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Surgery > OME Surg Subs 6/2017 > Flashcards

OME Surg Subs 6/2017 Flashcards

1
Q

Strong suspicion of intussusception in kid based on history and physical, confirm dx by ultrasound or give enema?

A

Enema - diagnostic and therapeutic

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2
Q

Air or barium enema for peds intussusception?

A

Either works, but prefer air because safer…

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3
Q

Baby with meconium ileus, next step gastrografin enema or sweat chloride test?

A

Gastrografin enema - relieve obstruction

Then test for cystic fibrosis with sweat chloride test

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4
Q

Persistent gastric ulcers despite behavioral modification, therapy, confirmed h.pylori eradication
Think…
Next step

A

think Zollinger-Ellison syndrome (gastrinoma)

get serum gastrin to dx (elevated above 1000)

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5
Q

Next steps for asymptomatic hypercalcemia and hypophosphatemia and normal Cr

A

PTH level – mechanism must be related to overactive pth and intact kidney

If pth high follow with Sestamibi scan to see which parathyroid glands acting up

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6
Q

When to get PTH-rp level

A

When clear hyperparathyroidism but PTH level low – PTH-rp performs pth function, paranroplastic syndrome of squamous cell carcinoma of the lung

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7
Q

Diagnostic workup for pheochromocytoma

A

Urine catecholamines or metanephrines during an episode

24-hour urine VMA or metanephrines between episodes

Followed by MIBG or CT to find source

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8
Q

Adrenal vein sampling is usually reserved for…

A

Conn syndrome (adrenal hyperaldosteronism)

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9
Q

Why urine metabolites before ct in workup for pheo

A

so you don’t go chasing incidentalomas – want to dx then soecify location

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10
Q

Hypotension amd hyperkalemia think…

A

Hyperaldosteronism

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11
Q

2 typical presentations of renal artery stenosis

A

Fibromuscular dysplasia in young woman

Atherosclerosis in old man

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12
Q

Is cushing’s primary or secondary hypercortisolism

A

Secondary hypercortisolism

Pituitary adenoma…

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13
Q

Work up cushing’s syndrome

A

Start with 24-hour urine cortisol measurement
Or overnight LOW-dose dexamethasone suppresion test (equivalent)

If cushings confirmed (hypercortisolism):

Check ACTH

  • if acth low, get CT to find adrenal adenoma
  • if acth high, do HIGH-dose dexamethasone suppression – pituitary adenoma suppressed get brain MRI to confirm get inferior petrosal sinus sample if mri negative tumor may be functional but small; cancer not suppressed get whole body ct looking for it almost always small cell lung cancer
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14
Q

Workup suspected coarcted aorta in an adult

A

XR for rib notching

Confirmed by CT w IV con, MRA, or simple angiogram (prefer MRA or angiogram in kids to expose less radiaton… echo if real youn eg 2yo…)

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15
Q

Treat renal artery stenosis from fibromuscular dysplasia

A

Percutaneous angiography with baloon dilation and stenting

Open surgical currection if above fails

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16
Q

Cyanotic heart condition not diagnosed at birth (aka pt lived for a bit before dx) think

A

Tetrology of fallot

The only cyanotic condition that baby can live with and present later in life aka after day 1 of life

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17
Q

Holosystolic murmur think…

A

VSD in a kid

Mitral Regurge in an adult

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18
Q

Manage a small asymptomatic vsd confirmed by echo causing a 3/6 holosystolic murmur in a toddler

A

Reassure and follow till 2yo as most small asymptomatic vsd’s will close spontaneously

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19
Q

Newborn cyanotic heart diseases

A

5 Ts, only 2 common in life and on test

Tetrology of Fallot
Transposition of Great Vessels

Tricuspid Atresia
Total Anomalous Venous Return
Truncus Arteriousus

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20
Q

Coarcted aorta suspected in 2yo not walking apparently due to pain with elevated ue bp’s and low le bp’s – next diagnostic step

