Flashcards in Part 1 - Intro, 1, 2, 3, 4, 5, 6, 7 Deck (162):
28 y/o female -- what must you always consider in this patient?
The possibility for pregnancy.
Malignant Hyperthermia definition and best treatment.
MH is rare, AD inheritance. Associated with rapid rise in temp up to 40.6C (105F), usually d/t induction by general anesthetic (succinylcholine and halogenated inhalant gases).
Prevention is best treatment.
Why order a CBC?
Assess for Anemia, Leukosytosis (infection), and/or thrombocytopenia.
Why order U/A and urine cultures?
Assess for Hematuria when Ureteral stones, renal CA, or trauma is suspected.
How is IV Pyelography useful?
IVP uses dye to assess the concentrating ability of the kidneys, the patency of the ureters, and the integrity of the bladder.
Also useful in detecting hydronephrosis, ureteral stones, and ureteral obstructions.
What is the MCC of Serosanguinous unilateral breast discharge?
What is the main concern of Serosanguinous unilateral breast discharge?
Breast cancer. If more than one duct is involved or a breast mass is palpated, the most likely cause is breast CA.
(End of Intro)
33 y/o F with 3 cm palpable L breast mass. L axilla and R breast normal. Next step? Likely therapy?
Next step: Core needle biopsy. If malignant --> Stage (includes b/l mammo)
Likely Tx: Bx = CA then Stage IIa is most likely --> Surgery then Adjuvant Tx OR Neoadjuvant chemo to shrink and then breast-conserving surgery (lumpectomy).
Neoadjuvant chemo is best when cosmetics/breast preservation are desired.
If breast CA is confirmed, then the metastatic w/u should be what?
CBC, LFTs, CXR, and possibly breast MRI.
T/F FNA can differentiate b/w in situ and invasive tumors
False, it cannot.
T/F FNA can provide a histologic diagnosis.
False, FNA --> Cytologic diagnosis. Core needle biopsy --> Histologic diagnosis (can dx b/w in situ and invasive, receptor status).
Difference b/w adjuvant and neoadjuvant chemotherapy
Adjuvant: chemo or rad therapy FOLLOWING surgery.
Neoadj: Chemo PRIOR to surgery (for conservation via shrinkage).
Level 1, 2, and 3 axillary nodes
Level 1: lateral to pectoris minor muscles.
Level 2: Deep to PM m.
Level 3: medial to PM m.
What % of breast cancers are triple negative?
10-15%; more common in pre-meno and black women.
What are the 2 options for axillary lymph node staging?
SLNB (Sentinel lymph node bx) and ALNB (Levels 1 and 2 axillary lymph node bx).
Why is SLNB > ALNB for most patients?
SLNB has been shown to provide satisfactory staging of the axilla and produce less morbidity. If SLNB is + for mets, then ALNB can be done (and usually is).
When is systemic chemotx considered?
To patients at risk for or have known Mets (stages 3 and 4).
Why do majority of Stage 2 or greater breast CA pts get systemic chemotx?
Pts with Stage 2 brca have a 33-44% chance of recurrence of dz at 20 years with locoregional (surgery) control only.
ER/PR+ breast tumors are given what drug and for how long?
Tamoxifen (anti-estrogen) for 5 years. Can be given alone or after completion of adjuvant therapy.
Post-menopausal women with ER+ breast CA are given what ?
T/F RCTs have demonstrated that neoadjuvant tx is superior to adjuvant tx in terms of mortality benefit.
False, neoadj = adj in mortality rates, but neo improves breast conservation rate and better cosmetic results.
If FNA is postive for malignant cells, what's next best step?
Do core-needle bx to assess for histology (in situ vs invasive, assess receptor status).
Core needle biopsy shows invasive cancer and ALNB is positive. Next best step?
Assess for mets -- PET + brain MRI.
Radiation tx is indicated for a patient with [...]
