• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/267

Click to flip

267 Cards in this Set

  • Front
  • Back
Where do you allow secondary intension wound healing?
good if dirty
perineum
scalp
What are the requirements for proceeding with tertiary wound intension healing?
< 10^5 bacteria
What are the three phases of healing? How long do they last?
Inflammatory 10 min to 4 days; lasts longer if secondary intension/wound closure
proliferative 2-3 days to 3-4 weeks
remodeling ~ 9 months
What does the inflammation phase of wound healing involve?
clot formation (platelets, fibrin)
vasoconstriction (PGF, Catecholamines, thromboxane)
vasodilation after hemostasis (prostaglandins, histamine) brings in inflammatory cells to clear debris (platelet derived growth factor, complement C5a, leukotriene B4)
What does the proliferation phase of wound healing involve?
Provisional matrix (mostly fibrin) becomes permanent matrix (collagen and ground substance, proteoglycans like hyaluronic acid)
Fibroblasts make collagen
Macrophages attract endothelial cells
Scar is red and raised
What does the remodeling phase of wound healing consist of?
starts with 'collagen equilibration' - collagen breakdown = collagen building
old collagen replaced by new, better organized, longitudinally aligned, stronger collagen
How fast do basal epithelial cells migrate?
1-2 mm day
What is epithelialization?
basal epithelial cells migrate along wound to create 1 cell layer, cell division and keratin formation creates stratum corneum
How long does epitheliazation take?
7-10 days
How does epithelialization occur in full thickness vs. partial thickness wounds?
full - damaged/no dermis - from wound edge
partial - dermis intact - epithelialize from dermal appendages (i.e. sweat glands and hair follicles)
What is the progressive wound strength? What determines this strength?
50% by 6 weeks therefore no heavy lifting for 6 weeks
70% is maximum strength attained by scar
determined by rate of collagen synthesis organization, and crosslinks
What is the proper care of a closed wound/primary intension wound?
epithelialization takes 1-2 days
keep wound dry during this time
after 2 days wash with water to clear debris
may remove sutures 1-2 weeks - but only modest strength
How is debris cleared from a wound?
PMN < 24 hrs
Mac 2-3 days
Lymphocytes chronic infection
What is considered in the proper care of a secondary intension or ulcer wound?
1. granulation tissue forms over subQ
2. epithelization marches over granulation tissue, front marching epthelium is inflammation, followed by proliferation, followed by reorganization of scar, faster w/moisture
3. wound contraction by fibroblasts accelerates closure but depends on availability of extra skin
4. bacterial colonization in all open wounds, bacterial infection deletrious to healing
5. role of O2 need 25-30 mmHg for PMN to kill bactera with superoxide radicals, edema reduces oxygenation
6. role of necrosis: dead tissue/protein exudates is good medium for bacteria, impairs healing
What is granulation tissue?
immature collagen and ground substance, new leaky capillaries, inflammatory cells
What is the progressive wound strength? What determines this strength?
50% by 6 weeks therefore no heavy lifting for 6 weeks
70% is maximum strength attained by scar
determined by rate of collagen synthesis organization, and crosslinks
What is the proper care of a closed wound/primary intension wound?
epithelialization takes 1-2 days
keep wound dry during this time
after 2 days wash with water to clear debris
may remove sutures 1-2 weeks - but only modest strength
How is debris cleared from a wound?
PMN < 24 hrs
Mac 2-3 days
Lymphocytes chronic infection
What is considered in the proper care of a secondary intension or ulcer wound?
1. granulation tissue forms over subQ
2. epithelization marches over granulation tissue, front marching epthelium is inflammation, followed by proliferation, followed by reorganization of scar, faster w/moisture
3. wound contraction by fibroblasts accelerates closure but depends on availability of extra skin
4. bacterial colonization in all open wounds, bacterial infection deletrious to healing
5. role of O2 need 25-30 mmHg for PMN to kill bactera with superoxide radicals, edema reduces oxygenation
6. role of necrosis: dead tissue/protein exudates is good medium for bacteria, impairs healing
What is granulation tissue?
immature collagen and ground substance, new leaky capillaries, inflammatory cells
What does the post-op care for wounds involve?
clean
debride
edema control
ischemia control
moist environment
What and how do systemic factors influence wound healing?
