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
Path, patient, Dx, and Tx of peripheral vascular disease (PVD)
Path: CAD but in different place (must treat these people as though they also have CAD); women > men
Patient: leg claudication (angina of the leg) (immediately rule out spinal stenosis), non-healing wounds
SEVERE - rest pain or change of position (white feet in bed)
PE: shiny shins, loss of hair (esp unilateral), change in temp, decreased pulses)
Dx: ankle-brachial index -> doppler U/s -> CT angiogram
Tx: assess person’s need to get revascularized - angioplasty and stenting - above the knee or small vessels
bypass - below the knee or long lesion
Also have to do medical management (A1C <7, statin, smoking cessation, ASA/clopidogrel, ACEi/beta blockers), can also increase exercise tolerance with cilostazol and pentoxifylline
How do you interpret ankle-brachial index results?
ABI > 1.4 - can’t use that, shouldn’t happen, have to do a toe brachial index
Normal ABI - 1.0-1.4
Equivocal ABI - 0.9-1.0 -> unclear, follow-up with exercise ABI
Mild - 0.8-0.9
Moderate - 0.4-0.8
Severe - <0.4
Path, patient, Dx, and Tx of acute limb ischemia
Path: cholesterol embolism following cath, embolism with atrial fibrillation, thrombus on top of PVD
Pt: 6 P’s:
Pulseless
Pale
Poikolothermia (cold limb)
Pain
Parasthesias
Paralysis
Dx: U/S with doppler, angiogram
Tx: embolectomy or tPA (intra-arterial directed at thrombus)
Must assess for compartment syndrome (cut open to relieve pressure if occurs)
Path, patient, Dx, Tx, and prevention of amblyopia
Path: cortical blindness Patient: strabismus or congenital cataracts Dx: clinical Tx: none Prevention: correcting illness
Path, patient, Dx, and Tx of strabismus
Path: “lazy eye”
Dx: clinical
Tx: congenital -> surgery to fix within 6 months
Acquired -> patch good eye, give glasses if refractory
Path, patient, Dx, and Tx of congenital cataracts
Path: positive at birth = TORCH infection
negative at birth = galactosemia
patient: cloudy/milky white thing in the front of the eye
Dx: clinical
Tx: removal of cataracts
Path, patient, Dx, Tx, and follow-up of retinoblastoma
Path: Rb gene
Patient: all white retina instead of red reflex
Dx: clinical
Tx: surgical, do not use radiation ever (induce second hit in the other eye and make them blind)
Follow-up: worry about osteosarcoma around puberty
Patient, Dx, Tx, and follow-up of retinopathy of prematurity
Patient: premature -> increased FiO2, will see growths on retina
Dx: clinical
Tx: laser ablation
Follow-up: consider other premature illnesses: bronchopulmonary dysplasia, intraventricular hemorrhage (U/S doppler), necrotizing enterocolitis
Onset, discharge, and Tx of chemical conjunctivitis
silver nitrate caused
Onset: <24 hours
Discharge: bilateral, non-purulent
Tx: use topical erythromycin (covers everything except chlamydia)
Onset, discharge, and Tx of gonorrhea conjunctivitis
Onset: 2-7 days old
Discharge: bilateral, purulent
Treatment: ceftriaxone, also culture (Chocolate Agar, PCR)
Onset, discharge, and Tx of chlamydia conjunctivitis
Onset: 5-14 days old
Discharge: unilateral, mucoid/purulent -> turns bilateral
Treatment: oral erythromycin, look for systemic illness (pneumonia), culture/PCR
Path, patient, Dx, and Tx of closed angle glaucoma
Path: pressure after pupil dilation Patient: 1. low lights - pupil dilation 2. flow out of chamber decreases 3. pressure = pain, HA, rigid eyeball 4. increased pressure = nonreactive, dilated pupil Dx: clinical, measure ocular pressures Tx: constrict pupil -> activate alpha, block beta (alpha agonists, beta blockers) decrease pressure -> laser NEVER GIVE ATROPINE
Patient, Dx, and Tx of periorbital cellulitis
Patient: inflammation of eye region -> can they move their eye?
If yes, periorbital cellulitis -> Abx
If no, CT scan to look for abscess. If abscess, incision and drainage + Abx
If you have a diabetic patient (especially if in DKA) with periorbital cellulitis, what should you consider? Treatment?
mucormycosis, tx = amphoteracin
Path, patient, Dx, and Tx of corneal abrasions
Path: something getting into eye
Patient: hobby/job where they should wear goggles, but they don’t, pain, tearing, redness
Tx: irrigate a lot
AFTER:
Dx: flourecine dye -> if bad enough, surgery
Path, patient, Dx, and Tx of retinal detachment
Path: trauma, such as MVA or HTN crisis
Patient: “floaters” = mild, “curtain” = severe
Dx: clinical
Tx: spot weld with laser
F/u: if this happens again, i.e. comes and goes -> amorasis fugax (pending retinal artery occlusion)
Path, patient, Dx, and Tx of retinal artery occlusion
Path: eye stroke
Patient: painless acute loss of vision, unilateral with NO OTHER focal neurologic deficits; cherry red spots on fovea
Dx: clinical
Tx: intra-arterial tPA; if you cannot do this, there are other things than can preserve vision loss, such as hyperventilation and global pressure
Path, patient, Dx, and Tx of cataracts
Path: age + diabetes
Patient: chronic, progressive vision loss, difficult with night time vision, white thing in anterior chamber
Dx: clinical
Tx: resection
Path, patient, Dx, and Tx of macular degeneration
Path: wet (20%) and dry (80%)
Patient: chronic progressive loss of central vision
Dx: look in back of eye: wet form -> fluid/blood
dry form -> drusen/pigment changes
Tx: wet -> laser; dry -> no treatment
path, Sx/patient, Dx, and Tx of basal cell carcinoma
Path: basal layers, no metastasis, locally invasive
Patient/Sx: pearly lesion on sun-exposed areas; lesion that fails to heal and bleeds easily
Dx: excisional biopsy (can do incisional biopsy if large lesion or on face); DO NOT pick punch biopsy
Tx: face = Mohs surgery; limbs/mild = excision; limbs/aggressive = might have to amputate limb
path, Sx/patient, Dx, and Tx of squamous cell carcinoma
Path: keratinocytes; can metastasize but rare, locally invasive
Patient/Sx: well-defined red papule; ulcer that is non-healing; lower lip hyperpigmentation; NO paraneoplastic syndrome
Dx/Tx: same as basal cell carcinoma
Path, Sx/patient, Dx, and Tx of melanoma
Path: melanocytes, metastasizes, locally invasive
Sx/patient: jet black lesion without hair, any skin lesion that meets ABCDE (D = diameter > 5mm)
Dx: punch biopsy (large lesions and those with low suspicion), excisional biopsy (preferred, small lesions, high suspicion)
Tx: based on Breslow’s depth:
<0.5 mm = excisional biopsy, margins of 0.5 cm
1-2 mm = excision + SLND if tracer is positive, margins of 1 cm
2-4 mm = same as 1-2 except margins of 2cm
>4mm = effectively metastatic disease; chemo/radiation; debulk for palliative care
Path, patient/Sx, Dx, and Tx of subarachnoid hemorrhage
Path: aneurysm (something vigorous usually sets it off)
Patient/Sx: thunderclap headache, sentinel bleed (little leak that went away), headache, neck stiffness, focal neurologic deficit, coma
Dx: non contrast CT scan, get Angiography (MR/CT); if CT scan is negative but still high suspicion of bleed, get lumbar puncture looking for xanthochromia (yellow-tinged CSF)
Tx: early (within 48 hours):
1. bleeding -> IV meds to get BP < 140/90, coiling, clipping
2. hydrocephalus -> VP shunt of serial lumbar punctures
3. seizures -> seizure prophylaxis (any primary first line epileptic
4. increased ICP -> hypertonic solutions (mannitol, hypertonic saline), elevate bed, hyperventilate
Late (5-7d):
1. vasospasm -> prophylaxis with CCB
When do you decide to do VP shunt vs serial LP and coiling vs clipping?
