SURGERY EOR EXAMS, PRACTICE EXAMS AND STUDY GUIDE EXAMS, Exams of Nursing

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SURGERY EOR EXAMS, PRACTICE EXAMS

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What is the treatment for colonic obstruction? Surgical treatment? IVF, NGT decompression, careful observation Surgical: acute colonic obstruction with cecal diameter greater than 12cm __________is the rotation of the large intestine on the axis formed by the mesentery. colonic volvulus 70% of colonic volvulus occur in the _____. 30% of colonic volvulus occur in the _____. sigmoid colon; cecum On abdominal series or barium enema, what is the classic appearance of a volvulus? birds beak or funnel The treatment for __________is rectal tube insertion for signmoid volvulus or emergent laparotomy if suspected perforation or cecal volvulus. colonic volvulus A _______is an obstruction of the perianal glands. Cryptoglandular in origin. Presents with perianal pain and swelling, spontaneous drainage of purulent material. What are the cardinal signs? Treatment? perianal abscess; pain, fever, redness, swelling, loss of function; I&D

What is Goodsall's rule? anterior-opening fistulas tend to follow a simple direct course while posterior-opening fistulas may follow a devious, curving path with some even being horseshoe-shaped before opening in the posterior midline.

______are painful linear tears in the lining of the anal canal. Frequently posterior. CP: dramatic pain with defecation and blood streaked stool, recent diarrhea or trauma to the area. Anal fissures _______is intussusception of a full thickness portion of the rectum through the anal opening. Often occurs in thin, asthenic women. 4-20cm of rectum. Rectal prolapse (procidentia) What is the presentation of a rectal prolapse? rectal pain, mild bleeding, mucous discharge, and a wet anus ______are vascular cushions in the anal canal. Disease is accompanied by constipation, increased pelvic pressure, portal hypertension, and excessive diarrhea. Hemorrhoids Hemorrhoid grading: Grade I = Grade II = Grade III = Grade IV = Grade I = no prolapse, bulge in anal canal lumen Grade II = prolapse upon defecation but spontaneously reduce Grade III = prolapse upon defecation - manually reducable Grade IV = prolapsed and cannot be manually reduced ________are when peritoneal sac and potentially peritoneal contents protrude through a weakness or defect in the muscle or fascia of the abdominal wall. Hernias _______hernias account for 96% of all groin hernias. Indirect are more common and presents how? Inguinal; protrusion into the scrotum In a _____inguinal hernia, peritoneal contents come directly through the abdominal wall and occur within Hesselbachs triangle. direct What is Hesselbach's Triangle? inguinal ligament, inferior epigastric vessels, and the lateral border of the rectus muscle ________hernias are typically small, less than 1cm defect in the abdominal wall due to incomplete umbilical closure. More common in females. Umbilical

_______hernias present with a bulge lower in groin through the femoral ring and often into the thigh. Mass inferior to the inguinal ligament. Femoral ________hernias present with a bulge or lump at the site of a previous surgical wound. Incisional ________hernias cannot be reduced -- more likely associated with pain, n/v. Femoral hernias are most likely to be this way because space is limited by the inguinal ligament, lacunar attachments, and Cooper's ligament. Incarcerated ________ are incarcerated hernias that also have vascular compromise. Strangulated. Bariatric surgery is approved for patients with BMI >____or with BMI >____with comorbidities (DM, OSA, CAD, CHF, arthritis, HTN). BMI>40; BMI> How do you calculate BMI? (weight (lbs) * 703)/(ht(inches)^2) What is the normal BMI? Overweight? Obese? Super obese? <25 (19.5-24.9); 25-29.9; >30; > Bariatric surgery options: _______is placing a adjustable band around the upper part of the stomach, and filling the band with saline fluid through a port that lies under the skin of the abdomen. Gastric band Bariatric surgery options: ________is making the stomach into a long pouch and removing the lateral stomach (which is responsible for most ghrelin production). Sleeve gastrectomy Bariatric surgery options: ________is a restrictive and malabsorptive procedure. Food bypasses the duodenum and initial part of the jejunum. Risks for nutritional deficiencies. Gastric Bypass and Roux-en-Y __________syndrome is when the stomach contents (usually sugars) move too rapidly through the small intestines. S/S are nausea, weakness, sweating, faintness, ocassionally diarrhea. Dumping

