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Surgery > Emma Holliday > Flashcards

Emma Holliday Flashcards

1
Q

Name two absolute contraindications to surgery.

A
  • diabetic coma

- DKA

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2
Q

Name two relative contraindications to surgery.

A
  • poor nutritional status defined as albumin <3, transferrin <200, or >20% weight loss
  • severe liver failure defined by bilirubin >2, PT > 16, ammonia > 150, or encephalopathy
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3
Q

Describe three values suggestive of poor nutritional status in a surgical candidate.

A
  • albumin less than 3
  • transferrin less than 200
  • greater than 20% weight loss
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4
Q

Describe four indicators of severe liver failure in a surgical candidate that may be relative contraindications to surgery.

A
  • bilirubin greater than 2
  • PT greater than 16
  • ammonia greater than 150
  • clinical encephalopathy
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5
Q

How long should smokers abstain from tobacco products prior to undergoing surgery?

A

8 weeks

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6
Q

Why should smokers stop smoking at least two months prior to undergoing surgery?

A

smoking is a negative predictor for wound healing

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7
Q

What is important for smokers and those with COPD in the immediate post-op period?

A

avoid excess O2 supplementation as it may suppress respiratory drive in these CO2 retainers

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8
Q

What is Goldman’s index?

A

an index of cardiac risk used to assess the risk for preoperative mortality in surgical patients

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9
Q

What are the three most important factors when calculating a patient’s Goldman index for cardiac risk?

A
  • history of CHF
  • history of MI within the last 6 months
  • presence of an arrhythmia
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10
Q

If a preoperative patient has a history of CHF or a history of MI within the last 6 months, what steps should be taken prior to surgery?

A
  • if CHF, get an echo; surgery is avoided unless absolutely necessary in patients with an EF less than 35%
  • if MI, get an ECG, then get a stress test if abnormal, then perform a cath if abnormal, then perform revascularization if cath is abnormal
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11
Q

Describe an aortic stenosis murmur.

A

it is a late systolic, crescendo-decrescendo murmur that radiates to the carotids and increases with squatting but decreases with standing

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12
Q

Why is aortic stenosis an important finding in the preoperative assessment?

A

it is a contributor of the Goldman’s index and is a marker for increased cardiac risk and perioperative mortality

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13
Q

Name five medications it is important to stop prior to surgery.

A
  • aspirin
  • NSAIDs
  • vitamin E
  • warfarin
  • metformin
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14
Q

If a patient is taking warfarin, how long before surgery should this be stopped and what is the desired INR going into surgery?

A

it should be stopped 5 days prior to surgery with a drop in INR to less than 1.5

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15
Q

Why is it important to stop taking metformin prior to undergoing surgery?

A

it increases the risk for lactic acidosis

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16
Q

How long before surgery should a patient stop taking aspirin, NSAIDs, and vitamin E?

A

two weeks

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17
Q

What changes to a patient’s insulin regiment should be made prior to surgery?

A

they should take half the morning dose of insulin on the day of surgery

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18
Q

Patients on dialysis should undergo dialysis how close to undergoing surgery?

A

they should be dialyzed within 24 hours preoperatively

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19
Q

Why do we check the BUN and creatinine in patients with CKD prior to surgery?

A

because a BUN greater than 100 increases the risk for post-op bleeding secondary to uremic platelet dysfunction

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20
Q

How does uremic platelet dysfunction appear on a coagulation panel?

A
  • platelet count is normal

- but bleeding time is prolonged

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21
Q

What is assist-control ventilation?

A
  • set the tidal volume and minimal rate

- patient can breath faster and if they initiate and extra breath, the ventilator gives the desired tidal volume

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22
Q

What is pressure support ventilation?

A
  • set the tidal volume but the rate is entirely patient driven
  • important for weaning patient from the ventilator
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23
Q

What ventilator mode is an important stepping stone when attempting to wean patients from the ventilator?

A

pressure support in which the tidal volume is set but the rate is entirely patient driven

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24
Q

How does pressure support differ from CPAP?

A
  • pressure support is a mode in which the tidal volume is set and adequate pressure is given to support that volume whenever the patient initiates a breath
  • CPAP is a continuous underlying pressure used to ensure the alveoli remain open
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25
Q

What is PEEP?

A

pressure given at the end of a respiratory cycle to keep the alveoli open, particularly in the case of ARDS or CHF

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26
Q

What mode of ventilation is used in those with ARDS or CHF?

A

PEEP

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27
Q

What is the best test to order when evaluating whether a patient on a ventilator is being appropriately managed?

A

ABG

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28
Q

How should a patient’s ventilation settings be changed if a patient has low PaO2?

A

FiO2 should be increased

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29
Q

PaCO2 is dependent on what two factors?

