Principles and Canned Phrases Flashcards
Review "go to" phrases for different pathology types/workup principles, etc
Any trauma patient
Start with the principles of ACLS
initiating a complete primary/secondary including
CXR/PXR/FAST
2 large bore
Comprehensive set of labs to include type and screen
Ensure blood available
Warm patient
estrogen exposure
Menarchy (early menarch increases risk)
Parity (less parity increases risk)
Breast feeding (less breast feeding increases risk)
Menopause (late menopause increases risk)
Hormone replacement therapy (HRT increases risk)
GI Bleed
Ensure blood is available
Obtain 2 large bore IVs for access
Obtain comprehensive set of labs including coags and type and screen
NGT placement to asses the source of the GI bleed (bloody - UGI, bilious - LGI, nb/nb nondiagnostic)
Anoscopy to r/o bleeding hemorrhoids
good history of blood thinners/nsaid use
Ensure Cr is normal
obtain CTA
Once localized - scope to help localize further
Can consider CSP, CTA, Tagged RBC, Endoscopy to localize
Endoscopic options for bleeding management:
Endoscopic clips
Bands
Epi injection
Cautery - increased chance of perf; particularly in R colon
Laser coagulation
OR is only after you have exhausted endoscopic/radiographic measures to find a bleed and the patient is unstable or worsening
Hs and Ts
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia
Tension ptx
Toxins
Thrombosis coronary
Thrombosis pulmonary
Epi dosing during code
1mg every 3-5 minutes
When to use alternate meds apart from epi for cardiac arrest algorithm?
Which meds?
What dose?
Consider after 2+ shocks and 1 epi for VF/pVT
Amiodarone 300mg 1st dose then 150mg 2nd dose
Lidocaine 1mg/kg 1st dose then 0.5 mg/kg 2nd dose
Alternate with epi
What is the shock energy for defibrillation?
Biphasic:
1st: 120-200J
2nd and subsequent should be equivalent to first or higher
Monophasic:
360J
Breath ratio once advanced airway achieved in CPR
1 breath every 6 seconds
10/min with compressions
Biochemical workup for adrenal mass
CBC
CMP
1mg dexamethasone suppression test (<1.8 normal, > 5 positive - confirmatory 24hr urine if borderline)
ACTH (suppressed if adrenal source)
Plasma renin/aldosterone
Plasma metanephrines (confirmatory 24hr urine if borderline or positive)
DHEA sulfate (high with ACC)
Biochemical/workup for hyperparathyroidism
Ca (normal 8.6-10.4)
PTH (normal 10-65)
24hr urinary calcium (>300 is usual - secrete a lot of calcium in urine)
Vitamin D (normal 20 ng/mL+)
Cr
Bone density scan
US + sestamibi or 4DCT
Indications for surgery for hyperparathyroidism
Surgical indications = biochemical diagnosis plus any of these criteria:
CA >1mg/dl upper limit of normal
Bone mineral density by DXA, Z score < 2.5 ; vertebral fracture by imaging
Kidney stones
Cr Clearance < 60
24hr urinary calcium > 400
Kidney stones on imaging
Age < 50 years
Neuropsychiatric symptoms
Any cancer workup
History - systemic symptoms; personal/family history of malignancy
PE - examine lymph node basins
Name/diagnosis
Stage
Treatment
(Neo)adjuvant therapies
check margins after resection
Consider Multidisciplinary Tumor Board
Genetics?
CSP follow-up schedule
1-2 tubular adenomas <1cm in size - 5 years
3 or more adenomas - 3 years
advanced adenomas (>1cm, high grade dysplasia or villous elements) - 3 years
numerous adenomas or large sessile adenoma removed piecemeal - short interval based on clinical judgment
follow-up exam normal (patients with only hyperplastic polyps are generally considered to have a normal examination) 5 years
Questions for pancreatic NE tumor stem?
PDAC - smoking, cancer history
Non-functional - back pain, n/v, jaundice
Insulinoma - hypoglycemic symptoms that improve w/glucose
Gastrinoma - retractory GERD/PUD
VIPoma - diarrhea, hypokalemia, achlorhydria
Glucagonoma - wt loss, DM, diarrhea, VTE
Somatostatinoma - wt loss, DM, diarrhea, steattorhea
Workup for PNET
H&P
Biochemical workup:
CBC
BMP
NF - PP (panc polypeptide, NSE, Chromogranin A
F - associated peptide
Insulin, c-peptide
Gastric
VIP
Glucagon
Somatostatin
Multiphase CT A/P
EUS/FNA - not always necessary if <1cm
PET/Dotatate CT
Discuss at MDTB
Resect if >2cm, discuss if 1-2cm, watch if <1cm; resect anything functional
Melanoma Staging
Pre-op:
Mis or T1a (<.8, nonulcerated) - no routine labs or imaging necessary
T4b (>4mm, ulcerated) and clinical node negative (IIB) - CT C/A/P
+Nodes or in-transit lesions: Whole Body PET CT and MRI brain
Post-op:
CT C/A/P is reasonable for anything Stage IIB or greater (>T3b or >2mm and ulcerated or >4mm)
Brain MRI for symptoms
Whole Body PET CT for higher stages
Melanoma margins:
WLE:
MiS: 0.5cm margins
<1mm: 1.0cm margins
>1 <2mm : 1.0-2.0cm margins
>2mm: 2.0cm margins
When to perform TLND: (therapeutic lymph node dissection) in Melnaoma:
Palpable nodes which are biopsy proven melanoma
Disease recurrence
Nodal disease with unknown primary - cant find lesion, but melanoma is present
Melanoma/skin lesions history questions
HPI:
Skin lesion
ABCDE
Asymmetry
Borders (irregular)
Color (changes/dark pigmentation)
Diameter (>6mm)
Evolution (enlarging)
B symptoms
PSH: ? Prior resections ? Prior melanomas
FH: melanoma/other skin cancers, cancer syndromes
SH: sun exposures, smoking, tanning
Surgical Margins for cutaneous BCC, SCC
BCC - 3-4mm margins (5-10 for high risk)
SSC - 4-6mm margins (6-10 for high risk)
PDAC Workup/Staging
Workup/diagnosis:
H&P
Labs:
CBC
CMP
Lipase
CA 19-9
Imaging:
US if just jaundiced
Triple phase contrast CT A/P
EUS/FNA:
Tissue biopsy
Staging:
CT pancreas protocol (if not obtained already)
CT Chest
Diagnostic laparoscopy
Indications for adjuvant therapy after GIST resection
