surgery_nbme_copy_20180426183822 Flashcards
what are you concerned about in a patient with a past history of radiation to the neck?
low dose ionizing radiation exposure (< 2000rad) carries 40% risk of thyroid cancer (MC - papillary ca)
what do you do in a pt who presents with nodule on thyroid with previous history of neck radiation?
proceed straight to thyroidectomy
what is special about diagnosis of medullary thyroid cancer?
AD Inheritance via mutation in RET Oncogene- measure calcitonin levels, if high screen for RET mutation- if mutation found, evaluate for MEN prior to surgery
patient has no identifiable risk factors for thyroid cancer but has a solitary nodule that is not hard nor fixed - what do you do next?
FNAB
when should you remove a cyst from the thyroid gland?
if it is > 4 cm big OR if it recurs several times following aspiration- determined by USG
standard of care for diagnosing thyroid nodules
FNAB
what do you do with a FNAB result of “colloid nodule”
benign result- medical management with thyroid suppression and routine F/U
what do you do with a FNAB result of “papillary carcinoma” or “medullary carcinoma?”
thyroidectomy
psammoma bodies on FNAB of thyroid
marker of papillary carcinoma - do thyroidectomy
amyloid deposits on FNAB of thyroid
suggest medullary cancer - do thyroidectomy
undifferentiated cells on FNAB of thyroid
suggests anaplastic cancer- do either chemotherapy or radiation OR salvage operative therapy
Hurthle cells on FNAB of thyroid
signifies either adenoma or low grade cancer- do lobectomy; if turns out to be cancer, total thyroidectomy indicated
follicular cells on FNAB of thyroid
does not rule out cancer, therefore must do a lobectomy for diagnostic purposes
lymphocytic infiltrate on FNAB of thyroid
suggests either lymphoma or chronic lymphocytic thyroiditis- can differentiate by flow cytometry
tx. of thyroid lymphoma
radiation
tx. of chronic lymphocytic thyroiditis
no surgical tx. necessary- may require thyroid hormone replacement therapy
major serious complications following thyroid surgery
- recurrent laryngeal N. paralysis - hoarseness or cord palsy (bilateral)2. external branch of superior laryngeal N. paralysis - high pitched singing voice3. hypoparathyroidism
MC type of thyroid cancer
papillary cancer- MC between age 30 and 40
tx. of pt with papillary cancer lesion < 1 cm and no history of previous radiation
thyroid lobectomy and isthmusectomy- had the pt had a previous history of neck irradation, you would do a total thyroidectomy
tx. of pt with papillary cancer lesion > 1.5 cm
total thyroidectomy
which thyroid ca. is more prevalent in iodine-deficient regions?
follicular cancer- MC between ages 40-50
Tx. of microinvasive follicular carcinoma
lobectomy and isthmusectomy- unless it is > 4 cm, then do total thyroidectomy
Tx. of clear follicular cell ca.
total thyroidectomy for any lesion > 1 cm
tx of medullary carcinoma
total thyroidectomy with removal of central neck LNs - lateral neck dissection usually needed for palpable nodes or large primary lesions
post op management of papillary thyroid ca.
thyroid suppression with thyroid hormoneI-131 ablation
post op management of follicular thyroid ca.
I-131 ablation- allows successful monitoring for recurrent thyroid ca.
post op management of medullary thyroid ca.
radioactive ablation is NOT useful bc tumors come from C-cells- external irradiation may be beneficial
what can you use to monitor pts with medullary thyroid ca. post-op?
serum calcitonin and CEA levels
what additional tests should you order in symptomatic hypercalcemia?
PTHserum ALPphosphate levels
MC lesions causing primary hyperparathyroidism
parathyroid adenomas
how do you tx. a parathyroid adenoma?
exploratory surgery of neck - surgeon examines the parathyroid and excises the adenoma with biopsy of one other gland to ensure normalcy
when would you do a radical resection of parathyroids?
carcinoma
how can you do minimally invasive parathyroid surgery?
do sestamibi scan first to determine site of adenoma, make small neck incision and remove only adenoma w/o exploration of remaining glands
what do you do if there is a “missing” parathyroid gland on surgery?
must find it- MC locations are thymus (inferior glands), intrathyroidal, tracheoesophageal groove and in carotid sheath
what do you do if you find a persistent intrathymic parathyroid?
thymectomy through cervical incision or median sternotomy
at what calcium level is parathyroid exploration warranted?
> 11 mEq/L
initial management of acute hypercalcemia
rehydration with Normal Saline- once rehydrated, give furosemide which leads to brisk diuresis high in Calcium
MC benign cause of hypercalcemia
parathyroid adenoma
tx. scheme of acute hypercalcemia with symptoms
- IVF - normal saline2. furosemide3. bisphosphonates4. tx. underlying cause
tx. of secondary hyperparathyroidism (for ex. due to renal failure)
surgical removal of all but 50g of parathyroid tissue (transplantation into forearm)
indications for surgical management of secondary hyperparathyroidism
bone painfracturesintractable pruritusectopic calcifications in soft tissues
you are undergoing neck exploration for a parthyroid adenoma in a patient with hypercalcemia- during operation he develops huge spike in BP - what should you do? what do you suspect?
terminate operation immediately, admit pt to ICU, give patient both alpha and beta blockers – evaluate for pheochromocytoma
what is important during resection of a pheochromocytoma?
- pt should be on alpha blockers for atleast 10 days prior to surgery2. must ligate venous drainage from tumor before manipulating tumor3. minimal manipulation of tumor- to prevent surge of catecholamines during surgery
where do extra-adrenal pheochromocytomas usually occur?
along abdominal aorta in a distribution similar to symphathetic chain
if h.pylori test is negative with basal serum gastrin > 00 pg/mL - what do you suspect
gastrinoma (Zollinger-Ellison) syndrome
diagnostic tests for Zollinger-Ellison
- serum gastrin > 1000 pg/dL2. positive calcium or secretin stimulation test3. localize lesion with CT or MRI
Tx. of sporadic, solitary gastrinoma
surgical resection
Whipple triad
- fasting hypoglycemia (< 60)2. sympomatic hypoglycemia3. relief by administration of glucose- seen in pts with insulinoma
if an insulinoma is non-resectable, what medical therapy can be used?
diazoxide - inhibitor of insulin release
MEN2a
medullary thyroid cancerparathyroid hyperplasiapheochromocytoma
management of incidentally discovered adrenal mass
lesions > 5 cm: surgery recommendedlesions < 5 cm: full biochemical workup; if nonfunctioning, can monitor with serial CT scans but if it changes in size, removal is necessary
worrisome features of a thyroid nodule
- young/male2. history of radiation to the neck3. solid mass on USG4. cold nodule on scan
diagnostic test of choice for thyroid nodule
FNA and cytology
next step if a FNAB of a thyroid nodule turns up indeterminate?
surgery- usually lobectomy first
tx of follicular cancer of thyroid
total thyroidectomy- mets tx. with radioactive iodine ablation
next step when lab results show you high Calcium and low phosphate levels
PTH determinationsestamibi scan to localize adenoma
first test in someone with Cushing features
overnight dexamethasone suppression test
diagnostic W/U for Cushing’s
- overnight dexamethasone suppression test- no suppression at low dose –> 24 hr urinary cortisol level2. high dose suppression test- if suppresses: do MRI of head (pituitary)- if she does not suppress: do MRI/CT of adrenals
pt comes in bc of virulent PUD; she has multiple duodenal ulcers in first and second portions of duodenum as well as watery diarrhea - dx?
Zollinger Ellison
dx. of Zollinger-Ellison
first: serum gastrin levels- may add secretin stimulation testsecond: CT scans with vascular and GI contrast of pancreas
baby with extremely low blood sugar is found to have high levels of insulin in the blood - dx and tx?
nesidioblastosis- tx. pancreatectomy
tx of insulinoma if inoperable
diazoxide- inhibits insulin release
48 yo woman with severe migratory, necrolytic dermatitis; she is thin, has mild stomatitis and mild DM - dx?
glucagonoma- determine glucagon levels and CT scan
tx. of glucagonoma
surgery- if inoperable, Somatostatin can help sx- streptozocin: chemotherapy agent
CF of hyperaldosteronism
female with HTNhypokalemia, hypernatremiametabolic alkalosis
initial diagnostic tests for hyperaldosteronism
determine aldosterone and renin levels- will show high aldosterone, low renin
how can you differentiate adrenal hyperplasia from an adenoma producing aldosterone?
adrenal hyperplasia shows postural changes (more aldsterone when upright than when lying down)
tx. of adrenal hyperplasia vs adenoma
hyperplasia - medically with spironolactoneadenoma - surgically
dx of pheochromocytoma
24 hr urinary metanephrine or VMA; if elevated, get a CT scan of adrenals
what test has high sensitivity and specificity for pheochromocytoma
MIBG scan
you find a young man to have elevated BP in both arms; in his legs, the BP is normal
dx. coarctation of aorta
first test to order in coarctation of aorta
CXR- then CT-angio
first test for renal artery stenosis
Duplex scan of renal arteries
tx of renal artery stenosis due to fibromuscular dysplasia
angiographic balloon dilation with stenting
what are the standard preoperative tests?
