1 Surgery Flashcards
What signs differentiate pericardial tamponade from tension pneumothorax?
In pericardial tamponade there is no respiratory distress. In tension pneumothorax there is severe respiratory distress, one side of the chest has no breath sounds and is hyperresonant to percussion, and there is tracheal deviation.
What is the initial treatment of hypovolemic shock?
Volume replacement with 2 L of Ringer lactate (without dextrose), and followed by PRBCs until urinary output 0.5–2 ml/kg/h, while not exceeding CVP of 15 mm Hg.
What is the management of pericardial tamponade?
Evacuation of the pericardial sac by pericardiocentesis, tube, pericardial window, or open thoracotomy. Fluid and blood administration. The diagnosis is clinical (if diagnosis is unclear sonogram may be used).
What are the signs of cardiogenic shock?
Hypotension with high CVP (distended veins). Cardiogenic shock is caused by massive myocardial damage (myocardial infarction or myocarditis). Treat with circulatory support.
What are the signs of vasomotor shock?
Vasomotor shock is seen in anaphylactic reactions and high spinal cord transection or high spinal anesthetic. Circulatory collapse in a flushed, pink and warm” patient. CVP is low (flat veins). Treatment is fluids vasoconstrictors.”
What is the treatment of linear skull fractures?
Linear skull fractures are not treated if closed. Open fractures require wound closure. Operative treatment is required if the fracture is comminuted or depressed.
What is the treatment of head trauma with unconsciousness?
Head trauma with unconsciousness requires a CT for intracranial hematomas. If negative and no neurologic deficits, patients can go home if family will wake them up frequently during next 24 h.
What are the signs of a fracture affecting the base of the skull?
Raccoon, eyes, rhinorrhea, otorrhea or ecchymosis behind ear. Cervical spine should be assessed with a CT. If the patient was unconscious, a CT of head is ordered to rule out intracranial bleeding.
What factors cause neurologic damage from trauma?
The initial blow, subsequent development of a hematoma that displaces the midline structures, and development of increased intracranial pressure. Surgery can relieve hematoma, and medical measures can prevent increased ICP.
What is the presentation of acute epidural hematoma?
Modest trauma to head causes unconsciousness, lucid interval, gradual lapse into coma again, fixed dilated pupil on side of hematoma, then contralateral hemiparesis with decerebrate posture. CT: lens–shaped hematoma. Craniotomy.
What is the presentation of acute subdural hematoma?
Severe trauma and unconsciousness. The patient is usually not fully awake at any point, and the neurologic damage is severe. CT scan shows a semilunar, crescent–shaped hematoma.
What is the treatment of subdural hematoma?
If midline structures are deviated, craniotomy is beneficial. If there is no deviation, therapy is ICP monitoring, elevate head, hyperventilate, and give mannitol or furosemide. Avoid over diuresis. Hypothermia will reduce brain oxygen demand.
What is diffuse axonal injury?
Occurs in more severe trauma. CT shows diffuse blurring of gray– white matter interface and punctate hemorrhages. There is no role for surgery unless there is a hematoma. Therapy is directed at preventing increased intracranial pressure.
What is chronic subdural hematoma?
Occurs in elderly or in alcoholics. A shrunken brain is injured by minor trauma, tearing the venous sinuses. Mental function deteriorates as a hematoma forms. CT is diagnostic, and treatment is evacuation.
What is the management of penetrating trauma to the neck?
Requires surgical exploration if there is an expanding hematoma, deteriorating vitals, or esophageal or tracheal injury (coughing, hemoptysis). Severe gunshot wounds of the middle zone of the neck are always explored.
What is the treatment of gunshot wounds to the upper neck zone?
Arteriographic diagnosis and management is preferred; for gunshot wounds to base of neck, arteriography, esophagogram (water–soluble), esophagoscopy, and bronchoscopy help determine the surgical approach.
What are the signs of spinal hemisection (Brown–Sequard syndrome)?
Usually caused by a knife blade, causing paralysis and loss of proprioception distal to the injury on the injury side and loss of pain perception distal to the injury on the other side.
What is the anterior cord syndrome?
Usually caused by burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temperature sensation on both sides distal to the injury. There is preservation of vibratory and positional sense.
What is central cord syndrome?
Occurs in the elderly with forced hyperextension of the neck after a rear–end collision. There is paralysis and burning pain in the upper extremities, with preservation of function in the lower extremities.
What is the management of spinal cord injuries?
Precise diagnosis of cord injury is with magnetic resonance imaging. High–dose corticosteroids immediately after the injury.
What is a pneumothorax?
Results from penetrating trauma (broken rib or penetrating weapon). Moderate shortness of breath, unilateral absence of breath sounds, hyperresonance to percussion. X–ray, chest tube (upper, anterior), connect to underwater seal.
What is the presentation of hemothorax?
Results from penetrating trauma. Affected side will be dull to percussion. Diagnosed by chest x–ray.
What is the treatment of hemothorax?
Chest tube placed low. Bleeding will usually stop spontaneously. Surgery is indicated if 1,500 ml or more is removed when the chest tube is inserted, or if >600 ml of blood drains out over 6 hours.
What is the management of severe blunt trauma to the chest?
Monitor with blood gases and chest x–rays to detect developing pulmonary contusion; check cardiac enzymes (troponins) and electrocardiogram to detect myocardial contusion. Traumatic transection of the aorta should be sought.
What is a sucking chest wound?
Characterized by a flap over a wound that sucks air with inspiration and closes during expiration. Tension pneumothorax develops. An occlusive dressing should be applied, which allows air out (tape on three sides) but not in.