__________is the most common pulmonary complication after surgery -- affecting 25% of patients who have abdominal surgery. Most often due to closure of bronchioles -- but can also be due to obstruction (such as from blood clots or COPD secretions). Atelectasis _______is bleeding into the bronchial tree. Causes are bronchitis, tumor mass, TB, bronchiectasis, pulmonary catheters, trauma. Hemoptysis Massive hemoptysis is more than _______cc/24 hours. 600cc The treatment for hemoptysis is laser coagulation or epinephrine injective for mild/moderate or bronchoscopy, intubation of unaffected side, fogarty occlusion of bleeding bronchus, bronchial A-gram, surgical resection of involved lung. Stop the bleeding! _________carcinoma is the MOST common cancer death in the US in men and women. It occurs more often in the ___lung and more common in the ____lobe. Bronchogenic; right; upper S/S of lung carcinoma, change in chronic cough, hemoptysis, chest pain, dyspnea, pleural effusion, hoarseness, superior vena cava syndrome, diaphragmatic paralysis, symptoms of metastasis/paraneoplastic syndrome, finger clubbing What are the most common metastases sites of lung cancer? [BLAK lung] bone, liver, adrenals, kidney _________tumor is a tumor at the apex of the lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading to pain, upper extremity weakness, and Horner's syndrome. Pancoast's _______syndrome is injury to the cervical sympathetic chain: Miosis, Anhydrosis of ipsilateral face, ptosis (MAP) Horner's _________syndromes are syndromes associated with tumors but may affect distant parts of the body; they may be caused by hormones released from endocrinologically active tumors or may be of uncertain etiology. Paraneoplastic

Contraindications for surgery for lung cancer: STOP IT superior vena cava syndrome, supraclavicular node metastasis, scalene node metastasis, tracheal carina involvement, oat cell carcinoma, pulm fx tests shows FEV<1, myocardial infarction, tumor elsewhere A _________ is a collection of fluid (pleural fluid, blood, pus) within the pleural cavity. Causes: pulmonary infex, CHF, SLE or RA, pancreatitis, trauma, PE, renal dz, cirrhosis, malignancy, postpericardiotomy syndrome pleural effusion What are physical s/s of a pleural effusion? SOB, CP, decreased tactile fremitus, asymmetrical chest expansion, egophony, pleural friction rub On physical exam, a pleural effusion reveals___and___. Evaluation with thoracentesis w cytology. percussion on side with air and dull on side with fluid. A ____is diagnostic to acquire pleural fluid for analysis, usually pleural effusion. What are the risks? Thoracentesis; pneumothorax, injury to lung, intraabdominal injury, pain, bleeding With a thoracentesis, a patient should _____as the catheter/needle is withdrawn. exhale A needle decompression converts a _______to a pneumothorax. Where should the needle be inserted? tension pneumothorax; between 2 and 3 rib, midclavicular line over the top of the 3rd rib With a needle decompression, after you hear the rush of air, what should be placed over the catheter? a flutter valve A ______is a tube inserted into pleural space for drainage of fluid and air. Where should it be placed? 4th or 5th intercostal space; tube should pass over top of rib due to neurovascular bundle What are some complications of inserting a chest tube? puncture of liver or spleen, bleeding, cardiac puncture A ________is when air builds up in the pleural space and is unable to escape -- results in collapse of lung on affected side and pressure on mediastinum. With inhalation, the lung collapses further. There is no place for the air to escape. pneumothorax What are some s/s of pneumothorax? trachea pushed to opposite side; absent breath sounds on affected side What is the tx of pneumothorax?

ABC's; oxygen, treat for shock, needle decompression of affected side, patient will need chest tube A _______is necessary when an emergent airway is required...extensive orofacial trauma preventing laryngoscopy, upper airway obstruction , unsuccessful endotracheal intubation Cricothyroidotomy What anatomic location should a cricothyroidotomy be performed? Between cricoid and thyroid cartilage The most common cause of post operative pneumonia or in hospital/ICU is ________. gram negative bacteria [Neisseria meningitidis, Pseudomonas aeruginosa] In community acquire pneumonia, what type of organisms is the most common cause? gram positive bacteria [Streptococcus pneumoniae & Staphylococcus aureus] If patient is supine, PNA most commonly involves which lobe____if supine or _________if patient is sitting/semirecumbant. RUL, RLL If a patient presents with slurred speech, what neurological problem is in your d/d? CVA or brain tumor If your patient presents with a motor and/or sensory loss, what is your imaging study of choice? CT scan -- test of choice to evaluate cervical spine Signs of ___are upon auscultation of the carotid and subclavian arteries -- reveals audible bruit in the neck. What is the diagnostic study of choice? carotid disease; Doppler ultrasound A ______is head trauma results in blood below the arachnoid membrane and above the pia. Most often supratentorial (contains the cerebrum). Subarachnoid hemorrhage What are the three most common causes of subarachnoid hemorrhage? 1 - trauma 2 - ruptured berry aneurysms 3 - AVM - arteriovenous malformations A ______is a secular outpouching of vessels in the circle of willis, usually at bifurcations). berry aneurysm A _____is a congenital abnormality of the vasculature with connections between arterial and venous circulations without interposed capillary network.