A

tidal volume (more efficient to change) and respiratory rate

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30
Q

Why is it mo re efficient to adjust a patient’s tidal volume than their respiratory rate if their PaCO2 is abnormal?

A

because increasing the respiratory rate also increases ventilation of dead space whereas altering the tidal volume changes more functional ventilation

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31
Q

How is the anion gap calculated and what is normal?

A
  • the gap equals (sodium - chloride - bicarb)

- normal is 8-12

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32
Q

What are possible causes of an anion gap metabolic acidosis?

A

MUDPILES

  • methanol
  • uremia
  • DKA
  • paraldehyde
  • iron, isoniazid
  • lactic acidosis
  • ethylene glycol
  • salicylates
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33
Q

What are possible causes of a non-gap metabolic acidosis?

A
  • diarrhea
  • diuretics
  • RTAs
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34
Q

How are metabolic alkaloses differentiated?

A

based on urine chloride

  • less than 20: vomiting/NG tube, antacids, diuretics
  • more than 20: Conn’s, Bartter’s, Gittleman’s
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35
Q

What are the first two things to check in a patient with hyponatremia?

A
  • check the plasma osmolality

- then check the patient’s volume status

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36
Q

What are potential causes of the following types of hyponatremia:

  • hypervolemic
  • normovolemic
  • hypovolemic
A
  • hypervolemic: CHF, nephrotic syndrome, cirrhosis
  • normovolemic: SIADH, Addison’s, hypothyroidism
  • hypovolemic: diuretics, vomiting
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37
Q

How is hyponatremia treated?

A
  • normally, fluid restriction plus diuretics
  • use normal saline if hypovolemic
  • use 3% saline if symptomatic (namely seizures) or have a sodium less than 110
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38
Q

What is an appropriate rate for correcting hyponatremia? What is the risk associated with correcting hyponatremia too quickly?

A
  • 0.5-1.0 mEq per hour

- central pontine myelinolysis

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39
Q

How is hypernatremia treated?

A

replace lost fluid with D5W or another hypotonic fluid

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40
Q

What is the risk associated with correcting hypernatremia too quickly?

A

cerebral edema

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41
Q

What are the symptoms of hypocalcemia and hypercalcemia?

A
  • hypocalcemia: numbness, chvostek sign, Troussaeu sign, prolonged QT interval
  • hypercalcemia: bones, stones, groans, psych overtones, and shortened QT syndrome
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42
Q

What are the symptoms of hypokalemia and hyperkalemia?

A
  • hypokalemia: paralysis, ileum, ST depression, U waves

- hyperkalemia: peaked T waves, prolonged PR and QRS, sine waves

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43
Q

What are the clinical features of hyperkalemia and how is it treated?

A
  • presents with ECG changes including peaked T waves, prolonged PR and QRS, and sine waves
  • treat with calcium gluconate first, then insulin and glucose
  • can use kayexalate, albuterol, and sodium bicarb as well
  • dialysis is a last resort
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44
Q

What is the preferred maintenance fluid?

A

D5 in half NS with 20 KCl (if peeing)

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45
Q

What are three risks associated with the use of TPN?

A
  • calculus cholecystitis
  • liver dysfunction
  • hyperglycemia, zinc deficiency, and other lyte problems
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46
Q

What is the appropriate treatment for a circumferential burn? Why?

A

an escharotomy because we are worried about compartment syndrome

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47
Q

What is the feared complication of smoke inhalation?

A

laryngeal edema compromising the airway

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48
Q

Describe the presentation of carbon monoxide poisoning?

A
  • altered mental status
  • headache
  • cherry read skin
  • history of exposure
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49
Q

Describe the presentation, diagnosis, and treatment of carbon monoxide poisoning.

A
  • presents with a history of exposure, altered mental status, headache, and cherry red skin
  • diagnose with a carboxyhemoglobin test (remember that pulse ox is worthless)
  • 100% oxygen or hyperbaric oxygen if carboxyhemoglobin is severely elevated
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50
Q

Why is SaO2 a poor test of someone suspected of having carbon monoxide poisoning?

A

because CO actually causes a leftward shift of the oxygen dissociation curve

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51
Q

What would a the most likely cause of a clotting disorder in the following populations:

  • the elderly
  • those with edema, hypertension, and foamy urine
  • a young person with family history
  • unresponsive to heparin
  • young woman with history of multiple spontaneous abortions
  • post operatively with thrombocytopenia
A
  • elderly: think malignancy
  • edema, HTN, foamy urine: nephrotic syndrome
  • young with FH: factor V leiden mutation
  • unresponsive to heparin: antithrombin III deficiency
  • young with multiple spontaneous abortions: lupus anticoagulant
  • post-op with thrombocytopenia: HIT
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52
Q

What is unique about the presentation and treatment of antithrombin III deficiency?

