Oral Exam Cases Flashcards
What does OPQRSTU stand for
onset, position, radiation, severity, timing, and relief
who gets an EKG
over 40 men and over 50 W
if anticoagulation is a concern, what do you get
PTT and PT
who gets a cardiac workup
history of heart disease or symptomatic disease
what meds do you stop 7 days out
NSAIs, anticoag, and ASA
neck mass history
problems swallowing, speaking, breathing, mouth ulcers, fever chill, night sweat, weight loss, alcohol, and tobacco products
what are family history questions with neck mass
MEN and thyroid
what is a neck mass if they have night sweats
lymphoma
physical exam for neck mass
full PE with recta, placate liver, east and lungs, look for Hand N and look in nose, mouth easy, palpate nodes all over including in the axilla. Are the nodes firm or ovable
imaging for neck mass
US and CT of head and neck CXR
testing for neck mass
FNA, quad endo- nasophargeoscopy, laryngoscopy, bonchoscopy, escogoscopy under anesthesia with mouth exam, tipsy for these and tumors can hide in the piriform sinuses
surgery for neck mass
RND which is radical neck dissection which incused the SCN, spinal accessory nerve, internal jugular vein and submandibular gland. Post op rnd.
what do you do for an excisional biopsy of these neck mass
frozen section and RND
if the neck mass is sebaceous cyst
close
if the neck mass is scc
RND
if the neck mass is unknown primary
RND
if the neck mass is lymphoma
no srugery, chamber and rads because medical illness
if the neck mass is malign melanoma
RND and repeat PE for melanoma above the wasit
if the neck mass is pap thyroid
total thyroid and modified RND for just nodes
if the neck mass is adenocarcinoma of colon primary
chemo rads if colon is primarry
if the neck mass is aden of salivary
RNd and take out the gladn
what if the LN is metastatic
yo should remove it for local disease control anyways
Thyroid histroy
hyperthyrod symptoms like increased energy, trouble sleeping, weight loss, diarrhea, hypothyroid symptoms like decreased energy, fatigue, eight gain, constipation, family history of endocrinopathies and MEDN, radiation exposure as child, work, dysphagia, hoarse, difficulty breathing
PE for thyroid
full PE and focus on the texture and movability of the node
labs for thyroid
TSH wouldn’t want to stick it if its hot because thyroid storm. if euthyroid or increased TSH
imaging for thryoid
US demonstrates >3mm or solid is worse.
RAU if the nodule is
hot. Hot nodules are less worrisome. Do this if the TSH is low. cold is worrisome and needs a biopsy
if TSH low what do you do
thyroid scan, t3/T4 and functional nodule, RAI, surgery, and methimazole and PTU
if the TSH is high or normal do
US FNA and
what are the Bethseda classes
Non-diagnositic- repeat FNA Benign- no surgery AUS/FLUS- repeat FNA FN/FSn- lobectomy suspicious or indeterminate- lobectomy or total thyroid malignant- total thyroid
papillary thyroid Ca mets
nodes
treatment for pap
total thyroidectomy and resection of is central nodes
if the nodes are positive for pap
modified radical for all + nodes
what is the addition tx for pap
RAI, suppressive T4
what is the tumor marker for recurrence of pap
thyroglobulin
follicular mets via
blood
tx follicular
total thyroidectomy
what is the addition tx follicular
ablation plus T4
what is the tumor marker for follicular
thyroglobulin
what does medullary met by
blood and nods
what type of cells does medullary affect
c cells which are parafollicular cells that secrete calcitonin
what is another name for calcitonin
pentagastrin
what is med associated with
MEN2a or 2B
what is the gene associated with MEN2
ret protoconcogene
treatmend for med
total thyroid plus ipsilateral LN conpartment plus T4
do medullar need RAi
no it does not take it up
medulllay tumor marker
calcitonin
anaplastic tx
no surgery just chemo and rads because it is only palliative for airway compression. locally aggressive
MEN1 associateion
parathyroid hyperplasia, pit adenoma, pancreatic adenocarcinoma
MENIIa
medually thyroid, phew, and para hyperplasia
MENIIB
marfanoid, med thyroid, mucosal neuromas, pheo
men has pheo where
tends to be bilateral
what can happen to a gallstone
nothing, block a cystic duct, block that acutely then infection, bloc CBD, empyema, hydrous GB, cholangitits, ileum, pancreatitis,
what grows if there is retrograde inflame of GB
ecoli, kleb, enterococcus, bacteriodes fragillus
what is it called if the CBD is blocked
choledocolithiasis
what is hydrous of the GB
type of acute cholecystitis, stone blocks the cystic dduct and bile pigments are reabsorbed leading to white bile
what are the common causes of choledoco in the uS and world
choledoclithaisis is US, and colorants sinuses is worldwide, cholangiocarcinoma and sclerosis cholangitis
what is PSC associated with
UC
what drugs can treat the ascending chol
Unasynand zoysn
what is chariots triad
jaundice, RUQ, fever, chills
reynolds pentad is
jaundice, RUQ, and fever ,chills, mental status changes, and hemodynamic instability.
where does the ileus for the GB occur
it causes SBO at the illeocecal valve the fistula is causes between the GB and duodenum.
how do you fix gb ileus
NGT and remove stone from bowel do not need to remove the GB
what are the causes of pancreatitis
B- bilairy
alcohol
drugs- thiazides and roads
scorpion bite, surgery
hypercalcemia, hyperlipidemia,
iatrogenic from the ERCP, SLE, coxsackie,
trauma and tumor of the head of the pancreas
treatment for pancreatitis
treat with bowel rest, IVF, NGT, and CT is diagnostic
diagnostic tests for GB
ERCP for shooting dye through the sphincter of Oddi can also need a sphinctorotmty remove the CBD stone. main complication is pancreatitis.
