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surgery > Surgery > Flashcards

Surgery Flashcards

1
Q

Management of heparin-induced thrombocytopenia

A

STOP heparin, and begin direct thrombin inhibitor (e.g., argatroban) or fondaparinux

When >150,000, can safely switch to warfarin

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2
Q

Trousseau syndrome

A

Migratory superficial thrombophlebitis associated with pancreatic cancer (among others)

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3
Q

If blunt abdominal trauma

A

Need to evaluate for intra-abdominal bleed

If hemodynamically stable:

  • NOT alert/AMS –> serial abdominal exams +/- CT
  • alert/no AMS –> FAST

FAST - –> serial abdominal exams +/- CT
FAST + –> CT abdomen

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4
Q

Causes of hyperbilirubinemia

A

UNCONJUGATED

  • overproduction (hemolysis)
  • reduced uptake (drugs, portosystemic shunt)
  • conjugation defect (Gilbert syndrome)

CONJUGATED

  • AST/ALT
    • viral hepatitis
    • autoimmune hepatitis
    • toxin/drug-related hepatitis
    • hemochromatosis
    • ischemic hepatitis
    • alcoholic hepatitis
  • alkaline phosphatase
    • cholestasis of pregnancy
    • malignancy (pancreas, ampullary)
    • cholangiocarcinoma
    • PBC
    • PSC
    • choledocholithiasis
  • normal liver enzymes
    • Dubin-Johnson syndrome
    • Rotor syndrome
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5
Q

Positive pressure ventilation in a hypovolemic patient

A

PPMV causes an acute increase in intrathoracic pressure, which, in a severely hypovolemic patient with low central venous pressure, can collapse venous capacitance vessels (e.g., IVC) and cut off venous return. This sudden loss of RV preload can cause acute circulatory failure and cardiac arrest.

Sedatives also cause relaxation of capacitance vessels and can also contribute to decreased venous return

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6
Q

Rupture of bladder dome

A

Urine leaks into peritoneal cavity causing chemical peritonitis

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7
Q

Pulmonary contusion

A

Intraalveolar hemorrhage and edema

Presents <24h after blunt trauma

Tachypnea, tachycardia, hypoxia

Rales or decreased breath sounds

CT (>CXR) w/ patchy alveolar infiltrate not restricted by anatomical borders

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8
Q

Hemothorax on CXR

A

pleural effusion

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9
Q

Green drainage in chest tube

A

Esophageal perforation

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10
Q

Esophageal perforation

A

Severe chest pain, pneumothorax, pneumomediastinum, subcutaneous emphysema, pleural effusion w/ GI fluid (green, lo pH, hi amylase, food particles)

Water contrast esophagography

Surgery

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11
Q

Post-traumatic neuroma

A
  • weeks to months after amputation
  • focal tenderness, altered sensation
  • decreased pain w/ anesthetic injection
  • management: excision
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12
Q

Surgical indications for severe chronic mitral valve regurgitation

A

The measured LVEF in MR patients overestimates LVEF because regurgitant flow accounts for a large amount of the stroke volume

Primary MR

  • surgery if LVEF 30-60%, regardless of sx
  • consider surgery if successful valve repair is highly likely:
    • symptomatic and LVEF <30%
    • asymptomatic and LVEF >60%

Secondary MR
-medical management

Repair is preferred over replacement

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13
Q

Splenic abscess

A

Fever and tender splenomegaly

A rare, life-threatening consequence of bacteremia from a distant infection

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14
Q

Concerning side effect of anticholinergics in elderly

A

Urinary retention

Need to cath

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15
Q

Heterogenous echotexture in testicular torsion

A

testicular necrosis

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16
Q

Recent diagnosis of DM in older adult

A

Pancreatic cancer

Especially atypical DM (thin, older patient)

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17
Q

Angiosarcoma

A

Malignant tumor from lining of blood vessels and lymphatics.

RF: localized radiation for cancer treatment; breast cancer survivors w/ chronic lymphedema

Ecchymoses or purpuric lesions

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18
Q

Indications for surgery in midshaft humerus fracture

A
  • open fractures
  • significant displacement (arm shortening)
  • neurovascular compromise (asymmetric radial pulses)
  • polytrauma
  • pathologic fractures
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19
Q

Necrotizing surgical site infection presentation and management

A

Presentation:

  • pain, edema, or erythema spreading beyond surgical site
  • systemic sx (fever, tachycardia, hypotension)
  • paresthesia or anesthesia at wound edges
  • purulent, cloudy-gray discharge (“dishwater drainage”)
  • subcutaneous gas or crepitus
  • more common in patients w/ DM and tend to be polymicrobial

Can develop into necrotizing fasciitis, so need emergent surgical debridement and parenteral antibiotics

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20
Q

Leriche syndrome

A

Aortoiliac occlusion

Triad:

  • bilateral hip, thigh, and buttock claudication
  • absent or diminished femoral pulses (often w/ symmetric atrophy of b/l LEs d/t chronic ischemia)
  • impotence
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21
Q

Risk of laparoscopic appendectomy vs laparotomy

A

Lap appy:

intra-abdominal abscess: fever and abdominal sx several days after abdominal operation

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22
Q

Treatment of acute bacterial prostatitis

A

Fluoroquinolone or TMP/SMX for 6 wks

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23
Q

If a bruit is heard under clavicle in clavicle fracture

A

ANGIOGRAM to rule out injury to subclavian artery

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24
Q

Femoral artery aneurysm

A

Pulsatile groin mass below the inguinal ligament

Anterior thigh pain

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25
Q

Anteromedial humerus fracture risk

A

Injury to the brachial artery and median nerve (pass ant. to humerus)

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26
Q

Anterolateral humerus fracture risk

A

Radial nerve injury

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27
Q

Dangerous side effect of succinylcholine

A

Life-threatening arrhythmia d/t hyperkalemia

More common in certain patients where there is upregulartion of ACh-R:

  • crush injury (hyperkalemia)
  • burns
  • diffuse muscle atrophy
  • denervation (Guillain-Barré, critical illness polyneuropathy)

To avoid, use nondepolarizing neuromuscular blockers (vecuronium, rocuronium)

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28
Q

Components of Glasgow coma scale

A

Does not diagnose coma, but shows severity of coma

  • eye opening (1-4)
  • verbal response (1-4)
  • motor response (1-6)
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29
Q

Tamponade findings

A
  • hypotension (unresponsive to IVF)
  • tachycardia
  • elevated JVP
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30
Q

CMV infection in immunosuppressed

A

Colitis or enteritis w/ fever, malaise, vomiting, bloody diarrhea, and abdominal pain.

