SURGERY

1. Hypotension not responsive to fluid administration is suggestive of ongoing blood loss and
such patients with abdominal trauma need an immediate exploratory laparotomy.

2. Vital signs, hemodynamic stability, and need for blood transfusion are important determinant
for surgical v/s non-surgical management of patient with splenic trauma.

3. Choledocholithiasis symptomatic of biliary colic and without any systemic toxicity is treated
with analgesic and spasmolytics and elective surgery is done at a later date.

4. Tetanus prophylaxis depends upon whether the patient had his 3 doses or not. If yes, it
depends upon when did he have it. For any wound, clean or minor, patients should be
administered tetanus toxoid if the last dose was administered 5 years ago. However, if the patient
has clean wound & he has previously received 3 or more doses, but received the last dose 10
years ago, then again he should receive the tetanus toxoid.

5. Transient submandibular gland swelling may occur during feeding due to partial obastruction
of its duct and further evaluation is required if swelling is persistent or recurrent.

6. In a young individual who present with a fleshy immobile mass on his hard palate, the most
likely Dx is torus palatinus. No medical or surgical therapy is required.

7. Technetium pertechnetate scintigraphy is the best diagnostic test for Meckel’s diverticulum.

8. Colonoscopy is difficult and rarely performed in settings of active bleeding. If the bleeding
stops, however, it should be done.

9. Angiodysplasia may be seen as cherry-red spots that may be coagulated.

10. Labeled erythrocyte scintigraphy, although not a very precise study, could be helpful to
define the site of bleeding.

11. The diaphragmatic rupture is more common on the left side, since the right side is protected
by the liver. The leakage of intraabdominal contents into the chest causes compression of the
lungs and mediastinal deviation. Elevation of the hemidiaphragn on the chest X-ray may be the
only abnormal finding. Sometimes, there may be evidence of small bowel in the thoracic cavity.

12. Approximately 5-10% of unconscious patients who present to the ED as result of a motor
vehicle accident or fall, have a major injury to the cervical spine. One third of injuries occur at
the level of C2, and one half of the rest occur at the level of C6 or C7. Most fatal cervical spine
injuries occur in upper cervical levels, either at craniocervical junction, C1 or C2.

13. It is important to rule out a fracture or dislocation of cervical spine as the first priority
because of grave consequences of missing a cervical spine injury.

14. Cast immobilization is recommended in the tx of all non-displaced scaphoid fractures

(fractures < 2mm displacement and no angulation).

15. Varicose veins with incompetent perforators may present with non-pitting edema, medial leg
ulcers, fatigue, and a brown discoloration at the ankles. The MC symptoms from varicose veins
are fatigue, tiredness in the leg, aching, swelling and occasional cramps at night.

16. History of a traumatic event and presence of crunching are compatible with fracture of
metatarsal.

17. Anterior cord syndrome is commonly associated with burst fracture of the vertebra and is
characterized by total loss of motor function below the level of lesion with loss of pain and
temperature on both sides below the lesion and with intact proprioception.

18. Central cord syndrome is characterized by burning pain and paralysis in upper extremities
with relative sparing of lower extremities. It is commonly seen in elderly secondary to forced
hyperextension type of injury to the neck. (rear end collision)

19. central cord syndrome may result from hyperextension injuries and is characterized by
weakness that is more pronounced in the upper extremities than in the lower extremities.

20. Brown Sequard syndrome is acute hemisection of cord and is characterized by ipsilateral
motor and proprioception loss and contra lateral pain loss below the level of lesion. (should be
suspected when there is unilateral paralysis.

21. Posterior cord syndrome: is usually associated with signs and symptoms of posterior
columns.

22. Patients with mild head injury can be discharged with a “head sheet” if they have a normal
CT scan.

23. Axillary nerve is the most commonly injuried nerve in anterior dislocation of shoulder.
(symptoms:numbness over the lateral aspect of the right shoulder).
24. Acute disk prolapse will be characterized by severe radicular pain with positive straight leg
raising test.

25. Cauda equine syndrome is characterized by paraplegia, variable sensory loss, urinary and
fecal incontinence.

26. With posterior dislocation of the shoulder (Tonic clonic seizures may result in posterior
dislocation of the shoulder joint), patient shows internally rotated arm, inability for external
rotation and intact sensations and reflexes.

27. The 2nd part of the duodenum is the most commonly injured portion of the duodenum and
needs a high degree of suspicion for Dx, especially in the presence of retroperitoneal air or
blunting of the right psoas shadow on X-ray. (*Remember the bicycle injury*)-the 2nd portion of
the duodenum, being retroperitoneal and the least mobile, is most commonly injured.

28. Duodenal injuries are best diagnosed with CT scan of the abdomen with oral contrast or an
upper GI study with gastrograffin, followed by barium, if necessary.

29. Muffled heart sounds are common in severe hypovolemia and do not necessarily indicate
pericardial fluid. Moreover, cardia tamponade is unlike without distention of the neck veins.

30. Whenever a patient is in decompensated hemorrhagic shock most probably from rupture
abdominal organ bleeding, next step is diagnostic peritoneal lavage or abdominal ultrasound
once the resuscitative efforts are begun.

31. Bee and hymenoptera stings account for more deaths in the U.S. than any other
envenomation. Anaphylactic shock should be promptly treated with subcutaneous epinephrine.
Then remove the bee stinger ASAP.

32. Acalulous cholecystitis occurs in critically ill patients and imaging studies show diagnostic
findings of thickening of the gall bladder wall and presence of pericholecystic fluid.

33. Diverticulosis is the MCC of bleeding in an elderly patient. Chronic constipation is the single
most predisposing factor to develop diverticulosis.

34. Whenever an open wound fails to heal after a prolonged period, biopsies have to be obtained
to ensure that the ulcer has not degenerated into a squamous cell carcinoma. These ulcers are
known as Marjolin’s ulcers.

