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Surgery Clerkship > General Surgery Cards > Flashcards

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
Q

Pathogenesis of postoperative obstruction?

A

Adhesions or hernias

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26
Q

When to suspect obstruction?

A

When patient has ileus to POD5.

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27
Q

How to diagnose obstruction?

A

Get a KUB. Will show proximal distention only. Distal is compressed.

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28
Q

How to treat abdominal obstruction?

A

Emergency surgery.

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29
Q

Ogilvie’s syndrome

A

Postoperative ileus in elderly after big surgery, but not abdominal surgery. Causes massively dilated colon.

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30
Q

How to treat ogilvie’s syndrome

A

Rectal tube and colonoscopy. IV neostigmine once mechanical obstruction is ruled.

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31
Q

Dehiscence

A

Failure of fascia to close properly and wound splits open.

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32
Q

How to patients with wound dehiscence present?

A

With hernia and serosanguinous drainage.

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33
Q

How to treat dehiscence?

A

Bind wound and limit straining. Elective OR repair.

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34
Q

Evisceration

A

Failure of whole wound to close, loops of bowel protruding.

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35
Q

How to treat evisceration?

A

Surgical emergency. DO NOT PUSH BACK IN. Warm saline and dressings with bedrest until OR.

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36
Q

Fistula

A

Epithelialized tract

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37
Q

Things that prevent fistula closure

A

FETID

Foreign body, epithelialization, tumor, IBD/irradiation/inflammation, distal obstruction.

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38
Q

How to treat fistulas

A

LIFT procedure. Nutritional support and protection of wound.

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39
Q

What causes unconjugated bilirubinemia

A

Hemolysis, hematoma

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40
Q

What causes both conjugated and unconjugated bilirubinemia

A

Genetic syndromes, hepatitis

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41
Q

What causes primarily conjugated bilirubinemia

A

Obstruction. Patient will have dark urine and clay stools.

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42
Q

How to diagnose gallstones

A

RUQ US shows pericholecystic fluid.

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43
Q

How to treat gallstones

A

ERCP with elective cholecystectomy.

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44
Q

Pancreatic cancer symptoms

A

Migratory thrombophlebitis, painless jaundice.

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45
Q

How to diagnose pancreatic/cholangiocarcinoma?

A

Esophageal ultrasound with biopsy.

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46
Q

How to treat pancreatic cancer

A

Whipple procedure (pancreaticoduodenectomy)

47
Q

How do patient’s with ampullary cancer present?

A

With positive FOBT

48
Q

How to diagnose ampullary cancer?

A

ERCP with biopsy.

49
Q

How does small bowel obstruction occur?

A

Hernias or adhesions

50
Q

How do patients with SBO present?

A

With colicky abdominal pain, constipation, high pitched bowel sounds that disappear.

51
Q

How to diagnose SBO?

A

KUB showing air fluid levels, then CT Scan with barium enema.

52
Q

How to treat incomplete obstruction?

A

Watch and wait, unless patient is floridly peritoneal, then do emergency surgery. If no change in 3 days, go to surgery.

53
Q

How to treat complete bowel obstruction?

A

Go to surgery

54
Q

How to treat suspected bowel obstruction if patient has peritoneal signs?

A

Emergency surgery

55
Q

Signs of acute abdomen?

A

Fever, leukocytosis, rebound tenderness, involuntary guarding.

56
Q

Direct hernia

A

Seen in adults, bowel passes directly through Hesselbach’s triangle

57
Q

Hesselbach’s triangle

A

Bounded by rectus, inguinal ligament, and inferior epigastric artery.

58
Q

Indirect hernia

A

Seen in babies, hernia passes through inguinal ring.

59
Q

Femoral Hernia

A

Seen in females, bowel passes under inguinal ligament.

60
Q

Ventral hernia

A

Iatrogenic, happens post op

61
Q

Algorithm for abdominal bulge

A

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
Q

Does a CT need to be performed to diagnose appendicitis?

A

No, diagnosis can be made on clinical signs alone.

63
Q

Symptoms of carcinoid syndrome?

A

Flushing, diarrhea, wheezing, right heart fibrosis with elevated JVP.

64
Q

How to diagnose carcinoid syndrome?

A

24 hour urine 5-HIAA

65
Q

Pancreatitis algorithm?

A

Epigastric pain that radiates to the back? Check a lipase amylase. If 3xULN, then pancreatitis. Give IVF, NPO, Pain control.

66
Q

When to get CT scan with pancreatitis?

A

If hemoglobin drop and low ranson. If early satiety, ascites, dyspnea weeks later. If fever, leukocytosis still persists days later.

67
Q

Complications of pancreatitis that can be observed with CT scan

A

Pseudocyst, pancreatic abscess, necrotizing pancreatitis.

68
Q

How to treat necrotizing pancreatitis?