CBC w/ electrolytesECG - if above 40 or with history of cardiac dzCXR
what type of anesthesia has fewer pulmonary complications?
spinal anesthesia
what patients is spinal anesthesia dangerous in?
pts with CADmarginal cardiac reserve w/ low EFvalvular heart dzdiabetic peripheral vascular disease w/ neuropathy
why is spinal anesthesia dangerous in pts with cardiac problems?
loss of peripheral vasoconstriction ability leads to hypotension and inability to increase CO
major drawbacks of general anesthesia
increased incidence of pulmonary complicationsmild cardiodepression
how long before surgery should a patient stop taking.. Aspirin (1)? NSAIDs (2)?
- 7-10 days (irreversible)2. 2 days (reversible effect)
what should be done prior to surgery in someone with history of previous MI?
cardiology consultation w/ possible exercise stress test and cardiac catheterization may be necessary prior to surgery
what pre-op precaution should be taken in a diabetic?
since pt is NPO after midnight, diabetics should receive IVF w/ dextrose
which drugs should not be given to a diabetic the morning of their surgery?
oral hypoglycemic drugs i.e. sulfonylureas
what do you do if an insulin-dep diabetic has a blood glucose > 250 mg/dL on morning of surgery? if glucose is < 250 mg/dL?
- give 2/3 of morning dose of NPH and regular insulin2. give 1/2 of morning dose
what do you do pre-op if a pt has a low hematocrit?
reason for anemia must be determined and surgery post-poned until then
what do you do pre-op if a pt has a high hematocrit?
ensure proper hydrationtx. underlying cause before surgery
optimal perioperative blood glucose levels
100-250 mg/dL- if higher than these values, should delay surgery until glucose under control
what are patients with poorly controlled DM at risk for post-op?
increased risk of wound infections
what do you do if a patient presents for surgery and on PE you find cellulitis from an infected hair follicle in his axilla?
elective surgery should be post-poned until acute infection is resolved, regardless of its location; otherwise, this significantly increases risk of wound infection
can you operate on someone who has a UTI?
no - surgery should be postponed until UTI has been treated w/ antibiotics and repeat UA and culture indicate resolution
what is diastolic BP > 110 a risk factor for?
development of CV complications such as malignant HTN, acute MI and CHF
how should you manage high BP perioperatively?
pt should continue on antihypertensive medications on the day of surgery - BB may reduce risk of cardiac complications following surgery
recommendations for a smoker about to undergo elective surgery?
6-8 weeks of abstinence can decrease post-op respiratory morbidity so patient should be advised to quit smoking prior to elective surgeries
what ABG results are associated with increased perioperative morbidity?
PaCO2 > 45 mmHgPaO2 < 60 mmHg
can you do laparscopic surgery in a pt with compromised pulmonary status?
no… increased CO2 absorption through blood requires excretion from lungs and increases pulmonary work
five factors that are used to predict risk for cardiac complications after vascular surgery
- Q waves on ECG2. history of ventricular ectopy requiring tx3. hx of angina4. DM5. age > 70
MCC of post-op early death following LE revascularization
MI
if pt has prior history of MI and is being qualified for vascular surgery, what should be done?
- ECG2. persantine thallium stress test or dobutamine echo3. if reversible ischemia is present, pt should undergo cardiac catheterization prior to surgery
recent MI within what time frame poses a risk for cardiac complications in a non-cardiac surgery
MI w/in 30 days
pts pre-op ECG shows LBBB
pt should have careful evaluation for underlying cardiopulmonary disease as LBBB is highly suggestive of underlying ischemic heart disease
how does having a CABG in the past affect pre-op evaluation of cardiac risk/
CABG w/in last 6 months to 5 years has been shown to reduce the risk of cardiac complications in pts who are undergoing other surgery
what test should you do in a pt about to undergo surgery who had a CABG 10 years ago?
graft patency is questionable at 10 years (esp. with saphenous grafts) therefore do a STRESS TEST to assess any reversible ischemia
pre-op evaluation in pt who had PCI with stent 2 years ago
cardiac evaluation with stress test needed- PCI has higher rate of restenosis than CABG
pre-op evaluation in pt who had PCI 2 days ago
noncardiac surgery should be delayed for several weeks following coronary angioplasty due to high probability of coronary thrombosis
on pre-op evaluation you note your patient has angina on moderate exertion and uses nitroglycerin - what test should you run?
coronary angiography to see if pt would benefit from stent or revascularization
pre-op evaluation ECG shows 6 premature ventricular complexes per minute - what does this imply and what test should be done?
> 5 PVCs/min increased cardiac mortality- assess ventricular dysfunction with stress test and echo
on preop evaluation you notice a loud right carotid bruit on your pt - what test should you do?
carotid duplex study to evaluate for carotid artery stenosis –> if high grade stenosis present, may need endarterectomy prior to surgery
what preop test should be done in pt who had a stroke 2 years ago…
carotid duplex study (if good neurologic recovery); no further tests needed if significant residual neurological deficit present
a pt being considered for umbilical hernia has a small ulcerated area on the hernia
the ulcer is due to pressure necrosis and has increased risk of rupture - should be repaired expediently
in an alcoholic patient, what is important pre-op?
that patient abstains from alcohol and has undergone withdrawl - alcoholic withdrawl is associated with high morbidity and mortality
a patient with cirrhosis has hemorrhoid that he would like removed - what are you worried about?
uncontrollable hemorrhage during surgical repair due to portal HTN
how do you manage bleeding in a patient with chronic kidney failure during surgery?
platelet dysfunction due to uremia can be managed with desmopressin- FFP may also temporarily correct the defect- postop hemodialysis may improve function
pt with chronic renal failure develops hypotension during surgery with no obvious cause or bleeding….
consider glucocorticoid deficiency- give hydrocortisone 25 mg intraoperatively followed by 100 mg in next 24 hrs
normal ratio of replacement fluids for post-op
3 ml of isotonic fluid for every 1 ml of estimated blood loss
normal maintenance fluid for post-op
5% dextrose - 1/2 NS plus KCl 20 mEq/L
if patient loses a lot of blood during operation, what fluid should you opt for?
lactated Ringer’s or 0.9% NaCl for first 24 hours
calculation of intraoperative fluid requirements
(EBL x 3 mL isotonic fluid/1mL blood loss) + UO - IVF in OR
how do you estimate fluid replacement for fluids lost from drains or fistulas?
replace mL for mL
formula for estimation of maintenance fluid requirements
1500 mL for first 20 kg20 mL/kg for every addition kg
normal urine output
0.5-1 mL/kg/hr
a post-op patient has a urine output of 10ml/hr for next 4 hours - what should you try first?
- catheter - irrigate and confirm position2. dehydration - try volume resuscitation
MCC of fever in the immediate post-op period
atelectasis- will hear fine crackles on lung auscultation
tx. of post-op atelectasis
pulmonary toiletincentive spirometry
2nd MCC of post-op fever (on day 3)
UTI
tx. of post-op UTI
oral TMP-SMX or ciprofloxacin
what should you do if on wound exam you noticed fluctuance?
this suggests a fluid collection beneath the skin, some sutures should be removed and pus should be drained followed with wet-to-dry dressings (BID) and irrigation
you notice that a patient’s indwelling IV has induration, edema and tenderness - what should you do?
remove the catheter and it should resolve- rotate IV lines every 4 days to prevent this
you notice a patient as a drop of pus on the skin at the venipuncture exit site…dx?
suppurative phlebitis- caused by presence of infected thrombus in the vein around the indwelling catheter
how do you tx. suppurative phlebitis
removal of catheterexcision of infected vein to first patent non-infected collateral branch
what do you do with a patient post-GI surgery that shows clinical signs of peritonitis post-op?
they require operative re-exploration
a 65 yo woman who had segment of necrotic bowel resected has intestinal contents draining from her wound on POD5 - what do you suspect?
leak at jejunostomy sitebreak in anastomosis sitemissed enterotomy
what study should you do in someone with suspected enteric fistula post-op?
