Abdomen, Perioperative Care, Burns & Wounds

Question 1

Define an abdominal aortic aneurysm.

Answer 1

Localized weakness of blood vessel wall with dilation

Question 2

Where are abdominal aortic aneurysms most commonly found?

Answer 2

Infrarenally

Question 3

A 61 yo male patient comes in with abdominal/flank/back pain. He reports he smokes. On exam, you auscultate an abdominal bruit. What is the most likely diagnosis? How would you treat it?

Answer 3

Abdominal aortic aneurysm

Tx:
Immediate surgery if symptomatic/ruptured.
Beta-blockers

Question 4

A patient comes in with hypotension. He reports he had a syncopal event prior to coming in. On exam, you notice a flank ecchymosis. What is the next best step in management and what is the most likely diagnosis?

Answer 4

Abdominal aortic aneurysm

If hemodynamically stable + symptomatic: Contrast CT

If hemodynamically unstable OR asymptomatic: bedside U/S

Question 5

What patient population meets the requirement for an abdominal aortic aneurysm screening?

Answer 5

One time screening via abdominal U/S in men 65-75 yo who ever smoked

Question 6

You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that is greater than/equal to 5.5 cm. What is the next best step in managing this patient?

Answer 6

Immediate surgical repair–even if asymptomatic

Question 7

You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that increased by 0.5 cm. What is the next best step in managing this patient?

Answer 7

Immediate surgical repair–even if asymptomatic

Question 8

You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that is >4.5 cm. What is the next best step in managing this patient?

Answer 8

Vascular surgeon referral

Question 9

You screen a 67 yo male smoker for an abdominal aortic aneurysm. On abdominal U/S, you notice focal aortic dilation that is 4-4.5 cm. What is the next best step in managing this patient?

Answer 9

Monitor by U/S q 6 months

Question 10

A patient comes post abdominal surgery. She complains of abdominal pain and vomiting. On exam, you note abdominal distension and visible peristalsis. What is the most likely diagnosis and how would you treat it?

Answer 10

Small bowel obstruction

NPO, IVF, NG suction (bowel decompression)
If strangulated: surgery

Question 11

A patient comes in with a history of Crohn disease. She reports abdominal pain and obstipation. What are you most likely to hear on auscultation of the abdomen?

Answer 11

Small bowel obstruction

High pitched tinkles

Question 12

A patient comes in with a current incarcerated hernia. You determine she has a small bowel obstruction with obstipation being a huge giveaway. What would best help you to definitively determine this diagnosis?

Answer 12

Abdominal XR - multiple air-fluid levels in a step ladder appearance/string of pearls sign. Dilated bowel loops.

CT: most sensitive.
- transition zone from dilated loops of bowel with contrast to an area of bowel with no contrast

Question 13

A patient comes in with abdominal pain and a low-grade fever. They describe having changes in their bowel habits. PE is normal while labs show leukocytosis. What is the most likely diagnosis and how would you treat it.

Answer 13

Diverticulitis

Sigmoid colon MC area

Metronidazole + Cipro/Levofloxacin

Question 14

A patient comes in with epigastric pain that is exacerbated by fatty and large meals. On exam, the patient demonstrates a positive Boas sign. What is this sign and what is the most likely diagnosis?

Answer 14

Acute cholecystitis

Boas sign: referred pain to the R shoulder/subscapular area

Question 15

A patient comes in with nausea and fever. You note a positive Murphy’s sign and determine this patient has acute cholecystitis. What is the most likely causative microorganism? What is the initial test of choice and how would you treat it?

Answer 15

Microbe: E. coli

U/S - initial

HIDA scan - most accurate

Tx: NPO, IVF, Ceftriaxone + Metro –> cholecystectomy

Question 16

A patient comes in complaining of epigastric gnawing pain. He notes he has been taking ASA for 3 months daily for his R knee pain. What is the most likely diagnosis and how would you treat it?

Answer 16

Peptic ulcer disease

Tx: Bismuth subsalicylate + Tetracycline + Metro + PPI x 14 days

Question 17

A patient comes in with an upper GI bleed. On exam, you notice the patient lays extremely still. You note rebound tenderness, guarding and rigidity on palpation. What is your next best step in managing this patient?

