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general Flashcards

1
Q

causes of postop fever (> 38.5)

A 
Wind: atelectasis, pneumonia
Water: UTI
Wound: infection
Walking: pulm embolus arising from a DVT
Wonder drug: drug fever
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2
Q

most common cause of fever on first POD

A

atelectasis

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3
Q

100/50/20 rule

A

fluid requirements for a 24 hr period

- 100 cc/kg for first 10 kg, 50 for next 10 and 20 for every kg over 20

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4
Q

4/2/1 rule

A

hourly fluid requirements

- 4 cc/kg for first 10 kg, 2 for next 10, 1 for every kg over 20

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5
Q

fluid in third space

A
  • tachycardia and decreased urine output
  • tx c IV hydration isotonic fluids
  • caution: third space fluids will mobilize back to intravascular space around POD 3 and can cause fluid overload
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6
Q

2 best fluids for increasing intravascular volume (resuscitation)

A

NS and Ringer’s solution (dextrose can cause hyperglycemia and osmotic diuresis)

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7
Q

when to avoid ringer’s soln

A

in pts with metabolic or respiratory alkalosis (lactate converted by liver into HCO3)

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8
Q

contraindication of adding K+ to fluid

A

if kidney’s don’t work

- make sure pt has adequate urine output

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9
Q

rough estimate of fluid requirements (mL/hr)

A

weight + 40

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10
Q

fluids for hypernatremia

A

dec. fluid intake but incr. insensible losses (ie: fever, burns)
- calculate water deficit = (TBW)(actual Na - desired Na)/desired Na
- if euvolemic replace c D5W
- if hypovolemic use NS (correct 1/2 in first 24 hrs, rest over next 1-2 days)
- lower 10-15 mEq/L/day not to exceed 25
- relace K+ after pt urinates

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11
Q

fluids for hyponatremia

A

calculate Na deficit = (140-Na)(TBW)

  • add to fluids
  • watch out for central pontine myelinolysis (don’t incr. by >2 mEq/L/hr or 10-12 mEq/L/day)
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12
Q

Tx hyperkalemia

A 
CBIGK
○	10% Calcium gluconate, 1g IV
○	Albuterol
○	Insulin + glucose
○	NaHCO3
○	Kayexolate
○	Dialysis
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13
Q

causes hyperkalemia

A

○ Renal failure
○ Spillage from cells in injury (also hemolysis)
○ Drugs: ACE-I’s, K+ sparing diuretics, Penicillin G, KCl in maintenance fluids, blood transfusions, digoxin toxicity
○ Hypoaldosteronism
○ Pseudohyperkalemia (lysed RBCs in test tube)
○ Acidosis
○ Insulin deficiency and DKA

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14
Q

hyperkalemia S/S

A

○ N/V/D, intestinal colic
○ Weakness, paralysis, respiratory failure
○ Arrhythmia, cardiac arrest

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15
Q

causes hypokalemia

A

○ Movement into cells b/c of insulin, catecholamines, alkalemia
○ Prolonged admin of K+- free fluids
○ TPN w/o adequate K+ replacement
○ GI losses: diarrhea, colonic fistulas, VIPoma
○ Diuretics

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16
Q

hypokalemia S/S

A

○ Ileus, constipation
○ Decreased reflexes, fatigue, weakness, paralysis
○ Cardiac arrest

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17
Q

Tx hypokalemia

A

○ First, check magnesium level, may have to correct with hypokalemia or won’t be able to get it back up
○ Replace potassium (4- current level)*100, in mEq
○ If asymptomatic, oral might be ok
○ Replace slowly and use ECG monitoring, don’t cause a fatal arrhythmia in your patient (no more than 40mEQ/hr)
○ Can cause IV burning, either use low flow (