A

these patients are unresponsive to heparin

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53
Q

Describe the lab findings suggestive of vWD.

A
  • normal platelet count

- prolonged bleeding time and PTT

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54
Q

What is the rule for fluid resuscitation of burn victims?

A
  • for adults, give kg x %BSA x 3-4 of LR or NS
  • for kids give kg x %BSA x 2-4 of LR or NS
  • give half over the first eight hours and the rest over the subsequent sixteen hours
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55
Q

What is unique about the antibiotics given to burn victims?

A

we avoid PO and IV antibiotics because it breeds resistance and instead we use topical antibiotics (silver sulfadiazine, mafenide, silver nitrate)

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56
Q

What are and what is unique about the three major topical antibiotics given to burn victims?

A
  • silver sulfadiazine: doesn’t penetrate eschars well and can cause leukopenia
  • mafenide: will penetrate eschars but is severely painful
  • silver nitrate: doesn’t penetrate eschars and causes hypokalemia and hyponatremia
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57
Q

If you suffer a chemical burn, what is the best next step?

A

irrigate for at least thirty minutes

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58
Q

If you suffer an electrical burn, what is the best next step? What about after that?

A

get an ECG, if abnormal these patients need at least 48 hours of telemetry

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59
Q

If you suffer an electrical burn and have an abnormal ECG, what is the best next step?

A

48 hours of telemetry

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60
Q

If a patient’s urine dipstick is positive for blood but is negative RBCs, this is indicative of what disease? What are the feared complications of this?

A

rhabdomyolysis, which is likely to cause ATN and hyperkalemia

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61
Q

What are two important complications of rhabdomyolysis?

A
  • ATN

- hyperkalemia

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62
Q

What are the criteria for compartment syndrome?

A
  • the five P’s: pain, pallor, paresthesia, pulselessness, paralysis
  • or a compartment pressure greater than 30 mmHg
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63
Q

What level of consciousness warrants intubation in a trauma patient?

A

if they come in unconscious or have a GCS less than 8

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64
Q

If a patient sustains trauma to the neck and you hear subcutaneous emphysema when palpating the neck, what should be your first step?

A

intubate using a fiberoptic bronchoscope because you may have a laryngeal injury

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65
Q

What should be the first step if a trauma patient comes in with a GCS of 7 after sustaining a severe facial injury?

A

perform a cricothyroidotomy in any circumstance where ET tube placement may be difficult

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66
Q

A widened mediastinum in a trauma patient is likely indicative of what?

A

a great vessel injury

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67
Q

Which patients with a hemothorax warrant thoracotomy?

A
  • greater than 1500cc upon placement of a chest tube

- greater than 200cc/hr over the first 4 hours

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68
Q

What are the criteria that define a flail chest?

A

two or more fractures on three or more consecutive ribs

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69
Q

How is flail chest treated?

A

supplemental oxygen and pain control with a nerve block (don’t use opioids which may decrease respiratory drive)

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70
Q

If a trauma patient presents with confusion, petechial rash on chest, and acute SOB, what are we worried about?

A

fat embolism

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71
Q

What are risk factors for an air embolism?

A
  • removal of a central line
  • lung trauma
  • vent use
  • post-op for heart vessel surgery
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72
Q

What is the best next step for a patient suffering from hypovolemic/hemorrhagic shock?

A
  • place 2 large bore PIV

- run 2L NS or LR over 20 min followed by blood if there isn’t an appropriate response

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73
Q

Electrical alternans is indicative of what disease process?

A

cardiac tamponade

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74
Q

What is pulsus paradoxus?

A

a fall in systolic blood pressure greater than 10mmHg with inspiration indicative of pericardial tamponade

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75
Q

What is the confirmatory test for pulsus paradoxes?

A

FAST scan or needle decompression if suspicion is high

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76
Q

What is the next best step for someone with a tension pneumothorax?

A

needle decompression followed by chest tube placement (you don’t have time for a CXR)

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77
Q

Describe the swan-ganz catheter findings in each of the following types of shock:

  • hypovolemic
  • vasogenic
  • neurogenic
  • cardiogenic
A
  • hypovolemic: low RAP/PCWP, high SVR, low CO
  • vasogenic: low RAP/PCWP, low SVR, high CO
  • neurogenic: low RAP/PCWP, low SVR, high CO
  • cardiogenic: high RAP/PCWP, high SVR, low CO
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78
Q

What is neurogenic shock?

