Flashcards in Surgery Deck (270):
T/F: Melanoma can be destructed by electrosurgical tech
What's Charcot triad?
Fever, jaundice, RUQ
MCC of cholangitis
Gallstone impacts bile duct => cholestasis + G-ve bacteria
Labs in cholangitis
Cystic duct obstruction by gall stone
RUQ + fever + N/V
+ Murphy sign (arrest of inspiration during palpation)
T/F: post CABG depression increases risk of subsequent cardiac disease
Would Rx post-CABG depression improves risk of subsequent events?
Just improve depressive Sx
Who is at haigher risk of post-CABG depression
Rapidly progressive / acute disease before surgery
What correlates best with pre-op risk of bleeding?
Hx of bleeding
Signs of cardiogenic shock
Low BP, urine, refill
High HR, CVP
Narrow pulse pressure
Is DVT prophylaxis recommended for hip surgery?
Nerve involved in thumb abduction + addiction
Abduction: interosseous of radial
Sx of carpal tunnel
Pain and numbness in dorsal thumb and index
What's relation b/w insulin + anti-hyperglycemic and dupuytren's contracture
Use of DM increase risk of contracture
Would steroid injections help dupuytren's contracture
Multiple injections needed to regress disease if mild-moderate
When is surgery indicated in dupuytren's contracture
Metacarpal joints contracture reaches 30 degrees
Associated with PIP joint at any degree
What levels of ALT indicates acute pancreatitis
3x normal limit
Local anesthetic lasts 2-4 hrs
Loading dose of unfractionated heparin
1. Bonus dose 80U/kg in 6hr
Rx of torsades de pointes
Drugs contraindicated in torsades de pointes
Tender breast lump
1st US = FNA
Post-op fever DDx
Wind 1, water 3, wound 5, walk 7
POD 1: atelectasis
POD 3: UTI
POD 5: wound infection
POD 7: DVT
How to reduce post-op resp complications
Steroids in COPD only
IE in IV drug users affects which valve
IE affects mitral mainly
But in IV users affects tricuspid.
Calcification in lung nodule
1. Central = tuberculoma / histoplastoma
2. Concentric = healed histoplasmosis
3. Popcorn = hamartoma.
Lung nodule > 1 cm
Tuberculin / histoplasmosis / coccidiomycosis
Rx infection or biopsy to r/o cancer?
Size > 1.5 cm
MCC of death in bariatric surgery?
PE > anastomatic leak
Maxillary fracture Sx
Rx of carotid stenosis?
> 70% endarterectomy
Rx of compression fracture
Vertebroplasty in 2 wks
No need for physical Rx
Female with RUQ mass
When is surgery indicated in hepatocellular carcinoma?
If lesion on surface of liver
Risk of bleeding + Ca transformation
Lisfranc fracture Sx
Hx of twist and fall
Can't bear weight
Mid-foot swelling + pain
+/- bruising on dorsum
Lisfranc vs middle cuneiform fracture
Cuneiform is due to direct blow to foot
Lisfranc due to twist injury
Rx anal fissure
2. Surgical (if medical failed)
Foot drop is sign of?
Peroneal nerve palsy
Marker for GI cancer?
Caecinoembryonic antigen CEA
CA 125: ovarian
CA 27-29: Breast
a-FP: hepatocellular carcinoma
MC site of venous ulcers
Origin of anorectal ulcer
Rx of solitary brain met
Whole brain radiation + resection cancer
Asymptomatic hematuria Rx
Repeat sample in 1 wk
Bedside test for ACL tear of knee?
+ve Lachman test
"Forward subluxation of tibia"
Normal- Can't subluxate
Abnormal- forward movement
Most reliable test for ACL tear of knee?
Bleeding after massive PRBC transfusion?
Lachman vs anterior drawer test?
Knee flexed at 30
2. Anterior drawer
Knee at 90
No femur stabilization
Rx of painful ingrown toenail?
If shows granulation or nail dystrophy = lateral matricectomy.
Mild - no granulation or dystrophy:
Cotton wick elevation
Recurrent - permanent nail ablation
Location of incision in ER tracheotomy? Why?
Above cricoid cartilage
Through cricothyroid membrane.
