High Yield Surgery Flashcards
Absolute CI to surgery?
Poor nutrition CI to surgery?
Severe liver failure criteria as CI to surgery?
Diabetic coma and DKA
Albumin <3, transferrin <200, weight loss <20%
Bili >2, PT >16, NH3 > 150 or encephalopathy
Goldmans index:
- If CHF, what should you check?
- If MI within 6 mo, what should you check?
CHF: check EF, if <35, no surgery
MI: EKG –> stress test –> cardiac cath –> revasc.
type of vent used in ARDS or CHF and why?
PEEP –> pressure given at the end of cycle to keep alveoli open
best test to evaluate management of a patient on a vent?
What do you do if PaO2 is low? High?
What do you do if PaCO2 is low (pH is high)? PaCO2 is high (pH is low)?
Get an ABG
PaO2 is low=Increase FiO2
PaO2 is high=Decrease FiO2
PaCO2 is low (pH high)=Decrease rate or TV
PaCO2 is high (pH is low)=increase rate or TV
causes of non-gap acidosis?
diarrhea
diuretics
RTAs
tx for hyponatremia? what If hypovolemic?
Tx-Fluid restriction and diuretics
If hypovolemic-Norma saline
Tx for hypernatremia? What would you worry about?
Tx-Replace w/D5W or hypotonic fluid
Worry about cerebral edema
Numbness, + Chvostek or Trousseaeu sign, prolonged QT interval?
Hypocalcemia
Bones, stones, groans, psycho moans. Shortened QT interval?
Hypercalcemia
Paralysis, ileum, ST depression, U waves? Tx?
Hypokalemia
Give K+, max 40 mEq/hr
Peaked T waves, prolonged PR and QRS, sine waves? Tx?
Hyperkalemia
Give CaGluconate –> then insulin plus glucose –> then Kayexalate, albuterol and NaHCO3
Last resort=dialysis
Formula for Maintenance IVFs and fluids to use?
Use D5 1/2 NS + 20 KCl (if peeing)
1st 10 kg=100 ml/kg/day
Next 10 kg=50 ml/kg/day
Above 20=20 ml/kg/day
tx for circumferential burns?
consider echarotomy
pt with confusion, HA, cherry red skin? Best test? Tx?
CO poisoning
Best test=Check carboxyHb (pulse ox=worthless)
Tx=100% O2 (hyperbaric if CO-Hb is increased significantly)
clotting, edema, HTN, and foamy pee?
nephrotic syndrome
clotting in a post op pt, low platelets? Tx how?
HIT (if hearing within 5-14 days)
Tx with leparudin or argatroban
bleeding and an isolated decrease in platelets?
ITP
bleeding with normal platelets but increased bleeding time and PTT?
vWD
Bleeding, low plts, increased PT/PTT/BT, low fibrinogen, high D-dimer, and schistocytes?
DIC
Caused by GN sepsis, carcinomatosis, OB stuff
Parkland formula for burn fluid replacement? fluid type?
Kg x %BSA x 3-4
LR or NS
Name the topical solution for burn tx:
- Doesnt penetrate eschar and can cause leukopenia?
- Pentetrates eschar but hurts like hell?
- Doesnt penetrate eschar and causes hypoK and hypoNa?
Silver sulfadiazine
Mafenide
Silver nitrate
best 1st step in an electrical burn? if abnormal?
EKG
48 hrs of telemetry (also if LOC)
in a burn pt, if affected extremity is extremely tender, numb, white, cold with barely dopplerable pulses? tx?
compartment syndrome –> 5 Ps or compartment pressure >30 mm Hg
Tx=Fasciotomy
Name some scenarios that require intubation in a trauma pt?
- Unconscious
- GCS < 8
- Stung by bee, develops stridor, tripod posturing
- Stabbed in neck, GCS=15, expanding mass in lateral neck
Airway for guy stabbed in neck, crackly sounds w/palpating anterior neck tissues?
fiberoptic bronchoscope
Airway for guy with huge facial trauma, blood obscures oral and nasal airway, and GCS of 7?
cricothyroidotomy
a pt has inward movement of the right ribcage on inspiration? Tx?
