Rosh Material #1 Flashcards
types of thyroid cancers mc to lc and their most significant rf
-papillary -> head/neck xrt
-follicular -> iodine deficiency
-medullary -> MEN2 (medullary thyroid ca, hyperparathyroid, pheocromocytoma)
-anaplastic -> presents w. dyshpagia/hoarseness
tx for AAA based on size
4.0-4.9 cm: annual US
5.0-5.4 cm: US q 6 mos
>5.5 cm or rapid expansion: elective surgery
what is ogilvie syndrome
massive dilation of the colon w.o mechanical obstruction
ogilvie syndrome is due to _ dysfxn
autonomic
3 rf for ogilvie syndrome
older age
bedbound
comorbidities
epidural anesthetics
meds
4 meds associated w. ogilvie syndrome
anticholinergics
antipsychotics
dopaminergics
opioids
supportive care can be used for ogilvie syndrome if the cecal diameter is < _
12 cm
supportive care for ogilvie syndrome
colonic decompression
neostigmine
due to opioids: methylnaltrexone
gs imaging for ogilvie syndrome
CT
major risk of anal fissure surgery
irreversible fecal incontinence
2 common indications for 1/2 NS
hypernatremia
DKA
2 s.e of 1/2 NS
fluid overload
pulmonary edema
most appropriate IVF for pre op pt who is NPO
LR
what are the vit K clotting factors
II
VII
IX
X
management of warfarin based on INR
-greater than goal, but < 5: skip next dose
-5-10, no bleeding risk: skip next 1-2 doses
->10, no bleeding or mod risk of bleeding: hold warfarin, give vit K
-> 10, serious bleeding or high risk for bleed: hold warfarin, give vit K and 4 factor prothrombin complex
-life threatening bleed: hold warfarin, give ffp and IV vit K
4 meds that cause pseudotumor cerebri
vit A derivatives
OCPs
steroids
tetracyclines
tx for pseudotumor cerebri
low Na diet
wt loss
acetazolamide
optic n sheath fenestration
shunt
dx for pseudotumor cerebri (2)
MRI w. venography
LP
how is hydrostatic reduction performed for intussusception (2)
barium enema
pneumatic reduction
best test for h. pylori if a pt has an actively bleeding ulcer, a recent ppi, or recent abx use (2)
stool antigen
vs
urea breath
best h. pylori testing if the pt is undergoing endoscopy, has a bleeding ulcer, or has recent ppi or abx use
biopsy urease during the procedure
slow growing neuroendocrine ca that arises from enterochromaffin cells of the digestive tract - commonly arise from SI, bronchus/lung, rectum
carcinoid tumor
5 sx of carcinoid tumor
diarrhea
flushing
wheezing
hemodynamic instability
metabolic acidosis
24 hr urine collection findings of carcinoid tumor
elevated 5-HIAA (5 hydroxyindoleacetic acid)
tumor marker for carcinoid tumor
chromogranin A
when performing excisional or shave bx of a suspected melanoma a _ margin should be maintained to minimize skin loss and reduce risk for missed dx
2 mm
when would you order ionized Ca if you suspect hyperparathyroidism
if Ca is normal
if it is high, then order PTH
gs dx for peripheral lung lesion
open lung bx
order of imaging for wilms tumor
- US - initial
- CT vs MRI
- bx - definitive
what is this showing
mediastinal air -> boerhaave syndrome
what is boerhaave syndrome
spontaneous perforation of the esophagus from sudden increase in intraesophageal pressure -
ex sudden onset of coughing/forceful vomiting
boerhaave syndrome mc involves the
left posterolateral aspect of the distal intrathoracic esophagus
hallmark PE finding of boerhaave syndrome
hamman crunch -> mediastinal crackling w each heartbeat
gs dx for boerhaave syndrome
esophagram w. water-soluble contrast
tx for boerhaave syndrome
emergent surgical consult
broad spectrum abx
what meds decrease mortality in STEMIs
-ASA
-P2Y12 receptor blockers (tigagrelor/prasugrel)
not clopidogrel
only tx for adrenocortical carcinoma
surgery
management of breast pain based on age
< 30: US of painful breast
30-39: US PLUS focused or bilat mammogram
>40: US PLUS bilat mammogram
tx for SAH
nimodipine (decreases vasospasm)
79 yo F w. hx htn and hypercholesterolemia - month long hx of worsening, dull, aching, generalized abd pain that lasts 30 mins and is worse after eating - she is avoiding eating and has lost 8 lb x 3 weeks
chronic mesenteric ischemia
2 types of necrotizing fasciitis
- polymicrobial - aerobic and anaerobic
- GAS
tx for necrotizing fasciitis
surgical debridement
abx
mc form of intestinal ischemia
ischemic colitis
2 mc locations for ischemic colitis
splenic flexure
rectosigmoid junction
ischemic colitis is caused by a
global low flow state:
CHF
MI
sepsis
hemorrhage
(unlike embolic w. mesenteric ischemia)
3 HPI clues for ischemic colitis
atherosclerotic dz
aortoiliac surgery
cardiopulmonary bypass
tx for ischemic colitis
supportive
what is paget-schroetter syndrome
primary upper DVT
5 hpi clues for paget-schroetter syndrome
-muscular
-repetitive overarm hyperabduction/external rotation
