Pestana - Surgery Flashcards
1
Q
Indications for intubation in trauma patient?
A
- Expanding hematoma in neck (nl intub.)
- Air present w/in tissues of lower neck/upper chest (bronchoscope)
- Pt in coma (nl intub.)
- Extensive facial fracture, drowning in blood (open cric, only do in OR)
2
Q
Reasons for trauma patient to be in shock?
A
- Hemorrhage
- Pericardial Tamponade
- Tension Pneumothorax
3
Q
How do you differentiate hemorrhage, pericardial tamponade, or tension pneumothorax in chest trauma?
A
- Normal/low CVP = hemorrhage
- High CVP + distended neck veins = Tamp or PTX (use difficulty breathing to distinguish)
4
Q
First rule to treat trauma patient with signs of hemorrhagic shock? Second?
A
- Find bleeding and stop (exploratory lap, etc.)
2. Fluid resusc. with LR and pRBC
5
Q
Best way to stop active visible bleeding?
A
Direct pressure
6
Q
What is the indication for starting IVF before stopping hemorrhage in traumatic hemorrhagic shock?
A
If bleeding source is difficult to find and diagnostic studies need to be done
7
Q
Can intracranial hemorrhage lead to hemorrhagic shock?
A
Cranial vault can’t accomodate enough blood loss to cause shock, look elsewhere for bleed source
8
Q
What is vasomotor shock and what can cause it? How do these patient’s appear and how do you treat?
A
- Loss of peripheral vascular resistance (warm, flushed)
1. Anaphylaxis
2. Spinal Cord interruption at higher level
Tx: Pharmacological treatment, pressors
9
Q
When/where should foreign bodies in trauma injury be removed?
A
Always in the OR, because hemorrhage risk
10
Q
When should skull fractures be taken to OR?
A
Depressed wound (linear fracture can be cleaned at bedside)
11
Q
Which trauma patients require head CT?
A
Any head injury with loss of consciousness
12
Q
What are signs of skull base fracture? What is the worry with this injury and how can you assess?
A
- Ecchymoses under eyes, fluid from eyes/ears/nose, hematoma behind ear
- Risk of neck/cspine injury (CT scan of head AND neck)
13
Q
What can be done to reduce O2 demand in head? When should this be done?
A
Sedation/hypothermia
Use when medical therapy to decrease ICP fails
14
Q
What are indications for surgical exploration in neck trauma?
A
- Penetrating injury below mandible and above sternum (especially anterolateral)
- Coughing/spitting up blood
- expanding hematoma
- signs of hypovolemic shock (must stop bleed!!)
15
Q
When do you NOT operate immediately for neck trauma? What steps should be taken?
A
- If penetrating injury above angle of mandible or below cricothyroid cartilage
- do arteriogram/radiographic imaging
- Possible embolization (surgery only if accessible location and after thorough planning)
16
Q
Best treatment for pain in painful chest trauma in elderly adult?
A
Topical anesthetic (big risk of resp depression if opioid given)
17
Q
How do you treat a “sucking” chest wall wound?
A
Dressing to block opening, to prevent tension PTX
18
Q
What is a sign of major deceleration injury? What are the risks and what should be done?
A
- Broken 1st rib, scapula, and sternum (hardest bones to break)
1. Monitor 48 hrs for heart/lung contusion
2. Look for transection of Aorta (CXR, spiral CT)
3. Repair if spiral CT + (aortogram if -)
19
Q
What are causes of emphysema in the neck?
A
- Esoph perforation (usually from EGD)
- Tension PTX
- transection/damage to trachea/bronchus
20
Q
Possible causes of air embolism and how to prevent?
A
- Subclavian lymph node biopsy (do in trendelenburg)
- Central line catheter disconnect
21
Q
Causes of pulmonary failure after chest trauma?
A
- Multiple broken ribs/fractures –> pulm contusion
- Multiple long bone fractures -> fat embo
22
Q
Indications for ex lap for ab trauma?
A
- Gunshot wounds below nipple line
- Knife wounds that penetrate peritoneum (viscera hanging out)
- blunt trauma w/ signs of acute abdomen
- Signs of hemorrhage w/ abd as only possible location for bleeding (confirm w/ CT if hemodynamic stable, Abd sonogram for blood if not)
23
Q
Major complications for ex laps of abdominal trauma?
A
- Coagulopathy from increased blood transfusions
- Hypothermia
- Abdominal compartment syndrome (which can cause resp failure if not recognized and abdomen forced close)
24
Q
W/u for pelvic trauma with stable hematoma?
A
Rule out additional injury to genitals, bladder, urethra, rectum:
do sigmoidoscopy, retrograde cystogram and pelvic exam (female),
25
Best steps to address unstable hemorrhage due to pelvic fracture?
- External fixation of pelvis
- Arteriogram (and embo) of bleeding vessels (33% utility)
- check pelvic organs/structures for injury
26
What is the order of repairs for major injury to extrimities?
1. Stabilize bone
2. Fix vessels
3. Fix nerves
4. Possible fasciotomy to prevent compartment syndrome
27
How can patient responsiveness to fluid be monitored and adjusted?
Produce 1-2 cc/kg/hr of urine (if less give more fluids, if more slow down)
28
What is the treatment necessary for all burns?
