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Surgery Flashcards

1
Q

Normal Bile Composition (3)

  • Why ileal resection increase risk for stone?
  • Why TPN patients increase risk for stone?
A

Bile = Cholesterol, Bile Salts, Phosphatidylcholine
- Ileal Resection = xBile Salt Reabsorption = supersaturated Chol bile = Chol Stones PPT

  • TPN: lack of proteins/FFA in duodenum = xCCK stimulation = increase risk for stones
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2
Q

Chemo Tx Definitions

  • Adjuvant/NeoAdjuvant
  • Induction, Consolidation, Maintenance
  • Salvage
A 
Adjuvant = treatment given in addition to Sx
NeoAdjuvant = treatment given just before surgery

Induction (initial dose killing to ≤5% tumor burden) –> Consolidation (further decrease burden) –> Maintenance (kill residual tumor to keep in remission)

Salvage: tx for disease after above standard regimens fail

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3
Q

MCC Syrinx (2)

A
  1. Congenital = 2/2 Arnold Chiari Malformation (herniation of cerbellar tonsils in FM; type I = +Syrinx, II = +Lumbar Myelocele)
  2. Spinal Trauma = CSF retention in central canal = Syrinx
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4
Q

Paralytic Ileus: 2 MCC

  • vs. SBO
  • vs. Ogivle’s?
A

Paralytic Ileus: complete distention of SI and LI (no bowel sounds)

  1. Intestinal Surgery (touching GI tract)
  2. Retroperitoneal Hemorrhage

vs. SBO: just distention of SI (think hyperactive bowel sounds)
vs. Ogilve’s: just large intestine

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5
Q

CAE Indications (2)

What to do for patients with stenosis who don’t meet criteria?

A

CAE in:

  1. Symptomatic patients 70-99% Stenosis
  2. Asymptomatic patients 60-99% Stenosis

If less, start ASA + Statin

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6
Q

4 Complications of PUD, Indicate MC*

A

Hemorrhage*
Perforation
Obstruction (Gastric Outlet)
Penetration

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7
Q

MC Thyroid Nodule

5 Thyroid Malignancies (MC –> LC)

A

Colloid

Papillary, Follicular, Medullary, Anaplastic, Lymphoma

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8
Q

MCCOD in Burn Patient

  • with adequate resuscitation
  • with inadequate resuscitation
A
  • with adequate resuscitation = Septic Shock

- with inadequate resuscitation = Hypovolemic Shock

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9
Q

2x Reasons Ventilation hastens death in hypovolemic shock?

A
  1. PPV = increase thoracic pressure = decrease volume = decrease VR
  2. Anesthesia given dilates capacitance vessels = decrease VR
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10
Q

DPA+ (2)

DPL+ (2)

A 
DPA+ = 10cc gross blood + feculent matter
DPL+ = ≥100K RBC, ≥500 WBC
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11
Q

FAST shows fluid around spleen. Next step based on ___.

A

HDS

  • If unstable –> EXLAP
  • if stable –> CT

The reason is to try and avoid splenectomy at all costs for immune function, especially in kids.

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12
Q

Erectile Dysfunction s/p Trauma (2)

A

Neurogenic: a/w urethral injuries
Venogenic: a/w penile fracture (b/c tunica albuginea, where veins are, are damaged)

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13
Q

Early vs. Late Prosthetic Infection

  • Timing
  • Bug
  • Tx
A
  1. Timing
    Replacement
    - Late = Replacement
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14
Q

Pt with breast cancer, wanting to start traztuzamab. Before doing so, need ____.

A

ECHO; cardiotoxic

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15
Q

Suspected Melanoma

  • 1st step?
  • Take margins @1st step?
  • Margins for different thickness?
  • When to get sentinel node study?
A
  • 1st step? = Excisional Biopsy
  • Take margins @1st step? NO!!! May interfere with lymph flow, difficult to ID sentinel node
  • Margins for different thickness?
  • 4mm = 3cm
  • When to get sentinel node study? Depth >1mm
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16
Q

2 Fx of CO on O2-Dissociation Curve

5 Things that Shift Curve to Right

A

CO: Left Shift (b/c CO increase Hb affinity for CO AND for O2) and ∆Curve Shape
*Both decrease O2 delivery to tissue

Shift Curve Right = CBEAT

  • CO2
  • 2,3 BPG
  • Exercise
  • Acidosis/Altitude
  • Temperature

**All things increase pO2 requirement to saturate Hb, making it easier to deliver O2 to tissues

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17
Q

Respiratory Quotient

  • Define + Normal Value
  • Value for Fats, Proteins, Carbs
  • What if >1.0
A
  • Define: ratio of CO2 production to O2 consumption, normally around 0.8.
  • Represents average oxidation (O2 consumption) of fats (0.7), proteins (0.8) and carbs (1.0).
  • If >1.0 = Mainly utilizing carbs

