ventilation in the setting of hypovolemic shock can cause cardiac arrest?
- Positive pressure mechanical ventilation causes an acute increase in intrathoracic pressure
- Can cause loss of right ventricular preload, loss of cardiac output, and cardiac arrest
Gallstone pancreatitis should be suspected in patients who have evidence of pancreatitis with ALT/AST levels >150. What management is indicated in all patients with gallstone pancreatitis who are medically stable enough to undergo surgery?
early cholecystectomy
Patient with mild scleral icterus following appendectomy as elevated indirect (unconjugated) bilirubin levels with normal liver function test results and no evidence of hemolysis. This is consistent with what?
Gilbert syndrome
Pathogenesis of Gilbert syndrome
decreased activity of UDP-glucuronosyltransferae, responsible for bilirubin conjugation in the liver
What is the mechanism by which Head elevation lowers intracranial pressure?
Increased venous outflow from the brain
What is the mechanism by which sedation lowers intracranial pressure?
decreased metabolic demand and control of HTN
what is the mechanism by which Hyperventilation lowers intracranial pressure
CO2 washout –> cerebral vasocontriction
This is characterized by intense pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus?
What is management?
- Necrotizing surgical infection
- Early surgical exploration
A pulsatile groin mass below the inguinal ligament is characteristic of this; anterior thigh pain is due to the compression of the femoral nerve
femoral artery aneurysm
patient with subacute pain over the midline sacrococcygeal with mucoid and bloody drainage most likely has what?
pilonidal disease
Describe what type of people are typically affected by pilonidal disease
- males age 15-30
- obese, sedentary lifestyles or occupations, deep gluteal clefts
Acute bacterial parotitis presents with painful swelling of the parotid gland that is aggravated by chewing. High fever and a tender, swollen and erythematous parotid gland are common. This post-operative complication can be prevented how?
- adequate fluid hydration
- oral hygiene
What is the most common infectious agent in acute bacterial parotitis
Staph aureus
in patient with suspected epidural hematoma, if they have dilation of the pupil on the ipsilateral side due to oculomotor nerve compression what is causing it
uncal herniation
What are the most common causes of massive hemothorax?
- traumatic laceration of the lung parenchyma
- damage to an intercostal or internal mammary artery
Describe the compensation by the heart in hypovolemic shock
-initial decrease in preload and cardiac output followed by a compensatory increase in systemic vascular resistance, heart rate, and ejection fraction
Describe the use and need for imaging in patients with classic signs of appendicitis
- should have immediate appendectomy to prevent appendiceal rupture
- imaging studies such as CT and US are useful for patients with NONclassic symptoms, equivocal findings on initial assessment, or delayed presentation
This results from staphylococcal folliculitis following nose picking or nasal hair plucking. It is potentially life threatening as it can spread to the cavernous sinus. Patients complain of pain, tenderness and erythema in the nasal vestibule
Nasal furunculosis
If a patient develops a whistling noise during respiration following rhinoplasty, on should suspect what?
nasal septal perforation likely resulting from a septal hematoma
Due to the risk of carbon dioxide retention, needle cricothyroidotomy is not ideal in patients with head injury who might require hyperventilation to prevent or treat intracranial HTN. However, it is preferred to surgical cricothyroidotomy in who and why?
- children <12
- easier to perform anatomically
Surgical cricothyroidotomy is preferred over surgical tracheostomy but should be converted to formal tracheostomy in 5-7 days if prolonged airway control is needed. Prolonged used of cricothyroidotomy has a high incidence of what complication?
tracheal stenosis
- Subacute fever, abdominal/flank pain radiating to groin
- Anorexia, weight loss
- Abdominal pain with hip extension (psoas sign)
Psoas abscess . . . get CT scan of abdomen and pelvis
Supracondylar fractures of the humerus are the most common fractures in the pediatric poulation. What is the most common complication associated with these fractures?
entrapment of the brachial artery or median nerve
Entrapment of the brachial artery and median nerve are the most common complication associated with supracondylar fractures of the humerus.
What are other complications?
- Cubitus varus deformity
- Compartment syndrome/Volkmann ischemia contracture
Limb length discrepancy is a complication of what upper extremity injuries in peds?
-Proximal humerus and distal forearm fractures
symptoms and timing of dumping syndrome
- Abdominal pain, diarrhea, nausea
- Hypotension/tachycardia
- Dizziness/confusion, fatigue, diaphoresis
- 15-30 minutes after meals
What is the pathogenesis of dumping syndrome
-rapid emptying of hypertonic gastric contents
What is the initial management of dumping syndrome
- Small/frequent meals
- Replace simple sugars with complex carbs
- Incorporate high-fiber and protein rich foods
This refers to the development of fever, hypotension, and noncardiogenic pulmonary edema within 6 hours of blood product administration. Because left ventricular function is typically normal, Pulmonary artery catch reveals normal or high cardiac index and normal or low PCWP
Transfusion-related acute lung injury (TRALI)
