Surgery COMAT Flashcards
What is the likelihood of a patient with an EF of <35% dying after undergoing surgery?
75%
What is the likelihood of a patient with an MI 3 months ago dying after undergoing surgery?
40%
What is the likelihood of a patient with an MI 6 months ago dying after undergoing surgery?
6%
What does it mean if albumin and pre-albumin CRP are both low?
do not have enough protein in the body -> malnourished
What does it mean if albumin is low but pre-albumin CRP is normal?
liver problem
What is the skin anergy test? What does it assess?
assess if you have enough immunoglobulins to form an allergic reaction; inject a protein, similar to TB test; if you get a reaction, you have sufficient protein and can proceed with surgery
When does smoking cessation need to occur before surgery?
8 weeks prior to surgery
What are the W’s of post-op fever?
wonder drugs, wind, water, walking, wound, wonder drugs (in that order)
If someone has a fever during surgery, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - during surgery
Diagnosis - malignant hyperthermia
How to diagnose - do not have time to diagnose them
Treatment - O2, dantrolene, cool them off with blankets/IVF
Prevention - ask about a family Hx
If someone develops a fever right after surgery, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - right after surgery
Diagnosis - bacteremia (esp after abdominal surgery)
How to diagnose - blood culture
Treatment - broad spectrum Abx
Prevention - be better; maintain sterile field, don’t accidentally poke bowel
If someone develops a fever on post-op day 1, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - post-op day #1 Diagnosis - atelectasis How to diagnose - CXR (negative consolidation) Treatment - no treatment Prevention - ICS, get out of bed
If someone develops a fever on post-op day 2, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - post-op day #2 Diagnosis - pneumonia How to diagnose - CXR (with consolidation) Treatment - broad spectrum Abx (HCAP) Prevention - ICS, get out of bed
If someone develops a fever on post-op day 3, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - post-op day #3 Diagnosis - UTI How to diagnose - U/A, confirmed by urine culture Treatment - Abx Prevention - take Foley out
If someone develops a fever on post-op day 5, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - post-op day #5 Diagnosis - DVT/PE How to diagnose - ultrasound of B/L LE Treatment - heparin -> warfarin bridge Prevention - out of bed walking around, LMWH upon return from surgery
If someone develops a fever on post-op day 7, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - post-op day #7
Diagnosis - cellulitis (wound)
How to diagnose - ultrasound (should be negative for abscess)
Treatment - Abx for cellulitis
Prevention - keep wound sterile and clean
If someone develops a fever on post-op day 10-14, what is the diagnosis? How do you make the diagnosis? What is the treatment? How could it be prevented?
When - post-op day #10-14
Diagnosis - abscess (wound)
How to diagnose - U/S (positive for abscess)
Treatment - Abx; incision and drainage
Prevention - keep wound sterile and clean
What do you use to treat sundowning in the elderly after surgery?
atypical anti-psychotics
What is normal urinary output?
0.5 cc/kg/hr
how do you evaluate for a urinary obstruction post-op?
bladder scan or in and out catheter
How do you evaluate for renal disease post-op?
give 500cc fluid bolus; if urine output picks up, they were just volume depleted, give more fluid
If urine output does not pick up, there is an intrinsic renal problem -> consult medicine
Path, Pt, Dx, and Tx of ileus
Path: functional
Pt: day 1 or 2 of no stool, no flatus
Dx: KUB (flat and erect) - will see small and large bowel dilation
Tx: fluids, potassium, get pt up and moving
Path, Pt, Dx, and Tx of obstruction?
Path: mechanical obstruction
Pt: day 5 of no stool, no flatus
Dx: KUB flat and erect - SBO - entire small bowel collapsed, distended distal to obstruction; LBO - normal small bowel, collapsed portion of large bowel with distended distally
Tx: NG tube, surgery
Path, Pt, Dx, and Tx of Ogilvie syndrome?
