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Rotation 1: Surgery > Let's do this! > Flashcards

Let's do this! Flashcards

1
Q

Lipoma

what is it?

1 tx?

A

soft, nontender, moveable mass made of adipose tissue

Tx: excision

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2
Q

Sebaceous/epidermal inclusion cyst

(same thing)

WHATS INSIDE?

COMES FROM?

1 TX?

A

filled with epidermal cells and waxy sebum from blocked sweat gland

**want to tx because it can become infected**

TX:

REMOVE THE ENTIRE SKIN AND THE BLOCKED GLAND OR WILL COME BACK

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3
Q

Breast Cyst

4 wualities?

changes with?

2 dx?

A

Firm, mobile, slightly tender with well defined borders

fluctuates with menstrual cycles

DX:

1. breast US

2. FNA….GREEN COLORED STRAW FLUID

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4
Q

incisional bx

A

partial removal of suspected tissue (takes some tissue)

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5
Q

excisional bx

A

Complete excision of all suspect tissue (mass)

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6
Q

what do you always want to do if there is a dirty wound?

A

evaluate for tetnans vaccination

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7
Q

primary wound closure

A

Close wound immediately with sutures/staples, adhesives etc

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8
Q

secondary wound closure

A

Wound is left open and heals overtime WITHOUT sutures (can have a dressing inside to collect the fluids

Heals by granulation, contraction, and epithelization over weeks

Ex: abcess…don’t want to close it with a ton of bacteria in it

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9
Q

Tertiary (delayed primary closure) would closure

A

Suture the wound closed in 3 to 5 days AFTER incision

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10
Q

How long does it take a wound to epithelize?

A

24-48 hours

48 hours or POD #2 when the dressing can be removed and the patient can take a shower because the wound has epithelized

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11
Q

What is negative pressure wound therapy?

A

Negative pressure system used to accelerate wound healing in chronic and acute

  1. draws edges together
  2. reduces edema
  3. promotes profusion
  4. facilitates formation of granulation tissue
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12
Q

Post op wound infxn

when does this happen?

most common organism?

4 sxs

4 tx

A

POD 5-7, MC staph aureus

SXS:

  1. pain
  2. erythema
  3. drainage
  4. fever

TX:

  1. remove skin, sutures, staples
  2. pack wound open
  3. abx and wound culture
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13
Q

if infxn occurs first 24 hours after surgery, what is the most likely cause?

A

streptococcus

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14
Q

clean wound

A

Elective nontraumatic wound without acute inflammation

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15
Q

clean contaminated wound

A

Operation on the GI tract or respiratory tract without unusual contamination or entry into the biliary or urinary tract

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16
Q

contaminated wound

A

Acute inflammation, traumatic wound, GI tract spillage, major break in sterile technique

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17
Q

dirty wound

A

Pus present, perforated viscus, dirty traumatic wound

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18
Q

what must you do for an abcess?

A

Do I&D–must be drained

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19
Q

what do you do to determine between a cystic and tissue mass in the breast?

A

US

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20
Q

Fibrocystic breast disease

when does this occur?

3 key sxs and 1 finding?

A

women 30-50

sxs:

  1. painful/tender
  2. size fluctuates with menstrual cycle
  3. straw colored fluid with FNA
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21
Q

Fibroadenoma

what is this?

key fact to know about this?

6 key descriptors?

2 dx?

tx options based on size?

A

benign tumor of breast

MC breast tumor in women less than 30

  1. SOLID
  2. FIRM, MOBILE
  3. WELL CIRCUMSCRIBED NONTENDER ROUND

DX:

core bx/FNA or US

TX:

  1. remove if over 3 cm
  2. if less than 3 cm, can go away on their own
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22
Q

where is the most common location of malignant breast neoplasms? 7 key descriptors make you think maligant?

A

UPPER OUTTER QUADRANT

  1. immobile
  2. dimpling
  3. retraction
  4. skin thickening peau d’orange
  5. exzematous changes
  6. ulcerations
  7. palpable nodes
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23
Q

what must you do before treating breast cancer?

A

stage it!

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24
Q

what drug do you use if the breast cancer is ER+ and they are post menopausal?

A

tomoxifen

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25
Q

Ductral carcinoma in situ

what does this lead to?

at risk for?

dx by? 2

3 tx options?

