Let's do this! Flashcards
1
Q
Lipoma
what is it?
1 tx?
A
soft, nontender, moveable mass made of adipose tissue
Tx: excision
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
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
4
Q
incisional bx
A
partial removal of suspected tissue (takes some tissue)
5
Q
excisional bx
A
Complete excision of all suspect tissue (mass)
6
Q
what do you always want to do if there is a dirty wound?
A
evaluate for tetnans vaccination
7
Q
primary wound closure
A
Close wound immediately with sutures/staples, adhesives etc
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
9
Q
Tertiary (delayed primary closure) would closure
A
Suture the wound closed in 3 to 5 days AFTER incision
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
11
Q
What is negative pressure wound therapy?
A
Negative pressure system used to accelerate wound healing in chronic and acute
- draws edges together
- reduces edema
- promotes profusion
- facilitates formation of granulation tissue
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:
- pain
- erythema
- drainage
- fever
TX:
- remove skin, sutures, staples
- pack wound open
- abx and wound culture
13
Q
if infxn occurs first 24 hours after surgery, what is the most likely cause?
A
streptococcus
14
Q
clean wound
A
Elective nontraumatic wound without acute inflammation
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
16
Q
contaminated wound
A
Acute inflammation, traumatic wound, GI tract spillage, major break in sterile technique
17
Q
dirty wound
A
Pus present, perforated viscus, dirty traumatic wound
18
Q
what must you do for an abcess?
A
Do I&D–must be drained
19
Q
what do you do to determine between a cystic and tissue mass in the breast?
A
US
20
Q
Fibrocystic breast disease
when does this occur?
3 key sxs and 1 finding?
A
women 30-50
sxs:
- painful/tender
- size fluctuates with menstrual cycle
- straw colored fluid with FNA
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
- SOLID
- FIRM, MOBILE
- WELL CIRCUMSCRIBED NONTENDER ROUND
DX:
core bx/FNA or US
TX:
- remove if over 3 cm
- if less than 3 cm, can go away on their own
22
Q
where is the most common location of malignant breast neoplasms? 7 key descriptors make you think maligant?
A
UPPER OUTTER QUADRANT
- immobile
- dimpling
- retraction
- skin thickening peau d’orange
- exzematous changes
- ulcerations
- palpable nodes
23
Q
what must you do before treating breast cancer?
A
stage it!
24
Q
what drug do you use if the breast cancer is ER+ and they are post menopausal?
A
tomoxifen
25
Ductral carcinoma in situ
## Footnote
what does this lead to?
at risk for?
dx by? 2
3 tx options?
becomes invasive ductal carcinoma, at risk for developement in _same breast_
## Footnote
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 +
26
Lobular carcinoma in situ
## Footnote
gives rise to?
at risk for cancer in?
how dx?
tx?
becomes infiltrating lobular cancer, at risk in **_BOTH BREASTS_**
SXS: None
DX: not seen on mammo, found incidentally on bx
TX: close follow up
27
infiltrating ductal carcinoma
## Footnote
2 descriptors
MC breast cancer!! 80%!!!
## Footnote
FIRM, IRREGULAR MASS PE
28
Infiltrating lobular carcinoma
## Footnote
percent?
10 of BC!!
29
colloid or mucinous carcinoma BC
clumps and straings of cells in pools of mucoid material
30
Inflammatory carcinoma of breast
## Footnote
3 characteristics?
prognosis?
EDEMA, ERYTHEMA, and PEAU D'ORANGE
## Footnote
POOR PROGNOSIS, only 25% live past 5 years
31
Pagets disease
## Footnote
what is this?
3 sxs?
1 dx need?
Exudative, dry, sclay appearance of the nipple
## Footnote
SXS:
itching, burning, sticking pain in the nipple
DX: NEED NIPPLE SKIN BX
32
what are indications for bx?
