Emma Holliday Flashcards
(210 cards)
1
Q
Name two absolute contraindications to surgery.
A
- diabetic coma
- DKA
2
Q
Name two relative contraindications to surgery.
A
- poor nutritional status defined as albumin <3, transferrin <200, or >20% weight loss
- severe liver failure defined by bilirubin >2, PT > 16, ammonia > 150, or encephalopathy
3
Q
Describe three values suggestive of poor nutritional status in a surgical candidate.
A
- albumin less than 3
- transferrin less than 200
- greater than 20% weight loss
4
Q
Describe four indicators of severe liver failure in a surgical candidate that may be relative contraindications to surgery.
A
- bilirubin greater than 2
- PT greater than 16
- ammonia greater than 150
- clinical encephalopathy
5
Q
How long should smokers abstain from tobacco products prior to undergoing surgery?
A
8 weeks
6
Q
Why should smokers stop smoking at least two months prior to undergoing surgery?
A
smoking is a negative predictor for wound healing
7
Q
What is important for smokers and those with COPD in the immediate post-op period?
A
avoid excess O2 supplementation as it may suppress respiratory drive in these CO2 retainers
8
Q
What is Goldman’s index?
A
an index of cardiac risk used to assess the risk for preoperative mortality in surgical patients
9
Q
What are the three most important factors when calculating a patient’s Goldman index for cardiac risk?
A
- history of CHF
- history of MI within the last 6 months
- presence of an arrhythmia
10
Q
If a preoperative patient has a history of CHF or a history of MI within the last 6 months, what steps should be taken prior to surgery?
A
- if CHF, get an echo; surgery is avoided unless absolutely necessary in patients with an EF less than 35%
- if MI, get an ECG, then get a stress test if abnormal, then perform a cath if abnormal, then perform revascularization if cath is abnormal
11
Q
Describe an aortic stenosis murmur.
A
it is a late systolic, crescendo-decrescendo murmur that radiates to the carotids and increases with squatting but decreases with standing
12
Q
Why is aortic stenosis an important finding in the preoperative assessment?
A
it is a contributor of the Goldman’s index and is a marker for increased cardiac risk and perioperative mortality
13
Q
Name five medications it is important to stop prior to surgery.
A
- aspirin
- NSAIDs
- vitamin E
- warfarin
- metformin
14
Q
If a patient is taking warfarin, how long before surgery should this be stopped and what is the desired INR going into surgery?
A
it should be stopped 5 days prior to surgery with a drop in INR to less than 1.5
15
Q
Why is it important to stop taking metformin prior to undergoing surgery?
A
it increases the risk for lactic acidosis
16
Q
How long before surgery should a patient stop taking aspirin, NSAIDs, and vitamin E?
A
two weeks
17
Q
What changes to a patient’s insulin regiment should be made prior to surgery?
A
they should take half the morning dose of insulin on the day of surgery
18
Q
Patients on dialysis should undergo dialysis how close to undergoing surgery?
A
they should be dialyzed within 24 hours preoperatively
19
Q
Why do we check the BUN and creatinine in patients with CKD prior to surgery?
A
because a BUN greater than 100 increases the risk for post-op bleeding secondary to uremic platelet dysfunction
20
Q
How does uremic platelet dysfunction appear on a coagulation panel?
A
- platelet count is normal
- but bleeding time is prolonged
21
Q
What is assist-control ventilation?
A
- set the tidal volume and minimal rate
- patient can breath faster and if they initiate and extra breath, the ventilator gives the desired tidal volume
22
Q
What is pressure support ventilation?
A
- set the tidal volume but the rate is entirely patient driven
- important for weaning patient from the ventilator
23
Q
What ventilator mode is an important stepping stone when attempting to wean patients from the ventilator?
A
pressure support in which the tidal volume is set but the rate is entirely patient driven
24
Q
How does pressure support differ from CPAP?
A
- pressure support is a mode in which the tidal volume is set and adequate pressure is given to support that volume whenever the patient initiates a breath
- CPAP is a continuous underlying pressure used to ensure the alveoli remain open
25
What is PEEP?
pressure given at the end of a respiratory cycle to keep the alveoli open, particularly in the case of ARDS or CHF
26
What mode of ventilation is used in those with ARDS or CHF?
PEEP
27
What is the best test to order when evaluating whether a patient on a ventilator is being appropriately managed?
