High Yield PDF Flashcards
What are absolute contraindications to surgery?
Diabetic coma, DKA
What are relative contraindications to surgery?
Poor nutrition, Sever liver failure, Smoking
What are signs of poor nutrition?
Albumin less than 3
Transferrin less than 200
Weight loss of 20% or more
What are signs of severe liver failure?
Bili greater than 2
PT greater than 16
Ammonia greater than 150 or encephalopathy
How long must a smoker abstain before a surgery?
8 weeks
What special management must CO2 retainers receive?
Limit O2 supplementation during post op. Chronic CO2 retainers rely on O2 levels for respiratory drive, and supplemental O2 may decrease their respiratory drive.
What does Goldman’s index tell you?
Assesses which patients are at greatest risk during surgery
What are the components of Goldman’s index?
1 - CHF EF less than 35% = no surgery
2 - MI w/in 6 mo EKG then stress test then cath lab then revasc
3 - Arrhythmia
4 - Old age (above 70)
5 - Emergent surgery
6 - Aortic stenosis, poor medical condition, surgery in chest/abdomen
Describe what physical exam signs that are present in aortic stenosis
Late systolic, crescendo-decrescendo murmur, radiates to carotids, increased with squatting/valsalva, decreased with decreased preload
What meds must be stopped prior to surgery?
NSAIDs (3-4 days before bc reversible), Aspirin, and Vit E (2 weeks before)
Warfarin 5 days before, use Vit K if necessary (INR less than 1.5)
What changes should diabetic patients make to their insulin before surgery?
Use 1/2 the normal morning dose
What should be done for patients with CKD on dialysis?
Dialyze 24 hours pre-op
Why are BUN and Creatinine important for surgical patients?
BUN greater than 100 may lead to uremic platelet dysfunction and increase bleeding.
If BUN is greater than 100, what would be seen on the coagulation panel?
Normal platelets
Prolonged bleeding time
What is assist-control in ventilation settings?
set tidal volume and rate but if pt takes a breath, vent gives the volume.
What is pressure support in ventilation settings?
pt rules rate but a boost of pressure is given (8-20).
Important for weening off vent
What does CPAP do?
pt must breathe on own but positive pressure given all the time.
How does PEEP work and how is it different from CPAP?
pressure given at the end of cycle to keep alveoli open (5-20).
Name two conditions PEEP is used in
CHF and ARDS
With a patient on a vent, what is the best test to evaluate management?
ABG
With a patient on a vent, what do you do if PaO2 is too low?
Increase FiO2
With a patient on a vent, what do you do if PaO2 is too high?
Decrease FiO2
With a patient on a vent, what do you do if PaCO2 is too low (i.e. pH is high)?
Decrease rate or tidal volume
With a patient on a vent, what do you do if PaCO2 is too high (i.e. pH is low)
Increase rate or tidal volume
If you have to adjust vent settings to increase or decrease PaCO2/pH, which setting is more efficient to change?
Tidal volume is more efficient. Dead space is a fixed volume and small decreases in TV have amplified effects at the alveoli
What are the HCO3 and pCO2 patterns for metabolic acidosis? For respiratory acidosis?
Metabolic: HCO3 low, pCO2 low (not producing HCO3, breathing off pCO2)
Respiratory: HCO3 high, pCO2 high (not breathing off pCO2, increased HCO3)
If a patient is acidotic, what are the next two steps?
First: Check HCO3 and pCO2 to determine resp vs met acidosis.
Second: Check anion gap (Na - (Cl + HCO3)) nl 8-12, increased = MUDPILES; nl = Diarrhea, diuretics, renal tubule acidosis
What does MUDPILES stand for?
Methanol Uremia DKA Propylene glycol/Paracetamol/ Isoniazid, Iron, Inborn errors of metabolism Lactate Ethylene glycol Salicylates
What are the HCO3 and pCO2 patterns for metabolic alkalosis? For respiratory alkalosis?
Metabolic: HCO3 high, pCO2 high (Kidney’s overproduce HCO3, respiratory compensation raises pCO2)
Respiratory: HCO3 low, pCO2 low (Respiration blows off pCO2, compensation is low HCO3)
If a patient is alkalotic, what are the next two steps?
First: determine respiratory vs metabolic: check HCO3 and pCO2
Next: Check urine Cl to help determine cause
What conditions does the urine [Cl] indicate in metabolic alkalosis?
Urine [Cl] less than 20: Decreased body Cl 2/2 Vomiting, nasogastric tube, diuretics, etc
Urine [Cl] greater than 20: Normal body chloride or “Chloride Resistant” - Conn’s, Bartter’s, Gittleman’s
What does a low [Na+] indicate?
Gain of water
What are the first steps after finding low [Na+]?
First check osmolality
Next check volume status
What conditions are found with high volume and low [Na+]?
Hypervolemic hyponatremia
CHF, Cirrhosis, Nephrotic syndrome
Low osmotic pressure = extra volume in the ECF, low circulating volume = increased ADH = inc water retention
What conditions are found with low volume and low [Na+]?
Hypovolemic hyponatremia
Vomiting, diarrhea, diuretics
Mechanisms lead to volume depletion = increased ADH = water retention with no Na+
What conditions are found with normal volume and low [Na+]?
Euvolemic hyponatremia
SIADH, Addison’s, hypothyroid
Excess ADH = excess water, but no third spacing limits total volume to normal range
How do you treat hypervolemic hyponatremia?
Fluid restrictions and diuretics, as in euvolemic. Ultimate cure relies on fixing the underlying condition (CHF, cirrhosis, nephrotic syndrome)
How do you treat hypovolemic hyponatremia?
Normal saline infusion, SLOWLY restore nl [Na+] due to risk of central pontine myolinolysis
When do you use 3% saline solution in hyponatremia?
Only when patients are symptomatic, esp. Seizures. [Na+] usually less than 110. Risk of central pontine myolinolysis.
What does an increase in [Na+] indicate?
Loss of water
How do you treat hypernatremia? What complications may occur in treatment?
Replace with D5 or hypotonic fluids.
Risk of cerebral edema
What do numbness, Chvostek sign, Trousseau sign, or prolonged QT indicate?
Hypocalcemia
What does bones, stones, groans, psychiatric overtones, or short QT indicate?
Hypercalcemia
What do paralysis, ileus, ST depression, or U waves indicate? How do you treat it?
Hypokalemia
Give K+, max 40 mEq/hr
What do peaked T waves, prolonged PR and QRS, and sine waves indicate? How do you treat it?
Hyperkalemia
Give Ca-gluconate, then insulin and glucose, kayexalate, albuterol, and sodium bicarb.
Last resort = dialysis
For maintenance fluids: what fluids are used and in what quantities?
Fluids: D5 1/2NS + 20KCl (if peeing) Volume: First 10 kgs = 100 mL/kg/day Next 10 kgs = 50 mL/kg/day All above 20 kgs = 20 mL/kg/day
What type of feeding is best and when should other types be used?
Enteral feeding is best: preserves gut mucosa, prevents bacterial translocation
TPN can be used if the gut can’t absorb nutrients due to functional or physical loss.
What risks are associated with TPN?
