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High Yield Flashcards

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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
What is the most common cause of Peripheral Arterial Disease
Atherosclerotic disease of the lower extremities
26
Sx of Peripheral Artery Disease
Intermittent Claudication which is reproducible pain/discomfort in the extremity brought on by exercise/walking and relieved with rest
27
What does it mean when there is resting leg pain
Advanced Disease
28
What is an acute arterial embolism
Usually caused by sudden occlusion 6 P's Parasthesias, Pain, Pallor, Pulselessness, Paralysis, Poikilothermia Livedo Reticularis: Mottling with arteriolar occlusion
29
How does Gangrene result with Peripheral Arterial Disease
When arterial perfusion is so poor that spontaneous necrosis occurs The tissue goes from purplish/blue to black
30
What is Wet Gangrene
Ulcers: Malodorous, copious, purulent, infected, blackened rgions
31
What is Dry Gangrene
Mummification of digits of foot
32
Sx of Peripheral Arterial Disease
``` Decreased or absent pulses Bruits Decreased capillary refill Atrophic skin changes, usually no edema Pale on elevation, dusky red with dependency LATERAL malleolus ulcers ```
33
Dx of Peripheral Arterial Disease | Gold Standard
Ankle Brachial Index: Normal is 1-1.2, positive if
34
Tx of Peripheral Arterial Disease
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
35
What is a pneumothorax
Air within the pleural space | Increasingly positive pleural pressure causes collapse of the lung
36
What is a Spontaneous Pneumothorax | Primary vs. Secondary
A ruptured bleb Primary: No underlying lung disease, mainly affects young men, tall, smokers, family hx Secondary: Underlying lung disease like COPD, Asthma, Menstruation
37
What is a Traumatic Pneumothorax
CPR, Thoracentesis, Subclavian lines or trauma
38
What is a Tension Pneumothorax
Positive air pressure pushes the lungs, trachea and heart to the contralateral side
39
Sx of a Pneumothorax
Chest pain, usually pleuritic and unilateral, Dyspnea Increased Hyperresonance, Decreased fremitus, Decreased breath sounds, unequal respiratory expansion, tachycardia, tachypnea, Hypotenion
40
Sx of a Tension Pneumothorax
Increased JVP and pulses paradoxus
41
Dx of Pneumothorax
CXR with expiratory view Decreased peripheral lung markings Deep Sulcus
42
Tx of Pneumothorax
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
43
what is an Aortic Dissection
Tear in the innermost layer of the aorta (intima)
44
Risk factors for Aortic Dissection
HTN, Age (50-60yrs), Vasculitis, traua, family hx, Collagen disorders (Marfans)
45
Sx of Aortic Dissection
Sudden onset of severe tearing chest/upper back pain Decreased peripheral pulses Variation in pulses between left arm and right arm HTN
46
Dx of Aortic Dissection | Gold Standard
MRI Angiogram is gold standard CXR: See widening mediastinum CT scan with contrast is becoming test of choice Trans Esophageal Echocardiograph
47
Tx of Aortic Dissection
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
48
``` Describe the features of a 3rd degree burn Depth Appearance Sensation Capillary Refill Prognosis ```
Full Thickness - Extends through entire skin Waxy, white, leathery, dry Painless No capillary refill Months to heal, does not spontaneously heal well
49
Tx for burns
``` 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 ```
50
Tx for 3rd degree burns
Cover with sterile dressing to prevent infection with nonadherent gauze and elastic guaze
51
What type of reaction is Urticaria (Hives)/Angioedea
Type I Hypersensitivity reaction (IgE)
52
What are common triggers for Urticaria
Antigen from foods, meds, infections, insect bites, drugs, environmental
53
