Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

00Step 2 > Surgery Pestana > Flashcards

Surgery Pestana Flashcards

1
Q

which pts do not require an airway placed

A

fully conscious and normal voice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

which pts require an airway

A

going to lose airway soon:

  • expanding hematoma (quick induction then intubate)
  • subcutaneous air/tissue emphysema

need airway now:

  • unconscious
  • gurgly noises
  • spinal cord injury (airway needed first)
  • facial trauma (cricothyroidotomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what does subcutaneous air/tissue emphysema indicate?

A

signifies tracheobronchial injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

how do you manage tracheobronchial injury

A

intubate over fiberoptic bronchoscope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

how do you you manage a pt with spinal cord injury and needing an airway

A

(pts will present with neck pain pro unable to move extremities)

establish airway first:

  • nasotracheal over fiberoptic bronchoscope
  • do not move/hyperextend neck
  • do not pick CT/XR as first action
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

how do you evaluate breathing?

A
  • pts are starting their own breathing motion
  • both lungs are spontaneously inflating
  • O₂ is being put into blood (O₂ sat)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

how does a classic trauma shock pt present?

A

BP <90
tachy, poor quality pulse
diaphoretic, pale, cold, shivering, anxious
trauma scenario

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what are the 3 conditions responsible for shock in trauma

A

bleeding

pericardial tamponade

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what is the most common cause of shock in trauma

A

hypovolemic hemorrhagic shock

“bleeding”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

where hypovolemic hemorrhagic shock present

A 
>1.5L lost
not enough space in head
neck and arm bleeds are visible
pericardial sac --> tamponade + high CVP
pleural cavity --> seen on CXR
abdomen, pelvis, thighs can hide big bleeds (pelvic instability, femur fractures)

empty (non-distended) veins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

how do you manage hypovolemic hemorrhagic shock

A

Emergency:
-ex lap

STOP BLEEDING before prioritizing resuscitation fluids, w/ exceptions
-“scoop and run” if you’re near medical help and you know where bleeding is (direct finger pressure)

2 large-bore (16 gauge) peripheral IVs:
arms, ankles, femoral vein
-1-2 L balanced electrolyte soln (LR; sugar = osmotic diuresis = invalidate UOP)
-followed by blood as available

eventually monitored by pt response and UOP/CVP

last-resort access in child:
intraosseous cannulation in proximal tibia
-20mL/kg initial bolus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

how do you identify pericardial tamponade in trauma setting

A

trauma to chest
DISTENDED VEINS; high CVP >20-25 (must be mentioned)
pt is BREATHING FINE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

how do you manage trauma pericardial tamponade

A

it’s based on clinical dx,
don’t ask for CXR or blood gases

empty the pericardial sac (window, pericardiocentesis, decompression)

meanwhile, give fluid and blood

  • heart is not failing, the ventricle just cant feel blood from the pressure buildup
  • more blood = more to squeeze = somewhat improve status

fix the underlying problem:
-start w/ sternotomy if tamponade is the only problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

how do you identify tension pneumothorax in trauma setting

A 
trauma to chest
DISTENDED VEINS AND BREATHING DIFFICULTY
-labored breathing/no breath sounds/tympany
-deviated trachea
-high CVP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

how do you manage tension pneumothorax

A

based on clinical dx,
don’t ask for CXR, CT, or blood gases

immediately decompress pleural space’s pressure

  • large bore needle in 2nd intercostal pleural space
  • follow with chest tube on suction and water seal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what 3 things can cause shock in non-trauma setting

A

bleeding
cardiogenic
vasomotor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

how does non-trauma bleeding shock happen

A

spontaneous; ruptured ulcer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

how does cardiogenic shock happen

A

non-trauma setting:

  • Myocardial infarction
  • high CVP; DISTENDED NECK VEINS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

how do you manage cardiogenic shock

A

Tx the MI

do not give fluids (this is intrinsic shock)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what is vasomotor shock

A

loss of peripheral vascular tone

  • low CVP, low BP, tachy
  • WARM AND FLUSHED

anaphylaxis
-bee sting, penicillin allergy, spinal anesthesia)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

how do you manage vasomotor shock

A

vasoconstrictors
restore vascular tone that’s been lost

(volume replacement does not hurt this pt)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

which head traumas need to be taken to the OR vs ER?

A

OR:

  • penetrating trauma (repair entry spot and control possible bleeding)
  • comminuted depressed skull fracture

ER/Other:

  • blunt
  • linear skull fracture
  • scalp laceration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

what is required for every pt who has LOC

A

CT scan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

what is indicated by:
ecchymosis in eyes or behind ear
clear fluid dripping from nose

A

basilar skull fracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

how are basilar skull fractures managed

A

evaluate airway
CT to look for potential hematoma
**also get cervical XR or CT head+neck to evaluate for neck injury, since this is big trauma

  • the skull fracture itself doesn’t need tx
  • Abx are not indicated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what head injury is caused by BIG trauma (like highway car crash)

A

subdural hematoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

how does subdural hematoma present on CT

A

concave semilunar crescent shaped hematoma

midline structures may shift to opposite side

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

management of subdural hematoma?

A

(neurosurgeons do craniotomy/decompression if structures are shifted)

control ICP:
hyperventilation
avoid fluid overload

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

what is prognosis of subdural hematoma

A

grim prognosis-

original trauma does a lot of damage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

how does chronic subdural hematoma present

A

elderly and alcoholics
-brain shrinks, can easily rattle, and tear venous sinus

slow bleed
-ex. become senile over 3-4 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

how do you manage chronic subdural hematoma

A

decompress/evacuate the hematoma

memory loss will return to normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

how does epidural hematoma present in pt and on CT

A

2/2 trivial trauma (baseball bat)
pt will be completely normal between LOC (LUCID INTERVAL)
blown pupil on ipsilateral side of injury

CT:
biconvex/lens shape
midline structures shift to opposite side (especially w/ materializing sings)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

how do you manage epidural hematoma

A

emergency craniotomy to evacuate the clot

excellent prognosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

what is a major concern of an acute hematoma?

A

CNS damage:

  • the initial trauma’s damage isn’t fixable
  • hematomas may push midline structures, which is fixed with surgery
  • swelling frequently follows trauma and ICP (mostly a medical fix)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

how does a diffuse axonal injury present in pt and on CT

A

trauma, coma, bilateral fixed pupils

CT:

  • diffuse blurring of grey/white interface
  • multiple small hemorrhages
  • no single large hematoma or displaced midline structures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

how do you manage diffuse axonal injury

A

no indication for surgery (no single large hematoma or displaced structures)

correct the high ICP without pushing the pt to dehydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

what are the absolute indications to go to the OR in neck trauma pts

A

any penetrating injury where pt is rapidly deteriorating
(low BP, not responding to fluids)

all GSW to middle neck
(asymptomatic stab to middle neck = observe)

any evidence of injury to important structures
(spitting up blood = tracheobronchial)
(hematoma = major vessel)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

how do you manage upper neck trauma

A

need proximal and distal control before fixing

  • difficult to operate
  • angiogram to identify injury
  • radiologist to embolize bleeding vessel
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

how do you manage base of neck trauma

A

Dx studies before operating

-arteriogram, esophagram, bronchoscopy, etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

what type of spinal cord injury presents with:
different sides/different functions
(R trauma = loss of proprioception on R; loss of pain on L)

A

Hemisection

AKA Brown Sequard Syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

what type of spinal cord injury presents with:
loss of motor, pain, temp on both sides distal to injury
with preservation of vibratory/positional sense

A

anterior cord syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

how does anterior cord syndrome happen

A

blow out of vertebral body

  • spinal cord is posterior to vertebral body
  • anterior section is damaged first
  • posterior cord is preserved

can also be seen with vascular puppy injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

what spinal cord injury occurs with neck hyperextension

A

central cord lesion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

how does central cord lesion present

A

neuro damage in UE
LE largely unaffected
(UE travels closer to center of cord)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

what does some evidence suggest is helpful in improving outcome of spinal cord lesions?

A

high dose steroids ASAP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

what are the bone clues of big chest trauma

A

sternum
first rib
scapula

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

what do you need to look for in major chest trauma

A

traumatic transection of aorta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

how do you manage penetrating chest trauma

A

penetrating trauma rarely requires surgery in the chest

however, a blunt trauma can cause a penetrating trauma, like when a rib is broken and pierces lung to create a penetrating scenario

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

what are 3 things you need to consider with blunt chest trauma

A

pulmonary contusion
myocardial contusion
traumatic transection of aorta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

what presents with “white out” lungs on CXR

A

pulmonary contusion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

how do you determine if pulmonary contusion needs respirator, fluid restrictions/diuretic?

A

blood gases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

how do you identify myocardial contusion

A

EKGs and cardiac enzyme monitoring

may be 2/2 sternal injury (tenderness, gritty bone-on-bone feeling by palp)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

which portions of the aorta move where in a traumatic transection of the aorta 2/2 deceleration injury

A

ascending moves forward
descending stays put/stops

most of these pts die on scene

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

what tears in a small subset of aorta transection pts?

A

small subset of pts who don’t die immediately get transection of intima/media with intact adventitia

a hematoma forms but is contained for several hours (asymptomatic)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

what is the work up for traumatic transection of aorta

A

widened mediastinum = high suspicion (not diagnostic)

spiral CT

arteriogram if at least 1 of those 2 is positive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

how does a pt develop pneumonia 2/2 rib fracture

A

elderly pt

hurts to breathe, avoids breathing, atelectasis, pneumonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

how do you manage rib fracture to prevent pneumonia

A

alleviate pain in a way that does not hinder breathing

  • local anesthetic/nerve block that alleviates focal pain (Lidocaine)
  • still allows pt to drive breathing

do not bind chest or prescribe heavy narcotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

what injury presents w/ large flap-like wound; sucking and air trapping with every breath

A

sucking chest wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

what happens to sucking chest wound if left untreated

A

pt will develop tension pneumo

air trapping with every breath

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

how do you manage sucking chest wound

A

occlusive dressing:

  • vaseline gauze stuck to chest wall
  • prevents air moving in during inspiration
  • taped on 3 sides to push some air out during expiration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

what injury presents w/ paradoxical breathing

A

flail chest

caves in with inhalation; bulges with exhalation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

how do you manage flail chest

A

tx underlying pulmonary contusion

  • fluid restriction and diuretics (sensitive to fluid overload)
  • give colloid over crystalloid
  • measure blood gases to watch for deterioration and intubate as needed
  • need a preventative chest tube if you intubate

continue to monitor for less obvious injuries:
-MI, transection, etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

what presents with shock, distended neck veins, and no breath sounds

A

tension pneumothorax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

how do you manage tension pneumo

A

needle for air escape

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

what presents with penetrating trauma, STABLE VITALS, no breath sounds?

A

plain pneumothorax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

how do you manage plain pneumothorax

A

CXR first
-no need to rush with placing an emergency needle

then chest tube in 2nd intercostal space

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

what presents with penetrating trauma, SOB, stable vitals, no breath sounds at base, dull to percussion, faint/distant breath sounds at apex?

A

hemothorax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

how do you manage hemothorax

A

CXR first

-pt is not actively dying; confirm hemothorax

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

where are most pts bleeding from in a hemothorax

A

most are bleeding from lung (a low pressure circuit)

-bleeding usually stops on its own (seldomly need to operate)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

how do you manage a hemothorax

A

if there’s penetration, there’s risk of infection/empyema

chest tube to evacuate pleural space

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

how can you identify bleeding source in hemothorax

A

place a chest tube:

lung bleed = some bleeding that tapers in next hour

systemic bleed = significant bleed and hypotension (commonly intercostal)

  • sums to 600cc in 6 hours
  • need a thoracotomy to stop bleed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

what does a large, single air/fluid level mean

A

need to manage both blood and air conditions in the lungs

begin with a chest tube

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

what does multiple air/fluid levels in chest mean

A

bowel in chest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

how does bowel in chest present

A

traumatic rupture of diaphragm
always L side
need abdominal surgical correction
imaging shows NG tube tip curve up into the chest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

what are 4 causes of air in chest

A

esophageal perforation
tension pneumo
major tracheobronchial injury
air embolism (rare)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

what scenario would you connect w/ esophageal perforation

A

ex. pt had endoscopy and now has air in chest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

how do you confirm dx of major trachobronchial injury

A

something has ripped in 2:

fiberoptic bronchoscopy to guide the airway/visualization to confirm dx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

how would you get air embolism sudden death in post-trauma intubated pt

A

rare

chest tube in pleural cavity
pt was previously hemodynamically stable
sudden cardiac arrest
injury to major bronchus and adjacent major vessel
respirator blows air into lung, leaks to vessel, travel to ventricle –> arrest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

how would you get air embolism sudden death in an awake pt

A

major vein near SVC becomes open to air in awake pt
if it happens when pt is inhaling to give neg pressure, it may suck enough air into the ventricle to make it foam –> arrest

put pt in Trendelenburg L side down; tube to suck air; cardiac massage

many pts die

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

how does fat embolism present

A 
severe trauma with long bone fractures
disorientation 12 hors later
petechial rash in axilla and neck
febrile, tachy
RESPIRATORY DISTRESS and hypoxemia
low platelets

CXR shows bilateral fat infiltrate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

how do you manage fat embolism

A

respiratory support and blood gas monitoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

what are the 3 circumstances where ex lap is required

A

every GSW to abdomen (below nipple line)

stab wound with clear penetration into abdominal cavity

penetrating or blunt trauma where pt develops acute abdomen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

what is the prep process for ex lap

A

indwelling catheter

large bore venous lines

broad spectrum Abx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

what are cons of diagnostic peritoneal lavage

A

invasive: cut belly + catheter

only gives yes/no; doesn’t give origin, or whether or not bleeding will stop naturally

vignette must say pt is hemodynamically unstable / needing resuscitation***
otherwise, you’d get a CT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

what are the pros of emergent CT scan

A

excellent to see presence of blood and source of bleeding

noninvasive

however, if pt is in shock/crashing, cannot leave ER to get CT scan
—must be hemodynamically stable (otherwise,get a DPL)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

how is a splenic laceration/ rupture handled

A

surgeons will do everything possible to repair rather than remove a spleen, esp in children

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

when is a splenectomy (vs spleen repair) indicated

A

shattered beyond repair

other critical life-threatening injuries that require time/attention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

what changes in a pt’s immune status after a splenectomy

A

pt now needs immunizations against encapsulated bacteria to prevent sepsis

  • pneumovax for pneumococcus
  • immunize for H influenza meningococcus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q

when should you suspect a coagulopathy in an abdominal trauma pt

A

multi-trauma pt requiring massive blood transfusions
>10-12 units of blood

blood oozing from all dissected surfaces and IV sites

hypothermia + acidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

how should you manage blood oozing from dissected surfaces and IV sites

A

pt has a coagulopathy

ideally, you’d do labs to determine what factor the pt needs,
but there’s no time

shotgun approach:
give FFP and plt bags

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

what is pt’s temp when oozing blood from IV sites?

