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STEP2 > Surgery > Flashcards

Surgery Flashcards

1
Q

What are the three most important factors when calculating a patient’s Goldman index for cardiac risk?

A
  • history of CHF
  • history of MI within the last 6 months
  • presence of an arrhythmia
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2
Q

If a preoperative patient has a history of CHF or a history of MI within the last 6 months, what steps should be taken prior to surgery?

A
  • if CHF, get an echo; surgery is avoided unless absolutely necessary in patients with an EF less than 35%; otherwise optimize patients with ACEi, B-blockers, and spironolactone
  • if MI, get an ECG and a stress test, then perform a cath if abnormal, then perform revascularization if cath is abnormal
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3
Q

What ejection fraction is the threshold for increased risk during a non cardiovascular surgery?

A

less than 35%

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4
Q

What is the revised cardiac risk index and how is it used?

A

patients receive 1 point for each of the following:
- history of ischemic heart disease
- history of congestive heart failure
- history of cerebrovascular disease
- history of insulin-dependent diabetes
- history of CKD with creatinine greater than 2
patients with a score of 2 or more should be given preoperative beta-blockers to reduce cardiac mortality

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5
Q

What is the ASA physical status classification system and how is it used?

A
  • a way of classifying the preoperative health of patients
  • patients with severe systemic illness are considered a 3; those with severe systemic disease that is constantly life threatening are a 4
  • scores of greater than 3 require preoperative assessment and testing for elective procedures and optimization for surgical emergencies
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6
Q

What preoperative cardiac testing is required for all patients?

A
  • patients under the age of 35 with no history of cardiac disease need only an ECG
  • patients over age 35 or with a history of cardiac disease need an ECG, stress test, and echo
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7
Q

What pulmonary disease risk assessment should be done preoperatively?

A

patients with known lung disease or a smoking history should have PFTs performed prior to surgery to evaluate vital capacity

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8
Q

When should patients stop smoking prior to surgery?

A

8 weeks pre-op

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9
Q

How is kidney disease managed intraoperatively?

A
  • patients with chronic kidney disease should be aggressively hydrated
  • those on dialysis should be dialyzed within 24 hours of the operation
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10
Q

How should the airway be secured in trauma patients?

A
  • orotracheal tube is preferred
  • use a cricothyroidotomy if patients have facial trauma
  • use a flexible bronchoscopy if patients have a cervical spine injury
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11
Q

What is the difference between each of the following:

  • SIRS
  • sepsis
  • severe sepsis
  • septic shock
A
  • SIRS: 2/4 criteria are met
  • sepsis: 2/4 criteria are met with a source of infection
  • severe sepsis: 2/4 criteria are met with a source of infection and organ dysfunction
  • septic shock: 2/4 criteria are met with a source of infection, organ dysfunction, and hypotension
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12
Q

What are the SIRS criteria?

A
  • temperature less than 36 or greater than 28
  • tachycardia greater than 90
  • tachypnea greater than 20
  • WBC less than 4000 or greater than 12000
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13
Q

For cardiogenic shock, what happens to the following:

  • temperature
  • CVP
  • SVR
  • HR
  • CO
  • LVEDP
  • PCWP
A
  • temperature: cool extremities
  • CVP: increased
  • SVR: increased
  • HR: increased
  • CO: decreased
  • LVEDP: increased
  • PCWP: increased
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14
Q

For neurogenic shock, what happens to the following:

  • temperature
  • CVP
  • SVR
  • HR
  • CO
  • LVEDP
  • PCWP
A
  • temperature: warm extremities
  • CVP: decreased
  • SVR: decreased
  • HR: increased
  • CO: decreased
  • LVEDP: decreased
  • PCWP: decreased
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15
Q

Describe the presentation, diagnosis, and treatment of a brain abscess.

A
  • presents with fever, headache, and focal neurological findings
  • best initial test is a CT without contrast, most accurate is an MRI with contrast
  • treat with IV antibiotics and surgical drainage
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16
Q

Describe the presentation, diagnosis, and treatment of an epidural abscess.

A
  • presents with the triad of fever, back pain, and focal neurologic findings
  • best first step is glucocorticoids followed by MRI of the spine
  • following diagnosis refer for surgical drainage and then start IV antibiotics
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17
Q

What is the most accurate test for anterior spinal artery syndrome?

A

an MRI

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18
Q

Describe the presentation and diagnosis of a basal skull fracture.

A
  • presents with ecchymoses around the eyes or behind the ears and CSF drainage from the nose or ears
  • diagnosis is with CT of the head and neck
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19
Q

Describe the presentation of a pneumothorax.

