Gen Surg 3/13/17

Question 1

MEN1

Answer 1

Pituitary (any pit tumor, functioning or non)

Parathyroid (hyper calcemia)

Pancreas (endocrine)

• Zollinger Ellison gastrinoma refractory PUD
• Insulinoma hypoglycemia… get C-peptide to check for endogenous vs exogenous, get Secratagogue screen to make sure not ingesting sulfonylureas
• The HARD P’s
• MEN Gene

Question 2

MEN2

Answer 2

Both Ret Oncogene

MEN2A
pheochromocytoma
medullary thyroid ca (Parafollicular C-cells calcitonin)
ParAthyroid

MEN2B
pheochromocytoma
medullary thyroid ca (Parafollicular C-cells calcitonin)
Neuronal Beuronal… also Marfanoid MEN2Barfanoid

Question 3

MEN syndromes

Answer 3

MEN1 *MEN Gene
Pituitary (any pit tumor, functioning or non)
Parathyroid (hyper calcemia)
Pancreas (endocrine)
-Zollinger Ellison gastrinoma refractory PUD
-Insulinoma hypoglycemia… get C-peptide to check for endogenous vs exogenous, get Secratagogue screen to make sure not ingesting sulfonylureas
*The HARD P’s

MEN2A *RET oncogene
pheochromocytoma
medullary thyroid ca (Parafollicular C-cells Calcitonin)
ParAthyroid

MEN2B *RET oncogene
pheochromocytoma
medullary ca (Parafollicular C-cells Calcitonin)
Neuronal Beuronal.. also Marfanoid MEN2Barfanoid

Question 4

TF

Von Hippel Lindae assoc w thyoid and parathyroid issue…

Answer 4

F
Pheochromocytoma
not thyroid parathyroid (that would be MEN2A)

Question 5

P53 mut think

Answer 5

retinoblastoma

colon cancer

Question 6

APC mut think

Answer 6

colon cancer

Question 7

VHL mut think

Answer 7

pheochromocytoma

Von-Hippel Lindau

Question 8

elevated calcium low phosphorous with normal renal function think…

Answer 8

parathyroid neoplasm

Question 9

key labs in vitamin D deficiency

Answer 9

HIGH PTH

stimulated by LOW CALCIUM

Question 10

layers of adrenal

Answer 10

GFR
glomerulosa fasciculata reticulata

the deeper you go the better it gets
salt sugar sex
aldo cortisol testosterone

Question 11

Cortisol excess causes

Answer 11

Cushing syndrome

Question 12

Causes of Cushing Syndrome

Answer 12

Cortisol excess

ACTH secreting Small Cell Lung Cancer
ACTH secreting Pituitary Adenoma
Cortisol secreting Adrenal Neoplasm
Exogenous Corticosteroids

Question 13

Cushing Syndrome vs Cushing Disease

Answer 13

Syndrome caused by any Cortisol Excess

• SCLC, Pit Ad secreting ACTH
• Adrenal Neoplasm secreting Cortisol, exogenous Corticosteroids

Cushing Disease is ACTH secreting Pituitary Adenoma

Question 14

Cushing Syndrome
Path
Pres
Dx
Tx

Answer 14

ACTH dep (pit ad, sclc) or indep (cort secreting adrenal neoplasm or exogenous corticosteroids)

HTN DM Obese (not a big help given America)
Moon facies, Acne, Truncal obesity, Buffalo hump, Purple striae

Low THen High + 24hr U Cort or Late Night Saliva Cort
-Low-dose Dexameth suppression - if does not suppress – Cushing Syndrome
-acTH
if norm, adrenal tumor CT MRI Resect
-If acTH HIGH, do HIGH-dose Dexaemth suppression test
if works Cushing Dz (prim pit acth adenoma) Resect
if fails Ectopic Cortisol Tumor (eg SCLC) Pan Scan

