Pastanas 1 Flashcards
Most common brain tumor in children
Medulloblastoma
-arises from cerebellum => classic cerebellar symptoms (stumbling, truncal ataxia)
Ddx of subcutaneous emphysema
Subcutaneous emphysema = air trapped in the layer (subQ) under the skin
- Boerrhaves (esophageal rupture)
- tension pneumothorax (lung bursts…)
- tracheal or major bronchus rupture
Features indicative of cauda equina syndrome
- perineal saddle anesthesia
- urinary incontinence
Post-op management of splenectomy
Vaccination against encapsulated bacteria
- H. influenza B
- pneumococcus
- meningococcus
Name the common brain tumors in adults
Most are mets (50% of which are from the lung)
Of primary brain tumors:
50% gliomas (w/ glioblastoma multiforme as the malignant counterpart)
20% meningiomas (usually benign)
When do you stop giving burn victims fluids?
Around day 3- you expect the plasma at the burn edges to resorb and then have a large diuresis
Why you give fluids- need to maintain intravascular space while tons of fluids escapes to the burn site
Differentiate tx for
(a) femoral neck fracture
(b) intertrochanteric fracture
(c) femoral shaft fracture
(a) Femoral neck fracture- often replace femoral head w/ prosthesis 2/2 risk of ischemia
- displacement of femoral head gives high risk of compromising blood supply
(b) Intertrochanteric fracture- ORIF and immobilization (therefore post-op anticoag is indicated)
- less likely than femoral neck fracture to lead to avascular necrosis => can ORIF instead of replacing w/ prosthesis
(c) femoral shaft fracture- intramedullary rod
MRCP vs. ERCP
MRCP- noninvasive, pt fully awake, detailed view of both ducts and surrounding parenchyma
ERCP- sedation, more invasive, risk of pancreatitis, but not just diagnostic also therapeutic
-sphincterotomies, retrive stones, deploy stents, biopsy tumors
First step in workup of suspected Cushings syndrome
Overnight low-dose dexamethasone suppression test
Why are fluids needed in treatment of burn victims?
Huge internal fluid shift from intravascular space into space below the burn- fluid accumulates below the burn
Common finding seen in these 2 populations:
- young F w/ fibromuscular dysplasia
- old M w/ atherosclerotic occlusive disease
Renovascular hypertension, 2/2 renal artery stenosis
-faint bruit over flank or upper abdomen
Adjuvant systemic therapy in pre vs. post menopausal F for ER+ breast cancer
Premenopausal = Tamoxifen
Postmenopausal = Anastrozole
Which fluid is best for resuscitation in hypernatremic pt
D5 1/2NS- want to give rapid volume w/o hypertonicity (b/c of cell lysis…)
Deep abdominal mass in child that is nonmobile
Thinking Wilm’s (nephroblastoma) or neuroblastoma (adrenal tumor)
Tx for the most common types of gastric cancer
Gastric cancers
Gastric adenocarcinoma- tx w/ surgery
-seen in the elderly
Gastric lymphoma- tx w/ chemo/radiation
-if low grade, first eradicate H. pylori
Differentiate FeNa values for prerenal vs. renal oliguria/AKI
FeNA = fractional excretional sodium
- in renal failure, FeNa is over 1
- if prerenal, FeNa is under 1
Pt presents w/ severe eye pain, frontal headache in the evening
-seeing halos around lights
(a) Dx
(b) Tx
(a) Acute angle closure glaucoma = acute buildup of intraocular fluid in the anterior chamber
(b) Opthamologic emergency- emergent laser hole to release the fluid trapped in the anterior chamber
How to determine if a lung cancer is operable
-small cell lung cancers get chemo and radiation, so workup for surgical candidacy only applies to non-small cell:
operability is dependent on residual function after resection, need at least 800 ml of FEV1 after resection
Next steps after diagnosing pelvic fracture
Look for (and rule out) injury to the rectum, bladder, vagina/urethra
Serum marker for cancer seen in ppl w/ HepB/C
Hep B/C => cirrhosis => HCC (hepatocellular carcinoma)
Serum marker = alpha-fetoprotein (AFP)
Tx for brain abscess
Surgical resection, not just I and D
At what ABI should further steps be taken to plan revascularization?
