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Miscellaneous USMLE Step 3 > Section 4: Preoperative and Postoperative Care > Flashcards

Section 4: Preoperative and Postoperative Care Flashcards

1
Q

What is the most important aspect of preoperative assessment of a patient for surgery?

Any other reason for preoperative assessment?

A

To identify comorbidities that preclude surgery

Modifications that may need to be instituted to prepare the patient for surgery?

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2
Q

List the cardiact risk factors for surgery and the modifications/interventions (M/I) that may be needed

A
  1. Ejaction fraction < 35%
    • Prohibits noncardiac surgery
  2. Jugular venous distension (sign of CHF)
    • Optimize medications with ACE inhibitors, beta blockers, digitalis, and diuretics should precede surgery
  3. Recent myocardial infarction
    • Defer surgery for 6 months after MI
  4. Severe progressive angina
    • Perform cardiac catherization to evaluate possible coronary revascularization
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3
Q

List the pulmonary risk factors for noncadiac surgery and the modifications/interventions that may be instituted

A

Smoking with compromised ventilation (high PCO2, FEV1 < 1.5)

  • Order PFTs to evaluate FEV
  • If FEV1 is abnormal, obtain blood gas
  • Cessation of smoking for 8 weeks prior to surgery
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4
Q

List the hepatic risk factors for noncadiac surgery and the modifications/interventions that may be instituted

A

Bilirubin > 2.0

Prothrombin time > 16

Serum albumin < 3.0

Encephalopathy

  • ~ 40% mortality with any single risk factor
  • ~ 80-85% mortality is predictable if three or more risk factors are present
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5
Q

List the nutritional risk factors for noncadiac surgery and the modifications/interventions that may be instituted

A

Loss of 20% of body weight over several months

Serum albumin < 3.0

Anergy to skin antigens

Serum transferrin < 200 mg/dL

Diabetic coma

  • Provide 5-10 days of nutritional supplements (preferably via gut) before surgery
  • Diabetic coma is an absolute contraindications to surgery. First stabilize diabetes. Rehydrate and normalize acidosis prior to surgery
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6
Q

A 57-year old woman who underwent emergent cholecystectomy for a perforated gallbladder 3 days prior now has a fever of 103oF and is complaining of chills. The patient has not been ambulating and says she is in great deal of pain at her incision. What is the most likely cause of her fever?

a. Atelectasis
b. UTI
c. Wound infection
d. DVT
e. Abscess

A

B. This is what it is most likely; however, all of the choices are possible. In this patient with a complicated surgery and obvious risk factors for other possibilities, you must use your clinical acumen to judge the most likely source of infection, but the
other choices are still on your mind for consideration.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 400). Kaplan Medical Test Prep. Kindle Edition.

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7
Q

List the mnemonic for post-operative fever

A

5 W’s

  • Wind = Atelectasis, Post-op Pneumonia
  • Water = Pneumonia, UTI
  • Walking = DVT, Thrombophlebitis of IV access
  • Wound = Wound infections and cellulitis
  • Wonder = drug fever or Deep abcess
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8
Q

Post-op Day 1-2 Fever

List the

  1. Possible causes
  2. Diagnostic tests
  3. Therapy
A
  1. Atelectasis or postoperative pneumonia
  2. Chest x-ray followed by sputum cultures
  3. Prevention by incentive spirometry; vancomycin and tazobactam-pipercillin for hospital-acquiredpneumonia

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 400). Kaplan Medical Test Prep. Kindle Edition.

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9
Q

Post-op Day 3-5 Fever

List the

  1. Possible causes
  2. Diagnostic tests
  3. Therapy
A

POD 3–5 Water

  1. Urinary tract infection
  2. Urine analysis showing positive nitrates and leukocyte esterase.Urine culture for species and sensitivity.
  3. Antibiotics appropriate for the organism

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 400). Kaplan Medical Test Prep. Kindle Edition.

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10
Q

Post-op Day 5-7 Fever

List the

  1. Possible causes
  2. Diagnostic tests
  3. Therapy
A

POD 5–7 Walking

  1. Deep vein thrombosis or thrombophlebitis of the IV access lines. Must also consider pulmonary embolism for new-onset tachycardia and chest pain.
  2. Doppler ultrasound of the extremities. Changing of IV access lines and culture of the IV tips.
  3. Heparin for 5 days as a bridge to coumadin for 3–6 months

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 400). Kaplan Medical Test Prep. Kindle Edition.

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11
Q

Post-op Day 7 Fever

List the

  1. Possible causes
  2. Diagnostic tests
  3. Therapy
A

POD 7 Wound

  1. Wound infections and cellulitis
  2. Physical exam of the wound for erythema, purulent discharge, and/or swelling
  3. Incision and drainage if abscess or fluid followed by antibiotics

POD 8–15 Wonder Drug fever or deep
abscess
CT scan for examination
of a deep fluid
collection
CT guided percutaneous
guided drainage of
the abscess; otherwise
surgery

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 400). Kaplan Medical Test Prep. Kindle Edition.

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12
Q

Post-op Day 8-15 Fever

List the

  1. Possible causes
  2. Diagnostic tests
  3. Therapy
A

POD 8–15 Wonder

  1. Drug fever or deep abscess
  2. CT scan for examination of a deep fluid collection
  3. CT guided percutaneous guided drainage of the abscess; otherwise surgery

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 400). Kaplan Medical Test Prep. Kindle Edition.

