Surgery Rosh Boost Exam

A 55-year-old woman presents to clinic for a routine appointment six months after having a Roux-en-Y gastric bypass as part of management of obesity. What long-term treatment is routinely indicated?

micronurient supplementation:

Vit B1, B12, folate, vit c (water soluble)

A, D, E, K (fat soluble)

calcium, copper, iron, selenium, zinc (minerals)

most important initial intervention for severely burned patients?

Fluid resuscitation with Ringer's lactate solution is the most important initial intervention for severely burned patients after removal of the source of the burn and ensuring adequate airway and breathing.

What Gram-negative bacteria most commonly cause burn wound infection?

Pseudomonas aeruginosa.

Consider escharotomy for which type of burns? Indicated when?

circumferential and full-thickness burns

indicated for eschar restricting airway, ventilation, or causing ischemia

Management for bullae due to a burn

Bullae should never be aspirated, and are instead left in place until they rupture and then may be debrided.

criteria for burn center transfer includes?

any full thickness burn

burns affecting the face, genitalia, perineum, hands, feet, or any major joint

most important risk factor for aortic dissection? aneurysm?

HTN

smoking

best therapy for ascending aortic dissection?

emergent open surgical repair

Ascending aortic dissection is a surgical emergency due to high risk for life-threatening complications like aortic regurgitation, cardiac tamponade, stroke, frank rupture, and myocardial infarction.

Descending aortic dissection can usually be managed medically with blood pressure control and imaging surveillance or sometimes endovascular repair

most common cause of esophageal varices

varices

pathophys of esophageal varices and why this is serious?

Cirrhosis is MCC of esophageal varices. Cirrhosis is an intrahepatic disease process, causing an increase in portal venous resistance and subsequent collateralization of venous blood.

Collateralization through the coronary and short gastric veins to the azygos vein is most important clinically because it leads to the formation of esophagogastric varices.

When esophageal or gastric varices bleed, they do so by rupturing from the increased pressure, often resulting in life-threatening hematemesis

If variceal bleeding is refractory to pharmacologic management, banding, and sclerotherapy, which procedure should be performed next?

Transjugular intrahepatic portosystemic shunt (TIPS)

ppx meds for long term management esophageal varices

nonselective beta-blockers (nadolol, propranolol)

eval solitary thyroid nodule algorithm

check tsh

1. If low --> thyroid scintigraphy/ RAIU

2. If normal or high --> thyroid ultrasound

If thyroid ultrasound is benign --> serial f/u

If thyroid ultrasound looks malignant, do FNA

If FNA is benign, serial f/u

If FNA is intermediate, repeat FNA

If FNA is malignant, do surgery

best intervention for suspected acute cholangitis

ERCP

evaluation and management acute (ascending cholangitis)

EVALUATION

Diagnosis of acute cholangitis should be suspected if a patient has fever, shaking chills, or laboratory evidence of an inflammatory response, in addition to abdominal pain, jaundice, or abnormal liver chemistries.

Definitive diagnosis can be made when a patient meets the previous criteria and also has biliary dilation or evidence of an etiology (e.g., stricture, stone, stent) on transabdominal ultrasonography (US).

Blood cultures and cultures from bile or stents should be obtained on all patients to help guide antibiotic therapy. Endoscopic retrograde cholangiopancreatography (ERCP) confirms the diagnosis of acute cholangitis and enables biliary drainage, which can be a life-saving intervention.

MANAGEMENT

Patients suspected of having acute cholangitis should be admitted to the hospital to monitor and treat sepsis, provide empiric and then tailored antibiotic therapy, and establish biliary drainage.

Since patients who develop acute cholangitis due to gallstones or benign stenosis are at high risk for recurrence, cholecystectomy and surgical repair, respectively, are generally recommended.

The most common causes of obstruction are biliary calculi, benign stenosis, and malignancy. Cholangitis is also a common complication of stent placement for malignant biliary obstruction. The infection usually ascends from the ____________.

Duodenum

best test to confirm dx and facilitate timely treatment of acute arterial embolism that is not immediately life threatening

CTA of the pelvis with runoff

Doppler ultrasound (C) is helpful in the initial evaluation to confirm blood flow but is not able to provide detailed information on the location of occlusion or collateral vessel patency and is highly operator-dependent.

