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Surgery > WiseMD Modules 2 > Flashcards

WiseMD Modules 2 Flashcards

1
Q

45 yo F p/w periumbilical colicky pain and abdominal distention x2d, N/V, no stool/flatus x48h

  • PSH: appendectomy at 14 yo
  • BS: rare and high pitched
  • PE: rebound on deep palpation
  • WBC 15k
  • plain film: dilated proximal small bowel w/ pneumatosis

(a) Dx
(b) Mgmt

A

(a) Dx = SBO

(b) Next step = NG tube, IV fluids, exploratory laparotomy
- surgery indicated since signs of peritonitis (rebound) and pneumatosis are concerning for bowel necrosis
- also indication for surgery = leukocytosis

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2
Q

Describe the transition epithelium makes at the dentate line and how this correlates to which type of hemorrohoids bleed

A

Dentate line = where rectal columnar mucosa meets squamous epithelium
-squamous epithelium is like skin, wouldn’t just spontaneously bleed = why external hemorrhoids are less likely to bleed

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3
Q

70 yo M w/ 15mins of weakness and paralysis of right arm w/ difficulty speaking

  • similar episode 3 days ago, both times syptoms resolved
  • PE: b/l carotid bruits

(a) Next step?
(b) Dx

A

(a) Next step = carotid duplex ultrasound
(b) Dx = TIAs, use US as first line b/c noninvasive way of diagnosing carotid stenosis/occlusion

-not recommended to use contrast (for contrast CTA) w/in first 24 hrs after onset of neurologic symptoms

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4
Q

First step in management for TIA

A

TIA management
First step = carotid ultrasound
-get that first before MRA/MRI
-anticoagulation is NOT recommended for tx of TIA

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5
Q

What are you looking for during rectal exam when suspecting SBO?

A
  • presence or absence of stool (if there’s stool they’re probably not obstructed)
  • guiac positivity
  • masses
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6
Q

White count expected in

(a) Acute appendicitis
(b) Perforated appendicitis

A

White count seen in

(a) Acute appendicitis = can be normal, often mild-moderately elevated to 12-15k
(b) Perforated appendicitis = crazy high like 18-20

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7
Q

Three physical exam signs indicative of acute appendicitis

A

Acute appendicitis on physical exam

  1. Rosving’s = pain in RLQ when pressure applied to LLQ
  2. Obturator sign = bend right leg at knee and rotate, exacerbates pain
  3. Psoas sign = pt rolls away, pull straight leg away behind the pt which exacerbates pain
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8
Q

Post-op management of exploratory laparotomy for SBO

A
  • Give IV fluids
  • remove NG tube when output is less than 200-250 cc/shift
  • can start PO fluids once the pt passes gas
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9
Q

80 yo F p/w 2 days of abdominal distention and obstipation

  • no h/o previous surgeries
  • Plain abdominal film: distended, coffee-bean loop of bowel w/ haustral markings in RUQ

Dx

A

Dx = sigmoid volvulus
-give away is the coffee bean sign

Haustral markings => you know it’s large bowel, distention and severe constipation (obstipation) => large bowel obstruction

One of the etiologies of mechanical LBO is volvulus

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10
Q

Narrowest part of an airway in a 6 yo

A

Cricothyroid junction- so a cricothyroidotomy is contraindicated in young children for emergency airway access

Needle jet ventilation and eventual tracheostomy in young children who need emergency surgical airway

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11
Q

What are you feeling for on the digital portion of a rectal exam?

A

Rectal tone, any palpable masses, any tenderness

-not feeling for hemorrhoids (most are way too small to feel)

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12
Q

Differentiate anoscope and proctoscope

A

Similar concept to gynecologic exam- anoscope looks into anus, while proctoscope goes further to assess entire length of the rectum

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13
Q

Post-op care for perirectal abscess drainage

(a) Symptomatic care
(b) Long term mornitoring

A

Post-op care for perirectal abscess drainage

(a) Symptoms after surgery are most commonly 2/2 levator ani spasms => sitz bath (literally submerge up to waist in warm water)
(b) Long term monitoring for anal fistula

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14
Q

List the causes of the two types of SBO

A

SBO: mechanical obstruction or motility issue

Mechanical obstruction: 60% adhesions, 20% tumor, 10% hernia, 5% Crohn’s
Functional obstruction = paralytic ileus