A

nl core temperature

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

how do you handle a coagulopathy with hypothermia + acidosis

A

stop operation ASAP

give FFP and plts

pack all areas that are bleeding

rewarm and tx the coagulopathy before resuming operation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

what is dx for surgical pt with abdominal wall edges that cannot be closed without tension

A

abdominal compartment syndrome

pt usually has lengthy ex lap procedure for multi-trauma abdomen
tension cutting through sutures, hypoxia, renal failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

what is the complication of pulling closed an abdomen w/ compartment syndrome

A

pulling closed –> unable to bleed, perfuse kidneys –> kidney failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

how is abdominal compartment syndrome managed

A

temporary closure w/ plastic or mesh stapled around opening

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

how can you identify a pelvic fracture

A

bleeding helped by fluids

pelvic hematoma

nearby viscera injury

  • rectum and urinary bladder
  • vagina (F)
  • urethra (M)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

how do you manage a pelvic hematoma

A

leave alone if not expanding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

how can you evaluate a pelvic fracture

A

proctoscopic / pelvic exam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

how do you manage a pelvic fracture

A

difficult to stop pelvic bleeding- unable to reach it easily in the OR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

what is the hallmark of urological injury

A

trauma with hematuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

where could the blood be coming from in a urological injury

A

kidney, bladder, or urethra (M)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

what does this story hint at as a source of urological bleed:

broken ribs with no fractured pelvis; flank injury

A

Kidney injury as source of bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

how do you manage kidney injury

A

a retrograde cystogram will be nl

CT scan next

most blunt kidney injuries don’t require surgical repair
-RARE possible AV fistula development –> overload circulation –> HF –> bruit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

what does this story hint at as a source of urological bleed:

pelvic fracture; blood at meatus; resistance from foley

A

bladder injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

where will dye appear on cystogram in a dome vs base/trigone of bladder injury

A

dome: dye will be seen in picture

base/trigone: dye will extravasate posterior/extraperitoneal; dye will not be seen
–you need a 2nd picture to identify this leak

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

what does this story hint at as a source of urological bleed:

blood in meatus

A

bladder or urethra injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

what is the next step when blood in meatus has been found

A

retrograde urethrogram w/ dye to find source of bleed: either bladder or urethra

do NOT place foley w/ evidence of potential urethral injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

what does this story hint at as a source of urological bleed:

high-riding prostate; sensation of needing to urinate but cannot

A

posterior urethra injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

how should you work up microhematuria in an adult vs pediatric pt

A

adult: inconsequential
big trauma justifies microhematuria

pediatric, esp w/ small trauma:
hematuria may be first sign of congenital abnormality or urinary tract
–need further studies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

what should you order in a scrotal hematoma

A

sonogram to evaluate testicles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

what injury results from “slip in shower” story

A

penile shaft hematoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
112
Q

what is the complication in a penile shaft hematoma

A

fracture of the tunica albugenia / corpora cavernosa

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
113
Q

how do you manage penile shaft hematoma

A

prompt surgical repair is indicated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
114
Q

what injury do you suspect in penetrating injury traveling antero-medial thigh

A

femoral artery/vein

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
115
Q

how do you manage a femoral artery/vein injury

A

arteriogram, even if pt has normal pulses

hematoma needs immediate surgical exporation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
116
Q

what should you focus on first if pt has a combined vasculature, nerve, and bony injury

A

greatest urgency is vascular
–repair/recovery is very technical

however, you should set the bones first
–repair requires violent maneuvers that could undo your intricate vascular repair

nerve repair last

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
117
Q

when and where is compartment syndrome likely to happen

A

likely to happen after prolonged ischemia –> reperfusion

most likely in the forearm and lower leg
–potentially permanently disabling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
118
Q

extent of GSW damage based on type of gun?

A

bigger bullet = more damage

low velocity <1500 ft/sec = injury limited to path of bullet
(civilian weapon)

high velocity >3000 ft/sec = E is dispersed into tissue; creates column of destruction; large exit wound
(hunting rifle, ex.)
likely needs debridement and amputation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
119
Q

what lab value makes you suspect a crush injury

A

myoglobinemia / myoglobinuria

–crush injury frees up myoglobin into blood –> kidney –> renal failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
120
Q

how should you manage a crush injury

A

IV fluids, osmotic diuretics to protect kidneys

monitor serum K (released from crushed muscle cells)

possible fasciotomy 2/2 compartment syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
121
Q

what are 3 types of thermal burns

A

confined environment burn

circumferential burn

small patch burn

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
122
Q

what should you think of with a confined environment burn

A

think respiratory burn (chemical burn of upper respiratory tract)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
123
Q

how do you manage an upper respiratory burn

A

confirm dx with fiberoptic bronchoscopy

monitor with blood gases
—only tx is via respiratory support (no steroids, Abx, or airway)

tx w/ 100% O₂ (shortens the life of carboxyhemoglobin)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
124
Q

what should you suspect in a dry, white, 3rd degree burn called

A

circumferential burn

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
125
Q

what happens in a circumferential burn

A

fluid escapes circulation and becomes trapped as edema

cuts off circulation to extremity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
126
Q

how do you manage circumferential burn

A

monitor circulation in that extremity
(pulse, cap refill, Doppler)

Escharotomy to enable skin to swell

  • -can do at bedside (skin is already anesthetized and contaminated)
  • -if the burn is on the trunk: escharotomy at breast plate w/ 4 cuts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
127
Q

what happens in a small patch burn

A

swelling underneath can easily push up eschar

–nothing happens

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
128
Q

which burn is “the gift that keeps on giving”

A

chemical burn

  • -will continue to burn until chemical is removed
  • -eliminate the chemical ASAP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
129
Q

how do you manage a chemical burn

A

acid (battery) or alkaline (Drain-O) is the same

do not play chemist
remove clothing
running water for 30 min before going to ER

  • -exception: drinking liquid plumber (you can’t drink water for 30min)
  • -play chemist a little bit
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
130
Q

what should a pt immediately do after swallowing alkali substance

A

give diluted vinegar, orange/lemon juice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
131
Q

what should a pt immediately do after swallowing acid substance

A

give milk, egg whites, antacids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
132
Q

what is the concern with electrical burn

A

far more tissue destruction than what initially appears

–bone and muscles are readily cooked, even if exterior skin doesn’t look that bad

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
133
Q

how do you manage electrical burn

A

extensive surgical debridement
potentially amputation
monitor for myoglobinemia
look for vertebral compression fractures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
134
Q

what are 2 long-term sequelae in electrical burns

A

long-term sequelae of cataracts and demyelination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
135
Q

what are 2 burns suspicious for child abuse

A

bilateral burns on buttocks w/ moist blisters (2nd degree)

glove pattern of hand/foot being immersed in boiling water

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
136
Q

what is the initial tx for burn victims

A

need vicious fluid resuscitation for ~2 days

  • -estimation formulas are used
  • -judge the adequacy based on UOP and CVP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
137
Q

what is the modified Parkland formula for adult surface area burns

A

Rule of 9s x 11 = 99%

9% head
9% each UE
9% x 4 in trunk (2 in front; 2 in back)
9% x 2 in each LE (1 in front; 1 in back)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
138
Q

what is the Parkland formula for child surface area burns

A

two 9%’s in head

trunk and UE’s are same as adult
9% x 4 trunk
9% in each UE

three 9%’s total for LE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
139
Q

what is the modified Parkland formula to calculate fluid resuscitation

A

cc’s of balanced electrolyte soln (LR) pt needs in the first 24 hours

(Body weight kg) x (%burned up to 50%) x (A factor)

A factor = 2-4 for adults; 4-6 for peds

being burned >50% means you’re already losing fluid at a max rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
140
Q

how should you distribute the cc’s of an electrolyte soln in a burn pt

A

give half in first 8 hours; other half over 16 hrs

pts typically cannot eat/drink; so give additional 2L for maintenance fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
141
Q

why should you not give a sugar fluid to burn pts

A

the osmotic diuresis invalidates UOP values

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
142
Q

how do you manage resuscitation in burn pt on day 2 and 3?

A

day 2: typically needs ~half of first day fluids

day 3: trapped fluid tends to go back to pt; may see extensive diuresis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
143
Q

what is a good initial rate rule for fluid resuscitation

A

~1000/hr for >20% burn initially;

then monitor UOP to adjust

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
144
Q

what is the normal UOP for fluid resuscitation

A

nl UOP is ~1cc/kg/hr, but anywhere between 0.5 -2x that is acceptable

(70kg M should produce 35-140 cc/hr)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
145
Q

what is the basic management for burn care

A

standard tetanus prophylaxis
suitable cleaning of areas; OR for cross-debridement
topical burn care (no parenteral Abx)
IV pain meds (cannot be subQ)
intensive nutritional support (GI tract; high calorie; high Nitrogen)
rehab beginning on Day 1 (function, not survival, is endpoint)

graft areas that did not regenerate after 2-3 weeks
or, take pt to OR on Day 1 if severe burn is isolated and can easily be grafted
–save time, money, pain/suffering

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
146
Q

what are the 3 types of topical burn care depending on pt presentation (standard, severe, eyes)

A

standard: silver sulfadiazine
- -soothing white paste; works well against bacterial infection

deep penetration w/ thick eschar or involved cartilage: mafenide acetate
–painful; can produce acidosis

near eyes: triple Abx ointment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
147
Q

how do you manage a bite from a provoked domestic dog

A

tetany prophylaxis

dog is presumably vaccinated and provoked, so has low risk of rabies

  • -no rabies prophylaxis needed
  • -vet puts animal under observation to look for rabies indication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
148
Q

how do you manage a wild animal (ex. coyote) bite w/ animal brought back alive

A

can kill animal to examine its brain and look for sings of rabies +/- rabies prophylaxis for bite victim

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
149
Q

how do you manage bat attack w/o animal to examine

A

rabies prophylaxis

includes immunoglobulin + vaccine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
150
Q

what is the description of a venomous rattlesnake

A

elliptical eyes fixed behind nostrils, big fangs, rattles

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
151
Q

how do you manage a snake bite, depending on timing and pt presentation

A

up to 1/3 of bites do not inject venom, even in a venomous snake

in ER 1 hr after bite; no local plain, swelling, or discoloration = no venom
–tx: wound cleaning, tetanus prophylaxis, observation

in ER 1 hr after bite; local pain, edema, ecchymosis = venom
–tx: anti-venom in large doses
at least 5 vials; maybe 10-20
venom has to do with size of envenomation, NOT size of pt
immediately type and cross (venom eventually interferes)
Coag studies and renal/liver function tests
surgical excision is rarely needed

do not:
cut/excise bite area
elevate extremity
fasciotomy
give sterods
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
152
Q

how do you tx anaphylaxis 2/2 bee sting

A

(wheezing, hypotension, purulent rash)

tx: 1/2 to 1/3 cc EPI
remove stinger carefully

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
153
Q

how does a black widow spider bite present

A

black spider w/ red hourglass

pt has N/V; severe muscle cramps

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
154
Q

how do you tx black widow spider bite

A

Tx: IV Calcium gluconate +/- muscle relaxants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
155
Q

how does a brown recluse spider bite present

A

hurts when it happens; develop an ulcer overnight; dead skin w/ halo of erythema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
156
Q

how do you tx brown recluse spider bite

A

Tx: local excision of ulcer
get rid of venom
may need skin graft

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
157
Q

how do you tx human bite / punch in the face?

A

ortho surgeons take to OR for massive irrigation and debridement to prevent bad infection
–could destroy joint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
158
Q

what is dx in newborn with uneven gluteal folds; hip can easily be dislocated posteriorly w/ jerk/click

A

developmental dysplasia of hip

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
159
Q

what is the concern with developmental dysplasia of hip

A

permanent disability if not recognized early

–femoral heads can grow outside of socket

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
160
Q

how do you dx and manage developmental dysplasia of hip

A

Dx w/ PE or sonogram
–XR in newborn is not helpful (not enough calcification)

manage: abduction splinting w/ pelvic harness; or double diapers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
161
Q

what is dx in ~6yo w/ insidious development of limping w/ decreased hip motion
+/- ipsilateral knee pain

A

avascular necrosis of capital femoral epiphysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
162
Q

how do you dx and manage avascular necrosis

A

dx w/ XR

manage: controversial; some use casting/crutches

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
163
Q

what is dx in ~13yo M, often overweight, with groin pain, limping, inverted foot; limited hip motion;
as hip is flexed, leg goes into external rotation and cannot be rotated internally

A

slipped capital femoral epiphysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
164
Q

how do you dx and manage slipped capital femoral epiphysis

A

dx w/ hip XR

manage: ortho emergency
pin femoral head into position so it does not die

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
165
Q

what is dx in ~toddler with febrile illness, then acute hematogenous osteomyelitis

A

septic hip

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
166
Q

how do you dx and manage septic hip

A

dx w/ radio nuclear bone scan (not CT)
–XR takes too long to show osteomyelitis

mange: Abx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
167
Q

what age is bow legged normal

A

(genu varum)
normal up to 3yo

do not prescribe ortho braces/casts etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
168
Q

how do you treat genu varum after 3yo?

