Term
| What is the differential for hypo-osmolar, hyponatremia and how is each condition managed? |
|
Definition
**Do not exceed 0.5 mEq/hr or get CPN**
1) Hypovolemic: Bolus NS and then maintenance (if severe give 3% NS)
- Volume loss (Renal will have high urine Na >20 and Extra-renal will have low urine Na <10)
2) Hypervolemic: Fluid/salt restriction +/- diuretics
- CHF
- Nephrotic
- Cirrhosis
3) Euvolemic: Free water restriction
- SIADH |
|
|
Term
| How can you determine the volume deficit in a patient with a sodium of 154 and how should it be replaced? |
|
Definition
1) Deficit= 0.6 * Weight * (154/140 - 1)
- For 70 kg, would be 4.2
2) Replace 1st half in 8h and 2nd half in 16h |
|
|
Term
| Describe the treatment approach for hyperkalemia |
|
Definition
1) Calcium gluconate first 1g
2) Give Insulin and Glucose (10U and 1 amp D5)
- also give beta agonists and alkalinize urine
3) Give kayexelate and diuretics. |
|
|
Term
| How should hypercalcemia of 12 in an asymptomatic patient be managed? |
|
Definition
Give fluids, bisphosphonates, calcitonin and occasionally steroids.
Could be endocrine issue, malignancy, granulomatous disease or meds. |
|
|
Term
How can each of the following causes of hyper-coagulability be managed?
1) Liver failure
2) Renal failure
3) vWD
4) Hemophilia A or B |
|
Definition
1) FFP
2) ddAVP
3) ddAVP
4) FFP if emergent or crypoppt. |
|
|
Term
| What are the major risks of receiving blood transfusions? |
|
Definition
1) Febrile/allergic reactions
2) Viral infection
3) Immunosuppresion (most significant)
4) Coagulopathy (dilutional TP or DIC)
5) Acidosis with hyperkalemia and hypocalcemia (citrate) |
|
|
Term
How is the nutritional status of a surgical patient monitored?
What are the general goals for calories and protein in a hospitalized patient? |
|
Definition
1) Follow pre-albumin, nitrogen balance and transferrin
2) 2000 cal and 60g protein (or 0.8g/kg/day)
- If entered, give at 20/h and increase 20/h every 6-12h ntil goal reached. |
|
|
Term
How are each of the following types of shock managed?
1) Vasomotor
2) Hypovolemic
3) Cardiogenic
4) SEptic |
|
Definition
1) Fluids and pressors
2) Fluids
3) Inotropes and nitroglycerine (if BP will tolerate)
4) Fluids, dobutamine, NE or dopamine |
|
|
Term
| How long should smoking and alcohol be abstained from before surgery? |
|
Definition
1) Smoking is 6-8 weeks
2) Alcohol 6-12 weeks |
|
|
Term
| What do you suspect in a patient with CKD who becomes acutely hypotensive during surgery? How could you prevent this? |
|
Definition
| Adrenal failure- pulsed steroids intra-operatively (25mg) |
|
|
Term
| What major factors would prevent a post-operative small-bowel fistula from healing? |
|
Definition
FRIEND
1) foreign body
2) radiation
3) infection
4) epitheliazation or tract
5) neoplasm
6) distal obstruction |
|
|
Term
| How is a Pancoast tumor managed? |
|
Definition
Two-phase
Diagnosis with CT, then get bronchoscopy and mediastinoscopy
1) Chemo-radiation
2) Surgery |
|
|
Term
| What is the first test you order for a young adult with hemoptysis? |
|
Definition
Think about bronchial adenoma (either adenocystic carcinoma or carcinoid)
- Order Bronchonscopy
- Treat with resection and LN sampling |
|
|
Term
| What tests should you perform in a patient with suspected aortic valvular disease? When should surgery be done? |
|
Definition
1) Cardiac cath
2) Duplex US (r/o carotid stenosis)
3) Surgery is done when EF is good. Risk determined by cath not be age |
|
|
Term
| What tests are necessary to order for staging esophageal cancer? |
|
Definition
1) EUS for depth of lesion
2) CT for LN spread |
|
|
Term
| How should an acute arterial occlusion be managed? |
|
Definition
| Heparinize and embolectomy with fogarty balloon cath |
|
|
Term
| What is Leriche syndrome? How would you assess cardiac risk in such a patient? |
|
Definition
1) Impotence, thigh/buttock claudication and absent femoral pulses.
Patient needs aorta-bifem bypass.
