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Surgery > Chapter 4: General Surgery > Flashcards

Chapter 4: General Surgery Flashcards

1
Q

How do you diagnose GERD when it’s ambiguous?

A

pH monitoring

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2
Q

When do you do surgery for GERD?

A

if complications have developed:

  1. ulceration
  2. stenosis
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3
Q

What’s the usual procedure that’s done for GERD?

A

Nissen fundoplication

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4
Q

Clinical pattern of motility problems?

A

crushing pain with swallowing in uncoordinated massive contraction

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5
Q

Pattern of dysphagia in achalasia?

A

solids are swallowed w less difficulty than liquids

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6
Q

How do you diagnose achalasia?

A
  1. barium swallow

2. manometry (diagnostic)

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7
Q

Most common treatment for achalasia?

A

balloon dilation by endoscopy

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8
Q

Presentation of cancer of esophagus?

A
  1. dysphagia starting with meat–> then other solids –> soft foods –> liquids–> saliva
  2. significant weight loss
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9
Q

Types of esophageal cancer?

A
  1. squamous cell carcinoma: seen in male smokers and drinkers
  2. adenocarcinoma: long-acting GERD
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10
Q

What should you do before endoscopy in diagnosing esophageal cancer to avoid inadvertent perforation?

A

barium swallow

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11
Q

How can you assess operability in esophageal cancer?

A

CT scan

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12
Q

Typical management for esophageal cancer?

A

palliative, most cases aren’t good for surgery

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13
Q

Diagnosis and treatment of mallory-weiss tear?

A

endoscopy and photocoagulation respectively

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14
Q

Sx of Boerhaave Syndrome

A
  1. prolonged, forceful vomiting
  2. continuous, severe epigastric pain + low sternal pain of sudden onset
  3. fever
  4. leukocytosis
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15
Q

Dx of Boerhaave Syndrome?

A

Contrast swallow:

  1. Gastrografin
  2. Barium
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16
Q

Tx of Boerhaave Syndrome?

A

surgical repair

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17
Q

Sx of gastric adenocarcinoma?

A 
anorexia
weight loss
vague epigastric distress
early satiety 
occasional hematemesis
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18
Q

Gastric adenocarcinoma diagnosis and treatment?

A

Dx: endoscopy and biopsies, CT to assess operability
Tx: surgery

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19
Q

Sx and diagnosis Gastric lymphoma?

A

similar to gastric adenocarcinoma

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20
Q

Gastric lymphoma tx?

A

surgery if you fear perforation as the tumor melts away

low-grade MALTOMAs can be reversed by eradicating H. pylori

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21
Q

initial treatment of mechanical small bowel obstruction?

A

NPO
NG suction
IV fluids

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22
Q

How long do you wait for resolution of complete sbos?

A

24 hs

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23
Q

how long do you wait before surgically treating a partial sob?

A

a few days

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24
Q

Difference bw bowel obstruction and strangulated obstruction?

A

strangulated= sbo sx + fever, leukocytosis, constant pain, signs of peritoneal irritation, and full-blown peritonitis and sepsis

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25
Q

Treatment for strangulated obstruction?

A

emergency surgery

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26
Q

Incarcerated hernia vs strangulated obstruction?

A

incarcerated hernia= irreducible hernia that used to be reducible

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27
Q

Carcinoid syndrome:

A

=small bowel carcinoid tumor with liver metastases

  1. diarrhea
  2. flushing of the face
  3. wheezing
  4. right-sided heart valve damage (look for prominent JVP)
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28
Q

What will be prominent in 24h urine collection of people with carcinoid syndrome?

A

5-hydroxyindoleacetic acid

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29
Q

Sx of anorexia?

A
  1. vague periumbilical pain
  2. sharp, severe, constant pain localized to the right lower quadrant of the abdomen
  3. tenderness, guarding, rebound in the right lower quadrant of the abdomen (not elsewhere in the belly)
  4. modest fever
  5. leukocytosis: 10,000-15,000 range
  6. neutrophilia and immature forms
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30
Q

What do you use to diagnose acute appendicitis when you’re not 100% certain of the diagnosis?

A

CT scan

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31
Q

Cancer of the Right Colon Sx:

A
  1. anemia (hypochromic, Fe defic) in elderly
  2. 4+ stools for occult blood
  3. Dx: colonoscopies and biopsies
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32
Q

Tx for right colon cancer?