What is the presentation of flail chest?
Multiple rib fractures allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing).
What is the treatment of flail chest?
The underlying pulmonary contusion is sensitive to fluid overload, thus treatment includes fluid restriction, use of colloids (plasma or albumin), and diuretics. If a ventilator is needed, bilateral chest tubes are placed to prevent tension pneumothorax.
What is the presentation of pulmonary contusion?
Occurs after chest trauma with deteriorating blood gases and white out” of the lungs on chest x–ray. It can appear up to 48 hours after the injury. Treatment is fluid restriction colloids diuretics and blood gas monitoring.”
What is the presentation of myocardial contusion?
Sternal fractures. ECG shows diffuse ST changes or T wave inversion. Troponins are specific. Treat arrhythmias.
What is the presentation of traumatic rupture of the aorta?
Occurs at junction of arch and descending aorta after deceleration injury. Asymptomatic until hematoma ruptures and causes death. X–ray shows wide mediastinum; transesophageal echocardiography, spiral CT, or MRI angiography.
What is the presentation of traumatic rupture of the trachea or major bronchus?
Subcutaneous emphysema in upper chest and lower neck, or a large air leak from a chest tube. X–ray shows of air in tissues, and fiberoptic bronchoscopy identifies the lesion and allows intubation beyond the lesion. Surgical repair.
What is the differential diagnosis of subcutaneous emphysema?
Rupture of the trachea, rupture of the esophagus (after endoscopy), and tension pneumothorax.
What is the presentation of air embolism?
Occurs when subclavian vein is opened to air (CVP disconnected). Sudden collapse and cardiac arrest. Immediate management includes positioning left side down. Prevented by using Trendelenburg when great veins are to be entered.
What is the presentation of fat embolism?
Respiratory distress after long bone fractures with petechial rashes in axillae/neck; fever, tachycardia, low platelets; hypoxemia, bilateral patchy infiltrates. Fat droplets in the urine. Treatment: respiratory support.
What is the management of gunshot wounds to the abdomen?
Exploratory laparotomy for repair of intraabdominal injuries. Low caliber gunshot wounds involving the right upper quadrant are managed with conservative therapy with close followup of clinical signs and serial abdominal CTs.
What is the management of stab wounds?
If penetration has occurred (protruding viscera) or if hemodynamic instability or signs of peritoneal irritation develop, exploratory laparotomy is mandatory. Otherwise, digital exploration of the wound may be sufficient.
What is the management of blunt trauma to the abdomen?
Exploratory laparotomy if there are signs of peritoneal irritation or signs of internal bleeding shock, low CVP, with no obvious external source of blood loss.
What are the signs of internal bleeding in a patient with blunt trauma?
Drop in blood pressure, with tachycardia, low CVP, and low urinary output; a cold, pale, anxious patient who is shivering, thirsty, and perspiring profusely. Signs of shock occur when 25 to 30% of blood volume is acutely lost (1,500 ml in an adult).
How is blunt trauma intraabdominal bleeding diagnosed?
CT shows blood or injury to liver or spleen. Patients with minor injuries who respond to fluid resuscitation do not need surgery. The patient with major injuries and vital signs that do not improve with fluid resuscitation requires surgery.
How is intraabdominal bleeding diagnosed in hemodynamically unstable, blunt trauma patients?
Sonogram is done in the ER or operating room to determine if there is blood in the peritoneal cavity. If ultrasound is positive, exploratory laparotomy is indicated.
What is the treatment of intraoperative coagulopathy during prolonged abdominal surgery for multiple trauma with multiple transfusions?
Empiric treatment with platelet packs and fresh–frozen plasma.
What is the presentation of the abdominal compartment syndrome?
Occurs when large volume of fluids and blood have been given during prolonged laparotomies; tissues are swollen and abdominal wound cannot be closed without excessive tension. A temporary cover is placed over the abdominal contents.
What is the management of pelvic fractures with hematoma bleeding?
Diagnosis is based on hypovolemic shock with a pelvic fracture and a large pelvic hematoma. External fixation is the best way to diminish the bleeding. For arterial bleeding, arteriographic embolization is effective.
What is the management of urologic injuries?
Penetrating urologic injuries are surgically explored and repaired. Blunt injuries may affect the kidney after lower rib fractures, or they may affect the bladder or urethra after a pelvic fracture.
What are the signs of urethral injury?
Occurs in men with pelvic fracture. Blood in meatus, scrotal hematoma. Sensation of bladder fullness with inability to avoid, and a high–riding” prostate. Foley should not be inserted but a retrograde urethrogram should be done.”
What is the management of bladder injuries?
Usually associated with pelvic fracture. Diagnosed by retrograde cystogram. Postvoid contrast films may demonstrate extraperitoneal leaks at the base of the bladder. Management is surgical repair with a suprapubic cystostomy.
What is the management of renal injuries secondary to blunt trauma?
Usually associated with lower rib fractures. Assessment is by CT scan. Surgical intervention is usually not necessary. Renal artery stenosis caused by trauma may lead to renovascular hypertension.
What is the management of scrotal hematomas?
Scrotal hematomas can become large, but do not need specific intervention unless a sonogram shows that the testicle is ruptured.
What is the management of fracture of the penis?
Fracture of corpora cavernosa or fracture of tunica albuginea occurs to erect penis during vigorous intercourse. Pain and a penile hematoma. Emergency surgical repair is required to prevent impotence caused by arteriovenous shunts.
What is the management of penetrating injuries of the extremities?
