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Senoir 21-2 > SRGRY BLOCK II > Flashcards

SRGRY BLOCK II Flashcards

1
Q

mainstay of evaluation of the mediastinum

A

Cervical mediastinoscopy

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2
Q

What is the procedure to sample nodes and biopsy tissue in anterior mediastinum

A

Anterior mediastinotomy - “Chamberlain Procedure “

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3
Q

most common evaluation of a solitary pulm nodule

A

Needle Bx

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4
Q

standard approach for open lung biopsy

A

Surgical Biopsy: thoracoscopy

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5
Q

PET vs CT in looking at mediastinal lympnodes

A

PET more accurate than CT scan in detection of cancer spread to mediastinal lymph nodes

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6
Q

PTX with loss of V/S in the ED or shortly after=

A

ED THORACOTOMY

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7
Q

Standard to Dx PTX

A

The posteroanterior (PA) and lateral chest radiograph

Exhalation accentuates the contrast & magnitude of collapse

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8
Q

How can you Dx a PTX from a Large Bullae

A

CT SCAN

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9
Q

Most common plueral problem

A

PTX

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10
Q

Are primary pleural tumors common

A

NO, involvement of the pleura with metastatic cancer is common

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11
Q

Pleural Effusion: Chylothorax

A

cloudy, milky fluid, numerous fat globules & few cells, mainly lymphocytes

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12
Q

Amount of fluid required to blunt the Costophrenic Angle on AP/PA films

A

300-500 mL fluid - blunting of the costophrenic angle

entire hemithorax opacified - 2000-2500 mL may be present

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13
Q

Imaging for complex, loculated, or recurrent collections of pleural effusions

A

CT

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14
Q

Threshold for Transudative Effusion

A

total protein content <3 g/dL,
an LDH level less than 200 units/dL,
and a specific gravity below 1.016

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15
Q

> 25% of all pleural effusions are secondary to

A

CANCER

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16
Q

Steps for Thoracocentesis in Pleural effusions

A

Identify needle insertion site

Anesthetize area

Sterile prep and drape

Insert needle under negative pressure
(9th or 10th Intercostal space, mid scapular line)

Collect/drain fluid

Withdraw needle and bandage

Send fluid to lab for analysis!!

Post procedure CXR!!

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17
Q

When chest tube output falls below 200 mL/day and reexpansion of the lung is verified

What is the next step

A

pleurodesis should be performed

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18
Q

Chest tube for malignant effusion

A 
Chest tube (20-28F) & closed-tube drainage for 24-48 hours then 
Pleurodesis
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19
Q

Dx of Choice for Empyemas

A

Procedure of choice for diagnosis: Thoracentesis

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20
Q

Chest tube for hemothoraces

A

Large-bore (32-36F) closed chest tube drainage

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21
Q

Diet for Chylothorax

A

Low fat diet

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22
Q

Agents for pleurodesis

A

talc, or doxycycline

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23
Q

Tx for a lung abscess

A

First-line - aerobic and anaerobic coverage for 4-6 weeks

In patients who do not respond - Percutaneous drainage

Operative intervention :
failure of clinical or radiological improvement after 4-6 weeks of abx therapy or Empyema

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24
Q

MC agent of Empyema

A

Staph

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25
Q

a pleural fluid glucose level less than 40 mg/dL and a pH less than 7.0

A

Empyema of more than 7 days

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26
Q

D shape density on CXR

A

EMPYEMA!

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27
Q

Dx for a Empyema

A

CXR: D shaped density

Thoracentesis - procedure of choice for diagnosis of thoracic empyema

Then bronchoscopy: r/o obstruction and CT scan: DDX lung abscess

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28
Q 
Thoracocentesis: 
pH <7.0
 glucose <40 mg/dL
LDH level >1000 units/L 
strongly suggest
A

Evolving Empyema

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29
Q

EMpyema Tx:

A

Initial treatment - closed tube thoracostomy

If question of therapeutic adequacy at 24-72 hours – CT scan

Candidates for open drainage
thoracoscopic or open lobectomy

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30
Q

MC central lung tumor

A

Small Cell

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31
Q

MC peripheral lung tumor

A

Adenocarcinoma

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32
Q

ipsilateral miosis, ptosis, and anhidrosis

A

Horners

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33
Q

ipsilateral shoulder and arm pain in the C8-T1 nerve root distribution, Horner syndrome, and a superior sulcus—usually squamous—lung cancer

