Emma Flashcards
absolute contraindications to surgery
DKA, diabetic coma
poor nutrition indicators to delay surgery
weight loss >20%, albumin
how to assess poor liver failure to delay surgery
bili>2, >16, ammonia>150, encephalopathy
smoker pre op and post op.
stop smoking 8 weeks before surgery. post op: they are CO2 retainers, go easy on the O2 during post op period because it can suppress respiratory drive
goldmans index
tells you who is at greatest risk for surgery. #1 factor= CHF. EFmust be >35. #2 factor: get EKG. MI w/i 6 months. arrhythmia, old age, AS.
what meds to stop before surgery
aspirin. NSAIDS. metformin (-> lactic acidosis). warfarin (7-10 days- can use vitamin K). if DM on insulin, 1/2 the morning dose.
why care about BUN and creatinine pre-op
uremic platelet disfunction-> increased risk bleeding
assist control vent setting
set TV and rate but if pt takes breath, vent gives volume.
pressure support vent setting
pt rules rate but a boost of pressure is given. important for weaning!
CPAP
continuous positive pressure. pt has all drive
PEEP
keeps alveoli open. ARDS
if PCO2 is low on vent, what to do
can adjust rate or tidal volume. tidal volume is more efficient. rate gives stuff to dead space but tidal volume doesnt.
things that cause anion gap acidosis. non anion gap?
Na-Cl- bicarb. anion gap: MUDPILES: methanol, uremia, DKA, isoniazid, lactic acidosis, ethylene glycol, salicilates. nonanion gap: diarrhea, diuretic, RTA
next step after alkalotic
check urine chloride. if 20: Conns, barriers, gittelmans
hyponatremia tx?
fluid restriction
hyponatremia but volume depleted. next steps?
fluid rescusistate!
hyponatremia
3% NS . but try to avoid bc you worry about CML.
how to treat hypernatremia
replace with D5W or hypotonic fluid but worry about cerebral edema
paralysis, ileus, St depressions, U waves on EKG
hypokalemia. give K. monitor renal function.
maintenance IVF of choice
D5 1/2NS + 20KCl (if peeing)
pt with clotting problem, edema, HTN, and foamy pee
nephrotic syndrome causes clotting problems
why do surgeons care about anti-thrombin II deficiency
heparin wont work!
post op patients with low platelets and high clotting.
HIT! give synthetic heparin like enoxaparin.
normal plus but increased bleeding time, and PTT
vWF
low platelets, increased PT, PTT
DIC. caused by GN sepsis, carcinomatosis, OB stuff.
burn topical that doesnt penetrate eschar and can cause leukopenia
silver sulfadiazine.
burn topical that penetrates eschar but hurts like hell
mafenide
burn topical that doesnt penetrate eschar and causes hypoK and hypoNa
silver nitrate
electrical burn, first step
EKG! look for arrhythmia. if abnormal get 48 hours of telemetry
if you have rhabdo, what do you check next
K+ that is what will kill you when cells break apart.
if guy is stabbed in neck, GCS=15, expanding mass in lateral neck
intubate!
guy is stabbed in neck, crackly sounds with palpating anterior neck tissues
intubate with fiberoptic bronchoscope. laryngeal injury form subQ emphysema.
if huge facial trauma, blood obscures oral and nasal airway, GCS is 7
cricothyroidomy. if you can’t assess where you’re putting tube
after intubating, breath sounds are decreased on left
you intubated right main bronchus. pull back your ET tube.
pt has hemothorax. what to do? when to go to OR?
put in chest tube. OR when high output- >1L. or if >200cc/hr over first two hours.
stab wound in upper neck above angle of mandible. next steps?
aortography and triple endoscopy
stab wound in middle neck
2D doppler +/- exploratory surgery
stab wound in lower neck
aortography
blunt abdominal trauma, HD stable, handebar sign
pancreas injury
blunt abdominal trauma, stable, epigastric pain. next steps? what if you find retroperitoneal bleeding?
abdominal CT. if RP bleed, worry that duodenum ruptured. not really acute abdomen trauma.
how to treat malignant hyperthermia
dantrolen sodium- blocks ryanodine receptor and decreases intracellular calcium
pain at incision site, edema, induration, without drainage
cellulitis. check bcx. give antibiotics
pain at incision site, edema, induration, with drainage
simple wound infection. open wound and repack. no antibiotics necessary.
pain with salmon colored fluid from incision site
dehiscence. go back to OR to close fascia.
