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Surgery Review 8
SR 8: Urology, Gyn, Neurosurgery, Ortho, Pediatric, Statistics
| Question | Answer |
|---|---|
| Describe the anatomy of the renal vasculature | Anterior to posterior – reval vein, renal artery, renal pelvis; right renal artery crosses posterior to IVC |
| What are the most common type of kidney stones? | oxalate - especially after small bowel resection |
| What type of kidney stones are associated with proteus infection? | struvite stones, "staghorn" - proteus produces urease |
| What are markers for non-seminomatous testicular cancer? | AFP and B-HCG |
| What tumor markers are elevated in a seminoma? | Often none (10% have B-HCG elevation, should not have AFP elevation) |
| What is the surgical approach to biopsy a testicular mass? | Orchiectomy via inguinal incision. Never trans-scrotal |
| What stage seminomas get RT? Chemotherapy? | All stages - very radiosensitive, Node+ get platinum-based chemo |
| What are the long term effects of cryptorchidism? | increased testicular cancer, orchiopexy can increase fertility but not decrease cancer risk |
| What is the treatment of nonseminotamous testicular cancer? | Stage I – orchiectomy and prophylactic retroperitoneal lymph node dissection, Stage II+ also get XRT, chemo, and resection of residual masses |
| How is PSA level affected after prostatectomy? | Should go to 0 within 3 weeks post surgery |
| What is the classic triad of renal cell carcinoma? | abd pain (capsule stretching), mass, hematuria |
| Where is erythropoetin made? What stimulates its production? | 95% made in kidney, stimulated by hypoxia, (decreased production in ESRD) |
| What causes fever and hypertension in a renal cell carcinoma patient? | Increased erythropoetin - erythrocytosis |
| What is the treatment of renal cell carcinoma with extension into the IVC? | Can still perform radical nephrectomy and pull tumor thrombus out of IVC |
| What is the most common tumor of the kidney? | Metastasis from the breast |
| What paraneoplastic syndromes are associated with renal cell carcinoma? | erythropoietin, PTHrp, ACTH, insulin |
| How does prostate surgery affect clotting? | Can release urokinase -> activates plasminogen -> thrombolysis |
| What is Von Hippel-Lindau syndrome? | Multifocal and recurrent renal cell carcinomas, renal cysts, CNS tumors, and pheochromocytomas |
| What is the treatment for transitional cell cancer of the renal pelvis? | radical nephroureterectomy |
| How is a urethral injury diagnosed? | retrograde urethrogram (RUG), do not place foley - needs suprapubic catheter |
| What is the treatment for a traumatic bladder injury? | Extraperitonal - a/w pelvic fx, foley only for drainage Intraperitoneal - no pelvic fx, usually dome rupture - laparotomy with multi-layer closure and foley |
| What is the treatment of bladder cancer? | intravesical BCG or transurethral resection if musle not involved (T1), if T2+ then cystectomy with ileal conduit, chemo, and XRT |
| What is the treatment of testicular torsion? | Bilateral orchiopexy |
| What is post-TURP syndrome? | hyponatremia secondary to irrigation with water; can precipitate seizures from cerebral edema |
| What is the treatment of stress incontinence? | Kegel exercises, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sling |
| What is the treatment of urge incontinence? | anticholinergics, behavior modification, cystoplasty, or urinary diversion as last resort |
| What is the treatment of overflow incontinence? | TURP (caused by BPH leading to distention and leakage) |
| What is a varicocele associated with? | Renal cell carcinoma (left gonadal vein drains into left renal vein, obstruction by renal tumor causes varicocele), or other retroperitoneal malignancy |
| What contains the uterine vessels? | Broad ligament |
| What contains the ovarian artery, vein, and nerve? | Infundibular ligament |
| What hormone do sertoli cells produce and secrete? | anti-mullerian hormone causing ipsilateral regression of mullerian ducts (eventual fallopian tubes, therefore not produced by females) |
| Which embryonic structure forms the epididymis, vas deferens, and seminal vesicles under the influence of local testosterone? | mesonephric ducts |
| What type of abortion is characterized by a 1st trimester bleeding, closed os, and absent heartbeat? | Missed abortion |
| What type of abortion is characterized by a 1st trimester bleeding and a positive heartbeat? | Threatened abortion |
| Rectal bleeding, irregular menses, pelvic pain, and bluish mass on proctoscopy in a female - what is the diagnosis? | Endometriosis involving the rectum |
