Adam Shared "Surgery" - 130 Picmonics

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Surgery

Abdominal Aortic Aneurysm
Screening
Screen Males 65-75 Who've Ever Smoked
Diagnosis
Ultrasound
Treatment
Observation
Asymptomatic and < 5 cm in Size
Surgical Repair
> 5.5 cm in Abdomen
Emergent Surgery
Ruptured or Symptomatic
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2 mins
Pulmonary Embolism Presentation and Diagnosis
Presentation
Sudden onset Shortness of Breath (S.O.B.)
Tachypnea
Pleuritic Chest Pain
Hemoptysis
Hypoxemia
Sudden Death
Diagnosis
Gold Standard: CT Pulmonary Angiography
X-Ray
D-Dimer
V/Q Scan
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1 min
Acute Bacterial Parotitis 4544
Dehydrated post-operative patients and the elderly are most prone to develop this infection
Most common infectious agent is Staphylococcus aureus
Presentation
Fever
Leukocytosis
Parotid inflammation
Painful swelling of the involved parotid gland that is aggravated by chewing
Physical exam
Tender, swollen and erythematous gland; with purulent saliva expressed from the parotid duct
Treatment
Adequate fluid hydration and oral hygiene, both pre- and post-operatively, can prevent this complication
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Small-Bowel Obstruction
History of prior abdominal surgery --> risk factor due to adhesion development (most common cause)
Crohn-related SBO usually results from chronic fibrosis late in disease process
Clinical presentat ion
Colicky abdominal pain, vomiting
Inability to pass flatus or stool if complete (no obstipation if partial)
Progression of SBO --> sounds may diminish and if ischemia occurs --> disappear altogether
Hyperactive --> absent bowel sounds
Distended & tympanitic abdomen
Complete proximal obstructions are characterized by early vomiting, abdominal discomfort, and abnormal contrast filling on x-ray
Diagnosis
Dilated loops of bowel with air-fluid levels on plain film or CT scan
Partial: Air in colon
Complete: Transition point (abrupt cutoff), no air in colon
Mild leukocytosis and amylase elevation can also be seen
Complications
lschemia/necrosis (strangulation)
Bowel perforation
Management
Bowel rest, nasogastric tube suction, intravenous fluids
Surgical exploration for signs of complications
Complicated SBO --> increased risk of ischemia, strangulation, and necrosis, warranting emergency abdominal exploration
Change in pain, fever, hemodynamics (hypotension, tachycardia), guarding, leukocytosis, metabolic acidosis
Peristaltic waves on the abdominal wall can also be observed
Some of the less common causes include hernia, neoplasm , volvulus, intussusception
Partial obstruction: supportive care and observation if no improvement in 12-24 hours --> surgery
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Prerenal Acute Kidney Injury
Etiology
Decreased renal perfusion
Tx: Intravenous isotonic fluid (eg, normal saline) to restore renal perfusion.
Volume depletion is further suggested by tachycardia
True volume depletion
Decreased EABV (eg, heart failure, cirrhosis)
Displacement of intravascular fluid (eg, sepsis, pancreatitis)
Renal artery stenosis
Afferent arteriole vasoconstriction (eg, NSAIDs)
Clinical features
Increase in serum creatinine ( eg, 50% from baseline)
Decreased urine output
Blood urea nitrogen/creatinine ratio > 20: 1
Fractional excretion of sodium <1%
Unremarkable ("bland") urine sediment
Decreased renal perfusion leads to a decreased glomerular filtration rate
If due to CHF then dont use IV fluid, use a diuretic
Use albumin for prevention of prerenal AKI following large-volume paracentesis in patients with decompensated cirrhosis
FEurea < 35% (used when the patient is on a diuretic because it messes with the FENa)
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Retroperitoneal Hematoma 4501
Causes
Cardiac Catheterization
Anticoagulants
Clinical Features
Hypotension
Tachycardia
Flat neck veins
Ipsilateral back/flank pain
Most hemorrhage or hematoma formation occurs within 12 hours of catheterization
Swelling of soft tissue
If the arterial puncture site is above the inguinal ligament, the hematoma can extend into the retroperitoneal space
Diagnosis
Non-contrast CT scan of abdomen and pelvis or abdominal ultrasound
Treatment is usually supportive, with intensive monitoring, bed rest, and intravenous fluids or blood transfusion
Surgical repair of hematomas or retroperitoneal hemorrhage is rarely required
Avoid strenuous activity or lifting heavy objects for one week post catheterization
Radial artery approach leads to fewer local vascular complications
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Thoracic Aortic Aneurysm
Associated with cystic medial degeneration
Balloon-like dilation of the thoracic aorta
RISK FACTORS
Hypertension
Bicuspid aortic valve
Connective tissue disease (Marfan and Ehler Danlos)
Also historically associated with 3° syphilis (obliterative endarteritis of the vasa vasorum) and aorta can present "tree-bark" appearance
complications
Major complication is dilation of the aortic valve root, resulting in aortic valve insufficiency (aortic regurgitation).
