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Clinical: General Surgery > Preoperative and Postoperative Care > Flashcards

Preoperative and Postoperative Care Flashcards

1
Q

what age pts should receive a preoperative EKGs

A

40 and older

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2
Q

if a patient has a prior hx of MI, what is the risk for post op MI?

A

5-10% risk

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3
Q

should patients taking antihypertensive medications take them the day of surgery

A

yes! take on the day of the procedure

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4
Q

when should patients optimally discontinue smoking prior to surgery

A

at least 8 weeks prior to scheduled surgery

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5
Q

what should be given to a patient with a hx of rheumatic heart disease undergoing surgery

A

prophylactic antibiotic therapy

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6
Q

what needs to be obtained prior to surgery for a patient with COPD

A
  • should be aggressively treated in order to achieve their best possible baseline level of function
  • a minimum of one week of therapy including cessation of smoking, admin of abx for purulent sputum and bronchodilators when indicated
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7
Q

for elective surgery, pts with asthma should have a peak expiratory flow rate greater than what prior to surgery

A

greater than 80 % of predicted or of their personal best prior to surgery

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8
Q

what needs to be administered to pts with asthma that require endotracheal intubation

A

administer an inhaled rapid-acting beta agonist two to four puffs or a nebulizer treatment within 30 minutes before intubation

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9
Q

what respiratory tract infections are absolute contraindications for elective surgery

A

tracheitis
bronchitis
pneumonia

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10
Q

in a pt with acute lower respiratory tract infection requiring emergency surgery, what needs to be done

A

humidification of inhaled gas
removal of lung secretions
continued administration of bronchodilators and antibiotics

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11
Q

what is the best perioperative glucose control for diabetic patients

A

IV insulin

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12
Q

what is postop glycemic control BG goals

A

Normal: 90-100mg/dL, preferred’ control with IV insulin
Mod control: 120-200mg/dL

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13
Q

what medications are commonly used for DVT/PE prophylaxis

A

Subcutaneous Heparin and Low-molecular-weight-heparin

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14
Q

what are scoring systems used for developing a postop VTE guide

A

Caprini Score for Venous Thromboembolism
American College of Chest Physicians (ACCP) recommendations

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15
Q

what is the leading preventable cause of death in the US?

A

Cigarette smoking

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16
Q

what are signs of tobacco intoxication

A

restlessness, insomnia, anxiety and arrhythmias

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17
Q

what are signs of tobacco withdrawal

A

irritability, HA, anxiety, weight gain, cravings

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18
Q

what is the treatment of tobacco use/dependence

A

cessation
- Buproprion
- Varenicline (chantix)
- Nicotine via other routes

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19
Q

what is the MOA of chantix

A

partial nicotine receptor agonists
mediates partial reward of nicotine yet blocks reward of nicotine

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20
Q

what medication has the highest success rate for smoking cessation

A

Varenicline (chantix)

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21
Q
A
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22
Q

what are signs of LSD use

A

pt wants to hurt themself. they state that they have ‘been freaking out’ and seeing things that arent there

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23
Q

what are common inhalants used to obtain a high

A

paint, petroleum, toluene, glues and nail polish

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24
Q

what is the MOA of Opioids

A

Mu receptor agonists
ex. morphine, heroin, methadone

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25
Q

what is the MOA of cocaine

A

block biogenic amine dopamine(DA), norepi (NE) and serotonin (5-HT) reuptake

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26
Q

what is the MOA of amphetamines

A

stimulates biogenic amine (DA, NE and 5HT) release and decreases reuptake

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27
Q

what is the MOA of MDMA (ecstacy)

A

effects 5HT more than dopamine acting similar to amphetamines. may damage serotonergic neurons

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28
Q

what are the 5W’s of post op fever

A

Wind-atelectasis (first 24-48hrs)
Water - UTI (anytime after POD3)
Wound - wound infxn (usu. after POD5)
Walking - DVT/thrombophlebitis (POD7-10)
Wonder Drugs - drug fever (anytime)

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29
Q

when do wound infections usually appear

A

between 5-10 days s/p surgery

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30
Q

what is the presentation of wound infections

A

pain at incision site,. erythema, drainage, inducation, warm skin, fever (usually first sign)

