Nike Flashcards
By definition a suture is a ?
How are sutures categorized
Foreign body
Material Configuration Strength Absorbability Diegradation
What type of suture material causes a more intense inflammatory reaction?
Define Tensile Strength
How is this strength annotated?
Natural
Amount of weight required to break a suture
#-0 (number indicates number of 0s: 3.0= 0.001)
Define Configuration
What type of configuration has an increased risk for infection
Number of filaments
Braided
What are the absorbable types of sutures?
What are the non-absorbable types?
Gut- monofilament
Monocryl- monofilament
Vicryl- multifilament
Ethilon- monofilament
Prolene- monofilament
Silk- miltifilament
Proper sutures should cause wound edges to take on ? appearance
When are Simple Interrupted sutures used?
How long are they left in place?
Evert
External closures
7-10 days
5 days- face
When are horizontal mattress sutures used and how long are they left in place?
When are vertical mattress sutures used?
Larger lacerations
7-10 days
Poorly everting lacerations
When are running sutures used?
Why would these be preferred?
What type of know is used at the end of the suture?
Subcuticular closures (buried)
Cosmetic- pastics/dec scar
Holds skin closed
Aberdeen knot (Fisherman)
Epidermal cysts are AKA ?
Why are these difficult to remove?
Sebaceous cyst
Recur if wall is not removed
Pilar cysts are AKA ?
When are time outs conducted in pre-op?
EIC/sebaceous cyst of the scalp
Prior to anesthetic injection
What type of scalpel blades make smaller/larger incisions?
What is the only exception to close a wound transversely and not longitudinally?
10- larger, hump of blade
15- smaller
11- puncture/cutting
Flexor surface
What are the three benefits of using staples for closure?
What is the down side?
High tensile strength
Quickly placed
Resistant to infection
More prominent scar
Wound care needs to be exercised to minimize scarring for ?mon after surgery?
What tool is used for suture removal?
12mon
Scissors or,
Elevate w/ Adson’s, cut w/ scissors, pull w/ Adson’s
The ideal anesthetic would be ?
Non-PILSNRS Non-irritating Penetrates Inexpensive Low toxicity Soluble Non-addictive Reversible Short latency
What is the drug used for:
Altering consciousness
Analgesia
Amnesia/anxiolysis
Muscle relaxation
Anesthesia adjunct
Propofol
Opioid
Benzo
Depolarizing agent
Dexemed, Ketamine
Anesthetics are classified in to ? or ?
What classification are the MC used in GenSurg and how can you tell them apart?
Amides- metabolized by liver
Esters- metabolized by plasma cholinesterase into PABA (allergen)
Amides- ‘i’ before ‘-caine’
Advantages and disadvantage of adding Epi to local anesthetics
These combos need to be avoided in ? PT populations?
What part of the body can these combos NOT be used in?
Adv: Inc duration
Dec bleeding/volume needed
Dis: Inc myocardial activity
Cardiac Dz
HTN DM Hyperthyroid
Tissues supplied by end arteries- penis ear nose toe finger
What are the MC adverse effects of using local anesthetics?
How are these adverse effects Tx?
Dermatitis Urticaria Edema Erythema
Steroid Antihistamine Fluid Epi O2
What are the prodomal Sxs of local anesthetic toxicity?
What are the S/Sxs of cardiovascular toxicity
Metallic taste
Curcumoral numbness/tingle
Light headed
Tinnitus
Hyper to HypoTN
Tachy/Brady
V-fib
Collapse
What are the S/Sxs of severe CNS toxicity from local anesthetics?
Max dose of Lidocaine w/ and w/out Epi
What is the ratio of lidocaine to Epi mixtures?
Tonic clonic
AMS
W/ Epi: 7mg/kg, max 500mg
W/out: 4mg/kg, max 300mg
1: 10mg/ml
2: 20mg/ml
What is the onset/duration of lidocaine?
Max dosage of Bupivacaine but don’t use in ? PTs?
Onset and duration of Bupivacaine?
On: 2-5min
Dur: 30-120min
2mg/kg, max 100mg
<12yrs
On: 5-10min
Dur: 2-4hrs
Anesthetic induced CNS toxicity is exacerbated by ? so how are they Tx?
