Surgery Flashcards
Prep evaluation (not for emergent) heart
Decompensater HF with EF <35%——if volume overload 75% die
MI-best to wait 6 months __if wait 4 months 40% die, 66 die 6% months
No surgery unless to fix heart problem
Goldman Index-higher bad…most points for JVD(EF<35%), recent MI
DX-do an EKG, echo, stress/LHC
Treat-MI=stent/CABG wait 6 month a revaluate
CHF-BB and ACE-I, volume overload diuress with loop diuretics
Pre op evaluation lungs
Ventilation more important than oxygenation
Can always Turn up oxygen but if bad lunches cant get rid of CO@ worsen acidosis, acid base status deranges
Pt-smoker, COPD, asthma, interstitial lung disease (DPLD)
Do-PFT, and day of maybe ABG look for increased CO2 or decreased O2
To-give oxygen for low oxygen, inhalers, STOP SMOKING (increas bronchial secretions immediately after…so need to stop smoking 8 week before and use nicotine patch)
Pre op evaluation liver
MELD score
Childs-pugh (a good, c dead)
Pt-albumin down, clotting factors absent PT/PTT up, total bilirubin elevated, ascites, encephalopathy
-if any of these have 40% of death, if all 5 100% death and no treatment other than transplant
Nutrition
Important for healing
Pt:thoselose 20% BW, albumin<3, skin anergy
Diagnose:prealbumin and CRP,
If albumin low, prealbumin low and CRP up no protein
If albumin low and prealbumin ok and CRP albumin liver problem
Fail skin anergy-cant go to surgery wont heal
Treat-oral>IV, give ten days of replacement>5 days
Metabolic preop evaluation
DKA=high blood sugar
NO surgery if DKA-IV fluids and IV insulin
If blood sugar out of control give insulin
CABG stent ok if bad
Yes emergent
Post op fever
Wind Water Walking Wound Wonder drugs
Fever during surgery
Malignant hyperthermia (wonder drugs) Anesthesia
Treat with O2, dantrolene and cool them off
Ask if had personal or family history to anesthesia bad reaction
Fever right after surgery
Bacteremia (surgeon prob)
Diagnose with blood culture
Treat broad spectrum antibiotics-vancomycin
Prophylaxis-maintain sterile field and be careful in gut and dont poke the bowel
Post op day 1 fever
Atelectasis
Diagnosis chest x ray to make sure no consolidation pneumonia
Treat-no treat
Prophylaxis ICS and out of bed , get them to move and breathe
Post op fever day 2
Pneumonia
Diagnose-chest x ray consolidation
Treat-broad spectrum antibiotics 0vancomymic
Prophylaxis-ICS and out of bed
Post op day 3
UTI
Diagnose UA urine culture-if cast pyelonephirits and prob had before surgery
Treat abx
Prophylaxis -foley taken out
Post op fever day 5
DVT/PE especially orthopedic
-2 cm bigger one leg, Pe hypoxia hypercapnia resp alkalosis
Diagnose-US bl lower extremitt
Treat heparin to warfarin bridge to prevent hypercoagulability
Prophylaxis-up and walking around and give low molecular weight heparin, usually give it after surgery
Post op day 7
Would cellulitis
Diagnose-US negative fo abscess
Treat antibiotics
Prevent keep sterile field and keep clean post op
Fever day 10-17
Abscess
Diagnose US positive for abscess or use CT
Treat antibiotics, back to OR for IND
Prophylaxis keep wound clean
Post op chest pain
MI, PE, or something else.
Get EKG and troponins for MI
Get US LE or spiral CT scan for P
If MI post op
PCI if stemi
Heparin if troponins are elevated NSTEMI
If PE post op
Heparin bridge to warfarin
Altered mental status post op
Electrolytes issue(NA, Ca)-get BMP
Sundowning-older people-atypical antipsychotics , reorient them
Hypoxemia-PE, pneumonia, ARDS(have to have prolonged intubation, transfusions, and intubations-will need PEEP),
DT-HTN, tachycardia post op pain meds dont work, sweaty and shake, can prevent seizures 48-72hrs on way to seizures. Give benzos.
Decreased urinary output post op
Normal is 0.5cc/kg/hour
If less bad
Urge? If yes have obstruction can evaluate with bladder scan or in and out cath
No urge? Nothing in bladder might be renal failure . Look at urinary output….any at all? Non!-mechanical probably kinked foley…unkink foley or irrigate it-if some output! Give 500cc bolus challenge and if increase urinary output they were volume down and give them more fluid. If dont though intrinsic renal disease and had some big hit or allergic reactions to get this.
Abdominal distinction post op
Ileus, obstruction, oliguria
Ileus
Functional day 1,2 no stool no fart
Get KUB flat and erect
See small bowel and large bowel dilated at same time
Treatment-fluids, K, and getting them to move
Obstruction
Obstruction
Person suspect has ileus but day 5 still no stool and no gas
Diagnose -upright erect KUB
If obstructed nothing gets by and see entire bowel decompressed in SBO, if LBO large bowel decompress and proximal distended and small bowel normal.
Treat-NG tube and surgery to undo damage0usually adhesions
Ogilvie syndrome
Functional but only impacts colon and elderly
Diagnose flat erect KUB
Small bowel normal large bowel distended but no distal area that’s good. Whole thing is big
Treat decompression with rectal tube , stigmine, may need colonoscopy to rule out cancer
Dehissence
Not that bad. Failure of the fascia, wound not open but underneath fasciae planes not closed
Get a ventral hernia, see serosanguinous drainage that is salmon colored.
Diagnose-Clinical
Treat-prevent evisceration, use binders , reduce straining, and need to reoperate eventuall to close ventral hernia
Don’t need to fix right away
Evisceration
Failure of whole wound. Skin and fascia beneath break down and looks of bowel pop out.