A

Pancoast

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34
Q

Paraneoplastic syndromes of carcinoid and small cell CA

A

Carcinoid syndrome

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35
Q

Paraneoplastic Syndrome of Small cell Cancer

A

SAIDH

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36
Q

Paraneoplastic Syndrome of Squamous, Large cell and Adenocarcinoma

A

Hypertrophic Pulmonary Osteoarthopathy (clubbing, growth fxs)

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37
Q

A pt presents with SAIDH
(low serum Na), Hyper pigmentation, and Cushings Syndome/ gl intolerance

Think

A

Small Cell Lung Caner

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38
Q

What is the approach to Dx a Lung Neoplasm

A

CT Scan + Upper Abdomen Scan
(With contrast to eval Mediastinum)

Serum Alk Phosphatase
(If elevated: bone scan+ brain MRI/CT)

PET Scan for metz

Drain if there is a Pleural Effusion

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39
Q

Threshold size for benign vs malignant neoplasm in the lung

A

Less than 2 cm is likely benign

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40
Q

absolute contraindications to standard resection of a pulm neoplasm

A

Significant pulmonary hypertension and myocardial infarction within 3 months

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41
Q

3 types of Aneurysm

A

Saccular- discrete outpouching of vessel wall

Fusiform- diffuse

Mycotic- associated with infection

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42
Q

If a AAA is palpable as a pulsatile mass on US

What is the approx size

A

5 cm

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43
Q

Most appropriate initial test to eval AAA

A

US

Best for following size of AAA

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44
Q

Gold standard for pre op imaging for a AAA

A

CTA

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45
Q

Threshold for repair or a AAA

A

Asymptomatic- elective if >5.5cm

Symptomatic- emergent repair regardless of size

Rapid expansion >1cm/year

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46
Q

What type of complication should be strongly considered in a pt with recent abdominal aortic surgery

A

Communication with GI tract -> aorto-enteric fistula (GI bleed)

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47
Q

What is the most reliable test to eval a Aortic Transection

A

CT Angio

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48
Q

Stanford A vs B

Which is more likely to rupture

A

Stanford A

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49
Q

Standard imaging for a Aortic Dissection

A

CT

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50
Q

Abrupt onset of tearing, chest/back/abdominal pain
Pulse deficit or BP difference >20mmHg
Wide mediastinum on CXR

Think

A

Aortic Dissection

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51
Q

Difference in treating ascending vs descending Aortic Dissections

A 
Ascending aortic dissections
Surgical management (EMERGENT)

Descending aortic dissections
Medical management

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52
Q

Acute vs Chronic Mesenteric Ischemia

A

Acute:

  • Severe/diffuse abdominal pain
  • Pain out of proportion to physical exam findings
  • Normally no signs of peritonitis
  • May lead to peritonitis if bowel becomes necrotic

Chronic:

  • Food fear- post prandial abdominal pain
  • Weight loss
  • Diarrhea, nausea, vomiting
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53
Q

Imaging study to Dx Mesenteric ischemia

A

CTA or arteriography > Ultrasound

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54
Q

Risk factors for ischemic colitis

A

cardiovascular insults, aortic bypass surgery, aneurysmal rupture, prolonged strenuous exercise, vasculitis, and hypercoagulable state.

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55
Q

Tx for colonic ischemia

A

Supportive care - IV fluids, bowel rest, and antibiotics

colonicinfarction - require surgical treatment

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56
Q

Threshold to define TIA vs CVA

A

If the neurologic deficit lasts no longer than 24 hours and has complete resolution, it is defined as a TIA.

Deficits lasting longer than 24 hours are classified as stroke.

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57
Q

What is often the 1st S/s of CAD

A

Amaurosis fugax

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58
Q

If you find hollenhorst plaques in the retina

What is the next step

A

The next study in this patient should be an ultrasound of the neck.