If patient is obtunded and doing poorly, may have to do craniotomy. If you are opening up skull, you have access to do VP shunt, and clipping
Path, patient/Sx, Dx, Tx, and follow-up of intraparenchymal hemorrhage
Path: HTN
Patient/Sx: focal neurologic deficits, headache, N/V, coma
Dx: CT scan
Tx: decrease ICP, craniotomy if needed, evacuate hematoma (via craniotomy)
f/u: daily CT scan, look for expansion/midline shift (if expands, have to evacuate)
Path, Patient/Sx, Dx, and Tx of brain cancer (in general)
Path: 70% are metastatic from lung, breast, GI; will see multiple lesions stuck at gray-white junction
30% primary - never metastasize, singular
Pt/Sx: focal neurologic deficit, seizure, HA worse in the morning, progressive N/V
Dx: neuroimaging (MRI with contrast is best) and biopsy
Tx: resection, radiation, chemo (doesn’t work great except for meningioma); steroids (palliative), seizure prophylaxis
What are the pituitary tumors you need to know?
- prolactinoma
- acromegaly
- craniopharyngioma
Craniopharyngioma
asymptomatic, kids, +/- short stature, calcification of the sella on imaging, for Dx, resect if they cause problems
2 brain tumors the posterior fossa that you should know? Who do they occur in?
Remember posterior fossa = peds
medulloblastoma and ependymoma
Medulloblastoma
highly malignant, seeds arachnoid space, distal lesions down spinal cord, resecting + radiation
Ependymoma
comes from the fourth ventricle, obstructive hydrocephalus predominates, look for the kid that is better in fetal position, no distal lesions, resection for Tx
What are the 2 brain tumors of the anterior fossa that you should know? Who do they usually affect?
Anterior fossa = Adults; meningioma and glioblastoma
Meningioma
comes from dura, resection is curative, causes a focal neurologic deficit specific to where it is located
Glioblastoma
located in the parenchyma, eats brain away, highly necrotic, highly mitotic, look for ring-enhancing deformity or bat wing/butterfly sign (can cross midline unlike other tumors), can try to resect but prognosis is dismal
Astrocytoma
likely glioblastoma without as bad of a prognosis
Schwannoma
presents with N/V, hearing loss, vertigo, tinnitus that goes away with resection
What is the first step in workup of a child with hematuria?
U/A to determine macro vs micro
Ped patient with hematuria. U/A shows microhematuria. What next?
usually self-limiting (watch and wait); if they had trauma, can do a CT scan
Ped patient with hematuria. U/A shows macrohematuria. What next?
urine microscopy:
2 possible results:
1. dysmorphic RBC casts
2. normal RBCs with no casts
Ped patient with macrohematuria on U/A. Microscopy shows dysmorphic RBC casts. Dx?
glomerular (could do kidney biopsy)
Ped patient with macrohematuria on U/A. Microscopy shows normal RBC with no casts. What’s the next step in workup?
This indicates nonglomerular causes. Get an U/S. Then decide between cystoscopy vs systemic imaging (CT/MRI)
What is an ultrasound useful for telling you?
tells you hydro vs nonhydro (not good at telling you the location of structures); hydro is usually associated with obstruction but in kids can also be associated with reflux
What does a voiding cystourethrogram tell you?
put catheter in, inject dye, kid pees, all dye should come out urethra. If some goes up into ureters, you have reflux; tells reflux or no reflux
What does a cystoscopy show you?
intraluminal lesions
When do you want to use a CT scan for imaging in Peds urology cases?
trauma = IV contrast stones = non contrast
Path, Patient/Sx, Dx, and Tx of posterior urethral valves
Path: cannot get urine out of the bladder, redundant tissue cases post obstructive uropathy
Patient/Sx: +/- oligohydramnios in prenatal care (might see on prenatal U/S) (but the test will probably give you someone with no prenatal care); presents with no urine output and distended bladder, +/- increased creatinine
Dx: U/S = hydro; VCUG = rule out reflux, insert catheter = massive urine output
Tx: surgery to fix anatomical problem
Path, patient/Sx, Dx, and Tx of hypo/epispadias
Path: epi = dorsal, hypo = ventral
Pt: clinical
Dx: clinical
Tx: cosmetic deformity; NEVER do a circumcision because you need the foreskin to rebuild the urethra
Path, patient/Sx, Dx, and Tx of ureteropelvic junction obstruction
Path: narrow lumen, normal for most of life with normal flow of urine; obstruction created with increased flow
Patient/Sx: teenager -> alcohol binge -> colicky abdominal pain that spontaneously resolves
Dx: ultrasound = hydronephrosis without hydroureter; VCUG to rule out reflux
Tx: surgery +/- stent to keep ureter open
Path, Patient/Sx, Dx, and Tx of ectopic ureter
Path: normal ureter that goes to the bladder, abnormal ureter implants where it wants to
Patient: boy = asymptomatic
girls = normal voiding function + constant leak, never dry
Dx: U/S = no hydro; VCUG to rule out reflux; radionucleotide scan
Tx: reimplantation of ectopic ureter
Path, Patient/Sx, Dx, and Tx of vesiculoureteral reflux
Path: retrograde flow
Patient: Dx on prenatal U/S showing hydro (but they won’t give you someone with prenatal care on the exam); will present with recurrent UTIs +/- pyelonephritis
Dx: U/S = hydro; VCUG = positive for reflux
Tx: give Abx and hope they outgrow but surgery will probably be needed
Path, Patient/Sx, Dx, Tx, and f/u of prostate cancer
Path: 5-DHT
Patient: old men > 70, no asymptomatic screening; screening offered for those with a first deg relative with prostate cancer
Sx: obstructive/BPH on DRE; DRE will show firm, nodular prostate
Dx: PSA, biopsy either transrectal (better sample) or transurethral; Gleason score = higher is worse
Tx: variable, resection = radiation = brachytherapy
Medications that can be use: anti-androgens (flutonide), GnRH analogs (leuprolide), bilateral orchiectomy
F/u: PSA (want to return to zero), anti androgens if you ever see a rise in PSA w/o symptoms; use radiation if increase in PSA and symptoms
Path, Patient/Sx, Dx, and Tx of bladder cancer
Path: transitional cell, related to toxic exposure to beta alanine dyes and smoking
Patient: painless hematuria, obstructive symptoms
Dx: get U/S if obstructive symptoms; otherwise start with cystoscopy with biopsy
Tx: transuretral resection + BCG, chemo (cisplatin based)
F/u: do periodic cystoscopies
Path, Patient/Sx, Dx, and Tx of testicular cancer
Path: germ cell
Patient: young male, 18-25 with painless mass that does not transluminate
Dx: U/S, do orchiectomy to Dx and Tx (DO NOT DO FNA ON TESTICULAR MASS BC YOU WILL SEED THE CANCER)
Tx: resection, might need chem-radiation based on stage (seminoma vs nonseminoma)
Seminomas are sensitive to cisplatin-based chemo
What are the nonseminoma testicular cancers, and what markers do you follow them with?
