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Surgery > Gren Surg Georgetown 3/4/17 > Flashcards

Gren Surg Georgetown 3/4/17 Flashcards

1
Q

what is pneumatosis intestinalis

A

gas cysts in the bowel wall

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2
Q 
Cellcept
generic
category
MOA
uses
contraindications
BBW
BW
A

mycophenolate
immunosuppresant
# cytostatic to B and T lymphos by inhib IMPDH inosine monophosphate dehydrogenase, thereby inhibiting guanosine nucleotide sythesis and proliferation
-renal, cardiac, hepatic transplants
-off-label refractory autoimmune hepatitis, lupus nephritis, myasthenia gravis, psoriasis
CI drug hypersensitivity, allergy to polysorbate 80…
BBW inc infection risk
BW inc lymphoma and skin malignancy risk

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3
Q 
Prograf
generic
category
MOA
uses
contraindications
BBW
BW
A 
tacrolimus
immunosuppressant (calcineurin inhibitor)
inhib T lympho activation by binding to FKBP-12 protein and complexing with calcineurin dependent proteins to inhibit calcineurin phosphatase activity (basically, calcineurin activates T cells and tacrolimus blocks that)
-prevent transplant rejection
-GVHD, uveitis
CI hsn to formulation
BBW - inc infection
BW - lymphoma, skin malignancy inc risk
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4
Q

define incisura of stomach

A

angle made by lesser curvature and antrum (pyloric antrum)

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5
Q

3 things that tell stomach to make acid

A

vagal input
gastrin
histamine

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6
Q

what to worry about when reducing say 50% of abdominal contents chronically externalized eg into the scrotum

A

loss of domain

must re-expand abdomen sufficiently before reducing contents

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7
Q

father of surgical outcomes measuring for quality improvement

A

ernest codman

surgeon in boston

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8
Q

blood supply to breast

A

-internal thoracic - from subclavian
(aka internal mammary)
-perforators from intercostals (from aorta running around posteriorly
-lateral thoracic - from axillary, continuation of subclavian

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9
Q

lymphatic drainage of breast

A

75% to axillary nodes

some to internal mamary nodes

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10
Q

levels of axillary lymph nodes

A

I - lat/inf to pec minor
II - post to pec minor
III - medial ot pec minor

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11
Q

what happens if you cut the long thoracic nerve

A

scapular winging

lost serratus anterior

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12
Q

what happens if you cut the thoracodorsal nerve

A

lose abduction ^90deg… climbing wall, combing hair

lost latissumus dorsi

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13
Q

how are long thoracic and thoracodorsal nerves orientated to each other

A

parallel down side
long thoracic to serratus anterior more ant
thoracodorsal to lat mor post

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14
Q

what happens if you cut the intercostobrachial nerve

A

lose sensation to medial arm
-second intercostal nerve does not divide like others into ant and post branches, just called the intercostobrachial nerve and crosses axilla into the medial side of the arm

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15
Q

what happens if you cut the lateral pectoral nerve

A

some pec weakenss

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16
Q

nerves of the axilla

watch out for them in breast surgery

A

Long thoracic to serratus ant
thoracodorsal to lat
intercostobrachial to med arm
lateral pectoral to pec

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17
Q

overview of breast exam

A

upright and supine
arm over head or pressing on waist to move pec
inspection palpation discharge axilla cervical supraclavicular infraclavicular
(nodules and nodes)

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18
Q

2 mammography views

A

axial
MLO medial-lateral oblique
(to see axillary tail, make sure you see pec so you know you have seen all of axillary tail)

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19
Q

do breasts become more or less dense with age

A

less - less milk producing

usually

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20
Q

characterize benign breast calcifications on mammography

A

scattered
large
monomorphic

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21
Q

characterize cancerous calcifications on mammography

A

clustered
pleomorphic
unstable over time

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22
Q

what is breast tomosynthesis

A

multiple slices like CT for better detection of invasive breast cancer
less compression because better resolution

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23
Q

first test for palpable breast mass or mass on mammography (not calcifications)