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59
Q

3 causes of carotid related CVA

A
  1. Embolization (Most Common)
    - Platelet aggregation on plaque and breaks off
    - Central plaque degradation and breaks off
  2. Cardioembolism - from Atrial fibrillation
  3. Flow-related brain ischemia
    - Narrow artery -> decreased brain perfusion
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60
Q

most useful test in Carotid Artery Dz

A

Duplex ultrasound- Most useful test

-assesses luminal diameter and blood flow

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61
Q

What is the gold standard eval for Carotid Artery Stenosis

A

Carotid/Cererbral arteriography - “Gold Standard” and usually only if surgery is anticipated

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62
Q

Tx for Carotid Artery Dz

A

STOP SMOKING

Daily 81 mg Aspirin
(Clopidogrel should not be initiated if pending surgery)

Serial Duplex Scans

If SRGRY: stenosis >50% within the ipsilateral internal carotid artery

  • > Endarterectomy
  • > stent (younger pt, need’s Clopidogrel for 6 weeks post op)
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63
Q

How long is Clopidogrel started post op for a carotid stent

A

6 weeks post op

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64
Q

A pt presents with Light headedness anytime they use their arm

Think of what vascular problem

A

Subclavian Steal Syndrome

Stenosis of the subclavian artery

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65
Q

What are the two most common sites for PVD

A

Superficial femoral and iliac arteries the most common

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66
Q

PVD with calf pain

What artery>?

A

Femoral

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67
Q

PVD with buttock/ Thigh pain

What artery

A

Iliac

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68
Q

PVD with impotence

What artery

A

Aortic disease

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69
Q

A pt with PVD that is Hang leg over edge to decrease pain or sleep in chair

Think

A

Impending limb loss (rest pain)

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70
Q

Pt presetns wtih decreased pedal pulses, with loss of hair over the legs and shinny skin

+dependent rubor

Think

A

PVD

Look for a decreased ABI

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71
Q

ABI - < 1.0 indicates

A

occlusive disease proximal to point of measurement

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72
Q

What is the main stay of vascular imaging in PVD

A

Duplex US

CTA if SRGRY is indicated

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73
Q

Single most important risk fx for PVD

A

Smoking!

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74
Q

Rx for PVD

A

Statins

Antiplatelet drugs 
(Aspirin &/ Clopidogrel)

Cilostazol
(phosphodiesterase inhibitor for vaso dilation)

Pentoxiphylline
(decrease blood viscosity)

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75
Q

6 Ps of acute arterial occlusion

A 
Pain out of proportion
Pallor 
Poikilothermia (cool)
Paresthesia
Pulseless
Paralysis
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76
Q

Tx for a acute arterial occlusion

A

Anticoagulate with heparin
(in atraumatic patients)

Arteriogram (if light touch is intact)

Embolic- thrombolytics or embolectomy

Emergent if neurologic compromise= Immediate surgical intervention; ie. skip imaging

Trauma- repair/embolize artery, +fasciotomy to prevent compartment syndrome

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77
Q

A pt presents with ischemia with exercise and is AS/s at rest

Atherosclerotic changes are absent on US

Thinks

A

Popliteal Artery Entrapment

  • Abnormal insertion of medial head of gastrocnemius
  • Medial deviation of popliteal artery

Treat with SRGRY

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78
Q

What is the workup for Symptomatic Penetrating injuries to the extremities

A

CT angiogram
Arteriogram
Ultrasound

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79
Q

Functional unit of the breast

A

Lobes are the functional unit of the breast and produce milk

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80
Q

What is the most common Cancer of the breast

A

Ductal carcinoma is most common

Lobular carcinoma is rare

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81
Q

What is mondors dz

A

Trauma of chest wall vein after trauma/surgery

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82
Q

W/u for Mastalgia

A

Address specific complaint

Complete CBE +/- CXR

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83
Q

What should be used to evaluate a mass in the breast

A

Mammography and ultrasonography should be used to evaluate a mass in a patient with fibrocystic condition.

84
Q

When do we cut out a fibroadenoma from the breast

(Young woman with decreased incidence approaching menopause
Smooth or slightly lobulated approx. 1-3cm in diameter)

A

Excise for >35YOA, >2.5 cm, interval growth, unclear on bx, or if patient desires

85
Q

When do we refer for SRGRY with nipple DC

A

Refer to surgery if unilateral or positive findings during w/u

86
Q

F/u for nipple DC

A

Most are intraductal papilloma or mammary duct ectasia (benign conditions)

<15% DCIS (ductal carcinoma in situ)

Reexamine every 3-4 months for a year
mammogram and an ultrasound !!