A

Echo – easy visual window in kid, avoid radiation

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21
Q

What enzymes to draw to assess MI after open heart surgery

A

CK-MB

Peaks later than troponin I but normalizes faster – so best for assessig repeat MI

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22
Q

When is CK-MB the best enzyme to draw for chest pain

A

To assess repeat MI in a short time (trops remain elevated while ckmb normalizes between infarcts)

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23
Q

Old guy with symptomatic aortic stenosis, next step in management

A

Coronary angiography to assess need for CABG before subsequent valve replacement

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24
Q

TF

Metoprolol and lisinopril to treat chf before valve replacement for aortic stenosis

A

F
Proceed to coronary angiography to assess need for CABG, then valve replacement, don’t watch and wait with medical therapy

Metoprolol and lisinopril for medical mgmt of chf, not tiding over for surgery

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25
Q

Low rumbling diastolic mirmur woth an opening snap

At midclavicular 5th intercostal space

A

Mitral stenosis

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26
Q

Treatment of mitral stenosis vs aortic stenosis

A

Mitral stenosis responds to commisurotomy or baloon angioplasty so try those endovascular procedures in young pt who will outlive a valve replacement because can only open the chest 3 times

Aortic stenosis does not respond to these (too calcified… maybe palliative for severe stenosis in a poor surgical candidate only) so will need valve replacement

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27
Q

TF

Coronary angiography to assess need for CABG prior to mitral valve baloon angioplasty or commissurotomy

A

F
Baloon angioplasty and commissurotomy are endovascular procedures

Assess for CABG need before open valve replacement to make sure heart can tolerate open heart surgery

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28
Q

Normal cardiac index

What is cardiac index

A

^3

CO / body surface area
L/min x m^2

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29
Q

Pt in severe cardiogenic shock, are you increasing furosemide dose or giving dobutamine

A

Give dobutamine

If it’s severe you are stepping it up from playing around with furosemide

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30
Q

Indication for open heart surgery (CABG)

A

Left mainstem equivalent or 3 vessel disease

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31
Q

When to give tPA in seting of MI

A

STEMI with no PCI available within 90 minutes

32
Q

CAD/typical angina medically managed now acutely worsening but ecg and trops negative, next step?

A

Angiography to asess for stent vs CABG

-watching with continued medical management not the answer if clear acutely worsening angina with hx/risk factors even if ecg and trops negative

33
Q

Manage a dissecting aortic aneurysm

A

CT angio (or trans esophageal echo or MRAngio if CT unavailable) to ID whether ascending or descending

Emergent surgery if ascending

IV Labetalol if descending (medical management)

34
Q

Manage a 4cm asymptomatic AAA found on physical exam in an old guy

A

Abdominal Ultrasound to characterize

Serial ultrasounds annually

Elective Surgery if ^5.5 cm or ^.5 cm growth in a year

Emergent surgery if symptomatic tender painful (impending rupture)

CT to assess renal arteries if Cr elevated kidneys appparently compromised

35
Q

Typical location of pain in rupturing aortic aneurysm

A

Lumbar back

36
Q

AAA screening

A

x1 in men who smoked, at age 65

37
Q

TF

Repeat peripheral bypass graft an option?

A

F
Salvage graft, not repeat
…or amputate…

38
Q

Acute limb ischemia by h and p, next step?

A

Angiography

To inform decision of tPA, embolectomy, bypass, amputation

39
Q

Diagnostic workup of peripheral vascular disease vs acute limb ischemia

A

PVD abi, us with doppler, angiography

ALI straight to Angiography to inform decision of tPA, embolectomy, bypass, amputation

40
Q

Stent or bypass lower extremity peripheral vascular disease

A

Stent if block is femoral and v3cm

Bypass if block is popliteal or ^5cm

41
Q

TF

Coumadin treats arterial thrombosis

A

F

Treats venous thrombosis

42
Q

Cilostazol
MOA
Use
CI

A

Cilostazol

MOA –| PDE III and thereby v cAMP… inhibiting platelet aggregation and causing vasodilation

Use - symptomatic relief from PAD (claudication)

CI - CHF, otherwise safe in PAD

43
Q

Clopidogrel amd/or Aspirin for PAD?

