WiseMD Modules Flashcards
Give 3 short term complications of thyroid surgery
3 short term complications of thyrodectomy
- Hematoma/seroma- need to be careful here b/c these can compress the airway
- Hypoparathyroidism => hypocalcemia
- look out for muscle hyperreactivity and perioral numbness - Voice hoarseness 2/2 manipulation of the recurrent laryngeal nerve
Define flail chest? Clinical significance?
Flail chest = fracture of 3 or more consecutive ribs so that an entire part of the chest wall moves independently = paradoxical breathing
-example of how trauma can cause the ‘B’ in ABCs to be dysfunctional
3 indications for surgical removal of thyroid tissue
3 indications for thyroid surgery
- malignancy
- symptomatic mass
- compressive symptoms - hyperfunctioning
- toxic adenoma refractory or contraindicated medical tx
29 yo F, 6 wks s/p gastric bypass w/ diaphoresis, abd pain, nausea, dizziness after dinner
-normal VS, nontender abdomen, normal abdominal CT
Dx?
Dumping syndrome
75 yo M presents w/ jaundice and 20 lb wt loss
-afebrile, nontender abdomen, palpable mass in RUQ
(a) What sign is this?
(b) Most likely diagnosis?
(a) Courvoisier’s sign = presence of enlarged GB on physical exam that is not tender and accompanied by mild jaundice
(b) Most likely cause of Courvoisier’s sign = malignant in head of the pancreas (pancreatic cancer)
Intermittent episodes of palpitations and excessive sweating + recent wt loss
Suspect pheochromocytoma = catecholamine producing tumor
-also expect HTN and headaches
Direct vs. indirect inguinal hernia
(a) Relationship to the inferior epigastric vessels
(b) Ability to extend into the scrotum
(c) Age
Direct inguinal hernia (thru Hasselbach’s triangle) 2/2 weakness in the abdominal wall
(a) medial to inferior epigastric vessels
(b) Can exit via superficial inguinal ring, but can’t extend into the scrotum
(c) Middle-aged/elderly since abdominal wall weakens w/ age
Indirect inguinal hernia
(a) sac protrudes laterally to the inferior epigastric vessels
(b) Can extend down into the scrotum and even be difficult to differentiate from testes
(c) Any age, especially young (since 2/2 congenital patency of inguinal canal)
45 yo F, 2 yrs s/p lap Roux-en-Y p/w 1 mo burning epigastric pain
- no N/V, masses, fever, tenderness
- only medication: NSAIDs for migraines
Most likely diagnosis?
Marginal ulcer- pts w/ gastric bypass have high risk of marginal ulcers (ulcers at gastrojejunal anastomosis)
-RF = NSAIDs
Marker for medullary thyroid cancer
Calcitonin = marker for medullary thyroid cancer
-MTC usually derived from C-cells and C-cells produce calcitonin
Medullary thyroid cancer accounts for 3% of all thyroid cancers (80% of thyroid cancers being papillary carcinoma)
2 risks of full axillary LN dissection over sentinel LN biopsy
- lymphedema
- nerve injury
Good abx choice for ppx in pt undergoing lap choley for acute cholecystitis
Cefazolin
-want coverage of GN bacilli, enterococcus, and clostridia species
50 yo F w/ US finding of suspicious breast mass
- OCPs x8 yrs, first child at age 32
- mother had breast cancer dx at 55
- PE: nontender w/ b/l, somewhat irregular, dense tissue and no discrete masses or lymphadenopathy
Next step
Next step to evaluate suspicious lesion after imaging = stereotactic (imaging guided) core-needle biopsy
-preferred over excisional biopsy which is an open procedure (more invasive)
Pain w/ defecation that lingers long afterwards
Hx and mechanism
Anal fissure
-pain lingers afterwards 2/2 spinchter spasm
T3 vs. T4
(a) Which is released from thyroid gland?
(b) Which is more active biologically?
