PESTANA3 et al Flashcards
How do you treat a rectal CA less than 5 cm from the anal verge?
Abdominoperineal Resection with end colostomy
What can be given preoperatively to a pt with hemophilia A?
DDAVP (increases vWF which increases the likelihood of binding factor VIII which is deficient- i.e. makes the most out of what you have)
What is the typical progression of sx of a brain tumor
Starts out with months (usually) of headache often worse in morning assoc with nausea or projectile vomiting that may eventually develop focal neurologic deficits
How would you tx a pt s/p CABG with fever, tachy, leukocytosis, and purulent drainage in JP’s?
Surgical debridment of mediastinum with immediate closure and prolonged abx; Acute mediastinitis
What is the most important aspect of managing fat embolus syndrome? How can you technically confirm the dx?
Respiratory support; Fat globules in urine (come on)
What is the cause of elevated PT in pancreatic cancer? What mood abnormality can pancreatic CA cause directly?
Malabsorption of vitamin K due to blockage of the CBD; depression
Name 2 adjuvant therapies for metastatic melanoma
Interferon, Vemurafenib
What problem in the post-op period can masquerade as urinary incontinence?
Urinary retention with overflow incontinence; you should palpate the bladder (bladder scan)
What must be done for a pt with ckd on dialysis preoperatively?
Dialyze 24 hours pre-op
What is the Parkland formula for adults? Kids?
Kg x %BSA x 3-4; Kg x % BSA x 2-3; Give half over the first 8 hours and the rest over the next 16
What is the most likely cause of death in a massive hemoptysis?
i.e. > 600 ml; asphyxiation > exsanguination
What is the deal with perforated diverticulitis mgmt?
If < 3 cm abscess can manage with IV abx and observation; if > 3 cm then CT-guided drainage by IR
What is done if those who wish to become pregnant with h/o prolactinoma fail bromocriptine therapy?
Transnasal transphenoidal surical removal of the prolactinoma
What is the most important diagnostic test in chest trauma after the ABC’s are done?
CXR!
CXR with NGT in pulmonary cavity following trauma
Traumatic rupture of the diaphgragm
What is the treatment for chronic rejection?
There is none it is irreversible (although I’d imagine there is some form of symptomatic mgmt, i.e. inotropes for the heart etc)
What medications must be stopped prior to surgery?
Aspirin, NSAIDs, clopidogrel, vitamin E (2 weeks before surgery); Warfarin 5 days before get INR below 1.5
Colonoscopy shows cyanotic mucosa with sharp transition points?
Ischemic colitis
What is the mgmt of duodenal hematomas?
If obstructing - TPN and NGT until resolve; if do not resolve surgical removal may be needed
What is the timing of fluids that should be given to a burn pt after calculating how much they need via the Parkland formula?
Half over the first 8 hours and the second half over the next 16 (cut the rate of the first half in half)
Where is the AS murmur best heard
Harsh midsystolic in R second IC space
What should you do when there is a large stone (i.e. 7mm or more at the UPJ )?
Extra-Corporeal Shockwave Lithotripsy (ESWL) – if not then basket extraction, laser, sonic probe, or even open surgery
What is the minimum FEV1 needed in order for a non-small cell CA to be operated on with pneumonectomy?
800 ml (that is if there is less than 800 predicted after surgery they are not a surgical candidate and need chemoradiation instead)
What is the appropriate way to excise a parotid tumor
Never open biopsy always do either a superficial parotidectomy if superficial to facial nerve or deep parotidectomy if deep to it
What is the classic presentation of ureteropelvic junction obstruction?
Colicky pain after a large diuresis (i.e. maybe someone with ICP needs mannitol or a kid who binge drinks for the first time) since the jxn can handle the usual volume but when a large volume is encountered it is an issue
How should you give antibiotics to burn pts?
Topically (silver sulfadiazine, mafenide acetate, triple abx cream)
When is surgery indicated in aortic insufficiency
At the first echocardiographic indication of LV dilatation
What abx penetrates the burn eschar but hurts like hell?
Mafenide acetate
What causes hyperacute rejection?
Preformed antibodies
What is the best initial mgmt of early dumping syndrome?
Dietary modification as it often resolves, if not octreotide can be added; ultimately conversion to roux en Y may be needed
What EKG findings may be seen in a pt s/p thyroidectomy?
QTc prolongation due to hypocalcemia from iatrogenic hypoparathyroidism
What is the number 1 cause of death in burn victims in the setting of adequate volume resuscitation?