-strenuous activity
-central line placement
-hypercoagulable state
paget-schroetter syndrome is caused by
compressive anomaly at the thoracic outlet
tx for paget-schroetter syndrome
NSAIDs
alteplase
heparin
venoplasty
compression stockings
which type of adenomatous polyps have the greatest risk of malignancy
villous
PLT transfusion thresholds for pt’s w. thrombocytopenia
CNS/ocular bleeding: <100,000
active bleeding: < 50,000
nonbleeding: < 10,000
direct visualization tests for colon ca screening and frequency they need to be performed
colonoscopy: q 10 yr
CT colonography: q 5 yr
flexible sigmoidoscopy: q 5 yr
flexible sigmoidoscopy PLUS FIT annually: 1 10 yr
what are the 3 accepted stool based tests for colorectal ca screening and frequency they need to be performed
gFOBT: annually
FIT: annually
FIT-DNA: q 1-3 yr
what is this showing
drug induced exanthem
what is this showing
uticaria
what is this showing
cuataneous small vessel vasculitis
what is thsi showing
exfoliative dermatitis: chronic erythema/scale involving > 90% of the body surface
what is this showing
SJS
what is this showing
erythema multiforme
what is this showing
erythematous/edematous plaques w. grayish center or frank bullae -> fixed drug rxn
tx for drug induced exanthems
topical tiramcinolone
PO hydroxyzine
most aggressive type of breast ca
triple negative
what is this showing
achalasia: loss of inhibitory neurons in the distal 2/3 of the esophagus -> absent peristalsis and increased tone in the LES
4 sx of achalasia
dysphagia to liquids and solids
CP
weight loss
regurgitation
dx for achalasia: initial vs gs
initial: EGD
gs: esophageal manometry
tx for achalasia (3)
graded pneumatic dilation
esophageal botulism
surgical myotomy
types of dysphagia and associated conditions
odynophagia: infectious esophagitis
progressive: stricture/ring/web/tumor
intermittent: eosinophilic esophagitis
liquid: dysmotility (infective vs achalasia)
halitosis/regurgitation of undigested food: zenker
abrupt onset: pill or chemical esophagitis
chest discomfort precipitated by activity
sx abate after activity
stable angina
ischemic sx suggestive of acute coronary syndrome
+/- ECG changes indicative of ischemia
unstable angina
troponin elevation
subendocardial ischemia
ECG w. ST depressions
NSTEMI
troponin elevation
transmural ischemia
ECG w. ST elevation
STEMI
what is this showing
diffuse increased iodine uptake in both thyroid lobes -> graves dz
what is this showing
normal thyroid
what is this showing
toxic multinodular goiter -> plummer dz
what is this showing
toxic adenoma
what is this showing
thyroiditis
management of thyroid nodules
benign: monitor q 12 mos
intermediate nodules: repeat FNA, molecular testing, diagnostic lobectomy
suspicious nodules: surgery
what is this showing
aortic dissection
abi < 0.9 indicates:
abi < 0.4 indicates
< 0.9 = > 50% stenosis
< 0.4 - ischemia
order of dx studies for PAD
- resting ABI
- toe-brachial
- exercise ABI (if dx unsure)
tx of hypoglycemia in diabetic pt’s based on BG
asymptomatic w. BG </= 70: repeat test, avoid driving, eat CHO, adjust meds
symptomatic: fast acting CHO (tabs/juice), followed by long acting CHO
severe/unconcious: glucagon, IV dex
3endoscopic features of a peptic ulcer suggestive of malignancy
-ulcerated mass protruding into lumen
-nodular/clubbed/fused folds surrounding ulcer
-overhanging, irregular, or thickened margins
mc type of gastric ca
adenocarcinoma
tx for toxic megacolon
subtotal colectomy w.end ileostomy
what is boas sign
hyperaesthesia, increased or altered sensitivy below the right scapula -> cholecystitis
what type of cholecystitis occurs in critically ill pt’s
acalculous
gs dx for cholecystitis
HIDA (cholescintigraphy)
pharm management of esophageal varices (3)
ocretotide -> decreases bleeding
vasopressin -> reduces portal pressure
bb -> secondary bleeding prophylaxis (not for acute)
endoscopic management of esophageal varices
banding ligation - preferred
sclerotherapy - high rate of rebleeding
downsides of balloon tamponade for esophageal varices
only temporary
many complications: aspiration death, perforation
pt needs to be intubated
indications for TIPS for esophageal varices
refractory
rebleeding
surgery for esophageal varices
PCS (esophageal transection or portacaval shunt)
2 abx for esophgeal varices
ceftriaxone
norfloxacin
order of tx for esophageal varices
- endoscopic band ligation vs sclerotherapy
- balloon tamponade (if endoscopic fails)
tx for cdiff
vanco vs fidaxomicin
what is this showing
corkscrew esophagus -> esophageal spasm
impairment of inhibitory innervation to the esophagus -> leads to both premature and rapidly prolonged or simultaneous contractions in the distal esophagus
