EH - Surgery Flashcards
1
Q
Absolute contraindication to surgery?
A
DKA, Poor nutritional status, Liver failure
2
Q
3 pre-operative measurements of nutritional status?
A
Albumin, Body Weight, Transferrin
3
Q
Albumin level that contraindicates surgery?
A
< 3
4
Q
Body weight loss that contraindicates surgery?
A
Loss of 20% BW
5
Q
Transferrin level that contraindicates surgery?
A
< 200
6
Q
Best strategy for maximizing patient nutrition?
A
Enteral feedings
7
Q
3 measurements of liver function?
A
Bilirubin, PT, NH3
8
Q
Best pre-operative advice for smokers?
A
Cessation 2 months before surgery
9
Q
Important consideration for smokers during anesthesia resuscitation?
A
Worry about chronic CO2 retention … strongest respiratory drive is hypoxia … need to keep O2 slightly hypoxic
10
Q
Value of Goldman’s Index?
A
Determines peri-operative mortality risk
11
Q
Most important factor in Goldman’s Index?
A
CHF … (EF %) … need ECHO
12
Q
2nd most important factor in Goldman’s Index?
A
Recent MI … need EKG
13
Q
Which type of murmur represents risk for peri-operative mortality?
A
Aortic stenosis
14
Q
Medications that should be stopped before surgery?
A
ASA, Metformin, NSAIDs, Warfarin
15
Q
How long before surgery should ASA be stopped?
A
7-10 days
16
Q
Why does metformin need to be stopped before surgery?
A
Risk of developing lactic acidosis
17
Q
Goal INR before surgery?
A
< 1.5
18
Q
Insulin considerations for patients about to undergo surgery?
A
Instruct patient to take ½ AM insulin dose … (NPO after midnight)
19
Q
Patient with CKD is preparing for surgery – when should last dialysis appointment be completed before surgery?
A
24 hour prior
20
Q
How do BUN and creatinine affect surgery?
A
Patients with CKD may have uremia … Uremia inhibits platelet clotting ability
21
Q
Effect of platelet count on coagulation panel?
A
NML
22
Q
Effect of bleeding time on coagulation panel?
A
Prolonged
23
Q
Role of Assist-control Ventilator setting?
A
Ventilator sets Tidal Volume and RR
24
Q
Important Ventilator setting for patient weaning off ventilator use?
A
Pressure support setting
25
Role of PEEP?
Patients with ARDS … allows alveoli to remain open
26
Patient on ventilator – which tests should be ordered regularly to assess ventilator function?
ABG
27
Patient on ventilator – PaO2 is low … what is the remedy?
Increase FiO2
28
Patient on ventilator – PaO2 is high … what is the remedy?
Decrease FiO2
29
Patient on ventilator – PaCO2 is low … what is the remedy?
Decrease RR, Decrease Tidal Volume
30
Patient on ventilator – PaCO2 is high … what is the remedy?
Increase RR, Increase Tidal Volume
31
Why is adjusting Tidal Volume more effective in adjusting PaCO2?
Multiplicative effect … Increasing RR will waste O2 on dead space
32
2 parameters for ventilation?
RR, Tidal Volume
33
2 types of non-AG metabolic acidosis?
RTA, Diarrhea, Diuretic abuse
34
Best treatment for hyponatremia + hypotensive?
NS
35
When should hypertonic saline used?
Severely symptomatic hyponatremia, Na < 110
36
Appropriate rate of Na+ correction in hyponatremia?
12-24 mEq per day
37
Best treatment for Hypernatremia?
Replace fluid with hypotonic solution
38
Complication of correcting hypernatremia too quickly?
Cerebral edema
39
EKG change associated with hypocalcemia?
Prolonged QT interval
40
EKG change associated with hypercalcemia?
Shortened QT interval
41
Appropriate next step in evaluation of hypo/hypercalcemia?
EKG
42
Best treatment for hypokalemia?
K+ … with renal monitoring
43
Best treatment for hyperkalemia?
Calcium gluconate … IV fluids … Diuretics … Insulin/Glucose … Albuterol … Dialysis
44
Role of giving Calcium gluconate in patients with hyperkalemia?
Cardio-protective
45
Maintenance IV fluids – best for nutrition?
D5 ½ NS + 20 mEq KCl
46
Patient presents with burn – erythematous, painful but not peeling – diagnosis?
1st degree burn
47
Skin layer involved in 1st degree burn?
Epidermis
48
Patient presents with burn – painful, peeling – diagnosis?
