Gen Surg Flashcards
numer one limiting factor prior to surgery is….
hx of cardiovascular disease
history of CV disease predisposing to surgery complications
- EF
if had a recent MI and surgery
must defer surgery for 6 months and stress the patient at that interval
patient has CHF and needs surgery for something else
give the drugs that decrease mortality:
ACE inhibitors, beta blockers, spironolactone
cardiovascular risk factor if male
male older than 45yo
patient with CV risk factors– what needs to be done before surgery
- bp meds adjusted
- daily finger sticks monitored
- insulin regimen adjusted
- stress test with ECG
(possibly ECHO if murmur)
preop assessment if under 35yo and no hx of cardiac disease
EKG ONLY
preop assessment if hx of cardiac disease and ANY AGE
- EKG
- stress testing– evaluate for ischemic coronary lesions
- ECHO for structural disease, and for ejection fraction
preop assessment PFT’s necessary for…
known lung disease
smoking history
preop patient is a smoker– what suggestions
quit smoking for 6-8weeks before surgery and use nicotine patch in meantime
preop assessment patient with renal disease
- give fluids before and during surgery
- if patient is on dialysis, dialyze pt 24hrs before surgery
ABC’s: airway
- no facial trauma= orotracheal tubes
- facial trauma= cricothyroidotomy
- C-spine injury= orotracheal tube with flexible bronchoscopy
ABC’s: breathing
O2 sats above 90%= ideal
ABC’s: circulation
insert 2 large bore IV cannulas and being aggressive fluid resuscitation to prevent hypovolaemic shock
cool skin, shock
cardiogenic or hypovolaemic shock
cardiogenic vs. hypovolaemic shock
PCWP/LVEDP:
cardio: increased
hypo: decreased
warm skin, shock
neurogenic, anaphylactic, septic
CO change in neurogenic shock
decreased CO
CO change in anaphylactic and septic shock
increased CO
PCWP change anaphylactic vs. septic shock
anaphylactic: decreased
septic: no change
sepsis definition
2/4 and infection source
SIRS criteria
2/4
- bp: less than 36, greater than 38
- HR: greater than 90bpm
- resp: tachypnea>20breaths/min, or O2 sats
severe sepsis
2/4 + infection source + organ dysfunction
septic shock definition
2/4 + infection source + organ dysfunction + HYPOtn
example of “infection source”
CXR: shows infiltrates= pneumonia
car accident and abdomen hurts, and end up with large ecchymosis on right flank, most likely diagnosis
HAEMORRHAGIC PANCREATITIS
complication 6-8 weeks after pancreatitis
pancreatic pseudocyst
differential for cullen sign
haemorrhagic pancreatitis
ruptured aortic aneurysm
grey turner sign
flank bruising–> RETROperitoneal haemorrhage
kehr sign
pain in L shoulder—> splenic rupture
balance sign
dull percussion of the L and shifting dullness on the R–> splenic rupture
seatbelt sign
bruising where the seatbelt was–> deceleration injury
free air under the diaphragm
perforation of the bowel, best initial test= UPRIGHT CXR
imaging of choice paralytic ileus
abdominal xray
abdominal trauma– imaging to be done
- US– ASAP
2. CT– check for retroperitoneal bleed (even if the US was normal)
blunting of costophrenic angle on chest XR and CT
hemothorax
urethral meatus injury and high riding prostate, what next…
- KUB followed by….
- RETROGRADE URETHROGRAM
- then….. foley catheter (don’t do this immediately because it can lead to further urethral damage; just placed to aid in urination)
MOST ACCURATE TEST–suffering from ischaemic bowel (severe pain out of proportion to physical findings)
ANGIOGRAPHY or surgery
severe abdo pain 10/10 no guarding, soft abdomen and no rebound tenderness
PAIN OUT OF PROPORTION= MESENTERIC ISCHAEMIA
best initial test ischemic bowel
CT of the abdomen
tx mesenteric ischaemia
IV normal saline, followed by surgical removal necrotic bowel
types of abdominal pain that DO NOT require surgery
MI
GERD
Lower lobe pneumonia
acute porphyrias
2 mc sites of mesenteric ischaemia
splenic and hepatic flexures
number one risk factor for mesenteric ischemia
A FIB— shoots off an emboli
best initial test ischaemic bowel vs. mesenteric ischaemia
ischaemic bowel= CT abdo
mesenteric isch= abdo XR: air in bowel wall
pain in tip of penis or perineum
referred pain from prostate
pain in the ears
referred pain from pharynx
crunching upon palpation of the thorax due to subcutaneous emphysema
HAMMAN’S sign– form boerhaave/ eso perforation
most common cause of esophageal perforation
IATROGENIC– endoscopy
mortality with boerhaave syndrome, even with surgery
25%
most accurate test in diagnosis of eso rupture
ESOPHOGRAM: using diatrizoate meglumine and diatrizoate sodium solution (GASTROGRAFFIN), which shows leakage of contrast outside the esophagus
barium used in esophagram for eso rupture?