T3 vs. T4
(a) 80% of the hormone released from the follicular cells is in the form of T4
(b) Then T4 is peripherally converted to T3, T3 = active form
Next step in workup when suspecting anastomotic leak in pt POD1 from lap gastric bypass
Upper GI series w/ water-soluble contrast
-need to rule out (or diagnose) a leak
Acute cholecystitis risk greater in M or F?
F to M 3:1 risk ratio
Describe why a hx of chronic cough might be relevant to someone w/ inguinal hernia
Anything that increases intraabdominal pressure (chronic cough, urinary retention 2/2 BPH, chronic constipation) can exacerbate abdominal wall hernias => they should be medically optimized before undergoing elective hernia repair
How does breast cancer spread?
Via lymphatics
-primarily to axillary LN, but also to internal mammary chain
4 days s/p elective cholecystectomy pt presents w/ severe abdominal pain and fever
- US revealed mild fluid in hepatorenal recess
- Xray shows no free air or dilated bowel
Next best step?
HIDA scan = nuclear imaging study to r/o bile leak, clip across the duct, or duct injury
26 yo M w/ painful indirect inguinal hernia on exam, next best step?
Symptomatic => Elective open inguinal hernia repair (surgery) at pt’s convenience
- watch and wait: noo b/c complications (strangulation etc) are dangerous (could do this if the pt was asymptomatic b/c then low risk of complications)
- wouldnt use an external sling: those for old dudes of who surgery is contraindicated
Use of ultrasound for breast mass in F over 40 yoa
Females over 40- mammogram as the primary mode of breast imaging
-but US can be helpful to assess further in pts w/ dense breast tissue
44 yo M 8 wks s/p lap adjustable gastric band placement p/w nausea and pain after eating
-not tolerating solid or liquids for 2 days
(a) Most likely dx
(b) Next step
(c) Tx
(a) Either band is too tight or it’s slipped
(b) Next step = upper gastrointestinal (GI) contrast study
(c) Tx = emergent decompression of band by removing fluid from the port = band adjustment
- deflate band by removing saline from the port
Most common location of internal hernia in pt s/p lap gastric bypass
Transverse megocolon (just the transverse colon)
-retrocolic (behind the colon) position of the Roux limb (which is what is routinely done) predisposes pts to developing an internal hernia thru the transverse colon
Name 2 feared complications of biliary colic (why we electively remove GB before it gets worse)
- cholangitis (infection/inflammation of the bile duct) 2/2 bile stasis
- gallstone pancreatitis
Mechanism of Dumping syndrome
Explain symptoms
Dumping syndrome = complication/side effect of gastric bypass, food (typically large carb load) emptys quickly from the stomach and enters SI undigested, causes rapid entry of water into intestinal lumen (fluid shift) =>
- hypo-osmotic diarrhea
- abdominal distention from excess fluid => crampy abdominal pain, N/V
- hypovolemia => vasomotor symptoms
Can also cause hypoglycemia b/c rapid dumping triggers large insulin bolus from the pancreas
Cause of pain in an indirect inguinal hernia
Compression of the ilioinguinal nerve (innervates groin and upper inner aspect of the thigh)
-lot less common (but possible) to be affected: genital branch of the genitofemoral nerve (innervates lateral aspect of the scrotum)
2 main complications of gastric bypass surgery
Complications of gastric bypass
- Anastamosis leak = leak at the connection site btwn the stomach and intestines
- risk below 1% - SBO
- risk below 2%
27 yo M p/w perianal pain, swelling, and pus drainage x2 wks
- 10lb wt loss, abdominal cramping, occasional mucus in stool, 7-8 stools/day
- mild abdominal TTP
- rectal exam: chronic-appearing fistula-in-ano
Dx
Crohn’s disease
-Crohn’s (not UC) is assocaited w/ perianal disease and fistualas
Mgmt for intra-abdominal abscess 2/2 appendicitis
Start IV abx, then do image-guided percutaneous drainage of the abscess