...stage I dz treated by lumpectomy (BCT).
Addition of rads to lumpectomy for stage 1 breast cancer reduces recurrence rate [...]
...from 30% to 9%.
Post-menopausal woman and a non-lactating woman present with red, tender breasts. Can we assume breast cancer?
YES! They may have inflammatory breast cancer!
Mechanism of Inflammatory breast cancer?
Edema, redness, and tenderness caused by tumor occlusion of dermal lymphatic channels.
Tamoxifen is associated with development of what cancer?
Endometrial carcinoma. Tamoxifen is estrogen antagonist in breast and agonist in uterus.
Why would you do Mammography after a core-needle biopsy shows carcinoma?
To assess for other occult abnormalities (eg, in contralateral breast).
What are the Locoregional treatment modalities for breast cancer?
Surgery and radiation tx
What are the systemic treatment modalities for breast cancer?
Chemotherapy and antiestrogen therapy.
(End of Case 1)
48 y/o M w/ 4 month Hx of daily burning epigastric/substernal pain. Worse after eating and lying down. PPI has not helped. Also has sx of reactive airway disease and hoarseness.
GERD with silent aspiration and pharyngitis.
decreased LES fxn, impaired esophogeal clearance, excess gastric acidity, diminished gastric emptying, and abnormal esophogeal barriers to acid exposure.
Complications of GERD?
Peptic stricture, Barret esophagus, and Extra-esophageal complications.
How many pts with GERD on PPIs get sx relief?
>95%. So if there's no sx relief, look for other causes and/or confirm GERD.
How can you confirm GERD?
Define Manometry and pH monitoring.
Combined procedure in which a small electronic pressure transducer is swallowed by the pt to be positioned in the vicinity of the LES. The most commonly used pH monitor involves a 24-hr ambulatory device that measures pH at 5 cm above the LES.
What are the extra-esophageal complications of GERD?
Caused by pharyngeal reflux and silent aspiration; include Reactive airway dz, laryngitis, recurrent PNA, and pulmonary fibrosis.
T/F When the LES is abnormally located in the chest, as with a hiatal hernia, the antireflux mechanism may be compromised in the GE junction.
What patients (with GERD) require further w/u?
Those with long-standing or atypical symptoms (wheezing, cough, hoarseness), recurrence of dz after cessation of medical tx, or unrelieved sx when taking max-dose PPIs.
What is the standard w/u prior to surgical anti-reflux procedure?
3. 24-hr pH probe testing
4. Barium esophagography.
What are the treatment options for GERD pts ?
1. Behavioral therapy
2. Medical therapy
3. Surgical therapy
4. Endoscopic therapy.
What are the behavioral tx options for GERD pts?
Avoid caffeine, EtOH, and high-fat foods.
Avoid meals w/in 2-3 hours of bedtime.
Elevate head when sleeping.
Medical therapy for GERD?
PPIs are #1.
Antacids, H2-blockers, prokinetic agents.
Surgical therapy for GERD (persistent sx even w/ max dose PPI therapy)?
Laparoscopic or open anti-reflux procedure. Nissen fundoplication is MC procedure (fundus of stomach is wrapped around the distal esophagus and sutured.
Long-term success is >90%.
Endoscopic therapy for GERD?
1) Radiofrequency energy directed at the GE jxn.
2) Endoscopic endoluminal gastroplication.
[...] should be performed when pts have long standing GERD and their sx are refractory to tx.
T/F Long term efficacy of PPIs and Anti-reflux surgery in reducing esophageal cancer development appears to be equivalent.
What are the surgical indications for GERD?
1. Documented GERD w/ persistent sx while on max dose PPIs
2. cannot tolerate PPIs
3. don't wish to be on lifelong meds.
T/F Response to PPIs is clinically reliable for a diagnosis of GERD.
True! one of the rare times when you can look at treatment response to make a diagnosis.
What is the most reliable objective indicator of GERD?