A

right hemicolectomy

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33
Q

Cancer of the left colon Sx:

A
  1. bloody bm (blood coats outside of stool)

2. constipation + stools of narrow caliber

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34
Q

Dx of left colon cancer?

A
  1. flexible proctosigmoidoscopic exam (45-60 cm)

2. biopsies

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35
Q

What must you do before surgery of left colon cancer?

A

full colonoscopy to r/o synchronous second primary

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36
Q

Tx of left colon cancer?

A
  1. surgery

2. pre-op chemotherapy + radiation for large rectal cancers

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37
Q

Colonic Polyps: descending order of probability of malignant degeneration

A
  1. familial polyposis (and variants such as Gardners)
  2. familial multiple inflammatory polyps
  3. villous adenoma
  4. adenomatous polyp
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38
Q

Non-malignant colonic polyps:

A
  1. Juvenile
  2. Peutz-Jeghers
  3. isolated inflammatory
  4. hyperplastic
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39
Q

Chronic ulcerative colitis (CUC) Tx:

A

medically managed

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40
Q

Chronic ulcerative colitis indications for surgery?

A
  1. disease present for longer than 20 years (high incidence of malignant degeneration)
  2. severe interference w nutritional status
  3. multiple hospitalizations
  4. need for high-dose steroids or immunosuppressants
  5. development of toxic megacolon (abdominal pain, fever, leukocytosis, epigastric tenderness, massively distended transverse colon on x-ray w gas wi wall of colon)
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41
Q

Definitive surgical treatment of chronic ulcerative colitis?

A

remove affected colon + all of the rectal mucosa (always involved)

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42
Q

Current most common abx that causes pseudomembranous enterocolitis?

A

cephalosporins

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43
Q

How to dx C-diff?

A

identify toxin in the stool

stool cultures too long, pseudomembrane not always seen on endoscopy

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44
Q

C-diff Tx of choice:

A

metronidazole

vancomycin (alternate)

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45
Q

What presentation in C diff requires emergency colectomy?

A

form that’s unresponsive to treatment
wbc >50,000
lactate >5

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46
Q

How to r/o cancer in all anorectal diseases?

A

proper physical exam (including proctosigmoidoscopic exam)

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47
Q

Internal hemorrhoids:

A

typically bleed when they’re internal
treat w rubber-band ligation
can become painful or itchy if they prolapse

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48
Q

External hemorrhoids;

A

typically hurt

surgery if conservative treatment fails

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49
Q

Who usually gets anal fissure? Sx?

A

young women
exquisite pain w defecation
blood streaks the stools
(may need to do physical exam under anesthesia to see fissure)

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50
Q

Typical location of anal fissure?

A

posterior midline

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51
Q

Cause of anal fissure? Tx?

A 
tight sphincter 
Tx:
1. stool softener
2. topical nitroglycerin
3. local injection of bolulinum toxin
4. forceful dilation 
5. lateral internal sphincterotomy 
6. calcium channel blocker (diltiazem ointment 2% TID) for 6 weeks: 80-90% success rate
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52
Q

Sign of Crohn’s disease?

A

fissure, fistula, or small ulceration that fails to heal and gets worse after surgical intervention *this area typically heals really well bc of excellent blood supply)

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53
Q

Should you do surgery on Crohn disease of anus?

A

NO!

if fisula is present: drain w setons while medical therapy is underway + remicade helps healing

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54
Q

Ischiorectal abscess sx:

A
  1. febrile
  2. exquisite perirectal pain that can’t sit down or have a bm
  3. classic findings of abscess: rumor, dolor, cal or, tumor (lateral to the anus bw the rectum and ischial tuberosity)
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55
Q

Tx of ischiorectal abscess?

A

Incision and Drain
make sure to do physical exam for cancer first!
In diabetics, watch for horrible necrotizing soft tissue infection

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56
Q

Fistula-in-ano

A

seen in some its who have had an ischiorectal abscess drained

  • epithelial migration from the anal crypts (where abscess originated)
  • epithelial migration from the perineal skin (where the drainage was done) form permanent tract
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57
Q

Fistula-in-ano presentation:

A
  1. pts complain of fecal soiling + occasional perineal discomfort
  2. Physical exam: opening lateral to the anus w cordlike tract and discharge that is expressed
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58
Q

Tx of fistula-in-ano?