2nd degree burn
49
Patient presents with burn – painless, peeling – diagnosis?
3rd degree burn
50
Skin layer involved in 3rd degree burn?
Dermis
51
Major concern in patients with circumferential burns?
Compartment Syndrome
52
Concern for elderly patients with sudden increased in clots?
Hypercoagulability of malignancy
53
Patient presents with new blood clots (hypercoagulability); PE shows patient is edematous, foamy urine – diagnosis?
Nephrotic Syndrome
54
What accounts for hypercoagulability in Nephrotic Syndrome?
Anti-thrombin 3 (anticoagulant) is one of the first proteins lost in urine
55
Most common inherited disease of abnormal clotting?
Factor V Leiden
56
Significance of anti-thrombin 3 deficiency in surgery?
Heparin won’t work
57
Young female presents with multiple spontaneous abortions?
Anti-Phospholipid Syndrome
58
Post-op patient presents with thrombocytopenia, but increased arterial + venous clotting – diagnosis?
HIT … paradoxical thrombosis in setting of thrombocytopenia
59
2 hallmark components of HIT?
Low platelets + Clotting
60
Best treatment for HIT?
Stop heparin, Start Argatroban
61
MOA of Argatroban?
Direct thrombin inhibitor
62
Patient presents with bleeding; Labs show isolated thrombocytopenia – diagnosis?
ITP
63
Patient presents with bleeding; Labs show NML platelets, increased bleeding time, increased PTT– diagnosis?
Von Willebrand Disease
64
Why not give burn patients IV/oral ABX, when they are more susceptible to infection?
Breeds resistance … give topical ABX
65
Which topical ABX for burn patients does not penetrate eschar, but causes leukopenia?
Silver sulfadiazine
66
Which topical ABX for burn patients will penetrate eschar, but causes pain?
Mafenide
67
penetrate eschar, but causes does not penetrate eschar, but causes hypokalemia, hyponatremia?
Silver nitrate
68
Next best step for patient with suspected electrical burns?
EKG … arrhythmia risk
69
Next best step of workup for burn patient with rhabdomyolysis?
CMP … check for K+ … arrhythmia risk
70
Best treatment for patient with facial + neck trauma; Unable to visualize airway during intubation?
Cricothyrotomy
71
Indications for taking patient with hemothorax to OR?
Lost 1.5L of blood; Lose 200mL per hour for first 4 hours
72
Treatment for pulmonary contusion?
Supportive
73
Best treatment for flail chest?
Nerve block (control pain)
74
Why are opioids contraindicated in flail chest?
Decrease respiratory drive
75
Patient presents with AMS, petechial rash, acute SOB; Reports recent MVC – diagnosis?
Fat embolism
76
Patient passes away suddenly after removal of central line – diagnosis?
Venous air embolism
77
Patient is hypotensive and tachycardiac; PE shows flat neck veins, NML central venous pressure – diagnosis?
Hypovolemic shock
78
Next best step for suspected hypovolemic shock?
2 large bore IV placement, 2L NML saline
79
Patient is hypotensive and tachycardiac; PE shows JVD, muffled heart sounds; EKG shows electrical alternans – diagnosis?
Cardiac tamponade
80
Diagnostic test for pericardial tamponade?
Symptomatic improvement with pericardiocentesis
81
Max verbal GCS score?
5
82
Max motor GCS score?
6
83
Max ocular GCS score?
4
84
How can you distinguish between acute and chronic subdural hemorrhage on head CT?
Acute = hyperdense (bright) fluid crescent; Chronic = hypodense (dark) fluid crescent
85
Initial management of increased ICP?
Elevate head of bed, Mannitol, Hyperventilate
86
Boundaries of Zone 3 in neck trauma?
Above angle of mandible
87
Best treatment for neck trauma that involves Zone 3?
Check aorta (aortogram), Endoscopy
88
Boundaries of Zone 2 in neck trauma?
Cricoid Cartilage >> Angle of Mandible
89
Best treatment for neck trauma that involves Zone 2?
2D Doppler
90
Boundaries of Zone 1 in neck trauma?
Clavicle >> Cricoid Cartilage
91
Best treatment for neck trauma that involves Zone 1?
Check aorta (aortogram), Endoscopy
92
Patient presents with stab wound; PE shows patient is stable – next step in management?
FAST exam
93
Next step in management of unstable patient after abdominal trauma?
Surgical intervention
94
Handle bar sign on PE after blunt abdominal trauma – diagnosis?
Pancreatic trauma
95
Patient presents after blunt abdominal trauma; PE shows stable vital signs; Patient complains of epigastric pain – next step?
