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Operative & PeriOperative Care > Pestana's Surgery Notes > Flashcards

Pestana's Surgery Notes Flashcards

1
Q

32 y/o male is involved in head on, high speed, accident. He is unconscious at the site, regains brief consciousness, but arrives to the ER in a deep coma. He has a fixed, dilated pupil. Dx? Txmt?

A

Acute subdural hematoma more likely over acute epidural hematoma. \nAcute craniotomy

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2
Q

Txmt of choice for acute epidural hematoma? Test of choice?

A

Craniotomy\nCT scan

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3
Q

Txmt of chronic subdural hematoma in elderly pt with progressive loss of function?

A

Surgical decompression via craniotomy

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4
Q

A car hits a pedestrian. He presents in a coma with either raccon eyes/clear rhinorrhea/clear fluid leaving from the ears/or ecchymosis behind the ears. Dx?

A

Base of the skull fx\nCT scan

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5
Q

A 45 y/o male presents after a high speed automobile collision in a coma, with fixed, dilated pupils. He has multiple other injuries. His BP is 70/50, with a feeble pulse, and a HR of 150. Why low BP and high HR?

A

hypovolemic shock due to hemorrhage

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6
Q

22 y/o with multiple gun shot wounds to the abd, is diaphoretic, cold, pale, shivering, and is asking for water. His BP is 60/40, and he has a feeble pulse rate of 150. Management?

A

Hypovolemic shock:\nBig Bore IV lines, Foley catheter, and IV antibiotics. Exp lap immediately and THEN fluid/blood administration. If OR not available, fluid resuscitation 1st.

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7
Q

How could specifically identify tension pneumothorax on PE?

A

Respiratory distress\nTracheal deviation\nabsent breath sounds on hemithorax, that is resonant to percussion.

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8
Q

What PE finding is seen in both cardiac tamponade and tension pneumothorax?

A

distened neck veins

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9
Q

22 y/o with multiple gun shot wounds to the abd, is diaphoretic, cold, pale, shivering, and is asking for water. His BP is 60/40, and he has a feeble pulse rate of 150. PE also shows distended neck veins, distant heart sounds, but no respiratory distress or tracheal deviation

A

Hypovolemic shock with cardiac tamponade

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10
Q

Most common presenting problem with blunt cardiac trauma?

A

45% cardiogenic, 40% arrhythmia

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11
Q

Fractures to the 1st and 2nd ribs that occur during trauma should make you alert to what major secondary injury? Gold standard test for Dx?

A

TRA: traumatic rupture of the aorta\nAortogram, but CT angiography is becoming more widely accepted

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12
Q

During blunt chest trauma, a widened mediastinum on CXR should raise your suspicion for? Other signs?Gold standard test?

A

TRA:\nApical pleural hematoma(cap)\nObliterated aortic knob\nDeviated NG tube

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13
Q

Emergent txmt for pericardial tamponade

A

Thoractomy with decompression

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14
Q

A 22 y/o presents to the ER with a gun shot to the Right chest. He has labored breathing, is cyanotic, diaphoretic, cold, and shivering. His BP is 60/40. His Pulse is 150 and feeble. He is in respiratory distress, has distended neck veins, and his trachea is deviated ot the left. The right side of chest is tympanic with absent breath sounds. Next step in management?

A

Tension pneumothorax:\nBore bore IV catheter into R pleural space, followed by tube thoracostomy into the R axillary chest wall.\nNOT XRAY!

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15
Q

Initial management of pneumothorax

A

Reexpansion of the lung

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16
Q

Recurrent spontaneous pneumothorax is most commonly seen in? What is most predictive of recurrence of pneumothorax?

A

Tall, thin, young males and smokers\nNumber of occurences. 80% reccurence rate after 3 incidents

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17
Q

A 33 y/o woman develops “air hunger” after placement of subclavian central line

A

pneumothorax

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18
Q

What PE finding may be used to differentiate pleural effusion from pneumothorax

A

Dullness to percussion over the chest wall on the affected side is seen with an effusion

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19
Q

A 17 y/o girl is stung by a swarm of bees/hives after penicillin/surgery under spinal anesthesia…develops BP of 75/25, pulse of 150, and look warm and flushed, not pale and cold. CVP is low. What is it? Management?

