Approach to surgical patient

Question 1

what is the purpose of the preoperative evaluation?

Answer 1

to evaluate the patient at higher risk of complication and implement interventions to mitigate or reduce that risk

Question 2

what is the KEY factor in improving outcome and lowering length of hospital stay in our patients?

Answer 2

mitigating or decreasing stress response to surgery and anesthesia

Question 3

when will complete gastric emptying occur in normal individuals?

Answer 3

90 minutes

between 90-120 in the rest

Question 4

why is keeping gastric emptying time in mind important when prepping your patient for surgery?

Answer 4

keep them NPO when necessary and possible, but if they need food give it outside this range

Question 5

a patient’s _______ _______provides valuable prognostic information regarding likelihood of developing intra-operative and post-operative complications

Answer 5

patient’s functional capacity

question the patient with regards to exercise tolerance

Question 6

what are the four components of a preoperative physical exam review?

Answer 6

1) BP (both arms)
2) thorough lung exam
3) cardiac exam with pulses
4) EKG looking for rhythm abnormalities

Question 7

it is important to try to avoid surgery for several months if patient has had a recent _____

Answer 7

MI

recent hx of MI markedly increases risk for a postoperative recurrent MI and mortality

Question 8

do patients with a 20+ pack year who stop smoking 2 months prior to surgery reduce their risk of peri and postoperative complications by much?

Answer 8

yes! significantly

Question 9

how long must a patient with a 20+ pack year stop smoking prior to surgery in order to have rates of complications similar to non-smokers?

Answer 9

6 months

Question 10

what is the predominant pathogen seen in endocarditis?

Answer 10

staph aureus

Question 11

what 2 factors must be present for endocarditis to occur?

Answer 11

1) endothelial injury or defect

2) PLUS bacteremia

Question 12

under what 6 circumstances do we give ABX PPX for high risk patients for endocarditis?

Answer 12

1) acquire valve disease with stenosis or regurgitation
2) those with congenital heart defect
3) those with prosthetic heart valve (all types)
4) hypertrophic cardiomyopathy
5) prior HX of endocarditis
6) heart transplant recipients

Question 13

if patient reporting for surgery has a HX of recurrent epistaxis, gum bleeding, and exceptionally heavy menses, how should you proceed?

Answer 13

inquire as to family hx of bleeding disorders

if bleeding diathetsis suspected: CBC, platelet count, PT/PTT/INR

Question 14

what is the ASA classification system?

Answer 14

system utilized for assessing fitness of patients before surgery

Question 15

a normal healthy patient with no operative risk is considered what class and grade?

Answer 15

class 1, grade 1a

Question 16

a patient with mild systemic disease or a normal healthy patient with some operative and anesthetic risk is considered what class and grade on the ASA system?

Answer 16

class 1, grade 1a

Question 17

who falls under class 4 on the ASA classification system?

Answer 17

patient with an incapacitating systemic disease that is a constant threat to life; patient with severe systemic disease that limits activity

Question 18

who falls under class 5 on the ASA classification system?

Answer 18

moribund patient not expected to survive 24 hours with or without operation

Question 19

under the current guidelines, what types of patients should receive beta blockers prior to surgery?

Answer 19

1) CAD
2) angioplasty
3) CABG
4) use of nitrates for chest pain
5) TIA or CVD
6) serum creatinine more than 2
7) pts with poorly controlled T2DM

Question 20

what is the benefit to using a beta blocker prior to surgery?

Answer 20

lower the heart rate which in turn reduces heart muscle O2 demand during stress of surgery and anesthesia

Question 21

who gets an echocardiogram prior to surgery?

Answer 21

all patients with clinical signs of heart failure and MURMUR

Question 22

describe the murmur of aortic stenosis

Answer 22

mid-systolic crescendo-descrescendo ejection murmur heard best over the right 2nd intercostal space with radiation into the right neck

Question 23

a palpably slow rise of the carotid upstroke may make you consider what valve dysfunction?

Answer 23

aortic stenosis

Question 24

aortic stenosis is a progressive disease, describe the typical course of symptoms throughout a patients life

Answer 24

mnemonia = ASC

1) Angina (early; usually stable)
2) Syncope (later; w exercise)
3) CHF (bc of hypertrophied LV)

Question 25

what will EKG of late aortic stenosis show?

