General surgery Flashcards
Cardiac contraindications of elective surgery
EF < 35%
MI < 6 months ago
Smoker who needs an elective surgery. What is the recommendation before going into surgery?
Smoking cessation 8 weeks before surgery + nicotine patch
Patient with fever during the surgery.
Dx, tx, and ppx?
Malignant hyperthermia
Tx: O2, dantrolene, cool IV
Ppx: Ask personal or family Hx to bad reaction to anesthesia
Patient with fever right after surgery.
Dx, next step, tx?
Bacteremia
Next step: Blood culture
Tx: Vancomycin+ piptazo
Patient with fever at POD #1
Dx, next step, ppx?
Atelectasis (wind)
Next step: CxR (negative for pneumonia)
Ppx: Incentive spirometry, patient out of bed
Patient with fever at POD #2
Dx, next step, Tx, ppx?
Pneumonia (wind)
Next step: CxR (positive)
Tx: Vancomycin+ piptazo
Ppx: Incentive spirometry, patient out of bed
Patient with fever at POD #3
Dx, next step, ppx?
UTI (water)
Next step: U/A, urinary culture
Ppx: Foley out ASAP
Patient with fever at POD #5
Dx, next step, Tx, ppx?
DVT, PE (walking)
Next step: Dooppler of lower extremities
Tx: Heparin to warfarin bridge
Ppx: LMWH, patient out of bed
Patient with fever at POD #7
Dx, next step, ppx?
Cellulitis (wound)
Next step: U/S (negative for an abscess)
Ppx: Sterile field, keeping wound clean
Patient with fever at POD #10–14
Dx, next step, tx, ppx?
Abscess (wound)
Next step: U/S (positive for an abscess)
Tx: Abx + incision and drainage
Ppx: Sterile field, keeping wound clean
Patient in POD #3 with chest pain and test suggestive of MI.
Tx?
PCI, heparine
tPA is contraindicated
Patient in POD #5 with chest pain, you rule out MI but suspect PE.
What tests you need?
ABG, lower limbs U/S, CT scan
Causes of altered mental status in a post-op patient
Electrolytes, sundowning (delirium), ARDS, and delirium tremens.
Normal urinary output in a post-op patient
> 0.5 cc/kg/hr
Post-op Patient with decreased urinary output who has a distended bladder. Next step?
In-and-out cath or foley
Post-op Patient with decreased urinary output with no urine in bladder. Next step?
500 cc bolus. If improvement, then hydrate. If no change, then intrinsic renal failure
Post-op Patient with cero urinary output. Next set?
Obstruction.
Unkink the catheter
Patient in POD 1-2, no poop, no gas.
Erect KUB shows dilation everywhere. Dx and tx?
Ileus
IVF, K, move patient
Patient in POD 5, no poop, no gas. Erect KUB (air-fluid levels, dilation proximal to obstruction). Dx and tx?
Obstruction
NG tube, surgery again
Old patient in post op with abdominal distension, no poop, no gas. Erect KUB (normal small bowel, distended large bowel).
Dx, tx?
Ogilvie
Rectal tube, colonoscopy
Patient in post-op, loups of bowel pop out of the surgical wound.
Dx, next step?
Evisceration
- Warm saline dressings
- NEVER push it back in
- Emergent surgery
Patient with painful jaundice, mild fever, mild leucocytosis, ↑AST, ↑ALT, ↑amylase, (+) murphy.
RUQ U/S showing dilated ducts
Dx, next step, tx?
Choledocholithiasis
Next step:
• MRCP
Tx:
• NPO, IVF, IV antibiotics
• Urgent ERCP (Endoscopic Retrograde Cholangio-Pancreatography)
• Elective cholecystectomy
Patient primary sclerosing cholangitis, who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.
Ct scan shows cholangiocarcinoma.
Next step and tx?
ERCP + Bx
Tx: resection
Patient with migratory thrombophlebitis, who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.
Dx, Next step and tx?
Pancreatic cancer
Next step: Endoscopic US with Bx
Tx: whipple procedure
Patient who has jaundice, no fever, normal WBC, negative murphy, no abdominal pain.
Negative CT scan, positive fecal blood test, negative colonoscopy
Dx, Next step and tx?
Ampullary cancer
Next step: ERCP + Bx
Tx: resection
Patient with stricture of the biliary tree. Tx?
Stenting*
*Except if Dx of primary sclerosing cholangitis, in which case the Tx is ursodeoxycholic acid while waiting for liver transplant
Alarm sx of GERD
- Nausea, vomiting
- Anemia
- Weight loss
If alarm signs, EGD + Bx
Patient with “nocturnal asthma” (wheezing, coughing only at night).