A

Vasomotor shock:\nVasoconstrictors

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20
Q

A 25 y/o is stabbed in the right chest. He is SOB, has stable vital signs. No breath sounds at R base, faint distant breath sounds at apex, dull to percussion. What is it? Next step in management?

A

Hemothorax:\nHis vital signs are stable, so do Xray 1st to confirm, then R chest tube/thoracotomy in the BASE of the pleural cavity

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21
Q

A 25 y/o is stabbed in the right chest. He is SOB, has stable vital signs. No breath sounds at R base, faint distant breath sounds at apex, and resonant to percussion. What is it? Next step?

A

Pneumothorax:\nstable vital signs mean xray 1st, then Chest tube, HIGH in the pleural cavity

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22
Q

What are some surgical indications for spontaneous pneumothorax?

A

Recurrence, persistant air leakage(malignancy, infection, CF), failure of lung to rexpand, scuba diver/aviator

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23
Q

Dilation of a pupil with sluggish response to light is an early indication of?

A

temporal lobe herniation, usually on same side, due to fucked up CN III

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24
Q

A pt is post Chest tube placement due to stab wound to Right chest. The tube recovers 450cc on the outset, followed by another 420cc in the next hr. Next step?

A

Thoracotomy to ligate intercostal vessel that has been damaged. \nNormal bleeding from lung parenchyma would have slowed down or haled.

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25
Q

25 y/o stabbed in the chest and has dullness at the lung base, with resonance at the apex

A

hemo–pneumothorax

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26
Q

A 33 y/o female presents with multiple rib fractures after a high speed collision. She is gasping for breath, cyanotic at the lips, with nostril flaring. BP is 60/45, and HR is 160. She has distended neck veins, is diaphoretic and the L hemithorax has no breath sounds and is tympanic to percussion?

A

tension pneumothorax

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27
Q

A 54 y/o lady crashes her car against a pole. She is in moderate respiratory distress, has multiple chest bruises, and her chest wall caves in upon inspirations.What is the true problem with flail chest? Txmt?

A

Pulmonary contusion:\nfluid restriction, diuretics, colloid fluids(not crystaloid), and respiratory support. NOT ways to mechanically stabalize the chest. This is not done anymore

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28
Q

A 54 y/o crashes her car at high speed. She is breathing well, but has multiple chest wall bruises and xrays shows multiple rib fractures. The lung parenchyma is clear and expanded. Two days later, a CXR shows “white out” of the lungs and she is in respiratory distress. What is it? Management?

A

Pulmonary contusion:\nDoes not always show up acutely.\nFluid restriction, diuretics, colloid fluid. If vitals fall, intubation, mechanical vent, PEEP.

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29
Q

54 y/o has a head on collision with a telephone pole. She is breathing well, but has extreme tenderness over the sternum and there is crepitance upon palpation. What is she at risk for? Next step?

A

Myocardial contusion and TRA.\nCT scan and arteriogram(aortogram)

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30
Q

A 54 y/o male is involved in a high–speed collision. He is respiratory distress and PE shows no breath sounds over the entire Left chest and percussion is unremarkable. CXR shows air–fluid levels in the L chest. What is it? Management?

A

Classic L diaphragmatic rupture. It is alwaus on the left.\nSurgery

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31
Q

A nasogastric tube curling up into the left chest might be seen in what traumatic injury?

A

traumatic diaphragmatic rupture

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32
Q

A lady with traumatic injuries and a pneumothorax develops progressive subcutaneous emphysema over her upper chest and neck. What is it? Management?

A

Traumatic rupture of the trachea or bronchus\nFriberoptic bronchoscopy to confirm dx and secure airway, then surgical repair.

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33
Q

Most esophageal ruptures occur where? What does this often lead to?

A

distal 1/3rd\nLeft pleural effusion with mediastinitis, CP, and eventually sepsis

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34
Q

Mortality outcome during esophageal rupture is dependent on?

A

Early dx and treatment…24hrs 40%

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35
Q

Best initial diagnostic test for confirming esophageal rupture

A

water–soluble contrast esophagogram

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36
Q

Most common cause of esophageal rupture

A

iatrogenic

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37
Q

If after Chest tube placement, the lung fails to reexpand, and significant air leakage is noted, what should you suspect?

A

major tracheobronchial injury.\nPerform bronchoscopy to determine dx and secure airway.