A

becomes invasive ductal carcinoma, at risk for developement in same breast

SXS: NONE

DX: microcalcifications on mammo, confirm with core needle bx or open

TX:

  1. lumpectomy + radiation
  2. mastectomy if polka dots
  3. tomoxifen ER +
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26
Q

Lobular carcinoma in situ

gives rise to?

at risk for cancer in?

how dx?

tx?

A

becomes infiltrating lobular cancer, at risk in BOTH BREASTS

SXS: None

DX: not seen on mammo, found incidentally on bx

TX: close follow up

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27
Q

infiltrating ductal carcinoma

2 descriptors

A

MC breast cancer!! 80%!!!

FIRM, IRREGULAR MASS PE

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28
Q

Infiltrating lobular carcinoma

percent?

A

10 of BC!!

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29
Q

colloid or mucinous carcinoma BC

A

clumps and straings of cells in pools of mucoid material

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30
Q

Inflammatory carcinoma of breast

3 characteristics?

prognosis?

A

EDEMA, ERYTHEMA, and PEAU D’ORANGE

POOR PROGNOSIS, only 25% live past 5 years

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31
Q

Pagets disease

what is this?

3 sxs?

1 dx need?

A

Exudative, dry, sclay appearance of the nipple

SXS:

itching, burning, sticking pain in the nipple

DX: NEED NIPPLE SKIN BX

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32
Q

what are indications for bx?

A

Persistent mass after aspiration

Solid mass

Blood in cst aspirate

Suspicious lesions by mammography/US/MRI

Bloody nipple discharge

Ulcer or dermatitis of the nipple

Pt concern of persistent breast abnormality

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33
Q

when do you do a needle aspiration bx for a breast lump?

A

if it appears to be a cyst

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34
Q

when do you do an open bx for a breast lump?

A

Second cyst recurrence

Bloody fluid in the cyst

Palpable mass after aspiration

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35
Q

what is the #1 RF for lung cancer?

A

SMOKING

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36
Q

Lung cancer

what are the 4 keys sxs?

how do you initially dx? 3

and confirm dx? 3

2 major groups?

A

SXS:

1. new or changing cough

2. hemoptosis

  1. dyspnea
  2. pleural effusions

DX:

  1. CXR/CT
  2. PET
  3. Needle Bx/ bronchoscopy with bx/open lung bx
  4. small cell lung cancer (SCLC)
  5. NON-small cell lung cancer
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37
Q

Small cell lung cancer (SCLC)

what is the type of cancer that fulls under this?

4 qualities?

  • when spreads?
  • tx options?
  • where spreads?
  • find anything else?
A

OAT CELL CANCER

  1. spreads early
  2. can’t tx with surgery!!!
  3. Central to Periphreal
  4. AGGRESSIVE, micrometasis with presentation (hence no surgery)
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38
Q

Non-small cell lung cancer (NSCLC)

3 types?

speed?

tx?

A

slower grower

can have surgery!!

includes:

  1. squamous cell
  2. adenocarcinoma
  3. large cell
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39
Q

NSCLC

sqamous

location?

think what two things?

often presents with?

A
  1. occur centrally
  2. squamous=think “sentrally and SMOKING”
  3. often presents with hemoptosis
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40
Q

NSCLC

adenocarcinoma

what is the KEY fact to know about this one?

location?

speed?

metastasis?

A

**MOST COMMON TYPE OF LUNG CNACER**

  1. occur periphreal
  2. rapid
  3. metasizes to distant organs
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41
Q

NSCLC

large cell

A
  1. large cell
  2. VERY MALIGNANT
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42
Q

what lung cancer arises in nonsmokers?

A

adenocarcinoma

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43
Q

what are the metastasis palces for lung cancer?

5

A

Brain

Bone

Adrenals

Liver

kidney

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44
Q

carcinoid lung mass

what is a key characteristic of this?

what does it look like?

tx?

A

neuroendocrine tumor

*can also be in the GI tract*

bronchoscopy shows red, yellow, purple mass that is well vascularized

tx: surgical ressection

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45
Q

pulmonary coin lesions

what and where are these?

What is the most common cause?

appearance?

2 dx?

how do you determine what to do about them?

A

intraparenchymal lessions LESS THAN 3 cm

MC are infectious granulomas

if round and sharply demarkated don’t need to bx, usually found incidently on imaging

DX:

  1. CXR: popcorn calcicifications
  2. Chest CT

TX:

  1. if low malignancy likelihood round and sharply demarkated can watch and monitor

2. if begins to change or have poor margins then must EXCISE

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46
Q

Appendicitis

what age?