Endodermal - AFP
Choriocarcinoma - beta HCG
teratoma - (very malignant in men, look for metastatic lesions)
Patient/Sx, Dx and Tx of renal cell carcinoma
Pt: flank pain, palpable mass, painless hematuria; could see paraneoplastic syndrome of erythrocytosis (bc the kidney makes EPO), can also see anemia
Dx: CT scan, DO NOT BIOPSY, nephrectomy to Dx
Tx: resection, chemo/radiation
Path, patient/Sx, Dx, and Tx of BPH
Path: prostate enlarges and obstructs urinary flow; grows in the center unlike cancer
Patient/Sx: >50 yo, lower urinary tract symptoms (hesitancy, dribbling, urgency, trouble emptying bladder, trouble initiating stream); DRE will be smooth and rubbery
Dx: UA with culture to rule out UTI
Tx: alpha blockers (tamsulosin), can add on 5 alpha reductase inhibitors (finasteride)
If this fails.. TURP (transurethral resection of the prostrate (leads to incontinence and ED)
What complication of BPH is also treated with a TURP? How does it present?
obstructive uropathy; presents with abdominal pain, distended bladder, elevated creatinine
put in foley -> suprapubic catheter to try to relieve first
Path, Patient/Sx, Dx, and Tx of erectile dysfunctio
Path: psych or organic cause
Patient/Sx: inability to achieve or maintain erection
Dx: night time tumescence
Tx: if night time tumescence test breaks -> psych -> need counseling or new partner
tumescence test does not break -> cannot achieve erections at night -> organic disease -> PDE-1 (sildenafil), pumps, prosthesis
Path, Patient/Sx, Dx, and Tx of testicular torsion
Path: testicle twists about its pedicle
Pt/Sx: spontaneous scrotal pain, horizontal lie of testicle, pain on elevation
Dx: ultrasound doppler
Tx: surgical emergency (if stays dark, gray, or husky you have to remove it), do B/L orchoplexy to tack them down
Path, Patient/Sx, Dx, and Tx of epididymitis
Path: infection
< 35 yo -> STD
> 55 yo -> E. coli
Pt/Sx: sudden onset scrotal pain, vertical lie, relief of pain on elevation of testicle
Dx: ultrasound with doppler -> negative
Tx: < 35 yo -> ceftriaxone + azithromycin
>55 yo -> fluoroquinolone like ciprofloxacin
Path, Patient/Sx, Dx, and Tx of prostatitis
Path: bacterial or inflammatory Pt/Sx: older male with "pyelonephritis" but no CVA tenderness and no casts in urine; when you do DRE = very tender Dx: UA and urine culture Tx: NEVER REPEAT DRE; bacterial -> Abx inflammatory -> NSAIDs
Path, Patient/Sx, Dx, and Tx of nephrolithiasis
Path: stones (most common = calcium oxalate)
Pt/Sx: colicky flank pain that radiates to the groin, often with hematuria
Dx: U/A -> if no hematuria, it’s not a kidney stone; best test = non contrast CT scan (if can’t get Ct, get U/S)
Tx: small < 0.5 cm -> fluids and pain control
0.5 cm -> add on CCB
<1.5 cm -> stenting, or lithotripsy
>2.0 -> surgery
Age, Patient/Sx, Dx, and Tx of developmental dysplasia of the hip
Age: newborn
Pt/Sx: clicky hip
Dx: U/S (4 weeks)
Tx: harness
Age, Patient/Sx, Dx, and Tx of Legg-Calve-Perthes
Age: 6 hears old
Pt/Sx: insidious, antalgic gait
Dx: XR
Tx: cast
Age, Patient/Sx, Dx, and Tx of slipped capital femoral epiphysis (SCFE)
Age: 13
Pt/Sx: growth spurt or fat, non traumatic joint pain
Dx: frog leg X-ray
Tx: surgery
Age, Patient/Sx, Dx, and Tx of septic joint
Age: any age
Pt/Sx: fever, leukocytosis, increased ESR/CRP, unable to bear weight
Dx: arthrocentesis with >50,000 WBC
Tx: drain + Abx
Age, patient/Sx, Dx, and Tx of transient synovitis
Age: any age
Pt/Sx: hip pain following viral illness, inability to bear weight
Dx: clinical
Tx: supportive
Path, patient/Sx, Dx, and Tx of Osgood Schlatters
Path: osteochondrosis
Pt/Sx: teenage athletes with knee pain and tibial swelling, pin point tenderness on tibia
Dx: clinical
Tx: sit out of sports = curative or work through it (will have palpable nodule rest of life)
Path, patient/Sx, Dx, and Tx of Scoliosis
Path: deformity of spine
Pt/Sx: teenage girl, moderate Sx (cosmetic - always tilted to right) or severe Sx (can present with dyspnea)
Dx: Adams test, X-ray
Tx: brace -> slow progression; surgery with rods for severe Sx
Path, patient/Sx, Dx, and Tx of osteosarcoma
Path: Rb gene, sunburst pattern on distal femur/bone
Pt/Sx: focal, atraumatic bone pain
Dx: X-ray, confirm with MRI and biopsy (biopsy is required for dx)
Tx: resection
Path, patient/Dx, and Tx of Ewing’s Sarcoma
Path: translation of 11,22, mid-shaft, onion skin
Pt/Sx: focal, atraumatic bone pain
Dx: X-ray, confirmatory with MRI and biopsy
Tx: resection
when do you have to fix fractures in children surgically?