Dx, next steps, tx?
GERD
Next steps:
- If no alarm style: lifestyle modifications and PPI
- Alarm sx or no improvement: EGD + Bx
- Gold standard: 24-hr pH monitor
Tx:
- PPI
- Metaplasia: High-dose PPI Nissen Fundoplication
- Dysplasia: Ablation
- Adenocarcinoma: resect
- Nissen fundoplication could be used in any context
Patient refers knot or ball of food stuck in the GE junction.
Barium swallow (bird’s beck deformity)
Dx, next steps, tx?
Achalasia
Next steps:
- Manometry to confirm
- EGD + Bx to rule out pseudo-achalasia (cancer)
Tx:
- Myotomy
- Botox or dilation if not a surgical candidate
Patient with progressive disphagia
Barium swallow (asymmetric mass)
Dx, next steps, tx?
Adenocarcinoma
Nex steps:
- EGD + Bx to confirm
- Tx: resection
Mallory-Weiss vs Boerhaave’s
Mallory-Weiss: superficial tear in the mucosa of esophagus
Boerhaave’s: transmural tear
Patient who was drinking this weekend and now is vomiting blood.
Dx, tx?
Mallory-Weiss
Treat like upper GI bleed
- 2 large bore IV
- IVF
- IV PPI
- Type and cross, transfuse as needed
- Call GI
Patient with Hx of bullimia who is vomiting blood. She has crepitus chest, crunching, rasping sound, synchronous with the heartbeat.
Dx, next steps, tx?
Boerhaave’s, potential mediastinitis
Dx:
- Gastrograffin swallow, if negative…
- Barium swallow, if negative….
- EGD
Tx: Surgery
Patient with colicky abdominal pain, no gas, no stool, Borborygmi sounds, abdominal distension.
No peritoneal findings
Dx, next steps, tx?
Small bowel obstruction
Nest steps:
- 1st: upright KUB showing air-fluid levels
- 2nd: CT scan
Tx:
- If incomplete obstruction: NG tube, IVF, K+ management
- If complete: Surgery
If develops peritoneal sings: Emergent surgery
Types of hernias according to location
- Direct: Male adults, goes through the muscle
- Indirect: baby males, through the inguinal ring
- Femoral: female, under the inguinal ligament
- Ventral: Iatrogenic, post-op, failure of fascia to close
Management of a hernia
- Reducible: elective sx
- Irreducible (incarcerated): Urgent sx
- Acute abdomen (strangulated): emergent sx
Periumbilical pain, Pain goes to McBurney’s point, Anorexia, N/V
Dx
Appendicitis
No dx step needed, but CT scan is often performed in real life (not the answer in the test)
Flushing, Wheezing, Diarrhea, Right-sided cardiac fibrosis.
Dx, next steps, tx?
Carcinoid
Next steps:
- Urine 5-HIAA
- CT scan to identify lesions
Tx: resect
Patient with Epigastric abdominal pain, Bore to back, Positional (hurts more if lean backwards), N/V.
Dx, next steps, tx?
Acute Pancreatitis
- Lipase is better than amylase
- CT scan is not generally needed (only if enzimes (-) and you’re sure it’s pancreatitis)
• Also used for complications
-RUQ U/S and triglycerides aren’t for Dx but for etiology (done after Dx is confirmed and tx initiated)
Tx:
-NPO, IVF, pain meds
Patient with acute pancreatitis who despite tx has persistent fever and leukocytosis.
Dx, next step, and tx?
Abscess
Next step: CT scan
Tx: abx, drainage
Patient with acute pancreatitis who has early satiety, weight loss, and pain, and ascites.
CT scan shows pseudycyst < 6 cm
Tx?
Uncomplicated pseudocyst
Tx: Wait as it will likely resolve
Patient with acute pancreatitis who has early satiety, weight loss, and pain, and ascites.
CT scan shows pseudycyst > 6 cm
Tx?
Complicated pseudocyst
Tx: Drain
Patient with acute pancreatitis who in addition is hypotensive and in shock.
Dx, next step, tx?
Necrotizing pancreatitis (poor prognosis)
Next step: CT scan
Tx:
- ICU
- Necrosectomy
- Carbapenem if infection confirmed by FNA
Post-menopausal woman or man of any age with iron deficiency anemia.
Dx, next step?
Colon cancer
Next step: Colonoscopy
Patient with alternating diarrhea, constipation and pencil thing stools.
Dx, next step?