- Tetanus ppx
- Silver sulfadiazene (Abx around eyes)
- Pain medication
- Grafts
- Intensive nutritional support
29
What is the key to identifying orthopedic diseases in Peds? Identify the 4 main categories:
AGE
- Birth -> developmental dysplasia, use sonogram
- Toddler -> Septic hip, aspirate to dx, drain
- 6 yo -> Legg Perthes or Vasc nexcrosis, do XRay
- 13 yo -> Slip capital fem epiphysis, pin femoral head
30
What scan should be done in child with febrile illness, no trauma, and severe local bone pain?
Do bone scan to rule acute hematogenous osteo
31
What is the most severe fracture that can occur in children? How does it usually occur?
Supra condylar fracture of humerus b/c risk of vascular necrosis
-Falls on hand w/ arm extended, breaks elbow w/ hyperextension
32
What is the physical exam finding of a patient with fracture of femoral head? how should you treat?
- leg shortened and externally rotated
| - hip replacement surgery b/c risk of avasc necrosis
33
What is a useful tool for diagnosing knee injuries?
Tenderness to palpitation identifies the part of the knee with the injury
34
What is the presentation of a patient with posterior dislocation of the hip? What is the treatment?
- Leg shortened, adducted and internally rotated
| - Surgical repair
35
What test should be done in all patients with suspected head trauma (like in a car accident)?
-CT Head and include the neck! (b/c any head injury can also involve the neck)
36
What must be done before all carpal tunnel surgery?
- Wrist XRay to r/o other causes
| - electromyography to confirm carpal tunnel
37
What are the best initial steps for a diabetic foot ulcer care?
- Control ulcer by keeping clean and foot elevated
- treat diabetes to prevent progression
- amputation last resort
38
What is the appearance of venous stasis ulcer? How do you treat?
- Above medial malleolus, indurated, hyperpigmented
| - Elastic stockings, boots etc. surgery in advanced cases
39
What is the risk of multiple ulcers that heal and break down over many years? How do you treat?
- Squamous cell carcinoma
| - Do biopsy and wide local excision
40
What are the major cardiac risks that preclude no operation?
Old/inactive patient, EF
41
What hepatic issues can increase risk of complications in surgical patients?
Cirrhosis, Increased BR, increased PT, albumin low (
42
What should be done before operating on patients who are severely malnourished?
5-10 days of direct nutritional support (PEG, or PEJ if possible)
43
How soon can you operate on patient in DKA?
Within hours as long as acidosis, hyperglycemia, dehydration and other main issues are corrected.
44
What are the 5 causes of postop fever?
1. Wind (atelectasis) - POD 1
2. Water (UTI) - POD 3
3. Walking (DVT) - POD 5
4. Wound (infection) - POD 7
5. Wonder where?? (Deep abscess) - POD 10
45
What is the risk of not treating atelectasis?
Pneumonia
46
What are the two most common causes of chest pain after surgery and how can you distinguish?
MI (during Op or POD 1 or 2)
| PE (POD 5 or 7)
47
What is the most common cause of MI perioperatively? What will identify?
- Hemorrhage and severe protracted hypotension
| - EKG tracing changes seen
48
What are the classic blood gas findings in pts w/ PE?
Hypoxemia AND hypocapnia
49
Best way to prevent further PE in postop patients?
IVC filter (since tPA can't be given)
50
What increases risk for tension pneumothorax for patient in surgery and how can you minimize?
- Severe damage to lungs (e.g. TB causing blebs, damage by ribs as in flail chest)
- Bilateral chest tubes (before, or if PTX occurs)
51
What are the causes of disorientation and coma postop?
Hypoxemia (decreased O2 to brain), ARDS, DTs (alcoholic), SIADH (hypoNa), DI (hyperNa), hepatic encephalopathy (cirrhotic pt)
52
How can you differentiate dehydration from renal failure in patients with low urine output postop?
Measure urine Na levels and FeNa (if Na 10-20 pt dehydrated, if Na > 40 pt renal failure)
53
What patient's are at risk of Ogilvie's syndrome? What is this condition and how do you treat?
Paralytic ileus of colon (massive colon dilation)
-Elderly pt, inactive preop, non Abdomen surgery (hips, Uro, etc.)
Tx: Colonoscopy
54
How do you treat a subcostal postop fistula draining green fluid?
Let nature heal itself!! but give patient lots of fluids to replete and TPN/other nutritional support
55
What are patients who lose fluid from GI tract at risk of and how can you treat?
- Initial volume loss followed by repletion with only free H2O (vs. isotonic electrolyte fluid) --> Hypovolemic HypoNa
- Give isotonic fluids to repelete
56
What is the amount of water lost with Na >140? How do you treat?
- 1L H2O lost for every 3 meq/L above 140
- If change happened quickly give D5W
- If change was slow give D5 1/2 NS (free water would be lethal b/c too rapid correction)
57
How do you treat HypoNa from SIADH?
Hypertonic saline if change happened quickly, water restriction if change was slow
58
What electrolyte must be repleted when treating a patient for DKA?
K+ at a rate up to 20mEq/hr if needed (because total body K+ lost and serum levels drop after DKA tx)
59
What are three major conditions that can lead to a sudden rise in K+ concentrations?
1. Crush Injury (cell destruction)
2. Blood transfusions (damaged RBCs)
3. Acidosis (K+ exchanged for H+ entry into cells)
60
What are patients who are in and out of shock for prolonged periods at risk of developing? How best to treat?
