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Surgery > OME Gen Surg June 2017 > Flashcards

OME Gen Surg June 2017 Flashcards

1
Q

Components of Child-Pugh score

A

Low alb, high bili, high INR, ascites, encephalopathy

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2
Q

Why treat dvt with heparin bridge to coumadin

A

Because coumadin makes hypercoagulable initially (disrupts proteins c and s)

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3
Q

manage a surgical wound infection presenting as fever and wound erythema and tenderness ~7 days postop

A

US to rule out deep abscess not palpable on exam

PO Abx if cellulitis only

IV Abx if toxic appearing

I and D if abscess

Laparotomy if dehiscence or evisceration

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4
Q

doing all postop care right, but now postop day 3 fever anyway, what is it probably due to

A

UTI

POD 1 atelectasis
POD 2 PNA
POD3 UTI
POD 5 DVT
POD 7+ wound
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5
Q

72 hours after surgery pt has htn tachyc hallucinations diaphoresis and ams

what is it
she is one step from ___

A

alcohol withdrawal

she is one step from seizing

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6
Q

general mechanism of alcohol withdrawal

A

upregulation of GABA receptors (compensating for chronic neural inhibition/depression) then withdrawal of the depressant leaves autonomics overly excitatory

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7
Q

order of alcohol withdrawal symptoms

A 
hypertensiona and tachycardia
then tremor
then diaphoresis and anxiety
then hallucinations - visual usually
ending with seizure
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8
Q

really old patient with total colonic dilation the only diagnosis is ______
treat with

A

Ogilvie syndrome

treat with rectal tube for decompression or neostigmine

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9
Q

what part of bowel does Ogilvie syndrome affect

A

colon only, like a paralytic ileus of the colon only

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10
Q

what part of the bowel does a paralytic ileus affect

A

the whole thing, the ENTIRE GI SYSTEM

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11
Q

how does duration of anuria after cath removal affect management

A

6 hours
(normal to urinate 4x/day, so roughly every 6 hours)
reassure before then
intervene after then - in/out cath to assess for residual volume – give fluids if low, leave cath in if high

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12
Q

abdominal compartment syndrome

  • classic presentation
  • management
A

ex lap trauma case got tons of fluids to support pressure intraoperatively and can’t close abdomen at end of case because both organs and fascia are swollen

leave open and cover with wound vac or absorbable mesh to prevent infection

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13
Q

why don’t you close abdominal compartment syndrome, aka ex lap trauma case got tons of fluids to support pressure intraoperatively and can’t close abdomen at end of case because both organs and fascia are swollen

A

because even if forced closed, organs will die from pressure and patient will die

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14
Q

ZERO urinary output in hospitalized patient suspect these 2 things

A

kinked foley most commonly, very rare even with big hypotensive hit / hemorrhage to have ZERO output, so reposition foley or give it a flush

ATN e.g. from hypotension/ischemia possible but will usually have SOME output early on in first 12 hours or so, so really suspect kinked foley

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15
Q

treat alcohol withdrawal

A

IV lorazepam or other short acting benzodiazepine

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16
Q

when do you use chlordiazepoxide in setting of alcohol withdrawal

A

to prophylax against withdrawal (long acting oral benzo)

use short acting benzo like lorazepam, to treat actual withdrawal

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17
Q

72 year old guy postop after significant abdominal surgery gets delirious, what do you do first

A

first supplement oxygen e.g. 100% non-rebreather

then lots of things as you work him up e.g.
BMP
blood glucose
pause any narcotics
cxr
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18
Q

how does a 100% non-rebreather oxygen mask work

what is the advantage

A

100% O2 inhaled from inflated bag, exhale through one-way valve into room air

allows for higher oxygen delivery than nasal cannula

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19
Q

TF
postop foley urine output gradually declining to concerning levels after a period of hypotension but patient has since been hemodynamically stabilized – first step reposition and flush catheter?

