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PANCE REVIEW > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What is a schatizki ring MC associated with?

A

sliding hiatal hernia

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2
Q

Two types of Hiatal Hernias

A

Type 1: “sliding hernia” this is where the GE junction and stomach slide up into the mediastinum. (Treat like GERD)

Type 2: “Rolling hernia” this is where the GE junction STAYS IN PLACE and the fundus of the stomach protrudes around it (Treat with surgery)

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3
Q

Type types of esophageal cancer

A

1) Squamous Cell: MC in world, ETOH and tobacco cause it

2) Adenocarcinoma: MC in USA, results from long term GERD, progressing to Barrett’s esophagus

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4
Q

Which type of ulcers have a higher risk of malignancy?

A

Gastric ulcers

**duodenal ulcers are more common

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5
Q

H Pylori Testing

A

1) uses breath test
2) stool antigen
3) endoscopy with bx
4) serologic antibodies

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6
Q

H. Pylori triple therapy

A

PPI
Clarithromycin
Amoxicillin

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7
Q

H. Pylori quadruple therapy

A

PPI
Bismuth
Metronidazole
Tetracycline

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8
Q

Signs of Gastric Cancer

A

weight loss, early satiety, dyspepsia

*linitus plastica on endoscopic bx

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9
Q

Gastric Cancer Risk Factors

A

H. PYLORI, slated, cured, smoked, pickled food

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10
Q

What are the two familial bilirubin disorders that would give you guidance without increased LFTs?

A

1) Dubin-Johnson Syndrome

2) Gilbert Syndrome

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11
Q

Key features of Dubin Johnson Syndrome

A
  • isolated elevated conjugated (direct) bilirubin without increased LFTs
  • Jaundice
  • Grossly black liver on bx
  • most are asx and no treatment is necessary
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12
Q

What is the enzyme needed to convert indirect biirubin to direct bilirubin?

A

(UGT)

-glucoronosyltransferase

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13
Q

Key features of Gilbert Syndrome

A
  • reduced UGT activity
  • transient episodes of jaundice that are caused by stress, illness, ETOH
  • no treatment needed for this mild dz
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14
Q

What do liver enzymes look like in alcoholic hepatitis vs viral hepatitis?

A

ETOH: AST: ALT >2 **S is high in alcohol

Viral: ALT>AST, with both normally over 1,000

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15
Q

What is the diagnostic test of choice for choledocolithiasis?

A

ERCP

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16
Q

What is the most common organism causing acute cholangitis, Tx?

A

E. Coli

treat with unasyn or zosyn

ERCP if needed

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17
Q

Charcot’s triad

A

For atue cholangitis:

  1. fever
  2. RUQ pain
  3. jaundice
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18
Q

Boas sign

A

Referred pain to the Right shoulder from acute cholecystitis

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19
Q

What is the Gold standard for diagnosing acute cholecystitis ?

A

HIDA scan, following a RUQ u/s

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20
Q

Acute Calculus Cholecystitis

A

gallbladder sludge blockage, MC in the seriously ill patients (seen post-op)

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21
Q

What is the MC cause of fulminant hepatitis ?

A

acetometaphen ingestion

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22
Q

Clinical manifestations of fulminant hepatitis

A

Encephalopathy: astrixis; give lactulose

Coagulopathy : Inc. PT/INR

Hepatomegaly, jaundice

-high ammonia, inc. PT/INR, hypoglycemia

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23
Q

Hep A transition and manifestations

A

Feco-oral transmission

-prodromal phase with SPIKING fever

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24
Q

Hep E transmission

A

Water born outbreak

  • highest mortality during pregnancy
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25
Q

Hep C transmission ; likelihood to become chronic

A

Parenteral transmission( IVDA)

*80% get chronic infection

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26
Q

Hep C Management

A

Pegylated interferon

*screen for Hcc

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27
Q

Hep D transmission

A

Requires hep B first to coinfect or superinfect

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28
Q

Hep B transmission

A

Parenteral, sexual

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29
Q

What would indicate a patient with the Heb B vaccine ?

A

Anti-HbS POSITIVE, all others negative

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30
Q

What would indicate a patient who resolved hepatitis B?

A

Anti-HbS positive, IgG present, all others negative

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31
Q

Budd-Chiari Syndrome

A

(Hepatic vein obstruction)

-leads to dec. liver drainage, therefore backs up causing portal HTN and cirrhosis

PRIMARY: thrombosis of the hepatic vein

SECONDARY: exogenous tumor compression

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32
Q

Clinical Triad of Budd-Chiari Syndrome

A

1) ascites
2) hepatomegaly
3) RUQ pain

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33
Q

Budd-Chiari Syndrome tx

A
  1. Shunts (TIPS)

2. Balloon angioplasty with stent

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34
Q

Lab value associated with hepatocellular carcinoma

A

alpha-fetoprotein

** MC liver cancer is not primary, but a result of METS

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35
Q

What classification system is used to stage liver cirrhosis?