Answer 17

Peptic ulcer disease

Upper endoscopy + bx - testing for H. pylori

Question 18

What is a complication of portal vein hypertension?

Answer 18

Esophageal varices

Question 19

A patient comes in with hematemesis, melena, and hematochezia. The patient notes he has alcohol use disorder. What is the next best step in managing this patient?

Answer 19

Esophageal varices

Upper endoscopy - both diagnostic and therapeutic

Question 20

A patient comes in to the ED with a massive upper GI bleed. How would you best stabilize this patient?

Answer 20

Esophageal Varices

2 large bore IVs and IVF

Endoscopy

Octreotide

Nadolol/Propranolol (nonselective beta blockers) for prevention of a rebleed

Question 21

A patient comes in with GERD. What is the pathology of this disease?

Answer 21

Incompetent lower esophageal sphincter

Question 22

A patient comes in complaining of chest pain. She notes the pain increases when she is lying down. She also reports hoarseness. What is the most likely diagnosis and how would you treat it?

Answer 22

GERD

Tx:

• Lifestyle modifications: elevate head of bed, avoid laying down for 3 hours after eating, avoid fatty/spicy foods, chocolate, caffeine
• If <2 episodes/week (mild or intermittent) Antacids and H2 receptor antagonists
• If severe or moderate (>2 episodes/week): PPI

Question 23

A patient comes in with dysphagia, odynophagia, weight loss and bleeding. What are you most concerned for? How would you diagnose it?

Answer 23

GERD

Concerned for Barrett’s esophagus –> esophageal adenocarcinoma

Clinical diagnosis. If confirmation needed: 24-hr ambulatory pH monitoring

Question 24

A patient comes in with epigastric pain hat radiates to the back. It is worsened when she is laying down and is relieved when she leans forward. What signs should you look out for on your exam? Tx?

Answer 24

Acute pancreatitis

Cullen’s sign (periumbilical ecchymosis) + Grey Turner Sign (flank ecchymosis)

Tx: NPO, IVF

Question 25

A patient comes in with acute pancreatitis. What are you looking for in labs/imaging?

Answer 25

Labs: - Increased lipase>amylase - Hypocalcemia Imaging: - abd CT - XR: sentinel loop

Question 26

What's the sequence of preoperative care?

Answer 26

Diagnostic workup Preoperative eval Preoperative prep

Question 27

What's the sequence of postoperative care?

Answer 27

Postanesthetic observation Intensive care Intermediate care Convalscent care

Question 28

A patient comes in to the ED. You determine they require surgery ASAP. What are the most important questions you should ask them prior to them starting surgery?

Answer 28

AMPLE ``` A: allergies M: meds P: past medical history L: last meal E: events preceding the emergency ```

Question 29

What would make someone have delayed wound healing, thus increasing their postsurgical risks?

Answer 29

use of corticosteroids severe anemia diabetes smoking decreased perfusion

Question 30

What classification tool helped determine the correct anesthetic to be used prior to surgery?

Answer 30

ASA Physical Status Classification 1: patient is fit and healthy 2: patient has mild systemic disease 3: severe systemic disease, not incapacitating though 4: incapacitating disease that's a constant threat to life 5: patient isn't expected to live with/without surgery E: emergency surgery NOT USED TO PREDICT OPERATIVE RISK

Question 31

What is a postop complication that presents within 24-48 hrs of postop?

Answer 31

Atelectasis | Pneumonia

Question 32

What is a postop complication that presents within 48-72 hrs of postop?

Answer 32

UTI

Question 33

What is the most common cause of fever 72 hrs postop?

Answer 33

Wound infection

Question 34

When is a thrombotic event concerning postop?

Answer 34

72 hrs postop

Question 35

How does COVID pathophysiologically enter the human body?

Answer 35

By attaching to the ACE2 receptor, found in alveoli, the intestines, kidney, and heart, which allows it to enter host cells.