How are CV Sxs Tx
Hypercarbia
Hyperventilate to dec CO2
Benzos for seizure
Fluids for HOTN
Shock wide/drug narrow
What types of anesthetics are more likely to cause malignant hyperthermia?
How do PTs present w/ this issue?
How are they Tx?
Volatile/succinylcholine
Hypermetabolic- fever, tetany, HyperK
Cool, BiCarb, Dantrolene
How is malignant hyperthermia avoided?
What is the sequence of effects exerted by local anesthetics?
Mix small amounts of multiple different agents
Loss of tone, dilation
Loss of pain/temp
Loss of pressure
Loss of motor
Peripheral nerve blocks are goof for ? use
Digital blocks can be done in ? areas?
Rib/digital blocks
Plantar/palmar aspects
What are spinal/subarachnoid block used for?
These types of blocks put ? combo of meds where?
Lower abdomen/extremity
GU/GYN
Anesthetic, narcotic, epi into CSF
Spinal/subarachnoid blocks inhibit ?
What is the MC adverse event?
Sympathetic Sensory Motor
Post-spinal HA- Tx w/ caffeine and blood patch
Central/Epidural anesthesia places local anesthetic into ?
What type of inhibition is provided?
What type of injury is this type of block good for?
Epidural space, not CSF
Sensory only
Rib Fx
Spinal cord terminates at ? level of the spine?
How is HOTN complications from central nerve blocks Tx
L1-L2
Pressors and fluid
How does a high spinal complication from central nerve blocks present and how is it Tx?
This is a concern d/t the diaphragm being innervated by ?
Brady HOTN Tingling
Ventilate
IV Naloxone
C3-5
How does central nerve block induced cauda equina syndrome present?
What is the MC complication that present later from central nerve blocks?
Bladder/bowel dysfunction
Motor/sensory changes in legs
Urinary retention
When would an epidural hematoma induced spinal cord compression be considered after a central nerve block?
Why would this outcome usually be avoided?
Anticoagulated PTs
Anesthesia avoided, endotracheal tube anesthesia recommended
What med would be used to help counter HOTN induced from spinal anesthesia?
What is the purpose of doing conscious sedation?
Phenylephrine
Analgesia and anxiolysis while allowing PT to maintain airway, respond to commands and provide retrograde amnesia
What types of combos are administered to induce conscious sedation?
Time to Peak and Duration of Propofol, Ketamine and Etomidate
Benzo/Propofol + Narcotic
Pro: 90-100min/5-10min
Ket: 30min/10-15min
Etom: 60min/4-10min
Conscious sedation can only be done on PTs w/ ? ASA classes?
What drugs are used for narcotic and benzo reversal?
1 and 2
Naloxone- narcotic
Flumazenil- benzo
What are the 3 goals of general anesthesia?
What drugs may be taken prior to surgery if PT is NPO
Cricoid pressure is AKA ?
Anesthesia Amnesia Relaxation
Antacid
Sellick maneuver
What are the PACU goals required for d/c?
Stable out of bed x 30min Stable VS AnO x 3 Ambulatory Controlled pain/nausea \+ void/PO intake
What post-op issues are more likely to occur <48hrs of surgery?
What issues can develop >48hrs after surgery?
Resp/CV- Sudden cardiac event HOTN Aspiration Ventilation failure
Local: UTI Pneumonia
Systemic: SIRS, MODS
What is one of the MC post-op complications of general anesthesia?
How can this be reduced/prevented in the pre-op setting?
Atelectasis
Smoking cessation >14days before procedure
How does pneumonia present on PE?
How does it appear on CXR if it’s early/late?
Fever Tachy Rales
Early- infiltrate
Late- consolidation
How is post-op pneumonia Tx?
How can VAP be avoided?
ABX
Pulmonary toilet
Ventilate: PCO2- 35-45
O2 >95%
HOB 30-45*
VLTrials daily
PUD/DVT prophylaxis
PO hygiene
How can aspiration pneumonia be prevented?
If aspiration occurs, how is the PT managed?
