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Surgery > Holliday > Flashcards

Holliday Flashcards

1
Q

The biggest absolute contraindication to surgery

A

DKA or diabetic coma

-blood sugars sky high, too many complications, infections, etc…

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2
Q

quantitative signs of poor nutrition, relative contraindications to surgery, eg delay if not emergent

A

alb v3
20% weight loss 3 mos
prealbumin/transferrin v200

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3
Q

ways to rescuscitate nutrition in order of preferability

A

po
enteral (g tube)
tpn (IV)

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4
Q

quantitative signs of severe liver failure, relatively contraindicating surgery, eg delay if not emergent

A

bili ^2
PT ^16
ammonia ^150
(or clinical encephalopathy)

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5
Q

how long must stop smoking for non emergent surgery

A

8 weeks

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6
Q

why is smoking a relative contraindication to surgery

A

impairs wound healing

especially in plastics… so must quit ^8wks for non-emergent surgery

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7
Q

what to watch out for in smoker waking up from anesthesia

A

don’t artificially sat O2 too high

in smokers/COPDers, chronic CO2 retainers, hypoxia is last respiratory drive, don’t suppress it by artificially satting too high

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8
Q

what does goldman’s index do and what are the most important factors

A

assesses cardiac risk of surgery

CHF (EF v35%) - check w echo

MI (MI v6mos ago) - check w EKG, stress test, cath (angio basically?), revascularize

arrrhythmias, elderly, aortic stenosis (late systolic crescendo decrescendo murmur), emergency surgery, also factors

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9
Q

what to expecially listen for on heart auscultation in preop patient`

A

late systolic crescendo decrescendo murmur - aortic stenosis

not good for goldman index, cardiac risks for surgery

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10
Q

medications to stop prior to surgery

A

aspirin (1-2wks prior)
NSAIDS, vitamin E (bleeding issues)
warfarin (want INR v1.5, can use Vit K)

Insulin - take half the morning dose because NPO after midnight

metformin (risk lactic acidosis)

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11
Q

when to get dialysis prior to surgery if CKD

A

24 hours prior

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12
Q

why do we check BUN and Cr prior to surgery?

A

uremic platelet dysfunction

BUN ^100 a risk for postop bleeding

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13
Q

numbers if preop patient at risk for uremic platelet dysfunction and postop bleed risk

A

BUN ^100
normal platelet count
prolonged bleeding time

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14
Q

Vent settings to know in SICU

A

Assist-Control - set TV and RR, if pt takes breath on their own the vent still gives the same TV… aka vent supports every breath whether pt or vent initiated… not good if pt tachypnic

Pressure Support - pt RR but boost of pressure (8-20) from vent, *important in weaning

CPAP - pt RR and TV but vent pressure all the time to keep alveoli open

PEEP - pressure given (5-20) at end of cycle to keep alveoli open *used in ARDS and CHF

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15
Q

vent setting important in ARDS and CHF

A 
PEEP
pressure given (5-20) at end of cycle to keep alveoli open
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16
Q

vent setting important in weaning

A

Pressure Support

pt RR but boost of pressure (8-20) from vent, *important in weaning

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17
Q

routine test to check while pt on vent

A

ABG

PaO2 PaCO2 pH

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18
Q

pt on vent
PaO2 too low
PaO2 too high

PaCO2 too low, pH is high
PaCO2 too high, pH is low

A 
inc FiO2
dec FiO2 (free radical damage can worsen ARDS)

dec TV more than RR
inc TV more than RR

(TV multiplicative, also, changes ventilation of functional space only, whereas RR changes ventilation of dead space as well… but consider adjusting RR if lung perf or something a concern… i think…)

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19
Q

adjust minute ventilation

A

RR or TV

MV = RR x TV

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20
Q

adjust vent for PaCO2 and pH off balance

A

PaCO2 too low, pH is high
-dec TV (preferred to dec RR because more bang for buck, no dead space involvement)

PaCO2 too high, pH is low
-inc TV (preferred to inc RR)

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21
Q

Which is more efficient, adjusting TV or RR?

