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284 Cards in this Set
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cardiac contraindications to elective surgery
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mi < 30d, decompensated CHF, significant arrythmias (ie block, symptomatic ventricular; not afib/aflutter); severe valvular disease
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how long to stop asa before surgery
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1wk (vs 2d for other NSAIDs)
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does hyperchol contraindicate surg?
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no
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what to do if concern for cardiac dz?
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cardiac c/s, ecg, ?stress test (exercise vs pharma) ==> cardiac cath if unstable angina
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what to do with morning insulin in diabetic on day of surgery?
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INSULIN ONLINE: if glucose > 250, give 2/3 AM dose; else give 1/2 AM dose; NO ORAL HYPOGLYCEMICS
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what BP greatly increases cardiovascular risk? What to do about it?
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DBP > 110 -- keep pt on beta-blockers/other antihypertensives on day of surgery
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how long after smoking cessation to operative risks linger?
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bronchial ciliary function returns in 2d, but operative mortality high for 6wks
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how to minimize operative risks in pt with respiratory pathology?
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can give perioperative bronchodilators, esp for COPD
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what to check in preop assessment if significant peripheral vascular disease?
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cardiac function (ie stress test) because PVD a/w CAD
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how does prior CABG affect periop risk if it was 6m-5y ago? >5y ago?
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if 6m-5y, PROTECTIVE (?formation of collaterals?); if > 5y, graft occlusion rates are high, so stress test needed to verify efficacy
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do preexisting CABG and PTCA have the same perioperative effects?
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no -- PTCA has much higher failure rate ==> need cardiac w/u prior to surgery
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what degree of stenosis warrants CEA?
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>70%
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what preop test appropriate if pt has a history of stroke?
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carotid duplex
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how should patients with chronic liver failure be prepped for anticipated surgery?
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1) abstain from ALCOHOL for 6-12 wks prior to surg (like tobacco for smokers); 2) control ASCITES medically [k-sparing diuretics, na, h2o restriction]
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what do chronic renal failure pts need to do immediately prior to surgery?
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undergo dialysis to optimize electrolytes
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how can renal failure cause bleeding problems? Whats the treatment?
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renal failure --> uremia --> platelet dysfunction; TREATMENT: not platelets b/c they wont work ==> 1) DDAVP (causes vWF release aiding platelet aggregation); 2) DIALYSIS (decreases uremia); 3) FFP (temporarily corrects plt deficit)
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how does valvular heart disease affect surgery? (elective and urgent)
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BOTH: eval preop for stability/compensation with ECHO, give abx if GI/dirty case to prevent SBE; ELECTIVE: can proceed iff pt is stable and valvular disease is compensated; URGENT: need intraop monitoring (a-line, ?TEE)
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what procedures need abx for SBE ppx? Which abx?
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DENTAL: amox unless pcn all --> ceph/clinda/clarithro; GI: amp/gent or vanc/gent if pcn all (gent only if high risk)
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what metabolic effects of golytely
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NONE (no ion/h2o movement)
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cloudy urine + mental status changes = what pathology? What's the tx?
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urosepsis; dx with u/a + cx, tx with broad spec abx;
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5ws of post-op fever
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1) WIND (pneumonia, atelectasis -- mcc); 2) WATER (UTI -- 2ndmcc, d3); 3) WALKING (DVT --> ?PE); 4) WOUND (infection); 5) WONDERDRUG (
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what does pus at venupuncture site suggest? How to tx?
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SUPPURATIVE PHLEBITIS (infection of thrombus in IV site) --> tx by pulling line, blood cx, IV Abx, and cutting out vein to first non-infected branch
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how to tx an enterocutaneous fistula?
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can be treated non-operatively ==> NPO, TPN, labs; should resolve in 4-5wks; if it doesn't, need to go to OR
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2 causes of HIGH post-op fever
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1) ATELECTASIS (not really a big deal); 2) WOUND INFECTION w gas-producing organism (clostridium, g-negs) --> can spread quickly along fascial plane, needs to be treated quickly with wide excision, debridement, and abx
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timing of healing of wound by primary intent (3)
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1) RE-EPITHELIALIZATION: 2d; 2) COLLAGEN production and cross-linking: 4-6wks; 3) COMPLETE remodeling and healing: 6mos
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when to use abx with wound infection
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first just drain and debride non-viable tissue, apply wet-dry dressings; if cellulitis continues to spread, give abx
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three levels of contamination of wounds; what kind of repair with each? When to use abx?
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1) CLEAN (eg no GI/resp/GU entry): 1' intent, no abx unless FB placed; 2) CLEAN-CONTAMINATED: GI/resp/GU entered but prepped, 1' intent, YES abx; 3) CONTAMINATED (eg stool in abdomen): 2nd/3rd intent, saline dressing, requires preop abx
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what are the indications for intubation (6)
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1) poor RESPIRATORY EFFORT; 2) decreased MS; 3) GCS <= 8; 4) can't PROTECT airway; 5) compromised RESPIRATORY MECHANISM; 6) suspected LARYNGEAL EDEMA [inhalation burn, trauma]
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tx of sucking chest wound (in order)
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1) occlusive dressing; 2) chest tube
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what can look like tamponade?
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myocardial contusion -- causes arrythmias rather than cardiac failure; detected by ECG, confirmed by cardiac enzymes/imaging
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how much blood loss with each of the classes of shock? When are changes in VS seen?
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CLASS I: <15%; CLASS II: 15-30%; CLASS III: 30-40%; CLASS IV: >40%; change in VS seen around CLASS III
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how to clear c-spine in a comatose patient?
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only with MRI -- CANNOT CLEAR CLINICALLY
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signs of fresh spinal cord injury (5)
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1) PRIAPISM (often first sign); 2) loss of ANAL sphincter tone; 3) loss of VASOMOTOR tone; 4) BRADYCARDIA; 5) ILEUS
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what to do with penetrating trauma below clavicle? What are you worried about?
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worried about subclavian vessel injury -- notoriously hard to diagnose; if pt STABLE, do angiogram; if UNSTABLE, explore operatively
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signs of aortic injury on CXR (2+)
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1) widened MEDIASTINUM; 2) indistinct AORTIC KNOB; OTHERS) apical cap, tracheal deviation
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in which patients do you get abdominal imaging even if there are no signs or symptomso f injury?
