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Surgery Shelf > High Yield PDF > Flashcards

High Yield PDF Flashcards

1
Q

What are absolute contraindications to surgery?

A

Diabetic coma, DKA

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2
Q

What are relative contraindications to surgery?

A

Poor nutrition, Sever liver failure, Smoking

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3
Q

What are signs of poor nutrition?

A

Albumin less than 3
Transferrin less than 200
Weight loss of 20% or more

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4
Q

What are signs of severe liver failure?

A

Bili greater than 2
PT greater than 16
Ammonia greater than 150 or encephalopathy

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5
Q

How long must a smoker abstain before a surgery?

A

8 weeks

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6
Q

What special management must CO2 retainers receive?

A

Limit O2 supplementation during post op. Chronic CO2 retainers rely on O2 levels for respiratory drive, and supplemental O2 may decrease their respiratory drive.

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7
Q

What does Goldman’s index tell you?

A

Assesses which patients are at greatest risk during surgery

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8
Q

What are the components of Goldman’s index?

A

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

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9
Q

Describe what physical exam signs that are present in aortic stenosis

A

Late systolic, crescendo-decrescendo murmur, radiates to carotids, increased with squatting/valsalva, decreased with decreased preload

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10
Q

What meds must be stopped prior to surgery?

A

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)

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11
Q

What changes should diabetic patients make to their insulin before surgery?

A

Use 1/2 the normal morning dose

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12
Q

What should be done for patients with CKD on dialysis?

A

Dialyze 24 hours pre-op

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13
Q

Why are BUN and Creatinine important for surgical patients?

A

BUN greater than 100 may lead to uremic platelet dysfunction and increase bleeding.

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14
Q

If BUN is greater than 100, what would be seen on the coagulation panel?

A

Normal platelets

Prolonged bleeding time

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15
Q

What is assist-control in ventilation settings?

A

set tidal volume and rate but if pt takes a breath, vent gives the volume.

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16
Q

What is pressure support in ventilation settings?

A

pt rules rate but a boost of pressure is given (8-20).

Important for weening off vent

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17
Q

What does CPAP do?

A

pt must breathe on own but positive pressure given all the time.

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18
Q

How does PEEP work and how is it different from CPAP?

A

pressure given at the end of cycle to keep alveoli open (5-20).

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19
Q

Name two conditions PEEP is used in

A

CHF and ARDS

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20
Q

With a patient on a vent, what is the best test to evaluate management?

A

ABG

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21
Q

With a patient on a vent, what do you do if PaO2 is too low?

A

Increase FiO2

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22
Q

With a patient on a vent, what do you do if PaO2 is too high?

A

Decrease FiO2

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23
Q

With a patient on a vent, what do you do if PaCO2 is too low (i.e. pH is high)?

A

Decrease rate or tidal volume

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24
Q

With a patient on a vent, what do you do if PaCO2 is too high (i.e. pH is low)

A

Increase rate or tidal volume

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25
Q

If you have to adjust vent settings to increase or decrease PaCO2/pH, which setting is more efficient to change?

A

Tidal volume is more efficient. Dead space is a fixed volume and small decreases in TV have amplified effects at the alveoli

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26
Q

What are the HCO3 and pCO2 patterns for metabolic acidosis? For respiratory acidosis?

A

Metabolic: HCO3 low, pCO2 low (not producing HCO3, breathing off pCO2)
Respiratory: HCO3 high, pCO2 high (not breathing off pCO2, increased HCO3)

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27
Q

If a patient is acidotic, what are the next two steps?

A

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

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28
Q

What does MUDPILES stand for?

A 
Methanol
Uremia
DKA
Propylene glycol/Paracetamol/
Isoniazid, Iron, Inborn errors of metabolism
Lactate
Ethylene glycol
Salicylates
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29
Q

What are the HCO3 and pCO2 patterns for metabolic alkalosis? For respiratory alkalosis?

A

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)

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30
Q

If a patient is alkalotic, what are the next two steps?

A

First: determine respiratory vs metabolic: check HCO3 and pCO2
Next: Check urine Cl to help determine cause

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31
Q

What conditions does the urine [Cl] indicate in metabolic alkalosis?

A

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

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32
Q

What does a low [Na+] indicate?

A

Gain of water

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33
Q

What are the first steps after finding low [Na+]?

A

First check osmolality

Next check volume status

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34
Q

What conditions are found with high volume and low [Na+]?

A

Hypervolemic hyponatremia
CHF, Cirrhosis, Nephrotic syndrome
Low osmotic pressure = extra volume in the ECF, low circulating volume = increased ADH = inc water retention

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35
Q

What conditions are found with low volume and low [Na+]?

A

Hypovolemic hyponatremia
Vomiting, diarrhea, diuretics
Mechanisms lead to volume depletion = increased ADH = water retention with no Na+

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36
Q

What conditions are found with normal volume and low [Na+]?

A

Euvolemic hyponatremia
SIADH, Addison’s, hypothyroid
Excess ADH = excess water, but no third spacing limits total volume to normal range

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37
Q

How do you treat hypervolemic hyponatremia?

A

Fluid restrictions and diuretics, as in euvolemic. Ultimate cure relies on fixing the underlying condition (CHF, cirrhosis, nephrotic syndrome)

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38
Q

How do you treat hypovolemic hyponatremia?

A

Normal saline infusion, SLOWLY restore nl [Na+] due to risk of central pontine myolinolysis

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39
Q

When do you use 3% saline solution in hyponatremia?

A

Only when patients are symptomatic, esp. Seizures. [Na+] usually less than 110. Risk of central pontine myolinolysis.

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40
Q

What does an increase in [Na+] indicate?

A

Loss of water

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41
Q

How do you treat hypernatremia? What complications may occur in treatment?

A

Replace with D5 or hypotonic fluids.

Risk of cerebral edema

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42
Q

What do numbness, Chvostek sign, Trousseau sign, or prolonged QT indicate?

A

Hypocalcemia

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43
Q

What does bones, stones, groans, psychiatric overtones, or short QT indicate?

A

Hypercalcemia

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44
Q

What do paralysis, ileus, ST depression, or U waves indicate? How do you treat it?

A

Hypokalemia

Give K+, max 40 mEq/hr

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45
Q

What do peaked T waves, prolonged PR and QRS, and sine waves indicate? How do you treat it?

A

Hyperkalemia
Give Ca-gluconate, then insulin and glucose, kayexalate, albuterol, and sodium bicarb.
Last resort = dialysis

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46
Q

For maintenance fluids: what fluids are used and in what quantities?

