Resident Readiness General Surgery (79 page)

COMPREHENSION QUESTIONS

1.
A 25-year-old male presents to your clinic for preoperative evaluation prior to repair of a right inguinal hernia. Your history and physical exam reveals a previous history of two episodes of intra-articular hemorrhage. If the patient has a congenital coagulopathy, he may have any one of the following diseases except which one?

A. Hemophilia A

B. Hemophilia B

C. Splenic sequestration

2.
What is the most important step in screening for the presence of a congenital coagulopathy?

A. Obtaining a complete blood count

B. Checking PT, INR, and PTT

C. Obtaining a ristocetin cofactor assay

D. Performing a thorough history and physical exam

3.
Administration of desmopressin (DDAVP) will help to correct all of the following congenital coagulopathies to some degree except which one?

A. vWD

B. Hemophilia A

C. Hemophilia B

4.
A preoperative history reveals previous episodes of epistaxis and prolonged bleeding after wisdom tooth extraction. The patient is likely to have any of the following congenital coagulopathies except which one?

A. Bernard-Soulier syndrome

B. Factor VII deficiency

C. Glanzmann thrombasthenia

D. vWD

Answers

1.
C
. A history of intra-articular hemorrhage suggests a problem with the coagulation cascade. This means either hemophilia A or B. Splenic sequestration, on the other hand, is a platelet disorder and rarely results in intra-articular hemorrhage.

2.
D
. A thorough history and physical exam should be used for screening in order to avoid unnecessary testing.

3.
C
. Desmopressin or DDAVP administration results in release of factor VIII and vWF from the endothelium (remember that factor VIII is the only factor that is not produced in the liver). Factor IX is synthesized in the liver and, therefore, DDAVP will have no efficacy in hemophilia B.

4.
B
. The symptoms described suggest a platelet disorder such as A, C, or D.

Bibliography

The following is a list of high-yield papers that you will hear referenced frequently. If you were only going to read 11 articles, these should be where you start.

Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.
Intensive Care Med
. 2008;34(1):17–60.

Duncan JE, Quietmeyer CM. Bowel preparation: current status.
Clin Colon Rectal Surg
. 2009;22(1):14.

Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization.
N Engl J Med
. 2007;356(21):e21.

Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis.
Crit Care Med
. 2010;38(11):2222.

McGee S, Abernethy WB III, Simel DL. Is this patient hypovolemic?
JAMA
. 1999;281(11):1022–1029.

Moore FA, Moore EE. Initial Management of Life Threatening Trauma. ACS Surgery: Principles and Practice. <
http://129.49.170.167/Volumes/ACSCD+July+2010/ACSCD/pdf/ACS0701.pdf
>; 2005.

Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.
Crit Care Med
. 2009;37(12):3124.

Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery.
Cochrane Database Syst Rev
. 2009;(1):CD001181. <
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001181.pub3/pdf/standard
>.

Ochoa JB, Caba D. Advances in surgical nutrition.
Surg Clin North Am
. 2006;86(6):1483.

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock.
N Engl J Med
. 2001;345(19):1368–1377.

Smith-Bindman R. Is computed tomography safe?
N Engl J Med
. 2010;363(1):1–4.

INDEX

Please note that index links point to page beginnings from the print edition. Locations are approximate in e-readers, and you may need to page down one or more times after clicking a link to get to the indexed material
.

Page numbers followed by
f
or
t
indicate figures or tables, respectively.

A

ABCDE (Airway, Breathing, Circulation, Disability, and Exposure/Environment),
42
,
45
,
155

“ABC” emergency protocol,
185

Abdomen, CT scan,
156
,
321

abdominal wall,
323

    checking,
323

abnormal air, within abdominal wall,
324
f

aorta,
329

appendicitis, acute,
328
f

celiac artery,
329
f

free fluid,
325
f

inferior vena cava,
329

intra-abdominal fluid,
324
,
325
f

Jackson-Pratt,
325

kidney hematoma, by motor vehicle crash,
327
f

liver abscess, liver fluid collection suspicious for,
327
f

liver/biliary tree,
326

lung window,
324
f

    free air,
323

oral contrast/intravenous (IV) contrast,
322

pancreas,
326

pelvic bones/spinal vertebrae,
329

radiology,
322
,
325

rules of thumb,
321

severe intestinal pneumatosis, bowel ischemia,
328
f

severe pancreatic inflammation,
327
f

spleen,
326

splenic laceration, by motor vehicle crash,
326
f

stomach and small bowel,
326

tubes/drains,
325

Abdominal aortic aneurysm (AAA),
114

Abdominal distension,
220

Abdominal pain,
47
–50,
84
,
225

acute abdomen,
64
–65

medical history,
47

overview of,
47
–49

severe,
63
–67

tips to,
49
,
65
–66

Abdominoperineal resection (APR),
290
–291

Abnormal inflammatory reaction,
78

Acetaminophen,
144
,
264
,
265

intravenous formulation of,
144

Acetylcysteine,
117

ACLS algorithm,
178

ACS protocol,
197

Acute event specifics, essentials of,
28
–29

Adaptive traits,
307

Admission note specifics, essentials of,
26
–27

Admissions,
33
–38

avoiding common admission mistakes,
37
–38

communication,
35
–36

ordering,
36
–37

    important aspect of,
37

scut work,
33

surgical,
33

time management,
34
–35

triage,
33
–34

Adrenal insufficiency

exogenous glucocorticoids, lack of,
273

Aerobic exercise,
11

Afferent nerve

types of,
219

Aggressive fluid resuscitation,
194

Agitation,
161
,
163

dosing strategies for,
153

Airway, Breathing, Circulation, Disability, and Exposure/Environment (ABCDE),
42

Airway specialist,
41

Alcohol hallucinosis,
123

Alcohol withdrawal syndromes,
121
–127,
123
t

complicated, risk factors for,
123

neurotransmitter dysfunction in,
122
f

symptom clusters,
122
t

type A symptoms,
125

    benzodiazepines for,
126
t

type B symptoms,
125

Alvarado score,
58

calculation of,
58
t

Alvimopan,
144

American Board of Surgery (ABS),
17
,
18

American Board of Surgery In-training Exams (ABSITEs),
14
,
15

American Burn Association,
130

American College of Surgeons (ACS),
3

Amiodarone,
175

Analgesia,
202

Anastomosis,
142

Anemia,
91

Ankle brachial index (ABI),
116

Antibiotics,
80
,
333

Antibiotic therapy,
137

determinants of,
103

Anticholinergic medications

diphenhydramine,
152

promethazine,
152

Anticoagulation,
117
,
120
,
283