Emma Holliday Flashcards
First step if suspect PE
(a) Tx for PE
If suspect PE, immediately give heparin first
-then workup w/ V/Q scan
(a) PE: treat w/ heparin-warfarin overlap
- IVC filter is pt has contraindication to chronic anticoagulation
1-2 years s/p AAA pt presents w/ brisk GI bleed
Aortoenteric fistula
Mesenteric ischemia
(a) Diagnostic test
(b) Tx
(a) Workup = angiography
- aorta and SMA/IMA
(b) Tx = embolectomy
- or aortomesenteric bypass if thrombus
MEN1
MEN1- 3 Ps
- Pituitary adenoma (prolactinoma)
- Parathyroid hyperplasia (4 gland)
- Pancreatic islet cell tumor (gastrinoma)
1 wk old w/ bileous vomiting and abdominal distention
Malrotation and volvulus
- Ladd’s bands kinking the duodenum
- problem here is the small mesenteric base which makes it at high risk for volvulus
Child w/ neck mass
(a) Anterior to SCM
(b) Lateral to SCM
Non-midline neck mass
(a) Anterior to SCM = branchial cleft cyst
(b) Lateral to SCM = cystic hygroma
- associated w/ chromosomal abnormalities: Turner’s, Down’s, Klinefelters
Give tx for kidney stones based on size
Kidney stones
- under 5mm: hydrate and let it pass
- over 5mm: shock wave lithotripsy
- over 2cm: surgical remoal
Differentiate which pts get the different types of esophageal carcinomas
(a) Squamous cell
(b) Adenocarcinoma
Esophageal cancer
(a) Squamous cell in smokers/drinkers in the middle 1/3 of the esophagus
(b) Long standing GERD => adenocarcinoma in the distal 1/3 of the esophagus
Name the type of fracture
(a) old lady falls on outstretched hand, distal radius is displaced
(b) young person falls on outstretched hand, tender anatomic snuff box
Fractures
(a) Colle’s fracture
(b) Scaphoid fracture
Genetic defect seen in ppl who get malignant hyperthermia
(a) Tx
Genetic defect causing malignant hyperthermia = ryanodine receptor gene defect
(a) Tx is dantrolene (blocks RYR)
Generalized etiology of neck mass that presents at
(a) 7 days old
(b) 7 mo old
(c) 7 yrs old
Neck mass
(a) 7 days old- inflammatory
(b) 7 mo old- cancer
(c) 7 yrs old- congenital
Lab abnormalities seen in acute mesenteric ischemia
leukocytosis, elevated Hgb, elevated amylase, metabolic acidosis (elevated lactate)
Why add epinephrine to lidocaine injections?
Larger doses of lidocaine can be used to increase duration
-epinephrine vasoconstricts arteries => delaying resorption of lidocaine and almost doubling the duration of anaestheisa
Dierticulosis vs. diverticulitis
Diverticulosis = just the outpuouching 2/2 low fiber diet (low fiber causes muscular hypertrophy of colon wall which narrows the lumen and therefore increases pressure)
Then when the outpouching becomes obstructed and forms abscess/perforates = diverticulitis
Differentiate Paget’s disease and inflammatory breast cancer
Paget’s disease: looks like eczema of the nipple
Inflammatory breast cancer- red, hot, swollen breast (not just the nipple)
- orange peel skin
- nipple retraction
Risk of BUN over 100 in the post-op period
Increased risk of post-op bleeding 2/2 uremic platelet dysfunction
Vent settings to manipulate
(a) PaO2
(b) PaCO2
Vent settings- evaluate vent management w/ ABG
(a) PaO2 correlates w/ FiO2
- if PaO2 is low, increase FiO2
(b) PaCO2 correlates w/ tidal volume and rate
- if PaCO2 is high (pH is low), increase rate or TV
Xray finding of necrotizing enterocolitis
Pneumocystis interstinalis = air in the intesitnal wall
Tx for nec in 5 day old
Bowel rest: NPO
- abx and resection of necrotic bowel
- TPN if necessary
When to use 3% saline in hyponatremic pt?
