General Surgery Flashcards

Question

acute cholangitis

Answer 1

cause is biliary stasis - bile duct obstruction from gallstones, malignancy, stenosis Charcot: 1) RUQ pain, 2) jaundice, 3) fever Reynolds: + hypotension, AMS significantly elevated alk phos and conjugated bili bile duct dilation on US or CT tx - abx coverage of enteric bacteria, biliary drainage by ERCP within 24-48hrs

Answer 2

age 15-30, M, obese, sedentary lifestyles issue is an infected hair follicle in the intergluteal region --\> abscess, sinus tract --\> recurrent abscesses

Answer 3

sx - tachy, leukocytosis, diarrhea abx implicated - clinda, FQs, penicillins, and cephalosporins * PPIs change colonic microbiome - increases risk of C diff proliferation (note the spores are acid resistant) * C diff carriage is 8-15% and extensive proliferation is required to reach exotoxin levels that are pathogenic get stool studies (PCR for toxin) - pt with negative studies may require sigmoidoscopy or colonoscopy with bx * bacterial toxins --\> apoptosis of colonic cells, loss of tight junctions tx with oral metro or vanc * mild-mod = WBC \< 15K, Cr \< 1.5x baseline - metro * severe = WBC \> 15K, Cr \> 1.5x baseline, serum albumin \<3 g/dl - oral vanc * if pt has an ileus --\> add IV metro and switch to rectal vanc * if pt develops WBC \> 20K, lactate \>2.2, toxic megacolon, or severe ileus --\> subtotal colectomy or diverting loop ileostomy with colonic lavage * fidaxomicin can also be used * note: IV vanc is not excreted into the colon (that is why it is not used)

Answer 4

no symptoms in between vomiting episodes, no underlying condition often fhx of migraines (CVS is thought to be related to abd migraine) for kids - 2/3 will outgrow sxs in 5-10yrs - can give sumatriptan for kids with fhx of migraines

Answer 5

Lynch, AD: CRC, endometrial cancer, ovarian cancer - defect in mismatch repair gene - early screening via colonoscopy and embx - ppx hysterectomy and BSO at age 40 FAP: CRC, desmoids, osteomas, brain tumors - side note - rectum is usually spared VHL, AD: hemangioblastomas, RCC, pheo MEN1, AD (adenomas): parathyroid adenomas, pituitary adenomas, pancreatic adenomas MEN2, AD: medullary thyroid cancer, pheo, parathyroid hyperplasia

Answer 6

type 1 cysts are most common - extrahepatic single cystic dilatation of the bile duct px - triad of pain, jaundice (obstructive cholestasis), and palpable mass - majority present at \< 10 yrs, infants can present with jaundice and acholic stools - adults present with vague epigastric pain/RUQ pain/cholangitis dx - US, ERCP if obstruction is suspected tx - surgical resection to relieve obstruction and prevent malignant transformation

Answer 7

hepatic steatosis - occurs due to increased transport of FFA from adipose to liver, decreased oxidation of FF in liver, and decreased clearance of FFA from liver (decreased VLDL production) - cause = peripheral insulin resistance --\> increased peripheral lipolysis and hepatic uptake of Fas - normally insulin decreases lipolysis in adipose cells px - mostly asx, metabolic syndrome, AST:ALT \< 1, hyperechoic texture on US tx - diet, exercise, and bariatric surgery if BMI \> 35 - safe to continue statin therapy in these patients note on AST and ALT - AST is in liver, heart, kidney, and skeletal muscule - ALT is in reduced quantities in other tissues but is predominantly in liver - more specific for hepatocyte injury (and usually more elevated in liver disease, except for alcoholic liver disease)

Answer 8

precipitating factors - drugs (sedatives, narcotics), hypovolemia, hypokalemia or metabolic alkalosis (acid-base problems), increased N load (GI bleeding), infection, TIPS - note - UGIB will present with **elevated BUN and nl Cr** tx - correct precipitating cause and decrease blood ammonia concentration (lactulose, rifaximin) - lactulose --\> metabolized to short-chain fatty acids by colonic bacteria --\> acidifies colon --\> ammonia becomes charged and trapped in stool

Answer 9

**acute pancreatitis** alcohol or gallstones - rarely drug-induced - valproate, diuretics, ACEi, IBD drugs, immunosuppressants, HIV meds, abx like metro and tet - drug-induced pancreatitis is usually mild - hypertriglyceridemia \>1000 mg/dL (xanthomas on exam) - infections - CMV, legionella, aspergillus - iatrogenic - post-ERCP, ischemic/atheroembolic dx - 2/below - acute epigastric pain radiating to back - (get first) amylase or lipase \>3 ULN - amylase rises 6-12hrs (remains elevated for 3-5d), lipase rises 4-8 hrs (remains elevated for 8-14d) - (next) abnormalities in imaging - (CA-19-9 can be elevated) Imaging - CT NOT required to dx pancreatitis, but it will show - swelling of pancreas, peri-pancreatic fluid, and fat-stranding - or RUQ US if you suspect biliary pancreatitis - ALT\>150 suggests biliary pancreatitis (also look at BMI, alk phos) Treatment - SUPPORTIVE (attacks are usu self-limited, resolve in 4-7d), IVFs, NPO, trend lipase (some people like to do this) - for gallstone pancreatitis - early lap chole - ERCP *only if* pt has cholangitis, visible CBD obstruction, or increasing LFTs - ppx abx are **not** used (unless there is a necrotizing infection) severe disease = pancreatitis with failure of 1 organ - pancreatic enzymes enter vascular system, SIRS --\> increased vascular permeability - fever, tachy, hypotension - dyspnea, tachypnea, basilar crackles - abd tenderness or distention - Cullens (periumbilical), Grey-Turner - associated with: age \>75, obesity, alcoholism, CRP \>150 at 48hrs, rising BUN/Cr in first 48hrs, CXR with pulm infiltrates or pleural effusion, CT with necrosis and extrapancreatic inflammation - complications - pseudocyst, peripancreatic fluid collection, necrotizing pancreatitis, ARDS, ARF, GI bleed acute hemorrhagic pancreatitis - daily CTs to monitor for **abscess development** (this is a common pathway to death) **pancreatic pseudocyst** - complications - spont infection, duodenal/biliary obstruction, pseudoaneurysm (due to digestion of adjacent vessels), pancreatic ascites, pleural effusion - no sxs - symptomatic therapy, NPO - sig sxs, size \> 6cm, older (\> 6wk), infection, pseudocyst, pseudoaneurysm - endoscopic drainage - cystgastrostomy - then pt starts vomiting --\> has aspirated pancreatic secretions --\> ARDS others - pancreatic abscess/necrosis, pleural effusion, ileus, ARDS

Answer 10

80% sporadic, 20% MEN1 (check PTH, ionized ca, prolactin) - located in duodenum or pancreas uncontrolled gastrin secretion --\> parietal cell hyperplasia --\> excessive production of gastric acid px - chronic diarrhea (inactivation of pancreatic enzymes and injury to mucosal brush border) and weight loss when do you suspect a gastrinoma? - thickened gastric folds, multiple peptic ulcers, refractory ulcers, ulcers in the jejunum (gastric acid cant be fully neutralized in the duodenum) suspected gastrinoma 1) check serum gastrin level off PPI therapy for 1 week - level \>1000 pg/mL is diagnostic - check gastric pH to make sure that achlorhydria (failure of gastric acid secretion is not the cause of elevated gastrin) - \<110 rules it out - for 110-1000 pg/mL, get secretin stimulation test - normal G cells are inhibited by secretin (but secretin will stimulate gastrinoma cells) - last ditch effort - calcium infusion study, calcium can lead to increased serum gastrin levels in gastrinoma pts 2) EGD (ulcers and thickened gastric folds) 3) CT/MRI and somatostatin receptor scintigraphy for tumor localization resection is the treatment of choice for primary pancreatic neuroendocrine tumors (insulinoma, glucagonoma, VIPoma) - insulinoma - reactive hypoglycemia (after meals)... - glucagonoma - by serum glucagon levels - VIPoma - VIP levels, somatostatin scintigraphy to localize - for these tumors - get CT to locate tumor \*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\* any perforated ulcer - strict NPO, NGT 5d --\> look for a leak

Answer 11

performed when a pt has ascites that does not respond to medical therapyORhas active/recurrent variceal bleeding even after appropriate treatment with upper endoscopy

Answer 12

cause - upper esophageal sphincter dysfunction and esophageal dysmotility dx - barium esophagram, esophageal manometry - side note - oral contrast in a pt with a hx of aspiration is associated with a risk of pneumonitis, but do this regardless because benefits \> risks management - open/endoscopic surgery, cricopharygneal myotomy complications - tracheal compression, ulceration with bleeding, regurgitation, and pulm aspiration

Answer 13

may have RUQ pain - pain may precede onset of vesicular rash - consider shingles in pts with recent cancer (and chemo)

Answer 14

bile is stored in upper small bowel during fasting for the first few wks-mo - diarrhea because of insufficient bile acid absorption by terminal ileum

Answer 15

**SBO** - hx of surgery, distention and INCreased bowel sounds (but will progress to absent bowel sounds, esp if bowel is ischemic), small bowel dilation (with no large bowel dilation) - will have return of bowel functional temporarily post-op - proximal v.s. mid/distal - proximal obstructions - early vomiting, abd discomfort, abnormal contrast filling on XR - distal - colicky abd pain, delayed vomiting, abd distention, constipation-obstipation - simple (luminal obstruction) v.s. strangulated (loss of blood supply) - partial v.s complete - partial - air in colon - complete - transition point, no air in colon - **transition point** - complications - ischemia/necrosis, bowel perf - tx - bowel rest, NG suction, IVFs - surgical exploration when you are concerned about risk of ischemia, strangulation, and necrosis (signs are fever, hemodynamic instability, metabolic acidosis) **ileus** - recent surgery - hrs-d - hypoK --\> what causes hypoK - GI losses, loops/excess aldosterone, correction of DKA (K rapidly moves into cells) - med induced - morphine (- pancreatitis) - possible distension, REDuced bowel sounds - small and large bowel dilation with no transition point - some degree of ileus occurs following most abdominal procedures, due to increased splanchnic nerve tone (peritoneal irritation) and inflammatory mediator release - however ileus of \>3-5d post-op is prolonged post-op ileus - techniques to prevent post-op ileus - epidural anesthesia, MIS, judicious peri-op use of IVFs (minimize GI edema) **Ogilvie** = paralytic ileus of the colon - massively dilated colon in elderly, sedentary post-op pts 1) fluid and electrolyte correction 2) colonoscopy to suck out air and place a long rectal tube clinically - 1) rectal enema for decompression, 2) neostigmine to promote evacuation (AchE inhibitor, admit to ICU because it can cause arrhythmias) **Return of bowel function?** gas/stool up, NG output down --\> resume feeding

Answer 16

focal nodular hyperplasia (benign) - anomalous arteries - arterial flow and central scar on imaging hepatic adenoma - benign epithelial tumor - long-term OCPs, anabolic androgen use, pregnancy - possible hemorrhage (so needle bx is not recommended) or malignant transformation hepatic angiosarcoma - rare - older men who have been exposed to toxins (vinyl chloride gas, arsenic compounds, thorium dioxide) regenerative nodules - acute or chronic liver injury HCC - B symptoms, chronic hepatitis or cirrhosis, elevated AFP - mass often with satellite lesions liver mets - multiple (**or can be solitary**, look at hx) - most commonly secondary to GI malignancies (portal system) = colon cancer - often silent until pressure on liver capsule or obstruction of biliary tree causes sxs - LFTs may be normal hydatid cysts - Echinococcus tapeworm infections - southwest - exposure to sheep and dogs entamoeba - tx with metro

Answer 17

pancreatic insufficiency - ..CF bile-salt related - Crohns, bacterial overgrowth (due to surgical blind loop or motility disorders like scleroderma), PBC, PSC, surgical resection of ileum (at least 60-100 cm) impaired intestinal surface epithelium - celiac disease, AIDs enteropathy, giardia other - Whipple disease, ZES, meds

Answer 18

mechanical obstruction - post-prandial pain, vomiting, early satiety - causes - malignancy, PUD, Crohns, strictures (pyloric stenosis) - physical exam will elicit abdominal succussion splash (auscultation maneuver) initial management - NG suction, IVFs, endoscopy for definitive dx