Cytopenias and atypical lymphocytes.

Large, shallow erosions or ulcers on colonoscopy.

Treat w/ gancyclovir and reduction of immunosuppressants

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31
Q

Ganglion cyst

A

Mobile, nontender swelling most commonly on dorsal surface of wrist

Diagnosis obvious on exam but can be confirmed with transillumination

Most resolve spontaneously

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32
Q

If appendicitis symptoms >5d, consider

A

appendiceal abscess

Maneuvers that assess deeper spaces (e.g., psoas sign) may be more revealing than anterior palpation of the abdomen

If stable, treat w/ IV hydration, antibiotics, bowel rest, and interval appendectomy (6-8 weeks later elective)

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33
Q

Evaluation of blunt genitourinary trauma

A
  • UA
  • contrast CT (if stable w/ hematuria)

If unstable, IV pyelography before surgery

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34
Q

MCL tear PE

A

Laxity on valgus stress test

MCL tears are caused by valgus stress or twisting

MRI most sensitive

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35
Q

Ruptured ovarian cyst symptoms and imaging findings

A

Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity. Can be complicated by hemoperitoneum and hemodynamic instability, especially in patients on anticoagulation.

US: pelvic free fluid

If unstable, needs surgery

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36
Q

Post-CABG patient presentinh w/ copious drainage from sternal wound

A

Concern for mediastinitis

Needs chest imaging –> fluid collections or pneumomediastinum

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37
Q

Giant cell tumor of bone

A

Progressive pain w/ lytic bone lesion

Benign but locally destructive

Pulmonary mets and malignant transformation may occur

Soap bubbles appearance

Surgery is first line

Danosumab (Ab against RANKL) can be used to shrink tumor

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38
Q

Complicated vs uncomplicated diverticulitis

A

Uncomplicated: in stable patients can be managed outpatient w/ bowel rest, oral antibiotics, and observation

Complicated: diverticulitis associated with an abscess, perforation, obstruction, or fistula formation

Fluid collection <3 cm: antibiotics and observation unless worsening symptoms
Fluid collection >3 cm: CT-guided percutaneous drainage. If symptoms not resolved by fifth day, surgical drainage and debridement.

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39
Q

Most common cause of small bowel obstruction

A

adhesions

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40
Q

Charcot joint

A

Neurogenic arthropathy.

Impaired sensation and proprioception in the foot lead to altered weight bearing, mechanical stresses, and recurrent trauma

Most commonly seen in diabetic peripheral neuropathy, other neuropathies (B12), syringomyelia, spinal cord injury, and tabes dorsalis

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41
Q

Peritonsilar abscess

A

Fever, pharyngeal pain, earache

Trismus, muffled voice, swelling of peritonsillar tissues w/ deviation of the uvula

Tx: needle aspiration or I&D w/ antibiotics

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42
Q

If stable gallstone pancreatitis

A

cholecystectomy

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43
Q

Indications for ERCP in gallstone pancreatitis

A
  • cholangitis
  • visible CBD dilation/obstruction
  • increasing liver enzymes
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44
Q

Most common cause of esophageal perforation

A

Endoscopy (especially w/ adjunctive procedures like biopsy or dilation)

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45
Q

Confirm esophageal perforation

A

Water-soluble contrast esophagography

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46
Q

Aortic injury risk factor

A

Rapid deceleration blunt chest trauma

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47
Q

Compartment syndrome

A

Common features:

  • pain out of proportion to injury
  • pain increased by passive stretch
  • rapidly increasing and tense swelling
  • paresthesia (early)

Uncommon:

  • decreased sensation
  • motor weakness (w/in hrs)
  • paralysis (late)
  • decreased distal pulses (uncommon)

Diagnosed by needle manometry (delta P [diastolic - compartment] <30 is suggestive)

Treat w/ urgent fasciotomy

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48
Q

Treatment of anal fissures

A
  • high-fiber diet and adequate fluid intake
  • stool softeners
  • Sitzs baths
  • topical anesthetics and vasodilators (nifedipine, nitroglycerine)

Surgical intervention (e.g., lateral sphincterotomy, fissure excision) is reserved for fissures that are refractory to medical therapy

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49
Q

Tramatic diaphragmatic injury

A

Migration of abdominal organs into the chest with resulting symptoms d/t lung compression (respiratory distress) or bowel obstruction (nausea, vomiting, abdominal pain)

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50
Q

Femoral vs inguinal hernia

A

Femoral is at higher risk for strangulation, so elective surgery is warranted, whereas inguinal hernias can be managed w/ reassurance and watchful waiting

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51
Q

Evaluation of suspected urethral injury

A

retrograde urethrogram

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52
Q

Indications for urethrogram

A
  • blood at meatus
  • hematuria
  • dysuria
  • urinary retention
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53
Q

Primary vs secondary polycythemia

A

Primary: decreased EPO

  • Polycythemia vera (JAK2 mutation)
  • EPO receptor mutations

Secondary: normal/increased EPO

  • hypoxemia (cardiopulmonary disease, OSA, high altitude)
  • EPO-producing tumors (renal, hepatic)
  • Congenital (high-affinity Hgb)
  • following renal transplantation
  • androgen supplementation
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54
Q

Anterior cord syndrome

A

Loss of movement, pain, and temperature

Intact position, vibration, and touch [dorsal columns spared]

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55
Q

Emphysemetous cholecystitis

A

Fever, RUQ pain, gas in GB wall, surrounding tissue, or hepatobiliary system; unconjugated hyperbilirubinemia, mildly elevated LFTs

d/t gas forming organisms like Clostridium or E. coli infecting damaged or ischemic tissue

SURGICAL EMERGENCY: immediate cholecystectomy

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56
Q

Delirium tremens

A

48-96h after last drink

Confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations

5% mortality

Treat w/ benzos

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57
Q

Preferred fluid for burn victims

A

Lactated Ringer’s (LR)

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58
Q

Why is LR preferred over NS for burns?

