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Flashcards in Surgery UWorld Deck (110):
1

some studies show that ALT >150 has a 95% PPV for diagnosing _____

gallstone pancreatitis

2

how do you treat gallstone pancreatitis

EARLY cholecystectomy

3

what's the next step after placing a central venous catheter

CXR prior to catheter use to confirm catheter tip placement

4

ideal placement of central catheter

lower SVC

tip is "just proximal to the angle between the trachea and right mainstream bronchus"

5

what are 3 common risks of an improperly placed central venous catheter

venous perforation (tip placement in smaller veins)

pneumothorax

pericardial tamponade

6

what is the risk of using succinylcholine

efflux of K ions,
leading to severe hyperkalemia and arrhythmias

7

what pathology is most likely to develop in a chronic non-healing wound

squamous cell carcinoma

8

squamous cell carcinoma arising within a burn wound is called ___

Marjolin ulcer

9

what type of injury is caused by severe valgus stress on knee

MCL

(blow to lateral knee)
(if they mention pain with abduction, think of the foot abducting while holding the lateral knee)

10

what type of injury is caused by severe varus stress on knee

LCL

(blow to medial knee)
(these injuries are rather uncommon)

11

what's the most sensitive test for soft tissue injuries

MRI

12

how do you treat uncomplicated MCL tear

non operatively, with RICE
rest, ice, compression, elevation

13

which injury is characterized by a small joint effusion with crepitus, locking, or catching with range of motion

medial meniscus tear

14

which injury occurs with chronic overuse, anterior knee pain, and tenderness

patellar tendonitis
"Jumper's knee"

15

what is most likely diagnosis of a nontender hard mass in hard palate of mouth, present for many years?

Torus Palatinus

16

what is an immediate step needed in pts with traumatic spinal cord injuries

urinary catheter placement to assess for urinary retention and prevent acute bladder distention/damage

17

when is IV atropine indicated

symptomatic bradycardia
(lightheadedness, presyncope, syncope)

18

which antibiotic is commonly given prophylactically before surgery

IV cefazolin
(usually within 60min of procedure)

19

what is indicative of free intraperitoneal air, and what is the next step in management

bowel perforation
immediate exploratory laparotomy

20

what "unusual" injury do you have to worry about with blunt abdominal trauma and damage to mesenteric blood supply

bowel perforation
(may take several days to present)

21

which bowel segment is most likely to perforate in mesenteric ischemia

jejunum

22

when is a diagnostic peritoneal lavage warranted? (buzzword?)

pts who are HEMODYNAMICALLY UNSTABLE with questionable beside ultrasound results,
or where emergency ultrasound or CT is unavailable

23

what is dx in pt who is hypotensive, abdominal pain, and CT scan showing enlarged aortic silhouette

rupture abdominal aortic aneurysm

24

how do you manage ruptured abdominal aortic aneurysm

immediate surgery

CT scanning is only done in stable pts;
--if you must confirm aneurysm presence, use bedside ultrasound

25

what is immediate next step once a bowel perforation is identified

urgent exploratory laparotomy

26

what is dx in pt with fever, tachy, hypotension, and poor urine output

septic shock

27

what is your goal of managing septic shock

restoring adequate tissue perfusion through IV 0.9% saline (crystalloid) and identifying the underlying infection

aggressive volume resuscitation!!

28

why is crystalloid the fluid of choice to quickly restore volume

it is as effective as albumin in terms of survival but less costly and easier to acquire

29

what is a common crystalloid fluid

0.9% Saline

30

what should you give to pt who fails to respond to crystalloid fluid, or who develops evidence of vol overload w/o improvement in blood pressure

give vasopressors (dopamine) to improve perfusion if pt is not responding to your volume resuscitation efforts

31

what are these scenarios indications for:
major electrolyte abnormalities
uremia
volume overload

indications to start urgent hemodialysis

32

when is the use of bicarbonate clearly indicated

in a pt who has severe acute acidosis (pH <7.2)

33

when is transfusion indicated in pts with septic shock

to keep hemoglobin > 7; or perhaps a higher hemoglobin and showing clear indications (active bleeding)