Question 15

lab workup in Cushing Disease

tx

Answer 15

low dose dexamethasone suppression test does not suppress cortisol or ACTH (confirms Cushing Syndrome)

ACTH high

High dose dexamethasone suppression test works, suppresses ACTH a bit

it’s a primary pituitary adenoma secreting ACTH
you need to Resect it

Question 16

lab workup in cortisol secreting adrenal neoplasm

tx

Answer 16

low dose dexamethasone suppression test does not suppress cortisol or ACTH (confirms Cushing Syndrome)

ACTH normal

it’s a primary adrenal adenoma secreting Cortisol
Confirm with CT MRI
Resect that shit

Question 17

Lab workup in ectopic ACTH producing neoplasm

tx

Answer 17

low dose dexamethasone suppression test does not suppress cortisol or ACTH (confirms Cushing Syndrome)

ACTH high

High dose dexamethasone suppression does not work, ACTH remains high

It’s an ectopic ACTH producing tumor (e.g. SCLC), PAN SCAN

Question 18

When can you say, “Cushing syndrome”

Answer 18

When cushing signs and symptoms

And

2/3 disgnostic tests

• Low dose dexamethasone suppression test (Cortisol not suppressed)
• 24hr urine cortisol
• Late night salivary cortisol

Question 19

Addison's disease
Define/Path
Pres
Dx
Tx

Answer 19

Primary hypOCortisolism
(Adrenal deficiency, not pituitary)

Acute (eg adrenal hemorrhage)
-hypotension because no cortisol for tone no aldosterone for fluid retention
-n/v, coma
Chronic (eg infiltrative.. autoimmune, mets)
-hypotension more Orthostatic (no Cortisol)
-hyperpigmentation (high ACTH)
-low sodium high potassium (no Aldo)

Early AM cortisol (if normal, not Addison’s)
If normal get
Cosyntropin (ACTH analogue) stim test
-if works, stims cortisol, pituitary issue,
get MRI, give Cortisol
-if does not work, cortisol still low, it’s primary adrenal addison’s
get CT and MRI, give Cortisol and Fludricortisone

Question 20

What secretes renin

Answer 20

Juxtaglomerular apparatus

in the Thick Ascending Limb

Question 21

What does Aldosterone do

Answer 21

Activates sodium transport resorption at the expense of potassium secretion so that more water can be resorbed across aquaporins

Question 22

When is renin secreted by juxtaglomerular cells in the thick ascending limb

Answer 22

When it sees low flow through the tubules

Question 23

TF

Aldosterone secreting tumor from adrenal affects hpa axis like cortisol secreting tumor

Answer 23

F

Aldo affects completely different axis, the RAAS

Question 24

Conn’s syndrome

Define

Answer 24

Primary aldosterone secreting adrenal tumor causing refractory hypertension (3+ meds) and hypokalemia (on test but not always in life)

Question 25

``` HyperAldosteronism Path Pres Dx Tx ```

Answer 25

``` Conn Syndrome -primary aldosterone secreting adrenal tumor Renovascular Hypertension -fibromyscular dysplasia young female -atherosclerosis old man ``` Refractory Secondary Hypertension -refractory to 3+ antihypertensive meds HypoKalemia (on test, maybe not in life) Aldo/Renin ratio -if both normal, licorice induced pseudohyperaldosteronism (by inhibiting an enzyme and making mineralcorticoid receptors super sensitive to cortisol... or a few genetic syndromes -if both elevated and ratio v10, Renovascular (still driven by renin), Angiogram to confirm stenosis FMD gets stented Atherosclerosis tx medically -if Aldo elevated ratio ^30, Conn Syndrome Salt Suppression test fails to vAldo MRI mass maybe but not always the cause Adrenal Vein Sampling to confirm Conn RESECT Conn