AVM - arteriovenous malformations How does a patient with a SAH present? "worst headache of my life" -- positive Kernig and Brudzinski sign What is the difference between nuchal rigidity, Kernig's, and Brudzinski's signs? nuchal rigidity - neck stiffness when bending neck forward Kernig's - inability to straighten the leg when the hip is flexed at a 90 degree angle Brudzinski's - when the examiner flexes the patient's neck, knees, and hips at the same time What is part of the work-up of SAH? CT scan and arteriogram (to look for aneurysms or AVMs) The most common cause of morbidity and mortality with a SAH is _____. vasospasm -- other complications are brain edema (increased ICP) and rebleeding What is the treatment for SAH? --Nimodipine CCB for vasospasm --surgical metal clipping for aneurysm (alternative is balloon occlusion or coil embolization) --AVM: pre op embolization -- for surgically inaccessible lesions, radiosurgery A ______is bleeding into the brain parenchyma. Prognosis poor. Dx w CT. intracerebral hemorrhage These are _____indications for intracerebral hemorrhage are CNIII palsy (oculomotor nerve) and progressive alteration of consciousness. 2/3 present with coma, lateral gaze preference, aphasia, homonymous hemianopsia. surgical ______is blood collection under the dura. Caused by tearing of "bridging" veins that pass through the space between. The cortical surface and the dural venous sinuses or injury to the brain surface with resultant bleeding from cortical vessels. Subdural hemorrhage What are the CT finding of a subdural hemorrhage? Treatment? CT findings = curved, crescent shaped hematoma (sUbdural = cUrved) Treatment = reduce mass effect usually by craniotomy with clot evacuation A ________is a collection of blood between the skull and dura. Usually in association with skull fracture as bone fragments lacerate meningeal arteries. What artery is most commonly affected? epidural hematoma; middle meningeal artery What are the CT findings with epidural hematoma?

lenticular or LENS shaped hematoma (Epidural = lEnticular) What are the s/s of basilar skull fracture? raccoon eyes and battle's sign, hemotypanum, CSF rhinorrhea/otorrhea What are the surgical indications for brain tumors? establishing a tissue diagnosis, relief of increased ICP, relief of neurologic dysfunction caused by tissue compression, attempt to cure in the setting of localized tumor What is the #1 and #2 most common intracranial tumor in adults? #1 - glioblastoma ("Greatest Brain Tumor Malignancy") #2 - meningiomas Some risk factors of _______are radiation exposure, neurofibromatosis 2, and female sex. meningiomas What are the most common brain tumors in children? medulloblastomas, astrocytomas, ependymonomas Cerebellar astrocytomas - peak age between 5 & 9 years old. In 75% of cases, they are completely _____. resectable Medulloblastoma - peak age 3-7 yo. Most common location is cerebellar vermis in children With pituitary tumors, the most common is a ____. The most common presentation is bitemporal hemianopsia (lateral visual fields blind). Medical tx = bromocriptine. Surgical tx = transsphenoidal resection. prolactinoma Explain the Glasgow Coma Score. Eyes 4 - opens spontaneously 3 - opens to voice 2 - opens to pain 1 - none

Verbal 5 - normal conversation 4 - disoriented conversation 3 - words, incoherent 2 - incomprehensible sounds 1 - none

Motor 6 - normal 5 - localizes to pain 4 - withdraws from pain 3 - decorticate posturing 2 - decerebrate posturing 1 - none Most edema (causes - CHF, meds, pregnancy, cirrhosis, kidney dz, lymphatic deficiency, lower extremity vein injury or weakness) is treatment with _____. Home remedies are elevation, movement, massage etc.

diuretics Causes of orthostatic hypotension dehydration, heart conditions, endocrine (addisons disease, hypoglycemia, DM), nervous system disorders (Parkinsons, multiple system atrophy, Lewy body dementia, pure autonomic failure, amyloidosis), meds (diuretics, alpha blockers, beta blockers, CCB, ACE inhibitors, nitrates) What is the treatment for urinary retention? foley catheter Dysuria: Pain starting at the start of urination may indicate ____pathology, whereas pain occurring at the end of micturition is usually of _____origin. urethral; bladder origin _______is more than 2x/night of voiding. Nocturia Urinary frequency during the day wo nocturia is usually related to _______. Nocturia without frequency may occur in ____ patient in whom intravascular volume and urine output increase when supine. Also, renal concentrating ability decreases with age; therefore urine production in the geriatric patient ________. anxiety; CHF; increases at night GU pain is usually associated with either ____or____. urinary tract obstruction or inflammation The source of GU pain: inflammation is most severe when it involves the _____of a GU organ. Do tumors in the GU tract cause pain? parenchyma (inflammation of hollow organs produces discomfort); usually not painful unless they produce obstruction -- also a late manifestation _____pain is caused by acute distention of the capsule and located on the back and can radiate across the flank anteriorly. Pain is steady. Obstruction fluctuates in intensity. Renal ______pain is acute and secondary to obstruction. Can be located around McBurney's point or lower vesicle irritability including frequency, urgency, and suprapubic discomfort. Ureteral ______pain is produced either by overdistention of the bladder as a result of acute urinary retention or by inflammation. Inflammatory conditions usually produce intermittent pain. Vesicle

