Surgery Rotation 10

Question 1

Side effect of succinylcholine

Answer 1

Hyperkalemia (arrhythmias)

Succ is a depolarizing agent; binds to ACh receptor triggering influx of Na+ and efflux of K+

Question 2

Major side effect of Halothan

Answer 2

Liver failure - due to hepatotoxic intermediates

Now rarely used

Question 3

Major side effect of Propofol

Answer 3

Severe hypotension due to arterial and venous dilation

Question 4

What is feared complication of scaphoid fracture

Answer 4

Scaphoid fx = pain in anatomical snuffbox

Fear of osteonecrosis because this is where blood supply enters (radial artery)

Question 5

signs of necrotizing surgical site infection

Answer 5

Dishwater drainage (purulent, cloud-gray discharge)
SubQ crepitus
Pain, edema, erythema
Systemic signs (fever, hypotension, tachycardia)
Parasthesia or anesthesia at edges of wound

Question 6

Tx of necrotizing surgical site infection

Answer 6

Parenteral abx + surgical debridement

Question 7

When are wound-vacs used

Answer 7

To accelerate healing process in healthy, granulating wounds

Not for infected or necrotic wounds

Question 8

What is the next step in management after placement of central line?

Answer 8

CXR to see if catheter tip is in SVC

Question 9

Management of patient who was successfully treated for acute pancreatitis due to gallstones?

Answer 9

Cholecystectomy to reduce risk of recurrent gallstone pancreatitis

Question 10

What is pilonidal disease?

Answer 10

Edematous, infected hair follicle in the intergluteal region becomes occluded

Abscess forms which can rupture and create a pilonidal sinus tract

Presents with fluctuant mass cephalad to anus with mucoid, purulent, or bloody drainage

Question 11

Tx of pilonidal disease?

Answer 11

Drainage of abscess and collected debris followed by excision of sinus tracts

Question 12

What is hidradenitis suppurativa?

Answer 12

Follicular occlusion disease presenting with multiple, recurrent, painful nodules in axilla, inguinal folds, and perineal areas

Question 13

Test used to determine diagnosis of peripheral artery disease

Answer 13

Ankle-brachial index

< 0.9 = abnormal

Question 14

What is emphysematous cholecystitis

Answer 14

Life-threatening form of acute cholecystitis due to infection with gas-forming bacteria (e.g. Clostridium)

Imaging shows air-fluid levels in gallbladder, gas in gallbladder wall, occasional pneumobilia

Question 15

Diagnose and treat: pain at incision site, edema, induration with no drainage

Answer 15

Cellulitis

Tx with abx

Question 16

Diagnose and treat: pain at incision site, induration with no drainage

Answer 16

Simple wound infection

Reopen wound and repack. No abx necessary

Question 17

Diagnose and treat: pain at incision site, with salmon colored fluid from incision

Answer 17

Dehiscence

Surgical emergency! Go to OR, IV abx, primary closure of fascia

Question 18

Describe stage 1 of pressure ulcer + tx

Answer 18

Skin intact but red. Blanches with pressure

Tx = basic, cream, decrease pressure

Question 19

Stage 2 pressure ulcer + tx

Answer 19

Blister or break in dermis

Tx = basic, cream, decrease pressure

Question 20

Stage 3 pressure ulcer + tx

Answer 20

SubQ destruction into muscle

Tx = surgery

Question 21

Stage 4 pressure ulcer + tx

Answer 21

Involvement of joint or bone

Tx = surgery

Question 22

Indications for surgery in spontaneous pneumothorax (e.g. emphysema rupture)

Answer 22

• Recurring spontaneous pneumo
• Bilateral
• Incomplete lung expansion
• Occupation that would be really bad if they pass out (e.g. pilot or scuba diver)

Question 23

Surgical tx for pneumothorax

Answer 23

VATS = video-assisted thoracic surgery

or Pleurodesis = shove stuff in there to make pleura stick

Question 24

Diagnose: small air-fluid level in lung

Answer 24

Abscess

Question 25

Tx of lung abscess

Answer 25

Initially with abx - not drainage!