Other complications include compression of mediastinal structures (e.g., airway or esophagus) and thrombosis/embolism.
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Spontaneous Pneumothorax
Mechanism
Accumulation of Air in Pleural Space
Tall and Thin Young Males
Underlying Disease
Bleb or Bulla Rupture
Signs and Symptoms
Chest Pain
Hypoxemia
Decreased Breath Sounds
Hyperresonance
Shortness of Breath (SOB)
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1 min
Scaphoid Fractures 3415
Most commonly fractured carpal bone
Pain at the radial wrist proximal to the base of the thumb
Examination shows tenderness in the shallow depression at the dorsoradial wrist
"Anatomic Snuffbox"
Bounded medially by the tendon of the extensor pollicis longus
Bounded laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis
Carry a significant risk of osteonecrosis
Initial x-rays can be normal in nondisplaced scaphoid fractures
CT scan or MRI can confirm the diagnosis, or repeat x-rays can be performed in 7-10 days
The wrist can be immobilized briefly in a thumb spica splint if repeat x ray is used
Displaced fractures should be considered for surgical intervention
Monitor with serial x-ray to rule out osteonecrosis
The radial artery supplies blood flow
Typically caused by fo rceful dors iflexion at the wrist
X-rays of the wrist in full pronation and ulnar deviation to better expose the scapho id
Radioscintigraphy bone scan in 3-5 days can also be used
Orthopedic surgeon if: tilt of lunate, fracture displaced >1 mm, nonunion on follow-up, osteonecrosis, scapholunate dissociation
Serial x-rays should be done in 2-week intervals to monitor healing after spica cast is used
Most commonly complicated by nonunion and avascu lar necrosis
Proximal fractures of the scapho id require longer immobilization (up to 12 weeks ) for adequa te healing
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Compartment Syndrome 3398
Serial compartment pressure monitoring is useful in determining the need for definitive operative management
Compartment decompression by fasciotomy or for circumferential burns, escharotomy
Eschar resulting from circumferential, full-thickness (third degree) burn often leads distal ACS
Longstanding elevated compartment pressure --> tissue ischemia and tissue death
Common
Pain out of proportion to injury
Pain increased on passive stretch
Rapidly increasing & tense swelling
Paresthesia (early)
Uncommon
Decreased sensation
Motor weakness (within hours)
Paralysis (late)
Decreased distal pulses (uncommon)
Diagnosis
Compartment pressure >30 mm Hg
Delta pressure (diastolic blood pressure - compartment pressure)
Clinical diagnosis, confirmed with compartment pressure
Serial measurements should be performed even if initial pressures are within normal limits
Time to intervention is the most important factor predicting complete functional recovery of the limb.
All const rictive cover ings (casts, dress ings) should be removed and supplemental oxygen given
Supportive measures to maintain perfusion pressure include keeping the limb at torso leve l and treat ing hypotens ion if present.
Additional findings
Arteria l and venous occlusion in the extremity results in anoxic muscle necrosis (rhabdomyolysis)
Lead to acute renal failure (ARF), particula rly in volume-depleted states (eg, hemorrhage) , which worsens vasoconstr iction and cast formation.
