Pestana Surgery Flashcards
(383 cards)
1
Q
What are 2 criteria that prove a patient’s airway is patent?
A
- Conscious
2. Speaking in normal tone of voice
2
Q
What are 4 criteria in which a patient will need an airway placed?
A
- Unconscious (GCS <8)
- Noisy or gurgling breathing
- Severe inhalation injury
- Necessary to connect them to respirator
3
Q
What is the most commonly used method of intubation?
A
Orotracheal intubation with laryngoscope
4
Q
What type of intubation is necessary when there is subcutanous emphysema in the neck?
A
Nasotracheal intubation with fiberoptic bronchoscope
5
Q
If a patient has severe maxillofacial injuries or an impacted foreign body, which type of intubation is preferred?
A
Cricothyroidotomy
6
Q
Under what age is cricothyroidotomy avoided?
A
Under 12
7
Q
What are the 2 criteria in establishing adequate breathing?
A
- Lung sounds on both sides of chest
2. Satisfactory pulse ox
8
Q
What are 3 clinical signs of shock?
A
- SBP <90
- Fast, feeble pulse
- UO <0.5 mL/kg/hr
9
Q
What is the urine output volume that defines shock?
A
Less than 0.5 mL/kg/hr
10
Q
What are the 3 most common causes of shock in the trauma setting? How would you distinguish between the 3?
A
- Hemorrhage/hypovolemic (low CVP)
- Tamponade/cardiogenic (high CVP)
- Tension pneumothorax (high CVP + resp distress)
11
Q
What are 5 features of tension pneumothorax?
A
- High CVP
- Resp distress
- No breath sounds on affected side
- Hyperressonance to percussion on affected side
- Mediastinum shifted to opposite side
12
Q
What is the criteria for volume resuscitation in hemorrhagic shock from a trauma?
A
Start with 2 L LRs (without glucose), then pRBCs until urinary output is 0.5-2 mL/kg/hr and CVP doesn’t exceed 15 mmHg
13
Q
What is the preferred method of IV access for fluid resuscitation in a trauma setting?
A
2 large-bore (16 gauge) peripheral lines
14
Q
If peripheral IV access cannot be obtained in a trauma setting, what are 3 other options for access?
A
- Percutaneous femoral vein catheter
- Saphenous vein cut-down
- Intraosseus cannulation of prox tibia in kids <6
15
Q
What is the preferred imaging modality to diagnosing pericardial tamponade?
A
Bedside US
16
Q
What are the steps to managing pericardial tamponade?
A
- Clinical suspicion
- Confirm with bedside US
- Fluid and blood resuscitation
- Pericardiocentesis
17
Q
What is the management of tension pneumothorax?
A
- Clinical suspicion
- DO NOT DO IMAGING or ABG
- Large needle or IV catheter into pleural space (anterior, high)
- Place chest tube connected to underwater seal
18
Q
What are 5 causes of hypovolemic shock?
A
- Hemorrhage
- Burns
- Peritonitis
- Pancreatitis
- Massive diarrhea
19
Q
What is the CVP in spinal cord shock?
A
Low
20
Q
What is the CVP in hypovolemic shock? Spinal cord shock? Cardiogenic? Septic?
A
Hypovolemic - low
Spinal cord - low
Cardiogenic - high
Septic - low
21
Q
What is the definitive treatment for spinal cord shock?
A
Vasopressors
22
Q
Treatment of penetrating skull injury
A
Surgery
23
Q
Treatment of penetrating head trauma
A
Surgery
24
Q
Treatment of skull fractures
A
If closed, nothing
If open, close wound
If comminuted, surgery
25
Who gets a CT of the head in trauma?
Anyone who loses consciousness
26
Signs of skull base fracture
Periorbital ecchymoses
Rhinorrhea
Otorrhea
Ecchymoses behind the ear
27
What is the next step if skull base fracture suspected?
Assess C-spine with CT
28
What kind of head trauma results in LOC then a lucid interval and gradual lapsing into coma?
Acute epidural hematoma
29
What are the CT findings in acute epidural hematoma?
Biconvex, lens shaped (football)
30
What is the treatment of epidural hematoma?
Craniotomy
31
Which head bleed presents with loss of consciousness with no lucid interval?
Acute subdural hematoma
32
What are the CT findings of an acute subdural bleed?
Semilunar, crescent-shape
33
What is the treatment for acute subdural hematoma?
If midline deviation- craniotomy
| If no midline deviation- prevent damage from inc ICP
34
What are 7 ways to manage increased ICP?
1. Mannitol
2. Furosemide
3. Elevate head
4. Hyperventilate to PCO2 35, if herniation
5. Avoid fluid overload
6. Sedation
7. Hypothermia
35
When should hyperventilation be started in head bleeds?
In acute subdural bleeds when evidence of herniation
36
What are the CT findings of diffuse axonal injury?
Blurring of gray-white interface + multiple small punctate hemorrhages
37
Blurring of gray-white interface + multiple small punctate hemorrhages
Diffuse Axonal Injury
38
Treatment of DAI?
Preventing further damage from increased ICP
39
What is the diagnosis and treatment of chronic subdural bleeds?
Dx -- non-con CT
| Tx -- surgery
40
What are the 3 cases in which a penetrating neck injury is treated with emergent surgical exploration?
