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Surgery oral exam Flashcards

1
Q

Management for apendicitis

A
  • Admit, IVF, abx, NPO
  • non-perf (<5 days): single dose unosyn pre-op, appy, no post-op abx
  • Perf: 5-7 days of zosyn
  • free perf: exlap, appy, wash and drain
  • small abscess: abx, interval appy (4-6 wks)
  • large abscess: percutaneous drainage, abx, interval appy
  • get cultures and sensitivities for this stuff!
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2
Q

CRC metastatic work-up

A
  • CXR
  • LFTs
  • CT abdomen/pelvis
  • Rectal ca: do a trans-anal ultrasound
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3
Q

CRC surgery

A

-preop: dose of cefoxitin, no post-op abx
-5cm margins (proximal and distal)
-hemi-colectomy –> tension free anastamosis
-12 Lymph nodes for adequate staging
-DVT ppx
(Stage 3/4: adjuvant FOLFOX)

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3
Q

Post-CRC surgery surveillance

A
  • CEA: q3 months x 1 yr, q 6months x 2 yrs

- colonoscopy: q6mo for 1st year, yearly for year 2, and every 3 years thereafter

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5
Q

Diverticulitis imaging

A

AXR

abdominal/pelvic CT

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6
Q

Diverticulitis management

A
  • IVF, NPO, foley, Abx (Unosyn) 7-10 days, NGT
  • surgery: perf, stricture, fistula
  • abscess 3cm –> CT-guided percutaneous drainage… no improvement after 3 days –> OR
  • Hartmann’s procedure: end colostomy, stapled rectal stump. reverse 2-3 mo. later
  • colonoscopy 6wk later to r/o CRC
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7
Q

Melanoma surveillance

A

FU w derm q 3 mo. x 1 yr, q 6mo x 5 yrs

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8
Q

Rx PVD

A
  • PACE + statin (PDE inhibitor, ASA, Cessation of smoking, Exercise)
  • Surgery: refractive claudication, rest pain, tissue necrosis, infxn
  • Open (bypass, endarterectomy) vs endovascular (angioplasty, stent)
  • bicarb and fluids w IV contrast
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9
Q

Rx acute limb ischemia

A
  • IV heparin
  • embolectomy (fogarty balloon)
  • Open bypass for embolectomy failure
  • stryke >30mmHg –> fasciotomy
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10
Q

Chronic mesenteric ischemia management

A
  • endarterectomy, bypass, angioplasty and stenting

- ASA

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11
Q

acute mesenteric ischemia management

A
  • CTA, EKG (pt in a fib?), IVF, abx*
  • small vessel: remove dead bowel, check doppler on remaining bowel, 2nd look 24 hr later
  • SMA emoblus: heparin, embolectomy
  • SMA thrombus: heparin, bypass, stenting
  • SMV thrombus: heparin
  • Papaverine for NOMI
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12
Q

Drugs implicated in acute mesenteric ischemia

A

digoxin, cocaine, diuretic, pressors

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13
Q

IBD management

A
  • Surgery: stricture/obstruction, fistula, perforation, abscess, refractory toxic megacolon, dysplasia
  • Toxic megacolon: steroids, abx, no improvement after 48 hrs –> OR
  • do appy in chrons
  • surgery: bowel resection, stricturoplasty
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14
Q

Gallbladder management

A
  • cholelithiasis: ccy if sxs
  • cholecystitis: IVF, abx, ccy w/in 72 hrs
  • choledocholithiasis: IVF, ERCP, ccy w/in 6 wks
  • Cholangitis: IVF, Zosyn 7-10 days. In shock: ERCP/PTC/open surgical decompression w t-tube. Stable: continue conservative management w ERCP in 24-48 hrs. - don’t improve w/in 24 hours? –> emergent ERCP
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15
Q

Carotid bruit imaging

A
  • duplex US: flow characteristics, not good for location

- Angiogram: can cause stroke, risk of contrast, ionizing radiation involved

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16
Q

Carotid bruit management

A
  • CEA for sxs >50% (study showed 70%), asxs >80% (study showed 60%)
  • Or angioplasty w stent: incr rate of stroke, decr rate of MI
  • ASA
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17
Q

CEA FU

A

-at 2 weeks, then every 6 months

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18
Q

SBO management

A
  • check for hernias!
  • NPO, NGT, IVF, Foley
  • Partial SBO/reducible hernia: conservative management. No improvement in 24-48 hrs –> OR
  • Complete SBO: Laparotomy and LOA, find transition poitn
  • Pre-op abx: cefoxitin
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19
Q

Pancreatitis imaging

A

CXR (ARDS), KUB, CT w contrast, US if thinking gallstones

-CT with IV and PO contrast for: severe pancreatitis, signs of sepsis, clinical deterioration

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20
Q

Pancreatitis management

A
  • NPO, IVF, foley, NGT
  • Enteral feeds > TPN after 7 days
  • Pain: Meperedine, Dilaudid
  • pancreatic necrosis: imipen
  • surgery for pseudocyst >6 wks
  • surgery for pancreatic abscess: abx + CT-guided drainage
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21
Q

Pancreatic necrosis management

A
  • suspect infxn? (7 days after onset of necrosis) –> CT guided FNA, blood cx, abx (Zosyn)
  • -> gram stan and culture
  • clinically unstable? –> surgical debridement
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22
Q

Anal fissure management

A

(fissure, hemorrhoids, anal cancer)

  • sitz baths, stool softener, fiber
  • flagyl great for anal infxn
23
Q

anal cancer work-up

A
  • Proctoscopic exam, colonoscopy, trans-anal US
  • abdm/pelvic CT, CXR, LFTs
  • chemo , radiation
24
Q