Question 36

What are the primary signs and symptoms of COVID19?

Answer 36

Cough Fever Dyspnea Anosmia (loss of smell) & ageusia (loss of taste) Pernio-like lesions (COVID toes) Palmar erythema Livedo reticularis - netlike pattern of reddish/blue skin discoloration

Question 37

A patient presents with sxs of COVID19. You decide to test them and get some labs. What is the gold standard for diagnostic testing of COVID19? What lab anomalies should you expect?

Answer 37

Test: reverse-transcription PCR Labs - low: - low lymphocyte count - low albumins - low platelets - low Hg Labs - high: - Lactate dehydrogenase - Ferritin - D-dimer - ALT & AST

Question 38

A patient presents with sxs of COVID19. You decide to get a CXR. What are you most likely to find on CXR? What about a chest CT?

Answer 38

CXR: Multifocal pneumonia CT: ground glass opacities

Question 39

A patient presents with sxs of COVID19. They are an obese 67 yo male with a history of smoking. He reports a history of CHF and TDM2. Which of his characteristics put him at risk for developing COVID19?

Answer 39

Not age: must be over 75 yo Not CHF. The only cardio risk factor is HTN. Not smoking - not listed in PPT. Diabetes Obesity!!

Question 40

A patient presents with sxs of COVID19? You decide to treat them in the outpatient setting. How would you proceed?

Answer 40

Supportive care DEF NO STEROIDS or ABX!!! If high risk for disease progression: consider monoclonal antibodies (Bamlanivimab or casirivimab+imdevimab)

Question 41

A patient presents with sxs of COVID19? You decide to treat them in the inpatient setting. How would you proceed?

Answer 41

If needing O2: Decadron Monoclonal antibodies: Bamlanivimab or casirivimab+imdevimab Anticoagulation/DVT prophylaxis

Question 42

In what kinds of burns should the Rule of Nines be considered?

Answer 42

Partial thickness burns or deeper areas

Question 43

Why are we more concerned about a geriatrics or pediatrics patient being burned that we would be for a young adult?

Answer 43

Kids and the elderly have a thinner dermal layer, so burns can be deeper than they appear

Question 44

What is the Rule of Nines?