A

Give penem drugs, do a daily CT, ICU, drain.

69
Q

How to treat pseudocyst?

A

If >6cm and >6weeks, drain. If

70
Q

How to treat pancreatic abscess?

A

Give antibiotics and drain.

71
Q

Pathogenesis of anal fissure

A

Tight sphincter rips posteriorly, causes painful defecation.

72
Q

How to treat anal fissure temporarily and definitively?

A

Temporarily with sitz baths and nitroglycerin cream. Definitively with lateral internal sphincterotomy.

73
Q

What types of patients get anal cancer?

A

Anoreceptive sex, MSM, HIV+

74
Q

How to diagnose anal cancer?

A

Anal pap, biopsy

75
Q

How to treat anal cancer?

A

Chemo and radiation (nigro protocol).

76
Q

Pilonidal cyst

A

Abscessed hair follicle

77
Q

How to teat pilonidal cyst

A

i and D, resect.

78
Q

Different types of visceral abdominal pain

A

Obstruction, inflammation, perforation, ischemia, distention

79
Q

Abdominal pain of obstruction. What causes it?

A

Colicky, high pitched bowel sounds, no fever, no WBC. Gallstones, kidney stones, sbo.

80
Q

Abdominal pain of inflammation? What causes it?

A

Constant, no comfort, + fever + WBC. caused by cholecystitis, diverticulitis, appendicitis

81
Q

Abdominal pain of perforation. What causes it

A

Pain can’t move. Peritoneal. XR shows free air. Caused by PUD, cancer, penetrating injury.

82
Q

Abdominal pain of ischemia. What causes it?

A

Pain out of proportion to physical exam. Patient is a vasculopath. Bloody BM.

83
Q

Distension

A

Referred pain, diffuse, vague.

84
Q

Stage 1 ulcers

A

Only through epidermis, nonblanching erythema

85
Q

Stage 2 Ulcers

A

Through epidermis and hypodermis

86
Q

Stage 3 ulcers

A

Through to fascia

87
Q

Stage 4 ulcers

A

Involve muscle or bone.

88
Q

Pressure ulcer locations

A

Sacrum, ankles knees, heels, shoulders/elbows.

89
Q

Diabetic ulcer location

A

Toes and heels.

90
Q

Arterial insufficiency ulcer appearance of skin and location

A

Toes, skin is hairless and shiny.

91
Q

How to treat arterial insufficiency

A

Exercise and smoking cessation

92
Q

Venous insufficiency ulcer location. Skin appearance

A

On medial malleolus. Skin is hyperpigmented and indurated.

93
Q

Marjolin ulcer pathogenesis

A

Squamous cell carcinoma, patient has a chronic wound with repeated healing/breakdown, or a continuous draining tract.

94
Q

How does a marjolin ulcer look?

A

Heaped up margins, ugly

95
Q

How to treat marjolin ulcer?

A

Wide resection.

96
Q

Pathogenesis of breast cancer

A

Estrogen (early menarche, nulliparity, late menopause, HRT)
Genes - BRCA 1 and @
Radiation (for lymphoma)

97
Q

How do patients with breast cancer present?

A

During asymptomatic screen, with a breast lump, or with s/s breast cancer (skin dimpling, fixed node, mass).

98
Q

Screening for mammograms?

A

q2 starting at 50

99
Q

How do diagnose breast cancer?

A

Mammogram with finding -> core biopsy or FNA in young women.

100
Q

Step if

A

Wait 1 or 2 cycles to see if it changes

101
Q

Step if

A

U/S

102
Q

Step if

A

FNA (blood, pus, fluid)

103
Q

> 30 or mass or bloody or recurrant mass?

A

Biopsy

104
Q

How to treat breast cancer (local, systemic, targeted)

A

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
Q

Side effect of doxorubicin vs trastuzumab

A

Doxorubicin causes irreversible dose dependent CHF

Trastuzumab causes reversible dose independent CHF.

106
Q

Tamoxifen vs raloxifene?

A

Tamoxifen increases risk of endometrial cancer but is more effective in breast.
Raloxifene does not have increased risk of endometrial cancer. `

107
Q

What is the cause of perioperative MI during procedure?

A

Usually hypotension. Mortality of MI associated with surgery is much higher than non-surgery MI

108
Q

Can you treat periopertive MI with TPA?

A

NO WAY, use stent or heparin

109
Q

Blood gases for PE

A

Hypoxemia and hypocapnia

110
Q

Pathogenesis and treatment of intraoperative pneumothorax

A

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
Q

Common source of coma in cirrhotic patient with bleeding esophageal varices?

A

Ammonia intoxication

112
Q

How to treat hemorrhoids?

A

hemorrhoidectomy or banding

113
Q

Best medication for anal fissure?

A

CCB ointment (diltiazem)

Surgery Clerkship (11 decks)

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