Chapter 1 / Introduction 25
Rubor
Redness; a classic sign of inflammation
Steatorrhea
Fatty stools as a result of decreased fat absorption
Stenosis
Abnormal narrowing of a passage or opening
Sterile field
Area covered by sterile drapes or prepped in sterile fashion using antiseptics (e.g., Betadine®)
Succus
Fluid (e.g., succus entericus is fluid from the bowel lumen)
Tenesmus
Urge to defecate with ineffectual straining
Thoracotomy
Surgical opening of the chest cavity
Transect
To divide transversely (to cut in half)
Trendelenburg
Patient posture with pelvis higher than the head, inclined about 45 (a.k.a. “headdownenburg”)
Urgency
Sudden strong urge to urinate; often seen with a UTI
Wet-to-dry W et-to-dry dressing
Damp gauze dressing placed on a wound and removed after the dressing dries to the wound, providing microdébridement
Surgery Signs, Triads and Sydromes
SURGERY SURGER Y SIGNS,TRIADS, ETC. YOU SHOULD SHOULD KNOW KNOW
What are the ABCDs of melanoma?
Signs of melanoma: A symmetric symmetric Border irregularities Color variation Diameter 0.6 cm and Dark color
26 Section I / Overview and Background Surgical Information
What is the Allen’s test?
Test for patency of ulnar artery prior to placing a radial arterial line or performing an ABG: Examiner occludes both ulnar and radial arteries with fingers as patient makes fist; patient opens fist while examiner releases ulnar artery occlusion to assess blood flow to hand
Ulnar artery Radial artery
Define the following terms: Ballance’s sign
Constant dullness to percussion in the left flank/LUQ and resonance to percussion in the right flank seen with splenic rupture/hematoma
Barrett’s esophagus
Columnar metaplasia of the distal esophagus (GERD related)
Battle’s sign
Ecchymosis over the mastoid process in patients with basilar skull fractures
Battle’s sign
Chapter 1 / Introduction 27
Beck’s triad
Seen in patients with cardiac tamponade: 1. JVD 2. Decreased or muffled heart sounds 3. Decreased blood pressure
Bergman’s triad
Seen with fat emboli syndrome: 1. Mental status changes 2. Petechiae (often in the axilla/thorax) 3. Dyspnea
Blumer’s shelf
Metastatic disease to the rectouterine (pouch of Douglas) or rectovesical pouch creating a “shelf” that is palpable on rectal examination
Boas’ sign
Right subscapular pain resulting from cholelithiasis
Borchardt’s triad
Seen with gastric volvulus: 1. Emesis followed by retching 2. Epigastric distention 3. Failure to pass an NGT
Carcinoid triad
Seen with carcinoid syndrome (Think: “FDR”): 1. Flushing 2. Diarrhea 3. Right-sided heart failure
Charcot’s triad
Seen with cholangitis: 1. Fever (chills) 2. Jaundice 3. Right upper quadrant pain (Pronounced “char-cohs”)
Chvostek’s sign
Twitching of facial muscles upon tapping the facial nerve in patients with hypocalcemia (Think: CH vostek’s CHeek)
Courvoisier’s law
Enlarged nontender gallbladder seen with obstruction of the common bile duct, most commonly with pancreatic cancer Note: not seen with gallstone obstruction because the gallbladder is scarred secondary to chronic cholelithiasis (Pronounced “koor-vwah-ze-ay”)
28 Section I / Overview and Background Surgical Information
Cullen’s sign
Bluish discoloration of the periumbilical area due to retroperitoneal hemorrhage tracking around to the anterior abdominal wall through fascial planes (e.g., acute hemorrhagic pancreatitis)
Umbilicus
Cushing’s triad
Signs of increased intracranial pressure: 1. Hypertension 2. Bradycardia 3. Irregular respirations
Dance’s sign
Empty right lower quadrant in children with ileocecal intussusception
Fothergill’s sign
Used to differentiate an intra-abdominal mass from one in the abdominal wall; if mass is felt while there is tension on the musculature, then it is in the wall (i.e., sitting halfway upright)
Fox’s sign
Ecchymosis of inguinal ligament seen with retroperitoneal bleeding
Goodsall’s rule
Anal fistulae course in a straight path anteriorly and a curved path posteriorly from midline (Think of a dog with a straight anterior nose and a curved posterior tail)
Chapter 1 / Introduction 29 Anterior
Posterior
Goodsall
Grey Turner’s sign
Ecchymosis or discoloration of the flank in patients with retroperitoneal hemorrhage as a result of dissecting blood from the retroperitoneum (Think: TURNer’s TURN side-to-side flank)
Hamman’s sign/crunch
Crunching sound on auscultation of the heart resulting from emphysematous mediastinum; seen with Boerhaave’s syndrome, pneumomediastinum, etc.
