Pestana notes Flashcards
Initial treatment of septic shock often includes a steroid bolus. Patients who respond beautifully at first but then suffer a relapse might not have septic shock at all but rather what
Adrenal insufficiency
Spinal cord injury that is typically from clean cut injury (knife blade) and has paralysis and loss of proprioception distal to the injury on the injury side and loss of pain distal to injury on opposite side
Hemisection (Brown-Sequard)
Spinal cord injury that is typically seen in burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, with preservation of vibratory and positional sense
Anterior cord syndrome
Spinal cord injury that occurs in the elderly with forced hyperextension of the neck (rear-end collision). There is paralysis and burning pain in the upper extremities, with preservation of most functions in the lower extremities.
Central cord syndrome
Rib fx can be deadly in elderly because of progression of pain to hypoventilation to atelectasis to pneumonia. How do you treat it
local nerve block and epidural catheter
When a chest tube is placed for hemothorax and we get 1500 mL or more of blood when inserted or more than 600 is collected in the ensuing 6 hours, what do we realize and what needs to be done
- systemic vessel is lacerated. this is typically an intercostal artery
- video-assisted thoracotomy will be needed to control the bleeding
Traumatic rupture of the diaphragm shows up as what
bowel in the chest
A rare but fascinating potential sequela of injuries affecting the renal pedicle is the development of what an Arteriovenous fistula leading to what
CHF
treatment of a large penile shaft hematoma due to fracture of penis
Emergency surgery
Order in which you should repair structures when arteries, nerves, and bone are involved
- Stabilize bone first
- then delicate vascular repair
- Nerve last
- Fasciotomy should be added because the prolonged ischemia could lead to compartment syndrome
Treatment of chemical burns
- Massive irrigation
- DO NOT play chemist and attempt to neutralize agent
What is an appropriate predetermined rate of fluid infusion in an adult who is severely burned
1,000 mL/H or Ringer lactate (without sugar)
Describe the topical agents used for burns
- Standard is silver sulfadiazine
- If deep penetration is desired (thick eschar, cartilage), mafenide acetate is choice
- Burns nears eyes are covered with triple antibiotic ointment (sulfadiazine is irritating to the eyes)
In a burn victim, describe when early excision and grafting may be used
- Fairly limited burns (under 20%)
- obviously third degress
if signs of envenomation from a snake bite are present (severe local pain, swelling, and discoloration developing within 30 minutes of the bite), what should be drawn?
-blood for typing and crossmatching, coagulation studies, and liver and renal function
What is antivenin for rattlesnakes
CROFAB
What is the only valid first aid measure for a snake bite
Splint the extremity during transportation
-DO NOT make cruciate cuts, suck out venom, wrap with ice, or apply a tourniquet
Brightly colored coral snakes have a neurotoxin that needs to be promptly neutralized with specific antivenin. don’t wait for signs of envenomation. True coral snakes are identified by what mnemonic?
- “Red on yellow, Kill a fellow”
- Meaning that red rings and yellow rings touch eachother
- Harmless brightly colored imitators have black rings separating yellow and red
treatment of anaphylaxis from bee stings
- Epinephrine
- Stingers should be removed without squeezing them
Black widow spiders are black, with a red hourglass on their belly. Bitten pts get nausea, vomiting, and severe generalized muscle cramps. What is the antidote
- IV calcium gluconate
- Muscle Relaxants
Brown Recluse spider bites are often not recognized at the time. By the next day a skin ulcer develops, with necrotic center and surrounding halo of erythema. What is treatment?
- Dapsone is helpful
- Surgical excision may be needed but should be delayed until the full extent of the damage is evident (as much as one week)
- Skin grafting may be needed
What do human bites require
-extensive irrigation and debridement (in the OR)
Signs of hip dysplasia at birth are uneven gluteal folds and easy dislocation posteriorly with a jerk and a “click” and returned to normal with a “snapping”. If signs are equivocal, what is diagnostic?
Sonogram . . .do NOT order x-rays; the hip is not calcified in the newborn
Treatment of a newborn with hip dysplasia
abduction splinting with pavlik harness for about 6 months
This occurs around age 6, with insidious development of limping, decreased hip motion, and hip (or knee) pain. Kids walk with an antalgic gait, and passive motion of the hip is guarded
Legg-Calve-Perthes disease (avascular necrosis of the capital femoral epiphysis)
Treatment of Legg-Calve-Perthes disease (avascular necrosis of the capital femoral epiphysis)
usually containing the femoral head within the acetabulum by casting and crutches
This is an orthopedic emergency in which the typical patient is a chubby (or lanky) boy, around age 13. They complain of groin (or knee) pain and are noted to be limping. When they sit with the legs dangling, the sole of the foot on the affected side points toward the other foot. ON PE there is limited hip motion, and as the hip is flexed the thigh goes into external rotation and cannot be rotated internally
Slipped capital femoral epiphysis
Treatment of slipped capital femoral epiphysis
surgical treatment pins the femoral head back in place
This is an orthopedic emergency. It is seen in little toddlers who have had a febrile illness and then refuse to move the hip. They hold the leg with the hip flexed, in slight abduction and external rotation and do not let anybody try to move it passively. They have elevated ESR
Septic hip
how is septic hip diagnosed
Aspiration of the hip under general anesthesia, and further open drainage is done if pus is obtained
Genu varum (bowlegs) is normal up to age 3. No treatment is needed. If persistent varus beyond age 3, what is most common cause?