Compartment pressure >30 mm Hg or delta pressure (diastolic blood - compartment) <20-30 mm Hg --> significant CS
Caues: traumatic long bone fractures , trauma wit hout fracture (e.g., crush injuries, thermal burns, and vascular injury in extremities) ,
Nontraumatic causes (e.g., prolonged limb compression, animal venom exposure , and nephrotic syndrome)
Can progress to infection, and skin ulceration and tissue necrosis, possibly requiring amputation of the limb
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Ankle-Brachial Index Interpretation 4494
Ankle-brachial index = higher ankle systolic pressure in lower extremity/higher brachial artery systolic pressure
Less than or equal to 0.90 - Abnormal
0.91 - 1.30 - Normal
Greater than or equal to 1.30 Suggestive of calcified & incompressible vessels; additional vascular studies should be considered
Ankle-brachial index (ABI) confirms the presence of peripheral arterial disease (PAD)
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Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
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1 min
Syringomyelia
Cystic cavity (syrinx) within central canal of spinal cord
Fibers crossing in anterior white commissure (spinothalamic tract) are typically damaged first
Results in a “cape-like,” bilateral loss of pain and temperature sensation in upper extremities
Fine (deep) touch sensation is preserved
Associated with Chiari I malformation
Most common at C8–T1
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Acute Abdominal/Pelvic Pain in Women 12160
Mittelschmerz
Recurrent mild & unilateral mid-cycle (around day 14) pain prior to ovulation
Pain lasts hours to days
No peritoneal signs
Ultrasound: Not indicated
Rupture of the follicle releases the egg; concomitant release of some blood during process irritates peritoneum
Reassure patients
Ruptured ovarian cyst
Sudden-onset, severe, unilateral lower abdominal pain immediately following strenuous or sexual activity
Nausea & vomiting
Unilateral, tender adnexal mass on examination
Can cause hemoperitoneum often while on anticoagulants
Diffuse severe abdominal pain, pleuritic chest pain, and shoulder pain (due to phrenic nerve irritation)
Gynecologic emergency typically occurring in premenopausal patients
Diffuse abdominal rigidity with rebound and guarding is present
Symptoms arise due to ischemia and eventually necrosis
Decreased hematocrit due to intra-abdominal blood loss
Twisting around its supporting structures (infundibulopelvic ligament or utero-ovarian ligament) which contains ovarian blood supply
Ultrasound + Doppler: Pelvic free fluid and possible adnexal mass if the cyst is incompletely drained
Enlarged ovary with decreased or absent blood flow
Dermoid cysts in particular have a higher likelihood of torsion than other types of ovarian masses
Treatment: prompt surgical laproscopy with detorsion, cystectomy, possibly removal of the adnexa (if necrosis despite restoration)
Untreated torsion may lead to chronic pelvic pain, infertility, hemorrhage, or peritonitis and sepsis
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Necrotizing Fasciitis 2749
Streptococcus pyogenes (group A streptococci) is the most frequently recovered
Staphylococcus aureus
Clostridium perfringens
Polymicrobial
Bacteria spread rapidly through subcutaneous tissue & deep fascia , undermining the skin
Most commonly involves extremities & perineal region
Often antecedent history of minor trauma
Erythema of overlying skin
Swelling & edema
Pain out of proportion to examination findings
Untreated necrotizing fasciitis progresses to rapid discoloration of the affected site, purulent discharge, bullae, and necrosis
Air in the deep tissue can cause crepitus
Systemic symptoms (eg, fever & hypotension)
Imaging reveals extent and air in the tissue bed; If necrotizing fasciitis is suspected, therapy should not be delayed to pursue imaging
Treatment
Requires surgical debridement & broad-spectrum antibiotics
Blue grey discoloration
Third Generation Cephalosporin + clindamycin + ampicillin
Can also result from significant peripheral vascular disease (ie, diabetes).