Flail chest = >3 consecutive rib fx
Tx=O2 and pain control
pt has confusion, petechial rash in chest, axilla, and neck, and acute SOB? When do you suspect this?
Fat embolism
After long bone fx (i.e., femur)
a pt dies suddenly after a 3rd yr med student removes a central line? when else can you suspect this dx?
air embolism
lung trauma, vent use, during heart vessel surgery
muffled heart sounds, JVD, electrical alternans, pulsus paradoxus? Confirmatory test? Tx?
Pericardial tamponade
FAST scan
Needle decompression, pericardial window or median sternotomy
Decreased breath sounds on one side, tracheal deviation away from collapsed lung? Next best step?
tension pneumothorax
needle decompression followed by chest tube
hypotensive, tachycardic, diaphoretic, cool and clammy extremities. Type of shock and tx?
Hypovolemic
Crystalloid resuscitation
AMS, hypotensive, warm, dry extremities (early), later hypotensive, tachycardia, cool and clammy. Type of shock and tx?
Vasogenic
Fluid resuscitation and tx offending org
Hypotensive, bradycardic, warm, dry extremities, absent reflexes and flaccid tone. Type of shock and tx?
Neurogenic
If adrenal insuff, tx with dexamethasone and taper over several weeks
Hypotensive, tachycardic, JVD, decreased heart sounds, normal breath sounds, pulsus paradoxus. Type of shock and tx?
Cardiocompressive (tamponade)
Tx is pericardiocentesis
SOB, clammy extremities, rales b/l, S3, pleural effusion decreased breath sounds, ascites, peripheral edema. Type of shock and tx?
Cardiogenic
Give diuretics up front, tx the HR to 60-100, then address rhythm. Give vasopressor support if necessary
Penetrating trauma to the following zones dx and/or tx:
Zone 1
Zone 2
Zone 3
Zone 1=Aortography and triple endoscopy
Zone 2=2D doppler +/- exploratory surgery
Zone 3=Aortography
Next best step in GSW to abdomen?
ex-lap + tetanus ppx
next best step if stab wound to abdomen, pt unstable, with rebound tenderness and rigidity, or w/evisceration?
ex-lap + tetanus ppx
next best step in abd stab wound but pt is stable?
FAST exam. DPL if FAST is equivocal
Ex-lap if either are positive
next best step in blunt abd trauma pt with hypotension/tachycardia?
ex-lap
next best step if you see air under the diaphragm in a chest/abd X-ray?
directly go to ex-lap
next best step if blunt abd trauma and unstable?
ex-lap
next best step if blunt abd trauma and stable?
abdominal CT
blunt abd trauma, lower rib fx plus bleeding into abdomen?
spleen or liver laceration
blunt abd trauma, lower rib fx plus hematuria?
kidney laceration
blunt abd trauma, kehr sign and viscera in thorax on cxr?
diaphragm rupture
blunt abd trauma and handle bar sign?
pancreatic rupture
blunt abd trauma, stable with epigastric pain. Next best test? what if retroperitoneal fluid is found?
abdominal CT
consider duodenal rupture
pelvic trauma, hypotensive, tachycardia. Next best step?
FAST and DPL to r/o bleeding in abd cavity
blood at urethral meatus and high riding prostate. next best test?
Retrograde urethrogram. Consider pelvic fx w/urethral or bladder injury
If retrograde urethrogram is normal, do a retrograde cystogram to evaluate bladder
tx for exztraperitoneal extravastation from bladder rupture? What about intraperitoneal?
extra=Bed rest + foley
intra=Ex-lap and surgical repair
how do you manage the following fx’s:
- Depressed skull fx
- Severely displaced or angulated fx
- Open fx (bone sticking out of skin)
- Femoral neck or intertrochanteric fx
Go to the OR
Shoulder pain s/p seizure or electrical shock?
post shoulder dislocation
arm outwardly rotated and numbness over deltoid?
ant should d/l
old lady FOOSH, distal radius displaced?