NPO >6hrs pre-op
NG decompression
Mechanical ventilation
ABC
Bronchial hygiene
Immediate suction (bronchoscopy)
What causes post-op pulmonary edema?
How are these PT managed?
Volume overload
CHF
RF
Diuretics/fluid monitoring
R/o MI/PE
Sit up
What causes post-op ARDS
How is this Tx
Inflammatory reaction
Non-cardiogenic pulmonary edema, not 2/2 fluid overload or HF and non-reponsive to diuretics
Mechanical vent w/ Inc PEEP 10-15cm Inc expiration time Low tidal volume 5-7ml FiO2 <60^
PTs being treated for post-op ARDS on ventilators are placed in ? position?
Why are central lines placed?
Prone
Administer caustic agents (TPN ABX Blood)
Monitor hemodynamis (Swan ganz Vigeleo)
Longer use than PIC
What are the complications that can arise from central line placements?
When do these need to be removed?
Ptx
Arterial injury
Tamponade
Infections
<7days
How are Fat Embolus PTs managed?
Wells criteria
PEEP ventilation
Diuretics
3pts: DVT Sxs/No alt Dx
1.5: Tachy >100/Immobile x 3/surgery 6= high
<4= low if D-dimer neg
<2= low
What images are ordered for PE work ups?
What is the most non-specific EKG change to occur due to PE?
CXR
Spiral CT
VQ scan (pregnant, RF)
Pulm arteriogram- Dx/Thx, invasive
New Afib/RBBB
S1Q3T3
How are PEs Tx w/ medication
What is used if PTs are unable/intolerant to PO meds and have distal DVTs?
IV heparin, SQ LMWH
PO warfarin x 3-6mon w/ goal INR 2-3
PO Xa/direct inhibitors (Diagatraban, Fondaparinux) to replace warfarin
IVC filter
How can surgery induced ileus’ be avoided?
How can GI bleeds be avoided?
Pre-op Alvimopan (Entereg)
PPI
H2 blockers
What are the MC causes of C Diff?
Wat criteria make PTs suspicious for this Dx?
Clindamycin
Cephalosporin
Floroquinolones
> 3 loose stools <24hrs
How is C Diff Tx?
What causes post-op pre/intra/post renal complications of oliguria
PO Vanc/Metronidazole
Pre: dehydration/hypovolemic
Intra: IV contrast, ABX, Diuretics, Myoglobin from crush injury
Post: BPH Urethral injury, Neurogenic bladder (DM Pts)
How is BPH induced post renal oliguria Tx
What is the MC complication after urinary catheterization?
A-blockers
UTIs
What nerve has been damaged and how will PT present post hernia repair?
What nerve has been damaged and how will PT present post mastectomy
Ilio-inguinal nerve; skin numbness
Long thoracic nerve; winged scapula
What nerve has been damaged and how will PT present post para/thyroid
What nerve has been damaged and how will PT present post carotid endarterectomy?
Recurrent laryngeal; hoarsenss
Hypoglossal; deviated tongue
If PT develops AMS post-op, what is the first consideration?
What is the definitive Tx for phomosis/paraphimosis?
Hypoxia/hypovolemia
Circumcisions
DIC is initially a ? condition that progresses into ?
How is it Tx?
Pro-thrombotic
Consumption of all coagulation proteins
FFP
Why do transfusions induce HypoCa?
How is TRALI Tx?
Ca binds to citrate
No diuretics
Stop transfusion, respiratory supportive care
What is the lethal triad?
How are large hematoma/seroma wound complications managed?
Metabolic acidosis
Coagulopathy
Hypothermia
Small- self resolving
Large- aspirate/open decompress
How do early/late fascial dehiscence present?
How are surgical site infections Tx?
Early: salmon fluid
Late: incisional hernias
Open Irrigate Pack
Leave open
What is the early sign of developing compartment syndrome?
What is a late finding?
PooP
Loss of function/distal pulse
If abdomen is closed after surgery, what are the 3 thing monitored for to detect developing compartment syndrome?
What are the 4 stages of decubitus ulcers?
Acidosis
Inc lactate
Dec urine output
1- Intact skin
2- open ulcer
3- visible fat
4- exposed tendon/muscle
Where are decubitus ulcers likely to develop?