A

LR is balanced (physiologic) and contains buffer to maintain pH while NS is not–
NS has supraphysiologic [Cl-] which can cause hyperchloremic metabolic acidosis. It has also been associated w/ hypocoagulability.

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59
Q

Cat bite

A

Amoxicillin-clavulanate

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60
Q

Atraumatic splenic rupture

A

Associated w/ hematologic malignancies, infection (EBV, malaria), inflammatory diseases (SLE)

Diffuse or LUQ pain w/ L shoulder pain (Kehr sign) and hemodynamis instability

Acute anemia
Intraperitoneal free fluid on imaging

Stable: catheter-based angioembolization
Unstable: emergency splenectomy

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61
Q

Cholangiocarcinoma markers

A

Elevated CEA and CA19-9

Normal AFP

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62
Q

Hypoparathyroidism

A

Hypocalcemia and hyperphosphatemia in the presence of normal renal function

Causes:

  • post-surgical (most common)
  • autoimmune
  • congenital absence or maldevelopment of paratyroid glands (DiGeorge syndrome)
  • defective calcium-sensing receptor on parathyroids
  • infiltrative destruction (hemochromatosis, Wilson disease, neck irradiation)
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63
Q

Complication of circumferential, full-thickness burns

A

compartment syndrome

d/t eschar formation that restricts venous and lymphatic drainage

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64
Q

Symptoms of diverticulutis

A
  • LLQ abdominal pain
  • N/V
  • bladder symptoms (urgency, frequency, dysuria) or sterile pyuria (+LE, – nitrites)
  • alterations in bowel habits (constipation, diarrhea)
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65
Q

Next step after central venous catheter placement

A

CXR (to confirm proper placement)

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66
Q

Anterior dislocation risk

A

Injury to the axillary nerve [innervates teres minor and deltoid]

Weakened shoulder abduction and decreased sensation over lateral shoulder

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67
Q

Management of massive hemoptysis

A
  • ensure adequate patent airway
  • maintain adequate ventilation and gas exchange
  • ensure hemodynamic stability
  • place patient so that bleeding lung is in dependent position (lateral)
  • bronchoscopy
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68
Q

Indications for ex lap in blunt abdominal trauma

A
  • hemodynamic instability
  • peritonitis (rebound tenderness, guarding)
  • evisceration
  • blood from NG tube or on rectal exam
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69
Q

Protocol for patients on warfarin who need urgent surgery

A

-prothrombin complex concentrate and IV vitamin K

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70
Q

Effect of hyperventilation on ICP

A

Decreases via vasoconstriction

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71
Q

Chronic bacterial prostatitis

A

Epi:

  • young and middle aged men
  • diabetes, smoking, UT procedure

Pathogenesis:

  • coliforms enter from urethra via intraprostatic reflux
  • E. coli causes >75%

Presentation:

  • recurrent UTI w/ same organism
  • +/- prostatic tenderness and swelling (often absent)
  • pain w/ ejaculation
  • h/o antibiotic treatment –> transient improvement

Dx:

  • pyuria and bacteriuria on UA
  • bacteria in prostatic fluid > bacteria in urine

Tx:
-fluoroquinolones for 6 wks

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72
Q

Urology consult indications for kidney stones

A
  • urosepsis (fever, tachycardia)
  • anuria
  • AKI
  • refractory pain
  • > 10mm stone
  • stones that don’t pass in 4-5 wks
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73
Q

Indications for surgery in extremity trauma

A

Hemodynamic instability or:

  • observed pulsatile bleeding
  • presence of bruit/thrill over injury
  • expanding hematoma
  • signs of distal ischemia (absent pulses, cool extremities)
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74
Q

Flail chest

A

Pathophys:
-/>3 contiguous ribs fractured in />2 locations –> flail chest segment

Findings:

  • paraxodical chest wall motion w/ respiration
  • chest pain, tachypnea, rapid shallow breaths
  • CXR: rib fractures +/- contusion/hemothorax

Management:

  • pain control, supplemental O2
  • PPV (+/- chest tube) if resp failure
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75
Q

Wound botulism

A

C. botulinum spores contaminate puncture injury and generate neurotoxin in vivo

Symmetric, descending neurological deficits, resp compromise, and autonomic dysfunction

Fever and leukocytosis may be present

Urgent treatment w/ equine botulinum antitoxin

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76
Q

Achalasia vs EoE

A

Achalasia: progressive, solids and liquids
EoE: intermittent, solids

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77
Q

Pharmacotherapy for DVT

A

unfractionated heparin followed by warfarin

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78
Q

Management of superficial wound dehiscence

A

If no induration, erythema, or purulent discharge, can be managed w/ regular dressing changes

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79
Q

Management of deep wound dehiscence

A

Involvement of fascia

Surgical emergency

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80
Q

Acute epididymitis

A

<35: STD (chlamydia, gonorrhea)
>35: bladder outlet obstruction (coliform bacteria)

  • unilateral, posterior testicular pain
  • epididymal edema
  • pain improved w/ testicular elevation
  • dysuria, frequency (w/ coliform bacteria)

Tx: ceftriaxone + doxycycline OR levofloxacin
NSAIDs and testicular elevation help

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81
Q

Which disease increases risk of osteosarcoma?