open fracture, comminuted or angular, if fracture is through growth plate
Path, Pt/Sx, Dx, and Tx of carpal tunnel syndrome
Path: compression of median n., inflammatory
Pt/Sx: pain -> paresthesias, paralysis, 1st 3 digits, flexion = worse (Phalen’s sign), tap on median n = painful (Tinel’s sign); if advanced will get thenar atrophy
Dx: EMG (only have to do before surgery)
Tx: 1. splinting and NSAIDs
2. steroids
3. surgery
Consider that carpal tunnel syndrome could be the presenting symptom of RA
Path, Pt/Sx, Dx, and Tx of jersey finger
Path: tear of flexor tendon Sx: unable to flex finger Dx: clinical Tx - 1. splinting and NSAIFs 2. steroids 3. surgery last resort (usually happens with someone grabbing a jersey and that person whipping away, hand forced open)
Path, Pt/Sx, Dx, and Tx of mallet finger
Path: tear extensor tendon Sx: cannot extend finger Dx: clinical Tx: 1. splinting and NSAIDs 2. intra-articular steroids 3. surgery last resort usually happens with catching some sort of ball
Path, Pt/Sx, Dx, and Tx, of trigger finger
Path: stenosing tenosynovitis Sx: cannot extend; when forced into extension, there is a pop Dx: clinical Tx: 1. splinting and NSAIDs 2. intraarticular steroids 3. surgery
Path, Pt/Sx, Dx, and Tx of Dequervain’s tenosynovitis
Path: tendonitis
Pt/Sx: thumb pain -> mom holding baby or male lifting weights
Dx: Finkelstein’s test (ulnar deviation and pain)
Tx: 1. splinting and NSAIDs
2. intraarticular steroids
Path, Pt/Sx, Dx, and Tx of Dupuytren contracture
Path: alcoholics and Scandanavian men
Pt/Sx: inability to extend with palpable fascial nodules
Dx: clinical
Tx: surgical release of fascia
Path, Pt/Sx, Dx, and Tx of Felon
Path: abscess of pulp of the finger usually after penetrating injury
Pt/Sx: a lot of pain, possible fever or leukocytosis
Dx: clinical
Tx: incision and drainage
Fracture Dx and Sx
Dx: two X-rays perpendicular to each other
Sx: pain, swelling
When do you have to fix an adult fracture with surgery?
open, comminuted, or angular (not a clean break)
Path, Sx, Dx, and Tx of anterior shoulder dislocation
Path = any trauma Sx = adduction position with ER (as if shaking hands), can have axillary n involvement with deltoid paresthesias Dx = X-ray Tx = relocate, sling
Path, Sx, Dx, and Tx of posterior shoulder rotation
Path = MASSIVE seizures, lightning Sx = adduction, IR (arm against chest) Dx = X-ray Tx = relocate and sling
Colles fracture path, pt/sx, dx, tx
path: old lady who falls on outstretched wrist, has osteoporosis
Sx: dorsally displaced
Dx: X-ray
Tx: cast/surgery
Monteggia fracture path/Sx, Dx, Tx
Path: blocking upward a downward shot; breaks ulna, displaces radius
Dx: X-ray
Tx: surgery vs. cast
Galeazzi fratture path, Dx, Tx
Path: downward block of an upward blow; ulna displaces, radius breaks
Dx: X-ray
Tx: surgery vs. cast
Scaphoid fracture path, sx, dx, and tx
path: fall on outstretched hand (not an old lady)
Sx: pain at anatomic snuff box
Dx: X-ray (normal on day 1)
Tx: cast
what is a boxer’s fracture?
punch against wall that breaks 4th and 5th digits
hip fracture path, sx, and tx
Path: trauma or old with osteoporosis Sx: leg will be shortened and ER; ensure intact pulses Tx: femoral head fracture = prosthesis intertrochanteric fracture = plates shaft = rods open = emergency washout traction helps during transportation
ACL/PCL Path, Sx, Dx, and Tx
Path: locked leg with a force; posterior trauma = ACL injury
Sx: positive anterior drawer (ACL); positive posterior drawer (PCL)
Dx: MRI
Tx: surgery (athletes)
casting (everybody else)
MCL/LCL Path, Dx, and Tx
Path: Valgus = lateral stress = injure MCL Varus = medial stress = injure LCL Dx: MRI Tx: surgery (athletes) hinge cast (everyone else)
meniscus Sx, Dx, and Tx
Sx: knee pain with click upon extension
Dx: MRI
Tx: arthroscopic repair
Stress fracture path, dx, and tx
Path: weekend warrior (a lot of extra work than you’re used to)
Dx: X-ray (normal)
Tx: cast anyway then crutches
Tib/Fib fracture path, dx, and tx
Path: fall from height or big trauma directly to side of shin (pedestrian struck)
Dx: X-ray
Tx: cast or surgery
ankle fracture path, Sx, Dx, and Tx
Path: Over eversion or over inversion
Sx: pain, swelling, non-ambulatory
Dx: X-ray
Tx: surgery
Achilles tendon path, sx, dx, and tx
Path: runs -> pop -> limp
Sx: gap where tendon should be
Dx: clinical
Tx: casting (months), surgery (weeks)
What are signs that someone might need an urgent airway?
expanding hematoma, cutaneous emphysema
What are signs that someone might need an emergent airway?
GCS < 8, apnea, gurgling/gasping
How is ventilation measured? How is it managed?
measured by CO2 with ABG; managed by adjusting minute volume via tidal volume and respiratory rate
How is oxygenation measured? How is it managed?
measured by O2 via pulse ox; managed by adjusting PEEP, FiO2
What does ETCO2 measure? What value do you want?
measures endotracheal placement; want 40
What lab/vital signs should alert you to possible shock?
systolic BP < 90 (MAP < 65), urinary output < 0.5cc/kg/hr, pale, cool, diaphoretic
What is the formula for MAP?
MAP = CO x SVR
What 3 things make up the CO?
HR x SV
and SV = preload x contractility
What might a patient with intraperitoneal hemorrhage present like? What is the Dx/Tx?
Sx: flat veins, normal heart, normal lungs, HR up, Hgb will not change in the acute setting
Dx: FAST = U/S
Tx: apply pressure -> OR (type and cross, fluid, blood, 2 large bore IVs on the way to surgery)
How does a patient with a tension pneumothorax present? What is Dx/Tx?
Path: crushes IVC, no blood can return to the right heart
Sx: engorged neck veins, normal heart, decreased breath sounds and hyperresonance, tracheal deviation
Dx: do not get CXR, clinical
Tx: needle decompression
How does a patient with a pericardial tamponade present? Dx/Tx?
Path: super pulmonary embolism
Sx: engorged neck veins, normal lung sounds, distant heart sounds, hypotension (beck’s triad)
Dx: FAST U/S (but clinical)
Tx: pericardiocentesis
Sx of someone in septic shock/anaphylactic shock/spinal trauma -> problem with SVR?
problem with vasodilation -> warm extremities despite hypotension
What signs should you make you think of a basilar skull fracture? What is the next step in Dx?
raccoon eyes, battle signs, clear otorrhea, clear rhinorrhea; get a CT scan to see if something worse underneath fracture
Epidural hematoma path, Sx, Dx, and Tx
Path: trauma to middle meningeal artery
Sx: trauma -> LOC -> lucid interval -> die
Dx: lens-shaped hematoma on CT scan
Tx: craniotomy to drain
Acute subdural hematoma Pt, Dx, Tx
Pt: young patient - shaken baby syndrome, adolescents with Superman syndrome; massive trauma -> LOC -> die
Dx: crescent-shaped hematoma on CT
Tx: reduce intracranial pressure with hyperventilation, increase head of bead, mannitol
Chronic subdural hematoma Pt, Dx, Tx
Pt: alcoholic or elderly -> shearing of bridging veins in minor trauma/falls; patient gets HA -> dementia
Dx: CT scan
Tx: craniotomy to drain
Concussion Pt, Dx, Tx
Pt: sports injury, +LOC, +retrograde amnesia
Dx: normal CT scan
Tx: home symptomatic care
Diffuse Axonal Injury Pt, Dx, and Tx
Pt: angular trauma (car spinning), +LOC -> coma
Dx: CT scan - gray/white blurring
Tx: pray
For a hemodynamically stable patient, what would you do for a penetrating neck wound to zone III?
