random 1/16/17 Flashcards
umbilical hernia vs omphalocele vs gastroschisis
covered by skin
covered by peritoneum
not covered
umbilical hernia path pres dx tx
incomplete closure of ab muscles around umbilical ring at birth
assoc w premie, af am, hypothyroid, ehlers danlo, beckwith wiedeman syndrome
soft nontender bulge covered by Skin protruding during crying coughing straining etc, may have small intestines omentum etc
easily reducible usually, little risk of incarceration or strangulation
clinical dx
spontaneous reduction by concentric fibrosis and scarring if small usually
if large (^1.5cm) or other medical issues may not reduce - surgery around age 5 if persisting or earlier if problematic
gastroschisis
define
tx
evisceration of bowel with no covering membrane, red, right of umbilical cord
surgical emergency
omphalocele
define
tx
protrusion of abdominal contents at base of umbilicus, covered by peritoneum without skin
immediate surgical repair for survival
umbilical granuloma
pres
tx
usually after umbilical cord cut, soft moist pink pedunculated friable
silver nitrate
tf
surgery usually required for umbilical hernia
f
usually reduces via concentric fibrosis wo incarceration or strangulation
-surg if not closed about age 5 (higher risk if large ^1.5cm or other medical issues) or earlier if problematic
-surg for omphalocele, gastroschisis
-silver nitrate for umbilical granuloma
how to know if aortic arch is widened on cxr
obscures left pulmonary artery/hilum
blunt aortic injury
path
pres
dx
mva or fall from height 10+ feet
not very specific htn tachyc anxiety
cxr mediastinal widening, maybe r trach dev, left mainstem bronchus depression
ct angio if cxr and hx equivocal
tf
mediastinal widening w myocardial contusion
f
tachyc
maybe see rib fractures
most common cxr finding after blunt chest injury
hemorrhagic lung opacities from pulmonary contusion
traumatic diaphragmatic rupture on cxr
herniation of abdominal contents into thorax
tf
any patient w blunt deceleration trauma (mva, fall 10 plus feet) gets cxr
t
mus ro aortic injury
anterior bursae of knee
- suprapatellar bursa between quad tendon and distal femur, continuous w joint capsule
- prepatellar bursa subcutaneously
- deep infrapatellar bursa between patellar tendon amd proximal tibia
- subcutaneous infrapatellar bursa
define bursa
synovial sac to alleviate friction at bony prominences and ligamentous attachments
pain w rom w inflamed bursa
active rom often painful
passive rom often not, less pressure on bursa
prepatellar bursitis aka
housemaid’s knee
pres
dx
tx
acute prepatellar bursitis
acute pain and tenderness anterieor knee in kneeling job
aspirate for cell count and gram stain (also crystals but less common) (acute prepatellar bursitis often infectious, staph aureus, from penetrating trauma, repeat friction, or extension of local cellulitis… other bursites usually not infectious…)
if cx positive drain and systemic abx
if cx neg activity mod, nsaids
patellar fx
path
pres
direct blow or sudden force under load (fall from height)
pain swelling tenderness inability to extend knee
patellofemoral pain gender preference
female
more valgus, maltracking
extra axial well-circumscribed or round enhancing dural-based mass on brain mri think...
meningioma
may also calcify and appear hyperdense on non-con ct
meningioma path pres dx tx
benign primary tumor of meningiothelial cells
middleage elderly woman
if large enough for mass eddect - headache, focal weakness numbness, seizure
extra axial
well-circumscribed or round, enhancing, dural-based, mass on brain mri (may also calcify and appear hyperdense on noncon head ct)
confirm intraoperatively (surg resection for symptomatic pts)
when to consider chemo for brain cancer
combo w resection amd radiation for highly malignant brain tumors (glioblastoma multiforme, medulloastoma…) or highly sensitive mets (eg testicular germ cell tumor..)