Abdominal CT
96
Patient presents after blunt abdominal trauma; Abdominal CT shows retroperitoneal fluid – what was injured?
Duodenum
97
Patient presents after pelvic trauma; PE shows blood at urethral meatus; Retrograde urethrogram is NML – what should you check next?
Evaluate bladder for bleeding; Retrograde cystogram
98
Result of retrograde cystogram that suggests bladder injury?
Dye extravasating from bladder
99
Elderly female experiences FOOSH – which fracture is most likely fracture?
Colles fracture … distal radius fracture
100
Which structures are injured in Boxer’s fracture (guy punched wall)?
4th/5th metacarpal neck
101
Most common location of clavicle fracture?
Between middle third + distal third
102
Most common cause of fever on postop Day #1?
Atelectasis
103
Best treatment of atelectasis on postop Day #1?
Incentive spirometry
104
Most common cause of very high fever on postop Day #1?
Necrotizing fasciitis
105
Route of spread for Necrotizing fasciitis?
Along Scarpa’s subcutaneous fascia
106
Most common pathogens responsible for Necrotizing fasciitis?
Strep, Clostridium
107
Best treatment for Necrotizing fasciitis?
Surgical debridement + IV penicillin
108
Most common cause of very high + muscle rigidity immediately after surgery?
Malignant hyperthermia … halothane/succinylcholine
109
Genetic defect that predisposes patients to Malignant hyperthermia?
Defects in ryanodine receptor
110
Best treatment for Malignant hyperthermia?
Dantrolene
111
MOA of Dantrolene in treatment of Malignant hyperthermia?
Inhibition of ryanodine receptor … decreases intracellular Ca2+ levels
112
Most common causes of fever on postop Day #3-5?
PNA, UTI
113
Most common cause of fever on postop Day #5-7?
DVT, Cellulitis
114
Clinical presentation of post-op cellulitis?
Pain at incision site without drainage
115
Best treatment for post-op cellulitis?
Blood cultures, ABX
116
Clinical presentation of post-op wound infection?
Pain at incision site with drainage
117
Best treatment for post-op wound infection?
Change wound packing; No ABX
118
Post-op patient develops pain at incision site; PE shows serosanguinous drainage – diagnosis?
Wound dehiscence
119
Location of problem in Wound dehiscence?
Violation of fascia
120
Best treatment for Wound dehiscence?
Surgical intervention
121
Patient undergoes gynecologic surgery; Develops unexplained fever late in post-op course – diagnosis?
Thrombophlebitis
122
Best treatment for Thrombophlebitis after gynecologic surgery?
ABX + Heparin
123
Etiology of pressure ulcers? (1 word)
Ischemia
124
Stage 1 of pressure ulcer development?
Blanchable
125
Treatment for Stage 1 of pressure ulcer?
Mattress … relieve pressure
126
Stage 2 of pressure ulcer development?
Blister, Break in dermis, Crusting
127
Treatment for Stage 2 of pressure ulcer?
Mattress … relieve pressure
128
Stage 3 of pressure ulcer development?
Erosion into muscle
129
Treatment for Stage 3 of pressure ulcer?
Surgical intervention
130
Stage 4 of pressure ulcer development?
Erosion to bone
131
Treatment for Stage 4 of pressure ulcer?
Surgical intervention
132
Complication of Marjolin’s ulcer?
Chronic ulcer that predisposes to Squamous Cell Carcinoma
133
Threshold for need of thoracentesis for pleural effusion?
Fluid collection in phrenic angle > 1cm
134
3 most common causes of transudative pleural effusion?
CHF, cirrhosis, nephrotic syndrome
135
Transudative pleural effusion with low pleural glucose – diagnosis?
Rheumatoid arthritis
136
Transudative pleural effusion with high lymphocyte count – diagnosis?
TB
137
Initial treatment of lung abscess seen on CXR?
ABX
138
Appearance of lung abscess on CXR?
Air-fluid levels
139
Characteristic of lung nodule that is a hamartoma?
Popcorn calcifications
140
Characteristic of lung nodule that is TB?
Concentric calcifications
141
Unique location of metastasis for lung adenocarcinoma?
Adrenal glands
142
Characteristic of exudative effusion seen in setting of lung adenocarcinoma?
High hyaluronic acid
143
Which type of lung CA are Pancoast tumors?
Squamous cell carcinoma
144
Lung CA that presents as ptosis that improves after looking up for 1 minute?
