High Yield Flashcards
What is Heart Failure
The inability of the heart to pump sufficient blood to meet the metabolic demands of the body at normal filing pressures
What is the most common cause of Heart Failure
CAD
Sx of Left sided Heart Failure
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
Sx of Right sided Heart Failure
Increased systemic venous pressure, signs of fluid retention
Peripheral Edema, JVD, Anorexia, N/V, Hepatosplenomegaly
Dx of Heart Failure
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)
What are common medications used in long term management of Heart Failure
Ace-Inhibitors: 1st line tx for HF ARBs if Ace-I can't be tolerated Beta-Blockers Nitrates Diuretics: Most effective for sx
What are Heart Failure medications that decrease mortality
Ace-I, ARB, Beta-Blckers, Nitrates + Hydralazine, Spironolactone
When is an implantable cardioverter defibrillator used in patients with Heart Failure
When ejection fraction is
What are Ventricular Dysrhythmias
Ventricular dysrhythmias are frequently unstable and unpredictable
They are potentially lethal because stroke volume and coronary flow are compromised
Associated with weird QRS complexes
What is a premature ventricular complex (PVC)
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
Tx for Premature Ventricular Complrex
Usually none
What is Ventricular Tachycardia
> 3 consecutive PVC’s at a rate of >100bpm
What is a sustained Ventricular Tachycardia
Duration of >30 seconds
What is the danger with Ventricular Tachycardias
They can turn into Torsades de Pointes which can in turn become Ventricular Fibrillation (bad!)
Tx for Stable Sustained Ventricular Tachycardia
Anti-Arrhythmics (Amiodarone, Lidocaine, Procainamide)
Tx for Unstable Ventricular Tachycardia with a pulse
Synchronized (direct current) cardioversion (DCC)
TX for Vetricular Tachycardia with no pulse
Defibrillation/CPR (treat as V.Fib)
Tx for Torsades de Pointes
IV Magnesium
What is Ventricular Fibrillation
A rapid inadequate heart beat
Tx of V.Fib
CPR and Defibrillation
What is Pulseless Electrical Activity
Organized rhythm seen on monitor but the patient has no palpable pulse
Tx of Pulseless Electrial Activity
CPR, Epinephrine, check for shockable rhythm every 2 minutes
What is Asystole Rhythm
No rhythm seen on monitor and no pulse
Tx of Asystole
CPR, Epinephrine, check for shockable rhythm every 2 minutes
What is the most common cause of Peripheral Arterial Disease
Atherosclerotic disease of the lower extremities
Sx of Peripheral Artery Disease
Intermittent Claudication which is reproducible pain/discomfort in the extremity brought on by exercise/walking and relieved with rest
What does it mean when there is resting leg pain
Advanced Disease
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
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
What is Wet Gangrene
Ulcers: Malodorous, copious, purulent, infected, blackened rgions
What is Dry Gangrene
Mummification of digits of foot
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
Dx of Peripheral Arterial Disease
Gold Standard
Ankle Brachial Index: Normal is 1-1.2, positive if
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
What is a pneumothorax
Air within the pleural space
Increasingly positive pleural pressure causes collapse of the lung
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
What is a Traumatic Pneumothorax
CPR, Thoracentesis, Subclavian lines or trauma
What is a Tension Pneumothorax
Positive air pressure pushes the lungs, trachea and heart to the contralateral side
Sx of a Pneumothorax
Chest pain, usually pleuritic and unilateral, Dyspnea
Increased Hyperresonance, Decreased fremitus, Decreased breath sounds, unequal respiratory expansion, tachycardia, tachypnea, Hypotenion
Sx of a Tension Pneumothorax
Increased JVP and pulses paradoxus
Dx of Pneumothorax
CXR with expiratory view
Decreased peripheral lung markings
Deep Sulcus
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
what is an Aortic Dissection
Tear in the innermost layer of the aorta (intima)
Risk factors for Aortic Dissection
HTN, Age (50-60yrs), Vasculitis, traua, family hx, Collagen disorders (Marfans)