when to consider ct cap for brain cancer
when visceral primary suspected cause of brain mets (multiple ring-enhancing lesions at gray-white junction (intraaxial))
typical appearance of brain mets on… mri? ct?
multiple ring-enhancing lesions at gray-white junction (intraaxial)
multiple ring-enhancing lesions at gray-white junction (intraaxial)
think…
metastasis to brain
indication for whole brain radiation
widely metastatic brain disease
ddx for anterior mediastinal mass
4 Ts thymoma thyroid neoplasm teratoma (and other germ cell tumors) terrible lymphoma
serum hormone levels in germ cell tumors
seminoma - 1/3 have ele b-hcg but usually normal afp
non-seminoma (yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed) - ele afp, some ele b-hcg
anterior mediastinal mass
w elevated afp amd b-hcg
think…
non-seminoma germ cell tumor (yolk sac tumor, choriocarcinoma, embryonal carcinoma, mixed) - ele afp, some ele b-hcg
(seminoma - 1/3 have ele b-hcg but usually normal afp)
how long can surgery for femoral neck fracture be delayed to stabilize acute comorbid medical problems
72hrs
longer risks further medical complication and less likely return to previous functional status
the 2 lobes of the parotid gland are separated by…
the facial nerve
hoarseness can result from surgery on…
thyroid or parathyroid glands
if recurrent laryngeal branches of vagus injured
tic doloroux
distribution
etiology
2nd and 3rd trigeminal branches (V2 V3)
external compression of trigeminal probably
tongue palsy can be caused by surgery…
in the submandibular region
if hypoglossal XII injured
jaw assymmetry can result from unilateral injury to
V3 which innervates muscles of mastication
exits foramen ovale and follows deep course to mastication muscles, so deep dissection needed to injure
strabismus results from what nerve injury
lr6so4ao3
extraocular muscles
abducens trochlear occulomotor
winged scapula a complication of this surg…
axillary lymphadenectomy for breast cancer if long thoracic nerve injured
2 most important exam findings for compartment syndrome
pain w pasilsive stretch
paresthesias
(and swollen, tense, inc pressure)
are paresthesias an early or late compartment syndrome symptom?
early
from sensory nerve ischemia
tf dec sensation motor weakness paralysis dec distal pulses
are common findings in compartment syndrome
f
uncommon findings
pain out of proportion, pain w passive stretch, paresthesias, tense swelling
are earlier more common findings
causes of compartment syndrome
direct trauma
prolongued compression
reperfusion after ischemia
tf
compartment syndrome responds well to narcotics
f
tf
paresthesias count as neurologic deficit in context of compartment syndrome
f
paresthesias early from sensory nerve ischemia
but neurologic deficits (dec sensation, motor weakness) arise later
tf
pallor is required to dx compartment syndrome
f
uncommon, not required
what does pallor signify in compartment syndrome and is it required for diagnosis
arterial occlusion
not required, uncommon, late finding
tf most compartment syndrome pts have dec distal pulses
f
most intact pulses
uncommon
not required for dx
most critical prognostic factor for compartment syndrome amd what does it mean for disgnostic method
time to fasciotomy
so in high risk pt (eg limb revascularization) don’t wait to measure compartment pressures - go straight to fasciotomy
tf
elevation and ice recommended for compartment syndrome
f
for inflammation
just keep cs at level of torso
differentiate compartment syndrome from dvt
cs more acute, severe, paresthesias, pallor rare but pallor if vascular component
dvt more insidious onset, no neuro sx, red and hot because vein occluded
diverticulitis on ct
inflammatory soft tissue stranding and colonic wall thickening
proportion of uncomplicated vs complicated diverticulitis
75%
25%
manage uncomplicated diverticulitis
bowel rest
oral abx
observation
but for elderly immunosuppressed significant fever or leukocytosis or significant comorbidities - admit amd iv abx
define complicated diverticulitis
and manage
abscess
perf
obstruction
fistula
fluid collection v3cm iv abx and obs
w surg if sx worsen
fluid collection ^3cm ct guided percutaneous drainage, if sx not controlled in 5 days surgical drainage and debridement, sigmoid resection for fistulas perfs w peritonitis obstruction recurrent diverticulitis
