General Surgery

Contraindications to surgery

• –Absolute: Diabetic Coma, DKA
• –Poor nutrition: albumin <3, transferrin <200,weight loss <20%
• –Severe liver failure: bili >2, PT >16, ammonia > 150 or encephalopathy
• –Smoker: stop smoking 8wks prior to surgery
• If a CO2 retainer, go easy on the O2 in the post-op period. Can suppress respiratory drive.

Goldman’s Index

• Tells you who is at greatest risk for surgery
• –#1 = CHF
  • Check EF. If <35%, no surgery
• –#2 = MI w/in 6mo
  • Check EKG -> stress test -> cardiac cath -> revascularization
• –#3 =arrhythmia
• –#4 =Old (age >70)
• –#5 =Surgery is emergent
• –#6 =Aortic Stenosis, poor medical condition, surg in chest/abd
  • Listen for murmur of AS
    • Late systolic, crescendo-decrescendo murmur that radiates to carotids.
    • ↑ with squatting, ↓ with decrease preload

Pre-operative Eval

Preoperative evaluation checklist

• Meds to Stop:
  • Aspirin
  • NSAIDs
  • vit E (2wks)
  • Warfarin (5 days) –drop INR to <1.5 (can use vit K)
  • Take ½ the morning dose of insulin, if diabetic
• If CKD on dialysis: Dialyze 24 hours pre-op
• Check the BUN and Creatinine:
  • –if BUN > 100
    • There is an increased risk of post-op bleeding 2/2 uremic platelet dysfunction
  • Expect on coagulation panel: Normal platelets but prolonged bleeding time

Vent Settings

• Assist-control -> set TV and rate but if pt takes a breath, vent gives the volume.
• Pressure support (Important for weaning) -> pt rules rate but a boost of pressure is given (8-20).
• CPAP -> pt must breathe on own but + pressure given all the time.
• PEEP  (Used in ARDS or CHF) -> pressure given at the end of cycle to keep alveoli open (5-20).

If a patient on a vent

• Best test to evaluate management: ABG
• If PaO2 is low: increase FiO2
• If PaO2 is high: decrease FiO2
• If PaCO2 is low (pH is high): Decrease rate of Tidal Volume
• If PaCO2 is high (pH is low): Increase rate or TV
• Tidal Volume is more efficient to change.
• *Remember minute ventilation equation & dead space*

During Surgery

Post-operative Fever

Fever on POD #1

• –Most common cause, low fever (<101) and non-productive cough: Atelectasis
  • Dx: CXR-see bilateral lower lobe fluffy infiltrates
  • Tx: Mobilization and incentive spirometry.
• –High fever (to 104!!), very ill-appearing: Nec Fasciitis
  • Pattern of spread: In subQ along Scarpa’s fascia.
  • Common bugs: GABHS or clostridium perfringens
  • Tx: IV PCN, Go to OR and debride skin until it bleeds
• –High fever (>104!!) muscle rigidity: Malignant Hyperthermia
  • Caused by: Succinate or Halothane
  • Genetic defect: Ryanodine receptor gene defect
  • Treatment: Dantrolene Na (blocks RYR and decrease intracellular calcium.

Fever on POD #3-5

• –Fever, productive cough, diaphoresis: Pneumonia
  • Tx: Check sputum sample for culture, cover w/ moxi etc to cover strep pneumo in the mean time.
• –Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley: UTI
• Next best test: UA (nitritie and LE) and culture.
• Tx: Change foley and treat w/ wide-spec abx until culture returns.