A

Paget disease of bone

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82
Q

Persistent pneumothorax and significant air leak following chest tube placement in a patient who sustained blunt chest trauma

A

tracheobronchial rupture

Other findings:

  • pneumomediastinum
  • subcutaneous emphysema
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83
Q

Mediastinitis

A

Post-operative fever (w/in 14d), fever, tachycardia, chest pain, leukocytosis, sternal wound drainage or purulent discharge

CXR: widened medisatinum (more common in non-surgical mediastinitis)

Requires drainage, surgical debridement w/ immediate closure, and prolonged antibiotic therapy

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84
Q

Management of small pneumothorax

A

observation and supplemental O2

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85
Q

von Hippel-Lindau disease

A

autosomal dominant germline mutation of VHL tumor suppressor gene on chromosome 3

  • cerebellar and retinal hemangioblastomas
  • pheochromocytoma
  • renal cell carcinoma (clear cell subtype)
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86
Q

Valve replacement in aortic stenosis

A

Severe AS + at least 1 of:

  • onset of symptoms (syncope, angina)
  • LVEF <50%
  • undergoing other cardiac surgery

[Severe AS:

  • aortic jet velocity />4 m/s OR
  • mean transvalvular pressure gradient />40
  • valve area usually /< 1 cm^2 but not required]
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87
Q

Bug causing osetomyelitis from puncture wound

A

Pseudomonas aureuginosa (Staph aureus too)

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88
Q

ABG in atalectasis

A
  • hypoxemia
  • hypocapnia
  • respiratory alkalosis
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89
Q

Brown recluse spider bite

A

Small ulcer developing at site of recent bite w/ an erythematous halo and necrotic center which can progress to an eschar

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90
Q

Which nerve may be damaged in parotid surgery?

A

Facial nerve (causing facial droop)

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91
Q

Management of congenital umbilical hernia

A

Observation (most close spontaneously by 5 y.o.)

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92
Q

Whistling noise when breathing after rhinoplasty

A

Perforated septum likely resulting from a septal hematoma

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93
Q

Perforated viscus

A

Severe abdominal pain, fever, tachycardia, peritonitis (rigidity, reduced bowel sounds, bound tenderness)

Can occur in the setting of peptic ulcer disease, which is often associated w/ NSAID and alcohol use

Dx: xray of chest and abdomen – free intraperitoneal air under the diaphragm

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94
Q

Perianal abscess

A

d/t occlusion of an anal crypt gland –> bacterial infection

Tender, fluctuant, erythematous mass w/ fever and worsening pain

RF:

  • anal sex
  • chronic constipation
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95
Q

Ottawa ankle rules

A

Xray of ankle if:
Pain at malleolar zone AND
-tender at posterior margin/tip of medial malleolus OR
-tender at posterior margin/tip of lateral malleolus OR
-unable to bear weight 4 steps (2 on each foot)

Xray of foot if:
Pain at the midfoot zone AND
-tender at the navicular OR
-tender at the base of the 5th metatarsal OR
-unable to bear weight 4 steps (2 on each foot)

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96
Q

Well-circumscribed liver lesion w/ central scar

A

Focal nodular hyperplasia

Benign regenerative liver nodule common in women 20-50

Central stellate scar surrounding a large congenital arterial anomaly

Hyperdense on helical CT

No treatment needed

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97
Q

Acute mesenteric ischemia

A

Presentation:

  • rapid onset of periumbilical pain (often severe)
  • pain out of proportion to exam findings
  • hematochezia (late)

RFs:

  • atherosclerosis (acute on chronic)
  • embolic source (thrombi, vegetations)
  • hypercoagulable disorders

Labs:

  • leukocytosis
  • elevated amylase and phosphate levels
  • metabolic acisosis (elevated lactate)

Dx:

  • CT
  • mesenteric angiography if diagnosis unclear

Tx:
-open embolectomy w/ vascular bypass or endovascular thrombolysis

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98
Q

Blunt abdominal trauma patients who are stable but with high risk features

A

CT

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99
Q

Fat embolism

A

Triad: respiratory distress, eurologic dysfunction, petechial rash

In the setting of fracture of marrow-containing bone, orthopaedic surgery, or pancreatitis

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100
Q

Consequence of mucus plugging

A

Large-volume atelectasis

CXR: opacification of the affected lung area and mediastinal shift toward area of atelectasis

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101
Q

Rising thyroglobulin in patient w/ post-thyroidectomy for thyroid cancer

A

recurrence

Patients need to take levothyroxine for 2 reasons:

  1. replaces thyroid gland function
  2. suppresses pituitary TSH release. Since TSH stimulates thyroid tissue growth, levothyroxine supplementation to suppress TSH (by causing a mild hyperthyroid state) may prevent thyroid cancer recurrence
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102
Q

TB vs. aspiration pneumonia

A

Aspiration pneumonia: usually affects the LOWER lobes. Acute symptoms of foul-smelling sputum production, dyspnea, and fever

TB: UPPER lobes. Subacute/chronic cough and cavitary upper lobe lesion. Low grade fever, fatigue, mild cough (worst in morning); weight loss, chest pain, dyspnea later

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103
Q

First line treatment of osteoarthritis

A

Exercise and strength exercises

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104
Q

If penetrating abdominal trauma w/ peritonitis

A

ex lap (instead of imaging)

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105
Q

Local vascular complication of cardiac catheterization

A

Retroperitoneal hematoma

  • sudden hemodynamic instability
  • ipsilateral back or flank pain

Dx: non-con CT of abdomen and pelvis (or abd US)

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106
Q

Cardiac cath complications:

hematoma vs pseudoaneurism vs AV fistula

A

Hematoma:
+/- mass
-no bruit

Pseudoaneurysm:

  • bulging, pulsatile mass
  • systolic bruit

AV fistula:

  • no mass
  • continuous bruit
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107
Q

Sliding inguinal hernia

A

Posterior wall of sac is a retroperitoneal viscous (colon or bladder)

More common on the L (sigmoid colon less fixed and more likely to slide down)

Clue: thickened posterior wall of hernia sac at surgery

More associated with INDIRECT inguinal hernia that has descended into scrotum

Higher risk of colonic injury during repair

Do not completely excise hernia sac

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108
Q

Femoral hernias

A

Femoral hernias occur in the femoral canal, inferior to the inguinal ligament traversing the empty space medial to the femoral vein

Higher risk of strangulation, so surgical repair is indicated

F>M

Multigravida is risk factor

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109
Q

Most common type of hernia in both men and women

A

INDIRECT inguinal hernia

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110
Q

Richter hernia

A

Only one wall of bowel protrudes into the hernia sac

Can incarcerate w/o signs or sx or radiological evidence, of SBO so can easily think is not incarcerated

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111
Q

Initial management of SBO

A
  • NPO
  • aggressive fluid resuscitation
  • NG decompression
  • CT w/ oral contrast
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112
Q

