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DU PA Surg 2 Stu Gui
Duke PA Surgery II Study Guide
| Question | Answer |
|---|---|
| list the three most common post-MI complications | VSD, Acute mitral insufficiency, LV aneurysm |
| list the criteria for CABG | left main disease >50%, three vessel coronary disease, failed medical management, failed angioplasty, decreased LV function, complicated disease, diabetes mellitus |
| what is the patency of the radial artery when used as a conduit for CABG | 84% five years |
| which conduit is most commonly used in CABG | greater saphenous |
| list the classic triad of symptoms associated with aortic stenosis | angina, syncope, CHF |
| indications for aortic valve replacement | dyspnea on exertion, decreased LV function, pressure gradient >50 mmHg by cath |
| shat are two important late symptomatic findings in aortic insufficiency | water hammer pulse (bounding), widened pulse pressure |
| mitral stenosis | opening snap, apical crescendo diastolic rumble |
| best for diagnosing aortic dissection | TEE |
| percentage of benign cardiac tumors | 75% |
| diagnosis of cardiac tumor | echo |
| diagnosis of pericarditis | echo |
| percentage of babies born with heart defect | 1% |
| most common congenital heart malformation | bicuspid aortic valve |
| second most common congenital heart malformation | atrial septal defect |
| interpretation of blood flow in a doppler ultrasound | BART-blue away, red toward |
| name the two anatomic r to l intracardiac/great vessel shunts in utero | foramen ovale, ductus arteriosus |
| location of the ductus arteriosus | small projection connecting the pulmonary artery to the aorta, bypassing the pumonary circulation |
| location of the ductus venosus | shunt from the umbilical vein to the inferior vena cava, bypassing the liver |
| major signs and symptoms of congenital heart disease | cyanosis, dyspnea/tachypnea, syncope, failure to thrive, edema/ascites |
| lab finding consistent with cyanosis | low oxygen sat, elevated hem |
| initial imaging modality of choice in suspected congenital heart disease | echo |
| eisenmenger's syndrome | phenomenon occuring with long standing L to R shunts in which increasing pulmonary arterial pressures and flow rate result in shunt reversal to R to L |
| location of ASD | hole between the right and left atria |
| three types of ASD | sinus venosus, ostium secundum, ostium primum |
| most commonly diagnosed congenital cardiac defect | VSD |
| location of VSD | hole between the right and left ventricles |
| finding in a patent ductus arteriosus | continuous precordial murmur (machinery) |
| most common of the mixed shunts | transposition of the great arteries |
| anatomical outcome in transposition of the great arteries | two separate closed systems |
| the two anatomical abnormalities that must be present in order for a patient to survive transposition of the great arteries | ASD, PDA |
| components of truncus arteriosus | single trunk from the heart, VSD |
| tetrology of fallot | pulmonary stenosis, VSD, overriding aorta)shigt to right ventrical), RV hypertrophy |
| anatomical abnormality that must be present for survival in tetrology of fallot | patent ductus arteriosus |
| anatomical abnormality in tricuspid atresia | hypoplasia of the R ventricle |
| what is fiven to patients in order to maintain a PDA | prostaglandins |
| most common congenital obstructing lesion | pulmonary stenosis |
| prominent physical findings in coarctation of the aorta | differential bp and pulses, greater in upper extremities than lower |
| anatomical cause of coarctation of the aorta | complication due to closure of the ductus arteriosus |
| most rare congenital heart disease | mitral valve disease |
| ABI in normal patients | <1 |
| ABI in patients with intermittent claudication | 0.5-0.7 |
| ABI in patients with rest pain | <0.3 |
| treatment for lower extremity rest pain | arteriography, bypass surgery |
| indications for surgical intervention in PVD | tissue loss, rest pain, lifestyle limiting claudication |
| leading cause of postoperative mortality | MI |
| risk of stroke in patients with carotid stenosis depends on | degree of stenosis, and presence of symptoms |
| what seemingly related symptoms are not associated with carotid disease | diplopia, syncope, paresthesias |
| which vessels are associated with the symptoms of diplopia, syncope, and paresthesias | vertebrobasilar arteries |
| physical exam finding is consistent with carotid vascular disease | carotid bruit |
| gold standard for defining anatomy of carotid artery disease | doppler US |
| gold standard for defining anatomy of carotid lesions | arteriography |
| cause of amaurosis fugax | embolization of the retinal artery, resulting in a transient monocular blindness |
| treatment for a 75% symptomatic carotid stenosis | carotid endarterectomy |
| at what size is AAA repair indicated | >5cm in diameter |
| ABCDE's of the primary survey for trauma | airway, breathing, circulation, disability, exposure |