Best tx for preterm infant w/ bilateral reducible inguinal hernias
High ligation of sac
-never use mesh
Describe the three parts of the Glasgow coma scale
(a) Max score
Glasgow coma score to quickly assess neurologic damage
- eye opening: 1-4 pts
- motor response: 1-6 pts
- verbal response: 1-5 pts
(a) Max of 15
Most important prognostic factor for breast cancer
Lymph node involvement
Indications for mastectomy over lumpectomy
- pt prefers mastectomy (that’s legit…pt choice baby)
- presence of a contraindication to radiation (can’t make the time commitment)
- multifocal or extensive disease (not just unifocal)
- unable to obtain negative margins on a previous lumpectomy
56 yo p/w 2-cm hard, irregular, fixed breast mass w/ overlying skin dimpling
-1.5 cm hard mass in right axilla, FNA of LN shows adenocarcinoma
Next step
- Neoadjuvant chemo
- locally advanced breast cancer gets chemo before surgery - Modified radical mastectomy
- Adjuvant radiation to decrease risk of recurrence
21 yo M p/w severe anal pain x24 hrs, worsening over past 3 hrs
- tachy
- rectal exam cannot be completed due to severe pain
Next step
Exam under anesthesia in OR
-high suspicion for intramuscular perirectal abscess => need to drain abscess
How long after lap-appy are abx indicated?
Once the appendix is removed there is no indication for continuation of abx
- give w/in 1 hr prior surgical incision for wound infection ppx, but abx not indicated at all after procedure
- max is to give for 24 hrs post-op
Management of asymptomatic adrenal hormones of the following types
(a) Pheo
(b) Aldosteronoma
(c) Cortisol
(a) Pheo- do surgery regardless b/c of high risk of hypertensive crisis
(b) Aldosteronoma- try medical tx w/ spironolactone before going to surgery
(c) Cortisol- usually do surgery unless pt is at high surgical risk
Give 2 possible long term complications of thyroid surgery
Possible long term complications of thyroid surgery
- Permanent hypoparathyroidism
- tx = give Ca and vit D supplementation - Permanent hoarseness
- if b/l injury to recurrent laryngeal, can lead to airway compromise
Describe how to perform a physical exam to detect a hernia
Have pt stand (gravity brings it down) and cough or bear down (increase intraabdominal pressure) and see if any abdominal contents protrude out
7 days s/p lap appy, 24 yo F p/w mild nausea and tenderness in RLQ w/o rebound
(a) Next step?
(b) Most likely dx
Suspecting (b) intra-abdominal abscess
(a) First step to assess = CT scan
Core needle bx shows atypical ductal hyperplasia, estimate relative risk of breast cancer
Atypical ductal hyperplasia is the step btwn ductal hyperplasia (benign, normal surveillance guidelines) and DCIS
-carries a 4x increase in relative risk of breast cancer
39 yo F, 6 wks s/p Roux-en-Y gastric bypass
- doing well w/ liquid and then solid diet, but progressively early satiety and postprandial nausea x2 wks
- no pain
(a) Most likely diagnosis
(b) Next step in mgmt
(a) Stenosis of the gastrojejunostomy
- strongly suggested by inability to tolerate progression from solids to liquids
(b) Next step = upper GI contrast study
- visualize stenosis
- can also treat the stenosis using balloon dilators
Lab test to diagnose pheochromocytoma
Pheo = catecholamine producing tumor
Dx by measuring urine or serum metanephrin and normetanephrines (catecholamine breakdown products)
Medical therapy for breast cancers that are
(a) ER/PR positive
(b) HER2/neu posiitve
Hormone therapy
a) ER/PR positive: Tamoxifen (SERM) or aromatase inhibitor
(b) HER2/neu positive: Herceptin (receptor blocker
Describe the 3 possible types of thyroid nodules
(a) First step in differentiating
Types of thyroid nodules
- Malignant
- papillary (80%), follicular (15%), medullary (3%), anaplastic (2%) - Benign
- hyperplastic, colloid - Hyperfunctioning = toxic adenoma
What determines the length of the Roux limb in a gastric bypass?