When no vessels in vicinity of injury: tetanus prophylaxis, cleaning. If penetration is near a vessel: Doppler or arteriograms are done. If there are absent distal pulses or expanding hematoma: exploration, repair, fasciotomy.
What is the management of Crushing injuries to the extremities?
May cause hyperkalemia, myoglobinemia, myoglobinuria, renal failure, compartment syndrome. Fluids, osmotic diuretics, alkalinization of the urine, and fasciotomy may be required for crush injuries.
What is the presentation of high–voltage electrical burns?
Severe muscle damage. Myoglobinemia–myoglobinuric–renal failure (fluids, mannitol; alkalinize urine), posterior dislocation of shoulder, compression fractures of vertebral bodies, cataracts, demyelinization.
What is the management of respiratory burns?
Burns around mouth or soot in throat. Diagnosis with fiberoptic bronchoscopy; blood gases. Intubation should be done if there is an inadequate airway. If carboxyhemoglobin is elevated, 100% oxygen will aid in removal.
What is the management of circumferential burns of the extremities?
Impaired blood supply because edema accumulates underneath the eschar. Circumferential burns of the chest may interfere with breathing. Escharotomies (no need for anesthesia) will provide immediate relief.
How is the extent of burns in the adult estimated?
Rule of nines.” The head and each of the upper extremities are assigned 9% of body surface each. Each lower extremity is assigned two 9% units and the trunk is given four units of 9% each. Second– and third–degree burns are counted.”
How are fluid requirements estimated for burns?
Parkland formula: kg weight x % burn x 4 ml = RL (without dextrose) required for first 24 h, half should be infused in first 8 h; other half in next 16 h. 2,000 ml of 5% D5W for maintenance. Urinary output should be 1–2 ml/kg/h.
How does the estimation of fluid requirements in burned babies differ from the adult?
Babies have larger heads and smaller legs; thus rule of nines” assigns two 9’s to head and both legs share a total of three 9’s. Babies need proportionally more fluid than adult; 4 to 6 ml/kg/%. Rate is 20 ml/kg/h if >20%.”
What is the management of burn injuries?
Tetanus, cleaning, silver sulfadiazine. Burns near eyes are covered with triple antibiotic. Pain medication IV. After 1 day of NG suction, intensive nutritional support is provided via gut. After 3 weeks, areas that have not regenerated are grafted.
What is the management of dog bites that are provoked?
If the dog was petted while eating or teased, no rabies prophylaxis is required, other than observation of the dog for developing signs of rabies. Tetanus prophylaxis.
What is the management of unprovoked dog bites or bites from wild animals?
The animal can be killed and the brain examined for signs of rabies. If the animal is not available, rabies prophylaxis should consist of immunoglobulin plus vaccine. Tetanus prophylaxis should be given.
What are the signs of snake envenomation?
30% of snake bitten are not envenomated. Signs of envenomation are severe local pain, swelling, discoloration within 30 min of bite. If present, draw blood for typing/cross, coagulation studies, liver/renal function.
What is the management of snakebites?
Treatment is antivenom, at least five vials. Surgical excision of the bite site or fasciotomy are rarely needed. Splint the extremity during transportation. Sucking out venom, wrapping with ice, and tourniquets are contraindicated.
What is the management of bee stings?
Bees kill many more people than snakes because of anaphylactic reactions. Wheezing, rash, hypotension caused by vasomotor shock (pink and warm” shock). Epinephrine 0.3 to 0.5 ml of 1:1000 solution. Stingers removed by scraping.”
What is the management of black widow spider bites?
Black with a red hourglass on the abdomen. The bite causes nausea, vomiting, and severe generalized muscle cramps. The antidote is IV calcium gluconate and a muscle relaxant.
What is the management of brown recluse spider bites?
A skin ulcer develops the next day, with a necrotic center and a surrounding halo of erythema. Dapsone. Surgical excision and skin grafting may be needed.
What is osteogenic sarcoma?
The most common primary malignant bone tumor. 25 years old, usually around the knee (lower femur or upper tibia). Sunburst” pattern on x–rays.”
What is Ewing sarcoma?
Second most common primary malignant bone tumor; it affects younger children (5 to 15), grows in the diaphyses of long bones. A typical onion skinning” pattern is seen on x–rays.”
What is the most common malignant bone tumor in adults?
Most malignant bone tumors in adults are metastatic from the breast in women or from prostate in men. Bone scan is more sensitive than x–rays (but not specific – if positive, should follow with x–rays). Lytic lesions may cause fractures.
What is the presentation of multiple myeloma?
Elderly men with fatigue, anemia, pain of bones. X–rays show multiple, punched–out lytic lesions. Bence–Jones protein in urine and abnormal immunoglobulins in blood by immunoelectrophoresis. Treated with chemotherapy.
What are soft tissue sarcomas?
Soft tissue mass that relentlessly grows over several months anywhere in the body. Firm, fixed to surrounding structures. Metastasize to lungs, but not to lymph nodes. MRI. Incisional biopsy with wide local excision, radiation, chemotherapy.
What is the treatment of clavicular fractures?
Typically at the junction of middle and distal thirds. Treated with a figure–of–eight device for 4 to 6 weeks.
What is the presentation of anterior dislocation of the shoulder?
Most common shoulder dislocation. Hold arm close to body but rotated outward as if they were going to shake hands. Numbness in a small area over deltoid from stretching of axillary nerve. AP and lateral x–rays are diagnostic.
What is the presentation of posterior shoulder dislocation?
