Surgery

Front 1

What are the risk factors for pulmonary complications in the sx pt?

Back 1

*known pulmonary dz
*abnormal PFTs
*Smoking
*increased OR time
*Age >60
*Obesity
*Upper abd or thoracic sx

Front 2

_______ has the highest M&M of all pulmonary complications post-op.

Back 2

PNA

Front 3

What is the variable presentation of C. diff colitis?

Back 3

May range from mild diarrhea & discomfort to severe pain, tenderness, fever, & inc WBC.

Front 4

_______ is the MCC of fever w/in 24 hrs of sx.

Back 4

Atelectasis

Front 5

ASA should be avoided ____ days preoperatively to allow for what?

Back 5

*10
*to allow return fxn of platelets, allow them to regenerate

Front 6

Re: diabetic meds and surgery, should po hypoglycemics be avoided or given on the day of sx? Insulin?

Back 6

*Avoid po on day of sx
*Give 1/2 the usual dose of insulin on am of sx.

Front 7

What are the steps of wound healing?

Back 7

*Coagulation
*Inflammation
*Collagen synthesis
*Angiogenesis (granulation)
*Epithelialization
*Contraction

Front 8

______ are essential for wound healing.

Back 8

Macrophages

Front 9

Epithelialization of surgical wounds closed primarily is usually complete by ___-____ hours.

Back 9

24-48

Front 10

What are the 5 W's of post-op fever?

Back 10

Wound- infection
Wind- atelectasis, PNA
Water- UTI
Walk- DVT
Wonder drugs- direct s/e or those w/compromising immunity, respiration or perfusion.

Front 11

What are the 4 classic signs of wound infections?

Back 11

Rubor- erythema, redness
Dolor- pain
Calor- heat, warmth
Tumor- swelling, edema

Front 12

What are the 3 poor operative techniques that may lead to wound failure?

Back 12

*suture material w/ inadequate tensile strength
*inadequate # of sutures
*too small bite size

Front 13

Hypertrophic scar and keloid formation are more common in which population?

Back 13

African-Americans

Front 14

What is the MCC of free air under the diaphragm?

Back 14

perforated peptic ulcer (90% of the time)

Front 15

What is the quality of pain of a perforated ulcer?

Back 15

Severe & sudden in nature.

Front 16

______ sign is seen in cholecystitis.

Back 16

Murphy's

Front 17

_____ sign is pain referred to the left shoulder due to irritation of the left hemidiaphragm. It is often seen w/ ________.

Back 17

*Kehr

*splenic rupture

Front 18

What are the surgical causes of abdominal pain?

Back 18

*perforated duodenal ulcer
*cholecystitis
*hepatic abscess
*retrocecal appendicitis

Front 19

_______ is still the MC surgical emergency in the pregnant woman.

Back 19

Appendicitis

Front 20

What is the pain of pancreatitis described as? Where does the pain radiate?

Back 20

*Boring
*To the back

Front 21

With cervical spine precautions or any trauma, what should you do first?

Back 21

Always clear the airway first!

Front 22

What are the S&S of a PTX?

Back 22

*dyspnea
*decreased breath sounds on same side
*hyper-resonance on same side
*usually asymptomatic, may have chest pain

Front 23

What is Kehr's sign? When does it increase?

Back 23

*pain radiating to left shoulder or neck secondary to splenic rupture
*inc when pt is in Trendelenburg position or w/LUQ palpation due to diaphragmatic irritation.

Front 24

The most frequently injured solid organ associated with penetrating trauma is the ______.

Back 24

Liver

Front 25

The most frequently injured solid organ(s) associated w/blunt trauma is/are _______.

Back 25

spleen, liver

Front 26

What is the Grade V Laceration on the renal injury scale?

Back 26

Completely shattered kidney

Front 27

If the skin is warm, it is ______ shock. If it is cold & clammy, it is ______ or ______. Shock w/bradycardia is ______ unless proven otherwise.

