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 Surgery
Flashcards
1 130 case-based flashcards for excellence
on the boards and wards
1 Master Tips help you shine on rounds
 Niket Sonpal. MD
.Assistant Clinical Professor of Medicine
Touro College of Medicine
.Assistant Clinical Professor of Medicine
St. Georges University
Department of Gastroenterology
Lenox Hill Hospital-NSLIJ Health System,
New York, New York

Conrad Fischer, MD
Residency Program Director
Brookdale University Medical Center
New York, New York

New York Chicago San Francisco Athens London Madrid Mexico City Milan
New Delhi Singapore Sydney Toronto
 Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy are required. The authors and the publisher of this work have checked
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error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been
involved in the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the
results obtained from use of the information contained in this work. Readers are encouraged to confirm the
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the information contained in this work is accurate and that changes have not been made in the recommended
dose or in the contraindications for administration. This recommendation is of particular importance in con-
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Copyright© 2016 by McGraw-Hill Education. All rights reserved. Except as permitted under the United
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any means, or stored in a database or retrieval system, without the prior written permission of the publisher,
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they may not be reproduced for publication.

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1 Hemodynamic Instability
2 Post-OP Complications
3 Head Trauma and Neurology
4 Chest Trauma
5 Abdominal Trawna
I Dermatology
7 Ophthalmology
8 Endocrine
9 Cardiovascular
10 Gastrointestinal
11 Hepatobiliary
12 Orthopedic.s
I would like to dedicate this publication to Dr. Robin Dibner, my program director in Internal Medicine. Thank you
for taking a chance on a medical student and turning him into a chief resident, physician, and educator. Forever
your student.
MMter th. Want.: ......,. n..hcarct. have been designed to serve •one stop" review of the 130 cases you are
most likely to see during your surgical clerkship and be teated on during your shelf exam. Bach flashcard provides
a common presenting case history (vignette) and clinic-pathologic features, combined with questions commonly
asked by your senior physicians and board l!JCUllB. On the back of each card. you'll find the most up to date diag-
nostic pearls, tests, and therapeutic algorithms for each disease. The deck is color-coded by system so you can carry
just what you need and organize your study for maximum results. Take them on rounds, take them on the subway
or use them at home. They will fit in your lab coat and you can become the all star you are meant to be on rounds.

Niket Sonpal. MD
 ABBR EM I A :r. I 0 NS
'Ihese are the abbreviations used commonly through these :Bashcards
AAA Aortic aneurysm PPP Fn!Bh frozen plasma
ACL Anterior Crud.ate Ligament GERD Gastroesophageal reflwi: disease
AFP Alpba·fetoprotein GI Gastrointestinal
ALT Alanine transaminase hCG Human chorioni.c gomdotropin
AST Aspartate transaminase IABP lntra· aortic balloon pump
BRBPR Bright red blood per rectum IBO Inflammatory bowel disease
CAD Coronary artery disease IIH Idiopathic int:racranial hypertension
CAUTI Catheter·associated UTI IMA Inferior mesenteric artery
CDAD Clostridium diffidle-a.ssociated diarrhea IVC Inferior vena cava
CHP Congestive heart failure LES Lower esophageal sphincter
CRAO Central nitinal artery occlusion LLQ Left lower quadrant
CSP Cerebrospinal fluid LP Lumbar puncture
CTA Computed tomography angiography MALT Mucosa·associated lymphoid tissue
CTPA Computed tomography pulmonary MRCP Magnetic resonance
angiography cholangiopancreatography
CVA Costovertebr.al angle MRSA Methicillin.-resistant
DRE Digital rectal eumination Stap}rylococcus aun:us
Dvr Deep venous thrombosis MS Mitral. stenosis
ERCP Endoscopic retrograde MSSA Methicillin·susceptible
cholangiopancreatography Stap}rylococcus aun:us
NPH Normal Pressure Hydrocephalus SSI Surgical site infection
NSAIDs Nonsteroidal anti-inflammatory drugs SVR systemic vascular resistance
PAD Peripheral arterial disease TMP-SMX Trimethoprim-sulfamethoxazole
PDT Photodynamic therapy TIPS Transjugular Intrahepatic portosystemic
PPI Proton pump inhibitor shunt
PSA Prostate-specific antigen TPN Total parenteral nutrition
RLQ Right lower quadrant TRUS Transrectal ultrasonography
RUQ Right upper quadrant UFH Unfractionated heparin
sec Squamous cell carcinoma WBC White blood cell
SIRS Systemic inflammatory response UTI Urinary tract infection
syndrome VP Ventriculoperitoneal
SMA Superior mesenteric artery VEGF Vascular endothelial growth factor
A 70-year-old woman presents with a cough, tachypnea, • What is the moat likely
and fever aft.er being hospitalized for a hip fracture diagnosis?
6 days prior. The patient has a productive cough of dark
green sputum, and has been noted by the staff to have • What Is the next best step?
increasing confusion, lethargy, cough, and fever. Her
• What Is the best therapy?
blood pressure is 84/60 mm Hg and heart rate is
120 beats/min after 4 L of intravenous normal saline.
• Moat likely diagnoale: Septic shock. SIRS is a global chosen. If pseudomonas infection is
inflammatory state that yields a particular set of symptoms unlikely, vancomycin combined with
and objective findings, and occurs prior to sepsis and shock. a third-generation cephalosporin,
There are 4 components of the SIRS aiteria. P..lactam/Jl-Iactamase inluoitor,
or a carbapenem is corMct.
1. Body temperature <36•c or >38"C However, if the patient has risk
2. Heart rate >90 beats/min factors for pseudotn011U such as
3. Tachypnea >20 breaths/ min, or Pco2 <32 mm Hg HCAP, neutropenia, or diabetes,
4. WBC count <4000 cells/ mm3 or >12,000 cells/mm3 vancomycin with 2 of the following
should be started: antipseudomonal
This patient has 4 criteria: tachypnea, tachycardia, elevated ceph.alosporin or 8.uoroquinolone.
WBC count, and fever. This combined with the hmgs as a
source, confusion (brain dysfunction), and evidence ofrenal
dysfunction yields severe sepsis. However, because the patient
is also hypotensive that does not improve with fluid, she enters
the caregory lmown as septic shock.
MASTER TIP
• Next best slep: Start norepinephrine. When the patient Two criteria= SIRS
has refractory hypotension or a blood pressure that does
not improve with fluids, vasopressors should be started.
Two criteria + Source of infection =
The best vasopressors in septic shock are norepinephrine or
Sepsis
phenylephrine. Phenylephrine is used when patients have Two criteria + Source of infection +
severe tachycardia or arrhythmia. Organ dysfunction = Severe sepsis
Two criteria + Source of infection +
• Best therapy: Antibiotic coverage directed against
Organ dysfunction + Hypotension =
both gram-positive and gram-negative bacteria should be
Septic shock
A 65-year-old woman presents with profuse watery • What i• the moat likely
diarrhea of 5 days duration and syncope. She was diagnosis?
recently treated for a UTI with dprofloucin. Stool
testing reveals that the patient bas Clostridium difficile. • What Is the next best step?
The patient on examination has orthostatic hypotension.
She does not remember passing out and denies any
postevent symptoms. Placement of Foley catheter in the
emergency department (ED) yields no urine output.
 ~ MASTERTIP
• Most lilmly dlagnoala: Hypovolemic: sboc.k. This patient
iB in hypovolemk shock caused by intravascular volume loss.
1he lack of volwne decreases the cardiac output because of
Cold and clammy - Tight arteries =
lack of preload. The SVR inaea.ses in an effort to compensate High&/R
fuy the ditnini.ahed cardiac output and maintain perfusion to
t.M vital orgma. You should expect to see organ dysfunction Warm and wet = Open arteries =
such u low urine output; cold. cbmmy ertmmties; and Low&VR
ta.chyg.rdia.