Upper GI bleed

A
  • PUD: PPI, erythromcyin/reglan, EGD: cautery, band, vasopressin
  • Gastritis
  • Mallory weiss
  • esophageal varices - IV vasopressin, octreotide, EGD banding or slcerotherapy, arteriography coil glue, blakemore. Do ppx abx for any cirrhotic hospitalized for bleeding (e.g. ceftriaxone).
  • cont…: surgery non-shunt - (esophageal transection w variceal ligation, devascularization of the GEJ) or shunting procedures/TIPS
  • gastric or esophageal cancer
  • erosive esophagitis
25
Labs for an upper GI bleed
- Chem 7, CBC, LFTs, PT/PTT, amylase, type and cross | - BUN/Cr >36 in UGIB +/- prerenal azotemia
26
Upper GI bleed management
- ABC (recheck vitals q 10 min) - IVF, foley, NPO, NGT (diagnostic) - Reverse coagulopathy if necessary - Triage to ICU etc - Put on heart monitor - IV PPI, IV erythromycin - EGD - coagulation/cautery and epi, ligation/banding for varices - -> arteriography coil, vasopressin, glue
27
breast cancer metastatic work-up
- LFTs - serum Ca2+/AlkPhos, bone scan - PET/CT - Brain MRI if s/s
28
Brest lump work-up
30: Mammogram - -> magnify imaging - -> core biopsy + hormone status receptors testing - also get an US, of axilla too - unsuscpicious/non-simple cyst: get FNA --> get tissue if bloody, i.e. get excisional biopsy
29
Admit orders
- Admit to step down - IVF @ __ - Foley - NPO - NGT if ileus/n/v - ?Telemetry - Daily labs: ___ - Serial exams q3hrs and vitals per floor routine - Pain: PCA intermittent Dilaudid - DVT ppx: IV heparin, SCDs, Teds - ?CIWA
30
Fever work-up
UA CXR Blood Cx Inspection of wound
31
Angiography
-therapeutic options: vasopressin, coiling, embolization, fibrin glue
32
PUD GERD
Trial of PPI, then EGD w bx, then high res manometry w ph probe. - NIssen for refractory GERD - PUD: - bleeding: oversew - Perforation: patch - Obstruction: highly selective vagotomy, gastrojejunostomy - Non-healing/intractibility: highly selective vagotomy, antrectomy/distal gastrectomy
33
CT bowel obstruction
PO contrast and IV contrast
34
Do not give PO contrast:
Mesenteric ischemia
35
CT for mesenteric ischemia
w contrast - see bowel thickening - pneumatosis intestinalis - bowel dilation - mesenteric stranding
36
Mesenteric ischemia Rx
- IVF, broad-spectrum abx - SMA embolus and thrombosis: IV heparin, embolectomy or bypass for large vessel - cannot do surgical revascularization in small vessels - SMV thrombosis: IV heparin - NOMI: correct the underlying problem - Papaverine - surgery for peritonitis = transmural ischemia - send home on ASA
37
Labs for mesenteric ischemia
- Chem 7 - CBC - LFTs - amylase - lactic acid - LDH - FOB - CTA, or mesenteric angiography
38
Management for ischemic colitis
- broad-spectrum abx, IVF, NPO, serial abdominal exams | - surgery: infarction, refractory to rx, stricture, hemorrhage, fulminan colitis
39
Melanoma late stages
- Stage 3: IFN-alpha - Stage 4: High-dose IL-2, BRAF inhibitors, CTLA-4 inhibitors, (immunotherapy based on genetic mutations present) clinical trial
40
Post wide-excision for FU of melanoma Stage 1/2
-Derm: q 3mo x 1 yr, q 6mo x 5 yr | looking for local recurrence
41
Breast cancer - pre-op metastatic work-up
- CXR - LFTs - alk phos, Ca2+ - Brain MRI if s/s
42
Breast ca. treatment
- DCIS: Lumpectomy (2mm margins) + radiation - Radiation: anyone w BCT - Chemo: anyone who has +node, or ER+ >5mm - ask about fertility before chemo! - Chemo can be neo- or adjuvant - LCIS: lumpectomy, treat per final pathology
43
Breast ca - lumpectomy for...
- tumor <5 cm - no CI to radiation post-lumpectomy - somebody wanting BCT
44
breast lumpectomy contraindications:
- can't get clear margins - diffuse suspcious microcalcifications - previous XRT to breast
45
Breast SLN for...
- DCIS: high-risk, mastectomy | - T1, T2, and T3 tumors
46
Breast cancer radiation
- most women having BCT for invasive cancer/DCIS - women >70 may not require XRT - Mastectomy negates need for radiation, except >4 LN, tumor invasion of chest wall, inflammatory breast ca.
47
ER+ tumors
- ->21 gene testing - low risk: may only need hromones (not chemo) - medium risk and up: may need chemo + hormones
48
Breast cancer T1 / 2 / 3/ 4
T0: no evidence of primary tumor Tis: DCIS/LCIS T1: 5cm T4: any size, extension to chest wall or skin
49
Breast cancer: chemo
- node + - ER + >5mm - Her2neu+ >1cm - Triple negative - Neoadjuvant for inflammatory breast ca.
50
Acute complication of AAA repair
MI, hemorrhage, distant emboli, renal failure, colonic ischemia
51
Late complication of AAA repair
AEF, graft infxn, graft thrombosis, anterior spinal syndrome
52
complication of CEA
-MI*, stroke, hematoma, wound infxn, superior laryngeal n, hypoglossal n injury, death. -Long term: restenosis (Post-op FU at 2 wks and every 6 mo.)
53
meds for pts w carotid stenosis
-ASA, statin, beta-blocker

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