Back 27

*distributive

*hypovolemic, cardiogenic

*neurogenic

Front 28

The MCC in the surgical or trauma pt is ______ shock.

Back 28

hemorrhagic

Front 29

Of the vital organs, the first "casualty" of hypovolemic or cardiogenic shock is the ______.

Back 29

kidneys --> blood is shunted away from the constricted renal arteries.

Front 30

What is the MCC of distributive shock? What are the other two causes?

Back 30

*Septic shock
*Neurogenic
*Anaphylactic

Front 31

What are the physical findings of anaphylactic shock?

Back 31

*urticaria & angioedema; esp around the lips
*laryngeal edema (stridor), wheezing

Front 32

What is intracellular fluid (ICF) mostly found? Is it higher in males or females?

Back 32

*skeletal muscle mass
*higher in males

Front 33

What is the MC fluid disorder?

Back 33

Volume deficit (dehydration)

Front 34

What are the causes of losses that mimic ECF?

Back 34

*Hemorrhage
*GI fluid-- V/D, NG suction, etc
*Post-op fluid sequestration (3rd)
*Intra-abd & retroperitoneal inflammation (pancreatitis, etc)
*Systemic inflammation response syndrome (SIRS), burns, sepsis, pancreatitis

Front 35

What are the losses that are principally water?

Back 35

*Fever
*Osmotic diuresis
*Diabetes insipidus
*Prolonged H2O deprivation
*Inadequate input during procedure

Front 36

What is the goal of fluid replacement?

Back 36

To replace the deficit in most pts over the next 24 hrs.

Front 37

What is the definition of hypernatremia?

Back 37

Sodium >145 mEq/L; always associated w/hyperosmolarity

Front 38

What are the causes of hypernatremia?

Back 38

*Loss of H2O --> (dehydration):
-DI, diuretics, sweating, GI loss
*Inc Na due to excess mineral-corticoid activity: ie. Cushing's, RAS, etc.

Front 39

What is the definition of hypercalcemia? What are some of the causes?

Back 39

*Ca >15 mg/dL
*Hyperparathyroidism
*CA (esp breast & multiple myeloma)
*Drugs (thiazides)

Front 40

What do esophageal motility disorders result from?

Back 40

abnormalities in the propulsive pump action of the esophagus or relaxation of the LES

Front 41

______ is the failure of the lower portion of the esophagus to relax during swallowing. The resulting dysphagia is due to which 3 mechanisms?

Back 41

*Achalasia
1- Complete absence of peristalsis in the esophageal body
2- Incomplete/impaired relaxation of the LES
3- Inc resting tone of the LES

Front 42

What are the S&S of achalasia?

Back 42

*dysphagia for both solids & liquids
*regurgitation of food
*severe halitosis (due to decomposition of stagnant food w/in the esophagus)

Front 43

What is the classic triad of achalasia?

Back 43

*dysphagia
*regurgitation
*weight loss

Front 44

What is the pathophysiology of GERD?

Back 44

LES resistance w/reflux of acidic gastric contents into the esophagus.

Front 45

What are some meds for the tx of GERD? What is the procedure of choice for surgical repair?

Back 45

*antacids, H2-blockers, PPIs

*Nissen fundoplication

Front 46

More than 90% of esophageal carcinomas are ______ and ______.

Back 46

*squamous cell
*adenocarcinoma

Front 47

What are the functions of parietal cells (oxyntic)?

Back 47

1- secrete HCl, accounting for the acidic pH of the stomach
2- secrete IF for absorption of vit B12 in the terminal ileum

Front 48

What is the fxn of chief (peptic) cells?

Back 48

To secrete pepsinogen, a proenzyme activated by gastric HCl to form pepsin, which digests protein.

Front 49

What type of cells are found in the antrum of the stomach? What is their function?

Back 49

*G cells
*Secrete gastrin, which stimulates gastric acid secretion, pepsin secretion, & mucosal growth of the GI tract (trophic action).

Front 50

Which environmental factors cause PUD?