A

breast ultrasound
dense mass will shadow
cyst will enhance posteriorly

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24
Q

when to get breast MRI

A

screen HIGH RISK pts
eval KNOWN BREAST CANCER - eg for neoadjuvant chemo to eval response
SETTLE other equivocal tests

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25
Q

read breast MRI

  • round, not enhancing
  • peripheral enhancement, irregular edge
  • very irregular, spiculated, enhancing, edema, satellite masses
A 
-round, not enhancing
FIBROADENOMA
-peripheral enhancement, irregular edge
BREAST CANCER WITH CENTRAL NECROSIS
-very irregular, spiculated, enhancing, edema, satellite masses
VERY BAD BREAST CANCER
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26
Q

BI-RADS

A

0 Incomplete assessment
1 Negative; routine mammo in 1 year
2 Benign finding; routine mammo in 1 year
3 Suspicious abnormality; short-term follow-up
4 Suspicious abnormality; biopsy, risk of malignancy 35-65%
5 Highly suggestive of malignancy, 95%
6 Known malignancy

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27
Q

who gets a screening mammogram

A

40-44yo - debated
45-55 - annually… debated
55-75 - every other year
75+ every other year if life expectancy ^10y

BRCA 1 or 2+ - biannual CBE q6mos starting 25yo or 10y prior to earliest age of onset in family

  • alternate MRI & mammo (mammo only if ^30)
  • screen for ovarian ca w US and CA-125 beginning age 35
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28
Q

how to biopsy breast mass

A

mammographically detected - stereotactic core needle bx

ultrasound detected - us guided core needle biopsy

MRI detected - MRI guided core needle biopsy… correlated to MRI, NOT LIVE… because can’t use metal needle in mri…

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29
Q

what is a stereotactic biopsy

A

use of xrays in MULTIPLE PLANES (2 views at least) to guide biopsy

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30
Q

% of breast cancer
sporadic
familial
hereditary

A

sporadic 70%
familial 20% (fam hx)
hereditary 10% (gen mut ID’d)

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31
Q

most impressive known risk factor for breast cancer

and what is the relative incidence of breast and ovarian

A

BRCA1 BRCA2

breast cancer
12% non-mut women get breast cancer in life
60% BRCA1 get by age 70
45% BRCA2 get by age 70

ovarian cancer
1.3% non-mut women get in life
50% BRCA1 get by age 70
20% BRCA2 get by age 70

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32
Q

who to refer for genetic testing for breast cancer

A

ashkenazi jew
1st degree fh breast cancer v50yo
2x+ 1st or 2nd degree fh breast cancer any age
fh male breast cancer
hx ovarian cancer in pt or 1st or 2nd degree relative

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33
Q

how much breast cancer is epithelial

how much ductal vs lobular

A

95% epithelial

more ductal than lobular

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34
Q

most common breast cancer and how is it detected usually

A

25% DCIS

usually found via clustered microcalcifications on mammography

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35
Q

XRT stands for..

A

xray therapy
radiotherapy
radation therapy
RT

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36
Q

treatment options for breast cancer

A

mastectomy with sentinal lymph node biopsy

breast conservation (limited resection) with XRT (ranges from intraop to 5-6 wks duration postop..)

endocrine therapy (ER/PR +)

chemo (age size grade nodes receptors mets)

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37
Q

what is Paget’s disease of the nipple and what should your reflex be

A

DCIS of nipple

get detailed breast imaging because 97% assoc w underlying breast cancer

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38
Q

radical mastectomy
vs
modified radical mastectomy

A

radical - take breast, pec major, lymph node levels I-III

modified radical - just take breast and lymph nodes I and II… we now know taking the pec and III is not necessary so don’t perform full radical anymore

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39
Q

tf

nipple preserving mastectomy preserves sensation

A

f

just cosmetic preservation

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40
Q

tf

most mastectomies don’t need radiation

A

t

usually adjuvant XRT for breast sparing resection not mastectomy

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41
Q

when can nipple sparing mastectomy be performed

A

ppx surgery

tumors away from the nipple

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42
Q

how is the sentinel lymph node identified

A

blue dye

and radioisotope

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43
Q

tf

if sentinel node is negative there is no need for axillary dissection for breast cancer