define
initial
total
terminal hematuria
at start if void
throughout void
at end of void
ddx for terminal hematuria
lower collecting system (bladder, prostate)
- urothelial cancer
- cystitis (infection vs radiation)
- urolithiasis
- bph
- prostate cancer
6 indications for cystoscopy
- gross hematuria w no evidence of glomerular disease or infection
- microscopic hematuria w no ev kf glom dz or inf but inc risk of cancer (^40 male smoker…)
- recurrent uti
- obstructive sx w signs of stone or stricture
- irritative sx wo infection
- abnorm urine cytology or imaging
tf
clots in urine think glomerular
f
clots rare w glomerular (diff from casts)
an get clots w bleeding from ureters or bladder…
initial hematuria (at start of void) think…
urethritis or trauma (catheter)
total hematuria (throughout void) think…
upper collecting system (kidneys, ureters)
- renal mass
- glomerulonephritis
- urolithiasis
- polycystic kidney disease
- pyelonephritis
- urothelial cancer
- trauma
tf
urinary clots are typically seen in renal causes of hematuria
f
clots not the same as casts
can get clots w urethral or bladder cause of hematuria
chronic nsaids episodic post prandial epigastric pain followed by acute severe constant pain think... tx
perforated peptic ulcer
expect pneumoperitoneum on upright xr between liver diaphragm
ng suction ivf iv abx iv ppi definitive mgmt w urgent exploratory laparotomy
q waves on ecg indicate…
old mi
pneumoperitoneum on upright xr
next step is ct w oral con?
no
already thinking per from xr, no need to repeat dx w ct
indications for upper gi endoscopy
upper gi bleed (hematemesis, melena)
weeks after resolved perfed peptic ulcer to eval for cancer h pylori infection or healing
what does viscus refer to
an internal organ
singular of viscera
what causes the classic coloration of venous stasis dermatitis
erythrocyte extravisation thru post-capillary venules and hemosiderin deposition
pathogenesis of venous stasis dermatitis
venous valvular incompetence, venous htn, fluid protein blood extravisation thru postcapillary venules
inflammation fibrin deposition platelet aggregation
microvascular dz, ulceration
xerosis
define
dry skin
vocabulary of venous stasis signs and sc
xerosis (dry skin) early
lipodermatosclerosis (inflammation of subq fat
ulcers
late)
stasis dermatitis most commonly involved what specific part of the body
medial leg between knee and inferior maleolus
raynaud disease /phenomenon
path
feared complication
arterial spasm in response to cold or emotional stress causing discoloration amd discomfort of distal digits
distal gangrene if severe
limb complications of neurosyphilis
tabes dorsalis - posterior spinal cord lesion causing dec sensation and proprioception of lowe extremities - paresthesias and ataxia
rivaroxaban
apixaban
fondaparinux
moa’s
rivaroXaBAN
apiXaBAN
direct factor Xa inhibitors
fondaparinuX
indirect factor Xa inhibitor
argatroban
bivalirudin
dabigatran
moa’s
argaTroBAN
bivalirudin
dabigaTran (oral)
thrombin (factor II) inhibitors
preferred long term oral anticoagulant in end stage renal dz
and moa
warfarin
vit k antag
(factors II VII IX X, proteins C and S
what clotting factors does heparin inhibit
XII XI IX
VII
X
II
(all a)
duration of anticoagulation after provoked dvt by surger
likely 3 mos
when to bridge to warfarin w ufh vs lmwh
ufh if end stage renal (lmwh ci - renally excreted)
how to bridge heparin to warfarin
4-5 days till inr 2-3 (start warfarin usually evening same day as heparin)
aspirin’s role in dvt
none
it’s a platelet inhibitor, not involved w clotting cascade
when to start anticoagulation therapy postop in a hemodynamically stable pt
and does it inc risk of bleeding
48-72 hours
does not significantly inc risk of bleeding
why bridge ufh to warfarin - why not just keep heparin goimg
heparin is iv only
so want to get to oral warfarin for discharge
mechanism of diaphragmatic rupture in blunt trauma
special presentation in kids
high intraabdominal pressures
or avulsion
-left more common because left posterolat diaphragm congenitally weak and lover protects right
some pts, kods especially, may have no s or s initially but delayed presentation mos yrs later w expansion of defect and herniation risk strangulation and high risk death
looks like diaphragm hernia on cxr, next diagnostic step?
