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Surgery EOR pearls Flashcards

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1
Q

What are the layers of the abdominal wall (8)?

A
  1. Skin
  2. Subcutaneous fat
  3. Scarpa’s fascia (Camper’s fascia is above)
  4. External oblique
  5. Internal oblique
  6. Transversalis fascia
  7. Preperitoneal fascia
  8. Peritoneum
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2
Q

Diverticular disease: how does it present and whats the evaluation of choice?

A

Presents as colicky abdominal pain, diarrhea and/or constipation, eventually fever.

Evaluate with CT abdomen.

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3
Q

Meckel diverticulum

A

Part of the fetal GI tract that is resorbed after birth in all but 2% of people. Obstruction can develop secondary to volvulus or intussiception.

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4
Q

What is the most common complication of acute pancreatitis?

A

Pancreatic pseudocyst. Suspect it if pt continues to have abdominal pain. It is a collection of fluid, including blood, pancreatic enzymes, and necrotic tissue. Forms in “lesser sac” of abdomen (between pancreas(posterior) and stomach/duodenum (anterior).

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5
Q

Desmopressin is the mainstay therapy for what disease?

A

Von Willibrand Disease. Note, these people will have a normal PT and aPTT (its a platelet, not a clotting disease).

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6
Q

What is the most common cause of massive lower GI bleeds?

A

Diverticular disease. Hemorrhoids are a more common cause of bleeds but do not cause “massive hemorrhage”

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7
Q

What is the most common electrolyte disturbance in surgical patients?

A

Hypokalemia. It can be caused by enhanced losses, hyperaldosteronism, inappropriate replacement, and intracellular shifts caused by alkalosis.

Sx include: constipation, neuromuscular weakness, diminished tendon reflexes, paralysis, and distinctive electrocardiographic changes (flat T-waves).

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8
Q

What electrolyte should you always check in a patient with hypokalemia that is refractory to K supplementation?

A

Magnesium! It can precipitate and potentiate hypokalemia. Calcium is also often related.

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9
Q

What is the most common source of an arterial occlusion of the lower extremity?

A

Atrial fibrillation

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10
Q

What is the most common site of metastasis for colon cancer?

A

Liver

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11
Q

Where in the leg is the most likely site of compartment syndrome?

A

Anterior compartment.

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12
Q

Paralytic ileus- signs and symptoms

A

Minimal abdominal pain, hypoactive or absent bowel sounds, obstipation, failure to pass flatus. Plain film will show gas in small and large bowel.

Note SBO is DDx. SBO will cause crampy abdominal pain, hyperactive bowel sounds with high pitched sounds, and show dilated small bowel on plain film.

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13
Q

PT/INR measures…

A

Extrinsic pathway (T’s are exes). This is the tissue factor and VII pathway (small one).

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14
Q

aPTT measures…

A

Intrinsic pathway (Ts are IN a relationship). This is the XII->XI–>IX–>X pathway.

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15
Q

What is the most common site of volvulus? How is it treated?

A

Sigmoid colon (bent inner-tube appearance on plain film). Treat it by therapeutic sigmoidoscopy to decompress the bowel. Insert rectal tube to act as stent.

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16
Q

What percent of people with a solitary solid tumor will end up with metastatic disease of the vertebra during their cancer course?

A

50%

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17
Q

Sx of hypocalcemia:

A

parasthesias

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18
Q

Sx of hypercalcemia:

A

constipation, bone pain. Groans, bones and psychic moans

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19
Q

What is the most common joint dislocated in children?

A

elbow (nursemaid).

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20
Q

Ascending cholangitis - Charcot’s triad? Reynaud’s pentad?

A

fever, jaundice, RUQ pain (+ mental status changes, hypotension). Note that ascending cholangitis is spread of an infectious obstructed common bile duct that ascends.

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21
Q

Leg is shortened, abducted and externally rotated. What’s the injury?

A

Femoral neck Fx.

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22
Q

Leg is shortened, adducted, and internally rotated. What’s the injury?

A

Posterior hip dislocation

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23
Q

What is the most common type of lung cancer among non-smokers?

A

Adenocarcinoma

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24
Q

What is the most common type of lung cancer among smokers?

