[01.04] CMD - Approach to the Surgical Patient V2.pdf

28 to 32 percent

What percentage of the global burden of disease is attributed to surgical conditions?

2 billion

How many people globally lack access to surgical care?

1.5 million

How many preventable deaths occur per year in LMICs due to lack of essential surgical care?

52.85 percent

What percentage of the Philippine population lives in rural areas?

Universal Health Care Act or RA 11223

Which 2019 legislation aims to ensure access to quality and affordable health care services for all Filipinos?

Primary care physician

Which type of physician can handle minor surgical conditions like skin cysts or small abscesses?

Elective urgent or emergent

What are the three categories of surgical cases based on timing?

Thyroid conditions

What is a common surgical case involving a gland in the neck?

Appendicitis cholelithiasis and hernia

What are three common surgical causes of abdominal pain?

Breast masses

What is a common surgical presentation in female patients?

Hemorrhoids and anorectal disorders

What is a common category of surgical presentations involving the lower GI tract?

Testicular torsion

What is a surgical emergency involving the male reproductive system?

Bowel obstruction

What is a surgical emergency characterized by the blockage of the intestines?

Comprehensive

What type of history should ideally be taken for a new surgical patient?

Focused

What type of history is necessary when treating an emergent surgical case?

Anatomy and logic

On what should a short list of differential diagnoses be based?

Selective

How should laboratory and imaging tests be requested according to the structured approach?

Red flags

What must a clinician identify that may show serious underlying pathology?

Stabilize

What must a clinician do before referring or managing a patient in distress?

OPQRST

What mnemonic is used to characterize symptoms like pain during history taking?

Past Medical History

Where are chronic conditions like diabetes and hypertension recorded?

Surgical History

Which section of the history includes dates types of previous operations and complications?

Medication agents to be avoided

What can surgical history help determine regarding the current procedure?

Current medications

What must include prescription over the counter and herbal remedies?

Social history

Where are smoking alcohol consumption and occupation recorded?

Social support system

What factor in the history determines if a patient has help at home after surgery?

Family history

Where are genetic conditions or anesthesia-related risks recorded?

Review of Systems

Which section helps identify problems the patient may have failed to volunteer?

Systems Approach

What is the individualized evaluation of a surgical patient to guide risk reduction strategies?

Surgical complications

What is the number one cause of mortality for patients?

Postoperative cardiac complications

What is the second highest cause of mortality for patients?

Risk stratify

What is the primary goal of the cardiovascular preoperative evaluation?

Optimization

What is the process of improving a patient's health with medications before an elective surgery?

MACE

What acronym represents major adverse cardiac events like MI or cardiac arrest?

METs or Metabolic Equivalents

What unit is used to assess a patient's functional capacity?

Duke Activity Status Index

Which 12-item questionnaire is used to assist with measuring peak METs?

Revised Cardiac Risk Index

What tool uses predictors like heart failure or high-risk surgery to estimate cardiac death risk?

0.4 percent

What is the cardiac risk for a patient with zero predictors on the RCRI?

ACS NSQIP

Which surgical risk calculator uses 21 patient predictors to estimate outcomes?

ACC AHA Guidelines

Which guidelines provide a stepwise approach to perioperative cardiac assessment?

Pneumonia and atelectasis

What are two common postoperative pulmonary complications?

Chronic Obstructive Pulmonary Disease

Which condition increases postoperative pulmonary risk approximately 2-fold?

Pack years

What metric is used to correlate smoking history with pulmonary complications?

4 to 8 weeks

How long before elective surgery should a patient be advised to cease smoking?

Obese

Which type of patient is particularly prone to atelectasis?

Obstructive sleep apnea

Which condition associated with obesity confers an increased risk for hypercapnia?

Proximity to the diaphragm

What procedure-related factor increases the chance of pulmonary complications?

50 percent

By how much do intrathoracic procedures decrease pulmonary function?

General anesthesia

Which type of anesthesia has an increased pulmonary risk compared to epidural?

ARISCAT

Which risk index is used to predict post-operative pulmonary complications?

FEV1

Which pulmonary function test parameter is helpful in assessing risk for lung resection surgery?