A

pt likely has Bowen’s disease if bow-legged persists past 3yo

needs surgical correction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
169
Q

what age is knock knee’d normal

A

(genu valgus)
normal up to 8yo

co not prescribe ortho braces/casts etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
170
Q

what does knee pain w/o swelling generally indicate

A

intrinsic knee problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
171
Q

what is dx and tx of tibial tubercle pain aggravated w/ quad contraction

A

osteochondrosis of tibial tubercle
AKA Osgood-Schlatter disease

Tx: immobilization of knee; extension cast 4-6 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
172
Q

what is dx of baby born w/ both feet turned inward

A

club foot
AKA congenital talipes equinovarus

adduction of forefoot
inversion of foot
flexion of ankle
internal rotation of tibia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
173
Q

how do you manage club foot

A

serial plaster casts beginning in neonatal period
–start most distal and move proximally

50% respond in 6mo and don’t require surgery
–do surgery <1yo before they’re ready to walk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
174
Q

what is dx in ~F w/ curved spine; hump in thorax when bending forward in premenstrual growth spurt yrs

A

scoliosis

S-form is seen lateral in progression
progresses as long as skeletal maturity has not yet been reached

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
175
Q

how do you manage scoliosis

A

corsets and casts +/- surgery until skeletal maturity

consider possible limited pulmonary function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
176
Q

what are “pros” of a childhood vs adult fracture

A

most have better outcome than adults- more plastic

faster healing and capacity for remoodeling- grow back straight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
177
Q

what are 2 bad childhood fractures

A

elbow

growth plate involvement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
178
Q

what is the concern w/ childhood elbow fracture

A

high risk of neovascular compromise

–monitor w/ cap filling; Doppler, pulse, etc for vascular supply

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
179
Q

what is the fracture in elbow fracture

A

supracondylar fracture of humerus

–distal fracture displaced posteriorly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
180
Q

what is needed with childhood fracture involving growth plate

A

precise re-alignment is needed

–open reduction and internal fixation is best

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
181
Q

what type of bone tumor has a sharply demarcated edge that distinguishes it from the rest of bone (boundary)

A

benign bone tumor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
182
Q

what type of bone tumor has fuzzy/ill-defined edge between tumor and bone

A

malignant bone tumor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
183
Q

what are the 2 buzzwords for malignant bone tumors on radiology

A

“sunburst” pattern (fuzzy demarcation edge)

periosteal onion-skinning (tumor is growing fast and displacing periosteum from bone; new layer of bone that gets displaced again)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
184
Q

what is the presentation of 2 childhood bone tumors:

osteogenic sarcoma vs Ewing sarcoma

A

osteogenic sarcoma:
10-25yo
around the knee (lower femur/ upper tibia)

Ewing sarcoma:
younger children
around diaphysis/shaft of bone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
185
Q

how do you manage malignant bone tumors

A

refer to specialized ortho surgeon

do not do anything invasive to this pt

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
186
Q

what are most adult bone tumors (primary or metastatic?)

A

metastatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
187
Q

what is the most common primary malignant bone tumor in adults

A

multiple myeloma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
188
Q

what is dx in pt who is old, anemic, multiple bones involved; Benz Jones protein in urine; abnl immunoglobins

A

multiple myeloma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
189
Q

how do you tx multiple myeloma

A

chemo usually

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
190
Q

what is a pathologic fracture and what does it signify

A

fracture 2/2 trivial event

signifies metastatic tumor presence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
191
Q

what does XR show on pathologic fracture

A

XR shows lytic lesion (eating bone) vs plastic lesion (growth of bone)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
192
Q

where do you assume bone metastasis in a male vs female

A

male: assume to be metastatic from lung
female: assume to be metastatic from breast

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
193
Q

what fracture commonly occurs in osteoporosis

A

vertebral compression fractures

all others need some sort of trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
194
Q

what is generic dx of an older pt with soft issue mass that grows, hard, fixed

A

sarcoma

(don’t know if it’s lipo, fibro, chondro, rhabdo - sarcoma yet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
195
Q

how do you dx sarcoma

A

MRI

do not do invasive maneuver

  • doc who discovers the tumor should not be doing the biopsy
  • pt requires large tissue sample and open bx from a specialist
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
196
Q

what imaging should you get for a fracture

A

XR at 90 degrees to each other;

include the obvious and suspicious fracture sites

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
197
Q

how do you manage clavicle fracture

A

spint w/ figure 8 device for 4-6 weeks to retract shoulders

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
198
Q

what is the buzzword for colles fracture

A

dinner fork shaped, painful wrist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
199
Q

what does XR show for colles fracture

A

dorsally displaced dorsally angulated fracture of distal radius;
small fracture of ulnar head

(dinner fork wrist)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
200
Q

how do you tx colles fracture

A

closed reduction and long arm cast

dinner fork wrist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
201
Q

what type of fracture gives you a broken ulna and a dislocated radius

A

Monteggia fracture

diaphysial fracture of proximal ulna with anterior dislocation of radial head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
202
Q

how does one typically get a Monteggia fracture

A

protecting with outstretched forearm

broken ulna; dislocated radius

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
203
Q

what type of fracture gives you a broken radius and dislocated ulna

A

Galeazzi fracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
204
Q

how should you cast a Galeazzi fracture

A

in supinated form

broken radius; dislocated ulna

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
205
Q

what is the general rule for fixing broken bones and dislocated bones, respectively

A

open reduction/internal fixation for the broken bone

closed reduction for the dislocated bone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
206
Q

what bone is commonly fractured with FOOSH, wrist pain, tender to palp over anatomic snuff box

A

scaphoid bone

XR will be negative for 3 weeks, so clinical dx is useful

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
207
Q

how do you manage scaphoid bone fracture

A

needs thumb spiker cast (not displaced)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
208
Q

what does a XR showing an adulated fracture of scaphoid notorious for

A

high rate of non-union/delayed healing (displaced)

this requires open/internal fixation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
209
Q

what is commonly fractured with a closed fist hit

A

fracture of 4th/5th metacarpal neck

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
210
Q

how do you manage the 4th/5th metacarpal neck fracture (closed fist hit)

A

management depends on degree of angulation, displacement, or rotary malalignment

mild: closed reduction and ulnar gutter splint
severe: wire plate fixation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
211
Q

which should dislocation is most common

A

anterior dislocation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
212
Q

what is dx for pt presenting holding arm close to body; rotated out as if to shake hands; numb in deltoid

A

anterior shoulder dislocation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
213
Q

how do you dx and tx anterior shoulder dislocation

A

dx: AP/lateral XR
tx: reduction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
214
Q

what is dx for pt presenting with arm held close to body; internally rotated

A

posterior dislocation of shoulder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
215
Q

how do you dx and tx posterior shoulder dislocation

A

difficult to dx; may have history of small clinic visit + pain meds that aren’t helping
(may occur when all muscles in body contract at same time- electrical burn, epileptic seizure, etc)

dx: axillary or scapular/lateral XR
tx: reduction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
216
Q

what is dx in shortened and externally rotated leg

A

broken hip

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
217
Q

what is concern in femoral neck fracture

A

the fracture will likely kill femoral head 2/2 tenuous blood supply

if this occurs in an elderly pt, they’ll be immobilized, pneumonia, and die

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
218
Q

how do you tx femoral neck fracture

A

OR to remove femoral head and replace w/ metal prosthesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
219
Q

how do you tx intertrochanteric fracture

A

open reduction and pinning

immobilization and anti-coag (esp in elderly pts at risk for DVT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
220
Q

how do you tx/manage femoral shaft fracture

A

intramedullary rod fixation

monitor for hypovolemic shock
monitor for fat embolism (low pO2)
–resp support to improve oxygenation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
221
Q

what is likely dx in pt who has h/o repetitive use of bone beyond toleration; localized tibia pain in specific area of bone

A

stress fracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
222
Q

how do you dx and tx stress fracture

A

XR is nl until later on

tx: cast

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
223
Q

what should you suspect hours after cast alignment when pt c/o persistent pain, tight muscle compartments, extreme pain with passive extension of toes

A

compartment syndrome

severe disability if not recognized

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
224
Q

how do you tx compartment syndrome in legs

A

emergency fasciotomy in all compartments (4 in legs) with 2 skin incisions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
225
Q

what is dx in out of shape pt who over-exerts, hears a loud pop; can initially move, but then progresses to being unable to move

A

achilles tendon rupture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
226
Q

how do you tx achilles tendon rupture

A

casting in equinus position (pt on tip toes to not stretch tendon) for several months

open surgical repair for faster healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
227
Q

what is dx in pt who falls on inverted/everted foot

A

malleoli fracture

it doesn’t matter which way they fall; both malleoli will be broken

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
228
Q

how do you manage malleoli fracture, depending on what XR shows

A

XR shows good position fracture: casting

XR shows displaced fractures: open reduction and internal fixation for proper ankle healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
229
Q

what is dx in pt with medial knee pain/swelling
passive abduction elicits pain
positive valgus stress test

A

medial collateral ligament injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
230
Q

which direction can you bend knee in MCL injury

A

can bend leg further in direction of broken ligament (medial) without limited motion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
231
Q

what is dx in pt with lateral knee pain/welling
passive adduction elicits pain
positive varus stress test

A

lateral collateral ligament injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
232
Q

how do you treat MCL/LCL injuries

A

hinge cast if that’s the only problem

otherwise, surgical repair

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
233
Q

what is dx in positive anterior drawer test

A

Anterior cruciate ligament tear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
234
Q

what is dx in positive posterior drawer test

A

posterior cruciate ligament tear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
235
Q

which imaging confirms a ligament tear

A

MRI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
236
Q

how do you manage knee ligament tear

A

immobilization and rehab for sedentary pts

athletes: arthroscopic reconstruction for quick healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
237
Q

what is dx in pt with catching and locking of knee that limits its motion; click when forcefully extended

A

meniscus injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
238
Q

how do you dx meniscus injury

A

XR is nl
difficult to dx
may have h/o small clinic visit with unhelpful tx

MRI shows meniscal tear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
239
Q

how do you tx meniscus tear

A

arthroscopic repair

try to save as much meniscus as possible to avoid degenerative arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
240
Q

how do you manage pt with cast and compartment syndrome

A

always remove cast immediately if pt presents with pain under recently placed cast
—do not select analgesics or XR to confirm bone placement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
241
Q

what are pulses in compartment syndrome

A

presence of pulses does NOT rule out compartment syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
242
Q

what is the buzzword for compartment syndrome

A

severe pain with passive extension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
243
Q

how do you manage exposed bone

A

OR, clean, cover, close bones within 6 hours

to avoid infection, osteomyelitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
244
Q

what is dx in pt who hit dashboard with knees

A

posterior dislocation of hip

drives the femur out of the socket backwards

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
245
Q

how do you manage posterior hip dislocation

A

reduction ASAP to prevent femoral head necrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
246
Q

what is likely dx in pt who stepped on rusty nail –> swollen dusky foot w/ gas crepitus 2-3 days later

A

gas gangrene

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
247
Q

how do you manage gas gangrene

A

requires extensive debridement +/- amputation

immediate tx:
large doses IV penicillin
surgical debridement (bugs feed on dead tissue)
hyperbaric O₂ to deactivate toxin

life threatening soft tissue infection
–can happen to anyone (vs an infection mostly happening in an immunocompromised/diabetic pt)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
248
Q

how do you evaluate nerve symptoms in a bone injury

A

reduce fracture and re-evalutate nerve function
(ex humeral fracture could damage radial nerve)

you could trap nerve when splinting bones and cause nerve symptoms
–need open reduction to unwrap nerve

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
249
Q

what artery is damaged with posterior dislocation of knee

A

popliteal artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
250
Q

how do you manage popliteal artery damage

A

immediate reduction of posteriorly dislocated knee w/ Doppler, pulses, arteriogram studies

feeble collateral circulation could cause damage –> leg loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
251
Q

what is dx in pt who falls and lands on feet

A

compression fracture of thoracic and lumbar spine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
252
Q

what should you also check in a pt with facial trauma

A

check cervical spine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
253
Q

what should you look for in pt with dashboard MVC injury

A

XR hip in MVC to evaluate a posterior dislocation of femur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
254
Q

what is dx in pt with numbness/tingling in hand, esp at night, esp hanging hand limply, esp pressing on carpal tunnel or pericostal

A

carpal tunnel syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
255
Q

what nerve distribution is involved with carpal tunnel syndrome

A

median nerve distribution (radial 3.5 fingers)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
256
Q

how do you dx and manage carpal tunnel syndrome

A

dx: XR including carpal tunnel views

tx: splints and anti-inflammatories
- –do not inject steroids
- –pt may need electromyography +/- surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
257
Q

what is dx in pt with finger acutely flexed; unable to extend; painful snap; almost exclusively F

A

trigger finger

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
258
Q

how do you manage trigger finger

A

steroid injections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
259
Q

what is dx in pt with painful radial wrist and 1st dorsal compartment; pain w/ flexion and simultaneous thumb extension