A

Adenocarcinoma. Though small-cell carcinoma has the strongest relationship with smoking, it is far less common.

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25
The murmur of aortic regurgitation- how does it sound, when and what do you do to accentuate?
It will be an early diastolic, soft, high-pitched, decrescendo murmur best heard over the L sternal border. It is accentuated by isometric hand grip exercises.
26
"dural tail" is a sign on MRI of what?
meningioma
27
haustra are located in the...
large bowel
28
What are some clues to distinguish between esophageal varices and mallory-weiss tear?
Esophageal varices will usually present with signs of severe liver disease while, a large volume of blood/emesis, and no precipitating event. Mallory-weiss tears are precipitated by severe wretching, which usually means there is vomiting or heaving before bleeding. Less blood.
29
After surgical resection of a colon tumor, what is done to monitor for recurrance?
annual colonoscopy
30
what are some warning signs in the presentation of a severe headache that suggest imaging should be performed?
``` SNOOP: systemic symptoms (fever, vomiting, stiff neck), neurologic sx, onset is new, Other associated conditions (eg, headache is subsequent to head trauma, awakens patient from sleep, or is worsened by Valsalva maneuvers), prior headache history is different. CT is imaging of choice if you suspect subarachnoid hemorrhage. ```
31
What is the antidote for heparin overdose?
protamine sulfate
32
what is the most common cause of large bowel obstruction?
adenocarcinoma (colon cancer)
33
what is an absolute contraindication to surgical resection of a lung tumor?
superior vena cava syndrome
34
What is the most common non-traumatic cause of subarachnoid hemorrhage?
cerebral aneurysm. Note HTN causes cerebral, not subdural hemorrhage.
35
twisting injury to knee will likely tear the...
ACL
36
What does a palpable, nontender gallbladder suggest?
Pancreatic carcinoma. This is Courvoisier's sign.
37
mid-epigastric pain, weight loss, and jaundice suggest
pancreatic carcinoma.
38
What is the preferred therapy for a toxic thyroadenoma?
thyroid lobectomy. According to uptodate you can also use radioiodine ablation but Lange says no.
39
What are the Salter Harris fracture classifications?
Physis- plate; metaphysis- long bone; epiphysis- distal head. SALTER I- Straight across (growth plate) II- Above (metaphysis and plate) III-Lower or BeLow (epiphysis and plate) IV- Two or Through (epiphysis AND metaphysis) V- Erasure of the growth plate (crushed)
40
Nifedipine- what is it and what are the side effects?
Dihydropyridine class of Ca channel blockers. Associated with headaches and perph edema.
41
A person with HIV develops an abdominal mass, is reactive for EBV, and has elevated LDH...what do they have?
Burkitt's lymphoma.
42
First line drugs for OCD:
SSRIs like fluoxamine
43
What is the most common histologic type of thyroid carcinoma?
papillary carcinoma
44
How do you treat a patient with EtOH liver disease presenting with confusion and asterixes?
Pt has hepatic encephalopathy. Tx is lactulose- which directly treats the elevated ammonia causing the sx.
45
What is a common sequelae of treatment for ALL?
Osteonecrosis is a common effect of tx with methotrexate and glucocorticoids.
46
What drug has no role in prevention of ischemic CVA or recurrent TIA?
Warfarin. Aspirin, dipyridamole, clopidogrel all do.
47
What is the drug of choice for prevention of NSAID-induced peptic ulcers?
Omeprazole (prilosec)
48
Contact dermatitis is which type of hypersensitivity reaction?
Type IV- delayed type
49
Hirchsprung disease
also known as congenital megacolon, is an abnormality in which certain nerve fibers are absent in segments of the bowel, resulting in severe bowel obstruction. Hirschsprung's disease is caused when cells in the wall of the colon (parasympathetic ganglion cells) do not develop before birth. The affected segment of the intestine lacks the ability to relax and move bowel contents along. As a result of this area of constriction, the bowel proximal (or above the stricture) dilates, producing megacolon (dilation of the colon).
50
Pyloric stenosis
Symptoms of gastric outlet obstruction (pyloric stenosis), consisting of non-bilious projectile vomiting, usually occurs at 3 - 5 weeks of age. Classically the hypertrophied pylorus is palpable as an olive. The ratio of males to females is 4:1. It is due to thickening and elongation of the circular muscles of the pyloric canal with narrowing of the pyloric lumen.
