Flashcards in UW Surgery Deck (639)
Patient got in a car accident and has blunt abdominal trauma. You do a FAST exam (ultrasound) and it shows no pericardial effusion, but intraperitoneal fluid. Next best step?
(Do NOT do a CT scan- you don’t have that kind of time. They are bleeding internally in their abdomen area and you need to stop that bleeding with surgery ASAP)
Which bone tumor has a “soap-bubble” appearance?
Giant cell tumor
What is a cholesteatoma?
Mass of keratin debris in the middle ear—> conductive hearing loss
*Rinne: bone conduction> air conduction
*Weber: louder on affected side (bc the obstruction blocks out background noise)
Elderly patient has sensorineural hearing loss in left ear, feels off balance, loss of feeling on left face. Diagnosis?
**Sensorineural hearing loss=
Rinne: air conduction > bone conduction
Weber: louder on good ear side
-unilateral hearing loss with imbalance (CN 8 dysfunction) + decreased facial sensation (CN 7 dysfunction)
(“7 heaven and 8 gate” affects the cerebellarpontine angle and presses on CN 7 and 8)
Elderly woman has frequent urges for bowel movements and small-volume stools or mucus. When bearing down, a red mass with concentric rings protrudes through the anus and then retracts back. Diagnosis?
-rectum protrudes through anal orifice
-it is associated with fecal incontinence, constipation, and/or mucus discharge
Risk factors for rectal prolapse?
How do we treat it?
Risk factors: vaginal delivery, pelvic surgery/ dysfunction, chronic constipation/ straining, and dementia or stroke
Treatment: high fiber diet, pelvic floor exercises, possibly surgical repair
Boy had an appendectomy 3 days ago. Now has jaundice, but LFTs and physical exam are normal. Most likely reason for his jaundice?
-decreased UGT conjugating activity in the liver during times of stress-> jaundice w/o symptoms
Does PE, atelectasis, and pleural effusion cause respiratory acidosis or alkalosis?
All cause respiratory alkalosis
Due to compensatory tachypnea (you start breathing rapidly to compensate for the thing causing you to be SOB)
How do you calculate A-a gradient? What number is normal?
A-a gradient= PAO2- PaO2 (oxygen in alveoli minus oxygen in the capillary...tells you how good the gas exchange is)
Normal A-a is <15
(Values increase with age, but >30 is a high A-a gradient no matter the age)
What is organomegaly?
Enlargement of organs
Woman has pain in LLQ. She hasn’t had a recent bowel movement, but is passing gas. She also has mild urinary urgency and positive leukocyte esterase but negative nitrites. Diagnosis?
Low fiber, high red meat diet, smoking—> parts of mucosa + go through muscularis propria of the bowel and protrude out—> outpouchings called diverticulosis—> they get inflamed—> diverticulitis
*bladder irritation can occur with diverticulitis due to the close proximity of the sigmoid colon
Is diverticulosis usually symptomatic?
Diverticulosis is usually asymptomatic, but 5-15% of patients develop diverticula bleeding or diverticulitis
Most common cause of lower extremity edema?
Venous valvular incompetence
(Backflow of blood—> increased hydrostatic pressure—> fluid leakage out of capillaries into interstitial tissue)
Patients with puncture wounds through the foot are at risk for osteomyelitis caused by what organsim?
Patient has abdominal pain and dissension. Has had watery diarrhea for several days, but no bowel movement since yesterday. Recently was hospitalized and treated for an ulcer. He has high WBC, fever, tachy, and X-ray shows dilation of the colon. Diagnosis?
C diff—> toxic megacolon (complication)
-recent antibiotics at the hospital for ulcer-> c diff w/ watery diarrhea
-symptoms of toxic megacolon: systemic toxicity (fever, low BP, tachy, lethargy), abdominal dissension and pain, leukocytosis, and large bowel dilation
-treatment: bowel rest, NG tube, aggressive c diff therapy (oral Vanco + Metronidazole)
Why do we hyperventilate patients (on a ventilator) with high ICP (intracranial pressure)?
Hyperventilation-> blow off more CO2-> less CO2 in blood (CO2= vasodilator of cerebral vasculature)-> cerebral vasoconstriction= dec cerebral blood flow= dec ICP
(1) hyperventilate patients with ICP to reduce intracranial pressure
(2) decreased CO2 in blood= decreased cerebral blood flow= decreased ICP
Old man has lower abdominal pain, loss of appetite, and constipation. This morning, he had sudden, severe lower abdominal pain that gradually involved the whole abdomen and vomiting. He has a fever, decreased bowel sounds, grading, rebound tenderness. Diagnosis?
