Pocket Pimped: General Surgery

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👀 What's the diagnosis? ⬇️ Scroll down to check out some of the most common questions you'll get asked after seeing a patient with this condition on your general surgery rotation!

Small Bowel Obstruction (SBO)

❓What are the three most common causes of SBO?
✅Most common: Adhesions from prior surgery
✅Second: Malignant tumor
✅Third: Hernia

❓What are the most common symptoms of a SBO?
✅Colicky abdominal pain, nausea, vomiting, distention, inability to pass stool or flatus.

❓Why are patients with SBOs at risk for dehydration?
✅Water and electrolytes accumulate in the dilated small bowel resulting in third spacing, which results in intravascular volume loss and dehydration.

❓What metabolic abnormalities are expected with frequent vomiting secondary to a SBO?
✅Hypochloremic hypokalemic metabolic alkalosis - due to loss of hydrochloric acid from the stomach. Lost H+ is replaced via the gastric H/K pump, resulting in hypokalemia.

❓What type of X-ray should be ordered to evaluate a SBO and what findings are consistent with obstruction?
✅Upright and supine abdominal x-rays. Air fluid levels on upright radiographs.

How would you have done if asked these questions on rotation?

💪 These are just some of the 1500 questions in "Pocket Pimped: General Surgery", a book designed to help you succeed on rotations and know the exact questions and answers you'll get asked!

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Let's talk FLUIDS!

What are some examples of crystalloid solutions? Colloid solutions?
Crystalloids - Normal saline (NS), Lactated Ringers (LR), Plasmalyte
Colloids - Albumin, Blood products (ie platelets, cryoprecipitate, RBCs, etc)

What are the mEq of Na and Cl in each of the 3 crystalloids listed above?
NS - Na: 154, Cl: 154
LR - Na: 130, Cl: 109
Plasmalyte - Na: 140, Cl: 98

What are the respective pHs of NS, LR and plasmalyte?
NS: 5.5
LR: 6.5
Plasmalyte: 7.4 (most physiologic)

What is the difference between resuscitative fluids and maintenance fluids?
Resuscitative fluids are used for patients who are intravascularly depleted from a biologic or metabolic process
Maintenance fluids are used in patients who are intravascularly replete, but are unable to take in oral fluids to maintain euvolemic status

Now that you have the basics down, let's kick it up a notch with more questions straight from Pocket Pimped: General Surgery....

What physiologic derangement occurs with administration of too much NS?

What is typically used for maintenance fluid in surgical patients? Why?

Happy Halloween

Cases involving axillary dissection can be very intimidating to study for, but we got you covered. 💪

Here are some of our favorite questions, straight out of "Pocket Pimped: General Surgery" we KNOW you'll be asked! 📖

#264. What are the 3 anatomic levels of axillary lymph nodes in relation to the pectoralis minor muscle?
▶️ Level I: lateral
▶️ Level II: posterior
▶️ Level III: medial (easiest to see when the pec. minor muscle is divided)

#265. What is a synonym for the interpectoral lymph nodes located between the pec. minor and major muscles?
▶️ Rotter’s nodes

268. What are the borders of the axilla?
▶️ Superior: axillary vein
▶️ Anterior: pectoralis muscle
▶️ Medial: serratus anterior muscle
▶️ Posterolaterally: latissimus dorsi

269. What 3 major motor nerves are commonly encountered during an axillary dissection? What do they innervate?
1️⃣ Long thoracic nerve: serratus anterior muscle
2️⃣ Thoracodorsal nerve: latissimus dorsi muscle
3️⃣ Medial pectoral nerve: pectoralis minor and major (partial) muscles

270. What is the primary sensory nerve encountered during an axillary dissection?
▶️ Intercostobrachial nerve

271. What pathology results from injury to the long thoracic nerve?
▶️ Winged scapula

🗣Airway management is a crucial part of surgical training and is covered in the trauma section of "Pocket Pimped: General Surgery", a pocket sized book of all the questions/answers you WILL be asked on rotations! Here are just a few questions from that section 📖

#1103. What is a definitive airway?
▶️Cuffed endotracheal tube below the vocal cords - orotracheal tubes, nasotracheal tubes, surgical
airway (i.e. cricothyroidotomy or tracheostomy)

#1104. What GCS score is an indication to intubate?
▶️< 8 (Remember: less than eight, intubate)

#1105. What are the superior and inferior surface landmarks for cricothyroidotomy?
▶️Superior - Thyroid cartilage
▶️Inferior - Cricoid cartilage

#1106. Should the incision be made vertically or horizontally, why?
▶️Vertically - avoids anterior jugular veins

#1107. When should a cricothyroidotomy be converted to a tracheostomy?
▶️Within 48 hours

It's never too late to start crushing your rotations and exams! 💯

Some humor for Monday!