Path: functional
Pt: elderly
Dx: KUB (flat and erect) - small bowel normal, entire large bowel distended
Tx: decompression with rectal tube, stigmine, colonoscopy to rule out cancer
Path, Pt, Dx, and Tx of dehiscence
Path: failure of fascia to close properly
Pt: hernia; will see serosanguinous drainage
Dx: clinical
Tx: binders, reduced straining, re-operate (electively)
Path, Pt, Dx, and Tx of evisceration
Path: failure of entire wound
Pt: loops of bowel popping out of wound
Dx: clinical
Tx: back to operating room emergently, apply warm saline dressings and NEVER push the bowel back in
What is the FETID mnemonic for fistulas? Dx and Tx?
F - foreign body E - epithelization T - tumor I - irradiation/inflamed/inflammatory bowel D - distal obstruction
Dx: clinical
Tx: resect fistula, diversion
What is the best test for evaluating gallbladder pathology, and why?
MRCP - better than ERCP because it gives you the same visualization without the risk factors
What is the treatment for acute choledocholithiasis?
ERCP or cholecystectomy with retrograde cholangiopancreatography (pick ERCP because it is faster)
What will you see on RUQ ultrasound with chronic obstruction of the gallbladder (stricture or cancer)?
distended gallbladder and massively dilated biliary tree
What is the best diagnostic test for cholangiocarcinoma?
ERCP with biopsy
What symptoms would someone with biliary cancer present with? What test do you perform?
painless jaundice, weight loss, clay-colored stools, distended gallbladder that is palpable and non painful; Get a CT scan (pick this, but the test you want is MRCP)
What signs indicate pancreatic cancer? What is the diagnostic test of choice?
migratory thrombophlebitis that comes and goes on different extremities; endoscopic ultrasound with biopsy
What is the treatment for pancreatic cancer?
Whipple procedure - at very least, remove the pancreas, duodenum, and parts of the liver
What condition predisposes someone to cholangiocarcinoma?
primary sclerosing cholangitis (PSC)
If you suspect biliary cancer, but the CT scan is negative, where should you think about cancer being? What would also make you think you of this?
ampulla of vater; FOBT+ but negative colonoscopy
What is the best diagnostic test for cancer located at the ampulla of vater?
ERCP with biopsy
What is the treatment for GERD, esophageal metaplasia, esophageal dysplasia, and esophageal adenocarcinoma?
GERD: PPI
Metaplasia: high-dose PPI
Dysplasia: ablation
Adenocarcinoma: resection
What is the workup/treatment difference between GERD with no alarm symptoms and GERD with alarm symptoms?
W/o alarm Sx: lifestyle changes and PPI (Do EGD with biopsy after PPI treatment of 4-6 weeks)
W/ alarm Sx: EGD with biopsy
What is the best test for GERD?
24 hour pH monitoring
What is a possible adverse effect of Nissan fundoplication?
achalasia if wrapped too tightly
What is the diagnostic test for achalasia?
barium swallow (look for bird’s beak); if do not see bird’s beak, next test is manometry (best test)
What do you have to do before treating achalasia and why?
EGD with biopsy to rule out pseudoachalasia (cancer)
What is the treatment for achalasia?
botox - for terrible surgical candidates
dilation - risk of perforation and you have to repeat the procedure
Heller myotomy - remove muscle of the LES (remove too much, you get GERD) (best treatment)
What cancer of the esophagus is commonly found in the upper 1/3 of the esophagus? What are risk factors for its development?
Squamous cell carcinoma; hot liquids and smoking are risk factors
What cancer of the esophagus is commonly found in the lower 1/3 of the esophagus? What are risk factors for its development?
adenocarcinoma; GERD is risk factor
What is the diagnostic work-up for esophageal cancer?
barium swallow (will see an asymmetric, fungating mass) then EGD with biopsy to confirm
What is the diagnostic work-up of someone vomiting blood?
(treated as acute GI bleed)
Two large-bore IVs, IV fluids, cross transfuse as needed, PPI, call GI
What is the difference between Mallory-Weiss teras and Boorheave’s?
Mallory-Weiss - superficial tear of the esophagus with self-limited GI bleed; usually due to episode of binge drinking
Boorheave’s - transmural esophageal tear in a career vomiter (bulimia or alcoholism) (much more serious presentation, progressing toward septic shock)
What is the presentation of physical findings Boorheave’s?
air in mediastinum, hammond’s crunch, mediastinitis (fever, cough)
What is the diagnostic workup of Boerheave’s?
gastrografian swallow
if neg -> barium swallow
if neg -> EGD
What is the first diagnostic step of small bowel obstruction?
upright abdominal X-ray looking for air fluid levels, then can follow up with CT scan with oral contrast
What is the treatment for an incomplete small bowel obstruction?
watch and wait with conservative management (without peritoneal signs)
What is the treatment for a complete small bowel obstruction?
surgery ASAP
How do you treat a poor surgical candidate with a complete small bowel obstruction?