A

TV, changes functional ventilation only

while RR involves dead space as well as functional volume

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22
Q

Approach to acidosis

A

pH v7.4

check HCO3 and pCO2
-if both high, respiratory acidosis
-if both low, metabolic acidosis
check anion gap (Na - Cl - HCO3… 8-12 wnl) if metabolic

  • GAP metabolic acidosis MUDPILES methanol uremia dka polyetheleneglycol/peraldehyde isoniazid lactate ethanol/etheleneglycol salicylates
  • NONGAP metabolic acidosis Diarrhea, Renal Tubular Acidoses, abuse of Diuretics
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23
Q

MUDPLES

A

for anion gap (Na - Cl - HCO3 = ^12) metabolic acidosis

methanol uremia dka polyetheleneglycol/peraldehyde isoniazid lactate salicylates

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24
Q

non-gap metabolic acidosis etiologies

A

diarrhea - pooping out anions (HCO3…)

renal tubular acidoses

abuse of diuretics

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25
Q

approach to alkalosis

A

pH ^7.4

check HCO3 and pCO2
-both low, respiratory alkalosis
-both high, metabolic alkalosis
check urine chloride for metabolic alkalosis
-if low uCl v20, vomiting (ejecting via mouth, not via urine) NGT suction, antacids, diruetcis
-if high uCl ^20, Conn’s (hyperaldosteronism), Bartter’s, Gittleman’s

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26
Q

when to check urine chloride in acid/base disorder

A

for metabolic alkalosis (pH ^7.4, HCO3 and pCO2 both high)

  • if low uCl v20, prob due to vomiting (ejecting via mouth, not via urine)
  • if high uCl ^20,
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27
Q

what causes hyponatremia

next best step?

A

too much water

check plasma osmolality (rule out eg hyperglycemia making plasma sodium seem low)

assess fluid status clinically

  • (edema, lung crackles), Hypervolemic hyponatremia think CHF, nephrotic syndrome, cirrhosis
  • (dry mucous membranes, flat neck veins), HypOvolemic hyponatremia think diuretics, vomiting
  • normovolemic hyponatremia think SIADH (get CXR! paraneoplastic of lung cancer), Addison’s (primary hypoaldosteronism… hypocortisolism…), hypothyroid
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28
Q

3 common causes of hypervolemic hyponatremia

A

CHF
nephrotic syndrome
cirrhosis

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29
Q

next step if suspect SIADH

A

CXR

paraneoplastic hormone of lung cancer…

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30
Q

how to treat hypervolemic hyponatremia?

A

fluid restriction, diuretics

common causes = CHF, nephrotic syndrome, cirrhosis

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31
Q

how to treat hypovolemic hyponatremia

A

IV normal saline

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32
Q

when to use 3% (hypertonic) saline

A

for severely symptomatic hyponatremia
eg seizures, AMS

or Na very low (eg v120)

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33
Q

how quickly to replete sodium?

why not faster?

A

.5-1 mEq / hr
or 12-24 mEq/day

careful not to correct too quickly (central pontine myolenolysis is life-threatening)

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34
Q

treat hypernatremia

what to watch out for

A

replete fluid with D5W or hypotonic fluid

don’t decrease more than 12-24 mEq / day because cerebral edemia

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35
Q

qt interval in calcium abnorms

A

prolongued qt - hypocalcemia

short qt - hypercalcemia

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36
Q

bones stones groans psychiatric overtones short QT

A

hypercalcemia

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37
Q

appropriate next best step if calcium too low or too high

A

ekg

to make sure pt not at risk for torsades (hyperca short qt, hypoca long qt)

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38
Q

paralysis ileus ST depression U waves

A

hypokalemia

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39
Q

treat hypokalemia

watch out for

A

replete K+ po or IV

check renal function first, if compromised you can make hyperkalemic pretty quick