What is the pathophysiology behind Urticaria
Mast cells release histamine which cause vasodilation of venules and edema of dermis and sub-q tissues
54
Sx of Urticaria
Blanchable, edematous pink papules, wheals or plaque
55
Sx of Angioedema
Painless, deeper form of urticaria affecting lips, tongue, eyelids, hands feet and genitals Anaphylaxis may occur
56
Tx of Urticaria/Angioedema
Oral Antihistamines Eliminate cause H2 blockers Corticosteroids
57
What is the clinical use of Anti-Thyroglobulin
Used to diagnose Hashimoto's in Hypothyroidism | Used to diagnose Autoimmune Thyroiditis
58
Sx of Hypothyroidism
``` Decreased basic metabolic rate Cold Intolerance Weight gain Goiter Fatigue, Sluggishness, memory loss radycardia, Decreased CO Menorrhagia ```
59
What is Hashimotos
Autoimmune | Hypothyroidism
60
Dx of Hashimotos
Thyroglobulin antibodies present
61
Tx of Hashimotos
Levothyroxine
62
What are the 4 types of Thyroid Cancers | Least aggressive to most aggressive
Papillary Follicular Medullary Anaplastic
63
``` What is the most common type of Thyroid Cancer Risk factors Age Characteristics Mets Prognosis Tx ```
``` Papillary Young females Least aggressive Local (cervical) mets Excellent prognosis Total Thyroidectomy ```
64
``` Discuss Follicular Thyroid Cancer Risk factors Age Characteristics Mets Prognosis Tx ```
``` Less often associated with radiation exposure 40-60yrs More aggressive Distant mets common Excellent prognosis Total Thyroidectomy ```
65
``` Discuss Medullary Thyroid Cancer Risk factors Age Characteristics Mets Prognosis Tx ```
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
66
``` Discuss Anaplastic Thyroid Cancer Risk factors Age Characteristics Mets Prognosis Tx ```
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
67
What is Hyperparathyroidism
Excess PTH production | Usually associated with MEN 1
68
What is Primary vs. Secondary Hyperparathyroidism
Primary: Parathyroid Adenoma or Parathyroid Hyperplasia Secondary: Increased PTH in response to hypocalcemia or Vitamin D deficiency, Chronic Kidney Disease
69
Sx of Primary Hyperparathyroidism
Signs of Hypercalcemia: Stones, Bones, Groans, and psychic Moans, Decreased DTR
70
Dx of Hyperparathyroidism
Hypercalcemia + Increased PTH + Decreased Phosphate | Increased 24 hour urine calcium excretion
71
Tx of Primary Hyperparathyroidism
Surgery: Parathyroidectomy
72
Tx of Secondary Hyperparathyroidism
Vitamin D and Calcium Supplement
73
What is Hypoparathyroidism
Low PTH or insensitivity to its action
74
What are 2 most common causes of Hypoparathyroidism
Accidental damage/removal during neck/thyroid surgery | Autoimmune destruction of parathyroid gland
75
Sx of Hypoparathyroidism
Signs of Hypocalcemia: Carpopedal Spasms, Trousseau and Chvostek Sign, Perioral Parasthesias, Increased DTR
76
Dx of Hypoparathyroidism
Hypocalcemia + Decreased PTH + Increased Phosphate
77
Tx of Hypoparathyroidism
Calcium Supplement and Vitamin D (Ergocalciferol or Calcitriol)
78
What is a Pheochromocytoma
Catecholamine secreting adrenal hormone | Secretes Norepinephrine and Epinephrine autonomously and intermittently
79
What are triggers for release of catecholamines from e Pheochromoctyoma
Surgery, exercise, pregnancy, meds (TCA, Opiates, metoclopramide, glucagon, Histamine)
80
Sx of Pheochromocytoma
HTN Palpitations, Headaches, Excessive Sweating Chest or abdominal pain, weakness, fatigue, weight loss
81
Dx of a Pheochromocytoma
24 hour urine catecholamines including metabolites: Metanephrine and Vanillylmandelic Acid MRI or CT to find adrenal tumor
82
Tx of a Pheochromoctyoma
Complete Adrenalectomy Preoperative non-selective alpha-blockers: Phenoxybenzamine or Phentolamine for 7-14 days followed by beta blockers or CCB to control HTN
83
What is Chronic Adrenocortical Insufficiency
