Flashcards in Gen Surg Deck (189):
1
numer one limiting factor prior to surgery is....
hx of cardiovascular disease
2
history of CV disease predisposing to surgery complications
- EF
3
if had a recent MI and surgery
must defer surgery for 6 months and stress the patient at that interval
4
patient has CHF and needs surgery for something else
give the drugs that decrease mortality:
ACE inhibitors, beta blockers, spironolactone
5
cardiovascular risk factor if male
male older than 45yo
6
patient with CV risk factors-- what needs to be done before surgery
- bp meds adjusted
- daily finger sticks monitored
- insulin regimen adjusted
- stress test with ECG
(possibly ECHO if murmur)
7
preop assessment if under 35yo and no hx of cardiac disease
EKG ONLY
8
preop assessment if hx of cardiac disease and ANY AGE
- EKG
- stress testing-- evaluate for ischemic coronary lesions
- ECHO for structural disease, and for ejection fraction
9
preop assessment PFT's necessary for...
known lung disease
smoking history
10
preop patient is a smoker-- what suggestions
quit smoking for 6-8weeks before surgery and use nicotine patch in meantime
11
preop assessment patient with renal disease
- give fluids before and during surgery
- if patient is on dialysis, dialyze pt 24hrs before surgery
12
ABC's: airway
- no facial trauma= orotracheal tubes
- facial trauma= cricothyroidotomy
- C-spine injury= orotracheal tube with flexible bronchoscopy
13
ABC's: breathing
O2 sats above 90%= ideal
14
ABC's: circulation
insert 2 large bore IV cannulas and being aggressive fluid resuscitation to prevent hypovolaemic shock
15
cool skin, shock
cardiogenic or hypovolaemic shock
16
cardiogenic vs. hypovolaemic shock
PCWP/LVEDP:
cardio: increased
hypo: decreased
17
warm skin, shock
neurogenic, anaphylactic, septic
18
CO change in neurogenic shock
decreased CO
19
CO change in anaphylactic and septic shock
increased CO
20
PCWP change anaphylactic vs. septic shock
anaphylactic: decreased
septic: no change
21
sepsis definition
2/4 and infection source
22
SIRS criteria
2/4
1. bp: less than 36, greater than 38
2. HR: greater than 90bpm
3. resp: tachypnea>20breaths/min, or O2 sats
23
severe sepsis
2/4 + infection source + organ dysfunction
24
septic shock definition
2/4 + infection source + organ dysfunction + HYPOtn
25
example of "infection source"
CXR: shows infiltrates= pneumonia
26
car accident and abdomen hurts, and end up with large ecchymosis on right flank, most likely diagnosis
HAEMORRHAGIC PANCREATITIS
27
complication 6-8 weeks after pancreatitis
pancreatic pseudocyst
28
differential for cullen sign
haemorrhagic pancreatitis
ruptured aortic aneurysm
29
grey turner sign
flank bruising--> RETROperitoneal haemorrhage
30
kehr sign
pain in L shoulder---> splenic rupture
31
balance sign
dull percussion of the L and shifting dullness on the R--> splenic rupture
32
seatbelt sign
bruising where the seatbelt was--> deceleration injury
33
free air under the diaphragm
perforation of the bowel, best initial test= UPRIGHT CXR
34
imaging of choice paralytic ileus
abdominal xray
35
abdominal trauma-- imaging to be done
1. US-- ASAP
2. CT-- check for retroperitoneal bleed (even if the US was normal)
36
blunting of costophrenic angle on chest XR and CT
hemothorax
37
urethral meatus injury and high riding prostate, what next...