| What is the treatment of endometriosis? | hormonal therapy / OCPs |
| What are the long-term effects of PID? | Increased risk of infertility and ectopic pregnancy |
| What is the staging of ovarian cancer? | I - limited to ovary (including bilateral involvement), II - in pelvis, III - throughout abdomen, IV - distant mets |
| What type of ovarian cancer has the worst prognosis? | Clear cell type |
| What is a Krukenberg tumor? | colon or stomach CA met to ovary - see signet ring cells on path |
| What is Meig's syndrome? | pelvic tumor causing ascites and hydrothorax |
| What are the indications for oophorectomy for an ovarian cyst? | Septated, increased vascular flow on Doppler, solid components, or papillary projections |
| What is the treatment for an ovarian mass found incidentally at time of laparotomy? | Oophorectomy with frozen section initially, if postmenopausal and cancer then TAH and BSO; if premenopausal and cancer, simply remove tube and ovary |
| What are contraindications to estrogen therapy? | Endometrial or breast cancer, active thromboembolic disease, undiagnosed vaginal bleeding |
| What is the difference between these types of peripheral nerve injuries: neuropraxis, axonotmesis, neurotmesis? | Neuropraxis - focal demyelination, improves Axonotmesis - loss of axon continuity (nerve and sheath intact). Regen 1mm/day Neurotmesis - loss of nerve continuity, surgery required for nerve recovery |
| What triggers ADH release? | Produced when high osmolarity is sensed at supraoptic nucleus of hypothalamus |
| What is Diabetes Insipidus? | Alcohol and head injury inhibit ADH release - high UOP, low urine SG, high serum osmolarity/Na |
| What is SIADH? | Increased ADH release most often by head trauma/tumors or SCLC. Oliguria, high urine osmolarity, low serum osmolarity/Na |
| What is the effect of ADH? | Causes increased free water absorption at the distal tubules and collecting ducts and increases peripheral vascular resistance |
| What is cerebral perfusion pressure? | Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP) Keep ~70 |
| When does maximal brain swelling occur after traumatic brain injury? | 48-72 hours after injury |
| What is Cushing's triad? | Hypertension, bradycardia, and Kussmaul respirations (slow, irregular) associated with increased ICP |
| Describe the Glasgow Coma Scale ratings | Motor: 6 commands, 5 localizes, 4 withdraw pain, 3 flexion, 2 extension, 1 none Verbal: 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none Eyes: 4 spont, 3 command, 2 pain, 1 none |
| What are the signs of spinal shock? | Hypotension with bradycardia, warm perfused extremities (vasodilation) Cord injury above T5 |
| What are the deficits in anterior spinal artery syndrome? | Lose bilateral motor, pain, and temperature. Keep position sense, light touch |
| What is Brown-Sequard syndrome? | Spinal cord hemi-transection Lose ipsilateral motor, contralateral pain and temperature |
| What is Central Cord Syndrome? | Acute cervical spinal cord injury characterized by bilateral loss of upper extremity motor, pain, and temperature; legs relatively spared. Often due to hyperextension |
| What are the indications to operate on a skull fracture? | If open or depressed |
| What test are useful for a paraganglioma? | urine metanephrines, MIBG for extramedullary chromatin tissue |
| What type of intracranial hemorrhage is seen in premature infants? Treatment? | Intraventricular (subependymal) hemorrhage, secondary to rupture of fragile vessels in germinal matrix after ECMO or in congenital heart disease. Tx – ventricular catheter for drainage and prevention of hydrocephalus |
| What is the treatment of a patient who presents in shock after XRT for a pituitary adenoma? | Steroids (cause is pituitary apoplexy) |
| What cells act as brain macrophages? | Microglial cells |
| What is a Salter-Harris fracture? Which types need open procedures? | fracture that involves the epiphyseal plate or growth plate of a bone Types III, IV, V are intra-articular and thus need open repair |
| What fractures are associated with non-union? | clavicle, 5th metatarsal fracture |
| What three fractures are prone to compartment syndrome? | Calcaneous, tibia, supracondyle of humerus |
| What three fractures are prone to AVN? | Femoral neck, talus, and scaphoid |
| What are the effects of L3-L4 disc herniation? | L4 root compresson - quadriceps, weak knee jerk |
| What are the effects of L4-L5 disc herniation? | L5 root compression - foot drop, possible big toe hyperesthesia |
| What are the effects of L5-S1 disc herniation? | S1 root compression - weakness in plantar flexion (pushing off toes), weak ankle jerk, hyperesthesia lateral foot/calf |