Rarely occurs after severe uncoordinated muscle contractions, such as an epileptic seizure or electrical burn. The arm is held close to the body, internally rotated. Axillary x–ray views or scapular lateral views are needed.
What is the presentation of Colles fracture?
Distal radius fracture from a fall on outstretched hand in elderly osteoporotic women. Deformed and painful wrist looks like a dinner fork.” Dorsally displaced dorsally angulated fracture of the distal radius. Close reduction and long arm casting.”
What is the presentation of Monteggia fracture?
Results from direct blow to the ulna. Diaphyseal fracture of the proximal ulna with anterior dislocation of the radial head.
What is the presentation of Galeazzi fracture?
The distal third of the radius receives a direct blow and is fractured; dorsal dislocation of the distal radioulnar joint. Treatment is open reduction and internal fixation of the radius, and closed reduction of the radioulnar joint.
What is the presentation of fracture of the scaphoid (carpal navicular)?
Young adult who falls on an outstretched hand. Wrist pain. Tender anatomic snuff box. X–rays are negative, but a thumb Spica cast is indicated. If displaced and angulated fracture, open reduction and internal fixation are needed.
What is the presentation of metacarpal neck fractures?
Typically the fourth or fifth metacarpal. Happen when a closed fist hits a hard surface. The hand is swollen and tender. X–rays are diagnostic. Close reduction and ulnar gutter splint for mild cases; Kirschner wire or fixation for malalignment.
What is the presentation of hip fractures?
Elderly who sustain a fall and have hip pain. The affected leg is shortened and externally rotated.
What is the presentation of femoral neck fractures?
Femoral neck fractures compromise the blood supply of the femoral head if displaced. Treatment is a femoral head prosthesis.
What is the treatment of intertrochanteric fracture?
Open reduction and pinning. Immobilization is high risk for deep venous thrombosis and pulmonary emboli. Post–op anticoagulation is recommended.
What is the treatment of femoral shaft fractures?
Intramedullary rod fixation. May cause significant internal blood loss. Open fractures require operative cleaning and closure within 6 hours. Multiple fractures may lead to the fat embolism syndrome.
What is the presentation of collateral knee ligament injuries?
Caused by sideways impact to knee. Lateral impact tears medial ligaments. With the knee flexed, passive abduction or adduction will allow displacement. Isolated injuries are treated with a hinged cast. When several ligaments torn, surgical repair needed.
What is the presentation of anterior cruciate ligament tears?
Anterior cruciate ligament injuries are more common than posterior. With knee flexed, leg can be pulled anteriorly (anterior drawer test). MRI. Sedentary patients treated with immobilization; athletes require arthroscopic reconstruction.
What are meniscal tears?
Pain and swelling after a knee injury, and may cause a catching and locking that limits knee motion, and a click” when knee is extended. MRI. Arthroscopic repair may save the meniscus. Meniscectomy leads to arthritis.”
What are tibial stress fractures?
Seen in young men subjected to forced marches. Tenderness to palpation over a very specific point on the bone, but x–rays are initially normal. Treat with a cast on crutches, and repeat the x–rays in 2 weeks.
What is the presentation of rupture of the Achilles tendon?
Middle–age men after severe strain. A loud popping noise is heard, followed by falling and clutching of the ankle. Pain, swelling, and limping. Palpation of the tendon reveals a gap. Surgery achieves a rapid cure.
What is the presentation of compartment syndrome?
Most frequently occurs in the forearm and lower leg. Caused by prolonged ischemia followed by reperfusion; crushing injuries. Tender and tight to palpation. Pulses may be normal. Emergency fasciotomy. Pain under a cast requires removing cast.
What is the presentation of posterior dislocation of the hip?
Occurs when the femur is driven backward, such as in a head–on car collision. Hip pain and lies with the leg shortened, adducted, and internally rotated (in a broken hip the leg is also shortened, but it is externally rotated). Emergency reduction.
What is the presentation of gas gangrene?
Occurs with deep, penetrating, contaminated wounds, after 3 days the patient becomes toxic and moribund. The site is tender, swollen, discolored, and gas crepitation. Treatment is penicillin, debridement, and hyperbaric oxygen.
What nerve is often injured by fractures of the humerus?
Radial nerve injury can be injured in oblique fractures of the middle to distal thirds of the humerus. If nerve paralysis develops, the nerve is entrapped and surgical exploration is required.
What artery is often injured by posterior dislocations of the knee?
Popliteal artery injuries can occur in posterior dislocations of the knee. Check pulses, Doppler studies, and arteriogram. Prompt reduction will minimize vascular compromise. Prophylactic fasciotomy if significant leg ischemia.
What is the treatment of carpal tunnel syndrome?
Wrist x–rays (including carpal tunnel view) should be done to rule out other causes. Initial treatment is splints and antiinflammatory agents. If surgery is needed, electromyography should be done first.
What is the presentation of trigger finger?
Occurs in women who wake up at night with an acutely flexed finger, and are unable to extend it unless they pull. Treatment is steroid injection; surgery.
What is the presentation of De Quervain tenosynovitis?
Occurs in young mothers who force their hand into wrist flexion and thumb extension to hold the baby’s head. Pain along the radial side of the wrist and the first dorsal compartment. Treatment is splinting, NSAIDs; steroid injection. Surgery rarely.
What is the presentation of Dupuytren contracture?
Occurs in older men of Norwegian ancestry with contracture of the palm and palmar fascial nodules. Surgery is the only effective treatment.
What is a finger felon?
Abscess in the pulp of a fingertip caused by a penetrating injury. Throbbing pain, abscess, fever. Treatment is surgical drainage.
