Specialty SUrgery Flashcards
pt exercises arm and gets coldness, tingling, muscle pain, as well as visual problems and difficulty balancing
subclavian steal syndrome. arteriosclerotic plaque at origin of the subclavian before the takeoff of the vertebral. allows enough blood to go to arm for normal activity but not with higher demands of exercise- then arm sucks blood away from brain by reversing blood flow in the vertebral. dx: duplex shows reversal of flow. tx: bypass surgery cures it.
when to do surg for AAA
5cm, or rapidly growing (1cm/year): surg
what is surg for AAA. outcome?
endovascular stent inserted percutaneously. 10 year outcome is encouraging is case is enraptured and neck is at least 2.5cm
tender AAA next steps
rupture within a day or two. immediate repair!
excruciating back pain in pt w/AAA next steps
aneurysm is leaking, retroperitoneal hematoma forming, blowout into peritoneal cavity a few minutes away. emergency surg!
pt has leg pain with walking that is relieved with rest. not THAT disruptive to life. next steps?
stop smoking and exercise! watch and wait. cilostazil for long term. surgery only done to relieve disabling sxs or to save extremity from impending necrosis.
workup for disabling intermittent claudication
doppler studies to look for pressure gradient. if none, dz is in small vessels and not amenable to surgery. if gradient, CT angio or MRI angio to identify good distal vessels to which a graft can be hooked
how to treat disabling intermittent claudication with a pressure gradient on doppler
short stenotic segments can be treated with angioplasty and stunting. more extensive disease may need bypass grafts, sequential stents, or longer stents. proximal lesions are repaired before distal lesions
how to do bypass grafts in various parts of body
grafts originating near aorta (aortabifemoral) are done with prosthetic material. bypasses between more distal vessels (femoropopliteal or beyond) are done with saphenous vein grafts
pt cannot sleep bc he has pain in calf. dangling the leg helps the pain, and it makes his pain leg deep purple.
rest pain is penultimate stage of the disease before ulceration and gangrene. physical exam shows shint atrophic skin without hair and no peripheral pulses. workup is doppler, and therapy is surgery is pressure gradient seen.
pt w/atrial fibrilliation or recent MI suddenly develops painful, pale, cold, pulseless, parasthetic and paralytic LE
arterial embolization from a distant source. dx and tx within 6 hours! doppler studies will show point of obstruction. early incomplete occlusion can be treated with clot busters. complete occlusion: embolectomy with fogarty cather
5 Ps of arterial embolization
poikilothermic (cold), painful, pale, pulseless, paresthetic, paralytic
pt with 5Ps and doppler that shows complete occlusion for several hours
fogarty cather and add fasciotomy if several hours have passed before revascularization
pootly controlled hypertensive gets sudden onset severe tearing chest pain that radiates to the back ad migrates down shortly after onset. unequal pulses.
rule out MI with EKG and cardiac enzymes. X-ray shows widened mediastinum. dissecting aneurysm of the thoracic aorta! tx: noninvasive- try to avoid high pressure injection needed for aortogram. spiral CT scan. consider MRI angiogram and TEE.
dissections of ascending vs descending aorta tx
ascending: surgery. descening: medical tx with control of HTN in ICU
how to dx cancer of the skin
full thickness (punch) biopsy at the edge of the lesion, including normal skin
mc types of skin cancer
BCC is 50%, SCC is 25%, melanoma is 15%
raised waxy lesion or non healing ulcer on upper part of face. next steps? mets? tx?
basal cell carcinoma! does not metastasize but kills by relentless local invasion. tx: local excision with negative margins (1mm) but other lesions may develop later
nonhealing ulcer on lower lip. mets? tx?
squamous cell carcinoma. can metastasize to LN. tx: excision with wider margins needed (0..5-2cm). node dissection is done if involved. or radiation therapy.
pigmented lesions with ABCD (.5cm diameter). dx?prognosis?
bx should give dx and depth of invasion. 4mm: terrible prognosis. 1-4mm: aggressive therapy including node dissection. also excision with wider margins (2-3 cm)
malignant melanoma. mets? tx?
usual places: LN, liver, lung, brain, bone. also weird places like LV muscle, duodenum etc. no predictable timeline. tx: interferon adjuvantly
6 year old has strabismus (eyes don’t look in same direction). concern?
amblyopia= vision impairment resulting from interference of processing of images by the brain during first 6-7 years of life. faced with two overlapping images, the brain suppresses one of them. concern for permanent cortical blindness in suppressed eye.
child has eyes that look in different directions. next steps?
verify strabismus by showing that reflection from a light comes from different areas of the cornea in each eye.
strabismus treatment?
true strabismus needs surgical correction to prevent amblyopia. if strabismus develops later in infancy, the problem is exaggerated convergence caused by refraction difficulties and give corrective glasses.
white pupil in a baby
emergency! may be retinoblastoma. also could be congenital cataract. that should be treated to prevent amblyopia.