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18
Q

MUDPILERS

A 
methanol
uremia
DKA
propylene glycol/paraldehyde
INH
lactic acidosis
EtOH/ethylene glycol
rhabdo/renal failure
salicylates
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19
Q

non-AG metabolic acidosis causes

A 
HARDUPS
hyperalimentation
acetazolamide
renal tubular acidosis
diarrhea
utero-pelvic shunt
post-hypocapnic
spironolactone
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20
Q

metabolic alkalosis causes

A 
CLEVER PD
contraction
licorice
endocrine (Conn's, Cushings, etc.)
vomiting
excess alkali
refeeding alkalosis
post-diuresis
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21
Q

S/S compartment syndrome

A

pain out of proportion to injury
pain incr. on passive stretch
parasthesia (early)
rapidly increasing & tense swelling

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22
Q

compartment syndrome

A

diagnosis: >30 mmHg
tx: fasciotomy (unless improving)
sx cause: repercussion of limb following artery-occlusive ischemia >4-6 hrs (edema)

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23
Q

local vascular complication of cardiac catheterization

A 
retroperitoneal hematoma (occurs within 12 hours)
less common: bleeding, dissection, thrombosis, AV fistula
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24
Q

S/S retroperitoneal hematoma

A

acute hemodynamic instability

ipsilateral flank or back pain

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25
Q

diagnosis of retroperitoneal hematoma

A

CT scan of abdomen and pelvis without contrast

Tx: supportive, monitor, fluids

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26
Q

difference btwn arterial thrombosis and embolism

A
  • embolism will have acute onset, thrombosis insidious

- thrombosis likely to be bilateral

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27
Q

pulsatile groin mass below the inguinal ligament

A

femoral artery aneurysm

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28
Q

how to tell difference between PAD at rest and peripheral neuropathy

A

PAD will be relieved by hanging leg over bed by peripheral neuropathy will not

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29
Q

amaurosis fugax

A

transient monocular vision loss
Causes: atheromatous disease of IC or ophthalmic artery, vasospasm, neuropathy, giant cell arteritis, glaucoma, increased ICP, steal phenomenon

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30
Q

3 mechanisms to move blood through veins in lower extremities

A
  1. negative intrathoracic pressure during inspiration
  2. musculoskeletal pump
  3. valves prevent back flow
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31
Q

migratory phlebitis indicates…..

A

abdominal cancer (esp. pancreatic carcinoma)

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32
Q

venous HTN skin manifestations

A

(bilateral) edema, stasis dermatitis, venous ulcerations

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33
Q

persistent JVD, hypotension (unresponsive to fluids), tachycardia in setting of thoracic trauma

A

cardiac tamponade (will have normal cardiac silhouette on CXR)

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34
Q

CXR of aortic injury

A

widened mediastinum, left hemothorax

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35
Q

bilateral hip, thigh, buttock claudication
impotence
bilateral atrophy of lower extremities

A 
aortoiliac occlusion (Leriche syndrome)
- may also have diminished pulses
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36
Q

venous vs. arterial ulcers

A

VENOUS: painful, irregular outline, superficial, possible dermatitis
ARTERIAL: deep, punched out, smooth edges, cool to touch, shiny taut pale skin

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37
Q

most common cause of aortic dissection

A

systemic HTN

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38
Q

test highly sensitive for PAD

A

ABI (ankle brachial index), normal 1-1.2, severe

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39
Q

most sensitive CXR finding for aortic injury

A

mediastinal widening (esp. in setting of trauma)

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40
Q

dyspnea/tachypnea
chest pain
hypoxemia worsened by IV fluids
patchy alveolar infiltrates on CXR

A

pulmonary contusion

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41
Q

types of non-hemorrhagic shock

A 
cardiogenic: tamponade, MI, contusion, etc.
tension pneumo: impedes venous return
neurogenic: spinal cord injury
septic
hypoadrenal: exogenous steroids
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42
Q

Parkland formula

A

fluid resuscitation in burn pts:

