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211 Cards in this Set

  • Front
  • Back
The most common tumor that metastasizes to the intestine
Melanoma
Management of a small bowel obstruction
NPO
Nasogastric Tube (NGT)
IV fluids
Serial abdominal radiographs
No bowel movements, but still passage of flatus
PARTIAL small bowel obstruction
No bowel movements and no passage of flatus
COMPLETE small bowel obstruction
Top 3 causes of small bowel obstruction
Adhesions
Hernia
Cancer
A paralytic state in which the bowel fails to maintain peristalsis
ileus
What GI tract complication should you be aware of in an elderly person who has atrial fibrillation?
AF makes people prone to forming blood clots. The clots can embolize and travel to the SMA causing mesenteric ischemia
How can you distinguish duodenal atresia from pyloric stenosis clinically?
Pyloric Stenosis - male infants, sx's apperar 4-6 week after birth, projectile vomiting WITHOUT bile

Duodenal Atresia - sx's are present at birth, projectile vomiting WITH bile
Best methods to diagnose duodenal ulcers
*Upper endoscopy*
Biopsy
Culture for H. pylori
Name this hernia:
gastroesophageal junction is in the chest as part of the segment of stomach that herniates into the mediastinum
Type I Hiatal Hernia (sliding)
Name this hernia:
Gastroesophageal junction is in a normal location, and a segment of stomach herniates up through the phrenoesophageal membrane into the chest
Type II Hiatal Hernia (paraesophageal)
Name the components of triple therapy for H. pylori infections
Method #1: PPI (omeprazole 20 mg BID), Metronidazole (flagyl 500 mg BID), and an abx (clarithromycin 250 mg BID)

Method #2: Metronidazole 500 mg BID, tetracycline 500 mg BID, and bismuth 262 mg QID)
What drugs are associated with the formation of ulcers?
NSAIDS
steroids

*Don't forget to ask your patients if they have recently discontinued use of any of these drugs
How long should you try medical management of peptic ulcer disease before considering surgery?
Treat mild PUD for 4-6 weeks and extend the duration of treatment to 8-12 wks for severe dz. If sx's persist after this time, surgical management is necessary.
If medical management of PUD fails, what surgical procedures are indicated?
-Highly Selective Vagotomy (HSV)
-Vagotomy and Antrectomy (V&A)
-Truncal vagotomy and Pyloroplasty (V&P)
Pro's and Con's of Highly Selective Vagotomy
Pro's: Low mortality rate, lowest rate of postoperative dumping sx compared to either V&P or V&A

Con's: higher rate of ulcer recurrence
Complications of vagotomy & antrectomy (V&A)
Anastomotic leak
Postoperative dumping syndrome
The ultimate procedure of choice for uncomplicated PUD
highly selective vagotomy (HSV)
Why is performing a rectal exam indicated in a patient that you suspect may have appendicitis?
To determine if the patient has an appendix located in the retrocecal position.
Name the 2 surgical options for removal of an appendix in a patient with appendicitis:
1. Laproscopy and visualization of the appendix

2. Exploration with a McBurneys Point incision
What is the exact location of McBurney's Point?
2/3 the distance from the umbilicus to the right ASIS

Or 1/3 the distance from the right ASIS
What should always be included in the physical exam of a woman suspected of having appendicitis?
Do a pelvic exam because she could have gynecological pathology (ectopic pregnancy, ovarian torsion, endometriosis, PID, etc.) that can mimic RLQ pain.
What are the peak incidences of age for persons with appendicitis?
Bimodal distribution:
Age 25 and 65 years old
Why must you be particularly cautious in a person who takes steroids and in whom you suspect has appendicitis?
Steroids can mask most or all signs and symptoms of any inflammatory process. The body's attempt to wall off inflammation and abscesses is blunted with steroids. Thus, in these patients, many of the warning signs of appendicitis are absent.
In a pregnant woman with appendicitis, what poses the greater risk of complications: performing an appendectomy or peritonitis from a ruptured appendix?
Peritonitis
You perform an appendectomy and discover a carcinoid tumor attached to the appendix. What characteristics of a carcinoid tumor warrants performing a right colectomy as treatment?
Carcinoid tumors 2 cm or greater in size suggests malignancy. In this case, treatment is a right colectomy.
Fever POD #1
Atelectasis
Fever POD #3
Pneumonia from unresolved atelectasis
UTI
Fever POD #5
DVT
Pulmonary Embolism
Fever POD #7
Abscess
Wound infection
You perform an appendectomy and discover a carcinoid tumor attached to the appendix. What characteristics of a carcinoid tumor warrants performing a right colectomy as treatment?
Carcinoid tumors 2 cm or greater in size suggests malignancy. In this case, treatment is a right colectomy.
What are the screening recommendations for colon cancer in normal healthy asymptomatic patients?
-Starting at age 50, colonoscopy Q10 yrs or. . .