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15
Q

55 yo M w/ 15-yo burn wound that has recently changed and started increasing in drainage

Next step

A

Recent change in chronic wound needs biopsy- check for Marjolin’s ulcer = squamous cell carcinoma that develops in a chronic burn wound

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16
Q

40 yo F p/w 2d periumbilical colicky pain and abdominal distention, N/V, no stool/flatus x2d
PSH: hysterectomy

Dx and etiology

A

Adhesive small bowel obstruction

-if w/o surgical history, would consider other etiologies of SBO like tumor, hernia, Crohn’s

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17
Q

List the causes of the two types of LBO

A

LBO: mechanical obstruction or motility issue

Mechanical: color cancer, diverticulitis, volvulus

Functional = Ogilvie’s syndrome = colonic ileus

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18
Q

72 yo F p/w 2d vom and intermittent colicky abd pain

  • distended abdomen, mildly tender
  • 10 yr h/o postprandial upper abdominal pain
  • high pitched and tinkling BS
  • Plain film: branching air collections over liver w/ distended small bowel and decompressed colon

Dx
(a) Explain imaging

A

Dx = gallstone ileus

(a) Branching air collections over liver = portal venous air, complication of bowel obstruction
- typical of SBO 2/2 gallstone stuck at the ileo-cecal valve

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19
Q

65 yo F 18 hrs s/p l. carotid endarterectomy w/ left mouth droop when asked to smile

(a) Cause of facial droop
(b) Mgmt

A

(a) Injury to marginal mandibular branch of the left facial nerve
(b) Most likely 2/2 mechanical disruption of nerve in surgery, not due to permanent nerve damage => no further mgmt. needed

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20
Q

How the following change risk of anorectal disease

(a) Diabetes
(b) Cirrhosis
(c) HIV/AIDS

A

Diabetes and cirrhosis increase infection risk => increased risk anorectal abscess

HIV/AIDS increase risk for AIN and other noeplastic processes of the anorectal region

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21
Q

What to check at post-op f/u visit after lap appy

A
  1. wound site for wound infection

2. palpate for RLQ fullness to detect intraabdominal abscess

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22
Q

Perianal vs. perirectal abscess

(a) Clinical features
(b) Tx

A

Perianal abscess- small, no signs of surrounding cellulitis
-can be drained in the office, no need for abx

Perirectal abscess- significant surrounding cellulitis
-drain in the OR (b/c need a lot of anesthesia) and give post-op IV abx

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23
Q

2 complications of perirectal abscess drainage

A

Complication of drainage of perirectal abscess

  • incontinence (esp to flatus) if abscess goes into rectal muscles
  • development of fistula in-ano (abscess heals leaving opening btwn anus and skin)
24
Q

Surgical indications for SBO

A

No prior abdominal surgery (only can medically manage SBOs 2/2 adhesions)
-febrile, leukocytosis, peritonitis, incarcerated hernia, primary SBO (tumor)

Or if medically managed but pt worsens or doesn’t improve w/in 2-5 days

25
Q

Open vs. laparoscopic laparotomy for SBO management

A

Most of the time chose midline incision over laparoscopic b/c pt so distended that you can’t pump enough air into abdomen to visualize laparoscopically

26
Q

Benefits of lap appy over oven appy

A

Decrease rate of infection, decreased pain, shorter LOS (faster recovery)

27
Q

63 yo F p/w abdominal distention and obstipation x2 days, vomit x2
-2 mo h/o diffuse dull lower abdominal pain and change in bowel habits

Dx

A

Dx = colon cancer

-more of a chronic process causing obstruction

28
Q

When to use allograft vs. autograft in wound healing

A

Autograft (self-graft) is permanent closure, but sometimes the burn surface area might be too much so you need to use cadeveric allograft which is temporary

29
Q

23 yo F p/w crampy abd pain, N/V x2d

  • similar episodes in the past which spontaneously resolve, no PSH
  • +guiac test

Abdominal CT most likely to show what?

A

Inflammation of terminal ileum

SBO 2/2 Crohn’s disease, fits w/ symptoms/time line, repeat episodes, bloody stool
-terminal ileum = most common location in the GI tract affected by Crohn’s

30
Q

81 yo M asymptomatic, found to have right carotid bruit
-Carotid duplex US shows >80% stenosis bilaterally of external carotids

Next step?