CT scan - to R/O intra-abdominal collection- if present, should drain
how do you tx an enterocutaneous fistula post-op?
NPO, give pt TPN and measure fistula output daily - most will heal on their own w/in a few weeks- if it does not close w/in 5-6 weeks and pt is free of infection, definitive repair should be planned
factors associated with a fistula that is failing to heal (6) - FRIEND
Foreign body in the woundRadiation damage to the areaInfection or IBDEpithelialization of fistula tractNeoplasmDistal bowel obstruction
an extremely high fever in the immediate post-op period….
atelectasis - but would have to be entire lungmost probably is a serious wound infection with gas-forming bacteria
how does a wound infection caused by a gas forming appear?
erythematous with advancing edge of brown discoloration and bleb formation; there is thin watery discharge with foul odor and crepitus near the wound edge
management of suspected gas gangrene wound infection
wound should be opened and cultured immediately with high dose penicillin G, debridement and hyperbaric O2 treatment
Goldman’s Index (8)
predictors of operative cardiac risk- JVD: 11 pts- recent MI w/in 6 months: 10 pts- age >70: 5 pts- PMBs or arrhythmias: 7 points each- aortic stenosis: 3 pts- poor general condition: 3 pts- chest/abdominal surg: 3 pts- emergency surgery: 4 pts
how do you assess compromised ventilation pre-op in a smoker?
first measure FEV1; if abnormal, measure ABGs - smoker will have low FEV1 and high PaCO2
how can you improve pulmonary risk in a smoker prior to elective surgery?
stop smoking for 6-8 weeks prior to operationintensive respiratory therapy
which parameters increase mortality in a cirrhotic patient that needs surgery?
bilirubin > 2albumin < 3PT > 16encephalopathy
contra-indications to a cirrhotic pt having surgery due to extremely high (100%) mortality
bilirubin > 4albumin < 2ammonia > 150 ng/dl
four indicators of severe nutritional depletion
weight loss > 20% of body weightlow albuminanergy to skin testserum transferrin < 200 mg/dl
tx of malignant hyperthermia
IV dantrolenesupport measures: 100% O2, correct acidosis, cooling blankets, watch for myoglobinuria
45 min after cystoscopy a patient develops chills and a high fever
so early on after an invasive procedure indicates bacteremia - > take blood cultures 3x and start empiric antibiotics
MCC of post-op fever
day 1 - Wind } atelectasis, pneumoniaday 3 - Water } UTIday 5 - Walking } DVT/ PEday 7 - Wound } infectionday 10 - Wonder where } deep abscesslate - wonder drugs (medication induced)
tx of post-op atelectasis
improve ventilation with deep breathing and coughing, postural drainage and incentive spirometry; ultimately, bronchoscopy if nothing
management of deep abscesses post-op
CT scans to find them and then drained percutaneously
when is post-op MI likely to occur? and how do you diagnose it?
either during the operation or up to POD3- order ECG and troponin levels
on 7th POD after hip surgery, pt suddenly develops severe pleuritic chest pain and SOB; he is anxious, diaphoretic and tachycardic and has prominent distended veins in neck and forehead
post-op PE
first test to order in post-op PE
ABGs - hypoxemia, hypocapniafollow with CT-angio
how can you prevent post-op PE?
pts w/o LE fractures - sequential compression stockingshigh risk pts require anticoagulation- age > 40, LE fractures, venous injury, femoral catheterization, prolonged immobilization
how do you manage pulmonary aspiration
lavage and removal of particulate matter (w bronchoscopy) followed by bronchodilators and respiratory support
halfway through surgery, the anesthesiologist notes it is becoming progressively harder to bag the pt and his BP is steadily declining while CVP is rising; no evidence of intraabdominal bleeding - dx and tx?
intraoperative tension PTX- cant put chest tube in- put hole in diaphragm or need placed in ant. chest under drape
major cause of post-op disorientation and first test to order?
hypoxia- order ABGs
Tx of ARDS
PEEP- in trauma patient, look for precipitating event ie. shock/sepsis
Tx of post op urinary retention
In and out bladder catheterization-don’t do foley until atleast twice
Urinary sodium in dehydration
U-Na < 10-20
Urinary sodium in renal failure
U-Na > 40
XR finding in paralytic Ileus
Dilated loops of bowel without air fluid level ( vs. mechanical obstruction which has fluid levels)
What metabolic abnormality can prolong paralytic Ileus?
Hypokalemia
Paralytic Ileus of the colon
Ogilvie syndrome
wound healing by primary intention
wound edges are closed w/ sutures, allowing very rapid coverage by epithelium and rapid wound healing
how long should patients wait after major surgery before lifting any significant weight?
atleast 6 weeks- wound is still producing collagen and cross-linking during this time
patient feels a hard, knot-like structure beneath his skin in the area of his surgical wound
likely a surgical knot - wait for wound to completely heal, it will either resolve or it can be removed w/ local
pt has a small, sore red area in his wound that intermittently drains a small amt of pus and then seals over…
stitch abscess - infection of a suture- remove the suture under local
pt has a 4 cm defect in the fascia (where his surgical wound used to be) and it bulges when he coughs
post-op ventral hernia due to fascial breakdown
tx. for post-op ventral hernia
surgical repair
pts scar post-op is red and sensitive to the touch still at 3 months
this is ok…complete wound remodelling and maturation may take up to 6 months
pts wound scar is raised and hypertrophic in appearance
observation until the scar stabilizes; revision may be appropriate but recurrence is common unless the wound is treated with steroid injections and local pressure dressings
keloid
scar that is raised and hypertrophic and spreading outside the immediate area of the incision
on POD3 you note an area of redness and tenderness in the middle of the pts wound - what should you do?
suspect wound infection- drain infection completely- debride any non-viable tissue- oral or IV antibiotics are not used
healing by secondary intention
wounds that were contaminated at the initial surgery or left open by the surgeon or wounds that became infected and required opening in the immediate post-op period
when can you use a split-thickness skin graft?
bacterial count on granulation bed must be < 10^5 bacteria/g of tissue; the graft is capable of revascularizing from granulation tissue (inosculation) and causing re-epithelialization of a wound that did not heal by primary intention
when is collagen produced in a healing wound?
collagen production first detected at 10 hours and peaks in 5-7 days
what growth factors are involved in wound healing?
- PDGF - chemotactic for fibroblasts, neutrophils and macrophages2. TGFB - increases collagen synthesis3. FGF - hastens wound contraction4. EGF - stimulates epithelial migration and mitosis (wound epitheliazation)
appropriate management of a clean wound with low risk of infection (<2%)?
close wound w/ primary intentionno antibiotics needed perioperatively (unless mesh is inserted like in hernia repair)
definition of “clean wound”
no entry is made into the GI, respiratory, genitourinary tracts and there is no active infection; less than 2% chance of infection
definition of “clean-contaminated wound”
the GI, respiratory or genitourinary tract is entered but the tract is prepared both mechanically and antibacterialls; less than 3% chance of infection
definition of “contaminated wound”
there is major contamination of the wound, such as gross spillage of stool from colon or infection in the biliary, respiratory or genitourinary tracts ex. bowel perforation; infection rate < 5%
who should get prophylactic antibiotics preoperatively?
- brief, predictable exposure to bacteria- implantation of device/prosthetic material- impaired host defenses such as immunosuppression or poor blood supply
what is the most effective way of administering perioperative antibiotics?
single dose 1 hr pre-op and single dose post-op
first step in asymptomatic pt who has a coin-lesion on CXR found pre-op?
previous previous CXR films for comparisonnext step should include CT scan w/ possible CT-guided needle biopsy
symptomatic coin lesion found on CXR and confirmed with CT scan - what next?
bronchoscopy - obtain tissue diagnosis and determine location
lung lesion associated with dental abscess or sinus tract with chest wall involvement
actinomycosis
lung lesion with concentric or homogenous calcification in an endemic area
histoplasmosis
lung lesion with thin-walled cavity often w/ air-fluid level in a pt living in endemic area
coccidiomycosis
lung lesions with associated chronic skin ulcers in an endemic area
blastomycosis
lung lesions in immunocompromised patient, often with meningeal involvement
cryptococcosis
lung lesion that presents as mycetoma with air-crescent sign
aspergillosis
lung lesion that presents with well-defined border with slight lobulations
hamartoma
lung lesion that is adjacent to thickened pleura and comet-tail vessel pattern
round atelectasis
what is the next step in a patient who presents with a stage 1 adenocarcinoma of the lung
thoracotomy- explore the mediastinum; if no spread outside lung, can proceed with lobectomy
what kind of tx. can you do for a hilar mass that involves a mainstem bronchus?
exploratory thoracotomy- pneumonectomy will likely be needed for complete removal
what is involved in a pneumonectomy?