A

chest pain, hyper resonance to percussion, and decreased breath sounds

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20
Q

What two things cause tracheal deviation and in which direction?

A
  • tension pneumothorax causes a shift away from the affected side
  • atelectasis causes a shift toward the affected side
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21
Q

Describe the workup for blunt abdominal trauma.

A
  • begin with a FAST exam in all cases
  • if stable, perform a CT which is the most accurate test for fluid
  • if unstable, perform an ex lap
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22
Q

What is the best next step in a patient who suffers a stab wound to the abdomen?

A
  • if stable, perform a FAST exam; use diagnostic peritoneal lavage if FAST is equivocal; ex lap if either is positive
  • if unstable, perform an ex lap
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23
Q

What is the best next step for a patient who suffers a GSW to the abdomen?

A

exploratory laparotomy plus tetanus prophylaxis

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24
Q

Describe the presentation, diagnosis, and treatment of splenic rupture.

A
  • patients will have a history of blunt abdominal trauma with free fluid in the abdomen found on FAST or CT
  • most accurate method for diagnosis is CT
  • patients who are stable with low-grade injuries can be monitored; patients who are unstable or have a laceration involving segmental or hilar vessels require ex lap
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25
Q

When removing the spleen it is important to give what vaccinations?

A
  • 13-valent pneumococcal followed 8 weeks later by the 23-valent
  • also give meningococcal and Hib
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26
Q

Describe the presentation and treatment of splenic infarction.

A
  • occurs in patients with a history of Afib or hypercoagulable states
  • presents with acute LUQ pain radiating to the left shoulder with tender splenomegaly
  • treat conservatively unless complications like abscesses form in which case splenectomy is needed
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27
Q

Describe the presentation, diagnosis, and treatment of splenic abscess.

A
  • presents with LUQ pain and splenomegaly, typically in a patient with endocarditis
  • the most accurate test is a CT scan
  • treat with antibiotics and splenectomy
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28
Q

Describe the presentation, diagnosis, and treatment of ischemic colitis.

A
  • damage of the mucosa leads to abdominal pain and bloody diarrhea
  • the best initial test is CT while the most accurate is angio
  • treat with IV fluids and antibiotics
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29
Q

Describe the pathogenesis, presentation, diagnosis, and treatment of acute mesenteric ischemia.

A
  • most often due to Afib and embolic occlusion of the SMA
  • presents with pain out of proportion to the physical exam, leukocytosis, and lactic acidosis
  • the best initial test is radiograph showing air in the bowel wall but the most accurate is angiography
  • treat with laparotomy
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30
Q

Describe the pathogenesis, presentation, diagnosis, and treatment of chronic mesenteric ischemia.

A
  • due to atherosclerotic disease of two or more mesenteric vessels
  • presents with intestinal angina also known as pain that increases with eating
  • the best test is angiography
  • treatment is with stenting or bypass
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31
Q

Describe the pathophysiology, presentation, diagnosis, and treatment of median arcuate ligament syndrome.

A
  • due to external compression of the celiac trunk b ythe median arcuate ligament
  • presents with severe postprandial pain, nausea, and weight loss
  • diagnosis is made with duplex ultrasound demonstrating reduced flow through the celiac artery
  • treatment is surgical
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32
Q

Where are Mallory Weiss tears and esophageal perforations most likely to be located within the esophagus?

A
  • tears at the GE junction

- perforations at the distal posterolateral aspect

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33
Q

How should Mallory Weiss tears and esophageal perforations be diagnosed?

A

with an esophagram using a solution of diatrizoate meglumine and diatrizoate sodium (aka gastrografin), whihch is less caustic than barium if it does leak from the esophagus

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34
Q

What is the feared complication of Boerhaave syndrome?

A

mediastinitis

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35
Q

What is the most common cause of esophageal perforation?

A

iatrogenic in those undergoing an upper endoscopy

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36
Q

What is the most common cause of gastric perforation? How should it be diagnosed and treated?

A
  • the most common cause is rupture of a gastric ulcer
  • the best initial test is upright chest x-ray looking for free air under the diaphragm, the most accurate is CT
  • treat with NPO, NGT, fluids, antibiotics, and laparotomy
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37
Q

What are the following signs of appendicitis:

  • psoas sign
  • obturator sign
  • rovsing sign
A
  • psoas sign: pain with hip extension
  • obturator sign: pain with internal rotation of the thigh
  • rovsing sign: palpation of the LLQ causes pain in the RLQ
38
Q

What is a HIDA scan?