ABI of 0.8 or less, do CT angio or MRI angio to assess anatomy and plan revascularization
First steps to evaluate smoker for pre-op pulmonary clearance
- FEV1
- b/c want to assess for ventilation (high pCO2), not oxygenation - if FEV1 is abnormal, f/u w/ bood gasses
- cessation of smoking for 8 weeks and intensive respiratory therapy should preceded surgery
Crohn’s vs. ulcerative colitis
(a) Which has transmural involvement?
(b) Which is surgically curative?
(a) Transmural involvement = Crohn’s
(b) UC can be cured w/ surgery
Step taken to prevent air embolism when placing a central venous line
When entering the great veins, use Trendelenberg (tip back head of the bed) for air embolism ppx
Tx for anal squamous cell carcinoma
As per Nigro protocol: chemoradiation, not resection
Differentiate etiology of ulcers on toe vs. heel of foot
Ulcers:
On toe: from arterial insufficiency (toe is the farthest away from the heart)
On heel of foot: from pressure (think 2/2 diabetic neuropathy)
Describe the anterior drawer test
With knee flexed 90 degrees, leg can be pulled anteriorly (like a drawer opening)
= anterior cruciate ligament (ACL) injury
Anterior more common than posterior
PUD resistant to H. pylori eradication
R/o Zollinger-Ellison (gastrinoma)
Workup for UTI in a child
UTI in a child always requires further workup- do voiding cystourethrogram to look for reflux (vesicoureteral reflux)
Presentation of subclavian steel syndrome
Subclavian steel syndrome = atheriosclerotic stenotic plaque at origin of subclavian before the takeoff of the vertebral: enough blood to the arm for normal activity but not during exercise
=> arm sucks blood away from brain by reverse flow
When arm is exercised pt presents w/ arm claudication and posterior neurologic signs (visual symptoms, equilibrium problems)
Most reliable physical exam finding for compartment syndrome
Excruciating pain w/ passive extension
What is Volkmann’s contracture?
Permanent claw-like deformity 2/2 undiagnosed compartment syndrome due to brachial artery obstruction
-fracture of elbow/upper arm (classically supracondylar fracture of the humerus) causing brachial artery obstruction => ischemia
Esophageal cancer- two most common types and RF
Esophageal cancer:
Squamous cell in men w/ h/o smoking and EtOH
Adenocarcinoma in ppl w/ long-standing GERD (Barret’s esophagus)
4 steps to initial treatment of a burn
- IV fluids
- tetanus prophylaxis
- debridement/cleaning of wound
- topical agent: usually silver sulfadiazine
Mechanism of 2 drugs for BPH
BPH (benign prostatic hypertrophy)
1st line: Tamsulosin = selective alpha-blocker
2nd line: Finesteride = 5alpha reductase inhibitor (for very large glands, above 40g)
Tetanus ppx after unprovoked dog bite
IVIG + tetanus vaccine
Ideal tx for pelvic fracture
Pelvic fixation and IR embolization of both internal iliac arteries
-but not available in all settings
Most common source of significant intraabdominal bleeding in blunt abdominal trauma
Splenic rupture
-most common source of general intraabdominal bleeding (both sig and insignificant) = hepatic rupture
Most common cause of malignant hyperthermia
Succinylcholine = neuromuscular blockade agent
Glasgow score that indicates intubation
Glasgow coma score of 8 or below indicates lack of consciousness => intubate
How to cure subclavian steel syndrome
Subclavian steel (atherosclerotic plaque at subclavian before the vertebral branches off) treated w/ bypass surgery
26 yo F w/ firm, rubbery, mobile breast mass
(a) Dx
(b) Mgmt
(a) Fibroadenoma
(b) FNA or sonogram
- removal optional (up to pt but not medically necessary)
How long after MI do you wait for surgery?
If you can hold off, want to defer surgery to 6+ mo post MI 2/2 risk of cardiac complications
-operative mortality w/in 3 mo of infarct is 40%, while it drops to 6% after 6 mo
Malignant bone tumor: lytic lesion vs. blastic lesion- most likely primary?
