Osler, part 2 Flashcards
HPI of pancreatic CA
Gradual onset
Pain in lower back or epigastric, straight through to back
Fairly constant, worse at night
Dull, gnawing, visceral quality
Better when sitting up or leaning forward or fetal position +/- worse with eating/laying supine
Related sx of pancreatic CA
Wt loss Anorexia Generalized malaise and weakness New onset DM Jaundice (early sign of pancreatic head due to bile duct obstruction) Pruritis Acholic stools Dark urine
PE of pancreatic CA
Courvoisier's sign: Palpable, nontender, distended GB associated with jaundice \+/- hepatomegaly \+/- RUQ mass Cachexia \+/- superficial thrombophlebitis
Signs of metastasis of pancreatic CA
Abdominal mass Ascites L supraclavicular LAD (Virchow's node) Periumbilical mass (Sister Mary Joseph's node) Palpable rectal shelf
Grey Turner’s sign
Bruising of the flanks
Appears as blue discoloration
Sign of retroperitoneal hemorrhage
Workup for pancreatic CA
MRI
CT with IV contrast
ERCP: useful if obstructive jaundice, or sx without evidence of mass on CT
EUS (endoscopic u/s): clarification of small (<2 cm) lesions in neg/equivocal CT findings
CA 19-9: post-op monitoring
Tissue dx not necessary unless neoadjuvant therapy is planned
Purpose of Nissen fundoplication
Treats refractory GERD to prevent Barrett’s esophagus
Pre-op evaluation of Nissen fundoplication
Most important test is upper endoscopy Esophageal manometry pH testing UGI series Esophagogram
HPI of GERD
In chest/throat Burning Severity around 5 Comes and goes Wheezing, CP, dysphagia
Sx of GERD- refractory
Sore throat Hoarseness Trouble swallowing Cough Noncardiac CP
Indications for TURP or open simple prostatectomy
Acute urinary retention
Persistent or recurrent UTIs
Significant hemorrhage or recurrent hematuria
Bladder calculi secondary to bladder outlet obstruction
Significant sx from bladder outlet obstruction that are not responsive to medical or minimally invasive therapy
Renal insufficiency secondary to chronic bladder outlet obstruction
S/sx of prostate CA
Urinary frequency Urgency Nocturia Hesitancy Hematuria- uncommon presentation Hematospermia- uncommon presentation
Major RF for prostate CA
Smoking
1st degree relatives also a RF
Labs/diagnostics for prostate CA
PSA levels
Prostate bx guided by TRUS
RFs for prostate CA
AA > whites
Genetic- BRCA2 mutation
Smoking
Diet- high red meat diet
USPSTF guidelines for prostate CA
Decisions about screening should be make on an individual basis after consultation with a provider (C Recommendation)
Recommends against PSA-based screening past the age of 70 (D recommendation)
Labs and decision making process for thyroid nodules- initial
Check TSH and T3/4
Order u/s
Labs and decision making process for thyroid nodules- low TSH
Order iodine uptake
If no increase uptake, then order FNA
If increased, so no FNA
Indeterminant: get FNA
Labs and decision making process for thyroid nodules- high or nl TSH
Cystic nodules need no further testing
Spongiform > 2 cm
Hyperechoic >1.5 cm
Hypoechoic >1 cm need FHx of thyroid CA
What should be done for thyroid nodules if you did not do an FNA?
F/u in 6-12 mos
In anaplastic thyroid CA, what is the tx?
Needs palliative surgery only
What categories of FNA bx are considered to be surgical?