Pt with severe eye pain or frontal headache in the evening (eyes have been dilated for a while) and sees halos. Phys exam: pupil is mid dilated and does not react to light, cornea is cloudy with greenish hue, eye is hard as rock.
Acute angle glaucoma. Emergency! Ophthalmologists will drill hole into iris with a laser into iris to provide drainage route for fluid trapped in the anterior chamber. While waiting, give systemic carbonic anhydrase (diamox). Topical BB and alpha 2 selective adrenergic agonists. Can also use mannitol and pilocarpine.
Pt has eyelids that are hot tender red swollen and pt is febrile. When eyelid pried open, pupil is dilated and fixed, and eye has limited motion
Orbital cellulitis. Emergency! There is pus in orbit. Do emergency CT scan and drainage.
Chemical burn of eye. Next steps?
Massive irrigation with plain water for 30 min, then go to ER. Continue irrigation, remove particles, test PH. Alkaline is worse.
Pt reports seeing flashes of light and having floaters in eye
Retinal detachment. Number of floaters is correlated to degree of problem. Tx: emergency intervention with laser spot welding to protect remaining retina
Elderly pt describes loss of vision from one eye. Dx? Next steps?
Embolization occlusion of retinal artery. 30 minutes-> irreversible damage. Pt should breathe into paper bag and have someone press hard and eye and release while he is in transit to vasodilator and shake clot into more distal area
1-2cm Midline neck mass at level of hyoid bone that retracts when pull tongue.
Thyroglobulin duct cyst. Tx: surgical removal of cyst, middle part hyoid bone, track that leads to base of tongue. May consider ascertain the location of normal thyroid first by radio nucleotide scan
Several cm cyst along anterior edge of sternocleidomastoid. May have little opening and blind tract in skin overlying them. What is it?
Branchial cleft cyst
Large mushy ill defined mass in supra clavicular area that seems to extend deeper into the chest (may extend into mediastinum)
Cystic hygroma. CT scan. Then surgical removal.
Months of persistent enlarged LN
Could be inflammatory but neoplasia has to be ruled out.
Young person with multiple enlarged nodes and has been suffering from low grade fever and night sweats. Next steps? Dx?
Suspect lymphoma. Remove node for pathological study. FNA can also be done. Chemo is usual treatment.
Metastatic tumor to supra clavicular node. Likely source? Next step?
Always from below clavicles.busually from lung or intrabdominal tumor. Remove node for dx.
Old HIV+ man who drinks and smokes with rotten teeth has a met node in neck. Also has persistent hoarseness, persistent painless ulcer in floor of mouth, persistent unilateral earache. Dx? Next steps? TX?
SCC of mucosae. Do triple endoscopy. Bx for diagnosis and CT scan for extent. FNA but NOT open bx bc that will interfere with surgical approach. Tx: resection, radiotherapy and platinum based chemo.
Adult with sensory hearing loss in one ear but not the other. Next step?
Acoustic nerve neuroma. Do MRI.
Pt has gradual unilateral facial nerve paralysis affecting both forehead and lower face. What if it were sudden? Dx modality?
Gradual: facial nerve neuroma. Sudden: Bell’s palsy. Do gadolinium enhanced MRI
Mass near ear at angle of the mandible. Painless? Painful and hard with facial nerve paralysis?Next steps?
Painless: pleiomorphic parotid adenoma. Painful and hard with facial nerve paralysis: parotid cancer. FNA but NOT OPEN BX.
Treatment for parotid cancer
Formal superficial parotidectomy to excise and bx parotid tumor, preventing recurrence and soaring facial nerve. Encyleation alone leads to recurrence. In malignant tumors, the nerve is sacrificed and a graft is done
2 year old with unilateral headache, unilateral rhinorrhea, or unilateral wheezing. Cause? Next steps?
Kid stuck a toy Into ear, nose, or bronchus. Endoscopy under anesthesia to extract.