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1) UNPROTECTED TRAUMA [eg ped, bicycle]; 2) HIGH-ENERGY TRAUMA [high speed, no restraints, large fall]; 3) HIGH-RISK pt [old, sick, immunosuppressed]
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biggest concern with splenectomy
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post-splenectomy sepsis
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management of splenic injury
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UNSTABLE --> OR; STABLE --> depends on grade of lac (I-III --> observe; IV-V --> OR); OR options include splenectomy, partial splenectomy, splenorrhaphy, angiography, embolization
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management of liver lac
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UNSTABLE --> OR; STABLE --> observe
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whats the concern with mesenteric injury?
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requires high force, so mesenteric injury usually suggests concomitant bowel injury
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what test to do prior to nephrectomy?
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IVP to confirm presence and functioning of contralateral kidney
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management of pancreatic injury
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REQUIRES EXPLORATION of panc + duo; MINOR injury --> drained and debrided; MAJOR injury (eg ductal injury) --> resection of pancreatic tissue, repair of duo
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mgmt of duo hematoma
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can obstruct lumen --> NPO, observe for 5-7d
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what are the 3 zones of non-penetrating RP hematoma? What is their management?
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I) CENTRAL: vascular territory, needs to be explored surgically [also duo and panc]; II) FLANK: usually renal, can observe if stable; III) PELVIC: observe if stable, but angiogram +/- embolization if unstable
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whats the big concern with head injury? How do you minimize risk? (3)
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big concern is cerebral edema --> increased ICP --> decreased CPP; MGMT: 1) elevation of head; 2) ?hyperventilation [mixed data, currently reserved for pts with impending hernia]; 3) mannitol
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what two injuries can cause blown pupil?
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1) tentorial herniation; 2) epidural hematoma
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what is branham's sign?
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a/w FISTULA; if fistula is compressed, HR drops 10 beats/min (?2/2 increased SVR?)
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what effect does PEEP have on preload?
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inc PEEP --> increased intrathoracic pressure --> decreased venous return --> decreased preload
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what to do if strong evidence of trachea / esophageal injury?
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EXPLORE
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what to do if neck injury but no obvoius sign of tracheal/esophageal injury
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laryngoscopy / bronchoscopy for airway; esophagoscopy / barium swallow for esophagus
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what to do if pt is hoarse following neck injury? Why?
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worried about airway injury, but could be nervous; --> need to explore or do laryngoscopy at minimum
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what is the parkland formula?
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4ml/kg/%BSA/d * weight * %BSA; 1/2 given in first 8 hrs, rest given in remaining 16hr
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whats the risk with myoglobinuria? How do you fix it?
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can cause ATN; tx with lots of fluids, alkanizing urine, and osmotic diuresis
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protein reqs in diff pts (3 diff types)
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1) NONDEPLETED: 1mg protein / kg / d; 2) DEPLETED (malnourished): less; 3) HYPERMETABOLIC: 2-2.5mg/kg/d
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what is the first clinical manifestation of free fatty acid deficiency?
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dry, scaly skin --> tx by administering lipids (eg soybean oil?)
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empirical w/u and tx of nonspecific epigastric pain
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labs, KUB, RUQ u/s to r/o cholecystitis/obstruction badness ==> then H2 blockers if negative
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what to do if h2 blocker empirical tx for epigastric pain fails?
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scope + biopsy to r/o ulcer dz / cancer; if normal, restart H2 blockers +/- h.pylori tx (for nonulcer dyspepsia)
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mgmt of GERD
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medical (h2 blockers); if fails, need surgical intervention (Nissen fundoplication)
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what needs to be documented prior to Nissen for GERD?
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need to show normal peristalsis by esophageal manometry to ensure normal post-op swallowing; may need 24-hr pH probe testing to confirm acid reflux if no explanation for reflux seen on manometery (eg nl LES tone)
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what are the two main tests in evaluation of GERD/esophagitis?
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1) MANOMETRY: measure LES pressure, show normal peristalsis in order to proceed with surgery; 2) 24-HOUR PH PROBE: confirm diagnosis of acid reflux
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natural progression of GERD (3)
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GERD --> esophagitis --> Barrett esophagitis --> ?cancer
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tx of non-Barrett esophagitis
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if MILD: med tx; if SEVERE: surg anti-reflux tx
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tx of Barrett esophagitis
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MILD: medical tx (85% effective) -- head up @ night, small meals, 8-12wks PPI, followed by regular surveillance scope + bx q18-24m; SEVERE: esophagectomy
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types and tx of hiatal hernia (2)
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TYPE I (sliding): tx like GERD (nonsurg); TYPE II (paraesophageal): repair necessary to avoid strangulation
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noninvasive test for h.pylori
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urea breath test
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tx for h.pylori
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triple therapy (usu PPI, metro, clarithro/amox; +/- bismuth, tetracycline)
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types and tx of acid producing ulcers
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(pyloric, duodenal, gastric types II and III): acid suppression and h.pylori tx ==> if fails (6wks), surgical tx (HSV vs vagotomy+antrectomy vs vagotomy+pyloroplasty)
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preferred surgical tx of PUD
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if uncomplicated, HSV (higher rate of recurrence, but fewer complications)
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big difference in management of gastric vs duodenal ulcers
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gastric ulcers have potential for malignancy -- REQUIRE BIOPSY (8-12 at edge of ulcer)
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tx of gastric ulcers
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scope, biopsy (to r/o cancer) ==> if benign: antacids, H2 blocker, +/- h.pylori tx
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what to do with gastric ulcers non-resolving on medical tx? (2 diff time points)
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at 12 WEEKS: repeat endoscopy, biopsy; at 18 WEEKS: ?resection; vagotomy unncessary unless type II or III ulcers (acid-related)
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tx of malignant gastric ulcer (early gastric cancer)
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1) STAGE -- CT/endoscopic ultrasound; 2) PARTIAL GASTRECTOMY
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types of gastric cancer (2) -- which is worse?