-Blount disease (a disturbance of the medial proximal tibial growth plate), . . . surgery
This is seen in teenagers with persistent pain right over the tibial tubercle, which is aggravated by contraction of the quadriceps. PE shows localized pain right over the tibial tubercle, and there is no knee swelling.
Osgood-Schlatter dx (osteochondrosis of the tibial tubercle)
This is an inflammation of the common digital nerve at the third interspace, between the third and fourth toes. it is palpable as a very tender spot.
Morton Neuroma
Cause of a morton neuroma
typically the use of pointed, high-heeled shoes (or pointed cowboy boots) that force the toes to be bunched together
Ejection fraction under what % poses prohibitive cardiac risk for noncardiace operations
under 35%
Whats the index and findings that predict trouble when evaluation a patient for preop clearance
- Goldman index
- JVD (Worst single finding)
- recent MI
- PVCs or any rhythm other than sinus
- over 70 y/o
- emergency surgery
- Aortic valve stenosis
- Poor medial condition
- surgery within the chest or abdomen
How long after MI should surgery be delayed
6 months
Cessation of smoking for how long prior to surgery is needed
8 weeks
What 2 clinical findings and 3 lab values are used to predict operative mortality in patients with liver disease . . . . child class
- encephalopathy
- Ascites
- Serum albumin
- Prothrombin time (INR)
- Bilirubin
Severe nutritional depletion is identified by what?
- loss of 20% of body weight over a couple of months
- serum albumin below 3
- anergy to skin antigens
- serum transferrin level of less than 200
Perioperative MI may occur during an operation (triggered most commonly by hypotension), in which case it is detected by the EKG as what
- ST depression
- T-wave flattening
After the diagnosis of PE, start treatment with heparinization. What do you add if PEs recur during anticoagulation or if anticoagulation is contraindicated
an IVC filter (Greenfield)
What is the first thing that has to be suspected when a post-op patients gets confused and disoriented
hypoxia
What can be quickly induced by liberal administration of sodium-free IV fluid (like D5W) in a postoperative patients with high levels of ADH (triggered by response to trauma)
hyponatremia
Surgical damaged to what structure can induce hypernatremia through large unreplaced water loss
-Posterior pituitary with unrecognized Diabetes insipidus
What is a common source of coma in a cirrhotic patient with bleeding esophageal varices who undergoes a portocaval shunt
Ammonium intoxication
describe the measurement of urinary sodium to determine if low urinary output is due to dehydration or renal failure
- if less than 10 or 20 then dehydrated with good kidneys
- if exceeds 40 then renal failure
What is the Fractional excretion of sodium level in renal failure
greater than 1
Postop paralytic ileus is prolonged by what electrolyte abnormality
Hypokalemia
Paralytic ileus is to be expected in the first few days after abdominal surgery. if this does not resolve after 5, 6, or 7 days then what is likely?
mechanical bowel obstruction
What is seen in elderly sedentary patients who have become further immobilized owing to surgery elsewhere (broken hip, prostatic sutgery). They develop large abdominal distention (tense but not tender) and imaging studies show a massively dilated colon
Ogilvie syndrome (Paralytic ileus of the colon)
management of Ogilvie syndrome
- After fluid and electrolyte correction, the safest thing to do is perform a colonscopy, suck out all the air, and place a long rectal tube
- IV neostigmine stimulate colonic motility but this drug is best AVOIDED and is lethal if inadvertently given to someone whose colon is actually obstructed
- post op day 5
- wound intact
- Salmon colored fluid soaking dressing
Wound dehiscence
management of wound dehiscence
- Wound has to be taped securely, abdomen bound, and mobilization and coughing done with great care
- Arrangements are made for prompt reoperation to prevent evisceration now or ventral hernia later on
management of evisceration
- patient kept in bed and bowel covered with large sterile dressings soaked with warm saline
- Emergency abdominal closure
What is the safe rate of potassium administration
10 mEq/hr
Describe the therapy of Hyperkalemia
- The ultimate therapy is hemodialysis
- while waiting for it we can help by “pushing K into cells (50% dextrose and insulin), sucking it out of GI tract (NG suction, exchange resins), or neutralizing its effect on the cellular membrane (IV calcium)
- The latter provides the quickest protection
In all cases of longstanding acidosis, describe the effect on K+
- renal loss of K+ leads to a deficit that does not become apparent until the acidosis is corrected
- thus we must prepare to replace
describe how to correct metabolic alkalosis
- In most cases, an abundant intake of KCl (b/t 5 to 10) will allow the kidney to correct the problem
- Only rarely is ammonium chloride or .1 N HCl needed
Describe the dysphagia seen with achalasia
- worse for liquids
- patient eventually learns that sitting up straight and waiting allows the weight of the column of liquid to overcome the sphincter
What is the most appealing current treatment of achalasia
-balloon dilatation done by endoscopy
Describe the diagnostic modalities and treatment of esophageal cancer
- Diagnosis is established with endoscopy and biopsies, but barium swallow must precede to help prevent inadvertent perforation
- CT scan assesses operability but most cases can only get palliative (rather than curative) surgery
Best therapy for gastric adenocarcinoma
surgery
Describe treatment of gastric lymphoma
- Treatment is based on chemo or radiotherapy
- Surgery is done if perforation is feared as the tumor melts away
- Low-grade lymphomatoid transformation (MALTOMA) can be reversed by eradication of H. pylori
Cancer of the right colon typically shows up with what?