Metastatic bone tumors in adults
- lytic lesions = from breast (in F)
- blastic lesions = from prostate (in M)
Vasomotor shock- what is it? Etiology?
Vasomotor shock- pink and warm shock- shock from producing vasodilation w/o fluid loss
-ex: anaphylaxis 2/2 bee sting
How long after an MI do you want to wait to do an elective surgery?
At least 6 mo s/p MI
-operative mortality w/in 3 mo of infarct is 40%
Define the type of operation
'tomy' 'ectomy' 'ostomy' 'plasty' 'pexy'
Type of operation
- tomy = cut
- ectomy = remove
- ostomy = make an opening (to the outside or anastamosing to something else)
- plasty = change in shape
- pexy = to fix in place
Branchial cleft cyst
(a) Etiology
(b) Location
Branchial cleft cyst = from failure of obliteration of the 2nd branchial cleft
(b) Location = anterior edge of the SCM (lateral neck)
Differentiate presentation of testicular torsion and acute epididymitis
Testicular torsion- sudden onset severe testicular pain, cord not tender, testes tender and high riding
Acute epididymitis- fever and pyuria, testes swollen and tender but in normal position
Initial tx for SBO
NPO (bowel rest), NG suction (bowel decompression), and IV fluids
Common complications of acute pancreatitis
Pancreatic pseudocyst and chronic pancreatitis
Best test for intra-abdominal bleed in HDS vs HDUS pt
HDS pt- CT scan
HDUS- FAST ultrasound = focused abdominal for trauma- basically look for blood in the peritoneal cavity
Contraindication to organ donation
The only absolute contraindication to organ donation is +HIV
-even hepatitis isn’t absolute (you can give organs to someone already w/ hepatitis)
When is surgery indicated in necrotizing enterocolitis
If infant develops
- abdominal wall erythema
- air in the portal vein
- intestinal pneumatosis (presence of gas in bowel wall)
- pneumoperitoneum (signs of intestinal necrosis and perforation)
Ideal candidate for early excision and grafting after a burn
Limited burn (less than 20% of body surface area) w/ third degree burn
Tx for hyperkalemia
- IV calcium to stabilize myometrial membrane
- D50 and insulin to push K+ into cells
- albuterol - Kaexalate (poop it out)
Green vomiting in newborn w/ multiple air-fluid levels on abdominal CT
(a) Dx
(b) Etiology
(a) Intestinal atresia = malformation of some part of the intestines where it narrows or even is a blind opening
(b) Vascular accident in utero
Next step after clinically recognizing a skull fracture
Expectant management, no real thing for the skull- but key is to assess the integrity of the cervical spine
Alzheimer’s pt POD4 from hip surgery c/o constipation and abdominal distention
Ogilvie syndrome- paralytic colonic ileus
-thought to be from unopposed sympathetic innervation to bowel (lack of parasympathetic innervation0
Carcinoid syndrome- what is it?
(a) Presenting symptoms
(b) Diagnosis
Carcinoid syndrome = paraneoplastic syndrome 2/2 serotonin-secreting tumor
(a) Diarrhea, flushing, wheezing (2/2 bronchoconstriction), 50% right heart valve damage
(b) Dx w/ 24 hr urine 5-HIAA
- not serum b/c serum only high if during one of the episodes/attacks
Differentiate presentation of plantar fasciitis and motor neuroma
Plantar fasciitis = overweight pt w/ sharp heel pain when foot strikes the ground
-TTP and visual bone spur on Cray
Motor neuroma = inflammation of common digitall ve at the 3rd interspace btwn 3rd and 4th toes
-TTP btwn 3rd and 4th toes
Most durable option to treat peripheral arterial occlusion
Saphenous vein graft: most durable option, but there is angioplasty and stents
Abdominal mass in child that moves up and down w/ respiartion
Think malignant liver tumor: hepatoblastoma or hepatocellular carcinoma
60 yo M who complains of muscle pain and tingling of arm and dizziness during exercise
Arm claudication + posterior neurologic signs when exercise the arm- think subclavian steal syndrome (stenotic plaque at subclavian before vertebral artery branches off)
When to do total mastectomy for DCIS
Only if there are multicentric lesions (a bunch of lesions where you’d be doing a bunch of lumpectomies anyway)
-otherwise DCIS technically cannot metastasize => no axillary sampling needed
After head trauma who gets a CT scan?