A

deQuervain’s tendosynovitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
260
Q

what are 2 unique actions that elicit pain in a pt with deQuervain’s tendosynovitis

A

pain w/ holding baby head

pain w/ holding thumb inside closed fist and forcing wrist into ulnar deviation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
261
Q

how do you tx deQuervain’s tendosynovitis

A

steroid injections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
262
Q

what is dx in pt with contracted hand; can no longer be extended; palmar fascial nodules palpated; commonly in Scandinavian M or chronic alcoholic

A

Dupuytren’s contracture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
263
Q

how do you tx Dupuytren’s contracture

A

surgery to free up fascia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
264
Q

what is dx in pt with abscess in pulp of index finger w/ throbbing pain, fever

A

felon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
265
Q

what is concern in pt with felon

A

pulp of finger has fascial trabeculae made for closed spaces

swelling –> necrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
266
Q

how do you tx felon

A

immediate surgical decompression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
267
Q

what is dx in pt with injury of ulnar collateral ligament of thumb

A

Game Keeper’s thumb

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
268
Q

what is PE in game keeper’s thumb

A

collateral laxity at 4th metacarpal phalangeal joint from thumb jam

can be dsyfunctional/painful –> arthritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
269
Q

what activity commonly causes Game Keeper’s thumb

A

skiing

thumb jam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
270
Q

how do you tx game keeper’s thumb

A

casting for opportunity to heal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
271
Q

what is dx in pt with injury to flexor tendon, for example when grabbing another person’s shirt

A

jersey finger

272
Q

what is PE in jersey finger

A

distal phalanx of ring finger doesn’t flex with others when making a fist

273
Q

how do you manage jersey finger

A

splint

274
Q

what is dx in pt with injury to extensor tendon; for ex when playing volleyball

A

mallet finger

275
Q

what is PE in mallet finger

A

distal phalanx cannot extend; tip of finger remains bent down; looks like hammer/mallet

276
Q

how do you manage mallet finger

A

splint

277
Q

how do you manage a severed finger

A

clean severed finger with sterile saline
wrap in saline-moistened gauze
place in plastic bag
then on bed of ice

278
Q

what is prognosis for severed fingers

A

replantation of severed extremities is done only for very distal parts

nerve regneration is limited, and replanting a denervated part is not useful

279
Q

what is dx in pt who has vague back pain that turns into “electrical shock” down the leg; severe back pain when lifting heavy objects; aggravated by sneezing, coughing, ambulating, or straining; pt will keep legs flexed to avoid pain

A

lumbar disc hernia

280
Q

how do you dx lumbar disc hernia

A

straight leg raise test produces excruciating pain

281
Q

what is dx in pt who has vague back pain

A

disc bulge (discogenic pain)

the disc bulge pushes anterior spinal ligament to cause the vague back pain

282
Q

what is pathogenesis of lumbar disc hernia

A

first you have a disc bulge that pushes anterior spinal ligament, producing vague back pain
then, a sudden/violent motion will herniate disc
compresses nerve root
gives you severe neurogenic root pain (“electric shock”)

283
Q

where is disc herniation located if pain radiates to big toe vs little toe

A

pain radiating to big toe = L4/L5

pain radiating to little toe = L5/S1

284
Q

how do you dx and manage a herniated disc, including 2 exceptions?

A

dx with MRI image (two soft tissue structures: disc and nerve)

bed rest for 3 weeks

2 exceptions:

  • -neurosurgical intervention if there’s progressive weakness
  • -sphincter defects are an emergency (rectum, bladder, etc); likely permanent if not quickly reversed
285
Q

what is dx in pt with “herniated disc” symptoms + distended bladder, flaccid retrosphincter, and perianal saddle anesthesia

A

cauda equina syndrome

286
Q

how do you manage cauda equina syndrome

A

surgical emergency

287
Q

what is dx in young M (20s-30s) with chronic progressive back pain that improves with activity (worse in the morning)

A

Ankylosing spondylitis

288
Q

what imaging goes with ankylosing spondylitis

A

eventually shows bamboo spine

289
Q

how do you manage ankylosing spondylitis

A

anti-inflammatories and PT

290
Q

what ulcer commonly presents:
pressure point, usually foot
classically the heel or 1st metatarsal
painless (neuropathy)

A

diabetic ulcer

291
Q

why do diabetic ulcers not heal wel

A

ulcer develops and does not heal due to poor peripheral vascular supply

292
Q

what is management of diabetic ulcer

A

control diabetes, stay in bed, keep leg horizontal

most diabetics suffer amputation; however, healing is possible

293
Q

what ulcer commonly presents:

atherosclerotic disease causing ulcer at tip of toe- blue/pulseless

A

ischemic ulcer

294
Q

how do you manage ischemic ulcers, depending on vessel size

A

big vessel: surgery, bypass big vessels

small vessel: surgery does not help

take BP at certain points to determine pressure gradient/blockage (or Doppler)

  • -no pressure gradient = no single point that can be bypassed; not a surgical candidate
  • -pressure gradient = next do an arteriogram for obstruction details
295
Q

what ulcer commonly presents:
above medial malleolus in hyper pigmented, edematous skin;
cellulitis
varicose veins

A

venous insufficiency ulcer

296
Q

how do you manage venous insufficiency ulcer

A

provide support so peripheral superficial veins are not engorged with blood

stockings, compression, stiff support, possible varicose vein surgery

297
Q

what cancer commonly develops in longstanding site of chronic irritation

A

squamous cell carcinoma

298
Q

what is this a classic story for:
chronic draining sinus in lower leg for years since osteomyelitis; but recently developed indolent, dirty ulcer with heaped up edges

A

squamous cell carcinoma

299
Q

what is this a classic story for:
chronic shallow ulcerations at burn scar site that heal/break down, but recently developed indolent dirty ulcer w/ heaped up edges that are not getting smaller

A

squamous cell carcinoma

300
Q

how do you dx and manage squamous cell carcinoma

A

biopsy of edge of ulcer where heaped up edge is

treat with wide resection and skin grafting

301
Q

what is dx in chronic inflammation of plantar fascia pulling, leading to bony spur

A

plantar fasciitis

302
Q

what presents with sharp heel pain with every strike on the ground; worse in the AM; with a bony spur matching pain site on XR and tenderness over bony spur on PE

A

plantar fasciitis

303
Q

how do you manage plantar fasciitis

A

supportive analgesics
rigged devices of stepping (NOT excision of the bony spur)

it usually goes away 1-2yrs

304
Q

what is dx in F wearing high heel/pointed shoes or a Cowboy wearing pointed boots
w/ pain from prolonged standing/walking; PE will be very tender on 3rd interspace

A

Morton’s neuroma

305
Q

what nerve is inflamed in Morton’s neuroma

A

common digital nerve

pointed shoes

306
Q

what is management of Morton’s neuroma

A

conservative management

wear better shoes

excision of neuroma

307
Q

what is dx in pt with red, painful swelling of 1st metatarsal joint

A

gout

308
Q

how do you dx and manage gout

A

dx: serum uric acid level or uric acid crystals in joint fluid
manage: medical (colchicine, allopurinol, probenecid)

309
Q

what cardiac risk factors need to be considered in a pre-op assessment

A

EF <35% = high risk of intraoperative MI

Goldman’s findings- high operative risk for non-cardiac surgery:
–age, chronically bedridden, emergency operation, major body cavity, recent MI, A-fib, premature ventricular beats, JVD

CHF (JVD), esp in elective surgery

recent MI, esp <6mo ago

Angina + AAA

310
Q

what is your mortality risk in a non-cardiac operation with a recent MI vs non-recent MI

A

MI <6mo ago = 40% mortality

MI >6mo ago = 6% mortality

311
Q

what should be done first in a pt with angina and AAA to improve operative cardiac risk

A

coronary revascularization before AAA repair

312
Q

how do you assess an operative pt’s pulmonary risk

A

smoking and ability to ventilate (vs oxygenate)

quantify with blood gases (high pCO2) or pulm studies (FEV1 = ability to ventilate)

313
Q

what value does FEV1 represent

A

ability to ventilate

314
Q

how can you reduce an operative pt’s pulm risk prior to surgery

A

cessation of smoking for 8 weeks

incentive respiratory therapy (PT, expectorants, IS, humidified air)

1st week of cessation = bronchorrhea and mucus secretions

315
Q

how do you assess a surgical pt’s hepatic risk

A

liver function is important for anesthetic operation

high Bil due to hepatocellular dysfunction = high risk
—can operate if high Bil is due to obstruction/hemolysis

high PT
low serum Alb
encephalopathy
high ammonia

316
Q

how do you assess a surgical pt’s nutritional risk

A

unable to eat / weight loss = malnutrition

serum Alb <3

allergy to skin test antigens

serum transferrin level <200

brief prior, intense nutritional support can lower operative mortality; preferably 7-10 days

317
Q

what must be done for DKA pts before an operation

A

cannot operate in DKA

need to rehydrate pt; no coma; begin to fix acidosis; lower blood glucose first

318
Q

what is dx in pt who develops intraoperative fever shortly after onset of general anesthesia >104

A

malignant hyperthermia

319
Q

what is pathology of malignant hyperthermia

A

congenital absence of enzyme needed to break down succinylcholine, so you generate heat from muscle activity

320
Q

what do lab values look like in pt with malignant hyperthermia

A

fever >104
metabolic acidosis
hypercalcemia
FHx

321
Q

how do you treat malignant hyperthermia

A

IV dantrolene (different MOA than succinylcholine) to stop muscle activity

100% O₂
cooling blankets
correct the acidosis
monitor for myoglobinemia/uria and treat accordingly

322
Q

how do you assess surgical pt’s aspiration risk

A

prefer to prevent vs treat

can kill pt or cause chemical injury to bronchial tree–> failure

NPO before elective surgeries
–give pts anti-acids pre-op

323
Q

how do you manage aspiration once it’s happened

A

bronchoscopy to lavage and remove particulate matter

bronchodilators and respiratory support

324
Q

how might an intraoperative pneumothorax happen

A

giving a pt positive pressure ventilation and a bleb breaks –> one way valve into pleural space

325
Q

what values indicate an intraoperative pneumothorax

A

BP decreases as CVP increases

326
Q

how can you manage an intraoperative pneumothorax

A

surgeon can poke a hole in the diaphragm w/ needle

place a chest tube at end of procedure

327
Q

what is dx in pt with post-op fever immediately after surgery

A

bacteremia

328
Q

how do you manage post-op bacteremia

A

blood cultures x 3

empiric Abx

329
Q

what are the 4 W’s in the ddx of post-op fever (actually 6)

A 
Wind
Water
Walking 
Wound
Wonder Where
Wonder drugs
330
Q

go through “wind” post op fever

A

♣ POD1: Inability to ventilate; atelectasis
• Tx: improve ventilation, breathing, coughing, IS, chest drainage
• Bronchoscopy rarely needed

♣ If continues to ~POD3 –> pneumonia
• Tx: CXR, Abx, sputum cultures

331
Q

go through “water” post op fever

A

♣ POD3: Urinary Tract Infection

• Dx: urinalysis

332
Q

go through “walking” post op fever

A

♣ POD5: DVT

• Could do Doppler studies of deep vein flow restrictions

333
Q

go through “wound” post op fever

A

♣ POD7: Wound infection
• Only erythema = Abx
• Pus = needs to be drained
o Sonogram helps

334
Q

go through “wonder where” and “wonder drugs” post op fever

A

Wonder where:
♣ POD10: Deep abscess infection
• Subphrenic, subhepatic, or pelvic abscess
• CT or sonogram to visualize

Wonder drugs:
♣ Potential cause when everything else has been ruled out

335
Q

what are the 2 big things on your ddx for post-op chest pain

A

MI POD 1-2

PE POD 5-7

336
Q

how do you dx and manage post-op MI

A

dx: EKG, cardiac enzymes; usually POD 1-2

cannot lyse clots in a fresh post-op pt
have to treat the complications of MI but without blood thinners

337
Q

what is seen in a preoperative MI

A

ST depression, T wave flattening; commonly 2/2 hypotension

dx: CK, CK-MB isoenzyme

338
Q

how does post-op PE present

A

POD 5-7

sudden severe SOB and pleuritic chest pain; prominent veins, anxious, diaphoretic, tachy

339
Q

how do you dx post op PE

A

ABGs show hypoxemia and hypocapnia

  • -cannot get O₂ into blood, but pt is also hyperventilating
  • -all areas that are perfused are ventilated; hypocapnia/hypocarbia is classic

V/Q scan only works if lungs are otherwise normal

spiral CT

340
Q

what lab values distinguish PE vs respiratory failure

A

PE:
hypocapnia/hypocarbia (classic)
–all areas that are perfused are ventilated

respiratory failure:
hypoxemia and hypercarbia
–cannot get O₂ in and CO₂ out of blood

341
Q

how do you manage post-op PE

A

anti-coagulation to prevent new clots (Heparin)
–lungs will lyse the existing clot

vena cava filter if the pt has experienced a PE while on anti-coagulators

342
Q

what is the ddx for disorientation

A

post-op hypoxia

drug overdose; hypoglycemia

ARDS

Delirium tremens

Acute water intoxication

diabetes insipidus

ammonium intoxication

343
Q

what is initial work-up of post-op disorientation

A

check ABGs for pulmonary insufficiency –> hypoxia

–inadequate brain oxygenation

344
Q

what should be an initial thought of pt in ER in coma

A

possible drug overdose, hypoglycemia (insulin)