1. KUB followed by....
2. RETROGRADE URETHROGRAM
3. then..... foley catheter (don't do this immediately because it can lead to further urethral damage; just placed to aid in urination)
38
MOST ACCURATE TEST--suffering from ischaemic bowel (severe pain out of proportion to physical findings)
ANGIOGRAPHY or surgery
39
severe abdo pain 10/10 no guarding, soft abdomen and no rebound tenderness
PAIN OUT OF PROPORTION= MESENTERIC ISCHAEMIA
40
best initial test ischemic bowel
CT of the abdomen
41
tx mesenteric ischaemia
IV normal saline, followed by surgical removal necrotic bowel
42
types of abdominal pain that DO NOT require surgery
MI
GERD
Lower lobe pneumonia
acute porphyrias
43
2 mc sites of mesenteric ischaemia
splenic and hepatic flexures
44
number one risk factor for mesenteric ischemia
A FIB--- shoots off an emboli
45
best initial test ischaemic bowel vs. mesenteric ischaemia
ischaemic bowel= CT abdo
mesenteric isch= abdo XR: air in bowel wall
46
pain in tip of penis or perineum
referred pain from prostate
47
pain in the ears
referred pain from pharynx
48
crunching upon palpation of the thorax due to subcutaneous emphysema
HAMMAN'S sign-- form boerhaave/ eso perforation
49
most common cause of esophageal perforation
IATROGENIC-- endoscopy
50
mortality with boerhaave syndrome, even with surgery
25%
51
most accurate test in diagnosis of eso rupture
ESOPHOGRAM: using diatrizoate meglumine and diatrizoate sodium solution (GASTROGRAFFIN), which shows leakage of contrast outside the esophagus
52
barium used in esophagram for eso rupture?
NOOOOO-- because it damages the tissues
53
tx of boerhaave
surgery
54
complication with high mortality rate in boerhaave surgery
MEDIASTINITIS
55
don't forget that gastric perforation can cause....
PANCREATITIS, recall ulcers erode--> release gastric acid--> activate enzymes
56
pain from gastric perforation
right shoulder pain
57
most accurate test for gastric perforation
abdo CT
58
best initial test for gastric perforation
erect CXR
59
tx for gastric perforation HYHYHYHYHYHHYHY
1. NPO
2. NG tube
3. Medical mgmt
4. Surgical mgmt
60
medical mgmt of gastric perforation
1. broad spectrum antibiotics-- combat infection
2. IV fluids in prep for surgery
61
surgical mgmt of gastric perforation
exploratory laporotomy and repair of the perforation
62
acute diverticulitis first round tx
medical tx-- antibiotics, fluids, pain etc.
63
recurrent diverticulitis tx
SURGERY
64
most common complication post-diverticulitis
ABSCESS
65
okay to do barium enema and colonoscopy in diverticulitis?
NOOOOO--causes perforation
66
right lower quadrant pain in someone>60yo
CECAL diverticulitis
67
diagnostic test for ovarian torsion
doppler US
68
diagnosis of abdominal abscess
CT scan
69
treatment of abdominal abscess
CT or US guided incision and drainage, and antibiotics
70
US findings of acute cholecystitis
pericholecystic fluid and thickened gallbladder wall
71
only 2 differentials for abdo pain radiating to the back
1. pancreatitis
2. aortic dissection
72
diagnostic test for appendicitis
CT scan
73
2 complications from appendicitis
abscess and gangrenous perforation
74
best imaging for pancreatitis
CT scan;
amylase= sensitive
lipase= specific
75
best imaging for diverticulitis
CT scan= best and most accurate
76
best initial imaging for cholecystitis
US
77
most accurate test for cholecystitis
HIDA scan
78
HIDA scan
for cholecystitis-- shows delayed emptying of gallbladder ( can't visualize gallbladder form isotope accumulation)
79
3 signs of appendicitis
rovsing sign
posts sign
obturator sign
80
rovsing sign
palpation of the LLQ causes pain in the RLQ
81
psoas sign
pain the hip E
82
obturator sign
pain with internal rotation of the right thigh