ABG
28
How should a patient's ventilation settings be changed if a patient has low PaO2?
FiO2 should be increased
29
PaCO2 is dependent on what two factors?
tidal volume (more efficient to change) and respiratory rate
30
Why is it mo re efficient to adjust a patient's tidal volume than their respiratory rate if their PaCO2 is abnormal?
because increasing the respiratory rate also increases ventilation of dead space whereas altering the tidal volume changes more functional ventilation
31
How is the anion gap calculated and what is normal?
- the gap equals (sodium - chloride - bicarb)
| - normal is 8-12
32
What are possible causes of an anion gap metabolic acidosis?
MUDPILES
- methanol
- uremia
- DKA
- paraldehyde
- iron, isoniazid
- lactic acidosis
- ethylene glycol
- salicylates
33
What are possible causes of a non-gap metabolic acidosis?
- diarrhea
- diuretics
- RTAs
34
How are metabolic alkaloses differentiated?
based on urine chloride
- less than 20: vomiting/NG tube, antacids, diuretics
- more than 20: Conn's, Bartter's, Gittleman's
35
What are the first two things to check in a patient with hyponatremia?
- check the plasma osmolality
| - then check the patient's volume status
36
What are potential causes of the following types of hyponatremia:
- hypervolemic
- normovolemic
- hypovolemic
- hypervolemic: CHF, nephrotic syndrome, cirrhosis
- normovolemic: SIADH, Addison's, hypothyroidism
- hypovolemic: diuretics, vomiting
37
How is hyponatremia treated?
- normally, fluid restriction plus diuretics
- use normal saline if hypovolemic
- use 3% saline if symptomatic (namely seizures) or have a sodium less than 110
38
What is an appropriate rate for correcting hyponatremia? What is the risk associated with correcting hyponatremia too quickly?
- 0.5-1.0 mEq per hour
| - central pontine myelinolysis
39
How is hypernatremia treated?
replace lost fluid with D5W or another hypotonic fluid
40
What is the risk associated with correcting hypernatremia too quickly?
cerebral edema
41
What are the symptoms of hypocalcemia and hypercalcemia?
- hypocalcemia: numbness, chvostek sign, Troussaeu sign, prolonged QT interval
- hypercalcemia: bones, stones, groans, psych overtones, and shortened QT syndrome
42
What are the symptoms of hypokalemia and hyperkalemia?
- hypokalemia: paralysis, ileum, ST depression, U waves
| - hyperkalemia: peaked T waves, prolonged PR and QRS, sine waves
43
What are the clinical features of hyperkalemia and how is it treated?
- presents with ECG changes including peaked T waves, prolonged PR and QRS, and sine waves
- treat with calcium gluconate first, then insulin and glucose
- can use kayexalate, albuterol, and sodium bicarb as well
- dialysis is a last resort
44
What is the preferred maintenance fluid?
D5 in half NS with 20 KCl (if peeing)
45
What are three risks associated with the use of TPN?
- calculus cholecystitis
- liver dysfunction
- hyperglycemia, zinc deficiency, and other lyte problems
46
What is the appropriate treatment for a circumferential burn? Why?
an escharotomy because we are worried about compartment syndrome
47
What is the feared complication of smoke inhalation?
laryngeal edema compromising the airway
48
Describe the presentation of carbon monoxide poisoning?
- altered mental status
- headache
- cherry read skin
- history of exposure
49
Describe the presentation, diagnosis, and treatment of carbon monoxide poisoning.
- presents with a history of exposure, altered mental status, headache, and cherry red skin
- diagnose with a carboxyhemoglobin test (remember that pulse ox is worthless)
- 100% oxygen or hyperbaric oxygen if carboxyhemoglobin is severely elevated
50
Why is SaO2 a poor test of someone suspected of having carbon monoxide poisoning?
because CO actually causes a leftward shift of the oxygen dissociation curve
51
What would a the most likely cause of a clotting disorder in the following populations:
- the elderly
- those with edema, hypertension, and foamy urine
- a young person with family history
- unresponsive to heparin
- young woman with history of multiple spontaneous abortions
- post operatively with thrombocytopenia
- elderly: think malignancy
- edema, HTN, foamy urine: nephrotic syndrome
- young with FH: factor V leiden mutation
- unresponsive to heparin: antithrombin III deficiency
- young with multiple spontaneous abortions: lupus anticoagulant
- post-op with thrombocytopenia: HIT
52
What is unique about the presentation and treatment of antithrombin III deficiency?
these patients are unresponsive to heparin
53
Describe the lab findings suggestive of vWD.