Ischemic orchitis

A

Acute testicular pain; decreased or absent flow on Doppler

Secondary to thrombosis or damage to the pampiniform plexus

Likely to occur in pts w/ large or densely adhesed scrotal hernia sacs

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113
Q

Sensation to the scrotum and cremaster reflex

A

Genital branch of the genitofemoral nerve

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114
Q

Ischemic bowel

A

Clues include

  • acidosis
  • fever
  • leukocytosis
  • severe localized pain (unusual in usual SBO)

Can be d/t CLOSED LOOP SBO

Need ex lap

115
Q

Bloody nipple discharge

A

Intraductal papilloma

BENIGN breast tumor

Treatment is excision

116
Q

Palpable breast mass irrespective of mammography results

A

US-guided core needle biopsy

117
Q

If history consistent w/ fibrocystic breast changes

A

Reassurance and re-examination in 1 mo

118
Q

Therapy for triple negative breast cancer

A

Lumpectomy, sentinel node biopsy, breast irradiation, and chemotherapy

119
Q

Paget disease of the breast

A

Eczematous, scaly, ulcerating lesion around the areola

Type of DCIS

Often misdiagnosed as eczema or psoriasis

Diagnosed w/ biopsy

120
Q

Trastuzumab

A

mAb that blocks HER-2 receptors

SE: cardiomyopathy, so ECHO before starting

121
Q

Worst type of DCIS

A

comedo-type DCIS (cf cribriform)

122
Q

Treatment of DCIS

A

Lumpectomy w/ wide margins

123
Q

LCIS vs DCIS

A

LCIS is considered a marker for malignancy in either breast.

DCIS (comedo type and cribriform type) has a high likelihood of turning into carcinoma, and thus lumpectomy is required w/ wide margins

124
Q

Elective surgery after MI?

A

Wait at least 4 weeks, though there is risk up to 6 months after.

Consider pre-operative stress test

Cardiac risk is high even in non-cardiac surgeries.

125
Q

Management of post-operative NSTEMI

A

Oxygen, morphine, beta-blocker, aspirin

Clopidogrel and heparin may also be given if the risk of bleeding is low

Consider stress test 4-6 wks later

NO PCI

126
Q

Most common cause of death up to 48h post-MI

A

ventricular arrhythmia

127
Q

Most accurate test to measure ejection fraction

A

MUGA scan (nuclear study)

128
Q

Worst type of aortic dissection

A

Stanford A: involves the ascending aorta and/or the aortic arch

Type B is more common and is descending

If involves the innominate artery, type A

129
Q

Managament of Stanford B aortic dissections

A

Medical management: BP control.

Unless evidence of malperfusion

130
Q

Management of right-sided MI

A

IV FLUIDS, since they are preload dependent

Avoid nitrates which further reduce preload

131
Q

Pre-operative pheochromocytoma management

A

Alpha-blockade (e.g., phenoxybenzamine) followed by beta-blockade

Patients are volume depleted d/t intense alpha-mediated vasoconstriction, so BP managed w/ alpha-blockers and then beta-blocker added to prevent reflex tachycardia

DO NOT begin w/ beta blockade or can precipitate a hypertensive crisis d/t unopposed alpha

132
Q

Open vs lap adrenalectomy for malignancy

A

OPEN (decreases risk of seeding; if benign, lap is preferred)

133
Q

Osteitis fibrosa cystica

A

skeletal disorder that results from a surplus of parathyroid hormone (PTH)

  • bone pain
  • bone fractures
  • skeletal deformities with bowing of the bones

Radiographs show thin bones, fractures, and cysts with a moth-eaten appearance

134
Q

First step if find adrenal mass incidentally

A

Biochemical workup for hormone excess (determine if tumor is functional or non-functional)

  • serum aldosterone
  • plasma renin activity
  • 24h urine for catecholamines, metanephrines, and cortisol
135
Q

Hypercalcemia

A

Bones, stones, groans, abdominal moans, psychiatric overtones

Causes:

  • prolonged immobilization
  • Paget disease
  • thiazide diuretics (increase renal Ca++ reabsorption)
136
Q

Glucagonoma

A
  • new-onset DM
  • diarrhea
  • necrolytic migratory erythema: annular, erythematous erosions with blisters over the lower abdomen
137
Q

Calcitonin as marker

A

medullary thyroid cancer

138
Q

Neurofibromatosis type 1

A
  • neurofibromas
  • cataracts
  • pheochromocytoma
139
Q

If multiple endocrine tumors, which comes out first?

A

Pheochromocytoma, since can cause issues during surgery for other endocrine tumors

140
Q

Paraganglioma

A

extra-adrenal pheochromocytoma

Most commonly found in the abdomen: organ of Zuckerkandl

More likely to be hereditary and malignant

Functional scan is best to diagnose metastatic disease, esp. when CT/MRI is negative

141
Q

If suspect neck hematoma

A

Immediately open neck wound at bedside and then take emergently to OR

142
Q

Superior laryngeal nerve injury

A

trouble hitting high notes when singing

The external branch of the superior laryngeal nerve permits singing in high pitch

adjacent to sup. thyroid artery

143
Q

Intraoperatively assess success in parathyroid resection

A

Intraoperative PTH level

Short half life

144
Q

Otomycosis

A

Aspergillus niger

Ear pain, headache, intense fullness in ear and pruritis (severe: blindness, seizures, coma)

PE: exudate from affected ear, NORMAL TM

RFs:

  • AML
  • DKA
145
Q

If metastatic lymph node on FNA

A

CT to find primary

If negative –> panendoscopy (triple endoscopy) w/ random biopsies

  • laryngoscopy
  • EGD
  • bronchoscopy
146
Q

Mastoiditis

A

Most commonly days to weeks after acute otitis media

Fevers, red swollen tender area behind ear; displaced ear on PE

Dx: CT

Tx: Mastoidectomy w/ insertion of tympanostomy tubes

147
Q

Laryngeal papillomas/recurrent respiratory papillomatosis

A

d/t HPV 6 and 11

Benign papillary tumors of the larynx –> hoarseness

Rarely gives rise to laryngeal carcinoma

Tx: Laser fulguration

148
Q

Diagnostic test for suspicion of Plummer-Vinson syndrome

A

Barium esophagram

149
Q

Direct vs indirect laryngoscopy

A

Indirect: in the office, has a mirror to visualize structures
Direct: in the OR

150
Q

Nutrition for severe pancreatitis

A

Enteral (NJ tube)

151
Q

Remove gallbladder for polyp?