-FOBT yearly plus flex sigmoidoscopy Q5 years or . . .

-Yearly FOBT (3 samples) - This is the most widely accepted screening test
What is one of the the major drawbacks of using flexible sigmoidoscopy as a screening test for colon cancer
The test misses up to 50% of colon polyps and cancer because these lesions often occur higher up in the colon where the flex sig scope cannot reach.
At what age should a person with risk factors for colon cancer begin cancer screening with colonoscopy?
10 years earlier at age 40 or 5 years earlier than the age of onset in the family member with cancer, which ever comes first.
In a person with previously resected colon cancer, what method(s) can be used to detect cancer recurrence?
Screen with carcinoembryonic antigen (CEA)
How do you medically manage a person with hemrrhoids?
-Add fiber to diet
-Stool softeners
-Sitz baths

*Most surgeons still recommend colonoscopy or sigmoidoscopy to rule out colon cancer

If bleeding reoccurs, then surgical removal is necessary
What are the "ABCD's" of melanoma?
A - asymmetry
B - irregular borders
C - color variation (red, brown, black, etc.)
D - diameter greater than 0.6 cm
What is the difference between an excisional biopsy and an incisional biopsy?
Excisional biopsy complete excises the lesion down to the subcutaneous tissue to determine the depth of the lesion, along with a rim of normal tissue.

Incisional biopsies excise a portion of the margin of the lesion w/ a segment of normal tissue.
Basal cell vs. squamous cell carcinoma:
Which skin cancer is locally aggressive and has a tendency to metastasize to local lymph nodes?
Squamous cell cacinoma

NOTE: Basal cell carcinoma rarely metastasizes, but they tend to reoccur frequently and can be locally invasive.
What is Bowen's disease?
Squamous cell carcinoma in situ
Melanoma: Clark Level I
cancer extends thru the epidermis only
Melanoma: Clark Level II
Cancer extends thru the epidermis and PARTIALLY thru the papillary dermis
Melanoma: Clark Level III
Cancer extends thru epidermis and all the way thru the papillary dermis
Melanoma: Clark Level IV
Cancer extends into the reticular dermis layer
Melanoma: Clark Level V
Cancer extends down into the subcutaneous tissue
What is the chance of cancer recurrence in a patient with metastasis of melanoma during the next 5 years?
75% chance of recurrence during the next 5 years!
What should you suspect in a patient with melanoma who presents to the ER with c/o worsening abdominal pain, nausea, and vomiting?
Metastasis to the peritoneal cavity! Melanoma has a tendency to metastasize here. Often presents as a small bowel obstruction. Prognosis is poor.
True or false: Sarcomas have a low rate of metastasis.
FALSE! Sarcomas have a high rate of metastasis. Most common sites of metastasis include liver, lung, bone, and brain.
What is the best diagnostic test for a patient suspected to have mesenteric ischemia?
Angiography
What is the most common post-operative day for a patient to have an MI and why?
POD #3
Most perioperative infarcts occur post-op when third spaced fluids return to the general circulation causing increase pre-load and myocardial oxygen consumption.
What is the pathogenesis of GASTRIC ulcers?
Decreased cytoprotection of the gastric lining of the stomach. (NSAIDS, steroids, caustic ingestion, alcohol, tobacco etc.)
What is the pathogenesis of DUODENAL ulcers?
increased acid production
In a pt with suspected appendicitis, you get labs that show urinary RBC's too numerous to count. What test(s) should you order next?
This finding could be a severe UTI or a kidney stone.