US for Gb
shadowing from the CBD is 6mm if dilated
HIDA scan
test of fun, not anatomy, if decreased EF after CCK, recreating of pain, or can’t see GB (blockage of cystic duct)
PCTA
percutaneous transhepatic angiogrpahy, use Klatskin tumor, cholangiocarcinoma at bifurcation of the biliary tree
If there is pancreatic cancer at head of the pancreas
whipple- pancreaticoduodenonectomy, whole, tranquil vagotomy,antrectomy, cholechojejunostomy/ A whipple is palliative because chemo and rads do nothing. Whipple is also good for cholangiocarcinoma
if cancer is in the body or tail
distal pancreatectomy if the pancreatic cancer is unresectable due to blood vessel involvement liver involvement or biliary obstruction do a plaintive stent with ERCP, the downside to the stent is infection because luminal obstruction in CBD and have to change it every 3 months
if chronic panc
Roux en Y choledocojejunostomy. This is a bypass from the CBD to the jejunum and it prevents alkaline gastritis, treat alkaline gastritis qiwth cholestyramine to decrease bile acid pool, or Ca2+ which chalets bile acids
if choronic pancreatitis obstructing pancreatic duct
longitudianl pancreatojejunostomy or distal pancreatiticjejunostomy
melanoma history
asymmetry, border irregularity, color variation, diameter greater 6mm/dark enlargement/elvation. Prior personal history of melanoma or other skin lesions. Family history of melanoma or skin cancer, first sunburn at a young age, employment, possible relations with halogenated compounds
melanoma PE
fill PE and focus on skin and LN
melanoma labs
LFT
imaging for melanoma
CXR
risks for melanoma
fair hair, red hair, white, >20 nevi, blue eyes, easily burned, unable to tan, age, gender, tanning lamps, UVA, higher SES, immunosuppressed.
where are melanocytes found
them and dendritic cells are found at the DE junction of the skin, mucosa of respiratory GI and LN capsules, and substantial nigra
types of melanoma
superficiaal spreading, nodular sclerosing, lentigo maligna, acral lentigionous common in AA, asians, hispnanic, palms/soles, nail beds
Clark staging
epiderma, pap dermis, junction of pap and ret dermis, reticular dermis, fat and subQ
Breslow index
depth of vertical height; overall survival in 5 years correlates with tumor thickness
palp LN present for melanoma
complete lymphadenecomy of the basin do an excision or fNA first
what do you need to do to map the LNE
SLN and biopsy
what stages get biochem for melanoma
Stage III and IV get interferon
margins melanoma
.5cm- melanoma insitu
1 lesions over 1mm in thickness
2cm lesions >1mm
get SLN for melanoma if
less than .75 mm no
>1mm yes
if SLN is positive
get chest and abdominal CT and brain MRI. Positive staging to exclude mets with biopsies, and resect if possible and radiation for brain mets
sLN+ and negative staging
complete lymphadenceomy. Give IFN alpha and high dose ipilmumab.
how do you treat advanced extremitiy melanoma
isolated limb perfusion and chemo
diverticulitits histroy
PQRSTU. constitutional with chills, fever, weight loss, night sweats, change in bowel habits, constipation, diarrhea, and change in diet
diverticulitis PE
rectal and abdominal exam
lab for diverticulitits
CBC for leukocytosis
imaging for diverticulitits
CT of abdomen, colonoscopy, barium enema with caution to avoid possible leak of barium into peritoneum
treatment uncomplicated diverticulitits
managed medically, mild cases with outpatient treatment. Should be hospitilized for IVF, antibiotics, bowel rest, observation. clinical resolution of acute with first episdoe and greater than 50 who are not compromised do not require further things
if immunocomp what should you tx for diverticulitits
Harmat
when does diverticulitits get elective surgery
two plus epidsodes or under 40 with one epi
one stage operation diverticulitits elective
resect involved segment and primary anastoamosis
complicated diverticulitits tx
perforated diverticulitis with peritonitis do surgical exploration. second MCC of free air in peritoneum
when do you give surg for diverticulitis
obstructon, fistula, perf, abscess that cannot be drained, sepsis, deterioration with conservative tx.
what are the most common causes of free air under diaphragm
duodenal perforation and diverticulitits
Hartmans
resection of involved segment with end colostomy/stapled rectal stump (subsequent reanastamosis 2-3 months)
diverticular fistula for dx and tx
sigmoid to bladder/vagina/skin/another loop of bowel and dx with barium enema, CT, and sigmoidoscopy
how do you dx for colovesical and colovaginal fistula
cystoscopy on vaginal speculum
diverticulitis fistula tx
resection of sigmoid, excision of fistulous tract, repair/resection of involved organ
colorectal cancer and polyps history
fever,chills, weight loss, night sweats, abdominal pain, diarrhea, constipation, blood install, changes in bowel habits, family history of colon ca, colonoscopy hx
colorectal cancer and polyps PE
PE and abdominal and fecal occult blood test
colorectal cancer and polyps labs
CBC, CMP, CEA
colorectal cancer and polyps imaging
EGD, colonscopy, small bowel contrast radiography, CXR, CT abdomen and pelvis to exclude metastatic disease
surgery prep for colon surgery
mechanical bowel prep, NPO starting at midnight, liquids only days before, non-absorbable oral abs day before can decrease risk of wound infection
for cecum what is the name for the removal
right hemicolectomy.
what if there is synchronous colon cancer
complete colectomy
if locally advanced colon cancer, what is the tx
en bloc resection of contiguous structures
if LN are involved with colon CA
need to resect or T4 need FolFOx which is leucovorin, 5 FU and oxialiplatin
what do you have to check if anatoamosis
there needs to be submucosa, no tension and good blood supply on either side
what if there ia 5 days POD and tacky fever afib and hypotensive after colectomy
anastamotic leak and need to perf drain if possible if not, open up and if its blown then colostomy
how long do you give post op abx
only 3 doses within 24 hours
what do you do for anticoagulation
lovanox, compression socks, sequential compression device, and ambulation
decrease PNA risk
incentive psiro, ambulate
decrease risk of wound infection
pre-and peri abx, glucose control, normothermia in the OR
rectal surgery PE
need endorectal US for radiologic TNM classification.