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38
Q

In a traumatic unstable pt in hypovolemic shock that is presumably due to an abdominal injury, what should be the initial test of choice?

A

Diagnostic peritoneal lavage or FAST scan

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39
Q

Any suspicion of a hollow viscus injury injury during laparoscopy should result in?

A

celiotomy

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40
Q

The FAST exam is extremely sensitive for? Not very sensitive for?

A

Pericardial injuries\nabdominal injuries

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41
Q

The most important part of secondary survey during abdominal trauma?

A

abd exam:\nany peritoneal signs is an indication for celiotomy

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42
Q

Primary survey for abd trauma

A

ABC’s\ncapillary refill\nheart sounds\nneck vein distention\nneuro exam\nupright CXR\nFAST exam

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43
Q

Is an abd CT sensitive in detecting diaphragm injuries?

A

NO!

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44
Q

A 19 y/o presents with a gsw to the epigastric area left of the midline. CT shows the bullet to be lodged in the R psoas muscle. Next step in management?

A

Prepare for laparascopic surgery:\nindwelling catheter, venous line for fluids, dose of broad spectrum antibiotics.

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45
Q

Pt presents after car wreck with tenderness over the left chest wall and xray shows fractures of the 8th–10th ribs. His BP is 85/68 and he has a pulse rate of 128. Next step in management? Then what?

A

Fluid resuscitation/blood transfusion, then if stable go to CT. If not stable, go to peritoneal lavage or US followed by exploratory lap.

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46
Q

Administration of what, is indicated for splenectomy?

A

Vaccines for encapsulated bacteria such as polyvalent pneumococcal vaccination, Hib, and meningococcus

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47
Q

Uncommon but devastating complication with splenectomy? More common in?

A

OPSS:\nMore common in children and those whose spleens are removed due to hematologic disease.

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48
Q

What test may be utilized to check for retained function of the spleen after partial removal?

A

Peripheral blood smear for howell jolley bodies, heinz bodies, and pappenheimer bodies.

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49
Q

Splenectomy for ITP is most likely to provide remission in what population?

A

those who respond to corticosteriods

50
Q

Dx of ITP is confirmed by? Initial txmt?

A

Bone marrow aspirate is seen as hypercellular megakaryocyte count.\nCorticosteroids

51
Q

A pt involved in a crash has a pelvic fx and blood is present in the meatus. Most likely dx? Confirmation?

A

Bladder or urethral injury\nRetrograde urethrogram because urethral injury would be compounded by foley cath

52
Q

A 19 y/o male is involved in a car crash. He presents with a pelvic fx, blood in the meatus, scrotal hematoma, and an inability to urinate. Dx?

A

Posterior urethral injury\nRetrograde urethrogram

53
Q

A pt is inovolved in a high speed auto accident and has a pelvic fx. There was no blood in the meatus and thus an indwelling catheter was placed, reached revealed frank hematuria. Dx? Test?

A

Bladder injury\nRetrograde cystogram

54
Q

John H gets smacked in the nuts with a knee, and presents with a scrotal hematoma the size of a grapefruit and is crying. Next step in management?

A

US for rupture or not. If no rputure, then treat symptoms only.

55
Q

A pt in a high speed car crash has multiple injuries. On insertion of a foley, there is gross hematuria and a retrograde cystogram is normal. Next step? Dx? Management?

A

Kidney injury:\nCT scan\nManagement:\nDoes not need surgery

56
Q

Does microhematuria in a post–trauma adult pt need to be investigated? Child?

A

No\nYes, usually signifies congenital abnormalities. Start with sonogram.

57
Q

Pt presents to the ER reporting that he slipped in the shower and injured his penis. Exam reveals a large penile shaft hematoma with normal glans. Dx?

A

Fx of the tunica albuginea, surgical emergency! consult urology!

58
Q

You get a frantic phone call from a mother who says her 7 y/o spilled drano all over her arms and legs, and she is screaming in pn. What is your initial step?

A

Copious amounts of water for at least 30 minutes before taking to the ER. \nChemical burns are treated with lots of water.

59
Q

A man is electrocuted by a high tension power line, and he has an entrance burn in the upper outer thigh and an exit burn lower down. What is often a complication and its txmt?

A

Myoglobinemia that leads to myglobinuria, and then renal failure. Due to large muscular tisue destruction.\nPt needs IV fluids, antibiotics, Mannitol(diuresis), and alkalinization of the urine.

