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129 Cards in this Set

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Tx Hemorrhoids
Sigmoid/Colonoscopy (hemorrhoids can mask CA)
↑ water, dietary fiber & stool softeners
poop as soon as you feel an urge, but let the bowel do the pushing
continued problems → surgery; rubber band hemorrhoiectomy; do not pack the anal canal [it will try to clamp down, you end up with a spastic anal sphincter]
Pilonidal Cyst
painful, infected cystic abscess near upper gluteal cleft containing hair and skin
hairy 20 yo men who sit a lot

maybe ingrown hair from sitting

Tx: incise and drain wait for infection to subside; once infection has subsided you must completely incise all of the epithelial lining; don't close the wound, let it stay open and granulate.
Mecke's Diverticulum
Rules of 2's

2% of the population
2 inches long, 2 feet from the ileocecal jnx
2% symptomatic,
2 ectopic tissue possibilities
present at 2 yo
males 2x as likely as females

absent on imaging? try technetium 99m scan for gastric mucosa.

"If you find one, take the darn thing out."
Devices used to maintain lumenal patency when constricted by pathology

"You're not curing anybody with a stent, you're making their life more livable."

~every specialty places stints
moving liquid to a different destination than its usual one

eg gastric bypass
Feeding Tubes
GI tract tolerates food, oral route not available

Many types: from soft small diameter nasogastric to PEG tubes
Baseline caloric needs
Young Adult Males 2700 ± 100 C/d
Young Adult Females 2100 ± 100 C/d

at least 50ml H20/h
Best indicator or blood volume
urine output
3 Things which can heighten your metabolic rate
any acute inflammatory state
major injury
Caloric Content of Nutrition Types
Protein & CHO 4Cal/gm
Fat 9 Cal/gm
EtOH 7 Cal/gm
Nutritional requirements for critically ill pts
considerable muscle breakdown

will need lots of protein, specifically Glutamine
+ A & C
Zinc helps wound healing
hypertonic solution into central venous access

expensive, a great culture medium, will require insulin even in non-diabetics

complications: infxn, small bowel atrophy, choliary stasis (et al), hepatic fatty metamophosis
protrusion of an organ through the wall of its normal anatomic location

you can have a henia of anything anywhere: eg. vastus lateralis thorugh fascia lata
most common hernia in women

its a trick question, femoral are more common in women then men but inguinal are more common than femoral in both
most common cause of hernia
valsalva maneover
hesselbach's triangle
fascia bordered by:

inguinal ligament
rectus sheith
inferior epigastric artery & vein

site of direct hernia
tension on the wall of a hollow strx
pressure on the wall * diameter of the wall
toddler with an umbilical hernias
majority resolve by age 4
Richter's Hernia
dangerous: no vomit, no air fluid level

fascial defect, one side of a piece of bowel has stuck into it but not all

bowel contents can't go by; you don't think its a hernia until they infarct and perf and die
Hernia progression, tx
majoirty of umbilical hernias resolve spontaneously

the rest get bigger, must tx

extrinsic: support
anatomic repair
tension free repair is the big deal now
Most common volvulus
Infants: midgut associated with congenital malrotation

Adults: Cecum or Sigmoid; usually a man with a redundant, very mobile colon;
beak on barium enema
tx volvlulus
sigmoid: be may do it
colonoscopy may work

otherwise → operate

save as much small bowel as you can
resect as much redundant colon as you can
who decides whether a pt needs surgery
the surgeon

"medical clearance" is not an indication for surgery

if you as a surgeon don't think surgery is indicated, you send the pt to a specialist to give a great explanation
Surgery and Social History

If you can get a pre-op pt to quit for 2 weeks you will markedly ↓ post-op pulmonary problems

(one week not as good but better than nothing)
Operative Consent
should be a fully informed one, including risks, benefits and alternatives
surgery under anesthesia w/in 3 mo of MI
30% risk for reinfarction
pre op Hgb
8gm enough for healthy person

need more if CV problems\

other peoples blood is NOT GOOD FOR YOU. Do not transfuse up to optimal Hg if you don't need to → serious complications
Swan-Ganz catheters
tells you the RA pressure


Do not insert one if you don't need to
Pre-op malnutrition
bad for healing
↑ risks infection/death

>10% body weight rdxn pre op, give TPN and try to get it back
Irradiated Tissue
Looks and acts like very old tissue

old tissue doesn't heal well
Spacial location of healing
healing progresses more slowly as you move distally. Face heals very well, feet not so much. plan accordingly for suture removal.
Birth Control and Surgery
increased disk for Throboses
low molecular weight heparin

decreases thromboembolic problems when given just before surgery
post-op ambulation
minimizes complications

pt needs to know about it pre-op
Newhoff's Law
if you don't get out of bed
you don't get any pain meds
PCA pump
self administered pain meds,best
Epideural Catheters with local anesthetics
greatly reduce post-op narcotic use, helps Gi motility

best if thoracic
Incentive spirometers
helpful post-op if used properly, but 10 little breaths aren't worth one deep breath
Post-Op Ileus
can be fatal, fixed quickly with an NG tube