A 
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
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47
Q

What type of feeding is best and when should other types be used?

A

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.

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48
Q

What risks are associated with TPN?

A

Acalculus cholecystitis, hyperglycemia, liver dysfunction, zinc deficiency, electrolyte problems

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49
Q

What is the treatment for circumferential burns?

A

Escharotomy. The burned tissue loses its elasticity, and may constrict underlying tissues when they are rehydrated, cutting circulation to the distal tissues.

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50
Q

What to consider if singed nose hairs, wheezing, soot in mouth/nose?

A

Intubation. Higher likelihood of respiratory burns

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51
Q

What is the best test for a patient with confusion, headache, and/or cherry red skin? Treatment?

A

Check carboxy hemoglobin, PULSE OX IS WORTHLESS!!

Treatment: 100% O2, Hyperbaric chamber if CO-Hb very high

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52
Q

Blood clots in the elderly?

A

Ddx: Cancer

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53
Q

Blood clots with edema, HTN, and foamy pee?

A

Ddx: Nephrotic syndrome

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54
Q

Blood clots in a young person (esp with +family history)

A

Ddx: Factor V leiden

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55
Q

What is special about clotting disorders with ATIII deficiency?

A

Heparin won’t work.

Binds and activates ATIII, which inactivates thrombin and factor Xa, and others.

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56
Q

What should you suspect in a young woman with multiple spontaneous abortions?

A

Lupus anticoagulant

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57
Q

What should you suspect in a post op patient with decreased platelets and clotting? Treatment?

A

HIT!! (If heparin was given within 5-14 days)

Leparudin or Agatroban

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58
Q

Patient with an isolated decrease in platelets?

A

ITP

Idiopathic Thrombocytopenia Purpura

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59
Q

Normal platelets but increased bleeding time & PTT?

A

von Willibrands Disease

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60
Q

Low platelets, Increased PT, PTT, BT, low fibrinogen, high D-Dimer and schistocytes?

A

DIC!! Caused by gram –sepsis, carcinomatosis, OB stuff

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61
Q

What type of abx should be given to burn victims?

A

NO PO or IV abx. Give topical.

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62
Q

What abx doesn’t penetrate eschar and can cause leukopenia?

A

Silver sulfadiazine

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63
Q

What abx penetrates eschar but hurts like hell?

A

Mafenide

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64
Q

What abx doesn’t penetrate escharand causes hypoK and HypoNa?

A

Silver Nitrate

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65
Q

Chemical burn, what to do?

A

Irrigate more than 30min prior to ER

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66
Q

Electrical Burn, best 1st step? If abnormal?

A

EKG!

48 hours of telemetry (also if LOC)

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67
Q

Burns: If urine dipstick + for blood but microscopic exam is negative for RBCs? Then what do you check?

A

Myoglobinuria = ATN

K+! (When cells break)

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68
Q

Burns: If affected extremity is extremely tender, numb, white, cold with barely dopplerable pulses? Criteria? Treatment?

A

Compartment syndrome!!
Criteria: 5 Ps or compartment pressure above 30mmHg
Treatment: May require fasciotomy. (at bedside!)

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69
Q

If trauma patient comes in unconscious?

A

Intubate

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70
Q

If GCS < 8?

A

Intubate

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71
Q

If guy stung by a bee, developing stridor and tripod posturing?

A

Intubate

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72
Q

If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck?

A

Intubate

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73
Q

If guy stabbed in the neck, crackly sounds w/ palpating anterior neck tissues?

A

fiberoptic broncoscope

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74
Q

If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7?

A

cricothyroidotomy

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75
Q

So you intubated your patient… next best step?

A

Check bilateral breath sounds

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76
Q

Intubated patient with dec breath sounds on the left? What to do? Next step?

A

Means you intubated the right mainstream bronchus
Pull back your ET tube
Check pulse ox, keep it above 90%

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77
Q

A patient has inward mvmtof the right ribcage upon inspiration.
–Dx?
–Tx?

A

Dx: Flail chest. More than 3 consec rib fractures
Tx: O2 and pain control.

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78
Q

A patient has confusion, petechial rash in chest, axilla and neck and acute SOB.
–Dx?
–When to suspect it?

A

Dx: Fat embolism
When: After long bone fx (esp femur)

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79
Q

A patient dies suddenly after a 3rdyear medical student removes a central line.
–Dx?
–When else to suspect it?

A

Dx: Air embolism
When: Lung trauma, vent use, during heart vessel surgery.

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80
Q

What to worry about if a patient is hypotensive, tachycardic?

A

shock

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81
Q

What to worry about if a patient has flat neck veins and normal CVP? Next best step?

A

Hypovolemic/Hemorrhagic

2 large bore periph IV-2L NS or LR over 20min followed by blood.

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82
Q

If muffled heart sounds, JVD, electrical alternans, pulsus paradoxes? Confirmatory test? Treatment?

A

Pericardial Tamponade
Confirmatory Test: FAST scan
Treatment: Needle decompression, pericardial window or median sternotomy

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83
Q

What to worry about if dec breathing sounds on one side, tracheal deviation AWAY from collapsed lung? Next best step?

A

Tension pneumothorax

Next step:
Needle decompression, followed by a chest tube.
DON’T do a CXR!!!

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84
Q

What are the three categories of the GCS and how many points are in each?

A

Eyes 4
Verbal 5
Motor 6

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85
Q

Patient presents with headache, vomiting, altered mental status. What is the ddx?

A

Cranial mass: hematoma, edema, tumor

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86
Q

Patient presents with headache, vomiting, altered mental status. What is the treatment?

A

Elevate HOB,
hyperventilate to pCO2 28-32,
give mannitol (watch renal fxn)

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87
Q

Patient presents with headache, vomiting, altered mental status. What surgical treatment may be performed?

A

Ventriculostomy

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88
Q

Patient with penetrating neck trauma. Where is region 3 and how do you work up the injury?

A

Region 3 is above the angle of the mandible

Workup includes aortography and triple endoscopy

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89
Q

Patient with penetrating neck trauma. Where is region 2 and how do you work up the injury?

A

Region 2 is from the cricoid to the angle of mandible.

Workup includes 2D doppler +/- exploratory surgery.

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90
Q

Patient with penetrating neck trauma. Where is region 1 and how do you work up the injury?

A

Region 1 is below the cricoid

Workup includes aortography

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91
Q

Surgery for patient with GSW to the abdomen?

