General Surgery Flashcards
(253 cards)
1
Q
What is a schatizki ring MC associated with?
A
sliding hiatal hernia
2
Q
Two types of Hiatal Hernias
A
Type 1: “sliding hernia” this is where the GE junction and stomach slide up into the mediastinum. (Treat like GERD)
Type 2: “Rolling hernia” this is where the GE junction STAYS IN PLACE and the fundus of the stomach protrudes around it (Treat with surgery)
3
Q
Type types of esophageal cancer
A
1) Squamous Cell: MC in world, ETOH and tobacco cause it
2) Adenocarcinoma: MC in USA, results from long term GERD, progressing to Barrett’s esophagus
4
Q
Which type of ulcers have a higher risk of malignancy?
A
Gastric ulcers
**duodenal ulcers are more common
5
Q
H Pylori Testing
A
1) uses breath test
2) stool antigen
3) endoscopy with bx
4) serologic antibodies
6
Q
H. Pylori triple therapy
A
PPI
Clarithromycin
Amoxicillin
7
Q
H. Pylori quadruple therapy
A
PPI
Bismuth
Metronidazole
Tetracycline
8
Q
Signs of Gastric Cancer
A
weight loss, early satiety, dyspepsia
*linitus plastica on endoscopic bx
9
Q
Gastric Cancer Risk Factors
A
H. PYLORI, slated, cured, smoked, pickled food
10
Q
What are the two familial bilirubin disorders that would give you guidance without increased LFTs?
A
1) Dubin-Johnson Syndrome
2) Gilbert Syndrome
11
Q
Key features of Dubin Johnson Syndrome
A
- isolated elevated conjugated (direct) bilirubin without increased LFTs
- Jaundice
- Grossly black liver on bx
- most are asx and no treatment is necessary
12
Q
What is the enzyme needed to convert indirect biirubin to direct bilirubin?
A
(UGT)
-glucoronosyltransferase
13
Q
Key features of Gilbert Syndrome
A
- reduced UGT activity
- transient episodes of jaundice that are caused by stress, illness, ETOH
- no treatment needed for this mild dz
14
Q
What do liver enzymes look like in alcoholic hepatitis vs viral hepatitis?
A
ETOH: AST: ALT >2 **S is high in alcohol
Viral: ALT>AST, with both normally over 1,000
15
Q
What is the diagnostic test of choice for choledocolithiasis?
A
ERCP
16
Q
What is the most common organism causing acute cholangitis, Tx?
A
E. Coli
treat with unasyn or zosyn
ERCP if needed
17
Q
Charcot’s triad
A
For atue cholangitis:
- fever
- RUQ pain
- jaundice
18
Q
Boas sign
A
Referred pain to the Right shoulder from acute cholecystitis
19
Q
What is the Gold standard for diagnosing acute cholecystitis ?
A
HIDA scan, following a RUQ u/s
20
Q
Acute Calculus Cholecystitis
A
gallbladder sludge blockage, MC in the seriously ill patients (seen post-op)
21
Q
What is the MC cause of fulminant hepatitis ?
A
acetometaphen ingestion
22
Q
Clinical manifestations of fulminant hepatitis
A
Encephalopathy: astrixis; give lactulose
Coagulopathy : Inc. PT/INR
Hepatomegaly, jaundice
-high ammonia, inc. PT/INR, hypoglycemia
23
Q
Hep A transition and manifestations
A
Feco-oral transmission
-prodromal phase with SPIKING fever
24
Q
Hep E transmission
A
Water born outbreak
- highest mortality during pregnancy
25
Hep C transmission ; likelihood to become chronic
Parenteral transmission( IVDA)
*80% get chronic infection
26
Hep C Management
Pegylated interferon
*screen for Hcc
27
Hep D transmission
Requires hep B first to coinfect or superinfect
28
Hep B transmission
Parenteral, sexual
29
What would indicate a patient with the Heb B vaccine ?
Anti-HbS POSITIVE, all others negative
30
What would indicate a patient who resolved hepatitis B?
Anti-HbS positive, IgG present, all others negative
31
Budd-Chiari Syndrome
(Hepatic vein obstruction)
-leads to dec. liver drainage, therefore backs up causing portal HTN and cirrhosis
PRIMARY: thrombosis of the hepatic vein
SECONDARY: exogenous tumor compression
32
Clinical Triad of Budd-Chiari Syndrome
1) ascites
2) hepatomegaly
3) RUQ pain
33
Budd-Chiari Syndrome tx
1. Shunts (TIPS)
| 2. Balloon angioplasty with stent
34
Lab value associated with hepatocellular carcinoma
alpha-fetoprotein
** MC liver cancer is not primary, but a result of METS
35
What classification system is used to stage liver cirrhosis?