A

Either but no benefit together, the same efficacy except give clopidogrel for stents

44
Q

Anesthesia paralysis pulseless chronic PAD now looking like acute limb ischemia

Manage?

A

Amputation

Extremity is dead, no salvage, just infrction risk

45
Q

Treat an erythematous skin lesion with light scale consistent with actinic keratosis (premalignant precursor) or Bowman’s disease (carcinoma in situ) – both local not yet invasive precursors to SCC

A

Treat local pre-SCC skin lesions (carcinoma in situ or better) with topical IMIQUIMOD or RADIOTHERAPY

46
Q

When is local excision appropriate for a cancerous skin lesion

A

Melanoma v0.5cm 5mm Diameter v1mm Depth (basically melanoma in situ)

47
Q

Treat BCC or SCC

A

Wide excision for both – a little wider for SCC because more mets

48
Q

TF

Reassurance is appropriate management for Seborrheic Keratosis

A

T

49
Q

When is wide excision and sentinel lumph node dissection indicated for melanoma

A

When ^1mm (Breslow) depth but no obvious mets

50
Q

Imiquimod moa

A

immune response modifier, a Toll-like receptor 7 agonist that activates immune cells. Topical application to the skin is associated with increases in markers for cytokines and immune cells.

51
Q

Diagnose skin cancer

A

Full Thickness Punch Biopsy of EDGE of lesion – to include good and bad skin for comparison

52
Q

TF

Punch biopsy of ulcersted skin lesion concerning for cancer should be taken at ulcer base

A

F
Take full thickness punch biopsy of EDGE of lesion – to include good and bad skin for comparison… ulcer demonstrates dead stuff not cancer i think…

53
Q

You are pretty confident in skin cancer diagnosis – can you skip punch biopsy amd go straight to excision with negative margins?

A

No – get punch biopsy first for depth

54
Q 
BCC
Description
Most typical location
Diagnose
Treat
Local invasion or mets?
When is amputation the answer?
A

BCC
Description - waxy or pearly, punched out or clean

Most typical location - upper face
Diagnose - full thickness punch biopsy
Treat - wide local excision with clear margins
Local invasion common, mets rare

When is amputation the answer?
When large or invasive on a limb

55
Q 
SCC
Description
Diagnose
Treat
Local invasion or mets?
When is amputation the answer?
A

SCC
Description - non-healing ulcer (NOT punched out - that’s BCC), or a darkly pigmented lesion that looks like melanoma but maybe more crusty/rugged less shiny/smooth

Diagnose - full thickness punch biopsy
Treat - wide local excision with clear margins
Local invasion common, mets rare

When is amputation the answer?
When large or invasive on a limb

56
Q 
How do SCC and BCC differ
Description?
Diagnostic workup?
Treatment?
Local invasion or mets?
When is amputation the answer?
A

Differ in appearance
SCC - non-healing ulcer (NOT punched out - that’s BCC), or a darkly pigmented lesion that looks like melanoma but maybe more crusty/rugged less shiny/smooth

BCC - waxy or pearly, punched out or clean

Diagnosed and Managed identically, both do Not really metastasize

full thickness punch biopsy
wide local excision with clear margins
Local invasion common, mets rare
Amputate when large or invasive on a limb

57
Q

Darkly pigmented skin lesion that may be SCC or Melanoma… hints in alpearance either way?

