Gen Surgery Flashcards
Normal blood pH
7.35 to 7.45
Normal pCO2
35-45 is normal
↑ CO2 and ↓pH = respiratory acidosis
↓ CO2 and ↑ pH = respiratory alkalosis
If you don’t see a change in the CO2 in relation to the pH then take a look at the HCO3
Normal HCO3
20-26
↓ HCO3 and ↓pH = metabolic acidosis
↑ HCO3 and ↑ pH =metabolic alkalosis
Respiratory Acidosis
- pH <7.30
- high pCO2 60
- Normal Bicarb 22
Lungs fail to excrete CO2: Breathing too slow, pulmonary disease, neuromuscular disease, drug-induced hypoventilation due to opiates or barbiturates
Respiratory alkalosis
- pH >7.52
- low PCO2 25
- Normal Bicarb 22
Excessive elimination of CO2: Breathing too fast, pulmonary embolism, fever, hyperthyroid, anxiety, salicylate intoxication, septicemia
Metabolic Acidosis
- pH <7.30
- Normal pCO2 40
- Low Bicarb 16
- Calculate anion gap to tighten ddx: Anion Gap = Na – (Cl + HCO3-)
- Normal anion gap is 10-16
Metabolic Acidosis
- Increased anion gap
> 16
- Addition of hydrogen ions: Lactic acidosis (think metformin), diabetic ketoacidosis, aspirin overdose
MUDPILES:
- Methanol
- Uremia
- Diabetic Ketoacidosis
- Paraldehyde
- Infection
- Lactic Acidosis
- Ethylene Glycol
- Salicylates
Metabolic Acidosis
- Decreased anion gap
<16
Loss of bicarbonate: think diarrhea, pancreatic or biliary drainage, renal tubular acidosis
Metabolic alkalosis
- pH >7.52
- Normal PCO2 40
- High Bicarb
- Loss of hydrogen: vomiting, bulimia, overdose of antacids, addition of bicarbonate (hyperalimentation therapy)
6 predictors of surgical cardiac complications
- Ischemic heart disease
- Congestive heart failure,
- Cerebrovascular disease
- A high-risk operation
- Preoperative treatment with insulin
- Preoperative serum creatinine greater than 2.0 mg/dL
Pre-op hx of MI
- risk
- testing
- 5% to 10% risk of postoperative MI
- Preoperative EKG on patients 40+ yo
- Current unstable angina: avoid elective surgeries
- Stage two HTN: control prior to surgery
- Patient should take antihypertensive medication on the day of the procedure
- History of rheumatic heart disease: prophylactic antibiotic therapy
- Send the patient to a cardiologist for clearance to have a stress test or Echo if any concerns
when is noninvasive stress testing indicated (non-cardio procedures)
- Active cardiac conditions (eg, unstable angina, recent MI, significant arrhythmias, or severe valvular disease)
- Patients who require vascular operations and have clinical risk factors and poor functional capacity
what is the most common type of perioperative complication
pulmonary
What are the two main determinations of post-op risk?
- operative site
- Presence of lung disease
Optimal time to stop smoking pre-op
8 weeks
Asthma and perioperative risk
- well controlled
- not well controlled
- no additional risk
- risk factor if not well controlled
Asthma control
- any surgery
- elective surgery
- step up therapy including systemic steroids if needed based on FEV1 and PVC
- PEV >80% and wheeze free
Asthma control and endotracheal intubation
- rapid inhaled beta agonist 2-4 puffs or nebulizer 30 min prior intubation
what pulm situations are absolute contraindications to elective surgery? what to do in emergency situations
Acute lower resp tract infections:
- tracheitis
- bronchitis
- pneumonia
Emergency: humidification of inhaled gas, remove lung secretions, bronchodilators and abx
What type of surgery have highest risk of post-op pulmonary risk
- upper abdominal
- open aortic aneurysm
- open thoracotomy
- head/neck operations
Postop strategy to reduce risk of pulm complications
- lung expansion: PT, breathing exercises, incentive spirometry, etc.
