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USMLE2 Surgery 6
GenSurg2
Question | Answer |
---|---|
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. |