MC cancer in non smoker? location and mets? characteristics of effusion?
adenocarcinoma. peripheral. mets to adrenals, liver, brain bone. effusion is exudative with high hyalduronidase.
lung cancer with kidney stones, constipation, low PTH, central lung mass
squamous= paraneoplastic of PTHrP. low PO4, high Ca.
what lung cancer is most likely to cause pan coast?
small cell
what lung cancer causes ptosis better after 1 minute of upward gaze
lambert eaton from small cell.
OLD SMOKER WITH NA= 125, mmm, n jvd?
SIADH from small cell. (almost all paraneoplastic come from small cell except squamous cell)
small cell vs non small cell treatment
surgery for non small cell cancer. small cell is sensitive to chemo and radiation
dx of ARDS
- radiographic features: fluffy white infiltrates. 2. PaO2/FiO2>200. 3. PCWP
dysphagia worse with hot and cold liquids and chest pain that feels like MI with NO regard. dx? tx?
diffuse esophogeal spasm. tx with NO and CCB
krukenberg
gastric cancer mets to ovary
blummers shelf
gastric cancer mets felt on DRE
virchows node
L supraclavicular fossa node from gastric cancer
sister mary joseph node
umbilical fossa
lymphoma association
HIV
MALT lymphoma association
H pylori
mentriere’s
protein losing enteropathy associated with enlarged rugae
what are gastric varices associated with
splenic vein thrombosis
mid epigastric pain better with eating
duodenal ulcer
which type of ulcer is more associated with H pylori
duodenal ulcer! healthy people
tx for duodenal ulcer
PPI, clarithromycin, amoxicillin for 2 weeks breath or stool test to test cure
what do you worry about if duodenal ulcers don’t get better with triple therapy?
ZEG. do secretin stimulation test (high gastrin even when we give secretin indicates tumor). tumor in pancreas- do resection. MEN1. look for pituitary and parathyroid.
a patient who lost 200 pounds has bilious vomiting and post prandial pain
SMA syndrome. the third part of the duodenum is compressed by the AA and SMA. tx= restore weight and nutrition, or roux en y.
complications of pancreatitis
pseudocyst (no cells), hemorrhage, abscess. third spacing-> ARDS
chronic mid epigastric pain, DM, malabsorption (steatorrhea)
chronic pancreatitis
splenic vein and chronic pancreatitis
CP-> splenic vein thrombosis-> gastric varcies
MC cancer of pancreas
adenocarcinoma.
courvoisiers sign
palpable non tender gallbladder. associate with pancreatic cancer.
trousseau’s sign
migratory thromboplebitis. associated with pancreatic cancer.
how to dx pancreatic cancer
EUS and FNA bx
pancreatic cancer treatment?
whipple if no mets outside of abdomen, portal vein, no liver mets, no peritoneal mets
sxs (sweat, tremors, hunger, seizures) + BGL
whiles triad of insulinoma!
labs for insulinoma
increased insulin, increased C peptide, increased pro insulin
tumor that presents with malabsorption
somatostatinoma. commonly malignant. ect from exocrine pancreas malfunction
watery diarrhea, flushing, hypokalemia, dehydration, flushing
VIPoma. looks similar to carcinoid syndrome. tx: octreotide can help symptoms.
cholecystitis vs symptomatic gallstones
fever is difference!
choledochal cysts type 1 and type 4
type 1: fusiform dilation of CBD-> tx with excision. type 4: Caroli’s dz- cysts in intrahepatic ducts-> need liver transplant.
cholangiocarcinoma risk factor? tx?
PSC (UC) x: surgery +/- radiation
2nd MC benign liver tumor. W>M but less likely to rupture. tx?
focal nodular hyperplasia. no tx needed.
what are most common bugs for bacterial abscess in liver? tx?
E coli, bacteriodes, enterococcus. surgical drainage and IV antibx
RUQ pain, profuse sweating and rigors, palpable liver. dx? tx?
amebic abscess. worse sxs than bacterial. tx: MDZ DONT DRAIN
what abscess don’t you drain
lung abscess. amebic liver abscess.
pt from Mexico presents with RUQ and multiple large liver cysts on US. mode of transmission? lab findings? tx?
echinococcus. transmission: dog poo. lab: eosinophilia bc parasite. positive casino skin test. tx: albendazole but then SURGERY but careful not to break cyst (can cause anaphylaxis)
MC location for carcinoid? sxs?
appendix (after a pass through the liver)! sxs: flushing, wheezing, diarrhea
nutritional deficincy in carcinoid
niacin (diarrhea, dementia, dermatitis). (serotonin and niacin are both used in tryptophan)
if carcinoid tumor is >2 cm, at base of appendix, or with positive LN, what tx?
hemicolectomy. otherwise just appendectomy.
