Surgery Clerkship

• On the wards
  
• See "Intro to the Wards" and then resign yourself to the fact that you will be waking up well before the crack of dawn and getting home after the sun sets. If you can handle the hours you're 3/4 of the way there.
• Learn to tie knots & suture.
  

• Books for the Shelf
• Real Text Books - It's up to you to decide if you like having a thorough reference or just want to stick with review books. If you're the text book type, the following two have been recommended by classmates and course directors.
• Essentials of General Surgery (Lawrence)
  
• The The Surgical Review: An Integrated Basic and Clinical Science Study Guide (Recall Series)
  
• Review Books
• Surgical Recall (Recall Series) - If one book is essential for the surgery clerkship, Surgical Recall is that book. Buy it, read it, and then read it again. Availble for your PDA here.
  
• First Aid for the Surgery Clerkship (First Aid Series) - Very helpful and manageable mid-week reading, not all inclusive, but pertinent.
  
• NMS Surgery - Dense and detailed, but the questions are useful.
  
• Blueprints Surgery: Principles and Methods (Blueprints Series) - Not enough detail, but again good questions, similar to those on the Shelf (a.k.a. long)
  
• Question Books
• Blueprints Q&A Step 2 Surgery - Great Shelf style questions with full explanations. Small book that is easy to carry around with you on the wards.
• Kaplan USMLE Step 2 CK Qbook - Do the 2 Surgery Tests, as for the Medicine Shelf, these questions are money.
  
• Surgery (Pretest Series) - Recommended with good coverage of questions seen on the Shelf. Now and then an answer is marked incorrectly, but the explanations are accurate.
  
• Case Files: Surgery (Lange Case Files) - High yield, with detailed answers.
  
• Appleton & Lange Review of Surgery - The questions are more difficult than those on the Shelf but useful especially for the sub-specialties.
  

Med-Spot on Med-Source: Videos of Surgical Procedures

Med-Spot: Videos of Surgical Procedures

If you have any desire to view a produce before you scrub in or just because, head over to MedlinePlus where they have 1 hr videos of nearly every commonly performed surgical procedure.

SHELF / USMLE Step 2 Practice Questions > Surgery (set #1)

SHELF / USMLE Step 2 Practice Questions > Surgery

Q1) You have been asked to perform a preoperative consultation on a 65-year-old male who will be undergoing a testicular hernia repair. Of the following findings, which is of most concern in predicting a cardiac complication in this patient undergoing noncardiac surgery?

a) Age over 60
b) History of myocardial infarction 3.5 years ago
c) Harsh systolic crescendo-decrescendo murmur radiating to the carotids
d) ECG and subsequent telemetry showing up to five PVCs per minute
e) Serum creatinine 2.0 mg/dL

Q2) A right hemicolectomy is performed on a 57-year-old woman with adenocarcinoma who had a preoperative elevation of carcinoembryonic antigen (CEA) to 144. After falling to normal levels postoperatively, her most recent (24-month) follow-up level was 86. Correct statements regarding CEA and colorectal tumors include which of the following?

a) elevated CEA is indicative of a tumor of gastrointestinal origin
b) a low CEA level after resection of a colon tumor is a poor marker of disease control
c) 90% of colorectal tumors produce CEA
d) there is a high likelihood of liver involvement if the CEA level is high (greater than 100 ng/mL)
e) CEA levels are unusually low in cigarette smokers

Q3) A 63-year-old man is seen 3-days post-op and shows signs of fever, abdominal pain, nausea, and anorexia. His urine output is 100 ml over the last 24 hrs. His blood pressure is 84/62, and his pulse is 138. His response to this physiologic state includes which of the following?

a) Increase in sodium and water excretion
b) Increase in renal perfusion
c) Decrease in cortisol levels
d) Hyperkalemia
e) Hypoglycemia

A1) c - harsh systolic crescendo-decrescendo murmur radiating to the carotids
A2) d - here is a high likelihood of liver involvement if the CEA level is high (greater than 100 ng/mL)
A3) d - hyperkalemia

Must have book on your surgery rotation: Surgical Recall

SHELF / USMLE Step 2 Practice Questions > Surgery (set #2)

SHELF / USMLE Step 2 Practice Questions > Surgery

Q1) A workup for a patient with frequent and multiple areas of cutaneous ecchymosis discloses a large spleen and evidence of immune (idiopathic) thrombocytopenic purpura (ITP). ITP includes which of the following?

a) A significant enlargement of the spleen
b) A high reticulocyte count
c) Megakaryocytic elements in the bone marrow
d) An increase in platelet count on cortisone therapy
e) Patient age of less than 5 years

Q2) 4. A 27-year-old man undergoes general anesthesia for a hernia repair. As the anesthesia begins, his jaw muscles tense and he becomes generally rigid. He becomes febrile, tachycardic, and tachypnic. Intravenous administration of which of the following agents may be lifesaving?

a) Suxamethonium
b) Nitrous oxide
c) Succinylcholine
d) Dantrolene
e) Phenobarbital