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
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
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
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
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
Tx for 3rd degree burns
Cover with sterile dressing to prevent infection with nonadherent gauze and elastic guaze
What type of reaction is Urticaria (Hives)/Angioedea
Type I Hypersensitivity reaction (IgE)
What are common triggers for Urticaria
Antigen from foods, meds, infections, insect bites, drugs, environmental
What is the pathophysiology behind Urticaria
Mast cells release histamine which cause vasodilation of venules and edema of dermis and sub-q tissues
Sx of Urticaria
Blanchable, edematous pink papules, wheals or plaque
Sx of Angioedema
Painless, deeper form of urticaria affecting lips, tongue, eyelids, hands feet and genitals
Anaphylaxis may occur
Tx of Urticaria/Angioedema
Oral Antihistamines
Eliminate cause
H2 blockers
Corticosteroids
What is the clinical use of Anti-Thyroglobulin
Used to diagnose Hashimoto’s in Hypothyroidism
Used to diagnose Autoimmune Thyroiditis
Sx of Hypothyroidism
Decreased basic metabolic rate Cold Intolerance Weight gain Goiter Fatigue, Sluggishness, memory loss radycardia, Decreased CO Menorrhagia
What is Hashimotos
Autoimmune
Hypothyroidism
Dx of Hashimotos
Thyroglobulin antibodies present
Tx of Hashimotos
Levothyroxine
What are the 4 types of Thyroid Cancers
Least aggressive to most aggressive
Papillary
Follicular
Medullary
Anaplastic
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
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
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
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
What is Hyperparathyroidism
Excess PTH production
Usually associated with MEN 1
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
Sx of Primary Hyperparathyroidism
Signs of Hypercalcemia: Stones, Bones, Groans, and psychic Moans, Decreased DTR
Dx of Hyperparathyroidism
Hypercalcemia + Increased PTH + Decreased Phosphate
Increased 24 hour urine calcium excretion
Tx of Primary Hyperparathyroidism
Surgery: Parathyroidectomy
Tx of Secondary Hyperparathyroidism
Vitamin D and Calcium Supplement
What is Hypoparathyroidism
Low PTH or insensitivity to its action
What are 2 most common causes of Hypoparathyroidism
Accidental damage/removal during neck/thyroid surgery
Autoimmune destruction of parathyroid gland
Sx of Hypoparathyroidism
Signs of Hypocalcemia: Carpopedal Spasms, Trousseau and Chvostek Sign, Perioral Parasthesias, Increased DTR
Dx of Hypoparathyroidism
Hypocalcemia + Decreased PTH + Increased Phosphate
Tx of Hypoparathyroidism
Calcium Supplement and Vitamin D (Ergocalciferol or Calcitriol)
What is a Pheochromocytoma
Catecholamine secreting adrenal hormone
Secretes Norepinephrine and Epinephrine autonomously and intermittently
What are triggers for release of catecholamines from e Pheochromoctyoma
Surgery, exercise, pregnancy, meds (TCA, Opiates, metoclopramide, glucagon, Histamine)
Sx of Pheochromocytoma
HTN
Palpitations, Headaches, Excessive Sweating
Chest or abdominal pain, weakness, fatigue, weight loss
Dx of a Pheochromocytoma
24 hour urine catecholamines including metabolites: Metanephrine and Vanillylmandelic Acid
MRI or CT to find adrenal tumor
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
What is Chronic Adrenocortical Insufficiency
Disorder where adrenal gland does not produce enough hormones
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
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
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
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
Tx of Adrenocortical Insufficiency
Hormone Replacement
Primary: Replace both Glucocorticoids (Hydrocortisone) and Mineralocorticoids (Fludrocortisone)
Secondary: Replace only Glucocorticoids
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
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)
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
Sx of Addisons Crisis