A

t

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44
Q

3 aromatase inhibitors

A

anastrozole
letrozole
examastane

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45
Q

tamoxifen vs anostrozole
demographic for use
side effects

A

tamoxifen for premenopauseal, ER antag in breast but ag elsewhere… so inc endometrial ca, dvt/pe, hot flashes, vaginal bleeding, etc

anostrozole aromatase inhib… for postmenopausal… no endometrial ca DVT hot flashes bleeding… but inc bone fractures and bone pain msk pain

46
Q

pronounce the orange thing in breast cancer

-and what does it signify

A

“Poh di-oranj”

-inflammatory breast cancer… from lymphatic infiltration and obstruction, swelling, ligaments of cooper intact

47
Q

tf

must rule out mets in locally advanced breast cancer

A

t
bone (ER+ espec)
liver brain (triple neg epec)
lung

48
Q

tf

imaging to screen brain for breast cancer mets

A 
f
diplopia
headache
dizziness
clinically apparent, no need for imaging
49
Q

tf

vegan diet is cholesterol free

A

t

no animals = no livers = no cholesterol = cholesterol free

50
Q

WHY are gallstones assoc w forty fat female fertile

A

because they change cholesterol metabolism, and change can precipitate stones

51
Q

what makes gallbladder contract

A

cck

52
Q

what causes acute cholecystitis

and how do you treat

A

block of cystic duct (GB to CBD)

cholecystectomy

53
Q

complete the sentence

“pus under pressure….”

A

makes you sick; general surgeons drain pus”

54
Q

Charcot’s triad for an abdominal thingy

Raynaud’s pentad for…

A

cholangitis
fever RUQ pain jaundice

hypotension and AMS
(dec urine too)
septic shock
(inflammatory mediators should be sent out by the liver, but it gets overwhelmed)

SO act on charcot’s triad to avoid raynaud’s pentad

55
Q

safety of ERCP in charcot’s pentad vs Raynaud’s triad

A

if Raynaud’s pentad (fever RUQ pain jaundice HYPOTENSION AMS)
sign liver overwhelmed by inflammatory mediators… ERCP involves injection of dye to make sure in bile duct not pancreatic duct… can force a bolus of inflammatory mediators into body and kill pt via shock)

56
Q

this disease is like MS of the liver
how so
how to treat

A

PSC
primary sclerosing cholangitis

multiple scleroses at different times and spaces - beads on a string

treat with steroids for immunosupression, consider UC association…

57
Q

treat cholangiits

A

iv abx IVF NPO
ERCP to remove stone / blockage
cholecystectomy once recovered to prevent more stones from causing

58
Q

PBC
alternate names
antibody test
treat

A 
primary biliary cirrhosis
primary biliary cholangitis
AMA anti-mitochondrial antibody
UDCA ursodeoxcholic acid
(dec bile secretion for stones but inclear why it helps in PBC..)
staroids... chemo.... transplant
59
Q

segments of liver

A

7 8 | 4a 2

6 5 | 4b 3

60
Q

describe the branches of the hepatic duct backward form common hepatic duct from 6 oclock clockwise

A

R hepatic duct
inferior branch to 6 and 7
superior branch to 5 and 8
-but branch to 5 hooks over 67 common branch and 5 is proximal right lower segment

Left hepatic duft
brances to 4….
branches to 2 superiorly and 3 inferiorly

61
Q

pt w afib, how to manage anticoagulation for surgery

A

d/c warfarin 5 days prior
bridge w lovenox till 24hrs prior

if lovenox CI because CKD, bridge w heparin

62
Q

3 common indications for warfarin therapy

A

afib
dvt
mechanical valve

63
Q

what is the difference between subq and iv heparin inpatient…

A

sq for ppx

iv for therapeutic – also nice that you can turn off/on on a dime eg for limb patient w frequent surgery