87
Q

What is the W/u for Galactorrhea

A

Not associated with breast cancer

Check for hyperprolactinemia or hyperthyroidism
-bitemporal hemianopsia

Diagnostic MMG

Reexamine every 3-4 months for a year
mammogram and an ultrasound

88
Q

What is the approach to acute mastitis

A

Antibiotics to cover staph and strep
(Culture dependent)

Localized moist heat

Continue to drain breast
(pump or continue to breast feed)

89
Q

What is the treatment for a breast abscess

A

Usually starts as mastitis
+ Systemic symptoms- fever, chills, sweats, leukocytosis

TX: Stop nursing

  • Admission and IV antibiotics
  • Incision & drainage in the OR
  • I&D and Bx can be done in OR
90
Q

What is polythelia

A

Extra nipple with or without underlying breast tissue

Normally noticed during pregnancy

Can occur anywhere along milk line

Completely cosmetic/benign

Tx: elective SRGRY

91
Q

Approach to Unilateral Gynecomastia

A

Normally in young men
-No nipple discharge

Usually cosmetic concern or can have tender mass behind nipple

Obtain MMG or US if warranted

Reassure that it is not likely malignant!!

Usually regress with time but teenagers are impatient

92
Q

What is the approach to BILATERAL Gynecomastia

A

Associated with decreased androgen production as a man ages

Reassurance or routine consult to General Surgery

93
Q

BIRADS categories

A

0- Additional imaging needed

1-Negative/Normal

2- Benign findings (vascular calcifications, stable lesions, etc…)

3- Probably benign (<2% risk of malignancy, repeat in 6 months or Bx)

4- Suspicious (consider Bx)

5- Highly suggestive of malignancy (definitely Bx)

6- Biopsy proven malignancy

94
Q

If US useful in the screening of Breast Cancer or Masses

A

US not useful in screening

Used to guide needle for Bx or aspiration

95
Q

What imaging modality is especially good for dense breast tissue or those with implants

A

MRI

96
Q

RSK fxs for Breast CA

A

Females

Advanced age

Excessive estrogen exposure

First degree relative with Breast Cancer
Breast Bx with atypia

BRCA oncogenes

  • BRCA 1- 50-70% lifetime risk of breast cancer
  • BRCA 2- 20-40% lifetime risk of breast cancer
97
Q

A pt finds a painless lump in the breast with irregular margins

Think

A

Breast cancer

May have: Skin dimpling
Nipple retraction
Fixation to chest wall
Axillary lymphadenopathy
Peau d’ orange
98
Q

What is the approach to imaging breast Cancer

A

Diagnostic MMG with F/U US

Then Bx as needed

99
Q

What is the Bx approach for a palpable mass

A

Open Bx

100
Q

What is the use of finding the sentinel lymphnode in breast cancer

A

If the lymph node does not have cancer, then metx is unlikely

If sentinel node does have cancer,
surgeon will perform axillary lymph node dissection and may need mastectomy/modified radical mastectomy, with chemo and radiation

101
Q

When looking at cancer bio markers
(ER, PR, and HER2)

A triple negative means what?

A

Triple negative breast cancer

  • Most are BRCA 1 oncogene positive
  • Negative for ER, PR and HER2

More aggressive than other breast cancers with no targeted Tx
-Worst prognosis

Mainstay Tx with Chemotherapy

102
Q

What is the treatment for breast cancer and a postive HER2 bio marker

A

HER2- Human Epidermal Growth Factor Receptor
-Poor prognosis 2/2 rapid metastasis

Treatment with monoclonal antibodies

103
Q

What is the approach to lobular and ductal carcinoma in Situ

A

Lobular Carcinoma In Situ

  • Marker for cancer
  • Still encapsulated in the lobe

30% chance of developing cancer

Ductal Carcinoma In Situ (80% of all BC)

  • Cancerous lesion and must be removed
  • After excision, XRT to remaining breast tissue
104
Q

What kind of breast cancer is more likely to be bilateral

A

Lobular

105
Q

What is the F/u for bilateral breast cancer

A

MMG

106
Q

Define Pagets Carcinoma

A

Ductal carcinoma involving the nipple

May or may not have palpable mass

Usually associated with nipple itching/burning

Eczematoid/crusted lesion on the nipple or areola

Any lesion refractory to topical abx or steroids >1 week should be referred to surgery!!