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31
Q

what is the most common etiology of wound infections

A

S. aureus (20%)
E.coli and enterococcus (10% each)

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32
Q

what is the treatment of wound infection

A

removal of skin sutures/staples
rule out fascial dehiscence
pack wounds open
send wound culture
administer abx

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33
Q

what is wound healing by secondary intention

A

delayed closures - leaving open wound to heal inside to outside

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34
Q

what are signs of DVT

A

leg pain and swelling
calf pain with dorsiflexion of foot
positive d-dimer

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35
Q

what is virchows triad

A

stasis, vascular injury, hypercoagulable state

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36
Q

what tests are used for DVT

A

d-dimer, venous duplex US (first line), venography (gold standard)

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37
Q

what is Homan sign

A

discomfort behind knee on forced dorsiflexion of the foot

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38
Q

what is the treatment of DVT

A

heparin to coumadin bridge

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39
Q

when is there an increase in fluid requirements

A

fever, hyperventilation and increased catabolism

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40
Q

what is the general rule for daily fluid deliver

A

2000-2500 mL of 5% dextrose in NS or LR solution

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41
Q

what should be avoided for the first 24 hours after surgery for fluids

A

potassium because it is increased during surgery (stress)

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42
Q

what surgical patients need to have ionized serum calcium replaced

A

s/p thyroidectomy or parathyoridectomy

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43
Q

what are indication for urinary catheter placement for surgery

A

anticipating long procedure
performing urologic or low pelvic surgery
need to monitor fluid balance

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44
Q

what is seen on EKG with hyperkalemia

A

peaked T waves

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45
Q

what is seen on EKg with hypokalemia

A

flattened T waves, U waves

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46
Q

what is seen on EKG with hypocalcemia

A

Long QT

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47
Q

what is seen on EKg with hypercalcemia

A

short QT

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48
Q

what is seen on EKG with hypomagnesemia

A

tall T waves

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49
Q

what is seen on EKg with hypermagnesemia

A

prolonged PR interval widened QRS

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50
Q

what is presumed if a patient has low urine sodium and polyuria, urine osmolality of less than 250 despite hypernatremia

A

diabetes insipidus

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51
Q

what is a deficient secretion of vasopressin from posterior pituitary

A

neurogenic (central) diabetes insipidus

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52
Q

what is caused by kidneys that are unresponsive to normal vasopressin levels

A

nephrogenic diabetes insipidus

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53
Q

what is the definition of hyponatremia

A

plasma sodium concentration less than 135mEq/L

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54
Q

how is hypernatremia defined

A

plasma sodium concentration greater than 145 mEq/L

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55
Q

what are the normal acid/base values

A

24 (HCOS, base)
7.4 (pH)
40 (CO2, acid)

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56
Q

what is the three step process to assessing acid-base disorders

A
  1. Look at pH (normal 7.35-7.45) - <7.35 (acidosis), >7.45 (alkalosis)
  2. Look at PCO2 (35-45 normal) - high CO2 and low pH - respiratory acidosis; low CO2 and high pH - Resp alkalosis
  3. finally, look at HCO3 (20-26 normal) - low HCO3 and low pH= metabolic acidosis, high HCO3 and High pH = metabolic alkalosis
57
Q

what are the values and causes for respiratory acidosis

A

values: pH 7.3, PCO2 60, Bicarb 22
causes: lungs fail to excrete CO2 - breathing too slow

58
Q

what are values and causes of respiratory alkalosis

A

values: pH 7.52, PCO2 25, HCO3 22
causes: excessive elimination of COS (breathing too fast)

59
Q

what are values and causes of metabolic acidosis

A

values: pH 7.3, PCO2 40, HCO3 16
causes: MUDPILES (methanol, uremia, DK, paraldehyde, infxn, lactic acidosis, ethylene glycol, salicylates

60
Q

What are values and causes of metabolic alkalosis

A

values: pH 7.52, PCO2 40, HCO3 40
Causes: loss of hydrogen (vomiting), bulimia, OD on antacids, addition of bicarbonate

61
Q

a 65yo male with hx of COPD and asthma is scheduled for elective hernia repair. during preop assessment, which of the following is the most appropriate management strategy to minimize his risk of pulmonary complications?
a. postpone surgery until complete resolution of COPD/asthma symptoms
b. admin high-dose systemic corticosteroids preoperatively
c. optimize his pulmonary condition, including bronchodilator therapy
d. proceed with surgery without any additional pulmonary interventions
e. perform surgery under local anesthesia only

