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WiseMD Modules 2 Flashcards

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1
Q

45 yo F p/w periumbilical colicky pain and abdominal distention x2d, N/V, no stool/flatus x48h

  • PSH: appendectomy at 14 yo
  • BS: rare and high pitched
  • PE: rebound on deep palpation
  • WBC 15k
  • plain film: dilated proximal small bowel w/ pneumatosis

(a) Dx
(b) Mgmt

A

(a) Dx = SBO

(b) Next step = NG tube, IV fluids, exploratory laparotomy
- surgery indicated since signs of peritonitis (rebound) and pneumatosis are concerning for bowel necrosis
- also indication for surgery = leukocytosis

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2
Q

Describe the transition epithelium makes at the dentate line and how this correlates to which type of hemorrohoids bleed

A

Dentate line = where rectal columnar mucosa meets squamous epithelium
-squamous epithelium is like skin, wouldn’t just spontaneously bleed = why external hemorrhoids are less likely to bleed

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3
Q

70 yo M w/ 15mins of weakness and paralysis of right arm w/ difficulty speaking

  • similar episode 3 days ago, both times syptoms resolved
  • PE: b/l carotid bruits

(a) Next step?
(b) Dx

A

(a) Next step = carotid duplex ultrasound
(b) Dx = TIAs, use US as first line b/c noninvasive way of diagnosing carotid stenosis/occlusion

-not recommended to use contrast (for contrast CTA) w/in first 24 hrs after onset of neurologic symptoms

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4
Q

First step in management for TIA

A

TIA management
First step = carotid ultrasound
-get that first before MRA/MRI
-anticoagulation is NOT recommended for tx of TIA

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5
Q

What are you looking for during rectal exam when suspecting SBO?

A
  • presence or absence of stool (if there’s stool they’re probably not obstructed)
  • guiac positivity
  • masses
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6
Q

White count expected in

(a) Acute appendicitis
(b) Perforated appendicitis

A

White count seen in

(a) Acute appendicitis = can be normal, often mild-moderately elevated to 12-15k
(b) Perforated appendicitis = crazy high like 18-20

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7
Q

Three physical exam signs indicative of acute appendicitis

A

Acute appendicitis on physical exam

  1. Rosving’s = pain in RLQ when pressure applied to LLQ
  2. Obturator sign = bend right leg at knee and rotate, exacerbates pain
  3. Psoas sign = pt rolls away, pull straight leg away behind the pt which exacerbates pain
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8
Q

Post-op management of exploratory laparotomy for SBO

A
  • Give IV fluids
  • remove NG tube when output is less than 200-250 cc/shift
  • can start PO fluids once the pt passes gas
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9
Q

80 yo F p/w 2 days of abdominal distention and obstipation

  • no h/o previous surgeries
  • Plain abdominal film: distended, coffee-bean loop of bowel w/ haustral markings in RUQ

Dx

A

Dx = sigmoid volvulus
-give away is the coffee bean sign

Haustral markings => you know it’s large bowel, distention and severe constipation (obstipation) => large bowel obstruction

One of the etiologies of mechanical LBO is volvulus

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10
Q

Narrowest part of an airway in a 6 yo

A

Cricothyroid junction- so a cricothyroidotomy is contraindicated in young children for emergency airway access

Needle jet ventilation and eventual tracheostomy in young children who need emergency surgical airway

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11
Q

What are you feeling for on the digital portion of a rectal exam?

A

Rectal tone, any palpable masses, any tenderness

-not feeling for hemorrhoids (most are way too small to feel)

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12
Q

Differentiate anoscope and proctoscope

A

Similar concept to gynecologic exam- anoscope looks into anus, while proctoscope goes further to assess entire length of the rectum

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13
Q

Post-op care for perirectal abscess drainage

(a) Symptomatic care
(b) Long term mornitoring

A

Post-op care for perirectal abscess drainage

(a) Symptoms after surgery are most commonly 2/2 levator ani spasms => sitz bath (literally submerge up to waist in warm water)
(b) Long term monitoring for anal fistula