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1) INTESTINAL: gland forming, better prognosis; 2) DIFFUSE: extends into submucosa --> bad, can develop into "linitis plastica"
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tx of perforated ulcer (duodenal, gastric)
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1) DUODENAL: if 1st time, do graham patch; if recurrent, consider HSV/V&P; 2) GASTRIC: ALWAYS resect
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how does time affect management of perforated duodenal ulcer?
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if fresh perforation (<12hrs old), can do whatever; if > 12 hrs old, sepsis risk very high, so do minimum -- graham patch, peritoneal debridement, IV Abx
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management of coffee-grounds emesis
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h2 blocker, observation -- scope not necessary
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management of bright red blood in emesis (3 scenarios)
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scope --> 1) WHITE-based ulcer: not actively bleeding, NTD; 2) CLOT in ulcer: recently bleeding, do ENDOSCOPIC HEMOSTASIS; 3) ACTIVELY BLEEDING ARTERY: need to go to OR vs ENDOSCOPIC tx
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what are the endoscopic treatments for a bleeding vessel?
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INJECTION of epi or sclerosing agents; THERMAL coagulation; LASER therapy; SUTURING
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whats different about surgical tx of bleeding duodenal vs gastric ulcers?
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duodenal: can oversew vessel; gastric: NEED TO EXCISE (cancer risk)
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tx of gastric varices
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1) endoscopic BANDING, COAGULOPATHY correction (if cirrhosis), VASOPRESSIN/OCTREOTIDE; 2) repeat ENDOSCOPY, retry banding; 3) TIPS or balloon TAMPONADE
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what coagulopathy results from liver failure (cirrhosis)? (2)
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1) FACTOR DEFICIENCIES (vit K dependent factors 2, 7, 9, 10); 2) THROMBOCYTOPENIA: from splenomegaly --> sequestration
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tx of mallory weiss syndrome
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control vomiting --> bleeding normally stops; if not, injection vs electrocautery
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what medication given for maintenance in tx of esophageal varices?
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oral beta blockers
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tx for gastric lymphoma
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depends on stage; h.pylori eradication --> surgery --> radiation --> chemo
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two main potential complications of cholecystectomy
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1) injury to BILE DUCT; 2) injury to HEPATIC ARTERY
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use of abx in symptomatic cholelithiasis vs acute cholecystitis
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symptomatic cholecystitis: give 1dose 1hr before procedure (clean-contaminated case); acute cholecystitis: give abx preop and 24hrs postop
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what are bilis with cholecystitis? What if they're higher?
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usually mildly elevated: 2-3; if higher (>=4), consider CBD obstruction
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tx of CBD stone
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if >=3mm, need to be REMOVED; mult options, including ERCP, lapchole->IOC/exploration
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how does elevated amylase affect cholecystitis management?
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if transient elevation, wait for it to drop back down, then perform lap chole with IOC (likely CBD stone); if persistent elevation (acute pancreatitis), wait for pancreatitis to resolve (hydration, analgesia, etc.) and delay cholecystectomy
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what do you worry about with gallbladder sx and fever? (4)
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cholangitis, empyema (pus in gall bladder), pericholecystic abscess, or just acute cholecystitis
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tx of empyema of gallbladder
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if STABLE, IV Abx and emergent exploration/excision; if UNSTABLE, IV Abx + cholostomy tube
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tx of acute cholangitis
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IVF, IV Abx; U/S --> if stone, requires urgent decompression: ERCP with sphincterotomy, STONE removal
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name 2 types of gallbladder emergencies
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1) PALPABLE painful gallbladder --> suggests inflammation, imminent rupture; 2) EMPHYSEMATOUS gallbladder -- gas forming org in wall
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what can be confused for cholangitis in patients s/p cholecystectomy? What is the tx?
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biliary stricture --> tx by surgical exploration + bypass
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how to w/u and manage ?biliary leak s/p cholecystectomy?
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WORKUP: two main tests 1) HIDA (detect leak) and 2) U/S (detect collection); if positive, treat with ERCP and STENT to close defect; drain collection if significant
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what imaging studies to use if ?pancreatic mass (3)
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1) transabdominal u/s; 2) abd CT; 3) endoscopic ultrasound (best)
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what do you need to know before excising a pancreatic mass? Why? (2)
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1) need PATHOLOGY -- if not cancer, DON'T RESECT (high m&m with procedure); often, pathology determined intraop before resection; 2) need IMAGING to make sure no METASTASES (don't resect if mets -- not curable); also look for mets INTRAOP
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what is Klatskin tumor?
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cholangiocarcinoma at bifurcation of hepatic ducts
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how do you w/u and tx a klatskin tumor?
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WORKUP: hard to see on CT --> need to w/u using ERCP; TREATMENT: surgical resection if no mets (like panc ca); most tumors unresectable / detected after mets
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what type of surgery for gallbladder cancer? Why?
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OPEN cholecystectomy (NOT laparoscopic --> risk of seeding trocar sites)
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what two types of gallbladder pathology predispose to gallbladder cancer?
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1) POLYPS > 2cm; 2) CALCIFIED (PORCELAIN) gallbladder
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how to w/u PANCREATITIS (imaging)
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obstructive series imaging; CT not indicated unless complicated
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tx for pancreatitis
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palliative: NPO, IVF, pain meds, observation, +/- TPN
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how to tx gallstone pancreatitis?
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palliative tx until resolution of pancreatitis symptoms (usu 48 hrs) followed by cholecystectomy and CBD stone removal
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if patient with acute pancreatitis begins to worsen and look ill, what are you worried about? How do you w/u and tx it?
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severe necrotizing pancreatitis with SIRS and thirdspacing of fluid ==> need CT to look for other causes of decompensation (unlike uncomplicated pancreatitis) ==> FLUID RESUSCITATION is essential, ventilation if development of ARDS
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correlation of amylase levels and pancreatitis
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none
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indications to intubate
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ABGs (PaO2 < 60, PaCO2 > 45) and CLINICAL STATUS
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tx of pancreatic abscess
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aspirate and culture for Abx, then drain
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specificity of amylase for pancreatitis
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poor --> can be elevated in peripancreatic inflammation, eg mesenteric ischemia, volvulus, etc.
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how do you tx a pancreatic pseudocyst?