- anemia (hypochromic, iron deficiency) for no good reason
- stools with be 4+ for occult blood
Cancer of the left colon typically shows with what?
- bloody BMs
- may be constipation
- stools may have narrow caliber
In cancers of the left colon, what needs to be done before surgery
- Full colonoscopy to rule out synchronous second primary
- Pre-op chemo and radiation may be needed for large rectal cancers
Describe the pseudomembranous enterocolitis (caused by overgrowth of C. diff) what would require emergency surgery
- unresponsive to surgery
- WBC about 50k
- serum lactate above 5
Describe the treatment of squamous cell carcinoma of the anus
- Starts with Nigro chemoradiation protocol
- followed by surgery if there is residual tumors
- 5 week chemo-radiation protocol has a 90% success rate, so surgery rarely is required
Massive upper GI bleeding in the stressed, multiple trauma, or complicated post-op patient is probably from stress ulcers. Endoscopy will confirm. What is the best therapeutic option?
How could it be avoided?
- Angiographic embolization
- maintain gastric pH above 4
Any patient who has survived 2 episodes of acute diverticulitis should have what?
elective surgical removal of the affected area before they get into trouble again
Describe X ray findings in Volvulus of the sigmoid
- air-fluid levels in the small bowel
- very distended colon
- A huge air-filled loop in the right upper quadrant that tapers down toward the left lower quadrant with the shape of a “parrot’s beak”
Describe the management of volvulus of the sigmoid
- Proctosigmoidoscopic exam with the old rigid intrument resolves the acute problem
- Rectal tube is left in
- Recurrent cases need elective sigmoid resection
In malignant obstruction of the biliary tree, what does the gallbladder look like on US
large, thin-walled, distended (Courvoisier-Terrier sign)
Surgical injuries to the biliary tract are devastating complications with lifelong adverse consequences, due to the tendency of those structures to do what as they heal
stricture
what lab value can differentiate edematous pancreatitis from hemorrhagic?
- in edematous hematocrit is elevated
- lower in hemorrhagic
In hemorrhagic pancreatitis, A common final pathway for death is the development of multiple pancreatic abscesses, and to anticipate them and drain them, if at all possible . . . what is recommended?
daily CT scans
In hemorrhagic pancreatitis, A common final pathway for death is the development of multiple pancreatic abscesses. What antibiotics are known to penetrate infected necrotic pancreas, and they may be used prior to surgical drainage
- Carbapenems
- quinolones
- metronidazole
The treatment of pancreatic pseudocyst is dictated by the size and age. Describe this
- Cysts 6 cm or smaller, or those that have been present for less than 6 weeks are not likely to have complications and can be observed for spontaneous resolution
- Bigger or olders cysts are more likely to rupture or bleed and they need to be treated . . drainage
Describe the screening and management of a woman who inherits the BRCA gene
- needs early and frequent screening, but it should be done with MRIs rather than mammagroma, which are carcinogenic if repeated frequently
- Furthermore, past the age of 30 they should consider prophylactic bilateral mastectomies if they have the BRCA2 mutations and that plus oophorectomies if they have the BRCA1 mutation
Cystosarcoma phyllodes is seen in the late 20s. They grow over many years, becoming very large, replacing and disorting the entire breast, yet not invading or becoming fixed. Most are benign, but they have potential to become outright malignant sarcomas. What management is mandatory?
- Core or incisional biopsy (FNA is NOT sufficient)
- removal
Intraductal papilloma is seen in young women (20s to 40s) with bloody nipple discharge. Mammogram is needed to identify other potential lesions, but it will NOT show the papilloma. What is diagnostic and management?
-Galactogram may be diagnostic and guides surgical resection
Breast cancer during pregnancy is diagnosed exactly as if pregnancy did not exist and is treated the same way except for: no radiotherapy or hormonal manipulations at any time during the pregnancy an no chemotherapy during which trimester?
1st
Describe the treatment of resectable breast cancer
- Starts with either of 2 operations
- Small lesions, located far away from the nipple and areola of a large breast, are removed within only a segment of the mammary gland . . lumpectomy, or segmental resection and MUST be followed by radiotherapy
- Large tumors lying right under the nipple and areola, and occupying most of a small breast, require a simple total mastectomy and do NOT need subsequent radiation
- If lymph nodes are not palpable in the axilla, either operation must include a sentinel node biopsy
- If enlarged lymph nodes are palpable in the axilla, they are resected
Inflammatory cancer of breast is the only variant with a much worse prognosis than infiltrating ductal carcinoma and what needs to be added pre operatively
chemotherapy
Inoperability of breast cancer is based on what?
local extent . . . not metastases
In breast cancer, Adjuvant systemic therapy should follow surgery in virtually all patients, particularly if axillary nodes are positive. Chemo is used in most cases nad hormonal therapy is added if the tumor is receptor positive. What do PREmenopausal women receive?
Post -menopausal?
- Tamoxifen
- Anastrozole
Persistent headache or back pain (with areas of localized tenderness) in women who recently had breast cancer suggest metastasis. MRIs are diagnostic. Brain mets can be radiated or resected. What is the favorite location in the spine?
vertebral pedicles
A total thyroidectomy is always done for which thyroid cancer?
Why?