A

c. optimize his pulmonary condition, including bronchodilator therapy

62
Q

55yo female with hx of T2DM is scheduled for elective cholecystecomty. her DM is poorly controlled, with a recent HbA1c of 9.2%. in the perioperative period, which of the following is most appropriate management strategy for her diabetes?
a. d/c all diabetic medications immediately before surgery to avoid hypoglycemia
b. switch to insulin therapy if not already on it to closely monitor blood glucose levels
c. continue oral hypoglycemic agents on the day of surgery
d. administer high-dose corticosteroids to manage stress hyperglycemia
e. no specific diabetic management is required if the pt is asymptomatic

A

b. switch to insulin therapy if not already on it to closely monitor blood glucose levels

63
Q

a 36yo female present for refill of her OCPs. she admits to smoking one pack of cigarettes per day. she should be counseled with regards to her risk of
a. venous thrombosis
b. varicose veins
c. atherosclerosis
d. peripheral edema

A

a. venous thrombosis

64
Q

which of the following dx test should be ordered initially to evaluate for suspected DVT of the leg?
a. venogram
b. arteriogram
c. duplex US
d. impendence plethysmorgrpahy

A

c. duplex US

65
Q

a 55yo pt presents with first episode of LE DVT confirmed with Doppler US. pt has ho hx of cancer, is hemodynamically stable, and shows no sign of severe symptoms or complications. which of the following is the most appropriate initial treatment?
a. admin IV UFH
b. IVC filter placement
c. Initiation of DOAC
d. thrombolytic therapy with alteplase
e. warfain with heparin bridge

A

c. initiation of DOAC
(DOACS like rivaroxiaban, apixaban and dabigatran, are now considered first line for most uncomplicated DVT cases.)

66
Q

smoking does not increase risk for which one of the following postoperative complications?
a. pneumonia
b. myocardial ischemia
c. Nausea and vomiting
d. wound infection
e. nonunion of fractured bones

A

c. nausea and vomiting

67
Q

what is the most common cause of fever on postop days 1-2

A

Wind - atelectasis (most likely cytokine release from tissue damage)

68
Q

what is a “complete” fever workup?

A

PE (look at wound, etc)
CXR
UA
Blood cultures
CBC

69
Q

what causes fever before 24 hours post op?

A

atelectasis, cytokine release, b-hemolytic streptococcal or clostridia wound infections, anastomotic leak

70
Q

what causes fever from post op days 3-5?

A

UTI
Pneumonia
IV site infection
wound infection

71
Q

what is an anesthetic cause of fever INTRAoperatively?

A

Malignant hyperthermia

72
Q

what is the treatment for malignant hyperthermia

A

Dantrolene

73
Q

what causes fever from post op days 5-10?

A

wound infxn
pneumonia
abscess
infected hematoma
c.diff
anastomotic leak
DVT
drug fever
PE

74
Q

what causes wound infection on post op days 1-2

A

Streptococcus clostridia (painful bronze-brown weeping wound)

75
Q

what are the most common bacteria found in post op wound infections?

A

S. aureus
ecoli
enterococcus

76
Q

what is a “clean” wound?

A

elective, nontraumatic wound without acute inflammation; usually closed primarily without use of drains

77
Q

what is a clean-contaminated wound?

A

operation on GI or respiratory tract without contamination or entry into biliary or urinary tract

78
Q

what is a contaminated wound?

A

acute inflammation, traumatic wound, GI tract spillage, or major break in sterile technique

79
Q

what is a dirty wound?

A

pus present, perforated viscus or dirty traumatic wound

80
Q

Name the electrolyte disorder which causes peaked T waves

A

Hyperkalemia

81
Q

Name the electrolyte disorder which cause flattened T waves, U waves

A

Hypokalemia

82
Q

Name the electrolyte disorder which cause long QT

A

Hypocalcemia

83
Q

Name the electrolyte disorder which causes short QT

A

hypercalcemia

84
Q

Name the electrolyte disorder which cause tall T waves

A

Hypomagnesemia

85
Q

Name the electrolyte disorder which cause prolonged PR interval widened QRS

A

Hypermagnesemia

86
Q

Low urine sodium and polyuria, urine osmolality of less than 250 despite hypernatremia

A

Diabetes insipidus

87
Q

deficient secretion of vasopressin

A

Neurogenic (central) diabetes insipidus

88
Q

Hyponatremia is defined as plasma sodium concentration less than ________ mEq/L

A

135 mEq/L

89
Q

what is the treatment of asymptomatic hyponatremia?

