Pistana's Surgery Notes Flashcards
(94 cards)
1
Q
What is the most common reason for esophageal perforation?
A
Instrumental perforation, usually after endoscopy
2
Q
Most common mechanical obstruction of the GI tract?
A
Adhesions, usually after a surgery
3
Q
What test can be used to dx appendicitis?
A
CT scan
4
Q
What is a common presentation of cancer of the right colon? Cancer of the left colon?
A
Right colon: anemia, left colon: bloody stools that are pencil thin
5
Q
Name malignant polyps of the colon
A
Villous, adenomatous and familial inflammatory
6
Q
Name benign polyps of the colon
A
Juvenile, Peutz Jeghers and hyperplastic
7
Q
What are anal fissures and what causes them
A
It is a tear in the mucosal lining below the pectinate line in the rectum, these are usually caused by passing thick, hard stools from a tight sphincter, these are extremely painful
8
Q
What is the treatment for anal fissures
A
Nitroglycerin, stool softners, local botulinum toxin injection, anything that can lower the tone of the sphincter would help in treating anal fissures
Nefidipine and local lidocaine
9
Q
If the mucosa of the GI tract fails to heal after surgery what should be suspected?
A
Crohns disease
10
Q
A patient present with blood per rectum, what tests should be done for the young and old?
A
For the young, upper GI endoscopy, for the old we should both upper and lower GI endoscopy
11
Q
Blood per rectum in a child? What test should be done?
A
Most probably from Meckel’s diverticulum, start with technetium scan
12
Q
What is the most common cause of perforated abdomen?
A
Perforated peptic ulcer
13
Q
Treatment of acute pancreatitis
A
NPO, NG tube suction and IV fluids
14
Q
What test do you use for ureter stones?
A
CT scan
15
Q
If there is obstructive jaundice suspected, what test should be done?
A
CT
16
Q
If nothing shows up on CT for obstructive jaundice, what is the next thing you want to do?
A
ERCP or MRCP
17
Q
What kind of skull fractures have to be treated in the OR?
A
Comminuted or depressed skull fractures, linear fractures are left alone
18
Q
Explain what is seen on CT for epidural hematoma and what is its treatment?
A
Emergent craniotomy is provides rapid relief, otherwise we have to monitor ICP, lens shaped blood collection is seen on CT
19
Q
Explain what is seen on CT for epidural hematoma and what is its treatment?
A
Emergent craniotomy provides rapid relief, otherwise we have to monitor ICP, semilunar/crecent shaped blood collection is seen on CT
20
Q
When do you do craniotomy for epidural and subdural hematoma?
What do you do otherwise?
A
Only when there is deviation of midline structures, otherwise we just monitor ICP.
21
Q
Explain comprehensive treatment of subdural hematoma
A
Patients are usually sicker - induce hyperventilation to reduce ICP, induce hyperthermia to reduce brain’s O2 demand, diurese the patient with mannitol.
22
Q
What imaging modality is used for spinal cord injuries?
A
MRI
23
Q
What produces anterior cord syndrome?
How is this different from rest of the spinal cord injuries?
A
Vertebral body burst fracture, there is loss of motor function as well in this type of injury as oppsed to posterior cord, Brown sequard and central cord injury (none of them has loss of motor function except for anterior cord syndrome)
24
Q
What is the cornerstone of treatment of rib fracture and how is it done?
A
Pain control, local nerve block and epidural catheter
25
How does pulmonary contusion usually present clinically?
Presents after trauma, it can happen either immediately after or within 48 hours of trauma, there is complete white out of the lungs on CXR
26
What is flail chest?
Happens after a major trauma, a portion of the chest wall bulge in during inspiration and bulge out during expiration
27
What is the treatment of flail chest and pulmonary contusion?
Treatment is monitoring blood gases, diuresis, fluid restriction and bilateral pulmonary respirator if needed
28
When there is pubic injury or uretheral injury, how does it usually present?
Blood at the meatus and scrotal hematoma
29
What is the next step in management for a pubic/uretheral injury?
Retrograde uretherogram
30
What are the 2 things that need to be done for a penetrating injury that does not injure a blood vessel?
Cleaning and debridment with tetanus prophylaxis
31
What does star field pattern on a brain MRI represent?
Fat emboli has reached to the brain
32
In what patients is nasotracheal tube intubation contraindicated?
Those that have sustained blunt trauma at the base of the skull/superior spine
33
Describe diffuse axonal injury on a CT scan
Blurring of the grey white junction and there are multiple small punctate hemorrhages
34
Describe management of gun shot wounds to the neck
Explorative surgery is mainstay of the treatment, if in the upper neck region arteriographic dx may be done first, if in the lower region of the neck, esophagoscopy would be done in addition to the above
35
What is the most common site of bleeding for hemothorax?
The lungs itself
36
When do you do surgery for hemothorax? What kind of surgery is it?
Only when there is > 1500ml of blood retrieved, video assisted thoracotomy
37
Where does traumatic injury of the aorta happens?
What kind of trauma causes this?
At the arch of the aorta and descending aorta, rapid deceleration
38
How is traumatic aortic injury dx?
