general Flashcards
(166 cards)
1
Q
causes of postop fever (> 38.5)
A
Wind: atelectasis, pneumonia Water: UTI Wound: infection Walking: pulm embolus arising from a DVT Wonder drug: drug fever
2
Q
most common cause of fever on first POD
A
atelectasis
3
Q
100/50/20 rule
A
fluid requirements for a 24 hr period
- 100 cc/kg for first 10 kg, 50 for next 10 and 20 for every kg over 20
4
Q
4/2/1 rule
A
hourly fluid requirements
- 4 cc/kg for first 10 kg, 2 for next 10, 1 for every kg over 20
5
Q
fluid in third space
A
- tachycardia and decreased urine output
- tx c IV hydration isotonic fluids
- caution: third space fluids will mobilize back to intravascular space around POD 3 and can cause fluid overload
6
Q
2 best fluids for increasing intravascular volume (resuscitation)
A
NS and Ringer’s solution (dextrose can cause hyperglycemia and osmotic diuresis)
7
Q
when to avoid ringer’s soln
A
in pts with metabolic or respiratory alkalosis (lactate converted by liver into HCO3)
8
Q
contraindication of adding K+ to fluid
A
if kidney’s don’t work
- make sure pt has adequate urine output
9
Q
rough estimate of fluid requirements (mL/hr)
A
weight + 40
10
Q
fluids for hypernatremia
A
dec. fluid intake but incr. insensible losses (ie: fever, burns)
- calculate water deficit = (TBW)(actual Na - desired Na)/desired Na
- if euvolemic replace c D5W
- if hypovolemic use NS (correct 1/2 in first 24 hrs, rest over next 1-2 days)
- lower 10-15 mEq/L/day not to exceed 25
- relace K+ after pt urinates
11
Q
fluids for hyponatremia
A
calculate Na deficit = (140-Na)(TBW)
- add to fluids
- watch out for central pontine myelinolysis (don’t incr. by >2 mEq/L/hr or 10-12 mEq/L/day)
12
Q
Tx hyperkalemia
A
CBIGK ○ 10% Calcium gluconate, 1g IV ○ Albuterol ○ Insulin + glucose ○ NaHCO3 ○ Kayexolate ○ Dialysis
13
Q
causes hyperkalemia
A
○ Renal failure
○ Spillage from cells in injury (also hemolysis)
○ Drugs: ACE-I’s, K+ sparing diuretics, Penicillin G, KCl in maintenance fluids, blood transfusions, digoxin toxicity
○ Hypoaldosteronism
○ Pseudohyperkalemia (lysed RBCs in test tube)
○ Acidosis
○ Insulin deficiency and DKA
14
Q
hyperkalemia S/S
A
○ N/V/D, intestinal colic
○ Weakness, paralysis, respiratory failure
○ Arrhythmia, cardiac arrest
15
Q
causes hypokalemia
A
○ Movement into cells b/c of insulin, catecholamines, alkalemia
○ Prolonged admin of K+- free fluids
○ TPN w/o adequate K+ replacement
○ GI losses: diarrhea, colonic fistulas, VIPoma
○ Diuretics
16
Q
hypokalemia S/S
A
○ Ileus, constipation
○ Decreased reflexes, fatigue, weakness, paralysis
○ Cardiac arrest
17
Q
Tx hypokalemia
A
○ First, check magnesium level, may have to correct with hypokalemia or won’t be able to get it back up
○ Replace potassium (4- current level)*100, in mEq
○ If asymptomatic, oral might be ok
○ Replace slowly and use ECG monitoring, don’t cause a fatal arrhythmia in your patient (no more than 40mEQ/hr)
○ Can cause IV burning, either use low flow (
18
Q
MUDPILERS
A
methanol uremia DKA propylene glycol/paraldehyde INH lactic acidosis EtOH/ethylene glycol rhabdo/renal failure salicylates
19
Q
non-AG metabolic acidosis causes
A