Disorder where adrenal gland does not produce enough hormones
84
What is Primary Adrenocortical Insufficiency (Addisons Disease)
Adrenal gland destruction which causes lack of cortisol and aldosterone Can be due to autoimmune, infection, vascular, or Mets
85
What is Secondary Adrenocortical Insufficiency
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
86
Sx of Primary Adrenocortical Insufficiency (Addisons)
``` 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 ```
87
Dx of Adrenocortical Insufficiency
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
88
Tx of Adrenocortical Insufficiency
Hormone Replacement Primary: Replace both Glucocorticoids (Hydrocortisone) and Mineralocorticoids (Fludrocortisone) Secondary: Replace only Glucocorticoids
89
What considerations should be taken in people with Adrenocortical Insufficiency prior to a surgery
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
90
What is an Adrenal (Addisonian) Crisis
Sudden worsening of adrenal insufficiency due to a stressful event (surgery, trauma, volume loss, hypotermia, MI, fever, sepsis, hypoglycemia, steroid withdrawal)
91
What can cause and Addison Crisis
Abrupt withdrawal of steroids Previously undiagnosed adrenocortical insufficiency Exacerbation of known Addison's Disease (surgery, trauma, etc.) Bilateral adrenal infarction
92
Sx of Addisons Crisis
Shock, decreased blood pressure Hypotension, Hypovolemia Abdominal pain, N/V, fever, weakness, lethargy, coma
93
Dx of Addisons Crisis
Hyponatremia, Hyperkalemia, Hypoglycemia | Cortisol levels, ACTH levels, CBC
94
Tx of Addisons Crisis
IV Fluids to correct Hypotension and Hypovolemia Glucocorticoids Reversal of electrolyte abnormalities Fludrocortisone (Florinef)
95
What is Cholecystitis
Cystic duct obstruction usually by gallstone which leads to inflammation/infection
96
Sx of Cholecystitis
``` 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) ```
97
Dx of Cholecystitis Initial test Gold Standard Labs
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
98
Tx of Cholecystitis
Conservative: NPO, IVF, Abx (cephalosporin + Metronidazole) | Cholecystectomy within 72 hours
99
What is fecal impaction
Severe impaction of stool in rectal vault which can result in obstruction to fecal flow and large bowel obstruction
100
What are predisposing factors of fecal impaction
``` Medications (Opioids) Severe psychiatric disease Prolonged bed rest Nerogenic disorders of colon Spinal cord disorders ```
101
Sx of Fecal Impaction
``` Anorexia N/V Abdominal Pain Distention DRE will have palpable firm feces ```
102
Tx of Fecal Impaction
Enemas: Saline, Mineral Oil Digital Disruption Improved care with stool softeners, increased fiber in diet and increased water intake
103
What is Intussusception
Intestinal segment invaginates or telescopes into adjoining intestinal lumen which leads to bowel obstruction Often occurs after viral infection Common in babies/kids
104
What is the most common site for Intussusception
Ileocolic Junction
105
What are lead points for Intussusception
``` Meckel Diverticulum Enlarged Mesenteric Lymph Node Hyperplasia of Payer's Patches Tumors Foreign Body ```
106
Sx of Intussusception
Vomiting, Abdominal Pain, Passage of blood per rectum (Currant jelly stools) Pain is colicky Sausage shaped mass in RUQ
107
Dx of Intussusception
Barium Contrast Enema Xray CT in adults
108
Tx of Intussusception
Barium or air insufflation enema | Surgery if refractory
109
What is Diverticulitis
Inflamed diverticula secondary to obstruction or infection (fecalith) Leads to distention
110
Sx of Diverticulitis
Fever, LLQ pain | N/V, Diarrhea, Constipation, Flatulence and Bloating
111
Dx of Diverticulitis
CT Increased WBC Positive Guaiac
112
Tx of Diverticulitis
Clear liquid diet, broad spectrum abx (Cipro or Bactrim) + Metronidazole