107
Q

Mastitis in non lactating women.. think

A

Inflammatory breasts cancer

Should be very high on differential in non-lactating woman!
-> biopsy - invasion of the subdermal lymphatics

Tx: neoadjuvant chemotherapy, surgery, and radiation

108
Q

Risk factors for breast cancer in men

A

average age at occurrence is about 70 years

increased incidence in men with prostate cancer

First-degree relatives are considered to be at high risk

BRCA2 mutations are common

109
Q

What is the most important prognostic variable for breast cancer

A

Most important prognostic variable

-whether the tumor has metastasized to the axillary lymph nodes

110
Q

When can drains be pulled from the breast after SRGRY

A

Normally drains are left in to prevent
Seromas

Drains are emptied daily/PRN and output measured

Drains are pulled when drainage <30ml/24H

111
Q

Winged scapula is damage to what nerve

A

Long thoracic nerve

112
Q

Loss of function to the latissimus dorsi is from what nerve injury

A

Thoarcodorsal nerve

113
Q

Duration of XRT for breast cancer

A

Usually 2-6 weeks after surgery 5X week for 6-8 weeks

114
Q

What is the most common metx for breast cancer

A

commonly metastasizes to the liver, lungs, and bone

115
Q

A pt with breast cancer that then presents with HA, imbalance, vertigo. Vision changes

Think

A

Metx to the brain \

Triple-negative and HER2-positive tumors have a higher rate of brain metastases

116
Q

What is TRAM SRGRY

A

Think about Priscilla

TRAM
(Transverse Rectus Abdominus Muscle) -flap can be used to reproduce the breast mound after mastectomy

After mastectomy, tissue expanders are often placed under flap

Gradually increase saline content to expand tissue until optimum size

Once desired size is achieved, permanent implant is placed

117
Q

What separates an inguinal vs femoral hernia

A

Inguinal hernia- originates above inguinal ligament
96% of groin hernias

Femoral hernia- originates below inguinal ligament
4% of groin hernias

118
Q

Layers of excision to repair a hernia

A

Skin.

Campers and Scarpas fascia

External and internal oblique

Transverse muscle and Fascia

Preperitoneal fat

Peritoneum

119
Q

What defines an indirect inguinal henria

A

Indirect inguinal hernias - develop at the internal inguinal ring and are lateral to the inferior epigastric artery.

120
Q

What defines a direct inguinal hernia

A

Direct inguinal hernias - occur through Hesselbach’s triangle

formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus muscle medially.

121
Q

Where do congenital hernias arise from

A

Congenital hernia from patent processus vaginalis

Same congenital defect which causes hydroceles

Intestinal contents travel down spermatic cord

Pass thorough the deep and superficial inguinal ring

Most common hernia in both sexes

122
Q

Direct inguinal hernia risk factors

A

Obesity

Pregnancy

Heavy lifting

Chronic cough

Straining to void (BPH/prostate ca)

Constipation

Cirrhosis with ascites

123
Q

W/u for an inguinal hernia

A

Finger in the scrotum

Testicular eval

+ DRE

124
Q

Initial Dx modality for an inguinal hernia

A

US (groin)

+/- KUB

+/- CT for SRG repair

125
Q

What are the indications for laparoscopic hernia repair

A

Recurrent

Bilateral

Or need for early return to play

126
Q

What nerve can be prophylactic devision to reduce chronic pain in an inguinal hernia

A

Ilioinguinal nerve

127
Q

Recovery time for inguinal hernia repair

A

Laparoscopic : about 15 days

Open: about 34 days

128
Q

Who is more likely to have femoral hernias

A

Women

129
Q

Where do epigastric hernias come from

A

Protrusion through the linea alba above the umbilicus

130
Q

What is the approach to umbilical hernias in newborns

A

Most spontaneously close prior to school age

Repair at age 2 if it persists

Rare to incarcerate

131
Q

What is the approach to umbilical hernias in adults

A

Risk factors: multiparity, obesity, ascites, intra-abdominal tumors

Slowly enlarge and may incarcerate

Refer for elective surgical repair
-Emergency repair is often necessary

132
Q

What is the approach to wound dehiscence

A

S/S: Yellow-pink (salmon) colored fluid
-Peritoneal fluid

Must return to OR for fascial closure PRIOR to evisceration

Call surgeon ASAP to evaluate patient and prepare for OR

Acute fascial dehiscence= evisceration
-Emergent surgical evaluation

Delayed fascial dehiscence =incisional hernia
-Urgent surgical consult

133
Q

What is a sports hernia

A

Not a true hernia

Series of micro tears of:

  • Adductor
  • Rectus
  • Femoris
  • Psoas
  • Hip flexor
  • Obliques
134
Q

What is the Tx for a sports hernia

A

SRGRY if:

  • Lifestyle limiting pain
  • Failure of conservative Tx >8 weeks
  • Exclusion of other Dx
135
Q