| key components of airway assessment | assess airway and pt's ability to protect airway, use chin lift or jaw thrust, keep low threshold for intubation |
| key components of breathing assessment | evaluate breath sounds/percussion, administer supplemental oxygen, treat pneumothorax/hemothorax, flail ches |
| key components of circulation assessment | control hemorrhage, obtain large bore IV access, administer fluids as needed |
| key components of disability assessment | evaluate level of consciousness/pupils/ability to move extremities, determine coma score |
| key components of exposure assessment | remove all clothing, treat/prevent hypothermia |
| a GCS of >13 correlates with what | mild brain injury |
| a GCS of 9-12 correlates with what | moderate brain injury |
| a GCS of <8 correlates with what | severe brain injury |
| which GCS indicates the need for intubation | <8 |
| general rule for the secondary survey | a finger or tube in every orifice |
| what does ample stand for | Allergies, Meds, PMH, Last meal, events related to injury |
| what two tubes should be placed in every trauma patient | foley, NG tube |
| radiographic components of the trauma triple | C-spine, portable chest xray, pelvic xray |
| seat belt sign | fracture of the L2 vertebrae, resulting in injury to the duodenum |
| most important lab test that should be ordered in a trauma patient | type and screen |
| during physical exam of a trauma patient, what must be maintained | midline immobilization |
| definition of concussion | temporary deficit without CT findings |
| definition of contusion | focal brain bruise |
| which intracranial injury is associated with lucid interval | epidural hemorrhage |
| signs of tension pneumo | trachial deviation, increased JVD, decreased breath sounds, tympany to percussion, hypotension |
| what is the treatment for tension pneumo | immediate needle decompression, chest tube placement |
| what is the treatment for an open pneumo | sterile, one way flutter valve dressing |
| in patients with hemothorax what is the indication for thoracotomy in the OR | >1500 ml blood upon chest tube placement or continuous output of >200 ml/hr |
| what is Beck's triad | muffled heart sounds, JVD, hypotension |
| treatment for cardiac tamponade | immediate pericardiocentesis or sternotomy in OR |
| definition of flail chest | two or more fractures in three consecutive ribs with paradoxical inspiration |
| what is diagnostic peritoneal lavage | aspiration of fluid from the peritoneal cavity to assess for intra abdominal hemorrhage |
| results of a positive DPL | aspiration of gross blood, >100,000 rbc/ml on laboratory exam of lavage fluid |
| advantage that abdominal CT has over DPL | ability to evaluate retroperitoneum |
| diagnostic technique indicated for penetrating trauma or for the unstable patient with obvious evidence of abdominal injury | exploratory laparotomy |
| upon arrival how should unstable patients with pelvic fractures be treated | emergent external fixation, pelvic angiography with embolization if bleeding continues |
| device commonly used to stabilize pelvic fractures | military anti shoch trousers MAST |
| treatment for femoral head fracture | early traction and ORIF |
| three reasons to intubate a trauma patient | impaired level of consciousness, mechanically compromised airway, inadequate ventilation (flail chest) |
| two of the earliest signs of hypovolemic shock | decreased pulse pressure, orthostatic hypotension |
| phases of wound healing | hemostasis, inflamation and recruitment, fibroblast proliferation and granulation, wound remodeling and contraction |
| inflammatory cells that migrate to the site of a wound | neutrophils and macrophages |
| how soon does migration of inflammatory cells occur after an injury | minutes to 24 hours |
| how soon does reepithelialization occur after an injury | 24-48 hours |
| how soon does collagen deposition occur after an injury | 7-14 days |
| how soon does increased tensile strenght occur after an injury | 6 months |
| what is a clean wound | incision through prepped skin without violation of GI, GU or repiratory tracts |
| what is a clean contaminated wound | incision through prepped skin and into GI GU or respiratory tracts that have also been prepped |
| what is a contaminated wound | GI, GU or respiratory tract surgery with active infection somewhere else in the body |
| what is an infected wound | existing infection at the site of operation |
| treatment for abscess | incision and drainage |
| wound closure by primary intention | immediate approximation of skin edges |
| wound closure by delayed primary (tertiary) intention | leaving a contaminated wound open for 2-5 days to allow for reduced bacterial counts, then close primarily |
| wound closure by secondary intention | leaving a wound oopen to allow for healing by reepithelialization and contraction |
| how should wounds at high risk for infection be closed | by secondary intention |