1. Expanding hematoma
2. HD instability
3. Esophageal or tracheal injury (coughing up blood)
41
What is the treatment for gunshot wound to upper zone of the neck?
Arteriogram
42
What is the treatment for gunshot wound to the base of the neck?
Arteriogram --> esophagogram --> esophagoscopy and bronchoscopy --> surgery
43
What is the treatment of uncomplicated stab wounds to the upper and middle zones of the neck?
Observation
44
What is the next best step in blunt trauma to the neck?
CT cervical spine
45
What are the findings associated with hemisection of the spinal cord leading to Brown-Sequard syndrome?
Loss of motor and propioception on SAME side as injury
| Loss of pain on OPPOSITE side as injury
46
What is a consequence of burst fractures of vertebral bodies?
Anterior cord syndrome -- loss of pain and motor BILATERALLY with preserved vibration/propioception (dorsal columns).
47
What injury is associated with central cord syndrome? What results?
Elderly with forced hyper extension of the neck (whiplash) causing paralysis and burning pain in BILATERAL upper extremities
48
What is the best way to diagnose spinal cord injuries?
MRI
49
What is the treatment of rib fractures in elderly?
Local nerve block + epidural catheter
50
What are the clinical signs of pneumothorax?
1. Shortness of breath
2. Decreased breath sounds on affected side
3. Hyperresonant to percussion on affected side
51
Best way to dx and treat pneumothorax
Dx -- CXR
| Tx -- chest tube (2nd IC space) connected to underwater seal
52
Clinical signs of hemothorax
1. Shortness of breath
2. Decreased breath sounds on affected side
3. Dull to percussion on affected side
53
What is the best way to dx and treat a hemothorax?
Dx -- CXR
| Tx -- chest tube (5th ICS) and rarely surgery
54
What are the indications for surgery in hemothorax?
1. >1500 mL output when chest tube inserted
2. >600 mL output over 6 hours
3. When a systemic vessel is source of bleeding
55
Dx of pulmonary contusion
CXR, ABG
56
Dx of myocardial contusion
Troponins, EKG
57
What is the giveaway for a flail chest?
Paradoxical breathing -- chest wall goes IN with inspiration and OUT with expiration
58
What is the treatment for pulmonary contusion?
1. Fluid restriction
2. Diuretics
3. Monitor ABGs
59
How do you treat myocardial contusions
Treat complications like arrythmias
60
Tx of diaphragmatic rupture
Ex-lap
61
Where is the most common location of traumatic rupture of the aorta?
Junction of arch and descending aorta
62
Why is an aortic rupture injury the "hidden injury?"
Asymptomatic until hematoma in the adventitia blows up and patient dies
63
What signs may indicate aortic rupture?
Deceleration injury
Fractures in first rib, scapula, sternum
Widened mediastinum in CXR
64
What is the best test for traumatic aortic rupture?
CT angiogram
65
What injury occurred if there is subcutaneous emphysema in upper chest or lower neck?
Rupture of trachea or bronchus
Rupture of esophagus
Tension pneumothorax
66
What is the dx and treatment of trachea or bronchus rupture?
Dx -- CXR and fiberoptic bronchoscopy
| Tx -- Intubation and surgery
67
What is the most likely cause of a sudden death in a patient with chest trauma who is intubated and on respiratory?
Air embolus
68
What are the risks of air embolism?
1. Chest trauma
2. Intubation and respirator
3. Supraclavicular lymph node biopsies
4. CV lines
69
What is the management of air embolus?
Immediate cardiac massage with left side down
70
What are the signs of a fat embolism?
1. Long bone fractures
2. Petechiae
3. Thrombocytopenia
4. Tachycardia
5. Fever
6. Resp distress
71
What is the treatment of fat embolism?
Respiratory support
72
Management of gunshot wound to abdomen
Ex-lap
73
What is the mgmt of stab wound to the abdomen?
If viscera seen, HD unstable, peritoneal = ex-lap
If none of above, digital exploration of wound and observation
If above fails, CT scan
74
What are some signs of internal bleeding?
1. Drop in SBP
2. Fast pulse
3. Low CVP
4. Low UO
5. Cool extremities
6. Pale, diaphoretic
75
What percent of blood loss must occur before shock sets in?
25-30% of total blood volume (about 1.5 L)
76
Where are the 3 locations that most commonly hide a massive amount of hemorrhage?
1. Abdomen
2. Pelvis
3. Upper legs
77
What is the MOST accurate method of detecting intra-abdominal hemorrhage?
CT scan
78
Who needs urgent ex-lap for intra-abdominal bleeding?
1. Peritoneal signs
2. Major injuries seen on CT scan (done if HD stable)
3. HD instability not improving with fluids
79
When do you do a CT abd in the setting of abd trauma?
If patient is hemodynamically stable
80
What is the workup of intra-abd bleeding?
If HD stable -- CT abd
| If HD unstable -- FAST scan then ex-lap if FAST pos
81
What is the most likely source of clinically significant traumatic intra-abd bleeding?
Ruptured spleen
82
What is the treatment of ruptured spleen?
Repair > removal + post-op immunization for strep pneumo, HiB, meningococcus
83
What is the treatment of intraoperative development of a coagulopathy during abd surgery for trauma?