A

r/o necrotic and draining tumor

treat with fistulotomy

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59
Q

Who gets squamous cell carcinoma of the anus?

A

HIV+ individuals

homoseuals w receptive sexual practices

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60
Q

Squamous cell carcinoma of the anus presentation + Dx?

A

fungating mass that grows out of the anus
metastatic inguinal lymph nodes felt
Dx with biopsy

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61
Q

Tx for squamous cell carcinoma of the anus?

A

Nigro chemoradiation protocol (5 weeks protocol has 90% success rate) + surgery (if residual tumor is there)

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62
Q

What proportion of GI bleeding originates from the upper GI tract?

A

3/4 cases

upper gi= from tip of nose to the ligament of Treitz

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63
Q

Where does the remaining 1/4 of cases of GI bleeding come from?

A

colon or rectum

very few originate from the jejunum and ileum

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64
Q

Etiology of GI bleeding that originates from the colon?

A
  1. angiodysplasia
  2. polyps
  3. diverticulosis
  4. cancer
    * *all are diseases of old people**
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65
Q

Young person w GI bleeding, where is it coming from?

A

most likely the upper GI

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66
Q

Old person w GI bleeding, where is it coming from?

A

anywhere (“equal opportunity”)

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67
Q

Vomiting blood: where is it coming from?

A 
upper GI (tip of nose to ligament of treitz) 
-same is true when blood is recovered by NG tube in pt who shows up w bleeding from rectum
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68
Q

Red blood per rectum work-up:

A
  • *could come from anywhere in the GI tract (even upper GI bc could have transited too fast to be digested) **
    1. pass an NG tube and aspirate gastric contents
    - -> if blood–> means it’s an upper source
    - -> if non-bilious–> can exclude territory from tip of nose to pylorus (duodenum could still be a source) –> do upper GI endoscopy –> if no blood and fluid is green (bile tinged), then entire upper GI has been excluded
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69
Q

Active bleeding per rectum when upper GI is excluded?

A
  1. Anoscopy first: to exclude bleeding hemorrhoids
    * * colonoscopy NOT helpful in active bleeding (incoming blood obscures the field)
    - -Two directions to go after r/o hemorrhoids–
    * *One
    a. look at rate of bleeding: if >2ml/min (1 unit of blood every 4 hrs) –> do angiogram which can find source and allow for hagiographic embolization
    b. if bleeding is wait until bleeding stops and then do colonoscopy
    c. for in-between cases–> do a tagged red-cell study (really slow study though)-> see if blood puddles somewhere–> can possibly do an angiogram then or if the tagged red cells don’t show up can plan a colonoscopy
    d. if bleeding is not found to be in the colon–> do capsule endoscopy to localize the spot in the small bowel
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70
Q

Blood per rectum in a child:

A

Meckel diverticulum

1. do technetium scan first to look for ectopic gastric mucosa

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71
Q

Massive upper GI bleeding in stressed or polytrauma or complicated post-op pt? Dx? Tx? Px?

A

probably stress ulcers

  • Dx: use endoscopy to confirm
  • Tx: angiographic embolization
  • Px: maintain gastric pH above 4
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72
Q

Acute abdomen: Perforation

A
  1. sudden onset
  2. constant, generalized, severe
  3. reluctant to move, very protective of abdomen
  4. signs of peritoneal irritation (tenderness, guarding, rebound)
  5. Dx: free air under the diaphragm in upright x-ray is confirmatory
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73
Q

Most common cause of perforation?

A

peptic ulcer perforation

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74
Q

Acute abdomen: obstruction

A
  1. sudden colicky pain
  2. pt moves constantly looking for a comfortable position
  3. few physical exam findings of peritoneal irritation limited to affected areas
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75
Q

Acute abdomen: inflammatory process

A
  1. gradual onset and slow buildup ( couple of hours at least- more commonly 6-10-12 hrs)
  2. constant, ill-defined (at first) –> eventually locates to area where problem is
  3. physical findings of peritoneal irritation in affected area
  4. systemic signs : fever and leukocytosis (except in pancreatitis)
76
Q

Ischemic bowel:

A

severe pain + blood in the lumen of gut

77
Q

Primary peritionitis:

A

Child: has nephrosis or ascitis
Adult: w ascitis who has “mild” generalized acute abdomen + equivocal physical exam findings + fever + leukocytosis
Culutre of ascitis fluid: yields a single organism

78
Q

Treatment for primary peritonitis?

