Surgery Learning Objectives

Front 1

What type of stomach ulcer is most commom?

Back 1

Type I, in the lesser curvature transition zone

Front 2

What are the different types of stomach ulcers? Which are associated with acid hypersecretion?

Back 2

Type I - lesser curvature transition zone
Type II (gastric and duodenal) and Type III (pyloric and prepyloric) are ass'd with increase acid secretion

Front 3

What are the 3 phases of gastric acid secretion and how are they regulated?

Back 3

Cephalic -ACh causes GRP release from antral cells and histamine from ECL cells; Gastric - distension causes gastrin release from G cells; Intestinal - small intestine distension causes hisamine release

Front 4

Describe the results of a gatric analysis for the following conditions: 1)Type I peptic ulcer 2) Type II and III ulcer and 3) ZE syndrome?

Back 4

1. BAO = low-nl, MAO=low-ml
2. BAO=high, MAO=higher
3. BAO=very high, MAO=no change

Front 5

Define the following gastric cancer eponyms: 1)Virchow's node, 2)Sister Mary Joseph's node, 3)Krukenberg tumor, 4)Blumer's shelf.

Back 5

1) supraclavicular lymph node 2) umbilical lymph node, possibly with bleeding 3) ovarian mets from stomach primary 4)shelf palpable on rectal exam due to mets growing in the rectovesical or rectouterine pouch

Front 6

What are the most common types of gastric tumor?

Back 6

Adenocarcinoma (h. pylori is a risk factor), Lymphoma is 2nd, and GIST

Front 7

What is the medical management for PUD?

Back 7

Triple: PPI, clarithromycin,
metronidazole; 4-drug regimen: H2 blocker, metronidazole, tetracycline and pepto-bismol

Front 8

What does free intraperitoneal air indicate? Where is a good place to look for it? How might you identify it on exam?

Back 8

indicates perforated viscus, look under diaphragm on xray, percuss under liver margin: hyperresonance indicates free air

Front 9

What is a hernia?

Back 9

Protrusion of all or part of a structure through the tissues that mornally contain it

Front 10

Define: Direct inguinal hernia, indirect, femoral, and incisional hernia.

Back 10

Direct: through defect in abd fascia, medial to inf epigastric a.
Indirect: through internal ring, lateral to inf epigastic a.
Femoral: thru femoral canal
Incisional: through prior incision

Front 11

Define the following less common hernias: Umbilical, Obturator, Lumbar, and Spigelian.

Back 11

Umbilical: imcomplete umbilical closure
Obturator: thru obturator canal (thigh parasthesis, elderly females)
Lumbar: thru superior lumbar triangle (Sacrospnious muscle, internal oblique and 12th rib)
Spigelian: thru semilunar line, lateral margin of rectus, cephalad to inf epigastric

Front 12

What structures define Hasselbach's triangle?

Back 12

rectus medially, inferior epigastrics superiorly, and inguinal ligament inferiorly

Front 13

What are the layers, from superficial to deep, of the abdominal wall?

Back 13

Skin, (camper's), Scarpas, external oblique, internal oblique, transversalis abdominus, transversalis fascia, preperitoneal fat

Front 14

What are the layers of the spermatic cord, from superficial to deep?

Back 14

skin, superficial (dartos) fascia, external spermatic fascia, cremaster muscle and fascia, internal spermatic fascia, parietal layer then visceral layer of tunica vaginalis

Front 15

What structure gives rise to the external (superficial) ring? Internal (deep) ring?

Back 15

External oblique aponeurosis, Transversalis fascia

Front 16

What type of hernia is most common?

Back 16

Indirect

Front 17

Define acute abdomen. How is it different from surgical abdomen?

Back 17

sudden non-traumatic disorder, signs and symptoms severe enough to warrent medical care and may require surgical intervention (surgical abd DOES require surgery)

Front 18

What characteristics will help you determine if abdominal pain is visceral, parietal or referred?

Back 18

Visceral: dull and poorly localized; parietal might be dull, but will also have sharp, well-localized pain

Front 19

What bowel sounds make you think of SBO?

Back 19

intemrittent high-pitched hyperactive BS (tinkles and rushes)

Front 20

What PE findings are consistent with peritonitis?

Back 20

involuntary guarding, rebound tenderness, tenderness to percussion

Front 21

What physical exam findings are consistent with appendicitis?