Platelet packs + FFP
84
What are 3 signs of abdominal compartment syndrome?
1. Abd distension with sutures cutting tissue
2. Hypoxia from difficulty breathing
3. Acute renal failure from IVC compression
85
What is the treatment for a non-complicated pelvic hematoma?
Leave it alone
86
What is the management of expanding pelvic hematoma?
Pelvic fixation and to IR for angiographic embolization
87
Treatment of penetrating urologic injuries
Surgical exploration
88
What are 4 clinical signs of urethral injury in men?
1. Blood at meatus
2. High-riding prostate
3. Feeling urge to void
4. Scrotal hematoma
89
Next step in suspected urethral injury?
Retrograde urethrogram
90
What are urethral injuries commonly caused by?
Pelvic fractures
91
Best test to diagnose bladder injuries?
Retrograde cystogram
92
Treatment of bladder injuries
Extraperitoneal leak -- Foley
| Intraperitoneal leak -- surgery and suprapubic cystostomy
93
How are renal injuries diagnosed and treated?
Dx -- CT abd/pelvis
| Tx -- observation
94
What are 2 rare complications of kidney injury?
AV fistula leading to CHF
| Renal stenosis causing HTN
95
Treatment of penetrating ext injuries
1. Assess vascular status
2. If no vas injuries, give tetanus and clean wound
3. If vasc injuries but asx, CT angio or Doppler US
4. If vasc injuries and pt is sx, surgery
96
What is the order of repair of vessels, nerves, bone?
Bone --> vessels --> nerves --> fasciotomy
97
What is the treatment of a crush injury?
1. IVF + osmotic diuretics + alkalinize the urine to prevent hyperK, myoglobinuria and renal failure
2. Fasciotomy to prevent compartment syndrome
98
Which is worse, alkaline or acid burns?
Alkaline
99
What is the treatment for chemical burns?
Irrigation with water
100
What is the biggest concern with high-voltage electrical burns? How is it treated?
Myoglobinemia --> myoglobinuria --> renal failure
| Treat with IVF, osmotic diuretics, alkalinize urine
101
What are 5 complications of high-voltage electrical burns?
1. Myoglobinuria causing acute renal failure
2. Posterior dislocation of shoulder
3. Compression fractures of vertebral bodies
4. Cataracts
5. Demyelinization syndromes
102
Treatment of inhalation injuries
1. Assess need for intubation via ABGs
2. Give O2 if carboxyhgb levels elevated
3. Confirm with fiberoptic bronchoscopy
103
What is the risk of circumferential burns of the extremities and chest? What is the treatment?
Development of eschars that cut off blood supply
| Treat with bedside escharotomies
104
What are the fluid resuscitation parameters for burn patients?
Resuscitate with 1 L LRs (no sugar) with pts >20% body surface burned to urine output of 1-2 cc/kg/hr while keeping CVP <15 mmHg
105
What are the fluid resuscitation parameters for babies with burns?
If burn >20% then start at 20 cc/kg/hr
106
Besides fluid resuscitation what are the steps in treating extensive burns (>20%)?
1. IVF
2. Tetanus ppx
3. Clean burned area
4. Silver sulfadiazine or mefenide acetate if cartilage involved
5. NGT suction for 1-2 days then tube feeds with high calorie, high nitrogen diet
6. After 2-3 weeks, skin grafts done
107
How are smaller burns (<20%) treated?
Early excision and grafting
108
How do you treat provoked dog bites?
Observe dog for signs of rabies
109
What is the treatment of snake bites?
1. Draw blood for T&S
2. Get coags, LFTs, BMP
3. Administer antivenin
110
Treatment of bee stings
1. Epinephrine
| 2. Remove stingers
111
Treatment of black widow spider bites
IV calcium gluconate
| Muscle relaxants
112
Treatment for brown recluse spider bites
Dapsone and surgical excision
113
Treatment of human bites
Surgical I&D
114
What is the diagnosis of DDH in a newborn?
1. Clinical -- Ortolani/Barlow, uneven gluteal folds
| 2. Confirm with ultrasound (NOT x-rays)
115
Tx of DDH in newborn
Abduction splinting in Pavlik harness for 6months
116
Insidious limping, hip pain and decreased hip motion in a 6 yr old
Leg-Calve-Perthes (AVN of capital femoral epiphysis)
117
How do you dx Legg-Calves-Perthes?
AP and lateral x-rays show flattened femoral head
118
How do you treat Legg-Calves-Perthes?
Casting and crutches to contain femoral head in acetabulum
119
Chubby young boy with groin pain, limp, decreased ROM at the hip
SCFE
120
Dx of SCFE
X-rays
121
Tx of SCFE
Orthopedic emergency -- pin the femoral head back in place
122
What is the classic picture of a pediatric septic hip?
Toddler with febrile illness who holds hip flexed, abducted and externally rotated
123
What is the diagnosis of septic hip?
Aspirate hip
124
What is the dx of a septic hip?
I&D + abx
125
For how long is varus normal in a child?
Normal until 3
| Blount disease if persists after 3 (surgery needed)
126
For which ages is valgus normal for kids?
Between 4-8
127
Features of Osgood-Schlatter's Disease
1. Teenagers
2. Persistent pain over tibial tubercle
3. Pain worse with activation of quads
128
What is the treatment of Osgood-Schlatter's Disease?
