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Surgery > High Yield > Flashcards

High Yield Flashcards

1
Q

What is Heart Failure

A

The inability of the heart to pump sufficient blood to meet the metabolic demands of the body at normal filing pressures

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2
Q

What is the most common cause of Heart Failure

A

CAD

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3
Q

Sx of Left sided Heart Failure

A

Dyspnea, Orthopnea, Pulmonary congestion, Edema, Paroxysmal Nocturnal Dyspnea
Transudative pleural effusions
HTN, Cheyne Stoke’s Breathing, S4
Dusky pail skin, diaphoresis, sinus tachycardia, cool extremities

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4
Q

Sx of Right sided Heart Failure

A

Increased systemic venous pressure, signs of fluid retention

Peripheral Edema, JVD, Anorexia, N/V, Hepatosplenomegaly

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5
Q

Dx of Heart Failure

A

Echo - Can measure Ejection Fraction and see size of heart (Cardiomegaly)
CXR - Can see Congestive HF well (cardiomegaly)
Increased BNP (these increase in number when there is fluid overload)

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6
Q

What are common medications used in long term management of Heart Failure

A 
Ace-Inhibitors: 1st line tx for HF
ARBs if Ace-I can't be tolerated
Beta-Blockers
Nitrates
Diuretics: Most effective for sx
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7
Q

What are Heart Failure medications that decrease mortality

A

Ace-I, ARB, Beta-Blckers, Nitrates + Hydralazine, Spironolactone

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8
Q

When is an implantable cardioverter defibrillator used in patients with Heart Failure

A

When ejection fraction is

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9
Q

What are Ventricular Dysrhythmias

A

Ventricular dysrhythmias are frequently unstable and unpredictable
They are potentially lethal because stroke volume and coronary flow are compromised
Associated with weird QRS complexes

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10
Q

What is a premature ventricular complex (PVC)

A

Premature beat originating from ventricle
Usually T-wave is in opposite direction of the R
Associated with compensatory pause which results in overall rhythm unchages

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11
Q

Tx for Premature Ventricular Complrex

A

Usually none

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12
Q

What is Ventricular Tachycardia

A

> 3 consecutive PVC’s at a rate of >100bpm

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13
Q

What is a sustained Ventricular Tachycardia

A

Duration of >30 seconds

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14
Q

What is the danger with Ventricular Tachycardias

A

They can turn into Torsades de Pointes which can in turn become Ventricular Fibrillation (bad!)

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15
Q

Tx for Stable Sustained Ventricular Tachycardia

A

Anti-Arrhythmics (Amiodarone, Lidocaine, Procainamide)

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16
Q

Tx for Unstable Ventricular Tachycardia with a pulse

A

Synchronized (direct current) cardioversion (DCC)

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17
Q

TX for Vetricular Tachycardia with no pulse

A

Defibrillation/CPR (treat as V.Fib)

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18
Q

Tx for Torsades de Pointes

A

IV Magnesium

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19
Q

What is Ventricular Fibrillation

A

A rapid inadequate heart beat

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20
Q

Tx of V.Fib

A

CPR and Defibrillation

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21
Q

What is Pulseless Electrical Activity

A

Organized rhythm seen on monitor but the patient has no palpable pulse

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22
Q

Tx of Pulseless Electrial Activity

A

CPR, Epinephrine, check for shockable rhythm every 2 minutes

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23
Q

What is Asystole Rhythm

A

No rhythm seen on monitor and no pulse

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24
Q

Tx of Asystole

A

CPR, Epinephrine, check for shockable rhythm every 2 minutes

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25
Q

What is the most common cause of Peripheral Arterial Disease

A

Atherosclerotic disease of the lower extremities

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26
Q

Sx of Peripheral Artery Disease

A

Intermittent Claudication which is reproducible pain/discomfort in the extremity brought on by exercise/walking and relieved with rest

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27
Q

What does it mean when there is resting leg pain

A

Advanced Disease

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28
Q

What is an acute arterial embolism

A

Usually caused by sudden occlusion
6 P’s
Parasthesias, Pain, Pallor, Pulselessness, Paralysis, Poikilothermia
Livedo Reticularis: Mottling with arteriolar occlusion

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29
Q

How does Gangrene result with Peripheral Arterial Disease

A

When arterial perfusion is so poor that spontaneous necrosis occurs
The tissue goes from purplish/blue to black

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30
Q

What is Wet Gangrene

A

Ulcers: Malodorous, copious, purulent, infected, blackened rgions

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31
Q

What is Dry Gangrene

A

Mummification of digits of foot

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32
Q

Sx of Peripheral Arterial Disease

A 
Decreased or absent pulses
Bruits
Decreased capillary refill
Atrophic skin changes, usually no edema
Pale on elevation, dusky red with dependency
LATERAL malleolus ulcers
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33
Q

Dx of Peripheral Arterial Disease

Gold Standard

A

Ankle Brachial Index: Normal is 1-1.2, positive if

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34
Q

Tx of Peripheral Arterial Disease

A

Platelet Inhbitors: Cilostazol, ASA, Plavix
Revascularizatio: PTA, Bypass grafts fem-pop, Endarterectomy
Supportive: Exercise, foot care,
Amputation if severe/gangrene
Acute Arterial Occlusion: Heparin for embolism, thrombolytics if thrombus, embolectomy

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35
Q

What is a pneumothorax

A

Air within the pleural space

Increasingly positive pleural pressure causes collapse of the lung

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36
Q

What is a Spontaneous Pneumothorax

Primary vs. Secondary

A

A ruptured bleb
Primary: No underlying lung disease, mainly affects young men, tall, smokers, family hx
Secondary: Underlying lung disease like COPD, Asthma, Menstruation

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37
Q

What is a Traumatic Pneumothorax

A

CPR, Thoracentesis, Subclavian lines or trauma

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38
Q

What is a Tension Pneumothorax

A

Positive air pressure pushes the lungs, trachea and heart to the contralateral side

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39
Q

Sx of a Pneumothorax

A

Chest pain, usually pleuritic and unilateral, Dyspnea
Increased Hyperresonance, Decreased fremitus, Decreased breath sounds, unequal respiratory expansion, tachycardia, tachypnea, Hypotenion