HARDUPS hyperalimentation acetazolamide renal tubular acidosis diarrhea utero-pelvic shunt post-hypocapnic spironolactone
20
Q
metabolic alkalosis causes
A
CLEVER PD contraction licorice endocrine (Conn's, Cushings, etc.) vomiting excess alkali refeeding alkalosis post-diuresis
21
Q
S/S compartment syndrome
A
pain out of proportion to injury
pain incr. on passive stretch
parasthesia (early)
rapidly increasing & tense swelling
22
Q
compartment syndrome
A
diagnosis: >30 mmHg
tx: fasciotomy (unless improving)
sx cause: repercussion of limb following artery-occlusive ischemia >4-6 hrs (edema)
23
Q
local vascular complication of cardiac catheterization
A
retroperitoneal hematoma (occurs within 12 hours) less common: bleeding, dissection, thrombosis, AV fistula
24
Q
S/S retroperitoneal hematoma
A
acute hemodynamic instability
ipsilateral flank or back pain
25
diagnosis of retroperitoneal hematoma
CT scan of abdomen and pelvis without contrast
| Tx: supportive, monitor, fluids
26
difference btwn arterial thrombosis and embolism
- embolism will have acute onset, thrombosis insidious
| - thrombosis likely to be bilateral
27
pulsatile groin mass below the inguinal ligament
femoral artery aneurysm
28
how to tell difference between PAD at rest and peripheral neuropathy
PAD will be relieved by hanging leg over bed by peripheral neuropathy will not
29
amaurosis fugax
transient monocular vision loss
Causes: atheromatous disease of IC or ophthalmic artery, vasospasm, neuropathy, giant cell arteritis, glaucoma, increased ICP, steal phenomenon
30
3 mechanisms to move blood through veins in lower extremities
1. negative intrathoracic pressure during inspiration
2. musculoskeletal pump
3. valves prevent back flow
31
migratory phlebitis indicates.....
abdominal cancer (esp. pancreatic carcinoma)
32
venous HTN skin manifestations
(bilateral) edema, stasis dermatitis, venous ulcerations
33
persistent JVD, hypotension (unresponsive to fluids), tachycardia in setting of thoracic trauma
cardiac tamponade (will have normal cardiac silhouette on CXR)
34
CXR of aortic injury
widened mediastinum, left hemothorax
35
bilateral hip, thigh, buttock claudication
impotence
bilateral atrophy of lower extremities
```
aortoiliac occlusion (Leriche syndrome)
- may also have diminished pulses
```
36
venous vs. arterial ulcers
VENOUS: painful, irregular outline, superficial, possible dermatitis
ARTERIAL: deep, punched out, smooth edges, cool to touch, shiny taut pale skin
37
most common cause of aortic dissection
systemic HTN
38
test highly sensitive for PAD
ABI (ankle brachial index), normal 1-1.2, severe
39
most sensitive CXR finding for aortic injury
mediastinal widening (esp. in setting of trauma)
40
dyspnea/tachypnea
chest pain
hypoxemia worsened by IV fluids
patchy alveolar infiltrates on CXR
pulmonary contusion
41
types of non-hemorrhagic shock
```
cardiogenic: tamponade, MI, contusion, etc.
tension pneumo: impedes venous return
neurogenic: spinal cord injury
septic
hypoadrenal: exogenous steroids
```
42
Parkland formula
fluid resuscitation in burn pts:
| = kg x 4 x %burned
43
Hesselbach's triangle
inf. epigastric a.