How are they managed?
Hip Elbow Buttocks Sacral
InD and debride necrotic tissue
What is the saying for working fevers up?
What cultures are taken?
Wind
Water
Wound
Blood Urine Sputum
What can cause parotiditis?
What can cause epistaxis?
What can cause Ototoxicity?
Poor PO hygiene/dehydration
Unhumidified O2
Aminoglycosides
Vancomycin
When rounding on PTs, when is GCS reported?
What drugs are used for anaphylaxis?
Not 15 or 3
Epi Diphenhydramine Steroids
What are the MC causes of nosocomial infections?
Define the ICU death spiral
SSIs C Dif Catheter Central line VAP
SIRS w/ 2: temp >101.5, Tachy, Tachy, Leukocytosis
Sepsis w/ SIRS source
Septic shock- EOD/MODS
Death
Define Inguinal Hernia
Define Femoral hernia
Originates above inguinal ligament
Originates below inguinal ligamentand medial of femoral canal
Define Incarcerated hernia
Define Strangulated hernia
Non-reucible contents
Incarcerated and ischemic contents
Define Indirect Inguinal hernia
Define Direct Inguinal Hernia
Develop at internal inguinal ring and lateral to inferior epigastric artery
Occurs through Hesselbech traingle
What are the boundaries of Hesselbech triangle?
How doe congenital hernias develop?
Inferior: inguinal ligament
Lateral: inferior epigastric artery
Medial: lateral rectus muscle
Patent processus vaginalis, same defect causing hydrocele
Where are contents located in congenital hernias?
This type of hernia is the MC ?
Down spermatic cord through superficial/deep inguinal rings
Hernia of both genders
Indirect inguinal hernia
What makes the hernia sac of congenital hernias?
Define complete hernia
Peritoneum passing lateral to epigastric vessels
Inguinal hernia reaching scrotum
How do direct inguinal hernias develop?
Where are they located near?
What structure is not involved w/ this type?
Weakened floor of inguinal canal
Medal to epigastric vessels
No passage through inguinal ring
When are direct inguinal hernias surgical emergencies?
What image is preferred for initial test?
What image is confirmatory?
Acute and non-reducible/incarcerated
Groin US
CT
What would be an example of an underlying issue that would need to be repaired prior to hernia repair surgery?
What findings indicate need for surgical repair under general anesthesia?
Prostatic hyperplasia
All Sx groin hernias
What type of prophylactic procedure may be done prior to inguinal hernia repair?
How are unilateral repair done compared to bilateral repairs?
Division of ilioinguinal nerve to dec neuroma/pressure related pain
Uni: open repair
Bilat: laparoscopic
Mesh for tension free repair
What type of hernia is more common in females?
How does it present?
Femoral hernia
Medial to femoral vein
N/V, Ilius
Pain exacerbated w/ valsalva/cough
What type of hernia repair has higher incidence of recurrence?
How do epigastric hernias present?
Laparoscopic
Protrusion of peritoneal fat through linea alba above umbilicus
How are epigastric hernias Tx
Surgically repair pediatric umbilical hernias if they don’t self-resolve by age ?
Routine surgery
Corset if not surgical candidate
2yrs
What’s the difference of risk between Peds and adult umbilical hernias?
How do incisional hernias develop?
Peds rarely incarcerates
Dehiscence through facial closure w/ intact skin
What are the RFs that if present increase the chance of incisional hernia development?
What type of condition may look like a hernia but is not defined/categorized as a hernia?
Infection
Cough
Obesity
ImmComp
Diastasis recti- widened linea alba w/ prominent midline bulge when PT raises head; do not repair
Define Sports Hernia
This type of hernia can be a manifestation of ? DDx
What are the indications to refer to surgery?
Not true hernia;
Micro tears in FAR HOP
Osteitis pubis
Pain
Conservative Tx x 8wks failure
Exlcusion
Define Hydrocele
Define Epididymitis
Patent processus vaginalis allows peritoneal fluid to collect next to testis into non-tender, trans-illuminating sac
Acute onset of pain associated w/ prostatitis/vasectomy
What abnormal lab result may be seen w/ epididymitis cases?
What how does Tx differ if PT is young/old?
