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Flashcards in Emma Holiday Review Deck (141):
1

Airway

If trauma patient comes in unconscious?

Intubate

2

Airway

If GCS < 8?

Intubate

3

Airway

-If guy stung by a bee, developing stridor and tripod posturing?

Intubate

4

Airway

-If guy stabbed in the neck, GCS = 15, expanding mass inlateral neck?

Intubate

5

Airway

-If guy stabbed in the neck, crackly sounds with palpating anterior neck tissues?

Fiberoptic Broncoscope, intubate

6

Airway

-If huge facial trauma, blood obscures oral and nasal airway and GCS =7?

Cricothyroidotomy

7

Breathing

You intubated your patient...next best step?

Check for bilateral breath sounds

 

8

Breathing

You intubated your patient, listen with stethoscope.... decreased sounds on the left? Why? What do you do? 

Next step?

Pull back, you have intubated the right mainstem broncus.

Pull back your ET tube.

Chest Xray

9

Patient in traumatic accident with trauma to the chest.

hypertensive, chest hurts, dyspneic, new murmurs

Traumatic Aortic Injury - get to OR immediately!!

10

Physical Exam for Pneumothorax... what might we hear?

Absent/decreased breathe sounds on side of pneumo

hyperresonance to percussion

JVD and trachea deviated away from the pneumothorax = Tension Pneumo

11

Chest Xray abnormal....

Listen and hear decreased breathe sounds, dull to percussion

Hemothorax - Chest tube, let drain

Indication for OR: high output >1.5 liter in chest tube or >200 CC/hr over 1st 4 hours 

12

Chest Xray... Rib fractures in a bad car accident after hitting the steering wheel.

"White out" lung

Tx?

Pulmonary Contusion

Tx: Pulmonary toilet, control pain from rib fractures, coughing, clearing secretions and taking deep breathes

13

Chest Trauma: pt has inward mvmt of the right ribcage upon inspiration.

Dx?

Tx?

Flail Chest, >3 consecutive rib fractures

O2 and pain control (not opiates - can decrease respiratory drive)

14

Chest Trauma: pt has confusion, petechial rash in chest, axilla and neck and acute SOB.

Dx:

When to suspect it?

Fat embolism

after long bone fractures (esp femur)

15

Chest Trauma: pt dies suddenly after a 3rd year medical student removes a central line.

Dx?

When else to suspect it?

Air embolism

Lung trauma, ventilator use, during heart vessel surgery 

16

Cardiovascular

If hypotensive, tachycardiac?

Shock

17

Cardiovascular

If flat neck veins and normal CVP - what type of shock?

Hypovolemic/Hemorrhagic Shock - most common 

18

Cardiovascular

Next step if you have identified your patient is in Hypovolemic/Hemorrhagic Shock?

2 large bore peripheral IV - 2L NS or LR over 20 min followed by blood

19

Cardiovascular

If muffled <3 sounds, JVD, electrical alternans, pulsus paradoxus?

Confirmatory test?

Treatment?

Pericardial tamponade

FAST Scan

Needle decompression, pericardial window or median sternotomy

20

Cardiovascular

If decreased Breathe Sounds on one side, tracheal deviation AWAY from collapsed lung?

Next best step?

Tension pneumothorax

needle decompression**, followed by a chest tube --> DON'T DO A CHEST XRAY!

21

FACT:  Head Trauma

GCS Max Scoring:  15
GCS Min Scoring: 3

Eyes: 4

Motor: 6

Verbal: 5 

22

Head Trauma:

Hematoma, edema, tumor can cause increased ICP

Symptoms?

Tx?

Surgical Intervention?

HA, projective vomiting, AMS

elevate head of the bed, give Mannitol to relieve pressure (water renal function), hyperventilate to pCO2 28-32

Ventriculostomy 

 

23

Neck Trauma

Penetrating trauma - Gunshot wound or stab wound

Zone 3 - boundaries? imaging?

Zone 2 - boundaries? imaging?

Zone 1 - boundaries? imaging?