Homans’ sign
Calf pain on forced dorsiflexion of the foot in patients with DVT
Howship-Romberg sign
Pain along the inner aspect of the thigh; seen with an obturator hernia as the result of nerve compression
Kehr’s sign
Severe left shoulder pain in patients with splenic rupture (as a result of referred pain from diaphragmatic irritation)
Kelly’s sign
Visible peristalsis of the ureter in response to squeezing or retraction; used to identify the ureter during surgery
Krukenberg tumor
Metastatic tumor to the ovary (classically from gastric cancer)
Laplace’s law
Wall tension pressure radius (thus, the colon perforates preferentially at the cecum because of the increased radius and resultant increased wall tension)
30 Section I / Overview and Background Surgical Information
McBurney’s point
One third the distance from the anterior iliac spine to the umbilicus on a line connecting the two
McBurney’s sign
Tenderness at McBurney’s point in patients with appendicitis
Meckel’s diverticulum rule of 2s
2% of the population have a Meckel’s diverticulum, 2% of those are symptomatic, and they occur within 2 feet of the ileocecal valve
Mittelschmerz
Lower quadrant pain due to ovulation
Murphy’s sign
Cessation of inspiration while palpating under the right costal margin; the patient cannot continue to inspire deeply because it brings an inflamed gallbladder under pressure (seen in acute cholecystitis)
Obturator sign
Pain upon internal rotation of the leg with the hip and knee flexed; seen in patients with appendicitis/pelvic abscess
Pheochromocytoma SYMPTOMS triad
Think of the first three letters in the word pheochromocytoma—“P-H-E”: Palpitations Headache Episodic diaphoresis
Pheochromocytoma rule of 10s
10% bilateral, 10% malignant, 10% in children, 10% extra-adrenal, 10% have multiple tumors
Chapter 1 / Introduction 31
Psoas sign
Pain elicited by extending the hip with the knee in full extension, seen with appendicitis and psoas inflammation
Raccoon eyes
Bilateral black eyes as a result of basilar skull fracture
Reynold’s pentad
1. Fever 2. Jaundice 3. Right upper quadrant pain 4. Mental status changes 5. Shock/sepsis Thus, Charcot’s triad plus #4 and #5; seen in patients with suppurative cholangitis
Rovsing’s sign
Palpation of the left lower quadrant resulting in pain in the right lower quadrant; seen in appendicitis
Saint’s triad
1. Cholelithiasis 2. Hiatal hernia 3. Diverticular disease
Silk glove sign
Indirect hernia sac in the pediatric patient; the sac feels like a finger of a silk glove when rolled under the examining finger
32 Section I / Overview and Background Surgical Information
Sister Mary Joseph’s sign (a.k.a. Sister Mary Joseph’s node)
Metastatic tumor to umbilical lymph node(s)
Virchow’s node
Metastatic tumor to left supraclavicular node (classically due to gastric cancer)
Virchow’s triad
Risk factors for thrombosis: 1. Stasis 2. Abnormal endothelium 3. Hypercoagulability
Trousseau’s sign
Carpal spasm after occlusion of blood to the forearm with a BP cuff in patients with hypocalcemia
Valentino’s sign
Right lower quadrant pain from a perforated peptic ulcer due to succus/ pus draining into the RLQ
Westermark’s sign
Decreased pulmonary vascular markings on CXR in a patient with pulmonary embolus
Whipple’s triad
Evidence for insulinoma: 1. Hypoglycemia (50) 2. CNS and vasomotor symptoms (e.g., syncope, diaphoresis) 3. Relief of symptoms with administration of glucose
Chapter
2
Surgical Syndromes
What is afferent loop syndrome?
Obstruction of the afferent loop of a Billroth II gastrojejunostomy
What does ARDS stand for?
