Surgery Flashcards
who is at the greatest risk for a hepatic adenoma
young women on prolonged oral contraception
- most are fine
- life-threatening complications can occur like malignant transformation or rupture can occur
-consider rupture in the setting on sudden-onset, severe right upper quadrant pain and signs of hemorrhagic shock
patient with puncture wound through shoe then gets osteomyelitis
pseudomonas osteomyelitis
-usually takes > 2 weeks
if pt has penetrating abdominal trauma, hemodynamic instability, peritonitis, evisceration, or impalement… whats your next step
exploratory laparotomy
how to manage uncomplicated renal stones (< 1 cm)
hydration, analgesics, alpha blockers
-list of alpha-blockers: tamsulosin and -osin
what is a potential complication of an epidural nerve block
-pt may present with progressive motor/sensory dysfunction, localized back pain, bladder/bowel dysfunction
spinal epidural hematoma
- more common in older people taking antithrombotics
- manage with urgent MRI and neurosurgical decompression
2 main signs that should prompt surgical exploration
free air on x-ray
clinical signs of peritonitis
what is malignant hyperthermia and when/how does it present
- genetic mutation altering intracellular calcium triggered by volatile anesthetics, succinylcholine, excessive heat
- manifests as: masseter/muscle rigidity, sinus tachy, hypercarbia, rhabdo, hyperkalemia, and late you’ll see hyperthermia
- can occur during or even be delayed till after youre done with anesthesia
- treat with respiratory/ventilation support, stop cessation of causative anesthetic, and dantrolene
what is a HIDA scan
aka. cholescintigraphy
most common symptom of pancreatic cancer and how do you test for it
insidious, continuous midepigastric pain that radiates to back/flanks and is worse with eating or lying down
-get abdominal CT as first step when suspected
cardiac myxoma
usually in LA
benign tumor but bits of it can embolize
tender, erythematous streaks proximal to wound
Lymphangitis
- regional tender lymphadenopathy (lymphangitis)
- systemic symptoms (fever, tachycardia)
- usually due to strep pyogenes and MSSA
- treat with cephalexin
what correlates to medullary thyroid cancer metastasis
neuroendocrine malignancy –> calcitonin secreting parafollicular C cells
calcitonin correlates to metastasis
how to manage osteoarthritis
- non-pharm –> exercise and weight loss
- topical or oral NSAIDs
- surgery or chronic pain management
how does the body get rid of low molecular weight heparin
renal removal
infection w/i retropharyngeal space can drain where..
into the superior mediastinum which can cause acute necrotizing mediastinitis
what is one of the first signs of IBD
toxic megacolon
- systemic toxicity (fever, tachy, hypotension)
- bloody diarrhea
- abdominal distension/peritonitis
- marked colonic distension on imaging
- treat with bowel rest, NG suction, abx, corticosteroids if IBD is associated, surgery if unresponsive to med management
description of giant cell tumor
only epiphyseal tumor
looks like soap bubble on x-ray
acute knee pain associated with catching or reduced range of motion suggests what…
- likely with crepitus too
- acute popping sensation may occur
- slow-onset joint effusion
meniscal tear
- persistent symptoms should have eval with MRI
- may need
how to initially manage patients with large surface area (> 20%) burns
extensive burns can lead to hypovolemic shock due to large release of proinflammatory mediators that increase vascular permeability and can cause third spacing of fluid
MANAGE WITH EXTENSIVE FLUID RESUSCITATION
-use parkland formula to figure out how much
-titrated to maintain adequate urine output
-put in urethral catheter to monitor
what is one of the earliest manifestations of autosomal dominant polycystic kidney disease
hypertension
- likely results from cyst expansion leading to localized renal ischemia and consequent increase in renin production with activation of RAA axis
- best treated with ACE inhibitors
biggest risk factor for pancreatic cancer
smoking
3 ways to assess for a melanoma
- ABCDE (more than 1 or 2 is suspicious) –> asymmetry, borders, color variation, diameter > 6mm, evolving appearance over time
- 7-point checklist (> 1 major or > 3 minor criteria is suspicious) –> MAJOR: change in size, shape, develops nodularity, or color MINOR: size > 7mm, local inflammation, crusting/bleeding, sensory symptoms like itching or bleeding
- ugly duckling sign –> one lesion significantly different from the others on the patient
if a patient has RA and then is slowly developing UMN and other nerve problems, what should come to your mind?
cervical myelopathy
- atlantoaxial instability which can be made worse if a pt needs to be intubated
- slowly progressive, spastic paraparesis involving upper and lower extremities, hyperreflexia, sensory changes, and a positive babinski sign
- hoffman sign may also be positive
patient who develops acute abdominal pain, shock, and anemia in the setting of one of the following likely has what
- hematologic malignancy
- infection
- systemic inflammatory disease
- anticoagulation
atraumatic splenic rupture
how to search for epiglotitis
get lateral neck radiograph to look for enlarge epliglotti s
50% of pts get what after a coronary artery bypass graft operation
pleural effusion, usually on the left side
-if its small, occurs shortly after surgery (post op day 1 or 2), and creates no respiratory problems then you can just observe it to make sure it goes away on its own
initial diagnostic study for hemodynamically stable pts with aortic dissection
CT angiography – reveals intimal flap separating true and false lumens
ulcerated tonsillar lesion in pt with long smoking history
oropharyngeal squamous cell carcinoma
what are the signs of a necrotizing surgical site infection
- pain, edema, erythema spreading beyond surgical site
- systemic signs: fever, tachycardia, and hypotension
- paresthesia or anesthesia at wound edges
- purulent, cloudy-gray discharge (dishwater drainage)
- subcutaneous gas or crepitus
-treat with parenteral abx and urgent surgical debridement
patient has intraperitoneal air on x-ray what do you think
possible peptic ulcer perforation and they need surgical exploration
classic triad for spinal epidural abscess and what is the progression
- epidural anesthesia is a common trigger due to direct inoculation
- if you suspect it then get spinal MRI
- treat with surgical decompression and antibiotics
- fever
- focal/severe back pain
- neurologic findings (motor/sensory change, bowel/bladder dysfunction, paralysis)
progression: focal back pain –> nerve root pain –> motor weakness, sensory changes, bowel/bladder changes –> paralysis
patient comes in with kidney stone in urethra, at what size do you change management of stone?