Child-Pugh
*based on bilirubin, albumin, INR, ascites, and encephalopathy
36
Manifestations of cirrhosis
1) encephalopathy; tx with lactulose or rifaximin
2) esophageal varacies
3) SBP, spontaneus bacterial peritonitis (infected ascitic fluid)
4) ascites, astrixis, gynecomastia
37
Primary Biliary Cirrosis Hallmarks
- MC in middle-aged women (40-60)
* intrahepatic autoimmune d/o of small bile ducts
- Fatigue, PRURITIS, RUQ pain, hepatomegaly, jaundice
- + AMA (anti-mitochondrial antibody)
38
TX of primary billiard Cirrhosis
1. ursodeoxycholic acid (reduces progression)
| 2. Cholestryramine & UV light (for puritis)
39
Primary Sclerosing Cholangitis Hallmarks
- Autoimmune FIBROSIS of intra AND extra hepatic ducts
- MC associated ulcerative colitis
- MC men 20-40
- jaundice, puritis, hepatosplenomegaly
- + P-ANCA , ERCP to dx
40
Primary Sclerosing Cholangitis tx
liver transplant
41
Ransons Criteria for pancreatitis
```
Glucose >200
Age >55
LDH >350
AST >250
WBC >16,000
```
* 3 or more= likely pancreatitis
Less than 3= unlikely
42
Clinical manifestations triad for chronic pancreatitis
1) calcifications (seen on AXR)
2) steatorrhea
3) DM
43
Pathoneumonic sign for pancreatic cancer
Painless jaundice
*courvoisier’s sign: non tender palpable gallbladder with jaundice
44
MC causes of small bowel obstruction
1. adhesions
2. hernia
3. Crohns
4. malignancy
45
Manifestations of SBO
1. abdominal pain
2. distention
3. vommiting
4. obstipation
46
PE and DX of small bowel obstruction
* high pitched tinkles on auscultation
| * air fluid levels with dilated bowel loops in step ladder pattern on abdominal radiograph
47
SBO tx
If non strangulated.. NPO and IV fluids, bowel decompression with NG tube
if strangulated ; surgery
48
Ogilvie's syndrome hallmarks
Colonic pseudo obstruction (colon dilation with NO obstruction)
- MC cecum and right hemicolon
- abdominal distention
- Xray shows dilated right colon from cecum with cutoff @ splenic flexure
- Give fluids and neostigmine in pt at risk of perforation. NG tube decompression
49
Diagnostic study and tx of diverticula dz
CT scan (barium enema CI)
Tx: cipro or Bactrim + metronidazole
*fiber will help
50
What is the treatment for diverticulitis?
cipro+flagyl
51
MC area effected by diverticulitis
sigmoid colon, LLQ pain
**diverticulosis is the most common cause of acute lower GI bleed
52
What is the MC location of a volvulus?
MC sigmoid colon, then cecum
53
Clinical manifestations of volvulus
pain, distension, n/v fever, tachycardia
54
Volvulus management
endoscopic decompression 1st line, 2nd line is surgery
55
Definition of toxic megacolon
dilation > 6 cm + signs of systemic toxicity
tx is decompression
56
Buzz words for Ulcerative Colitis
- only colon, rectum always involved
- LLQ colicky pain
- bloody diarrhea
- complications are primary sclerosing cholangitis, CA, toxic mega colon
- smoking is protective
- uniform inflammation (stovepipe sign)
- P-ANCA
57
Buzz words for Crohns
- entire GI tract (MC terminal ilium)
- RLQ pain
- transmural skip lesions with fistula sand granulomas (cobblestone)
- string sign on barium study
- ASCA +
58
3 Types of colon polyps and their probability for malignancy
1) pseudopolyp: not cancerous, due to IBD
2) Hyperplastic: low risk
3) Adenomatous polyps: normally become malignant in 10-20yrs
59
3 types of adenomatous polyps
1) tubular adenoma: nonpedunculated (MC and best prognosis)
2) tubulovillous: mixture of both
3) villous adenoma: high cancer risk
60
Tumor marker used for colorectal cancer
CEA
61
An "apple core" lesion found on barium enema is a classic finding of what?
Colon cancer
62
Colorectal cancer screening
colonoscopy q 10 years @50 OR flex sig q 5 years
| Fecal Occult blood test annually
63
Indirect Inguinal Hernia
- MC overall type of hernia in men & women
- MC in young children, young adults
- persistent patent process vaginalis
- origin is LATERAL to the inferior epigastric artery
- can protrude all the way to the scrotum; could cause scrotum swelling
64
Direct Inguinal hernia
- protrudes MEDIAL to the inferior epigastric artery
- within Hesselbach's triangle
- does NOT reach strotum
65
What are the boundaries of hesselbachs triangle ?