Late findings of acute arterial embolism?

paralysis (loss motor function), gangrene, and loss of sensation

poikilothermia also later sx

The primary risk associated with CTA is what?

contrast nephropathy.

gold standard of diagnosing arterial occlusion?

Digital subtraction angiography is the gold standard of diagnosing arterial occlusion and has the additional benefit of potential treatment at the time of assessment, however, availability often limits the use of this method

complications acute arterial embolism

reperfusion injury

compartment synd

common offending agents for orthostatic hypothension?

doxazosin (alpha adrenergic ANTAgonist)

antiHTN meds

nitrates

antidepressants

A 60-year-old man presents to his primary care provider with the complaint of feeling lightheaded and dizzy when he stands. The patient is currently prescribed hydrocortisone and fludrocortisone for treatment of adrenal insufficiency, doxazosin for treatment of urinary symptoms from enlarged prostate, and erythropoietin for anemia due to renal failure. What is the most appropriate treatment to decrease his orthostatic hypotension symptoms?

a) decrease salt intake

b) d/c doxazosin

c) d/c EPO

d) d/c fludrocortisone

Decreasing salt intake (A), discontinuing erythropoietin (C), and discontinuing fludrocortisone (D) will all have the effect of lowering blood pressure.

Treating orthostatic hypotension includes increasing salt and water intake.

In patients that continue to be symptomatic despite non-pharmacologic measures, fludrocortisone can be used as monotherapy.

Patients with both anemia and orthostatic hypotension should begin a trial of erythropoietin.

What tumors are commonly associated with multiple endocrine neoplasia type 1?

Parathyroid gland, anterior pituitary, and enteropancreatic endocrine cell tumors.

(3Ps: parathyroid, pituitary, pancreas)

A fasting serum vasoactive intestinal peptide level (B) is the proper test to screen for WHAT, which causes watery diarrhea, hypokalemia, and dehydration?

VIPoma

A subarachnoid hemorrhage is most commonly caused by what?

a ruptured saccular aneurysm.

what is xanthochromia?

hgb degradiation products (RBC + CSF --> enzymes --> bilirubin (creates xanthochromia)

assoc with SAH

What medication is given in patients with subarachnoid hemorrhage to prevent vasospasm and subsequent mortality?

Nimodipine (calcium channel blocker).

indications for whole blood transfusion vs RBC transfusion? Difference?

Red blood cell transfusions are given to raise the hemoglobin level in patients with anemia or to replace losses after acute bleeding episodes.

Red blood cell transfusions are available as packed red blood cells or as whole blood.

The major difference is that most or all of the plasma has been removed from the packed red blood cell transfusions resulting in a smaller volume than whole blood.

This is generally preferred over transfusing whole blood to minimize volume overload.

whole blood: may be appropriate when massive bleeding requires a transfusion of more than 5-7 units of RBCs

what is FFP vs cryoprecipitate? indications? indications for platelet transfus?

FFP: all soluble plasma proteins and clotting factors

- bleeding/ expected bleeding in all pts with def. of multiple coag factors

- reversal of an elevated international normalized ratio for patients taking a vitamin K antagonist

- patients with vitamin K deficiency

- for replacement of coagulation factors in patients with deficiencies

- and as a part of massive transfusion protocols.

Cryo: fibrinogen, facors 8 and 9, VWF

Platelet transfus:

- treatment of active bleeding or prophylaxis for bleeding in patients with low platelet counts, platelet function defects, and in patients who are receiving a large number of red blood cell transfusions

most sensitive test for acute cholecystitis/ GS test?

HIDA

gallbladder visualied w/in 1 hr after injection of radioactive tracer on cholescintigraphy scan. Meaning?

gallbladder not visualied w/in 4 hrs after injection of radioactive tracer on cholescintigraphy scan. Meaning?

no disease, this is normal

cholecystitis or cystic duct obstruction

What is the mechanism thought to be responsible for acalculous cholecystitis?

