Clinical Surgery Flashcards

24 sample cards from the Surgery deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. Define massive hemothorax and its indications for thoracotomy.

   Massive hemothorax is $>1500\,\text{mL}$ blood on initial chest tube drainage. Thoracotomy indicated for initial drainage $>1500\,\text{mL}$, or ongoing $>200\,\text{mL/hr}$ for 2-4 hours, or persistent need for transfusion.

2. What defines flail chest and its underlying physiologic problem?

   Two or more consecutive ribs fractured in two or more places, creating a free segment with paradoxical movement. The main morbidity is the underlying pulmonary contusion causing hypoxia; treated with analgesia and pulmonary support.

3. What is the Cushing reflex and what does it indicate?

   The triad of hypertension (widened pulse pressure), bradycardia, and irregular respirations—a sign of raised intracranial pressure and impending brain herniation.

4. Compare epidural and subdural hematoma in terms of vessel, CT appearance, and clinical course.

   Epidural: middle meningeal artery, biconvex (lens-shaped) not crossing sutures, classic lucid interval. Subdural: bridging veins, crescent-shaped crossing sutures, more common in elderly/alcoholics with slower onset.

5. What is the initial management of a positive FAST with hemodynamic instability in abdominal trauma?

   Emergent exploratory laparotomy. Hemodynamically stable patients with positive imaging may undergo CT and possible nonoperative management or angioembolization.

6. Which solid organ is most commonly injured in blunt abdominal trauma, and what grades favor nonoperative management?

   The spleen. Low-grade injuries (AAST grades I-III) in hemodynamically stable patients are often managed nonoperatively $\pm$ angioembolization; high grades or instability favor splenectomy.

7. What vaccinations are required after splenectomy and why?

   Vaccines against encapsulated organisms: Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b—to prevent overwhelming post-splenectomy infection (OPSI). Give ideally 2 weeks before elective splenectomy or 2 weeks postop.

8. What is the Ottawa Ankle Rule and its purpose?

   A clinical decision rule to determine need for ankle/foot X-rays: image if pain in the malleolar zone plus bony tenderness at the posterior edge/tip of either malleolus, or inability to bear weight for 4 steps. Reduces unnecessary radiographs.

9. What is compartment syndrome and the '6 Ps' of its presentation?

   Elevated pressure within a fascial compartment compromising perfusion. The 6 Ps: Pain (out of proportion, worse on passive stretch), Paresthesia, Pallor, Poikilothermia, Pulselessness (late), and Paralysis (late). Treated with emergent fasciotomy.

10. At what compartment pressure or delta pressure is fasciotomy indicated?

    Absolute compartment pressure $>30\,\text{mmHg}$, or a delta pressure (diastolic BP minus compartment pressure) $<30\,\text{mmHg}$. Clinical suspicion outweighs numbers.

11. What is the difference between an open (compound) and closed fracture, and how does management differ?

    Open fracture communicates with the external environment through broken skin; closed fracture does not. Open fractures require urgent antibiotics, tetanus prophylaxis, and surgical irrigation/debridement due to infection risk (Gustilo-Anderson classification).

12. What is the classic triad and diagnostic triad for achalasia, and what is the surgical treatment?

    Presentation: dysphagia to solids and liquids, regurgitation, weight loss. Manometry shows failure of LES relaxation and absent peristalsis; barium swallow shows 'bird's beak.' Surgical treatment: laparoscopic Heller myotomy with partial fundoplication (or POEM).

13. What is Boerhaave syndrome and its typical presentation?

    Spontaneous transmural esophageal rupture from forceful vomiting, usually the left posterolateral distal esophagus. Presents with Mackler triad: vomiting, chest pain, and subcutaneous emphysema. Requires urgent surgical repair.

14. What operation is standard for a Zenker diverticulum, and where does it arise?

    A pharyngoesophageal (pulsion, false) diverticulum arising through Killian's triangle above the cricopharyngeus. Treatment: cricopharyngeal myotomy with diverticulectomy or diverticulopexy (or endoscopic stapling).

15. What is the modified Johnson classification of gastric ulcers by location and acid status?

    Type I: lesser curve/incisura (normal-low acid); Type II: gastric body + duodenal (high acid); Type III: prepyloric (high acid); Type IV: high lesser curve near GE junction (normal-low acid); Type V: NSAID-related, anywhere.

16. What are the risk factors for gastric adenocarcinoma and the surgical margins required?

    Risk factors: H. pylori, chronic atrophic gastritis, pernicious anemia, smoked/salted foods, smoking, prior gastric surgery. Surgery requires gastrectomy with $\geq 5\,\text{cm}$ margins and D2 lymphadenectomy.

17. State Charcot's triad and Reynolds' pentad for cholangitis.

    Charcot's triad: fever, right upper quadrant pain, and jaundice. Reynolds' pentad adds hypotension and altered mental status, indicating suppurative cholangitis requiring urgent biliary decompression.

18. What are the components of Calot's triangle and its surgical significance?

    Bounded by the cystic duct, common hepatic duct, and inferior liver edge; contains the cystic artery and Lund's node. Identifying the 'critical view of safety' here prevents common bile duct injury during cholecystectomy.

19. How is acute pancreatitis diagnosed, and what two scoring systems assess severity?

    Diagnosis requires 2 of 3: characteristic epigastric pain radiating to back, lipase/amylase $>3\times$ upper limit of normal, or characteristic imaging. Severity assessed by Ranson's criteria and APACHE II (also BISAP).

20. What is the Whipple procedure (pancreaticoduodenectomy) and what structures are removed?

    Resection for periampullary/pancreatic head tumors: removal of the pancreatic head, duodenum, gallbladder, common bile duct, and often the gastric antrum, followed by pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy.

21. What is the difference between an anterior resection and abdominoperineal resection (APR) for rectal cancer?

    Anterior/low anterior resection removes the tumor with restoration of bowel continuity, preserving the anal sphincter. APR removes the rectum and anus with a permanent end colostomy, used for very low tumors involving the sphincter.

22. What is the recommended surgical margin and lymph node yield for colon cancer resection?

    Proximal and distal bowel margins of $\geq 5\,\text{cm}$ with high ligation of the feeding vessel; a minimum of 12 lymph nodes should be examined for adequate staging.

23. What is the CHA2DS2-VASc score used for, and which cardiac surgery addresses refractory AF?

    It estimates stroke risk in atrial fibrillation to guide anticoagulation (Congestive heart failure, Hypertension, Age $\geq75$ [2 pts], Diabetes, Stroke/TIA [2 pts], Vascular disease, Age 65-74, Sex female). The surgical Cox-Maze procedure treats refractory AF.

24. For an abdominal aortic aneurysm, at what diameter is elective repair indicated and what is the classic ruptured-AAA triad?

    Elective repair when diameter $\geq 5.5\,\text{cm}$, rapid expansion ($>0.5\,\text{cm}$ in 6 months), or symptomatic. Ruptured AAA triad: hypotension, pulsatile abdominal mass, and abrupt back/flank pain.

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