A

F
reposition and flush if acute ZERO urine output highly suspicious of kinked foley obstruction

gradual urine output drop in setting of just prior episode of hypotension probably prerenal aki – so give 1L NS fluid bolus

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20
Q

painful jaundice in an adult is essentially always caused by…

A

gallstones

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21
Q

painful jaundice in an adult consistent with probable obstructing gallstone, what do you expect to see on biliary tree sonogram

A

dilated biliary tree

no obstructing stone
(obstructing stone rarely seen on US but will see on ERCP)

non-obstructing gallstones in gallbladder
(even though obstructing stone difficult to see on US, will probably see other stones in gallblader)

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22
Q

describe acute cholecystitis on US

A

pericholecystic fluid, thickened gallbladder wall, and gallstones

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23
Q

pericholecystic fluid, thickened gallbladder wall, and gallstones on RUQ US describes what diagnosis

A

acute cholecystitis

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24
Q

distended thin-walled gallbladder with biliary dilation on RUQ US describes what diagnosis

A

painless jaundice associated with slowly-progressing cancer

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25
Q

painless jaundice associated with slowly-progressing cancer, what do you expect on RUQ US

A

distended thin-walled gallbladder with biliary dilation

26
Q

the only way to get acute onset of an elevated unconjugated bilirubin is ___ so get ___

A

the only way to get acute onset of an elevated unconjugated bilirubin is HEMOLYSIS so get a BLOOD SMEAR to tell you what type of hemolysis

27
Q

TF

acute onset of an elevated unconjugated bilirubin, get a RUQ US

A

F
the only way to get acute onset of an elevated unconjugated bilirubin is HEMOLYSIS so get a BLOOD SMEAR to tell you what type of hemolysis

28
Q

6 things that put AST and ALT into the thousands

A 
acetaminophen overdose
acute viral hepatitis
autoimmune hepatitis
afla-toxin (death cap mushrooms)
budd-chiari syndrom (hepatic vein thrombosis)
shock liver

aaaabs

29
Q

young person gets malaise weakness anorexia jaundice with mixed hyperbilirubinemia and transaminases into the 1000s a few weeks after traveling to a third world country

most likely cause

A

acute viral hepatitis A

30
Q

when is liver biopsy the answer

in acute hepatic failure?

A

liver biopsy is rarely the correct answer, reserved for confirmatory diagnosis of a rarer cause of cirrhosis

rarely the answer in acute hepatic failure

31
Q 
weight loss, migratory thrombophlebitis, painless obstructive jaundice
suspect..
order...
if negative, suspect..
order...
A

suspect pancreatic cancer
order CT abdomen (or maybe just get MRCP)
if negative suspect PSC causing stricture (get MRCP) or cholangiocarinoma versus ampullary cancer (get ERCP)

32
Q

treatment of choice for primary sclerosing cholangitis

A

ursodeoxycholic acid

33
Q

ca19-9 is a tumor marker for

A

pancreatic cancer

34
Q

progressive painless jaundice, weight loss, smoking history, the most likely diagnosis is

A

pancreatic cancer

35
Q

conifirm diagnosis of pancreatic cancer

A

EUS with biopsy

endoscopic ultrasound

36
Q

history of PSC and painless jaundice you get an ERCP to diagnose…

A

cholangiocarcinoma

37
Q

negative CT scans despite painless jaundice you get an ERCP to diagnose…

A

ampullary cancer

38
Q

MRCP is used to diagnose

A

PSC and Chronic Pancreatitis

structural visualization is the same without the risk of causing pancreatitis – so do MRCP before ERCP, do ERCP if biopsies are needed

39
Q

for what 3 cancers are biopsies skipped and go straight to resection for diagnosis

A

renal cell carinoma
lymphoma
testicular cancer

40
Q

In painless jaundice patient, absence of this
1 demographic
2 presenting symptoms

Make you less concerned for cancer

A

Absence of
Older age
Weight loss, migratory thrombophlebitis

41
Q

What is the advantage of MRCP over ERCP

What is the disadvantage?