stone size < 10mm –> medical management with hydration, pain control, alpha blockers, and strain urine (can be done outpatient)
-if that doesnt work/help or pt has uncontrolled pain with no stone passage in 4-6 weeks then get a urology consult
stone size > 10mm –> urology consult
- note that most ureteral stones < 5mm in diameter pass spontaneously and alpha blockers can be used to help stones 6-10mm
- if larger than 10mm, refractory pain, anuria, aki, urosepsis then consult urology
pt has abdominal/flank/groin pain, pulsatile mass, flank ecchymosis, and limb ischemia
what do you think
unstable abdominal aortic aneurysm
how do you work up a suspected aaa in a stable pt
CT scan
3 local complications of cardiac catheterization
- hematoma (possible mass)
- pseudoaneurysm (bulging pulsatile mass with systolic bruit)
- AV fistula (no mass with continuous bruit)
if a pt has celiac disease what should be an additional concern
osteoporosis due to vitamin D malabsorption
Patient presents with hypoxia, characteristic pulse ox of ~85% with a large oxygen saturation gap
Acquired Methemoglobinemia
- results from oxidation of iron hemoglobin
- due to topical anesthetic agents or dapsone
pilonidial cyst/disease
- most frequently affects males age 15-30
- obese individuals
- most common symptom is a painful, fluctuant mass on the upper coccyx with mucoid, purulent, and bloody discharge
what is the best way to diagnose diverticulitis
abdominal CT with oral or IV contrast
whatre the surgical indications for pts with cerebellar hemorrhage
- signs of neurologic deterioration
- radiologic evidence of hemorrhage > 3mm
- brainstem compression
- obstructive hydrocephalus
patient had gastric bypass and then presents with abdominal pain, bloating, flatulence, malabsorption, weight loss, anemia, vitamin deficiency
small intestinal bacterial overgrowth
-dx with jejunal aspirate and culture > 10^3 or carbohydrate breath testing
what predisposes someone to small intestinal bacterial overgrowth
conditions that alter intestinal mobility
- systemic sclerosis
- diabetes
anatomy problems
-stricture
gastric/pancreatic secretions
- atrophic gastritis
- chronic pancreatitis
patient has whip-lash like injury in the setting of underlying cervical spondylosis… what do you think of
central cord syndrome
-presents only with upper extremity abnormalities
patient with post-op hypotension, distended JVD, and new onset right bundle branch block
massive pulmonary embolism
in a transfusion problem how do you tell the difference b/w TRALI and TACO
TRALI (transfusion related acute lung injury)
- no JVD
- normal ejection fraction
- normal BNP
TACO (transfusion associated cardiac overload)
- JVD present
- possible S3 present
- decreased ejection fraction
- high BNP
if you suspect appendicitis in a non-pregnant adult then how do you diagnose it
abdominopelvic CT
cushing triad
used in late stages of acute head injury due to increased intracranial pressure
- hypertension
- bradycardia
- irregular respirations
If a trauma pt is presenting with blood loss but none is found intraperitonealy or pericardially then where do you look or what do you think of
pelvic fracture where the blood is “hidden” in the retroperitoneal space
-hemorrhagic shock is most common in trauma pts
mnemonic for lots of blood loss in trauma pt
blood on the floor and 4 more
- external bleeding on the floor up to entire blood volume
- chest: up to 40% of blood volume/hemithorax
- abdomen (peritoneal cavity): up to entire blood volume
- pelvis: up to entire blood volume and usually its hidden in the retroperitoneum
- thigh: up to 1-2L of blood
patient has significant head trauma that leads to ipsilateral hemiparesis, ipsilateral mydriasis, and strabismus, contralateral hemianopsia, and altered mentation
transtentorial herniation of parahippocampal uncus
major risk factors for development of acute urinary retention (AUR)
- dx with bladder ultrasound
- pt presents with agitation, tachycardia, lower abdominal/suprapubic tenderness
male sex advanced age (>80) history of BPH history of neurologic disease surgery
patient has elevated alk phos and elevated GGT with mild focal dilations within both intra and extra-hepatic biliary ducts
primary sclerosing cholangitis
-associated with UC so patients should get colonoscopy
- patients have fibrous obliteration of small bile ducts with concentric replacement by connective tissue in onion-skinning pattern
- complications: biliary stricture, cholangitis/cholelithiasis, cholangiocarcinoma, colon cancer, biliary cancer, cholestasis (decreased fat-soluble vitamins, osteoporosis)
how does care change with a breast mass in pts above or below 30
below 30: ultrasound with maybe mammography then if simple cyst get needle aspiration if pt wants it, but if complex cyst/mass then get image-guided core biopsy
30 or above: mammography with maybe ultrasound then if suspicious for malignancy get core biopsy
patient with blunt trauma and renal injury
get CT of abdomen and pelvis
charcots triad vs reynolds pentad
signs and symptoms suggesting obstructive ascending cholangitis (infection of biliary system) TRIAD 1. RUQ pain 2. fever 3. jaundice
PENTAD
- shock (hypotension, tachycardia)
- altered mental status
patient presents with the following below, how do you diagnose them
- jaundice, pruritis, acholic stools, dark urine
- weight loss
- RUQ pain
- RUQ mass or hepatomegaly
- increased direct bilirubin, ALP, GGT
malignant biliary obstruction dx via -serum tumor markers: CEA, CA-19, AFP -abdominal imaging: ultrasound, CT scan -EUS or ERCP for tissue diagnosis if unclear
how to treat septic arthritis
IV abx and adequate drainage of purulent material via needle aspiration, arthroscopic irrigation, or open surgical drainage
note that serial procedures are often required to completely clear the infection
diabetic pt presents with fever, RUQ pain, nausea/vomiting, crepitus in abdominal wall adjacent to gall bladder
-additional risk factors are vascular compromise and immunosuppression
emphysematous cholycystitis
- dx: air-fluid levels in gallbladder, gas in gallbladder wall, cultures with gas forming Clostridium or Ecoli, unconjugated hyperbilirubinemia, mildly elevated aminotransferases
- treatment: emergent cholycystectomy with broad spectrum abx that include clostridium coverage (penicillin-tazobactam)
risk factors for different types of esophageal cancer and how to initially look for it
(distal esophagus) adenocarcinoma: uncontrolled GERD, obesity, male –> presents with solid food dysphagia
(proximal and mid esophagus) squamous cell carcinoma: smoking, alcohol, n-nitros containing foods (processed meat)
*do upper endoscopy for both with biopsies while CT and PET scan can be used for staging
hemobilia
bleeding into the biliary tract
- rare cause of upper GI bleeding that usually occurs as complication of hepatic or biliopancreatic procedures
- presents with RUQ pain, jaundice, and upper GI bleeding
how to manage hemothorax
tube thoracostomy is usually sufficient but pts need emergent thoractomy for extreme bleeding
-initial bloody output > 1,500mL or persistent hemorrhage > 200mL/hr for > 2hrs or continuous need for blood transfusion to maintain hemodynamic stability
*used to prevent exsanguination
compare and contrast basal cell carcinoma and squamous cell carcinoma
basal cell: pearly, flesh colored pink nodule with telangiectatic vessels is usually found on head or neck. most common skin malignancy
squamous cell: most common skin malignancy in pts on chronic immunosuppressive therapy or history of organ transplant or burn pts/sun exposure, very aggressive and can cause drainage
shin splints vs stress fracture
stress fracture will have point tenderness but shin splints will have diffuse tenderness on anterior shin
narrowed intercostal spaces and mediastinal shift toward problematic lung on x-ray
bronchial mucus plug
if pt has spinal cord compression due to spinal injury/malignancy/infection… what do you do
- emergent MRI
- IV glucocorticoids
- neurosurgery +/- radiation oncology consult
patient with turners syndrome gets pregnant, what are they at increased risk for?
aortic dissection due to hemodynamic changes of pregnancy placing additional strain on aorta
lateral wrist pain, overuse syndrome involving tendons of abductor pollicis longus and extensor pollicis brevis
-occurs most commonly where tendons pass under extensor retinaculum in first dorsal compartment
de Quervain tendinopathy
patient has abdominal distension then has persistent bloody ascites found on multiple paracenteses suggests what
underlying malignancy
-most common is hepatocellular carcinoma
flank pain and hemodynamic instability
possible ruptured abdominal aortic aneurysm
how to test for PE in clinically stable patient
CT angiography
3 main components to glascow coma scale
eye opening
verbal response
motor response
how to treat pts with hypercalcemia due to immobilization
its due to increased osteoclastic bone resorption so giving bisphosphonates helps
ottawa ankle rules
tells you when to get plain radiographs of ankle with pain of malleolus
-point tenderness over posterior margin or tip of malleolus
OR
-inability to bear weight after injury and for 4 steps during medical evaluation
patient presents with leg injury and pain increased on passive stretch with parethesia
- also pain out of proportion to injury
- rapidly increasing and tense swelling
compartment syndrome
patient presents with insidious onset of flank pain and systemic symptoms (fever, weight loss)
- usually with history of UTI or extrarenal infection (bacteremia) in last 2 months
- urinalysis shows pyuria, bacteriuria, and proteinuria but can be normal
renal and perinephric abscesses
-urinalysis will be normal if abscess is not in contact with collecting ducts
pt with severe hypertensiona dn recurrent flash pulmonary edema in the setting of diffuse atherosclerosis suggests….