(Zone III is closest to the face); try to avoid surgery -> Get an arteriogram
For a hemodynamically stable patient, what would you do for a penetrating neck wound to zone II?
surgery
For a hemodynamically stable patient, what would you do for a penetrating neck wound to zone I?
(zone I is right above the collar bone) try to avoid surgery; get an arteriogram + bronchoscopy
What is the new diagnostic algorithm for deciding to go to surgery or not for a penetrating neck wound?
+ hard signs -> surgery
+ soft signs -> CT angiogram
+ CT -> surgery
otherwise no hard or soft signs (stable) -> observe
What are the hard signs used in the new penetrating neck trauma algorithm?
airway compromise -> gurgling, stridor, loss of airway
vasculature -> expanding hematoma, pulsatile bleeding (arterial), stroke, shock
What are the soft signs used in the new penetrating neck trauma algorithm?
dysphonia, dysphagia, esophagus, subcutaneous air, or any mild hard sign
What information does the dorsal column/medial lemniscus spinal tract carry? Where does it cross?
proprioception and vibratory; crosses up in the brain
Where does the motor tract cross?
up in the brain
What information is carried by the ALS spinal tract? Where does it cross?
pain and temperature; crosses at the level
If you had a hemisection of the spinal cord at level T10 what deficits would you expect? (Brown-Sequard)
At the level of the lesion = low motor neuron Sx:
- C/L loss of pain/temp (ALS)
- I/L loss of sensation (DCML)
- I/L loss of motor (flaccid paralysis, no reflexes)
Below the level of the lesion = upper motor neuron Sx:
- Loss of pain/temp (ALS)
- Loss of sensation (DCML)
- Spastic paralysis and increased reflexes, upper-going babinski
Cord compression presentation, Dx, Tx
Pt: focal neurologic deficit, erectile dysfunction, urinary/bowel incontinence
Dx: MRI
Tx: dexamethasone (BEFORE MRI)
Anterior cord lesion symptoms and cause
lose everything but maintain DCMLS:
proprioception good, lose pain/temp, loss of motor; caused by spinal artery occlusion
Central cord lesion symptoms and 2 possible causes/scenarios
- slow erosion - syringomyelia/syrinx - loss of pain and temp in a cape-like distribution
- sudden/explosive - elderly with hyperextension of neck; loss of pain and temp and loss of motor in cape-like distrubution (hands > feet)
Posterior cord lesion symptoms
lose DCMLS (loss of proprioception/vibratory sensation)
Rib fracture presentation, Dx, Tx
Pt: blunt trauma, chest pain, decreased breathing (can lead to pneumonia), +/- crepitus
Dx: CXR
Tx: no binders, pain control
Pneumothorax presentation, Dx, Tx
Pt: penetrating trauma, dyspnea, decreased breath sounds, resonance, decreased tactile fremitus
Dx = CXR, vertical lung shadow
Tx = thoracostomy
Hemothorax presentation, Dx, Tx
Pt: penetrating trauma, dyspnea, pooling of blood in base of lung with air-fluid level, dullness, decreased breath sounds, decreased fremitus
Dx: CXR with horizontal shadow
Tx: thoracostomy
What deter Ines if a hemothorax must go to the operating room or not?
amount of blood that comes out (pulmonary vasculature likely to resolve without surgery)
20 ccs/kg at once (approx 1500ccs) or 3 ccs/kg/hr (200ccs/hr) -> means it’s probably peripheral and needs surgery
Sucking Chest Wound path, pt, dx, tx
Path: penetrating trauma from outside body (no rib fracture)
Pt: dyspnea, tension pneumo
Dx: visual inspection, CXR
Tx: occlusive dressing, thoracostomy
Flail chest pt, dx, tx
Pt: huge blunt trauma, 2+ ribs broken in 2+ places, will see paradoxical motion
Dx: visual inspection, CXR
Tx: binder/weight -> operate and put in plates if binders fail
If you see flail chest, there is an indication that something else might be going on like pulmonary contusion
Pulmonary contusion pt, dx, tx
Pt: huge trauma, day 1 CXR normal then develop profound dyspnea
Dx: CXR 24-48 hours after presentation -> see white out
Tx: avoid crystalloids; colloids (blood/albumin) if you need fluids, PEEP, diuresis
Myocardial contusion pt, dx, tx
Pt: huge trauma, “heart attack”
Dx: check prophylactic 12 lead EKGs and troponins
Tx: MONABASH, treat CHF or arrhythmias if they show up
Might consider pericardial tamponade
Aortic dissection pt, dx, tx
pt: complete tear = dead on arrival (DOA)
incomplete tear = adventitial hematoma; unequal blood pressures left to right, CXR shows widened mediastinum
Dx: CT-angiogram (TBE/MRI second choice) -> will see false lumen
Tx: immediate surgery, use IV beta blockers to decrease BP
For penetrating wounds to the abdomen (gun/knife), when do you know that you do not need to go to surgery?
if you probe the wound and do not reach peritoneum
Who has to go to the operating room in the case of blunt trauma to the abdomen?
blood on fast u/s, blood or air under
What is the most common organ bleed in abdominal trauma? How do you fix it?
liver
Fix: repair if possible, lobectomy (might have to do Pringle maneuver where you impress the hepatic artery, portal vein, and hepatoduodenal ligament for better visualization)
What is the 2nd most common organ bleed in abdominal trauma? How do you fix it?
spleen; repair or resect
Have to remember to vaccinate against encapsulated organisms if the spleen is resected (strep + neisseria)
Ruptured diaphragm path, pt, dx, tx
Path: blunt trauma
Pt: bowel sounds in chest following trauma
Dx: CT scan
Tx: ex-lap
Ruptured hollow viscous path, dx, tx
Path - air under diaphragm
Dx - KUB (which you don’t want to get, but if you do get will see air under diaphragm)
CT scan - air at the top of t he scan
Tx - ex-lap to find hole
pelvic fracture path, pt, dx, tx
path: enormous trauma (MVA or pedestrian hit)
pt: extreme pain with hip rocking or hips go in diff directions with rocking
Tx: external fixation even if bleeding into pelvis (just transfuse); surgery only if bleeding into the peritoneum
urethral injury pt, dx, tx
Pt: high-riding prostate, blood at urethral meatus
Dx: retrograde urethrogram - looking for extravasation or stricture
Tx: do NOT put in catheter
if having problems urinating -> suprapubic cath not indwelling cath
how do you diagnose a rectal injury?
proctoscope
how do you diagnose a ureter injury
intravenous pyelogram
When you diagnose a pelvic fracture, what other 3 injuries should you also consider?
