Other surgery stuff Flashcards
0
Q
most common benign tumor of the liver?
A
hemangioma
it’s usually asymptomatic
1
Q
how do you dx and tx focal nodular hyperplasia of the liver?
A
dx with angiography
no need to tx. it has no malignant potential
“central scar” on CT
2
Q
liver mass assoc with estrogen/OCP use
how do you tx it?
A
hepatic adenoma
excise it b/c risk of hemorrhage and malignant potential
3
Q
most common met to the liver?
A
colorectal cancer
4
Q
what must you r/o before biopsying a liver mass
A
hemangioma b/c risk of bleeding
5
Q
most common cause of GI tract fistulas
A
diverticulitis
6
Q
what’s the 3:1 rule?
A
- administer 3 cc of crystalloid for every 1 cc of blood lost
- this is b/c at equilibrium, only 1/3 of isotonic crystalloid remains in the intravascular space
7
Q
amylase and lipase levels correlate with the prognosis for acute pancreatitis (T/F)
A
F
they are only good for diagnosing
8
Q
what should you r/o first in a woman with nipple discharge
A
pregnancy
9
Q
which increases your risk of breast ca?
- fibrocystic changes
- diffuse papillomatosis
- intraductal papilloma
A
diffuse papillomatosis
10
Q
2 most common severe complications following CEA
A
MI
stroke
11
Q
in working up carotid stenosis, if duplex results are equivocal –> get this study
A
MRI
12
Q
when to do a Whipple procedure
A
localized malignancies near the ampulla of vater
13
Q
most common cause of incidental finding of hypercalcemia and how to tx it?
A
primary hyperparathyroidism
usually tx with surgery
14
Q
common cause (besides primary hyperparathyroidism) of hypercalcemia in a hospitalized patient
A
malignancy
15
Q
what electrolyte imbalances do you see in hyperparathyroidism
A
hypercalcemia hypercalcinuria low serum phosphate high serum chloride low serum bicarbonate
16
Q
patient with perforated ulcer, signs of sepsis, ischemic changes on ECG. what do you do?
A
abx, invasive monitoring, early surgical intervention
-a perfed ulcer is a surgical emergency!!! the ECG changes are most likely secondary to the sepsis
17
Q
dobutamine stress test is highly sensitive or specific
A
sensitive
18
Q
how to evaluate preop risk in this patient:
-underwent coronary stenting 4 years ago and has had no recurrence of sxs
A
H&P, labs, ECG
stress test is not needed
19
Q
you suspect PUD. what do you do next?
A
EGD… see if there’s H Pylori
20
Q
medical therapy for PUD
A
antacids H2 antagonists PPI sucralfate prostaglandins
21
Q
what should be done in the work up for PUD?
A
endoscopy
+ biopsy if it’s a gastric ulcer due to risk for malignancy
22
Q
CT scans are great for solid organ and retroperitoneal injuries but not so great for _______
A
hollow viscus injuries
23
Q
what is myasthenia gravis assoc with and how do you tx it?
A
thymoma –> tx with complete resection
-staging takes place at the time of surgery via macroscopic inspection
24
XY gonadal dysgenesis is associated with testicular cancer (T/F)
T
25
are testicular cancers more commonly derived from germ cells or stromal cells?
germ cells, half of which are seminomas
26
if you palpate a supraclavicular mass in someone with testicular cancer...
think metastasis (Virchow node)
27
mass in the testis of a young man... what do you do?