113
What is Peptic Ulcer Disease
Imbalance of mucosal protective factors and damaging factors lead to ulcers in duodenum or stomach
114
What are causes of PUD
H.Pylori NSAIDS Zollinger Ellison Syndrome
115
Sx of PUD
``` Dyspepsia Epigastric pain Gastric: pain worse with meals Duodenal: pain worse 2-3 hours after meal Upper GI Bleeding ```
116
Dx of PUD Gold Standard Others
Endoscopy with biopsy is gold standard Upper GI Series H.Pylori Testing -Urea breath test, stool antigen, serologic antibodies
117
Tx of PUD
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
What is Meckel's Diverticulum
Ileal Diverticulum | Persistent portion of embryonic vitteline duct (yolk stalk)
119
What are the rule of 2's associated with Meckel's Diverticulum
``` 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
Sx of Meckel's Diverticulum
Usually Asymptomatic | Painless rectal bleeding or ulceration if ectopic gastric tissue
121
Dx of Meckel's Diverticulum
Physically look during laparoscopic procedure
122
Tx of Meckel's Diverticulum
Excision if symptomatic
123
What is Pyloric Stenosis
Hypertrophy and Hyperplasia of the muscular layers of pylorus which can cause obstrucion Common in babies
124
Sx of Pyloric Stenosis
Non-Bilious projectile vomiting Dehydration, Malnutrtion, jaundice, metabolic alkalosis Olive-Shaped mass right of umbilicus
125
Dx of Pyloric Stenosis
Ultrasound | Upper GI series shows String Sign
126
Tx of Pyloric Stenosis
Pyloromyotomy | Rehydration
127
What is Crohn's Disease
Inflammatory Bowel Disease | Affects any segment of the GI from mouth to anus
128
Where is the most common location of Crohn's Disease
Terminal ileum, RLQ pain
129
What is the depth and what do you see on colonoscopy
Transmural | Skip Lesins with cobblestone appearance
130
Sx of Crohn's Disease
RLQ pain, weight loss | Diarrhea WITHOUT visible blood
131
What is a common marker for Crohn's Disease
ASCA
132
Dx for Crohn's Disease | Test of choice for acute
Acute: Upper GI series with small bowel follow through, don't want to do colonoscopy for risk of performation
133
Tx of Crohn's Disease
Aminosalicylates (Sulfasalazine, Mesalamine) Corticosteroids Immune Modifying Agents (6-Mercaptopurine, Aathioprine, Methotraxate, Anti-TNF agents)
134
What is Acute Mesenteric Ischemia
Sudden decrease of mesenterial blood supply to the bowel which leads to inadequate perfusion usually at the splenic flexure This is an emergency
135
What causes Acute Mesenteric Ischemia
Occlusion such as an embolus or thrombus | Shock
136
Sx of Acute Mesenteric Ischemia
Severe abdominal pain that is out of proportion to physical findings Poorly localized pain, N/V, diarrhea
137
Dx of Acute Mesenteric Ischemia Definitive Others Labs
Angiogram is definitive Colonoscopy see patchy necrotic areas Increased WBC, Lactic Acidosis
138
Tx of Acute Mesenteric Ischemia
Revascularization via angioplasty with stenting or bypassing | Surgical resection if bowel is not salvagable
139
What are common causes of Acute Pancreatitis
Alcohol and gallstones
140
What happens in Acute Pancreatitis
Acinar cell injury leads to intracellular activation of enzymes and auto-ingestion of pancreas See edema, interstitial hemorrhage, coagulation and cellular fat necrosis
141
Sx of Acute Pancreatitis
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
Dx of Acute Pancreatitis Labs Test of choice Others
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
Tx of Acute Pancreatitis
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
What is an Anal Abscess
Results from bacterial infection of anal ducts/glands
145
What are common pathogens involved in Anal Abscess
Staph. Auerues, E.Coli, BActeroids, Proteus, Streptococcus
146
Where is an Anal Abscess typically seen
Posterior rectal wall