urethral injury, rectal injury, ureter injury
1st degree burns
epidermis intact
“sunburn”
erythema
minor warmth/pain
2nd degree burns
partial thickness
increased pain
presence of blisters
3rd degree burns
full thickness through dermis (muscle and bone exposed)
no pain
white/charred flesh
surrounded by 2nd degree burns
chemical burns path, skin vs ingestion management
Path: alkali (worse) or acid burns
Skin: NEVER BUFFER; irrigate
Ingested: NEVER BUFFER, NEVER EMESIS, NEVER NG TUBE, serial exams/monitoring, endoscopy eventually, keep NPO
Respiratory burn pt, dx, tx
Pt: closed fire/explosions -> smoke/chemical inhalation, stridor, soot/singed nares
Dx: ABG/SpO2, peak flow, bronchoscopy
Tx: intubation
Electrical burns path, pt, dx, and tx
Path: lightning strike, high voltage wires
Pt: entrance and exit wounds, can get arrhythmias (heart burn) or rhabdo (muscle burn), posterior dislocation of the shoulder
Dx: CK level, Cr
Tx: IVF and mannitol
Circumferential burns
compromises the vascular supply
Dx: clinical
Tx: cut the eschar
What burns should be referred to a burn center?
hand, face, genitals, burns > 10% BSA, circumferential burns
What is the rule of 9s for calculating body surface area affected by burns?
head = 9 front chest = 9 back chest = 9 front abdomen = 9 back abdomen = 9 front leg = 9 (2 legs) back leg = 9 (2 legs) 1 entire arm = 9 (2 arms) genitalia = 1
(for 2nd and 3rd degree burns only)
What is the parkland formula for resuscitation of burns?
4 x kg of body weight x % BSA burned = amount of fluids you need to give in the first 24 hours
50/50 rule - give 50% of above number in the first 8 hours and then 50% in the next 16 hours
(2nd and 3rd degree burns only)
What prophylactic medication are you going to give to prevent infections in burn patients?
antibiotics - topical mupirocin or sulfadiazine
What 3 characteristics of a snake make you more likely to need to use anti venom?
- slit-like eyes
- cobra cowl
- rattler
What 3 characteristics of a snake bite make you more likely to need to use anti venom?
- skin changes
- erythema
- pain
pt, dx, and tx of a black widow spider bite
pt: abdominal pain/pancreatitis
dx: clinical
tx: IV Calcium
Brown recluse pt, dx. and tx
think souther states, old boxes/attic
Pt: bite -> ulcerate -> necrosis
Dx: clinical
Tx: debride -> grafting
Dog/cat bite pt, dx, and tx
pt: pasturella
dx: clinical
Tx: irrigation, leave open to prevent infection, amoxicillin/clavulonic acid, tetanus Ig and tetanus toxoid if > 5 years since last tetanus
human bite pt, dx, and tx
pt: gram - and anaerobes, sex acts or fist fights
dx: clinical
tx: irrigation, leave open to prevent infection, amoxicillin/clavulonic acid, tetanus Ig and tetanus toxoid if >5 years since last tetanus
ingested form, anion gap, osmolar gap, tx for EtOH
alcoholic beverages, no anion gap, +osmolar gap, supportive tx
ingested form, anion gap, osmolar gap, tx of isopropyl alcohol
rubbing alcohol, no anion gap, + osmolar gap, supportive treatment
ingested form, anion gap, osmolar gap, tx of ethylene glycol
antifreeze; causes renal failure, can diagnose with wood’s ;amp on urine, +anion gap, +osmolar gap, tx with fomepizole or EtOH
infested form, anion gap, osmolar gap, and tx of methanol
“moonshine” -> blindness; + anion gap, + osmolar gap, tx with fomepizole or EtOH
path, pt, dx, and tx of acetaminophen toxicity
path: pain pills -> drug-induced liver injury
pt: intentional (chugs bottle in suicide attempt) vs unintentional (will be someone on chronic pain medication that also takes acetaminophen); AST, ALT > 1000
dx: acetaminophen level
tx: if above treatment nomogram line, give n-acetylcysteine; if below nomogram line, observe
f/u: fulminant liver failure -> transplant
pt, dx, tx of salicylate toxicity
pt: takes aspirin;
early: tinnitus, N/V, vertigo, respiratory alkalosis
late: anion gap acidosis, obtunded, hyperpyrexia
dx: salicylate level
tx: alkalization of the urine, force diuresis
carbon monoxide path, pt, dx, and tx
path: smoke inhalation
pt: SpO2 = 100%, HA, N/V, delirium
Dx: ABG, carboxy HgB load
Tx: 100% FiO2, hyperbarics
cyanide toxicity path, pt, dx, and tx
path: sodium nitroprusside, smoke inhalation in fires
pt: super sick, cherry red skin or cherry red blood
dx: clinical
tx: thiosulfate, amyl nitrate (avoid in smoke inhalation injuries bc it can make carbon monoxide toxicity worse)
organophosphate toxicity path, pt, dx, and tx
path: weapons of terrors, pesticides, myasthenia graves tx
pt: salivation, lacrimation, urination, defecation, GI upset, emesis
dx: clinical
tx: atropine (block acetylcholine activity; treats symptoms) + pralidoxine (to prevent irreversible AChE inhibition)
What are Hgb and Hct levels expected to be for a patient with acute blood loss anemia?
initial Hgb and Hct values in patients with acute blood loss will be normal because the body has not yet adequately responded to the volume loss by shifting fluid in the intravascular space
Pt, Dx, and Tx of pancreatitis pseudocyst
Pt: this patient will start to improve after an episode of acute pancreatitis but will then plateau in their recovery; epigastric pain, N/V that does not improve over a period of a week with adequate IVF, pain control, and oral restriction. Labs will show a persistently elevated amylase level + leukocytosis.
Dx: abdominal CT that will show a discreet pocket of fluid near the pancreas
Tx: close monitoring to determine progression, supportive pain control and fluids; eventually catheter drainage of the pseudocyst may be necessary
How is the presentation of pancreatic pseudocyst different than that of chronic pancreatitis?
chronic pancreatitis - the patient would present with episodic abdominal pain lasting about 10 days with generally a few months in between episodes. N/V is not common, and the patient will generally be able to tolerate oral intake. The patient will have steatorrhea and possibly glucose intolerance/diabetes
What does abdominal CT scan show in the case of chronic pancreatitis?
pancreatic calcifications with absence of characteristic fluid collection seen in pancreatic pseudocyst
What are the different spinal degrees/managements of scoliosis?
< 20 deg = observation with follow up in 6-9 months for repeat X-ray
>5 deg increase in spinal curve angle at follow-up = bracing
30-40 deg and skeletally immature = bracing
>/= 50 deg = posterior spinal fusion regardless of skeletal maturity
What is trash foot?
embolization of atherosclerotic debris to small pedal arteries; complication that can occur after revascularization surgery of the aortoiliac branches in patients with significant peripheral artery disease
What diagnostic test is the gold standard for diagnosing avascular necrosis of bone?
MRI
cyanosis from birth, a single heart sound, LVH, and right atrial enlargement?
tricuspid atresia
How is the diagnosis of ARDS made?
- plain CXR showing B/L lung opacities
- PaO2/FiO2 < 300mmHg on ventilator settings
- Exclude cariogenic pulmonary edema (BNP should be less than 100, no S3 or S4 gallop, no increased JVP)
- If Dx is still uncertain, can do bronchoalveolar lavage to investigate other causes of hypoxemia respiratory failure
What are the inciting events of ARDS and when does it present?