- Metabolic acidosis from hypoperfusion
| - Give Ringer's Lactate (treats acidosis and increases perfusion pressure)
61
What is the best treatment for patients w/ metabolic alkalosis from severe protracted vomiting?
Potassium Chloride (KCl) at up to 10-15 mEq/Hr
62
What is the indication for endoscopy for GERD?
Progressive heartburn for many years w/ some symptomatic improvement w/ antacids (do scope to assess for damage)
63
What is the indication for surgery for GERD and how do you decide what surgery needs to be done?
- Refractory to medical tx (PPIs etc.)
- If dysplastic changes are present, need to resect portion of esophagus
- If no dysplasia, do fundoplication
64
How do you work up a patient w/ suspected esophageal cancer?
1. Barium swallow to assess level of obstruction etc.
2. Endoscopic exam w/ biopsies
3. Palliative surgery
65
How do you assess damage for a patient w/ suspected Boerhaave's syndrome?
Gastrografin swallow (barium will penetrate mediastinum)
66
What is the primary initial treatment for mechanical SBO? What is the patient at risk for?
-NGT, IVF, NPO then wait and watch for fever, white count up, worsening pain which would be signs of SB strangulation
67
What is the indication for operating in SBO?
- pt develops fever, leukocytosis, worsening tenderness in abdomen
- if SBO caused by hernia that got incarcerated and strangulated (now if sx above, later if pt stable)
68
Provide the list of polyps that may cause cancer in order of most malignant to least:
FAP > Villous Adneoma > Tubular adenoma > Benign polyp disease (juvenile polyposis, Peutz jegher disease, inflammatory/hyperplastic polyps)
69
What are the indications for surgery in ulcerative colitis?
1. Chronic UC (because increased risk of cancer)
2. High dose steroid treatment (a sub sign of chronic UC)
3. Toxic Megacolon
70
What should not be used in patients with C-Diff?
Anti-diarrhea meds
71
Indications for surgery in C-Diff?
Failure of medical treatment, WBC >50k, Lactate >5
72
What presenting signs can be used to distinguish the 3 different types of hemorrhoids?
Painless bleeding -> Internal hemorrhoids
Painful, non-bloody -> External hemorrhoids
BOTH -> prolapsed internal
73
What are the indications for surgery of hemorrhoids?
External or prolapsed internal (if internal, can treat in office w. rubber band ligation)
74
What should be looked at closely for patients with isciorectal abscess?
- Make sure it's not a necrotic cancer causing it
| - Follow diabetics closely if doing incision and drainage
75
What is the presentation and treatment for squamous cell carcinoma of the anus?
Fungating mass in HIV + patient, has enlarged peripheral lymph nodes
Tx: chemoradiation (Nigro protocol ) and surgery once shrunk
76
What are the causes of lower GI bleeding and who are more likely to get?
Polyps, cancer, hemorrhoids, diverticulosis, angiodysplasia (all are more common in eldely!!)
77
What should be done for a patient with massive lower GI bleeding?
Tagged RBC study to look for site of bIood Ioss, foIIowed by ateriogam. If no bIood seen on tagged study, conside coIonoscope.
78
What should be done in patients with dark red blood per rectum?
Do NGT if actively bleeding NOW -> If blood present you confirm UGI source; if green bile do arteriogram if 2cc/min, Tagged RBC if .5 - 2cc/min, or colonoscope if
79
What is the most likely cause of lower GI bleeding in a child? What needs to be done?
Meckel's diverticulum -> Do Technitium 99 scan
80
What are pro inflammatory cytokines that can cause SIRS?
TNF alpha, IL1, IL6
81
What are the associated congenital anomalies?
VACTERL - vertebral, anal imperforate, cardiac, tracheal, esophageal atresia, renal, limbs
82
What does double bubble sign with some normal gas pattern beyond suggest? How can you confirm?
Malrotation
Do contrast enema
83
What must be ruled out in patient's with "acute abdomen" and how is this done?
Mimicks of AA:
1. MI, r/o w/ EKG
2. Ureter stone, r/o w/ AXR or CT A/P
3. Pancreatitis, r/o w/ amylase/lipase
4. Lower lobe Pneumonia, r/o w/ CXR
5. Primary bacterail peritonitis (signs of acute abdomen but pt has ascites) - do tap and culture fluid to confirm
84
What is the treatment of mesenteric ischemia?
- If found early (acute abd w/ afib in elderly) do arteriogram and embolectomy
- If found late (signs above and blood in stool) do ex lap w/ resection of dead segment of bowel
85
What physical sign can distinguish perforation from obstruction?
Perforation is sudden constant and patient doesn't want to move
Obstruction is sudden but colicky, and patient moves around attempting to improve pain w/ positioning
86
What test is done to confirm gall stones? Ureter stones?
Sonogram for gall, CT for ureter
87
What are the lab signs of obstructive jaundice and what should be done when suspecting this?
Very high alk phos
Do sonogram
88
What does distended thin walled gall bladder on sonogram suggest?
Cancer, do CT abd and/or ERCP if needed
89
What are the three cancers that can cause obstructive jaundice? How best do you visualize each?
1. Head of pancreas - CT
2. Cholangiocarcinoma - ERCP
3. Cancer of Ampulla of vater - endoscopy (causes anemia from bleeding to lumen)
90
How can you differentiate acute cholecystitis and acute ascending cholangitis? What do you treat ascending cholangitis with?