Question 26

``` Pheochromocytoma Path Pres Dx Tx ```

Answer 26

Primary catecholamine secreting tumor of adrenal medulla Paroxismal Pain (headache) Pressure (htn) Palpitation (tachyc) Persperation Plasma free catecholamines if pretty sure and needs urgent tx 24Hr Urine Metanephrines or VMA more sensitive if less urgent have more time CT MRI abd Adrenal Vein Sampling ``` Alpha block (don't want to respond to masdive cc release with adrenal manipulation) Beta block (don't want beta unopposed by alpha) Resect ```

Question 27

``` Adrenal Incidentaloma Path Pres Dx Tx ```

Answer 27

Probably nothing, no pathogenesis Mass found incidentally on imaging for something else Rule out Cushing Pheo Conn with 24Hr Urine study (Cortisol, Metanephrines/VMA) and with Aldo:Renin ratio Resect if ^4cm or hyperfunctioning Follow if v4cm not hyperfunctioning

Question 28

Toddler with claudication limiting ambulation Suspect this Get this

Answer 28

suspect Coarctation of the aorta get Chest CT Angiogram

Question 29

Adult with Resistant HTN and Rib Notching on CXR Suspect this Get this

Answer 29

Coarctation of the Aorta Chest CT Angiogram

Question 30

Which has reduced pulses and pressures below the waist Aortic Coarctation or PAD

Answer 30

both If suspect coarctation, Chest CT Angiogram

Question 31

Barterr syndrome looks like.... Gitelman syndrome looks like....

Answer 31

Barterr syndrome looks like.... Furosemide... Gitelman syndrome looks like.... HCTZ...

Question 32

When does HTN cause CKD | vs CKD cause HTN

Answer 32

early closer to normal CKD caused By HTN later closer to dialysis CKD Causes HTN

Question 33

How to prevent iatrogenic adrenal insufficiency after prolongued chronic steroid therapy

Answer 33

Taper the steroids, don't stop abruptly

Question 34

Most common cause of adrenal insufficiency in USA

Answer 34

Autoimmune adrenalitis

Question 35

Common cause of hemorrhagic adrenalitis what history would increase your suspicion

Answer 35

Meningococcemia | history of fever rash obtundation increases your suspicion

Question 36

Most common cause of adrenal insufficiency in the world

Answer 36

Tubercular adrenalitis

Question 37

Most common cause of adrenal insufficiency in USA World

Answer 37

usa - Autoimmune adrenalitis world - TB tubercular adrenalitis

Question 38

How can ectopic tumors produce hypercortiolism

Answer 38

secrete ACTH | eg SCLC

Question 39

Prednisone and Fludrocortisone Which has more glucocorticoid vs mineralcorticoid activity

Answer 39

Both have both Prednisone used mainly for Glucocorticoid Fludrocortisone used mainly for mineralcorticoid -- inc sodium resorb and potassium secretion, an aldosterone analogue -- but has high glucocorticoid activity as well

Question 40

Test you can consider in probable pheochromocytoma pt between CT scan showing adrenal mass and Adrenal Vein Sampling

Answer 40

MIBG scan a radionucleotide scan that can localize hyperfunctioning adrenal medullary tissue, as a mass seen on CT or MRI is not always the cause of hyperfunction, could be incidentaloma And renal vein sampling is technically difficult amd invasive, the last step prior to prepping for resection

Question 41

Aldo:Renin way high Get CT or renal vein sampling?

Answer 41

CT first But will sample renal vein before resecting primary aldosterone secreting adenoma for Conn syndrome

Question 42

When to get inferior petrosal sinus sampling in workup of cushing syndrome

Answer 42

When Low dose Dex suppression fails to suppress cortisol ACTH is elevated High dose Dex suppression test suppresses ACTH a little bit So you are suspecting pituitary adenoma But brain MRI can't demonstrate it So you are suspecting pituitary Microadenoma