A
  • a nuclear imaging study used to diagnose cholecystitis
  • if cholecystitis is present, it will show delayed emptying of the gallbladder by failure to visualize the gallbladder from isotope accumulation
39
Q

How should bowel obstruction be diagnosed and treated?

A
  • start with a plain radiograph, but the most accurate is CT
  • treat with NPO, NGT, and fluids
  • if patients have a complete obstruction or fail to improve with medical management, treat surgically
40
Q

How are biliary colic and cholecystitis treated?

A
  • biliary colic requires elective cholecystectomy

- cholecystitis requires urgent cholecystectomy

41
Q

Describe the presentation, diagnosis, and treatment of cholangitis.

A
  • presents with a pentad of fever, jaundice, RUQ pain, altered mental status, and hypotension
  • the best first test is ultrasound but the most accurate is MRCP
  • all patients need IV antibiotics; decompress the common bile duct with ERCP if stable and transhepatic percutaneous drainage if unstable
  • follow with a cholecystectomy
42
Q

Describe the presentation, diagnosis, and treatment of a bile leak.

A
  • presents with fever, abdominal pain, and bilious ascites following cholecystectomy
  • the most accurate test for diagnosis is HIDA scan
  • ERCP finds the leak and is used to close it
43
Q

Describe the presentation, diagnosis, and treatment of sphincter of oddi dysfunction.

A
  • presents with biliary-type pain and pancreatitis without another apparent cause
  • the most accurate test is manometry
  • if liver tests are normal, medical management is appropriate, but if elevated, patients need sphincterotomy
44
Q

Describe the etiology, presentation, diagnosis, and treatment of pancreatic cancer.

A
  • most cases are adenocarcinoma of the head of the pancreas
  • presents with painless jaundice and weight loss, typically in a patient with a history of smoking
  • the most accurate test is a CT scan
  • treat with whipple if resectable; otherwise perform a palliative CBD stent
  • monitor response to therapy with CA 19-9
45
Q

Describe the etiology, presentation, diagnosis, and treatment of cholangiocarcinoma.

A
  • it is a cancer of the bile duct most commonly seen in patients with a history fo PSC
  • presents with painless jaundice and weight loss with elevated alkaline phosphatase
  • MRCP is the best imaging test but ERCP allows for biopsy
  • treat with surgery and chemotherapy then monitor response with CA 19-9
46
Q

Describe the etiology, presentation, diagnosis, and treatment of gall bladder cancer.

A
  • most cases are adenocarcinoma and frequently associated with chronic typhoid infection
  • presents with RUQ pain, jaundice, and a palpable gallbladder
  • the best initial test is ultrasound but the most accurate is CT abdomen
  • treat with surgery and chemotherapy
47
Q

What is the best test to diagnose a pyogenic liver abscess? What is unique about the following etiologies:

  • enteric gram-negatives
  • Klebsiella
  • Burkholderia
  • E. histolytica
A
  • diagnose with ultrasound
  • enteric gram-negatives: although most cases are polymicrobial, this is the most common organism found
  • Klebsiella: associated with CRC and necessitates a colonoscopy
  • Burkholderia: associated with travel to southeast asia
  • E. histolytica: associated with travel to central and south america as well as with preceding diarrhea
48
Q

How are gallbladder polyps managed?

A
  • 5mm or less are considered benign and require repeat ultrasound in one year to ensure they are stable
  • 6-9mm are likely benign but monitored yearly and removed if they begin to enlarge
  • 10mm or grater are treated as malignant and removed
49
Q

What population is most at risk for acalculus cholecystitis and why?

A

patients who are critically ill or receiving TPN because they have diminished release of CCK which induces gallbladder contraction

50
Q

What is the treatment for each of the following:

  • biliary colic
  • cholecystitis
  • acalculous cholecystitis
  • cholangitis
A
  • biliary colic: elective cholecystectomy
  • cholecystitis: urgent cholecystectomy
  • acalculous cholecystitis: urgent cholecystectomy
  • cholangitis: antibiotics, CBD decompression with ERCP or PCI, and elective cholecystectomy
51
Q

Describe the pathophysiology, presentation, and treatment of pilonidal cysts.

A
  • they are acute or chronic abscesses in the sacrococcygeal region that arise due to skin trauma
  • present with pain in the intergluteal region and possibly drainage that worsen with stretching fo the natal cleft
  • treat with incision and drainage
52
Q

What is the treatment for anal fissures?

A
  • start with a combination of situ baths, increased fiber or stool softeners, and topical vasodilators like nitroglycerin
  • if patients fail to improve after 8 weeks, consider lateral internal sphincterotomy or botox injection
53
Q

How is rectal prolapse treated?