Symptomatic (seizures), or Na under 110
POD7 fever, pain at excision site w/
(a) edema and induration, no drainage
(b) induration with drainage
(c) salmon colored drainage
Give dx and tx
(a) Edema and induration w/o drainage = cellulitis
- Take BCx first, then start abx
(b) Induration w/ drainage = simple wound infection
- open wound and repack, no abx necessary
(c) salmon colored drainage = wound dehiscence
- immediately to OR, IV abx, primary closure of fascia (surgical emergency)
Tx for newborn w/ diaphragmatic hernia
Plan for birth in a hospital w/ ECHMO access- let lungs mature then do surgery on day 3-4
-biggest concern here is pulmonary hypoplasia 2/2 compression of lungs by abdominal contents
Most common oral cancer
Most common oral cancer = squamous cell
-seen in smokers and drinkers
Why do you not want to fix hyper/hyponatremia too quickly?
Don’t fix hyponatremia too quickly b/c of central pontine myolinolysis
Don’t fix hypernatremia too quickly (aka give free water) b/c of risk of cerebral edema
Tx for volvulus- first line
Last resort?
First line tx for volvulus = decompression from below (if not strangulated)
Last resort = surgical removal and colostomy
‘Small blue’ tumor of femur in pediatric pt with night pain and fever
Ewing Sarcoma
- diaphysis of long bones
- night pain, fever, elevated ESR
- Xray: lytic bone lesion w/ onion skinning
- small blue = neuroendocrine tumor
Benign liver tumor in F not on OCPs
Think focal nodular hyperplasia = 2nd most common benign liver tumor
General tx for DCIS/LCIS
Same outcome:
- modified radical mastectomy w/ SLN (w/o adjuvant RT)
- Lumpectomy w/ SLN + adjuvant radiation therapy
- chemo if node +
62 yo M p/w severe epigastric pain x1 hr
- episodic postprandial epigastric discomfort x2 wks
- PMH: DM2, HTN, HLD, CAD
- PSH: CABG
- Meds: ASA for osteoarthritis
- CXR shows air under right diaphragm
(a) Dx
(b) Next step
(a) Perforated peptic ulcer- acute onset epigastric pain w/ chronic NSAID use, intraperitoneal free air (pneumoperitoneum)
(b) Urgent ex lap
Give 2 ddx for 3 day old who has not passed meconium
(a) Give diagnostic test
- Meconium ileus
(a) Gastrograffin enema is dx and tx - Hirschspruing’s
(a) Gold standard is biopsy of mucosa showing absence of ganglia
F/u for benign-appearing solitary lung nodule
CXR or CT scan q2mo to check for growth
How long before surgery should a smoker stop
8 wks
MEN2A
MEN2A
- MTC
- Pheo
- Parathyroid hyperplasia (4 gland)
POD1 pt develops 104F, very ill appearing
Nec Fasc
Pt dies suddently after removal of central line
Air embolism
Baby born in respiratory distress w/ scaphoid abdomen
(a) Dx
(b) First step in dx
(a) Diaphragmatic hernia
(b) Xray to see abdominal contents in the thorax
2 wk old infant w/ bileous vomiting
-pregnancy complicated by polyhydramnios
Intestinal atresia or annular pancreas
Diagnostic test for TE-fistula
Place a feeding tube, then take Xray to see if it’s actually going into the stomach (or just stuck at blind pouch)
2 parts of the colon that are most susceptible to ischemic colitis
The arterial watershed areas: splenic flexure and rectosigmoid junction, b/c they have the least collateral blood supply
First step after
(a) Chemical burn
(b) Electrical burn
After
(a) Chemical burn- irrigate for 30+ minutes prior to ER
(b) Electrical burn- get EKG
S/p trauma- pt has confusion, petechial rash in chest/axilla/neck, acute SOB
Dx
Dx = fat embolism
-suspect after a long bone fracture (esp. femur)
Adverse effect of rocuronium
Possible allergic rxn in asthmatics
Give brief standard of tx for
(a) Colon cancer
(b) Rectal cancer
(a) Colon cancer = remove affected segments + chemo if node is positive
(b) Rectal cancer:
Stage I/II
-upper/middle 1/3 get LAR (lateral anterior resection)
-lower 1/3 gets APR
Stage III/IV: neoadjuvant chemo/radiation
What anal entity is treated w/ topical lidocaine and nifedipine?