Answer 25

left ventricular hypertrophy with LV strain bc of pressure overload

Question 26

has mild to moderate asthma been shown to pose a significant perioperative pulmonary risk?

Answer 26

no

Question 27

your patient just had an acute exacerbation of their asthma or COPD, what should you tell them in regards for their upcoming tonsillectomy?

Answer 27

wait

you should delay purely elective surgery for patients with recent acute exacerbation

Question 28

if a patient has COPD or severe asthma, what should you give post op?

Answer 28

scheduled nebulizers with albuterol and ipratropium q4 hours

Question 29

your COPD patient is post-op hip replacement and goes into an acute COPD exacerbation. should you give steroids?

Answer 29

discuss with surgical team

remember that steroids may impair wound healing!

Question 30

what do we do for prophylaxis for acute withdrawal syndrome/delerium tremens should a suspected alcoholic require a surgical procedure?

Answer 30

combination of

1) benzos
2) clonidine
3) chlormethiazole
4) haldol

most hospitals have set protocol for these patients at high risk

Question 31

jaundice and clay-colored schools should raise suspicion for what GI disorder?

Answer 31

choledocolithiasis

Question 32

diagnosis and treatment of choledocolithiasis?

Answer 32

ERCP to TX/DX

cholecystectomy down the line

Question 33

obstruction of the common bile duct or cystic duct will cause _____ type pain

Answer 33

colicky pain

Question 34

where is the gallstone if you are getting inflammation of just the gallbladder?

Answer 34

obstruction of the cystic duct

cholecystitis

Question 35

what are the risk factors for cholecystitis?

Answer 35

• increased age
• female sex (2x MC)
• pregnancy
• certain meds
• obesity

Question 36

DX and TX of cholecystitis?

Answer 36

DX = ultrasound
TX = cholecystectomy

Question 37

you should always perform a _____ on a patient with a perianal abscess

Answer 37

DRE

Question 38

true or false, when documenting anatomical findings near the rectum you should use numbers according to a clockface

Answer 38

FALSE

use proper anatomical terms

Question 39

management of simple perianal abscess?

Answer 39

1) incision and drain

2) discharge home for warm tub soaks, bulk-forming fiber laxatives, +/- analgesics

Question 40

abscesses with associated signs of sepsis or extensive abscesses should be managed the same way as a perianal abscess, true or false?

Answer 40

false

get these people in the OR (likely a fistula) – much more complicated and requires surgery

Question 41

initial treatment of acute pancreatitis?

Answer 41

1) keep patient NPO
2) aggressive IV fluids
3) pain control

Question 42

how do we manage advanced cases of pancreatitis?

Answer 42

require admission and subsequent surgery if an obstructive etiology is the cause

Question 43

how will a patient with acute pancreatitis present?

Answer 43

1) severe epigastric pain
2) radiates to back or should blade
3) nausea, vomiting
4) anorexia
5) fever, chills

Question 44

what will more advanced stages of pancreatitis look like?

Answer 44

hemodynamic instability, tachycardia, hypotension, respiratory depression

Question 45

most common causes of pancreatitis?

Answer 45

alcohol, gallstones, smoking, metabolic disorders (hereditary pancreatitis, hypercalcemia, hyperlipidemia, malnutrition)

Question 46

what might you find on PE of a patient with acute pancreatitis?

Answer 46

1) grey-turners (flank hemorrhage)

2) cullens sign (umbilicus hem.)

Question 47

what is couvoiresier’s sign?

Answer 47

if obstruction is due to a cause other than a stone in the gallbladder, would be able to dilate and thus be palpable on examination (in RUQ)

Question 48

are grey-turner’s/cullens sign specific to pancreatitis?

Answer 48

nope

also retroperitoneal hemorrhage, blunt trauma, ruptured AAA, ruptured ectopic PG, spontaneous bleeding

Question 49

if patient stops breathing in and winces to “catch” a breath while gently applying pressure to the RUQ and asking them to inspire, what might be going on?

Answer 49

positive murphy signs

gallbladder pathology