Bacterial infxn
How do you manage post-pericardiotomy syndrome?
NSAIDs and steroids with pericardiocentisis if tamponade physiology develops
How does elevation of head of bed decrease ICP? How does sedation?
Increases venous outflow; decreases metabolic demand of the brain
Care must be taken to avoid too much of what dietary component in a ventilated pt?
Carbs; it can increase the respiratory quotient and give them a respiratory acidosis secondary to hypercarbia that will make weaning more difficult
What test is diagnostic for atrial septal defect? What is the mgmt?
echo; surgical closure or catheterization
What is the first line therapy for acute organ rejection?
steroid boluses
When can anticoagulation safely be restarted post-op?
In 48-72 hours if pt is hemodynamically stable
What drug is indicated in asymptomatic bradycardia?
none; but if symptomatic, then atropine would be first line
After doing a DRE and finding a tender prostate c/w acute bacterial prostatitis how often should you do serial DRE’s?
Try not to do them as palpation of the infected prostate can cause sepsis
What are the 2 indications for surgery in aortic stenosis
When there are indications of CHF (syncope, angina, or dyspnea); or when the valvular gradient is greater than 50 mmHg
How do you diagnose a cancer of the lung if sputum cytology is equivocal?
Percutaneous bx for peripheral lesions or bronchoscopy (EBUS) for internal lesions; if those are unsuccessful then VATS with wedge resection
What abx does not penetrate the burn eschar and can cause hyponatremia and hypokalemia
Silver nitrate
Which IBD more classically has rectal bleeding
UC
What is excruciating back pain in a normotensive pt with known AAA
It is already leaking into the retroperitoneum and blowout into the peritoneal cavity is minutes to hours away
How do you avoid a workup for lung CA when you find a “coin lesion” on CXR?
Check to see if there is an old film in which the lesion was present and verify that it is unchanged since
How would you work up galactorrhea and amenorrhea in a young woman?
rule out pregnancy, rule out hypothryoidism, determine prolactin levels and if high do MRI of brain
How do you manage a tender AAA?
It will probably rupture within the next day or 2 so immediate repair is indicated
How do you manage a kid who cant pee after being born?
Insert foley catheter to decompress bladder; A voiding cysteourethrogram should then be done (you are looking for posterior urethral valves) these can then be fulgurated or resected
What is a fleshy immobile mass on the hard palate most likely to be? What is the tx?
Torus palatinus (exostosis of midline suture); if ulcerates or symptomatic, surgery can fix
Shock in a post-surgical pt is presumed to be from what until proven otherwise?
Hemorrhage!
Which cyanotic heart lesion kills more like a noncyanotic heart lesion?
Truncus arteriosus because it overloads the pulmonary circ
What is urine dripping out of the vagina of a small girl suggestive of? What test can be ordered?
Low implantation of the ureter; intravenous pyelogram will show it
If an elderly person with comorbidities fractures their hip when should they go to OR?
The rule is ASAP, BUT, surgery can be delayed 48-72 hours in order to optimize their health
Nasal whistling after rhinoplasty is most likely due to?
Septal perforation
How is the presentation of a brain abscess different from a brain tumor?
Much shorter timetable and often a fever and a clear source such as otitis media or mastoiditis
What is the most important prognostic factor in a developing comparment syndrome?
Time to fasciotomy
Why should you bolus a pt with IVF prior to putting them on a ventilator?
In a pt with low CVP, positive pressure ventilation will increase the intrathoracic pressure and lower CVP even more
For which lung cancers must you assess operability?
Non-small cells only
What should be added to pre-op orders in a pt who is on warfarin and needs and ex lap
FFP
What nodal mets are ok in lung CA surgically and which preclude a curative resection?
Hilar mets are ok but carinal and mediastinal mets preclude curative resection
What are 2 absolute contraindications to surgery?
Diabetic coma (nonketotic hyperosmolar coma) and DKA
Why is there decreased capillary refill in trauma?
There is peripheral vasoconstriction
What abx does not penetrate a burn eschar and can cause leukopenia?
Silver sulfadiazine
What condition must be ruled out when acute epididymitis is suspected?
Testicular torsion; so still perform a US doppler but in torsion the cord is not tender and it is in epididymitis; epididymitis is treated with antibiotics
If you are to confirm a diagnosis of pericardial tamponade, in trauma, how would you do it?
