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USMLE2 Surgery 6


probability of perioperative MI in pt with EF=35% 75-85%
hyperglycemia in the periop period is associated with…. (2) increased infection and poor wound healing
DVT during periop period is more likely in which types of patients? pts with some kind of malignancy
what should you give to Hemophilia A pt to reduce intraoperative bleeding? FFP
woman on warfarin for afib needs to go into emergent surgery. What is recommended to help control her bleeding before and during surgery? FFP. Warfarin prevents the production of vitamin K-dependent factors (2,7,9,10). Repletion of vit K-dependent factors with FFP is indicated in any patient taking warfarin. Vitamin K may also be given but requires a minimum of 6 hours to have an effect.
What does DDAVP do and what is it used for? DDAVP causes release of factor VIII and von Willebrand factor and is used in patients who have von Willebrand disease.
When should FFP be given to control intraoperative bleeding? immediately preop
what reduces the incidence of surgical site infections? (5) shorter duration of operation, clippers (not razor) to shave surgical site immediately prior to incision, maintenance of normothermia, IV abx within 1 hour of incision, limit foreign bodies and necrotic tissue in the wound
For what reason do most postoperative myocardial infarctions occur on postop day 2 or 3? Postoperative MIs typically occur on postop days 2 to 3 and are caused by the return of third-spaced fluids into the intravascular space.
What is the most common cause for hypoxia in postop patients? hypoventilation as a result of diminished drive related to fatigue, effects of anesthesia, and side effects of narcotics contained in analgesics.
A postoperative patient in acute respiratory distress with: hypoxemia, hypercarbia, jugular venous distention, chest x-ray with bilateral pulmonary infiltrates, and pulmonary capillary wedge pressure (PCWP) of 22 mm Hg. What is the most likely diagnosis? Congestive heart failure (CHF). Postoperative respiratory distress with jugular venous distention, bilateral pulmonary infiltrates on chest x-ray, and PCWP >18 is most likely caused by congestive heart failure
A postoperative septic patient in acute respiratory distress with: hypoxemia, hypercarbia, chest x-ray with bilateral pulmonary infiltrates, and pulmonary capillary wedge pressure (PCWP) of 12 mm Hg. What is the most likely diagnosis? Acute respiratory distress syndrome (ARDS). The diagnosis of ARDS includes bilateral pulmonary infiltrates, hypoxia, and no evidence of congestive heart failure (PCWP <18) in the context of severe injury or sepsis.
most common cause of postoperative renal failure in the surgical patient hypotension arising from hypovolemia (dehydration, hemorrhage), sepsis, or cardiogenic shock.
A patient who has oliguria and low hemoglobin has what kind of values (FeNa, urinary sodium, urine output, and urine osmolarity). FeNa <1%, urinary sodium <20 mEq/L, a low urine output (<0.5 mL/kg/h), and high urine osmolarity (>500 mOsm/kg/H2O).
A pt s/p appy on POD has abdominal pain, distention, high nasogastric tube output, high-pitched bowel sounds, and fever. What is this and what to do next? ischemic small bowel obstruction. the patient needs an emergent laparotomy.
CA 19-9 tumor marker for pancreatic cancer
Drug-induced pancreatitis can be caused by which drugs? SAND - Didanosine (antiretroviral)
is the most likely complication of gastroesophageal reflux disease Barrett esophagus (mucosal change from squamous cell to columnar epithelium
bird’s beak achalasia
63-year-old man w h/o smoking 2ppd for 30 y and alcohol abuse c/o hoarseness for 1 mo with cervical LAD. What is the most appropriate initial diagnostic study? Barium swallow (pt has cancer of the esophagus). Hoarseness is concerning, because it indicates that the CA has invaded the recurrent laryngeal nerve, a sign of unresectability.
Boerhaave syndrome - what is the initial test? Gastrografin is the next best step and is diagnostic. Barium swallow is used if Gastrografin is negative.