Shock, decreased blood pressure
Hypotension, Hypovolemia
Abdominal pain, N/V, fever, weakness, lethargy, coma
Dx of Addisons Crisis
Hyponatremia, Hyperkalemia, Hypoglycemia
Cortisol levels, ACTH levels, CBC
Tx of Addisons Crisis
IV Fluids to correct Hypotension and Hypovolemia
Glucocorticoids
Reversal of electrolyte abnormalities
Fludrocortisone (Florinef)
What is Cholecystitis
Cystic duct obstruction usually by gallstone which leads to inflammation/infection
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)
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
Tx of Cholecystitis
Conservative: NPO, IVF, Abx (cephalosporin + Metronidazole)
Cholecystectomy within 72 hours
What is fecal impaction
Severe impaction of stool in rectal vault which can result in obstruction to fecal flow and large bowel obstruction
What are predisposing factors of fecal impaction
Medications (Opioids) Severe psychiatric disease Prolonged bed rest Nerogenic disorders of colon Spinal cord disorders
Sx of Fecal Impaction
Anorexia N/V Abdominal Pain Distention DRE will have palpable firm feces
Tx of Fecal Impaction
Enemas: Saline, Mineral Oil
Digital Disruption
Improved care with stool softeners, increased fiber in diet and increased water intake
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
What is the most common site for Intussusception
Ileocolic Junction
What are lead points for Intussusception
Meckel Diverticulum Enlarged Mesenteric Lymph Node Hyperplasia of Payer's Patches Tumors Foreign Body
Sx of Intussusception
Vomiting, Abdominal Pain, Passage of blood per rectum (Currant jelly stools)
Pain is colicky
Sausage shaped mass in RUQ
Dx of Intussusception
Barium Contrast Enema
Xray
CT in adults
Tx of Intussusception
Barium or air insufflation enema
Surgery if refractory
What is Diverticulitis
Inflamed diverticula secondary to obstruction or infection (fecalith)
Leads to distention
Sx of Diverticulitis
Fever, LLQ pain
N/V, Diarrhea, Constipation, Flatulence and Bloating
Dx of Diverticulitis
CT
Increased WBC
Positive Guaiac
Tx of Diverticulitis
Clear liquid diet, broad spectrum abx (Cipro or Bactrim) + Metronidazole
What is Peptic Ulcer Disease
Imbalance of mucosal protective factors and damaging factors lead to ulcers in duodenum or stomach
What are causes of PUD
H.Pylori
NSAIDS
Zollinger Ellison Syndrome
Sx of PUD
Dyspepsia Epigastric pain Gastric: pain worse with meals Duodenal: pain worse 2-3 hours after meal Upper GI Bleeding
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
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
What is Meckel’s Diverticulum
Ileal Diverticulum
Persistent portion of embryonic vitteline duct (yolk stalk)
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
Sx of Meckel’s Diverticulum
Usually Asymptomatic
Painless rectal bleeding or ulceration if ectopic gastric tissue
Dx of Meckel’s Diverticulum
Physically look during laparoscopic procedure
Tx of Meckel’s Diverticulum
Excision if symptomatic
What is Pyloric Stenosis
Hypertrophy and Hyperplasia of the muscular layers of pylorus which can cause obstrucion
Common in babies
Sx of Pyloric Stenosis
Non-Bilious projectile vomiting
Dehydration, Malnutrtion, jaundice, metabolic alkalosis
Olive-Shaped mass right of umbilicus
Dx of Pyloric Stenosis
Ultrasound
Upper GI series shows String Sign
Tx of Pyloric Stenosis
Pyloromyotomy
Rehydration
What is Crohn’s Disease
Inflammatory Bowel Disease
Affects any segment of the GI from mouth to anus
Where is the most common location of Crohn’s Disease
Terminal ileum, RLQ pain
What is the depth and what do you see on colonoscopy
Transmural
Skip Lesins with cobblestone appearance
Sx of Crohn’s Disease
RLQ pain, weight loss
Diarrhea WITHOUT visible blood
What is a common marker for Crohn’s Disease
ASCA
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
Tx of Crohn’s Disease
Aminosalicylates (Sulfasalazine, Mesalamine)
Corticosteroids
Immune Modifying Agents (6-Mercaptopurine, Aathioprine, Methotraxate, Anti-TNF agents)
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
What causes Acute Mesenteric Ischemia
Occlusion such as an embolus or thrombus
Shock