35. A long-standing cycle of repeated healing and breaking down my eventually give rise to a
squamous cell carcinoma of the skin, know as Marjolin’s ulcer. Biopsy is need for diagnosis.

36. In stable patients with abdominal trauma, CT scan with contrast is the single best study to
evaluate solid organ damage.

37. Nosocomial infections are defined as infections acquired as a result of hospitalization, and
they manifest at least 48 hours after hospitalization. A urinary tract infection is the MC type of
nosocomial infection; however, it is easy to treat and has the best prognosis. *The case didn’t
specify the source or cause of infection. That means you have to select the MC nosocomial
infection.*

38. Widening of the mediastinum: Mediastinittis, hemorrhage, large pericardial effusion.

39. Recognize the mediastinitis, a post CABG (coronary artery bypass grafting) complication by
systemic signs of inflammation, chest pain, breathlessness and mediastinal widening on chest X-
ray; it is a serious condition and it requires thoracotomy for debridement and drainage +
antibiotics.

40. Mastitis associated with breast-feeding is treated with antibiotics and continuation of breast-
feeding from the affected breast is recommended.

41. When blunt chest trauma occurs with a widened mediastinum on chest x-ray, aortic injury
must be suspected. Either a CT scan or ECHO will be diagnostic.

42. Ludwig’s angina (rapidly spreading bilateral cellulites to the submaxillary and sublingual
glands) is infection of the submaxillary and sublingual glands. The source of the infection is
from an infected tooth.

43. Recognize the classic presentation of a tension pneumothorax. Remember the hypotension,
shortness of breath, jugular venous distension and decreased breath sound.

44. Absent bowel sounds with gaseous distention of both small and large bowel indicates
paralytic ileus. (secondary to retroperitoneal hematoma, dropped hematocrit, that affects
paraspinal ganglia.)

45. Dumping syndrome is common postgastrectomy complication. The symptoms usually

diminish over time and dietary changes are helpful to control the symptoms. In resistant cases,
octreotide should be tried. Reconstructive surgery is reserved for intractable cases.

46. Pneumomediastinum: may accompany a spontaneous pneumothorax: the air from ruptured
alveoli or bulla dissects along the vessels into the hilum and mediastinum. Pneumomediastinum
associated with tension pneumothorax usually responds to chest tube drainage and it does not
usually require surgical decompression. (Tx: chest tube + observation)

47. Heroin overdose: deep coma, bradypnea, hypotension.

48. Clavicle is one of the most commonly fractured bones and is treated with figure of eight
bandage.

49. After an AAA repair (abdominal arterial aneurysm), diarrhea with blood in the stools should
raise the suspicion of ischemic colitis. If the CT scan is inconclusive a
sigmoidoscopy/colonoscopy is recommended.

50. Oratracheal intubation and surgical cricothyroidectomy are preferred way to establish an
airway in apneic patient with head injury (who is unconscious).

51. If tachyneic conscious patient, to secure the air way, chin lift with face mask.

52. Aortic rupture should be ruled out in all the chest trauma patients with hypotension.
Screening for aortic trauma can best be done with a chest X-ray. Confirmation test is
angiography or spiral CT scan.

53. Pain on passive extension of fingers is the most sensitive physical sign of compartment
syndrome.

54. After placement of a central line, a chest x-ray must be obtained to ensure proper line
placement. A central line is an intravenous catheter or IV placed into a large vein.

55. Where is a central line placed:

ï‚· Subclavian vein (chest)
ï‚· Femoral vein (groin)
ï‚· Jugular vein (neck)

56. Percutaneus drainage is the standard Tx approach for pelvic abscess.

57. Penile fracture is a medical emergency and needs prompt surgical repair. But should be
always be preceded by a retrograde urethrogram to rule out a urethral injury which is very
common with penile fracture.

58. Circumcision is the treatment of choice for paraphimosis.

59. Atelectasis is not uncommon after abdominal surgery and can be responsible for early
postoperative fever.

60. Fever occurring in the first 1-2 days after surgery is usually due to atelectasis.

61. Treatment of acute subdural hematoma is essentially conservative if no midline shift is

present on CT scan.

62. The direction of force that produces a fracture often predicts the possibility of other less
obvious injuries. The vertical fall depicted in this vignette classically results in compression
fractures of thoracic and lumbar vertebral bodies. (Do X-ray films of thoracic and lumbar spine)

63. Acute epidural hematoma has a classic presentation of unconsciousness followed by a lucid
interval followed by gradual deterioration of consciousness. CT scan is diagnostic and it show a
biconvex hematoma.

64. Hypoventilation is a frequent occurrence after abdominal hernia repair and early
physiotherapy and respiratory exercises are mandatory.

65. Neutralization of gastric pH should be considered for severely ill patients to prevent gastric
stress erosions. Gastric pH measured through nasogastric tube should be 5 or above.

66. Patients with head injury should be triaged according to the Glasgow Coma Scale (GCS):
can’t tell if there is ICP by GCS.
Eye opening:
Spontaneous 4
To verbal command 3
To pain (or shout) 2
None 1

Verbal response:
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible sounds 2
None 1

Motor response:
Obeys 6
Localization 5
Flexion 4
Abnormal flexion (Decorticate) 3
Extension (Decerebrate) 2
None 1
Total:15

67. Clinical signs of increased intracranial pressure (ICP) include:

ï‚· Papillary findings like bilaterally dilated pupils, anisocoria, or non-reactivity of one or both
pupils.
ï‚· Flaccidity or decerebrate or decorticate motor posturing, or progressing neurological
deterioration not attributable to other causes.
ï‚· papilledema

67. Intubation with mechanical ventilation and administration of IV fluid, analgesics and
sedatives should be done in all the patients with severe head trauma as indicated by GCS.