Have person stand too early or strain too soon
Diagnose clinical
Treat surgical emergency yikes and apply warm saline dressings keep everything moist and never ever push it back in …then get to the OR
Fistula
Foreign body EPithelization Ttumour Irrigation/inflamed/inflammatory bowel (crohn) Distal obstruction
FETID
Treat-resect fistula may need to do a diversion
Prehepatic jaundice
Hemolysis and hematomas
Excess unconjugated indirect
INTRAhepatic jaundice
Genetic
Hepatitis
Mixed
Posthepatic jaundice
Obstruction
Gallstones
Cancer
Strictures
Increased conjugated
Gallstones
Dislodged in biliary tree choledectolithiasis
Mild dilation and inflammation of biliary tree and gallbladder
Expect to see increase temp and WBC and positive Murphy’s sign
Acute painful jaundice wiht inflammation
Diagnosis-RUQ US, MRCP bc can visualize with out ercp complication
Treat ercp or cholecystectomy
Stricturecancer
No inflammation bc not acute, no temp no WBC and no Murphy sign, no pain
Coursvier sign painless jaundice
Diagnose-RUQ US, MRCP
Treat-endoscopic US with biopsy, ERCP with biopsy may stent or resect dependent on underlying disease
Painless jaundice what do
Stricture or cancer
Bili20-26 (so single digits in gallstone)
Obstructive
Clay colored stool weight loss
Can’t get bilirubin into the stool
Cancer by saying in addition weight loss
Cancer
Obstructive
Distended gallbladder nonpainful
Obstructive
Work up obstructive jaundice weight loss clay colored stool, painless jaundice, distended non painful gallbladder
CT scan if +pancreatic mass its pancreatic cancer look for migratory thrombophlebitis
Diagnose pancreatic cancer with EUS with biopsy
Treat whipple remove parts of liver, pancreas duodenum
Positive CT with biliary tree with painless jaundice, weight loss, clay colored stool and distended gallbladder
Cholangiocarcinome
Diagnose-ERCP and biopsy
Treat resection
Negative CT with weight loss and clay stools, painless jaundice, distended gallbladder non painful
Ampulla of vater malignancy
-FOBT positive and negative colonoscopy
Diagnose-ERCP with biopsy can see malignancy
Treat resection
Obstructive jaundice stricture
Stenting and PSC
Gerd
Weakened LES, acid reflux retro sterna burn
Increased with flat and spices
Better sitting up and antiacids
Nocturnal asthma, gets up at night wheezing coughing acid comes up while laying on back
Diagnosis-no alarm symptoms with lifestyle and PPI
Avoid coffe peppermint chocolate and alcohol
Alarm symptoms or 4-6 week failure PPI lifestyle…EGD with biopsy
N/V, weight loss, anemia to biopsy first
If better lifestyle PPI continue treat this way. But Barrett’s metaplasia treat with high dose PPI anytime undergo metaplasia
Dysplasia now do ablation
Adenocarcinoma-resect
Nissen fundoplication-GERD surgery best test before this is 24 hr pH monitoring so want to do this before
If Ph low and symptoms consider nissen..but if too tight can creat achlasia
Achalasia
LES wont relax
Food gets stuck knot or call of food stuck at GE junction
Dysphasia-first fo barium swallow
See bird beak
But best test is monometry
Diagnosis -bird beek but next step is manometry
Before treat must do EDG with biopsy to rule out pseudo achlasia to rule out cancer
Treat-Botox temporary reserved for bad surgical candidates
- dilation but risk perforation if cant take surgery
- BEST WAY IS MYOTOMY remove muscle do too much get GERD
Upper third esophagus cancer
Squamous cellhot liquid, smoking
Lower third esophagus cancer
Adenocarcinoma
Related to gerd
Esophageal cancer
Dysphagia to large substances and smaller food and then water progressive dysphagia
1. Barium swallow ass asymmetric fungating mass
2,. Confirm endoscopy with biopsy
Always barium swallow first
Treat resection
Mallory Weiss tear
Superficial tear in mucosa in esophagus
Self limiting bleed
In someone vomiting as weekend warrior,
Diagnosis no-but treat like GI bleed, IV PPI call GI, CBC
Treat no
Boerhave
Trans mural tear esophageal perforation
Career vomiter
Bulemia or alcoholism
Air in mediastinum not contained crepitus in chest when breath hear and feel it
Hammands crunch from air around pericardium
Mediastinitis-fever, cough, septic
Diagnosis-1. Gastrograffin (bad for lung) swallow
2. If neg do barium swallow
3. If negative do endoscopy.
Stop when positive
Treat-surgical emergency to OR immediately
Small bowel obstruction
Adhesions if had surgery, hernia if not had surgery
Pt: positive flatus and bowel movements but then have obstipation with colicky abdominal pain with distant ion
Borborygmi->silent bowel sound
Gas and fluid proximal to obstruction and abdominal distinction.
DiagnoseL upright KUB look for air fluid levels follow that up with CT scan . If contrast material makes to rectum incomplete obstruction if non complete obstruction
- KUB then CT
Treat incomplete-contrast material reach rectum …conservative NG tube decomression IV fluids if no improvement surgery, if become peritoneal get emergent surgery
KUB must be upright look for air fluid levels
If complete-surgery
Hernia
Direct-adult, transversalis, i Guinean
Indirect-babies, inguinal ring, intestine in scrotum, inguinal
Femoral-female under inguinal ligament
Ventral-iatrogenic, failure of fascia to close, post op
Present as abdominal bulge-PE figure out what type.
Reducible hernia
Can push back in pops back out
In and out
Electively surgery
Incarcerated
Can’t reduce
SBO
Risk strangulation
Take care of it urgent surgery
Strangulated
Intestine dies, cuts off blood supply.