Inciting events: sepsis, lung contusion, pneumonia, toxic inhalation, pancreatitis, trauma, blood transfusion
ARDS presents within 1 week of inciting factor with dyspnea and respiratory distress
What pain management is used in the case of rib fractures?
in patients whose ability to breathe is significantly impacted by the pain of a rib fracture, intercostal nerve block is the most effective form of treatment
Path, Pt, and Dx of mitral regurgitation post MI?
Path: secondary to pupillary muscle rupture secondary to inferior wall MI
Pt: 12-48 hours after MI, severe dyspnea due to pulmonary edema
Dx: blowing systolic murmur at the apex with S4 gallop; definitive Dx made with TEE
What post MI complication presents 5-14 days after MI? How does it present?
free wall rupture; presents with chest pain, hypotension, and loss of pulse
What post MI complication presents 3-5 days after MI? How does it present?
ventricular septal rupture; present with hypotension, tachycardia, and a new-onset pan systolic murmur most prominent along the left sternal border, palpable thrill
most common in anterior wall MI
What is the treatment for Ogilvie syndrome?
initially conservative management for 48 hours. If that fails, neostigmine; if that fails, colonoscopic decompression; if that fails, surgery or percutaneous colostomy
What is the difference in the presentation between cholangiocarcinoma and pancreatic cancer?
cholangiocarcinoma = painless jaundice while pancreatic cancer usually has dull epigastric pain
What is the difference between oral CMV lesions and HSV oral lesions? What is the treatment of each one?
CMV = linear, deep ulcerations and erosions in the esophagus; history analysis shows intranuclear or intracytoplasmic inclusion bodies; treatment = ganciclovir
HSV = well-circumscribed “volcano-like” ulcerations in the esophagus; histology shows ground glass nuclei and eosinophilic inclusion; treatment = acyclovir
Path, Pt, Dx, and Tx of cavernous sinus thrombosis
Path: bacterial infection within the centrally located dural sinuses (pass here from the facial veins and pterygoid plexus via the ophthalmic veins)
Pt: sharp HA and visual changes, fever, ophthalmoplegia, ptosis, chemises, and periorbital edema
Dx: orbital CT scan that shows thickening of the walls, increased enhancement, and enlargement of the involved cavernous sinus
Tx: empiric Abx
What is the difference between orbital cellulitis and cavernous sinus thrombosis?
visual changes are less common in orbital cellulitis compared to cavernous sinus thrombosis
acute hemolytic transfusion reaction path, pt, f/u
Path: ABO blood incompatibility
Pt: hypotension, tachycardia, fever, flank pain, myoglobinuria; evidence of hemolysis on labs (elevated indirect bilirubin, elevated lactate dehydrogenase, decreased serum haptoglobin); direct anti globulin test (Coombs) will be positive
f/u: DIC
delayed hemolytic transfusion reaction path, pt
Path: caused by a previous sensitization to RBC alloantigens (from pregnancy, previous blood transfusion, or transplantation)
Pt: low-grade fever and a declining hematocrit 2-10 days after receiving a blood transfusion
febrile non hemolytic transfusion reaction path, pt
Path: caused by cytokines that are generated during the storage of blood products
Pt: fever, chills, and mild dyspnea 1-6 hours after receiving blood or platelet transfustion
post-transfusion purpura Pt
Pt: thrombocytopenia 7-10 days after transfusion of a platelet-containing product; look for mucosal bleeding (epistaxis), petechiae, and superficial ecchymoses
Path, Pt, Dx, and Tx of fibromuscular dysplasia
Path: occurs in the absence of inflammation or atherosclerosis; most commonly affects the renal arteries followed b the carotid arteries
Pt: HTN, HA, and pulsatile tinnitus; epigastric bruit on PE.
Dx: confirmed with imaging, including CT angiography or MR angiography or duplex U/S (Dx gold standard = catheter-based digital subtraction angiography, which shows “string of bead” appearance of renal artery)
Tx: anti-HTN +/- surgery
Path, Pt, Dx of takayasu’s arteritis
Path: large vessel vasculitis that occurs most commonly in young women; preferentially affects the aorta and its major branches
Pt: fatigue, weight loss, joint and muscle pains, pulselessness and HTN secondary to renal artery stenosis can occur
Dx: elevated ESR an dCRP, confirmed with CT or MR angiography
When is surgery for a hepatic adenoma indicated?
symptomatic at any size or adenoma that is > 5cm in diameter
When should fresh frozen plasma (FFP) be administered in a patient with active GI bleeding?
in a patient taking warfarin with INR > 1.5
Path, Pt, Dx, and Tx of papillary thyroid cancer
Path: most common type of thyroid cancer; invovles thyroid epithelial cells; most common risk factor is ionizing radiation as a child
Pt: painless thyroid nodule; new-onset hoarseness or dysphagia
Dx: FNA showing intranuclear cytoplasmic inclusions (Orphan Annie nuclei), calcified microscopic deposits (Psammoma bodies), abundant cytoplasm, and a large pale nucleus
Tx: thyroidectomy, radioactive iodine, and TSH suppression therapy
Anaplastic thyroid cancer path, pt, tx
Path: undifferentiated carcinoma
Pt: older pt with long hx of goiter who develops a rapid increase in thyroid size, associated with vocal cord paralysis or dysphagia
Tx: supportive care
Follicular thyroid cancer path, pt, dx, and tx
Path: well-differentiated cancer
Pt: presents as a cold thyroid nodule
Dx: cannot do FNA (looks like an adenoma)
Tx: thyroidiectomy, radioadctive iodine, and TSH suppression therapy
Medullary thyroid cancer path and tx
Path: parafollicular cells; secrete calcitonin, associated with MEN2a and 2b
Tx: thyroidectomy and lymph node dissection
thyroid lymphoma path, pt, dx, and tx
Path: older patients with a history of chronic lymphocytic thyroiditis
Pt: rapidly enlarging mass associated with a hx of goiter or a dx of Hashimoto’s; neck pressure, hoarseness and dysphagia
Dx: open biopsy and tissue analysis demonstrating sheets of B cells
Tx: radiation and chemotherapy
ASD presentation, dx, and tx
Pt: fatigue, dyspnea, or asymptomatic; physical exam shows systolic ejection murmur heard most prominently at the left sternal border, and a widely and fixed split second heart sound
Dx: CXR may be normal or show cardiomegaly; confirmed with echocardiography
Tx: surgical closure of defect to prevent pulmonary HTN
VSD Path, Pt, Dx, and Tx
Path: most common congenital heart defect
Pt: PE: holosytolic murmur heard best at the left sternal border; larger defects can develop heart failure and signifiant pulmonary vascular congestions
Dx: confirmed with echocardiography
Tx: large defects require surgical closure
What cancers are those with Lynch syndrome at higher risk of (highest to lowest increased risk)
colorectal > endometrial > ovarian > gastric > pancreatic > breast
What is the treatment for a pulmonary nodule larger than 30mm?
surgical resection of the mass with video-assisted thoracic surgery/wedge resection
if frozen section reveals malignancy, the surgery is converted into a lobectomy with mediastinal node sampling
Ludwig’s angina Path, Pt, management
Path: submental, sublingual, and submandibular spaces become infected and edematous, compromising the integrity of the patient’s airway
Pt: painful and swollen neck and floor of mouth, displacement of tongue, “hot potato” voice
Mangament: maintain arie -> intubation
Insulinoma path, pt, dx
Path: neuroendocrine tumor of the pancreas involving the insulin-secreting beta cells
Pt: signs and symptoms of hypoglycemia (diaphoresis, nausea, blurry vision, confusion, weakness, and tremor)
Dx: measure insulin, proinsulin, and C-peptide levels (all three should be elevated in insulinoma)
When is EGD indicated in patients with GERD symptoms?