Below vocal cords
By-pass laryngeal obstruction
Preferred tracheotomy site in OR/controlled situation?
Below cricoid cartilage at isthmus + 3-4 tracheal rings
Absolute indication for tonsillectomy
Risks for plantar fasciitis
Plantar fasciitis Sx
Inferior heel pain on weight bearing
Pain: throbbing, searing or piercing
Pain in morning (first steps) or after inactivity.
Improves with walking.
Worse barefoot, on-toe walk, stairs.
Tenderness medial calcaneal tuberosity at plantar aponeurosis
Rx plantar fasciitis
What causes pseudocyst in pancreatitis?
When do they appear?
Pseudocysts lack true epithelium, they're duct leakage.
Appear > 2 wks of episode.
Resolves with time if persists or gets infected/necrotic surgery
Is barbiturate addictive?
Barbiturates withdrawal Sx
Brachial neuritis Sx
AKA: neurologic amyotrophy.
Acute sever shoulder sharp pain esp. night.
Not worsen by movement of shoulder
Dx brachial neuritis
Glioblastoma multiforme Sx
At 50 Yrs
Mass effect Sx: N/V, headache, visual
Dx: MRI/CT irregularly enhancing mass
Temporal Fracture classic
Battle sign (post auricular ecchymosis)
Ear bleeding (hemotympanum or blue tympanic membrane).
+/- vertigo, CN7 palsy
Complications of gastric bypass (early + late)
MC: anemia + B12 deficiency
Unequal pupil size
Anisocoria + sever headache
Outpatient diverticulitis Rx
Cipro 500 BID
Metro 500 TID
Impatient diverticulitis Rx
Unilateral absence of vas deference associate w/
Ipsilateral renal agenesis
When to check sperm count after vasectomy
Patellofemoral pain syndrome
AKA runner's knee or anterior knee pain
Tenderness on medial retinaculum
Normal tendon strength
Patellar deviation with knee flexion at 90
Rx of patellofemoral knee
Lumbar radiculopathy Sx + Dx
Weak ankle jerk reflex
Anterior cranial fossa fracture
Snake bite Rx
Minutes: venom extractors
2-6 hrs: Antivenin (CroFab > horse-serum)
Traumatic iritis Sx
Change in intraocular pressure
Corneal abrasion Sx
Foreign body sensation
Pain w/ extraocular movement
Retinal detachment Sx
Flashing light (photopsia)
Shower of floaters
Vision loss (cloudy / curtain like)
What incision used in felon?
Longitudinal (superficial w/ foreign body or discharge)
Mid-lateral (deep w/o foreign body or discharge)
Fishmouth incision in felon
Lead to unstable pulp
Assess motor function of median nerve
Thumb + 5th
Radial nerve injury Sx
No thumb extension
Rx of boxers fracture
Ulnar gutter splint
Pre-op assessment in cataract surgery
Not needed in asymptomatic patients.
Thyroid nodules algorithm
All thyroid nodules = TSH + US
Nodule > 5mm + micocalcifications = FNA
Nodule > 5mm + no calcification = Repeat in 6-12 mo
Nodule > 1cm = FNA
Size of renal stones need admission
Needs surgical intervention
> 4 mm
Surgery for > 5 mm
Hasn't passed in 2-4 wks
Aortic stenosis replacement indications
Aortic-valve gradient > 50
Valve area < 1 cm
Rotator cuff muscles
Infra + Supra spinatus
Abdication of shoulder
How long can NGT used?
Side effects of NGT
Diarrhea esp. c. Diff
Signs of moderate - sever ingrown toe nail
Rx of sever ingrown toe nail
Partial nail avulsion and phenolization
Surgical excision of matrix
What's lateral epicondyltisi?
How is it Dx?
Pain with extension
Dx by history + PE
Dilated veins of pampiniform plexus of scrotum
Cause reversible testicular atrophy
-ve trans illumination
Radial nerve dermatome
Dorsum of hands
Acute back pain following trauma / lifting
Due to lumbosacral MS strain
Rx NSAIDs + bedrest 3 days
MCC of fat embolism
Long bone fracture
Diff eye surgeries
Laser thermal keratoplasty
Intrastromal corneal ring
Refractive for myopia + hyperopia
Corneal flap, ablation of corneal stroma w/ no sutures.