A

with surgery

54
Q

How are hemorrhoids treated?

A
  • begin with dietary management, situ baths, and topical steroids
  • then move on to rubber band ligation or hemorrhoidectomy
55
Q

What is a comminuted fracture?

A

one in which the bone gets broken into multiple pieces

56
Q

Describe the diagnosis and treatment of stress fractures.

A
  • radiographs aren’t sensitivities, so use a CT or MRI

- treat with rehabilitation, reduced physical activity, and casting; move to surgery if the problem persists

57
Q

What is suggested if an older patient fractures a rib while coughing?

A

this is a pathological fracture and suggests an underlying condition

58
Q

Describe the presentation and treatment of trigger finger.

A
  • presents as an acutely flexed and painful finger

- treat with steroids first and then surgical decompression if necessary

59
Q

Describe the presentation, diagnosis, and treatment of anterior and posterior should dislocations.

A
  • anterior are far more common and posterior are typically seen with seizures or electrocution
  • anterior are likely to come in with the arm held in external rotation while posterior are likely to be internally rotated
  • in both cases radiographs are the best initial test while MRI is the most accurate
  • use reduction and a simple arm sling to treat
60
Q

How is achilles tendon rupture diagnosed and treated?

A
  • the most accurate test is an MRI

- treated surgically

61
Q

Describe the presentation and treatment of fat PE.

A
  • triad of petechial rash, dyspnea, and confusion in a patient with recent long bone fracture
  • treat with oxygen and respiratory support as needed
62
Q

What are the 6 P’s of compartment syndrome?

A
  • pain
  • pallor
  • paresthesia
  • pulselessness
  • paralysis
  • poikilothermia
63
Q

The knee is best imaged using what modality?

A

MRI

64
Q

What are the anterior and posterior draw tests of the knee?

A
  • the anterior draw test will show laxity if there is an ACL tear
  • the posterior draw test with show laxity if there is a PCL tear
65
Q

Describe the treatment of hiradenitis suppurativa.

A
  • begin with tobacco cessation, weight loss, topical antibiotics, and skin hygiene
  • oral tetracycline can be used to supplement this
  • TNFa inhibitors and surgery are options for refractory disease
66
Q

Describe the presentation and treatment of BPH.

A
  • presents with urinary frequency, urgency, and nocturia as well as a diminished urinary stream and hesitancy
  • on exam the prostate is diffusely enlarged, firm, and non-tender
  • best initial treatment is a1-antagonsits like terazosin and tamsulosin because these act immediately
  • add a 5a-reductase inhibitor like finasteride to shrink the prostate if a1-antagonists are insufficient
67
Q

Why are a1-antagonists preferred to 5a-reductase inhibitors for the treatment of BPH?

A

because 5a-reductase inhibitors take several months to have an effect

68
Q

Describe the two types of priapism, their diagnosis, and their treatment.

A
  • both are defined as erection lasting more than 4-6 hours without sexual stimulation
  • ischemic is due to decreased venous flow while nonischemic is due to a fistula between the cavernosal artery and corporal tissue following perineal trauma
  • it is a clinical diagnosis and the two forms are distinguished using a corporeal blood gas analysis
  • treat ischemic with phenylephrine injection and blood aspiration; nonischemic can be monitored
69
Q

When should hydroceles be surgically corrected?

A

if they persist beyond 12 months of life

70
Q

What is the most accurate test for varicocele?

A

an ultrasound showing dilation of the pampiniform plexus to greater than 2mm

71
Q

Describe the timeline for correcting cryptorchidism.

A

orchiopexy should be performed between 4 months and 2 years of life

72
Q

How does cryptorchidism affect future cancer risk?

A

it increases it regardless of whether orchiopexy is performed but there is greater risk without intervention

73
Q

Describe the etiology, presentation, diagnosis, and treatment of Fournier gangrene.

A
  • this is a necrotizing fasciitis of the perineum and scrotum from a mixed aerobic and anaerobic infection
  • presents with severe pain, skin break down, crepitus, and subcutaneous gas in addition to systemic findings
  • CT is the most accurate test
  • surgical debridement and antibiotics are required
74
Q

What are the indications and contraindications for bariatric surgery?

A
  • indicated for those with a BMI greater than 40 or greater than 35 with at least one serious comorbidity
  • contraindicated for those with untreated depression, psychosis, or eating disorder
75
Q

What are the most common side effects for the following bariatric procedures:

  • Roux-en-Y
  • sleeve gastrectomy
  • gastric band
A
  • Roux-en-Y: marginal ulcer, cholelithiasis, dumping syndrome, and weight regain
  • sleeve gastrectomy: stenosis of the remnant, leaks, and GERD
  • gastric band: band erosion into the stomach or slippage off the stomach
76
Q

How is AAA defined and managed?