64
Q

pt npo for surgery… how to manage insulin

A

continue long acting at 1/2 dose (still blood sugar from glycogenolysis, cortisol stress response…)

don’t take short acting obviously that is only with meals and the pt is npo

65
Q

mnemonic for communicating sensitive news

A

SPIKES

  • setting (turn off beeper, have kleenex available, ask for privacy unless pt prefers otherwise)
  • perception
  • invitation
  • knowledge (send shot across bow fist .. e.g. it’s not what we hoped for…)
  • empathy
  • summary
66
Q

air pressures for laparoscopy vs thorascopy

A

15mmhg for lap

v5mmhg for thora because higher will compress vena cava

67
Q

what did the iron lung do

A

provided negative pressure for breathing when the chest was open, eg kids with TB

68
Q

Ranson criteria

A 
Hour 0
age ^55
wbc ^16
glucose ^200
LDH ^350
AST ^250
Hour 48
hematocrit v 10 points
BUN ^ 5 ponts
Ca v8
PaO2  v60
base deficit ^4
fluid sequestration ^6L
1-3 mild pancreatitis... like 10% mort
4+ significantly inc mortality
(purpose to predict mortality risk from acute pancreatitis)
say 4-7 30% mort
^7 0% mort
69
Q

explain glucose in Ranson criteria

A

glucose^200
marker of acute inflammation (stress)
also, pancratitis can’t secrete insulin

70
Q

explain age in Ranson criteria

A

^55yo
less able to withstand a code… just more accumulated physiologic insults to heart vs a younger person who can withstand a code better

71
Q

why is it called the pancreas

A

pan (all)
creas (flesh)

feeds all flesh
digests all flesh

72
Q

conceptually define pancreatitis

A

inflammation damaging body as collateral in trying to prevent pancreatic enzymes from eating the body

73
Q

explain wbc in Ranson criteria

A

wbc^16

inflammation, not infection

74
Q

explain AST in Ranson criteria

A

AST^250
first pass effect of inflammatory cytokines, liver gets overwhelmed, can’t digest them fast enough, gets damaged
-not just biliary back up, that would make alk phos elevated…

75
Q

explain LDH in Ranson criteria

A

LDH^250
marker of cell lysis
(there are 5 subtypes of LDH… 1 is cardiac specific… the others are just systemic inflammatory markers)

76
Q

explain Ca in Ranson criteria

A

pancreatic lipase converts TAGs to FFAs
leaks into peripancreatic fat in pancreatitis
FFAs are divalent anions
bind readily to available divalent cations - Calcium Ca++
= fat saponification
looks like buckshot on imaging

77
Q

explain hct in Ranson criteria

A 
v10 points
(NOT 10%... not 4 points... 10 percentage points)
bleeding from splenic artery or gastroduodenal artery, or gastric varix from splenic vein thrombus)

take straight to IR for embolizaiton if hemorrhagic artery…. splenectomy to treat upper GI bleed from gastric varix from splenic vein thrombosis from pancreatitis

78
Q

explain O2 in Ranson criteria

A

PaO2v60

from ARDS from inflammatory cytokines… getting into lungs…?

79
Q

“3” fluid spaces of body

relative sizes

A

1st space intracellular
2nd space intravascular and intra-CSF and intra-synovial etc
3rd space extra both… interstitial

1st space intracellular is 2/3 TBW

3rd space is smallest… like 1/3 of remaining 1/3 so like 1/9 TBW

80
Q

explain BUN in Ranson criteria

A

dehydration
from third spacing
from inflammatory craziness
so kidney retaining urea for countercurrent multiplier

81
Q

explain base deficit in Ranson criteria

A

eg HCO2 v 4

from lactic acidosis… from shunting centrally… according to Jackson

82
Q

explain fluid sequestration Ranson criteria

A

from 3rd spacing from inflammation

83
Q

treat acute pancreatitis

A

ride out the storm
batton down the hatches
supportive care

84
Q

diagnose pancreatitis

A

classic pain pattern
elevated lipase
cross sectional imaging shows inflammation

need 2/3 of above to dx

85
Q

what kind of CT to get for diverticulitis

A

CT w PO contrast

-don’t get PO for diverticular or other GI BLEED, will obscure therapeutic options aka IR intervention