A

antibiotics, not surgery

79
Q

Tx for generalized acute abdomen?

A
  1. Ex lap: no need to have a specific diagnosis
  2. If doesn’t look like primary peritonitis only need to r/o those things that mimic acute abdomen or things that don’t require surgery:
    a. MI (EKG)
    b. lower lobe pneumonia (chest x-ray)
    c. pulmonary embolism (immobilized pt)
    d. pancreatitis (amylase)
    e. urinary stones (CT scan of abdomen)
80
Q

Acute pancreatitis presentation:

A 
alcoholic w "upper' acute abdomen 
1. constant, epigastric pain
2. radiates straight through to back 
3. nausea + vomiting + retching 
Physical exam: 
1. modest findings in upper abdomen 
2. Dx: serum or urinary amylase or lipase (12-48h for serum, urinary from 3-6th day) 
OR if diagnosis is not clear, do CT
81
Q

Tx for acute pancreatitis:

A
  1. NPO
  2. NG suction
  3. IV fluids
82
Q

Ureteral stones:

A
  1. sudden onset colicky flank pain
  2. radiates to inner thigh and scrotum (or labia)
  3. urinary urgency and frequency
  4. microhematuria in UA
  5. CT is best diagnostic test
83
Q

Acute diverticulitis:

A

1.acute abdominal pain in left lower quadrant (the fallopians and ovaries are other potential sources in women)
2. middle-aged or beyond pt
3. fever
4. leukocytosis
5. peritoneal irritation in the LLQ on physical exam
6. palpable tender mass sometimes in LLQ
Dx: CT scan

84
Q

Acute diverticulitis Tx:

A
  1. NPO
  2. IV fluids
  3. Abx
  4. emergency surgery in ones that don’t resolve with the above
    - - radiologically guided percutaneous drainage of abscess precedes resection
  5. elective surgery if had at least two or more attacks
85
Q

Volvulus of the sigmoid:

A
  1. in old people
  2. signs of obstruction + severe and distention
    Dx: x-rays ( air-fluid levels, very distended colon, huge air-filled loop in right upper quadrant that tapers down toward the LLQ with shape of “parrot’s beac”
86
Q

Tx of volvulus of sigmoid?

A

proctosigmoidoscopic exam w old rigid instrument resolves problem

  • leave rectal tube in
  • elective sigmoid resection for recurrent cases
87
Q

Mesenteric ischemia?

A
  1. most common in elderly + a fib pt + recent MI (latter two are source of clot that breaks off & lodges in SMA)
  2. in very old, presentation is more subtle and often diagnosis is made late when there’s blood in the bowel lumen and acidosis and sepsis have already developed
  3. arteriogram and embolectomy can save the day in early cases
88
Q

What is primary hepatoma?

A

HCC

89
Q

HCC presentation:

A
  1. vague RUQ discomfort
  2. weight loss
  3. Dx: alpha-fetoprotein is the specific serum marker
  4. Dx: CT scan shows location and extent
  5. Tx: resection if possible
90
Q

Metastatic cancer of the liver:

A

outnumbers primary cancer of liver in US 20:1

  1. suspect when see a rise in carcinoembryonic antigen (CA) in those who had colon cancer
  2. Tx: if primary is slow-growing and mets are confined to one lobe–> resection is done OR radio ablation
91
Q

Hepatic Adenoma:

A
  1. can arise as OCPs complication
  2. tend to rupture and bleed massively in abdomen
    3 . Dx: CT
  3. Tx: emergency surgery
92
Q

Pyogenic liver abscess:

A

most often biliary tract disease complication (esp. acute ascending cholangitis)

  1. Presentation: fever, leukocytosis, tender liver
  2. Dx: US or CT
  3. percutaneous drainage required
93
Q

Amebic abscess of liver

A
  1. most commonin me with a “mexico connection)
  2. presents and diagnosed similarly to pyogenic liver abscess
  3. Tx: empiric metronidazole; seldom requires drainage
  4. Dx: serology (ameba doesn’t grow in pus)…takes two weeks for test to be reported though
  5. if pt doesn’t improve w metronidazole drainage is done
94
Q

Hemolytic anemia:

A
  1. low bilirubin: 6-8

2. all is unconjugated (indirect), no elevation of the direct, conjugated

95
Q

Hepatocellular jaundice

A
  1. high direct AND indirect bilirubin
  2. very high transaminases
  3. modestly elevated alk phos
    HEPATITIS is most common cause
96
Q