FAST; a CXR would not show an enlarged cardiac silohuette since it is acute and the pericardium has not had time to expand
What is the best treatment of a massive hemoptysis (i.e. > 600 ml)
Bronchoscopy
Which congenital defect often has a history of frequent colds?
atrial septal defect
What should you think if a person has facial nerve paralysis after trauma? What if they were normal at first but develop it later?
There is true trauma to the facial nerve; there is swelling that is affecting it but it will go away with time
How is a brain tumor most likely to present in a child?
With cerebellar symptoms like stumbling or ataxia
What is the clicking sensation of a Morton neuroma called?
Mulder sign
How do tumors of the pineal gland present?
Parinaud syndrome (loss of upper gaze)
What margins are needed for basal cell CA?
1 mm negative margins
What is the surgical mgmt of mitral stenosis? What is the surgical mgmt of mitral regurg?
Commissurotomy or balloon valvuloplasty; Annuloplasty (preferred over replacement)
What is the number 1 cause of a central line infxn?
S. epidermidis (CoNS)
What occurs when there is bleeding into the pituitary?
Pituitary apoplexy - look for clues or a hx of pituitary tumor with an acute event i.e. headache, visual changes, and signs of pituitary destruction like stupor and hypotension
How do you establish an airway in a pt with poor pulse ox and serious maxillofacial trauma?
Crictothryotomy
How is tic dolouroux managed?
Often successfully with anticonvulsants (carbamazepine (Tegretol)); if not radiofrequency ablation
What should you think when a baby has respiratory distress with a “crowing respiration” i.e. hyperextends the neck?
Vascular rings or laryngomalacia; if difficulty swallowing is also present it is most likely a vascular ring if only the resp sx are present then probs laryngomalacia
What mode on the ventilator setting is important for weaning a pt?
Pressure support (i.e. a pt controls the rate but gets a boost of pressure)
What is the best initial step in mgmt of an electrical burn?
EKG; if abnml admit to telemetry floor 48 hours
What is the treatment of a contrast enhancing cyst on CT of kidneys?
Surgical excision by nephrectomy or nephron-sparing nephrectomy; This is a Bosniak III-IV lesion
What is the most likely cause of immediate post-op fever in a pt who was tranfused?
Febrile nonhemolytic transfusion rxn (fever and chills occur since leukocytes in the stored blood still release cytokines)
What is the only absolute contraindication to organ donation?
Positive HIV status
What is technically the most accurate test for detecting DAI?
MRI; though classically, minute punctate hemorrhages the grey white jxn are picked up on CT of head in trauma
What is the safe INR preoperatively?
1.5
Moh’s microsurgery is standard of care for what?
Squamous cell carcinoma of the skin
What can present in a similar manner to a ruptured AAA but occurs within 12 hours of angiogram?
Retroperitoneal hematoma from groin access site; i.e. the ateriotomy site will seem normal because the hematoma is spreading retrograde (Dx = non con CT)
How do you diagnose and treat reflex sympathetic dystrophy?
A sympathetic block is diagnostic and sympathectomy is curative
What if you have ureteral colic type symptoms and a distended abdomen?
Probably a ureteral stone with a vagus rxn causing paralytic ileus
What if you need to anticoagulate someone with antithrombin III deficiency?
Cant give heparin!!!
What is the operative mgmt of a kid with a vascular ring?
i.e. a double aortic arch; surgically divide the smaller of the arches
Why must you be careful giving too much supplemental O2 to a COPD pt in the post-op period?
Too much O2 can suppress the respiratory drive
What is the most likely cause of signs of deteriorating liver function in the first few days after a liver transplant?
Technical difficulities from the surgery not acute rejection; the first step is to get a US for CBD obstruction and doppler for vascular thrombosis
What do you do in a pt with penetrating abdominal trauma who is stable? Unstable? What do you do in a pt with blunt abdominal trauma who is stable? Unstable?
FAST or DPL; Ex lap w/ tetanus ppx; CT; Ex lap w/ tetanus ppx
If a urine dipstick is positive for blood but negative for RBC’s, what electrolyte may also be elevated?
K; since myoglobinuria is assoc. with cellular damage and leakage of K (hyperkalemia)
How do you workup a painless testicular mass?
Radical orchiectomy via inguinal route with pre-op tumor markers B-hCG and AFP; most testicular tumors are very radiosensitive and chemosensitive
What is the indication for high dose steroids in burn victims?
There is none, since burn victims are already hyperglycemic and immunosuppressed! Steroids would worsen both of these
What would the arm symptoms minus the neurologic symptoms of subclavian steal be?