A

a form of vasogenic shock in which spinal cord injury, spinal anesthesia, or adrenal insufficiency causes an acute loss of sympathetic vascular tone

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79
Q

Describe the treatment for each of the following types of shock:

  • hypovolemic
  • vasogenic
  • neurogenic
  • cardiogenic
A
  • hypovolemic: crystalloid resuscitation
  • vasogenic: fluid resuscitation and treatment of the offending agent (antibiotics or anti-histamines)
  • neurogenic: dexamethasone if due to adrenal insufficiency
  • cardiogenic: give diuretics, treat the HR to 60-100, then address the rhythm, and finally give vasopressor support if necessary
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80
Q

How is GCS calculated?

A
  • 4 eyes: spontaneous, to speech, to pain, no response
  • 6 motor: obeys, localizes, withdraws from pain, abnormal flexion, abnormal extension, no response
  • 5 verbal: oriented, confused, inappropriate words, incomprehensible sounds, no response
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81
Q

What is the best first test in someone who has sustained head trauma?

A

CT

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82
Q

How can an acute subdural be differentiated from a chronic subdural?

A
  • acute subdural are hyperdense

- chronic subdural are hypodense

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83
Q

What signs and symptoms are indicative of increased intracranial pressure?

A
  • papilledema
  • headache
  • vomiting
  • altered mental status
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84
Q

How is increased intracranial pressure treated?

A
  • elevate the head of the bed
  • give mannitol
  • hyperventilate to pCO2 of 28-32
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85
Q

Where are the three zones of penetrating trauma to the neck and what is important about each?

A
  • zone 1 is low, below the cricoid; need to do an aortography
  • zone 2 is in the middle; need to do a 2D doppler to explore the potency of the vessels and you may want to do an exploratory surgery
  • zone 3 is high, above the angle of the mandible; need to perform an aortography and triple endoscopy
86
Q

If a patient comes in with free air under the diaphragm, what is the best next step?

A

exploratory laparotomy

87
Q

What is the best next step for a patient who suffers a GSW to the abdomen?

A

exploratory laparotomy plus tetanus prophylaxis

88
Q

What is the best next step in a patient who suffers a stab wound to the abdomen?

A
  • if stable, perform a FAST exam; use diagnostic peritoneal lavage if FAST is equivocal; ex lap if either is positive
  • if unstable, perform an ex lap
89
Q

What is the best next step in a patient who suffers blunt trauma to the abdomen?

A
  • if stable, perform an abdominal CT

- if unstable, perform an ex lap

90
Q

What should you suspect in a patient who suffers blunt abdominal trauma has the following:

  • lower rib fracture plus blood in the abdomen
  • lower rib fracture plus hematuria
  • kehr sign and viscera in thorax on CXR
  • handlebar sign
A
  • spleen or liver laceration
  • kidney injury
  • diaphragm rupture (kehr sign is referred pain to the shoulder)
  • pancreatic rupture (handlebar sign is the circular imprint on the abdomen)
91
Q

Retroperitoneal fluid found on CT in a trauma patient is likely indicative of what?

A

duodenal rupture

92
Q

How should a pelvic fracture be fixed?

A

internally if the patient is stable and externally if the patient is unstable

93
Q

If a patient suffers pelvic trauma and is now hypotensive or tachycardia, what is the best next step and why?

A

concern is that they’re bleeding into their abdomen/pelvis, so do a FAST or diagnostic peritoneal lavage

94
Q

What are two signs of urethral injury?

A
  • high riding prostate

- blood at the urethral meatus

95
Q

What is the next best step in a patient with a suspected urethral injury?

A
  • do a retrograde urethrogram

- never place a foley

96
Q

If a patient has blood at the urethral meatus but a normal retrograde urethrogram, what is the next best step?

A

do a retrograde cystogram to evaluate the bladder, looking for extravasation of the dye (need two views to identify a trigone injury)

97
Q

If a retrograde cystogram demonstrates extraperitoneal or intraperitoneal extravasation, what is the best next step?

A
  • extraperitoneal: bed rest with a foley for comfort

- intraperitoneal: exploratory laparotomy

98
Q

Name four types of fractures that go to the OR.

A
  • depressed skull fractures
  • a femoral neck or intertrochanteric fracutre
  • any open fracture
  • any severely displaced or angulated fracture
99
Q

What type of fracture should be suspected in the following circumstances:

  • shoulder pain s/p seizure or electrical shock
  • shoulder pain with an outwardly rotated arm and numbness over the deltoid
  • older woman who fell on outstretched hand now with a displaced radius
  • young person who fell on outstretched hand now with anatomic snuff box tenderness
  • punched a wall
A
  • posterior shoulder dislocation
  • anterior shoulder dislocation
  • colle’s fracture
  • scaphoid fracture
  • boxer’s fracture
100
Q

Where along the clavicle is it most often fractured?

A

between the middle and distal thirds

101
Q

What is the treatment for atelectasis?