if its in the upper 2/3 of the rectume over 10 cm above the anus
resect and reanastamosis with resection of the margin of 10 cm proximal and 2 cm distal to the lesion
if its in the lower 1/3 surgery-T1 and well diff and under 3
t1 lesion well diff and under 3 cm then local eosin to the level of the elevator Dani muscles and leva the anal canal and sprinter intact for anastomosis later
if its in the lower 1/3 surgery- and more than T1 or 3 cm
abdominoparineal resection- resection of the rectum and anal cancel and sphincter for low lying cancer wit ha permanent colostomy
T3 or T4if its in the lower 1/3 surgery-
need chemoraditation followed by abdominoperineal resection
screening for colon
every 10 years starting at 50
if there is an adenomatous polyp removed when is the next colonoscopy
every 3 years and then if its free after then go to 5 years
what type of polyp increases the risk of cacncer
larger villous poly
when is polypectomy curative
submucosal penetration ahs not occured. if invasive it needs resection
what is the colonoscopy schedule for FAP, HNPCC, IBD
colonoscopy starting at 25 with yearly FOBT, colonoscopty every 3 years
Dukes classes for Colon cancer
A- mucosa only
B into muscular
C LN positive
D distant mets
acute abdomen
sudeen sever abdominal pain
what do you start with acute abdomen
vitals, O2, NGT, IVF, foley
histroy for acute abdomen
OPQRSTU, V, hemateesis, alcoholism. PMH, SH< FH, meds, allergies
exam for acute abdomen
abdomniam exam
if there is positive signs of peritonitis what do you do
go to the OR- diffuse abdominal tenderness
labs for acute abdomen
CBC, CMP, ABG for acidosis
differential for acute abdomen
perforated ulcer, appendix, gallbladder, pancreatitis, volvulus
tx for ruptured ulcer
graham patch, highly selective vagotomy, pyloroplasty, tranquil agotomy, antrectomy inclusing ulcer for gastric ulcer.
chest pain and epigastric pain with emesis, history of alcohol, emerges, abdominal pain, exam has rebound and no radiation, decreased Bs, -ddx
PUD, gastritis, biliary colic, gastric volvuvlus, Mallory weiss
tests for listed above case
free air, EKG wit positive tropinins.
plan for the case
nitro drip with swan gang to check the filling pressure, and beta blocker and antibiotics in the OR
OR for perforated duodenal ulcer
graham pouch with momentum.
if there is a perf gastric ulcer
antrectomy for gastric perforation
closing the abdomen and the BP is 50…
use an inartistic balloon pump attached to EKG in femoral artery aorta. When n systole, the balloon is collapsed, in diastole it inflates, gives a diastolic kick to get blood into coronaries (increasing preload) and creates a suction in systole to decrease after load
RLQ history
PQRSTU, fever chills, nvd, pain with urination, hematemesis, changes in bowel habits, vaginal discharge, LMP if female, sexually active
RLQ PE
focus on abdominal, pelvic, and rectal exams, rebound tenderness, involuntary guarding, distention, rovsig pain RLQ when palpate LLQ, psoas, obturators
RLQ ddx
GI: appendicitis meckels, mesenteric lymphadenitits, diverticulitis of cecum, IBD, gastroenteritits, valentinos apendicitis. PID, TOA, mittelschmitertz, pyelo, UTI, kidney stone, ectopic pregnancy, RLL pneumonia, pancreatitis
labs for RLQ pain
CBC with diff, UA , urine HCG, type and screen, CMP and amylase and lipase
atypical RLQ
gets a CT
what is the preferred testing for gyn
US instead of CT
what is the typical progression of appendicitis
facecloth luminary obstructs the appendix, lymphoid hyperplasia in teens, and food matter
what does the facecloth cause in terms of obstruction
obstruction increases the mucus secretion and venous lymphatic congestion,and bacterial overgrowth leading to necrosis and perforation
rupture appy in F can cause
adhesions in pelvics and serility- tell this if the case is unclear from CT and want to progress to lap
why are there QBC in the UA
it is from the appendix lying on the ureter and causing inflammation
what you do if you suspect appendicitis
remove it
if there is a normal appendix
can take a look around to look for other stuff. If normal can still remove it.
mass in the tip of the appendix
if less than 2 cm take out appendix and if greater than 2 cm then do right hemicolectomy.
tubo-ovarian abscess tx
unilateral salpingo-oopherectomy- with hysteretcomy
crohns in ileum- what to do
do not take out the appendix if the re cecums involved because it can risk developing a fistula.
fistula causes
foreign body, radiation, immunocompromised/infection, epithelialization, neoplasia, distal obstruction, steroids. treat acute crohns with steroids
MEckels tx
amputate at the base or resect the base if there is a wide width or an ulcer opposite it
suppurative thrombophelbitits
pain 48 hours after vaginal delivery acute abdomen and increased WBC-
what is the etesing for suppurative thrombophelbitits
abdominal xr will be normal and the abdominal CT has a tubular structure in the retroperitoneum
Tx for suppurative thrombophelbitits
exalt finds large ovarian vein with suppurative thrombophelbitits due to ureter compressing the vein and with development of the coloniszation remove vein and give abx
acute GI bleed ABC
are they able to maintain airway or loss of protective reflex, intubate if concerted. Low BP suggests excessive bleeding, need 16-18 gauge needles and IVs with 2L NS followed by blood products
if unstable with acute GI bleed- blood per NG
Upepr gi
if unstable with acute GI bleed- proctoscopy +
rectal bleed
if there is upper GI bleeding what could you do
EGD and fix it
RBC scitogrpahy
high SN- negative do a colonoscopy if there is high volume. if bleeding stops colonscopy
angiography is
the most specific
if the patient is stable with acute GI bleed
colonscopy and EGD
history for acute GI bleed
alcoholic, previous ulcer, varices, history of AAA repair
differential for acute GI bleed
esophageal varices, perforated gastric or duodenal ulcer into the GDA, angiodysplasia, aortoenteric fistula
Labs for acute GI bleed
CHC with hemoglobin, CMP, LFT if alcoholic, type and cross, tox screen and blood alcohol level
what does 1 unit of PRBC equal
1gm of hb
varices tx
1- volume resuscitate and IV octreotide and abs
2- look at it with endoscope. if its stopped bellying do a beta blocker then band 1-2 weeks later. continued bleeding- balloon tamponade and increased risk of necrosis. Early rebleeding- repeat endoscopy therapy and need a TIPS or shunt surgery if there is recurrent hemorrhage
sclerotherapy
using sodium morrhuate
vasopressin what is the risk for varices
risk of MI
portocaval shunt
TIPS need to do early- increased risk of encephalopathy because liver is not clearing as much hammonia
what is the pathophysiology of cirrhotic liver
scar tissue impedes blood flow into the portal vein, increased pressure in the portal system gets shunted to the splenic vein, and short gastric, esophageal plexus, also in the umbilical vein, inferior rectal and retroperitoneal
what is the pathophys of enecphalopatyh
gut bacteria normall detoxifid in the liver, check this by measuring arterial ammonia
Childs Criteria
predicts the operative mortality- no ascetis, bill <2, no encephalopathy, alb>3.5 good nutrition, measure with transferring na pre albumin, and operative mortality is the same as if not cirrhotic.