BMI
Roux limb 75 cm - 150 cm
75 for BMI 35, 150 cm for BMI of 50 or above
Which layer of tissue needs to be divided to expose a
(a) femoral hernia
(b) indirect inguinal hernia
(a) Femoral hernia: divide the transversalis fascia to expose the femoral canal
(b) Indirect inguinal hernia: patency of processus vaginalis is the hallmark of an indirect inguinal hernia
51 yo s/p gastric bypass 10 yrs ago presenting w/ worsening abdominal pain, N/V x3 days
- tachycardic, hypotensive
- abdominal CT: dilated proximal small bowel w/ profoundly dilated mid jejunum
(a) Dx
(b) Next step
(a) Bowel obstruction, most likely 2/2 internal hernia
(b) Emergent laparoscopy
- can’t NG tube and serial abdominal exam (as you would in SBO in pt w/o gastric bypass) b/c internal hernia can more quickly lead to ischemia/necrosis and perf
What is dexamethasone?
Dexamethasone = steroid w/ same function as cortisol (so supress CRH/ACTH release) but doesn’t change the measurable serum level of cortisol
Parafollicular cells
(a) Location
(b) Purpose
Parafollicular cells = C cells
(a) thyroid cells
(b) produce calcitonin to inhibit ostoclast activity and decrease serum calcium
When to operate on abdominal aortic aneurysm?
When it gets above 5.5 cm in diameter
-where rupture risk starts to be above 3-4%
If below 5.5cm- operate if symptomatic
40 yo F w/ 1.5cm firm, mobile, nontender, slightly irregular but well-defined right breast mass
- no skin changes or dimpling
- mammo: dense tissue w/ no suspicious lesion
- US: does not demonstrate cystic lesion
Next step
Next step = core-needle biopsy
-even if not seen on imaging, important that palpable masses get biopsied
Core-needle bx much more accurate than FNA (high false negative rate)
2 structures you need to identify w/ laryngoscope for intubation
Identify epiglottis and vocal cords w/ laryngoscope, then pass the tube thru the vocal cords and inflate 5-10cc of air and connect tube to vent
Clinical features of Cushing’s syndrome
Truncal obesity, easy bruising
- classic stretch marks
- weakness
- osteoporosis
- HTN, DM
- hirsuitism
- ‘buffalo hump’
Example of how anatomy can make a candidate unsuitable for a conventional endograph repair of an AAA
To do endograph repair of abdominal aortic aneurysm (thread up internal liner thru femoral veins) the iliac arteries must be thick enough for endograph to pass, and need a long enough segment of normal aorta below the renal artery for the graft to seal
-so a short aortic neck is unsuitable for conventional endographic repair
29 yo POD1 s/p lap gastric bypass w/ severe tachycardia and left shoulder pain
Dx
Until proven otherwise, s/p lap gastric bypass w/ tachycardia = anastomotic leak
-persistent tachy = very sensitive finding for anastomotic leak
Indications for bariatric surgery
- BMI > or = 40
- BMI > or = 35 w/ comorbidities: OSA, DM, HTN
Differentiate lab values expected in
(a) Cholelithiasis
(b) Cholecystitis
(c) Choledocholithiasis
(d) Cholangitis
(e) Gallstones pancreatitis
Lab values
(a) Cholelithiasis- grossly normal labs
(b) Cholecystitis (inflammed GB) - white count 12-15k
(c) Choledocholithiasis- elevated LFTs, white count, and alk phos
- alk phos made in the walls of the CBD
(d) Cholangitis (inflammed BD): WBC to 20k, both bili and AST/ALT elevated, elevated LDH
- can cause sepsis
(e) Gallstone pancreatitis: same as cholangitis + elevated amylase/lipase
What is adrenal venography w/ serum sampling?