AAC is usually in older, sicker patients, and LFTs are very deranged because pus fills up biliary ducts, alk phos is very high (lfts relatively normal in acute cholecystitis)
Tx: Immediate decompression of biliary tract w/ ERCP by GI, Abx and eventual cholecystectomy
91
What situations are more likely to require emergent cholecystectomy?
Male patients, pts w/ diabetes, and failure of medical therapy (NPO, NGT, IVF, Abx)
92
What are the two major types of acute pancreatitis and how do you differentiate?
more benign edematous form and more severe hemorrhagic form which usually p/w lower hematocrit
93
How can you distinguish severity of hemorrhagic pancreatitis and how do you manage it?
-Ranson Criteria (Hct, Ca, BUN, pH)
Tx: NPO, NGT, IVF, put patient in ICU and watch for ARDS, get daily CT scans to look for pancreatic abscess which needs immediate drainage
94
How are pseudocysts formed and how do you treat?
-Pancreatitis or car accident w/ Abd trauma ~5 weeks prior to presentation (leakage of pancr fluid, wall off)
Tx: if >6 cm or around >6 weeks do Cystogastrost(jejunost)omy, PerQ IR drainage, or endo drainage into stomach
95
Which hernias should not be repaired?
Umbilical in peds
96
What must be done in women p/w breast mass?
Radiologically guided core biopsy
97
What are fibroadenomas?
Firm, movable rubbery mass in the breast of younger women
98
What is fibrocystic breast disease and how do you manage it?
Benign cystic disease of breast tissue that waxes and wanes and goes away after menopause
Do mammogram to look for other masses and get aspiration of cyst fluid if it does not go away on its own
99
What is intraductal papilloma presentation? How do you manage?
35 yo women w/ bloody discharge of the breast
Retrograde galactogram and resection
100
What is the classic presentation for breast abscess?
Recently pregnant LACTATING MOTHER, w/ hot swollen mass near areola
101
What are the limitations for breast cancer treatment in pregnant women?
No chemotherapy in 1st trimester and no radiotherapy at all
102
What are the key buzz words for identifying breast cancer?
Woman in late 50s or in 60s, hard large mass, ill defined border, orange peel on skin, swollen red skin, present for many months, movable from chest wall but not breast, mammogram with area of irregular edges and microcalcifications
103
What must be done in women getting segmentectomies and lumpectomies for breast cancer?
Radiotherapy to chest (along with standard chemo/hormonal therapy all breast cancer pts should get)
104
What should be done for women with intraductal carcinoma?
Search for other lesions, lumpectomy and Radiotherapy
105
What is the treatment for women w/ large fungating, progressed breast masses?
This is cancer, start w/ RT/CT and then do palliative resection
106
What needs to be done in women w/ history of breast cancer now resolved for 2+ years, who presents with headache (or back pain) that does not resolve w/ over the counter meds?
Likely Brian (or spine Mets)
Do Head MRI/CT (or bone scan first for spine)
107
What is the main risk of follicular carcinoma and what needs to be done?
Hematagenous spread
Do TOTAL thyroidectomy to ensure no thyroid tissue remains, in case of recurrent metastases, in which case radioactive iodine therapy can kill any follicular mets
108
What lab findings support hyperparathyroid and what is the most likely cause? What must be done next?
High PTH and High Calcium, likely parathyroid adenoma
Do sestamibi scan to localize lesion and resect
109
How can you distinguish what is causing cushing syndrome if low dose dexamethasone suppresion test is negative?
Do High dose dexa test, if there is suppression cause likely pituitary adenoma, if there is no suppression cause is likely adrenal gland
110
What is the most characteristic sign of glucagonoma?
Migratory necrolytic dermatitis
111
What is the difference in treatment in fibromuscular dysplasia vs renal atherosclerosis disease?
FMD requires immediate balloon and stent of renal artery (atherosclerosis depends on old mans risk factors and scores etc.
112
How do you differentiate hyperaldosteronism from hyperplasia vs. adenoma?
In hyperplasia, aldosterone responds to postural changes, adenoma does not
113
What are the constellation of findings in congenital anomalies?
VACTERL - Vertebral, Anal imperforation, cardiac, Tracheal, esophageal, renal, limbs
114
What should be checked in newborns with imperforate anus?
Check for VACTERL
Look for nearby fistula (if present can repair later)
115
What is the major risk of diaphragmatic hernia in newborns?
Hypoplastic lung --> Respiratory failure (need intubation and ventilator support and possible ECMO)
116
What does a baby with gastroschisis require?
Silo to help move bowel slowly into abdomen over time and TPN because "angry bowel" can't digest well
117
What needs to be done in the case of extrophy of urinary bladder?
Surgical correction w/in 1-2 days at an advanced med center
118
What are the conditions associated w/ double bubble sign on Abd XRay? What needs to be done next?
1. Duodenal Atresia
2. Annular Pancreas
3. Malrotation (normal gas pattern beyond)
Tx: Barium enema/swallow study; surgical correction immediately if malrotation
119
What are the signs of intestinal atresia? How does this occur?
Secondary to in utero vascular accident
Gas patterns throughout abdomen and multiple dilated loops
120
What are the conditions associated w/ double bubble sign on Abd XRay and how can you differentiate?