Back 21

Positive iliopsoas sign (pain with hip flexion or extension) or obturator sign (pain with hip rotation), Pain starts periumbilically, moves to McBurney's point and may be accompanied by rebound tenderness, Rovsing's sign (pain in RLQ when you press elsewhere on the abdomen)

Front 22

How migh acute appendicits present differently in a pregnant patient?

Back 22

Pain in RUQ due to displacement of appendix by the fundus

Front 23

What is the dDx for appendicitis?

Back 23

PID, pyelo, IBD, gastro, endometriosis, ovarian cyst, Meckel's, diverticulitis

Front 24

How would antibiotic treatment differ from appendicitis to perforated appendicitis?

Back 24

2nd or 3rd gen Cef for either, but with no perf cna d/c after 24 hours post-op, with perf continue until pt afebrile and WBC normalizes

Front 25

What test is preferred for evaluation of gallbladder disease?

Back 25

U/S

Front 26

What distinguishes acute cholecystitis from chronic "biliary colic"?

Back 26

Acute will be sharp pain, well-localized, and may be ass'd with n/v, fever, and leukocytosis

Front 27

What lab results are consistent with obstructive jaundice?

Back 27

increased direct bili, increase in alk phos >>> increase in AST/ALT if biliary (reverse is true if hepatocellular)

Front 28

What is the proper treatment for common bile duct obstruction?

Back 28

ERCP - can diagnose and treat simultaneously

Front 29

What features of a breast mass are suspiscious for cancer?

Back 29

irregular, fixed mass, usually painless

Front 30

What are the features of benign breast lesions?

Back 30

Freely mobile, discrete borders (fibroadenoma), fluid filled simple cyst, pain may be cyclic and accompanied by fluctuation in size cyclically (FCC)

Front 31

What are the major risk factors for breast cancer? Minor risk factors?

Back 31

Major: famHx, atypical hyperplasia, previous CA, previous DCIS or LCIS
Minor: estrogen, age, gender, race (esp caucasian), EtOH, HRT, Radiation exposure

Front 32

What is the appropriate management plan for a patient with a chief complaint of a new breast mass?

Back 32

H&P (ID risk factors, do inspection, then palpation of breast, axilla and nodes)
Mammo in pt >30, US if younger
if fluid filled: watch, drain after 2-3 months, proceed to biopsy if it does not resolve, if it is not simple, or if the fluid is bloody
if solid:biopsy

Front 33

What is the most common cause of non-lactating nipple discharge?

Back 33

intraductal papilloma

Front 34

What is the appropriate treatment plan for breast cancer based on stage?

Back 34

0-1: lumpectomy +/- radiation
2-3: lumpectomy or mastectomy, then radiation, +/-chemo or hormonal therapy based on type
4: systemic chemo +/- surgical option

Front 35

What is the appropriate treatment of Paget's disease of the breast?

Back 35

local excision of mipple/areolar complex if localized, +radiation

Front 36

What defines local-regional breast cancer?

Back 36

lymph node involvement (which cannot be present to categorize the cancer as "local only")

Front 37

What are the risk factors for developing colorectal cancer?

Back 37

low fiber/high fat diet, age, UC, radiation

Front 38

What is the etiology of colorectal cancer? How long does it take to become malignant?

Back 38

Polyps can proceed to cancer over the course of 5-10 years

Front 39

What histologic type of polyp has the highest malignant potential?

Back 39

villous >> tubulovillous > tubular

Front 40

What are the risk factors for the development of anal cancer?

Back 40

Crohn's, condyloma, herpes, smoking

Front 41

What is diverticulitis?

Back 41

Micro (or more rarely macro) perforation of an obstructed diverticulum that leads to LLQ pain, fever, maybe a palpable mass

Front 42

What are the signs and symptoms of diverticulosis?

Back 42

mild ttp in LLQ, abd pain, bleeding/constipation/diarrhea

Front 43

How can xray findings help you differentiate SBO from colon obstruction?

Back 43

dilation will be more proximal in SBO, looks like a stack of nickels; in colon obstruction the dilation will be more distal, you can see haustra

Front 44

What are the features of UC that distinguish it from Crohn's? When is surgery indicated?

Back 44

Rectal involvement, continuous lesions, submocusa and mucosa only, severe BLOODY diarrhea, toxic megacolon. Surgery is curative.

Front 45

What are the features of Crohn's that distinguish it from UC? When is surgery indicated?