mil ascites- bili 2-3, alb 3-3.5- nitrition no encephalotpy- additional mortality of 155 of the operation
ascite- alb<3, and encephalopathy- morality is 40% plus the risk of the operation. TIPS is places between hepatic vein and branch of portal vein to kill time before transplant
Most common reason for transplant
Heptatitis C or B in world, alcohol, and quickly is becoming NASH
red whale sign
the impending vatical hemorrhage
what are the indications to shunt
stopped drinking, not class C, determine if blood in portal vein goes to or from the liver (retropedal is bd because increased encephalopathy, want heptofugal flow)
how do you test for the flow of the liver
colo dopler of portal vein or measure portal pressure by hepatic vein wedge pressure, if <24 do NOT shunt because poor portal flow
shunt choices
portocaval- highest risk of encephalopathy. Splenorecnal shnt of Warren does not help portal pressure but lowers encephalopathy because it diverts the spleen flow
reflux dz hx
PQRSTU, associated with food, lying down, tight clothing, hoarseness wheeling, difficulty breathing, ffever, weight loss, chills, sweats, smoking and drinking
reflux dz PE
full
reflux dzlabs
CBC, CMP, cardiac enzymes if there is reason
reflux dz imaging
endoscopy for erosive or barriers
barium- locate the GE junction in relation to the diaphragm. hiatal hernia or shortened esophagus, evaluates for gastric outlet obstruction shows spontaneous reflux,
reflux dz 24 hr PH moniter-
correlates symptoms with episodes of reflux, stick a probe down the to the GE junction that correlates reflux symptoms with ph
reflux dz mamomatry
evaluates the competency of the LES, adequacy of peristalsis, motility disease based on pressure readings
reflux dz what else should you order
breathe test for pylori urease
tx for reflux dz behavioral
avoid irritants, high fat meals, no ells before lying down, elevate head of bed, lose weight, stop smoking
reflux dz tx medical
ntacids, ppi, prokinetic, h2 blockers
reflux dz surgical
laproscopic or open surgery with persistent GERD on max of PPI. Nissan which is a 360 degree wrap of the funds around the GE junction
50 yo F with halitosis bead breath, food getting stuck, and emesis after eating, difficulty swallowing liquids as well:
hx, test, diagnosis, treatments
tests- esophagoscope shows undigested food, barium swallow- dialed esophagus with corkscrew appearance and bid beak sign. manometry confirms achalas
dx of achalasia with manometry
failure of the LES to relax with swallowing and increased LES pressure with inability to relax.
tx for achalasia
esophagomyotomy- cut hypertensive outer muscle. ballon dilation of the sophagus, CCBs, fundoplication with toupee, botox
my food gets stuck- test shoes esophagitis
esophagoscope shows grade 2 esphogitits and barrettes
how to treat above person with barrets if its low grade
Nissen
how to treat it if its high grade barretts
esophagastrectomy
grading of esophagitis
1- erythema
2- linear ulceration
3- circular ulceration
4- stricture
my food gets stuck part 3 he esophagoscope shows stricture and no barrels with hernia- treatment
Nissen and ballon dialtion for stricture
food stuck- what risk factors do you need to ask
smoking, alcohol, reflux, barrettes, previous radiation, dsyphagia, weight loss, hoarseness
what are the tests for food stuck- esophagoscope shows fun gating mass- what do you do
metastatic workup with CXR, lFT, bone scan, CT, EUS stage then esophagectomy then do a stomach wing to bring up intestine or colon but make sure it does not have cancer. if there is invasion, must do chemo and radiation prior to surgery
Lung cancer histroy
cough, productive, hemotypsis, oarse, fever, chills, nv, weihgt loss, sweats, smoking, asbestos, family history of lung ca, previous ca anywhere else.
PE for lung cancer
chest exam, LN palp and skin exam, look for pink puffer or blue bloater
labd for lung CA
CBS, LFT, Po4, ABG, PFT
what FEV1 is fine for srugery
800-1000 cc
lung CA imaging
compare CXR, CT with contrast and chest and abdomen to look at size, location, solid or cystic, and LN for kediatonum or mets to liver or adrenal
where does lung CA like to go
liver and adrenals
what test do you do to look for distant mets
PET scan, and detects increased rate of glucose metabolism that occurs in malignant lesions, if you see a PET with bright spots on kidney and bladder, this does not mean there are mets, just contrast is renally excreted.
what disqulaifies from lung surgery
mets, low PFT
if there are no mets and PFt is okay what are the next steps
bronchoscopy- check for central lesions- if positive, no surgery
mediastonostomy- scope through the tranchemostomy incision to sample LN if + no surgery.
lobectomy is possible- only 1/3 are resectable.
if its a central lesion, what do you do
probably small cell- either sample by branch and mediastinoscopy- no surgery from there
breast Ca- hx
personal or family hx, pain, nipple discharge or inversion, skin changes, change with menstrual cycle, nulliparous, age at first prep (increased if over 30, age of menopause increased if over 55, OCP are protective, HRT increases risk, overweight because more estrogen.
PE for breast Ca
breast exam, look for peak de orange, nipple inversion, tenderness, skin dimples. palpable mass
BRCA1
breast and ovarian cancer
BRCA2
male breast cancer
labs for breast Ca
CBC, LFT, Ca, PO4, BRCA if young.
imgaing breast Ca
bilateral mamography with US, if abdominal pain, ab CT, neuro get head CT, bone pain get bone scan, CXr for lung mets
surgery for breast breast Ca
get US guided core needle buoy with 10-14 gauge.
what is the size of t1
less than 2 cm
what is the size of T2
205 cm
what is the size of T3
> 5 cm
if there an no nodes + then
no axilalry dissection, get genetic panel
if T1/T2 with 1-2 positive nodes and is lumpectomy
just do radiation
if T1/T2 with 1-2 positive nodes and is mastectomy then
do full azillary dissection
if there is more than T1/T2 and more than 1-2 positive nodes then
axillary dissection
what treats the T and what treats N and M
T is treated by surgery and NM is treated with radiation and chemo
sentinel node
take the hottest, the 10% of the hottest, palpable, blue, and any with blue going to it.
