Emma Holliday Surgery lectures Flashcards
(450 cards)
0
Q
Other contraindications to surgery
A
poor nutrition - ------albumin < 3,, ------transferrin < 200 ------weight loss of total body < 20% Lever failure - High bili, Pt > 16 ammonia > 150 SMoker - stop 6-8 wks prior
1
Q
Absoulte contrindications to surgery
A
diabetic coma and DKA
2
Q
Meds to stop prior to surgery
A
aspirin
NSAIDS
vit E ( 2 weeks)
3
Q
If have CKD what do you do 24 hrs proior to surgery
A
diayllsis 24 hours prior
4
Q
What post surgical complication would you worry about with the BUN > 100
A
Platlet dysfunction and bleeding
5
Q
What would the labs show for uremia induced platlet dysfunction
A
Normal platlets but prolonged bleeding time
6
Q
SIMV
A
You get a set TV. therfore if the patient starts the breath they get the full volume
7
Q
PVRC
A
Pt determines the rate but a boost of pressure is given for each breath
8
Q
CPAP
A
Pt must breath on their own but prssure is given all the time
9
Q
PEEP
A
- pressure delivered at the end of the cycle to help th avelooi open VERY important top help in ARDS
10
Q
What would you change on a vent if : PaCO2 is Hihg and pH is low
A
increase Rate or TV
11
Q
What would you change on a vent if : Paco2 is low and Ph is high
A
decrease rate OR TV
12
Q
IF Hco2 is low and pCO2 is low
what is the cuase and what do you check next
A
Metabolic acidosis
next check anion gap - ( Na- [cl+ hco3])
13
Q
Causes of metabolic acidosis With a HIgh anion gap
A
M-methanol U- uremia D- DKA P-propylene gylcol I-iron, isoniazid -L - lactic acidosis E- etholnol S- Siacylic acid
14
Q
Causes of metabolic acidosis With a normall anion gap
A
diarrhea, diuretics RTA I< II, IV
15
Q
If HCO3 is high and PCO2 is high and cl- in the urine is < 20
A
Vomiting/NG tube antacids, diuretics
16
Q
If HCO3 is high and PCO2 is high and cl- in the urine is > 20
A
Conns Bartters Gittlemans
17
Q
then you have low sodium when do you use 3% Na iv
A
when the patient is symptomatic with seizures or sodium is below 110
18
Q
complication of correctio of hyponatermia too quickly
A
Centeral pontine myoliinolysis
19
Q
If you ahve an increase in total body sodium what do you replace with and what is a complication
A
replace with D5 or hypoteonic fluid
risk of cerebral brain edema
20
Q
Numbness chvostek, or troussaeus sign or Prolonged Qt interval
A
Decrease Ca2+
21
Q
Bone pain, kidney stones, Abdominal discomfort from constipation, Depression anexity trouble sleeping anorexiaOR shortened QT
A
Increased Ca2+
22
Q
Paraylsis, Ileus, ST depression U waves
Cause and Treatment ?
A
Cause decrease K and treatment Give K max 40 mEq/hr
23
Q
Peaked T waves ( generalized) prolonged PR and QRS waves
Cause?
Treatment?
A
Cause - give Ca gluconate then insulin + glucose and kayexalate albuterol and sodium bicarb….. last resort is diaylsis
24
Maintenacne IVF equation
$: 2;1
0-10 kg - 4ml/kg/hr
10-20 - 2 ml/kg/hr
all above 20kg: 1ml/kg/hr
25
Complication of TPN
Acalculus cholecystitis hyperglycemia liver dysfuxn, zinc def. lyte prob
26
If someone hasa circumferential burn
consider escharotmy
27
If someone has signed nose hairs wheezing and soot in mouth
Bad intubation - low threshold
28
Patient with confusion and cherry red skin
CO - best test is carboxy hb - DONT use pulse Ox
29
HYPER-Clotting. In the elderly
CAcner especiially pancreatic
30
Hyper- Clotting and Edema Htn and foamy pee
nephrotic syndrom
31
HYPER- Clotting in a young person with a + Family hx
factor V leiden
32
If you have AtIII def what medicatio will not work on the clots
heparin
33
HYper- clotting and a young women with a PMH of spontenous abortions
Lupus anticoagulant
34
Post Op HYper Clotting decrease in Plt
HIT - if heparin was given w/in 5-14 days
35
How do you treat HIT
leparudin and agatroban
36
Bleeding problem with an isolated decrease in Pltss
ITP
37
Normal PLts but increase in bleeding time and Ptt
von willibrands disease
38
Low Plts, Increase PT, PTT BT Low Fibrinogen, high D dimer and schistocytes
DIC!!! caused by Gram - sepsis carcinomatosis and OB stuff.
39
RULE of 9 for burns Adults Vs children
Adults- 9 for each Arm, 9 for the head, 18 front, 18 back, 1 genitals, 18 for each leg
Babies- 18 for the head, 0 for each arm, 18 front and 18 back and 1 genitals and 14 legs
40
Parkland forumla adults and babies
| and how fast do you give the voluem
adults : KG* %BSA * 3-4
Kids : Kg* %BSA* 2-4
- this gives you a value in Ml and you give 1/2 over the 1st 8 hrs and rest over the next 16hrs
41
How do you abx to Burn patients
TOPICAL !!!!
42
Silver sulfadiazine
Doesnt penetrate eschar and can cause leukopenia
43
Mafenide
Penetrates eschar but hurts like helpp
44
silver nitrate
Doesnt penetrate Eschar and causes hypoK and HypoNa
45
Chemical burn 1st step
irrigate > 30 min
46
Electrical burn
| 1st test and then amangement
1st test: Get and EKG to check for arrthymias
managment: check for myogliobinuria and ATN
Check K levels from cell lysis
Monitor limb temperature for compartment syndrome
- criteria - 5 P and pressure > 30mmhg
47
When a smoker is coming out of anesthetics do you want to keep their pulse ox at 100
No because smokers and Co2 retainers need the low oxygen for the respiratory drive
48
Goldmans risk what is the MOST important Risk
CHF- check EF < 35% NO SURGERY for you
49
Goldmans risk what is the Second MOST important Risk
MI w/in 6 mon
| EKG-> stress test--> cardiac cath --> revasc.