Radial incision to change corneal shape.
No corneal flap needed
Laser directly to cornea
Shrink cornea + change shape
Plastic ring into cornea to change shape
Rx of foot tendinopathy
Immobilize in cast boot for 2-3 weeks.
Steroids inj contraindicated
Tendinopathy of foot?
Can't flex, invert or stabilize medial arch
Painful flat foot
Can't heel raise.
What must be tested in rheumatoid arthritis before surgery,
Sign of Achilles rupture
Rx of open fracture
Abx (aminoglycoside + 2G cephalosporin)
Rx of sigmoid volvulus
Ulnar nerve sensation
1/2 4th finger
Motor: thenar + hypothenar
Median nerve sensory
Thenar muscle (motor)
Palmar side of thumb, index, middle and 1/2 ring fingers.
Radial nerve sensory
Dorsolateral thumb, index, middle + 1/2 ring fingers
What's Volkman's ischemia
Ischemia from increased pressure by cast!
Iatrogenic compartment syndrome.
Worsening pain even at rest, not relieved by meds.
Tibial nerve injury?
Loss of plantarflexion
Loss of toe flexion
+ loss of sensation on posterior of leg and sole of foot
Patient on Abx develops high INR?
Vit K def
MCC of SBO
Adhesion > hernia > Ca
MCC of post op lung abscess
Aspiration of oral secretions
What's a ranula?
Pseudocyst of Mucin collection from a ruptured salivary gland duct
Caused by trauma
Asymptomatic + Rx with surgical excision (marsupialization)
When to stop BB in CHF/arryrhemia/HTN Before surgery?
Continue as scheduled
What explains urinary Hg without RBC?
How does porphyria affect urine?
Makes urine burgundy in color
But no hemoglobin in urine
How to judge adequacy of fluid replacement?
Urine output 1-2 ml/kg/hr
What's Parkland formula for burns?
4 x kg x BSA
1/2 in 8hr
1/2 in 16hr
Add 2000 ml to total for maintenance fluid.
4 x kg x BSA + 2000
Indications for bariatric surgery?
BMI > 35 + Co-morbidities
BMI > 40 even w/o morbidities
With failure lose weight
Alcohol use is contraindication
MC site of stress fracture in children?
Sx of TMJ syndrome?
Tenderness of chewing ms
Stuffiness in ear
Neck stiffness radiating to arm
What causes foot drop?
Common peroneal branch of sciatic nerve
Rx of open (compound) lower leg fracture
Abx (cephalosporin + aminoglycoside)
Closed > open reduction.
Scaphoid fracture Sx, Rx
Fall on stretched hands
1. XRay (repeat in 2wk in -ve)
2. Immobilization (thumb splint) 2 wks
Axillary nerve innervation
Sensation of glenohumeral joint and skin on deltoid.
Axillary nerve injury
Dysfunction of deltoid muscle.
Can't do forward elevation of shoulder (<30 degrees)
Rx of prostate with < 5% low grade tumor?
How to asses for osteomyelitis in diabetic ulcer?
Look for palpable bone at base of ulcer.
What's Reynolds Pentad?
Septic shock from ascending cholangitis
5. Altered mental status
Sign of rotator cuff injury
+ve impingement (Hawkin's)
Flex arm at 90
Flex shoulder at 90
Internal rotation of arm
Pain = +ve.
Dx anterior glenohumeral instability
+ve apprehension test
Flex arm at 90
Pain = +ve
Complication of undescended testis?
Lifetime risk of testicular cancer w/ undescended testis 9.7x higher.
Complication of cataract surgery
1. Cystoid macular edema:
Breakdown of blood-retina barrier = fluid accumulation.
More in DM
Prevent with NSAIDs
Dx by fluorescein angiogram
Rx of hydrocele
Observe in 1st year
Surgery after 1 year if not resolved
Sx of orbital fracture
Eye stuck downward
Numbness on cheek / lip
Dx orbital fracture?
