Firecracker Surgery Flashcards
Most common cause of Vertebral osteomyelitis in IVDA?
Tx?
Cause: MRSA
Tx: IV Vancomycin + IV Cefotaxime
Vancomycin alone won’t cover possible G- spp.
What is the treatment of compartment syndrome, and the most critical prognostic factor?
Emergency fasciotomy is treatment, and time to fasciotomy is the most important prognostic factor.
Types of necrotizing infections
Type I: Involves at least one anaerobe (Bacteroides, Clostridium, Peptostrep) in combo w/ a facultative anaerobic Strep and Enterobacter
Type II: Group A Strep. infection
Steps in evaluating goiter
First obtain a TSH level
If it is asymmetric then a thyroid US should be done to see if there are any nonpalpable nodules.
First step in mgmt of a urethral injury:
A retrograde urethrogram
In the setting of rib fractures what is the best treatment to prevent atelectasis and pneumonia?
An intercostal nerve block.
This will alleviate pain without decreasing the respiratory drive and causing hypoventilation leading to atelectasis.
What is the most likely dx with absent lower extremity pulses and a widened mediastinum?
Aortic rupture - the pt will also likely be tachycardic and have HTN (as opposed to HoTN in cardiac tamponade)
What is the best management for PTX and hemothorax?
PTX requires a thoracotomy to release the air
Hemothorax can be managed with a thoracostomy tube to drain the fluid, but may require a thoracotomy if the tube doesn’t solve the problem.
Who should be routinely monitored by US for AAAs?
Patients over 65 with any history of smoking
What is the mgmt for Ascending v. Descending aortic dissections?
Ascending aka Stanford A require immediate surgical repair, even if unruptured - the risk for mortality and cxs is extremely high.
Descending aka Stanford B can be managed with strict BP control (esmolol) if there are no signs of leakage, rupture or end organ compromise.
What role does APC play in colorectal cancer progression?
It’s a tm. suppressor gene, so loss of both alleles can lead to activation of KRAS a proto-oncogene.
Most common site of colorectal ca. mets?
Liver
Which genetic pathway would most likely lead to sessile serrated adenomas and invasive mucinous adenocarcinomas?
The MMR/microsatellite instability pathway.
These typically form on the right side of the colon.
What factors determine the severity of ischemic colitis?
The severity and duration of compromise, and the vessels affected.
Risk factors for ischemic bowel disease:
Normally in older pts w/cardiac or valvular disease. Others: DM Atherosclerosis CHF PVD Lupus
What portion of the GI tract does ischemic colitis affect?
It is ischemia and necrosis of the LARGE intestine – secondary to vascular compromise.
What is the most common type of hernia in men and women?
In both it is the INDIRECT inguinal.
Direct inguinals increase with age, but indirect are still more common.
Non-neoplastic polyps:
Hyperplastic
Inflammatory
Hamartomatous (Peutz-Jegher)
Neoplastic Polyps:
Aka adenomatous polyps - In order of increasing malignant potential:
Tubular adenoma
Tubulovillous adenoma
Villous adenoma
Polyps >1.5 cm in diameter have increased risk of malignancy.
When should a colonoscopy be performed on pts. w/ rectal bleeding?
In any cases of undetermined bleeding, and in any cases of patients >50 even with a known cause for their bleeding (ex: hemorrhoids).
What chromosome is the APC gene located on?
Chromosome 5- its a tm. suppressor gene
What gene is mutated in Puetz-Jagher syndrome?
STK11
It commonly presents w/intussusception, intestinal infarction, acute or chronic rectal bleeding from ulceration, or extrusion of the polyp through the rectum.
They also have hyperpigmented mucocutaneous macules, often in the perioral region.
Most common cause of osteomyelitis in setting of diabetic foot ulcer:
MRSA
Coagulase negative staph.
Aerobic G- bacilli
What is normal ICP?
20 mmHg or less
Anything >20mmHg is considered intracranial HTN and needs CSF drainage.