A

Exploratory laparotomy plus tetanus prophylaxis

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92
Q

Penetrating Abdominal Trauma: If stab wound & pt is unstable, with rebound tenderness & rigidity, or w/ evisceration?

A

Exploratory laparotomy (plus tetanus prophylaxis)

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93
Q

Penetrating Abdominal Trauma: If stab wound but pt is stable?

A

FAST exam.
Diagnostic Peritoneal Lavage if FAST is equivocal.
Ex-lap if either are positive.

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94
Q

Penetrating Abdominal Trauma: If blunt abdominal trauma pt with hypotension/tachycardia?

A

Ex-lap.

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95
Q

Blunt Abdominal Trauma: If patient is stable? If unstable?

A

Abdominal CT

Ex-lap.

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96
Q

Blunt Abdominal Trauma: If lower rib fx plus bleeding into abdomen?

A

Spleen or liver lac.

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97
Q

Blunt Abdominal Trauma: If lower rib fx plus hematuria?

A

Kidney lac.

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98
Q

Blunt Abdominal Trauma: If Kehr sign & viscera in thorax on CXR?

A

Diaphragm rupture.

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99
Q

Blunt Abdominal Trauma: If handlebar sign

A

Pancreatic rupture.

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100
Q

Blunt Abdominal Trauma: If stable w/ epigastric pain:
•Best test?
•If retroperitoneal fluid is found?

A

Test: Abdominal CT.

Fluid found: Consider duodenal rupture.

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101
Q

Pelvic Trauma: First steps if hypotensive, tachycardic

A

FAST and DPL to r/o bleeding in abdominal cavity.

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102
Q

Pelvic Trauma: Treatment for bleeding into pelvis?

A

stop bleeding by fixing fracture
internal if stable
external if not

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103
Q

Pelvic Trauma: What to consider if blood at the urethral meatus and a high riding prostate? Next best test? If normal?

A

Consider pelvic fracture w/ urethral or bladder injury.
Retrograde urethrogram (NOT FOLEY!)
Retrograde cystogram to evaluate bladder

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104
Q

Pelvic Trauma: What are you looking for in a retrograde cystogram to evaluate bladder?

A

Check for extravasation of dye. Take 2 views to ID trigone injury.

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105
Q

Pelvic Trauma: What treatments if a retrograde cystogram shows extraperitoneal extravasation? If intraperitoneal extravasation?

A

Extraperitoneal: Bed rest + foley

Intraperitoneal: Ex-lap and surgical repair

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106
Q

Ortho Trauma: Fractures that go to the OR

A

–Depressed skull fx
–Severely displaced or angulated fx
–Any open fx (sticking out bone needs cleaning)
–Femoral neck or intertrochanteric fx

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107
Q

Common Ortho Trauma: Shoulder pain s/p seizure or electrical shock

A

Posterior shoulder dislocation

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108
Q

Common Ortho Trauma: Arm outwardly rotated, & numbness over deltoid

A

Anterior shoulder dislocation

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109
Q

Common Ortho Trauma: old lady FOOSH, distal radius displaced.

A

Colle’s fracture

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110
Q

Common Ortho Trauma: young person FOOSH, anatomic snuff box tender.

A

Scaphoid fracture

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111
Q

Common Ortho Trauma: “I swear I just punched a wall…”

A

Metacarpal neck fracture “Boxer’s fracture”. May need K wire

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112
Q

Common Ortho Trauma: Clavicle most commonly broken where?

A

Between middle and distal 1/3s. Need figure of 8 device

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113
Q

Fever on POD #1: Most common cause, low fever (<101) and non productive cough?
•Dx?
•Tx?

A

Atelectasis
Dx: CXR-see bilateral lower lobe fluffy infiltrates
Tx: Mobilization and incentive spirometry.

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114
Q

Fever on POD #1: High fever (to 104!!), very ill appearing.
•Pattern of spread?
•Common bugs?
•Tx?

A

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

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115
Q

Fever in surgery: High fever (above 104!!) muscle rigidity.
•Caused by?
•Genetic defect?
•Treatment?

A

Malignant Hyperthermia
Cause: Succ or Halothane
Genetic defect: Ryanodine receptor gene defect
Tx: Dantrolene Na (blockes RYR and decr intracellular calcium.

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116
Q

Fever on POD #3-5: Fever, productive cough, diaphoresis?

•Tx?

A

Pneumonia

Tx: Check sputum sample for culture, cover w/ moxi etc to cover strep pneumo in the mean time.

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117
Q

Fever on POD #3-5: Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley.
•Next best test?
•Tx?

A

UTI
Next step: UA (nitritie and LE) and culture.
Tx: Change foley and treat w/ wide-spec abx until culture returns.

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118
Q

Fever POD 7:With Pain & tenderness at IV site?

•Tx?

A

Central line infection

Tx: Do blood cx from the line. Pull it. Abx to cover staph.

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119
Q

Fever POD 7: With pain @ incision site, edema, induration but no drainage?
•Tx?

A

Cellulitis

Tx: Do blood cx and start antibiotics

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120
Q

Fever POD 7: With pain @ incision site, induration WITH drainage.
•Tx?

A

Simple Wound Infection

Tx: Open wound and repack. No abx necessary

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121
Q

Fever POD 7: With pain w/ salmon colored fluid from incision.
•Tx?

A

Dehiscence

Tx: Surgical emergency! Go to OR, IV abx, primary closure of fascia

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122
Q

Fever POD 7: Unexplained fever
•Dx?
•Tx?

A

Abdominal Abscess
Dx: CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
Tx: Drain it! Percutaneously, IR-guided, or surgically.

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123
Q

Fever POD 7: Random causes?

A

thyrotoxicosis, thrombophlebitis, adrenal insufficiency, lymphangitis, sepsis.

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124
Q

Pressure Ulcers: Cause?
Dx?
Prevention?

A

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

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125
Q

Pressure Ulcers: Describe Stage 1. Stage 2. And treatment?

A

Stage 1 = skin intact but red. Blanches w/ pressure
Stage 2 = blister or break in the dermis
Tx: get special mattress, barrier protection

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126
Q

Pressure Ulcers: Describe Stage 3, Stage 4. And treatment?

A

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

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127
Q

How do you detect pleural effusions and what is the first step in treatment?

A

see fluid greater than 1cm in lateral decubitus position

thoracentesis!

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128
Q

What to suspect if analysis of pleural effusion shows transudate?
•If low pleural glucose?
•If high lymphocytes?
•If bloody?