It is thought to be secondary to hypoperfusion of the gallbladder.

displacement of the gastroesophageal junction and herniation of a portion of the gastric fundus into the thoracic cavity. Most likely diagnosis?

paraesophageal hiatus hernia

explain types of hiatal hernias

T1: sliding

- GE junction slides through the diaphragmatic hiatus to an abnormal position int eh chest

T2-4: rolling/ paraesophageal

- 2: GE junction is fixed

- 3: have elements of both type 1 and 2, both the GE junction and the fundus herniates through hiatus. The fundus lies above the GE junction

- 4: presence of other organs other than the stomach in the hernia sac (colon, spleen, pancreas, SI)

What is another name for hypertensive peristalsis?

Nutcracker esophagus

mc late complication gastric bypass

anemia

RF afib

HTN

CAD

rheumatic heart dx

binge drinking

fhx cardiopulmonary/ renal disease

MLDX if bloody bowel movement, mild LLQ tenderness over last 12 hours, hypotensive, tachycardic, and Hx afib and MI

ischemic colitis

most likely imaging to confirm dx of diverticulitis

abd CT with C

abx for diverticulitis

combination of metronidazole and ciprofloxacin

or moxifloxacin monotherapy

A 60-year-old woman presents to the clinic reporting left lower quadrant abdominal pain, constipation, and bloating. She denies nausea, vomiting, fever, or consumption of undercooked foods. On physical exam, there is moderate tenderness to palpation of the left lower quadrant but no rigidity or guarding. Bowel sounds are hypoactive throughout. All vital signs are within normal parameters for age. MLDX?

diverticulitis

what patients may present with right abdominal pain due to diverticulitis?

asian patients

What is recommended for management of patients with symptomatic carotid artery disease and 70-99% occlusion whose perioperative morbidity and mortality risk is less than six percent?

Carotid endarterectomy

**Patients should have a carotid plaque that is surgically accessible, no previous endarterectomy, and no risk factors for a greater increase in morbidity and mortality from surgery

Stenting is used in carotid lesions that are not easily accessible with surgery, patients with a previous endarterectomy, or comorbidities that put patients at increased risk of complications from surgery.

stent if greater than 6% (high risk patients)

GS for carotis artery disease

cerebral angiography

Patients are at a greater risk for possible stroke as a complication of which surgical procedure for carotid artery stenosis?

Carotid artery stenting.

aaa screening

men 65-75 with hx of smoking: 1x abd US

AAA monitoring based on size?

4.0-4.9 cm: US annually

5.0-5.4 cm: US every 6 months, can also use CT or MRI (MRI is preferred over time due to less radiation)

The most common cause of massive hemoptysis is what? What diseases are the most common sources of hemoptysis in resource-rich countries?

bleeding from a bronchial artery (d/t TB, bronchiectiasis, and lung abscess)

bronchitis, bronchiectasis, and bronchogenic carcinoma

best next step in eval of pt with hemoptysis

CXR

pt presents with burning in his rectum. Earlier today, he had severe, sudden pain while having a bowel movement and noted a small amount of bright red blood on the toilet paper while wiping. MLDX?

anal fissure

this typically occurs in extremely old individuals. The condition is typically painless and associated with bloody or mucoid discharge

procidentia --> rectal prolapse

pt presents to the ED with moderate shortness of breath. Decreased right breath sounds. The X-ray results show a pneumothorax on the right side with 10% of the pleural space affected. Vest next step in the management of this patient's condition? explain

supplemental O2

EXPLANATION

The initial management of a spontaneous pneumothorax focuses on removing the air from the pleural space, and the use of supplemental oxygen helps facilitate the reabsorption of air by the pleura.

Young, otherwise healthy patients that are found to have a pneumothorax of small to moderate size on X-ray (generally less than 20% of the pleural space affected) and no prior history of lung disease can be managed using supplemental oxygen and are typically appropriate to return home with adequate follow-up after 6 hours of monitoring in the ED.

Once treated with supplemental oxygen, most symptoms typically resolve within 24 hours.

OTHER TREATMENTS

chest tube placement and needle decompression are used for patients with significant symptoms or cases of larger pneumothorax that generally occupy more than 20% of the pleural space

Once needle decompression is completed, a follow-up X-ray after 6 hours should be ordered to look for resolution. If the pneumothorax still exists, then a chest tube can be placed for 1 to 2 days.

