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200 Cards in this Set
- Front
- Back
Rx for adrenal crisis
|
IV steroids (dexamethasone), volume resuscitation
|
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When should transfusion with FFP be given?
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On call to the OR
|
|
Factors that predispose to fistula formation and may prevent closure
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Foreign body
Radiation Inflammation Epithelialization of the tract Neoplasm Distal obstruction Steroids |
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Fever, chills, hypotension, oliguria, pain at IV site
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Hemolytic tranfusion reactions (due to reaction of recipient Abs against transfused antigens)
|
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Management of pt with hemophilia A who needs surgery
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If severe disease: e-aminocaproic acid (AMICAR; inhibits fibrinolysis) and desmopressin (DDAVP, increases VIII and vWF)
If mild: DDAVP alone |
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Why can FFP not be used successfully in hemophiliacs?
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Factor levels are too low; need cryo or recombinant factos
|
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NSAIDs can cause ___ dysfunction
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Platelet
|
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Potential vitamin deficiency syndromes from gastrectomy and Bilroth II procedure
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Megaloblastic anemia (decreased intrinsic factor)
Microcytic anemia (iron deficiency from decreased uptake in duodenum) Osteoporosis (decreased calcium absorption from duodenum/jejunum) Steatorrhea (fat malabsorpion) |
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Diagnostic test for suspected ureteral injury (intraop and postop)
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Intraop: methylene blue administration
Postop: CT to see hydronephrosis or fluid collection (urinoma), then IV pyelogram |
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Tingling sensation and muscle cramps after thyroid surgery
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Hypocalcemia, likely short-term due to transient ischemia of parathyroid gland
|
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Rx for symptomatic hypocalcemia
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IV calcium infusion (or oral if only mild symptoms); Vitamin D if persistent
|
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Massive transfusion is associated with what electrolyte abnormality?
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Hypocalcemia 2/2 chelation with citrate in banked blood
|
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Numbness, Chvostek's sign, and prolonged QT
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Hypocalcemia
|
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Best fluid replacement for enteric losses
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Ringer's lactate
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Rx for hyperkalemia
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Kayexalate (to bind it)
Sodium bicarb, dextrose, insulin (all to shift it intracellularly) Calcium gluconate (to counteract myocardial effects) |
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Best drainage system and location to minimize wound infections
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Closed drainage system that exits skin away from surgical incision
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When epithelialization is delayed beyond 3 wks, the incidence of ? increases
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Hypertrophic scarring
|
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Ex of epidermal burn
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Sunburn
|
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Why are superficial partial thickness burns painful?
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Exposed superficial nerves
|
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What leads to healing of superficial partial thickness burns?
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Regeneration of epidermis from keratinocytes w/in sweat glands and hair follicles (areas with more will heal more quickly)
|
|
Rx for superficial partial thickness burns and why?
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Antimicrobial creams and occlusive dressings (epithelialization is faster in a moist environment)
|
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Rx for deep partial thickness wounds
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Excise to a viable depth and then skin graft, esp if in cosmetic location since healing is slow and associated with contraction
|
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Rx for full thickness injuries
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All should be excised and grafted unless <1cm and no compromise of function, b/c all regenerative elements have been destroyed
|
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When is the best time to graft burns?
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Within 5 days of injury to minimize blood loss
|
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Ideal skin covering choice?
