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Flashcards in MTB/meded Deck (60)
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1
Q

Limiting factors prior to surgery: ejection fraction below?
Recent MI defer the surgery for how long?
How to optimize the patient with CHF?

A

EF below 35% at increased risk and non-cardio surgery
Defer surgery for six months and cases of MI
Optimize CHF with Ace-inhibitors, beta blockers and spironolactone to decrease mortality

2
Q

Patient only needs an EKG prior to surgery if?

If cardiac disease, regardless of age, they must have?

A

Only EKG if under 35 and no history of cardiac disease

If cardiac disease, need EKG, stress testing, echo

3
Q

Risk factors

A

Diabetes, hypertension, high cholesterol, male over 45

Don’t forget about age!

4
Q

If a smoker quit? Prior to surgery

A

Quit smoking 6 to 8 weeks prior to surgery

Also, if lung disease or smoking history need PFTs

5
Q
Cullen sign:
Grey Turner sign:
Kehr sign:
Balance sign:
Seatbelt sign:
A

Cullen sign: around umbilicus, Hemorrhagic pancreatitis, ruptured AAA
Grey Turner sign:flank bruising, retroperitoneal hemorrhage
Kehr sign:pain in the left shoulder, splenic rupture
Balance sign:dull percussion on the left and shifting down this on the right, splenic rupture
Seatbelt sign: deceleration injury

6
Q

Tension pneumothorax pushes the trachea away from the involved lung
In contrast, what pulls the trachea toward the involved lung?

A

Atelectasis

7
Q

Blood at the urethral meatus and a high riding prostate, what to do next?

A

Get a KUB followed by an RUG: retrograde urethrogram

8
Q

If suspect mesenteric ischemia (abdominal pain out of proportion to the exam, severe pain after eating, +/- history of cardiovascular disease)
what to do next?

A

Get angiography, consider surgery

9
Q

Ischemic bowel disease versus mesenteric ischemia

A

Ischemic: due to lack of blood flow, progressive, S/S: abdominal pain after eating, bloody diarrhea
Mesenteric: acute occlusion of arteries: SMA, a fib #1 risk factor, pain out of proportion to the PE, elevated lactic acid, ^Wbc’s

10
Q

Ischemic bowel disease versus mesenteric ischemia diagnosis and treatment

A

Ischemic: best initial test is a CT scan, angiography is most accurate; treat with IV NS followed by surgery to remove necrotic bowel
Mesenteric: best initial test is abdominal X-RAY showing air in the bowel wall, most accurate is angiography; treat with emergent laparotomy with resection of necrotic bowel, endovascular therapy is indicated if unable to go to sx

11
Q

Most common site of a Boerhaave tear?

Mallory Weiss?

A

Left posterior lateral aspect of the distal esophagus

Mallory: GE junction

12
Q

Esophageal perforation diagnosis and treatment

A

Esophagram using Gastrografin (Diatrizoate Meglumine, Diatrizoate sodium solution)
do not use barium as it is caustic to the tissues
Treatment: surgical exploration with the Bremen of the mediastinum enclosure of the perforation, mediastinitis is a complication

13
Q

Acute, worsening of abdominal pain that radiates to the right shoulder plus peritoneal signs, think?
Best test?

A

Gastric perforation, radiates to the right shoulder due to acid irritation of the phrenic nerve
Initial test: up right CXR shows free air under the diaphragm, most accurate is CT scan

14
Q

What tests are Contraindicated in diverticulitis and why?

What is the most common complication of diverticulitis?

A

Do not use a barium enema or colonoscopy due to risk of perforation
Abscess formation is the most common complication

15
Q

Diverticulitis treatment

A

First episode maybe treated medically: NPO, NG tube, broad-spectrum antibiotics
if there are complications or it is recurrent will need resection of the affected loop of bowel

16
Q

What med has been shown to alleviate obstruction from stool impaction in patients on chronic opioids?

A

Methylnaltrexone (Relistor)

17
Q

Bowel obstruction diagnosis

A

Best initial test: abdominal XR shows multiple air fluid levels with dilated loops
Most accurate test: CT scan of abdomen shows transition zone
Labs: elevated lactate with marked acidosis, +/- elevated white count

18
Q

Bowel obstruction treatment

A

NPO, NG tube with suction, IV fluids, surgical decompression if complete obstruction or lack of improvement with medical management

19
Q

Injection of what medication has been shown to decrease incontinence episodes by 50%?

A

Dextranomer/hyaluronic acid (Solesta)

20
Q

What is a comminuted fracture?

A

A fracture in which the bone is broken into multiple pieces, most commonly caused by crush injuries

21
Q

Most common site for stress fracture? How to diagnose?

A

Metatarsals

Diagnosed with CT or MRI as x-ray does not show evidence

22
Q

How to diagnose shoulder dislocations?

A

X-rays the best initial test, MRI is the most accurate

23
Q

What injury took out for if anterior shoulder dislocation?

What to look out for if clavicle fracture?

A

Axillary artery or nerve injury

Subclavian artery or brachial plexus injury

24
Q

Trigger finger is caused by? How to treat?

A

Caused by a stenosis of the tendon sheath, treat with steroid injection, It fails surgery to cut the sheath that is restricting the tendon
Do not confuse with Dupuytren contracture, Whole hand cannot extend, surgery

25
Q

ABG shows P02 less than 60, CXR shows infiltrates, UA may show fat droplets, think?

