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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

okay to give heparin without knowing if there is a PE?

NOOOOO, must have dx of PE before give heparin