renal artery stenosis
- associated findings: CKD, secondary hyperaldosteronism (hypokalemia, elevated serum bicarb)
- dx with renal ultrasound with doppler
how to treat aortic dissection
pain control
IV beta blockers
maybe sodium nitroprusside (if SBP >120)
emergent surgical repair for ascending dissection
risk factors for atherosclerosis
diabetes
hypertension
smoking
if patient discusses occasional leg cramping what do you think of so what do you do
intermittent claudication
-ABI (ankle-brachial index) = SBP of dorsalis pedis or posterior tibial artery / SBP of brachial artery
-ABI Scores
less than 0.9 = PAD
0.91-1.3 = Normal
more than 1.3 = calcified and uncompressible vessels
expected labs with normal pressure hydrocephalus
ventriculomegaly with normal opening pressure on lumbar puncture
- not all symptoms (wet, wobbly, wacky) may be present in early disease
- can be due to secondary insults to brain: subarachnoid hemorrhage, trauma, meningitis all due to scarring of arachnoid granulations responsible for CSF
how to treat normal pressure hydrocephalus
ventriculoperitoneal shunting
chronic alcohol use disorders and postprandial epigastric pain should lead you to think of what and what do you see on paracentesis
chronic pancreatitis
-paracentesis: serosanguinis/yellow fluid with high amylase, high total protein, and low serum ascites albumin gradient
patient has a history of forceful retching then has epigastric/back/retrosternal pain, what are the two things on the top of your differential and describe them
Mallory-Weiss tear
- mucosal tear
- submucosal venous or arterial plexus bleeding
- hematemesis (bright red or coffee ground appearance)
- possible hypovolemia
- upper GI is diagnostic and therapeutic to treat persistent bleeding
- manage with acid suppression but most heal spontaneously
Boerhaave syndrome
- transmural tear
- spillage of esophageal air/fluid into surrounding tissues
- crepitus, crunching sound (Hamman sound)
- odynophagia, dyspnea, fever, sepsis
- CXR can show pneumothorax, pneumomediastinum, pleural effusion
- esophagography or CT with water soluble contrast to confirm
- manage with acid suppression, abx, NPO and emergency surgical consultation
patient has recent T2DM diagnosis, what are they now at a higher risk for
pancreatic cancer
25% of pancreatic cancer is heralded by recent < 2 year dx of DM
how to transport an amputated body part to be attached
transported by wrapping it in saline-moisturized gauze, sealing it in a plastic bag, and placing the bag in an ice water bath
what is a succussion splash
the noise of air and fluid moving around in an area likely due to an outlet obstruction and causing a backing up into the organ being discussed
splenic abscess triad and most common association
- fever
- leukocytosis
- LUQ pain
- patients can develop left sided pleuritic chest pain, left pleuritic effusion, and splenomegaly
- most common association: infective endocarditis
- risk factors: hematogenous spread, immunosuppression, IV drug use, trauma, and hemoglobinopathies
more pain with knee flexion or pressing on the kneecap
patellofemoral pain syndrome
-first line treatment is to do quadriceps exercises
new baby presents b/w 2-8 weeks with jaundice, pale stools, small or absent gall bladder, what do they have and what labs do you expect
biliary atresia
- high direct bilirubin, high GGT, and normal reticulocyte count
- manage with surgical hepatoportoenterostomy (kasai procedure) or liver transplant
incidence of pancreatic cysts in aging population is 40% of people > 70, which is not really a problem cause usually they are low risk and not malignant but what would make you think it might be able to have a malignant transformation and how do you manage that
- large size > 3cm
- solid or calcific
- main pancreatic duct involvement (ductal dilation)
- thickened or irregular cyst wall
-manage with endoscopic ultrasound-guided biopsy and possibly surgical resection
what are the two most common causes of acute mesenteric ischemia
- cardiac embolic events with a.fib, valvular disease, or cardiovascular aneurysms
- acute thrombosis due to peripheral arterial disease or low cardiac output states
risk factors: atherosclerosis, embolic source, hypercoagulable disorders
what should you expect to see with acute mesenteric ischemia
pt present with: rapid onset of periumbilical pain, pain out of proportion to examination findings, and late onset of hematochezia
labs: leukocytosis, elevated hemoglobin, elevated amylase, and metabolic acidosis with elevated lactate
dx: CT preferred but can do MR angiography then do mesenteric angiography if diagnosis is unclear
after cardiac surgery pt describes clicking and shifting of chest (chest wall instability) when bending or moving upper extremities, what is this and what do you do
sternal dehiscence
- surgical complication when 2 approximated edges of sternum separate
- usually due to loosening or fracture of suture wire
- if with infection its called mediastinitis
- manage with surgical exploration and repair
laryngeal ulcer in a smoker… what do you think of
-pt presents with persistent hoarseness
squamous cell carcinoma
-make sure you get a laryngoscopy
how to manage pancreaticopleural fistula
bowel rest to help with fistula closure and possible ERCP with sphincterectomy or stent placement to help drain fluid through ampulla of vater instead of through fistula
ludwig angina
rapid, progressive cellulitis of submandibular space usually due to dental infections in mandibular molars that spread contiguously down the root of the tooth
- usually polymicrobial with mixture of oral aerobic (viridans) and anaerobic bacteria
- early intervention with IV abx usually helps prevent airway compromise
patient presents with shoulder pain, horner syndrome, arm pain, and/or hand weakness… what do you think of
superior pulmonary sulcus tumor
-get chest x-ray
how to manage pts with small spontaneous pneumothorax
observation and supplemental oxygen (regardless of O2 saturation) because it enhances the speed of resorption
how quickly can someone become vitamin K deficient
7-10 days
how to manage massive amounts of hemoptysis from pt (>600mL/day OR >100mL/hr)
secure airway and breathing but if bleeding continues then treat cause of bleeding via bronchoscopy, embolization, or resection
-if bleeding stops then manage like mild or moderate where you do a full workup first
when to do an urgent thoracotomy/surgical intervention for hemoptysis
pts with unilateral bleeding who continue to bleed even after bronchoscopy and/or arterial embolization
pt has hypophosphatemia (key finding!) plus other electrolyte abnormalities, muscle weakness, arrhythmias, and congestive heart failure… what do you think of
refeeding syndrome
- due to reintroduction of nutrition in pts with chronic malnourishment
- hypophosphatemia is due to increase insulin and cellular electrolyte uptake and the subsequent increase in phosphate utilization during glycolysis
aspiration pneumonitits vs aspiration pneumonia
aspiration pneumonitis
- acute lung injury presents within hours secondary to chemical burn from aspiration of gastric contents
- lung inflammation
- can be asymptomatic or have decreased O2 with nonproductive cough
- only treat with supportive care
aspiration pneumonia
- infectious disease presents days after caused by aspiration of infected oropharyngeal secretions
- pts present with productive cough
- can lead to abscess formation
- treat with abx (clinda or beta-lactam with beta-lactamase inhibitor)
all trauma pts should get what imaging
- portable chest and abdominal x-rays
- Focused Assessment with Sonography or Trauma (FAST)
- cervical spinal imaging (CT preferred)
indications for spinal CT
- high energy mechanism of injury
- neurological deficit
- spinal tenderness
- altered mental status
- intoxication
- distracting injury
*note that presence of single vertebral fracture (especially cervical) is an indication to image the entire spine because risk of additional spinal fracture increases 20%
what can trigger catecholamine surges in pts with pheochromocytomas (from adrenal medulla)
surgical procedures
induction of anesthesia
various medications (give alpha blockers before giving nonselective beta blockers)
what type of dislocation happens to an abducted externally rotated arm
anterior dislocation
-most commonly injured nerve is axillary which innervates teres minor and deltoid causing weakened shoulder abduction and decreased sensation in skin overlying lateral shoulder
common cause of postop fever (temp > 100.4)
due to cytokine release including IL-6 (pyretic) in response to tissue trauma, blood cell lysis, or bacterial endo/exotoxins
- within hours = tissue trauma
- 1+ weeks after surgery = bacterial infection
patient has some stressor then has increased unconjugated bilirubin but nothing else wrong
gilberts syndrome
pt presents < 24hrs after blunt thoracic trauma with tachypnea, tachycardia, hypoxia
- pulm exam: rales and decreased breath sounds
- CT scan or CXR with patchy alveolar infiltrates not restricted by anatomical borders
pulmonary contusion
-manage with pain control, pulmonary hygiene (incentive spirometry, chest PT), supplemental O2 and ventilatory support
if pt has blunt abdominal trauma with persistent nausea what do you think of
pancreatic duct injury
what are the indications for foot imaging (x-ray or MRI) with a diabetic foot ulcer
- deep (exposed bone or positive probe-to-bone testing)
- long-standing (present > 7-14 days)
- large ( > 2cm)
- associated with elevated ESR or CRP
- associated with adjacent soft tissue infection
*note –> always check for infection and osteomyelitis no matter what
explain everything about a varicocele
presentation: soft scrotal mass, bag of worms appearance, decreases in supine position, increases with standing and valsalva, subfertility, testicular atrophy
imaging (ultrasound): retrograde venous flow, tortuous anechoic tubules adjacent to testis, dilation of pampiniform plexus veins
