Surgery Flashcards
Best initial step when suspecting pancreatic cancer
Spiral CT Scan→mass, dilated pancreas, local spread, and dilated bile ducts
- Endoscopic retrograde cholangiopancreatography (ERCP) locates tumors not seen with CT→too invasive to be initial
- Endoscopic US→helpful for staging and to guide fine-needle aspiration biopsy (suspicion of periampullary neoplasm, small tumors, nodal and major vascular involvement)
How do you see the liver adenoma in a technetium-99 sulfur colloid scan? Why?
Majority of liver adenoma don’t have Kupffer cells→don’t take up sulfur colloid→cold spots in the scan
Treatment for iridocyclitis
Immediate ophthalmology referral
- Cyclopegics→block nerve impulses to the pupillary sphincter and ciliary muscles (easing pain and photophobia) [muscarinic receptor blockers: atropine, tropicamide]
- Topical steroids →↓inflammation (only initiated after consultation with ophthalmology)
Mainstay treatment for osteoarthritis
- Exercise→muscle strength and resistance training
- Weight loss
Hospital admission criteria in a colic pain by renal stone?
- Patient can not tolerate oral hydration
- Pain is uncontrolled with oral medications
- Infection
- One kidney
- Significant renal impairment
What are the recommendations if a renal stone fails to pass spontaneously?
- Stones <1cm at proximal ureter→Extracorporeal shock wave lithotripsy (ESWL)
- Stones >1cm at proximal ureter→percutaneous nephrolithotomy, ureteroscopia
- Stones at distal ureter→ESWL or ureteroscopia
How do you differentiate Lumbar spinal stenosis vs Lumbar disc herniation at physical exam?
- Lumbar spinal stenosis→Flexion of the spine relieves the pain
- Lumbar disc herniation→Flexion of the spine worst the pain
What is the purpose to measure the postvoid residual (PVR)?
Rule out overflow incontinence or urinary retention
- Men normal < or same 50 mL
- Women normal < or same 150 mL
What is the next step when you suspect foreign body in the eye and don’t see it with slit lamp?
Fluorescein application→abrasion or foreign body may be present although not seen on gross examination
Surgery time after supportive treatment of a complicated gallstones disease (acute cholecystitis, choledocholitiasis, gallstone pancreatitis)
Early cholecystectomy (within 72 hours)
*Reduces disease duration, duration of hospitalization and mortality compared to delayed cholecystectomy (>7 days after hospitalization)
Treatment of choice in acalculous cholecystitis
- Antibiotics
- Percutaneous cholecystostomy
*Cholecystectomy when medical condition stabilizes
Radiologic signs of acalculous cholecystitis
- Gallbladder wall thickening and distension
- Pericholecystic fluid
Next steps in a hemodynamically stable patient with blunt abdominal trauma without peritonitis
*If Alert/normal mental status
- FAST:
(+) CT scan of abdomen→Determine need of laparotomy
(-) Serial abdominal exams +/- CT scan
*If NO normal/alert mental status→Serial abdominal exams +/- CT scan
Next steps in a hemodynamically unstable patient with blunt abdominal trauma without peritonitis
- FAST (+) Laparotomy Inconclusive: Diagnostic Peritoneal Lavage [(+) Lapratomy, (-): (-) Signs of extra-abdominal hemorrhage: Yes→Stabilize (ex, angiography, splint) No→Stabilize and CT of abdomen
Physiopathology and treatment of urinary urgency incontinence
- Overactive bladder→detrusor instability
- Tx: Kegel exercises, bladder training (timed voiding, distraction or relaxation techniques), antimuscarinics
(eg, oxybutynin), B-agonists (eg, Mirabregon)
Which is the most appropriate next step when suspect an obstructive jaundice caused by tumor?
