OME Surg Subs 6/2017 Flashcards
Strong suspicion of intussusception in kid based on history and physical, confirm dx by ultrasound or give enema?
Enema - diagnostic and therapeutic
Air or barium enema for peds intussusception?
Either works, but prefer air because safer…
Baby with meconium ileus, next step gastrografin enema or sweat chloride test?
Gastrografin enema - relieve obstruction
Then test for cystic fibrosis with sweat chloride test
Persistent gastric ulcers despite behavioral modification, therapy, confirmed h.pylori eradication
Think…
Next step
think Zollinger-Ellison syndrome (gastrinoma)
get serum gastrin to dx (elevated above 1000)
Next steps for asymptomatic hypercalcemia and hypophosphatemia and normal Cr
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
When to get PTH-rp level
When clear hyperparathyroidism but PTH level low – PTH-rp performs pth function, paranroplastic syndrome of squamous cell carcinoma of the lung
Diagnostic workup for pheochromocytoma
Urine catecholamines or metanephrines during an episode
24-hour urine VMA or metanephrines between episodes
Followed by MIBG or CT to find source
Adrenal vein sampling is usually reserved for…
Conn syndrome (adrenal hyperaldosteronism)
Why urine metabolites before ct in workup for pheo
so you don’t go chasing incidentalomas – want to dx then soecify location
Hypotension amd hyperkalemia think…
Hyperaldosteronism
2 typical presentations of renal artery stenosis
Fibromuscular dysplasia in young woman
Atherosclerosis in old man
Is cushing’s primary or secondary hypercortisolism
Secondary hypercortisolism
Pituitary adenoma…
Work up cushing’s syndrome
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
Workup suspected coarcted aorta in an adult
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…)
Treat renal artery stenosis from fibromuscular dysplasia
Percutaneous angiography with baloon dilation and stenting
Open surgical currection if above fails
Cyanotic heart condition not diagnosed at birth (aka pt lived for a bit before dx) think
Tetrology of fallot
The only cyanotic condition that baby can live with and present later in life aka after day 1 of life
Holosystolic murmur think…
VSD in a kid
Mitral Regurge in an adult
Manage a small asymptomatic vsd confirmed by echo causing a 3/6 holosystolic murmur in a toddler
Reassure and follow till 2yo as most small asymptomatic vsd’s will close spontaneously
Newborn cyanotic heart diseases
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
Coarcted aorta suspected in 2yo not walking apparently due to pain with elevated ue bp’s and low le bp’s – next diagnostic step
Echo – easy visual window in kid, avoid radiation
What enzymes to draw to assess MI after open heart surgery
CK-MB
Peaks later than troponin I but normalizes faster – so best for assessig repeat MI
When is CK-MB the best enzyme to draw for chest pain
To assess repeat MI in a short time (trops remain elevated while ckmb normalizes between infarcts)
Old guy with symptomatic aortic stenosis, next step in management
Coronary angiography to assess need for CABG before subsequent valve replacement
TF
Metoprolol and lisinopril to treat chf before valve replacement for aortic stenosis
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
Low rumbling diastolic mirmur woth an opening snap
At midclavicular 5th intercostal space
Mitral stenosis
Treatment of mitral stenosis vs aortic stenosis
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
TF
Coronary angiography to assess need for CABG prior to mitral valve baloon angioplasty or commissurotomy
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
Normal cardiac index
What is cardiac index
^3
CO / body surface area
L/min x m^2
Pt in severe cardiogenic shock, are you increasing furosemide dose or giving dobutamine
Give dobutamine
If it’s severe you are stepping it up from playing around with furosemide
Indication for open heart surgery (CABG)
Left mainstem equivalent or 3 vessel disease
When to give tPA in seting of MI
STEMI with no PCI available within 90 minutes
CAD/typical angina medically managed now acutely worsening but ecg and trops negative, next step?
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
Manage a dissecting aortic aneurysm
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)
Manage a 4cm asymptomatic AAA found on physical exam in an old guy
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
Typical location of pain in rupturing aortic aneurysm
Lumbar back
AAA screening
x1 in men who smoked, at age 65
TF
Repeat peripheral bypass graft an option?
F
Salvage graft, not repeat
…or amputate…
Acute limb ischemia by h and p, next step?