NG tube decompression, IVF, and make sure potassium is good for 3 days. If do not improve, surgery
What type of hernia is a direct hernia?
- adult males
- goes through the muscle, not the ring
- goes through transversalis
- inguinal
What type of hernia is an indirect hernia?
- male babies
- goes through inguinal ring
- inguinal (usually in scrotum)
What type of hernia is a femoral hernia?
- females
- goes under inguinal ligament
What type of hernia is a ventral hernia?
- iatrogenic
- post-op
- failure of fascias to close
What is treatment for a reducible hernia?
elective surgery
What is the treatment for an incarcerated hernia?
urgent surgery
What is the treatment for a strangulated hernia with peritoneal signs?
emergent surgery
Symptoms found in someone with carcinoid syndrome?
flushing, wheezing, diarrhea, right-sided cardiac fibrosis
What is the diagnostic work-up for carcinoid syndrome?
check urine for 5-HIAA, then if positive, do a CT scan to look for lesions
In what cases do you give antibiotics for pancreatitis? Which ones?
give carbapenem antibiotics IF FNA has proven infection (shows growth of a bug)
What is the treatment of pancreatitis? When is surgery considered?
Tx = NPO, IVF, pain meds; only considered with dx of necrotizing pancreatitis
When do you get a CT in diagnosis of pancreatitis?
usually you don’t need one; get one IF:
hours to days: sick as shit, hypotensive
5-7 days: septic, ongoing fever, leukocytosis that won’t go away
at follow-up visit with: early satiety, weight loss, abdominal pain
What is treatment of a pseudocyst of the pancreas?
<6 weeks, <6cm -> watch and wait then get CT scan if not improved
> 6 weeks or >6cm -> drain
What would be found on imaging of cholecystitis?
- pericholecystic fluid
- thickened wall
- gallstones
What is the treatment for cholecystitis?
NPO, IVF, IV Abx, urgent cholecystectomy (48-96 hours) (cholecystostomy for a nonsurgical candidate)
What is the treatment for cholelithiasis?
elective cholecystectomy or ursodeoxycholic acid (old person who is not a good surgical candidate)
RUQ abdominal pain, jaundice, fever - what triad? What does it indicate?
Charcot’s triad; indicates cholangitis
RUQ pain, jaundice, fever, hypotension, AMS - what pentad? What does it indicate?
Reynold’s pentad; indicates cholangitis
What test do you do in workup of cholangitis?
ERCP (will need IVF, IV Abx, NPO also)
What is the treatment for cholangitis?
emergent ERCP (cholecystectomy later, urgently)
What antibiotics would you give for cholangitis?
cipro + metronidazole
ampicillin/gentamycin + metronidazole
Piperacillin/tazo - DON’T PICK
If colon cancer is found on a colonoscopy, what are the next steps?
CT scan in order to stage, then chemo (FOLFOX or FOLFIRI) and radiation
When does UC require surgical consult?
(diagnosed via colonoscopy by seeing continuous inflamed colon, no skip lesions) 8 years after diagnosis (need colon cancer screening q1 year) and get a prophylactic colectomy (curative)
When does Crohn’s disease require surgical consult?
(diagnosed via colonoscopy with skip lesions and fistulas); surgeon can treat fistulas via fistulatomy (when refractory to medications) otherwise these do not need to be seen by surgeons
What is the difference between internal and external hemorrhoids?
Internal - bleed but do not hurt
External - hurt and itch but do not bleed
What is the treatment for hemorrhoids?
Internal - banding to stop bleeding
External - resection
(after creams do not work)
What is the path, sx, dx, and tx for anal fissures?
Path: tight anal sphincter
Sx: pain on defecation that lasts hours
Dx: clinical
Tx: lateral internal sphincterotomy (when nitroglycerin paste and sitz baths don’t work)
What is the diagnosis and treatment of anal cancer?