Back 45

Rectal sparing, full thickness of bowel wall, less severe nonbloody diarrhea, cobblestoning, fistulas, skip lesions, granulomas. Surgery is only palliation, and laparoscopic surgery is preferred to avoid adhesions.

Front 46

Idenfity several signs and symptoms of dehydration.

Back 46

Skin tenting, dry skin, dry MM, sunken eyes, tachycardia, decreased UOP

Front 47

Identify objective measurements of fluid balance.

Back 47

Weight, elevated Hct, oliguria, prerenal azotemia

Front 48

What percentage of body weight is fluid? What percentage is Intracellular? Extracellular? Intravascular?

Back 48

60% BW = fluid volume
2/3 fluid is intracellular
1/3 is extracellular - 8% of ECF is intravascular (this is important because when you give someone fluids because they are hypovolemic, the fluid does not stay in the vessels)

Front 49

What are the common causes of hypernatremia? How is it treated?

Back 49

Hypovolemia due to vomiting, diarrhea, fever, sweating or renal losses, euvolemic if DI, hypervolemic if due to too much IVF. Give fluids, but correct slowly (<50% in first 24-48 hours)

Front 50

WWhat are the common causes of hypOnatremia? How is it treated?

Back 50

Excessive fluid retention (CHF, kidney failure, cirrhosis) in hypervolemic, SIADH if euvolemic. Free water restriction

Front 51

What are the ECG abnormalities ass'd with hyperkalemia? HypOkalemia?

Back 51

Hyper = peaked t, wide QRS, flat p, sine wave
HypO = blunted t, U wave

Front 52

What are the normal values for an Arterial blood gas? Mixed venous? Venous?

Back 52

7.4/40/24/90 - arterial
7.36/45/24/40 - mixed
7.36/45/26/40 - venous

Front 53

What is Charcot's triad? Reynauld's pentad? What do these entities indicate?

Back 53

Fever, RUQ pain, jaundice.
+ AMS and hypotension = pentad
indicates cholangitis

Front 54

What criteria are used to determine Child's criteria?

Back 54

labs = bilirubin and albumin
clinical = nutrition, encephalopathy, and ascites

Front 55

What are Ranson's criteria for pancreatitis?

Back 55

Measured at admission (age, white count, glucose, LDH and AST) and 48 hours (BUN, Ca, Hct, pO2, base excess) gives you mortality information

Front 56

Describe the treatment options for ruptured spleen.

Back 56

If hemodynamically unstable or grade V injury: splenectomy
If stable but significant damage to organ: splenorrhapy with debridement and compression with collagen and mesh repair
If stable and manageable damage to spleen (esp in kids): bedrest and careful monitoring

Front 57

What are the maintenance fluid requirements for infants and children?

Back 57

Preemies: 140-150ml/kg/day up to 2 kg
all others: 100ml/kg/day for first 10kg
+50ml/kg/day for next 10 kg
+20ml/kg/day for additional kg

Front 58

Example of fluid requirements: 7 kg infant, 16kg toddler, 25 kg child need what fluids?

Back 58

7kg infant = 7x100 =700ml/day
16kg=(10x100)+(6x50)=1300ml/day
25kg=(10x100)+(10x50)+(5x20)=1600ml/day

Front 59

What is the normal urine output for infants and children?

Back 59

1-3ml/kg/day

Front 60

What are the normal blood volumes for infants and children?

Back 60

neonate: 85ml/kg
infant: 75ml/kg

Front 61

When should you replace blood in infants and children? How can this be done?

Back 61

when blood loss >10%, thru IV or tibial interosseous line

Front 62

What is the presentation of pyloric stenosis in an infant?

Back 62

projectile vomiting, nonbilious, dehydration and lethargy; epigastric olive on physical exam

Front 63

What is the presentation of reflux in an infant?

Back 63

colicy behavior afer eating, spitting up, don't gain weight well, apnea or pneumo from aspiration

Front 64

What is the presentation of intussesseption in an infant or child?

Back 64

SBO, currant jelly stools, severe intermittent pain

Front 65

Signs and symptoms of peripheral arterial insufficiency?

Back 65

claudication, sensorimotor loss, skin ulceration, gangrene, erectile dysfunction--rest pain equate to more advanced disease

Front 66

Methods of noninvasive vascular testing?

Back 66

doppler, ABI, arteriography

Front 67

Treatments for peripheral arterial disease?