Interventions to decrease ICP
Osmotic therapy -- Mannitol Hyperventilation Hypothermia Decompressive craniectomy Glucocorticoids
Cxs of Hiatal hernias
Acid reflux Esophagitis Esophageal strictures Perforation Volvulus Strangulated hernia pouch
Best diagnostic tool of hiatal hernias
Upper endoscopy – shows retrograde movement of the stomach
What is Nissen fundoplication, when is it used?
Procedure for refractory hiatal hernias.
Wraps the fundus around the GEJ to prevent further herniation
Most common sxs of hiatal hernias
Acid reflux
Chest pain
Nausea
Early satiety
Paraesophageal v. Sliding hiatal hernia
Paraesophageal only the proximal stomach moves, the GEJ stays in place.
Sliding, the proximal stomach and the GEJ move
Paraesophageal have much higher risk of volvulus and strangulation.
Initial tx for hiatal hernias
PPIs and dietary modification
What is hiatal hernia?
When upper portion of stomach protrudes through the esophageal hiatus of the diaphragm.
Conditions that increase risk for SCC of esophagus:
Zenker diverticulum
Achalasia
Esophageal webs (inc. Pulmmer-Vinson)
Presentation of Esophageal ca:
Progressive dysphagia -- solids then liquids Weight loss Odynophagia Hoarseness GERD Vomiting
Definitive dx of esophageal ca:
EGD w/biopsy
Cxs of an Esophagectomy:
Respiratory compromise Anastomotic leak Fistula formation Laryngeal n. injury Infection Venous thromboembolic disease
What imaging studies are used to stage esophageal cas?
CT and US
3 Zones of injury in a burn wound:
1- Zone of Coagulation: central zone of caogulative necrosis
2- Zone of stasis: Intermed area of vascular damage w/cytokine recruitment.
3- Zone of hyperemia: Outer zone of increased blood flow, generally heals.
What does the systemic edema from large burns cause?
Decreased BV and Cardiac output
Increased blood viscosity and SVR
Tachycardia
What effects can large burns have on renal function?
Large burns decrease CO which leads to decreased renal BF –> prerenal azotemia and ATN.
Colles fracture
Dorsally displaced distal radius fracture
Fall on outstretched hand in dorsiflexion.
Smith’s fracture
Volar displaced distal radius fracture
Boxer fracture
Most common fracture of the metacarpals.
Involves distal 5th metacarpal– specifically the neck.
Happens by punching something hard.
Monteggia fracture
Forearm injury, fracture of the proximal 1/3 of the ulna w/concurrent radial head dislocation.
Often in kids w/fall onto outstretched hand or from trauma.
Cx of Monteggia fracture
Compartment syndrome
Galeazzi fracture
forearm injury w/fracture of the distal 1/3 of the radial shaft w/concurrent disruption of the distal radioulnar ligament.
Tx of Glaeazzi fracture
Surgical open reduction and casting.
Has high risk of compartment syndrome.
What are the tests used to confirm hypercortisolism?
- 24-hr urinary free cortisol test
- Low-dose dexamethasone supression test
- Late evening cortisol test
Most important imaging in ACTH-independent hypercortisolism
Adrenal CT w/thin slicing to look for tumors
What medical therapies may be used to block steroid synthesis in hypercortisolism?
Ketoconazole = DoC
Metyrapone
Aminoglutethimide
Etomidate
What is used to accomplish medical adrenalectomy?
Mitotane
What imaging studies are used to localize the source in ACTH-dependent hypercortiolism?
Pituitary MRI- look for adenoma
CXR or CT- look for SCLC.
When is surgery indicated in Aortic Stenosis?
When the patient is exhibiting signs of CHF.
Valve replacement is necessary
What valvular pathology is likely to accompany aortic dissection?
If a dissection extends to the aortic root then it may cause aortic regurgitation which will cause a large drop in DBP and widened pulse pressure.
What structures are affected in the unhappy triad involving the knee?
ACL
MCL
Lateral Meniscus
How will a Subscapularis tear present?
decreased internal rotation against resistance
Increased passive external rotation
Inability to lift the hand off the back when its placed behind them.
Treatment of Osgood Schlatter disease:
NSAIDs and continuation of activity is intitial management.
Ice and PT are also recommended.