Where do hydroceles come from

A

Results from patent processus vaginalis

Peritoneal fluid ->hydrocele

136
Q

What is the treatment for epididymitis in a young vs old man

A

Young man

  • STI panel
  • NSAID
  • Scrotal support
  • ABX for STIs!
Older man
-STI panel
-Scrotal support
-NSAID
-ABX for Gm neg rods!!
(E Coli)
137
Q

What is the treatment for Spermatocele

A

Benign finding
Confirm with US
Surgical intervention

138
Q

Varicocele on the R side of the pt

Think

A

If on right or later in life, evaluate for mass occluding spermatic vein

139
Q

When should SRGRY be done for pts with Varicocele

A

Surgery reserved for infertility of spermatic vein occlusion

140
Q

Solid Mass on a testicle is…

A

Cancer UPO

Urgent referral for US and surgery

141
Q

W/u for testicular torsion

A

Urgent US with Doppler and surgical evaluation

If testis viable ->
re-profuse and perform orchiopexy

If ischemic/necrotic -> orchiectomy

142
Q

Most common post surgical complications 0-48 hours

A

Respiratory and cardiovascular issues

  • Failure to maintain ventilation
  • Aspiration
  • Sudden cardiac event
  • Hypotension
143
Q

Most common post operative complications 48hours -30 days

A

Localized

  • UTI
  • Pneumonia

Systemic

  • SIRS- Systemic Inflammatory Response Syndrome
  • MODS- Multi Organ System Failure
144
Q

Most common complication following anesthesia

A

Atelectasis

```
Presentation:
-Low grade fever
usually post operative
-Decreased breath sounds
-Basilar rales
Seen on CXR
~~~

145
Q

Tx for post surgical pneumonia

A

Antibiotics

Aggressive pulmonary toilet

Intubation/mechanical ventilation

  • Maintain PCO2 35-45
  • Maintain O2 sats >95%
146
Q

What is the single greatest risk factor for VAP

A

Single greatest risk factor is the duration of mechanical ventilation
-peaks at day 5 plateaus at day 15, and then significantly declines

147
Q

Tx for aspiration in SRGY

A

Suction immediately
-Bronchoscopy

Bronchial hygiene

Antibiotics

Mechanical ventilation

148
Q

Pulmonary edema that does not responde to diuretics
(Is not 2/2 HF)

Think

A

ARDS

Treat with mechanical ventilation: -Increased PEEP
increases functional residual capacity

149
Q

Tx for ARDS

A

Moderate PEEP settings 10-15cm (>15cm PEEP considered high)

Lower tidal volumes 5-7ml/kg IBW vs traditional 10-15ml/Kg IBW

Maintain FiO2 <60% to avoid O2 toxicity

Increase the expiration time (inspirational hold) ->more alveoli open

Prone ventilation

Airway Pressure Release Ventilation

Lower Vt

Shorter burst breaths with low amplitude but rapid frequency at Vt max

150
Q

When should we remove central lines

A

removal when not necessary or <7 days

151
Q

A pt presents with resp insufficiency, confusion or coma, with petechia

After a long bone fx

Think

A

Fat embolus

152
Q

What is the tx for a fat embolus

A

Supportive care

  • positive end-expiratory pressure ventilation
  • diuretics

Monitor ABG

Rule out MI/PE

Early fracture management
-External fixation or ORIF

153
Q

RSK factors for a DVT

A 
Major trauma
 malignancy
age > 40
pregnancy, post partum or OCP use prior DVT
prolonged immobility 
(travel by air, bus, long car ride)

Surgery specific

  • Post op bed rest
  • Pelvic/lower extremity surgery
  • Major general surgery
  • Central lines
154
Q

W/u for a DVT

A

Duplex US

155
Q

Prevention and Tx for DVT

A

Prevention

  • Elastic stockings for compression
  • Early ambulation
  • Sequential Compression Devices (SCD)

Treatment - Anticoagulation
-Heparin, LMWH

-Anti-Xa or Direct thrombin inhibitors
Dabigatran & edoxaban require IV anticoagulation prior to initiation

-Warfarin

156
Q

Wells criteria

A

S/S of DVT (3 points)

No other Dx (3 points)

TachyHR (1.5 points)

Immobilized x 3 days (1.5 points)
(Or SRGY in past month)

Prior DVT (1.5 points)

Hemoptysis (1 point)

malignancy (1 point)