Acalculus cholecystitis, hyperglycemia, liver dysfunction, zinc deficiency, electrolyte problems
What is the treatment for circumferential burns?
Escharotomy. The burned tissue loses its elasticity, and may constrict underlying tissues when they are rehydrated, cutting circulation to the distal tissues.
What to consider if singed nose hairs, wheezing, soot in mouth/nose?
Intubation. Higher likelihood of respiratory burns
What is the best test for a patient with confusion, headache, and/or cherry red skin? Treatment?
Check carboxy hemoglobin, PULSE OX IS WORTHLESS!!
Treatment: 100% O2, Hyperbaric chamber if CO-Hb very high
Blood clots in the elderly?
Ddx: Cancer
Blood clots with edema, HTN, and foamy pee?
Ddx: Nephrotic syndrome
Blood clots in a young person (esp with +family history)
Ddx: Factor V leiden
What is special about clotting disorders with ATIII deficiency?
Heparin won’t work.
Binds and activates ATIII, which inactivates thrombin and factor Xa, and others.
What should you suspect in a young woman with multiple spontaneous abortions?
Lupus anticoagulant
What should you suspect in a post op patient with decreased platelets and clotting? Treatment?
HIT!! (If heparin was given within 5-14 days)
Leparudin or Agatroban
Patient with an isolated decrease in platelets?
ITP
Idiopathic Thrombocytopenia Purpura
Normal platelets but increased bleeding time & PTT?
von Willibrands Disease
Low platelets, Increased PT, PTT, BT, low fibrinogen, high D-Dimer and schistocytes?
DIC!! Caused by gram –sepsis, carcinomatosis, OB stuff
What type of abx should be given to burn victims?
NO PO or IV abx. Give topical.
What abx doesn’t penetrate eschar and can cause leukopenia?
Silver sulfadiazine
What abx penetrates eschar but hurts like hell?
Mafenide
What abx doesn’t penetrate escharand causes hypoK and HypoNa?
Silver Nitrate
Chemical burn, what to do?
Irrigate more than 30min prior to ER
Electrical Burn, best 1st step? If abnormal?
EKG!
48 hours of telemetry (also if LOC)
Burns: If urine dipstick + for blood but microscopic exam is negative for RBCs? Then what do you check?
Myoglobinuria = ATN
K+! (When cells break)
Burns: If affected extremity is extremely tender, numb, white, cold with barely dopplerable pulses? Criteria? Treatment?
Compartment syndrome!!
Criteria: 5 Ps or compartment pressure above 30mmHg
Treatment: May require fasciotomy. (at bedside!)
If trauma patient comes in unconscious?
Intubate
If GCS < 8?
Intubate
If guy stung by a bee, developing stridor and tripod posturing?
Intubate
If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck?
Intubate
If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues?
fiberoptic broncoscope
If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7?
cricothyroidotomy
So you intubated your patient… next best step?
Check bilateral breath sounds
Intubated patient with dec breath sounds on the left? What to do? Next step?
Means you intubated the right mainstream bronchus
Pull back your ET tube
Check pulse ox, keep it above 90%
A patient has inward mvmtof the right ribcage upon inspiration.
–Dx?
–Tx?
Dx: Flail chest. More than 3 consec rib fractures
Tx: O2 and pain control.
A patient has confusion, petechial rash in chest, axilla and neck and acute SOB.
–Dx?
–When to suspect it?
Dx: Fat embolism
When: After long bone fx (esp femur)
A patient dies suddenly after a 3rdyear medical student removes a central line.
–Dx?
–When else to suspect it?
Dx: Air embolism
When: Lung trauma, vent use, during heart vessel surgery.
What to worry about if a patient is hypotensive, tachycardic?
shock
What to worry about if a patient has flat neck veins and normal CVP? Next best step?
Hypovolemic/Hemorrhagic
2 large bore periph IV-2L NS or LR over 20min followed by blood.
If muffled heart sounds, JVD, electrical alternans, pulsus paradoxes? Confirmatory test? Treatment?
Pericardial Tamponade
Confirmatory Test: FAST scan
Treatment: Needle decompression, pericardial window or median sternotomy
What to worry about if dec breathing sounds on one side, tracheal deviation AWAY from collapsed lung? Next best step?
Tension pneumothorax
Next step:
Needle decompression, followed by a chest tube.
DON’T do a CXR!!!
What are the three categories of the GCS and how many points are in each?
Eyes 4
Verbal 5
Motor 6
Patient presents with headache, vomiting, altered mental status. What is the ddx?
Cranial mass: hematoma, edema, tumor
Patient presents with headache, vomiting, altered mental status. What is the treatment?
Elevate HOB,
hyperventilate to pCO2 28-32,
give mannitol (watch renal fxn)
Patient presents with headache, vomiting, altered mental status. What surgical treatment may be performed?
Ventriculostomy
Patient with penetrating neck trauma. Where is region 3 and how do you work up the injury?
Region 3 is above the angle of the mandible
Workup includes aortography and triple endoscopy
Patient with penetrating neck trauma. Where is region 2 and how do you work up the injury?
Region 2 is from the cricoid to the angle of mandible.
Workup includes 2D doppler +/- exploratory surgery.
Patient with penetrating neck trauma. Where is region 1 and how do you work up the injury?
Region 1 is below the cricoid
Workup includes aortography
Surgery for patient with GSW to the abdomen?
Exploratory laparotomy plus tetanus prophylaxis
Penetrating Abdominal Trauma: If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration?
Exploratory laparotomy (plus tetanus prophylaxis)
Penetrating Abdominal Trauma: If stab wound but pt is stable?
FAST exam.
Diagnostic Peritoneal Lavage if FAST is equivocal.
Ex-lap if either are positive.
Penetrating Abdominal Trauma: If blunt abdominal trauma pt with hypotension/tachycardia?
Ex-lap.
Blunt Abdominal Trauma: If patient is stable? If unstable?
Abdominal CT
Ex-lap.
Blunt Abdominal Trauma: If lower rib fx plus bleeding into abdomen?
Spleen or liver lac.
Blunt Abdominal Trauma: If lower rib fx plus hematuria?
Kidney lac.
Blunt Abdominal Trauma: If Kehr sign & viscera in thorax on CXR?
Diaphragm rupture.
Blunt Abdominal Trauma: If handlebar sign
Pancreatic rupture.
Blunt Abdominal Trauma: If stable w/ epigastric pain:
•Best test?
•If retroperitoneal fluid is found?
Test: Abdominal CT.
Fluid found: Consider duodenal rupture.
Pelvic Trauma: First steps if hypotensive, tachycardic
FAST and DPL to r/o bleeding in abdominal cavity.
Pelvic Trauma: Treatment for bleeding into pelvis?
stop bleeding by fixing fracture
internal if stable
external if not
Pelvic Trauma: What to consider if blood at the urethral meatus and a high riding prostate? Next best test? If normal?
Consider pelvic fracture w/ urethral or bladder injury.
Retrograde urethrogram (NOT FOLEY!)
Retrograde cystogram to evaluate bladder
Pelvic Trauma: What are you looking for in a retrograde cystogram to evaluate bladder?
Check for extravasation of dye. Take 2 views to ID trigone injury.