Colles fx
Punched a wall?
metacarpal neck fx (Boxers fx)
Where is the clavicle most commonly broken? how to tx?
between middle and distal 1/3
figure of 8 device
fever post-op day 1, MC cause, low five (<101) and nonproductive cough? How to dx and tx?
atelectasis
Dx with CXR-b/l lower lobe fluffy infiltrates
Tx with mobilization and incentive spirometry
fever post-op day 1, high fever (>101), very ill appearing?
nec fasc
pattern of spread of nec fasc in a pt post-op day 1? Common bugs? Tx?
SubQ along Scarpas fascia
GABHS or C perfringens
IV PCN, go to OR and debride skin until it bleeds
fever post-op day 1, high fever (>104), muscle rigidity? what is it caused by? genetic defect? tx?
Malignant hyperthermia
Succinylcholine or Halothane
Ryanodine receptor gene defect
Dantrolene Na (blocks RYR and decreases IC Ca)
fever POD 3-5, productive cough, diaphoresis, lobe infiltrate? tx?
pneumonia
check sputum sample for culture, cover with moxi to cover S pneumonia in mean time
fever POD 3-5, dysuria, frequency, urgency, pt has a foley? Next best test? Tx?
UTI
UA (nitrite and LE) and culture
Change foley and tx with wide-spec abx until culture returns
Fever POD 7, pain and tenderness at IV site? tx?
Central line infx
Blood cx from the line. Pull it. Abx to cover staph
Fever POD 7, pain at incision site, edema, induration? Tx?
Cellulitis
Blood cx and start abx
Fever POD 7, pain at incision site, induration with drainage? tx?
Simple wound info
Open wound and repack. No abx necessary
Fever POD 7, pain with salmon colored fluid from incision? Tx?
Dehiscence
surgical emergency! Go to OR, IV abx, primary closure of fascia
Unexplained fever POD 7? Dx? Tx?
Abdominal abscess
CT w/oral, IV, and rectal contrast to find it. Diagnostic lap
Drain it! Percutaneously, IR-guided, or surgically
SubQ destruction into the muscle. What ulcer stage?
3
4=involvement of joint or bone
1=skin intact but red. blanches with pressure
2=blister or break in the dermis
How to tx stage 1-2 ulcers?
get special mattress, barrier protection
how to tx stage 3-4 ulcers?
get flap reconstruction surgery
RA, TB, and malignant or PE cause what type of pleural effusion?
transudative
transudative pleural effusion and low pleural glucose?
RA
transudative pleural effusion and high lymphocytes?
TB
translative pleural effusion and bloody?
malignant or PE
What is Light’s criteria?
Translative pleural effusion if:
- LDH <200
- LDH eff/serum < 0.6
- Protein eff/serum < 0.5
MC CA in non-smokers?
AdenoCA
Occurs in scars of old pneumonia
Where does lung CA MC metastasize?
bone, brain, liver, adrenals
characteristic of effusion in pt with lung CA?
exudative with high hyaluronidase
Pt with kidney stones, constipation and malaise, low PTH and central lung mass?
Squamous cell CA
Paraneopastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca
Pt with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia. Has shoulder pain, ptosis, constricted pupil and facial edema?
Superior sulcus syndrome from Small Cell CA. A Central CA
Pt with lung CA sx, ptosis that is better after 1 min of upward gaze?
Lambert eaton syndrome from Small Cell CA. Ab to pre-synaptic Ca channels
Pt with lung CA sx, old smoker presenting with Na=125, moist mucous membranes, no JVD?
SIADH from small cell CA. Produces euvolemic hyponatremia
Fluid restrict +/- 3% saline in <112
Pt with lung CA sx, CXR showing peripheral cavitation and CT showing distant mets?
Large cell CA
tx for ARDS?
Mechanical ventilation with PEEP
SEM, cresc/decresc, louder with squatting, softer w/ valsalva
AS
SEM, louder with valsalva, softer with squatting or handgrip
HOCM
Late systolic murmur with click, louder with valsalva and handgrip, softer with squatting
MV prolapse
Holosystolic murmur radiates to axilla with left atrial enlargement
mitral regurgitation
Holosystolic murmur with late diastolic rumble in kiddos
VSD
continuous machine-like murmur
PDA
wide, fixed, and split S2
ASD
Rumbling diastolic murmur with an opening snap, left atrial enlargement, and A fib
Mitral stenosis
blowing disastolic murmur with widened pulse pressure and eponym parade
aortic regurgitation
Bad breath and snacks in the AM? Tx? True or false diverticulum?