lateral border of rectus abdominis
inguinal ligament
(direct hernias)
44
```
acidosis
low urine output
hypotension
tachypnea
fever
```
septic shock (start tx with normal saline)
45
what to do with results of FAST exam
positive: laparotomy
inconclusive: peritoneal diagnostic lavage
negative: stabilize
46
tx hemodynamically unstable pt c penetrating abdominal trauma
```
ex lap (don't wait for imaging)
abdomen: anything below nipple line
```
47
pain that radiates to the shoulder(s)
suggests sub diaphragmatic peritonitis or acute cholecystitis
48
part of the bladder covered by peritoneum
only the bladder dome (injury can cause peritonitis)
49
when to do ex lap and when to do more diagnostics in abdominal trauma pt
ex lap if pt is hemodynamically unstable
| imaging in stable pt (ie: responding to fluids)
50
free air under diaphragm
- ok if following laparotomy or laproscopic surgery
| - otherwise indicates ruptured viscus (i.e.: perf peptic ulcer)
51
obturator sign
pain on internal rotation of the leg with hip and knee flexed
- appendicitis
52
psoas sign
pain on extension of hip with knee in full extension or pain on flexing hip against resistance
- appendicitis
53
indications for surgical tx of upper GI bleed
- 6 or more units of blood needed in 24 hrs
- esophageal variceal bleeding refractory to meds
- perforation
- gastric outlet obstruction
54
best way to administer rapid resuscitation fluids
2 large bore peripheral IVs (16-18 gauge) are better than central line
55
most common cause of lower GI bleeds
upper GI bleeds, then diverticulosis
56
```
cramping abd pain (maybe in intervals)
vomiting
abd distension
+/- fever, tachy, hyptension
no stool
```
SBO (need to differentiate from ileus via imaging)
| - also high-pitched and hypoactive bowel sounds, abd tenderness
57
indications for surgical tx of SBO
- complete SBO
- vascular compromise
- hemodynamic instability
- >3 days duration with no resolution
58
appearance of colorectal cancer on barium enema x-ray
apple-core lesion of encircling carcinoma in descending colon
59
clinical difference between cholelithiasis and acute cholecystitis
S/S: same except cholecystitis is more severe and of longer duration
TX: same except add IV antibiotics (pip/tazo, bacterium) for cholecystitis
60
```
RUQ pain
fever
jaundice
shock
altered mental status
```
Reynold's pentad = acute cholangitis
61
```
* painful hepatomegaly
RUQ pain
weight loss
ascites
jaundice
```
hepatocellular carcinoma
62
Charcot's triad
RUQ pain, fever, jaundice = pathognomonic for acute cholangitis (?)
63
ecchymotic discoloration of the flank
Grey Turner's sign
| - pancreatic hemorrhage
64
ecchymosis of periumbilical area
Cullen's sign
| - pancreatic hemorrhage
65
tumor of hepatic bile ducts
cholangiocarcinoma (Klatskin's tumor)
| - symptomatic late in development = poor prognosis
66
Ranson's criteria
measure of severity of acute pancreatitis
| >3 = likely
67
defect in direct vs. indirect hernia
direct: defect in transveralis fascia from mechanical breakdown
indirect: congenital patent processus vaginalis
68
which hernia occurs more commonly in women than men?
femoral (also has highest risk of incarceration and strangulation due to narrow canal)
69
layers of abdominal wall (superficial to deep)
skin, subcutaneous fat, Scarpa's fascia, ext. oblique, int. oblique, transverses abdomens, transversalis fascia, peritoneum
70
type 1 vs. type 2 hiatal hernia
1 (sliding): GE junction and fundus displaced into mediastinum
2 (paraesophageal): fundus herniates but GE junction remains in normal position
71
6 P's of acute arterial occlusion
pain, paralysis, pallor, parasthesia, poikilothermic, pulselessness
72
S/S of breast cancer
mass tenderness
mass hard, irregular, fixed
nipple discharge/retraction
change in symmetry, appearance
73
most common cause of bloody nipple discharge
intraductal papilloma (benign)
74
anterior shoulder dislocation threatens....
axillary nerve
75
supracondylar humeral fracture threatens....
median nerve and brachial artery
76
distal radius fracture threatens....
median nerve
77
when to discontinue ASA before surgery
7-10 days (NSAIDS 2 days)
78
perioperative glucose control
before: don't give PO hypoglycemic agents morning of, gluc should be 100-250
after: incr. risk of post-op wound infection
79
3 reasons to delay surgery
infection, anemia, gluc >250
80
appearance of benign vs. malignant coin chest lesions
benign: smooth, popcorn, bull's eye, calcium
mal: spiculated
81
which type of lung cancer is not amenable to surgical resection
small-cell (use chemo)
82
pleural effusion in an older pt
cancer until proven otherwise
83
3 vessel disease vessels
right coronary, left anterior descending, circumflex
84
etiology of mitral regurgitation and stenosis
reg: myxomatous degeneration, myocardium ischemia
stenosis: rheumatic and scarlet fever
85
3 symptoms of severe aortic stenosis
syncope, SOB, angina
86
structures to avoid in carotid endarterectomy
hypoglossal n., vagus n., marginal branch of facial n.