ct to confirm
diaphragmatic hernia on cxr
left lower lung opacity
(usually left because weaker there and liver protects right)
left elevated hemidiaphragm
mediastinal shift right
what about severe burns provides good substrate for infection
avascular
immunilogically poor
protein-rich
bugs in burns
staph a (g+) immidiately, from sweat glands and hair follicles
pseudomonas and candida (g- and fungi) 5 days out
systemic signs of burn wound sepsis
temp v36.5 (97.7)
^39. (102.2)
progressive tachyc ^90
progressive tachyp ^30
refractory hypot sbp v90s and s of burn wound sepsis
oliguria, unexplained hyperglycemia, thrombocytopenia, ams
temp v36.5 (97.7)
^39. (102.2)
progressive tachyc ^90
progressive tachyp ^30
refractory hypot sbp v90
burn wound sepsis pres dx expected bugs tx
large area (^20% bsa high risk)
wound changing for worse eg getting deeper or failing skin graft
oliguria, hyperglycemia, thrombocytopenia, ams
t v36.5 97.7 ^39 102.2, tachyc tachyp hypot
wound cx ^10^5/g tissue
bx for histopath depth
staph a from sweat glands and follicles immediately
5 days out pseudomonas candida
broad abx piptazo carbapenem
vanc maybe for mrsa
aminoglycoside maybe for mdr pseudo
local wound care and debridement
tf
CO exposure can cause a delayed neuropsych syndrome / ams
t
sometimes it can
temp inc w drastic metabolic rate inc eg w large burn
up to 38.5 101.3
typically first signs of burn wound infection
change in appearance (getting deeper, necrotic)
failed skin graft
pts of primary vs secondary pmeumothorax
prim - thin young men no hx
sec - copders / lung dz
s and s
tension pneumo vs spontaneous pneumo
hemodynamic instability and trachial deviation away
in addition to usual cp sob dec chest wall movement hyperresonance
tf
spontaneous pneumothorax most often occurs at rest
t
spontaneous rupture of subpleural blebs
(thin male in 20’s, marfan, smoker, thoracic endometriosis… all risks)
manage small primary spontaneous pneumothorax in medically stable pt
obs
and supplemental o2 (speeds resorption of pneumo… how..?)
manage primary spontaneous pneumothorax
- obs and supplemental o2 to speed resorption if small pneumo clinically stable
- large bore needle (14 or 18 gage) decompression via 2nd or 3rd mid-axillary intercostal (sup border of rib) or 5th intercostal mid or ant axillary if large pneumo clinically stable
- emergent tube thoracostomy if possible otherwise needle decompression if hemodynamically unstable
when to get cct after cxr for suspected pneumothorax
don’t usually
can if dx uncertain
or loculated pneumo suspected
or thoracostomy concern
when to consider VATS for pneumothorax
video assisted thorascopic surgery
for failure to reexpand ^90%
or recurrence
can patch or pleurodese
how might recent fever and sore throat in young athlete predispose to splenic laceration
could have been mono
splenomegaly
higher risk of laceration with blunt abdominal trauma
epidermal hematoma typically from trauma to this bone
sphenoid
(mma)
middle meningeal artery
epidural hematoma most common in what age group
children and adolescents
from trauma
level of the diaphragm
up to 4th (nipple) thoracic dermatome on right and 5th (just below pec) on left w expiration
down to 12th thoracic dermatome w inspiration (posteriorly?)