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40
Q

Sx of a Tension Pneumothorax

A

Increased JVP and pulses paradoxus

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41
Q

Dx of Pneumothorax

A

CXR with expiratory view
Decreased peripheral lung markings
Deep Sulcus

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42
Q

Tx of Pneumothorax

A

Obesrvation if small
Chest Tube if large
If Tension Pneumothorax: Needle aspiration first then chest tube. Needle is placed in 2nd intercostal space at midclavicular line of the affected side

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43
Q

what is an Aortic Dissection

A

Tear in the innermost layer of the aorta (intima)

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44
Q

Risk factors for Aortic Dissection

A

HTN, Age (50-60yrs), Vasculitis, traua, family hx, Collagen disorders (Marfans)

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45
Q

Sx of Aortic Dissection

A

Sudden onset of severe tearing chest/upper back pain
Decreased peripheral pulses
Variation in pulses between left arm and right arm
HTN

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46
Q

Dx of Aortic Dissection

Gold Standard

A

MRI Angiogram is gold standard
CXR: See widening mediastinum
CT scan with contrast is becoming test of choice
Trans Esophageal Echocardiograph

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47
Q

Tx of Aortic Dissection

A

Surgery if ascending or if there are complications such as vital rogan involvement, impending rupture
Medical t if descending, usually with Labetalol with sodium nitroprusside

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48
Q 
Describe the features of a 3rd degree burn
Depth
Appearance
Sensation
Capillary Refill
Prognosis
A

Full Thickness - Extends through entire skin
Waxy, white, leathery, dry
Painless
No capillary refill
Months to heal, does not spontaneously heal well

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49
Q

Tx for burns

A 
Wash wound with mild soap and water
Do not apply ice directly or ointments
Debridemement, ruptures blisters should be removed
Acetaminophen, NSAIDS for pain
IV fluid resuscitation
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50
Q

Tx for 3rd degree burns

A

Cover with sterile dressing to prevent infection with nonadherent gauze and elastic guaze

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51
Q

What type of reaction is Urticaria (Hives)/Angioedea

A

Type I Hypersensitivity reaction (IgE)

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52
Q

What are common triggers for Urticaria

A

Antigen from foods, meds, infections, insect bites, drugs, environmental

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53
Q

What is the pathophysiology behind Urticaria

A

Mast cells release histamine which cause vasodilation of venules and edema of dermis and sub-q tissues

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54
Q

Sx of Urticaria

A

Blanchable, edematous pink papules, wheals or plaque

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55
Q

Sx of Angioedema

A

Painless, deeper form of urticaria affecting lips, tongue, eyelids, hands feet and genitals
Anaphylaxis may occur

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56
Q

Tx of Urticaria/Angioedema

A

Oral Antihistamines
Eliminate cause
H2 blockers
Corticosteroids

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57
Q

What is the clinical use of Anti-Thyroglobulin

A

Used to diagnose Hashimoto’s in Hypothyroidism

Used to diagnose Autoimmune Thyroiditis

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58
Q

Sx of Hypothyroidism

A 
Decreased basic metabolic rate
Cold Intolerance
Weight gain
Goiter
Fatigue, Sluggishness, memory loss
radycardia, Decreased CO
Menorrhagia
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59
Q

What is Hashimotos

A

Autoimmune

Hypothyroidism

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60
Q

Dx of Hashimotos

A

Thyroglobulin antibodies present

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61
Q

Tx of Hashimotos

A

Levothyroxine

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62
Q

What are the 4 types of Thyroid Cancers

Least aggressive to most aggressive

A

Papillary
Follicular
Medullary
Anaplastic

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63
Q 
What is the most common type of Thyroid Cancer
Risk factors
Age
Characteristics
Mets
Prognosis
Tx
A 
Papillary
Young females
Least aggressive
Local (cervical) mets
Excellent prognosis
Total Thyroidectomy
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64
Q 
Discuss Follicular Thyroid Cancer
Risk factors
Age
Characteristics
Mets
Prognosis
Tx
A 
Less often associated with radiation exposure
40-60yrs
More aggressive
Distant mets common
Excellent prognosis
Total Thyroidectomy
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65
Q 
Discuss Medullary Thyroid Cancer
Risk factors
Age
Characteristics
Mets
Prognosis
Tx
A

Not associated with radiation exposure
Associated with MEN 2
Low cure rates
Secretes calcitonin, may cause diarrhea and flushing
Poorer prognosis
Total Thyroidectomy, Calcitonin levels used to monitor residual disease or to detect recurrence

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66
Q 
Discuss Anaplastic Thyroid Cancer
Risk factors
Age
Characteristics
Mets
Prognosis
Tx
A

May occur many years after radiation exposure
Males >65yrs
Most aggressive, rapid growth
Local and distant mets, may invade trachea
Poor prognosis
Most not amenable to surgical resection, External beam radiation, chemo

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67
Q

What is Hyperparathyroidism

A

Excess PTH production

Usually associated with MEN 1

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68
Q

What is Primary vs. Secondary Hyperparathyroidism

A

Primary: Parathyroid Adenoma or Parathyroid Hyperplasia
Secondary: Increased PTH in response to hypocalcemia or Vitamin D deficiency, Chronic Kidney Disease

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69
Q

Sx of Primary Hyperparathyroidism

A

Signs of Hypercalcemia: Stones, Bones, Groans, and psychic Moans, Decreased DTR

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70
Q

Dx of Hyperparathyroidism

A

Hypercalcemia + Increased PTH + Decreased Phosphate

Increased 24 hour urine calcium excretion

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71
Q

Tx of Primary Hyperparathyroidism

A

Surgery: Parathyroidectomy

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72
Q

Tx of Secondary Hyperparathyroidism

A

Vitamin D and Calcium Supplement

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73
Q

What is Hypoparathyroidism

A

Low PTH or insensitivity to its action

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74
Q

What are 2 most common causes of Hypoparathyroidism

A

Accidental damage/removal during neck/thyroid surgery

Autoimmune destruction of parathyroid gland

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75
Q

Sx of Hypoparathyroidism

A

Signs of Hypocalcemia: Carpopedal Spasms, Trousseau and Chvostek Sign, Perioral Parasthesias, Increased DTR

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76
Q

Dx of Hypoparathyroidism

A

Hypocalcemia + Decreased PTH + Increased Phosphate

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77
Q

Tx of Hypoparathyroidism

A

Calcium Supplement and Vitamin D (Ergocalciferol or Calcitriol)