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
33
when do you do a needle aspiration bx for a breast lump?
if it appears to be a cyst
34
when do you do an open bx for a breast lump?
Second cyst recurrence
Bloody fluid in the cyst
Palpable mass after aspiration
35
what is the #1 RF for lung cancer?
SMOKING
36
Lung cancer
## Footnote
what are the 4 keys sxs?
how do you initially dx? 3
and confirm dx? 3
2 major groups?
SXS:
**_1. new or changing cough_**
**_2. hemoptosis_**
3. dyspnea
4. pleural effusions
DX:
1. CXR/CT
2. PET
3. Needle Bx/ bronchoscopy with bx/open lung bx
1. small cell lung cancer (SCLC)
2. NON-small cell lung cancer
37
Small cell lung cancer (SCLC)
## Footnote
what is the type of cancer that fulls under this?
4 qualities?
- when spreads?
- tx options?
- where spreads?
- find anything else?
**_OAT CELL CANCER_**
## Footnote
1. spreads early
2. **_can't tx with surgery!!!_**
3. Central to Periphreal
4. AGGRESSIVE, micrometasis with presentation (hence no surgery)
38
Non-small cell lung cancer (NSCLC)
## Footnote
3 types?
speed?
tx?
slower grower
can have surgery!!
includes:
1. squamous cell
2. adenocarcinoma
3. large cell
39
NSCLC
**sqamous**
location?
think what two things?
often presents with?
1. occur centrally
2. squamous=think "sentrally and SMOKING"
3. often presents with hemoptosis
40
NSCLC
## Footnote
**_adenocarcinoma_**
what is the KEY fact to know about this one?
location?
speed?
metastasis?
**_\*\*MOST COMMON TYPE OF LUNG CNACER\*\*_**
1. occur periphreal
2. rapid
3. metasizes to distant organs
41
NSCLC
**_large cell_**
1. large cell
2. VERY MALIGNANT
42
what lung cancer arises in nonsmokers?
**_adenocarcinoma_**
43
what are the metastasis palces for lung cancer?
5
Brain
Bone
Adrenals
Liver
kidney
44
carcinoid lung mass
what is a key characteristic of this?
what does it look like?
tx?
neuroendocrine tumor
\*can also be in the GI tract\*
**_bronchoscopy shows red, yellow, purple mass that is well vascularized_**
tx: surgical ressection
45
pulmonary coin lesions
## Footnote
what and where are these?
What is the most common cause?
appearance?
2 dx?
how do you determine what to do about them?
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_**
46
Appendicitis
## Footnote
what age?
MC cause?
4 key sxs?
5 key signs?
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\*\*
47
Appendicitis
## Footnote
2 dx?
2 tx?
DX:
1. US
2. CT
TX:
1. laproscopic appendectomy
2. 2nd generation cephalosporin
48
perforated hollow viscus
## Footnote
what is this?
Intraperitoneal free air on abdominal xray and abdominal pain
Severe acute abdominal pain
49
Diverticulitis
## Footnote
what age does this effect?
what is this?
MC location?
RF?
50-80 y/o MC
weakness in the bowel wall where blood vessels enter
**_MC SIGMOID_**
**_RF: low fiber diet_**
50
Diverticulitis
## Footnote
2 key sxs?
2 dx options? TOC?
tx options?
4 times suregery is appropriate
SXS
**_1. reccurent abdominal pain usuall LLQ_**
**_2. combination of bowel bleeding, constipation, diareaah_**
DX
**_1. CT IS THE TEST OF CHOICE!!!_**
2. 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
51
what is the most common type of hernia in kids?
Indirect
52
what side is more effected in inguinal hernias?
right side
53
what are 3 RF for inguinal hernia?
Chronic cough
Strain with defecation
Heavy lifting
54
Direct inguinal hernia
## Footnote
where do these occur?
MC in?
Occur medial to inferior epigastric through hasselbachs triangle
## Footnote
MC older men
55
Indirect inguinal hernia
## Footnote
where does this occur?