A

Child-Pugh

*based on bilirubin, albumin, INR, ascites, and encephalopathy

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36
Q

Manifestations of cirrhosis

A

1) encephalopathy; tx with lactulose or rifaximin
2) esophageal varacies
3) SBP, spontaneus bacterial peritonitis (infected ascitic fluid)
4) ascites, astrixis, gynecomastia

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37
Q

Primary Biliary Cirrosis Hallmarks

A
  • MC in middle-aged women (40-60)
  • intrahepatic autoimmune d/o of small bile ducts
  • Fatigue, PRURITIS, RUQ pain, hepatomegaly, jaundice
    • AMA (anti-mitochondrial antibody)
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38
Q

TX of primary billiard Cirrhosis

A
  1. ursodeoxycholic acid (reduces progression)

2. Cholestryramine & UV light (for puritis)

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39
Q

Primary Sclerosing Cholangitis Hallmarks

A
  • Autoimmune FIBROSIS of intra AND extra hepatic ducts
  • MC associated ulcerative colitis
  • MC men 20-40
  • jaundice, puritis, hepatosplenomegaly
    • P-ANCA , ERCP to dx
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40
Q

Primary Sclerosing Cholangitis tx

A

liver transplant

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41
Q

Ransons Criteria for pancreatitis

A 
Glucose >200 
Age >55
LDH >350
AST >250
WBC >16,000
  • 3 or more= likely pancreatitis
    Less than 3= unlikely
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42
Q

Clinical manifestations triad for chronic pancreatitis

A

1) calcifications (seen on AXR)
2) steatorrhea
3) DM

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43
Q

Pathoneumonic sign for pancreatic cancer

A

Painless jaundice

*courvoisier’s sign: non tender palpable gallbladder with jaundice

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44
Q

MC causes of small bowel obstruction

A
  1. adhesions
  2. hernia
  3. Crohns
  4. malignancy
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45
Q

Manifestations of SBO

A
  1. abdominal pain
  2. distention
  3. vommiting
  4. obstipation
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46
Q

PE and DX of small bowel obstruction

A
  • high pitched tinkles on auscultation

* air fluid levels with dilated bowel loops in step ladder pattern on abdominal radiograph

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47
Q

SBO tx

A

If non strangulated.. NPO and IV fluids, bowel decompression with NG tube

if strangulated ; surgery

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48
Q

Ogilvie’s syndrome hallmarks

A

Colonic pseudo obstruction (colon dilation with NO obstruction)

  • MC cecum and right hemicolon
  • abdominal distention
  • Xray shows dilated right colon from cecum with cutoff @ splenic flexure
  • Give fluids and neostigmine in pt at risk of perforation. NG tube decompression
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49
Q

Diagnostic study and tx of diverticula dz

A

CT scan (barium enema CI)

Tx: cipro or Bactrim + metronidazole

*fiber will help

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50
Q

What is the treatment for diverticulitis?

A

cipro+flagyl

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51
Q

MC area effected by diverticulitis

A

sigmoid colon, LLQ pain

**diverticulosis is the most common cause of acute lower GI bleed

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52
Q

What is the MC location of a volvulus?

A

MC sigmoid colon, then cecum

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53
Q

Clinical manifestations of volvulus

A

pain, distension, n/v fever, tachycardia

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54
Q

Volvulus management

A

endoscopic decompression 1st line, 2nd line is surgery

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55
Q

Definition of toxic megacolon

A

dilation > 6 cm + signs of systemic toxicity

tx is decompression

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56
Q

Buzz words for Ulcerative Colitis

A
  • only colon, rectum always involved
  • LLQ colicky pain
  • bloody diarrhea
  • complications are primary sclerosing cholangitis, CA, toxic mega colon
  • smoking is protective
  • uniform inflammation (stovepipe sign)
  • P-ANCA
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57
Q

Buzz words for Crohns

A
  • entire GI tract (MC terminal ilium)
  • RLQ pain
  • transmural skip lesions with fistula sand granulomas (cobblestone)
  • string sign on barium study
  • ASCA +
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58
Q

3 Types of colon polyps and their probability for malignancy

A

1) pseudopolyp: not cancerous, due to IBD
2) Hyperplastic: low risk
3) Adenomatous polyps: normally become malignant in 10-20yrs

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59
Q

3 types of adenomatous polyps

A

1) tubular adenoma: nonpedunculated (MC and best prognosis)
2) tubulovillous: mixture of both
3) villous adenoma: high cancer risk

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60
Q

Tumor marker used for colorectal cancer

A

CEA

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61
Q

An “apple core” lesion found on barium enema is a classic finding of what?

A

Colon cancer

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62
Q

Colorectal cancer screening

A

colonoscopy q 10 years @50 OR flex sig q 5 years

Fecal Occult blood test annually

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63
Q

Indirect Inguinal Hernia

A
  • MC overall type of hernia in men & women
  • MC in young children, young adults
  • persistent patent process vaginalis
  • origin is LATERAL to the inferior epigastric artery
  • can protrude all the way to the scrotum; could cause scrotum swelling
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64
Q

Direct Inguinal hernia

A
  • protrudes MEDIAL to the inferior epigastric artery
  • within Hesselbach’s triangle
  • does NOT reach strotum
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65
Q

What are the boundaries of hesselbachs triangle ?