- dividing the mainstem bronchus just distal to carina and sewing/stapling it closed2. dividing the pulmonary artery and two pulm. veins
what is involved in a sleeve lobectomy?
- dividing the mainstem bronchus above and below the origin of the right upper lobe bronchus and reattaching the bronchus by suture technique2. blood supply to the unaffected lobes is left in tact
tx. for stage 2 lung cancer
stage 2 - involvement of hilar LN - tx. is surgical resection but prognosis is worse
pt with lung mass has mediastinal LN positive for mets - stage ?
stage 3 lung cancer
tx. for stage 3 lung cancer
chemotherapy and radiation therapy- if tumor decreases in size, then can undergo resection
pt with lung cancer has PET scan positive for distant mets - stage? tx?
stage III or IV- tx. chemo and radiation
what can the Pancoast tumor invade?
lower cords of brachial plexussubclavian arterysympathetic gangliachest wall
tx. of Pancoast tumor
- irradiation of area over 6 week period2. surgical resection of involved chest wall and lung
hemoptysis in otherwise healthy young woman with atelectasis….dx?
obstructed bronchus - most likely a bronchial adenoma
two types of “bronchial adenomas”
- carcinoid tumors - usually benign when in lung2. adenocystic carcinomas - MC in upper airway; invade locally
how can you diagnose bronchial adenoma?
CT scan but ultimately, bronchoscopy w/ biopsy is needed for diagnosis
tx. of bronchial adenoma
lobectomy - with removal of tumor-containing bronchus
an older patient comes in with a pleural effusion…what are you concerned about?
a pleural effusion in an older patient signifies cancer until proven otherwise
what is the next step in diagnosis of a pleural effusion in an old man (w/o CHF)?
thoracentesis and pleural biopsy
only potential tx. of mesothelioma
extrapleural pneumonectomy- irradiation and chemotherapy are ineffective
what is an extraplural pneumonectomy?
entire lung along with parietal/visceral pleura, pericardium and diaphragm are resected en bloc
tx. for pneumothorax
chest tube (tube thoracostomy)- polyethylene tube (size 24) w/ a one way-valve (Heimlich valve)- tube attached to a water-seal type drain
what is the purpose of a water seal in the chest tube?
maintains negative pressure in the pleural space and chest tube so that air and fluids may escape from the chest
how do you tx. persistent or recurrent pneumothorax?
thoracoscopic excision of blebs and pleurodesis (pleural abrasion)- also used for bilateral spontaneous PTX
pt with pneumonia tx at home with antibiotics improves; she then notes an increased pain in her chest, increased cough and recurrent fever - CXR shows a pleural effusion in the right lung - diagnosis?
empyema- community - strep pneumo- hospital - staph or gram negatives
tx. of empyema of lung
- antibiotics2. chest tube drainage - evacuates pus and re-expands the lung
tx. of empyema that has become loculated (i.e. bc it was not drained early enough)
thoracotomy and decortication (removal of the thick inflammatory tissue trapping the lung)
tx. for pt with three-vessel disease and reduced EF
CABG
MC grafts used in CABG
greater saphenous vein graftsinternal mammary artery grafts - best graft patency
what are the MC reasons of death following cardiac transplantation?
infection - related to immunosuppressive drugsaccerelated coronary atherosclerosis (form of chronic rejection)
histopath findings in achalasia
loss of sm mm. ganglionic cells of Auerbach plexus and neuronal degeneration
what is the proper sequence of diagnostic tests in a patient presenting with dysphagia?
- barium swallow2. endoscopy w/ biopsy3. CT scan
best test for staging of esophageal cancer
endoscopic USG- assesses wall penetration and can identify adjacent node enlargement
primary tx for cancers of the cervical and upper third of esophagus
chemoradiation therapy
primary tx. of cancers of the middle third of esophagus
neoadjuvant tx. with irradiation and chemo followed by surgical resection
transhiatal esophagectomy
stomach is brought up well into the neck and joined w/ the pharynx
formal esophagectomy (Ivor Lewis procedure)
gastroesophgeal anastomosis in the chest or may be altered to permit anastomosis in the neck
if stomach is used in reconstruction of esophagus after esophagectomy, what other procedure is necessary?
pyloroplasty - to prevent gastric outlet obstruction
tx. of esophageal cancer with distant mets
chemotherapy only
tx. of esophageal cancer in lower 1/3 of esophagus
esophagectomy and proximal gastrectomy with intra-thoracic esophagogastric anastomosis
what tumors arise in the anterior mediastinum?
thymomas - look for sx. of myasthenia gravisteratomaslymphomas - both Hodgkins and NHLgerm cell tumorsbenign dermoid tumors (calcium deposits)
tx. for thymomas (and other tumors other than lymphomas in ant. mediastinum)
surgery (median sternotomy)
MC tumors of middle mediastinum
lymphatic tumorscysts
bronchogenic cysts
from foregut remnants; found in both lung and mediastinum - benign growths lined by columnar epithelium
what type of cysts have a “water bottle” appearance/
pericardial cysts
tx. of cysts in middle mediastinum
surgical removal w/ posterolateral thoracotomy
MC tumors in posterior mediastinum
neurogenic tumors (MC - neurilemoma)- arise from nerves and nerve sheaths near vertebral bodies and contain both fibrous and neural elements
what test is indicated next if you find a tumor in the posterior mediastinum?
CT scan - to indicate whether tumor is present in spinal canal also
Noise with breathing OUT?
Think asthma
Noise with breathing IN?
Think tracheomalacia
Noise with breathing AND difficulty swallowing?
Think vascular ring
Baby presents with strider and episodes of respiratory distress with crowing respiration during which he assumes a hyperextended position; there is also mild difficulty swallowing
Vascular ring
What diagnostic test(s) do you order if you suspect a vascular ring?
Barium swallow- will show extrinsic compression from the abnormal vessel Bronchoscopy- confirms segmental tracheal compression and R/O tracheomalacia
Tx of vascular ring compressing airway and esophagus
Surgery - dividing smaller of the double aortic arches
12 yo girl found to have a pulmonary flow systolic murmur with a fixed split second heart sound; she has a history of frequent colds and URIs - dx? Test?
Atrial septal defectTest - echo
Tx of ASD
Closure of defect by open surgery or cardiac catheterization
3 month old baby with failure to thrive has a loud pansystolic murmur best head over left sternal border; chest shows increased pulmonary vascular markings
Ventricular septal defect - mc in membranous septum- dx with echo tx with surgery
What type of VSD has good chance to close on its own within first 2-3 years?
Small, restrictive VSD located low in the muscular septum
3 day old premature baby has trouble feeding and pulmonary congestion; on exam she has bound peripheral pulses and a continuous machinery like murmur- shortly thereafter the baby goes into overt heart failure
Patent ductus arteriosus
What are indications for surgical closure of PDA?
Failed indomethacin txCHF Full term babies (intraluminal coils or surgery)
What are characteristics of R–>L SHUNTS
Decreased vascular markings on CXRCyanosis
72 yo man with history of angina, SOB and Exertional syncope has a harsh midsystolic murmur best heard at right 2nd intercostal space - dx? Test?
Aortic stenosis- do echo
When is surgery indicated for aortic stenosis?
Pressure gradient >50 mmHgFirst indication of CHF, angina or syncope } symptomatic patients have limited life expectancy
72 yo man with wide pulse pressure, blowing diastolic murmur heard best at right 2nd intercostal space and along left lower sternal border; on echo, there is evidence of beginning LV dilatation - dx? What should you do?
Chronic aortic insufficiency - tx with aortic valve replacement at first sign of LV dilatation
Tx for acute aortic insufficiency caused by endocarditis
Emergency valve replacement and antibiotics
35 yo lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis progressive for about 5 years; she has atrial fibrillation and a low pitched rumbling diastolic apical heart murmur. At age 15 she has rheumatic fever - dx?