treatment: gonadal vein ligation (in boys and young men with testicular atrophy), scrotal support and NSAIDs (older men who don’t want kids)
patient presents with duodenal and jejunal ulcers plus persistent diarrhea and fatty poop, what do you think of
zollinger-ellison
- workup with endoscopy, CT/MRI, somatostatin receptor, scintigraphy for tumor localization
- all the increased acid causes inactivation of pancreatic enzymes which can lead to malabsorption
what is a nissen fundoplication surgery used for
those with refractory GERD symptoms (anti-reflux surgery)
6 Ps of acute limb ischemia and how to manage it
Pain Pallor Paresthesia Pulselessness Poikilothermia (cool extremity) Paralysis (late)
-manage with anticoagulation and thrombolysis/surgery
humerus fracture, what arteries and nerves are you worried about
proximal: Axillary nerve
mid-shaft: Radial nerve
distal: Median nerve, Brachial artery
patient with gallstone pancreatitis, fevers, RUQ pain, jaundice, altered mental status, and hypotension
acute cholangitis
-do ERCP to relieve biliary obstruction and prevent serious infectious complications
fever, RUQ pain, leukocytosis, altered LFTs
-dx with abdominal CT showing well-defined, hypoattenuating, rounded lesion often surrounded by peripherally enhancing abscess membrane
pyogenic liver abscess
- can result from direct spread from biliary tract or from hematogenous seeding of distal infection, particularly those involving the portal system (diverticulitis)
- manage with blood cultures, abx, aspiration, and drainage
how is TPN usually administered
central venous catheter
free-living marine bacterium that causes food-borne illness (with what?) and wound infections which can be anything from mild to rapid-onset/severe necrotizing fasciitis with hemorrhagic bullous lesions and septic shock
Vibrio Vulnificus
- food-borne via oysters
- pts with liver disease: cirrhosis, viral hepatitis, hereditary hemochromatosis are at high risk for worse infections
what are the signs of a urethral injury
- blood at the urethral meatus
- high-riding prostate
- resistance while trying to pass a foley catheter
pelvic fracture, gross hematuria, suprapubic pain/tenderness, difficulty voiding
extraperitoneal bladder wall rupture
adducted and internally rotated hip
posterior hip dislocation
pt has mechanical fall then has shortening and external rotation of one leg
Femoral neck or intertrochanteric fracture
OR
anterior hip dislocation (but less common)
how do pts with sudden onset pneumothoraxes present
tachycardia, tachypnea, hypoxemia, decreased or absent breath sounds on affected side
what arteries are most commonly affected by fibromuscular dysplasia
renal and internal carotid
- pts present with hypertension and/or recurrent headaches
- may find bruits on neck and abdomen
pt has hip pain and long-term steroid use, what do you think
long-term steroid use increases the likelihood of avascular necrosis
what is stool elastase a marker for
pancreatic exocrine function (low in chronic pancreatitis)
management of gallstones
asymptomatic: no treatment
typical biliary colic symptoms: elective laparoscopic cholecystectomy or possibly just give ursodeoxycholic acid in poor surgical candidates
complicated disease (acute cholecystitis, choledocholithiasis, gallstone pancreatitis): cholecystectomy within 72 hours
how to diagnose and treat an esophageal perforation
etiology: instrumentation (endoscopy), trauma, effort rupture (boerhaave syndrome), esophagitis (infectious/pills/caustic)
DX
- chest x-ray or CT scan: widened mediastinum, pneumomediastinum, pneumothorax, pleural effusion (low pH and very high amylase maybe even with food particles)
- CT scan: esophageal wall thickening, mediastinal fluid collection
- esophagography with water-soluble contrast: leak from perforation
TX
- NPO, IV abx, and PPI
- emergency surgical consultation
what is used as a tumor marker for thyroid tumors
thyroglobulin (made by normal and malignant thyroid tissue)
-used as a tumor marker once thyroid tissue has been removed
patient presents within 1 week of having gastric bypass with fever, abdominal pain, tachypnea, and tachycardia… what do you think of
anastomotic leak
- confirm with CT with contrast or upper GI
- treat with urgent surgical repair
fibrotic intestinal stricture vs adynamic/paralytic ileus
both present with bilious emesis, severe abdominal pain, partial or incomplete obstruction, distension
- fibrotic stricture usually presents in crohns pt or smoking history (anything to make you think lots of inflammation)
- adynamic ileus presents with absent bowel sounds and gastric dilation/gas-filled loops of large and small intestine after insult stuns the bowel (intra-abdominal surgery or high-dose opioids)
patient has persistent clear unilateral rhinorrhea that increases with increased intracranial pressure (like bending over or bowel movements)…
CSF rhinorrhea
- most often caused by head trauma
- can result in meningitis
- manage with bed rest, head elevation, avoidance of straining, lumbar drain placement, and surgical repair
aortic stenosis
- criteria for severe
- indications for surgery
Severe
- aortic jet velocity > 4 m/sec OR
- mean transvalvular pressure gradient > 40 mmHg
- valve area usually < 1 1.0 cm2 but not required
Indications for valve replacement (severe AS + 1 of the following)
- onset of symptoms (angina, syncope)
- left ventricular ejection fraction < 50%
- undergoing other cardiac surgery (CABG)
patient with spinal cord injury above T6… what do you worry about
possible autonomic dysreflexia
- noxious stimuli below injury level trigger unregulated sympathetic response leading to severe hypertension
- compensatory parasympathetic response above the lesion typically causes bradycardia
- manage with removing noxious stimuli and treating hypertension
if pt has prerenal acute kidney injury what do you expect their BUN/creatintine ratio to be
> 20:1
also expect oliguria (< 500mL/day) and unremarkable urine sediment
what is the most likely cause of acute epididymitis for those under vs over the age of 35
under 35 likely due to STD (chlamydia, gonorrhea)
over 35 likely due to bladder outlet obstruction (coliform bacteria)
furuncle
- skin abscess usually due to staph aureus
- painful pustule or nodule and drains purulent material
- kinda looks like a small pimple with a tiny white head
intertrigo
due to candida infection and presents as well-defined, erythematous plaques with satellite vesicles or pustules in intertriginous and occluded skin areas
how does a rectus sheath hematoma occur
occur due to rupture of inferior epigastric artery from blunt trauma or forceful abdominal contractions (severe coughing), particularly in those receiving anticoagulation therapy
when to suspect acalculous cholecystitis
- can lead to sepsis and death
- fever and leukocytosis, most pts cant talk cause this usually happens in the severely ill
- radiology: gallbladder wall thickening and distention with presence of pericholecystic fluid
- immediately give antibiotics and do percutaneous cholecystostomy with abscess drainage if necessary
how to treat acute vs chronic hyponatremia
ACUTE (< 48hrs)
-any symptoms give hypertonic 3% saline
CHRONIC (> 48hrs)
- better tolerated
- give hypertonic 3% saline only if sodium is < 120mEq/L
*hyponatremic pts are at risk for brain herniation
how to differentiate epidermal inclusion cyst and lipoma
epidermal inclusion cyst: benign nodule containing squamous epithelium that produces keratin, can change in size and usually resolves spontaneously
lipoma: benign painless subq mass with normal overlying epidermis, usually soft and rubbery and irregular, do not regress or recur
hepatic finding with a central stellate scar
focal nodular hyperplasia
-grows around blood source
only major modifiable risk factor that affects severity and progression of Crohn disease
smoking
-tell all pts to stop smoking
most common cause of nosocomial bloodstream infections
central venous catheters
-direct pathway for colonized skin organisms
slowly enlarging abdominal mass that enlarges with valsalva, palpable fascial edges in nonobese pts, possible delayed presentation for months to years
incisional hernia
- breakdown of prior fascial closure
- risk factors: obesity, smoking, poor wound healing, vertical or midline incision, surgical site infection
- dx with clinical symptoms or CT scan of abdomen
explain the return to consciousness after anesthesia and what is delayed emergence
- emergence w/i 15 mins
- in tact protective reflexes (gag) w/i 30-60mins
- delayed emergence: pt fails to regain consciousness w/i expected window due to 3 things
1. drug effect of preop drugs
2. metabolic disorder (hyper/hypo -glycemia, -thermia, or liver disease)
3. neurologic disorder (stroke, seizure, or elevated icp)
> 50yo obese woman presents with chronic lateral hip pain worse with abduction of leg and repetitive hip flexion (climbing stairs/walking uphill) or lying on affected side
-pt also has focal tnderness over trochanter… what is it and what do you do
Greater trochanteric pain syndrome (GTPS)
- overuse syndrome involving tendons on gluteus medius and minimus where they run over greater trochanter (trochanteric bursitis)
- x-ray to rule out hip joint pathology
- ultrasound: degeneration of tendons, tendinosis
treatment
- exercise, PT, activity modification
- NSAIDs
- corticosteroid injection
how to manage diverticulitis (uncomplicated vs complicated)
Uncomplicated
- stable: outpatient with bowel rest, oral abx, and observation
- elderly/immunosupressed/high fever or leukocytosis/comorbidites: admit with IV abx
Complicated (diverticulitis + abscess, perforation, obstruction, or fistula)
- fluid collection < 3cm treat with IV abx and observe then surgery if worse
- fluid collection > 3cm treat with abx and CT-guided percutaneous drainage and if that doesnt help then do surgical drainage and debridement
tachypnea, hypoxia, segment of chest wall that moves inward during inspiration… what do you think
flail chest
