Surgery

Question 1

differential for anterior mediastinal mass

Answer 1

4 T’s 1. Thymoma (normal bHCG, AFP)

2. Teratoma (elevated bHCG, AFP)
3. Thyroid neoplasm
4. Terrible Lymphoma (normal bHCG, AFP)

Question 2

scrotal mass that increases in size with valsalva…what is it and what is tx

Answer 2

Varicocele “bag of worms” -presents with subfertility, testicular atrophy -us finding of retrograde venous flow -dilation of pampiniform venous plexus tx: gonadal vein ligation, scrotal support, NSAIDS

Question 3

how to confirm presence of peripheral artery disease

Answer 3

Ankle-brachial index

<0.9 abnormal (diagnostic of occlusive PAD)

0.91-1.3 normal

>1.3 suggestive of calcified and uncompressible vessels

Question 4

treatment of gallstones

1. Gallstones without symptoms
2. Gallstones with typical biliary colic sx
3. Complicated gallstone dz

Answer 4

1. gallstones w/o sx –> no tx necessary
2. gallstones with typical biliary colic sx –> elective laparoscopic cholecystectomy
3. complicated gallstone dz (acute cholecystitis, choledocolithiasis, gallstone pancreatitis) –> surgery within 72 hours

Question 5

physical exam findings indicative of a urethral injury

Answer 5

blood at the meatus, high riding prostate

Question 6

pubic ramus fx, return of frank blood on foley insertion without resistance and NO blood at meatus

Answer 6

EXTRAperitoneal bladder rupture (contusion or rupture of the neck, anterior wall, or anteriorlateral wall of bladder

Question 7

intra vs extra peritoneal rupture of the bladder

Answer 7

intra –> rupture of the dome of the bladder resulting in intraperitoneal leakage and presents with signs of chemical peritonitis (guarding, diffuse abd tenderness)

extra –> localized pain in lower abd and pelvis, pelvic fracture almost ALWAYS seen, gross hematuria present

Question 8

most critical prognostic indicator of compartment syndrome

Answer 8

time to fasciotomy (go to OR right away…NO time for eval or elevation or ice)

-in fact, the leg should be kept at the level of the torso, not higher or lower

Question 9

retropharyngeal abscess

Answer 9

presents with neck pain, odynophagia, and fever following penetrating trauma to the posterior pharynx. This infection can drain into the superior mediastinum. -If it extends through the alar fascia, it can enter the “danger fascia” and transmit infection into the POSTERIOR mediastinum and result in acute nectrotizing mediastinitis

Question 10

ludwig angina

Answer 10

rapidly progressive bilateral cellulitis of the submandibular and sublingual spaces arising from an infected mandibular molar

Question 11

succession splash over the epigastrum and a hx of acid ingestion several months ago in a suicide attempt

Answer 11

pyloric stricture = gastric outlet obstruction caused by mechanical obstruction leading to postprandial pain and vomiting and early satiety

-can be caused by gastric malignancy, crohns, PUD, ingestion of caustic agents

Question 12

timeline of post-op fever

Answer 12

0-2 hours: prior trauma/infection, blood products, malignant hyperthermia

24hrs-1 week: nosocomial infection, noninfective (MI, DVT, PE), Group A strep, Clostridium perfringes

1 week-1 month: other bacteria not above, catheter infection, drug fever, dvt, pe

>1 month: viral infections, SSI (indolent organisms)

Question 13

post-op fever defined as what temp

Answer 13

>100.4 = 38

Question 14

tx of anal fissures

Answer 14

• topical anesthetics and nifedipine
• sitz bath
• high fiber diet and adequate fluid intake
• stool softeners

Question 15

paradoxical chest wall movement

Answer 15

seen in flail chest with multiple rib fractures. Chest expands when inhales and retracts when exhale

Question 16

colonic thickening and fat stranding, think what

Answer 16

ischemic colitis

Question 17

persisting pneumo despite bilateral chest tube placement

Answer 17

think of tracheobronchial rupture secondary to blunt thoracic trauma. The right main bronchus is most commonly injured in these patients

-also may see pneumomediastinum or subq air

Question 18

whistling noise post rhinoplasty, suggests what?

(think Me Myself and Irene)

Answer 18

septal perforation likely resulting from a septal hematoma

Question 19

treatment of pancreatic pseudocyst that is symptomatic

Answer 19

endoscopic drainage (these psuedocysts can release amylase into circulation)
-if the patient is asymptomatic, no treatment is needed

Question 20

heparin to use in end stage kidney disease pts

Answer 20

use: unfractionated heparin

do NOT use: LMWH (enoxaparin) and rivaroxaban

Question 21

complicated diverticulitis treatment

(you saw this)

Answer 21

CT guided percutaneous drainage of abscess

Question 22

acute mesenteric ischemia presentation

Answer 22

sudden onset severe, poorly localized mid-abdominal pain accompanied by nausea and vomiting

Question 23

acalculus cholycystitis occurs in what type of pts?