Peritoneal signs
Emergently to surgery
Appendicitis
Feaclith
Don’t need diagnostic steps bc clinical
Periumbilical pain go away and return at McBurney’s point , anorexia, N/V
CT scan-not needed for test but board service we like
Treat surgery
Carcinoid
Neuroendocrine tumor secretes serotonin only seen with Mets to liver to take effect
Liver and lung
Flushing, wheezing, diarrhea, heart R, fibrosisi
Diagnosis 5-HIAA
Treat CT scan and resect
Peritonitis
OR
Pancreatitis
Epigastric radiates through back
Positiona;, N/V
Lipase three times normal limit, amylase
Symptoms
Imaging CT US dont need it on day 1, but if person getting SICK hypotensive why r third spacing get CT scan bc worried about necrotizing fasciitis, WILL NEED NECROSECTOMY surgery after wait and conceal it dont go in too early ICU, do carbapenem antibiotics if FNA proven infection so need biopsy of necrotic tissue shows bug in order to give antibiotics so do FNA is nec p. OR 5 days to a week looks septic and ongoing fevers and leukocytosis might be abscess, so get CT scan and give antibiotics and tak them to surgery for IND, or early satiety weight loss and abdominal pain get CT scan might have pseudo cyst and size and time (<6 weeks and less 6 cm uncomplicated and watch and wait. If >6 weeks or greater 6 cm complicated high chance infection drainage how drain doesn’t matter. Just drain
CT scan good for complications of pancreatitis
NPO, Ivf, pain meds
Triglyceride panel
Chronic pancreatitis
Do not operate ! Pain-give pain meds, might need insulin and enzymes do not remove pancreas do not operate
Cholelithiasis
Mixed cholesterol
Fat female forty fertile
Pigmented-hemolysis
Present-colickyy RUQ pain radiates to shoulder worse with fatty foods
Figure out if have gallstones
Diagnosis-RUQ US see gallstones.
Treat-cholecystectomy elective when pt wants
-can use URODOXYCHOLIC ACID for old people not good surgical candidate
Cholecystitis
Gallstone pops out ends up in cystic duct
Have some inflammation ..proximal to stone inflamed
Gallbladder inflamed
Caused by gallstones in cystic duct see pericholecystic fluid, thickened gallbladder wall and gallstones
Present: constant RUQ pain with positive Murphy’s sign (if stop breathing bc of pain-arrest of inspiration)
Inflammation
Mild fever milld leukocytosis
Diagnosis-RUQ US look for thickened gallbladder wall and pericholcystic fluid …if not show what want get HIDA scan looking for perfusion after inject tracer if have will not fill up of gallbladder.
Treat-NPO, IV fluids, IV antibiotics and cholecystectomy URGENT have to be done 72-96 hours or will get hard and hard to get out…higher conversion to open and bad outcome
Cholecystostomy in non surgical candidate
Choledocolithiasis
Can get inflammation liver with increase AST ALT can get inflammation pancreas with increased lipase and amylase and bc liver continues to make bilirubin excreting conjugated so no where to go…..so first get dilation of duct and eventually bilirubin spill back over into blood and cause jaundice
Gallstones in common bile duct. May have hepatitis, pancreatitis, WILL HAVE JAUNDICE
Painful jaundice
May have Murphy sign
Have inflammation-mild fever and leukocytosis
Diagnosis-RUQ US for obstruction and see dilated ducts wont see an obstructing stone. If US negative get MRCP not HIDA
Treat-ERCP NPO give fluids and IV antibiotics, goal is ERCP
Can also go straight to cholecystectomy
ERCP urgent and then cholecystectomy electively
Flu-can see ball valve effect-stone move up and down get better then worse then better then worse
Cholangitis
Dilated ducts , gallstones in gallbladder and obstructing stone but have stagnant fluid and bacteria grow which ascends the biliary tree
Gallstone in common bile duct with infection usually with gut flora (gram negative rods and anaerobes)
RUQ abdominal pain, jaundice, and fever->charcots triad. If also have hypotension and altered mental status Reynolds pentad
Diagnosis-RUQ US see dilated ducts like in choledocolithiasis wont see stone but effects, then
Treat and diagnose-ERCP EMERGENT
Then can do cholecystectomy usually urgently
If spot want to jump to ercp but while get ready need IV fluid antibiotics and NPO
Antibiotics gallbladder
Cipro(gram neg) and metro(anaerobes)
Ampicillin-gentamicin (gam neg) and metronidazole(anaerobes)
WRONG IF PIP/TAZO bc expensive and covers both and covers gram positive like strep so over covering but done in hospital
Colon cancer diagnosis
Asymptomatic screening , postmenopausal man with iron defiency anemia, change in poop, bowel movement, and weight loss.
Catch with colonoscopy where see cancer (CT scan to stage and chemo radiation), FAP(thousands of polyps in young give colesectomy), polyp
Polyp
Good-small pedunculated, tubular
Bad-sessile no stalk, large and Villous
Look at polyp size a number and decide how soon should come back
- few-come back 5 years
- premalignant lesion-3 years
- a lot or dysplasia-come back every year
Ulcerative colitis
Superficial mucosa of colon
Patient bloody bowel movements rectal pain and weight loss
Get colonoscopy and see continuously inflamed rectum superficial inflammation on biopsy no skip lesions treated medically until 8 years then need colon cancer screening every year and get a prophylactic colectomy . If resect colon they are cured
Crowns disease
Not surgical unless fistula
Trans mural. Skip lesions can connect to other things
Fistula bc fecal soiling
Fistula diagnosis-fistula
Treat-fistulotomy
Better to use meds bc if remove another spot will pop up
Hemmorhoids
Internal -bleed dont hurt
External-hurt and itch but dont bleed
Diagnosis-visual inspection.
Anoscopy in internal hemorrhoids, just peek in through hole
Treat-surgical banding internal hemorrhoids and respecting external hemorrhoids. If remove too much can be left with a scar prevents ability to empty the rectum. BUT not gonna start with surgery start with sitz bath and preparation h
Anal fissure
Tight sphincter
Patient presents pain on delectation lasts for hours, so hold it in and get constipated and tears it even more
Diagnosis-see it
Treat-lateral internal sphincterotomy, nitroglycerin paste, sitz bath, then move to lateral internal sphincterotomy
Anal cancer
HPV=seamen causes squamous cell carcinoma
Patient-anoreceptive see especially men who have sex with men and HIV positive.
Screen with anal pap.
Diagnosis -use chemo and radiation. Usually works, nigro protocol
Pilonidal cyst
Abscess hair follicle
Congenital disease have to have a hairy butt
Diagnose-see
Treat-IND then OR to resect the cyst.
