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General Surgery Flashcards

0
Q

Pyelonephritis work up and tx

A

Urine cx
IVP or U/S

Tx: hospitalize, IV Abx

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1
Q

Contraindications to IVP

A

Creatinine > 2

Allergies to dye

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2
Q

Newborn male unable to urinate?

A 
#1 MCC = Posterior urethral valves
#2 meatal stenosis
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3
Q

Tx for posterior urethral valves?

A

Dx: voiding cystourethrogram
Tx:
Catheterization to empty bladder
Endo fulguration or resection

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4
Q

Vesicureter reflex tx

A

1 empiric abx (then culture-guided abx)
2 IVP + voiding cystogram to look for issue
3 long term abx until child grows out of problem

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5
Q

Little girl who is wet with urine all the time

A

Low implantation of ureter

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6
Q

Teen binge drinking for first time who then gets colicky flank pain

A

UPJ obstruction (cannot handle large diuresis)

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7
Q

Work up of hematuria

A
  1. Ct scan

2. Cystoscopy

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8
Q

Acute urinary retention tx

A

Indwelling catheter for at least 3 days
Long-term therapy:
1. Alpha blockers
2. If >40g, use 5-alpha reductase inhibitors

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9
Q

Most important measure of preventing future ureteral stones?

A

Abundant water intake

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10
Q

Txt for ureteral stones

A

< or = 3mm : 70% chance of spontaneously resolving so analgesics, fluids, and observation

> 3mm: extra corporal shock wave lithotripsy (eswl) unless pregnant, bleeding diathesis, or giant stones

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11
Q

Only absolute contraindication to organ donation

A

HIV positive status

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12
Q

Rejection of liver transplant:

  1. Signs?
  2. Work up?
A

Signs: rising ggt, alk phos, bili
Steps:
#1 u/s to rule out biliary obstruction
#2 Doppler to rule out vascular thrombosis

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13
Q

Therapy for acute transplant rejection

A 
First line is steroid boluses
#2 is antithymocyte serum (or antilymphocyte agents like OKT3 which are more toxic)
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14
Q

Monitoring post heart transplant

A

Routine ventricular biopsies via jugular, SVC, and right atrium)

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15
Q

Evaluation of a penetrating urologic injury (hematuria)

A

Requires exploratory laparotomy as first line of management

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16
Q

All patients with hematuria require work up for cancer except in whom?

A

Except for the adult who has microscopic hematuria after significant trauma

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17
Q

Fluid resuscitation: what infusion rate should be aimed for?

A

Aim for an hourly urinary output of 1-2 ml/kg/hr while AVOIDING a CVP over 15 mmHg

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18
Q

Predictors of mortality regarding hepatic risk

A

40% mortality if any of following four are present: bilirubin > 2, albumin < 3, prothrombin time > 16, or encephalopathy

80% mortality if 3/4 above are present (100% mortality if 4/4 present), or if any of the following are present: bilirubin > 4, albumin < 2, or blood ammonia > 150 mg/dl

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19
Q

Diagnosis and tx?
A stormy complicated postop period who becomes progressively disoriented and unresponsive. Bilateral pulmonary infiltrates and hypoxia but no evidence of congestive heart failure.

A

ARDS

Tx. Peep. Note: a source of sepsis must be sought

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20
Q

Therapy for hyperkalemia

A

Ultimate therapy is hemodialysis but while waiting…

1) IV calcium (quickest)
2) 50% dextrose and insulin
3) NG suction / exchange resins

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21
Q

Dx of Mallory Weiss tear?

A

Bright red blood after prolonged vomiting

Dx with endoscopy which allows photocoagulation via laser

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22
Q

Boerhaave syndrome

A

Prolonged vomiting leads to esophageal perforation and then fever/leukocytosis
Dx: contrast swallow (gastrograffin, then barium if negative)
Tx: emergency surgical repair

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23
Q

Tx for squamous cell carcinoma of anus

A

Nitro chemoradiation protocol (5-week is 90% successful)

If residual tumor after protocol, then surgery.