Medial=Rectus Abdominus
Lateral= Inferior epigastric vessels
Inferior= Poupart's ligament
*use the pneumonic RIP
66
3 presentations of inguinal hernias
1. Asymptomatic: swelling or fullness at hernia site
2. Incarcerated: painful, enlargement of an irreducible hernia
3. Strangulated: incarcerated hernia turned ischemic, systemic toxicity; severe painful bowel movements
* most require surgical repair
67
Femoral Hernias
- MC in women
- protrusion of contents of the abdominal cavity through the femoral canal BELOW the inguinal ligament
- More likely to become strangulated so surgery often done
68
Umbilical hernia
- most are congenital
| - observe till 2 yrs old, surgery if present past age 5
69
Incisional hernia is also called what
ventral hernia , often seen in obese patients
70
Obturator hernia
- through pelvic floor and through obturator foramen
| - MC in women
71
Classification of internal hemorrhoids
I. does not prolapse,
II. prolapses with defecation, reduces spontaneously
III. prolapse with deification, requires manual reduction
IV. irreducible & may strangulate
72
Presentation of internal hemorrhoids
intermittent rectal bleeding, hematochezia, itching
73
Presentation of external hemorrhoids
perianal pain, aggravated with defication, maybe mass or skin tag,
74
Hemorrhoids treatment
high fiber diet, sit baths, rubber band ligation if severe or strangulated
75
Where are most anorectal access located?
MC in the posterior rectal wall
76
Hallmarks of a pilonidal access/cyst
- near the gluteal cleft, towards midline of sacrum or coccyx
- Small midline pits may be present
- I&D for treatment
77
BMI to diagnose anorexia
BMI <17.5, or body weight <85% ideal
78
When to hospitalize an anorexic patient
if <75% ideal body weight, or medical complications
79
Risk Factors for post-op n/v (Apfel's simplified risk score)
female sex, nonsmoker status, previous history of postoperative nausea and vomiting, and use of postoperative opioids
80
how to prevent most op n/v
Patients at high risk for PONV (ie, those with four risk factors according to Apfel's simplified risk score) should receive three or more interventions (ie, antiemetics, modification of anesthesia, acupuncture)
81
What are the two main causes of pyloric stenosis in adults? What is the treatment?
1) peptic ulcer dz
2) malignancy
Tx with endoscopic ballooning (if high surgery risk) , or surgical fix (ideal)
*patient will present with s/s of upper GI obstruction
82
What is a pancreatic pseudocyst ?
Encapsulated, mature fluid collections occurring outside the pancreas that have a well-defined wall with minimal or no necrosis, occur as a complication of pancreatitis
83
Pancreatic pseudocyst management
If asx, monitor q3-6 months, if severely symptomatic, IR guided drainage
84
What is the MC type of small bowel carcinoma ?
Carcinoid tumor; MC overall and MC in the ilium
*adenocarcinoma is the MC in the duodenum
85
Postop N/V gives you what kind of acid-base disturbance?
hypochloremic metabolic acidosis
86
Grading and Management of AAA
Immediate surgery: >5.5 cm or grows .5cm in 6 months
Vascular surgeon referral: 4.5-5.4
ultrasound q 6 months: 4-4.5
anual ultrasound: 3-4 cm
*considered aneurysmal when it reaches 3cm
87
Common presentations of AAA
- Most Asx.
| - If rupture: syncope and hypotension with tearing back pain
88
What layer of the aorta is torn in a direction?
Intima
89
PE findings of a patient with an aortic dissection
- tearing chest pain radiating to the back
- Variation in extremity pulses
- Acute new onset aortic regurgitation
90
Gold standard for dx of aortic dissection
MRI Angiography
91
MC spot for an AAA
infrarenally
92
Where is the best anatomical location for a peritoneal dialysis catheter placement?
in the pouch of douglas (between the bladder and rectum)
93
Venus Ulcers
Found on the medial ankles
-edema, hyperpigmentation
94
Arterial ulcers
Found on the lateral ankles
-atrophy, decreased pulses, shiny skin
95
MC location of a herniated disc?
-L5, S1
96
s/s of herniated disc at L4
- ANTERIOR thing pain
- medial ankle sensory loss
- weak ankle dorsiflexion
- Loss of knee jerk
97
s/s of herniated disc at L5
- LATERAL thigh, hip, groin pain and parethsias
- sensory loss to the dorsum of the foot
- weak big toe extension
- Normal reflexes
98
s/s of herniated disc at S1
POSTERIOR leg/calf pain
- sensory loss to the plantar surface of the foot
- weak plantarflexion
- Loss of ankle jerk
99
Spondylolysis
pars interarticular defect from failure to fuse or stress fracture
100
Spondylolisthesis
forward slipping of a vertebra on another due to progressively worsening spondylolysis
*tx is surgical if it is high enough grade.. most people will have to go to PT and have injections before insurance will authorize
101
RCRI cardiac risk assessment
1 point for each of the following:
- High risk surgery
- Hz of stroke
- Hz of CHF
- Pre-Op insulin use
- HZ of ischemic heart dz
- Pre-Op Cr>2
102
What are high risk surgeries?
