General Surgery Flashcards
Treatment of pancreatic pseudocyst
6 and 6 rule: 6 weeks and 6 cm. If < 6 weeks and < 6 cm, you just wait and watch, then repeat the CT in 2 weeks to assess for resolution.
Failure to resolve in 6 weeks, or larger than 6 cm warrants intervention.
How to prevent hospital acquired pneumonia?
The only way to prevent this is to get the patient BREATHING; this is done with Incentive Spirometry which reminds the patient to open up their lungs.
What is a Marjolin ulcer?
It is cancer
ulcer that can be anywhere and repeatedly breaks and drains but never heals
Needs wide resection following biopsy.
Breast cancer treatment
Her2Neu positive –> Trastuzumab
ER/PR positive–> if pre-menopausal use SERMS (Raloxifene) or post-menopausal use Aromatase-inhibitors (Anastrozole)
SERMs and Aromatase-inhibitors are never combined
What is Ogilvie syndrome?
REALLY OLD patient who also has TOTAL COLONIC DILATION
Get a rectal tube for decompression or neostigmine
What is Paralytic Ileus?
Most common thing following surgery. It just means the body hasn’t caught up yet. The ENTIRE GI SYSTEM will be dilated. The patient just needs to move around and eat, while we need to correct their potassium.
No urine post surgery management
6 hours without a void post-op warrants an in-and-out cath to assess for post-residual voids. If high, leave catheter. If low, give fluids. If all else fails, look for intrinsic renal disease.
Treatment for DVT/PE
Day 5 post-op a DVT/PE is likely
Use an ultrasound to diagnose and a heparin drip to coumadin bridge to treat DVT
CT scan to diagnose and a heparin drip to coumadin bridge to treat PE
Treatment for patient with peritoneal sign
“Air under the diaphragm” means “ruptured hollow viscous” and equals “peritoneal sign,” which means “acute abdomen.” Any of those words means to immediately go to exploratory laparotomy.
Young healthy female with breast lump
In a woman with no risk factors (<30, no history of cancer or radiation, no family history to suggest BRCA 1/2) a breast lump doesn’t need investigation; it’s likely related to the menstrual cycle and needs 1 or 2 cycles to pass to see what happens.
Colicky flank pain without leukocytosis and without fever that radiates to the groin
Flank pain that radiates to the groin and is associated with hematuria is a kidney stone.
Diagnose it with a CT scan of abdomen without contrast.
Post op fever day 10
Probably an abscess
Make sure with ultrasound or CT scan
What is Ranson criteria?
Estimate mortality in patients with acute pancreatitis
11 parameters,5 assessed at admission and 6 more during the next 48 hours
higher score= worse mortality
Treatment for patient with necrotizing pancreatitis actively worsening into ARDS?
Pancreatitis can lead to ARDS.
Early intubation, PEEP, and proning (prone positioning) can save their life.
CT scan of pancreas and FNA biopsy to confirm infection
THEN IV meropenem
Treatment for anal fissures
Get them to poop regularly by using sitz baths, botulinum, and topical lidocaine
Docusate and senna to soften stool
Lateral internal sphincterotomy is the ultimate therapy for when medications fail.
Management of Partial bowel obstruction
Complete bowel obstruction is treated with emergent surgery, partial bowel obstruction is treated with conservative measures (NG tube, IV Fluid, NPO)
Management of compartment syndrome in the abdomen
Leave the abdomen open, let the swelling go down, and try to close later
leave it open with temporary absorbable mesh (wound vac)
Management of diverticulitis
Fever, leukocytosis and acute abdomen
Diverticulitis is a perforation of the diverticula
1st diagnose w/ CT scan with IV contrast
Treat w/ IV ciprofloxacin (gram -) and metronidazole (anaerobes)
Older person with progressive, painless jaundice, weight loss, and a smoking history
Most likely diagnosis is pancreatic cancer
1st- CT scan…..if (+)
THEN endoscopic ultrasound which allows us to visualize the mass through the lumen of the gut and take directed biopsies for confirmatory diagnosis.
Only cancers diagnosed by removal are
Renal cell carcinoma
Lymphoma
Testicular cancer
No biopsies are performed, only resection, and we use that as our “biopsy”
Patient with right-sided valvular fibrosis, diarrhea, and hot flashes / flushing
Classic for carcinoid
Carcinoid is an intestinal neuroendocrine tumor that releases serotonin.
Serotonin is metabolized by the liver and the lungs, thus why it must metastasize to become symptomatic, and it also explains why only the right sided heart valves are affected
Diagnose with Urinary 5-HIAA
Management of pyogenic abscess
Pyogenic abscess - a bacterial abscess in the liver
Complication of ascending cholangitis
Antibiotics are insufficient on their own to cure the abscess.
tx: Drainage of the abscess, aspiration of the pus, and culture and sensitivities from the aspirate to target antibiotic treatment
Treatment of echinococcus
Liver abscess
Open resection of the lesion
Risk of anaphylaxis is great should the cyst rupture
Treatment of Entamoeba Histolytica
Entamoeba Histolytica causes liver abscess
Drawing titers for ameba first THEN treat with metronidazole
Fever and leukocytosis after a bout of acute pancreatitis is likely to be from?
Pancreatic abscess
Do CT scan to find out
Treatment is surgical drainage and antibiotics
elevation of the UNconjugated bilirubin is indicative of
Hemolysis- Only way to get an acute onset of an elevated, unconjugated bilirubin is hemolysis
Start with blood smear to find type of hemolysis going on
Days after surgery and Post op fever
Day 1: Atelectasis
Day 2: Pneumonia
Day 3: UTI
Day 5: DVT
Day 7+: Wound
Combination of obstructive jaundice and heme-positive stool
Lesion that could both obstruct the lumen of the biliary tree and bleed into the lumen of the GI tract is AMPULLARY CANCER
Require an ERCP for visualization and biopsy. It is curable with resection.
Acute cholecystitis on ultrasound
Pericholecystic fluid, thickened gallbladder wall, and gallstones
Fever, leukocytosis, and a positive Murphy’s sign, and there will be no elevation of the bilirubin (since the stone is in the cystic duct and not in the common bile duct)
RUQ cancer on ultrasound
Distended, thin-walled gallbladder with biliary dilatation
pruritus, jaundice, and no pain
weight loss, dark urine, or clay-colored stools.
Acute choledocholithiasis on ultrasound
Dilated biliary tree, no obstructing stone (will not be visible on US but need ERCP), gallstones in the gallbladder
Painful jaundice, elevated bili especially Direct, no fever, no leukocytosis, no inflammation,
Cardiotoxic breast cancer chemotherapy
CHF is a side effect of breast cancer chemotherapy; early, reversible disease is caused by Trastuzumab while late, irreversible disease is caused by a dose-dependent cardiotoxicity by Doxorubicin or Daunorubicin.
AST and ALT are in the thousands. What causes this?
- Acetaminophen overdose
- Acute viral hepatitis
- Autoimmune hepatitis
- Shock liver (hypotensive ischemic hit)
- Budd-Chiari
- Aflatoxin (death-cap mushrooms)
What is the Child- Pugh scoring system?
Score for Cirrhosis Mortality
Components of the Child-Pugh score are serum albumin, bilirubin, INR, and the presence of ascites and encephalopathy.
Any single derangement on the Child-Pugh scoring system is a marker for 30% mortality. Decompensated liver disease has a high perioperative mortality.
Breast cancer screening recommendations for patients at high risk
Very high risk patients receive MRI screening annually. Look for a history of Hodgkin’s Lymphoma with Mantle Radiation or BRCA1/2 carriers who have not yet had a mastectomy.