51
A patient with acute appendicitis is almost never...
hungry
52
What is the preferred treatment for carotid dissection? What does it look like on angiogram?
On angiogram there is string sign (dye travels further in one edge of the vessel than the rest of the lumen in that cross-section) Tx is anticoagulation.
53
using serum folate, RBC folate, and serum B12, how can you distinguish between a combined B12 and folate deficiency and a pure folate or B12 deficiency?
Serum folate does serve to distinguish combined folate and B12 deficiency from vitamin B12 deficiency alone. Low serum folate indicates only negative folate balance but not folate deficiency. The triad of low serum folate, normal serum B12 and decreased red cell folate is consistent with the diagnosis of folate deficiency.
54
Achalasia puts patients at risk for what?
esophageal cancer.
55
The most consistent early sign of compartment syndrome is:
pain on passive stretching of involved muscle. Cyanosis or pallor also occurs early but is not specific to compartment syndrome.
56
What are the phases of wound healing and what is happening in each?
1- inflammatory- platelet activation and migration of WBCs. Neovascularization begins. Days 0-4 2- Proliferative phase- production of collagen. Begins day 4 and lasts 3 weeks. 3- Remodeling- 7 months. 50% of tensile strength is there by 6 weeks.
57
For a person on chronic corticosteroids for RA who has just had joint replacement, what supplement will promote wound healing?
Vitamin A.
58
What is a "clean-contaminated" case?
any operation of respiratory, GI, or GU tracts where those areas are entered in a controlled fashion and there is no intraoperative contamination, like open cholecystectomy. Bowel resection is a "dirty" procedure.
59
What is the best prognostic respiratory indicator for whether a patient will be able to wean off of a ventilator?
FEV1 (>1). Less than 1 indicates higher risk of complications.
60
What are the most common types of shock encounteresd in the surgical or trauma patient?
hypovolemic and hemorrhagic. If post op day 4 for bowel surgery then its prob septic.
61
What is the most common gall stone type in the US?
Mixed
62
What are black gall stones associated with?
hemolysis and cirrhosis
63
What race in the US has the highest incidence of gall stones?
American Indians.
64
A pt with RUQ pain, nausea, vomiting and NO jaundice likely has...
obstruction of CYSTIC duct with inflammation.
65
What is Courvoisier sign? What does it suggest?
a palpable, NONTENDER gallbladder. Suggests pancreatic malignancy.
66
What ultrasound finding is commonly associated with coledocholithiasis?
Dilated hepatic ducts
67
If you find a post-hepatic obstruction on US, what is the best study to localize the obstruction?
CT abdomen.
68
What is the treatment of cholelithiasis?
cholecystectomy.
69
What are Randon's criteria?
They grade the severity of pancreatitis with lab and clinical findings measured at admission and again within the next 48 hrs. Signs are: Age, WBC, glucose, LDH, and AST elevation. Within 48 hrs HCT, BUN, Ca, pO2, base deficit, and estimated fluid sequestration are measured. When
70
What is the most important prognostic indicator for a breast tumor?
Axillary lymph node involvement.
71
What symptom is very specific for abdominal pain secondary to chronic intestinal ischemia??
Fear of eating. Nausea, vomiting, bloody diarrhea, and guarding are more suggestive of acute intestinal ischemia.
72
How do the ulcers of arterial insufficiency typically present?
Painful with punched-out appearance and a pale or necrotic base. Typically on toes, heels, or dorsum of foot.
73
Ulcers that occur on the maleoli are usually...
venous stasis ulcers. Typically also have lower extremity edema and pigmination changes with granulation tissue at the base.
74
How do you treat localized low grade dysplasia of distal colon?
Proctocolectomy with anal pull-through
75
How are hemorrhoid classified?
I - non pro lapsing II- prolapses only during defecation, then reduces itself III- requires manual reduction IV- incarcerated
76
TNM classification