60
Q

A man is rescued from a burning building, and is noted to have burns around the mouth and nose, with dark black soot within the mouth and throat. Initial step?Test? Management?

A

Intubation for respiratory support.\nCarboxyhemoglobin levels and bronchoscopy

61
Q

A man suffers circumferential burns to his body that are dry, white, and leatherly anesthetic. What complication must you be aware of? PE? Txmt?

A

Circumferential burns will cause edema beneath the area of leather eschar that does not expand. This leads to cut off of the circulation, and in the chest, respiratory compromise. \nMonitor capillary refill and peripheral pulses\nEscharotomy at bedside.

62
Q

Txmt for burns in child who presents with moist, painful, blistering on the buttocks.

A

silvadene(silver sulphadiazine)

63
Q

Formula for fluid resuscitation in burn victims

A

4ccxkg of weightx%burned\n1/2 dose given in 1st 8 hrs!!!\nRINGERS LACTATE!!!!

64
Q

A burn pt undergoes fluid resuscitation over a period of 3 days, however, on the 3rd day he begins to urinate heavily, filling his cath bag over. What is the problem?

A

Nothing;\nThe fluid from his edema has gone back into circulation.

65
Q

Used to treat deep burn areas such as cartilage and thick eschar? Side effect?

A

sulfamyelon\nMetabolic acidosis

66
Q

What would you monitor to ensure that you have given enough fluid resuscitation?

A

CVP= 15 or 20\nUrine output: 1ml/kg/hr

67
Q

Rule indicating % body area of certain parts

A

Rule of 9’s:\nHead is 9, arms are 9 a piece, legs are 18 a piece, and trunk is 36.

68
Q

A 30 y/o man has 2nd and 3rd degree burns on his torso and chest that measure up to 20% of tbsa. What is the definitive txmt?

A

Early wound excision followed by autologous split–thickness skin graft.\n–This is done on small 3rd degree burns\n–Decreases sepsis and increases functional recovery.

69
Q

A gangleader comes in with a small, 1cm deep cut over his knuckle of the right middle finger. He says he did this with a screwdriver. Txmt?

A

Its most likely actually from a tooth that was lodged during a fight. Becuase the oral cavity is a harbinger of bacteria, ortho must come in and surigcally explore.

70
Q

A 69 y/o sailor comes in with a non–healing, indolent ulcer on the lip, 1.5 cm in size, that has been enlarging over the last year. He smokes a pipe, but has no other significant findings. Dx? Confirmation? Txmt?

A

Squamous cell carcinoma\nBiopsy\nSurgical resection with 1cm margins. Local radiation therapy is needed.

71
Q

A 65 y/o Kansas farmer shows up with with an indolent, raised, waxy 1.2 cm skin mass over the nose that has been growing for 3 yrs. There are no enlarged lymph nodes present. What is it? Dx via? Txmt?

A

Basal cell carcinoma:\nFull thickness punch biopsy at the edge\nClear 1cm margin surgical excision

72
Q

A 23 y/o freckled red head presents with an asymmetrical, 1.8cm lesion, with irregular borders and varying colors on her shoulder What is it? Managment?

A

Melanoma\nFull thickness edge biopsy\nSurigical excisoon with clear margins if superficial melanoma(

73
Q

71 y/o kansas farmer presents with a non–healing, indolent, punched out clean 2cm ulcer over the temple that has slowly enlarged over 3 yrs. What is it?

A

Basal cell carcinoma:\nSlowly grows\nBiopsy, surgical excision

74
Q

A change in the appearance of a mole is suggestive of?

A

melanoma

75
Q

A 44 y/o pt presents with multiple liver metastasis, but no primary tumor has been identified. The only PE finding is a missing toe which was removed 30 yrs ago due to a black tumor under the nail. What is it?

A

melanoma:\nCan metastasize slowly over several yrs\nAlt version: glass and history of enucleation for a tumor of the eye…

76
Q

A 23 y/o freckled red head presents with an asymmetrical, 1.8cm lesion, with irregular borders and varying colors on her shoulder What is it? Managment?

A

Melanoma\nFull thickness edge biopsy\nSurigical excisoon with clear margins if superficial melanoma(

77
Q

71 y/o kansas farmer presents with a non–healing, indolent, punched out clean 2cm ulcer over the temple that has slowly enlarged over 3 yrs. What is it?

