Uworld: Surgery Rotation

Good and bad days, navigation problems, frequent falls, initially no short term memory loss dx:

Lewy body dementia

lewy body dementia symptoms

hallucinations, good and bad days, navigation issues (early), frequent falls/motor manifestations, memory problems (late), visuospacial deficits (clock drawing problems)

dementia before parkinsons

Lewy body dementia

loud noises cause myoclonus dx:

Startle myoclonus due to Prion-related dementias like Creutzfeld-Jakob disease

Primitive reflexes (rooting, sucking, glabellar) + dementia

Frontotemporal dementia

medications associated with drug induced pancreatitis

thiazides, ACE inhibiotrs

Indications for ERCP

Cholangitis-visibile common bile duct dilation/obstruction or increasing liver enzyme levels

Indications for endoscopic ultrasonography in setting of cholangitis

Patient that has cholangitis (dilated common bile duct) on U.S. but no increase in LFTs --> instead ERCP they can get endoscopic ultrasonography to see if there are stones in CBD and then remove gall bladder

Indications for hepatobiliary iminodiacetic acid (HIDA)

For evaluating the presence of cholecystitis in patients with no gall bladder wall thickening or signs of biliary obstruction on U.S. Procedure- nuclear tracer that is excreted in bile-->failure to see it in gall bladder suggests obstruction

Gall stone pancreatitis treatment

cholecystectomy after being medically stable enough for srugery

ALT>150U/L, nausea, vomiting, gall stones suggests

Gall stone pancreatitis

early onset arthroplasty infection (first 3m) symptoms

wound drainage, erythema, swelling and fever

arthroplasty infection (e.g. prosthetic knee joint inf) within the first 3m is due to which organisms

S. aureus, or gram neg anaerobes

treatment of prosthetic knee infection within first 3m due to wound

implant removal or change, or debridement and implant retention

persistent joint pain, implant loosening or sinus tract infection in first 3m after knee replacement can be due to which organisms

Coag neg staph (staph epi), propionibacterium species (enterococci)

treatment for infection in person with knee replacement >3m ago

implant removal, or exchange

Post Gastrectomy hypotension, nausea, vomiting, tachycardia, diaphoresis 20-30min post food

Dumping syndrome

Mechanism of Dumping Syndrome post gastrectomy

damage to pyloric sphincter during surgery or surgical bypass of the sphincter leading to rapid emptying of hypertonic gastric content into the duodenum and SI-->fluid shifts from intravascular space to the small intestine-->hypotension, ANS stimulation-->vasoactive peptide release

Dumping syndrome treatment

change diet: more fibers, more complex carbs, more small meals

Motor vehicle accident + lower extremity fractures + scalp lacerations+ abdominal bruising+ shortness of breath + low bp that became high and pulse that went from high to low after fluids and then development of progressive weakness on the right side of his body. What does the patient have? and what CN may be injured? What artery may be injured?

Due to right sided weakness but left sided injury, there may be Uncal Herniation due to middle meningeal artery rupture-->expanding hematoma. Cushing reflex occurs because the expanding hematoma + fluid recussitation causes there to be elevated intracranial pressure--> constriction of arterioles-->cereberal ischemia-->brain senses inc pCO2 and dec pH--> central reflex sympathetic to increase perfusion pressure + hyperventillate-->hypertension because brain thinks patient is hypptensive--> reflex bradycardia due to strestching of baroreceptors. CN 3 injury occurs due to uncal herniation-->down and out pupil

occlusion of PICA causes damage to which CN

Accessory 11

jugular foramen syndrome(posterior fossa tumor) causes damage to which nerve

Glossopharyngeal nerve (CN IX) --> loss of gag reflex, loss of taste and sesnation on posterior 1/3 of tongue, loss of pharyngeal sensation and dysfxn of carotid sinus reflex leading to inc risk of syncope

transtenorial herniation can lead to

ipsilateral hemiparesis, ipsilateral mydriasis and strabismus, contralateral hemianopsia and AMS (altered mental status)

Lesion compressing the contralateral crus cerebri against the tentorial edge causes

ipsilateral hemiparesis

compression of ipsilatearl CNIII by herniated uncus causes

loss of parasympathetic innervation causing mydraisis (occurs early); loss of motor innervation causes ptosis and a downa nd out gaze of ipsilateral pupil due to unopposed CNIV and VNVI action

compression of reticular formation causes

AMS and coma

fever, dysphagia, odynophagia, drooling and redness near submandibular and sublingual area can suggest

Ludwig angina = rapidly progressive bilateral cellulitis of submandibular and sublingual spaces usually due to an infected mandibular molar

tachypnea, tachycardia, hypoxia within first 24h after blunt injury with rib fractures suggests, chest wall bruising, decreased breath sounds on side of injury

pulmonary contusion (bruised lung parenchyma)

chest x-ray shows rib fractures and patchy irregular infiltrate in a tachypneaic, tachycardic, hypoxemic patient -- diagnosis

pulmonary contusion

ARDS vs Pulmonary contusion

ARDS8 occurs within first 24-48 h whereas pulm contusion* occurs in first 24h. Bilateral lung involvement is in ARDS.

hemothorax on CXR is detected as

pleural effusion with hypotension if its significant

thrombocytopenia, petechiae, mental changes, hypotension tachypnea, tachycardia following trauma suggest

bone fat embolism

GCS factors

1. ability to open eyes 2. motor response 3. verbal response (e.g. oriented, disoriented, confusion8

GCS is calculated when?