- occurs when fracture of > 3 contiguous ribs in > 2 locations creates isolated chest wall segment (flail segment) that moves paradoxically (opposite) to rest of rib cage during respiration
- impairs generation of negative intrathoracic pressure and causes ineffective ventilation
- pulmonary contusion
- atelectasis
chronic mitral regurg surgical indications
Primary
-surgery if LVEF 30-60% (regardless of symptoms)
Secondary
-medical management, valve surgery rarely indicated
intermittent solid food dysphagia most commonly in younger men with atopic conditions
eosinophilic esophagitis
- untreated can cause esophageal stricture and food impaction
- manage with dietary therapy, PPI, topical glucocorticoids
middle mediastinal mass ddx
- bronchogenic cysts
- tracheal tumors
- pericardial cysts
- lymphoma
- lymph node enlargement
- aortic aneurysms
anterior mediastinum masses
4Ts
- thymoma
- teratoma
- thyroid neoplasm
- terrible lymphoma
amiodarone side effects
hepatic steatosis and cholestasis
common causes of ischemic hepatitis (shock liver)
- cardiac insults (MI, unstable arrythmias)
- respiratory failure
- hypovolemia
- septic shock
first step in a tension pneumothorax
- needle thoracostomy in order to prevent cardiovascular collapse
- precedes intubation cause intubation can actually cause cardiovascular collapse
whats so interesting about a diaphragmatic rupture
usually children with traumatic diaphragmatic injury may initially have no symptoms but can present months to years later after progressive expansion of the diaphragmatic defect
-get CT of chest and abdomen
what is a risk of being on chronic glucocortioid therapy if you are exposed to an acute stressor (surgery, illness, or trauma)
secondary adrenal insufficiency and can develop adrenal crisis
- presents with hypotension and shock that is refractory to initial volume resuscitation
- treat with IV hydrocortisone or dexamethasone with aggressive volume repletion
how to treat chronic bacterial prostatitis
fluoroquinolones for 6 weeks
how to treat a penile fracture
- if pt presents with blood at meatus, dysuria, urinary retention then they need retrograde urethrography due to urethral injury
- then after that they need urgent operative repair
if you think someone might have a corneal abrasion (cause they had a high-velocity injury to the globe) but dont see it then what can you do
fluorescein instillation cause it may reveal an open globe laceration by extrusion of fluid through laceration
-in corneal defect itll be stained and appear yellow
how to stage a gastric adenocarcinoma
after initial endoscopy/biopsy positive for adenocarcinoma
- get CT of abdomen and pelvis
- PET/CT, endoscopic ultrasound, laparoscopy, CT chest +/- paracentesis/peritoneal lavage
- if limited stage then do surgical resection
- if advanced stage then do chemo +/- palliative surgery
how does benzo w/d present
agitation, tremors, perceptual changes, psychosis, elevated vital signs, delirium, and seizures
-symptoms present w/i 24-48hrs
patient presents with shoulder pain (with abduction and external rotation) and weakness and has a positive drop arm test where pt cant bring arm down so it just falls
MRI can confirm dx
rotator cuff tear
how to manage cat bites
-can cause pasteurella or any anaerobic bacteria
copious irrigation and cleaning
prophylactic amox/clav
tetanus booster as indicated
avoid closure
how to deal with septic shock pt
secure airway, restore adequate tissue perfusion with normal saline
then identify underlying infection and treat it
what is the pathophys of struvite kidney stones
increased urine ammonia production
- pts have recurrent UTIs
- stone removal usually required
how does a peptic duodenal ulcer typically present
periodic epigastric pain relieved by meals
meniere disease
- caused by increased endolymphatic fluid volume or pressure in vestibular system
- causes episodic vertigo and hearing loss as well as aural fullness/tinnitus lasting 20mins to 1 day
- lack triggers
what are the 4 types of post-amputation pain
- acute stump pain
- tissue and nerve injury causing severe pain lasting 1-3 weeks - ischemic pain
- swelling, skin discoloration, wound breakdown, decrease in transcutaneous oxygen tension - post-traumatic neuroma
- weeks to months after amputation
- focal tenderness, altered local sensation
- decreased pain with anesthetic injection - phantom limb pain
- onset usually w/i 1 week
- increased risk in pts with severe acute pain
- intermittent crampting, burning felt in distal limb
what is a charcot joint
- aka neurogenic arthropathy
- impaired sensation and proprioception
- altered weight bearing and recurrent trauma
- acute inflammatory response
- causes impaired ambulation, foot and ankle deformity, mild pain
- x-ray: bone and joint destruction, fragmentation, subluxation/dislocation
- mange with mechanical offloading and correction of joint mechanics (casting, orthotics)
what is most important to help a pt with an isolated rib racture and atelectasis
adequate pain control
-if you dont have this then you increase the risk of pneumonia (frequent complication of rib fractures)
most common primary brain malignancy
glioblastoma
- increased intracranial pressure
- headaches, papilledema, change in personality
- CT/MRI show butterfly appearance with possible central necrosis
what should you look out for when giving a pt desmopressin
its an analogue of ADH so you could potentially induce SIADH
what is the most common complication after an ERCP
acute pancreatitis
for pts with penetrating abdominal trauma when is immediate exploratory laparotomy indicated
- hemodynamic instability (SBP < 90)
- peritonitis (rigidity, rebound tenderness)
- evisceration (externally exposed intestines)
what is the most common type of liver cancer
metastasis from another primary source
what are the hard signs indicating that due to extremity vascular trauma someone will need surgical exploration and fixation
- observed pulsatile bleeding
- presence of bruit/thrill over injury
- expanding hematoma
- signs of distal ischemia
- hemodynamic instability
-if pt doesnt have tehse then do CT angiography for further evaluation
spinal cord
Anterior
- ascending: pain, temp, crude touch, pressure
- descending: voluntary motor
Posterior
-ascending: pressure, vibration, fine touch, proprioception
what are you concerned about in spinal cord lesions above T1
neurogenic shock due to interruption of descending sympathetic fibers
-unopposed parasympathetic stimulation causing hypotension, bradycardia, hypothermia
most common cause of small-bowel obstruction
Adhesions
-ladd bands may be congenital in children but adhesions typically result from abdominal operations or inflammatory processes
how does small-bowel obstruction present
depends on where the obstruction is
- vomiting (causing hypokalemia, decreased oral intake, dehydration, and orthostasis)
- proximal: early vomiting, abdominal discomfort, abnormal contrast filling on x-ray
- mid/distal: colicky abdominal pain, delayed vomiting, prominent abdominal distension, constipation-obstipation, hyperactive bowel sounds, dilated loops of bowel on abdominal x-ray
sphincter of oddi
muscular valve controlling flow of bile and pancreatic juice into duodenum
how to treat acute colonic pseudoobstruction (ogilvie syndrome)
bowel rest and colonic decompression and aided by IV neostigmine
- patient with back pain increased with standing, walking, and lying on back
- tenderness of affected level
- first felt pain while moving boxes but had a negative straight leg test
vertebral compression fracture
-usually due to osteoporosis (decreased bone mineral density)
besides malignant hyperthermia what is a big side effect of succinylcholine
- its a depolarizing neuromuscular blockers
- can cause life-threatening hyperkalemia in pts with condition leading to upregulation of postsynaptic acetylcholine receptors (skeletal muscle trauma, burn injury, stroke)
-these pts should use vecuronium or rocuronium (nondepolarizing neuromuscular blocking agents) instead
how does von hippel-linau present
- cerebellar and retinal hemangioblastomas
- pheochromocytomas
- renal cell carcinoma (clear cell subtype)
how to tell the difference b/w small bowel obstruction and ileus
SBO- surgery was weeks to years ago, pts presents with distension and increased bowel sounds, small bowel dilation is present (not large bowel)
Ileus- recent surgery (hours to datys), metabolic (hypokalemia, or medication induced, pt presents with possible distention and reduced/absent bowel sounds, both small and large bowel dilation
torus palatinus/mandibulari
chronic mass
- benign bony growth (exostosis) at midline suture of hard palate or lingual surface of mandible
- surgery is only indicated if mass becomes symptomatic somehow
medullar thyroid carcinoma
rare neuroendocrine carcinoma of thyroid parafollicular C cells that can be sporadic or associaated with RET germline mutation (MEN2)
patient with smoking history presents with nontender, solitary cervical lymph nodes (hard mass under mandible)
mucosal head and neck squamous cell carcinoma
acute GVHD
- usually within 100 days of transplant
1. maculopapular rash: painful/confluent and may look like SJS
2. profuse, watery diarrhea: secretory pattern with crampy abdominal pain, n/v
3. liver inflammation: damage to biliary tract epithelium, leading to elevated bilirubin, alk phos, and transaminases
patient with history of retinoblastoma has thigh pain, what do you think of
osteosarcoma
-retinoblastoma and osteosarcoma are linked by RB1 tumor suppressor gene
what makes you worried about a parotid mass for malignancy
cranial nerve dysfunction (facial droop, facial numbness) increases concern for malignancy
what is an angiosarcoma
rare malignant tumor derived from internal lining of blood vessels of lymphatic vessels
- strongest risk factor for getting this is: past radiation therapy
- breast cancer survivors with chronic lymphedema are also at risk
what to think of if you have a circular 3rd degree burn that results in eschar formation..?
