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Flashcards in Osler, part 2 Deck (55):
1

HPI of pancreatic CA

Gradual onset
Pain in lower back or epigastric, straight through to back
Fairly constant, worse at night
Dull, gnawing, visceral quality
Better when sitting up or leaning forward or fetal position +/- worse with eating/laying supine

2

Related sx of pancreatic CA

Wt loss
Anorexia
Generalized malaise and weakness
New onset DM
Jaundice (early sign of pancreatic head due to bile duct obstruction)
Pruritis
Acholic stools
Dark urine

3

PE of pancreatic CA

Courvoisier's sign: Palpable, nontender, distended GB associated with jaundice
+/- hepatomegaly
+/- RUQ mass
Cachexia
+/- superficial thrombophlebitis

4

Signs of metastasis of pancreatic CA

Abdominal mass
Ascites
L supraclavicular LAD (Virchow's node)
Periumbilical mass (Sister Mary Joseph's node)
Palpable rectal shelf

5

Grey Turner's sign

Bruising of the flanks
Appears as blue discoloration
Sign of retroperitoneal hemorrhage

6

Workup for pancreatic CA

MRI
CT with IV contrast
ERCP: useful if obstructive jaundice, or sx without evidence of mass on CT
EUS (endoscopic u/s): clarification of small (<2 cm) lesions in neg/equivocal CT findings
CA 19-9: post-op monitoring
Tissue dx not necessary unless neoadjuvant therapy is planned

7

Purpose of Nissen fundoplication

Treats refractory GERD to prevent Barrett's esophagus

8

Pre-op evaluation of Nissen fundoplication

Most important test is upper endoscopy
Esophageal manometry
pH testing
UGI series
Esophagogram

9

HPI of GERD

In chest/throat
Burning
Severity around 5
Comes and goes
Wheezing, CP, dysphagia

10

Sx of GERD- refractory

Sore throat
Hoarseness
Trouble swallowing
Cough
Noncardiac CP

11

Indications for TURP or open simple prostatectomy

Acute urinary retention
Persistent or recurrent UTIs
Significant hemorrhage or recurrent hematuria
Bladder calculi secondary to bladder outlet obstruction
Significant sx from bladder outlet obstruction that are not responsive to medical or minimally invasive therapy
Renal insufficiency secondary to chronic bladder outlet obstruction

12

S/sx of prostate CA

Urinary frequency
Urgency
Nocturia
Hesitancy
Hematuria- uncommon presentation
Hematospermia- uncommon presentation

13

Major RF for prostate CA

Smoking
1st degree relatives also a RF

14

Labs/diagnostics for prostate CA

PSA levels
Prostate bx guided by TRUS

15

RFs for prostate CA

AA > whites
Genetic- BRCA2 mutation
Smoking
Diet- high red meat diet

16

USPSTF guidelines for prostate CA

Decisions about screening should be make on an individual basis after consultation with a provider (C Recommendation)
Recommends against PSA-based screening past the age of 70 (D recommendation)

17

Labs and decision making process for thyroid nodules- initial

Check TSH and T3/4
Order u/s

18

Labs and decision making process for thyroid nodules- low TSH

Order iodine uptake
If no increase uptake, then order FNA
If increased, so no FNA
Indeterminant: get FNA

19

Labs and decision making process for thyroid nodules- high or nl TSH

Cystic nodules need no further testing
Spongiform > 2 cm
Hyperechoic >1.5 cm
Hypoechoic >1 cm need FHx of thyroid CA

20

What should be done for thyroid nodules if you did not do an FNA?

F/u in 6-12 mos

21

In anaplastic thyroid CA, what is the tx?

Needs palliative surgery only

22

What categories of FNA bx are considered to be surgical?

FN/SFN
SFM
MGT

23

Labs for toxic multinodular goiter

Low TSH
High T3/T4
Order U/s
TSAb

24

When to do surgery for toxic multinodular goiter

If meds don't work or if having ocular sx

25

Sx of nonfunctioning goiter

Hoarseness
Dysphagia
Discomfort (esp when lying down)
SOB

26

Indications for tonsillectomy- absolute

Enlarged obstruction, dysphagia, sleep d/o, cardiopulm complications
Peritonsillar abscess unresponsive to medical management/drainage
Tonsillitis + febrile seizures
Tonsils requiring bx to define tissue pathology

27

Indications for tonsillectomy- relative

Persistent/foul taste or breath d/t chronic tonsillitis
Chronic/recurrent tonsillitis (seven in one year, five each in two years, or three each in three years) d/t strep, unresponsive to beta lactamase
Unilateral tonsillar hypertrophy, neoplasm