Answer 23

occurs in critically ill hospitalized patients. Pts have jaundice in addition to pain/mass in URQ

Question 24

retroperitoneal hematoma dx, presentation, tx

Answer 24

non-con abd pelvis CT

presents: as sudden hemodynamic instability and ipsilateral back pain

tx: supportive

Question 25

dx of suspected urethral injury

Answer 25

retrograde urethrogram (x-ray of lower GI tract with injection of radiopaque contrast in the urethra)

Question 26

acute bacterial parotidis

Answer 26

usually occurs in dehydrated post-op patients with crappy oral hygiene

Question 27

ALT \>150 in regards to pancreas

Answer 27

95% PPV for gallstone pancreatitis

Question 28

tx of spontaneous pneumo in your tall athletic kiddo with no trauma

Answer 28

1. If small (\<2cm), give O2 and supportive 2. If large, do small needle decompression

Question 29

torus palantinus

Answer 29

benign, hard immobile mass on the roof of the mouth ## Footnote - the thin epithelium tends to ulcerate and takes a long time to heal given poor vascular supply - surgery only indicated if symptomatic

Question 30

anterior cord syndrome is seen with what procedure and presents how?

Answer 30

seen in thoracic aortic aneurysm repair The anterior spinal artery provides blood to the anterior 2/3 of the spinal cord including motor tracks and sensory tracks (spinothalamic) - The dorsal column is SPARED (vibration and proprioception) - Presents with bilateral flaccid paralysis with UMN signs \*\*ALSO seen in whiplash injuries in old people

Question 31

the two lobes of the parotid gland are separated by what?

Answer 31

the FACIAL nerve

Question 32

chronically wounded, burned, scarred skin predispose to what?

Answer 32

Squamous cell carcinoma -If arise within a burn called a **majorlin** ulcer

Question 33

what pH is sodium bicarb indicated?

Answer 33

\<7.2

Question 34

hypocalcemia pt presentation

Answer 34

initially nonspecific symptoms such as fatigue anxiety, depression - Involuntary contractions involving the lips, face, and extremities are seen when more severe - prolonged QT \*surgically this is common in post-thyroidectomy pts

Question 35

ejection fraction in hypovolemic shock

Answer 35

INCREASED The left ventricle is decreased due to decreased filling volume tries to compensate by increasing ejection fraction - also see an increase in sympathetic nervous system resulting in an increase in total peripheral resistance and HR - presents with, hypotension, tachycardia, cold extremities, and evidence of poor organ perfusion (somnolence, unresponsiveness) and physical exam findings of hypovolemia (flat neck veins)

Question 36

nasopharyngeal carcinoma is associated with reactivation of what?

Answer 36

EBV - It is especially endemic in China - often presents with nasal congesion and epistaxis, HA, CN palsy (facial numbness) and/or serious otitis media

Question 37

Aflatoxin B1

Answer 37

mycotoxin that contaminates agricultural products and is associated with an increased risk of Hepatocellular Carcinoma

Question 38

Broken penis, what do ya do?

Answer 38

- First, this is rupture of the corpus cavernosum due to traumatic tear in tunica albuginea - MUST do retrograde urethrogram and then take pt to OR for surgery

Question 39

acute adrenal insufficiency (adrenal crisis)

Answer 39

- seen in acute adrenal hemorrhage or infarction or stressors such as surgery - presents as hypotension/shock, n/v, abd pain, weakness, fever occurs in patients with primary adrenal insufficiency (addisons) or suppression of HPA axis due to chronic glucocorticoid use tx: hydrocortisone or dexamethasone

Question 40

supracondylar fx of the humerus in a child has what common complication

Answer 40

entrapment of median nerve or brachial artery

Question 41

acalculus cholycystitis

Answer 41

most often seen in severely ill pts in the ICU with multisystem organ failure, severe truama, sepsis... - likely due to cholestasis or gallbladder ischemia leading to secondary infection by enteric organisms - raise suspicion with gallbladder wall thickening and presence of pericholystic fluid tx: abx and cholycystectomy

Question 42

tx meningioma | (think HA clinic pt)

Answer 42

surgical resection (dx is confirmed intraoperatively)

Question 43

stasis dermatitis

Answer 43

result of lower extremity venous valvular incompetence resulting in pooling of blood and increased pressures in the postcapillary venules

Question 44

leriche syndrome

Answer 44

aortoiliac occlusion Triad: 1. bilateral hip, thigh, gluteal claudication 2. impotence 3. symmetric atrophy of lower extremities due to chronic ischmeia