Ophthalmos or enophthalmos
Entrapment of nerve
Fracture > 50% floor
Rx of ankle sprain
Semi-rigid brace (air-cast)
Predictors of increased post-op cardiac disease
Unstable MI, acute MI, recent MI
Sever valvular disease
Hx of stroke
Dx anterior cruciate ligament?
1st: anterior drawer test
Knees flexed 90 and leg pulled anteriorly.
Indications for ORIF?
1. Displaced intra-articular
2. Displaced epiphyseal
3. Avulsion fracture
4. Non union
+ Talar > 10 degree
Complication of mandibular fracture
Malocclusion of teeth
Rx of thrombosed external hemorrhoid
Excision under local
+ sitz baths
MCC of cellulitis post-breast resection
Lymphadema from Axillary LN resection.
MC bug: non-GAS
What's hamate fracture?
Fracture of hamate (MC bone)
Due to direct blow by handle of tennis racket/golf club.
End of racket forced into the palm
Direct pressure on hypothenar
Radial head subluxation ass with what fracture?
Pull of extended arm
Fall on hyper extended arms fractures? (3)
When to give pre-op Abx?
1hr prior to surgery
Rx of hammer toe
If can't = weak pulses = costume made shoes
1st step in hypovolemic shock?
Facts on varicocele
Appear in teenage
Let > Rt
Dx clinically or US
T/F: Rt sided varicocele needs referral to uro
Or child < 10
What's le Fort fracture?
Maxillary bone fracture
Classic in facial trauma
Thalamotomy and pallidotomy
For disabling tremor / dyskinesia
Facial trauma + can't breath
You've no tools?
Cricothyroid membrane opening via needle.
It's between anterior cricoid + thyroid.
LDL in aortic disease?
Types of onychomycosis
3. White superficial
Ottawa ankle and foot rules?
1. Ankle X-ray:
- Bone tenderness at posterior / tip lateral malleoulus
- Bone tenderness at posterior / top of medial malleolus
- can't bear weight
2. Foot X-ray:
- Tenderness at base of 5th metatarsal
- tenderness at navicular
- Can't bear weight
When to repair aortic aneurysm?
Prognosis of prostate Ca
Stage and Gleason grade
Avulsion of attachment of ulnar collateral ligament
Not associated with direct blow
What finger fracture associated with direct blow?
Baseball finger / mallet finger.
When does delirium termens starts?
2-10 days after alcohol
Sx of delirium termens?
Hallucinations esp. visual
Sx: shoulder stiffness, loss of active + passive ROM, pain esp. night.
Frozen shoulder vs rotator tear?
Frozen = loss of ROM active + passive
Rotator cuff tear = loss of active, normal passive
Medial collateral ligament tear Sx?
Pain and swelling on medial knee
Knee abduction > 5 mm = tear.
Technetium-99 in lower GI bleed?
Vaccination after splenectomy
2 wks before surgery
Tibilal posterior tendinitis
Pes anserine tendinitis
Tibialis stress = tenderness + pain w/ less activity.
Posterior tendinitis = pain extends to medial malleolus
Pos anserine = pain proximal to knee
Rx of Achilles tendinopathy
1. Conservative (3-6 mo)
Extracorporeal shock wave
Deep friction massage
Eccentric strength training
2. Surgery only if medical fails.
Role of NSAIDs in Achilles tendinopathy
No role? No inflammation
Sx of lumbar lordosis
Pain with spine extension = walking downhill
What's central extensor slip?
Tear of extensor slip tendon.
- Passive flexion of PIP during active extension.
- Dx: hold joint at 15-30 degree flexion, patient can't actively extend finger, but passive flexion possible.
And tenderness on dorsal middle phalanx.
- Rx: split PIP in full extension 6 weeks.
- complication: boutonnière
What could follow aneurysmal subarachnoid hemorrhage? When?
What's Leriche Syndrome?
No femoral pulse
Pain w/ walking (claudication)
It's atherosclerosis of GI arteries.
P's of compartment syndrome
Common scenario of anterior leg compartment syndrome
Compression during prolonged recumbency related to alcohol or drugs
Complication of slipped capital femoral epiphysis
A vascular necrosis
Contents of carpal tunnel?