US or transilluminate to find out if it's solid
- if it's solid, then get CXR and get beta-HCG and AFP levels
- perform radical inguinal orchiectomy for dx and tx
- if it's cancer, then obtain CT abd/pelvis for met workup
- depending on what kind of cancer it is, tailor your tx
28
which testicular cancer is really sensitive to XRT and chemo?
seminoma
29
anal skin tag assoc with what?
anal fissure
30
how to examine someone suspected of having an anal fissure?
exam under anesthesia, anoscopy, proctoscopy
31
how to conservatively manage anal fissures
increasing dietary bulk, sitz baths, stool softeners, nitroglycerin ointment
32
nonhealing anal fissure or anal fissure located anywhere but directly posterior... include these 2 things in your ddx
Crohn's or malignancy
33
how to tx thrombosed external hemorrhoids not responding to meds
excisional thrombectomy (NOT I&D)
34
3 lab values for pheochromocytoma
VMA, metanephrine, normetanephrine
35
what to do to work up an adrenal incidentaloma
- H&P
- functional assessment: get various labs for pheo, hyperaldo, hypercortisolism
- CT or MRI (PET if h/o malignancy) for anatomic assessment
36
how to tx an adrenal mass
- functional: remove it
| - nonfunctional: remove if > 4 cm OR if < 4 cm but growing OR if it looks sketchy on imaging
37
most common met to the adrenal glands is _______
lung carcinoma
| -others include: breast, colon, kidney, stomach, melanoma
38
pheo 10% rule
10% are bilateral, extra-adrenal, multiple, malignant, familial
39
what imaging is used to see pheo?
CT or MRI initially
| MIBG has higher specificity so you confirm with this
40
in doing surgery for pheo, what must you be sure to do?
alpha blockade before beta blockade to prevent a hypertensive crisis
-also just be aware that BP may be low after tumor excision due to massive vasodilation... just support them with a pressor then they will be fine in the end
41
adrenal incidentalomas are usually functional (t/f)
F
42
when do you biopsy an adrenal mass?
only when you think it's a met
43
what is hesselbach's triangle?
direct inguinal hernias go through it
| -rectus sheath, inferior epigastric vessels, inguinal ligament
44
femoral hernia occurs below the _______
inguinal ligament
45
where does indirect hernia occur?
lateral to the epigastrics
46
scrotal or labial swelling... what kind of hernia?
indirect inguinal hernia
47
medial thigh hernia in old women
obturator hernia
48
nec fasc after
-water contact
-trauma
what species?
- vibrio
| - clostridial
49
presentation of wilm's tumor?
| how to tx wilm's tumor?
presentation- usually appear healthy, has abdominal mass and hematuria
tx
- depends on imaging
- in most cases, nephrectomy then chemo
- if tumor is really big and invading, then neoadjuvant chemo before nephrectomy
- XRT only if tumor spillage occurs
50
pediatric adrenal mass with failure to thrive... what is it?
neuroblastoma
51
how to tx adrenal neuroblastoma in kids?
biopsy --> neoadjuvant chemo --> surgery
52
most common enlarged renal mass in neonate
hydronephrosis
53
-young woman with easy bruising and bleeding, petechiae, thrombocytopenia, lots of megakaryocytes on bone marrow bx
what is it?
idiopathic thrombocytopenia purpura (ITP)
54
what causes ITP?
idiopathic...
| but it's due to production of anti-platelet IgG by the spleen
55
how to tx ITP?
start with steroids
| splenectomy solves the problem if steroids don't work
56
what does the spleen do?
produce antibodies
| remove erythrocytes after 120 days
57
overwhelming post splenectomy sepsis (OPSS) is more common in adults (T/F)
F
| it's more common in children and it can have mortality > 50%
58
the people with ITP who respond the best to steroid therapy will respond the ______ to splenectomy
best
59
patient with Crohn's disease presents with disease exacerbation... what tests do you want?
CT
small bowel follow through
colonoscopy
60
you manage most things in Crohn's medically (T/F)
| what's the exception
T- surgery is reserved for sxs that are refractory to medical management
-exception is fibrotic strictures, which will not improve with medications alone
61
surgery option for pts with refractory UC involving their whole colon
proctocolectomy with ileal pouch-anal anastamosis
62
you find high grade dysplasia in the colon of someone with UC.. what do you do?
total proctocolectomy
63
main indications for surgery in UC:
-fulminant colitis or toxic megacolon, dysplasia or cancer, intractable disease
64
extra intestinal manifestations of UC
```
ankylosing spondylitis
uveitis
scleroderma
PSC
arthritis
dermatomyositis
hypercoagulable state
```
65
most common area for herniated disk?