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Split skin autograft from unburnt areas
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Alopecia, poor wound healing, night blindness, anosmia, neuritis, skin rashes
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Zinc deficiency
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Excessive diarrhea may lead to a ___ deficiency
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Zinc
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Cardiomyopathy may be due to a ___ deficiency
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Selenium
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Pts on long-term TPN may develop this deficiency w/ hyperglycemia, peripheral neuropathy, and encephalopathy
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Chromium
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Potential abnormality following administration of large volumes of normal saline
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Non anion-gap metabolic acidosis (due to increased chloride concentrations)
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Both LR and NS are both __ (acidic/alkalotic) w/ respect to plasma
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Acidic
pH of LR is 6.5 pH of NS is 4.5 |
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Two good situations for NS and for LR
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NS: vomiting or significant nasogastric suction losses (b/c pt will have tendency toward metabolic alkalosis)
LR: replacing GI losses and correcting ECF deficits |
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3 indications for a vena caval filter
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- Anticoagulation contraindication/ failure
- Free-floating venous clot - Chronic PE complicated by pulm HTN |
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Earliest signs of sepsis
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Altered mental status, flushed skin, tachypnea --> respiratory alkalosis
|
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Body's response to stress causes
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Increased CO
Hyperglycemia Peripheral vasodilation Decreased arteriovenous oxygen difference (from decreased peripheral use of O2) |
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Rx for hemolytic transfusion reaction
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- Fluid resuscitation
- Foley for diagnosis and monitoring of Rx - Mannitol to induce diuresis (so can clear hemolyzed red cell membranes and avoid renal damage) - Alkalinization of urine to prevent Hb clumping |
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Surgery for C. diff colitis
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Subtotal colectomy with end ileostomy
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Caloric requirements for 70kg man who is:
Nml Postop Septic Multiple trauma/ventilated Major burn |
Nml: 1450
Postop: 1500 Septic: 2000 Multiple trauma/ventilated: 2500 Major burn: 3000 |
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Bleeding from trach
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Bleeding from tracheoinnominate artery fistula
|
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Management of tracheoinnominate artery fistula
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If still bleeding: stop (inflate balloon or compress)
Once bleeding stopped: fiberoptic exploration in the OR |
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Criteria for extubation
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Negative inspiratory force >-20
Weaned to 5cm H2O PEEP Minute ventilation <10L/min RR <20/min Rapid shallow breathing index btwn 60 and 105 |
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What is the rapid shallow breathing index?
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Ratio of RR to tidal volume
|
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Anesthetic not to use in SBO operations and why
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Nitrous oxide, b/c is less dense than air so may cause distension of air-filled spaces
|
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Changes in ARDS
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Hypoxemia
Decreased compliance Decreased FRC Alveolar collapse from leakage of protein-rich fluid |
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Oxygen dissociation curve shifts (right/left) indicate?
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Right: increased tissue oxygen uptake
Left: decreased tissue oxygen uptake |
|
Do the following conditions shift the oxygen dissociation curve R or L?
Acidosis Increased PaCO2 Increased temp Increased 2,3-DPG Chronic lung diseases Banked blood |
All right except banked blood (b/c low in 2,3-DPG)
Chronic lung diseases shift it right via an increase in 2,3-DPG due to chronic hypoxia |
|
Dopamine at low doses
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Vasodilation of renal/mesenteric vessels and peripheral vasoconstriction, redirecting blood to kidneys/bowels
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Dopamine at high doses
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Increases HR, CO, BP and causes peripheral vasoconstriction
|
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Dopamine at all doses
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Increases diastolic BP and coronary blood flow
|
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Best pressor choice for cardiogenic shock
|
Dobutamine (positive inotrope and vasodilates, but minimal chronotropic effect so only mild increase in O2 demand)
|
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Reversal of epidural opiates
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IV (not epidural) maloxone
|
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Cardiac index =
|
CO/BSA
|
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Rx for acalculous cholecystitis
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Percutaneous drainage
|
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Hemodynamics in postop septic shock (early)
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Increased CO, decreased SVR, normal central pressures
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Rx for postop septic shock
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Fluids, pressors, Abx (against gram negative rods and anaerobes, esp after bowel surgery), laparotomy and drainage of intraabdominal abscess when identified/ if pt stable
|
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Indications for cholecystectomy in asymptomatic pts
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Immunocompromised
Porcelain gallbladder (calcified) Gallstones >3cm (associated w/ dev't of gallbladder carcinoma) |
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Why is an intraop cholangiogram often performed in cholecystectomies?
|
To r/o common bile duct stones
|
|
2 major complications of a cholecystectomy
|
Injury to the common duct (--> chronic biliary strictures, infection, and cirrhosis)
Injury to hepatic artery (--> hepatic ischemia or bile duct ischemia and stricture) |
|
Most common bacteria in cholecystitis
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E coli, enterobacter, klebsiella, enterococcus
|
|
Antibiotics for cholecystitis
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2nd generation cephalosporin preop and for 24hrs postop
|
|
When is lap chole indicated in cholecystitis?
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Within 48-72hrs
|
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Symptomatic cholelithiasis + elevated bili or elevated LFTs
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Suspect common bile duct obstruction
|
|
When is removal of common duct stones not necessary?