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40
Q

signs of hyperkalemia

A

peaked T waves
prolonged PR and QRS
sine waves

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41
Q

treat hyperkalemia

A

Ca-gluconate to stabilize cardiac membrane

insulin and glucose to shift K+ into cells

K exlate to reduce GI absorption

dialysis last resort

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42
Q

Ideal maintanence IVFs

and how much to give

A 
D5 1/2 NS
     \+ 20 KCl if peeing
100ml/kg/day up to 10kg
50ml/kg/day next 10kg
20ml/kg/day all above 20kg
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43
Q

why are enteral feeds preferred to tpn

A

maintains health of gut mucosa

prevents bacterial translocation

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44
Q

risks of TPN

A 
acalculous cholecysitis
hyperglycemia
liver dysfunction
zinc deficiency
other electolyte issues
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45
Q

TF

pt w 3rd degree burn can’t feel it

A

Tish Fish
can’t feel 3rd degree burn - to fascia, nerves destroyed

but 2nd and 1st degree burns around it will hurt very much

so something will hurt

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46
Q

feared complication of circumferential burns

A

compartment syndrome

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47
Q

how to clinically check airway in burn patient, what to watch out for, how to react?

A

singed nose hairsm, wheezing, soot in mouth/nose

watch out for laryngeal edema

low threshold for intubation

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48
Q

burn patient with confusion, headache, cherry red skin

next best test?
Treat?

A

carboxy-Hb (CO poisoning)

give 100% O2
consider hyperbaric treatment if severe poisoning

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49
Q

clot in elderly think…

A

cancer

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50
Q

clotting in setting of edema, htn, foamy pee think…

A

nephrotic syndrome

antithrombin III one of the first proteins to be urinated out…

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51
Q

is nephrotic syndrome a risk for bleeding or clotting?

A

clotting

antithrombin III one of the first proteins to be urinated out…

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52
Q

young person with clot and positive family hx think…

A

factor V leiden…

coag factor V insensitive to activated protein C, which is an anticoagulant… so these pts hypercoagulable

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53
Q

what can’t we give someone with ATIII deficiency

A

heparin
because it won’t work
because heparin potentiates the action of antithrombin III, thereby preventing activation of factors II (thrombin), IX X XI XII

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54
Q

yount woman with multiple spontaneous abortions think…

A

lupus anticoagulant

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55
Q

postop pt with clots but low platelets think…

treat with…

A

HIT
heparin induced thrombocytopoenia
from antibody against heparin bound to platelet factor IV PF4

anticoagulate with a non-heparin anticoagulant, like argatroban or bivalirudin (direct thrombin inhibitors)

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56
Q

young women with bleed and isolated decrease in platelets think…

A

ITP
immune thrombocytopenia
idiopathic thrombocytopenic purpura
immune thrombocytopenic purpura

caused by acquired autoantibodies against platelet antigens

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57
Q

normal platelets but inc bleeding time and PTT think…

eg in woman with heavy periods, nose bleeds, easy bruising…

A

von Willebrand disease
(problem of platelet Function, not number)

inherited mut impairing von Willebrand factor function

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58
Q 
low platelets
high PT PTT BT
low fibrinogen
high d-dimer
shistocytes on smear
think...
A

DIC
disseminated intravascular coagulation

caused by gram negative sepsis (via LPS), OB stuff, carcinomatosis

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59
Q

define carcinomatosis

A

multiple carcinomas develop simultaneously, usually after dissemination from a primary source

implies more than spread to regional nodes and even more than just metastatic disease

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60
Q

rule of 9’s for burn victims

A

estimating body surface area
head and arms are 9%
torso front and back are 18% each
legs are 18% each

in kids,
head is 18%, so are torso front and back each
arms are still 9%
legs are 14%

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61
Q

abx for burn victim?