CT Scan of the abdomen
*Usually ultrasonography is done first
Most common tumors that can cause obstructive jaundice
- Adenocarcinoma at the head of the pancreas
- Adenocarcinoma of the ampulla of Vater
- Cholangiocarcinoma arising in the common duct itself
Most appropriate first step in management trauma of the urethra
Retrograde urethrography or urethrogram
Most appropriate next step when diagnosed basal cell carcinoma on the face
Mohs Micrographic Surgery➡sequential removal of thin skin layers with microscopic inspection to confirm the margins cleared of malignant tissue
How do you explain hematuria in a Abdominal Aortic Aneurysm rupture?
Rupture into the retroperitoneum→create aortocaval fistula with inferior cava vena→venous congestion in retroperitoneal structures (bladder)→fragile and distended veins rupture►gross hematuria
Triad to suspect biliary cyst
Abdominal pain, jaundice (obstructive cholestasis) and palpable mass
*Normal gallbladder on sonography
Treatment for biliary cyst. What do you want to avoid?
Surgical resection►relieves the obstruction and reduces the risk of malignancy➡cholangiocarcinoma, gallbladder cancer, pancreatic cancer
Pneumobilia + Hyperactive bowel sounds + Nausea, Vomiting + Dilated loops of bowel + Diffuse abdominal pain in several days. Disease and mechanism.
Gallstone ileus→stones pass through a biliary-enteric fistula and advances by the intestinal tract (usually lodges in ileum, also stomach, colon, jejunum)
*Mechanical obstruction
Potential cause and explanation of splenic abscess
Complication of bacteremia from a distant infection (infective endocarditis, cholecystitis)
Risk factors of splenic abscess
Immunosupression from HIV, diabetes mellitus, hematologic malignancy
Most common cause of referred otalgia
- Dental disease and Temporomandibular joint disorders
- Common presentation of mucosa head and neck squamous cell carcinoma (HNSCC)→IX CN (base of tongue, external auditory canal), X CN (larynx, hypopharynx, external auditory canal)►Tumor at base of tongue or larynx/hypopharynx
How may you distinguish a cardiogenic from a hypovolemic shock?
- Both are pale/cool
- Cardiogenic: ↑Left ventricular end diastolic pressure (LVEDP) or Pulmonary capillary wedge pressure (PCWP)
- Hypovolemic: ↓LVEDP or PCWP
Warm and flushed types of shock, How do you differentiate them?
- Neurogenic shock: ↓Cardiac output
- Septic shock: ↑Cardiac output
Warm/flushed type of shock with elevated cardiac output and decreased PCWP?
Anaphylactic shock
*No change PCWP and ↑CO→Septic shock
Best management in an unstable patient with pelvic fracture
External pelvic binder (provides stability and tamponade effect) and angiographic embolization
*External and internal pelvic fixation if pelvic binder is not an option, but surgery on a bleeding pelvis is risky
Types of bladder injuries in a pelvic fracture and management
- Extraperitoneal bladder injury (bladder neck/trigone rupture)→ place Foley catheter
- Intraperitoneal bladder injury (bladder dome rupture)→surgical correction
Malignancies to think in young men (15-35)
Testicular cancer, Lymphoma, Leukemia
Metastatic process of testicular cancer and associated symptoms
- Retroperitoneal lymph nodes→compression adjacent structures [nerves roots, psoas muscle]►Lumbar back pain
- Lung and liver mestastasis
- Lung→nodules►cough or dyspnea
Symptoms and signs of schwannoma and why are they caused?
- Cochlear nerve compression→unilateral sensorineural hearing loss
- Vestibular nerve damage→Imbalance, most when depriving visual input (Ex, walking at night)
- Extension from internal auditory canal into the cerebellopontine angle
- CN V compression→facial numbness
- CN VII compression→facial weakness
Sensorineural hearing loss
Air conduction>Bone conduction, lateralization to the unaffected ear
Conductive hearing loss
Bone conduction>air conduction, lateralization to the affected ear
What might suggest a bruising on the flank after trauma? Which is the sign?
Grey Turner sign➡Retroperitoneal hemorrhage
Most accurate test for acute and chronic mesenteric ischemia and ischemic colitis
Angiography