A

Transudate: likely CHF, nephrotic, cirrhotic
Low glucose: Rheumatoid Arthritis
High lymphocytes: Tuburculosis
Bloody: Malignant or Pulmonary Embolus

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129
Q

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):

A

Likely parapneumonic, cancer, etc.

Complicated: Insert chest tube for drainage.

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130
Q

What is Light’s Criteria for transudate?

A

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)

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131
Q

What is the pathophysiology of Spontaneous Pneumothorax?

Who is suspect for one?

A

Sub-pleural bleb ruptures causing lung collapse.

–Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)

132
Q

How do you diagnose and treat spontaneous PTX? What are the indications for surgery?

A

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)

133
Q

What is the usual cause of Lung Abscess? What are the most common involved lobes?

A

usually 2/2 aspiration (drunk, elderly, enteral feeds)

–Most often in post upper or sup lower lobes

134
Q

Treatment for lung abscess?

What are the indications for surgery?

A

Tx: initially w/ abx (IV PCN or clindamycin)
Indications for surgery: abx failure,
abscess greater than 6cm, or if empyema is present.

135
Q

Work up of a Solitary Lung Nodule:

1st step?

A

Find an old CXR to compare

136
Q

Work up of a Solitary Lung Nodule:
Characteristics of benign nodules?
Treatment?

A

–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

137
Q

Work up of a Solitary Lung Nodule - Characteristics of malignant nodules? Treatment?

A

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.)

138
Q

A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pna or lung collapse.
•MC cancer in non-smokers?

A

Adenocarcinoma. Occurs in scars of old pan

139
Q

Adenocarcinoma: Location and mets?

A

Peripheral cancer. Mets to liver, bone, brain and adrenals

140
Q

Adenocarcinoma: Characteristics of effusion?

A

Exudative with high hyaluronidase

141
Q

Patient with kidney stones, constipation and malaise, low PTH + central lung mass?

A

Squamous cell carcinoma.

Paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca

142
Q

Patient with shoulder pain, ptosis, constricted pupil, and facial edema. Syndrome and cancer?

A

Superior Sulcus Syndrome from Small cell carcinoma. Also a central cancer.

143
Q

Patient with ptosis better after 1 minute of upward gaze?

A

Lambert Eaton Syndrome from small cell carcinoma. Ab to pre-syn Ca chan

144
Q

Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD? Initial treatment?

A

SIADH from small cell carcinoma. Produces Euvolemic hyponatremia.
Fluid restrict and +/- 3% saline in those under Na+ 112

145
Q

CXR showing peripheralcavitation and CT showing distant mets?

A

Large Cell Carcinoma

146
Q

What is the pathophys of ARDS?

A

inflammation leading to impaired case xchange, inflammatory mediator release, and ultimately hypoxemia

147
Q

What are the causes of ARDS?

A

Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis.

148
Q

Diagnosis and Treatment of ARDS?

A

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

149
Q

Murmur: Systolic Ejection Murmur cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardus

A

Aortic stenosis

150
Q

Murmur: SEM louder w/ valsalva, softer w/ squatting or handgrip.

A

Hypertrophic Obstructive Cardiomyopathy

151
Q

Murmur: Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting

A

Mitral Valve Prolapse

152
Q

Murmur: Holosystolic murmur radiates to axilla w/ Left Atrial Enlargement

A

Mitral Regurgitation

153
Q

Murmur: Holosystolic murmur w/ late diastolic rumble in kiddos

A

VSD

154
Q

Murmur: Continuous machine like murmur

A

PDA

155
Q

Murmur: Wide fixed and split S2

A

ASD

156
Q

Murmur: Rumbling diastolic murmur with an opening snap, Left Atrial Enlargement and A-fib

A

Mitral stenosis

157
Q

Murmur: Blowing diastolic murmur with widened pulse pressure and eponym parade.

A

Aortic Regurgitation

158
Q

Patient with bad breath & snacks in

the AM? Tx?

A

Zenker’s diverticulum. False diverticulum. Only contains mucosa
Tx: surgery

159
Q

Patient with dysphagia to liquids & solids. Tx? Other associated conditions?

A

Achalasia.
Tx w/ CCB, nitrates, botox, or heller myotomy
Assoc w/ Chagas dz and esophageal cancer.

160
Q

Patient with dysphagia worse w/ hot & cold liquids + chest pain that feels like MI without regurgitation symptoms. Dx? Treatment?

A

Diffuse esphogeal spasm.

Tx w/ CCB or nitrates

161
Q

Patient with epigastricc pain worse after eating or when laying down cough, wheeze, hoarse. Dx? Tx? Indications for surgery?

A

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.

162
Q

Patient with hematemesis (blood occurs after vomiting) w/ subQ emphysema. Can see pleural effusion, w/ ↑amylase. Dx? Next best test? Tx?

A

Boerhaave’s/Esophageal Rupture

Next step: CXR, gastrograffin esophagram. NO endoscopy

Tx: surgical repair if full thickness

163
Q

If gross hematemesis unprovoked in a cirrhotic w/ pHTN. Dx? If patient is in hypovolemic shock? Tx of choice?

A

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

164
Q

Patient with progressive dysphagia/wgt loss. Dx? Different subtypes and locations? Best 1st test?

A

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.

165
Q

Acid reflux pain after eating, when laying down? Types and descriptions?

A

Hiatal Hernia
Type 1: Sliding GE jxn herniates into thorax. Worse for GERD. Tx sxs.
Type 2: Paraesophageal. Abd pain, obstruction, strangulation needs surgery.

166
Q

Abd pain worse w/ eating, NSAIDs. Dx?
Work up?
Surgery if?

A

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.

167
Q

Most common Gastric Cancer?

A

Adenocarcinoma most common. Esp in Japan

168
Q

What is Mentriers?

A

protein losing enteropathy, enlarged rugae.

169
Q

How do Gastric Varices form?

A

splenic vein thrombosis

170
Q

What is Dieulafoy’s?

A

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

171
Q

Mid Epigastric pain better w/ eating. Dx? Most common cause?

A

Duodenal Ulcers

95% assoc w/ H. pylori

172
Q

Duodenal Ulcers work up? Treatment?

A

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

173
Q

What to suspect if mid Epigastric pain/ulcers don’t resolve? Best test?
Tx?
What else to look for?

A

ZE Syndrome
Test: Secretin Stim Test (find inapprop high gastrin)
Treatment: Surgical resection of pancreatic/duodenal tumor
Ddx: Pituitary and Parathyroid problems.

