Surgery Rotation 1 Flashcards
What is the problem and presentation of polycythemia vera
Mainly proliferation of RBCs
Presentation:
♣ Increased blood viscosity
• Plethora (flushed face)
• Transient blurred vision
• Headache
• Erythromelalgia (severe, burning pain and red-blue coloration in the extremities due to episodic blood clots in vessels of extremities)
♣ Thrombosis (e.g Budd Chiari)
♣ Bleeding
♣ Itching after bathing (aquagenic pruritis)
♣ Gouty arthritis due to increased RBC turnover
♣ Splenomegaly
Treatment of polycythemia vera
♣ Phlebotomy
♣ Hydroxyurea (if increased risk of thrombus)
What is essential thrombocythemia + presentation
o Mainly a proliferation of platelets o JAK2 kinase mutation o Presentation: ♣ Increased bleeding – dysfunctional platelets ♣ Thrombosis – too many platelets
What is myelofibrosis and findings
o Obliteration of bone marrow with fibrosis due to increased fibroblast activity
o JAK2 kinase mutation
o Findings:
♣ “Teardrop” RBCs – due to marrow fibrosis
♣ Splenomegaly – extra-medullary hematopoiesis
Is EPO high or low in polycythemia vera
o Increased red cell mass, without elevated EPO (unlike other causes of erythrocytsosis)
Cause and presentation of thrombotic thrombocytopenic purpura (TTP)
o Platelets used up in pathologic formation of microthrombi in small vessels
o Due to decreased ADAMTS13, enzyme that normally cleaves vWF for degradation
♣ No vWF degradation = abnormal platelet adhesion = microthrombi
o Findings (Pentad):
♣ Thrombocytopenia = platelets being used up
♣ Microangiopathic hemolytic anemia = RBCs sheared by microthrombi
♣ Renal insufficiency (thrombi involve vessels of the kidney)
♣ Neurological symptoms (confusion, HA, seizures, coma) – thrombi involve vessels of CNS
♣ Fever
Cause and presentation of hemolytic uremic syndrome
o Platelets used up in pathologic formation of microthrombi in small vessels
o Commonly caused by Shiga toxin-producing E. Coli O157:H7 (STEC)
♣ Accompanied with diarrhea
o Findings (triad):
♣ Microangiopathic hemolytic anemia
♣ Renal insufficiency (thrombi involve vessels of the kidney)
♣ Thrombocytopenia
What causes metabolic acidosis
• Anion gap Adding acid to the blood o MUDPILES: ♣ M – Methanol ♣ U – Uremia (renal failure) ♣ D – Diabetic ketoacidosis ♣ P – Propylene glycol/Paraldehyde ♣ I – Isoniazid/Iron ♣ L – Lactic acidosis ♣ E – Ethylene glycol (antifreeze) ♣ S – Salicylates (aspirin) • Non-anion gap Losing excessive HCO3- o Diarrhea, Renal tubular acidosis, Spironolactone, Acetazolamide
What causes metabolic alkalosis
♣ Causes: • Losing H+ excessive vomiting, diuretics, hyperaldosteronism ♣ Differential of metabolic alkalofis (pH > 7.45; HCO3- > 24) • Low urine chloride ♣ Will respond to saline o Vomiting/nasogastric aspiration o Prior diuretic use • High urine chloride o Hypovolemia/euvolemia ♣ Current diuretic use • Will responds to saline ♣ Bartter & Gitelman syndrome • Saline unresponsive o Hypervolemia ♣ Excessive mineralocorticoid activity o Saline unresponsive • Primary hyperaldosteronism • Cushing disease • Ectopic ACTH production
Fluid given for euvolemic hypernatremia
• Free water supplementation
Fluid given for hypovolemic hypernatrermia (both symptomatic and asymptomatic)
• Non-symptomatic
o 5% dextrose
• Symptomatic
o 0.9% saline (isotonic solution) until Euvolemic, then 5% dextrose (hypotonic solution)
Pathogenesis of DKA
♣ Lack of insulin means glucose cannot get into the cell for glycolysis to make ATP cell instead uses fatty acid beta oxidation which breaks down into ketone bodies
♣ Sodium levels will be low
• Hyponatremia due to sodium loss via diuresis
Will Na+ and K+ be high or low in DKA?
