13 Gen Surg Flashcards
how many hours after removal of foley after surgery do you worry if no urine output
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.
Marjolin’s ulcer
- vignette
- what is it, presentation
- tx
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
Breast CA general rule:
- screening test
- confirm test
mammogram
core bx
Breast CA surgery options.
- what is equivalent?
- CIS vs invasive, difference?
Lumpectomy+Rad = Mastectomy
Also do ALND, if sentinel LN bx was positive.
If invasive carcinoma on bx, also add chemo/targeted systemic tx
Post op AMS
-what to think (2 common causes, 2 to think of for test)
- hypoxia
- e-lytes, glucose
- ARDS
- DTs
BRCA 1/2
-what do they get
ppx mastectomy and b/l salping-oopherectomy
If not, do MRI and mmamography q1y
Pt needs elective surgery but had MI 1 month ago. Do what
do heart cath, delay 6 months.
Post op ileus:
-At what post-op day to be worried when not resolving
If day 5-7 still ileus, concern for obstruction. Get KUB
Also make sure K+ repleted. hypoK can cause ileus
Breast lump workup in young woman:
Mammogram not sens in young females
- If <30, wait 2-3 cycles.
- persists, get U/S (mass vs cyst)
- 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
29y F presenting with asx breast lump. do what
Reassurance b/c <30y. Wait, often goes away in 1-2 menstrual cycles (fibrocystic change). So, RTC 6wks
Pt with Breast CA on systemic tx, has CHF
think what?
Doxorubicin/Daunorubicin has dose-dependent irreversible CHF. LATE
Trastuzumab has non dose dependent, reversible CHF. EARLY. Get echos q3mo
Surgery contraindications:
-Pulm risk, how to eval
-when to do smoking cessation
- 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)
Venous insufficiency:
why is skin darker
blood sitting so long, deposits hemosiderin
Surgery contraindications:
hepatic risk
use Child-Pugh/MELD score
-bili, alb, PT, encephaloopathy, ascites. If any 1 is abnormal, 40% mortality.
Post op chest pain
-think what
2 things:
PE, MI
Breast CA neo and adjuvant tx:
-what meds, when to use which
Find out Her2Neu, ER, PR receptors:
- ER/PR+ and:
premenopausal: tamoxifen or raloxifene
postmenopausal: anastozole/letrozole (aromatase i) - Her2Neu+ can use: Trastuzumab
Her2Neu- uses Bevacizumab - Chemo
Fistulas
-Causes
FRIEND:
foreign bodies radiation infxn epithelialization neoplasm distal obstruction
Ogilvie’s syndrome
- how looks on KUB
- tx
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
Post op fever
-what causes
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
Surgery contraindications: Cardiac risk (2)
-what tests to get
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
Post op wounds:
dehiscence vs evisceration
-what to do
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.
Post op low urine output
-how to workup?
- Does pt feel like urinating? If so, may be retention. Do straight cath
- Zero output? Maybe kinked foley
- There is some output. Do 500ml fluid challenge. If urine comes out, then simply dehydrated. If not, then maybe intrarenal dz.
29F with hx of Hodgkin’s lymphoma 10y ago treated with radiation.
-how to screen breast CA
-b/c rad hx, do annual MRI
Breast CA ppx meds?
Tamoxifen vs Raloxifene
Tamoxifen: stronger, but more DVT and endo CA
Ralox: weaker, but no DVT or endo CA
Surgery contraindications: malnutrition -how to eval, what 3 main things? -what other important tests? -how to treat
- weight loss >20% in 3mo
- albumin <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