- Follicular
- It can take radioactive iodine if it does not have to compete with normal thyroid tissue . . therfore a total thyroidectomy permits use of radioactive iodine in the future to identify and treat any potential metastasis
Treatment of medullary thyroid cancer
- it is aggressive so radical surgery is justified
- Workup for Pheo is indicated as they often coexist (MEN 2)
Anaplastic thyroid cancer is seen in old people. It grows like wildfire and often all that can be done is what
tracheostomy
Treatment of hyperthyroidism
Radioactive iodine in most cases. There is very limited role for surgery on patients who have a “hot” adenoma
Describe the management of Hyperparathyroidism?
- Repeat Calcium determination and look for low phosphorus and rule out cancer with bone mets
- If findings persist, do parathyroid hormone determination
- Asymptomatic patients become symptomatic at a rate of 20% per year; thus elective intervention is justified
- 90% have a single adenoma nad removal is curative
- Sestamibi scan helps locate the offending gland or glands and intraoperative PTH asssay confirms that hey have been extirpated
Describe the management of the few patients who have parathyroid hyperplasia?
transplantation of all the parathyroids to the forearm facilitates future titration to keep the disease under control
Describe the diagnostic workup of Cushing syndrome
- Overnight low dose dexamethasone suppression test
- if suppression then no disease but if NO suppression then do 24 hour urine free cortisol
- if elevated we go to high dose
- Suppression identifies pituitary microadenoma
- No suppression at either identifies adrenal adenoma (or paraneoplastic syndrome)
- Do appropriate imaging studies (MRI for pituitary. CT scan for adrenal) and remove
This is a devastating hypersecretion of insulin in the newborn, requiring 95% pancreatectomy
Nesidioblastosis
What is the dermatologic finding associated with a glucagonoma?
-severe migratory necrolytic dermatitis
Resection is curative of a glucagonoma but what meds can help those with metastatic, inoperable disease
- Somatostatin
- Streptozocin
Surgery to resect a Pheo requires careful pharmacologic preparation with what
alpha-blockers
what imaging is usually diagnostic of coarctation of the aorta
Spiral CT scan enhanced with IV dye (CT angio)
Esophageal atresia shows up with excessive salivation noted shortly after birth, or choking spells when first feeding is attempted. . . Describe that the VACTER constellation is and what workup needs to be done
- vertebral . . xray
- anal . . look for imperforation
- cardiac . . echo
- tracheal
- esophageal
- renal . . sonogram
- radial
management of esophageal atresia
Primary surgical repair is preferred, but if it has to be delayed, a gastrostomy has to be done to protect lungs from acid reflux
Describe the management of an imperforate anus
- Look for a fistula nearby (to vagina or perineum
- If present, repair can be delayed until further growth (but before toilet training time)
- If no fistula, a colostomy needs to be done for high rectal pouches (and later the repair) or . . . a primary repair can be done right away if the blind pouch is almost to the anus
In an imperforate anus, how is the level of the pouch determined?
-x-rays taked upside down (so that the gas in the pouch goes up), with a metal marker taped to the anus
A congenital diaphragmatic hernia is always on which side
left
Describe the management of a congenital diaphragmatic hernia
- The real problem is not the mechanic one, but the hypoplastic lung that still has fetal-type circulation
- Repair must be delayed 3 or 4 days to allow maturation
- Babies are in respiratory distress and need endotracheal intubation, low-pressure ventilation (careful not to blow up the other lung), sedation, and NG suction
What imaging diagnoses a congenital diaphragmatic hernia
Prenatal sonagram
Describe a Gastroschisis
- cord is normal (reaches baby)
- defect is to the right of the cord
- NO protective membrane
- bowel looks angry and matted
Describe an omphalocele
-Cord goes to the defect, which has a thin membrane under which one can see normal looking bowel and a little slice of liver
Describe the management of Gastroschisis/omphalocele
- Small defects can be close primarily
- Large ones require construction of a Silastic “silo” to house and protect the bowel
- The contents are squeezed into the belly a little bit every day, until complete closure can be done in about a week
- Babies with Gastroschisis also need vascular access for parenteral nutrition, because the angry-looking bowel will not work for about 1 month
Describe Exstrophy of the urinary bladder
-Abdominal wall defect, but over the pubis (which is not fused)
-a medallion of red bladder mucosa, wet and shining with urine
-
Management of Exstrophy of the urinary bladder
- The baby has to be transferred immediately to a specialized center where a repair can be done within the first 1 or 2 days of life
- delayed repairs do not work
Green vomiting and a “double-bubble” picture in x-rays (a large air fluid level in the stomach, and a smaller one to its right in the first portion of the duodenum) are found in what conditions
- Duodenal atresia
- Annular pancreas
- Malrotation
- All of these anomalies require surgical correction but malrotation is the most dangerous because the bowel can twist on itself, cut off its blood supply and die
If in addition to the double bubble on xray there is a little normal gas pattern beyond, the chances of which condition are higher?
malrotation
How is malrotation diagnosed
- with contrast enema (safe, but not always diagnostic)
- Upper GI study (more reliable, but more risky)
How does intestinal atresia show up
-newborn with green vomiting but instead of a double bubble, there are multiple air-fluid levels throughout the abdomen
In intestinal atresia, there may be more than one atretic area, but no other congenital anomalies have to be suspected because this condition results from what?
