Surgery Flashcards
What are the three most important factors when calculating a patient’s Goldman index for cardiac risk?
- history of CHF
- history of MI within the last 6 months
- presence of an arrhythmia
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?
- 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
What ejection fraction is the threshold for increased risk during a non cardiovascular surgery?
less than 35%
What is the revised cardiac risk index and how is it used?
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
What is the ASA physical status classification system and how is it used?
- 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
What preoperative cardiac testing is required for all patients?
- 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
What pulmonary disease risk assessment should be done preoperatively?
patients with known lung disease or a smoking history should have PFTs performed prior to surgery to evaluate vital capacity
When should patients stop smoking prior to surgery?
8 weeks pre-op
How is kidney disease managed intraoperatively?
- patients with chronic kidney disease should be aggressively hydrated
- those on dialysis should be dialyzed within 24 hours of the operation
How should the airway be secured in trauma patients?
- orotracheal tube is preferred
- use a cricothyroidotomy if patients have facial trauma
- use a flexible bronchoscopy if patients have a cervical spine injury
What is the difference between each of the following:
- SIRS
- sepsis
- severe sepsis
- septic shock
- 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
What are the SIRS criteria?
- temperature less than 36 or greater than 28
- tachycardia greater than 90
- tachypnea greater than 20
- WBC less than 4000 or greater than 12000
For cardiogenic shock, what happens to the following:
- temperature
- CVP
- SVR
- HR
- CO
- LVEDP
- PCWP
- temperature: cool extremities
- CVP: increased
- SVR: increased
- HR: increased
- CO: decreased
- LVEDP: increased
- PCWP: increased
For neurogenic shock, what happens to the following:
- temperature
- CVP
- SVR
- HR
- CO
- LVEDP
- PCWP
- temperature: warm extremities
- CVP: decreased
- SVR: decreased
- HR: increased
- CO: decreased
- LVEDP: decreased
- PCWP: decreased
Describe the presentation, diagnosis, and treatment of a brain abscess.
- 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
Describe the presentation, diagnosis, and treatment of an epidural abscess.
- 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
What is the most accurate test for anterior spinal artery syndrome?
an MRI
Describe the presentation and diagnosis of a basal skull fracture.
- 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
Describe the presentation of a pneumothorax.
chest pain, hyper resonance to percussion, and decreased breath sounds
What two things cause tracheal deviation and in which direction?
- tension pneumothorax causes a shift away from the affected side
- atelectasis causes a shift toward the affected side
Describe the workup for blunt abdominal trauma.
- 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
What is the best next step in a patient who suffers a stab wound to the abdomen?
- 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
What is the best next step for a patient who suffers a GSW to the abdomen?
exploratory laparotomy plus tetanus prophylaxis
Describe the presentation, diagnosis, and treatment of splenic rupture.
- 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
When removing the spleen it is important to give what vaccinations?
- 13-valent pneumococcal followed 8 weeks later by the 23-valent
- also give meningococcal and Hib
Describe the presentation and treatment of splenic infarction.
- 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
Describe the presentation, diagnosis, and treatment of splenic abscess.
- 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
Describe the presentation, diagnosis, and treatment of ischemic colitis.
- 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
Describe the pathogenesis, presentation, diagnosis, and treatment of acute mesenteric ischemia.
- 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
Describe the pathogenesis, presentation, diagnosis, and treatment of chronic mesenteric ischemia.
- 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
Describe the pathophysiology, presentation, diagnosis, and treatment of median arcuate ligament syndrome.
- 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
Where are Mallory Weiss tears and esophageal perforations most likely to be located within the esophagus?
- tears at the GE junction
- perforations at the distal posterolateral aspect
How should Mallory Weiss tears and esophageal perforations be diagnosed?
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
What is the feared complication of Boerhaave syndrome?
mediastinitis
What is the most common cause of esophageal perforation?
iatrogenic in those undergoing an upper endoscopy
What is the most common cause of gastric perforation? How should it be diagnosed and treated?
- 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
What are the following signs of appendicitis:
- psoas sign
- obturator sign
- rovsing sign
- 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
What is a HIDA scan?
- 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
How should bowel obstruction be diagnosed and treated?
- 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
How are biliary colic and cholecystitis treated?
- biliary colic requires elective cholecystectomy
- cholecystitis requires urgent cholecystectomy
Describe the presentation, diagnosis, and treatment of cholangitis.
- 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
Describe the presentation, diagnosis, and treatment of a bile leak.
- 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
Describe the presentation, diagnosis, and treatment of sphincter of oddi dysfunction.