Answer 44

``` Head - 9% Each arm - 9% Anterior torso - 18% Posterior torso - 18% Anterior leg - 9% Posterior leg - 9% Genitalia - 1% Palm - 1% ```

Question 45

A patient presents with a burn to her arm. It is erythematous without blistering. How would you categorize the burn? Tx?

Answer 45

1st degree/Superficial Tx: - lotion/emollients - analgesia OTC - oral hydration

Question 46

Under what conditions MUST the burn center be contacted?

Answer 46

If the burn occurs on a child or over a joint

Question 47

A patient presents with a burn to her arm. It is erythematous and wet with blistering and dermal loss. When you push against the burn, it blanches. The patient is in pain. How would you categorize the burn? Tx?

Answer 47

2nd degree/partial thickness Tx: - Face: ALWAYS bacitracin. Quickly switch to a facial lotion once healing is evident - Other areas: silver gel/Xeroform/Petroleum gauze

Question 48

Which treatments should not be used on a burn and why?

Answer 48

Silver sulfadiazine Triple antibiotics These will stain the skin

Question 49

A patient comes in with an arm that appears pale in some areas and cherry red in others. It is dry, no blanching, and no pain. How would you categorize the burn?

Answer 49

3rd degree/full thickness

Question 50

What is a 4th degree burn?

Answer 50

Full thickness burn (dry, pale, cherry red) + loss of body part

Question 51

What category of burns require an immediate referral to a burn center?

Answer 51

Partial thickness burns >10% | Full thickness burns

Question 52

List the order of normal wound healing

Answer 52

Hemostasis - coagulation Inflammation - removal of debris - minor:24 hrs, major: 48 hrs Proliferation - fill and cover Remodeling/Maturation - scar - can take 2 years!! - increases tensile strength!

Question 53

Scars increase __% per week and are __% stronger after 5 weeks.

Answer 53

10. | 50.

Question 54

How long does it take in weeks for a scar to reach full healing strength?

Answer 54

10 weeks (3 months)

Question 55

Normally, a scar will be thickest __ weeks after the skin cells have closed and sealed the surface. Then they soften by __ back to normal in another 6 weeks (3 months after wounding) and 80% in 6 months. It takes a full year for the thickness to soften all the way.

Answer 55

6 | 50%

Question 56

What are the most common etiologies of a small bowel obstruction?

Answer 56

1. adhesions 2. hernias 3. Meckel's diverticulum 4. Mesenteric ischemia

Question 57

A patient presents with a small bowel obstruction. What sxs would he present with?

Answer 57

Crampy abdominal pain Abdominal distension Vomiting (bilious) Obstipation

Question 58

You hear high-pitched tinkles on auscultation and visible peristalsis on PE. What is the most likely diagnosis and how would you tx it?

Answer 58

Small bowel obstruction NPO, IVF, Bowel decompression

Question 59

What is the most common etiology of a large bowel obstruction?

Answer 59

Fecal impaction

Question 60

What is SIRS?

Answer 60

2 or more of the following: - Temp >38C (100.4) or <36C - RR >20 or PaCO2 <32 - HR >90 - WBC >12,000, <4,000, or >10% Bands

Question 61

What is sepsis?

Answer 61

SIRS + source of infection

Question 62

What is severe sepsis?

Answer 62

Evidence of organ dysfunction - lactic acidosis >2 - Systolic BP <90

Question 63

What is septic shock?

Answer 63

Severe sepsis + hypotension despite adequate fluid resuscitation (30mL/kg of crystalloid)

Question 64

A patient comes in with sepsis. What are some common sources of infection?

Answer 64

- Pneumonia - Intrabdominal - Primary bacteremia - IV drug use, catheter - Urinary

Question 65

A patient comes in with sepsis. How do you treat? (4 steps)

Answer 65

1. Blood cultures --> Early antibiotics (within 3 hours) 2. Early crystalloids (30 mL/kg within first 3 hours) 3. Initial and repeat lactic acid if >2 within the next hours 4. Early vasopressors (NE)

Question 66

A patient presents with sepsis. You treat with empiric antibiotics. What does this include?

Answer 66

Ceftriaxone/Cephipim Pip/Tazo Ampicillin/Sulbactam Levofloxacin NEVER VANCOMYCIN (this only treats gram positive)

Question 67

What's the difference between a direct and an indirect hernia?

Answer 67

Direct hernia - origin of the sac is MEDIAL to the inferior epigastric artery (direct message = DM)) Indirect hernia - origin of the sac is LATERAL to the inferior epigastric artery - MC of hernia in both sexes, young kids, and young adults

Question 68

This is often congenital due to a persistent patent process vaginalis.

Answer 68

indirect hernia

Question 69

A patient comes in with swelling at the lower abdomen. It enlarges with valsalva. It is extremely painful and is irreducible. What is the most likely diagnosis?

Answer 69

Incarcerated indirect hernia - key words: painful, irreducible

Question 70

A patient comes appearing extremely toxic. They complain of fullness at the lower abdomen and severe painful bowel movements that make them refrain from defecating. What is the most likely diagnosis?

Answer 70

Strangulated indirect hernia - surgical emergency! - key words: toxic, painful BM

Question 71

A patient comes in with a painless growing lump in her midabdominal region. It's been there for as long as she can remember but reports it's getting bigger. What's the most likely diagnosis and how would you treat it?

Answer 71

Umbilical hernia This is congenital. Usually resolve by 2 years of age Surgery if persistent in 5+ years of age to avoid incarceration or strangulation

Question 72

What medical problems must be addressed prior to a hernia repair, why?

Answer 72

Morbid obesity DM Smoking Hernia recurrence If any of these are present, this is considered a complex hernia. Getting these taken care of help to reduce recurrence risks.

Question 73

A patient comes in with a bulge at the superior portion of a vertical incision. He reports it is painful and notes obstipation. What is the next best step?

Answer 73

Incisional (ventral) hernia CT/MRI