1. RICE
| 2. If refractory, extension or cylinder cast for 4-6 weeks
129
What is the treatment for clubfoot in newborns?
1. Serial plaster casts
| 2. If refractory by 9-12mo, Achilles tenotomy and long-term braces
130
Treatment of scoliosis
1. Bracing to prevent progression
| 2. If refractory, surgery
131
Which fractures in children are most concerning and may require surgical intervention instead of reduction and casting?
Supracondylar fractures of humerus
132
Child falls onto hand with hyperextended elbow
Supracondylar fracture of humerus
133
What is the most important complication of supracondylar fractures of humerus in kids?
Volkmann Contracture
134
How are growth plate fractures treated?
If epiphyses and growth plate displaced but in one piece, closed reduction
If epiphyses and growth place in two pieces, ORIF
135
What are features of primary malignant bone tumors?
Persistent achy pain for months
Invasion of soft tissues
Sunburst appearance
Periosteal onion-skinning
136
What is the MC primary malignant bone tumor? Where is it usually located?
Osteogenic sarcoma, around knee, sunburst pattern
137
What bone tumor in children is common? Where is it located?
Ewing sarcoma, diaphysis of long bones
138
What is the most common bone tumor in adults?
Mets (breast, prostate)
139
Bone x-rays with multiple punched-out lytic lesions
Multiple myeloma
140
Treatment for multiple myeloma
1. Chemo
| 2. Thalidomide
141
Most common location for sarcoma mets?
Lungs
| NEVER lymph nodes
142
Best diagnosis of sarcoma
Incisional biopsy
143
Treatment of sarcomas
Very wide local excision --> XRT and chemo
144
Treatment of clavicle fractures
Figure of Eight sling
145
What nerve is potentially damaged from anterior shoulder dislocations?
Axillary
146
Colles fracture
Dorsally displaced fracture of distal radius in elderly women who fall on outstretched hand
147
Tx of Colles fracture
Closed reduction, long-arm cast
148
Monteggia fracture
Diaphyseal fracture of proximal ulna and anterior dislocation of radial head due to blow to ulna
149
Galeazzi fracture
Distal radius fracture with dorsal dislocation of distal radioulnar joint
150
Tx of Monteggia fracture
ORIF for broken bone
| Closed reduction of dislocation
151
Tx of Galeazzi fracture
Closed reduction of dislocation
| ORIF of broken bone
152
Young adult falls on outstretched hand
Scaphoid fracture
153
Dx of scaphoid fractures
Initially -- clinical (wrist pain, TTP of snuffbox)
| Later -- X-rays
154
Treatment of scaphoid fractures
If undisplaced -- thumb spica cast
| If displaced -- ORIF due to non-union rates
155
Closed fist hits a hard surface
Metacarpal neck fractures
156
Position of patient during hip fracture
Shortened and ext rotated limb
157
Tx of femoral neck fractures
Replace femoral head with prosthesis
158
Tx of intertronchanteric fractures
ORIF + post-op anticoagulation
159
Tx of femoral shaft fractures
If HD unstable, ex-fix and then IM nailing when stable
If open, orthopedic emergency - I&D and closure in 6 hrs
If closed and stable - IM nailing
160
Treatment of tibial stres fractures
Cast and crutches, repeat x-ray in 2 weeks
161
MC locations of compartment syndrome
Forearm
| Lower leg
162
Patient position with a posterior hip dislocation
Leg shortened, adducted, internally rotated
163
Tx of gas gangrene
IV penicillin
Emergent I&D
Hyperbaric oxygen
164
Tx of necrotizing fasciitis
Repeated, massive excisions of necrotic tissue
| Broad spectrum abx
165
What nerve is injured in mid-shaft humerus fractures? Deficits?
Radial nerve
| Loss of extension of wrist
166
What is injured in posterior dislocations of the knee?
Popliteal artery
167
Fractures with fall from height
Feet, leg
| Lumbar or thoracic spine
168
Fractures with head-on MVC
Face, head
| Femoral head/neck if knees hit dashboard
169
Tx of carpal tunnel
Splints, NSAIDs, EMGs and then surgery
170
Tx of trigger finger
Steroid injection and then surgery
171
What is a felon and what is the treatment?
Abscess in the pulp of a fingertip
| I&D
172
Gamekeeper thumb
Injury of ulnar collateral ligament from forced hyperextension of the thumb, requires casting to prevent arthritis
173
Jersey vs Mallet finger
Jersey-- injury to flexor tendon when flexed finger forcefully extended
Mallet-- injury to extensor tendon when extended finger forcefully flexed
174
How can you differentiate between herniated disc and spinal stenosis pain?