A

Basal cell carcinoma:\nSlowly grows\nBiopsy, surgical excision

78
Q

A change in the appearance of a mole is suggestive of?

A

melanoma

79
Q

A 44 y/o pt presents with multiple liver metastasis, but no primary tumor has been identified. The only PE finding is a missing toe which was removed 30 yrs ago due to a black tumor under the nail. What is it?

A

melanoma:\nCan metastasize slowly over several yrs\nAlt version: glass and history of enucleation for a tumor of the eye…

80
Q

A 23 y/o freckled red head presents with an asymmetrical, 1.8cm lesion, with irregular borders and varying colors on her shoulder What is it? Managment?

A

Melanoma\nFull thickness edge biopsy\nSurigical excisoon with clear margins if superficial melanoma(

81
Q

71 y/o kansas farmer presents with a non–healing, indolent, punched out clean 2cm ulcer over the temple that has slowly enlarged over 3 yrs. What is it?

A

Basal cell carcinoma:\nSlowly grows\nBiopsy, surgical excision

82
Q

A change in the appearance of a mole is suggestive of?

A

melanoma

83
Q

A 44 y/o pt presents with multiple liver metastasis, but no primary tumor has been identified. The only PE finding is a missing toe which was removed 30 yrs ago due to a black tumor under the nail. What is it?

A

melanoma:\nCan metastasize slowly over several yrs\nAlt version: glass and history of enucleation for a tumor of the eye…

84
Q

A 27 y/o female Mexican immigrant has a 12x10x7 mass in her left breast. It has been there for 7 yrs and has slowly grown. The mass is firm, rubbery, and is not attached to the chest wall or overlying skin. What is it? Management?

A

Cystosarcoma phylloides\nCore or incisional biopsy(may become lamignant), with margin free resection to follow.

85
Q

An 18 y/o has a firm, rubbery mass in the left breast that moves easily with palpation. Next step in management?

A

FNA or core biopsy, or excisional biopsy.

86
Q

At what age may a mammogram be used for screening techniques?

A

28, before then, must use sonogram.

87
Q

A woman with a hx of fibrocystic disease appears with a firm, round, 2cm mass that has not gone away for 6 wks. Next step?

A

Aspiratoion of the cyst w/wo mammogram or sonogram.

88
Q

A 34 y/o has been having bloody discharge from the right nipple, on and off for several months. there are no palpable masses. Management?

A

Intraductal papilloma:\nMammogram 1st to find the papilloma, if negative, then find and resect

89
Q

A 49 y.o. has a firm, 2cm mass in the right breast, that has been present for 3 months. Management?

A

Core or excisional biopsy

90
Q

A 69 y/o woman has a 4cm hard mass in the breast, with ill defined borders, moveable from the chest wall, but not moveable within the breast. The skin overlying the mass is retracted and has ano orange peel appearance. Management?

A

Core or excisional biopsy. If the skin is involved, you could also do a punch biopsy.

91
Q

62 y/o female has an eczematous skin lesion under the areola. It has been present for 3 months and has not gone away with lotions or ointments with steriods.

A

Pagets disease\nPunch biospy or core or excisional

92
Q

A 58 y/o lady discovers a mass in her right axilla. She has a discreet, hard, moveable 2cm mass. Exam of her breast is negative. Management?

A

Mammogram to check for undetectable mass on PE

93
Q

A 62 y/o woman has a routine mammogram done, that reveals an area of increased density with microcalcifications, that is new from previous studies. Management?

A

Stereotactic core biopsy

94
Q

How does FNA and core biopsy differ in their staging of breast malignancy?

A

An FNA can identify malignant cells but cannot differentiate invasive vs in situ cancers.

95
Q

Define stage 1,2,3 breast ca via tumor size

A

T1 2cm,5cm

96
Q

Level 1,2,3 axillary nodes

A

Level 1: lateral to pec minor\nLevel 2: deep to pec minor\nLevel 3: medial to pec minor

97
Q

A 44 yr old lady presents with a 2cm mass in the upper outer quadrant of her right breast. A core(stereotactic) biopsy shows inflitrating ductal carcinoma. She has no palpable nodes. Next steps?

A

Lumpectomy with radiation and axillary lymph node disection for local control, staging, and adjuvent therapy.