One topic that lends itself to ALOT of questions is hernia surgery. Here, we ask only a few questions related to this topic (for a full list of must know questions be sure to check out your Pocket Pimped: General Surgery book).

1️⃣What are the options for repair of an inguinal hernia?
➡️Open vs. laparoscopic
➡️Open repair options:
⏩⏩Tension free (mesh): Lichtenstein plug and patch
⏩⏩Primary tissue repair: Bassini, Cooper’s ligament repair, McVay repair, Shouldice
2️⃣What is a Bassini repair? Shouldice repair?
➡️Bassini: suture repair of an inguinal hernia where the transverse abdominus aponeurosis is sutured to the inguinal ligament
➡️Shouldice: suture repair of an inguinal hernia where the hernia is repaired in multiple layers

3️⃣What is a McVay repair? When is this repair utilized?
➡️Primary tissue repair where Cooper’s ligament is sutured to the transverse abdominus aponeurosis
➡️Utilized in the repair of a femoral hernia

4️⃣What is the difference between a TAPP and a TEP hernia repair?
➡️TAPP: trans-abdominal, pre-peritoneal approach
➡️TEP: totally extra-peritoneal approach
➡️Main difference is the way in which the pre-peritoneal space is accessed
⏩⏩TAPP: pre-peritoneal space is accessed laparoscopically by opening from inside the abdominal cavity
⏩⏩TEP: abdominal cavity is never entered; a balloon dissector is used to create a space within the pre-peritoneal cavity

5️⃣What are the indications for mesh placement in repairing an umbilical hernia?
➡️

Let’s review some general knowledge of circulation! Here are some must know facts related to this topic

1️⃣What is Beck’s triad (associated with cardiac tamponade)?
☑️Hypotension, muffled heart sounds, JVD

2️⃣What is Kussmaul’s sign?
☑️JVD with inspiration

3️⃣What is pulsus paradoxus?
☑️Decrease in SBP >10 mmHg during inspiration

4️⃣What minimum systolic BP is required to have a palpable radial pulse? Carotid/femoral?
☑️Radial: 80 mmHg
☑️Carotid/femoral: 60 mmHg

5️⃣What are the landmarks for femoral central venous access?
☑️1 cm below the inguinal ligament
☑️Medial to the femoral artery

6️⃣What is the orientation from lateral to medial of the femoral artery, vein, nerve and lymphatics?
☑️Nerve ➡️ Artery ➡️ Vein ➡️ Lymphatics
‼️Remember: “NAVeL”

7️⃣What is Poiseuille’s law and why is this important for vascular access in trauma patients?
☑️Flow rate is proportional to (radius)4 of the cannula and inversely proportional to cannula length
☑️Short, large-caliber catheters are preferred for rapid infusion

8️⃣Where are acceptable intraosseous access sites?
☑️Proximal humerus, distal femur, proximal tibia (most common), distal tibia

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Let’s review something’s about the appendix! While on your rotation, the appendix is one of the most commonly asked anatomic structures. Here are some must know appendix general anatomy questions you may be asked!

1️⃣What is the function of the appendix?
✅Immunologic organ, secretes immunoglobulins (IgA)

2️⃣Is the appendix foregut, midgut, or hindgut?
✅Midgut

3️⃣How is the appendix located? What is the most common location? Other locations?
✅Follow the convergence of the taeniae to the tip of the cecum
✅Most common location: retrocecal
✅Other locations: (counter clock-wise) subcecal, pelvic, pre-ileal, post-ileal

4️⃣What is the blood supply to the appendix?
✅Appendiceal artery

5️⃣Name the blood supply to the appendix starting at the aorta.
✅SMA ➡️ ileocolic artery ➡️ appendiceal artery

6️⃣What is the normal length of the appendix? Diameter?
✅Length: ~9 cm
✅Diameter:

Knowledge bombs 💣

Make sure you’re ready for your General Surgery rotation!

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Test your knowledge!

Are you ready for rotations?

📕 “Pocket Pimped: General Surgery” is a collection of the 1500 questions you’ll get asked on rotations. No fluff, just the questions you’ll be asked and the answers they want to hear.

Study smarter! 💡

Happy Independence Day!

🚨 F.A.S.T Exam 🚨

Focused Assessment with Sonography for Trauma (FAST) is a rapid bedside test used identify free fluid in trauma patients.