174
Q

A patient has bilious vomiting and post-prandialpain. Recently lost 200lbs on “Biggest Loser”. Dx?
Pathophys?
Tx?

A

SMA Syndrome

Pathophys: 3rd part of duodenum compressed by AA and SMA

Tx: restore weight/nutrition. Can do Roux-en-Y

175
Q

MEG pain straight through to the back. Dx?
Most common etiologies?
Workup?

A

Dx: Pancreatitis
Etiology: Gallstones & ETOH
W/u: Increased amylase & lipase. CT is best imaging test

176
Q

Pancreatitis: Tx?
Bad prognostic factors?
Complications?

A

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

177
Q

Chronic Pancreatitis S/sx?

Can cause splenic vein thrombosis which leads to …?

A

S/sx: Chronic MEG pain, DM, malabsorption(steatorrhea)

Gastric varices!

178
Q

What is Courvoisier’s sign?

A

large, nontender GB, itching and jaundice, seen in adenocarcinoma in head of pancreas

179
Q

Two signs of pancreatic adenocarcinoma?

A

Courvoisier’s sign

Trousseau’s sign

180
Q

What is Trousseau’s sign?

A

migratory thrombophlebitis

181
Q

Pancreatic adenocarcinoma:
Workup?
–Tx?

A

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.

182
Q

Four conditions of the endocrine pancreas?

A

Insulinoma
Glucagonoma
Somatistainoma
VIPoma

183
Q

Insulinoma-
–Whipple’s triad?
–Labs?

A

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

184
Q

Glucagonoma-
–Sxs?
–Characteristic rash?

A

–Sxs? Hyperglycemia, diarrhea, weight-loss

–Characteristic rash? necrolytic migratory erythema

185
Q

Somatistainoma-
Benign or malignant?
S/sx?

A

Commonly malignant.

S/sx: malabsorption, steatorrhea, ectfrom exocrine pancreas malfxn

186
Q

VIPoma-
Sxs?
Tx?
Ddx?

A

Sis: Watery diarrhea, hypokalemia, dehydration, flushing.

Tx: Octreotide can help sis

Ddx: Looks similar to carcinoid syndrome.

187
Q

RUQ pain back, n/v, fever, worse s/p fatty foods. Dx?
Best 1st test?
Tx?

A

Dx: Acute Cholecystitis
Test: U/S
Tx: Cholecystectomy. Perc cholecystostomy if unstable

188
Q

RUQ pain, high biliand alk-phos. Dx?
Workup?
Tx?

A

Dx: Choledocolithiasis
W/u: U/S will show CBD stone.
Tx: Chole +/-ERCP to remove stone

189
Q

RUQ pain, fever, jaundice, ↓BP, AMS. Dx?

Tx?

A

Ascending Cholangitis

Tx: fluids & broad spec abx. ERCP and stone removal.

190
Q

Choledochal cysts-
Type 1?
Type 5?

A

Type 1: Fusiform dilation of CBD Tx w/ excision

Type 5: Caroli’s Dz. Cysts in intrahepatic ducts needs liver transplant

191
Q

Cholangiocarcinoma risk factors? Tx?

A

Rare
Risk factors: Primary sclerosing cholangitis (UC), liver flukes and thorothrast exposure.
Tx w/ surgery +/-radiation.

192
Q

Hepatitis-

1) AST = 2x ALT - Dx?
2) AST > ALT high (1000s) - Dx? 
3) AST & ALT high s/p hemorrhage, surg, or sepsis - Dx? 

A

1 - Alcoholic hepatitis
2 - Viral hepatitis
3 - Shock liver

193
Q

Cirrhosis and Portal HTN-
Tx?
Esophageal varices tx?

A

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.

194
Q

TIPS relieves portal HTN but… ?

Treat complications with?

A

worsens hepatic encephalopathy

Tx: Lactulose. helps rid body of ammonia.

195
Q

Hepatocellular Carcinoma

Risk factors?

A

chronic hepB carrier greater than hepC. Cirrhosis for any reason, plus aflatoxin or carbon tetrachloride

196
Q

Hepatocellular Carcinoma
Workup?
Tx?

A

W/u: high AFP (in 70%), CT/MRI.

Tx: can surgically remove solitary mass, use radiation or cryoablation for palliation of multiple masses

197
Q

Women on OCP with palpable abd mass or spontaneous
rupture and hemorrhagic shock. Dx?
Workup?
Tx?

A

Dx: Hepatic Adenoma
W/u: U/S or MRI
Tx: d/c OCPs. Resect if large or pregnancy is desired

198
Q

2nd Most common benign liver tumor. W>M but less likely to rupture.
Tx?

A

Focal Nodular Hyperplasia

No tx needed.

199
Q

Bacterial Liver Abscess.
Most common bugs?
Tx?

A

Most common:E. coli, bacteriodes, enterococcus.

Tx: Surgical drainage and IV abx.

200
Q

RUQ pain, profuse sweating and rigors, palpable liver.
Dx?
Tx?

A

Dx: Entamoeba histolytica.

Tx: Metronidazole. DON’T drain it.

201
Q

Patient from Mexico presents w/ RUQ pain and large liver cysts found on U/S. Dx?

A

Enchinococcus.

202
Q

Enchinococcus:
Mode of transmission?
Lab findings?
Tx?

A

Transmission: Hydatid cyst paracyte from dog feces.
Lab: eosinophilia, +Casoni skin test
Treatment: albendazole and surgery to remove ENTIRE cyst, rupture leads to anaphylaxis

203
Q

Post-Splenectomy:
Post op thrombocytosis Tx?
Prophylaxis?

A

Thrombocytosis: above 1 million give aspirin.

Prophylaxis: PCN + Strep pneumo, Heamophilus influenza and Neisseria meningitidis vaccines.

204
Q

Patient with bleeding gums, petechiae, nose bleeds?

A

Consider ITP in isolated thrombocytopenia

205
Q

ITP:
Platelet levels and bone biopsy findings?
Spleen changes?
Tx?

A

Decr plt count, inc megakaryocytes in marrow.
NO splenomegaly.
Tx: steroids 1st. If relapse splenectomy

206
Q

S/sx of hereditary spherocytosis?
Other associated condition?
Tx?

A

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).

207
Q

Patient with L lower rib fx and intra abdominal hemorrhage. Major concern?
What is Kehr’s sign?

A

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.

208
Q

Patient with pain in umbilical area moving to RLQ,+ n/v. Dx?
Indications for surgery?
Contraindications for surgery and alt tx?