A

mobilization and IS

102
Q

What is the most common cause of a low or a high fever on POD 1?

A
  • atelectasis if low

- necrotizing fasciitis if high

103
Q

What is the pattern of spread for necrotizing fasciitis?

A

subcutaneously along Scarpa’s fascia

104
Q

What are the two most common etiologic agents responsible for necrotizing fasciitis?

A
  • C. perfringens

- GABHS

105
Q

What is the treatment for necrotizing fasciitis?

A

use IV penicillin and debride in the OR until the skin bleeds

106
Q

Describe the cause, triggers, and treatment of malignant hyperthermia.

A
  • a genetic defect involving the ryanodine receptor
  • triggered by succinylcholine or halothane
  • treated with dantrolene to block the RYR and reduce intracellular calcium
107
Q

What is the empiric treatment of post-op pneumonia while awaiting cultures?

A

a fluoroquinolone to cover for strep pneumo

108
Q

What is most likely to cause a fever:

  • immediately post-op
  • POD 1
  • POD 3-5
  • POD 7 or beyond
A
  • immediate: malignant hyperthermia
  • POD1: nec fas or atelectasis
  • POD3-5: pneumonia or UTI
  • POD7: central line infection, cellulitis, dehiscence, abdominal abscess
109
Q

What is the preferred treatment for post-op UTI?

A
  • get a UA and culture

- change the foley and treat with a broad-spectrum antibiotic until cultures come back

110
Q

What is suggested by pain and tenderness at an IV site? What is the proper treatment?

A
  • suggests a central line infection

- get blood cultures from the line, pull the line, and provide antibiotics to cover staph

111
Q

What is suggested by pain at an incision site with edema, induration, and drainage? What about without drainage?

A
  • with drainage is more suggestive of a simple wound infect

- without drainage is more suggestive of cellulitis

112
Q

What is the treatment for a simple post-op wound infection?

A

open the wound and repack; no antibiotics are necessary

113
Q

What is the treatment for post-op cellulitis?

A

draw blood cultures and start antibiotics

114
Q

What is the most likely diagnosis and the best next step if a patient has pain and salmon colored fluid draining from his incision?

A
  • most likely dehiscence

- treat with IV antibiotics and primary closure of the fascia

115
Q

How is abdominal abscess diagnosed and treated?

A
  • most likely to present with unexplained fever and a history of abdominal surgery
  • diagnose with a CT or a diagnostic laparotomy if necessary
  • treat with drainage, either percutaneous, IR-guided, or surgically
116
Q

What is the treatment for thrombophlebitis?

A

antibiotics and heparin

117
Q

What is the best prevention for pressure ulcers?

A

q2 turns

118
Q

What is a Marjolin’s ulcer?

A

it is a chronic ulcer that leads to increased cell turnover and ultimately to squamous cell carcinoma

119
Q

Why tissue biopsy a pressure ulcer?

A

to rule out Marjolin’s ulcer and squamous cell carcinoma

120
Q

How are pressure ulcers staged and treated?

A
  • stage 1: skin intact but erythematous and blanches
  • stage 2: blisters or breaks in the dermis are present
  • stage 3: subq destruction of the muscle is present
  • stage 4: involvement of the joint or bone
  • stages 1 and 2 require barrier protection, stages 3 and 4 require flap reconstruction
121
Q

What are the indications for a diagnostic throacentesis?

A

more than 1 cm of fluid on a lateral decubitus view

122
Q

What are the criteria for a transudative or exudative pleural effusion?

A

transudative if:

  • LDH less than 200
  • LDH effusion/serum less than 0.6
  • protein effusion/serum less than 0.5
123
Q

What are the likely causes of transudative and exudative pleural effusions?

A 
transudative (LDH less than 200, LDH ratio less than 0.6, protein ratio less than 0.5)
- CHF, nephrotic syndrome, cirrhosis
- RA if low pleural glucose
- TB if high pleural lymphocyte count
- malignancy or PE if bloody effusion
exudative
- parapneumonic or cancer
124
Q

What would cause a transudative pleural effusion with low glucose?

A

RA

125
Q

What would cause a transudative pleural effusion with blood?

A

malignancy or PE

126
Q

What would cause a transudative pleural effusion with a high lymphocyte count?

A

TB

127
Q

What would suggest an exudative pleural effusion and what are potential causes?

A
  • suggested by LDH greater than 200, LDH ratio of effusion/serum greater than 0.6, protein ratio of effusion/serum greater than 0.5
  • caused by parapneumonic process or cancer
128
Q

What is a complicated pleural effusion and how is it treated?

A
  • complicated if there is a positive gram stain or culture, pH less than 7.2, or low glucose
  • requires insertion of a chest tube
129
Q

How is a spontaneous pneumothorax diagnosed and treated?