*guide nutrition in ICU patients

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18
Q

Acute Mediastinitis

  • MCC (2)
  • P/w
  • CXR Finding
  • Tx (3)
A

MCC = intraop infection of sternotomy wound + s/p esophageal rupture

P/w = purulent drainage from sternum

CXR finding = wide anterior mediastinum

Tx = Immediate Debridement + WOUND CLOSURE + Long term antibiotics

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19
Q

3 Signs of Tracheobronchial Performation + Management

A
  1. SubQ Emphysema
  2. Pneumomediastinum on CXR
  3. Persistent pneumothorax despite chest tube

Management = ABCs —> Bronch to locate injury —> repair

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20
Q

Uncomplicated vs. Complicated Diverticulitis Def + Management

When is colonic resection indicated? (4)

A
  1. Uncomplicated:
    - LLQ Pain, Fever, CT with thickened colon +/- soft tissue stranding.
    - Manage outpt with bowel rest, abx, pain rx
  2. Complicated: IHOP (Infection, Hemorrhage, Obstruction, Perf)
    - P/w above findings + IHOP (HOP managed as below)
    - Abscess
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21
Q

Central Cord Syndrome

  • Who gets it and how?
  • Presentation?
A
  • Think older patients with cervical DJD with hyperextension injury
  • P/w damage to xCST&raquo_space;> decussating spinothalamic tract

xMotor in arms, ok in legs (b/c morphology of fibers in CST with arms being more central)

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22
Q

Esophageal Varices

  • Who needs screening?
  • ASx Management
  • Syx Management
A
  • Screen ALL Cirrhotics
  • ASx Management = Propranolol
  • Sx Management = Octreotide / Endoscopic Scleropathy
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23
Q

Insulinoma (3) vs. Glucagonoma (4) Presentation. Tx of inoperable glucagonoma (2)?

A

Insulinoma = Whipple Triad

  • Fasting HypoGluc
  • Neurohypoglycemic Symptoms
  • Resolve with Glucose

Glucagonoma = 4Ds

  • Diabetes (mild)
  • Dermatitis (NME)
  • DVT
  • Diarrhea

Tx

  1. Somatostatin
  2. Streptozocin
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24
Q

Early vs. Late Dumping Syndrome

  • Timing
  • Paph
  • Management
A

Early

  • Timing: Minutes after meal
  • Paph: increase osmotic load to SI –> increase vasoactive peptides
  • Tx: reassurance (will resolve), small meals, octreotide