Obstructive Jaundice:

A
  1. high direct AND indirect bilirubin
  2. modestly high transaminases
  3. very high alk phos
    Dx: US to look for dilation of biliary ducts; can’t usually see stone obstructing the CBD which can’t dilate bc of chronic irritation, can see stone in the gallbladder
97
Q

Malignant obstructive jaundice:

A

Courvoisier-Terrier sign :large, thin-walled, distended gall-bladder

98
Q

Obstructive jaundice caused by stones:

A
  1. obese, fecund woman in forties
  2. high alkaline phosphatase
  3. dilated ducts on sonogram
  4. non-dilated gallbladder
99
Q

Tx for obstructive jaundice caused by stones:

A
  1. ERCP to confirm diagnosis + sphincterotomy (remove the common duct stone)
  2. then follow with cholecystectomy
100
Q

Obstructive jaundice caused by tumor etiology:

A
  1. maybe adenocarcinoma of the head of the pancreas
  2. adenocarcinoma of the Ampulla of Vaster
  3. Cholangiocarcinoma of the CBD itself
101
Q

Obstructive jaundice due to tumor presentation:

A
  1. dilated gallbladder on sonogram first sign
  2. then do CT scan (can usually see pancreatic cancers)
    • –if negative–> do ERCP (can show ampullary cancers or cancers of the bile duct that are too small for CT
  3. percutaneous biopsy next
102
Q

Ampullary cancers:

A

suspect when you have:
malignant obstructive jaundice + anemia + positive blood in stool
- 40% cure
Dx: endoscopy is first test bc of its location

103
Q

Pancreatic cancer:

A

seldom cured even when huge Whipple (pancreatoduodenectomy is done)

104
Q

Most common populations to get gallstone problems?

A

mexican americans and native americans

105
Q

What do you do about Asx gallstones?

A

leave them alone

106
Q

biliary colic Sx:

A
  1. colicky pain in RUQ
  2. radiates to right shoulder
  3. band like
  4. nausea + vomiting
  5. following fatty meal ingestion
  6. NO signs of peritoneal irritation
  7. NO systemic signs of inflammation
  8. self-limited episode: lasts 10-20-30 mins
107
Q

Easy way to stop biliary colic sx?

A

anticholinergic

108
Q

Management of biliary colic?

A

if gallstones seen on sonogram-> elective cholecystectomy

109
Q

Acute cholecystitis sx:

A
  1. biliary colic + stones stay in the cystic duct
  2. get inflammatory process: fever + leukocytosis
  3. peritoneal irritation in RUQ
  4. LFTs minimally affected
  5. Diagnostic test: sonogram
110
Q

Signs of acute cholecystitis on sonogram:

A
  1. gallstones
  2. thickened gallbladder
  3. pericholecystic fluid
111
Q

Test for cholecystitis?

A

radionuclide HIDA scan:

would show uptake in the liver, common duct, duodenum, but NOT the gallbladder

112
Q

Management of cholecystitis?

A

To “cool down” gallbladder:

  1. NPO
  2. NG
  3. abx
  4. IV fluids

then–> cholecystectomy

113
Q

What if patients don’t respond to gallbladder “cool down”

A

emergency cholecystectomy

114
Q

What if you can’t do cholecystectomy due to surgical risk?

A

emergency percutaneous transhepatic cholecystostomy

115
Q

Acute ascending cholangitis? what is it? who gets it?

A
  1. stones reached the common duct producing partial obstruction and ascending infection
  2. typically older pts
116
Q

Cholangitis Sx:

A
  1. Temp spike to 104-105 F
  2. chills
  3. very high WBC–> means there’s sepsis
  4. some hyperbilirubinemia
  5. Key finding: high levels of alk phos!
117
Q

Cholangitis Tx:

A
  1. IV fluids
  2. Emergency decompression of CBD via:
    a. ERCP
    b. percutaneous transhepatic cholangiogram (PTC)
    c. surgery (rarely)
  3. eventually cholecystectomy
118
Q

Obstructive jaundice w/o ascending cholangitis? cause?

A

complete rather than partial biliary stone obstruction

119
Q

Biliary pancreatitis? Cause?