Small cell CA … Lambert Eaton
145
Lung CA that presents as advanced masses with multiple early metastasis?
Large cell lung CA
146
Location of Large cell lung CA?
Peripheral
147
Significance of Small cell vs. Non-Small cell lung CA?
Small cell = can’t resect; Non-small cell = surgical resection
148
3 diagnostic criteria for ARDS?
CXR shows bilateral infiltrates; PaO2/FiO2 > 200; NML pulmonary capillary wedge pressure (< 18)
149
Ventilator setting used in treatment of ARDS?
PEEP
150
Holosystolic murmur that radiates to axilla?
MR
151
Holosystolic murmur with late rumble?
VSD
152
Rumbling diastolic murmur with opening snap?
Mitral stenosis
153
Blowing diastolic murmur with widened pulse pressure?
AR
154
Characteristic of all R-sided murmurs?
Increase with inspiration
155
Best treatment of achalasia?
CCBs + Myotomy
156
2 DOC for esophageal spasm?
CCBs, Nitrates
157
3 atypical symptoms of GERD?
Wheezing, dry cough, hoarseness
158
Best first step of workup for Boerhave’s Syndrome?
CXR … avoid barium
159
Type 1 hiatal hernia?
Sliding
160
Type 2 hiatal hernia?
Paraesophageal
161
Most common type of gastric CA?
Adenocarcinoma
162
Epidemiology of gastric lymphoma?
AIDS patients
163
Etiology of gastric varices?
Splenic vein thrombosis
164
Are gastric or duodenal ulcers more likely to be associated with H. pylori?
Duodenal
165
Concern if H. pylori treatment does not relieve peptic ulcers?
Zollinger-Ellison Syndrome
166
Patient recently lost a lot of weight; Presents with bilious vomiting, post-prandial abdominal pain – diagnosis?
SMA Syndrome
167
Diagnostic test for pancreatitis?
Abdominal CT
168
Complications of pancreatitis?
Pseudocyst, Hemorrhage, Abscess, ARDS
169
Chronic pancreatitis may lead to ____ thrombosis
Splenic vein
170
When is surgery not contraindicated in pancreatic cancer?
Localized to pancreas
171
Whipple’s Triad seen in insulinoma?
Low BG, Symptoms of BG, Symptomatic improvement with glucose administration
172
2 symptoms that distinguish cholelithiasis from cholecystitis?
Cholecystitis = fever, RUQ pain
173
Best initial test for suspected cholecystitis?
RUQ US
174
2 labs associated with choledocholithiasis?
Elevated Alkaline Phosphatase, Elevated bilirubin
175
Best treatment for ascending cholangitis?
ERCP (to remove the CBD stone) + ABX
176
Location of Type 1 biliary cysts?
Extrahepatic
177
Location of Type 4 biliary cysts?
Intrahepatic
178
Patient’s labs show ALT and AST in 1000s; ALT > AST – diagnosis?
Viral hepatitis
179
Elevated AST and ALT after cardiovascular surgery – diagnosis?
Hypotension (shock)
180
AE of TIPS procedure?
Encephalopathy
181
Etiology of Encephalopathy after TIPS procedure?
Retained NH3
182
Most common benign lesion in lever?
Hepatic angioma
183
Female on OCPs with palpable liver mass – diagnosis?
Hepatic adenoma
184
Best management of Hepatic adenoma?
OCP cessation
185
2nd most common benign lesion in lever?
Focal Nodular Hyperplasia
186
Bacterial liver abscess is most commonly caused by …
E. coli, Bacteroides, Enterococcus
187
Lab test seen in Echinococcus infection?
Eosinophilia
188
Best test for carcinoid tumor that is > 2cm in base of appendix, or with (+) LN involvement – best surgery?
Hemicolectomy
189
Best test for carcinoid tumor that is < 2cm in tip of appendix, or with (-) LN involvement – best surgery?
Appendectomy
190
2 indications for surgery in patient with SBO?
Conservative management fails after 48 hours; (+) peritoneal sign
191
Appearance of post-op ileus on XR?
Dilation throughout entire intestine
192
Etiology of 2 Ogelby’s syndrome?
Isolated colonic ileus … especially cecum
193
2 treatments for Ogelby’s syndrome?
Neostigmine, Colonic decompression
194
AE of Neostigmine?
Bradycardia
195
Which electrolyte deficiency can contribute to post-op ileus?
Hypokalemia
196
Appearance of cecal volvulus on XR?
Birds beak
197
Appearance of sigmoid volvulus on XR?
Coffee bean … crease = mesenteric vessel