Zone 3: above angle of the mandible; aortography and triple endoscopy (trachea, esophagus) 

Zone 2: angle of mandible to level of cricoid; 2D doppler +/- exploratory surgery 

Zone 1: below level of cricoid; aortography

24

Abdominal Trauma

If Gunshot wound to the abdomen? (free air under a diaphragm)

DIRECTLY TO OR with Exploratory Laparotomy + Tetanus prophylaxis 

25

Abdominal Trauma

If stab wound & pt is unstable, with rebound tenderness & rigidity or with evisceration?

Ex-lap + tetanus prophylaxis 

26

Abdominal Trauma

-If stab wound but pt is stable?

FAST exam. (intraabdominal bleeding?)
DPL, if FAST is equivocal.
Ex-lap if either are positive. 

27

Abdominal Trauma

If blunt abdominal trauma pt with hypotension/tachycardia.

OR for ex-lap

28

Blunt Abdominal Trauma

if unstable? 

if stable?

unstable: OR + Ex-Lap

stable: abdominal CT

29

Blunt Abdominal Trauma

STABLE PT - what's injured?

-if lower rib fx + bleeding into abdomen

-if lower rib fx + hematuria

-if Kehr sign (referred pain in left shoulder bc of phrenic nerve) & viscera in thorax on CXR

-if handlebar sign

-if epigastric pain, best test?
-if retroperitoneal fluid is found

-if lower rib fx + bleeding into abdomen: Spleen or Liver Laceration

-if lower rib fx + hematuria: Kidney laceration

-if Kehr sign (referred pain in left shoulder bc of phrenic nerve) & viscera in thorax on CXR: Diaphragm rupture 

-if handlebar sign: Pancreatic rupture

-if epigastric pain, best test? Abdominal CT
​-if retroperitoneal fluid is found: Consider duodenal rupture 

30

Pelvic Trauma

If hypotensive, tachycardic?

FAST and DPL to r/o bleeding in abdominal cavity. 

31

Fact: Pelvic Trauma

Can bleed out into pelvis --> stop bleeding by fixing pelvic fracture

Internal Fixation --> if stable

External Fixation --> If not

32

Pelvic Trauma

If blood at the urethral meatus and a high riding prostate?

Next best test?

If normal urethrogram? what next test?

What are you looking for?

Consider pelvic fracture with urethral or bladder injury. 

Retrograde urethrogram (NOT FOLEY!)

Retrograde cystogram to evaluate bladder --> check for extravasation of dye. Take 2 views to ID trigone injury.

33

Pelvic Trauma

During a retrogram cystogram to evaluate the bladder, check for extravasation of dye. Taking 2 views to ID trigone injury.

If extraperitoneal extravasation - what Tx?

If intraperitoneal extravasation - wht Tx?

Extraperitoneal: Bed rest + Foley (for comfort) 

Intraperitoneal: Ex-lap and surgical repair 

34

FACT: Ortho Trauma - Fractures that go to OR

-Depressed skull fx

-severely displaced or angulated fx

-any open fx (sticking out bone needs cleaning)

-femoral neck or intertrochanteric fx 

 

35

Ortho Trauma: Common Fractures

(1) Shoulder pain s/p seizure or electrical shock

(2) Arm outwardly rotated & numbness over deltoid

(3) Old lady falls on outstretched hand, distal radius displaced

(4) Young person falls on outstretched hand, anatomic snuff box tenderness

(5) "I swear I just punched a wall..."

(1) Posterior shoulder dislocation

(2) Anterior shoulder dislocation (axillary nerve damage)

(3) Colle's fracture

(4) Scaphoid fracture - normal 1st Xray --> BEWARE!! 

(5) Metacarpal neck fracture (4th or 5th digit) aka "Boxer's Fracture".
      May need a K Wire.

 

36

Ortho Trauma

Clavicle most commonly broken where?

Between middle and distal 1/3.
Need a figure 8 device. 

37

Fever on Post-Op Day (POD) #1: 

Most common cause of low fever (<101 F) and non-productive cough

Dx: ?

Tx: ? 

Atelectasis 

CXR - see bilateral lower lobe fluffy infiltrates

Mobilization and incentive spirometry

GET UP AND MOVE OR GET PNEUMONIA AND DIE! 

38

Fever on Post-Op Day (POD) #1: 

High Fever (up to 104 F), very ill-appearing

Pattern of spread?

Common Bugs?

Tx?