- normal platelet count
| - prolonged bleeding time and PTT
54
What is the rule for fluid resuscitation of burn victims?
- for adults, give kg x %BSA x 3-4 of LR or NS
- for kids give kg x %BSA x 2-4 of LR or NS
- give half over the first eight hours and the rest over the subsequent sixteen hours
55
What is unique about the antibiotics given to burn victims?
we avoid PO and IV antibiotics because it breeds resistance and instead we use topical antibiotics (silver sulfadiazine, mafenide, silver nitrate)
56
What are and what is unique about the three major topical antibiotics given to burn victims?
- silver sulfadiazine: doesn't penetrate eschars well and can cause leukopenia
- mafenide: will penetrate eschars but is severely painful
- silver nitrate: doesn't penetrate eschars and causes hypokalemia and hyponatremia
57
If you suffer a chemical burn, what is the best next step?
irrigate for at least thirty minutes
58
If you suffer an electrical burn, what is the best next step? What about after that?
get an ECG, if abnormal these patients need at least 48 hours of telemetry
59
If you suffer an electrical burn and have an abnormal ECG, what is the best next step?
48 hours of telemetry
60
If a patient's urine dipstick is positive for blood but is negative RBCs, this is indicative of what disease? What are the feared complications of this?
rhabdomyolysis, which is likely to cause ATN and hyperkalemia
61
What are two important complications of rhabdomyolysis?
- ATN
| - hyperkalemia
62
What are the criteria for compartment syndrome?
- the five P's: pain, pallor, paresthesia, pulselessness, paralysis
- or a compartment pressure greater than 30 mmHg
63
What level of consciousness warrants intubation in a trauma patient?
if they come in unconscious or have a GCS less than 8
64
If a patient sustains trauma to the neck and you hear subcutaneous emphysema when palpating the neck, what should be your first step?
intubate using a fiberoptic bronchoscope because you may have a laryngeal injury
65
What should be the first step if a trauma patient comes in with a GCS of 7 after sustaining a severe facial injury?
perform a cricothyroidotomy in any circumstance where ET tube placement may be difficult
66
A widened mediastinum in a trauma patient is likely indicative of what?
a great vessel injury
67
Which patients with a hemothorax warrant thoracotomy?
- greater than 1500cc upon placement of a chest tube
| - greater than 200cc/hr over the first 4 hours
68
What are the criteria that define a flail chest?
two or more fractures on three or more consecutive ribs
69
How is flail chest treated?
supplemental oxygen and pain control with a nerve block (don't use opioids which may decrease respiratory drive)
70
If a trauma patient presents with confusion, petechial rash on chest, and acute SOB, what are we worried about?
fat embolism
71
What are risk factors for an air embolism?
- removal of a central line
- lung trauma
- vent use
- post-op for heart vessel surgery
72
What is the best next step for a patient suffering from hypovolemic/hemorrhagic shock?
- place 2 large bore PIV
| - run 2L NS or LR over 20 min followed by blood if there isn't an appropriate response
73
Electrical alternans is indicative of what disease process?
cardiac tamponade
74
What is pulsus paradoxus?
a fall in systolic blood pressure greater than 10mmHg with inspiration indicative of pericardial tamponade
75
What is the confirmatory test for pulsus paradoxes?
FAST scan or needle decompression if suspicion is high
76
What is the next best step for someone with a tension pneumothorax?
needle decompression followed by chest tube placement (you don't have time for a CXR)
77
Describe the swan-ganz catheter findings in each of the following types of shock:
- hypovolemic
- vasogenic
- neurogenic
- cardiogenic
- hypovolemic: low RAP/PCWP, high SVR, low CO
- vasogenic: low RAP/PCWP, low SVR, high CO
- neurogenic: low RAP/PCWP, low SVR, high CO
- cardiogenic: high RAP/PCWP, high SVR, low CO
78
What is neurogenic shock?
a form of vasogenic shock in which spinal cord injury, spinal anesthesia, or adrenal insufficiency causes an acute loss of sympathetic vascular tone
79
Describe the treatment for each of the following types of shock:
- hypovolemic
- vasogenic
- neurogenic
- cardiogenic
- hypovolemic: crystalloid resuscitation
- vasogenic: fluid resuscitation and treatment of the offending agent (antibiotics or anti-histamines)
- neurogenic: dexamethasone if due to adrenal insufficiency
- cardiogenic: give diuretics, treat the HR to 60-100, then address the rhythm, and finally give vasopressor support if necessary
80
How is GCS calculated?