WBCs in urine
Young: ABX for STIs (Ceftriax/Doxy)
Old: ABX for gram neg rods (Evo)
Define Spermatocele
Where are varicoceles more likely to develop?
Why is this one investigated more heavily?
Fluid filled, non-tender mass attached to epidiymis
L side
If on R, evaluate for mass occluding spermatic vein
Related to infertility
What is the functional unit of the breast?
What is the MC and rare form of breast Ca?
Lobuloalveolar units (milk producing)
MC- Ductal carcinoma
Rare- Lobular carcinoma
What is the suspensory ligament of the breast?
What are the 4 PT positions for a CBE?
Cooper (suspensory) ligament
Sitting leaning forward
Sitting w/ arms raised
Sitting w/ pecs flexed
Supine
Additional to the four quadrants of the breast, what else is examined during a CBE and why?
Although common, mastalgia can be related to what two things?
Tail of spence- lymph flows from breast to axillary/internal mammary nodes
Fibrocystic changes
Infection
Define Mondor’s Dz
How is it Tx?
Thrombophlebitis of superficial breast vein as tender/palpable cord
NSAIDs ABX
Persistent= surgical referral for definitive management/Dx
What drugs are avoided during the Tx of mastalgia?
What can be done for Tx
80% of breast masses are benign and due to ?
Danazol Diuretics Tamoxifen Iodine Narcotics
Support bra
Reduce caffeine/saturated fat
Primrose oil
Vit B6/E
Fibrocystic*/adenoma
Fat necrosis
Gynecomastia
How do fibrocystic changes present to clinic?
What timing to menses can help w/ Dx
Child bearing age w/ bialteral pain, nipple d/c and palpable mass
Correlate to menses
Tenderness peaks w/ late luteal phase
How are fibrocystic changes managed?
How are these PTs managed?
US/Mammogram
Biopsy
Vitamin E/primrose oil
Avoid caffeine
NSAIDs
Support bras
How do fibroadenomas present
These PTs are ok to Tx w/ observation if ? criteria is met?
Young w/ dec incidence approaching menopause w/ smooth/lobulated mass 1-3cm in diameter
Benign exam, MMG, FNA
When are fibroadenomas removed?
What meds can induce nipple discharge?
> 35y/o or,
PT requests
Antipsychotics Cimetidine Anti-hypertensives Narcotics Sedatives
Most nipple d/c are due to ? Dxs?
How are these PTs managed?
Benign intraductal papilloma
Mammary duct ectasia
Duct carcinoma in situ
Mamm/US q3-4mon
How does galactorrhea present
Labs are drawn to assess ? levels?
How is this Dx and how are the PTs managed?
Bilateral milky d/c in non-lactating female
Hyperprolactinemia
Hyperthyroidism- bitemporal hemianopsia
MMG
Re-examine q3-4mon
What microbes usually cause mastitis?
How are these PTs worked up?
How are they Tx?
Staph A*/Strep
Culture/sensitivity
ABX
Moist heat w/ continued feeding
What are he two types of breast masses?
How are these PTs Tx
Acute- normal lactating breast
Chronic- duct ectasia- wide duct w/ thick green/black d/c in 40-60y/o female
Stop nursing
Admit w/ IV ABX
InD
Define Macromastia
How are supernumerary nipples managed?
These tend to develop during ? week of fetal development?
Breast hypertrophy
Noticed during pregnancy along nipple line, completely benign/cosmetic
Surgical excision
6th
What images are ordered for unilateral gynecomastia?
If referred to surgery, what is the name of the procedure?
Mammogram w/ f/u US
Subcutaneous mastectomy- spares skin and nipple
What causes bilateral gynecomastia
What conditions can cause excess/dec estrogen and cause this condition?
Dec androgen production as men age
Inc estrogen- testicular tumor, lung Ca, starvation, thyrotoxicosis
Dec estrogen- Klinefelters, secondary teste failure
What meds can cause bilateral hynecomastis?
How can this be Tx w/out surgery?
What PE findings makes med Tx not an option?
INH Cimetidine Mariujuana Estrogen Digoxin Steroids
Tamoxifen Raloxifene Aromatase inhibitors
Solitary hard mass
What is the goal of screening mammography?