Back 50

*H. pylori
*NSAIDs
*Smoking

Front 51

What are the causes of duodenal ulcers?

Back 51

*H. pylori
*NSAIDs/steroids
*Zollinger-Ellison (ZE) syndrome

Front 52

ZE accounts for 0.1-1% of pts w/_____, but over 90% of pts w/ZE have ______.

Back 52

*ulcer
*PUD

Front 53

What is a sign of posterior duodenal perforation? Anterior duodenal perforation? Which is more common?

Back 53

*Posterior --? Bleeding from the Back, involving gastroduodenal artery
*Anterior-- Free Air from Ant duodenal perf.
*MC is ANTERIOR!

Front 54

What are the S&S of gastric ulcers?

Back 54

*Burning, gnawing epigastric pain that occurs w/anything in the stomach; worse after eating
*Anorexia/wt loss
*Vomiting
*Associated w/ blood type A

Front 55

What is the risk of ulcers rebleeding in-hospital? Which type of ulcers are more likely to rebleed?

Back 55

*1/3
*Gastric ulcers are 3x more likely to rebleed than duodenal ulcers.

Front 56

What is the MC type of malignant gastric tumors?

Back 56

Adenocarcinoma --> comprises 95% of malignant gastric CA.

Front 57

What are the tx options of Gastric Volvulus?

Back 57

*Sx repair of accompanying hernia
*Gastropexy-- fixes stomach to anterior abd wall
*Gastric resection if there is necrosis.

Front 58

What is the ligament of Treitz?

Back 58

Where the duodenum ends and jejunum begins

Front 59

Re: peristalsis, intestinal contractions occur at a rate of _____.

Back 59

1-2 cm/sec

Front 60

What is the MCC of a SBO?

Back 60

adhesions from prior surgery

Front 61

If a pt w/a SBO is stable or has a partial SBO, what does the management trial consist of?

Back 61

*NPO
*NG suction
*IV hydration
*Foley
*Monitor electrolytes

Front 62

What is the definition of Crohn's disease?

Back 62

Inflammatory bowel dz characterized by transmural inflammation involving any part of the GI tract, from mouth to anus, of unknown etiology. Discontinuous, results in skip lesions, often leads to fibrosis, obstruction & fistulae formation.

Front 63

Describe the typical hx of Crohn's disease.

Back 63

Prolonged diarrhea w/abd pain, weight loss, and fever w/ or w/o gross bleeding.

Front 64

A 70 y/o male w/a hx of PVD and hyperlipidemia presents to the ER w/severe, diffuse abd pain. BP is 170/100 & HR is 90 bpm. Supine AXR shows free air in the abd & w/in the wall of the small intestine. Most likely dx?

Back 64

small bowel infarction

Front 65

What is diverticular disease?

Back 65

Herniation of the mucosa thru the muscular layers of the bowel wall at sites where arterioles penetrate, forming small outpouchings or diverticula

Front 66

What is the classic S&S of diverticulosis? (Absent in diverticulitis)

Back 66

*Massive, painless lower GI bleeding.
*But 80% of pts are asymptomatic

Front 67

What is the test of choice for suspected diverticulitis and what does it show?

Back 67

*CT scan
*Periocolonic inflammation w/ or w/o abscess formation.

Front 68

What is the Tx of a large bowel obstruction?

Back 68

1- correct F&E abnormalities
2- NGT for decompression
3- Broad-spectrum IV ABX (i.e. cefoxitin)
4- Relieve obstruction sx

Front 69

What are the 3 MCCs of obstruction of the large bowel?

Back 69

1- adenocarcinoma (65%)
2- scarring secondary to diverticulitis (20%)
3- volvulus (5%)

Front 70

What is the definition of a volvulus of the colon and where is the MC location?

Back 70

*rotation of a segment of intestine about its mesenteric axis
*characteristically occurs in the sigmoid (75%) or cecum (25%).

Front 71

What is the MC S&S of colorectal polyps?

