Surgery

Question 1

Management of increased ICP due to acute subdural hematoma (7)

Answer 1

1. ICP monitoring***
2. elevate head
3. hyperventilate
4. avoid fluid overload
5. mannitol or furosemide
6. sedation
7. hypothermia

Question 2

tx of rib fracture

Answer 2

**esp impt in elderly

local nerve block + epidural catheter

Question 3

pulmonary contusion on CXR

Answer 3

white out of lungs

Question 4

gunshot wound to abdomen management

Answer 4

exploratory laporatomy

Question 5

management of intraoperative development of coagulopathy

Answer 5

platelet packs + FFP

**if hypothermia and meta acid –> stop laparotomy

Question 6

penetrating injury of extremities management

Answer 6

** determine if vascular injury based on anatomic location
if no –> tetanus prophylaxis + cleaning
if yes and asym–> Doppler/CT angio +/- surgery
if yes and sx –> surgery

Question 7

circumferential burns

Answer 7

** edema can cutoff blood supply

tx + escharotomies

Question 8

GI fistula

Answer 8

if all contents don’t leak outside, can cause sepsis
if draining freely with no fever or peritoneal irritation, can cause 1) fluid and lytes loss, 2) nutritional depletion, 3) erosion/digestion of belly wall **worse the higher the fistula is in GI tract

Tx = fluid/lyte replacement, nutritional support, protect abdominal wall (with suction, ostomy)

Nature will heal the fistula if no FETID (foreign body, epithelialization, tumor, infection/ irradiated tissue/IBD, distal obstruction

Question 9

int vs ext hemorrhoids

Answer 9

internal - bleed, tx = rubber band ligation (if prolapsed can become itchy and painful)

external - painful, tx = conservative or surgery

Question 10

workup of SCC of HEENT mucosa

Answer 10

triple (pan) endoscopy to look for primary
biopsy establishes dx
NO open biopsy

Question 11

acute epididymitis

Answer 11

men old enough to be sexually active
severe sudden onset testicular pain + fever + pyuria
testis is swollen and tender, in normal position, cord is tender
tx = abx (US to rule out testicular torsion)

Question 12

uretopelvic junction obstrtuction

Answer 12

normal urine flow is fine, but with large diuresis (e.g. after beer binge) the area is too narrow –> colicky flank pain

Question 13

testicular cancer workup

Answer 13

biopsy with radical orchiectomy
preop serum markers: alpha fetoprotein, beta HCG
platinum based chemo *very radio and chemo sensitive

Question 14

scaphoid fracture

Answer 14

fall on outstretched hand
wrist pain + tenderness over snuffbox
initial xrays negative but postive 3 weeks later
tx = thumb spica cast (ORIF if displaced)

Question 15

wound dehiscence

Answer 15

~POD 5
wound looks intact, but there is large amounts of pink/salmon colored fluid soaking dressings (peritoneal fluid)
tx = securely tape and bound abdomen, re-operation for closure

Question 16

SCC of anus

Answer 16

HIV+, receptive anal sex
fun gating mass grows out of anus, +/- metastatic LNs
Dx = biopsy
Tx = nigro chemoradiation +/- surgery

Question 17

tx of resectable breast cancer

Answer 17

if small lesion and away from nipple/areola –> lumpectomy + rad
if large tumor or laying below nipple/areola –> mastectomy

Question 18

chronic constrictive pericarditis

Answer 18

exertion dyspnea + hepatomegaly + ascites
cardiac Cath shows square root sign and equalization of pressures
tx = surgical

Question 19

morton neuroma

Answer 19

inflammation of common digital nerve of the third interspace between 3rd and 4th toes
palpable tender spot
common cause is pointed high heels or cowboy boots
tx = analgesics, better shoes, +/- surgical excision

Question 20

zero urinary output?