- Intrathoracic
- Intraparetoneal
- suprainguinal vascular
103
pathophysiology of Graves dz
autoimmune process where patient makes TSH receptor antibodies...therefore TSH is "low" resulting in clinical hyperthyroid.
***MC cause of hyperthyroid
104
Physical exam findings specific to Graves dz
1. thyroid bruits
2. Opthalmopathy (lid lag, proptosis, exophthalmos)
3. Pretibial Myxedema (nonpitting, edematous pink/brown plaques)
**diffuse radioactive iodine uptake
105
Arrythmia associated with thyroid storm
A fib
106
treatment for thyroid storm
1. PTU or mithimozole (prevents conversion)
2. BB (slow you down) DO THIS FIRST
3. IV glucocorticoids (prevents concersion)
107
What level of thyroid hormone do most people with thyroid cancer present in
euthyroid
108
What are the 4 types of thyroid cancer
1. papillary, only local mets, good prog.
2. follicular, distant mets, good prog
3. medulary,MEN2 association, secrete calcitonin
4. anaplastic , older men, rapid growth to invade trachea, most die in 1 yr and need tracheostomy
109
MEN2 syndrome is made up of what diagnoses
1. Hyperparathyroid
2. Medullary thyroid cancer
3. Pheochromocytoma
110
MEN1 syndrome is made up of what diagnosis
1. Hyperparathyroid
2. Pancreatic cancer
3. Pituitary tumor
111
Hallmarks of Toxic multi nodular Goiter (aka plumber's dz)
- Functional palpable nodules, MC in elderly
- Clinical hyperthyoid, NO SKIN OR EYE changes (those are only in Grave's)
- Patchy areas of iodine uptake
- Treat with radioactive iodine, with surgery if symptoms persist
112
Risk factors for thyroid nodules
- extremes of age
- head/neck radiation
* *most in men and children are malignant
* **most in females are benign
113
Thyroid nodule presentation
- mostly asx
| - may have compressive s/s of difficulty swallowing or breathing
114
PE findings that would support a malignant thyroid nodule
- NO MOVEMENT WITH SWALLOWING, fixed in place, rapidly growing ,
- euthyroid, cold nodules are MC for malignancy
115
What is the most common type of thyroid nodule?
Follicular adenoma (colloid)
*these are benign
116
What is a pheochromocytoma?
catacholamine secreting adrenal tumor
*diagnosed by 24 hr urine catecholamines with elevated metanephrine and vanillylmandelic acid
117
Pheocromocytoma treatment
Adrenalectomy
**need alpha blockade with PHEnoxybenzamine or PHEntolamine x2 weeks pre-surgery
BB post surgery
118
Causes of hyperparathyroidism
PRIMARY: parathyroid adenoma or hyperplasia
***occurs in 20% of people taking LITHIUM
SECONDARY: caused by CKD
119
Lab values used to confirm primary hyperparathyroid
- High PTH
- High Ca
- Low phosphorus
120
An adrenal adenoma would present as what endocrine disorder
Cushing's syndrome
121
What is the most common type of skin cancer in the US?
Basal cell carcinoma
122
Clinical manifestations of Basal Cell Carcinoma
- small, raised translucent pearly waxy papule with central ulcerations **
- They are found in sun exposed areas
- Often bleed easily (friable)
- Slow growing, invade locally with little mets
123
Basal Cell Carcinoma tx
- electrodesiccation/curettage
| - Mohs micrographic surgery in those that are recurrent of difficult
124
Layers of the skin impacted by cellulitis
dermis and subcutaneous tissue
**not well demarcated!
125
MC causative organisms of cellulitis
S. Aureus MC
-GABHS (strep pyogenes)
126
Erysipelas
- Caused by GABHS
- WELL DEMARCATED, often on the face
- Treat with PCN
127
Lymphangitis
spread of cellulitis through the lymph vessels leaving streaking
128
Medical management of cellulitis
Cephalexin; dicloxacillan
129
Hallmarks of malignant melanoma
- Highly aggressive!! High METS
- 80% associated with UV radiation exposure
- MC skin cancer related death
130
Malignant melanoma clinical manifestations
```
A-asymetry
B- borders irregular
C- color varied (blue, black)
D-diameter >6mm
E-Evolution
```
131
what is the most important prognostic indicator for METS of malignant melanoma?