Get a pyelogram or a CT scan w/o constrast to look for a kidney stone
You examine a woman suspected to have appendicitis. On pelvic exam you note cervical discharge. What tests should you order next?
Stain for gonococcus and get a gyn consult b/c this pt likely has PID.
What is the peak age(s) of incidence of acute appendicitis?
Age 25 and again at age 65
You surgically explore a man with appendicitis and discover a mass at the end of the appendix. What is it? Can you proceed with the appendectomy?
Most likely a carcinoid tumor.

You can do the appendectomy if the tumor meets the following criteria:
- less than 2 cm diameter
-no evidence of spread to cecum or nearby nodes
What characteristics of carcinoid tumors suggest malignancy?
-Greater than 2 cm in size
-Located at the BASE of the cecum or appendix (as opposed to the the tip of the appendix)

*Do a right hemicolectomy if these criteria are met
What is the medical management of carcinoid tumors?
-Get baseline urinary 5-HIAA level
-Get serum serotonin level
How do you manage a pt with a pelvic abscess?
Most likely to present POD# 7

Drain the abscess with a percutaneously placed catheter
What is the most widely accepted screening test for colon cancer?
Yearly fecal occult blood test (FOBT)

-Must get 3 separate samples!

-High false negative rate (doesn't detect blood in stool when it's actually there!)
What other test is commonly combined with FOBT in the screening of colon cancer?
Flexible sigmoidoscopy.

Start at age 50 if no + family hx of colon cancer, then follow up Q5 yrs
What is a major disadvantage of flexible sigmoidoscopy in the detection of colon cancer?
It misses up to 50% of colon cancers and polyps which occur higher up in the colon where the scope can't reach
What is the best method to detect cancer recurrence after primary colon cancer?
Screen with CEA measurements
Name some common complications of routine colectomy:
-Anastomotic leak
-Infection
-Damage to the ureter(s)
-Need for a colostomy if greater complications occur during the time of surgery.
What type of anemia is most commonly assoc'd with RIGHT sided colon cancer?
Microcytic anemia
What substances are used for a mechanical bowel prep prior to colon cancer surgery?
-GOLYTELY (polyethylene glycol)
-magnesium citrate

Taken the day before surgery
How can you decrease the risk of infection and the level of colonic bacteria during colon cancer surgery/
To decrease colon bacteria levels: give ORAL NON-ABSORBED antibiotics

To decrease wound infection:
give a SINGLE PRE-op dose of a 2nd gen cephalosporin
What surgical procedure is used to remove a right sided colon cancer?
-Right colectomy or hemicolectomy

Don't forget that you must also remove the surrounding mesenteric tissue and the regional lymph nodes
How long should a pt who had a colectomy remain NPO and on IV fluids?
Until bowel function returns (+flatus, bowel movement)

Once the pt can tolerate food, they can be discharged
What is the staging of colon cancer based on?
-Depth of invasion of the primary lesion
-Presence of regional lymph nodes
-Distant metastasis
The diagnostic test for acute cholecystitis
sonogram - ultrasound of the RUQ

If results are equivocal, do a HIDA scan next
What is the best management of generalized acute peritonitis?
Emergency exploratory laparotomy
A CXR of a pt with excruciating abdominal pain that shows free air under the diaphragm. What condition do you suspect?
Perforated duodenal ulcer
What is the first step in the evaluation of a patient with ureteral colic (flank colicky pain of sudden onset that radiates to the inner thigh)?
Get a KUB first, then you could get an ultrasoud.
What test is used to diagnose acute diverticulitis?
CT scan of abdomen
How do you medically manage acute diverticulitis?

How would you treat RECURRENT diverticular disease?
Make the patient NPO, give antibiotics.

For recurrent disease, do elective sigmoid resection.
The leading cause of SBO in adults?