What is the use for diagnostic mammography?
What are the two standard views used?
Detect Ca before it’s palpable
F/u after lesion found on screening/abnormal exam
Craniocaudal
Mediolateral
What does BI-RADS stand for
What are the Bi-RAD categories for mammograms?
Breast Imaging- Reporting And Data System
0- additional images needed 1- neg/normal 2: benign finding 3- prob benign, rpt 6mon/biopsy 4- suspicious, consider biopsy 5- suggestive of Ca, definitely biopsy 6- biopsy proven malignancy
What are the findings that could be sen in BI-RADS 2 results
Circumscribed homogenous Macrocalcificaion Dense calcification Calcified blood vessels Stable, no change from last MMG
What image is ordered if mass is found on MMG?
How do different results appear?
US
Cyst- smooth walled= benign
Irregular- further workup
Almost all PTs will receive ? image prior to surgery?
This mode of imaging is better for ? PT populations
MRI
Dense tissue
Implants
What is the MC found lump in the breast during SBE?
How does this MC present
Ca
Painless Unilateral No d/c
Hard w/ irregular margins
What is the Dx procedure of choice for palpable and image detected abnormalities?
Why is this method preferred?
Core needle biopsy
Tumor markers over expression can be seen
When is a localized needle biopsy done for breast Ca Dx?
What is the difference between incisional and excisional biopsy?
Non-palpable mass seen on MMG/US
In: piece taken, better cosmetics
Ex: entire mass removed
What are the steps of a sentinel node biopsy and lumpectomy
Injection into mass
PT scanned and uptake noted
No uptake in first node, likely
no nodal spread, no axillary dissection needed
Perform lumpectomy and post-op radiation
How are estrogen receptor breast Cas Tx
How are progesterone receptor breast Cas Tx
Antiestrogens
Antiprogesterones
How is HER2 breast Ca Tx
Define Triple Negative breast Ca
Poor prognosis, metastasis
Monoclonal antibodies
BRCA1 pos
ER PR HER2 neg
Worse prognosis, chemo mainstay
What is a finding that signifies a favorable breast Ca prognosis?
What is the MC type of breast Ca
Presence of E/P receptors
Infiltrating ductal carcinoma
What are the pre-invasive forms of breast Ca?
What type is cancerous and must be removed?
Lobular carcinoma in situ- marker for Ca while still encapsulated in lobe
Ductal carcinoma in situ:
Cancerous lesion must be removed, f/u w/ chemo
When is breast cancer more likely to be bilateral?
What is the next step?
How are they Tx
FamHx
<50yo
Primary tumor is lobular
Mammogram
Mastectomy Tamoxifen
Define Paget Carcinoma
When do these PTs need to be referred to surgery?
Ductal carcinoma of nipple w/ itch/burning
Refractory to ABX/steroids >1wk
What is the MC Cause of Paget Carcinoma
What is the most malignant form of breast Ca
Ductal Carcinoma In Situ
Inflammatory breast Ca
When should inflammatory breast Ca be high on DDx
How are these PTs Tx
Non-lactating woman
Neochemo
Surgery
Radiation
Men w/ prostate Ca are at increase risk for developing ?
How is most breast Ca Tx
Breast Ca
Modified radical mastectomy: removes breast, nipple and axillary nodes
How is radical mastectomy different from modified?
What is the most important prognostic variable
Removes breast, pec muscle, skin and lymph
Metastases to axillary lymph node
PT w/ damage to thoracodorsal nerve during mastectomy will present w/ ? issue
What Tx is usually done after surgery
Lat dorsi- difficult w/ shoulder internal rotation/abduction
2-6wks post-op
Radiation 5x/wk x 6-8wks
Tangent beams to body
What muscle is used for cosmetic breast reconstruction
What area of breast and chest tissue is examined during Ca screening?
TRAM- transverse rectus abdominus muscle
Lateral sternal border to posterior axillary line
What is the MC lesion of the breast?
Once FNA is done for fibrocystic work up, what is next if?
Fibrocystic changes
Suspicious and non-malignant, non-resolving= core needle biopsy/excision
What is the only FDA approved drug for fibrocystic pain
What s/e makes this drug intolerable?