Necrotizing Fasciitis 

in subQ along Scarpa's Fascia

Group-A Beta-Hemolytic Strep (GABHS) or clostridium perfringens

IV PCN, go to OR and debride skin until it bleeds 

39

Fever on Post-Op Day (POD) #1: 

High fever (>104 F) with muscle rigidity

Caused by?

Genetic Defect?

Tx?

Malignant Hyperthermia

Succinylcoline or Halothane

Ryanodine Receptor gene defect

Dantrolene Na --> Blocks RyR1 receptor and decreases intracellular calcium

40

Fever on Post-Op Day (POD) #3-5:

Fever, productive cough, diaphoresis

CXR: shows consolidation

Treatment?

Pneumonia

Check sputum sample for culture

Cover with FQN (Moxi) to cover strep pneumo in the mean time. 

41

Fever on Post-Op Day (POD) #3-5:

Fever, dysuria, frequency, urgency, paritcularly in a patient with a foley

Next best test?

Tx? 

UTI

UA and Culture

Abx, change out foley

42

Fever POD #7 and beyond 

Pain & Tenderness at IV Site?

Tx? 

 

Central Line Infection

Do blood cx from the line. 
Pull the line.
Abx to cover staph.

43

Fever POD #7 and beyond 

Pain @ incision site, edema, induration but no drainage.

Tx?

Cellulitis

Do blood Cx. 
Start Abx. 

44

Fever POD #7 and beyond 

Pain @ incision site, induration WITH drainage.

Tx?

Simple Wound Infection

Open wound and repack. 
No Abx. 

45

Fever POD #7 and beyond 

Pain with salmon-colored fluid from incision.

Tx?

Dehiscence (violation of the fascia)

Surgical emergency!!
Go to OR, give IV Abx and do primary closure of the fascia. 

46

Fever POD #7 and beyond 

Unexplained fever?

Dx?

Tx?

Abdominal Abscess

CT with oral, IV and rectal contrast to find the abscess. 
Diagnostic Lap if needed.

Drain it! Percutaneously, IR-guided or surgically. 

47

Fact: Fever > POD 7 and beyond...

Random causes of Fever
-Thyrotoxicosis
-Thrombophlebitis (after ObGyn procedures)
-Adrenal Insufficiency
-Lymphangitis
-Sepsis 

48

Fact: Pressure Ulcers are caused by impaired blood flow --> Ischemia

Don't Culture --> cause just get skin flora.
Check CBC and Blood Cultures.
Could be bactermia or osteomyelitis. 
Tissue biopsy to r/o Marjolin's Ulcer --> Squamous Cell Carcinoma 
Best prevention is turning pt q2hrs. 

 

49

Fact: Pressure Ulcers are caused by impaired blood flow --> Ischemia​

Stage 1: Skin intact but red. Blanches with pressure.

Stage 2: Blister or break in the dermis. 

Stage 3: SubQ destruction into the muscle.

Stage 4: Involvement of joint or bone. 

Tx for Stages 1-2: Mattress with cream on it. No big deal. 

Tx for Stages 3-4: Surgery with flap reconstruction. Before surgery, albumen must be >3.5 and bacterial load must be <100K. 

50

Thoracic - Pleural Effusions

see fluid >1 cm on CXR at the costovertebral line in lateral decub position. 

What must you do?

Thoracentesis, see what kind of fluid you are dealing with.

51

Thoracic - Pleural Effusions (fluid > 1cm) 

If transudative, likely systemic cause...CHF, nephrotic or cirrhotic

If transudative with low pleural glucose?

If transudative with high lymphocytes?

If transudative and bloody?

low pleural glucose - Rheumatoid Arthritis

high lymphocytes - TB

bloody - Malignant Cancer or PE

52

Thoracic - Pleural Effusions (fluid > 1cm) 

If exudative -- likely ??

If complicated (+ gram or cx, pH <7.2, glucose low (Cause cancer cells or bugs eating it)) -- Tx?

Light's Criteria - transudative if....

 

exudative: parapneumonic, cancer, etc. 

complicated: insert chest tube for drainage

If LDH < 200
LDH effusion/serum <0.6
Protein effusion/serum <0.5 

53

Spontaneous Pneumothorax can happen in emphysema pts or in young, healthy, tall, thin men. 