- 4 eyes: spontaneous, to speech, to pain, no response
- 6 motor: obeys, localizes, withdraws from pain, abnormal flexion, abnormal extension, no response
- 5 verbal: oriented, confused, inappropriate words, incomprehensible sounds, no response
81
What is the best first test in someone who has sustained head trauma?
CT
82
How can an acute subdural be differentiated from a chronic subdural?
- acute subdural are hyperdense
| - chronic subdural are hypodense
83
What signs and symptoms are indicative of increased intracranial pressure?
- papilledema
- headache
- vomiting
- altered mental status
84
How is increased intracranial pressure treated?
- elevate the head of the bed
- give mannitol
- hyperventilate to pCO2 of 28-32
85
Where are the three zones of penetrating trauma to the neck and what is important about each?
- zone 1 is low, below the cricoid; need to do an aortography
- zone 2 is in the middle; need to do a 2D doppler to explore the potency of the vessels and you may want to do an exploratory surgery
- zone 3 is high, above the angle of the mandible; need to perform an aortography and triple endoscopy
86
If a patient comes in with free air under the diaphragm, what is the best next step?
exploratory laparotomy
87
What is the best next step for a patient who suffers a GSW to the abdomen?
exploratory laparotomy plus tetanus prophylaxis
88
What is the best next step in a patient who suffers a stab wound to the abdomen?
- if stable, perform a FAST exam; use diagnostic peritoneal lavage if FAST is equivocal; ex lap if either is positive
- if unstable, perform an ex lap
89
What is the best next step in a patient who suffers blunt trauma to the abdomen?
- if stable, perform an abdominal CT
| - if unstable, perform an ex lap
90
What should you suspect in a patient who suffers blunt abdominal trauma has the following:
- lower rib fracture plus blood in the abdomen
- lower rib fracture plus hematuria
- kehr sign and viscera in thorax on CXR
- handlebar sign
- spleen or liver laceration
- kidney injury
- diaphragm rupture (kehr sign is referred pain to the shoulder)
- pancreatic rupture (handlebar sign is the circular imprint on the abdomen)
91
Retroperitoneal fluid found on CT in a trauma patient is likely indicative of what?
duodenal rupture
92
How should a pelvic fracture be fixed?
internally if the patient is stable and externally if the patient is unstable
93
If a patient suffers pelvic trauma and is now hypotensive or tachycardia, what is the best next step and why?
concern is that they're bleeding into their abdomen/pelvis, so do a FAST or diagnostic peritoneal lavage
94
What are two signs of urethral injury?
- high riding prostate
| - blood at the urethral meatus
95
What is the next best step in a patient with a suspected urethral injury?
- do a retrograde urethrogram
| - never place a foley
96
If a patient has blood at the urethral meatus but a normal retrograde urethrogram, what is the next best step?
do a retrograde cystogram to evaluate the bladder, looking for extravasation of the dye (need two views to identify a trigone injury)
97
If a retrograde cystogram demonstrates extraperitoneal or intraperitoneal extravasation, what is the best next step?
- extraperitoneal: bed rest with a foley for comfort
| - intraperitoneal: exploratory laparotomy
98
Name four types of fractures that go to the OR.
- depressed skull fractures
- a femoral neck or intertrochanteric fracutre
- any open fracture
- any severely displaced or angulated fracture
99
What type of fracture should be suspected in the following circumstances:
- shoulder pain s/p seizure or electrical shock
- shoulder pain with an outwardly rotated arm and numbness over the deltoid
- older woman who fell on outstretched hand now with a displaced radius
- young person who fell on outstretched hand now with anatomic snuff box tenderness
- punched a wall
- posterior shoulder dislocation
- anterior shoulder dislocation
- colle's fracture
- scaphoid fracture
- boxer's fracture
100
Where along the clavicle is it most often fractured?
between the middle and distal thirds
101
What is the treatment for atelectasis?
mobilization and IS
102
What is the most common cause of a low or a high fever on POD 1?