Anyone w/ head trauma + LOC gets head CT to r/o intracranial hematoma
Basal cell vs. squamous cell carcinoma
(a) location
(b) invasive vs. metastatic potential
(c) Margins
Basal cell (50%) skin cancers vs. squamous (25%)
(a) Basal cell above the mouth vs. squamous more likely lips and below
(b) Basal very locally invasive, while squamous can metastatsize
(c) Basal cell: remove w/ .1mm margins
Squamous cell: remove w/ .5 to 2cm margins (need wider margins 2/2 metastatic potential)
Acute epidural vs. subdural hematoma
(a) Shape of hematoma on imaging
(b) Tx
Acute epidural hematoma
(a) lens-shaped hematoma b/c confined by sutures
(b) Emergent craniotomy can be curative
Acute subdural hematoma
(a) Crescent shaped hematoma b/c blurs past suture lines
(b) Much more severe, hyperthermia or hyperventilate to reduce O2 demand
- craniotomy not curative here
Best indicator of wether or not a ureteral stone will pass
Size!
3mm or under- 70% will pass spontaneously
7mm or over- only 5% will pass spontaneously
Differentiate hyperacute, acute, and chronic transplant rejection
3 mechanisms by which transplanted organ can be rejected
1st = hyperacute w/in minutes (happens as soon as blood supply to organ is reestablished) caused by vascular thrombosis by preformed antibodies
-prevent by ABO matching and lymphocytotoxic crossmatch (so not seen)
2nd = acute rejection from 5 days to 3 mo
-can occur despite appropriate maintenance immunosuppression
3rd = chronic rejection
-gradual, insidious loss of organ fxn
Ischemic stroke vs. TIA
Both are 2/2 occlusion/ischemia, difference is the permanent consequence (whereas ischemic stroke has permanent damage and TIA does not)
How to correlate serum sodium w/ amount of water lost
Every 3 mEq/L in serum Na over 140 represents about 1L of water loss
ex: Serum Na of 146 = about 2L of water loss
Following trauma: resistance felt while attempting to pass foley catheter in a male + scrotal hematoma
(a) Dx
(b) Next step
Urethral injury- next step r/o pelvic fracture
Presenting feature of achalasia
Achalasia = incomplete LES relaxation/increased LES tone
Presenting feature = dysphagia worse w/ liquids than solids
What is Ludwig’s angina?
(a) Complication
(b) Tx
Ludwig’s angina = abscess on the floor of the mouth, often from a bad tooth infection
(a) Complication = threat to airway
(b) Tx = I and D immediately, also make sure to secure airway (even if intubation/tracheostomy needed)
Thyroglossal duct cyst
(a) Etiology
(b) Presentation
(c) Tx
Thyroglossal duct cyst = leftover thyroid tissue from embryologic development
(b) Presents w/ irregular central mass at the level of the hyoid bone
(c) Tx = surgical removal
Young female w/ blood in the abdomen w/o trauma and liver mass on CT
Hepatic adenoma = complication of OCPs
-tendency to rupture => bleed into abdomen
Hypovolemic vs. cardiogenic shock
(a) CVP
(b) use of IVF in treatment
Hypovolemic shock
(a) Low CVP
(b) IV fluids is necessary in tx
Cardiogenic shock
(b) High CVP- see big distended neck veins
(b) IV fluids can be lethal! avoid fluids
Treatment for Legg-Calve-Perthes disease
Tx for avascular necrosis of the capital femoral epiphysis (ischemia of the femoral head which leads to necrosis and bone loss => hip instability)
-need to take pressure off the joint => casting and crutches
What is a duplex?