Herniated disc pain is exacerbated by coughing, sneezing or defecating (from increased pressure)
175
Cauda equina syndrome
Distended bladder
Flaccid rectal sphincter
Perineal saddle anesthesia
176
Ulcers located on pressure points
Diabetic ulcers
177
Location of arterial ulcers
Tips of toes
178
Dx of arterial ulcers
Clinical, Doppler
179
Tx of arterial ulcers
Fix PVD -- angioplasty and stents
180
Location of venous stasis ulcers
Medial malleolus
181
What kinds of people get venous stasis ulcers
Pts with chronic lower ext edema, varicose veins
182
Dx of venous ulcers
Duplex
183
Tx of venous ulcers
Support stockings then surgery
184
Marjolin ulcers
SCC of skin in chronic ulcers, wounds, burns, chronic draining sinuses from osteomyelitis
185
Dx of marjolin ulcers
Biopsy
186
Tx of marjolin ulcers
Wide local excision and skin grafts
187
Plantar fasciitis
Sharp heel pain on every foot strike that is worse in AM and may be caused by a bone spur
188
Tx of plantar fasciitis
Should resolve in 12-18 months, surgery to remove bone spur may help
189
Morton neuroma
Inflammation of common digital nerve at the 3rd interspace between 3rd and 4th toes caused by toes that get squished in shoes
190
Acute tx of gout
Indomethacin + colchicine
191
Chronic control of gout
Allopurinol + probenecid
192
At what EF are non-cardiac surgeries contraindicated?
EF <35%
193
What are risk factors for intra-op cardiac events used in preop assessment?
```
JVD
Recent MI
PVCs or arrhythmia
Age >70
Emergency surgery
Aortic stenosis
Poor health
Chest or abd surgery
```
194
What is the WORST single finding predicting high cardiac risk?
JVD
195
4 drugs used to pre-treat someone with elevated JVP from CHF prior to surgery
1. Beta blockers
2. Digitalis
3. ACEIs
4. Diuretics
196
How should a patient with COPD or smoking history be evaluated preoperatively?
Obtain FEV1 then ABGs
197
When should smoking cessation occur prior to surgery?
8 weeks
198
What are 5 parameters used to predict risk in patients with liver disease?
1. Encephalopathy
2. Ascites
3. Serum albumin
4. INR
5. Bilirubin
199
What are the 4 parameters of severe nutritional depletion?
1. Loss of >20% body weight in few months
2. Albumin <3
3. Anergy to skin antigens
4. Transferrin <200
200
What should you do preoperatively for someone with severe nutritional deficiencies?
At least 4-5 (7-10 better) of enteric feeds
201
Intra-op fever
Malignant hyperthermia
202
What are 2 metabolic derangements that occur with malignant hyperthermia?
1. Metabolic acidosis
| 2. Hypercalcemia
203
Treatment of malignant hyperthermia
1. IV dantrolene
2. 100% O2
3. Correct acidosis
4. Cooling blankets
204
Fever within 30-45 minutes of invasive procedures
Bacteremia with chills, fever
| Get blood cx and start empiric abx
205
Causes of post-op fever temporally
Atelectasis --> pneumonia --> UTI --> DVT/PE --> wound -->abscesses
206
Fever on post-op day 1
Atelectasis
207
Dx and tx of atelectasis
1. CXR
| 2. Incentive spirometry and if refractory, bronchoscopy
208
What is the sequelae of untreated atelectasis?
Pneumonia
209
Fever on POD3
Pneumonia or UTI
210
Dx and tx of post-op pneumonia
1. CXR and sputum culture
| 2. Abx 1
211
Dx and Tx of post-op UTI
Dx -- UA with culture
| Tx -- abx
212
Fever on POD5
DVT
213
Dx and Tx of DVT
Dx -- Doppler
| Tx -- heparin drip
214
Fever on POD7
Wound infection
215
Dx and Tx of wound infection
Dx -- clinical
| Tx -- IV abx if cellulitis, I&D if abscess
216
Fever on POD10-15
Deep abscess
217
Dx and Tx of post-op abscess
Dx -- CT scan
| Tx -- percutaneous IR guided drainage
218
What causes an MI intraoperatively?
Hypotension
219
When does post-op MI typically occur?
POD2-3
220
Treatment of post-op MI
Stents
| NOT tPA
221
When do PEs typically occur post-operatively?
POD7
222
Physical exam findings of PE
1. Pleuritic chest pain
2. SOB
3. Anxious, diaphoretic patient
4. Tachycardia
5. Elevated JVP
6. Hypoxia and hypocapnia
223
Dx and Tx of PE
Dx -- spiral CT/CT angio
| Tx -- IV heparin drip or IVC filter if anticoagulation contraindicated or PEs recur while on heparin
224
Risk factors for DVT/PE
1. Patients >40
2. Immobilization
3. Pelvis or leg fractures
4. Venous injury
5. Femoral venous catheter
225
What are the signs of intraoperative tension pneumo?
Hypotensive with elevated CVP and more difficult to bag
226
How is an intraoperative tension pneumo treated?
If abdominal surgery, can needle decompress via diaphragm
| If non-abdominal surgery, can needle decompress via 2nd IC space
227
What is the FIRST thing to be suspected in a post-op patient who is confused and disoriented?
Hypoxia
228
Tx of ARDS
PEEP at low volumes
229
When is the onset of DTs?
2-3 days post-op
230
What is the treatment for DTs?
IV benzos or IV alcohol (5% in D5)
231
Cause of rapid, acute post-op hyponatremia
Giving Na-free IVF (like D5) in post-op patients who already have high ADH
232
When should a patient be straight cath'd post-op if no urine output? When does a Foley go in?
After 6 hours of not voiding
| After 2-3 repeated straight cath without spontaneous void
233
What is the MCC of Anuria?
