General Surgery Flashcards

1
Q

Define the acute abdomen. What physical exam signs suggest its presence?

A

Inflamed peritoneum (peritonitis), which is often due to a surgically correctable problem. Best physical exam confirmations are rebound tenderness (letting go quickly after deep palpation of abdomen causes acute pain) and involuntary guarding (abdominal wall muscle spasms that cannot be controlled). Voluntary guarding and tenderness to palpation are softer signs often present in benign diseases.

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2
Q

What should you do if you are not sure whether a stable patient has an acute abdomen?

A

Use minimal as needed pain medications (to avoid masking symptoms), perform serial abdominal exams, and consider CT scan.

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3
Q

Name a few causes of peritonitis that do not require laparotomy or laparoscopy.

A

Pancreatitis, many causes of diverticulitis, spontaneous bacterial peritonitis

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4
Q

Which condition is associated with pain and peritonitis in the upper right abdominal quadrant?

A

Gallbladder/biliary (cholecystitis, cholangitis) or liver (abscess)

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5
Q

Which condition is associated with pain and peritonitis in the upper left abdominal quadrant?

A

Spleen (rupture with blunt trauma)

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6
Q

Which condition is associated with pain and peritonitis in the lower right abdominal quadrant?

A

Appendix (appendicitis), pelvic inflammatory disease

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7
Q

Which condition is associated with pain and peritonitis in the lower left abdominal quadrant?

A

Sigmoid colon (diverticulitis), pelvic inflammatory disease

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8
Q

Which condition is associated with pain and peritonitis in the epigastric area?

A

Stomach (peptic ulcer) or pancreas (pancreatitis)

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9
Q

What are the classic symptoms and signs of gallstone disease?

A

Postprandial, colicky pain in the RUQ with bloating and/or nausea and vomiting. Pain usually begins 15-60 minutes after a meal (esp. fatty meal). Look for Murphy sign (palpation of RUQ under rib cage causes arrest of inspiration 2/2 pain) in cholecystitis.

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10
Q

What are the six Fs of cholecystitis? How are the demographics of patients with pigment stones different from those with cholesterol stones?

A

Fat, Forty, Fertile, Female, Flatulent, Feather
Pts with pigment (i.e. calcium bilirubinate) stones are classically young with hemolytic anemia (e.g. sickle cell disease, hereditary spherocytosis).

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11
Q

How is a clinical suspicion of cholecystitis confirmed and treated?

A

Ultrasound is the best first imaging study for gallbladder disease. May show gallstones, thin layer of fluid around gallbladder, and/or thickened gallbladder wall. Nuclear hepatobiliary scintigraphic study (e.g. hepato-iminodiacetic acid [HIDA] scan) clinches the diagnosis with nonvisualization of gallbladder. Tx is cholecystectomy.

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12
Q

Define cholangitis. How does it differ from cholecystitis?

A

Cholangitis is inflammation of the bile ducts, whereas cholecystitis is inflammation of the gallbladder. Cholangitis is classically due to biliary obstruction with subsequent bile stasis and infection. Autoimmune cholangitis (e.g. sclerosing cholangitis) and primary infection (e.g. Clonorchis sinensis) are other causes.

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13
Q

How does cholangitis classically present? How is it treated?

A

Charcot triad: (1) RUQ pain, (2) fever or shaking chills, and (3) jaundice
Tx: broad-spectrum antibiotics to cover bowel flora (e.g. piperacillin with tazobactam); then definitive management with cholecystectomy or biliary stent placement

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14
Q

Describe the classic presentation appendicitis. How is it treated?

A

10-30 year-old with a history of crampy, poorly localized periumbilical pain followed by nausea and vomiting. Then pain localizes to RLQ, and peritoneal signs develop with worsening nausea and vomiting. “Hamburger” sign - pt who is hungry and asking for food does NOT have appendicitis. Rovsing sign - palpate a different quadrant then release hand, pt feels pain at McBurney point.
Tx: appendectomy

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15
Q

What is the cause of left lower quadrant pain and fever in a patient over 50 years old until proven otherwise? How is it treated?