–inject with 50% dextrose

345
Q

what is the classic story for an ARDS pt

A

classically in a long, complicated post-op pt

–good chance that sepsis is present

346
Q

what is the work-up for post-op ARDS

A

CT scan to look for source/drainage

347
Q

what will you see in post-op ARDS

A

pulmonary infiltrates, low pO2, no evidence of CHF

348
Q

how do you manage post-op ARDS

A

mechanical respiration support and PEEP; max 40% O₂ long-term

PEEP: allow some degree of hypercapnia to not push more than necessary

349
Q

what is dx in post-op alcoholic who is disoriented, combative, hallucinating

A

delirium tremens

350
Q

how do you manage delirium tremens

A

IV 5% alcohol and 5% dextrose

psychiatrists disagree- tx addiction w/ non-addictive agent

351
Q

what is likely dx in pt who is hours post-op with confusion, lethargy, HA, grand mal seizures, and coma

A

acute water intoxication

their 5% dextrose in water infusion was running way too high
(a large fluid that does not include Na –> water retention)

352
Q

what will pt get with acute water intoxication

A

SIADH (metabolic response to trauma)

353
Q

how do you dx acute water intoxication

A

serum Na concentration is low (water retention is diluting Na)

354
Q

how do you manage acute water intoxication

A

high morbidity and mortality scenario

carefully administer hypertonic saline

    • acute hyponatremia + CNS symptoms = brain has not adapted
  • -acceptable to use hypertonic saline
355
Q

what is dx in pt hours post-op who is lethargic, confused, comatose
with high UOP despite normal IV fluid rate

A

Diabetes insipidus

356
Q

what is pathology of diabetes insipidus

A

inability to produce ADH

surgery was ~near pituitary; transient interference

357
Q

how do you diagnose diabetes insipidus

A

serum Na concentration is high (losing water in urine)

358
Q

how do you manage diabetes insipidus

A

rapidly reverse with several liters of D5W or diluted 1/3 to 1/4 normal saline

or ADH absorption via nasal mucosa

359
Q

what is dx in pt with liver failure and delirium

A

ammonium intoxication

360
Q

how might a pt with ammonium intoxication present with labs

A

liver failure:
cirrhotic, hypokalemic alkalosis, high CO, low PVR

delirium

bleeding varices (belly full of blood)

361
Q

what is pathogenesis of ammonium intoxication

A

pt has hepatic failure/ delirium, and is bleeding from varices (belly full of blood)

blood from GI tract is absorbing ammonium
liver cannot convert it to ammonia

362
Q

how do you manage ammonium intoxication

A

clean out bowel with enemas

locally acting Abx to rid the ammonium source

363
Q

what is the story of a pt with post-op urinary retention

A

needs to void but unable

palpable suprapubic mass dull to percussion

364
Q

how do you manage post-op urinary retention

A

catheter into bladder to empty

if you need to do it 2 or 3 times, some docs will leave in an indwelling catheter

or a prophylactic catheter (common/predictable problem)

365
Q

what is the likely dx in a pt with zero UOP

A

mechanical problem-

plugged/kinked catheter

366
Q

what are the 2 possibilities of a pt with oliguria (low UOP with normal vital signs)

A

pt is either behind on fluids or in acute renal failure

367
Q

walk through the 3 tests to distinguish between behind on fluids vs Acute Renal Failure

A

Test:
bolus 500cc IV NS over 10-20min
–pt behind on fluids will increase UOP
–pt in renal failure is already making max UOP; the bolus won’t improve UOP

Test:
measure urine Na
–pt behind on fluids (dehydration) Na conc <20mEq/L (good kidneys; they’re holding onto fluid via Na retention)
–pt in renal failure will have urinary Na conc >40mEq/L (bad kidneys; making plasma filtrate; cannot change Na conc)

TesT:
fractional excretion of Na
–Dehydration <1
–Renal failure >1

368
Q

how do you manage a dehydrated pt vs a renal failure pt with oliguria

A

dehydrated: fluid administration

renal failure: fluid restriction

369
Q

what are 3 things on the ddx for post-op abdominal distension

A

post-op paralytic ileus
mechanical obstruction
Ogilvie syndrome

370
Q

what is dx in pt with ~POD4 abdominal distension w/o pain; no bowel sounds/flatus vs ~POD6-8

A 
POD4 = post-op paralytic ileus
POD6-8 = mechanical obstruction
371
Q

what does XR show in post-op paralytic ileus

A

dilated Small bowel loops w/o air-fluid levels

372
Q

what lab abnormality can perpetuate a paralytic ileus

A

hypokalemia

373
Q

what does barium study show in a paralytic ileus vs obstruction

A

inject 30cc via NG tube:

paralytic ileus: barium goes to colon

obstruction: barium stops moving

374
Q

how do you manage a post-op mechanical obsturction

A

re-operation to fix adhesions/anastamotic defect

375
Q

what is likely dx in pt with ~POD5 abdominal distension; tense, but not tender; and occasional bowel sounds; typically elderly M who isn’t active, then further immobilized from surgery

A

Ogilvie syndrome

376
Q

what does XR in Ogilvie syndrome show

A

massively distended colon w/ a few distended small bowel loops

377
Q

what is management of Ogilvie syndrome

A

colonoscopy

  • -suck out gas that’s diluting the colon
  • -rule out cancer of the colon
  • -long rectal tube left in place for continued gas exit

rarely, a cecostomy or colonostomy is needed

378
Q

what is dx in pt with salmon-colored clear fluid soaking wound dressings, and what is that fluid

A

wound dehiscence

peritoneal fluid

379
Q

what causes wound dehiscence

A

deeper layers of surgery have failed to heal before skin heals

380
Q

how do you manage wound dehiscence

A

careful protection of wound
keep in bed; don’t move
tape the wound together; use abdominal binders

later: re-operate to prevent vental hernia (non-emergency)

381
Q

what is the concern with wound dehiscence

A

could turn into evisceration

  • -wound opens and small bowel falls out
  • -emergency; high morbidity/mortality
382
Q

how do you manage evisceration following wound dehiscence

A

pt back to bed, cover bowel w/ moist dressings soaked in warm saline

  • -rush to OR for immediate closure
  • -do not allow bowel to dry out
  • -avoid hypothermia
383
Q

what is dx in pt with ~POD7 fever and red, hot, tender wound

A

wound infection

384
Q

how do you manage wound infection caused by either cellulitis or abscess

A

cellulitis: Abx directed toward nl skin flora
Abscess: drainage (check via sonogram)

385
Q

what is dx in pt with luminal content leaking through belly and afebrile

A

fistula

386
Q

describe fistula fluid from proximal GI tract

A

high volume 2-3 L /day

causes a fluid/electrolye/nutirition problem because the fluid has digestive enzymes digesting the abdominal wall

387
Q

how do you manage proximal GI fistula

A

maintenance fluids and replacement electrolytes (LR)

nutritional replacement distal to fistula (NPO)

protection of abdominal wall; do not let fluid soak dressing; protect skin

388
Q

describe fistula fluid from distal GI tract

A

low fluid / nutritional absorption /enzymes

non-life threateningn

389
Q

what happens with most GI fistulas 2/2 anastomosis

A

most heal unless something is preventing closure

390
Q

what would cause fistula closure prevention

A 
"FETID"
foreign body
Epithelialization 
Tumor
Infection
Irradiated tissue
IBD
Distal obstruction

requires surgical intervention

391
Q

describe epithelialization in a GI fistula

A

granulation tissue grows from conduit while epithelium is migrating from inside the lumen

long and narrow hole = granulation tissue will win and fill epithelium

short and wide hole = epithelialization; hole will not close

392
Q

what is likely dx in pt with hypernatremia (water loss) 2/2 surgery acutely

A

DI

393
Q

how do you manage acute DI

A

diluted fluid to replenish loss with several liters of D5W, 1/3 to 1/4 NS +/- ADH

every 3mEq that serum Na is above 140 represents ~1L water lost

394
Q

what is likely dx in pt who is awake/alert but hypernatremia (dehydrated)

A

chronic hypernatremia

  • selectively lost water
  • developed hypernatremia over ~days, so the brain has adapted (normal mentation)
395
Q

how do you manage chronic hypernatremia

A

reverse the volume loss over ~hrs to improve hemodynamics/kidneys

correct the hypertonicity over ~days
using 5L D5 1/2 NS
–fluid that’s neither as diluted as D5W nor as concentrated as NS
–rapid correction of volume and ~modest/safe impact on tonicity

396
Q

what is likely dx in pt with hyponatremia (water gain_ 2/2 rapid drip of Na-free soln during an inappropriate ADH response to trauma

A

acute water intoxication

every cell is swollen, including the brain
–> comatose

397
Q

how do you manage acute water intoxication

A

hypertonic 3-5% Saline in small quantities

mannitol

398
Q

what is likely dx in pt who is alert/awake but hyponatremia (water retention)

A

chronic hyponatremia

too much ADH

hyponatremia has developed over ~days, so brain has adapted (normal mentation)

399
Q

how do you manage chronic hyponatremia

A

slow correction of serum Na

  • -water restriction (cannot take away the excess ADH in the body)
  • -meds to counteract ADH effects

a rapid correction would cause central pontine lysis of myelin

400
Q

what is pathogenesis in “loss of hypertonic fluids” or “selective loss of Na”

A

doesn’t realistically happen- no mechanism to selectively lose Na to cause chronic hyponatremia

first, the pt begins losing isotonic fluids via vomiting (Na-containing, but still isotonic)
–the initial insult is dehydration w/o tonicity change

several days –> volume depletion; pt is likely unable to eat/drink, so cannot replace fluids being lost
–body is eager to retain fluids at this point

pt drinks Na-free fluid (water/soda vs HCO3/Na) –> production of free water

  • -body is willing to sacrifice tonicity to retain volume
  • -fluid drank is stained
  • -does not correct vol depletion; you’ve created a tonicity gradient, so the water ends up in cells but with a low serum Na due to retaining water and losing isotonic fluids

the pt lost isotonic fluid then eventually retained water –> hyponatremia

401
Q

how do you manage chronic hyponatremia

A

slowly correct the hyponatremia with rapid correction of volume replenishment

use isotonic fluids to rapidly correct the volume and slowly correct tonicity

NS: when pt is alkalotic (vomiting gastric acid and juice)
LR: when pt is acidotic (vomiting small bowel content, bile, pancreatic juice, alkaline fluids)

402
Q

how do you manage severe DKA

A

insulin + IV fluids + K

403
Q

what is the rationale for giving K to a DKA pt

A

pt is acidotic
–excessive H+ in blood is pushed into cells in exchange for K being brought out of cells

high K in blood is seen by the kidneys, so kidney puts K into urine

when you correct the pt’s acidosis, the H+ goes back into the blood, and K tries to go back into cells
–> profound hypokalemia

404
Q

what is the normal safe upper limit of K administration in a normal vs DKA pt

A

normal pt:
10 mEq/hr = 24 mEq/day

DKA pt :
20 mEq/hr = 480 mEq/day

405
Q

what lab abnormality are you likely to see after a crush injury

A

hyperkalemia

adding K to the blood via:

  • -crushed/killed cells
  • -blood transfusions (hemolysis in the blood bank as blood ages)
  • -acidosis with H+ moving into cells
406
Q

how do you manage dangerous hyperkalemia 2/2 crush injury

A

dangerous hyperkalemia >6

hemodialysis (long process)

50% glucose and insulin to create momentary anabolic phase (K into cells)

GI tract to remove K (NG suction)- not effective
–Kayaxolate resins: exchange Na for K in lower GI

IV Ca administration: highly effective and protective of myocardium while waiting for hemodialysis

407
Q 
run through metabolic acidosis with pH 7.1
pCO2 36
Na 138
Cl 98
HCO3 15
A

look at pH = acidosis
look at pCO2; low = hyperventilating to try to compensate by breathing faster and removing CO₂ and therefore acid

causes:
either excessive production of acids, insufficient buffering from HCO3 loss, or inability of kidney to make necessary adjustments
–renal acidosis takes several days to develop
–HCO3 loss: biliary fistula, pancreatic fistula ostomy output, diarrhea
–high H+ production: pt is in a low-flow state (shock, hypotension, not perfusing well, cells using anaerobic metabolism with high lactic acid levels)

408
Q 
how do you manage metabolic acidosis with pH 7.1
pCO2 36
Na 138
Cl 98
HCO3 15
A

correct the underlying problem

this pt needs rehydration to correct the low-flow state so the pt can correct the acidosis

  • -fluid that doesn’t compound the existing acidosis
  • -use LR, a primary volume expander, which also contains a little HCO3

giving HCO3 or a precursor (like acetate/lactate) does not address the volume problem

  • -give HCO3 if pt is losing HCO3 via fistula and doesn’t have enough to buffer
  • -do not give NaHCO3: it makes a ppt
409
Q

run through hypochloremic metabolic alkalosis 2/2 loss of acid gastric juice

A

protracted vomiting of clear gastric contents ~days

need to rehydrate and also correct the metabolic alkalosis
–rarely, provide hydrogen NH4Cl or HCl diluted in amino acid solution (buffers)

410
Q

how do you manage hypochloremic metabolic alkalosis 2/2 loss of gastric acid and juice

A

help the kidney correct the problem

kidney can: bring in NaCl, NaHCO3, or exchange Na/K or Na/H

pt is alkalotic in this scenario (H+ depleted)
–do not want to put H+ into urine or retrieve HCO3-

want to: bring in NaCl or exchange Na for K

  • -give generous KCl to retrieve Na without using HCO3/H+
  • -only works if pt has functioning kidneys
411
Q

when should you use pH monitoring to evaluate esophagus

A

use in pain that cannot be well characterized and cannot be timed

412
Q

how can you dx reflux with pH monitoring

A

if pain coincides w/ low pH: reflux

413
Q

when do you use manometry to evaluate esophagus

A

use if pt has horrible pain w/ every swallow; uncoordinated contractions

414
Q

what is dx in pt who has burning, retrosternal pain and heartburn w/ bending, tight clothes, lying flat;
symptomatic relief with antacids, seems to be progressive; present ~yrs