MC cause?

4 key sxs?

5 key signs?

A

MC emergent surgical illness

10-30 y/o MC

patho: obstruction of the appendicieal lumen MC from lymphoid hyperplasia and formation of FECALITH

SXS:

  1. periumbilical pain that goes to RLQ

2. N/V

3. + mcburneys, rovsings, obturator, psoas, heal strike

4. rebound tenderness

5. imvoluntary guarding

**if the patient appeares suddenly better worry about rupture**

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47
Q

Appendicitis

2 dx?

2 tx?

A

DX:

  1. US
  2. CT

TX:

  1. laproscopic appendectomy
  2. 2nd generation cephalosporin
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48
Q

perforated hollow viscus

what is this?

A

Intraperitoneal free air on abdominal xray and abdominal pain

Severe acute abdominal pain

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49
Q

Diverticulitis

what age does this effect?

what is this?

MC location?

RF?

A

50-80 y/o MC

weakness in the bowel wall where blood vessels enter

MC SIGMOID

RF: low fiber diet

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50
Q

Diverticulitis

2 key sxs?

2 dx options? TOC?

tx options?

4 times suregery is appropriate

A

SXS

1. reccurent abdominal pain usuall LLQ

2. combination of bowel bleeding, constipation, diareaah

DX

1. CT IS THE TEST OF CHOICE!!!

  1. colonscopy possible if no acute inflammation

TX:

  1. abx, most heal here
  2. surgery if

A. perforation, obstruction, bleeding, fistula

B. Electively after first episode if young

C. electively for reccurrent

D. hartmans for acute case with complication

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51
Q

what is the most common type of hernia in kids?

A

Indirect

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52
Q

what side is more effected in inguinal hernias?

A

right side

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53
Q

what are 3 RF for inguinal hernia?

A

Chronic cough

Strain with defecation

Heavy lifting

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54
Q

Direct inguinal hernia

where do these occur?

MC in?

A

Occur medial to inferior epigastric through hasselbachs triangle

MC older men

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55
Q

Indirect inguinal hernia

where does this occur?

MC in?

from?

where can it go?

A

occur lateraly to inferior epigastric, MC children

from weakness in the processus vaginalis

**can extend into the testes**

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56
Q

Inguinal hernia

3 sxs?

ways to repair?

A

sxs:

groin bulge

scrotal mass

silk glove sign

TX:

  1. anterior mesh repair (open)
  2. preperitoneal repair (open)
  3. laproscopic repair
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57
Q

Intestinal obstruction

what are the differences between the presentation of L intestine and small intestine?

2

4

what likely causes each?

2

3

A

Large intestine

distention and pain

D/T intussceptions, volvulus, neoplasm

Small Intestine

abdominal pain, distention, vomiting, high pitched bowel sounds that become silent!

D/T hernias and adhesions

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58
Q

where is the most common location for intestinal obstruction?

A

sigmoid colon

59
Q

what is the most common cause for colonic obstruction?

A

ADENOCARCINOME 65%

60
Q

closed loop obstruction

what is this?

3 things?

tx?

A

“complete obstruction”

  1. massive colonic distention
  2. increased risk of perforation
  3. no flatus or stool 8-12 hours

TX: emergency surgery

61
Q

intestinal obstruction

2 dx with 3 key findings?

2 tx options?

A

DX:

  1. Xray
  2. CT

distended proximal colon

air fluid levels

multiple dilated loop of bowel

TX:

  1. laparotomy with or without colostomy if perforated

2. nasogastric suction

URGENT SURGERY IF TOTAL OBSTRUCTION SUSPECTED

62
Q

Volvulus

what is this?

2 MC palces?

4 sxs?

2 dx with 2 key findings

2 tx options depending where it is?

A

twisting of intestine MC sigmoid or cecum since “floppy”

can lead to gangrene and perforation

RF: age since colon gets stretched and logner

SXS:

  1. massive abdominal distention
  2. crampy abdominal pain
  3. N/V
  4. tympany

DX:

  1. xray- “kidney bean appearance”
  2. barium enema- funnel narrowing like birds beak
  3. CT

TX:

sigmoid: sigmoidoscopy to decompress volvuls then surgery if failed
cecum: always surgery

63
Q

incisional/ventral hernia

what is this?

3 RF?

2 dx?

2 tx options?