nutrition - serum albumin < 3 g/dL bad
aging
chemo and steroids - give Vit A to steroid users
O2 - decreased with smoking/nicotine patches, radiation, edema, diabetes, atherosclerosis, vasculitis, pressure, venous insufficiency, fibrosis
What topical antibiotics should be used when closing wounds? What about systemic antibiotics?
bacitracin/neosporin - moistens for epithelization
silvadene - penetrates eschar, good for burns
Systemic anitbiotics - little use
What is the proper care for a contusion?
evacuate hematoma
if early (12 - 24 hours) give ice to prevent pooling
if late - keep warm to absorb blood
What is the time limit on amputations?
replace if < 6hrs
How do you manage a dirty wound?
can be closed after debridement
may leave open if
1. heavy bacterial inoculum (think bites)
2. delayed closure
3. crushed/ischemic tissue
4. systemic steroids use
follow up <48 hours to check for infection
What constitutes a split thickness graft?
epidermis + part of dermis
What are the steps in graft healing?
serum/plasma inbibition (diffusion of nutrition) 48 hours
inosculation of capillary growth (vessels line up) 72 hours
revascularization 5 days
How do you evaluate a graft?
at 5 days
is it mobile? bad
is it pink? good
What are some reasons grafts fail?
hematoma
infection
movement/shearing
decreased vascularity
traumatic handling
How do you estimate the %TBSA?
Hands are worth 2% each
Describe the four degrees of burn injury:
1st - erythema without break in skin
2nd - blister, can be superficial partial (upper dermis) or deep partial (lower dermis)
3rd - full thickness, painless
4th - into muscle, bone, etc.
What are the main respiratory concerns for people with burns?
burn eschar may constrict chest - escharotomy
CO poisoning - displace CO with 100% O2
smoke inhalation, pulmonary injury - may need intubation
What is the Parkland formula?
resuscitation for burns
4 cc LR/Kg/%TBSA
1/2 in first 8 hrs
1/2 in next 16 hours
How do you monitor resuscitation efforts in burn patients?
UO 30-55 cc/hr in adults
UO 1.2 cc/kg/hr in children <12 y/o
P<120, HCO3 > 18, CO > 3.1 L/m2
What is the standard treatment for burn wounds?
1. graft
2. topical antibiotics - silvadene, sulfamylon
3. debride - excise, layered, enzymatic, hydrotherapy
What labs should be initially ordered on burn patients?
CBC
UA
ABG
electorlytes
renal function tests
type and cross
carboxyhemoglobin!
What are the major complications in burn victims?
renal failure
GI bleed - Rx antacids, H2 blockers
burn wound sepsis - monitor with biopsies, mental status changes, CHF, ards
pulmonary insufficiency - smoke, inhalation, CHF, sepsis
How do identify pulmonary insufficiency in burn victims?
hypoxia
hypercarbia
shunt
acidosis
What is the treatment strategy for chemical burns?
dilute for 12 hours
debride
topical antibiotics
close
What are the complications of electrical burns?
cardiopulmonary - anoxia and fibrillation; early and late EKG rhythmn abnormalities
renal failure - myoglobin/hemoglobin: ATN, want 77 cc/hr UO
spinal cord demyelination
vascular thrombosis by current - continues - delayed rupture
What is the treatment of myoglobin/hemoglobin induced acute tubular necrosis as a cause of renal failure in patients of electrical burns?
alkalinize urine with NaHCO3 (heme soluble) mannitol (to clear protein load)
How do you treat frostbite?
40 C waterbath
amputate after demarcation
How do you treat hypothermia?
LRS with 1 amp NaHCO3
EKG monitoring - lidocaine for arrhythmia
Breast cancer has an increased chance (i.e. marker not precursor) in both breasts with?
a. LCIS
b. DCIS
a. LCIS
Breast cancer tends to reoccur in the same area (i.e. precursor not maker) with?
a. LCIS
b. DCIS
b. DCIS
What is the most common form of invasive breast cancer?
ductal carcinoma 80%
lobular 10%
What are the characteristics of medullary carcinoma of the breast?
large cancer cells
immune cells
What are the characteristics of colloid carcinoma of the breast?
mucinous
makes mucinous
better prognosis
What are the characteristics of inflammatory breast cancer?
spread through lymphatics
indicates stage IIIb
What are various biopsy techniques for breast cancer?
core needle
fine needle aspiration
sterotactic needle biopsy
What additional tests should be considered in breast cancer?