A

Medial=Rectus Abdominus

Lateral= Inferior epigastric vessels

Inferior= Poupart’s ligament

*use the pneumonic RIP

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66
Q

3 presentations of inguinal hernias

A
  1. Asymptomatic: swelling or fullness at hernia site
  2. Incarcerated: painful, enlargement of an irreducible hernia
  3. Strangulated: incarcerated hernia turned ischemic, systemic toxicity; severe painful bowel movements
    * most require surgical repair
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67
Q

Femoral Hernias

A
  • MC in women
  • protrusion of contents of the abdominal cavity through the femoral canal BELOW the inguinal ligament
  • More likely to become strangulated so surgery often done
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68
Q

Umbilical hernia

A
  • most are congenital

- observe till 2 yrs old, surgery if present past age 5

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69
Q

Incisional hernia is also called what

A

ventral hernia , often seen in obese patients

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70
Q

Obturator hernia

A
  • through pelvic floor and through obturator foramen

- MC in women

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71
Q

Classification of internal hemorrhoids

A

I. does not prolapse,
II. prolapses with defecation, reduces spontaneously
III. prolapse with deification, requires manual reduction
IV. irreducible & may strangulate

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72
Q

Presentation of internal hemorrhoids

A

intermittent rectal bleeding, hematochezia, itching

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73
Q

Presentation of external hemorrhoids

A

perianal pain, aggravated with defication, maybe mass or skin tag,

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74
Q

Hemorrhoids treatment

A

high fiber diet, sit baths, rubber band ligation if severe or strangulated

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75
Q

Where are most anorectal access located?

A

MC in the posterior rectal wall

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76
Q

Hallmarks of a pilonidal access/cyst

A
  • near the gluteal cleft, towards midline of sacrum or coccyx
  • Small midline pits may be present
  • I&D for treatment
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77
Q

BMI to diagnose anorexia

A

BMI <17.5, or body weight <85% ideal

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78
Q

When to hospitalize an anorexic patient

A

if <75% ideal body weight, or medical complications

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79
Q

Risk Factors for post-op n/v (Apfel’s simplified risk score)

A

female sex, nonsmoker status, previous history of postoperative nausea and vomiting, and use of postoperative opioids

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80
Q

how to prevent most op n/v

A

Patients at high risk for PONV (ie, those with four risk factors according to Apfel’s simplified risk score) should receive three or more interventions (ie, antiemetics, modification of anesthesia, acupuncture)

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81
Q

What are the two main causes of pyloric stenosis in adults? What is the treatment?

A

1) peptic ulcer dz
2) malignancy

Tx with endoscopic ballooning (if high surgery risk) , or surgical fix (ideal)

*patient will present with s/s of upper GI obstruction

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82
Q

What is a pancreatic pseudocyst ?

A

Encapsulated, mature fluid collections occurring outside the pancreas that have a well-defined wall with minimal or no necrosis, occur as a complication of pancreatitis

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83
Q

Pancreatic pseudocyst management

A

If asx, monitor q3-6 months, if severely symptomatic, IR guided drainage

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84
Q

What is the MC type of small bowel carcinoma ?

A

Carcinoid tumor; MC overall and MC in the ilium

*adenocarcinoma is the MC in the duodenum

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85
Q

Postop N/V gives you what kind of acid-base disturbance?

A

hypochloremic metabolic acidosis

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86
Q

Grading and Management of AAA

A

Immediate surgery: >5.5 cm or grows .5cm in 6 months

Vascular surgeon referral: 4.5-5.4

ultrasound q 6 months: 4-4.5

anual ultrasound: 3-4 cm

*considered aneurysmal when it reaches 3cm

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87
Q

Common presentations of AAA

A
  • Most Asx.

- If rupture: syncope and hypotension with tearing back pain

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88
Q

What layer of the aorta is torn in a direction?

A

Intima

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89
Q

PE findings of a patient with an aortic dissection

A
  • tearing chest pain radiating to the back
  • Variation in extremity pulses
  • Acute new onset aortic regurgitation
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90
Q

Gold standard for dx of aortic dissection

A

MRI Angiography

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91
Q

MC spot for an AAA

A

infrarenally

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92
Q

Where is the best anatomical location for a peritoneal dialysis catheter placement?

A

in the pouch of douglas (between the bladder and rectum)

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93
Q

Venus Ulcers

A

Found on the medial ankles

-edema, hyperpigmentation

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94
Q

Arterial ulcers

A

Found on the lateral ankles

-atrophy, decreased pulses, shiny skin

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95
Q

MC location of a herniated disc?

A

-L5, S1

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96
Q

s/s of herniated disc at L4

A
  • ANTERIOR thing pain
  • medial ankle sensory loss
  • weak ankle dorsiflexion
  • Loss of knee jerk
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97
Q

s/s of herniated disc at L5

A
  • LATERAL thigh, hip, groin pain and parethsias
  • sensory loss to the dorsum of the foot
  • weak big toe extension
  • Normal reflexes
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98
Q

s/s of herniated disc at S1

A

POSTERIOR leg/calf pain

  • sensory loss to the plantar surface of the foot
  • weak plantarflexion
  • Loss of ankle jerk
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99
Q

Spondylolysis

A

pars interarticular defect from failure to fuse or stress fracture

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100
Q

Spondylolisthesis

A

forward slipping of a vertebra on another due to progressively worsening spondylolysis

*tx is surgical if it is high enough grade.. most people will have to go to PT and have injections before insurance will authorize

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101
Q

RCRI cardiac risk assessment

A

1 point for each of the following:

  • High risk surgery
  • Hz of stroke
  • Hz of CHF
  • Pre-Op insulin use
  • HZ of ischemic heart dz
  • Pre-Op Cr>2
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102
Q

What are high risk surgeries?