2) DTS stress test. If recent MI, wait 3 months |
|
|
Term
| What are the complications of endovascular and open AAA repair? |
|
Definition
1) Endovascular
- Endoleak and Dye
2) Open
- Remember 3rd spacing post-op, which will mobilize and then require diuretics. |
|
|
Term
| What should you do first in a patient with suspected AAA rupture? What post-op compilations are typical? |
|
Definition
1) Take to OR- resuscitate later
2) Ischemic injury to colon, Graft infection, Aortoenteric Fistula |
|
|
Term
| What is the first step in the work-up for a chronic mesenteric ischemia? |
|
Definition
| Same as acute. Get Mesenteric arteriogram |
|
|
Term
| What test do you order for a suspected Thoracic Aortic Dissection? |
|
Definition
CTA
- Distal will get medical (Beta blocker), while Apical will need surgery |
|
|
Term
| How should post-op DVT be managed? |
|
Definition
1) Bolus Heparin (70-100 U/kg)
2) Maintain at 15-25 U/kg for 5-7d (PTT 1.5-2x normal)
3) Continue Warfarin for 3-6m |
|
|
Term
| Describe the workup for a patient with GERD |
|
Definition
1) Try PPI/H2 blocker
2) If fails, get Upper GI
3) Follow with EGD with biopsy and Manometry (determine intact peristalsis)
4) Consider Nissen Fundoplication. If peristalsis is abnormal, consider partial wrap. |
|
|
Term
| What test should be performed in a patient with medically-refractory duodenal PUD before proceeding to HSV? |
|
Definition
| Gastrin level- Consider ZES |
|
|
Term
| How does the management of non-healing ulcers of the stomach differ for type 1-4 ulcers? |
|
Definition
- Types 2-3 get Vagotomy, whereas 1 and 4 get Gastrectomy
- Watch out for post-gastrectomy dumping syndrome |
|
|
Term
What tests should be used to stage gastric cancer?
How is early vs. infiltrating cancer managed? |
|
Definition
Lymphoma or Adenocarcinoma
1) EUS (Depth and LN spread) and CT (distant Mets)
2) Early gets sub-total gastrectomy
3) Infiltrating gets total gastrectomy, with momentum and 15 LNs |
|
|
Term
Patient has epigastric pain with a surgical abdomen and leukocytosis.
What do you do next? |
|
Definition
Likely perforated ulcer
1) Get upright CXR to look for free air.
2) If free air, resuscitate and take to OR immediately. |
|
|
Term
| When should asymptomatic gallstones be treated? |
|
Definition
1) Immunosuppression
2) Large stone (>3cm)
3) Porcelain gallbladder |
|
|
Term
| How should a pregnant patient with symptomatic cholelithiasis be treated? |
|
Definition
Hydration and pain management- avoid surgery if possible.
IF necessary, perform during second trimester |
|
|
Term
| What should you do if a patient who recently had a lap cholecystectomy develops post-operative fever and abdominal pain? |
|
Definition
Infection or Biliary Leak likely
- Get US and then HIDA scan |
|
|
Term
| What is the first test to order for a patient with painless Jaundice? Whats next? |
|
Definition
RUQ US
CT-contrast of abdomen, followed by ERCP or percutaneous transhepatic cholangiography (PTC) |
|
|
Term
| What is the appropriate test to order in a patient with suspected necrotizing pancreatitis? |
|
Definition
| CT scan. Consider placing PA catheter |
|
|
Term
| What should you order in an elderly patient with elevated amylase/lipase and abdominal pain? |
|
Definition
| RUQ US, but also CT to r/o AMI and volvulus |
|
|
Term
| What test is appropriate for a hepatic mass suspected to be a Hemangioma? |
|
Definition
|
|
Term
| Describe the workup for a stable and unstable patient with suspected acute ischemic bowel. |
|
Definition
1) Stable
- Get CTA or angiogram
- Give antibiotics and hydration
- IF lesion identified, perform revascularization
2) Unstable
- Go directly to OR for revascularization
**If bloody diarrhea, perform sigmoidoscopy- full thickness needs resection, but mucosal does not** |
|
|
Term
What tests should be ordered in a patient with suspected Rectal Carcinoma.
How does it spread and how is it treated? |
|
Definition
1) Colonoscopy to find other lesions. If none, get transrectal US and CT to determine invasion.
2) Spread to regional LN (sacral, internal illiac, inferior mesenteric)
3) Abdominal-perioneal resection (can de-bulk with pre-op chemo-radiation)
- Complications include impotence and bladder dysfunction |
|
|
Term
What tests should be ordered in a patient with suspected Anal Carcinoma.