- atelectasis if low
| - necrotizing fasciitis if high
103
What is the pattern of spread for necrotizing fasciitis?
subcutaneously along Scarpa's fascia
104
What are the two most common etiologic agents responsible for necrotizing fasciitis?
- C. perfringens
| - GABHS
105
What is the treatment for necrotizing fasciitis?
use IV penicillin and debride in the OR until the skin bleeds
106
Describe the cause, triggers, and treatment of malignant hyperthermia.
- a genetic defect involving the ryanodine receptor
- triggered by succinylcholine or halothane
- treated with dantrolene to block the RYR and reduce intracellular calcium
107
What is the empiric treatment of post-op pneumonia while awaiting cultures?
a fluoroquinolone to cover for strep pneumo
108
What is most likely to cause a fever:
- immediately post-op
- POD 1
- POD 3-5
- POD 7 or beyond
- immediate: malignant hyperthermia
- POD1: nec fas or atelectasis
- POD3-5: pneumonia or UTI
- POD7: central line infection, cellulitis, dehiscence, abdominal abscess
109
What is the preferred treatment for post-op UTI?
- get a UA and culture
| - change the foley and treat with a broad-spectrum antibiotic until cultures come back
110
What is suggested by pain and tenderness at an IV site? What is the proper treatment?
- suggests a central line infection
| - get blood cultures from the line, pull the line, and provide antibiotics to cover staph
111
What is suggested by pain at an incision site with edema, induration, and drainage? What about without drainage?
- with drainage is more suggestive of a simple wound infect
| - without drainage is more suggestive of cellulitis
112
What is the treatment for a simple post-op wound infection?
open the wound and repack; no antibiotics are necessary
113
What is the treatment for post-op cellulitis?
draw blood cultures and start antibiotics
114
What is the most likely diagnosis and the best next step if a patient has pain and salmon colored fluid draining from his incision?
- most likely dehiscence
| - treat with IV antibiotics and primary closure of the fascia
115
How is abdominal abscess diagnosed and treated?
- most likely to present with unexplained fever and a history of abdominal surgery
- diagnose with a CT or a diagnostic laparotomy if necessary
- treat with drainage, either percutaneous, IR-guided, or surgically
116
What is the treatment for thrombophlebitis?
antibiotics and heparin
117
What is the best prevention for pressure ulcers?
q2 turns
118
What is a Marjolin's ulcer?
it is a chronic ulcer that leads to increased cell turnover and ultimately to squamous cell carcinoma
119
Why tissue biopsy a pressure ulcer?
to rule out Marjolin's ulcer and squamous cell carcinoma
120
How are pressure ulcers staged and treated?
- stage 1: skin intact but erythematous and blanches
- stage 2: blisters or breaks in the dermis are present
- stage 3: subq destruction of the muscle is present
- stage 4: involvement of the joint or bone
- stages 1 and 2 require barrier protection, stages 3 and 4 require flap reconstruction
121
What are the indications for a diagnostic throacentesis?
more than 1 cm of fluid on a lateral decubitus view
122
What are the criteria for a transudative or exudative pleural effusion?
transudative if:
- LDH less than 200
- LDH effusion/serum less than 0.6
- protein effusion/serum less than 0.5
123
What are the likely causes of transudative and exudative pleural effusions?
```
transudative (LDH less than 200, LDH ratio less than 0.6, protein ratio less than 0.5)
- CHF, nephrotic syndrome, cirrhosis
- RA if low pleural glucose
- TB if high pleural lymphocyte count
- malignancy or PE if bloody effusion
exudative
- parapneumonic or cancer
```
124
What would cause a transudative pleural effusion with low glucose?
RA
125
What would cause a transudative pleural effusion with blood?
malignancy or PE
126
What would cause a transudative pleural effusion with a high lymphocyte count?
TB
127
What would suggest an exudative pleural effusion and what are potential causes?
- suggested by LDH greater than 200, LDH ratio of effusion/serum greater than 0.6, protein ratio of effusion/serum greater than 0.5
- caused by parapneumonic process or cancer
128
What is a complicated pleural effusion and how is it treated?