A
  • Intrathoracic
  • Intraparetoneal
  • suprainguinal vascular
103
Q

pathophysiology of Graves dz

A

autoimmune process where patient makes TSH receptor antibodies…therefore TSH is “low” resulting in clinical hyperthyroid.
***MC cause of hyperthyroid

104
Q

Physical exam findings specific to Graves dz

A
  1. thyroid bruits
  2. Opthalmopathy (lid lag, proptosis, exophthalmos)
  3. Pretibial Myxedema (nonpitting, edematous pink/brown plaques)

**diffuse radioactive iodine uptake

105
Q

Arrythmia associated with thyroid storm

A

A fib

106
Q

treatment for thyroid storm

A
  1. PTU or mithimozole (prevents conversion)
  2. BB (slow you down) DO THIS FIRST
  3. IV glucocorticoids (prevents concersion)
107
Q

What level of thyroid hormone do most people with thyroid cancer present in

A

euthyroid

108
Q

What are the 4 types of thyroid cancer

A
  1. papillary, only local mets, good prog.
  2. follicular, distant mets, good prog
  3. medulary,MEN2 association, secrete calcitonin
  4. anaplastic , older men, rapid growth to invade trachea, most die in 1 yr and need tracheostomy
109
Q

MEN2 syndrome is made up of what diagnoses

A
  1. Hyperparathyroid
  2. Medullary thyroid cancer
  3. Pheochromocytoma
110
Q

MEN1 syndrome is made up of what diagnosis

A
  1. Hyperparathyroid
  2. Pancreatic cancer
  3. Pituitary tumor
111
Q

Hallmarks of Toxic multi nodular Goiter (aka plumber’s dz)

A
  • Functional palpable nodules, MC in elderly
  • Clinical hyperthyoid, NO SKIN OR EYE changes (those are only in Grave’s)
  • Patchy areas of iodine uptake
  • Treat with radioactive iodine, with surgery if symptoms persist
112
Q

Risk factors for thyroid nodules

A
  • extremes of age
  • head/neck radiation
  • *most in men and children are malignant
  • **most in females are benign
113
Q

Thyroid nodule presentation

A
  • mostly asx

- may have compressive s/s of difficulty swallowing or breathing

114
Q

PE findings that would support a malignant thyroid nodule

A
  • NO MOVEMENT WITH SWALLOWING, fixed in place, rapidly growing ,
  • euthyroid, cold nodules are MC for malignancy
115
Q

What is the most common type of thyroid nodule?

A

Follicular adenoma (colloid)

*these are benign

116
Q

What is a pheochromocytoma?

A

catacholamine secreting adrenal tumor

*diagnosed by 24 hr urine catecholamines with elevated metanephrine and vanillylmandelic acid

117
Q

Pheocromocytoma treatment

A

Adrenalectomy

**need alpha blockade with PHEnoxybenzamine or PHEntolamine x2 weeks pre-surgery

BB post surgery

118
Q

Causes of hyperparathyroidism

A

PRIMARY: parathyroid adenoma or hyperplasia

***occurs in 20% of people taking LITHIUM

SECONDARY: caused by CKD

119
Q

Lab values used to confirm primary hyperparathyroid

A
  • High PTH
  • High Ca
  • Low phosphorus
120
Q

An adrenal adenoma would present as what endocrine disorder

A

Cushing’s syndrome

121
Q

What is the most common type of skin cancer in the US?

A

Basal cell carcinoma

122
Q

Clinical manifestations of Basal Cell Carcinoma

A
  • small, raised translucent pearly waxy papule with central ulcerations **
  • They are found in sun exposed areas
  • Often bleed easily (friable)
  • Slow growing, invade locally with little mets
123
Q

Basal Cell Carcinoma tx

A
  • electrodesiccation/curettage

- Mohs micrographic surgery in those that are recurrent of difficult

124
Q

Layers of the skin impacted by cellulitis

A

dermis and subcutaneous tissue

**not well demarcated!

125
Q

MC causative organisms of cellulitis

A

S. Aureus MC

-GABHS (strep pyogenes)

126
Q

Erysipelas

A
  • Caused by GABHS
  • WELL DEMARCATED, often on the face
  • Treat with PCN
127
Q

Lymphangitis

A

spread of cellulitis through the lymph vessels leaving streaking

128
Q

Medical management of cellulitis

A

Cephalexin; dicloxacillan

129
Q

Hallmarks of malignant melanoma

A
  • Highly aggressive!! High METS
  • 80% associated with UV radiation exposure
  • MC skin cancer related death
130
Q

Malignant melanoma clinical manifestations

A 
A-asymetry 
B- borders irregular
C- color varied (blue, black) 
D-diameter >6mm
E-Evolution
131
Q

what is the most important prognostic indicator for METS of malignant melanoma?

A

THICKNESS

132
Q

Dx and tx of malignant melanoma

A

DX: full thickness wide excision bx + lymph node bx

TX: complete wide surgical excision

133
Q

What is bowen’s disease?