Everyone: CXR
If Symptoms: Bone scan, CT (organs), MRI (brain)
PET if looking for entire body mets
CBC, liver fx
PR +ER, HER-2/neu (if invasive)
What are the various T levels in the TNM staging of breast cancer?
Tis - DCIS/LCIS
T1 < 2 cm
T2 2-5 cm
T3 > 5 cm
T4 skin or cest wall
What are the various N levels in the TNM staging of breast cancer?
N0 no nodes
N1 1-3 ipsilateral nodes
N2 3-10 nodes
N3 > 10 nodes
What stage is a T4 NM breast cancer?
IIIb (inflammatory)
What stage is a T N1 M breast cancer?
IIIa
What stage is a TN M1 breast cancer?
IV
What are the indications for mastectomy in the local treatment of breast cancer?
Hx of radiation
multifocal Dx
Pregnant
> 5cm tumor
What are the treatments for systemic disease?
chemo: trastuzumab (herceptin) only with mets
hormone therapy: tamoxifen for mets and to prevent reoccurance, toremifene, fulvestrant, aromatase ihibitors, GRNH agonists, megase
What is the treatment algorithm for LCIS?
LCIS is a RF for Cx therefore
close observation w/H&P
mammograms +/- 5 yrs Tamoxifen or double mastectomy
What is the treatment algorithm for DCIS?
excision bx then...
widespread dz/+ margins - masectomy 2 w/o node resection
negative margins - lumpectomy + radiation or masectomy
negative margins/low grade/<0.5 cm - lympectomy w/o radiaiton ok

5 yrs tamoxifen, H&Ps Q 6 months, mammogram and pelvic q year
What is the work up for invasive carcinomas?
CBC, LFTS, CXR, bilateral dx mammograms, ER/PR/HER, bone scan if symptomatic, CT or MRI for Stage II
What is the treatment for invasive carcinomas?
Tumor < 2cm lumpectomy + radiation + node resection
if no nodes - radiate breast
Tumor > 2cm mastectomy or neoadjubant
if + nodes/>5 cm radiate post mastectomy
What are the indications for adjuvant therapy wrt breast cancer?
<0.5 cm, < 1cm tubular, colloid, or low grade ductal w/o nodes - no chemo
> 1 cm always get chemo
+ nodes and HR positive - 5 yrs tamoxifen and chemo
What are the characteristics of cardiogenic shock?
decreased CO
increased PCWP, SVR
white skin
What are the characteristics of hypovolemic shock?
decreased CO, PCWP
increased SVR
white skin
What are the characteristics of vasogenic (spetic/anaphylactic) shock?
decreased CO, PCWP, and SVR
pink skin
What are the characteristics of neurogenic shock?
decreased CO< PCWP, and SVR
pink skin
What is the path of a swan-ganz catheter?
jugular
SVC
RA
RV
Pulmonary artery
What is the normal PCWP? What is this indicative of?
6-12 mm Hg
LAP/end-systolic LVP (preload)
Cardiac Output = ?
BP/SVR
HR*SV
O2 consump/(O2 Pul Vein - O2 Pul Artery)
What are the classes of shock? What is the blood loss? What are the characteristics?
I - 0-15% VS nml
II - 15-30% HR+, postural hypotension
III - 30-40% HR++, BP-
IV - > 40% HR+++, BP<60
What is the treatment of hypovolemic shock?
ABCs
resuscitation with isotonic solution to maintain pressures
O- blood if not responsive
What is the treatment of cardiogenic shock?
O2
treat arrhythmia
mechanical ventilation to remove the work of breathing
In cardiogenic shock, DDx includes? How to work up?
MI - angiogram, thrombolytics or cath/stent/balloon
MONAB - morphine, oxygen, nitro, aspirin, beta blockers
What is the marker of sufficiently treated cardiogenic shock?
target PCWP - 15-20 mmHg
What are the common causes of SBO?
adhesions, neoplasms, hernias, Crohn's
What are the common causes of LBO?
colon cancer, diverticulitis, volvulus (cecum, sigmoid), hernia
What are the common causes of adynamic ileus?
celiotomy
inflammatory
retroperitoneal (ureter, blood)
thoracic (pneumonia)
systemic (hypokalemia, hyponatremia, sepsis)
drugs (anticholenergics, opiates, Ca++ blockers)
How do you tell if it is a partial or complete bowel obstruction? What are the differences in treatment?