A

fluid restriction

90
Q

doughy skin with skin tenting may represent which electrolyte abnormality?

A

Hypernatremia

91
Q

what is the most common electrolyte abnormality with furosemide or bumetanide?

A

Hypokalemia

92
Q

what other electrolyte must be corrected in the tx of hypokalemia?

A

Magnesium

93
Q

what electrolyte abnormality potentiates the cardiac toxicity of digoxin?

A

Hypokalemia

94
Q

A patient with the following ABG has what type of acid-base disorder? pH 7.52, PCO2 25, Bicarb 22.
A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

(ph 7.35-7.45, PCO2 35-45, Bicarb 20-26 - normals)

A

B. Respiratory alkalosis

95
Q

A pt with the following ABG has what type of acid-base disorder? pH 7.52, PCO2 40, Bicarb 38
A. respiratory Acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

(ph 7.35-7.45, PCO2 35-45, Bicarb 20-26 - normals)

A

D. metabolic alkalosis

96
Q

A pt with the following ABG has what type of acid-base disorder? ph 7.30, PCO2 60, bicarb 22
A. respiratory Acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

(ph 7.35-7.45, PCO2 35-45, Bicarb 20-26 - normals)

A

A. Respiratory Acidosis

97
Q

A pt with the following ABG has what type of acid-base disorder? ph7.30, PCO2 40, Bicarb 16

A. respiratory Acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis
(ph 7.35-7.45, PCO2 35-45, Bicarb 20-26 - normals)

A

C. Metabolic acidosis

98
Q

a 55yo male is seen in follow-up for a complaint of chest pain. pt states that he has had this chest pain for about one year now. the pt further states that the pain is retrosternal with radiation to the jaw. “it feels as though a tightness, or heaviness is on and around my chest”. This pain seems to come on with exertion however, the past two weeks he has noticed that he has episodes while at rest. if the pt remains inactive the pain usually resolved in 15-20 minutes. pt has a 60-pack year smoking hx and drinks a martini daily at lunch. pt appears overweight on inspection. based upon this hx what is the most likely diagnosis?
a. acute MI
b. preinzmetal variant angina
c. stable angina
d. unstable angina

A

d. unstable angina

99
Q

a 58yo male who is otherwise healthy presents with chest pain and is found to have left main coronary artery stenosis of 75%. the most important aspect of his management now is…
a. daily ASA to prevent MI
b. nitrate therapy for angina
c. aggressive risk factor reduction
d. referral for coronary artery revascularization

A

d. referral for coronary artery revascularization

100
Q

a 60yo male with hx of HTN and hyperlipidemia presents with intermittent chest heaviness for one month. the pt states he has had occasional heaviness in his chest while walking on the treadmill at home or shoveling snow. he also admits to mild dyspnea on exertion. his symptoms are relieved with 2-4 minutes of rest. he denies lightheadedness, syncope, orthopnea, or lower extremity edema. vitals reveal a BP of 130/90, HR 70, regular, RR 14. cardiac exam revealed a normal S1 and S2, without MRG. lungs were clear to auscultation. extremities are without edema. EKG reveals no acute changes and cardiac enzymes are negative. which of the following is the most appropriate next diagnostic study?
a. Cardiac catheterization
b. nuclear exercise stress test
c. helical (spiral) CT
transthoracic enchocardiogram

A

b. nuclear exercise stress test

101
Q

a 60yo male is brought to the ED complaining of severe onset of chest pain and intrascapular pain. the pt states that the pain feels as though “something is ripping and tearing”. the pt appears shocky; the skin is cool and clammy. the pt has an impaired sensorium. PE reveals a loud diastolic murmur and variation in BP between the right and left arm. based on this presentation, what is the most likely diagnosis?
a. aortic dissection
b. acute MI
c. cardiac tamponade
d. PE
e. thoracic aortic aneurysm