1. Duodenal Atresia
2. Annular Pancreas
3. Malrotation (normal gas pattern beyond)
121
What are the presenting signs of meconium ileus?
Bilious vomit, ground glass on AXR, FHx of cystic fibrosis
122
What are the indications for sugery in necrotizing enterocolitis?
Pneumoperitoneum, abdominal wall erythema and air in portal vein
123
What are the key signs of meconium ileus? How do you dx/tx?
1-2 month old w/ bilious comit, AXR w/ dilated loops of bowel w/ ground glass appearance, hx of cystic fibrosis
Dx/Tx: Gastrografin enema, treat cystic fibrosis
124
How is therapy for acute subdural hematoma determined?
Midline shift!!
If present, do craniotomy and evacuation
If no shift, focus on medical therapy to control ICP
125
What is a major problem associated with circumferential burns of the extremities? What needs to be monitored?
Cutoff of blood supply as edema builds up under unyielding eschar
Must monitor capillary refill and peripheral pulses
126
Key features of plyoric stenosis in peds? How do you treat?
3 week old w/ projectile vomiting, olive like mass, child hungry soon after vomiting
Tx1: Correct hypochloremic, metabolic alkalosis
Tx2: Pyloromyotomy
127
how do you manage biliary atresia in newborns?
1. Phenobarbital (to stimulate biliary tract)
2. HIDA scan after 1 week
3. Attempt repair, but most likely need liver transplant
128
What is the key finding of Hirschprung's disease?
Chronic constipation in newborn
129
how do you manage biliary atresia in newborns?
1. Phenobarbital (to stimulate biliary tract)
2. HIDA scan after 1 week
3. Attempt repair, but most likely need liver transplant
130
What should be considered in 7 yo boy w/ large bloody bowel movements and no signs of infection? What test will confirm this?
Meckel's diverticulum
Technitium scan for gastric mucosa
131
What is a characteristic feature of peds w/ ASD?
history of recurrent infections ("frequent cold symptoms")
132
What should be the first step for any suspected morphological anomalies of the heart?
Echo
133
When will you not be able to use indomethacin for PDA?
If baby is in overt heart failure
134
What are the two major cyanotic congenital heart defects and how do you best differentiate the two?
Tetralogy of Fallot and Transposition of great vessels
- TOF usually 4-6 yo child
- TOGV will not survive past few days w/o intervention
135
What are indications for surgery in aortic stenosis?
Pressure gradient >50mm Hg, angina, syncope, CHF
136
When will you not be able to use indomethacin for PDA?
If baby is in overt heart failure
137
What is the treatment for acute aortic insufficiency as in bacterial endocarditis?
Emergency valve replacement and IV antibiotics
138
Can you repair a damaged aortic valve?
NO, it always must be replaced
139
What is the murmur heard in mitral stenosis? Mitral regurgitation?
MS: Rumbling diastolic apical murmur
MR: high pitch holosystolic murmur radiating to back and axilla
140
What is the indication for mitral valve replacement, as with MS?
Disabling symptoms (cachexia, dyspnea on exertion, a-fib, signs of CHF)
141
What is the surgery done for patients with disabling symptoms who have mitral stenosis? Mitral regurgitation?
MS: MV comissurotomy or balloon valvuloplasty
MR: Annuloplasty
(can do valve replacement if repair is not possible)
142
What are indications for surgical coronary intervention?
Progressive disabling unstable angina
143
What is the best current method for surgical evaluation of coronary disease?
Cardiac Catheterization
144
What are indications for surgical coronary intervention?
Progressive disabling unstable angina
145
How does one decide between stenting vs. CABG for coronary artery disease?
More simple problems = stent
| More complex disease (e.g. multi vessel disease) = CABG
146
What is cardiac index and normal value for it? Normal PCWP?
Cardiac output per meter squared of body surface area
normal CI is about 3 L/min per meters squared
normal PCWP is 10-12 mmHg
147
How do you evaluate a cardiac surgery post-op patient with cardiac index of 1.7?
1. This CI is low therefor patient either not getting enough fluids or having heart failure
2. Measure Left atrial end diastolic pressure
3. if low then not enough fluids, if high then heart failing
148
A patient is POD 3 following triple CABG w/ CO 2.3 and PCWP 27mm Hg. What should this patient receive?
Low CO and high LA EDP signify heart failure
Give inotropes for failing heart
149
What is the best predictor for cancer of the lung in a coin lesion on CXR? What is a good follow up test if high suspicion of cancer?
Age -> more likely in 60 y.o former smoker
Do sputum cytology and CT of chest and upper abdomen (upper ab to look for liver Mets)
150
How do you diagnose central/peripheral lesions for cancer? Difficult location?
Central - bronchoscopy w/ biopsy
peripheral - transthoracic needle
difficult - thoracotomy and wedge resection
151
What is the best predictor for cancer of the lung in a coin lesion on CXR?
Age -> more likely in 60 y.o former smoker
152
What is absolutely essential to determine before considering surgical resection (lobectomy, pneumonectomy) of a cancerous lesion in the lung?
1. Diagnosis (small cell = NO surgery, squamous/large etc = surgery)
2. Do CT scan to determine extent (metastases or lymph node involvement) - or mediastinoscopy w/ LN biopsy
3. Do PFT and V/Q scan to Determine FEV1 and perfusion
4. Estimate FEV1 after resection -> needs post-op FEV1 to be AT LEAST 800 to operate
153
What are indications for not doing an invasive study in the diagnostic work-up of a suspected lung cancer?