Fever > POD 7

• –Pain & tenderness at IV site: Central line infection
  • Tx: Do blood cx from the line. Pull it. Abx to cover staph.
• –Pain @ incision site, edema, induration but no drainage: Cellulitis
  • Tx: Do blood cx and start antibiotics
• –Pain @ incision site, induration WITH drainage: Simple Wound Infection
  • Tx: Open wound and repack. No abx necessary
• –Pain w/ salmon colored fluid from incision: Dehiscence
  • Tx: Surgical emergency! Go to OR, IV abx, primary closure of fascia
• –Unexplained fever: Abdominal Abscess
  • Dx: CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
  • Tx: Drain it! Percutaneously, IR-guided, or surgically.
• –Random -> thyrotoxicosis, thrombophlebitis, adrenal insufficiency, lymphangitis, sepsis.

Post Operative Problems

Altered Mental Status

Acid-Base Disorders

• Check pH -> if <7.4 = acidotic.
• Next Check HCO3 and pCO2:
  • –If HCO2 is high and pCO2 is high: Respiratory Acidosis
  • –If HCO2 is low and pCO2 is low: Metabolic Acidosis
• Next Check anion gap (Na –[Cl+ HCO3]), normal: 8-12
• Gap acidosis = MUDPILES
• Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV)
• Check pH if >7.4 = alkalotic.
• Next Check HCO3 and pCO2:
  • –If HCO3 is low and pCO2 is low -> Respiratory Alkalosis
  • –If HCO3 is high and pCO2 is high -> Metabolic Alkalosis
    • Next Check urine [Cl]
    • If [Cl] < 20: Vomiting/NG, antacids, diuretics
    • If [Cl] > 20: Conn’s, Bartter’s Gittleman’s.

Breast Cancer

Chest Pain

Murmur Buzzwords

Aortic Stenosis

• SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvuset tardus

HOCM

• SEM louder w/ valsalva, softer w/ squatting or handgrip.

Mitral Valve Prolapse

• Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting

Mitral Regurgitation

• Holosystolic Murmur radiates to axilla w/ LAE

VSD

• Holosystolic murmur w/ late diastolic rumble in kiddos

PDA

• Continuous machine like murmur-

ASD

• Wide fixed and split S2-

Mitral Stenosis

• Rumbling diastolic murmur with an opening snap, LAE and A-fib

Aortic Regurgitation

• Blowing diastolic murmur with widened pulse pressure and eponym parade.

Thoracic

Pleural Effusions

• see fluid >1cm on lateral decubitus -> thoracentesis!
• –If transudative, likely CHF, nephrotic, cirrhotic
  • If low pleural glucose: 0.5Rheumatoid Arthritis
  • If high lymphocytes: Tuberculosis
  • If bloody: Malignant or Pulmonary Embolus
• –If exudative, likely parapneumonic, cancer, etc.
• –If complicated (+ gram or cx, pH < 7.2, glc< 60):
  • Insert a chest tube for drainage.
• –Light’s Criteria -> transudative if:
  • LDH < 200
  • LDH eff/serum < 0.6
  • Protein eff/serum < 0.5

Spontaneous Pneumothorax

• Spontaneous Pneumothorax -> subpleuralbleb ruptures ->lung collapse.
• –Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)
• –Dxw/ CXR, Txw/ chest tube placement
• –Indications for surgery = ipsior contra recurrence, bilateral, incomplete lung expansion, pilot, scuba, live in remote area VATS, pleurodesis(bleo, iodine or talc)

Lung Abscess

• Lung Abscess -> usually 2/2 aspiration (drunk, elderly, enteral feeds)
  • –Most often in post upper or sup lower lobes
  • –Tx initially w/ abx -> IV PCN or clindamycin
  • –Indications for surgery = abx fail, abscess >6cm, or if empyema is present.

Solitary Lung Nodule

• 1st step = Find an old CXR to compare!
• Characteristics of benign nodules:
  • –Popcorn calcification = hamartoma(most common)
  • –Concentric calcification = old granuloma
  • –Pt< 40, <3cm, well-circumscribed
  • –Tx: CXR or CT scans q2mo to look for growth
• Characteristics of malignant nodules:
  • –If pt has risk factors (smoker, old), If >3cm, if eccentric calcification
  • –Tx: Remove the nodule (w/ bronc if central, open lung biopsy if peripheral.