50
Metformin important prior to surgery
YOU must stop because of lactitic acidosis
51
What is more effective for your patient to increase Rate or Volume ?
By increasing rate you are not increasing the amount of I2 to the aveoli
by increasing TV you are increasing the effective oxygenation
52
Low sodium but signs of fluid retention
CHF, nephrotic cirrotic
53
DEcrease volume and decrease sodium
diureticcs or vomiting and free water
54
NOrmal volume but decrease in NA
SIADH ! addisons and hypothyroidism
55
When do you use hypotonic saline 5%
patient is symptomatic with seizures or sodium less then 110
56
Maintenacne IVF for daily requirments
up to 10Kg - 100ml/kg/day
NExt 10 -> 50ml/kg/day
All above 20 -> 20ml/kg/day
57
1st degree burn what layer of skin
epidermis
58
Why dont you give IV or PO antibiotics to a burn victom
it breeds resisitance
59
If yo have low sodium what do you want to check
the serum osmolarity because high glucose makes the plasma look too dilute
60
What kills you in rhado!
The hyperkalemia
61
Patient is unconscious
INTUBATE
62
If a guy is stabbed in the neck and there is subcutenous stridor then what to do
Use fibrooptic broncoscope to secure the airway
63
when do yo immeadatly brind a patietn to the OR
Upput is greater then 1500 ml when the tube is first placed or greater then 200ml/hr in the first 4 hours
64
If patient was inward mvmt of the right ribcage upon inspiration
FAIL chest > 3 consec rib fractures
65
Fail chest treatment
o2 and pain control ( NERVE BLOCK) - do not give morphine because it decreases repiratory drive
66
A patient is confused petechial rash in hte chest and axilla and neck with Acute SOB post Car accident multiple bone injuries
Fat embolism - mcc after long bone fracture s
67
A patient dies suddenly dies after a centeral line
AIR embolism
68
Causes of air embolism
lung trauma ( too much TV) , vent use, during heart vessel surgery
69
If the neck veins are flat and the CVP is normal what type of shock
Hypovolemic/ hemorraghic
70
After hypovolemic shock has been indentified whats the next best step
2 large bore iv-2L NS or LR over 20 min followed by the blood
71
If muffled heart sounds, Disteneded JVD, electracal alternas on EKG Pulsus paradoxus
pericardial tamponade
72
What test to confrim pericardial tamponade
FAST scan
73
Treatmetn for Pericardial tamponade
needle decompression pericardial window or median sternotomy
74
IF decrease breath sounds on one side tracheal deviation away from the collapsed lung
Tension pneumothorax
You do not need to confrim - simply place the need and then a chest tube
*NO CXR nessisary *
75
NEurogenic shock physical findings
Bradycardia, warm dry extremities
NO relfexs or flaccid muscle tone.
CAN HAVE hyponatermia and Hypokalemia d/t adrenal insufficency - give dexamethasone
76
Neurogenic shock swan ganz catheter pressures
Increase CO
Systemic Vascular rsistance - decreases SVR
PCWP- Decrease
77
Vasogenic physical exam
AMS!, Warm Dry extremities ( early)
| LATE APPEARSlike hypovolemic shock
78
Vasogenic swan ganz catheter pressures
PCWP decrease
SVR decrease
CO increase
79
Cuase of neurogenic shock
loss of sympathetic input there for dilatation of the vascular tone.
80
Physical presentation of cardiocompressive shock
hypotensive tackycardiac JVD decreased heart sounds normal breath sounds Pulsus paradoxcus
81
Cardiogenic shock physical exam
SOB ( pulmoary edema) clammy extremities rales b/l S3 pleural eddusion and decrease breath sounds ascities and peripheral edema
82
Cardiogenic pressure readings
PCWP - increase ( back up of blood)
SVR increase
CO decrease
83
Physical exam for hypovolemic shock
Hypotensive tackycardiac diaphoretic cool clammy extremites
84
Lung pressures
PCWP decrease
SVR increase
CO decrease
85
Increased ICP
Heachache, projectile vomiting and AMS ! also papilledema ( visual cahnges
86
What are the besd side treatments for increase ICP
Elevate HOB, Hyperventilate to ppCO2 28- 32
| give mannitol watch renal failure
87
Surgical managmnt for head trauma and bleeding
Ventriculostomy - or BUrr hole
88
Zone 3 of the neck
ABOVE The angle of the mandible
89
WORK up for damage of zone 3 of the neck
AOrtography and triple endoscopy to make sure the trachea nd esophagus are still patetn
90
zone 2 neck location
Angle of the mandible to the cricoid
91
ZOne 2 work up for neck trauma
2d Doppler (vessels) and +/- exploraoty surgery
92
zone 1 location
below the cricoid
93
work up for zone 1 damage
angiography
94
IF Gun shot wound to the abdomen where for you go
OR immeadatly + tetnus prophaylaxis
95
If stab wound and patient is unstable with rebound tenderness and rigidy or evisceration
OR immeadatly + tetnus prophalaxis
96
If blunt ab trauma pt with hypotension/tachycardia
OR ex lap
97
If stab wound to the abdomen but patient is stable
FAST exam
DPL ( diagnositc peritoneal lavage ) if FAST is equivocal
EX lap if EITHER are postive
98
BAT + unstable vitals
OR immeadatly
99
BAT + hemodynamically stable next best step
CT Of the abdominal
100
BAT + hemodynamically stable + Ct shows Lower rib fracture and bleeding intothe abdomen
Spleen or liver laceration
101
BAT + hemodynamically stable + Ct shows Lower rib fracture and hematuria
Kidney laceration
102
BAT + hemodynamically stable + Ct shows Viscera in the chest aznd patient complains of shoulder pain - kehr sign
Diaphragmatic rupture
103
BAT + hemodynamically stable + Ct shows handler bar sign ( bruising in the mid epigastrium )
Pancreatic rupture
104
BAT + hemodynamically stable + Ct shows retroperitoneal fluid
Consider duodenal ruptures
105
Pelvic trauma + Hypotensiive and tachycardia
Bleeding into the pelvic cavity - Use FAST AND DPL to r/o bleeding
106
Treatment for a pelvic fracture
IS to stabilize the pelvis with a large sheet and because it is a bowel remeber there is most likely two fracture points