24-hr pH monitoring.
T/F Barret esophagus will always progress to esophageal adenocarcinoma.
False, Barret esophagus is a metaplasia and reversible.
(End of Case 2)
43 y/o male presents w/ spontaneous thoracic esophogeal perforation (Boerhaave syndrome). The pt has a left pneumothorax and exhibits a septic process from the mediastinitis. Next step in mgnt?
Place chest tube (left), fluids, broad-spectrum Abx, followed by water-soluble contrast study of esophagus.
T/F Esophageal rupture is a surgical emergency.
When do most esophageal ruptures occur?
Iatrogenic (diagnostic/therapeutic procedures).
Most are d/t Endoscopy.
Spontaneous esophageal rupture (ie, non-iatrogenic or Boerhaave syndrome) occur at what rate?
15% (ie, less than iatrogenic).
Classic presentation of Boerhaave syndrome?
Acute onset of CHEST PAIN after an episode of vomiting.
Others: shoulder pain, SOB, mid-epigastric pain.
75% of pts w/ Boerhaave syndrome present with [...] indicating disruption of mediastinal pleura.
How does Boerhaave's syndrome lead to mediastinitis and chest pain?
Contamination of mediastinum w/ esophageal luminal contents.
How come most (2/3) of the pleural effusions seen in esophageal rupture occur in left lung?
...because most spontaneous ruptures occur in DISTAL THIRD of esophagus above the GE jxn.
(20% occur on right side)
What is the most common presenting symptom of spontaneous esophageal rupture?
Shoulder and abdominal pain are less common.
What is the order that you would expect to see symptoms with someone w/ spontaneous esophageal rupture?
1. Chest pain (immediate)
2. SubQ emphysema (1 hr)
3. Pleural effusion on CXR (immed or late [>6hr])
4. Fever, leukocytosis (>4 hr)
5. Death (usually late diagnosis)
From what can sepsis occur in esophageal rupture?
Sepsis from mediastinitis.
What is the best initial diagnostic test to confirm an esophageal rupture?
Water-soluble contrast esophagram. Identifies 90% of perfs.
Clinical triad of spontaneous esophageal rupture?
1. Chest pain after vomiting.
2. SubQ emphysema on PEx
3. Left pleural effusion on CXR.
Which test is more sensitive in diagnosing esophageal rupture?
Barium study > Water-soluble (Gastrografin).
So why is water-soluble study preferred over barium study?
Ba study --> Ba leak --> mediastinitis and peritonitis.
Do Ba study if water-soluble study fails.
What is the most important factor that determines the outcome in esophageal perf?
The duration b/w the event and the corrective surgery. Delay is associated increased risk of infection and sepsis.
When the esophageal perforation is less than 24 hours old, what is generally done?
Primary esophageal surgical repair.
(End of Case 3)
30 y/o male has a suspicious pigmented skin lesion on his left shoulder. Has been present for several months, increased in size and darkened over time.
Most likely Dx?
Next best step?
Best Tx plan?
MLDx: Malignant Melanoma.
Next best step: Excisional biopsy.
Best Tx plan: Wide-local excision w/ appropriate clear margin. Evaluation and excision of the regional lymph nodes may be appropriate depending on the DEPTH of the tumor.
B: Border irregularity
C: Color change
Define Malignant melanoma staging
Surgical staging procedure that depends on:
1. Depth of invasion
3. Lymph node status.
What are the genetic risk factors of Melanoma?
Fair skin, red hair, white, more than 20 nevi on body, blue eyes, easily burned/can't tan, familial cases, prior hx of Melanoma.
What are the environmental risk factors of melanoma?
UV B sunlight, Areas near equator, First sunburn at young age.
What are the 4 types of melanoma?
1. Superficial spreading.
2. Nodular sclerosing.
3. Lentigo maligna.
4. Acral lentiginous.
What is the MC type of melanoma?
Superficial spreading (70%).