= kg x 4 x %burned

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43
Q

Hesselbach’s triangle

A

inf. epigastric a.
lateral border of rectus abdominis
inguinal ligament
(direct hernias)

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44
Q 
acidosis
low urine output
hypotension
tachypnea
fever
A

septic shock (start tx with normal saline)

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45
Q

what to do with results of FAST exam

A

positive: laparotomy
inconclusive: peritoneal diagnostic lavage
negative: stabilize

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46
Q

tx hemodynamically unstable pt c penetrating abdominal trauma

A 
ex lap (don't wait for imaging)
abdomen: anything below nipple line
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47
Q

pain that radiates to the shoulder(s)

A

suggests sub diaphragmatic peritonitis or acute cholecystitis

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48
Q

part of the bladder covered by peritoneum

A

only the bladder dome (injury can cause peritonitis)

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49
Q

when to do ex lap and when to do more diagnostics in abdominal trauma pt

A

ex lap if pt is hemodynamically unstable

imaging in stable pt (ie: responding to fluids)

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50
Q

free air under diaphragm

A
  • ok if following laparotomy or laproscopic surgery

- otherwise indicates ruptured viscus (i.e.: perf peptic ulcer)

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51
Q

obturator sign

A

pain on internal rotation of the leg with hip and knee flexed
- appendicitis

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52
Q

psoas sign

A

pain on extension of hip with knee in full extension or pain on flexing hip against resistance
- appendicitis

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53
Q

indications for surgical tx of upper GI bleed

A
  • 6 or more units of blood needed in 24 hrs
  • esophageal variceal bleeding refractory to meds
  • perforation
  • gastric outlet obstruction
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54
Q

best way to administer rapid resuscitation fluids

A

2 large bore peripheral IVs (16-18 gauge) are better than central line

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55
Q

most common cause of lower GI bleeds

A

upper GI bleeds, then diverticulosis

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56
Q 
cramping abd pain (maybe in intervals)
vomiting
abd distension
\+/- fever, tachy, hyptension
no stool
A

SBO (need to differentiate from ileus via imaging)

- also high-pitched and hypoactive bowel sounds, abd tenderness

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57
Q

indications for surgical tx of SBO

A
  • complete SBO
  • vascular compromise
  • hemodynamic instability
  • > 3 days duration with no resolution
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58
Q

appearance of colorectal cancer on barium enema x-ray

A

apple-core lesion of encircling carcinoma in descending colon

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59
Q

clinical difference between cholelithiasis and acute cholecystitis

A

S/S: same except cholecystitis is more severe and of longer duration
TX: same except add IV antibiotics (pip/tazo, bacterium) for cholecystitis

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60
Q 
RUQ pain
fever
jaundice
shock
altered mental status
A

Reynold’s pentad = acute cholangitis

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61
Q 
* painful hepatomegaly
RUQ pain
weight loss
ascites
jaundice
A

hepatocellular carcinoma

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62
Q

Charcot’s triad

A

RUQ pain, fever, jaundice = pathognomonic for acute cholangitis (?)

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63
Q

ecchymotic discoloration of the flank

A

Grey Turner’s sign

- pancreatic hemorrhage

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64
Q

ecchymosis of periumbilical area

A

Cullen’s sign

- pancreatic hemorrhage

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65
Q

tumor of hepatic bile ducts

A

cholangiocarcinoma (Klatskin’s tumor)

- symptomatic late in development = poor prognosis

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66
Q

Ranson’s criteria

A

measure of severity of acute pancreatitis

>3 = likely

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67
Q

defect in direct vs. indirect hernia

A

direct: defect in transveralis fascia from mechanical breakdown
indirect: congenital patent processus vaginalis

68
Q

which hernia occurs more commonly in women than men?