reconstruction of the breast
favorable tumor in frozen section need rads
bilateral mastectomy needs
bilateral SLN
in axillary dissection, which levels do you take
1 and 2 if you take 3 then it increases the risk of lymphedema
who gets chemo with breast Ca
+LN, HR negative, Her2 +, ER+ patients with genetics of high recurrence.
what chemo is used for breast
5Fu, adriamysin and cyclophosphamise
what to neoadjuvant do
it decreases tumor size, allowing for respectability and BCT,
hromonal therapy does what
decreases the risk of local and systemic recurrence, and opposite side cancer. Tamoxifen is for premoneopausal
what are the risks of tamoxefen
increased risk of DVT, endometrial cancer, hot flashes, estrogen analog in endometrium.
what do postmenopausal get
aromatase inhibitors- check FSH and LH to assure menopause and bone scan before anastrozole. Supplement with Ca and exercise myalgians and decrease in bone density so need to do weight baring exercise.
how long do you do hormone therapy
5 years
what drugs for breast Ca have cardiac risk
adriamycin and herceptin
what is the order of treatment for breast
surgery, chemo, radiation, hormone therapy
testicular mass history
trauma, pain, if yes do PQRSTU because Ca is not painful. family history and cryptorchistim. fever, chills, weight loss, night sweats
what is the tumor of the testicle in old men
lymphoma so many have secondary symptoms
PE for testicular mass
GU exam with transillumination, digital rectal exam, is the mass hard or soft, LN palpation
labs for testicular mass
beta hcg, alpha fetoprotein, CEA, LFT
imaging testicular mass
US of the scrotum tumor can have fluid around it. CXR to exclude mets
surgery for testicular mass
take out that damn testicle, radical femoral orchiectomy- through the inguinal incision over the cord, take the testis, spermatic cord at the iliac ring, ligate the artery and pampiniform plexus to not seed the sumor. Do not need a forzen section. Onceits confits. look in the retroperitoneum and aggressive chemo and rads
which is the most sensitive for radation
seminoma
what are more testicular mass derive from
germinal epitherlium
how is lung mets from testicular mass treated
chemo only
hic hLN does it hit first
paraarotic LN
where does the scrotum drain
femoral LN do not make an incision on the scrotum or will need to take more nodes
75 yo with history of mental illness comes to the ER with obtunded with severe hip pain and clutched her hip and fell
pathologic hip fracture.
what is the hx questions for this
circumstances of break, hx of factures, medical problems/medication, diet, constitutional symptom
shows breast mass, and externally rotated him
breast CA
what would long QT indicate
increased CA- can go to torsade
Labs for increased Ca
CMP and albumin, Ca is extremely high so need PTH
what is the first treatment for hyperCa
give NS and monitor UO
if the urine calcium is high hand Ca high and path high- what
primary hyperparathyroid
if Ca high, PTH high and low Caurine
familiar hypercalcemic hypocalciuria- asymptmatic
imaging for patient with breast mass and fracture of hi
CXR, mamogram, and xr of hip
differential for pathologic fracutre
Ca supplementation, hyperparathyroid, iatrogenic from thiazides, mets from breast, milk alike, pages, addisons, acromegaly, neoplasm of the bcolon, breast, protester, mm, ZE, excess D, A, sarcoid
what is the number 1 pit tumor
prolactinoma
what is the number one pancreatic utmor
gastrinoma
what is the most common malignant of the familial MEN1 tumors
glucagonomas and gastrinoma
treatment for hypercalcium
slaine loading and resuscitation with NS, and lassie to increase Ca in the urine, and rod the femor with hip replacement and breast cancer treatment
why don’t you use LR in kidney failure or high Ca
it has calcium and K in the kidney failure can fuck things up
how to treat primary hyperparathyroid
exploratory neck surgery give methane blue to stain the PT glands blu. if there s one big glad then its adenoma if there are 2 or more than hyperplasia. Most sensitive test during surgery is eyes. Tech 99 and gamma probe. IF there is a only 3 glands visible and are normal need to find missing most likely in thymic area.
Pt hyperpalsia treatment
remove all the glands and leave 30 mg of tissue in the non-dominant forearm
PT carcinoma
remove the carcinoma and ipsilateral thyroid lobe and all enlarged nodes.
what to do if the gland is missing
do a lobectomy and what on path, sestamibi washout to lightup the PT glands in the OR or Ct scan to see if its in the thymus. Remove thymus if so
tx for secondary HPTH
correct Ca nd phos and then renal transplant should fix it
tertialry HPTH treatment
correct Ca nd phos and remove all and reimplant 30 mg into the forearm if refractory.
what is A in trauma
airway if there is not patentcy- orotracheal intubation with manual inline traction performed by assistant. Angioedema from new ACE can cause airway compromise. ETI for comptose, RSI for agitated with Cspine and immobilized or patients who haven’t been NPO
b trauma
breathing, bag valve mask, ambubag hyperventilate 1005 O2. Chest tubes re 32 french
what size are chest tubes
32 french
C trauma
2 16-18 large bore IC peripheral with rapid infusion of 1 L of LR- or 20cc per Kg in child
when do you add a foley
during C if there is no blood at the mature or in heavy scrotum.
what do you dod if there is blood at the meatus
then you do a retrograde urethrogram
D trauma
disability- uick neuro with GCS- verbal, movement to stimulus and eye opening
E trauma
exposure and encironment- remove all clothing but try to keep them warm
Secondary survey
AMPLET-
allergies, medicine, past history, last meal, events around the accident, tetanus or vaccination
what is after AMPLET
PE from head to toe and get an NGT if there is no evidence of basilar skull fracture
what are the tests for trauma
CBC, utox, alcohol, ABD, CXR, pelix, lateral Cspine, CT/fast exam,
what must the patient be to get a ct
hemodynamically stable
where do aortic transections happen
isthmus near the lugamentum arteriosum or at the base of the heart
how to do you diagnose an aortic transection
widened mediastinum and apical cap is lost with aortic knob and shift of the mediastinum
if you see a wide mediastimun what do yo uneed
CTA if stable
what would paraplegia plus an aortic transection indicated
anterior spinal artery or spine ischemia
what are signs of a basilar skull fracture
battle sign which is bruising behind the ears, raccoon eyes, CSF, otorhea, rhino rhea, hemotympanum, if present, place an orogastric tube
what is considered the abdomen
nipples to groin
what signs tell you there might be abdominal trauma
tachy, hypotensive, abdominal tenderness
penetrating abdomen- gunshot
ABCDE, primary, resuscitation, secondary, XR maybe and slap with no CT
penetrating abdomen- stab wounds if unstable
OR
if stab is stable and numb skin what first
locally explore
if stab is into the peritoneum
lap maybe ex lap
if the stab is not into the peritoneum
do not need further eval
Blun abdominal trauma- patient arrives in C collar backboard and BP is 50- what do you do
primary survey, resuscitation, secondary survey, surgery if needed.