Diverticulitis-> diverticulum perforation
-common symptoms of diverticulitis: vague lower abdominal pain, anorexia, constipation
-all this + fever and peritonitis (guarding and rebound tenderness)= diverticular perforation
*free air can be seen on abdominal imaging (X-ray, CT)
How does diverticular perforation present?
You get the symptoms of diverticulitis (vague lower abdominal pain, anorexia, constipation) + fever and peritonitis (guarding, rebound tenderness)
Moment of perforation—> sudden, severe pain (plus or minor vomiting, lightheadedness, or syncope)
After perforation to 2 hrs—> less pain as the inflamed organ decompresses
>2 hrs after perforation—> generalized, constant pain due to peritonitis (plus or minus sepsis)
**free air can be seen on abdominal imaging (X-ray, CT) from the perforation
Patient presents with osteoarthritis in his knees. What is your first approach to treatment?
Recommend exercise (quadriceps strengthening exercises)
*to take pressure off the joint and protect the articular cartilage from further stress
*if exercise/ weight loss fails to improve symptoms, then try NSAIDs. If that fails, then try corticosteroid injections (short-term relief). If all else fails, surgery (knee replacement).
What is Wells criteria used to predict?
The probability of PE
*If PE is likely (>4 points), do CTA (CT angiogram of pulmonary vessels) or V/Q scan if the patient has renal failure and can’t handle the contrast.
*If PE is unlikely (<4 points), you can do a D-dimer if you want to be sure you can rule it out (PE excluded if D-dimer <500)
50 year old guy is fatigued, lost 15 lb in the last month w/o dieting, and has tenderness in the epigastrium. He is a smoker. Fell and hit his head last month. Diagnosis?
*don’t be distracted by falling on his head! Smoker w/ cancer symptoms and epigastric pain= pancreatic cancer
**other class symptoms of pancreatic cancer: painless jaundice (or epigastric abdominal pain worse at night) and migratory thrombophlebitis (Trousseau sign)
What imaging test can you do to diagnose pancreatic cancer?
If jaundice (suggesting pancreatic head tumor)—> ultrasound
If no jaundice (suggesting pancreatic body/ tail tumor)—> CT scan
Boy has fever, earache, sore throat that he can barley open. Right tonsil is enlarged and uvula deviated to the left. Rapid strep test is negative. Diagnosis?
*Symptoms: fever + sore throat + earache
*Exam findings: trismus (jaw muscle spasms), muffled voice, enlarged tonsil w/ deviated uvula going the over direction
*Treatment: aspiration or incision and drainage + antibiotics (cover group A strep and respiratory anaerobes)
20 year old guy has had multiple joint dislocations, easy bruising, poor wound healing. He is normal height with no heart problems. Most likely diagnosis?
(Joint hyper mobility, multiple joint dislocations, poor wound healing, associated with mitral valve prolapse)
In cervical spine trauma (patient fell and landed on neck), paralysis of what is your main concern?
-the diaphragm is innervated by C3-C5 (“C3, C4, C5 keeps the diaphragm alive!”), so if injury occurs at these roots, patients may have immediate diaphragmatic paralysis
-if patient is injured below C5, a delayed diaphragmatic paralysis may occur due to ascending edema
*signs to look for: Hypercapnic respiratory failure and use of accessory muscles (intubate!)
Normal leukocyte (WBC) count?
4,500- 11,000 (4.5- 11k)
Elderly man has nausea, early satiety, unexplained weight loss, abdominal dissension, can’t eat solid food w/o vomiting. You hear a succussion splash listening to his stomach. K+ is low, bicarb is high, glucose is very high. Diagnosis?
-early satiety, intractable N/V, weight loss-> gastric outlet obstruction (can be cancer- 80%, peptic ulcer dz, bezoar, gastric polyps, etc.). In this case, pancreatic cancer is invading the duodenum
*succussion splash= “splash” heard on abdominal auscultation when rocking the patient back and forth at the hips- suggests retained food in stomach
-new-onset diabetes in an old person suggests pancreatic cancer (the pancreas stops producing adequate insulin)
-K+ is low and bicarb high (metabolic alkalosis) due to vomiting (loss of H+, Cl-, K+ from the stomach-> alkalosis and hypOkalemia)
What is a gastric bezoar?
Solid mass of indigestible material (hair, foreign objects) that can cause blockage
*rare, most people will have an underlying motility disorder (gastroparesis) or prior gastric surgery
Most common cause of esophageal perforation?
Having an endoscopy done
(If a tube is going down your esophagus, there is risk that the tube will perforate the esophagus if not done right)