A

femoral (also has highest risk of incarceration and strangulation due to narrow canal)

69
Q

layers of abdominal wall (superficial to deep)

A

skin, subcutaneous fat, Scarpa’s fascia, ext. oblique, int. oblique, transverses abdomens, transversalis fascia, peritoneum

70
Q

type 1 vs. type 2 hiatal hernia

A

1 (sliding): GE junction and fundus displaced into mediastinum
2 (paraesophageal): fundus herniates but GE junction remains in normal position

71
Q

6 P’s of acute arterial occlusion

A

pain, paralysis, pallor, parasthesia, poikilothermic, pulselessness

72
Q

S/S of breast cancer

A

mass tenderness
mass hard, irregular, fixed
nipple discharge/retraction
change in symmetry, appearance

73
Q

most common cause of bloody nipple discharge

A

intraductal papilloma (benign)

74
Q

anterior shoulder dislocation threatens….

A

axillary nerve

75
Q

supracondylar humeral fracture threatens….

A

median nerve and brachial artery

76
Q

distal radius fracture threatens….

A

median nerve

77
Q

when to discontinue ASA before surgery

A

7-10 days (NSAIDS 2 days)

78
Q

perioperative glucose control

A

before: don’t give PO hypoglycemic agents morning of, gluc should be 100-250
after: incr. risk of post-op wound infection

79
Q

3 reasons to delay surgery

A

infection, anemia, gluc >250

80
Q

appearance of benign vs. malignant coin chest lesions

A

benign: smooth, popcorn, bull’s eye, calcium
mal: spiculated

81
Q

which type of lung cancer is not amenable to surgical resection

A

small-cell (use chemo)

82
Q

pleural effusion in an older pt

A

cancer until proven otherwise

83
Q

3 vessel disease vessels

A

right coronary, left anterior descending, circumflex

84
Q

etiology of mitral regurgitation and stenosis

A

reg: myxomatous degeneration, myocardium ischemia
stenosis: rheumatic and scarlet fever

85
Q

3 symptoms of severe aortic stenosis

A

syncope, SOB, angina

86
Q

structures to avoid in carotid endarterectomy

A

hypoglossal n., vagus n., marginal branch of facial n.

87
Q

fever & diarrhea POD 3 s/p AAA rupture repair

A

ischemic injury to colon, dx c sigmoidoscopy

tx: abx, bowel rest, resection possible

88
Q

fever, inflamed femoral incision 2 mo s/p AAA rupture repair

A

vascular graft infection, dx c CT

tx: remore graft, debride, bypass, abx

89
Q

upper GI bleed 1 yr s/p AAA rupture repair

A

aortoenteric fistula: erosion of graft into duodenum

tx: remore graft, repair, bypass

90
Q

tearing chest and back pain

A

aortic dissection (usually of arch)

91
Q

2 reasons for distended neck veins following trauma

A

tension pneumo, tamponade

92
Q 
muffled heart sounds
pulsus paradoxus
Kussmaul sign (incr. in CVP on inspiration)
A

tamponade

93
Q

signs of adequate initial resuscitation

A

acceptable urine output, better HR, mental status and BP

94
Q

widened mediastinum with trauma

A

aortic injury

95
Q

high CVP in trauma

A

tamponade or pneumo (high CVP gives distended neck veins)

96
Q

low CVP and “pink and warm”

A

vasomotor shock (anaphylaxis, neurogenic)

97
Q

trauma, unconsciousness, lucid interval

A

epidural hematoma

98
Q

paralysis and loss of proprioception distal to clean cut injury and loss of pain perception on other side

A

hemisection (Brown-Sequard)

99
Q

loss of motor function and pain/temp on both sides

no loss of vibratory/positional sense

A

anterior cord syndrome (burst fractures of vertebral bodies)

100
Q

paralysis and burning pain in upper extremities

preservation of most lower extremity function

A

central cord syndrome (elderly with forced hyperextension of neck i.e.: rear-end collision)