The most common form (type II) usually occurs in individuals with no concurrent medical illness usually from GAS
Type I is usually seen in patients with underlying diabetes and peripheral vascu lar disease usually polymicrobal
Staphylococcus aureus, Bacteroides fragilis, Escherichia coli, group A Streptococcus, and Prevotella species
Antibiotics to use according to uworld
Piperacillin/tazobactam or a carbapenem for GAS and anaerobes
Vancomycinw ill cover Staphylococcus aureus
Clindamycin is added to inhibit toxin formation by streptococci/staphylococci
Once culture information is available, antibiotic therapy should be narrowed based on identified pathogens
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Nasal Polyps, Angiofibroma and Nasopharngeal Carcinoma
Nasal Polyp
Protrusion of edematious, inflamed nasal mucosa
Secondary to repeated bouts of rhinitis; occurs in cystic fibrosis and aspirin-intolerant asthma, kartagener
Aspirin-intolerant asthma consists of asthma, aspirin-induced bronchospasms, nasal polyps
Surgery often temporary relief, polyps recur; ultimate treatment should be management of underlying etiology
Not just aspirin, any NSAIDs
Can do aspirin desensitization if aspirin is required
Treatment includes management of the patient's underlying asthma and chronic rhinosinusitis
Avoidance of NSAIDs, and desensitization if NSAID use is required
Leukotriene inhibitors (zileuton) and leukotriene antagonists (montelukast) --> improved resp/nasal symptoms
Considered a pseudoallergy
Angiofibroma
Benign tumor of nasal mucosa composed of large blood vessels and fibrous tissue; classically seen in adolescent males
Profuse epistaxis
Can cause nasal obstruction and nasal drainage
Nasopharyngeal Carcinoma
Malignant
EBV association; classically African children/Chinese Adults
Risk is thought to be higher in these locations due to diet (salt-cured food, early exposure to salted fish) and genetic predisposition
Pleomorphic keratin-positive epithelial cells (poorly differentiated squamous cell carcinoma) in a background of lymphocytes
Often presents with cervical lymph node involvement
EBV assays are often used to monitor treatment response and disease relapse
Invades adjacent tissues --> congestion, epistaxis, headache, CN palsy, serous otitis media (eustachian obstruction)
Nasal congestion with epistaxis, headache, cranial nerve palsies (eg , facial numbness), serous otitis media (eustachian tube obstruction)
Early metastatic spread to the cervical lymph nodes may cause a nontender neck mass
Nasopharyngeal endoscopy should be considered
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Ileus
Intestinal hypomotility without obstruction
Symptoms
Constipation and decreased flatus
Distended/tympanic abdomen with decreased bowel sounds
Associations
Abdominal surgeries
Opiates
Hypokalemia
Sepsis
Treatment
Bowel rest, electrolyte correction, cholinergic drugs (stimulate intestinal motility).
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Peritonsillar Abscess (Quinsy) 2847
An acute bacterial infection of the region between the tonsil and the pharyngeal muscles
Most common in older adolescents and young adults, and drug or alcohol use increases the risk
Fever
Sore throat, difficulty swallowing
Trismus (spasm of the jaw muscles)
Muffled "hot potato " voice
Uvula deviation away from enlarged tonsil
Pooling of saliva
Ear ache
Can be fatal secondary to airway obstruction or spread of infection into the parapharyngeal space --> carotid sheath
Treatment
Needle aspiration or incision and drainage (if aspiration fails to remove purulent material)
Antibiotic therapy to cover Group A hemolytic streptococci and respiratory anaerobes
Clinical diagnosis (no imaging required)
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Emphysematous Cholecystitis 2940
Risk factors
Diabetes mellitus
Vascular compromise
Gallstones
lmmunosuppression
Clinical presentation
Fever, right upper quadrant pain, nausea/vomiting
Crepitus in abdominal wall adjacent to gallbladder
Complications include gangrene and perforation
Diagnosis
Air-fluid levels in gallbladder, gas in gallbladder wall
Cultures with gas-forming Clostridium, Escherichia coli
Unconjugated hyperbilirubinemia, mildly elevated aminotransferases
Gas in the gallbladder wall, and occasionally pneumobilia (air within the hepatobiliary system)
Treatment
Emergent cholecystectomy
Broad-spectrum antibiotics with Clostridium coverage (eg, ampicillin-sulbactam)
Can cause ileus (decreased or absent bowel sounds)
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Anterior and Middle Mediastinal Mass 2590
Diagnosis of mediastinal tumors is based on chest-x rays and CT scans
Anterior
4 T's
Thymoma
Teratoma
One must also include other germ cell tumors
Teratomas distinguished from other germ cell tumors on imaging by the presence of fat or calcium, particularly if in the form of a tooth
Serum B-HCG can be elevated in 1/3 of patients with a seminoma
Patients with a nonseminomatous germ cell tumor have elevated AFP, some also have elevated B-HCG
Diagnos can be confirmed with biopsy
Testicular ultrasound should be per formed to exclude a small primary tumor
Thyroid neoplasm
Terrible lymphoma
Middle
Bronchogenic cysts are are benign entities
May be seen on the AP chest x-ray
Tracheal tumors, pericardial cysts, lymphoma, lymph node enlargement, and aortic aneurysms of the arch
Posterior
All neurogenic tumors are located in the posterior mediastinum
These include: meningocele, enteric cysts, lymphomas, diaphragmatic hernias, esophageal tumors, and aortic aneurysms
MRI is the best modality to evaluate posterior mediastinal masses
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