_______pain is usually secondary to inflammation with secondary edema and distention of the prostatic capsule. Pain is poorly localized -- frequency associated with irritative sx such as frequency, dysuria, and in prostatic edema Prostatic ______pain primarily arises from w/in the scrotum and is usually secondary to acute epididymitis, torsion, or testicular appendices. Testicular ________is usually related to noninflammatory conditions such as a hydrocele, varicocele, and pain is characterized as dull, heavy sensation in testes that does not radiate. Chronic scrotal pain ____pain is acute, scrotum is red and warm to touch. Relief with elevation of the testis of the appropriate side. Epididymal Testicular carcinoma are most typically what type of tumors? malignant germ cell tumors (either seminomatous 35% or nonseminomatous 65%) or non germ cell tumors (rare and usually benign) What is the s/s of testicular carcinoma? What is the diagnostic study of choice? painless firm mass inside the testis; scrotal u/s What are the tumor markers for testicular carcinoma? B-hcg, alpha fetoprotein, lactic dehydrogenase What age do patients usually present with testicular carcinoma? What is the surgical treatment? age 18-40; inguinal orchiectomy with retro peritoneal lymph node dissection

A _____is a embryonic tumor of renal origin. Ave age of dx is 2-4 years old. S/S: abdominal mass; Dx: abdominal/chest CT; Tx: radical resection of affected kidney Wilm's Tumor A associated abnormality with a Wilm's tumor is ___________syndrome ie. a umbilical defect, macroglossia, gigantism, neurofibromatosis, horseshoe kidney. beckwith Wiedemann Think Wilms=beckwith Wiedemann

The second most common urologic malignancy is _____. 90% have _______carcinoma. Remaining cases are squamous or adenocarcinoma. bladder carcinoma; transitional cell carcinoma What are the s/s of bladder cancer? painless hematuria, with or without irritative symptoms, frequency bladder Treatment varies according to stage: Stage O: bladder chemo Stage A: Trans-urethral resection of the bladder (TURB) Stage B&C: radical cystectomy, node dissection, removal of prostate/uterus/ovaries/anterior vaginal wall, urinary diversion Stage D: superficial, isolate tumor, apical with 3cm margin from any orifices _________cancer is the most common neoplasm after skin cancer. 2nd most common cause of death due to cancer. Cause unknown. More than 75% of men have this on autopsy. Prostate Annual screening for prostate cancer should be performed for all men >____and black men >____. What lab should be drawn for screening? 50; 45; serum PSA - prostate specific antigen On DRE for prostate cancer, what is felt? rock hard nodule _______cell carcinoma is the most common urologic malignancy. Specifically what kind of cancer? Renal; adenocarcinoma What are the most common metastases sites for kidney cancer? What is the diagnostic study of choice? lungs and bone; CT scan What are the s/s of renal carcinoma? hematuria, flank pain, flank mass, possible complaints due to metastases sites (lung/bone) The surgical tx of renal carcinoma is radical nephrectomy. If the tumor is less than 4cm, what can be done? partial nephrectomy ______________is defined as presence of kidney damage (usually detected as urinary albumin

30mg/day) or decreased kidney fx (defined as estimated GFR <60 mL/min) for 3 or more months, irrespective of cause. Chronic kidney disease

Dialysis is needed when approximately _____or more of kidney function is lost. 90% What are the indications for dialysis? AEIOU acidosis, excessive hyperkalemia, intractable volume overload (missed dialysis appointments), overdoses, uremia (sx of renal failure) Dialysis vascular access: _________is the preferred access method. Creates a direct connection between an artery and vein. Located under skin usually in lower arm. Created 2-4 months before it will be used. AV (arteriovenous) fistula Dialysis vascular access: _________is used when patients veins are not suitable for creating a fistula. Flexible rubber tube is used to create a path b/w artery and vein. Can be used 2 weeks after they are created. Possible narrowing of blood vessels and infection. Synthetic AV bridge graft Dialysis vascular access: _________uses a thin, flexible tube that is placed into a large vein (neck usually) -- can be used immediately. Highest infection risk and poorest function. Central venous catheter ______dialysis uses the peritoneum as a membrane across which fluids and dissolved substances are exchanged from the blood. Fluid introduced through a permanent tube in abdomen and flushed out either every night while patient sleeps or via regular exchanges throughout the day. Peritoneal Dialysis Most common causes of ___________disease are atherosclerosis of aorta and renal artery, and fibromuscular dysplasia. renal vascular disease; renovascular HTN less common causes are renal artery emboli, renal artery aneurysms, renal artery dissection, hypoplasia of renal arteries, and stenosis of the suprarenal aorta ______due to renal artery stenosis: results from kidneys response to decrease blood flow: renin is secreted, which acts on circulating angiotensinogen to form angiotensin I, which is converted to angiotensin II by ACE. This constricts arterioles, increases aldosterone secretion and promotes sodium retention. Hypertension Due to excess aldosterone, hypertension becomes volume dependent. Persistent elevation of ________is usually the only abnormal PE finding. diastolic pressure ________presents with flank pain, hematuria, pyelonephritis, previous stone passage, mod-severe renal pain, n/v, CVA tenderness.