A

Depends on size. Take out if >10 mm

152
Q

Obstructive jaundice

A

Elevated serum conjugated bilirubin (d/t inability of GI system to get rid of it)

Also elevated in the urine (tea-colored)

153
Q

Treatment of isolated gastric varices

A

Splenectomy, since they typically arise in association with splenic vein thrombosis (most common cause: pancreatitis)

154
Q

If suspect ischemic colitis

A

Flexible sigmoidoscopy

155
Q

If a child is positive for APC gene

A

Colonoscopy starting at age 10

Once a polyp is seen: colectomy

156
Q

Screening colonoscopy in UC

A

Annually starting 8 yrs after diagnosis with random biopsy

157
Q

Follow up for uncomplicated diverticulitis

A

Colonoscopy to rule out cancer (CT can’t distinguish diverticulitis from colon cancer)

158
Q

If find carcinoid tumor in appendix

A

R hemicolectomy

159
Q

What can falsely elevate CEA levels?

A

Smoking

160
Q

If colonoscopy can’t identify bleeding source for LGIB

A

RBC scintigraphy

161
Q

Bugs associated w/ colon cancer

A
  • streptococcus bovis

- clostridia septicum

162
Q

Most common primary malignant brain tumor

A

Glioblastoma multiforme (type IV astrocytoma)

163
Q

Central cord syndrome

A

Bilateral hand weakness and loss of sensation. LEs are spared.

From hyperxtension (or hyperflexion) of the cervical spine

164
Q

Decrease ICP

A

Hypertonic (3%) saline

Draws fluid out of tissues and into the blood

165
Q

If HIV patient w/ CD4 50-100 w/ ring-enhancing lesion on CT

A

Treat for toxoplasmosis w/ pyrimethamine and sulfadiazine. If symptoms don’t resolve, brain biopsy for CNA lymphoma

166
Q

Epidural abscess

A

Triad

  • focal back pain (or HA if intracranial)
  • abnormal inflammatory parameters (fever, leukocytosis, ESR)
  • neurologic deficits

MRI

Long-term IV abx and surgical drainage

167
Q

SCFE physical exam finding

A

Trendelenburg sign shift of the torso over the
affected hip due to gluteus muscle weakness (weakness in hip abduction). In addition, physical exam may reveal that the patient’s gait is altered with the patient taking a short step on the affected side to minimize weight bearing due to pain. The anterior hip may
be tender to palpation

168
Q

Is the palmar surface affected in carpal tunnel syndrome?

A

NO: The median nerve controls sensation to the thumb, index, middle, and half of the ring finger. Palmar sensation is not affected by carpal tunnel syndrome (C) because the superficial palmar
cutaneous branch of the median nerve passes superficially to the carpal tunnel.

169
Q

Ewing sarcoma on xray

A

onion peel

170
Q

Most immediate concern in gastroschisis

A

Dehydration–cover defect with moist gauze and begin fluid resuscitation

171
Q

Imaging finding suggestive of necrotizing enterocolitis

A

Pneumatosis intestinalis (gas in walls of the intestine)

172
Q

Mohs surgery is best for

A

BCC and SCC of face

NOT for melanoma

173
Q

Which type of melanoma has worst prognosis

A

Nodular

Uniformly dark blue or black “berry-like”

Ulceration is common, portending an even worse prognosis

174
Q

If combo of DVT + stroke, think

A

paradoxical embolism (clot from venous system enters systemic as opposed to pulmonary circulation)

Intracardiac shunt (PFO or ASD) most likely

Check w/ bubble study

175
Q

Limitation of FAST exam

A

Retroperitoneal bleed

176
Q

If major pancreatic injury w/ duct leak

A

Ex lap

177
Q

Most common bug to infect burn patients

A

Pseudomonas aeruginosa

178
Q

Management of duodenal injury

A

Duodenal hematoma w/o contrast extravasation: observation

Contrast extravasation: ex lap

179
Q

If priapism in trauma

A

neurogenic shock from acute spinal cord injury (d/t onopposed parasympathetic tone)

180
Q

If UGI bleed AND obstructive jaundice

A

ampullary cancer

181
Q

If endoscopy can’t control bleeding ulcer

A

surgery

182
Q

Imaging for suspected nephrolithiasis

A

KUB and non-contrast CT abdomen/pelvis

Contrast may interfere w/ visualization of stone

183
Q

If penile fracture

A

urgent surgical repair

184
Q

Sudden-onset of R-sided varicocele

A

Suspect renal cell carcinoma that has occluded the IVC

185
Q

Managament of testicular torsion

A

BILATERAL orchiopexy

186
Q

Leydig cell tumors

A

Benign

Androgen-producing

Precocious puberty

Reinke crystals

187
Q

Diagnosis of peripheral arterial disease

A

ABI < 0.9

188
Q

AAA screening recs

A

One time screen for MEN >65 who have ever smoked

189
Q

CEA indication

A

symptomatic high (70–99%)-grade ICA stenosis OR asymptomatic with >60% stenosis

Symptoms include ipsilateral arm/leg weakness or contralateral amaurosis fugax

190
Q

CEA for 100% stenosis?

A

Since strokes from ICA stenosis are characteristically embolic, once the artery completely occludes (B), there is no longer any embolic risk and thus no benefit from CEA

191
Q

Common peroneal nerve injury

A

foot drop (difficulty dorsiflexing the foot against resistance or gravity) along with numbness of the dorsum of the foot

192
Q

Antihypertensive to use in stroke if needed

A

(only if ischemic and >220/120)

Labetalol

Nitroglycerine and nitroprusside should be avoided d/t vasodilation –> increased ICP

193
Q

Prevent cerebral vasospasm post hemorrhage

A

Nimodipine

194
Q

Buerger disease (thromboangiitis obliterans)

A

A non-atherosclerotic vascular occlusive disease seen in young (<40), mostly male smokers. It predominantly involves the arteries in the leg below the knee (popliteal and tibial arteries). It also causes venous thrombosis.