A

a. aortic dissection

102
Q

what type of chest pain is most commonly associated with a dissecting aortic aneurysm?
a. squeezing
b. dull, aching
c. ripping, tearing
d. burning
e. sharp and stabbing

A

c. ripping, tearing

103
Q

for a asymptomatic abdominal aortic aneurysm measuring 5.5cm in diameter in a male pt, which of the following is the most appropriate management strategy?
a. immediate open surgical repair
b. endovascular aneurysm repair (EVAR)
c. serial US monitoring every 6 months
d. aggressive control of HTN with medication
e. lifestyle modifications only

A

b. endovascular aneurysm repair (EVAR)

104
Q

what are causes of aortic aneurysm?

A

HTN
atherosclerosis
infection
trauma
hereditary/acquired connective tissue disorders

105
Q

are aortic aneurysm more common in men or women?

A

Men: 10:1

106
Q

what is the gold standard dx modality of AAA?

A

angiography

107
Q

what is the MC location of AAA

A

Infrarenal aorta

108
Q

what is screening recommendation for AAA?

A

US
males age 65-75 and ever a smoker

109
Q

what is the tx of ruptured AAA?

A

Emergent surgery

110
Q

A pt presents with sudden-onset chest and back pain. further work-up reveals an ischemic right leg. what is your dx?

A

suspect an acute aortic dissection when chest or back pain is associated with ischemic and/or neurologic deficits

111
Q

where do aortic dissections most commonly occur?

A

proximal ascending aorta

112
Q

what may an XR of a pt with aortic dissection reveal?

A

widening the superior mediastinum

113
Q

what is the gold standard evaluation of aortic dissection?

A

MRI angiography

114
Q

which drugs should be administered to lower the BP in a pt with thoracic aortic dissection?

A

sodium Nitroprusside. a BB should also be used to reduce the dp/dt

115
Q

what is intermittent claudication?

A

pain, cramping, or both of LE usually in calf muscle, after walking a specific distance; then the pain/cramping resolves after stropping for a specific amount of time while standing

116
Q

What is Leriche’s syndrome?

A

claudication of the buttocks and thighs, impotence, atrophy of legs

117
Q

What ABIs are associated with Normlas, claudicators and rest pain?

A

Normal ABI: >1.0
Claudicator ABI: <0.6
Rest pain ABI: <0.4

118
Q

a 64yo pt with known hx of T1DM for 50 years has developed pain radiating from right buttock to the calf. pt states that the pain is made worse with walking and climbing stairs. based upon this hx which of the following would be most appropriate test to order?

A

arterial duplex scanning

119
Q

56yo male with known hx of polycythemia suddenly compains of pain and paresthesia in left leg. PE reveals left leg is cool to the touch and toes are cyanotic. popliteal pulse is absent by palpation and Doppler. the femoral pulse is absent by palpation but weak with doppler. the right leg and UE has 2+ and 4+ pulses throughout. given these findings what is the most likely diagnosis?
a. Venous thrombosis
B. arterial thrombosis
C. thomboangiitis obliterans
d. thrombophlebitis

A

b. arterial thrombosis

120
Q

a pt presents with an acutely painful and cold left leg. distal pulses are absent. leg is cyanotic. there are no signs of gangrene or other open lesions. symptoms occurred one hour ago. which of the following treatments is most appropriate?
a. vena cava filter
b. embolectomy
c. amputation
d aspirin

A

b. embolectomy

121
Q

what is the most common cause of embolus from the heart?

A

Afib

122
Q

what is the most common site of arterial occlusion by an embolus?

A

common femoral artery (SFA is m/c due to atherosclerosis)

123
Q

what is a Fogarty?