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14
Q

List the causes of the two types of SBO

A

SBO: mechanical obstruction or motility issue

Mechanical obstruction: 60% adhesions, 20% tumor, 10% hernia, 5% Crohn’s
Functional obstruction = paralytic ileus

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15
Q

55 yo M w/ 15-yo burn wound that has recently changed and started increasing in drainage

Next step

A

Recent change in chronic wound needs biopsy- check for Marjolin’s ulcer = squamous cell carcinoma that develops in a chronic burn wound

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16
Q

40 yo F p/w 2d periumbilical colicky pain and abdominal distention, N/V, no stool/flatus x2d
PSH: hysterectomy

Dx and etiology

A

Adhesive small bowel obstruction

-if w/o surgical history, would consider other etiologies of SBO like tumor, hernia, Crohn’s

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17
Q

List the causes of the two types of LBO

A

LBO: mechanical obstruction or motility issue

Mechanical: color cancer, diverticulitis, volvulus

Functional = Ogilvie’s syndrome = colonic ileus

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18
Q

72 yo F p/w 2d vom and intermittent colicky abd pain

  • distended abdomen, mildly tender
  • 10 yr h/o postprandial upper abdominal pain
  • high pitched and tinkling BS
  • Plain film: branching air collections over liver w/ distended small bowel and decompressed colon

Dx
(a) Explain imaging

A

Dx = gallstone ileus

(a) Branching air collections over liver = portal venous air, complication of bowel obstruction
- typical of SBO 2/2 gallstone stuck at the ileo-cecal valve

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19
Q

65 yo F 18 hrs s/p l. carotid endarterectomy w/ left mouth droop when asked to smile

(a) Cause of facial droop
(b) Mgmt

A

(a) Injury to marginal mandibular branch of the left facial nerve
(b) Most likely 2/2 mechanical disruption of nerve in surgery, not due to permanent nerve damage => no further mgmt. needed

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20
Q

How the following change risk of anorectal disease

(a) Diabetes
(b) Cirrhosis
(c) HIV/AIDS

A

Diabetes and cirrhosis increase infection risk => increased risk anorectal abscess

HIV/AIDS increase risk for AIN and other noeplastic processes of the anorectal region

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21
Q

What to check at post-op f/u visit after lap appy

A
  1. wound site for wound infection

2. palpate for RLQ fullness to detect intraabdominal abscess

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22
Q

Perianal vs. perirectal abscess

(a) Clinical features
(b) Tx

A

Perianal abscess- small, no signs of surrounding cellulitis
-can be drained in the office, no need for abx

Perirectal abscess- significant surrounding cellulitis
-drain in the OR (b/c need a lot of anesthesia) and give post-op IV abx

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23
Q

2 complications of perirectal abscess drainage

Study These Flashcards
A

Complication of drainage of perirectal abscess

  • incontinence (esp to flatus) if abscess goes into rectal muscles
  • development of fistula in-ano (abscess heals leaving opening btwn anus and skin)
24
Q

Surgical indications for SBO

Study These Flashcards
A

No prior abdominal surgery (only can medically manage SBOs 2/2 adhesions)
-febrile, leukocytosis, peritonitis, incarcerated hernia, primary SBO (tumor)