L4-L5
| L5-S1
66
ways to dx biliary atresia
US and HIDA are pretty good
| the only definitive way to dx it is intra-operative cholangiogram
67
treatment for babies with biliary atresia
before 120 days, Kasai procedure
| after 120 days, list for liver transplant
68
jaundice in neonates after ______ is rarely physiologic, esp if it's mainly conjugated bilirubin
2 weeks
69
most common complication of portoenterostomy (Kasai) for biliary atresia
cholangitis --> tx with abx and steroids
| others include cessation of bile flow and portal hypertension
71
apple core lesion on barium enema means
colon cancer
72
pneumobilia (air in biliary tree) and SBO seen on KUB
gallstone ileus (which is really an obstruction, not an ileus)
73
KUB: bent inner tube, coffee bean, parrot's beak
sigmoid volvulus
74
CXR: looks like air in the cardiac silhouette
| how to dx it?
hiatal hernia
| dx with Ba swallow
75
"white out" of the lungs
| 3 causes
CHF
ARDS
pulmonary contusion
76
most common kind of melanoma
superficial spreading
77
a few days post-op: if someone looks like they're in sepsis (fever, AMS) but they have hypertension (rather than hypotension), think about this....
and how do you tx it?
alcohol withdrawal
| tx with ativan/serax
78
when to operate for carotid stenosis
> 70% if symptomatic
| > 80% if asymptomatic
79
foot drop and numb dorsum of foot (1st and 2nd toes)... what injury is this?
deep peroneal nerve (anterior compartment)
80
which local anesthetic has higher rate of allergy
esters and PABA allergy
81
know classes of hemorrhagic shock...
ok
82
preop coronary concern... what tests do you get?
stress/cath
83
valve concern or CHF concern, what test?
echo
84
mitral stenosis caused by....
rheumatic fever
85
ARDS criteria
bilateral infiltrates
PCWP < 18
PaO2/fiO2 < 200
86
MI 5 days ago and acute decompensation.... 3 possible causes
1. papillary muscle rupture/mitral regurg
2. VSD: new harsh and loud holosystolic murmur
3. LV rupture
87
4 Ts of cyanotic congenital heart issues
tetralogy of fallot
truncus arteriosus
TGA
tricuspid valve
88
co-arctation associated with _______ syndrome
Turner
- rib notching
- variable BP/pulses
89
```
when to operate for aneurysms:
thoracic
abdominal
iliac
distal/visceral
```
```
7 (lower threshold to operate on ascending)
5
3
2
or acute increases or symptomatic
```
90
how to tx claudication
exercise, no smoking --> ABI --> duplex --> arteriogram
91
ABI limits for claudication, rest pain, and ulcers
claudication < 0.9
rest pain < 0.6
ulcers < 0.5
92
know the lung volumes
ok
93
SOB after central line placement is most likely ________
Ptx
94
tachycardia, R heart strain, desaturation is most likely a ______
PE
95
ship yard/asbestos exposure puts you at risk for what
mesothelioma
96
how to work up zenker's diverticulum
Ba swallow and upper GI --> cut the cricopharyngeus
97
hiatal hernia:
_________ does not need repair
_________ needs the OR
type 1- sliding
| type 2- paraesophageal
98
chronic cough + high BMI may be ______
GERD
99
EGD shows Barrett's.... what do you do?
tx with anti-acid and anti-reflux
| -do not do esophagectomy until high grade dysplasia/cancer
100
central stellate scar in the liver... what is it and what do you do?
focal nodular hyperplasia
| -no need to resect or treat
101
cholecystitis causes jaundice (t/f)
F!!!!!