| how long should an operative dressing be left in place | 48 hours |
| traditional dressing for open contaminated wound | wet to dry |
| best dressing for open contaminated wound | wound VAC |
| factors that reduce wound healing | infection, malnutrition, increased age, ischemia, smoking, diabetes, steroids, radiation and chemo |
| highest rates of esophageal cancers are found in | northern China and Japan |
| most common type of proximal esophageal tumor | squamous cell carcinoma |
| most common type of distal esophageal tumor | adenocarcinoma |
| which form of esophageal cancer is on the rise | adenocarcinoma |
| risk factors for esophageal cancer | barret's, reflux, iron def anemia, poor nutrition, family history, heavy smoking, heavy alcohol |
| most common presenting signs in esophageal cancer | dysphagia, wt loss, pain |
| etiology of esophageal cancer | dysplasia of the squamous epithelium |
| imaging modality that is the gold standard for evaluation of esophageal tumor stage | esophageal ultrasound |
| treatment that offers the best chance for survival in absence of metastases with esophageal cancer | surgical resection of involved esophagus, proximal stomach and regional lymph nodes and anastomosis |
| best methods of palliation in the absence of metastases with esophageal cancer | stent, photodynamic therapy, gastrostomy feeding tube |
| most common post operative complication following esophageal resection | pneumonia |
| lung cancer is the most common cause of death by malignancy in which population | men |
| in which population is there an increasing incidence in lung cancer | young, white, non-smoking females |
| what is the most common cause of death in lung cancer | distant metastases |
| what lung tumor is the most common | non-small cell |
| of the non-small cell lung cancers which are the most common centrally | squamous cell carcinoma |
| of the non-small cell lung cancers which are the most common peripherally | adenocarcinoma |
| what constitutes stage IV lung cancer | and degree of metastasis |
| which stages of lung cancer are resectable | stages I-IIIa |
| initial imaging modality for suspicion of lung cancer | chest x-ray |
| a __ lesion on chest x-ray is considered malignant until proven otherwise | non-calcified |
| imaging used to evaluate for mets | pet, brain ct, mr |
| imaging modality considered the standard of care in proper staging of lung tumors | bronchoscopy |
| gold standard for lymph node evaluation with lung cancer | cervical mediastinoscopy |
| general management for traumatic wounds | irrigation, bleeding control, close vs don't close |
| treatment for clean wounds less than 6-8 hours old | primary closure, dry dressing 2-3 days, suture removal in 3-10 days |
| treatment for dirty wounds or wounds older than 8 hours | healing by secondary intention, dressing change after 1-3 days, antibiotics in presence of cellulitis or lymphadenopathy, delayed primary closure with steri-strips in 3-5 days after granulation tissue has formed |
| treatment of puncture wounds | pack with clean gauze to allow for bottom to top healing |
| purpose of wet to dry dressing | facilitates mechanical debridement of the wound (does not prevent bacterial colonization) |
| three indications for primary closure | wound <6-8 hours old, edges come together without tension, clean wound |
| common local anesthesia used in office or clinic | topical or subcutaneous infiltration at wound site |
| common method for field block anesthesia | infiltration circumferentially around the wound |
| common method for peripheral nerve block | injection of local anesthetics adjacent to the appropriate peripheral nerve |
| effects of epinephrine when used as an anesthetic additive | causes vasoconstriction, decreases rate of systemic vascular absorption |
| effects of sodium bicarbonate when used as an anesthetic additive | neutralizes the pH of anesthetic, decreasing pain secondary to injection |
| most commonly used lidocaine dosages | 1% solution, 0.5 cc/kg of body weight, common dose, 35ml of 1% in 70kg pt |
| areas where epi should never be used in conjunction with lidocaine | distal appendages: ears, fingers, nose, toes, hose |
| type of anesthesia most useful for procedures on digits | peripheral nerve block, injected on both sides of the metacarpo-phalangeal joint |
| first sign of lidocaine tox | tinnitus |
| ultimate sign of lidocaine tox | seizure |
| characteristics of a tetanus prone wound | >6 hours old, stellate or avulsion, depth >1cm, missile/crush/burn/frostbite, devitalized tissue, contaminated with dirt or saliva |
| tetanus prophalaxis for a tetanus prone wound, last booster >5 years ago | tetanus toxoid alone |
| tetanus prophalaxis fora tetanus prone wound, never immunized previously or unknown | tetanus toxoid plus tetanus immune globulin at separate site |
| tetanus prophalaxis for a non-tetanus prone wound, last booster >10 years ago | tetanus toxoid alone |