A cute Respiratory Distress S yndrome (poor oxygenation caused by leaky capillaries)
Chapter 2 / Surgical Syndromes 33
What is blind loop syndrome?
Bacterial overgrowth of intestine caused by stasis
What is Boerhaave’s syndrome?
Esophageal perforation
What is Budd-Chiari syndrome?
Thrombosis of hepatic veins
What is carcinoid syndrome?
Syndrome of “B FDR”: Bronchospasm Flushing Diarrhea Right-sided heart failure (caused by factors released by carcinoid tumor)
What is compartment syndrome?
Compartmental hypertension caused by edema, resulting in muscle necrosis of the lower extremity, often seen in the calf; patient may have a distal pulse
What is Cushing’s syndrome?
Excessive cortisol production
What is dumping syndrome?
Delivery of a large amount of hyperosmolar chyme into the small bowel, usually after vagotomy and a gastric drainage procedure (pyloroplasty/ gastrojejunostomy); results in autonomic instability, abdominal pain, and diarrhea
What is Fitz-Hugh-Curtis syndrome?
Perihepatic gonorrhea infection
What is Gardner’s syndrome?
GI polyps and associated findings of Sebaceous cysts, Osteomas, and Desmoid tumors (SOD); polyps have high malignancy potential (Think: A Gardner plants SOD)
What is HITT syndrome?
Heparin-Induced Thrombocytopenic Thrombosis syndrome: Heparin-induced platelet antibodies cause platelets to thrombose vessels, often resulting in loss of limb or life
34 Section I / Overview and Background Surgical Information
What is Leriche’s syndrome?
Claudication of buttocks and thighs, Impotence, A trophy of legs (seen with iliac occlusive disease) (Think: CIA )
What is Mallory-Weiss syndrome?
Post-emesis/-retching tears in the gastric mucosa (near gastroesophageal junction)
What is Mendelson’s syndrome?
Chemical pneumonitis after aspiration of gastric contents
What is Mirizzi’s syndrome?
Extrinsic obstruction of the common hepatic bile duct from a gallstone in the gallbladder or cystic duct
What is Munchausen syndrome?
Self-induced illness
What is Ogilvie’s syndrome?
Massive nonobstructive colonic dilatation
What is Peutz-Jeghers syndrome?
Benign GI polyps and buccal pigmentation (Think: Peutz Pigmentation)
What is Plummer-Vinson syndrome?
Syndrome of: 1. Esophageal web 2. Iron-deficiency anemia 3. Dysphagia 4. Spoon-shaped nails 5. Atrophic oral and tongue mucosa Typically occurs in elderly women; 10% develop squamous cell carcinoma
What is RED reaction syndrome?
Syndrome of rapid vancomycin infusion, resulting in skin erythema
What is refeeding syndrome?
Hypokalemia, hypomagnesemia, and hypophosphatemia after refeeding a starved patient
What is Rendu-Osler-Weber (ROW) syndrome?
Syndrome of GI tract telangiectasia/A-V malformations
What is short-gut syndrome?
Malnutrition resulting from 200 cm of viable small bowel
Chapter 3 / Surgical Most Commons 35
What is SIADH?
S yndrome of Inappropriate A ntiDiuretic Hormone (Think: Inappropriately Increased ADH)
What is another name for Sipple’s syndrome?
MEN II
What is superior vena cava (SVC) syndrome?
Obstruction of the SVC (e.g., by tumor, thrombosis)
What is thoracic outlet syndrome?
Compression of the structures exiting from the thoracic outlet
What is Tietze’s syndrome?
Costochondritis of rib cartilage; aseptic (treat with NSAIDs)
What is toxic shock syndrome?
Staphylococcus aureus toxin-induced syndrome marked by fever, hypotension, organ failure, and rash (desquamation— especially palms and soles)
What is Trousseau’s syndrome?
Syndrome of deep venous thrombosis (DVT) associated with carcinoma
What is another name for Wermer’s syndrome?
MEN I
What is Zollinger-Ellison syndrome?
Gastrinoma and PUD
Chapter
3
What is the most common: Indication for surgery with Crohn’s disease?
Surgical Most Commons Small bowel obstruction (SBO)
Type of melanoma?
Superficial spreading
Type of breast cancer?
Infiltrating ductal