Late

  • Timing: hours later
  • Paph: increase duodenal load = increase insulin release
  • Tx: as above (except octreotide)
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25
Timing of 4 Tx Reactions
Immediate: Anaphylaxis (IgA Deficiency; should've WASHED RBC) 1 hr: Febrile non-hemolytic (2/2 Residual leuks releasing cytokines; should've LUEKOREDUCED) + ARDS (TRALI) >1 day: Delayed Hemolytic
26
What trauma causes anterior cord syndrome?
Vertebral burst factures
27
ZES/Gastrinoma - 2 EGD Findings - 3 Steps in Protocol
EGD - Prominent gastric folds - Ulcers in beyond duodenal bul W/U 1. Gastrin >1000 diagnostic, or 2. Secretin Stimulation increasing gastrin, or 3. Ca Stimulation
28
Management of - Mild Claudication (4) - Severe (2)
Mild = ASA, STatin, Smoking Cessation and Supervised Execise SEvere = Cilastozol (PDEI) and Surgery
29
Duodenal Hematoma - P/w - Management (2)
P/w SBO s/p abdominal injury Management = NGT + TPN
30
ABI Intepretation
``` >0.91 = Normal ≤0.9 = Diagnostic of PAD >1.3 = DM with Calcified Vessels --> FURTHER STUDIES NEEDED ```
31
Next step in HDS patient s/p abdominal trauma who p/w LUQ tenderness, Kerr Shoulder sign and drop in BP?
CT scan with contrast for splenic trauma. If unstable --> EXLAP
32
Next best step for post-chole syndrome?
ERCP/MRCP **Just like in severe cholangitis, you have to remove whatever is in the bile duct. If ERCP fails, use T tube for decompression
33
Can medical students practice procedures on newly deceased patients?
YES, if the patient or patient's family gives permission
34
Bacterial Parotitis - 2 populations of patients - MC Bug - Prevention
- Common in OLD and DEHYDRATED post-op patients - Bug = Staph Aureus - Prevention = IVF + oral hygiene
35
Next step in patient with Direct HyperBili, normal LFTs and elevated Alk Phos?
Abd USG * If LFTs were up, think hepatitis --> serology would be next * If no LFTs or Alk Phos ∆ --> Dubin Johns/Rotor
36
Cystinuria - Paph - Diagnostic Study (2)
Paph = poor dibasic AA transport across tubular cells (Cystine, Ornithine, Lysine and Arginine = COLA); cystine poorly soluble in water = PPT Diagnostic Study (2) - UA = hexagonal crystals - Urine Cyanide Nitroprusside test: detects elevated cystine levels
37
Esophageal Perforation - MCC - 2 PE Findings - CXR Findings (3) - Dx Procedure - Tx (3)
- MCC: Esophageal instrumentation (dilation for achalasia) >>> Boerhave's Syndrome - 2 PE Findings: Hamman's sign (crunching auscultation) + subQ emphysema - CXR Findings (3): Wide Mediastinum, Air in Mediastinum, Pleural Effusion (Left sided) - Dx Procedure: Water Soluble Contrast (Gasrografin Swallow) - Tx (3): TPN, Broad Spectrum ABx and Surgery (don't forget TPN, b/c even after management they ain't gonna be eating!)
38
1 week S/p Blunt Upper Abdominal Trauma pt has fever, chills and "deep abdominal pains". Initial CT scans negative.
Missed pancreatic injury (pancreas crushed against vertebral bodies); normal CTs initially so have to f/u with serial CT scans; pt now probably has retroperitoneal abscess
39
6 Stages (0-5) Diabetic Foot Ulcers 6 Components to Management
Stage 0: high risk foot, no ulcer Stage 1: full thickness, no subQ tissue involvement Stage 2: deep ulcer penetrating into muscle/ligament, no bone Stage 3: deep ulcer penetrating to bone / osteo Stage 4: Local Gangrene Stage 5: Extensive gangrene Management 1. Off-loading 2. Debridement (stage 2) 3. Wound Care (all) 4. Abx (stage 3) 5. Revascularize 6. Amputate (for stage 3 + 4)
40
Penile Fracture - When does it occur? - Presentation - Paph - Management (2)
- Occurs when penis is erect = Sex - Presentation: woman on top, snapping sensation - Paph: breaking of tunica albuiguina (encasing corpus) --> hematoma - Mgmt = Retrograde Urethrogram --> Surgical evacuation of hematoma
41
80 y/o man with usual nl ADL managed by himself has suddenly gotten senile/demented over last 2 weeks. Fell down 2 weeks ago. Dx and management?
Subdural Hematoma --> CT Scan Dx --> Surgical Decompression = Cure
42
Base of Skull Fx: - How do you diagnose? - How do you manage? (3)
``` Dx = CT Scan (> Plain film) Manage = NSG for repair + ANTIBIOTICS + CSpine Clearance ```
43
Resonant/tympanitic to percussion vs. dull to percussion s/p stab to chest?
PT vs. Hemothorax
44
Mgmt of hemothorax?
- Most just need chest tube as low pressure lung bleeding stops spontaneously - If putting out >1L / >400 cc/hr ---> thoracatomy b/c systemic vessel is involved
45
Pt in accident has sternal fracture. 2 Concerns with tests?
1. Myocardial Contusion: EKG/Enzymes | 2. Aortic Injury: CT/ TEE (---NOT AORTOGRAPHY)
46
4 Places bleeding can cause hypovolemia?
1. Abdominal Viscera 2. Pelvic Fx 3. Upper Thighs 4. Scalp Lac
47
