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Surgery > Gen Surg 3/13/17 > Flashcards

Gen Surg 3/13/17 Flashcards

1
Q

MEN1

A

Pituitary (any pit tumor, functioning or non)

Parathyroid (hyper calcemia)

Pancreas (endocrine)

  • Zollinger Ellison gastrinoma refractory PUD
  • Insulinoma hypoglycemia… get C-peptide to check for endogenous vs exogenous, get Secratagogue screen to make sure not ingesting sulfonylureas
  • The HARD P’s
  • MEN Gene
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2
Q

MEN2

A

Both Ret Oncogene

MEN2A
pheochromocytoma
medullary thyroid ca (Parafollicular C-cells calcitonin)
ParAthyroid

MEN2B
pheochromocytoma
medullary thyroid ca (Parafollicular C-cells calcitonin)
Neuronal Beuronal… also Marfanoid MEN2Barfanoid

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3
Q

MEN syndromes

A

MEN1 *MEN Gene
Pituitary (any pit tumor, functioning or non)
Parathyroid (hyper calcemia)
Pancreas (endocrine)
-Zollinger Ellison gastrinoma refractory PUD
-Insulinoma hypoglycemia… get C-peptide to check for endogenous vs exogenous, get Secratagogue screen to make sure not ingesting sulfonylureas
*The HARD P’s

MEN2A *RET oncogene
pheochromocytoma
medullary thyroid ca (Parafollicular C-cells Calcitonin)
ParAthyroid

MEN2B *RET oncogene
pheochromocytoma
medullary ca (Parafollicular C-cells Calcitonin)
Neuronal Beuronal.. also Marfanoid MEN2Barfanoid

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4
Q

TF

Von Hippel Lindae assoc w thyoid and parathyroid issue…

A

F
Pheochromocytoma
not thyroid parathyroid (that would be MEN2A)

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5
Q

P53 mut think

A

retinoblastoma

colon cancer

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6
Q

APC mut think

A

colon cancer

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7
Q

VHL mut think

A

pheochromocytoma

Von-Hippel Lindau

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8
Q

elevated calcium low phosphorous with normal renal function think…

A

parathyroid neoplasm

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9
Q

key labs in vitamin D deficiency

A

HIGH PTH

stimulated by LOW CALCIUM

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10
Q

layers of adrenal

A

GFR
glomerulosa fasciculata reticulata

the deeper you go the better it gets
salt sugar sex
aldo cortisol testosterone

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11
Q

Cortisol excess causes

A

Cushing syndrome

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12
Q

Causes of Cushing Syndrome

A

Cortisol excess

ACTH secreting Small Cell Lung Cancer
ACTH secreting Pituitary Adenoma
Cortisol secreting Adrenal Neoplasm
Exogenous Corticosteroids

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13
Q

Cushing Syndrome vs Cushing Disease

A

Syndrome caused by any Cortisol Excess

  • SCLC, Pit Ad secreting ACTH
  • Adrenal Neoplasm secreting Cortisol, exogenous Corticosteroids

Cushing Disease is ACTH secreting Pituitary Adenoma

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14
Q 
Cushing Syndrome
Path
Pres
Dx
Tx
A

ACTH dep (pit ad, sclc) or indep (cort secreting adrenal neoplasm or exogenous corticosteroids)

HTN DM Obese (not a big help given America)
Moon facies, Acne, Truncal obesity, Buffalo hump, Purple striae

Low THen High + 24hr U Cort or Late Night Saliva Cort
-Low-dose Dexameth suppression - if does not suppress – Cushing Syndrome
-acTH
if norm, adrenal tumor CT MRI Resect
-If acTH HIGH, do HIGH-dose Dexaemth suppression test
if works Cushing Dz (prim pit acth adenoma) Resect
if fails Ectopic Cortisol Tumor (eg SCLC) Pan Scan

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15
Q

lab workup in Cushing Disease

tx

A

low dose dexamethasone suppression test does not suppress cortisol or ACTH (confirms Cushing Syndrome)

ACTH high

High dose dexamethasone suppression test works, suppresses ACTH a bit

it’s a primary pituitary adenoma secreting ACTH
you need to Resect it

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16
Q

lab workup in cortisol secreting adrenal neoplasm

tx

A

low dose dexamethasone suppression test does not suppress cortisol or ACTH (confirms Cushing Syndrome)

ACTH normal

it’s a primary adrenal adenoma secreting Cortisol
Confirm with CT MRI
Resect that shit

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17
Q

Lab workup in ectopic ACTH producing neoplasm

tx

A

low dose dexamethasone suppression test does not suppress cortisol or ACTH (confirms Cushing Syndrome)

ACTH high

High dose dexamethasone suppression does not work, ACTH remains high

It’s an ectopic ACTH producing tumor (e.g. SCLC), PAN SCAN

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18
Q

When can you say, “Cushing syndrome”