Answer 19

endoscopy is the most common cause - with severe vomiting - occurs when pt is resisting vomiting reflex px - ... Hammans sign (crunching sound on chest auscultation) dx - CXR or CT scan will show wide mediastinum, pneumomediastinum, pneumothorax, pleural effusion (late) - can see esophageal wall thickening, mediastinal air-fluid level on CT - gastrin esophagram tx - NPO, abx, IV PPI - surgical repair (for significant leak with SIRS) **Mallory-Weiss** tear associated with alcohol use and hiatal hernia - bleeding stops spontaneously in 90% of pts - for ongoing bleeding - endoscopic electrocoagulation or local epi injection

Answer 20

work-up - orophargyneal dysphagia (difficulty initiating swallowing + cough, choking, nasal regurg) - videofluoroscopic modified barium swallow (swallow study) - stroke, dementia, oropharyngeal malignancy, NM disorder (myasthenia) - px with aspiration pneumonia - esophageal dysphagia - solids + liquids --\> motility disorder - 1) barium swallow, 2) manometry - solids then progressing to liquids --\> mechanical obstruction - hx of prior radiation, caustic injury, stricture, or surgery for esophageal/larygneal cancer - if yes barium swallow then egd - if no --\> EGD - in general - alarm sxs --\> proceed straight to EGD achalasia - dysphagia to solids and liquids - mild weight loss - chest pain and heartburn (many pts are initially diagnosed with GERD) - dx by \*manometry\* - loss of peristalsis in the distal esophagus with lack of LES relaxation; barium esophagram - tx - EGD to exclude malignancy, lap myotomy, **pneumatic balloon dilation** (other options include botox, nitrates, CCBs) pseudoachalasia - due to esophageal cancer - sxs are usu more rapid onset and associated with weight loss - risk factors for squamous cell (anywhere) - tobacco, alcohol - risk factors for adeno (distal) - Barrett's, GERD , smoking, obesity - classically presents with dysphagia to solids (bread, meat), chest pain, weight loss - CXR will show narrowing of distal esophagus - barium swallow prior to EGD for cancers - to prevent inadvertent perf - get EGD and CT for staging - differentiate by EGD (with bx) - achalasia - normal mucosa, easy to pass endoscope through LES (unlike in malignancy) globus sensation - no abnormalities on barium swallow polymyositis - affects upper third of esophagus (striated muscle) - also other sxs of weakness (difficulty climbing stairs)

Answer 21

**Crohns** - more women, smoking risk factor - non-bloody diarrhea (if diarrhea is bloody, it is colitis), oral ulcers, arthritis, uveitis, scleritis, erythema nodosum, \*lung disease\* - mouth to anus - rectum spared, skip lesions, perianal disease (skin tags, fistulas) - **transmural** inflammation, linear mucosal ulcerations, cobblestoning, creeping fat, noncaseating granulomas - intestinal complications - fistulas, strictures (bowel obstructions), abscesses - perianal crohns - treat with **medical** management (fistula tract will appear as a nodule/mound of granulation tissue) - treat with - 5-ASA, corticosteroids, biologics - things on differentials - TB enteritis **UC** - males, A. Jews, bimodal distribution - mucosal and submucosal inflammation, erythema and friable mucosa - pseudopolyps - crypt abscesses - other manifestations - arthritis, uveitis, episcleritis, erythema nodosum - complications - toxic megacolon, **primary sclerosing cholangitis**, erythema nodosum, pyoderma gangrenosum (looks like necrotic skin infection), spondyloarthritis - start screening for CRC 8-10 after disease dx toxic megacolon - inflammation limited to colonic mucosa in UC - however subset of pts have inflammation that extends to smooth muscle layers --\> muscle paralysis --\> colonic dilation - usu occurs early in the disease - will see systemic toxicity - dx - abd xray and 3/following: temp \>39, pulse \>120, WBC \> 10.5, anemia - abd xray - will see dilated colon (**haustra markings that dont cross the entire lumen**), right colon \> 6cm - note - small bowel will look like stacked coins - medical EMERGENCY --\> colonic perf - tx - IVFs, BS abx, bowel rest, corticosteroids, surgery if unresponsive to medical management - DONT give opioids - because they have antimotility effects and can promote colonic perforation **PSC** - frequently asx or present with chronic fatigue and pruritis - inflammation of intra and extrahepatic bile ducts - onion skin connective tissue pattern and lymphocytic infiltration on liver bx (but this is not necessary for dx) - pos pANCA - ERCP/MRCP will confirm diagnosis - complications - biliary stricture, cholangitis and cholelithiasis, cholangiocarcinoma, cholestasis (ADEK deficiency, osteoporosis), colon cancer

Answer 22

anorexia, \*liver pain\*, jaundice, leukocytosis (predominantly neutrophils), decreased albumin if malnourished... LFTs elevated, AST:ALT 2, \<300 IU/L - GGT elevated - ferritin - acute phase reactant, elevated - leukocytosis abd imaging may show fatty liver for these pts - have them discontinue alcohol (and drug use) and repeat LFTs in 6 mo - if transaminitis persists - then pt has chronic alcoholic liver disease - test for hemochromatosis, viral hep, and fatty liver for treatment of acute AH - quit drinking, supportive therapy - prednisolone used to treat severe cases - fever, abd pain, jaundice, N&V

Answer 23

**angiodysplasia** - painless GI bleeding (maroon stools), venous and low volume - pts with anemia/gross or occult bleeding can be treated with cautery during endoscopy - increased incidence after age 60, most common in the R colon - more frequent in pts with advanced renal dz and vW disease (maybe because of tendency to bleed in these diseases) - may also be more common in pts with AS - possibly due to acquired vW deficiency (turbulent valve space) - angiodysplasia can be missed on colonoscopy - due to poor bowel prep **colon cancer** - microcytic anemia **diverticulOSIS** - arterial bleeding --\> BRBPR, painless - most common cause of lower GI bleeding in adults - deformation in the colonic wall can cause weakness in associated arterial supply --\> bleed - diverticulosis is more common in sigmoid, bleeding more common in R colon - confirmed with colonoscopy - *most cases will resolve spontaneously* - strongly associated with chronic constipation --\> acute diverticular complications are lower in inds with high fiber intake - seeds and nut = myth **ischemic colitis** - abd pain --\> rectal bleeding/bloody diarrhea in 24hrs **hemorrhoids** - rarely cause massive bleeding **active bleeding per rectum** - first exclude upper GI bleed 1) bleeding hemorrhoids - anoscopy 2) \>2 mL/hr - angiogram (may allow for angiographic embolization) 3) \<0.5 mL/min - wait for bleeding to stop --\> colonoscopy 4) 0.5-2 - tagged red cell study for past blood per rectum - young - get EGD - old - EGD and colonscopy

Answer 24

definitive dx? cirrhosis by liver bx jaundice, hyperestrinism (spider angiomata, gynecomastia, loss of sexual hair, testicular atrophy, palmar erythema), ecchymosis and edema (hepatic synthetic dysfunction), portal HTN (esophageal varices, splenomegalcy, ascites, caput medusa, anorectal varices) - cirrhosis can cause direct gonadal injury, HPA dysfunction, and increased estradiol - liver also synthesizes thyroid-binding proteins - total T3 and T4 will be reduced (but free levels are unchanged) - can have parotid gland enlargement - due to fatty infiltration compensated cirrhosis - asx or non-specific sxs - uncompensated - jaundice, prurits, upper GU bleeding, ascites, hepatic encephalopathy if you dx someone with alcoholic liver disease - check for potential complications - varices (EGD), HCC (screening US every 6 mo) complications - variceal hemorrhage - non-selective b-blockers and annual EGD - ascites - dietary Na restriction, diuretics, paracentesis, quit drinking - hepatic encephalopathy - id cause, lactulose - chronic PVT presents as variceal bleeding - acute PVT - sudden-onset abdominal pain pts with small varices + risk factors for bleeding, or medium-large varices - primary ppx - non-selective b-blocker = propranolol or nadalol (reduces portal blood flow and portal pressure) (or endoscopic variceal ligation in patients with contraindications) TIPS in pts with refractory ascites or varices

Answer 25

dehydrated post-op patients and elderly are most prone S. aureus adequate fluid hydration and oral hygiene pre- and post-op will prevent this complication

Answer 26

peri-op b-blockers in pts with CAD decreases likelihood of myocardial ischemia peri-op MI is due to hypotension - will usu not present with chest pain

Answer 27

give routine for pts undergoing abdominal surgery

Answer 28

**thoracic aneurysm** - definitive dx by \*MR angio\*/CT angio - ascending - repair with surgery - descending - repair with HTN control (ICU) **abd aneurysm** is \>3cm - involves all aortal layers and does not create and intimal flap or false lumen (unlike thoracic aortic aneurysms) **AAA rupture** - blood can collect into adventitial layer, rupture can occur into peritoneum or retroperitonuem - sxs - abd pain/back pain and hypotension (syncope) - CT only in stable pts, OR for unstable pts - AAA can rupture into retroperitoneum and create and aortocaval fistual --\> venous congestion in bladder --\> gross hematuria complications following repair - for thoracic aortic aneurysm - anterior spinal cord syndrome - because anterior spinal artery is dependent on thoracic aorta blood, px will be \*bilateral\* flaccid paralysis and impaired pain/temp sensation - late complication from AAA repair is aortoenteric fistula - duodenum..

Answer 29

definition - T\> 38.6 **immediate** * prior trauma/infection * blood products * mal hyperthermia (...metabolic acidosis, hypercalcemia, muscle rigidity) * bacteremia - 30-45min classically * normal post-op physiologic response - will be less than 38.5 **5Ws** - atelectasis (doesnt cause fever), pneumonia, UTI, DVT, wound infection, deep abscess **POD1d-1wk** * nosocomial infections - S epi will be from central line, enteric orgs will be associated with foley * VAP - after 48hrs of being on ventilator * surgical site infection due to group A strep (beta hemolytic strep classically causes high fevers early in the post-op period) or clostridium * non-infectious - MI, PE, DVT (doppler) * *many institutions dont recommend removing dressing until 24hrs post-op* **POD1wk-1mo** * surgical site infection due to other orgs - C diff, E coli and MRSA (d5-7) * drug fever - DOE, occurs 1-2 wks after mediation administration, often accompanied by rash and peripheral eosinophilia (drugs implicated are anticonvulsants, abx, allopurinol) * PE/DVT **POD1mo and more** * viral infections (from blood products) * infective endocarditis * surgical site infection due to indolent orgs * note on necrotizing SSI - DM, polymicrobial - pain, edema, or erythema spreading beyond the surgical site * systemic signs (SIRS) * paresthesia or anesthesia at edges of the wound * dishwater drainage * subQ crepitus --\> EARLY surgical exploration (to prevent nec fasc) **reactions to blood products** * febrile nonhemolytic transfusion reaction - small amounts pf cytokines in PRBC bag (due to plasma or leukocyte debris) --\> transient fevers, chills, malaise within 1-6hrs after transfusion * acute hemolytic reaction * TRALI **Fever in the SICU** \>38.5 * fever at 38 in - patients on CVVH (dialysis), immunosuppressed/transplant * fever in ICU - 50% of febrile ICU patients have no source of infection other notes * temps are greater in the evenings compared to mornings * temp below 35 or above 40 indicates severe disturbance of body's autoregulatory system * at T \> 40, cellular damage will begin - **important to control temp**

Answer 30

common features - POOP, pain on passive stretch, rapidly increasing and tense swelling, parasthesia - uncommon - decreased sensation, motor weakness, paralysis (late), decreased distal pulses - when will you see this? - ischemia-reperfusion syndrome - also with lower extremity embolectomy - circumferential eschar - constricts venous and lymphatic drainage... - dx by compartment pressure \> 30 mm HG - if compartment pressures are improving - pts may be observed - pts with elevated pressures and no signs of improvement --\> fasciotomy **v.s an embolism** - absent pulses, pallor of affected limb, lack of local swelling **v.s. DVT** - vague aching pain (rather than this exquisite pain)

Answer 31

more common on L some pts (esp kids) will have no sxs initially - will px mo-yrs later with vague chest pain (due to expansion of diaphragmatic defect and herniation of abdominal organs) CXR - abdominal contents in thorax, shifting of mediastinum - may see NG tube in thorax - but CT is more sensitive so get CT if CXR is unrevealing

