Surgery Rotation 6

Question 1

Damage and presentation of anterior shoulder dislocation

Answer 1

Axillary nerve damage - sensation to lateral shoulder and deltoid (shoulder abduction) weakness

Question 2

Damage and presentation of humeral mid-shaft fracture

Answer 2

Damage to radial nerve - sensation to posterior arm, forearm, and dorsolateral hand; extensor muscles

Question 3

Presentation of uncal herniation

Answer 3

Ipsilateral hemiparesis and CN III (oculomotor) palsy

Question 4

Presentation of pulmonary contusion

Answer 4

Presents <24 hours after blunt thoracic trauma

Tachypnea, tachycardia, hypoxia

CT scan or CXR with patchy, alveolar infilatrate

Question 5

Positive Neer’s impingement test indicates what?

Answer 5

Rotator cuff impingement or tendinopathy

Question 6

What is wound dehiscence

Answer 6

Opening of wound

Salmon colored fluid coming from closed wound, indicating that peritoneal fluid is leaking out - aka deeper layers are not healed yet

Question 7

Treatment of wound dehiscence

Answer 7

Protection of wound, minimal activity, give it time to heal without increased abd pressure

At a convenient time, repair wound

Question 8

Management of abd fistula

Answer 8

• fluid replacement
• electrolyte replacement
• elemental nutrient replacement (something that won’t stir up enzymes)
• protection of abd wall from bowel contents (suction device)

Question 9

Things that prevent a fistula from healing

Answer 9

FETID

• Foreign body
• Epithelialization (epithelium from skin and from bowel can grow towards each other to line the lumen)
• Tumor
• Infection, irradiated tissue, IBD
• Distal obstruction

Question 10

Studies to evaluate blunt GU trauma

Answer 10

Clinical signs of renal trauma (e.g. CVA tenderness) = contrast CT

Clinical signs of urethral injury (e.g. gross hematuria) = gross hematuria

Question 11

CAUSECause of hypoxia in flail chest

Answer 11

Pain causes patients to take shallow breaths

Rib fracture may cause lung contusion/hemothorax

Question 12

Management of flail chest

Answer 12

Pain control, supplemental O2

Positive pressure ventilation (+/-) chest tube if respiratory failure

Question 13

Presentation of esophageal rupture

Answer 13

subcutaneous crepitus in chest and pneumomediastinum

Question 14

Will you have increased or decreased bowel sounds in small bowel obstruction and in ileus

Answer 14

SBO = increased bowel sounds
Ileus = decreased/absent bowel sounds

Question 15

Muscles of rotator cuff

Answer 15

SItS:

• Supraspinatus (initial abduction of arm, before deltoid)
• Infraspinatus (lateral rotation)
• Teres minor (lateral rotation and adduction)
• Subscapularis (medial rotation and adduction)

Question 16

Test used to assess damage to supraspinatus

Answer 16

Drop arm test = patient’s arm is abducted above the head and patient is asked to lower arm slowly - in a tear, the arm will drop rapidly around mid-adduciton

Question 17

What structures are at risk for damage in a supracondylar fracture of the humerus (right above the elbow)

Answer 17

Entrapment of brachial artery (which branches into radial and ulnar artery) or median nerve

Question 18

Steps to find the source of blood per rectum

Answer 18

Could be from upper or lower GI:

1) NG tube to aspirate gastric contents to check for blood - if no blood, then you can exclude tip of nose to pylorus
2) Upper GI endoscopy to exclude duodenum - want to see green fluid (bile tinged)
3) Anoscopy to exclude hemorrhoids (cannot do colonoscopy during active bleeding b/c blood obscures the field)
4a) 1/2 options - angiogram for more severe bleeds
4b) 2/2 options - if less blood, wait until bleeding stops and do a colonoscopy

Question 19

Most common cause of perforated abd

Answer 19

Perforated peptic ulcer

Question 20

Presentation of glucagonoma

Answer 20

Necrolytic dermatitis, diabetes (hyperglycemia), DVT, weight loss, depression

Question 21

Difference in gallbladder in obstruction caused by stones vs. malignancy

Answer 21

Stones = dilated ducts with nondilated gallbladder full of stones

Malignancy = large, thin-walled distended gallbladde

Question 22

Describe the percentage of body surface area when dealing with burns in adults

Answer 22

Rule of 9s:

Head = one 9
Each upper extr = one 9
Trunk = four 9s; two in front and two in back
Each lower extr = two 9s; one in front and one in back

Question 23

Describe the percentage of body surface area when dealing with burns in kids

Answer 23

Rule of 9s:

Head = two 9s
Each upper extr = one 9
Trunk = four 9s; two in front and two in back
Both lower extr = total of three 9s; 1.5 each