A

occurs through prior fascial incisions

RF:

  1. previous abdominal surgery
  2. things increase abdominal pressure aka obesity, COPD, constipation
  3. previous repair

DX:

  1. inspection
  2. CT in obese

TX:

  1. repair with mesh open or laproscopic
  2. component seperation to strengthen and reconstruct the abdominal wall
64
Q

what are the most common type of colon polyp?

A

tubular

65
Q

where is the most common place for colon polyps?

A

rectosigmoid

66
Q

what are the two groups of polyps?

A
  1. imflammatory polyps/psuedopolyps benign
  2. adenomas premalignant

(tubular, tubulovillous, villous)

67
Q

of the colon adenomas “premalignant” explain the 3 different types?

A

malignancy potential goes up from tubular to vilous

  1. tubular

least malignant, most commonly pedunculated

  1. tubulovillous

more commonly pedunculated

  1. villous“villous think villian”

more commonly sessile, highest potentiall for maligancy

68
Q

what are the two shapes of colon polyps? which are worse?

A
  1. sessile-more malignant

flat and intimately attached to mucosa

  1. peduncaulated-less malignant

rounded on stalk

69
Q

how do you dx colon polyps?

A

colonoscopy with polpectomy TOC

70
Q

if pt has familial polyposis syndrome, how often should they be evaluated and starting at what age?

A

evaluated ever 1-2 years starting at the age of 10-12 with colonscopy…have essentially a 100% risk of developing colon cancer!!

71
Q

Colon Cancer

who is this in?

what type of cancer?

where?

where most common metastasis?

A

MC over 50

Adenocarcinoma

MC LLQ

MC metastasis liver

72
Q

microcytic anemia in M/W is what?

A

colon cancer until proven otherwise

73
Q

what is the screening for colon cancer? when does it start?

A

starts age 50

Colonoscopy every 10 years

Sigmoidoscopy every 5 years

Fecal occult blood test every 1 year

FIT every year

74
Q

colon cancer

what are the 3 sxs of this?

2 dx methods?

3 tx?

A

SXS:

  1. iron deficient anemia, rectal bleeding, alternating constipation and diarreah “change in bowel habits”
  2. feeling of incomplete passage of stool since three is mass

3. anemia in elderly must supect this and rule out

**Sxs depend on location:

right side: melena MC

left side: hematochezia MC**

DX:

  1. occult blood
  2. colonoscopy

TX:

  1. excision of the portion of the colon supplied by that blood supply
  2. CHEMO 5-FU BEFORE SUGERY

3. radioation if penetrated the wall

75
Q

what do you use to monitor for GI cancers?

A

Carcinoembryonic antigen (CEA) **monitoring only**

76
Q

acute cholecystitis

2 cuases of this?

4 sxs? 1 test?

1 dx method with 2 findings?

2 tx options?

A

patho:

  1. acute inflammation/infection of the GB
  2. sustained obstruction of the cystic duct

SXS:

  1. CONSTANT** **steady or cresendo in RUQ/epigastric that can radiate to back/shoulder

2. N/V, fever

3. pain worse with movement

4. + muprhys sign (cessation of inspiration because of pain in RUQ)

5. localized guarding

DX:

US-distended GB thickened wall over 3 mm with fluid collection

tx:

  1. cholecystectomy-give abx if acute and wait for things to calm down
  2. cholecystomy if too sick surgery- drain fluid to decompress
77
Q

Cholithiasis

patho?

describe the 2 types of stones?

1

2

5 RF?

A

path: supersaturation of bile with cholesterol
1. cholesterol stones 75%
2. pigmented 25%

Brown: infection

black: hemolytic disease and cirrosis calcium biilrubinate

RF:

FEMALE, FERTILE, FAT, FORTY, Bariatric surgery

78
Q

cholithiasis

what are the 7 sxs of this?

TOC for DX? two others?

1 tx?

A

sxs:

1. RUQ pain radiate to back

2. dull achying pain last 1-4 hours

3. post prandial pain esp after fatty meal

4. can awaken at night

5. N/V

6. EPISODIC, well between episodes!!

7. patient restless and uncomfortable

8. NO FEVER

DX:

  1. TOC IS US!!!!!!!!!!!
  2. MRC-magnetic resonsance cholangiography

imaging of the biliary and pancreatic ducts

  1. HIDA scan

shows if there is obstruction in the cystic duct since doens’t fill Gb

TX: cholecystectomy

79
Q

peritonitis

what is this caused by?