Thoracic outlet obstruction
What is the mgmt of non-small cell central lung lesion? Peripheral?
Pneumonectomy; Lobectomy
What is the best initial treatment if you suspect smoke inhalation? What is the best test?
100% O2 via non-rebreather mask with low threshold for intubation; Carboxyhemoglobin levels as pulse ox is useless
How do you manage a UTI in children?
Should always have a “urologic workup” just like in men since it is a complicated UTI so a voiding cystorurethrogram or US
How do you treat incomplete arterial occlusions vs. complete arterial occlusions?
Incomplete can be txd with thrombolytics; complete can be treated with Fogarty catheter embolectomy and often times a fasciotomy; done within 6 hours
In what category is stress incontinence commonly seen?
Middle aged women who have had lots of kids who leak urine when laughing, sneezing, etc.
What should you start considering when there is fracture of the first or second rib?
Possible underlying aortic or carotid injury (CXR and carotid US)
What determines whether a superficial or deep parotidectomy is done?
The location of the tumor with respect to the facial nerve
What is the next best step after intubating a pt?
Check for breath sounds bilaterally; if only one one side prob intubated a main bronchus so pull back on the tube
What is the usual mechanism by which a person acquires a psoas abscess?
Hematogenous spread
What is the most common cause for a newborn boy to not urinate after being born?
Posterior urethral valves (keyhole deformity); also look for meatal stenosis
Can a person with hepatitis be an organ donor?
yes but only if the recipient also has the same hepatitis
What is a major difference in the clinical presentation of a occlusive cause of stroke (thrombotic or embolic) vs a hemorrhagic cause?
Occlusive causes often have no headache while hemorrhagic causes often have a headache
What is the treatment for small cell CA?
Chemoradiation
What if a coin lesion is found on CXR and there is no old film to compare it to?
Check sputum cytology and get CT of chest and upper abdomen (i.e. to evaluate the liver for mets)
What should you think if there are nosebleeds in an 18 year old
Suspect cocaine or juvenile angiofibroma (requires surgery but is benign)
What surgery should not be done on a kid with hypospadias?
Circumcision as you need the excess skin for the reconstruction
A person was transfused with blood 4 hours ago and is developing respiratory distress with a normal PCWP?
TRALI
What is the cause of bloody bowel movements IMMEDIATELY after AAA repair?
Ischemic colitis from compromising the IMA; if months or years after it could be a Aortoenteric fistula but these are rare and it would probably more likely be a diverticular bleed
While waiting for surgery of a brain tumor, how is ICP treated?
Dexamethasone (Decadron)
What surgery can be done for hormonal control in prostatic CA?
Orchiectomy
What will a CT of pancreatitis show?
Maybe nothing but can show enlarged pancreas with stranding of adjacent fat planes
What are the best tests for painless jaundice?
Helical CT scan or endoscopic US
When do you start screening colonoscopies in pts with FMHx of FAP?
10 years old
How do you treat Ludwig angina?
I/D and possibly need to intubate
Fever, white count, and elevated LFT’s in a hospitalized pt in the absence of hypotension
Acalculous cholecystitis; if hypotensive could be shock liver
Emphysematous cholecystitis is often seen in pts with what other condition?
Type II DM
What is the concern if there is a high BUN (>100) prior to surgery?
Bleeding secondary to qualitative platelet dysfunction (normal platelets, increased bleeding time)
How does the workup of pneumaturia start?
CT scan since it is probably diverticulitis or crohns
What can an organ donor with metastatic cancer donate?
Cornea
What is Foster-Kennedy syndrome?
A tumor at the base of the frontal lobe that produces inappropriate behavior, optic nerve atrophy on the side of the tumor, papilledema and anosmia
What chronic issue may occur secondary to compartment syndrome?
Volkmann’s Ischemic Contracture - a deformed extremity as a result of dead muscle being replaced by fibrous tissue
How is hyperacute rejection prevented?
ABO matching and lymphocytic crossmatching
What anesthetic drug can precipitate adrenal crisis in pts with known HPA supression?
Etomidate, avoid in anyone on chronic steroid use (> 20 mg per d for 3 weeks)
How do you manage a pt who has been trying to spontaneously pass a ureteral stone that suddenly becomes febrile, and has chills?
IV abx, and immediate decompression of the urinary tract with either a percutaneous nephrostomy or a ureteral stent
When is surgery indicated in patent ductus arteriosus?
Those who fail indomethacin, already in CHF, or a full term baby