107
IF Blood at the urethral meatus and high riding prostate
consider pelvic fracture with uretheral or bladder injugy
| - remeber you are preforming rectal exam at the same time as the spinal exam
108
IF suspected adamage to the urethreal meatus what is the next best test -
Retrograde urethrogram - not foley
- ---if normal then do retrograde cytogram to evaluate bladder
- -- you are looking for extravastation ofthe sye and ***you need to see 2 views to See trigone injury *****
109
IF you see extravastion on the retrograde uretherogram what isthe management
FOR Extraperitoneal
VS intraperitoneal
extraperitoneal - Bed rest and Foley
| intraperitoneal - ex-lap and surigal
110
What part of the bladder is the most susceptable to dsamge
The dome of the blader
111
Does this fracture go to the OR immeadatly or NOT ? Depressed skull fracture
GO TO THE OR
112
Does this fracture go to the OR immeadatly or NOT ? Severely displaced or angulated Fx
GO TO THE OR
113
Does this fracture go to the OR immeadatly or NOT ? Any Open fx ( sticking out bone needs cleaning)
GO to the OR
114
Does this fracture go to the OR immeadatly or NOT ? Femoral neck or intertrochanteric FX
GO TO THE THE OR
115
Shoulder pain s/p seizure or electrical shock
posterior should dislocations
116
Arm extrnerally rotated and numbness over the deltoid
Anterior dislocation wiht damage to the axiallary nerve
117
Old lady feel on her wrist and the distal radius is aNTERIORLY displaced
Colle fracture aka dinner fork deformity
118
Young person fell on outstretched hand, tenderness on antomically snuffbox
scaphoid fracture
X ray is normal at first wait ten days and repeat
hiGH index of suspicion is important
119
Young man pouches a wall
metacarpel ( 4th and 5th) neck fracture may need a k wire
120
Clavical is most commonly fractured where
between the middle and the distal 1/3 need figure of 8 device
121
Fever on POD 1 with a low fever <101 and non productive cough
Atelectasis
122
How to diagnosis atelectasiss
CXR - look for bilateral lower lobe fluffy infiltrates
123
Treatment for post op atelectasis
MOVE Around and incentive spirometry
124
Fever to 104 on post OP day 1 + appearing very ill
Necrotizing fasciatius
125
HOw does post op necrotizing fascitits spread
Along Scarpa fascia in the SubQ region.
126
Common bugs that cause post op necrotizing fascitits
Strep and colstridium perfingenes
127
Trement for post op necrotizing fascitits
BAck tot he tOR and debride until it bleeds
| also IV antibiotics
128
POst op day one fever > 104 and muscle rigidity
maligant hyperthermia
129
What drugs cause maligant hyperthermia
succyline choline or halothane
130
Genetic defect for MAligant hyperthermia
Ryanodine receptor -
131
Treatment for maligant hyperthermia
Dantrolene NA - it blokcs the RYR recptors and decreases the intracellular Ca
132
Fever on POD 3-5 with productive cough and diaphoresis
Pneumonia - get a sputum sample for culture cover with respiratory quinolone aka MOxi ( for strep pneumo )
133
Fever POD 3-5 with fever dysuria frequency urgency in a patient with a foley
WHat is it and howdo you confrim
UTI, Next best test is UA - Nitrite and LE and culture
134
Treatmetn for POD 3-5 fever d/t UTI
Change foley and treat with wide spectrum abx until culture returns
135
POD & Fever pain and tenderness at the IV site:
| Cuase and treatment
Centeral line infection
| Txt: 1st draw blood for cultures, then remove the line and then start IV abx especially for Staph
136
POD & Fever & pain at the incision site, with edema , induration BUT NO DRAINAGE
Cause
Txt
CELLULITUS
| txt Do blood culture and *start antibiotics*
137
POD & Fever pain @ incision site induration with drainage
Simple wound infection
Open wound and reack
*No abx necessary *
138
POD & Fever Pain at incision site with salmon coloured fluid leaking from the inscision
DHEISCENCE
Txt - Surgical emergency
Go to the OR IV abx primary closure of the fascia
- this is an infection that has compromised the fascia
139
Unexplained fever on POD
Abdominal abscess - use a ct to scan fdor it with oral/iv / rectal contrast or if nothing diagnostic lap
140
Treatment for intrabdminal abscess
DRAIN IT
141
OTHER CAUSES OF FEVER
```
Thyroitoxicosis
THrombophlebitis - *Especially after a OB/GYN SURgery - Heparin + Abx*
Adrenal insufficency
Lymphangitis
sepsis
```
142
Cuases of pressure ulcers
Ischemia
143
Do you culture a pressure ulcer?
No because you will get skin flora - check CBC and blood cultures - if something found can be bactermeia or osteomyleitis
144
MARJOLIN ULCER how do you diagnosis
agressive ulcerating squamous cell cancer
145
How do you prevent pressure ulcers
- turning every 2 hours
146
Stages of presure ulcers
stage 1 - skin intact but red - BLANCHES with pressure
Stage 2- Blister or break in the dermis
Stage 3 - gets inot the sub q destruction into the muscles
Stage 4 involvment of the joint or bone
147
Treatment for stage 1-2 pressure ulcer
no big deal - cream adn special matress and barrier protection
148
treatment for stage 3-4
SUrgery :get flap reconstruction * before sugery make sure albumin ( nuitritional status) is 3-5 and bacteria load below 100k*
149
PLeural effsion on a chest xray at what level must you do a thoracentesis
if you see 1cm of fluid on thoracentesis
150
Light criteria
IF Protein > 0.5
LDH > 0.6 ( or > 200)
LDH greater 2/3 of the serum
then excudative
151
Transudative - with low pleural glucose
rheumatoid artitiris
152
transudative with high lyphocytes and adenosine deaminase
TB
153
transudative with blood present
maligancy and pulmonary embolus
154
If exudative
parapneumonic
or
cancer
155
Complicated effusion for 3 reasons
Bacteria is present
ph is < 7.2
Glucose is low
156
Sponentous penumothroax d/t ?
