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General Surgery Cards Flashcards

1
Q

Cardiology requisites for surgery

A

EF>35, there can’t be JVD

No MI in the last 6 months

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2
Q

What is more important ventilation or oxygenation? What must be done before surgery?

A

Ventilation. Smoking cessation 8 weeks before surgery.

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3
Q

Childs Pugh Score components,

Mortality for any 1, mortality for all?

A

Albumin, PT/PTT, Bilirubin, Ascites, Encephalopathy
40% mortality for 1,
100% mortality for 5

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4
Q

Nutritional requisites for surgery?

A

Can’t have lost 20% of body weight in last 3 months, albumin must be higher than 3, must pass skin anergy test.

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5
Q

How to diagnose malnutrition?

A

Look at prealbumin and CRP. If prealbumin is low, then malnutrition. If prealbumin is normal then liver disease.

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6
Q

General categories of things that cause post-operative fever

A

Wind, water, walking, wound, wonder drugs

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7
Q

Fever during surgery

A

Malignant hyperthermia, treat with dantrolene O2, and IVF. Elicit family hx before anesthesia

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8
Q

Fever right after surgery

A

Bacteremia, diagnose with blood cultures, treat with antibiotics

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9
Q

Fever POD1 (dx, ppx)

A

Atelectasis, diagnose with CXR, no tx, ppx with incentive spirometer and OOB

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10
Q

Fever on POD2 (Dx Tx Ppx)

A

Pneumonia, dx with CXR, tx with abx (vanc, zosyn), ppx with incentive spirometer and OOB.

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11
Q

Fever on POD3 (dx, tx, ppx)

A

UTI, dx with Ua and culture, tx with ABX, ppx by removing foley

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12
Q

Fever on POD5 (dx, tx, ppx)

A

DVT/PE, dx with LE US, tx with hep/coumadin, ppx with heparin

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13
Q

Fever on POD7

A

Wound infection, ultrasound is negative for abscess, give abx, ppx with sterile field

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14
Q

Fever on POD10

A

Wound abscess, ultrasound positive for abscess, I and D plus abx, sterile field and clean.

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15
Q

Differential for postoperative AMS?

A

Electrolyte abnormalities, hypoxia, DT, ARDS

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16
Q

Which electrolyte abnormalities cause altered mental status?

A

Na or Ca

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17
Q

How does ARDS present?

A

CXR white out, give PEEP, tumultuous course.

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18
Q

Delerium tremens

A

Patient 48-72 hours after drink presents with tremulousness and delerium, htn, tachycardia. Treat with benzos

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19
Q

Algorithm for postoperative low urine output?

A

If less than 0.5ml/kg/hour, ask if patient has urge to void. If yes, then there’s an obstruction. Place an in and out cath. If no urge, then it’s renal failure. Check to see if there’s any output. If none at all, the foley is kinked (flush and unkink). If there’s some output, give the patient a 500cc bolus. If he puts out, it was prerenal. If no change, then intrarenal pathology.

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20
Q

Three things that cause postoperative abdominal distention?

A

Obstruction, paralytic ileus, ogilvie’s

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21
Q

Presentation of paralytic ileus.

A

Starts on POD1, patient has no flatus or stool.

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22
Q

How to diagnose ileus?

A

Diagnose with KUB. Will show small and large bowel distention.

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23
Q

How to treat paralytic ileus?

A

Get patient moving and eating.

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24
Q

Potassium and paralytic ileus

A

Ileus is worse with hypokalemia, watch K levels and replete as necessary.