partial - flatus, colonic gass on AXR, adhesions ~ 70% nonoperative
complete - no gas, no colonic gas - operate
What are the signs of strangulation?
tachycardia, fever, increased WbC, focal pain
Hypokalemic, hypochloremic metabolic alkalosis means:
vomiting
What are the indications for operation of bowel obstruction?
strangulated
peritonitis
>48 hours
pneumoperitoneum (perforation)
closed loop
complete
no hx of surgery
large bowel
P11
elimina viento, elimina calor y beneficia graganta (exceso), abre los orificios, recobra conciencia ( anapilectico), descenso y dispersion de pulmon, exceso corazon

Expel Wind, release exterior, clear Heat, cool Blood, resolve Dampness, benefits sinews & joints, regulate Ying & Blood
What is thoracic outlet syndrome?
compression of subclavian artery, vein, or brachial plexus
What causes thoracic outlet syndrome?
congenital (cervical rib)
trauma (crush injuries)
repetitive motion
What are the symptoms of thoracic outlet syndrome?
paresthesias, weakness (arterial or nerve), cold arm (arterial), edema (veinous)
What is the most common depressed nerve in thoracic outlet syndrome?
ulnar
Most common chest wall benign tumors? treatment?
fibrous rib dysplasia
chondroma
osteochondroma

wide excision + graft
Most common malignant chest wall tumors? treatment?
fibrosarcoma, chondroxarcoma, osteosarcoma, rhabdymyosarcoma, myeloma, Ewing's tumor

wide excision, possible radiation
What are the causes of pleural effusion?
transudates: systemic
CHF, constrictive pericarditis, cirrhosis, nephrotic syndrome
exudates: local
lung parenchymal infection, malignancy, PE, CVD, GI: pancreatitis, hemothorax, post-CABG
How do you diagnose pleural effusion?
thoracentesis - transudate or exudate? check LDH, protein, cytology
Lights criteria protein in fluid/serum > 0.5 and LDH in fuid/serum > 0.6 - exudate
What is the diagnosis of recurrent pneumothorax? treatment?
pleurodesis
scar lung with talc or abrasion
What are the 4 most common causes of anterior mediastinum masses?
teratoma 14% malignant
T-cell lymphoma - nodular sclerosing Hodgkin's Lymphoma
Thymoma - 75% with myasthenia gravis
thyroid malignancy
What are the risk factors for SCC of the esophagus?
smoking
alcohol
achalasia
radiation
nitrosamines
What are the risk factors for adenocarcinoma of the esophagus?
obesity
Barrett's
radiaiton
smoking
anticholinergics
What is the conversion rate for Barrett's to adenocarcinoma? What is the treatment for Barrett's?
0.5% conversion to cancer/year
surveillance with endoscopy, ablation + PPIs
What are the symptoms of esophageal cancer?
dysphagia
weight loss
hx of reflux
What are the signs of esophageal cancer?
lymphadenopathy (Virchow's node)
pleural effusion
What studies to do conduct if you are suspicious of esophageal cancer?
esophogogram - structure or ulcer
endoscopy, CT for mets, PET
What % of esophageal cancers are found to be unresectable or have distant mets upon Dx?
50%
How do you Rx esophageal cancer?
local - surgery or radiotherapy
advanced - chemo but palliative, last a few months
What cancers are associated with MEN1?
parathyroid
pituitary
pancreatic islet tumor
What cancers are associated with MEN2A?
parathyroid
medullary
pheo
What cancers are associated with MEN2B?
Medullary
Pheo
Mucosal and GI neuromas
What is the DDx for a thyroid nodule?
CA (thyroid, PT, lymphoma)
thyroditis
multinodular goiter
cyst
adenoma
What is the best test for determining what a thyroid nodule is?
FNA (5% FN)
can use US, I 123 scan, TSH, Ca++
What is the histological hallmark for papillary thyroid cancer? What are the metastatic spread patterns?
psammoma bodies
node spread - no effect on prog
What are the characteristics of follicular CA of the thyroid?
heme spread to bone
slightly worse prog
Hurthe variant
What is the treatment for medullary CA of the thyroid?
total thyroidectomy
median node resection
What are the most common causes of primary hyperparathyroidism?