NOOOOO– because it damages the tissues
tx of boerhaave
surgery
complication with high mortality rate in boerhaave surgery
MEDIASTINITIS
don’t forget that gastric perforation can cause….
PANCREATITIS, recall ulcers erode–> release gastric acid–> activate enzymes
pain from gastric perforation
right shoulder pain
most accurate test for gastric perforation
abdo CT
best initial test for gastric perforation
erect CXR
tx for gastric perforation HYHYHYHYHYHHYHY
- NPO
- NG tube
- Medical mgmt
- Surgical mgmt
medical mgmt of gastric perforation
- broad spectrum antibiotics– combat infection
2. IV fluids in prep for surgery
surgical mgmt of gastric perforation
exploratory laporotomy and repair of the perforation
acute diverticulitis first round tx
medical tx– antibiotics, fluids, pain etc.
recurrent diverticulitis tx
SURGERY
most common complication post-diverticulitis
ABSCESS
okay to do barium enema and colonoscopy in diverticulitis?
NOOOOO–causes perforation
right lower quadrant pain in someone>60yo
CECAL diverticulitis
diagnostic test for ovarian torsion
doppler US
diagnosis of abdominal abscess
CT scan
treatment of abdominal abscess
CT or US guided incision and drainage, and antibiotics
US findings of acute cholecystitis
pericholecystic fluid and thickened gallbladder wall
only 2 differentials for abdo pain radiating to the back
- pancreatitis
2. aortic dissection
diagnostic test for appendicitis
CT scan
2 complications from appendicitis
abscess and gangrenous perforation
best imaging for pancreatitis
CT scan;
amylase= sensitive
lipase= specific
best imaging for diverticulitis
CT scan= best and most accurate
best initial imaging for cholecystitis
US
most accurate test for cholecystitis
HIDA scan
HIDA scan
for cholecystitis– shows delayed emptying of gallbladder ( can’t visualize gallbladder form isotope accumulation)
3 signs of appendicitis
rovsing sign
posts sign
obturator sign
rovsing sign
palpation of the LLQ causes pain in the RLQ
psoas sign
pain the hip E
obturator sign
pain with internal rotation of the right thigh
hyperactive tinkling bowel sounds
small bowel obstruction, = intestinal fluid and air are under high pressure in the bowel
patient on chronic opiod with stool impaction, tx:
methylnaltrexone (relistor)
labs for small bowel obstruction
elevated WCC
elevated lactate
SIGNIFICANT ACIDOSIS
best initial test for SBO
abdo XR: multiple air fluid levels with delated loops of small bowel
most accurate test for SBO
CT scan of the abdomen
HYHYHYHHYHYHYHYHY mgmt of SBO
- NPO
- NG tube with suction
- medical mgmt
- surgical mgmt
medical mgmt of SBO
IV fluids to replace volume lost via third pacing
surgical mgmt of SBO
complete obs= EMERGENCY
lack of improvement with medical mgmt
fecal incontinence dx
CLINICAL
best initial test for fecal incontinence
flexible sigmoidoscopy or anoscopy
most accurate test for fecal incontinence
anorectal manometry
hx of anatomic injury with fecal incontinence
endorectal manometry
3 types of tx for fecal incontinence
- medical
- biofeedback
- surgical
medical mgmt fecal incontinence
bulking agents–fiber
biofeedback mgmt fecal incontinence
control exercises and muscle strengthening exercises
what injection can decrease incontinence by 50%
dextranomer/hyaluronic acid (soloist)
dx of all fractures
XR
CLOSED REDUCTION
mild fractures without displacement
ORIF:
severe fractures with displacement or misalignment of bone pieces
open fractures mgmt
skin must be closed and the bone must be set in the operating room with debridement
PC of all fractures
pain/swelling/deformity
fracture where bone is shattered into multiple pieces
comminuted fractures
MCC of comminuted fractures
crush injuries
complete fracture from repetitive insults to bone
stress fracture
most common site of stress fractures
metatarsals
athlete with persistent pain—>
STRESS FRACTURE
Dx of stress fracture
CT or MRI> XR (doesn’t show)
fracture of vertebrae in osteoporosis
compression fracture
location of compression fractures
1/3= lumbar 1/3= thoracolumbar 1/3= thoracic
older person fractures rib from coughing—->
PATHOLOGIC fracture
tx of pathologic fracture
surgical realignment
tx underlying disease
broken bone pierces skin
open fracture
tx for open fracture
ALWAYS ALWAYS ALWAYS SURGERY
strain on glenohumeral ligaments
anterior shoulder dislocation
arm held to the side with ER forearm with severe pain
anterior shoulder dislocation
anterior shoulder dislocation damages
axillary nerve/artery
best initial test for anterior shoulder dislocation, posterior shoulder dislocation and clavicular fracture