Answer 20

usually mechanical prob - kicked or blocked catheter

Question 21

correcting hypernatremia

Answer 21

start with D51/2NS

every 3 meq/L that Na is above 140 equals 1.L of fluid lost

Question 22

anal fissure

Answer 22

young women with super painful, blood streaked stools
fear of pain causes constipation
exam under anesthesia
cause = tight sphincter
tx = stool softeners, topical nitroglycerin, botox, forceful dilatation, lateral internal spincterectomy , diltiazem ointment

Question 23

obstructive jaundice caused by tumor

Answer 23

thin walled dilated gallbladder
CA: pancreas head adenocarcinoma, ampulla of vatar adenocarcinoma (jaundice + anemia + occult blood in stool), cholangiocarcinoma
do CT scan then ERCP if necessary, endoscopy of ampullary suspected

Question 24

full blown renal cell CA

Answer 24

hematuria + flank pain + flank mass
hypercalcemia, erythrocytosis, elevated LFTs
workup = CT –> heterogenic solid tumor (can grow into renal vein or vena cava
tx = surgery

Question 25

transitional cell cancer of the bladder

Answer 25

``` *smokers hematuria, irritated voiding dx = CT, cystoscopy tx = surgery, intravesical BCG high rate of local recurrence *lifelong F/U ```

Question 26

topicals for burns

Answer 26

silver sulfadiazine mafenide acetate for deep penetrations (thick eschar, cartilage) triple abx cream for burns near eye

Question 27

obstruction AND infection of urinary tract

Answer 27

emergency!! can lead to kidney death, sepsis, death within hours can happen while someones waits to spontaneously pass ureteral stone tx = IV abx, immediate decompression of urinary tract (ureteral stent or percutaneous nephrostomy)

Question 28

Ogilvie syndrome

Answer 28

paralytic ileus of the colon seen in elderly sedentary patients that are further immobilized because of surgery elsewhere large abdominal distention (tense, not tender), massively dilated colon tx = fluid and late correction, colonoscopy to suck out air/decompression, place long rectal tube

Question 29

primary peritonitis

Answer 29

classic: child with ascites and nephrosis or adult with ascites and mild generalized abdomen +/- fever, leukocytosis tx = abx

Question 30

diagnostic and therapeutic enema for meconium ileum

Answer 30

gastrogaffin

Question 31

management of arterial embolization of extremitiy

Answer 31

doppler to locate site of obstruction incomplete obstruction --> clot busters complete --> embolectomy w/ Fogarty catheter (+ fasciotomy if several hrs pass before revascularization)

Question 32

brachial cleft cyst vs cystic hygroma

Answer 32

brachial cleft cyst: anterior edge of SCM, several cm +/- opening and blind tract cystic hygroma: base of neck, large and mushy ill defined mass, occupies entire supraclavicular area and extend deeper into chest *CT before surgical removal

Question 33

penetrating neck trauma

Answer 33

upper zone gunshot: arteriogram GSW at base of neck: arteriogram + esphagogram + esophagoscopy + bronchoscopy before surgery surgical exploration if expanding hematoma, deteriorating vital signs, clear signs of esophageal or tracheal injury

Question 34

dx of intraabdominal bleeding

Answer 34

stable --> CT | unstable --> FAST exam

Question 35

tx of acute organ rejection

Answer 35

steroid bolus 1st line antithymocyte serum anti lymphocyte agents (OKT3) have high toxicity

Question 36

leg ulcers | -diabetic vs arterial insufficiency vs venous stasis vs marjolin ulcer

Answer 36

diabetic ulcer: pressure points art insufficiency: tips of toes (as far from heart as possible), look dirty, no granulation tissue, pt with other CAD signs, workup = doppler, angio venous stasis: chronic edema, indurated and hyperpigmented skin above medial malleolus, painless with granulating bed, varicose veins and cellulitis bouts, workup = duplex scan marjolin ulcer: SCC develops in chronic leg ulcer *untreated 3rd degree burns or chronic draining sinuses from osteomyelitis, dirty looking deeper ulcer develops with heaped up tissue growth around the edges, biopsy, wide local excision and grafting