68. The most rapid method available to lower ICP is hyperventilation to lower PaCO2, which
leads to decreased cerebral blood flow and ICP

69. When suspecting pulmonary embolism, order an arterial blood gas first. Confirmation is by
ventilation-perfusion scan.

70. The rule of abdominal gunshot wounds is simple: an exploratory laparotomy should be done
in every case, before there are obvious signs of either bleeding or peritonitis.

71. A crescent-shaped hematoma: seen in acute subdural hematoma

72. A biconvex, lens-shaped hematoma: seen in acute epidural hematoma.

73. Radial nerve is the MC injured nerve in association with fracture of midshaft humerus.

74. Child abuse is very likely in following conditions:

ï‚· Scalds and burns on feet or buttocks indicative of forceful immersion.
ï‚· Circular burn marks indicative of cigarette burns.
ï‚· Incoherent story of the event.
ï‚· Delay in seeking care after the injury.
ï‚· Torsional fracture of lower limbs
ï‚· Bruises and fractures in various stage of healing. Bruising on normally non bruised areas like
thighs, abdomen, cheeks and genitalia.
ï‚· Subdural hematoma and retinal hemorrhages in very young infant

What to do in a suspected child abuse?

ï‚· Admit the patient to ensure further safety
ï‚· Skeletal survey is mandatory in children less than 2 yo
ï‚· For children older 2 yo a decision is to be made depending on the strength of suspicion.
ï‚· A thorough physical examination to look for other associated injuries should also be done.
ï‚· Report to child safety services.

75. Mesenteric thrombosis (arterial or venous) or non-occlusive ischemia can lead to massive
fluid sequestration in the bowels. Hypovolemic shock and hemoconcentration usually ensue. The
extreme elevation of CK suggesting massive ischemia is characteristic. The intensive abdominal
pain out of proportion to the physical findings and diarrhea, which may contain occult blood,
further support the Dx. Poor neurologic condition in this patient is probably due to brain
hypoperfusion as a consequence of shock.

76. Recognize the clinical presentation of mesenteric thrombosis. Severe abdominal pain out of
proportion to the physical findings along with bloody diarrhea should make you think about this.

77. Colles fracture is the MC fracture of distal radius characterized by dorsal displacement and
dorsal angulation. Tx: closed reduction and casting. Also can be associated with a fracture of the
ulnar styloid.

78. Smith fracture: is reverse Colles fracture and is characterized by fracture of distal radius
metaphysic with dorsal angulation of distal radius and hand, and the wrist displaced volarly with
respect to the foremarm.

79. Barton’s fracture: is a fracture of radial styloid process and is commonly seen in persons
operating automobiles that require cranking to start.

80. In patients who present with ulcers on the soles of the foot, neuropathic ulcer from diabetes
should be suspected.

81. Scoliosis:
ï‚· Idiopathic scoliosis: no cause is determined. MC type, and right thoracic curve is most
commonly seen. It can be further classified as:
-infantile type: age<3
-juvenile type: 3-10
-adolescent type: >10
ï‚· Neuromuscular scoliosis: secondary to neuromuscular disturbance or muscle disease.
ï‚· Congenital scoliosis: secondary to structural bony deformities.

82. Highest detection rate of prostatic carcinoma in early stages---PSA+digital rectal

examination

83. Kidney stones:

ï‚· Oxalate stones: in a patient who undergoes bowel resection and then develops kidney stones,
one should always suspect oxalate.
ï‚· Cystine stones: rare and occurs as part of a rare inherited disorder of defective renal transport
resulting in over-excretion of cystine. Sone formation begins in childhood and are a rare cause of
staghorn calculi.
ï‚· Uric acid stones: occur when urine is saturated with uric acid in the presence of an acidic
urine and dehydration. Seen in gout, myeloproliferative disorders and diarrhea. Tx: fluid,
alkalinization of urine, allopurinol.
ï‚· Struvite stones: form in the collecting system and become infected with urea splitting
organisms. Condicitons required for formation of struvite stones are presence of high urine pH,
magnesium, ammonium and carbonate levels.
ï‚· Calciu phosphate stones: associated with hypercalciuria (sarcoidosis, immobilization,
Cushing’s syndrome, renal tubular acidosis.) std Tx: fluid, thiazide.(note Furosemide in CI).

84. Acute appendicitis: Rovsing’s sign +. Requires immediate surgery.

85. Acute appendicitis may be complicated by pelvic abscess that presents with lower abdominal
pain, malaise, low-grade fever and tender pelvic mass on rectal examination. (most of the pelvic
abscesses are due to perforation of appendix. Tx. Drainage of the abscess).

86. Laxatives should not be given in the setting of intestional obstruction.

87. Intestinal obstruction with metabolic acidosis and shock indicates serious disease and it
requires laparotomy. (suggesting bowel ischemia or necrosis).

88. In case of simple mechanical obstruction, there would be metabolic alkalosis.

89. Patients who present more than 5 days after the onset of symptoms of appendicitis, and have
localized right lower quadrant findings, should be treated with IV hydration, antibiotic and bowel
rest. Antibiotics should cover enteric gram-negative organisms and anaerobes (cefotetan)

90. Cefotetan: has a good coverage of gram-negative organisms and anaerobes; therefore, this
can be used as monotherapy in complicated appendicitis.
91. Erythromycin and vancomycin are effective against gram-positive organisms, they do not
cover gram-negative organisms or anaerobes.

92. Persistent symptoms (e.g. mechanical symptoms) in patients with probable meniscal injury
should be further evaluated by MRI or arthroscopy. Surgery (arthroscopic or open) is often
necessary to correct the problem.

93. Boerhaave’s syndrome is esophageal perforation due to severe vomiting and it produces
pneumomediastinum.

94. Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to
have an intravenous access in trauma patients with collapsed veins.