Somatic, visceral and neuropathic pain
Somatic-tissue pain prob with tissue , know where it is can point to it
Visceral pain- hijack the nerves above the skin of embryologist origin, referred…no pain receptors so what organs feel is stretch and obstruction
Neuropathic-damage to nerve, so thing it inner ages is bad and burning sensation pins and needles, nothing wrong. With the organ
Visceral pain forms
Obstructive0must be holoviscous some sort of peristalsis which comes up on obstruction and passes. Colicky in nature and since only in obstruction no fever and no leukocytosis. Think about diseases like cholelithiasis and nephrolithiasis
—no position will be comfortable writhe around
Inflammatory pain-pain becomes constant with fever and can be leukocytosis, person writhing around in agony and no comfortable position , organ is inflamed so think about cholecystitis and pyelonehpritis
Perforation-sick as shit, constant abdominal pain, motionless, moving will hurt, laying still, get an X RAY show free air have to do upright film think of cancer, penetrating trauma, or peptic ulcer dz
Ischemic pain-patient present with pain out of proportion they will be soft and writhing, touch belly soft but bowel is dying and becoming toxic or bloody bowel movement or sepsis think of ischemic injury, ppl with risk factors are CAD, afib and mesenteric ischemia ,
RUG
Lung, diaphragm, liver, gallbladder
LUQ
Lung, diaphragm, spleen,
RLQ
Kidney, ureter, appendix , ovaries and testes, colon
LLQ
Diverticulum, kidney, ureter, still have ovaries and testes
Supra public
Bladder, uterus
Epigastric
Heart, aorta, esophagus, pancreases, stomach,
Chest
Constipation, DNA, MI
Ulcers
Compression, diabetic, arterial insuffiency, venous insuffiency, Marjolin ulcer,
Stage 1
Nonbloody erythema
Stage 2
Dermis
Stage 3
Fascia
Stage 4
Bone muscle
Compression ulcer
Pressure points if lay still putting pressure on the skin you’re going to get micro vascular ischemia and tissue die and get an ulcer. Happen to people bed ridden and wheelchair bound, CONSTITUTES AS ABUSE
Diagnosis-Clinical
Treat-also prevent-roll get out of bed and cushions and air mattress
Diabetic ulcer
Microvascular changes and neuropathy
DM heels and balls of feet, if touch they dont feel
Should do monofilament test
Diagnosis-Clinical
Treat0control DM, elevate leg, amputation and make sure have good shoes inspect feet loose shoes wont compress
Arterial ulcer
Macro vascular
Patient have peripheral vascular disease, look for hairless legs, shiny scaly skin and absent pulses especially in person who smokes a lot ,will get ulcer furthest from vascular supply
If see ulcer tips of toes
Diagnose-get ankle brachial index followed by US Doppler and angiogram
Treat-stent or I pass graft, stent small lesion above knee, bypass large or popliteal
Venous stasis ulcers-cant get blood out
Can’t get blood out
Pt have edema (CHF, cirrhosis)
Hyperpigmentation can get indurated
Medical malleolus-it is venous stasis ulcer
Diagnosis-Clinical
Treat-compression stockings to hel push fluid up, elevate legs, give diuretics
Marjolin ulcer
Squamous cell carcinoma
Present-ulcer with sinus tract or one that breaks down and heals over and over
Heaped up margins
Biopsy Marjolin ulcer and treat with wide resection.
How get breast cancer
Estrogen-early menarche, late menopause, nulliparity, HRT (dont give it too long), OCP are safe.
Radiation-person been treated with radiation for lymphoma leading to increased risk of cancer
3-BRCA1/2
How present with breast cancer
Asymptomatic screen
Breast lump
Obvious breast cancer(skin dimpling , fixed a ill art nodes, large breast mass).
How screen breast cancer
Don’t do self exams
Physician exam NO
Mammogram start at 50 and do every 2 years,
MRI is best way though it is expensive so only use in people wiht high risk people with BRCA and previous radiaiton
How diagnose breast cancer
Get mammogram then biopsy with core needle biopsy. *******
FNA and excision always biopsy when know its cancer
I found a lump what do i do about it
<30, just wait 1,2 cycles and goes away with cycle ignore but if come back and still there get US to tell different between mass and cyst
<30 and cyst on US get FNA (bloody-cancer, pus-abscess, fluid-benign)
<30 cyst and resolves you are done.
> 30 or had mass or bloody or recurred then go back to mammogram core biopsy
Cancer breast treat
Based on stage
Local therapy-procedures radiation, and surgery recast concerving lumpectomy and radiation and auxiliary lymph node dissection (always do sentinel lymph node biopsy before and its negative chances of spreading small not worth doing auxiliary node dissection, positive sentinel do auxiliary lymph node dissection)
Systemic therapy-chemo (doxorubicinwith-cause CHF in dose dependent and irreversible way….get repeat echos. cyclophosphamide and paclitaxel)and
targeted therapy look for HER2-Neu+ give trastuzimab-also causes CHF but nothing to do with dose and reversible still get echos
Her2-Neu negative-bevecizumab
ER/PR+ serms tamoxifen and raloxifen if premenopausal, use aroma tase inhibitors if post menopausal.
Follow up breast cancer
BRCA1/2 should have prophylactic mastectomy and salpingooopharectomy if not increased screening
Tamoxifen-better, cause DVT and endometrial cancer, agonist in uterus
Raloxifen-not as good but no risk DVT or cancer , estrogen receptor antagonist
TEF fistula
Atresia and/or fistula multiple types
Present: gurgling connection food and air hole and bubbling
Diagnosis-coil NG tube get x ray and see coiling
Treat-surgical repair but consider vacterl
Imperforate anus
Mild-close
Severe-distant
Patient present no butt hole
Diagnose-Clinical look
Need cross table x ray to see severity
Treat-surgical mild fix now, if severe give colostomy, and reverse before fixing it before toilet training.
VACTERL
If find any one of them dont just go to surgery first look for ther features
TEF , can INTUBATE?