Sx of Acute Mesenteric Ischemia
Severe abdominal pain that is out of proportion to physical findings
Poorly localized pain, N/V, diarrhea
Dx of Acute Mesenteric Ischemia
Definitive
Others
Labs
Angiogram is definitive
Colonoscopy see patchy necrotic areas
Increased WBC, Lactic Acidosis
Tx of Acute Mesenteric Ischemia
Revascularization via angioplasty with stenting or bypassing
Surgical resection if bowel is not salvagable
What are common causes of Acute Pancreatitis
Alcohol and gallstones
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
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)
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
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
What is an Anal Abscess
Results from bacterial infection of anal ducts/glands
What are common pathogens involved in Anal Abscess
Staph. Auerues, E.Coli, BActeroids, Proteus, Streptococcus
Where is an Anal Abscess typically seen
Posterior rectal wall
Sx of Anal Abscess
Throbbing rectal pain worse with sitting, coughing, or defecation
Tx of Anal Abscess
Incision and Drainage
NO abx
What is a Anal Fissure
Painful linear tear in the distal anal canal
Where is an Anal Fissure usually seen
Posterior Midline
What can cause Anal Fissure
Low fiber diet
Passage of large, hard stools
Anal Trauma
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
Tx of Anal Fissures
Most resolve spontaneously
Conservative: Sitz baths, high fiber diet, increased water intake, stool softeners,laxatives,mineral oil
What is a Small Bowel Obstruction
Post-surgical adhesions are the most common cause
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
Dx of SBO
Abdominal Xray: See air-fluid levels, Dilated bowel loops
Tx of SBO
NPO, bowel rest, IV fluids
NG tube
Surgery if strangulated
What is Pancreatic Cancer
Alcohol, DM, smoking, Obesity are all risk factors
Most have Mets by dx
What are the types of Pancreatic Cancer
Adenocarcinoma is most common
Ampullary and Duodenal
Cystoadenoma and Cystocarcinoma
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
Dx of Pancreatic Cancer
CT scan is test of choice
Increased CEA, CA-19-9
Tx of Pancreatic Cancer
Tail
Advanced
Whipple
If in tail: resect
Advanced: ERCP with stent
What is GERD
Transient relaxation of the LES leads to reflux and esophageal mucosal injury
What is concerning about GERD
Can lead to Barrett’s Esophagus which is precursor to cancer
Sx of GERD
Alarm sx
Heartburn, Retrosternal chest pain, Postprandial chest pain
Regurgitation, dysphagia, cough at night
Alarm: Dysphagia, odynophagia, weight loss, bleeding
Dx of GERD
Gold Standard
Others
Clinical
Endoscopy
Esophageal Manometry will show decreased LES pressure
24 hour pH monitoring is gold standard
Tx of GERD
Lifestyle modifications
H2 receptor antagonistsPPI in severe
Nissen if refractory
What is Gastric Cancer
Adenocarcinoma is most common
Risk factors for Gastric Cancer
H.Pylori
Salted, cured, smoked, pickled food that contain Nitrites
Alcohol
Sx of Gastric Cancer
Indigestion, weight loss, early satiety, abdominal pain/fullness
N/V, dysphagia, melena, hematemesis
Superaclavicular lymph node swelling
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
Tx of Gastric Cancer
Gastrectomy
Chemo, Radiation
Poor prognosis
What is a Condylomata Acuminata (warts in anus)
Can lead to anorectal sx
Caused by HPV
Risk factors for Condylomata Acuminata
Homosexual men
HIV positive adults
Where are Condylomata Acuminata typically seen
Perianal skin and extend within the anal canal up to 2 cm above dentate line
Sx of Condylomata Acuminata
Asymptomatic
Itching, Bleeding, Pain
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
Sx of Condylomata Acuminata
Painless, papules that evolve into soft, fleshy cauliflower like lesions
Tx of Condyloma Acuminata
Chemical, Salicylic Acid, Cryotherapy, Laser, and Podophyllin
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
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)
Dx of Hodgkin’s Lymphoma
Mona marrow Biopsy showing Reed Sternberg Cells
Mediastinal lymphadenopathy, pet/CT scan for staging
Tx of Hodgkin’s Lymphoma
Radiation therapy and Chemo
Very curable!