(SCC caused by HPV with anoreceptive sex)
Dx: anal pap with biopsy
Tx: chemo and radiation (Nigro protocol - anal cancer differs from cervical cancer in that it does not respond to the leep procedure)
Path, Sx, Dx, and Tx of pilonidal cyst
Path: abscessed hair follicle on buttocks
Pt: congenital, hairy butt, pain/fever/puss
Dx: clinical
Tx: incision and drainage then resect with surgery
What is Stage 1 of an ulcer?
non blanching, erythema, in epidermis but not dermis
What is Stage 2 of an ulcer?
both epidermis and dermis are penetrated but not the fascia
What is Stage 3 of an ulcer?
epidermis, dermis, and fascia are penetrated but not the tissue
What is Stage 4 of an ulcer?
muscle and bone exposed
path, patient, dx, tx of compression ulcers
path: pressure points
patient: bed-ridden, wheelchair, abuse
dx: clinical
tx: q2 hour rolls, get out of bed, air-mattresses (this is the same as prevention of compression ulcers)
path, patient, dx, tx, and prevention of diabetic ulcers
path: microvascular neuropathy (can’t feel, glove and stocking neuropathy)
pt: diabetic (probably fairly uncontrolled), heels/balls of feet
dx: clinical
tx: control blood glucose, elevate legs, amputations
prevention: inspect feet, have good shoes
path, patient, dx, and tx of arterial insufficiency ulcers
path: macrovascular (problem getting blood in)
patient: peripheral vascular disease, hairless legs, scaly skin, absent pulses, ulcers on tips of toes
dx: ankle-brachial index, u/s doppler, angiogram when wanting to treat (diagnose peripheral vascular disease if it has not already been diagnosed)
tx: stent, bypass (stent small lesions above the knee and bypass any lesion of the popliteal artery or any large length of lesion)
path, patient, dx, and tx of venous stasis ulcers
path: microvascular (problem getting blood out)
patient: edema (and something that causes them to get that edema like CHF, cirrhosis, nephrotic syndrome) -> stasis dermatitis with hyperpigmentation, indurated, medial malleolus ulcer
dx: clinical
tx: compression stockings, elevate legs, diuretics
path, patient, dx, and tx of Marjolin ulcer
path: SCC
patient: ulcer with sinus tract or one that breaks and heals over and over again; will have heaped up margins
dx: biopsy
tx: wide resection
What are the three ways of predisposing to breast cancer?
- Estrogen (early menarche, late menopause, nulliparity, hormone replacement therapy (NOT OCPs)
- Radiation (for lymphoma)
- Genetic (BRCA1/2)
What are the three ways a woman can present with breast cancer?
- asymptomatic screen
- breast lump
- obvious breast cancer (skin dimpling, fixed axillary nodes, large breast mass)
When should women undergo mammograms for breast cancer screening? When are MRIs indicated?
USPSTF recommends q2 years for women age 50 and older (pick this one if asked)
ACS-NCI recommends q1 year for women age 40 and older (more sensitive, but more biopsies were being done)
MRIs are the best way to screen people, but they re expensive, so they are only used for those with previous radiation and those with BRCA1/2
What type of biopsy is used to diagnose breast cancer?
core needle biopsy
What do you do when someone less than 30 finds a breast lump?
watch and wait for 1-2 cycles to see if it goes away with their menstrual cycle
if it persists -> get an ultrasound, which will tell you if it is a mass or cyst
What is the next step in management when a cyst is found in someone less 30yo on ultrasound?
FNA
What are the 3 possible results of FNA and what they mean?
bloody -> probably cancer
pus -> abscess
fluid -> benign cyst
What happens when you are over 30 and have a mass or cyst on ultrasound?
If patient meets any criteria, you go back to mammogram for diagnosis:
- over 30
- mass found on U/S
- bloody cyst found on FNA
- cyst recurs
What systemic chemotherapy is given for breast cancer?
doxorubicin (or donorubicin) based with cyclophosphamide and paclitaxel
remember that doxorubicin or donorubicin can cause CHF, so you need to keep getting echos
What chemotherapy is given for HER2 positive breast cancer? Is this good or bad prognosis?
traztuzumab (can also cause CHF, gets better with removal); bad prognosis
What chemotherapy is given for HER2 negative breast cancer?
bevacizumab
What chemotherapy is given for estrogen/progesterone receptor positive cancer? Is this good or bad prognosis?