83
hyperactive tinkling bowel sounds
small bowel obstruction, = intestinal fluid and air are under high pressure in the bowel
84
patient on chronic opiod with stool impaction, tx:
methylnaltrexone (relistor)
85
labs for small bowel obstruction
elevated WCC
elevated lactate
SIGNIFICANT ACIDOSIS
86
best initial test for SBO
abdo XR: multiple air fluid levels with delated loops of small bowel
87
most accurate test for SBO
CT scan of the abdomen
88
HYHYHYHHYHYHYHYHY mgmt of SBO
1. NPO
2. NG tube with suction
3. medical mgmt
4. surgical mgmt
89
medical mgmt of SBO
IV fluids to replace volume lost via third pacing
90
surgical mgmt of SBO
complete obs= EMERGENCY
lack of improvement with medical mgmt
91
fecal incontinence dx
CLINICAL
92
best initial test for fecal incontinence
flexible sigmoidoscopy or anoscopy
93
most accurate test for fecal incontinence
anorectal manometry
94
hx of anatomic injury with fecal incontinence
endorectal manometry
95
3 types of tx for fecal incontinence
1. medical
2. biofeedback
3. surgical
96
medical mgmt fecal incontinence
bulking agents--fiber
97
biofeedback mgmt fecal incontinence
control exercises and muscle strengthening exercises
98
what injection can decrease incontinence by 50%
dextranomer/hyaluronic acid (soloist)
99
dx of all fractures
XR
100
CLOSED REDUCTION
mild fractures without displacement
101
ORIF:
severe fractures with displacement or misalignment of bone pieces
102
open fractures mgmt
skin must be closed and the bone must be set in the operating room with debridement
103
PC of all fractures
pain/swelling/deformity
104
fracture where bone is shattered into multiple pieces
comminuted fractures
105
MCC of comminuted fractures
crush injuries
106
complete fracture from repetitive insults to bone
stress fracture
107
most common site of stress fractures
metatarsals
108
athlete with persistent pain--->
STRESS FRACTURE
109
Dx of stress fracture
CT or MRI> XR (doesn't show)
110
fracture of vertebrae in osteoporosis
compression fracture
111
location of compression fractures
1/3= lumbar
1/3= thoracolumbar
1/3= thoracic
112
older person fractures rib from coughing---->
PATHOLOGIC fracture
113
tx of pathologic fracture
surgical realignment
tx underlying disease
114
broken bone pierces skin
open fracture
115
tx for open fracture
ALWAYS ALWAYS ALWAYS SURGERY
116
strain on glenohumeral ligaments
anterior shoulder dislocation
117
arm held to the side with ER forearm with severe pain
anterior shoulder dislocation
118
anterior shoulder dislocation damages
axillary nerve/artery
119
best initial test for anterior shoulder dislocation, posterior shoulder dislocation and clavicular fracture
XR
120
most accurate test for anterior shoulder dislocation, posterior shoulder dislocation and clavicular fracture
MRI
121
tx anterior shoulder dislocation
relocation and immobilization
122
seizure or electrical burn
posterior shoulder dislocation
123
arm held to the side and medially rotated
posterior shoulder dislocation
124
tx of posterior shoulder dislocation
traction and surgery if pulses or sensation diminished during physical exam
125
tx clavicular fracture
simple arm sling
126
FOOSH
scaphoid fracture
127
imaging for scaphoid fracture
3 WEEKS for the XR to show
128
tx of scaphoid fracture
thumb spica cast
129
simple arm sling or figure 8 sling for clavicular fracture
SIMPLE ARM SLING-- since the figure 8 is not any better
130
tx trigger finger
steroid injection
131
definitive tx trigger finger
cut the sheet thats restricting the tendon
132
DUPUTYRENS IS NOT TRIGGER FINGER
duputyrens: men over 40yo, palmar fascia constricted, and hand cannot extend properly
133
only effective tx for duputyren