In children?
Adults = adhesions from previous abdm surgery

Children = hernia
What is obstipation?
No passage of flatus or stool, as seen in complete obstruction of the small bowel.
What is the common pain presentation in a person with SBO?
Crampy abdominal pain with a recurrent crescendo-decrescendo pattern at 5-10 minute intervals
You ascultate the abdomen of a patient you suspect has a SBO. What are you likely to hear?
High-pitched tinkles and peristaltic rushes.
What are the 2 most common treatment options for the surgical correction of a sigmoid volvulus?
1. Sigmoid colectomy with diverting colostomy

2. Resection with primary anastamosis
Acute massive dilation of the cecum and right colon w/o evidence of mechanical obstruction
Ogilvie's syndrome (acute pseudoobstruction)

Commonly occurs in the cecum
Treatment of Ogilvie's syndrome
-Endoscopic decompression
-can also try brief trial of neostigmine
What is the most common location for an anal fissure?
Posterior midline
How do you manage a patient with anal fissures?
Stool softeners, sitz baths, bulk agents.

For deep and chronic anal fissures, do a lateral sphincterotomy which divides a portion of the internal anal sphincter.
What condition should you suspect in a person with persistent perianal drainage?
Fistula-in-ano

Results from a residua of a a previous abscess that failed to completely heal
How do you treat a fistula-in-ano?
1. Unroof the tract
2. Drain out any undrained collection of fluid
3. Allow the tract to re-epithelize
What is the primary treatment of a perianal abscess?
Drainage! Not antibiotics.
Common clinical presentation of a patient with suspected perianal abscess
Severe anal pain with a tender fluctuant mass, and fever.
Pain and drainage in the scrococcygeal area of the lower back
Pilonidal abscess = infection in a hair-containing sinus in the sacrococcygeal area

Treatment: unroof the abscess, remove all hair, leave the wound open to heal by secondary intention.
An artificially created opening between the intestine or urinary tract and the abdominal wall
Stoma (ostomy)
What is the most common form of management of a pyogenic liver abscess?
Percutaneous drainage performed by interventional radiology
How do you treat an amoebic liver abscess?
It DOES NOT have to be drained unlike other abscesses.

Instead, treat with metronidazole

Remember that you cannot grow the amoeba from the pus. So don't think you can aspirate the pus and send it for culture!
How do you predict mortality assoc'd with pancreatitis?
Use Ranson's criteria
What are Ranson's criteria ("on admission")
Used to determine mortality from pancreatitis:

-Glucose > 200 mg/dl
-Age > 55 yrs
-LDH >350
-AST > 250
-WBC > 16,000
Ranson's criteria (48 hrs after admission)
-Ca 2+ < 8.0 mg/dl
-Hematocrit decreases by 10%
-Pa02 < 60 mmHg
-Base excess > 4 mEq/L
-BUN increases by 5 mg/dl
-Sequestered fluid > 6L
Risk of mortality from pancreatitis with Ranson's criteria signs:

3-4 signs
5-6 signs
> 7 signs
3-4 = 20%

5-6 = 40%

>7 = 100%
Most common location of pancreatic cancer
Head of the pancreas
What is Courvoisier's sign?

What is Trousseau's sign?
C's sign = palpable, non-tender gallbladder

T's sign = migratory thrombophlebitis

Both are assoc'd with pancreatic cancer
The progression from colon polyp to invasive cancer takes approximately how long?
10 years
Are higher-grade obstructive lesions more likely to be assoc'd with right or left sided colon cancer?
Left-sided cancers
What stage colon cancer warrants the use of adjuvant chemotherapy?
Stage 3 colon cancer

-Adjuvant therapy includes 5-FU and leucovorin, or 5-FU and levamisole. This improves survival by 30-40% and decreases the recurrence rate.
Name some post-op complications of en elective colectomy:
-leakage from the anastomosis causing persistent ileus

-Mechanical obstruction due to adhesions, internal hernia or an obstructed anastomosis
How do you medically manage an anastomotic leak?
NPO and IV fluids.

Most colon fistulas will close with this therapy.
Most common indication for intubation in a trauma patient
Altered mental status
What test must you order in a patient who has been hit over the head and lost consciousness?

