Adam Shared "Surgery" - 130 Picmonics
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Surgery
Abdominal Aortic Aneurysm
- Screening
- Screen Males 65-75 Who've Ever Smoked
- Diagnosis
- Ultrasound
- Treatment
- Observation
- Asymptomatic and < 5 cm in Size
- Surgical Repair
- > 5.5 cm in Abdomen
- Emergent Surgery
- Ruptured or Symptomatic
2 mins
Pulmonary Embolism Presentation and Diagnosis
- Presentation
- Sudden onset Shortness of Breath (S.O.B.)
- Tachypnea
- Pleuritic Chest Pain
- Hemoptysis
- Hypoxemia
- Sudden Death
- Diagnosis
- Gold Standard: CT Pulmonary Angiography
- X-Ray
- D-Dimer
- V/Q Scan
1 min
Acute Bacterial Parotitis 4544
- Dehydrated post-operative patients and the elderly are most prone to develop this infection
- Most common infectious agent is Staphylococcus aureus
- Presentation
- Fever
- Leukocytosis
- Parotid inflammation
- Painful swelling of the involved parotid gland that is aggravated by chewing
- Physical exam
- Tender, swollen and erythematous gland; with purulent saliva expressed from the parotid duct
- Treatment
- Adequate fluid hydration and oral hygiene, both pre- and post-operatively, can prevent this complication
Small-Bowel Obstruction
- History of prior abdominal surgery --> risk factor due to adhesion development (most common cause)
- Crohn-related SBO usually results from chronic fibrosis late in disease process
- Clinical presentat ion
- Colicky abdominal pain, vomiting
- Inability to pass flatus or stool if complete (no obstipation if partial)
- Progression of SBO --> sounds may diminish and if ischemia occurs --> disappear altogether
- Hyperactive --> absent bowel sounds
- Distended & tympanitic abdomen
- Complete proximal obstructions are characterized by early vomiting, abdominal discomfort, and abnormal contrast filling on x-ray
- Diagnosis
- Dilated loops of bowel with air-fluid levels on plain film or CT scan
- Partial: Air in colon
- Complete: Transition point (abrupt cutoff), no air in colon
- Mild leukocytosis and amylase elevation can also be seen
- Complications
- lschemia/necrosis (strangulation)
- Bowel perforation
- Management
- Bowel rest, nasogastric tube suction, intravenous fluids
- Surgical exploration for signs of complications
- Complicated SBO --> increased risk of ischemia, strangulation, and necrosis, warranting emergency abdominal exploration
- Change in pain, fever, hemodynamics (hypotension, tachycardia), guarding, leukocytosis, metabolic acidosis
- Peristaltic waves on the abdominal wall can also be observed
- Some of the less common causes include hernia, neoplasm , volvulus, intussusception
- Partial obstruction: supportive care and observation if no improvement in 12-24 hours --> surgery
Prerenal Acute Kidney Injury
- Etiology
- Decreased renal perfusion
- Tx: Intravenous isotonic fluid (eg, normal saline) to restore renal perfusion.
- Volume depletion is further suggested by tachycardia
- True volume depletion
- Decreased EABV (eg, heart failure, cirrhosis)
- Displacement of intravascular fluid (eg, sepsis, pancreatitis)
- Renal artery stenosis
- Afferent arteriole vasoconstriction (eg, NSAIDs)
- Clinical features
- Increase in serum creatinine ( eg, 50% from baseline)
- Decreased urine output
- Blood urea nitrogen/creatinine ratio > 20: 1
- Fractional excretion of sodium <1%
- Unremarkable ("bland") urine sediment
- Decreased renal perfusion leads to a decreased glomerular filtration rate
- If due to CHF then dont use IV fluid, use a diuretic
- Use albumin for prevention of prerenal AKI following large-volume paracentesis in patients with decompensated cirrhosis
- FEurea < 35% (used when the patient is on a diuretic because it messes with the FENa)
Retroperitoneal Hematoma 4501
- Causes
- Cardiac Catheterization
- Anticoagulants
- Clinical Features
- Hypotension
- Tachycardia
- Flat neck veins
- Ipsilateral back/flank pain
- Most hemorrhage or hematoma formation occurs within 12 hours of catheterization
- Swelling of soft tissue
- If the arterial puncture site is above the inguinal ligament, the hematoma can extend into the retroperitoneal space
- Diagnosis
- Non-contrast CT scan of abdomen and pelvis or abdominal ultrasound
- Treatment is usually supportive, with intensive monitoring, bed rest, and intravenous fluids or blood transfusion
- Surgical repair of hematomas or retroperitoneal hemorrhage is rarely required
- Avoid strenuous activity or lifting heavy objects for one week post catheterization
- Radial artery approach leads to fewer local vascular complications
Thoracic Aortic Aneurysm
- Associated with cystic medial degeneration
- Balloon-like dilation of the thoracic aorta
- RISK FACTORS
- Hypertension
- Bicuspid aortic valve
- Connective tissue disease (Marfan and Ehler Danlos)
- Also historically associated with 3° syphilis (obliterative endarteritis of the vasa vasorum) and aorta can present "tree-bark" appearance
- complications
- Major complication is dilation of the aortic valve root, resulting in aortic valve insufficiency (aortic regurgitation).