Clinical suspicion, patient has experienced rapid deceleration and doing spiral CT (CT angio)
39
Stab wounds to the abdomen management?
Digital exploration (sticking a gloved finger in the wound) if the patient is stable, explorative laparotomy if unstable
40
What 3 places in the body can hide significant amount of blood to cause a shock?
Abdomen, pelvis and the thighs
41
Image of modality of abdomen trauma when the patient is stable?
CT
42
Image of modality of abdomen trauma when the patient is hemodynamically unstable?
FAST, Focussed Abdominal Sonogram for Truama, this can be done at the same time resuscitation efforts are under way
43
When do you have to absolutely stop surgery?
When the patient develops hypothermia and goes into acidosis
44
Abdominal compartment syndrome treatment?
Provide cover to the swollen organs, allow edema to resolve and then go back to put the abdominal contents back
45
Treatment of pelvic hematomas?
They are left alone if not bleeding
46
How is pelvic hemorrhages managed?
Cant access these blood vessels surgically so: (1) Immobilize the pelvis, (2) do a CT angio (3) let the IR embolize the specific bleeding artery
47
How are bladder injuries dx due to trauma?
Retrograde cystogram
48
Describe renal injuries due to trauma and what is a fascinating sequelae of these?
Usually due to rib fractures, rare but renal injuries may lead to the development of arteriovenous fistula which can lead to heart failure
49
Management of scrotal hematomas?
Left alone unless testes are ruptured which can be check by sonogram
50
What usually results due to a crushing injury to an extremity?
Myoglobinemia, myoglobinuria, hyperkalemia and later the patient may develop compartment syndrome
51
Where is pain illicited in hip pathology in children?
At the hip or knee
52
State and describe the 3 main hip pathologies
What imaging modalities should be done?
1. Developmental dysphasia of the hip
2. Legg-Claves-Perthes disease
3. Slipped capital femoral epiphysis
Developmental dysphasia of the hip is genetic, hip can pop out and can be put back in place (click and a pop sound), these children have uneven gluteal folds
Legg-Calves_Perthes is avascular necrosis of the hip joint, there is sudden development of limping, pain and decreased hip motion
Slipped capital femoral syndrome is an orthopedic emergency, usually happen in chunky boys that complain of groin pain and start limping. When hip is flexed their leg goes into external rotation.
For all of these, CT is diagnostic except for hip dysplasia since their bones are not calcified as of yet
53
What is the most common bone tumor
Osteogenic sarcoma, happens usually around the knee, has a sunburst pattern to it
54
What is the second most common bone tumor
Ewing sarcoma, grows from diaphysis of the long bone, it has onion skinning pattern on X ray
55
Describe shoulder dislocation
Anterior rotation is the most common, arm is kept close to the body and externally rotated like they are going to shake hands with someone, CXR is diagnostic/
Posterior dislocation is rare, the arm is internally rotated
56
Colle's fracture
Usually happens due to falling on an outstretched hand, deformed and painful wrist looks like a dinner fork, it is a fracture of the distal radius, treat by closed reduction and cast
57
Monteggia vs Galeazzi fracture
Monteggia involves fracture of the Ulna with proximal radial dislocation anteriorly
Galeazzi involves fracture of the Radius with distal radioulnar dislocation posteriorly
MUGR - mnemonic
58
Describe how the leg moves after a hip fracture
Affected leg is shortened and externally rotated
59
Femoral head fractures treatment?
Compromise blood flow by the lateral femoral circumflex artery, tx is femoral prosthesis for faster recovery
60
In what kind of injury does the patient complain of locking of knee and clicking sound when forcefully extended
Meniscal tears
61
When is the leg internally rotated and shortened?
When there is posterior dislocation of the hip, in this case emergency reduction is needed to avoid avascular necrosis of the femoral neck
Contract this with hip fracture where the leg is externally rotated
62
Explain trigger finger, De Quervain tenosynovitis, jersey finger, mallet finger, felon and Gamekeeper's thumb.