Echocardiogram can tolerate surgery or another before pick
Look out for diagnostic steps for vacterl before proceed to surgery
Congenital diaphragmatic hernia
Bachdalect posterior
Anterolater morgangi
Hole in diaphragm and bowel into chest
See scaphoid abdomen
Bowel sound in chest
Diagnosis-x ray
Treat-surgery
Premature lung even though normal term may need to INTUBATE and give surfactant to expand lung MANAGE HYPOPLASTIC LUNG
Necrotizing enterocolitis
Premature
Present with bloody bowel movement
Diagnosis:x ray and see air in the wall of the intestine -pneumatosis intestinalis -air in the wall of the intestine
Treat-immediate bowel rest NPO->TPN bowel is dying not sterile put on IV antibiotics. Some babies can get through without surgery but if fail to improve surgery cut out bad segment
Also recognize other diseases of premature infants that can arise
Intracranila hemorrhage, bronchopulmonary dysplasia,retinopathy of prematurity.
Intusseption
Sudden onset ab pain, fetal position better knees to chest relieves the pain
Sausage shaped mass
Currant jelly diarrhea is infarcter bowel -want to intervene before that happens s
Diagnosis-x ray
Treat-air contrast enema both diagnostic and therapeutic.
Biliary atresia
No biliary tree worsening bili 2 weeks
Diagnose US if neg
Phenobarbital and HIDA
Treat-surgery
Choanal atresia
Can’t get air from nose to pharynx
Present-unlatch cant feed blue with feeding
Pink while crying
Hear snoring baby
Diagnosis-passing a catheter can do a flexible scope not necessary
Treat-surgical removal
Endocrine
1watch endocrine lectures
Htn and hypokalemia
Primary hyperaldosteronism(conn)-HTN and hypoK Diagnosis-aldo/renin ratio>20, if positive follow up with salt suppression test, fail to suppress in Conn to then CT MRI, but want to so adrenal vein sampling Treat-resection
RAS-old man with atherosclerosis or young women with fibrovascular dysplasia,
Renal artery stenosis decrease volume to kidney s increase renting and aldosterone . Aldo/renin<10. Do US with Doppler , best test is angiogram
Treat-young woman should be stunted, old guy medically manage by blocking with ACE-I, ARB, or aldosterone antag like spironolactone
Pheochromocytoma
Catecholamines cause HTN and tachycardia 5Ps Paroxysms bc pulsation and random Pressure Pain Palpitations Perspire
Diagnosis-urinary VMA and metanephrines over 24 hours
—then CT or MIBG to identify where it is, renal vein sampling as well
Treat-resect but if poke get HTN crisis, have to reduce BP first catecholamines stimulate alpha and beta so stop both. First have alpha blockade then beta blockade then resection.
Cushing syndrome
Cortisol up
ACTH driven or not?
Present: HTN, diabetic, woman, buffalo hump, striae, moon fancies, acne,
Diagnose -low dose dexamethasone suppression test fail to suppress. Late night salivary cortisol or 24 our urine NEED ONE OF THOSE TWO to support….so Cushing need to know if acth or not. So not acth dependent and acth low it is primary adrenal tumor so get imaging (CT/MRI) Cain sampling ,and resect
If acth elevated it is acth dependent so is it from pituitary or somewhere else. If pituitary can suppress high dose dexamethasone test CUSHING DISEASE PITUITARY ADENOMA GET MRI AND RESECT . If fails then coming from somewhere else and ectopic tumor usually lung cancer, get CT to identify.
Coarctation or the aorta
Somewhere after the great vessels
Torso HTN so legs hypotension
Usually in kids with Claudia toon will refuse to walk bc hurts so stay crawling, arm warm, leg cold.
Teenager or early twenties
Adult-get collaterals or rib notching
Diagnosis-angiogram
Treat-resect and reanastomose
Adults
Murmurs grade 3 or higher or diastolic murmur investigate with echo
Kids diagnose get echo
Aortic stenosis
Path Calcifications
Patient-old men with CAD, CP, syncope, CHG
Heard intercostal space right eternal border, crescendo. Decrescendo in systole and radiates to carotid
Diagnose with echo
Treatment-replacement . Can’t do balloon!
F/u TAVI/TAVR
Mitral regurgitation
Infection, infarction (papillary muscle**(more common or chordae tendinae rupture)
Systolic murmur
Heard best at cardiac apex
Radiates to Avila
Holosystolic
Diagnose: echo
Treatment replacement
Aortic regurgitation
Infection, infarction, dissection
Acute presentation
Or
Chronic (insidious)
Diastolic, heard best at 4th intercostal space left eternal border. Decrescendo, blowing
Diagnosis confirmed by echo
Treat-replacement
F/u CABG
Mitral stenosis
Path: rheumatic heart disease
Heard during diastole at cardiac apex rumbling murmur with opening snap -occur earlier the worse the murmur is. May present with CHF or Afib
Diagnose echo
Treatment medical therapy, can do balloon valvotomy, replaced.
Bovine organic valves replaced
<10 years and dont need anticoagulation
Mechanical valve
10-20 years last
Need anticoagulation
Warfarin INR 2.5-3.5
CAD
Obese, HTN, DM female over 55, male over 45
Present: substernal chest pain , worse pain with exercise, improved with nitroglycerin and rest
Diagnose-ekg->STEMI to cath emergently
EKG normal troponins elevated ->cath urgently
If no change get stress test and have symptomatic CAD->left heart cath
Treat LIMA tether to most important artery. Every other vessel with saphenous vein graft and bypass other blockages you can find after put on bb, aspirin, ace-I and statin
Cath 1-2 vellels
Stent and clopidogrel
Cath 3+ vessels or left main stem equivalent (left main or LAD and left circ)
CABG
AAA
Product of atherosclerosis
Male, smoker(d)
Asymptomatic pulsating mass.
Diagnose-men over 65 who ever smoke get one time screen
Or get CT scan for ab pain and happen to identify but US is right.
Treat >3.5 screen every year
>4.5 cm get rescreened every 6 months
>5 cm or growing .5 cm per 6months go to surgery
Endovascular repair=open fix
*person old smoke but tender pulsation mass and back pain means about to burst take to OR immediately
Aortic dissection.