101
Q

chest trauma: deteriorating blood gases, whiteout of lungs on CXR

A

pulmonary contusion

102
Q

sternal fracture: high troponin

A

myocardial contusion

103
Q

bowel in left side of chest after trauma

A

traumatic rupture of diaphragm

104
Q

developing subcutaneous emphysema in upper chest and lower neck

A

rupture of trachea or bronchus

105
Q

ideal hourly urinary output for burns

A

1-2 mL/kg/h while avoiding CVP > 15

106
Q

kid c groin/knee pain and limping

as hip is flexed, thigh cannot be rotated internally

A

slipped capital femoral epiphysis

ortho emergency

107
Q

toddler c hx of febrile illness that refuses to move hip

A

septic hip

108
Q

kids c hx of febrile illness and severe localized bone pain (no trauma)

A

acute hematogenous osteomyelitis

109
Q

teenager c persistent pain over tibial tubercle aggravated by contraction of quadricep (no knee swelling)

A

Osgood-Schlatter disease

110
Q

where do sarcomas metastasize to?

A

lungs (not lymph nodes)

111
Q

MOA posterior shoulder dislocation

A

massive uncoordinated mm. contraction such as epileptic sz or electrical burn; rare

112
Q

pt on stretcher has shortened and externally rotated leg after fall

A

hip fracture

113
Q

MOA compartment syndrome

A

prolonged ischemia followed by repercussion

crush injuries

114
Q

pain shooting down leg
exacerbated by sneezing, coughing, defecating
difficulty ambulating

A

lumbar disk herniation

115
Q

distended bladder
flaccid rectal sphincter
perineal saddle anesthesia

A

cauda equina syndrome

116
Q

ileus in elderly pt following non-abdominal surgery

A

Ogilvie syndrome

rule out SBO

117
Q

severe, continuous epigastric/low sternal pain of sudden onset
followed by fever, leukocytosis
prolonged, forceful vomiting

A

Boerhaave syndrome (esophageal rupture due to vomiting)

118
Q

vague epigastric distress
early satiety
hematemesis

A

gastric adenocarcinoma

119
Q

colicky abdominal pain
protracted vomiting
abd. extension

A

SBO

- obstructed if also fever, peritonitis

120
Q

diarrhea
right-sided heart valve damage
wheezing

A

carcinoid syndrome

121
Q

when is surgery indicated for UC?

A 
longer than 20 years
severe malnutrition
multiple hospitalizations
toxic megacolon
high-dose steroids/immunosuppressants needed
122
Q

when is colectomy indicated for C. diff?

A

WBC > 50,000, lactate >5, and unresponsive to tx

123
Q

exquisite pain with defecation
blood streaked stool
fear of defecation leads to constipation

A

anal fissure

  • if fever, probably abscess present
  • exam may need to be done under anesthesia
124
Q

sudden onset, generalized, very severe abd. pain
reluctant to move
guarding

A

perforation

dx via free air under diaphragm on x-ray

125
Q

sudden onset colicky flank pain radiating to inner thigh and scrotum/labia

A

ureteral stones

126
Q

air-fluid levels in small bowel on KUB
distended colon
huge air-filled loop in RUQ with “parrot’s beak”

A

volvulus of sigmoid

127
Q

do you need to do SLNB in DCIS?

A

no, no metastasis potential

128
Q

virulent peptic ulcer disease resistant to all usual therapy

A

gastrinoma (Zollinger-Ellison)

129
Q

hypokalemia, HTN in female not on diuretics

also, hypernatremia, metabolic alkalosis

A

primary hyperaldosteronism

- aldo high, renin low

130
Q

VACTERL

A

vertebral, anal, cardia,tracheal, esophageal, renal, limb abnormalities

131
Q

green vomiting
double-bubble on x-ray
kid

A

duodenal atresia, annular pancreas, or malrotation

- all require surgery

132
Q

CF
feeding intolerance
bilious vomiting
xray: dilated loops, ground-glass appearance