5 things that can cause this?

4 sxs?

2 tx?

A

bacteria in a normal sterile environment

causes:

  1. gastric ulcer
  2. abcess
  3. acute appenditicits
  4. colonic perforation
  5. diverticulitis

SXS:

  1. acute abdominal pain
  2. fever
  3. leukocytosis
  4. marked tenderness with involuntary guarding

TX

  1. fix the cause
  2. volume resuscitation
  3. broad spectrum abx
80
Q

acute pancreatitis

what are 2 main causes of htis?

5 sxs, 2 of which are 2 key signs?

3 dx?

2 tx options?

A

causes:

  1. ALCOHOL USE AND BILLIARY STONES 85%
  2. GALLSTONES

SXS

1. epigastric pain radiating to the back

2. PAIN ALLEVAITED WITH SITTING OR STANDING

3. fever

4. GREY TURNER SIGN-BRUISING ON SIDE

5. CULLEN SIGN-PERIUMBILCAL BRUISE

DX:

  1. ELEVATED LIPASE/Amylase
  2. US to look for stones
  3. CT

TX:

  1. NPO
  2. cholecystectomy/ERCP to remove the stone
81
Q

what are the criteria you use for pancreatitis?

A

ransons criteria or APACHEII

82
Q

hemmoroids

what are these?

3 causes?

2 types and key features of each?

A

Engorgements of the venous plexsus of the rectum anus or both with protrusion of the mucosa

causes:

  1. constipation/straining
  2. pregnancy
  3. portal HTN
  4. INTERNAL

originate above dentate line so PAINLESS, commonly BLEED!!!

  1. EXTERNAL

Originate below the dentate line SO PAINFUL SINCE INNERVATED

83
Q

hemmoroids

2 sxs?

5 tx options for hemmorids?

A

SXS:

  1. bleeding
  2. pain/itching

TX:

  1. high fiber diet
  2. sitz bath
  3. supposititories or debulking agents (works first line for external since heal on their own typically)
  4. rubber band ligation- protrudes with defecation or must be reduced manually (internal first line basically)
  5. hemmoridectomy if must reduce manually, or permanently incarcerated

***in external hemmoroids: usually don’t cause problems but REMOVE if interfere with hygiene or pruritis***

84
Q

what are the 4 differnet classificationsf or internal hemmoroids?

A
  1. internal only
  2. protrudes with defecation then reduces
  3. protrudes and then needs manual reduction
  4. protrudes permanently, incarcerated
85
Q

ischemic bowel

3 sxs

2 dx

1 tx

A

sxs

  1. post prandial pain mild to sever

2. foodphobia

3. weight loss

4. sudden onset of severe abdominal pain out of proportion to exam findings

DX

  1. CT angiogram
  2. mesenteric angiography

TX: mesenteric revascularization

86
Q

where are gastric ulcer perforations most liketly to occur?

A

lesser curvature

87
Q

what are the RF for gastric ulcers?

A

smoking

NSAIDS

ALcohol

Male

88
Q

Perforated Ulcer

4 sxs?

3 tx optiosn?

A

SXS

  1. worse after eating

2. N/V

3. acute onset upper abdominal pain

4. periotoneal signs

TX:

  1. nasograstic resuciation
  2. GASTRIC ULCER: oversoe ulcer using piece of omentum Graham patch followed by PPI OPEN Or laproscopic
  3. duodenal ulcer: patch the ulcer, harder ones harder to close and need extensive surgery
89
Q

where is the most common location for duodenal ulcer?

A

duodenal bulb

90
Q

Prostate Cancer

who is this most common in?

age/race?

type of cancer?

sxs?

2 dx?

1 tx? with 3 possible additional options?

A

MC 70-90 y/o

MC African Americans

ADENOCARCINOMA

frequent metastasis

ASYMTOMATIC TILL FOUND DRE

DX:

  1. transrectal US
  2. transrectal BX

TX: radical prostatectomy +/- lymph node dissection, androgen ablation, radiation

91
Q

what do you screen for Prostate cancer with and what age?

A
  1. PSA
  2. DRE

start when over 50

92
Q

what do you use to stage prostate cancer?

A

gleason score

93
Q

hydrocele

what is this?

2 types?

1 dx?

1 tx?