subpleural bleb
in a tall thing young men
Or asthma
Or COPD empysema
157
Spontenous pneumothorax indications for surgery
Recurrance in the smae spot or aanywhere else
If Bilateral, if there is incomlete lung expansion,
If pilot, scuba diver or live in a remote area
158
Treatment for recurrant spontenous pneumothorax
Video assisted throcentesis or pleurodesis - bleo iodine or talc
159
Who gets lung abscess
Alcoholics, elderly
demented or neuronal damage
emtera; feeds
160
diagnossis of the lung abscess
Chest X ray with a air fluid interface
161
Treaetmetn of lung abscess
Abx - Penicillin or clinda mycin
| if abx fail then SURGERY
162
Abscess indications for surgery
abscess > 6 cm or if empyema is present or if abx fail
163
SLN with popcorn calcification
harmartoma - most common
164
concenteric calcification in an SLN
old granuloma
165
SLN but the Pt < 40, <3cm well circumscribed
Most likely benign and f/u with CT or Cxr in 2 months
166
SLN but pt is a smoker, or is the lesion is >3cm or if calcification is spiculated
more liekly maligant and you will need to biopsy it
167
Physcial presentation of a patient with lung cancer
Weight loss, cough, dyspnea, hemoptysis, repeated lung collapse, repeated pneumonia ( from the obstruction) Clubbing
168
MC lung cancer isnon smokers femals and asians
adenocarcinoma occuring at the point of old scars ( can be from pneumonia) in the lungs
169
where does adenocarcinoma metasize tooo
metd to liver bone, brain and to the adrenals and can present with hypoaderenalism
170
Adenocarcinoma has what type of pleural effusions
Exudative and *high hyaluronidase *
171
Paitent presents with kidney stones, constipation, malaise LOW PTH and centeral lung mass
sQUAMOUS CELL CANCER
| paraneoplastic suyndrom pthrp low PO4 high Ca
172
Patient has shoulder pain ptois constricted pupil and facial edema
superior sulcus
173
XR shoing peripherial caviatio and CT whoing distant mets
LArge cell carcinoma
174
Patietn has euvolmeia but hyponatermia and hx of smoker
Siadh frmo small cell carcinom produces evolemia hyponatermia
175
Patiente has ptossis and it impoves after staring up for a long time
Lambert eatons syndrom from small cell carcinoma - binds to the Ca channel on the pre nerves
176
ARDS diagnosistc critear
Pao2/fio2 > 200 < 3000 means acute lung injury
Bilateral alveolar infiltrates on CXR
PCWP < 18 ( means that the edema is not cardiogenic )
177
SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvuset tardus
Aortic stenosis
178
SEM louder w/ valsalva, softer w/ squatting or handgrip.
HOCM
179
Late systolic murmur w/ click louder w/ valsalvaand handgrip, softer w/ squatting
Mitral valve prolapse
180
Holosystolicmurmur radiates to axilla w/ LAE
Mitral regurgitation
181
Holosystolic murmur w/ late diastolic rumble in kiddos
VSD
182
Continuous machine like murmur-
PDA
183
Wide fixed and split S2-
ASD
184
Rumbling diastolic murmur with an opening snap, LAE and A-fib
Mitral stenosis
185
Blowing diastolic murmur with widened pulse pressure and Corrhamer pulse, quinkes, Water hammer
Aortic regurgitation
186
Patietne has new onset bad breath sometimes finds undigested food in their mouth
Zenkers diverticulum tx with surgery
| - it is a false divrticulum
187
Dysphagia to liquids an solids
| what is themedical and surigcal treatment
MEdical treatment - CCB nitrates botox
| Surgical heller myotomy
188
What cancer is ass to achalasia
Esphogeal squamous cell cancer
189
Epigastric pain worse after lying down
| CAn have cough wheeze or HOarse voice
GERD the other symptoms are abnormal presentation represenitng silent aspiration
190
Test for GERD
24 hour PH monitoring
191
When Do you do an endoscopic examination for gerd
Alarm signs - Bleeding
192
Dyphasgia WORSE to hot and cold liiquids chest pain that seems like an MI
no reguirgitation
DIffuse esophageal spasm
193
Indications for surgery in GERD
Strictures, refractory to medical managment
194
Acid reflux pain after eating, when laying down
Hiatal hernia
195
Hiatial hernia type 1
Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs.
196
Type 2 hiatal hernia
aesophageal. Abd pain, obstruction, strangulation needs surgery.
197
Mid esophageal pain worse when eating
Gastric ulcers
198
Test for gastric ulcers
UlcersDouble-contrast barium swallow-punched out lesion w/ reg margins. EGD w/ bx can tell H. pylori, malign, benign.
199
When do you preform surgery on the gastric ulcers
Lesion persists after 12wks of treatment.
200
Krukenberg
Gastric cancer spreads to the ovaries
201
Virchows nodes
Left supraclavicular lymph node
202
Lymohoma
MCC extra nodal site common in HIV patients
203
Blummer shlfs
Mets felt on DRE
204
Sister mary joseph node
mets to the umbilical node
205
Malt- oma
H. Pylori
206
Protein loosing enteropathy with foamy pee and enlarged stomach rug
mentriers
207
Gastric varices
splenic thrombosis
208
Dieulafoy -
eorded vessel in the stomach causes massive stomach hematemesis
209
Mid epigastric pain that gets better with food
dueodenal ulcesr
210
which ulcer stomach or duodenal is most associated with h pylori
Duodenum
211
Treatment for h pylori
PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.