A

Next step = observation and anti-platelet therapy

-key is EXTERNAL artery stenosis, which is not associated w/ significant risk of TIA/stroke

31
Q

22 mo old boy p/w paroxysms of severe colicky abdominal discomfort
-plain film: dilated loops of small bowel

(a) Dx
(b) Next step

A

(a) Intussusception = loop of bowel going in and out of target point
(b) Next step for both diagnosis and therapeutic benefit = barium enema

32
Q

80 yo Fs/p hip replacement p/w constipation and abdominal distention x4 days

Dx

A

Ortho procedure => pt probably on opioids = common cause of colonic ileus (Ogilvie’s syndrome)

= Functional etiology of LBO

33
Q

TIA vs. CVA

(a) Clinically
(b) Imaging Findings

A

Transient ischemic attack

(a) Clinically symptoms are under 24 hrs, transient
(b) Ischemia, but NOT infarct

Cerebral vascular accident

(a) Symptoms persist over 24 hrs
(b) Infarction

34
Q

70 yo M w/ 2hrs of right arm/leg weakness and speech difficulties

  • symptoms slightly improved, but weakness still present
  • b/l carotid bruits

Best next step

A

Next step = CT w/o contrast

-get CT w/o contrast to exclude evidence of bleed (r/o intracranial hemorrhage) before considering lytic therapy w/ tPA

35
Q

Next step after suspecting sigmoid volvulus from history, physical, and abdominal plain film

A

Next step for sigmoid volvulus = sigmoidoscopy, then surgery after

-sigmoid volvulus requires decompression prior to definitive surgery to avoid recurrence

36
Q

4 risks of ANY AND ALL SURGERIES

A
  1. bleeding
  2. infection
  3. recurrence of the problem
  4. injury to nearby structures
37
Q

Briefly describe pathophysiology of acute appendicitis

A

Acute appendicitis develops due to appendiceal lumen obstruction (lymphatic hyperplasia, infection, IBD, etc)

  • intestinal bacteria in the appendix multiple => WBC recruited => pus and increase in pressure
  • then when intraluminal pressure overcomes venous pressure you get venous outflow obstruction => ischemia => gangrene/necrosis etc
38
Q

Name the three structures in the carotid sheath

A
  1. carotid artery
  2. internal jugular vein
  3. vagus nerve
39
Q

Complications to monitor for s/p exploratory laparotomy for SBO

A

Much higher complication if bowel had to be resected or anastamosed (b/c exposing outside to intraabdominal contents)

  • intra-abdominal abscess POD5 of later
  • anastamotic leak
40
Q

65 yo F 2 hrs s/p carotid endarterectomy develops tense swelling of neck on side of surgical incision
-reports choking sensation and increasing SOB

Next step?

A

Immediately decompress the surgical wound
-relieve the hematoma before intubating (you won’t be able to intubate w/ all the blood in that area!)

Decompress wound from carotid endarterectomy by relieving all three layers (skin, superficial cervical fascia = platysma, deep cervical fascia)

41
Q

60 yo M w/ lower abdominal pain and tenesmus x5d

  • 2 previous episodes managed outpt
  • h/o chronic constipation
  • 100.8F
  • LLQ tenderness w/ guarding w/o rebound
  • WBC 12.4

(a) Dx
(b) Next step

A

(a) Dx = diverticulitis- often presents w/ low grade temp, LLQ pain and tenderness, and leukocytosis
- supported by previous episodes

(b) Next step = CT to confirm diagnosis and r/o other possibilities, also see if diverticulitis is complicated (ex: by perforation or abscess)

42
Q

55 yo M w/ sudden inability to speak coherently

  • knows what to say, but cannot find the words
  • no weakness/numbness, no trauma
  • BP 160/90
  • can write coherently, but cannot find words to speak

(a) Name this condition
(b) Locate the cerebral defect

A

(a) Aphasia = inability to find the right words
(b) Aphasia caused by ischemia of the pt’s dominant hemisphere
For right handed pt: expect embolus to left anterior circulation

43
Q

Pt p/w intense pain during defecation that lasts a for a few minutes after completion

Most likely dx

A

Anal fissure

  • pain lasts 2/2 spasms of levator ani muscle
  • intense pain => localizes issue to below the dentate line
44
Q

36 yo M w/ 24h of diffuse abdominal pain, obstipation, N/V

  • appendectomy at 5 yoa
  • normal VS
  • distended abdomen w/ high pitched BS and tympanic percussive sounds, TTP over all 4 quadrants

Most likely cause of obstruction?