MC in?
from?
where can it go?
occur lateraly to inferior epigastric, MC children
from _weakness in the processus vaginalis_
\*\*can extend into the testes\*\*
56
Inguinal hernia
## Footnote
3 sxs?
ways to repair?
sxs:
**_groin bulge_**
**_scrotal mass_**
**_silk glove sign_**
TX:
1. anterior mesh repair (open)
2. preperitoneal repair (open)
3. laproscopic repair
57
Intestinal obstruction
## Footnote
what are the differences between the presentation of L intestine and small intestine?
2
4
what likely causes each?
2
3
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
58
where is the most common location for intestinal obstruction?
sigmoid colon
59
what is the most common cause for colonic obstruction?
ADENOCARCINOME 65%
60
closed loop obstruction
## Footnote
what is this?
3 things?
tx?
"complete obstruction"
## Footnote
1. massive colonic distention
2. increased risk of perforation
3. no flatus or stool 8-12 hours
TX: emergency surgery
61
intestinal obstruction
## Footnote
2 dx with 3 key findings?
2 tx options?
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
Volvulus
what is this?
2 MC palces?
4 sxs?
2 dx with 2 _key findings_
2 tx options depending where it is?
twisting of intestine MC sigmoid or cecum since "floppy"
## Footnote
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
incisional/ventral hernia
## Footnote
what is this?
3 RF?
2 dx?
2 tx options?
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
what are the most common type of colon polyp?
tubular
65
where is the most common place for colon polyps?
rectosigmoid
66
what are the two groups of polyps?
1. imflammatory polyps/psuedopolyps **benign**
2. adenomas **premalignant**
(tubular, tubulovillous, villous)
67
of the colon adenomas "premalignant" explain the 3 different types?
malignancy potential goes up from tubular to vilous
## Footnote
1. **_tubular_**
least malignant, most commonly **pedunculated**
2. **_tubulovillous_**
more commonly **pedunculated**
3. **_villous_**"villous think villian"
more commonly **_sessile, highest potentiall for maligancy_**
68
what are the two shapes of colon polyps? which are worse?
1. sessile-more malignant
## Footnote
flat and intimately attached to mucosa
2. peduncaulated-less malignant
rounded on stalk
69
how do you dx colon polyps?
colonoscopy with polpectomy TOC
70
if pt has familial polyposis syndrome, how often should they be evaluated and starting at what age?
evaluated ever 1-2 years starting at the age of 10-12 with colonscopy...have essentially a 100% risk of developing colon cancer!!
71
Colon Cancer
## Footnote
who is this in?
what type of cancer?
where?
where most common metastasis?
MC over 50
Adenocarcinoma
MC LLQ
MC metastasis liver
72
microcytic anemia in M/W is what?
colon cancer until proven otherwise
73
what is the screening for colon cancer? when does it start?
starts age 50
## Footnote
**_Colonoscopy every 10 years_**
Sigmoidoscopy every 5 years
Fecal occult blood test every 1 year
FIT every year
74
colon cancer
## Footnote
what are the 3 sxs of this?
2 dx methods?
3 tx?
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
what do you use to monitor for GI cancers?
Carcinoembryonic antigen (CEA) \*\*monitoring only\*\*
76
acute cholecystitis
## Footnote
2 cuases of this?
4 sxs? 1 test?
1 dx method with 2 findings?
2 tx options?
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
Cholithiasis
## Footnote
patho?
describe the 2 types of stones?
1
2
5 RF?
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
cholithiasis
## Footnote
what are the 7 sxs of this?
TOC for DX? two others?
1 tx?
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
3. HIDA scan
shows if there is obstruction in the cystic duct since doens't fill Gb
TX: cholecystectomy
79
peritonitis
## Footnote
what is this caused by?
5 things that can cause this?
4 sxs?
2 tx?
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
acute pancreatitis
## Footnote
what are 2 main causes of htis?
