Term
| What studies can you perform if you suspect aortic injury? |
|
Definition
| angiography, CT angiography, transesophageal echocardiography |
|
|
Term
| What is the treatment for blunt cardiac injury? |
|
Definition
| supportive care (inotropes); operative repair for cardiac rupture |
|
|
Term
| What is the order of events that should occur during treatment of a trauma victim? |
|
Definition
| ABCs, Secondary survey, IV lines and blood studies, pt re-examined for any change in clinical status |
|
|
Term
| How do you treat rib fractures? |
|
Definition
| management of the associated pain and chest wall splinting that may lead to hypoventilation, atelectasis, and pneumonia |
|
|
Term
| T/F It is reasonable to control pain from rib fractures with epidural anesthesia. |
|
Definition
|
|
Term
| What should you make sure happens after you place a chest tube to correct a pneumothorax? |
|
Definition
| should look for full reexpansion; failure to reexpand or persistent air leak= consider major tracheobronchial injury |
|
|
Term
| Name for insertion of a chest tube= |
|
Definition
|
|
Term
| How does blunt cardiac injury present? |
|
Definition
| 40% with arrhythmia, 45% with cardiogenic shock, and 15% with anatomic defects |
|
|
Term
| What is a pulmonary contusion? |
|
Definition
| hemorrhage into the alveolar and interstitial spaces |
|
|
Term
| What is the treatment for pulmonary contusion? |
|
Definition
| supportive measures (possible ventillation based on clinical status); fluid restriction advised unless the patient needs to be resusitated |
|
|
Term
|
Definition
| traumatic rupture of the aorta |
|
|
Term
| What kinds of injuries cause TRA? |
|
Definition
| generally frontal impact (acceleration, deceleration) but also can occur on side impact collisions |
|
|
Term
| What is the major determining factor of the outcome of TRA? |
|
Definition
| whether or not the rupture iscontained by the mediastinal pleura |
|
|
Term
| What is the gold standard for diagnosis of TRA? |
|
Definition
|
|
Term
| What is the most widely accepted way to diagnose TRA? |
|
Definition
|
|
Term
| What other injuries should make you suspicious of a TRA? |
|
Definition
| first and second rib fractures, scapular fracture |
|
|
Term
| What are signs on a CXR of TRA? |
|
Definition
| widened mediastinum, apical pleural hematoma ("cap"), obliterated aortic knob, loss of perivertebral stripe, deviated NGT |
|
|
Term
| What are the symptoms of fat embolism? |
|
Definition
| hypoxemia, and CNS effect such as confusion or coma; also possible petechiae and retinal lesions |
|
|
Term
| What are the disadvantages for using CT imaging for abdomenal pain? |
|
Definition
| limited sensitivity for early papendicitis and pelvic pathology |
|
|
Term
| When is clinical observation with serial laboratory studies an inappropriate treatment for abdomenal pain? |
|
Definition
| when the patient has localized pain, fever, and leukocytosis |
|
|
Term
| What percent of appendicitis is chronic or recurrent? |
|
Definition
|
|
Term
| What is thought to possibly an appendicitis to become chronic? |
|
Definition
| early administration of antibiotics |
|
|
Term
| When is an interval appendectomy indicated? |
|
Definition
| when appendicitis is complicated by abscess or phlegmon |
|
|
Term
| Describe the steps of an interval appendectomy. |
|
Definition
| broad spectrum antibiotic therapy with CT guided drainage of the abscess to resolve the infectious process, followed by appendectomy after several weeks |
|
|
Term
| What is mesenteric adenitis? |
|
Definition
| when a viral illness causes painful lymphadenopathy in the small bowel mesentery; the process can be associated with right lower quadrant pain and tenderness and is especiallycommon in children |
|
|
Term
| How does obstruction lead to appendicitis? |
|
Definition
| obstruction leads to an increase in mucous secretion and bacterial overgrowth leading to venous and lymphatic congestion |
|
|
Term
| What is the classic history of appendicitis? |
|
Definition