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
Sx of vWF Disease
Bleeding, especially mucous membranes
Epistaxis, gums, GI, Menorrhagia
Petechia
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
Tx of vWF Disease
Mild: None
Moderate: DDAVP (Desmopressin)
Severe: Cryoprecipitate (has Factor 8, fibrinogen and vWF)
What is Hemophilia A
Deficiency in Factor 8 which is important for clotting cascade
Inability to form hematomas
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
Dx of Hemophilia A
Low Factor 8
Prolonged PTT, mixing study corrects PTT
Normal Platelet levels
Tx of Hemophilia A
Factor 8 infusion
Desmopressin (increases vWF and Factor 8)
What is Hemophilia B
Deficiency in Factor 9
Almost exclusively in males
Sx of Hemophilia B
Deep tissue bleeding
Hemarthrosis
Excessive hemorrhage
Dx of Hemophilia B
Decreased Factor 9
Prolonged PTT, mixing study corrects PTT
Tx of Hemophilia B
Factor 9 Infusion
No desmopressin because it only increased Factor 8 and vWF
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
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
Sx of Disseminated Intravascular Coagulation
Bleeding typically with catheters or incisions
Progressive
Dx of Disseminated Intravascular Coagulation
Thrombocytopenia, prolonged PTT and PT
D-Dimer is elevated
Tx of Disseminated Intravascular Coagulation
Tx underlying disorder
Blood products if significant hemorrhage occurs
Low dose Heparin
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
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)
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
Tx of TIA
ASA and Plavix
NO Thrombolytics
Place supine to increase cerebral perfusion
Reduce modifiable risk factors such as DM, HTN, A.Fib
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
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
What is a Cerebral Infarction
Thrombotic or embolic occlusion of a major vessel leading to cerebral infarction
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
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
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
Dx of a Stroke
CT without contrast (want to look for hemorrhage)
Do this before administering ASA or antithrombotic agents
Tx of Stroke
If Lacunar: ASA, control risk factors
If major circulation: Thrombolytic therapy (rTPA, Alteplase) within 3 hours of onset of sx
What is Bell’s Palsy
Idiopathic facial paresis
Unilateral Facial Nerve Involvement
What causes Bell’s Palsy
Idiopathic but strongly associated with HSV reactivation, VZV, Lyme Disease
Risk factors for Bell’s Palsy
DM, Pregnancy, Post URI
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
Dx of Bell’s Palsy
Clinical
Tx of Bell’s Palsy
Prednisone
Artificial Tears
What is Testicular Cancer
Most common solid tumor in young men
What are risk factors for Testicular Cancer
Cryptochidism, Caucasians
What are the types of Testicular Cancer
Germinal Cell Tumors: Seminoma, Non-seminoma (embryonal cell carcinoma, teratoma, choriocarcnioma)
Non-Germinal Cell: Leydig, Sertoli, Gonadoblastoma
Sx of Testicular Cancer
Painless testicular nodule, solid mass or enlargemet
Hydrocele may be present
Gynecomastia may be present
Dx of Testicular Cancer
Scrotal Ultrasound
Alpha-Fetoprotein, HcG, LDH
What are imaging and lab features of Seminomatous Germ Cell Tumors
Radiosensitive
NO tumor markers
Seminomas are Sensitive and Simple
What are imaging and lab features for Non-Seminomatous Germ Cell Tumors
Increased Alpha-Fetoprotein, Increased HcG
Radioresistant
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
What is Benign Prostatic Hypertrophy
Porstate Hyperpasia of the periurethral/transitional zone
Leads to bladder outlet obstruction
Sx of BPH
Frequency, Urgency, Nocturia, Hesitancy, Weak/Intermittent Stream force, Incomplete Emptying, and Incontinence
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
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)
What are pathogens associated with Typical Pnemonia
Strep. Pneumoniae
H.Influenza
Kelbsiella
Staph. Aureus
What are pathogens associated with Atypical Pneumonia
Mycoplasma
Chlamydia
Legionella
Viruses
What do you see on X ray with Typical vs. Atypical Pneumonia
Typical: Lobular
Atypical: Patchy infiltrates
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
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
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
Tx of Hospital Acquired Pneumonia
Cefepime/Imipenem/Zosyn/Piperacillin + Levafloxacin/Gatifloxacin/Moxifloxacin/Gemifloxacin