a vascular accident in utero
This is seen in premature infants when they are first fed. There is feeding intolerance, abdominal distention, and a rapidly dropping platelet count (in babies, a sign up sepsis)
Necrotizing enterocolitis
Treatment for necrotizing enterocolitis
- Stop all feedings and administer broad spectrum antibiotics, IV fluids, and IV nutrition
- Surgical intervention is required if the infant develop abdominal wall erythema, air in the portal vein, intestinal pneumatosis (presence of gas in the bowel wall), or pneumoperitoneum (signs of intestinal necrosis and perforation)
This is seen in babies who have cystic fibrosis (often hinted at by the mother having it). They develop feeding intolerance and bilious vomiting. X-rays show multiple dilated loops of small bowel and a ground glass appearance in the lower abdomen
Meconium ileus
What is both diagnostic and therapeutic for Meconium ileus
-Gastrografin enema (shows microcolon and inspissated pellets of meconium in the terminal ileum) . . . draws fluid in and dissolves the pellets
This shows up at age 3 weeks, more commonly in firstborn boys, with NONbilious projective vomiting after each feeding
Hypertrophic pyloric stenosis
In hypertrophic pyloric stenosis, if the mass cannot be felt, what is diagnostic?
-sonogram
Describe the therapy for hypertrophic pyloric stenosis
-begins with rehydration and correction of HYPOchloremic HYPOkalemic metabolic alkalosis, followed by Ramstedt pyloromyotomy or balloon dilatation
This should be suspected in 6 to 8 week old babies who have persistent, progressively increasing jaundice (which includes a substantial conjugated fraction)
Biliary atresia
Describe the management of Biliary atresia
- Do serologies and sweat test to rule out other probelms and do HIDA scan after 1 week of phenobarbital (which is a powerful choleretic)
- If no bile reaches the duodenum even with phenobarbital stimulation, surgical exploration is needed
- About 1/3 can get a long lasting surgical derivation
- About 1/3 need a liver transplant after they survived for a while with a surgical derivation
- about 1/3 need the transplant right away
Hirschprung disease (aganglionic megacolon) can be recognized in early life or may go undiagnosed for many years. What is the cardinal symptom
chronic constipation
Diagnosis of Hirschsprung disease is made how
Full-thickness biopsy of rectal mucosa
This is seen in 6 to 12 month old chubby, healthy looking kids who have episodes of colicky abdominal pain that makes them double up and squat. The pain lasts for about 1 minute, and the kid looks perfectly happy and normal until he gets another colic. Physical exam shows a vague mass on the right side of the abdomen, an “empty” right lower quadrant, and “currant jelly” stools
Intussusception
What is both diagnostic and therapeutic in intussusception
Barium or air enema . . if reduction is not achieved radiologically (or there is recurrences), surgery is done
What are some classic presentation of child abuse
- Subdural hematoma plus retinal hemorrhages (shaken baby syndrome)
- Multiple fractures in different bones at different stages of healing
- all scalding burns, particularly burns of both buttocks (the child was held by arms and legs and dipped into boiling water)
This should be suspected in lower GI bleeding in the pediatric age group
Meckel diverticulum
Management of meckel diverticulum
Do radioisotope (technetium) looking for gastric mucosa in the lower abdomen
At what age does an undescended testicle needs to be surgically brought down into the scrotum and fixed in place (orchiopexy)
age 1
A testicle that is in the canal at birth, but can be easily pulled down where it belongs is not an undescended testicle but is what?
an overactive cremasteric muscle . . parents need to be reassured of the benign nature
If an abdominal mass is found in a child and it moves up and down with respiration, it is most likely what?
a malignant liver tumor (hepatoblastoma or hepatocellular carcinoma)
-Alpha fetoprotein is likely to be elevated
If an abdominal mass in a child is deeper and nonmobile, there is an even chance it is what
- A wilms tumor arising from the kidney or
- a neuroblastoma growing in the adrenal gland
Describe the prognosis of a neuroblastoma
- Depends on the childs age when it is discovered
- The younger the patient is, the better the cure rate
- It also may involute and spontaneously revert to a benign neuroma
Inspiratory wheezing is seen in what?
Tracheomalacia, where the tracheal rings collapse
if parents report that the child has some difficulty swallowing, as well as episodes of respiratory distress, with crowing respiration, stridor, and hyperextension of the neck, the problem is what?
Vascular ring, a congenital anomaly in which the trachea and esophagus are encircled by abnormal blood vessels
What is seen on barium swallow and bronchoscopy of a vascular ring
extrinsic compression
treatment of a vascular ring
surgery divides the smaller of the two arches
Left to right cardiac shunts share the presence of what?