A

When cushing signs and symptoms

And

2/3 disgnostic tests

  • Low dose dexamethasone suppression test (Cortisol not suppressed)
  • 24hr urine cortisol
  • Late night salivary cortisol
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19
Q 
Addison's disease
Define/Path
Pres
Dx
Tx
A 
Primary hypOCortisolism
(Adrenal deficiency, not pituitary)

Acute (eg adrenal hemorrhage)
-hypotension because no cortisol for tone no aldosterone for fluid retention
-n/v, coma
Chronic (eg infiltrative.. autoimmune, mets)
-hypotension more Orthostatic (no Cortisol)
-hyperpigmentation (high ACTH)
-low sodium high potassium (no Aldo)

Early AM cortisol (if normal, not Addison’s)
If normal get
Cosyntropin (ACTH analogue) stim test
-if works, stims cortisol, pituitary issue,
get MRI, give Cortisol
-if does not work, cortisol still low, it’s primary adrenal addison’s
get CT and MRI, give Cortisol and Fludricortisone

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20
Q

What secretes renin

A

Juxtaglomerular apparatus

in the Thick Ascending Limb

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21
Q

What does Aldosterone do

A

Activates sodium transport resorption at the expense of potassium secretion so that more water can be resorbed across aquaporins

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22
Q

When is renin secreted by juxtaglomerular cells in the thick ascending limb

A

When it sees low flow through the tubules

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23
Q

TF

Aldosterone secreting tumor from adrenal affects hpa axis like cortisol secreting tumor

A

F

Aldo affects completely different axis, the RAAS

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24
Q

Conn’s syndrome

Define

A

Primary aldosterone secreting adrenal tumor causing refractory hypertension (3+ meds) and hypokalemia (on test but not always in life)

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25
Q 
HyperAldosteronism
Path
Pres
Dx
Tx
A 
Conn Syndrome
-primary aldosterone secreting adrenal tumor
Renovascular Hypertension
-fibromyscular dysplasia young female
-atherosclerosis old man

Refractory Secondary Hypertension
-refractory to 3+ antihypertensive meds
HypoKalemia (on test, maybe not in life)

Aldo/Renin ratio
-if both normal, licorice induced pseudohyperaldosteronism (by inhibiting an enzyme and making mineralcorticoid receptors super sensitive to cortisol… or a few genetic syndromes
-if both elevated and ratio v10, Renovascular (still driven by renin),
Angiogram to confirm stenosis
FMD gets stented Atherosclerosis tx medically
-if Aldo elevated ratio ^30, Conn Syndrome
Salt Suppression test fails to vAldo
MRI mass maybe but not always the cause
Adrenal Vein Sampling to confirm Conn
RESECT Conn

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26
Q 
Pheochromocytoma
Path
Pres
Dx
Tx
A

Primary catecholamine secreting tumor of adrenal medulla

Paroxismal Pain (headache) Pressure (htn) Palpitation (tachyc) Persperation

Plasma free catecholamines if pretty sure and needs urgent tx
24Hr Urine Metanephrines or VMA more sensitive if less urgent have more time
CT MRI abd
Adrenal Vein Sampling

Alpha block (don't want to respond to masdive cc release with adrenal manipulation)
Beta block (don't want beta unopposed by alpha)
Resect
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27
Q 
Adrenal Incidentaloma
Path
Pres
Dx
Tx
A

Probably nothing, no pathogenesis

Mass found incidentally on imaging for something else

Rule out Cushing Pheo Conn
with 24Hr Urine study (Cortisol, Metanephrines/VMA)
and with Aldo:Renin ratio

Resect if ^4cm or hyperfunctioning
Follow if v4cm not hyperfunctioning

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28
Q

Toddler with claudication limiting ambulation

Suspect this

Get this

A

suspect Coarctation of the aorta

get Chest CT Angiogram

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29
Q

Adult with Resistant HTN
and Rib Notching on CXR

Suspect this

Get this

A

Coarctation of the Aorta

Chest CT Angiogram

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30
Q

Which has reduced pulses and pressures below the waist

Aortic Coarctation
or
PAD

A

both

If suspect coarctation,
Chest CT Angiogram

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31
Q

Barterr syndrome looks like….

Gitelman syndrome looks like….