If premenopausal:
SERMS - tamoxifen/raloxifene
If post-menopausal:
aromatase inhibitors; better prognosis
What should you do for a BRCA positive patient?
prophylactic bilateral mastectomy and bilateral salpingo-o-phorectomy
What is the difference between tamoxifen and raloxifene?
- Tamoxifen works better than raloxifene
- Tamoxifen can cause DVTs and endometrial cancer (Raloxifene does not)
- Both are estrogen receptor antagonists in the breast, but tamoxifen is an estrogen receptor agonist in the uterus
path, patient/sx, dx, tx of TE Fistula in a newborn
Path: atresia/fistula
Pt: gurgling, coughing, bubbling
Dx: NG tube coiling, X-ray
Tx: surgery
What other conditions do you have to consider with TE Fistula in a newborn?
Other components of VACTERL syndrome (check for imperforate anus, get an echocardiogram) - do all of this BEFORE surgery for one component
Path, patient/Sx, Dx, and Tx of imperforate anus
Path: mild = rectum very close to anus; severe = rectum a long way from anus
Pt: no anus
Dx: clinical, but you need an X-ray to see severity
Tx: surgical; mild -> fix now; if severe, wait to let baby grow in order to have more bowel to work with (do colostomy and then reverse it before toilet training)
what is the difference between gastroschisis, omphalocele, and entropy of the bladder?
gastroschisis: bowel without a membrane, located to the right of midline (name sounds angry and it is the angriest)
omphalocele: bowel contained in membranous sac at midline
extrophy of the bladder: bladder coming out of abdomen at midline
What are hints that you are dealing with extrophy of the bladder rather than omphalocele?
no bowel, wet, shining, red
What is the treatment for gastroschisis and omphalocele?
surgical silo
Path, patient, Dx, and Tx of congenital diaphragmatic hernia (CDH)
Path: posterior (Bochdalek), anterolateral (Morgagni)
patient: scaphoid abdomen, will hear bowel sounds in the chest
Dx: confirm with X-ray
Tx: Surgery
What complication is a concern after treatment of congenital diaphragmatic hernia?
hypoplastic lung (lung wasn’t able to develop normally due to bowel in chest cavity), may need to be given surfactant
Your newborn has biliary emesis. You get an X-ray and see the double-bubble sign with normal gas distally. What is the diagnosis?
malrotation
What is the first step in management after diagnosing malrotation in a newborn?
contrast enema (can be both diagnostic and therapeutic)
if this doesn’t work, get upper GI series. If that doesn’t work, go do surgery
Your newborn has biliary emesis. You get an X-ray and see the double-bubble sign with multiple air fluid levels. What is the diagnosis?
intestinal atresia
What is the cause of intestinal atresia? What is the treatment? What is a possible complication of the treatment?
inutero infarcts due to maternal use of cocaine
treatment = surgery, remove the necrotic portions of bowel
complication = if you remove too much bowel, you end up with short gut syndrome
Your newborn has biliary emesis. You get an X-ray and see the double-bubble sign with no gas in the bowel. What is the diagnosis? What is the treatment?
either duodenal atresia or annular pancreas; surgery
path, patient, diagnosis, and treatment of necrotizing enterocolitis
path: premature
patient: bloody BM
Dx: X-ray (will see air in the wall of the intestine, AKA pneumotosis intestinalis)
Tx: bowel rest, start TPN, IV Abx that cover gut flor; if baby does not improve on this regimen, they will need surgery to cut out necrotic bowel
path, patient, dx, and tx of meconium plug
Path: cystic fibrosis (will have to tell you it was positive on prenatal screen or that there was not prenatal care)
Patient: failure to pass meconium, +/- biliary emesis
Dx: X-ray - might see a gas-filled plug; use water-soluble contrast enema (Tx)
Tx: water soluble contrast enema, also treat cystic fibrosis (replace pancreatic enzymes, supplement fat soluble vitamins (DEAK), pulmonary toilet, prevent infections)
path, patient, dx, and tx of Hirschsprung’s disease
Path: failure of inhibitory neurons to migrate to distal colon; no Auerbach plexus, no myenteric plexus
Patient: 1 of 2 presentations:
1. failure to pass meconium OR
2. toddler age where they will begin having overflow incontinence with toilet training
Dx:
1. failure to pass meconium - contrast enema (will see dilated colon, transition point, and normal-looking colon.