A
  • diagnosed with CXR
  • treat with a chest tube
  • indications for surgery include an ipsilateral or contralateral recurrence, bilateral, incomplete lung expansion after thoracotomy, live in remote area
  • surgery involves pleurodesis to make the pleura stick to the chest wall and prevent collapse
130
Q

Lung Abcsess

A
  • usually secondary to aspiration in alcoholics or the elderly
  • most often seen in the posterior upper or superior lower lobes on the right
  • seen as a mass with air fluid level on chest x-ray
  • treat initially with antibiotics, usually IV penicillin or clindamycin
  • surgery indicated by failure of the antibiotics, abscess greater than 6 cm, or the presence of an empyema
131
Q

First step in a patient with a solitary lung nodule?

A

find an old CXR for comparison

132
Q

What do popcorn calcifications in a solitary lung nodule suggest

A

a benign hamartoma

133
Q

What do concentric calcifications in a lung nodule suggest?

A

an old granuloma

134
Q

What features suggests that a lung nodule is benign? What is the next step?

A
  • popcorn calcifications, concentric calcifications, patient less than 40, size less than 3 cm, or well-circumscribed suggest it is benign
  • treat with CXR or CT scans every 2 months to look for growth
135
Q

What is the next step if a lung nodule appears malignant?

A

remove the nodule with if central and open lung biopsy if peripheral

136
Q

What are potential symptoms of lung cancer?

A
  • weight loss
  • cough
  • dyspnea
  • hemoptysis
  • repeated pneumonia
  • lung collapse
137
Q

What is the most common form of lung cancer in non-smokers?

A

adenocarcinoma, which tends to occur in the scars of old pneumonia

138
Q

Describe common features of adenocarcinoma.

A
  • most common form in non-smokers
  • tends to occur in the scars of old pneumonia
  • found in the periphery
  • often metastasizes to the liver, bone, brain, and adrenals
  • has a characteristics exudative effusion with high hyaluronidase
139
Q

What is the classic presentation for squamous cell carcinoma of the lung?

A
  • paraneoplastic syndrome secondary to PTH-rP including kidney stones and constipation
  • low PTH levels, low phosphate, high calcium
  • central lung mass
140
Q

What is superior sulcus syndrome?

A

a syndrome of shoulder pain, ptosis, constricted pupil, and facial edema associated with small cell carcinoma

141
Q

What is the likely problem in someone with a lung nodule who has ptosis that improves after 1 minute of upward gaze?

A

they likely have small cell carcinoma with lambert-eaton syndrome

142
Q

What is lambert-eaton syndrome?

A

a paraneoplastic syndrome involving antibodies against pre-synaptic calcium channels and associated with small cell carcinoma

143
Q

Which lung cancer is associated with each of the following:

  • non-smokers
  • Lambert Eaton syndrome
  • superior sulcus syndrome
  • PTH-rP
  • exudative effusion with high hyaluronidase
  • adrenal mets
  • SIADH
  • hyponatremia
  • peripheral cavitations
A
  • non-smokers: adenocarcinoma
  • Lambert Eaton syndrome: small cell carcinoma
  • superior sulcus syndrome: small cell carcinoma
  • PTH-rP: squamous cell carcinoma
  • exudative effusion with high hyaluronidase: adenocarcinoma
  • adrenal mets: adenocarcinoma
  • SIADH: small cell carcinoma
  • hyponatremia: small cell carcinoma
  • peripheral cavitations: large cell carcinoma
144
Q

What is the important distinction between small and non-small cell carcinoma of the lung?

A

small cell is more chemo and radio sensitive but non-small cell cancer is more amenable to surgery

145
Q

What are potential causes of ARDS? What criteria are used for diagnosis? How is it treated?

A
  • causes include sepsis, gastric aspiration, trauma, low perfusion, and pancreatitis
  • diagnosed based on PaO2/FiO2 < 200, bilateral alveolar infiltrates on CXR, PCWP < 18
  • treat with PEEP
146
Q

What is described as a systolic ejection murmur that gets louder with valsalva? Softer with valsalva?

A
  • louder: HOCM

- softer: aortic stenosis

147
Q

How can you differentiate HOCM from aortic stenosis on auscultation?

A
  • aortic stenosis is a systolic cres-decres ejection murmur that gets softer with valsalva
  • HOCM is a systolic cres-decres ejection murmur that gets louder with valsalva
148
Q

What is described as a late systolic murmur with a click?

A

mitral valve prolapse

149
Q

What is described as a holosystolic murmur that radiates to the axilla?

A

mitral regurgitation

150
Q

What is described as a holosystolic murmur with a late diastolic rumble?

