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SURGERY USMLE Flashcards

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1
Q

dysphagia that is worse for liquids

A

Achalasia

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2
Q

Cancer of the esophagus

A

SCCA- smokers

Adenocarcinoma - GERD

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3
Q

Mallory Weiss tear

A

junction of stomach and esophagus
forceful vomiting
Bright red hematemesis

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4
Q

Booerhave’s syndrome

A

prolonged vomiting

esophageal perforation

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5
Q

Gasric adenocarcinoma

A

Anorexia
Weight loss
Vague epigastric distress or early satiety
Occasional hematemesis

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6
Q

Treatment for gastric lymphoma

A

Chemotherapy
Surgery if perforation is feared
Low grade lymphomatoid transformation can e reversed by eradication of H. pylori

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7
Q

Mechanical intestinal obstruction

A

typically caused by adhesions

colicky abdominal pain, protracted vomiting, progressive abdominal distension, and no passage of gas or feces.

Xrays: distented bowel loops of small bowels, with air fluid levels

TX: NPO, NG suction, IV fluids
Surgery if no improvement within 24 hours

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8
Q

Strangulated obstruction

A

compromised blood supply leading to bowel ischemia
starts as MBO then fever, leukocytosis, constant pain, signs of peritoneal irritation, full blowen peritonitis and sepsis

TX: surgery

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9
Q

Carcinoid syndrome

A

SB carcinoid tumor with livers mets

Diarrhea, flushing of face, wheezing, R heart valvular damage

DX: 24 hour urinary collection of 5- hydroxyindolacetic acid

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10
Q

Classic picture of acute appendicitis

A

begins with anorexia, followed by:
vague periumbilical pain -> localizing RLQ
Tenderness, guarding
Modest leukocytosis (10000-15000) with neutrophilia and immature forms

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11
Q

Cancer of the Right colon

A

presents with anemia (hypochromic)
50-70
stool +4 FOBT

Colonoscopy and biopsies
TX: Right hemicolectomy

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12
Q

Cancer of the Left colon

A

bloody bowel movements and obstruction
Flexible proctosigmoidoscopic exam (45-60 cm) and biopsies
Full colonoscopy to r/o synchronous second primary lesion proximally

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13
Q

Colonic polyps

A

may be premalignant (familial polyposis, familial multiple inflammatory polyps, villous adenoma and adenomatous polyp)

not Premalignant ( juvebile, PEutz Jeghers, isolated inflammatory, and hyperplastic)

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14
Q

Chronic ulcerative colitis

A

managed medically

Surgery: >20 years (high incidence of malignant degeneration, ), severe interference of nutritional status, multiple hospitalizations, toxic megacolon.

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15
Q

Pseudomembranous enterocolitis

A

overgrowth of Clostridium difficile
Clindamycin - first one to cause
Cephalosporin - most common cause

Profuse watery diarrhea, crampy abdominal pain, fever, leukocytosis.

TX: Metronidazole with vancomycin as alternative
>50 000 WBC and serum lactate >5 mg/dL requires emergency colectomy

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16
Q

Anal fissure

A

young women
exquisite pain with defecation and blood streaks

TX; stool softeners, topiccal nitoglycerin, local injection of botulinum toxin, diltiazem ointment 2% TID topically for 6 weeks

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17
Q

Crohn’s disease

A

often affects anal area
starts with a fissure, fistula or small ulceration
dx should be suspected when the area fails to heal and gets worse after surgical intervention

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18
Q

Ischiorectal abscess

A

febrile with exquisite perirectal pain that does not let him sit down or have bowel movements

Classic findings of abscess in the lateral to the anus
TX: IND

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19
Q

Fistula -in-ano

A

Epithelial migration from the anal crypts and from the perineal skin form a permanentt tract.

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20
Q

Squamous cell carcinoma of the anus

A

more common in HIV and in patients with receptive sexual practices.

fungating mass, metatastic inguinal nodes

TX: Nigro chemoradiation protocoal followed by surgery

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21
Q

Steps of wound healing

A 
Coagulation
Inflammation
Colllagen synthesis
aniogenesis
Epithelization 
Contraction
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22
Q

Phases of wound healing

A

Hemostasis and inflamamtion
Proliferation
maturation
remodelling

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23
Q

Most common cause of post operative fever within th first 24 hours

A

Atelectasis

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24
Q

Acute abdomen

A

abrupt onset of abdominal pain usually accompanied by one or more peritoneal signs.