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If they're smaller than 3mm
|
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Management of symptomatic cholelithiasis or gallstone pancreatitis in pregnancy
|
Pain meds and hydration
If needed, cholecystectomy (ideally in 2nd trimester) or ERCP |
|
Management of cholecystitis + elevated amylase
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Cholangiogram (and cholecystectomy) is mandatory with biliary pancreatitis
|
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Cholecystitis + severe symptomatic pancreatitis
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Delay cholecystectomy
|
|
Ddx for very high fever, gallstones, and hypotensive
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Acute cholecystitis, cholangitis, empyema of gall bladder, or pericholecystic abscess
|
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Management of suppurative cholangitis
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Emergent ERCP with sphincterotomy, decompression of biliary tree, stone removal
|
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What causes a palpable gallbladder?
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Inflamed gallbladder with omentum attached
|
|
Management of palpable gallbladder?
|
Emergent cholecystectomy due to high rupture risk
|
|
What is an emphysematous gallbladder?
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Air in the wall due to gas-forming organism that has invaded the tissues
|
|
Management of emphysematous gallbladder
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Urgent surgery
|
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Jaundice, fever, and RUQ pain/tenderness
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Acute (or ascending) cholangitis
|
|
Management of acute cholangitis
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Resuscitation, Abx, US of biliary tree
If obstruction or dilation of CBD seen, then ERCP and biliary decompression |
|
Name for a common duct stone occurring w/in 2yrs of a cholecystectomy
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Retained stone
|
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Management of biliary stricture
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Surgical exploration and bypass of stricture usually w/ choledochojejunostomy
|
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What two tests should be done in a pt with fever or pain after a lap chole?
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Abdominal ultrasound and hepatobiliary nuclide scan (HIDA scan: hepatoiminodiacetic acid) looking for infection or biliary leak
|
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How does the gallbladder look on a HIDA scan in a pt with acute cholecystitis?
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Doesn't visualize
|
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Management of postop biliary leak identified on HIDA scan
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ERCP to define anatomy
If large collection: biliary drainage w/ temporary stent placed during ERCP |
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Tender lymph nodes in the groin
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Lymphadenitis (or, lower likelihood, malignancy)
|
|
Tender testicle (acte vs. gradual)
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Acute: torsion of testis
Gradual: viral ochitis or epididymitis |
|
Hernia pt with N/V/abdominal distention
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Incarcerated/ strangulated hernia
|
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Hernia pt w/ fever, leukocytosis, and acidosis
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Strangulated segment of bowel
|
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Most hernia repairs involve attaching which two structures?
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Transversalis fascia to either inguinal ligament or periosteum of pubic ramus
|
|
Most common hernia repair type
|
Lichtenstein repair (prosthetic mesh approximates superior abdominal wall structures to inguinal ligament)
|
|
Advtg of mesh?
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Avoids creating tension on fascial structures, lessening postop pain and recurrence
|
|
Nerves at risk of injury in hernia repair
|
Genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous
|
|
Pediatric hernias represent a
|
Persistent patent processus vaginalis, NOT an abdominal wall defect/ defect in floor of inguinal canal
|
|
Sliding hernias may involve which other structures herniating?
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Bladder, cecum, or sigmoid colon
|
|
When are ventral hernias difficult to repair?
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Inadequate tissue strength, insufficient tissue, infection, or poor nutrition
|
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Management of a perforated duodenal ulcer
|
Emergent celiotomy and ulcer closure
If no Hx of PUD, can close ulcer w/ omental patch; if long-standing disease, antrectomy w/ truncal vagotom |
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Postop postprandial weakness, sweating, lightheadedness, crampy abdominal pain, diarrhea
|
Dumping syndrome
|
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When should dumping syndrome symptoms abate?