when to do surgery for SBO
peritoneal signs, increased WBC, no improvement in 48 hours
direct vs indirect hernias
indirect is more common. through the inguinal ring lateral to the epigastric vessels. usually congenital. direct is more often from acquired weakness
which IBD can cause Fe deficiency
Crohns. involves terminal ileum.
which IBD is more likely to have granulomas on biopsy
Crohns
skin manifestation of UC
pyoderma gangenosum
sxs of left sided colon cancer? sxs of right sided colon cancer? rectal?
right: bleeding. left: obstruction (pencil thin stools). rectal: pain/fullness, bleeding/obstruction
post op complications for AAA. number 1 complications?
do surg when >5cm. MI.
bloody diarrhea after AAA surgery
ischemic colitis
AAA surgery-> weakeness, decreased pain with preserved vibration and proprioception
ASA syndrome
ASA syndrome-> 1-2 years later have brisk GI bleeding
AV fistula
acute abdominal pain in pt w/a fib sub therapeutic on warfarin or pt s/p high dose vasoconstrictor (shock, bypass)
suspect acute mesenteric ischemia. workup is angiography of SMA/IMA. tx= embolectomy. if thrombus, or aortomesenteric bypass
severe MEG pain after eating, pain out of proportion to physical exam
chronic mesenteric ischemia. slow progressing stenosis of 2.5 vessels-> celiac, SMA, and IMA. dx with duplex or angiography. tx: aortomesenteric bypass or transaortic mesenteric endarterectomy
acute arterial occlusion: 5Ps and no dopplerable pulses. next steps?
immediate heparin and prepare for surgery. thrombolytics may be possible if no surg in
complications of treatment for acute arterial occlusion
compartment syndrome during reperfusion. do fasciotomy and watch for myoglobiuria.
best test for claudication and tx for diff types.
ankle brachial index surgery.
how to treat DVT. complications?
hepatin-> warfarin for 3-6 months. comp: post phlebotic syndrome= chronic valvular incompetence, cyanosis, and edema
how do different types of thyroid cancer spread (2)
papillary: lymph, psammoma bodies. follicular: blood, must excise whole thyroid.
adrenal nodule+ high BP, catechol symptoms. test? dx?
get urine and plasma metanephrines. pheochromocytoma.
adrenal nodule + high BP, low K, low PRA
primary aldosteronism. get plasma aldo-renin ratio
adrenal nodule + virilization/feminization
adrenocortical carcinoma- get urine 17 ketosteroids
tx for adrenal nodule
if observe and CT scan q6mo. if >6cm or funcitonal-> surgical excision
MEN1
parathyroid hyperplasia, pituitary adenoma, pancreatic islet cell tumor (ZES
MEN2
pheo, parathyroid hyperplasia, medullary thyroid cancer
MEN3
Marfanoid features, pheo, medullary thyroid cancer
fibrocystic change in breast features and tx
cysts are painful and change with menses. fluid is typically green or straw colored. tx: restrict caffeine, take vitamin E, wear a supportive bra
tx for DCIS
excision with clear margins or simple mastectomy if multiple lesions (no node sampling) + adjuvant therapy
tx for LCIS
more often bilateral. consider b/l mastectomy only if FH, hormone sensitive, or prior hx of breast cancer
infiltrating ductal/lobular carcnoma tx
if small and away from nipple, can do lumpectomy with ax node sampling. adjuvant RT. chemo if node + tamoxifen/raloxifen if ER. or modified radial mastectomy w/ax node sampling w/o adjutant RT
tx for Pagets Dz
do mammo to find mass
tx for melanoma
need full thickness bx bc depth is #1 prognosis. tx with excision. 1 cm margin if 4mm. high dose IFN or IL2 may help
painless enlarging mass. dx? tx?
sarcoma. dx with bx (NOT FNA). excisional if
spread of sarcoma
hematogenously. first to the lungs. can do wedge resection if only met and primary is under control
hard round mass on extremity.
lymphangiosarcoma. can occur in areas of chronic lymphedema.
why give lidocaine with epi
to prevent systemic absorption-> numb tongue, seizures, hypotension, arrythmias. no epic in fingers, nose, penis
who gets spinal subarachnoid anasthesia
for people who can’t be intubated. but also can’t be given if increased ICP
what happen if a high blood of epidural (local + opioid)
blocks heart SNS nerves and phrenic nerve
meperidine side effect
can lower seizure threshold in pts with renal failure
succinylcholine side effect
can cause malignant hyperthermia, hyperK (not for burn or crush victim)
rocuronium side effect
sometimes causes allergic rxn in asthamtic
halothane side
can cause malignant hyperthermia (dantrolene NA) liver toxicity)