When can this patient be discharged from the ER/hospital?
CT scan of the head

The pt can be discharged only if the CT scan and neurologic exam are normal AND if the pt's family agrees to wake him up frequently during the next 24 hrs to make sure he isn't going into a coma.
The following physical findings represent what type of head trauma:

-Raccoon eyes
-Ecchymosis behind the ear
-Clear fluid dripping out of the nose and/or ear
Basal skull fracture

-Get a head CT if the pt is in a coma
-Don't forget to evaluate the cervical spine for pts with this much head trauma
Head CT show lens-shaped hematoma and deviation of the midline structures to the opposite side
Epidural hematoma

90% occur on the right side!
What cancer would you suspect in a patient with extrinsic compression of both the common and pancreatic ducts?
Cancer of the head of the pancreas
Can you surgically operate on a patient who has demonstrated a malignant pleural effusion ?
NO! At this stage, you can only offer radiation and chemotherapy as palliative treatments.
What are the first two steps in the medical management in a person who you suspect has tension pneumothorax?
#1 Immediate decompression of the pleural space with insertion of a large bore needle into the pleural space

#2 Chest tube placement
Traumatic deceleration injuries sustained in a car accident is most likely to cause what type of damage to the heart/great vessels?
Transection of the aorta. So, look for a widened mediastinum on CXR. The nest diagnostic step would be to do a CT scan of the chest.
What antimircobial agent should you use in a patient with severe burns?
Silver sufadiazine.

But do not use this for burns around the eyes. For burns in this location, use triple antibiotic ointment.
What locations of the body are most vulnerable for developing compartment syndrome?
Forearm and lower leg
What is the most common cause of compartment syndrome?
Prolonged ischemia followed by reperfusion
The first line therapy for trigger finger
Steroid injections
The leading cause of GI bleeding in a 7 year old child
Meckel's diverticulum
Name some indication for performing an exploratory laparotomy in the trauma patient
-Development of an acute abdomen
-Any penetrating gunshot wound to the abdomen
If an obese patient sustains a penetrating stab would to the abdomen, is an exploratory lapartotomy necessary?
Not necessarily. Obese patients may have enough fat padding in their abdomen such that no structures were pierced with the object.

Best management would be to insert a gloved finger into the wound for digital exploration.
How much blood does a person have to lose in order to develop hypovolemic shock?
Must lose 25-30% of total blood volume (approx. 1.5 L of blood in a person with a total blood vol = 5 L)
What is the contraindication to getting an abdominal CT scan in the trauma patient with suspected trauma to the abdominal cavity?
You cannot get a CT scan if the patient is crashing! Abdm CT scan is the best test only when the pt is hemodynamically stable.

Perform a sonogram or diagnostic peritoneal lavage instead.
If you must surgically remove a patient's spleen, what vaccines should they receive?
1. Pneumovax
2. Meningococcus
3. Haemophilus influenzae B
What are the 2 main things you should be concerned about in a person with a crush injury?
1. Muscles that have been crushed release myoglobin --> myoglobinemia, which can cause kidney damage leading to acute renal failure

2. Delayed swelling from the injury can lead to compartment syndrome
What are the 3 main anatomical structures that you should be concerned about in a patient who has a pelvic fracture?
Rectum, vagina in women, and bladder
What is the hallmark of urologic injuries in the trauma setting?
Blood in the urine (either from kidneys, bladder or the urethra in males.)

NOTE: since the urethra in females is much smaller, it is not likely that it will be injured in a trauma setting.
What is the firstline management in a male patient with a pelvic fracture an blood at the urethral meatus on physical exam?
Evaluation starts with a retrograde urethrogram.

DO NOT insert a Foley if you see blood at the meatus b/c this can cause further urethral damage!
A female patient sustains a pelvic fracture. Insertion of a Foley catheter shows gross hematuria. What does this represent and what test will you order?
A bladder injury, so get a retrograde cystogram
A patient sustains multiple rib fractures in a car accident but does NOT fracture his pelvis. Insertion of a Foley shows gross hematuria and retrograde cystogram is normal. Where is his injury coming from?
Blood is likely coming from the kidneys and not the bladder.

Diagnose with a CT scan.
What electrolyte parameter value would you likely want to monitor in a patient with a crush injury to her muscles?
Monitor potassium b/c crushed muscles often release K+ into the blood.
How do you manage myoglobinemia/myoglobinuria that results from a muscle injury (crush, electrical burn, etc.)?
-Plenty of IVF
-Give mannitol to diurese the patient
-Alkalinize the urine to protect the kidney
Smoke inhalation represents what type of burn?
A respiratory burn that represents a chemical burn
In a patient with smoke inhalation (respiratory chemical burn):

1. What test(s) do you use to monitor the patient?

2. How would you confirm the diagnosis?
1. Monitor blood gasses and carboxyhemoglobin. Treat increased carboxyhemoglobin with 100% oxygen.