Subpleural Bleb ruptures --> Lung collapses.

Symptoms/Signs: ??

Dx: ??

Tx: ??

Indications for surgery: ??
Do what: ??

 

 

S/S: sudden dyspnea (or asthma or COPD-emphysema)

Dx: CSR

Tx: Chest Tube placement 

Indications for Surg: Ipsi or contralateral REcurrence, bilateral, incomplete lung expansion, occupations (pilot, scuba), live in remote areas

Surg: VATS, pleurodesis (bleo, iodine or talc)

54

Lung Abscess usually 2/2 aspiration (drunk, elderly, enteral feeds) seen on CXR.

-most often in posterior _______ or _________ lower lobes

Tx: initially with Abx (not drainage)--> give ____ or ______

Indications for Surgical drainage: ?? 

upper or superior lower lobes

give IV PCN or Clindamycin

Indications: abx fail, abscess >6 cm, emphysema present 

55

Work up of a Solitary Lung Nodule

1st Step: ??

 

Find an old CXR to compare!!

56

Characteristics of a Solitary Benign Lung Nodule:

Popcorn calcification: ??

Concentric calcification: ??

Pt <40 yo, <3 cm, well-circumscribed: ?? 

Tx: ?? 

Popcorn calcification: Hamartoma (MOST COMMON)

Concentric calcification: old granuloma (old TB)

Pt <40 yo, <3 cm, well-circumscribed: close follow-up, not a big deal  

Tx:  CXR or CT scans q2mo to look for growth 

57

Characteristics of a Solitary Malignant Lung Nodule:

-If pt has risk factors (smoker, old), >3cm, if calcifications

Tx: ??

Remove the nodule
-with broncoscopy if central
-open lung biopsy if peripheral 

58

Diagnosis?

Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia (same side) or lung collapse.

Lung Cancer 

59

Lung Cancer - Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. 

Most common cancer in non-smokers?

Location and mets?

Characteristics of effusion?

Adenocarcinoma, can occur in scar tissue of old pneumonia

Peripheral cancer, mets to liver, bone and brain and adrenals

Exudative effusion with high hyaluronidase 

 

 

60

Lung Cancer - Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. 

Patient with kidney stones, constipation and malaise.
Low PTH + Central lung mass?

Squamous Cell Carcinoma

Paraneoplastic syndrome (it makes a parathyroid hormone) 2/2 secretion of PTH-rP = Low PO4 and High Ca++ (hypercalcemia)

61

Lung Cancer - Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. 

Patient with shoulder pain, ptosis, constricted pupil and facial edema?

(Pancoast Tumor) Superior Sulcus Syndrome from small cell carcinoma.

a Central Cancer. 

62

Lung Cancer - Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. 

Patient with ptosis better after 1 minute of upward gaze?

Lambert Eaton Syndrome (paraneoplastic syndrome) from small cell carcinoma.

Antibodies to pre-synaptic Ca++ channel. 

63

Lung Cancer - Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. 

Old smoker presenting w/Na = 125, moist mucus membranes, no JVD?

SIADH (paraneoplastic syndrome) from small cell carcinoma

Produces Euvolemic hyponatremia.

Tx: Fluid restriction +/- 3% saline in <112. 

64

Lung Cancer - Pt presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse. 

CXR showing peripheral cavitation and CT showing distant mets?

Large Cell Carcincoma 

65

4 Types of Lung Cancers?

Peripheral:
1.
2.

Central:
3.
4.

Peripheral:
1. Adenocarcinoma
2. Large Cell Carcinoma

Central:
3. Small Cell Carcinoma
​4. Squamous Cell Carcinoma 

66

What type of lung cancers can we operate on?

Non-Small Cell Cancers (Adenocarcinoma, Squamous Cell Carcinoma and Large Cell Carcinoma)

67

ARDS (Acute Respiratory Distress Syndrome)

Pathophys: inflammation --> impaired gas exchange, inflammatory mediator release, hypoxemia

Etiology: gram neg sepsis, gastric aspiration, trauma, low perfusion, pancreatitis

Dx: ??
1.
2.
3.

Tx: ??

