Surgery Rotation 9

Question 1

Management for fx of metatarsal

Answer 1

Middle metatarsals (2, 3, 4) - can usually heal with rest and analgesics

5th metatarsal has increased risk for nonunion - managed with casting or internal fixation

Question 2

Causes of post-op fever

Answer 2

Malignant hyperthermia (immediate)
Bacteremia
Atelectasis
Pneumonia 
UTI (3 days later)
DVT (5 days later)
Wound infection 

Remember: 4 Ws for timing
Wind - atelectasis 
Water - UTI
Walking - DVT 
Wound - infection 
Wonder where - abscess

Question 3

Contents of the spermatic cord

Answer 3

Ductus deferens
Testicular artery
Pampiniform plexus
Genital branch of genitofemoral nerve
Cremasteric muscle

Question 4

What is the referred subscapular pain from gallstones called?

Answer 4

Boas sign

Question 5

What is Charcot’s triad

Answer 5

For cholangitis

Jaundice, fever, RUQ pain

Question 6

What is the pentad of sx associated with cholangitis

Answer 6

Reynold’s pentad

jaundice, fever, RUQ pain, hypotension, AMS

Question 7

Boundaries of femoral canal

Answer 7

1. Cooper’s ligament posteriorly
2. Inguinal ligament anteriorly
3. Femoral vein laterally
4. Lacunar ligament medially

Question 8

Most important factors for predicting mortality for surgery

Answer 8

1. CHF - check EF
2. MI within 6 months - check EKG
3. Arrhythmias
4. Old age
5. Emergent surgery
6. Aortic stenosis - listen for murmur (late systolic, crescendo-decrescendo)

Question 9

Meds to stop before surgery

Answer 9

Aspirin, NSAIDs, Warfarin, metformin (lactic acidosis)

Question 10

Formula for anion gap + normal value

Answer 10

Na - (Cl + HCO3)

Normal = 8-12

Question 11

What is the concern when correcting hypernatremia

Answer 11

Cerebral edema

Question 12

Treatment for hyperkalemia

Answer 12

Calcium gluconate (to stabilize cardiac membranes), insulin and glucose, albuterol (also shifts K+ into cells), last resort = dialysis

Question 13

Formula for fluid resuscitation in adult burn victim

Answer 13

(Kg) x (% burn surface area) x (3-4)

Question 14

Formula for fluid resuscitation in child burn victim

Answer 14

(Kg) x (% burn surface area) x (2-4)

Question 15

What do you see on X-ray of paralytic ileus

Answer 15

Dilated gas-filled loops of bowel with no transition point

Question 16

What will you see on CT in colonic ischemia

Answer 16

Edema and air (pneumatosis) in the bowel wall

Question 17

What will you see on colonoscopy of colonic ischemia?

Answer 17

Segments of cyanotic mucosa and hemorrhagic ulceration with sharp transition from affected to unaffected mucosa

Question 18

Management of colonic ischemia

Answer 18

• IV fluids and bowel rest
• Antibiotics with enteric coverage
• Colonic resection only if necrosis develops

Question 19

Management of penile fracture

Answer 19

Urological emergency = urgent operative care

If there is evidence of urethral injury (blood at meatus, hematuria, dysuria, urinary retention) - indication for retrograde urethrogram

Question 20

Management of blunt abd trauma in hemodynamically unstable patients

Answer 20

FAST (US) exam

• If positive (intraperitoneal fluid) = urgent laparotomy
• If negative = stabilize if signs of extra-abd hemorrhage, or stabilize then CT if no signs of extra-abd hemorrhage

Question 21

Management of blunt abd trauma in hemodynamically stable patients

Answer 21

Positive FAST exam = CT abd

Question 22

Management of hemodynamically stable patient with penetrating abd trauma and signs of peritonitis (rebound/guarding)

Answer 22

Urgent exploratory laparotomy

Question 23

Causes of hypervolemic hyponatremia

Answer 23

CHF, nephrotic syndrome, cirrhosis

Question 24

Causes of hypovolemic hyponatremia

Answer 24

vomiting, diuretics

Question 25

Causes of euvolemic hyponatremia

Answer 25

SAIDH, Addisons, hypothyroidism

Question 26

Cause of post op pt with thromocytopenia and increased clots

Answer 26

HIT - Heparin-induced thrombocytopenia

Question 27

Cause of bleeding with normal platelets but increased bleeding time and PTT

Answer 27

vWD vWF needed to activate platelets = increased BT vWF stabilizes factor VIII = increased PTT

Question 28

Damage and presentation of humeral mid-shaft fracture

Answer 28

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

Question 29

Presentation of uncal herniation

Answer 29

Ipsilateral hemiparesis and CN III (oculomotor) palsy

Question 30

Presentation of pulmonary contusion

Answer 30

Presents <24 hours after blunt thoracic trauma Tachypnea, tachycardia, hypoxia CT scan or CXR with patchy, alveolar infilatrate

Question 31

Management of abd fistula

Answer 31

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

Question 32

Things that prevent a fistula from healing

Answer 32

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 33

Management of flail chest

Answer 33

Pain control, supplemental O2 Positive pressure ventilation (+/-) chest tube if respiratory failure

Question 34

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

Answer 34

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

Question 35

Muscles of rotator cuff

Answer 35

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

Question 36

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

Answer 36

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

Question 37

Components of Whipple procedure

Answer 37

- 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 38

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

Answer 38

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

Question 39

What causes metabolic alkalosis

Answer 39

``` ♣ 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 40

What causes metabolic acidosis

Answer 40

``` • 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 41

IV fluids given to treat DKA

Answer 41

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