HTN , mar fans, syphilis
- Tearing chest pain radiates to the back2. Asymmetric BP arm to arm
- Widen mediastinum
Ascending-A
After great vessels-type B descending
Diagnosis-CT angiogram looking for false lumen
TEE=MRI if cant do CT angiogram
Treat A-operate and replace the aortic valve
Treat B-treat medically get BP and HR down with IV BB
Peripheral vascular disease
CAD in a different place. Associated wiht Cholesterol, DM, HTN, smoker, women
Present with leg claudication pain distal to obstruction. If butt pain aortic problem
Or
Non healing wounds
If severe have pain at rest or change position)leg pale dangle purple ad blood return)
Physical-shiny shins or loss of hair PVD. Problems with pulses and cooler temperatures especially left to right.
Diagnose-ankle brachial index .if>1.4 calcified have to. Go to toe brachial index 1-1.4 normal .9-1 equivocal-get exercise ABI .8-.9 mild .4-.8 mod
Acute limb ischemia
Path cholesterol following cath . Embolism-afib. thrombus form on top of PVD no time to get collaterals Pt Pulselessness Pallor Poikilothermia(cold limb) Pain Parasthesias Paralysis
Diagnosis-US Doppler angiogram
Treat embolectomy or TPA
NoteL assess compartment syndrome in anyone refer fused
Closed glaucoma
Path: pressure after dilation
Present low light causes pupils to dilate
Flow out of chamber decreases
Increased pressure=eye pain, HA, rigid eyeball
Increased pressure=worsens condition dilated pupil that’s non reactive
Diagnose-Clinical measure ocular pressures
Treat-constricted pupil
Activate alpha block beta
and relieve pressure with laser drill hole in eyeball
Never give atropine will precipitate acute crisis.
Periorbital cellulitis
Inflammation around eye region
Can they move their eye? If yes its a periorbital cellulitis just need antibiotics get CT scan and if find something treat with I and D, antibiotics.
F/u DM/DKA consider mucor=amphotericin B
Corneal abrasions
Path-something getting in the eye
Pt hobby/job without goggles
Pain, tear, red
Treat-irrigate a lot
Diagnosis-flarevn dye
With or without surgery
Retinal detachment
Path-trauma=mva or HTN crisis.
Floater-mild
Curtain-severe
Diagnosis-Clinical retina not attached
Treat-spot weld with laser
If floaters or curtain come and go it is anorasir fugox impending retinal artery occlusion
Retinal artery occlusion
Path-eye stroke. Painless acute loss of vision 1.unilateral painless vision loss No other focal neurologic deficits Cherry red spot in the fovea
Diagnosis-Clinical
Treat-stroke intra arterial TPA
Hyperventilation, global pressure
Cataracts
Age and DM
Present chronic, progressive vision loss
Night vision
White thing in anterior chamber
Diagnosis clinical
Treat resection
Macular degeneration
Wet (20%) dry (80%)
Pt chronic progressive loss of central vision diagnose wet: blood/fluid
Dry drusen and pigment changes
Treat wet laser
Treat dry nothing
Substrate for skin cancer
Jobs in sun-navy and ships, outdoor labor, farmer, construction, landscaping
Areas that get sun-face and hands, back of shoulders
Sun people -people with fair skin and fair hair
Bad burns previously
Prevent with wide brim hate sun screen and avoidance of the sun
Basal cell carcinoma
Cancer of basal layer
Will not metastasize but locally invade
Present-pearly lesion on sun exposed areas. But also described as lesion that fails to heal and bleeds easily.
Diagnosis-excision always biopsy (incisional biopsy)
Treat-face-mohs, limb-excision always biopsy, limb aggressive-amputate limb
Squamous cell carcinoma
Path-keratinocytes
Can metastasis and locally invade
Present-well definedred papules or like Marjolin ulcer that heals and breaks down over and over
Lower lip hyperpigmentation. Do after squamous cell carcinoma.
No paraneoplastic syndrome
Diagnose same as BCC
Treat BCC
Melanoma
Path-melanocytes
Metastasize and can locally invade tiny lesion may kill you
Hey black lesion without any hair ABCDE Asymmetric Irregular borders Colors Diameter 5 mm Evolution over time
Diagnosis-punch biopsy=large lesions and los suspicion , excisional biopsy when small or high index of suspicion. BRESLOW depth
Treat-how deep tumor went
4 mm-chemo and radiation. Already been metastasized and debulking for palliative care.
Subarachnoid hemorrhage
Aneurysm either leaks or bleed and got HTN generally (sex, exercise causes rupture)
Thunderclap headache, may have history of sentinel bleed
Neck stiffness to HA, FND, COMA
Diagnosis-CT scan of the head if negative can get LP-looking for old blood xanthochronia
Bleeding in meninges blood filling cisterns or ventricles
Once make diagnosis look at vessels with MR/CT angiogram
Treat-early(within 48 hours)-bleeding decrease MAP <140/90 with IV BB CCB then coiling or clipping -hydrocephalus do serial LP or VP shunt. .
Late(5-7d)-seizures prophylactic with levetiracetam, increased ICP give hypertonic solutions like mannitol or hypertonic saline, elevate bed, hyperventilate. -vasospasm-CCB if it happens increase BP with vasopressin if fail not for test just for wards
Intraparenchymal hemorrhage IPH
Path-HTN,
Present-FND< HA, N/V, coma
Diagnosis-CT scan
Treat-decrease CIP, craniotomy if need, evacuate hematoma
Follow up with daily CT scans looking for expanding hematoma may crosss midline. Midline shift eventually herniate . Uncalled herniation through foramen magnum fixed dilated pupils and dead.
Brain cancer
70% metastatic -lung, breast, GI, melanoma
See multiple lesions stuck at the grey white junction
30% primary-never metastasize brain cancer doesn’t leave he brain
Present-FND, seizure, HA, N/V
Diagnosis-neuroimagine, MRI if contrast able yes>CT try to give with contrast
Biopsy
Best MRI, biopsy
Treat-resection, radiation, chemo , steroids(palliative only), seizure prophylaxis for everyone with brain tumor
Craniopharyngioma
Asymptomatic pituitary tumor in kids
Short stature bc consumes hormone producing centers
Calcification of the sella on CT or xray
Can resect
Anterior vs posterior
Anterior-adults
Posterior-peds
Pituitary tumors
Prolactinoma, acromegaly, craniopharyngioma
Posterior tumor
Medulloblastoma, ependynoma
Both hydrocephalus
Meduloblastoma-highly malignantand seeds arachnoid space and spreads can get distal spinal cord lesions
Do surgery and radiation with it to get after lesions.