A

GERD

415
Q

how do you dx GERD

A

endoscopy and biopsy to determine extent of damage

416
Q

how do you manage severe peptic esophagitis

A

surgery is indicated if there’s progression despite strict adherence to PPI meds

417
Q

how do you manage Barret’s esophagus

A

this is pre-malignant
–a Nissen fundoplication only helps with acid reflux

you need intensive treatment directed at acid

  • -PPIs can take care of histological damage, but high doses are required for a long time
  • -may create a carcinoid tumor 2/2 PPI from long-term achlorhydria
418
Q

what is the purpose of each study before esophageal surgery

  • endoscopy
  • manometry
  • gastric emptying study
  • barium swallow
A

endoscopy: evaluate extent of mucosal damage
manometry: evaluate motility

gastric emptying study: evaluate for pyloric obstruction

barium swallow: evaluate location of LE sphincter and GE junction

419
Q

what is dx of pt with difficulty swallowing liquids > solids

A

achalasia of esophagus

420
Q

what type of problem is achalasia

A

functional/motility problem

421
Q

which esophageal problem starts with difficulty swallowing solids

A

mechanical problem

422
Q

what is this a classic story for:

middle aged F who sits up straight when eating; has regurgitation of undigested food, like finding food on a pillow

A

achalasia

423
Q

how do you dx achalasia

A

manometry to assess motility
–establishes that LE sphincter doesn’t relax

(Barium swallow/ endoscopy would both show mega-esophagus, but not the nature of the problem)

424
Q

how do you manage achalasia

A

treat medically with repeat dilations

or surgery with Heller myotomy

425
Q

which esophageal cancer classically develops with history of smoking, drinking, and black race

A

squamous cell carcinoma

426
Q

which esophageal cancer classically develops with long-standing GERD

A

adenocarcinoma

progresses from Barrett’s esophagus

427
Q

how do you dx cancer of esophagus

A

first, Barium swallow to visualize tumor and amount of lumen left to avoid perforation

then CT to determine surgical candidacy

Endoscopy and biopsy

Trans-hiatal esophageestomy for short-term palliation

428
Q

what is tear in mucosa of esophagus 2/2 repeated vomiting and profuse bright red blood

A

Mallory Weiss Tear

429
Q

how do you dx Mallory Weiss tear

A

endoscopy to visualize bleeding point

430
Q

how do you manage Mallory Weiss tear

A

photocoagulation to stop bleeding

431
Q

what is perforation of lower esophagus 2/2 repeated/forceful vomiting with sudden onset of wrenching epigastric pain and lower sternal pain; diaphoretic, febrile, and WBC count

A

Boerhaave syndrome (rare)

432
Q

how do you manage Boerhaave syndrome

A

prognosis depends on timing of dx/tx

begin with gastrographing swallow (water-soluble solution)
–bad quality pictures, but safe if the fluid extravasates (vs harmful high-quality Barium swallow)

Negative gastrography –> Ba swallow study

immediate surgical repair of perforation

433
Q

what is dx in pt with severe, constant, retrosternal pain ~hrs after GI endoscopy;
febrile, diaphoretic, subQ emphysema

A

instrumental perforation of esophagus

434
Q

how do you manage instrumental perforation of esophagus

A

begin w/ gastrographing swallow

  • -positive –> surgical repair
  • -negative –> Ba swallow

Abx and overnight watching if the tear is very small

if the perforation was made ~3 days ago, you need to do an esophageal derivation in the neck (cannot repair now with all of the inflammation)
–derivation at GE junction; and eventual esophageal repalcement

435
Q

what is likely dx in older pt with weight loss, anorexia, and epigastric discomfort

A

stomach malignancy

436
Q

how do you manage a suspected stomach cancer

A

endoscopy and biopsy
–you don’t need a Barium swallow because there’s enough lumen to not require a safety roadmap

if the biopsy shows cancer,
do a CT scan to determine if it’s resectable,
then surgery

437
Q

what is likely dx in pt with protracted colicky abdominal pain; vomiting, hyperactive bowel sounds; progressive distension

A

mechanical obstruction of small bowel

438
Q

what will XR show in mechanical small bowel obstruction

A

distended bowel loops and air-fluid levels

439
Q

what is most likely causes of mechanical bowel obstruction

A

2/2 previous surgery adhesions

440
Q

how do you initially manage mechanical small bowel obstruction

A

since the SB has avoided falling into adhesion trap in the past, it is likely that the bowel can un-trap itself

manage w/ NG suction, NPO, IV fluids, and wait to let the bowel extricate itself

441
Q

how do you manage a partial vs complete small bowel obstruction

A

complete:
typically willing to wait 24 hours before taking to the OR

partial:
typically willing to wait 3-5 days

monitor pt for deadly complication:
bowel becomes wedged/compromised/strangulated
–pt will have early fever/WBC –> constant pain/peritoneal –> peritonitis –> septic shock
–immediate OR if pt begins to develop these signs

442
Q

what is dx in pt with SB obstruction + growing mass that’s no longer reducible

A

strangulated/incarcerated hernia

443
Q

how do you manage strangulated/incarcerated hernia

A

OR
–esp if discolored/strangulated/fever/WBC

operate electively, even if not strangulated, to indefinitely fix problem

444
Q

what is likely dx in pt with protracted diarrhea, bizarre h/o flushing face, expiratory wheezing, prominent JVD?

A

carcinoid syndrome/tumor

445
Q

where is carcinoid tumor likely to be

A

in small bowel / ileum

446
Q

why does a carcinoid tumor produce its particular symptoms

A

carcinoid tumor is serotonin-producing

serotonin is normally deactivated in the liver, but if the pt has liver mets, the serotonin may dump into IVC –> systemic serotonin

  • -R heart damage (JVD)
  • -lungs can deactivate serotonin, so L heart is protected
447
Q

how do you dx carcinoid tumor

A

serum 5-HIAA (byproduct of serotonin breakdown)

448
Q

how do you manage carcinoid tumor

A

remove primary tumor

treat/remove liver mets

tends to be slow growing, so any palliative effort is helpful

449
Q

what is likely dx in young adult w/ anorexia, vague periumbilcial pain –> sharp, severe, constant, well-localized RLQ pain with guarding/rebound tenderness

A

acute appendicitis

450
Q

what will pt labs look like in acute appendicitis

A

mild fever w/ WBC count

L shift neutrophilia

451
Q

how do you dx acute appendicitis

A

based on clinical presentation;

additional lab tests aren’t necessary

452
Q

how do you manage acute appendicitis in a pt before vs after perforation

A

before: emergency appendectomy

after perforation: appendectomy; ICU with prolonged post-op care

453
Q

what are 98% of colon cancers

A

adenocarcinomas (grow out of mucosa)

–can impinge along lumen or bleed

454
Q

how do you dx colon cancer

A

endoscopy and biopsy

start with flexible sigmoidoscopy to evaluate L sided cancer (any doc can do)

then do a full-length colonoscopy for R/L sided cancer
(done by surgeon doing the full colonoscopy)

455
Q

how do you manage colon cancer

A

blood transfusions

CT scan to assess OR candidacy

cancers are often multi-centric

colectomy

456
Q

what is dx in classic pt with anemia + occult blood in stool

A

R sided olon cancer

457
Q

why is impingement unlikely in R sided colon cancer

A

liquid feces + larger lumen

458
Q

what is dx in classic pt with change in bowel habits, constipation, and change in caliber/shape of stool (“toothpaste”); with blood visibly surrounding already-solid feces

A

L sided colon cancer

459
Q

what should you think with villous adenoma in rectum and adenomatous polyps in the descending/sigmoid colon

A

most likely to be malignant:
a pre-malignant condition of Familial polyposis (Gardner’s syndrome)
–it’s ~100% predictive to progress to cancer
–should do proctocolectomy

next most likely to be malignant: villous adenoma

  • -50% progress to cancer
  • -should do resection

next most likely: adenomatous polyp:

  • -remove, often endoscopically
  • -surgery if sessile

no malignant potential: Juvenile polyps, Peutz Jehgers, or inflammatory/hyperplastic polyps
–no surgery is necessary

460
Q

what are the indications for surgery in chronic ulcerative colitis

A

> 20 yrs of UC = risk of malignancy

low weight
many hospitalizations (interfering with nutritional status or lifestyle of pt)

needing long-term steroids to control disease

toxic megacolon (abdominal pain, fever, distended transverse colon)
--emergency
461
Q

what determines need for surgery in ulcerative colitis

A

surgery depends on extent of disease

  • rectal mucosa will always be removed
  • ileoanal anastomosis or ileostomy
462
Q

what is likely dx in pt with watery diarrhea, crampy pain, febrile, WBC, and usually told specific Abx treatment (esp taking clindamycin)

A

pseudomembranous enterocolitis 2/2 Clostridium difficile

463
Q

how do you dx pseudomembranous colitis 2/2 C diff

A

stool cultures (takes time)

proctosigmoid scope exam (helpful if disease is severe)

best: toxin in stool with kit (rapid)

464
Q

how do you manage pseudomembranous colitis 2/2 C diff

A

stop offending Abx

do not use anti-diarrheal (keeps toxin in GI)

some docs prefer vancomycin or metronidazole or replenish normal flora

465
Q

what does the management of anal/rectal problems always begin with

A

always begin with r/o cancer
–never prescribe meds over the phone

do rectal exam and proctosigmoid exam to r/o cancer

466
Q

what is likely dx in BRB after bowel movement; painless

A

internal hemorrhoids

467
Q

how do you manage internal hemorrhoids

A

rubber band ligation or laser/destruction

468
Q

what is likely dx in painful perianal area w/o blood

A

external hemorrhoids

469
Q

how do you manage external hemorrhoids

A

formal operation w/ anesthesia

470
Q

what is dx in pt w/ severe pain with defecation and blood streaks, causing them to avoid BMs and not allow a PE

A

anal fissure

471
Q

what is anal fissure thought to be caused by

A

thought to be 2/2 tight sprinter tone, causing limited blood supply, and unable to heal the tears

472
Q

what is management of anal fissure

A

first examine pt to r/o cancer
–likely have to do under anesthesia since pt might refuse a painful PE

manage conservatively:

  • -stool softeners and topical agents
  • -nitroglycerin cream to relax sphincter

surgical management:
–lateral internal sphinterotomy, forceful dilation, Botox injections to paralyze sphincter

473
Q

what should you suspect in a pt w/ h/o operation making a perianal fistula worse, causing an unsealing ulcer and purulence

A

Crohn’s disease affecting the anus

474
Q

how should you manage crohn’s disease affecting the anus

A

rectal endoscopy exam to r/o necrotic cancer

475
Q

what is likely dx in pt saying it’s painful to sit or have BM, fever/chills; hot, tender, red defluction mass between anus and ischial tuberoscity

A

anorectal abscess

476
Q

how should you manage anorectal abscess

A

r/o cancer or a fun gating tumor

drain all abscess with I&Ds

477
Q

what should you think in a diabetic/immunocompromised pt with an anorectal abscess

A

if pt is diabetic/immunocompromised: the abscesses tend to be the beginning of necrotizing fasciitis
–treat with close F/U over next few hours to monitor the development of a soft tissue infection

478
Q

when will an anal fistula develop

A

only in pts who have previously had ischial rectal abscess drainage

the abscess bacteria comes from anal crypts of the anal canal
drained through skin of perineum
epithelial migration
tract formation

479
Q

how will an anal fistula pt present

A

pt must have previously had an ischial rectal abscess drainage

fecal streaks soiling underwear

PE shows perianal opening in skin and cord-like tract palpated from opening to inside

480
Q

how do you manage anal fistula

A

r/o cancer

then surgery to to unroof the fistula so granulation tissue can fill in the tunnel

481
Q

what is dx in blood coating the outside of stool + changed bowel habits

A

sigmoid adenocarcinoma

482
Q

where does sigmoid adenocarcinoma metastasize to

A

metastasis only to Lymph nodes inside abdomen

483
Q

what is dx more likely in an HIV+/homosexual pt (no viral connection)
grows close to anal canal opening; often felt as mass protruding from anus

A

squamous cell carcinoma of anus

484
Q

where does squamous cell carcinoma of anus metastasize to

A

metastasizes to lymph nodes inside abdomen (like sigmoid adenocarcinoma),
but ALSO GROIN NODES

485
Q

how do you dx and manage squamous cell carcinoma of anus

A

dx: biopsy the mass

manage: best to first shrink before surgery
- -Nigro protocol: combo of chemo + radiation
- -+/- resection if necessary

486
Q

where are pts likely to be bleeding from in a GI bleed, statistically

A

75% pts are bleeding from upper GI
(nose to Ligament of Trietz in duodenum)

25% of pts are bleeding from distal GI tract
(mainly colon)

487
Q

which location of bleed is common in younger vs older pts

A

upper GI: common in younger pts

lower GI: common in older pts (except hemorrhoids)
–elderly = equal opportunity bleeders

488
Q

what are 5 things possibly causing a lower GI bleed

A

hemorrhoids, polyp, cancer, angiodysplasia, diverticulosis

489
Q

what does vomiting blood tell you

A

upper GI bleed

490
Q

how do you identify upper GI bleed site

A

endoscopy easily identifies an upper GI bleed site

–blood goes away as soon as you pass lesion

491
Q

how do you manage upper GI bleed

A

stop bleeding with photocoagulation

492
Q

what does a GI bleed with an NG tube w/ clear green fluid w/o blood mean

A

the fluid contains bile; you’ve sampled the duodenum

you can r/o it as a source of bleeding

493
Q

what does a GI bleed with an NG tube w/ clear white fluid w/o blood mean

A

you can r/o the tip of the nose to the pylorus as a source of bleeding
–could still be in duodenum