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manage expectantly for 6wks: NPO, IVF, TPN; if no improvement after 6 wks, need to DRAIN surgically
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why wait 6 wks to operate on pancreatic pseudocyst? (2)
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1) often resolve spontaneously; 2) in 6 wks, enough fibrous tissue to facilitate surgical closure
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are hepatic lesions usually benign or malignant? What are common types of each?
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usually BENIGN; 1) BENIGN: cystic (simple cyst) or solid (hemangioma); 2) MALIGNANT: HCC, mets, cholangiocarcinoma
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what are three types of hepatic collections and their treatment?
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1) SIMPLE CYST: ntd; 2) MULTILOCULATED CYST: operative steralization and excision; 3) ABSCESS: if pyogenic, IV Abx + drainage; if amebic, tx with metronidazole (no drainage)
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differential of solid hepatic masses (BENIGN and MALIGNANT)
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BENIGN: hemangioma, focal nodular hyperplasia, hepatic adenoma (+/-); MALIGNANT: HCC, metastatic cancer
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most common solid hepatic mass
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hemangioma (benign)
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dx of hemangioma
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RBC SCAN (inc uptake) or CT with CONTRAST (out --> in enhancement); avoid biopsy if possible --> risk of bleeding
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tx of hemangioma, focal nodular hyperplasia, and hepatic adenoma
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HEMANGIOMA: none (unless symptomatic); FOCAL NODULAR HYPERPLASIA: none; HEPATIC ADENOMA: resection if large/persistent (risk of rupture or development of HCC)
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dx of focal nodular hyperplasia. how do you tell it's not hepatic adenoma or cancer?
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often see CENTRAL STELLATE SCAR on imaging; hard to distinguish from more dangerous pathology, so BIOPSY necessary
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which hepatic lesion is a/w oral contraceptive use / pregnancy?
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hepatic adenoma
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tx of HCC
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if nonmetastatic (do CT first), SURGICAL;
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tx of hepatic abscess
|
if PYOGENIC, small/multiple --> IV abx x 6wk; large/singular --> need to drain + abx; if AMEBIC: just metronidazole (no surg)
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mgmt of small bowel obstruction
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KUB, NPO, IVF, NG tube; watch for a couple days (most RESOLVE SPONTANEOUSLY). take to OR if worsened or new indications
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indications to take SBO to OR (5)
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1) high fever, 2) high WBC, 3) decreased pH (suggests ischemia), 4) peritonitis/local tenderness, 5) failed medical management (don't improve while observed)
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definition and tx of closed loop obstruction
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DEFN: inlet and outlet of loop of bowel is obstructed --> TX: OPERATE
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operative mgmt of closed loop obstruction
|
assess viability of bowel -- if dead, cut it out; if possibly viable, two options: 1) RESECT, reanastamose; 2) CLOSE, observe, REEXPLORE in 24 hrs
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how to confirm dx of SBO if question of SBO vs ileus
|
upper GI with SBFT
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what post-op risks a/w accidental enterotomy? (2)
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1) post-op LEAK; 2) small bowel FISTULA
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how to w/u and manage stable pt with ?ischemic bowel
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INITIALLY, need dx: 1) sigmoidoscopy (should see ischemic colon) or if negative, 2) angiography (gold standard); if no evidence of NECROSIS, medical management -- fluids, npo, abx; LATER, can do prophylactic revascularization and longterm ASA
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what operative risks a/w polycythemia? how do you manage them?
|
polycythemia --> hypercoagulable state; need to correct prior to procedure (PHLEBOTOMY, HYDRATION)
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what does bloody diarrhea suggest in ischemic bowel? mgmt?
|
suggests NECROSIS; do SIGMOIDOSCOPY --> if just mucosa, can manage medically; if involves full thickness, requires SURGERY
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difference in etiology of colonic vs small bowel ischemia
|
colonic is rarely 2/2 an arterial obstruction (more likely low flow state) --> less likely to benefit from or be diagnosed by angiography
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MCC of SBO in pt with crohn's disease
|
stricture
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mgmt of fistula or stricture a/w crohns
|
NONOPERATIVE: NPO, TPN, bowel rest, observation; if no resolution, tx surgically
|
|
how to manage perianal problems in crohn's?
|
metronidazole; surgery if abscess
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|
timeline of increased cancer risk with UC? what are the implications for surveillance frequency?
|
minimal inc in cancer risk for first 10 yrs, then increases steadily. after 8 yrs, need colonoscopy every 1-2yrs --> resection if severe dysplasia on biopsy
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what is pouchitis? how do you treat it?
|
inflammation of ileal pouch after colectomy; seen in 1/3 of pts with ileal pouch; tx with metronidazole (like perianal problems in Crohn's)
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tx of toxic megacolon
|
MEDICAL MANAGEMENT: bowel rest, decompression (NG tube), IV steroids ===> if no improvement in a few days or new findings (free air, peritonitis, fever, etc.), SURGERY
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what does air in wall of colon suggest?
|
IMPENDING PERFORATION --> operative intervention
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how to interpret pyuria in w/u of ?appendicitis
|
could be UTI/pyelonephritis, or peri-appendiceal ABSCESS; if not gross pyuria, could STILL BE APPENDICITIS (periappendiceal inflammation)
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radiographic sign of crohn's disease
|
string sign
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|
how to elicit tenderness with retrocecal appendicitis?
|
via RECTAL EXAM
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|
most common ages for appendicitis
|
BIMODAL (25 and 65)
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why is appendicitis bad in the very young and very old
|
very young: often present after perf; very old: present with vague, nonspecific sx
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what to do if appendicitis in pregnant woman?
|
OPERATE (peritonitis much more dangerous than appendectomy)
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what does carcinoid tumor look like? where is it found? how do you test for it?
|
yellow mass, often in appendix or small bowel; more common in appendix, but more likely to met from small bowel (esp ileum); check for 5-HT and 5-HIAA levels in urine
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|
management of carcinoid tumor in appendix -- how do size and location affect management?
|
if >2cm or in base of appendix, need to perform RIGHT HEMICOLECTOMY; if <2cm and at tip, can get away with SIMPLE APPENDECTOMY
|
|
management of carcinoid tumor in small bowel?
|
RESECTION, esp of ileum and lymph nodes (high rate of metastasis to liver)
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what is recommendation for screening of CRC?