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78
Q

What is a Pheochromocytoma

A

Catecholamine secreting adrenal hormone

Secretes Norepinephrine and Epinephrine autonomously and intermittently

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79
Q

What are triggers for release of catecholamines from e Pheochromoctyoma

A

Surgery, exercise, pregnancy, meds (TCA, Opiates, metoclopramide, glucagon, Histamine)

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80
Q

Sx of Pheochromocytoma

A

HTN
Palpitations, Headaches, Excessive Sweating
Chest or abdominal pain, weakness, fatigue, weight loss

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81
Q

Dx of a Pheochromocytoma

A

24 hour urine catecholamines including metabolites: Metanephrine and Vanillylmandelic Acid
MRI or CT to find adrenal tumor

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82
Q

Tx of a Pheochromoctyoma

A

Complete Adrenalectomy
Preoperative non-selective alpha-blockers: Phenoxybenzamine or Phentolamine for 7-14 days followed by beta blockers or CCB to control HTN

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83
Q

What is Chronic Adrenocortical Insufficiency

A

Disorder where adrenal gland does not produce enough hormones

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84
Q

What is Primary Adrenocortical Insufficiency (Addisons Disease)

A

Adrenal gland destruction which causes lack of cortisol and aldosterone
Can be due to autoimmune, infection, vascular, or Mets

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85
Q

What is Secondary Adrenocortical Insufficiency

A

Pituitary failure of ACTH secretion (lack of Cortisol)
Aldosterone is intact because it is regulated by RAAS system
Exogenous steroid use is the main cause

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86
Q

Sx of Primary Adrenocortical Insufficiency (Addisons)

A 
Hyperpigmentation due to increased ACTH
Decreased Aldosterone
-Orthostatic Hypotension (syncope, dizziness)
-Hyponatremia
-Hyperkalemia
-Metabolic Acidosi
-Hypoglycemia
Decrease sex hormones: in women leads to loss of libido, amenorrhea, loss of axillary and public hair
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87
Q

Dx of Adrenocortical Insufficiency

A

First get a baseline ACTH, Cortisol, and Renin levels
Second, High dose ACTH Stimulation Test
-Normal response is rise in blood/urine cortisol levels
-Adrenocortical Insufficiency: Little or no increase in cortisol levels
Third, CRH Stimulation Test
-Primary: High ACTH, Low Cortisol
-Secondary: Low ACTH, Low Cortisol

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88
Q

Tx of Adrenocortical Insufficiency

A

Hormone Replacement
Primary: Replace both Glucocorticoids (Hydrocortisone) and Mineralocorticoids (Fludrocortisone)
Secondary: Replace only Glucocorticoids

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89
Q

What considerations should be taken in people with Adrenocortical Insufficiency prior to a surgery

A

Remember cortisol is a stress hormone and surgery is a stressful stimulant
Prior to and after surgery, patient must be given IV Glucocorticoids and IV Isotonic fluids to mimic the body’s natural response

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90
Q

What is an Adrenal (Addisonian) Crisis

A

Sudden worsening of adrenal insufficiency due to a stressful event (surgery, trauma, volume loss, hypotermia, MI, fever, sepsis, hypoglycemia, steroid withdrawal)

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91
Q

What can cause and Addison Crisis

A

Abrupt withdrawal of steroids
Previously undiagnosed adrenocortical insufficiency
Exacerbation of known Addison’s Disease (surgery, trauma, etc.)
Bilateral adrenal infarction

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92
Q

Sx of Addisons Crisis

A

Shock, decreased blood pressure
Hypotension, Hypovolemia
Abdominal pain, N/V, fever, weakness, lethargy, coma

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93
Q

Dx of Addisons Crisis

A

Hyponatremia, Hyperkalemia, Hypoglycemia

Cortisol levels, ACTH levels, CBC

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94
Q

Tx of Addisons Crisis

A

IV Fluids to correct Hypotension and Hypovolemia
Glucocorticoids
Reversal of electrolyte abnormalities
Fludrocortisone (Florinef)

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95
Q

What is Cholecystitis

A

Cystic duct obstruction usually by gallstone which leads to inflammation/infection

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96
Q

Sx of Cholecystitis

A 
Biliary Colic (Episodic RUQ/Epigastric pain beginning abruptly, continuous in duration, resolves slowly lasting 30 minute- hours, preciptated by fatty foods or large meals)
Fever, N/V, Palpable GB (Positive Murphy's Sign)
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97
Q

Dx of Cholecystitis
Initial test
Gold Standard
Labs

A

Ultrasound is initial test of choice
HIDA scan is gold standard (positive if gallbladder can’t be visualized)
Increased WBC, Increased Bili, Increased ALP and LFT

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98
Q

Tx of Cholecystitis

A

Conservative: NPO, IVF, Abx (cephalosporin + Metronidazole)

Cholecystectomy within 72 hours

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99
Q

What is fecal impaction

A

Severe impaction of stool in rectal vault which can result in obstruction to fecal flow and large bowel obstruction

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100
Q

What are predisposing factors of fecal impaction

A 
Medications (Opioids)
Severe psychiatric disease
Prolonged bed rest
Nerogenic disorders of colon
Spinal cord disorders
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101
Q

Sx of Fecal Impaction

A 
Anorexia
N/V
Abdominal Pain
Distention
DRE will have palpable firm feces
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102
Q

Tx of Fecal Impaction

A

Enemas: Saline, Mineral Oil
Digital Disruption
Improved care with stool softeners, increased fiber in diet and increased water intake

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103
Q

What is Intussusception

A

Intestinal segment invaginates or telescopes into adjoining intestinal lumen which leads to bowel obstruction
Often occurs after viral infection
Common in babies/kids

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104
Q

What is the most common site for Intussusception

A

Ileocolic Junction

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105
Q

What are lead points for Intussusception

A 
Meckel Diverticulum
Enlarged Mesenteric Lymph Node
Hyperplasia of Payer's Patches
Tumors
Foreign Body
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106
Q

Sx of Intussusception

A

Vomiting, Abdominal Pain, Passage of blood per rectum (Currant jelly stools)
Pain is colicky
Sausage shaped mass in RUQ

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107
Q

Dx of Intussusception

A

Barium Contrast Enema
Xray
CT in adults

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108
Q

Tx of Intussusception

A

Barium or air insufflation enema

Surgery if refractory

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109
Q

What is Diverticulitis

A

Inflamed diverticula secondary to obstruction or infection (fecalith)
Leads to distention