- Early mobilization (facilitates deep breathing)
What does elevated glucose level increase risk for?
surgical site infection (SSI)
how to control glucose perioperative period
IV insulin
Glycemic control
Normal: 90-100
Moderate: 120-200
Renal disease
- CKD c dialysis: sig increase in post-op complications (hyperkalemia, pneumonia, fluid overload, bleeding)
- Dialysis 24 hours before surgery
- monitor electrolytes immediately before and after surgery
- monitor weight, I&Os, and renal function
Hepatic disease
complications
hemorrhage, infection, renal failure, encephalopathy, substantial mortality rate
Hepatic disease
- elective surgery
- reduce ascites: leads to wound dehiscence and hernias
- reduce encephalopathy: worsened by sedatives and analgesics
- reduce coagulopathy: vitamin K +/- plasma transfusion
Hepatic disease
- postop
- platelet number and function
- electrolyte disturbances, esp hypernatremia
- Risk for upper GI hemorrhage (esophageal or gastric varies)
- etoh: malnutrition and vitamin deficiencies
tobacco use risks
- decreases functional capacity
- increases risk of bleeding, infection, wound dehiscence
- increased risk of hernia recurrence
Chronic steroid use
- perioperative risks
- Postop infection, dehiscence, mortality, poor wound healing, staple line leaks
- Addisoninan crisis if inadequate pre-op dose
When should perioperative stress hormone be given ?
primary or secondary adrenal insufficiency
- current regimen of more than 20 mg prednisone
- monitor glucose levels!
Dx of DVT
- first line if low prob
- preferred
- D-dimer: >500 positive
- compression US with doppler: preferred
DVT
- management
- Anticoagulation
- IVC filter if risk of bleed > risk VTE
- LMWH if cancer
- Pregnancy: SQ LMWH or temp IVC filter
- Thrombectomy: massive iliofemoral or fail other management
DVT prevention
- early ambulation
2. compression stockings 2 years
PE
- screening tests (3)
- CXR: normal, +/- atelectasis or pleural effusion. **Hampton’s Hump and Westermark’s sign
- D-dimer
- EKG: S1Q3T3
PE
- diagnostic tests
- Helical CT
- doppler US (only helpful if positive…)
- VQ scan
- Increased A-a (alveolar-arterial) gradient
- CT pulmonary angiography (gold standard!!)
- ABG- resp alkalosis
what test is used first to establish dx of jaundice
Fractionated bilirubin
Jaundice
- pre-hepatic causes
red cell breakdown
- hemolysis
- erythropoiesis
- hematoma reabsorption
- myoglobin breakdown
Jaundice
- pre-hepatic often leads to what kind of bilirubin
unconjugated/indirect
Jaundice
- intrahepatic causes
- autoimmune
- infectious (hepatitis)
- genetic defects (Gilbert, Crigler-Najjar)
- Pharm
Jaundice
- posthepatic
- usu biliary obstruction
- infectious (cholecystitis, cholangitis)
- secondary to neoplasm around the biliary tract
Pheochromocytoma
- first test for high risk pt
plasma fractionated metanephrines
Pheochromocytoma
- first test for low risk pt
24 hour urine fractionated metanephrines
Pheochromocytoma
- associated disorders
Familial tumor disorders:
- MEN2
- von Hippel-Lindau
Pheochromocytoma
- triad
- palpitations/tachycardia
- episodic HA
- diaphoresis
*usu have hx of HTN
Pheochromocytoma
- testing after biochemical testing
- CT or MRI to locate tumor
- poss genetic testing
Pheochromocytoma
- What medication given pre-op
a-adrenergic blockade to prevent unopposed alpha agonism once give beta blocker
- phenoxybenzamine or phentolamine
Pheochromocytoma
- med given during sx
beta blocker: maintain CV and hemodynamic stability
MCC appendicitis
fecalith
Surgical site infection
- def by timing
- 30 days of procedure
- 90 days if prosthetic material is used
Surgical site infection
- RF
- smoking
- older
- obesity
- malnutrition
- DM
- immunosuppressed
Surgical site infection
- highest risk is sx of what location
abdominal
Then CABG, C-section, vascular, joint prosthesis
Cellulitis surgical site infection
- PE
- red, warm, purulent drainage
- no wound dehiscence or fluctuance
Surgical site infection Tx
- cellulitis
- abscess
- abx, no open drainage needed
- I and D
Burns
- Parkland formula
Ringers lactate = 4 ml X total BSA of burn % X body weight (kg)
- first half over first 8 hours
- second half of next 16 hours
Burn
- steps to tx
- ABCDE
- fluid resuscitation with Ringer’s lactate via Parkland formula
Medication to treat hemophilia A
DDAVP / desmopressin
analogue of vasopressin which promotes factor VII and VWF release from storage pools
how to give iron to a patient post bariatric surgery with risk of inadequate absorption
IV
for example post Roux-en-Y
What should be done pre-op for pts with COPD who have increased respiratory sx, reduced exercise tolerance, new lung auscultation findings?
CXR to r/o active infection and heart failure
Functional Capacity
- indicator of what
Postop cardiac complication risk
- assess at initial prep evaluation
- expressed in METs
Functional Capacity
- 4 levels of METs
1: can care for self: eat, dress, use toilet
3-4: walk up steps or hill, walk on level ground
4-10: heavy work around the house, climb two flights of stairs
>10: can do strenuous sports
Painless mass on testicle: diagnostic steps
- PE: painless mass
- trans-scrotal US
- CT scan
How much of a margin should excision of melanoma contain
2 cm margin
Esophageal stricture
- MCC
long standing gastric reflux: form at GE junction as part of healing process of ulcerative esophagitis and lead to narrowing of the lumen
Esophageal stricture
- clinical
dysphagia: slow progressive to solids
- regurgitation
- episodic food impaction
Esophageal stricture
- dx
- upper endoscopy: direct visualization of gastric mucosa
- biopsy during endoscopy to r/o malignancy
Esophageal stricture
- Tx
- dilation during endoscopy
- acid-suppressive therapy with PPI to prevent recurrence
Empiric therapy for cellulitis
should cover MRSA
- clindamycin
- Bactrim
- Tetracycline (doxy or mino)
clinical signs of perforation of acute cholecystits
hypoactive bowel sounds
- also high fever, toxic signs (tachycardia, tachypnea), rebound tenderness abd pain
DVT
- diagnostic test of choice
doppler US (will show non compressibility of imaged vein = thrombus)
DVT
- timing of presentation post surgery
more than one week postop
Nephrotic syndrome leads to edema of what area of the body
- non-ambulatory
- ambulatory
- sacrum
- peripheral (usu LE) and periorbital
Solitary thyroid nodule
- TSH
- first test
- if normal or high = thyroid US
Solitary thyroid nodule
- on US is benign
- serial f/u
Solitary thyroid nodule
- on US is malignant
- FNA
Solitary thyroid nodule FNA is
- benign
- indeterminate
- malignant
- serial f/u
- repeat FNA
- sx removal
Where do the majority of diverticula form?
sigmoid colon - highest pressure bc it has the smallest diameter of the colon
describe diverticula
sacs that form in weak areas of the colon all where the vasa recta penetrate the muscle layer
What helps cause diverticula
- pressure
- colonic wall tension
- bowel wall radius
Diverticulosis
- clinical
- usually asx
- maybe bloating, crampy abd pain
- painless rectal bleeding
Diverticulosis
- dx
- CT
- colonoscopy
- nuclear scan/angiogram
Diverticulosis
- management
- supportive, most stop bleeding spontaneously
- sx for persistent bleeding
Tx for ascending aortic dissection
emergent open surgical repair
Aortic dissection
- s/sx
- acute onset severe, sharp, knife like pain in middle of chest, radiating to back
- new decrescendo diastolic murmur RSB
- wide pulse pressure
- hypotension
Aortic dissection
- dx
- XR: widened mediastinum
- CT angiography to confirm and differentiate between ascending and descending
Aortic dissection management
- ascending
- descending
- surgical emergency
- medically with bp control and imaging surveillance
Courvoisier sign
- pancreatic cancer and gallbladder malignancy
- painless, palpable gallbladder
- dt obstruction of biliary tree
Pancreatic cancer
- dx
- CT
- Serum CA 19-9
- Endoscopic US
- ERCP
Pancreatic cancer
- s/sx
- vague, diffuse pain in epigastrium, LUQ
- diarrhea, weight loss
- depression
- painless jaundice
- Courvoisier sign
Pancreatic cancer
- management
- surgery (body and tail tumors rarely eligible)
- chemo
- palliation
SBO
- MC metabolic disturbance postop
- metabolic alkalosis
- volume contraction + gastric fluid loss
- sx = aggressive third spacing into peritoneal cavity
- Postop NG decompression = acid and K loss
- Bicarb released into serum in reaction to increased HCl production by stomach
** hypochloremic, hypokalemic metabolic alkalosis
MC post-surgical complication after sx tx for PUD?
Weight loss
- limit food intake due to early satiety
- maldigestion or dumping syndrome
- counsel to eat smaller, more frequent meals
Diverticulitis
- first line dx
Abd CT with contrast
MCC esophageal squamous cell carcinoma
smoking and alcohol
MCC esophageal adenocarcinoma
Barrett’s metaplasia dt GERD
primary biliary cholangitis
- pruritus, jaundice, RUQ pain, fatigue
- AMA
- elevated alk phos, AST, ALT
spontaneous bacterial peritonitis
- MC bacteria
- Best abx
- Escherichia coli, Klebsiella pneumoniae, and Streptococcus spp.
- 3rd gen ceph like cefotaxime
Toxic megacolon
- diagnostic criteria
radiographic evidence of dilated colon plus 3+:
- Fever >38
- WBC >10.5
- HR >120
AND 1+
- dehydration
- electrolyte disturbance
- hypotension
Disease processes that precipitate toxic megacolon
- IBD (most common)
- pseudomembranous colitis
- CMV colitis
- Bacterial colitis
Medication to treat claudication
ASA
Ticlopidine
Adrenal carcinoma
- dx
- tx
CT with contrast
adrenalectomy
lab findings in hyperparathyroidism
- High PTH
- High calcium
- Low phosphorus
- osteopenia and elevated vitamin Dfalphaf
Colon polyps
- f/u based on findigns
- single polyp - 10 years (same as no polyp)
- multiple hyperplastic polyps, hyperplastic polyps at site other than distal, tubular polyps: 5 year f/u
- villous polyp: 3 year f/u
What blood glucose level is the “sole predictor” of SSI
> 140 mg/dL
What type of surgery is at a higher risk of perioperative thromboembolism
colorectal (vs. general surgery)
what two meds are used to reduce both deep venous thrombosis and pulmonary embolism
SQ warfarin and LMWH
Low-molecular-weight heparin has a simplified dosing regimen and a decreased incidence of heparin-induced thrombocytopenia, however, it is more expensive and there seems to be a dose-related increased risk of bleeding complications
Also Fondaparinux, a newer Xa inhibitor
DVT prophylaxis recommendations
- Very low risk: early ambulation alone
- Low risk: mechanical prophylaxis with intermittent pneumatic compression (IPC) devices
- Moderate risk: options of low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin or IPC
- High risk: IPC in addition to either LMWH or low-dose heparin
- Furthermore, an extended course (4 weeks) of LMWH may be indicated among patients undergoing resections of abdominal or pelvic malignancies
How to bridge patients who currently take Warfarin prior to surgery
- last warfarin in day -6
- start LMWH day -3, last dose AM of day -1
- resume bridging back to Warfarin one hemostasis has occurred, 24 hours in low bleeding sx, 48-72 hours high risk bleeding
When to stop/start ASA around sx
Stop 7 days before, restart 7 days after
What does a SSI with clostridium present like?
bronze-brown weeping tender wound
what is a common adverse effect after cardiac surgeries?
Acute kidney injury (10-30%)
How to reduce risk of kidney injury preoperatively?
- pushing fluids
- avoiding NSAIDs and exposure to IV contrast should be minimized or avoided
perioperative maintenance fluids
- loss
- calculation for replacement
- other considerations
- Daily maintenance for sensible and insensible loss in adult = 1500 to 2500 mL depending on age, gender, weight, BSA
- Multiply patient weight (kg) × 30 = fluid over 24 hours
- Increased requirements for fever, hyperventilation, and increased catabolism
**General rule: 2000 to 2500 mL of 5% dextrose in normal saline or lactated Ringer’s solution delivered daily
Should K be added to fluids perioperativeLY?
Do not add potassium during the first 24 hours because K+ is already increased during surgery (stress) with increased aldosterone activity
when to place urinary catheter
(1) anticipating long procedure
(2) performing urologic or low pelvic surgery
(3) need to monitor fluid balance
Hyponatremia
- presentation
Muscle cramps and seizures
Hyponatremia
- tx
- asymptomatic: free water restriction
- moderate: IV normal saline, loop diuretics may be added
- severe hyponatremia: hypertonic (3%) saline
*Serum Na should be corrected slowly—by ≤ 10 mEq/L over 24 h to avoid osmotic demyelination syndrome
Hypernatremia
- s/sx
Poor skin turgor, dry mucous membranes, flat neck veins, hypotension, increased BUN/CR ratio > 20:1
Hypernatremia
- tx
intravenous (IV) 5% dextrose in water (D5W). Rapid overcorrection causes cerebral edema and pontine herniation
Hyperkalemia
- Presentation
- Peaked T waves
- Prolonged QRS
- Muscle fatigue
Hyperkalemia
- tx
- calcium
- Insulin, sodium bicarbonate and glucose.
Hypokalemia
- presentation
- Muscle cramps
- Constipation
- Flattened/inverted T waves
- U waves
Hypokalemia
- tx
- Potassium repletion
- Remember to NOT use dextrose-containing fluids as this will stimulate insulin release and shift potassium within the cell which worsens the hypokalemia
Hypocalcemia
- presentation
- QT prolongation
- Trousseau’s sign, Chvostek’s sign
- Labs: ↓ Ca+ ↓ PTH ↑ phosphate
Hypocalcemia
- tx
IV calcium gluconate or calcium chloride
Hypercalcemia
- presentation
“Stones, bones, abdominal groans, psychiatric moans”, EKG: shortened QT interval.
Blood: ↑ PTH, ↑ Calcium, ↓ phosphorus
Associated with malignancy and hyperparathyroidism
Hypercalcemia
- tx
Normal IV saline and furosemide
Hypomagnesemia
- presentation
- Muscle weakness
- hyperreflexia
- prolonged QT, PR and wide QRS
- ventricular tachycardia
- torsades de pointes
Hypomagnesemia
- tx
IV magnesium sulfate (acute) or oral magnesium oxide (chronic)
Hypermagnesemia
- presentation
Muscle weakness
- prolonged QT, PR and wide QRS
- *same as hypomagnesmemia
Hypermagnesemia
- tx
- IV isotonic saline
- loop diuretics can be considered
Hyperphosphatemia
- etiology
- presentation
- treatment
- Etiology: Chronic kidney disease
- Presentation: typically asymptomatic
- Treatment: calcium carbonate, restrict potassium
Hypophosphatemia
- presentation
- treatment
- Presentation: weakness, muscle and bone pain, osteomalacia, rickets
- Treatment: IV phosphate replacement
Hyperthyroidism
- Tx
- beta blockers for heart rate symtpoms
- PTU and *methimazole (PTU during pregnancy and breastfeeding)
- IV methylprednisolone for ophthalmopathy
Cold vs. hot nodule after RAI scan
- Cold: no uptake = hypo functioning, require sx
- Hot: increased uptake = functional, lower risk of malignancy
What medication is CI in isolated PAD?