A
  1. stones impacted distally in the ampulla

2. temporarily obstructs pancreatic + biliary duct

120
Q

Biliary pancreatitis Sx? Dx?

A
  1. stones often pass spontaneously so get:
  2. brief, mild cholangitis
  3. elevated amylase or lipase (classic pancreatitis)
  4. Dx: sonogram shows gallstones
121
Q

Biliary pancreatitis Tx?

A
  1. NPO
  2. NG suction
  3. IV fluids
    …improvement in sx…
  4. Then cholecystectomy later
  5. if no improvement–> ERCP and sphincterotomy needed to dislodge stone
122
Q

Acute pancreatitis types?

A
  1. edematous
  2. hemorrhagic
  3. supprative
123
Q

Acute edematous pancreatitis sx;

A
  1. epigastric and miabdominal pain after heavy meal or bout of alcoholic intake
  2. constant
  3. radiates straight through to the back
  4. nausea + vomiting + retching
  5. tenderness and mild rebound in the upper abdomen
  6. high serum or urinary amylase/lipase
    • elevated hematocrit identifies edematous nature
124
Q

Acute hemorrhagic pancreatitis:

A
  1. starts like edematous pancreatitis
  2. But also have low hematocrit (degree of amylase elevation doesn’t correlate with severity of disease)
  3. elevated WBC
  4. elevated blood glucose
  5. low serum calcium
    Day 2
  6. hematocrit even lower
  7. serum calcium stays low
  8. BUN goes up
  9. metabolic acidosis
  10. low PaO2
125
Q

Tx of acute pancreatitis:

A 
intensive supportive therapy
IV imipenem (or meropenem in those wo seizure disorder) in its with signs of infected pancreatitis
126
Q

Common final pathway for death from acute pancreatitis?

A

multiple pancreatic abscesses

-anticipate and drain them early

127
Q

What imaging study should you get daily in acute pancreatitis?

A

CT scan to look for abscesses

128
Q

What is necrosectomy?

A
  1. removal of necrotic pancreas
  2. usually best to wait as long as possible for necrotic tissue to delineate well (usually wait at least 4 weeks before deriding dead pancreatic tissue)
129
Q

How long does it take for pancreatic pseudocyst to develop?

A

5 weeks

sx: early satiety, vague discomfort, deep palpable mass

130
Q

Tx of pancreatic pseudocyst?

A 
cysts t likely to have complications and will probably resolve spontaneously 
3 ways to drain a pseudocyst:
1. drainage percutaneously 
2. drainage surgically into GI
3. drainage endoscopically into stomach
131
Q

Sx of chronic pancreatitis?

A
  1. steatorrhea (can give pancreatic enzymes)
  2. diabetes (can give insulin)
  3. constant epigastric pain (not responsive to most modalities of therapy)
132
Q

Tx of chronic pancreatis?

A

if ERCP shows specific its of obstruction and dilation, can do operations to drain the pancreatic duct

133
Q

Management of hernias?

A

all should be electively repaired to avoid risk of obstruction and strangulation eXCEPT:

  1. pts younger than 2-5 years old (these typically close on their own)
  2. esophageal sliding hiatal hernia (not a “true” hernia)
134
Q

What must you rule out in all breast disease?

A

cancer! even if presentation suggests benign disease

135
Q

How do you rule out cancer of breast definitively?

A

tissue biopsy analyzed by pathologist

136
Q

What’s the best correlate for the odds of breast cancer?

A

age:

  • unknown in teens
  • rare in young women
  • quite possible in middle aged women
  • very likely in elderly
137
Q

Can mammography diagnose breast cancer?

A

NO

it’s an adjunct to physical exam (can catch masses that are missed by palpation and vice versa)

138
Q

At what age should mammograms be started?

A

Age 40 (earlier if there’s a family history)

  • not done before age 20 (breasts too dense)
  • not done during lactation (all you see is milk)
  • CAN do them during pregnancy
139
Q

Fibroadenomas? age?

A
  1. young women: late teens, early 20s
  2. firm, rubbery moves easily with palpation
  3. do FNA or sonogram to establish diagnosis
140
Q

Giant juvenile fibroadenomas? age? Tx?

A
  1. seen in very young adolescents
  2. associated with very rapid growth
    Tx: remove to avoid deformity and distortion of breast
141
Q

Cystosarcoma phyllodes? age? Dx? Tx?