Dx: 
1. CXR - bilateral fluffy alveolar infiltrates (lung infiltrates and edema)
2. PAO2/Fi02  (<300 means acute lung injury) = hypoxia
3. PCWP (wedge pressure) < 18 (means pulmonary edema is non-cardio - lungs screwed up, not heart)

Tx: PEEP 

68

Murmur Buzzwords:

-cresc/descrend Systolic Ejection Murmur
-louder with squatting
-softer with valsalva (decreases preload)
-parvus et tardus

Aortic Stenosis 

69

Murmur Buzzwords:

-louder with valsalva (decreases preload) Systolic Ejection Murmur
-softer with squatting or handgrip
-little kid or tennager on pre-sports physical 

Hypertrophic Obstructive Cardiomyopathy (HOCM)

70

Murmur Buzzwords:

-Late Systolic Ejection Murmur with CLICK
-softer with squatting
-louder with valsalva (decreases preload) and handgrip
 

Mitral Valve Prolapse (MVP)

71

Murmur Buzzwords:

Holosystolic murmur radiates to axilla w/Left atrial enlargement

Mitral Regurgitation

72

Murmur Buzzwords:

-Holosystolic murmur with late diastolic rumble in kids 

Ventricular Septal Defect (VSD)

73

Murmur Buzzwords:

-Continuous machine like murmur

PDA - Patent Ductus Arteriosus

74

Murmur Buzzwords:

-Wide fixed and split S2 

ASD - Atrial Septic Defect

75

Murmur Buzzwords:

-rumbling diastolic murmur with an opening snap, left atrial enlargement and A-fib

Mitral Stenosis

76

Murmur buzzwords:

Blowing diastolic murmur with widerned pulse pressure and eponym parade

Aortic Regurgitation

77

Murmur Buzzwords: louder with inspiration - left or right-heart?

Right-sided heart issues

78

Esophagus

Diagnosis: Pt with bad breathe and snacks in esophagus in the AM?

True or False diverticulum?

Tx: ? 

Zenker's Diverticulum

False Diverticulum - only contains mucosa

Tx: surgery 

79

Esophagus

Diagnosis: dysphagia to liquids & solids.

Barium Swallow: Bird's Beak

Tx: ?

It's associated with __________ and ___________ cancer.

Achalasia

Tx: CCB, nitrates, botox or heller myotomy 

Chagas, esophageal cancer 

80

Esophagus

Diagnosis: Dysphagia worse with hot & cold liquids + chest pain that feels like MI with NO regurgitation.

Barium Swallow: spasming esophagus

Tx: ??

Diffuse esophageal spasms

Tx: CCB or nitrates

 

81

Esophagus

Diagnosis: Epigastric pain worse after eating or when laying down. Silent aspirations: chronic dry cough, wheeze hoarseness. 

Most sensitive test: ?

When do you do an endoscopy: ?

Tx before surgery: ?

Indications for surgery?

GERD

24 hour pH monitoring (manometry)

Endoscopy if "danger signs' present

Tx with behavioral modifications and then antacids, H2 blockers, PPI's 

Surgery: bleeding, stricture, Barrett's, incompentent LES, max dose PPI with still symptoms or doesn't want meds. 

82

Esophagus

Diagnosis: If hematemesis (blood occurs after vomiting with subQ emphysema - transmural tear). Can see pleural effusion with increased Amylase.

Next Best test?

Tx?

 

Boerhaave's Esophageal Rupture 

CXR, gastrograffin esophagram, NO endoscopy 

Surgical Repair, if full thickness 

83

Esophagus

Diagnosis: gross hematemesis, unprovoked in a cirrhotic patient with portal HTN. 

Tx of choice?

Gastric Varices 

Tx: Endoscopic sclerotherapy or banding 

**DON'T Prophylactically band asymptomatic varices. Give BB**

84

Esophagus

With Gastric varices, if in hypovolemic shock... what tx?

Resuscitation with ABCs, NG lavage, medical tx with Octreotide or SS. 

Balloon tamponade ONLY if need to stabilize for transport. 

85

Esophagus

Diagnosis: Progressive dysphagia with weight loss?

Smokers/drinkers in middle 1/3 of esophagus?

Ppl with long standing GERD in the distal 1/3 of esophagus?

Best first test: ?