86
Q

which attack is usually the worst in diverticulits

A

the first one

87
Q

is diverticulitis usually from true or false diverticula

A

false diverticula (mucosa thru muscular wall at vasa recta…. not true full thickness mucosa and muscle balooning out - that is congenital usually)

88
Q

pathogenesis of appendicitis vs diverticulitis

A

appy - obstruction of apendiceal orifice eg by fecolith, and engorgement of lymphatics…

diverticulitis - micro perforations…

89
Q

why doesn’t diverticulitis extend to the rectum

A

because teniae coli coalesce into full circumference outer longitudinal muscle layer at rectum… no muscular wall weakness for microperfs

90
Q

how many lower gastrointestinal bleeds are from diverticulum

A

~40%

from ruptured vasa recta

91
Q

tf

upper gi bleed is never bright red per rectum

A

f

can be, if a very brisk bleed

92
Q

how to continually assess airway in trauma pt

A

interview

get history, keep them talking

93
Q

5 areas hemorrhage can cause shock

A 
chest
peritoneum
retroperitoneum
thighs
floor

large enough

94
Q

GCS

A

4eye spont verb pain none
5verbal oriented confused inappropriate incomprehensible none
6motor obeys localizes withdraws decorticate decerebrate none

95
Q

how many IVs to start in trauma pt

A

2 large bore peripheral IVs

avoid obviously injured extremity if possible

96
Q

infusion rate of 1L crystalloid fluids

A

wide open 30min
pressure bag 15min
level one infuser 5 min

97
Q

top 5 causes of shock in trauma pt

A 
bleeding
bleeding
bleeding
bleeding
bleeding
98
Q

4 types of shock

A

hypovolemic
septic
cardiogenic
neurogenic

99
Q

classes of hemorrhage

A

0-15% blood loss
15-30% blood loss
30-40% blood loss
^40% blood loss

class I II III IV
think tennis scoring 15 30 40
100
Q

signs and symptoms, treatment of class I hemorrhage

A

v15% (750cc) loss
-minimal clinical signs
not even tachy above 100
no measurable bp, pulse, respiratory change… like anna kournakova looks striking doesn’t pack a punch
-No iVF needed, blood restored by natural compensatory mechanisms within 25hrs

101
Q

signs and symptoms, treatment of class II hemorrhage

A

15-30% (750cc-1.5L) loss

  • inc cc - inc pvr, tachy hr^100, dec pulse pressure, tachypnea 20-30, subtle cns anxiety fright hostility, mild dec urine output
  • stabilize with crystalloid, may eventually require transfusion
102
Q

signs and symptoms, treatment of class III hemorrhage

A

30-40% (1.5-2L) loss
tachy hr^120, tachypnea 30-40, hypOtensive, cns sig anxious combative, marked urine dec
-colloid and blood resuscitation, stop source of hemorrhage

103
Q

signs and symptoms, treatment of class IV hemorrhage

A

^40% 2L blood loos

  • life-threatening, marked tachy hr^140, marked tachypnea ^40, dec systolic BP, very narrow pulse pressure or unattainable diastolic bp, negligible urine output, depressed mental status, cold pale
  • rapid transfusion, immediate surgery… 50% loss means loss of consciousness pulse and blood pressure
104
Q

basics of treating any significant bleed

A

stop bleeding
replace volume lost
resolve base deficit
normalize lactate

105
Q

lethal triad of trauma

A

acidosis makes hypothermic (by dec heart performance…) makes coagulopathic

106
Q

blood volume is what % of body weight

A

7%

so ~5L in 70kg person

107
Q

guidelines for volume resuscitation in trauma

A

1L crystalloid
2 units blood for adults
10cc/kg for kids
start with O (+ because - rare and expensive not always available) uncrossmatched
give type specific or crossmatched bloodwhen available

108
Q

highest GCS score when intubated

A

11t
4 eyes
6 motor
1(t) verbal because intubated

109
Q

highes GCS score when paralyzed

A

3pt
lowest score is 3
nonresponsive eyes verbal motor
intubated

110
Q

why is it called a tension pneumo

A

because HYPOTENSION

Surgery (22 decks)

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