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Within 3mo of surgery
|
|
Mechanism of omeprazole
|
Irreversabily inhibits H+/K+ ATPase in gastric parietal cells
|
|
Management of ITP w/:
Plts >30,000 Plts <30,000 Active bleeding Refractory |
Observe
Prednisone (+/- IVIG) Plt transfusion Splenectomy |
|
Management of appendical adenocarcinoma
|
R hemicolectomy
|
|
Management of achalasia
|
Calcium channel blockers or long-acting nitrates; endoscopic dilation; Botox injection
|
|
Pts with achalasia are at increased risk of
|
Squamous cell carcinoma
|
|
Which symptoms improve in UC pts after total proctocolectom?
|
Peripheral arthritis, ankylosing spondylitis
|
|
Indications for UC surgery
|
Toxic megacolon, fulminant colitis, high grade dysplasia/carcinioma, definitive management of intractable disease (need end ileostom yas well)
|
|
Pancreatic fluid collection 4-6wks after acute pancreatitis
|
Pancreatic pseudocyst
|
|
Rx for pancreatic pseudocyst or pancreatic abscess
|
Percutaneous catheter drainage w/ Abx
|
|
CEA and amylase levels in pancreatic malignancy
|
High and low
|
|
Conditions associated w/ familial autonomous polyposis
|
Colon cancer
Fundic gland hyperplasia in stomach Premalignant polyps in duodenum and perampullary region Extraintestinal malignancies Retroperitoneal and abdominal wall desmoid tumors Benign osteomas |
|
Most frequent serious complication of end colostomes
|
Parastomal herniation
|
|
Cause of parastomal herniation
|
Stoma placed lateral to, rather than thru, rectus muscle
|
|
Management of parastomal herniation
|
If symptomatic, needs operative relocation
|
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Prolapse occurs most frequently w/ what type of colostomy?
|
Transverse loop colostomy
|
|
Management of transverse loop colostomy prolapse
|
Restoration of intestinal continuity or converstion to end colostomy
|
|
Contraindication for pancreatic cancer excision
|
Involvement of superior mesenteric artery
|
|
Management of variceal bleed
|
Fluisd, octreotide or vasopressin to decrease splanchnic blood flow, beta-blockers for long term prevention
|
|
Surgical option for recurrent bleeding varices
|
TIPS (transjugular intrahepatic portosystemic shunt)
|
|
2 classes and 4 types of ulcers
|
Acid associated (II: body of stomach + duodenum; III: prepyloric)
Not acid associated (I: body or lesser curvature; IV: GE junction) |
|
Surgical indications for ulcers
|
Hemorrhage, perforation, refractory to medical Rx, inability to r/o malignancy
|
|
What surgery is required for ulcers?
|
Billroth I or II, + vagotomy if ulcer is a Type II or III (i.e. acid-associated)
|
|
Billroth I reconstruction
|
Distal gastrectomy w/ gastroduodenostomy
|
|
Billroth II reconstruction
|
Distal gastrectom w/ gastrojejunostomy
|
|
What is a Klatskin tumor?
|
Cholangiocarcinoma
|
|
DDx of biliary obstruction (5)
|
Pancreatic head cancer, periampullary carcinoma, cholangiocarcinoma, stricture of CBD, CBD stone impacted in ampulla
|
|
2 types of pts who often get CBD strictures
|
Chronic alcoholics w/ chronic pancreatitis
Pts w/ prior biliary surgery |
|
What is a "double duct" sign?
|
Dilated CBD and pancreatic duct due to narrowing of distal CBD
|
|
Option for surgical palliation in pts w/ unresectable pancreatic cancer, and what it helps avoid
|
Biliary and gastric bypass
Prevents gastric outlet or duodenal obstruction and bile duct obstruction |
|
Dilated intrahepatic ducts (intrahepatic obstruction) but no dilation of the CBD (extrahepatic obstruction)
|
Cholangiocarcinoma
|
|
Where are cholangiocarcinomas located?
|
At the bifurcation of the hepatic ducts
|
|
ERCP or this alternative test can be used to identify the tumor especially if high in the bile duct
|
Percutaneous transhepatic cholangiography
|
|
Rx for cholangiocarcinoma
|
If primary tumor only, excision (5 yr survival still only 15%)
If unresectable, palliative stenting (5% 5yr survival) No role for chemo/radiation |
|
Biliary cancer with best cure rate
|
Ampullary adenocarcinoma
|
|
Resection method for ampullary adenocarcinoma
|
Whipple
|
|
Why is lap chole not a suitable option for malignant gallbladder adenocarcinoma?
|
Need open to remove hepatic tissue (common direct spread to the liver)
|
|
Management of calcified (porcelain) gallbladder and why
|
Chole b/c of 50% association with adenocarcinoma
|
|
What test is necessary to ensure not missing other potential diagnoses in a pt with suspected pancreatitis
|
Obstructive abdominal series (rule out perforated ulcer w/ free air, etc.)