BUT in general start oral intake ASAP. hiccups means they're not ready.
Dressing the surgical area
make it neat and small → faster psychological recovery for pt if they think it was a minor procedure
NG/drain outputs
abnormal losses, should be replaced with appropriate fluids

gastric juice = chloride
pancreatic jucie= alkaline
Daily labs
don't order them; wasting blood and money; order what you need.
Febrile post-op after clean surgery
First 48 hours think atelectasis
days 3-5 foley infx if there is one
after that: superficial or deep wound infx
Post-op shock w/in 24 hours after abdominal/thoracic surgery
bleeding until proven otherwise
Bleeding with good Hgb & Hct
you bleed whole blood: you don't know how much you've lost until you've expanded their volume
acute abdomen
severe pain w/ rapid onset


pt too sick not to have surgery
acalculous cholecystitis
sludge from no duodenal CCK

usually people who've already beeni n the ICU for a while
gallstone ileus, how did it get there
erosion through the wall
could not possibly pass through sphincter of Oddi & be big enough to obstruct bowel
Antibiotics & Surgery
Don't start utnil 30 minutes before: all that would do would make sure that anything in the gut is resistant

repeate q4h intra-op

Do not continue post op for clean cases → c dif
abdominal pain, fat, sweaty and shakey

insulinomas: eating something makes their blood sugar better
pseudocyst of pancreas
from chronic pancreatitis
cancer of the pancreas
first sign of tail pancreatic CA is infiltration into nerveous strx behind wall

head may be caught earlier
Laproscopic Surgery
significant advantages

consult MUST say possible open on operative consent
nice because you don'thave to take them out
gas gangrene
rapid advancement: cut all all tissue
Major e⁻lyte balances
correct slowly

take as long to fix them as it takes to dvlp
Fat as an endocrine organ
converts adrenal androgens to estrogens → anovulatory women, gynecomastia in men
Thyroid pills
you'll lose weight: sweat like crazy, hair falls out
Malabsorption Surgical Procedures
Jejunocolic & Jejunoileal bypass

malabsorption surgical procedure

lots of problems: so much of your absorption in the terminal ileum
Restrictive Procedures
subtotal gastrectomy
gastric bypass
gastric banding
sleeve gastrectomy
Combined Weight Loss Surgical Procedures
Roux-Y "short limb" gastric Bypass is the gold standard

Biliopancreatic diversion (Scopinaro)
"Long-limb" gastric bypass
Duodenal switch
Dumping Syndrome
good in distal bowel releases PYY and GLP-1 from L cells, geos to hypothalamus and induce satiety
What is the crescent sign?
small microfractures around the head of the femoral epiphysis, early after avasculature in Legg Calve Perthes disease
What is a Herndon hump?
"pistol grip" appearance of femoral neck as it widens and dvlps a protuberance while remodelling in chronic stage of SCFE
What is the Klein’s line used for?

drawn along superior aspect of femoral neck

in normal hip epiphysis overlaps kline line
When examining the hip, what range of motion tests are the most important?
internal rotation
What views are obtained when doing plain film x-rays of the hip to rule out LCPD?
anteroposterior and lateral views with comparison of the opposite side

frong-lateral if hip involved
Describe the presentation of a toddler’s fracture
Accidental spiral tibial fractures in toddlers 2° to trivial mechanism, tripping

toddler refuses o bear weight, PE and imaging subtle,

pain when knee and ankle passively twisted in oppostie directions

tx: long leg cast
toddler refuses to bear weight on one leg

pain when knee and ankle passively twisted in oppostie directions
toddler's fracture

Accidental spiral tibial fractures in toddlers 2° to trivial mechanism, tripping

tx: long leg cast
child w/ limp hx sexually active
GC or reactive arthritis
child w/ limp hx bleeding disorder
child w/ limp hx insect bite
child w/ limp hx pharyngitis
rheumatic fever
child w/ limp hx trauma
fx, soft tissue injury
child w/ limp hx back pain
diskitis, vertebral osteomyelitis
child w/ limp hx abd pain
psoas abscess, accute abdomen
child w/ limp hx intermittent pain at rest
child w/ limp hx improves with activity
child w/ limp hx worses with activity
overuse injury, stress fracture
child w/ limp hx diarrhea
reactive arthritis
child w/ limp hx recent
infectious or traumatic
child w/ limp hx insidious
child w/ limp hx worse in morning
transient synovitis or JIA
child w/ limp hx pain that awakens child at night
child w/ limp hx fever & malaise
CA or rheumatologic
child w/ limp hx weight loss
child w/ limp hx recent URI
transient synovitis
Child w/ limp
PE: T>100.4
infectious or neoplastic
Child w/ limp
PE: abdominal mass
neuroblastoma, psoas abscess
Child w/ limp
PE:abdominal tenderness
Child w/ limp
PE:conjunctivitiy, enthesitis, urethritis
reactive arthritis
Child w/ limp
PE:erythema chronicum migrans
Child w/ limp
PE: external rotation w/ hip flexion
Child w/ limp
PE: galeazzi sign
leg lenth discrepency
Child w/ limp
PE: lymadenopathy, splenomegaly
Child w/ limp
PE: loss of internal rotation
Child w/ limp
PE: Obesity
Child w/ limp
PE: overlying warmth, redness
inflammatory arthritis, osteomyelitis, septic arthritis
Child w/ limp
PE: painless, no-pruritic vesiculopustular skin lesions
Child w/ limp
PE: psoas sign
appy or psoas abscess
Child w/ limp
PE: metaphyseal rib, or vertebral fractures or finger fracture in non-ambulatory children
child abuse
Septic Arthritis
EMERGENCY: usually hematogenous dissemiation of staph aureus;

child appears systemically ill w/ rapidly progressive joint pain, limited ROM & fever.