A

Fluid filled sac in the processus vaginalis

Types:

  1. Communicating hydrocele: fluid is able to backtack into the peritoneal cavity so can get bigger than smaller
  2. Noncommunicating: doesn’t communicate so stays about the same size

DX: TRANSILUMINATE THE SCRTOM

tx: drain fluid

94
Q

varicocele

what is this?

A

Abnormal dilation of the spermatic vein in the spermatic cord

“Bag of worms”

95
Q

Testicular Cancer

age?

MC type?

1 key RF?

2 sxs?

1 dx?

1 tx?

A

MC 20-40 y/o

Germ cell cancer 95%

RF: crytochidism failutre of tesicle to descend

SXS:

  1. PAINLESS LUMP/swelling
  2. firness in 1 testicle

DX:

scrotal US/ PE

TX:

inguinal orchiectomy (removal of testicle)

96
Q

what are the two tumor markers used for testicular cancer?

A
  1. Beta-human chorionic gonadotropin (B-HCG)

  1. alpha fetoprotein
97
Q

DVT prophylaxsis for surgery

5 things

A
  1. SQ LMWH if trauma

caution can cuase heparin induced thrombocytopenia or low platelets

  1. unfractioned heparin everyone
  2. SCDs
  3. early ambulation
  4. compression stockings
98
Q

who is at increased risk of DVT?

7 populations

A
  1. virchows triad

stasis, hypercoag, endothelial injury

  1. trauma
  2. cancer
  3. ortho surgery
  4. obesity
  5. smoking
  6. BC
99
Q

what is virchows triad?

A

icnreased risk of DVT/clot

  1. stasis
  2. hypercoag
  3. endothelial injury
100
Q

DVT

4 sxs?

1 dx?

2 tx?

A

SXS:

  1. leg redness
  2. increased warmth or pain
  3. tenderness to palpation
  4. leg swelling
  5. palpable cord

DX

duplex US

homans sign

probability with wells score

TX:

  1. LMWH bridge to warfarin
  2. Inferior vena cava filter (IVC)
101
Q

Acute arterial occlusion

what is the most common cause of this?

6 sxs?

1 tx?

A

MC embolism from heart in afib

6 P’s

PAIN

PALLOR

PULSELESSNESS

POLAR

PARESTHESIA

PARALYSIS

*patient can tell you exactly when and where it started*

TX:

surgical embolectomy with cutdown and fogarty balloon

102
Q

what is the thing you worry about as a complication of arterial emboli?

A

compartment syndrome

103
Q

periphreal arterial insufficiency

what is this?

6 key sxs of this?

2 key dx and gold standard?

A

occlusive athlerosclerosis of the LE

SXS:

  1. intermitten claudication

2. rest pain (typically at night)

3. erectile dysfunction

4. absent pulses

5. decreased hair growth and muscular atrophy

6. tissue necrosis, ulcers, infections

DX:

  1. ABI LESS THAN 0.6
  2. ateriogram GOLD standard
104
Q

periphreal arterial insufficiency

what are the 5 tx options you try before surgeyr?

what are the 4 indications for surgery?

A

TX:

  1. Conservative for most patients
    - exercise walking program
    - smoking cessation
    - TX of HTN
    - diet
    - ASA
  2. SURGERY IF
    - severe claudication

- tissue necrosis

- infection

-rest pain

105
Q

dry gangrene

A

dry necrosis of tissue without signs of infection “mummified tissue”

tissue dries and may be brown to purplish-blue to black in color, often falls off; infection typically not present

Tx: surgical debridement and abx

106
Q

wet gangrene

A

moist necrotic tissue with signs of infection

Tissue swells or blisters, pus is present

Serious and potentially life-threatening due to quick spread

TX: srugical debridement and abx

107
Q

what are the 5 W’S of postoperative fever?

A
  1. wind-atelectais
  2. water- UTI
  3. wound
  4. walking-DVT
  5. wonder drugs
108
Q

postoperative fever

atelectasis

when does this occur?

from?

3 tx?

A

24-48 hours after surgery

from not breathing deeply and limited mobility

TX:

  1. stop smoking 2 weeks before surgery
  2. IS
  3. beta agonists
109
Q

postoperative fever

water-UTI

when does this occur?

A

48-72 hours after

indwelling foley

SXS: cloudy urine

DX: urine cultures

TX: abx that are sensitivity driven

110
Q

postoperative fever

Wound

what does this occur?

what is the most common cause?

A

After 72 hours

MC cause of fever after this point

STAPH MOST COMMON!