A
  1. late 20s
  2. very large, replace and distort entire breast but don’t invade or become fixed
  3. most are benign w malignant potential
    Dx: core or incisional biopsy necessary (FNA INSUFFICIENT)
    Tx: mandatory removal
142
Q

Mammary dysplasia

A
  1. 30-40s
  2. bilateral tenderness related to menstrual cycle (worse in last 2 weeks)
  3. multiple lumps that come and go (cysts) that also follow the menstrual cycle
  4. Dx: If no dominant or persistent mass, only need mammogram
    Dx: If there’s a persistent mass, do aspiration (NOT FNA, something with a bigger needle and drying) –> if clear fluid + mass goes away –> no further action
    –if mass persists after aspiration–> formal biopsy needed
    –if bloody fluid–> send fluid off to cytology
143
Q

Intraductal papilloma age? Dx?

A
  1. young women 20-40s w bloody nipple discharge
  2. Dx: mammogram to identify other potential lesions, won’t show papilloma though bc they’re too small
    * galactogram is diagnostic and guides surgical resection*
144
Q

Breast abscess: population? Tx?

A
  1. only seen in lactating women (if in non-lacatating woman, then it’s cancer until proven otherwise)
  2. I&D
  3. biopsy of abscess wall needed, too
145
Q

Breast cancer indicators?

A
  1. age
  2. ill-defined fixed mass
  3. retraction of overlying skin
  4. “orange peel” skin
  5. recent retraction of nipple
  6. eczematoid lesions of the areola
  7. reddish orange-peel skin over the mass (inflammatory cancer)
  8. palpable axillary nodes
146
Q

Does a history of trauma rule out breast cancer?

A

NO

147
Q

Breast cancer during pregnancy? Dx? Tx?

A

Dx: exact same as if not pregnant
Tx: same treatment but NO radiation and NO chemo during FIRST trimester, NO need to terminate pregnancy

148
Q

Tx of resectable breast cancer?

A
  1. lumpectomy + axillary sampling + post-op radiation (only for small lumps not near nipple or areola) OR modified radical mastectomy with axillary sampling
149
Q

Infiltrating ductal carcinoma:

A
  1. standard form of breast cancer
150
Q

Breast cancer with the worst prognosis and need for pre-op chemo?

A

inflammatory infiltrating ductal cancer

151
Q

other variants of infiltrating ductal carcinoma?

A
  1. lobular
  2. medullary
  3. mucinous
152
Q

Variant of infiltrating ductal breast carcinoma that has a high incidence of bilaterally?

A

lobular

153
Q

Which breast cancer can’t metastasize?

A

ductal carcinoma in situ (thus don’t need axillary sampling)

154
Q

Ductal carcinoma in situ prognosis?

A
  1. doesn’t metastasize
  2. high incidence of recurrence if only local excision is done though
  3. total simple mastectomy is recommended if multi centric lesion throughout breast
  4. lumpectomy + radiation if lesion is confined to 1/4th the breast
155
Q

Treatment for inoperable cancer of the breast?

A
  1. chemotherapy + radiation maybe
156
Q

How is inoperably of breast cancer assessed?

A

local extent, not metastases

157
Q

Who gets adjuvant systemic therapy in breast cancer?

A

virtually all pts if axillary nodes are positive
chemo + hormonal therapy if tumor is receptor positive
a. tamoxifen for premenopausal
b. anastazole for post-menopausal

158
Q

What does persistent headache or back pain in women who recently had breast cancer indicate?

A

metastases to:

  1. brain
  2. vertebral pedicle
159
Q

Thyroid nodule in euthyroid patient management:

A
  1. FNA–> if benign, follow but don’t intervene
  2. FNA-> if malignant or indeterminant–> thyroid lobectomy –> hisotological frozen section
  3. total thyroidectomy should be performed in follicular cancers
160
Q

Lab values in hyperthyroid “hot nodules” & Tx

A

TSH: low
T4: high

Treatment: radioactive iodine

161
Q

What can help locate parathyroid adenoma prior to surgery?

A

sestamibi scan

162
Q

Sx of cushing?

A
  1. round, ruddy, hairy face
  2. buffalo hump
  3. supraclavicular fat pads
  4. obese trunk w abdominal stria
  5. thin, weak extremities
  6. osteoporosis
  7. diabetes
  8. hypertension
  9. mental instability
163
Q

Dx for cushing?