Back 67

remove the risk factors (smoking, sedentary lifestyle), bypass, endarterectomy, angioplasty, amputation

Front 68

6 P's of acute major arterial occlusion?

Back 68

palor, pain, poiklothermia, parasthesias, pulselessness, paralysis

Front 69

Signs and symptoms of AAA?

Back 69

Abdominal pain, back pain, pulsitile mass (rupture=hypotension)

Front 70

Treatments for AAA? Prognosis?

Back 70

< 5cm = U/S at reg intervals; >5cm, exapansion > 1cm/year or symptomatic = repair (high perioperative cardic mortality)

Front 71

Mortality of a AAA rupture?

Back 71

50%

Front 72

Diagnositc approach to PE?

Back 72

CT angiogram, V/Q mismatch; PE dyspnea, tachy, tachipny, hemoptosis, fever

Front 73

What is the mechanism of a CVA?

Back 73

usually atherosclerotic embolus which occludes in a watershed area

Front 74

What is the stroke risk in a patient with 50-60% carotid stenosis? >70%?

Back 74

50-60% = 10% risk >70% = 25% risk

Front 75

How is cartoid stenosis diagnosed?

Back 75

Neuro exam, bruits, ultrasound, arteriography, MRI

Front 76

Signs and symptoms of SBO?

Back 76

colicy pain, constipation/obstipation, can have diarrhea, n/v, tinkling/rushing bowel sounds

Front 77

What signs or symptoms suggest a strangulated SBO?

Back 77

peritoneal signs (rebound, guarding, Ttpercussion) sepsis

Front 78

MCC of SBO?

Back 78

Adhesions (hernias in kids)

Front 79

MC bacteria found in post-op wound infection?

Back 79

Staph, E. coli, Entercoccus

Front 80

Which bacteria cause fever and wound infections 24 hours after a surgery?

Back 80

Strep, Clostridia

Front 81

What factors influence the development of infections?

Back 81

hypothermia, surgeries > 2 hours, foreign body, decreased blood flow, strangualtion of tissues by too tight of suture

Front 82

Primary treatment for a wound infection?

Back 82

I and D (unless amebiasis!!)

Front 83

What features of a thyroid nodule suggest malignancy?

Back 83

1. single nodule, 2. cold nodule, 3. palpable lymph nodes, 4. h/o previous radiation

Front 84

What diagnostic tests are helpful in evaluating a patient with hypercalcemia?

Back 84

PTH, Vit D, Urine Ca, bone scan, renal fnx, PTH-rp, Phos

Front 85

What are the 4 M's of medullary CA of the thyroid?

Back 85

1. MENII, 2. aMyloid, 3. Median lymph node dissection, 4. Modified neck dissection if lateral nodes are +

Front 86

4 F's of follicular cancer?

Back 86

1. Far-away mets (spreads hematogenously), 2. Female (3:1), 3. FNA cannot dx, 4. Favorable prognosis

Front 87

What are the components of the secondary survey?

Back 87

AMPLE: allergies, meds, PMH, last meal, events surrounding the accident

Front 88

Dx and treament of upper airway obstruction?

Back 88

talking = no obstruction; no-talking:stabilize spine, inspect airway, suction, try oral or nasopharyng airway, give O2, if that fails-> intubation, if failed -> cric

Front 89

Dx and treatment for shock?

Back 89

Hypotension, tachy, changes in color (unless neurogenic); tx: volume repletion, ID the cause (MI, hemorrhagic, tube for pneumo)

Front 90

Implications of diagnostic peritoneal lavage?

Back 90

> 100,000 RBC = blunt trauma; >1,000 = penetrating trauma

Front 91

What are the induction agents MC used in anesthesia?

Back 91

Propofol, midazolam, thipentol, ketamine

Front 92

What are the non-depolarizing agents?

Back 92

Vecuronium, rocuronium (both intermed), Pancuronium (longer acting)

Front 93

What is the polarizing agent for paralysis?

Back 93

Succinylcholine (6 minutes)

Front 94

What is used to reverse non-depolarizing agents?

Back 94

neostigmine, edriphonium

Front 95

Where do you not want to give epi?

Back 95

Finger, nose, toes, penis, ears

Front 96

Why is epi given with lidocaine?

Back 96

Epi vasoconstricts allowing the lidocaine to stay in the area without being swept up in the blood stream.

Front 97

What are the signs and symtoms of lidocaine overdose?

Back 97

tinitus, numbness, dizziness, metalic taste in mouth