111
Q

Postoperative fever:

walking-DVT

2 findings?

2 tx options?

A

+ homans sign, unilateral edema

TX:

  1. heparin/LMWH
  2. IVC in those with contraindicatiosn
112
Q

postoperative fevers:

wonder drugs

2 causes?

when does it occur?

DX OF?

A

anesthetics and sulfa drugs

occur after 1 week

DX OF EXCLUSION

113
Q

Abdominal Aortic Aneurysm

what are the 3 sxs?

2 dx methods?

2 tx methods?

A

aneurysm if over 3 CM

SXS:

  1. ususally asymptomatic and discovered incidentlally
  2. abdominal pain or back pain
  3. may have signs of limb ischemia

DX:

  1. abdominal US TOC
  2. CT for further measurement/characterization

TX:

  1. surgical repair if over 5 cm with endovascualr stent or open graft repair
  2. if less than 5 cm watchful reimaging and smoking cessation
114
Q
A
115
Q

what ist he most common indication for operative repair of gastric ulcers?

A

perforation

116
Q

what is the most common indiation for operative repair of duodenal ulcers?

A

bleeding

117
Q

what is the difference in the repair strategy for direct and indirect hernias?

A

direct=can watchfully weight unless sxs then do surgery

indirect=do surgery because higher risk if strangulation

118
Q

internal gangrene

A

when gangrene occurs inside the body due to blocked blood flow to an internal organ

119
Q

gas gangrene

A

are but dangerous

When infection develops deep inside the body, such as muscles or organs, usually as a result of trauma

120
Q

Antibiotic prophylaxis…

A

should be administered within 60 min of first incision; may need to be repeated more than once depending on length of surgery

121
Q

for patients having NON-gastric, NON-biliary, NON-colorectal surgery want abx do you want to give before surgery?

A

CEFAZOLIN (ANCEF)

122
Q

for any gastric/biliary/colorectal surgery what abx do you want to give ahead of time?

A

Cefoxitin (mefoxin)

123
Q

what are some things you would consider doing before surgery and for who should you do them?

A

CBC: age >55, expected blood loss, fatigue, h/o anemia, blood loss, or liver disease

Creatinine: age >40, h/o renal disease, DM, OSA, COPD, HTN, diuretics, chemo

Coagulation studies: history, h/o VTE, anticoagulation use, liver disease

ECG: age > 40 male, >50 female, HTN, CAD, CHF, DM, arrhythmias, family history

CXR: age >60, underlying cardiopulmonary disease, hospitalized

Urinalysis: signs of cystitis, GU, new hardware or implant procedure, hospitalized

124
Q

pulmonary embolism

what are the 3 symptoms a patient with often present with ? what are 6 signs you may see on examination?

A

tachypnea, dyspnea, pleuritic chest pain (sharp stab) on inspiration 97% of patients will have at least one of these

must have high suspicion because 50% of pt lack these characteristc symtoms

clinical signs:

1. crackles

2. S4 gallop (since right ventricle get stiff from the increase in pressure you hear right atrial contraction)

3. decreased S2 splitting

4. friction rub

5. positive homans sign (calf pain with dorsiflexion)

6. plasma D-Dimer (elvated in thrombus/degredation of fibrin)

125
Q

pulmonary embolism

what are the four test you use to diagnose and what would you see on each test? Explain the flow chart for PE diagnosis?

A

ELEVATED D-DIMER, NONSPECIFIC

1. CXR-ATELECTASIS, PLEURAL EFFUSIONS, INFILTRATES

  • westermarks sign (avascular markings distal to embolus)
  • hamptons sign (wedge shaped infiltrate that shows infarction)
    2. Helical CT angiography

proximal vessel thromboembolism

3. EKG- S1Q3T3 classic for cor pulmonae

4. Pulmonary angiogram GOLD STANDARD

-the issue with this test is it is an invasive procedure that puts a catheter in the heart and injecting dye into a high pressure area, people can have a reaction to the dye or the kidney can be effected only indicated when VQ and CT scans are indeterminant and PE is still suspected

probability PE 4+

126
Q

pulmonary embolism

what are the four treatment options and order for treating PE? when do you use each and explain them!