212
If the duodenal ulcers don't resolve after therapy
COnsdier ZE
213
Test for zollinger ellsion syndorm
Secretin stim test - find high levels of gastrin
214
Treatment for zollinger ellison syndrome
Surgical resection of pancreatic/duodenal tumor
215
what other cancers if Zollinger elision associated with
pituitary and parathyroid as part of MEN 1
216
Bilious vomiting and post prandial pain - recently loss a lot of weight
SMA syndrom --- Where the 3rd part of the duodenum is compressed against the aorta
217
How to treat SMA SYNDROME
restore nutrition and weight or ROUX-en-Y
218
Most common cause of pancreatitis
ETOH and gallstones
219
Bad prognostic factors for pancreatitis
```
AGE
WBC > 16
Glc > 200
LDH > 350
AST> 250
Drop in HCT , Ca PH and hypoxia
```
220
Complication of pancreatitis
abscess, pseudocyts, hemorrhage ARDS
| Thrid spacing of fluid
221
Chronic pancreatitis presentations
Mid epigastric pain DM and Malabsorption
222
Chronic pancreatitis can cause
SPlenic vein thrombosis - gastric varices
223
Pancreatitis adenocarcinoma presentation
Large NON tender GB, Itching and jaundice - cousvioar signs
224
Trousseaus sign
migratory thrombophlebitis
225
DX pancreatic cancer
EUS and FNA
226
Surgical treatment w
WHIPPLES -
| and only if no mets are found
227
Presentations of Insulinoma
sxs (sweat, tremors, hunger, seizures) + BGL < 45 + sxs resolve w/ glc admin
228
Glucagonoma + rash!
Hyperglycemia, diarrhea, weight-loss
| With necrolytic migratory erthyema
229
Somatistainoma ( prognosis )
Commonly malignant. see malabsorption, steatorrhea, ectfrom exocrine pancreas malfxn
230
VIPOMA
Water diarrhea, hypokalemia, dehydration and flushing - LOKS like a carcinoid tutor
231
TREATMENT of VIPOMA
OCtreotide
232
Patient presents with RUQ pain with shoulder or back pain - N/v fever
Acute cholecystitis
233
Acute cholecystitis first test
U/s
234
Treatment for Acute cholecystitis
Removal of the gallbladder -
| perutenous drainage if unstable
235
RUQ pain with High bill and all phase
Choledocolithiasis
236
Choledocolithiasis dx
U/s will show the stone in the CBD
237
Choledocolithiasis txt
Might remove the gall bladder and +/- ERCP
238
RUQ PAin fever jaudice Low bp, ams
Reynold pentad-ascending chalnagititis
| Txt abx and ERCP
239
Choledocal Cysts type 1
Mild - fusiform dilation of the common bile duct - txt with excision
240
Cholecohal cyst type 4
aka carol disease
intrahepatic duct cysts
need liver transplant
241
Cholangiocarcinoma
klatskin tumor for the bile duct epithelium
242
Cholangiocarcinoma RF
Primary sclerosisng chlangitis ass with UC, Liver flukes, thorothrast exposure
243
F AST 2x ALT
ALCOHOL
244
If ALT is higher then AST but both are in 1000's
VIRAL
245
AST & ALT high s/p hemorrhage surgery ( cardiovascular ) or sepsis
SHOCK LIVER - hypotnension liver injurgy
246
cirrhosis and portal htn medical txt
somatostatin - vasocontrict to decrease portal pressure
247
Tips used to but might cause
relieves portal htn but can cause encephalopathy
248
txt with hepatic encephalopathy
Lactulose
249
RF for hepatocellular carcinoma
Chronic HEp B ( DNA VIRUS ) > hep C
cirrhosis for any reason
*Aflatoxin or CCL4*
250
Tumor marker for HCC
AFP it is high in 70%
251
If multiple masses for HCC
| txt vs singular mass
Multiple is radiation and cryoablation
| Surgically remove singular
252
Women on OCP with a palpable abdominal mass or sponteous rupture -> hemorrhagic shock
hepatic adenoma
253
hepatic adenoma DX
US or MRI
254
hepatic adenoma - Surgery needed when
refractory to treatment
Large
Women wasn't to be pregnant
255
*2ndMC benign liver tumor. W>M but less likely to rupture
Focal nodular hyperplasia
256
Focal nodular hyperplasia what shows up on CT
Stellate scar
257
Bacterial Abscess- liver
*E. coli, bacteriodes, enterococcus.*
| txt Drainage and IV antibiotics
258
RUQ pain, profuse sweating and rigours palpable liver
entamoeba histolytica
259
Txt of entamoeba histolytica
Metronidiazole ---DONT DRAIN IT ---
260
Patient from Mexico presents with ruq pain and large liver Cysts found on U/S
Enchinococcus - hydatic cyst parasite from dogs fees
261
Enchinococcus lab
esonipholia- + Casoni skin test
262
Enchinococcus txt
albendazole and surgery to remove the entire cyst
| if ruputure the patient dies
263
Post Splenectomy what do you check
platelets if high can give aspirin
264
Propholatic treatment post splenectomy
Prophylactic PCN + S. pneumo, H. flu and N. meningitidisvaccines.
265
ITP presentations
isolated thrombocytopenia - bleeding gums, petechiae and nosebleeds
NO splenomegaly
266
IPT treatment
steroids if a relapse then surgery
267
IPT bone marrow findings
Increase megakaryocytes in the marrow
268
Hereditary sphereocytosis
| SXS
- hemolytic anemia - increase indirect bilirubin
Increase LDH
Decrease Haptoglobine
Elevated reticulocyte count
269
Traumatic splenic rupture
consider w/L lower rib fracture
| and kerhs sign
270
Appendix when do you go to surgery
high clinical suspicion
271
Would you go to surgery with abscess or perforation
no first drain abscess and txt with ABX then removes
272
number 1 site for carcinoid tumor
appendix
273
Carcinoid syndrom sxs
Flushing, wheezing and diarrhea ( it needs to mets to the liver or beyond)
274
IF carcinoid is > 2cm at the base of the appendix or w/ + nodes
HEMICOLECTOMY
275
Vitamine deficient in carcinoid syndrom
niacin - needed for tryptophan
| Diarrhea dementia dermatitis
276
pain, constipation, obstipation, vomiting. sxs
SBO
277
When is surgery indicated
peritoneal signs, IncrWBC, no improvement w/in 48hrs.