| vague pain in the periumbilical region, nausea, vomiting, and the urge to defecate, followed by localization of the pain the the RLQ associated with localized peritonitis |
|
|
Term
| What percent of pts with appendicitis perforate within the first 24 hours? |
|
Definition
|
|
Term
| What causes atypical presentations of appendicitis? |
|
Definition
| usually the appendix is in a strange position (retrocolic or pelvic); administration of antibiotics may also change the presentation |
|
|
Term
| What percent of people have a classic presentation of acute appendicitis? |
|
Definition
|
|
Term
| Luminal obstruction of the appendix causes what symptoms? |
|
Definition
| poorly localized periumbilical pain, nausea, vomiting, and urge to defecate |
|
|
Term
| Inflammation of the appendix causes what signs/symptoms? |
|
Definition
| location of pain depends on position of appendix; peritonitis is present only if the inflamed appendix or inflammatory changes involve the peritoneum |
|
|
Term
| What are the clinical signs and symptoms associated with perforation of the appendix? |
|
Definition
| transient improvement in pain but an increase in systemic toxicity |
|
|
Term
| What should you do to work up a patient with a classic acute appendicitis presentation? |
|
Definition
| thorough H and P, UPT if woman, CBC with diff, U/A |
|
|
Term
| When you have a high clinical suspicion of PE, what is the next step? |
|
Definition
| epirical systemic anticoagulation while waiting for confirmatory imaging |
|
|
Term
| What is the ddx for a postmenopausal woman with sudden onset CP and SOB following surgery? |
|
Definition
| cardiac ischemia, respiratory tract infection, acute lung injury and PE |
|
|
Term
| T/F Patients with PE who are treated with early aggressive anticoagulation therapy are less likely to experience treatment failure or develop recurrences |
|
Definition
|
|
Term
| What is venous duplex scanning? |
|
Definition
| an accurate, noninvasive imaging modality combining ultrasonagraphy and Doppler technology to assess the patency of veins and the presence of blood clots in veings; especially useful in the lower extremities |
|
|
Term
|
Definition
| a radioisotype scan used to identify V/Q mismatches (can indicate PE and other pulmonary conditions but results must be interpreted based on coexisting pulmonary pathology and the clinical picture) |
|
|
Term
| What is the sensitivity of CT in detecting PEs? |
|
Definition
| 64% to 93%; highly sensitive for PEs involving the central pulmonary arteries but insensitive for subsegmental clots |
|
|
Term
| What test can be combined with chest CT to increase its accuracy for detecting PE? |
|
Definition
| venous duplex or pelvic CT venography |
|
|
Term
| What is the gold standard for diagnosis of PE? |
|
Definition
|
|
Term
| What is the accuracy rate of pulmonary angiography for PE? false negative rate? |
|
Definition
| 96% accurate (false negative= 0.6%) |
|
|
Term
| What are the drawbacks of using pulmonary angiography to diagnose PE? |
|
Definition
| major complication rate of 1.3%; mortality rate of 0.5%; and time delay associated with the procedure |
|
|
Term
| What are the contraindications to systemic thrombolytic therapy for PE? |
|
Definition
| recent major surgery (within 10 day period), recent severe closed head injury |
|
|
Term
| What is a pulmonary embolectomy? |
|
Definition
| surgical retrieval of clots in the pulmonary artery through a median sternotomy, requiting cardiopulmonary bypass |
|
|
Term
| When is pulmonary embolectomy indicated? |
|
Definition
| massive PE with hemodynamic instability and hypoxia, where thrombolytic therapy is contraindicated |
|
|
Term
| What is the mortality rate of pulmonary embolectomy? |
|
Definition
|
|
Term
|
Definition
| stasis, hypercoagulability, and vein wall injury |
|
|
Term
| What is the occurence of DVT in general surgery pts post op without prophylaxis? |
|
Definition
|
|
Term
| What is the post op DVT risk in gen surg pts with low dose heparin prophylaxis? |
|
Definition
|
|
Term
| What is the post op DVT risk in gen surg pts with low-molecular-weight heparin prophylaxis? |
