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Surgery > Pestana > Flashcards

Pestana Flashcards

1
Q

Do you deal with airway first or spine injury first?

A

airway

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2
Q

Intubation options in the setting of cspine injury? (2)

A
  • orotracheal w/o moving head

- nasotracheal over bronchoscope

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3
Q

Airway management options in maxillofacial injuries? (2)

A
  • cricothyroidectomy

- percutaneous transtracheal ventilation (not good for hyperventilation for CNS injury)

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4
Q

How to assess breathing?

A
  • breath sounds on both sides

- pulse ox

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5
Q

Causes of shock in trauma setting (3)

A
  • bleeding
  • pericardial tamponade
  • tension ptx
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6
Q

Treatment of hemorrhagic shock

  • in urban setting and penetrating trauma, ______ then ________
  • in all other settings, give _____ and _____ until urine output reaches ________ (don’t exceed CVP of _____)
A
  • surgery, then volume

- 2L LR, pRBC, 0.5-2 mL/kg/hr, CVP

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7
Q

trauma preferred route of resuscitation

A
  • 2 16-gauge peripheral IVs

- alternatives: percutaneous femoral vein or saphenous vein cutdown, tibial IO in kids

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8
Q

Which 2 trauma things are clinical diagnoses?

A

pericardial tamponade and tension ptx

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9
Q

management of pericardial tamponade?

A

-clinical diagnosis
prompt evacuation (pericardiocentesis, tube, window, open thoracotomy)
-fluid and blood while evacuation is being set up

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10
Q

management of tension ptx?

A
  • clinical diagnosis

- needle or tube decompression then chest tube

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11
Q

management of cardiogenic shock? what should you NOT do?

A
  • circulatory support

- DO NOT GIVE FLUID OR BLOOD

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12
Q

vasomotor shock presentation and management?

A
  • anaphylactic rxns, high spinal transection/high spinal anesthetic
  • flushed, pink and warm, low CVP
  • tx: drugs to increase PVR, fluids help
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13
Q

management of penetrating head trauma?

A

-requires surgical intervention

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14
Q

management of skull fxs?

  • closed linear
  • open
  • comminuted/depressed
A
  • closed linear- nothing
  • open- wound closure
  • comminuted/depressed- OR treatment
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15
Q

mgt of head trauma and unconscious?

A

head CT –> if negative and neuro intact, go home if family is responsible

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16
Q

signs of basal skull fx? (4)

A

raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind the ear

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17
Q

tx of basal skull fx?

A

-cspine imaging, no abx

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18
Q

3 ways trauma can cause neurologic damage

A
  1. initial blow
  2. hematoma causing midline shift- surgery may help
  3. increased ICP- medical measures can help
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19
Q

acute epidural hematoma presentation, dx, and tx

A
  • presentation: lucid interval then fixed and dilated ipsilateral pupil and contralateral hemiparesis with decerebrate posture
  • dx- lens shape on CT
  • tx- emergency craniotomy
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20
Q

acute subdural hematoma presentation, dx, and tx

A
  • bigger trauma, sicker pt, worse neuro damage
  • dx: CT shows crescent
  • tx:
    • if midline shift –> craniotomy
    • if no shift–> ICP monitor and prevent elevated ICP (hyperventilate, elevate head, diuretics)
    • sedation and hypothermia
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21
Q

diffuse axonal injury presentation, dx, and tx

A
  • more severe trauma
  • dx: CT shows diffuse blurring of gray white interface and multiple small hemorrhages
  • tx: prevent increased ICP
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22
Q

chronic subdural hematoma presentation, dx, and tx

A
  • elderly, alcoholics: mental function deteriorates over weeks
  • dx with CT
  • tx with surgical evacuation
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23
Q

penetrating trauma to neck… when is surgery needed? (3)

A
  • expanding hematoma
  • deteriorating VS
  • clear signs of esophageal or tracheal injury
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24
Q

gunshot to upper neck zone.. what to do?