90% adenomas (high Ca++)
10% hyperplasia (MEN)
1% CA
How do you diagnose primary hyperparathyroidism?
sestamibi scan Tc99 to dx and localize
How do you treat primary hyperparathyroidism?
fluids + lasix
explore 4 glands, remove adenoma, biopsy 3 nml glands
What are the causes of secondary and tertiary hyperparathyroidism?
secondary - from low Ca++ renal failure
tertiary - after renal transplant PT glands remain hypertrophic (high Ca++)
How do you treat tertiary hyperparathyroidism?
remove 3 1/2 glands or 4+ forearm transplant (leave at least 30 mg)
How do you Dx a pheo?
urine VMA, metanephrine
What are the patterns of melanoma?
superficial spreading
nodular (deep - worst)
lentigo maligna (best)
acral lentiginous
What is the clarks classification of melanomas?
I in situ (epidermis)
II papillary dermis
III papillary/reticular dermis jnctn
IV reticular dermis
V subQ fat
What is the breslow classification of melanomas?
<0.76 mm 90% cure
>4 mm 80% reoccurance/met
What are the common sites of melanoma mets?
brain
bone
liver
lungs
heart
bowel
Anus
What is the most common met to the bowel?
melanoma
What are the rules for rx of melanoma?
basted on depth
in situ (0.5 mm) - 0.5 margin
< 1 mm - 1 cm margin +/- SLND
1-4 mm - 2 cm margin + SLND
> 4 mm - 2 cm margin +/- SLND (often already distant mets)
node + - INF-a (chemo and radiation do not work, regional node resection)
How do you handle brain metastatic melanoma?
radiation
What are some extrapulmonary signs of lung cancer?
Horner's syndrome
Hoarse voice
SVC syndrome
Dysphagia
What is SVC syndrome? Treatment?
central tumor
SVC compression
face or arm swelling, venous distension of neck and chest wall, dyspnea, cough, headach
initial treatment steroids, diuretics until dx
What are the characteristics of SCLC?
neuroendocrine - ACTH, PTH-rp
fast doubling time
early metastasis
What is the Rx for SCLC?
chemo +/- radiation
platinum agents like cisplatin (crosslinks DNA) most effective
What is the staging for SCLC?
limited - encompassed by single tolerable radiaiton port (hemithorax)
extensive - get CT, bone scan, MRI of brain
What are the types of NSCLC?
adenocarcinoma
SCC
large cell carincoma
Where to NSCLC drain to?
drains to hilum and mediastinal nodes
What is the appropriate workup of NSCLC?
CXR: 96% abnormal
CT: detects local invasion, node status
PET: improves sens/spec of node status with CT
Bronchoscopy: standard node biospy
Mediastinoscopy: standard for node biopsy
Brain MRI and Bone scan: if N2 (mediastinal, subcarinal nodes)
When is surgery appropriate in the treatment of NSCLC? What is the surgery? What is the most important post op consideration?
if IIIa or less (no nodes or isplat hilar nodes, not extensively invasive)
pneumonectomy or lobecotmy + lymph node dissection
need post-op FEV1 of 1 L
What is the work-up of a solitary incidental nodule on CXR in someone without CA RFs?
follow growth over time
doubling - 28% increase in Diameter
cancer doubling is about 25-250 days
if less than 500 days is benign
Ca++ benign
Where is foregut pain referred?
phayrynx - D3
epigastric
Where is midgut pain referred?
periumbilical
Where is hindgut pain referred?
rectum
suprapubic
I say 'board-like' abdomen, you say?
perforated ulcer
What can abdominal films show you in the eval of acute abdomen?
calcification
gas pattern
fluid levels
fecolith
What can a CXR show you in the eval of acute abdomen?
pneumoperitoneum
What can US show you in the eval of acute abdomen?
liver
spleen
gallbladder
pancreas
appendix
kidneys
gyn
What can a CT show you in the eval of acute abdomen pain?
diverticulosis
abcess
pancreatitis
Indications for operation of acute abdominal pain?
peritonitis
pain + sepsis
perforation
ischemic
What is the root cause of aneurysms?
collagen/elastin defect
What is the typical aneurysm patient?
male
70
smoker
HTN
+ FHx
What is the normal size of the abdominal aorta? At what size do we consider it an AAA?
1.2 - 2cm
> 3cm
What is the management of AAA?
> 3.8 cm yearly U/S mointoring
> 5 cm U/S every month
> 5.5 cm repair (women 5 cm)
consider growth average 1/2 cm/year
What is the mortality of a ruptured AAA?