A

yes
but TOPICAL
NOT PO or IV because those breed resistance…
-Silver and Sulfadiazine Don’t Penetrate Eschar and cause Leuokopenia
-Mafenide Penetrates Eschar but Hurts like hell
-Silver Nitrate Doesn’t Penetrate Eschar and causes HypoKalemia and HypoNatremia

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62
Q

first best step for

chemical burn

electrical burn

A

wash/irrigate for 30 minutes

EKG, if abnormal, monitor on telemetry for 2 days (also if LOC loss of consciousness)

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63
Q

blood on urine dipstic but no RBCs on microscopic exam in burn pt think…
check…

A

rhabdomyolysis
(especially in electrical burn pt)
causing myoglobinuria
causing renal failure

check K+, if massively released from dying cells can cause arrhythmia

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64
Q

pressure diagnostic for compartment syndrome…

A

compartment pressure ^30mmhg

… but correlate clinically… 5 P’s…

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65
Q

trauma pt unconscious… what to do…

A

intubate!

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66
Q

trauma pt GCS v8… what to do…

A

intubate!

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67
Q

pt stung by bee, getting stridor, tripod posturing… what to do…

A

intubate!

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68
Q

guy stabbed in neck, GCS 15, talking to you, but expanding mass in lateral neck… what to do…

A

intubate!

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69
Q

guy stabbed in neck, subcutaneous emphysema w palpation… what to do…

A

intubate! carefully, with a fiberoptic bronchoscope, because may be an airway laryngeal tracheal bronchial injury

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70
Q

huge facial trauma, oral and nasal airways obscured and difficult to identify, GCS v 8… what to do…

A

crycothyroidotomy

don’t intubate if you can’t make out the airway at all due to trauma

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71
Q

you intubated your trauma pt, now auscultating for breath sounds, decreased on left… what to do…

A

pull back ET tube, you have intubated the Right manstem bronchus

72
Q

once trauma pt intubated or not, auscultation clear, next best step…

A

assess oxygenation status

did A and part B, not done with B after just auscultation…

73
Q

HVMVA, pt dyspneic, hypotensive, chest hurts, new murmur…. suspect…

A

aortic injury

74
Q

physical exam findings in pneumothorax

A

decreased/absent breath sounds
hyperresonant to percussion

if tension pneumo…
distended neck veins, trachea deviated away from tension pneumo

75
Q

treat hemothorax

A

chest tube

to OR if chest tube output ^1.5 L immediately, or ^200cc/hr over first 4 hours

76
Q

when do you take hemothorax to OR?

A

HIGH OUTPUT through chest tube

to OR if chest tube output ^1.5 L immediately, or ^200cc/hr over first 4 hours

77
Q

treat flail chest

A

O2 and NERVE BLOCK for pain control

  • so they will keep breathing while ribs heal
  • Don’t give opiods for pain because suppress respiration
78
Q

trauma pt w confusion, petechial rash on chest and axilla, acute shortness of breath… think….

A

fat embolism

eg after long bone fracture, classically femur

79
Q

4 sudden death situations to consider air embolus…

A

MS3 removes central line
lung trauma
vent use aggressive w TV
heart vessel surgery

80
Q

TF

can have hemorrhagic or hypovolemic shock with flat neck veins and normal central venous pressure

A

T

81
Q

treat hypovolemic/hemorrhagic shock

A

2 large bore peripheral IVs
2L LR or NS over 20 minutes
followed by blood if hemodynamics fail to stabilize

82
Q

treat pericardial tamponade

A

needle decompression

83
Q

EKG finding in pericardial tamponade

A

Electrical alternans

  • alternation of QRS complex amplitude or axis between beats
  • possible wandering base-line.

thought to be related to changes in the ventricular electrical axis due to fluid in the pericardium, as the heart essentially wobbles in the fluid filled pericardial sac.

84
Q

strong clinical suspicion of tension pneumothorax… next best step..