Anal fissures
-give to posterior mucosal anal tear w/ skin tag, don’t need colonoscopy (more worried about lateral, not posterior, lesions)
Gastrocschisis vs. omphalocele
(a) Elevated maternal AFP
(b) Associated disorders
(c) Covered by sac
(d) Relationship to midline
Newborn abdominal wall defects
(a) Gastrochiesis (no sac) is assocaited w/ elevated maternal AFP
(b) Omphalocele (yes sac) associated w/ cardiac abnormalities
(c) Gastrochiesis- no sac covering, omphalocele- yes sac covering
(d) Omphalocele (sac) midline, gastrochesis (no sac) lateral to umbilicus
Tx for
(a) acute rejection
(b) Chronic rejection
Tx
(a) Acute rejection (5 days to 3 mo): steroid bolus and antilymphocyte agent (OKT3)
(b) Chronic rejection (after years): no tx, needs re-transplantation
Huge facial trauma, blood obscuring oral and nasal airway, GCS of 7
Next step?
Cricothyroidotomy- don’t want blood in the tube for endotracheal intubation
IBD associated w/
(a) terminal ileum vs. rectum
(b) PSC
(c) Fistulae
(d) Gramulomas
(e) Transmural inflammation
(f) Cured by colectomy
(g) Smoking
(h) Colon cancer risk
(i) p-ANCA
IBD: Crohn’s vs. UC
(a) Crohn’s = terminal ileum, vs. UC always involves the rectum
(b) UC and PSC (increased risk of cholangiocarcinoma)
(c) Fistulae in Crohn’s (give metronidazole)
(d) Granulomas and Crohn’s
(e) Transmural inflammation in Crohn’s
(f) UC is cured by cholectomy
(g) Smoking- decreased risk of UC, higher risk of Crohn’s
(h) Higher colon cancer risk in Crohn’s
(i) UC associated w/ p-ANCA
Newborn w/ respiratory distress and excess drooling
Respiratory distress and excess drooling in newborn = TE fistula
tracheo-esophageal fistula
-think VACTERL association
Tx for asymptomatic gastric varices
Beta-blockers
-don’t prophylactically band them if asymptomatic
For a CKD pt on dialysis who needs surgery, when should they get dialysis pre-op?
Dialyze 24 hrs post-op
(a) 4-5 yo kid w/ painless limp
(b) 12-13 yo w/ knee/thigh pain and sickle cell disease
Peds Ortho
(a) 4-5 yo w/ painless limp: think Leg-Calve-Perthe’s avascular necrosis of the femoral head
(b) SCFE
ABI where you’d expect
(a) Claudication
(b) Limb ischemia
(c) Ulcers
(d) Gangrene
ABIs
(a) Claudication under .9
(b) Limb ischemia: 0.2-0.4 (surgery indicated)
(c) Ulcers w/ claudication at under .9
(d) Gangrene at under .2 (may require amputation)
How should a chronic smoker be treated differently post-op?
Chronic smoking => chronic CO2 retention
-shouldn’t be given high O2 post-op b/c that could suppress respiratory drive
Describe the metabolic complications seen in pyloric stenosis
Pyloric stenosis => lots of vomiting (non-bileous) => losing HCl => hypochloremic metabolic alkalosis
2 anesthetic agents most commonly associated w/ malignant hyperthermia
Succinylcholine and halothane
Pathophysiology of malrotation and volvulus
Embryologically, bowel doesn’t rotate 270 ccw around the SMA
Clinical symptoms of
(a) hypocalcemia
(b) hypercalcemia
Clinical signs of
(a) Low Ca = numbness, Chvostek/Troussaeu, prolonged QT
(b) High Ca = ‘bones, stones, groans, psychiatric undertones’, shortened QT
Blood at the urethral meatus w/ a high riding prostate
(a) Next best test
Think: urethral injury 2/2 pelvic fracture
(a) Next best test = retrograde urethrogram
Management of adrenal nodule
(a) First step
(b) How size matters
Adrenal nodule
(a) First- check functional status
- high BP (pheo or primary aldo), cushingoid?
(b) Under 5cm and nonfunctional- can observe w/ CT scan q6mo
- if over 6cm (functional or not) => surgical removal
Describe the pathophysiology of nec fasc
(a) Location
(b) Most common bugs
(c) Tx
Nec fasc = pt looks super sick, flesh eating bacteria of bound, super febrile (like 104) on POD1
(a) spreads along the fascial plane, in the subQ tissue (along Scarpa’s fascia
34 yo M w/ severe pain in penis that started during intercourse
-grossly swollen penis deviated to the right
Tx?