Mitral valve stenosis- start with echo
Tx of mitral valve stenosis
Surgical repair - mitral commissurotomy or balloon valvuloplasty
55 yo lady has had mitral valve prolapse for many years, she now has developed signs of LHF and atrial fibrillation; she has an apical high pitched holo systolic heart murmur that radiates to the axilla and back
Mitral regurgitation
Tx of mitral valve regurgitation
Surgical repair (annuloplasty) or possibly valve replacement
Candidates for coronary revascularization
- stenosis > 70% in atleast one vessel- good distal vessels (often bad in smokers and diabetic)- minimal LV damage (measured by EF)
Cardiac index
CO / BSAnormal = 3 L/ min /m2
How do you interpret PCWP, LAP or LEDV, in the setting of low cardiac index or cardiac output?
0-3- need more fluids (dehydrated)> 20 - ventricular failure
What is the first step after you find a solitary coin lesion on an XR?
Find a previous CXR to compare- if same lesion is found on older XR ( one year or more) it is likely not cancer and no further work up is needed for now but follow up with CXR in a few months
What is the management approach to a coin lesion in the lung that was no previously there?
- Sputum cytology and CT scan2. Biopsy- bronchoscopy if central, percutaneously if peripheral - if unsuccessful, thoracoscopy with wedge resection
What is the minimal FEV1 to survive pulmonary resection/pneumonectomy?
800 ml
How do you calculate how much FEV1 patient would have after resection of lung?
Take the percent from V/Q scan (%) and multiple it by calculated fev1 during assessment
How do you adequately assess extent of disease in lung cancer ?
CT scanCT scan plus PET - if status of mediastinal nodes unclearEndobronchial USG - to same nodes- do not need to determine fev1 or nodal status in small cell ca. Bc it not treated surgically
how do you repair duodenal ulcer in pt with no prior history of ulcer disease and perforation is only several hours old
closure of perforation, using Graham patch (piece of omentum placed over perforation)
if pt with perforated ulcer has prior history of peptic ulcer disease - tx?
closure of perforation and HSV or V&P
management of patient who is laying in ICU with coffee-ground material in her NG aspirate?
- initiate H2 blockade, sucralfate or antacids w/ gastric pH monitoring2. upper GI endoscopy is not necessary for this type of bleed3. prophlyactic therapy may be given for pts at high risk of bleeding
EGD finding of duodenal ulcer with clean, white base and no active bleeding - management?
white base = has not bled recently- can be observed w/o endoscopic tx.- H2 blocker or PPI to maintain gastric pH > 5
EGD finding of duodenal ulcer with fresh clot adherent to the ulcer - management?
evidence of recent rebleeding- endscopic hemostatic therapy
indications for endoscopic hemostatic therapy of bleeding ulcer
- active or recent bleeding2. large initial blood loss3. high risk of rebleeding or death from bleed
EGD finding of duodenal ulcer with fresh clot and visible artery at its base - management
visible artery - highest risk of rebleeding- inject area around artery to attempt local control- operate in next 24-48 hours
where is an ulcer with a visible artery presenting with massive bleeding likely found?
posterior duodenum and involves the gastroduodenal artery
EGD finding of duodenal ulcer with fresh bleeding in a patient with the onset of hypotension - management?
immediate resuscitation w/ normal saline and PRBCs; send to OR
management of duodenal ulcer in pt with ARF and creatinine of 6 mg/dL
this pt who has uremia, likely has platelet dysfunction making bleeding more likely; tx. involves dialysis and desmopressin but otherwise, management is the same as other cases
what do you do if a patient presents with bleeding gastric ulcer?
management is the same as for duodenal ulcers, but biopsy must be done once patient is stable and bleeding is resolved; if surgery is needed, excision rather than oversewing as with duodenal ulcers
management of gastric varices in setting of chronic cirrhosis pt
- do not respond to banding or sclerotherapy- may respond to injection of cyanoacrylate glue- if bleeding is severe, TIPs or splenectomy may be needed
management of gastric varices in setting of chronic pancreatitis
due to splenic vein thrombosis (left-sided portal HTN) –> Tx. splenectomy
what should patients with esophageal varices be treated with as prophylaxis against rebleeding?
B-blocker
what test is useful if diagnosis of GERD is uncertain?
24 hr esophageal pH monitoring
approach to patient with symptoms resembling GERD
R/O gallstones, cardiac problems, pancreatitis- if negative, start trial of H2 blockers or PPIs –> if it helps, no W/U; if pt does not improve, order EGD
classic GERD symptoms
burning retrosternal pain - brought about by bending over, wearing tight clothes or lying flat in bed at nightantacids provide symptomatic relief
what test should be recommended to someone with long-standing GERD who was never formally diagnosed/treated?
EGD with biopsy- assess for extent of esophagitis and possible complications
you do EGD in pt with symptoms of GERD but find nothing….
non-ulcer dyspepsia- symptomatic tx with PPIs and h.pylori tx
tx. of Barret’s esophagus/esophagitis
medical therapy with PPIs (8-12 weeks should resolve it); behavior modification
indications for nissen fundoplication
intractable GERD symptoms despite max medical therapysevere esophagitisesophageal stricture
what kind of surveillance is needed in pt with diagnosed Barret’s?
EGD+biopsy every 18-24 months to monitor for dysplasia
what diagnostic tests should you do in a patient with symptoms of GERD despite max medical treatment?
EGD w/ biopsyesophageal manometry - to demonstrate intact esophageal peristalsis before surgery
Dx. of Zenker’s diverticulum
barium swallow followed by upper endoscopy
Tx. of Zenker’s diverticulum
transection of cricopharyngeal mmif large, excision at origin of posterior pharynx
47 yo woman complains of difficulty swallowing (liquids»_space; solids) and she has to sit up straight and wait for fluids to make it through. She occasionally regurgitates large amts of undigested food - dx?
achalasia- poor peristaltic contractions- increased LES tone
diagnostic test for achalasia
barium swallow firstconfirm with manometry
tx of achalasia
CCBsballoon dilation w/ endoscopyHeller myotomy w/ surgery
older man with history of smoking and drinking presents with difficulty swallowing meats and solids that has progressed to include liquids; he has history of 30 pound weight loss - dx?
esophageal ca- likely squamous cell ca. - if longstanding GERD hx, think adenocarcinoma
characteristic signs/symptoms of esophageal ca.
progressive dysphagia (solids -> liquids)odynophagiaconstant painregurgitationTE fistula formationhoarseness/coughing
diagnostic sequence of esophageal ca.
barium swallow firstendoscopy with biopsyCT scan to assess extentendoscopic USG - for staging
most accurate way to stage esophageal ca.
endoscopic ultrasound- assess wall penetration and adjacent node involvement
pt with history of forceful or persistent vomiting followed by vomiting bright red blood - dx?
Mallory Weiss syndrome- multiple linear erosions in gastric mucosa at GE junction
dx. and tx of Mallory Weiss tears
usually resolve on their own so w/u is conservative; if bleeding persists, consider EGD with photocoagulation
if laser coagulation is not working for a Mallory Weiss tear, what should you do next?
surgery- oversew the laceration through anterior longitudinal gastrostomy
patient who has been vomiting repeatedly presents bc during a particularly violent episode he felt a severe, wrenching epigastric/lower sternal pain of sudden onset; on exam, he is diaphoretic, has fever, leukocytosis and looks ill - dx?