XR
most accurate test for anterior shoulder dislocation, posterior shoulder dislocation and clavicular fracture
MRI
tx anterior shoulder dislocation
relocation and immobilization
seizure or electrical burn
posterior shoulder dislocation
arm held to the side and medially rotated
posterior shoulder dislocation
tx of posterior shoulder dislocation
traction and surgery if pulses or sensation diminished during physical exam
tx clavicular fracture
simple arm sling
FOOSH
scaphoid fracture
imaging for scaphoid fracture
3 WEEKS for the XR to show
tx of scaphoid fracture
thumb spica cast
simple arm sling or figure 8 sling for clavicular fracture
SIMPLE ARM SLING– since the figure 8 is not any better
tx trigger finger
steroid injection
definitive tx trigger finger
cut the sheet thats restricting the tendon
DUPUTYRENS IS NOT TRIGGER FINGER
duputyrens: men over 40yo, palmar fascia constricted, and hand cannot extend properly
only effective tx for duputyren
surgery
fat embolism syndrome
- confusion
- petechial rash
- SOB
dx fat embolism
- ABG pO2
tx fat embolism
oxygen over 95%;
mechanical ventilation if become severely hypoxic
spinal stenosis leg pain
bilateral
alleviated by leaning forward (since opens the spinal canal)
claudication leg pain
unilateral
NO relief by leaning forward
dx spinal stenosis
spine MRI
tx of spinal stenosis
NSAID’s or surgery
electric shock down dermatome distribution
herniated disc
patient group for herniated disc
elderly a/w lifting
dx of herniated disc
straight leg raise
confirmatory herniated disc
NSAID’s
tx of herniated disc
NSAID’s and activity modification
6P’s of compartment syndrome (first 3= early)
Pain– mc first; SEVERE, worse with muscle stretch
Pallor
Paresthesia
Paralysis
Pulselessness
Poikilothermia: cold to touch
mgmt torn ACL
arothroscopic repair
direct trauma to front of knee, pain and positive lachman
torn ACL
direct trauma to back of knee, pain and positive posterior drawer
torn PCL
traumatic injury to the knee, with POPPING SOUND with flexion and extension
meniscale injury
arthroscopic repair for which knee injuries
- ACL
- PCL
- meniscal injury
surgical repair for which knee injury
medial and lateral collateral ligament
trauma to opposite side of injury
medial and lateral collecteral ligament
trauma to bent knee
medial collateral ligament
dx of ALL KNEE injuries
MRI
most common knee ligament injury
ACL
UNHAPPY TRIAD
medial OR lateral meniscus
medial collateral
ACL
most common sites for disc herniation
L4-5, L5-S1
AAA 3-4cm
US every 2-3 years
AAA 4-5.4cm
US or CT every 6-12mos
AAA greater than 5.5cm
surgical repair
ado US screening
former or current smokers over 65yo– gives info on size, cost-effective, monitoring
relationship of AAA to surrounding vessels
CT/MRI
FASTEST diagnostic test for aortic disection
TEE – used if patient clinical UNSTABLE
aortic dissection and patient is stable
MRA
mgmt ascending dissection
Sx ASAP and bp control
mgmt descending dissection
medical tx bp control
bp mgmt in dissection
- BETA BLOCKERS= best intial,
2. followed by sodium nitroprusside (never give on own)
tricky question— patient had emergency cholecystectomy, 3 days post-op, currently has fever
= UTI
post op day 1-2
WIND: atelectasis or postop pneumonia
post op day 3-5
WATER: uti
post op day 5-7
WALKING: DVT or thrombophlebitis at IV access lines
post op day 7
WOUND: wound infections or cellulitis
post op day 8-15
WEIRD: drug fever or deep abscess
how to prevent post op atelectasis or post op pneumonia
incentive spirometry
hospital acquired pneumonia tx
piptazo
UTI Dx
urinalysis: nitrates and leukocyte esterase
urine culture
DVT dx
doppler uS of LL
change IV access lines and culture IV tips
tx for DVT:
5 days heparin, as bridge to warfarin for 3-6months
deep abscess post op
dx: CT
tx: CT guided percuranteous drainage, otherwise sx
post op confusion
- hypoxic: atelectasis/pneumonia OR PE
- septic: bacteremia or UTI
DX ARDS
CXR: bilateral pul infiltrates WITHOUT JVD
Tx ARDS
positive end expiratory pressure, PEEP
best initial dx of PE
EKG: sinus tachycardia without evidence of ST changes
[cardiac enzymes and trooping to exclude cariidac chest pain]
tx of PE
heparin as a brdige to warfarin
patient has second PE while on warfarin
IVC filter via inguinal catheterization
next best step for PE…. and have allergy to IV contrast
EKG + V/Q scan
next best step for PE…. and have allergy to IV contrast
EKG + spiral CT scan
okay to give heparin without knowing if there is a PE?
NOOOOO, must have dx of PE before give heparin