M=F 3-6; hip will be flexed, abducted and externally rotated

Tx: prompt surgical drainage & antibiotics following US, arthrocentesis w/ fluid & blood cultures
Transient Synovitis
sterile effusion resolves without tx or sequelae

child awakens with limp in morning and refuses to walk; after loosening up limp may improve.

Dx of exclusion following WBC, Sed Rate &CRP to distinguish from septic arthritis
Growing Pains
Dx of exclusions

moderate severe, typically symmetrical pain noticeable in evening while resting after day of activity during which there was no limp;

simple analgesics, thermal tx relieves;
child appears systemically ill w/ rapidly progressive joint pain, limited hip ROM & fever.
Septic Arthritis: EMERGENCY

usually hematogenous dissemiation of staph aureus;

child appears systemically ill w/ rapidly progressive joint pain, limited ROM & fever.

M=F 3-6; hip will be flexed, abducted and externally rotated

Tx: prompt surgical drainage & antibiotics following US, arthrocentesis w/ fluid & blood cultures
moderate symmetrical pain noticeable in evening while resting after day of activity during which there was no limp;
Growing Pains, Dx of exclusion

simple analgesics, thermal tx relieves;
child awakens with limp in morning and refuses to walk; limp improves after lostening up
Transient synovitis: sterile effusion resolves without tx or sequelae

Dx of exclusion following WBC, Sed Rate &CRP to distinguish from septic arthritis
Describe a positive Trendelenburg sign, the muscle & nerve involved, and the “Trendelenburg gait”
Describe a “short-leg” gait.
longer leg will stay in flection when standing or child will walk on toes of shorter leg.

pelvis will move up and down more than normal walking; not antalgic;

anatomical or fnx: addxn contraction will cause affected LE to seem shorter, abdxn makes it seem longer
Describe a “steppage” gait.
inability to dorsiflex the foot, so instead flex hip and knee so toes can clear ground
Describe a “equinus” gait.
toe walking, a variety of causess: cerebral palsey, tight achilles tendon, calcaneal fracture, foreing body in foot
Which type of gait is a “painful” gait?
antalgic gaints
Fist Percussion over CVA
pain = pyelonephirits or obstructive uropathy
Obturator sign
is psoas sign

flecion and internal rotation vs resistance
severe abdominal pain out of propoortion
mesenteric ischemia until proven otherwise
Potantial life threatening conditions of acute abdomen
ruptured leaking abdominal aortic aneurism
perforated viscus
acute pancreatitis
intestinal obstrx
mesenteric ischemia
onset of page
rapid: vascular problem like ischemia, passage of stone rupture of viscous cyst or ectopic pregnancy

slow: inflmmation, like appendicitis or cholecystitis
duration of abdominal pain in history
<24 hours and and increasing intensity likely to be a surgical problem
character of abdominal pain
dull, achy, burning = visceral
sharp/stabbing = peritoneal
crapming = osbstruction
tearing = dissecting aneurism
severe, out of proportion abdominal pain
mesenteric ischemia or pancreatitis
abdominal pain aggregated by omovement
parietal paritoneal pain
abominal pain releived iwth eating
ulcer pain
abdominal pain releaved by change in position:
pancreatitis and other peritonitises releived by fetal position
What are the risk factors that identify the patients at greater risk for having a significant disease process, who present with abdominal pain?
extremes of age: vitals do not accurately reflect degree of illness.
any abnormal vital sign
severe pain w/ rapid onset
pallor & diarphoresis
What is the importance of discussion of “number of times the diaper is wet” in a pediatric patient?
decreasing frequency ≈ dehydration
Discuss importance of General Appearance on physical exam of patient presenting with abdominal pain.
pale, sweaty and still are more acutely ill w/ peritonitis

pts who are writinghave visceral pain
Discuss the importance of vital signs in the physical exam of a patient with abdominal pain.
appendicitis or cholecysitis generally >100
101+ raises suspicion of salpingitis, pyelonephritis, bacteiral enteritis, ruptured viscus
abdominal pain with nausea and vomiting
almost any pathology

excessive ≈ pancreatitis or obstrx
lack ≈ ovarian/uterine

vomitting AFTER onset of pain ≈ surgical
vomiting BEFORE onset of pain ≈ gastroenteritis
diarrhea plus vomiting almost always ≈ gastroenteritis