- complicated if there is a positive gram stain or culture, pH less than 7.2, or low glucose
- requires insertion of a chest tube
129
How is a spontaneous pneumothorax diagnosed and treated?
- diagnosed with CXR
- treat with a chest tube
- indications for surgery include an ipsilateral or contralateral recurrence, bilateral, incomplete lung expansion after thoracotomy, live in remote area
- surgery involves pleurodesis to make the pleura stick to the chest wall and prevent collapse
130
Lung Abcsess
- usually secondary to aspiration in alcoholics or the elderly
- most often seen in the posterior upper or superior lower lobes on the right
- seen as a mass with air fluid level on chest x-ray
- treat initially with antibiotics, usually IV penicillin or clindamycin
- surgery indicated by failure of the antibiotics, abscess greater than 6 cm, or the presence of an empyema
131
First step in a patient with a solitary lung nodule?
find an old CXR for comparison
132
What do popcorn calcifications in a solitary lung nodule suggest
a benign hamartoma
133
What do concentric calcifications in a lung nodule suggest?
an old granuloma
134
What features suggests that a lung nodule is benign? What is the next step?
- popcorn calcifications, concentric calcifications, patient less than 40, size less than 3 cm, or well-circumscribed suggest it is benign
- treat with CXR or CT scans every 2 months to look for growth
135
What is the next step if a lung nodule appears malignant?
remove the nodule with if central and open lung biopsy if peripheral
136
What are potential symptoms of lung cancer?
- weight loss
- cough
- dyspnea
- hemoptysis
- repeated pneumonia
- lung collapse
137
What is the most common form of lung cancer in non-smokers?
adenocarcinoma, which tends to occur in the scars of old pneumonia
138
Describe common features of adenocarcinoma.
- most common form in non-smokers
- tends to occur in the scars of old pneumonia
- found in the periphery
- often metastasizes to the liver, bone, brain, and adrenals
- has a characteristics exudative effusion with high hyaluronidase
139
What is the classic presentation for squamous cell carcinoma of the lung?
- paraneoplastic syndrome secondary to PTH-rP including kidney stones and constipation
- low PTH levels, low phosphate, high calcium
- central lung mass
140
What is superior sulcus syndrome?
a syndrome of shoulder pain, ptosis, constricted pupil, and facial edema associated with small cell carcinoma
141
What is the likely problem in someone with a lung nodule who has ptosis that improves after 1 minute of upward gaze?
they likely have small cell carcinoma with lambert-eaton syndrome
142
What is lambert-eaton syndrome?
a paraneoplastic syndrome involving antibodies against pre-synaptic calcium channels and associated with small cell carcinoma
143
Which lung cancer is associated with each of the following:
- non-smokers
- Lambert Eaton syndrome
- superior sulcus syndrome
- PTH-rP
- exudative effusion with high hyaluronidase
- adrenal mets
- SIADH
- hyponatremia
- peripheral cavitations
- non-smokers: adenocarcinoma
- Lambert Eaton syndrome: small cell carcinoma
- superior sulcus syndrome: small cell carcinoma
- PTH-rP: squamous cell carcinoma
- exudative effusion with high hyaluronidase: adenocarcinoma
- adrenal mets: adenocarcinoma
- SIADH: small cell carcinoma
- hyponatremia: small cell carcinoma
- peripheral cavitations: large cell carcinoma
144
What is the important distinction between small and non-small cell carcinoma of the lung?
small cell is more chemo and radio sensitive but non-small cell cancer is more amenable to surgery
145
What are potential causes of ARDS? What criteria are used for diagnosis? How is it treated?
- causes include sepsis, gastric aspiration, trauma, low perfusion, and pancreatitis
- diagnosed based on PaO2/FiO2 < 200, bilateral alveolar infiltrates on CXR, PCWP < 18
- treat with PEEP
146
What is described as a systolic ejection murmur that gets louder with valsalva? Softer with valsalva?
- louder: HOCM
| - softer: aortic stenosis
147
How can you differentiate HOCM from aortic stenosis on auscultation?
- aortic stenosis is a systolic cres-decres ejection murmur that gets softer with valsalva
- HOCM is a systolic cres-decres ejection murmur that gets louder with valsalva
148
What is described as a late systolic murmur with a click?
mitral valve prolapse
149
What is described as a holosystolic murmur that radiates to the axilla?
mitral regurgitation
150
What is described as a holosystolic murmur with a late diastolic rumble?
