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Limiting factors prior to surgery: ejection fraction below?
Recent MI defer the surgery for how long?
How to optimize the patient with CHF?

EF below 35% at increased risk and non-cardio surgery
Defer surgery for six months and cases of MI
Optimize CHF with Ace-inhibitors, beta blockers and spironolactone to decrease mortality


Patient only needs an EKG prior to surgery if?
If cardiac disease, regardless of age, they must have?

Only EKG if under 35 and no history of cardiac disease
If cardiac disease, need EKG, stress testing, echo


Risk factors

Diabetes, hypertension, high cholesterol, male over 45
Don't forget about age!


If a smoker quit? Prior to surgery

Quit smoking 6 to 8 weeks prior to surgery
Also, if lung disease or smoking history need PFTs


Cullen sign:
Grey Turner sign:
Kehr sign:
Balance sign:
Seatbelt sign:

Cullen sign: around umbilicus, Hemorrhagic pancreatitis, ruptured AAA
Grey Turner sign:flank bruising, retroperitoneal hemorrhage
Kehr sign:pain in the left shoulder, splenic rupture
Balance sign:dull percussion on the left and shifting down this on the right, splenic rupture
Seatbelt sign: deceleration injury


Tension pneumothorax pushes the trachea away from the involved lung
In contrast, what pulls the trachea toward the involved lung?



Blood at the urethral meatus and a high riding prostate, what to do next?

Get a KUB followed by an RUG: retrograde urethrogram


If suspect mesenteric ischemia (abdominal pain out of proportion to the exam, severe pain after eating, +/- history of cardiovascular disease)
what to do next?

Get angiography, consider surgery


Ischemic bowel disease versus mesenteric ischemia

Ischemic: due to lack of blood flow, progressive, S/S: abdominal pain after eating, bloody diarrhea
Mesenteric: acute occlusion of arteries: SMA, a fib #1 risk factor, pain out of proportion to the PE, elevated lactic acid, ^Wbc's


Ischemic bowel disease versus mesenteric ischemia diagnosis and treatment

Ischemic: best initial test is a CT scan, angiography is most accurate; treat with IV NS followed by surgery to remove necrotic bowel
Mesenteric: best initial test is abdominal X-RAY showing air in the bowel wall, most accurate is angiography; treat with emergent laparotomy with resection of necrotic bowel, endovascular therapy is indicated if unable to go to sx


Most common site of a Boerhaave tear?
Mallory Weiss?

Left posterior lateral aspect of the distal esophagus
Mallory: GE junction


Esophageal perforation diagnosis and treatment

Esophagram using Gastrografin (Diatrizoate Meglumine, Diatrizoate sodium solution)
do not use barium as it is caustic to the tissues
Treatment: surgical exploration with the Bremen of the mediastinum enclosure of the perforation, mediastinitis is a complication


Acute, worsening of abdominal pain that radiates to the right shoulder plus peritoneal signs, think?
Best test?

Gastric perforation, radiates to the right shoulder due to acid irritation of the phrenic nerve
Initial test: up right CXR shows free air under the diaphragm, most accurate is CT scan


What tests are Contraindicated in diverticulitis and why?
What is the most common complication of diverticulitis?

Do not use a barium enema or colonoscopy due to risk of perforation
Abscess formation is the most common complication


Diverticulitis treatment

First episode maybe treated medically: NPO, NG tube, broad-spectrum antibiotics
if there are complications or it is recurrent will need resection of the affected loop of bowel


What med has been shown to alleviate obstruction from stool impaction in patients on chronic opioids?

Methylnaltrexone (Relistor)


Bowel obstruction diagnosis

Best initial test: abdominal XR shows multiple air fluid levels with dilated loops
Most accurate test: CT scan of abdomen shows transition zone
Labs: elevated lactate with marked acidosis, +/- elevated white count


Bowel obstruction treatment

NPO, NG tube with suction, IV fluids, surgical decompression if complete obstruction or lack of improvement with medical management


Injection of what medication has been shown to decrease incontinence episodes by 50%?

Dextranomer/hyaluronic acid (Solesta)


What is a comminuted fracture?

A fracture in which the bone is broken into multiple pieces, most commonly caused by crush injuries


Most common site for stress fracture? How to diagnose?

Diagnosed with CT or MRI as x-ray does not show evidence


How to diagnose shoulder dislocations?

X-rays the best initial test, MRI is the most accurate


What injury took out for if anterior shoulder dislocation?
What to look out for if clavicle fracture?

Axillary artery or nerve injury

Subclavian artery or brachial plexus injury


Trigger finger is caused by? How to treat?

Caused by a stenosis of the tendon sheath, treat with steroid injection, It fails surgery to cut the sheath that is restricting the tendon
Do not confuse with Dupuytren contracture, Whole hand cannot extend, surgery


ABG shows P02 less than 60, CXR shows infiltrates, UA may show fat droplets, think?