2. Confirm diagnosis with a fiberoptic bronchoscopy
Name the degree of burn:

Painful, moist, blistering
second degree
Name the degree burn:

Anesthetic, white, leathery
third degree
What is normal urinary output for the average 70 kg person?
1 ml urine/kg body weightt/hr (~70 ml urine/hr)

Can go as low as 0.5 ml urine/body wt/hr (~ 35 ml urine/hr)

Rate will be higher in burn patients
How does the appearance of 3rd degreee burns differ in children than adults?
They appear bright red, rather than white and leathery in the adult
What topical agent should be used for a deep penetrating skin burn?
Mafenide acetate
What topical agent should be used in skin burns sustained around the eyes?
Triple antibiotic ointment
When is early excision and grafting (going to the OR on the day the burn accident occurs) of a skin burn warranted?
When the skin burn is serious (3rd degree), but small in size.
What is the antidote for a black widow spider bite?
IV calcium gluconate
What are the classic physical manifestations of a black widow spider bite?
-Severe generalized muscle cramps
-Also nausea and vomiting
What type of insect bite is this:

painful area of ulceration with a necrotic center and surrounding halo of erythema
brown recluse spider
What other cardiac event is a patient at risk for who has previously had a TIA?
Myocardical infarction
What is amaurosis fugax?
Transient blindness that results from emboli to the carotid artery.

Remember that the opthalmic artery is the first branch off of the internal carotid artery, so watch out for this is patients who had a TIA.
What is the time frame for a TIA
A brief neurologic deficit that completely resolves WITHIN 24 HOURS!
What is the pathophysiology behind development of a TIA?
Atherosclerotic plaques at the bifurcation of the carotids or internal carotid artery region become ulcerated --> form an embolous --> travel to the blood vessels in the brain
What are the 2 main therapeutic options for treatment of a patient who has 80% stenosis of the the left internal carotid artery?
1. Aspirin
2. Carotid endarterectomy
Name indications for endarterectromy
-TIA
-Amaurosis fugax

-Asymptomatic carotid bruit plus >70% internal carotid artery stenosis

-Completed stroke w/ major neurological recovery plus >70% stenosis of the internal carotid artery
When performing a carotid endarterectromy, what 3 nerves must you be careful not to damage during surgery?
1. Marginal branch of the facial nerve
2. Vagus
3. Hypoglossal
How do you evaluate a patient with an asymptomatic carotid bruit?
Get a carotid artery duplex study.
A patient with asymptomatic right-sided carotid bruit receives a carotid duplex study that shows 60% stenosis of the artery? What is the next appropriate step?
Get a carotid endarterectomy
What are the 6 P's of acute arterial occlusion?
Pain

Pulselessness

Pallor

Parathesias (pins and needles feeling)

Poikiothermia (skin is cold below the level of the occlusion)

Paralysis
What is the procedure of choice for treating an acute arterial occlusion (such as in the iliofemoral artery of the leg)?
Balloon catheter embolectomy (Fogarty catheter embolectomy)
How does compartment syndrome develop?
Occurs after reperfusion of an ischemic muslce
in compartment syndrome, at what compartment pressure does irreversible ishemic injury to muscles and nerves occur?
20-40 mmHg
You have a patient with compartment syndrome of the lower leg. What is your next best step in the management of this patient?
Go the OR now for fasciotomy! Do not wait for more serious symptoms (nerve and muscle weakness, etc.) to develop.
Exercise-induced ishemic pain of the claves and thigh that is relieved by rest
claudication
ABI of a person with mild claudication
0.6 - 0.8

Remember that the normal ABI is >1.0
True or False: Most patients with claudication alone will require surgery as treatment for their condition?
FALSE! In most patients, non-operative exercise management has proven successful.
The best test for diagnosing a tear of the anterior cruciate ligament
MRI
How does the presentation of a posterior dislocation of the hip differ from that of a broken hip?
Posterior dislocation: leg shortened, adducted, and INTERNALLY rotated

Broken hip: same as above , except hip is EXTERNALLY rotated
What is this diagnosis:

