General Surgery

Question 1

Define the acute abdomen.

What physical examination signs suggest its presence?

Answer 1

Acute abdomen = an inflamed peritoneum (peritonitis), usually exhibited by rebound tenderness and involuntary guarding (uncontrolled muscle spasms)

Question 2

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

Answer 2

use minimal as needed pain medications (to avoid masking symptoms before you have a diagnosis), perform serial abdominal examinations, and consider a CT scan.

If the patient becomes unstable, proceed to laparoscopy and/or laparotomy.

Question 3

Name 3 causes of peritonitis that do not require laparotomy or laparoscopy.

Answer 3

Pancreatitis

many cases of diverticulitis

spontaneous bacterial peritonitis.

Question 4

Specify which conditions are associated with pain and peritonitis in the:

URQ

ULQ

LRQ

LLQ

Epigastric area

Answer 4

Question 5

What are the classic symptoms and signs of gallstone disease?

What are some physical findings to look for?

Answer 5

postprandial, colicky RUQ pain (usually 15-60 min after a fatty meal)

bloating

+/- N/V

Look for Murphy sign (palpation of the RUQ under the rib cage causes inspiratory arrest as a result of pain)

Question 6

What are the six Fs of cholecystitis?

How are the demographics of patients with pigment stones different from those with cholesterol stones?

Answer 6

fat, forty, fertile, female, and flatulent

the sixth F is febrile (indicates that patients has developed acute cholecystitis)

pigment (i.e., calcium bilirubinate) stones are classically young patients with hemolytic anemia (e.g., sickle cell disease, hereditary spherocytosis).

Question 7

How is a clinical suspicion of cholecystitis confirmed and treated?

What are some confounders of the diagnostic tests?

Answer 7

US + Murphy’s sign (variant anatomy + significant obesity can create uncertainty)

Nuclear hepatobiliary scintigraphic study (e.g., hepato-iminodiacetic acid [HIDA] scan) clinches the diagnosis with nonvisualization of the gallbladder

Treatment: pain control + cholecystectomy (antibiotics indicated if infection is suspected)

Question 8

Define cholangitis and cholecystitis.

How does one differ from the other in terms of cause + presentation?

How is it treated?

Answer 8

Cholangitis - inflammation of the bile ducts; usually caused by biliary obstruction with subsequent bile stasis and infection. Managed with biliary stent placement for unresectable cases. Causes of obstruction include:

• Choledocholithiasis
• malignancy
• Autoimmune cholangitis (e.g., sclerosing cholangitis)
• primary infection (e.g., Clonorchis sinensis) are other causes.

Cholecystitis - inflammation of the gallbladder; usually caused by gall stones; presents with Charcot triad: (1) RUQ pain, (2) fever or rigors, and (3) jaundice. Managed with cholecystectomy

Question 9

Describe the classic presentation of appendicitis.

How is it diagnosed and treated?

Answer 9

presents in 10-30 yo with a history of crampy, poorly localized periumbilical pain followed by N/V. Pain localizes to the RLQ with peritoneal signs and worsening of N/V

Look for:

• Rovsing sign: when a different quadrant is palpated and then quickly release, patient feels pain at McBurney point (2/3 of the way from the umbilicus to the ASIS).
• McBurney point: area of maximal tenderness in the RLQ and the site where an open appendectomy incision is made.

CT is increasingly used to confirm the diagnosis before surgery in stable patients

Question 10

What is the cause of LLQ pain and fever in a patient older than 50 years until proved otherwise?

How is it treated?

Answer 10

Diverticulitis

treat with broad-spectrum antibiotics (e.g., ciprofloxacin plus metronidazole), NPO, and a NGT if N/V are present.

Question 11

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?

Answer 11

should: CT

should not: colonoscopy (due to increased risk of colon rupture), barium enema

Question 12

Describe the typical history, physical examination, and laboratory findings of pancreatitis.

How is it treated?

What 2 complications should you be concerned about?