| What does the median nerve do? | thumb apposition, sensation to most of palm, 1st 2 1/2 fingers (carpal tunnel) |
| What does the ulnar nerve do? | intrinsic musculature of hand, finger abduction, wrist flexion, sensation to 2 1/2 fingers/back of hand |
| What does the radial nerve do? | Wrist/finger extension, sensation to back of lateral hand; no motor in hand |
| What is commonly injured in shoulder dislocation? | axillary nerve in anterior dislocation (90% of dislocations), axillary artery in posterior dislocation |
| What is a Monteggia fracture? What is the treatment? | proximal ulnar fracture with radial head dislocation Treat with ORIF |
| Which nerve injury results in foot drop? Which nerve injury results in decreased foot eversion? | Foot drop = deep peroneal nerve Foot eversion = superficial peroneal nerve |
| What is the terrible triad of O'Donaghue? | lateral blow to knee - injury to ACL, MCL, medial meniscus |
| What are the benefits of early ORIF in femur fracture? | early mobilization decreased fat embolization |
| What are the signs of hip dislocation? | Posterior (90%) - internal rotation, flexed, abducted thigh Anterior - frog leg (external rotation, abduction) |
| What is treatment of knee dislocation? | Most texts say arteriogram all posterior, but at least some vascular assessment (ABI/CT angio/duplex US) is necessary to evaluate popliteal injury even in the presence of normal vascular assessment |
| What is a Volkmann's contracture? What is the treatment? | Permanent flexion contracture of the hand at the wrist. Caused by supracondylar humerus fx -> compromised anterior interosseous artery -> deep forearm flexor compartment syndrome Needs fasciotomy |
| What does a tender snuffbox indicate? | Navicular/scaphoid fracture - even with negative XR, requires cast up to elbow |
| What is most commonly injured after lower extremity fasciotomy? | Superficial peroneal nerve |
| What is a Dupuytren's contracture? What is the treatment? | Progressive proliferative of palmar fascia causing flexion contracture of fingers of hand, unknown exact cause (trauma, DM, EtOH, epilepsy) Treatment with steroids, physical therapy, but may need fasciotomy |
| What is a sunburst pattern on x-ray suggest? | Osteogenic sarcoma |
| What does "onion layering" on x-ray suggest? | Ewing sarcoma |
| What do pseudorosettes on path suggest? | Ewing sarcoma |
| What is the last sign in compartment syndrome? | Loss of pulses |
| What is compartment syndrome most likely to occur? | Anterior compartment of the lower extremity |
| What is AVN in a child under 2 years old? | Legg-Calve-Perthes disease, caused by hypercoagulable state resulting in a painful gait limp |
| What is tibial tuberosity apophysitis caused by traction injury from quadriceps in adolscents aged 13-15? | Osgood-Schlatter disease |
| What is pulmonary sequestration? Treatment? | mass of non-functioning primitive tissue in the lung Extralobar - systemic artery and vein - resection not necessary Intralobar (75%) - aorta in and pulmonary vein out - lobectomy for recurrent infections |
| What is the most common presentation of pulmonary sequestration? | recurrent pulmonary infections |
| What is the cause of respiratory distress at birth, and massive hyperinflation of a single lobe of the lung? What is the treatment? | Congenital lobar emphysema Rx: lobectomy, excellent prognosis |
| What is the treatment for a choledochal cyst? | Must excise, leaving cyst increases cancer, pancreatitis, and cholangitis risks Transplant if type IV or V |
| What are the types of choledochal cysts? | I - (>90% of cysts) dilatation of CBD (part or whole) II - diverticulum III - choledochocele involving sphincter IV - intra and extrahepatic cysts (Caroli's disease) V - intrahepatic cysts |
| Lateral neck mass in infancy with rotation of the head? Treatment? | congenital torticollis Treatment = physical therapy, rarely surgical resection of muscle |
| What is a cystic hygroma? What is the most common location? | lymphangioma - left posterior triangle of neck |
| What is the #1 complication of cystic hygroma? | infection |
| What is the most common branchial cleft cyst of childhood? | 2nd, on anterior border of SCM muscle (goes through carotid bifurcation into tonsillar pillar) |
| What is the treatment for a thyroglossal duct cyst? | Sistrunk procedure - en bloc excision of cyst (midline) with hyoid bone (there is a risk of malignant degeneration of thyroid tissue in cyst) |
| What is the treatment for a strawberry hemangioma | observation - most involute by age 7 |