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110
Q

Sx of Diverticulitis

A

Fever, LLQ pain

N/V, Diarrhea, Constipation, Flatulence and Bloating

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111
Q

Dx of Diverticulitis

A

CT
Increased WBC
Positive Guaiac

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112
Q

Tx of Diverticulitis

A

Clear liquid diet, broad spectrum abx (Cipro or Bactrim) + Metronidazole

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113
Q

What is Peptic Ulcer Disease

A

Imbalance of mucosal protective factors and damaging factors lead to ulcers in duodenum or stomach

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114
Q

What are causes of PUD

A

H.Pylori
NSAIDS
Zollinger Ellison Syndrome

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115
Q

Sx of PUD

A 
Dyspepsia
Epigastric pain
Gastric: pain worse with meals
Duodenal: pain worse 2-3 hours after meal
Upper GI Bleeding
116
Q

Dx of PUD
Gold Standard
Others

A

Endoscopy with biopsy is gold standard
Upper GI Series
H.Pylori Testing
-Urea breath test, stool antigen, serologic antibodies

117
Q

Tx of PUD

A

H.Pyolori Eradication with Triple Therapy (Clarithromycin, Amoxicillin, PPI), Metronidazole if PCN allergy
If H.Pylori negative: PPI, H2 blocker, Bismuth compounds
Parietal cell vagotomy if refractory

118
Q

What is Meckel’s Diverticulum

A

Ileal Diverticulum

Persistent portion of embryonic vitteline duct (yolk stalk)

119
Q

What are the rule of 2’s associated with Meckel’s Diverticulum

A 
2 feet from ileocecal valve
2% asympomtomatic
2 inches in length
2 types of ectopic tissue (gastric or pancreas)
2 years old is most common age
2 times more common in boys
120
Q

Sx of Meckel’s Diverticulum

A

Usually Asymptomatic

Painless rectal bleeding or ulceration if ectopic gastric tissue

121
Q

Dx of Meckel’s Diverticulum

A

Physically look during laparoscopic procedure

122
Q

Tx of Meckel’s Diverticulum

A

Excision if symptomatic

123
Q

What is Pyloric Stenosis

A

Hypertrophy and Hyperplasia of the muscular layers of pylorus which can cause obstrucion
Common in babies

124
Q

Sx of Pyloric Stenosis

A

Non-Bilious projectile vomiting
Dehydration, Malnutrtion, jaundice, metabolic alkalosis
Olive-Shaped mass right of umbilicus

125
Q

Dx of Pyloric Stenosis

A

Ultrasound

Upper GI series shows String Sign

126
Q

Tx of Pyloric Stenosis

A

Pyloromyotomy

Rehydration

127
Q

What is Crohn’s Disease

A

Inflammatory Bowel Disease

Affects any segment of the GI from mouth to anus

128
Q

Where is the most common location of Crohn’s Disease

A

Terminal ileum, RLQ pain

129
Q

What is the depth and what do you see on colonoscopy

A

Transmural

Skip Lesins with cobblestone appearance

130
Q

Sx of Crohn’s Disease

A

RLQ pain, weight loss

Diarrhea WITHOUT visible blood

131
Q

What is a common marker for Crohn’s Disease

A

ASCA

132
Q

Dx for Crohn’s Disease

Test of choice for acute

A

Acute: Upper GI series with small bowel follow through, don’t want to do colonoscopy for risk of performation

133
Q

Tx of Crohn’s Disease

A

Aminosalicylates (Sulfasalazine, Mesalamine)
Corticosteroids
Immune Modifying Agents (6-Mercaptopurine, Aathioprine, Methotraxate, Anti-TNF agents)

134
Q

What is Acute Mesenteric Ischemia

A

Sudden decrease of mesenterial blood supply to the bowel which leads to inadequate perfusion usually at the splenic flexure
This is an emergency

135
Q

What causes Acute Mesenteric Ischemia

A

Occlusion such as an embolus or thrombus

Shock

136
Q

Sx of Acute Mesenteric Ischemia

A

Severe abdominal pain that is out of proportion to physical findings
Poorly localized pain, N/V, diarrhea

137
Q

Dx of Acute Mesenteric Ischemia
Definitive
Others
Labs

A

Angiogram is definitive
Colonoscopy see patchy necrotic areas
Increased WBC, Lactic Acidosis

138
Q

Tx of Acute Mesenteric Ischemia

A

Revascularization via angioplasty with stenting or bypassing

Surgical resection if bowel is not salvagable

139
Q

What are common causes of Acute Pancreatitis

A

Alcohol and gallstones

140
Q

What happens in Acute Pancreatitis

A

Acinar cell injury leads to intracellular activation of enzymes and auto-ingestion of pancreas
See edema, interstitial hemorrhage, coagulation and cellular fat necrosis

141
Q

Sx of Acute Pancreatitis

A

Epigastric pain that is constant and may radiate to the back
Relieved with leaning forward, sitting or fetal position
N/V, Fever
May see Cullen’s Sign (Periumbilical ecchymosis) or Turner’s Sign (Flank Ecchymosis)

142
Q

Dx of Acute Pancreatitis
Labs
Test of choice
Others

A

Leukocytosis, Increased glucose, Hypocalcemia, Increased Bilirubin
Increased lipase at 7-14 days
Amylase
Increased ALT (3x indicates gallstones)
Abdominal CT is test of choice
Ultrasound
Abdominal Xray: See sentinel loop, colon cutoff sign

143
Q

Tx of Acute Pancreatitis

A

Supportive: NPO, IV Fluids, Analgesics
Abx not usually used, but if you do use broad spectrum (imipenem). Usually used in necrotizing pancreatitis
ERCP if biliary sepsis suspected

144
Q

What is an Anal Abscess

A

Results from bacterial infection of anal ducts/glands

145
Q

What are common pathogens involved in Anal Abscess

A

Staph. Auerues, E.Coli, BActeroids, Proteus, Streptococcus

146
Q

Where is an Anal Abscess typically seen

A

Posterior rectal wall

147
Q

Sx of Anal Abscess

A

Throbbing rectal pain worse with sitting, coughing, or defecation

148
Q

Tx of Anal Abscess

A

Incision and Drainage

NO abx

149
Q

What is a Anal Fissure

A

Painful linear tear in the distal anal canal

150
Q

Where is an Anal Fissure usually seen

A

Posterior Midline

151
Q

What can cause Anal Fissure

A

Low fiber diet
Passage of large, hard stools
Anal Trauma

152
Q

Sx of Anal Fissure

A 
Severe painful BM
Patient's may fear having BM and refrain from doing so
Constipation
Bright red blood per rectum
Rectal Pain
Skin tags may be seen if chronic
153
Q

Tx of Anal Fissures

A

Most resolve spontaneously

Conservative: Sitz baths, high fiber diet, increased water intake, stool softeners,laxatives,mineral oil

154
Q

What is a Small Bowel Obstruction

A

Post-surgical adhesions are the most common cause

155
Q

Sx of SBO

A

Crampy abdominal pain, vomiting, diarrhea, obstipation (severe constipation)
Abdominal distention, Hyperactive bowel sounds that start as high pitched tinkles then eventual hypoactive bowel sounds

156
Q

Dx of SBO

A

Abdominal Xray: See air-fluid levels, Dilated bowel loops

157
Q

Tx of SBO

A

NPO, bowel rest, IV fluids
NG tube
Surgery if strangulated

158
Q

What is Pancreatic Cancer

A

Alcohol, DM, smoking, Obesity are all risk factors

Most have Mets by dx

159
Q

What are the types of Pancreatic Cancer

A

Adenocarcinoma is most common
Ampullary and Duodenal
Cystoadenoma and Cystocarcinoma

160
Q

Sx of Pancreatic Cancer

A

Painless Jaundice, Weight Loss
Abdominal pain that radiates to the back
Pruritis
Courvoisier’s Sign: Palpable, non-tender distended Gallbladder associated with jaundice

161
Q

Dx of Pancreatic Cancer

A

CT scan is test of choice

Increased CEA, CA-19-9

162
Q

Tx of Pancreatic Cancer
Tail
Advanced

A

Whipple
If in tail: resect
Advanced: ERCP with stent

163
Q

What is GERD

A

Transient relaxation of the LES leads to reflux and esophageal mucosal injury

164
Q

What is concerning about GERD

A

Can lead to Barrett’s Esophagus which is precursor to cancer

165
Q

Sx of GERD

Alarm sx

A

Heartburn, Retrosternal chest pain, Postprandial chest pain
Regurgitation, dysphagia, cough at night
Alarm: Dysphagia, odynophagia, weight loss, bleeding

166
Q

Dx of GERD
Gold Standard
Others

A

Clinical
Endoscopy
Esophageal Manometry will show decreased LES pressure
24 hour pH monitoring is gold standard

167
Q

Tx of GERD

A

Lifestyle modifications
H2 receptor antagonistsPPI in severe
Nissen if refractory

168
Q

What is Gastric Cancer

A

Adenocarcinoma is most common

169
Q

Risk factors for Gastric Cancer

A

H.Pylori
Salted, cured, smoked, pickled food that contain Nitrites
Alcohol

170
Q

Sx of Gastric Cancer

A

Indigestion, weight loss, early satiety, abdominal pain/fullness
N/V, dysphagia, melena, hematemesis
Superaclavicular lymph node swelling

171
Q

Dx of Gastric Cancer

A

Upper endoscopy with biopsy

May see Linitis Plastica which are diffuse thickening of stomach wall which indicates a bad gastric cancer

172
Q

Tx of Gastric Cancer

A

Gastrectomy
Chemo, Radiation
Poor prognosis

173
Q

What is a Condylomata Acuminata (warts in anus)

A

Can lead to anorectal sx

Caused by HPV

174
Q

Risk factors for Condylomata Acuminata

A

Homosexual men

HIV positive adults

175
Q

Where are Condylomata Acuminata typically seen

A

Perianal skin and extend within the anal canal up to 2 cm above dentate line

176
Q

Sx of Condylomata Acuminata

A

Asymptomatic

Itching, Bleeding, Pain

177
Q

Dx of Condylomata Acuminata

A

Biopsy so that you can distinguish it from Conyloma Latal (syphilis) or Anal Cancer
Mucosal HPV: Whitening of lesions with acetic acid application

178
Q

Sx of Condylomata Acuminata

A

Painless, papules that evolve into soft, fleshy cauliflower like lesions

179
Q

Tx of Condyloma Acuminata

A

Chemical, Salicylic Acid, Cryotherapy, Laser, and Podophyllin

180
Q

What is Hodgkin Lymphoma

A

Painless lymphadenopathy
Reed-Sternberg Cells
Malignant cell is derived from B lymphocytes of germinal center origin
it has a contiguous orderly spread of lymph nodes

181
Q

Sx of Hodgkin’s Lymphoma

A

Bimodal age distribution: Peak at 20 years and again over 50 years
Painless mass, commonly on neck
Constitutional sx (fever, weight loss, night sweats, generalized pruritus)

182
Q

Dx of Hodgkin’s Lymphoma

A

Mona marrow Biopsy showing Reed Sternberg Cells

Mediastinal lymphadenopathy, pet/CT scan for staging

183
Q

Tx of Hodgkin’s Lymphoma

A

Radiation therapy and Chemo

Very curable!

184
Q

What is Von Willebrand Disease

A

Most common inherited bleeding disorder - Ineffective Platelet Adhesion
vWF binds to platelets to suendothelial surfaces, aggregates platelets and prolongs half-life of Factor 8

185
Q

Sx of vWF Disease

A

Bleeding, especially mucous membranes
Epistaxis, gums, GI, Menorrhagia
Petechia

186
Q

Dx of vWF Disease

A

Decreased vWF levels
Prolonged PTT, corrects with mixing study
Bleeding times and PTT prolongation is worse with ASA
Decreased Ristocetin Activity is Gold Standard

187
Q

Tx of vWF Disease

A

Mild: None
Moderate: DDAVP (Desmopressin)
Severe: Cryoprecipitate (has Factor 8, fibrinogen and vWF)

188
Q

What is Hemophilia A

A

Deficiency in Factor 8 which is important for clotting cascade
Inability to form hematomas

189
Q

Sx of Hemophilia A

A

Hemarthrosis, especially in weight bearing joints (ankles, knees, elbows)
Excessive hemorrhage in response to trauma and surgery/incisional bleeding
Don’t typically see petechiae

190
Q

Dx of Hemophilia A

A

Low Factor 8
Prolonged PTT, mixing study corrects PTT
Normal Platelet levels

191
Q

Tx of Hemophilia A

A

Factor 8 infusion

Desmopressin (increases vWF and Factor 8)

192
Q

What is Hemophilia B

A

Deficiency in Factor 9

Almost exclusively in males

193
Q

Sx of Hemophilia B

A

Deep tissue bleeding
Hemarthrosis
Excessive hemorrhage

194
Q

Dx of Hemophilia B

A

Decreased Factor 9

Prolonged PTT, mixing study corrects PTT

195
Q

Tx of Hemophilia B

A

Factor 9 Infusion

No desmopressin because it only increased Factor 8 and vWF

196
Q

What is Thrombotic Thrombocytopenic Purpura

A

Thrombocytoepnia (Petechiae, brusing ,purpura, mucocutaneous bleeding)
Microangiopathic hemolytic anemia (Anemia, jaundice, fragmented RBC/Schistocytes)
Kidney Failure
Neurologic sx (Headache, CVA, AMS)
Fever

197
Q

What is Disseminated Intravascular Coagulation

A

Results from uncontrolled local or systemic activation of coagulation which leads to depletion of coagulation factors and platelets which are quickly activated and consumed
A frequent cause of thrombocytopenia in hospitalized patients
Prolonged activated PTT and PT time
Thrombocytopenia and decreased fibrinogen levels

198
Q

Sx of Disseminated Intravascular Coagulation

A

Bleeding typically with catheters or incisions

Progressive

199
Q

Dx of Disseminated Intravascular Coagulation

A

Thrombocytopenia, prolonged PTT and PT

D-Dimer is elevated

200
Q

Tx of Disseminated Intravascular Coagulation

A

Tx underlying disorder
Blood products if significant hemorrhage occurs
Low dose Heparin

201
Q

What is a Transient Ischemic Attack

A

Transient episode of neurological deficits caused by focal brain, spinal cord or retinal ischemia without acute infarction
Usually lasts

202
Q

Sx of TIA

A

Internal Carotid Artery: Amaurosis Fugax (monocular vision loss, temporary lamp shade down on one eye), weakness in contralateral hand
ICA/MCA/ACA: Sudden headache, speech changes, confusion
Verebrobasilar: Brainstem/Cerebellar sx (gait, proprioception)

203
Q

Dx of TIA

A 
CT to rule out hemorrhage
Assess CVA risk with ABCD (Age, BP, Clinical features, Duration of sx)
Carotid Doppler
CT Angiography, MR Angiography
Serum glucose
EKG
204
Q

Tx of TIA

A

ASA and Plavix
NO Thrombolytics
Place supine to increase cerebral perfusion
Reduce modifiable risk factors such as DM, HTN, A.Fib

205
Q

What is a Stroke

A

Sudden onset of neurologic deficit of cerebrovascular origin

Patient often has a history of HTN, DM, Smoking, A.Fib or Atherosclerosis

206
Q

What is a Lacunar Infarction

A

Small lesions that occur in the distribution of short penetrating arterioles in basal ganglia, pons, cerebellum, internal capsule, thalamus and white matter

207
Q

What is a Cerebral Infarction

A

Thrombotic or embolic occlusion of a major vessel leading to cerebral infarction

208
Q

Sx of Stroke located at Middle Cerebral Artery

A

Contralateral sensory/motor/hemiparesis greater in face/arms
Gaze preference towards side of lesion
If Left side dominant: Aphasia, Broca (expressive), Wernicke (sensory)
If Right side dominant: Spatial deficits, Dysarthria, L-side neglect, Anosognosia

209
Q

Sx of Stroke located at Anterior Cerebral Artery

A

Contralateral sensory/motor/hemiparesis greater in leg/foot
Face is spared and speech is preserved
Frontal lobe and mental status impairment, Personality Changes (flat affect)
Urinary Incontinence

210
Q

Sx of Stroke at Posterior Cerebral Artery/Basilar Artery/Vertebral Artery

A

Visual Hallucinations, contralateral homonymous hemianopsia (crossed sx)
CN palsies, decreased vision
Vertigo, N/V, Nystagmus, Diplopia, Ipsilateral Ataxia

211
Q

Dx of a Stroke

A

CT without contrast (want to look for hemorrhage)

Do this before administering ASA or antithrombotic agents

212
Q

Tx of Stroke

A

If Lacunar: ASA, control risk factors

If major circulation: Thrombolytic therapy (rTPA, Alteplase) within 3 hours of onset of sx

213
Q

What is Bell’s Palsy

A

Idiopathic facial paresis

Unilateral Facial Nerve Involvement

214
Q

What causes Bell’s Palsy

A

Idiopathic but strongly associated with HSV reactivation, VZV, Lyme Disease

215
Q

Risk factors for Bell’s Palsy

A

DM, Pregnancy, Post URI

216
Q

Sx of Bell’s Palsy

A

Sudden onset of ipsilateral hyperacusis (ear pain)
Unilateral facial paralysis
Unable to lift eyebrows, wrinkle forehead, smile on affected side
Drooping of corner of mouth, taste disturbance, biting inner cheek, Eye Irritation

217
Q

Dx of Bell’s Palsy

A

Clinical

218
Q

Tx of Bell’s Palsy

A

Prednisone

Artificial Tears

219
Q

What is Testicular Cancer

A

Most common solid tumor in young men

220
Q

What are risk factors for Testicular Cancer

A

Cryptochidism, Caucasians

221
Q

What are the types of Testicular Cancer

A

Germinal Cell Tumors: Seminoma, Non-seminoma (embryonal cell carcinoma, teratoma, choriocarcnioma)
Non-Germinal Cell: Leydig, Sertoli, Gonadoblastoma

222
Q

Sx of Testicular Cancer

A

Painless testicular nodule, solid mass or enlargemet
Hydrocele may be present
Gynecomastia may be present

223
Q

Dx of Testicular Cancer

A

Scrotal Ultrasound

Alpha-Fetoprotein, HcG, LDH

224
Q

What are imaging and lab features of Seminomatous Germ Cell Tumors

A

Radiosensitive
NO tumor markers
Seminomas are Sensitive and Simple

225
Q

What are imaging and lab features for Non-Seminomatous Germ Cell Tumors

A

Increased Alpha-Fetoprotein, Increased HcG

Radioresistant

226
Q

Tx of Testicular Cancer

A

Low Grade Non-Seminoma: Orchiectomy with Retroperitoneal lymph node dissection
Low Grade Seminoma: Orchiectomy followed by radiation
High grade Seminoma: Debulking chemo followed by orchiectomy and radiation

227
Q

What is Benign Prostatic Hypertrophy

A

Porstate Hyperpasia of the periurethral/transitional zone

Leads to bladder outlet obstruction

228
Q

Sx of BPH

A

Frequency, Urgency, Nocturia, Hesitancy, Weak/Intermittent Stream force, Incomplete Emptying, and Incontinence

229
Q

Dx of BPH

A

DRE: Uniformly enlarged firm rubbery prostate
Urinalysis: Normal
Increased PSA: Correlates with risk of sx progression
Urine Cytology: If increased risk of bladder cancer

230
Q

Tx of BPH

A

Observation, Avoid Antihistamines and Anticholinergeics
5-alpha Reductase Inhibitors: Finasteride, Dutasteride (Reduces size and need for surgery)
Alpha-1 Blockers: Tamsulosin, Alfuzosin, Doxazosin (treats sx)
Surgery: Trans Urethral Resection of Prostate (TURP)

231
Q

What are pathogens associated with Typical Pnemonia

A

Strep. Pneumoniae
H.Influenza
Kelbsiella
Staph. Aureus

232
Q

What are pathogens associated with Atypical Pneumonia

A

Mycoplasma
Chlamydia
Legionella
Viruses

233
Q

What do you see on X ray with Typical vs. Atypical Pneumonia

A

Typical: Lobular
Atypical: Patchy infiltrates

234
Q

Sx of Typical vs. Atypical Pneumonia

A

Typical: Sudden onset of fever, productive cough with purulent sputum, pleuritic chest pain, tachycardia
Atypical: Low grade fever, Dry, non-productive cough, Myalgias, Malaise, Sore throat, Headache, N/V

235
Q 
What does the color of sputum tell you about an organisms
Rusty/Blood Tinges
Currant Jelly
Green
Foul Smelling
A

Rusty/Blood Tinged: Strep. Pneumoniae
Currant Jelly: Kelbsiella
Green: H.Influenza, Pseudomonas
Foul Smelling: Anaerobes

236
Q

Tx of Community Acquired Pneumonia

Outpatient vs. Inpatient vs. ICU

A

Outpatient: Clarithromycin/Azithromycin or Doxycycline
Inpatient: Levafloxacin/Moxifloxacin/Gemifloxacin or Ceftriaxone/Cefotraxime/Unasyn + Azithromycin/Clarithromycin
ICU: Ceftriaxone/Cefotraxime/Unasyn + Azithromycin/Clarithromycin

237
Q

Tx of Hospital Acquired Pneumonia

A

Cefepime/Imipenem/Zosyn/Piperacillin + Levafloxacin/Gatifloxacin/Moxifloxacin/Gemifloxacin

238
Q

What is Tuberculosis

A

Mycobacterium Tuberculosis leading to granuloma formation

239
Q

What is Primary TB

A

Initial infection

Patients are contagious

240
Q

What is Chronic/Latent TB

A

Patients have granuloma so TB is contained
Not contagious
PPD will be positive in 2-4 weeks after infection

241
Q

What is Secondary/Reactivation TB

A

Latent TB with waning immune defenses (HIV, elderly, steroid use, malignancy)
Patients are contagious
TB is seen in upper lobes with cavitary lesions

242
Q

Sx of TB

A

Pulmonary sx: Chronic productive cough, chest pain, Hemoptysis
Constitutional sx: Fever, night sweats, chills, fatigue, weight loss, anorexia
Rales or Rhonchi near apices, Dull to percussion
Lymphadenopathy

243
Q

With a PPD test what do the following values tell you about someone with TB
>5
>10
>15

A

Person is considered positive if:
>5: with HIV, Immunosuppressed (prednisone), Close contacts to person with known TB
>10: High risk populations
>15: No known risk factors for TB

244
Q

Dx for TB

A

Acid-Fast smear and sputum culture for 3 days
AFB Culture is gold standard
CXR and PPD

245
Q

Tx of TB

A 
First 2 months with RIPE
Followed by 4 months of RI
Rifampine
Isoniazid
Pyrazinamide
Ethambutol
246
Q

What are the side effects of TB drugs

A

Rifampine: Thrombocytopenia, Orange colored secretions
Isoniazid: Hepatitis, Peripheral Neuropathy
Pyrazinamide: Hepatitis and Hyperuricemia, GI sx
Ethambutol: Optic Neuritis, Peripheral neuropathy

247
Q

What is a PE

A

Thrombus in pulmonary artery or brnches

248
Q

Sx of PE

A

Dyspnea, Tachypnea, Pleuritic chest pain, Hemoptysis
Post-op patient with sudden onset of tachypnea
Syncope, Hypotension, Pulseless electrical activity

249
Q

Dx of PE
Initial
Gold Standard

A 
Helical CT is first
Pulmonary Angiography is Gold Standard
V/Q scan
Doppler Ultrasound
CXR: See Westermark's Sign, Hampton's Hump
EKG: See sinus tachycardia
250
Q

Tx of PE

A

Anticoagulation: Heparin, Warfarin for 3-6 months
IVC Filter
Thrombolysis with Alteplase (tPA) only if massive PE or hemodynamic compromise when anticoagulation is contraindicated

251
Q

What are prophylaxis for PE

A

Early Ambulation
Elastic Stockings, Pneumatic Compression Devices/Venodyne Boots
Low molecular weight Heparin if undergoing ortho or neurosurgery, trauma

252
Q

What are the 3 main components that should be addressed in the pre-operative cardiac risk assessment

A
  1. Riks of major Cardiac Complication
  2. Current Functional Status
  3. Cariac Risk associated with Planned Procedure
253
Q

What is considered a major Cardiac Risk

A

MI within 6 months with persistent ischemic symptoms
Decompensated CHF
Significant Arrhythmias
Severe Valvular Disease

254
Q

What is considered an Intermediate Cardiac Risk

A 
MI >6 months
Stable/Unstable Angina
Decompensated prior to CHF
DM
Renal Insufficiency
255
Q

What is considered a Minor Cardiac Risk

A 
Advanced Age
Abnormal EKC
Rhythm other than sinus (A.Fib)
Poor Functional Capacity
History of Stroke
Uncontrolled HTN
256
Q