278
•Post-Op Ileus-Radiography
| Txt
- dilated small bowel loop through the entire small bowel
| Give lactulose or erthyromycin
279
Ogilvie syndrom
Dilation of the colon
280
What is the threshold of treatment for olive syndrome
| what is the management and treatment
```
10 cm the need decompression with ng tube or colonoscope
and neostigmine ( watch for bradycardia )
```
281
What is this
Small bowel obstruction as the divisions go allthe way through representing the Plecae of the small bowel
282
IS this a cecal or sigmoid volvulus - birds beak
This is a birds beak - cecal
283
IS this a cecal or sigmoid volvulus - coffee bean
Coffee bean the crease is the mesenteric artery - sigmoid
284
Umbilical hernia in a 1 year old what isthe advice given
They will close spontenously by age 2
285
what adults get umbilical hernia
obese ascites and pregnancy
286
indirect inguinal
THROUGH the inguinal ring and lat to the epigastric vessels
*R>L *
more often congential patent proc vaginals
287
Direct inguinal hernia
Hasselbacks triangle and medial to the epigastric vessels
| More often acquired weakness
288
Femoral hernia more common in
women & more common to strangulate
289
What iBD affects the terminal ileum
chrons
290
Which ibd mimics appendicitis
chrons
291
Which IBD can result in FE deficiency
Chrons - d/t ileitus
292
Continously involving the ileum
Uc, ( can have backwash iliititis
293
Increased risk of PSC and Cholangiocarcinoma
UC
294
Often has fistulas and what is the medical management
Crohns
| Give metronidazole
295
Has granulomas on biopsy
crohns
296
Transmural inflammation
CRohns
297
CURED by colectomy
UC
298
Smokers have a decreased risk
UC, but smokers have an increased risk of Crohns
299
Associated with *p-ANCA*
UC
300
Treatment for IBD
ASA, Sulfasalzine,
| corticosteroids to induce remission
301
Chrons disease txt
Give metranidazole for any ulcer or abscess
| azathioprine 6MP and methotrexate
302
lead pip colon xray
ulcertive colitis
303
String sign is
Pagets disease
| do* mammogram to find the mass -dcis*
304
Pyroderma gangersoum
chrons
305
Diverticular disease
Etiology
and complications
2/2 to a *low fiber diet*
| complication of *bleeding, obstruction and infection*
306
Diverticulitis
Forms a abscess that can perforate
307
Whats the best test for diverticular disease ?
*CT *not barium enema
308
When is colonscopy recommended after diverticulosis
4-6 weeks
309
When is surgery indicated- for colorectal cancer
multiple episodes, age < 50, elective is always better then emergency
310
RF for colorectal cancer
```
FAP,
Lynch syndrom
HNPCC
Gardners - soft tissue tumors
Cowdens
Turcots- Carnial tumors
```
311
Presentation of colorectal cancer Right sided cancer
Bleeding
312
Presentation of left sided cancer
Obstruction
313
RECTAL cancer presentation
PAin/fullness, bleeding/ obstruction
314
What work up is done for colorectal cancer
DRE, Transrectal ultrasound ( this is to determine *depth* of invasion and prognosis )
colonoscopy
CEA measurements for recurrence
CT for staging
315
Treatment for coloncancer
Remove the affected regions + chemo if nodes are postive
316
Treatment for rectal cancer -if upper/middle 1/3
| if lower 1/3
- if upper and middle get *lower anterior resection*
| - if lower 1/3 get *abdominal peritoneal resection* - permanant colostomy
317
Screening FOR AAA
MEN 65- 75 who have ever smoked- screen with U/S
318
What type of AA do you treat conservatively
if < 5cm and asymptomatic monitor growth every 3-12 months
319
Surgery indicated 2 reasons
> 5 cm in women
> 5.5cm men
*Growting > 4mm/yr*
320
complications of aaa surgery
#1 cause of death MI
Bloody diarrhea - ischemic colitis
ASA syndrom
-1-2 years later brisk GI bleeding- d/t aorticenteric fistula,
- heamturia - aroticvesiclular fistula
- Aortic caval fistula - with the IVC ( look for increase in venouse congestion)
321
Post AAA surgery *Weakness & decreased pain sensation* w/ preserved vibratory and proprioception
*Anterior spinal artery syndrom*
322
Acute mesenteric ischmeia TXT
Surgical emergency - embolectomy - if thrombus
| Aortomesenteric bypass if plaque
323
WOrk up for acute mesenteric ischemia
angiography - *most common place is the SMA*
324
Presentation:acute abdominal pain in a pt with a-fib subtherapeutic on warfarin or pt s/p high dose vasoconstrictors
MESENTERIC ISCHEMIA
325
Chronic mesenteric ischemia
Slow progression stenosis - req stenosis of *2.5 vessels* - celiac & SMA & IMA
326
Physical presentation- chronic mesentric ischemia
Mid epigastric pain after eating food fear and weight loss - *PAIN is out of proportion to exam*
327
For acute arterial occlusion when should surgery be preformed
*within 6 hours* of insult to avoid tissue damage
328
Complications of surgery for acute arterial occlusion
compartment syndrom
| 5p's
329
For acute arterial occlusion if surgery is not an option then what medical management
thrombolytics
| * watch for hemorrhagic stroke**
330
ABI of 0.4-0.8 + ulcers
Best medical managment
331
ABI of 0.2-0.4 + limb ischemia
Surgery is indicated
332
ABI <0.2 + gangrene
may require amputation
333
How to diagnosis DVT
Duplex and US also check for PE
334
How to treat DVT
txt with heparin, then overlap w/ warfarin for 5 days then continue warfarin for 3-6 mons
335
Complications of a DVT
*Post phlebotic syndrom* = chronic valvular incompetence cyanosis and edema
336
PE the signs
EKG
CXR
ABG
EKG - signs of Right heart failure - sinus tachycardia
CXR decreased vascular markings wedge infarct
ABG- low Co2 and o2 - alkalosis
337
What txt is provided if you suspect a dvt
Give heparin 1st - then work up with V/q scan ---- then spiral CT
338
What is the gold standard test for a PE
pulmonary angiography
339
```
Work up for a thyroid nodule
1st step check what level?
If level is Low ?
If normal ?
IF benign ?
If maligant?
If intermediate ?
If COLD?