A
  • defined as an increase in aortic diameter of at least 1.5 normal
  • 3-4cm, perform ultrasound every 2-3 years
  • 4-5.4cm, perform ultrasound or CT every 6-12 months
  • 5.5cm is an indication for surgical repair
77
Q

Why are vasodilators not used as monotherapy for those with aortic dissection?

A

because they can induce reflex tachycardia, which increases shearing forces

78
Q

What are the three types of thoracic outlet syndrome?

A
  • neurogenic which manifests as pain, weakness, and thenar atrophy
  • venous which manifest with swelling, pain, and cyanosis
  • arterial which manifests as pain, coldness, and pallor
79
Q

What is Adson sign?

A

a loss of radial pulse with rotation of the head to the ipsilateral side with neck extended while taking a deep inspiration, which indicates thoracic outlet syndrome

80
Q

Describe the presentation, diagnosis, and treatment of thoracic outlet syndrome.

A
  • may present with a combination of pain, weakness, thenar atrophy, and cyanosis or pallor depending on whether the nerve, artery, or vein is involved
  • positive Adson sign is loss of radial pulse with rotation fo the head to the ipsilateral side with neck extended during inspiration
  • the best initial test is ultrasound, but the most accurate is MRA
  • treat with physical therapy in most cases; surgical decompression is for vascular symptoms, weakness, or unbearable pain
81
Q

Where are indirect, direct, and femoral hernias?

A
  • indirect: through the internal inguinal ring, lateral to the inferior epigastric vessels
  • direct: through Hesselbalch’s triangle medial to the inferior epigastric vessels
  • femoral: below the inguinal ligament and through the femoral ring
82
Q

What is the most common type of hernia?

A

indirect inguinal is most common in both genders; however, femoral is more common in females than in males

83
Q

What is the timeline for post-operative fever?

A
  • wind: pneumonia and atelectasis between 1-2 days post
  • water: UTI 3-5 days post-op
  • walking: DVT/PE 5-7 days post-op
  • wound: cellulitis or wound infection beyond 7 days post
  • weird: drug fever and deep abscesses 8-15 days post-op
84
Q

How should suspected PE be managed?

A
  1. start with an ECG and get troponin to confirm the pain is non-cardiac
  2. then get a CTA or V/Q scan to confirm the diagnosis
85
Q

When would you use a V/Q scan to diagnose PE?

A

it is preferred during pregnancy and for those with contrast allergy

86
Q

When is D-dimer used to assess PE?

A

it is highly sensitive and used in unlikely cases to rule out PE; it plays no role in those with a high suspicion

87
Q

How should the following medications be handled pre-operatively:

  • anticoagulants
  • antiplatelets
  • beta-blockers
  • diuretics
  • lipid-lower agents
  • oral hypoglycemics
  • insulin
  • estrogen
  • herbal medications
  • NSAIDs
  • immunomodulators
  • smoking
A
  • anticoagulants: discontinue
  • antiplatelets: discontinue for non cardiac patients
  • beta-blockers: continue in all
  • diuretics: discontinue on the day of surgery
  • lipid-lower agents: discontinue on the day of surgery
  • oral hypoglycemics: discontinue three days before
  • insulin: hold short-acting on the morning of surgery and give half the long-acting
  • estrogen: stop several weeks prior to surgery
  • herbal medications: stop one week prior to surgery
  • NSAIDs: stop one week prior to surgery
  • immunomodulators: discontinue two weeks before surgery unless transplant patient, then only stop sirolimus
  • smoking: stop 8 weeks prior to surgery
88
Q

How is dumping syndrome treated?

A
  • dietary modification including small, frequent meals and separation of solid foods from liquid intake by at least 30 minutes
  • a trial of octreotide can be used for refractory symptoms
89
Q

What is the best initial and most accurate test for post-op ileus?

A
  • best initial test is abdominal radiograph

- most accurate is CT

90
Q

Describe the pathogenesis, presentation, prevention, and treatment of post cardiac surgery syndrome.

A
  • it is a form of pericarditis that can following any surgery in which the pericardium is opened
  • it results from damage to mesothelial pericardial cells, which release cardiac antigens, stimulating an immune response
  • presents with tachycardia, tachypnea, distant heart sounds, and cardiomegaly on CXR
  • prevent with colchicine and treat with NSAIDs and colchicine

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