the eschar restricts venous and lymphatic drainage which then leads to acute compartment syndrome
what to give pts prophylatically for surgery who are undergoing a clean surgery (no viscera/bowel will be cut)
need coverage against gram-positive skin flora with 1st or 2nd gen cephalosporin (cefazolin) or with vanc or clinda
*if its not clean based on surgical site but usually you need broader coverage
most common malignancies in young men
- testicular cancer
- lymphoma
- leukemia
painless jaundice with weight loss, what do you think of
pancreatic cancer (adenocarcinoma)
what is the BEST way to help prevent pulmonary complications before a surgery
incentive spirometry and deep breathing exercises
what is a retrograde cystography
bladder is passively filled with water-soluble contrast then imaged (CT scan) to confirm dx of intraperitoneal rupture/bladder rupture
patient with cirrhosis and NEW ONSET ascites, what do you think of
acute obstruction of portal or hepatic veins due to thrombus or hepatocellular carcinoma
-get abdominal ultrasound
what screening is important in pts with cirrhosis of any kind
abdominal ultrasound every 6 months to evaluate for new onset Hepatocellular carcinoma
if pt has basal cell carcinoma on their face or ears how do you get rid of it
Mohs micrographic surgery
-sequential removal of skin layers with microscopic inspection to confirm margins are clear of malignant tissue (has the highest cure rate)
how to determine if cervical spine imaging should be performed
NEXUS low-risk criteria
- neurologic deficit
- spinal tenderness
- altered mental status
- intoxication
- distracting injury
patient has diabetic foot ulcer, when do you test for osteomyelitis (bone biopsy)
- positive probe-to-bone test
- ulcer larger tahn 2cm
- ulcer lasting > 1 week
- note that fever, pain, elevated ESR, and sinus tract drainage may be present
how to treat a meningioma
complete surgical resection
what is the first step after pt has open-book pelvic fracture with disruption of the pelvic ring and anterior widening
they are at risk of life-threatening hemorrhage so the first step is to put on a pelvic binder to decrease pelvic volume and promote tamponade of venous bleeding
what are the possible bladder symptoms of diverticulitis
urinary urgency, frequency, sterile pyuria (+ leukocyte esterase with - nitrite/bacteria) due to bladder irritation from adjacent sigmoid colon inflammation
what lab valdue has a 95% positive predictive value for diagnosing gallstone pancreatitis and how do you manage these pts
ALT > 150 U/L
-early cholecystectomy is indicated in all pts who are medically stable enough to undergo surgery
if pt has infected prothetic with coagulase-negative staph (epidermitis) then what do you expect compared to staph aureus
- delayed onset
- chronic pain
- implant loosening
- gait impairment
- sinus tract formation
how to confirm and treat bronchial rupture
bronchoscopy and treat with operative repair
von hippel-lindau is associated with what
excess production of catecholamines due to pheochromocytomas
patient with COPD has a secondary spontaneious pneumothorax … what do you think of
rupture of alveolar bleb (most common cause of acute respiratory symptoms in COPD pts)
greatest risk factor for prostate cancer
advanced age
-approximately 30-80% of men older tahn 70 have histologic evidence of prostate cancer
general diagnostic workup of solid, firm, nontender testicular mass
testicular cancer until proven otherwise
- bilateral scrotal ultrasound
- serum tumor markers
- radical inguinal orchiectomy
what does a fixed teardrop pupil indicate
open globe injury
most common cancers causing liver metastases
- GI tract
- lung
- breast
patient with sickle cell and hip pain, what do you think of
avascular necrosis (osteonecrosis)
pt presents with hematuria, renovascular congestion (enlarged kidney on imaging), elevated LDH with maybe AKI, and flank pain
renal vein thrombosis
-dx with CT or MR angiography or renal venography
first step in diagnosing gastric cancer
EGD
-then you can do test for H pylori stool testing or anything else
where should a central venous catheter be placed and why
ideal: lower superior vena cava
- if you do it in smaller veins it predisposes to venous perforation or pneumothorax
- get portable chest x-ray right after to make sure it was placed correctly if you dont use ultrasound guided CVC placement
indications for open reduction and surgical exploration of fractures
- open fractures
- neurovascular compromise
- significant displacement
it you think a pt has wound dehiscence following a surgery what should your next step be
management is determined by extent of tissue involvement –> get imaging of the affected area
-usually after chest/sternal surgery
soft tissue: only superficial tissues, use local wound care or debridement followed by primary closure
sternal: separation of edges of sternum seen by clicking or rocking on palpation, surgical emergency and requires sternal rewiring to prevent cardiac trauma
pt with intestine problem (or anything causing fat malabsorption) presents with nephrolithiasis, what do you think of
oxalate crystals in kidney cause gut probs usually increase its absorption
how to manage venous air embolism
- left lateral decubitus positioning to trap the VAE on the lateral wall of the right ventricle preventing RVOT obstruction and further embolization into pulmonary circulation
- high-flow or hyperbaric oxygen to encourage absorption of air embolus
what is a complication of thoracic aortic aneurysm repair and how does it present
anterior spinal cord ischemia
-distal, bilateral flaccid paralysis, loss of pain/temp and crude touch sensation and urinary retention
what complication are burn pts at risk for especially if their burns cover > 20% of their surface area
- pts present with temp, tachy, hypotension, oliguria, hyperglycemia, thrombocytopenia, and mental status changes
- dx with quantitative wound culture and biopsy for histopathology
wound infections and sepsis
- soon after injury: gram + sepsis
- after 5 days: gram - and fungi
- note that a change in burn wound appearance of the loss of skin graft is often the first sign on burn wound infection
patient getting laparoscopic surgery gets CO2 insufflation then gets bradycardic, AV block, and sometimes even asystole… why?
increased intra-abdominal pressure stimulates stretch receptors on peritoneum that respond by triggering increase in vagal tone
how to treat basal cell carcinoma
excisional biopsy with narrow margin
how to diagnose a rotator cuff tear
MRI of area
-usually get treated with surgery (preferrably within 6 weeks of injury)
how to visualize soft tissues
MRI
how to treat tympanic membrane barotrauma
usually heals spontaneously within a few weeks
postop hematoma in pt with no personal or family history
insufficient hemostasis
variceal hemorrhage bleed algorithm
- place 2 large-bore IV catheters
- volume resuscitation, IV octreotide, antibiotics
- urgent endoscopic therapy of esophageal varices
- if that stops the bleeding then give beta-blockers and do endoscopic band ligation 1-2 weeks later
- if they continue to bleed do balloon tamponade temporarily then TIPS or shunt surgery
- if they have early rebleeding then do endoscopic therapy again then TIPS or shunt surgery if needed
if you see intraperitoneal free air on imaging what does this confirm?