30 percent

High risk for lung complications is associated with an FEV1 less than what percentage of predicted?

Chest physiotherapy

What preoperative strategy helps patients prepare for thoracic procedures?

Lung expansion maneuvers

What strategy is specifically used to reduce the chance of atelectasis?

Chronic kidney disease

What condition is a significant risk factor for postoperative cardiovascular events and deaths?

Creatinine 2.0 or higher

What specific baseline creatinine level is an independent risk factor for cardiac complications?

Fluid overload

What specific sign should be looked for in a patient with renal insufficiency?

Erythropoietin

Anemia in renal patients is often due to a decreased production of what?

Qualitative

What type of platelet dysfunction is seen in uremic patients even with normal counts?

Serum chemistry panel

Which laboratory test is essential to assess electrolytes in renal patients?

Acute hepatitis

In which condition should elective surgery be postponed until labs have normalized?

Greater than 3 mg per dL

At what serum bilirubin level do jaundice and icterus become evident?

Spider angiomas and palmar erythema

What are two skin signs indicative of liver dysfunction?

Muscle wasting

What can be prominent on the physical exam of a patient with advanced liver disease?

Hepatocellular enzymes

Elevations in which enzymes suggest acute or chronic hepatitis?

AST to ALT ratio greater than 2

What specific enzyme ratio suggests alcoholic hepatitis?

Child Turcotte Pugh

Which scoring system for cirrhosis uses parameters like albumin and ascites?

10 percent

What is the mortality rate for Child Class A cirrhosis during abdominal operations?

31 percent

What is the mortality rate for Child Class B cirrhosis during abdominal operations?

76 percent

What is the mortality rate for Child Class C cirrhosis during abdominal operations?

Model for End Stage Liver Disease or MELD

Which scoring system has a highly predictive outcome for liver disease severity?

MELD greater than 15

At what MELD score is elective surgery usually contraindicated?

Stressful

How is surgery characterized in terms of its effect on the body?

Cardiac complications and wound infections

What are the two major surgical risks for diabetic patients?

Silent myocardial ischemia

What cardiac risk is associated with DM due to autonomic dysfunction?

140 to 180 mg per dL

What is the target glucose range that should be maintained preoperatively?

Fasting postprandial glucose and HbA1c

What are three glucose-related screening tests done preoperatively?

TSH

Which specific parameter is the primary evaluation for thyroid function in surgical patients?

Thyroid storm

What is a potentially fatal postoperative risk for an untreated hyperthyroid patient?

Myocardial dysfunction and coagulation problems

Severe hypothyroidism is associated with which two risks?

HPA axis

What system stimulates the release of ACTH during surgical stress?

Suppression

What happens to the HPA axis in patients taking exogenous corticosteroids?

ACTH Stimulation Test

What test determines if the adrenal glands can respond to surgical stress?

Greater than 18 to 20 micrograms per dL

What cortisol level after stimulation indicates a normal HPA response?

Supplementation

What is needed for patients with confirmed HPA axis suppression?

Optimize the immune system

How do you minimize the risk of infection and wound breakdowns?

Anemia coagulopathy or hypercoagulable state

What three hematologic conditions must be identified preoperatively?

Oxygen

Anemia is important to address because the body needs what for wound healing?

Hgb 10

Blood transfusion is generally not indicated in stable patients if hemoglobin is above what value?

Window period

Why is blood transfusion not 100 percent guaranteed to be free of infections like AIDS or Hepatitis?

Autologous

What type of transfusion involves patients donating their own blood for elective procedures?

3 seconds

Prothrombin Time should be within how many seconds of the control?

10 seconds

PTT should be within how many seconds of the control?

INR 1.5 or less

What is the coagulation goal after stopping Vitamin K antagonists?

50,000

What is the minimum required platelet count for most surgeries?

Extrinsic

Which pathway is assessed by the PT?

Intrinsic

Which pathway is assessed by the aPTT?

Aspirin

Which medication reduces platelet clotting and increases perioperative bleeding risk?

7 to 10 days

How many days before surgery should aspirin be stopped?

Warfarin

What is a common Vitamin K antagonist that affects blood clotting?