- Other complications include compression of mediastinal structures (e.g., airway or esophagus) and thrombosis/embolism.
Spontaneous Pneumothorax
- Mechanism
- Accumulation of Air in Pleural Space
- Tall and Thin Young Males
- Bleb or Bulla Rupture
- Underlying Disease
- Signs and Symptoms
- Hypoxemia
- Chest Pain
- Decreased Breath Sounds
- Hyperresonance
- Shortness of Breath (SOB)
1 min
Scaphoid Fractures 3415
- Most commonly fractured carpal bone
- Pain at the radial wrist proximal to the base of the thumb
- Examination shows tenderness in the shallow depression at the dorsoradial wrist
- "Anatomic Snuffbox"
- Bounded medially by the tendon of the extensor pollicis longus
- Bounded laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis
- Carry a significant risk of osteonecrosis
- Initial x-rays can be normal in nondisplaced scaphoid fractures
- CT scan or MRI can confirm the diagnosis, or repeat x-rays can be performed in 7-10 days
- The wrist can be immobilized briefly in a thumb spica splint if repeat x ray is used
- Displaced fractures should be considered for surgical intervention
- Monitor with serial x-ray to rule out osteonecrosis
- The radial artery supplies blood flow
- Typically caused by fo rceful dors iflexion at the wrist
- X-rays of the wrist in full pronation and ulnar deviation to better expose the scapho id
- Radioscintigraphy bone scan in 3-5 days can also be used
- Orthopedic surgeon if: tilt of lunate, fracture displaced >1 mm, nonunion on follow-up, osteonecrosis, scapholunate dissociation
- Serial x-rays should be done in 2-week intervals to monitor healing after spica cast is used
- Most commonly complicated by nonunion and avascu lar necrosis
- Proximal fractures of the scapho id require longer immobilization (up to 12 weeks ) for adequa te healing
Compartment Syndrome 3398
- Serial compartment pressure monitoring is useful in determining the need for definitive operative management
- Compartment decompression by fasciotomy or for circumferential burns, escharotomy
- Eschar resulting from circumferential, full-thickness (third degree) burn often leads distal ACS
- Longstanding elevated compartment pressure --> tissue ischemia and tissue death
- Common
- Pain out of proportion to injury
- Pain increased on passive stretch
- Rapidly increasing & tense swelling
- Paresthesia (early)
- Uncommon
- Decreased sensation
- Motor weakness (within hours)
- Paralysis (late)
- Decreased distal pulses (uncommon)
- Diagnosis
- Compartment pressure >30 mm Hg
- Delta pressure (diastolic blood pressure - compartment pressure)
- Clinical diagnosis, confirmed with compartment pressure
- Serial measurements should be performed even if initial pressures are within normal limits
- Time to intervention is the most important factor predicting complete functional recovery of the limb.
- All const rictive cover ings (casts, dress ings) should be removed and supplemental oxygen given
- Supportive measures to maintain perfusion pressure include keeping the limb at torso leve l and treat ing hypotens ion if present.
- Additional findings
- Arteria l and venous occlusion in the extremity results in anoxic muscle necrosis (rhabdomyolysis)
- Lead to acute renal failure (ARF), particula rly in volume-depleted states (eg, hemorrhage) , which worsens vasoconstr iction and cast formation.