A

FULL ANTICOAGULATION FOR 3-6 MONTHS, LONG IS BETTER AND MOST DO 6 MONTHS **THIS PREVENTS FUTURE CLOTS**

1. LMWH or unfractioned heparin (START THEN TRANSITION TO WARFARIN)

low molecular weight heparin is usually preferred because it has a more predictive dose and is the same if not more effective that unfractioned heparin, but some people still use it 5-7 days while transitioning to warfarin

  1. warfarin

goal PTINR 2-3, can use new oral drugs like dabigatran, rivroxaban, apixaban they don’t need monitoring and may work better than warfarin, but more $$$

  1. Streptokinase, urokinase, TPA

used in urgent situations to directly lyse intravascular thrombi and accelerate the 1st 24 hours, does not decrease mortality which is why it is used in URGENT cases

4. mechanical/surgical extraction

this is LAST RESORT when the patient is hemodynamically unstable and is bascailly going to die anyway because the surgery is a basic death sentence by opening them up and taking out the clot

127
Q

when wouldn’t you do a mechanical/surgical intervention for PE? (5 things)

A
  1. if the patient is hemodynamically stable
  2. active internal bleeding
  3. stroke in prior two months
  4. trauma in the last 6 weeks
  5. uncontrolled hypertension
128
Q

what can you do in a patient who has an absolute contraindication for coagulation for PE prophylaxis?

A

venal caval interruption filters

129
Q

PE is the _______ cause of inpatient death?

A

3rd leading cause of inpatient death

130
Q

what is the criteria you use to determine the probabillity of DVT/PE?

A

wells score

over 2 mod probability

over 6 high prob

131
Q

surgical risk is dependent on these things:

A
  1. functional status
  2. emergency case
  3. systemic disease
  4. steroid use
  5. acities within 30 days
  6. sepsis within 48 hours
  7. ventilator dependent
  8. disseminated cancer
  9. diabets
  10. HTN
  11. CHF
  12. dyspnea
  13. smoker
  14. COPD
  15. dialysis
  16. ARF
  17. BMI
132
Q
A
133
Q

timed method for srubbing

A

2-4 minutes

fingers, hands, arms

134
Q

what are the surgical scrubbing brushes made of?

A

chlorohexadate gluconate

povidone iodine

135
Q

what tempreautre level should require investigation?

A

38 degress, go investigating

136
Q

what is most often the cause of post op fever?

A

most common from atelectasis

90% of POD#1 fevers!!

**so not as much worried about fever day 1-2 of surgery**

137
Q

postoperative pneumonia

when does this come form often?

3 sxs?

aspiration suspected if? 4

A

frequently through secondary to atelectasis

SXS:

  1. FEVER

2. SOB

3. gradual decrease in O2 sat

***consider from aspiration if***

  • gastirc distension
  • mental status changes
  • head injuries
  • edlery
138
Q

postoperative pneumonia

3 prevention?

3 dx?

2 tx?

A

prevention:

  1. ambulation
  2. cough
  3. incentive spirometry

DX

1. crackels in lower lobes

2.CXR

3. elevated WBC

tx: abx and chest physiotherapy

139
Q

Ventilator associated pneumonitis

3 causes

2 prevention

3 tx

A

causes:

  1. ventilator tube as reservoirs–not sterile

2. ET tube is good for bacteria to grow

3. humification fluid is warmed—good for bacteria

prevention:

ASEPTIC TECHNIQUE

AVOID PROLONGED INTUBATION

TX:

  1. ventilatory
  2. suction with culture
  3. abx
140
Q

Bacteria that cause ventilator associated peumonitis

3 types

gram

shape

A
  1. Gram - pseudomonas, serratia
    * Clusters*
  2. Gram + MRSA
    * strands*
141
Q

postoperative MI

what is KEY STAT TO KNOW ABOUT THIS?

when does this occur? KEY?

6 sxs?

tx?

A

MC cause of morbidity or mortality after NON cardiac surgery–STRESS

typically withing 5 days of surery, but not first 48 hours

SXS:

  1. post operative ischemia on EKG is omnious sign
  2. HF
  3. unexplained SOB
  4. tachycardia
  5. hypotension
  6. possible atypical CP

TX: consult with surgeon or cardiolgy

142
Q

what is the purpse of a pre-operative evaluation?

A

identify highr risk for complications associated with the surgical procedure and implent interventions to prevent risk

143
Q

what is the classification system that is used to deteremine a persons fittness for surgery?

A

America society of Anesthesiologists (ASA) physical status classification system

“ASA classification”

Rotation 1: Surgery (1 decks)

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