THICKNESS
132
Dx and tx of malignant melanoma
DX: full thickness wide excision bx + lymph node bx
TX: complete wide surgical excision
133
What is bowen's disease?
squamous cell carcinoma in situ; slow growing and rarely mets
134
Hallmarks of squamous cell carcinoma
- 2nd MC skin cancer after basal cell
- Often preceded by ACTINIC KERATOSIS, or HPV infection
- malignancy of the keratinocytes resulting in hyperkeratosis and ulceration
- RED thick nodules with WHITE scaly, bloody margins
135
Rule of 9's
Skin burn surface area grading as follows:
- Head 9% total
- 1 Arm 9% total
- Upper torso (front and back total) 18%
- Lower torso (front and back total ) 18%
- 1 Leg 18% total
- Genitalia 1%
136
When is an escharotomy recommended?
For circumferential burns to prevent compartment syndrome
137
Antibiotic use in burns
- Use topical if it is a non superficial burn
- Silver sulfadiazine is commonly used (CI in sulfa allergy, face, preggo, <2 months old)
-Bacitracin used for superficial burns
138
Parkland fluid resuscitation formula for burn patients
4mL x kg x % BSA= amount of lactated ringers
*Give 1/2 in first 8 hrs, then the rest over the next 16 hours
139
Types of burns
1) Superficial (1st deg): epidermis, sunburn
2) Superficial Partial Thickness: (2nd deg)
- epidermis + superficial dermis (papillary)
- BLISTERS, moist and weeping
- most painful of all burns
- 14-21 days to heal
3) Deep Partial Thickness: (2nd deg)
- epidermis+ deep dermis (reticular)
- dry, pale white and yellow, blisters
- NO PAIN
- absent capillary refill
- Up to 2 months recovery; scarring common
4) Full Thickness Burn: (3rd deg)
- entire skin
- waxy, white, leather
- Painless with no blanching
5) 4th degree burn:
- into bone and muscle
- Black, charred
140
Pressure Ulcer staging
Stage I: superficial, nonblanchable redness
Stage II: epidermal into dermis, resembles abrasion or blister
Stage III: full thickness of skin with sub Q
Stage IV: extends beyond fascia to muscle, tendon, bone
141
Ulcer management
Wet to dry dressings
stages 3, 4 may need surgical debridement
142
Hallmarks of SAH
- Sudden onset of "worse headache of my life"
- Arterial bleed between arachnoid and pia matter (MC berry aneurysm rupture or AVM)
- stiff neck, photophobia, delirium, possible LOC
- Diagnosed by CT, if inconclusive then LP showing xanthochromia
- Gradually lower BP gradually with nicardipine
143
Epidural hematoma
- arterial bleed between skull and dura
- Often middle meningeal artery after temporal bone fracture
- LOC, lucid period, coma, n/v
- lConvex, lens shaped bleed that does NOT cross suture lines
144
Subdural Hematoma
Venus bleed between dura and arachnoid
- MC in elderly, tearing of cortical bridging veins
- MC blunt trauma
- Concave, cresent snapped bleed that DOES cross suture lines
145
Anterior Chord Syndrome
- lower extremity motor deficit
- loss of pain and temp sensation
- bladder dysfunction
- commonly caused by flexion compression
146
Central Cord Syndrome
- upper extremity motor and sensory deficits in a SHAWL like distribution (esp. hands)
- loss of pain and temp
- Caused by extension injuries
147
Brown Sequard Syndrome
- Ispilateral motor and proprioception deficit
- Contralateral pain and temp deficit
- Caused by penetrating injuries
148
Posterior Cord Syndrome
loss of proprioception and vibration only
149
An infarct in which part of the brain would cause speech impediments
LEFT hemisphere
150
Causes of a prolonged PTT
- Issues with the INTRINSIC pathway
- Factors 8,9,11,12
- Heparin, vWD, hemophilia
151
Causes of prolonged PT
- Issues with EXTRINSIC pathway
- Factors 7, 10
- Warfarin, vitamin K
152
Pathophysiology of TTP
Antibodies against ADAMTS13 causes a low level. ADAMTS13 is used to cleave vWF, so with this low level there is a lot of free vWF resulting in platelet sequestration
153
TTP treatment
Plasmaphoresis
154
Pentad of thrombotic thrombocytopenia purpura
1) thrombocytopenia (petechiae, mucocutaneous bleed)
2) neuro s/s
3) microangiopathic hemolytic anemia
4) kidney failure
5) fever
155
Hallmarks of DIC
- Pathological activation of coag system
- Widespread micro thrombi with thrombocytopenia
- Caused by infection (gram - sepsis MC) , malignancy, obstetric complications, massive injury
- increased PT, PTT, PTINR, D-dimer
156
Hemophilia A Hallmarks
- Factor 8 deficinecy
- Intrinsic issue resulting in prolonged PTT
- hemarthrosis with excessive hemorrhage in response to trauma or surgery
-Tx with factor 8 infusion or desmopressin
157
Hemophilia B hallmarks
- Factor 9 deficiency
- intrinsic issue resulting in prolonged PTT
- deep tissue bleeding
-factor 9 infusion , NO desmopressin
158
Von Willebrand Disease Hallmarks
- Ineffective platelet adhesion due to autosomal dominant issue with vWF
- Mucocutaneous bleeding, PETECHIAE
- Intrinsic issue resulting gin prolonged PTT
- VWF, Factor 8, desmopressin for tx
159
American Society of Anesthesiologists (ASA) Classes
ASA 1—patient with no systemic disease
ASA 2—pt with mild systemic disease
ASA 3—pt with severe systemic disease that limits activity
ASA 4—pt with incapacitating disease that is a constant threat to life
ASA 5—pt is moribund and not expected to survive 24 hours
160
Cardiac Meds that can be continued the day of surgery
BB, A2 agonist, CCB, statin
161
GI meds that can be continued the day of surgery
H2 blocker, PPI
162
When to hold anticoagulants ?