|
|
Pancreatitis + severe deterioration and hypotension
|
Severe necrotizing pancreatitis
|
|
Two criteria systems for pancreatitis
|
Ranson criteria or APACHE II
|
|
Pt recovering from percutaneous pancreatic abscess drainage when suddenly becomes hypotensive and drainage becomes bloody
|
Erosion of cathether or abscess into a major artery (diagnose w/ angiography; control w/ embolization)
|
|
Management of elderly pt with suspected pancreatitis
|
Abdominal CT b/c of concern for other pathologies (mesenteric ischemia and volvulus)
|
|
Management of hepatic mets found during colectomy for colon cancer?
|
Wedge resection
|
|
Hernias are defects in what?
|
Transversalis fascia
|
|
Air in biliary tract of nonseptic pt?
|
Biliary enteric fistula
|
|
Complication of biliary enteric fistula
|
Gallstone ileus (stone into duodenum causes SBO at distal ileum)
|
|
Colonic syndrome w/o malignant potential and why not
|
Peutz-Jeghers (intestinal polyposis and melanin spots on oral mucosa), b/c are hamartomas
|
|
Management of gallstone ileus
|
Ileotomy, removal of stone, cholecystectomy (or interval chole if too inflamed at time of op)
|
|
Surgical indications for diverticular disease
|
Hemorrhage, recurrent diverticulitis, intractable to medical Rx, complicated diverticulitis (perforated +/- abscess and fistula)
|
|
Rx for diverticular abscess
|
Percutaneous drainage then definitive resectional therapy
|
|
Rx for perforated diverticulitis
|
Hartmann's procedure (sigmoid resection w/ end colostomy and rectal stump) or sigmoid resection, anastomosis, and diverting loop ileostomy
|
|
Rx for biliary dyskinesia
|
Cholecystectomy
|
|
Rx for gallbladder polyp
|
<1cm: observe w/ serial US
Suspected carcionma: chole w/ intraop frozen section |
|
Management of acalculous cholecystitis
|
Abx and perc chole tubes until inflammation has resolved, then lap chole
|
|
Appendicitis presentation in the elderly (+anticoag, trauma, or sudden muscular exertion) plus mass on CT
|
Hematoma of rectus sheath: conservative management
|
|
Acute pancreatitis that won't resolve
|
Pancreatic pseudocyst
|
|
Diagnostic test and management of pancreatic pseudocyst
|
CT
NPO, TPN, observe; if not improved w/in 6wks, cystogastrostomy to drain fluid into GI tract (+biopsy to r/o cancer) |
|
Management of simple hepatic cyst
|
Observe; if persistently symptomatic, aspiration and then sclerosant or excision
|
|
Multilocular cyst in liver w/ calcifications (and management)
|
Suspect echinoccal cyst from GI parasite: need operative sterilization and excision
|
|
Hepatic abscess
|
IV antibiotics and CT-guided drainage
|
|
Amebic hepatic abscess
|
Metronidazole, no surgery
|
|
DDx for solid liver lesion
|
Hemangioma, focal nodular hyperplasia, hepatic adenoma, mets, HCC
|
|
Pts with hepatic adenoma usually have a history of?
|
OCP use
|
|
How to diagnose a hemangioma?
|
Labeled RBC scan
|
|
Indications for surgical removal of benign liver mass
|
Symptomatic, risk of spontaneous rupture, uncertainty of diagnosis
|
|
Why is biopsy not performed when hemangioma or hepatadenoma are suspected but uncertain diagnoses?
|
High risk of bleeding
|
|
Management of hepatic adenoma?
|
Stop OCPs
|
|
Why must persistent or large hepatic adenomas be resected?
|
Risk of rupture or of development into HCC
|
|
When do hepatic adenomas have the highest risk of rupture?
|
During pregnancy
|
|
What is Bowen's disease?
|
Squamous cell carcinoma in situ
|
|
Melanoma location with worst prognosis
|
Face or trunk
|
|
Additional primary melanomas occur in what percentage of pts?
|
5%
|
|
Which melanoma pts need adjuvant therapy, and what does it consist of?