bowel perforation which should prompt emergent surgical exploration
-presents as bowel contusion then mesenteric ischemia
how to manage a peritonsillar abscess
IV abx therapy and urgent drainage of abscess
-pt will have deviation of uvula and unilateral lymphadenopathy
most common causes of cirrhosis
- alcohol abuse
- chronic viral hepatitis
- nonalcoholic fatty liver disease (hx of DM and obesity)
*note pts usually dont know they have cirrhosis until they get variceal bleeding or hepatocellular carcinoma
what type of fluid resuscitation do you wanna use for burn patients
lactated ringer solution b/c it maintains a normal blood pH whereas normal saline can cause hyperchloremic metabolic acidosis
what are the best predictors of postop outcomes following lung resection surgery
FEV1 and DLCO
how to manage upper extremity DVT (usually within 7-14 days of PICC insertion)
- dx with duplex ultrasonography
- treat with 3 months of anticoagulation
how to help manage pts with AD polycystic kidney disease
- treatment is mainly supportive
- vasopressin-2 receptor antagonist (tolvaptan) may slow progression in some pts
benefits of neonatal circumcision
reduced risk of…
- uti in first year of life
- penile phimosis
- cancer
- inflammatory disorders in adulthood
-decreases risk of acquiring some (not all) stds
what are the risk factors for head and neck squamous cell carcinoma and what do you think if a pt has it without these risk factors
- presents as enlarged ulcerated tonsil with ipsilateral cervical adenopathy
- risk factors: smoking and alcohol
- if pt doesnt have these then look for HPV if pt is younger than expected (HPV-16)
most sensitive test for medial collateral ligament tear
MRI
-pt will have medial knee and valgus laxity
how to treat acute bacterial prostatitis
usually due to e.coli or proteus so treat for 6 weeks with…
-fluoroquinolone
OR
-TMP-SMX
patient presents with abdominal pain, diarrhea, nausea, hypotension/tachycardia, dizziness/confusion, fatigue, diaphoresis about 15-30mins after meals
-usually after postgastrectomy
Dumping syndrome
- rapid emptying of hypertonic gastric contents
- caused by loss of normal action of pyloric sphincter due to injury or surgical bypass
- manage with small/frequent meals, replace simple sugars with complex carbs, incorporate high-fiber and protein-rich foods
patient with thoracic trauma and extensive extrapulmonary air (chest tube with persistent large air leak)
likely tracheobronchial injury
-get bronchoscopy to confirm dx before operative repair
upper extremity DVT risk factors and presentation
risk factors: central venous catheters, repeptitive arm motions (baseball pitching), weight lifting, malignancy
manifestations: acute arm edema, heaviness, pain, erythema, dilated subq collateral veins in chest/upper extremity, pulmonary embolism
if pt has decline in renal function with addition of ACE inhibitors what do you think of
renal artery stenosis
-dx made with renal vascular imaging (renal doppler u/s)
recurrent peptic ulcer disease with multiple ulcers and jejunal ulceration suggest what…
zollinger-ellison syndrome (gastrinoma)
first step in dx of esophageal cancer based on age…
- younger pts under 50 start with barium swallow
- older pts over 50 OR younger with alarm symptoms have endoscopy right away
what abx to give for breast abscess
dicloxacillin or cephalexin
diabetic foot infections most likely get the bone how…
polymicrobial (gram + and - and anaerobic bacteria) via contiguous spread from the wound
how to treat stress hyperglycemia (usually due to sepsis, burns, or major trauma/hemorrhage)
-occurs due to stress triggering cortisol and catecholamines increasing glycogenolysis and gluconeogenesis
- minimization of glucose in IV fluids
- insulin to maintain blood glucose at 140-180 mg/dL
classic fat embolism syndrome triad
- respiratory distress (hypoxemia, dyspnea, tachypnea, tachycardia)
- neurologic dysfunction (confusion, visual field defects)
- petechial rash
*note: immediate CXR is normal but after 24-48hrs youll see bilateral pulmonary infiltrates
what form of imaging is required for pancreatic lesions
CT scan of abdomen has sensitivity > 90%
how to confirm a ganglion cyst
transillumination of mass
how to manage pts with primary hyperparathyroidism
-parathyroid imaging and parathyroidectomy
- hypercalcemia with elevated PTH
- parathyroidectomy recommended for symptomatic pts (nephrolithiasis)
- younger pts < 50 are likely to have complications during lifetime and should be offered surgery
what is a main cause of atelectasis as a postop complication
-pts present with hypoxia (low pO2) which increases respiratory rate causing low pCO2
shallow breathing and weak cough due to pain
- usually occurs on postop day.2 or 3
- pts need adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry to help decrease incidence
pathophys of peyronie disease
acquired disorder with fibrosis of tunica albuginea of penis (dorsal nodules/plaques)
-restricts expansion and flexibility during erections
risk factors for splenic abscess
- usually presents with persistent fever, LUQ pain, anorexia, weight loss
- dx made with CT scan of abdomen
- immunocompromised
- hematologic malignancy
- DM
-treat with abx plus splenectomy is usually needed cause most pts fail percutaneous aspiration (due to presence of occult microabscesses)
how to manage AAA 3-5.5cm large
lifestyle modification (smoking cessation is best)
patient presents with murmur after permanent pacemaker placement
tricuspid regurgitation
- adverse effect of pacemaker
- can cause cor pulmonale
what is a characteristic image finding in pts with entamoeba histolytica
single, subcapsular, low-density lesion in the right lobe of the liver cause it has more blood supply than the left
-dx made with serology (needle aspiration not needed)
when to think about scurvy (vitamin C deficiency)
- common in alcoholism
- usually within 3 months of vitamin C deficient diet
- presents with the following
1. cutaneous manifestations: follicular hyperkeratosis, perifollicular hemorrhage, ecchymosis, petechiae, coiled hairs
2. gingivitis: receded gums that bleed easily and dental caries
3. impaired wound healing
4. systemic symptoms: arthralgias, malaise, weakness
what is a size of lung nodule that independently correlates with > 50% malignant probability
2cm or larger
-always biopsy and
when to manage a stress fracture why referring to ortho
for fracture at high risk of malunion
-ex: anterior tibial cortex, 5th metatarsal
what is fournier gangrene (presents as rapid onset skin infection of lower abdomen, scrotum, and perineum with crepitus and significant systemic manifestations like hypotension, high fever and leukocytosis)
-DO SURGERY RIGHT AWAY
life-threatening necrotizing fasciitis
- quickly progresses to sepsis and death without intervention
- occur in the setting of cutaneous breakdowns in perianal/genital region that allow portal entry of polymicrobial colonic or urogenital organisms
- spreads along subQ fat via fascial planes
how to empirically treat human bite wounds
aerobic and anaerobic oral organsims so give amox-clav
if a patient is on long term total parenteral nutrition what should you look out for
TPN can cause gallbladder stasis and predisposes to gallstone formation and bile sludging, both of which may lead to cholecystitis
patient with any enlarging ballotable neck swelling near an incision should be dealt with how
its likely a hematoma and is life threatening cause it can become a lethal upper airway obstruction
-immediately drain the hematoma and explore the wound in the OR to control the source of bleeding and see if a endotracheal tube is needed or not
how to describe hypoventilation based on lab values
normal A-a gradient and respiratory acidosis
what is a surgical cricothyrotomy
when you trach their neck to make sure you have airway access if endotracheal intubation doesnt work
patient get a bite then develops a small ulcer, what do you think of
brown recluse spider bite
-over the course of a few days a deep skin ulcer develops with erythematous halo and a necrotic center, which can progress to an eschar
at what platelet count should you be okay to put someone on warfarin
> 150,000
-if its below dont put them on it yet
how to diagnostically evaluate heparin-induced thrombocytopenia
- serotonin release assay is the gold standard confirmatory test
- start treatment in suspected cases prior to confirmatory tests
greater trochanteric pain syndrome
overuse syndrome involving tendons of gluteus medius and minimus at greater trochanter
- chronic lateral hip pain
- treat with exercise, pt, nsaids, and steroid injections
indications for bariatric surgery
BMI > 40
BMI > 35 with serious comorbidity (T2DM, hypertension, OSA)
BMI > 30 with resistant T2DM or metabolic syndrome
what is radiation proctitis (acute vs chronic)
-colonoscopy demonstrates mucosal pallor, friability, and telangiectasias confined to the rectum
- caused my mucosal damage associated with pelvic radiation therapy
- acute RP presents < 8weeks post-radiation with diarrhea, tenesmus, and mucus discharge
- chronic RP occurs months to years after radiation, resulting in hematochezia, anemia, and possibly strictures
tender, nonpurpuric, erythematous, or violaceous nodules measuring 2-3 cm and usually located on shins
erythema nodosum
-associated with IBD (especially crohn disease)
how to confirm a posterior urethral injury
retrograde urethrography
-pt will present with blood at the urethral meatus and a high-riding prostate
CT with gall bladder that looks calcified on the outside
porcelain gallbaladder
-associated with increased risk for gallbladder adenocarcinoma and usually requires cholecystectomy
what to give a patient on warfarin who emergently needs surgery
prothrombin complex concentrate and IV vitamin K
-if PCC is unavailable you can give fresh frozen plasma
if an old fracture or break hasnt come back together yet what might they have
chronic osteomyelitis
- pt presents with: intermittent pain/swelling and sinus tract formation
- open bone biopsy for assessment and treat with surgical debridement of infected and necrotic bone
what type of tumor produces EPO
renal cell carcinoma
patient presents with oropharyngeal infection (pharyngitis or tonsillitis)
-leads to local invasion of lateral pharyngeal wall and infection of neurovascular bundle (especially internal jugular vein)
Lemierre syndrome
- caused by Fusobacterium necrophorum
