Key Things to Remember in Surgery

Cardiac

• In LHF, the cause of dyspnea is primarily due to pulmonary congestion resulting from increased left atrial pressure.

• RHF will have systemic symptoms like peripheral edema and JVD

• CHF = LHF + RHF

• Cor pulmonale = right heart failure secondary to chronic lung disease, leading to increased pressure in the pulmonary arteries and eventual right ventricular hypertrophy.

  • In other words, cor pulmonale is due to pulmonary HTN

  • P2 is loud

  • Endothelin antagonists are treatment

• ASD = fixed, wide splitting

  • PFO —> ASD

  • Do not repair unless there is pulmonary HTN, arrhythmia, or paradoxical embolus

• VSD: pan-systolic murmur with diastolic rumble

  • Repair = more LV pressure, less LA and RV

  • No cyanosis at birth; cyanosis at 1 year if not repaired

• The common cause of mitral regurgitation is post-MI papillary muscle rupture

  • MR seen first with rheumatic heart disease

  • If only MR, do not do stress test

    • If MR with heart failure or ischemia, do stress test

  • Punt to surgery if severe pulmonary symptoms

• “Opening snap” is not everything; just because you don’t see it/hear it doesn’t mean there isn’t mitral stenosis

  • Balloon valvuloplasty for mild MS; valve replacement for severe

• Bicuspid valve causes aortic stenosis

  • Punt to surgery if cross section area is <1.0

• Tricuspid regurgitation increases with inspiration

  • Common cause is pulmonary HTN

• If an infant is born with normal APGAR but develops cyanosis a month later, it’s because of closure of PDA

• Systolic murmur during times of infection/anemia/pregnancy = functional flow murmur; reassurance and observation

• Punt to surgery for AAA if size is 5.5+

  • Do not punt to surgery if terminal disease or comorbidities in an advanced state

  • Pharmacologic stress test to assess perioperative MI risk

• Pulmonary AV fistula is in HHT

• An elderly patient with history of TIA, normal BP and EKG gets 24 hour ambulatory EKG monitoring

  • If AFib is picked up, next best step is echo

• V-Tach looks like mountains on EKG; SVT looks like needles

• Unstable angina, NSTEMI and STEMI all get coronary catheterization

• Do NOT use nitrates in right MI

• Quinidine and ibulitide —> TdP

  • Mg = cure

• With infective endocarditis, blood cultures before antibiotics

• There are only 4 conditions which require endocarditis prophylaxis

  • Hx of endocarditis

  • Any prosthetic material

  • Incomplete repair of cyanotic heart disease

  • Hx of heart transplant

    • If any of these 4 are NOT present, no prophylaxis is needed

• Exercise stress test for stable angina

• Exercise echo for HF with exertion

• Pharmacologic stress test only if the patient cannot exercise for some reason or will be doing AAA repair

• Temporal arteritis get steroids before biopsy

Respiratory

• FEV1/FVC normal is 0.7

  • Less = obstructive

  • Normal or more = restrictive

• Small cell carcinoma gets chemo only; no surgery

  • This is the one with paraneoplastic syndromes

• Adenocarcinoma of the lung is the one that causes SVC syndrome

• Mesothelioma = pleural thickening

• Lung biopsy to confirm interstitial fibrosis

  • Treatment = perfenidone

• COPD exacerbation will have high CO2

• Any history of early onset emphysema = alpha 1 antitrypsin deficiency

• Initial step of diagnosing asthma = spirometry

• If hospitalized for asthma, on discharge, they get ICS

• Between SABA/LABA, LAMA, and ICS for COPD vs asthma

  • COPD: LAMA, ICS (it’s about stopping the constriction more and keeping down inflammation)

  • Asthma: SABA for quick relief, ICS as maintenance therapy (it’s about stopping the inflammation and opening up the airway)

• Fever and difficulty breathing 24 hours post-op —> atelectasis

• OSA —> cor pulmonale and depression

• Systemic sclerosis will have pulmonary fibrosis leading to pulmonary HTN

• If a patient on warfarin and gets a PE, get CT first, then IVC filter

• Pneumonia —> parapneumonic effusions —> empyema

• Chylothorax develops when lymphatic fluid accumulates in the pleural space, often due to trauma or malignancy.