Which melanoma type is more common in "minorities" -- blacks, hispanics, and asians?
Acral lentiginous (palms/soles, nails).
T/F Nodular sclerosing type has a poor prognosis.
True. Partially b/c it has vertical progression.
The incidence of melanoma is directly related to [...]
Where are melanocytes found histologically?
Where are melanocytes found grossly?
choroids of eye
mucosa (GI, Respiratory tracts
lymph node capsules
What is the Breslow method of microstaging?
Based on depth of melanoma invasion, which is the vertical height from the granular layer to the area of deepest penetration.
What is the 5-year survival rate for stage I melanoma with a thickness of <0.75 mm?
What do each parameters (letters) of the TNM staging mean?
T = Thickness and ulceration
N = Metastatic nodes and metastatic nodal mass (micro vs macro)
M = metastatic sites and LDH levels
When would you consider doing a prophylactic lymph node dissection for possible metastatic melanoma?
Pts w/ INTERMEDIATE-depth (0.76 - 4 mm). This shows that even pts w/o clinical evidence of lymphedenopathy could benefit from it.
Stage I and II melanoma benefits from [...]
surgical intervention, but not significantly from adjuvant therapy.
Stage 3 melanoma benefits from [...]
adjuvant therapy (Interferon-2A), but poorly tolerated.
Although stage 4 melanoma prognosis is dismal (6-9 months survival), the FDA approved [...], which has a decent efficacy.
High dose Interleukin-2. Has a known complete, durable response rate of 9% and partial response rate of 8%.
(End of Case 4)
63 y/o male with HTN complains of a 6-month hx of difficulty voiding and feeling as if he cannot empty his bladder completely. Had 2 Cystitis episodes in the past. denies dysuria, urgency and does not have urethral d/c.
MLDx? Best therapy?
MLDx: Benign prostatic hyperplasia
Best therapy: Transurethral prostatectomy (TURP)
What is the physiologic fxn of the prostate?
Produce the ejaculate that serves as the "vehicle" for spermatozoa.
What are some symptoms of BPH?
Sx of urinary (bladder) outlet obstruction:
1. frequent urination but w/ small amounts.
2. incomplete voiding feeling.
3. slow flow.
6. extreme form - urinary retention
Mimics of BPH?
1. Urethral stricture disease
2. UTI (including prostatitis)
3. Prostate CA
Pt presents w/ prostatism sx. Next steps?
H and P
ROS for neurologic abnormalities (eg, Parkinson's)
U/A (exclude UTI and microscopic hematuria)
PSA blood test
Creatinine (renal fxn)
DRE for size and nodules
What are the MEDICAL options for BPH?
Initial tx is medical for newly diagnosed BPH:
alpha-1-antagonists and 5-alpha-reductase inhibitors.
What are some alpha-1-antagonists used for medical therapy of BPH?
Prazosin, terazosin, doxazosin, Tamsulosin.
How do alpha-1-antagonists work?
cause relaxation of prostate smooth muscle, thereby increasing the functional diameter of the urethra.
Example of 5-a-reductase inhibitor
blocking testosterone conversion to DHT --> involution of prostate glandular tissue and shrinkage of the overall size of the prostate.
What is the surgical procedure done if medical therapy fails for BPH?
TURP = Trans-Urethral Resection of Prostate
After TURP is done, what is the next step in management?
Pt needs to be monitored thereafter for response to therapy b/c residual glandular tissue will continue to grow.
T/F BPH can lead to prostate carcinoma
False, they are not pathologically related, although age of onset of these 2 overlaps and both can co-exist in the same patient.
(End of Case 5)
Pt has sx, sy, and rad evidence of high grade mechanical small bowel obstruction.
Place NGT to decompress stomach,
Begin fluid resuscitation,
Place Foley catheter to monitor uop and assess his response to fluid rescucitation.
What are the complications of a mechanical SBO?