95. Interosseous membrane cannulation is an alternative route in children <4 yo but not in adults.

96. Cardiac contusion can be associated with various arrhythmias and is best monitored by
continous ECG monitoring. ECHO is used only if murmurs are detected on auscultation.

97. Pulmonary contusion: is not uncommon after high-speed car accidents. The symptoms
usually develop in the first 24 hours and a patchy alveolar infiltrate on chest X-ray is typical.

98. Necrotized surgical infection: characterized by intensive pain in the wound, decreased
sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. Early
surgical exploration is essential.

99. Enterolysis: is used to diagnose small bowel tumors and other pathology, which can cause
intestinal obstruction.

100. Colonoscopy: is not indicated for the right-sided pathology and shoul not be performed in
acute pathology of the bowel wall because of the risk of perforation.

101. Ileus: sometimes is due to a vagal reaction due to ureteral colic. Needle shaped crystals on
urinalysis indicate uric acid stones. Uric acid stones, which are radiolucent, have to be evaluated
by either CT of the abdomen or intravenous pyelography. CT of the abdomen is also useful to
diagnose other pathology such as appendicular abscess etc.

102. Isolated duodenal hematoma: is treated conservatively with nasogastric tube and parenteral
nutrition.

103. Stress fracture or March fracture or insufficiency fracture: is commonly seen in young
active adults (like a dancer) involved in vigorous and excessive exercise.

104. Osgood schlatter disease: is an epiphysitis of the tibia tubercle and is characterized by pain
over tibial tubercle, which is exacerbated by contraction of quadriceps muscle. Almost
exclusively seen in young men and women of less than 19 years age whose growth centers are
still active. The typical patients is a 13-14 yo boy or 11-12 yo girl who has had recent rapid
growth spurt.

105. The characteristic findings of tear of patellar tendon: proximal displacement of patella.

106. Intraductal papilloma: a benign tumor of major lactiferous ducts and clinically manifests as
serous or bloody discharge. Mammogram does not show papilloma, as they are too small.
Mammogram is not useful for young women, since their breast tissue is dense. Resection has to
be done to provide relief and is guided by a galactogram.

107. Esophageal perforation due to iatrogenic cause is very frequent and radiography with water-
soluble contrast is the best way to diagnose esophageal perforation.

108. The presence of pulses does not rule out compartment syndrome and suspicion should be
high hence fasciotomy is the Tx and must be done urgently. (surgical emergency)

109. 10% of calcaneal (heel, most commonly fractured tarsal bone) fractures secondary to fall
from height is associated with compression fracture of thoracic or lumber vertebra.

110. Pain relief should be the prime objective in management of rib fracture in elderly. Local
nerve block can be used if oral or systemic analgesics are not useful. (intercostals nerver blocks
provide pain relief without affecting respiratory function, although it carries some risk of
pneumothorax.

111. Brown recluse spider bite causes deep necrotic ulcer at the bite site.

112. Breast mass that produces non-bloody aspirate and disappears completely on aspiration
does not need any further evaluation other than observation. (cyst)

113. In acute pancreatitis patient who is septic, the cystic lesion must be regarded as abscess,
until proven otherwise. An abscess anywhere in the body of the pancrease needs to be drained
and external drainage is preferred for pancreatic abscess.

114. Pseudocyst engaging tail of the pancreas could be resected.

115. Galactogram guide resection is the Tx of choice for intraductal papilloma which presents
with serous or bloody nipple discharge.

116. In right ventricular infarction, consider IV normal saline and do not give diuretics or nitrate.

117. The usual sequence of management of injury to bone, artery and nerve is to stabilize the
bone followed by repair of vasculature followed by the nerve repair. (B-A-N)

118. CT scan is the investigation of choice to diagnosis intraabdominal abscess

119. Ulcers on the medial aspect of the leg are generally from venous disease. Venous HTN may
be due to vein varicostities and incompetent perforators.

120. Bladder rupture can be classified into the following types:

ï‚· Type 1: bladder contusion
ï‚· Type 2: extra peritoneal rupture is more common than intra peritoneal rupture and usually
occurs at lateral border or base
ï‚· Type 3: intraperitoneal rupture is less common but is commonly seen in patients with full
bladder at accident due to rupture of dome of bladder.
ï‚· Type 4: combined intra and extra peritoneal rupture: it accounts for 10% of bladder injury.

118. Fixation:
ï‚· Closed intramedullary nailing: preferred over open nailing in closed femoral shaft fractures
(associated with less chances of infection, less soft tissue disruption and do not compromise
periosteal circulation)
ï‚· External fixation: indicated in certain cases of open fracture but not in closed fracture.
ï‚· Plate and screw fixation: needs soft tissue dissection and would disrupt fracture hematoma. It
may be used in cases of fracture of femoral neck.
ï‚· Most of fractures of shaft of femur can be managed with closed intramedullary fixation of
fracture.
ï‚· Lower limb skin traction would significantly increase the immobilization duration and its
complications. Also the fracture union is not satisfactory in most cases. It can be used as a Tx.
option in pediatric patients.

121. Preoperative DVT prophylaxis is dependent on the patients individual risk factors and the
type of surgery being performed. The best DVT prophylaxis for high-risk surgical patients who
are undergoing an orthopedic operation includes either oral warfarin or LMWH.

122. Risk of DVT in surgical patients:

ï‚· Low risk: minor surgery in a patient <40 yo with no additional risk factors present. Without
prophylaxis, the risk of DVT <2%
ï‚· Moderate risk: patients >40 yo, one or more additional risk factors, minor/non-major surgery.
The risk of DVT is 2-10%.
ï‚· High risk: patients > 40 yo, additional risk factors, major operation (e.g. orthopedic
procedures of the lower extremity). The risk of DVT in these patients is between 10-20%.

