General Surgery Flashcards
What is the dosage of octreotide ?
25-100mcg initial bolus, and 25-50 mcg/h for 2-5 days thereafter
What is the difference between indirect and direct bilirubin?
indirect- unconjugated
direct- conjugated
What are the causes of postoperative fever?
Wind- POD #1-2- pulminary atelectasis, pneumonia Water POD #3-7 (urine, UTI) Wound POD #3-7 Walk POD #8 (thrombosis- DVT/PE) Wonder drugs #1- drug fever
What are the typical instructions for wound care?
-Shower POD #2-3 after epithelialization of wound
-Dressings remove POD #2 and left uncovered if dry
-Skin sutures and staples can be removed POD #7-10
unless–> at which time they were removed at POD #14
a)crosses a crease
b)closed under tension
c)in extremeties
d)patient factors (elderly, corticosteroid use, immunosuppressed)
What are the types of drains?
Penrose drain- open- higher risk of infection
Jackson-Pratt-closed- connection to suction
When to remove drains?
drains should be removed once drainage is minimal (less than 30-50cc/24 hours)
What are the typical pathogens that cause surgical site infections?
Staphylococcus Aureus
Escheria. Coli- gram negative rods
Enterococcus
Streptococcus species- Group A, B, C–> can present at 24 hours
Clostridium spp- clostridium- can present at 24 hours
What are wells criteria?
Active cancer +1
Bedridden recently >/= 3days or major surgery within 12 weeks+1
Calf swelling >3cm compared to other leg +1
collateral superficial veins present (nonvericose) +1
Entire leg swollen +1
Localized tenderness along the deep venous system +1
Pitting edema, confined to symptomatic leg +1
Paralysis, paresis, or recent plaster immobilization of the lower extremity +1
Previously documented DVT +1
Alternative diagnosis to DVT at least as likely +2
Wells score 0 or lower risk of DVT
What is the negative predictive value of a d-dimer?
94%
What is the differential diagnosis of a small bowel primary mass?
GI primary tumors are rare to begin with, so these things are all rare
A-adenocarcinoma
C-Carcinoid
L-lymphoma
S-stromal tumor (GIST)
Gastrointestestinal stromal tumor (GIST)
- most common type of stromal tumors of the GI tract
- only 1% of primary GI tumors
- all GIST’s >1cm have malignant potential
- tx is resection and/or treatment with Gleevec (imatinib) a tyrosine kinase inhibitor 400mg to 800mg OD x 3years
- imatinib works best in Kit9 + mutation GISTS but does not improve mortality
What are the main differences between a hodgkins and non-hodgkins lymphoma
Hodgkins
-has reed sternberg cells
-more likely to present with B symptoms
-more commonly associated with epstein barr virus
-CHOP is most common form of chemotherapy
(cyclophosphamide, hydroxydoxorubicin (Adriamycin), vincristine (Oncovin), prednisone)
Non-hodgkins
-more commonly associated with immunodefficiency, autoimmune disease and infections
-most common subtypes are follicular (indolent) and DLBCL (aggressive)
-some forms are very responsive to chemotherapy
CHOP is most common form of chemotherapy
(cyclophosphamide, hydroxydoxorubicin (Adriamycin), vincristine (Oncovin), prednisone)
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What is Dapsone, and what is it used for?
Dapsone is an antibiotic that is useful in treating leprosy, dermatitis herpetiformis and some other complicated skin infections.
It was used for a patient who had poor wound healing in conjunction with doxycycline.
Dapsone is a competitive antagonist of para-aminobenzoic acid and prevents bacterial utilization of PABA in the synthesis of folic acid
The dosing is heavily dependant on the type of infection being treated, so just look it up
What are the reversal agents for anticoagulation and what are their dosages?
Warfarin-
Octaplex or other prothrombin complex concentrates- (increases the levels of vitamin-K dependant coagulation factors-II, VII, IX, X [1972]
-dosing is INR and weight dependant
-the INR declines rapidly within 10 minutes
Vitamin K- promotes liver synthesis of clotting factors (II, VII, IX and X through an unknown mechanism)
- it takes 12-14 hours for IV INR to return to normal
- dosing is INR dependant
Heparin
1mg of protamine sulfate neutralizes 100 units of heparin
What are the reversal guidelines from the 2011 ACP for warfarin?
INR10 (no evidence of bleeding)- administer vitamin K
If minor bleeding at any INR elevation vitamin K 2.5-5mg orally and monitor INR more frequently
If major bleeding at any INR- four factor prothrombin complex concentrate and IV vitamin K 5-10mg
Preprocedural/surgical INR normalization in patient receiving warfarin- oral 1-2.5mg once administered on the day before surgery
What is the CHADS2 score?
Congestive Heart Failure Hypertension history Age>/= 75 Diabetes mellitus history Stroke or previous TIA symptoms previously
score >2 start on warfarin
What are the he features of DCIS that would suggest doing a sentinel node biopsy?