|
Stage III and IV
Interferon or dacarbazine Possibly radiation |
|
Management of large macular brown lesion on cheek
|
Lentigo maligna (Hutchinson freckle): monitor closely, remove if changing b/c is a precursor to lentigo malignant melanoma
|
|
Management of subungal melanoma
|
Biopsy requires excision of portion of nail in continuity w/ lesion; reexcision following diagnosis involves amputation at DIP
|
|
Prognosis for anal melanoma
|
As with other mucosal melanomas, mortality is near 100% at 5 years
|
|
Firm, painless mass that is larger than most benign tumors
|
Sarcoma
|
|
Fibrosarcoma and lymphangiosarcoma are associated w/ what two exposures?
|
Fibrosarcoma: therapeutic radiation
Lymphangiosarcoma: axillary lympadenectomy |
|
Management of suspected sarcoma
|
Excision biopsy if <3cm
Incisional biopsy if >3cm NO FNA |
|
Poor prognostic indicators in sarcoma
|
Mitoses, degree of necrosis, >15cm, symptomatic
|
|
Which pts need met workup, what does it consist of, and most common locations for mets
|
All! (22% have mets at presentation)
CT, MRI, CXR Liver, lung, bone, brain |
|
Surgical option for sarcoma
|
Extensive: often total resection of tissue compartment or amputation of extremity
|
|
Best adjuvant therapy for sarcoma
|
Radiation
|
|
Management of sarcoma recurrence in the lung
|
Thoracic wedge resection (one of the whom tumors in which excision of pulmonary mets can result in long-term disease-free survival)
Same with liver mets |
|
7 factors that slow wound healing
|
Malnutrition
Diabetes Jaundice Uremia Steroids Chemo Smoking |
|
Why can pts not do heavy lifting for 6wks postop?
|
Collagen production and cross-linking are still occurring, so not yet at full tensile strength, prone to injury/disruption
|
|
Hard knot-like structure underneath surgical wound
|
Likely a suture knot: should resolve if was absorbable suture, otherwise can be removed under local anesthesia once wound is fully healed
|
|
What is healing by third intention?
|
Delayed primary closure
|
|
Erythema and some pus drainage around wound 3mo postop
|
Stitch abscess
|
|
Management of a stitch abscess
|
Explore opening w/ hemostat and remove suture under local anesthesia
|
|
Management of postop ventral hernia thru wound
|
Surgery
|
|
How long should a wound be observed for before considering revision for its appearance?
|
6mo
|
|
Management of hypertrophic scar
|
Steroid injections and local pressure dressings
Revision usually not appropriate as are likely to recur |
|
Raised hypertrophic scar that is spreading outside immediate area of incision
|
Keloid (same as treatment for hypertrophic)
|
|
Management of wound infection
|
Drainage and debridement; usually don't require Abx (only if cellulitis spreading despite drainage)
|
|
2 types of wounds that heal by secondary intention
|
Wounds that are intentionally left open
Wounds that become infected and require opening in immediate postop period |
|
What is the process of a graft revascularizing from granulation tissue called?
|
Inosculation
|
|
What is the advantage of split thickness skin grafts for wounds?
|
Reduce wound contraction by 60%
|
|
Disadvantage of skin grafts
|
More susceptible to trauma than normal skin
|
|
What is required for the skin graft to attach successfully?
|
Bacterial count on granulation bed must be <10^5 bacteria/gram of tissue
|
|
Four categories of wounds
|
Clean, clean-contaminated, contaminated, infected
|
|
Management of contaminated wound
|
Leave open to heal by secondary infection, treat with saline-soaked gauze
|
|
Definition of a clean wound
|
No entry made into GI, respiratory, or GU tracts and no active infection
|
|
Definition of clean-contaminated wound
|
There is entry into GI, resp, or GU tract but it is prepared both mechanically and antibacterially (e.g. bowel prep before surgery)
|
|
Need for prophylactic Abx for clean, clean-contaminated, and contaminated
|
Clean: none
Clean-contaminated: single preop and postop dose |
|
4 situations in which prophy Abx are indicated
|
Exposure to bacteria
Prosthetic material Immunosuppression Poor bloody supply |
|
When should prophy Abx be given?
|
1 hr preop
Postop: multiply half-life of drug by 1-2.5 |