Pelvic Trauma: What treatments if a retrograde cystogram shows extraperitoneal extravasation? If intraperitoneal extravasation?
Extraperitoneal: Bed rest + foley
Intraperitoneal: Ex-lap and surgical repair
Ortho Trauma: Fractures that go to the OR
–Depressed skull fx
–Severely displaced or angulated fx
–Any open fx (sticking out bone needs cleaning)
–Femoral neck or intertrochanteric fx
Common Ortho Trauma: Shoulder pain s/p seizure or electrical shock
Posterior shoulder dislocation
Common Ortho Trauma: Arm outwardly rotated, & numbness over deltoid
Anterior shoulder dislocation
Common Ortho Trauma: old lady FOOSH, distal radius displaced.
Colle’s fracture
Common Ortho Trauma: young person FOOSH, anatomic snuff box tender.
Scaphoid fracture
Common Ortho Trauma: “I swear I just punched a wall…”
Metacarpal neck fracture “Boxer’s fracture”. May need K wire
Common Ortho Trauma: Clavicle most commonly broken where?
Between middle and distal 1/3s. Need figure of 8 device
Fever on POD #1: Most common cause, low fever (<101) and non productive cough?
•Dx?
•Tx?
Atelectasis
Dx: CXR-see bilateral lower lobe fluffy infiltrates
Tx: Mobilization and incentive spirometry.
Fever on POD #1: High fever (to 104!!), very ill appearing.
•Pattern of spread?
•Common bugs?
•Tx?
Nec Fasc
Pattern: In subQ along Scarpa’s fascia.
Bugs: GABHS or clostridium perfringensIV PCN,
Tx: Go to OR and debride skin until it bleeds
Fever in surgery: High fever (above 104!!) muscle rigidity.
•Caused by?
•Genetic defect?
•Treatment?
Malignant Hyperthermia
Cause: Succ or Halothane
Genetic defect: Ryanodine receptor gene defect
Tx: Dantrolene Na (blockes RYR and decr intracellular calcium.
Fever on POD #3-5: Fever, productive cough, diaphoresis?
•Tx?
Pneumonia
Tx: Check sputum sample for culture, cover w/ moxi etc to cover strep pneumo in the mean time.
Fever on POD #3-5: Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley.
•Next best test?
•Tx?
UTI
Next step: UA (nitritie and LE) and culture.
Tx: Change foley and treat w/ wide-spec abx until culture returns.
Fever POD 7:With Pain & tenderness at IV site?
•Tx?
Central line infection
Tx: Do blood cx from the line. Pull it. Abx to cover staph.
Fever POD 7: With pain @ incision site, edema, induration but no drainage?
•Tx?
Cellulitis
Tx: Do blood cx and start antibiotics
Fever POD 7: With pain @ incision site, induration WITH drainage.
•Tx?
Simple Wound Infection
Tx: Open wound and repack. No abx necessary
Fever POD 7: With pain w/ salmon colored fluid from incision.
•Tx?
Dehiscence
Tx: Surgical emergency! Go to OR, IV abx, primary closure of fascia
Fever POD 7: Unexplained fever
•Dx?
•Tx?
Abdominal Abscess
Dx: CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
Tx: Drain it! Percutaneously, IR-guided, or surgically.
Fever POD 7: Random causes?
thyrotoxicosis, thrombophlebitis, adrenal insufficiency, lymphangitis, sepsis.
Pressure Ulcers: Cause?
Dx?
Prevention?
Impaired blood flow = ischemia
Dx: Don’t culture will just get skin flora. Check CBC and blood cultures. Can mean bacteremia or osteomyelitis.
–Can do tissue biopsy to rule out Marjolin’sulcer
Best prevention is turning q2hrs
Pressure Ulcers: Describe Stage 1. Stage 2. And treatment?
Stage 1 = skin intact but red. Blanches w/ pressure
Stage 2 = blister or break in the dermis
Tx: get special mattress, barrier protection
Pressure Ulcers: Describe Stage 3, Stage 4. And treatment?
Stage 3 = SubQ destruction into the muscle
Stage 4 = involvement of joint or bone.
Tx: get flap reconstruction surgery, Before surgery, albumen must be greater than 3.5 and bacterial load must be under 100K
How do you detect pleural effusions and what is the first step in treatment?
see fluid greater than 1cm in lateral decubitus position
thoracentesis!
What to suspect if analysis of pleural effusion shows transudate?
•If low pleural glucose?
•If high lymphocytes?
•If bloody?
Transudate: likely CHF, nephrotic, cirrhotic
Low glucose: Rheumatoid Arthritis
High lymphocytes: Tuburculosis
Bloody: Malignant or Pulmonary Embolus
What to suspect if analysis of pleural effusion shows exudate?
What is the treatment if it is complicated (+ gram or cx, pH less than 7.2, clc less than 60):
Likely parapneumonic, cancer, etc.
Complicated: Insert chest tube for drainage.
What is Light’s Criteria for transudate?
At least one of the following:
LDH less than 200
Effusion LDH/Serum LDH less than 0.6 (light LDH)
Effusion Protein/Serum Protein less than 0.5 (light protein)
What is the pathophysiology of Spontaneous Pneumothorax?
Who is suspect for one?
Sub-pleural bleb ruptures causing lung collapse.
–Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)
How do you diagnose and treat spontaneous PTX? What are the indications for surgery?
Dx: CXR
Tx: chest tube placement
Indications for surgery: Ipsilateral or contralateral recurrence, bilateral, incomplete lung expansion, pilot, scuba, live in remote area = VATS, pleurodesis(bleo, iodine or talc)
What is the usual cause of Lung Abscess? What are the most common involved lobes?
usually 2/2 aspiration (drunk, elderly, enteral feeds)
–Most often in post upper or sup lower lobes
Treatment for lung abscess?
What are the indications for surgery?
Tx: initially w/ abx (IV PCN or clindamycin)
Indications for surgery: abx failure,
abscess greater than 6cm, or if empyema is present.
Work up of a Solitary Lung Nodule:
1st step?
Find an old CXR to compare
Work up of a Solitary Lung Nodule:
Characteristics of benign nodules?
Treatment?
–Popcorn calcification = hamartoma(most common)
–Concentric calcification = old granuloma
–Pt under age 40, less than 3cm, well circumscribed
Tx: CXR or CT scans q2mo to look for growth
Work up of a Solitary Lung Nodule - Characteristics of malignant nodules? Treatment?
If pt has risk factors (smoker, old), If greater than 3cm, if eccentric calcification
Tx: Remove the nodule (w/ bronc if central, open lung biopsy if peripheral.)
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pna or lung collapse.
•MC cancer in non-smokers?
Adenocarcinoma. Occurs in scars of old pan
Adenocarcinoma: Location and mets?
Peripheral cancer. Mets to liver, bone, brain and adrenals
Adenocarcinoma: Characteristics of effusion?
Exudative with high hyaluronidase
Patient with kidney stones, constipation and malaise, low PTH + central lung mass?
Squamous cell carcinoma.
Paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca
Patient with shoulder pain, ptosis, constricted pupil, and facial edema. Syndrome and cancer?
Superior Sulcus Syndrome from Small cell carcinoma. Also a central cancer.
Patient with ptosis better after 1 minute of upward gaze?