Colon cancer
Next step: Colonoscopy
Patient in whom a colonoscopy shows multiple polyps spread in the colon.
Dx, tx?
Familial adenomatous polyposis
Tx: colectomy
Patient in whom a colonoscopy shows cancer
Tx?
CT scan, resection, chemo (folfox) + radio
Patient with anal bleeding without pain. You suspect internal hemorrhoid.
Next step and tx?
Next step: anoscopy
Tx: banding
Patient with anal pain without bleeding. You suspect external hemorrhoid.
Tx?
Resecting if creams and sits baths don’t work
Risk factors and tx of anal cancer
- “Like cervical cancer of the anus;” HPV causing squamous cell carcinoma
- Anal receptive sex
- MSM
- HIV +
Tx: chemo and radiation regardless of stage
Patient with Colicky abdominal pain, No fever, Normal WBC. Type abdominal pain and examples of causes?
Obstructive
E.g., cholelithiasis, nephrolithiasis
Patient with Constant abdominal pain, fever, and ↑ WBC. Type of and pain?
Inflammatory
E.g., cholecystitis, pyelonephritis
Patient in shock, with constant abdominal pain, and motionless. Type of and pain?
Perforation
E.g., peptic ulcer disease, cancer, penetrating trauma
Patient with Pain out of proportion, Bloody bowel movement, and Sepsis.
Dx?
Mesenteric ischemia
Causes of RUQ pain
Lung
Diaphragm
Liver
Gallbladder
Get U/S
Causes of Epigastric pain
MI Aorta Esophagus Pancreas stomach
Causes of LUQ pain
Lung
Diaphragm
Spleen
Get CT + contrast
Causes of diffuse abd pain
Constipation
DKA
Mesenteric ischemia
Causes of RLQ pain
Kidney / ureters
Ovaries / testes
Colon = appendix
Get CT + contrast
Causes of Supra pubic pain
Bladder
uterus
Causes of LLQ pain
Kidney / ureters
Ovaries / testes
Colon = diverticula
Get CT + contrast
Stages of legs ulcers
i: non-blanching erythema
II: Epidermis and partial dermis
III: Through epi and dermis (fascina is exposed)
IV: Muscle/bone exposed
Bed-ridden, Wheelchair patient with ulcers in the sacrum.
Dx, tx?
Compresion ulcer
Roll the person q2h, out of bed, air-mattresses, wound care
Diabetic patient with ulcer in feet.
Tx and ppx?
Tx:
- Control DM
- Elevate legs
- Wound care
- Amputate
Ppx:
- Loose shoes (diabetic shoes)
- Inspection
- Monofilament test
Patient with ulcer on Tips of toes. Hairless legs, Scales, Absent pulses.
Dx, next steps, tx?
Arterial insufficiency
Dx:
- Ankel-brachial infex
- Limbs U/S
- Angiogram
Tx:
- Stent
- Bypass
Patient with ulcer in Medium malleolus. Edema, Hyperpigmentation, and Induration.
Dx, tx?
Venous insufficiency
Tx:
- Compression stockings
- Elevate legs
- Diuresis
Leg ulcer with sinuous track that breaks and heals over and over.
Dx, next step, tx?
Marjolin’s (squamous cell carcinoma)
Dx: Bx
Tx: wide resection
Risk factors for breast cancer
- Exposure to estrogen (early menarche, late menopause, nulliparity, hormone replacement therapy)
- Hx of Radiation
- BRCA 1 and 2
55 y-o patient with breast lump. Mammogram is positive.
Next step?
Core needle Bx (better than FNA and excisional Bx)
24 y-o patient with breast lump. Next step?
Wait 2 cycles to see if ot resolves alone. If not, get a U/S. If positive findings on U/S, perform FNA.
Local tx of breast cancer?
Radiation + Surgery
• Lumpectomy + axillary lymph node dissection + radiotherapy = mastectomy + axillary lymph node dissection
• Do the sentinel lymph node biopsy before doing the axillary lymph node dissection
Systemic tx of breast cancer?
Chemo
o Doxorubicin
o Cyclophosphamide
o Paclitaxel
Targeted therapy
o Her2Neu (+) (bad prognosis): Traztusumab
o Estrogen/Progesterone receptors:
Pre menopause: Selective estrogen receptor modulators (e.g., tamoxifen)
Post menopause: aromatase inhibitors
Patient with BRCA 1 or 2 (+). Tx?
Bilateral mastectomy + bilateral salpingo oophorectomy
Side effects of tamoxifen?
- DVT
* Endometrial cancer (tamoxifen is estrogen agonist in the uterus)
