Surgery Rotation 2

Question 1

What percent is normal saline?

Answer 1

0.9%

Question 2

Next steps in a patient with signs of GERD

Answer 2

Upper GI endoscopy

Question 3

Causes of post-operative atelectasis

Answer 3

♣ Accumulation of pharyngeal secretions
♣ Tongue prolapsing posteriorly into the pharynx
♣ Airway tissue edema
♣ Residual anesthetic effects

Question 4

What are the ways in which head trauma can cause problems

Answer 4

• Damage of the initial blow
• Intracranial bleed displacing brain structures
• Intracranial hemorrhage

Question 5

What is the difference between an epidural and subdural hematoma (on XR and clinically)

Answer 5

Epidural = lens shaped; can occur from less serious trauma; longer lucid interval

Subdural = crescent shaped; can be acute with severe trauma, or chronic

Question 6

What type of brain bleed can easily occur the elderly and alcoholics and why

Answer 6

Subdural

Their brains have shrunk but cranial cavity is the same size so it is easy for the brain to be “rattled” and to tear bridging veins

Question 7

How do you manage head trauma in a patient with no bleed

Answer 7

Prepare for edema

Mannitol, furosimide, hyperventilation

Question 8

Describe Cushing reaction (Triad of hypertension, bradycardia, and respiratory depression in response to increased intracranial pressure)

Answer 8

Increased ICP = pressure constricts arterioles in brain = cerebral ischemia = sympathetic response increases peripheral vasoconstriction, thus increasing BP = aortic baroreceptors sense increased BP = respond with reflex bradycardia and respiratory depression

Question 9

How does hyperventilation help with cerebral edema

Answer 9

A drop in PaCO2 due to hyperventilation causes vasoconstriction = decreased cerebral blood flow = decreased ICP

Question 10

Which way will the trachea deviate in tension pneumothorax

Answer 10

Away from side of lesion

Air enters the pleural space but cannot exit, and air continues to build up with each breath

Question 11

What is a pleural effusion

Answer 11

Build up of fluid around the lung

Trachea deviates away from side of lesion

Question 12

Where is the damage in initial hematuria (blood only at beginning of voiding)

Answer 12

Urethral damage

Question 13

Where is the problem in terminal hematuria (blood at end of voiding)

Answer 13

Bladder, prostate, or posterior urethra

Question 14

Where is the problem in total hematuria (blood throughout entire voiding)

Answer 14

Kidney or ureters

Question 15

What is the “psoas sign”

Answer 15

Abd pain with hip extension

Question 16

Damage to what part of the bladder may cause peritonitis (diffuse abdominal pain and guarding)

Answer 16

Dome of the bladder (superior and lateral surfaces of the bladder which are bordered by the peritoneal cavity)

Rupture can cause the spilling of urine into the peritoneum

Question 17

Irritation of what structure causes referred pain to the shoulder

Answer 17

Diaphragm

Can be irritated by many things (e.g. peritonitis or pericarditis)

Question 18

What would be the clinical presentation of rupture to anterior bladder wall or bladder neck?

Answer 18

Usually caused by pelvic fracture

Causes extraperitoneal leakage of urine, leading to localized lower abdominal pain; signs of peritonitis should not be present

Question 19

What are the retroperitoneal structures?

Answer 19

o	SAD PUCKER
♣	S  Suprarenal (adrenal gland)
♣	A  Aorta and IVC
♣	D  Duodenum (2nd through 4th parts)
♣	P  Pancreas (except tail)
♣	U  Ureters
♣	C  Colon (descending and ascending)
♣	K  Kidneys
♣	E  Esophagus (thoracic portion)
♣	R  Rectum (partially)

Question 20

Signs of basilar skull fracture

Answer 20

• Hematoma of the mastoid process or periauricular hematoma (Battle’s sign)
• Bilateral peri-orbital hematoma (raccoon eyes)
• Hemotympanum
• CSF fluid otorrhea
• Cranial nerve palsies (resulting in anosmia, vertigo, tinnitus, or hearing loss)

Question 21

Potential complication of thoracic aortic aneurysm surgery that causes bilateral flaccid paralysis and loss of pain/temp in lower extremities

Answer 21

Spinal cord infarction (due to aortic cross-clamping) leading to anterior spinal cord syndrome

Question 22

What do hyperactive bowel sounds suggest?

Answer 22

Diarrhea, malabsorption (e.g. Celiac or lactose intolerance), incomplete mechanical bowel obstruction

Question 23

Most common cause of bowel obstruction

Answer 23

Adhesions

Question 24

Presentation of syringomyelia

Answer 24

• Anterior white commissure:
o Loss of pain and temp with sparing of fine touch and position “cape-like” distribution
• Anterior horn involvement can occur with progression of disease
o Lower motor neuron effects
• Lateral horn of hypothalamospinal tract
o Horner syndrome

Question 25

Presentation of ALS

Answer 25

UM and LMN deficits (twitching, muscle weakness, cramping) NO loss of sensory function