The patient has a distended bladder, flaccid rectal sphincter, and loss of sensation in the perineal saddle region
Cauda equina syndrome

This is a surgical emergency that requires immediate surgical decompression
Squamous cell carcinoma of the skin that develops in a person with chronic leg ulcer
Marjolin ulcer
Best treatment for club foot (talipes equinovarus)
serial plaster casts that begin in the neonatal period
Genu valgus
Knocknee - this is normal in children up to ages 4-8
Genu varum
Bow-legged - this is normal in children up to age 3
What is the difference in treatment of a bone fracture in a child that does not involve the growth plate compared to a fracture that splits the growth plate into 2 or more pieces?
If the growth plate itself is not fractured, then a closed reduction will be sufficient.

If the growth plate is fractured, then you must do an open reduction and internal fixation.
What is a common vascular complication that can occur in a person who has sustained a fracture of the femoral head?
Avascular necrosis
Why must you surgically reduce an open fracture of a bone within 6 hours?
If you wait longer than 6 hours to reduce these injuries, the risk of developing permanent osteomyelitis greatly increases.
Name this condition:

A person steps on a rusty nail. Three days later his foot is swollen, dusky, and you can palpate gas crepitation.
Gas gangrene
What is the medical management of gas gangrene?
IV penicillin (clostridium perfringens is susceptible to this abx)

surgical debridement of the affected tissue

Hyperbaric oxygen treatment (helps deactivate the toxin produced by clostridium perfringens)
What artery can be damaged in a posterior knee disclocation?
Popliteal artery

You must check the integrity of the pulses, get an artiogram, and promptly reduce the injury!
What "hidden" injury should you suspect in a person who has sustained a closed head injury?
A fracture(s) to the cervical spine. So, don't forget to get cervical x-rays/CT scans to rule out a fracture in this area
A patient presents with symptoms of carpal tunnel syndrome. What imaging study would you order?

What is the treatment?
Get wrist x-rays (including carpal tunnel views)

Tx: splints and anti-inflammatory drugs
The best treatment for De Quervain's tenosynovitis
steroid injections (but splints and anti-inflammatories can also help)
What is felon?
A type of abscess that occurs in the pulp of a finger.

Treat with drainage b/c the pulp is a closed space and can develop compartment syndrome
A wood cutter accidentally cuts off his index finger. Before heading to the ER, what should he do with the severed finger?
-Clean the finger with saline
-Wrap the finger in saline-soaked gauze
-Place the finger in a plastic bag
-Place the bag on ice
The most common age of incidence for a lumbar disk herniation
45 years old
What are the most common nerve roots affected in a lumbar disk herniation?
L4 - L5 or L5- S1
Best method for diagnosing a lumbar disk herniation

What is the best form of management?
Dx = MRI

Management = Bed rest!
How is the pain assoc'd with lumbar disk herniation described by most patients?
Lightning!
A patient with a lumbar disk herniation complains of pain that feels like "lighting" that shoots out of her pinky toe. What is the most likely nerve root(s) involved?
L5- S1
A patient with a lumbar disk herniation complains of pain that feels like "lighting" that shoots out of her big toe. What is the most likely nerve root(s) involved?
L4 - L5
What condition should you suspect in a 34 year old man with progressive back pain and morning stiffness, pain that is worse at rest but improves with activity?
Ankylosing spondylytis

Look for bamboo spine on x-ray
Are leg ulcers in a diabetic more likely to be caused by a decrease in microcirculation or from neuropathy?
Neuropathy, but once the ulcer has developed it is unlikely to heal due to poor microcirculation
What is the difference in pathophysiology of the type of leg ulcers seen in diabetics vs. patients with atherosclerotic disease?
Diabetics = ulcers occur at PRESSURE POINTS due to neuropathy

Atherosclerotic disease = ulcers are caused by poor blood circulation --> ischemia of tissues --> so, ulcers are more likely to occur in areas farthest away from the heart
What type of ulcer would you suspect in a patient with an ulcer above her medial malleolous with surrounding skin that is thick and hyperpigmented. She has a history of cellulitis and vericose veins.
Venous stasis ulcers
How do you work-up a patient with an ischemic ulcer?
-Doppler studies to determine if there is a pressure gradient

-If there is a pressure gradient, then next step is to get an arteriogram
What is the first diagnostic step for a Marjolin ulcer?
Remember that Marjolin ulcer is a squamous cell carcinoma that develops in a person with CHRONIC skin irritation (such as repeated ulcers in the same location)

Diagnose with a biopsy!