5 sxs, 2 of which are 2 key signs?
3 dx?
2 tx options?
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
what are the criteria you use for pancreatitis?
ransons criteria or APACHEII
82
hemmoroids
## Footnote
what are these?
3 causes?
2 types and key features of each?
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
1. INTERNAL
originate above dentate line so _PAINLESS, commonly BLEED!!!_
2. EXTERNAL
Originate below the dentate line _SO PAINFUL SINCE INNERVATED_
83
hemmoroids
## Footnote
2 sxs?
5 tx options for hemmorids?
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)
3. rubber band ligation- protrudes with defecation or must be reduced manually (internal first line basically)
4. 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
what are the 4 differnet classificationsf or internal hemmoroids?
1. internal only
2. protrudes with defecation then reduces
3. protrudes and then needs manual reduction
4. protrudes permanently, incarcerated
85
ischemic bowel
## Footnote
3 sxs
2 dx
1 tx
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
where are gastric ulcer perforations most liketly to occur?
lesser curvature
87
what are the RF for gastric ulcers?
smoking
NSAIDS
ALcohol
Male
88
Perforated Ulcer
## Footnote
4 sxs?
3 tx optiosn?
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
where is the most common location for duodenal ulcer?
duodenal bulb
90
Prostate Cancer
## Footnote
who is this most common in?
age/race?
type of cancer?
sxs?
2 dx?
1 tx? with 3 possible additional options?
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
what do you screen for Prostate cancer with and what age?
1. PSA
2. DRE
start when over 50
92
what do you use to stage prostate cancer?
gleason score
93
hydrocele
## Footnote
what is this?
2 types?
1 dx?
1 tx?
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
varicocele
what is this?
Abnormal dilation of the spermatic vein in the spermatic cord
“Bag of worms”
95
Testicular Cancer
## Footnote
age?
MC type?
1 key RF?
2 sxs?
1 dx?
1 tx?
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
what are the two tumor markers used for testicular cancer?
1. Beta-human chorionic gonadotropin (B-HCG)
## Footnote
2. alpha fetoprotein
97
DVT prophylaxsis for surgery
## Footnote
5 things
1. SQ LMWH if trauma
## Footnote
caution can cuase heparin induced thrombocytopenia or low platelets
2. unfractioned heparin everyone
3. SCDs
4. early ambulation
5. compression stockings
98
who is at increased risk of DVT?
## Footnote
7 populations
1. virchows triad
stasis, hypercoag, endothelial injury
2. trauma
3. cancer
4. ortho surgery
5. obesity
6. smoking
7. BC
99
what is virchows triad?
icnreased risk of DVT/clot
## Footnote
1. stasis
2. hypercoag
3. endothelial injury
100
DVT
## Footnote
4 sxs?
1 dx?
2 tx?
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
Acute arterial occlusion
## Footnote
what is the most common cause of this?
6 sxs?
1 tx?
MC embolism from heart in afib
## Footnote
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
what is the thing you worry about as a complication of arterial emboli?
compartment syndrome
103
periphreal arterial insufficiency
## Footnote
what is this?
6 key sxs of this?
2 key dx and gold standard?
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
periphreal arterial insufficiency
## Footnote
what are the 5 tx options you try before surgeyr?
what are the 4 indications for surgery?
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
dry gangrene
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
wet gangrene
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
what are the 5 W'S of postoperative fever?
1. wind-atelectais
2. water- UTI
3. wound
4. walking-DVT
5. wonder drugs
108
postoperative fever
atelectasis
when does this occur?
from?
3 tx?
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
postoperative fever
water-UTI
when does this occur?
48-72 hours after
indwelling foley
SXS: cloudy urine
DX: urine cultures
TX: abx that are sensitivity driven
110
postoperative fever
Wound
what does this occur?
what is the most common cause?