Danazol
Acne Edema Hirsutism
Female should examine breast for fibrocystic changes when?
What is a normal variant of breast tissue seen in these PTs
Post-menstruation
Lumpy cobblestone w/ ridges
Sxs of fibrocystic changes improve w/ ? and are gone w/ ?
What is the MC benign breast lesion
OCPs
Menopause
Fibroadenoma
How often are fibroadenoma PTs f/u w/?
What procedure is done if PT requests excision of benign fibroadenoma
US and CBE q6mon
Enucleation of lesion
In decreaseing frequency, what are the MC causes of nipple discharge in non-lactating breasts?
Bloody d/c is suggestive of ? but is usually ?
Duct ectasia
Intraductal papilloma
Carcinoma
Ca
Benign papilloma
When can PTs w/ nipple discharge be managed w/ f/u and observation?
Nipple d/c is the ?MC breast complaint after ?
Non-localized
Non-palpable mass
Non-bloody d/c
Re-examine q3-4mon w/ mammogram and US
3rd
Mastalgia
Mass
What type of nipple d/c is considered pathological
What is the next best step?
How long can pregnancy induced gallactoria remain
Bright red, rusty/brown or green
Dx mammogram
2nd trimester - 2yrs post partum
How is macromastia Tx conservatively
What BIRAD score does an abnormal screening mammogram get?
Weight loss
Posture therapy
0
1-2: Annual mammogram
3: ipsilateral mammogram in 6mon/bilatera mammogram in 12, 24mon
4-5: require tissue diagnosis
What is the most significant risk for developing breast cancer?
When do these risks fluctuate?
Age
Rises until 60s
Peaks in 70s
Drops after
What risk assessment tool is used for validating risk of developing Ca?
Breast lesions suspicious for malignancy should have biopsy, preferrably ?
Gail 2
Percutaneous needle biopsy
What serum markers can help follow breast Ca but not Dx
Disadvantages of FNA
CEA
CA 15-3
CA 27.29
Pathologist training
Sampling problem
What is the Dx procedure of choice for palpable and image detected abnormalities
Why is this type of biopsy preferred
Core needle biopsy
Tumor markers can be performed
Lesions that can’t be amendable by core biopsy are excised by ?
? is primarily used for staging and radiation planning?
What is the preferred alternate?
Needle wire localization biopsy
Axillary dissection
Sentinal node biopsy
When is sentinal node biopsy appropriate
What makes PTs ineligible for this?
Invasive cancer but negative nodes
Pos nodes- must have full ALND or neo therapy
Tumors w/ ? tend to have more indolent dz process
Tumors that lack ? have higher risk for recurrence, metastases and have worse survivals
Receptor positive
Triple negative- ER PR HER2
What is the only therapy for reducing metastases in receptor negative Ca
Status of ? is the most important negative prognosis factor
A high nuclear grade has a ? factor
Cytotoxic chemo
Axillary nodes
Negative prognostic
What is the hallmark of DCIS
Most cases of Pagets Carcinoma have ? underlying issue
Noeplastic cell fills duct/lobule and not penetrate basement membrane
DICS
Invasive cancer
Biopsy result of suspected inflammatory cancer showing dermal lymphatic involvement means ?
What is the risk for PTs receiving trastuzumab based Tx regimens
Don’t classify as inflammatory Ca
Cardiomyopathy
What is the most serious long term risk for Pts undergoing radiation?
When is a solitary thyroid nodule more likely to be Ca
CADz
Male <20 or >60
Functioning thyroid nodule will have ? lab results
How would RAI look like on hyperthyroid or thyroiditis?
Los TSH, High T3 T4
“Hot”, benign
Hyper: low TSH, inc uptake
Itis: low TSH, dec uptake
First step in investigating solitary thyroid nodule?
What are the indications to refer solitary thryoid nodule to surgery
US FNA
Suspected/proven Ca (pappillary atypical medullary follicular) Hormonally active Cystic nodule x2/>4cm Functionally malignant Cosmesis
What are the benign tumors of the thyroid
Follicular adenoma: benign hyperplasia surrounded by capsule
Toxic adenoma: hyper functioning tissue
<4cm- radioactive iodine
>4cm- thyroidectomy
How does malignant thyroid nodule present?