123. Bucket handle tear of medial meniscus is the MC meniscus injury at knee and leads to
locking of the knee joint during terminal extension.

124. Lachman’s test is the most sensitive physical test for Dx of anterior cruciate ligament
injury. (A popping or snapping sensation is commonly felt at the time of ACL injury, ACL
prevents anterior gliding of the tibia under the femoral condyles). Patients complain of instability
of the knee. Commonly associated with injury to medial meniscus and medial collateral ligament
of the knee (terrible triad). Lachman’s test: is done with knee flexed at 20 degrees, and pulling
the proximal tibia with one hand while stabilizing the femur with the other hand.

125. Anterior cruciate ligament: prevents anterior glinding of the tibia under the femoral
condyles. Isolated injury is seen after hyperextension of the knee. A “popping or sanpping”
sensation is commonly felt at the time of injury. Patients complain of instability of the knee
(giving out, looseness etc.) It is commonly associated with injury to medial meniscus and medial
collateral ligament of the knee. (terrible triad)

126. Osgood Schlatter disease: is an apopysitis of tibial tubercle seen in young teenager due to
overuse. (swelling and marked tenderness over the tibial tubercle. Pain increases on contraction
of quadriceps muscle.)

127. Slipped femoral capitis: is an emergency condition and should be promptly corrected with
external screws. (Dx is made by a high degree of clinical suspicion in presence of limited range
of hip movements. Loss of abduction and internal rotation are very characteristic and external
rotation of thigh is seen when hip is flexed. Frog-leg lateral view X-ray of hip joint is the
imaging technique of choice for Dx.)

128. Lateral collateral ligament injury: tackled while playing football, knee pain, swollen, direct
palpation over the lateral aspect of the knee elicit pain. Anterior drawer and posterior drawer test,
and Lachman test are all negative.

129. Anterior drawer test: is also used for Dx of ACL injury but is less sensitive. It is done in
supine position with the knee flexed at 90 degrees and hips flexed at 45 degrees, while tibia is
pulled forward over femur to note the degree of displacement.
130. Posterior drawer test: is used for Dx of posterior cruciate ligament injury. It is similar to
anterior drawer test except that posterior pressure is exerted on tibia to note posterior
displacement.

131. McMurray’s test: is used for Dx of meniscus injury. In case of meniscus injury a click is
heard on forced flexion and rotation of the knee. (popping sound on passive flexion/extenstion of
the joint)-specific for meniscal injury.

132. Valgus stress test: is used for Dx of medial collateral ligament injury in which case valgus
stress leads to marked angulation of knee joint as compared to the normal knee.

133. The immediate management of splenic trauma caused by blunt abdominal injury depends on
the patient’s hemodynamic status and response to IV fluids. If the patient is initially
hemodynamically unstable but improves with fluid administration, the best next step is to obtain
an abdominal CT scan. If the patient is initially hemodynamically unstable and is unresponsive
to fluid administration, then emergent exploratory laparotomy is required.

134. Intermittent claudication is best treated with aspirin and an exercise program.

135. MRI is now the investigation of choice for ligamentous injuries of the knee with an
accuracy rate of 95%. Surgery is rarely necessary for MCL tear.

136. Non-communicating hydrocele disappears spontaneously by 12 months of age and it is

therefore managed expectantly.

137. CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with
blurring of grey-white interface. It is the most significant cause of morbidity in patients with
traumatic brain injuries.

138. A sternal fracture is very likely to be complicated by myocardial contusion, serial ECG is
needed.

139. Paget’s disease of the nipple: Dx-mammogram and punch biopsy.

140. Tx. of Mitral stenosis: cardiovascular surgeons prefer to repair the patient’s own mitral
valve, rather than replacing it. Stenosis is due to fusion at the commissures---commissurotomy
can correct.

141. As a rule: internal hemorrhoids bleed but do not hurt, wherears external hemorrhoids hurt
but do not bleed. (discomfort could be pain, or itchy)
142. Brain examinations:
ï‚· CT scan is our best tool when intracranial bleeding is suspected.
ï‚· MRI is our choice when brain tumor is suspected..
ï‚· Duplex scanning is our choice if transient ischemic attack is suspected.

143. Fogarty balloon tipped catheters: an embolectomy used in treating embolic occlusion of the
artery. Heparin etc anticoagulants are an adjunct to vascular procedures, but are not the primary
Tx for a clot that has already traveled from the atrial appendage to the lower extremity.
Anticoagulants cannot dissolve existing clots.

144. The urinary retention is extremely common in the immediate postoperative period after
lower abdominal inguinal or perineal surgery. Tx: in and out bladder catheterization. (don’t use
indwelling Foley catheter unless in and out fails twice to resolve the urinary retention.)

145. If a scaphoid fracture is suspected, even without a visible fracture on X-ray, it must be
treated as if there was a fracture. (long arm cast)---fall on an outstretched hand. Pain with wrist
movement, tenderness in the anatomical snuffbox. 10% go on to develop avascular necrosis due
to tx error.

146. Spinal cord ischemia with lower spastic paraplegia is a rare complication of abdominal
aneurism surgery.

147. Acute adrenal insufficiency is a potentially lethal postoperative complication. Preoperative

steroid use is the main cause. A high index of suspicion is required. Commonly, they present
with nausea, vomiting, abdominal pain, hypoglycemia, and hypotension.