- toddler - anal manometry (will show constant tone)
- biopsy - shows absent nerve plexuses
Tx: surgery - remove bad part of colon
Path, patient, Dx, and Tx of intussusception
Path: telescoping bowel (90% with no lead point)
patient: sudden abdominal pain, knee-chest positive relieves, sausage-shaped mass on imaging, currant jelly diarrhea (late finding, hopefully you intervene before this)
Dx: air contrast enema
Tx: air contrast enema
Path, patient, Dx, and Tx of pyloric stenosis
Path: gastric outlet obstruction
Patient: projectile vomiting, first-born male, olive-shaped mass, visible peristalsis
Dx: ultrasound showing donut sign (also must get a BMP, likely to have hypokalemia, hypochloremic metabolic alkalosis due to the vomiting)
Tx: pyloromyotomy; if you see a metabolic alkalosis, you have to give IVF and replete electrolytes inpatient BEFORE U/S or surgery
Path, patient, Dx, and Tx of biliary atresia
Path: no development of biliary tree, so you cannot get conjugated bilirubin out of your system
Patient: worsening direct hyperbilirubinemia, usually at 2 weeks of life
Dx: phenobarbital for 1 week, get HIDA scan - only going to get contrast to the level of the liver
Tx: surgery
Path, patient, Dx and Tx of choanal atresia
Path: nose is not connected to pharynx
Patient: blue with feeding, pink while crying, snoring baby
Dx: pass catheter, coils in nose
Tx: surgical fixation
If you find a thyroid nodule with a low TSH level, what is the risk of malignancy, and what is the next step in management?
low-risk nodule; get a radioactive iodine uptake scan
If you find a thyroid nodule with a low TSH level, and on RAIU, you find a hyper-functioning nodule, what is the diagnosis and treatment?
hyperthyroidism/hot nodule -> treat medically
If you find a thyroid nodule with a low TSH level, and on RAIU, you find a non-functioning nodule, what is the next step in management?
U/S or FNA
If you find a thyroid nodule with a high TSH, what is the risk of malignancy, and what is the next step in management?
high-risk nodule; get U/S
If you find a thyroid nodule with a high TSH, and on U/S, you find a nodule that is >1 cm, what is the next step in management?
FNA
If you find a thyroid nodule with a high TSH, and on U/S you find a nodule that is < 1 cm, what is the next step in management?
observe; U/S q6 months
What are the three potential results of thyroid FNA and the next step in management for each step?
- cancer -> surgery
- not cancer -> q6 months U/S
- not sure -> repeat biopsy immediately
Path, patient, Dx, and Tx of gastrinoma? What could this lead to without treatment?
Path; gastrin secretion
Patient: virulent ulcer (does not get better with PPIs or when you do endoscopy, there’s ulcers everywhere), diarrhea
Dx: gastrin level (off PPI), if only small elevation (triple digits) -> secretin stimulation test (normally turns gastrin/parietal cells off)
If 4 digit gastrin level -> somatostatin receptor scintigraphy or CT scan to localize disease
Tx - surge resection
Could lead to gastric cancer
Path, patient, Dx, and Tx of insulinoma?
Path: insulin secretion
Pt: hypoglycemia even in the presence of fasting
(hypoglycemia defined both low value and symptoms)
Dx: insulin level, C-peptide, and sulfonylurea screen (insulin level should be elevated in this case, elevated if insulin is coming from their own pancreas, insulinoma will have negative sulfonylurea screen)
Tx - resection
(and fix glucose)
Path, patient, Dx, and Tx of glucagonoma?
Path: glucagon secretion
Patient: migratory necrolytic dermatitis
Dx: glucagon level (will be elevated), CT scan to locate
Tx: resection
(do not have to do glucagon secretion test)
Patient, Dx, Tx, and complication of primary hyperparathyroidism?