147
Sx of Anal Abscess
Throbbing rectal pain worse with sitting, coughing, or defecation
148
Tx of Anal Abscess
Incision and Drainage | NO abx
149
What is a Anal Fissure
Painful linear tear in the distal anal canal
150
Where is an Anal Fissure usually seen
Posterior Midline
151
What can cause Anal Fissure
Low fiber diet Passage of large, hard stools Anal Trauma
152
Sx of Anal Fissure
``` 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
Tx of Anal Fissures
Most resolve spontaneously | Conservative: Sitz baths, high fiber diet, increased water intake, stool softeners,laxatives,mineral oil
154
What is a Small Bowel Obstruction
Post-surgical adhesions are the most common cause
155
Sx of SBO
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
Dx of SBO
Abdominal Xray: See air-fluid levels, Dilated bowel loops
157
Tx of SBO
NPO, bowel rest, IV fluids NG tube Surgery if strangulated
158
What is Pancreatic Cancer
Alcohol, DM, smoking, Obesity are all risk factors | Most have Mets by dx
159
What are the types of Pancreatic Cancer
Adenocarcinoma is most common Ampullary and Duodenal Cystoadenoma and Cystocarcinoma
160
Sx of Pancreatic Cancer
Painless Jaundice, Weight Loss Abdominal pain that radiates to the back Pruritis Courvoisier's Sign: Palpable, non-tender distended Gallbladder associated with jaundice
161
Dx of Pancreatic Cancer
CT scan is test of choice | Increased CEA, CA-19-9
162
Tx of Pancreatic Cancer Tail Advanced
Whipple If in tail: resect Advanced: ERCP with stent
163
What is GERD
Transient relaxation of the LES leads to reflux and esophageal mucosal injury
164
What is concerning about GERD
Can lead to Barrett's Esophagus which is precursor to cancer
165
Sx of GERD | Alarm sx
Heartburn, Retrosternal chest pain, Postprandial chest pain Regurgitation, dysphagia, cough at night Alarm: Dysphagia, odynophagia, weight loss, bleeding
166
Dx of GERD Gold Standard Others
Clinical Endoscopy Esophageal Manometry will show decreased LES pressure 24 hour pH monitoring is gold standard
167
Tx of GERD
Lifestyle modifications H2 receptor antagonistsPPI in severe Nissen if refractory
168
What is Gastric Cancer
Adenocarcinoma is most common
169
Risk factors for Gastric Cancer
H.Pylori Salted, cured, smoked, pickled food that contain Nitrites Alcohol
170
Sx of Gastric Cancer
Indigestion, weight loss, early satiety, abdominal pain/fullness N/V, dysphagia, melena, hematemesis Superaclavicular lymph node swelling
171
Dx of Gastric Cancer
Upper endoscopy with biopsy | May see Linitis Plastica which are diffuse thickening of stomach wall which indicates a bad gastric cancer
172
Tx of Gastric Cancer
Gastrectomy Chemo, Radiation Poor prognosis
173
What is a Condylomata Acuminata (warts in anus)
Can lead to anorectal sx | Caused by HPV
174
Risk factors for Condylomata Acuminata
Homosexual men | HIV positive adults
175
Where are Condylomata Acuminata typically seen
Perianal skin and extend within the anal canal up to 2 cm above dentate line
176
Sx of Condylomata Acuminata
Asymptomatic | Itching, Bleeding, Pain
177
Dx of Condylomata Acuminata
Biopsy so that you can distinguish it from Conyloma Latal (syphilis) or Anal Cancer Mucosal HPV: Whitening of lesions with acetic acid application
178
Sx of Condylomata Acuminata
Painless, papules that evolve into soft, fleshy cauliflower like lesions
179
Tx of Condyloma Acuminata
Chemical, Salicylic Acid, Cryotherapy, Laser, and Podophyllin
180
What is Hodgkin Lymphoma
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
Sx of Hodgkin's Lymphoma
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
Dx of Hodgkin's Lymphoma
Mona marrow Biopsy showing Reed Sternberg Cells | Mediastinal lymphadenopathy, pet/CT scan for staging
183
Tx of Hodgkin's Lymphoma
Radiation therapy and Chemo | Very curable!