34

what noninvasive test is highly sensitive and specific for peripheral artery disease in symptomatic pts

ankle-brachial index

35

how do you calculate and interpret ankle-brachial index to diagnose peripheral artery disease

ABI is calculated by dividing the higher ankle (dorsals pedis or posterior tibial) systolic pressure in each lower extremity by the higher brachial artery (left or right) systolic pressure

ABI <0.9 = abnormal (diagnostic of occlusive PAD)

ABI 0.91-1.30 = normal

ABI >=1.30 = suggestive of calcified and incompressible vessels; additional vascular studies should be considered

36

what is suspected dx in pt with intermittent claudication

Peripheral artery disease

37

which injury includes lucid interval

epidural hematoma

38

what is dx in pt with trauma to sphenoid bone with tearing of Middle meningeal artery

epidural hematoma

39

what is ipsilateral CN3 palsy and hemiparesis indicative of

uncal herniation in an epidural hematoma

(dilation of pupil on ipsilateral side of lesion 2/2 compression of oculomotor nerve; and ipsilateral hemiparesis 2/2 contralateral crus cerebri compression)

40

what are symptoms of elevated intracranial pressure

nausea/vomiting
headache

41

how do you manage epidural hematoma

emergent craniotomy in pts w/ focal neuro deficits to prevent brain herniation and death

42

what is dx in pt with traumatic acceleration/deceleration shearing forces that causes diffuse damage

diffuse axonal injury

43

what 2 things tell you that you have a concussion vs an epidural hematoma

concussions don't usually have elevated intracranial pressure or focal neuro deficits
imaging is usually normal

44

what is dx in pt who has traumatic head injury then develops headache and confusion gradually over 1-2 days

subdural hematoma

45

what is ripped in subdural hematoma

tearing of bridging veins

46

what is dx in pt w/ recent h/o skin infection who presents with fever and abdominal pain radiating to the groin

psoas abscess

47

what does PE of pain with hip extension indicate

psoas sign- psoas abscess

48

what is required to confirm dx of psoas abscess

CT scan

will show enlarged/inflammed psoas muscle just lateral to vertebrae

49

what is management of psoas abscess

drainage with antibiotics

50

what must you have high suspicion for in pts involved in MVCs or falls >10 ft

blunt aortic injury

51

what is most sensitive image finding for blunt aortic injury

mediastinal widening

(enlarged, widened aortic arch contour obscuring the pulmonary artery)

52

what commonly causes myocardial contusion in blunt trauma

rib fractures

53

what is dx in CXR with prominent bulge along the L heart border

LV aneurysm

54

how is LV aneurysm most commonly seen

LV aneurysm is most commonly seen as a complication of transmural myocardial infarction

--not associated with trauma
--best diagnosed w/ echocardiogram

55

what is dx in pt with fever, RUP pain, N/V, and crepitus in abdominal wall near gallbladder

emphysematous cholecystitis

56

what are 2 common gas-forming bacteria that may cause crepitus

Clostridium

E coli

57

what is dx in pt with air-fluid levels in gallbladder, gas in gallbladder wall,
unconugated hyperbilirubinemia,
mildly elevated aminotransferases
gas-forming bacteria (clostridium, E coli)

emphysematous cholecystitis

58

what is tx for emphysematous cholecystitis

emergent cholecystectomy

broad spectrum Abx with clostridium coverage (ampicillin-sulbactam)

59

what is dx in pt with whistling noise during respiration following rhinoplasty

nasal septal perforation,

likely resulting from a septal hematoma

60

what is next step when pt presents with "classic" appendicitis

laparoscopic appendectomy

don't wait for further imaging tests- not necessary, and appendix may rupture in the meantime

61

what is a known complication of abdominal aortic aneurysm repair

bowel ischemia
it results from inadequate colonic collateral arterial perfusion to the L and sigmoid colon after loss of the IMA during aortic graft placement

62

what fracture presents with pain at radial wrist proximal to the base of the thumb

scaphoid fractures

(most commonly fractured carpal bone)

63

what is dx in PE of tenderness in the shallow depression at the dorsoradial wrist bounded medially by the tendon of the extensor pollicis longs and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis "anatomic snuff box"

scaphoid fracture

64

what is the concern in scaphoid fracture

osteonecrosis
because blood supply enters at the distal pole and flows proximally, which can be disrupted by the fracture