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25
Pathogenesis of postoperative obstruction?
Adhesions or hernias
26
When to suspect obstruction?
When patient has ileus to POD5.
27
How to diagnose obstruction?
Get a KUB. Will show proximal distention only. Distal is compressed.
28
How to treat abdominal obstruction?
Emergency surgery.
29
Ogilvie's syndrome
Postoperative ileus in elderly after big surgery, but not abdominal surgery. Causes massively dilated colon.
30
How to treat ogilvie's syndrome
Rectal tube and colonoscopy. IV neostigmine once mechanical obstruction is ruled.
31
Dehiscence
Failure of fascia to close properly and wound splits open.
32
How to patients with wound dehiscence present?
With hernia and serosanguinous drainage.
33
How to treat dehiscence?
Bind wound and limit straining. Elective OR repair.
34
Evisceration
Failure of whole wound to close, loops of bowel protruding.
35
How to treat evisceration?
Surgical emergency. DO NOT PUSH BACK IN. Warm saline and dressings with bedrest until OR.
36
Fistula
Epithelialized tract
37
Things that prevent fistula closure
FETID | Foreign body, epithelialization, tumor, IBD/irradiation/inflammation, distal obstruction.
38
How to treat fistulas
LIFT procedure. Nutritional support and protection of wound.
39
What causes unconjugated bilirubinemia
Hemolysis, hematoma
40
What causes both conjugated and unconjugated bilirubinemia
Genetic syndromes, hepatitis
41
What causes primarily conjugated bilirubinemia
Obstruction. Patient will have dark urine and clay stools.
42
How to diagnose gallstones
RUQ US shows pericholecystic fluid.
43
How to treat gallstones
ERCP with elective cholecystectomy.
44
Pancreatic cancer symptoms
Migratory thrombophlebitis, painless jaundice.
45
How to diagnose pancreatic/cholangiocarcinoma?
Esophageal ultrasound with biopsy.
46
How to treat pancreatic cancer
Whipple procedure (pancreaticoduodenectomy)
47
How do patient's with ampullary cancer present?
With positive FOBT
48
How to diagnose ampullary cancer?
ERCP with biopsy.
49
How does small bowel obstruction occur?
Hernias or adhesions
50
How do patients with SBO present?
With colicky abdominal pain, constipation, high pitched bowel sounds that disappear.
51
How to diagnose SBO?
KUB showing air fluid levels, then CT Scan with barium enema.
52
How to treat incomplete obstruction?
Watch and wait, unless patient is floridly peritoneal, then do emergency surgery. If no change in 3 days, go to surgery.
53
How to treat complete bowel obstruction?
Go to surgery
54
How to treat suspected bowel obstruction if patient has peritoneal signs?
Emergency surgery
55
Signs of acute abdomen?
Fever, leukocytosis, rebound tenderness, involuntary guarding.
56
Direct hernia
Seen in adults, bowel passes directly through Hesselbach's triangle
57
Hesselbach's triangle
Bounded by rectus, inguinal ligament, and inferior epigastric artery.
58
Indirect hernia
Seen in babies, hernia passes through inguinal ring.
59
Femoral Hernia
Seen in females, bowel passes under inguinal ligament.
60
Ventral hernia
Iatrogenic, happens post op
61
Algorithm for abdominal bulge
Do a physical exam and see if it's reducible. If yes, then schedule elective surgery. If not, then hernia is incarcerated and patient must have urgent surgery. If patient has peritoneal signs, then hernia is strangulated and emergency surgery must be performed.
62
Does a CT need to be performed to diagnose appendicitis?
No, diagnosis can be made on clinical signs alone.
63
Symptoms of carcinoid syndrome?
Flushing, diarrhea, wheezing, right heart fibrosis with elevated JVP.
64
How to diagnose carcinoid syndrome?
24 hour urine 5-HIAA
65
Pancreatitis algorithm?
Epigastric pain that radiates to the back? Check a lipase amylase. If 3xULN, then pancreatitis. Give IVF, NPO, Pain control.
66
When to get CT scan with pancreatitis?
If hemoglobin drop and low ranson. If early satiety, ascites, dyspnea weeks later. If fever, leukocytosis still persists days later.
67
Complications of pancreatitis that can be observed with CT scan
Pseudocyst, pancreatic abscess, necrotizing pancreatitis.
68
How to treat necrotizing pancreatitis?
Give penem drugs, do a daily CT, ICU, drain.
69
How to treat pseudocyst?