A

overnight low-dose dexamethasone suppression test

  1. suppression at low dosage r/o the disease
  2. if no suppression –> 24 h urine free cortisol –> if elevated–> do high-dose suppression test (if then suppressed, then there’s a pituitary micro adenoma)
    - no suppression at either dosage identifies adrenal adenoma (or paraneoplastic syndrome)

OR

  1. measure 24h free cortisol (cushing its have levels 3-4x higher than normal)
  2. measure corticotropin to differentiate pituatary adenoma or adrenal adenoma
164
Q

What imaging modality detects pituatary adenoma?

A

MRI

165
Q

What imaging modality detects adrenal adenoma?

A

CT

166
Q

Zollinger-Ellison (gastrinoma)

A
  1. virulent peptic ulcer disease
  2. resistant to ALL usual therapy (including eradication of H pylori)
  3. several ulcers rather than just one
  4. ulcers extend beyond first part of the duodenum
  5. watery diarrhea
167
Q

Dx zollinger-ellison?

A
  1. measure gastrin
  2. measure secretin
  3. locate tumor w CT scan of the pancreas and nearby areas
168
Q

Tx of zollinger-ellison?

A
  1. remove it tumor

2. omeprazole helps with metastatic disease in Zollinger-Ellison

169
Q

Insulinoma sx?

A
  1. CNS sx always when the person is fasting bc of low blood sugar
  2. high insulin
  3. high C-peptide
170
Q

Differential Dx in insulinoma?

A
  1. reactive hypoglycemia ( attacks occur after eating)
  2. self-administration of insulin: high serum insulin, low serum C-peptide
    * *some pts use sulfonylureas to induce endogenous insulin secretion to raise C-peptide levels…so measure levels of sulfonylureas also in work-up
171
Q

Nesidioblastosis? what is it? Tx?

A

insidious disease of hyper secretion of insulin in the newborn
Tx: 95% pancreatectomy

172
Q

Glucagonoma Sx?

A 
1. severe migratory necrolytic dermatitis (resistant to all forms of therapy) 
pt has:
1. mild diabetes
2. slight anemia
3. glossitis 
4. stomatitis
173
Q

Diagnosis of glucagonoma?

A
  1. glucagon assay diagnostic

2. use CT scan to locate tumor

174
Q

Tx of glucagonoma?

A
  1. resection is curative

2. somatostatin and streptzocin help those with metastatic, inoperable disease

175
Q

Primary Hyperaldosteronism causes? Sx?

A 
Causes:
1. adrenal adenoma 
2. adrenal hyperaldosteronism  
Sx:
1. hypokalemia 
2. hyperension 
3. usually female pts. 
4. modest hypernatremia 
5. metabolic alkalosis 
6. high aldosterone
7. low renin
176
Q

Unique presentation of hyperaldosteronism due to hyperplasia?

A

postural changes:

1. more aldosterone when upright than lying down

177
Q

Management of hyperplasia vs adenoma in hyperaldosteronism?

A

hyperplasia: medically treat
adenoma: surgical removal

178
Q

Typical pheochromocytoma pt?

A
  1. thin
  2. hyperactive
  3. attacks of pounding headache
  4. perspiration
  5. palpitations
  6. pallor
179
Q

Dx of pheochromocytoma:

A
  1. 24h urinary vanillylmandelic acid (VMA) levels –can give false positive
  2. metanephrines (more SPECIFIC)
  3. or free urinary catecholamines
  4. do CT of adrenals or radionuclide study to look for extra adrenal sites
180
Q

What must you give the pheo patient before surgery?

A

alpha-blockers

181
Q

Coarctation of aorta presentation?

A
  1. young pt with hypertension in arms
  2. normal/low pressure or no clinical pulses in lower extremities
  3. scallopin got the ribs on chest X-ray (from collaterals)
182
Q

Diagnostic test for coarctation of aorta?

A
  1. Spiral Ct scan enhances with IV dye (CT angio)
183
Q

Cure for coarctation of aorta?

A

Surgical correction

184
Q

Renovascular hypertension pt population?

A
  1. young women w fibromuscular dysplasia

2. old men with arteriosclerotic occlusive disease

185
Q

Dx of renovascular ht?

A
  1. faint bruit over flank or upper abdomen
  2. Duplex scanning of renal vessels
  3. CT angio
186
Q

Tx of renovascular ht?

A

balloon dilation and stenting

Surgery (9 decks)

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