Question 24

Definition of “-pexy”

Answer 24

To hold in place

Question 25

Definition of "-rrhaphy"

Answer 25

To saw together

Question 26

Components of Whipple procedure

Answer 26

- Cholecystectomy - Truncal vagotomy - Antrectomy - Pancreaticoduodenectomy—removal of head of pancreas and duodenum - Choledochojejunostomy—anastomosis of common bile duct to jejunum - Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum - Gastrojejunostomy—anastomosis of stomach to jejunum

Question 27

Definition of "-tomy"

Answer 27

To cut

Question 28

Definition of "-ectomy"

Answer 28

To take out or resect

Question 29

Definition of "-ostomy"

Answer 29

To make a mouth/opening Could be from a single organ to the outside (colostomy) or could be an anastomoses between two organs (gastrojejunostomy)

Question 30

Definition of "-plasty"

Answer 30

To change the shape of something

Question 31

Fluid given for hypovolemic hypernatrermia (both symptomatic and asymptomatic)•

Answer 31

Non-symptomatic o 5% dextrose Symptomatic o 0.9% saline (isotonic solution) until Euvolemic, then 5% dextrose (hypotonic solution)

Question 32

What causes metabolic alkalosis

Answer 32

``` ♣ Causes: • Losing H+ excessive vomiting, diuretics, hyperaldosteronism ♣ Differential of metabolic alkalofis (pH > 7.45; HCO3- > 24) • Low urine chloride ♣ Will respond to saline o Vomiting/nasogastric aspiration o Prior diuretic use • High urine chloride o Hypovolemia/euvolemia ♣ Current diuretic use • Will responds to saline ♣ Bartter & Gitelman syndrome • Saline unresponsive o Hypervolemia ♣ Excessive mineralocorticoid activity o Saline unresponsive • Primary hyperaldosteronism • Cushing disease • Ectopic ACTH production ```

Question 33

Differential dx of acute abd

Answer 33

Perforation Obstruction Inflammatory process Ischemic process

Question 34

Cause and presentation of thrombotic thrombocytopenic purpura (TTP)

Answer 34

o Platelets used up in pathologic formation of microthrombi in small vessels o Due to decreased ADAMTS13, enzyme that normally cleaves vWF for degradation ♣ No vWF degradation = abnormal platelet adhesion = microthrombi o Findings (Pentad): ♣ Thrombocytopenia = platelets being used up ♣ Microangiopathic hemolytic anemia = RBCs sheared by microthrombi ♣ Renal insufficiency (thrombi involve vessels of the kidney) ♣ Neurological symptoms (confusion, HA, seizures, coma) – thrombi involve vessels of CNS ♣ Fever

Question 35

Will Na+ and K+ be high or low in DKA?

Answer 35

♣ Sodium levels will be low • Hyponatremia due to sodium loss via diuresis (osmotic diuresis due to increased glucose) ♣ High serum potassium but low total body potassium • Cells will exchange H+ for K+ causing high potassium • Potassium in the blood will be excreted cause low total body potassium

Question 36

What causes metabolic acidosis

Answer 36

``` • Anion gap Adding acid to the blood o MUDPILES: ♣ M – Methanol ♣ U – Uremia (renal failure) ♣ D – Diabetic ketoacidosis ♣ P – Propylene glycol/Paraldehyde ♣ I – Isoniazid/Iron ♣ L – Lactic acidosis ♣ E – Ethylene glycol (antifreeze) ♣ S – Salicylates (aspirin) • Non-anion gap Losing excessive HCO3- o Diarrhea, Renal tubular acidosis, Spironolactone, Acetazolamide ```

Question 37

IV fluids given to treat DKA

Answer 37

♣ 0.9% normal saline initially | ♣ Add dextrose 5% when serum glucose <200 mg/dL

Question 38

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

Answer 38

Epidural = lens shaped; can occur from less serious trauma; longer lucid interval Subdural = crescent shaped; can be acute with severe trauma, or chronic

Question 39

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

Answer 39

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 40

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

Answer 40

Prepare for edema Mannitol, furosimide, hyperventilation

Question 41

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

Answer 41

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 42

How does hyperventilation help with cerebral edema

Answer 42

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

Question 43

Where is the damage in: 1. initial hematuria (blood only at beginning of voiding) 2. terminal hematuria (blood at end of voiding) 3. total hematuria (blood throughout entire voiding)

Answer 43

1. Urethral damage 2. Bladder, prostate, or posterior urethra 3. Kidney or ureters

Question 44

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

Answer 44

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

Question 45

What do hyperactive bowel sounds suggest?

Answer 45

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