A

Dx: Appendicitis
Indication: If clinical picture is convincing
Contraindication: perforated/abscess. Drain, abx (to cover e.coli & bacteriodes), and do interval appendectomy

209
Q

1 site of Carcinoid Tumors?

A

Appendix

210
Q

Carcinoid syndrome sxs?
When do they happen?
What else to look out for?

A

Sxs: Diarrhea, Wheezing.

Happens: When metastasizes to liver. (1st pass metabolism of serotonin and kallikrein)

Else: Diarrhea, Dementia, Dermatitis

211
Q

Carcinoid syndrome treatment:
If >2cm, @ base of appendix, or w/ + nodes?
Otherwise?

A

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

212
Q

Small Bowel Obstruction
Conditions that cause SBO?
–Sxs?

A

Conditions: hernia, prior GI surgery (adhesions), cancer, intussusception, IBD.

Sxs: pain, constipation, obstipation, vomiting.

213
Q

SBO:
1st test?
Tx?

A

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.

214
Q

Volvulus

Treatment for either cecal or sigmoid?

A

Decompression from below if not strangulated. Otherwise, need surgical removal and colostomy.

215
Q

Post-Op Ileus:
Potential contributing factors?
Imaging may show?
Treatment and indication for surgery?

A

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.

216
Q

What is Ogilvie’s syndrome? Tx?

A

See massive colonic distension. If greater than 10cm, need decompression w/ NG tube and neostigmine (watch for bradycardia) or colonoscopic decompression.

217
Q

Umbilical hernias. Tx in peds? Tx in adults?

A

In kiddos, close spontaneously by age 2.

In adults: 2/2 obesity, ascites or pregnancy.

218
Q

Indirect Inguinal hernias: How common? Anatomic landmarks involved? Cause?

A

Most Common type of hernia.
through inguinal ring (lat to epigastric vessles) in spermatic cord.
R>L, more often congenital (patent proc vaginals)

219
Q

Direct Inguinal hernias? Anatomic landmarks involved? Cause?

A

through Hasselbeck’s triangle (med to epigastric vessles), more often acquired weakness.

220
Q

Femoral hernias: most common sex?

A

more common in women.

221
Q

Hernia treatment (any type)?

A

Emergent surgical repair if incarcerated to avoid strangulation. Elective if reducible.

222
Q

What type of Inflammatory Bowel Disease involves the terminal ileum? What condition does it mimic, and what deficiency is found?

A

Crohn’s. Mimics appendicitis. Fe deficiency.

223
Q

What type of Inflammatory Bowel Disease is Continuous involving rectum?

A

Ulcerative Colitis. Rarely ileal backwash but never higher

224
Q

What type of Inflammatory Bowel Disease increases risk for Primary Sclerosing Cholangitis? What may PSC lead to?

A

UC.

PSC leads to higher risk of cholangiocarcinoma

225
Q

What gross and microscopic features are seen in crohn’s?

A

Fistulae are likely

Granulomas and Transmural inflammation on biopsy

226
Q 
What type of Inflammatory Bowel Disease is:
Cured by colectomy?
Smokers have lower risk?
Highest risk of colon cancer?
Associated w/ p-ANCA?
A

Ulcerative colitis,
smokers have increased risk for crohn’s.
Risk of colon cancer is another reason to perform colectomy.

227
Q

Inflammatory Bowel Disease: Drugs to induce remission? Drugs to maintain remission?
Tx for abscesses in CD?
Drugs for severe disease?

A

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.

228
Q

Diverticulosis-
True or false diverticulum?
Cause?
Complications?

A 
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
229
Q

Diverticulitis:
Sxs?
Imaging?
Do colonoscopy when?

A

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.

230
Q

Diverticulitis:
Medical Tx?
Indications for surgery?

A

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)

231
Q

Colorectal Cancer:
Genetic risk factors?
Other risk factors?

A

Genetic: AFP, Lynch Syndrome, HNPCC, Gardners, Cowdens

Other: Ulcerative colitis

232
Q

Colorectal cancer Sxs:
Right sided cancer?
Left sided cancer?
Rectal cancer?

A

Right: bleeding
Left: obstruction
Rectal: pain/fullness, bleeding/obstruction

233
Q

Colorectal cancer:

Work up?

A

Digital Rectal Exam (DRE), transrectal ultrasound (depth of invasion), CT for staging, Colonoscopy! Carcinoembryonic antigen (CEA) to measure recurrance

234
Q

Colorectal cancer Tx
For colon?
For rectum?

A

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)

235
Q

AAA
Screening?
Sxs?

A

Screening: men 65-75 who have ever smoked. Do abdominal U/S.
Sxs: pulsatile abdominal mass.

236
Q

AAA Tx
conservatively if?
Surgery indicated if?

A

Conservative: if under 5cm and asymptomatic, monitor growth every 3-12mo.
Surgery: greater than 5cm, growing faster than 4mm/yr

237
Q

AAA: Rupture Sxs? Mortality?

A

Sxs: severe sudden abdomen, flank or back, shock, tender pulsatile mass.
Mortality: 50% die before reaching the hospital.

238
Q

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?

A

1: MI

Diarrhea: Ischemic colitis
Weakness: ASA syndrome
GI bleed: Aortoenteric Fistula

239
Q

Acute Mesenteric Ischemia:
Presentation?
Risk factors?

A

Presentation: Patient with acute abdominal pain
Risk: Hypercoagulable or vasoconstrictor states. A-fib and sub therapeutic warfarin, high dose vasoconstrictors, etc.

SURGICAL EMERGENCY!!

240
Q

Acute mesenteric ischemia:
Work up?
Tx?

A

W/u: Angiography (aorta and SMA/IMA)

Tx: Embolectomy. If thrombus, or aorto-mesenteric bypass.

241
Q

Chronic Mesenteric Ischemia:
Pathophys?
Sxs?

A

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”.

242
Q

Chronic Mesenteric Ischemia:
Dx?
Tx?

A

Dx: duplex or angiography

Tx: aortomeseteric bypass or transaortic mesenteric endarterectomy.

243
Q

Peripheral Artery Disease:

5P’s of Acute arterial occlusion?

A

5P’s: pulseless, pallor, pain, paresthesias, paralysis

244
Q

Acute arterial occlusion:
Tx?
Surgery timeline?

A

Tx: immediate heparin + prepare for surgery.
Surgery: embolectomy or bypass done w/in 6hrs to avoid loss.