102
how to work up and tx acute cholecystitis
dx with US
| tx with supportive measures (ex. NPO, IV fluids, abx) and interval cholecystectomy
103
high alk phos and T bili
US shows dilated CBD
what is it and how to tx?
choledocolithiasis
| tx with ERCP and sphincterotomy and interval cholecystectomy
104
RUQ pain, fever, jaundice +/- septic
dilated CBD, high alk phos and T bili
what is it and how to tx?
acute cholangitis
| tx with abx and ERCP decompression
105
how to tx gallstone pancreatitis?
cholecystectomy once the patient and his/her amylase levels stabilize
106
PSC vs. PBC
- intra and extrahepatic ducts = ________
- intra hepatic ducts, antimitonchondrial Ab = __________
PSC
| PBC
107
SBO.... indications for OR?
complete SBO
incarcerated hernia
fever, high WBC
108
ileum resection causes diarrhea... why?
less bile salt absorption/less fat absorption
109
non bilious vomiting in a first born male... what is it and what's the tx?
pyloric stenosis
| tx with pyloromyotomy
110
malrotation causing bilious vomiting is an emergency (t/f)
T
111
abdominal pain, currant jelly stool, "knees drawn up"
| what is it and what's the tx?
intussusception
tx with air or gastrograffin enema
if peritonitic, go to the OR
in adults, it could be cancer
112
if someone has ulcerative colitis and you see colonic dysplasia, what do you do?
total colectomy
113
someone complains of diarrhea but there is hard stool by DRE/KUB... what do you do?
enema b/c this is usually fecal impaction
114
3 common causes of anal pain
anal fissure
thrombosed external hemorrhoid
perirectal abscess
115
unless your patient has CHF, keep UO above approximately _____
30 cc/hr
116
normal urine gravity range
1.010 to 1.025
117
indications for dialysis
```
AEIOU
acidosis
electrolyte issues (esp hyperkalemia)
ingestion of toxins
overload of volume
uremia
```
118
when operating on a pheochromocytoma, what MUST you do?
alpha blockade before beta blockade
| otherwise, they'll go into hypertensive crisis
119
blood in urine:
- pain = _____
- painless = _______
stone
| most likely cancer
120
renal transplant failure in a few hours post-op
| what's the cause and what do you do?
poor blood flow vs. ATN
| get ultrasound of renal vasculature
121
2 important transplant meds
1. azathioprine/mycophenylate (imuran/cellcept)
- inhibit purine synthesis, inhibit T cells
2. cyclosporine/program (FK-506/Tac)
- inhibit genes for cytokine synthesis
122
hyper Ca
presentation: ______________
____ QT
bones, stones, groans, psychiatric moans
| short
123
hypo Ca
________ signs on clinical exam
_____ QT
Chvostek's and Trousseau's
| long
124
```
hyper K
ECG findings (3): ____, _____, _____
```
wide QRS, peaked T, sine wave
125
hypo K
ECG findings (3): ____, ______, _______
GI finding: _______
flat T, long QT, U wave
| constipation
126
neonates with biliary atresia or choledocal cysts should be assessed for ________ before surgery
coagulopathy
127
woman with blunt abdominal injury, stable vitals, abdomen has guarding and rebound… what to do?
ex lap
128
woman picks up grocery bag and her arm snaps in the middle of her humerus… what is it?
metastatic osteolytic cancer
129
cirrhotic man with bill 3.5, PT 28, albumin 2.5, ascites, and encephalopathy needs surgery
he's not a surgical candidate
130
how to dx mets to the spine from breast cancer
MRI
131
man with GERD who is non compliant with meds and now has esophagitis, Barrett's, and mild dysplastic changes… tx?
Nissen fundoplication
| esophagectomy reserved for severe dysplastic changes
132
man with sudden severe abdominal pain that is constant and has rebound
-negative CXR, EKG, lipase, and CT
what is it?
perforation of a hollow viscus due to the sudden nature of severe pain
133
blunt abdominal trauma that is successfully resuscitated…no peritoneal irritation
what to do next?