```
* 1ststep? check TSH
* If low? Do raiu to find the hot nodule - excise or radioactive I
* If normal? FNA
* If benign? Leave it alone
* If malignant? Surgically excise
* If indeterminate? re-biopsy or check RAIU
* If cold? Surgiclaly excise and check pathology
340
Papillary
MC type -- spreads via lymph
341
papillary thyroid histology
psammoma bodies
342
Follicular how does it spread
spreads via the blood, must surgically excise whole thyroid
343
MEdullary what other test do you run
Look for MEN 2 pheo and hyperca
344
medullary histology
amyloid calcitonin
345
Anaplastic
80% mortality in the 1st year
346
thyroid lymphoma
hashimotos predisposes to it
347
Work up for adrenal nodule
1: Check functional status
- symptoms of a function tumor
2: if < 5 cm and non functional - observe with CT scans for q6mon
if > 6cm or functional - if surgical excision
348
Clinical features of pheochromocytoma
| and test
high blood pressure - sweating and weight loss
| Urine and plasma - metanephrines
349
Primary aldosteronism
| symptoms and test
HIGH BP and Low K and High Na
| test : plasma aldosterone to renin ratio
350
adrenocortical carcinoma
Virilization or feminization
| URINE 17 ketosteroids
351
Cushing or silent cushing
Cushing symptoms or normal examination results
| test is dexamethasone
352
Patient with *perioral numbness* and chvortek and trousseau sign
what are the labs suspected
Hypoparathryoidism - after thyroidectomy
| decrease CA increase Po4 DEcrease Pth
353
Hyperparthyroidism presentation
Usually asymptomatic but increase in CA can present with stones, moans, bones ect.
Increase Ca decrease Po4 increase vit D increase Pth
354
MEN 1
pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor.
355
MEN 2a
parathryoidhyperplasia, medullary thyroid cancer, pheochromocytoma
356
Men 2b
medullary thyroid cancer, pheochromocytoma, Marfanoid neuromucco- gangliomas
357
Work up for beast cancer
us to determine if it is solid or cystic
358
What type of breast tissue does MRI work on
good for dense breast tissue
359
IF a cystic mass is found what is the next step
aspiration of the fluid
| Send for cytology if it is bloody orhas recurred x2
360
IF a mass is solid
FNA
361
If cysts are painful and change with menses what is ir
Fibrocystic change
- fluid is green or straw coloured
-txt - restrict caffiene & chocolate
take vit E and wear a supportive bar
362
RF for breast cancer
Brac 1 or 2 or hx of breast cancer in the family nulliparity endo/exogenous estrogen
363
DCIS
Lumpectomy with clear margins or simple mastectomy if multiple lesions ( no NODES) + adjuvant RT
364
LCIS- lobular carcinoma in situ
*Often bilateral* - consider b/l mastectomy if FH+, Hormone senstive or prior hx of breast cancer
365
For infiltrating carcinoma that is small -
Can do lumpectomy with ax node biopsy + adjuvant _ chemo ( if the node +) + hormone therapy if +
______
OR
______
modified radical mastectomy with ax node sampling w/o adjuvant RT gives the same prognosis
366
Looks like eczema of the nipple
Pagets disease
| do mammogram to find the mass -dcis
367
Inflammaotry breast cancer
Red hot swollen breast - orange peel skin nipple retractione
368
Basal cell carcinom
Shave or punch biopsy then surgical remove
369
Squamous cell carcinoma what is the precursor lesion
aktinokeratosis or keratoacanthoma
370
Tx of squamous cell carcinoma
5FU or excision
371
Melanoma superifical spreading
Best prognosis most common
372
Melanoma
nodular poor prognosis
373
acrolintiginous
palms soles mucous membranes in darker complected races
374
Lentigo maligna
*head and neck* good prognosis
375
What is the prognosis factor for melanoma
DEPTH
376
TXT for melanoma -
for < 1 mm thick
1-4 mm
>4mm
< 1 mm thick -1 cm margin
1-4 mm 2 cm margin
>4mm- 3 cm margin
377
Medical treatment of *melanoma*
high dose of *IFN or IL2*
378
Rules for time for the neck mass
7 days
7 months
7 years
7 days - inflammatory
7 months -cancer
7 years -congential
379
*Most common* neck lesion
Reactive node so the #1 step is to investigate for inflammatory lesions - tonsils and teeth
380
If neck node is firm rubbery and B sxs are present - whats the next step
excisional bx looking for lymphoma
381
Excisonal biopsy of the lymph node finds predominatly lymphocytes and reed sternberg cells
hodgkins lymphoma
382
If neck mass is *midlne* and moves when the *tongue is protrouded*
*thyroglossal duct cysts*
| move tongue and move the mass
383
IF the mass is *anterior to the SCM* >
Brachial cleft cyst- can occur any where along the lenght of the SCM.
384
If spongy diffuse and lateral to the SCM
cystic hygroma - turners down, klinefelter
385
ORAL cancers MCC
Squamous cell cancer - seen in *alcoholics* and smokers
Can present with unilateral hearing loss, a non healing ulcer in the base of the mouth especially in patients with poor dental hygeine
txt with radial dissection
386
laryngeal cancer mcc in adults
squamous cell
387
Most common *laryngeal cancer* in kids with *stridor*
Laryngeal *papilloma* with stridor or cough
388
Pleomorphic adenoma
mc *parotid gland tumor* - Usually parotid benign but recurs-*painless and mobile*- cartilage and spithelium
389
Warthlin tumor
*papillary cystadenoma lymphomatosum* - itis a cystic lesion with a double layer of epithelium surronding a cystic space-----benign on parotid gland
WATCH for 7th nerve damage
390
Mucoepidermoid carcinoma
*MC malignant tumor*
arises from duct causes pain CNVII palsy
painful mass
has mucinous and squamous components
391
Baby born with respiratory distress scaphoid abdomen
Diaphragmatic hernia- always on the left
392
What is the biggest concern then the diaphragmatic hernia
Pulmonary hypoplasia
393
Best treatment for diaphrgamatic hernia
at delivery place ECMO. let lungs mature 3-4 days then do surgery
394
Baby is born with *respiratory distress* with *excess drooling*
te - fistula
395
Best test for fistula
Place feeding tube and take X ray and see it Coiled in the thorax
396
Gastroschisis has what elevated in amniotic fluid
AFP
397
Gastrochisisis
Defect lateral usually Right of the midline -- NO SAC - matted angry appearing bowel, child must remain TPN for 2 weeks
398
Complications with gastrochisis surgery
bowel may be atretic or nectotic and require removal -
| *SHORT gut syndrome*
399
OMphalceocele associated with
Edwards And patau and beckwidth widemen
400
Umbilical hernia what else is associated
congential hypothyroidism and big tongue
401
A vomiting baby 4 week old non bileous vomting and palpable olive
pyloric stenosis
402
metabolic complications of severe vomting
*hypochloremic* metabolic alkalosis
403
2 wk old infant with *bilious vomiting* the pregnancy was complicated by *polyhydramnios*
*Intestinal atresia* or* annular pancreas *
both are associated with down syndorme
intestinal aterisa have multiple air fluid levels
annular pancrease has the double bubble sign.