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material: A
A- size 8 endotracheal tube to 22 cm so at clavicles on the CXR- CXR to check the tube placement. NG tube patients with >20% burns often get paralytic ileum which increased vomiting and aspiration risk
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material: B
ventilator onOMV with 100% O2, bilateral chest tubes if pneumothroaz. If on vent for greater than 2 weeks need a track to prevent trachemoinnomanate fistula between the brachiocephalic artery
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material:C
defibrillater for vfib and epi, 2L IV saphenous vein if the arms are burned. Parkland formal.
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material: hands turn black
escharotomy of the mediolateral area because there is pressure leading to compartment syndrome and to relieve the ongoing edema and restore circulation no anesthesia.
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material: what should UO be
it should be 30cc/hr
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material: labs
ABg 20 minutes after intubation. CBC, CMP, UA for myoglobin, carboxyhemoglobin
if there is myoglobin in the urine what should you do
hydrate and alkaliazize the urine
30 yo with second and third degree burns covering 45% of the TBSA and strider and coughing up carbonaceous material: management
debride and early excision of burns except deep to palms, soles, generals and face- apply topical abs
sulamylon
painful and penetrates the eschar and irritates the nerve endings- metabolic acidosis because of the Ca inhibitors
silvadene
transient neutropenia
dilver nitrate
metabolic alkalosis due t hypoK and hypoNa turns everything black
bacitracin
possible allergy
betadine
can kill tissue by drying out the wound
aceteic acid
can cause acidosis if poor kidneys
what temp do burn patients needs to be kept at
986
what do you use to evaluate upper airway of burn patients
bronchoscopy to evaluate the upper airway burns and wash out carbonaceous material to prevent atelectasis and pneumonia- diagnosistic and therapeutic
what does flueorscene do to the burns
if it glows, it is perfused, if not the excision is inadequate
3-7 days out from the burns what do you do
debris the deep wounds of the palms, soles, genitals, and face
when do you do skin grafts
not on the night of the burn because need to resusitate the fluids first, let edema resolve around POD3 before applying skin grafts, but usually over 1 week out from the injury
30 yo F with TAH with changes in metal status- what is the change in mental status assumed to be first
due to hypoxia until proven otherwise
30 yo F with TAH with changes in metal status- A
intubate using size 8- the tip should be 2cm above the carina the tube should be in a round 22 cm
30 yo F with TAH with changes in metal status- B
volume controled ventilation- continuous mandartoy vent- c
what is continuous mandatory vent
set rate and TV and patient is ignored
assist control
set rate with a demand set tidal volume- patient has effort will take in whole tidal volume
synchronized intermittent mandartory vent
reate and tidal volume set with demand- they get their normal volume and will not get a forced breath in the same cycle
CPAP
demadn rte and TV but the patient must initiate the breaths
RR on vent
10-14 breaths. low PCO2 suggests RR should be decreased high CO2 increase the RR
what is normal vent TV
6 cc/kg lean body mass
choosing FiO2
choose the lowest FiO2 to hit 92% sat-
what should you do to the FiO2 for COPD or chronic hypoxemia
use low concentration of O2 because that will correct low PaO2 because they are chronic retainers O2 is their only drive to breath. Too high and get toxicity
Peep
at the trend of the res cycle, the glottis covers the cords AND its against the closed glottis. Upside expected to improve lung mechanics and gas exchange as it recruits alveolar units, decrease in atelectasis, improve oxygenation without increase in Fi)2. Increased iCP, and increased onemothroaz and decreased venous return
what are the best initial vent settings
IMV, TV of 10-15cc kg, rate is 10 and FitO2 is 100% then wean down. Peep 5 cm. It takes aday to get oxygen toxic, but if notice they have a history of COPD then turn it down
who gets the vent
PaO2<60, Pco2>60 unless COPD, loss of protective reflex, RR>33-35, clinical judgement
30 yo F with TAH with changes in metal status- C
check BP and vitals
PaO2 of 40,50,60 correlates to what on pulse ox
70,80,90
at what level does the HbO2 curve shift
Pao2 of 60
PE30 yo F with TAH with changes in metal status
look for wound infection, check for cyanosis, listen to lungs, humans, check of asymmetry of legs
Further tests: 30 yo F with TAH with changes in metal status
CXR and check ET placement
what is Westermarks sign
wedge shaped, hyper lucent area due to decreased pulmonary vasculature.