Question 26

Presentation of multiple sclerosis

Answer 26

``` Due to autoimmune demyelination of CNS ♣ Charcot triad of symptoms SIN: • Scanning speech • Intention tremor, Incontinence, Internuclear ophthalmoplegia • Nystagmus ♣ Hemiparesis, hemisensory symptoms ```

Question 27

Causes of syringomyelia

Answer 27

• Arnold Chiari I malformation • Prior spinal cord injury o Clasically an MVC with whiplash o Symptoms develop months or years after the initial injury and progress gradually

Question 28

What are the 3 components of Glasgow coma scale (GCS)

Answer 28

Eye opening Verbal response Motor response

Question 29

What is a furunculosis

Answer 29

Deep infection of the hair follicle leading to abscess formation and accumulation of pus and necrotic tissue

Question 30

How do you differentiate between compartment syndrome and DVT

Answer 30

CS = swelling + excruciating pain worse with passive movement; presence of neuro sx; diagnosed with compartment pressure DVT = pain and swelling with less insidious onset and less severe; diagnosed with doppler US

Question 31

What are the 2 main complications caused by rib fractures What is the most important part of management

Answer 31

Pain leads to hypoventilation which may cause atelectasis and pneumonia Pain control is the most important part of management

Question 32

When is surgical repair of rib fracture indicated?

Answer 32

Flail chest with failure to wean from ventilator, refractory pain, significant chest wall deformity Not indicated in single, uncomplicated rib fractures

Question 33

What will be the BUN:Cr ratio in Pre-renal, intrinsic, and post-renal azotemia

Answer 33

Pre-renal = BUN:Cr > 20 (BUN is reabsorbed and Cr is not) Intrinsic = BUN:Cr < 15 (damage to tubules) Post-renal = > 20 early on and < 15 later stage when tubular damage occurs

Question 34

What form of diagnosis is needed for appendectomy

Answer 34

Classic clinical and lab findings of appendicitis Imaging (US or CT) is not needed unless patient has atypical presentation or other possible causes of RLQ pain

Question 35

Presentation of Toxic shock syndrome

Answer 35

Fever, hypotension, diffuse rash

Question 36

What are the ABCs of melanoma

Answer 36

``` A = asymmetry B = irregular border C = color variability D = diameter > 6 mm E = evolution of size/appearance ```

Question 37

What is the difference between conductive and sensorineural hearing loss

Answer 37

Conductive • Obstruction of external sound to inner ear Sensorineural • Involves the inner ear, cochlea, or auditory nerve

Question 38

Describe Rinne test and how results differ in conductive vs. sensorineural hearing loss

Answer 38

♣ Vibrating tuning fork placed on mastoid bone until patient can’t hear it ♣ Still-vibrating fork then held outside auditory canal until patient can’t hear it ♣ Results: • Normal = Air-conducted (AC) sound should be heard twice as long as bone-conducted (BC) sound • Conductive hearing loss = BC > AC in affected ear; AC > BC in unaffected ear • Sensorineural hearing loss = AC > BC in both ears

Question 39

Describe Weber test and how results differ in conductive vs. sensorineural hearing loss

Answer 39

♣ Vibrating tuning fork placed on middle of head or forehead equidistant from both ears ♣ Results: • Normal: o Midline • Conductive hearing loss: o Lateralizes to the affected ear because that ear cannot hear ambient noise of the room • Sensorineural hearing loss: o Lateralize to the unaffected ear because the inner ear of the affected ear cannot sense the vibration

Question 40

What is otosclerosis

Answer 40

Abnormal remodeling of the otic capsule though to be a possible autoimmune process; the stapes footplate becomes fixed to the oval window Causes conductive hearing loss

Question 41

What type of hearing loss is caused by ototoxic antibiotics

Answer 41

Sensorineural

Question 42

What is Meniere disease

Answer 42

``` • Increased pressure and volume of endolymph • Features: o Recurrent vertigo o Ear fullness/pain o Unilateral sensorineural hearing loss o Tinnitus ```

Question 43

Affected areas in rheumatic heart disease

Answer 43

Early disease = mitral regurg Late disease = mitral stenosis

Question 44

Cause of secondary hyperparathyroidism

Answer 44

Due to decreased calcium, usually secondary to renal disease

Question 45

Cause and content of transudative pleural effusion

Answer 45

Low protein content (Think: TRANSudate = TRANSparent) Due to increased hydrostatic pressure (e.g. CHF) or decreased oncotic pressure (e.g. cirrhosis or nephrotic syndrome)

Question 46

Cause and content of exudative pleural effusion

Answer 46

High protein content, cloudy Due to pleural and lung inflammation resulting in increased capillary and pleural membrane permeability (e.g. malignancy, pneumonia, trauma, connective tissue disease)

Question 47

What is atrioventricular nodal reentry tachycardia

Answer 47

Subtype of SVT Caused by a reentrant circuit formed by 2 separate conducting pathways (one fast and the other slow) within the AV node Characterized by sudden onset and termination, rapid (140-250/min) regular rhythm, narrow QRS complexes, and absence of definite P waves

Question 48

Most common cause of atrial fibrillation

Answer 48

Ectopic foci within the the pulmonary veins

Question 49

Treatment of Prinzmetal / Vasospastic angina

Answer 49

- Calcium channel blocker (preventive) | - Sublingual nitroglycerin (abortive)

Question 50

What are the dihydropyridine CCBs?

Answer 50

"-dipine" suffix Nifedipine, Nimodipine

Question 51

What are the non-dihydropyridine CCBs?

Answer 51

Verapamil | Diltiazem

Question 52

Management of healthy patient with a thyroid nodule

Answer 52

Measurement of TSH + thyroid US