Surgery Flashcards
What chronic disease can mimic acute appendicitis?
IBD - Crohns
How to w/u appendicitis?
CBC, CMP, KUB, CXR (look for fecalith), UA
US for kids and women
CT scan if unsure
clinical dx in 80% of cases
How to manage acute appendicitis?
NPO, prophylactic IV abx (24 hrs)*CTX, appendectomy
*continue abx if concerns that arise in surgery
What are complications and tx of them for Appendicitis?
wound infection -abx
intra-abdominal abscess - dx with CT, do CT guided drainage or open drainage
enterocutaneous fistula - might need right ehmicolectomy
small bowel obstruction
Ddx of abd distention, vomiting, and not passing gas?
large bowel obstruction d/t cancer/mass
diverticulitis
pseudo obstruction (functional obstruction - anticholinergic effect of meds)
sigmoid volvulus
What are the most common causes of small bowel obstruction?
- adhesions!
- hernia
- tumors
How to treat large bowel obstruction?
inpt
NPO
IV hydration
manage electrolyte disturbances with repletion
NG tube if bowel is dilated
gastrograffin or barium enema, colonoscopy and emergent ex lap
How to dx colon cancer?
bowel prep with golytely and abx (oral and IV)
must have colonoscopy and biopsy - entire colon must be evaluated
stage with CXR and CT scan
What does a barium enema show when colon cancer is present?
“apple core lesion”
How do you treat pseudo-obstruction?
correct electrolytes, stop anticholinergic meds
colonoscopy can be dx and tx
How to dx and tx colonic volvulus?
dx with ct scan
dx/tx with colonoscopy or contrast enema
surgery only for recurrent or nonviable bowel (acute abdomen)
How to dx/tx diverticulitis?
CT scan
IV abx, IV fluids, bowel rest
if acute abdomen - surgical emergent laparotomy
barium enema or colonoscopy *not in acute stage d/t risk for perforation to make sure not colon cancer!
Initial w/u of suspected small bowel obstruction?
CBC, CMP, LFTs, amylase/lipase
KUB
How to tx small bowel obstruction?
NG tube to decompress
IV fluids
foley catheter
serial abdominal exams and xrays
bowel rest
monitor and replete electrolytes
*if turns to complete obstruction (no flatus or gas in rectum, no bowel movement for 12 hrs, peritonitis) -emergent surgery!
What is the difference between ilues and obstruction?
ileus doesn’t have pain like an obstruction
How to work up and treat concern for an acute arterial embolus in an extremity?
start hepain
angiogram - to dx
surgical embolectomy to remove the clot
*if compartment syndrome - fasciotomy
How do you work up and tx cholecystitis?
RUQ U/S
HIDA scan if US doesn’t dx the cholecystitis
NPO
IV abx
cholecystecomy if symptoms worsen or do not improve in 24-72 hours with abx
*if symptoms improve acutely, f/u with elective cholecystectomy in 6-8 wks
What is long term counseling for a pt without a gall bladder?
avoid large meals amounts of fatty food!
What abdominal dx has the hallmark sign of pain out of proportion to exam?
mesenteric ischemia
What do labs show in mesenteric ischemia?
lactic acidosis - ph acidic
guaiac pos stool
no other significant findsing than pain
hx of a fib
How to tx mesenteric ischemia?
can do supportive treatment with IV NS and anticoagulation with heparin if pt doing ok
otherwise. ..
1. mesenteric angiography
2. surgical exploration for embolectomy and possible bowel resection if peritonitic
What are the 2 most common causes of pancreatitis?
alcohol or gallstones
How to work up and tx testicular torsion?
*clinical - go straight to surgery
if unsure…
doppler US of testicle for blood flow
order KUB to look for signs of incarcerated hernia
tx: emergent surgery to detorse with bilateral orchiopexy (goal within 4 hrs)
How to evaluate and tx stab to abdomen?
CBC, type and cross, floey catheter placement (look for blood), KUB and CXR)
- abdominal CT scan with IV contrast (looking for free air or fluid)
If penetrates fascia (into peritoneum) - surgical exploration
If does not penetrate - close the wound
IF SIGNS OF SHOCK GO STRAIGHT TO OR
How do you manage a penetrating abdominal gunshot wound?