A

needle decompression
followed by chest tube

(don’t have to get cxr)

85
Q

which way does trachea deviate in tension pneumo

A

away from tension pneumo
(duh, air filling that side, pushing everything away)

deviates away in non-tension pneumo as well… but deviates toward in lung collapse…

86
Q 
what happens to RAP/PCWP
(right atrial pressure / pulmonary capillary wedge pressure) in these types of shock:
hypovolemic
vasogenic
neurogenic
cardiocompressive
cardiogenic
A 
hypovolemic - dec
vasogenic - dec
neurogenic - dec
cardiocompressive - inc?
cardiogenic - inc
87
Q

what pCO to aim for when hyperventilating pt w inc ICP

A

28-32

88
Q

what to watch out for when giving mannitol to pt w inc ICP

A

renal function

don’t dehydrate too much

89
Q

treat epidural or subdural hematoma causing inc ICP

A

neurosurg ventriculostomy, burr hole, craniotomy

90
Q

boundaries of the zones of neck trauma

A

above the angle of the mandible (III)
cricoid - angle of mandible (II)
below cricoid (I)

91
Q

for which zone of neck trauma do you consider triple endocsopy

A 
zone III (uppermost, above angle of mandible)
-because multple passages there... airway, esophagus... why called triple... I don't know... evals... pharynx, larynx, esophagus, trachea, and bronchi
92
Q

other than emergent exlap for gunshot to abdomen…

A

tetanus prophylaxis

93
Q

stab wound but pt stable… next?

A

-stick a (sterile?) finger in there, see if penetrates peritoneum
FAST
DPL diagnostic peritoneal lavage

ex-lap if any of above are positive

94
Q

what does a DPL diagnostic peritoneal lavage entail?

A

incision between umbilicus and pubis
attempt to aspirate any dependent fluid contents
if unable to aspirate, inject 1L NS and drain 5 minutes later and send for analysis

95
Q

blunt abdominal trauma, pt hypotensive and tachycardic… next step…

A

to OR

maybe get FAST on the way… but answer is OR

96
Q

Kehr sign

A

diaphragmatic irritation referred to left shoulder pain

97
Q

handlebar sign

A

bruising and pain in handlebar pattern (eg. abdomen to steering wheel or bike handlebars) along epigastric/inferior rib border

-suspect pancreatic rupture

98
Q

blunt abdominal trauma, pt stable.. next step…

A

CT abd

99
Q

abdominal trauma, lower rib fracture, bleeding into abdomen, suspect…

A

liver laceration if R rib fxs

spleen laceration if L rib fxs

100
Q

lower rib fracture with hematuria… suspect…

A

kidney injury

101
Q

blunt abdominal trauma, pt stable, with epigastric pain… best test… dx to suspect…

A

CT abd (best test for any blunt abdominal pt stable)

if retroperitoneal fluid on CT abd - suspect DUODENAL RUPTURE

pancreatic rupture would show handelbar sign (epigastric ecchymosis)?

102
Q

blood at urethral meatus, high riding prostate…

next best tes…

A

urethral or bladder injury from pelvic trauma…

retrograde urethrogram /cystogram
… looking for extravisating dye

103
Q

tf

if blood at urethral meatus, foley is a good idea

A

FALSE.. well maybe, but not first thing to do
do not attempt to place foley for urethral injury… maybe if after retrograde urethrogram/cystogram you know injury is extraperitoneal….

if intraperitoneal will need ex-lap and surgical repair

104
Q

extravisation on retrograde urethrogram/cystogram, how to react if extravisation is…

extraperitoneal?
intraperitoneal?

A

extraperitoneal - bed rest and foley

intraperitoneal - ex-lap and surgical repair

105
Q

ortho fractures that definitely go to OR

A

depressed skull fx
severely depressed or angulated
open fx ANY OPEN FX
femoral neck or intertrochanteric

106
Q

what is injured with numb deltoid shoulder pain and external rotation

A

axillary nerve

from anterior shoulder dislocation

107
Q

fever how high with atelectasis

A

v101

108
Q

fever ^104 postop

very ill appearing, suspect…

A

nec fasc

109
Q

how does necrotizing fasciitis spread in abdomen

A

along scarpa’s fascia

110
Q

common bugs in nec fasc

A

strep pneumo

clostridium perfringens

111
Q

treat necrotizing fasciitis

A

Debride in OR

IV Penicillin

112
Q

how to prevent postop atelectasis

A

scare the shit out of your patients – get out of bed and walk! Incentive spirometry! or else pneumonia and die!