A

Diverticulitis. Treat medically with broad-spectrum antibiotics, avoidance of eating, and an NG tube if nausea and vomiting are present. For disease that recurs or is refractory to medical therapy, consider sigmoid colon resection.

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16
Q

What tests should and should not be done to confirm possible cases of diverticulitis? What test does every patient need after a treated episode of diverticulitis?

A

Colonoscopy should NOT be performed in the acute setting because colon rupture may occur. Barium enema is also avoided for the same reason. However, one of these tests should be done in every patient after tx to exclude colon CA. Order a CT scan, if necessary, to confirm the diagnosis.

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17
Q

Describe the typical history, physical exam, and lab findings of pancreatitis. How is it treated?

A

Epigastric pain that radiates to the back in an alcohol abuser or pt with history of gallstones. Serum amylase and/or lipase should be elevated. Also decreased bowel sounds, localized ileus (“sentinel” loop of bowel on abd radiograph) and nausea, vomiting, and/or anorexia.
Tx: SUPPORTIVE! Narcotics for pain control (meperidine favored over morphine b/c sphincter of Oddi spasm; fentanyl), NG tube for n/v, IV fluids

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18
Q

Describe the usual history of a perforated ulcer. How is it treated?

A

Usually no history of alcohol abuse or gallstones but history of peptic ulcer disease. Abdominal radiographs show free air under diaphragm. Perforated bowel can cause an increased amylase level! Treat surgically.

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19
Q

What are the hallmarks of small bowel obstruction? How is it treated?

A
Bilious vomiting (early symptom), abdominal distention, constipation, hyperactive bowel sounds (high-pitched, rushing sounds), and usually poorly localized abdominal pain. Radiographs show multiple air-fluid levels. Pts often have history of previous surgery.
Tx: withold food, place NG tube, give IV fluids. If obstruction does not resolve or peritoneal signs develop, laparotomy is usually needed.
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20
Q

What are the common causes of small bowel obstruction?

A

In adults, most common cause is adhesions (usually from prior surgery). Incarcerated hernias and Crohn’s disease are other common causes. Other causes include Meckel diverticulum and intussusception (both typically seen in children).

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21
Q

Describe the signs and symptoms of large bowel obstruction. What causes it? How is it treated?

A

Gradually increasing abdominal pain, distention, constipation, and feculent vomiting (late symptom). In older adults, most common causes are diverticulitis, colon CA, and volvulus. In children, watch for Hirschsprung disease.
Tx: withhold food and place NG tube for n/v. Sigmoid volvulus can often be decompressed with endoscope. Other refractory causes require surgery to relieve obstruction.

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22
Q

Describe an indirect hernia

A

Most common type in both sexes and all age groups. Hernia sac travels through inner and outer inguinal rings (protrusion begins lateral to inferior epigastric vessels) and into scrotum or labia because of patent processus vaginalis (congenital defect).

23
Q

Describe a direct hernia

A

No sac. Hernia protrudes medial to inferior epigastric vessels because of weakness in abdominal musculature of Hesselbach’s triangle.

24
Q

Describe a femoral hernia

A

More common in women. Hernia (no sac) goes through femoral ring onto anterior thigh (located below inguinal ring).

25
Q

Which type of hernia is most susceptible to incarceration and strangulation?

A

Femoral hernia

26
Q

Define incarcerated and strangulated hernias.

A

Incarcerated - herniated organ is trapped and becomes swollen and edematous; most common cause of small bowel obstruction in pts without history of previous abdominal surgery
Strangulated - occurs after incarceration when entrapment becomes so severe that blood supply is cut off; can lead to necrosis (can present with small bowel obstruction and shock) - surgical emergency

27
Q

True or false: Generally, patients should not eat or drink for 8 or more hours before surgery.