A

Adhesions

-don’t get confused by demographics (36 yo M) and think internal hernia, hernias only account for 5% of SBOs while adhesions (which can even be from minor surgeries) account for 60% SBO

45
Q

Anterior vs. posterior cerebral ischemia symptoms

Which would be expected from carotid endarterectomy clot?

A

Clot from carotid –> middle meningeal artery –> end branch vessel anteriorly causing anterior symtpoms

Anterior symptoms: contralateral weakness, contralateral numbness, ipsilateral monocular blindness

vs. Posterior symptoms of diplopia (double vision), dysarthria (trouble w/ speech), ataxia, circumoral numbness

46
Q

When can SBO be managed w/o surgery?

A

Only ppl who are candidates for medical surgery are those who you are saying cause is adhesions

=> if pt has no previous abdominal surgeries you can’t manage them medically!

Pt must be: afebrile, normal white count, no signs of peritonitis

47
Q

Most common location for carotid body tumor?

(a) Appearance on MRA
(b) Mgmt

A

At the carotid bifurcation

(a) very vascular w/ abundant supply from external carotid artery
(b) Surgical resection
- Doesn’t respond to radiation, can’t just leave it b/c it tends to expand and cause mass effect

48
Q

25 yo M w/ severe bloody diarrhea and abdominal pain x4 wks w/o f/c, obstipation x1d

  • h/o 2 similar episodes tx outpatient
  • PSH: appendectomy at age 12
  • WBC 11.3, Hb 12

Dx

A

Dx = Crohn’s

  • progressive symptoms w/ bloody stool in right age group
  • adhesive SBO wouldn’t have bloody diarrhea (or chronic time course)
49
Q

70 yo M 1 hr s/p left carotid endarterectomy develops RUE weakness

Next step

A

Next step = immediate re-exploration of carotid artery

  • occlusion of LCA at endarterectomy site
  • suspecting embolic event s/p endarterectomy = immediate surgical re-exploration
50
Q

What would you expect to see on abdominal physical exam in a pt w/ SBO

(a) Inspection
(b) Auscultation
(c) Percussion
(d) Palpation

A

(a) Inspection- central distention, no visible masses, possible scars from previous surgeries
(b) Auscultation- really nonspecific findings, potentially hear high pitched rush (but really not a reliable finding)
(c) Tympanic/hyperresonant to percussion indicating air and not fluid in the bowel
(d) Palpation- mildly tender to palpation, but no guarding or masses/organomegaly

51
Q

71 yo M s/p TIA, carotid duplex US showing over 80% stenosis of left internal carotid artery
Next step?

A

Next step = carotid endarterectomy b/c symptomatic and stenosis over 70%

-if asymptomatic, cutoff would be stenosis over 80%

52
Q

70 yo M w/ several 10 minute episodes of transient blindness in left eye over 2 weeks

  • Fundoscopic exam: yellow highly retractable debris in left eye
  • carotid duplex US: >80% stenosis of internal carotids b/l

(a) Dx
(b) Next step?

A

(a) Dx = episodes of amaurosis fugax
- presence of Hollenhorst plaques (in retinal artery) on fundoscopic exam

(b) Next step = further characterization of the anatomy w/ CTA of head and neck
- also confirms degree of stenosis provided by US

53
Q

Pre-op mgmt of acute appendicitis

A
  1. Start IV fluids

2. Start IV abx (often Cefoxitan)

54
Q

60 yo F w/ incidental finding of left carotid bruit
-Carotid duplex US showed 50% stenosis of left internal carotid artery

Next step

A

Next step = anti-platelet therapy (ASA) w/ repeat duplex scan in 12 mo

-no indication for surgery given asymptomatic and less than 80% stenosis

55
Q

Why is it indicated to do a UA on a pt in which you suspect SBO?

A

UTIs can cause paralytic ileus, which is a functional etiology of SBO

56
Q

Technique used to ensure contrast is in the right place when assessing for acute appendicitis

A

1 hr post contrast ingestion- use scout radiograph (abdominal Xray) to ensure that the contrast is in the right colon
-need contrast to make structures visible, almost impossible to diagnose acute appendicitis w/o contrast

Surgery (10 decks)

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