Patient: elevated Ca, decreased phosphate, and elevated PTH, bone pain
Dx: sestanibi scan (tells you which parathyroid glad is overproducing)
Tx: resection
Complication: other glands have atrophied and can take awhile to turn back on -> post-op hypocalcemia with perioral tingling, Trosseau’s sign,, chvostek’s sign
What are the actions of PTH on the body?
Resorption of bone, which increases Ca + increases Phos
Absorption of Ca in the gut, increasing Ca + increasing Phos
Resorption of Ca from the kidneys, increasing Ca + DECREASING phos
Patient, Dx, and Tx of primary hyperaldosteronism (Conn Syndrome)
patient: HTN and hypokalemia (an obvious aldosterone problem)
Dx: Aldo:renin ratio > 20 -> salt suppression test -> CT/MRI -> adrenal vein sampling
Tx: resection
Patient, Dx, and Tx of renal artery stenosis
patient: old man with hypertension or young woman with fibromuscular dysplasia; present with HTN and hypokalemia (kidney is volume down, so tries to increase reabsorption by increasing renin)
Dx: Aldo:renin < 10 (both elevated) -> u/s with doppler (angiogram is technically the best test)
Tx: young woman -> stent
old man -> medically manage +/- surgery
Path, patient, Dx, and Tx of pheochromocytoma
Path: catecholamines
Patient: 5 P’s: Paroxysms of elevated blood Pressure with Pain, Palpitations, and Perspiration
Dx: 24 hour urinary VMA and metanephrines -> localize with CT, MRI, or MIGB scan, adrenal vein sampling before resection
Tx: resection but have to reduce BP prior to surgery (first alpha blockade THEN beta blockade THEN resection)
Path, patient, Dx, and Tx of Cushing’s syndrome
Path: cortisol (ACTH driven or not?)
Patient: hypertensive and diabetic; buffalo hump, purple striae, moon facies, acne
Dx/Tx: low dose dexamethasone suppression test; follow-up with either late night salivary cortisol or a 24 hour urine
If this fails -> Cushing Syndrome
Test ACTH:
ACTH low -> primary adrenal tumor; get CT/MRI, adrenal vein sampling, resect
ACTH high -> high dose dexamethasone suppression test:
suppresses -> Cushing Disease (pituitary adenoma) -> MRI of pituitary and resect
fails to suppress -> ectopic tumor (usually with lung cancer) -> get CT scan
Patient, Dx, and Tx of coarctation of the aorta
Patient: HTN in UE, hypotension in LE, kids, claudication (will refuse to walk), temp difference between UE/LE
Dx: CT angiogram
Tx: resect and re-anastomose
What are the three types of L -> R shunts in children?
ASD, VSD, PDA
Path, patient, Dx, and Tx of ASD in children
Path: hole that allows blood flow from LA -> RA (primum/secundum)
Patient: any age, FIXED, SPLIT S2
Dx: echo
Tx: close the hole (done with a device so as to not crack the chest)
Path, patient, Dx, and Tx of VSD in children
Path: hole that allows blood flow from LV -> RV; associated with Down’s syndrome
Patient: < 1 yo (MC), asymptomatic but loud murmur OR inaudible murmur with failure to thrive and CHF
Dx: echo
Tx: asymptomatic/loud - can wait up to 1 year to see if it will go away on its own
CHF -> surgical repair
Path, patient, Dx, and Tx of PDA in children
Path: connection between aorta and pulmonary artery remains after birth
patient: murmur that is not present on day 0; will be described as a continuous, machine-like (multi-phase) murmur
Dx: echo
Tx: closure when needed: indomethacin
(give prostaglandins to maintain PDA before you can get to surgery)
What are the right to left shunts in children?