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25
kehr's sign
pain referred to the left shoulder due to irritation of the left hemidiaphragm. often seen with splenic rupture and residual pneumoperitoneum after laparoscopy
26
Pain relieved by vomiting
supportive of SBO, afferent loop syndrome
27
Bilious vomiting
Proximal SBO
28
Mucoid diarrhea with blood (red currant jellys tool)
Intussusception
29
Mcburney's point
Appendicitis
30
Beck's tamponade triad
Hypotension JVD Muffled heart sounds
31
Clinically apparent tamponaded
as little as 60-100mL of blood in the pericardial space
32
Pneumothorax
air in the pleural space Chest pain Dyspnea Hyperresonant of affected side Decreased breath sounds on affected sides TX; tube thoracostomy
33
tension pneumothorax
life threatening emergency caused by air entering the pleural space and unable to escape Ipsilateral lung collapse and mediastinal shift (away from the injured lung), impairing venous return and thus decreased cardiac output, resulting to shock TX: needle decompression followed by tube thoracostomy
34
Hemothorax
presence of blood in the chest
35
Indications for thoracostomy
1500 cc initial drainage from the chest tube 200 cc/hr for 4 hours continued drainage; Thoracic great vessel injury Esophageal injury ptients who decompensate after stabilization
36
Size of chest tube to use:
For adult large hemothorax: 36-40 French For adult pneumothorax: 24 French or pigtail catheter For children: four times the size of appropriate endotracheal tube size: ET tube size = age+16/4
37
seat belt sign
ecchymotic area found in the distribution of the lower anterior abdominal wall and can be associated with perforation of the bladder or bowel as well as a lumbar distraction fracture
38
Cullen's sign
Periumbilical ecchymosis (indicative of intraperitoneal hemorrhage
39
Grey-Turner's sign
flank ecchymoses (indicative of retroperitoneal hemorrhage)
40
Acute pancreatitis
suspected in an alcoholic who develops an upper acute abdomen rapid onset for an inflammatory process and the pain is constant, epigastric, radiating straight through the back, with nausea, vomiting, and retching
41
Primary Hepatoma
vague right upper quadrant discomfort and weight loss. AFP Resection is done if technically possible
42
Hepatic adenoma
arise as a complication of birth control pills | tendency to rupture and bleed massively
43
Pyogenic liver abscess
complication of biliary tract disease, particularly acute ascending cholangitis. Fever, leukocytosis and a tender liver
44
Amebic abscess of the liver
Treated with metronidazole abd rarely require drainage
45
Biliary colic
occurs when a stone temporarily occludes the cystic duct. Causes colicky pain in the right upper quadrant radiating to the right shouder and back.
46
Charcot's triad
fever, jaundice, RUQ pain
47
Reynold's Pentad
fever, jaundice, RUQ pain, altered mental status, evidence of sepsis (hypotension)
48
Acute pancreatitis
may be edematous, hemorrhagic, or suppurative
49
Acute edematous pancreatitis
occurs in the alcoholic or pt with gallastones Epigastric and midabdominal pain radiating straight through the back, accomapanied by nausea, vomiting, and continued retching Amylase and lipase is elevated and hematocrit are high due to hypovolemia
50
Fibroadenoma
firm, rubbery mass that moves easily with palpation. | FNA or core biopsy
51
Indirect Inguinal hernias
``` Rule of 5's 5% lifetine incidence in males 5x more common than direct inguinal hernias 5-10x more common in males than females Generally occur by 5th decade of life ```
52
Inguinal Hernias
MDs Dont Lie Medial to the inferior epigastric artery - DIRECT Lateral to the IEA - INDIRECT
53
Abdominal HErnia
Defect in the abdominal wall causing abnormal potrusion of intra-abdominal contents RF: activities which increase intra-abdominal pressure Congenital abnormality (patent processus vaginalis) Previous hernia repair Loss of tissue strength and elasticity
54
Hesselbach's triangle
Lateral : inferior epigastric artery Inferior: inguinal ligament Medial: lateral margin of rectus sheath
55
Inguinal Canal Walls
MALT x 2 2M roof = 2 muscles (internal oblique, trasversus abdominis) 2A Anterior wall - 2 aponeurosis (external and internal oblique) 2L Floor = 2 ligaments (inguinal and lacunar) 2T Posterior wall = Transversalis fascia, conjoint Tendon
56
Classification of Hernia
Complete: Hernia sac and contents protrude Incomplete: partial protrusion through the defect Internal: sac herniating into or involving intra-abdominal wall External: sac protrudes completely through the abdominal wall Strangulated: vascular supply of protruded viscus is compromised Incarcerated: Irreducible hernia, not necessarily strangulated Sliding: part of wall of hernia sac formed by retroperitoneal structure (colon)
57
Richter's Hernia
only part of the bowel circumference *usually anti-mesenteric border) is incarcerated or strangulated
58
femoral hernia
affects mostly females Pregnancy - weakness of pelvic floor musculature Increased intra-abdominal pressure Into femoral canal, below the ingunial ligament but may override it Medial to femoral vein within femoral canal
59
Superdicial Inguinal Ring