A

SCC porbably more crusty/rugged

Melanoma probably more shiny/smooth

58
Q

ABCD is relevant for what skin lesion

A

Melanoma

Asymmetry
Borders irregular
Color variable
Diameter ^.5cm 5mm

59
Q

TF

Melanoma relapses and remits spontaneously

A

T

60
Q

A melanoma with hair is called a…

A

Nevus or mole

61
Q

Manage greasy crusted large stuck on appearing skin lesion likely sebhorreic keratosis

A

Punch biopsy to rule out bad SCC then reassurance for actinic keratosis

62
Q

Manage skin lesion erythematous with a light scale confirmed Actinic Keratosis by punch biopsy

A

imiquimod if not growing out or deep

Otherwise local resection

63
Q

Skin cancer that mets and kills in strange ways

A

Melanoma

64
Q

TF

Melanoma responds to chemo amd radiation

A

F

It can be locally resected and that is about it

65
Q

First step in diagnosing erectile dysfunction

A

Night time tumescence test (eval spontaneous erections in sleep) - if abnormal/suboptimal rules out non-organic/psychologic/lack of stim etc for daytime erections

66
Q

TF

Follow abnormal night time tumescence test with penile angiography in workup of ED

A

F
If abnormal night time tumescence rules out nonorganic/psych etc and pt history points to atherosclerosis you go ahead and treat pharmacologically with SILDENAFIL or VARDENAFIL (PDE inhibitors), if that fails next option is PROSTHESIS

67
Q

TF

You can stent penile arteries to treat ED

A

F
You NEVER stent penile arteries

If abnormal night time tumescence rules out nonorganic/psych etc and pt history points to atherosclerosis you go ahead and treat pharmacologically with SILDENAFIL or VARDENAFIL (PDE inhibitors), if that fails next option is PROSTHESIS

68
Q

Urgency or frequency wothout dysuria, or difficulting starting or stopping, with a smooth rubbery prostate on exam
Dx
Tx

A

BPH
Tamsulosin (alpha blocker)
+ Finasteride (5 alpha reductase inhibitor) if necessary

69
Q

TF

Biopsy prostate to dx BPH

A

F
Dx by history and treatment

Urgency or frequency wothout dysuria, or difficulting starting or stopping, with a smooth rubbery prostate on exam

Tamsulosin (alpha blocker)
+ Finasteride (5 alpha reductase inhibitor) if necessary

70
Q

Ureteral kidney stone causing obstruction hydronephrosis elevated Cr AKI

Manage

A

Percutaneous Ureterostomy to relieve obstruction and kidney injury

Followed by
Open surgical removal of stone if ^3.5cm
Lithotripsy if .5-3.5cm
IVF and analgesia if v.5cm 5mm

71
Q

BPH meds that dilate the urethra and help the urinary stream

A

Alpha blockers

Tamsulosin doxasosin terazosin

72
Q

Clear testicular torsion by presentation – acute pain with predisposing factor and horizontal lying testicle on exam
To surgery or doppler first?

A

To surgery

Only doppler if dx in question

73
Q

TF

Orchiopexy of contralateral testicle is part of treatment for testicular torsion

A

T

Do both sides

74
Q

Treat erectile dysfunction caused by radiation or surgery

A

Penile prosthetic is best treatment

Neurogenic not atherosclerotic, pde inhibitor won’t help

But Next Best Step might be sildenafil just to do everything to try to avoid surgery

Aka PROSTHESIS IS RESERVED FOR FAILED MEDICAL TREATMENT

75
Q

TF

you want a patient to stop smoking acutely before surgery

A

F

First 8 weeks of smoking cessation riddled with increased sputum coughing labored breathing

76
Q

Tranfusion guidelines for anemia

A

If symptomatic

Or prophylactically for H or H of 7 or 21

77
Q

Chances of perioperative death in decompensated cirrhotic

A

30% if 1 on child-pugh scoring system

100% if all criteria of child-pugh scoring system

(Low alb, high bili, high INR, ascites, encephalopathy)

Surgery (22 decks)

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