1. Extensive Disease progression - Significant weight loss, palpable supraclavicular lymph nodes, abnormal LFTs -> DO CT FIRST
2. Limited pulm fxn -> COPD, pt huffing and puffing --> PFTs first
154
What is absolutely essential to determine before considering surgical resection (lobectomy, pneumonectomy) of a cancerous lesion in the lung?
1. Diagnosis (small cell = NO surgery, squamous/large etc = surgery)
2. Determine FEV1 to assess pulm fxn
3. Estimate FEV1 after resection -> needs AT LEAST FEV1 = 800
155
What is the golden rule of surgery of lung tumors?
Surgery is NEVER palliative, always done to cure
156
What should be done in a patient with suspicious lung lesion (likely cancer) if the status of mediastinal lymph nodes cannot be determined from CT scan?
1. PET scan
| 2. Mediastinoscopy w/ biopsies to check carinal nodes (do not proceed if affected)
157
When must AAA be repaired?
1. Repair if 5-6 cm or greater (monitor w/ sonogram)
2. If signs of abdominal tenderness (AAA is leaking, will rupture in 1-2 days)
3. Excruciating back pain (leak present, blowout w/in minutes to hours)
158
What should be done for new onset intermittent claudication?
1. cessation of smoking
2. exercise
3. cilostazol
159
When must AAA be repaired?
1. Repair if 5-6 cm or greater (monitor w/ sonogram)
2. If signs of abdominal tenderness (AAA is leaking, will rupture in 1-2 days)
3. Excruciating back pain (leak present, blowout w/in minutes to hours)
160
What should be done for a patient with worsening claudication?
1. Do Doppler studies to establish pressure gradient (aka establish ankle brachial index)
2. if present do arteriogram to establish location of blockage
3. Surgery w/ Fem-pop-bypass or aorto bifemoral bypass or angioplasty
161
When should one intervene in claudication?
If symptoms worsen to negatively affect lifestyle, and don't improve w/ exercise and smoking cessation
162
What should be done for a patient with worsening claudication?
1. Do Doppler studies to establish pressure gradient (aka establish ankle brachial index)
2. if present do arteriogram to establish location of blockage
3. Surgery w/ Fem-pop-bypass or aorto bifemoral bypass or angioplasty
163
How do you treat arterial embolization of lower extremities?
1. Clot busters for incomplete occlusion
2. Embolectomy with fogarty catheter for complete obstruction
3. Fasciotomy if several hours have passed before revascularization (prevent compartment syndrome)
164
What are signs of arterial embolization to the extremities?
Pale, painful, cold, pulseless, paresthetic and paralytic extremity
Grossly irregular pulse --> A FIB
165
What interventions are necessary for dissecting aneurysms of the Aorta?
Descending aorta - medical therapy to decrease HTN (can't operate because of vertebral spinal artery branches)
Ascending Aorta - surgery
166
What test should be done in a patient with tearing chest pain with widened mediastinum on CXR?
Do spiral CT
167
What interventions are necessary for dissecting aneurysms of the Aorta?
Descending aorta - medical therapy to decrease HTN
Ascending Aorta - surgery
168
What type of excision should be done for squamous cell carcinoma?
Excision w/ 1-2 cm margins and sentinel biopsy of Lymph nodes
169
What determines the plan for treating melanoma and what are the various plans involved?
Depth of the lesion:
1. If 4mm (deep invasive) horrible prognosis
3. If 1-4mm - do aggressive treatment including wide local excision and sentinal lymph node biopsy
170
What are two abnormal properties of advanced melanoma?
Metastases to ANYWHERE in the body (liver, lung, brain, bone, duodenum, wall of LV)
No predictable time frame (problems immediately after excision, problems years after excision)
171
What should be considered if a white pupil is discovered in a baby? What should be done?
DDx = retinoblastoma vs. cataract
Aggressive treatment for Rb and treat cataract to prevent amblyopia
172
What are the signs and symptoms of orbital cellulitis?
Dilated and fixed pupil, tender red swollen eye
173
How do you treat chemical burns of the eye?
1. Immediate Massive irrigation for 30 minutes to 1 hr then go to ER
2. Thorough examination and debridement of the eye
174
What are the signs and symptoms of retinal detachment? And how can you determine degree of severity?
1. Flashes of light and floaters in the eye - low severity
| 2. Dozens of floaters, snow storm in the eye, big dark cloud at the top of visual field
175
How can you differentiate central retinal artery occlusion from a stroke? How do you manage RA occlusion?
Occlusion would NOT be associated with any neurological signs
Tx: give patient aspirin, have them breathe deeply into paper bag, press and release eyeball repeatedly
176
What are the signs and symptoms of retinal detachment? And how can you determine degree of severity?
1. Flashes of light and floaters in the eye - low severity
| 2. Dozens of floaters, snow storm in the eye, big dark cloud at the top of visual field
177
How can you differentiate central retinal artery occlusion from a stroke?
Occlusion would NOT be associated with any neurological signs
178
How can congenital neck masses be easily differentiated from other ENT masses?
Younger patients, who present when the mass gets infected
179
What locations do branchial cleft cysts present at?
In front of SCM, anywhere from tragus to base of neck
180
What is the med-late presentation for squamous cell carcinoma in the head and neck?