65

what tx can be considered for non displaced scaphoid fractures

wrist immobilization

but pts should be monitored with serial XRs to r/o osteonecrosis and non-union of the fracture

66

what FOOSH injury can cause compressive neuropathy of median nerve

lunate dislocation

67

what is dx in pt with recurrent, episodic pain in RUQ or epigastric region w/ corresponding elevations in aminotransferases and alk phos; dilated common bile duct in absence of stones; made worse by opioid analgesics

Sphincter of Oddi dysfunction

due to dyskinesia or stenosis of Sphincter of Oddi

68

why do opioids make Sphincter of Oddi dysfunction worse

sphincter contraction, which precipitates symptoms

69

what is gold standard for dx of sphincter of oddi dysfunction and tx

sphincter of oddi manometry

tx w/ sphincterectomy

70

what is dx in pt with recent cardiac catheterization, anticoagulation with Heparin, sudden onset hypotension, tachy, flat neck veins, and back pain

retroperitoneal hematoma due to bleeding from arterial access site

71

when do most hemorrhage or hematoma formations occur after a catheterization

within 12 hours

72

how do you confirm dx of retroperitoneal hematoma

non-contrast CT of abdomen and pelvis
or abdominal ultrasonography

73

how do you tx retroperitoneal hematoma

usually supportive with bed rest, intensive monitoring, and IV fluids +/- blood transfusion

surgery is rarely needed

74

what is dx in pt with subacute pain over the midline sacrococygeal (intergluteal, cephalic to anus) with mucoid and bloody drainage.
Most commonly affects young adult M, obese, sedentary

Pilonidal disease

75

what is pathogenesis of pilonidal disease

edematous, infected hair follicle in intergluteal region becomes occluded

infection spreads subcutaneously, forms an abscess, which can rupture and create a pilonidal sinus tract

as pt moves around, hair and debris are forced into sinus tract,
causing recurrent infections and foreign-body rxns

76

what is tx of pilonidal disease

drainage of intergluteal abscess and excision of sinus tracts

open closure is preferred due to decreased recurrence rates

77

what are 5 interventions for lowering ICP

head elevation
-increased venous outflow from brain

sedation
-decreased metabolic demand and control of HTN

IV mannitol
-extraction of free water from brain tissue --> osmotic diuresis

hyperventilation
-CO₂ washout --> cerebral vasoconstriction

removal of CSF
-reduction of CSF volume/pressure

78

what is "pain on passive movement" and paresthesias buzzwords for

compartment syndrome

79

what is dx in pt with persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma; other findings of pneumomediastinum and subcutaneous emphysema

tracheobronchial injury

80

what is dx in pt with tachy, BBB, arrhythmia, and sternal fracture

myocardial contusion

81

what is dx in pt with tamponade (muffled heart sounds), hypotension, distended neck veins

myocardial rupture

82

what are some signs/symptoms that would warrant intubation in a burn pt

burns on face
singing of eyebrows
oropharyngeal inflammation/blistering
oropharyngeal carbon deposits
carbonaceous sputum
stridor
carboxyhemoglobin level >10%
h/o confinement in a burning building

presence of >=1 of these warrants early intubation to prevent airway obstruction by edema

83

what are the hard signs of vascular injury, therefore indicating the need for surgical intervention

observed pulsatile bleeding
presence of bruit/thrill over injury
expanding hematoma
signs of distal ischemia (absent pulses, cool extremities)

in the presence of a penetrating injury, these signs are almost always predictive of the need for urgent surgical repair

84

what are the 3 things in an initial evaluation of a severe extremity injury

hemorrhage control

radiography of skeletal injuries

evaluation of neurovascular bundle

85

what is an immigrant pt with foamy red sputum w/ significant blood a buzzword for?