Q3) An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain, distention, and diarrhea. A cautiously performed transanal contrast study reveals an apple core configuration in the rectosigmoid area. Which of the following is the most appropriate management at this time?

a) Colonoscopic decompression and rectal tube placement
b) Saline enemas and digital disimpaction of fecal matter from the rectum
c)Colon resection and proximal colostomy
d)Oral administration of metronidazole and checking a Clostridium difficile titer
e)Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic mesenteric ischemia

A1) d - An increase in platelet count on cortisone therapy (Corticosteroid therapy increases the platelet count in over 75% of cases and provides the best indication that splenectomy will be of lasting benefit.)
A2) d - this is a case of malignant hyperthermia, pts may become severely acidotic and develop rhabdomyolysis. Pathology shows diffuse segmental muscle necrosis. Tx is dantrolene, which prevents release of calcium from the SR, and supportive measures.
A3) c - Colon resection and proximal colostomy. An apple core lesion in the distal colon is diagnostic of colon cancer

Must have book on your surgery rotation: Surgical Recall

SHELF / USMLE Step 2 Practice Questions > Surgery (set #3)

SHELF / USMLE Step 2 Practice Questions > Surgery

Q1) A 75-year-old male undergoes an abdominal CT looking for liver metastases from a known colonic adenoma. On the CT a 4.9 cm abdominal aortic aneurysm(AAA). Which of the following risk factors is NOT a contributor to this pt's AAA?

a) His age.
b) Hypercholesterolemia.
c) Diabetes.
d) Smoking.
e) Hypertension.

Q2) A 64 year old diabetic male with a history of PVD presents to vascular clinic with pain and paresthesias of the L foot. The pain improves with rest but always returns after walking approximately 6 city blocks. Which of the following likely represent this patients test results after and ABI?

a) ABI = 1.1 - 1.4
b) ABI = 0.9 - 1.0
c) ABI = 0.6 - 0.8
d) ABI = 0.4 - 0.5
e) ABI < 0.3

Q3)A 7-year-old girl fell while sledding and suffered a jagged wound to her right eyebrow and forehead. After local anesthesia and thorough cleaning, you plan for primary closure. Which of the following statements is true concerning facial wound repair?

a) Permanent suture material is preferred
c) Sutures should be removed in 2 weeks to minimize infection
d) Sutures should be placed 3 to 4 mm apart and 4 mm from the wound edge
e) Knots should be centered on the wound

A1) c - diabetes. The Aneurysm Detection and Management Veterans Affairs Cooperative Study Group trial (commonly referred to as the ADAM trial) found the following factors to be associated with increased risk for an AAA: advanced age, greater height, coronary artery disease, atherosclerosis, high cholesterol levels, hypertension, and smoking. The risk is lower in women, African Americans, and diabetic patients.

A2) c - ABI = 0.6 - 0.8. An ABI < 0.95 indicates significant narrowing of one or more blood vessels in the legs
ABI < 0.8 indicates pain in the foot, leg, or buttock may occur during exercise (intermittent claudication).
ABI < 0.4, symptoms may occur when at rest.
ABI < 0.3 indicates severe limb-threatening PAD is probably present

A3) a - Permanent suture material is generally preferred for the face. Needle marks can be prevented by removing sutures earlier rather than later. The knot should be brought to one side of the wound, and tension should be adjusted so that the skin edges are opposed without compromising the blood supply. On the face, sutures should be ~3-4 mm apart and be placed 2 mm from the wound edge.

Must have book on your surgery rotation: Surgical Recall

SHELF / USMLE Step 2 Practice Questions > Surgery (set #4)

SHELF / USMLE Step 2 Practice Questions > Surgery

Q1) A 15-year-old male cut his arm while climbing a chain link fence. No foreign bodies are found in the cut anf the wound is thoroughly cleaned. The patient was never immunized against tetanus toxoid. Which of the following represents appropriate management?

a) The patient may be given a toxoid booster.
b) The patient may be immunized in three separate doses.
c) The patient may be treated with penicillin as prophylaxis against Clostridia tetani.
d) Passive immunization with tetanus immunoglobulin is recommended.
e) The wound should not be sutured.

Q2) A 64 year patient who has been on IV heparin for 3 days for a DVT begins to have hematemesis from a bleeding GI ulcer. What is the appropriate management?

a) Decrease the heparin dose & administer blood products as needed.
b) Switch to Coumadin.
c) Stop heparin and observe for 3 day to see if the DVT resolves.
d) Stop the systemic heparin and administer thrombolytics directly to the femoral vein.
e) Stop the systemic heparin and place an IVC filter.

Q3) A 43 y/o male presents to the ED with abdominal pain and 3 days of emesis. On 1st assessment he has a temp of 103.2, a bp of 72/40 and a rigid abdomen. Which of the following diagnostic studies would most likely reveal the diagnosis?

a) a CBC with diff.
b) an abdominal flat plate
c) ESR
d) an obstruction series
e) an upper GI

A1) b - The patient may be immunized in three separate doses as long as the wound is clean.