- a murmur
- overloading of the pulmonary circulation
- long term damage to the pulmonary vasculature
This is a very minor, low pressure, low volume shunt. Patients typically grow into late infancy before it is recognized. A faint pulmonary flow systolic murmur and fixed split second heart sound are characteristic. A history of frequent colds is elicited
Atrial septal defect
Treatment of atrial septal defect
Closure can be achieved surgically or by cardiac catheterization
These heart defects when in a more typical location (high in the membranous septum) lead to trouble early on. Within the first few months there will be “failure to thrive”, a loud pansystolic murmur best heard at the left sternal border, and increased pulmonary vascular markings on chest xray
VSD
management of VSD
Echo and surgical closure
This becomes symptomatic in the first few days of life. There are bounding peripheral pulses and a continuous “machinery-like” heart murmur. Echo is diagnostic
Patent ductus arteriosus
Describe the management of a PDA
- In premature infants who have not gone into CHF, closure can be achieved with indomethacin
- Those who do not close, those who are already in failure, or full term babies need surgical division or radiological embolization with metal coils
All of these general heart abnormalities share the presence of a murmur, diminished vascular markings in the lungs, and cyanosis
Right to left shunts
What are the 2 right to left shunts covered in this book
- Tetralogy of Fallot
- Transposition of the great vessels
This, although crippling, often allows children to grow up into infancy. It is also the most common cyanotic anomaly and thus any exam question in which a 5 or 6 year old is cyanotic is bound to be this. The children are small for their age, have a bluish hue in the lips and tips of their fingers, clubbing, and spells of cyanosis relieved by squatting. There is a systolic ejection murmur in the left third intercostal space, a small heart, diminished pulmonary markings on chest xray, and EKG signs of right ventricular Hypertrophy
Tetralogy of fallot
Diagnosis and management of Tetralogy of Fallot
- Echo
- Surgery
This leads to severe trouble early on. The kids are kept alive by an ASD, VSD, or PDA (or combination), but die very soon if not corrected. Suspect this in a 1 or 2 day old child with cyanosis who is in deep trouble
Transposition of the great vessels
In Aortic stenosis, surgical valvular replacement is indicated when?
- if there is a gradient of more than 50 mm Hg
- or at the first indication of CHF, angina, or syncope
Patients with chronic aortic insufficiency are often followed with medical therapy for many years but should undergo valvular replacement at the first evidence of what?
at the first evidence on Echo of beginning left ventricular dilatation
Patients with a prosthetic valve need antibiotic prophylaxis for what
subacute bacterial endocarditis
As symptoms of mitral stenosis become more disabling, what becomes necessary
-mitral valve repair with a surgical commissurotomy or a balloon valvuloplasty
in worsening mitral regurg describe in generalities the repair of the valve
repair of the valve (annuloplasty) preferred over prosthetic replacement
Describe the post op care of heart surgery patients
- often requires that cardiac output be optimized
- If it is considerably under normal (5L/min or a cardiac index of 3), the pulmonary wedge pressure (or left atrial pressure, or left end-diastolic pressure) should be measured
- Low number (0-3) suggest the need for more IV fluids
- high numbers (20 or above) suggest ventricular failure
This produces dyspnea on exertion, hepatomegaly, and ascites, and shows a classic “square root sign” and equalization of pressure (right atrial, right ventricular diastolic, pulmonary artery diastolic, pulmonary capillary wedge, and left ventricular diastolic) on cardiac cath
Chronic constrictive pericarditis
What relieves chronic constrictive pericarditis
surgical therapy
Describe the workup of a coin lesion found on chest x-ray
- has 80% chance of being malignant in people over the age of 50, even higher if there is a history of smoking.
- A very expensive workup for cancer of the lung can be avoided if an older (a year or 2) chest x-ray shows the same unchanged lesion (it is not cancer).
- Thus, seeking an older x-ray is always the first thing to do in the patient found to have a coin lesion
- If no older chest x ray or lesion not present before then sputum cytology and CT scan of chest and upper abdomen (looking for mets) . . could do biopsy
management of small call lung cancer
chemo and radiation
Describe the rationale on operability of lung cancer
- predicated on residual function after resection. Assuming pneumonectomy (Central lesion) is required. For lobectomy (peripheral lesion), function is less of an issue
- A minimum FEV1 of 800 mL is needed
- If clinical findings (COPD, SOB) suggest this may be the limiting factor pulmonary function studies are done
- Determine FEV1, determine fraction that comes from each lung (by ventilation-perfusion scan), and figure out what would remain after pneumonectomy
- If less than 800 mL, do NOT continue expensive test . . the patient is NOT a surgical candidate . . treat with chemo and radiation
This is when an arteriosclerotic plaque at the origin of the subclavian (before the takeoff of the vertebral) allows enough blood supply to reach the arm for normal activity, but does not allow enough to meet higher demands when the arm is exercised. When that happens, the arm sucks blood away from the brain by reversing the flow in the vertebral. Clinically the patient describes claudication of the arm (coldness, tingling, muscle pain) and posterior neurologic signs (visual symptoms, equilibrium problems) when the arm is exercised.
-Vascular symptoms alone would suggest Thoracic outlet syndrome but the combination with neurologic symptoms identifies subclavian steal syndrome
What is diagnostic of subclavian steal syndrome and what cures it
- Duplex scanning shows reversal of flow
- Bypass surgery
Describe when you need to repair a AAA
- if 5-6 cm
- or aneurysms that grow 1 cm per year or faster
Describe how to repair a AAA
- Traditionally done by open laparotomy
- about 70% of them are now performed by percutaneously inserted vascular stents
What to do about a TENDER AAA
-it is going to rupture within a day or two, and thus immediate repair is indicated
Excrutiating back pain in a patient with a large AAA means what?