BB - will worse claudication
Management of AAA by size
- < 3.0 cm no testing
- 3 - 4.4 cm annual US
- 4.5 - 5.0 cm US every 6 months
- 5.0 - 5.4 cm US every 3 months
- > 5.5 or more than 0.5 cm expansion in 6 months : immediate sx repair, even if asx
Medication to treat TIA
Aspirin + dipyridamole or clopidogrel monotherapy
Tremor associated with hyperthyroid
high frequency, low amplitude tremor that is present with action
What two electrolytes can cause palpitations if out of nl range
hypokalemia, hypomagnesemia
MCC secondary hyperparathyroidism
chronic kidney disease (physiologic response to hypocalcemia or vitamin D deficiency)
MCC primary hyperparathyroidism
PTH secreting parathyroid ADENOMA
Antibodies in Graves disease
Anti-thyrotropin antibodies
MCC cellulitis
S. aureus (GABHS)
Cellulitis
- tx
- Outpatient nonpurulent: dicloxacillin, cefazolin, clindamycin
- Outpatient purulent: Clinda, bactrim, tetracycline (MRSA)
- Inpatient: IV abx
Treatment for postop urticaria
- stop offending agent
- anthistamines
- steroids
MC type melanoma
superficial spreading - on sun exposed parts of body
2nd MC type melanoma
nodular
- older patients
- often ulcerate and hemorrhage
What size of lesion is suspicious for melanoma
> 6 mm
Do stage I pressure ulcers blanch?
NO
Stages of pressure ulcer
- Stage I: erythema of localized area, usually non-blanching over a bony surface. If the area blanches, it is not a stage 1 pressure ulcer. If it stays red, it is a stage 1 pressure ulcer.
- Stage II: partial loss of dermal layer, resulting in pink ulceration
- Stage III: full dermal loss often exposing subcutaneous tissue and fat
- Stage IV: full thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present
Early signs of local anesthetic toxicity
Tinnitus, perioral/tongue numbness metallic taste blurred vision muscle twitches drowsiness
MCC postop vision loss
corneal abrasion
Other reasons for postop vision loss
- central retinal artery occlusion
- ischemic optic neuropathy
- cerebral vision loss
aphasia
- inability to comprehend or formulate language because of damage to specific brain regions
- typically caused by a postoperative cerebral vascular accident (stroke), or head trauma
dysarthria
- motor speech disorder resulting from neurological injury of the motor component of the motor-speech system
- Causes include toxic, metabolic, degenerative diseases, traumatic brain injury, or thrombotic or embolic stroke
Anterior cord injury
Loss of pain and temperature below the level with preserved joint position/vibration sense
Central cord syndrome
Loss of pain and temperature sensation at the level of the lesion, where the spinothalamic fibers cross the cord, with other modalities preserved (dissociated sensory loss)
Complete cord transection
Rostral zone of spared sensory levels (reduced sensation caudally, no sensation in levels below injury); urinary retention and bladder distention
Brown-Sequard syndrome
(hemisection of the cord)
- Loss of joint position sense and vibration sense on the same side as lesion and pain and temperature on the opposite side a few levels below the lesion
- Lesion of half-ipsilateral cervical cord lesion
- Contralateral sensory findings: pain and temperature loss
Carotid artery disease
- treatment
- Smoking cessation
- Antiplatelet therapy for symptomatic patients: Clopidogrel, Aspirin plus dipyridamole
- Statins for all patients
- Operative - carotid artery revascularization if Stenosis > 70%, Post-transient ischemic attack or stroke
- Surgeries: Carotid endarterectomy (CEA): first-line for patients who can tolerate surgery. Carotid artery stenting: for patients unable to tolerate CEA
bladder carcinoma
- gold standard for dx
Cystoscopy with biopsy
bladder carcinoma
- tx
- Endoscopic resection with cystoscopy every 3 months
- Recurrent or multiple lesions can be treated with intravesical chemotherapy.
classic sign of urinary retention in elderly
confusion
Postoperative Urinary Retention (POUR)
common complication of both spinal and epidural anesthesia is a prolonged blockade of parasympathetic fibers that innervate the bladder with resultant urinary retention and the need for a urinary bladder catheter
indications for extracorporeal shock wave lithotripsy
stones greater than 6 mm in size or intractable pain.