1)the women is going to be having a complete mastectomy as you can’t go back in and do the sentinel node biopsy after a mastectomy
2) high grade on pathology
3) necrotic features on pathology
What are the benefits of radiation therapy in DCIS?
Rt significantly reduces the odds of in breast recurrence but does not change the odds of distant recurrence or mortality
What are the most important things to know about prostate cancer?
Eating a diet high in fat increases your risk by 2x
Having a first and second degree relative with prostate cancer increases your risk by 9x whereas just having a first degree relative increases it by 2x
African men are at higher risk than Caucasian men
90 % are adenocarcinoma, the rest are made up of urothelial carcinoma and other rate types
There is a 50 % risk at age 50 of getting prostate cancer, but only a 3% lifetime risk of mortality
Having a psa equal to or less than 10 and Gleason score equal to or less than 7
What are the screening guidelines for prostate cancer?
Canadian Urological Association Guidelines (2011) re: CaP Screening • harms and benefits of PSA testing must be explained to the patient and an informed, shared decision to test must be established • initial screening should include both serum PSA and DRE • all men should be offered screening at age 50 if >10 yr life-expectancy • high-risk individuals (family hx of CaP or African ancestry) should be offered screening at age 40 if >10 yr life-expectancy • standard has been annual screening, but q2-4 yr screening acceptable • no strict cutpoint for when to biopsy. Decision to biopsy should be based on more than a single PSA value *new guidelines under development, however, AUA guidelines recommend against universal routine PSA screening for CaP
What are the differentiating factors between an internal and external hemorrhoid?
Internal hemorrhoid
-painless
What is the structural part of antibiotics that determines their cross reactivity, or likelihood to cause an allergic reaction?
In the US the predominant structure that people have issues with is the central core group
In Europe, it is mainly the r groups
What are the contraindications to ocp?
Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
●Venous thromboembolism
●Known thrombogenic mutations
●Known ischemic heart disease
●History of stroke
●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
●Systemic lupus erythematosus (positive or unknown antiphospholipid antibodies)
●Migraine with aura at any age
●Breast cancer
●Cirrhosis
●Hepatocellular adenoma or malignant hepatoma
What are the most common liver cancers?
Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver
Secondary cancers are the most common cancers of the liver, the most common locations for these being the
GI (colorectal most common), lung, breast, pancreas, ovary, uterus, kidney, gallbladder, prostate
What are the management recommendations for pediatric appendicitis?
Early (non ruptured)
- single dose of prophylactic antibiotics with same choices as advanced, just less of them
- IV fluids
- pain management with morphine or ketoralac
Advanced (gangrenous or ruptured)
- IV fluids
- NG if child has persistent vomiting
- catheter if patient is dehydrated
- preoperative antibiotics, and should receive antibiotics until tolerating regular diet and and are afebrile.
- choice of antibiotics in children should start with Pip Taz , but second line can be ceftriaxone flagyl. Can use gent- flagyl if patients allergic to penicillins and cephalosporins
What is the management of an NSTEMI
L M N O P
Lasix Morphine Oxygen/ other (B-blocker and statin) Nitro Positioning
\+ Antiplatlet therapy Theraputic anticoagulation Maintain K and Mg above 4 and 2 respectively \+ Discontinue NSAIDS immediately due to increased risk of cardiovascular events on them \+ TIMI or GRACE scoring
What is the dosing of Lasix IV
Lasix 20-40mg IV initially, if not sufficient may repeat dose in 1-2 hours
Lasix dosing for acute pulmonary edema is 10-20mg IV over 1-2 minutes, if no response within 1 hour, may increase dose to 80mg IV
What is the dosing of nitroglycerin in ACS
1-2 sparys SL q5 minutes to max of 3 sprays in 15 minutes
What medications should be held the day before surgery?
Stop
ACE inhibitors- discontinue night before surgery unless using for HF and baseline BP inadequate
Non statin lowering lipid drugs- discontinue day before sugery
asprin discontinued approximately 7 days prior to non cardiovascular surgery
tigagrelor, clopidegrel (P2Y12 receptor blockers) stopped 7-10 days prior depending on agent
Do not stop
- Beta blockers
- PPI’s
- H2 blockers
- inhaled bronchodilators
- psychotropics including SSRI’s for most procedures. for some high risk bleeding procedures, stop SSRI’s
What is the management of hernias?
Perincisional hernias- all should be fixed
All other hernias- don’t fix unless
- symptomatic
- encarcerated
- strangulated
What are the types of hernias?
Inguinal
- direct: comes through haselbachs triangle medial to inferior epigastric artery
- indirect: originates in deep inguinal ring lateral to inferior epigastric artery. Often descends into scrotal sac or labia majora
Femoral: into femoral canal below inguinal ligament but medial to femoral vein, but may overide it
How are metastatic breast cancers stratified?