A

fogarty balloon catheter

124
Q

76yo male with 5yr hx of afib presents to the ED wtih an inability to move his left leg. the pt notes that he first noted that his leg “felt funny” about 2 hours ago, and that it appeared to be more pale than normal. since the leg started feeling funny, his ability to move it has decreased, to the point where he can no longer move it. he recently ran out of his warfain and has not taken any in 2 weeks. on PE his vitals are WNL. Neuro exam reveals pale, painful leg with absent femoral pulese and dorsalis pedis pulses. he has no other strength deficits and pulses in right leg and right arm are intact. which of the following would be the appropriate first action for this pts condition?
a. thrombolysis
b. embolectomy
c. fasciotomy
d. amputation
e. no intervention necessary

A

b. embolectomy

125
Q

pharmacologic management of peripheral arterial disease includes:
a. elastic compression stockings
b. CCB
c. cilostazol
d. warfain
e. propranolol

A

c. cilostazol

126
Q

72yo smoker with positive hx of severe degenerative arthritis, DM, and CVD presents to your office complaining of bilateral leg pain that occurs after walking 200 years. he reports that rest improves his symptoms. which of the following would be appropriate?
a. ABI
b. MRI of lumbar spine
c. US of LE
d. EMG Of LE
e. arteriogram of LE

A

A. ABI

127
Q

what is the most common site of arterial atherosclerotic occlusion in LE

A

occlusion of superficial femoral artery (SFA) in hunters canal

128
Q

How can the medical conservative treatment for claudication be remembered?

A

PACE
pentoxifylline
ASA
cessation of smoking
exercise

129
Q

28yo woman is admitted to hospital for further evaluation of her syncopal episodes after a Holter monitor reveals three runs of SVT that lasted between 20-30 seconds. while in the hospital, her monitor tracings reveal multifocal PVCs. she has no symptoms, a 12 lead ECG is w/o evidence of ST-segment elevation or depression. what study would you recommend to evaluate her ventricular excitability?
a. loop recorder
b. electrophysiology study
c. exercise treadmill stress test
d. transesophageal echocardiogram

A

b. electrophysiology test

130
Q

23yo female comes to ED for syncopal episode. just prior to syncopal episode, the pt experienced painful menstrual cramping. she experienced a cold sweat and palpitations with cramping. the pt describes similar episodes to her menstrual cramps int he past. her vital signs and PE are normal. ECG is unremarkable. what is the like dx for her syncope?
a. vasovagal syndrome
b. AV node re-entrant tachycardia
c. long QT syndrome
d. hypertrophic obstructive cardiomyopathy

A

a. vasovagal syndrome

131
Q

50yo male presents to ED complaining of CP, palpitations, dizziness after syncopal episode. the pt feels his heart racing. EKG reveals a narrow complex tachycardia consistent with PSVT. vitals: P: 188bpm, regular; BP: 78/52 supine. what is the best treatment for this patient in this scenario?
a. defibrilation
b. IV adenosine
c. IV diltiazem
D. synchronized cardioversion
e. vagal maneuvers

A

d. syncronized cardioversion

132
Q

71yo woman with hx of HTN presents with ulcer on anterior aspect of right leg. she presents to the office because she shopped all day yesterday and has developed significant edema. the skin in the pretibial region appears thin and has excessive brown pigment. what is the most likely dx?
a. venous insufficiency
b. arterial insufficiency
c. expected complication of DM
d. peripheral neuropathy

A

a. venous insufficiency

133
Q

what are risk factors for chronic venous insufficiency>

A

advancing age
family hx of venous disease
ligamentous laxity
prolonged standing
increased BMI
smoking
sedentary lifestyle
LE trauma

134
Q

what is the name given to the skin inflammation resulting from chronic varicose veins?

A

stasis dermatitis

135
Q

what is postphlebitic (post thrombotic) syndrome?

A

symptomatic chronic venous insufficiency after DVT

136
Q

what is the best diagnostic tool for dx of chronic venous insufficiency?

A

doppler US

137
Q

a 65yo female presents with dilatered tortuous veins on medial aspect of her LE. which of the following would be the most common initial complaint?
a. pain in calf with ambulation
b. dull aching heaviness brought on by periods of standing
c. brownish pigmentation above ankles
d. edema of LE

A

b. dull aching heaviness brought on by periods of standing

138
Q

a retired OR nurse comes into clinic complaining of dull ache in her legs after prolonged standing. she notes her legs feel heavy and she has mild ankle edema when she spends the day shopping. the aching pain and edema resolves spontaneously if the pt elevated her legs. she denies calf tenderness or dyspnea. PE reveals +1 ankle edema bilaterally. what is her most likely dx?
a. DVT
b. lymphedema
c. varicose veins
d. intermittent claudicaton

A

c. varicose veins

Clinical: General Surgery (10 decks)

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