A

squamous cell carcinoma in situ; slow growing and rarely mets

134
Q

Hallmarks of squamous cell carcinoma

A
  • 2nd MC skin cancer after basal cell
  • Often preceded by ACTINIC KERATOSIS, or HPV infection
  • malignancy of the keratinocytes resulting in hyperkeratosis and ulceration
  • RED thick nodules with WHITE scaly, bloody margins
135
Q

Rule of 9’s

A

Skin burn surface area grading as follows:

  • Head 9% total
  • 1 Arm 9% total
  • Upper torso (front and back total) 18%
  • Lower torso (front and back total ) 18%
  • 1 Leg 18% total
  • Genitalia 1%
136
Q

When is an escharotomy recommended?

A

For circumferential burns to prevent compartment syndrome

137
Q

Antibiotic use in burns

A
  • Use topical if it is a non superficial burn
  • Silver sulfadiazine is commonly used (CI in sulfa allergy, face, preggo, <2 months old)

-Bacitracin used for superficial burns

138
Q

Parkland fluid resuscitation formula for burn patients

A

4mL x kg x % BSA= amount of lactated ringers

*Give 1/2 in first 8 hrs, then the rest over the next 16 hours

139
Q

Types of burns

A

1) Superficial (1st deg): epidermis, sunburn

2) Superficial Partial Thickness: (2nd deg)
- epidermis + superficial dermis (papillary)
- BLISTERS, moist and weeping
- most painful of all burns
- 14-21 days to heal

3) Deep Partial Thickness: (2nd deg)
- epidermis+ deep dermis (reticular)
- dry, pale white and yellow, blisters
- NO PAIN
- absent capillary refill
- Up to 2 months recovery; scarring common

4) Full Thickness Burn: (3rd deg)
- entire skin
- waxy, white, leather
- Painless with no blanching

5) 4th degree burn:
- into bone and muscle
- Black, charred

140
Q

Pressure Ulcer staging

A

Stage I: superficial, nonblanchable redness

Stage II: epidermal into dermis, resembles abrasion or blister

Stage III: full thickness of skin with sub Q

Stage IV: extends beyond fascia to muscle, tendon, bone

141
Q

Ulcer management

A

Wet to dry dressings

stages 3, 4 may need surgical debridement

142
Q

Hallmarks of SAH

A
  • Sudden onset of “worse headache of my life”
  • Arterial bleed between arachnoid and pia matter (MC berry aneurysm rupture or AVM)
  • stiff neck, photophobia, delirium, possible LOC
  • Diagnosed by CT, if inconclusive then LP showing xanthochromia
  • Gradually lower BP gradually with nicardipine
143
Q

Epidural hematoma

A
  • arterial bleed between skull and dura
  • Often middle meningeal artery after temporal bone fracture
  • LOC, lucid period, coma, n/v
  • lConvex, lens shaped bleed that does NOT cross suture lines
144
Q

Subdural Hematoma

A

Venus bleed between dura and arachnoid

  • MC in elderly, tearing of cortical bridging veins
  • MC blunt trauma
  • Concave, cresent snapped bleed that DOES cross suture lines
145
Q

Anterior Chord Syndrome

A
  • lower extremity motor deficit
  • loss of pain and temp sensation
  • bladder dysfunction
  • commonly caused by flexion compression
146
Q

Central Cord Syndrome

A
  • upper extremity motor and sensory deficits in a SHAWL like distribution (esp. hands)
  • loss of pain and temp
  • Caused by extension injuries
147
Q

Brown Sequard Syndrome

A
  • Ispilateral motor and proprioception deficit
  • Contralateral pain and temp deficit
  • Caused by penetrating injuries
148
Q

Posterior Cord Syndrome

A

loss of proprioception and vibration only

149
Q

An infarct in which part of the brain would cause speech impediments

A

LEFT hemisphere

150
Q

Causes of a prolonged PTT

A
  • Issues with the INTRINSIC pathway
  • Factors 8,9,11,12
  • Heparin, vWD, hemophilia
151
Q

Causes of prolonged PT

A
  • Issues with EXTRINSIC pathway
  • Factors 7, 10
  • Warfarin, vitamin K
152
Q

Pathophysiology of TTP

A

Antibodies against ADAMTS13 causes a low level. ADAMTS13 is used to cleave vWF, so with this low level there is a lot of free vWF resulting in platelet sequestration

153
Q

TTP treatment

A

Plasmaphoresis

154
Q

Pentad of thrombotic thrombocytopenia purpura

A

1) thrombocytopenia (petechiae, mucocutaneous bleed)
2) neuro s/s
3) microangiopathic hemolytic anemia
4) kidney failure
5) fever

155
Q

Hallmarks of DIC

A
  • Pathological activation of coag system
  • Widespread micro thrombi with thrombocytopenia
  • Caused by infection (gram - sepsis MC) , malignancy, obstetric complications, massive injury
  • increased PT, PTT, PTINR, D-dimer
156
Q

Hemophilia A Hallmarks

A
  • Factor 8 deficinecy
  • Intrinsic issue resulting in prolonged PTT
  • hemarthrosis with excessive hemorrhage in response to trauma or surgery

-Tx with factor 8 infusion or desmopressin

157
Q

Hemophilia B hallmarks

A
  • Factor 9 deficiency
  • intrinsic issue resulting in prolonged PTT
  • deep tissue bleeding

-factor 9 infusion , NO desmopressin

158
Q

Von Willebrand Disease Hallmarks

A
  • Ineffective platelet adhesion due to autosomal dominant issue with vWF
  • Mucocutaneous bleeding, PETECHIAE
  • Intrinsic issue resulting gin prolonged PTT
  • VWF, Factor 8, desmopressin for tx
159
Q

American Society of Anesthesiologists (ASA) Classes

A

ASA 1—patient with no systemic disease
ASA 2—pt with mild systemic disease
ASA 3—pt with severe systemic disease that limits activity
ASA 4—pt with incapacitating disease that is a constant threat to life
ASA 5—pt is moribund and not expected to survive 24 hours

160
Q

Cardiac Meds that can be continued the day of surgery

A

BB, A2 agonist, CCB, statin

161
Q

GI meds that can be continued the day of surgery

A

H2 blocker, PPI

162
Q

When to hold anticoagulants ?