|
if NORMAL RISK: starting at 50y, get 1) colonoscopy q10y; OR 2) sigmoidoscopy q5y and FOBT q1y
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|
what past medical history increase recommended screening of CRC? how?
|
1) FAP: sigmoidoscopy q1y (will see polyps in sigmoid); 2) HNPCC: colonoscopy q1-2y (few polyps, might be in nonsigmoid); 3) ADENOMATOUS POLYP or CRC RESECTION: colonoscopy 3y after removal, then q5y, CEA q3m for CRC resection
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intial tx for hemorrhoids; tx if refractory
|
INITIAL: sitz baths, stool softeners, increased fiber; REFRACTORY: depends on location -- internal: endoscopic banding/ligation; external: surgical excision; COLONOSCOPY/SIGMOIDOSCOPY to r/o cancer
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|
types and tx of polyps (2)
|
1) PEDUNCULATED: usu can excise with snare (polypectomy) --> pathology --> cancer in stalk --> partial colectomy, else scope every 3 yrs; 2) SESSILE: excise -- <2cm endoscopically, >2cm surgically; need f/u surveillance colonoscopies
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|
tx of colon cancer
|
SURGICAL RESECTION +/- adjuvant chemotherapy (5-FU, levamisole); NOT radiation
|
|
what labs to follow with colon cancer?
|
CEA (for recurrence) and LFTs (for liver mets)
|
|
what histology suggests poor prognosis with CRC? (3)
|
1) poorly differentiated; 2) mucin-producing; 3) signet-cell
|
|
potential causes of obstruction following colectomy (2 big categories)
|
1) LEAK: from anastamosis --> inflammatory ileus; 2) MECHANICAL: adhesions, internal hernia, obstructed anastamosis; late complications include cancer recurrance and stricture
|
|
w/u and tx of anastamotic leak
|
WORKUP: often see feculant matter from wound --> CT to see if drainable collection, gastrograffin enema or colonoscopy if unsure about patency of anastamosis; TREATMENT: observation (npo, ivf) --> most will close (unless distally obstructed --> operate)
|
|
how does location affect tx of rectal cancer?
|
if within 5cm of anal verge, need to do abdominoperineal resection (cant keep margins clean without destroying anal sphincter) --> permanent ostomy; if >5cm from anal verge, can do low anterior repair
|
|
how does rectal cancer spread? to where?
|
DIRECT EXTENSION (anterior structures incl bladder, ureter, prostate, seminal vesicles) and LYMPHATICS (internal iliac nodes, sacral nodes, inferior mesenteric nodes)
|
|
what to do with large, bulky rectal cancer?
|
PREOP RADIATION (often effective enough to not require surgery!)
|
|
tx of anal cancer
|
NIGRO PROTOCOL: chemo, radiation, NO SURGERY
|
|
tx of diverticulitis (depending on patient)
|
HEALTHY patient: liquid diet, abx x 7-10d; ELDERLY: IVF, NPO, bowel rest, IV Abx; if >1 episode or COMPLICATIONS (perf, abscess): ELECTIVE RESECTION (in 4-8 wks after colonoscopy to r/o cancer)
|
|
initial w/u of upper GI bleed
|
NG Lavage to make sure not upper GI bleed --> if positive, get upper endoscopy; else get anoscopy
|
|
MCC lower GI bleed
|
1) AVM; 2) diverticulosis
|
|
does lower GI bleed need to be admitted if bleeding stops?
|
YES -- need to observe and determine etiology (make sure not cancer) -- colonoscopy when stable
|
|
why not perform colonoscopy while pt is actively bleeding?
|
1) can't see anything; 2) higher perf risk (can't see wall)
|
|
how to stop diverticular/AVM bleeding?
|
vast majority stop by themselves -- just manage expectantly; if don't stop, can try colonoscopic or operate
|
|
what to do if persistent lower GI bleeding?
|
can try colonoscope for tx of AVM or polyps; if persistent bleeding and 4-6u of blood given, need to ID source (angiogram if stable, RBC scan if unstable) and go to OR
|
|
dx and management of sigmoid volvulus
|
dx by barium enema; tx: 1) "detorsing" by rigid proctoscope if STABLE, or 2) sigmoid colectomy with colostomy/anastamosis depending on patient stability
|
|
tx of cecal volvulus? how does it differ from sigmoid volvulus?
|
URGENT SURGERY -- detorsion, colectomy, cecopexy; (nonoperative tricks used for sigmoid volvulus don't work)
|
|
what is ogilve's syndrome, and how is it treated?
|
pseudobstruction, esp of cecum/rectum; if colon < 8cm, just watch; if colon > 10cm, decompress endoscopically or surgically
|
|
most common location and tx of anal fissure
|
mc location: posteromedial; tx: sitz baths, high fiber diet, stool softeners (like hemorrhoids)
|
|
malignancy of coin lesions in lungs
|
depends on age -- 50% at 50yo
|
|
characteristics of lung lesion on xray that suggest malignancy
|
poorly defined border, no calcifications
|
|
w/u of solitary pulm nodule found on cxr
|
CT --> BRONCHOSCOPY (bx lesion), MEDIASTINOSCOPY (bx nodes), ?needle biopsy
|
|
what to do with solitary pulm nodule w/u showing benign lesion? Malig lesion?
|
BENIGN: follow with CT in 6-12mo; MALIGNANT: stage, then resect if Stage I/II, chemo/rads if Stage III
|
|
how to stage lung cancer? Management of each stage?
|
STAGE I: solitary lung cancer (resection); STAGE II: lung cancer + LN in lung (resection); STAGE III: lung cancer + LN in mediastinum or elsewhere (can't resect, need to do chemo/rads)
|
|
two big categories of lung cancer; what are the differences in management?
|
1) SCLC -- usu presents with mets, so can't resect ==> chemo; 2) NSCLC -- often resectable +/- chemorads; usu adeno vs squamous cell (scc a/w pthrp)
|
|
how does surgical management of NSCLC differ if it invovles an airway?
|
if NOT involved airway, can do thoracotomy --> lobectomy; if BRONCHUS involved, need thoracotomy --> pneumonectomy (remove whole lung), can also consider "sleeve lobectomy" = lobectomy + removal of section of bronchus -- safer but harder
|
|
what are the sx of pancoast's tumor? Whats the management?