Ependymoma-4th ventricle obstructive hydrocephalus predominates look for kid that’s better int he fetal position, not distal lesions so just do resection
Anterior tumors
Meningioma-product of dura, can diagnose on CT and resection is curative and reverse FND
Glioblastoma -in parenchyma, highly necrotic and mitotic can try to resect dismal prognosis of less than a year, ring enhancing lesion or bats wing deformity.
Urethra pets pathology
Posterior urethral valve,
Hypo/epi spadias
Bladder
Hematuria(non glomerular)
Level or ureters
Ureteropelvic junction obstruction
Ectopic ureter-low implantation
Vesiculouretreal reflux
Level of kidney
Malignancy(wilms)
Hematuria (glomerular)
Hematuria
U/A to see if micro or macro
Micro-self limiting unless blunt trauma then do CT scan otherwise watch and wait..
Macro-need more-look at urine micro
- dysmorphic cells or RBC cast-glomerular disease so get U/A and kidney biopsy
- normal RBC and no casts have nonglomerular causes (in lumen for kidney to urethra, trauma, stones, cancer) first get US then cystoscopy versus systemic imaging like ct or MRI
US
1st step usually
Hydro or not-usually obstruction, but in kids can also be reflux so differentiate this with VCUG
VCUG
Put cath in inject dye in dye should go out, but if ends up in ureters sign reflux. So reflux or no. AfterUS can show diverticula too
Is hydro from reflux
CT scan/cystoscopy
Usually as last steps to investigate if bleeding/lesion is in lumen or on top of kidney
CT-trauma also use IV contrast want to know if leaking.
-if think there are stones use non contrast wanna see radioopaque stone and contrast is radiopaque
Cystoscopy-intraluminal , access to ureters so can also fix
Posterior urethral valves
Baby cant get urine out of bladder from day 1
Redundant tissue causes a post o structure uropathy
Present-oligohydramnios during pregnancy, no urinary output and a distended bladder, prenatal US, increased CR
Diagnosis-US, show hydro
then VCUG to rule out reflux, start catheter and get massive urinary output
Treat-catheter
Hypo/epispadias
Path-
Epi dorsal, hypo ventral
Present-Clinical
Diagnosis-Clinical
Treat-never do a Circumscision!! Need the extra tissue to rebuild the urethra, will need to foreskin to reconstruct
Ureteropelvic junction obstruction
Narrow lumen -normal for must of life but when have increased flow they simulate an obstruction.
Present teenager been through life wiht no difficulty first alcohol binge and large diuretics gives colicky abdominal pain that spontaneously resolves
Diagnosis US see hydronephrosis without hydroureter
VCUG to rule out reflux,
Treat-surgery may stent
Ectopic ureter/low implantation
Normal=bladder
Abnormal-ectopic
Boys completely asymptomatic
Girls normal urinry behavior and have constant leak never have been dry
Diagnosis US
VCUG
Radionucleotide
Treat-reimplant
Vesiculoureteral reflux
Path-retrograde flow
Patient-diagnosed on prenatal US showing hydro
Recurrent UTI if not diagnosed prenatal and pyelonephriritis (not good reason to have it in kids so have this)
Diagnosis-US hydro
VCUG-+ reflux
Treat-suppressive antibiotics if not severe and grow out
Or surgery
Prostate cancer
5-DHT
Old men over 70
Screen if has family history
Think about it when have obstructive symptom of BPH diagnosed on DRE find firm NODULAR prostate***
Diagnosis-if firm NODULAR prostate get PSA if elevated get a biopsy transrectal (usually cancer is posterior so rectal sample best or transurethral
Gleesan score? Higher more likely prostate cancer
Treat-resection=radiation=brachytherapy and can use anti androgens like flutamide, GNRH analogs like leuprolide, can do bilateral orchioectomy (if very old bc it is testosterone driven
F/u with PSA if haverise in PSA but no signs it is biochemical evidence of recurrence and use antiandrogens. If symptoms and increased PSA use radiation and antiandrogens.
Bladder cancer
Transitional cell carcinoma associated with beta alanine dyes, and smoking.
Present with painless hematuria may also see obstructive symptoms if just have hematuria: US, but best is cystoscopy!!!!** bc look up and take a biopsy.
Treat-remove transurethrally andgive intravesicular BCG or chemo
Only remove bladder if invasive to muscular or a lot of recurrences(cystectomy)-if do chemo cisplatin based
F/u cystoscopy regularly and remove
Testicular cancer
Germ cell
Young male
18-35
Painless mass does not transiluminate (means solid mass not fluid)
Diagnosis: US DO NOT DO VIOPSY..orchioectomy
Treat-resect
And separate into seminoma(cisplatin chemo and radiation) and non seminoma (endodermis sinus tumorAFP, choriocarcinoma bHCG, teratomas (being in women malignant in men)
Just remove it do not biopsy
Renal cell carcinoma
Flank pain, palpable mass, painless hematuria , paraneoplastic of erythrocytosis, anemia
Diagnos-CT scan and nephrectomy to diagnose.
Treat-resect
BPH
Prostate enlarges and closes urinary flow
Over 50, lower urinary tract symptoms, DRE smooth rubbery prostate
Diagnosis-UA, urinary culture which willl be negative.