What are the two most common types?
What are the two more rare types?
Solitary nodule early/late in life
Papillary
Follicular
Medullary
Anaplastic
Papillary thyroid carcinoma is more common in ?
How do papillary/follicular spread through body?
Iodine deficient
Kids
Post-XRT PTs
Papillary- lymph
Follicular- hematogenous
How do each mailignant thyroid Cas present
Papillary- multi-focal w/ spread to contralateral lobe and regional nodes
Follicular- solitary, encapsulated, soft/rubbery
Medullary: multifocal multilobular metastic
How are follicular neoplasms worked up and Dx
Partial thyroidectomy
Sample frozen, Dx by pathologist
F adenoma= no resection
F carcinoma= complete ectomy
Where does follicular neoplasms like to metasases to?
Medullary neoplasms metastases to ?
Via hemoategenous to lung/bone
Liver
What adjuvant therapies are used for thyroid Ca
What type of thyroid Ca causes back pain and what is the prognosis?
Thyroxine
Radioactive iodine
XRT
Chemo
Follicular
Define Thyroglossal duct cyst
How is it worked up
How is it Tx
Benign; thyroglossal tract persists into cyst from development
US, Thyroid function
ABX then elective surgery
No InD
Goiter
Iodine poor regions
Congenital/Hashimoto
Responds to hormone Tx
Mass and Dyspnea Sxs
Normal function test or,
Dec TSH, Inc uptake
What types of masses can grow in the mediastinal areas
Anterior
Thymoma- MC neoplasm
Substernal thyroid- MC presentation
Middle:
Lymphoma
Bronchogenic cyst
Posterior:
Neurogenic tumor
What are the MC causes of hyperthyroidism thyrotoxicosis
How can this kill PTs?
Graves- hyper secretory goiter
Plummer- toxic multinodular goiter
Thyroid storm
HF
Cachexia
How does achilles reflex relate to thyroid health?
What will be seen on PE during Graves Dz
Short- hypo
Prolonged- hyper
Pretibial myxedema
Exophthalmosis
Vitiligo
How does thyrotoxicosis appear on lab results
What are two additional tests used for Dx mild hyperthyroidism
Dec TSH
Inc T3 T4 and uptake
T3 suppression- fail to suppress radioiodine when given T3
TRH test- TSH levels don’t inc when given TRH
How is thryotoxicosis Tx
Methimazole 30-100mg PO/day
PTU- not as often d/t s/e but in prep for surgery, 300-1000mg PO/day
R-131 after euthyroid or if +40y/o, poor surgical candidate or recurrent hyperthyroid
Thyroidectomy
How are hyperthyroid PTs requiring emergent surgery/thyroid storm Tx
What do PCMs doe for thyroid nodules?
Lugol iodine- prevent release of preformed thyroid hormone
BBs
Propylthiouracil to dec T4 to T3 conversion
T3 T4 TSH CBC CMP US CXR Refer- IM if hyper/thyroiditis GenSurg/ENT if nodule/large GTDCyst
Feeback/stimulation of Parathyroid
High Ca stims release of CT
CT inhibits clasts to dec Ca
Low Ca stims release of PTH
PTH promotes absorption of Ca and kidney release of calcitriol
Calcitriol sims inc Ca absorption from food
Lab results indicative of hyperparathyroid
Lab results indicative of secondary hyperparathyroidism
What are the different names by number of glands involved
High PTH and Ca
High PTH, low Ca
Adenoma- single gland
Hyperplasia- multiple
What can cause secondary hyperparathyroidism
Why are hand x-rays ordered for this?
What other x-ray finding will be seen?
Chronic RF
Malabsorption
Osteitis fibrosa cystica
Mottled skull
PT w/ high serum Ca and low serum phosphate points to ? dx
Why do hyperparathyroid PTs have bone pain?
Breast Ca
Inc alk phos
What does PCM order for hyperparathyroid
CMP- Ca PO4 E+ BUN/Cr AlkPhos
PTH
CXR
Refer to Endo/Surgery