A

ASA-7 days
anti-platelets: 7 days
NOAC: 3 days high risk, 2 days low risk
Coumadin: stop 5 days prior and bridge with heparin

163
Q

How long should you hold SSRI before surgery ?

A

3 weeks

164
Q

Post op fluid management

A

4:2:1 Rule

  • 4mL/hr for the first 10 kg
  • 2mL/hr for the next 10kg
  • 1mL/hr for additional kg
165
Q

Post Op fluid resucitation in an elderly patient

A

25 mL/kg in a 24 hr period

166
Q

When is dialysis indicated

A

GFR <10

Cr >8

167
Q

What surgery predisposes a patient to hypomagnesemia ?

A

small bowel bypass

168
Q

How does hypomagnesemia present?

A

Signs of hypocalcemia

Neuro s/s: increased DTRs, tetany, AMS, cramps

Torsades

169
Q

Treatment of hypomagnesemia

A

magnesium sulfate

170
Q

How does hypermagnesemia present?

A

N/V, flushing, dizziness, decreased DTR, muscle weakness

May show EKG signs of hyperkalemia

171
Q

MC causes of hypermagnesemia

A

1) Renal Insufficiency

2) increased Mg intake

172
Q

Treatment of hypermagnesemia

A

IV fluids, furosemide (mild to moderate)

Calcium gluconate ( severe)

173
Q

Hypokalemia findings

A

K<3.5
Muscle weakness, rhabdo, decreased DTR, nephrogenic diabetes insipidus

Flattened T waves/U waves

  • INCREASED RISK OF DIGOXIN TOXICITY
174
Q

Causes of hyperkalemia

A

***psuedohyperkalemia: MC cause… this is a lab error where vile was shaken… not true hyperK

1) AKI or CKD: decreased excretion
2) Meds: k sparing diuretics, ACE, BB, NSAID
3) decreased aldosterone: adrenal insufficiency
4) Cell lysis
5) metabolic acidosis

175
Q

Hyperkalemia findings

A

K>5
Ascending weakness, paresthesias, flaccid paralysis
Peaked T waves

176
Q

To of uncomplicated UTI

A
  • Nitrofurantoin (macrobid) *used in pregnancy
  • fluoroquinolone *DOC in pyelo
  • Bactrim

** 3 days is normal dose!

177
Q

Do not exceed this rate of sodium replacement for a patient with hyponatrimia

A

no faster than 0.5 mEq/L per hour to prevent central pontine myelinolysis

178
Q

Clinical symptoms of hyponatremia

A

faitgue, headache, n/v, cramps, seizures, coma, respiratory arrest

179
Q

Two man categories of testicular cancer

A

1) Germinal cell tumors:
- seminoma
- nonseminomatous

2) Nonterminal Cell Tumors:
- Leydig cell tumor
- Sertoli cell tumor

180
Q

Characteristics of seminoma type testicular cancer

A

-MC in men 30-30, useually malignant

Simple; normal tumor markers
Sensitive; to radiation
Slow; slow to grow
Stepwise spread

-Treat with orchiectomy and radiation (+ debunking chemo if severe)

181
Q

Characteristic of nonseminomatous testicular cancer

A
  • Germinal Cell type
    • alpha fetoprotein, inc. B-HCG
  • RADIORESISTANT
182
Q

Presentation of renal cell carcinoma

A
  1. hematuria
  2. flank pain
  3. palpable mass

-left sided varicocele, HTN, hypercalcemia

183
Q

Where is a renal cell tumor located?

A

Proximal convoluted renal tubule cells

184
Q

Risk factors for renal cell carcinoma

A
  • smoking
  • dialysis
  • HTN
  • obesity
  • men
185
Q

What is the MC type of bladder cancer?

A

Transitional cell is 90%

186
Q

Risk factors for bladder cancer

A

SMOKING

  • occupational exposure to dyes, rubber, leather
  • 3x more common in white males
187
Q

2 medications with an increased risk of bladder cancer

A
  • Cyclophosphamide

- Pioglitizone

188
Q

dx & tx of bladder cancer

A
  • Painless gross hematuria
  • cystoscopy with bx
  • transurethral resection
  • radical cystectomy if invasive
  • intravesicular BCG vaccine if recurrent
189
Q

What is another name for wilms tumor?