SUMMARY

< small ≤ 2-3 cm in a healthy patient: observation with oxygen administration

> large > 2-3 cm: needle aspiration or chest tube thoracostomy

What sclerosing agent can be considered to help prevent recurrence of a pneumothorax (i.e., pleurodesis)?

talc

severe abdominal pain disproportionalt to clinincal findings. MLDX and diagnostic studies?

hematochezia, diarrhea, lower abdominal pain. MLDX and diagnostic studies?

postprandial pain, fear of eating, wt. loss. MLDX and diagnostic studies?

acute mesenteric ischemia --> ct angio

Ischemic colitis --> colonoscopy

chronic mesenteric ischemia --> angiography

bleeding with defecation and anal pruritus, prolapse, and pain

hemorrhoid

pain is d/t thrombosisA 22-year-old woman on her first postoperative night in the hospital complains of constant chest tightness and shortness of breath for the past hour. She has well-controlled asthma and is a lifelong nonsmoker. Vitals include a temperature of 98.8°F, heart rate 64 beats per minute, blood pressure 116/78 mm Hg, and oxygen saturation 99%. Physical exam reveals bilateral expiratory wheezing. Bedside chest radiograph and chest computed tomography are unremarkable. Best therapy for the most likely diagnosis?

albuterol for bronchospasm

Patients may present with dyspnea, wheezing, chest tightness, tachypnea, or hypercapnia. Bronchospasm may be caused by exacerbation of a chronic lung condition (COPD, asthma), aspiration, histamine release due to medications, or due to trachea stimulation from secretions, suctioning, or endotracheal intubation.

Hypovolemic shock results from low intravascular volume within the body. This can be further classified as hemorrhagic shock related to blood loss, or nonhemorrhagic shock related to fluid loss. Management for each?

In nonhemorrhagic shock, treatment is replacement of volume with intravenous fluids, typically in the form of crystalloid solutions.

Treatment of hemorrhagic shock is with blood products.

PCWP (preload), SVR (afterload), and CO with hypovolemic shock? Cardiogenic? Obstructive? Distributive

Hypovolemic: all low

Cardiogenic: CO is low, PCWP high, SVR high

Obstructive: CO is low, PCWP high, SVR high

Distributive: SVR low

melanoma that is less than 1 mm in thickness on biopsy, next step? greater than 1mm?

A wide excision with a 1 cm wide margin of normal tissue

- The 1 cm wide margin should be measured in the short axis of the elliptical incision.

- The excised tissue should extend down to the deep fascia

A wide excision with a 2 cm margin of normal tissue (D) is used for tumors greater than 1 mm in thickness.

What basic metabolic panel abnormality is associated with upper GI bleeding?

Elevated BUN/Cr ratio

Uncomplicated appendicitis, referring to a stable patient with no evidence of perforation or abscess, may be managed nonoperatively with antibiotics alone for 7-10 days or with surgical intervention. Antibiotic options?

If there is evidence of perforation, abscess, appendicolith, diffuse peritonitis, pregnancy or immunocompromised state, or hemodynamic instability, the patient should undergo surgical intervention with an appendectomy with administration of prophylactic antibiotics to prevent intra-abdominal and wound infections. PPX abx options?

In patients with a penicillin or cephalosporin allergy, the recommended antibiotic regimen is?

piperacillin-tazobactam alone

or a combination of metronidazole with cefazolin, cefuroxime, ceftriaxone, ciprofloxacin, or levofloxacin.

A single dose of cefotetan 2 g, cefoxitin, or cefazolin IV is recommended for preoperative administration.

clindamycin plus ciprofloxacin, levofloxacin, gentamicin, or aztreonam.

RF for small bowel CA?

hereditary cancer syndromes and adenocarcinoma (Lynch, Peutz-Jeghers, FAP, IBD)

chronic inflammation (Crohns)

Dietary factors (alc, refined sugar, red meat, salt-cured and smoked foods)

neuroendocrine tumors

NOT SMOKING, OBESITY, HX IBS

Where are small bowel carcinoid tumors most commonly found?

ileum

Antiemetics that can be used to relieve post-op N/V

transdermal scopolamine, dexamethasone, ondansetron, prochlorperazine, and droperidol

Risk factors for postoperative nausea and vomiting?