EGD is indicated in patients with upper GI symptoms and:
- who fail empiric therapy with a PPI
- are over 60 years old
- with alarm features:
- family hx of upper GI malignancy
- unintentional weight loss
- hematemesis
- worsening dysphagia
- odynophagia (esophageal ulcer likely)
- iron-deficiency anemia
- LAD or other palpable neck mass
- jaundice
When is bariatric surgery indicated as treatment for obesity?
BMI > 40 or BMI > 35 with comorbid disease (type 2 diabetes, HTN, hyperlipidemia, OSA) in whom lifestyle changes have been ineffective at decreasing weight
What cancers can be followed with alpha fetoprotein?
hepatocellular carcinoma and testicular germ cell tumors
What cancers can be followed with CA-125?
ovarian cancer
What cancers can be followed with CA-19-9?
pancreatic cancer
What cancer can be followed with CEA?
colon cancer
Epidural spinal cord compression path, pt, tx
Path - most commonly a complication of metastatic cancer to the spine
Pt - back pain that precedes the development of LE weakness or paraplegia by several weeks; pain that radiates to the thoracic dermatomes, decreases sensation in the LE (particularly the saddle area); bowel incontinence and urinary retention are ominous late manifestations
Tx - high-dose corticosteroids; definitive management = surgical decompression and/or external beam radiation therapy
Fat embolism syndrome path, pt, tx
path - long bone fractures
pt - hypoxemia, AMS, petechial rash
tx - methylprednisolone is used to prevent the development of FES; tx is supportive
Candidates for liver transplant
- Patients with cirrhosis who develop cholestatic liver disease (intractable pruritus, bilirubin > 10, progressive bone disease, or recurrent ascending cholangitis
- Patients with serum albumin < 3g/dL, or a prothrombin time > 3 seconds above normal
- Patients who develop complications of liver cirrhosis (severe/recurrent hepatic encephalopathy, refractory ascites, recurrent spontaneous bacterial peritonitis, recurrent esophageal vatical bleeding, severe chronic fatigue and weakness, worsening malnutrition, hepatorenal syndrome, evidence of new small heaptocellular carcinoma)
Cholestyramine MOA and use
non-absorbable resin that binds bile acids in the intestinal tract; first line tx for patients with moderate to severe pruritus due to cholestasis
Rifampin use
tx option for cholestatic pruritus (MOA unknown)
Ursodeoxycholic acid MOA and use
common tx for PBC (primary biliary cirrhosis) that delays the progress to end-stage liver disease (at high doses, it can help with pruritus associated with PBC)
What will ascitic fluid of patients with spontaneous bacterial peritonitis show? What does serum analysis show?
Lab analysis shows hypoalbuminemia, leukocytosis, and a prolonged PT.
Ascitic fluid analysis shows WBC > 500, with more than 25% of those being PMN leukocytes, low fluid pH and an increased SAAG
What is the best step in diagnosis of a suspected PE when a patient is in shock? What if they were stable?
transthoracic echocardiogram; If stable, CT scan of the chest is used to confirm the dx of PE
What is the best step in treatment of a PE in a patient in shock?
thrombolytics as long as there are not contraindications (intracranial tumor, recent intracranial surgery or trauma, internal bleeding within the past 6 months, hx of hemorrhagic stroke or bleeding diathesis, SBP > 110, ischemic stroke within 2 months, surgery in the past 10 days, or thrombocytopenia)
If tPA is contraindicated, surgical or catheter embolectomy is the next best step
What is the best step in treatment of a PE in a stable patient?
IV heparin
chronic mesenteric ischemia pt, pe, dx, tx
Pt: pain after eating; “intestinal angina;” food fear
PE: unremarkable; may find evidence of vascular disease, such as diabetic ulcers or poor hair growth on LE
Dx: angiography of the vessels
Tx - revascularization, performing either angioplasty or surgical vascular reconstruction
What is the definition of an acute abdomen? What is the next best step in management?
severe diffuse abdominal pain, guarding, and abdominal rigidity (peritoneal signs); exploratory laparotomy
What is the best imaging modality to use in a pregnant patient with suspected appendicitis?
graded compression ultrasonography
fever, jaundice, RUQ abdominal pain - Dx? Tx?
ascending cholangitis; tx = empiric brand spectrum Abx +/- biliary drainage with ERCP, depending on the severity of the illness; cholecystectomy is recommended once the patient is stabilized
When is cystoscopy useful?
provides direct visualization of the bladder cavity and allows for biopsy of the bladder wall; current standard of care for diagnosis of bladder cancer
What is the first line treatment for vertebral compression fracture?
oral analgesic
What is the treatment of gastric dumping syndrome?
dietary changes, including smaller, more frequent meals, elimination of sweet foods, and lying down for 30 minutes after eating
acarbose - alpha-glucosidase inhibitor - interferes with carb absorption in the small intestine - can help th elate symptoms of dumping syndrome
octreotide - somatostatin analog - can help prolong the gastric emptying Tim, thus improving postprandial symptoms (use if dietary measures fail to achieve control)
primary biliary cirrhosis sx and tx
sx of cholestasis, including generalized pruritus, hyperpigmentation of the skin, fatigue, and hepatomegaly
dx - elevated alkaline phosphatase in the prescience of antimicrobial antibodies; liver bx demonstrating cholangitis and destruction of the bile ducts is supportive but not required
globe rupture sx, dx, and tx
sx - pain, blurry vision, nausea
dx - clinically or with CT scan demonstrating an irregular sclera contour and volume loss in eye
tx - protect the eye, empiric Abx, surgical consult
What are the two types of priapism and their causes? What will ultrasound show in each case? What is the treatment for each one?
- Ischemic priapism - most commonly due to impaired relaxation of the cavernosal smooth muscle (sickle cell disease and intracavernosal injections of papaverine are risk factors); ultrasound will show minimal or absent blood flow in the cavernosal arteries; will have black blood on aspiration of the corpora cavernosa; tx = IVF, oxygenation, pain control -> aspiration and irrigation of the corpora cavernosa
- Nonischemic priapism - commonly due to a fistula between the cavernosal artery and the corpus cavernous; ultrasound will show high blood flow; will have red blood upon aspiration of corpora cavernosa; tx = observation or arteriography and arterial embolization for definitive treatment
Where does PAD in the superficial femoral artery produce symptoms?
upper two-thirds of the calf
**most common artery affected in peripheral artery occlusive disease
Where does PAD in the iliac artery cause symptoms?
hip, gluteal, thigh, and calf muscles; men may also have erectile dysfunction
Where will PAD in the posterior tibial artery cause symptoms?
sole of the foot