113
Q

differentiate postop
cellulitis
wound infection
dehiscence

and how to treat

A

cellulitis - pain erythema NO DRAINAGE - ABX

wound infection - pain erythema DRAINAGE - OPEN and REPACK… no abx necessary

dehiscence - salmon serosanguenous drainage - SURGICAL EMERGENCY OR for PRIMARY CLOSURE, IV ABX

114
Q

OB/GYN pt late in postop course develops unexplained fever…

suspect. ..
tx. ..

A

pelvic thrombophlebitis

abx and heparin

115
Q

unexplained postop fever (UTI, PNA, BCx, line infection, wound infection, etc all negative)…

suspect. ..
test. ..
tx. ..

A

abscess - CT… diagnostic lap - drain percitaneously, IR guided, or surgically

thrombophlebitis (eg late postop in OB/GYN) - CT? abx, heparin

thyrotoxicosis, adrenal insufficiency, lymphangitis, spesis all possible and rare…

116
Q

tf

culture pressure ulcer

A

f
will just get skin flora

DO get BCx and CBC if worried about infection

117
Q

treat pressure ulcer

A

stage 1 and 2 - soft mattress, rolls, creams…

stage 3 and 4 - need surgery, flap reconstruction

118
Q

bacterial load and nutrition before surgery for stage 3 or 4 pressure ulcer…

A

Bacterial load v100K

Albumin ^3.5

119
Q

when to tap (thoracentisis) pleural effusion

A

when ^1cm on lat decub xr

120
Q 
thoracentisis transudative think...
transudative and:
-low pleural glucose think...
-high lymphocytes think...
-bloody think...
A
  • transudative think… systemic, CHF Nephrotic syndrome Cirrhosis
  • low pleural glucose think… RA… random…
  • high lymphocytes think… TB
  • bloody think… Cancer or PE
121
Q

if thoracentesis exudative think..

A

pneumonia

cancer

122
Q

when to insert chest tube for drainage of pleural effusion

A

if “complicated”

thoracentesis demonstrates:
positive Gram Stain
low pH v7.2
low Glucose (cancer or bugs eating it)

123
Q

lights criteria

A

for transudative pleural effusion
LDH ratio eff vs plasma v0.6
Protein ratio eff vs plasma v0.5

124
Q

dx spontaneous pneumothorax

tx

A

CXR (in setting of tall thin young male, asthma, COPDer usually)

Chest tube

Surgery (VATS vs Pleurodesis) if:

chest tube does Not Decompress… incomplete lung expansion,

Recurrence (ipsilateral or contralateral… any recurrence),

scuba or pilot pressure changes

live in remote area low access to care if becomes complicated

125
Q

drain lung abscess?

A

F
one of the few (two ish…) abscesses that you do not drain…

tx w Abx (Penicillin for staph, Clindamycin for anaerobes aspirated)

Surgery if

  • Abx Fail
  • ^6cm
  • Empyema (pus in pleural space) present
126
Q

treat lung abscess

A

Abx (Penicillin for staph, Clindamycin for anaerobes aspirated)

Surgery if

  • Abx Fail
  • ^6cm
  • Empyema (pus in pleural space)