Management of anterior vs. posterior urethral injury?
* Note determined b/c both get retrograde urethrogram - Anterior = Immediate Surgery - Posterior = Suprapubic cath with delayed repair
48
S/p pelvic fracture, patient has foley put in with gross hematuria. Retrograde cystogram is NORMAL. Dx?
Nl retrograde cystogram R/o bladder injury, bleeding is coming from kidneys --> CT Scan
49
Microscopic hematuria in adults vs. kids?
Adults = microscopic does not always need investigation (gross does) Kids = microscopic always does because it could signify renal abnormalities (renal USG)
50
S/p kicked in the nuts, patient has scrotal hematoma. Next step?
Sonogram; if ruptured testes --> surgery. If not --> symptomatic
51
Management of chemical burn?
Esp alkali > acid, regardless of location = COPIUS IRRIGATION x30 minutes BEFORE rushing to ED
52
Management of patient s/p electricution/electric burns?
BURNS ARE ALWAYS DEEPER = debridement, look out for posterior shoulder dislocation, bone and nerve problems. Myoglobinuria too
53
Script + Management of Respiratory Burn
Pt in burning building has dark soot around mouth and inside mouth. Dx with Bronchoscopy. Remember, have low threshold for intubating these patients!
54
Parkland Formula
4xWTxTBSA %Burned = cc/24 hr
55
What to do for a 3rd degree burn (white leathery, vs. second degree = blistery, moist)
Early excision with grafting
56
Patient has multiple small tumors in heart. Or in duodenum?
Metastatic Melanoma, recall it goes weird places
57
32 y/o woman with h/o multiple painful breast swellings during menses now has 2cm cyst for 6 weeks. Dx + Management?
- Dx is likely still persistent cyst | - F/u regular protocol FNA if cystic vs. core biopsy if solid
58
Woman with breast abscess; after I&D + ABx, what needs to be done?
Have to biopsy the abscess wall!
59
How do you w/u Paget's disease of breast?
It's still a cancer! Use same 35 protocol ---> Tissue needed!
60
Old lady with normal PE is found to have mammogram findings suspicious of cancer. Next step?
Follow protocol Nik! >35 --> CBE with Diagnostic Mammogram (done in this case) ---> Need Tissue **Because she has mammogram with discrete lesion and a normal PE, STEREOTACTIC GUIDED BIOPSY is option
61
Management of ductal carcinoma without palpable axillary nodes in: - Patient with normal breast size and 2 cm tumor - Patient with small breast and 4 cm tumor
- Patient with normal breast size and 2 cm tumor * Lumpectomy with radiation * Axillary node dissection needed - Patient with small breast and 4 cm tumor * Modified radical mastectomy * Axillary node dissection needed
62
Treatment for +nodes in pre- vs. post-menopausal woman?
- Pre = Chemotherapy | - Post = Hormonal Therapy (including Aromataes inhibitors)
63
Baby has huge shining eyes?
Congenital glaucoma + tearing = shiny eyes; optho immediately or else blind
64
Suspect mallory weiss tear. Next step + management?
Next step = endoscopy | Mgmt = usually will resolve on its own (but have to do the EGD)
65
- R Sided CRC findings | - L Sided CRC findings
- R Sided CRC findings: Anemic with +FOBT | - L Sided CRC findings: Blood coating stools + narrow stools
66
4 Pre-malignant 4 Benign POLYPS
Pre-Malignant 1. FAP 2. HNPCC 3. Villous Adenoma 4. Tubular Adenoma Non 1. Juvenile 2. Peutz (Harmatomas) 3. Hyperplastic 4. Inflammatory
67
Patient with known hemorrhoids reports BRBPR?
STILL NEED COLONOSCOPY Compare this to question about young patient with anal fissure and no other GI symptoms and has obvious anal fissure on PE --> no colonoscpy
68
HIV patient has fungating mass just inside anal verge - Dx - Management
- Dx = Squamous cell carcinoma of anus | - Mgmt = still need full colonoscopy
69
Patient with signs of intestinal obstruction has plain film showing distention of small and large bowel from RUQ --> LLQ. Dx and next step?
Sigmoid Volvulus --> Proctosigmoidosocpy for relief
70
Which hepatic abscess does not need surgical excision/drainage?
Amebic --> Flagyl will take care of it!
71
Pt with obstructive jaundice has normal CT other than dilated bile ducts. Pancreatic duct not dilated. Next step + DDx (2)?
ERCP DDx = Cholangiocarcinoma vs. Sphincter of Odi Dysfunction
72
Tx for acute cholangitis?
Need immediate decompression of CBD = ERCP; if ERCP fails that's when you do the T Tube
73
Management of hemorrhagic pancreatitis?
Serial CT scans to monitor for formation of MCCOD = pancreatic abscess
74
Two weeks after any surgery a patient develops fever and leukocytosis? Next best step?
Think ABSCESS --> CT Scan
75
Next step in baby with TE Fistula?
Screen for other VACTERL associations before surgery: - Vertebral / limb - XRAY - Anal atresia - PE - Cardiac = ECHO - GU = Renal USG
76