Back 71

Asymptomatic

Front 72

Microcytic anemia in an elderly male or postmenopausal woman is ______ until proven otherwise.

Back 72

Colon CA

Front 73

What is the old system used for staging Colon CA?

Back 73

Dukes system:
*A- limited to wall
*B- thru wall of bowel but not to lymph nodes
*C- Mets to regional lymph nodes
*D- distant mets

Front 74

What is the tx of pilonidal cyst?

Back 74

I&D under local anesthesia w/removal of involved hairs.

Front 75

In young pts, what is the MCC of luminal obstruction of the appendix? Older pts?

Back 75

*Young --> lymphoid tissue hyperplasia
*Older --> fecalith

Front 76

What is McBurney's point and what is it a +test of?

Back 76

*tenderness at 1/3 the distance from ASIS to umbilicus

*appendicitis

Front 77

What is a very sensitive test in the dx of appendicitis?

Back 77

abdominal CT w/contrast

Front 78

How do elderly pts tend to present w/ appendicitis? They have a higher risk of _____ than in younger pts.

Back 78

*present atypically, leading to delay in dx; present later in the course & w/less pain, may present as SBO; delayed leukocytosis
*inc risk of perf & inc mortality than in younger pts

Front 79

What is the MC condition requiring major abd sx?

Back 79

abdominal wall hernias

Front 80

What is the ratio prevalence between males & females developing hernias?

Back 80

male to female ratio is 7:1

Front 81

What is the MC hernia in males and females?

Back 81

indirect inguinal hernia

Front 82

How would you differentiate between a hydrocele and a hernia?

Back 82

transilluminate --> hernias will not light up

Front 83

What is an indirect inguinal hernia? They are b/l ____% of the time?

Back 83

*Herniation through the internal inguinal ring traveling to the external ring.
*33% (1/3)

Front 84

Re: pediatric umbilical hernias, sx repair is indicated if which 3 conditions are met?

Back 84

1- the defect is >2 cm
2- child is >3-5 y/o
3- protrusion is disfiguring & disturbing to the child or parents

Front 85

How does the liver get it's O2 supply? Where does the majority of its blood supply come from?

Back 85

*50% L&R hepatic arteries
*50% portal vein

*75% portal vein
*25% hepatic arteries

Front 86

What should be the first test performed in all pts w/a suspicion of gallstones?

Back 86

u/s

Front 87

Jaundice is yellowing of the skin & sclera due to an elevation in total bilirubin > ______.

Back 87

2.5

Front 88

What are the S&S of obstructive jaundice?

Back 88

*yellow skin & sclera
*pruritis
*may have hepatomegaly tenderness of RUQ, or signs of cirrhosis
*dark urine
*clay-colored stools
*anorexia, nausea

Front 89

In obstructive jaundice, the _____ level rises more quickly than the bilirubin level. Also, when obstruction is relieved, the _____ level falls more quickly than the bilirubin level.

Back 89

*Alkaline phosphatase (ALP)

*ALP

Front 90

In the US, most hepatic abscesses (80%) are of ______ origin.

Back 90

bacterial

Front 91

What are some pyogenic risk factors for hepatic abscesses? Amebic risk factors?

Back 91

Pyogenic --> usually secondary to bacterial sepsis or biliary or portal vein infxn; can also occur from a perforated infected gallbladder cholangitis, diverticulitis, liver CA, or liver mets. Amebic --> pts from Central America, homosexual men, institutional pts and ETOH.

Front 92

80-90% of pts w/hepatocellular carcinoma have underlying ________. What is the most predominant type? (in the US)

Back 92

*cirrhosis

*ETOH cirrhosis

Front 93

The MCC of portal HTN in the US is ______. The MCC outside North America is ______.

Back 93

*cirrhosis from ETOH

*schistosomiasis

Front 94

What are the S&S of portal HTN?