- means it is already leaking
- Retroperitoneal hematoma is already forming, and blowout into the peritoneal cavity is only minutes or hours away
- Emergency surgery is required
Long term treatment of Arteriosclerotic occlusive disease of the lower extremity
- cessation of smoking
- exercise
- Cilostazol
Difference between treating a dissection of ascending aorta vs. descending
- Ascending surgically . . . could be valve damage
- Descending medically with control of HTN in ICU . . devastating consequences of interrupting the blood supply to the spinal cord make surgery a risky proposition, and it is rarely done
What are the 2 situations in which FNA is contraindicated
- hemangioma in the liver. Should the patient take a deep breath when the needle is in, it could slice the hemangioma, leading to fatal bleeding
- Testicular mass. These are almost invariably malignant and will quickly spread through the needle tract
typical features of basal cell carcinoma
- favors upper part of face
- timetable measured in years
- does NOT metastasize
What is the sophisticated surgery called to remove a Basal cell carcinoma
- Mohs surgery
- repeated microscopic sections as the excision is eing done
This is a vision impairment resulting from interference with the processing of images by the brain during the first 6 or 7 years of life. The most common expression of this phenomenon is the child with strabismus. Faced with 2 overlapping images, the brain suppresses one of them. If the strabismus is not corrected early on, there will be permanent cortical blindness of the suppressed eye, even though the eye is perfectly normal . . Should an obstacle impede vision in one eye during those early years (for instance, a congenital cataract), the same problem will develop
Amblyopia
this is verified by showing that the reflection from a light comes from different areas of the cornea in each eye
Strabismus
Strabismus should be surgically corrected when diagnosed to prevent what
development of amblyopia
When reliable parents relate that a child did not have strabismus in the early years but develops it later in infancy, what is the problem and how is it corrected?
- an exaggerated convergence caused by refraction difficulties
- Corrective glasses instantly resolve the problem
- True strabismus does not resolve spontaneously
on PE the pupil is mid-dilated and does not react to light, the cornea is cloudy with a greenish hue and they eye feels “hard as a rock”
acute angle closure glaucoma
In acute angle closure glaucoma, emergency treatment is required (ophthalmologists will drill a hole in the iris with a laser beam to provide a drainage route for the fluid that is trapped in the anterior chamber). While waiting for the ophthalmologist, What can you administer?
- systemic carbonic anhydrase inhibitors
- apply topical beta-blockers and alpha-2 selective adrenergic Agonists
- Mannitol and pilocarpine may also be used
This is an ophthalmologic emergency in which the eyelids are hot, tender, red, and swollen. The patient is febrile but they key finding when the eyelids are pried open is that the pupil is dilated and fixed and the eye has very limited motion. There is pus in the orbit
Orbital cellulitis
treatment of orbital cellulitis
-emergency CT scan and drainage
Treatment of retinal detachment
Emergency intervention with laser “spot welding” will protect the remaining retina
Embolic occlusion of the retinal artery is an emergency although little can be done about it. The patient (typically elderly) describes sudden loss of vision from one eye. In about 30 minutes the damage will be irreversible. What is the standard recommendation
for the patient to breathe into a paper bag and have someone repeatedly press hard on the eye and release while hi is in transit to the ER
-The idea is to vasodilate and shake the clot into a more distal location, so that a smaller area is ischemic
This is located on the midline, at the level of the hyoid bone and seems to be somehow connected to the tongue (pulling at the tongue retracts the mass. They are typically 1 or 2 cm in diameter
Thyroglossal duct cyst
Surgical removal of a thyroglossal duct cyst includes removal of what?
- the cyst
- middle segment of the hyoid bone
- the track that leads to the base of the tongue
- Some practitioners insist that the location of the normal thyroid should first be ascertained by radionuclide scan
This occurs along the anterior edge of the sternomastoid muscle, anywhere from in front of the tragus to the base of the neck. They are several cm in diameter and sometimes have a little opening and blind tract in the skin overlying them
Brachial cleft cyst
This is found at the base of the neck as a large mushy ill defined mass that occupies the entire supraclavicular area and seems to extend deeper into the chest. Indeed, they often extend into the mediastinum
Cystic hygroma
management of Cystic hygroma
CT scan before attempted surgical removal
This is typically seen in young people; they often have multiple enlarged nodes (in the neck and elsewhere) and have been suffering from low-grade fever and night sweats
Lymphoma
workup and treatment of lymphoma
- FNA can be done, but usually a node has to be removed for pathologic study to determine specific type
- Chemo is usual treatment
What are usually the primary tumors when metasastasis is found in supraclavicular node
- invariably comes from below clavicles
- lung or intraabdominal
- The node itself may be removed to help establish a tissue diagnosis
This is seen in old men who smoke and drink and have rotten teeth. Patients with AIDS are also prime candidates. Often the first manifestation is a metastatic node in the neck (typically to the jugular chain).
Squamous cell carcinoma of the mucosae of the head and neck
Describe the diagnostic workup of Squamous cell carcinoma of the mucosae of the head and neck
- triple endoscopy (or panendoscopy) looking for the primary tumor or tumors
- Biopsy of the primary establishes diagnosis, and CT scan demonstrates the extent
- FNA of the node may be done, but open biopsy of the neck mass should NEVER be done . .an incision in the nick for that purpose will eventually interfere with the appropriate surgical approach for the tumor
treatment of squamous cell carcinoma of the mucosae of the head and neck
-resection, radical neck dissection, and often radiotherapy and platinum-based chemo
What are other presentations of squamous cell carcinoma of the mucosae of the head and neck
- persistent hoarseness
- persistent painless ulcer in the floor of the mouth
- persistent unilateral earache
This should be suspected in an adult who has sensory hearing loss in one ear, but not the other (and who does not engage in sport shooting that would subject one ear to more noise than the other)
Acoustic nerve neuroma
Best diagnostic modality of acoustic nerve neuroma
MRI
These produce gradual unilateral facial nerve paralysis affecting both the forehead and lower face (Paralysis of sudden onset suggests Bell’s palsy)
Facial nerve tumors
Best diagnostic study for facial nerve tumors
Gadolinium enhanced MRI
Parotid tumors are visible and palpable in front of the ear or around the angle of the mandible. Most are what type?