Question 43

5 types of external ulcers 4 stages of ulcers

Answer 43

Compression Diabetic Arterial insufficiency Venous insufficiency Marjolin Stage 1 - painful nom-blanching erythema, epidermis only 2 - epidermis and dermis 3 - epidermis dermis fascia 4 - epidermis dermis fascia deep tissue (muscle, bone)

Question 44

``` Compression ulcer Path Pres Dx Tx ```

Answer 44

Prolongued pressure externally and internally from bone at pressure points causes local microcascular ischemia and tissue death Bed-ridden or wheelchair bound Sacral Decibitus or other pressure points Clinical diagnosis Can stage 1-4 (epidermal non-blamching erythema, dermis, fascia, deep tissue muscle bone) Prevent Q2h rolls OOB Air mattress

Question 45

TF | Pressure ulcer in nursing home constitutes abuse

Answer 45

T

Question 46

TF | If you see bone in a stage 4 ulcer you can diagnose osteomyelitis

Answer 46

T | Effectively, yes

Question 47

generic Wound Care of any ulcer includes

Answer 47

Abx Debridement of necrotic tissue Hygiene

Question 48

``` Diabetic ulcer Path Pres Dx Tx ```

Answer 48

Microvascular compromise, neuropathy, unnoticed micro or frank trauma DM ulcer on heel or ball of foot Clinical dx Blood glucose control Elevate feet Amputate Ppx w foot inspections, loose padded diabetic shoes

Question 49

``` Arterial insufficiency ulcer Path Pres Dx Tx ```

Answer 49

PAD Macro vascular compromise ``` PAD Hairless legs Shiny skin Absent pulses Toe ulcers - distal most ``` ABI v.9 Doppler US Angiogram if planning intervention Stent small arteries above knee Bypass popliteal vessels and lengthy vessel involvements

Question 50

Key difference | Diabetic ulcer vs Arterial insufficiency ulcer

Answer 50

Diabetic microvascular | Arterial macrovascular

Question 51

``` Venous stasis ulcer Path Pres Dx Tx ```

Answer 51

Venous insufficiency, e.g. from fluid overload expanding veins wider than valvular competence ``` often in setting of CHF Cirrhosis Nephrotic syndrome Venous Stasis Dermatitis Hyperpigmented Indurated Woody Medial Malleolus ulcer "always" venous stasis ``` Clinical dx Compression stalkings Elevate legs Diuretics Treat underlying condition

Question 52

Ulcer on medial malleolus think this kind of ulcer

Answer 52

Venous stasis ulcer

Question 53

``` Marjolin Ulcer Path Pres Dx Tx ```

Answer 53

actually SCC Squamous Cell Carcinoma Ulcer with Sinus Tract Cycles of Healing and Breakdown Heaped Up Margins Biopsy Resect w Wide Margins

Question 54

Sacral Decubitus ulcer think this type of ulcer

Answer 54

Pressure Ulcer

Question 55

Tips of Toes ulcers think this type of ulcer

Answer 55

Arterial insufficiency ulcer

Question 56

Location hints for type of ulcer

Answer 56

Tips of toes Arterial insufficiency ulcer (distal most vasculature) Heel and Balls of feet Diabetic ulcer (desensitized) Medial Malleolus Venous stasis ulcer Sacral decibitus Pressure ulcer

Question 57

How do you hide a dollar from an internist?

Answer 57

Put it under a dressing

Question 58

How do you hide a dollar from a surgeon?

Answer 58

Put it in the chart

Question 59

TF | Burn injury can cause compartment syndrome

Answer 59

T The eschar resulting from a circumferential, full-thickness (3rd degree) burn often does constrict venous and lymphatic drainageamd cause compartment syndrome

Question 60

How to treat compartment syndrome caused by the eschar after a circumferential full-thickness (3rd degree) burn

Answer 60

Escharotomy | Otherwise compartment syndrome usually treated with fasciotomy

Question 61

What kind of arthritis commonly affects mp joints?

Answer 61

Inflammatory eg Rheumatoid arthritis

Question 62

Symptomatic difference in Pain and Pressure between Venous Thrombosis and Compartment Syndrome

Answer 62

both have pain and swelling but Compartment Syndrome had greater tissue tension/Tightness and Severe pain

Question 63

How do you identify 3rd degree burns?

Answer 63

Insensate They are insensate, thru dermis into fat, nerves gone

Question 64

replete fluids in burn patient

Answer 64