Or if medically managed but pt worsens or doesn’t improve w/in 2-5 days

25
Open vs. laparoscopic laparotomy for SBO management
Most of the time chose midline incision over laparoscopic b/c pt so distended that you can't pump enough air into abdomen to visualize laparoscopically 
26
Benefits of lap appy over oven appy
Decrease rate of infection, decreased pain, shorter LOS (faster recovery)
27
63 yo F p/w abdominal distention and obstipation x2 days, vomit x2 -2 mo h/o diffuse dull lower abdominal pain and change in bowel habits Dx
Dx = colon cancer | -more of a chronic process causing obstruction
28
When to use allograft vs. autograft in wound healing
Autograft (self-graft) is permanent closure, but sometimes the burn surface area might be too much so you need to use cadeveric allograft which is temporary
29
23 yo F p/w crampy abd pain, N/V x2d - similar episodes in the past which spontaneously resolve, no PSH - +guiac test Abdominal CT most likely to show what?
Inflammation of terminal ileum SBO 2/2 Crohn's disease, fits w/ symptoms/time line, repeat episodes, bloody stool -terminal ileum = most common location in the GI tract affected by Crohn's
30
81 yo M asymptomatic, found to have right carotid bruit -Carotid duplex US shows >80% stenosis bilaterally of external carotids Next step?
Next step = observation and anti-platelet therapy -key is EXTERNAL artery stenosis, which is not associated w/ significant risk of TIA/stroke
31
22 mo old boy p/w paroxysms of severe colicky abdominal discomfort -plain film: dilated loops of small bowel (a) Dx (b) Next step
(a) Intussusception = loop of bowel going in and out of target point (b) Next step for both diagnosis and therapeutic benefit = barium enema
32
80 yo Fs/p hip replacement p/w constipation and abdominal distention x4 days Dx
Ortho procedure => pt probably on opioids = common cause of colonic ileus (Ogilvie's syndrome) = Functional etiology of LBO
33
TIA vs. CVA (a) Clinically (b) Imaging Findings
Transient ischemic attack (a) Clinically symptoms are under 24 hrs, transient (b) Ischemia, but NOT infarct Cerebral vascular accident (a) Symptoms persist over 24 hrs (b) Infarction
34
70 yo M w/ 2hrs of right arm/leg weakness and speech difficulties - symptoms slightly improved, but weakness still present - b/l carotid bruits Best next step
Next step = CT w/o contrast | -get CT w/o contrast to exclude evidence of bleed (r/o intracranial hemorrhage) before considering lytic therapy w/ tPA
35
Next step after suspecting sigmoid volvulus from history, physical, and abdominal plain film
Next step for sigmoid volvulus = sigmoidoscopy, then surgery after -sigmoid volvulus requires decompression prior to definitive surgery to avoid recurrence
36
4 risks of ANY AND ALL SURGERIES
1. bleeding 2. infection 3. recurrence of the problem 4. injury to nearby structures
37
Briefly describe pathophysiology of acute appendicitis
Acute appendicitis develops due to appendiceal lumen obstruction (lymphatic hyperplasia, infection, IBD, etc) - intestinal bacteria in the appendix multiple => WBC recruited => pus and increase in pressure - then when intraluminal pressure overcomes venous pressure you get venous outflow obstruction => ischemia => gangrene/necrosis etc
38
Name the three structures in the carotid sheath
1. carotid artery 2. internal jugular vein 3. vagus nerve
39
Complications to monitor for s/p exploratory laparotomy for SBO
Much higher complication if bowel had to be resected or anastamosed (b/c exposing outside to intraabdominal contents) - intra-abdominal abscess POD5 of later - anastamotic leak
40
65 yo F 2 hrs s/p carotid endarterectomy develops tense swelling of neck on side of surgical incision -reports choking sensation and increasing SOB Next step?
Immediately decompress the surgical wound -relieve the hematoma before intubating (you won't be able to intubate w/ all the blood in that area!) Decompress wound from carotid endarterectomy by relieving all three layers (skin, superficial cervical fascia = platysma, deep cervical fascia)
41
60 yo M w/ lower abdominal pain and tenesmus x5d - 2 previous episodes managed outpt - h/o chronic constipation - 100.8F - LLQ tenderness w/ guarding w/o rebound - WBC 12.4 (a) Dx (b) Next step
(a) Dx = diverticulitis- often presents w/ low grade temp, LLQ pain and tenderness, and leukocytosis - supported by previous episodes (b) Next step = CT to confirm diagnosis and r/o other possibilities, also see if diverticulitis is complicated (ex: by perforation or abscess)
42