Old male w/ Hx of smoking and EtOH, who presents with large LN in the jugular chain of the neck (metastases from primary tumor in the H&N)
181
What are the contraindications to getting FNA for biopsy of a suspicious mass or LN?
1. Liver w/ suspicion for hemangioma (when patient takes breath, may reopen bleeding vessels)
2. Scrotal (testicular) mass, b/c most likely carcinoma, and will spread via needle tract
182
What does an enlarged, firm and movable supraclavicular lymph node suggest?
Metastases, from primary tumor below neck (intestine, pancreatic, renal cell carcinoma)
183
How should a head and neck mass suspicious for squamous cell carcinoma be investigated? What should not be done in this situation?
Do triple (or pan-) endoscopy - visualize mouth, pharynx, nasopharynx, larynx, trachea, to search for primary tumor and biopsy
Never do an open biopsy, as this will interfere with future resective surgeries
184
What is the presentation/appearance of a cystic hygroma?
Young pt who is asymptomatic with a mass present for many years (which potentially gets affected)
PLUS
supraclavicular area, with mushy texture
185
What is the best study to evaluate suspicion of a mass in head/neck?
MRI
186
How can you differentiate Bells Palsy from Tumor affecting CN VII?
With tumor there is as slow progressive paralysis of all of one side of the face (bells palsy, pt wakes up suddenly one morning w/ paralysis)
187
What is the nature of any tumor in front of the ear, behind ear, or around angle of mandible? What is the usual presentation for such a mass?
Parotid tumor until proven otherwise
Often pleomorphic adenoma -> no pain and no effect on facial nerve
188
What should always be considered in a pediatric patient presenting with a unilateral problem of the ear, nostril or other head/neck location?
Foreign body insertion
189
What is ludwig angina, and what is essential in treating this condition?
Abscess on the floor of the mouth
Major risk of aspiration during I&D of mass - may require intubation or even trach to secure airway
190
What is the preferred treatment for Bell's Palsy?
Antivirals and steroids
191
What should be done in a patient with severe facial trauma, who presents the next day with CN VII paralysis?
Nothing, just watch the patient
this is due to edema
192
What is in the differential diagnosis for epistaxis in 18 year old patient with no source of anterior bleeding? Treatment?
1. Septal perforation from cocaine abuse (posterior packing)
| 2. Posterior juvenile nasopharyneal angiofibroma (surgical removal)
193
What should be done for an elderly patient with a copious nose bleed and elevated blood pressure?
Epistaxis due to HTN
1. Control BP
2. Posterior packing
3. Endoscopic ligation
194
How do you work up a patient presenting with TIA?
Involves carotid artery therefore need duplex scanning (ultrasound) which will give info on stenosis and flow
195
How do you workup a patient presenting with TIAs that include posterior brain neurological symptoms?
1. Duplex scan of carotids
| 2. Aortic Arch study to evaluate all vessels feeding into the brain (vertebral arteries are affected)
196
How can you differentiate a vaso-occlusive stroke from a hemorrhagic one?
Headache, no pain in VO stroke, horrible headache and hx of HTN in hemorrhagic
197
A patient presents with progressive HAs over 4 months, worse in the morning. Recently she has projectile vomiting and optho exam reveals b/l papilledema. What should you do for her next?
Likely brain tumor:
1. MRI to visualize
2. High dose steroids - Decadron - to decrease edema that is causing increased ICP
198
What is the Cushing reflex and how do you treat it?
Bradycardia and severe HTN in response to increased ICP from brain tumor edema, in an attempt to keep perfusion pressure of brain normal (perfusion pressure = arterial pressure - ICP)
199
What is Foster-Kennedy syndrome?
Tumor at the base of the frontal lobe of the brain (causes anosmia, optic nerve atrophy and personality changes)
200
What should be ruled out in a patient with signs suspicious for prolactinoma? Treatment?
Do pregnancy test and check TSH!!!
Tx w/ bromocriptine (unless refractory or wants to get pregnant, then do surgery)
201
How do you diagnose acromegaly?
Determination of somatomedin C (IGF-1) and MRI of pituitary
202
What are the key patient history features of pituitary apoplexy? Immediate treatment?
Severe sudden HA w/ low BP, accompanies by months of progressive HA w/ decrease peripheral vision and amenorrhea
-Sudden bleeding into pituitary --> Give DECADRON
203
What is the key feature of Parinaud syndrome?
"Sunset eyes" or loss of upward gaze (often accompanied by projectile vomiting and progressive HA over months, indicative of pineal tumor)
204
What is the most common location of brain tumors in children?
Bellow tentorium in the posterior fossa
205
What is a characteristic physical positioning of a child w/ posterior fossa tumor?
On all 4's w/ head bent forward, done to decrease the elevated ICP caused by tumor compressing CSF outflow
206
How can you differentiate a brain abscess from a tumor? What should be done once identified?
Similar description of symptoms as with tumor, but over much shorter duration - develops over days to weeks following recent infection of Head/Neck
-Do CT scan followed by drainage
207
What is the most common tumor of the spinal cord, and how do you work it up?
Metastatic extradural, which can affect the pedicles of the vertebral bodies
Do MRI, consult spine surgeon
208
How can you differentiate the localization of herniated lumbar disk based on symptoms? How do you work-up and treat?