- thrombosis of the vein allows dissemination of septic emboli to distal sites
trousseau syndrome
- hypercoagulability disorder
- recurrent and migratory superficial thrombophlebitis at unusual sites (arm, chest)
- usually associated with occult visceral malignancy: pancreatic is most common, stomach, lung, or prostate carcinoma
when preoperatively should pts getting a pheochromocytoma removed take alpha blockers
7-14 days prior to surgery followed by beta blockers 2-3 days prior to surgery
*never give beta without alpha blockers first cause otherwise you can cause a hypertensive crisis
how to manage atrial flutter
- results from large reentrant circuit involving cavotricuspid isthmus of right atrium
- risk for arterial thromboembolism so pts should be on chronic anticoagulation
triad of aortoiliac occlusion (Leriche syndrome)
-men with atherosclerosis who smoke are at high risk for this
- bilateral hip, thigh, and buttock claudication
- impotence
- absent or diminished femoral pulses (often with symmetric atrophy of bilateral lower extremities due to chronic ischemia)
what is pituitary apoplexy
sudden hemorrhage into enlarged pituitary adenoma
- pts present with sudden onset headache and visual disturbances
- severe hypotension and distributive shock
most common cause of a lung abscess
aspiration of oropharyngeal anaerobic bacteria
- symptoms may look like TB with subacute fever, night sweats, weight loss, and cough with putrid sputum
- x-ray reveals cavitary infiltrates often with air-fluid levels
patient presents after cardiac surgery with what looks like an infection with chest pain… what do you think
acute mediastinitis
- fever
- chest pain
- leukocytosis
- mediastinal widening on x-ray
-requires drainage, surgical debridement, and prolonged antibiotic therapy
pt presents with episodic headache, hypertension, hyperglycemia
pheochromocytoma
-measurement of urine or plasma metanephrines is initial step in diagnostic evaluation
irregular scrotal mass that increases in size with valsalva and doesnt transilluminate
varicocele
patient with lower and upper motor neuron signs… what do you do you think if its def not lou-gerigs
cervical myelopathy
-gait dysfunction is usually the first sign
acute tonsillitis presentation
- tonsillar erythema and exudates
- tender anterior cervical nodes and palatal petechiae
*if pt has pooling of saliva (trismus) and uvular deviation then its more likely peritonsillar abscess
how does a nonanion gap metabolic acidosis present
- loss of bicarb
- can happen with pancreatic or small bowel leaks
3 essential elements of informed consent
- diagnosis
- risks and benefits of both proposed treatment and alternatives
- risk of refusing treatment
what does the coffee bean sign mean on x-ray
volvulus
- dilated, inverted, u-shaped loop of colon
- patients without perforation or peritonitis can undergo flexible sigmoidoscopy to reduce twisted segment and avoid emergency surgery
how does sigmoid volvulus present
risk factors: sigmoid colon redundancy (dilation/elongation from chronic constipation) and colonic dysmotility (underlying neurologic disorders)
presentation
- slowly progressive abdominal discomfort/distension possibly with obstructive symptoms
- abdomen distension and tympanic to percussion
imaging
- x-ray: dilated, inverted u-shaped loop of colon (coffee bean sign)
- CT scan: dilated sigmoid colon, mesenteric twisting (whirl sign)
management
- endoscopic detorsion (flexible sigmoidoscopy) and elective sigmoid colectomy
- emergency sigmoid colectomy if perforation/peritonitis present
how to treat small bowel obstruction
- NG tube for gastric decompression
- emergency laparotomy due to high risk of life-threatening complications (bowel ischemia, perforation)
key finding in pts with otosclerosis (conductive hearing loss)
improvement of speech understanding in noisy environment
what is the most common neuropathy in hemodialysis patients
carpal tunnel syndrome
- 1/3 of pts get it
- symptoms usually get worse during hemodialysis treatments
how is hemodialysis access obtained
surgically creating AV fistula
-forms enlarged vein serving as access point and facilitates adequate blood flow to and from hemodialysis machine
note: if the AV fistula gets too big that can lead to high-output heart failure
symptoms of primary adrenal insufficiency
main clinical features: hypotension and shock
fatigue, weight loss, abdominal pain, anorexia, and GI disturbance
clinical indicators of thermal and smoke inhalation injuries
note: treat all these pts with high flow oxygen via non-rebreather mask with a low threshold for intubation (key reason to intubate is progressive airway edema)
- burns of face
- singeing of eyebrows
- oropharyngeal inflammation
- blistering or carbon deposits
- carbonaceous sputum
- stridor
- carboxyhemoglobin level > 10%
- history of confinement in burning building
woman > 40yo with multiparity, vaginal delivery, and chronic constipation/straining
rectal prolapse
- protruding rectal mass that occurs with valsalva
- treatment is surgical
how to treat cataracts (loss of acuity, glare, halos around lights, lens opacification, loss of red reflex)
surgical removal of lens with implantation of prosthetic lens
patient presents with obliterative endarteritis and submucosal fibrosis (which stiffens the rectum and impairs its compliance) –> resulting in urgency and fecal incontinence
chronic radiation proctitis –> chronic tissue hypoxia results in neovascularization and telangiectasia formation (which are prone to hemorrhage)
what should be considered in post-menopausal women with new-onset abdominal pain and/or concerning gastrointestinal symptoms
epithelial ovarian cancer
HPV can cause what to the anus
anal squamous intraepithelial lesion which is a precursor to anal squamous cell carcinoma
- small lesions can be treated topically with trichloroacetic acid
- larger lesions managed with radiofrequency ablation
sudden development of limb ischemia in pts with no previous problems
embolic arterial occlusion
-most arterial emboli are cardiac in origin
constricting apple core mass on x-ray
most frequently associated with constriction of lumen of colon by stenosing ANNULAR COLORECTAL CARCINOMA
-most appropriate next step is proctocolectomy
younger woman with hypertension and carotid stenosis
fibromuscular dysplasia of renal artery
how to treat transitional cell carcinoma
endoscopic resection
breast mass with clear brown fluid on aspiration
fibrocystic disease
-if its clear milky then its a galactocele
what to look out for after radiation to bone
hypercalcemia and hypercalcemic crisis
patient on steroid stops taking them then has severe hypotension unresponsive to LR or saline… what do you do
give IV steroids
possible side effect of diphenhydramine
urine retention
3cm cavity in upper lobe of lung with round 2cm mass in lumen in pt with hemoptysis, what do you think of
aspergilloma
first step to examine for AAA in stable pt
bedside transabdominal ultrasound
patient with rapidly progressive painful ulcer with purulent base and violaceous border following small local trauma like a bump or something
-they will also have some sort of underlying systemic inflammatory disorder
pyoderma gangrenosum
-usually get skin biopsy and treat with steroids
patient presents with GI bleeding that cant be seen on endoscopy or colonoscopy and hes pretty old > 60
angiodysplasia
-associated with aortic stenosis which is associated with low levels of vWF multimers
patients who undergo splenectomy should be given what drugs to take if they get a fever before theyve had their vaccinations
amox-clav
what is the post burn injury hypermetabolic response
- hachycardia, hypertension
- increased gluconeogenesis and insulin resistance = hyperglycemia
- increased basal metabolic rate = febrile
- increased protein and lipid catabolism = increased lean muscle wasting
-treat: early excision and grafting, propranolol, insulin, nutrition, and anabolic steroids
what can be an early sign of sepsis in burn pts
acute enteral feeding intolerance which can indicate end-organ hypoperfusion and dysfunction
how to treat a calcaneal spur
incidental finding and do not require treatment
-they usually dont cause pain on their own
what are you concerned about in a patient with a lung transplant
look for bronchiolitis obliterans
- gradually progressive dyspnea, non-productive cough and an obstructive pattern (FEV1/FVC < 70%)
- chronic lung transplant rejection
- get bronchoalveolar lavage to rule out infection
- biopsy will show submucosal lymphocytic infiltrate
if someone has rhabdo, what are you nervous about
pts with rhabdo are likely to have hyperkalemia so avoid K-containing fluids
patient with cholecystectomy then has unremitting diarrhea WITHOUT fever or leukocytosis
bile acid diarrhea
- unresorbed bile acids spill into the colon, irritating the mucosa
- secretory diarrhea (fasting diarrhea with nocturnal episodes)
- unremarkable serum and stool studies
- treat with bile acid binding resins (cholestyramine and colestipol)
budesonide
used to treat microscopic colitis
myositis ossificans
formation of lamellar bone in extraskeletal tissues
- can be traumatic or neurogenic
- pt presents with intramuscular mass, pain, swelling, induration days to weeks following the injury
- increased Alk Phos, ESR, CRP
- x-ray shows periosteal bone reaction and calcification with radiolucent center
- treat with ROM exercise/NSAIDs or surgical excision
what type of injury should make you think of an acute rotator cuff injury
acute glenohumeral dislocation
- decreased abduction due to pain BUT in tact sensation
- positive drop arm test- arm held in 90 degree abduction and released, inability to hold arm steady suggests a tear
what is tertiary hyperparathyroidism
- look for this in pts with CKD
- chronic hypocalcemia and hyperphosphatemia
- due to parathyroid hyperplasia and loss of feedback inhibition of PTH by calcium
- VERY HIGH PTH
- mild hypercalcemia and hyperphosphatemia
- usually refractory to medical therapy
- parathyroidectomy often needed
how to treat a lung abscess
first-line: ampicillin-sulbactam, imipenem, or meropenem
alternate: clindamycin
what is the landmark for distinguishing surgical levels of axillary lymph does during dissections
pectoralis minor muscle
pt presents with general body pain and random vessels with signs of narrowing, thrombosis, and/or ischemia
polyarteritis nodosa
- segmental, transmural inflammation of medium-sized arteries
- usually kidney and gi tract are affected