Nephrolithiasis What is the initial diagnostic evaluation for nephrolithiasis? ultrasound - or CT scan Nephrolithiasis lab findings:

1. hematuria
2. alkaline urine means _______salts
3. acidic urine means ______salts
4. infection means _______stone
5. calcium salts
6. uric acid salts
7. struvite stones Kidney stones measuring less than _____mm and located more distally may pass spontaneously. 5 mm What medical management is used to treat nephrolithiasis? NSAIDs or opiods for pain; alpha adrenergic blockers (tamsulosin) or CCBs (nifedipin) to dilate ureters _________can be used to pulverize the stone, 80% of stones are amenable, some degree of acute kidney injury, bleeding. Extracorporeal Shock Wave Lithrotripsy (ESWL) Ureterscopic intervention or placing a ________can be used for stones >10mm. ureteral stent _____________can be used for symptomatic large pelvic stones; nephroscope passes inside the renal collecting system through the appropriate calix to remove the stone. Percutaneous nephrolithomy When there are contraindications for other methods of stone removal, ______is used for removal. open surgery Tx: For Calcium stones, remove PTH tumor, if present. Restrict dietary sodium, limit proteins and CHO, HCTZ reduces calcium in urine by 50%, cellulose sodium phosphate prevents absorption of Ca in the gut. Tx: For calcium oxalate stones, reduce oxalate in coffee, tea, chocolate, and green vegetables. Tx: For uric acid stones,

alkalinize urine to 6.5 -- acetazolamide (Diamox). At 7.0, risk for Ca stone formation. Limit purines in diet, allopurinol (reduces kidney stone recurrences) Tx: For _______stones -- acidification of urine and long term abx use. struvite ________syndrome is a nonspecific kidney disorder characterized by proteinuria, hypoalbuminemia and edema. Increase in permeability of the capillary walls of glomerulus leading to presence of high levels of protein passing from the blood into the urine. What is the main cause? Nephrotic syndrome; glomerulonephritis ________syndrome is not only loosing protein but also blood cells. Characterized by pores in the podocytes of the glomerulus large enough to permit protein and RBCc to pass into urine ie. CASTS. What is the main cause? Nephritic syndrome; streptococcal glomerulonephritis and crescentic (acute) glomerulonephritis ________is the inability to return the retracted foreskin over the glans. Condition leads to pain and edema treated by circumcision. Paraphimosis A _____is the imaging modality of choice in modern urology work-up of hematuria. CT urogram _________is increased secretion of PTH by parathyroid glands; marked by elevated calcium, low phosphorus. Hyperparathyroidism _________is increased serum PTH resulting from calcium wasting caused by renal failure or decreased GI calcium absorption, rickets or ostomalacia; calcium levels are usually low. Secondary hyperparathyroidism _________is persistent HPTH after correction of secondary HPT results from autonomous PTH secretion not responsive to normal negative feedback due to elevated Ca levels. Tertiary hyperparathyroidism What is the most common cause of hyperparathyroidism? adenoma What are the classic s/s of hyperparathyroidism? "stones, bones, groans, and psychic overtones" -- kidney stones, bone pain, pathologic fractures, subperiosteal resorption, muscle pain and weakness, pancreatitis, gout, constipation, depression, anorexia, anxiety. The initial medical treatment for PTH:

IV fluids and furosemide -- NOT thiazide diuretics (If from hyperplasia, then removing PTH except for 30mg tissue; If from adenoma, remove adenoma; If from carcinoma, remove carcinoma) The most common cause of hyperthyroidism is _________. What are three classic s/s of hyperthyroidism? Graves disease; hyperthyroidism, exophthalmos, and pretibial myxedema Hyperthyroidism is caused by circulating antibodies that stimulate _____receptors on follicular cells of the thyroid and cause deregulated production of thyroid hormones. Female to Male ratio?? TSH; Female:Male is 6: What is the medical therapy for hyperthyroidism? What is the most popular therapy? What is the surgical therapy? medical blockage with iodide, propranol, prophythiuracil (PTU), methimazole, Lugol's solution (potassium iodide); RADIOIODIDE ABLATION ; bilateral subtotal thyroidectomy Thyroid nodules are evaluated using ____& _____. They are distinguished as being either hot or cold. What is the difference? Which is more likely to be malignant? FNA - fine needle aspiration & thyroid scan[injects radioactive dye] "cold" nodules: decreased radioactive iodine uptake "hot" nodules: increased radioactive iodine uptake cold nodules are more likely to be malignant (25%) ______is the most common cause of thyroid enlargement. Multinodular goiter Administration of thyroid hormone suppresses TSH secretion and up to half of benign thyroid nodules will _____. disappear ________disease is a toxic multinodular goiter. Plummer's disease What is the most popular type of thyroid carcinoma? Papillary carcinoma (80%) What are the 5 main types of thyroid carcinoma? papillary, follicular, medullary, Hurthle cell, anaplastic/undifferentiated An ______carcinoma presents with a failed dexamethasone suppression test, high cortisol, low ACTH. Tx: surgical excision. Adrenal carcinoma