How does it spread and how is it treated? |
|
Definition
SSC
1) Biopsy
2) Spreads to inguinal and superior rectal
3) Small gets local excision, Large gets abdominal-perineal resection |
|
|
Term
| Why might pneumaturia develop in a patient with diverticulitis? |
|
Definition
|
|
Term
| How would you work up a patient with Lower GI bleeding after a colonoscopy is performed? |
|
Definition
1) Stable: Technetium 99 scan
2) Unsable: Mesenteric Angiography |
|
|
Term
| How is a sigmoid volvulus diagnosed? |
|
Definition
|
|
Term
| What test might you order in a patient with elevated calcium and PTH? |
|
Definition
| 24h urine calcium to rule out FHH. Also Cr to evaluate for renal failure. |
|
|
Term
| What test is used to assess chromatin tissue in suspected Pheo? |
|
Definition
| MIGB test. If positive, follow with Adrenalectomy |
|
|
Term
| What is the workup for a patient with hyperparathyroidism and intractable duodenal ulcers? |
|
Definition
Sounds like MEN1
- For ulcers, measure Gastrin, and if >600, get Secretin/calcium stimulation test looking for ZES |
|
|
Term
| Describe the management of an incidentally discovered adrenal mass |
|
Definition
| Only resect if symptomatic or > 5cm. Otherwise follow with serial CT scans |
|
|
Term
| What are 4 signs of a fresh spinal chord injury? |
|
Definition
1) Priapism
2) Loss of anal tone
3) Bradycardia
4) Intestinal Ileus |
|
|
Term
| How should you manage a splenal laceration detected on CT? |
|
Definition
- Avoid transfusions if possible
- Try angio/embolization and preserve spleen if possible |
|
|
Term
| What should you do if increased ICP is suspected? |
|
Definition
| Elevate head, mannitol, hyperventilate and maintain MAP |
|
|
Term
| When should surgery be performed for a traumatic AV fistula with high-output HF? |
|
Definition
| After cardiac status improves (place PA catheter) |
|
|
Term
Who needs to be transferred to a burn center?
What are the care priorities there? |
|
Definition
deep 2nd or 3rd degree burns over >30% of body.
Return plasma volume to normal. Give LR with 1st half over 8h and second half over 16h.
Calculation is %BSA x weight, x 4 ml/kg. In 70 kg man, this would be 30 X 70 x (4*70)
Give colloid AFTER 24 have passed. |
|
|
Term
| What are the TPN demands of a hyper-metabolic patient? |
|
Definition
| 2-2.5 g/kg/day with calories 50-100% above baseline requirements. Maintain positive Nitrogen balance |
|
|
Term
| Why might a patient on TPN fall into a coma? |
|
Definition
HHNK- hyperglycemia leads to dehydration via osmotic diuresis.
Stop TPN and give Insulin |
|
|
Term
| How is a congenital diaphragmatic hernia managed? |
|
Definition
1) High frequency, low pressure PEEP (barotrauma is lethal in pulmonary hypoplasia).
- If ventilation fails, will need ECMO
2) Need to prevent acidosis, which can cause persistent fetal circulation and cause pHTN (use NO).
3) Stabalize for a few days before surgery |
|
|
Term
How should esophageal atresia with distal TEF be managed pre-operatively?
What is the most common complication of repair? |
|
Definition
1) Decompress proximal pouch, Give H2 blocker, maintain upright position.
2) GERD or stricture (get UGI to confirm) |
|
|
Term
| How is a Meconium illeus diagnosed/managed? |
|
Definition
Common in kids with CF presenting with feeding intolerance and vomiting
1) Gastrograffin enema and LGI series
2) Gastrograffin enema |
|
|
Term
What is the biggest source of Mortality in Omphalocele?
What about in Gastroschisis? |
|
Definition
1) Chromosomal abnormalities and Heart Disease
Initial management is conservative
2) Sepsis and Short gut syndrome |
|
|
Term
| What is the diagnostic workup for pyloric stenosis in a child? |
|
Definition
1) Get US and if equivocal get UGI series
2) Correct alkalosis and then perform Ramsted pyloromyotomy |
|
|
Term
| What would you do for a patient with abdominal pain who is drawing there knees to their chest? |
|
Definition
Sounds like Intussusception
Get AXR to look for free air and signs of obstruction
If negative, get US.
Barium enema is diagnostic and therapeutic |
|
|
Term
| How is developmental hip dysplasia diagnosed and treated? |
|
Definition
1) US
2) Abduction splinting |
|
|
Term
| Generate a differential diagnosis for a child with hip pain |
|
Definition
1) Congenital dysplasia: Click, get US and abduction splinting
2) Legg-calve-perthes: Guarding passive ROM, get XR
3) Slipped Capital Femoral Epiphysis: young, chubby boy, X ray and surgery
4) Septic Hip: Pain with passive ROM and elevated ESR
5) Osteomyelitis: MRI and treat with ABX |
|
|
Term
| How does lumbar disk herniation present and how is it diagnosed? |
|
Definition
1) Vague pain followed by acute exacerbation
2) Watch and wait and confirm with MRI
**if flaccid rectal tone, saddle anesthesia and urinary retention, think CES** |
|
|
Term
What type of post-op complication is associated with each of the following? What do you do?