Boerhaave syndrome - transmural esophageal tear(perforation)
management of Boerhaave syndrome
gastrograffin (water soluble) swallowfollowed by emergent surgery
pt who recently had upper endoscopy returns complaining of severe, constant retrosternal pain; he has a very high fever, is diaphoretic and there is a hint of subcutaneous emphysema at the base of the neck - dx?
esophageal perforation (due to instrumentation)
approach to esophageal perforation
- gastrografin swallow 2. emergency surgical repair- if < 24 hours: primary closure- if > 24 hrs: diversion and exclusion followed by delayed reconstruction
approach to bleeding esophageal varices
endoscopic band ligationcorrect coagulopathy (FFP, platelets)IV octreotide or vasopressin- if pt rebleeds, repeat endoscopy and ligation
what can you consider doing if multiple attempts at endoscopic ligation of esophageal varices are unsuccessful?
portosystemic shunt - mortality of 50%balloon tamponade - pt must be intubated; high risk of esophageal necrosisTIPs
management of a duodenal ulcer
4-6 weeks of triple therapy for h.pylori (8-12 weeks for severe disease)- if symptoms persist, repeat EGD: if ulcer still there or it enlarged, consider surgery (highly selective vagotomy)
what always must be done for a gastric ulcer?
biopsy
tx of linitus plastica
total gastrectomy with splenectomy
pt presents with large weight loss with a history of anorexia and vague epigastric discomfort - what do you do?
endoscopy with biopsy- looking for cancerif cancer, CT scan to assess for extent/operability
pt presents with colicky abdominal pain, protracted vomiting and abdominal distention; he has not had a bowel movement or passed gas for 5 days. On exam he has high-pitched, loud bowel sounds that coincide with colicky pain - what are you considering and what test should you order?
consider bowel obstruction- order abdominal XR
XR finding in bowel obstruction
distended loops of small bowel and air-fluid levels
Management of bowel obstruction due to adhesions
NG suction, IVF and careful observation- surgery if no improvement w/in 24 hours
pt is being tx for bowel obstruction and he develops fever, leukocytosis, abdominal tenderness and rebound tenderness - dx?
signs of peritoneal irritation in pt with bowel obstruction suggests strangulation from compression of mesenteric blood supply- need emergency surgery
pt presents with signs and symptoms of intestinal obstruction; on physical exam you not a groin mass, the patient says he used to be able to push it back at will but for past 5 days has been unable to do so - dx?
intestinal obstruction caused by incarcerated hernia- tx. with surgical intervention
diagnosis of carcinoid syndrome
24 hr urine 5-HIA levelCT scan to assess liver mets
characteristic symptoms of appendicitis
vague periumbilical pain that becomes severe, constant and well localized to RLQ- abdominal tenderness, gaurding and rebound- high fever- elevated WBC with neutrophilia and immature forms
an older pt presents with bloody stools; the blood is visible and has been present on and off for last few weeks - he has been constipated for past 2 months with narrow calibre stools - dx?
suspect cancer of distal, left colon
diagnostic approach to distal, left-sided colon cancer
start with flexible proctosigmoidoscopyeventual colonscopy and CT scan to assess extent
premalignant polyps
familial polyposisfamilial multiple inflammatory polypsvillous adenomasadenomatous polyps
indications for surgery in ulcerative colitis
disease > 20 years (high risk of malignancy)severe interference with nutritionmultiple hospitalizationshigh dose steroids/immunosuppressiontoxic megacolon
XR findings in toxic megacolon
massively distended transverse colongas within wall of colon
what are the indications for emergent colectomy in a case of pseudomembranous colitis?
failure of medical management with:WBC count > 50 000serum lactate > 5 mmol/L
how can you differentiate between internal and external hemorrhoids?
internal - bleed but don’t hurtexternal - pain (discomfort when sitting, itching), but less likely to bleed
pt presents with symptoms likely due to hemorrhoids, what must you do?
must rule out cancer!- do proctosigmoidoscopic exam with DRE, anoscopy and flexible sigmoidoscope
tx. of hemorrhoids
internal - rubber band ligationexternal or prolapsed - surgery
young woman complains for exquisite pain with defection and blood streaks on outside of stool; she avoids having bowel mvts due to pain and when she does they are hard and even more painful
anal fissure - usually posterior, in midline
management approach to anal fissures
physical exam is diagnostic but cancer must be ruled out- in young pts with no risk factors: do flexible sigmoidoscopy- all others do colonscopy (esp. if unusual location - anterior/lateral or symptoms of Crohns)
tx. of anal fissures
sitz baths, fibre/stool softenerstopical anesthetic agentstopical nitroglycerin
tx of chronic anal fissure that is not responding/healing
surgery - lateral internal sphincterectomy
man comes in with exquisite perianal pain; he cannot sit down, bowel mvts are very painful and he has been having chills/fever. On exam there is a hot, tender, red fluctuant mass between anus and ischial tuberosity - dx?
ischiorectal abscess
management of ischiorectal abscess
drainage of abscessmust r/o cancer
62 yo man complains of perianal discomfort and reports fecal streaks soiling his underwear. 4 months ago he had a perirectal abscess drained surgically. On exam, there is a perianal opening in the skin and a cord-like tract going from the opening toward the inside of the anal canal; brownish purulent discharge can be expressed from the tract -dx?
fistula in ano- only develops in pts with previous anorectal fistula
management of fistula in ano
R/O cancer with proctosigmoidoscopy - necrotic tumors can drain- elective fistulotomy
HIV positive man has a fungating mass growing out of anus and rock-hard enlarged LN in both groins; he has lost a lot of weight and looks emaciated and ill - dx?
squamous cell carcinoma of anus- take a biopsy of mass
management of squamous cell ca. of anus
Nigro protocol (tumors < 5 cm)- preop chemotherapy (5FU and mitomycin) and radiation followed by surgery
indications for surgery in GI bleed
- failure of medical tx- hemodynamic instability despite > 3U of blood transfused- recurrent bleed despite 2x endoscopic hemostasis attempts- hypovolemic shock- >3U/day of blood needed
pt vomits large amt of bright red blood
upper GI bleed- above the ligament of Treitz
first test to do in upper GI bleed?
endoscopy
what is the next step in assessment of a dark red bowel movement?
place NGT with aspiration
NG tube aspirate returns copious amts of bright red blood - next steps in management?
defines upper GI bleed- establish IV access- give H2 blockers and monitor pH- when stable, proceed with endoscopy
NG tube aspirate returns clear, green fluid without blood
R/O upper GI bleed - must be distal to Ligament of Treitz
diagnostic approach to a lower GI bleed
always do anoscopy to look for hemorrhoids firsttagged red cell study (0.5-2.0 ml/min)angiogram (> 2 ml/min i.e. 1 U blood every 4 hrs)colonscopy (wait; < 0.5 m/min)
a pt comes in bc they had dark bloody stools 2 days ago; they are not currently bleeding and NG tube shows clear fluid - dx?
young pt - EGDolder pt - EGD and colonoscopy
management of stress ulcer in ICU pt
keep pH > 4-5 with H2 blockers, antacids or both- if bleeding happens, endoscopy and angiographic embolization of L.gastric aa may be needed
pt with liver cirrhosis and ascites presents with generalized abdominal pain; moderate tenderness, some guarding and rebound with mild fever and leukocytosis - dx?
in pt with ascites and history of cirrhosis, think of SBP –> do NOT do surgery
tx of SBP
culture of ascitic fluid and antibiotics
sudden onset excruciating abdominal pain; pt has rigid abdomen, is laying motionless, there are no bowel sounds. XR shows air under diaphragm - dx?
perforated viscus (most likely duodenal ulcer)- emergent laparotomy
diagnosis of acute pancreatitis
serum amylase or lipase (more specific)
who should receive a CT scan in acute pancreatitis?
- pts who do not improve on conservative tx- pts suspected of having complications- unclear diagnosis
diagnostic test for ureteral colic
CT scan
older woman with LLQ pain, tenderness and vaguely palpable mass; she has fever and leukocytosis - dx? and test?
acute diverticulitistest - CT scan
82 yo man develops severe abdominal distention, NV and colicky abdominal pain; he has not passed any gas or stool; XR shows very large gas shadow in RUQ that tapers toward LLQ with shape of a parrots beak - dx?
sigmoid volvulus
tx. of sigmoid volvulus
proctosigmoidoscopy- leave rectal tube in place
first test to do in pt with sx. of biliary colic
USG
USG finding of gallstones in asymptomatic pt - management?
elective cholecystectomy not recommended unless pt is IC, has porcelain gallbladder or stones > 3 cm in size
tx. of symptomatic gallstones
elective cholecystectomy
what USG findings are suggestive of gallbladder disease?
thickened gallbladder wallpericholecystic fluidpresence of gallstones
what type of medications usually help the symptoms of biliary colic?
anti-cholinergic medications
does a patient with uncomplicated, symptomatic cholelithiasis require antibiotics?
no - just single preop dose of first gen. cephalosporin
major complication of cholecystectomy?
injury to common bile duct- may result in chronic biliary strictures, infection and even cirrhosis
what symptoms will make you think of acute cholecystitis?
symptoms of biliary colic along with high WBC count, fever, elevated ALP and signs of peritoneal irritation
tx. approach in acute cholecystitis
- antibiotics after obtaining culture (2nd gen. cephalosporin)2. IVF, NPO and NGT (if nausea/vomiting)3. laparoscopic cholecystectomy in 48-72 hours
what is an alternate way to diagnose acute cholecystitis?