♣ Sodium levels will be low
• Hyponatremia due to sodium loss via diuresis (osmotic diuresis due to increased glucose)
♣ High serum potassium but low total body potassium
• Cells will exchange H+ for K+ causing high potassium
• Potassium in the blood will be excreted cause low total body potassium
IV fluids given to treat DKA
♣ 0.9% normal saline initially
♣ Add dextrose 5% when serum glucose <200 mg/dL
Replacement of one cell type by another
Metaplasia
Abnormal cells, lacking differentiation
Dysplasia
What is atelectasis
Collapse of lung
Ptosis, diplopia, weakness
Myasthenia gravis
Clinical presentation of Lambert-Eaton
- Proximal muscle weakness that improves with use
- Autonomic symptoms (dry mouth, impotence)
- Eyes usually spared
Tumor associated with Lambert eaton
Small cell carcinoma of lung
Clinical presentation of Parkinsons
TRAPS + mask-like facies T - Tremor (resting) R - Rigidity (cogwheel) A - Akinesia P - Postural instability S - staggering gait
What is akinesia
Impairment of voluntary movement
Compare histology of Alzheimers, Frontotemporal dementia, Parkinsons dementia, Lewy Body dementia
Alzheimers - Extracellular beta-amyloid plaques; intracellular neurofibrillary tangles made of tau protein
Frontotemporal dementia - Pick bodies (round aggregates of tau protein)
Parkinsons - Lewy bodies (eosinophilic inclusions of alpha-synuclein) within neurons
Lewy Body dementia - Lewy bodies within the cortex (aggregates of a-synuclein)
What is the striatum and where is it located
Striatum = caudate + putamen
Caudate located lateral to ventricles
Putamen located lateral to globus pallidus
(look up image)
Components of Whipple procedure
- Cholecystectomy
- Truncal vagotomy
- Antrectomy
- Pancreaticoduodenectomy—removal of head of pancreas and duodenum
- Choledochojejunostomy—anastomosis of common bile duct to jejunum
- Pancreaticojejunostomy—anastomosis of distal pancreas remnant to jejunum
- Gastrojejunostomy—anastomosis of stomach to jejunum
What is seborrheic keratosis (gross and histology)
“Stuck on” coin-like plaque
HIstology = keratin pseudocysts
What is actinic keratosis
Hyperkeratotic scaly plaque
Precursor lesion of SCC
Histology = ???
What are the boundaries of the upper GI
Tip of nose to ligament of Treitz
What is the ligament of Treitz
Suspensory ligament connecting the duodojejunal junction to the retroperitoneum (connective tissue surrounding the Celiac artery and SMA)
Steps to find the source of blood per rectum
Could be from upper or lower GI:
1) NG tube to aspirate gastric contents to check for blood - if no blood, then you can exclude tip of nose to pylorus
2) Upper GI endoscopy to exclude duodenum - want to see green fluid (bile tinged)
3) Anoscopy to exclude hemorrhoids (cannot do colonoscopy during active bleeding b/c blood obscures the field)
4a) 1/2 options - angiogram for more severe bleeds
4b) 2/2 options - if less blood, wait until bleeding stops and do a colonoscopy
Most common cause of blood per rectum in a child
Meckel diverticulum
Differential dx of acute abd
Perforation
Obstruction
Inflammatory process
Ischemic process
Most common cause of perforated abd
Perforated peptic ulcer
Difference in gallbladder in obstruction caused by stones vs. malignancy
Stones = dilated ducts with nondilated gallbladder full of stones
Malignancy = large, thin-walled distended gallbladder
Cancers that may cause gallbladder obstruction
- Head of pancreas
- Cholangiocarcinoma (of duct)
- Ampulla of Vater
What is the sphincter of Oddi
Muscular valve that controls the flow of digestive juices into the ampulla of Vater
What are the 3 major openings of the diaphragm
♣ THINK: I ate ten eggs at twelve
• I ate = “I” for IVC and “ate” for T8
• Ten eggs = “Ten” for T10 and “eggs” for esophAGus and vAGus
• At twelve = “At” for AAT (Aorta, Azygous, Thoracic) and twelve for T12
Histological difference between ductal and lobular carcinoma in the breast
Ductal (most common) = Small, glandular, duct-like cells
Lobular = Single file row of cells due to loss of e-cadherin
What disease presents with stones, thrones, bones, groans, and psychiatric overtones
Hyperparathyroidism
Presentation of glucagonoma
Necrolytic dermatitis, diabetes (hyperglycemia), DVT, weight loss, depression
What substances are measured to assess for pheochromocytoma?
Vanillylmandelic acid (VMA), metanephrines, catecholamines
Definition of “-tomy”
To cut
Definition of “-ectomy”
To take out or resect
Definition of “-ostomy”
To make a mouth/opening
Could be from a single organ to the outside (colostomy) or could be an anastomoses between two organs (gastrojejunostomy)
Definition of “-plasty”
To change the shape of something
Definition of “-pexy”
To fix in place
Defintion of “-rrhaphy”
To saw together
Describe the percentage of body surface area when dealing with burns in adults
Rule of 9s:
Head = one 9
Each upper extr = one 9
Trunk = four 9s; two in front and two in back
Each lower extr = two 9s; one in front and one in back
Describe the percentage of body surface area when dealing with burns in kids
Rule of 9s:
Head = two 9s
Each upper extr = one 9
Trunk = four 9s; two in front and two in back
Both lower extr = total of three 9s; 1.5 each