A

True. This reduces the chance of aspiration and subsequent pneumonia.

28
Q

What is the best test (other than a good history) for preoperative evaluation of pulmonary function?

A

Spirometry, which gives functional vital capacity, forced expiratory volumes, and maximal voluntary ventilation

29
Q

What measures help to prevent intraoperative and postoperative deep venous thrombosis and pulmonary embolus?

A

Compressive/elastic stockings, early ambulation, and/or low-dose heparins (unfractionated or low molecular weight)

30
Q

What is the most common cause of fever in the first 24 hrs after surgery?

A

Atelectasis. Prevent and treat with early ambulation, chest physiotherapy/percussion, incentive spirometry, and proper pain control. Both too much pain and too many narcotics (decrease respiratory effort) increase the risk.

31
Q

What are the other common causes of postoperative fever?

A
Water - UTI
Wind - atelectasis and pneumonia
Walk - DVT
Wound - surgical wound infection
Weird - drug fever
In pts with daily fever spikes that do not respond to antibiotics, think about an intraabdominal abscess
32
Q

Define fascial or wound dehiscence. How do you recognize it?

A

Occurs when the surgical wound opens spontaneously, usually 5-10 days postoperatively. Look for leakage of serosanguineous fluid from the wound, particularly after the pt coughs or strains. Frequently the wound is infected. Surgical reclosure of the wound and treatment of infection are required.

33
Q

Explain the ABCDEs of trauma. How are they used?

A

Airway, Breathing, Circulation, Disability, and Exposure

Keys to the initial management of trauma patients. Follow them in order if simultaneous management is not possible.

34
Q

What is the different between airway and breathing in trauma protocol?

A

Airway - provision, protection, and maintenance of an adequate airway at all times (may require intubation or cricothyroidotomy)
Breathing - similar to airway but even pts with an open airway may not be breathing spontaneously (may require intubation or cricothyroidotomy)

35
Q

Explain circulation, disability, and exposure in trauma protocol.

A

Circulation - circulating blood volume; if pt seems hypovolemic give IV fluids (lactated Ringers or NS) and/or blood products
Disability - neurologic function (Glasgow coma scale)
Exposure - expose and examine the entire body; remove all clothes and “put a finger in every orifice”

36
Q

What imaging films are routinely ordered for most patients with at least moderately severe trauma?

A

Cervical spine, chest, and pelvic radiographs

37
Q

What is the imaging study of choice for head trauma?

A

Noncontrast CT (better than MRI for acute trauma)

38
Q

How do you manage a patient with blunt abdominal trauma?

A

If awake, stable, and examination is “benign”, observe patient and repeat abdominal exam later. If patient is hemodynamically unstable, proceed directly to laparotomy

39
Q

How is penetrating abdominal trauma managed?

A

With any gunshot wound that may have violated the peritoneal cavity, proceed directly to laparotomy. Stab wounds management is controversial. Either proceed directly to laparotomy (esp. if unstable) or perform CT scan.

40
Q

Which six thoracic injuries can be rapidly fatal?

A
  1. Airway obstruction 2. Open pneumothorax 3. Tension pneumothorax 4. Cardiac tamponade 5. Massive hemothorax 6. Flail chest
41
Q

How do you recognize and treat airway obstruction?

A

No audible breath sounds, cannot answer questions even if awake, and may be gurgling. Treat with intubation. If this fails, do cricothyroidotomy (or a tracheostomy in OR if time allows).

42
Q

How do you recognize and treat an open pneumothorax?

A

Present with an open defect in the chest wall and decreased or absent breath sounds on the affected side. Causes poor ventilation and oxygenation. Treat with intubation, positive-pressure ventilation, and closure of the defect in the chest wall (gauze and tape it on 3 sides only - allows excessive pressure to escape so that you do not convert into a tension pneumothorax)

43
Q

How do you recognize and treat a tension pneumothorax?