HIDA scan- see uptake in liver, CBD and duodenum but no uptake of material in gallbladder
a patient with symptomatic cholelithiasis is admitted with elevated ALP and bilirubin - what do you suspect? what next test do you do?
- obstruction of CBD2. USG - will show dilated bile ducts
tx. of common bile duct obstruction
ERCP followed by laparoscopic cholecystectomy
what do you do if a pregnant patient presents with symptomatic gallstones?
manage non-operatively with hydration and pain medication; cholecystectomy after pregnancy
pt with symptomatic gallstones has an elevated serum amylase?
biliary pancreatitis
tx. of biliary pancreatitis
conservative - NPO, NGT, IVF- amylase usually returns to normal quickly and then cholecystectomy can be performed (with intraoperative cholangiogram)
USG examination shows a gallbladder that is distended with fluid that has internal echoes and gallstones - dx?
empyema of gallbladder
tx. of empyema of gallbladder
IV antibioticsemergent exploration w/ cholecystectomy- if risk of surgery too high, percutaneous cholecystostomy to drain gallbladder
USG shows previous removal of gallbladder, dilated CBD and air in the biliary system - dx?
suppurative cholangitis- bacterial infection with bile duct obstruction
tx. of suppurative cholangitis
urgent decompression of bile duct (ERCP w/ spincterotomy)IVF and antibiotics
how might elderly patients present with sepsis?
signs of hypothermia and leukopenia
palpable gallbladder in patient with high fever and signs of sepsis
inflamed gallbladder- emergent cholecystectomy after resuscitation due to high risk of rupture (high mortality)
air in the wall of the gallbladder
emphysematous gallbladder
basic steps in evaluation and tx of acute cholangitis?
- resuscitation and antibiotics2. urgent USG3. ERCP and biliary decompression4. cholecystectomy once stable
CBD stone occuring w/in 2 years after a cholecystectomy
retained stone
CBD stone occuring after 2 years post cholecystectomy
primary CBD stone
tx, if biliary stricture
surgical exploration and bypass with choledochojejunostomy
post-op fever and abdominal pain in a pt after cholecystectomy
can be either infection or biliary leak- order an abdominal USG or HIDA scan- maybe CT scan to R/O hepatic abscess
what do you do if you find a biliary leak or obstruction following cholecystectomy?
ERCP
USG of pt with painless jaundice shows dilated intrahepatic ducts but no dilation of the common bile duct - what do you suspect?
cholangiocarcinoma - Klatskin tumor
Klatskin tumor
tumor of the biliary tree at the bifurcation of the hepatic ducts
next step after finding dilated intrahepatic bile ducts on USG?
ERCP or percutaneous transhepatic cholangiogram w/ biopsy and cytology- not CT- looking for cholangiocarcinoma
tx. of ampullary adenocarcinoma
Whipple’s procedure if resectable- much better prognosis than pancreatic or biliary cancer
tx. of duodenal adenocarcinoma
- if it involves ampulla - Whipple’s- if in first or fourth segment - segmental resection- usually have worse prognosis due to involvement of nearby structures
you find a mass in the gallbladder fossa on USG - what test do you do next? what do you suspect?
- should do a CT scan- suspect malignant gallbladder adenocarcinoma
tx. of gallbladder carcinoma
- open cholecystectomy with wedge resection of liver (2-3 cm margin) and hilar node resection
tx. of gallbladder polyps
> 2 cm = cholecystectomysmaller polyps are usually observed
patient with pancreatitis with a drain for pancreatic abscess suddenly becomes hypotensive and has blood in the drain - what do you suspect?
erosion of the catheter or abscess into a major artery (splenic, gastroduodenal or SMA)- dx. with angiography- tx. embolization
cystic lesion with no internal echoes found in liver - what might this be? what do you do next?
- simple cyst2. no further management required - usually asymptomatic
liver USG finding of multilocular cyst with calcifications in the wall and internal echoes - what might this be? management?
- echinococcal cyst2. tx. operative sterilization with injection of hypertonic saline followed by excision of cyst taking extreme caution not to spill
you suspect a cavernous hemangioma on USG - how can you confirm the diagnosis?
- labelled RBC scan2. bolus enhanced CT or MRI scan - vascular lesion that fills from the periphery to the centre
tx. of liver hemangioma
usually asymptomatic and found incidentally; removal is not warranted
indications for surgical removal of benign hepatic masses
- symptomatic lesions2. lesions with high risk of spontaneous rupture3. lesions with uncertainty of diagnosis
which two liver lesions have high risk of bleeding with biopsy?
hemangiomahepatic adenoma
CT scan shows a liver lesion with a central stellate scar - what do you do next? and what is your tx?
- liver biopsy to establish diagnosis of focal nodular hyperplasia2. no tx. indicated
what is the tx. for hepatic adenoma?
surgical resection if large or persistent due to risk of rupture and HCC development
preferred tx. for multiple, small pyogenic liver abscesses
broad spec. IV antibiotics for 4-6 weeks
first test to do in suspected liver cancer?
CT scan of abdomen and chest
diagnostic test to confirm ruptured hepatic adenoma?
CT scan
tx. of pyogenic liver abscess
drainage - either percutaneously or surgicallyIV antibiotics
tx of multiple, small pyogenic liver abscesses
IV antibiotics for 4-6 weeks
tx. of amebic abscess
metronidazoleparomomycin - to eliminate intraluminal cysts
features of hemolytic jaundice
bilirubin 6-8 - mostly UCB, no CBno bile in urine
management of obstructive jaundice- first test?
USG - look for dilated intrahepatic ducts
next test after USG in obstructive jaundice?
ERCP - possibly w/ stone removal if due to gallstones
pt comes in with progressive obstructive jaundice and weight loss; on USG you see dilated intra/extrahepatic ducts and a very distended, thin-walled gallbladder - dx?
malignant obstructive jaundice- MCC is adenoca of head of pancreas, ampulla of vater or cholangiocarcinoma
Courvoisier-Terrier sign
dilated intrahepatic and extrahepatic ducts with a very distended, thin-walled gallbladder
an USG finding shows thin-walled, distended gallbladder in pt with jaundice - next steps?
CT scanERCP - if CT scan is not diagnostic
pt with obstructive jaundice also has postive FOBT and anemia - dx?
likely ampullary carcinoma - can bleed into lumen of duodenum
dx. of ampullary carcinoma
endoscopy
in addition to obstructive jaundice and distended gallbladder on USG, what are the characteristic pain findings in pancreatic cancer?
persistent, nagging mild pain deep in epigastrium and upper back
you suspect pancreatic cancer, you do a CT scan and no mass is seen - what is the next step?
upper endoscopy with EUS
what features deem a pancreatic cancer unresectable?
distant metslocal invasion of visceral vesselsLN mets in periaortic or celiac nodes
indications for removal of gallbladder in asymptomatic patients?
immunocompromised patientsporcelain gallbladderstones > 3 cm
pt has signs of biliary colic along with sx of peritoneal irritation, fever and elevated WBC count - dx?
acute cholecystits
when do you suspect acute cholangitis?
signs of biliary colic, peritoneal irritation, high fever, elevated WBC count, elevated bilirubin and ALP
Reynold’s pentad
RUQ painhigh feverjaundiceconfusion (neuro sx.)hypotension (shock)
how do you confirm dx of acute cholangitis?