87
fever & diarrhea POD 3 s/p AAA rupture repair
ischemic injury to colon, dx c sigmoidoscopy
| tx: abx, bowel rest, resection possible
88
fever, inflamed femoral incision 2 mo s/p AAA rupture repair
vascular graft infection, dx c CT
| tx: remore graft, debride, bypass, abx
89
upper GI bleed 1 yr s/p AAA rupture repair
aortoenteric fistula: erosion of graft into duodenum
| tx: remore graft, repair, bypass
90
tearing chest and back pain
aortic dissection (usually of arch)
91
2 reasons for distended neck veins following trauma
tension pneumo, tamponade
92
```
muffled heart sounds
pulsus paradoxus
Kussmaul sign (incr. in CVP on inspiration)
```
tamponade
93
signs of adequate initial resuscitation
acceptable urine output, better HR, mental status and BP
94
widened mediastinum with trauma
aortic injury
95
high CVP in trauma
tamponade or pneumo (high CVP gives distended neck veins)
96
low CVP and "pink and warm"
vasomotor shock (anaphylaxis, neurogenic)
97
trauma, unconsciousness, lucid interval
epidural hematoma
98
paralysis and loss of proprioception distal to clean cut injury and loss of pain perception on other side
hemisection (Brown-Sequard)
99
loss of motor function and pain/temp on both sides
| no loss of vibratory/positional sense
anterior cord syndrome (burst fractures of vertebral bodies)
100
paralysis and burning pain in upper extremities
| preservation of most lower extremity function
central cord syndrome (elderly with forced hyperextension of neck i.e.: rear-end collision)
101
chest trauma: deteriorating blood gases, whiteout of lungs on CXR
pulmonary contusion
102
sternal fracture: high troponin
myocardial contusion
103
bowel in left side of chest after trauma
traumatic rupture of diaphragm
104
developing subcutaneous emphysema in upper chest and lower neck
rupture of trachea or bronchus
105
ideal hourly urinary output for burns
1-2 mL/kg/h while avoiding CVP > 15
106
kid c groin/knee pain and limping
| as hip is flexed, thigh cannot be rotated internally
slipped capital femoral epiphysis
| ortho emergency
107
toddler c hx of febrile illness that refuses to move hip
septic hip
108
kids c hx of febrile illness and severe localized bone pain (no trauma)
acute hematogenous osteomyelitis
109
teenager c persistent pain over tibial tubercle aggravated by contraction of quadricep (no knee swelling)
Osgood-Schlatter disease
110
where do sarcomas metastasize to?
lungs (not lymph nodes)
111
MOA posterior shoulder dislocation
massive uncoordinated mm. contraction such as epileptic sz or electrical burn; rare
112
pt on stretcher has shortened and externally rotated leg after fall
hip fracture
113
MOA compartment syndrome
prolonged ischemia followed by repercussion
| crush injuries
114
pain shooting down leg
exacerbated by sneezing, coughing, defecating
difficulty ambulating
lumbar disk herniation
115
distended bladder
flaccid rectal sphincter
perineal saddle anesthesia
cauda equina syndrome
116
ileus in elderly pt following non-abdominal surgery
Ogilvie syndrome
| rule out SBO
117
severe, continuous epigastric/low sternal pain of sudden onset
followed by fever, leukocytosis
prolonged, forceful vomiting
Boerhaave syndrome (esophageal rupture due to vomiting)
118
vague epigastric distress
early satiety
hematemesis
gastric adenocarcinoma
119
colicky abdominal pain
protracted vomiting
abd. extension
SBO
| - obstructed if also fever, peritonitis
120
diarrhea
right-sided heart valve damage
wheezing
carcinoid syndrome
121
when is surgery indicated for UC?
```
longer than 20 years
severe malnutrition
multiple hospitalizations
toxic megacolon
high-dose steroids/immunosuppressants needed
```
122
when is colectomy indicated for C. diff?