A ______is a tumor of the adrenal medulla and sympathetic ganglion (from chromaffin cell lines) that produces catecholamines. pheochromocytoma NE>E What are the classic s/s of a pheochromocytoma? palpitations, headache, episodic diaphoresis, HTN (most common sign!) Dx tests for pheochromocytoma Urine screen for VME (vanillylmandelic acid), metanephrine, epinephrine, norephinephrine Surgical treatment of pheochromocytoma? Possible perioperative complications? tumor resection with early ligation of venous drainage (lower possibility of catecholamine release); hypertensive crisis, hypotension w total removal of tumor, cardiac dysrhythmias Use __&___to evaluate breast malignancy? ultrasound and mammography Nipple Discharge duct ectasia (when lactiferous duct becomes clogged or blocked), abscess (tender fluctuant mass), blood discharge 10-15% of breast malignancy is unilateral ______ from a single duct. bloody discharge _____is a common benign breast tumor, late teens to early twenties, 1-3cm in size, fibrous stromal tissue and tissue clefts, FNA for dx. Fibroadenoma ______is the most common breast mass in women 40-50 years old. Screening mammogram, u/s, aspiration. Core-needle biopsy if complex on u/s. Breast cyst PE of breast exam should be in what 3 positions? sitting, supine, and leaning forward "akimbo" What are suspicious signs in a physical breast exam? skin dimpling, asymmetry, discoloration, edema, everted nipples wo rash or ulceration A ___________is recommended for tumors under 4cm. Post op radiation decreases to 30% recurrence rate. Lumpectomy

Contraindications of lumpectomy (instead....simple/total mastectomy, modified radical mastectomy, axillary dissection, sentinel lymph node biopsy, breast reconstruction) dermal lymphatic involvement, diffuse or multiple tumors, unwillingness or inability to undergo radiation treatment, expectation of a poor cosmetic outcome Indications for chemotherapy node positive disease, tumors greater than 1cm Hormone therapy ie. ____decreases recurrence, contralateral breast cancer by 40% for estrogen positive tumors. tamoxifen Follow-up mammograms after breast cancer: Lumpectomy: bilateral mammogram 6 months after completing radiation therapy Radical mastectomy: annual contralateral mammogram PE: q 3-6 months for 3 years...then annually Pre-malignant breast cancers --atypical ductal & lobular hyperplasia --lobular hyperplasia --lobular carcinoma in situ (LCIS) Breast malignancies --ductal carcinoma in situ (non-invasive) DCIS --invasive ductal carcinoma --invasive lobular carcinoma --Paget disease of nipple Post-op drug eruptions: Anaphylaxis is the most severe form of immediate ______hypersensitivity. Characterized by s/s affecting multiple organ systems. (Pruritis, urticarial, angioedema, laryngeal edema, wheezing, nausea, vomiting, tachycardia, impending doom, occasionally shock) Tx? type I/IgE-mediated drug reaction; epinephrine Anaphylaxis: for bronchospasm not relieved with epinephrine, what can be used? Albuterol Itching/hives reaction only treatment? ______onset can also be used to prevent biphasic or protracted reactions but onset can take several hours H1 antihistamine like Cetirizine or Diphenhydramine; glucocorticoid ________is second most common drug eruption after exanthematous drug eruptions. Characterized by short lived swelling of the skin, oropharynx, or genitalia. Transient leakage of plasma from small blood vessels into surrounding connective tissue of the dermis resulting in wheals.

Urticaria The most common drugs causing drug induced urticarial are ____. The most common drugs causing angioedema are ____&____. penicillins; ACEs & ARBs The concomitant use of opiates and vancomycin may increase the frequency of what syndrome? red man syndrome ____is blanching erythema from superficial dermal/epidermal infection (usually strep more than staph). What treatment is usually effective? Cellulitis; penicillins or first generation cephalosporins ________burns are more serious because the body cannot buffer , thus allowing them to burn for longer. Alkali Most destruction from _______burns is internal and follows nerves, blood vessels, and fascia. Cardiac dysrhythmias, myoglobinuria, acidosis, and renal failure. electrical ________is the presence of myoglobin in the urine usually associated with rhabdomyolysis or muscle destruction. Myoglobinuria How do you treat myoglobinuria? Think HAM! hydration with IV fluids, alkalization of urine with IV bicarbonate, and Mannitol diuresis Explain the four levels of burn injuries. 1st degree: epidermis only - painful, dry, red areas that do not blister (subburn) 2nd degree: epidermis and varying levels of dermis - painful, open weeping areas, blisters 3rd degree: full thickness, entire dermis, PAINLESS, like dried leather 4th degree: burn injury to bone or muscle Explain the Rule of 9's. Each upper limb: 9% Each lower limb: 18% Anterior & Posterior trunk: 18% each Head & Neck: 9% Perineum & Genitalia: 1% What is the Parkland Formula for initial resuscitation of a burn patient? V = TBSA burn% x weight in kg x 4