245
Q

Acute arterial occlusion:
Thrombolytics may be possible if?
Complications?

A

Thrombolytics if: no surgery in previous 2wks, no hemorrhagic stroke.

Complications: Compartment syndrome during reperfusion period (Tx: fasciotomy, watch for myoglobinuria.)

246
Q

Claudication:
Sxs?
Best test? What is normal?

A

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)

247
Q

Claudication Ankle:Brachial index values and Tx:
Claudication & Ulcers?
Limb ischemia?
Gangrene?

A

Claudication: 0.4-0.8; medical management
Ischemia: 0.2-0.4; Surgery is indicated
Gangrene: less than 0.2; May require amputation

248
Q

DVT:
Dx?
Tx?
Complications?

A

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

249
Q

PE:
Random signs?
First step?

A

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.

250
Q 
PE:
Tx?
Thrombolytic contraindications?
Indications for surgery?
Indications for IVC filter?
A

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.

251
Q

Work up of a Thyroid Nodule
1st step?
If low?
If normal?

A

1st: Check TSH
Low: Do RAIU to find the “hot nodule”. Excise or radioactive I-131
Nl: FNA

252
Q 
Work up of a Thyroid Nodule post FNA:
If benign?
If malignant?
If indeterminate?
If cold?
A

Benign: Leave it alone.
Malignant: Surgically excise and check pathology
Indeterminate: Re-biopsy or check RAIU
Cold: Surgically excise and check pathology

253
Q

5 types of thyroid malignancies?

A 
Papillary
Follicular
Medullary
Anaplastic
Thyroid Lymphoma
254
Q

MC type of thyroid malignancy, spreads via lymph, psammoma bodies?

A

Papillary

255
Q

Thyroid malignancy that spreads via blood, must surgically excise whole thyroid?

A

Follicular

256
Q

Thyroid malignancy associated w/ MENII (look for pheo, hyperCa). Amyloid/calci?

A

Medullary

257
Q

Thyroid malignancy with 80% mortality in 1st year?

A

Anaplastic

258
Q

Thyroid malignancy that Hashimoto’s predisposes to?

A

Thyroid lymphoma

259
Q

Work up of an Adrenal Nodule
1st step?
2nd step?
Tx?

A

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

260
Q

Pheochromocytoma
Features?
Test?

A

Sxs: High blood pressure, catechol symptoms

Test: Urine-and plasma-free metanephrines

261
Q

Primary aldosteronism:
Features?
Test?

A

Features: High blood pressure, low K+, low PRA*

Test: Plasma aldosterone-to-renin ratio

262
Q

Adrenocortical carcinoma:
Features?
Test?

A

Features: Virilization or feminization

Test: Urine 17-ketosteroids

263
Q

Cushing or “silent” Cushing syndrome:
Features?
Test?

A

Features: Cushing symptoms or normal examination results

Test: Overnight 1-mg dexamethasone test

264
Q

Hypoparathyroidism:
Most common cause?
Sxs?
Serum labs?

A

Cause: Typically comes from thyroidectomy
Sxs: perioral numbness, Chvortek, Trousseau
Labs: ↓Ca+, ↑PO4+, ↓*PTH+

265
Q 
Hyperparathyroidism:
Sxs?
Labs?
Dx?
Tx?
A

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.

266
Q

Cancers of MEN1?

A

pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor.

267
Q

Cancers of MEN2a?

A

parathyroid hyperplasia, medullary thyroid cancer, pheochromocytoma

268
Q

Cancers of MEN2b?

A

medullary thyroid cancer, pheochromocytoma, Marfanoid

269
Q

Work up of a Breast Mass

Best uses for U/S and MRI?

A

•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)

270
Q

Work up of a Breast Mass:
Imaging?
Next step for cystic? For solid?
Next step if mass is palpable or fluid returns?

A 
Imaging: U/S or MRI
Cystic: Aspiration of fluid
Solid: FNA
Palp/returns: Excisional biopsy
Mammaographicallyguided multiple core biopsies
271
Q

Breast Cancer risk factors?

A

BRCA1 or 2, personal hx of breast cancer, nulliparity, endo/exogenous estrogen.

272
Q

DCIS Tx?

A

Either excision w/ clear margins or simple mastectomy if multiple lesions (no node sampling) + adjuvant RT.

273
Q

LCIS Tx?

A

More often bilateral. Consider bilateral mastectomy only if +FH, hormone sensitive, or prior hx of breast cancer

274
Q

Infiltrating ductal/lobular carcinoma Tx?

A

–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.

275
Q

Paget’s Dz appearance and workup?

A

Looks like eczema of the nipple.

Do mammogram to find the mass

276
Q

Inflammatory breast cancer appearance?

A

Red, hot, swollen breast. Orange peal skin. Nipple retraction

277
Q

Basal Cell Carcinoma Tx?

A

Shave or punch bx then surgical removal (Mohs)

278
Q

Squamous Cell Carcinoma-
Precursor lesion and Tx?
Tx of SCC?

A

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.

279
Q

Melanoma-
2 types?
Acrolentiginous form occurs where and in who?
Lentigo Maligna?

A

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)

280
Q

Melanoma:
Biopsy spec?
Tx?
Medication therapy?

A

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

281
Q 
Soft Tissue Sarcoma-
Appearance?
Dx?
Tx?
Spread and 1st mets?
A

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.

282
Q

Liposarcoma

Source?

A

99% DON’T come from lipoma

283
Q

Fibrosarcoma/Rhabdomyosarcoma/ Lymphangiosarcoma
Sxs?
Common association?

A

Sxs: Hard round mass on extremity.

Association: Can occur in areas of chronic lymphedema

284
Q

Rule of 7s for Neck Mass

A

•7 days = inflammatory, 7 mo= cancer, 7 yrs= congenital

285
Q

Neck Mass:
Most Common cause?
Exam for lesion lasting more than 2 weeks?
If node is firm, rubbery and “B sxs” are present? 

A

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

286
Q

Neck Mass:

Lymphoma subtypes?

A

Hodgkins vs Non-Hodgkins

287
Q

Neck Mass:
Good prognostic factors for hodgkins? non-hodgkin?
Work up?

A

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

288
Q

Neck Mass:
If midline?
If anterior to SCM?
If spongy, diffuse and lateral to SCM?

A

Midline: thyroglossalduct cyst, move tongue and mass moves. Remove surgically.
Anterior: branchial cleft cyst
Spongy: cystic hygroma (Turners, Down’s, Klinefelters)

289
Q

Oral Cancer-
Most common type?
Population?
Tx?