Answer 12

• epigastric pain that radiates to the back in an alcohol abuser or a patient with a history (or risk factors) of gallstones.
• elevated serum amylase and/or lipase
• decreased bowel sounds, localized ileus (“sentinel” loop of bowel on abdominal radiograph) and nausea, vomiting, and/or anorexia

Treatment: supportive: pain control (hydromorphone or fentanyl), NPO, NGT if N/V present, IVF

Complications: pseudocyst and pancreatic abscess

Question 13

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

Answer 13

look for a history of peptic ulcer disease

diagnosis: KUB, may cause increased amylase and lipase.

treat with surgery

Question 14

What are the hallmarks of small bowel obstruction?

How is it diagnosed and treated?

Answer 14

hallmarks: bilious vomiting (early symptom), abdominal distention, constipation, hyperactive bowel sounds (high-pitched, rushing sounds), and usually poorly localized abdominal pain, history of abdominal surgery
diagnosis: multiple air-fluid levels on Xray, CT scan to confirm if diagnosis is uncertain
treatment: ex-lap

Question 15

What are the common causes of a small bowel obstruction?

Answer 15

adhesions secondary to prior surgery

Crohns

incarcerated hernia

Meckels diverticulum

intussusception

Question 16

Describe the signs and symptoms of large bowel obstruction.

What are the top 4 causes? How is it treated?

Answer 16

gradually increasing abdominal pain, abdominal distention, constipation, and feculent vomiting (late symptom).

causes: diverticulitis, colon cancer, volvulus, Hirschsprung
treatment: NPO, NGT for N/V, endoscope decompression if it is a sigmoid vovulus, surgery to relief the decompression if it is refractory

Question 17

List and differentiate the three common types of groin hernias.

Of the three, which one is the most susceptible to incarceration and strangulation?

Answer 17

3 = most susceptibe to incarceration and strangulation; all treated with elective surgical repair if symptomatic

1. Indirect hernias - most common in both sexes and all age groups; (+) hernia sac travels through the inner + outer inguinal rings (protrusion begins lateral to the inferior epigastric vessels) and into the scrotum or labia because of a patent processus vaginalis (congenital defect).
2. Direct hernias (ø sac) - protrude medial to the inferior epigastric vessels because of weakness in the abdominal musculature of Hesselbach’s triangle.
3. Femoral hernias - common in women; (no sac) goes through the femoral ring onto the anterior thigh (located below the inguinal ring).

Question 18

Define incarcerated and strangulated hernias.

Answer 18

Incarceration - herniated organ is trapped and becomes swollen and edematous; most common cause of SBO

• Treatment: prompt surgery

Strangulation - occurs after incarceration when the entrapment becomes so severe that the blood supply is cut off; can lead to necrosis. Patients may come to the hospital with symptoms of SBO and shock.

• Treatment: prompt surgery

Question 19

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

Answer 19

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

Question 20

What is the best test for preoperative evaluation of pulmonary function?

Answer 20

Spirometry - gives FVC, FEV, and maximal voluntary ventilation.

A good history (e.g., activity level, exercise tolerance) is also useful.

Question 21

What 3 measures help prevent intraoperative and postoperative DVTs and PEs?

Answer 21

Compressive/elastic stockings

early ambulation

low-dose heparins (unfractionated or low molecular weight)

Question 22

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

What are 3 ways that you can prevent and treat this?

Answer 22

Atelectasis - prevent and treat with early ambulation, incentive spirometry, and proper pain control. Too much pain and too many narcotics (both can decrease respiratory effort) increase the risk of atelectasis.

Question 23

What are the other common causes of postoperative fever?

What should you think about if the patient has daily fever spikes that do not respond to antibiotics? What should you do in this case?

Answer 23

five Ws—water, wind, walk, wound, and weird drugs

• water = urinary tract infection
• wind = atelectasis and pneumonia
• walk = DVT
• wound = surgical wound infection
• weird drugs for drug fever.