What is the presentation of gamekeeper thumb?
Injury of the ulnar collateral ligament caused by forced hyperextension of the thumb. Collateral laxity at the thumb–metacarpophalangeal joint causes joint dysfunctional and pain leading to arthritis. Casting is usually done.
What is Jersey finger?
Injury to the flexor tendon sustained when the flexed finger is forcefully extended. The distal phalanx of the injured finger does not flex with the others.
What is Mallet finger?
The extended finger is forcefully flexed, and the extensor tendon is ruptured. The tip of the affected finger remains flexed when the hand is extended, resembling a mallet. Treatment is splinting.
What is the management of traumatically amputated digits?
The amputated digit should be wrapped in a saline–moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice.
What is the presentation of lumbar disk herniation?
Occurs at L4–L5 or L5–S1. Peak age is 45–46 years. Vague aching pain before sudden severe pain precipitated by a forced movement.Electrical shock that shoots down the leg.” Cannot ambulate affected leg is flexed. Straight leg–raising test. MRI.”
What is the treatment of lumbar disk herniation?
Bedrest. Pain control with nerve blocks. Surgical intervention is needed if progressive weakness and emergency surgery is required if cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia).
What is the presentation of cauda equina syndrome?
Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia. Surgical emergency requiring immediate decompression.
What is the presentation of ankylosing spondylitis?
Occurs in young men in thirties or early forties with chronic back pain, morning stiffness. Pain is worse at rest, improves with activity. Symptoms are progressive. X–rays: bamboo spine.” Associated HLA B–27 antigen. Treatment: NSAIDs physical therapy.”
What are the signs of metastatic spine malignancy?
Elderly with progressive back pain worse at night, unrelieved by rest or position. Weight loss. X–rays lytic breast cancer metastases at pedicles in women; blastic metastases from prostate in men. Bone scan is a more sensitive. MRI.
What are diabetic ulcers?
Located at pressure points (heel, metatarsal head, tip of toes, necrotic base with some granulation); caused by neuropathy, and microvascular disease. Healing may occur with control of diabetes, cleaning, leg elevation.
What are arterial insufficiency ulcers?
Affect feet, tip of toes. Pale base without granulation tissue. Absent pulses, trophic changes, claudication, rest pain. Doppler demonstrates pressure gradient. Absence of a pressure gradient indicates microvascular disease.
What are venous stasis ulcers?
Develop in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus. Painless with granulating bed. Varicose veins. Treatment is support stockings, Ace bandages, Unna boot. Vein stripping, grafting of the ulcer.
What is the presentation of Marjolin ulcer?
Squamous cell carcinoma of skin, developing in a chronic leg ulcer. A dirty–looking, deeper ulcer develops at the site, with heaped up tissue growth around the edges. Biopsy is diagnostic. Wide local excision and skin grafting.
What is the presentation of plantar fasciitis?
Common problem of older, overweight patients with sharp heel pain when walking. The pain is worse in the mornings. X–rays show a bony spur. Tenderness to palpation over spur. Spontaneous resolution in 12–18 months. Treatment is symptomatic.
What is the presentation of Morton neuroma?
Inflammation of common digital nerve at the third interspace, between the third and fourth toes. The neuroma is palpable and very tender. Caused by pointed, high heel shoes that force the toes together. Management: analgesics and wide shoes.
What is the presentation of gout?
Swelling, redness, pain of sudden onset at first metatarsal–phalangeal joint in a middle–age, obese man with high uric acid. Uric acid crystals in joint fluid.
What is the treatment of gout?
Treatment for the acute attack is indomethacin and colchicine. Allopurinol and probenecid for chronic control.
What cardiac ejection fraction is a contraindication to surgery?
Ejection fraction under 35% (normal is 55%) is a prohibitive cardiac risk for noncardiac operations. Mortality would be 55–90%.
What is Goldman’s index of cardiac risk?
11 points for JVD, 10 points for recent MI, 7 points for PVCs or arrhythmia, 5 points for age >70, 4 points emergency surgery, 3 points for aortic stenosis, poor medical condition, or chest/abdomen surgery. Risk is 1% with total of 5.
What is the presurgical management of long–term smokers?
Smokers have a high PCO2, low forced expiratory volume in 1 second. Cessation of smoking for 8 weeks and intensive respiratory therapy should precede surgery.
What are hepatic risk factors for surgery?
40% mortality with either bilirubin above 2, albumin below 3, PT >16, or encephalopathy. 85% mortality if three of the above are present, or with either bilirubin>4, albumin 150 mg/dl.
What are the signs of severe nutritional depletion?
Loss of 20% of body weight over months, serum albumin below 3, anergy to skin antigens, or serum transferrin level of less than 200 mg/dl. 5–10 days of preoperative nutritional support will reduce surgical risk.
What is the presentation of malignant hyperthermia?
Develops after onset of anesthetic (halothane or succinylcholine). T >104 F. Metabolic acidosis, hypercalcemia, myoglobinuria.. Family history. Treatment: dantrolene, oxygen, correction of acidosis, and cooling blankets.
What are the causes of postoperative fever?
Fever in the range 101 –103 F is caused by atelectasis, pneumonia, urinary tract infection, deep venous thrombophlebitis, wound infection, or abscesses.
What is atelectasis?
Most common cause of post–op fever on the first day. Rule out other causes by auscultating, x–ray, deep breathing and coughing, postural drainage, incentive spirometry. Bronchoscopy for severe cases.
When does pneumonia develop after surgery?