Lambert Eaton Syndrome from small cell carcinoma. Ab to pre-syn Ca chan
Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD? Initial treatment?
SIADH from small cell carcinoma. Produces Euvolemic hyponatremia.
Fluid restrict and +/- 3% saline in those under Na+ 112
CXR showing peripheralcavitation and CT showing distant mets?
Large Cell Carcinoma
What is the pathophys of ARDS?
inflammation leading to impaired case xchange, inflammatory mediator release, and ultimately hypoxemia
What are the causes of ARDS?
Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis.
Diagnosis and Treatment of ARDS?
Dx: 1.) Ratio of PaO2:FiO2 less than 200 (less than 300 means acute lung injury)
2.) Bilateral alveolar infiltrates on CXR
3.) PCWP is less than 18 (means pulmonary edema is non-cardio)
Tx: Mechanical ventilation w/ PEEP
Murmur: Systolic Ejection Murmur cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardus
Aortic stenosis
Murmur: SEM louder w/ valsalva, softer w/ squatting or handgrip.
Hypertrophic Obstructive Cardiomyopathy
Murmur: Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting
Mitral Valve Prolapse
Murmur: Holosystolic murmur radiates to axilla w/ Left Atrial Enlargement
Mitral Regurgitation
Murmur: Holosystolic murmur w/ late diastolic rumble in kiddos
VSD
Murmur: Continuous machine like murmur
PDA
Murmur: Wide fixed and split S2
ASD
Murmur: Rumbling diastolic murmur with an opening snap, Left Atrial Enlargement and A-fib
Mitral stenosis
Murmur: Blowing diastolic murmur with widened pulse pressure and eponym parade.
Aortic Regurgitation
Patient with bad breath & snacks in
the AM? Tx?
Zenker’s diverticulum. False diverticulum. Only contains mucosa
Tx: surgery
Patient with dysphagia to liquids & solids. Tx? Other associated conditions?
Achalasia.
Tx w/ CCB, nitrates, botox, or heller myotomy
Assoc w/ Chagas dz and esophageal cancer.
Patient with dysphagia worse w/ hot & cold liquids + chest pain that feels like MI without regurgitation symptoms. Dx? Treatment?
Diffuse esphogeal spasm.
Tx w/ CCB or nitrates
Patient with epigastricc pain worse after eating or when laying down cough, wheeze, hoarse. Dx? Tx? Indications for surgery?
Dx: GERD. Most sensitive test is 24-hr pH monitoring. Do endoscopy if “danger signs” present.
Tx: Behavior modification 1st, then antacids, H2 block, PPI.
Indications for surgery: bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/ still sxs, or no want meds.
Patient with hematemesis (blood occurs after vomiting) w/ subQ emphysema. Can see pleural effusion, w/ ↑amylase. Dx? Next best test? Tx?
Boerhaave’s/Esophageal Rupture
Next step: CXR, gastrograffin esophagram. NO endoscopy
Tx: surgical repair if full thickness
If gross hematemesis unprovoked in a cirrhotic w/ pHTN. Dx? If patient is in hypovolemic shock? Tx of choice?
Gastric Varices
W/ hypovolemic shock: do ABCs, NG lavage, medical tx w/ octreotide or SS. Balloon tamponade only if you need to stablize for transport
Tx: Endoscopic sclerotherapy or banding *Don’t prophylactically band asymptomatic varices. Give BB
Patient with progressive dysphagia/wgt loss. Dx? Different subtypes and locations? Best 1st test?
Esophageal Carcinoma. Squamous cell in smoker/drinkers in the middle 1/3. Adeno in ppl with long standing GERD in the distal 1/3.
Test: Barium swallow, then endoscopy w/ bx, then staging CT.
Acid reflux pain after eating, when laying down? Types and descriptions?
Hiatal Hernia
Type 1: Sliding GE jxn herniates into thorax. Worse for GERD. Tx sxs.
Type 2: Paraesophageal. Abd pain, obstruction, strangulation needs surgery.
Abd pain worse w/ eating, NSAIDs. Dx?
Work up?
Surgery if?
Dx: Gastric Ulcers
Workup: Double-contrast barium swallow-punched out lesion w/ reg margins. EGD w/ bx can tell H. pylori, malign, benign.
Surgery if: Lesion persists after 12wks of treatment.
Most common Gastric Cancer?
Adenocarcinoma most common. Esp in Japan
What is Mentriers?
protein losing enteropathy, enlarged rugae.
How do Gastric Varices form?
splenic vein thrombosis
What is Dieulafoy’s?
a medical condition characterized by a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract.[1] It can cause gastric hemorrhage
Mid Epigastric pain better w/ eating. Dx? Most common cause?
Duodenal Ulcers
95% assoc w/ H. pylori
Duodenal Ulcers work up? Treatment?
W/u: blood, stool or breath test for H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer.
Treatment: PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.
Healthy patients under 45y/o can do trial of H2 block or PPI
What to suspect if mid Epigastric pain/ulcers don’t resolve? Best test?
Tx?
What else to look for?
ZE Syndrome
Test: Secretin Stim Test (find inapprop high gastrin)
Treatment: Surgical resection of pancreatic/duodenal tumor
Ddx: Pituitary and Parathyroid problems.
A patient has bilious vomiting and post-prandialpain. Recently lost 200lbs on “Biggest Loser”. Dx?
Pathophys?
Tx?
SMA Syndrome
Pathophys: 3rd part of duodenum compressed by AA and SMA
Tx: restore weight/nutrition. Can do Roux-en-Y
MEG pain straight through to the back. Dx?
Most common etiologies?
Workup?
Dx: Pancreatitis
Etiology: Gallstones & ETOH
W/u: Increased amylase & lipase. CT is best imaging test
Pancreatitis: Tx?
Bad prognostic factors?
Complications?
Tx: NG suction, NPO, IV rehydration and observation
Bad factors: old, WBC above 16K, Glc above 200, LDH above 350, AST above 250… drop in HCT, decr calcium, acidosis, hypox
Complications: pseudocyst (no cells!), hemorrhage, abscess, ARDS
Chronic Pancreatitis S/sx?
Can cause splenic vein thrombosis which leads to …?
S/sx: Chronic MEG pain, DM, malabsorption(steatorrhea)
Gastric varices!
What is Courvoisier’s sign?
large, nontender GB, itching and jaundice, seen in adenocarcinoma in head of pancreas
Two signs of pancreatic adenocarcinoma?
Courvoisier’s sign
Trousseau’s sign
What is Trousseau’s sign?
migratory thrombophlebitis
Pancreatic adenocarcinoma:
Workup?
–Tx?
W/u: Endoscopic US and FNA biopsy
Tx: Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoneal mets.
Four conditions of the endocrine pancreas?
Insulinoma
Glucagonoma
Somatistainoma
VIPoma
Insulinoma-
–Whipple’s triad?
–Labs?
Whipple’s triad: sxs (sweat, tremors, hunger, seizures) + BGL under 45 + sxs resolve w/ glc admin
Labs: inc insulin, inc C-peptide, inc pro-insulin
Glucagonoma-
–Sxs?
–Characteristic rash?