ASA-7 days
anti-platelets: 7 days
NOAC: 3 days high risk, 2 days low risk
Coumadin: stop 5 days prior and bridge with heparin
163
How long should you hold SSRI before surgery ?
3 weeks
164
Post op fluid management
4:2:1 Rule
- 4mL/hr for the first 10 kg
- 2mL/hr for the next 10kg
- 1mL/hr for additional kg
165
Post Op fluid resucitation in an elderly patient
25 mL/kg in a 24 hr period
166
When is dialysis indicated
GFR <10
| Cr >8
167
What surgery predisposes a patient to hypomagnesemia ?
small bowel bypass
168
How does hypomagnesemia present?
Signs of hypocalcemia
Neuro s/s: increased DTRs, tetany, AMS, cramps
Torsades
169
Treatment of hypomagnesemia
magnesium sulfate
170
How does hypermagnesemia present?
N/V, flushing, dizziness, decreased DTR, muscle weakness
May show EKG signs of hyperkalemia
171
MC causes of hypermagnesemia
1) Renal Insufficiency
| 2) increased Mg intake
172
Treatment of hypermagnesemia
IV fluids, furosemide (mild to moderate)
Calcium gluconate ( severe)
173
Hypokalemia findings
K<3.5
Muscle weakness, rhabdo, decreased DTR, nephrogenic diabetes insipidus
Flattened T waves/U waves
* INCREASED RISK OF DIGOXIN TOXICITY
174
Causes of hyperkalemia
***psuedohyperkalemia: MC cause... this is a lab error where vile was shaken... not true hyperK
1) AKI or CKD: decreased excretion
2) Meds: k sparing diuretics, ACE, BB, NSAID
3) decreased aldosterone: adrenal insufficiency
4) Cell lysis
5) metabolic acidosis
175
Hyperkalemia findings
K>5
Ascending weakness, paresthesias, flaccid paralysis
Peaked T waves
176
To of uncomplicated UTI
- Nitrofurantoin (macrobid) *used in pregnancy
- fluoroquinolone *DOC in pyelo
- Bactrim
** 3 days is normal dose!
177
Do not exceed this rate of sodium replacement for a patient with hyponatrimia
no faster than 0.5 mEq/L per hour to prevent central pontine myelinolysis
178
Clinical symptoms of hyponatremia
faitgue, headache, n/v, cramps, seizures, coma, respiratory arrest
179
Two man categories of testicular cancer
1) Germinal cell tumors:
- seminoma
- nonseminomatous
2) Nonterminal Cell Tumors:
- Leydig cell tumor
- Sertoli cell tumor
180
Characteristics of seminoma type testicular cancer
-MC in men 30-30, useually malignant
Simple; normal tumor markers
Sensitive; to radiation
Slow; slow to grow
Stepwise spread
-Treat with orchiectomy and radiation (+ debunking chemo if severe)
181
Characteristic of nonseminomatous testicular cancer
- Germinal Cell type
- + alpha fetoprotein, inc. B-HCG
- RADIORESISTANT
182
Presentation of renal cell carcinoma
1. hematuria
2. flank pain
3. palpable mass
-left sided varicocele, HTN, hypercalcemia
183
Where is a renal cell tumor located?
Proximal convoluted renal tubule cells
184
Risk factors for renal cell carcinoma
- smoking
- dialysis
- HTN
- obesity
- men
185
What is the MC type of bladder cancer?
Transitional cell is 90%
186
Risk factors for bladder cancer
SMOKING
- occupational exposure to dyes, rubber, leather
- 3x more common in white males
187
2 medications with an increased risk of bladder cancer
- Cyclophosphamide
| - Pioglitizone
188
dx & tx of bladder cancer
- Painless gross hematuria
- cystoscopy with bx
- transurethral resection
- radical cystectomy if invasive
- intravesicular BCG vaccine if recurrent
189
What is another name for wilms tumor?
nephroblastoma
190
Hallmarks of Wilms tumor
- MC abdominal malignancy in children
- 1st 5 years of life
- MC presents as a painless palpable mass that doesn't cross the midline
- Hematuria, HTN, anemia, n/v
191
dx and tx of Wilms Tumor
1st ultrasound
2nd CT or MRI contrast
-Nephrectomy followed by chemotherapy (90% cure rate)
192
Risk factors for kidney stones
```
Dec. water intake
male sex
medications (loop, antacids, chemo)
gout
PCKD
UTI (with urea splitting organisms)-Struvite
```
193
4 types of kidney stones
1) calcium (normal ph)
2) Uric acid (high protein foods, acidic)
3. Struvite (urea splitting bacteria, alkaline)
4. Cystine stones (congenital, acidic)
194
What are the urea splitting bacteria?