what is spiral CT for
pe
cor pul on EKG
flipped T waves and ST depression
what would a duplex be for in 30 yo F with TAH with changes in metal status
to check for DVT
30 yo F with TAH with changes in metal status- management
check ABG again after 20 minutes- medication need heparin to prevent further clotting. follow the PT which you want 1.5-2 time the normal with an INR off 2-3. Consider thrombolytics if the patient is unstable but cannot if there has been surgery in the past two week. Consider transfer to coumadin or the following 306 months
30 yo F with TAH with changes in metal status- management if allergic to coumadin
put a filter in the Ivc just below the renal arteris
30 yo F with TAH with changes in metal status- if there is no filter available
use miles clips on the IVC below which let some blood through but need to check to make sure there is an intact azygous system
Jockey is kicked by a horse in the left chest, dyspnea, increased RR-A
intubate and NGT
Jockey is kicked by a horse in the left chest, dyspnea, increased RR- B
peep as needed in case of pulmonary contusion which would look like a white out on CXR, if there is a tension penumo (JVD and anxiety) then throw with a 12 gauge needle in the second space of the midcalvicuar line- need to get all the blood out. put a chest tube in the 4th space of the midaxillary line-
what size hemothorax do you need to thora
1500 cc immediately or 200 per hour for 4 hours
Jockey is kicked by a horse in the left chest, dyspnea, increased RR-C
2 large bore IV and foley
Jockey is kicked by a horse in the left chest, dyspnea, increased RR-labs
CBC, CMP, type and cross
Jockey is kicked by a horse in the left chest, dyspnea, increased RR- tests
CXR after chest tubes are places, chest CT if there are broke rubs, abdominal and pelvic CT
Jockey is kicked by a horse in the left chest, dyspnea, increased RR- tx
epidural to minimize the pain and do not do a big dose of PCA because it will decrease respiratory drive. iNect below the rib. Pulmonary toilet and diuretics, minimize fluid intake and avoid PNA
Jockey is kicked by a horse in the left chest, dyspnea, increased RR-complication- late the BP drops to 70 with 2 boluses of fluids do not bring it back up…. tx
remove the spleen and do an autotransplant by chopping it into small pieces then putting it into a pocket of omentum
65 yo with a carotid bruit on the right- history
asymptomatic, ask for fainting, weakness, amerces fugal, pmhx for MI or stroke
65 yo with a carotid bruit on the right exam
listen for carotid bruit
65 yo with a carotid bruit on the right- tests
doppler flow study
65 yo with a carotid bruit on the right if symptomatic
surgery
what percent stenosis for surgery if asymptomatic
80%
65 yo with a carotid bruit on the right- preop
cardiac workup for EKG and stress test, or use cardiolyte and thallium if cannot use a treadmill- dilate the arteries and veins if there ischemia need to do a cath do it and fix it
if left main is occluded what to do
CABG
65 yo with a carotid bruit on the right- prep labs
coats if there is a history of bleeds or bruising- CBC, BMP, CXR,
what ahoudl the anesthesiologist have on hand for 65 yo with a carotid bruit on the right
prophylactic abx heaprin 100u/kg dopamine to keep pressure up alpha blocker such as clonidine preop have a nitrodrip ready for HTN crisis
65 yo with a carotid bruit on the right what operation
carotid endarterectomy
what is the pathophysiology HTN with carotid stenosis operation
carotid body is clamped off therefore it thinks you are in hypotension and there is no blood getting there so arenas get signal to increase catecholamines and increase the BP, and you need to turn off the carotid body by injecting ti would lidocaine to inhibit the action potential of the nerves and the carotid body stops communicating
65 yo with a carotid bruit on the right patient wakes up and cannot move the left side of the body- what next
need to duplex the carotid artery and then ope nan explore to find the intimal flap and scrape off the intima at the intimate medical junction
why do you give prophylactic antibiotics with carotid endarterectomy
there is mesh added dacron need it
65 yo with known medical issues shows egg shell mass in mid abdomen- causes
atherosclerosis, collagen ascualr diseas,e salmonella, syphillus, TB
65 yo with known medical issues shows egg shell mass in mid abdomen- other symptoms
vague back pain or abdominal pain
65 yo with known medical issues shows egg shell mass in mid abdomen- ddx
acute pancreatitis, aortic dissection mesenteric ischemia, mi , perforated ulcer, diverticulosis
65 yo with known medical issues shows egg shell mass in mid abdomen-tests
US shows an infrarenal AA wait
65 yo with known medical issues shows egg shell mass in mid abdomen-arteriogram
<5cm- low risk follow up i 3 mo
>5 cm operate
if if grown >1/2 cm in 6 months- operate
65 yo with known medical issues shows egg shell mass in mid abdomen-preop
cardiac, cxr, bmp for renal function and acid base status, peripheral vascular exam, prophylactic abs with in 30 minutes iof incision, bowel prep. legation fhb eh IMA and the marginal gives out you can get translation of bacteria.
65 yo with known medical issues shows egg shell mass in mid abdomen- when would you go straight to surgery
peritoneal signs, weird BP and vitals- needs an immediate operation for rupture or leak
65 yo with known medical issues shows egg shell mass in mid abdomen-options of surgery
prosthetic gradt placement wrapped in native aneursym adventitia, endovascualr repair with femoral cath placed stents for poor candidates, aortobiliac or aortobifemoral grade if the iliac are occluded or iliac aneurysms are present
65 yo with known medical issues shows egg shell mass in mid abdomen-early complicatiosn- 1 week later shows up with blood in the stool and diarrhea and abdominal pain
colonic ischemia from the IMA sacrifice and durgety and lack of good collateral. Need a hart mans much, and mucous fistula and resection of the necrotic colon, and end colostmy
65 yo with known medical issues shows egg shell mass in mid abdomen- starts vomiting blood a few months later with decreased BP and increased HR-ddx
ulcer from gastric mucosal defect bleeding from underlying av malformation, esophageal varices, PUD, aortoenteric fistula
65 yo with known medical issues shows egg shell mass in mid abdomen- starts vomiting blood a few months later with decreased BP and increased HR- ABC
2 large bore 16 gague IVs in arms with 2 liter of isotonic fluid, 2 chest tubes, NGT, ET tube, foley need a UOP at .5 cc/kg/hr
65 yo with known medical issues shows egg shell mass in mid abdomen- starts vomiting blood a few months later with decreased BP and increased HR-aoricoenteric fistula usually from
graft infection
65 yo with known medical issues shows egg shell mass in mid abdomen- starts vomiting blood a few months later with decreased BP and increased HR-aoricoenteric fistula usually from graft infection by what
staph epi
65 yo with known medical issues shows egg shell mass in mid abdomen- starts vomiting blood a few months later with decreased BP and increased HR-aoricoenteric fistula- management
endoscopy in the OR, look for gas bubble for the sign of graft infection- take out the infected graft, irrigate with butadiene peroxide, extra anatomic bypass with both ends of the aorta oversewn. This is from the axilla to the femoral artery then to the other femoral to stay out of the infected areas.
60 yo whoe right leg is colder than left for one day- history
look of the 6Ps: pain, paralysis, pallor, paresthesia, pulselessness, palr
60 yo who right leg is colder than left for one day-PE
pulses are not palp and right foot is colder than left and fib is present
60 yo who right leg is colder than left for one day-tests
ABI and ABI are not accurate in the diabetics because the vessels are calcified and do not contract with the BP cuff. It is more accurate to do toe pressure. IF its below 75 then the toe is ischemic.
Doppler- no flow from the knee down on the right. No pain because of neuropathy.