ARDS

• Pathophys:
  • inflammation -> impaired gas exchange, inflammation mediator release, hypoxemia
• Causes:
  • –Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis.
• Diagnosis:
  • 1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
  • 2.) Bilateral alveolar infiltrates on CXR
  • 3.) PCWP is <18 (means pulmonary edema is non-cardio
• Treatment:
  • Mechanical ventilation w/ PEEP

Cancers

A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse.

• MC cancer in non-smokers:
  •  Adenocarcinoma. Occurs in scars of old pneumonia
• Location and mets:
  • Peripheral cancer. Mets to liver, bone, brain and adrenals
• Characteristics of effusion:
  • Exudative with high hyaluronidase
• Patient with kidney stones, constipation and malaise low PTH + central lung mass:
  • Squamous cell carcinoma. Paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca
• Patient with shoulder pain, ptosis, constricted pupil, and facial edema:
  • Superior Sulcus Syndrome from Small cell carcinoma. Also a central cancer.
• Patient with ptosis better after 1 minute of upward gaze:
  • Lambert Eaton Syndrome from small cell carcinoma. Ab to pre-syn Ca chan
• Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD:
  • SIADH from small cell carcinoma. Produces Euvolemic hyponatremia. Fluid restrict +/-3% saline in <112
• CXR showing peripheral cavitation and CT showing distant mets:
  • Large Cell Carcinoma

Gastrointestinal Disorders

Esophageal Disorders

Achalasia

• Dysphagia to liquids & solids
• Tx w/ CCB, nitrates, botox, or heller myotomy
• Assoc w/ Chagas dz and esophageal cancer.

Boerhaave’s Esophageal Rupture

• If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase
• Next best test:
• CXR, gastrograffin esophagram. NO endoscopy
• Tx: surgical repair if full thickness

Diffuse esophageal spasm

• Dysphagia worse w/ hot & cold liquids + chest pain that feels like MI w/ NO regurgitating symptoms.
• Tx w/ CCB or nitrates

Esophageal Carcinoma

• If progressive dysphagia/weight loss
• Carcinoma Squamous cell in smoker/drinkers in the middle 1/3. Adeno in ppl with long-standing GERD in the distal 1/3.
• Best 1sttest: barium swallow, then endoscopy w/ biopsy, then staging CT.

Gastric Cancer

• Adeno most common. Especially in Japan
• – Krukenberg: Gastric Ca -> Ovaries
• – Virchow’s node: L supraclavicular fossa
• – Lymphoma: HIV
• – Blummer’s Shelf: METS felt on DRE
• – Sister Mary Joseph: Umbilical node
• – MALT-lymphoma: H-pylori

Other GI disorders

• –Mentriers = protein losing enteropathy, enlarged rugae.
• –Gastric Varices = splenic vein thrombosis.
• –Dieulafoy’s = massive hematemesis -> mucosal artery erodes into stomach

Gastric Ulcers

• MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids
• –Work up = Double-contrast barium swallow-punched out lesion w/ reg margins. EGD w/ bx can tell H. pylori, malign, benign.
• –Surgery if – Lesion persists after 12wks of treatment.

Gastric Varices

• If gross hematemesis unprovoked in a cirrhotic w/ pulmonary HTN.
• If in hypovolemic shock:
  • do ABCs, NG lavage, medical tx w/ octreotide or SS. B
  • balloon tamponade only if you need to stabilize for transport
• Tx of choice:
  • Endoscopic sclerotherapy or banding
  • *Don’t prophylactically band asymptomatic varices. Give BB.

GERD

• Epigastric pain worse after eating or when laying down, cough, wheeze, hoarse.
• Most sensitive test is 24-hr pH monitoring.
• Do endoscopy if “danger signs” present.
• Tx w/ behavior mod 1st, then antacids, H2 block, PPI.