surgery
134
fat embolism syndrome
- confusion
- petechial rash
- SOB
135
dx fat embolism
1. ABG pO2
136
tx fat embolism
oxygen over 95%;
mechanical ventilation if become severely hypoxic
137
spinal stenosis leg pain
bilateral
alleviated by leaning forward (since opens the spinal canal)
138
claudication leg pain
unilateral
NO relief by leaning forward
139
dx spinal stenosis
spine MRI
140
tx of spinal stenosis
NSAID's or surgery
141
electric shock down dermatome distribution
herniated disc
142
patient group for herniated disc
elderly a/w lifting
143
dx of herniated disc
straight leg raise
144
confirmatory herniated disc
NSAID's
145
tx of herniated disc
NSAID's and activity modification
146
6P's of compartment syndrome (first 3= early)
Pain-- mc first; SEVERE, worse with muscle stretch
Pallor
Paresthesia
Paralysis
Pulselessness
Poikilothermia: cold to touch
147
mgmt torn ACL
arothroscopic repair
148
direct trauma to front of knee, pain and positive lachman
torn ACL
149
direct trauma to back of knee, pain and positive posterior drawer
torn PCL
150
traumatic injury to the knee, with POPPING SOUND with flexion and extension
meniscale injury
151
arthroscopic repair for which knee injuries
1. ACL
2. PCL
3. meniscal injury
152
surgical repair for which knee injury
medial and lateral collateral ligament
153
trauma to opposite side of injury
medial and lateral collecteral ligament
154
trauma to bent knee
medial collateral ligament
155
dx of ALL KNEE injuries
MRI
156
most common knee ligament injury
ACL
157
UNHAPPY TRIAD
medial OR lateral meniscus
medial collateral
ACL
158
most common sites for disc herniation
L4-5, L5-S1
159
AAA 3-4cm
US every 2-3 years
160
AAA 4-5.4cm
US or CT every 6-12mos
161
AAA greater than 5.5cm
surgical repair
162
ado US screening
former or current smokers over 65yo-- gives info on size, cost-effective, monitoring
163
relationship of AAA to surrounding vessels
CT/MRI
164
FASTEST diagnostic test for aortic disection
TEE -- used if patient clinical UNSTABLE
165
aortic dissection and patient is stable
MRA
166
mgmt ascending dissection
Sx ASAP and bp control
167
mgmt descending dissection
medical tx bp control
168
bp mgmt in dissection
1. BETA BLOCKERS= best intial,
2. followed by sodium nitroprusside (never give on own)
169
tricky question--- patient had emergency cholecystectomy, 3 days post-op, currently has fever
= UTI
170
post op day 1-2
WIND: atelectasis or postop pneumonia
171
post op day 3-5
WATER: uti
172
post op day 5-7
WALKING: DVT or thrombophlebitis at IV access lines
173
post op day 7
WOUND: wound infections or cellulitis
174
post op day 8-15
WEIRD: drug fever or deep abscess
175
how to prevent post op atelectasis or post op pneumonia
incentive spirometry
176
hospital acquired pneumonia tx
piptazo
177
UTI Dx
urinalysis: nitrates and leukocyte esterase
urine culture
178
DVT dx
doppler uS of LL
change IV access lines and culture IV tips
179
tx for DVT:
5 days heparin, as bridge to warfarin for 3-6months
180
deep abscess post op
dx: CT
tx: CT guided percuranteous drainage, otherwise sx
181
post op confusion
- hypoxic: atelectasis/pneumonia OR PE
- septic: bacteremia or UTI
182
DX ARDS
CXR: bilateral pul infiltrates WITHOUT JVD
183
Tx ARDS
positive end expiratory pressure, PEEP
184
best initial dx of PE
EKG: sinus tachycardia without evidence of ST changes
[cardiac enzymes and trooping to exclude cariidac chest pain]
185
tx of PE
heparin as a brdige to warfarin
186
patient has second PE while on warfarin
IVC filter via inguinal catheterization
187
next best step for PE.... and have allergy to IV contrast
EKG + V/Q scan
188
next best step for PE.... and have allergy to IV contrast
EKG + spiral CT scan
189