What is Tuberculosis
Mycobacterium Tuberculosis leading to granuloma formation
What is Primary TB
Initial infection
Patients are contagious
What is Chronic/Latent TB
Patients have granuloma so TB is contained
Not contagious
PPD will be positive in 2-4 weeks after infection
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
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
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
Dx for TB
Acid-Fast smear and sputum culture for 3 days
AFB Culture is gold standard
CXR and PPD
Tx of TB
First 2 months with RIPE Followed by 4 months of RI Rifampine Isoniazid Pyrazinamide Ethambutol
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
What is a PE
Thrombus in pulmonary artery or brnches
Sx of PE
Dyspnea, Tachypnea, Pleuritic chest pain, Hemoptysis
Post-op patient with sudden onset of tachypnea
Syncope, Hypotension, Pulseless electrical activity
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
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
What are prophylaxis for PE
Early Ambulation
Elastic Stockings, Pneumatic Compression Devices/Venodyne Boots
Low molecular weight Heparin if undergoing ortho or neurosurgery, trauma
What are the 3 main components that should be addressed in the pre-operative cardiac risk assessment
- Riks of major Cardiac Complication
- Current Functional Status
- Cariac Risk associated with Planned Procedure
What is considered a major Cardiac Risk
MI within 6 months with persistent ischemic symptoms
Decompensated CHF
Significant Arrhythmias
Severe Valvular Disease
What is considered an Intermediate Cardiac Risk
MI >6 months Stable/Unstable Angina Decompensated prior to CHF DM Renal Insufficiency
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
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
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
What is considered an Intermediate Cardiac Risk Procedures
CHOPIN Carotid Endarterectomy Head Procedures Orthopedic Procedures Prostatectomy Intraperitoneal and Intrathoracic Procedures Neck Procedures
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
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
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
How do you manage someone pre-operatively who uses Steroids
Continue Usual Dose
Discuss ASA with regards to Perioperative Management
Continued for high risk vascular complications
Discontinued 7 days before surgery, resumed 24 hours after surgery
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
Discuss Clopidogrel with regards to Perioperative Management
Stopped 7-10 days before surgery
Discuss NSAIDS with regards to Perioperative Management
Stopped at least 3 days before surgery
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
What is considered MET >7
Excellent
Squash, jogging a 10 minute mile, scrubbing floors, singles tennis
What is considered MET 4-7
Moderate
Cycling, Climbing a flight of stairs, Golf without a cart, Walking 4 mph, Yardwork
What is considered MET
Poor Vacuuming Activities of Daily Living Walking 2 mph Writing
What is Wound Dehiscence
Undesired spontaneous separation of wound edges
What causes wound dehiscence
Infection and Excessively tight sutures
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
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
What are the steps involved in Wound Preparation
Debridement
Foreign Body Removal
Irrigation
Disinfection
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
What is an Abdominal Aortic Aneurysm
Focal dilation of aortic diameter at least 1.1.5x
>3.0cm is usually considered an aneurysm
What are Risk Factors for developing an Aneurysm
Atherosclerosis
Age >60yrs
Smoking
Hyperlipidemia, DM, Connective Tissue Disorder
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
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
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
What leads to DVT (Triad)
Stasis, Intimal Damage, Hypercoagulability
DVT thought to start at induction of anesthesia so need to prophylaxis treat
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
What is Respiratory Acidosis
Anything that decreases respiration CNS depression, cardiopulmonary arrest, pneumonia Low pH High CO2 Normal HCO3
What do you see with Respiratory Alkalosis
High pH
Normal/Low CO2
High HCO3
What do you see with Metabolic Acidosis
Low pH
Normal CO2
Low HCO3
What do you see with Metabolic Alkalosis
High pH
Normal CO2
High HCO3