Lead to strangulation, bowel necrosis, and sepsis. Vomiting may result in Aspiration Pneumonitis.
When unrecognized or untreated, intravascular fluid loss (from 3rd space fluid loss and vomiting) can lead to prerenal azotemia and acute renal insufficiency.
What's the probable therapy for mechanical SBO?
Exploratory lap after fluid resuscitation.
Mechanical SBO may result from prior abdominal surgery bc...
...intra-abdominal adhesions may result.
A change in pain pattern from what to what makes a possible SBO concerning?
Intermittent pain to persistent pain
What may SBO with persistent abdominal pain signify?
Severe bowel distention (which may produce venous congestion, decreased bowel perfusion, and necrosis)
Bowel ischemia secondary to strangulation.
What vital signs and lab finding indicate complicated SBO?
Fever, tachycardia, leukocytosis.
Radiographic evidence of complicated SBO?
Dilated small bowel with air-fluid levels and "high-grade" SBO
How does depletion of intravascular volume occur?
Mechanical SBO --> decrease bowel absorptive fxn --> accumulation of fluid in bowel lumen and wall, in addition to transudative extravasation of fluid into peritoneal cavity.
Net result of fluid shifts is Depletion of intravascular volume and decreased perfusion of all organs.
Because of fluid shifts caused by mechSBO, what's an important treatment goal?
General anesthesia is volume depleted pt can lead to what?
Profound hypotension. Therefore give fluids PRIOR to operation.
Why put an NGT for mech SBO?
Prevent vomiting and aspiration.
Define closed-loop obstruction
Develops when intestinal blockage occurs at both the proximal and distal ends of bowel segment.
Example of closed-loop obstruction
Small bowel incarcerated in a tight hernia defect and intestinal volvulus. This situation is associated with more rapid progression to strangulation, and it's unlikely to resolve without operative therapy.
Distention of small bowel and/or colon from non-obstructive causes.
Aka Functional obstruction (as opposed to anatomical)
What are common causes of Ileus?
Local or systemic inflammatory or infectious processes,
Variety of metabolic derangements,
Recent abdominal surgery,
Adverse effect of meds.
Define internal hernia
Congenital or acquired defect within the peritoneal cavity that can lead to SBO.
Define gallstone Ileus.
Mechanical obstruction of small bowel bc of large gallstone(s) in bowel lumen.
When does gallstone Ileus occur?
Occurs when a stone or stones in GB enter adjacent duodenum.
Clinical presentation of Gallstone Ileus.
INTERMITTENT bowel obstruction for several days until stone lodges into distal bowel and causes complete obstruction.
Causes of Mechanical SBO in young PEDS pt (6)
SBO in adult most commonly due to...
Does a presence of bowel movement rule out SBO? Why or why not?
No it does not bc stimulation of peristalsis with evacuation of DISTAL GI contents.
What is a "high-grade" SBO?
Nearly complete or complete obstruction where there may be cessation of flatus and stool passage FOLLOWING initial bowel movement.
Pt with SBO has what finding on abdominal exam?
T/F Successful NGT decompression improves the nonspecific (diffuse) abdominal pain of uncomplicated SBO pt.
T/F localized abdominal pain in suspected SBO pt my indicate severe disease and ischemic bowel.
Possible ischemia but not specific. Finding is suggestive.
DRE of SBO pt shows...
Little or no stool in rectal vault bc continued of peristalsis and evacuation of stool from distal bowel.
The finding of large stool in rectum on DRE in suspected mechanical SBO pt suggests...
Unusual finding and may suggest ILEUS (non-obstructive/mechanical) as cause of distention.
Proximal SBO vs Distal SBO
Proximal SBO - more vomiting, less distention, little air filled bowel on XR.
Distal SBO -- less vomiting, more distention, fluid filled with little air.
Complications of distal SBOs.
Bacterial overgrowth and lead to feculent vomitus.