A

meconium ileus

133
Q

kid
subdural hematoma
retinal hemorrhages

A

shaken baby syndrome

134
Q

toddler
episodes of colicky abd pain that makes them double up and squat
currant jelly stools

A

intussusception

135
Q

how to determine operability of lung cancer

A

FEV1 of 800 mL needed

136
Q

coldness, tingling, mm. pain of arm

posterior near signs (visual/equilibrium problems) when arm is exercised

A

subclavian steal syndrome (if just vascular problems, probably TOS)

137
Q

surgical indications for arterial disease of lower extremities

A
  • to relieve disabling symptoms

- to save limb from impending necrosis

138
Q

absolute contraindication in parotid tumor dx

A

open biopsy

139
Q

best study for facial tumors

A

MRI

140
Q

abscess of floor of mouth after tooth infection

A

Ludwig angina = threat to airway
ENT ermergency
tx: I & D

141
Q

diplopia in a pt c frontal or ethmoid sinusitis

A

cavernous sinus thrombosis

142
Q

hemorrhagic vs. vascular neuro disease

A

occlusive vascular: sudden onset s headache

hemorrhagic: very severe headache

143
Q

MOA TIA

A

> 70% stenosis of internal carotid or ulcerated plaque at carotid bifurcation

144
Q

months of headache, worse in mornings

signs of increased ICP: blurred vision, vomiting

A

brain tumor

145
Q

loss of upper face and sunset eyes

A

tumor of pineal gland

146
Q

kid relieving headache with knee-chest position

A

brain tumor

147
Q

very severe testicular pain, sudden onset

no fever, pyuria, mumps

A

testicular torsion

148
Q

severe testicular pain of sudden onset

fever, pyruia

A

acute epididymitis

149
Q

pneumaturia MOA

A

MOA: fistula between bladder and GI tract, usually from diverticulitis

150
Q

absolute contraindication for organ donation

A

HIV

151
Q

hyperacute rejection

A

minutes

MOA: preformed antibodies

152
Q

acute rejection

A

> 5 days and

153
Q

chronic rejection

A

years

irreversible

154
Q

prohibitive cardiac risks for noncardiac surgery

A
  • worst = JVD (indicates CHF)
  • 2nd worst = MI within 6 mo (defer if possible until 6 mo)
  • ejection fraction
155
Q

causes of fever at POD 1, 3, 5, 7, 10

A 
1 - atelectasis
3 - pneumonia, UTI
5 - DVT
7 - wound infection
> 10 - deep abscess (CT and drain)
156
Q

post-op causes of hypokalemia

A

lost from GI tract (GI fluids have lots of K) or urine (loop diuretics)

157
Q

safe speed for IV K administration

A

10 mEq/h

158
Q

causes of hyperkalemia

A
  • K dumped from cells into blood from crushing injuries, dead tissue, acidosis
  • renal failure (K not excreted)
159
Q

hepatic adenoma risk

A

OCT

- risk of rupture and massive bleed (emergency surgery)

160
Q

causes of paralytic ileus

A 
abdominal surgery
retroperitoneal hemorrhage (ie: with vertebral fracture)
161
Q

free intraperitoneal fluid following trauma

A

probably spleen or liver laceration

162
Q

acute pain and swelling of midline sacrococcygeal skin/tissue

A

infection of pilonidal cyst

tx: drain and excise pilonidal sinus

163
Q

nonhealing wound in burn area

A

Marjolin ulcer = squamos cell carcinoma

164
Q

postgastrectomy
postprandial abdominal cramps
weakness

A

gastric dumping syndrome

tx: dietary changes (octreotide if resistant)

165
Q

SBO with fever, tachy, metabolic acidosis

A

strangulation (emergency ex lap)

166
Q

how does short-term hyperventilation help decrease ICP?

A

causes cerebral washout of CO2 leading to vasoconstriction

surgery (2 decks)

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