Score above 4= think PE
Less than 4= D dimer
Less than 2= PERC them out

157
Q

PERC out criteria

A

Age <50
heart rate <100
O2 sat >95

No hemoptysis 
No Estrogen use 
No Prior DVT or PE 
No Edema 
No SRGRY in past 4 weeks
158
Q

New onset a fib or a RBBB
In a post SRGRY pt

Think

A

possible PE

159
Q

Test of choice for a PE

A

Spiral CT pa

VQ if pregnant or poor renal function

160
Q

Tx for a PE

A 
Supplemental O2 and IV access
\+Anticoagulation
-SQ low molecular weight heparin
-IV unfractionated heparin
 (where bleeding is a concern)

Oral warfarin for 3-6 months
-Therapeutic INR 2-3

Oral Xa or direct thrombin inhibitors

  • Rivaroxaban and apixaban
  • Dabigatran and edoxaban – require parenteral anticoagulation

Inferior Vena Cava filter (IVC filter)
-Use with PE from distal DVT and contraindicated for oral anticoagulation

161
Q

What Rx can be given pre op to mitigate ileus

A

Mitigate with pre-op Entereg (alvimopan) and minimizing bowel manipulation

162
Q

What is the most common cause of C. Diff

A

Most common cause: antibiotic associated diarrhea
-Clindamycin, cephalosporins, floroquinolones

ABX disrupt gut flora

C. dif overgrowth (spore forming, anaerobic, gm postitive bacillus resistant to most abx)

Suspect in patient with > 3 loose stools in 24 hours

163
Q

Tx for C. Diff

A

Oral Vanc or metro

164
Q

How long should a pt have a catheter in place s/p SRGRY to the sacral plexus

A

4-5 days

165
Q

Most common complication of bladder Cath

A

Most common complication- UTI
Use sterile technique to insert
Remove ASAP when no longer needed

166
Q

What is the treatment for DIC

A

Fresh frozen plasma - indicated for the replacement of coagulation factors

167
Q

What is the treatment for post surgical seroma/ hematoma

A

Small- resolve spontaneously

Large- aspirate or open to decompress

168
Q

What is the tx for surgical site infections

A

Surgical Site Infection
Open, irrigate and pack
Avoid temptation to reclose

169
Q

Tx of compartment syndrome

A

Prevention/treatment
-Incise from skin through fascia

Fasciotomy- allows muscle to swell without compressing vessels

(Can also result from vascular trauma and insertion of IO into fractured long bone)

170
Q

What is the approach to abdominal compartment syndrome

A

If the abdomen is closed, evaluate frequently for acidosis, decreased urine out put and increased lactate.

Can be mitigated by:

  • Abdomen not closed and covered with wound vac
  • Allows for tissue expansion and minimizes tissue ischemia and dehiscence
171
Q

What is the wind water wound for fever in a post SRGRY pt

A

Wind- Atelectasis, pneumonia
Water- UTI
Wound- SSI

172
Q

What is the risk of using Vanc or Aminoglycosides

A

Ototoxicity

173
Q

What is the ICU death spiral

A 
Systemic Inflammatory Response Syndrome (SIRS)
2 or more of the following
-Temp >38.5°C (101.5° F)
-Tachycardia
-Tachypnea
-Leukocytosis

Sepsis
-SIRS with a source

Septic shock
-Sepsis with end organ failure or MODS

Death

174
Q

Exposure to XRT increases the risk of what type of thyroid cancer

A

Papillary

175
Q

TSH low with high T3, T4

A

Hyperthyroidism (functional nodule)

176
Q

What are two thyroid abs

A

Antithyroglobulin and antimicrosomal

177
Q

What is the 1st line Dx of a solitary thyroid nodule

A

FNA

178
Q

When should you use RAI scan

A

In a pt with hyperthyroidism, and evaluation of a nodule

Hot vs cold nodules
(follicular neoplasm)

Most nodules are cold

If hot (hormonally active) likely benign
T3-T4 high and TSH low
179
Q

On RAI scan

A pt has Low TSH and increased RAI uptake

A

Hyperthyroidism

180
Q

On RAI scan a pt has low TSH and decreased RAI uptake

A

Subacute thyroiditis

181
Q

Indications for thyroidectomy

A

Suspected or proven cancer on FNA

Malignant (papillary or medullary)

Follicular neoplasms
-Can’t differentiate between adenoma (benign) and carcinoma (malignant)