Pneumonia may develop after 3 days if atelectasis is present. Fever. Chest x–ray shows infiltrates. Sputum cultures. Treat with appropriate antibiotics.
When does urinary tract infection cause fever after surgery?
Urinary tract infection causes fever starting on post op day 3. Urinalysis, urinary cultures. Treat with antibiotics.
When does deep vein thrombophlebitis cause fever after surgery?
Produces fever starting on post operative day 5. Doppler study of deep leg and pelvic veins is the best diagnostic modality. Anticoagulate with heparin.
When does wound infection cause fever after surgery?
Wound infection produces fever on post op day 7. Erythema, warmth, and tenderness. Treat with antibiotics if there is only cellulitis. Open and drain the wound if there is an abscess. A sonogram may be used to evaluate for abscess.
When do deep abscesses cause fever after surgery?
Subphrenic, pelvic, or subhepatic cause fever around post operative days 10–15. CT scan is diagnostic. Percutaneous radiologically guided drainage is therapeutic.
When do pulmonary emboli occur after surgery?
Pulmonary emboli occur on post op day 7 in elderly/immobilized. Sudden pleuritic pain, dyspnea, anxiety, diaphoresis, tachycardia, distended neck veins. Hypoxemia, hypocapnia. Spiral CT. After diagnosis, start heparin.
What is the presentation of adult respiratory distress syndrome?
Seen in patients with a complicated post–op course, often complicated by sepsis. There are bilateral pulmonary infiltrates and hypoxia with no evidence of congestive heart failure.
What is the presentation of delirium tremens?
Delirium tremens is common in alcoholics. Confusion, hallucinations, combative behavior on second or third postoperative day. IV benzodiazepines are the therapy for delirium tremens.
What are the complications of hyponatremia?
Induced by excessive hypotonic IV fluids (D5W) in a postoperative patient with high levels of antidiuretic hormone caused by trauma. Confusion, seizures, coma, death. Treatment is hypertonic saline (500 ml of 3%).
What are the complications of hypernatremia?
Confusion, lethargy, and coma if rapidly induced by unreplaced water loss. May be caused by surgical damage to the posterior pituitary with unrecognized diabetes insipidus. Replacement of fluid deficit with D5 1/2 NS.
What is the cause of zero urinary output after surgery?
Zero urinary output typically is caused by a mechanical problem, rather than a renal cause. Zero urinary output is often caused by a plugged or kinked Foley catheter.
What is the evaluation of low urinary output after surgery?
Urinary output 40 mEq/L in RF. Fractional excretion of Na >1 in RF.
What is paralytic ileus?
Occurs in the first few days after abdominal surgery. Bowel sounds are absent, there is no passage of gas. Mild distension, no pain.
What are the x–ray signs of small bowel obstruction?
Early mechanical bowel obstruction is caused by adhesions. X–rays will show dilated loops of small bowel and air–fluid levels. CT scan shows a transition point between proximal dilated bowel and distal collapsed bowel at site of obstruction.
What is the presentation of Ogilvie syndrome?
Paralytic ileus of colon in elderly, sedentary. Abdominal distention. X–rays: dilated colon. Colonoscopy decompress colon, and rules out a mechanical cause of the obstruction, such as cancer of the colon. Long rectal tube.
What is the presentation of wound dehiscence?
Occurs around fifth post–op day after laparotomy. Wound may appear intact, but salmon–colored” peritoneal fluid is soaks dressings.Wound should be taped securely abdomen should be bound. Reoperation at a later date to correct a ventral hernia.”
What is the presentation of evisceration?
A wound dehiscence where the skin opens up and the abdominal contents escape when the patient coughs, strains, or gets out of bed. The bowel should be covered with large sterile dressings soaked with warm saline. Emergency abdominal closure.
What is the treatment of hypernatremia?
Loss of water (or other hypotonic fluids) and hypertonicity. Every 3 mEq/L that the serum sodium concentration is above 140, represents 1 L of water lost. Therapy requires volume repletion with NS, then 1/2 NS.
What is the treatment of hyponatremia?
Water has been retained. Rapid hyponatremia requires 3% hypertonic saline. In slowly developing hyponatremia, therapy is water restriction. In hypovolemic, dehydrated losing GI fluids, volume restoration with NS will correct hypovolemia.
What are the causes of hypokalemia?
Develops when potassium is lost from the GI tract or urine (loop diuretics, or excessive aldosterone). Hypokalemia develops very rapidly when K moves into cells when diabetic ketoacidosis corrected. Therapy is potassium. Max IV K is 10 mEq/h.
What are the causes of hyperkalemia?
Occurs slowly in renal failure, and occurs rapidly in crushing injuries, acidosis. Therapy is 50% dextrose and insulin, exchange resins, IV calcium, and dialysis.
What are the causes of metabolic acidosis?
Excessive acids (DKA, lactic acidosis), loss of bicarbonate GI, or inability of kidney to eliminate acids (RF). pH is low (10).
What is the most common cause of metabolic alkalosis?
Occurs from loss of acidic gastric fluid. There is a high blood pH (>7.4), high serum bicarbonate (>25). An increased intake of KCl (between 5 to 10 mEq/h) will usually allow the kidney to correct the problem.
What is the most common cause of respiratory acidosis?
Impaired ventilation causes acidosis. Abnormal hyperventilation causes alkalosis. Pco2 is low in alkalosis, high in acidosis with abnormal pH of the blood. Therapy: ventilation in acidosis.
What are the symptoms of gastroesophageal reflux?