VSD
151
What is described as a continuous machine-like murmur?
PDA
152
What is described as a wide fixed and split S2?
ASD
153
What is described as a rumbling diastolic murmur with an opening snap?
mitral stenosis, potentially complicated by left atrial enlargement and a-fib, often have a history of rheumatic fever
154
What is described as a blowing diastolic murmur with widened pulse pressure?
aortic regurgitation
155
Which murmurs get louder with inspiration?
right sided murmurs
156
Left sided murmurs tend to get louder with what two things?
sitting up and expiring
157
Is Zenker's diverticulum a true or false diverticulum?
a false one as it only contains the mucosa
158
How is achalasia treated?
- conservatively with CCBs, nitrates, or boto
| - surgically with a myotomy
159
What presents as dysphagia worse for hot and cold liquids that is accompanied by chest pain similar to an MI and without regurgitation? How is it treated?
this describes diffuse esophageal spasm and should be treated medically with CCBs or nitrates
160
What is the most sensitive test for diagnosing GERD?
24-hour pH monitoring
161
What are the indications for endoscopy in a patient with GERD?
do an endoscopy if danger signs are present
162
How is GERD treated? When do we use surgical intervention?
- treat conservatively with behavior modification, antacids, H2 blockers, and PPIs
- do surgery for bleeding, stricture, Barrett's esophagus, an incompetent LES, symptoms with maximal medical treatment
163
What would usually cause a pleural effusion with increased amylase?
boerhaave's syndrome (esophageal rupture)
164
What is the best next step and the treatment if a patient presents with likely boerhaave's syndrome?
- next step: CXR and gastrograffin esophogram (no barium so no endoscopy)
- treatment is surgical repair
165
How are gastric varies treated?
- do ABCs
- perform a NG lavage
- treat medically with octreotide or somatostatin
- balloon tamponade only if you need to stabilize for transport
- remember, no prophylactic treatment, only treat symptomatic cases
166
What are the best next steps in someone with suspected esophageal cancer?
- barium swallow
- then endoscopy with biopsy
- then staging CT
167
What is the difference between a type 1 and a type 2 hiatal hernia?
- type 1 is a sliding hernia whereas type 2 is a paraesophageal hernia
- type 1 produces worse GERD and is usually medically managed
- type 2 is more likely to present with abdominal pain, obstruction, strangulation, and a need for surgical intervention
168
What is the typical presentation for gastric ulcers?
mid-epigastric pain worse with eating in those with a history of H. pylori, chronic NSAID use, or steroid use
169
What is the workup for gastric ulcers? What is the treatment?
- initially get a barium swallow to demonstrate punched out lesions with regular margins
- need an EGD with biopsy to tell if it's related to H. pylori and is benign or malignant
- treat medically for 12 weeks and perform surgery if it persists
170
Gastric lymphoma is associated with what other disease?
HIV
171
MALT-lymphoma is associated with what other disease?
H. pylori infection
172
What is Blummer's Shelf?
metastases felt on DRE from gastric cancer
173
What is Mentriers disease?
a protein losing enteropathy (foamy pee) with enlarged rugae seen on EGD
174
What are gastric varices most often caused by and associated with?
associated with splenic vein thrombosis following pancreatitis
175
What is Dieulafoy's disease associated with?
massive hematemesis resulting from a mucosal artery eroding into the stomach
176
What is the treatment for H. pylori?
PPI, clarithromycin, and amoxicillin for 2 weeks followed by a breath or stool test for cure
177
What is the preferred test for duodenal ulcer?
- blood, stool, or breath test for H. pylori will most likely be positive as 95% are associated with infection
- but an endoscopy with biopsy is best because it can also exclude cancer
178
What is the most likely diagnosis if a patient has recurrent, multiple, or refractory duodenal ulcers?
ZE syndrome
179
How is Zollinger-Ellison diagnosed and managed?
- test with a secretin stimulation test to find inappropriately high gastrin (should suppress it)
- treat with surgical resection of pancreatic/duodenal tumor and look for pituitary or parathyroid problems (MEN1)
180
What are the two most common causes of pancreatitis?
gallstones and alcohol consumption
181
What is the best imaging test for pancreatitis?
CT
182
How is pancreatitis treated?
NG suction, NPO, IV rehydration, and observation
183
What are the feared complications of pancreatitis?
pseudocysts, hemorrhage, abscess, and ARDS
184
What are four common manifestations of chronic pancreatitis?
- chronic mid-epigastric pain
- diabetes mellitus
- malabsorption and steatorrhea
- splenic vein thrombosis and gastric varices
185
How is pancreatic adenocarcinoma diagnosed?
endoscopic ultrasound and FNA
186
What is Courvoisier's sign?
palpable, non-tender gall bladder associated with pancreatic cancer
187
What is Trousseau's sign?
migratory thrombophlebitis associated with pancreatic cancer
188
What must be true for pancreatic cancer to be a candidate for surgery?
- no mets outside the abdomen, to the liver, or to the peritoneum
- no extension into the portal vein or SMA
189
Describe the findings consistent with an insulinoma.
- symptoms of sweating, tremors, hunger, and seizures
- blood glucose less than 45
- symptom resolution with glucose administration
- hyperinsulinemia, increased C-peptide, and increased pro-insulin
190
What are the symptoms of glucagonoma?
- hyperglycemia
- diarrhea
- weight loss
- necrolytic migratory erythema
191
What are the symptoms of VIPoma?
watery diarrhea, hypokalemia, dehyration, and flushing that respond to octreotide (similar to carcinoid syndrome)
192
What disease is indicated in a patient presenting with RUQ pain referring to the pain, n/v, fever, and pain that increases after fatty foods?
Acute cholecystitis
Dx: u/s
Tx: cholecystectomy
193
What is the first test that is indicated when acute cholecystitis is suspected?
Ultrasound
194
What disease is suspected in a patient that presents with RUQ pain that has high bilirubin and alk-phos?
Choledocolithiasis
Dx: u/s
Tx: chole (+) ERCP for stone removal
195
What disease is suspected in a patient presentign with RUQ pain, fever, jaundice, HPN, altered mental status?
Ascending cholangitis
| Tx: Abx, ERCP
196
What are the two main types of choledochal cysts? What are their treatments?
Type 1: Fusiform dilation of CBD- excision
| Type 4: Caroli's in intrahepatic ducts - liver transplant
197
What are the (3) risk factors for cholangiocarcinoma?
1. Primary sclerosing cholangitis
2. Liver flukes
3. Thorothrast exposure
Tx: surx (+) radiation
198
What causes an AST = 2x ALT?
Alcoholic hepatitis
199
What is suspected if ALT > AST, but both are in the 1,000s
Viral heptatis
200
What is suspected if AST/ALT are increased after hemorrhage, surgery, or sepsis?
Shock liver
201
What are (3) medical treatments for cirrhosis --> portal HTN?
1. Somatostatin
2. Vasopressin
3. Beta blockers
202
What can you use to treat hepatic encephalopathy to remove excess ammonia?
Lactulose
203
What are (4) risk factors for hepatocellular carcinoma?
1. Chronic Hep. B carrier or Hep. C
2. Cirrhosis
3. Aflatoxin
4. Carbon tetrachloride
204
What is the tumor marker used in hepatocellular carcinoma?
ARP
205
What diseases is suspected in a woman on OCP who presents with a palpable abdominal mass or spontaneous rupture leading to hemorrhagic shock?
Hepatic adenoma
206
What (3) organisms are the most common causes of hepatic abcesses? What is the treatment?
1. E. coli
2. Bacteriodes
3. Enterococcus
Tx: drainage and Abx
207
What bug is suspected if a patient presents with RUQ, profuse sweating and chills, and palpable liver? What is the treatment?
Entamoeba histolytica
Tx: NO drainage, metronidazole only
208
What bug is suspected in a patient who recently returned from Mexico with RUQ and large liver cysts found on u/s? What is the mode of transmission, lab findings, and treatment?
Echinococcus
MOT: dog feces
Lab: eosinophilia, +Casoni skin test
Tx: albendazole, surx and AVOID RUPTURE
209
What (3) vaccines are indicated in patients after splenectomy? What other medication is necessary?
1. s. pneumo
2. h. flu
3. N. meningitidis
+ prophylactic PCN
210
What nutritional deficiency results with carcinoid syndrome? What are the symptoms?
Niacin: dementia, diarrhea, dermatitis, wheezing