Pleomorphic adenomas, which are benign but have potential for malignant degeneration
-They do NOT produce pain or facial nerve paralysis
A hard parotid mass that is painful or has produced paralysis is what?
parotid cancer
Describe the management of parotid cancer
- FNA of these may be done
- open biospy is an ABSOLUTE CONTRAINDICATION
- A formal superficial parotidectomy (or superficial and deep if the tumor is deep to the facial nerve) is the appropriate way to excise (and thereby biopsy) parotid tumors, preventing recurrences and sparing the facial nerve
- Enucleation alone leads to recurrence
- In malignant tumors the nerve is sacrificed and a graft done
This is the cause of unilateral ENT problems in toddlers
A 2 year old with unilateral earache, unilateral rhinorrhea, or unilateral wheezing has this
foreign bodies in his ear canal, up his nose, or into bronchus
-The appropriate endoscopy under anesthesia will allow extraction
This is an abscess of the floor of the mouth, often the result of a bad tooth infection. The usual findings of an abscess are present, but the special issue here is the threat to the airway.
Ludwig angina
management of Ludwig angina
-Incision and drainage are done, but intubation and tracheostomy may also be needed
Facial nerve injuries sustained in multiple trauma produce paralysis right away. Patients who have normal nerve function at the time of admission and later develop paralysis have what?
swelling that will resolve spontaneously
This is heralded by the development of diplopia (from paralysis of extrinsic eye muscles), along with facial pain and high fever, in a patient suffering from frontal or ethmoid sinusitis. This is a rare but very serious emergency (30% mortality) that requires hospitalization
Cavernous sinus thrombosis
Describe the diagnosis and treatment of Cavernous sinus thrombosis
- Diagnosis is best done with MRI
- Treatment is based on early and aggressive IV antibiotic administration, for a minimum of 3-4 weeks, with penicillinase-resistant penicillin plus a 3rd or 4th gen cephalosporin
- While the cavernous sinus itself would not benefit from operative intervention, the responsible paranasal sinuses should be surgically drained
A TIA is a sudden, transitory loss of neurologic function that comons on without headache and resolves sponteneously leaving no neurologic sequela. What is the most common origin?
- High grade stenosis (70% or above) of the internal carotid
- or ulcerated plaque at the carotid bifurcation
The importance of TIAs is that they are predictors of strokes, and what may prevent or minimize the possibility?
-timely elective endarterectomy
describe workup and treatment of TIA
- starts with noninvasive Duplex studies
- Surgery possible
- angioplasty stent can be done if a filter is first deployed to prevent embolization of debris to the brain
Ischemic strokes that have been present for longer than how long are NOT amenable to revascularization procedures?
- 3 hours
- best if started within 90 minutes
Preferred imaging study for brain tumors
MRI
While awaiting surgical removal of a brain tumor, What is the increased ICP treated with
high dose steroids
This brains tumor occurs in youngsters who are short for their age, and they show bitemporal hemianopsia and a calcified lesion above the sella on CT scan
Craniopharyngioma
tumors of this produce loss of upper gaze and the physical finding known as “sunset eyes” (Parinaud syndrome)
pineal gland
This brain tumor of children sometimes pivots and affected children often assume the knee-chest position to open the flow of CSF and relieve their headache
Ependymoma
This develops several months after a crushing injury. There is constant, burning, agonizing pain that does not respond to the usual analgesics. The pain is aggravated by the slightest stimulation of the area. The extremity is cold, cyanotic, and moist.
Reflex sympathetic dystrophy (causalgia)
What is diagnostic of Reflext sympathetic dystrophy?
curative?
- Successful sympathetic block
- sympathectomy
describe the use of IV pyelogram
almost disappeared, along with the nephrotoxicity and allergic reactions that made it risky
Acute bacterial prostatitis is seen in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam. IV antibiotics are indicated, and care should be taken not to repeat any more rectal exams. Continued prostatic massage could lead to what?
septic shock
What is the most common reason for a new born boy not to urinate during the first day of life
- Posterior urethral valves
- Meatal stenosis should also be looked for
This is usually asymptomatic in little boys but leads to a fascinating clinical presentation in little girls. The patient feels normally the need to void, and voids normally at appropriate intervals, but she is also wet with urine all the time
Low implantation of a ureter
-Careful vaginoscopy should identify the ectopic ureter
The classic presentation of this is an adolescent who goes on a beer-drinking binge for the first time in his life and develops colicky flank pain
Ureteropelvic junction obstruction
-The anomaly allows normal urinary output to flow without difficulty, but if a large diuresis occurs, the narrow area cannot handle it
What is the best way to diagnose bladder cancer
- cystoscopy
- but it should be preceded by CT scan
Acute urinary retention from BPH is often precipitated during what situation?
-during a cold, by the use of antihistamines and nasal drops, and by abundant fluid intake
Small ureteral stones (3 mm or less) at the ureterovesical junction have a 70% chance of passing spontaneously. Such cases can be handled with analgesics, plenty of fluids, and watchful waiting. On the other hand, a 7-mm stone at the UPJ has only a 5% probability of passing. Intervention will be required. What is the most common tool used?
- Extra-corporeal shock-wave lithotripsy (ESWL)
- Cannot be used in pregnancy, bleeding diathesis, stones that are several cm large