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24
In a resectable breast cancer, under what conditions can you do a lumpectomy + axillary sampling + postop radiation?
Only when tumor is small in a large breast away from the areola and nipple. Otherwise a modified radical mastectomy with axillary sampling is done
25
Work up and tx of squamous cell carcinoma of the mucosa of head and neck
#1 triple endoscopy and bx of the primary Ct scan establishes the extent Tx: resection, radical neck dissection, and very often radiotherapy and platinum based chemo Note: OPEN BIOPSY OF NECK SHOULD NEVER BE PERFORMED AS IT WILL INTERFERE WITH LATER SURGICAL APPROACH
26
Tx for brain tumor while awaiting surgery?
High dose steroids (dexamethasone) to decrease ICP
27
Tx for brain abscess?
Actual resection because drainage doesn't suffice
28
MCC for inability to urinate during first day of life?
Posterior urethral valves => diagnose with voiding cysto urethrogram and tx with endoscopic fulguration Note: you can catheterization to empty bladder
29
Hemo thorax: indications for surgery?
1. Recovery of > 1500 ml when chest tube is inserted | 2. Collecting over 600 ml in tube drainage over the ensuing 6 hours
30
Tx for bladder injury with extraperitoneal leaks?
Placement of Foley catheter
31
Tx for bladder injury with intraperitoneal leaks?
Surgical repair with suprapubic cystostomy
32
Why is sugar not included in fluid resuscitation?
So as not to induce osmotic dieresis from glycosuria which would invalidate the meaning of monitoring hourly urinary output in order to adjust fluid infusion rates
33
Dislocation where pt holds arm close to body and internally rotated?
Posterior dislocation of shoulder | Regular X-rays will miss it. Must order axillary views or scapular lateral views
34
Dislocation associated with epileptic seizures or electrical burns ?
Posterior dis location of shoulder
35
Tx for displaced fx of both malleoli?
Orif
36
Back pain exacerbated by coughing sneezing and/or defacating?
Disk herniation
37
Three classic symptoms of cauda equine syndrome?
Bladder distension Perineal saddle anesthesia Relaxed sphincter
38
Inflammation of common digital nerve at third interspace, between third and fourth toes?
Morton neuroma
39
Tx for acute gout? Chronic gout?
``` Acute= indomethacin and colchicine Chronic = allopurinol and probenecid ``` "CIA PAC"
40
Dx and tx of PE?
Dx w ct Angio Tx w heparinization. Add ivc filter (greenfield) if PE recurs while anticoaglated or if anticoagulantion is contraindicated.
41
Three options for Diagnostic work up of low urinary output?
1. Fluid challenge test ( bolus of 500ml of IV fluid infused over 10-20 minutes. Dehydrated patients respond to fluid challenge but those in ARF do not. 2. Measure urinary sodium. Dehydrated patients: < 20 mEq/L but in ARF it will be > 40 3. Fractional excretion of sodium, which in renal failure exceeds 1.
42
Zero urinary output means likely what?
A plugged or kinked catheter
43
IV fluids Correction of hypernatremia?
D5 half normal saline (but diabetes insipidis you can use D5W.) Ever 3 mEq/L of Na over 140 is every 1 L water lost.
44
Solids easier to swallow than liquids, what do X-rays show? What is a Tx?
Achalasia shows a megaesophagus on xray Tx is balloon dilatation via endoscopy
45
Work up of esophageal motility problems
Barium enema is done first | Then manometry study
46
Tx options for anal fissure
Therapy aimed at relaxing sphincter Stool softeners, topical nitroglycerin , local injection of botulinum toxin, forceful dilatation, and lateral internal sphincterotomy DILTIAZEM (calcium channel blocker) ointment 2% TID topically for 6 weeks has a 80-90% success rate (vs 50% for botulinum toxin).
47
Bleeding gastric ulcer...at what point do you decide to do surgery sleep intervention?
6 transfusions within 24 hr period
48
Surgical treatment for gastric ulcer
Always must resect gastric ulcers! Bc the risk of malignancy
49
Postop risk of gastrojejunostomy
Dumping....nutritional deficiency and hypoglycemia
50
Steps in work up of obstructive jaundice caused by tumor
1. Ultrasound. If shows a distended gallbladder, proceed... 2. CT scan 3a. Positive CT----->percutaneous biopsy 3b. Negative CT---->ERCP
