Comprehensive Surgical Review Notes

Alright, let's move on now to our complete surgery review. Now, in this video, we're going to have 120 surgery review questions. You will be prepared for Shelf and Step 2. And of course, you will have fun along the way. Now, let me begin with the following introduction. Here is your surgery attending. Now, you have to use your surgeon attending to your advantage. Now, what I mean by this is that you have to imagine him screaming at you. I mean, I know you're used to this. But you need to imagine him screaming at you things that you want to remember. For example, the Parkland formula for burns. Four times body weight times surface area. And then you remember, for the rest of your life, not the nasty things that he would say about you, but instead, the Parkland formula for burns, and everything else that you need to know for surgery. And with this introduction, let's begin with question one. Question one. Which medication must be stopped seven days before surgery? Now of these choices, the only one that must be stopped seven days before surgery is naproxen, one of the NSAIDs. All NSAIDs and COX-2 inhibitors must be stopped seven days before surgery. And another one that I wrote over here are herbal supplements. These must be stopped a week before surgery. Beta blockers don't need to be stopped. They can be continued along with calcium channel blockers. Diuretics we stop on the day of surgery. And long-acting insulin we don't stop, but short-acting ones we do on the day of. And steroids, of course, we don't stop. We get a higher dose. And we'll talk about stress dosing later. Let's move on. Question two. Which intraoperative cardiac risk is worse? A, a patient with EF under 35%, or B, a patient with a transmural MI six months ago? And the answer is A, a patient with an EF under 35%. This has a 75% mortality rate during surgery. As for B, patients with a transmural MI six months ago don't have a relatively high mortality rate, only 6%. And that's exactly why we recommend waiting until six months post-MI to get surgery. Question three, why do surgeons beg their patients to stop smoking eight weeks before surgery? Compromised ventilation or oxygenation? And the answer is compromised ventilation. Patients with compromised ventilation may develop high PCO2 with low FEV1. They can't get the carbon dioxide out. I wrote a note over here that smoking is the most common, by far the most common cause of increased pulmonary risk during surgery. And that's why we convince patients to no avail to stop smoking, to use nicotine replacement therapy, and if not, bupropion or varenicline. Question four. Which person has the highest risk of dying during surgery? A patient with significant aortic stenosis, a patient over 70, or a patient with JVD? And the answer is C, a patient with JVD, because signs of heart failure, JVD, which represents heart failure, is the absolute worst finding. And if possible, we treat with ACE inhibitors, beta blockers. Question five, surgical timeouts. I'm not going to read the whole thing because the answer is all of the above are true. They occur just prior to skin incision. It includes the patient identity, and it includes the site and laterality, i.e. the side of the operation. Now I wrote other patient safety reminders on the bottom over here. Preoperative patient identity verification in the holding area, along with verification of operation type and laterality, documentation by at least two providers. And we use permanent markers during surgery for operative site, and we never mark non-operative sites. Question six, what are causes of post-operative fever? And the answer is all of the above. We know the mnemonic. Now I wrote on the top over here that atelectasis is the most common cause of fever first day post-op. And we prevent this with antidepressants. deep breathing exercises. And if we need to, we go with bronchoscopy. Pneumonia follows three days later if the atelectasis is not resolved. UTI presents usually on day three, TBT on day five, wound infection on day seven, and abscess post-operative day 10 to 15. Question seven, wounds that have been freshly debrided are treated with wet to dry dressings. We want to kind of dry them out. It's only once they're healthy and we have beautiful granulation tissue do we get moisture retaining dressings. Question eight. What's the treatment for a linear skull fracture? And the answer is observation. If they're linear, we don't go with surgery. That's only with open fractures. Question nine. A patient develops sudden pleuritic chest pain seven days after surgery. The APG shows hypoxemia and hypocapnia. This sounds like pulmonary embolism. After confirming the diagnosis, what is the next step? And the answer is we give heparin. We only go with the IVC filter if the P's recur during anticoagulation or if the anticoagulation is contraindicated. Question 10. which cranial nerve can be damaged during nissen fundoplication to treat GERD? And the answer is, during this procedure, the vagus nerve, cranial nerve 10, can be damaged, and this leads to gastroparesis, in which we see early satiety, bloating, and weight loss. And management includes dietary modifications such as small meals low in fat and metoclopramide, which promotes motility. 11. In paralytic ileus, what do we see? Bowel sounds are absent. We don't hear bowel sounds. There's usually not pain, but bowel sounds are absent. And here we just have an x-ray. of paralytic ileus. I wrote a note over here that paralytic ileus is prolonged by hypokalemia. In this condition, there may be mild distension, but it's usually self-regulatory. So conservative management and serial exams is what we do. Question 12. The physician thought it was paralytic ileus, but now it's been six days of neural resolution. What's the most likely diagnosis? And the answer is mechanical bowel obstruction due primarily to adhesions. X-rays show dilated... loops of small bowel and aeroflu levels, and we confirm this diagnosis with an abdominal CAT scan, and we treat it with surgery. Question 13. Which of the following interventions is recommended during intubation to reduce the risk of pneumonia, for example, due to aspiration? And the answer is, all of these are appropriate. We minimize patient transport in order to avoid movement of the endotracheal tube. We suction subglottic secretions and we elevate to a semi-recumbent position, i.e. 30 to 45 degrees elevation. All of these prevent aspiration ammonia associated with the intubation. Question 14. Shortly after a duodenal switch operation, the patient can expect to be significantly lighter? Probably not yet. They have to wait some time. And the answer is no longer need his type 2 diabetic medications. It's quite fascinating. Had duodenal switch. which operation kind of gets rid of diabetes in over 95% of patients. They don't need their medications anymore, and they're no longer hyperlipidemic. And why, of course, don't all diabetic patients get this, at least the ones that are obese? And the answer is because there are lots of associated issues. 15. How do bee stings lead to shock? And the answer is, bee stings lead to anaphylaxis, and there's dilation of blood vessels, in which there's reduced blood flow. And here we just compare the various types of shocks. Question 16. A two-year-old child has chronic constipation, and when a rectal exam is done, there's explosive expulsion. pulsion of stool. Barium enema shows dilated proximal colon. What's the next step? And this is Hirschsprung's disease, and the next step is a full thickness biopsy of the rectal mucosa. Hirschsprung's disease is also known as congenital aganglionic megacolon, because that's what's going on. It's aganglionic. Question 17. A 69-year-old man can't sleep because of pain in his calves. He can't walk a block without getting the same pain. PE shows loss of hair, muscle atrophy, and no pulses in the foot. What's the next step? So here we see intermittent claudication. And here we want to get an ABI, i.e. we calculate the pain. calculate the lower and upper systolic pressure. That's what ABI does. It uses an ultrasound. We get the systolic pressure at the ankle, and we divide it by the systolic pressure in the arm. If it's less than 0.9, that's a diagnosis of PAD, peripheral artery disease, and we follow with the CT angiogram or MRI angiogram to assess and plan revascularization. Question 18. What should be avoided in a patient with acute subdural hematoma, assuming there's no midline deviation? And the answer is warm fluid infusion. We want to give cold water infusion. We want to induce hypothermia in this hemorrhage to reduce the oxygen demand. And by the way, I wrote a note over here that hypertonic solutions can also reduce intracranial pressure. Question 19, a patient's brought to the ED with a puncture wound and broken ribs. During positive pressure ventilation, he develops tachycardia hypotension and unilaterally absent breath sounds. What's the diagnosis? So this is a complication of positive pressure ventilation, and that is tension pneumothorax. And that's why he has this tachycardia hypotension and the absent breath sounds on one side. In this condition, we temporarily managed with needle compression, and formal chest tubes are placed in later. Now I want to draw your attention to this chart I made over here, where I compare regular pneumothorax with tension pneumothorax. In tension pneumothorax, we see air in the pleural space through a one-way leak. Now in this condition, we contrast with atelectasis, because in atelectasis, the tracheal deviation is toward the affected lung, because the problem is the collapse of the lung. As opposed to in tension pneumothorax, we see tracheal deviation away from the evolved lung, because we see a balloon filling up on the affected side. Question. Question 20. A 19-year-old woman endures a motorcycle accident. She has rib fractures. Two days later, she suddenly develops hypoxemia and hypercapnia. The CXR is shown. What's the diagnosis? So over here, we see this whitening over here, and this represents a pulmonary contusion. Pulmonary contusion doesn't only happen at the time of the injury. It can happen up to 48 hours later. It's delayed in 40% of cases. This is not pulmonary embolism. Pulmonary embolism, chest x-ray, often doesn't show much, but we may see various findings, such as the Fleischner sign. and the Hampton hump. And in fat embolism, we perhaps see bilateral haziness on chest x-ray, but we don't see this one-sided whitening. Question 21. If peripheral ivy lines are unsuccessful in the trauma setting, what's the next step in adults? Or intraosseous, do