Treat-alpha blockers tamsulosin most bladder specific least orthostatic hypotension. Add 5-a reductive inhibitors like finasteride undo the BPH part willundo the blockade help down road while tamsulosin helps now
If fail TURP-but can causes incontinence or ED
F/u obstructive uropathy from BPH have put in catheter before TURP
Never biopsy for BPH , dont do a PSA
Erectile dysfunction
Psych or organic
Inability to acheive or maintain an erection
Diagnose-night time tumescence take if breast its psych
If not break then cant get erection and its an organic disease
Organic treat-phosphodiesterase inhibitors , pumps, prosthesis
F/u no nitrates with phsophodiesterase inhibitors
Testicular torsion
Testicle twists about pedicle
Spontaneous pain horizontal lie, pain on elevation
Diagnosis-US with Doppler shows no blood flow
Treat untwist OR emergency if stay gross after surgery remove it
Do bl orchiplexy if one does it other can do it too. If remove one tac down the other
Epididymitis
Infection of epididymitis <35 STD, >55 E. coli
Spontaneous scrotal pain testical in vertical lie and relief of pain on elevation
Diagnosis US with Doppler to r/o torsion
Treat-<45 ceftriaxone and azithromycin if >55 use ciprofloxacin (fluoroquionlone)
Prostate tissue
Bacterial or inflammatory? Must separate bc treatments are different
Present old male with pyelo, urgency dysuria, frequency, vomiting but no CVA tenderness or casts in urine and DRE very tender.
Treat never repeat the DRE bc increase chance of send to blood stres
Diagnose-UA and urine culture
Treat antibiotics if bacterial,NSAIDS if inflammatory
Kidney stones
Calcium oxalate most common
Colicky flank pain radiates to groin often with hematuria
Diagnosis-UA, non contrast CT of abdomen ->US look for hydro if pregnant ofcant do CT
Treat
Carpal tunnel
Inflammatory disorder compression of median nerve
Control sensation and move first three digits
Ulnar digits four and five sensation and motor
Pain progress to paresthesias->paralysis in first three digits
Flexion make symptoms worse phablets sign , tap on median nerve tinsel’s sign worse, the air atrophy
Hypothyroid, DM, ppl moving, pregnant
Diagnosis-EMG
Treat-1. Splinting and NSAIDS,2. Interarticular steroids. 3. Surgery
F/u could be presenting symtpom of rheumatoid arthritis
Jersey finger
Tear flexor tendon patient cant flex that finger . When make a fist that finger stays up open hand and try to close that finger remains extended
Diagnosis clinical
Treatment-splinting NSAIDS, steroids, surgery last resort
Mallet finger
Catching some sort of ball. Tear extensor tendon . Can’t extend digit person makes fist fine try to open bad finger doesn’t go up. Can I’ve passively
Diagnosis clinical
Treat standard. 1 splint NSAIDS, steroids, surgery last
Trigger finger
Can’t extend digit a stenosis tenosynovitis inflammation compresses the tendon when forced into extension there is a pop.
Diagnosis clinical
Treat standard splint NSAIDs, steroids, surgery.
Dequervain tenosynosynoviitis
Path: tendinitis
Thumb pain -pregnant, men lifting weights
Diagnosis: fist thumb twist test(thumb inside fist stretches tendon hurts
Treat-splinting NSAIDs, steroids, then SURGERY IS NOT AN OPTION BC inflammatory dz
Duputyreins contracture
German and Scandinavian men
Present: contracture fascia balls up and pulls fingers together, inability to extend and palpable fasciae nodules on palm and hand contracture
Diagnosis-clinical
Treatment-release surgically fasciae dz NSAIDs dont do anything
Felon
Abscess of pulp of the finger. Pain, fever, leukocytosis
Usually from penetrating injury
Diagnosis-Clinical
Treat-IND…rarely may need antibiotics
Fracture
Two x rays perpendicular to each other
Pain, swelling
Treat with open reduction internal fixation (open, angular, comminuted) OR casting (hope line up right way have to have closed wound with good approximation)
Open-go to OR for emergent wash out
Anterior dislocation
Any trauma
Abducted and externally rotated as though shaking hands
May have deltoid paresthesias bc of Szilard nerve
Diagnosis-Clinical can get x ray
Treat-relocate and sling
Posterior dislocation
Massive trauma-MVA, seizures, lightening strike
Abducted and internal rotated
Diagnose x ray
Treat relocate sling
Collies fracture
Old lady fall on outstretched wrist common osteoporosis fracture radius and ulna dorsally displaced
Diagnose x ray
Treat cast or surgery
Monteggia fracture
Upward block downward blow
Ulna breaks, radius dislocated
Diagnose x ray
Treat cast vs surgery
Galezzia
Downward block
Upward blow
Breaks radius and displaces ulna
Diagnose x ray
Treat surgery vs cast
Scaphoid fracture
FOSH not old lady then pain at an atomic snuff box
X ray-normal
Cast anyways bc turns positive
Don’t want a vascular necrosis
Boxers fracture
Punch against wall where fourth and 5th digits break
Hip fracture
A lot of trauma or old lady wiht osteoporosis
Leg shortened and externally rotated want make sure ok pulses below
Femoral head had tenuous vascular supply so if have fracture of femoral head will have to do prosthesis
Intratrochanteric fracture-use plates
Shaft-use rods
Open-emergency wash out in OR traction will help
Rehabilitation
ACL/PCL injuries
Locked leg with some sort of force
Posterior trauma-ACL injury anterior drawer sign
Anterior trauma=PCL injury posterior draw sign
Diagnosis-MRI
Treat surgery(athletes) Casting (everyone else)
MCL/LLL
Valgus-MCL
Varus-LLL
Hit from lateral side injur MCL called valves stress and opposite
Diagnosis MRIsurgery(athletes) Hinge cast(everyone else)
Meniscus
Knee pain and click on extension
Diagnosis MRI
Treat arthroscopic repair
Stress fracture
Weekend warriors or forced march
Xray-normal probably
Cast anyway with crutches
Back in few days x ray positive
Tib/fib fracture
Usually both together
Trauma-fall from height, pedestrian struck
Diagnose-X ray
Treat cast or surgery
Ankle fracture
Over eversion
Over inversion
Pain and swelling after and is non ambulatory (if can walk dont need x ray)
Diagnosis x ray
Treat surgery
Achilles’ tendon
Run hear pop then they limp reach back gap where tendon should be
Diagnosis clinically
Treat cast takes months to heal
Surgery takes weeks
Compartment syndrome
When reperfuse ischemic injury get edema and if get tense can shut off vascular supply
Upon repercussion if get tense painful leg that is hard as rock if elevated compartment pressure do fasciotomy