CT
134
when to remove adrenal masses
> 5 cm or when they are functional
135
what's the secretin test used for?
ZES- gastrinoma
| when you give secretin, gastrin levels stay inappropriately high
136
what does coumadin affect?
| how to monitor and reverse?
vitamin K dependent factors: II, VII, IX, X; protein C and S
monitor with PT/INR
reverse with vitamin K or FFP (immediate)
137
```
how does heparin work?
________ for tx
________ for prophylaxis
how do you monitor?
what does heparin cause in certain ppl and how do you treat it?
```
```
binds ATIII
IV
SubQ
PTT
HIT (prothrombotic) --> tx with lepirudin or argatroban
```
138
how does aspirin work?
| how to reverse?
- inhibits platelets
| - technically irreversible but can give plts if immediate surgery is needed
139
how does plavix work?
inhibits platelets
140
consumptive coagulopathy
"bleeding from IV sites"
increased PTT and INR
decreased platelets and fibrinogen
DIC
141
multiple blood transfusions can cause _________ (electrolyte issue)
hypocalcemia
142
gastroesophageal varices with normal liver
pancreatitis --> splenic vein thrombosis --> gastroesophageal varices --> hematemesis
-tx with splenectomy
143
jowell holly bodies usually indicate what?
| also, what do they look like?
they indicate a damaged spleen
| they look like a RBC with a basophilic dot inside
144
absence of jowell holly bodies s/p splenectomy means what?
| what do you do?
accessory spleen
| need a spleen scan... most common location is splenic hilum
145
post splenectomy sepsis prophylaxis and tx?
| also, what 3 vaccines to give?
prophylaxis = PCN, tx = vanco/cefepime
| vaccines: pneumococcus, meningococcus, H flu
146
what to do for spleen autoinfarcts in sickle cell
no need for resection
147
HIV and bloody diarrhea... what causes it?
CMV
148
3 microbes of nec fasc
group A strep
clostridium
polymicrobial
149
artificial heart valve prophylaxis with what abx?
amoxicillin
150
fungus in a blood culture can be a contaminant (t/f)
F (esp in PICC line pts getting TPN)
151
diarrhea, WBC > 30, abdominal pain
| what is it and how to tx?
c diff
d/c other abx
tx with metronidazole or vanc
152
what to do with undescended testes?
fix them down by age 1
| -still increased cancer risk but you can do better surveillance
153
direct inguinal hernia goes through _____________
Hesselbech's triangle (epigastric vessels, rectus abdominus, inguinal ligament)
154
acute testicular pain... what to do? 2 possible dxs
US
| -testicular torsion vs. acute epididymitis
155
if you suspect ovarian torsion, first dx test?
pelvic ultrasound
156
DCIS is ________and often found on _________
dx with ______
tx with ___________
precancerous, mammography
core needle bx
lumpectomy and XRT if localized
simple mastectomy +/- sentinel node biopsy if multicentric
157
LCIS is _______ NOT __________
a breast CA risk factor, not a precancerous lesion
158
infiltrating ductal carcinoma
| 2 surgical approaches: ________ or ________
modified radical mastectomy or lumpectomy + postop XRT
may need chemo and/or tamoxifen
sentinel node biopsy +/- axillary dissection
159
how to tx inflammatory breast CA
chemo and radiation and then possible mastectomy
160
________ increased risk of breast ca, endometrial ca, ovarian ca
________ increased risk of breast ca, male breast ca
BRCA 1
| BRCA 2
161
what to do with breast cyst --> _______
if bloody --> ______
if recur --> ______
drain it
send for cytology
excise
162
how to dx and tx Paget's disease of breast (scaly nipple)
dx: biopsy of nipple skin
tx: resection
163
metformin is a risk for _______
metabolic acidosis
164
anion gap acidosis causes?? mnemonic
MUDPILES
| methanol, uremia, DKA, propylene glycol, infection, lactic acidosis, ethylene glycol, salicylates