Zenkers diverticulum
Surgery
False
Dysphagia to liquids and solids, birds beak appearance? Tx?
Achalasia
Tx with CCB, nitrates, botox, or Heller myotomy
Dysphagia worse with hot and cold liquids plus chest pain that feels like MI w/ nighttime regurg? Tx?
Diffuse esophageal spasm
Tx with CCB or nitrates
Epigastric pain worse after eating or when laying down, cough, wheeze, hoarseness? Most sensitive test? What if danger signs? Tx? Indications for surgery?
GERD
Most sensitive test=24 hr pH monitoring.
Danger signs=Endoscopy
Tx=Behavior modification 1st, then antacids, H2 block, PPI
Surgery=bleeding stricture, Barretts, incompetent LES, max dose PPI w/ still sx, or no want meds
If hematemesis (blood occurs after vomiting, w/ subQ emphysema), can see pleural effusion with increased amylase? Next best test? Tx?
Boerhaave’s –> esoph rupture
CXR, Gastrograffin esophagram. NO ENDOSCOPY
Tx with surgical repair if full thickness
If gross hematemesis unprovoked in a cirrhotic w/portal HTN?
gastric varices
what if ruptured gastric varices and in hypovolemic shock? Tx of choice?
do ABCs, NG lavage, medical tx with octreotide or SS. Balloon tamponade only if you need to stabilize for transport
Endoscopic sclerotherapy or banding
How to tx asymptomatic gastric varices?
B blockers
Best 1st test if suspecting esophageal carcinoma?
barium swallow, then endoscopy with biopsy, then staging CT
Work up for MEG pain worse with eating (gastric ulcer)?
Double-contrast barium swallow - punched out lesion with regular margins
EGD with bx can tell H pylori, malignant/b9
Surgery for gastric ulcer if?
lesion persists after 12 wks of tx
MEG pain better with eating? Biggest association? Dx? Tx?
Duodenal ulcer
95% assoc with H pylori
Dx with blood, stool, or breath test for H pylori but Endoscopy with biopsy (CLO test) is BEST b/c it can also exclude CA
Tx is PPI, clarithromycin, and amoxicillin for 2 weeks. Breath or stool test can be test of cure
What to suspect if MEG pain/ulcers don’t resolve? Best test? Tx? What else to look for?
ZE syndrome
Secretin stim test (find inappropriately high gastrin)
surgical resection of pancreatic/duodenal tumor
Look for pituitary and parathyroid problems
Pt has bilious vomiting and post-prandial pain. Recently lost 200 lbs on “Biggest loser”? Pathophys? Tx?
SMA syndrome
3rd part of duodenum compressed by AA and SMA
Restore weight/nutrition. Can do Roux-en-Y
large, nontender GB, itching and jaundice, migratory thrombophlebitis should suspect what?
Pancreatic adenoCA
Tx pancreatic adenoCA with Whipple if?
no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoneal mets
sweaty, tremors, hunger, seizures, blood glucose <45, and sxs resolve with glucose administration? What will labs show?
insulinoma
increased insulin, C peptide, and pro-insulin
hyperglycemia, diarrhea, weight loss, and necrolytic migratory erythema?
glucagonoma
Malabsorption, steatorrhea, ect from exocrine pancreas malfx?
somatostatinoma
watery diarrhea, hypoK, dehydration, and flushing? Tx?
VIPoma (looks like a carcinoid)
Octreotide can help sxs
Res for cholangiocarcinoma?
PSC (UC)
Liver flukes
thorotrast exposure
Tx with surgery +/- radiation
AST=2x ALT is ___
AST > ALT (high 1000’s) is __
AST and ALT high s/p hemorrhage, surgery, or sepsis is ___
alcoholic hepatitis (reversible)
viral hepatitis
Shock liver
RFs for HCC?