• TRALI = ARDS-like symptoms following a transfusion within 6 hours

  • If more than 6 hours, that’s transfusion associated circulatory overload

• Treatment for croup = racemic epinephrine

Renal

• BUN/Cr > 20 = prerenal cause of acute kidney injury; important to assess fluid status and potential dehydration.

• Any acute blood loss/diminished perfusion —> ATN

• PSGN occurs weeks after; IgA nephropathy occurs days after

  • PSGN is caused by GAS; IgA nephropathy is caused by viral

  • PSGN will have low C3 and ↑ Streptolysin

• MPGN is associated with Hep C, heroin, malignancy

• Lupus nephritis is DPGN

  • With MPGN and DPGN, get renal biopsy

• FSGS is associated with heroin, sickle cell, HIV

• Aminoglycosides cause ATN because they are not okay (nephrotoxic and ototoxic)

• AIN will have eosinophiluria and maculopapular rash

  • 5 Ps of AIN: pain (NSAIDs), pee (diuretics), penicillin, PPIs, rifamPin

• RTA I: can’t send out H+

  • RTA II: can’t bring in HCO3- effectively, leading to bicarbonate wasting and metabolic acidosis.

  • RTA IV: can’t respond to aldosterone

• With renal artery stenosis, ACEi and ARBs will increase renin and Cr

  • Caused by atherosclerosis

• Fibromuscular dysplasia is NOT related to atherosclerosis

• Any kind of uremic conditions need hemodialysis first

• Thiazides prevent calcium oxalate stones

• Acute pyelonephritis has low bacteria on urinalysis and gets treated with ceftriaxone or cipro

• Cystitis gets nitrofurantoin; general UTIs get TMP/SMX

• Urethral injury gets retrograde urethrogram, bladder injury gets retrograde cystourethrogram, ureteral injury gets retrograde pyelogram

• Blunt trauma to the kidney: if ecchymoses with flank pain ± hematuria, CT with contrast

  • If none of the above, urinalysis to check for microscopic hematuria

    • Positive: CT scan

    • Negative: discharge

GI

• Sliding hiatal hernia: a condition where part of the stomach bulges through the diaphragm into the chest cavity, often associated with gastroesophageal reflux disease (GERD).

• GERD

  • Low LES tone

  • Obesity and hiatal hernia are risk factors

  • PPI > H2 blocker

  • PPI → 24h pH monitoring → fundoplication (which should be done in severe cases)

• Barrett esophagus leads to adenocarcinoma

  • Smoking → SCC

  • New-onset dysphagia is the main symptom

  • In both cases, get endoscopy first; if endoscopy shows something, get biopsy

• Propranolol/beta blocker is prophylactic for esophageal varices; banding and endoscopy is the definitive treatment

  • Esophageal varices are lethal if they rupture

• The way ulcers develop via H. pylori is they secrete proteinaceous material which damages the lining

• Succussion splash is associated with gastric outlet obstruction

• Since pernicious anemia is autoimmune, if there is macrocytic anemia with history of other autoimmune diseases, it’s that

• Pancreatic adenocarcinoma needs CT to diagnose

  • Need to see how pissed off it got

  • Whipple procedure for head; distal pancreatectomy for tail

• Cholangiocarcinoma needs ERCP for diagnosis

• Choledocholithiasis gets ultrasound first, then ERCP

• UC → PSC

  • Positive p-ANCA

• Before CT for pancreatitis, fluids, bowel rest, NG tube decompression

• In SBP, you need to get the cell count first before the gram stain

• NG tube is diagnostic for EA and choanal atresia

  • Barium swallow for Zenker and achalasia

  • Gastrogaffin swallow for esophageal perforation

  • Esophageal manometry after barium swallow for achalasia

  • Endoscopy for suspected esophageal cancer

  • Abdominal ultrasound first for cholecystitis, choledocholithiasis, intussusception in kids, and pyloric stenosis

    • If negative, HIDA for cholecystitis, ECRP for choledocholithiasis

    • If positive for intussusception, enema

  • X-ray for obstruction, volvulus, NEC

  • Upper GI series for midgut volvulus

• Colonoscopy for IBD should be started 8 years after diagnosis and done every 2-3 years