• Next best amp: The best next s~ in any p~tient wi.t h

hypovolemk shock is rapid volwne repletion. Fluid
re11usdtation should be at lea.at 10-15 mls per kg. You an
also infuse 500 ml-1000 ml of ftuids every 20-30 minutes
and repeat the blood pn!saure.
Use normal saline or ringers lactate u the initial fluid to
infuse.
A 75-year-old woman presents to the HD with severe • What is the moat likely
back pain of 2 days dur.ation. The patient is on aspirin. diagnosis?
dopidogrel, and rivaro.xaban for recently placed
drug-eluting stents and atrial fibrillation. Physical • What Is the best lnHlal test?
examination shows a bruise over the left flank and
• What Is the best therapy?
around the umbilicus. Urine output has been 0 mL for
3hours.
• Moat likely diagnoale: Hemorrhagic shock secondary to
retroperitoneal bleed. Hemorrhagic shock presents similar to MASTER TIP
hypovolemk shock except the underlying volume loss is pure
Flank ecchymosis = Grey Turner
blood.
sign
• Best lnltlal test: Computed tomography (CT) scan of the Periumbilical ecchymosis =Cullen
abdomen allows for the rapid diagnosis of retroperitoneal sign
bleeding and provides useful information on the type, site,
and extent of the collection.

• Beat therapy: In the case of spontaneous retroperitoneal

hemorrhage, the first-line treatment is conservative,
with withdrawal of anticoagulation therapy, correction
of coagulopathy, volume resuscitation, and supportive
measures. If the patient decompensates, surgical
intervention or angiography is the next best step in
management.
A 25-year-old woman presents with a painless sore on • What is most likely diagnosis?
her labia. She states that about 2 weeks ago she had an
unprotected sexual encounter. She denies any vaginal • What Is the best therapy?
discharge or fevers. Physical examination is notable for
small, red papule with superficial eroded nonulcerated
surface and heaped-up borders that exudes a serous fluid.
She is given an intramuscular (IM) dose of penicillin,
and after a few minutes she develops respiratory distress
with a rate of 28 breaths/min. Auscultation of the lungs
reveals wheezing at the bases. Tachycardia is present. The
patient is unable to speak, feels light-headed, and has
shortness of breath. There are generalized hives present,
and the patient's lips are swollen.
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