The medical treatment approach to patients with metastatic breast cancer can be stratified by whether the cancer is hormone receptor-positive (estrogen receptor [ER] and/or progesterone receptor [PR]-positive) and whether or not human epidermal growth factor 2 (HER2) is overexpressed (ie, HER2-positive):
●For patients with hormone receptor-positive, HER2-negative breast cancer, we suggest endocrine therapy with or without targeted agents, provided they are appropriate candidates.
●For patients with hormone receptor-positive, HER2-positive breast cancer, we recommend a HER2-directed agent as part of any treatment strategy. We suggest HER2-directed treatment plus endocrine therapy rather than chemotherapy or single-agent HER2 therapy in appropriately selected patients.
●For patients with hormone receptor-negative, HER2-negative breast cancer, we recommend chemotherapy. These patients are not candidates for endocrine therapy.
●For patients with hormone receptor-negative, HER2-positive metastatic breast cancer, we recommend HER2-directed therapy in combination with chemotherapy
What are important questions to ask in breast cancer?
Family history
Menopausal status
What are the classification of colonic polyps?
• non-neoplastic:
- hyperplastic: most common non-neoplastic polyp
- mucosal polyps: small tubulovillous > tubular
What is the difference between a villous and tubular polyp and what are there associated cancer risk?
Tubular polyps often have a pedunculated stalks, less than 2 cm in size, and have a lower cancer risk
Sessile polyps do not have a stalk, are often greater then 2 cm, have a left sided predominance, and have a higher cancer risk
what are the layers of the small
from inside out: mucosa submucosa muscularis (composed of muscularis interna, and muscularis externa) serosa
What are the clinical manifestations of zollinger ellison syndrome
chronic diarrhea
- results from high volume of gastric acid secretions
- high gastrin secretion inhibits absorbtion of sodium and water by the small intestines
- amount of stomach acid exceeds the amount of bicarbonate produced by the pancreas interfering with pancreatic enzymes and bile acids, resulting in steatorrrhea
what are the retroperitoneal structures of the abdomen
SAD PUCKERS
Suprarenal (adrenal)glands
A aorta/IVC
D duodenum (2nd and third )
P pancreas (except tail) U ureters C colon (ascending and descending) K kidneys E esopagus R rectum
What is the management of an NSTEMI?
Clinical suspiscion leads to lab tests
- ECG, troponins, cbc, lytes, creatinine, CXR, serum glucose
- Asprin 162 to 325mg immediately and 81 mg daily from thereon in
- clopidogrel 300mg loading dose and 75mg OD for 12 months
- antithrombin therapy in the form of
a) fondaparinux in patients who do not have a high bleeding risk 2.5mg SQ OD
b) unfractionated heparin in patients with a high bleeding risk or in patients with renal impairment - PCI vs angiography
1. 5.1 Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk.
1.5.2 Offer conservative management without early coronary angiography to patients with a low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less).
What is the management of barretts esophagus?
25% of patients with Barretts esophagus do not complain of GERD symptoms
Barretts is metaplasia of normal squamous epithelium to abnormal columnar epithelium containing intestinal metaplasia
rate of malignant transformation is 0.12% per year prior to dysplasia
management is acid suppression with high dose PPI indefinitely + endsocopy q3yrs if no dysplasia
what are the red flags for dyspepsia
- unintended weight loss
- persistent vomiting
- progressive dysphagia
- odynophagia
- unexplained anemia of iron deficiency
- hematemesis
- jaundice
- palpable abdominal mass or lymphadenopathy
- family history of upper GI cancer
- previous gastric surger
What is the difference between GERD and dyspepsia?
- dyspepsia is intermittent discomfort, characteristically develops after eating
- GERD- a condition in which the stomach contents leak backwards from the stomach into the esophagus
What is the role of Gastrin in the stomach, and in what syndrome is gastrin produced, and what is a common relation to this syndrome?
Gastrin stimulates H+ production from parietal cells
Gastrin is produced in excess in Zollinger Ellison syndrome
zollinger ellison is a form of pancreatic CA
What are the the most common etiology of peptic ulcer disease?
Duodenal
- H.pylori (90%)
- NSAIDS (7%)
- Idiopathic (15%)
Gastric
- H.pylori (60%)
- NSAIDS (35%)
- Idiopathic (10%)
What are the typical symptoms of a duodenal ulcer?
epigastric pain, may localize to tip of xiphoid burning develops 1-3 hours after meals relieved by eating and antacids interrupts sleep periodicity
what are the treatment steps in PUD?
stop NSAIDS
acid neutralization
H.pylori eradication
quit smoking
What is the usual diameter of the common bile duct?
Common bile duct (CBD): The normal CBD diameter increases with age and in patients who have had a cholecystectomy. In patients in their 40s, the normal mean diameter is 4 mm. The normal mean diameter then increases by 1 mm every decade [2-5], and authors have proposed that in older patients the normal upper limit of normal be set at 8.5 mm [6]. The CBD is commonly up to 10 mm in patients who have undergone a cholecystectomy.