Ultrasound + doppler
ex: When assessing for DVT
Next step after a respiratory burn
Respiratory burn = inhalation injury
Next step: blood gases to assess for need for respirator
Treatment/management of malignant hyperthermia
IV Dantrolene
What is malignant hyperthermia?
Temp of or above 104F shortly after onset of anesthetic (halthane or succinylcholine)
-also get metabolic acidosis and hypercalcemia
Proposed mechanism:
Clinical signs of skull fracture
Racoon eyes, rhinorrhea, otorrhea, eccymosis behind the ear
Most common location for scoliosis
Scoliosis- most common in adolescent girls in the thoracic spine, most commonly curved to the right
What is strabismus?
(a) Why must it be corrected?
Strabismus = when eyes don’t share a common fixation point (cross eyed), when reflection of light comes from a different area of the cornea in each eye
(a) Must correct stabismus to prevent amblyopia (brain and eye not working well together to process images)
First thought for post-op pt who develops fever on
(a) POD1
(b) POD3
(c) POD5
(d) POD7
(e) POD10-15
Post-op fever
(a) POD1 = atelectasis
(b) POD3 = pneumonia 2/2 undiagnosed atelectasis
(c) POD5 = deep thrombophlebitis
(d) POD7 = wound infection
(e) POD10-15 = deep abscess
Imaging finding of chronic pancreatitis
Calcifications of the pancreas
First step when someone gets chemicals in the eyes
Flush w/ water…immedately
-literally flush w/ water for 30 minutes, then go to the ED
Tenderness to palpation over the anatomic snuffbox
Fracture of the scaphoid (small wrist bone)
- ex: adult falls on outstretched hand => wrist pain
- fracture doesn’t show on Xrays until 3 weeks later
Acute abdomen in pt w/ AFib
Mesenteric ischemia
10 yo w/ onion skinning bone lesion on Xray in femur
Ewing sarcoma = second most common primary malignant bone tumor
-younger children (5-15) in diaphysis of long bones
First line tx for acute organ rejection s/p transplant
Steroid bolus
Describe the cause of air fluid levels in the bowel
Normal peristaltic churning motion makes foam out of the air and fluid normally in the GI tract
When obstructed, normal movement isn’t functioning so fluid goes to bottom and air stays on top
Factors used to predict operative mortality in pts w/ liver disease
2 clinical findings and 3 lab values
Clinically: encephalopathy, ascites
Lab values: serum albumin, prothrombin time (INR), bilirubin
What malignant tumros come from the three layers of the embryo?
- Ectoderm => epithelial tumors = carcinoma
- Mesoderm => sarcomas
- Endoderm => adenocarcinoma
Sudden complete loss of vision in one eye in pt w/ atherosclerotic disease
Think embolic occlusion of the retinal artery
USe of IV pyelogram vs. cystoscopy
IV pyelogram to look at the renal parenchyma, ureters, and bladder
Cystoscopy gives much better look at the bladder (IV pyelogram would miss bladder carcinoma): gives detail of the bladder mucosa
What is a pancreatic pseudocyst?
(a) Tx
Collection of pancreatic juice outside the pancreatic ducts
-complication of acute pancreatitis
(a) Tx = drainage of the cyst if big (over 6 cm b/c of rupture/bleed risk)
- not surgical rmeoval!
How to decide volume of fluids to give a burn victim
There are a bunch of intense long algorithms, but instead what is actually used:
Start w/ arbitrary amount (usually about 1,000 ml/hr) then adjust to urinary output of 1-2 ml/kg/hr
Fear of first feed in premature infant
Nec = necrotizing enterocolitis (bowel necrosis)
-2nd most common cause of morbidity in premature infants
Current classification system to assess for hepatic risk during pre-op workup
Child class: takes into account encephalopathy, ascites, serum albumin, INR, and bilirubin
Medication helpful to tx claudication
Cilostazol = quinolone derivative (why Gma Evelyn drinks tonic water which has quinolones), PDE3 inhibitor that works as selective vasoconstrictor
Surgical vs. radiological tx for intracranial aneurysm
Intracranial aneurysm (dangerous b/c can cause subarachnoid bleeding)
Surgical tx = clipping
Radiologically = endovascular coiling
Mgmt when suspect wound dehiscence
Surgical emergency 2/2 risk of evisceration (abdominal contents fall out): go back to OR, debride the wound and close again w/ new margins
3 ways to differentiate small bowel vs. colon on CT
- Location: small bowel centrally, colon laterally
- Size: colon is larger
- Fine details: haustral markings (small indentations that don’t go all the way across) on colon, vs. small lines that go all the way across in small bowel
Choice of fluid for resuscitation in hyponatremic pt
Use NS only if there is alkalsosi
-LR for acidotic pts and those w/ normal pH
3 markers to assess nutritional status of high risk patient
- albumin: normal of 4
- half life like 20 days - pre-albumin: normal over 16
- half life 2-3 days - transferrin: normal over 200
Benefits of core biopsy over FNA
FNA only gives cells (cytology), doesn’t give architecture (histology) so much less sensitive
What is wound dehiscence?