|
Definition
|
|
Term
| What is the post op DVT risk in gen surg pts with elastic stockings or intermittent pneumatic compression devices as prophylaxis? |
|
Definition
|
|
Term
| Which pts are at extremely high risk of DVT/PE? |
|
Definition
| major orthopedic surgery and major trauma |
|
|
Term
| Which locations for DVT are more likely to cause a PE? |
|
Definition
| tibial level veins are lower risk; femoral and/or iliac veins have a dramatically increased risk (30-50% get PE); and subclavian and UE veins have the highest risk of all |
|
|
Term
| In general, all patients with DVT and PE should undergo treatment with.... |
|
Definition
| systemic anticoagulation therapy with heparin infusion, oral warfarin or subcutaneous low molecular weight heparin |
|
|
Term
| What is the duration of therapy for DVT? PE? |
|
Definition
| 3 months, 6 months; unless they have documented hypercoagulability in which case they should undergo anticoagulation therapy for life |
|
|
Term
| What are the major indications for vena cava filter placement? |
|
Definition
| recurrent PE despite adequate anticoagulation, complications from anticoagulation, and contraindication to anticoagulation |
|
|
Term
| What are the two different kinds of heparin and their various aliases? |
|
Definition
| unfractionated heparin vs. low molecular weight heparin or fractionated heprin |
|
|
Term
| Which heparin is better for DVT treatment? |
|
Definition
| LMWH (3% recurrence; 1% major bleed; lower risk of HIT) vs. unfractionated heparin which has 6% recurrence, 3% major bleed risk; 1-3% risk of HIT |
|
|
Term
| When is thrombolytic hterapy indicated for DVT? |
|
Definition
|
|
Term
| What is the use of a D-dimer level in patients with suspected DVT/PE? |
|
Definition
| D-dimer levels are elevated in 99.5% of pts with DVT/PE but this is also seen following trauma and surgery and so the test is highly sensitive but nonspecific |
|
|
Term
| What does a low probability V/Q scan mean? |
|
Definition
| with high clinical suspicion can mean likelihood of PE is 40%; with low clnical suspicion= 4%; with intermediate or uncertain clinical suspicion= 16% |
|
|
Term
| T/F Pneumaticcompression devices have no proven efficacy in teh prevention of DVT in the high risk trauma patient. |
|
Definition
|
|
Term
| T/F The benefits of prophylactic measures against DVT/PE are additive and should be applied together to reduce risk. |
|
Definition
|
|
Term
| T/F A serial surveillance duplex scan should be obtained in very high risk patients despite DVT prophylaxis. |
|
Definition
|
|
Term
| What is an abdominoperineal resection? |
|
Definition
| resection of the rectum and anal canal including anal sphincter complex for low lying rectal carcinoma; the procedure leaves the patient witha permanent colostomy |
|
|
Term
| Whatis a low anterior resection? |
|
Definition
| resection of the rectum to the level of the levator ani muscles leaving the anal canal and analsphincter muscles intact so that a stapled or hand sewn anastomosis can be performed |
|
|
Term
| What is the bowel prep for elective colon surgery? |
|
Definition
| a mechanical preparation consisting of a large volume of polyethylene glycol solution or a smaller volume of phosphosoda and a broad spectrum intravenous and/or oral nonabsorbable antibiotic; the goal is to decrease the bacterial count in the event of spillage of colonic contents |
|
|
Term
| What are the two most common causes of death from cancer? |
|
Definition
|
|
Term
| What percent of colorectal cancers initially develop as an adenomatous polyp? |
|
Definition
|
|
Term
| What is the recommendation for colonoscopy screening for pts with average risk? |
|
Definition
| every ten years beginning at age 50 |
|
|
Term
| What is the followup for patients who have an adenomatous polyp bigger than 1 cm identified and removed during colonoscopy? |
|
Definition
| repeat colonoscopy should be done in 3 years; when the colon is clear of polyps colonoscopy can be done every 5 years |
|
|
Term
| What is the most common presenting symptom of colorectal cancer? |