Plugged or kinked Foley
234
What are the 2 causes of post-op oliguria in someone with normal perfusion (not in shock)? How can they be distinguished?
1. Fluid deficit
2. Acute renal failure
500cc fluid bolus challenge -- after 20 min, dehydrated patients will have temporary increase in UO and patients with ARF won't
235
When is the differentiation between post-op ileus vs SBO?
Ileus is painless and normal with first few days, but if it doesn't resolve after 5-7 days it is most likely an early SBO
236
Dx and tx of post-op SBO
1. KUB -- dilated SB and air-fluid levels
2. Confirm with CT abd to find transition point
Tx -- surgery
237
Ogilivie Syndrome
Paralytic ileus of the colon that happens in elderly, sedentary patients who have had surgery anywhere OTHER THAN the abdomen
238
Tx of Ogilvie syndrome
1. Fluid and electrolyte correction
| 2. Colonoscopy with rectal tube
239
When does wound dehiscence typically occur?
POD5
240
What is the sign of wound dehiscence?
Pink, "salmon-colored" fluid (peritoneal fluid) leaking out of wound
241
Tx of wound dehiscence
1. Securely tape and bind wound
| 2. Prompt reoperation to prevent evisceration and hernia
242
What is the tx of wound evisceration
1. Keep pt immobilized
2. Cover bowel with warm, sterile, saline-soaked dressing
3. Emergency closure
243
What are the 2 ways in which fluid leaks out of post-op fistulas?
1. Leaks into cesspool that sits and slowly leaks out -- sepsis
2. Leaks directly out
244
3 problems with post-op fistulas
1. Fluid, electrolyte imbalance
2. Nutritional depletion
3. Erosion of abdominal wall
245
Tx of post-op fistulas
1. IVF and electrolytes
2. Elemental nutrition PAST fistula
3. Suction tubes and ostomy bags to protect abd wall
246
What are factors that prevent natural healing of post-op fistulas?
FETIDS -- foreign body, epithelialization, tumor, infection/irradiated tissue/IBD, distal obstruction, steroids
247
How does a post-op patient become hypernatremia?
Patient losing free water -- every 3 mEq of Na above 140 = 1 L of H20 lost
248
Tx of hypernatremia
D5 1/2NS to volume replete but SLOWLY replete tonicity
249
What are the 2 causes of hyponatremia in post-op patients?
1. SIADH (may be normal state or malignancy)
2. If pt is losing large amts of isotonic fluid via GI tract, they will retain water if not replaced with isotonic fluids
250
Tx of hyponatremia
Acute hyponatremia w/sx -- hypertonic 3 or 5% NS slowly
Chronic hyponatremia -- fluid restrict
Acute dehydrated pt losing GI fluids -- isotonic fluids to correct hypovolemia (NS if alkalotic, LR if acidotic or normal pH)
251
3 causes of post-op hypokalemia
1. GI losses
2. Loop diuretics
3. Increased Aldo from stress response
252
Causes of hyperkalemia postop
1. Renal failure
2. Aldosterone antagonists
3. Crush injuries
4. Tissue ischemia
5. Acidosis
253
Treatment of hyperkalemia
1. IV calcium
2. D50 + insulin
3. NGT suction or resins (kayexalate)
4. Dialysis
254
Causes of post-op acidosis
1. Excess production -- DKA, lactic, low-flow states
2. Loss of buffers -- loss of bicarb in GI tract
3. Inability to excrete acid -- kidney failure
255
When do we order X-rays?
Broken or dislocated bones
CXR
KUB
256
Dx of carcinoid
Urinary 5HIAA
257
Right-sided colon cancer presents how?
Iron-deficiency anemia and occult blood loss
258
How is right-sided colon cancer diagnosed?
Colonoscopy with biopsy
259
How does left-sided colon cancer present?
Decreased stool caliber
Bloody stool
Constipation
260
Dx of left-sided colon cancer
Flexible sigmoidoscopy and then colonoscopy prior to resection
261
What are 5 indications for colectomy in UC?
1. Disease >20 yrs
2. Nutritional depletion
3. Multiple hospitalizations
4. Need for steroids or immunosuppressants
5. Toxic megacolon
262
Best dx test for C.diff
Stool C.diff toxin assay
263
Best tx for C.diff
Metronidazole
264
When does C.diff infection require colectomy?
1. Refractory to treatment
2. WBC >50
3. Lactate >5
265
Which hemorrhoids hurt?
External
266
Which hemorrhoids bleed?
Internal
267
How are internal hemorrhoids treated?
rubber band ligation
268
Where are anal fissures most commonly located?
Posterior midline
269
What is the cause of anal fissures?
Tight sphincter
270
What are 6 methods of treating anal fissures?
1. Stool softeners
2. Topical nitroglycerin
3. Topical calcium channel blockers
4. Botox
5. Forceful dilatation
6. Lateral internal sphincterotomy
271
Exquisitely painful defection with blood-streaked stool and avoidance of bowel movements leading to constipation
Anal fissure
272
Exquisite peri-rectal pain, fever, difficult to sit or have bowel movement
Perirectal abscess
273
Tx of perirectal abscess
I&D
274
What is a serious complication of perirectal abscess?