A

Barterr syndrome looks like….
Furosemide…

Gitelman syndrome looks like….
HCTZ…

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32
Q

When does HTN cause CKD

vs CKD cause HTN

A

early closer to normal CKD caused By HTN

later closer to dialysis CKD Causes HTN

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33
Q

How to prevent iatrogenic adrenal insufficiency after prolongued chronic steroid therapy

A

Taper the steroids, don’t stop abruptly

34
Q

Most common cause of adrenal insufficiency in USA

A

Autoimmune adrenalitis

35
Q

Common cause of hemorrhagic adrenalitis

what history would increase your suspicion

A

Meningococcemia

history of fever rash obtundation increases your suspicion

36
Q

Most common cause of adrenal insufficiency in the world

A

Tubercular adrenalitis

37
Q

Most common cause of adrenal insufficiency in

USA

World

A

usa - Autoimmune adrenalitis

world - TB tubercular adrenalitis

38
Q

How can ectopic tumors produce hypercortiolism

A

secrete ACTH

eg SCLC

39
Q

Prednisone and Fludrocortisone

Which has more glucocorticoid vs mineralcorticoid activity

A

Both have both

Prednisone used mainly for Glucocorticoid

Fludrocortisone used mainly for mineralcorticoid – inc sodium resorb and potassium secretion, an aldosterone analogue – but has high glucocorticoid activity as well

40
Q

Test you can consider in probable pheochromocytoma pt between CT scan showing adrenal mass and Adrenal Vein Sampling

A

MIBG scan
a radionucleotide scan that can localize hyperfunctioning adrenal medullary tissue, as a mass seen on CT or MRI is not always the cause of hyperfunction, could be incidentaloma
And renal vein sampling is technically difficult amd invasive, the last step prior to prepping for resection

41
Q

Aldo:Renin way high

Get CT or renal vein sampling?

A

CT first

But will sample renal vein before resecting primary aldosterone secreting adenoma for Conn syndrome

42
Q

When to get inferior petrosal sinus sampling in workup of cushing syndrome

A

When

Low dose Dex suppression fails to suppress cortisol

ACTH is elevated

High dose Dex suppression test suppresses ACTH a little bit

So you are suspecting pituitary adenoma

But brain MRI can’t demonstrate it

So you are suspecting pituitary Microadenoma

43
Q

5 types of external ulcers

4 stages of ulcers

A

Compression Diabetic Arterial insufficiency Venous insufficiency Marjolin

Stage
1 - painful nom-blanching erythema, epidermis only
2 - epidermis and dermis
3 - epidermis dermis fascia
4 - epidermis dermis fascia deep tissue (muscle, bone)

44
Q 
Compression ulcer
Path
Pres
Dx
Tx
A

Prolongued pressure externally and internally from bone at pressure points causes local microcascular ischemia and tissue death

Bed-ridden or wheelchair bound
Sacral Decibitus or other pressure points

Clinical diagnosis
Can stage 1-4 (epidermal non-blamching erythema, dermis, fascia, deep tissue muscle bone)

Prevent
Q2h rolls
OOB
Air mattress

45
Q

TF

Pressure ulcer in nursing home constitutes abuse

A

T

46
Q

TF

If you see bone in a stage 4 ulcer you can diagnose osteomyelitis

A

T

Effectively, yes

47
Q

generic Wound Care of any ulcer includes

A

Abx
Debridement of necrotic tissue
Hygiene

48
Q 
Diabetic ulcer
Path
Pres
Dx
Tx
A

Microvascular compromise, neuropathy, unnoticed micro or frank trauma

DM ulcer on heel or ball of foot

Clinical dx

Blood glucose control
Elevate feet
Amputate
Ppx w foot inspections, loose padded diabetic shoes

49
Q 
Arterial insufficiency ulcer
Path
Pres
Dx
Tx
A

PAD Macro vascular compromise

PAD
Hairless legs
Shiny skin
Absent pulses
Toe ulcers - distal most

ABI v.9
Doppler US
Angiogram if planning intervention

Stent small arteries above knee
Bypass popliteal vessels and lengthy vessel involvements

50
Q

Key difference

Diabetic ulcer vs Arterial insufficiency ulcer

A

Diabetic microvascular

Arterial macrovascular

51
Q 
Venous stasis ulcer
Path
Pres
Dx
Tx
A

Venous insufficiency, e.g. from fluid overload expanding veins wider than valvular competence

often in setting of
CHF Cirrhosis Nephrotic syndrome
Venous Stasis Dermatitis
Hyperpigmented
Indurated
Woody
Medial Malleolus ulcer "always" venous stasis

Clinical dx

Compression stalkings
Elevate legs
Diuretics
Treat underlying condition

52
Q

Ulcer on medial malleolus think this kind of ulcer

A

Venous stasis ulcer

53
Q 
Marjolin Ulcer
Path
Pres
Dx
Tx
A

actually SCC Squamous Cell Carcinoma

Ulcer with Sinus Tract
Cycles of Healing and Breakdown
Heaped Up Margins

Biopsy

Resect w Wide Margins

54
Q

Sacral Decubitus ulcer think this type of ulcer

A

Pressure Ulcer

55
Q

Tips of Toes ulcers think this type of ulcer

A

Arterial insufficiency ulcer

56
Q

Location hints for type of ulcer

A

Tips of toes Arterial insufficiency ulcer (distal most vasculature)

Heel and Balls of feet Diabetic ulcer (desensitized)

Medial Malleolus Venous stasis ulcer

Sacral decibitus Pressure ulcer

57
Q

How do you hide a dollar from an internist?

