Surgery Yost Oral Exam Notecards

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Yost 

Surgery 

Notecard11 

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DVT/PEVirchow’s Triad: hypercoagulability, stasis, endothelial damage

DIFFERENTIAL DIAGNOSES

−  DVT

−  Compartment Syndrome

−  Chronic Venous Insufficiency → ulceration 

−  Cellulitis → fever/chills, erythema, ↑WBCs −  Decreased Venous Return → CHF, cirrhosis 

−  Trauma

−  Lymphangitis

−  Renal Failure

1) HISTORY 

−  HPI:

•  Pain: PQRST 

•  Unilateral vs. Bilateral  

•  Swelling  

•  Recent ∆s: trauma, kidney problems 

−  ROS: F/C, SOB, pleuritic CP, cough, hemoptysis −  PMHx: prior DVT, CA, coagulopathy (factor V leiden, homocysteinemia, anti-phospholipid Ab, polycythemia vera),

recent immobilization/paralysis, hospitalization in past 6 mos, pregnancy 

−  PSHx: trauma/surgery in prior 6 mos 

−  Meds/Allergies: HRT/OCP, warfarin, ASA 

−  FHx: DVT in ≥2 1° relatives, PE 

−  SHx: smoking, recent travel, occupation, EtOH, IVDU 

2) PHYSICAL EXAM

−  Vitals/General Appearance: ↑HR 

−  Cardiopulmonary: tachypnea, pleural friction rub (PE), tachycardia, S3 (CHF) 

−  EXT: 

•   Appearance: erythema, dilated superficial veins, color changes 

•  Palpation: warmth, localized tenderness along veins, palpable cord, calf >3cm larger than ASx side •  Homan’s Sign: calf pain w/ dorsiflexion 

3) LABS 

−  DVT: D-Dimers, CBC (↑ w/ polycythemia vera), coags 

−  PE: Coags, ABG (↓ pO2/pCO2 d/t hyperventiliation) 

4) IMAGING/STUDIES 

−  DVT: duplex U/S 

−  PE: EKG, CXR, PT-protocol CT, pulse ox 

5) TREATMENT 

−  Anticoagulation: 

•  Options:○  IV unfractionated heprin (100 U/kg bolus → 25 U/kg/hr for 4-6 days) → target PTT = 2x normal 

+ Followed by warfarin → therapeutic INR = 2-3 ○  Lovenox + warfarin (starting on day 1 of Lovenox) 

•  Length:○  1

st event: 3-6 months (known cause) vs 5 years (unknown etiology) 

+ Once stopped→ d-dimer and U/S○  2

nd event/active cause: 12 mos – lifelong 

•  Complications:

○  Heparin → HIT 

○  Warfarin → hypercoagulable state in first several days 

−  TPA: only used in extensive cases of DVT/PE → causing hemodynamic compromise 

−  Thrombectomy: indicated in cases of limb-threatening ischemia 

−  Greenfield Filter: placed in IVC by IR •  Indications: anticoag CI (GI bleed, recent CVA, cerebral AVM, hemophilia, pulm HTN, recurrent DVT/PE) 

−  Complications 

•  Recurrence → most common in 1st few months 

○  Tx: admit to hospital, IV heparin, support hose

•  Post-Thrombotic Syndrome (10%) → edema, ulceration @ ankles, venous claudication, pain, color  ∆s○  Tx: support hose

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Yost 

Surgery 

Notecard17 

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•  Unstable: arteriography (detects rates ≥ 0.5 cc/min) → potentially tx-ic (vasopressin injxn/embolization) 

•  Surgical Tx: >6U pRBCs/24h; >3U pRBCs to stabilize; big rebleed (esp if known site), CA/obstrxn/perf  ○  Known site w/ massive bleeding: segmental resection ○  Unknown site: ex-lap (+/- SI enteroscopy) + subtotal colectomy w/ ileorectal anastomosis 

•   /↓

 endoscopy fail: capsule endo, push enteroscopy, enteroclysis, bleeding scan, Tc-99/merkel scan 

−  Tx: 

•  Diverticulitis: bleeding usually stops spontaneously 

○  Endoscopic Tx (epi injxns), arterial vasopressin, embolization, surgery → other options ○  Surgical Indications: Cx (fistula/obstrxn/stricture), recurrent episodes, hemorrhage, CA, abscess 

•  Fissure: sitz baths, stool softeners, ↑ fiber diet, topical CaCB, surgery = lateral internal sphincterotomy 

•  Hemorrhoids: same as fissure + band ligation, surgery → hemorrhoidectomy ○  Hemorrhoidectomy Cx: exsanguinations (in colon lumen), infection, incontinence, anal stricture

•  Bleeding Polyps/Vascular Ectasias: laser, electrocoagulation, local epi injection 

•   Angiodysplasia: arterial vasopressin, endoscopic tx (epi), surgery, hormonal risk•  Unknown Etiology w/ Unstable Patient: total abdominal colectomy (85% effective)

○  Reconstruct w/ ileostomy or ileorectal anastamosis

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