Necrotizing fasciitis esp in diabetics
275
Fecal soiling and perineal discomfort after having peri-rectal abscess drained
Fistula-in-ano
276
Treatment of fistula-in-ano
Fistulotomy
277
Fungating mass growing out of anus +/- inguinal lymphadenopathy
SCC of anus
278
Dx of SCC of anus
Biopsy
279
Tx of SCC of anus
Nigro chemo/XRT + surgery IF there is residual tumor
280
4 causes of colonic GI bleed
1. Diverticulitis
2. Malignancy
3. Angiodysplasia
4. Polyps
281
Best next diagnostic step in upper GI bleeds
EGD
282
Diagnostic test for melena
EGD
283
First step in work-up of bright red blood per rectum
NG tube and aspiration to rule out upper GI cause
If blood, upper GI
If no blood or bile, could be duodenum
If no blood but bile, lower GI
284
After Upper GI bleed has been ruled out, what is the next step in work-up of BRBPR?
Rule out hemorrhoids with anoscopy
285
What are the diagnostic steps to determining location of lower GI bleed?
Colonoscopy (if <0.5 cc/min) or tagged RBC study (if 0.5-2cc/min) or angiogram (if >2cc/min)
286
Blood per rectum in a young adult is from where?
Upper GI source
287
Blood per rectum in an older patient is from where?
Upper or lower GI
288
Blood per rectum in a child is from where?
Meckel's diverticulum
289
Tx of massive upper GI bleed from stress ulcers
Angiographic embolization
290
What are the 4 categories of acute abdominal pain?
Obstruction
Ischemia
Inflammation
Perforation
291
Free air under diaphragm
Likely perforated peptic ulcer, need emergency surgery P
292
Sudden onset, constant, generalized, severe abdominal pain with peritoneal signs
Perforation of peptic ulcer
293
Acute onset, colicky abdominal pain with patient moving constantly to find painless position
Obstruction -- ureter, cystic or CBD, SBO
294
Gradual onset of increasing intensity abdominal pain that is diffuse and becomes focal later and is associated with fever and leukocytosis
Inflammatory process causing abd pain
295
Acute onset severe, constant epigastric pain radiating to the back with nausea and vomiting
Acute pancreatitis
296
Dx of acute pancreatitis
Amylase and lipase and confirm with CT scan
297
Tx of acute pancreatitis
NPO, NG tube, IVF, pain control
298
What would show in the UA in a patient with kidney stones?
Microscopic hematuria
299
Best diagnostic test for kidney stones
CT scan
300
Acute LLQ abdominal pain, fever, leukocytosis
Diverticulitis
301
Dx of diverticulitis
CT scan
302
Tx of diverticulitis
```
NPO
IVF
Pain control
Abx -- cipro/flagyl
IR guided drainage if abscess
Elective resection if >2 attacks
```
303
Dx of sigmoid volvulus
KUB -- small bowel air-fluid levels, distended colon that tapers toward LLQ
304
Tx of sigmoid volvulus
Flexible sigmoidoscopy with rectal tube
| Elective sigmoidoscopy if recurrent
305
Tx of mesenteric ischemia
Early -- arteriogram with embolectomy
| Late -- ex-lap and resection
306
Blood marker of hepatocellular carcinoma
Alpha-fetoprotein
307
Alpha-fetoprotein is a marker for what
HCC
308
Dx of HCC
CT scan
309
Tx of HCC
Resection if possible
310
What is a potential consequence of hepatic adenomas?
Rupture and bleed massively
311
Dx of hepatic adenomas
CT scan
312
Tx of hepatic adenomas
Resection
313
Fever, leukocytosis and tender liver on palpation
Pyogenic liver abscess secondary to acute ascending cholangitis
314
What is a complication of acute ascending cholangitis?
Pyogenic liver abscess
315
Tx of pyogenic liver abscess
Percutaneous drainage
316
How do pyogenic liver abscesses form?
Result from ascending cholangitis
317
3 categories of jaundice
Hemolytic
Obstructive
Intra-hepatic
318
Slightly increased total bilirubin with indirect predominance and normal direct bilirubin
Hemolysis
319
Elevated total bilirubin, with increased direct and indirect and high levels of AST/ALT and mildly elevated alk phos
Hepatitis
320
Elevated total bilirubin with increased direct > indirect, mildly increased AST/ALT and very high alk phos
Obstructive jaundice
321
What are the signs of a malignant gallbladder obstruction?
Large, thin-walled, distended gallbladder
322
Pt with jaundice, RUQ pain, leukocytosis
Choledocholithiasis
323
US findings of choledocholithiasis
Non-distended gallbladder filled with stones and dilated CBD
324
Dx of choledocholithiasis
US and confirm with ERCP
325
Tx of choledocholithiasis
ERCP with sphincterotomy then elective cholecystectomy
326
What are 3 cancers that can cause obstructive jaundice?
Pancreatic adenocarcinoma of head
Adenocarcinoma of Ampulla of Vater
Cholangiocarcinoma of CBD
327
Dx of pancreatic adenocarcinoma
```
CT scan
(If negative, then do MRCP)
```
328
Dx of adenocarcinoma of ampulla of vater
MRCP
329
Dx of cholangiocarcinoma of CBD
MRCP
330
How are pancreatic adenocarcinoma biopsied?
CT-guided percutaneous biopsy
331
How are ampulla of vater adenocarcinomas biopsied?