Answer 32

each hemithorax is capable of holding up to 50% of circulating blood volume - massive hemothorax is \>1.5L or 600 mL/6hrs - most common cause of massive hemothorax are traumatic lac to lung parenchyma, damage to **intercostal** or internal mammary artery

Answer 33

lobar or segmental collapse --\> decreased lung volume - decreased FRC? - will hear decreased breath sounds in that section post-op atelectasis - accumulation of pharyngeal secretions, tongue prolapsing into pharynx, airway tissue edema, residual anesthetic effects, splinting - low pO2 (small-airway mucus plugging) and low pCO2 (fast shallow breathing) - loss of lung volume - side note - in this regard, intercostal nerve blocks have shown success in reducing post-op pulm complications ABG - pt will be hypoxemia due to lung collapse and V/Q mismatch - low PaO2 - pt will hyperventilate due to hypoxemia - low PaCO2

Answer 34

atelectasis, bronchospasm or exacerbation of chronic lung disease, prolonged mechanical ventilation risk factors - age \>50, emergency surgery or surgery longer than 3hrs, HF, COPD, poor general health (ASA \>2) pre-op strategies - smoking cessation 8wks pre-op - note on smoking - issue with ventilation = **high PCO2**, low FEV1 - no issue with oxygenation - sx control of COPD (pre-op glucocorticoids) - tx of respiratory infections prior to surgery - pt education of pulm toilet post-op strategies - pulm toilet, epidural instead of opioids, PEEP

Answer 35

1) place 2 large bore IVs - volume resus, IV octreotide (leads to splanchnic vasoconstriction and decreased portal flow), abx (ppx abx for pts with cirrhosis, to prevent SBP) urgent endoscopic therapy with band ligation or sclerotherapy - if no further bleeding - start b-blocker and endoscopic band ligation 1-2 wks later - if continued bleeding - balloon tamponade (eponymed tubes) temporarily --\> TIPS/shunt - if early rebleeding - repeat endoscopic therapy --\> recurrent hemorrhage --\> TIPS/shunt in approx 50% of variceal bleeding - **hemorrhage ceases on its own** - in other UGIB - this rate is 90% side note - current guidelines suggest keeping **hgb \>9** in variceal hemorrhage

Answer 36

oliguria \<500 mL/24hrs **Pre-renal** * decreased renal perfusion - true volume depletion, decreased EABV (heart failure, cirrhosis), displacement of intravascular fluid (sepsis, pancreatitis), renal artery stenosis (afferent arteriole vasoconstriction), NSAIDs * features - increase in serum Cr (50% from baseline), decreased UOP * BUN/Cr \>20:1 * BUN increases because it is passively reabsorbed during the active reabsorption of Na and water * FeNa \<1% * treat by restoring renal perfusion - give bolus of saline b-lactam abx - cause acute **interstitial nephritis** * will see WBC on UA and a skin rash * if blood flow drops too much --\> acute tubular necrosis **Evaluation** suspect AKI - get urine lytes, AKI increases mortality risk * if pt has been on diuretics in the last 3d, FeNa is unreliable - get FeUrea **Other** ACE/ARB in SICU pt - dont restart post-operatively --\> causes vasodilation and AKI???

Answer 37

soft scrotal mass (bag of worms) - more common on L side - left spermatic vein drains into left renal vein (passes in between the SMA and aorta) - can be compressed beneath SMA - v.s. the R spermatic vein - drains directly into IVC - R-sided varicoceles are rare and can be a sign of malignant compression or thrombosis - can cause elevated scrotal temps --\> subfertility, testicular atrophy - US - retrograde venous flow, tortuous, anechoic tubules adjacent to testis - dilation of pampiniform plexus veins - tx - gonadal vein ligation - boys and young men with testicular atrophy - scrotal support and NSAIDs - for men who dont desire children other testicular masses - spermatocele - painless mass at superior pole of testis - testicular cancer- painless mass, almost always malignant - tx by radical orchiectomy, metastatic dz responsive to radiation or platinum-based chemo - hydrocele

Answer 38

at home - IRRIGATION airway - supraglottic airway is very susceptible to direct thermal injury --\> edema and blistering - subglottic airway is protected from injury by reflexive closure of vocal cords upon exposure to extremely hot air - **all burn pts should be given high-flow O2** - maintain a low threshold for intubation increased metabolic rate - due to release of inflammatory mediators - increased basal temp, tachycardia and tachypnea, hyperglycemia steroids are contraindicated in burn pts - steroids are diabetogenic and immunosuppresive and burn pts are already prone to metabolic derrangements and immunosuppression infections - immediately after a severe burn - gram pos organisms dominate - after 5d - gram negative or fungi dominate (pseudomonas, candida) - burn wound sepsis - partial-thickness injury turns into full-thickness injury, temp changes, tachycardia, tachypnea, refractory hypotension, oliguria, unexplained hyperglycemia, TCP, and AMS - quantitative wound culture and bx for histopathology - treat with BS iv abx (pip/tazo, carbapenem), MRSA (vanc), MDR pseudomonal coverage (AG) - local wound care and debridement other things - tetanus - silver sulfadiazine = standard - if thick eschar, cartilage - mafenide acetate - triple abx near eye

Answer 39

pathophys - non-occlusive, occurs in watershed areas - splenic flexure (SMA and IMA) and rectosigmoid (between sigmoid and superior rectal) - underlying atherosclerotic disease/thrombus (...recent MI, infective endocarditis emboli) = small bowel ischemia - low blood flow - post-AAA repair - adverse effect can be minimize by checking sigmoid colon perfusion following placement of aortic graft px - mod abd pain and tenderness, urge to defecate, hematochezia, diarrhea, leukocytosis, lactic acidosis (low bicarb) - elevated amylase and phosphate dx - CT will show colonic wall thickening and fat stranding - mesenteric angio if dx unclear - EGD will was edematous and friable mucosa management - IVFs and bowel rest, abx, anticoag to limit clot expansion (if pt is not actively bleeding) - immediate operative eval if evidence of bowel infarct - embolectomy w/ bypass or endovascular thrombolysis - colonic resection if necrosis develops **v.s. chronic mesenteric ischemia** - epigastric pain shortly after eating (blood is shunted away from intestines to feed the stomach) - atherosclerosis - smoking, dyslipidemia - food aversion, abdominal bruit in 50% of pts - get CT angio - tx - risk reduction, nutritional support, and endovascular or open surgical revascularization

Answer 40

one of the most common intra-abdominal complications of BAT signs - hypotension, pleuritic CP, left abd wall bruising or tenderness, abd guarding pts who are hemodynamically stable - FAST --\> if negative FAST --\> CT for pts with high risk features - pts with AMS - proceed directly to CT if operative intervention is required - every effort is made to SAVE the spleen note - if someone has mono (fever, sore throat, spleen will be enlarged), there is a greater risk of splenic injury encapsulated bacteria - S. pneumoniae, Hib, N. meningitidis, E. Coli, Salmonella, Klebsiella, Group B streptococci

Answer 41

any old abscess - if you leave a penrose drain in place - you dont need packing - wound will drain and heal by secondary intention abdominal abscess - not amenable to drainage - start IV abx, trend WBC, CT scan in 5d (will not see any appreciable change if you scan earlier) psoas abscess - fever, abd/flank pain that radiates to the groin - abdominal pain with hip extension (psoas sign) - risk factors - HIV, IVDA, DM, crohns disease - can be direct (even from diverticulitis) or hematologic seeding - get CT abd/pelvis and BC and abscess cultures - tx - drainage, broad spectrum abx - note psoas abscess is on the differential for **fever of unknown origin**

Answer 42

often causes bloody stools - usu presents for the first time within the first of treatment

Answer 43

because of diaphragm movement during inspiration and expiration * any penetrating injury **below the nipple line** has the potential to involve the abdomen * infact it is thought to involve the thorax and abdomen until proven otherwise * for a hemodynamically unstable pt --\> ex lap (even if there is no peritoneal fluid on fast exam) * ED thoracotomy for refractory shock, SBP \< 60 * for a stable pt and fast negative - get CT **GSW to abdomen** * can involve chest cavity - consider if you perform and ex lap and find no blood in the abdomen * can vent chest (pericardial window) through the diaphragm

Answer 44

place urinary cath - to assess for urinary RT and prevent possible bladder injury (from acute distention)

Answer 45

place limb/digit in sterile, saline moistened gauze and in a plastic bag --\> place the bag on ice

Answer 46

Rovsing sign - RLQ pain with deep palpation of LLQ for pts with classical presentation --\> lap appy - for pts where dx is unclear - CT or US to confirm dx - pts with appendicitis who have had sxs for \>5d usu have phlegmon with abscess (phlegmon = localized area of acute inflammation of the soft tissues) - IV abx, bowel rest, and delayed appendectomy (6-8wks later, because presently the appendix will be inflamed, infection, friable) - these pts will present without peritoneal signs, instead they may have pos psoas sign mesenteric adenitis - RLQ pain, guarding, tenderness - can be mistaken for appendicitis - get CT

Answer 47

scenario - fall pre-hospital - spinal immobilization, careful helmet removal, airway oxygenation ED - orotracheal intubaion - RSI if pt is unconscious pts who are breathing but need ventilatory support - cervical stabilization unless it interferes with intubation - CT Cspine - monitor for neurogenic shock when would you get CT c-spine - basilar skull fracture, blunt neck trauma, facial fracture, CHI

Answer 48

**securing an airway** 1) jaw thrust, head tilt-chin lift 2) bag mask (6-8 breaths/min) 3) RSI - 7Ps (prep, pre-oxygenate, pretreatment, paralysis w sedation [sux], protection and positiioning, placement with proof, post-intubation management) - ET tube - 2 cm from carina - LEMON - look externally, eval 332 fingerbreadths (mouth opening, hyoid, thyroid cartilage), mallampati, obstruction/obesity, neck mobility unable to intubate (mulitple attempts) - surgical airway (cric) nasotracheal intubation - blind procedure - contraindicated in apneic/hypopneic pts - also contraindicated in basillar skull fracture as these fractures may have cribiform plate disruption (tube could enter brain) subQ emphysema - fiberoptic bronchoscope cric is FAST - needle cric - not ideal in pts with head injury (these pts may require hyperventilation to treat intracranial HTN) - cric has risk of CO2 retention - surgical crich - prolonged use of cric has a high incidence of tracheal stenosis surgical tracheostomy, formal tracheostomy - dreaded complication - tracheoinominate fistula

Answer 49

more common in males, most common inherited disorder of bilirubin glucuronidation AR or AD - decreased UDP-glucuronosyltransferase activity --\> increased UCB px - intermittent mild jaundice provoked by stress only lab abnormality will be unconjugated hyperbilirubinemia - Hgb will be normal - NO evidence of hemolysis tx - reassurance and supportive care

Answer 50

critically ill hospitalized pts - severe trauma or recent surgery, prolonged fasting/TPN, critical illness (mechanical vent) - likely due to cholestasis and gallbladder ischemia --\> secondary infection **unexplained fever, leukocytosis**, elevated LFTs and bili (but normal results dont exclude the dx), RUQ pain - jaundice and RUQ pain are less common dx - US - will see thickened gallbladder wall with distention, pericholecystic fluid - get HIDA or CT if needed tx - perc cholecystostomy and chole after pt's medical condition improves - enteric abx coverage complications - sepsis, death, gangrene, perf, emphysematous cholecystitis (cholecystitis with clostridium)

Answer 51

get UA for hemodynamically stable pts --\> contrast CT to id and stage renal trauma unstable pts --\> IV pyelogram --\> surgery - note - most renal injuries can be managed non-operatively

Answer 52

O2 delivery doesnt become deficient until Hgb \< 7g/dL DDAVP increases factor 8 levels (indirectly) - give pre-op to patients with hemophilia A plts \>**50K** will provide adequate hemostasis for most procedures