esophageal spasm
dx for esophageal sapsm
esophageal manometry
tx for esophageal spasm
ccb
tca
isodorbide-sildenafil
botulinum
first line surgical tx for achalasia
laparascopic heller myotomy
what is this showing
apple core lesion -> colorectal ca
what is this showing
bcc
basophilic staining cells with peripheral palisading nuclei
bcc
grades of hepatic encephalopathy
I: disordered sleep, dpn, irritability, mild cognitive dysfxn
II: lethargy, confusion, personality changes, disorientation, asterixis
III: somnolence, confusion, inability to follow commands, disorientation
IV: coma
tx for hepatic encephalopathy
lacutlose
rifamixin
_ correlates w. severeity of hepatic encepalopathy
CSF glutamine
t/f: atelectasis is mc asymptomatic unless the pt develops hypoxemia or pna
2 types of choledocholithiasis
primary: stone originates in cbd
secondary: stone originates in gallbladder -> cbd
types of stone mc found in primary vs secondary choledocholithiasis
primary: pigmented (brown)
secondary: cholesterol vs mixed
what is this showing
u-shaped bent inner tube -> sigmoid volvulus
4 rf for sigmoid volvulus
ltc pt’s
advanced age
bedridden
chronic constipation
tx for sigmoid volvulus
flexible sigmoidoscopy -> reduces volvulus
surgery -> prevents recurrence
management of asthma patients pre op
SABA vs nebulizer 30 min prior to surgery if intubation is needed
what is this showing
pyloric stenosis
duodenum w. a corkscrew appearance
volvulus
whirlpool sign noted w. craniocaudal movement of US transducer
volvulus
string sign
pyloric stenosis
breast bx options
core needle -> preferred initiallyl
FNA -> intraprocedural
surgical
skin punch -> consider for paget’s/inflammatory
6 rf for incisional hernia
old age
obesity
smoking
malnutrition
immunosuppressive therapy
connective tissue d.o
imaging for aortic dissection
hemodynamically unstable: TEE
hemodynamically stable: CTA vs MRA
mc location from which hemorrhoids arise
superior hemorrhoidal cushion
mcc of larg bowel obstruction: benign vs non-benign
benign: volvulus
non-benign: colorectal ca
mc location for large bowel obstruction
sigmoid colon
clotting labs associated w. DIC
elevated: PT, PTT, thrombin clotting time, fibrin split products
low: PLT, fibrinogen
post prandial pain w. duodenal ulcers occurs _ after eating food
2-5 hr
location of PAD based on pain
calf -> distal superficial femoral a
behind knee, into calf -> popliteal a
thigh/lower leg -> deep femoral a (uncommon)
thigh/buttocks -> common iliac a
irregular erythematous plaque w. a hemorrhagic crust
scc
2 mc indications for preop dialysis
hyperkalemia
fluid overload
what is this showing
aortic dissection
sx of type A vs type B aortic dissection
type A: chest pain radiating to the back, syncope
type B: HTN
order of managemetn for aortic dissection
- bb - labetalol vs esmolol
- nitroprusside for further bp control
- morphine
- type A: emergent surgery
indication for surgery for type B aortic dissection
end organ damage
htn refractory to meds
what surgery is preferred for type B aortic dissection
thoracic stent graft repair
mc presentation of an obturator hernia
female 70-90 yo
SBO
what PE sign is associated w. obturator hernias
howship-romberg: pain extends down the medial aspect of the thigh w. movement of the knee
3 sites for central line access based on risk of infxn: low to high
subclavian
interna jugular
femoral
which presentation is chronic GERD mc associated w. in terms of metaplasia
columnar metaplasia of the squamous epithelium
where do adenocarcinomas of the esophagus mc occur
distal 1/3 of the esophagus near the gastroesophageal junction
where does squamous cell carcinoma of the esophagus occur
proximal 2/3 of the esophagus
2 mc rf for adenocarcinoma of the esophagus
barrett esophagus
obesity
2 mc rf for squamous cell carcinoma of the esophagus
chronic etoh
tobacco
cobblestoning
skip lesions
transmural inflammation
crohn dz
what is the recommended minimum pre op PLT count based on procedure
-transfuse if <10,000: hematologic malignancies, allogenic hematopoietic cell transplant, solid tumors
-transfuse if < 40,000-50,000: major procedures
-transfuse if <20,000: bone marrow aspirate, insertion/removal of a central line
normal ALP/ALT/AST with jaundice
gilbert syndrome
crigler-najjar syndrome
elevated ALP elevation greater than ALT/AST elevation
intrahepatic cholestasis
biliary obstruction
eleavted GGT and ALP
cholestasis
5 causes of AST elevation
etoh
APAP
NSAIDs
ACEI
abx
AST:ALT > 2
etoh hepatitis
AST: ALT < 1
hepatocellular necrosis
causes of ALP elevation
hepatocellular dz
cholestatic dz
may be normal in healthy kids and pregnant
causes of elevated GGT
etoh
phenobarbital
warfarin