Fat embolism, presents with confusion, petechial rash, shortness of breath


How to differentiate claudication from pseudo-claudication secondary to spinal stenosis

If due to spinal stenosis will be equal bilaterally in the pain is alleviated by leaning forward which opens the spinal canal and alleviates nerve root compression, get a spine MRI
Most common at L1, C2
Treatment: NSAIDs or surgery


AAA management

If 3 to 4 cm: ultrasound every 2 to 3 years
4-5.4 cm: ultrasound or CT every 6 to 12 months
If more than 5.5 cm: surgical repair


Imaging for aortic dissection

TEE is the fastest, so best if I unstable
MRA is the best if stable
CTA is another option


Aortic dissection treatment

If ascending, emergent surgery and BP control
If descending, just BP control
Control BP with beta blockers followed by vasodilators such as sodium nitroprusside, never use vasodilators alone as reflex tachycardia can increase sheering forces


Postop fever causes

Day 1 to 2: wind, atelectasis or pneumonia
Day 3 to 5: water, UTI
Day 5 to 7: walking, DVT or PE
Day 7: wound, infections and cellulitis
Day 8 to 15: weird, drug fever or deep abscess


Treatment for hospital acquired pneumonia

Vancomycin and Zosyn


Treatment for DVT

Heparin for 5 days as a bridge to Coumadin for 3 to 6 months


Liver function scores: MELD, Childs-Pugh look at what factors

low albumin, prolonged PT/PTT, ^T. bili, ascites, encephalopathy


if MI after surgery, how to manage ?

PCI, heparin
CANNOT do tPa after sx


etiologies of fistulas

Foreign body
Distal obstruction


if these ? alarm symptoms with GERD do what ?

n/v, anemia, w/l, not improving after 4-6 weeks PPI
get EGD with biopsy


how to dx achalasia

see "bird's beak" on barium swallow, but to diagnose need manometry
next step: EGD with biopsy to r/o pseudo-achalasia, which is cancer
tx: Heller myotomy


Pancreatitis dx

Lipase (3x upper limit) + s/s
ONLY CT if sure of dx based on s/s but negative Lipase
next day: RUQ u/s and TGs looking for etiology (stones, hyperTG)


when else to get CT in pancreatitis
5-7 wks
few wks out

NOW: if SAS, HTN (necrotizing pancreatitis: necrosectomy, carbapenem abx if FNA proven)
5-7 ds: sepsis, ongoing fevers/^WBC (abscess: I/D, ax)
Few wks out: early satiety, w/l, abdominal pain (pseudocyst: if +6wk, +6cm: complicated, need to drain)


cholecystitis dx/tx

RUQ u/s
HIDA to confirm
tx: NPO, IVF, IV abx
urgent cholecystectomy


choledocholithiasis dx/tx

RUQ u/s
tx: NPO, IVF, IV abx, urgent ERCP then elective cholecystectomy


cholangitis dx/tx

RUQ u/s
tx: emergent ERCP with NPO, IVF, IV abx "given on the way", urgent cholecystectomy


chole abx

cipro + metronidazole
amp/gent + metronidazole
pip/tazo (zosyn) will see on wards but not right
(need G- and anaerobe coverage)


CRC: right vs left

right BLEEDS


CRC tx

chemo (FOLFOX) + radiation


UC management

8 years after dx begin colonoscopy q1y, may need prophylactic colectomy


hemorrhoid tx

start: prepH, sitz bath, CCB, topical lidocaine
BAND internal
RESECT external


anal fissure tx

start: nitroglycerin, sitz baths
lateral internal sphincterotomy


anal cancer tx

"Nigro protocol" of chemo/radiation, generally very responsive


pilonidal cyst

abscessed hair follicle, congenital, hairy
tx: I/D then surgical resection


how to tx arterial disease

STENT small lesions above the knee
BYPASS any popliteal lesion or if large area artery affects


ulcer on medial malleolus, think?

venous insufficiency
edematous condition: CHF, cirrhosis, nephrotic syndrome


marjolin ulcer tx

biopsy, wide resection


who gets breast MRI instead of mammogram for screening

previous radiation to chest or BRCA+
MRI is the best test


what to do if +mammogram

core biopsy, NOT FNA


if less than 30 yo presents with breast lump

1st time just wait
if persists, get U/S; tells between cyst or mass
if cyst: FNA
bloody: cancer, pus: abscess, fluid: cysts


if older than 30 yo presents with breast lump
OR it's a mass OR bloody OR recurred



breast cancer tx

local : lumpectomy + axillary LN dissection (if +sentinel LN biopsy) + radiation, surgery
systemic: chemo (doxorubicin, cyclophosphomide, paclitaxel)


HER2Neu tx

+: trastuzumab (causes CHF but not dose dependent and IS reversible, in contrast to doxu/danurubicin)
-: bevacizumab



SERMs if premenopausal
aromatase inhibitors if postmenopausal