- Compartment pressure >30 mm Hg or delta pressure (diastolic blood - compartment) <20-30 mm Hg --> significant CS
- Caues: traumatic long bone fractures , trauma wit hout fracture (e.g., crush injuries, thermal burns, and vascular injury in extremities) ,
- Nontraumatic causes (e.g., prolonged limb compression, animal venom exposure , and nephrotic syndrome)
- Can progress to infection, and skin ulceration and tissue necrosis, possibly requiring amputation of the limb
Ankle-Brachial Index Interpretation 4494
- Ankle-brachial index = higher ankle systolic pressure in lower extremity/higher brachial artery systolic pressure
- Less than or equal to 0.90 - Abnormal
- 0.91 - 1.30 - Normal
- Greater than or equal to 1.30 Suggestive of calcified & incompressible vessels; additional vascular studies should be considered
- Ankle-brachial index (ABI) confirms the presence of peripheral arterial disease (PAD)
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
1 min
Syringomyelia
- Cystic cavity (syrinx) within central canal of spinal cord
- Fibers crossing in anterior white commissure (spinothalamic tract) are typically damaged first
- Results in a “cape-like,” bilateral loss of pain and temperature sensation in upper extremities
- Fine (deep) touch sensation is preserved
- Associated with Chiari I malformation
- Most common at C8–T1
Acute Abdominal/Pelvic Pain in Women 12160
- Mittelschmerz
- Recurrent mild & unilateral mid-cycle (around day 14) pain prior to ovulation
- Pain lasts hours to days
- No peritoneal signs
- Ultrasound: Not indicated
- Rupture of the follicle releases the egg; concomitant release of some blood during process irritates peritoneum
- Reassure patients
- Ruptured ovarian cyst
- Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity
- Nausea & vomiting
- Unilateral, tender adnexal mass on examination
- Can cause hemoperitoneum often while on anticoagulants
- Diffuse severe abdominal pain, pleuritic chest pain, and shoulder pain (due to phrenic nerve irritation)
- Gynecologic emergency typically occurring in premenopausal patients
- Diffuse abdominal rigidity with rebound and guarding is present
- Symptoms arise due to ischemia and eventually necrosis
- Decreased hematocrit due to intra-abdominal blood loss
- Twisting around its supporting structures (infundibulopelvic ligament or utero-ovarian ligament) which contains ovarian blood supply
- Ultrasound + Doppler: Pelvic free fluid and possible adnexal mass if the cyst is incompletely drained
- Enlarged ovary with decreased or absent blood flow
- Dermoid cysts in particular have a higher likelihood of torsion than other types of ovarian masses
- Treatment: prompt surgical laproscopy with detorsion, cystectomy, possibly removal of the adnexa (if necrosis despite restoration)
- Untreated torsion may lead to chronic pelvic pain, infertility, hemorrhage, or peritonitis and sepsis
Necrotizing Fasciitis 2749
- Streptococcus pyogenes (group A streptococci) is the most frequently recovered
- Staphylococcus aureus
- Clostridium perfringens
- Polymicrobial
- Bacteria spread rapidly through subcutaneous tissue & deep fascia , undermining the skin
- Most commonly involves extremities & perineal region
- Often antecedent history of minor trauma
- Erythema of overlying skin
- Swelling & edema
- Pain out of proportion to examination findings
- Untreated necrotizing fasciitis progresses to rapid discoloration of the affected site, purulent discharge, bullae, and necrosis
- Air in the deep tissue can cause crepitus
- Systemic symptoms (eg, fever & hypotension)
- Imaging reveals extent and air in the tissue bed; If necrotizing fasciitis is suspected, therapy should not be delayed to pursue imaging
- Treatment
- Requires surgical debridement & broad-spectrum antibiotics
- Blue grey discoloration
- Third Generation Cephalosporin + clindamycin + ampicillin
- Can also result from significant peripheral vascular disease (ie, diabetes).