USG - will show dilated ducts
tx of acute cholangitis
IV antibiotics and emergent decompression with ERCP –> follow with cholecystectomy once pt stable
tx of biliary pancreatitis if pt does not improve or deteriorates on conservative tx
ERCP w/ sphincterectomy
older patient presents with abdominal pain and increased amylase levels - next step?
must R/O other causes such as mesenteric ischemia or volvulus- order CT scan
signs of acute pancreatitis, elevated amylase and high hematocrit
acute edematous pancreatitis
management of hemorrhagic pancreatitis
intensive support in ICUserial CT scans daily
about 10 days after onset of pancreatitis, patient begins to spike fever and has leukocytosis - what are you considering? what test do you order?
pancreatic abscess- order CT scan with contrast
tx of pancreatic abscess
drainageimipenem or meropenem (pts with seizures)
2 most common ways of presentation of pancreatic pseudocyst
- can occur few weeks after tx of pancreatitis OR after blunt trauma to the abdomen in a car accident for ex
CF in pancreatic pseudocyst
vague upper abdominal discomfortearly satiety (pressure symptoms)ill-defined epigastric mass
diagnostic test of choice for pancreatic pseudocyst
CT scan
approach to management of pancreatic pseudocyst
smaller than 6 cm - observe for spontaneous resolution> 6 cm or 6 weeks - surgical intervention
best surgical tx. for pancreatic pseudocysts
endoscopic cystogastrostomy- always take biopsy to ensure it is actually inflammatory
best diagnostic test in chronic pancreatitis
ERCP - chain of lakes appearance
Hutchinson freckle
large, macular brown lesion on the cheek, may be present for many years or decades and is a precursor for lentigo malignant melanoma
management of Hutchinson freckle
close observation looking for changes
malignant melanoma on the sole of the food
acral-lentiginous melanoma - MC in dark-skinned pts; tend to be thicker with poorer prognosis
tx. of subungual melanoma
amputation at the DIP
tx. of anal melanoma
thick lesions require abdominoperineal resection of the anorectum- very poor prognosis
Characteristics of basal cell carcinoma (4)
Waxy, raised lesion or punched out ulcer Indolent, slow growing Does not metastasize - no enlarged LNPreference for upper face
Diagnosis of basal cell carcinoma
Full thickness biopsy at edge of lesion (punch or knife)
Tx. Basal cell carcinoma
Surgical excision with clear margins (1mm; 2-4 mm for larger, more aggressive lesions)Topical 5FU or radiation may also be used
Non-healing indolent ulcer on the lower lip that has been enlarging for 8 months
Consider squamous cell carcinoma
Diagnosis of squamous cell carcinoma of skin
Full thickness biopsy at edge of lesion
Tx. Squamous cell carcinoma
Surgical resection with wider margins (1 cm)If palpable LN, need to do node dissectionLocal radiation also an option
When can you do an incisional biopsy of melanoma?
If lesion is > 2-3 cm or if the lesion is contiguous with important structures on the face
What are the excision margins for melanoma?
1 mm for superficial melanoma 2-3 cm margin if deep melanoma
Tx of in situ melanoma
Re- excise lesion with 0.5-1 cm margin of normal tissue
What is a common presentation of melanoma mets
Mets to peritoneal cavity and viscera - common presentation is small bowel obstruction. - exploration indicated and prognosis is poor
what are the exceptions to surgical repair for hernias?
- umbilical hernias in pts < 2 yo2. esophageal sliding hiatal hernias
management of hernias in adults
elective surgical repair
incarcerated hernia
hernia that cannot be pushed back/reduced
tx of paraesophageal hernia
surgical repair due to risk of gastric volvulus and necrosis
ambylopia
vision impairment resulting from interference with processing of images during first 6-7 years of life
tx. of strabismus in a young infant
must be surgically corrected when diagnosed
you notice a white pupil on a baby - what should you consider?
white pupil (leukocoria) = retinoblastoma- urgent/emergency opthalmologist consult
woman complains of frontal headache and nausea; she sees halos around lights in the parking lot, pupils are mid-dilated, do not react to light, corneas are cloudy and eyes feel hard - dx?
acute glaucoma
tx. of acute glaucoma
drill hole in iris with laser beam to provide drainage route for fluid that is trapped behind anterior chamber
medical tx. of acute glaucoma
systemic carbonic anhydrase inhibitorstopical beta blockersalpha-2 selective adrenergic agonistsmannitol and pilocarpine may also be used
pt presents with swollen, red, hot, tender eyelid on left eye with fever and leukocytosis; pupil is dilated and fixed and there is very limited motion of the left eye
orbital cellulitis
management of orbital cellulitis
opthalmologic emergency1. CT scan - to assess extent of infection2. surgical drainage
tx. of chemical burns of the eye (ex. draino, bleach)
copious irrigation with cold water for atleast 30 minutes before patient comes to ER
pt. reports seeing flashes of light at night when his eyes are closed as well as “floaters” during the day and a cloud at the top of his visual field
retinal detachment
tx. of retinal detachment
opthalmologic emergency- laser tx. to spot weld the retina and prevent further detachment
an older patient calls you because he suddenly lost vision in his right eye - dx?
embolic occlusion of retinal aa
management of embolic occlusion of retinal aa
opthalmologic ER- tell patient to take aspirin, breathe into paper bag and someone press hard on eye and release it and hurry up to ER
a diabetic patient complains to you about blurry vision that he usually gets after eating a big dinner and watching tv…
the lens swells and shrinks in response to fluctuations in blood sugar
eye care recommendation for diabetics
regular opthalmologic follow-up for retinal complications
newborn child has uneven gluteal folds; on P/E they can be displaced posteriorly and snapped back into place - dx?
developmental dysplasia of the hip
what test should be ordered if you suspect developmental dysplasia of the hip?
USG
tx. of developmental dysplasia of hip
Pavlik harness - abduction splinting
6 yo boy comes in due to development of limping and decreased hip motion; he also complains of knee pain on the same side and walks with an antalgic gait - dx?
suspect Legg-Perthes disease (avascular necrosis of the capital femoral epiphysis)
what test do you do if you suspect Legg-Perthes disease?
AP and lateral XR of the hip
tx. of Legg Perthes disease
controversial- contain the femoral head w/in the acetabulum with casting and crutches
a 13 yo obese/lanky boy comes in because he recently started limping and has pain in his groin; when he sits you notice the sole of the foot on the affected side points toward the other foot - what do you suspect? what test should you order?
slipped capital femoral epiphysis- order AP and lateral XR
what do you find on PE in slipped capital femoral epiphysis?
there is limited hip motion and when the hip is flexed, the leg goes into external rotation and cannot be internally rotates
tx. for slipped capital femoral epiphysis
orthopedic surgery - pin the femoral head into place
a mother brings her toddler in because he refuses to move one of his legs; he was recently sick with the flu and now he is in pain and holds the leg with the hip flexed, in slight abduction and external rotation - what do you suspect?
septic hip - his ESR will be elevated
tx. for septic hip in a toddler
aspiration under general anesthesia and open arthrotomy for drainage if pus present
a child with a febrile illness (no history of trauma) present with persistent, severe localized pain in a bone - dx?
acute hematogenous osteomyelitis
how do you confirm dx. of osteomyelitis? and how would you tx it?
MRI- give antibiotics
a 2 year old child is brought in by concerned parents bc he is bow-legged
genu varum - normal up to age of 3
Blount disease
genu varum that persists after age 3- disturbance of the medial proximal tibial growth plate- should be tx. surgically
a 5 yo child is brought in by parents because he is knock-kneed
genu valgus is normal between ages 4-8 and no treatment is needed
physical exam findings in Osgood-Schlatter disease
aka. osteochondrosis of tibial tubercle- persistent pain/localized tenderness over tibial tubercle that is aggravated by contraction of quadriceps
tx. of Osgood-Schlatter disease
first - RICEsecond - immobilization of knee in an extension or cylinder cast for 4-6 weeks
deformities present in club-foot (4)
plantar flexion of ankleinversion of footadduction of the forefootinternal rotation of tibia- both feet are turned inward
tx. of clubfoot deformity
serial plaster casts in the neonatal period- if surgery done, it should be done after age 6-8 months but before age 1-2
what is the most important thing in management of scoliosis?
the disease will continue progressing until skeletal maturity is reached, so if you patient is before puberty they should be braced to prevent progression- surgery for severe cases
what do you do if you do an XR on a child with a broken bone in a cast and it shows significant angulation of the broken bone?
nothing… kids have tremendous ability to heal and remodel broken bones
what kind of fracture can you suspect in a young patient who breaks their arm by hyperextension injury?
supracondylar fracture of humerus
why is a supracondylar fracture in a child worrisome?
may produce vascular or nerve injuries resulting in Volkmann contracture
Tx. of fracture of long bone, involving the growth plate and epiphysis (laterally displaced but in one piece)
closed reduction and cast
tx. of fracture that goes through the growth plate
precise alignment with open reduction and internal fixation (or else growth will be disturbed)
MC primary malignant bone tumor
osteogenic sarcoma- location: around knee (lower femur, upper tibia)
patient population that usually gets osteogenic sarcoma
young adolescents - between age 10-25
second MC primary malignant bone tumor
Ewing Sarcoma- young children 5-15 yo- usually in diaphysis of long bones
a 66 yo woman picks up a bag of groceries and breaks her arm - what should you immediately think of and what further tests are needed?
- think of bone tumor (usually metastatic in older patients)- order XR, whole body bone scans and CT scans to find the primary tumor
an older woman presents with a soft tissue mass in her thigh that has been growing for months; it is firm and fixed to surrounding structures - dx? test?
- think of soft tissue sarcoma- order MRI and refer to experts
