Gen Surg 3/13/17 Flashcards
MEN1
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
MEN2
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
MEN syndromes
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
TF
Von Hippel Lindae assoc w thyoid and parathyroid issue…
F
Pheochromocytoma
not thyroid parathyroid (that would be MEN2A)
P53 mut think
retinoblastoma
colon cancer
APC mut think
colon cancer
VHL mut think
pheochromocytoma
Von-Hippel Lindau
elevated calcium low phosphorous with normal renal function think…
parathyroid neoplasm
key labs in vitamin D deficiency
HIGH PTH
stimulated by LOW CALCIUM
layers of adrenal
GFR
glomerulosa fasciculata reticulata
the deeper you go the better it gets
salt sugar sex
aldo cortisol testosterone
Cortisol excess causes
Cushing syndrome
Causes of Cushing Syndrome
Cortisol excess
ACTH secreting Small Cell Lung Cancer
ACTH secreting Pituitary Adenoma
Cortisol secreting Adrenal Neoplasm
Exogenous Corticosteroids
Cushing Syndrome vs Cushing Disease
Syndrome caused by any Cortisol Excess
- SCLC, Pit Ad secreting ACTH
- Adrenal Neoplasm secreting Cortisol, exogenous Corticosteroids
Cushing Disease is ACTH secreting Pituitary Adenoma
Cushing Syndrome Path Pres Dx Tx
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
lab workup in Cushing Disease
tx
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
lab workup in cortisol secreting adrenal neoplasm
tx
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
Lab workup in ectopic ACTH producing neoplasm
tx
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
When can you say, “Cushing syndrome”
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
Addison's disease Define/Path Pres Dx Tx
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
What secretes renin
Juxtaglomerular apparatus
in the Thick Ascending Limb
What does Aldosterone do
Activates sodium transport resorption at the expense of potassium secretion so that more water can be resorbed across aquaporins
When is renin secreted by juxtaglomerular cells in the thick ascending limb
When it sees low flow through the tubules
TF
Aldosterone secreting tumor from adrenal affects hpa axis like cortisol secreting tumor
F
Aldo affects completely different axis, the RAAS
Conn’s syndrome
Define
Primary aldosterone secreting adrenal tumor causing refractory hypertension (3+ meds) and hypokalemia (on test but not always in life)
HyperAldosteronism Path Pres Dx Tx
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
Pheochromocytoma Path Pres Dx Tx
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
Adrenal Incidentaloma Path Pres Dx Tx
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
Toddler with claudication limiting ambulation
Suspect this
Get this
suspect Coarctation of the aorta
get Chest CT Angiogram
Adult with Resistant HTN
and Rib Notching on CXR
Suspect this
Get this
Coarctation of the Aorta
Chest CT Angiogram
Which has reduced pulses and pressures below the waist
Aortic Coarctation
or
PAD
both
If suspect coarctation,
Chest CT Angiogram
Barterr syndrome looks like….
Gitelman syndrome looks like….
Barterr syndrome looks like….
Furosemide…
Gitelman syndrome looks like….
HCTZ…
When does HTN cause CKD
vs CKD cause HTN
early closer to normal CKD caused By HTN
later closer to dialysis CKD Causes HTN
How to prevent iatrogenic adrenal insufficiency after prolongued chronic steroid therapy
Taper the steroids, don’t stop abruptly
Most common cause of adrenal insufficiency in USA
Autoimmune adrenalitis
Common cause of hemorrhagic adrenalitis
what history would increase your suspicion
Meningococcemia
history of fever rash obtundation increases your suspicion
Most common cause of adrenal insufficiency in the world
Tubercular adrenalitis
Most common cause of adrenal insufficiency in
USA
World
usa - Autoimmune adrenalitis
world - TB tubercular adrenalitis
How can ectopic tumors produce hypercortiolism
secrete ACTH
eg SCLC
Prednisone and Fludrocortisone
Which has more glucocorticoid vs mineralcorticoid activity
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
Test you can consider in probable pheochromocytoma pt between CT scan showing adrenal mass and Adrenal Vein Sampling
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
Aldo:Renin way high
Get CT or renal vein sampling?