1) Chest pain on POD 2-3
2) Chest pain on POD 7
3) Bilateral pleural infiltrates
4) Hyponatremia
5) Hypernatremia
6) Urinary Retention |
|
Definition
1) MI- get troponin and EKG and perform emergent angioplasty/stenting
2) PE- Get CTA and then Heparinize
3) ARDS- Low volume PEEP
4) SIADH- ddAVP. If severe and hypovolemic, use small amounts of 3% NS
5) Could be nDI or fluid loss- give D5 1/2
6) Cath at 6h, and if fails x2 start foley |
|
|
Term
| 6w old boy exhibits worsening Jaundice. What do you do? |
|
Definition
Probably biliary atresia.
Get HIDA after 1w Phenobarbital followed by possible surgery |
|
|
Term
What congenital heart problem matches each murmur?
1) Fixed S2
2) Loud pan-systolic murmor
3) Machine-like murmur |
|
Definition
All L-to-R shunts
1) ASD
2) VSD
3) PDA |
|
|
Term
| How is subclavian steel syndrome diagnosed and treated? |
|
Definition
1) Duplex US showing reversal of vertebral flow
2) Bypass |
|
|
Term
| What is the diagnostic test of choice for Acoustic Neuromas and Facial nerve tumors? |
|
Definition
|
|
Term
| What types of intracranial tumors are seen in children and adults, respectively? |
|
Definition
1) Adults: Meningioma and Gliomas (glioblastoma is worst)
2) Children: Restinoblastoma and Ependymoma |
|
|
Term
| How can reflex sympathetic dystrophy (causalgia) be treated |
|
Definition
|
|
Term
| Discuss workup for child with painful testical |
|
Definition
Torsion or Epididymitis.
Get US. Tender chord usually Epididymitis. |
|
|
Term
What congenital urological condition is described by each of the following and how is it diagnosed?
1) Urinary retention
2) Always "wet" with urine
3) Voids well until large drinking |
|
Definition
1) Posterior urethral valves- Voiding Cystourethrogram
2) Low implantation- Vaginoscopy
3) UPJ obstruction |
|
|
Term
| How are mid-clavicular fractures managed? |
|
Definition
| Non-operatively, but Angiogram is needed if vascular compromise is suggested |
|
|
Term
| How are midshaft humerus fractures managed? What is typically injured? |
|
Definition
1) Reduction and internal fixation
2) Radial nerve injury (wrist drop) |
|
|
Term
What nerves are injured in the following humeral fractures? What is the consequence?
1) Surgical neck fracture
2) Mid-shaft of humerus
3)-supracondyler fracture |
|
Definition
1) Axillary nerve- Loss of abduction
2) Radial- wrist drop
3) Median nerve: ulnar deviation (on wrist flexion)+loss of opposition, Loss of sensation over the palmer surface of the lateral 3 1/2 digits. |
|
|
Term
| How does the management of most Ligament sprains differ from fractures? |
|
Definition
1) Sprain get RICE
2) Fractures are immobilized for 6-10w |
|
|
Term
| What injury is associated with falling on an outstretched hand and what is injured usually? |
|
Definition
Supracondylar fracture of humerus.
Median Nerve and Brachial Arter |
|
|
Term
| Who gets IG for tetanus and who gets vaccinated and who gets both? |
|
Definition
- 3 vaccines with booster in last 5 years (for dirty) or 10 years (clean) gets NOTHING.
- Unknown vaccine history with dirty gets both. |
|
|
Term
| What nerve gives sensation to the medial thigh? What about the anterior thigh and medial LE? |
|
Definition
|
|
Term
| What is the major concern with a retropharyngeal abscess? How is it managed? |
|
Definition
Acute Necrotizing Medistinitus- Surgical debridement and antibiotics
Fever chills, chest pain and mediastinal widening |
|
|
Term
| How do ligamentous tears differ from meniscal tears in their presentation? |
|
Definition
Ligamentous show rapid swelling due to hemarthrosis (Get MRI)
Meniscal tears have graduate swelling |
|
|
Term
| What is a common complication of retroperitoneal hemorrhage following vertebral fractures? |
|
Definition
| Paralytic illeus- management is conservative |
|
|
Term
| What test should be ordered in a patient that develops ipsilateral flank pain and back pain with hemodynamic instability after a cardiac cath? |
|
Definition
| Non-con CT A/P. This suggests post-op retroperitoneal hematoma. |
|
|
Term
| If a CXR suggests diaphragm injury what should you do? |
|
Definition
|
|