404
1 wk old baby w/ bileous vomiting draws up his legs has abdominal distension
*malrotation and volvulus* -- Ladd bands can kink the duodenum
( doesnt rotate 270 ccw around the sma )
405
3 day old newborn has still not passed meconium
| what 2 things could it be
meconium ileus - consider Cystic fibrosis if FH + or gastrograffin enema is dx and tx
________
OR
_________
Hirschaprung DRE explosion of poo bx showing no ganglia is gold standard
406
```
A new day old baby who was premature develops bloody diarrhea
what is it
what is on the X ray
TXT
risk factors
```
* necrotizing enterocolitis*
* XR findings* = pneumocystis intestinalis ( air in the intestine walls)
* txt* - NPO TPN antibiotics and resection of the nectotic bowel
* risk factors*: premature gut, introduction feeds and formula
407
2month old baby has colicky ab pain and current jelly stool with a palpable mass in the RUQ
intussuception - barium enema is DX and TX-- Dance sign - ( knees to chest )
408
What medications make BPH worse
*ANTI*cholinergics
409
how do you treat acute urinary retension
foley
410
what is the best treatment BPH
medical tx 1st tamsulosin (a-1 blockers) or finasteride- *Decreases the size of the prostate *
411
TURP Syndrome:
*Hyponatremia and water intoxication* (symptoms resembling brain stroke in an elderly presenting patient) caused by an overload of *fluid absorption* (e.g. 3 to 4 Litres) from the open prostatic sinusoids during the procedure. This complication can lead to *confusion, changes in mental status, vomiting, nausea, and even coma*.
412
Prostate cancer
nodules on DRE or elevate/rising PSA means = trans rectal ultrasound and bx.
*tx with surgery radiation & leuprolide & flutamide*
413
WHAT IS THE BEST TEST FOR KIDNEY STONES
CT- without contrast
414
Kidney stone less then 5 mm
hydrate and pain killers to let pass
415
IF > 5mmm
do shock wave lithotripsy
416
KIDNEY SOTNE > 2 CM
Surgical removal
417
Scrotal mass
transilumiante U/s and excision [never biopsy allows for seeding]
418
Testicular torsion
acute pain and swelling with *high riding testies* pain is excerbated by movment.
419
Testicular torsion Studies
STAT Doppler U/S (will show *no flow* ) contrast with epididymitis where flow is maintained
420
how much time to salvage testies- after testiclular torsion
6 hours
421
Avscular necrosis in a 4-10 ( mean age 7) year kid with a *painless limp*
leg calve perthe disease
422
Avascular necrosis in a kid 12-13
slipped capital femoral epiphyseals - the ball slipps off in a backward direction-- Can present with Knee pain from the obturator nerve and look for an externally held *passively in external rotation*
423
Avascular necrosis in an adults
steroids and femur fracture ( look for a shortened an extrenally rotated foot)
424
Osteosarcoma
| where and what radiological sign
distal femur/proximal tibia/ at metaphysis around the knee
| codman triangle and sunburst apperance
425
Ewing sarcoma
seen at the disphysis of the long bones - *night pain fever and elevated ESR*
426
Ewing sarcoma radiological
lytic bone lesions - onion skinning (lytic); t 11:22, small round blue cell tumor
427
Hyperacute Rejection
Vascular thrombosis with in *minutes*
| Caused by *preformed antibodies*
428
Acute rejection
Organ dysfunction - INCREASED GGT in the liver
| or CR depending on organ w/ in 5 days - 3months
429
Acute rejection what cell is responsible
T lymphocytes
430
Technical problems common in the liver
1st biliary obstruction w u/S then check for thrombosis by doppler
431
Heart transplant complications
sx come late so check with *ventricular bx* periodically
432
How to treat the acute rejection
*OKt3* antilymphocytic agent tx + *steroid bolus*
433
chronic rejection
occurs after yeas - d/t t-lypmhocytes
| cant treat
434
Where *cant* you get epi in the body
fingers, nose, Penis & Toes
435
Spinal subarachnoid -
bupivacine etc.
436
epidural
Local + opioid
437
Merperidine
Norperidine metabolite can *lower seizure threshold* especial in patients with *renal failure*
438
Succinylcholine:
Can cause malignant hyperthermia, hyperK (not for *burn or crush victim* because of upregulation of receptors)
439
Rocuronium,
Sometimes allergic rxn in *asthmatics*
440
Halothane
Can cause malignant hyperthermia (dantroline Na), *liver toxicity*.
441
Seminoma what marker is increase
placental alp
442
Yolk sac tumor aka endodermal sinus tumor
Increased AFP
443
choricoarinoma
increased HCG hematogenous mets to the brain
444
teratoma
increased HCG adn AFP
445
Embryonal carcinoma
increased hcg
446
Superficial spreading melanoma
4th -6th decade of life and fiar skinned people
trunk males
legs - femals
Long radial growth phase then verticle growth
447
Nodular melanoma
6th decade - 2nd MC
6th decade on trunk head and neck
M>F
NO radial growth
448
Letigo meligna
7th decade uncommon on face nose & cheek under the hutichens freckle
acitinic background - chronic expose to the sun
449
Acral lentigous melanoma
Palms and soles of the feet and nail bed
| more rapid vertical phase