A

nephroblastoma

190
Q

Hallmarks of Wilms tumor

A
  • MC abdominal malignancy in children
  • 1st 5 years of life
  • MC presents as a painless palpable mass that doesn’t cross the midline
  • Hematuria, HTN, anemia, n/v
191
Q

dx and tx of Wilms Tumor

A

1st ultrasound
2nd CT or MRI contrast

-Nephrectomy followed by chemotherapy (90% cure rate)

192
Q

Risk factors for kidney stones

A 
Dec. water intake
male sex
medications (loop, antacids, chemo) 
gout 
PCKD 
UTI (with urea splitting organisms)-Struvite
193
Q

4 types of kidney stones

A

1) calcium (normal ph)
2) Uric acid (high protein foods, acidic)
3. Struvite (urea splitting bacteria, alkaline)
4. Cystine stones (congenital, acidic)

194
Q

What are the urea splitting bacteria?

A

Proteus, klebiella, pseudomonas, serratia, enterobacter

195
Q

Nephrolithiasis location and associated pain

A

Proximal ureter: flank pain

Midureter: midabdominal pain

Distal Ureter (VUJ) : groin pain

196
Q

Which stones appear on KUB?

A

calcium, struvite

197
Q

How to treat nephrolithiasis

A

IF LESS THAN 5mm:

  • IVF, analgesic, antiemetics
  • Tamulosin **

IF GREATER THAN 7mm:

  • extracorporeal shock wave lithotripsy
  • uretoscopy with stent (immediate relief)
  • Percutaneous nephrolitotomy (over 10mm or strive stone)
198
Q

What is the narrowest point of the urinary tract?

A

ureterovesicular junction

199
Q

Etiologies of toxic colon

A
  • IBD
  • ischemic cholitis
  • infective cholitis
  • diverticulitis
  • volvulus
  • obstructive colon cancer
200
Q

Management of toxic mega colon

A

IVF
Fix underlying dz
Vancomycin and metronidazole
NG rube decompression and bowel rest

201
Q

Anatomical structures around a femoral hernia (through femoral canal)

A
  • femoral vein laterally
  • lacunar ligament medically
  • coopers ligament below
202
Q

How do you make the diagnosis of renal artery stenosis?

A

renal arteriography

203
Q

Management of renal artery stenosis

A
  1. angioplasty with stent for definitive management
  2. ACEi
    * *This is contraindicated if BOTH KIDNEYS INVOLVED
204
Q

Where does lung cancer MET to?

A 
Brain
bone
Liver
Lymph 
Adrenals
205
Q

3 types on non small cell carcinoma

A

1) adenocarcinoma
2) squamous call
3) large cell

206
Q

Key features to non- small cell adenocarcinoma

A
  • MC type in nonsmokers and females
  • PERIPHERAL
  • presents with gynecomastia
  • surgical resection
207
Q

Key features to squamous cell carcinoma

A
  • CENTRALLY located
  • Cavitary lesions
  • hyperCalcemia
  • pancoast syndrome (tumor at the superior sulcus causing :
    1) shoulder pain
    2) horners syndrome
    3) atrophy of hand muscles
208
Q

Small cell carcinoma key features

A

1) SVC syndrome: dilated neck veins, facial plethora, prominent chest veins
2) SIADH(hyponatrimia)
3) Cushing syndrome
4) lambert Eaton syndrome (like MG but weakness improves with use)
* chemo is TOC no surgery

209
Q

What is the MC cause of post op fever day 1?

A

Atelectasis

210
Q

What does a pseudomonas infection look like?

A

blue green with a fruity smell

211
Q

What types of fluid cause a pleural effusion

A

1) Purulent fluid (empyema)
2) Blood (hemothorax)
3) noninflected fluid secondary to bacterial pneumonia ( parapneumonic effusion)
4) lymphatic fluid (chylothorax)

212
Q

Physics exam findings in a pleural effusion

A

DECREASED tactile fremitus,
DECREASED breath sounds
DULLNESS to percussion

213
Q

CXR findings in pleural effusion

A

blunting of costophrenic angles

Lateral decubitus film is best

214
Q

What is light’s criteria for exudative effusions?

A
  • LDH>.6
  • Protein >.5
  • LDH 2/3 upper limit of normal
215
Q

Treatment of pleural effusion

A

1) treat underlying condition
2) Thoracentesis
3) Chest tube for drainage
4) Pleurodesis : obliteration of pleura space with talc (MC) or doxycycline

216
Q

Tension pneumothorax Physical exam

A

JVP, pulsus paradoxus, hypotension

217
Q

Fibrocystic breast disease presentation

A

-Tender, mobile nodules that change in size around the time of menstrual period

MC benign breast dz

-typically 30-50 y/o

218
Q

What does fibrocystic breast disease look like on fine needle aspiration?

A

straw-colored fluid with no blood

219
Q

Fibroadenoma of the breast presentation

A
  • 2nd MC benign breast dz
  • Late teens to early 20s
  • NONtender, mobile, gradually grows over time, does not fluctuate with menstruation
220
Q

Types of breast cancer

A

Infiltrative ductal carcinoma (MC)

Ductal carcinoma in situ

Infiltrative lobular carcinoma

Lobular carcinoma in situ

221
Q

Presentation of breast cancer

A

Firm, non mobile, painless lump

  • MC in upper outer quadrant
  • Unilateral nipple discharge, may be blood
222
Q

Pages disease of the breast

A

chronic eczematous itchy, scaling rash on the nipples and areola

223
Q

Inflammatory breast cancer

A

red, swollen, WARM, itchy breast.