Parkland formula: the first half of fluid should be given over the first _____and the second half of fluid given over _____. 8 hours; 16 hours The fluid used after the first 24 hours of burn is ____. Use D5W and 5% albumin at 0.5cc/kg/%burn surface area. colloid pressure ulcer stage _____ is the most superficial indicated by nonblanchable redness that does not subside after pressure is relieved. The skin may be hotter or cooler than normal, have an odd texture, or be painful. I; reactive hyperemia; resolves itself within 3/4 time the pressure was applid, blanches when pressure is applied pressure ulcer stage _____is damage to the epidermis extending into but no deep than the dermis. May be referred to a blister or abrasion. II pressure ulcer stage _____involves full thickness of the skin and may extend into the subcutaneous tissue layer. LOOK FOR FAT. Poor blood supply, difficult to heal. III pressure ulcer stage _____is the deepest, extending into the muscle, tendon, or bone. IV ________pressure ulcers are covered with dead cells, eschar, and wound exudate such that the depth cannot be determined. Unstageable _____________is the most common skin cancer and most common human cancer. Slow growing, locally destructive, no mets. Basal cell carcinoma What type of BCC is the most common? Appearance? nodular bcc; pearly white or pink dome shaped papule w overlying telangiectasias, ulceration, raised borders, bleeding, scaling Other BCC types and appearances: Superficial BCC looks like __________. Pigmented BCC looks like __________. Morpheaform BCC looks like _______.

--scaly plaques/papules - can look like psoriasis, eczema, others --resembles melanoma --least common, white to yellow patch w poorly defined borders Squamous cell carcinoma is aka _______disease if it is SCC in situ. A potentially invasive malignancy of keratinocytes in the skin or mucous membranes. Bowen's disease Squamous cell carcinoma presentation: flesh, pink, yellow, or red indurated papules, plaques, or nodules with scale. Can have ulcerations and erosions. Melanoma presentation: flat, raised, nodular, or ulcerated -- variable color -- consider in any new mole or a mole changing in shape, size, or color What is the ABCDE for melanoma? A - asymmetry B - border C - color D - diameter E - evolution The most common type of melanoma is ________. Asymmetric, flat, lesions >6mm, vary in color, lateral spread superficial spreading melanoma Nodular melanoma is most common where? Acral lentiginous melanoma is primarily? Nodular melanoma:: extremities Acral lentiginous hands, feet, and nails. MC in blacks and Asians. Amelanotic melanoma is innocent-appearing pink to red colored papules that enlarge to plaques and nodules. Scary. Which type of suture is good for maximizing wound eversion? vertical mattress Are Nylon, Prolene, Stainless Steel, and Silk sutures absorbable or non-absorbable? non-absorbable Are vicryl, monocryl, PDS (polydioxanone), chromic, and gut sutures absorbable or non-absorbable?

absorbable Which suture is smaller: a 5.0 or a 3.0? a 5.0 How long does it take a wound to heal in the skin and mucosa? 5-7 days How long does it take a wound to heal in subcutaneous and peritoneum tissues? 7-14 days How long does it take a wound to heal affecting the fascia? 14-28 days What are some local and systemic factors that affect wound healing? Local: wound cleanliness, controlled bleeding, radiation, infection Systemic: nutrition, uncontrolled DM, medications, chronic illness, smoking, hypoxia What are the three stages of wound healing? inflammatory, epithelialization & neovascularization, tissue remodeling The ________stage of wound healing occurs in the first few days. The initial injury leads to the recruitment of inflammatory cells into the wound, once a clot forms in response to disrupted blood vessels. Complex interaction between local tissue mediators and cells that migrate to the wound. inflammatory The _______stage of wound healing results from the increase in cellular activity. Granulation tissue forms and depends on specific growth factors for further organization to occur in the completion of the healing process. Weeks to months. Epithelialization and neovascularization _________occurs over 6-12 months in which the wound contraction and tensile strength is achieved. Tissue Remodeling CDC Surgical Wound Classification: _________are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Operative incisional wounds, primarily closed or closed drainage. Clean wounds CDC Surgical Wound Classification: _________are operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and wo unusual contamination. Biliary tract, appendix, vagina, oropharynx are in this category.