28

Surgical workup for tonsillectomy

Coagulation parameters
-FHx
--If neg- no coags needed
--If pos, coags needed
If malignancy- XR, CT, or MRI
Antibodies for streptolysin-O (ASLO)
Histology- only if CA suspected

29

Presentation of MI

May present as nl MI that we've learned, may also be a "silent" presentation (ex. women, diabetics, elderly)
Retrosternal CP radiating to jaw, down left arm, SOB

30

Labs/tests for potential CABG pt

EKG- T wave inversion is 1st sign
Troponins
CBC
CMP
Lipid profile
CXR

31

Cath lab results and CABG

Do a CABG if:
50% stenosis found in LCA
-3-vessel dz
Proximal LAD stenosis
Failure of PCI
CABG is better for diabetic pts than stenting

32

RFs of aortic stenosis

HTN
DM
Smoking
Hypercholesterolemia

33

Presentation of aortic stenosis

Usually asx until the development of syncope, angina and dyspnea/CHG when aortic valve is <1.0 cm
Narrowed valve leads to hypertrophied left ventricle

34

PE of aortic stenosis

Systolic ejection murmur that is harsh/rumbling crescendo-decrescendo
Murmur increases with squatting/leg raise, sitting and leaning forward. Decreases with valsalva/standing
Pulsus parvus et tardus: small, delayed carotid pulse
Narrowed pulse pressure
S4
Hand-grip maneuver- murmur will decrease

35

Disease that can cause aortic regurgitation

Rheumatic heart dz
Endocarditis
Bicuspid valve dz
Aortic root dz
Aortic dissection
RA
SLE
Myxomatous disease

36

PE of aortic regurgitation

Diastolic decrescendo blowing murmur heard at LUSB
Murmur increases with squatting, sitting forward, and handgrip. Decreases with Valsalva, standing. May radiate to LSB.
Austin-Flint murmur: bounding pulses. Wide pulse pressure

37

PE of chronic aortic regurgitation

Water hammer pulse
Swift upstroke and rapid fall of radial pulse accentuated with wrist elevation. May have S3 and rales

38

Presentation of mitral stenosis

Can present as right-sided heart failure, pulmonary HTN with hemoptysis, and a-fib

39

PE of mitral stenosis

Diastolic rumble at the apex
Opening snap, loud S1
Pulses usually reduced

40

Tx of aortic stenosis

Aortic valve replacement

41

Dx of aortic stenosis

Echo and cardiac cath

42

Dx of aortic regurgitation

Echo and cath

43

Tx of aortic regurgitation

Surgery is definitive and indicated in acute and symptomatic AR or symptomatic with EF <55%
Should have valve replacement

44

Dx of mitral stenosis

CXR and echo
CXR: left atrial enlargement
Echo: LAE, thick calcified valve, "fish mouth" shaped orifice

45

S/sx of mitral stenosis

DOE
Orthopnea
PND
Palpitations
CP
Hemoptysis
Thromboembolism
All sx will increase with exercise and pregnancy

46

PE of mitral stenosis

RVF (JVD, hepatomegaly)

47

Diseases where mitral regurgitation will present- acute

Endocarditis
Papillary muscle rupture
Chordae tendinae rupture

48

Diseases where mitral regurgitation will present- chronic

MVP
Rheumatic fever
Marfan syndrome
Cardiomyopathy

49

S/sx of mitral regurg

DOE
PND
Orthopnea
Palpitations
Pulmonary edema

50

PE of mitral regurg

Holosystolic murmur at the apex, radiates to the back or clavicular area
AFib is common
Diminished S1, widening of S2, laterally displaced PMI, loud palpable P2

51

Dx of mitral regurg

CXR and echo
Valve replacement must be performed if left ventricular function is too severely compromise

52

Cause of infective endocarditis

Most common d/t IV drug use, previous congenital or acquired cardiac lesions, immunocompromise, IV catheters

53

Presentation of infective endocarditis

Fever
Weakness
Night sweats
Anorexia
Murmur
Splinter hemorrhages
Osler nodes
Janeway lesions
Roth spots

54

Dx of infective endocarditis

BCx and echo revealing valvular vegetations

55

When is surgery indicated for infective endocarditis?

Reserved for prosthetic valve endocarditis, failure of medical management, life-threatening emboli, severe valvular insufficiency, obstruction, and CHF