*Lung abscess is one of the few (two ish…) abscesses that you do not drain…

127
Q

solid pulmonary lung nodule workup

A

find old CXR to compare

benign:
popcorn calc - hamartoma
concentric calc - old granuloma eg TB
v40yo v3cm well-circumscribed
- CXR or CT q2mos to assess change
malignant:
calc not popcorn or concentric...
^3cm
smoker, elderly
-bx for path (bronch if central, open if peripheral...)
128
Q

symptoms of lung cancer

A 
coughing
coughing blood hemoptosis
sob
recurrent pneumonia
(post-obstructive pneumonia)
lung collapse
129
Q

most common lung cancer in non-smokers

A

adenocarcinoma

130
Q

this cancer occurs in scars of old pneumonia

A

adenocarcinoma

131
Q

lung adenocarcinoma mets to…

A

BBLA bone brain liver adrenals

132
Q

characteristics of pulmonary effusion caused by adenocarcinoma

A

exudative with high hyaluronidase

133
Q

is lung adenocarcinoma central or peripheral?

A

peripheral

134
Q

pt with kidney stones, constipation, malaise, low PTH, central lung mass… think…

A

SCC squamous cell carcinoma of lung

-paraneoplastic PTHrp… low serum PO4 high Ca

135
Q

pt with shoulder pain, ptosis, constricted pupil, facial edema… think…

A

pancoast tumor
aka superior sulcus syndrome
usually SCLC

136
Q

what type of lung cancer causes pancoast tumor / superior sulcus syndrome?

A

SCC squamous cell carcinoma

137
Q

TF

small cell carcinoma and squamous cell carcinoma of the lung are the same thing

A

F

squamous cell carcinoma is Non-small cell

138
Q

TF

SCLC is a carcinoma

A

T
Small Cell Lung Cancer
Small Cell Lung Carcinoma
Small Cell Carcinoma

all the same thing

139
Q

pt with ptosis better after 1 minute of upward gaze… think…

A

Lambert Eaton Syndrome

  • autoantibodies against presynaptic VCaCs voltage gated calcium channels… so no calcium influx cannot release Ach vesicles
  • THINK SCLC PARANEOPLASTIC.. strong association
140
Q

old smoker presenting with Na 125, moist mucous membranes, no JVD, think…

A

SIADH

SCLC PARANEOPLASTIC

141
Q

CXR shows peripheral cavitation and CT showing distant mets… think…

A

Large Cell Carcinoma

142
Q

central vs peripheral lung cancers

A

squamous cell carcinoma
small cell carcinoma
(Sentral)

adenocarcinoma
large cell carcinoma
(peripheral)

143
Q

paraneoplastic syndromes in lung cancer

A

PTHrp - squamous cell carcinoma

SIADH, Lambert Eaton - small cell lung cancer

144
Q

name 4 lung cancers

A

adenocarcinoma
squamous cell carcinoma
small cell carcinoma
large cell carcinoma

145
Q

name non-small cell lung cancers

why the small cell vs non-small cell distinction

A

squamous cell carcinoma
adenocarcinoma
large cell carcinoma

small cell not surgical treatment, chemo and radiation sensitive

non-small cell more surgical treatment

146
Q 
ARDS
causes
path
dx, 3 criteria
tx
A 
gram negative sepsis
gastric aspiration
trauma
low perfusion
pancreatitis

inflammation - impaired gas exchange - hypoxemia

PaO2/FiO2 ratio ^200… ish…
bilateral fluffy infiltrates on cxr
PCWP v18 to rule out CHF

PEEP

147
Q

systolic ejection murmur, crescendo decrescendo, louder with squatting, softer with valsalva. pulsus parvus et tardus

A

aortic stenosis

148
Q

systolic ejection murmur, louder w valsalva, softer w squat or hand grip

A

HOCM

149
Q

how to tell aortic stenosis and HOCM apart

A

valsalva

aortic stenosis gets quieter
HOCM gets louder

(valsalva decreases volume in heart)

150
Q

late systolic murmur with a click, louder with valsalva and handgrip, softer with squatting

