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