When the abdominal wall tension (intraabdominal pressure) overcomes the strength of the closure (sutures/staples)
- can be partial or complete, both are surgical emergencies
- dangerous when pt coughs/strains/gets out of bed (basically when they increase intraabdominal pressure)
Symptoms of vascular rings
Symptoms of pressure of the tracheobronchial tress (stridor and respiratory distress) and pressure on the esophagus (dysphagia)
What is pseudomembranous enterocolitis?
(a) Most common etiology
Pseudomembranous enterocolitis = C. diff overgrowth
(a) Most commonly by cephalosporins
Define severe nutritional depletion
Loss of 20% of body weight over a couple months, serum albumin below 3, transferrin under 200 mg/dl
-huge increase in operative risk => if possible, defer surgery for at least 4-5 days
30 yo w/ tibia fracture, ORIF and casting, develops increasing pain in leg
Immediately remove cast to assess for compartment syndrome
Clinical finding of wound dehiscence
Abundant pink (‘salmon colored’) fluid soaking thru the dressing = serosanguinous peritoneal fluid
5 P’s of compartment syndrome
Compartment syndrome
- pallor
- poikilothermia (warmth)
- pulseness
- pain
- parasthesia/paralysis
Most common presentation of testicular cancer
Painless testicular mass in a young male
-biopsy always done b/c benign testicular tumors are virtually nonexistant
Why it is so important to appropriately diagnose testicular torsion vs. acute epididymitis
Testicular torsion needs emergency surgery, while acute epidiymitis is tx w/ abx
-so key not to miss testicular torsion that even if you’re sure it’s acute epididymitis (fever, pyuria), do US to r/o torsion (doppler flow), then start the abx
Presentation of esophageal cancer
Esophageal cancer classically presents w/ dysphagia of solids progressing to liquids
When is surgery indicated for coronary stenotic disease?
Stenosis of 70-99%
Pneumothorax vs. hemothroax
(a) Percussion
(b) Placement of chest tube
Pneumothorax
(a) Hyperresonant to percussion- b/c just dead air space
(b) Place chest tube superiorly and anteriorly- air rises
Hemothorax: drain to prevent empyema
(a) Dull to percussion
(b) Place chest tube inferiorly- b/c duh gravity
Current system used to classify operative mortality in pts w/ liver disease
Child class
- class A: 10% mortality, class B 30%, class C 80%
- considers: encephalopathy, ascites, INR, serum albumin, bilirubin
Most feared fungal infection seen in soft tissue infections
(a) Tx
Mucormycosis
(a) IV amphotericin
Tx of intestinal atresia of the newborn
Tx of intestinal atresia = laparotomy (open abdominal surgery) to remove damaged part of intestines and anastamose normal parts back
How to treat strabismus in child
Want to suppress the dominant eye (eye patch, atropine drops) to force the brain to function w/ the weaker eye
-don’t want strabismus to let brain suppress image from the weaker eye, which can eventually lead to unilateral blindness
White pupil in a baby
Absence of red reflex- need to r/o retinoblastoma (opthalmologic emergency)
-may be congenital cataracts, but still needs to be tx
Most common skin cancers
Basal cell carcinoma 50%
squamous cell carcinoma 25%
melanoma 15%
Describe a closed reduction
Bones that are not badly displaced or angulated: align by external manipulation, then immobilize in case
Most common cause of pneumaturia
Pneumaturia (air in the urine) most commonly 2/2 vesicoureteral fistula from diverticulitis
Tx of gout
(a) acute
(b) chronic
Tx of gout
(a) Acutely: indomethacin (NSAID) for the pain + colchicine
(b) Chronically: give allopurinol = xanthine oxidase inhibitor to reduce uric acid formation