A

Fat embolism, presents with confusion, petechial rash, shortness of breath

26
Q

How to differentiate claudication from pseudo-claudication secondary to spinal stenosis

A

If due to spinal stenosis will be equal bilaterally in the pain is alleviated by leaning forward which opens the spinal canal and alleviates nerve root compression, get a spine MRI
Most common at L1, C2
Treatment: NSAIDs or surgery

27
Q

AAA management

A

If 3 to 4 cm: ultrasound every 2 to 3 years
4-5.4 cm: ultrasound or CT every 6 to 12 months
If more than 5.5 cm: surgical repair

28
Q

Imaging for aortic dissection

A

TEE is the fastest, so best if I unstable
MRA is the best if stable
CTA is another option

29
Q

Aortic dissection treatment

A

If ascending, emergent surgery and BP control
If descending, just BP control
Control BP with beta blockers followed by vasodilators such as sodium nitroprusside, never use vasodilators alone as reflex tachycardia can increase sheering forces

30
Q

Postop fever causes

A

Day 1 to 2: wind, atelectasis or pneumonia
Day 3 to 5: water, UTI
Day 5 to 7: walking, DVT or PE
Day 7: wound, infections and cellulitis
Day 8 to 15: weird, drug fever or deep abscess

31
Q

Treatment for hospital acquired pneumonia

A

Vancomycin and Zosyn

32
Q

Treatment for DVT

A

Heparin for 5 days as a bridge to Coumadin for 3 to 6 months

33
Q

Liver function scores: MELD, Childs-Pugh look at what factors

A

low albumin, prolonged PT/PTT, ^T. bili, ascites, encephalopathy

34
Q

if MI after surgery, how to manage ?

A

PCI, heparin

CANNOT do tPa after sx

35
Q

etiologies of fistulas

A
"FETID"
Foreign body
Epithelialization
Tumor
Irradiation/Inflammation/IBD
Distal obstruction
36
Q

if these ? alarm symptoms with GERD do what ?

A

n/v, anemia, w/l, not improving after 4-6 weeks PPI

get EGD with biopsy

37
Q

how to dx achalasia

tx?

A

see “bird’s beak” on barium swallow, but to diagnose need manometry
next step: EGD with biopsy to r/o pseudo-achalasia, which is cancer
tx: Heller myotomy

38
Q

Pancreatitis dx

A

Lipase (3x upper limit) + s/s
ONLY CT if sure of dx based on s/s but negative Lipase
next day: RUQ u/s and TGs looking for etiology (stones, hyperTG)

39
Q

when else to get CT in pancreatitis
NOW
5-7 wks
few wks out

A

NOW: if SAS, HTN (necrotizing pancreatitis: necrosectomy, carbapenem abx if FNA proven)
5-7 ds: sepsis, ongoing fevers/^WBC (abscess: I/D, ax)
Few wks out: early satiety, w/l, abdominal pain (pseudocyst: if +6wk, +6cm: complicated, need to drain)

40
Q

cholecystitis dx/tx

A

RUQ u/s
HIDA to confirm
tx: NPO, IVF, IV abx
urgent cholecystectomy

41
Q

choledocholithiasis dx/tx

A

RUQ u/s
MRCP
tx: NPO, IVF, IV abx, urgent ERCP then elective cholecystectomy

42
Q

cholangitis dx/tx

A

RUQ u/s

tx: emergent ERCP with NPO, IVF, IV abx “given on the way”, urgent cholecystectomy

43
Q

chole abx

A

cipro + metronidazole
amp/gent + metronidazole
pip/tazo (zosyn) will see on wards but not right
(need G- and anaerobe coverage)

44
Q

CRC: right vs left

A

right BLEEDS

left OBSTRUCTS

45
Q

CRC tx

A

chemo (FOLFOX) + radiation

46
Q

UC management

A

8 years after dx begin colonoscopy q1y, may need prophylactic colectomy

47
Q

hemorrhoid tx

A

start: prepH, sitz bath, CCB, topical lidocaine
BAND internal
RESECT external

48
Q

anal fissure tx

A

start: nitroglycerin, sitz baths

lateral internal sphincterotomy

49
Q

anal cancer tx

A

“Nigro protocol” of chemo/radiation, generally very responsive

50
Q

pilonidal cyst

A

abscessed hair follicle, congenital, hairy

tx: I/D then surgical resection

51
Q

how to tx arterial disease

A

STENT small lesions above the knee

BYPASS any popliteal lesion or if large area artery affects

52
Q

ulcer on medial malleolus, think?

etiologies?

A

venous insufficiency

edematous condition: CHF, cirrhosis, nephrotic syndrome

53
Q

marjolin ulcer tx

A

biopsy, wide resection

54
Q

who gets breast MRI instead of mammogram for screening

A

previous radiation to chest or BRCA+

MRI is the best test

55
Q

what to do if +mammogram

A

core biopsy, NOT FNA

56
Q

if less than 30 yo presents with breast lump

A

1st time just wait
if persists, get U/S; tells between cyst or mass
if cyst: FNA
bloody: cancer, pus: abscess, fluid: cysts

57
Q

if older than 30 yo presents with breast lump

OR it’s a mass OR bloody OR recurred

A

mammogram–>biopsy

58
Q

breast cancer tx

A

local : lumpectomy + axillary LN dissection (if +sentinel LN biopsy) + radiation, surgery
systemic: chemo (doxorubicin, cyclophosphomide, paclitaxel)

59
Q

HER2Neu tx

A

+: trastuzumab (causes CHF but not dose dependent and IS reversible, in contrast to doxu/danurubicin)
-: bevacizumab

60
Q

ER/PR+

A

SERMs if premenopausal

aromatase inhibitors if postmenopausal