Most common type of testicular sex-cord stromal tumors:
Leydig-cell
They are capable of producing virilization/feminizing sxs.
Most common endocrine manifestation: gynecomastia.
Other signs/sxs: loss of libido, ED, impotence and infertility.
Children may present w/precocious puberty.
Most likely treatment to cure liver mets?
Surgical resection
Characteristics of splenic abscesses
Presents w/ LUQ pain, fever, leukocytosis, L-sided pleural effusion, L-sided pleuritic chest pain and splenomegaly
Should be suspected in IVDU esp w/ hx of endocarditis or infection at another site.
Requires splenectomy
Tx for post-splenectomy sepsis:
Broad-spectrum abx: Vancomycin and Ceftriaxone
Tx for ITP:
Start with High-dose steroids and IVIG
If these fail, then splenectomy.
Rituximab is used in pts refractory to splenectomy
What anastomosis leads to caput medusae?
Paraumbilical and superficial epigastric veins
What auto-Abs are present in PBC?
Antimitochondrial Abs
Antinuclear Abs
What is 1st line tx in PBC?
Ursodeoxycholic acid – it delays progression toward end-stage liver dx and increases survival.
Vits A and D should also be added.
Best step in diagnosing a kidney stone?
Non-contrast CT
Ligation of which ligament during gyn surgery is likely to injure the ureter?
The cardinal/transverse ligament, it lies just anterior to the ureter and contains the uterine vessels to be ligated during surgery.
Most common cause of Gastric Outlet Obstruction:
Pancreatic adenocarcinoma, impinging on duodenum or stomach.
What to look for in a pt w/Glucagonoma:
New-onset DM2 and skin rashes (Necrolytic migratory erythema).
How does a central retinal a. occlusion typically present?
Vision loss that is:
Painless
Acute onset
Monocular
What is Amaurosis fugax?
Transient loss of vision either monocular or biocular, resulting from carotid artery disease.
Any patient experiencing a transient loss of vision like “a curtain being pulled over their eye” with CV risk factors should undergo carotid duplex ultrasound.
What are the treatment options for retinal artery occlusions?
Little can be done to reverse it.
Hyperbaric O2 and ocular massage (to dislodge the embolus) may be tried en route to the hospital
Thrombolytic therapy in the hospital should be done w/in 4hrs of onset.
How does a central retinal VEIN occlusion present?
Blurred vision
Graying of vision
Painless loss of vision
What will fundoscopy of a central retinal v. occlusion look like?
Cotton wool spots
Dilated retinal blood vessels
Hemorrhages
Edema
Treatment of central retinal v. occlusion:
Laser photocoagulation
Intraocular anti-VEGF injections (bevacizumab)
Steroids
Fundoscopy of central retinal a. occlusion:
Whitening of the fundus
Cherry red spot
Decreased blood vessel size
Leser-Trelat syndrome
Sudden onset of seborrheic keratosis as a paraneoplastic syndrome for gastric malignancy.
Classic finding of metastatic gastric ca.
Supraclavicular nodes (Virchow’s node) or periumbilical nodes (Sister Mary Joseph node).
Characteristics of adrenal adenomas
> 90% of adrenal adenomas are non-functioning.
If it is a functioning adenoma then it is likely to produce Cushing OR Conn’s syndrome, but not both.
If the syndromes appear together it is likely an adrenocortical carcinoma.
Common presentation of adrenocortical carcinomas:
Triad of Cushing’s syndrome, Conn’s syndrome and Hirsutism from the increased cortisol, aldosterone and androgens respectively.
What effect would an upper GI bleed have on BUN?
Upper GI bleeds allow the blood to be absorbed as it passes through the small bowel which in turn will increase the BUN.
Number one cause of Gastric MALTomas:
H. pylori
Once it is eradicated the MALToma typically recedes.
Normal mediastinum width:
Less than 8cm
What is an important pre-op step in pts. w/TEF?
Investigate for other VACTERL components
Get an ECHO to make sure their heart can handle the stress of surgery
Components of VACTERL:
Vertebral Defects Anal atresia Cardiac defects TEF Renal anomalies Limb abnormalities
What treatment may be required after surgical correction of CDH?