A

MRCP does not involve instrumentation, so no 30% risk of pancreatitis and smaller risk of later stricture

But cannot biopsy or remove stones with MRCP

42
Q

When do you biopsy via EUS vs ERCP

A

EUS for biopsy outside biliary system, e.g. to confirm dx of pancreatic cancer seen on imaging (MRCP or CT)

43
Q

Combination of obstructive jaundice and heme positive stool makes you think

A

Ampullary cancer

-the only lesion really that can obstruct biliary tree and bleed into GI lumen

44
Q

How common is ampullary cancer
How do you diagnose it
How do you treat it

A

Ampullary cancer is rare

Dx with ERCP
(CT and MRCP will not see it)

Resection is curative

45
Q

________ will present with obstructive jaundice in setting of PSC, a stricture on MRCP, no lesion of the head of the pancreas

Diagnose with

A

CHOLANGIOCARCINOMA will present with obstructive jaundice in setting of PSC, a stricture on MRCP, no lesion of the head of the pancreas

Diagnose with ERCP with Biopsy to rule out a simple stricture

46
Q

How do Boerhaave’s and Mallory Weiss tears differ with respect to bleeding and toxicity

A

Boerhaaves is toxic and does not bleed

Mallory Weiss bleeds and is not toxic

47
Q

Treat Mallory Weiss tear

A

Support with fluid and blood as necessary, will self-resolve

48
Q

Transmural esophageal rupture aka

A

Boerhaave’s

49
Q

Smoker drinker hot tea drinker with dysphagia suggestive of esophageal SCC

Next 3 steps in management

A

Barium swallow to map esophagus

EGD with Biopsy to confirm

CT to stage

50
Q

Risk factors for esophageal SCC

Location

A

Smoker drinker hot tea drinker
Older Black

Upper third of esophagus before glandular tranformation starts and progresses to the les

51
Q

Major risk of egd

A

Perforation

52
Q

Manage an esophageal perforation disgnosed by history and physical

A

Gastrografin swallow

Barium swallow if gastrograffin negative

EGD if either swallow positive

Surgery

53
Q

What is the confirmatory diagnlstic test for GERD

A

Esophageal pH monitoring

54
Q

Work up GERD

A

Start with Lifestyle modification and PPI trial for 6 weeks if no alarm (aka cancer) symptoms (odynophagia dysphagia weight loss nausea vomiting anemia)

EGD to visualize and biopsy - aka rule out cancer and metaplasia and confirm esophagitis, if alarm symptoms or failure of 6 week PPI trial

24-hour pH monitoring to confirm that esophagitis due to reflux

55
Q

Alarm symptoms in GERD

A

Cancer signs – odynophagia dysphagia weight loss nausea vomiting anemia

56
Q

Crunching sounds with each heart beat signifies

A

Pneumomediastinum

57
Q

Crunching sounds with each heart beat aka

A

Hamman’s crunch

Pneumomediastinum

58
Q

Hamman’s crunch

aka

A

Crunching sounds with each heart beat signifying pneumomediastinum

59
Q

Why gastrograffin swallow for pneumomediastinum but barium for odynophagia/dysphagia?

A

Gastrograffin less toxic to mediastinum (but less sensitive test so if negative still get Barium swallow)

Barium less toxic to lung so better for dysphagia odynophagia in case aspirated

60
Q

TF

Emergency thoracotomy for pneumomediastinum from esophageal rupture

A 
F
Gastrograffin swallow
Barium swallow
EGD
then surgery for esophageal rupture

To emergently open chest you need something emergently threatening like uncontrolled bleeding, traumatic arrest, etc

61
Q 
Marjolin ulcer
Define
Diagnose
Treat
Prognosis
A

SCC that chronically ulcerates and heals at site of chronic wound or scar

Biopsy

Wide resection

Aggressive, poor prognosis, high risk of recurrence and metastasis

62
Q

Venous stasis ulcer occurs most commonly at

A

The malleolus

Surgery (22 decks)

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