WBC > 50,000, lactate >5, and unresponsive to tx
123
exquisite pain with defecation
blood streaked stool
fear of defecation leads to constipation
anal fissure
- if fever, probably abscess present
- exam may need to be done under anesthesia
124
sudden onset, generalized, very severe abd. pain
reluctant to move
guarding
perforation
| dx via free air under diaphragm on x-ray
125
sudden onset colicky flank pain radiating to inner thigh and scrotum/labia
ureteral stones
126
air-fluid levels in small bowel on KUB
distended colon
huge air-filled loop in RUQ with "parrot's beak"
volvulus of sigmoid
127
do you need to do SLNB in DCIS?
no, no metastasis potential
128
virulent peptic ulcer disease resistant to all usual therapy
gastrinoma (Zollinger-Ellison)
129
hypokalemia, HTN in female not on diuretics
| also, hypernatremia, metabolic alkalosis
primary hyperaldosteronism
| - aldo high, renin low
130
VACTERL
vertebral, anal, cardia,tracheal, esophageal, renal, limb abnormalities
131
green vomiting
double-bubble on x-ray
kid
duodenal atresia, annular pancreas, or malrotation
| - all require surgery
132
CF
feeding intolerance
bilious vomiting
xray: dilated loops, ground-glass appearance
meconium ileus
133
kid
subdural hematoma
retinal hemorrhages
shaken baby syndrome
134
toddler
episodes of colicky abd pain that makes them double up and squat
currant jelly stools
intussusception
135
how to determine operability of lung cancer
FEV1 of 800 mL needed
136
coldness, tingling, mm. pain of arm
| posterior near signs (visual/equilibrium problems) when arm is exercised
subclavian steal syndrome (if just vascular problems, probably TOS)
137
surgical indications for arterial disease of lower extremities
- to relieve disabling symptoms
| - to save limb from impending necrosis
138
absolute contraindication in parotid tumor dx
open biopsy
139
best study for facial tumors
MRI
140
abscess of floor of mouth after tooth infection
Ludwig angina = threat to airway
ENT ermergency
tx: I & D
141
diplopia in a pt c frontal or ethmoid sinusitis
cavernous sinus thrombosis
142
hemorrhagic vs. vascular neuro disease
occlusive vascular: sudden onset s headache
| hemorrhagic: very severe headache
143
MOA TIA
>70% stenosis of internal carotid or ulcerated plaque at carotid bifurcation
144
months of headache, worse in mornings
| signs of increased ICP: blurred vision, vomiting
brain tumor
145
loss of upper face and sunset eyes
tumor of pineal gland
146
kid relieving headache with knee-chest position
brain tumor
147
very severe testicular pain, sudden onset
| no fever, pyuria, mumps
testicular torsion
148
severe testicular pain of sudden onset
| fever, pyruia
acute epididymitis
149
pneumaturia MOA
MOA: fistula between bladder and GI tract, usually from diverticulitis
150
absolute contraindication for organ donation
HIV
151
hyperacute rejection
minutes
| MOA: preformed antibodies
152
acute rejection
> 5 days and
153
chronic rejection
years
| irreversible
154
prohibitive cardiac risks for noncardiac surgery
- worst = JVD (indicates CHF)
- 2nd worst = MI within 6 mo (defer if possible until 6 mo)
- ejection fraction
155
causes of fever at POD 1, 3, 5, 7, 10
```
1 - atelectasis
3 - pneumonia, UTI
5 - DVT
7 - wound infection
> 10 - deep abscess (CT and drain)
```
156
post-op causes of hypokalemia
lost from GI tract (GI fluids have lots of K) or urine (loop diuretics)
157
safe speed for IV K administration
10 mEq/h
158
causes of hyperkalemia
- K dumped from cells into blood from crushing injuries, dead tissue, acidosis
- renal failure (K not excreted)
159
hepatic adenoma risk
OCT
| - risk of rupture and massive bleed (emergency surgery)
160
causes of paralytic ileus
```
abdominal surgery
retroperitoneal hemorrhage (ie: with vertebral fracture)
```
161
free intraperitoneal fluid following trauma
probably spleen or liver laceration
162
acute pain and swelling of midline sacrococcygeal skin/tissue
infection of pilonidal cyst
| tx: drain and excise pilonidal sinus
163
nonhealing wound in burn area
Marjolin ulcer = squamos cell carcinoma
164
postgastrectomy
postprandial abdominal cramps
weakness
gastric dumping syndrome
| tx: dietary changes (octreotide if resistant)
165
SBO with fever, tachy, metabolic acidosis
strangulation (emergency ex lap)
166
how does short-term hyperventilation help decrease ICP?
causes cerebral washout of CO2 leading to vasoconstriction