pulmonary tuberculosis

86

what is the initial step of management in a pt suspicious for pulmonary tuberculosis

respiratory isolation

to prevent the spread of infection before further diagnostic evaluation and tx

87

what is the initial management in a pt with massive hemoptysis (>600mL/24hrs or 100mL/hr)

secure airway, breathing, and circulation

pt should be placed in dependent position of the bleeding lung

bronchoscopy is initial procedure to localize the bleeding site

88

what is dx in pt with extra-axial well-circumscribed or round homogeneously enhancing dural-based mass on MRI; usually undergoes calcification and can appear hyper dense;
usually in middle-aged to elderly F with neuro symptoms (headache, seizure, focal weakness/numbness) from mass effect

meningioma (benign)

89

what is tx of choice for pts with symptomatic meningioma

complete resection in OR
typically leads to cure in most pts

90

what is dx in pt with multiple ring-enhancing lesions at the grey-white junction in brain (intra-axial)

brain metastasis

91

what is dx in pt with hypocalcemia and hyperphosphatemia

hypoparathyroidism

92

what are 3 causes of hypoparathyroidism

post-surgical

autoimmune /non-autoimmune PTH destruction

defective calcium-sensing receptor

93

what is most common dx in pt with unilateral LE edema that worsens when leg is dependent and improves with leg elevation/sleeping.

venous valve insufficiency

94

what is pathology of venous valve insufficiency

failure of venous valves
blood pooling in dependent areas
increased capillary hydrostatic pressure
favors increased filtration of fluid out of the capillaries into the interstitial fluid

causes a decrease in intravascular volume,
so kidneys are stimulated to retain water and salt
ultimately leading to more edema

95

what is classic dx in pt who falls then presents with pain and immobility of affected arm, holding it with the contralateral hand

clavicle fracture

96

what should be done in all cases of clavicle fracture

a careful neurovascular exam,
due to proximity to subclavian artery and brachial plexus

this could include PE of hand/arm and angiogram

97

what is dx in pt who chronically uses NSAIDs that has frequent postprandial pain --> constant; with XR showing pneumoperitoneum

perforated peptic ulcer

98

how do you tx perforated peptic ulcer

urgent exploratory laparotomy

99

what do Q waves on an EKG indicate

old myocardial infarction

100

what is the 4 T ddx for an anterior mediastinal mass

thymoma
teratoma
thyroid neoplasm
terrible lymphoma

101

what are beta-hCG and AFP levels in pts with a seminoma vs nonseminomatous germ cell tumor

Seminoma:
--serum beta-hCG can be elevated in 1/3 of pts with seminoma
--AFP is essentially always normal

Non-seminomatous germ cell tumor:
--most pts have an elevated AFP
--considerable amount also have elevated beta-hCG

102

what type of tumor is also included in the category of teratoma; and how do you distinguish

germ cell tumors

teratomas can often be distinguished from other germ cell tumors on imaging by the presence of fat or calcium,
esp in the form of a tooth

103

what are the 3 forms of nonseminomatous germ cell tumors

yolk sac tumor
choriocarcinoma
embryonal carcinoma

104

what is dx in pt with abdominal pain, diarrhea, nausea, hypotension, tachy, dizziness/confusion, fatigue, diaphoresis with a recent gastrectomy

dumping syndrome

105

what causes dumping syndrome

loss of normal action of pyloric sphincter due to injury or surgical bypass

leads to rapid emptying of hypertonic gastric contents into duodenum and small intestine

causes fluid shifts from intravascular space to small intestine,
leading to hypotension, stimulation of autonomic reflexes, and release of intestinal vasoactive polypeptides

106

what does dietary modification look like in a pt with dumping syndrome

consume small, frequent meals and eat slowly
avoid simple sugars
increase fiber and protein
drink fluids between, rather than during, meals

107

what is dx in pt with:

1- distended veins; normal breathing

2- distended veins; respiratory distress

3- flat veins

1- pericardial tamponade

2- tension pneumothorax

3- hemorrhagic/hypovolemia

108

what's the difference between primary vs secondary spontaneous pneumothorax

primary:
no preceding event or lung disease; typically thin young men

secondary:
underlying lung disease (COPD)

109

what is immediate treatment for tension pneumothorax

needle thoracostomy

110

what is the clinical triad of fat embolism syndrome

respiratory distress

neurologic dysfunction (confusion)

petechial rash