Dx with what?
Tx?
Chronic Hep B > Hep C
Cirrhosis for any reason
Aflatoxin
CCl4
Dx with high AFP (in 70%), CT/MRI
Tx: can surgically remove solitary mass, use rads or cryoablation for palliation of multiple
RUQ pain, profuse sweating and rigors, palpable liver? Tx?
entamoeba histolytica
Tx with MTZ. DONT DRAIN!
Pt from Mexico has RUQ and large liver cysts found on U/S has what? Mode of transmission? Labs? Tx?
Echinococcus
Hydatid cyst parasite from dog feces
Eosinophilia + Casoni skin test
Albendazole and surgery to remove entire cyst, rupture —> anaphylaxis
Isolated thrombocytopenia (bleeding gums, petechiae, nosebleeds), decreased plt count, incr megakaryocytic in marrow, no splenomegaly?
ITP
Tx with steroids 1st. If relapse –> splenectomy
Hemolytic anemia (jaundice, incr indir bili, LDH, der haptoglobin, elev retic count) + round RBCs on smear and + osmotic fragility test and prone to gallstones?
Hereditary spherocytosis
Tx with splenectomy
Aside from the diarrhea and wheezing, what else to look out for in carcinoid syndrome?
diarrhea, dermatitis, dementia
If carcinoid is >2 cm at base of appendix or w/ + nodes….next best step? Otherwise?
Hemicolectomy
Otherwise, appendectomy is good enough
1st test in a SBO? Tx?
1st test=upright CXR to look for free air. CT can show point of obstruction
Tx with IVF, NG tube
Surgery if peritoneal signs, incr WBC, no improvement within 48 hrs
If a pt has ogilvies syndrome, >10 cm colonic distention, what should you do?
need decompression with NG tube and neostigmine (watch for bradycardia) or colonoscopies decompression
where do you see indirect inguinal hernias?
through inguinal ring, lateral to epigastric vessels in spermatic cord
R>L
More often congenital –> patent processus vaginalis
where do you see direct inguinal hernias?
through Hasselbecks triangle, medial to epigastric vessels
More often acquired weakness
Which IBD involves terminal ileum?
Which IBD is continuous involving rectum?
Crohns. Mimics appendicitis. Fe deficiency
UC. Rarely ill backwash but never higher
Which IBD increases risk for PSC?
Which IBD is fistulae more likely?
UC. PSC leads to higher risk of cholangiocarcinoma
Crohns. Give MTZ
Which IBD do you see granulomas on bx?
Which IBD is transmural inflammatory?
Crohns for both
Which IBD is cured by colectomy?
Which IBD do smokers have lower risk?
Both UC
UC needs colonoscopy 8-10 yrs after dx
Smokers have higher risk for crohns
Which IBD has highest risk of colon CA?
Which IBD assoc with p-ANCA?
Both UC
What is tx to maintain remission of IBD?
What is tx to induce remission of IBD?
ASA, Sulfasalazine to maintain remission
Corticosteroids to induce remission
What should you give to a crohns pt for any ulcer or abscess? What about severe dz?
Give MTZ for ulcer or abscess
Azathioprine, 6MP, and MTX for severe dz
What is best way to evaluate for abscess in diverticulitis?
CT=best imaging
NO BARIUM ENEMA!
Tx for diverticulitis?
NPO
NG suction
IVF
Broad spec abs and pain control
Do colonoscopy 4-6 wks later
when is surgery indicated in diverticulitis?
multiple episodes, age <50. Elective is better than emergency (can do primary anastomosis)
in colorectal CA, which sided bleeds and which side obstructs?
right=bleeds
left=obstructs
who gets screened for AAA?
men 65-75 who have ever smoked. do abdominal US
Tx for AAA <5 cm and asx?
monitor growth every 3-12 mos
surgery indicated for AAA when?
> 5 cm, growing <4 mm/yr
1 cause of death from post-op complications of AAA repair? Other complications?