we go with a percutaneous femoral vein catheter? Or intraosseous cannulation of the proximal tibia? And the answer is percutaneous femoral vein catheter. Choice B is what we do in children under six years of age. But in adults, we go with percutaneous femoral vein or saphenous vein catheter. Question 22. A woman develops DIC during during surgery for an intra-abdominal hemorrhage. Blood is oozing from the IV sites. Her body temperature is normal. What's the next step? This is DIC. Do we stop the surgery or go with FFP and platelets? And the answer is we go with FFP and platelets. We don't stop surgery simply because of DIC. That's only if hypothermia and acidosis develop. Question 23. A man gets shot in his upper lateral thigh. The bullet is embedded in the vastus lateralis, which we see in the picture. Upon evaluation, no major vascular injury has occurred. What's the next step? And the answer is tetanus. is prophylaxis. Our terogram is only needed if there's vascular damage, and removal of the bullet is generally not what we go with. We go with prophylaxis for tetanus. Question 24. A patient has a plural LDH of 70 and a serum of 80. So remember the formula, Leitz criteria, where we have to divide plural by serum, and if it's more than 0.6, we call it an exudative effusion, and that's what's going on over here. It's more than 0.6, so we know it's an exudative effusion. Exudative effusions can be various things, but over here we see milky... white fluid. And that's seen in chylothorax. In empyema, we see purulent fluid. And in malignancy, we see a clear or cloudy fluid. And in chylothorax, we see milky fluid. Another question 24. A 73-year-old woman fell. She's lying in pain with her right leg shortened and externally rotated. This sounds like a fracture. X-rays show an intracranial fracture of the right hip. What's the best treatment? And the answer is open reduction and post-op anticoagulation. We don't go with hip replacement. We go with open reduction. And the post-op anticoagulation is important to prevent DVT and PE because she's not going to be moving much after the surgery. Question 25. A 34-year-old woman with a pyloric obstruction secondary to acid ingestion has protracted non-bileous and non-bloody vomiting. She's visibly dehydrated and these are her electrolytes. What's the next step? So she keeps on vomiting because she once ingested acid and that caused ipyloric stricture. So which fluid resuscitation do we give? And the answer is normal saline with KCL because this is a metabolic alkalosis. Remember, metabolic alkalosis is primarily caused by protracted vomiting. So since she has a metabolic alkalosis, we treat this with potassium chloride. Question 26. Which is an absolute contraindication to surgery? Over 100 years of age? Nah. You look in the news, you'll see people who are over 100 who got surgery. And the answer is diabetic coma. We don't perform surgery on patients in diabetic coma. We must rehydrate them, regain urinary output, and at least partially correct the acidosis and hyperglycemia before surgery. Question 27, halothane and succinylcholine can lead to, and the answer is, malignant hyperthermia. And we treat this condition with dantrolene. This is my little mnemonic. Inhaled and sucks, malignant hyperthermia oh shucks, and dantrolene deluxe. That inhaled anesthetics and succinylcholine can lead to malignant hypothermia, and we treat with dantrolene. 28, four months after pelvic radiation therapy for cervical cancer, a woman develops rectal bleeding and telangiectasias viewed via colonoscopy. What's the diagnosis? So this happened four months later. This is chronic radiation proctitis. Acute occurs within eight weeks. Chronic occurs after three months. And we see bleeding and teledrectasias. 29. A 19-year-old male with a blunt lower abdominal trauma cannot void and has abdominal distension with a positive fluid wave. BUN is 63. Creatinine is 4.2. Temperature is normal. What is the diagnosis? So since he has this positive fluid wave, we know this is a bladder rupture. And pee, or urine, is leaking into the abdominal space. That's what's leading to this fluid wave. In small bowel rupture, we'd see fever and abdominal rigidity. But in bladder rupture, we'd see the fluid wave representing the urine and fluid floating in the abdomen. And we confirm diagnosis with retrograde cystography and we treat with surgical repair. 30. Fever, flank pain, and dark urine 10 minutes after blood transfusion. This is acute hemolytic transfusion reaction. It has the classic triad of fever, flank pain, and dark red urine. The first step is the Coombs test and this condition may lead to acute kidney injury or DIC. 31. large diabetic foot ulcers require which of the following? Pressurizing the wound? No, we try to give it space. And the answer is imaging. With x-ray MRI, we want to rule out osteomyelitis because diabetic foot ulcers can lead to osteomyelitis. Other indications include if there are elevated inflammatory markers or associated fever. 32. What is the greatest risk factor for spinal amygdoma? In which we would see, for example, spinal cord compression leading to bilateral arm and leg weakness. And the answer is radiation is the greatest risk factor. 33. Older age is also a risk. as well as female, and NF2, neurofibromatosis type 2. But radiation, exposure to ionizing radiation, is the greatest risk factor. 33. A 23-year-old woman got punched in the left eye by her boyfriend, who is now detained by the cops. Which of the following is an indication for CT scan of the orbit? And the answer is, all of these are indications for CT scan of the orbit. A palpable bony step-off? That's a sign of fracture. Limited or painful ocular movements, as well as decreased visual acuity. Question 34. Acute angle closure glaucoma. where we see sudden onset headache, nausea, ocular pain, decreased vision, and conjunctival redness is initially treated systemically with, and the answer is, carbonic anhydrase inhibitor, acetazolamide, in addition to the topicals, timolol, apriclonidine, and pilocarpine. But the definitive treatment is laser iridotomy. 35, the first step in managing acute upper GI bleed is to establish vascular access with two large bore IV lines, 14 or 16G. These are the big ones that we want to use. Again, two of them. So if you only have one of them, The answer would be to add another. Question 36. A 64-year-old woman has right heel pain worsened by passive dorsiflexion of the big toe. Foot x-ray shows a calcaneal bone spur, but no fracture. What's the next step? So this sounds like plantar fasciitis. And the next step. This heel inserts, that's first line. Along with activity modification and stretches, it's first line for plantar fasciitis. These spurs, by the way, are seen often in patients with plantar fasciitis. Steroid injection would be second line if the initial treatments with activity modification and stretches didn't work. Question 37. A week after Roux-en-Y bypass, a 37-year-old woman develops fever abdominal pain along with tachypnea, heart rate is 125, and what's the next step? So here we need to be concerned about a leak of the anastomosis. We gotta get a CT scan to assess for anastomotic leak. Question 38. Which medication is contraindicated in a patient with a history of aortic aneurysm? And the answer is levofloxacin because fluoroquinolones not only have a risk of tendon rupture but also of aortic aneurysm. Question 39. The ideal placement of a central venous catheter should be in the... Lower SVC Smaller veins predisposed to venous perforation. That's why we go with the lower SVC. We need to get a portable chest x-ray to confirm the placement. And this should be just proximal to the angle between the trachea and the right main stem bronchus. Question 40. A patient has symptoms of There we see high-pitched bowel sounds and no signs of peritonitis, such as guarding. 41. A patient has signs of a spinal epidural abscess, i.e. back pain, fever, in an immunocompromised patient. What's the next step? And the answer is MRI with contrast. That allows us to properly see the tissues and the extent of infection. By the way, fever is not always present in spinal epidural lapis. That's just important to know. A tender mass near the top of the coccyx in a hairy 25-year-old man is treated with? There's, of course, pilonidal cyst, and we treat this with drainage, along with excision of sinus tracts. Question 43. Conductive hearing loss, for example, improved understanding in noisy places, in young patients with a family history, is due to? The answer to this is stapes stiffening, because this is otosclerosis. It may be either sporadic or, as in this case, autosomal dominant. 44. After laparoscopic surgery, a patient develops fever abdominal pain with guarding and leukocytosis. So what's the next step? These findings... should be further assessed with abdominal CAT scan to assess for laparoscopy-associated bowel injury, for example, perforation or burn of the instruments used during the procedure. Question 45. Asymptomatic biliary cysts are treated with surgery due to a huge risk for malignancies of the biliary ducts, gallbladder, and pancreas. 46. CT imaging of ischemic colitis. For example, a patient has abdominal pain, hematocasia, diarrhea, and lactic acidosis shows, and the answer is it shows colonic wall thickening and air in the bowel wall. That's what we. what we see in CT imaging of ischemic colitis. We treat ischemic colitis with fluids, antibiotics, and surgical resection is done if necrosis develops. Question 47. Which features favor purulent pericardial effusion over viral? Why would we think that it's purulent? And the answer is we see a severely sick patient with marked leukocytosis. We don't see these in pericardial effusion. But as for choice B, distant heart sounds and fever, that's seen in both conditions. 48. A young patient with decreased urinary flow and a feeling of incomplete emptying. That is due to urethral stricture. That's why a young patient could develop. Question 49. What is the cause of kidney stones in Crohn's disease or gastric bypass? And the answer is, patients with these conditions get hyperoxaluria. And what happens is, fatty acids aren't absorbed in these conditions. So calcium binds the fatty acids. So calcium is not available to bind oxalate. Oxalate can now be reabsorbed, and it's dumped into the urine, leading to hyperoxaluria. Now the oxalate in the urine combines with the calcium to produce the stones. Question 50. High PaCO2 in a surgical patient reflects... And the answer... Answer is alveolar hypoventilation. In other pulmonary conditions, such as PE, pleural effusion, and pulmonary edema, there's a decrease in PaCO2, not an increase. And that due to tachypnea. 