494
Q

when is a lower endoscopy/colonoscopy not helpful in locating a GI bleed

A

if the pt is presently and significantly bleeding

–it’s too bloody distal to the lesion

495
Q

what imaging is helpful to r/o hemorrhoids

A

anoscopy

496
Q

what imaging is helpful in >=2cc/min GI bleeding

A

arteriogram

497
Q

how do you calculate the extent of GI bleeding

A

calculate how often you’re perfusing to keep stable vitals

2cc/min = 120cc/hr = every 4 hours a unit of blood is required

<5cc/min = every 16 hours a unit of blood is required (no arteriogram)

498
Q

when can you perform a colonoscopy to evaluate a small bleed <5cc/min

A

after bleeding as stopped

499
Q

what study can be done to evaluate “in-between” bleeds of 0.5-2cc/min

A

tagged RBC study

500
Q

who does a tagged RBC study work to show where GI bleed is

A

can give rough indication of which side for hemicolectomy

some docs always order this before an arteriogram

some docs skip this and go straight to arteriogram

  • -pt has stopped bleeding by the time you get results back
  • -no guarantee the arteriogram will work, though
501
Q

what imaging is helpful if the pt last bled 2 days ago from GI bleed

A

double endoscopy

tagged RBC or arteiogram is useless

502
Q

what is dx in young child w/ bloody BM

A

Meckel’s diverticulum

503
Q

what test can you do to dx Meckel’s diverticulum

A

radioactively labeled Technetium scan to identify gastric mucosa

504
Q

what is dx in pt with multiple shallow furiously bleeding ulcers in gastric mucosa 2/2 complicated ICU course

A

stress ulcers

505
Q

how do you dx and manage stress ulcers

A

dx: endoscopy

prefer to prevent vs tx
–ICU pts get H2 blockers, antacids, or both

manage:
radiologic angiogram to selectively catheterize stomach blood supply (L gastric artery)

506
Q

what is the generic/broad ddx of acute abdominal pain

A

perforation
obstruction
inflammatory process

507
Q

what classically presents as sudden onset, constant severe pain that is GENERALIZED

A

abdominal perforation

508
Q

what is the most common abdominal perforation

A

duodenal ulcer perforation

509
Q

what is dx in pt who lies motionless to avoid pain in abdomen and PE elicits extreme peritoneal irritation (pain to palp, guarding, rebound tenderness); and absent bowel sounds

A

abdominal perforation

510
Q

how do you manage abdominal perforation

A

r/o other things before arriving at perforation

first: CXR to r/o lower lobe pneumonia

EKG for coronary ischemia

plain abdominal XR for free air perforation, ureteral stone

amylase for pancreatitis

then, immediate ex lap

511
Q

what is classic dx for sudden onset of pain, colicky, that is localized w/ associated radiation

A

abdominal obstruction

stone in ureter, cystic duct, common duct, or small bowel lumen

512
Q

what is dx in pt who is moving around looking for positional comfort and PE localizes to the problem

A

obstruction

513
Q

what is most likely in female, fat, forty, fertile

A

gall stones

stones could be asymptomatic
low rate of conversion –> symptomatic

514
Q

what is typical PE in biliary tract disease

A

severe RUQ colicky pain that radiates to R shoulder towards back, N/V that turns into constant pain

PE will show tender to palp, guarding/rebound
mild fever and WBC

515
Q

what is abdominal pain that quickly resolves with OTC meds, often 2/2 fatty foods; and no residual findings after pain subsides

A

biliary colic

no residual findings afters stone falls back

516
Q

how do you manage biliary colic

A

cholecystectomy to prevent further episodes

517
Q

what is abdominal pain that persists to constant, localized pain with fever and WBCs;

A

acute cholecystitis

518
Q

how do you dx acute cholecystitis

A

sonogram to show stones
thickened gallbladder wall
pericholecystic fluid

rarely, and inconclusive US will cause you to do a HIDA scan

HIDA scan shows bile flow NOT in the gallbladder

519
Q

how do you manage acute cholecystitis

A

anticholinergics do not resolve symptoms

typically tx w/ medical management, including NG suction, NPO, Abx, and IV fluids

then do an elective cholecystectomy

520
Q

what is likely dx in pt with abdominal pain and highly elevated Alkaline Phosphatase

A

Ascending cholangitis

pt will be very sick- high 104 fever, high WBC

521
Q

what causes ascending cholangitis

A

partial obstruction from a stone that allows an ascending infection

522
Q

how do you manage ascending cholantigis

A

emergency

IV Abx, hospitalization, decompress biliary tract with ERCP
catheter above the stone to drain the duct; percutaneous PTC

523
Q

how does a stone cause acute pancreatitis

A

stone stuck at ampulla of Vater

occludes both common bile duct and pancreatic duct

524
Q

what is dx in pt with sudden onset flank pain, radiates to thigh/scrotum; and microhematuria

A

ureteral stone

525
Q

how do you dx ureteral stone

A

IV pyelogram, sonogram, CT scan

526
Q

what is dx in elderly pt w/ abdominal distension, N/V, no flatus/BM, tympanic abdomen, and hyperactive bowel sounds

A

sigmoid volvulus

527
Q

what does sigmoid volvulus XR show

A

distended loops w/ air fluid levels and “bird beak” sign

528
Q

how do you manage sigmoid volvulus

A

proctosigmoid exam
try to untwist bowel and leave long rectal tube to prevent coil

surgery may be indicated

529
Q

what is likely dx in elderly pt w/ A fib or a recent MI now presenting with an acute abdomen

A

mesenteric iscemia

530
Q

how does a recent MI or A fib cause mesenteric ischemia

A

embolus occluding SMA

531
Q

how is the bowel affected in an SMA occlusion

A

distension up to transverse colon

532
Q

what does a sick pt with acute abdomen and acidosis likely have

A

mesenteric ischemia that has progressed to a dead bowel

533
Q

how do you manage mesenteric ischemia

A

ex lap to resect dead bowel

call vascular surgeon ASAP to try arteriogram to prevent irreversible necrosis

534
Q

what is dx in pt with gradual onset of abdominal pain, which builds up to maximal intensity in 2-12 hrs; constant, and localized

A

some sort of inflammatory process

535
Q

what generic dx will have an abdominal exam showing peritoneal, but localized; and likely signs of systemic inflammation (fever, WBC)

A

abdominal inflammatory process

536
Q

what presents with ascites + vague acute abdomen

A

bacterial hematogenous peritoniits

537
Q

how do you dx and manage bacterial hematogenous peritonitis

A

sample ascites for culture

then tx

538
Q

what is dx in alcoholic pt with abdominal pain that radiates to back w/ N/V

A

pancreatitis

539
Q

how do you dx pancreatitis, depending on when pt presents

A

serum amylase/lipase if recent onset

urinary amylase/lipase if seeing the pt 3 days later

540
Q

what is dx in pt with abdominal pain with: inflammatory mass; LLQ pain; pain building up to a constant, localized pain; with fever and WBC

A

diverticulitis

541
Q

what is the blood marker for HCC

A

alpha-fetoprotein

542
Q

what is alpha-fetoprotein a blood marker for

A

HCC

543
Q

who gets HCC

A

only seen in pts who already have cirrhosis

544
Q

what is the most common liver cancer in the US

A

metastatic cancer to the liver

20:1 metastatic in the US

545
Q

where does liver mets likely come from

A

h/o colon cancer

546
Q

what is blood marker for liver mets

A

carcinogenic antigen CEA

547
Q

what is carcinogenic antigen (CEA) a blood marker for

A

liver mets

548
Q

how do you manage liver cancer

A

CT to evaluate extent of tumor

attempt surgical resection or radioablation

549
Q

what is commonly seen in females on chronic birth control

A

hepatic adenoma

550
Q

what presents in a female on birth control with sudden abdominal pain that leads to faint, pale, tachy, hypotensive, and mildly distended/tender abdomen

A

hepatic adenoma

birth control can develop hepatic adenomas with tendency to bleed

551
Q

how do you dx and manage hepatic adenoma

A

dx w/ CT scan to show adenoma

tx with surgical resection
–not common and not an indication for a female to discontinue OCPs

552
Q

what is likely dx in late-pregnancy female who suddenly experiences shock

A

visceral aneurysm of hepatic artery bleeding into abdomen

553
Q

what type of liver abscess is a complication of biliary tract disease

A

pyogenic liver abscess

554
Q

how do you manage pyogenic liver abscess

A

needs drainage (percutaneous)

555
Q

what type of liver abscess will commonly present with a “Mexico connection”, likely in a M

A

amoebic liver abscess

556
Q

what do labs look like for amoebic liver abscess

A

fever, WBC, tender over liver, jaundice, elevated Alk phos

557
Q

what will sonogram show in amoebic liver abscess

A

normal biliary tree and liver abscess

558
Q

how do you dx and manage amoebic liver abscess

A

dx: serology (requires time for pt to develop antibodies)

manage:
empiric tx w/ metronidazole
drain if pt is not responding to Abx and the abscess is growing
do not draw pus to send to lab for growth; the amoeba grows from the wall of the abscess

559
Q

what type of jaundice gives you:

mild 6-10 Bil elevation with almost ALL INDIRECT (not being processed by liver)

A

hemolytic jaundice

560
Q

what is your work up geared toward with a mid Bil elevation that’s almost all indirect

A

this is hemolytic jaundice, so you should direct your focus on what’s destroying the RBCs

561
Q

what type of jaundice gives you:
both high Bil’s
very high transaminases
only modest elevation of Alk Phos

A

hepatocellular jaundice (hepatitis)

562
Q

what should your work up be directed at with very high transaminases

A

identifying the type of hepatitis the pt has

563
Q

what type of jaundice gives you:
classically both high Bil’s (direct is high in early cases)
mildly high transaminases
very high alk phos

A

obstructive jaundice

564
Q

what should your work up be directed at with very high alk phos

A

sonogram to identify where the obstruction is

565
Q

what is the quick/obvious jaundice answer when labs show:

elevated Bil that is all indirect

very high transaminases

very high alk phos

A

indirect Bil = hemolytic jaundice

transaminases = hepatocellular

alk phos = obstructive

566
Q

what type of obstruction occurs when the gallbladder is contracted, thick-walled, and full of stones

A

benign obstruction

567
Q

what are the next steps after you identify a benign gallbladder obstruction

A

ERCP and sphincterotomy to retrieve stones

then cholecystectomy to prevent more stones

568
Q

what type of obstruction occur when the gallbladder is nontender, distended, and thin-walled

A

malignant obstruction

cancer of the pancreas, common duct, or ampulla of Vater/hepatopancreatic duct

569
Q

what is the next step after a malignant gallbladder obstruction has been identified

A

CT scan to determine cancer location

570
Q

what type of pancreatic cancer will be symptomatic

A

pancreatic cx will be advanced if it’s big enough to be symptomatic

571
Q

what does a negative CT scan in a malignant gallbladder obstruction mean

A

a negative CT scan = small cancer of pancreatic head, cholangiocarcinoma, or ampulla of Vater carcinoma

next = ERCP

572
Q

what gives you apple core appearance on ERCP

A

cholangiocarcinoma

573
Q

what are the next steps after dx cholangiocarcinoma

A

brushings to obtain cytologic confirmation

whipple procedure (relatively curable, vs pancreatic tumor)

574
Q

what gives you a slightly anemic pt with blood in GI lumen and evidence of malignant gallbladder obstruction

A

ampullarf cancer

575
Q

how do you manage ampullary cancer

A

CT scan will unlikely show this small cancer

endoscopy (not ERCP) to see the tumor, biopsy it, and confirm dx

easily resectable

576
Q

what gives you evidence of malignant gallbladder obstruction, growing into retroperitoneum w/ milk pain deep to epigastrium and upper back; possibly w/ FHx

A

pancreatic head cancer

577
Q

what are your next steps after suspecting pancreatic head cancer

A

first: sonogram
next: CT shows big cancer (big enough to be symptomatic)

percutaneous biopsy

palliative biopsy

578
Q

what is dx in alcoholic pt with abdominal pain

A

acute pancreatitis

579
Q

how do you dx acute pancreatitis

A

blood or urine amylase / lipase

580
Q

when does serum vs urine elevation occur in acute pancreatitis with amylase / lipase

A

serum elevation occurs 12hrs - 2 days after onset of symptoms

urine elevation occurs 2- 5 days after onset of symptoms

581
Q

what is dx when pt has plasma deposited around pancreas

A

benign edematous pancreatitis

582
Q

how do you dx benign edematous pancreatitis

A

dx with a high Hct (hemoconcentrated blood)

plasma has been removed from the blood and deposited around the pancreas

583
Q

how do you manage benign edematous pancreatitis

A

NPO, NG suction, IV fluids

pt will improve

584
Q

which pancreatitis is diagnosed with a low Hct

A

Hemorrhagic pancreatitis (losing blood)

585
Q

what is used to calculate the prognosis of hemorrhagic pancreatitis

A

Ranson’s Criteria

586
Q

what is happening with lab values in bad hemorrhagic pancreatitis

A 
the Hct is continuing to drop
low serum Ca
high BUN
metabolic alkalosis
low pO2
high blood glucose
587
Q

how do you treat hemorrhagic pancreatitis

A

intensive ICU support and expect lots of complications

588
Q

what is concerning for oncoming death in hemorrhagic pancreatitis

A

pancreatitis abscess development often means death is coming

you have a destroyed, necrotic, hemorrhagic gland

589
Q

what should be done daily to monitor hemorrhagic pancreatitis

A

daily CT scans to find the earliest indication of pus collection

drain the abscesses immediately as the only hope to survive

590
Q

what is dx in pt with chronic epigastric pain that radiates to back for ~yrs.
pt may also have DM, steatorrhea, malnourishment, alcoholism
pt typically has no job, family, home, and frequents ER for pain control