- The most common form (type II) usually occurs in individuals with no concurrent medical illness usually from GAS
- Type I is usually seen in patients with underlying diabetes and peripheral vascu lar disease usually polymicrobal
- Staphylococcus aureus, Bacteroides fragilis, Escherichia coli, group A Streptococcus, and Prevotella species
- Antibiotics to use according to uworld
- Piperacillin/tazobactam or a carbapenem for GAS and anaerobes
- Vancomycinw ill cover Staphylococcus aureus
- Clindamycin is added to inhibit toxin formation by streptococci/staphylococci
- Once culture information is available, antibiotic therapy should be narrowed based on identified pathogens
Nasal Polyps, Angiofibroma and Nasopharngeal Carcinoma
- Nasal Polyp
- Protrusion of edematious, inflamed nasal mucosa
- Secondary to repeated bouts of rhinitis; occurs in cystic fibrosis and aspirin-intolerant asthma, kartagener
- Aspirin-intolerant asthma consists of asthma, aspirin-induced bronchospasms, nasal polyps
- Surgery often temporary relief, polyps recur; ultimate treatment should be management of underlying etiology
- Not just aspirin, any NSAIDs
- Can do aspirin desensitization if aspirin is required
- Treatment includes management of the patient's underlying asthma and chronic rhinosinusitis
- Avoidance of NSAIDs, and desensitization if NSAID use is required
- Leukotriene inhibitors (zileuton) and leukotriene antagonists (montelukast) --> improved resp/nasal symptoms
- Considered a pseudoallergy
- Angiofibroma
- Benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue; classically seen in adolescent males
- Profuse epistaxis
- Can cause nasal obstruction and nasal drainage
- Nasopharyngeal Carcinoma
- Malignant
- EBV association; classically African children/Chinese Adults
- Risk is thought to be higher in these locations due to diet (salt-cured food, early exposure to salted fish) and genetic predisposition
- Pleomorphic keratin-positive epithelial cells (poorly differentiated squamous cell carcinoma) in a background of lymphocytes
- Often presents with cervical lymph node involvement
- EBV assays are often used to monitor treatment response and disease relapse
- Invades adjacent tissues --> congestion, epistaxis, headache, CN palsy, serous otitis media (eustachian obstruction)
- Nasal congestion with epistaxis, headache, cranial nerve palsies (eg , facial numbness), serous otitis media (eustachian tube obstruction)
- Early metastatic spread to the cervical lymph nodes may cause a nontender neck mass
- Nasopharyngeal endoscopy should be considered
Ileus
- Intestinal hypomotility without obstruction
- Symptoms
- Constipation and decreased flatus
- Distended/tympanic abdomen with decreased bowel sounds
- Associations
- Abdominal surgeries
- Opiates
- Hypokalemia
- Sepsis
- Treatment
- Bowel rest, electrolyte correction, cholinergic drugs (stimulate intestinal motility).
Peritonsillar Abscess (Quinsy) 2847
- An acute bacterial infection of the region between the tonsil and the pharyngeal muscles
- Most common in older adolescents and young adults, and drug or alcohol use increases the risk
- Fever
- Sore throat, difficulty swallowing
- Trismus (spasm of the jaw muscles)
- Muffled "hot potato " voice
- Uvula deviation away from enlarged tonsil
- Pooling of saliva
- Ear ache
- Can be fatal secondary to airway obstruction or spread of infection into the parapharyngeal space --> carotid sheath
- Treatment
- Needle aspiration or incision and drainage (if aspiration fails to remove purulent material)
- Antibiotic therapy to cover Group A hemolytic streptococci and respiratory anaerobes
- Clinical diagnosis (no imaging required)
Emphysematous Cholecystitis 2940
- Risk factors
- Diabetes mellitus
- Vascular compromise
- Gallstones
- lmmunosuppression
- Clinical presentation
- Fever, right upper quadrant pain, nausea/vomiting
- Crepitus in abdominal wall adjacent to gallbladder
- Complications include gangrene and perforation
- Diagnosis
- Air-fluid levels in gallbladder, gas in gallbladder wall
- Cultures with gas-forming Clostridium, Escherichia coli
- Unconjugated hyperbilirubinemia, mildly elevated aminotransferases
- Gas in the gallbladder wall, and occasionally pneumobilia (air within the hepatobiliary system)
- Treatment
- Emergent cholecystectomy
- Broad-spectrum antibiotics with Clostridium coverage (eg, ampicillin-sulbactam)
- Can cause ileus (decreased or absent bowel sounds)
Anterior and Middle Mediastinal Mass 2590
- Diagnosis of mediastinal tumors is based on chest-x rays and CT scans
- Anterior
- 4 T's
- Thymoma
- Teratoma
- One must also include other germ cell tumors
- Teratomas distinguished from other germ cell tumors on imaging by the presence of fat or calcium, particularly if in the form of a tooth
- Serum B-HCG can be elevated in 1/3 of patients with a seminoma
- Patients with a nonseminomatous germ cell tumor have elevated AFP, some also have elevated B-HCG
- Diagnos can be confirmed with biopsy
- Testicular ultrasound should be per formed to exclude a small primary tumor
- Thyroid neoplasm
- Terrible lymphoma
- Middle
- Bronchogenic cysts are are benign entities
- May be seen on the AP chest x-ray
- Tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, and aortic aneurysms of the arch
- Posterior
- All neurogenic tumors are located in the posterior mediastinum
- These include: meningocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, and aortic aneurysms
- MRI is the best modality to evaluate posterior mediastinal masses