Best ppx/treatment for fight bite / dog bite / cat bite?
Augmentin (≠Amoxicillin and ≠Clinda)
77
What does atelectasis affect? 3 ways to comabat?
Atelectasis decreases FRC 1. Elevated HOB 2. Incentive Spirometry 3. Cough
78
Gradual vs. Sudden Onset Bell's Palsy
- Gradual = suggests neoplastic process (MRI) | - Acute = suggestions Lyme, Sarcoid, etc (Will resolve / start antivirals)
79
Management of Ludwig's Angina? (2)
1. Tracheostomy | 2. Then InD
80
Girl picks her nose all the time gets severe epistaxis. Management (2)
Control bleeding from the anterior septal plexus - Phenylephrine Spray - Pressure
81
Which cancer if found in lung is NOT treated with surgery? Which cancer in lung IS SURGICALLY removed?
No Surgery = Small Cell (use platinum chemo) Surgery = Non-small cell
82
What WBC count on synovial analysis for GC arthritis?
75K (lax with the 10^5)
83
Patient has arm claudication + vertigo, ∆vision and ∆speech. Dx and next step?
Likely subclavian steal syndrome Get angiography showing retrograde flow through the vertebral artery
84
Patient with history of Cushing's syndrome treated with b/l adrenalectomy now has bitemporal hemanopia and low BP?
NELSON SYNDROME - original cushing disease was not a problem with adrenals, but the pituitary - adenoma continued to grow, low BP b/c no adrenals
85
Foster-Kennedy Syndrome
Brain Tumor of Frontal Lobe - Personality ∆ - Optic Nerve Atrophy on ipsilateral side (compare to papilldema on opposite side) - Anosmia
86
60 y/o woman with soft tissue mass in thigh located deep and fixed to surrounding tissue? Dx and Next Step?
- Sarcoma | - MRI (≠biopsy)
87
Open fractures ned repair within _______.
6 hours of injury Don't confuse with femoral neck fractures which need repair in 72 hours (b/c need to w/u underlying condition)
88
(T/F) Posterior shoulder dislocations can be missed on AP/lateral xrays?
True, get axillary and scapular views; remember always get two views 90 degrees away from each other
89
Runner has tibial stress fracture. Management? Compare this to metatarsal fracture?
Don't image right away, wont' show up. Manage with casting and repeat imaging in 2 weeks. With metatarsal fracture, don't need to cast b/c the other metatarsals act like splints. You can just do rest and analgesia.
90
Patient with stone develops pyelo. Managemetn?
ABx + Surgical Decompression with Stent/percutaneous nephrostomy
91
(T/F) Patient found to have Porcelain gallbladder needs it removed?
True increase risk for adenocarcinoma of gallbladder
92
(T/F) Medical therapy with bromo or cabergoline is indicated for both MICRO AND MACRO adenomas. (T/F) Vision ∆ 2/2 pituitary adenoma is reason for surgery.
True = Rx for both micro and macro adenomas False = vision change does NOT immediately = surgery, still try bromo/cabergoline
93
High amylase in pleural fluid?
Effusion 2/2 esophageal perforation
94
Anastrazole + Exemestane = when used?
These aromatase inhibitors are used in POST-MENOPAUSAL women with breast cancer
95
(T/F) Mastectomy and BCS are equally effective.
Mastectomy = BCS AND RADIATION (can't not radiate).
96
Cell of Origin for Pancreatic Cancer?
Ductal Epithelium *Recall depression is almost = PNP for Pancreatic Cancer
97
Management of acalculous cholecystitis? (2)
1. Emergent Percutaneous Cholecystostomy | 2. Once stable, chole
98
MC laceration / visceral injury after blunt abdominal trauma?!!!!!!!
SPLEEN SPLEEN SPLEEN SPLEEN
99
How long do you have to fix a femoral neck fracture in old person and why does this matter?
72 hours; this matters b/c (in older persons especially), it is important to investigate the cause of the (likely) original fall that caused the fracture (CXR, EKG, ECHO)
100
Patient with OBVIOUS anal fissure and no signs/symptoms of CRC who is 35 y/o. Do you need a colonoscopy?
No
101
Patient with Charcot's triad is on broad spectrum ABx but becomes persistently confused and febrile. Next step?
ERCP!!! (not T Tube, do T tube if ERCP is not working). Point is, patient needs immediate decompression of CBD, and ERCP is best to do this!
102
How is the management of hairline fracture of the metatarsals different from other stress fractures?
Usually stress fractures needed splinting / casting, but the adjacent metatarsals act as splint so management of these = Rest, Analgesia
103
Head Trauma Definition + Management - Minor - Mild - Moderate/Severe
- Minor: GCS 15, normal neuro exam, no h/o LOC * No head imaging, send home with reliable individual - Mild: GCS 13-15 with brief LOC / vomiting / HA * CTH --> D/C home if normal with reliable individual - Moderate / Severe: anything greater than above = Head imaging and admit for neuro checks

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