-If shooting electrical pain exits from big toe then L4-5, if pain exits little toe then L5-S1
-Do MRI
Tx: Rest and pain control, steroid block by anesthesia
209
What is autonomic disk reflexia? How do you treat?
-Occurs in paraplegics w/ high transection of SC
-Any visceral stimulation (e.g. full bladder) triggers increased alpha adrenergic stimulation causing HTN
Tx: Alpha 1 blockers immediately, and Ca Channel blockers long term
210
What should be done for patients presenting with signs of trigeminal neuralgia?
- Do MRI to r/o organic lesions
| - Carbamazepine, and surgery if that doesn't work
211
What is causalgia? How do you diagnose and treat?
-Reflex sympathetic dystrophy - constant burning agonizing pain several months after crush injury
Dx: Sympathetic nerve block
Tx: Surgical sympathectomy
212
How can you distinguish testicular torsion from acute epididymitis? What should be done for the latter?
Torsion presents with displaced testicle (high riding)
| AE has signs of infection (fever, chills etc.) --> Must do doppler study to rule out torsion
213
What must be done in a patient who is trying to pass a 3mm ureteral stone who develops fever and chills?
This patient has an infection superimposed upon an obstruction --> Must relieve the obstruction immediately, give IVF/Abx and place nephrostomy tubes
214
What should be done in a 30 yo female who p/w UTI and later develops flank pain, fever, chills, N/V?
This is UTI complicated by pyelonephritis. Pt must get IVF/Abx, UCx, AND Sonogram to rule out obstruction
215
Which patients need a urological workup (sonogram etc.)?
Peds w/ microhematuria, Young males who get UTIs and UTIs that are complicated by pyelonephritis --> these situations increase the likelihood for a ureteral obstruction, which needs to be ruled out ASAP
216
What are possible causes for inability to urinate within the first 24 hrs in newborn males? What should be done in this situation?
Meatal stenosis or posterior uretheral valves
For posterior valves do straight cath to drain bladder, urethrogram and endoscopic fulgration
217
What should not be done in hypospadias?
Circumcision, prepuce needed for reconstruction
218
How do you best diagnose and treat vesicoureteral reflux?
Dx: Do voiding cystogram to visualize ureters and bladder
Tx: Give immediate Abx if current infection and also for ppx, surgery if needed (but most likely child will "grow out" of the problem as the bladder gets bigger with age)
219
What is the best diagnostic study to do in a young male who went out for a night of drinking and developed severe flank pain, especially when trying to void?
Sonogram to look for Ureteropelvic obstruction
220
What is needed to diagnose renal cell carcinoma? What needs to be identified before surgery?
Dx: CT scan is sufficient
| -Watch for renal vein/IVC involvement of the tumor before operating
221
What is the difference between initial/terminal and total hematuria?
Total: Blood throughout urine stream, source is kidney ureter or bladder
Initial/Term: Source in bladder, prostate or urethra
222
What needs to be checked for in a patient with bladder Ca?
Tumor extending to upper urinary system (ureters/kidneys)
223
What needs to be done in patients who have partial resection for bladder carcinoma?
- Constant vigilant followup because of high rate of recurrence
- BCG injections into bladder
224
What can be done to treat a patient who presents with bone mets years after a radical prostatectomy for prostate cancer?
Tx: B/l orchiectomy OR medical tx:
1. LH releasing agonist (leuprolide)
2. Anti-androgen (flutamide)
225
At what age are PSAs no longer beneficial?
> or = 75 years old, because not much will be done for prostate masses after this point
226
What should be done for a patient who is found to have a testicular mass? What should not be done?
1. Make sure it is indeed testicular, not epididymal etc.
2. Radical orchiectomy via inguinal route (NEVER do biopsy or FNA, b/c all are malignant)
3. Measure AFPs and beta-hcg
4. Possible LN dissection and chemo/RT later on
227
What should be done for a patient who is found to have pulmonary metastases 2/2 testicular mass?
Same as w/ just primary -> do radical orchiectomy, and start PLATINUM based chemotherapy and radiation (teste tumors are highly sensitive to chemo/RT)
228
What are contraindications to shockwave therapy for ureteral stones?
- Pregnancy
- Bleeding diathesis
- Large stones (like staghorn calculous)
229
What fractures in Peds warrant more specialized care?
Supracondylar fx of humerus, fractures of any bone involving growth plate (angulation will improve better in Peds vs. adults)
230
What is the management of intertrochanteric fractures?
Open reduction and internal fixation with postop anticoagulation
231
What is the most common esophagotracheal abnormality?
Proximal esophageal atresia with distal TE fistula
232
What abnormality is observed in congenital vascular rings?
Segmental tracheal compression from aortic arches -> stridor and respiratory distress observed with crowing respiration
233
What should be done for a patient with extensive smoking and drinking history, found to have unilateral earache, serous otitis media, and induration on the pharynx?
Panendoscopy (triple endo) and biopsies, bc high risk patient
234
What are the most important medical therapies for reducing risk of stroke?
1. Reduce BP most important
2. Statin
3. Multi anti platelet therapy
4. Smoking cessation, weight loss, glucose control
235
What is the rule for treating penetrating urological injuries?
Surgical exploration
236
What should be done is suspecting a metastases to the spine/brain in someone with a history of breast cancer?
Go right to MRI
237
What would be found on cardiac cath/pcwp monitoring in someone with constrictive pericarditis?
Equalization of all pressures