CT first
But will sample renal vein before resecting primary aldosterone secreting adenoma for Conn syndrome
When to get inferior petrosal sinus sampling in workup of cushing syndrome
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
5 types of external ulcers
4 stages of ulcers
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)
Compression ulcer Path Pres Dx Tx
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
TF
Pressure ulcer in nursing home constitutes abuse
T
TF
If you see bone in a stage 4 ulcer you can diagnose osteomyelitis
T
Effectively, yes
generic Wound Care of any ulcer includes
Abx
Debridement of necrotic tissue
Hygiene
Diabetic ulcer Path Pres Dx Tx
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
Arterial insufficiency ulcer Path Pres Dx Tx
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
Key difference
Diabetic ulcer vs Arterial insufficiency ulcer
Diabetic microvascular
Arterial macrovascular
Venous stasis ulcer Path Pres Dx Tx
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
Ulcer on medial malleolus think this kind of ulcer
Venous stasis ulcer
Marjolin Ulcer Path Pres Dx Tx
actually SCC Squamous Cell Carcinoma
Ulcer with Sinus Tract
Cycles of Healing and Breakdown
Heaped Up Margins
Biopsy
Resect w Wide Margins
Sacral Decubitus ulcer think this type of ulcer
Pressure Ulcer
Tips of Toes ulcers think this type of ulcer
Arterial insufficiency ulcer
Location hints for type of ulcer
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
How do you hide a dollar from an internist?
Put it under a dressing
How do you hide a dollar from a surgeon?
Put it in the chart
TF
Burn injury can cause compartment syndrome
T
The eschar resulting from a circumferential, full-thickness (3rd degree) burn often does constrict venous and lymphatic drainageamd cause compartment syndrome
How to treat compartment syndrome caused by the eschar after a circumferential full-thickness (3rd degree) burn
Escharotomy
Otherwise compartment syndrome usually treated with fasciotomy
What kind of arthritis commonly affects mp joints?
Inflammatory eg Rheumatoid arthritis
Symptomatic difference in Pain and Pressure between
Venous Thrombosis and
Compartment Syndrome
both have pain and swelling but
Compartment Syndrome had greater tissue tension/Tightness and Severe pain
How do you identify 3rd degree burns?
Insensate
They are insensate, thru dermis into fat, nerves gone
replete fluids in burn patient
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%
TF
losing pulses distal to burn, do a fasciotomy
F
do an Escharotomy
TF
can tell difference between oxygenated blood and carbon monoxide poisoning grossly
F
get a carboxy-hb
TF
run burn under cool water
F
can convert 2nd degree to 3rd degree by vasoconstriction
Run under Room Temp or Warm water
Trauma mnemonic
ABCDES airway breathing circulation disability exposure secondary survey
TF
Most referred shoulder pain from diaphragm in trauma pt is from diaphragmatic injury
F
From hemorrhage irritating diaphragm
Key component of secondary survey in trauma pt
Focused Assessment WITH Ultrasound FOR Trauma
TF
Aorta injury a common cause of blood loss in BAT blunt abdominal trauma pt
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
First line, most effective measure to ppx postop pneumonia
And other measures
INCENTIVE SPIROMETRY
Deep breathing exercises
CPAP
Intermittent positive pressure breathing
All aimed at ling expansion
First line, most effective measure to ppx postop pneumonia
And other measures
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
When is albuteral inhaler used for postop pna ppx
pt w asthma or copd with wheezing or dyspnea postop
Not routinely used in pts wo preexisting pulmonary dz
5 causes/contributors to postop atelectasis
What procedures are higher risk
Pharyngeal secretion accumulation
Tongue prolapse posteriorlu into pharynx
Smoking cessation at least __ weeks prior to surgery for decreased risk of pulmonary complications
Smoking cessation at least 8 weeks prior to surgery for decreased risk of postop pulmonary complications
How to handle asthma/COPD/reactive airway disease in elective surgery vs emergency surgery
Postpone elective surgery
Hairline Stress Fracture can be negative on plain film for first __ weeks
Hairline Stress Fracture can be negative on plain film for first 6 weeks
Manage a stress fracture
Refer to orthopod if
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)
Most commonly involved metatarsal in stress fracture
5th metatarsal (subject to extremes of loading during gait)
XR findings in stress fracture
Hairline lucency
Focal cortical thickening
TF
CT, MRI, Scintographic bone scan often needed in stress fracture as XR may be negative for 6weeks
F
Usually not needed
Can dx clinically if XRs negative?