Very invasive, but you put catheters bilaterally into adrenal veins to measure the difference in the hormone production
Objective way of assessing ‘disability’ in the ABCDEs of trauma rescucitation
Disability refers to neurologic status Objective test = Glasgow coma score -eye opening: 1-4 pts -motor response: 1-6 pts -verbal response: 1-5 pts
Describe the pathophysiology of Murphy’s sign
Murphy’s sign: liver and GB are pushed down by the diaphragm w/ inspiration: pt stops breathing (GB is tender) as GB comes into contact w/ examiner’s finger’s
-so w/ inspiration the diaphragm pushes the inflamed GB into the examiner’s hand = winces w/ a ‘catch in breath’
What is Hasselbach’s triangle?
(a) Clinical relevance
Hasselbach’s triangle = part of the transversalis fascia that lines the floor of the inguinal canal
(a) Place where abdominal contents protrude thru forming a direct inguinal hernia
21 yo M college basketball player w/ groin pain found to have bilateral reducible inguinal hernias
Best mgmt?
Laparoscopic hernia repair
-wouldn’t do watchful waiting in someone so young (and
Open hernia is indicated in all cases except: bilateral inguinal hernias, surgery contraindicated
Cholecystitis vs. cholangitis
Inflammation/infection of the gall bladder (cholecystitis) vs. inflammation/infection of the bile duct (cholangitis
Risk factors for AAA
- male gender
- age over 50
- smoking
- HTN, vascular disease
- FHx
Contents of the inguinal canal in M and F
M- spermatic cord
F- round ligament
HTN could be indicate of which adrenal masses?
HTN and adrenal mass: basically all except sex-hormone producing
- Cushing’s from excess cortisol
- Pheo from extra epi and norepi
- Aldosteronoma from excess blood volume
Most common location for aortic aneurysms
95% are infrarenal (below the renal arteries)
Is gastric bypass restrictive or malabsorptive?
Both- it’s a combo
- restrictive b/c you make the stomach much smaller (15mm pouch)
- malabsorptive b/c you cut out a lot of intestines: leave a 75-150 cm Roux limb of intestines
What is Reynold’s pentad
Charcot’s triad (RUQ pain, fever, jaundice) + sepsis/shock/altered mental status
-suggesting diagnosis of obstructive ascending cholangitis
Two important parts of abdominal exam for pre-op workup for bariatric surgery
- Scars for evidence of evidence of previous abdominal surgery
- adhesions may make laparoscopic more difficult - Assess for hernias- concomitant repair can be done
Pt w/ clinical exam findings almost certain slamdunk for cancer- next step?
1st do mammography to get BI-RADS category
-core needle biopsy will eventually be needed, but do mammogram first to characterize mass and look for any other nonpalpable lesions that might also deem further evaluation
Deciding factor for if hernias should be surgically repaired
Symptoms!?
Asymptomatic- watch and wait, low rate of complications
Symptomatic- surgically repair
Lumpectomy w/ radiation vs. mastectomy
(a) Rate of recurrence
(b) Survival
(a) Rate of recurrence:
lumpectomy w/ radiation = 10%
mastectomy = under 5%
(b) Survival: no difference!!!
48 yo M has 6.2 left adrenal nodule found incidentally on CT
-lab results do not demonstrate functionality
Next step?
Laparascopic adrenalectomy b/c of size
Adrenal masses over 6cm have a 25% chance of malignancy => remove regardless of symptoms
-adrenal masses under 4cm are most likely benign (2% malignancy) => could watch and wait
52 yo G3P1 F discovers breast mass during self-exam, 1-cm hard, irregular, immobile, nontender mass in outer lower quadrant of right breast
-no skin retraction or axillary lymphadenopathy
Most likely dx?