|
multiple sx: brachial plexus sx, horner's, pain from chest wall invasion; usu invasive at time of dx --> Tx occurs in two phases: 1) preop radiation for debulking followed by 2) surgical resection
|
|
what is the concern with hemoptysis + atalectasis? What is the management?
|
bronchial obstruction causing infection, decreased lung function; worrisome causes include BRONCHIAL ADENOMA: has malignant potential --> requires lobectomy
|
|
tx of mesothelioma
|
extrapleural pneumonectomy -- bad prognosis despite aggressive tx (<1yr)
|
|
mcc of nonresolving PTX with chest tube
|
techincal error: improper placement or leak at site of entry --> replace tube
|
|
what causes empyema in lung? What bugs? How to tx?
|
pus in pleural cavity -- occurs as a complication of pneumonia, usu from s.pneumo/gnr; tx in 3 steps: 1) Abx, 2) Drainage, 3) Reinflate lung (CT usually sufficient, but may need minithoracotomy/VATS if loculated)
|
|
how does IMA compare to other vessels for CABG?
|
best patency rate (90% at 10 yrs)
|
|
what are the risk of cardiopulmonary bypass?
|
causes a generalized inflammatory response which can lead to hemorrhagic, respiratory, and myocardial complications in postop period
|
|
in what cases does aortic valve stenosis require surgery? How do you determine patient's operative candidacy?
|
if SEVERE and symptomatic (angina, syncope, etc.) -- base operative candidacy on cath results, NOT age
|
|
what is the prognosis for dilaed cardiomyopathy? How do you treat it?
|
1/3 do better, 1/3 do worse, 1/3 stay the same; tx with beta-blockers (decreased demand) and, if necessary, heart transplant
|
|
causes of death following heart transplant (2)
|
1) INFECTION; 2) ATHEROSCLEROSIS (a type of chronic rejection)
|
|
name 2 types of esophageal diverticula. Where are they located? How do they form? How do you tx them?
|
1) ZENKER'S (above cricothyroid m.), 2) EPIPHRENIC (above LES); form 2/2 inappropriate muscle tone --> increased pressure --> force diverticulum out; sx include choking, regurgitation of unswallowed food, bad mouth odor; tx by cutting muscle + excising diverticulum
|
|
tx of achalasia
|
CCB + surgical release of lower esophagus (open or endoscopically)
|
|
how to tx esophageal tumors?
|
depends on location: lower 1/3 --> surgery; mid 1/3 --> surg vs chemo/rads; upper 1/3 --> chemorads
|
|
most common mediastinal tumors
|
thymoma, teratoma, lymphoma, germ cell tumor (in young pts)
|
|
three areas of mediastinum and common masses in each
|
SUPEROANTERIOR (thymoma, lymphoma); MIDDLE (cysts, lymphoma); POSTERIOR (neurogenic tumors, cysts)
|
|
tx of cysts in mediastinum. Why?
|
cysts are benign but may have inflammatory complications including fistula --> NEED TO BE REMOVED
|
|
3 big risk factors for thyroid cancer
|
1) hx of radiation, 2) fam hx of thyroid cancer, 3) voice/airway symptoms
|
|
how to w/u pt with neck mass + h/o radiation?
|
SURGERY --> further eval unnecessary
|
|
what syndrome a/w medullary thyroid cancer?
|
MEN 2 (RET gene mutation) -- pheochromocytoma, parathyroid cancer, thryoid cancer
|
|
w/u of thyroid nodule
|
FNA, U/S (NOT radioactive iodine study -- FNA is quite accurate)
|
|
how to tx thyroid cyst
|
aspiration; if > 4cm or recurrent, inc risk of malignancy --> excision
|
|
which type of thyroid cancer is BAD?
|
anaplastic / undifferentiated --> needs chemo, rads, NOT surgery (usually already too advanced)
|
|
4 types of potential surgical complications a/w thyroidectomy
|
1) U/L RECURRENT LARYNGEAL NERVE injury (hoarseness); 2) B/L RECURRENT LARYNGEAL NERVE injury (vocal cord paralysis); 3) EXTERNAL LARYNGEAL NERVE injury (distorted high pitched singing voice); 4) PARATHRYOID injury (hypoparthyroidism)
|
|
for which thyroid cancers do you use I_131 or TH for thryoid suppression postop?
|
follicular and papillary; doesn't help for medullary since that's parafollicular (c-cell) hyperplasia
|
|
mcc primary hyperparathyroidism? Whats the tx?
|
pituitary adenoma (carcinoma in < 2% cases) --> need to explore neck (+/- preop sestamibi imaging)
|
|
procedure for exploring primary hyperparthyroidism
|
If preop SESTAMIBI, can just take out the adenomatous parathryoid glands ("minimally invasive"); if NO PREOP SESTAMIBI, need to explore all 4 parathryoid glands
|
|
what if only find 3 parathryoid glands?
|
have to find 4th -- often intrathyroid
|
|
what does elev Ca and PTH suggest? How to tx?
|
primary hyperparathyroidism -- if adenoma, explore/resect; if carcinoma, radical resection
|
|
what does dec Ca and elev PTH suggest? How to tx?
|
secondary hyperparathyroidism (eg CRF) -- tx medically unless symptomatic (pain, fractures, ectopic calcifications, intractibile pruritis) --> SURGICAL MANAGEMENT (remove 3.5 PTH glands +/- relocation of remaining 0.5 to arm for easy accessibility)
|
|
what is a dangerous cause of hypercalcemia?
|
metastatic carcinoma to bone (esp breast, prostate)
|
|
what is the vicious cycle of hypercalcemia? How do you break it?
|
hypercalcemia --> osmotic diuresis --> dehydration --> hypercalcemia; break it by first rehydrating aggressively, followed by loop diuretic (calcium wasting), and bisphosphonates
|
|
rule of 10s with pheochromocytoma
|
10% malignant, 10% bilateral, 10% extra-adrenal, 10% epinephrine producing
|
|
tx of pheo
|
immediate tx of crisis is alpha + beta blockade (MUST HAVE BOTH) --> OCTREOTIDE SCAN to localize tumor --> ADRENALECTOMY
|
|
what is de quervain's thyroiditis? How to dx? How do you tx it?