A

chronic pancreatitis

591
Q

what does XR show in chronic pancreatitis

A

upper abdominal Ca

592
Q

why can amylase no longer be used in dx of pancreatitis in chronic pts

A

pt has a history of continuing to drink after alcoholic pancreatitis –> destroyed pancreas

593
Q

how do you tx chronic pancreatitis

A

attempt to control DM, pancreatic enzymes for steatorrhea, but the pain isn’t well treated

ERCP to drain pancreatic duct

total pancreatectomy: usually die 2/2 extremely poorly controlled DM

594
Q

what is dx in pt with ill-defined upper abdominal discomfort, early satiety, and h/o recent d/c from hospital for pancreatitis tx

A

pancreatic pseudocysts

595
Q

what will PE show in pancreatic pseudocysts

A

large epigastric mass deep in the abdomen

596
Q

what is dx in pt with vague upper abdominal discomfort, early satiny, and h/o recent MVC hitting the steering wheel

A

pancreatic pseudocysts

597
Q

how long is the “incubation” period for pancreatic pseudocysts

A

typically ~5 weeks between trauma/pancreatitis and fluid collection/pressure

598
Q

what causes pancreatic pseudocysts

A

trauma/pancreatitis leading to pancreatic juice leaking out of duct and collecting nearby

599
Q

where is the classic collection site for pancreatic pseudocyst fluid

A

lesser sac

600
Q

how do you dx pancreatic pseudocysts

A

sonogram or CT showing fluid collection

601
Q

how do you manage pancreatic pseudocysts based on 4 outcomes

A

careful monitoring w/imaging for resolution

spontaneously resolve:
–go away within 6 weeks

deadly complications typically happen >6 weeks later

  • -rupture into peritoneal cavity –> massive fulminating peritonitis
  • -erode into major vessels –> bleeds and exsanguinate
  • -infected juice 2/2 arterial infection; pseudocyst–> pancreatic abscess –> death

endoscopic internal drainage by gastroscopy:
–create a cystogastrostomy that can drain it without a fistula (via perc drain)

602
Q

what is the standard recommendation for any hernia

A

repair electively to prevent possible incarceration/strangulation of bowel

603
Q

what is the exception for fixing hernias

A

umbilical hernia <2yo child

will resolve/close spontaneously

604
Q

what is recommendation for sliding esophageal hernia

A

not an actual hernia;
not an indication for surgery itself,
but paraesophageal hernia is indicative for surgery

605
Q

what does breast disease management always begin with

A

r/o cancer

606
Q

what is the only way to certainly r/o or dx breast cancer

A

pathology report

clinical/radiology can only suspect cancer

607
Q

what are the 5 types of breast biopsies from least to most invasive

A

least invasive:
FNA cells from mass, cytology

core biopsy: needle collects cores of tissue

mammotome to obtain bigger mass

incisional bx in the OR

most invasive:
excision biopsy (remove the entire suspicious mass)
608
Q

what does the extent of breast biopsy depend on

A

depends on clinical suspicion

609
Q

what is the most important factor for clinical suspicion of breast pathology

A

age

610
Q

what method would you use in a young person vs middle-aged to r/o breast pathology

A

young: non-invasive r/o measures

middle aged: either a core biopsy or bigger biopsy; may not even stop until an excision biopsy is done

611
Q

what should your clinical suspicion be in a female pt with recent trauma to breast

A

do not allow recent trauma to r/o potential dx of cancer by assuming it’s fat necrosis or a hematoma

–still need mammogram and tissue sampling

612
Q

what is the role of a mammogram

A

does not dx cancer of the breast
it detects potential/probable cancer that’s too small to be palpated
–always done first is mass is found on exam in a F >30yo

613
Q

what is description of irregularities suspicious for cancer

A

irregular density
no sharply demarcated borders
fine microcalcifications
recent finding (not present on mammogram ~2yrs ago)

614
Q

what are 2 contraindications for mammogram

A

<20yo (dense breast tissue won’t allow pathology visualization)

lactating (only see milk)

615
Q

can you do a mammogram during pregnancy

A

YES!

616
Q

what is dx in young F with rubbery mass; easily movable

A

fibroadenoma

617
Q

what is the term for a quickly growing fibroadenoma

A

giant juvenile fibroadenoma

618
Q

what is work up for fibroadenoma suspicion

A

FNA/sonogram to confirm dx of fibroadenoma

+/- remove mass depending on pt preference

619
Q

what is dx in late 20s F with a mass, typically long history, grows big, remains movable; no axillary involvement

A

cystosarcoma phyllodes

620
Q

what is management of cystosarcoma phyllodes

A

removal is mandatory; malignant potential

621
Q

what is dx in 20-40yo F with painful cyclical lumps that come/go

A

fibrocystic disease: mammary dysplasia, cystic mastitis

622
Q

how do you manage fibrocystic disease

A

mammogram for baseline picture and cyst visualization

if cyst becomes firm and doesn’t go away with cycle:

  • -aspiration of cyst (not FNA) to remove cystic fluid
  • -retrieve clear fluid and mass disappears: you’re done
  • -retrieve blood fluid: send for cytology
  • -if mass doesn’t go away/quickly returns: needs formal tissue sampling/bx
623
Q

what is dx in F with blood discharge from nipple w/o palpable masses

A

intraductal papilloma

624
Q

what is a small benign tumor 2-3mm that grows inside breast duct

A

intraductal papilloma

625
Q

how do you manage intraductal papilloma

A

need to r/o carcinoma possibility

  • -mammogram first
  • —lesion = probably cancer; need bx

can see with galactogram or retroareolar surgical exploration: remove that section of breast

626
Q

what is the pt presentation that is only acceptable in a lactating F

A

crack in nipple with red, hot, tender mass in breast with fever and WBC

otherwise, assume it’s cancer until proven benign

627
Q

how do you manage a F with cracked nipple, red, hot, tender mass in breast with fever and WBC

A

r/o cancer, but no point in a mammogram if the F is lactating (only see milk)

need I&D, but also take small sample from the wall to path to r/o infected cancer

628
Q

what are the 2 limitations of pregnancy and breast cancer

A

cannot give chemo in 1st trimester of pregnancy

cannot give radiation at any time during pregnancy (diagnostic XRs are ok)

not necessary to terminate pregnancy

629
Q

what is dx in classic orange peel / retracted skin with red/swollen breast

A

inflammatory breast cancer

630
Q

what is prognosis and management of inflammatory breast cancer

A

lethal

manage w/ mammogram, tissue sampling, pre-op chemoradiation

631
Q

what is dx in F with hard mass under nipple causing nipple retraction

A

desmoplastic rxn of breast cancer

632
Q

how do you manage desmoplastic rxn of breast cancer

A

mammogram, generous tissue sampling

633
Q

what is dx of non-palpable eczematous lesion in areola of F not improved w/ lotions

A

Paget’s disease of breast

it’s infiltrative under areolar tissues

634
Q

how do you manage Paget’s disease of breast

A

mammogram, biopsy, then proceed

635
Q

what is dx in mass in axilla; discrete, hard, movable, and a negative breast PE

A

breast cancer metastatic to axilla

636
Q

how do you manage metastatic breast cancer to axilla

A

mammogram needed to show primary tumor; then proceed

if negative, biopsy and remove the axillary lymph node

637
Q

how should you manage incidental micro calcifications off mammogram

A

tissue biopsy,
core biopsy by radiologist 8-12 samples
surgical removal w/ wire guidance for path

638
Q

what are your management options for breast cancer after dx

A

lumpectomy + radiation

modified mastectomy

axillary sampling

also need to look for signs of systemic metastasis

639
Q

when is lumpectomy + radiation indicated

A

relatively small cx compared to breast ratio and far from nipple
–also need axillary sampling

640
Q

when is modified mastectomy indicated

A

relatively large cx compared to breast ratio or near the nipple

  • -includes axillary sampling
  • -no radiation necessary
641
Q

how is axillary sampling conducted

A

different from axillary dissection

axillary sampling = sentinel node biopsy
–inject radioactive material into tumor; migrate via lymph; trapped by 1st LN –> biopsy that LN

642
Q

what are the 2 breast cancers that call for a special management, and what is it

A

inflammatory carcinoma of breast
or Carcinoma in situ

pre-op radiation/chemo before surgical resection

643
Q

how do you manage/ what should you suspect in h/o breast cancer w/ recent onset HAs

A

need CT san looking for brain mets
resect any resectable brain mets
TNM classification

644
Q

how do you manage/ what should you suspect in h/o breast cancer w/ recent onset back pain

A

need radio bone scan (sensitive, not specific)
–positive –> XR to see it light up; or consider other causes (fracture; arthritis)

manage bone mets with radiation, ortho stabilization, braces, etc

645
Q

what are 4 rules for systemic tx of breast cancer

A

any pt with positive axillary lymph nodes

premenopausal pts: prefer chemotherapy

postmenopausal pts: prefer hormonal therapy (Tamoxifen), esp if ER/PR positive

give chemo to everyone who already has obvious metastasis (liver, bone, brain)

646
Q

how do you manage ductal carcinoma in situ

A

standard recommendation: simple total mastectomy

  • -offers 100% cure
  • -not yet capable of metastasis
  • -axillary examination is not needed
647
Q

how do you manage thyroid masses based on biopsy results

A

negative: leave alone
positive: operate to remove tumor (most are benign)

indeterminate: operate

648
Q

what is dx in pt who is losing weight, big appetite, heart palps, heat intolerance, thin, fidgety, diaphoretic, tachy

A

hyper functioning thyroid adenoma- “hot” –> hyperthyroidism

649
Q

how do you dx and manage hyperthyroidism

A

high free T4 or low TSH

localize with radioactive iodine scan

  • -surgically resect the isolated area
  • -or radioactive iodine tx if whole thyroid lights up
650
Q

what is dx in lateral mass near thyroid

A

metastasis from follicular carcinoma of thyroid that has completely replaced a lymph node

651
Q

how do you manage metastatic follicular carcinoma of thyroid

A

thyroid scan to identify primary tumor

then surgery

652
Q

what is dx in pt with high serum Ca and low serum P

A

hyperparathyroidism

653
Q

how does hyperparathyroid pt present

A

“stones, bones, moans, psychiatric overtones”

nephrolithiasis
cystic bone lesions
GI complains w/ pancreatitis
peptic ulcer
constipation
psych
654
Q

how do you dx hyperparathyroidism

A

verify primary hyperPTH with simultaneous high serum Ca

655
Q

what are most hyperparathyroid conditions

A

90% are adenomas (vs hyperplasia)

656
Q

how do you tx primary hyperparathyroidism

A

remove offending adenoma
–localize with Sestamibi, sonogram, CT scan prior to surgery

–high rate of conversion, so you should treat even if pt is asymptomatic

657
Q

what is dx in pt who goes pretty –> monster (lolz)

A

cushing

658
Q

what is dx in pt with round face, acne, hair, hump, supraclavicular fat pads, thin extremities, truncal centripetal obesity w/ striae

A

cushing

659
Q

what should you think in a pt with HTN, DM, osteoporosis, amenorrhea, wide mood swings +/- psych service

A

cushing

660
Q

how do you work up cushing

A

measure AM and MP cortisol (high; and no longer diurnal variation)

Dexamethasone tests

661
Q

what is dx in pt whose cortisol is suppressed with small dose of dexamethasone

A

does not have Cushing’s

662
Q

what is dx in pt whose cortisol is not suppressed with low-dose dexamethasone

A

Cushing’s

don’t know location/cause yet

  • -could be pituitary adenoma –> both adrenals
  • -or adenoma in adrenal –> cortisol
663
Q

what is dx in pt whose cortisol suppresses at high doses of dexamethasone

A

ACTH-secreting pituitary micro-adenoma

664
Q

what is dx in pt whose cortisol does not suppress at high doses of dexamethasone

A

adrenal or extra-adrenal cortisol production

665
Q

depending on your Dex results, what is your next step

A

MRI of pituitary or CT of adrenals

–remove the offender

666
Q

what is dx in pt with gastronoma of pancreas or duodenum

A

Zollinger-Ellison syndrome

667
Q

what is dx in pt with extremely virulent PUD that does not respond to normal therapy + watery diarrhea

A

Zollinger Ellison syndrome

–gastrinoma

668
Q

what is work up up for Zollinger Ellison syndrome

A

measure serum gastrin
CT scan of pancreas/duodenum to see primary tumor
resect the gastronoma

669
Q

what is ddx for hypoglycemia

A

terminal stage liver failure, retroperitoneal sarcoma

insulinoma

reactive hypoglycemia

injecting insulin

670
Q

what is dx in pt who gets a hypoglycemic attack during fasting (skip breakfast; late for lunch)

A

insulinoma

671
Q

what will labs be in insulinoma

A

endogenous insulin = high C peptide + high insulin

672
Q

what is dx in pt who gets hypoglycemia attack after a big meal

A

reactive hypoglycemia (pancreas overreacts)

673
Q

what are labs in reactive hyoglycemia

A

endogenous insulin - high C peptide + high insulin

674
Q

what is dx in pt who gets hypoglycemia attack and has knowledge of how insulin works

A

injecting insulin

refer pt to psych to determine motivation of action

675
Q

what will labs look like for a pt injecting insulin

A

exogenous insulin = low C peptide + high insulin

00Step 2 (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions