Emma Holiday Review Flashcards
(141 cards)
1
Q
Airway
If trauma patient comes in unconscious?
A
Intubate
2
Q
Airway
If GCS < 8?
A
Intubate
3
Q
Airway
-If guy stung by a bee, developing stridor and tripod posturing?
A
Intubate
4
Q
Airway
-If guy stabbed in the neck, GCS = 15, expanding mass inlateral neck?
A
Intubate
5
Q
Airway
-If guy stabbed in the neck, crackly sounds with palpating anterior neck tissues?
A
Fiberoptic Broncoscope, intubate
6
Q
Airway
-If huge facial trauma, blood obscures oral and nasal airway and GCS =7?
A
Cricothyroidotomy
7
Q
Breathing
You intubated your patient…next best step?
A
Check for bilateral breath sounds
8
Q
Breathing
You intubated your patient, listen with stethoscope…. decreased sounds on the left? Why? What do you do?
Next step?
A
Pull back, you have intubated the right mainstem broncus.
Pull back your ET tube.
Chest Xray
9
Q
Patient in traumatic accident with trauma to the chest.
hypertensive, chest hurts, dyspneic, new murmurs
A
Traumatic Aortic Injury - get to OR immediately!!
10
Q
Physical Exam for Pneumothorax… what might we hear?
A
Absent/decreased breathe sounds on side of pneumo
hyperresonance to percussion
JVD and trachea deviated away from the pneumothorax = Tension Pneumo
11
Q
Chest Xray abnormal….
Listen and hear decreased breathe sounds, dull to percussion
A
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
Q
Chest Xray… Rib fractures in a bad car accident after hitting the steering wheel.
“White out” lung
Tx?
A
Pulmonary Contusion
Tx: Pulmonary toilet, control pain from rib fractures, coughing, clearing secretions and taking deep breathes
13
Q
Chest Trauma: pt has inward mvmt of the right ribcage upon inspiration.
Dx?
Tx?
A
Flail Chest, >3 consecutive rib fractures
O2 and pain control (not opiates - can decrease respiratory drive)
14
Q
Chest Trauma: pt has confusion, petechial rash in chest, axilla and neck and acute SOB.
Dx:
When to suspect it?
A
Fat embolism
after long bone fractures (esp femur)
15
Q
Chest Trauma: pt dies suddenly after a 3rd year medical student removes a central line.
Dx?
When else to suspect it?
A
Air embolism
Lung trauma, ventilator use, during heart vessel surgery
16
Q
Cardiovascular
If hypotensive, tachycardiac?
A
Shock
17
Q
Cardiovascular
If flat neck veins and normal CVP - what type of shock?
A
Hypovolemic/Hemorrhagic Shock - most common
18
Q
Cardiovascular
Next step if you have identified your patient is in Hypovolemic/Hemorrhagic Shock?
A
2 large bore peripheral IV - 2L NS or LR over 20 min followed by blood
19
Q
Cardiovascular
If muffled <3 sounds, JVD, electrical alternans, pulsus paradoxus?
Confirmatory test?
Treatment?
A
Pericardial tamponade
FAST Scan
Needle decompression, pericardial window or median sternotomy
20
Q
Cardiovascular
If decreased Breathe Sounds on one side, tracheal deviation AWAY from collapsed lung?
Next best step?
A
Tension pneumothorax
needle decompression**, followed by a chest tube –> DON’T DO A CHEST XRAY!
21
Q
FACT: Head Trauma
GCS Max Scoring: 15
GCS Min Scoring: 3
Eyes: 4
Motor: 6
Verbal: 5
A
22
Q
Head Trauma:
Hematoma, edema, tumor can cause increased ICP
Symptoms?
Tx?
Surgical Intervention?
A
HA, projective vomiting, AMS
elevate head of the bed, give Mannitol to relieve pressure (water renal function), hyperventilate to pCO2 28-32
Ventriculostomy
23
Q
Neck Trauma
Penetrating trauma - Gunshot wound or stab wound
Zone 3 - boundaries? imaging?
Zone 2 - boundaries? imaging?
Zone 1 - boundaries? imaging?
A
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
Q
Abdominal Trauma
If Gunshot wound to the abdomen? (free air under a diaphragm)
A
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 \< 200** (\<300 means acute lung injury) = hypoxia
3. PCWP **(wedge pressure) \< 18** (means pulmonary edema is non-cardio - lungs screwed up, not heart)
## Footnote
**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)
## Footnote
**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
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**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**
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**Gallbladder: Cholangiocarcinoma - rare**
Risk Factors: ?
Primary Sclerosing cholangitis (UC), liver flukes and thorothrast exposure.
**Tx:** surgery +/- radiation
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**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
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**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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