Tetralogy of Fallot, Transposition of the great vessels
Path, patient, Dx, and Tx of transposition of the great vessels
Path: moms with diabetes (not gestations); week 8 -> failure to twist
Two systems:
RA -> RV -> aorta -> vena cava
LA -> LV -> pulmonary artery -> pulmonary vein
PDA allows temporary survival
Patient: blue baby, dies if you do nothing
Dx: echo (but not really time for this)
Tx: prostaglandins to keep PDA open for surgery
Path, patient, Dx, and Tx of Tetralogy of Fallot
Path: endocardial cushion defect; associated with Down’s syndrome
Four parts:
1. VSD
2. Overriding aorta
3. Pulmonic stenosis
4. Right ventricular hypertrophy
Patient: either a blue baby that dies at birth OR slightly older kid that gets TET spells (hypoxic until squatting)
Dx: CXR that shows boot-shaped heart (don’t have to get this), echocardiogram
Tx: surgery
How are the diagnostic steps of coarctation of the aorta different in a kid vs and adult?
do not do an angiogram in a child. Do not do a CXR looking for rib notching because those collaterals will not have developed in a child. Still do echo
Path, patient, Dx, and Tx of aortic stenosis
Path: calcifications
Patient: old men with CAD, chest pain, syncope, CHF, murmur at 2nd ICS R sternal border, crescendo-decrescendo murmur in systole that radiates to the carotids
Dx: echocardiogram
Tx: valve replacement: endoscopic repair TAVI/TAVR for non open chest patient
Path, patient, Dx, and Tx of mitral regurgitation
Path: infection, infarction (papillary muscle or chord tendonae rupture with papillary m. way more common)
Patient: systolic murmur heard best at cardiac apex, radiates to axilla, holosytolic
Dx: echo
Tx: valve replacement
Path, patient, Dx, and Tx of aortic regurgitation
Path: infection, infarction, or dissection
Patient: acute (devastating); chronic (insidious); diastolic heard best at the 4th ICS L sternal border, decrescendo, blowing murmur
Dx: echo
Tx: replacement
Also have to consider doing a CABG at the same time
Path, patient, Dx, and Tx of mitral stenosis
Path: rheumatic heart disease
Patient: diastolic, heard at cardiac apex; rumbling murmur with opening snap (occurs earlier in the murmur the worse the murmur is); LA dilates and can present with CHF or atrial fibrillation
Dx: echo
Tx: medical therapy -> balloon valvotomy -> eventual replacement possible
Wha is the difference between bovine (organic) and mechanical valves?
Bovine (organic) - last < 10 years, do not require anticoagulation
Mechanical - 10-20 years, require anticoagulation with warfarin for target INR 2.5-3.5
Path, patient, Dx, and Tx of CAD
Path: obese, HTN, DM, smokes, HLD; greater risk for women > 55yo and men > 45yo
Patient: chest pain is likely to be coronary if:
1. substernal
2. worse with exercise
3. improved by nitroglycerin or rest
Dx/Tx: EKG -> STEMI -> Cath lab immediately
EKG normal but elevated troponin -> NSTEMI -> Cath lab urgently; EKG normal, troponins normal -> still think cardiac, get stress test
Once in the Cath lab for treatment of CAD, how do the treatments differ based on disease severity?
1-2 vessels involved: stent + clopidogrel
3 or more vessels or left main dominant disease: CABG (left internal mammary artery -> tether to most important artery; every other vessel is grafted with saphenous vein); post surgery give CAD meds (aspirin, ACE inhibitor, beta blocker, statin)
Path, patient, Dx, and Tx of AAA
Path: atherosclerosis (gender and smoking matter most)
Patient: males >65 yo that have smoked with an asymptomatic pulsatile mass
Dx: ultrasound (screening), CT scan (wrong answer on test) (do not get an arteriogram)
Tx: size >3.5 cm = AAA, screen q12 months
>4.5 cm = AAA, screen q6 months
>5.5 cm OR >0.5 cm/6 months -> go to surgery
Path, patient, Dx, and Tx of aortic dissection
Path: HTN
Patient: 1. tearing chest pain that radiates to the back
2. asymmetric BP arm to arm
3. widened mediastinum
Two different types:
Type A - before great vessels
Type B - after great vessels
Also look for someone with Marfan’s or syphilis (poor, STDs, check RPR)
Dx: CT angiogram (wills ee false lumen) (cannot do CT angiogram if they have renal failure - TEE = MRI as second option)
Tx: ascending (Type A) -> must operate and have to evaluate for aortic valve replacement (can cause aortic regurgitation)
descending (Type B) -> treat medically (beta blockers) by decreasing HR and BP