The only effective treatment is smoking cessation.

It is associated with high rates of amputation, especially if the patient continues smoking.

195
Q

Subclavian steal syndrome

A

due to an atherosclerotic stenosis or occlusion of the subclavian artery, most commonly on the left side.

This leads to claudication symptoms of
the affected arm and can be detected on physical examination based on diminished pulses, a significant (>20 mmHg) difference in arm blood pressure (C), and often a bruit above the clavicle. In addition, as the patient exercises, the arteries in the affected arm dilate, lowering resistance, so as to receive more blood.

Since the occluded subclavian artery cannot increase blood flow, blood instead travels in a reverse
fashion down the vertebral artery (the first branch off the subclavian) down to the arm, essentially stealing blood from the posterior circulation (A), leading to simultaneous symptoms of dizziness and vertigo.

196
Q

hidradinitis suppurativa

A

inflammation of the APOCRINE glands

197
Q

Acidosis w/ pancreatic drain

A

Drainage of pancreatic fluid can cause (non-AG) metabolic acidosis from loss of bicarb

198
Q

Treatment of bilateral adrenal hyperplasia

A

Aldosterone antagonists (e.g., spironolactone)

199
Q

Best measure of adequate resuscitation

A

Urine output

200
Q

Consideration for large volume transfusions

A

If only transfuse RBCs, quantity of platelets is decreased, which causes bleeding

Need 1:1:1 ratio of RBCs:plts:plasma

In general, after 4th RBC transfusion, give platelets

201
Q

Type of shock with high PCWP

A

cardiogenic

202
Q

Consideration for surgery in patients on chronic steroids

A

May need stress dose

Watch for adrenal insufficiency (low BP)

203
Q

Most important PFT value in consideration of pneumonectomy

A

FEV1

204
Q

Best screen for cervical trauma

A

lateral x-ray

205
Q

If dilated colon in young patient

A

Consider toxic megacolon from IBD (UC)

206
Q

Need imaging for appendicitis?

A

No, diagnosis is clinical…

207
Q

If positive margins

A

re-excision

208
Q

Hypovomenic shock parameters

A

Cardiac index: low
Mean pulmonary arterial pressure: low
PCWP: low
SVR: HIGH

209
Q

Dialysis before surgery?

A

For patients w/ chronic renal failure (e.g., high BUN), YES b/c need to prevent coagulopathy of uremia which causes hemorrhage

210
Q

Most common cause of chylous (milky white) ascites

A

Lymphoma

211
Q

Hypercalcemia in lung cancer

A

Squamous cell carcinoma

d/t PTHrP

212
Q

Intubate under which GCS?

A

Under 8, intubate!

213
Q

Parkland formula

A

Volume or LR for burn victim = 4 mL x % of body burned x kg weight

214
Q

If patient wants to cancel operation right after narcotics are given, what do you do?

A

Cancel operation

215
Q

LAPAROSCOPY vs LAPAROTOMY

A

DO NOT CONFUSE THEM

216
Q

Low implantation of ureter

A

little girls (asymptomatic in boys)

Wet with urine all the time- urine drips into distal urethra/vagina from the low implanted ureter

Patient feels a normal need to void and voids normally at appropriiate times (urine deposited into bladder by normal ureter)

Tx: surgery

217
Q

Manage a chemical burn

A

WATER

218
Q

Cyanotic congenital heart diseases [w/ mnemonic]

A

1 finger. truncus arteriosus [1 vessel]
2 fingers. transposition of the great vessels [2 vessels]
3 fingers: tricuspid atresia [3 = tri]
4 fingers: tetralogy of Fallot [4 = tetra]
5 fingers: total anomalous pulmonary venous return [5 = 5 words]

219
Q

Ogilvie syndrome

A

Paralytic ileus of colon

Tx: fluid and electrolyte correction, colonoscopic decompression

220
Q

Jersey vs mallet finger

A

Jersey finger: sustained extension [think Jersey shore- flipping someone off]

Mallet finger: sustained flexion

Tx: splinting

221
Q

Immunizations post splenectomy

A
  • pneumococcus
  • H. influenzae
  • meningococcus
222
Q

Presentation and treatment of malignant hyperthermia

A

Presentation:

  • after anesthesia
  • T > 104
  • metabolic acidosis
  • hypercalcemia

Tx:

  • IV dantrolene
  • 100% O2
  • correct acidosis
  • cooling blankets
  • watch for myoglobinuria
223
Q

Parinaud syndrome (sunset eyes) due to

A

damage to pineal gland

224
Q

Dysphagia worse for liquids

A

Achalasia

225
Q

Treat trigger finger

A

Steroid injection

Surgery is last resort

226
Q

Treatment of Menière disease

A

diuretics

227
Q

Anterior vs posterior urethral injury tx

A

Ant: immediate surgical repair
Post: delayed repair in 6mo

228
Q

Hemothorax w/ excessive output from chest tube

A

Thoracotomy

Immediate output 1000-1500 mL or bleeding >200 mL/hr

229
Q

Superficial partial thickness burn management in children

A

Bismuth petroleum gauze or biosynthetic dressings such as Biobrane

230
Q

Best imaging for gallstone ileus

A

CT

231
Q

Should hot thyroid nodule be biopsied?

A

NO- rarely cancerous

Monitor clinically

232
Q

Cognitively impaired person doesn’t want curative surgery for pancreatic cancer but mother who is surrogate decision maker does. Whose decision rules?

A

Proxy since patient is cognitively impaired

233
Q

Seminoma treatment based on staging

A

I (confined to testicle): surveillance or radiation
IIA (retroperitoneal nodal involvement <2 cm): radiation therapy
IIB, III: chemotherapy

234
Q

If suspect ruptured AAA

A

emergent open repair

235
Q

No blood at urethral meatus but hematuria on Foley

A

Bladder injury (traumatic bladder rupture)

CT cystography

236
Q

Treat choledocholithiasis

A

ERCP

237
Q

Treatment of cecal volvulus

A

Hemicolectomy

238
Q

Treatment of sigmoid volvulus

A

Sigmoidoscopy w/ endoscopic decompression

239
Q

First line for UC

A

ASA compounds

240
Q

Most common paraneoplastic syndrome for lung adenocarcinoma

A

Hypertrophic pulmonary osteoarthropathy (HPOA)

Vascular and epithelial growth factors cause proliferation of tissues in the joints, bones, and digits —> DIGITAL CLUBBING

241
Q

DDH treatment

A

Pavlik harness (flexion-abduction orthosis)

242
Q

If suspect acute cholecystitis but US inconclusive

A

HIDA scan

243
Q

In addition to regular symptoms, what else is seen in post-op MI?