–Sxs? Hyperglycemia, diarrhea, weight-loss
–Characteristic rash? necrolytic migratory erythema
Somatistainoma-
Benign or malignant?
S/sx?
Commonly malignant.
S/sx: malabsorption, steatorrhea, ectfrom exocrine pancreas malfxn
VIPoma-
Sxs?
Tx?
Ddx?
Sis: Watery diarrhea, hypokalemia, dehydration, flushing.
Tx: Octreotide can help sis
Ddx: Looks similar to carcinoid syndrome.
RUQ pain back, n/v, fever, worse s/p fatty foods. Dx?
Best 1st test?
Tx?
Dx: Acute Cholecystitis
Test: U/S
Tx: Cholecystectomy. Perc cholecystostomy if unstable
RUQ pain, high biliand alk-phos. Dx?
Workup?
Tx?
Dx: Choledocolithiasis
W/u: U/S will show CBD stone.
Tx: Chole +/-ERCP to remove stone
RUQ pain, fever, jaundice, ↓BP, AMS. Dx?
Tx?
Ascending Cholangitis
Tx: fluids & broad spec abx. ERCP and stone removal.
Choledochal cysts-
Type 1?
Type 5?
Type 1: Fusiform dilation of CBD Tx w/ excision
Type 5: Caroli’s Dz. Cysts in intrahepatic ducts needs liver transplant
Cholangiocarcinoma risk factors? Tx?
Rare
Risk factors: Primary sclerosing cholangitis (UC), liver flukes and thorothrast exposure.
Tx w/ surgery +/-radiation.
Hepatitis-
1) AST = 2x ALT - Dx?
2) AST > ALT high (1000s) - Dx?
3) AST & ALT high s/p hemorrhage, surg, or sepsis - Dx?
1 - Alcoholic hepatitis
2 - Viral hepatitis
3 - Shock liver
Cirrhosis and Portal HTN-
Tx?
Esophageal varices tx?
Tx: Somatostatin and Vasopressin vasoconstrict to decrease portal pressure, beta blockers also decrease portal pressure.
Don’t need to treat esophageal varices prophylactically, but band/burn them once they bleed once.
TIPS relieves portal HTN but… ?
Treat complications with?
worsens hepatic encephalopathy
Tx: Lactulose. helps rid body of ammonia.
Hepatocellular Carcinoma
Risk factors?
chronic hepB carrier greater than hepC. Cirrhosis for any reason, plus aflatoxin or carbon tetrachloride
Hepatocellular Carcinoma
Workup?
Tx?
W/u: high AFP (in 70%), CT/MRI.
Tx: can surgically remove solitary mass, use radiation or cryoablation for palliation of multiple masses
Women on OCP with palpable abd mass or spontaneous
rupture and hemorrhagic shock. Dx?
Workup?
Tx?
Dx: Hepatic Adenoma
W/u: U/S or MRI
Tx: d/c OCPs. Resect if large or pregnancy is desired
2nd Most common benign liver tumor. W>M but less likely to rupture.
Tx?
Focal Nodular Hyperplasia
No tx needed.
Bacterial Liver Abscess.
Most common bugs?
Tx?
Most common:E. coli, bacteriodes, enterococcus.
Tx: Surgical drainage and IV abx.
RUQ pain, profuse sweating and rigors, palpable liver.
Dx?
Tx?
Dx: Entamoeba histolytica.
Tx: Metronidazole. DON’T drain it.
Patient from Mexico presents w/ RUQ pain and large liver cysts found on U/S. Dx?
Enchinococcus.
Enchinococcus:
Mode of transmission?
Lab findings?
Tx?
Transmission: Hydatid cyst paracyte from dog feces.
Lab: eosinophilia, +Casoni skin test
Treatment: albendazole and surgery to remove ENTIRE cyst, rupture leads to anaphylaxis
Post-Splenectomy:
Post op thrombocytosis Tx?
Prophylaxis?
Thrombocytosis: above 1 million give aspirin.
Prophylaxis: PCN + Strep pneumo, Heamophilus influenza and Neisseria meningitidis vaccines.
Patient with bleeding gums, petechiae, nose bleeds?
Consider ITP in isolated thrombocytopenia
ITP:
Platelet levels and bone biopsy findings?
Spleen changes?
Tx?
Decr plt count, inc megakaryocytes in marrow.
NO splenomegaly.
Tx: steroids 1st. If relapse splenectomy
S/sx of hereditary spherocytosis?
Other associated condition?
Tx?
S/sx: hemolytic anemia (jaundice, increased indirect bili, LDH, decreased haptoglobin, elevated retic count) + spherocytes on smear and + osmotic frag test.
Prone to gallstones.
–Tx: splenectomy(accessory spleen too).
Patient with L lower rib fx and intra abdominal hemorrhage. Major concern?
What is Kehr’s sign?
Traumatic Splenic Rupture
Kehr’s sign: the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated (blood irritates L diaphragm). Classic sign of ruptured spleen.
Patient with pain in umbilical area moving to RLQ,+ n/v. Dx?
Indications for surgery?
Contraindications for surgery and alt tx?
Dx: Appendicitis
Indication: If clinical picture is convincing
Contraindication: perforated/abscess. Drain, abx (to cover e.coli & bacteriodes), and do interval appendectomy
1 site of Carcinoid Tumors?
Appendix
Carcinoid syndrome sxs?
When do they happen?
What else to look out for?
Sxs: Diarrhea, Wheezing.
Happens: When metastasizes to liver. (1st pass metabolism of serotonin and kallikrein)
Else: Diarrhea, Dementia, Dermatitis
Carcinoid syndrome treatment:
If >2cm, @ base of appendix, or w/ + nodes?
Otherwise?
Hemicolectomy - removing the cecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first one-third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes.
Otherwise: Appendectomy is good enough
Small Bowel Obstruction
Conditions that cause SBO?
–Sxs?
Conditions: hernia, prior GI surgery (adhesions), cancer, intussusception, IBD.
Sxs: pain, constipation, obstipation, vomiting.
SBO:
1st test?
Tx?
1st test: upright CXR to look for free air. CT can show point of obstruction.
Tx: IVF, NG tube. Do surgery if peritoneal signs, Increased WBC, or no improvement w/in 48hrs.
Volvulus
Treatment for either cecal or sigmoid?
Decompression from below if not strangulated. Otherwise, need surgical removal and colostomy.
Post-Op Ileus:
Potential contributing factors?
Imaging may show?
Treatment and indication for surgery?
Factors: hypoK(make sure to replete), opiates
Imaging: dilated loops of small bowel w/ air-fluid level
Tx: Give lactulose/erythromycin. Do surgery for perforation.
What is Ogilvie’s syndrome? Tx?
See massive colonic distension. If greater than 10cm, need decompression w/ NG tube and neostigmine (watch for bradycardia) or colonoscopic decompression.
Umbilical hernias. Tx in peds? Tx in adults?
In kiddos, close spontaneously by age 2.
In adults: 2/2 obesity, ascites or pregnancy.
Indirect Inguinal hernias: How common? Anatomic landmarks involved? Cause?
Most Common type of hernia.
through inguinal ring (lat to epigastric vessles) in spermatic cord.