- existing nausea and vomiting prior to surgery,

- female gender,

- history of previous postoperative nausea and vomiting or motion sickness,

- non-smoking status,

- increasing age,

- history of chemotherapy-induced nausea and vomiting,

- general anesthesia,

- longer duration of anesthesia, and

- opioid administration.

Clostridioides difficile infection causes frequent diarrhea with significant bicarbonate loss leading to metabolic _______

acidosis

Pheochromocytomas are catecholamine-secreting tumors that arise from _________ cells of the adrenal medulla.

chromaffin

tx pheo

Treatment with an alpha-adrenergic blocker, such as phenoxybenzamine, is started first to control blood pressure and expand the contracted blood volume.

- This is continued for 10-14 days preoperatively.

After adequate alpha-adrenergic blockade is achieved, beta-adrenergic blockade is initiated, usually with propranolol.

Laparoscopic adrenalectomy is the procedure of choice

SE phenoxybenzamine

orthostasis, nasal stuffiness, marked fatigue, and in men it can cause retrograde ejaculation.

medical tx for acute hypertensive crisis d/t pheo?

phentolamine

Na nitroprusside

nicardipine

Which of the following is the gold standard for diagnosing renal artery stenosis?

renal arteriography

In younger patients, renal artery stenosis is often due to _________, while in older adults it is due to ___________. Location of each.

fibromuscular dysplasia

atherosclerosis

Atherosclerosis usually involves the ostial or proximal segment of the arteries, whereas fibromuscular dysplasia involves the middle or distal segment and has characteristic angiographic findings.

A systolic-diastolic or continuous periumbilical bruit that lateralizes to one side could be a sx of what?

renal artery stenosis

A 65-year-old man with a history of benign prostatic hyperplasia presents to the urologist for removal of a Foley catheter. The catheter was placed to decompress the bladder due to acute urinary retention. What type of medication could be prescribed prior to catheter removal that would relax the smooth muscle of the bladder neck and prostatic capsule and thereby relieve the obstruction and prevent early recurrence of retention?

alpha-1-adrenergic ANTAgonsits

- alfuzosin

- tamsulosin

- doxazosin

- terazosin

Alpha-1 adrenergic antagonists have been proven to decrease the incidence of early recurrence. They have also been shown to postpone the need for surgery in many patients

5-alpha reductaase inhibitors examples and indications?

finasteride

dutasteride

helpful in the prevention of long term risk of acute urinary retention, but must be used for a year to be beneficial so they are not used to prevent early recurrence of retention.

phosphodiesterase-5 inhibitor ex and indication

tadalafil

ED

ex of anticholinergic used to tx BPH

oxybutynin

TURP is what and done when?

transurethral resection of prostate

refractory BPH (fails 2 voiding trials)

What type of hernia has only a portion of intestinal wall involved?

Richter hernias involve only the antimesenteric wall of the intestine.

Symptoms of strangulated hernias?

tenderness, pain, abdominal distension, nausea, vomiting, erythema over the hernia site, fever, and peritonitis.

tx femoral hernia? Why?

all femoral hernias should be surgically treated, as they have a high risk of incarceration and strangulation.

management perirectal abscess

Perirectal abscesses require prompt drainage.

Simple perianal abscesses can be drained in the ED; however, all other perirectal abscesses require drainage in the operating room.

Antibiotics are indicated in patients with associated cellulitis, signs of systemic infection, diabetes, valvular heart disease, or immunosuppression.

dull, aching rectal pain for 2 days that is constant, unrelated to BM, no fever, no other sx. Perianal erythema and flucturance that doesn't extend into anus. MLDX?

perirectal abscess

perianal are located just outside the anal verge

What medication should be started to help achieve hemostasis in patient who is likely still bleeding d/t esophageal varices?

octreotide

Octreotide is the preferred agent in the United States; terlipressin is not available in the United States but has shown mortality benefit. These medications work by decreasing portal blood flow. As a group, they have been shown to reduce mortality and improve hemostasis specifically in patients with variceal bleeding. At this time, a bolus dose of octreotide following by a continuous infusion should be started.