| infection of hair follicle cuased by obstruction | furuncle |
| infection of the terminal phalanx or pulp of the finger | felon |
| infection involving the subepithelial folds of tissue around the nailbed | paronychia |
| technique for fusiform excision | length to width ratio of 3:1 with corner angles at approximately 30 degrees |
| most common benign epithelial skin tumor | seborrheic keratosis |
| most common type of skin cancer | basal cell carcinoma |
| characteristic appearance of a basal cell carcinoma | pearly lesion |
| treatment for all pigmented lesion | punch biopsy or excision biopsy |
| 5 conctraindications for laparoscopic surgery | ongoing intra-abdominal sepsis, bowel obstruction, morbid obesity, pregnancy, cardiopulmonary compromise |
| 7 operations that can be performes using laparoscopic technique | evaluate ab trauma, stage intra-ab cancers, biopsy, gastric bypass, appendectomy, cholecystectomy, splenectomy |
| mos common complication of laparoscopic surgery | bleeding, infection, bowel obstruction |
| advantages of minimally invasive surgery | reduced post-op pain, reduced hospital stay, quicker return to normal, improved cosmesis, reduced wound complications associated with large scar |
| disadvantages of minimally invasive surgery | expensive equipment, need for additional training, loss of tactile sensation, loss of 3D vision, general anesthesia necessary |
| 4 procedures that can be performed thoracopically | lung biopsy, wedge resection, pericardial window, pleurodesis in pneumothorax |
| pre-operative testing necessary in a patient <50 y/o prior to orthopedic surgery | none |
| pre-operative testing necessary in a patient 50-75 y/o prior to orthopedic surgery | EKG |
| pre-operative testing necessary in a patient >75 y/o prior to orthopedic surgery | EKG and H/H |
| guidlines for pre-operative antibiotics | cefazolin 1gm IV on call to OR given 1 hour prior to OR |
| two methods utilized in prophylaxis of postoperative DVT | TED hose, LMWH/coumadin |
| metabolic abnormality associated with post-operative infection | perioperative hyperglycemia |
| what intervention helps to reduce the risk of perioperative hyperglycemia | intraoperative insulin |
| diagnosis given to patients who present with a traumatic knee effusion, until proven otherwise | ACL tear |
| possible graft choices in an ACL repair | bone-patellar tendon-bone, hamstring autograft, cadaver allograft |
| best non-surgical treatment for osteoarthritis | wt loss |
| most common cause of shoulder pain | impingement |
| initial treatment for rotator cuff tendonitis | physical therapy and NSAIDS |
| comorbid illness that predisposes to adhesive capsulitis | diabetes |
| single most sensitive and specific physical exam finding in rotator cuff tears | weakness with resisted external rotation and or abduction |
| indications for rotator cuff repair | <60 yo, or 60-70 yo with favorable medical history and comorbities |
| shoulder dislocation that is the most common | anterior |
| two fractures associated with the shoulder | Bankart, Hillsach |
| test that should be ordered to rule out DVT in the case of shoulder pain | doppler ultrasound |
| initial test to be ordered to evaluate post-operative pain | x-ray to evaluate for hardware failure |
| indications for intubation | inability to oxygenate patient (SpO2,90%), inability to ventilate patient (resp acidosis), patient unable to protect airway |
| most common cause of airway obstruction in an unconscious patient | tongue |
| three maneuvers to temporarily relieve airway obstruction | chin lift/jaw thrust, oral airway in an unconscious patient, nasopharyngeal airway |
| five signs of airway compromise | agitation, tachypnea, increased resp effort, stridor, hoarseness |
| proper oxygenation of a patient prior to intubation | 100% oxygen via mask for 5 min |
| which endotacheal tube should be used in patients <8 years old | uncuffed to avoid tearing of airway due to overinflation |
| size of ET tube used for most women | 7-8 mm |
| size of ET tube used for most men | 7.5-9 mm |
| size of ET tube used for most pediatrics | diameter of patients little finger |
| how should the laryngoscope blade be inserted | on the right side of the mouth and used to sweep the tongue to the left |
| three benefits of applying cricoid pressure | prevents aspiration of gastric contents, prevents intubation into the esophagus, aids in visualization of the cords |
| five methods used to confirm tube placement | condensation in the ET tube, auscultate both lung bases, observe chest movement and symmetry, attach end-tidal CO2 analyzer to ET tube, check stat chest x-ray (tube should be 4-5 cm above the carina) |
| which method of ET tube confirmation is most accurate | end-tidal CO2 detection |
| after intubation, if breath sounds are heard on teh right but not on the left, what should be done | pull back on the ET tube and auscultate again |
| the early complications of intubation | aspirations, trauma, equipment failure, inability to intubate |