|
Definition
|
|
Term
| What are the characteristic changes in bowel habits seen in left sided colon cancer? |
|
Definition
| decrease in the caliber of stools and diarrhea |
|
|
Term
| What are the two ways to stage colon cancer? |
|
Definition
| tumor-node-metastasis system and Astler-Coller modification of the Duke classification |
|
|
Term
|
Definition
| primary tumor can not be assessed |
|
|
Term
|
Definition
| no evidence of primary tumor |
|
|
Term
|
Definition
|
|
Term
|
Definition
| tumor invasion into submucosa |
|
|
Term
|
Definition
| tumor invasion into muscularis propia |
|
|
Term
|
Definition
| tumor invasion through muscularis propria |
|
|
Term
|
Definition
| tumor perforation of visceral peritoneum |
|
|
Term
|
Definition
| tumor invasion of adjacent structure |
|
|
Term
|
Definition
| regional lymph nodes cannot be assessed |
|
|
Term
|
Definition
| regional lympho nodes cannot be assessed |
|
|
Term
|
Definition
|
|
Term
|
Definition
| >4 regional lymph nodesinvolved |
|
|
Term
|
Definition
| regional lymph nodes involved along a major vascular structure |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What is stage 1 colon cancer? |
|
Definition
|
|
Term
| What is stage 2 coloncancer? |
|
Definition
|
|
Term
| What is stage 3 colon cancer? |
|
Definition
|
|
Term
| What is stage IV colon cancer? |
|
Definition
|
|
Term
| What is stage A colon cancer? |
|
Definition
|
|
Term
| What is stage B colon cancer? |
|
Definition
|
|
Term
| What is stage C1 colon cancer? |
|
Definition
| T1, T2, T3; N1, N2, N3; M0 |
|
|
Term
|
Definition
|
|
Term
| What is stage D colon cancer? |
|
Definition
|
|
Term
| RIsk of carcinoma with an adenomatous polyp smaller than 1cm? |
|
Definition
|
|
Term
| Risk of carcinoma for an adenomatous polyp from 1-2 cm? |
|
Definition
|
|
Term
| Risk of carcinoma with an adenomatous polyp greater than 2cm? |
|
Definition
|
|
Term
| What studies constitute a good workup for mets in a patient undergoing colonic adenocarcinoma resection? |
|
Definition
| CXR, abdomenal and pelvic CT |
|
|
Term
| Which has less risk of anastomotic dehiscence and stricture, hand-sewn or stappling for colonic anastomosis? |
|
Definition
|
|
Term
| What are the current chemotherapy regimens for adjuvant therapy of stage III colon cancer after resection? |
|
Definition
| FOLFOX4 regimen= 5-FU, leucovorin, and oxaliplatin |
|
|
Term
| 5 yr survival of colon cancer stage 1= |
|
Definition
|
|
Term
| 5 yr survival of colon cancer stage 2= |
|
Definition
|
|
Term
| 5 yr survival of colon cancer stage 3= |
|
Definition
|
|
Term
| 5 yr survival of colon cancer stage IV= |
|
Definition
|
|
Term
| What percent of all colorectal cancer is invasive adenocarcinoma of the rectum? |
|
Definition
|
|
Term
|
Definition
| lowest 15 cm of the rectum |
|
|
Term
| What is the preoperative workup for rectal cancer? |
|
Definition
| CXR, CT scan of abdomen and pelvis; endoscopic U/S of the perirectal lymph nodes |
|
|
Term
| If a tumor is low lying in the rectum, how do you resect it? |
|
Definition
| transanally with tumor free margins |
|
|
Term
| Transanal resection of rectal cancers have the best outcome when... |
|
Definition
| cancer is less than 1/3 the circumference of the rectum, less than transmural involvement, a well to moderately differentiated histologic grade and unaffected rectal lymph nodes |
|
|
Term
| How do you resect a rectal cancer with lymph node metastasis? |
|
Definition
| surgical resection of the involved rectum and surrounding lymph nodes is necessary |
|
|
Term
| How do you resect rectal tumor above the sphincters? |
|
Definition
| low anterior resection (LAR) |
|
|
Term
| How do you resect rectal tumors near the sphincter complex? |
|
Definition
| abdominoperineal resection (APR) with permanent colostomy |
|
|
Term
| What is the risk of having subsequent colorectal cancer after being "cured" of initial neoplasm? |
|
Definition
|
|
Term
| How should a colon cancer pt be managed after remission? |
|
Definition
| serial colonoscopies; yearly H and Ps and serial CEA measurements |