Answer 53

tetany, seizures, LONG QT - Chvostek sign, Trousseau sign (carpopedal spasm upon inflation of blood pressure cuff) **primary** - post-surgical - most common cause, takes a modest decrease to cause sxs - automimmune primary hypoparathyroidism - congenital absence of parathyroid glands (DiGeorge syndrome) - defective Ca-sensing receptor on parathyroid glands - non-autoimmune destruction of parathyroid gland due to infiltrative diseases (hemochromatosis, Wilson disease, neck irradiation) **secondary:** insufficient Ca intake --\> secondary hyperparathyroidism --\> increased PTH and hyperplasia of parathyroids --\> increased Ca and increased renal phosphate loss (hypophosphatemia) **tertiary:** due to chronic renal disease (very increased PTH --\> increased Ca) other reasons - CYP450 inducers (phenytoin, carbamazepine, rifampin) cause vitamin D deficiency by degrading vitamin D into inactive metabolites - kidneys convert 25-OH-D to 1,25-OH-D - note - serum phosphorous is low in vitamin D deficiency - precipitation of Ca with phosphate - renal failure, rhabdo, phosphate administration **PTH actions** - bone - long-term indirect action on osteoclasts --\> increased Ca and phosphate - kidney - increased Ca reabsorption and phosphate excretion vitamin D - increased Ca and phosphate absorption from gut and kidney

Answer 54

can be seen post-thyroidectomy - can also see hyponatremia

Answer 55

local vascular complications at the cath site are the most common complications - bleeding - hematoma - localized or with retroperitoneal extension (back pain) - arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula cholesterol emboli - s/p cardiac cath - pts who have risk factors for aortic atherosclerosis - signs and sxs - livedo reticularis, blue toe syndrome, AKI, pancreatitis, mesenteric ischemia

Answer 56

4Ts: thymomas, teratoma, thyroid neoplasm, terrible lymphoma teratoma - Ca deposition (tooth), fat - note - for seminoma, only bhCG will be elevated

Answer 57

UPPER gi bleed- PUD, gastritis, esophagitis, Mallory-Weiss teargive anti-secretory medication (PPI)

Answer 58

retropharyngeal compartment - infection in this compartment drains to superior mediastinum - spread to the carotid sheath --\> thrombosis of IJ and deficits of CN 9-12 - extension through danger space (two fascias) --\> posterior mediastinum and diaphgram - acute necrotizing mediastinitis - fever, chest pain, dyspnea, odynophagia, requires urgent surgical intervention paranasal sinus infection --\> bone --\> subdural empyema infected molar --\> Ludwig angina - bilateral cellulitis of submandibular and sublingual spaces - AIRWAY - infection in central face area --\> cavernous sinus thrombosis - occurs due to valveless facial venous system nasal furunculosis is potentially life threatening as it can spread to cavernous sinus - px = diplopia, facial pain, fever - **EMERGENCY** - dx with MRI, tx with early IV abx, and drain affected paranasal sinuses

Answer 59

complication of cardiac surgery - due to intra-op wound contamination px - within 14d post-op, fever, tachy, chest pain, leukocytosis, sternal wound drainage (or purulence) - widened mediastinum tx - surgical debridement with immediate closure and prolonged abx therapy other things post-cardiac surgery - afib is common - self-limited, rate control with b-blockers or amiodarone is best - anticoagulation and/or cardioversion reserved for patients with atrial fib \>24hrs post - pericardiotomy syndrome - fever, leukocytosis, tachy, and chest pain - autoimmune, occurs few wks following procedure where incision was made into pericardium - NSAIDs to treat (any) pericardial inflammation)

Answer 60

majority of duodenal ulcers are cause by H pylori infection and NSAIDs - if H pylori is likely - start eradication triple therapy (PPI, amox, clarithro) dx - EGD tx - NG suction, IVFs, broad spectrum abx, \*\*IV PPI\*\* - for stable pts with Hgb \< 7 - give PRBC - transfuse at Hgb \<9 for pts with ACS - for pts with active bleeding and hypovolemia - transfuse at higher Hgb levels

Answer 61

acute - only takes 100-200mL to compromise hemodynamics, cardiac silhouette may appear normal chronic processes (malignancy, renal failure) cause slow accumulation of pericardial fluid - 1-L before intrapericardial reaches a critical point - globular cardiac silhoutte

Answer 62

sxs - abd pain, diarrhea, nausea - hypotension, tachycardia - dizziness/confusion, fatigue, diaphoresis - 12-30 min after meals common postgastrectomy - 50% of pts - due to loss of normal action of the pyloric sphincter due to injury or surgical bypass - \*rapid emptying\* of hypertonic gastric contents - causes fluid shifts from intravascular space to SI = hypotension, stimulation of autonomic reflexes, release of intestinal vasoactive polypeptides initial management - small frequent meals - replace simple sugars with complex carbs - incorporate high fiber and protein-rich foods - drink fluids in between meals (not during meals)

Answer 63

acute diverticulitis - inflammation due to microperforation of diverticulum LLQ abd pain, fever, N&V, ileus (peritoneal irritation) - can have urinary signs from an inflamed sigmoid colon - dx - abd CT (oral and IV contrast) uncomplicated (75%) - can be managed outpatient with bowel rest, oral abx, observation - hospitalization recommended if pt is elderly, immunosuppressed, severe comorbidities, or high fever/WBCs complicated (25%) - abscess, perf, obstruction, or fistula formation - fluid collection \<3cm - tx with IV abx and obs - fluid collection \>3cm - CT-guided perc drainage --\> surgical drainage and debridement recommended if sxs dont improve by 5d on your differential - epiploic appendigitis

Answer 64

intracapsular - femoral neck and head - higher risk of avascular necrosis extracapsular - intertrochanteric, subtrochanteric - greater need for implant devices - requires immobilization - high risk of DVT and PE, recommend post-op anticoagulation in general - operate asap - may delay surgery up to \*72hrs\* if need to address an unstable medical comorbidity (do skeletal traction in the meantime) - need medical stability prior to operating

Answer 65

nutritional deficiencies - banana bag useless, give high dose IV thiamine scurvy - signs arise w/i 3 mo of deficiency - follicular hemorrhage, bleeding gums, arthralgias, weakness, impaired wound healing - vasomotor instability if severe/prolonged - dx by serum ascorbic acid level - tx - oral/injectable vitamin C (sxs resolve w/i days), watch for tox (abd pain, diarrhea, nausea)

Answer 66

1) give crystalloid (it is cheaper than albumin) - 500-1000mL boluses to achieve SBP \>90 2) vasopressors - dopamine 3) IV hydrocortisone other randoms - hemodialysis if: uremia, fluid overload, major electrolyte abnormalities (AEIOU) - bicarb if severe acute acidosis (pH \<7.2)

Answer 67

initial hematuria (urethra issue) - urethritis, trauma (cath) total hematuria (kidney) - renal mass, glomerulonephritis, urolithiasis, PKD, pyelo, urothelial cancer, trauma - renal cell carcinoma - tx is surgery terminal hematuria (bladder issue) - urothelial cancer, cystitis, urolithiasis, BPH, prostate cancer - clots suggest bleeding in bladder or ureters (get cystoscopy) - cancer of bladder - SMOKING most cases of hematuria are benign - 1) CT scan, 2) cystoscopy

Answer 68

guarding, rigidity, reduced bowel sounds, rebound tenderness = perforated viscus complications - subphrenic abscess (rare)

Answer 69

impairs to laryngeal defenses --\> aspiration of gastric contents, hypoventilation sux (rapid on/off)- depolarizing NM blocker, binds to postsynaptic AchR --\> influx of Na and efflux of K --\> temp paralysis - contraindicated in crush injury - pt can be at risk for life-threatening cardiac arrhythmia due to severe hyperkalemia (use roc instead) - side note - post-syn AchR upregulated in skeletal muscle injury (burn, disuse muscle atrophy, and denervation also have this) etomidate - inhibits 11b-hydroxylase --\> adrenal insuffiency - elderly and critically ill are most susceptible NO - inactivates B12, problems for pts with pre-existing B12 def propofol - severe hypotension (due to myocardial depression)

Answer 70

following major thoracic trauma acute circulatory failure (hypotension, SOB) and neuro signs (stroke type signs) immediate management - cardiac massage

Answer 71

indications for urgent ex lap - hemodynamic instability - peritonitis - evisceration - blood from NG tube or on DRE no indications for urgent ex lap --\> locally explore wound and get eFAST (to asses for pneumo- and hemothorax) penetrating neck trauma - surgical exploration IF expanding hematoma, deteriorating vital signs, or signs of esophageal/tracheal injury - upper zone - arteriography - base of neck - arteriography, esophagram, esophagoscopy, bronchoscopy penetrating urologic injury is surgically explored

Answer 72

hard signs --\> surgical exploration - observed pulsatile bleeding - bruit/thrill over the injury - expanding hematoma - signs of distal ischemia (absent pulses, cool extremity) soft signs - hx of hemorrhage, diminished pulses, bony injury, neuro abnormality --\> injured extremity index (\<0.9 is ABnormal) --\> CT/CT angio, doppler

Answer 73

**hypovolemic** - hypovolemic shock drop in blood pressure occurs when 25-30% of blood volume has been lost - low CO - if you mechanically ventilate someone in hypovolemic shock --\> increase intrathoracic pressure --\> collapse of venous system, loss of RV preload **obstructive** - PE, cardiac tamponade

Answer 74

primary v secondary (underlying lung disease) - small (\<2cm) - observe and supplemental O2 (enhances the speed of reabsorption, though this is disputed and dependent on surgeons) - large and stable - needle aspiration (stable) or chest tube (unstable) if lung fails to re-expand (\<90% expansion) and persistent air leak is present - place one-way valve, blood patch, or VATs - recurrence - VATS pleurodesis or chemical pleurodesis algorithm: place CT --\> 48 hrs to suction --\> water seal --\> remove and discharge to home - limit air travel for 3 weeks, for spontaneous ptx dont scuba dive ever

Answer 75

local trauma, IBD, malignancy - spasm of sphincter contributes to the pain and creates tension across the wound most common at posterior anal midline - chronic fissure may have skin tag at distal end (sentinel pile) tx 1) high fiber, adequate fluids, stool softeners, sitz baths, topical anesthetics and vasodilators (CCBs, to reduce pressure and increase blood flow to anal sphincter) 2) surgery - lateral sphincterotomy and fissure excision

Answer 76

Hb catabolized --\> bili --\> UCB + albumin --\> hepatic artery - liver: conjugation by hepatic UDG enzyme --\> conjugated bilirubin **conjugation happens in the liver** - deconjugation in intestine by b-glucuronidase --\> 1) enterohepatic recycling of UCB, 2) excretion in feces and urine (urobilinogen) - UCB is tightly bound to albumin - so it will NOT be renally excreted - when you have excess UCB (hemolysis) --\> more conjugation --\> more excrete as urobilinogen (pos urobilinogen assay) - hepatic dysfunction (portosystemic shunt), biliary duct obstruction, storage defects - bilirubin will build up in plasma conjugated --\> check LFTs (will likely be a hepatobiliary problem because bilirubin conjugates are shunted into plasma when excretion into bile is slowed) 1) AST ALT are elevated - viral/autoimmune/toxin/drug-induced/ischemic/alcoholic hepatitis, hemochromatosis - autoimmune - pos ANA and anti-smooth muscle titers, give glucocorticoids 2) elevated alk phos (=cholestasis) - cholestasis of pregnancy, malignancy (pancreas or ampullary), cholangiocarcinoma, PBcholangitis, psc, choledocholithiasis - get US to assess hepatic parenchyma and biliary ducts (biliary dilatation is extrahepatic cholestasis) 3) normal LFTs - Dubin-Johnson, Rotors - Dubin-Johnson - decreased bilirubin excretion in bile canaliculi - Rotors - rare, benign, hereditary defect in hepatic secretion of conjugated bilirubin into biliary system **unconjugated** - overproduction - hemolysis (haptoglobin will be decreased) - reduced uptake - drugs, portosystemic shunt - conjugation defect - Gilbert's pattern of LFTs - elevated alk phos, normal transaminases - inherited bilirubin disorders - elevated transaminases, normal alk phos - liver issue - elevated alk phos \>\> transaminases - intrahepatic cholestasis, biliary obstruction

Answer 77

small bowel follow-through - detects stricture, obstruction, masses in the small bowel barium enema - detects strictures or inflammation (IBD)

Answer 78

chronic, intermittent epigastric pain and postprandial discomfort causes - NSAIDs, gastric/esophageal cancer, functional dyspepsia, GERD, PUD with H pylori (demographics! India) definitive dx by EGD - but only perform in pts \>55 or with alarm sxs (weight loss, bleeding, anemia, dysphagia, persistent vomiting)