| the late complications of intubation | ventilator associated pneumonia, accidental extubation, vocal cord dysfunction or paralysis |
| the max amount of time that ventilations should be interrupted to perform intubation | 30 sec |
| most important anatomical divider used in classification of intracranial tumors | tentorium |
| a tumor in the supratentorial region may result in which pathologic disorder | epilepsy |
| which cancers met to the brain the fastest | lung and renal |
| in which area of the brain do most met tumors arise | cerebrum 80% |
| five step algorithm for diagnosis and treatment of a patient with suspected brain tumor | MRI is study of choice for confirmation of brain tumor. Pan CT of chest/abd/pelvis to detect other tumors. Biopsy of distant tumor or resection of brain tumor to confirm pathology. Radiation/chemo for malignancy. Follow-up surveillance MRI, PET |
| medically intractable epilepsy | failure of two or more medications to prevent further seizures |
| indicate the success rate of temporal lobectomy for the treatment of epilepsy | 85-90% remain seizure free for life |
| status epilepticus | ongoing seizure for 30 min or multiple seizure in succession without sensorium returning to normal between them |
| what is the fisher grade used for | classify appearance of sub arachnoid hemorrhage on scan |
| what is the Hunt Hess scale used for | classify severity of symptoms in sub arachnoid hemorrhage |
| components on Triple H therapy for subarachnoid hemorrhage | hypervolemia, heme dilution, hypertension |
| when can a burr-hole be done to treat subdural hemorrhage | 2 weeks after injury |
| treatment for myelomeningocele | planned c section, emergen closure of defect withing 24 hours |
| tethered cord | abnormally low conus medullaris |
| major cause of increased demand for organs | hepatitis C |
| antigen presenting cell APC | a cell that displays foreign antigen complesed with MHC on its surface, which is then recognized by t-cell receptors on T cells |
| major histocompatibility complex MHC | genes expressed on the surface of cells in all jawed vertebrates and display fragments of foreign molecules to T cells |
| define cross match | a test for determining tissue compatibility between a transplant donor and the recipient before transplantation, in which the recipient's serum is tested for antibodies that may react with the lymphocytes or other cells of the donor |
| which cytokine is responsible for the majority of immune cell activation | interleukin 2 IL-2 |
| immediate killing of a transplanted organ occuring in patients with preformed antibodies to the donor in the bloodstream | hyperacute rejection |
| rejection of the transplanted organ occuring between 5-90 days due to the infiltration of the recipient's immune system into the donor organ | acute rejection |
| chronic allograft vasculopathy due to development of atherosclerosis | chronic rejection |
| antilymphocyte antibodies used to prevent rejection during first few days after transplant | induction immunosuppression |
| maintenance immunosuppression | long term therapy with two or three drugs |
| treatment of acute rejection | steroids and antilymphocyte preparations given over period of several days |
| most important side effect of cyclosporine | nephrotoxicity |
| most important complication of immunosuppression | opportunistic infection |
| how are donor organs transported | hypothermic storage with UW solution |
| why is the left kidney preferred in renal transplant | the renal vein is longer on the left side |
| what lab value is used to evaluate success of liver transplant | PT/INR |
| what lab value is used to evaluat the success of pancreatic transplant | glucose |
| 1-year survival rate following liver transplant | 85% |
| 1-year survival rate following heart transplant | 80% |
| 1-year survival rate following lung transplant | 70% |
| what imaging modality is used to evaluate liver and kidney anastomoses post-operatively | ultrasound |
| what consideration must be made regarding pancreas transplant | risk of diabetic complications vs complications of lifelong immunosuppression therapy |
| what clinical sign is associated with acute heart transplant rejection | tachycardia |
| approach to the patient 3 hours post renal transplant who stops making urine | flush foley cath, assess fluid status(give 500cc crystalloid LR or NS), ultrasound to assess renal artery/vein patency, return to OR |
| why must you be overly concerned for infectious processes in patients s/p organ transplant | immunosuppression therapy results in a blunted inflammatory response and thus, the patient will no present with typical symptoms |
| fever threshold in immunocompetent | 38.5 C |
| fever threshold in immunocompromised | 38.0 C |
| what are patients s/p lung transplant at greatest risk for | infection secondary to aspiration |
Created by:
bwyche
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