In patients with daily fever spikes that do not respond to antibiotics, think about an intraabdominal abscess -> CT scan to locate the abscess, and then drain it if present.

Question 24

Define fascial or wound dehiscence. When does it usually occur?

How do you recognize and treat it?

Answer 24

occurs when the surgical wound opens spontaneously, usually 5 to 10 days post-op.

Look for: leakage of serosanguineous fluid from the wound, particularly after the patient coughs or strains.

Treatment: immediate surgical reclosure of the wound and treatment of infection

Question 25

Explain the ABCDEs of trauma. How are they used?

Answer 25

1. Airway 2. Breathing 3. Circulation 4. Disability 5. Exposure They are the keys to the initial management of trauma patients. Follow them in order if simultaneous management is not possible. For example, if a patient is bleeding to death and has a blocked airway, address airway management first.

Question 26

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

Answer 26

**_Airway_** ***-*** *provision, protection, and maintenance of an adequate airway at all times*. If the patient can speak, the airway is fine. You can use an oropharyngeal airway in uncomplicated cases and give supplemental oxygen. When you are in doubt or the patient's airway is blocked, intubate. If intubation fails, do a cricothyroidotomy. **_Breathing_ -** similar to airway, but even patients with an open airway may not be *breathing spontaneously*. The end result is the same. When you are in doubt or the patient is not breathing, intubate. If intubation fails, do a cricothyroidotomy.

Question 27

Explain circulation, disability, and exposure.

Answer 27

1. **Circulation *-*** *circulating blood volume*. Start two large-bore IV lines and give a bolus of 10 to 20 mL/kg (roughly 1 L) of LR or NS. Then reas- sess the patient after the bolus for improvement. Repeat the bolus, if needed. 1. If patient seems hypovolemic (tachycardic, bleeding, weak pulse, pale, diaphoretic, capillary refill \> 2 seconds), give IV fluids and/or blood products. 2. **Disability -** *need to check neurologic function* via Glasgow coma scale assessment 3. **Exposure** - remove all of the patient's clothes and “put a finger in every orifice” so that you do not miss any occult injuries.

Question 28

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

Answer 28

Cervical spine, chest, and pelvic radiographs.

Question 29

What is the imaging study of choice for head trauma?

Answer 29

Noncontrast CT (better than MRI for acute trauma)

Question 30

How do you manage a patient with blunt abdominal trauma?

Answer 30

If the patient is awake and stable and exam is “benign” * observe patient and repeat abdominal exam later * can do a FAST scan to check for free fluid in the abdomen and pelvis * If (+) FAST scan (i.e., there is free fluid, presumably blood, in the abdomen) -\> ex-lap * perform a CT scan of the abdomen and pelvis with PO and IV contrast If the patient is hemodynamically unstable (hypotension and/or shock that does not respond to fluid challenge) * proceed directly to ex lap

Question 31

How is penetrating abdominal trauma managed?

Answer 31

In patients with penetrating abdominal trauma (e.g., gunshot, stab wound), the type of injury and the initial findings determine the course of action. * Gunshot wound that may have violated the peritoneal cavity -\> ex lap * stab wound: either proceed directly to ex lap (if patient is unstable) or perform a CT scan (if patient is stable). * If nonoperative management -\> serial abdominal examinations.

Question 32

Which six thoracic injuries can be rapidly fatal?

Answer 32

1. Airway obstruction 2. Open pneumothorax 3. Tension pneumothorax 4. Cardiac tamponade 5. Massive hemothorax 6. Flail chest You may be asked to recognize and/or treat any of these six conditions on the USMLE.

Question 33

How do you recognize and treat airway obstruction?

Answer 33

* no audible breath sounds * cannot answer questions even if awake * may be gurgling treatment: intubation, cricothyroidotomy or tracheostomy if intubation fails

Question 34

How do you recognize and treat an open pneumothorax?