Further intra-abdominal and pulmonary (aspiration) infectious complications.
Labs for SBO
CBC with differential, serum e-, amylase, U/A, ABGs (select pts).
SBO pt with mild leukocytosis (10-14K). What happens to lc with treatment?
Why is persistent leukocytosis after hydration a concern?
It should raise suspension of complications and may mandate early surgical intervention or an additional diagnostic evaluation.
Elevated amylase is seen with what ?
Pancreatitis and with Complicated SBO.
CT is recommended when?
Functional obstruction (Ileus)
What's a diagnostic finding on CT for mechanical obstruction of bowel?
Identify transition from dilated to decompressed bowel.
What's the alternative radiographic study to a CT for possible bowel obstruction symptoms?
Upper GI and small bowel follow-through (UGI/SBFT) - can Dx bw mechanical obstruction and Ileus (functional obstruction).
Consequence of CT and UGI/SBFT?
They have contrast that goes into bowel lumen, thus may aggravate vomiting and contribute to aspiration.
What are the goals of suspected SBO pt evaluation?
1. Diagnose bowel obstruction
2. Identify factors that may indicate progression to Intestinal strangulation.
Treat uncomplicated, partial SBO from adhesions
Initial trial of NON-OPERATIVE therapy:
NPO, NGT, monitor fluid status, serial clinical exams, lab and radiographic f/u.
Absence of early improvement with non-operative tx should prompt further evaluation with ???
CT or UGI/SBFT to confirm the diagnosis and/or further define the obstruction for possible surgical therapy.
What is post-op SBO?
sx of mechanical SBO or Ileus developing within 30 days following abd operation.
Causes: adhesions, persistent inflammation.
How to tx post-op SBO?
SUPPORTIVE CARE + NGT:
Exact determination is not necessary b/c non-operative observation is the usual tx for both ileus and mech SBO. CT may be useful if you're thinking infection.
Pt had appy 25 days ago. Na 140, K 4.2, Cl 105, HCO3 is 16 today. What's going on (possibly)?
Anion-gap metabolic acidosis (Lactic acidosis) d/t ischemic bowel or severe fluid depletion.
T/F Many patients with SBO can be treated conservatively.
What are "conservative" treatment measures for SBO?
NPO, NGT, close monitoring of fluid status, serial clinical exams, lab and rad follow up, while frequently assessing for bowel ischemia and/or strangulation (surgical emergencies).
(End of Case 6, finally)
Carpal tunnel syndrome. Mechanism? Next step in therapy?
Mech: Median nerve compression --> axonal damage, narrowing of nerve and vessels (ischemia) --> paresthesias of radial 3 fingers and sometimes weakness; worse at night.
Best Tx: Nighttime splint and NSAIDs (aka CONSERVATIVE).
The median nerve in the carpal tunnel is dorsal to what ?
transverse carpal ligament.
where is the ulnar nerve relative to the transverse carpal ligament?
on ulnar side and ventral (closer to palm), so this ligament divides the 2 nerves.
Why are sx worse at night (theoretically)?
Hand edema and possible tenosynovitis.
Ratio of women to men?
3:1; pregnancy causes high volume state (~ edema) and they not uncommonly get CTS.
What physical exam tests/findings can be done?
Tinel sign (percuss) and Phalen maneuver (flex together towards gravity)
How often is CTS b/l?
Up to 50%.
X-ray useful why?
check for fractures or arthritis
Electrphysiologic study useful why?
compare median, ulnar sensory stimulation values and CONFIRM diagnosis.
Are CTs or MRIs ever needed?
A pt with possible CTS has equivocal EMG. Next best step?
MRI b/c it has highest Sn and Sp.
When is surgery indicated for CTS?
when conservative and medical therapy (splint, NSAIDs, local steroid injections) have failed.
Where is the ulnar nerve commonly compressed?
Not at the wrist! Fibromuscular groove posterior to the MEDIAL EPICONDYLE.