Opening in external abdominal aponeuorosis; palpable superior and lateral to pubic tubercle Medial border: medial crus of external abdominal aponeurosis Lateral border: lateral crus of external oblique aponeurosis Roof: intercrural fibers
60
Deep inguinal Ring
Opening in transversalis fascia: palpable superior to mid-inguinal ligament Medial: inferior epigastric vessels Superior-LAteral border: Internal oblique and transversus abdominis muscle Inferior border: inguinal ligament
61
Mcburney's sign
Tenderness 1/3 the distance from the ASIS to the umbilicus n the right side
62
Crohn's Major Patterns
Ileocecal 40% (RLQ pain, fever, weight loss) Small intestine 30% (especially terminal ileum) Colon 25% (diarrhea)
63
Findings in Crohn's disease
Cobblestoning on mucosal surface due to edema and linear ulcerations Skip Lesions: normal mucosa in between Creeping fat: mesentery infiltrated by fat granulomas: 25-30%
64
Findings in Ulerative colitis
(+) diarrhea with or without blood colicky abdominal pain, urgency, tenesmus, and incontinence Presence of extraintestinal manifestaions Endocoscopically, there is loss of vascular markings, erythema, granularity of mucosa, petechiae, exudates, edema, erosions, and spontaneous bleeding Biopsy: crypt abscesses, crypt blanching, shortening and disarray and crypt atrophy Inflammation is continuous and usually involves the rectum
65
Top 3 cause of LBO
cancer diverticulitis Volvulus
66
Clinical Features of LBO
Open loop *incompetent ileocecal valce) - similar with SBO Closed loop (80-90%) - competent ileocecal valve resulting in proximal and sital occlusions
67
Functional LBO
Colonic Pseudo Obstruction (Ogilvie's Syndrome) Acute pseudo obstruction Distention of the colon without mechanical obstruction in distal colon
68
Diverticulum
abnormal sac like protrusion from the wall of a hollow organ
69
Diverticulosis vs Divericulitis
Diverticulosis - presence of diverticuli within the colonic wall Diverticulitis 0 inflammation of one or more diverticuli
70
Hinchey Staging and treatment for Diverticulitis
1 - Phlegmon/small pericolic abscess (medical) 2 - Large abscess/fistula (Medical, abscess drainage resection) 3 - Purulent peritonitis (resection or hartmann procedure) 4 - Feculent peritonitis (hartmann procedure)
71
Familial Adenomatous Polyposis
autosomal dominant inheritance, mutation in adenomatous polyposis coli (APC) gene on chromosome 5q21
72
Gardner's syndrome
FAP + Extra-intestinal lesions (sebaceous cysts, osteomas, desmoid tumors)
73
Turcot syndrome
FAP + CNS tumors (childhood cerebellar medulloblastoma)
74
LYNCH syndrome
Hereditary Non-polyposis colorectal cancer autosomal dominant inheritance, mutation in a DNA mismatch repair gene (MSH2, MSH6, MLH1) resulting in microsatellite instability genomic instability and sbsequent mutations) early age of Onset RIGHT>left
75
Amsterdam criteria for Lynch syndrome
3 or more relatives verified and 1 must be 1st degree relative of the other 2 2 or more generations involved 1 case must be diagnosed before 50 years old FAP is excluded
76
Staging for Colorectal cancer
I - T1M2 N0M0 II - T3,4 N0M0 III- TxN + M0 IV - TxNxM1
77
CRC (right coloon)
25% Exophytic lesions with occult bleeding weight loss, weakness, rarely obstruction Iron deficiency anemia, RLQ mass
78
CRC (left colon)
35% Annular, invasive lesions Constipation +/- overflow (alternating bowel patterns), abdominal pain, decreased stool caliber, rectal bleeding BRBPR, LBO
79
CRC (rectum)
30% ulcerating Obstruction, tenesmus, rectal bleeding Palpable mass on DRE, BRBPR
80
Primary tumor staging of CRC
T0 - no primary tumor Tis - Carcinoma in situ T1 - Invasion into submucosa T2 - Invasion into musculariss propria T3 - Invasion through muscularis propria and into serosa T4 - Invasion into adjacent structures or Organs
81
Regional LN staging CRC
``` N0 = no N1 = 1-3 N2 = 4 or more ```
82
Toxic Megacolon
extension of inflammation into smooth musce layer causing paralysis Damage to the myenteric plexus and electrolyte abnormalities are not consistently found Etology: IBD (UC> CD) Infectious colitis Dx Criteria: Must have both colitis and systemic manifestations Radiologic evidence of dilated colon 3 of : fever, HR>120, WBC>10.5, anemia 1 of : fluid and electrolyte disturbances, hypotension, or altered LOC
83
Fistula
abnormal communication between 2 epithelized surfaces
84
Park's classification of Perianal fistulas
Transphicteric - Most common, Results form ischiorectal abscesses with extension of the tract through the external sphincter Intersphicteric - Confinded to the intersphincteric space and internal sphincter, result from perianal abscesses Suprasphincteric - Pass through the levator ani, over the top of the puboretalis, and into the intersphincteric space. Result from Supralevator abscesses Extrasphincteric - bypass the anal canal and sphincter mechanism, passing through the ischiorectal fossa and levator ani muscle and open high in the rectu,
85
Goodsall's rule
The anal line divides it into anterior and posterior regions. If the abscess is in the posterior region, it usually drains in the midline and follows a curvilinear tract. In the anterior region, the abscess will usually drain straight to the anus. It follows a radial tract of drainafe except if external canal is beyond 3cm of the line.

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