Answer 34

* open defect in the chest wall * decreased or absent breath sounds on the **affected** side, resulting in poor ventilation and oxygenation. Treatment * intubation with positive-pressure ventilation * closure of the defect in the chest wall using gauze and tape on three sides only; allows excessive pressure to escape so that you do not convert an open pneumothorax into a tension pneumothorax

Question 35

How do you recognize and treat a tension pneumothorax?

Answer 35

* usually after blunt or penetrating trauma to the chest; results in air forced into the pleural space cannot escape, which collapses the **affected** lung and then shifts the mediastinum and trachea to the opposite side of the chest * absent breath sounds on the affected side * hypertympanic percussion sound * Hypotension and/or distended neck veins may result from impaired cardiac filling Treatment: needle thoracentesis, followed by insertion of a chest tube.

Question 36

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

Answer 36

* classically associated with penetrating trauma to the **left** side of the chest * hypotension (caused by impaired cardiac filling) * distended neck veins * muffled heart sounds * **pulsus paradoxus** (exaggerated fall in blood pressure on inspiration) * **normal** breath sounds Treatment: depends on stability of patient * If unstable, treat with pericardiocentesis; put a catheter through the skin and into the pericardial sac and aspirate blood and fluid * If stable, do an ECHO to confirm the diagnosis

Question 37

Define massive hemothorax. How is it diagnosed and treated?

Answer 37

defined as a loss of **\> 1 L** of blood into the thoracic cavity, resulting in * decreased breath sounds in the affected area * dull note on percussion * hypotension * collapsed neck veins (from blood leaving the vascular tree) * tachycardia treatment: * chest tube to drain blood * IVF + blood BEFORE placing chest tube * CT to look for remaining blood or pathology * emergent thoracotomy if bleeding does not stop

Question 38

How do you recognize and treat flail chest?

Answer 38

* occurs when several ribs are broken in \>2 places, causing **paradoxical chest wall movements** during respiration (inward during inspiration, outward during expiration). * usually associated with a **pulmonary contusion**, which, combined with **pain**, may make respiration inadequate. * When you are in doubt or the patient is not doing well, **intubate** and give **positive pressure ventilation.**

Question 39

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

Answer 39

aortic rupture CXR shows widened mediastinum Order a CT scan or angiogram if a contained aortic rupture is suspected Treatment: immediate surgical repair

Question 40

How do patients with splenic rupture usually present? What is usually present in their history? Patients who will have to remove their spleens should receive which vaccinations?

Answer 40

hypotension, tachycardia, shock, and/or **Kehr sign** (referred pain in the left shoulder) history of blunt abdominal trauma, EBV infection/infectious mono, splenomeagly Make sure patients needing splenectomy have received vaccinations for encapsulated bacteria * pneumococcal * meningococcal * H. influenzae

Question 41

What clues suggest a diagnosis of diaphragmatic rupture? Which side is it more commen in? What are some physical findings of this? How is it treated?

Answer 41

usually occurs after blunt trauma usually **left** side (because the liver protects the right side of the diaphragm) may hear **bowel sounds** when listening to the chest or see bowel that has herniated into the thorax on CXR. Treatment: surgical repair of the diaphragm.

Question 42

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

Answer 42

* **Zone I -** base of the neck from sternal notch to inferior border of cricoid cartilage * **Zone II** - inferior border of cricoid cartilage to the angle of the mandible * **Zone III** - from angle of the mandible to the base of the skull Management * With zone I and III injuries, you generally should order an arteriogram before going to the OR. * With zone II injuries, proceed to the OR for exploration w/o an arteriogram. * In patients with obvious bleeding or a rapidly expanding hematoma in the neck, proceed directly to OR, no matter where the injury is.

Question 43

How should a choking victim be managed?

Answer 43

Always leave choking patients alone if they are speaking, coughing, or breathing. If they stop doing all of these, perform the Heimlich maneuver.

Question 44

What should you do if a tooth is knocked out?

Answer 44

Put the tooth back in place **WITHOUT 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.