R>L, more often congenital (patent proc vaginals)
Direct Inguinal hernias? Anatomic landmarks involved? Cause?
through Hasselbeck’s triangle (med to epigastric vessles), more often acquired weakness.
Femoral hernias: most common sex?
more common in women.
Hernia treatment (any type)?
Emergent surgical repair if incarcerated to avoid strangulation. Elective if reducible.
What type of Inflammatory Bowel Disease involves the terminal ileum? What condition does it mimic, and what deficiency is found?
Crohn’s. Mimics appendicitis. Fe deficiency.
What type of Inflammatory Bowel Disease is Continuous involving rectum?
Ulcerative Colitis. Rarely ileal backwash but never higher
What type of Inflammatory Bowel Disease increases risk for Primary Sclerosing Cholangitis? What may PSC lead to?
UC.
PSC leads to higher risk of cholangiocarcinoma
What gross and microscopic features are seen in crohn’s?
Fistulae are likely
Granulomas and Transmural inflammation on biopsy
What type of Inflammatory Bowel Disease is: Cured by colectomy? Smokers have lower risk? Highest risk of colon cancer? Associated w/ p-ANCA?
Ulcerative colitis,
smokers have increased risk for crohn’s.
Risk of colon cancer is another reason to perform colectomy.
Inflammatory Bowel Disease: Drugs to induce remission? Drugs to maintain remission?
Tx for abscesses in CD?
Drugs for severe disease?
Corticosteroids to induce remission.
ASA (aminosalicylates), sulfasalzine to maintain remission.
For CD, give metranidazole for ANY ulcer or abscess. Azathioprine, 6MP and methotrexate for severe dz.
Diverticulosis-
True or false diverticulum?
Cause?
Complications?
False diverticulae (only out-pouchings of mucosa) Occur 2/2 low fiber diet in areas of weakness where blood vessels penetrate Complications are bleeding, obstruction, diverticulitis
Diverticulitis:
Sxs?
Imaging?
Do colonoscopy when?
Sxs: LLQ pain, either constipation or diarrhea,
Imaging: Look for free air (upright abd X-ray), CT is best imaging to evaluate for abscess. No Barium enema!
Colonoscopy: 4-6 weeks later.
Diverticulitis:
Medical Tx?
Indications for surgery?
Tx: NPO, NG suction, IVF, broad spec abx & pain control
Indications: multiple episodes, age under 50. Elective is better than emergency (can do primary anastamosis)
Colorectal Cancer:
Genetic risk factors?
Other risk factors?
Genetic: AFP, Lynch Syndrome, HNPCC, Gardners, Cowdens
Other: Ulcerative colitis
Colorectal cancer Sxs:
Right sided cancer?
Left sided cancer?
Rectal cancer?
Right: bleeding
Left: obstruction
Rectal: pain/fullness, bleeding/obstruction
Colorectal cancer:
Work up?
Digital Rectal Exam (DRE), transrectal ultrasound (depth of invasion), CT for staging, Colonoscopy! Carcinoembryonic antigen (CEA) to measure recurrance
Colorectal cancer Tx
For colon?
For rectum?
Colon: remove affected segments & chemo if node +
Rectum: upper/middle 1/3 get a LAR, lower 1/3 gets an Abdominal peritoneal resection (APR - remove sphincter, permanent colostomy)
AAA
Screening?
Sxs?
Screening: men 65-75 who have ever smoked. Do abdominal U/S.
Sxs: pulsatile abdominal mass.
AAA Tx
conservatively if?
Surgery indicated if?
Conservative: if under 5cm and asymptomatic, monitor growth every 3-12mo.
Surgery: greater than 5cm, growing faster than 4mm/yr
AAA: Rupture Sxs? Mortality?
Sxs: severe sudden abdomen, flank or back, shock, tender pulsatile mass.
Mortality: 50% die before reaching the hospital.
AAA Post-op complications:
#1 cause of death?
Bloody diarrhea indicates?
Weakness, decreased pain w/ preserved vibration & proprioception?
1-2 yrs later if patient has brisk GI bleeding?
1: MI
Diarrhea: Ischemic colitis
Weakness: ASA syndrome
GI bleed: Aortoenteric Fistula
Acute Mesenteric Ischemia:
Presentation?
Risk factors?
Presentation: Patient with acute abdominal pain
Risk: Hypercoagulable or vasoconstrictor states. A-fib and sub therapeutic warfarin, high dose vasoconstrictors, etc.
SURGICAL EMERGENCY!!
Acute mesenteric ischemia:
Work up?
Tx?
W/u: Angiography (aorta and SMA/IMA)
Tx: Embolectomy. If thrombus, or aorto-mesenteric bypass.
Chronic Mesenteric Ischemia:
Pathophys?
Sxs?
Slow progressing stenosis (requires stenosis of 2.5 vessels: Celiac, SMA and IMA).
Sxs: Severe MEG pain after eating, food fear and weight loss. “Pain out of proportion to exam”.
Chronic Mesenteric Ischemia:
Dx?
Tx?
Dx: duplex or angiography
Tx: aortomeseteric bypass or transaortic mesenteric endarterectomy.
Peripheral Artery Disease:
5P’s of Acute arterial occlusion?
5P’s: pulseless, pallor, pain, paresthesias, paralysis
Acute arterial occlusion:
Tx?
Surgery timeline?
Tx: immediate heparin + prepare for surgery.
Surgery: embolectomy or bypass done w/in 6hrs to avoid loss.
Acute arterial occlusion:
Thrombolytics may be possible if?
Complications?
Thrombolytics if: no surgery in previous 2wks, no hemorrhagic stroke.
Complications: Compartment syndrome during reperfusion period (Tx: fasciotomy, watch for myoglobinuria.)
Claudication:
Sxs?
Best test? What is normal?
Sxs: Pain in butt, calf thigh upon exertion
Test: Ankle-Brachial Index, ratio of BP at ankle/Brachial
Normal ratio: greater than 1 (nl higher BP in ankles)
Claudication Ankle:Brachial index values and Tx:
Claudication & Ulcers?
Limb ischemia?
Gangrene?
Claudication: 0.4-0.8; medical management
Ischemia: 0.2-0.4; Surgery is indicated
Gangrene: less than 0.2; May require amputation
DVT:
Dx?
Tx?
Complications?
Dx: Duplex U/S & also check for PE
Tx: heparin, then overlap w/ warfarin for 5 days, then continue warfarin for 3-6mo.
Complications: post-phlebotic syndrome = chronic valvular incompetence, cyanosis and edema
PE:
Random signs?
First step?
signs: right heart strain on EKG, sinus tach, decreased vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2.
1st step: give heparin 1st! Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard.
PE: Tx? Thrombolytic contraindications? Indications for surgery? Indications for IVC filter?
Tx: heparin to warfarin overlap.
Use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke.
Surgical thrombectomy if life threatening.
IVC filter if contraindications to chronic coagulation.
Work up of a Thyroid Nodule
1st step?
If low?
If normal?
1st: Check TSH
Low: Do RAIU to find the “hot nodule”. Excise or radioactive I-131
Nl: FNA
Work up of a Thyroid Nodule post FNA: If benign? If malignant? If indeterminate? If cold?
Benign: Leave it alone.