Tx for low-grade mucosa-associated lymphoid tissue (MALTOMA) Triple therapy for H. pylori
How to tx CA of the anus? nigro chemoradiation
Initial dx study for pt whom you suspect L colon CA Flexible proctosigmoidoscopy
what is the most common complication of a ishiorectal abscess? Necrotizing soft-tissue infection
most common polyps found in patients who have familial adenomatous polyposis Adenomatous polyps
most common location for colon cancer Sigmoid colon
What characteristic of a gastric ulcer places the patient at greatest risk for rebleeding after endoscopic attempts at hemostasis? visible vessel
How to dx GIB in massive ongoing gastrointestinal hemorrhage requiring transfusion of a large amount of blood Emergency angiography. will detect bleeding at a rate of more than 0.5 mL/min. Angiography has the additional advantage of allowing intervention, such as vasopressin infusion or embolization, to control the bleeding.
What type of imaging to dx perforated bowel? upright CXR showing free air under diaphragm
Initial management of small bowel obstruction resuscitation with intravenous fluids, placement of a nasogastric tube to decompress the gastrointestinal tract, and placement of a Foley catheter to monitor the patient's fluid status
Indications for surgery in diverticulitis 1) free-air perforation w fecal peritonitis, 2) peritonitis 2/2 ruptured abscess, 3) abd or pelvic abscess (not amenable to percutaneous drainage), 4) fistula formation, 5) suspicion of CA, 6) intestinal obstruction, and 6) failure of medical therapy.
What does surgery for diverticulitis involve? Surgery traditionally involves resection of the inflamed segment of colon and proximal diversion into a colostomy, with closure of the rectal stump. Total colectomy is not indicated.
tx for hepatic adenoma stop OCPs and resection
CA-125 tumor marker for ovarian CA
Beta hCG tumor marker for choriocarcinoma and testicular cancer
initial treatment for inflammatory breast cancer chemo
what does In situ carcinoma mean? lack of tumor invasion through the basement membranes, suggesting that the lesion remains in the "preinvasive" stage and implying that the risk for systemic metastases is almost nonexistent.
Which is more common? DCIS or LCIS DCIS
Which is a pre-invasive lesion? DCIS or LCIS DCIS. LCIS is not a preinvasive lesion but is a marker for an increased risk for breast cancer development, 6 to 12 times the nl population.
How to manage pt with LCIS Contrary to DCIS, there is no need for complete excision of LCIS-only close clinical followup every 6 months.
lifetime risk for invasive breast cancer in women who have a BRCA 1 or 2 mutation 60 to 70%
BRCA1 on which chromosome? What does the mutation do? BRCA1 is located on chromosome 17q and is responsible for transcriptional activation and involvement in repair of double-stranded DNA breaks
BRCA2 on which chromosome? What does the mutation do? BRCA1 is located on chromosome 13q and is responsible for transcriptional activation and involvement in repair of double-stranded DNA breaks
What percent of breast cancers overall have the BRCA 1/2 mutations 0.05
80% of gallstones are what type? cholesterol, the rest are pigment stones made of bilirubin
Who gets pigment stones? people who have cirrhosis, biliary tract infections, and hereditary blood disorders, such as sickle cell anemia, in which too much bilirubin is formed
right upper quadrant pain, jaundice, and fever triad of cholangitis (Charcot's triad)
Tx for cholangitis resuscitation, intravenous antibiotics, and decompression of biliary tree by way of a stent placed during an ERCP or percutaneous transhepatic cholangiogram.
Reynolds pentad mental status changes, sepsis, right upper quadrant pain, jaundice, and fever
definitive tx of gallbladder CA complete resection
Tx for asymptomatic inguinal hernia Asymptomatic hernias do not need to be repaired. The risk for incarceration is small in prospective trials that followed men for decades; when symptoms occur (pain, limitation of activity) the treatment can be pursued with a standard repair with mesh.
Created by: christinapham



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