A

Put it under a dressing

58
Q

How do you hide a dollar from a surgeon?

A

Put it in the chart

59
Q

TF

Burn injury can cause compartment syndrome

A

T
The eschar resulting from a circumferential, full-thickness (3rd degree) burn often does constrict venous and lymphatic drainageamd cause compartment syndrome

60
Q

How to treat compartment syndrome caused by the eschar after a circumferential full-thickness (3rd degree) burn

A

Escharotomy

Otherwise compartment syndrome usually treated with fasciotomy

61
Q

What kind of arthritis commonly affects mp joints?

A

Inflammatory eg Rheumatoid arthritis

62
Q

Symptomatic difference in Pain and Pressure between
Venous Thrombosis and
Compartment Syndrome

A

both have pain and swelling but

Compartment Syndrome had greater tissue tension/Tightness and Severe pain

63
Q

How do you identify 3rd degree burns?

A

Insensate

They are insensate, thru dermis into fat, nerves gone

64
Q

replete fluids in burn patient

A 
Parkland formula
4ml x TBSA (%) x kg
50% given first 8 hours
50% given next 16 hours
LR NOT NS...
palm = 1% bsa
arm = 9%
face = 9%
leg = 18%
1 side of trunk = 18%
65
Q

TF

losing pulses distal to burn, do a fasciotomy

A

F

do an Escharotomy

66
Q

TF

can tell difference between oxygenated blood and carbon monoxide poisoning grossly

A

F

get a carboxy-hb

67
Q

TF

run burn under cool water

A

F
can convert 2nd degree to 3rd degree by vasoconstriction

Run under Room Temp or Warm water

68
Q

Trauma mnemonic

A 
ABCDES
airway
breathing
circulation
disability
exposure
secondary survey
69
Q

TF

Most referred shoulder pain from diaphragm in trauma pt is from diaphragmatic injury

A

F

From hemorrhage irritating diaphragm

70
Q

Key component of secondary survey in trauma pt

A

Focused Assessment WITH Ultrasound FOR Trauma

71
Q

TF

Aorta injury a common cause of blood loss in BAT blunt abdominal trauma pt

A

F
v1% BAT pts get aorta injury
and often fatal before reaching hospital if they do happen, often spine or pelvic fractures assoc if they do happen

72
Q

First line, most effective measure to ppx postop pneumonia

And other measures

A

INCENTIVE SPIROMETRY

Deep breathing exercises
CPAP
Intermittent positive pressure breathing

All aimed at ling expansion

73
Q

First line, most effective measure to ppx postop pneumonia

And other measures

A

INCENTIVE SPIROMETRY

Deep breathing exercises
CPAP (if pulm compx despite IS… not first line because mire complications)
Intermittent positive pressure breathing

All aimed at ling expansion

74
Q

When is albuteral inhaler used for postop pna ppx

A

pt w asthma or copd with wheezing or dyspnea postop

Not routinely used in pts wo preexisting pulmonary dz

75
Q

5 causes/contributors to postop atelectasis

What procedures are higher risk

A

Pharyngeal secretion accumulation

Tongue prolapse posteriorlu into pharynx

76
Q

Smoking cessation at least __ weeks prior to surgery for decreased risk of pulmonary complications

A

Smoking cessation at least 8 weeks prior to surgery for decreased risk of postop pulmonary complications

77
Q

How to handle asthma/COPD/reactive airway disease in elective surgery vs emergency surgery

A

Postpone elective surgery

78
Q

Hairline Stress Fracture can be negative on plain film for first __ weeks

A

Hairline Stress Fracture can be negative on plain film for first 6 weeks

79
Q

Manage a stress fracture

Refer to orthopod if

A

Rest and analgesics
(reduced weight-bearing 4-6 weeks)
(Simple analgesics preferred eg acetaminophen, avoid nsaids as may delay healing)

Refer to orthopod if high risk for malnutrition (e.g. Anterior tibial cortex, 5th metatersal fracture)

80
Q

Most commonly involved metatarsal in stress fracture

A

5th metatarsal (subject to extremes of loading during gait)

81
Q

XR findings in stress fracture

A

Hairline lucency

Focal cortical thickening

82
Q

TF

CT, MRI, Scintographic bone scan often needed in stress fracture as XR may be negative for 6weeks

A

F
Usually not needed
Can dx clinically if XRs negative?

Surgery (22 decks)

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