Answer 79

immune-mediated destruction of \*intrahepatic\* bile ducts often middle aged women px with chronic fatigue, pruritis, - jaundice, hepatomegaly, cirrhosis - xanthomas, xanthelasmas - pos anti-mitochondrial antibody, severe hypercholesterolemia tx - ursodeoxycholic acid delays progression, liver transplantation for advanced disease complications - malabsorption and fat soluble vitamin deficiencies - metabolic bone disease - osteoporosis, osteomalacia - HCC

Answer 80

causes - blood - trauma, malignancy, rarely TB - milky - chylous, pancreatic - turbid - infection - straw color - benign **new onset ascites** - dx cirrhosis - labs, imaging, abd US to evaluate for splenomegaly or HCC - paracentesis for all pts with new-onset ascites - liver bx only if dx is unclear **characterizing ascitic fluid** neutrophils: \>250 means peritonitis (secondary or SBP) protein - high \>2.5 - CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd-Chiari, fungal - low \<2.5 - cirrhosis, nephrotic syndrome serum ascites albumin gradient - \>1.1 indicates portal HTN - cardiac ascites, cirrhosis, Budd-Chiari - \<1.1 indicates absence of portal HTN - TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome SBP - low grade-high grade temp (pts with cirrhosis after often hypothermic), abd pain/tenderness, AMS (connect the numbers test) - hypotension, hypothermia, paralytic ileus (dilated loops of bowel) with severe infection - due to bacterial translocation or hematogenous spread to liver and ascitic fluid - ascitic fluid: PMN \>250 and pos culture (often gram negatives, E coli, Klebsiella) - tx - empiric abx (cefotaxime), FQs for SBP ppx note - ascites separates the visceral and parietal peritoneal surfaces --\> wont have peritoneal signs even with perf viscus small portion of cirrhotics/pts with portal HTN have hepatic hydrothorax = pleural effusion due to ascites passing through defects in diaphragm - usually on R side due to less muscular hemidiaphragm - tx - salt restriction and diuretic administration - can do therapeutic thoracentesis for sx pts - **DONT use chest tube -** because it can result in large-volume protein, fluid, and electrolyte losses (and renal fialure) - definitive option - liver transplant

Answer 81

can be precipitated by emotional stress chest pain that is relieved by nitrates (can also give CCBs) - relax myocytes in esophagus get esophageal *manometry* - will show repetitive (non-peristaltic, high-amplitude simultaneous contractions in middle and lower esophagus) - spont or after ergonovine stimulation - esophagram will show corkscrew pattern - issue is dysfunction of inhibitory neurons

Answer 82

straight forward GERD - start empiric trial of PPI for 2 mo - refractory sxs --\> switch to different PPI or bid dosing - persistent sxs --\> consider EGD or esophageal pH monitoring men age \>50 with sxs for \>5yrs or cancer risk factors (tobacco use) or alarm sxs - EGD - either esophagitis or no esophagitis (pursue further work-up by esophageal manometry) - **alarm sxs** = melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia/odynophagia tx - lap nissen, radiofrequency ablation if there are severe dysplastic changes

Answer 83

AR hepatic copper accumulation --\> leak from damaged hepatocytes --\> deposits in BG and cornea px - hepatic, neuro sxs (parkinsonism), psychiatric changes decreased ceruloplasmin, increased urinary cu excretion tx - chelators, zinc (interferes cu absorption) - for pts with fulminant liver failure or drug-resistant disease - liver transplant

Answer 84

causes - diverticular disease, crohns, malignancy dx - abd ct with oral or rectal contrast (NOT IV) - colonoscopy to exclude malignancy

Answer 85

adenomas = neoplastic - findings that suggest greater risk of malignant transformation - villous features and high-grade dysplasia, large size, high number (3+), sessile

Answer 86

abdominal pain, vomiting, diarrhea + neuro symptoms (agitation, paresthesia, confusion) - may be triggered by isoniazid - but symptoms are episodic (rather than chronic)

Answer 87

in older patients - assume GI loss until proven otherwise - single fecal occult blood test is **not** sufficient to exclude GI bleeding - get colonoscopy and EGD - even if one fecal occult test is negative

Answer 88

neuroendocrine tumor skin flushing (85%), cutaneous telangiectasias, GI upset (secretory diarrhea), valvular lesions (R \> L), bronchospasm - other - niacin deficiency (pellagra) dx - elevated 24hr urinary excretion of 5HIAA - CT/MRI abd/pelvis to localize the tumor - octreotide scan to detect mets - echo - if there are sxs of heart disease tx - octreotide for symptomatic pts and prior to surgery and anesthesia - surgery for liver mets - mets to liver means that products are released directly into circulation (before being neutralized by liver)

Answer 89

multi-system illness commonly seen in white men, 40-60s GI - abd pain, diarrhea, malabsorption - migratory polyarthropathy, chronic cough, myocardial/valvular involvement, dementia - PAS pos material in LP

Answer 90

fatty acids in duodenum --\> stimulate endocrine cells to release CCK --\> CCK causes smooth muscle contractions of the GB and relaxation of the sphincter of Oddi vagus nerve also plays a role (hepatobiliary branches of the vagus?)

Answer 91

alcohol use, CF, ductal obstruction (malignancy, stones), autoimmune sx - chronic epigastric pain (intermittent, pain-free interval), malabsorption, DM - pain is relieved by sitting upright or leaning forward CT scan - calcifications, dilated ducts, enlarged pancreas treatment - pain management, alcohol and smoking cessation, frequent and small meals - enzymes based on sxs and stool fat content (sxs - bloating, diarrhea) secretin test - measures ability of pancreatic ducts to produce bicarb - good for diagnosing chronic pancreatitis

Answer 92

MALT also extranodal marginal zone B cell lymphomas H pylori - chronic inflammation from H pylori --\> stimulation of B and T cells in gastric lamina test for H pylori - early-stage MALT - H pylori eradication therapy (quadruple therapy) - more advanced dz or H pylor negative tumors - radiation, immuno, or chemo

Answer 93

risk factors - cigarette smoking, high salt intake, consumption of N-nitroso compounds (processed foods) - NSAIDs are protective - H pylori is a risk factor - eradication is recommended for pts with resectable disease to reduce risk of developing second cancer - pernicious anemia increases risk for gastric adenocarcinoma (and gastric carcinoid tumors)

Answer 94

pill esophagitis - tets, ASA, NSAIDs, bisphosphonates, KCl, Fe - typical sxs are **sudden-onset** odynophagia and retrosternal pain - most common in mid-esophagus (due to compression by the aortic arch or enlarged LA) - EGD - discrete ulcers with relatively normal appearing surrounding mucosa (though dx can be made clinically)

Answer 95

elevated alk phos and elevated GGT - likely biliary in origin (otherwise likely of bone origin) - get RUQ US and AMA - if AMA pos or abnormal hepatic parenchyma - get liver bx --\> if dilated bile ducts - get ERCP - if both normal - liver bx, ERCP, observation pos AMA = primary biliary cholangitis

Answer 96

most commonly seen in Asian-Americans colonic bacteria ferment lactose --\> bloating dx - lactose hydrogen breath test - rise in breath hydrogen level after ingestion of lactose - indicates bacterial carbohydrate metabolism diarrhea will have high osmotic gap due to unmetabolized lactose and organic acids - OG = 290 - [2(stool Na + stool K)] - stool pH will be acidic - due to fermentation products

Answer 97

1-2 small adenomatous polyps on colonoscopy - q5yrs FHx of adenomatous polyps or CRC - at 40 or 10 yrs before dx of affected relative - q5yrs IBD - UC or Crohns with colonic involvement - 8-10 yrs post-dx - q1-2 yrs = frequent surveillance - prophylactic colectomy if dysplasia is identified classic FAP (APC gene mutation) - sigmoidoscopies at age 10-12 - annual colonoscopies once colorectal adenomas are detected - usu proctocolectomy by early 20s HNPCC (Lynch syndrome) - age 20-25 - q1-2yrs

Answer 98

due to malignancy - cholangiocarcinoma, pancreatic or HCC, mets px - jaundice, pruritis, weight loss, acholic stools with dark urine - exam - normal or RUQ mass, tenderness, or hepatomegaly - labs - elevated direct bili, elevated alk phos and GGT, normal-elevated AST and ALT evaluation - abd imaging (US, CT) - MRCP or ERCP if imaging is nondiagnostic

Answer 99

cirrhosis, heart failure, DM, hypogonadism, arthritis

Answer 100

persistent abd pain or dyspepsia (nausea) post-op can be due to - retained CBD or cystic duct stone - bile duct injury (?) - note that bile ducts stricture so these injuries can be devastating - biliary dyskinesia - pancreatitis - PUD - CAD elevated alk phos, mildly abnormal serum aminotransferase, dilated CBD - 1) US, 2) ERCP

Answer 101

diarrhea, international travel (rural areas, developing countries, mtns), foul-smelling stools, bloating - contaminated water, fecal-oral route abd exam benign get stool antigen assay - can also look for oocysts and trophozoites in stool tx - metronidazole - but note - short course of cipro is empiric treatment for travelers diarrhea

Answer 102

bacteria from the colon are inappropriately present in the SI - DM, jejunocolonic fistula greasy diarrhea

Answer 103

cecal - blood per rectum rectal cancer - diarrhea (obstructed above) - 1) chemo, 2) surgery junction of ascending and sigmoid - bloating - note - colon cancer 1) surgery, 2) chemo

Answer 104

12 minimum

Answer 105

basal cell (50%) - waxy, raised, or ulcer (pearly telangiectatic papules with central ulceration) - kills by relentless local invasion (rodent ulcer) (does not met) - timetable is yrs - resection - 1mm margin squamous cell carcinoma (25%) - associated with UV light and chronically wounded, scarred, or inflamed skin - SCC arising with burn = Marjolin ulcer - mets to LNs - timetable is mo melanoma - most lethal, ABCD (\>0.5 cm) E - prognosis and management by depth, lesions beyond 4 mm have terrible prognosis - disseminated melanoma - cant be cured, IFN improves survival time note - ulcers should be bx at edge, other things can be completely excised

Answer 106

thryoglossal duct cyst - surgical excision involves removing cyst, track, and attaching part of hyoid bone branchial cleft cysts - anterior edge of SCM, can have opening and blind tract onto skin cystic hygroma - supraclavicular area + deep chest - get CT prior to excision

Answer 107

recently discovered - will most likely be benign - f/u in 3-4wks - if persistently enlarged - have to rule out neoplasia lymphoma - remove node, chemo tx squamous cell carcinoma of mucosa - old men who drink, smoke and have rotten teeth, AIDS - other pxs - persistent hoarseness, persistent painless ulcer in floor of mouth, persistent unilateral earache - first sign will be a metastatic node in neck --\> panendoscopy to look for primary - CT to look for extent - can do FNA, NEVER do open bx - scar will make future surgery difficult

Answer 108

most are pleomorphic adenomas - benign but have malignant potential hard parotid mass, painful, facial nerve paralysis - cancer superficial parotidectomy to excise - spares facial nerve - in malignant tumors - take nerve

Answer 109

treat with antivirals (and sometimes steroids)

Answer 110

little children - epistaxis, give phenylephrine spray and local pressure juvenile nasopharyngeal angiofibroma - surgical resection is mandatory - because it will eat away at nearby structures cocaine use - packing elderly and nose bleeds - posterior packing, may require surgical ligation

Answer 111

inner ear - room spinning, give **meclizine**, promethazine, diazepam brain - unsteady

Answer 112

diabetic complication, rocker bottom deformity, swelling - inflammation is the issue pulses are fine will have peripheral sensory neuropathy

Answer 113

TIA - IC stenosis (\>70%) or ulcerated plaque at carotid bifurcation - 1) Doppler hemorrhagic stroke - control HTN brain bleeds - if midline shift --\> surgery - acute subdural - work on lowering ICP - SAH - 1) CT first, 2) arteriogram to look for aneurysm brain cancer - approx 50% from lung elevated ICP (with a brain tumor) - tx with high dose steroids until you can surgically remove pituitary apoplexy - steroid replacement is necessary brain abscess - resection is required reflex sympathetic dystrophy (formerly called CRPS?) - develops after a crushing injury - doesnt respond to usual analgesics - extremity is cold, cyanotic, and moist - requires surgical sympathectomy