Angiography
To inform decision of tPA, embolectomy, bypass, amputation
Diagnostic workup of peripheral vascular disease vs acute limb ischemia
PVD abi, us with doppler, angiography
ALI straight to Angiography to inform decision of tPA, embolectomy, bypass, amputation
Stent or bypass lower extremity peripheral vascular disease
Stent if block is femoral and v3cm
Bypass if block is popliteal or ^5cm
TF
Coumadin treats arterial thrombosis
F
Treats venous thrombosis
Cilostazol
MOA
Use
CI
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
Clopidogrel amd/or Aspirin for PAD?
Either but no benefit together, the same efficacy except give clopidogrel for stents
Anesthesia paralysis pulseless chronic PAD now looking like acute limb ischemia
Manage?
Amputation
Extremity is dead, no salvage, just infrction risk
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
Treat local pre-SCC skin lesions (carcinoma in situ or better) with topical IMIQUIMOD or RADIOTHERAPY
When is local excision appropriate for a cancerous skin lesion
Melanoma v0.5cm 5mm Diameter v1mm Depth (basically melanoma in situ)
Treat BCC or SCC
Wide excision for both – a little wider for SCC because more mets
TF
Reassurance is appropriate management for Seborrheic Keratosis
T
When is wide excision and sentinel lumph node dissection indicated for melanoma
When ^1mm (Breslow) depth but no obvious mets
Imiquimod moa
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.
Diagnose skin cancer
Full Thickness Punch Biopsy of EDGE of lesion – to include good and bad skin for comparison
TF
Punch biopsy of ulcersted skin lesion concerning for cancer should be taken at ulcer base
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…
You are pretty confident in skin cancer diagnosis – can you skip punch biopsy amd go straight to excision with negative margins?
No – get punch biopsy first for depth
BCC Description Most typical location Diagnose Treat Local invasion or mets? When is amputation the answer?
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
SCC Description Diagnose Treat Local invasion or mets? When is amputation the answer?
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
How do SCC and BCC differ Description? Diagnostic workup? Treatment? Local invasion or mets? When is amputation the answer?
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
Darkly pigmented skin lesion that may be SCC or Melanoma… hints in alpearance either way?
SCC porbably more crusty/rugged
Melanoma probably more shiny/smooth
ABCD is relevant for what skin lesion
Melanoma
Asymmetry
Borders irregular
Color variable
Diameter ^.5cm 5mm
TF
Melanoma relapses and remits spontaneously
T
A melanoma with hair is called a…
Nevus or mole
Manage greasy crusted large stuck on appearing skin lesion likely sebhorreic keratosis
Punch biopsy to rule out bad SCC then reassurance for actinic keratosis
Manage skin lesion erythematous with a light scale confirmed Actinic Keratosis by punch biopsy
imiquimod if not growing out or deep
Otherwise local resection
Skin cancer that mets and kills in strange ways
Melanoma
TF
Melanoma responds to chemo amd radiation
F
It can be locally resected and that is about it
First step in diagnosing erectile dysfunction
Night time tumescence test (eval spontaneous erections in sleep) - if abnormal/suboptimal rules out non-organic/psychologic/lack of stim etc for daytime erections
TF
Follow abnormal night time tumescence test with penile angiography in workup of ED
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
TF
You can stent penile arteries to treat ED
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
Urgency or frequency wothout dysuria, or difficulting starting or stopping, with a smooth rubbery prostate on exam
Dx
Tx
BPH
Tamsulosin (alpha blocker)
+ Finasteride (5 alpha reductase inhibitor) if necessary
TF
Biopsy prostate to dx BPH
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
Ureteral kidney stone causing obstruction hydronephrosis elevated Cr AKI
Manage
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
BPH meds that dilate the urethra and help the urinary stream
Alpha blockers
Tamsulosin doxasosin terazosin
Clear testicular torsion by presentation – acute pain with predisposing factor and horizontal lying testicle on exam
To surgery or doppler first?
To surgery
Only doppler if dx in question
TF
Orchiopexy of contralateral testicle is part of treatment for testicular torsion
T
Do both sides
Treat erectile dysfunction caused by radiation or surgery
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
TF
you want a patient to stop smoking acutely before surgery
F
First 8 weeks of smoking cessation riddled with increased sputum coughing labored breathing
Tranfusion guidelines for anemia
If symptomatic
Or prophylactically for H or H of 7 or 21
Chances of perioperative death in decompensated cirrhotic
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)