Question 26

Indication for surgical drainage of lung abcscess

Answer 26

Abx fail, abscess > 6cm, or if empyema is present (collection of pus in a pre-existing abd cavity)

Question 27

1st step of solitary lung nodule

Answer 27

Compare to previous x-ray

Question 28

Tx of small benign solitary lung nodule

Answer 28

Close follow up | Don't need to remove

Question 29

4 main types of lung cancer

Answer 29

1. Small cell 2. Non-small cell 2a. Squamous cell 2b. Adenocarcinoma 2c. Large cell carcinoma

Question 30

Most common type of lung cancer in non-smokers

Answer 30

Adenocarcinoma

Question 31

Is adenocarcinoma peripheral or central?

Answer 31

Peripheral

Question 32

Is squamous cell carcinoma peripheral or central

Answer 32

Central

Question 33

Disease associated with squamous cell carcinoma of lung

Answer 33

Paraneoplastic | May produce PTH = hypercalcemia

Question 34

What lung cancer is associated with Pancoast tumor

Answer 34

Small cell

Question 35

Presentation of pancoast tumor

Answer 35

• Hoarseness recurrent laryngeal nerve • Horner syndrome (ptosis, miosis, anhydrosis) superior cervical ganglion • SVC syndrome superior vena cava o Facial plethora o Jugular venous distension o Edema and blue discoloration of arms and face • Sensorimotor deficit

Question 36

What cancer is associated with Lambert Eaton

Answer 36

Small cell carcinoma

Question 37

Paraneoplastic syndromes associated with small cell carcinoma of lung

Answer 37

- ADH = SIADH - ACTH = Cushing’s - Antibodies against pre-synaptic Ca2+ channels = Lambert-Eaton

Question 38

Is large cell lung carcinoma peripheral or central

Answer 38

Peripheral Large cell has poor prognosis

Question 39

Causes of ARDS

Answer 39

Gram neg sepsis, gastric aspiration, trauma, low perfusion, pancreatitis

Question 40

How do you diagnose ARDS?

Answer 40

1. Bilateral alveolar infiltrates on CXR 2. PaO2/FiO2 ratio < 200 (=hypoxia) 3. Rule out cardiac cause - PCWP < 18 (means pulmonary edema is non-cardio)

Question 41

Treatment of ARDS

Answer 41

PEEP

Question 42

What murmur is increased by valsalva?

Answer 42

Valsalva increases intrathoracic pressure, thus decreasing preload (opposite of inspiration) Decreases the intensity of most murmurs EXCEPT increases intensity of hypertrophic cardiomyopathy

Question 43

Holosystolic blowing murmur

Answer 43

Mitral regurg

Question 44

Holosystolic murmur with late diastolic rumble in kids

Answer 44

VSD

Question 45

Continuous machine like murmur

Answer 45

PDA

Question 46

Wide fixed and split S2

Answer 46

ASD - Occurs during right heart overload (e.g. atrial septal defect) - ASD = L-to-R shunt = increased RA and RV volumes = increased flow through pulmonic valve such that, regardless of breath, pulmonic closure is delayed

Question 47

Rumbling diastolic murmur with an opening snap

Answer 47

Mitral stenosis

Question 48

Blowing diastolic murmur with widened pulse pressure

Answer 48

Aortic regurgitation

Question 49

Tx of Zenker's diverticulum

Answer 49

False diverticula in the esophagus (bad breath) Tx = surgery

Question 50

Tx of achalasia

Answer 50

Dysphagia to liquids and solids + bird beak barium swallow Tx = CCB, nitrates

Question 51

Tx of GERD

Answer 51

Behavioral modification, antacids, H2 blockers, PPIs

Question 52

What are indications for surgery with GERD

Answer 52

Bleeding, stricture, Barrett's, incompetent LES, max dose PPI with persistent sx

Question 53

Tx of asymptomatic esophageal varices

Answer 53

DO NOT prophylactically band! Give beta blockers Only band symptomatic varices

Question 54

Management of suspected esophageal cancer (e.g. progressive dysphagia with weight loss)

Answer 54

Barium swallow, then endoscopy with biopsy