For all trauma patients in order to triage based on severity and prognosis of coma

anterior mediastinal mass DDX

Four Ts Thymoma, Teratoma, Terrible lymphoma, Thyroid neoplasm

Germ cell tumor types

Seminomatous - Elevated Beta HcG in 1/3 of cases but normal AFP. Non-seminomatous = yolk sac tumor, choriocarcinoma, embryonal carcinoma, Mixed germ cell tumor = mix of non-seminomatous germ cell tumors. Non-semis have elevated AFP but often also elevated BHCG

arteries damaged in hemothorax

MC due to laceration of lung parenchyma or damage to intercostal or internal mammary arteries

flaccid paralysis and diminished pain and temp sensation but preserved vibration post thoracic aortic aneurysm repair is due to

ischemia to anterior spinal artery that supplies (branches from artery of Adamkieqicz and other radicular arteries of the thoracic aorta) the anterior 2/3 of the psinal cord. The ischemia is due to either cross clamping or hypotension from bleeding.

Nasogastric tube in chest x-ray above diaphragm =

diaphragmatic hernia

Diaphragmatic hernia caused by trauma mechanism

trauma causes increased abdominal pressure that makes diaphragm explode and intestine or stomach go through it

vitals of diaphragmatic hernia

stable

diaphragmatic hernia CXR

tension pneumothorax vitals

unstable (hypotensive)

three or more adjacent rib fractures that break in 2 places + create an unstable chest wall segment that moves in a paradoxical motion with respiration (during inspiration it contracts instead of bulging out and bulges out during expiration when it normally should retract) is consistent with

flail chest

diaphragmatic hernia is usually on which side

left because right side is protected by liver

CXR of diaphragmatic hernia description

deviation of mediastinal contents to opposite side; elevation of hemidiaphragm; nasogastric tube in pulmonary cavity or intestines there

nausea, abdominal distention, obstipation, hypoactive bowel sounds that persist for >3-5days post-op

Post-operative ileus

etiologies of Post Op Ileus

increased splanchnic nerve sympathetic tone following peritoneal instrumentaton, local release of inflammatory mediators and post operative opiate analgesics (dec. motility)

preventative measures to prevent Post Op ileus

epidural anesthesia, minimal invasive surgery, judicious perioperatve use of I.V. fluids to minimize gastrointestinal edema

MCC of mechanical bowel obstruction in U.S.

adhesions--following previous abdominal surgeries

difference between mechanical vowel obstruction vs post-op ileus

Bowel sounds hyperactive bowel sounds in mechanical bowel obstruction vs hypoactive in post op ileus. MBO- have temporary return of bowel fxn prior to symptom onset (think of daniel...patient who went home and came back). X-ray -both have dilated loops of bowel but compared to PPI, x-rays in MBO are more likely to have air- fluid levels and clear transition points of the bowel

burn victims - initial management

1. ABC-- secure airway by giving oxygen first and ventillating if there is evidence the airway was burned/damged thermally (>10% carboxyhemoglbin level, tridor, carbenaceous sputum, burns to face, oropharyngeal inflam) etc. intubate sooner than later due to increasing edema in airway post burn

inability to extend knee, acute swelling, tenderness of patella region after falling or direct blow to knee =

fracture of patella

episodic pain and tenderness at inferior patella and pateller tendon usually seen in atheletes in jumping sports or in occupations with repetitive forceful knee extension

patellar tendenitis

chronic anterior knee pain that is MC in women, presents with peripatellar pain worsened by activity or prolonged sitting

patellofemoral pain syndrome

anterior knee pain, tenderness, erythema, localized swelling, MC in occupations requiring repetitive kneeling (housewives, plumbers), Often due to S.aureus which can infect the bursa from penetrating trauma or repetitive friction or extension of local cellulitis =

prepatellar bursitis

prepatellar bursa

high riding prostate on DRE, blood in urethra, inability to void post car accident, scrotal or perineal hematomas suggests

posterior urethral injury

suspected posterior urethral injury management

1. Retrograde urethrogram prior to insertion of a Foley catheter because you can increase the urethral tear or cause infection of the periurethral hematoma