A

VSD

151
Q

What is described as a continuous machine-like murmur?

A

PDA

152
Q

What is described as a wide fixed and split S2?

A

ASD

153
Q

What is described as a rumbling diastolic murmur with an opening snap?

A

mitral stenosis, potentially complicated by left atrial enlargement and a-fib, often have a history of rheumatic fever

154
Q

What is described as a blowing diastolic murmur with widened pulse pressure?

A

aortic regurgitation

155
Q

Which murmurs get louder with inspiration?

A

right sided murmurs

156
Q

Left sided murmurs tend to get louder with what two things?

A

sitting up and expiring

157
Q

Is Zenker’s diverticulum a true or false diverticulum?

A

a false one as it only contains the mucosa

158
Q

How is achalasia treated?

A
  • conservatively with CCBs, nitrates, or boto

- surgically with a myotomy

159
Q

What presents as dysphagia worse for hot and cold liquids that is accompanied by chest pain similar to an MI and without regurgitation? How is it treated?

A

this describes diffuse esophageal spasm and should be treated medically with CCBs or nitrates

160
Q

What is the most sensitive test for diagnosing GERD?

A

24-hour pH monitoring

161
Q

What are the indications for endoscopy in a patient with GERD?

A

do an endoscopy if danger signs are present

162
Q

How is GERD treated? When do we use surgical intervention?

A
  • treat conservatively with behavior modification, antacids, H2 blockers, and PPIs
  • do surgery for bleeding, stricture, Barrett’s esophagus, an incompetent LES, symptoms with maximal medical treatment
163
Q

What would usually cause a pleural effusion with increased amylase?

A

boerhaave’s syndrome (esophageal rupture)

164
Q

What is the best next step and the treatment if a patient presents with likely boerhaave’s syndrome?

A
  • next step: CXR and gastrograffin esophogram (no barium so no endoscopy)
  • treatment is surgical repair
165
Q

How are gastric varies treated?

A
  • do ABCs
  • perform a NG lavage
  • treat medically with octreotide or somatostatin
  • balloon tamponade only if you need to stabilize for transport
  • remember, no prophylactic treatment, only treat symptomatic cases
166
Q

What are the best next steps in someone with suspected esophageal cancer?

A
  • barium swallow
  • then endoscopy with biopsy
  • then staging CT
167
Q

What is the difference between a type 1 and a type 2 hiatal hernia?

A
  • type 1 is a sliding hernia whereas type 2 is a paraesophageal hernia
  • type 1 produces worse GERD and is usually medically managed
  • type 2 is more likely to present with abdominal pain, obstruction, strangulation, and a need for surgical intervention
168
Q

What is the typical presentation for gastric ulcers?

A

mid-epigastric pain worse with eating in those with a history of H. pylori, chronic NSAID use, or steroid use

169
Q

What is the workup for gastric ulcers? What is the treatment?

A
  • initially get a barium swallow to demonstrate punched out lesions with regular margins
  • need an EGD with biopsy to tell if it’s related to H. pylori and is benign or malignant
  • treat medically for 12 weeks and perform surgery if it persists
170
Q

Gastric lymphoma is associated with what other disease?

A

HIV

171
Q

MALT-lymphoma is associated with what other disease?

A

H. pylori infection

172
Q

What is Blummer’s Shelf?

A

metastases felt on DRE from gastric cancer

173
Q

What is Mentriers disease?

A

a protein losing enteropathy (foamy pee) with enlarged rugae seen on EGD

174
Q

What are gastric varices most often caused by and associated with?

A

associated with splenic vein thrombosis following pancreatitis

175
Q

What is Dieulafoy’s disease associated with?

A

massive hematemesis resulting from a mucosal artery eroding into the stomach

176
Q

What is the treatment for H. pylori?

A

PPI, clarithromycin, and amoxicillin for 2 weeks followed by a breath or stool test for cure

177
Q

What is the preferred test for duodenal ulcer?

A
  • blood, stool, or breath test for H. pylori will most likely be positive as 95% are associated with infection
  • but an endoscopy with biopsy is best because it can also exclude cancer
178
Q

What is the most likely diagnosis if a patient has recurrent, multiple, or refractory duodenal ulcers?

A

ZE syndrome

179
Q

How is Zollinger-Ellison diagnosed and managed?

A
  • test with a secretin stimulation test to find inappropriately high gastrin (should suppress it)
  • treat with surgical resection of pancreatic/duodenal tumor and look for pituitary or parathyroid problems (MEN1)
180
Q

What are the two most common causes of pancreatitis?

A

gallstones and alcohol consumption

181
Q

What is the best imaging test for pancreatitis?

A

CT

182
Q

How is pancreatitis treated?