Trigger finger: Patients wake up at night with a finger flexed, has to extend it with other hand and there is a popping sound, steroids and anti inflammatory is tx
De Quervain tenosynovitis: there is pain on the radial side of the handhand is flexed and thumb extended (like holding a baby's head), fisting the thumb and then ulnar deviation produces the pain, splint and anti inflammatory may help
Jersey finger: flexed finger is extended abruptly (like when trying to grab a jersey), flexor tendon is broken so the finger doesn't flex
Mallet finger: extended finger is flexed, extensor tendon is broken so the DIP joint doesn't extend, usually from playing volleyball
Felon: painful abscess at the tip of the finger due to poor wound care
Gamekeeper's thumb: fracture of the ulnar collateral ligament of the thumb, treat with casting and anti inflammatory, if it doesnt heal it can lead to arthritis, usually from skiing injuries
63
Trigger finger
Trigger finger: Patients wake up at night with a finger flexed, has to extend it with other hand and there is a popping sound, steroids and anti inflammatory is tx
64
Jersey finger
Jersey finger: flexed finger is extended abruptly (like when trying to grab a jersey), flexor tendon is broken so the finger doesn't flex
65
Mallet finger
Mallet finger: extended finger is flexed, extensor tendon is broken so the DIP joint doesn't extend, usually from playing volleyball
66
De Quervain tenosynovitis
De Quervain tenosynovitis: there is pain on the radial side of the handhand is flexed and thumb extended (like holding a baby's head), fisting the thumb and then ulnar deviation produces the pain, splint and anti inflammatory may help
67
Felon
Felon: painful abscess at the tip of the finger due to poor wound care
68
Gamekeeper's thumb
Gamekeeper's thumb: fracture of the ulnar collateral ligament of the thumb, treat with casting and anti inflammatory, if it doesnt heal it can lead to arthritis, usually from skiing injuries
69
Most common place for lumbar disk herniation
L4 - L5 or L5 - S1
70
Cauda equina syndrome
Distended bladder, flaccid rectal sphincter and perineal saddle anesthesia, it is a surgical emergency requiring immediate decompression
71
Marjolin ulcer
Squamous cell carcinoma arises from the ulcer site, typically an ulcer that has been breaking down and healing for many years
72
What pathology is associated with wearing pointed shoes
Mortons neuroma, it is an inflammation of the common digital nerve, between third and forth toes, NSAIDs and better shoes are involved in tx
73
What is the most common cause of fever after surgery
Atelectasis
74
What is the tx of atelectasis
Bronchoscopy
75
If a patient has no urinary output 6 hours after surgery what should be down
A quick in and out catheter to empty the bladder
76
If a patient has no urinary output (to the bladder) after a significant period of time, what should be done
Zero urinary output with normal BP means either acute renal failure or dehydration, we can differentiate this by administering a bolus of fluid, if no urinary output increases then it probably is acute renal failure
77
What condition prolongs paralytic ileus?
Hypokalemia
78
What is ogilvie syndrome
Happens in the very elderly, usually demented patients, there is massive dilation of the colon, treatment is colonoscopy and then a rectal tube is put in place
79
What is wound dehiscence, how is it managed and what it may lead to?
Wound dehiscence usually happens after a laporotomy in which pink, salmon colored fluid fills the wound site (it is peritoneal fluid), wound has to be securely taped and the patient has to be immobilized and told to cough with care. The patient is taken back to OR for wound repair.
If wound dehiscence breaks, it leads to evisceration which is expulsion of abdominal contents out at the wound site
80
What do you give a patient who has developed metabolic alkalosis?
Abundant amount of KCl
81
What is the management of intestinal obstruction such as development of adhesions?
Conservative treatment first such as IV fluids, NG tube and NPO, if the situation doesn't resolve then the patient is taken for surgery
82
What is the difference between Mallory Weiss and Boerhaav syndrome
Same pathophysiology except the tear in boerhaav syndrome leads to esophageal perforation
83
What test is done for Boerhaav syndrome?
Contrast swallow (Gastrografin and then barium if the first is negative)
84
What are the two cancers of stomach that may present similarly and what are their treatments?
Gastric adenocarcinoma is treated with surgery, gastric lymphoma is treated with chemotherapy and radiation
85
What is the most common source of bleeding in the GI tract? Upper or lower?
Upper, from the tip of the nose to the ligament of treitz
86
How do you check for upper GI bleed?
Put in a NG tube, if blood is retrieved then the upper GI tract as the source of the bleed has been identified
87
Algorithm of isolating the source of bleeding when patient presents with blood per rectum?
1. First step is to identify if it is an upper GI or lower GI bleed, this can be done by passing the NG tube
2. If no blood is retrieved in NG tube then the source of bleeding is the lower GI tract
3. Exclude hemorrhoids as source of bleeding by physical
4. Active bleeding, if significant should be followed by an angiogram and then embolization of the bleeding source
5. if not significant amount of bleed, wait for the patient to stop and do conolonscopy
6. For in between do a tagged red blood cell study and then follow with angiogram (tagged red blood cell study shoes where the blood is pooling)
88
What is the most common reason of blood per rectum in a young child/infant
Meckel's diverticulum
89
Following gastroschisis surgery what kind of post op measures need to be taken in the baby?
TPN for 1 month since the bowel that has been placed back in the abdomen will not work immediately
90
What is the treatment for exstrophy of the bladder?
Immediate surgery, has to be within 1 or 2 days
91
What does double bubble sign and green vomiting signify in a baby?
Duodenal atresia, annular pancreas and malrotation of the gut
92
Management and signs of necrotizing enterocolitis
1. Feeding intolerance, abdominal distension, rapidly dropping platelets (sign of sepsis in babies)
2. Broad abx, IV fluids and TPN
3. If abdominal erythema and GI perforation signs are present, surgery has to be done
93
Management and signs of meconium ileus
1. Feeding intolerance and bilious vomiting
2. X ray shows ground glass appearence of abdomen, dilated bowels.
3. Gastrografin enema is diagnostic and therapeutic
94
Management and signs of meconium ileus
1. Seen in 6 to 12 month year olds, colicky pain is experienced
2. RLQ is empty and stool has a currant jelly appearence
3. Barium or air enema is dx and tx