After 72 hours
MC cause of fever after this point
**_STAPH MOST COMMON!_**
111
Postoperative fever:
walking-DVT
2 findings?
2 tx options?
+ homans sign, unilateral edema
## Footnote
TX:
1. heparin/LMWH
2. IVC in those with contraindicatiosn
112
postoperative fevers:
wonder drugs
2 causes?
when does it occur?
DX OF?
anesthetics and sulfa drugs
occur after 1 week
DX OF EXCLUSION
113
Abdominal Aortic Aneurysm
## Footnote
what are the 3 sxs?
2 dx methods?
2 tx methods?
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
115
what ist he most common indication for operative repair of gastric ulcers?
perforation
116
what is the most common indiation for operative repair of duodenal ulcers?
bleeding
117
what is the difference in the repair strategy for direct and indirect hernias?
direct=can watchfully weight unless sxs then do surgery
indirect=do surgery because higher risk if strangulation
118
internal gangrene
when gangrene occurs inside the body due to blocked blood flow to an internal organ
119
gas gangrene
are but dangerous
When infection develops deep inside the body, such as muscles or organs, usually as a result of trauma
120
Antibiotic prophylaxis...
should be administered within 60 min of first incision; may need to be repeated more than once depending on length of surgery
121
for patients having NON-gastric, NON-biliary, NON-colorectal surgery want abx do you want to give before surgery?
**_CEFAZOLIN (ANCEF)_**
122
for any gastric/biliary/colorectal surgery what abx do you want to give ahead of time?
Cefoxitin (mefoxin)
123
what are some things you would consider doing before surgery and for who should you do them?
**_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
pulmonary embolism
## Footnote
what are the 3 symptoms a patient with often present with ? what are 6 signs you may see on examination?
**_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
pulmonary embolism
## Footnote
what are the four test you use to diagnose and what would you see on each test? Explain the flow chart for PE diagnosis?
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
pulmonary embolism
## Footnote
what are the four treatment options and order for treating PE? when do you use each and explain them!
_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**
2. **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 $$$
3. **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
when wouldn't you do a mechanical/surgical intervention for PE? (5 things)
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
what can you do in a patient who has an absolute contraindication for coagulation for PE prophylaxis?
venal caval interruption filters
129
PE is the _______ cause of inpatient death?
3rd leading cause of inpatient death
130
what is the criteria you use to determine the probabillity of DVT/PE?
wells score
## Footnote
over 2 mod probability
over 6 high prob
131
surgical risk is dependent on these things:
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
133
timed method for srubbing
2-4 minutes
## Footnote
fingers, hands, arms
134
what are the surgical scrubbing brushes made of?
chlorohexadate gluconate
povidone iodine
135
what tempreautre level should require investigation?
38 degress, go investigating
136
what is most often the cause of post op fever?
most common from atelectasis
90% of POD#1 fevers!!
\*\*so not as much worried about fever day 1-2 of surgery\*\*
137
postoperative pneumonia
## Footnote
when does this come form often?
3 sxs?
aspiration suspected if? 4
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
postoperative pneumonia
## Footnote
3 prevention?
3 dx?
2 tx?
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
Ventilator associated pneumonitis
3 causes
2 prevention
3 tx
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
Bacteria that cause ventilator associated peumonitis
## Footnote
3 types
gram
shape
1. Gram - **_pseudomonas, serratia_**
* Clusters*
2. Gram + **_MRSA_**
* strands*
141
postoperative MI
## Footnote
what is KEY STAT TO KNOW ABOUT THIS?
when does this occur? KEY?
6 sxs?
tx?
MC cause of morbidity or mortality after NON cardiac surgery--STRESS
## Footnote
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
what is the purpse of a pre-operative evaluation?
identify **highr risk for complications** associated with the surgical procedure and implent interventions to prevent risk
143
what is the classification system that is used to deteremine a persons fittness for surgery?
America society of Anesthesiologists (ASA) physical status classification system
"**ASA classification"**