|
acutely enlarged/inflamed thryoid with initial hyperthyroidism; DIAGNOSE by elev ESR, histology showing granulomas and degenerating follicles; TREAT with aspirin and analgesics, NOT SURGERY
|
|
when to operate in acute thryoiditis?
|
if suppurative/bacterial, need surgical drainage
|
|
tx of hashimotos
|
thyroid replacement, biopsy surveillance to ensure no cancer (hashimotos a/w increased risk)
|
|
how to tx gastrinoma (Zollinger Ellison syndrome)
|
can be sporadic or metastatic; if SPORADIC, RESECT; if METASTATIC to liver and LN, consider GASTRIC RESECTION vs HSV to prevent ulcerative complications
|
|
with which syndrome is gastrinoma associated?
|
MEN-1 (MENIN gene mutation); pancreatic, parathryoid, pituitary cancers
|
|
what classic triad with insulinoma?
|
WHIPPLE triad: 1) fasting hypoglycemia; 2) symptomatic hypoglycemia; 3) relief with glucose administration
|
|
tx of insulinoma
|
if sporadic, RESECT; if not, can use diazoxide (inhibitor of insulin release)
|
|
management of incidentally discovered adrenal mass
|
depends on size; if < 5cm, check labs for indication of malignancy (VMA, potassium, cortisol), then remove vs observe depending on outcome; if > 5cm, high risk of cancer --> wide resection + look for mets
|
|
defn of a TIA; how do you manage it?
|
transient neuro findings < 24 hrs usu 2/2 embolus from carotid bifurcation; MGMT: need to do duplex u/s of carotids, followed by CEA if > 70% stenosis; may need ECHO if heart murmur
|
|
when is CEA indicated?
|
if >70% stenosis in symptomatic patient; in asymptomatic patient, less well defined -- definitely CEA if > 80% stenosis, maybe if > 60%
|
|
what precautations needed to prevent stroke during CEA procedure?
|
intraop EEG monitoring, BP control
|
|
what possible complications with CEA? (3)
|
1) hypoglossal nerve injury; 2) mandibular branch of facial nerve injury; 3) vagus nerve injury
|
|
tx of amaurosis fugax
|
same as CEA: carotid duplex --> CEA if >70% stenosis
|
|
what to do if amaurosis fugax or TIA with PERSISTENT neuro findings (ie STROKE)?
|
OBSERVE for 2-4wks, then CEA when stable
|
|
what are the 6ps of acute arterial occlusion
|
Pain, Pallor, Pulselessness, Poikilothermia, Paralysis, Paresthesias (these last two happen first -- nerves most sensitive to anoxia)
|
|
how does acute arterial occlusion happen? How do you tx it?
|
embolus from heart (70%) or artery/aneurysm (30%); tx is REVASCULARIZATION in < 6hrs or else amputation; start with HEPARIN IMMEDIATELY --> OR for balloon catheter embolectomy
|
|
what is a dangerous finding postop with balloon catheter embolectomy for acute arterial occlusion?
|
COMPARTMENT SYNDROME resulting from ischemia-reperfusion injury --> edema
|
|
what are the three classifications of acute arterial occlusion? How do you know if the limb is not salvagable?
|
VIABLE, THREATENED, and IRREVERSIBLE (no dopplerable venous pulses, paralyzed, insensate)
|
|
what is the most common site of acute arterial occlusion?
|
LE, specifically common femoral artery
|
|
how do you workup intermittent claudication?
|
look for ulcers, skin changes, neuro deficits; TESTS include ABI (determines severity) and DOPPLER waveforms (normally triphasic)
|
|
most common site and findings with intermittent claudication
|
superifical femoral artery at the adductor hiatus --> loss of popliteal and pedal pulses
|
|
when to do angiogram in claudication?
|
ONLY as a PREOPERATIVE test (ie if you don't plan to operate, don't do an angiogram)
|
|
what is a normal ABI
|
>1
|
|
how to tx pt with intermittent claudication
|
operate only if grossly disturbing patient's lifestyle -- if with activity and mildly aggravating, treatment is EXERCISE + lifestyle modification
|
|
what does claudication + absent femoral pulse suggests? How does that change management?
|
suggests AORTOILIAC disease -- more progressive than distal disease, so SURGERY should be considered if sx progress
|
|
what are the tx options for aortoiliac dz? When do you pursue each? (2)
|
1) BYPASS: if multiple or long segments of disease; 2) PTA (angioplasty): if single, short segment
|
|
how to w/u pt with PVD and ULCER? When to tx? What options?
|
key is adequacy of blood supply -- if SBP > 65 (or 90 in DM), supply should be adequate for healing; if NOT, tx surgically: ANGIOGRAM to define anatomy (remember this is preop test) --> graft vs angioplasty/stent
|
|
what longterm tx do most pts with PVD receive?
|
ASA
|
|
what is a "trash foot" (complication of PVD repair)? How is it managed?
|
ischemic digit 2/2 atheroembolization --> blue, painful toe; TREATMENT is heparin and long-term anti-platelet therapy
|
|
what major risk associated with surgery in pt with vascular disease? How to workup preop?
|
CARDIAC DISEASE often a/w vascular dz (MI risk during op) --> need CARDIAC W/U: stresstest/thallium --> angiogram if positive with CABG/PTCA if dz; if testing negative, do operation with intraop monitoring if pt has other risk factors (sick, old)
|
|
mgmt of AAA
|
elective repair if > 5cm; observe if <5cm
|
|
what to watch for in postop period with AAA repair?