51, muscular rigidity, altered mental status, and fever five days after surgery are concerning for? And the answer is haloperidol exposure. This is not malignant hyperthermia because we're talking about five days later. We're talking about neuroleptic malignant syndrome, which occurs days later with similar symptoms of malignant hyperthermia. And the treatment is to stop the antipsychotic or what's ever causing it, give benzos and dantrolene if refractory. Question 52, how is acute triglyceride-induced pancreatitis managed? And the answer is insulin. We give insulin. This manages the triglyceridemia faster than fibrates. And we give dextrose to prevent hypoglycemia. Question 53, fascial dehiscence with evisceration is treated with emergency surgery. This is a problem. There's a risk of strangulation. 54, pain reproduced by medial lateral squeezing of the calcaneus. This is calcaneal stress factor due to repetitive microchroma. and we confirm with imaging such as x-ray or MRI. You can take a look at other choices over here. 55. Hammy produces an aphasia in a child who fell while sucking on a lollipop, so what we're concerned with over here is a carotid artery dissection. It can happen while a child is also brushing his teeth. And we confirm with MR or CT angiogram. Question 56. Abrupt onset scrotal pain in an adolescent with absent cremastaric reflex. This is 10. Vesticular torsion, and the Doppler confirms the diagnosis. What's the next step? We want to go with surgical detorsion. We only go with the manual one if surgical detorsion is not available yet, but if it's available, we want to go with surgery. 57, recurrent fever, abdominal pain, and shortness of breath a week after laparoscopic appendectomy. So what are these symptoms concerning for? Abscess, a subphrenic abscess. 58, if melanoma is suspected, for example, we see asymmetry, border irregularity, color variation, diameter more than six, and evolving, or we see the ugly duckling sign, what's the next step? So here we suspect melanoma. The answer is full thickness excisional biopsy with initial margins of one to three millimeters of normal tissue. This is versus nasal cell carcinoma where first line management is with MOSE or a not a full thickness excisional biopsy. 59, small bowel obstruction with hemodynamic instability. What's the next step? Urgent surgical exploration. For example, you would see in a case of hemodynamic instability, fever, tachycardia, hypotension, acidosis. 60, bladder cancer, where we would see hematuria, dysuria, and flank pain. This is suspected. What's the next step? We want to go with histoscopy. I'm not really sure why I wrote these choices of a prostate over here, but the point is we go with histoscopy in order to evaluate for bladder cancer. 61, abrupt onset dyspnea, cough, and hypoxemia in an hour after intubation. Complicated by emesis, was cleared with suction. So here we have aspiration. We manage this with supportive care. This is chemical pneumonitis aspiration due to inhalation of gastric acid, which can occur within minutes to hours of intubation. Aspiration ammonia, however, would not develop an hour later. That would develop days later, and that's treated with antibiotics. Thanks. For example, ceftriaxone and azithromycin. Question 62. What is contraindicated in a patient who develops MI two days after surgery? And the answer is TPA. Angioplasty and stenting are not contraindicated in a patient who develops MI after surgery, but TPA is. And I wrote a note over here that remember, an MI, myocardial infarction, can occur during operations. 63. A 45-year-old woman has had her gallbladder removed last year. Now she has persistent abdominal pain, elevated LFTs, and CBD dilation ultrasound. What's the next step? So we want to go with ERCP to diagnose the etiology of her post-cholestectomy syndrome. She had her gallbladder removed. Now she has this syndrome. We want to evaluate the etiology. 64, patients with chronic pancreatitis often require supplemental. The answer is insulin and a pancreatic enzyme replacement. The pancreas is not working properly, so we need to replace what it's supposed to provide. Now, I wrote a note over here, but the pain that people with chronic pancreatitis experience is resistant to most modalities of therapies, and it's very debilitating. 65. What separates acute from subacute cardiac tamponade? And the answer is cardiac silhouette. JVD, hypotension, and distant heart sounds, Beck's triad, are seen in both acute and subacute forms, but the cardiac silhouette is generally associated only with subacute. It occurs after days to weeks. Here, the cardiac silhouette is going to be abnormal, as opposed to in the acute one. 66. Perennial skin swelling, tenderness, and crepitus with hypotension is initially managed with emergency surgery because over here we're dealing with fornay gangrene which is very deadly and we debride immediately 67 patients on total parental nutrition develop gallstones due to so a person's not eating through their mouth why do they develop gallstones and the answer is gallbladder stasis now the reason for this is that the normal stimulus for ckk release and gallbladder contraction is absent in these patients bile becomes more concentrated since the gallbladder is responsible normally for absorbing water from the bile and that's why we have this sludge and gallstones develop 68 which findings support pseudogynocomastia over true gynecomastia? Pseudogynocomastia is when a person's just very heavy, so it looks like they have big breasts. They don't really have gynecomastia. And the answer is signs of pseudogynocomastia include soft, fatty mass that are non-tender, as opposed to true gynecomastia, they're mobile. We see rubbery mass and the breasts may be tender. And we treat pseudogynocomastia, of course, with weight loss. 69, the most important thing to do in rib fracture management. After chest x-ray rules that pneumothorax and effusion is analgesics. We want to provide pain relief. This ensures appropriate ventilation and reduces the risk, not the risk, the risk of pneumonia. Question 70. A patient with asymptomatic open and global coma should be managed with, how do we treat asymptomatic? open angle glaucoma. Again, this is not painful. We find it often incidentally, and the answer is topical prostaglandins. Remember, we treat closed angle glaucoma with acetazolamide and other medications, but this one, open angle, we treat with topical prostaglandins. For example, etanoprost, beta blockers are second line, and laser trabeculoplasty is third step, third line. 71, a 25-year-old female has a palpable breast mask diagnosed as a fibroadenoma. What's the next step? So we want to go with ultrasound. Usually in adolescence, we reassure them, but there are more more reasons to image an adult. And removal is optional. Women want them out, so we're happy to help them. But if the malignancy is suspected, we also get a mammogram. 72, empyema is our most commonly caused by, and the answer is strep and anaerobes. And that's why it smells bad. 73, stress hyperglycemia is treated with nothing. Only when the glucose goes above 190 milligrams or 200 are we concerned. But if it's at 150, we're totally fine with that. 74, fractures of ribs, 9 through 12, visualized via chest x-ray requires, the answer is CT of the ass. abdomen because we need to be concerned for organ damage because ribs 9 through 12 cover the liver on the right and the spleen on the left and 12 covers the kidneys in the back. 75. Recurrent intussusception in a baby should be valued with? The answer is scintigraphy. Question 76. A woman undergoes a hip dislocation, pulses are intact, no signs of hematoma or fracture. What's the next step? We want to go with closed reduction, the open ones if we see a fracture and CT angiogram if there's a hematoma or we see no pulses. 77. In refeeding syndrome we see muscle weakness arrhythmias. For example, when an anorexic adolescent put on a feeding tube, which lab value is seen, and we see the hypos, hypophosphatemia, and hypokalemia. This is due to insulin secretion, which promotes cellular uptake of these electrolytes, hypokalemia, hypophosphatemia. 78, besides a detailed history of PE, Pre-operative evaluation in a young patient with no significant medical history, undergoing a non-major surgery, requires, and the answer is, nothing. If, however, they have a MACE risk of at least 1%, meaning there's at least a 1% chance that they're going to have an adverse cardiac effect, then we would get an 8 kg. 79, high-riding patella seen in? Well, if it's high-riding, then the thing on the bottom got ripped, and that's the patella tendon. In quadriceps tendinor rupture, we would see a low-riding patella. And by the way, patients with patella tendon rupture can't extend the knee against gravity. gravity. 80. Paralytic ileus of the colon is called. That's Ogilvy syndrome. It occurs in elderly sedentary patients who have some non-abdominal surgery, and now they develop large painless abdominal distension. We treat with fluid electrolyte correction and colonoscopy to suck out the air. 81. Which brain herniation can compress the anterior cerebral artery without compromising brainstem structure function or cranial nerves? That's the one on the top, the cingulate subvalcine one. It's able to affect the anterior cerebral artery, causing, for example, contralateral leg weakness without affecting the the cranial nerves or the brainstem. 82. A cirrhotic patient with bleeding esophageal varices undergoes a portal cable shunt. He goes into a coma. So why would a cirrhotic patient go into a coma over here? Serum ammonium will reveal the etiology. That's why these patients, they go into a hepatic coma due to the ammonium. 83. The bug which most commonly causes osteomyelitis in sickle cell anemia patients is also the most common cause of, the answer is osteomyelitis and puncture wounds. This is pseudomonas. By the way, this is why sickle cell patients require clindamycin for staph coverage and ceftriaxone. that's for the pseudomonas coverage as opposed to other kids for example with osteomyelitis they don't require ceftriaxone clindamycin would be sufficient 84 peri-enal abscess with associated fever is treated with incision drainage and antibiotics for example metronidazole and ciprofloxacin other indications for antibiotics in peri-enal abscess besides fever is immunosuppression diabetes and cellulitis question 85 a smoker with a one-month history of a palpable neck mass should first be assessed with and the answer is laryngopharyngoscopy because we need to visualize for head and neck swim and cell carcinoma. 86, breast cancer in young women is generally aggressive. It doesn't show up in young women very much, but when it does, it's often aggressive. And by the way, breast cancer is virtually unknown in teens. 87, cystosarcoma phylloides is diagnosed with biopsy. Seen in women in their 30s and 40s, it grows very large, distorting the breast, and we treat it with removal. 88, ductal carcinoma in situ with lesions throughout the breast is managed with simple mastectomy. If we do local excision, it will recur. Question 89, what is given to severe thermal burn patients? And the answer is all of the above. Of course, we we give fluids because they die of dehydration, tetanus prophylaxis, and peprosome tazobactam, or meropenem, and vancomycin. Fluids, as I mentioned at the beginning, is four times surface area of the burns times weight. 90, diverticulitis, where we see abdominal pain, fever, and vomiting. That's diagnosed with, and the answer is, CT scan with contrast. We treat this condition of diverticulitis with rest and antibiotics, and we follow up with colonoscopy in six to eight weeks after resolution of the diverticulitis. If it recurs, we offer elective surgery to remove the affected zone of the diverticulitis. flail chest is defined as fracturing in at least three adjacent ribs in at least two locations. These patients have impaired breathing, often require ventilation support. 92, a patient from Vietnam with fatigued bone pain and significantly elevated AFP most likely has hepatocellular carcinoma. With metastasis to the bones, we may also see systemic symptoms and or abdominal pain. And by the way, the AFP is not always elevated. When it is, we think of hepatocellular carcinoma, especially in a patient from an endemic area. 93, Three, laryngomalacia findings include, and the answer is, omega-shaped epiglottis. The expiratory stride or no? It's an inspiratory one. In fact, the condition is defined as an inspiratory collapse of glottic tissues during inspiration, which is worse, by the way, when supine. It's seen often in babies from 48 months, and it usually dissolves by 20 months of age, so we manage it with reassurance in most cases. 94, acute severe chest pain in a short 17-year-old girl with primamineria. This is aortic dissection seen in Turner syndrome, and we confirm with CT angiogram. 95. 95, acromegaly is managed with transvenoidal pituitary surgery, just like, by the way, craniofaringioma. Radiation is second line. 96, a child with sunset eyes, paranoid syndrome, may have which tumor? Pineal gland tumor. Sunset eyes, by the way, are also seen in MS. 97, besides increased fiber intake and sitzpads. Painful anal fissures are treated with topical anesthetics and topical vasodilators, such as nifedipine or nitroglycerin. They reduce pain and facilitate healing. 98. Swelling and pain at the shoulder joint after a subacromial steroid injection is concerning for septic bursitis. By the way, the same thing can happen at a joint where it leads to septic arthritis. Only diagnose the septic bursitis with ultrasound-guided aspiration. Question 99. Fever, right upper quadrant pain, elevated LTs, and an rounded dark area shown on CD contrast of the liver in a non-traveler. So this sounds like a pyogenic liver abscess. In Iconococcus, we see thin-walled septate lesions. You might be able to see that in this small picture over here. And it's often asymptomatic, unless the lesion is about to pop. Entamoeba looks just like a pyogenic liver abscess, but it has to be in someone who traveled to these areas, such as Mexico or India. Diagnosis, by the way, of pyogenic liver abscess is per continuous aspiration, and this is also therapeutic. 100. Which form of fluid resuscitation in trauma patients, for example, hemorrhagic shock, reduces mortality the most? And the answer is whole blood does. We don't always give it because it's not always available, but there are increasing efforts to make this more possible. But even so, blood products are administered only as is needed for tissue perfusion until we do definitive treatment with surgery. When blood products are given, not whole blood, they should be administered in a ratio of 1 to 1 to 1, fresh frozen plasma to pack the red blood cells to platelets to reduce coagulopathy, which is a major cause of mortality in trauma patients. 101, pulmonary nodules, hemoptysis, and nodules weeds. So this is Osler-Weber-Rendu syndrome. and we treat these AV malformations with endovascular embolization. 102, asymptomatic simple breast cysts are managed with observation. FNA, fine needle aspiration, is only if it's symptomatic. 103, a patient undergoes surgery, for example, a cabbage without infection or an organ entry, requires which prophylactic antibiotics? So if a person undergoes surgery, they require prophylaxis against skin infections. That's why we give cefazolin. If a person's allergic to cefazolin, then we give clindamycin or vancomycin. 104. Acute severe hyponatremia is managed with hypertonic 3% saline and the maximum of 8 mEq per liter of correction in 24 hours. Now, since it's acute, we're okay with giving the 3% saline because the neural adaptations in the brain have not yet occurred. There's less of a worry in acute severe hyponatremia of osmotic demyelination syndrome. 105. Wound healing provides greatest stability to the affected area during which phase? During the maturation phase, where we see collagen 1 cross-linking. Not primary and secondary hemostasis, not during inflammation. Proliferation may be great, but there we see type 3 collagen. But remember, the strongest type of collagen is collagen type 1. 106, thyroid nodular workup begins with TSH and ultrasound. If the TSH is normal or elevated, we consider final aspiration. If the nodule is bigger than one centimeter, for example. If there's low TSH, we go with radioactive iodine scintigraphy. If there's a hot nodule, meaning there's increased isotope uptake, we call this hyperthyroidism and we treat it. Question 107. Sudden hemodynamic instability. We receive hypotension and tachycardia and ipsilateral flank plane after cardiac catheterization. This should be diagnostically confirmed with, and the answer is, imaging. Because this is concerned for retroperitoneal hematoma. So we get a CT with contrast to confirm the diagnosis. Retroperitoneal hematoma is a complication of cardiac cath. 108. CT without contrast in a head trauma patient is unrevealing. Now the MRI shows punctured hemorrhages in the white manner. What's the diagnosis? This is diffuse axonal injury. where the impairment is way worse than the imaging findings, and it's caused by acceleration or deceleration injuries, and the prognosis is very poor. 109, a 2-centimeter pulmonary nodule with irregular borders in a 67-year-old female smoker should be surgically excised. We don't reassess, we use surgically excised because there are so many risk factors over here for malignancy. And by the way, once it's 2 centimeters, it already has a 50% malignancy probability. 110, hypovolemic shock due to penetrating chest trauma leading to massive hemothorax is treated with... emergency thoracotomy. It prevents exsanguination. Tubes are when it's non-massive. 111, sudden onset severe unilateral lower abdominal pain after a 39-year-old woman exercises with pelvic-free fluid. So she exercises and now she gets this severe pain. This is a rupture of ovarian cyst. It's not always benign. It can lead to big problems. For example, if the blood continues to leak into the abdominal cavity, it can lead to hemodynamic instability and we treat it with emergency surgery in that case. Another 111, patients with thyroid storm. For example, sudden onset fever, attack cardiosphere, hypertension, die from... High output cardiac failure, where we see an increased cardiac output, decreased SVR, and an increased PCWP because there's congestion from the insane venous return, which the increased cardiac output of the heart can't even keep up with. 112. Sudden onset respiratory distress, hypoxemia, shock, and cardiac arrest after central venous catheter replacement is due to, the answer is, a venous air embolism. The air is introduced into circulation that leads to these problems, and we manage it with left lateral decubitus positioning and high flow or hyperbaric oxygen. 113, idiopathic pulmonary fibrosis is managed with smoking cessation and perfinadone and nitidaneb. These are antifibrotics. They have revolutionized management of idiopathic pulmonary fibrosis. Now, it doesn't restore lung function, but it slows the progression of the disease. 114, bloody nipple discharge. with overlying skin retraction. This is invasive ductal carcinoma. Bloody nipple discharge is also seen in intra-ductal papilloma, but there we don't see skin retractions. Skin retractions are seen in the invasive ductal carcinoma. 115, treatment of zancro diverticulum is my Myotomy, cricopharyngeal myotomy. 116, thoracic lap headache and hypotension and bilateral visual fetal defects. This is not subarachnoid hemorrhage. There we would see hypertension generally. Rather, this is pituitary apoplexy. And the hypotension is a result of the adrenal crisis in this condition. 117. Which medication should an asplenic patient be told to take if he develops fever? And the answer is amoxicillin clavulinate, Augmentin. And we tell the patient to go to the hospital to evaluate the fever after they take the antibiotics. By the way, if they have an allergy to amoxicillin clavulinate, they can take levofloxacin. 118. Acute cholangitis in the setting of the gallstone pancreatitis should be managed with? ERCP. To relieve the biliary obstruction, for example, the stone extraction, or to perhaps put it in a stent. 119. What is the treatment for a pancreatic pseudocyst? Where we see abdominal distention, well-subscribed. blue collection on cc's again in a patient with pancreatitis and the answer is endoscopic drainage and this is only if there are significant symptoms such as vomiting or pain otherwise we just give supportive care the same way we would do for the pancreatitis itself 120 a 24 year old man is brought in with a pelvic fracture he endured when he fell off a small cliff he has blood at the meatus along with hematoma and scrotum what is the first step in his urologic workup and the answer is retrograde urethrogram he has urethral injury and this is typically associated with pelvic fracture we may see blood at the meatus but of course we don't want to get a foley because it exacerbates Alright, now that I have completely lost my voice, I'm going to have some more high-yield surgery points. Here we go.

Here is your surgery attending. Now, you have to use your surgeon attending to your advantage. Now, what I mean by this is that you have to imagine him screaming at you. I mean, I know you're used to this.

But you need to imagine him screaming at you things that you want to remember. For example, the Parkland formula for burns. Four times body weight times surface area. And then you remember, for the rest of your life, not the nasty things that he would say about you, but instead, the Parkland formula for burns, and everything else that you need to know for surgery.

And with this introduction, let's begin with question one. Question one. Which medication must be stopped seven days before surgery?

Now of these choices, the only one that must be stopped seven days before surgery is naproxen, one of the NSAIDs. All NSAIDs and COX-2 inhibitors must be stopped seven days before surgery. And another one that I wrote over here are herbal supplements.

These must be stopped a week before surgery. Beta blockers don't need to be stopped. They can be continued along with calcium channel blockers.

Diuretics we stop on the day of surgery. And long-acting insulin we don't stop, but short-acting ones we do on the day of. And steroids, of course, we don't stop. We get a higher dose.

And we'll talk about stress dosing later. Let's move on. Question two.

Which intraoperative cardiac risk is worse? A, a patient with EF under 35%, or B, a patient with a transmural MI six months ago? And the answer is A, a patient with an EF under 35%.

This has a 75% mortality rate during surgery. As for B, patients with a transmural MI six months ago don't have a relatively high mortality rate, only 6%. And that's exactly why we recommend waiting until six months post-MI to get surgery.

Question three, why do surgeons beg their patients to stop smoking eight weeks before surgery? Compromised ventilation or oxygenation? And the answer is compromised ventilation. Patients with compromised ventilation may develop high PCO2 with low FEV1.

They can't get the carbon dioxide out. I wrote a note over here that smoking is the most common, by far the most common cause of increased pulmonary risk during surgery. And that's why we convince patients to no avail to stop smoking, to use nicotine replacement therapy, and if not, bupropion or varenicline. Question four.

Which person has the highest risk of dying during surgery? A patient with significant aortic stenosis, a patient over 70, or a patient with JVD? And the answer is C, a patient with JVD, because signs of heart failure, JVD, which represents heart failure, is the absolute worst finding. And if possible, we treat with ACE inhibitors, beta blockers. Question five, surgical timeouts.

I'm not going to read the whole thing because the answer is all of the above are true. They occur just prior to skin incision. It includes the patient identity, and it includes the site and laterality, i.e. the side of the operation. Now I wrote other patient safety reminders on the bottom over here.

Preoperative patient identity verification in the holding area, along with verification of operation type and laterality, documentation by at least two providers. And we use permanent markers during surgery for operative site, and we never mark non-operative sites. Question six, what are causes of post-operative fever? And the answer is all of the above. We know the mnemonic.

Now I wrote on the top over here that atelectasis is the most common cause of fever first day post-op. And we prevent this with antidepressants. deep breathing exercises. And if we need to, we go with bronchoscopy. Pneumonia follows three days later if the atelectasis is not resolved.

UTI presents usually on day three, TBT on day five, wound infection on day seven, and abscess post-operative day 10 to 15. Question seven, wounds that have been freshly debrided are treated with wet to dry dressings. We want to kind of dry them out. It's only once they're healthy and we have beautiful granulation tissue do we get moisture retaining dressings. Question eight.

What's the treatment for a linear skull fracture? And the answer is observation. If they're linear, we don't go with surgery.

That's only with open fractures. Question nine. A patient develops sudden pleuritic chest pain seven days after surgery. The APG shows hypoxemia and hypocapnia. This sounds like pulmonary embolism.

After confirming the diagnosis, what is the next step? And the answer is we give heparin. We only go with the IVC filter if the P's recur during anticoagulation or if the anticoagulation is contraindicated.

Question 10. which cranial nerve can be damaged during nissen fundoplication to treat GERD? And the answer is, during this procedure, the vagus nerve, cranial nerve 10, can be damaged, and this leads to gastroparesis, in which we see early satiety, bloating, and weight loss. And management includes dietary modifications such as small meals low in fat and metoclopramide, which promotes motility. 11. In paralytic ileus, what do we see?

Bowel sounds are absent. We don't hear bowel sounds. There's usually not pain, but bowel sounds are absent. And here we just have an x-ray.

of paralytic ileus. I wrote a note over here that paralytic ileus is prolonged by hypokalemia. In this condition, there may be mild distension, but it's usually self-regulatory. So conservative management and serial exams is what we do. Question 12. The physician thought it was paralytic ileus, but now it's been six days of neural resolution.

What's the most likely diagnosis? And the answer is mechanical bowel obstruction due primarily to adhesions. X-rays show dilated...

loops of small bowel and aeroflu levels, and we confirm this diagnosis with an abdominal CAT scan, and we treat it with surgery. Question 13. Which of the following interventions is recommended during intubation to reduce the risk of pneumonia, for example, due to aspiration? And the answer is, all of these are appropriate.

We minimize patient transport in order to avoid movement of the endotracheal tube. We suction subglottic secretions and we elevate to a semi-recumbent position, i.e. 30 to 45 degrees elevation. All of these prevent aspiration ammonia associated with the intubation.

Question 14. Shortly after a duodenal switch operation, the patient can expect to be significantly lighter? Probably not yet. They have to wait some time. And the answer is no longer need his type 2 diabetic medications. It's quite fascinating.

Had duodenal switch. which operation kind of gets rid of diabetes in over 95% of patients. They don't need their medications anymore, and they're no longer hyperlipidemic. And why, of course, don't all diabetic patients get this, at least the ones that are obese? And the answer is because there are lots of associated issues.

15. How do bee stings lead to shock? And the answer is, bee stings lead to anaphylaxis, and there's dilation of blood vessels, in which there's reduced blood flow. And here we just compare the various types of shocks.

Question 16. A two-year-old child has chronic constipation, and when a rectal exam is done, there's explosive expulsion. pulsion of stool. Barium enema shows dilated proximal colon. What's the next step? And this is Hirschsprung's disease, and the next step is a full thickness biopsy of the rectal mucosa.

Hirschsprung's disease is also known as congenital aganglionic megacolon, because that's what's going on. It's aganglionic. Question 17. A 69-year-old man can't sleep because of pain in his calves.

He can't walk a block without getting the same pain. PE shows loss of hair, muscle atrophy, and no pulses in the foot. What's the next step? So here we see intermittent claudication.

And here we want to get an ABI, i.e. we calculate the pain. calculate the lower and upper systolic pressure. That's what ABI does.

It uses an ultrasound. We get the systolic pressure at the ankle, and we divide it by the systolic pressure in the arm. If it's less than 0.9, that's a diagnosis of PAD, peripheral artery disease, and we follow with the CT angiogram or MRI angiogram to assess and plan revascularization. Question 18. What should be avoided in a patient with acute subdural hematoma, assuming there's no midline deviation?

And the answer is warm fluid infusion. We want to give cold water infusion. We want to induce hypothermia in this hemorrhage to reduce the oxygen demand.

And by the way, I wrote a note over here that hypertonic solutions can also reduce intracranial pressure. Question 19, a patient's brought to the ED with a puncture wound and broken ribs. During positive pressure ventilation, he develops tachycardia hypotension and unilaterally absent breath sounds.

What's the diagnosis? So this is a complication of positive pressure ventilation, and that is tension pneumothorax. And that's why he has this tachycardia hypotension and the absent breath sounds on one side. In this condition, we temporarily managed with needle compression, and formal chest tubes are placed in later. Now I want to draw your attention to this chart I made over here, where I compare regular pneumothorax with tension pneumothorax.

In tension pneumothorax, we see air in the pleural space through a one-way leak. Now in this condition, we contrast with atelectasis, because in atelectasis, the tracheal deviation is toward the affected lung, because the problem is the collapse of the lung. As opposed to in tension pneumothorax, we see tracheal deviation away from the evolved lung, because we see a balloon filling up on the affected side. Question.

Question 20. A 19-year-old woman endures a motorcycle accident. She has rib fractures. Two days later, she suddenly develops hypoxemia and hypercapnia.

The CXR is shown. What's the diagnosis? So over here, we see this whitening over here, and this represents a pulmonary contusion. Pulmonary contusion doesn't only happen at the time of the injury.

It can happen up to 48 hours later. It's delayed in 40% of cases. This is not pulmonary embolism. Pulmonary embolism, chest x-ray, often doesn't show much, but we may see various findings, such as the Fleischner sign. and the Hampton hump.

And in fat embolism, we perhaps see bilateral haziness on chest x-ray, but we don't see this one-sided whitening. Question 21. If peripheral ivy lines are unsuccessful in the trauma setting, what's the next step in adults? Or intraosseous, do we go with a percutaneous femoral vein catheter?

Or intraosseous cannulation of the proximal tibia? And the answer is percutaneous femoral vein catheter. Choice B is what we do in children under six years of age.

But in adults, we go with percutaneous femoral vein or saphenous vein catheter. Question 22. A woman develops DIC during during surgery for an intra-abdominal hemorrhage. Blood is oozing from the IV sites.

Her body temperature is normal. What's the next step? This is DIC. Do we stop the surgery or go with FFP and platelets? And the answer is we go with FFP and platelets.

We don't stop surgery simply because of DIC. That's only if hypothermia and acidosis develop. Question 23. A man gets shot in his upper lateral thigh. The bullet is embedded in the vastus lateralis, which we see in the picture.

Upon evaluation, no major vascular injury has occurred. What's the next step? And the answer is tetanus.

is prophylaxis. Our terogram is only needed if there's vascular damage, and removal of the bullet is generally not what we go with. We go with prophylaxis for tetanus. Question 24. A patient has a plural LDH of 70 and a serum of 80. So remember the formula, Leitz criteria, where we have to divide plural by serum, and if it's more than 0.6, we call it an exudative effusion, and that's what's going on over here. It's more than 0.6, so we know it's an exudative effusion.

Exudative effusions can be various things, but over here we see milky... white fluid. And that's seen in chylothorax. In empyema, we see purulent fluid. And in malignancy, we see a clear or cloudy fluid.

And in chylothorax, we see milky fluid. Another question 24. A 73-year-old woman fell. She's lying in pain with her right leg shortened and externally rotated.

This sounds like a fracture. X-rays show an intracranial fracture of the right hip. What's the best treatment?

And the answer is open reduction and post-op anticoagulation. We don't go with hip replacement. We go with open reduction.

And the post-op anticoagulation is important to prevent DVT and PE because she's not going to be moving much after the surgery. Question 25. A 34-year-old woman with a pyloric obstruction secondary to acid ingestion has protracted non-bileous and non-bloody vomiting. She's visibly dehydrated and these are her electrolytes.

What's the next step? So she keeps on vomiting because she once ingested acid and that caused ipyloric stricture. So which fluid resuscitation do we give? And the answer is normal saline with KCL because this is a metabolic alkalosis.

Remember, metabolic alkalosis is primarily caused by protracted vomiting. So since she has a metabolic alkalosis, we treat this with potassium chloride. Question 26. Which is an absolute contraindication to surgery?

Over 100 years of age? Nah. You look in the news, you'll see people who are over 100 who got surgery.

And the answer is diabetic coma. We don't perform surgery on patients in diabetic coma. We must rehydrate them, regain urinary output, and at least partially correct the acidosis and hyperglycemia before surgery. Question 27, halothane and succinylcholine can lead to, and the answer is, malignant hyperthermia.

And we treat this condition with dantrolene. This is my little mnemonic. Inhaled and sucks, malignant hyperthermia oh shucks, and dantrolene deluxe. That inhaled anesthetics and succinylcholine can lead to malignant hypothermia, and we treat with dantrolene. 28, four months after pelvic radiation therapy for cervical cancer, a woman develops rectal bleeding and telangiectasias viewed via colonoscopy.

What's the diagnosis? So this happened four months later. This is chronic radiation proctitis. Acute occurs within eight weeks. Chronic occurs after three months.

And we see bleeding and teledrectasias. 29. A 19-year-old male with a blunt lower abdominal trauma cannot void and has abdominal distension with a positive fluid wave. BUN is 63. Creatinine is 4.2.

Temperature is normal. What is the diagnosis? So since he has this positive fluid wave, we know this is a bladder rupture.

And pee, or urine, is leaking into the abdominal space. That's what's leading to this fluid wave. In small bowel rupture, we'd see fever and abdominal rigidity. But in bladder rupture, we'd see the fluid wave representing the urine and fluid floating in the abdomen. And we confirm diagnosis with retrograde cystography and we treat with surgical repair.

30. Fever, flank pain, and dark urine 10 minutes after blood transfusion. This is acute hemolytic transfusion reaction. It has the classic triad of fever, flank pain, and dark red urine. The first step is the Coombs test and this condition may lead to acute kidney injury or DIC.

31. large diabetic foot ulcers require which of the following? Pressurizing the wound? No, we try to give it space. And the answer is imaging.

With x-ray MRI, we want to rule out osteomyelitis because diabetic foot ulcers can lead to osteomyelitis. Other indications include if there are elevated inflammatory markers or associated fever. 32. What is the greatest risk factor for spinal amygdoma? In which we would see, for example, spinal cord compression leading to bilateral arm and leg weakness. And the answer is radiation is the greatest risk factor.

33. Older age is also a risk. as well as female, and NF2, neurofibromatosis type 2. But radiation, exposure to ionizing radiation, is the greatest risk factor. 33. A 23-year-old woman got punched in the left eye by her boyfriend, who is now detained by the cops. Which of the following is an indication for CT scan of the orbit?

And the answer is, all of these are indications for CT scan of the orbit. A palpable bony step-off? That's a sign of fracture.

Limited or painful ocular movements, as well as decreased visual acuity. Question 34. Acute angle closure glaucoma. where we see sudden onset headache, nausea, ocular pain, decreased vision, and conjunctival redness is initially treated systemically with, and the answer is, carbonic anhydrase inhibitor, acetazolamide, in addition to the topicals, timolol, apriclonidine, and pilocarpine. But the definitive treatment is laser iridotomy. 35, the first step in managing acute upper GI bleed is to establish vascular access with two large bore IV lines, 14 or 16G.

These are the big ones that we want to use. Again, two of them. So if you only have one of them, The answer would be to add another. Question 36. A 64-year-old woman has right heel pain worsened by passive dorsiflexion of the big toe.

Foot x-ray shows a calcaneal bone spur, but no fracture. What's the next step? So this sounds like plantar fasciitis. And the next step.

This heel inserts, that's first line. Along with activity modification and stretches, it's first line for plantar fasciitis. These spurs, by the way, are seen often in patients with plantar fasciitis. Steroid injection would be second line if the initial treatments with activity modification and stretches didn't work. Question 37. A week after Roux-en-Y bypass, a 37-year-old woman develops fever abdominal pain along with tachypnea, heart rate is 125, and what's the next step?

So here we need to be concerned about a leak of the anastomosis. We gotta get a CT scan to assess for anastomotic leak. Question 38. Which medication is contraindicated in a patient with a history of aortic aneurysm? And the answer is levofloxacin because fluoroquinolones not only have a risk of tendon rupture but also of aortic aneurysm.

Question 39. The ideal placement of a central venous catheter should be in the... Lower SVC Smaller veins predisposed to venous perforation. That's why we go with the lower SVC. We need to get a portable chest x-ray to confirm the placement.

And this should be just proximal to the angle between the trachea and the right main stem bronchus. Question 40. A patient has symptoms of There we see high-pitched bowel sounds and no signs of peritonitis, such as guarding. 41. A patient has signs of a spinal epidural abscess, i.e. back pain, fever, in an immunocompromised patient.

What's the next step? And the answer is MRI with contrast. That allows us to properly see the tissues and the extent of infection. By the way, fever is not always present in spinal epidural lapis. That's just important to know.

A tender mass near the top of the coccyx in a hairy 25-year-old man is treated with? There's, of course, pilonidal cyst, and we treat this with drainage, along with excision of sinus tracts. Question 43. Conductive hearing loss, for example, improved understanding in noisy places, in young patients with a family history, is due to?

The answer to this is stapes stiffening, because this is otosclerosis. It may be either sporadic or, as in this case, autosomal dominant. 44. After laparoscopic surgery, a patient develops fever abdominal pain with guarding and leukocytosis. So what's the next step? These findings...

should be further assessed with abdominal CAT scan to assess for laparoscopy-associated bowel injury, for example, perforation or burn of the instruments used during the procedure. Question 45. Asymptomatic biliary cysts are treated with surgery due to a huge risk for malignancies of the biliary ducts, gallbladder, and pancreas. 46. CT imaging of ischemic colitis.

For example, a patient has abdominal pain, hematocasia, diarrhea, and lactic acidosis shows, and the answer is it shows colonic wall thickening and air in the bowel wall. That's what we. what we see in CT imaging of ischemic colitis.

We treat ischemic colitis with fluids, antibiotics, and surgical resection is done if necrosis develops. Question 47. Which features favor purulent pericardial effusion over viral? Why would we think that it's purulent? And the answer is we see a severely sick patient with marked leukocytosis.

We don't see these in pericardial effusion. But as for choice B, distant heart sounds and fever, that's seen in both conditions. 48. A young patient with decreased urinary flow and a feeling of incomplete emptying.

That is due to urethral stricture. That's why a young patient could develop. Question 49. What is the cause of kidney stones in Crohn's disease or gastric bypass?

And the answer is, patients with these conditions get hyperoxaluria. And what happens is, fatty acids aren't absorbed in these conditions. So calcium binds the fatty acids.

So calcium is not available to bind oxalate. Oxalate can now be reabsorbed, and it's dumped into the urine, leading to hyperoxaluria. Now the oxalate in the urine combines with the calcium to produce the stones.

Question 50. High PaCO2 in a surgical patient reflects... And the answer... Answer is alveolar hypoventilation. In other pulmonary conditions, such as PE, pleural effusion, and pulmonary edema, there's a decrease in PaCO2, not an increase.

And that due to tachypnea. 51, muscular rigidity, altered mental status, and fever five days after surgery are concerning for? And the answer is haloperidol exposure. This is not malignant hyperthermia because we're talking about five days later.

We're talking about neuroleptic malignant syndrome, which occurs days later with similar symptoms of malignant hyperthermia. And the treatment is to stop the antipsychotic or what's ever causing it, give benzos and dantrolene if refractory. Question 52, how is acute triglyceride-induced pancreatitis managed? And the answer is insulin. We give insulin.

This manages the triglyceridemia faster than fibrates. And we give dextrose to prevent hypoglycemia. Question 53, fascial dehiscence with evisceration is treated with emergency surgery. This is a problem. There's a risk of strangulation.

54, pain reproduced by medial lateral squeezing of the calcaneus. This is calcaneal stress factor due to repetitive microchroma. and we confirm with imaging such as x-ray or MRI. You can take a look at other choices over here. 55. Hammy produces an aphasia in a child who fell while sucking on a lollipop, so what we're concerned with over here is a carotid artery dissection.

It can happen while a child is also brushing his teeth. And we confirm with MR or CT angiogram. Question 56. Abrupt onset scrotal pain in an adolescent with absent cremastaric reflex. This is 10. Vesticular torsion, and the Doppler confirms the diagnosis. What's the next step?

We want to go with surgical detorsion. We only go with the manual one if surgical detorsion is not available yet, but if it's available, we want to go with surgery. 57, recurrent fever, abdominal pain, and shortness of breath a week after laparoscopic appendectomy. So what are these symptoms concerning for? Abscess, a subphrenic abscess.

58, if melanoma is suspected, for example, we see asymmetry, border irregularity, color variation, diameter more than six, and evolving, or we see the ugly duckling sign, what's the next step? So here we suspect melanoma. The answer is full thickness excisional biopsy with initial margins of one to three millimeters of normal tissue. This is versus nasal cell carcinoma where first line management is with MOSE or a not a full thickness excisional biopsy. 59, small bowel obstruction with hemodynamic instability.

What's the next step? Urgent surgical exploration. For example, you would see in a case of hemodynamic instability, fever, tachycardia, hypotension, acidosis.

60, bladder cancer, where we would see hematuria, dysuria, and flank pain. This is suspected. What's the next step?

We want to go with histoscopy. I'm not really sure why I wrote these choices of a prostate over here, but the point is we go with histoscopy in order to evaluate for bladder cancer. 61, abrupt onset dyspnea, cough, and hypoxemia in an hour after intubation. Complicated by emesis, was cleared with suction. So here we have aspiration.

We manage this with supportive care. This is chemical pneumonitis aspiration due to inhalation of gastric acid, which can occur within minutes to hours of intubation. Aspiration ammonia, however, would not develop an hour later.

That would develop days later, and that's treated with antibiotics. Thanks. For example, ceftriaxone and azithromycin. Question 62. What is contraindicated in a patient who develops MI two days after surgery? And the answer is TPA.

Angioplasty and stenting are not contraindicated in a patient who develops MI after surgery, but TPA is. And I wrote a note over here that remember, an MI, myocardial infarction, can occur during operations. 63. A 45-year-old woman has had her gallbladder removed last year. Now she has persistent abdominal pain, elevated LFTs, and CBD dilation ultrasound. What's the next step?

So we want to go with ERCP to diagnose the etiology of her post-cholestectomy syndrome. She had her gallbladder removed. Now she has this syndrome. We want to evaluate the etiology. 64, patients with chronic pancreatitis often require supplemental.

The answer is insulin and a pancreatic enzyme replacement. The pancreas is not working properly, so we need to replace what it's supposed to provide. Now, I wrote a note over here, but the pain that people with chronic pancreatitis experience is resistant to most modalities of therapies, and it's very debilitating. 65. What separates acute from subacute cardiac tamponade? And the answer is cardiac silhouette.

JVD, hypotension, and distant heart sounds, Beck's triad, are seen in both acute and subacute forms, but the cardiac silhouette is generally associated only with subacute. It occurs after days to weeks. Here, the cardiac silhouette is going to be abnormal, as opposed to in the acute one.

66. Perennial skin swelling, tenderness, and crepitus with hypotension is initially managed with emergency surgery because over here we're dealing with fornay gangrene which is very deadly and we debride immediately 67 patients on total parental nutrition develop gallstones due to so a person's not eating through their mouth why do they develop gallstones and the answer is gallbladder stasis now the reason for this is that the normal stimulus for ckk release and gallbladder contraction is absent in these patients bile becomes more concentrated since the gallbladder is responsible normally for absorbing water from the bile and that's why we have this sludge and gallstones develop 68 which findings support pseudogynocomastia over true gynecomastia? Pseudogynocomastia is when a person's just very heavy, so it looks like they have big breasts. They don't really have gynecomastia. And the answer is signs of pseudogynocomastia include soft, fatty mass that are non-tender, as opposed to true gynecomastia, they're mobile.

We see rubbery mass and the breasts may be tender. And we treat pseudogynocomastia, of course, with weight loss. 69, the most important thing to do in rib fracture management. After chest x-ray rules that pneumothorax and effusion is analgesics. We want to provide pain relief.

This ensures appropriate ventilation and reduces the risk, not the risk, the risk of pneumonia. Question 70. A patient with asymptomatic open and global coma should be managed with, how do we treat asymptomatic? open angle glaucoma.

Again, this is not painful. We find it often incidentally, and the answer is topical prostaglandins. Remember, we treat closed angle glaucoma with acetazolamide and other medications, but this one, open angle, we treat with topical prostaglandins. For example, etanoprost, beta blockers are second line, and laser trabeculoplasty is third step, third line. 71, a 25-year-old female has a palpable breast mask diagnosed as a fibroadenoma.

What's the next step? So we want to go with ultrasound. Usually in adolescence, we reassure them, but there are more more reasons to image an adult. And removal is optional.

Women want them out, so we're happy to help them. But if the malignancy is suspected, we also get a mammogram. 72, empyema is our most commonly caused by, and the answer is strep and anaerobes. And that's why it smells bad.

73, stress hyperglycemia is treated with nothing. Only when the glucose goes above 190 milligrams or 200 are we concerned. But if it's at 150, we're totally fine with that.

74, fractures of ribs, 9 through 12, visualized via chest x-ray requires, the answer is CT of the ass. abdomen because we need to be concerned for organ damage because ribs 9 through 12 cover the liver on the right and the spleen on the left and 12 covers the kidneys in the back. 75. Recurrent intussusception in a baby should be valued with?

The answer is scintigraphy. Question 76. A woman undergoes a hip dislocation, pulses are intact, no signs of hematoma or fracture. What's the next step?

We want to go with closed reduction, the open ones if we see a fracture and CT angiogram if there's a hematoma or we see no pulses. 77. In refeeding syndrome we see muscle weakness arrhythmias. For example, when an anorexic adolescent put on a feeding tube, which lab value is seen, and we see the hypos, hypophosphatemia, and hypokalemia. This is due to insulin secretion, which promotes cellular uptake of these electrolytes, hypokalemia, hypophosphatemia.

78, besides a detailed history of PE, Pre-operative evaluation in a young patient with no significant medical history, undergoing a non-major surgery, requires, and the answer is, nothing. If, however, they have a MACE risk of at least 1%, meaning there's at least a 1% chance that they're going to have an adverse cardiac effect, then we would get an 8 kg. 79, high-riding patella seen in?

Well, if it's high-riding, then the thing on the bottom got ripped, and that's the patella tendon. In quadriceps tendinor rupture, we would see a low-riding patella. And by the way, patients with patella tendon rupture can't extend the knee against gravity. gravity. 80. Paralytic ileus of the colon is called.

That's Ogilvy syndrome. It occurs in elderly sedentary patients who have some non-abdominal surgery, and now they develop large painless abdominal distension. We treat with fluid electrolyte correction and colonoscopy to suck out the air.

81. Which brain herniation can compress the anterior cerebral artery without compromising brainstem structure function or cranial nerves? That's the one on the top, the cingulate subvalcine one. It's able to affect the anterior cerebral artery, causing, for example, contralateral leg weakness without affecting the the cranial nerves or the brainstem. 82. A cirrhotic patient with bleeding esophageal varices undergoes a portal cable shunt.

He goes into a coma. So why would a cirrhotic patient go into a coma over here? Serum ammonium will reveal the etiology.

That's why these patients, they go into a hepatic coma due to the ammonium. 83. The bug which most commonly causes osteomyelitis in sickle cell anemia patients is also the most common cause of, the answer is osteomyelitis and puncture wounds. This is pseudomonas. By the way, this is why sickle cell patients require clindamycin for staph coverage and ceftriaxone. that's for the pseudomonas coverage as opposed to other kids for example with osteomyelitis they don't require ceftriaxone clindamycin would be sufficient 84 peri-enal abscess with associated fever is treated with incision drainage and antibiotics for example metronidazole and ciprofloxacin other indications for antibiotics in peri-enal abscess besides fever is immunosuppression diabetes and cellulitis question 85 a smoker with a one-month history of a palpable neck mass should first be assessed with and the answer is laryngopharyngoscopy because we need to visualize for head and neck swim and cell carcinoma.

86, breast cancer in young women is generally aggressive. It doesn't show up in young women very much, but when it does, it's often aggressive. And by the way, breast cancer is virtually unknown in teens. 87, cystosarcoma phylloides is diagnosed with biopsy. Seen in women in their 30s and 40s, it grows very large, distorting the breast, and we treat it with removal.

88, ductal carcinoma in situ with lesions throughout the breast is managed with simple mastectomy. If we do local excision, it will recur. Question 89, what is given to severe thermal burn patients?

And the answer is all of the above. Of course, we we give fluids because they die of dehydration, tetanus prophylaxis, and peprosome tazobactam, or meropenem, and vancomycin. Fluids, as I mentioned at the beginning, is four times surface area of the burns times weight.

90, diverticulitis, where we see abdominal pain, fever, and vomiting. That's diagnosed with, and the answer is, CT scan with contrast. We treat this condition of diverticulitis with rest and antibiotics, and we follow up with colonoscopy in six to eight weeks after resolution of the diverticulitis. If it recurs, we offer elective surgery to remove the affected zone of the diverticulitis. flail chest is defined as fracturing in at least three adjacent ribs in at least two locations.

These patients have impaired breathing, often require ventilation support. 92, a patient from Vietnam with fatigued bone pain and significantly elevated AFP most likely has hepatocellular carcinoma. With metastasis to the bones, we may also see systemic symptoms and or abdominal pain. And by the way, the AFP is not always elevated. When it is, we think of hepatocellular carcinoma, especially in a patient from an endemic area.

93, Three, laryngomalacia findings include, and the answer is, omega-shaped epiglottis. The expiratory stride or no? It's an inspiratory one.

In fact, the condition is defined as an inspiratory collapse of glottic tissues during inspiration, which is worse, by the way, when supine. It's seen often in babies from 48 months, and it usually dissolves by 20 months of age, so we manage it with reassurance in most cases. 94, acute severe chest pain in a short 17-year-old girl with primamineria.

This is aortic dissection seen in Turner syndrome, and we confirm with CT angiogram. 95. 95, acromegaly is managed with transvenoidal pituitary surgery, just like, by the way, craniofaringioma. Radiation is second line. 96, a child with sunset eyes, paranoid syndrome, may have which tumor?

Pineal gland tumor. Sunset eyes, by the way, are also seen in MS. 97, besides increased fiber intake and sitzpads. Painful anal fissures are treated with topical anesthetics and topical vasodilators, such as nifedipine or nitroglycerin. They reduce pain and facilitate healing.

98. Swelling and pain at the shoulder joint after a subacromial steroid injection is concerning for septic bursitis. By the way, the same thing can happen at a joint where it leads to septic arthritis. Only diagnose the septic bursitis with ultrasound-guided aspiration.

Question 99. Fever, right upper quadrant pain, elevated LTs, and an rounded dark area shown on CD contrast of the liver in a non-traveler. So this sounds like a pyogenic liver abscess. In Iconococcus, we see thin-walled septate lesions.

You might be able to see that in this small picture over here. And it's often asymptomatic, unless the lesion is about to pop. Entamoeba looks just like a pyogenic liver abscess, but it has to be in someone who traveled to these areas, such as Mexico or India. Diagnosis, by the way, of pyogenic liver abscess is per continuous aspiration, and this is also therapeutic.

100. Which form of fluid resuscitation in trauma patients, for example, hemorrhagic shock, reduces mortality the most? And the answer is whole blood does. We don't always give it because it's not always available, but there are increasing efforts to make this more possible. But even so, blood products are administered only as is needed for tissue perfusion until we do definitive treatment with surgery. When blood products are given, not whole blood, they should be administered in a ratio of 1 to 1 to 1, fresh frozen plasma to pack the red blood cells to platelets to reduce coagulopathy, which is a major cause of mortality in trauma patients.

101, pulmonary nodules, hemoptysis, and nodules weeds. So this is Osler-Weber-Rendu syndrome. and we treat these AV malformations with endovascular embolization.

102, asymptomatic simple breast cysts are managed with observation. FNA, fine needle aspiration, is only if it's symptomatic. 103, a patient undergoes surgery, for example, a cabbage without infection or an organ entry, requires which prophylactic antibiotics?

So if a person undergoes surgery, they require prophylaxis against skin infections. That's why we give cefazolin. If a person's allergic to cefazolin, then we give clindamycin or vancomycin. 104. Acute severe hyponatremia is managed with hypertonic 3% saline and the maximum of 8 mEq per liter of correction in 24 hours.

Now, since it's acute, we're okay with giving the 3% saline because the neural adaptations in the brain have not yet occurred. There's less of a worry in acute severe hyponatremia of osmotic demyelination syndrome. 105. Wound healing provides greatest stability to the affected area during which phase?

During the maturation phase, where we see collagen 1 cross-linking. Not primary and secondary hemostasis, not during inflammation. Proliferation may be great, but there we see type 3 collagen.

But remember, the strongest type of collagen is collagen type 1. 106, thyroid nodular workup begins with TSH and ultrasound. If the TSH is normal or elevated, we consider final aspiration. If the nodule is bigger than one centimeter, for example.

If there's low TSH, we go with radioactive iodine scintigraphy. If there's a hot nodule, meaning there's increased isotope uptake, we call this hyperthyroidism and we treat it. Question 107. Sudden hemodynamic instability.

We receive hypotension and tachycardia and ipsilateral flank plane after cardiac catheterization. This should be diagnostically confirmed with, and the answer is, imaging. Because this is concerned for retroperitoneal hematoma. So we get a CT with contrast to confirm the diagnosis.

Retroperitoneal hematoma is a complication of cardiac cath. 108. CT without contrast in a head trauma patient is unrevealing. Now the MRI shows punctured hemorrhages in the white manner. What's the diagnosis?

This is diffuse axonal injury. where the impairment is way worse than the imaging findings, and it's caused by acceleration or deceleration injuries, and the prognosis is very poor. 109, a 2-centimeter pulmonary nodule with irregular borders in a 67-year-old female smoker should be surgically excised.

We don't reassess, we use surgically excised because there are so many risk factors over here for malignancy. And by the way, once it's 2 centimeters, it already has a 50% malignancy probability. 110, hypovolemic shock due to penetrating chest trauma leading to massive hemothorax is treated with... emergency thoracotomy. It prevents exsanguination.

Tubes are when it's non-massive. 111, sudden onset severe unilateral lower abdominal pain after a 39-year-old woman exercises with pelvic-free fluid. So she exercises and now she gets this severe pain. This is a rupture of ovarian cyst.

It's not always benign. It can lead to big problems. For example, if the blood continues to leak into the abdominal cavity, it can lead to hemodynamic instability and we treat it with emergency surgery in that case.

Another 111, patients with thyroid storm. For example, sudden onset fever, attack cardiosphere, hypertension, die from... High output cardiac failure, where we see an increased cardiac output, decreased SVR, and an increased PCWP because there's congestion from the insane venous return, which the increased cardiac output of the heart can't even keep up with.

112. Sudden onset respiratory distress, hypoxemia, shock, and cardiac arrest after central venous catheter replacement is due to, the answer is, a venous air embolism. The air is introduced into circulation that leads to these problems, and we manage it with left lateral decubitus positioning and high flow or hyperbaric oxygen. 113, idiopathic pulmonary fibrosis is managed with smoking cessation and perfinadone and nitidaneb. These are antifibrotics.

They have revolutionized management of idiopathic pulmonary fibrosis. Now, it doesn't restore lung function, but it slows the progression of the disease. 114, bloody nipple discharge.

with overlying skin retraction. This is invasive ductal carcinoma. Bloody nipple discharge is also seen in intra-ductal papilloma, but there we don't see skin retractions.

Skin retractions are seen in the invasive ductal carcinoma. 115, treatment of zancro diverticulum is my Myotomy, cricopharyngeal myotomy. 116, thoracic lap headache and hypotension and bilateral visual fetal defects. This is not subarachnoid hemorrhage.

There we would see hypertension generally. Rather, this is pituitary apoplexy. And the hypotension is a result of the adrenal crisis in this condition.

117. Which medication should an asplenic patient be told to take if he develops fever? And the answer is amoxicillin clavulinate, Augmentin. And we tell the patient to go to the hospital to evaluate the fever after they take the antibiotics.

By the way, if they have an allergy to amoxicillin clavulinate, they can take levofloxacin. 118. Acute cholangitis in the setting of the gallstone pancreatitis should be managed with? ERCP. To relieve the biliary obstruction, for example, the stone extraction, or to perhaps put it in a stent.

119. What is the treatment for a pancreatic pseudocyst? Where we see abdominal distention, well-subscribed. blue collection on cc's again in a patient with pancreatitis and the answer is endoscopic drainage and this is only if there are significant symptoms such as vomiting or pain otherwise we just give supportive care the same way we would do for the pancreatitis itself 120 a 24 year old man is brought in with a pelvic fracture he endured when he fell off a small cliff he has blood at the meatus along with hematoma and scrotum what is the first step in his urologic workup and the answer is retrograde urethrogram he has urethral injury and this is typically associated with pelvic fracture we may see blood at the meatus but of course we don't want to get a foley because it exacerbates Alright, now that I have completely lost my voice, I'm going to have some more high-yield surgery points.

Here we go.

Transcript for:Comprehensive Surgical Review Notes

Transcript for:
Comprehensive Surgical Review Notes