Hiatal Hernia

• Acid reflux pain after eating, when laying down
• –Type 1 = Hernia Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs
• –Type 2 = Paraesophageal. Abd pain, obstruction, strangulation -> needs surgery.

Zenker’s diverticulum

• Bad breath & snacks in the AM.
• Only contains mucosa
• Tx w/ surgery

Indications for surgery

• bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/ still sxs, or no want meds.

Distended Abdomen

Duodenal Ulcers

• -MEG pain better w/ eating
• –95% associated w/ H. pylori
• –Healthy pts< 45y/o can do a trial of H2 block or PPI
• –Dx: blood, stool, or breath test for H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer.
• –Tx: PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.

ZE Syndrome

• If MEG pain/ulcers don’t resolve
• –Best test: Syndrome Secretin Stim Test (find inapprop high gastrin)
• –Tx: Surgical resection of pancreatic/duodenal tumor
• –What else to look for: Pituitary and Parathyroid problems.

SMA Syndrome

• A patient has bilious vomiting and post-prandial pain. 
• –Pathophys: 3rd part of duodenum compressed by AA and SMA
• –Tx: SMA by restoring weight/nutrition. Can do Roux-en-Y

Abdominal Disorders

Pancreas

Colorectal

Ulcers

Pressure Ulcers

• Caused by impaired blood flow -> ischemia
  • –Don’t culture will just get skin flora. Check CBC and blood cultures. Can mean bacteremia or osteomyelitis.
  • –Can do tissue biopsy to rule out Marjolin’sulcer
  • –Best prevention is turning q2hrs
  • –Stage 1 = skin intact but red. Blanches w/ pressure
  • –Stage 2 = blister or break in the dermis
  • –Stage 3 = SubQdestruction into the muscle
  • –Stage 4 = involvement of joint or bone.
• Management:
  • Stage 1-2: get special mattress, barrier protection
  • Stage 3-4: get flap reconstruction surgery
    • –Before surgery, albumen must be >3.5 and bacterial load must be <100K

Metabolic Disorders

Sodium Abnormalities

• ↓Na = Gain of water
  • –Check osm, then check volume status.
  • –↑volume ↓Na: CHF, nephrotic, cirrhotic
  • –↑volume ↓ Na: diuretics or vomiting + free water
  • –Normal volume ↓Na: SIADH, Addisons, hypothyroidism
  • –Treatment: Fluid restriction & diruetics
  • –If hypovolemic: Normal Saline
  • –When to use 3% saline: SalineSymptomatic (Seizures), < 110
  • –What would you worry about: 110Central Pontine Myolinolysis
• ↑Na =Loss of water
  • –Treatment: Replace w/ D5W or hypotonic fluid
  • –What would you worry about: cerebral edema

Other Electrolyte Abnormalities

• ↓Ca = Numbness, Chvostek or Trousseau, prolonged QT interval.
• ↑Ca = Bones, stones, groans, psycho. Shortened QT interval.
• ↓K = Paralysis, ileus, ST depression, U waves.
  • –Treatment: give K (kidneys!), max 40mEq/hr↑K
• ↑K = Peaked T waves, prolonged PR and QRS, sine waves.
  • –Treatment: Give Ca-gluconate then insulin + glucose, kayexalate, albuterol, and sodium bicarb. Last resort = dialysis

Urinary Disorders

Fluid and Nutrition

• Maintenance IVFs: D51/2NS + 20KCl (if peeing)
• –Up to 10kg: 100mL/kg/day
• –Next 10 kgs: 50mL/kg/day
• –All above 20: 20mL/kg/day
• Enteral Feeds: best to keep gut mucosa intact and prevent bacterial translocation.
• TPN: indicated if gut can’t absorb nutrients 2/2 physical or functional loss.
• –Risks = acalculus cholecystitis, hyperglycemia, liver dysfunction, zinc deficiency, other ‘lyte probs