Malignant: Surgically excise and check pathology
Indeterminate: Re-biopsy or check RAIU
Cold: Surgically excise and check pathology
5 types of thyroid malignancies?
Papillary Follicular Medullary Anaplastic Thyroid Lymphoma
MC type of thyroid malignancy, spreads via lymph, psammoma bodies?
Papillary
Thyroid malignancy that spreads via blood, must surgically excise whole thyroid?
Follicular
Thyroid malignancy associated w/ MENII (look for pheo, hyperCa). Amyloid/calci?
Medullary
Thyroid malignancy with 80% mortality in 1st year?
Anaplastic
Thyroid malignancy that Hashimoto’s predisposes to?
Thyroid lymphoma
Work up of an Adrenal Nodule
1st step?
2nd step?
Tx?
1st: check functional status
2nd: CT imaging
Tx: if less than 5cm and non-function = observe w/ CT scans q6mo.
If more than 6cm or functional = surgical excision
Pheochromocytoma
Features?
Test?
Sxs: High blood pressure, catechol symptoms
Test: Urine-and plasma-free metanephrines
Primary aldosteronism:
Features?
Test?
Features: High blood pressure, low K+, low PRA*
Test: Plasma aldosterone-to-renin ratio
Adrenocortical carcinoma:
Features?
Test?
Features: Virilization or feminization
Test: Urine 17-ketosteroids
Cushing or “silent” Cushing syndrome:
Features?
Test?
Features: Cushing symptoms or normal examination results
Test: Overnight 1-mg dexamethasone test
Hypoparathyroidism:
Most common cause?
Sxs?
Serum labs?
Cause: Typically comes from thyroidectomy
Sxs: perioral numbness, Chvortek, Trousseau
Labs: ↓Ca+, ↑PO4+, ↓*PTH+
Hyperparathyroidism: Sxs? Labs? Dx? Tx?
Sxs: –Usually asymptomatic ↑Ca, but can present w/ kidney stones, abdominal or psychiatric sis
Labs: –↑Ca+, ↓PO4+, ↑vitD, ↑*PTH+
Dx: FNA of suspicious nodules. Can use Sestamibi scan.
Tx: surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in forearm.
Cancers of MEN1?
pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor.
Cancers of MEN2a?
parathyroid hyperplasia, medullary thyroid cancer, pheochromocytoma
Cancers of MEN2b?
medullary thyroid cancer, pheochromocytoma, Marfanoid
Work up of a Breast Mass
Best uses for U/S and MRI?
•U/S can tell if solid or cystic. U/S good for determining fibroadenoma/cysto-sarcoma phyllodes.
MRI is good for evaluate dense breast tissue, evaluating nodes and determining recurrent cancer.
MRI –Best imaging for the young breast (dense)
Work up of a Breast Mass:
Imaging?
Next step for cystic? For solid?
Next step if mass is palpable or fluid returns?
Imaging: U/S or MRI Cystic: Aspiration of fluid Solid: FNA Palp/returns: Excisional biopsy Mammaographicallyguided multiple core biopsies
Breast Cancer risk factors?
BRCA1 or 2, personal hx of breast cancer, nulliparity, endo/exogenous estrogen.
DCIS Tx?
Either excision w/ clear margins or simple mastectomy if multiple lesions (no node sampling) + adjuvant RT.
LCIS Tx?
More often bilateral. Consider bilateral mastectomy only if +FH, hormone sensitive, or prior hx of breast cancer
Infiltrating ductal/lobular carcinoma Tx?
–If small and away from nipple, can do lumpectomy w/ axillary node sampling.
Adjuvant RT.
Chemo if node +.
Tamoxifen or Raloxifen if ER +
–Modified radical mastectomy w/ axillary node sampling w/o adjuvant RT gives same prognosis.
Paget’s Dz appearance and workup?
Looks like eczema of the nipple.
Do mammogram to find the mass
Inflammatory breast cancer appearance?
Red, hot, swollen breast. Orange peal skin. Nipple retraction
Basal Cell Carcinoma Tx?
Shave or punch bx then surgical removal (Mohs)
Squamous Cell Carcinoma-
Precursor lesion and Tx?
Tx of SCC?
Precursor: AK is precursor lesion (txw/ 5FU or excision) or keratoacanthoma.
SCC Tx: Excisional bxat edge of lesion, then wide local excision. Can use rads for tough locations.
Melanoma-
2 types?
Acrolentiginous form occurs where and in who?
Lentigo Maligna?
Types: Superficial spreading (best prog, most common); Nodular (poor prog)
Acrolentiginous: palms, soles, mucous membranes in darker complected races
Lentigo Maligna: a melanoma in situ that consists of malignant cells but does not show invasive growth (head and neck, good prog)
Melanoma:
Biopsy spec?
Tx?
Medication therapy?
Biopsy: Need full thickness biopsy b/c depth is #1 prog
Tx: excision-1cm margin if less than 1mm thick, 2cm margin if 1-4mm thick, 3cm margin if greater than 4mm
Meds:High dose IFN or IL2 may help
Soft Tissue Sarcoma- Appearance? Dx? Tx? Spread and 1st mets?
Appearance: Painless enlarging mass. (Don’t confuse w/ bruised muscle.
Dx: biopsy (NOT FNA). Excisional if less than 3cm otherwise incisional.
Tx: wide, local excision or ampulation+ RT.
Spread/mets: Spreads 1st to the lungs (hematogenously) can do wedge resection if only met and primary is under control.
Liposarcoma
Source?
99% DON’T come from lipoma
Fibrosarcoma/Rhabdomyosarcoma/ Lymphangiosarcoma
Sxs?
Common association?
Sxs: Hard round mass on extremity.
Association: Can occur in areas of chronic lymphedema
Rule of 7s for Neck Mass
•7 days = inflammatory, 7 mo= cancer, 7 yrs= congenital
Neck Mass:
Most Common cause?
Exam for lesion lasting more than 2 weeks?
If node is firm, rubbery and “B sxs” are present?
Most common: reactive node, so #1 step is to examine teeth, tonsils, etc for inflammatory lesion
2 weeks: FNA
Firm w/ B sxs: excision bx looking for Lymphoma
Neck Mass:
Lymphoma subtypes?
Hodgkins vs Non-Hodgkins
Neck Mass:
Good prognostic factors for hodgkins? non-hodgkin?
Work up?
Hodgkins= lymphocyte predominant is good progfactor. Reed Sternberg cells.
Non-Hodgkins= nodular and well-diferentialted are good prognostic factors.
Workup: Staging CT, CXR and laparotomy for chemo and XRT treatment
Neck Mass:
If midline?
If anterior to SCM?
If spongy, diffuse and lateral to SCM?
Midline: thyroglossalduct cyst, move tongue and mass moves. Remove surgically.
Anterior: branchial cleft cyst
Spongy: cystic hygroma (Turners, Down’s, Klinefelters)
Oral Cancer-
Most common type?
Population?
Tx?
Most freq: squamous cell.
Population: In smokers & drinkers
Tx: XRT or radical dissection (jaw/neck)
Laryngeal Cancer-
Types in peds vs adults?
Tx?
Laryngeal papilloma in kiddo w/ stridor or cough
Squamous cell in adults.