70%
What are popliteal aneurysms assocaited with?
limb loss
aneurysms elsewhere
What is aorto-illiac disease? AKA? Typical patient? Rx?
Lariche syndrome: butt/thigh claudication, impotence, proximal atrophy
Typical patient: 50, smoker, often effects life style
Surgery usually successful
What is the typical femoral-politeal patient?
70
DM
patients often adapt to Dx
What is the thearpy for fem-pop disease?
medical therapy often effective - stop smoking, exercise, cilostazol, pentoxiphylline
What is the indications for surgery of fem-pop disease?
limb threat - rest pain, ischemic ulcer, gangrene
refractory to medical treatment
What is the difference between stroke and a TIA?
stroke > 24 hours CNS deficit
TIA < 24 hours CNS deficit
What is the treatment of stroke?
CEA prevent future strokes
What is the treatment of TIA?
Sx + 50% stenosis = CEA
No Sx + 80% stenosis = CEA, NNT = 7
How much time do I have to restore arterial blood supply to an area undergoing acute arterial insufficiency?
6 hours
What are the causes of acute arterial insufficiency?
trauma
emboli
thrombosis (rare)
What are the 6 (P) symptoms of acute arterial insufficiency?
pain
paralysis
parasthesis (1st)
pallor
pulselessness
poikilothermia
What is one complication of re-perfusion after acute arterial insufficiency?
compartment syndrome
What is the indication for surgery with hemothorax?
chest tube gives off >1500 cc or > 200 cc/hr
How is the GCS determined?
motor 1-6
voice 1-5
eye 1-4
Trauma patient arrives with blown pupils, what are you suspicious of?
ipsilateral mass (hematoma, etc.)
Trauma patient with hemotympanum, raccoon eyes, ororrhea, rhinorrhea. Dx?
Basilar Fracture
What are the indications for exploratory laporatomy of a trauma patient?
+ 10 cc blood from syringe or > 10,000 RBC/mm3 or > 500 WBC/mm3
Patient with abdominal bullet wound, what do you do?
ex lap
Patient with abdominal knife wound, what do you do?
local exploration
DPL
ex lap
What do you do if you have an increased intracranial pressure?
head up
mannitol
craniectomy + hyperventalate
anticonvulsant prophylaxis
What are the zones of penetrating neck trauma?
zone I to cricoid
zone II to mandible
zone III above mandible
explore with zone II
What is the initial s/s of spinal cord injury? Rx?
spinal shock causes decreased BP
fluids, steroids < 48 hours
What are 4 things that can kill a trauma patient in 15 min?
tension PTX
sucking PTX
massive hemoTX
tamponade
What genes are associated with colorectal cancer?
FAP
Gardner's
HNPCC
What are the risk factors for colorectal cancer?
genetic
UC>Chronh's
Diet
What is the usual presentation of L sided colorectal cancer?
anemia
What is the usual presentation of R sided colorectal cancer?
obstructive symptoms
What is the usual presentation of rectal cancer?
hematochezia
What is the Dukes' stages for colorectal cancer?
A - submucosa
B - serosa
C - nodes
What are the prognostic factors for colorectal cancer?
sx
obstruction
perf
rectosigmoid
ulcerative
invasion
CEA
age
What is the appropriate surgery for cecal, ascending colon colorectal cancer?
R hemicolectomy (ileocecal, R colic arteries cut)
What is the appropriate surgery for hepatic flexure colorectal cancer?
R hemicolectomy including middle colic artery
What is the appropriate surgery for transverse colorectal cancer?
transverse colectomy
What is the appropriate surgery for descending colon colorectal cancer?
L hemicolectomy IMA cut
What is the appropriate surgery for upper 1/3 rectum colorectal cancer?
anterior resection
What is the appropriate surgery for middle 1/3 rectum (8-12 cm from the anal verge) colorectal cancer?
low anterior resection
What is the appropriate surgery for distal 1/3 rectum (<8 cm from the verge) rectal cancer?
abdominoperineal resection
What is the appropriate surgical treatment of colorectal cancer associated with FAP, UC or Gardners'?
total proctocolectomy + ileostomy OR
total colectomy + mucosal proctectomy + ileoanal anastomosis
What do you do if your colorectal cancer has nodes or mets?
chemotherapy 5FU
What do you do if your RECTAL cancer has positive nodes?
radiation
What is the follow-up after surgery for colorectal cancer?