must consider both chest and abdominal trauma w gunshot wound at what level
anywhere nipples or below (t4 dermatome or lower) - diaphragm can get up there with expiration
possible abdominal trauama after gunshot wound, pt hemodynamically unstable, best procedural next step?
what if stable?
fast focused assessment w sonography for trauma
(for hemoperitonium, peritoneal effusion, pericardial effusion)
if pos
exploratory laparotomy for any gsw hemodynamically unstable, peritonitis, or organ evisceration
if equivocal
dpl diagnostic peritoneal lavage
if neg
look for other reasons for hemorrhage - pelvic… long bone fx… - and stabilize
-ct when stable
if stable w neg us or diagnostic peritoneal lavage, ct to determine need for exploratory laparotomy
dpl diagnostic peritoneal lavage done in hemodynamically ____ pts w ____ abdominal trauma w inconclusive ____
unstable
blunt abdominal trauma
inconclusive fast focused assessment w sonography for trauma
reverse warfarin for emergent laparotmomy
ffp
vit k not fast enough… relies on synth of new vit k dependent clotting factors ii vii ix x by liver
treat acute bowel perf from afib thrown clot infarct perf
ng tube decompression ivf iv abx ffp to reverse warfarin emergency laparotomy
tf
preop transfusion is often required for pt w chronic anemia
f
usually not
generally, tissue oxygen delivery not deficient till hb v7
consider risk factors for ischemia and anticipated operative blood loss
when is desmopressin ddavp given preoperatively
pt had hemophilia a
(ddavp indirectly inc factor viii by releasing vwf from endothelial cells
penile fracture is a fx of the…
corpus cabernosum
w tear in tunica albuginea which envelopes it
detumescence
subsiding of swelling, tension, or sexual arousal
presentation of penile fracture
audible snap when erect
detumescence
pain ranging w severity of fx
hematoma bends shaft
manage penile fracture
emergent urologic surgery
too many complications with medical mgmt… erectile dysfunction, painful erections, etc
when to get retrograde urethrogram for penile fracture
urethral injury suspected
blood at meatus, hematuria, dysuria, urinary retention
normal serum calcium
8.4-10.2
normal serum phosphorus
3.0-4.5
describe neuromuscular irritability from hypocalcemia
perioral tingling and numbness muscle cramps tetany carpopedal spasms seizures qt prolongation
which is symptomatically worse, acute or chronic hypocalcemia
acute
can be very symptomatic even with small decrease if fast enough
chronic may be asymptomatic at a quite low number
causes of primary hypoparathyroidism
post surgical autoimmune congenital (digeorge eg) defective ca receptors on pt gland infiltrative dz eg hemochromatosis wilson's neck irradiation
what is subtotal parathyroidectomy moat commonly done for
eg removal of 3.5/4 parathyroid glands for parathyroid hyperplasia
3 drugs that cause vitamin D deficiency
phenytoin
carbamazepine
rifampin
by inducing cytp450 in liver, breaking vit d into imactive metabolites
kidney function in vit d metab
1a-hydroxylase converts 25hydroxy to 1,25dihydroxyvitamin d
ca resorb
phos excrete
failure gives hypocalcemia hyperphosphatemia and seconday hyperparathyroidism
Treat AFib after CABG
BB or Amio
Usually resolves v24 hours
If persists, then start thinking about cardioversion and anticoagulation
Eval bunt genitouronary trauma
UA – for hematuria basically
CT AP if hemodynamically stable
IV Pyelogram before Surgery if hemodynamically unstable