Intubation and surfactant therapy to treat a hypoplastic lung. The bowel in the chest will keep the lung from developing.
What is the management for flail chest?
PEEP
Lab findings in Sickle Cell Disease
Decreased Hb and Hct Increased reticulocyte count Decreased haptoglobin Increased UC BR Elevated LDH
In addition to vaccines what should be given to sickle cell patients to prevent infections?
Antibiotic ppx w/ Penicillin or erythromycin (for those w/pen allergy) should begin w/in first 3 months and continue until age 5.
What is grading of a tumor?
The histopathological evaluation of the lesion, based on the degree of cellular differentiation.
What do patients with Achalasia have an increased risk for?
Esophageal SCCa.
What would dysphagia only to solids indicate?
An obstructive lesion – like cancer.
Treatments for achalasia
Esophagomyotomy
Botulinum toxin
Nitrates
CCBs
Another option: Balloon dilation – has risk of esophageal rupture.
Abx of choice for bite wounds?
Amoxicillin-clavulanate
Also give tetanus booster if they havent had one in the last 5 years.
3 most common bacterial causes of otitis media:
S. pneumoniae
H. influenzae
Moraxella catarrhalis
Cholesteatoma
Overgrowth of desquamated keratin debris in the middle ear.
May erode the ossicles or mastoid air cells –> conductive hearing loss
A cx of chronic otitis media
Common presentation and causes of carcinoma of the external ear:
Often SCCa - nodular, ulcerated lesion
or Basal cell ca. - telangiectatic, pearly papules.
Both are linked to UV radiation and most common are on the pinna.
Most common cause of Otitis Externa
P. aeruginosa is #1
otitis externa occurs when normal ear flora changes from predominately G+s to predominately G-s.
Clinical manifestations of labyrinthitis:
Tinnitus, vertigo Hearing loss Loss of balance Nausea and vomiting Labyrinthitis = inflammation of the inner ear
Choanal atresia
Obliteration/Blockage of the posterior nasal aperture d/t failure of cannalization.
What are the most common causes of orbital cellulitis and how is it treated?
S. aureus, S. penumo and other strep spp. are the most common pathogens.
Orbital cellulitis is an emergency requiring IV abx – Vancomycin and cefotaxime are used to cover all the most common organisms.
Chalazion
Granulomatous inflammatory disorder d/t obstruction of the meibomian (sebaceous) gland of the eyelid.
Can be painful or painless.
Initial tx: warm compress or gentle eyelid scrub w/baby shampoo and warm water.
Non-responsive lesions may need I&D or rarely steroid injections.
What does recurrent chalazion after surgical removal indicate?
Malignancy. Should be biopsied for histo confirmation.
Dacryocystitis
Infection of the lacrimal sac.
Normally d/t obstruction of the nasolacrimal system.
Presents w/ acute onset erythema, tenderness, swelling inferonasal to the medial epicanthus.
May also have purulent discharge and conjunctival injection.
Tx of Dacryocystitis
Systemic abx – Amoxicillin/clavulanate
Warm compresses, digital massage over the lacrimal sac.
Cases complicated by orbital cellulitis require IV abx.
Chronic cases may require surgery – dacryocystorhinostomy.
What sxs are likely to be seen in Craniopharyngiomas?
These are the most common childhood tms. They can cause a number of sxs d/t mass effect and increased ICP but almost all will present w endocrine dysfxn d/t pituitary compression.
The tms are derived from the remnants of rathkes pouch.
Major causes of avascular necrosis:
Chronic alcohol use Cushing's SLE Antiphospholipid syndrome Sickle cell
Most common cause of conductive hearing loss in the elderly?
Otosclerosis
It is inherited AD.
Presbycusis
Age-related loss of inner hair cells at the base of the basilar membrane.
Characterized by loss of high-F hearing.
Most common cause of sensorineural hearing loss in the elderly.
Weber’s test results
For conductive loss the patient would hear the fork loudest in the AFFECTED ear.
Sensorineural would be loudest in the unaffected ear.
Conductive then would have BC>AC on rinnes.
Cleft lip is failure of fusion of what?
Medial nasal eminence and Maxillary process