The typical FAST exam consists of 4 views.
1️⃣ RUQ- Perihepatic and Hepatorenal spaces
2️⃣ LUQ- Perisplenic and Splenorenal spaces
3️⃣ Pelvis and Pouch of Douglas
4️⃣ Pericardium

You just know normal anatomy and physiology before you can identify abnormal.
⏩ SWIPE to check out some normal images from a FAST exam. Make sure you know what anatomic regions visible in each portion of the exam!

🗓 July 1st and the start of a new academic year is almost here - make sure you’re prepared!

“Pocket Pimped: General Surgery” for all of the most know questions and answers for your rotations. No fluff, just the need to know info to help you stand out! 🏆

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July is almost here, are you READY? 📖

Happy Father’s Day to all those you are fathers during medical school, residency, fellowship, and/or while practicing. It is a tough journey by itself and those who are fathers during these times are further tested (but also greatly rewarded)!

All the info you need to crush your rotations in one book and now available on your phone! 📱

“Pocket Pimped: General Surgery” is a collection of the 1,500 questions and answers you’ll be asked on rotations. Preparation is everything, make sure you’re ready for your next rotation!

Now available on your phone through the Memorang app so you can study on the go!
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Study the way that works best for you! Make sure you’re ready to go. For many of you, these next few months will shape your future!

Sometime you just need to laugh. Hope this helps!

Pocket Pimped reviews airway management. Here are some must know questions (and answers) related to this topic. How would you have done if you were asked these questions by the program director while on your general surgery rotation?
•
1️⃣What is a definitive airway?
✔️Cuffed endotracheal tube below the vocal cords
✔️Orotracheal tubes, nasotracheal tubes, surgical airway (i.e. cricothyroidotomy or tracheostomy)

2️⃣ What GCS score is an indication to intubate?
✔️≤8
➡️Remember: less than eight, intubate

3️⃣What are the landmarks for an emergency cricothyroidotomy?
✔️Thyroid cartilage (superior): “Adam’s apple”
✔️Cricoid cartilage (inferior)
✔️Incise the cricothyroid membrane

4️⃣Why is a vertical skin incision best for a cricothyroidotomy?
✔️Avoids the anterior jugular veins

5️⃣When should a cricothyroidotomy be converted to a tracheostomy?
✔️Within 48 hours

6️⃣What are potential causes of unilaterally decreased or absent breath sounds?
✔️Main stem intubation, pneumothorax, kinked endotracheal tube, bronchus occlusion

Mesenteric ischemia occurs following interruption of the blood supply to various portions of the small bowel leading to ischemia and secondary inflammatory changes. While an uncommon cause of abdominal pain overall, it is likely something you’ll get asked about!

Here are some our favorite questions from the book- for more like these check out the whole book, “Pocket Pimped: General Surgery” 📖
⏩⏩ POCKETPIMPED.COM ⏪⏪

📕 #1481. What is the most common cause of acute mesenteric ischemia? What artery is most commonly affected?
▶️ Embolic occlusion secondary to atrial fibrillation
▶️ The superior mesenteric artery (just distal to the first jejunal branch

📕 #1482. What is the most common symptom of acute mesenteric ischemia?
▶️Sudden onset of abdominal pain out of proportion to exam (Hematochezia is a late finding)

📕 #1483. What drug has been associated with acute mesenteric ischemia?
▶️ Digitalis

Bonus: Which letter in the figure represents the SMA? Message us the correct answer and we’ll give you a 20% off coupon good for 24 hours only!

🚨 Resuscitative Thoracotomy 🚨
While not so common that most people will see one, that doesn’t mean you won’t get asked about it!

INDICATIONS:
▶️ Penetrating thoracic trauma in a pulseless patient who has signs of life or has been without signs of life for

Pocket Pimped wishes everyone a Happy Easter!

Pocket Pimped reviews wound healing. Here are some must know questions (and answers) related to this topic. Hope this helps!
•
1️⃣What are some factors that inhibit wounds from healing?
✔️Infection, ischemia/hypoxia, diabetes, ionizing radiation, malnutrition, vitamin deficiencies (A and C), mineral deficiencies (zinc, iron), drugs (i.e. doxorubicin, cyclophosphamide, methotrexate)

2️⃣How do steroids affect wound healing? What vitamin can assist in reversing these effects?
✔️Prevent fibroblast proliferation and collagen synthesis which prevents granulation tissue from forming
✔️Vitamin A