MI=#1 cause of death
Bloody diarrhea-Ischemic colitis
Weakness, decreased pain w/ preserved vibr, prop=ASA syndrome
1-2 yrs later if have brisk GI bleeding=Aortoenteric fistula
Pt has acute abd pain w/ A fib, sub therapeutic on warfarin or pt s/p high dose vasoconstrictors (shock, bypass). Dx? Workup? Tx?
Acute mesenteric ischemia=Surgical emergency
Work up is angiography (aorta and SMA/IMA)
Tx is embolectomy. If thrombus, or aortomesenteri bypass
__ is a slow progressing stenosis (req stenosis of 2.5 vessels –> Celiac, SMA, IMA). Pt has severe MEG pain after eating, food fear and weight loss (pain out of proportion to exam). How to dx? How to tx?
Chronic mesenteric ischemia
Dx with duplex or angiography
Tx w/ aortomesenteric bypass or trans aortic mesenteric endarterectomy
Best test for claudication?
Normal=?
Claudication & ulcers=?
Limb ischemia=?
Gangrene=?
ABI
Normal > 1
Claudication and ulcers= 0.4-0.8, use med mgmt
Limb ischemia= 0.2-0.4, surgery indicated
Gangrene= <0.2, may require amputation
how to dx DVT? Tx? Complications?
Dx with duplex US and also check for PE
Tx w/ heparin then overlap with warfarin for 5 days, then continue warfarin for 3-6 mos
Complications- Post-phlebotic syndrome= chronic valvular incompetence, cyanosis, and edema
Right heart strain on EKG, sinus tach, decr vascular markings of lungs on CXR, wedge infarct, ABG with low CO2 and O2 indicates what?
PE
If suspect PE, what should you do?
give heparin 1st
Then work up w/ V/Q scan then spiral CT
Pulm angiography is gold standard
When to use IVC filter in pt with PE?
contraindications to chronic coagulation
you check the TSH in a pt with a thyroid nodule and it is low. Next best step?
Do RAIU to find “hot nodule”. Excise or radioactive I-131
You check the TSH in a pt with a thyroid nodule and it is normal. Next best step?
FNA
You check the TSH in a pt with a thyroid nodule and it is normal, and FNA is b9. Next best step? What if it is malignant? what if indeterminate?
b9=leave it alone
malignant=surgically excise and check pathology
indeterminate=re-biopsy or check RAIU
What to do if you have cold thyroid nodule?
surgically excise and check pathology
This thyroid CA is MC type, spreads via lymph, psammoma bodies
Papillary
This thyroid CA spreads via blood, must surgically excise the whole thyroid
follicular
this thyroid CA assoc with MENII (look for pheo, hyperCa). Amyloid/Calci.
medullary
This thyroid CA has 80% mortality within 1st year
Anaplastic
fibrocystic change –> cysts that are painful and change with menses. Fluid is typically green or straw colored. Ways to tx or prevent?
restrict caffeine
Vitamin E
Supportive bra
Tx for DCIS?
either excision with clear margins
OR
Simple mastectomy if multiple lesions (no node sampling) plus adjuvant RT
if a pt has infiltrating ductal/lobular carcinoma and is small and away from the nipple….tx?
lumpectomy with axillary node sampling. Adjuvant RT.
Chemo if node +
Tamoxifen or Raloxifen if ER+
Dx and tx of BCC of skin?
Shave or punch bx then surgical removal (Mohs)
Precursor lesion for SCC? How to tx?
Actinic keratosis
Excisional bx at edge of lesion, then wide local excision
which melanoma has best prognosis/most common? Poor prognosis?
Superficial spreading=Best/MC
Nodular=Poor
Melanoma of palms, soles, mucous membranes in darker complected races?
Acrolintiginous
Melanoma of head and neck that has good prognosis?
Lentigo maligna
Dx of melanoma?
Tx of melanoma if:
<1 mm thick __
1-4 mm thick __
>4 mm thick__
Dx with full thickness bx b/c depth is #1 prog
1 cm margin if <1 mm thick
2 cm margin if 1-4 mm thick
3 cm margin if >3 mm thick
midline neck mass that moves with the tongue? tx?
thyroglossal duct cyst
surgical removal
neck mass anterior to SCM?
brachial cleft cyst
neck mass that is spongy, diffuse and lateral to SCM?
cystic hygroma (turners, downs, klinefelters)
most frequent oral cancer? who do you see it in? tx?