Treat with wide local excision and skin grafting
Name this condition:

Inflammation of the common digital nerve that causes pain/tenderness between the 3rd and 4th toes, common seen in women who wear high-heeled shoes or persons who wear pointy cowboy boots
Morton neuroma

Tx= wear more comfortable shoes
Best management for wound evisceration
-Put the patient back in bed (if they were standing up when the abdm wound opened up)

-Cover the bowel with large moist dressings soaked in saline (prevents the bowel from drying out and decreases risk of hypothermia for the pt)

-Get to the OR immediately to close up the abdm wound!
Diagnostic test of choice for achalasia

How would you confirm your findings?
Barium swallow

Confirm with manometry
A patient that has more difficulty swallowing liquids rather than solids is likely to have what condition?
Achalasia
Progressive dysphagia for solids --> soft foods --> liquids

What is the likely diagnosis?
Carcinoma of the esophagus
Best method for diagnosing suspected carcinoma of the esophagus
Endoscopy and biopsies
Name the 5 things that can prevent a fistula from healing:
Think F.E.T.I.D

F - Foreign body
E - Epithelialization
T - Tumor
I - Infection, inflammatory bowel disease, or irradiated tissue (tissue is not viable enough for proper healing)
D - Distal obstruction
For patients with elevated serum sodium concentrations:

How much fluid is lost for every 3 mEq/L above a normal sodium value of 140 mEq/L?
1 liter of fluid is lost for every 3 mEq/L above the normal of 140 mEq/L

Example: serum sodium of 152 mEq/L = 4 liters or fluid lost (deficit = 12 mEq/L)
Sudden paralysis of the facial nerve
Bell's palsy
Most common cause of epistaxis in the following age groups:

1. Children
2. 18 year old
3. Elderly
1. Picking their nose - bleeding comes from the anterior septum. Treat with phenylephrine spray and local pressure controls

2. Coccaine abuse - from septal perforation. Treat with posterior packing. Can also be caused by juvenile angiofibroma - do surgical resection

3. Blood loss in this age group can be copious and lifethreatening. Do posterior packing, surgical ligation of feeding vessels may be necessary
The only test that can look at the bladder mucosa in detail (i.e. looking for early cancers)
cystoscopy
Best test to identify renal tumors
CT scan
Best test to look for dilation (obstruction) of the renal system
Sonogram
What test provides excellent views of the kidneys, collecting system, and has limited views of the bladder (b/c it cannot detect early cancers)?
Intravenous pyelogram
Name some limitations of intravenous pyelogram:
-Potential allergic rxn to the dye

-Cannot be used in patients with limited renal function (Cr > 2.0)
What is the difference in clinical presentation of testicular torsion vs. epididymitis?
Both have testicular pain, but,

-Testicular torsion: NO fever, pyuria or hx of recent mumps infection! Also location of the testes is high riding and the spermatic cord IS NOT tender. An IMMEDIATE surgical emergency!

-Epididymitis: Assoc'd with fever and pyuria! Normal location of the testes. Not a surgical emergency - can tx with abx and get a sonogram to r/o testicular torsion
Clinical presentation of testicular torsion
-No fever
-No pyuria
-No recent mumps infecion
-Extreme testicular pain
-Testes are high riding
-IMMEDIATE surgical emergency
Clinical presentation of epididymitis
-Fever
-Pyuria
-Extreme testicular pain
-Testes are in normal location
-NOT a surgical emergency
-Treat with abx
Most common reason for a newborn not to urinate during the first day post-partum
Posterior urethral valves
Best test to diagnose posterior urethral valves:

Best method for getting rid of the valves:
Voiding cystourethrogram

Endoscopic fulguration or resection
True or False: Circumcision should always be performed on a child with hypospadias
FALSE! It should never be performed b/c the skin of the prepuce will be needed for the plastic reconstruction that will eventually take place
Most common presentation for cancers of the kidney, ureter or bladder
Hematuria, so any patient who presents with this needs a workup to r/o cancer