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What is Von Willebrand Disease
Most common inherited bleeding disorder - Ineffective Platelet Adhesion vWF binds to platelets to suendothelial surfaces, aggregates platelets and prolongs half-life of Factor 8
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Sx of vWF Disease
Bleeding, especially mucous membranes Epistaxis, gums, GI, Menorrhagia Petechia
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Dx of vWF Disease
Decreased vWF levels Prolonged PTT, corrects with mixing study Bleeding times and PTT prolongation is worse with ASA Decreased Ristocetin Activity is Gold Standard
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Tx of vWF Disease
Mild: None Moderate: DDAVP (Desmopressin) Severe: Cryoprecipitate (has Factor 8, fibrinogen and vWF)
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What is Hemophilia A
Deficiency in Factor 8 which is important for clotting cascade Inability to form hematomas
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Sx of Hemophilia 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
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Dx of Hemophilia A
Low Factor 8 Prolonged PTT, mixing study corrects PTT Normal Platelet levels
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Tx of Hemophilia A
Factor 8 infusion | Desmopressin (increases vWF and Factor 8)
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What is Hemophilia B
Deficiency in Factor 9 | Almost exclusively in males
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Sx of Hemophilia B
Deep tissue bleeding Hemarthrosis Excessive hemorrhage
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Dx of Hemophilia B
Decreased Factor 9 | Prolonged PTT, mixing study corrects PTT
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Tx of Hemophilia B
Factor 9 Infusion | No desmopressin because it only increased Factor 8 and vWF
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What is Thrombotic Thrombocytopenic Purpura
Thrombocytoepnia (Petechiae, brusing ,purpura, mucocutaneous bleeding) Microangiopathic hemolytic anemia (Anemia, jaundice, fragmented RBC/Schistocytes) Kidney Failure Neurologic sx (Headache, CVA, AMS) Fever
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What is Disseminated Intravascular Coagulation
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
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Sx of Disseminated Intravascular Coagulation
Bleeding typically with catheters or incisions | Progressive
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Dx of Disseminated Intravascular Coagulation
Thrombocytopenia, prolonged PTT and PT | D-Dimer is elevated
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Tx of Disseminated Intravascular Coagulation
Tx underlying disorder Blood products if significant hemorrhage occurs Low dose Heparin
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What is a Transient Ischemic Attack
Transient episode of neurological deficits caused by focal brain, spinal cord or retinal ischemia without acute infarction Usually lasts
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Sx of TIA
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)
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Dx of TIA
``` 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 ```
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Tx of TIA
ASA and Plavix NO Thrombolytics Place supine to increase cerebral perfusion Reduce modifiable risk factors such as DM, HTN, A.Fib
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What is a Stroke
Sudden onset of neurologic deficit of cerebrovascular origin | Patient often has a history of HTN, DM, Smoking, A.Fib or Atherosclerosis
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What is a Lacunar Infarction
Small lesions that occur in the distribution of short penetrating arterioles in basal ganglia, pons, cerebellum, internal capsule, thalamus and white matter
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What is a Cerebral Infarction
Thrombotic or embolic occlusion of a major vessel leading to cerebral infarction
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Sx of Stroke located at Middle Cerebral Artery
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
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Sx of Stroke located at Anterior Cerebral Artery
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
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Sx of Stroke at Posterior Cerebral Artery/Basilar Artery/Vertebral Artery
Visual Hallucinations, contralateral homonymous hemianopsia (crossed sx) CN palsies, decreased vision Vertigo, N/V, Nystagmus, Diplopia, Ipsilateral Ataxia
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Dx of a Stroke
CT without contrast (want to look for hemorrhage) | Do this before administering ASA or antithrombotic agents
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Tx of Stroke
If Lacunar: ASA, control risk factors | If major circulation: Thrombolytic therapy (rTPA, Alteplase) within 3 hours of onset of sx
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What is Bell's Palsy
Idiopathic facial paresis | Unilateral Facial Nerve Involvement
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What causes Bell's Palsy
Idiopathic but strongly associated with HSV reactivation, VZV, Lyme Disease
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Risk factors for Bell's Palsy
DM, Pregnancy, Post URI
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Sx of Bell's Palsy
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
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Dx of Bell's Palsy
Clinical
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Tx of Bell's Palsy
Prednisone | Artificial Tears
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What is Testicular Cancer
Most common solid tumor in young men
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What are risk factors for Testicular Cancer
Cryptochidism, Caucasians
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What are the types of Testicular Cancer