What is the most common cause of a transudative pleural effusion? exudative?

congestive heart failure

malignancy

patient tried fiber for anal fissure and failed. Next step for patients who continue to have hard stools despite adequate fiber intake?

stool softeners or laxatives

Topical analgesics such as 2% lidocaine jelly and sitz baths are also recommended

Topical vasodilators such as nifedipine or nitroglycerin are often used along with these supportive measures for treatment of anal fissures

is PT or PTT prolonged in VWD?

PTT

PT may be prolonged due to anticoagulant use, vitamin K deficiency, liver disease resulting in low vitamin K production, disseminated intravascular coagulation, the presence of antiphospholipid antibodies which result in prothrombin (factor II) deficiency, or deficiency in one or more of the components of the extrinsic coagulation pathway.

who gets preop CXR?

patients with COPD and increasing respiratory symptoms, decreasing exercise tolerance, or new lung auscultation findings on exam to rule out an active infection and heart failure.

A preoperative CXR may also be helpful in patients with known cardiopulmonary disease and patients over 50 years old prior to high-risk procedures, such as upper abdominal, aortic, esophageal, and thoracic surgery

Atrophic squamous epithelium is the pathologic histologic finding associated with _________ .

The main histologic feature of _________ disease is increased intraepithelial lymphocytes in the duodenum.

Stratified squamous epithelium is the ________ histology of the distal esophagus and metaplastic columnar epithelium is the histology seen with __________

atrophic vaginitis.

celiac

normal

chronically untreated dyspepsia/ barretts

pt presents to the clinic for presurgical consultation for an epidermal inclusion cyst removal. Has hx of hemophilia A for which he is not taking any daily prophylactic therapy. What therapy should be employed prior to his surgery?

Desmopressin (DDAVP)

after initial history and PE for patient who had syncopal episode, what's next step?

ECG

Cause of syncope in the following patients:

Adolescent athlete + syncope:

Young woman + abdominal pain + syncope

Older man + abdominal or flank pain + syncope

Sudden-onset severe HA + syncope

Woman + prodrome of nausea, sweating, warmth + syncope

Malignancy + sudden-onset SOB + syncope

Adolescent athlete + syncope: HOCM (hypertrophic cardiomyopathy)

Young woman + abdominal pain + syncope: ectopic pregnancy

Older man + abdominal or flank pain + syncope: AAA

Sudden-onset severe HA + syncope: SAH

Woman + prodrome of nausea, sweating, warmth + syncope: vasovagal

Malignancy + sudden-onset SOB + syncope: PE

At what age should individuals with Lynch syndrome begin colorectal cancer screening via colonoscopy?

Every one to two years beginning at age 20 to 25 years, or two to five years prior to the earliest age of colorectal cancer diagnosis in the family, whichever comes first.

MC inherited CRC? inheritance pattern?

lynch synd

autosomal dom

eval and management epidural hematoma

CT scan of the head without contrast should be the initial diagnostic study, but MRI can also be used. Lumbar puncture is contraindicated due to the increased risk of brain herniation.

This is a neurosurgical emergency. Craniotomy is performed to evacuate the hematoma and anticoagulation should be reversed in patients taking anticoagulants.

A 20-year-old office worker presents with nine months of gradually worsening pain and swelling at his intergluteal cleft. Physical exam demonstrates a slightly tender mass near his natal cleft accompanied by purulent drainage with a hair protruding near the sinus opening. He is afebrile and there is no evidence of abscess. What intervention is likely to have the best long-term outcome for him?

Surgical excision of all sinus tracts for chronic pilonidal disease

__________ occurs when the skin and subcutaneous tissue at or near the upper region of the natal cleft of the buttocks becomes infected, often in the setting of ongoing inflammation and damage of local hair follicles.

pilonidal disease

What is the appropriate approach to managing patients with asymptomatic pilonidal disease? Tx for symptomatic?

Education on hygiene and monitoring for signs of infection, without pursuing surgical interventions, is generally recommended for patients with asymptomatic pilonidal disease.

Incision and drainage (C) is necessary in the setting of an acute pilonidal abscess, but is not the definitive step in management due to high recurrence rates after incision and drainage treatment alone.

abx if also have cellulitis otherwise not required

High frequency and low amplitude tremor is assoc with what? tx? explain

hyperthyroid

The cause of the tremor is thought to be a heightened beta-adrenergic state which is why this type of tremor typically responds favorably to propranolol