ABCs
OR
How to work up and tx suspected esophageal perforation?
CBC, EKG, CXR, KUB
upper gi wtih gastrograffin contrast showing contrast leak into chest
tx: IV fluid, broad spectrum Abx
OR exploration and repair if leakage into thorax
*if cervical loaction, can watch without OR if doing well
What is the difference between an omphalocele and gastroschisis?
omphalocele - encased in a peritoneal wall
gastroschisis - no peritoneal wall
How to manage an omphalocele?
surgical repair
How to manage gastroschisis?
surgery with silo procedure (bowel inflammed and can not be closed)
NICU, IV abx
When do you repair umbilical hernias in children?
if still there when child is over 5 years old
How to assess and manage a diabetic foot ulcer?
intiial labs - CBC, xray
MRI to look for osteomyelitis
*if present, surgical debridement/poss amputation and broad spectrum abx, send tissue for culture
IV abx long term if osteomyelitis
*if no osteo, Abx, glucose control, bed rest, wound care
What are the indications for surgery with an abdominal aortic aneurysm?
size > 5 cm
growth > 0.5 cm per year
symptomatic
rupture
How to evaluate/work up AAA?
CBC, electrolytes
EKG
CXR
CT scan with IV contrast (for initial dx!)
*US can be used for f/u surveillance
What is the ddx of bloody nipple discahrge?
intraductal papilloma (most common)
breast carcinoma
trauma
breast abcess
How to work up and dx breast mass?
mammography
U/S
excisional biopsy of mass for dx
What are the types of breast cancer and how to tx?
- ductal carcinoma in situ
*tx with mastectomy or radiotherapy + 2 yrs hormonal tx if receptor +
- lobular carcinoma in situ
*tx with close watch or bilat mastectomy if high risk (BRCA1 +)
- ductal carcinoma infiltrative
*surgery (mastectomy or lumpectomy w/radiation) + chemo/hormonal
- lobular carcinoma infiltrative
*surgery (mastectomy or lumpectomy w/radiation) + chemo/hormonal
What is the ddx for a lump in neck (thyroid)?
nodular goiter
thyroid cancer
thyroid adenoma
How to work up thyroid mass?
TFTs
Fine needle aspiration cytology and US
What syndromes are associated with medullary carcinoma?
MEN type 2A
MEN type 2B
How to tx medullary thyroid cancer in MEN syndromes?
take out pheochromocytoma first, then take out thyroid cancer
How to stage and tx thyroid cancer?
remove thyroid gland (total thyroidectomy)
then stage with radioactive iodine scan for any other thyroid tissue in the body
*if positive, do therapuetic iodide tx and then recheck scan in 6 wks
What long term management do pts with thyroid cancer post resection need?
long term thyroid replacement (levothyroxine)
How to work trouble swallowing food?
CBC, CMP, CXR, upper GI swallow w/ barium study
next step: upper endoscopy and biopsy
What is the best test to look for local invasion of tumors of GI tract?
endoscopic US
What is the most common type of esophageal cancer and how to manage?
adenocarcinoma from GERD
monitor with endoscopy
when Barrett’s goes to high grade dysplasia - resect
How to tx carpal tunnel syndrome?
rest
orthotic splints
NSAIDs
steroid injections
*if need surgery (very rare) must get EMG adn nerve conduction study first to confirm dx
How to work up a scaphoid fracture (of the wrist)?
Wrist x ray (but may be negative at first)
splint/cast
repeat x rays in 1-2 wks
*if not definitive, get MRI to dx
How to dx pancreatic cancer?
CA 19-9 elevated
CT scan is gold standard to dx
How to tx pancreatic cancer?
pancreaticoduodenectomy (Whipple)
*will not resect if tumor is not encased in blood vessels or has positive lymph nodes in liver or liver mets
How to manage congenital diaphragmatic hernia?
place NG to decompress
ABCs - intubation
operative repair