3️⃣What is the most common cause of wound healing failure? How can you assess for this?
✔️Ischemia
✔️Transcutaneous oxygen pressure (assess wound perfusion and oxygenation)
➡️Pressure 200 mmHg during hyperbaric oxygen therapy suggests potential benefit from hyperbaric oxygen therapy

4️⃣How does hyperbaric oxygen therapy work?
✔️Inhalation of 100% oxygen at 1.9 to 2.5 atmospheres increases the PO2 in the tissues 10x higher than normal
✔️Higher PO2 supplies the tissues with the necessary metabolic requirements for healing

5️⃣What is a prerequisite before hyperbaric oxygen therapy?
✔️Evaluation of vascular supply to the target area

6️⃣How does negative pressure wound therapy (i.e. wound vac) affect wound healing?
✔️Removes chronic edema, increases local blood flow, and stimulates granulation tissue

7️⃣What are some disease processes associated with abnormal wound healing?
✔️Osteogenesis imperfecta, Ehlers-Danlos syndrome, Marfan syndrome, scurvy, epidermolysis bullosa

Several academies have released statements saying how important rotation performance is becoming due to recent pass/fail nature of the USMLE. More than ever, it is important to highlight your skill set and knowledge while on your general surgery rotation. How good is your neck anatomy? Do you think you’d be able to answer questions about this topic while on your general surgery rotation? Remember, you are there to impress the residence and the attendings. How well would you do if asked the following questions (answers below)?
•
QUESTIONS
1️⃣ what are the four infrahyoid (“strap”) muscles commonly used as landmarks during thyroid surgery?
2️⃣ What posterior suspensory structure is the primary point of fixation of the thyroid to surrounding structures, including the trachea?
3️⃣ What does the external branch of the superior laryngeal nerve innervate?
4️⃣ What are the origins of the superior and inferior thyroid arteries?
•
ANSWERS
1️⃣ Omohyoid, sternohyoid, thyrohyoid, and sternothyroid
2️⃣ ligament of Berry
3️⃣ Cricothyroid muscle
4️⃣ superior: external carotid artery; inferior: thyrocervical trunk (from the subclavian artery)
•
These are only for questions of general anatomy related to the thyroid. There are so many more questions that can be asked and they can easily be found in Pocket Pimped General Surgery. Be sure to have all of the questions that are likely to be asked related at your fingertip. Best of luck on your endeavors!

Congrats to all of those who matched! Pocket Pimped is proud of all of your hard work! Enjoy the moment.
•
For all of those who are about to start the process, will be here before you know it. With a growing emphasis on rotation performance and knowledge (due to a Pass/Fail USMLE), being prepared is more important than ever! Pocket Pimped wants to help you succeed. To celebrate, we are offering a 20% off discount on any of our books (including the series) until 3/20/22 at 23:59. Study hard!
•
Use code Match20 at PocketPimped.com
•

Pocket Pimped reviews the Basic Principles of Abdominal Hernias! Here are some most know principles:
•
What is a hernia? What does it mean when a hernia is reducible? Incarcerated? Strangulated?
1️⃣Hernia: abnormal protrusion of tissue through a defect in the surrounding tissues
2️⃣Reducible: contents of the hernia can be pushed back through the defect and are not stuck
3️⃣Incarcerated: hernia cannot be reduced
4️⃣Strangulated: the blood supply to the tissues within the hernia has been compromised
•
What is the most common type of hernia?
1️⃣Inguinal
•
Which is the most common type of inguinal hernia: direct or indirect?
1️⃣Indirect
➡️Most common in both males and females
•
Are indirect inguinal hernias more common on the right or left? Why?
1️⃣Right
2️⃣Delayed descent of the right testicle during development causes delayed closure of the processus vaginalis

Can you make the diagnosis based on this chest X-ray? 👀

⬇️ Scroll down for the answer ⬇️

Hiatal hernias occur when stomach content herniate through the esophageal hiatus. There are 4 types that are commonly asked!
Type 1: Sliding hernia
➡️ Dilation of the hiatus
Type 2: Paraesophageal
➡️ Stomach slides up in to the chest along the esophagus through a hole in the diaphragm; GE junction remains intra-abdominal.
Type 3: Combined (types 1&2)
Type 4: Entire stomach + another organ (ie colon,spleen etc).

Surgical repair consists of full reduction of the hernia sac, repair of the hernia defect, and Nissan fundoplication).

📖 “Pocket Pimped: General Surgery” is a collection of the 1500 most commonly asked questions you’ll be asked. We took all the guess work out of it -just the questions and answers you need to know in a book that fits in your pocket! 📖

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