 

Esophageal Carcinoma 

Squamous cell (middle 1/3)

Adenocarcinoma (distal 1/3)

Barium Swallow, then endoscopy with biopsy, then staging CT 

 

86

Stomach

Acid reflux pain after eating, when laying down (not GERD)

Type 1: GE jxn herniates into thorax. Worse for GERD. Tx -> symptoms.

Type 2: Abdominal pain, obstruction, strangulation. Tx -> surgery

Hiatal Hernia 

Type 1: Sliding

Type 2: Paraesophageal 

87

Stomach

Mid-epigastric pain worse with eating. H pylori, NSAIDS, steroids.

Work up: ?

Surgery if: ?

Gastric Ulcers 

Work up: double-contrast barium swallow - punched out lesion with regular margins. EGD with biopsy can tell H. Pylori, malignant, benign. 

Surgery if: Lesion persists after 12 weeks of treatment. 

88

Stomach: Gastric Cancer

Most common, esp in Japan: ?

Krukenberg Tumor: ?

Virchow's Node: ?

Lymphoma: ?

Blummer's Shelf: ?

Sister Mary Joseph: ?

MALT-lymphoma: ? 

Most common, esp in Japan: Adenocarcinoma

Krukenberg Tumor: Gastric Cancer --> Ovaries

Virchow's Node: L Supraclavicular fossa

Lymphoma: HIV

Blummer's Shelf: Mets felt on DRE

Sister Mary Joseph: Umbilical node

MALT-lymphoma: H. Pylori (only cancer that can be treated with antibiotics) 

89

Fact

Stomach: Randoms

Mentriers: protein losing enteropathy (foamy pee), enlarged rugae 

Gastric Varices: splenic vein thrombosis

Dieulafoy's: vessel erodes in to the stomach and can have hematemesis 

90

Duodenum

-mid-epigastric pain better with eating 
-95% associated with H. Pylori
-Healthy pts <45 yo cna do trial of H2 Blockers or PPI 

 

Duodenal Ulcers 

91

Duodenal Ulcers

What is the best test for diagnosis?

Tx?

Best Test: CLO test - endoscopy with biopsy b/c it can also exclude cancer

Blood, stool or breath test can be used for H. Pylori specifically

Tx: TRIPLE THERAPY --> PPI, clarithromycin & amoxicillin for 2 weeks. Breath or stool test can be done to test for cure. 

92

Duodenum

-Mid-epigastric pain/ulcers that don't resolve with medical therapy?

ZE Syndrome

93

Best Test for ZE Syndrome?

Tx?

What else to look for if diagnosed?

Best Test: Secretin Stimulator Test (find inappropriate high gastrin; gastrin should be suppressed)

Tx: Surgical Resection of pancreatic/duodenal tumor 

Else to look for: Syndrome pancreatic tumor is associated with... Pituitary and Parathyroid problems. 

94

Duodenum

-patient has bilious vomiting and post-prandial pain. 
-recently lsot 200 lbs on "Biggest Loser" 

Pathophys of this condition: ?

Tx: ?

SMA Syndrome bc 3rd part of duodenum is compressed in area between aorta and SMA (Superior mesenteric artery)

Tx: restoring weight/nutrition; last resort: Roux-en-Y 

95

Exocrine Pancreas

-Mid-epigastric pain radiating through to the back

Acute Pancreatitis

96

Pancreatitis

Most common causes: ?

How to Dx: ?    Best Imaging: ?

Tx: ?

Bad Prognostic Factors - What criteria? 

Complications: ?

Common Causes: Gallstones & ETOH

Dx: Increased amylase & Lipase
Best Imaging: CT

Bad Prognostic Factors: Ranson's Criteria

Complications: Pseudocyst (no cells!), Pancreatic ascites, Hemorrhage, Respiratory Failure (ARDS), Abscess/Necrosis, Splenic Vein thrombosis, GI Obstruction 

 

97

Chronic Pancreatitis: Chronic mid-epigastric pain, DM, Malabsorption symptoms (Steatorrhea)

Can cause splenic vein thrombosis --> which leads to .... ?

Gastric varices 

98

Pancreatic Adenocarcinoma:  Usually don't have sxs until advanced.

If in head of pancreas --> may have palpable (large), non-tender GB with itching and jaundice called _____________ sign. 

Migratory Thrombophlebitis called ___________ sign. 