Answer 114

acute epididymitis - will present with fever and pyuria - \*get doppler to rule out testicular torsion\* obstruction + infection - IV abx, immediate decompression (?) erection longer than 4 hrs - drain blood from penis posterior urethral valves - voiding cystourethrogram to dx, surgery/endoscopy to tx VUR - consider in child with UTI, get voiding cystourethrogram, long term abx until child grows out of problem low implantation of ureter - issue in girls, ureter will leak urine (constantly) into vagina UPJ - renal/bladder system can empty normal amounts of urine, pt will present with colicky pain after a night of binge drinking... prostate cancer - dx by transrectal needle bx impotence due to chronic dz (arteriosclerosis) - viagra penile fracture - rupture of corpus cavernosum (tissue around urethra) due to traumatic tear in tunica albuginea (fibrous covering around entire penis) - crack, detumescence, variable pain, hematoma foramtion - urologic emergency - get RUG (because urethral injury is a common complication) - note other indications for RUG are blood at meatus, hematuria, dysuria, URT

Answer 115

1) CT scan 2) inflammatory diverticular mass 3) sigmoidoscopy to rule out cancer

Answer 116

hyperacute - vascular thrombosis in min, due to incompatbile ABO and lymphocytes (so pre-formed abs) acute - 5d-3mo, organ dysfunction, get bx - liver - usu technically problems cause an issue --\> get doppler to evaluate for biliary obstruction and vascular thrombosis - heart - routine bx (otherwise its becomes too late to intervene) - give steroid boluses - mediated by mononuclear macrophages and T lymphocytes (leukocytic infiltration) chronic - yrs, insidious organ loss - T- cell mediated (foreign mhc looks like a self mhc that is carrying an antigen) --\> intimal thickening and fibrosis of graft vessels) - no tx - get bx - to make sure it is not a delayed and treatable case of acute rejection

Answer 117

1) repair bone first 2) vascular - because this can be disrupted when you reduce a fracture 3) nerve

Answer 118

fall from height - check (L/T) spine herniated disk - will most likely resolve cauda equina syndrome - distended bladder (late), flaccid rectal sphincter, perineal saddle anesthesia - condus medularis is similar - but will have EARLY urinary and fecal incontinence

Answer 119

acute attack - indomethacin, colchicine chronic control - allopurinol and probenicid

Answer 120

if they dont drain out directly --\> sepsis if they drain freely (pt is afebrile with no signs of peritoneal irritation) - consequences are only fluid and electrolyte loss, nutritional depletion, and erosion and digestion of belly wall - high volume losses from high in GI tract - tx - give enteral nutrition (past the fistula), protect abd wall - fistula will heal on its own

Answer 121

in all anorectal disease - rule out cancer ischiorectal abscess - perirectal pain that prevents sitting - watch diabetics closely - can progress to necrotizing soft tissue infection fistula-in-ano - develops in some pts who have had an ischiorectal abscess drained - anal crypt --\> skin - fecal soiling - r/o necrotic and draining tumor treat with fistulotomy SqCC of anus - bx first - tx 1) chemoradiation, 2) surgery is there is residual tumor

Answer 122

need systemic therapy for systemic disease - so chemo for mets T tumor - T4 invasion of adjacent structures N M

Answer 123

most thyroid nodules are benign but have to work all up to exclude malignancy 1) US --\> 2) TSH/radionuclide scan --\> 3) FNA --\> ... - except follicular hot nodules are rarely malignant - toxic multinodular goiter - TSH-independent hyperfunctioning follicular cells **thyroiditis** - Hashimotos (autoimmune) - subacute (follows viral infection) - silent - associated with thyroid abs, can occur post-partum - Reidels - fibrosing **neoplasia** - autopsy, f-ed, pissed off, will present as a nodule (decreased I uptake in adenoma and carincoma) --\> get FNA - follicular adenoma - follicular carcinoma - FNA cant distinguish between follicular adenoma and carcinoma --\> partial thyroidectomy --\> total thyroidectomy if cancer - papillary carcinoma (80%) - old lady with exposure to ionizing radiation as a child - medullary carcinoma - C cells, aggressive --\> radical surgery - anaplastic (elderly, invades local structures...)

Answer 124

have to rule out cancer ALWAYS - lymph nodes! \<30 - US - simple breast cyst (can be quite painful) - posterior acoustic enhancement (fluid), no echogenic debris... - cystic fluid can reaccumulate so pt should f/u in 2-4 mo for repeat clinical breast examination - no recurrence or sx - annual visits screening MRI - cancer - and use it for women with increased risk of cancer (BRCA and their relatives, genetic syndrome, hx of radiation during ages 10-30 diagnostic mammography - DONT in women \< 30 (dense breast tissue prevents visualization, radiation risk) - diagnostic to evaluate risk - needle aspiration for breast mass - core bx if suspicious imaging (mammogram) - for complex cysts, masses, or recurring mass when would you image - unilateral breast discharge, bloody or serous d/c, or palpable lump or skin changes - mammo or US accordingly - nipple discharge that looks benign - UPT, TSH, prolactin, guaiac fibroadenoma - FNA or sonogram cystosarcoma phyllodes - grow over many years --\> distort entire breast, dont become fixed - core or incisional bx --\> removal mammary dysplasia (fibrocystic disease, cystic mastitis) - linked to estrogen cyst - aspirate --\> clear ok --\> recurs --\> get formal bx - bloody send for cytology - intraductal papilloma - get mammogram (though it will not show the mass) **treatment**: for resectable cancer (infiltrating ductal, DCIS, small lesions away from nipple/areola) - 1) lumpectomy, 2) radiotherapy - otherwise - total mastectomy (no need for radiation) - if LNs are not palpable - get sentinel node bx - if LNs are palpable - take them out - inoperable breast cancer - based on local extent --\> give chemo - follow every surgery with adjuvant chemo

Answer 125

coin lesion 1) sputum cytology, 2) CT chest/abdomen to look for mets, 3) biopsy - operability is based on FEV1 remaining after the surgery \> 800 mL - sufficient FEV1 --\> look for mets (carinal and mediastinal mets preclude resection) - not surgical candidate - chemo and rads **small cell** = s tumors are associated with smoking, sentral, syndromes (paraneoplastic, ADH, ACTH, Eaton-Lambert) - small cell --\> chemo **non-small cell** - adenocarincoma - squamous cell - PTHrP - carcinoid tumor **screening guidelines** - low-dose chest CT annually in pts 55-80 who have a \>30-pack-yr smoking hx AND are currently smoking or quit in the past 15 yrs

Answer 126

hyponatremia (\<120) * check serum Na, serum osm, UA, physical exam * urine Na low (\<20) - primary polydypsia * urine Na high (\>20) - look at volume status * hypervolemic - cirrhosis, chf, nephrotic syndrome * euvolemic - siadh, adrenal insufficiency, hypothyroidism * hypovolemic - cerebral salt wasting, diarrhea, diruetics hypernatremia (\>145) * due to net loss of free water - large wound (burn), open abd, GI tract loses, lungs (humidifier air), kidneys * or due to net gain of sodium * check urine SG (can also get serum and urine osm)

Answer 127

insulin brings K into cells hypokalemia - weakness, constipation --\> frank muscle necrosis --\> ascending paralysis, arrhythmias are uncommon - due to renal loss, metabolic alkalosis, diarrhea - less often due to redistribution hyperkalemia (5.5) - fatigue, muscle weakness, flaccid paralysis, paresthesias, cardiac excitability (can lead to heart block and vfib) - impaired renal excretion (AKI), metabolic acidosis, rhabdo - tx - 1) ca gluconate to stabilize heart, 2) insulin to shift K into cells, 3) excrete K (lasix, hemodialysis)

Answer 128

entamoeba histolytica - abd pain, chronic diarrhea (bloody)

Answer 129

intraoperative hemorrhage (requiring blood transfusion) increases risk px - lack of chest pain, possibly because of peri-op pain control

Answer 130

px - fever, hypotension, pulm edema within 6 hrs of blood product administration

Answer 131

leukemoid reaction - WBC \> 50K, due to severe infection - leuk alk phos - high - mature neutrophil precursors v. s. CML - WBC \> 100K, Bcr-abl - low leuk alk phos - due to cytochemically abnormal neutrophils - less mature neutrophli precursors, absolute basophilia

Answer 132

bronze diabetes, transaminitis/hepatomegaly, hypogonadism, cardiomyopathy - MSK - arthralgia, arthropathy, **chondrocalcinosis** - pts with pseudogout should be elevaluated for seocndary causes - hyperparathryoidism, hypothyroidism, hemochromatosis - hemaochromatosis - get Fe studies, manage with serial phlebotomy - infections - increased susceptibility to Listeria, Vibrio vulnificus, Yernsinia enterocolitica

Answer 133

gastric bypass

Answer 134

acute liver failure --\> liver transplant - jargon note - ALF is acute liver injury in a pt without cirrhosis - triad of 1) elevated AST/ALT (1000s), 2) hepatic encephalopathy, 3) synthetic liver dysfunction (INR \> 1.5) - rising serum bili and PT - indicative of worsening ALF - cerebral edema is a potential complication --\> coma and brainstem herniation - acute renal insufficiency is common - esp with acetaminophen (because it is directly toxic to renal tubules) - as a note - signs of HE differentiates ALF from acute hepatitis

Answer 135

urinary RT * straight cath OR * insert foley, keep for 1 week --\> f/u with urology for fill (w 500 cc) and void trial CA-UTI * bacteria properties - biofilm * avoid by clean intermittent cath - every 4-6 hrs * condom cath - no difference in CAUTI rate compared to foley compare to indwelling catheters - changed monthly * risks - increased UTI, stricture, bladder spasm other option - suprapubic tube placement

Answer 136

gastrograffin contrast - very irritating to chest/pleura —\> ARDS - for esophageal rupture - use barium contrast

Answer 137

want INR \< 2 prior to surgery * INR of FFP is 1.6-1.7 - so not possible to bring INR below that (is what is taught) * in reality - properties differ in bag vs in vivo, so it is possible to bring INR below 1.5

Answer 138

type 1 (sliding, 90%) - GE junction migrates above diaphragm * widening of muscular hiatal tunnel, circumferential laxity of phrenoesophageal ligament type 2 (rolling) - GE junction normal, fundus herniates through diaphgram * localized defect in phrenoesophageal ligament type 3 (mixed) - type 1 + type 2 * progressive enlargement of hernia through hiatus causes phrenoesophageal ligament to stretch type 4 - something other than stomach herniates (omentum, colon, small bowel) phrenoesophageal ligament - extenion of inferior diaphragmatic fascia, upper and lower limbs (which attach to superior and inferior surfaces of the diaphragm) vagus nerve CN10 * along the esophagus - anterior (from primarily L vagus) and posterior (R vagus) trunks * function * PSNS to all orans from neck to second segment of transverse colon (acid secretion) * controls skeletal muscles of neck, palate, pharynx, larynx * fibers that innervate the pharynx - gag reflex * 5-HT3 receptor mediated vagus stimulation in gut --\> vomiting * role in satiety * SNS (via peripheral chemoreceptors, activated due to hypoxemia) - vasoconstriction and increased BP * PSNS - heart, SA node paraesophageal hernia - heartburn, dysphagia * pre-op eval - barium esophagram, upper EGD, sometimes 24hr esophageal pH study/manomatery (but are omitted if it is difficult to instrument the esophagus) * steps: 1) divide gastroheaptic ligament, 2) divide gastrosplenic ligament (now both crus are visualized), 3) Nissen (360) * if the esophagus below the diaphgram is too short --\> Collis gastroplasty - staple down left side of esophagus into stomach creating a neoesophagus (can now sufficiently wrap fundus around esophagus) * complications of Nissen - gas bloat syndrome, dysphagia, dumping syndrome, vagus nerve injury, achalasia (rare) * post-op - remove NGT on POD1, barium swallow on POD1 to evaluate for a leak, start CLD if there is no leak * discharge on POD2 * f/u in 1 mo with another barium swallow

Answer 139

triple therapy - clarithomycin, flagyl, omeprazole - recent literature has shown quadruple therapy to be superior start empiric treatment when patients can tolerate po