148. Burns:
ï‚· 1st degree: superficial burns, confined to the epidermis with minimal skin damage. The skin is
mildly erythematous and pain is the chief complaint. (such as sunburn, heals without scaring.)
ï‚· 2nd degree: partial thickness burns-involves the entire epidermis and various layers of the
dermis. Skin is painful, red, edematous and blistered.
ï‚· 3rd degree: full thickness burns-no dermal appendages remain, all epidermis and dermis is
completely destroyed. (flame burn)

149. Patients have obvious signs of hemorrhagic shock (loss of about 25-30%, 1500 mL blood),
can only occur with intraabdominal bleeding, intrathoracic bleeding, and fracture of femur,
pelvic, extremities or bleeding in neck. USG and DPL are the procedure of choice to diagnose
intra abdominal bleeding in an unstable trauma patient. (ultrasonogram, diagnostic peritoneal
lavage).
150. In case of amputation injury, amputated parts should be retrieved and brought to the ED.
The amputated part should be wrapped in a saline-moistened gauze sponge placed in a plastic
bag. The plastic bag should be sealed and placed on ice.

151. Cirrhotic patients with ascites may develop spontaneous primary bacterial peritonitis, which
gives a “mild picture of acute abdomen”, Dx: culture of the ascetic fluid.

152. Sigmoid volvulus, a common condition in elderly patients. The endoscopic instrument
(proctosigmoidoscopy) can untwist the bowel from the inside, relieve the obstruction, and allow
placement of a long rectal tube.

153. Nerves of the lower extremities:

Femoral N.:innervated the muscles of the anterior compartment of the thigh, and is therefore
responsible for knee extension and hip flexion. It provides sensation to the anterior thigh and
medial leg via the saphenous branch.
Tibial nerve: supplies the muscles of the posterior compartment of the thigh, posterior
compartment of the leg, and plantar muscles of the foot. The tibial nerve provides sensation to
the leg (except medial side) and plantar foot.
The obturator nerve: innervated the medial compartment of the thigh (ie, gracilis adductor
longus, adductor brevis, anterior portion of adductor magnus), and controls adduction of the
thigh. It provides sensation over the medial thigh.
The common peroneal nerve: gives rise to the superficial and deep peroneal nerves. These two
nerves supply the muscle of the anterior and lateral leg. These nerves provide sensation to the
anterolateral leg and dorsum of the foot.

154. Current Tx. to full thickness burn: immediate excistion, grafting

155. DDH:
Ultrasound is the most sensitive investigation for DDH (developmental dysplasia of the hip) for
infants less than 6 months of age.
X-ray of hip is not useful in young infants, as the cartilage and epiphysis are not ossified.
However, in older infants and children, plain radiography is the preferred modality of
investigation.
MRI of hip joint though sensitive is reserved for complicated cases
CT though sensitive is not the first investigation of choice. It is particularly used for evaluating
complicated dislocations and for postoperative evaluation of the hip.
156. After rhinoplasty, if there is whistling noise during respiration, one should suspect nasal
septal perforation.
157. Unless strangulation or perforation is suspected, bowel obstruction is treated conservatively
with fluids, nasogastric suction and enemas.

158. Retrograde cystogram with post void film is the investigation of choice for patients with
suspected bladder trauma.

159. Retrograde urethrogram should be the first step in management of suspected posterior
urethral injury. (inability to void, trauma history, high riding prostate)

160. Anterior urethral injury due to injury to urethra anterior to the perineal memebrane. Anterior
urethral injuries are most commonly due to blunt trauma to the perimeum (straddle injuries), and
many have delayed manifestation.

161. Posterior urethra consists of the prostatic urethra and memebranous urethra. Posterior
urethral injuries are most commonly associated with pelvic fracture. (presents with blood at
meatus, high riding prostate, scrotal hematoma and inability to void in spite of sensation to void).

162. When suspecting a urethral injury, do a retrograde urethrogram, inject the dye directly into
the urethra. Inserting a Foley catheter is absolutely contraindicated in suspected urethral injury,
you may change a partial urethral disruption into a complete transaction.

163. Retrograde ejaculation occurs in up to 90% patients undergoing transurethral resection of

the prostate (TURP).

164. TUIP (transurethral incision of the prostate) involves incision of the periurethral prostate
without resection of any tissue. This procedure is minimally invasive and can be performed on an
outpatient basis. It frequently results in symptomatic relief without the adverse effects of TRP.

165. The disease with the highest incidence of perioperative death or cardiac event is a recent
myocardial infarction. (other causes: coronary disease, worsened or poor baseline exercise
tolerance, recent infarction)

166. Postoperative period, patient has persistent difficulty swallowing solids and even more
difficulty swallowing liquids. Any attempts to do so results in violent coughing ans
aspiration.Lesion: ----------sensory fibers of the 9th (glossopharyngeal) nerve.

167. When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive
Dx of ruptured abdominal aortic aneurysm must be entertained and the patient should be taken
straight to the operating room.
168. Aortic aneurysm rupture, best diagnostic exam: Spiral CT scan or MRI angiogram.

169. Ureteropelvic junction obstruction and profuse diuresis: a congenital narrowing at the
ureteropelvic junction allows normal passage of urine at a normal flow rate, but the lumen can’t
accomadate a suddenly increased flow rate. (remember, beer is a wonderful diuretic.)

170. Most common nontraumatic casue for SAH is: berry aneurysm in the anterior portion of the
circle of Willis.

171. Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound
below the 4th intercostals space (level of nipple) is considered to involve the abdomen.

172. Subluxation of radial head is a common condition in preschool children and needs closed
reduction by flexion and supination of forearm.

173. Small amount of intraperitoneal bleed that is not visible on abdominal ultrasound can be
detected by diagnostic peritoneal lavage.

174. Consider bowel ischemia and infarction as an early complication of operation on the
abdominal aorta.

175. Hallmark triad of urethral injury is:

ï‚· Blood at urethral meatus
ï‚· Inability to void
ï‚· Distended bladder

176. For carcinoid tumors located at the tip of the appendix, appendectomy is sufficient Tx.
Carcinoids do not have the tendency to spread and have a good prognosis. When carcinoid
spreads to the liver, it may produce the carcinoid syndrome, which is characterized by flushing,
diarrhea, cramping, and valvular heart lesions.