Overweight individual with burning retrosternal pain and heartburn” that is exacerbated by bending over or lying flat in bed and relieved by the ingestion of antacids or H2 blockers. Barrett esophagus may develop. Endoscopy biopsies.”
What are the indications for surgical treatment of hiatal hernia?
Laparoscopic Nissen fundoplication for gastroesophageal reflux is indicated for ulceration, stenosis, or dysplastic changes.
What is the evaluation of hiatal hernia?
pH monitoring, endoscopic biopsies. Lower esophageal sphincter weakness is measured by manometry. Stomach emptying is assessed by emptying study. Esophagogastric junction is determinated by barium swallow.
What is the presentation of achalasia?
More common in women. Dysphagia is worse for liquids; regurgitation of undigested food. X– rays show megaesophagus. Manometry is diagnostic. Treatment is dilatations or myotomy.
What are the signs of cancer of the esophagus?
Dysphagia of solids, then soft foods, liquids, and finally saliva. Weight loss. Squamous cell carcinoma occurs in male smokers/drinkers. Adenocarcinoma is seen with gastroesophageal reflux. Most are treated with palliative surgery.
What is the presentation of a Mallory Weiss tear?
Occurs after prolonged, forceful vomiting. Bright red blood. Endoscopy establishes diagnosis and allows photocoagulation (laser).
What is the presentation of Boerhaave syndrome?
Prolonged, forceful vomiting leads to esophageal perforation. Epigastric/sternal pain of sudden onset, followed by fever, leukocytosis, and a septic appearance. Contrast (Gastrografin swallow, barium if negative) is diagnostic.
What are the signs of instrumental perforation of the esophagus?
Epigastric and low sternal pain after completion of endoscopy. Emphysema in the lower neck. Instrumentation is the most common cause of esophageal perforation. Contrast studies and prompt repair are indicated.
What is the presentation of gastric adenocarcinoma?
More common in the elderly with anorexia, weight loss, vague epigastric pain or early satiety, hematemesis. Endoscopy and biopsies. CT scan assesses operability. Surgery is the best therapy.
What is the presentation of gastric lymphoma?
Anorexia, weight loss, early satiety. Treatment: chemotherapy or radiotherapy. Surgery is done if perforation. Low–grade lymphomatoid transformation (MALTOMA) can be reversed by eradication of H. pylori.
What are the signs of small bowel obstruction?
Caused by adhesions from a prior laparotomy. Colicky abdominal pain, vomiting, abdominal distention, and no passage of gas or feces. High–pitched bowel sounds coincide with pain. X–ray: distended loops of small bowel, with air–fluid.
What is the treatment of small bowel obstruction?
NPO, NG suction, and IV fluids. Spontaneous resolution may occur.
What are the signs of strangulated obstruction?
Compromised blood supply causes fever, leukocytosis, constant pain, signs of peritoneal irritation, peritonitis and sepsis. Emergency surgery is required.
What is the presentation of carcinoid syndrome?
Small bowel carcinoid tumor with liver metastases with diarrhea, flushing of the face, wheezing, and right–sided heart valvular damage with prominent jugular venous pulse. Twenty–four–hour urinary collection for 5–hydroxyindolacetic acid is diagnostic.
What is the presentation appendicitis?
Anorexia, followed by periumbilical pain becomes sharp, severe, constant, localized to right lower quadrant. Tenderness, guarding, rebound on right below umbilicus. Fever, leukocytosis 10000, with neutrophilia, immature forms. CT: inflammed appendix.
What is the presentation of cancer of the right colon?
Presents with anemia (hypochromic, iron deficiency) in elderly. Stools will be 4+ for occult blood. Colonoscopy and biopsies are diagnostic. Treatment is right hemicolectomy.
What is the presentation of cancer of the left colon?
Blood–coated, narrow caliber stools, constipation. Proctosigmoidoscopic biopsies. Full colonoscopy to rule out a second primary. CT assesses operability and extent. Pre–op chemotherapy and radiation may be needed for large rectal cancers.
Which types of colonic polyps have a high probability of malignant degeneration?
Familial polyposis (and variants such as Gardner), villous adenoma, and adenomatous polyp. Polyps that are not premalignant include juvenile, Peutz–Jeghers, inflammatory, and hyperplastic polyps.
What are the indications for surgery for chronic ulcerative colitis?
Disease for >20 years, severe interference with nutrition, multiple hospitalizations, high–dose steroids or immunosuppressants, or toxic megacolon (pain, fever, leukocytosis, epigastric tenderness, distended colon).
What is pseudomembranous enterocolitis?
Overgrowth of C difficile caused by antibiotics. Any antibiotic; clindamycin was first antibiotic described; cephalosporins are most common cause. Profuse, watery diarrhea, crampy pain, fever, leukocytosis. Diagnosis by toxin in stool.
What is the treatment of pseudomembranous enterocolitis?
Antibiotic should be discontinued. Metronidazole is the treatment of choice, with oral vancomycin is an alternate.
What are the signs of hemorrhoids?
Internal hemorrhoids are associated with bleeding, or external hemorrhoids are painful. Internal hemorrhoids can become painful and produce itching if prolapse occurs.
What is the treatment of internal hemorrhoids?
Treated with rubber band ligation. External hemorrhoids may need surgery if conservative treatment fails.
What are the signs of an anal fissure?
Severe pain with defecation; blood streaks on stools. Fissure is usually posterior, in midline. Treatment is stool softeners, topical nitroglycerin, local injection of botulin toxin, dilatation, or lateral internal sphincterotomy.
What are the anal manifestations of Crohn disease?