Answer 140

monitor by serial H&H rectus sheath hematoma - **non-operative** management strep anginosus - linked to hematomas

Answer 141

G-G fistula can occur - will see dilated gastric remnant

Answer 142

anastomotic bleed - will typically resolve on its own - CT - look for bleeding and extravasation

Answer 143

gallstone impacted at gallbladder neck --\> chronic inflammation and fibrosis --\> obstruction and erosion of CBD wall

Answer 144

hypoxemic (PO2 \< 60) or hypercarbic (PCO \> 50) large vs small airway obstruction altered complaince (rib fxs, pulm contusion), alveolar-capillary abnormality, V/Q mismatch

Answer 145

heparin preferred - because it is reversable * use in cases of abnormal renal fx * hep gtt - need to track PTT lovenox - use in cases of normal renal fx, can check anti-10A levels to monitor doacs (direct oral anti-coagulant) - K centra (prothrombin complex concentrate) can be used for "reversal" eliquis - po only for people on comaudin, add heparin bridge pre-op only if they are high risk for VTE

Answer 146

fever, respiratory distress, hypoxemia, bilateral opacities associated with infections, trauma, massive transfusion, pancreatitis * lung injury --\> release of proteins, inflammatory cytokines, neutrophils into alveolar space --\> alveolar collapse and diffuse alveolar damage --\> shunting, increased physiologic dead space, impaired gas exchange, decreased lung compliance * PaO2/FiO2 \<300 mm Hg * increased A-a gradient will also have increased pulmonary arterial pressure - hypoxic vasoconstriction, destruction of lung parenchyma, and compression of vascular structures (PAP in mechanically ventilated pts) **PaO2** goal - 55-80 mm Hg (88-95%) ways to improve low PaO2 - increase FiO2 or \*PEEP\* * high PEEP approaches may improve mortality in pts with severe ARDS * too much --\> barotrauma and venous return issues * want FiO2 \<60% - higher increases the risk of O2 tox (generation of pulmonary free radicals) * permissive hypercapnia - up to pH 7.28 * avoid overdistending alveoli (LTVV, 6 mL/kg ideal body weight or lower) - improves mortality * run dry * prone patients (18 hr trial) - recruits lung spaces with more blood flow * proning patients and paralysis are the two measures where literature has shown improved outcomes * paralysis - so patient doesnt fight the vent settings note - ways to change PaCO2 is TV and RR * increasing TV increases peak inspiratory pressure (and risk of barotrauma)

Answer 147

lung problem vs airway problem pt is in distress and hypoxic on vent --\> d/c vent, start bagging, look at airway, suction * DOPE - dislodged tube, obstruction of ETT, ptx, equipment failure chronic vent - pseudomonas colonization, only treat symptomatic patients

Answer 148

gleevac - tyrosine kinase inhbitor (also good for CML)

Answer 149

ACT (activated clotting time) R - time to clot angle - how quickly you make a clot, property of fibrinogen MA (max amplitude) - clot strength lysis 30 min

Answer 150

vs staples - can use same edge of cut bowel for anastomosis

Answer 151

1) . NC 2) non-breather - face mask 3) high-flow - higher FiO2 than NC or non-rebreather

Answer 152

will be forehead temp --\> get oral temp

Answer 153

**Why?** - decompression, administration of oral agents (activated charcoal, tube feeds, meds), eval of GI bleeding - contraindications - maxillofacial trauma, inability to protect airway, esophageal abnormalities (recent caustic ingestion, known esophageal stricture, varices are NOT a contraindication) with insertion - when tube is connected to suction --\> should be return of gastric contents - if patient is in respiratory distress or cant talk - you are in the wrong place - for Dobhoff - if you meet resistance when removing the wire, withdraw tube and try again - no suction - always confirm placement with KUB complications - endotracheal placement, epistaxis, sinusitis, esophageal perf, aspiration, ptx bridled NGT - tube with prongs for each nostril and a magnet that holds the prongs in place across the nasal septum Dobhoff NGT - small bore, **flexible**, weighted tip, more comfortable, can be left in place for 6 weeks - tube inserted over a guide wire - NOT attached to suction - tip should be in 2nd or 3rd part of duodenum (but most are placed in stomach) - used for nutrition in pts who require mechanical ventilation, AMS, swallowing disorders **Residuals** - less than 100 --\> pull

Answer 154

factor Xa inhibitors - rivaroxaban, apixaban, fondaparinux (indirect) - factor X activates thrombin direct thrombin inhibitors - argatroban, bivalirudin, dabigatran - thrombin converts fibrinogen to fibrin provoked DVT due to surgery - **3 mo** of treatment - start on unfractionated heparin/LMWH, warfarin later that same day - continue unfractionated heparin/LMWH for 4-5d - until INR is at 2-3 - dont use LMWH and rivaroxaban in pts with ESRD - because these are both metabolized by the kidney

Answer 155

get BMP, mag, phos

Answer 156

G tube - balloon keeps this in place (until tract forms) J tube - J tube is very long - will be suprising if this falls out, can remove fluid in balloon on POD1 - additionally - balloon in J tube balloon can obstruct bowel lumen - NO crushed meds in J tube - tube is prone to clogging - if clogged - put coke (or pancreatic enzymes) in J tube

Answer 157

bugs crawling on walls

Answer 158

**D/C** 1) Suction (initially and in cases of air leak) --\> 2) water seal, CXR after --\> 3) pull, CXR after * suction - opposes parietal and viscerla pleura **If chest tube gets clogged** (empyema, etc.): 1) early VATS or 2) TPA in tube * TPA in tube - qd x3d then get repeat CT * administer --\> 15 min in upright, supine, and lateral x2 positions * may see increased output following administration * difficult to do VATS if you give TPA - TPA increases inflammatory reaction and makes VATS more challenging

Answer 159

alcohol neurotin

Answer 160

Treatment for gastroparesis

Answer 161

When would you start TPN? - If you know it will be used for at least 3d * also easier to change composition of TPN (than to change composition of tube feeds) long-term TPN - risk of cholestasis * ex: pts with short gut syndrome will sometimes get a prophylactic chole * definition of short-gut \<200 cm of short bowel (normal is about 600 cm (or 20ft)

Answer 162

Hold nephrotoxic home meds (acei, arb, diuretic) until patient is on regular diet * dont want to restart ACEI in setting of rising Cr * induction anesthetics and ACEI together have been associated with refractory hypotension, AKI, and death b-blockers - restart, improved outcomes in surgical patients (POISE trial) anti-retrovirals (HIV patient) - dont restart in non-complaint HIV patient, can lead to highly resistant strains of HIV

Answer 163

**Cardiac** Goldman's index 1) JVD 2) recent MI (last 6 mo) 3) PVCs, non-sinus rhythm 4) age over 70 5) emergency surgery 6) AS 7) poor medical condition 8) surgery in chest/abd - goldmans is outdated, preferred method is assessing functional status **hepatic risk** - encephalopathy, albumin ascites, bili, INR **nutritional risk** - more than 20% body weight loss over couple mo (serum albumin \<3, anergy, serum transferrin \<200) - 4-5 d enteric feeds will fix the issue DKA is absolute contraindication to surgery

Answer 164

consider hypoxia DTs occur POD 2-3 - confused, hallucinations, combative **drugs** - anti-emetics (scop path, etc) will worsen delirium - haldol - long QT - dont give anyone \>50 benadryl, ambien --\> delirium

Answer 165

extremely common - esp after surgery in the lower abdomen, pelvis, perineum, or groin pt will often have dribbling - signs of overflow incontinence straight cath at 6hrs post-op with no voiding - indwelling foley after 2x or 3x straight caths

Answer 166

salmon colored fluid (peritoneal fluid) immediate concern - evisceration late issue - ventral hernia

Answer 167

colace - fiber senna - stimulant, can cuase cramping miralax - osmotic agent

Answer 168

post-op hypotension causes - hypothermia, hypovolemia (continued blood loss, new hemorrhage, under resusciation, medical coagulopathy, third spacing), myocardial dysfunction, meds (narcotic OD, pre-op meds, residual anesthetic effect), PE, sepsis, tension pneumo 1) check cuff size 2) vital signs * hemorrhagic/hypovolemic shock * bolus, transfuse * cardiogenic shock, PE - get CT PE (d-dimer has no role in surgical patient, all will have elevated d-dimer) * septic shock - blood cultures, CBC, lactate, CXR, UA (infectious work-up) * pressors - levophed (NE), vaso 3) check access - PIV, CVC

Answer 169

diverticulitis - levo/flagyl (because they will be going home on these meds, like to see how pts respond) complicated appy/chole - ctx/flagyl (because these meds will most likely be d/c'ed prior to discharge) CTX - 1000 q24hrs flagyl - 500 q8hrs

Answer 170

replace 1/2 volume

Answer 171

cold-induced diuresis - can't trust UOP in a hypothermic (\<32) patient Swiss system of hypothermia classification 1. alert, shivering - 35-32 2. drowsy, non-shivering - **32**-28 3. unconcious, 28-24 4. not breathing, \< 24

Answer 172

**GO TIME** Glucose Oxygen Toxins - iatrogenic Ischemia Metabolic Epilepsy \*concerns particularly in a post-op patient - hypoglycemia, hypoxemia **Treatments** * haldol - for acute episodes of agitation, 5 mg --\> 10 mg -\>\> 500 mg (check for Qtc, bradycardia) * B52 - benadryl, 5mg haloperidol, 2 mg lorazepam * for an agitated patient - go up on sleep meds first (melatonin, trazodone) instead of starting an anti-psychotic * benzo (sedative, etc.) - can worsen delirium * versed (midazolam, benzo) - byproduct is active metabolite * ativan (lorazepam) - byproduct is inactive

Answer 173

goal BG in ICU patients = 140-180

Answer 174

SBT - pressure support S - secretions O - oxygenation A - airway alertness P - parameters * RSBI (rapid shallow breathing index) - RR/TV in L, \>105 suggests that extubation will be difficult to tolerate * NIF (negative inspiratory force) - mesaure of intercostals and diaphragm, 80-120 in ICU * FVC * cuff leak - to rule out airway edema

Answer 175

**FloTrac** - volume status measurements via a-line Can be used: * if you have a good arterial tracing Can't be used: * heart rate variability (arrhythmias) * if the patient is not on a balloon pump (HR calculated by upstrokes from arterial pressure tracing, cardiac index calculated from HR, monitor cant differentiate the diastolic augmentation wave from a second heart beat) * severe aortic valve disease SVV (stroke volume variability) - that occurs during inspiration and expiration on ***mechanically ventilated patients*** * in a ventilated pt (on AC), with normal lung compliance and regular HR - SVV \> 13% suggests that the patient might be dry (and thus on the volume-response portion of the Frank Starling curve SV vs preload) * if patient has non-compliant lungs, they could still be dry with an SVV of \< 13% **Swan** - for patients who have multiple types of shock (septic and cardiogenic, etc.) **Other ways to assess volume status** - echo (RA-RV anterior-LV lateral, LA by esophagus)

Answer 176

precedex (dexmedetomidine) - centrally acting a2 agonist (similar to clonidine) * provides sedation *without* respiratory depression, also has analgesic properties (but is opioid sparing so does NOT cause respiratory depression) * can also be used to treat withdrawal side effects * sedation mirrors natural sleep * many studies suggest that precedex for sedation may reduce time to extubation * side effects - biphasic effect on blood pressure --\> lower readings at lower drug concentrations and higher readings at higher concentrations * may enhance effects of sedatives, anesthetics, and b-blockers with co-administration * dose - loading dose + maintenance infusion * metabolized by liver (P450) propofol - sedation * side effects - \*hypotension\* * high lipid content (lipid emulsion) - so can elevate TG levels when used over several days * PRIS (propofol-related infusion syndrome) - usually occurs in children following infusion of large doses of propofol --\> renal failure, rhabdo, AMS

Answer 177

b-blockers help with long-term outcomes in patients with TBI - propranolol (crosses BBB)