When are Beta-Blockers recommended prior to surgery

A

Patients who are already taking Beta-Blockers for angina, arrhythmia or HTN
Patients undergoing vascular surgery who have cardiac ischemia on preoperative evaluation
Target is resting heart rate of 60 bpm

257
Q

What is considered a low Cardiac Risk Procedure

A 
ABCDE-TURP
Ambulatory Procedures
Breast Procedures
Cataract Procedures
Dermatologic Procedures
Endoscopic Procedures
Trans-Urethral Resection of the Prostate
258
Q

What is considered an Intermediate Cardiac Risk Procedures

A 
CHOPIN
Carotid Endarterectomy
Head Procedures
Orthopedic Procedures
Prostatectomy
Intraperitoneal and Intrathoracic Procedures
Neck Procedures
259
Q

What is considered a High Cardiac Risk Prcoedure

A

EVA
Emergency Major Procedures
Vascular Procedures
Anticipated prolonged surgical procedures associated with large fluid shifts or blood loss

260
Q

What are risk factors for perioperative pulmonary complications

A 
Surgery on chest or abdomen
Neck or Intracranial surgery
Chronic lung disease
CHF
Current tobacco use
Morbid Obesity
Age >60yrs
Prior Stroke
Altered Mental Status
Low Albumin
261
Q

How do you manage someone pre-operatively with DM who is on insulin vs. not on insulin

A

On insulin: Give insulin morning of surgery with glucose drip
Not on insulin: Omit oral hypoglycemic the day before surgery

262
Q

How do you manage someone pre-operatively who uses Steroids

A

Continue Usual Dose

263
Q

Discuss ASA with regards to Perioperative Management

A

Continued for high risk vascular complications

Discontinued 7 days before surgery, resumed 24 hours after surgery

264
Q

Discuss Warfarin with regards to Perioperative Management

A

Stopped 4-5 days before surgery and replaced with Heparin
Unfractionated heparin is stopped 5 hours before surgery
LMWH stopped 12-24 hours before surgery

265
Q

Discuss Clopidogrel with regards to Perioperative Management

A

Stopped 7-10 days before surgery

266
Q

Discuss NSAIDS with regards to Perioperative Management

A

Stopped at least 3 days before surgery

267
Q

What is MET regarding pre-operative risk assessment

A

Metabolic Equivalent, a unit used to estimate the energy/oxygen consumption during physical activity
1 MET = Oxygen consumption of a 70kg, 40 year old man in a resting state

268
Q

What is considered MET >7

A

Excellent

Squash, jogging a 10 minute mile, scrubbing floors, singles tennis

269
Q

What is considered MET 4-7

A

Moderate

Cycling, Climbing a flight of stairs, Golf without a cart, Walking 4 mph, Yardwork

270
Q

What is considered MET

A 
Poor
Vacuuming
Activities of Daily Living
Walking 2 mph
Writing
271
Q

What is Wound Dehiscence

A

Undesired spontaneous separation of wound edges

272
Q

What causes wound dehiscence

A

Infection and Excessively tight sutures

273
Q

What are risk factors for wound dehiscence

A

Host: Smoking, Malnutrition, Steroids, Infection, Hypoxia/Hypovolemia, Radiation, Trauma, Uremia, DM, Drugs, Advanced Age

Operator: Tissue injury, Poor blood supply, Poor apposition of tissue

274
Q

What is 1st intention healing, 2nd intention healing, Delayed primary closure

A

1st Intention: When tissue is cleanly incised and reapproximated and repair occurs without complication
2nd Intention: Occurs in open wounds through the formation of granulation tissue and eventual coverage of defect by normal migration of epithelial cells
Delayed Primary Closure: Combines 1st intention and 2nd Intention. Would allowed to heal open for 5 days then reapproximated using suture or other ligature

275
Q

What are the steps involved in Wound Preparation

A

Debridement
Foreign Body Removal
Irrigation
Disinfection

276
Q 
When should sutures be removed for
Face
Scalp
Trunk/Arm/Hand
Leg/Foot
A

Face: 3-5 days
Scalp: 5-7 das
Trunk/Arm/Hand: 7-10 days
Leg/Foot: 10-14 days

277
Q

What is an Abdominal Aortic Aneurysm

A

Focal dilation of aortic diameter at least 1.1.5x

>3.0cm is usually considered an aneurysm

278
Q

What are Risk Factors for developing an Aneurysm

A

Atherosclerosis
Age >60yrs
Smoking
Hyperlipidemia, DM, Connective Tissue Disorder

279
Q

Sx of Abdominal Aortic Aneurysm

A

Asymptomatic until rupture usually
Older male with severe back or abdominal pain who presents wit syncope or hypotensio
Tender pulsatile abdominal mass

280
Q

Dx of Abdominal Aortic Aneurysm
1st test
Gold Standard
Others

A

Abdominal Ultrasound: 1st test, screnning and monitoring
Angiography: Gold Standard
CT Scan: choice for Thoracic Aneurysm
MIR/MRA

281
Q

Tx of Abdominal Aortic Aneurysm

A

3-4cm: Monitor by ultrasound
4-4.5cm: Monitor by ultrasound every 6 months
>4.5cm: Vascular surgeon referral
>5.5cm: Surgery immediately or if it grows >0.5 cm within 6 months

282
Q

What leads to DVT (Triad)

A

Stasis, Intimal Damage, Hypercoagulability

DVT thought to start at induction of anesthesia so need to prophylaxis treat

283
Q

What are Prophylaxis Options for DVT and what are risks

A

Unfractionated Heparin: 5,000 units every 8-12 hours preoperatively and continued until patient is fully ambulatory. Risk of Hematoma formation.
Low Molecular Weight Heparin: Prefered for trauma patients or those with abdominal or pelvic cancer
Warfarin: Mainly in ortho after initial use of Heparin. Need to monitor INR (2-3 is goal). Bleeding complications
Fondaparinux: Lower incidence of bleeding complications
Sequential Compression Devices to both lower extremities

284
Q

What is Respiratory Acidosis

A 
Anything that decreases respiration
CNS depression, cardiopulmonary arrest, pneumonia
Low pH
High CO2
Normal HCO3
285
Q

What do you see with Respiratory Alkalosis

A

High pH
Normal/Low CO2
High HCO3

286
Q

What do you see with Metabolic Acidosis

A

Low pH
Normal CO2
Low HCO3

287
Q

What do you see with Metabolic Alkalosis

A

High pH
Normal CO2
High HCO3

Surgery (12 decks)

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