Pt with bad tooth infection gets an abscess of floor of mouth
Ludwig angina. Worry about them rest to airway. Tx: i&d but may need intubation and tracheostomy
Sudden paralysis of facial nerve. Next steps?
Bell’s palsy. Not emergency. Use antiviral quickly. Can also use steroids.
Patient with frontal or ethmoid sinusitis gets diplopia. Next steps?
Cavernous sinus thrombosis! Diplopia from paralysis of extrinsic eye muscles. Emergency! Need hospitalization, IV antibx, CT scan, drain affected sinus.
Nosebleed in children. Cause? Next steps?
Usually from nose picking. Bleeding from anterior septum. Phenylephrine spray and local pressure.
Epistaxis in 18 year old. Causes and tx?
Cocaine abuse with septal perf, or juvenile angiofibroma. Cocaine tx: posterior packing. Angiofibroma tx: surgical resection (tumor is benign but it eats at nearby structures).
Nosebleed in HTN elderly
Nosebleeds can be copious and life threatening. Control blood pressure. Posterior packing. Sometimes surgical ligation of feeding vessels.
Dizziness with room spinning
Inner ear is culprit. Tx: meclizine, phenergan, diazepam
Dizziness where the room is not spinning
Cerebral disease problem. Need neuro workup
Adolescent boy with severe testicular pain of sudden onset, no fever, pyuria, hx of recent mumps. Testis is swollen, tender, high riding, with horizontal lie. Cord is not tender.
Testicular torsion! Urological emergency. No time for tests! Immediate surgical intervention. Untwist testes and then do an orchipexy. Many also fix the other side.
Young men old enough to be sexually active. Testicular pain of sudden onset. Fever and pyuria present. Testis swollen and tender in normal position. Cord is also tender.
Acute epididymitis. Tx: antibiotics. Possibility of missing testicular torsion is so bad that you do a sonogram anyway to rule it out.
Acute epididymitis vs testicular torsion
AE has fever and pyuria and is in normal position with a tender cord. TT has no fever or pyuria, high riding testis, cord is not tender.
Pt being allowed to pass a ureteral stone spontaneously suddenly develops chills, fever spike (104-105), and flank pain.
Combo of obstruction and infection of urinary tract. Dire emergency! Can lead to destruction of kidney in a few hours and sepsis death. Tx: IV antibiotics, immediate decompression of urinary tract (ureteral stent or percutaneous nephrostomy)
How to look at renal tumors?
CT scan
How to look at dilation in urologic workup
Sonogram
Intravenous pueblo gram
Excellent views of kidneys, collecting system, ureters, bladder. BUT potential allergic rxns, and not in pts with creatinine>2.
Older man with chills, fever, dysuria, urinary frequency, diffuse low back pain, exquisitely tender prostate on rectal exam
Acute bacterial prostatitis. Tx: IV antibiotics. No more rectal exams! Continued prostatic massage could lead to septic shock.
Hematuria. What are you worried about
Usually benign dz, especially after trauma. But need to rule out cancer bc it is the most common presentation for cancer of kidney, bladder, ureter
How to workup hematuria
CT scan. Cystoscopy: only reliable way to rule out bladder cancer
Hematuria, flank pain, flank mass
Renal cell carcinoma. Get CT for best detail- show mass to be heterogenic solid tumor. Surgery is the only effective therapy
Pt with hx of smoking with hematuria and irritative voiding symptoms
Worry about cancer of the bladder. Start wiThe CT scan. Then cystoscopy is the best test. Tx: surgery and intravesical BCG. High rate local recurrence.
Young man with painless testiclar mass.
Testiclar cancer. Never really benign. Do bx with a radical orchiectomy by the inguinal route. Take blood samples preop- AFP, BHCG- which will be useful for follow up. May need LN dissection. Usually very radio sensitive and chemosensitive (platinum based therapy).
Old man with a cold taking antihistamines and nasal drops with lots of fluid intake. Wants to void but can’t. Huge distended bladder is palpable.
Acute urinary retention in man with hx of BPH. Place indwelling catheter for at least 3 days.long term therapy is alpha blockers. If gland >40: 5a reductase inhibitor. Rarely do TURP
Post op pt with involuntary release of urine every few minutes. Huge distended bladder is palpable.
Overflow incontinence from retention. Tx: indwelling catheter
Colicky flank pain with irradiation to inner thigh and labia or scrotum. +/- N/v.