177. Rule out vascular injuries in case of penetrating wound near the site of important vessels.
(arteriogram)

178. Monteggia fracture: an isolated fracture of proximal third of ulna, with anterior dislocation
of radial head. May be associated with injury to radial nerve, so careful neurovascular
examination at the time of evaluation is mandatory. Tx: open reduction and internal fixation in
adults, closed reduction and casting are optimal for children.

179. Galeazzi fracture: an isolated radial shaft fracture, associated with disruption of distal radio
ulnar joint also need open reduction and internal fixation.

180. Osteogenic sarcoma usually presents with painful swelling around the knee without any
systemic signs and radiographic findings are osteolytic lesions with periosteal reaction.

181. Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral
vasoconstriction and thus decresing cerebral blood flow. (goal: to have pCO2 in the range of 30-
35 mmHg.)

182. Harvesting team’d evaluate any dying patient as a potential donor.

183. Typical history for fracture of the posterior lateral talar tubercle: standing on a chair and
falls backward, a cracking sound -develop pain and swelling behind the ankle. Pain is
exacerbated by plantar flexion and dorsiflexion of the hallus (big toe).Tx: with immobilization in
a cast for 4-6 weeks. Dx: lateral x-ray film of the ankle.

184. After rectal surgery, patient experience impotence, cause?-erectile nerve damage.

185. In cirrhotic patient with hepaticencephalopathy, porto-systemic shunt may worsen the
encephalopathy.

186. Patient with cirrhosis may have upper GI bleeding due to:
ï‚· Erosive gastritis
ï‚· Varices
ï‚· PUD (peptic ulcer disease)
ï‚· Mallory-Weiss tears.

187. In cases of bleeding esophageal varices, need for 5 or more units of blood transfusion in a
period of 24 hours is considered an indication for surgery and transjugular intrahepatic
portosystemic shunt is the best choice in emergency situations.

188. When clavicle injuries occur and a bruit is present, an anterial injury must be ruled out with
an angiogram.

189. Atelectasis on chest X-ray can be confused with pneumonia and pleural effusion. However,
it is more common after surgery in smoker and requires bronchoscopy to remove the mucus plug.

190. Fever on the first postoperative day is almost invariably from atelectasis, the Tx of which
requires active participation and cooperation from the patient. If atelectasis does not resolve, it
leads to the development of pneumonia, which can be identified in chest x-ray and confirmed
with sputum cultures.

191. Sclerotherapy and surgery are indicated after first variceal bleeding, but not
prophylactically. (sclerotherapy may have complications such as perforation, stenosis, and
bleeding.)

192. Pelvic X-ray should be routinely done in all patients with trauma to screen for pelvic injury.

193. Fibrocystic disease: (mammary dysplasia) typically seen in women aged 20-40. It is
characterized by painful breasts and recurrent formation of cysts.

194. Malrotation: 3 week old infant, protracted bilious vomiting. With double bubble sign with a
little gas beyong is highly suggestive. Dx must be promptly confirmed by barium enema or
contrast study from above. Tx: emergency surgery.

195. A patient must be left with at least 800mL in FEV1 to live a semi-decent life.

196. Even being left with at least 800 mL in FEV1, a patient with SCC in lung still needs to do a
CT scan of the chest and upper abdomen to rule out lymph metastasis before a pneumonectomy
can be done.

197. The best initial therapy for rhabdomyolysis is infusion of copious amounts of alkalinized
saline to assist the kidneys in clearing the myoglobin from the blood. Alkalinizing the urine
allows the renal tubules to retain the myoglobin and excrete it in the urine. (saline+bicarbonate)

198. Percutaneous lithotomy: used for large renal sontes located within the pelvicaliceal system.
Smaller stones located in this position are best treated with ESWL.

199. Extracorporeal shock wave lithotripsy (ESWL): particularly effective on stones impacted in
the distal ureter that have failed to pass spontaneously with conservative management.

200. Testicular torsion needs immediate de-torsion if the testis is to be saved. No time should be
wasted doing further studies.

201. In patients sustaining trauma, there is a chance of bony cervical spine injury-lateral cervical
spine x-ray can rule it out.

202. A COPD patient with a 1100 mL in FEV1, suffers from a SCC at the hilar. What to do? ---
only radiation + chemotherapy. If surgery and have the bad lung removed, then only leave him
40% FEV1 (440 mL).
203. Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture. Clinical
signs of basilar skull fracture includes rhinorrhea, raccoon eyes (black eyes), and ecchymosis
behind the ears and otorrhea. Patient’s head should be elevated and fluid intake should be
restricted to 1200 mL/day. Patient should also be cautioned against the maneuvers that increase
the intracranial pressure like blowing the nose.

204. Legg calve Perthes disease (avascular necrosis) is serious but self-limiting condition of
young children characterized by avascular necrosis of femoral head. Can be painless. But hip
pathology can present as referred knee pain. Also named: avascular necrosis of the capital
femoral epiphysis.

205. The Tx of choice for isolated diaphyseal humeral fracture is by closed methods.

206. Scaphoid fracture: nonunion and avascular necrosis are common complications. The
proximal third of the scaphoid is prone to avascular necrosis in fractures involving the wrist or
proximal pole.

207. Gentle traction to attempt alignment of the fragments of a fractured long bone is important
to prevent further vascular and neurological damage and it should be attempted immediately.

208. Nasopharyngeal cancer usually presents initially as a painless neck mass. (other symptoms:
epistaxis, hearing loss, nasal blockage)

209. Warfarin treated patients should be given fresh frozen plasma instead of vitamin K when
emergency surgical procedure is to be performed.

210. Intravenous pyelography is very useful for the Dx of renal stones.

211. Open fractures should not be closed primarily because of the associated increased risk of
infection and subsequent osteomyelitis.