A

NG suction, NPO, IV rehydration, and observation

183
Q

What are the feared complications of pancreatitis?

A

pseudocysts, hemorrhage, abscess, and ARDS

184
Q

What are four common manifestations of chronic pancreatitis?

A
  • chronic mid-epigastric pain
  • diabetes mellitus
  • malabsorption and steatorrhea
  • splenic vein thrombosis and gastric varices
185
Q

How is pancreatic adenocarcinoma diagnosed?

A

endoscopic ultrasound and FNA

186
Q

What is Courvoisier’s sign?

A

palpable, non-tender gall bladder associated with pancreatic cancer

187
Q

What is Trousseau’s sign?

A

migratory thrombophlebitis associated with pancreatic cancer

188
Q

What must be true for pancreatic cancer to be a candidate for surgery?

A
  • no mets outside the abdomen, to the liver, or to the peritoneum
  • no extension into the portal vein or SMA
189
Q

Describe the findings consistent with an insulinoma.

A
  • symptoms of sweating, tremors, hunger, and seizures
  • blood glucose less than 45
  • symptom resolution with glucose administration
  • hyperinsulinemia, increased C-peptide, and increased pro-insulin
190
Q

What are the symptoms of glucagonoma?

A
  • hyperglycemia
  • diarrhea
  • weight loss
  • necrolytic migratory erythema
191
Q

What are the symptoms of VIPoma?

A

watery diarrhea, hypokalemia, dehyration, and flushing that respond to octreotide (similar to carcinoid syndrome)

192
Q

What disease is indicated in a patient presenting with RUQ pain referring to the pain, n/v, fever, and pain that increases after fatty foods?

A

Acute cholecystitis
Dx: u/s
Tx: cholecystectomy

193
Q

What is the first test that is indicated when acute cholecystitis is suspected?

A

Ultrasound

194
Q

What disease is suspected in a patient that presents with RUQ pain that has high bilirubin and alk-phos?

A

Choledocolithiasis
Dx: u/s
Tx: chole (+) ERCP for stone removal

195
Q

What disease is suspected in a patient presentign with RUQ pain, fever, jaundice, HPN, altered mental status?

A

Ascending cholangitis

Tx: Abx, ERCP

196
Q

What are the two main types of choledochal cysts? What are their treatments?

A

Type 1: Fusiform dilation of CBD- excision

Type 4: Caroli’s in intrahepatic ducts - liver transplant

197
Q

What are the (3) risk factors for cholangiocarcinoma?

A
  1. Primary sclerosing cholangitis
  2. Liver flukes
  3. Thorothrast exposure

Tx: surx (+) radiation

198
Q

What causes an AST = 2x ALT?

A

Alcoholic hepatitis

199
Q

What is suspected if ALT > AST, but both are in the 1,000s

A

Viral heptatis

200
Q

What is suspected if AST/ALT are increased after hemorrhage, surgery, or sepsis?

A

Shock liver

201
Q

What are (3) medical treatments for cirrhosis –> portal HTN?

A
  1. Somatostatin
  2. Vasopressin
  3. Beta blockers
202
Q

What can you use to treat hepatic encephalopathy to remove excess ammonia?

A

Lactulose

203
Q

What are (4) risk factors for hepatocellular carcinoma?

A
  1. Chronic Hep. B carrier or Hep. C
  2. Cirrhosis
  3. Aflatoxin
  4. Carbon tetrachloride
204
Q

What is the tumor marker used in hepatocellular carcinoma?

A

ARP

205
Q

What diseases is suspected in a woman on OCP who presents with a palpable abdominal mass or spontaneous rupture leading to hemorrhagic shock?

A

Hepatic adenoma

206
Q

What (3) organisms are the most common causes of hepatic abcesses? What is the treatment?

A
  1. E. coli
  2. Bacteriodes
  3. Enterococcus

Tx: drainage and Abx

207
Q

What bug is suspected if a patient presents with RUQ, profuse sweating and chills, and palpable liver? What is the treatment?

A

Entamoeba histolytica

Tx: NO drainage, metronidazole only

208
Q

What bug is suspected in a patient who recently returned from Mexico with RUQ and large liver cysts found on u/s? What is the mode of transmission, lab findings, and treatment?

A

Echinococcus
MOT: dog feces
Lab: eosinophilia, +Casoni skin test
Tx: albendazole, surx and AVOID RUPTURE

209
Q

What (3) vaccines are indicated in patients after splenectomy? What other medication is necessary?

A
  1. s. pneumo
  2. h. flu
  3. N. meningitidis
    + prophylactic PCN
210
Q

What nutritional deficiency results with carcinoid syndrome? What are the symptoms?

A

Niacin: dementia, diarrhea, dermatitis, wheezing

Surgery (2 decks)

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