``` Parkland formula 4ml x TBSA (%) x kg 50% given first 8 hours 50% given next 16 hours LR NOT NS... ``` ``` palm = 1% bsa arm = 9% face = 9% leg = 18% 1 side of trunk = 18% ```

Question 65

TF | losing pulses distal to burn, do a fasciotomy

Answer 65

F | do an Escharotomy

Question 66

TF | can tell difference between oxygenated blood and carbon monoxide poisoning grossly

Answer 66

F | get a carboxy-hb

Question 67

TF | run burn under cool water

Answer 67

F can convert 2nd degree to 3rd degree by vasoconstriction Run under Room Temp or Warm water

Question 68

Trauma mnemonic

Answer 68

``` ABCDES airway breathing circulation disability exposure secondary survey ```

Question 69

TF | Most referred shoulder pain from diaphragm in trauma pt is from diaphragmatic injury

Answer 69

F | From hemorrhage irritating diaphragm

Question 70

Key component of secondary survey in trauma pt

Answer 70

Focused Assessment WITH Ultrasound FOR Trauma

Question 71

TF | Aorta injury a common cause of blood loss in BAT blunt abdominal trauma pt

Answer 71

F v1% BAT pts get aorta injury and often fatal before reaching hospital if they do happen, often spine or pelvic fractures assoc if they do happen

Question 72

First line, most effective measure to ppx postop pneumonia And other measures

Answer 72

INCENTIVE SPIROMETRY Deep breathing exercises CPAP Intermittent positive pressure breathing All aimed at ling expansion

Question 73

First line, most effective measure to ppx postop pneumonia And other measures

Answer 73

INCENTIVE SPIROMETRY Deep breathing exercises CPAP (if pulm compx despite IS... not first line because mire complications) Intermittent positive pressure breathing All aimed at ling expansion

Question 74

When is albuteral inhaler used for postop pna ppx

Answer 74

pt w asthma or copd with wheezing or dyspnea postop Not routinely used in pts wo preexisting pulmonary dz

Question 75

5 causes/contributors to postop atelectasis What procedures are higher risk

Answer 75

Pharyngeal secretion accumulation | Tongue prolapse posteriorlu into pharynx

Question 76

Smoking cessation at least __ weeks prior to surgery for decreased risk of pulmonary complications

Answer 76

Smoking cessation at least 8 weeks prior to surgery for decreased risk of postop pulmonary complications

Question 77

How to handle asthma/COPD/reactive airway disease in elective surgery vs emergency surgery

Answer 77

Postpone elective surgery

Question 78

Hairline Stress Fracture can be negative on plain film for first __ weeks

Answer 78

Hairline Stress Fracture can be negative on plain film for first 6 weeks

Question 79

Manage a stress fracture Refer to orthopod if

Answer 79

Rest and analgesics (reduced weight-bearing 4-6 weeks) (Simple analgesics preferred eg acetaminophen, avoid nsaids as may delay healing) Refer to orthopod if high risk for malnutrition (e.g. Anterior tibial cortex, 5th metatersal fracture)

Question 80

Most commonly involved metatarsal in stress fracture

Answer 80

5th metatarsal (subject to extremes of loading during gait)

Question 81

XR findings in stress fracture

Answer 81

Hairline lucency | Focal cortical thickening

Question 82

TF | CT, MRI, Scintographic bone scan often needed in stress fracture as XR may be negative for 6weeks

Answer 82

F Usually not needed Can dx clinically if XRs negative?