Proteus, klebiella, pseudomonas, serratia, enterobacter
195
Nephrolithiasis location and associated pain
Proximal ureter: flank pain
Midureter: midabdominal pain
Distal Ureter (VUJ) : groin pain
196
Which stones appear on KUB?
calcium, struvite
197
How to treat nephrolithiasis
IF LESS THAN 5mm:
- IVF, analgesic, antiemetics
- Tamulosin **
IF GREATER THAN 7mm:
- extracorporeal shock wave lithotripsy
- uretoscopy with stent (immediate relief)
- Percutaneous nephrolitotomy (over 10mm or strive stone)
198
What is the narrowest point of the urinary tract?
ureterovesicular junction
199
Etiologies of toxic colon
- IBD
- ischemic cholitis
- infective cholitis
- diverticulitis
- volvulus
- obstructive colon cancer
200
Management of toxic mega colon
IVF
Fix underlying dz
Vancomycin and metronidazole
NG rube decompression and bowel rest
201
Anatomical structures around a femoral hernia (through femoral canal)
- femoral vein laterally
- lacunar ligament medically
- coopers ligament below
202
How do you make the diagnosis of renal artery stenosis?
renal arteriography
203
Management of renal artery stenosis
1. angioplasty with stent for definitive management
2. ACEi
* *This is contraindicated if BOTH KIDNEYS INVOLVED
204
Where does lung cancer MET to?
```
Brain
bone
Liver
Lymph
Adrenals
```
205
3 types on non small cell carcinoma
1) adenocarcinoma
2) squamous call
3) large cell
206
Key features to non- small cell adenocarcinoma
- MC type in nonsmokers and females
- PERIPHERAL
- presents with gynecomastia
* surgical resection
207
Key features to squamous cell carcinoma
- CENTRALLY located
- Cavitary lesions
- hyperCalcemia
- pancoast syndrome (tumor at the superior sulcus causing :
1) shoulder pain
2) horners syndrome
3) atrophy of hand muscles
208
Small cell carcinoma key features
1) SVC syndrome: dilated neck veins, facial plethora, prominent chest veins
2) SIADH(hyponatrimia)
3) Cushing syndrome
4) lambert Eaton syndrome (like MG but weakness improves with use)
* chemo is TOC no surgery
209
What is the MC cause of post op fever day 1?
Atelectasis
210
What does a pseudomonas infection look like?
blue green with a fruity smell
211
What types of fluid cause a pleural effusion
1) Purulent fluid (empyema)
2) Blood (hemothorax)
3) noninflected fluid secondary to bacterial pneumonia ( parapneumonic effusion)
4) lymphatic fluid (chylothorax)
212
Physics exam findings in a pleural effusion
DECREASED tactile fremitus,
DECREASED breath sounds
DULLNESS to percussion
213
CXR findings in pleural effusion
blunting of costophrenic angles
*Lateral decubitus film is best*
214
What is light's criteria for exudative effusions?
- LDH>.6
- Protein >.5
- LDH 2/3 upper limit of normal
215
Treatment of pleural effusion
1) treat underlying condition
2) Thoracentesis
3) Chest tube for drainage
4) Pleurodesis : obliteration of pleura space with talc (MC) or doxycycline
216
Tension pneumothorax Physical exam
JVP, pulsus paradoxus, hypotension
217
Fibrocystic breast disease presentation
-Tender, mobile nodules that change in size around the time of menstrual period
MC benign breast dz
-typically 30-50 y/o
218
What does fibrocystic breast disease look like on fine needle aspiration?
straw-colored fluid with no blood
219
Fibroadenoma of the breast presentation
- 2nd MC benign breast dz
- Late teens to early 20s
- NONtender, mobile, gradually grows over time, does not fluctuate with menstruation
220
Types of breast cancer
Infiltrative ductal carcinoma (MC)
Ductal carcinoma in situ
Infiltrative lobular carcinoma
Lobular carcinoma in situ
221
Presentation of breast cancer
Firm, non mobile, painless lump
- MC in upper outer quadrant
- Unilateral nipple discharge, may be blood
222
Pages disease of the breast
chronic eczematous itchy, scaling rash on the nipples and areola
223
Inflammatory breast cancer
red, swollen, WARM, itchy breast.