Flexor policis longus
4 flexor digitorum profundus
Risk of peri-op MI is highest in which surgeries?
Aortic and peripheral vascular
MCC of anterior cruciate ligament tear?
Low-velocity non-contact injuries
Esp. Basketball, football, skiing.
T/F: Anterior cruciate ligament more in females
T/F: strength exercise prevent ACL tear
Dx and Rx of non-displaced forearm fracture
Dx: fat pad sign
Rx: posterior splint 1-2 wks w/ repeat X-ray
Effect of loss of one testis on fertility
Patient with biliary colic and no stones on US?
Mostly biliary dyskinesia
Dx w/ nuclear scan
Hoarseness after thyroidectomy?
Recurrent laryngeal nerve = vocal cord paralysis.
Dx acute pancreatitis
Which ones show on X-ray?
Glass > 2 mm
Urchin spine (has Ca)
Most serious complication of supracondyl fracture
Transversalis fascia defect
Direct inguinal hernia
- medial to inferior epigastric
- lateral to rectus
- superior to inguinal ligament
Indirect inguinal hernia anatomy
In deep inguinal ring
Lateral to inferior epigastric
Descend into scrotal sca / labia majora
T/F: stress fracture needs casting
Rx of foot stress fracture in runners
Rest 4-8 wks start activity as tolerated.
Different degrees of hemorrhoids and Rx
- 1st degree:
Bleed w/ defecation
Rx: diet (fiber), recurrent bleeding (sclerotherapy, coagulation, band)
- 2nd degree:
Prolapse w/ defecation + reduce spontaneously
Rx: band ligation
- 3rd degree:
Prolapse need Manual reduction
(Destroyed suspensory ligament)
Rx: band ligation or resection.
- 4th degree:
Prolapse and can't be reduced
Sx of de quervain's tenosynvitis? Rx?
Pain at thumb side of wrist.
Pain worse w/ movement
Pain w/ opening and closing thumb
Finkelstein's test +ve
Rx: NSAISa early => steroids if constant Sx
Rx of enlarging hematoma in wound sit?
Remove suture and ligate
Elderly w/ mid-heel pain worse in evenings
Not better w/ NSAIDs
Normal PE + X-ray
Fat-pad vs plantar fasciitis
Fat pad worse at night
Fasciitis worse in morning
Prevention of decubitus ulcer
Alternate Rt + Lt 30 degrees oblique positions
Well tolerated by elderly
Humeral shaft fracture palsy?
Supracondylar fracture at distal humerus injures what nerve?
Fracture of humeral surgical neck injures what nerve?
Glasgow Coma Scale?
Obeys command: 6
Localize pain: 5
Overuse of forearm extensors syndrome?
Tennis elbow (lateral epicondylitis)
Rx of massive / saddle shaped PE
1. No trauma or contraindication: tPA
2. Trauma: embolectomy
Patient w/ AFib for surgery.
Need for anticoagulant
1. Lone Afib (no Hx thrombus)
Stop warfarin 3-4 days pre-op
Resume as indicated by surgeon.
2. Afib w/ Hx of thrombus:
Stop heparin 3-4 days pre-op
Give prophylactic heparin post-op
In high risk (prosthetic valve): give therapeutic in INR below normal.
Absolute contraindication to laparoscopy
1. Coagulation abnormalities
3. High ICP
4. Retinal detachment
What's malignant hyperthermia
Inherited myopathy in sarcoplasmic reticulum => high intercellular Ca => sustained contraction + hyper metabolic state.
Trigger of malignant hyperthermia
Inhalation anesthetics (halothane)
Sx of malignant hyperthermia
Increases Ms tone + rigidity
Rx of malignant hyperthermia
Dantrolene + cooling
What's Dressler's syndrome?
2 weeks after surgery = low grade fever + chest pain
What's osteitis pubis
Chronic lower abdominal pain + medial thigh w/ exercise.
Dx of osteitis pubis
Lower abdominal + medial thigh pain w/ exercise
Tenderness on pubis
Widened pubis on X-ray
What surgery has high risk of post-op DVT?
Orthopedics esp. hip replacement.
Dx quada equine?
MRI w/ gadolinium
What's a jersey finger?