Four main types of kidney stone
- Calcium oxalate (MC): 75% to 85% – stones are radiopaque
- Uric Acid: 5% to 8% – stones are radiolucent.
Form in individuals with persistently acidic urine. - Cystine: < 1% (stones are radiolucent)
- Struvite: 10% to 15% (radiopaque)
Gold standard diagnosis for nephrolithiasis
Noncontrast CT of the Abdomen and Pelvis
Urinalysis will often show microscopic hematuria
Nephrolithiasis treatment by stone size
- Stones < 5 mm will have an 80% chance of spontaneous passage
- Stones > 5 – 10 mm have a 20 % chance of passage and may require elective lithotripsy, patients should be considered for early elective intervention.
- Stones > 10 mm may are not likely to pass spontaneously. Ureteral stent or percutaneous nephrostomy (gold standard) should be used if renal function is jeopardized.
- Urgent treatment with extracorporeal shock wave lithotripsy can be used for renal stones of less than 2 cm or for ureteral stones of less than 10 mm.
renal cell carcinoma triad clinical
flank pain, hematuria and a palpable abdominal/renal mass
Renal cell carcinoma MC RF
smoking
Renal cell carcinoma 2 types
- Renal clear cell carcinoma MC 80%
- Transitional cell is the second most common type (20%)
Renal cell carcinoma
- dx
- CT
- bx
renal vascular disease
- dx imaging
- US usually first line
- Renal arteriography is GOLD STANDARD for diagnosis
renal vascular disease
- management
- Stenting
- Percutaneous transluminal angioplasty (PTA) plus stent placement or with surgical bypass of the stenotic segment
MCC testicular cancer
seminoma
AV fistula for dialysis
large vein that is close to the skin, cephalic vein is a great option
what other electrolyte disorder is hypokalemia associated with?
hypomagnesemia
which electrolyte disorder is associated with malignancy
hypercalcemia
definitive diagnosis of testicular cancer
Radical inguinal orchiectomy
classic hemodialysis access fistula
radial artery to cephalic vein arteriovenous fistula
best type of graph autogenous vs. prosthetic
autogenous fistula formation > prosthetic
*To maximize autogenous vein utilization, current practice includes transposing deep veins such as the basilic vein in the upper arm to the subcutaneous tissue
Indications for hemodialysis
- Uremic symptoms: pericarditis, encephalopathy, GI complications (anorexia, nausea, vomiting), azotemia
- GFR <10 mL/min/1.73 m2
- Fluid overload unresponsive to diuresis
- Refractory hyperkalemia
What do Petechiae suggest?
problem with platelets
what two electrolyte disorders are associated with fatigue?
hypercalcemia and hyponatremia
3 MCC hemoptysis
- bronchitis
- tumor mass
- TB
Other: bronchiectasis, pulmonary catheters, trauma, pulmonary hemorrhage
What foods increase sx of heartburn
Caffeine, chocolate, ethanol, peppermint, fatty foods and nicotine
external hemorrhoids
- initial pharm treatment
- topical steroids
Three MCC SBO
- Postoperative adhesions are the most common cause of SBOs (70%)
- Cancer (20%)
- Incarcerated hernias (10%).
Toxic megacolon
- first dx test
plain film
Trousseau’s syndrome
Related to the hypercoagulability that accompanies many cancers, and is found on examination as tender migratory thrombophlebitis which can occur in crops of veins at different times.
Primary biliary cholangitis
- autoimmune
- rare disease of the liver that causes progressive cholestasis and can result in end-stage liver disease
- loss of these bile ducts causes the signs and symptoms of cholestasis
- fatigue, pruritus and right upper quadrant discomfort
- AMA
- increased ALT, AST, Alk phos
MC surgical emergency in preg women
appendicitis