CEA
Hx
PE + hemocult q 6 M for 3 years
then q 12 months
LFTs, CT, CSR, colonoscopy q 12 months
What are the s/s of Gardner's syndome?
neoplastic polyps
sebaceous cysts
osteomas
desmoid tumors
How do you Dx diverticulosis? What is the treatment?
barium enema
not surgical unless complications
increase fiber in diet
How do you Dx diverticulitis? What is the Rx?
Dx: CT, not BE or colonoscopy in acute setting
Rx: IV antibiotics, fluids, bowel rest, +/- NG
What are the indications for surgery in diverticulosis/itis? What is that surgery?
for recurrence, complications
elective primary or emergent Hartmann's
Causes of acute pancreatitis?
I - idiopathic. Thought to be hypertensive sphincter or microlithiasis.
G - gallstone.
E - ethanol (alcohol)
T - trauma
S - steroids
M - mumps (paramyxovirus) and other viruses (Epstein-Barr virus, Cytomegalovirus)
A - autoimmune disease (Polyarteritis nodosa, Systemic lupus erythematosus)
S - scorpion sting (e.g. Tityus trinitatis), and also snake bites
H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia
E - ERCP
D - drugs
What are Ranson's Criteria?
At admission:
age in years > 55 years
white blood cell count > 16000 cells/mm3
blood glucose > 10 mmol/L (> 200 mg/dL)
serum AST > 250 IU/L
serum LDH > 350 IU/L
At 48 hours:
Calcium (serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
Hematocrit fall > 10%
Oxygen (hypoxemia PO2 < 60 mmHg)
BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
Base deficit (negative base excess) > 4 mEq/L
Sequestration of fluids > 6 L
How shall we treat acute pancreatitis?
IV flues (monitor BUN, UO)
electrolyte correction (Ca++)
glucose management
blood gases
nutrition
antibx for abscess
monitor mental status
What is the role for surgery in acute pancreatitis?
elective chole surg
correctable lesions: pancreas divisum, obstruction
What is the treatment of pancreatic pseudocst?
< 5 cm watch
> 5 cm ERCP, percutaneous drainage if noncommunication
surgery at 6 weeks if communication with duct
What is and what is the treatment for pancreatic abscess?
infected pseudocyts or necrotizing pancreatitis
debris in cyst, positive cultures

Tx: wide surgical excision, debridement and antibx
What are the s/s of chronic pancreatitis?
persistent pain
epigastric to back, worse with food/alcohol
malabsorption (late)
What is the best way to Dx chronic pancreatitis?
ERCP
NOT lipase/amylase
What are the indications for surgery of chronic pancreatitis? What are the possibilities?
for intractable pain
pancreatojejunostomy
pancreatic resection if in tail/body
whipple if pancreatic head involvement
How are body fluids distributed?
60% of BW
What is the risk for resuscitation with normal saline?
too much > 5ml causes
hypercholoremic metabolic acidosis
What are the considerations when resuscitation with LR solution?
has 4 mEq of K so not if renal failure
lactate - HCO3 - alkalosis but bad if Liver failure
What is the advantage of D5W for resuscitation?
distributed in all body water compartments
How many gm of dextrose in D5W? How many calories?
1000 ml
50 gm dextrose
4 kcal/g = 200 kcal
What is needed for fluid maintenance?
4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr for 2nd 10 kg
1 cc/kg/hr thereafter
What is the goal for urine output during resuscitation?
min 30 cc/hr
720 cc/day for a 60 kg person
or 1/2 cc/kg/hr
What are the consequences of hyponatremia?
ileus
fatigue, confusion, seizure, coma
What is the consequence of quickly correcting hyponatremia?
central pontine myelinolysis
What is the Rx for hypernatremia?
D5W
How do you calculate water deficit?
0.6 x wt x (Na-145)/145
What is the consequence for hypokalemia?
ileus
tetany, paresthesia
What are the signs on EKG of hypokalemia?
T wave flattening
U waves
How do you treat hypokalemia?
KCl
What are the s/s of hyperkalemia?
decreased DTR, weakness, paresthesia, paralysis
EKG - T wave peaking, QRS widening, V tach, V fib
How do you treat hyperkalemia?
Ca+
HCO3
insulin/D5
furosemide
albuteral
dialysis
What EKG changes are seen in hypocalcemia/ What is the Rx?
long QT, delayed repolarization
Ca++ gluconate
What are the EKG changes seen in hypercalcemia? What is the Rx?
short QT, long PR
NS and furosemide
What are the causes of hypercalcemia?
