Surgery Rotation 5

Question 1

Absolute contraindication to surgery

Answer 1

DKA

Question 2

Measures of poor nutrition

Answer 2

Albumin > 3
Transferrin > 200
Lost more than 20% of body weight

Question 3

Most important factors for predicting mortality for surgery

Answer 3

1. CHF - check EF
2. MI within 6 months - check EKG
3. Arrhythmias
4. Old age
5. Emergent surgery
6. Aortic stenosis - listen for murmur (late systolic, crescendo-decrescendo)

Question 4

Meds to stop before surgery

Answer 4

Aspirin, NSAIDs, Warfarin, metformin (lactic acidosis)

Question 5

What do you do on a vent if patient’s paCO2 is low?

Answer 5

Patient is blowing off too much CO2

So want to decrease tidal volume (preferable) or rate

Question 6

What is the formula for anion gap?

Answer 6

Na - (Cl + HCO3)

Normal = 8-12

Question 7

Causes of hypervolemic hyponatremia

Answer 7

CHF, nephrotic syndrome, cirrhosis

Question 8

Causes of hypovolemic hyponatremia

Answer 8

vomiting, diuretics

Question 9

Causes of euvolemic hyponatremia

Answer 9

SAIDH, Addisons, hypothyroidism

Question 10

When do you use hypertonic saline solution (3%)

Answer 10

Symptomatic hyponatremia (e.g. seizures) or extremely low Na level (< 110)

Question 11

Why don’t you use hypertonic solution to always fix hyponatremia?

Answer 11

Central pontine myolinolysis

Question 12

Treatment of hypernatremia

Answer 12

D5W or hypotonic solution

Question 13

What is the concern when correcting hypernatremia

Answer 13

Cerebral edema

Question 14

Treatment for hyperkalemia

Answer 14

Calcium gluconate (to stabilize cardiac membranes), insulin and glucose, albuterol (also shifts K+ into cells), last resort = dialysis

Question 15

Boundaries of axilla for dissection

Answer 15

Superior boundary = axillary vein

Posterior = long thoracic nerve

Lateral = latissimus dorsi muscle

Medial = pec minor muscle

Question 16

Common cause of hypercoagulable state in the elderly?

Answer 16

Cancer

Question 17

Hypercoagulable state with edema, HTN, and foamy pee?

Answer 17

Nephrotic syndrome (will lose protein such as ATIII in the urine)

Question 18

Most common inherited hypercoagualable disorder?

Answer 18

Factor V Leiden

Question 19

Why is Antithrombin III deficiency important?

Answer 19

Heparin won’t work

Question 20

Cause of young woman with multiple spontaneous abortions

Answer 20

Lupus anticoagulant

Question 21

Cause of post op pt with thromocytopenia and increased clots

Answer 21

HIT - Heparin-induced thrombocytopenia

Question 22

How do you treat HIT?

Answer 22

Synthetic heparin - Leparudin or agatroban

Question 23

Cause of bleeding with isolated decreased platelets?

Answer 23

ITP

Question 24

Cause of bleeding with normal platelets but increased bleeding time and PTT

Answer 24

vWD

Question 25

Cause of bleeding with low platelets, increased PT, PTT, BT, low fibrinogen, high Ddimer, schistocytes

Answer 25

DIC

Question 26

Formula for fluid resuscitation in adult burn victim

Answer 26

(Kg) x (% burn surface area) x (3-4)

Question 27

Formula for fluid resuscitation in child burn victim

Answer 27

(Kg) x (% burn surface area) x (2-4)

Question 28

Ddx of pt with oliguruia who is not in shock

Answer 28

Not enough fluid or acute renal failure

Question 29

Hoe can you differentiate between lack of fluids and acute renal failure

Answer 29

Measure Na of urine - will be low in pt with low fluids because they are trying to reabsorb as much as possible. Will be high in pt with kidney dysfunction

Question 30

Nerves susceptible to damage during axillary dissection

Answer 30

Long thoracic (serratus anterior)
Thoracodorsal (latissimus dorsi)
Medial pectoral
Lateral pectoral

Question 31

What are the suspensory ligaments of the breast called

Answer 31

Cooper’s ligament

Question 32

What is the tail of breast tissue that tapers into the axilla

Answer 32

Tail of Spence

Question 33

What do you see on X-ray of paralytic ileus

Answer 33

Dilated gas-filled loops of bowel with no transition point

Question 34

What are the W’s associated with post-op fever?

Answer 34

Wind - atelectasis
Water - UTI
Wound - infection
Walking - DVT
Wonder drug - drug fever

Question 35

What is the diagnosis: persistent pneumothorax following chest tube placement in a patient who sustained chest blunt trauma. + pneumomediastinum and subcutaneous emphysema

Answer 35

Tracheobronchial rupture

Question 36

What will you see on CT in colonic ischemia

Answer 36

Edema and air (pneumatosis) in the bowel wall

Question 37

What will you see on colonoscopy of colonic ischemia?

Answer 37

Segments of cyanotic mucosa and hemorrhagic ulceration with sharp transition from affected to unaffected mucosa

Question 38

Management of colonic ischemia

Answer 38

• IV fluids and bowel rest
• Antibiotics with enteric coverage
• Colonic resection only if necrosis develops

Question 39

Pathology of penile fracture

Answer 39

Rupture of corpus cavernosum due to traumatic tear in tunica albuginea (which envelops the corpus cavernosum)

Question 40

Management of penile fracture

Answer 40

Urological emergency = urgent operative care

If there is evidence of urethral injury (blood at meatus, hematuria, dysuria, urinary retention) - indication for retrograde urethrogram

Question 41

Management of blunt abd trauma in hemodynamically unstable patients

Answer 41

FAST (US) exam

• If positive (intraperitoneal fluid) = urgent laparotomy
• If negative = stabilize if signs of extra-abd hemorrhage, or stabilize then CT if no signs of extra-abd hemorrhage

Question 42

Management of blunt abd trauma in hemodynamically stable patients

Answer 42

Positive FAST exam = CT abd

Question 43

Management of hemodynamically stable patient with penetrating abd trauma and signs of peritonitis (rebound/guarding)

Answer 43

Urgent exploratory laparotomy