Back 94

*ascites
*jaundice
*splenomegaly
*palmar erythema
*spider angiomata
*truncal obesity w/wasting of extremities
*asterixis (flapping tremor)
*hepatic encephalopathy

Front 95

______ is the MC clinical finding in portal HTN.

Back 95

splenomegaly

Front 96

What are the Tx options for ascites?

Back 96

*decrease Na intake
*K+ sparing diuretic
*abd paracentesis

Front 97

85% of stones in the gallbladder are composed of primarily _______.

Back 97

cholesterol

Front 98

What is Charcot's triad?

Back 98

*jaundice
*RUQ pain
*fever

Front 99

Where is the MC site of obstruction in gallstone ileus?

Back 99

ileocecal valve

Front 100

_______ is an uncommon tumor that may occur anywhere along the intrahepatic or extrahepatic biliary tree. It is MC located at _______. Nearly all are ______.

Back 100

*cholangiocarcinoma
*@ the bifurcation of the R&L hepatic ducts (60-80% of cases)
*adenocarcinomas

Front 101

What are the 3 MC causes of acute pancreatitis in the US?

Back 101

*ETOH abuse (40-50%)
*Gallstones (40%)
*Idiopathic (10%)

Front 102

What are the two lab studies that should be ordered on a pt w/suspected pancreatitis?

Back 102

*lipase --> only found in gastric & intestinal mucosa & liver, in add to the pancreas --> more SPECIFIC
*amylase --> also found in salivary glands, sm bowel, ovaries, testes & skeletal muscle, so is not a specific marker for pancreatitis.

Front 103

Which pain med should be avoided in acute pancreatitis? Why? Which should be used instead?

Back 103

*morphine
*possible spasm of the sphincter of Oddi
*meperidine (Demerol)

Front 104

What is the MCC of chronic pancreatitis? ______ are not a common cause of chronic pancreatitis.

Back 104

*ETOH abuse (70%)

*Gallstones

Front 105

Which two things are associated w/chronic pancreatitis that may be seen on imaging?

Back 105

*pancreatic calcifications
*stones

Front 106

Tumors of the pancreatic tail are usually unresectable b/c they are asymptomatic during growth & thus present @ a later stage. Why do tumors @ the head of the pancreas present earlier?

Back 106

b/c they cause biliary obstruction

Front 107

A 40 y/o male c/o chronic epigastric pain shortly following meals & notices needing increasing doses of his anti-ulcer med. What is the most likely dx?

Back 107

Gastrinoma

Front 108

What is a gastrinoma? It is aka ______. 90% are located where?

Back 108

*Neoplasm associated w/overproduction of gastrin
*Zollinger-Ellison syndrome
*"gastrinoma triangle"

Front 109

All protein hormones are produced in locations starting w/ P...

Back 109

*parathyroid
*pancreas
*pituitary

Front 110

What are the causes of hyperthyroidism? (6)

Back 110

*Graves' dz
*Toxic Nodular Goiter
*Toxic thyroid adenoma
*Subacute thyroiditis
*Functional metastatic thyroid CA
*Struma ovarii (abn thyroid tissue in ovary)

Front 111

What are the causes of hypothyroidism?

Back 111

*Autoimmune thyroiditis
*Iatrogenic: s/p thyroidectomy, s/p radioablation, secondary to antithyroid meds
*Iodine deficiency

Front 112

What is the Tx if a pt presents in myxedema coma?

Back 112

Thyroxine po or IV emergently

Front 113

What are the 3 main bacteria that cause acute thyroiditis?

Back 113

*Strep pyogenes
*Staph aureus
*Pneumococcus pneumoniae

Front 114

______ is the MC type of thyroid CA, but ______ has the worst prognosis.

Back 114

*Papillary

*Anaplastic

Front 115

What are the common S&S of hyperparathyroidism?

Back 115

*"Stones, bones, groans, & moans."
*kidney stones
*bone pain, fxs
*N/V/C, muscle pain, etc
*lethargy, confusion, depression, paranoia

Front 116

What is Cushing's syndrome? Name some causes.