|
|
Term
| What pts are at a higher risk for colon cancer? |
|
Definition
| those with FAP syndrome, familial cancer (first degree relatives), HNPCC syndrome, and a history of IBD, particularly ulcerative colitis |
|
|
Term
| What is the screening process for children of people with FAP? |
|
Definition
| flex sig every 1-2 yrs beginning at 10-12 years of age; initial upper endoscopy at age 20 or at age of prophylactic colectomy (upper endoscopy every 2-3yrs if mild duodenal disease; every 6moto1 yr if severe duodenal disease |
|
|
Term
| What is the recommended screening for individuals with a strong family history of colon cancer? |
|
Definition
| initial C scope at 40 or when they are 10 yrs younger the the age at which the relative was diagnosed, whichever comes first |
|
|
Term
| What is the recommneded screening for pts with HNPCC syndrome? |
|
Definition
| initial c scope at 25 followed by yearly FOBT and c scope very 3 years |
|
|
Term
| How should ulcerative colitis pts be monitored for colon cancer? |
|
Definition
| c scope 7-8 years after UC started then every 1-2 years subsequently |
|
|
Term
| IF a patient has a s scope and suboptimal clearance of polyps, what should be the followup? |
|
Definition
|
|
Term
| T/F Flexible upper endosocpy is recommneded for all first degree relatives of FAP, gardner syndrome and turcot syndrome patients. |
|
Definition
|
|
Term
| How should first degree relatives of pts with FAP be monitored? |
|
Definition
| flexible upper endoscopy, abdominal CT for desmoid tumors |
|
|
Term
| What is the sureveillance of first degree relatives of Turcot syndrome patients? |
|
Definition
| flexible upper endoscopy; CT scan of the brain |
|
|
Term
| Which BRCA carries an increased risk of colon cancer? |
|
Definition
|
|
Term
| T/F Radiation therapy is generally indicated for patients with rectal carcinoma, |
|
Definition
|
|
Term
| Why do patients with FAP need upper endoscopies? |
|
Definition
| they are also at high risk for adenomas and adenocarcinomas of the duodenum |
|
|
Term
| Why should you never do an excisional biopsy of a mass that could be a STS? |
|
Definition
| because of difficulty in achieving adequate resection margins which would compromise the definitive care of the patient (brachytherapy radioactive catheters are placed intraoperatively, if indeed it is a STS then you need to have a 2 cm margin from the tumor, with large tumors in deep locations you should get an MRI or CT preop to define tumors relationship to major structures and perhaps have preop chemo to shrink the tumor so you don't have to sacrifice a limb, etc.) |
|
|
Term
| What clinical features of a mass should raise suspicion for STS? |
|
Definition
| increased size, absence of a psecific event to account for a hematoma of this size, firmness of th emass, and the absence of surrounding skin changes to suggest an inflammatory or infectiousprocess |
|
|
Term
| T/F Pts with STS often have associated symptoms such as regional lymphaednopathy, weight loss, night sweats or cachexia. |
|
Definition
|
|
Term
|
Definition
| false; rapid tumor growth can cause tissue necrosis causing pain which is why STS can look like an abscess |
|
|
Term
| What are the three categories of sarcoma? |
|
Definition
| extremity, superficial truncal and visceral/retroperitoneal |
|
|
Term
| What types of cancers are associated with Li-Fraumeni syndrome? |
|
Definition
| soft tissue sarcoma, breast cancer, leukemia, osteosarcoma, melanoma, and cancer of the colon, pancreas, adrenal cortex, and brain |
|
|
Term
| What is the gene linked to Li-Fraumeni syndrome? |
|
Definition
| more than half have identifiable TP53 gene |
|
|
Term
| STS should be suspected for any mass that is... |
|
Definition
| increasing in size, or a mass bigger than 5 cm in diameter |
|
|
Term
| Name some examples of different STS. |
|
Definition
| liposarcoma, fibrosarcoma, leiomyosarcoma, and malignant fibrohistiocytoma |
|
|
Term
| What embryological tissue do sarcomas arise from? |
|
Definition
|
|
Term
|
Definition
| core needle biopsy or a fine needle biopsy |