51
Ransons criteria
For hemorrhagic pancreatitis (in addition to low Hct) 1. Leukocytosis 2. Elevated glucose 3. Low calcium
52
Abx choice for infectious pancreatitis
IV Imipenem (meropenem if seizure disorders)
53
Tx of pancreatic pseudocyst
Depends on size and age of pseudocyst: | 6cm or >6weeks = likely to bleed or rupture so it needs to be drained
54
Premature baby with rapidly dropping platelet count
A sign of sepsis, so think necrotizing enterocolitis if there is abdominal distension
55
Tx for necrotizing enterocolitis in premature baby?
1. IV antibiotics, IV fluids, IV nutrition, NPO
56
When is surgery required in necrotizing enterocolitis?
1. Abdominal wall erythema 2. Air in portal vein 3. Intestinal pneumatosis (presence of gas in bowel wall) 4. Pneumoperitoneum (signs of intestinal necrosis and perforation)
57
Etiology of prosthetic joint infection?
< 3 months = staph aureus or pseudomonas | > 3 months = staph epidermidis
58
How to diagnose an esophageal perforation?
Water-soluble esophogram
59
Tx for Ureteral stone + signs of infection
Coexisting stone and UTI is an emergency. Need IV Abx and emergent decompression of ureter via ureteral stent OR nephrostomy tube
60
Diagnostic tool for venous stasis ulcer?
Duplex scan
61
Two ways to fix hypoxia via ventilation?
1. Increase FiO2 | 2. Increase PEEP
62
Sx of VIPoma?
Non-a non-B islet cell pancreatic tumor (WDHA syndrome) copious Watery Diarrhea Hypokalemia Achlorhydria Can present as facial flushing and abdominal distension
63
MC adrenal tumor in children
Neuroblastoma | Dx: elevated HVA
64
Work up in a patient with a widened mediastinum after MVA?
Must order an AP xray (other views may distort the image)...then.... Aortic angiography is the gold standard for diagnosis. CT scan of chest is also acceptable.
65
MC source of posterior nosebleeds in adult?
Sphenopalatine artery
66
Tx for biliary pancreatitis
Cholecystectomy with intraop cholangiogram (cholangiogram is mandatory with biliary pancreatitis)
67
Elderly patients may manifest signs of sepsis with ?
Hypothermia and leukopenia
68
Ddx for Painless jaundice
1) cancer of head of pancreas or periampullary carcinoma or cholangiocarcinoma. These are associated with weight loss and tobacco use. 2) stricture of common bile duct. Usually associated with chronic alcoholic with chronic pancreatitis or patient with prior biliary surgery 3) stone impacted in ampulla
69
Best study to visualize the distal common bile duct?
CT scan. Ultrasound is not best for distal bile duct or pancreas because intestinal gas obscures the view.
70
Tx for amebic abscess in liver?
Metronidazole alone. No surgery required
71
Tx for multiple myeloma
``` #1. Chemo #2. If chemo fails, try Thalidomide ```
72
Soft tissue sarcoma Dx work up and tx?
Dx via incisional biopsy Tx: wide local excision, irradiation, chemo
73
Dislocation associated with axillary nerve damage?
Anterior dislocatin
74
Monteggia fracture
Direct blow to ulna resulting in a diaphyseal fracture of the proximal ulna, with anterior dislocation of the radial head Tx: ORIF of fx and then closed reduction of dislocation
75
Galeazzi fracture
Mirror image of the Monteggia fracture, so you see a distal radial fracture from a direct blow to radius....with dorsal dislocation of distal radio ulnar joint Tx: ORIF of fx and then closed reduction of dislocation
76
How do postural changes help determine cause of primary hyperaldosteronism?
``` Hyperplasia = Upright position causes more release of aldosterone than when lying down= medical management (spironolsctone) Adenoma= lack of response to positional change-= CT scan = resection ```
77
Tx for achalasia?
Balloon dilatation via endoscopy
78
What is needed in order to operate on non small cell lung cancer?
Predicted FEV1 > 800ml Steps: 1. Determine current FeV1 2. VQ scan to determine what fraction comes from each lung 3. Calculate what would remain after pneumectomy 4. If <800ml, then do chemoradiation. Do not operate.
79
Tx of aortic dissection?
Ascending : surgical tx | Descending: med management of HTN in ICU

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