A

Most freq: squamous cell.
Population: In smokers & drinkers
Tx: XRT or radical dissection (jaw/neck)

290
Q

Laryngeal Cancer-
Types in peds vs adults?
Tx?

A

Laryngeal papilloma in kiddo w/ stridor or cough
Squamous cell in adults.

Tx: laryngoscope laser or resection

291
Q

Pleomorphic Adenoma

Location?

A

Most Common salivary glad tumor. Usually on parotid. Benign but recurs

292
Q

Warthlin’s Tumor-
Location?
Complications?

A

Papillary cyst adenoma lymphomatosum. Benign on parotid gland.
Can injure facial nerve (look for palsy sxs in question Stem)

293
Q

Mucoepidermoid Carcinoma-
Common?
Source tissue?

A

MC malignant tumor.
Arises from duct.
Causes pain and CN VII palsy

294
Q

Baby is born w/ respiratory distress, scaphoid abdomen & bowels in lung space on CXR.
Dx?
Biggest concern?
Best treatment?

A

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

295
Q

Baby is born w/ respiratory distress w/ excess drooling.
Most likely Dx?
Best diagnostic test?

A

Dx: TE-Fistula
Test: Place feeding tube, take xray, see it coiled in thorax

296
Q 
Defect lateral (usually R) of the midline, no sac.
Dx?
Labs?
Assoc w/ other disorders?
Complications?
A

Dx: Gastroschisis
Labs: will see high maternal AFP
Assoc: Not usually. May be atretic or necrotic req removal.
Complications: Short gut syndrome

297
Q

Newborn with defect in the midline. Covered by sac.
Dx?
Assoc w/ other disorders?

A

Dx: Omphalocele

Assoc: yes (not specified in handout)

298
Q

Defect in the midline. No bowel present outside abdomen.
Dx?
Assoc w/ other disorders?
Treatment?

A

Dx: Umbilical Hernia

Assoc: Assoc w/ congenital hypo-thyroidism. (also big tongue)

Tx: Repair not needed unless persists past age 2 or 3.

299
Q

4wk old infant w/ non-bileous vomiting and palpable “olive”
Dx?
Metabolic complications?
Tx?

A

Dx: Pyloric Stenosis

Metabolic comp: Hypochloremic, metabolic alkalosis

Tx: Immediate surg referral for myotomy

300
Q

2wk old infant w/ bileous vomiting. The pregnancy was complicated by poly-hydramnios.
Dx?
Assoc w/?

A

Dx: Intestinal Atresia Or Annular Pancreas

Assoc: Down Syndrome (esp duodenal)

301
Q

1 wk old baby w/ bileous vomiting, draws up his legs, has abd distention.
Dx?
Pathophys?

A

Dx: Malrotation and volvulus *Ladd’s bands can kink the duodenum

Pathphys: Doesn’t rotate 270 ccw around SMA

302
Q

A 3 day old newborn has still not passed meconium.

DDX? (name 2)

A

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

303
Q

A 5 day old former 33 weeker develops bloody diarrhea

Dx?

A

Necrotizing Enterocolitis

304
Q

Necrotizing Enterocolitis:
What do you see on xray?
Treatment?
Risk factors?

A

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.

305
Q

A 2mo old baby has colicky abd pain and current jelly stool w/ a sausage shapend mass in the RUQ.
Dx?
Workup and tx?

A

Dx: Intussusception

W/u: Barium enema is dx and tx

306
Q

BPH-
Effect of anticholinergics?
Tx for acute urinary retention?
Tx?

A

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)

307
Q

Prostate Cancer-
Signs?
Workup?
Tx?

A

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.

308
Q

Kidney Stones
Best test?
Tx?
Indication for surgery?

A

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.

309
Q

Scrotal Mass-
Workup?
Tx?

A

Workup: Transilluminate, U/S,
Tx: excision! (don’t bx). Know hormone markers!

310
Q

Testicular Torsion
Sxs?
Workup?
Tx?

A

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.

311
Q

Avascular Necrosis-
Common causes in kids?
Common causes in adults?

A

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.

312
Q

Osteosarcoma
Location?
Appearance?

A

Location: Seen in distal femur, proximal tibia
@ metaphysis, around the knee

Appearance: Codman’s triangle and Sunray appearance

313
Q 
Ewing Sarcoma-
Location?
Sxs?
X-ray appearance?
Tumor type?
A

Seen at diaphysis of long bones,

Sxs: night pain, fever& elevated ESR

X-ray: Lytic bone lesions, “onion skinning”.

Type: Neuroendocrine (small blue) tumor

314
Q

Hyper acute transplant Rejection
Signs?
Cause?

A

Sign: Vascular thrombosis w/in minutes

Caused by preformed antibodies

315
Q

Acute Transplant Rejection
Signs?
Timing?
Cause?

A

Signs: Organ dysfunction (incrGGT or Cr depending on organ)

Time: w/in 5days –3mo.

Cause: Due to T-lymphocytes.

316
Q

Acute transplant rejection
Workup for technical problems with liver?
Heart transplant concerns?
Treatment?

A

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)

317
Q

Chronic Rejection-
Timeline?
Cause?
Tx?

A

Time: Occurs after years.

Cause: Due to T-lymphocytes.

Tx: Can’t treat it. Need re-transplantation.

318
Q

Anesthesia:
Why give local-(lidocaine, etc) with epi?
Sxs of problems with local?

A

To prevent systemic absorption

Sxs: numb tongue, seizures hypotension, bradycardia, arrhythmias

319
Q

Do not give epi with local anesthesia in which locations?

A

Fingers, nose, penis, toes

320
Q

Who gets Spinal-Subarachnoid anesthesia?

Contraindications?

A

Patients who can’t be intubated.
Can’t give if increased ICP or hypotensive
bupivacaine and others are used

321
Q

What happens in a “high block” epidural?

A

blocks heart’s SNS nerves and phrenic nerve

322
Q

Meperidine uses?

A

Anesthesia drug

Norperidine metabolite can lower seizure threshold esp in pts w/ renal failure.

323
Q

Succinylcholine complications? Contraindications?

A

Can cause malignant hyperthermia, hyperK (not for burn or crush victim)

324
Q

Rocuronium complications?

A

Sometimes allergic rxn in asthmatics

325
Q

Halothane complications?

A

Can cause malignant hyperthermia (dantroline Na)

Liver toxicity.

Surgery Shelf (9 decks)

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