Atypical cells

Hormonally active nodules

Cystic nodules which recur after 2+ aspirations

Functionally malignant

Cosmesis

182
Q

benign tissue hyperplasia surrounded by fibrous capsule

May be cold or hot

A

Follicular adenoma

SRGICAL removal

183
Q

A hyperfunctioning adenoma that is less than 4cm

A

Rads Iodine

184
Q

hyper functional adenoma >4cm

A

SRGRY

185
Q

3 Ms of medullary thyroid cancer

A

Multi focal
Multi lobular
Metx

186
Q

Role or thyroxine in cancer treatment

A

replace hormone and suppress mets

187
Q

Radioactive iodine post cancer treatment

A

after thyroidectomy, reduce recurrence and increase survival, treat recurrence and mets

188
Q

When would XRT be used for thyroid cancer

A

XRT- local invasion, recurrent, metastatic or unresectable mass

189
Q

Approach to a thyroglossal cyst

A

Ultrasound for evaluation

Check thyroid function tests

Treat with antibiotics prior to elective surgery (avoid I&D)

190
Q

Most common neoplasm to the anterior mediastinum

A

Thymoma – most common neoplasm

Substernal thyroid – most common clinical presentation

191
Q

Most common neoplasm to the middle mediastinum

A

Lymphoma

Bronchogenic cyst

192
Q

Most common neoplasm to the posterior mediastinum

A

Neurogenic tumor

Bronchogenic cyst

193
Q

If a goiter has localized areas of hardness or rapid growth

What should you do

A

Aspiration biopsy cytology

194
Q

Most common causes of hyperthyroidism

A

Hypersecretory goiter (Graves disease)
Or
Toxic multinodular goiter (Plummer disease)

195
Q

Two tests in the eval of Thyrotoxicosis

A

T3 suppression test - hyperthyroid patients fail to suppress the thyroidal uptake of radioiodine when given exogenous T3.

TRH test - serum TSH levels fail to rise in response to administration of TRH in hyperthyroid patients.

196
Q

Tx for Thyrotoxicosis

A

Methimazole

usually used in preparation for surgery or RAI treatment but may be used as definitive treatment

Then Radiodine

  • after the patient has been treated with antithyroid medications and has become euthyroid
  • indicated if over 40 years or are poor risks for surgery & for patients with recurrent hyperthyroidism
197
Q

What is the Treatment of hyperthyroid patients requiring an emergency operation or those in thyroid storm

A

prevent release of preformed thyroid hormone - Lugol iodine solution or with ipodate sodium

give β-adrenergic blocking agents to antagonize the peripheral manifestations of thyrotoxicosis

decrease thyroid hormone production and extrathyroidal conversion of T4 to T3 by giving propylthiouracil

198
Q

A pt with a decreased serum Ca2+ and an elevated PTH

Think

A

Secondary hyperparathyroidism (decreased serum Ca +elevated PTH)

  • Chronic renal failure
  • Malabsorption
199
Q

What are the lab findings in Primary Hyperparathyroidism

A

High serum calcium - most important

Low phosphate

Increased alkaline phosphatase

Elevated BUN and creatinine

Hyperchloremic metabolic acidosis

200
Q

If a pt presents with High serum calcium and a low phosphate

Think

A

Cancer (breast)

201
Q

What is the imaging to find Substernal parathyroid glands

A

Advanced imaging- sestamibi, CT, MRI

202
Q

Differnce between primary and secondary hyperparathyroidism

A

Primary (benign)- parathyroid glands excrete excess PTH

  • Parathyroid adenoma
  • Parathyroid hyperplasia

Secondary (malignant)- tumors produce PTH mimicking hormone or other cancer has metastasized to the bone

203
Q

What is the surgical critera to remove parathyroid glands

A

Significant symptoms

  • Renal stones
  • Osteoporosis
  • Hypercalcemic crisis

Or if serum calcium is greater than 1 mg above NML

GFR less than 60

T score less than 2.5 or h/o Fx

Age less than 50

204
Q

What is the threshold for suspicion in a incidentaloma

A

Greater than 5 cm

If <5cm and confirmed benign, repeat CT in 3-6 months

205
Q

A pt presents with Hyponatremia, hyperkalemia (aldosterone deficiency)
Hyperpigmentation (increased ACTH and CRH-> melanocytes)

Think

A

Renal failure

Adisonian Crisis

206
Q

What tumor should be suspected in part with neurofibramatosis

A

Pheo

Senoir 21-2 (77 decks)

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