Dx: trauma pt w/ hypovolemic shock of unknown etiology w/ normal CXR and no evidence of pelvic or femur fracture
Intraabdominal bleed until proven otherwise
Only 3 places in the body (abdomen, thighs, pelvis) that can hide enough blood to cause hypovolemic shock
First line tx for Ogilvie’s
Colonoscopy to suck out the air
- neostigmine (acetylcholinesterase inhibitor) to stimulate colonic motility
- -works b/c immobility is 2/2 unopposed sympathetic activity, also explains why epidurals sometimes work here
Bone tumors in children: sunburst vs. onion skinning
Sunburst appearance on Xray = osteogenic sarcoma (most common primary malignant bone tumor)
Onion skinning on Xray = Ewing sarcoma (second most common primary malignant bone tumor)
First step to work up melena
Melena = black, tarry stool = digested blood
First step = upper GI endoscopy
Mechanism by which smoking increases pulmonary operative risk
Smoking increases pulmonary risk by compromising ventilation (high pCO2), not by poor oxygenation (not by low pO2)
Preferred adjuvant systemic therapy for metastatic melanoma
Interferon
Pulmonary coin-shaped lesion found on CXR
Workup
First- find old Xray to compare it to
-new found coin lesion on CXR has 80% chance of being malignant if pt over 50
First: compare to old CXR (if available), then get CT (better picture) and sputum cytology
If cytology is not diagnostic- do bronc and biopsy for central lesion, or percutaneous biopsy for peripheral lesion
POD3 pt develops hallucinations, confusion, and becomes very aggressive
(a) Dx
(b) Tx
Is this dude an alcoholic?
(a) Thinking delirium tremens which develops around the 3rd day of withdrawal
(b) IV benzos
- also sometimes give IV alcohol to tx the withdrawal
Complication of wound dehiscence
(a) Short term
(b) Long term
Wound dehiscence is a surgical emergency b/c
(a) Short term- worried about evisceration: abdominal organs just falling out!!
(b) Long term worried about ventral hernia
Finding of hypokalemia in a hypertensive F
First- is she on diuretics?
If not, suspect primary hyperaldosteronism
What is a cystic hygroma?
(a) How to plan for surgical removal
Cystic hygroma = irregular development/formation of the lymphatic system => large, mushy, ill-defined mass in the supraclavicular area
(a) Often extends into the mediastinum so need to do CT scan before surgical removal is attempted
20 yo w/ sunburst pattern lesion on Xray in the upper tibia
Osteogenic sarcoma: ages 10-25 around the knee (lower femur or upper tibia)
Final complication of strabismus (adult vs. child)
Strabismus (cross eyed) will cause double vision in adults, but due to neuroplasticity of the child- child’s brain will adapt and suppress image from one eye => can have permanent cortical blindness of the completely normal eye due to suppression
What lung cancers get surgery vs. chemoradiation?
Small cell lung caners get chemotherapy and radiation
Operability only applies to non-small cell cancer
Pt seeing flashes of light and floaters in the eye
Retinal detachment = emergency
Hypospadias- what is it?
(a) Tx?
Hypospadias = urethral opening present on the ventral side of the penis
(a) Don’t circumcise, then use foreskin for plastic reconstruction
Name the 3 places in the body that can hide enough bleeding to cause hypovolemic shock
Need to lose 25-30% of blood volume (about 1,500 ml in average sized person) to go into hypovolemic shock => most spaces (ex: head, lungs, heart, neck) can’t accumulate that much blood w/o being overtly obvious
When have hemorrhage w/o obvious cause:
- abdomen
- thighs
- pelvis