Anterior urethral injury management

1. Immediate surgical repair (ocassionally) 2. Treat with urinary diversion via suprapubic catheter while the primary injuries/hematomas heal. 2. Once healing is over, urethral stricture/residual damage is assessed and repaired

diagnosis of bladder injury

retrograde cystogram

fever, sore throat, difficulty swallowing, muffled hot potato voice, uvula deviation awaya from enlarged tonsil and pooling of saliva =

peritonsillar abscess ( acute bacterial inf between tonsil and pharyngeal muscles)

treatment for peritonsillar abscess

needle aspiration or incision and drainage + antibiotic therapy to cover Group A hemolytic strep and respiratory anaerobes

fever, pharyngeal pain, earache and deviation of uvula to oppositve side of swollen tonsil =

peritonsillar abscess

compartemnt syndrome etiology

direct trauma or prolonged compression of an extremity or revascularization of an acutely ischemic limb

excruciating pain worsened on passive range of motion that does not respond well to narcotics after trauma or prolonged compression of an extremity =

compartment syndrome

Early paresthesia from sensory nerve ischemia after trauma to the leg + later neuro defecits (sensory loss, motor weakness) suggests

compartment syndrome

compartment syndrome treatment

Immediate fasciotomy!!!

Labs for Acute mesenteric ischemia

1. elevated wBC, hemoglbin, amylase, metabolic acidosis, inc lactate

Patient had MI in past and now has leukocytosis, elevated amylase + phosphate levels, metabolic acidosis (inc lactate, elevated hemoglobin and pain out of proportion to examination findings on abdominal P.E. =

Acute mesenteric ischemica

diagnosis of acute mesenteric ischemia

CTangio (preferred), or MRI angiography, Mesenteric angiography if diagnosis is unclear

treatment of Acute mesenteric ischemia

1. either embolectomy with vascular bypass or endovascular thrombolysis 2. Broad spectrum antibiotics 3. anti-coagulants to reduce risk of clot expansion (unless contraindicated)

penis is deviated to right after sex with female on top- whats the initial management

1. Retrograde urethrogram followed by surgical exploration of penis

diagnosis of fat embolism

fat droplets in urine or intraarterial fat globules on fundoscopy

timeline for fat embolism

12-72h post injury

air embolism etiology

subclavian vein access or trauma patient on respirator

sudden upward pulling on the arm can cause

injury to lower brachial plexes (C8-T1) causing Klumpy's palsy. which causes Injury to ulnar nerve --> atrophy of interosseous and hypothenar muscles--> claw hand

humeral neck fracture presents as

swelling, ecchyosis, crepitus over a fracture--axillary nerve injury may be present

pain after femoral embolectomy in right calf with burning sensation =

compartment syndrome-- ischemia-reperfusion syndrome

compartment syndrome is associated with

long bone fractures or traumatic injuries of the extremities; any condition that causes increased pressure in a confined tissue space and compromises blood flow

diagnosis of compartment syndrome

Compartment pressure>30mmHg or delta pressure (diastolic bp- compartment pressure) <20-30mmHg

treatment of compartment syndrome

if compartment pressures improve rapidly, observe them and if not do fasciotomy

Homan sign =

pain with passive stretching of calf --> indicative of DVT

eschar formation in a burn suggests

Acute compartment syndrome with so much edema that there is tissue ischemia and venous and lymphatic compromise -->eschar (third degree burn)

treatment of acute compartment syndrome

fasciotomy or escharotomy (think of the syrian patient)

crutches can cause

radial nerve injury

fraction of humeral shaft causes

radial nerve injury

blocking a basketball shot can cause

anterior shoulder dislocation and axillary nerve injury

symptoms of radial nerve injury

wrist drop and sensory loss on posterior arm, forearm and lateral dorsal hand

fracture of medial epicondyle injures

ulnar nerve

symptoms of ulnar nerve injury

claw hand, sensory loss of dorsal and ventral aspects of hand

Uncomplicated vs Complicated Diverticulitis

Uncomplicated = 75% diverticulitis with no abscess, occurs in stable patients and can be treated with bowel rest, oral antibiotics, observation, hospitalize + I.V. antibiotics are needed for elderly, immunocomp, high fever or significant leukocytosis patients. Complicated = 25% diverticulitis + abscess, perforation, obstruction or fistual formation.

Complicated Diverticulitis + <3cm fluid collection treatment

I.V. antibiotics + observation

Complicated diverticuliits + abscess >3cm treatment

CT-guided percutaneous drainage and surgical if it fails

If symptoms of complicated diverticulitis are not controlled by the 5th day - treatment?

surgical drainage and debridement

when should sigmoid resection be done in diverticulitis patients?

Fistulas, perforation with peritonitis, obstruction, recurrent attacks of diverticulitis

pain, edema or erythema spreading beyond surgical site infection suggests

necrotizing surgical site infection

symptoms of necrotizing surgical site infection

1) Pain, edema, or erythema spreading beyond surgical site 2) systemic signs such as fever, hypotension, tachycardia 3) paresthesia or anesthesia at the edges of the wound 4) purulent, cloudy gray discharge (dishwater drainage) 5) subcutaneous gas or crepitus

testing for meniscus tears

Thessaly and McMurray test

Thessaly test