Germinal Cell Tumors: Seminoma, Non-seminoma (embryonal cell carcinoma, teratoma, choriocarcnioma) Non-Germinal Cell: Leydig, Sertoli, Gonadoblastoma
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Sx of Testicular Cancer
Painless testicular nodule, solid mass or enlargemet Hydrocele may be present Gynecomastia may be present
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Dx of Testicular Cancer
Scrotal Ultrasound | Alpha-Fetoprotein, HcG, LDH
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What are imaging and lab features of Seminomatous Germ Cell Tumors
Radiosensitive NO tumor markers Seminomas are Sensitive and Simple
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What are imaging and lab features for Non-Seminomatous Germ Cell Tumors
Increased Alpha-Fetoprotein, Increased HcG | Radioresistant
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Tx of Testicular Cancer
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
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What is Benign Prostatic Hypertrophy
Porstate Hyperpasia of the periurethral/transitional zone | Leads to bladder outlet obstruction
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Sx of BPH
Frequency, Urgency, Nocturia, Hesitancy, Weak/Intermittent Stream force, Incomplete Emptying, and Incontinence
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Dx of BPH
DRE: Uniformly enlarged firm rubbery prostate Urinalysis: Normal Increased PSA: Correlates with risk of sx progression Urine Cytology: If increased risk of bladder cancer
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Tx of BPH
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)
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What are pathogens associated with Typical Pnemonia
Strep. Pneumoniae H.Influenza Kelbsiella Staph. Aureus
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What are pathogens associated with Atypical Pneumonia
Mycoplasma Chlamydia Legionella Viruses
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What do you see on X ray with Typical vs. Atypical Pneumonia
Typical: Lobular Atypical: Patchy infiltrates
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Sx of Typical vs. Atypical Pneumonia
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
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``` What does the color of sputum tell you about an organisms Rusty/Blood Tinges Currant Jelly Green Foul Smelling ```
Rusty/Blood Tinged: Strep. Pneumoniae Currant Jelly: Kelbsiella Green: H.Influenza, Pseudomonas Foul Smelling: Anaerobes
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Tx of Community Acquired Pneumonia | Outpatient vs. Inpatient vs. ICU
Outpatient: Clarithromycin/Azithromycin or Doxycycline Inpatient: Levafloxacin/Moxifloxacin/Gemifloxacin or Ceftriaxone/Cefotraxime/Unasyn + Azithromycin/Clarithromycin ICU: Ceftriaxone/Cefotraxime/Unasyn + Azithromycin/Clarithromycin
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Tx of Hospital Acquired Pneumonia
Cefepime/Imipenem/Zosyn/Piperacillin + Levafloxacin/Gatifloxacin/Moxifloxacin/Gemifloxacin
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What is Tuberculosis
Mycobacterium Tuberculosis leading to granuloma formation
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What is Primary TB
Initial infection | Patients are contagious
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What is Chronic/Latent TB
Patients have granuloma so TB is contained Not contagious PPD will be positive in 2-4 weeks after infection
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What is Secondary/Reactivation TB
Latent TB with waning immune defenses (HIV, elderly, steroid use, malignancy) Patients are contagious TB is seen in upper lobes with cavitary lesions
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Sx of TB
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
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With a PPD test what do the following values tell you about someone with TB >5 >10 >15
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
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Dx for TB
Acid-Fast smear and sputum culture for 3 days AFB Culture is gold standard CXR and PPD
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Tx of TB
``` First 2 months with RIPE Followed by 4 months of RI Rifampine Isoniazid Pyrazinamide Ethambutol ```
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What are the side effects of TB drugs
Rifampine: Thrombocytopenia, Orange colored secretions Isoniazid: Hepatitis, Peripheral Neuropathy Pyrazinamide: Hepatitis and Hyperuricemia, GI sx Ethambutol: Optic Neuritis, Peripheral neuropathy
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What is a PE
Thrombus in pulmonary artery or brnches
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Sx of PE
Dyspnea, Tachypnea, Pleuritic chest pain, Hemoptysis Post-op patient with sudden onset of tachypnea Syncope, Hypotension, Pulseless electrical activity
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Dx of PE Initial Gold Standard
``` 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 ```
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Tx of PE
Anticoagulation: Heparin, Warfarin for 3-6 months IVC Filter Thrombolysis with Alteplase (tPA) only if massive PE or hemodynamic compromise when anticoagulation is contraindicated
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What are prophylaxis for PE
Early Ambulation Elastic Stockings, Pneumatic Compression Devices/Venodyne Boots Low molecular weight Heparin if undergoing ortho or neurosurgery, trauma
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What are the 3 main components that should be addressed in the pre-operative cardiac risk assessment
1. Riks of major Cardiac Complication 2. Current Functional Status 3. Cariac Risk associated with Planned Procedure
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What is considered a major Cardiac Risk
MI within 6 months with persistent ischemic symptoms Decompensated CHF Significant Arrhythmias Severe Valvular Disease
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What is considered an Intermediate Cardiac Risk