Answer 178

**RSI** 1) induction - fast on/off, some analgesia * etomidate - 0.3 mg/kg, GABA receptor, few BP effects * midazolam - 0.1-0.3 mg/kg, GABA receptor, hypotension * ketamine - 1-2 mg/kg, NMDA receptor, preserves respiratory drive * propofol - 1.3-3 mg/kg, helps relieve bronchospasm, safe in cranial injuries, hypotension, burning at injection site 2) paralytic * sux - 6-10 min onset, 1.5 mg/kg, depolarizing muscular blocker (fasiculations) * DONT use in mal hyperthermia, hyperK * roc - 45 min, NAch receptors, non-depolarizing blockade * things that are **not** paralyzed - heart, gut, autonomic reflex (pupillary response) \*phenylepi at bedside maybe helpful for a patient who is at risk of becoming hypotension during the procedure someone is intubated in the field - how do you confirm ETT placement? * direct visualization * capnography (yellow mellow) * someone can be spontaneously breathing, have and insecure airway, and have a tube in the esophagus - will have normal breath sounds and saturation

Answer 179

blood collection between tunica adventitia and tunica media * hole in intima vs aneurysm - weakening/bulging of all layers of vessel wall

Answer 180

umbilical hernia - spont resolution by age 5 - due to incomplete closure of abd muscles round umbilical ring - most commonly associated with AA, premies, Ehlers-Danlos, Beckwith-Wiedemann, hypothyroidism - note - spontaneous closure is less likely for hernias \> 1.5cm umbilical granuloma - appears after the umbilical cord has separated - tx - silver nitrate gastrochisis - defect to the R of the cord insertion - immediate surgery after birth - will require TPN for sometime because bowel will be angry, matted omphalocele - umbilical cord inserts at apex of defect - immediate surgery after brith

Answer 181

esophageal atresia - rule out VACTER anomalies imperforate anus - look for fistula nearby - if fistula is present - can repair imperforate anus before potty training (otherwise repair immediately) green vomiting - double bubble - duodenal atresia, annular pancreas, malro - if there is a normal gas pattern beyond double bubble - malro is likely (malro is diagnosed with contrast enema) biliary atresia - **6-8 wk old babies** with progressive jaundice - normal work-up - 1) phenobarb (powerful choleretic), 2) hida scan neuroblastoma tracheomalacia - wheezing, stridor, dysphagia, hyperextension of neck - vascular ring that encircles trachea and esophagus - shown on barium swallow and bronchoscopy - surgery to divide (aortic) arches

Answer 182

c11p15 --\> gene that encodes ILGF2 physical exam - fetal macrosomia, hemihyperplasia, macroglossia rapid growth until late childhood - omphalochele/umb hernia - will close by age 5 - monitor newborns for hypoglycemia - occurs due to fetal hyperinsulinemia - complications - Wilms tumor, hepatoblastoma - surveil with AFP and abd/renal US through adolescence note - pts with isolated hemihyerplasia are at increased risk for Wilms tumor and hepatoblastoma...

Answer 183

arterial - triphasic, venous - biphasic (venous hum) ABI segmental limb pressures plethysmogram - pulse-volume correlation, independent of compliance

Answer 184

triad of 1) bilateral hip, thigh, and buttock claudication 2) impotence 3) symmetric atrophy of LE due to chronic ischemia occurs in a men with risk factors for atheroscloersis - pain is exercise-induced and relieved by rest

Answer 185

claudication - no need to work-up if it does not disrupt pt's lifestyle for severe, disabling claudication: SBP of ankle artery (DP or PT)/SBP of brachial artery ABI should be used for initial diagnosis of PAD - high sensitivity and specificity \<0.90 - abnormal --\> CT angio or MRI angio 0.91-1.30 - normal (or small vessel disease that is not amenable to surgery) \>1.30 - suggestive of calcified and uncompressible vessels - consider additional studies intermittent claudication --\> rest pain - rest pain = pain at night, pain relieved by gravity (dangling legs off bed), **shiny atrophic skin without hair**, no peripheral pulses

Answer 186

CAD: intervention if one or more vessels have **70%** (or greater) stenosis and there is a good distal vessel - stenting or bypass subclavian steal syndrome - plaque at origin of subclavian--\> results in retrograde flow during times of exercise - AND posterior circulation neuro signs

Answer 187

1) popliteal artery aneurysm 2) femoral artery aneurysm - pulsatile mass in groin, thigh pain (due to compression of fem nerve) - may be associated with AAA

Answer 188

arterial embolization to leg (afib) --\> doppler to localize - incomplete occlusion - clot busters - complete occlusion - Fogarty catheter to remove embolism

Answer 189

stress ulcer ppx = sulcralfate (in DG) for * patients on mechanical ventilation \> 48hrs + iatrogenic/intrinsic coagulopathy * burn, head bleed, steroids, etc. PPI - for GERD, etc.

Answer 190

Risk of rebleeding in ulcer (Forrest score) - without endoscopic intervention 1a active pulsating bleeding, 1b active nonpulsating bleeding = 55% 2a visible non-bleeding vessel = 43% 2b adherent clot = 25% 2c ulcer with hematin (blue-black, byproduct of Hgb) on ulcer base = 10% 3 ulcer with clean base = 5%

Answer 191

Zone 1 - midline retroperitoneum (supramesocolic, inframesocolic), zone 2 - upper later retroperitoneum, zone 3 - pelvic retroperitoneum, porta hepatitis/retrohepatic IVC

Answer 192

HTN emergency (urgency v emergency no longer used) * SBP \> 160 + end-organ damage (BMP [Cr], trop, +/-lactate are indicators of end-organ damage) * note - HTN will kill you over years (hypertension in the hospital is not an issue) * except for cases of ischemic cardiomyopathy and hemorrhagic stroke hydralazine - 2.5-5mg starting dose, venodilator, rebound tachy labetolol - bradycardia

Answer 193

repleting lytes - no need to recheck after repletion (can get am labs next day) transfusing - only get repeat CBC in someone who is acutely/actively bleeding * vs someone who has had a slow downtrend in H&H - transfuse, dont recheck

Answer 194

epi - a1, a2, b1, b2 NE - a1, a2, b1 phenylepi - a1 **Receptors** * a1 (post-synaptic) - vasoconstriction, contraction of smooth muscles (ureter, vas deferens, urethral spinchter, uterus, ciliary body), glycose metabolism * a2 (presynaptic) - glucose metabolism, contraction of anal sphincter, inhibits release of NE, inhibits renin release, lower blood pressure * b1 (postsynaptic) - HEART chronotropic (rate), dromotropic (increases impulse conduction), inotropic (contractility), increased EF; increased renin release by juxtaglomerular cells, increased ghrelin release (hunger) * b2 (postsynaptic) - smooth muscle relaxation (bronchus, bronchioles, detrusor, uterine muscle), contraction of urethral sphincter, renin release, glucose metabolism, lipolysis, thickened salivary secretion

Answer 195

post-op oliguria \< 400 mL/24hrs (catherized pt) or not voiding for 6-7 hrs * pre-renal - sepsis, meds, NSAIDs/ACEI, intravascular volume contraction, hypovolemia, hemorrhage, dehydration, atherosclerotic emboli * renal - renal ischemia, drugs (AG, amphoB), contrast, interstitial nephritis * post-renal - cellular debris (ATN usu due to hypotension or ischemia), crystals, uric acid, oxylate, pigment, myoglobin, hemoglobin * with ATN - sometimes a single high-dose loop diuretic (100 mg furosemide slow ivp) will re-initiate renal function solute in = solute out (0.5 mL/kg/hr is a myth, though there is evidence of increased risk of AKI with uop \< 1 mL/kg/hr) 1) foley issues - clogged, clamped, actually in bladder --\> flush, bladder scan 2) intravascular volume and volume status - bolus * in patients with a-line - perform passive straight leg raise or turn on PEEP to 20 --\> if SBP drops \< 10 (?), patient is fluid responsive

Answer 196

hold anticoagulation before epidural placement

Answer 197

can bypass heart and lungs (V-A ecmo) or lungs (V-V echmo) indications - ARDS

Answer 198

get post-bronch CXR - to confirm placement of ETT (3-5 cm above carina)

Answer 199

yes - paralytics dont work on smooth muscle (gut)

Answer 200

hypertonic saline vs mannitol * hypertonic saline (3%) - becoming more popular recently (though data is vague), need CVC * mannitol - can be given through PIV, also a diuretic

Answer 201

adducted and internally rotated leg - acetabular fracture with post hip dislocation pelvic fracture - pain in low abd/groin, bruising along scrotum and perineum - men with pelvic fractures are at high risk for posterior urethral injury - will present with blood at urethral meatus and high-riding prostate - for suspected urethral injury - get retrograde urethrogram (contrast should enter bladder uninterrupted) - tx with temporary urinary diversion by suprapubic catheter --\> delayed urethral repair with pelvic fracture - you can also get bladder rupture - gross hematuria and difficultly voiding - use retrograde cystogram bladder rupture - retrograde cystogram - need post-void films to look for leaks at base of bladder

Answer 202

prolonged bleadding after AVF access - due to central venous stenosis (consult IR) * in interim (?) - place prolene U stitch in skin

Answer 203

ddx - carotid duplex US

Answer 204

WBC count dropping - get diff, check for bands

Answer 205

"A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care" * In critically ill patients, restrictive transfusion (Hgb \>7 g/dL) is associated with better survival compared to liberal strategy (Hgb \>10).

Answer 206

ketamin resets pain receptors

Answer 207

1 - 2 - 3 - craniofacial disociation, pull midface

Answer 208

if someone is intubated and going to OR - you dont have to stop tube feeds unless they will be prone during surgery or you are operating on the digestive tract * can suction out stomach via NGT

Answer 209

types of wounds * clean - no hollow viscus entered, primary wound closure, no inflammation, no breaks in aseptic technique, elective procedure * clean-contaminated - hollow viscus entered but controlled, no inflammation, primary wound closure, minor break in aseptic technique, mechanical drain used, pre-op bowel prep * contaminated - uncontaminated spillage from viscus, inflammation apparent, open traumatic wound, major break in aseptic technique * dirty - untreated, uncontrolled spillage from viscus, pus in operative wound, open suppurative wound, severe inflammation infection rate depends on type of wound - clean 1-3% --\> clean-contaminated 5-8% --\> contaminated 20-25% --\> dirty 30-40%

Answer 210

max safe dosage of lidocaine * lido wo epi - 4.5 mg/kg, 30-60 min duration, max 300 mg * lido w epi - 7 mg/kg, 120-360 min duration * lido w epi - many surgoens choose not to administer epi due to vasospasm and risk for delayed bleeding and patient's rxn to lido * 1% lidocaine = 10 mg lido in 1 cc * concern is lidocaine toxicity - patient will start seizing (eyes may roll into back of head) --\> secure airway, administer O2, observe until twitching ceases and normal mentation returns bupivacaine - longer duration of action (120-420 min, depending on if you use epi)

Answer 211

dont implant hardware in the setting of an active infection

Answer 212

hold metformin pre-operatively

Answer 213

1. clinically healthy 2. mild systemic disease 3. severe disease that limits activity but is not incapacitating 4. incapacitating disease that is a constant threat to life 5. moribund patient who is not expected to live 24hrs w/wo surgery reliable indicator of mortality

Answer 214

even asymptomatic males over 45 should have EKG (and women over 50)

Answer 215

**continue**: b-blockers, anti-arrhythmics, pulm inhaled/nebulized meds anticonvulsants, antihypertensives, psychiatric medications - take with sip of water

Answer 216

cardiac disease is the greatest risk for mortality in patients undergoing **both** cardiac and non-cardiac surgery * important factors - PVD, METs, algorithm for cardiac assessment, prior cardiac procedures, knowing probability of cardiac disease, hx of chest pain, EKG, chest pain w vigorous activity surgery can proceed as soon as 7 days after revascularization (stent placement), just consider risks associated with anticoagulation cardiac risk calculators - Goldman cardiac risk index, Detsky modified multifactorial index, Eagle's criteria for cardiac risk assessment, evised cardiac risk index

Answer 217

affects cytochrome P450 enzymes - discontinue 5d pre-op

Answer 218

SCIP guidelines: 1. abx should be given wi 1 hr before surgical incision 2. ppx abx selection should be appropriate 3. abx should be discontinued wi 24hrs after surgery end time (wi 48hrs for CV procedures colorectal operations: orally administered antimicrobial bowel prep + pre-op parental abx (cefotetan OR cefoxitin, cefazolin + metro is a cost-effective alternative)

General Surgery Flashcards

(243 cards)