Often causes anal fissures, fistula, or small ulceration that fails to heal and gets worse after surgical interventions.
What is the presentation of ischiorectal abscess?
Fever with exquisite perirectal pain that prevents sitting or bowel movements. Rubor, dolor, calor, and tumor lateral to the anus between the rectum and the ischial tuberosity. Incision and drainage.
What is the presentation of fistula in ano?
Permanent tract develops after drainage of an ischiorectal abscess. Fecal soiling and perineal discomfort. Opening is lateral to the anus, a cordlike tract may be felt, and discharge may be expressed. Treat with fistulotomy.
What is the presentation of squamous cell carcinoma of the anus?
More common in HIV and homosexuals who practice anoreceptive sex. Fungating mass grows out of the anus; metastatic to inguinal nodes. Treatment with chemoradiation, followed by surgery.
What are the causes of lower gastrointestinal bleeding?
Colon angiodysplasia, polyps, diverticulosis, cancer, hemorrhoids. Elderly patients with anal bleeding usually have an upper GI tract source. The upper GI is the most common source of lower GI bleeding.
What is the most likely source of bloody emesis?
Vomiting blood always indicates a source within the upper GI (tip of the nose to the ligament of Treitz). A NG tube should be placed in a patient with bleeding per rectum. The next diagnostic test is upper GI endoscopy.
What is the evaluation of melena?
Black, tarry stools indicates digested blood, originating in the upper GI tract. Workup starts with upper GI endoscopy.
What is the diagnostic evaluation for red blood per rectum?
Red blood per rectum can be caused by upper or lower source. First pass an NG tube and aspirate gastric contents. If blood is retrieved, an upper source has been established (follow with upper endoscopy).
What is the diagnostic evaluation of red blood per rectum if the NG tube retrieves nonbilious fluid without blood?
If no blood is retrieved and fluid nonbilious, the nose to pylorus has been excluded. Upper endoscopy should follow. If no blood is recovered from NG tube and fluid is green (bile), an upper GI has been excluded.
What is the evaluation of active bleeding per rectum, when an upper GI source has been excluded?
Anoscopy for bleeding hemorrhoids. If hemorrhoids have been excluded and if bleeding >2 mL/min, an angiogram should be done. If bleeding
What is the evaluation of patients with a recent history of blood per rectum who not actively bleeding at the time of presentation?
Start workup with upper GI endoscopy if they are young; elderly patients need an upper and a lower GI endoscopy at the same session.
What is the evaluation of blood per rectum in a child?
Usually caused by Meckel diverticulum. Workup is technetium scan, looking for the ectopic gastric mucosa.
What is the most common cause of massive upper GI bleeding in a multiple trauma or complicated post–op patient?
Stress ulcers. Endoscopy will confirm. Angiographic embolization is the best treatment.
What are the signs of acute abdominal pain caused by perforation?
Sudden, constant pain. Avoids movement, guarding. Signs of peritoneal irritation include tenderness, guarding, rebound, silent abdomen. Free air under diaphragm in upright x–rays. Perforated peptic ulcer is most common cause.
What are the signs of acute abdominal pain caused by obstruction?
Sudden onset of colicky pain. The patient moves constantly, seeking a position of comfort.
What disorder is uniquely characterized by severe abdominal pain with blood in the lumen of the gut?
Ischemic colitis.
What is the presentation of primary peritonitis?
Child with nephrosis and ascites, or an adult with cirrhotic ascites with a diffuse acute abdominal pain with equivocal physical findings, and fever and leukocytosis. Cultures of the ascitic fluid will yield a single organism. Treat with antibiotics.
What are the signs of acute pancreatitis?
Alcoholic with an upper, acute abdomen. Rapid onset over 2–3 h, with constant, epigastric pain, radiating straight through to back, with nausea, vomiting, retching. Increased amylase or lipase. CT shows pancreatic enlargement and inflammation.
What is the treatment of pancreatitis?
Nothing per oral, nasogastric suction, IV fluids.
What is the presentation of biliary tract disease?
Obese woman in her forties with multiple children and right upper quadrant abdominal pain.
What are the signs of ureteral stones?
Sudden onset of colicky flank pain radiating to inner thigh and scrotum/labia, urgency and frequency; microhematuria on urinalysis. Plain x–rays usually show the stone; CT scan is best diagnostic test.
What is the presentation of acute diverticulitis?
Inflammatory processes giving acute abdominal pain in the left lower quadrant. Elderly with fever, leukocytosis, peritoneal signs in left lower quadrant; tender mass. CT. Treatment: NPO, IV fluids, antibiotics. Surgery if no response to antibiotics; elec
What is the presentation of volvulus of the sigmoid?
Elderly with severe abdominal distention. X–rays: air–fluid levels small bowel, distended colon, air–filled loop in RUQ that tapers down toward LLQ (parrot’s beak).
What is the treatment of volvulus of the sigmoid?
Rigid proctosigmoidoscope resolves problem. Rectal tube is left in place. Recurrences are treated with elective resection.
What are the signs of mesenteric ischemia?
Occurs in elderly with atrial fibrillation or a MI (thrombus in superior mesenteric artery) with an acute abdomen. Blood in the bowel lumen (the only condition of pain with GI bleeding), acidosis and sepsis. Treatment is supportive.
What is the presentation of hepatocellular carcinoma?
Hepatocellular carcinoma is seen only with cirrhosis. Vague right upper quadrant discomfort and weight loss. Blood marker is alpha–fetoprotein. CT scan will show location and extent. Treatment is resection.