A2) e - Stop the systemic heparin and place an IVC filter. PE must be prevented, however anticoagulants cannot be given in the setting of a bleed.

A3) d - an obstruction series will demonstrate free air (peritonitis, perforated viscus) on the CXR.

Must have book on your surgery rotation: Surgical Recall

Foolproof Templates for Surgery Notes

Here are templates for pre-op, post-op, and progress notes that will ensure you don't forget anything important when rounding on your surgical patients

Surgery Pre-Op Note
Surgery Post-Op Note
Surgery Progress Note

I am currently studying for my surgery Shelf Exam and have come across 2 great books, both are cased based and work through clinical scenarios much like the actual exam:

Surgical Attending Rounds: presents each topic as a realistic clinical case with question-and-answer teaching points and clinical decision-making algorithms

NMS Surgery Casebook: surgical cases that begin with a clinical scenario and go through the decision-making process of patient management step-by-step.

Med-Spot on Med-Source: Cardiac Clearance for Non-Cardiac Surgery

Med-Spot 6.24.07: Guidelines for Cardiac Clearance for Non-Cardiac Surgery

Case Scenario:
R.J. is a 76-year-old man who is scheduled for a right hip arthroplasty in two weeks. He presents at the request of his orthopedic surgeon for a medical consultation before surgery. He had an inferior MI one year ago for which he received antithrombolytic therapy with complete resolution of his symptoms. He has never smoked, has no history of cerebrovascular disease or diabetes, has a normal ejection fraction, and normal renal function. R.J. usually walks one to two miles in the morning, but his function has been severely limited over the past two months because of hip pain. He is taking hydrochlorothiazide (Esidrix) and simvastatin (Zocor). Although his primary care physician prescribed a beta blocker after his MI, R.J. stopped taking it after a bout of bronchitis two weeks ago. He is asymptomatic from a cardiac and respiratory standpoint. His vital signs are normal except for a blood pressure of 157/92 mm Hg. His physical examination is within normal limits, and electrocardiography demonstrates Q waves inferiorly. Should he undergo cardiovascular stress testing before surgery, and is he a candidate for perioperative beta blockade or other medical therapy?

To answer this question use the figure below referring to the 2 tables below the figure when necessary (see end of post for answer).

CLICK HERE FOR CARDIAC RISK ASSESSMENT FLOW CHART

TABLE 1: Clinical Predictors of Increased Perioperative Cardiovascular Risk
Major Unstable coronary syndromes Acute or recent* MI with evidence of important ischemic risk by clinical symptoms or noninvasive study Unstable or severe† angina (Canadian class III or IV‡) Decompensated heart failure Significant arrhythmias High-grade atrioventricular block Symptomatic ventricular arrhythmias in the presence of underlying heart disease Supraventricular arrhythmias with uncontrolled ventricular rate Severe valvular disease	Intermediate Mild angina pectoris (Canadian class I or II‡) Previous MI by history or pathologic Q waves Compensated or prior heart failure Diabetes mellitus (particularly insulin-dependent) Renal insufficiency	Minor Advanced age (older than 75 years) Abnormal electrocardiography results (e.g., left ventricular hypertrophy, left bundle branch block, ST-T abnormalities) Rhythm other than sinus (e.g., atrial fibrillation) Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension

Table 2: Cardiac Risk Stratification for Noncardiac Surgical Procedures

High (reported cardiac risk often >5 percent)

Emergent major operations, particularly in patients older than 75 years

Aortic and other major vascular surgery

Peripheral vascular surgery

Anticipated prolonged surgical procedure associated with large fluid shifts and/or blood loss

Intermediate (reported cardiac risk generally 1 to 5 percent)

Carotid endarterectomy

Head and neck surgery

Intraperitoneal and intrathoracic surgery

Orthopedic surgery

Prostate surgery

Low† (reported cardiac risk generally <1>

Endoscopic procedures

Superficial procedures

Cataract surgery

Breast surgery

Resolution of the Case:
Hip arthroplasty is an intermediate-risk surgery. Based on the Lee revised cardiac risk index (Table 3),11 the patient in the case scenario receives 1 point for CAD, putting him at low risk. Because his functional status was good before his recent hip problems and he is having no cardiovascular symptoms, after referring to Figure 12 and considering the results of the CARP study, the physician decides in collaboration with the patient that cardiovascular stress testing is not necessary. Because he was taking beta blockers before his recent illness and should remain on them because of his CAD whether or not he is having surgery, the physician chooses to resume them. However, the patient would not otherwise be a candidate for beta blockade. Continuing statin therapy would neither harm nor benefit him for his current surgery.

sources: AAFP (http://www.aafp.org/afp/20070301/656.html) , ACC, AHA

Knots & Suturing

• Basic Knot Tying & Suturing Videos - A great use for the slow end of your 2xav plug-in.
• Free suture practice kit from Ethicon (you have to call and ask for it, you're entitled as a med student).