A

fever

244
Q

Most common cause of death in mitral stenosis

A

CHF

245
Q

If suspect C. diff

A

PCR or enzyme immunoassay

Culture does not distinguish between pathogenic strains that produce toxins A and B

246
Q

Most common cause of SBO in <18

A

Incarcerated hernia (most commonly inguinal)

247
Q

What types of tumors are Klinefelter syndrome patients at hight risk for?

A

Germ cell tumors

Especially extragonadal tumors in the mediastinum (mediastinal nonseminomatous germ cell tumors)

Also no-Hodgkin lymphoma and breast cancer

Also chronic bronchitis, bronchiectasis, emphysema, SLE

248
Q

SBO with peripheral eosinophilia

A

Consider parasite infection such as Ascaris lumbricoides (tx: mebendazole)

249
Q

Primary hyperaldosteronism metabolic derangements

A
  • hypokalemia
  • hypernatremia
  • metabolic alkalosis
250
Q

TIPS complication

A

Hepatic encephalopathy

251
Q

Who gets TURP?

A

Failed medical management of BPH

252
Q

If asymptomatic acute drop in sodium

A

Draw labs from the other arm; may be spuriously low d/t drawing blood from arm receiving hypotonic saline…

253
Q

Potential complications of hepatic adenoma

A
  • malignant transformation

- rupture [sudden-onset severe RUQ pain w/ s/sx of shock]

254
Q

Lemierre syndrome

A

Severe life-threatening infection that affects young immunocompetent patients

d/t Fusobacterium necrophorum (Gram negative anaerobic bacillus)

Begins w/ an infection, usually tonsillitis (or dental work or mastoiditis)

Internal jugular vein thrombosis and infection
Septic thromboemboli to organs like lungs (nodules on CXR)

255
Q

Cause and treatment of hypertension in polycystic kidney disease

A

Cyst expansion leading to localized renal ischemia and consequent increased renin release –> RAAS

This is best treated w/ an ACE inhibitor

256
Q

Management of linear skull fractures

A

OR only if open, otherwise fine to send home

257
Q

Management of subdural hematoma

A

If no meddling deviation: ICP monitoring, elevate head, hyperventilation, avoid fluid overload, mannitol or furosemide
If midline deviation: craniotomy

258
Q

Management of epidural hematoma

A

Craniotomy

259
Q

Timing for pulmonary contusion

A

Right away to 48h after chest trauma

White out of lungs on CXR

260
Q

If angulated fracture in children

A

Don’t worry too much because remodeling is more likely to occur

Worry about supracondylar fractures of the humerus and fractures of any bone that involve the growth plate

261
Q

Management of intertroahcanteric fractures

A

Open reduction and internal fixation

Post-op anticoagulation

262
Q

Management of femoral neck fractures

A

Replace femoral head w/ prosthesis

263
Q

Management of femoral shaft fractures

A

Intramedullary rod fixation

264
Q

Signs of severe nutritional depletion

A
  • loss of 20% of body weight over a couple of months
  • serum albumin <3
  • anergy to skin antigens
  • serum transferrin <200

As few as 4-5d of preoperative nutritional support (preferably via the gut) can make a big difference, and 7-10d is optimal if surgery can be deferred that long

265
Q

Vascular ring

A

Congenital anomaly in which the trachea and esophagus are encircled by abnormal blood vessels

Extrinsic compression demonstrated by barium swallow and bronchoscopy

Surgery

266
Q

Operability of lung cancer

A

FEV1 > 800

Need to determine fraction from each lung

If <800, not a surgical candidate

267
Q

Management of extremity arterial embolization from distant source

A

Incomplete –> clot busters

Complete –> embolectomy w/ Fogarty catheter + fasciotomy if several hours have passed before revascularization

268
Q

Diagnosis of aortic dissection

A

MRI angiogram > CT angiogram, esp. if pt has renal dysfunction

269
Q

Cavernous sinus thrombosis

A

Diplopia, facial pain, high fever

MRI

Agressive IV antibiotics for 3-4 wks

270
Q

Overactive cremasteric muscle

A

A testicle in the canal at birth that can be easily pulled down but then snaps back up

BENIGN

271
Q

Abdominal mass in baby that moves up and down w/ respiration

A

Malignant liver tumor (hepatoblastoma or HCC)

Elevated AFP

272
Q

Genu valgus

A

Knock-knee

NORMAL between 4 and 8

273
Q

Genu varum

A

Bowlegs

NORMAL up to age 3

Persistent after 3y.o. usually Blount disease, for which surgery can be done

274
Q

If fracture from something very minor

A

think metastatic osteolytic cancer

275
Q

In a car crash where knees hit the dashboard, consider

A

Posterior dislocation of the hip

Emergency reduction

276
Q

Hepatic risk for operation

A
  • encephalopathy
  • huge ascites
  • albumin <2
  • INR twice normal
  • bilirubin >4
277
Q

Wound dehiscence buzzword

A

Pink salmon-colored fluid

Wound intact

Tape the wound securely while prepare to re-operate to prevent eviscaeration or hernia

278
Q

Diagnosis of mets in breast cancer w/ back pain

A

MRI

279
Q

Management of patent ductus arteriosus

A

Indomethacin

If in CHF: surgery

280
Q

Most common intervention for ureteral stones

A

Extracorporeal shock-wave lithotripsy

281
Q

Treat shock from epidural placed too high

A

VASOMOTOR SHOCK, so vasopressors and fluid

282
Q

If bitten by wild animal

A

Kill animal and examine brain for rabies

Otherwise, prophylaxis (Ig + vaccine)

283
Q

First step in workup of PAD

A

Doppler (ABI)

surgery (2 decks)

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