• Crohn’s and UC get 5-ASA (mesalamine, sulfasalazine) first

  • 5-ASA → steroids (prednisone) → TNF-alpha

• HBsAg = currently sick with Hep B

  • HBeAg = easily spreading Hep B

  • Anti-HBc antibodies = came across Hep B i.e won’t cee (see) through the window period

  • Anti-HBe antibodies = anti-easily spread

  • Anti-HBs antibodies = anti-sick

  • If mother is confirmed Hep B, the infant gets Hep B Ig

Gyn/Male Reproductive

• Between not being to retract penile foreskin and not being able to replace it, not being able to replace it is an emergency

• Testicles get 6 months to descend on their own; after that, they will need help surgically to prevent infertility and testicular carcinoma

• Epididymitis

  • Under 35: likely Chlamydia or gonorrhea

  • Over 35: likely E. coli

• Hydroceles in infants less than 1 year old do not need treatment

• Varicoceles will come from the left side

• Stress incontinence does not get medications

  • If Kegel exercises fail, go to mid-urethral sling surgery

• Urge incontinence gets anti-muscarinics

  • Voiding is parasympathetic; you need an anti-parasympathetic

  • If a beta-3 agonist is given as an answer and that’s the only viable answer, consider that it may help with overactive bladder symptoms by relaxing the bladder muscle and increasing bladder capacity.

• Overflow incontinence gets the pro-muscarinics; before that though, you need to drain the bladder through getting post-void volume or getting a catheter in there

  • Voiding is parasympathetic, and in this case, you need a pro-parasympathetic

  • If BPH is the cause, tamsulosin or finasteride to treat the BPH

• The biopsy method for DCIS is needle-guided open biopsy

• Screening mammograms are done every 2 years

• Fibrocystic change of the breast is not an aggressive/severe condition so it will not require aggressive/severe testing and treatment

• Between mastitis and abscess, check the fluctuation

  • Fluctuation + = abscess

  • Fluctuation - = mastitis

• Prostate cancer metastasis to the bone is osteoblastic

  • Methylprednisolone for symptomatic bone metastasis, radiation for asymptomatic

• In BPH, the transurethral resection of prostate is done if tamsulosin and finasteride fail

Neuro

• In ischemic strokes, you have 4.5 hours to give alteplase; anything on the other side of that you will need to give aspirin

• Hemorrhagic strokes: get the BP down first, then reverse anticoagulation if applicable

• Breast or lung cancer history and now the patient is having an altered mental status? It’s because of hypercalcemic crisis

• Pseudotumor cerebri is associated with idiopathic intracranial HTN

• Communicating hydrocephalus: it can flow, it’s just not getting reabsorbed

• Essential tremor: alcohol will relieve, give propranolol

• Resting tremor: Wilson’s or Parkinson’s

• Intention tremor: cerebellar or essential

Ortho

• Humeral neck fracture will injure axillary nerve

  • Midshaft humeral will injury the radial nerve

  • Supracondylar fracture will injure the median nerve

• Guyon canal syndrome only really affects the ulnar side of hand and hook of hamate fracture is the one that messes with the ulnar nerve

• deQuervain tenosynovitis: deviating hand towards the ulnar side hurts

• Herniated disc initial treatment is light exercise and NSAIDs; they need to move around some

  • Same goes for paraspinal muscle strain and sciatica; they should move around

• Surgery usually doesn’t need to be done for surgery; the only treatment is the brace if Cobb angle is between 25-40˚

• Knee crepitus distinguishes patellofemoral instability from patellar tendonitis

• DDH treatment is the Pavlik harness

• Legg-Calves-Perthes disease will be avascular necrosis due to no known reason

  • They will need hip replacement because avascular necrosis is dangerous

  • This is mostly in kids under 10

• SCFE gets surgical pinning

  • This is mostly in kids 10-13 years old

• Osteoporosis risk factors: family history > female > over 65

• In an ankle sprain, there needs to be pain in 2 spots to warrant X-ray

  • Posterior to lateral or medial malleolus

  • Tip of lateral or medial malleolus

• Juvenile idiopathic arthritis is RA in kids

  • Might see a maculopapular salmon rash

  • Arthrocentesis will show leukocytes

• With polymyositis and dermatomyositis, there will be weakness on physical exam

  • Shawl rash of dermatomyositis = a characteristic rash that appears on the back and shoulders, resembling the shape of a shawl.