Squamous cell
smokers and drinkers
Tx with radiotherapy or radical dissection (jaw/neck)
MC salivary gland tumor, usually on parotid?
pleomorphic adenoma
papillary cyst adenoma lymphomatosum. Benign on parotid gland, can injury facial n. (look for palsy sxs)?
warthlins tumor
baby is born w/ resp distress, scaphoid abdomen? Biggest concern? Best tx?
diaphragmatic hernia
Pulm hypoplasia
If dx prenatally, plan delivery at place with ECMO. Let lungs mature 3-4 days then do surgery
baby is born with resp distress w/ excess drooling? Best dx test?
TE-fistula
place feeding tube, take X-ray, see it coiled in thorax
defect lateral (usually right) of midline, no sac? Assoc with other d/o’s? complications?
Gastroschisis (will see high maternal AFP)
Not usually assoc with other d/os
may be athletic or necrotic requiring removal. Short gut syndrome
Defect in the midline covered by sac?
omphalocele
Defect in the midline, no bowel present? assoc with other d/o’s? tx?
Umbilical hernia
ASsoc with congenital hypothyroidism and big tongue
repair not needed unless persists beyond age 2-3
1 wk old baby with bilious vomiting, draws up his legs, has abd distention? pathophys?
malrotation and volvulus (Ladd’s bands can kink the duodenum)
Doesn’t rotate 270 degrees ccw around SMA
dx and tx of meconium ileus? gold standard dx of hirschsprungs?
gastrograffin enema
bx showing no ganglia
5 day old former 33 weaker develops bloody diarrhea? what do you see on X-ray? tx? RF’s?
necrotizing enterocolitis
Pneumocystis intestinalis
NPO, TPN (if nec) , abc and resection of necrotic bowel
Premature gut, introduction of feeds, formula
2 mo old baby has colicky abd pain and currant jelly stool with sausage shaped mass in RUQ? Dx and tx?
Intussusception
Barium enema for dx and tx
medical tx for BPH?
tamsulosin or finasteride
you feel nodules on DRE and have elevated/rising PSA levels. Next best step?
transracial US and bx. Bone scan looks for blastic lesions
tx for prostate ca?
surgery
radiation
leuprolide or flutamide
best test for a kidney stone? tx for <5 mm? Tx if >5 mm? Tx if >2 cm?
CT is best test
<5 mm=hydrate and let pass
> 5 mm=shock wave lithotripsy
> 2 cm=surgical removal
acute pain and swelling with high riding testis? best test? tx?
Testicular torsion
Do STAT doppler US –> no flow
Surgically salvage if <6 hrs. Do orchiopexy to BOTH balls
4-5 y/o with a painless limp?
leg-calve-perthes dz (avascular necrosis)
12-13 yo kid with knee pain or sickle cell pt?
SCFE (avascular necrosis)
Codmans triangle and sunburst appearance seen in distal femur, proximal tibia at metaphysis, around the knee?
osteosarcoma
seen at diaphysis of long bones, night pain, fever, and elevated ESR. Lytic bone lesion, “onion skinning”, neuroendocrine (small blue) tumor?
Ewing sarcoma
hyperactute rejection occurs with vascular thrombosis within minutes and caused by __
preformed Abs
Acute rejection is due to what cells?
T cells
Tx for acute transplant rejection?
steroid bolus and anti lymphocyte agent (OKT3)
Chronic rejection due to what cells? tx?
T cells
Cant tx it. need re-transplantation
Why give epi with lidocaine?
to prevent systemic absorption –> numb tongue, seizures, hypotension, bradycardia, arrythmias
places to not give lidocaine with epi?
fingers
nose
penis
toes
caution using meperidine anesthetic in who?
pts with renal failure –> can lower seizure threshold
who to not use succinylcholine?
not for burn or crush victim since it can cause hyperK and malignant hyperthermia
this anesthetic can cause malignant hyperthermia and liver toxicity
halothane
give dantrolene Na