Endoscopic biopsy
332
How are cholangiocarcinomas biopsied?
ERCP with brushings
333
Obstructive jaundice + anemia + occult blood in stool
Ampulla of Vater adenocarcinoma
334
Dx of biliary colic
US
335
Tx of biliary colic
Elective cholecystectomy
336
Constant RUQ pain + fever + leukocytosis
Acute cholecystitis
337
Tx of acute cholecystitis
```
NGT
NPO
IVF
Abx
Urgent cholecystectomy
```
338
Constant RUQ pain, high fever, chills, prominent leukocytosis, extremely high alk phos
Ascending cholangitis
339
Tx of ascending cholangitis
IV abx
| ERCP
340
Fever and leukocytosis about a week after diagnosis and treatment of acute pancreatitis
Pancreatic abscess (drain it)
341
Early satiety, epigastric discomfort, deep palpable mass in a patient with history of acute pancreatitis or abdominal trauma
Pancreatic pseudocyst
342
Tx of pancreatic pseudocysts
If <6cm or <6weeks, observation
| If >6cm or >6weeks, drainage
343
A patient with long-standing epigastric pain, steatorrhea, new-onset diabetes
Chronic pancreatitis
344
All hernias should be electively repaired to prevent strangulation and obstruction EXCEPT in which 2 cases?
1. Umbilical hernias in kids 2-5
| 2. Sliding hiatal hernias
345
Breast cancer most commonly mets to which 2 locations?
Brain
| Bone
346
Where do sarcomas typically met to?
Lungs
347
Screening guidelines for mammograms
Starting at 40 and every 2 years
348
Best way to biopsy breast masses?
US guided core biopsies
349
Firm, rubbery breast mass that moves with palpation in young women
Fibroadenoma
350
Dx of fibroadenoma
US or FNA
351
Tx of fibroadenoma
Resection is optional, more for cosmetics
352
Very large, palpable breast masses that distort entire breast in women in their 20s
Cystosarcoma phyllodes -- benign but can become malignant, core biopsy, resection
353
Multiple lumps in bilateral breasts that relate to the menstrual cycle in women in 30s and 40s
Fibrocystic changes
354
Dx of fibrocystic breast changes
Mammogram unless persistent mass, then aspiration (clear fluid= normal cyst, bloody = send for cytology)
355
Bloody nipple discharge in 20s-40s
Intraductal papilloma
356
Dx of intraductal papilloma
Mammogram to r/o other lesions
357
Tx of intraductal papilloma
Galactogram and resection
358
Tx of breast abscess
I&D + biopsy of abscess wall
359
Features of malignant breast masses
```
Ill-defined
Fixed, non-mobile
Skin retraction
Peau du orange
Nipple retraction
Eczema of areola
Reddish orange skin
Palpable axillary lymph nodes
```
360
How is breast cancer managed during pregnancy?
No XRT or hormones during pregnancy
| No chemo during 1st trimester
361
Radiological features of malignant breast cancer
Fine microcalcifications not present before
Irregular, spiculated mass
Asymmetric density
362
For which types of breast cancers can lumpectomy be used?
Small lesions far from nipple and areola
363
How is a small breast lesion far away from nipple and areola treated?
Lumpectomy + XRT
364
How are large breast masses that lie close to nipple and areola managed?
Total mastectomy (with no XRT)
365
Which sub-type of infiltrating ductal carcinoma has the worst prognosis?
Inflammatory
366
Which subtype of infiltrating ductal carcinoma has a higher rate of bilaterality?
Lobular
367
How is DCIS managed?
If lesions are in ONE quadrant of breast, lumpectomy + XRT
| If multiple lesions scattered, total mastectomy + SNB
368
What hormonal therapy can be used for pre and post menopausal women with breast cancer?
Premenopausal - tamoxifen
| Postmenopausal - anastrazole
369
Tx of brain mets from breast cancer
Resection or XRT
370
Where do bony mets from breast cancer prefer?
Vertebral pedicles
371
Which type of thyroid cancer is NOT easily diagnosed by FNA?
Follicular
372
Tx of follicular thyroid cancer
Total thyroidectomy
373
Which cells does medullary thyroid cancer come from?
C-cells (make calcitonin)
374
Calcitonin is associated with what type of thyroid cancer?
Medullary
375
Tx of hyperthyroidism due to hot nodules
Radioactive iodine
376
What must be done prior to parathyroidectomy?
Sestamibi scan to locate gland prior to surgery
377
First step in the work-up of Cushing
Low-dose dexamethasone suppression test
| If suppresses cortisol, not Cushings
378
If there is no suppression of cortisol with a low-dose dexamethasone test, what is the next test?
24 hr urine cortisol levels
| If elevated, suspect Cushings and confirm location with high-dose dex suppression test
379
Watery diarrhea and multiple ulcers extending past 1st part of duodenum
Zollinger-Ellison
380
Dx of Zollinger Ellison
Gastrin levels and CT scan
381
Tx of Zollinger Ellison
Resect mass
382
Migratory necrolytic dermatitis
Glucagonoma
383
Hypokalemia in a hypertensive patient not on diuretics
Primary hyperaldosteronism from adenoma or hyperplasia (differentiate by postural changes -- in hyperplasia more Aldo when upright and less when lying down)