Clean-contaminated CDC Surgical Wound Classification: _________are open, fresh, accidental wounds, operations w major breaks in sterile technique or gross spillage from the GI tract, and incisions in which acute, nonpurulent inflammation is encountered. Contaminated CDC Surgical Wound Classification: _________ are old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. Dirty or infected IV Fluid -- What fluid should you NOT use with a brain injury because of worsening brain edema? no sugar!!!!!!!!!! What is the 421 rule for adult fluid replacement? 4mL/kg for first 10kg/hr 2ml/kg for second 10kg/hr 1ml/kg for each additional kg/hr Patients with GI loss or 3rd space losses may require a ______amount of saline to maintain volume balance. higher Normal replacement of fluids in surgical patients is _____mEg/kg of sodium and ______mEg/kg of potassium per day. 1mEg/kg of sodium; 0.5mEg/kg of potassium RANDOM FLASH CARDS NOW RANDOM FLASH CARDS NOW Potassium rule of thumb: 10meq of potassium is expected to raise a patient's potassium level by ____. 0.1 points When surgeons talk about classic "breast cancer", what form are they specifically talking about? invasive ductal carcinoma Why is DCIS noninvasive? because it does not penetrate the basement membrane With breast cancer, what is the one specific case when chemotherapy is not necessary? IN ALL OTHER CASES, CHEMOTHERAPY IS DONE!

estrogen receptor negative AND HER negative AND size less than 2cm What are the three most common breast malignancies? DCIS - ductal carcinoma in situ, invasive ductal carcinoma,invasive lobular carcinoma Goldman Criteria

1. Age >70 - 5 points
2. MI wi 6 months - 10 points
3. S3 gallop, JBP>12cm - 11 points
4. Valvular Stenosis - 3 points
5. Rhythm not sinus - 7 points
6. PVC's >5/min at any time - 7 points
7. PO2<60, PCO3>50, K<3, HCO3<20, BUN>50, Cr>3, Chronic liver dz, debilitation - 3 points
8. Intraperitoneal, intrathoracic, aortic surgery - 3 points
9. Emergency Surgery - 3 points Class I - 0-5 points - 1% risk Class II - 6-12 points - 7% risk Class III - 13-25 points - 14% risk Class IV - >25 points - 78% risk What is the gastrinoma triangle? This is where 90% of gastrimomas or non B cell pancreatic tumor are found. junction of cystic duct & common bile duct, 2nd and 3rd portions of the duodenum, the junction of the neck and body of the pancreas Invasive procedures are usually not performed when _______are <50,000 and _____>1.5. Platelets, INR Gastric cancer is associated with ______ingestion. betel-nut Most gastric cancer is found in what region of the stomach? antral prepyloric region Stages of _________: Stage I - submucosa Stage II - muscularis propia Stage III - serosa Stage IV - adjacent structures gastric cancer _______syndrome occurs in patients with severe peptic ulceration and evidence of a gastrinoma Zollinger-Ellison Syndrome

Gastrinomas are a _______disease despite the malignant nature of most tumors. curable Ranson Criteria for assessing the severity of acute pancreatitis. GA LAW glucose > 200mg/dl Age > 55 Lactate Dehydrogenase > 350u/L Aspartate Aminotransferase > 250u/L WBC>16,000 With the Ranson Criteria, what criteria means a worsening prognosis in the 1st 48 hours of pancreatitis? CHOBBS Hematocrite drop >10% BUN rise >5mg/L PO2<60mmHg Ca<8mg/dL Base Deficit>4meq/L Estimated fluid sequestration>6L Kidney stones: _______(like in cystic fibrosis) causes ingested fat to bind Ca allowing free oxalate to be absorbed....thus causing hyperoxalurea. Steatorrhea What are the medical treatments (conservative) that can be used to help anal fissure pain? CCB, nitroglycerine -- they try to relax interal and external sphincter muscle What type of hernia is most common in African Americans? umbilical What are three important questions to ask a patient with a hernia needing surgery? history of BPH, constipation, or COPD/coughing --- all these things can interfere with healing post-op because of straining A _____hernia is midline along the linea alba. ventral A _____hernia is at or below the junction between the vertical semilunar line and lateral to the rectus abdominus muscle. spigelian A ___is a combination of a direct and indirect hernia that straddles the inferior epigastric vessels. Pantaloon

A sliding hernia contains ____organs. intra-abdominal An ___hernia is common in thin, elderly women, SBO from herniation into the obturator canal. obturator A _____hernia contains a Meckel's diverticulum. Littre A Richter hernia is when a portion of bowel protrudes, the lumen is patent, what is the result? usually gangrenous necrosis A _____is a bulge and weakness of the linea alba, no actual herniation. diastasis recti What is the most common type of lung cancer? Non-Small cell 85 % ie. adenocarcinoma (35%) squamous (30%) large cell (10%) Lung Adenocarcinoma usually occurs at the _____. periphery Lung Squamous cell carcinoma usually occurs _____. What is this cancer associated with? Patients may present with hypercalcemia, Pancoast's syndrome, and hypertrophic pulmonary osteoarthropathy centrally; associated with smoking, NO oat cell appearance Lung Small cell carcinoma is usually located where? What is it associated with? What is the classic appearance? centrally; associated with smoking; oat cell appearance Lung_______carcinoma is associated with paraneoplastic syndromes small cell _______syndrome presents with flushing, diarrhea, and palpitations. Elevated 5-HIAA levels Carcinoid 50% of carcinoids are found where? The rest are found throughout the GI tract. appendix