212. Rhabdomyolysis can occur with severe crush injuries and should be managed with IV
fluids, osmotic diuretics and alkalinization of urine.

213. Hyperkalemia due to crush injuries needs IV calcium gluconate (acts as a membrane-
stabilizing agent to balance against the imminent hyperkalemia-induced global depolarization of
the myocardium.

214. Elderly patients with displaced femoral neck fractures should be treated with primary
arthroplasty.

215. Tx of choic for intertrochanteric fracture: internal fixation with sliding screw and plate and
early mobilization.

216. Patients treated with high-dose methylprednisolone within eight hours of spinal cord injury
have significant and sustained neurological improvement, thus its use is warranted as the first
priority after stabilizing the patient. *important Q.!!!*

213. Garden classification for femoral neck fracture:

ï‚· Type 1: valgus impaction of femoral head commonly seen with stress fracture
ï‚· Type 2: complete but non-displaced femoral neck fracture.
ï‚· Type 3: complete fracture with displacement <50%
ï‚· Type 4: complete fracture with displacement >50%

217. Delayed emergency from anesthesia is characterized by hypotension, which is evident by

decreased in respiratory rate, HTN progressing to hypotension, tachycardia progressing to
bradycardia, restlessness and pallor/cyanosis.

218. After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the
left lower chest, one should suspect a diaphragmatic perforation.(Dx. barium swallow)

219. Patient with head injury can never have hemorrhagic shock due to intracranial bleeding.

220. Beck’s triad of hypotension, elevated JVP, and muffled heart sounds confirms the Dx of
pericardial tamponade.

221. Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the
dead muscle has been replaced with fibrous tissue. Tx: immediate fasciotomy.

222. Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be
complicated by Volkmann’s ischemic contracture.

223. Presence of brachial pulse on the fracture side can’t rule out the possibility of vascular
compromise because of collateral flow.

224. Two locations in the body have the highest risk for development of the dreaded
compartment syndrome: the forearm and the lower leg.

225. Hirschsprung’s disease in neonate presenting with obstruction: diverting ileostomy

+appendectomy (for Dx. of the disease). Definite repair can be done when the child is older.

226. A known complication of ling-standing use of birth control pills is the development of
hepatic adenomas that may rupture and bleed. (acute onset of abmominal pain, followed by a
faint)

227. The MC site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial
epicondylar groove. *extremely HY Q for USMLE* (decreased sensation over the 4th and 5th
fingers of the hand and a weaker grip compared to the normal side.) Prolonged, inadvertent
compression of the nerve by leaning on the elbows while working at a desk or table is the typical
scenario.

228. APKD (adult onset polycystic kidney disease) diagnosed, you should order an MRA
(magnetic resonance angiogram) of the brain to rule out berry aneurysms. (10%-20% incidence
of this in APKD).

229. Virtually all solid testicular masses are malignant tumors. The best way to avoid
dissemination is to open the inguinal canal, do a high ligation of the cord, and pull the testicle
out.(radical inguinal orchiectomy)

230. Mixed connective tissue disease represents the over lapping symptoms of SLE, scleroderma
and myositis. It is associated with autoantibody to ribonuclear protein.

231. The rule is that lymph nodes that progressively enlarge over several months are malignant.

232. Lymph nodes which are in the supraclavicular area, typically harbor metastasis from a
primary tumor below the clavicles (i.e., not in the head and neck).

233. Inhalation injury is common in burns patients and may take several days to manifest.
Diagnosis is best done with a bronchoscopy.

234. Body surface involved in burn injury is calculated with the rule of 9:
ï‚· Each arm: 9%
ï‚· Each lower extremity: 18%
ï‚· Anteiror torso: 18%
ï‚· Posterior torso: 18%
ï‚· Face 9%
ï‚· Perineum: 1%

235. Burns patients need 4 ml/kg/% of the body area involved of fluid in first 24 hours, half of
which is given in the first 8 hours. Plus 2000 mL dextrose 5% in water.

236. Infection is the MCC of death in burns patients.

237. Burns:
ï‚· Superficial and erythematous burns while painful do not require any special wound care (not
even antibiotics)
ï‚· Early excision therapy is indicated for extensive partial-thickness and full-thickness burns, as
they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications.
ï‚· Prophylactic systemic antibiotic is not indicated in all the patients. However, topical
antibiotics should be used for burn wound care.
ï‚· The most commonly used topical anti bacterial agent: silver sulphadiazine. Mafenide sulphate
is only used if deep penetration is required in case of wound with eschar. Mafenide sulfate is
associated with severe pain and acidosis.
ï‚· Eschar is dead rigid tissue formed in burns wounds. The eschar restricts outward expansion of
the compartment as edema occurs in the injured extremity following the burns. As a result,
interstitial pressure rised to the point that vascular flow is compromised. This can be relieved by
performing an escharoctomy.
ï‚· Tetanus prophylaxis should be considered in all the burns wound patients using std guidelines
as burn wounds are prone to tetanus infection.
238. Cholesteatoma is an epithelial cyst that contains desquamated keratin. Patients generally
present with chronic ear discharge and granulation tissue that are unresponsive to antibiotic
treatment. (This is not a tumor)

239. Carcinoids are most commonly found on the appendix; however, patients who present with
carcinoid syndrome usually have carcinoids located in the small bowel.

240. Dog bite:

ï‚· May result in rabies (fatal disease)
ï‚· Post exposure prophylaxis: active and passive immunization.
ï‚· Capture the dog, if fails to do so, the dog is assued to be rabid and post exposure prophylaxis
is indicated.
ï‚· If the dog is available and it does not show any features of rabies, observed it for the
development of rabies (10 days). If it shows rabies, it is killed and its brain is examined to
confirm the presence of rabies and post exposure prophylaxis is given when rabies in dog is
confirmed by FA.(fluorescent antibody)