Get CT. Ureteral stones. 7mm: extra corporal shock wave lithotripsy. Also basket extraction, sonic probes, laser beams, open surgery.
Newborn boy can’t urinate
Posterior urethral valves. Look at meatal stenosis. Dx: cath to empty bladder. Then voiding cystourethrogram. Tx: Endoscopic fulguration or resection
Child with burning on urination, frequency, low abdominal and perineal pain, flank pain, fever and chills in a child
Vesicoureteral reflux. IV antibiotics and then culture guided choice. Then do voiding cystogram and IVP to look for reflux. If found, long term antibiotics until pt grows out of problem
Young girl with normal voiding but also wet with urine all the time
Low implantation of ureter. Urine drips into vagina from low implanted ureter.dx: physical exam or IVP. Tx: surgery
Adolescent who goes on a beer drinking binge for the first time in his life and develops colicky flank pain
Ureteropelvic junction obstruction. Usually normal urine output until a large dieresis.
What is absolute contraindication to organ donation
Only positive HIV status
Reestablish blood supply to organ after transplant. Minutes later, there is vascular thrombosis.
Hyperactive rejection. Caused by preformed antibodies. Prevented by ABO matching and lymphocytic cross match. Usually not seen clinically.
5 days - 3 months after organ transplant. Pt has signs of organ disfunction.
Acute rejection. Get bx to confirm. Give steroid boluses. Then try anti lymphocytic agents like OKT3 (but highly toxic). Newer antithymocyte serum is tolerated better.
Years after transplant, pt has chronic insidious loss of organ function
Chronic rejection. Poorly understood. Irreversible. No tx. Can have transplant biopsies to hope that it is delayed and treatable cause of acute rejection.
What to do if you suspect acute rejection of liver transplant
Technical problems are more frequent Than immunological rejection. Check GGT, all phos, and bilirubin to rule out biliary obstruction by ultrasound and vascular thrombosis by Doppler.
Heart transplant follow up for acute rejection
Can’t wait to see signs of functional deterioration. Routine ventricular biopsies are done at set intervals
Angina and exertional syncopal episodes. Harsh mid systolic heart murmur best heard at second intercostal space and along LSB.
Aortic stenosis! Get echocardiogram. Tx: surgery when gradient is >50mmHg, or at first indication of CHF, angina, or surgery
Pt has wide pulse pressure and a blowing high pitched diastolic heart murmur at 2nd ICS along LSB, with pt in full expiration
Chronic aortic insufficiency! Follow with medical therapy but should get valvular replacement at first evidence on echo of LV dilatation
Young drug addict suddenly develops CHF and a new loud diastolic murmur at right second intercostal space
Acute aortic insufficiency because of endocarditis. Tx: need emergency valve replacement and long term antibiotics
Older patient from another country gets dyspnea on exertion, orthopnea, PND, cough, hemoptysis. Low pitched rumbling diastolic apical heart murmur.
Mitral stenosis secondary to rheumatic fever. Workup starts with echocardiogram. As symptoms become more disabling, mitral valve repair with balloon commissurotomy or a balloon valvuloplasty
Pt develops exertional dyspnea, orthopnea, a fib. There is apical high pitched, holosystolic heart murmur that radiates to Axilla and back.
Mitral regurgitation. Workup with echo. As symptoms become more severe, surgery indicated. Repair of valve (annuloplasty) preferred to prosthetic replacement
Middle aged sedentary man with FH or coronary dz, smoking, DM2, hypercholesterolemia. Progressive unstable disabling angina
Coronary disease! Do cardiac cath. Tx: if vessel>70 with good ventricular function-> angioplasty and stent. Triple vessel disease, or left main, or anterior descending disease -> surgery.
Post op monitoring of heart surgery pts
Optimize cardiac output. If CO
Dyspnea on exertion, hepatomegaly, ascites
Chronic constrictive pericarditis. Dx: cardiac cath shows square root sign and equalization of pressures. Tx: surgical therapy
50+ year old hasCoin lesion on CXR. Next steps.