EKG shows afib
60 yo who right leg is colder than left for one day-management
go to the OR you do not need cardiac clearance in an emergency. anticoagulant with heparin, slow the ventricular response with digoxin which decreases the conduction of the AV node, arteriogram if possible. Put in a fogarty balloon catheter in the femoral and placate past the embolus and inflate the balloon and pull back to remove the embolus
40 yo farmer with prior leg injury now has ulcers on the medial malleolus that will not heal-exam
edema over the entire leg and palp pulses
40 yo farmer with prior leg injury now has ulcers on the medial malleolus that will not heal-labs
CMC, CMP, coats which are all normla
40 yo farmer with prior leg injury now has ulcers on the medial malleolus that will not heal-tests
doppler
what is the pathophysiology of a venous stasis ulcer
DVD, destroys the veins, reanalyze the veins, poor valves will lead and venous insufficiency, increased hydrostatic pressure and increased intersitital pressure, decreased tissue perfusion of end o organ and skin
40 yo farmer with prior leg injury now has ulcers on the medial malleolus that will not heal-why would you biopsy it
could be a marjolins ulcer if there is proves run or osteomyelitits- sc. of the ulceration
40 yo farmer with prior leg injury now has ulcers on the medial malleolus that will not heal-treatment
unna boot with zinc, dressing changes, elevate to decrease interstitial pressure, compression socks, that go above the knee
40 yo farmer with prior leg injury now has ulcers on the medial malleolus that will not heal-surgery
linton procedure which is a subfascial ligation of the veins
25 yo marine recruit with BP of 210/120 HR 140 and EKG shows SVT- hx
any symptoms, headaches, blurry vision, drugs, family history, surgical history medications ace and beta blocker since started
25 yo marine recruit with BP of 210/120 HR 140 and EKG shows SVT- PE
pulses and heart and lungs and listen for bruits all over- flank bruits
25 yo marine recruit with BP of 210/120 HR 140 and EKG shows SVT-diagnostic workup
duplex of the renal arteries if hear bruits- do a hypertensive IVP and
25 yo marine recruit with BP of 210/120 HR 140 and EKG shows SVT-on testing if the intravenous pyelogram and one kidney lights up then
renal artery stenosis.
what are the two causes of RAS
fibromsucular dysplasia in middle age women and old men smokers with atheroscelosis
what so you treat fibromuscular dysplasia with
angioplasty with percutaneous renal transluminal angioplasty and stinting if this fails you can bypass and graft interposition or endarterectomy.
what can you not give RAS patients and why
they block any II and will allow the efferent arteriole to dilate
buffalo hump, striae, central obesity, mon face, copper skin- first test
am and pm cortisol then high and low dose suppression tests
what is the different between disease and syndrome
disease is no cortisol suppression with low does and suppression with high dose so the source is in the pit. syndrome shows no change in cortisol with the dexamethasone
adrea adenoma treatment
unilateral adrenalecomy if causing symptoms
adrenal carcinoma- size and what to do
surgical excision if possible and over 7
extopic acTH tumor
surgical excision if possible
what else can you do with adrenal hyperplasia bilateral from disease cushings
remove the pit
coarctation of the aorta- test
get ABIS, CXR, echo, cardiac cath
kids with murmur and good pulses in arsm
think coarctation
how can you treat coarctation
resection with end to end anastamosis, subclavian artery flap, patch great, interposition graft or endovascular repair in adults only
palpations, episodic headache , and episodes of sweating
pheo
labs for pheo
VMA, metanephrines, nrometaneprhiens, urine/serum epi, ne
tumor localiation for pheo
CT< mRI, 131 MIBG- metalodobenzelguanidine.
if see adrenal mass on PET scan what size is worrisome
over 5cm
where is the most common site of extraadreanal pheo
organ of zuckerandle- abdominal aorta
what is the medical treatment for pheo
alpha block with pehnoxybenzamine or parson which increases the intravascular volume and dilutes the catecholamine induced vasoconstriction.
what is the surgical treatment for pheo
tumor resection with early ligation of venous drainage to minimize the catecholamine release
how to differentiate between Conns and RAS
give captopril and then measure the renin and aldosterone. if low renin and high aldo then its Conn. If the renin and aldosterone are both low then its RAS
labs for COnns
CMP, and high aldo level, normal to decreased renin
further testing for COnns
iodocholesterol scan, selective venous sampling of an adrenal in to see if one makes more than the other. if R=L then its hyperplasia not cancer or adenoma.
what is the saline infusion test
decreases aldosterone levels is normal- patients with Conn have increased aldo
treatment for COnn- preop
give spiro because its a receptor antagonist
surgery for conn
adnemoa- unilarteral adrenelectomy- lap, unilateral hyperplasia unialteral removal, bulateral hyperplasia only do spiro
what is the physiology of conn
aldosteron causes na retention for exchange of K in distal tubules, resulting in fluid retention and hypertension
30 yo F with HTN with no risk facts and hard to control HTN- ddx
conn, cushing, pheo, RAS, coarctation
30 yo F with HTN with no risk facts and hard to control HTN- labs
electrolytes (ca comes back at 12), albumin normal, need to check thyroid with calcitonin
30 yo F with HTN with no risk facts and hard to control HTN-tests
MIBG lights up the left renal artery, CT shows mass in the left adrenal medulla, 24 hour urinary catecholamine, and VMA, EKg is normla
30 yo F with HTN with no risk facts and hard to control HTN-preop
alpha blocker if you give a beta block then it will increase BP. intravascular tone will decrease so you nee to watch scan ganz to make sure wedge pressure is normal
30 yo F with HTN with no risk facts and hard to control HTN- slain load protocol
infuse 2 L isotonic fluid, check wedge pressure and stop with 2 l or 18 mmhm to get good CO and IV colume
how many adrenal veins are there
3 adrenal veins
what do you need to do preop
type and cross
30 yo F with HTN with no risk facts and hard to control HTN-anesthesia needs what on hand
pressors, good IVs for fluids
what is the rule of 10s for pheo
10% malig, bilateral, familial, ex-adrenal, malignat
how many criteria do yo uahve to have to meet MEN2A criteria
2 out of the 3: pheo, medullary thyroid cancer, and parathyroid hyperplasia.
what surgery would you have to do for MEN2a first
have to do the pheo first because any other operation will kill them.