``` MI >6 months Stable/Unstable Angina Decompensated prior to CHF DM Renal Insufficiency ```
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What is considered a Minor Cardiac Risk
``` Advanced Age Abnormal EKC Rhythm other than sinus (A.Fib) Poor Functional Capacity History of Stroke Uncontrolled HTN ```
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When are Beta-Blockers recommended prior to surgery
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
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What is considered a low Cardiac Risk Procedure
``` ABCDE-TURP Ambulatory Procedures Breast Procedures Cataract Procedures Dermatologic Procedures Endoscopic Procedures Trans-Urethral Resection of the Prostate ```
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What is considered an Intermediate Cardiac Risk Procedures
``` CHOPIN Carotid Endarterectomy Head Procedures Orthopedic Procedures Prostatectomy Intraperitoneal and Intrathoracic Procedures Neck Procedures ```
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What is considered a High Cardiac Risk Prcoedure
EVA Emergency Major Procedures Vascular Procedures Anticipated prolonged surgical procedures associated with large fluid shifts or blood loss
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What are risk factors for perioperative pulmonary complications
``` 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 ```
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How do you manage someone pre-operatively with DM who is on insulin vs. not on insulin
On insulin: Give insulin morning of surgery with glucose drip Not on insulin: Omit oral hypoglycemic the day before surgery
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How do you manage someone pre-operatively who uses Steroids
Continue Usual Dose
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Discuss ASA with regards to Perioperative Management
Continued for high risk vascular complications | Discontinued 7 days before surgery, resumed 24 hours after surgery
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Discuss Warfarin with regards to Perioperative Management
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
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Discuss Clopidogrel with regards to Perioperative Management
Stopped 7-10 days before surgery
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Discuss NSAIDS with regards to Perioperative Management
Stopped at least 3 days before surgery
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What is MET regarding pre-operative risk assessment
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
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What is considered MET >7
Excellent | Squash, jogging a 10 minute mile, scrubbing floors, singles tennis
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What is considered MET 4-7
Moderate | Cycling, Climbing a flight of stairs, Golf without a cart, Walking 4 mph, Yardwork
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What is considered MET
``` Poor Vacuuming Activities of Daily Living Walking 2 mph Writing ```
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What is Wound Dehiscence
Undesired spontaneous separation of wound edges
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What causes wound dehiscence
Infection and Excessively tight sutures
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What are risk factors for wound dehiscence
Host: Smoking, Malnutrition, Steroids, Infection, Hypoxia/Hypovolemia, Radiation, Trauma, Uremia, DM, Drugs, Advanced Age Operator: Tissue injury, Poor blood supply, Poor apposition of tissue
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What is 1st intention healing, 2nd intention healing, Delayed primary closure
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
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What are the steps involved in Wound Preparation
Debridement Foreign Body Removal Irrigation Disinfection
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``` When should sutures be removed for Face Scalp Trunk/Arm/Hand Leg/Foot ```
Face: 3-5 days Scalp: 5-7 das Trunk/Arm/Hand: 7-10 days Leg/Foot: 10-14 days
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What is an Abdominal Aortic Aneurysm
Focal dilation of aortic diameter at least 1.1.5x | >3.0cm is usually considered an aneurysm
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What are Risk Factors for developing an Aneurysm
Atherosclerosis Age >60yrs Smoking Hyperlipidemia, DM, Connective Tissue Disorder
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Sx of Abdominal Aortic Aneurysm
Asymptomatic until rupture usually Older male with severe back or abdominal pain who presents wit syncope or hypotensio Tender pulsatile abdominal mass
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Dx of Abdominal Aortic Aneurysm 1st test Gold Standard Others
Abdominal Ultrasound: 1st test, screnning and monitoring Angiography: Gold Standard CT Scan: choice for Thoracic Aneurysm MIR/MRA
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Tx of Abdominal Aortic Aneurysm
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
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What leads to DVT (Triad)
Stasis, Intimal Damage, Hypercoagulability | DVT thought to start at induction of anesthesia so need to prophylaxis treat
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What are Prophylaxis Options for DVT and what are risks
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
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What is Respiratory Acidosis
``` Anything that decreases respiration CNS depression, cardiopulmonary arrest, pneumonia Low pH High CO2 Normal HCO3 ```
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What do you see with Respiratory Alkalosis
High pH Normal/Low CO2 High HCO3
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What do you see with Metabolic Acidosis
Low pH Normal CO2 Low HCO3
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What do you see with Metabolic Alkalosis
High pH Normal CO2 High HCO3

Surgery (12 decks)

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