Tx: laryngoscope laser or resection
Pleomorphic Adenoma
Location?
Most Common salivary glad tumor. Usually on parotid. Benign but recurs
Warthlin’s Tumor-
Location?
Complications?
Papillary cyst adenoma lymphomatosum. Benign on parotid gland.
Can injure facial nerve (look for palsy sxs in question Stem)
Mucoepidermoid Carcinoma-
Common?
Source tissue?
MC malignant tumor.
Arises from duct.
Causes pain and CN VII palsy
Baby is born w/ respiratory distress, scaphoid abdomen & bowels in lung space on CXR.
Dx?
Biggest concern?
Best treatment?
Dx: Diaphragmatic hernia
Concern: Pulmonary hypoplasia
Tx: If dx prenatally, plan delivery at @ place w/ ECMO. Let lungs mature 3-4 days then do surgery
Baby is born w/ respiratory distress w/ excess drooling.
Most likely Dx?
Best diagnostic test?
Dx: TE-Fistula
Test: Place feeding tube, take xray, see it coiled in thorax
Defect lateral (usually R) of the midline, no sac. Dx? Labs? Assoc w/ other disorders? Complications?
Dx: Gastroschisis
Labs: will see high maternal AFP
Assoc: Not usually. May be atretic or necrotic req removal.
Complications: Short gut syndrome
Newborn with defect in the midline. Covered by sac.
Dx?
Assoc w/ other disorders?
Dx: Omphalocele
Assoc: yes (not specified in handout)
Defect in the midline. No bowel present outside abdomen.
Dx?
Assoc w/ other disorders?
Treatment?
Dx: Umbilical Hernia
Assoc: Assoc w/ congenital hypo-thyroidism. (also big tongue)
Tx: Repair not needed unless persists past age 2 or 3.
4wk old infant w/ non-bileous vomiting and palpable “olive”
Dx?
Metabolic complications?
Tx?
Dx: Pyloric Stenosis
Metabolic comp: Hypochloremic, metabolic alkalosis
Tx: Immediate surg referral for myotomy
2wk old infant w/ bileous vomiting. The pregnancy was complicated by poly-hydramnios.
Dx?
Assoc w/?
Dx: Intestinal Atresia Or Annular Pancreas
Assoc: Down Syndrome (esp duodenal)
1 wk old baby w/ bileous vomiting, draws up his legs, has abd distention.
Dx?
Pathophys?
Dx: Malrotation and volvulus *Ladd’s bands can kink the duodenum
Pathphys: Doesn’t rotate 270 ccw around SMA
A 3 day old newborn has still not passed meconium.
DDX? (name 2)
Meconium ileum-consider Cystic Fibrosis if +FH *gastrograffin enema is dx & tx
Hirschsprung’s: DRE leads to explosion of poo. Biopsy showing no ganglia is gold standard
A 5 day old former 33 weeker develops bloody diarrhea
Dx?
Necrotizing Enterocolitis
Necrotizing Enterocolitis:
What do you see on xray?
Treatment?
Risk factors?
X-ray: Pneumocystis intestinalis (air in the wall)
Tx: NPO, TPN (if nec), antibiotics and resection of necrotic bowel
RF: Premature gut, introduction of feeds, formula.
A 2mo old baby has colicky abd pain and current jelly stool w/ a sausage shapend mass in the RUQ.
Dx?
Workup and tx?
Dx: Intussusception
W/u: Barium enema is dx and tx
BPH-
Effect of anticholinergics?
Tx for acute urinary retention?
Tx?
Anticholinergics meds make it worse
Retention: foley for acute urinary retention.
Tx: 1st Medical Tx w/ tamsulosin or finasteride
2nd Surgical Txw/ TURP (hyponatremia, retro-ejac)
Prostate Cancer-
Signs?
Workup?
Tx?
Signs: Nodules on DRE or elevated/rising PSA
Workup: transrectal ultrasound and bx. Bone scan looks for blastic lesions.
Tx: surgery, radiation, leuprolide or flutamide.
Kidney Stones
Best test?
Tx?
Indication for surgery?
CT is best test.
If stone less than 5mm, hydrate and let it pass.
If greater than 5mm, do shock wave lithotripsy.
Surgical removal if greater than 2cm.
Scrotal Mass-
Workup?
Tx?
Workup: Transilluminate, U/S,
Tx: excision! (don’t bx). Know hormone markers!
Testicular Torsion
Sxs?
Workup?
Tx?
Sxs: Acute pain and swelling w/ high riding testis.
W/u: Do STAT doppler U/S = will show no flow (contrast w/ epididymitis)
Tx: Can surgically salvage if under 6hrs. Do orchiopexy to BOTH testes.
Avascular Necrosis-
Common causes in kids?
Common causes in adults?
Kids: Leg-Calve-Perth’s dz in 4-5 y/o w/ a painless limp and SCFE in a 12-13 y/o w/ knee pain or sickle cell pts
Adults: steroid use, s/p femur fracture.
Osteosarcoma
Location?
Appearance?
Location: Seen in distal femur, proximal tibia
@ metaphysis, around the knee
Appearance: Codman’s triangle and Sunray appearance
Ewing Sarcoma- Location? Sxs? X-ray appearance? Tumor type?
Seen at diaphysis of long bones,
Sxs: night pain, fever& elevated ESR
X-ray: Lytic bone lesions, “onion skinning”.
Type: Neuroendocrine (small blue) tumor
Hyper acute transplant Rejection
Signs?
Cause?
Sign: Vascular thrombosis w/in minutes
Caused by preformed antibodies
Acute Transplant Rejection
Signs?
Timing?
Cause?
Signs: Organ dysfunction (incrGGT or Cr depending on organ)
Time: w/in 5days –3mo.
Cause: Due to T-lymphocytes.
Acute transplant rejection
Workup for technical problems with liver?
Heart transplant concerns?
Treatment?
Technical problems common in Liver 1st check for biliary obstruction w/ U/S then check for thrombosis by Doppler.
In heart, sxscome late, so check ventricular bx periodically.
Tx: steroid bolus and anti lymphocyte agent (OKT3)
Chronic Rejection-
Timeline?
Cause?
Tx?
Time: Occurs after years.
Cause: Due to T-lymphocytes.
Tx: Can’t treat it. Need re-transplantation.
Anesthesia:
Why give local-(lidocaine, etc) with epi?
Sxs of problems with local?
To prevent systemic absorption
Sxs: numb tongue, seizures hypotension, bradycardia, arrhythmias
Do not give epi with local anesthesia in which locations?
Fingers, nose, penis, toes
Who gets Spinal-Subarachnoid anesthesia?
Contraindications?
Patients who can’t be intubated.
Can’t give if increased ICP or hypotensive
bupivacaine and others are used
What happens in a “high block” epidural?
blocks heart’s SNS nerves and phrenic nerve
Meperidine uses?
Anesthesia drug
Norperidine metabolite can lower seizure threshold esp in pts w/ renal failure.
Succinylcholine complications? Contraindications?
Can cause malignant hyperthermia, hyperK (not for burn or crush victim)
Rocuronium complications?
Sometimes allergic rxn in asthmatics
Halothane complications?
Can cause malignant hyperthermia (dantroline Na)
Liver toxicity.