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13
Q

List the (1) diagnosis, (2) etiology, (3) diagnostic tests, and (4) Rx of the following shoulder injury based on the following CF:

  • Arm held to the side
  • Externally rotated forearm
  • Severe pain
A
  1. Anterior shoulder dislocation
  2. Any injury that causes strain on the glenohumoral ligaments. Most common type, more than 95%.
  3. X-ray is the best initial test and MRI is the most accurate test.
  4. Shoulder relocation and immobilization

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 395). Kaplan Medical Test Prep. Kindle Edition.

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14
Q

List the (1) diagnosis, (2) etiology, (3) diagnostic tests, and (4) Rx of the following shoulder injury based on the following CF:

  • Arm held to the side
  • Arm is medially rotated
A
  1. Posterior shoulder dislocation
  2. Seizure or electrical burn
  3. X-ray is the best initial test and MRI is the most accurate test
  4. Traction and surgery if pulses or sensation are diminished during physical exam

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 395). Kaplan Medical Test Prep. Kindle Edition.

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15
Q

List the (1) diagnosis, (2) etiology, (3) diagnostic tests, and (4) Rx of the following shoulder injury based on the following CF:

  • Pain over the clavicle
  • Trauma to site
A
  1. Clavicular fracture
  2. Trauma
  3. X-ray is the best test
  4. Simple arm sling

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 395). Kaplan Medical Test Prep. Kindle Edition.

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16
Q

List the (1) diagnosis, (2) etiology, (3) diagnostic tests, and (4) Rx of the following shoulder injury based on the following CF:

  • Persistent pain in the anatomical “snuffbox”
A
  1. Scaphoid fracture
  2. Falling on an outstretched hand
  3. X-ray won’t show results for 3 weeks
  4. Thumb spica cast

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 395). Kaplan Medical Test Prep. Kindle Edition.

17
Q

A 39-year-old woman awoke from a nap with severe pain in her index finger and found it to be flexed while all other fingers were extended. When she tried to pull it free she heard a loud popping sound and the pain subsided. The following day she comes to her doctor’s office concerned about the sound and pain. What is the most appropriate next stop in the management of this patient?

a. Amputate the finger
b. Steroid injection
c. Rehabilitation
d. Admit to the hospital
e. NSAID therapy

A

B. Trigger finger is an acutely flexed and painful finger. Steroid injections have been shown to decrease pain and recurrence of trigger finger. It is the most cost-effective treatment, and studies have shown a trial of steroids should be attempted prior to surgery. Trigger finger is caused by a stenosis of the tendon sheath leading to the finger in question. If steroids fail, surgery to cut the sheath that is restricting the tendon is the definitive treatment. Do not confuse trigger finger with Dupuytren contracture, a condition more common in men over the age of 40. Dupuytren contracture is when the palmar fascia becomes constricted and the hand can no longer be properly extended open. Surgery is the only effective therapy.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 395). Kaplan Medical Test Prep. Kindle Edition.

18
Q

True or False:

Figure of 8 slings are the Rx for clavicular fracture

A

False

For clavicular fractures, figure 8 slings are no longer used, as their outcomes have not been shown to be any better than a simple arm sling.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 395). Kaplan Medical Test Prep. Kindle Edition.

19
Q

List the (1) diagnosis, (2) diagnostic tests, and (3) Rx of the following knee injury based on the following CF:

  • Trauma to the opposite side of the injury
  • Pain
A
  1. Medial and lateral collateral ligament injury
  2. MRI
  3. Surgical repair

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

20
Q

List the (1) diagnosis, (2) diagnostic tests, and (3) Rx of the following knee injury based on the following CF:

  • Direct trauma to the knee
  • Pain
  • Positive anterior drawer sign
A
  1. Anterior cruciate ligament
  2. MRI
  3. Arthroscopic repair

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

21
Q

List the (1) diagnosis, (2) diagnostic tests, and (3) Rx of the following knee injury based on the following CF:

  • Direct trauma to the knee
  • Pain
  • Positive posterior drawer sign
A
  1. Posterior cruciate ligament
  2. MRI
  3. Arthroscopic repair

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

22
Q

List the (1) diagnosis, (2) diagnostic tests, and (3) Rx of the following knee injury based on the following CF:

  • Traumatic to the knee
  • Popping sound upon flexion and extension
A
  1. Meniscal injury
  2. MRI
  3. Arthroscopic

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

23
Q

True or False:

Anterior cruciate ligament (ACL) injury is the most common knee ligament injury.

A

True

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

24
Q

List the unhappy triad of knee injury in the setting of
sports trauma and the 3 structures involved

A
  1. The anterior cruciate ligament
  2. The medial collateral ligament
  3. The lateral or medial meniscus

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

25
Q

A 41-year-old man presents to the ED after acute onset of lower back pain that began after he tried to lift an engine block at his job. He says he feels like lightning
bolts are shooting down his legs and he is unable to move. Physical exam reveals a positive straight leg raise test and positive anal wink. What is the most appropriate next diagnostic step?
a. X-ray of the cervical spine
b. MRI of the spine
c. CBC
d. ESR
e. Lumbar puncture

A

B. A patient who presents with acute onset of back pain and is under the age of 50 should have an MRI to rule out spinal cord compression due to a slipped disc or lumbar disc herniation. If asked for the most appropriate next step in management, answer antiinflammatory agents. The most common sites of lumbar disc herniation are L4-L5 and L5-S1. The other choices are applicable but the most appropriate next step is an MRI. Lumbar puncture, however, has no role in the treatment of slipped disc.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 398). Kaplan Medical Test Prep. Kindle Edition.

26
Q

List causes of blastic metastatic bone lesions

A

Prostrate cancer

Breast cancer

27
Q

List causes of lytic metastatic bone lesions

A

Lung cancer

Renal cancer

Breast cancer

Thyroid cancer

Miscellaneous USMLE Step 3 (11 decks)

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