55 yo M w/ sudden inability to speak coherently - knows what to say, but cannot find the words - no weakness/numbness, no trauma - BP 160/90 - can write coherently, but cannot find words to speak (a) Name this condition (b) Locate the cerebral defect
(a) Aphasia = inability to find the right words (b) Aphasia caused by ischemia of the pt's dominant hemisphere For right handed pt: expect embolus to left anterior circulation
43
Pt p/w intense pain during defecation that lasts a for a few minutes after completion Most likely dx
Anal fissure - pain lasts 2/2 spasms of levator ani muscle - intense pain => localizes issue to below the dentate line
44
36 yo M w/ 24h of diffuse abdominal pain, obstipation, N/V - appendectomy at 5 yoa - normal VS - distended abdomen w/ high pitched BS and tympanic percussive sounds, TTP over all 4 quadrants Most likely cause of obstruction?
Adhesions -don't get confused by demographics (36 yo M) and think internal hernia, hernias only account for 5% of SBOs while adhesions (which can even be from minor surgeries) account for 60% SBO
45
Anterior vs. posterior cerebral ischemia symptoms Which would be expected from carotid endarterectomy clot?
Clot from carotid --> middle meningeal artery --> end branch vessel anteriorly causing anterior symtpoms Anterior symptoms: contralateral weakness, contralateral numbness, ipsilateral monocular blindness vs. Posterior symptoms of diplopia (double vision), dysarthria (trouble w/ speech), ataxia, circumoral numbness
46
When can SBO be managed w/o surgery?
Only ppl who are candidates for medical surgery are those who you are saying cause is adhesions => if pt has no previous abdominal surgeries you can't manage them medically! Pt must be: afebrile, normal white count, no signs of peritonitis
47
Most common location for carotid body tumor? (a) Appearance on MRA (b) Mgmt
At the carotid bifurcation (a) very vascular w/ abundant supply from external carotid artery (b) Surgical resection - Doesn't respond to radiation, can't just leave it b/c it tends to expand and cause mass effect
48
25 yo M w/ severe bloody diarrhea and abdominal pain x4 wks w/o f/c, obstipation x1d - h/o 2 similar episodes tx outpatient - PSH: appendectomy at age 12 - WBC 11.3, Hb 12 Dx
Dx = Crohn's - progressive symptoms w/ bloody stool in right age group - adhesive SBO wouldn't have bloody diarrhea (or chronic time course)
49
70 yo M 1 hr s/p left carotid endarterectomy develops RUE weakness Next step
Next step = immediate re-exploration of carotid artery - occlusion of LCA at endarterectomy site - suspecting embolic event s/p endarterectomy = immediate surgical re-exploration
50
What would you expect to see on abdominal physical exam in a pt w/ SBO (a) Inspection (b) Auscultation (c) Percussion (d) Palpation
(a) Inspection- central distention, no visible masses, possible scars from previous surgeries (b) Auscultation- really nonspecific findings, potentially hear high pitched rush (but really not a reliable finding) (c) Tympanic/hyperresonant to percussion indicating air and not fluid in the bowel (d) Palpation- mildly tender to palpation, but no guarding or masses/organomegaly
51
71 yo M s/p TIA, carotid duplex US showing over 80% stenosis of left internal carotid artery Next step?
Next step = carotid endarterectomy b/c symptomatic and stenosis over 70% -if asymptomatic, cutoff would be stenosis over 80%
52
70 yo M w/ several 10 minute episodes of transient blindness in left eye over 2 weeks - Fundoscopic exam: yellow highly retractable debris in left eye - carotid duplex US: >80% stenosis of internal carotids b/l (a) Dx (b) Next step?
(a) Dx = episodes of amaurosis fugax - presence of Hollenhorst plaques (in retinal artery) on fundoscopic exam (b) Next step = further characterization of the anatomy w/ CTA of head and neck - also confirms degree of stenosis provided by US
53
Pre-op mgmt of acute appendicitis
1. Start IV fluids | 2. Start IV abx (often Cefoxitan)
54
60 yo F w/ incidental finding of left carotid bruit -Carotid duplex US showed 50% stenosis of left internal carotid artery Next step
Next step = anti-platelet therapy (ASA) w/ repeat duplex scan in 12 mo -no indication for surgery given asymptomatic and less than 80% stenosis
55
Why is it indicated to do a UA on a pt in which you suspect SBO?
UTIs can cause paralytic ileus, which is a functional etiology of SBO
56
Technique used to ensure contrast is in the right place when assessing for acute appendicitis
1 hr post contrast ingestion- use scout radiograph (abdominal Xray) to ensure that the contrast is in the right colon -need contrast to make structures visible, almost impossible to diagnose acute appendicitis w/o contrast

Surgery (10 decks)

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