Cancer (most likely DCIS)- irregular, immobile, nontender mass
Briefly go through ABCDE of trauma resuscitation
A- airway patency
B- breathing (auscultate chest b/l, pulse ox)
C- circulation (feel pulses, take BP)
D- disability (evaluate neurological status)
E- Exposure (check entire body for wounds etc)
Calcitonin
(a) Purpose
(b) Release stimulated by
(c) Couterregulatory hormone
Calcitonin
(a) Decrease serum calcium
- inhibits osteoclast activity (inhibit bone breakdown)
- increased renal excretion of Ca2+
(b) Calcitonin release stimulated by high serum calcium
(b) Counterregulatory hormone of calcitonin = PTH
Clinical manifestation of hernia
- intermittent bulge in groin
- pain radiating to the testicles
- started when lifting something heavy (increased intra-abdominal pressure)
Ddx for abdominal pain after cholecystectomy
- bleeding
- bile leak
- missed enterotomy (surgical cutting open of intestines, aka knicked the bowel)
- common bile duct injury
Mechansim of fistula-in-ano as a complication of perianal abscess
Chronic granulation tissue that fails to heal
-start in the anal crypts and erode through the sphincter muscle
Mechanism of incarceration in inguinal hernia
Adhesions btwn the abdominal wall and the intestines
40 yo F p/w 10hrs severe cramping, N/V
- 12 mo s/p lap gastric bypass
- Abdominal plain film: dilated loops of small intestines and dilated excluded stomach
Next step
Emergent diagnostic laparoscopy = laparoscopic repair of obstruction 2/2 internal hernia
- Dilated loops of bowel in gastric bypass = bowel obstruction from internal hernia until proven otherwise
- Can’t delay b/c quickly can cause ischemic bowel/perf
42 yo M w/ 3cm left adrenal nodule found incidentally on CT
Next step
3 cm is below the size limit (4cm) for concern of malignancy
Next step is to assess for functionality- is the nodule producing hormones? (30% of adrenal masses are hormonally active)
-order BMP: K+
-24 hr urine sample: urine serum meta and normetanephrines to r/o pheo
50 yo M w/ found to have asymptomatic small inguinal hernia in right groin during routine physical exam
Next step
Reassurance and tell pt to return if symptoms develop
-asymptomatic hernias = low complication risk => can watch and wait
Purpose of ultrasound jelly
Remove artifact made by the air space btwn the transducer and the skin
Amount of wt loss expected from gastric bypass surgery
Expect about 70% wt loss
-so for every 100 lbs overweight a person is, expect 70 lb wt loss
Biggest risk of endograph repair of AAA
Endoleak = bleeding around the graft
-residual blood flow thru the aneurysmal sac b/c not directly replacing the weakened vessel wall like you are w/ an open repair
23 yo F wants bariatric surgery
- doesn’t want any malabsorptive procedure
- wants to get pregnant after
Best option?
Laparosocopic gastric banding = only one w/o a malabsorptive component
-recall: gastric bypass has both restrictive and malabsorptive component
What stimulates release of cortisol from adrenal medulla?
CRH from the hypothalamus stimulates ACTH release from pituitary
-ACTH stimualtes cortisol release
Significance of BI-RADS guidelines
BI-RADS guidlines = standardized way of reporting/communicating risk of breast cancer based on imaging findings
-categories based on imaging to convey level of suspicion and/or recommended management
1 = negative 2= benign 3 = probably benign 4 - suspicious for malignancy 5 = highly suggestive of malignancy 6 = proven malignancy (known on biopsy)
How can you noninvasively guess benign vs. malignant adrenal tumor?
By density on CT scan (Houndsfield units), also can see on MRI
-less dense indicates benign, very dense on CT indicates malignant adrenal mass
Pts w/ gastric bypass are most prone to developing deficiency in which vitamin?
B12
Less surface area of stomach => less intrinsic factor => decreased ability of intestines to absorb B12
Courvoisier’s sign- what is it?