A

mitral valve prolapse

151
Q

concept behind heart maneuvers
valsalva
hand grip
squatting

A

valsalva decreases volume in heart

hand grip increases resistance

squatting increases venous return, increases volume in heart

152
Q

holosystolic murmur radiates to axilla

A

mitral regurge

153
Q

holosystolic murmur with late diastolic rumble in child

A

VSD

154
Q

continuous machine-like murmur in child

A

PDA

155
Q

wide fixed split S2

A

ASD

156
Q

TF

atrial septic defect requires surgical correction

A

F

usually not

157
Q

rumbling diastolic murmur with opening snap

A

mitral stenosis

158
Q

murmur most often caused by past rheumatic fever

A

mitral stenosis

rumbling diastolic murmur with opening snap

159
Q

blowing diastolic murmur with widened pulse pressure

A

aortic regurge

160
Q

key buzz for right sided heart murmur

A

louder with inspiration

161
Q

bad breath and food in mouth in the morning think…

A

zenker’s diverticulum

162
Q

is Zenker’s diverticulum true or false diverticulum?

A

false

mucosa only, through muscular layer… not full thickness muscle layer ballooning as well

163
Q

how to treat Zenker’s diverticulum of esophagus

A

surgery

164
Q

dysphasia to solids and liquids, bird beak sign on barium swallow
diagnosis
tx
associations

A

achalasia

CCB, nitrates, botox
heller myotomy (if med mgmt fails)

chagas disease,
esophageal cancer

165
Q

dysphasia worse with hot and cold liquids, chest pain that feels like MI, no regurge
diagnosis
tx

A

diffuse (aka all up and down) esophageal spasm

CCBs, nitrates

166
Q

epigastric pain worse after eating or laying down, cough, wheeze, hoarse
dx
tx
indications for surgery

A

GERD
24Hr pH monitoring most sensitive

behavior mod, antacids, H2 blocker, PPI

surgery (EGD first) if bleeding, stricture, Barrett’s, incompetent LES, max dose PPI not resolving, or just patient preference to medications

167
Q

hematemesis, subQ emphysema, pleural effusion, inc amylase
next best test?
test to avoid?
tx?

A

boerhaave’s (esophageal rupture)
-full thickness -subq emphysema
(mallory weiss partial thickness)

CXR, Gastrograffin (avoid barium because more irritating to mediastinum)

NO ENDOSCOPY

Surgical repair if full thickness

168
Q

gross hematemesis unprovoked in cirrhotic with pulmonary hypertension
diagnosis
treatment

A

gastric varices

ABCs
NG lavage

octreotide
balloon tamponade only if need to stabilize for transport
-endoscopic sclerotherapy or banding

169
Q

do you treat asymptomatic varices found incidentally on endoscopy?

A

No
give beta blockers

IF SYMPTOMATIC treatment is endoscopic sclerotherapy or banding… once stabilized with ABCs NG lavage octreotide balloon tamponade if necessary

170
Q

when to balloon tamponade esophageal varices

A

if need to stabilize for transport

definitive treatment is endoscopic sclerotherapy or banding on endoscopy

171
Q

progressive dysphagia and weight loss makes you think…

A

esophageal cancer

SCC or Adenocarcinoma

172
Q

types of esophageal cancers and locations and presentations of each

A

SCC middle 1/3 smokers drinkers

Adenocarcinoma in distal 1/3 in long-standing GERD

both present with progressive dysphagia and weight loss

173
Q

workup for esophageal cancer

A

barium swallow

endoscopy with biopsy

staging CT

174
Q

other than GERD, what else should be on differential fir acid reflux pain after eating and lying down

A

hiatial hernia

175
Q

hiatial hernia types, presentation, treatment

A

Type 1 hiatial hernia Sliding

  • GE junction slides into thorax
  • exacerbation of GERD sx (acid reflux pain after eating, lying down)
  • tx GERD sx (antacid, H2 blockers, PPI)

Type 2 hiatial hernia ParaEsophageal

  • abdominal pain, obstruction, strangulation
  • surgery
176
Q

what causes cough, wheeze, hoarse in GERD

A

atypical symptoms from reflux high enough to get back into airway

Surgery (22 decks)

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