13 Gen Surg

Question 1

how many hours after removal of foley after surgery do you worry if no urine output

Answer 1

6 hours before doing any intervention

then can try in/out cath, and assess for post-residual void. if high post residual, leave in catheter. Low, give fluids.

Question 2

Marjolin’s ulcer

• vignette
• what is it, presentation
• tx

Answer 2

Mexican immigrant with ulcer. (pt usu immigrant b/c would be fixed in USA)

• SCC from chronic inflamm. site of chronic draining sinus tract or chronic wound
• ugly, deep, heaped up margins

-bx to confirm, do wide excision

Question 3

Breast CA general rule:

• screening test
• confirm test

Answer 3

mammogram

core bx

Question 4

Breast CA surgery options.

• what is equivalent?
• CIS vs invasive, difference?

Answer 4

Lumpectomy+Rad = Mastectomy

Also do ALND, if sentinel LN bx was positive.

If invasive carcinoma on bx, also add chemo/targeted systemic tx

Question 5

Post op AMS

-what to think (2 common causes, 2 to think of for test)

Answer 5

1. hypoxia
2. e-lytes, glucose
3. ARDS
4. DTs

Question 6

BRCA 1/2

-what do they get

Answer 6

ppx mastectomy and b/l salping-oopherectomy

If not, do MRI and mmamography q1y

Question 7

Pt needs elective surgery but had MI 1 month ago. Do what

Answer 7

do heart cath, delay 6 months.

Question 8

Post op ileus:

-At what post-op day to be worried when not resolving

Answer 8

If day 5-7 still ileus, concern for obstruction. Get KUB

Also make sure K+ repleted. hypoK can cause ileus

Question 9

Breast lump workup in young woman:

Answer 9

Mammogram not sens in young females

1. If <30, wait 2-3 cycles.
2. persists, get U/S (mass vs cyst)
3. If cystic, FNA (fluid is cyst, bloody can be CA)

If female >30, or U/S shows mass, or aspirate is bloody, or cyst recurs:
Get mammogram

Question 10

29y F presenting with asx breast lump. do what

Answer 10

Reassurance b/c <30y. Wait, often goes away in 1-2 menstrual cycles (fibrocystic change). So, RTC 6wks

Question 11

Pt with Breast CA on systemic tx, has CHF

think what?

Answer 11

Doxorubicin/Daunorubicin has dose-dependent irreversible CHF. LATE

Trastuzumab has non dose dependent, reversible CHF. EARLY. Get echos q3mo

Question 12

Surgery contraindications:
-Pulm risk, how to eval

-when to do smoking cessation

Answer 12

• evaluate high risk (smoker, COPE, asthma, ILD). Ventilation more important than oxygenation b/c surgery creates acidosis
• FEV1/FVC and ABG

Also, smoking cessation must be started 8 weeks+ (any earlier is more secretions)

Question 13

Venous insufficiency:

why is skin darker

Answer 13

blood sitting so long, deposits hemosiderin

Question 14

Surgery contraindications:

hepatic risk

Answer 14

use Child-Pugh/MELD score

-bili, alb, PT, encephaloopathy, ascites. If any 1 is abnormal, 40% mortality.

Question 15

Post op chest pain

-think what

Answer 15

2 things:

PE, MI

Question 16

Breast CA neo and adjuvant tx:

-what meds, when to use which

Answer 16

Find out Her2Neu, ER, PR receptors:

1. ER/PR+ and:
   premenopausal: tamoxifen or raloxifene
   postmenopausal: anastozole/letrozole (aromatase i)
2. Her2Neu+ can use: Trastuzumab
   Her2Neu- uses Bevacizumab
3. Chemo

Question 17

Fistulas

-Causes

Answer 17

FRIEND:

foreign bodies
radiation
infxn
epithelialization
neoplasm
distal obstruction

Question 18

Ogilvie’s syndrome

• how looks on KUB
• tx

Answer 18

Unlike postop ileus, Ogilvie’s has only colon dilated. Postop ileus has small bowel and colon dilated.

• rectal tube to decompress
• colonoscopy to r/o CA and help decompress

Question 19

Post op fever

-what causes

Answer 19

5 W’s
Wind, Water, Walking, Wound, Wonder Drugs
1/2,3,5,7/10
Atelectasis (1), PNA (2), UTI, DVT, wound (7), abscess (>10)
drugs either end of spectrum

wonder drugs means: halothane/succ malignant hyperthermia (give dantrolene)

Also, fever immediately after surgery can mean infection

Question 20

Surgery contraindications:
Cardiac risk (2)

-what tests to get

Answer 20

2 main things:
1. EF<35%
2. MI within 6 mo
Also, Goldman index. includes JVD, arrythmia, age>70, etc

Get: Echo, EKG, arteriogram, possibly CABG

Question 21

Post op wounds:
dehiscence vs evisceration
-what to do

Answer 21

Dehisence: skin intact, but fasica failed. Serosanguinous salmon colored drainage. Bind and limit straining. Potential hernia, so nonemergent surgery to fix

Eviseration. skin and fascia fail. Cover bowel with warm saline dressings, don’t put back in.

Question 22

Post op low urine output

-how to workup?

Answer 22

1. Does pt feel like urinating? If so, may be retention. Do straight cath
2. Zero output? Maybe kinked foley
3. There is some output. Do 500ml fluid challenge. If urine comes out, then simply dehydrated. If not, then maybe intrarenal dz.

Question 23

29F with hx of Hodgkin’s lymphoma 10y ago treated with radiation.

-how to screen breast CA

Answer 23

-b/c rad hx, do annual MRI

Question 24

Breast CA ppx meds?

Answer 24

Tamoxifen vs Raloxifene

Tamoxifen: stronger, but more DVT and endo CA

Ralox: weaker, but no DVT or endo CA

Question 25

Surgery contraindications:
malnutrition
-how to eval, what 3 main things?
-what other important tests?
-how to treat

Answer 25

1. weight loss >20% in 3mo
2. albumin <3
3. anergy to skin antigens

Also, prealbumin tells you nutritional production. If alb low but prealb normal, then there is a liver disfxn, not malnutrition.

Vigorous nutritional support. PO>IV, 10 days>5days