If >6cm and >6weeks, drain. If
70
How to treat pancreatic abscess?
Give antibiotics and drain.
71
Pathogenesis of anal fissure
Tight sphincter rips posteriorly, causes painful defecation.
72
How to treat anal fissure temporarily and definitively?
Temporarily with sitz baths and nitroglycerin cream. Definitively with lateral internal sphincterotomy.
73
What types of patients get anal cancer?
Anoreceptive sex, MSM, HIV+
74
How to diagnose anal cancer?
Anal pap, biopsy
75
How to treat anal cancer?
Chemo and radiation (nigro protocol).
76
Pilonidal cyst
Abscessed hair follicle
77
How to teat pilonidal cyst
i and D, resect.
78
Different types of visceral abdominal pain
Obstruction, inflammation, perforation, ischemia, distention
79
Abdominal pain of obstruction. What causes it?
Colicky, high pitched bowel sounds, no fever, no WBC. Gallstones, kidney stones, sbo.
80
Abdominal pain of inflammation? What causes it?
Constant, no comfort, + fever + WBC. caused by cholecystitis, diverticulitis, appendicitis
81
Abdominal pain of perforation. What causes it
Pain can't move. Peritoneal. XR shows free air. Caused by PUD, cancer, penetrating injury.
82
Abdominal pain of ischemia. What causes it?
Pain out of proportion to physical exam. Patient is a vasculopath. Bloody BM.
83
Distension
Referred pain, diffuse, vague.
84
Stage 1 ulcers
Only through epidermis, nonblanching erythema
85
Stage 2 Ulcers
Through epidermis and hypodermis
86
Stage 3 ulcers
Through to fascia
87
Stage 4 ulcers
Involve muscle or bone.
88
Pressure ulcer locations
Sacrum, ankles knees, heels, shoulders/elbows.
89
Diabetic ulcer location
Toes and heels.
90
Arterial insufficiency ulcer appearance of skin and location
Toes, skin is hairless and shiny.
91
How to treat arterial insufficiency
Exercise and smoking cessation
92
Venous insufficiency ulcer location. Skin appearance
On medial malleolus. Skin is hyperpigmented and indurated.
93
Marjolin ulcer pathogenesis
Squamous cell carcinoma, patient has a chronic wound with repeated healing/breakdown, or a continuous draining tract.
94
How does a marjolin ulcer look?
Heaped up margins, ugly
95
How to treat marjolin ulcer?
Wide resection.
96
Pathogenesis of breast cancer
Estrogen (early menarche, nulliparity, late menopause, HRT) Genes - BRCA 1 and @ Radiation (for lymphoma)
97
How do patients with breast cancer present?
During asymptomatic screen, with a breast lump, or with s/s breast cancer (skin dimpling, fixed node, mass).
98
Screening for mammograms?
q2 starting at 50
99
How do diagnose breast cancer?
Mammogram with finding -> core biopsy or FNA in young women.
100
Step if
Wait 1 or 2 cycles to see if it changes
101
Step if
U/S
102
Step if
FNA (blood, pus, fluid)
103
>30 or mass or bloody or recurrant mass?
Biopsy
104
How to treat breast cancer (local, systemic, targeted)
Local = lumpectomy + radiation + sentinal LN biopsy (with possible axillary lymph node dissection Systemic = chemo (doxo, cyclophosphamide, paclitaxel). Targeted therapy- her2neu + trastuzumab Her2neu - bevacizumab ER/PR +? Tamoxifen/raloxifene
105
Side effect of doxorubicin vs trastuzumab
Doxorubicin causes irreversible dose dependent CHF | Trastuzumab causes reversible dose independent CHF.
106
Tamoxifen vs raloxifene?
Tamoxifen increases risk of endometrial cancer but is more effective in breast. Raloxifene does not have increased risk of endometrial cancer. `
107
What is the cause of perioperative MI during procedure?
Usually hypotension. Mortality of MI associated with surgery is much higher than non-surgery MI
108
Can you treat periopertive MI with TPA?
NO WAY, use stent or heparin
109
Blood gases for PE
Hypoxemia and hypocapnia
110
Pathogenesis and treatment of intraoperative pneumothorax
Can happen during surgery in a patient with blunt trauma and broken ribs once PEEP has been established. Treat with needle decompression through the diaphragm if the abdomen is open. If not, go to thorax.
111
Common source of coma in cirrhotic patient with bleeding esophageal varices?
Ammonia intoxication
112
How to treat hemorrhoids?
hemorrhoidectomy or banding
113
Best medication for anal fissure?
CCB ointment (diltiazem)

Surgery Clerkship (11 decks)

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