  • often with Peau d’orange appearance due to lymphatic obstruction
  • poor prognosis
224
Q

Neoadjuvant Endocrine therapy for ER positive breast cancer

A

1) Anti-estrogen drugs
- Tamoxifen, Raloxifene

2) Aromatase Inhibitors
- Letrozole, Anastrozole

225
Q

Neoadjuvant endocrine therapy for HER2 + breast cancer

A

Monoclonal Ab treatment

-Trastuzumab (Herceptin)

226
Q

Breast cancer screening

A

Mammography every 2 years if 50-74 y/0

227
Q

Breast cancer prevention in high risk patients

A

SERM therapy with tamoxifen or raloxifene

228
Q

How long post-op is dehissence MC?

A

5-8 days

229
Q

Common causes of post-op hyponatremia

A

1) Excess Sodium Loss
- Thiazide diuretics
- Metabolic alkalosis
- Ketoacidosis
- Adrenal insufficiency

2) Artifact- uncommon
Hyperproteinemia
Hyperlipidemia

3) Excess water- very common
Ingestion or infusion of hypotonic fluids when isotonic fluids are lost, polydipsia
Physiologic response to surgical stress or hypovolemia
Catabolism of tissue damaged in surgery
SIADH

Advanced cardiac, renal or liver disease

230
Q

Hyperkalemia treatment

A
  • calcium gluconate
  • 10 U regular insulin
  • albuterol
  • Amp D50
  • Dialysis
231
Q

What increases a patient’s risk of post-op atelectasis ?

A
  • COPD
  • Obesity
  • abdominal surgery
  • Increased age
232
Q

Signs of atelectasis

A

Post-op fever in the first 48 hrs

  • Tachycardia
  • Tachypnea
  • Hypoxia

-may have pleuritic chest pain

233
Q

Post-op pneumonia is often caused by what organisms?

A
  • Gram negatives (which colonize the oropharynx)

- often polymicrobial

234
Q

Possible etiologies of Post-Op dyspnea

A

1) Pneumonitis: 2/2 aspiration of gastric secretions
2) Pnemothorax
3) Pulmonary Embolus
4) Extrapulmonary causes: acidosis, MI, sepsis, CHF

235
Q

Hypoxic vs. Hypercapnic Post-Op respiratory failure

A

Hypoxic: failure of oxygenation; requires an increase in the Fi02

Hypercapnic: failure of ventilation ; requires an increase in the minute volume

236
Q

Risk factors for development of a post op MI

A
  1. hz of CHF
  2. CAD
  3. over 70 y/o
  4. Surgery for arteriosclerosis manifestation

**hypoxia and hypotension in the post op period will predispose the patient to MI

237
Q

What percentage of post of MI is asymptomatic

A

OVER 50 %

238
Q

Ways to prevent Post-Op MI

A

1) postpone elective surgury 3-6 months after MI
2) aggressively treat CHF preoperatively
3) HTN controll

239
Q

Most common cause of post op CHF?

A
  • Excessive IV fluids to a patient with a limited myocardial reserve
  • suspect in patient with hypoxia and dyspnea
240
Q

Post-Op CHF presents with edema where?

A

sacral edema

241
Q

Etiologies of post of hypotension

A
  1. vasodilation from narcotics
  2. blood loss
  3. 3rd spacing of fluid
242
Q

Causes of post op ileus

A
  • anesthesia and surgical manipulation decrease gut action

- worsened by opioids, infection, inflammation (pancreatitis) , pain

243
Q

How long post of does it typically take for peristalsis and colonic function to return ?

A

Peristalsis: 24 hrs (at least 48 in abdominal laparotomy)

Colonic function: 3-5 days

244
Q

Post-op ileus presentation and treatment

A
  • n/v, obstipation, constipation, distension, pain

- NG tube, and consult the surgeon

245
Q

Who gets a foley pre op?

A
  • operation over 3 hrs
  • large IV fluid volumes to be given
  • pt unable to ambulate post op
246
Q

Definition of Oliguria

A

UOP <30cc/hr

OR

<400mL/day

247
Q

What is the goal glycemic control on random glucose checks for a general surgery patient?

A

<180-200

**we let it be higher due to post op hypoglycemia

248
Q

Signs of likely post op infection

A
  • fever occurs over 48 hrs post op
  • Pre-Op trauma
  • Initial temp above 101.5
  • leukocytosis over 10,000
  • Post-op BUN of 15 or more
  • Poor protoplasm
249
Q

The 5 W’s of post op fever

A

WIND: atelectasis, pneumonia, PE, aspiration with pneumonitis

WATER: UTI, IV infected

WOUND: infection, after day 4

WALKING: DVT, PE

WONDER DRUG

250
Q

Drugs associated with post op fevers (wonder drug)

A
  • Beta-lactamase antibiotics
  • procainamide
  • isoniazid
251
Q

S/S of post op necrotizing Fasciitis

A

pain out of proportion to exam, swelling, fever, hemorrhagic skin bull, cellulitis

252
Q

necrotizing fasciitis treatment

A
  • aggressive surgical debridement at least within 6 hrs onset
  • broad spectrum abx
  • hyperbaric O2
253
Q

Organisms Causing necrotising fasciitis

A
  • Group A strep
  • klebsiella
  • E. coli
  • other gram - bacteria

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