|
FLUID SHIFTS -- massive intraop thirdspacing, usually reversed by around day 3 --> massive fluid overload if not expected
|
|
three big complications associated with AAA repair
|
1) ISCHEMIC BOWEL -- presents with diarrhea +/- blood in first 3d, 2/2 sigmoid ischemia from IMA occlusion; 2) VASCULAR GRAFT INFECTION -- from graft seeding with skin flora, but may not present for months-years; 3) AORTOENTERIC FISTULA -- grossly bloody stool, usu from fistula between aorta and duodenum
|
|
threatment of three big complications of AAA repair
|
1) ISCHEMIC BOWEL -- need SIGMOIDOSCOPY to determine depth of ischemia; if SUPERFICIAL tx with bowel rest; if FULL THICKNESS, resect + colostomy; 2) VASCULAR GRAFT REPAIR -- remove graft, debride tissue, extra-anatomic bypass, long-term abx; 3) AORTOENTERIC FISTULA -- 3 steps: REMOVE graft, REPAIR GI, extra-anatomic aortic GRAFT
|
|
presentation, w/u and tx of chronic mesenteric ischemia
|
PRESENTS with post-prandial pain and resultant weight loss; WORKUP with angiogram (b/c of intent to operate); TREAT with surgical bypass (aorta --> vessel)
|
|
types of aortic dissection and management (3)
|
TYPE I: ascending only (OPERATE) TYPE II: ascending + descending (OPERATE) TYPE III: descending only (MED MGMT); control hypertension with all types
|
|
tx for DVT? How long?
|
anticoagulation (heparin --> warfarin) x 3-6m
|
|
what is low dose heparin (LDH) therapy?
|
prophlyactic heparin for high risk pts -- 5000U subq heparin q8-12hrs postop
|
|
ABG Findings in PE
|
dec PCO2 due to hyperventilation
|
|
what is the tx of PE?
|
SAME AS DVT (anticoagulation x 3-6m)
|
|
what is phlegmasia cerulea dolens? How to tx?
|
acute obstruction of venous outflow --> DANGEROUS (can cause sensorymotor loss and eventually gangrene) ==> URGENT TX (ANTICOAGULATION, LEG ELEVATION); VENOUS THROMBECTOMY RARELY INDICATED
|
|
indications for excision of skin lesion (4)
|
ABCD, ulceration, recent changes, nodularity
|
|
tx of basal cell vs squamous cell carcinoma
|
basal cell rarely metastatic -- just need to do local excision to clear margins; squamous cell slightly more metastatic (to LN) ==> need to do local excision + LN resection if palpable LN on exam
|
|
how to assess malignant potential of melanoma? Whats the management?
|
dangerous, malig potential depends on depth; TREATMENT: local resection with margins = f(depth). Lymphadenopathy = metastatic dz --> use IMMUNOTHERAPY (interferon)
|
|
tx of dysplastic nevus
|
excision if atypia on histo
|
|
what observable factors worsen prognosis of malignant melanoma?
|
ulceration, face/skin involvement
|
|
implications of lymphadenopathy for malignant melanoma
|
suggests metastatic dz --> use immunotherapy (interferon)
|
|
how to w/u a soft tissue sarcoma?
|
MRI, biopsy
|
|
causes of painful testicle (3)
|
ACUTE: torsion; SUBACUTE: orchitis, epididymitis
|
|
when to surgically treat hernia
|
if incarcerated/strangulated (URGENT); if not, essentially elective -- tx if giving patient problems
|
|
what repair in kids with inguinal hernia?
|
in kids, 2/2 patent processus vaginalis --> likely bilateral --> bilateral high ligation of the sac
|
|
what cancers predisposed by BRCA1 mutation? (2)
|
breast and ovarian
|
|
screening recommendations for breast cancer (based on level of risk)
|
NORMAL RISK: q1y mammo with clinical exm starting at age 40; HIGH-RISK: q1y mammo with q6m exam starting at age 30
|
|
what study should follow finding of microcalcifications on mammogram?
|
MAGNIFICATION mammogram --> stereotactic vs open biopsy depending on low vs high suspicion (open biopsy allows excision)
|
|
tx for DCIS
|
if unifocal, lumpectomy; if multifocal, simple mastectomy
|
|
when to combine radiation therapy with mastectomy?
|
NEVER -- no need for radiation if breast has been resected
|
|
implications and tx of LCIS
|
LCIS is an incidental finding on breast bx that is an INDICATOR, not PRECURSOR of malignanch --> no role for resection, only for close surveillance (q6m exam/mammo)
|
|
w/u of simple cyst in breast
|
aspiration --> if resolves, NTD; if bloody or persistent, need cytology --> excision
|
|
characteristics and w/u of fibrocystic dz
|
often multiple, bilateral, fluctuates with menstrual cycle; TREATMENT: cyst aspiration --> 3mo f/u --> bx/excision if persistent
|
|
characteristics and tx of fibroadenoma
|
most common lesion in young females (<25y); benign; TREATMENT: multiple, including excision, biopsy, or observation (if small)
|
|
characteristics and tx of phyloodes tumor
|
LARGE, BULKY mass --> excision
|
|
mgmt of bloody nipple discharge
|
suggests intraductal papilloma -- need surgical bx +/- excision
|
|
mgmt of clear, non-milky nipple discharge from multiple ducts
|
likely fibrocystic disease --> observation
|
|
how does age affect breast cancer prognosis?
|
younger women do worse
|
|
what types of skin changes can be seen with breast cancer? (3)
|
ALL ARE BAD -- ULCERS: suggest inflammatory carcinoma; PEAU D'ORANGE/EDEMA: suggests lymphatic involvement; SKIN/NIPPLE RETRACTION: suggests invasion of support structures;
|
|
what does eczematoid lesion of nipple suggest? Whats the management?
|
Paget's disease of the nipple, almost always a/w underlying malignancy --> mammo/PE --> mastectomy+staging if mass, biopsy nipple if not
|
|
when to do lumpectomy/simple mastectomy VS modified radical mastectomy?
|
depends on size of solitary tumor: if <5cm, can do lump/simplemast; if >5cm, need to do modified radical mastectomy
|
|
how to tx metastatic breast cancer?
|
Stages III and IV --> palliative chemo/rads/surg + hormonal tx
|
|
how does menopause change adjuvant treatment for breast cancer?
|
premenopausal: chemo; postmenopausal: hormonal
|
|
how to deal with local recurrence following breast surgery?
|
if 1st surgery was mastectomy, do local excision; if first surgery was lumpectomy, do mastectomy
|
|
what do you suspect in pt with h/o breast cancer who presents with coma?
|
hypercalcemia
|
|
tx for mastitis
|
warm compresses, antibiotics (for staph and strep)
|
|
tx of breast abscess
|
surgical drainage (I&D), NOT needle drainage
|