|
|
Term
| Patients with STS are at highrisk of pulmonary metastasisif... |
|
Definition
|
|
Term
| What metastatic work up should you do for a patient with STS? |
|
Definition
| pts with large tumorsor withhighly mitotic tumors are at increased risk for pulmonary metastasis so you should get a CT scan of the lung |
|
|
Term
| What is the staging of an extremity STS isbased on what factors? |
|
Definition
| size (less than or equal to 5cm is favorable), grade, and superficial versus deep |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| two unfavorable signs, one favorable |
|
|
Term
|
Definition
|
|
Term
|
Definition
| either lymph node or distant metastasis |
|
|
Term
| Is pts survival better with distant metastasis or regional lymph node metastasis for STS? |
|
Definition
|
|
Term
| 5 yrs survival of STS that is less than 5 cm with favorable grade? |
|
Definition
|
|
Term
| 5 yr survival for pts with soft tissue sarcomas greater than 5cm and with a high grade? |
|
Definition
|
|
Term
| What is the 5 yr surival of pts with stage IV STS? |
|
Definition
| 10-15%; unless tha pulmonary metastasis are amenable to complete resection= 35% |
|
|
Term
| T/F Pts who have complete amputations to treat their STS have a greater survival rate than those treated with limb saving surgery. |
|
Definition
| false; the survival rates are the same |
|
|
Term
| How much do you need to take out when removing a STS? |
|
Definition
| all efforts need to be made to obtain negative microscopic margins but amputation confers no survival risk so they should not be done; complete resection of a muscle compartment results in greater functional loss and is generally unnecessary; complete resection with a 2 cm gross margin is reasonable to insure negative microscopic margins |
|
|
Term
| Do you ever treat STS with anything other than surgical resection? |
|
Definition
| radiation therapy should be considered for stage 2 and 3 disease; either via brachytherapy, or external beam therapy |
|
|
Term
|
Definition
| radioactive catheters placed directly in the tumor resection bed |
|
|
Term
| When should you use brachytherapy vs external beam in treating stage 2 or 3 STS? |
|
Definition
| brachy therapy for high grade tumors; and external beam therapy for large, low grade, or deeply located tumors |
|
|
Term
| T/F Local recurrence of STS takes place despite resection with grossly clear margins. |
|
Definition
|
|
Term
| How do you follow up pts who have had a STS? |
|
Definition
| low risk pts can have a biyearly physical examination and yearly CXR; high risk pts can have an exam every 3 months with CXRsobtained every 3-6 months indefinately |
|
|
Term
| How is the cause of death due to recurrent STS in an extremity vs retroperitoneal different? |
|
Definition
| extremity STS will recur at a distant site; retroperitoneal sarcomas will recur at the same site and cause death as a result of local involvement |
|
|
Term
| What are the 2 and 5 yr survival rates of pts with resection of retroperitoneal sarcoma? |
|
Definition
| 80% at 2 yrs; 60% at 5 yrs |
|
|
Term
| Although distant metastasis with retroperitoneal sarcoma is uncommon, it most often goes to the... |
|
Definition
|
|
Term
| What is a reasonable followup for pts after resection of their retroperitoneal STS? |
|
Definition
| CT scans performed at 6 month intervals |
|
|
Term
| What physical factors predispose to STS? |
|
Definition
| prior radiation, lymphedema, and chemical exposure (including prior chemotherapy) |
|
|
Term
| What are the genetic predisposing factors that lead to STS? |
|
Definition
| neurofibromatosis, Li-Fraumeni, Retinoblastoma, familial polyposis coli (gardner syndrome) |
|
|
Term
| Neurofibromatosis predisposes to what cancers? |
|
Definition
| sarcomas arising from nerve structures as well as paragangliomas and pheochromocytomas |
|
|
Term
| Pts with familial polyposis coli have an increased risk of developing... |
|
Definition
| desmoid tumors, which are generally considered benign tumors witha predilection for local recurrence following excision |
|
|