Most likely diagnosis
(a) Courvoisier’s sign = presence of enlarged GB on physical exam that is not tender and accompanied by mild jaundice
(b) Most likely cause of Courvoisier’s sign = malignant in head of the pancreas (pancreatic cancer)
What step may be necessary after thyroid removal in thyroid cancer pt
Radioactive iodine to really kill any thyroid tissue that may have been left over
28 yo F p/w “something falls out of my rectum w/ every BM and I have to push it back in”
-rectal mucosa protrudes from anus when she strains
Dx
Internal hemorrhoids
- often accompanied by BRB w/ prolapsing of tissue being strangled
- reducible and minimal pain => can’t be external
- associated w/ pregnancy and straining for defecation
48 yo w/ 1cm hard irregular mass in right breast, core needle biopsy showing infiltrating ductal carcinoma, HER2/neu negative, ERPR positive
Next step
- Lumpectomy w/ sentinel node biopsy
2. Radiation (to decrease risk of recurrence) + hormone therapy (since ER/PR positive)
Ultrasound findings of thyroid mass that are suggestive of malignancy
Concerning ultrasound findings
- hypoechogenicity
- irregular borders
- margins not obeying fascial planes
- microcalcifications*
- intranodal vascularity (assess w/ doppler)
Breast surveillance guidelines for
(a) Women over 39
(b) Women 20-39
Breast cancer surveillance guidelines
(a) Women over 39
- annual mammogram
- annual clinical breast exam
- optional monthly self exam
(b) Women 20-39
- clinical breast exam q3 years
- optional monthly self exam
Differentiate cholelithiasis from acute cholecystiti
Difference is time course- intermittent or constant
Cholelithiasis (biliary colic) is when a stone temporarily obstructs the bile duct as it contracts to release bile, when BD isn’t contracting there isn’t obstruction => pain is intermittent
-stone goes in and out of duct
Acute cholecystitis is when the stone remains stuck in (and obstructing) the bile duct => constant pain
Complications of patent processus vaginalis
Patent processus vaginalis:
- peritoneal fluid can travel down = hydrocele
- blood can accumulate = hematocele
- intestines can protrude = indirect inguinal hernia
- also testicular tosion since lack of attachment to the inner lining of the scrotum leaves the testicles free to twist
Mechanism of direct vs. indirect inguinal hernia
Direct inguinal hernia- 2/2 weakening of the abdominal wall
Indirect inguinal hernia- 2/2 failure of embryonic closure of deep inguinal ring after the testicle has descended
-inguinal ring left more open than necessary for the spermatic cord
Best imaging study for diagnosis of AAA
Best imaging study to diagnose AAA is an abdominal Xray
-AAA made visible by a rim of calcification
Then if operating usually need CT to give precise measurement and measure extent of disease
What cell produces the hormone that is the major regulator of our metabolic rate
T3/T4 are the major regulators of our metabolic rate- produced by thyroid follicular cells
How does aldosteronoma => HTN
Aldosterone (release stimulated from RAAS cascade when low renal perfusion is sensed) stimulated Na+ retention and K+ secretion
First step of labs when suspecting hormone producing adrenal mass
- BMP
- -hypernatremia/ (1)hypokalemia may indicate aldosteronoma
-(2) Urinary meta and normetanephrines to r/o pheochromocytoma (catecholamine producing tumor)
(3) Can do dexamethasone suppression test if suspect Cushing’s
- Only order sex hormones if see clinical reason: virilization, feminization
(4) Plasma aldo/renin ratio: under 20 r/o aldosteronoma
Most common thyroid malignancy
Papillary thyroid cancer (from follicular cells): 80% of thyroid cancers
- 15% follicular
- 3% medullary (only one that is from C-cells)
- 2% anaplastic
40 yo w/ breast mass
- Core needle biopsy: ERPR negative, HER2/neu negative, infiltrating ductal carcinoma
- Lumpectomy: clear surgical margins w/ negative nodes
Next step
Next step = Chemotherapy and radiation
-triple negative breast cancers tend to be more aggressive => pt would benefit for adjuvant chemo
38 yo F w/ 4-week h/o painful bowel movements associated w/ small blood on TP
- occasional constipation
- no meds or other PMH, normal VS
- PE: posterior midline skin tag that is TTP
Dx
Chronic anal fissure- often from minor anal trauma (constipation)
- pain increased w/ defecation
- most common along posterior midline b/c the least distensible area of the sphincter
Pre-op testing for AAA repair
Nuclear stress test to assess for underlying cardiac pathology
-also sometimes do carotid artery duplex scan 2/2 risk stroke