Dx = penile fracture, due to tearing of the tunica albuginea which invests the corpus cavernosum
Tx = retrograde urethrogram (need to asses for urethral injury) + emergency surgery to evacuate hemoatoma and mend the torn tunica albuginea
Characteristics of malignant lung nodules
- new (not on old CXR)
- smoker
- over 40
- over 3cm
- calcified
Most sensitive SCR finding for blunt aortic trauma
Mediastinal widening
- see enlarged aortic bulge on superior cardiac silhouette
- suspect aortic trauma in pt who suffers from blunt deceleration trauma (MVA or fall from more than 10 ft)
39 yo M w/ r. hip pain that makes it difficult to lie on his right side while sleeping
-localizes pain to outer surface of his thigh
Dx
Dx for middle aged adult w/ unilateral hip pain exacerbated by external pressure to upper lateral thigh = trochanteric bursitis
= inflammation of the bursa surrounding the insertion of the gluteus medius onto the femur’s greater trochanter
Contraindication to succinylcholine
Burn or crush victims b/c suc can cause hyperkalemia
Name 3 fractures that go directly to the OR
- depressed skull fracture (broken bones are displaced inwards)
- any open fracture- bone sticking out needs cleaning
- femoral neck or intertrochanteric fx
2 mo old w/ colicky abdominal pain and current jelly stool
Intussusception
-barium enema is dx and tx
MEN2B
MEN2B
- MTC
- Pheo
- Marfanoid body habitus and neuromas
What other concerns do you have when a newborn is diagnosed w/ TE-fistula?
VACTERL association Vertebral Anal atresia Cardiac abnormalities TE- fistula Renal/kidney defects Limbs
Meds to stop pre-op
(a) Name 3 meds to stop for 2 wks
(b) What to do w/ warfarin
(c) What to do w/ insulin
Pre-op meds to stop
(a) Stop for 2 wks: aspirin, NSAIDs, vit E
(b) Stop warfarin for about 5 days, goal is to drop INR below 1.5, can use vitamin K
(c) Take half the morning dose of insulin
Spread of papillary vs. follicular thyroid cancer
Papillary thyroid cancer (most common) spreads via lymph nodes => can do lobectomy
Follicular thyroid cancer spreads via blood => must surgically remove entire thyroid
Most common cancer in nonsmokers
Adenocarcinoma
Midline neck mass that moves when pt sticks out tongue
(a) Tx
Midline neck mass in child that moves when tongue is protruded = thyroglossal duct cyst
(a) Remove surgically
Tx for pyloric stenosis in 4wk old
Tx = immediate referral to surgery for myotomy
-cut/ligate the muscle around the pyloric sphincter
Absolute contraindication to surgery
Diabetic coma, DKA
2 other irregularities associated w/ umbilical hernia in newborn
Associated w/ umbilical hernia
- hyperglossia (large tongue)
- congenital hypothyroidism
Salivary gland cancers
(a) Most common salivary gland tumor
(b) Most common malignant salivary gland tumor
(c) Warthlin’s tumor
Salivary gland cancers
(a) Most common salivary gland tumor = pleomorphic adenoma
- benign but recurs, usually on parotid
(b) Most common malignant salivary gland tumor = mucoepidermoid carcinoma
- pain and facial nerve palsy
(c) Warthlin’s tumor = benign parotid gland tumor, can injur facial nerve
Utility of Goldman’s index?
(a) Name a few of the criteria
Goldman’s index- used to estimate a pt’s perioperative cardiac risk
(a) CHF, MI in the past 6 mo
Adverse event associated w/ Merperidine
Seizures b/c merperidine lowers the seizure threshold, especially in pts w/ renal failure
5 day old ex-33 weeker develops bloody diarrhea
Dx
Necrotizing enterocolitis
-often upon introduciton of feeds/switch to formula in a premature gut
Name 4 contraindications to surgery
- Diabetic coma/DKA = absolute contraindication
- poor nutrition
- albumin under 3, transferin under 200, wt loss of more than 20% - severe liver failure
- current smoker
1 cause of death s/p AAA repair
MI
Diverticulitis
(a) Clinical presentation
(b) CT findings
(c) Tx
(d) F/u
Diverticulitis
(a) Presents w/ LLQ pain + constipation or diarrhea
(b) See free air on imaging (if perf), see abscess on CT
(c) Tx = bowel rest and decompression (NPO, NG tube), broad spec abx and pain
(d) F/u- do colonoscopy 4-6 wks later
Enlarging nodule gradually growing over site of chronic draining wound from burn 4 years ago
Marjolin ulcer = squamous cell carcinoma that arises w/in a chronically wounded, scarred, or inflamed skin
What cancer does Hashimoto’s thyroiditis predispose pt to?
Thyroid lymphoma