Tear of flexor digitorum profundus tendon of finger
Classically by catching finger in opponent's clothes
Rx of jersey finger?
Splint in slightly flexed position and refer to surgeon for tendon re-attachment
MCC of bowel obstruction in elderly
2. Groin hernia
What Morton's Neuroma
Tenderness in 3rd interspace between 3-4 toes.
No inflammation or redness.
What's the female athlete triad
Essential findings in brain death (3)
Absence of brain stem reflexes
Dx brain death
- R/o hypotension, hypothermia <32, drugs, brain stem encephalitis, encephalopathy, low PO4
- GCS 3
- No pupillary reflex
- HR < 5 after atropine
- No resp. w/ high CO2
- +ve apnea test if no resp w/ PCO2 > 60 mmHg on 100 O2
Initial Rx in coma
ABC (airway, IVF, viral signs)
Dx rotator cuff
Painful abduction > 90
Weak external rotation (specific)
Who gets more than ECG in pre-op evaluation
1. Unstable MI
2. Sever VHD
3. Uncompensated CHF
4. Significant arrhythmia
Who gets ECG in pre-op
Males > 45
Females > 55
SE of spironolactone in men?
Gynecomastia (Uni > bi)
What's contraindicated in anesthesia of penile surgery / circumcision?
What's penumocephalus? What does it indicate?
Air in cranium
Skull fracture, trans-sphenoidal surgery, tumors in base of skull
Serious complication of chronic calculous cholecystitis?
Shoulder pain after gall bladder surgery
Referred pain (C3-5)
Rx of buckle fracture of wrist
Patient high risk for DVT post-op
SubQ enoxaparain 1-2hr before surgery + 24hr after.
Bariatric surgery recommended BMI
1. BMI > 40
2. BMI > 35 + comorbidity
Effect of bariatric surgery on T2DM
Resolve disease in 75%
Pain in spinal stenosis vs herniated disk
Stenosis = improves w/ setting
Disk = improves by standing
Odds of having breast Ca? Die of breast ca?
1 in 8
1 in 30 dies of breast Ca
Physical / mechanical prevention of DVT?
When do osgood-schlatter fracture resolve?
Typical pain in Osgood-schlatter?
Confined to tibial tubercle.
T/F: Osgood-schlatter not ass w/ trauma
MC injured ligaments of knee
When to refer varicocele to urology
If testicular volume 2ml less than normal
Primary closure after animal bite?
Face / scalp
W/in 6hr of injury
No devitalized tissue
Femoroacetabular impingement pain
Worsening anterolateral hip pain
Sharp moving from seated position
Pain w/ ROM exam
Most sensitive test for femoroacetabular impingement
Pain w/ hip Flexion, adduction, internal rotation
Rx of nursemaid's elbow
Manual reduction w/ supination-flexion techniques
Where's CN XI?
Posterior neck triangle
Innervates trapezius => dropped shoulder + can't raise hand above head.
Complication of scaphoid fracture / snuffbox?
A vascular necrosis
Risk of post-op delirium in elderly?
Rx of closed colle's fracture
Slight flexion, full pronation, full ulnar deviation reduction
What improves Ca Oxalate stones?
High Ca diet
Imp risk of lung post-op?
Age > 80
Intestinal pseudo-obstruction with massive distention of colon or bowel after surgery.
No mechanical obstruction.
Herb to be stopped week before surgery
Ginseng = hypoglycemia + anticoagulant
When to start ROM exercise in ankle sprain
Early to maintain flexibility
Rx of femoral neck + intratrochanteric fracture
Femoral neck: internal fix
Intratrochanteric: compression screw + side plate
Diff dementia + delirium
Delirium = previously healthy + mental status fluctuates on successive visit.
Surgery for rotator cuff injury
Young + Active
< 6wk of injury
MCC of fistula-in-ano?
Zanker's diverticulum (cricopharyngeal)
Spitting food swallowed hrs ago
Rx of choice in BCC
BCC cure rate w/ mohs surgery
How to decrease pain from inj local anesthetic
Add Na HCO3
Episodes of sharp pain in rectum lasts minutes
T/F: Achilles' tendon rupture patient can't do single leg toe raise