- 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
Describe the etiology, presentation, diagnosis, and treatment of pancreatic cancer.
- 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
Describe the etiology, presentation, diagnosis, and treatment of cholangiocarcinoma.
- 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
Describe the etiology, presentation, diagnosis, and treatment of gall bladder cancer.
- 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
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
- 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
How are gallbladder polyps managed?
- 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
What population is most at risk for acalculus cholecystitis and why?
patients who are critically ill or receiving TPN because they have diminished release of CCK which induces gallbladder contraction
What is the treatment for each of the following:
- biliary colic
- cholecystitis
- acalculous cholecystitis
- cholangitis
- biliary colic: elective cholecystectomy
- cholecystitis: urgent cholecystectomy
- acalculous cholecystitis: urgent cholecystectomy
- cholangitis: antibiotics, CBD decompression with ERCP or PCI, and elective cholecystectomy
Describe the pathophysiology, presentation, and treatment of pilonidal cysts.
- 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
What is the treatment for anal fissures?
- 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
How is rectal prolapse treated?
with surgery
How are hemorrhoids treated?
- begin with dietary management, situ baths, and topical steroids
- then move on to rubber band ligation or hemorrhoidectomy
What is a comminuted fracture?
one in which the bone gets broken into multiple pieces
Describe the diagnosis and treatment of stress fractures.
- 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
What is suggested if an older patient fractures a rib while coughing?
this is a pathological fracture and suggests an underlying condition
Describe the presentation and treatment of trigger finger.
- presents as an acutely flexed and painful finger
- treat with steroids first and then surgical decompression if necessary
Describe the presentation, diagnosis, and treatment of anterior and posterior should dislocations.
- 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
How is achilles tendon rupture diagnosed and treated?
- the most accurate test is an MRI
- treated surgically
Describe the presentation and treatment of fat PE.
- triad of petechial rash, dyspnea, and confusion in a patient with recent long bone fracture
- treat with oxygen and respiratory support as needed
What are the 6 P’s of compartment syndrome?
- pain
- pallor
- paresthesia
- pulselessness
- paralysis
- poikilothermia
The knee is best imaged using what modality?
MRI
What are the anterior and posterior draw tests of the knee?
- 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
Describe the treatment of hiradenitis suppurativa.
- 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
Describe the presentation and treatment of BPH.
- 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
Why are a1-antagonists preferred to 5a-reductase inhibitors for the treatment of BPH?
because 5a-reductase inhibitors take several months to have an effect
Describe the two types of priapism, their diagnosis, and their treatment.
- 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
When should hydroceles be surgically corrected?
if they persist beyond 12 months of life
What is the most accurate test for varicocele?
an ultrasound showing dilation of the pampiniform plexus to greater than 2mm
Describe the timeline for correcting cryptorchidism.
orchiopexy should be performed between 4 months and 2 years of life
How does cryptorchidism affect future cancer risk?
it increases it regardless of whether orchiopexy is performed but there is greater risk without intervention
Describe the etiology, presentation, diagnosis, and treatment of Fournier gangrene.
- 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
What are the indications and contraindications for bariatric surgery?
- 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
What are the most common side effects for the following bariatric procedures:
- Roux-en-Y
- sleeve gastrectomy
- gastric band
- 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
How is AAA defined and managed?
- 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
Why are vasodilators not used as monotherapy for those with aortic dissection?
because they can induce reflex tachycardia, which increases shearing forces
What are the three types of thoracic outlet syndrome?
- 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
What is Adson sign?
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
Describe the presentation, diagnosis, and treatment of thoracic outlet syndrome.
- 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
Where are indirect, direct, and femoral hernias?
- 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
What is the most common type of hernia?
indirect inguinal is most common in both genders; however, femoral is more common in females than in males
What is the timeline for post-operative fever?
- 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
How should suspected PE be managed?
- start with an ECG and get troponin to confirm the pain is non-cardiac
- then get a CTA or V/Q scan to confirm the diagnosis
When would you use a V/Q scan to diagnose PE?
it is preferred during pregnancy and for those with contrast allergy
When is D-dimer used to assess PE?
it is highly sensitive and used in unlikely cases to rule out PE; it plays no role in those with a high suspicion
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
- 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
How is dumping syndrome treated?
- 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
What is the best initial and most accurate test for post-op ileus?
- best initial test is abdominal radiograph
- most accurate is CT
Describe the pathogenesis, presentation, prevention, and treatment of post cardiac surgery syndrome.
- 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