T is size- 2-5 cm is T2 t1 is 5. T4 means invasion of chest wall or skin. N is nodes- N1 is 1-3 nodes, axillary only. N2 is fixed (immobile) ipsilateral axillary or internal mammory nodes without axillaries. n3 is ipsilateral nodes like infraclavicular or both axillary and internal mammory M is metastasis
77
What is an absolute contraindication to resection of a lung tumor?
Malignant pleural effusion or MI within 3 months
78
What is the preferred management of simple achalesia without complications?
Myotomy or pneumatic dilation
79
How do you treat superficial phlebitis?
Warm compresses and NSAIDs
80
How is a subarachnoid hemorrhage approached surgically?
If grade II or lower and within 72 hours of rupture- treat with craniotomy with clipping of the neck If grade III OR higher, treat with coiling after the patient is stabilized
81
Whats the largest risk when operating on the thyroid or parathyroid?
Damaging bilateral recurrent laryngeal nerve- it will cause abduction of both vocal folds and closure of the airway.
82
What is the preferred treatment of papillary carcinoma of the thyroid?
This is the most common thyroid cancer. Tx is total thyroidectomy with post op radioiodine ablation
83
What is the first step in preparing the patient for resection of a pheochromocytoma?
Alpha blockers to reduce the BP- pt is severely vasoconstricted. Alpha blockers end in -zosin...universally.
84
What is the appropriate diagnostic test for a patient who sustained blunt force trauma?
Ultrasound (focussed assessment with sonography for trauma)
85
Treatment for small splenic laceration
Non surgical management
86
What's the preferred treatment for a patient with complete intrahepatoc portal vein thrombosis?
End to side portocaval shunt
87
What is the most common cause of surgical splenectomy?
Trauma
88
What is the most common site of an acute arterial occlusion due to embolic disease?
Femoral artery
89
What is the underlying pathophysiology of acute appendicitis?
Obstruction of the lumen of the appendix. Causes are: 1 lymphoid hyperplasia and 2 fecalith
90
At what age is surgery indicated for an asymptomatic umbilical hernia?
Age 4 to 5
91
What is a Hartman procedure and what is it indicated for?
It's indicated for acute perforation large bowel. Procedure includes resection of the affected portion of bowel, a temporary diverting colostomy and oversewing of the distal rectal stump. The second stage of the procedure will involve taking down the colostomy with anastomosis to the rectal stump. It is preferred for an unprepped bowel.
92
What is the most important risk factor for the development of colon cancer?
Age
93
What is the preferred treatment for epidermoid carcinoma of the anal canal?
Local resection, chemotherapy, and external beam radiation
94
What is the most common etiology of an incisional hernia?
Deep wound infection
95
Which physical exam findings pathognomonic of advanced gastric carcinoma?
A palpable umbilical nodule
96
What imaging modality is preferred in patients suspected of having Zollinger Ellison syndrome?
Somatostatin receptor scintography...aka octreotide scan. It's for detecting pancreatic and neuroendocrine tumors. ZE syndrome is a pancreatic gastrinoma
97
List some ways to differentiate ulcerative colitis from Crohn's disease.
Ulcerative colitis: Colon only, continuous, you Cosa and submucosa only, no granulomas, bleeding common. Crohn's disease: can occur in any part of the G.I. tract, skip lesions, transmural involvement, noncaseating granuloma's, fistulae and strictures common
98
What are some good ways to differentiate the clinical presentation of esophageal cancer versus achalasia?
Achalasia presents with dysphasia. Esophageal cancer tends to present with odynophagia and weight loss.
99
What laboratory finding suggests SIADH? What can cause this?
Urine Na > Blood Na. Typically urine Na is >20mEq/L. AIDS, tumors, CNS dysfunction, or drugs (especially SSRIs in elderly patients).
100
How do signs and symptoms of gastric and duodenal ulcers differ?
Gastric- typically in older patients, smoking is a risk factor. Pain is exacerbated by eating. H. pylori in 60-70%. Duodenal- typically younger patients, with lower rate of malignancy than peptic. Caused by NSAIDs with 70-90% H. pylori prevalence. Eating relieves pain. Pain worse at night.
101
Scoliosis should be treated if there is deformity beyond....
20 degrees
102
Leg is flexed, abducted and externally rotated. Injury?
Anterior hip dislocation

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