Dx with Endoscopic US and FNA Biopsy

Tx w/Whipple if: ___________________

 

Courvoisier's Sign 

Trousseau's Sign

Tx with Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoneal mets.

99

Endocrine Pancreas - Insulinoma

Whipple's Triad: what is it?

Labs: ?

Whipple's Triad:
(1) sxs (sweat, tremors, hunger, seizures)
(2) Blood glucose <45 
(3) sxs resolve with glucose admin 

Labs: 
- Inc. Pro-Insulin
- Inc. C-peptide 
- Inc. Insulin

*If faking, the C-peptide and Pro-insulin would be low. 

100

Endocrine Pancreas: Glucagonoma

Sxs: ?

Characteristic rash is called: ?

Sxs: hyperglycemia, diarrhea, weight-loss

Necrolytic migratory erythema

101

Fact.

Endocrine Pancreas - Somatostatinoma

-Commonly malignant
-An extremely rare tumor that occurs in the pancreas or part of the small intestine
-Sxs: Malabsorption, steatorrhea, ect from exocrine pancreas malfunction

102

Endocrine Pancreas: VIPoma

Sxs: ? (looks similar to Carcinoid Syndrome)

Tx: ?

Watery diarrhea, Hypokalemia, dehydration, flushing

Tx: Octreotide

103

Gallbladder

Diagnosis: RUQ Pain --> radiating to back/shoulder, N/V, fever, worse s/p fatty foods

Best 1st Test: ?

Tx: ? 

Acute Cholecystitis

U/S

Cholecystectomy; Perc Cholecystomstomy, if unstable

 

104

Gallbladder

Diagnosis: RUQ Pain, high bili and alk-phos

Dx: ?

Tx: ? 

Choledocolithiasis

U/S shows common bile duct stone

Chole +/- ERCP to remove the stone 

105

Gallbladder

Diagnosis: RUQ Pain, fever, jaundice, dec BP, AMS

Tx: ? 

Ascending Cholangitis 

Tx: Fluids and broad-spectrum Abx and ERCP to remove stone 

106

Gallbladder: Choledochal Cysts 

Type 1: ?

Type 4: ?

Type 1: Fusiform dilation of Common Bile Duct --> tx with excision 

Type 4: Caroli's Disease - cysts in intrahepatic ducts --> needs liver transplant

107

Gallbladder: Cholangiocarcinoma - rare

Risk Factors: ?

Primary Sclerosing cholangitis (UC), liver flukes and thorothrast exposure. 

Tx: surgery +/- radiation 

108

Liver: Hepatitis causes...

AST = 2x ALT --> ___________

ALT > AST (both high 1000s) --> ____________

ALT & AST high s/p hemorrhage, surg or sepsis --> ___________

Alcoholic heptatitis (reversible)

Viral hepatitis

Shock Liver 

109

Liver: Cirrhosis & Portal HTN

Tx: Somatostatin and Vasopressin vasoconstrict to decrease portal pressure
      B Blockers also decrease portal pressure

*Don't need to treat esophageal varices prophyactically, but band/burn them once they bleed. 

TIPS procedure relieves portal HTN but.... what complication? tx?

worsens Hepatitic Encephalopathy bc promotes clearance of ammonia resulting in higher ammonia levels

Tx: Lactulose (poop out the ammonia)

 

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Liver: Hepatocellular Carcinoma

Risk Factors: ??

Tumor Marker: ??

Dx (Imaging): ?

Tx: can surgically remove solitary mass
      use radiation or cryoablation for pallation of multiple masses

 

RF: Chronic Hep B Carrier, Hep C Carrier, Cirrhosis for any reason, aflatoxin or carbon tetrachloride

Tumor Marker: AFP (in 70%)

Dx: CT/MRI

 

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Liver: 

-women on OCP (estrogen helps it grow)
-palpable abdominal mass or spontaneous rupture --> Hemorrhagic shock 

Hepatic Adenoma

Dx: U/S or MRI 

Tx: Stop the OCPs.
     Resect if large or pregnancy is desired. 

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Liver

-2nd Most Common benign liver tumor 
-women > men
-less likely to rupture
-no Tx needed

Focal Nodular Hyperplasia 

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Liver: Bacterial Abscess

3 Most common bugs: ??  

Tx: ??