98
Q

Most common chemo regime for breast cancer? At what stage is this usually given?

A

FAC:\n5–flourouracil, doxorubicin(adriamycin), and cyclophosphamide.\nStage II, due to increased risk of recurrence and metastasis.

99
Q

A 50 y/o woman presents to the ER with bleeding from her R breast. PE shows a large, ulcerating, fungating mass that is firmly attached to the chest wall, and has grown over the last couple of yrs. Next step?

A

Palliative therapy with chemo. This is advanced Breast CA and is inoperable and incurable.

100
Q

A 38 y/o female is noted to have a painless 1cm left breast mass on PE. There is no skin changes or adenopathy. A FNA reveals malignant cells. Next best step?

A

Core needle biopsy for histology, receptor status, and tumor biology.

101
Q

A 37 y/o lady has a lumpectomy and ALND for a 3cm infiltrating ductal CA. the path report states clear margins and 4/17 nodes are positive. Next step? What if she was postmenopausal?

A

Adjuvent therapy with chemo(becuase this is stage III)\nA postmenopausal women gets hormonal therapy instead of chemo

102
Q

With regards to adjuvent therapy, when is it wise to use chemo vs radiation therapy?

A

Systemic chemo is given to pts who are at risk for, or have stage III/IV. However, because the risk for recurrence is very high in stage II, most are also given the choice of systemic therapy, rather than locoregional. So essentially, only stage I is treated with radiation.

103
Q

A 60 y/o female undergoes lumpectomy for a 0.3 cm tumor. Nodes are negative. Next best step

A

radiation therapy

104
Q

A 39 year old female with a past hx of breast ca, and completed her adjuvent chemo 6 months ago, comes to the office complaining of back pn for 3 weeks, and is tender to palpation. Next step?

A

bone scan

105
Q

Generally, how long is hormonal therapy given to pts with estrogen or progesterone positive breast tumors?

A

5 yrs\nAI’s have actually become the mainstay of therapy dut to their lesser side effect profile.

106
Q

What is the main role of mammography?

A

To detect non palpable breast tumors

107
Q

A 44 year old female undergoes stereotactic core biopsy of a suspicious lesion on mammography. The biopsy reveals lobular carcinoma in situ. Management?

A

Tamoxifen, clinical examination and mammography every 6 months.

108
Q

What txmt has been approved for chemoprevention in high risk breast ca pts and has been reported to reduce occurence of ca?

A

Tamoxifen

109
Q

What risk factor carries the greatest risk of breast ca?

A

BRCA gene

110
Q

Selective pts with a strong family hx of known BRCA gene mutation may be treated with?

A

bilateral prophylactic mastectomy

111
Q

A mother presents to your office with an 18 month old baby and you happen to notice that one of the pupils is white. Next step?

A

Retinoblastoma:\nOptho consult RIGHT NOW!

112
Q

A parent arrives to your office with her child that has “huge, shiny eyes.” What is it?

A

congenital glaucoma

113
Q

ER management of acute glaucoma?

A

Optho consult, diamox or pilocarpine, or mannitol

114
Q

A 77 y/o man suddenly loses sight in his R eye and calls to phone you immediately. He has no pain or other neuro symptoms. Management?

A

Embolic occlusion of the retinal artery:\nSurgical emergency

115
Q

Management of orbital cellulitis

A

CT scan then surgical debridement

116
Q

A 35 yr old woman presents with increased fatigue and a whitish nipple discharge. She has no previous operations, no meds, or health concerns. Next best step?

A

HCG, to rule out preggos\nThen, do prolactin level, and TSH levels for hypothyroidism, before MRI of brain.

117
Q

What condition of nipple discharge is associated with breast CA

A

diffuse papillomatosis

118
Q

A prolactin level of what, is determined suspicious for an adenoma?

A

100ng/mL…bilateral nipple discharge

119
Q

Common causes of gallactorrhea

A

pregnancy\nmedications\nhypothyroidism\npituitary adenoma

120
Q

What test is often recommended for women with nipple dx, that is quicker and may be of more use than cytological examination? A positive result should be managed how?

A

ductogram\nBegin with mammogram for suspicious lesions, then US for retroareolar thickening, and then do ductogram.\nSurgical excisional biopsy

Operative & PeriOperative Care (2 decks)

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