80% chance of being malignant. Compare to previous CXR. If not available: sputum cytology and CT scan (including chest and liver).
dx of lung cancer if not established by cytology
central lesion: bronchoscopy and biopsies. peripheral lesions: percutaneous biopsy. if those are unsuccessful, video assisted thoracic surgery (VATS) and wedge resection.
what factors determine how far you go in lung cancer workup
- probablity of cancer (elderly, smoker, non calcified lesion on CT). 2. assurance that surgery can be done (residual pulmonary function will suffice. 3. chances surgery will be curative (no mets to mediastinal or carinal nodes, other lung, or liver)
tx of small cell cancer of lung
chemo and radiotherapy. no operation!
what determines operability of lung cancer
residual function that remains after resection. central lesions require pneumonectomy. peripheral lesions require lobectomy (less of an issue). minimum of FEV1=800mL is needed. if COPD or SOB, get PFT. FEV1 for each lung and determine how much would remain after resection. if
how to determine potential cure by surgical removal of cancer
hilar mets can be removed but nodal mets at carina or mediastinum preclude curative resection. find by CT. PET can find actively growing tumor. endobronchial U/S is a more invasive option to sample mediastinal nodes. rarely need cervical mediastinal exploration. mets to other lung or liver can be found on CT.
newborn has stridor and episodes of respiratory distress with “crowing” respiration, where baby assumes a hyperextended position.
vascular rings putting pressure on tracheobronchial tree. if only respiratory sxs present without swallowing issue, consider osteomalacia. swallowing problems= vascular rings putting pressure around esophagus.
how to best see morphologic cardiac anomalies
echocardiogram
baby has murmur, overloading of pulmonary circulation, and long term damage to pulmonary vasculature.
left to right shunts. volume and consequences of shunts are different at different locations.
late infant with history of frequent colds has faint pulmonary flow systolic murmur and fixed split second heart sound.
get echo! ASD. closure can be achieved surgically or by cardiac catheterization.
newborn first few months has failure to thrive, a loud pan systolic murmur best heard at LSB, and increase pulmonary vascular markings on CXR.
VSD high in membranous septum. get echo. do surgical closure
3 day old baby gets bonding peripheral pulses and a machine like murmur
do echo. patent ductus arteriosus! in premies who has not gone into CHF-> try indomethacin. in those who do not close, those in CHF, or full term babies, need surgical division (or embolization with coils)
cyanotic baby with a murmur, diminished vascular markings in lungs, and cyanosis.
right to left shunt. includes teratology of fallot, transposition of the great vessels.
5 year old that is small for age, bluish tinge in lips and tips of fingers, clubbing, spells of cyanosis relieved by squatting. dx? phys exam? CXR and EKG? next test? tx?
metrology of fallot.
systolic ejection murmur in third space, a small heart,
diminished pulmonary markings on CXR, and EKG signs of RVH. echo is dx. surgical repair is done.
1-2 day old child with cyanosis in deep trouble.
transposition of great vessels! get echo. kept alive by ASD, VSD, PDO (one or both or all). get surgery!
drug addict suddenly gets CHF and is febrile with a large diastolic murmur at the right ICS and a BP of 120/20.tx?
acute aortic insufficiency bc of endocarditis. need emergency valve replacement and long term antibiotics
man who was in multiple traumas is brought to er. at first all his facial nerves are intact. the next morning, the patient has unilateral facial paralysis. cause and tx?
edema compressing nerve. no specific therapy bc it should resolve spontaneously.
how does cavernous sinus thrombosis present
development of diplopia in patient suffering ethmoid or frontal sinuitis
10 days after cadaveric liver transplant and initiation of standard immunosuppressive regimen, a 55 year old recipient begins to have elevated GGT, alk phos, and bilirubin. work up should start with
ultrasound and doppler studies to rule out biliary obstruction. rule these out before considering immunologic rejection bc they are more common. if not, consider acute rejection- give steroid boluses and then try anti lymphocyte agents (OKT3)
62 year old man has dyspnea on exertion, hepatomegaly, and ascites. swan ganz records pressures of RA, RV(d), PA(d), pulm cap wedge, LV(d). these show a square root sign and equalization. dx?
chronic constrictive pericarditis.
brain tumor pt has irregular breathing, increase BP, bradycardia.
cushing reflex. it is a compensatory response to preserve brain perfusion.
49 yo woman has severe ureteral colic and CT scan shows a 7mm ureteral stone at uteropelvic junction. +n/v. next steps? she is post menopausal and has a normal coagulation profile.
extracorporeal shock wave lithotripsy (ESQL). contraindicated in preggos and bleeding diathesis. 7mm stone has only 5% chance of passing. 3mm or less stone has 70% chance of passing spontaneously.