3 Bugs: E. Coli, Bacteriodes, Enterococcus 

tx: surgical drainage and IV abx 

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Liver

RUQ pain, profuse sweatings and rigors, palbable liver?

Tx: ? 

Entamoeba Histolytic

Tx: Metronidazole - DON'T drain it

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Liver

Pt from Mexico presents w/RUQ and large liver cysts found on U/S?

Mode of transmission?

Lab findings?

Tx? 

Enchinococcus

Mode of transmission: Hydatic cyst paracyte from dog feces

Lab: Eosinophilia, +Casoni skin test (from IgE in skin from eosinophils) 

Tx: Albendazole and surgery to remove ENTIRE cyst
     Ruptured cyst --> Anaphylaxis, even death

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What 2 abscesses in the body are NOT treated by drainage?

1. 

2.

1. Lung Abscess 

2. Entamoeba histolytic Liver abscess 

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Fact - Spleen:  Post-Splenectomy check platelets

-if Post-op thrombocytosis >1 mil --> give Aspirin to prevent clots 

-give Prophylactic PCN bc of spleen's role in immune functions

-3 Vaccines to give:  S. Pneumo, H. Flu and N. Meningitidis vaccines 

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Fact - Spleen:  ITP

-consider in isolated thrombocytopenia (bleeding gums, petechiae, nosebleeds)

-Decreased platelet count, increased megakaryocytes in bone marrow

-NO splenomegaly

-Tx: 1st - Steroids
       Relapse - splenectomy

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Fact - Spleen: Hereditary Spherocytosis

Sxs: hemolytic anemia (jaundice, increased indirect bilirubin, LDH, decr haptoglobin, elevated retic count) + spherocytes on smear + osmotic fragility test

-prone to gallstones

Tx: Splenectomy (accessory spleen too)

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Fact - Spleen: Traumatic Splenic Rupture

consider with Lower rib fractures and intra-abdominal hemorrhage

-Kehr's Sign (Irritates L Diaphragm resulting in Left shoulder pain)

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Appendix

pain starts in peri-umbilical area --> sharp RLQ pain, N/V

When surgery: ?

If perforated/abscess: ? 

Appendicitis 

when: clinical picture is convincing, not imaging necessary but typically CT scan done

perf/abscess: drain, abx (to cover E. Coli & Bacteriodes) and do interval appendectomy  

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#1 Site for a Carcinoid Tumor: ??

Appendix

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Appendix: Carcinoid Tumor

#1 site

-Carcinoid Syndrome sxs: ??

-When does it happen: ??

-What else to look out for: ??

-If >2cm, @ base of appendix or with + nodes: ??

Otherwise: appendectomy is good enough

Sxs: Diarrhea, Wheezing, Flushing 

When: mets to liver (1st pass metabolism)

What else: Diarrhea, Dementia, Dermatitis (NIACIN DEFICIENCY)
Note: Serotonin and Niacin both made from Tryptophan so if all of it is going to make Serotonin --> Niacin will be low. 

If >2cm: Hemicolectomy

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Bowel Obstruction: Small Bowel Obstruction

-Suspect in hernia, prior GI surgery (Adhesions), Cancer, Intussusception, IBD 

-Sxs: pain, constipation, obstipation, vomiting 

-FIRST TEST: ??
 
CT can show point of obstruction.

-Tx: IVF, NG Tube

-When surgery: ??

 

First test: Upright CXR to look for free air 

Do surgery if peritoneal signs, increased WBC, no improvement within 48 hours 

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Fact:

Bowel Obstruction: Volvulus - either cecal or sigmoid

-Decompression from below if not strangulated. Otherwise, need surgical removal and colostomy. 

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Bowel Obstruction: Post-Op Ileus (general stasis of bowel)

-consider if hypoKalemic (make sure to replete), opiates

What will you see on an flat/upright KUB? 

-Do surgery for perforation.

Give what medicine?

Dilated loops of small bowel with air-fluid levels 

Lactulose/erythromycin 

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Bowel Obstruction: Ogilvie's Syndrome

-massive colonic distension

-If >10cm, need _____________ (procedure) and ___________ (watch for bradycardia) or colonscopic decompression. 

decompression with NG Tube and Neostigmine 

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