Back 116

*excessive cortisol production
*iatrogenic administration of corticosteroids
*pituitary tumor that secretes ACTH
*ectopic ACTH secretion by tumor elsewhere
*adrenal tumor that secretes cortisol

Front 117

What is the MCC of Cushing's syndrome?

Back 117

iatrogenic administration of corticosteroids

Front 118

What is the MCC of ectopic ACTH production? 2nd MCC?

Back 118

*small cell lung CA (aka oat cell carcinoma)
*carcinoid tumors

Front 119

What are some conditions associated w/rupture of the spleen?

Back 119

*malaria
*mono
*blunt LUQ trauma
*splenic abscess

Front 120

The ______ is the MC injured organ in blunt abdominal trauma.

Back 120

spleen

Front 121

______ is the MC reason for splenectomy.

Back 121

trauma

Front 122

Which vaccine will be needed for pts undergoing splenectomy? When may it be given?

Back 122

*Pneumococcal
*May be given on the day of hospital d/c

Front 123

When is it ideal to perform self breast exams?

Back 123

*@ the same time each month (one week after menstrual period)

Front 124

The smallest breast mass palpable on physical exam is ______.

Back 124

1 cm

Front 125

The MCC of a persistent breast mass after trauma is ______.

Back 125

fat necrosis

Front 126

______ is the development of female-like breast tissue in males. At least ___ cm of excess subareolar breast-tissue is required to make the dx.

Back 126

*gynecomastia
*2

Front 127

What are the side effects of hormonal therapy such as Tamoxifen?

Back 127

Those that stimulate menopause:
*hot-flashes
*irregular menses
*thromboembolism
*inc risk for endometrial CA due to selective hormone agonist action

Front 128

What is the MCC of burn injuries? ___% may be treated as outpatient.

Back 128

*scalding
*80%

Front 129

Incidence of burns is higher during ______. 75% of burn-related deaths can be attributed to ______.

Back 129

*winter months
*house fires

Front 130

The risk of infection of burned tissue is increased b/c _______. The neoeschar and lack of vascularity limit _______.

Back 130

*the wound is protein rich & moist, and is thus a good culture medium
*ABX delivery

Front 131

An increase in fluid requirements is necessary in which type of burn injuries?

Back 131

*high-voltage electrical
*inhalation
*delayed resuscitation
*intoxicated at time of injury

Front 132

The MC compartment requiring fasciotomy is the ______ compartment.

Back 132

anterior tibial

Front 133

Burn pts are very prone to which type of infections?

Back 133

*PNA
*catheter-related infections

Front 134

Carbon monoxide is a colorless, tasteless, odorless gas and has an affinity for Hgb ____x that of O2.

Back 134

200

Front 135

Which type of skull fx carries a much greater risk of underlying brain injury & complications, such as meningitis and post-traumatic seizures?

Back 135

depressed

Front 136

Recovery of cerebral concussion is often complete; however, residual effects such as ______ may last for some time.

Back 136

headache

Front 137

A 19 y/o male w/a head injury has LOC followed by a brief lucid interval. He presents to the ED in a coma, w/an ipsilateral fixed & dilated pupil and contra-lateral hemiparesis. What is the most likely dx?

Back 137

Epidural hematoma

Front 138

______ is a collection of blood between the dura and the skull w/the majority associated w/tearing of the middle meningeal artery from an overlying temporal bone fx.

Back 138

Epidural hematoma

Front 139

Describe a subdural hematoma.

Back 139

Collection of blood below the dura and over the brain. Results from tearing of the bridging veins, usually secondary to an acceleration-decel mechanism.

Front 140

Diffuse patterns of coronary vessel obstruction, as can occur in diabetes, may not be amenable to ______.

Back 140

CABG

Front 141

_______ is the dx method of choice for peripherally located lung nodules. Most are _____ guided.

Back 141

*Transthoracic needle bx (TNB)
*CT

Front 142

What is the MC site for acute osteomyelitis?

Back 142

*the metaphyseal end of a single long bone (esp around the knee)