CHIMPANZEES
Ca++
HPT
HT
Hypocalciuric hypercalcemia
Iastrogenic (thiazides)
Mets
Paget's dz
Addison's
Neoplasm
ZE
Excess D
Excess A
Sarcoid
What can hypomagnesemia cause?
hypokalemia
What is the treatment of hypermagnesemia?
Ca++
insulin/D5
furosemide
dialysis
What is the treatment of hyperphosphatemia?
aluminum hydroxide
What are the protein requirements for a person?
1-2 g/kg/day
What size of breast tumor make sit T3?
> 5 cm
What is the necessary time from MI to elective surgery?
6 mo
Most common cause of primary hyperparathyroidism?
parathyroid adenoma
Which vein limits the ability to resect during the Whipple procedure?
SVM
Patient with perforation of duodenal ulcer exanguinates, what happened?
penetrated into gastrodudodenal artery
Patient undergoing AAA repair, postop develops exanguination, what happened?
aortoduodenal fistula
I say Budd-Chiari syndrome, you think?
thormbosis of the hepatic vein
What is a spigelian hernia?
herniation lateral and ventral
through semilunaris
semicircular line of douglas
Most common cause of acute anal pain?
anal fissure
Most likely cause of thrombocytopenia in a person with history of ITP post-splenectomy?
accessory spleen
Causes of midline incision dehiscence?
infection
tension
hematoma
What is the workup for a lower GI bleed?
R/O UGI bleed
Rectal Exam
TRBC or angiogram
sigmoidoscopy or colonoscopy
Man from Honduras with fever, leukocytosis, and RUQ mass?
amebic abscess
Artery most commonly damaged during cholcystecomty?
right hepatic
Child with bilious vomit?
must R/O midgut volvulus
What are the best indicators of tissue perfusion?
color
pulse
capillary refill
abscence of acidosis
urination
mentation
DDX of distended neck veins?
Tension pneumothorax
massive hemothroax
cardiac tamponade
myocardial injury with heart failure
What are the causes of diabetic foot ulcer?
decreased sensation
decreased perfusion
decreased neutrophils function
What is the most irritating suture? Least irritating?
non-absorbable braided suture - least
monofilament absorbable - least irritating
Survival rates for Duke's A, B, C, D?
A - 94-97%
B - 56 - 83%
C - 15-86 %
D - 5 %
What is Adamkiewicz syndrome?
occlusion of radicular artery
What is the Edward's procedure?
replacement of aorta and aortic valve in aortic dissection
What is Mondor's Dx?
thrombophlebitis of thoracoepigastric veins and also thrombophlebitis of superficial breast veins
What is Belsey Marks IV procedure?
270 degree fundoplication
What is Battle's sign?
ecchymosis over mastoid process in basilar skull fracture
What is mitotane?
durg that kills cortisol producing cells
What is metyrapone?
11 beta hyroxylase inhibitor
What is Nelson's syndrome?
hypersecretion of pituitary hormones
What is the organ of Zuckernadl?
chormoaffin cell near aorta
What is the breast tissue in the axilla called?
tail of Spence
What is whipples traid?
hypoglycemia
vasomotor sx
relief of sx with administration of glucose in insulinoma
What is Beck's triad?
increased JVD, hypotension, faint heart sounds
cardiac tamonade
MEN 1 aka?
Wermer's syndrome
MEN 2a aka?
Sipple's syndrome
What is Ogilvies syndrome?
paralytic dialation of colon
treat with colonscopy and physostigmine
Early wound infection?
group A strep - erysipelas
clostridia dirty dishwater discharge, crepitance
Tumor marker AFP?
testicular or hepatoma
Most common cause of maetabolic gap acidosis in surgery?
lactic acidosis
Telangictasis around lips?
Peutz-Jeghers
Diffuse telangictasias?
Osler-Rendu-Weber
Hammond's sign?
crunching, rasping sound, synchronous with the heartbeat,[3] heard over the precordium in spontaneous mediastinal emphysema.
How do you treat hypercalcemic crisis?
saline, furosemide, bisphosphonates, mithramycin, plicamycin, calcitonin.
How do you treat hypercalcemic crisis?
saline, furosemide, bisphosphonates, mithramycin, plicamycin, calcitonin.