FN/SFN
SFM
MGT
Labs for toxic multinodular goiter
Low TSH
High T3/T4
Order U/s
TSAb
When to do surgery for toxic multinodular goiter
If meds don’t work or if having ocular sx
Sx of nonfunctioning goiter
Hoarseness
Dysphagia
Discomfort (esp when lying down)
SOB
Indications for tonsillectomy- absolute
Enlarged obstruction, dysphagia, sleep d/o, cardiopulm complications
Peritonsillar abscess unresponsive to medical management/drainage
Tonsillitis + febrile seizures
Tonsils requiring bx to define tissue pathology
Indications for tonsillectomy- relative
Persistent/foul taste or breath d/t chronic tonsillitis
Chronic/recurrent tonsillitis (seven in one year, five each in two years, or three each in three years) d/t strep, unresponsive to beta lactamase
Unilateral tonsillar hypertrophy, neoplasm
Surgical workup for tonsillectomy
Coagulation parameters -FHx --If neg- no coags needed --If pos, coags needed If malignancy- XR, CT, or MRI Antibodies for streptolysin-O (ASLO) Histology- only if CA suspected
Presentation of MI
May present as nl MI that we’ve learned, may also be a “silent” presentation (ex. women, diabetics, elderly)
Retrosternal CP radiating to jaw, down left arm, SOB
Labs/tests for potential CABG pt
EKG- T wave inversion is 1st sign Troponins CBC CMP Lipid profile CXR
Cath lab results and CABG
Do a CABG if: 50% stenosis found in LCA -3-vessel dz Proximal LAD stenosis Failure of PCI CABG is better for diabetic pts than stenting
RFs of aortic stenosis
HTN
DM
Smoking
Hypercholesterolemia
Presentation of aortic stenosis
Usually asx until the development of syncope, angina and dyspnea/CHG when aortic valve is <1.0 cm
Narrowed valve leads to hypertrophied left ventricle
PE of aortic stenosis
Systolic ejection murmur that is harsh/rumbling crescendo-decrescendo
Murmur increases with squatting/leg raise, sitting and leaning forward. Decreases with valsalva/standing
Pulsus parvus et tardus: small, delayed carotid pulse
Narrowed pulse pressure
S4
Hand-grip maneuver- murmur will decrease
Disease that can cause aortic regurgitation
Rheumatic heart dz Endocarditis Bicuspid valve dz Aortic root dz Aortic dissection RA SLE Myxomatous disease
PE of aortic regurgitation
Diastolic decrescendo blowing murmur heard at LUSB
Murmur increases with squatting, sitting forward, and handgrip. Decreases with Valsalva, standing. May radiate to LSB.
Austin-Flint murmur: bounding pulses. Wide pulse pressure
PE of chronic aortic regurgitation
Water hammer pulse
Swift upstroke and rapid fall of radial pulse accentuated with wrist elevation. May have S3 and rales
Presentation of mitral stenosis
Can present as right-sided heart failure, pulmonary HTN with hemoptysis, and a-fib
PE of mitral stenosis
Diastolic rumble at the apex
Opening snap, loud S1
Pulses usually reduced
Tx of aortic stenosis
Aortic valve replacement
Dx of aortic stenosis
Echo and cardiac cath
Dx of aortic regurgitation
Echo and cath
Tx of aortic regurgitation
Surgery is definitive and indicated in acute and symptomatic AR or symptomatic with EF <55%
Should have valve replacement
Dx of mitral stenosis
CXR and echo
CXR: left atrial enlargement
Echo: LAE, thick calcified valve, “fish mouth” shaped orifice
S/sx of mitral stenosis
DOE Orthopnea PND Palpitations CP Hemoptysis Thromboembolism All sx will increase with exercise and pregnancy
PE of mitral stenosis
RVF (JVD, hepatomegaly)
Diseases where mitral regurgitation will present- acute
Endocarditis
Papillary muscle rupture
Chordae tendinae rupture
Diseases where mitral regurgitation will present- chronic
MVP
Rheumatic fever
Marfan syndrome
Cardiomyopathy
S/sx of mitral regurg
DOE PND Orthopnea Palpitations Pulmonary edema
PE of mitral regurg
Holosystolic murmur at the apex, radiates to the back or clavicular area
AFib is common
Diminished S1, widening of S2, laterally displaced PMI, loud palpable P2
Dx of mitral regurg
CXR and echo
Valve replacement must be performed if left ventricular function is too severely compromise
Cause of infective endocarditis
Most common d/t IV drug use, previous congenital or acquired cardiac lesions, immunocompromise, IV catheters
Presentation of infective endocarditis
Fever Weakness Night sweats Anorexia Murmur Splinter hemorrhages Osler nodes Janeway lesions Roth spots
Dx of infective endocarditis
BCx and echo revealing valvular vegetations
When is surgery indicated for infective endocarditis?
Reserved for prosthetic valve endocarditis, failure of medical management, life-threatening emboli, severe valvular insufficiency, obstruction, and CHF