- often with Peau d'orange appearance due to lymphatic obstruction
- poor prognosis
224
Neoadjuvant Endocrine therapy for ER positive breast cancer
1) Anti-estrogen drugs
- Tamoxifen, Raloxifene
2) Aromatase Inhibitors
- Letrozole, Anastrozole
225
Neoadjuvant endocrine therapy for HER2 + breast cancer
Monoclonal Ab treatment
| -Trastuzumab (Herceptin)
226
Breast cancer screening
Mammography every 2 years if 50-74 y/0
227
Breast cancer prevention in high risk patients
SERM therapy with tamoxifen or raloxifene
228
How long post-op is dehissence MC?
5-8 days
229
Common causes of post-op hyponatremia
1) Excess Sodium Loss
- Thiazide diuretics
- Metabolic alkalosis
- Ketoacidosis
- Adrenal insufficiency
2) Artifact- uncommon
Hyperproteinemia
Hyperlipidemia
3) Excess water- very common
Ingestion or infusion of hypotonic fluids when isotonic fluids are lost, polydipsia
Physiologic response to surgical stress or hypovolemia
Catabolism of tissue damaged in surgery
SIADH
Advanced cardiac, renal or liver disease
230
Hyperkalemia treatment
- calcium gluconate
- 10 U regular insulin
- albuterol
- Amp D50
- Dialysis
231
What increases a patient's risk of post-op atelectasis ?
- COPD
- Obesity
- abdominal surgery
- Increased age
232
Signs of atelectasis
Post-op fever in the first 48 hrs
- Tachycardia
- Tachypnea
- Hypoxia
-may have pleuritic chest pain
233
Post-op pneumonia is often caused by what organisms?
- Gram negatives (which colonize the oropharynx)
| - often polymicrobial
234
Possible etiologies of Post-Op dyspnea
1) Pneumonitis: 2/2 aspiration of gastric secretions
2) Pnemothorax
3) Pulmonary Embolus
4) Extrapulmonary causes: acidosis, MI, sepsis, CHF
235
Hypoxic vs. Hypercapnic Post-Op respiratory failure
Hypoxic: failure of oxygenation; requires an increase in the Fi02
Hypercapnic: failure of ventilation ; requires an increase in the minute volume
236
Risk factors for development of a post op MI
1. hz of CHF
2. CAD
3. over 70 y/o
4. Surgery for arteriosclerosis manifestation
**hypoxia and hypotension in the post op period will predispose the patient to MI
237
What percentage of post of MI is asymptomatic
OVER 50 %
238
Ways to prevent Post-Op MI
1) postpone elective surgury 3-6 months after MI
2) aggressively treat CHF preoperatively
3) HTN controll
239
Most common cause of post op CHF?
- Excessive IV fluids to a patient with a limited myocardial reserve
* suspect in patient with hypoxia and dyspnea
240
Post-Op CHF presents with edema where?
sacral edema
241
Etiologies of post of hypotension
1. vasodilation from narcotics
2. blood loss
3. 3rd spacing of fluid
242
Causes of post op ileus
- anesthesia and surgical manipulation decrease gut action
| - worsened by opioids, infection, inflammation (pancreatitis) , pain
243
How long post of does it typically take for peristalsis and colonic function to return ?
Peristalsis: 24 hrs (at least 48 in abdominal laparotomy)
Colonic function: 3-5 days
244
Post-op ileus presentation and treatment
- n/v, obstipation, constipation, distension, pain
| - NG tube, and consult the surgeon
245
Who gets a foley pre op?
- operation over 3 hrs
- large IV fluid volumes to be given
- pt unable to ambulate post op
246
Definition of Oliguria
UOP <30cc/hr
OR
<400mL/day
247
What is the goal glycemic control on random glucose checks for a general surgery patient?
<180-200
**we let it be higher due to post op hypoglycemia
248
Signs of likely post op infection
- fever occurs over 48 hrs post op
- Pre-Op trauma
- Initial temp above 101.5
- leukocytosis over 10,000
- Post-op BUN of 15 or more
- Poor protoplasm
249
The 5 W's of post op fever
WIND: atelectasis, pneumonia, PE, aspiration with pneumonitis
WATER: UTI, IV infected
WOUND: infection, after day 4
WALKING: DVT, PE
WONDER DRUG
250
Drugs associated with post op fevers (wonder drug)
- Beta-lactamase antibiotics
- procainamide
- isoniazid
251
S/S of post op necrotizing Fasciitis
pain out of proportion to exam, swelling, fever, hemorrhagic skin bull, cellulitis
252
necrotizing fasciitis treatment
- aggressive surgical debridement at least within 6 hrs onset
- broad spectrum abx
- hyperbaric O2
253
Organisms Causing necrotising fasciitis
- Group A strep
- klebsiella
- E. coli
- other gram - bacteria