A

May occur after blunt or penetrating trauma to the chest. Air forced into the pleural space cannot escape and collapses the affect lung, then shifts the mediastinum and trachea to the opposite side. Findings include absent breath sounds on affected side and a hypertympanic percussion sound. Hypotension and/or distended neck veins may result from impaired cardiac filling. Treat with needle thoracentesis, followed by chest tube insertion.

44
Q

Describe the usual presentation of cardiac tamponade. How is it diagnosed and treated?

A

Classically associated with penetrating trauma to the left chest. Presents with hypotension (2/2 impaired cardiac filling), distended neck veins, muffled heart sounds, pulsus paradoxus (exaggerated fall in BP on inspiration), and normal breath sounds. If pt is unstable, treat with pericardiocentesis. If pt is stable, do echocardiogram to confirm diagnosis.

45
Q

Define massive hemothorax. How is it diagnosed and treated?

A

Loss of more than 1 L of blood into the thoracic cavity. Pts have decreased (not absent) breath sounds in affected area, dull note on percussion, hypotension, collapsed neck veins (from blood leaving vascular tree), and tachycardia. Placement of chest tube allows blood to come out. Give IV fluids and/or blood before placing chest tube if diagnosis is known in advance. If bleeding stops after initial outflow, order CXR or CT to check for remaining blood or pathology. Treat supportively. If bleeding does not stop, do emergent thoracotomy.

46
Q

How do you recognize and treat flail chest?

A

Several adjacent ribs are broken in multiple places, causing affected part of chest wall to move paradoxically during respiration (inward during inspiration, outward during expiration). Almost all pts have associated pulmonary contusion, which, combined with pain, may make respiration inadequate. When you are in doubt or the pt is not doing well, intubate and give positive pressure ventilation.

47
Q

What is the most common cause of immediate death after an automobile accident or a fall from a great height?

A

Aortic rupture. Look for widened mediastinum on CXR and an appropriate history of trauma. Order CT scan or angiogram if a contained aortic rupture is suspected. Aortic laceration, traumatic aortic injury, and traumatic pseudoaneurysm all describe the phenomenon seen in initial survivors: an aortic rupture contained by a hematoma or an inadequate amount of surrounding tissue (e.g. adventitia only). Treat with immediate surgical repair.

48
Q

What is the most commonly injured organ in blunt trauma?

A

Spleen

49
Q

How does splenic rupture present?

A

History of blunt abdominal trauma, hypotension, tachycardia, shock, and/or Kehr sign (referred pain in left shoulder). Pts with EBV or infectious mononucleosis should avoid contact sports to prevent rupture. Make sure pts needing splenectomy have received the pneumococcal, meningococcal, and H. influenzae vaccines.

50
Q

What clues suggest a diagnosis of diaphragmatic rupture? How is it treated?

A

Diaphragm rupture usually occurs after blunt trauma and on the left side (liver protects the right side). May hear bowel sounds when listening to chest or see bowel that has herniated into chest on CXR. Treat with surgical repair.

51
Q

What are the 3 zones of the neck? How is trauma in each of the different zones managed?

A

Zone I - base of neck from 2 cm above clavicles to level of clavicles
Zone II - midcervical region from 2 cm above clavicle to angle of mandible
Zone III - top of neck from angle of mandible to base of skull
With zone I and III, order arteriogram before going to OR. With zone II, proceed to OR for surgical exploration. In pts with obvious bleeding or rapidly expanding hematoma in the neck, proceed directly to OR no matter where the injury is.

52
Q

How should a choking victim be managed?

A

Always leave them alone if they are speaking, coughing, or breathing. Otherwise, do Heimlich maneuver.

53
Q

What should you do if a tooth is knocked out?

A

Put the tooth back in place with no cleaning (or only saline to rinse it off) and stabilize the tooth in place. The sooner this is done, the better the prognosis for salvage of the tooth.