| What gene is neuroblastoma associated with? | N-myc |
| What is elevated in neuroblastoma? | VMA - Vanillyl mandelic acid HVA - homovanillic acid, metanephrines, and catecholamines; NSE (neuron-specific enolase) elevated in all patients with metastases |
| What is the treatment for a Wilm's tumor? | nephrectomy (80% cure), all patients except stage I weighing less than 500g get vincristine and actinomycin |
| What is the #1 pediatric malignancy overall? | Leukemia |
| What is the #1 cause of painless GIB in children? | Meckel's diverticulum |
| What is the embryologic origin of a Meckel's diverticulum? | Persistent omphalomesenteric/vitelline duct |
| What are the two types of tissue in a Meckel’s diverticulum? | Pancreatic (most common) and gastric (most likely to be symptomatic) |
| What metabolic disorder is present in pyloric stenosis? | hypochloremic, hypokalemic metabolic acidosis |
| What is the treatment of intussusception in children? | air/contrast enema (max 120mm Hg) IV glucagon can help (relaxes smooth muscle) OR if free air/peritonitis |
| What is the cause of intestinal atresia? | Intra-uterine vascular events Mother may have polyhydramnios |
| What is the most common type of tracheo-esophageal fistula? | Type C - blind esophagus, distal TE fistula. Spit up feeds, NGT won't pass |
| What other abnormalities can a patient with a tracheoesophageal fistula have? | VACTERL - vertebral, anal atresia, cardiovascular, TEF, esophageal atresia, renal, limb defects - structures derived from embryonic mesoderm |
| What is the surgical treatment for malrotation? | Ladd's procedure - appendectomy, take down bands, counterclockwise rotation |
| What is the treatment for a meconium ileus? | Gastrograffin enema - diagnostic and therapeutic, can also use N-acetylcysteine enema |
| What test should be performed after diagnosis of meconium ileus? | sweat chloride test or PCR for Cl channel defect |
| How does necrotizing enterocolitis in a newborn present? | After initiating feeds in a neonate (premie) in the 2nd or 3rd week of life with blood in the stool OR free air/peritonitis/acidosis Classic triad: abd dist, bloody stools, pneumatosis |
| What is the treatment for imperforate anus? | If low (below levators) - anoplasty If high (meconium in urine, fistula to bladder, vagina, or urethra) - need colostomy |
| What are the characteristics of gastroschisis? | Congenital abd wall defect, intrauterine rupture of umbilical cord, no associated defects (except maybe malrotation), lateral (right) defect, edematous inflamed bowel, no sac |
| What are the characteristics of omphalocele? | midline defect, may contain liver or other non-bowel contents, frequent anomalies, has peritoneal sac |
| What anomalies are associated with omphalocele? | Cantrell pentology: Cardiac, Pericardium, Sternal, Diaphragmatic, and Omphalocele |
| What is the first sign of CHF in children? | hepatomegaly |
| What is the #1 cause of a colon obstruction in a newborn? | Hirschsprung disease - no BM in first 24 hrs, diagnose with rectal bx |
| What is caused by absence of ganglion cells in myenteric plexus? | Hirschsprung’s disease |
| What is the treatment for biliary atresia? | Kasi procedure - hepatoportoenterostomy - before age 3 months. 1/3 get better, 1/3 go on to liver transplant, 1/3 die |
| What is characterized by hypoplasia of abdominal wall, urinary tract abnormalities with dilated urinary system, and bilateral cryptorchidism? | Prune-belly syndrome |
| Describe a type I error | rejects null hypothesis incorrectly – falsely assumed there was a difference when no difference exists |
| Describe a type II error | accepts null hypothesis incorrectly because of small sample size |
| What type of bias does a randomized controlled trial avoid? | Treatment bias |
| What type of bias does a double-blind controlled trial avoid? | Observational bias |
| How do you calculate relative risk? | incidence in exposed / incidence in unexposed |
| How do you calculate power of a test? | 1 – probability of type II error |
| How do you calculate sensitivity? | true positives / (true positives + false negatives) |
| How do you calculate specificity? | true negatives / (true negatives + false positives) |
| How do you calculate positive predictive value? | true positives / (true positives + false positives) |
| How do you calculate negative predictive value? | true negatives / (true negatives + false negatives) |
| What values depend on disease prevalence? | Predictive value, whereas sensitivity and specificity are independent of prevalence |
Created by:
jclanton82
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