A

arteriogram

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25
Q

gunshot to base of neck

A

arteriogram, esophagogram, esophagoscopy, bronchoscopy –> maybe surgery

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26
Q

stab wounds to ___ and ____ zones of neck in asymptomatic patients can be safely observed

A

upper and middle

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27
Q

in blunt trauma to neck, get cspine xrays if ______ or _______

A

neuro deficits, cspine tenderness

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28
Q

clean cut injury (knife blade) to spinal cord
paralysis and loss of proprioception ipsilateral
loss of pain contralateral

A

brown-sequard

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29
Q

burst fractures of vertebral bodies associated with _____ (spinal cord issue)

A

anterior cord syndrome

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30
Q

loss of motor and pain/temp on both sides

intact vibratory and positional sense

A

anterior cord syndrome

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31
Q

forced hyperextension of neck (rear end collision) associated with ______ (spinal cord issue)

A

central cord syndreom

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32
Q

paralysis and burning pain in UE

LE are fine

A

central cord syndrome

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33
Q

how to dx and treat spinal cord injuries

A

dx with MRI

tx with high dose steroids immediately after injury

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34
Q

how to tx rib fracture in elderly?

A

local nerve block to prevent atelectasis and pneumonia

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35
Q

moderate SOB, no breath sides on one side, hyper resonant to percussion. what is it?

A

plain ptx

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36
Q

how to dx and treat ptx?

A

CXR, place CT

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37
Q

how to dx and tx hemothorax?

A

dx with CXR

tx with CT (low)

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38
Q

indications for thoracostomy in hemothorax?

A

> 1500 mL drained initially OR

>600 mL drained in first 6 hours

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39
Q

sucking chest wound can cause _____

A

tension ptx

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40
Q

how to manage a sucking chest wound?

A

occlusive dressing that lets air out (taped on 3 sides)

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41
Q

how to tx pulmonary contusion?

A

fluid restriction
colloids > crystalloids
diuretics
monitor blood gases

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42
Q

flail chest associated with what other injury?

A

pulm contusion

seek out aortic injury

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43
Q

if you need to intubate someone with flail chest, what should you do first?

A

chest tubes bilaterally to prevent tension ptx

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44
Q

presentation of pulmonary contusion

A

deteriorating blood gases
“white out” of lungs
may appear up to 48 hours after the event

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45
Q

how to manage myocardial contusion

A
  • ECG monitoring
  • cardiac enzymes
  • tx the complications
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46
Q

which side does diaphragmatic rupture occur?

A

left side

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47
Q

how to evaluate traumatic diaphragm rupture?

A

laparoscopy

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48
Q

how to dx aortic injury in trauma

A
  • suspicion- first rib/scapula/sternum fxs
  • normal mediastinum –> CT
  • widened mediastinum –> aortogram if inconclusive CT –> surgical repair
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49
Q

workup for rupture of trachea

A

CXR confirms air –> bronchoscopy and intubation –> surgical repair

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50
Q

ddx for subcutaneous emphysema (3)

A
  • rupture of trachea
  • rupture of esophagus
  • tension ptx
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51
Q

sudden death in chest trauma patient who is intubated and mechanically ventilated. what is it?

A

air embolus

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52
Q

how to tx air embolus

A

trendelenberg with left side down

cardiac massage

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53
Q

clinical presentation of fat embolism

A
  • petechial rashes in axilla and neck
  • fever, tachycardia, low pot
  • respiratory distress, hypoxemia, bilateral patchy infiltrates
  • tx with respiratory support
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54
Q

gunshot wound to abdomen…

A

needs exlap

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55
Q

indications for ex lap in stab wounds

A
  • signs of clear penetration (ex. protruding viscera)
  • hemodynamic instability
  • peritoneal irritation
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56
Q

indications for ex lap in blunt trauma

A
  • peritoneal irritation

- hemodynamically unstable internal bleeding

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57
Q

3 places 1500 mL blood can hide in the body

A
  • abdomen
  • pelvis
  • thigh
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58
Q

best way to dx intra-abdominal bleeding?

A

CT scan

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59
Q

when to do CT scan? patient must be _____

A

hemo stable

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60
Q

if hemp unstable and source of bleeding is not clear, do a ____ or ______

A

DPL or FAST

-if either is positive, go to exlap

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61
Q

most common source of significant intra-abdominal bleeding in blunt abdominal trauma?

A

spleen

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62
Q

most common overall source of intra-abd bleeding in blunt and trauma?

A

liver

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63
Q

post-op splenectomy vaccines

A

pneumococcus
H flu
meningococcus

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64
Q

coagulopathy during surgery… what to do?

A

FFP and plts

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65
Q

coagulopathy + hypothermia + acidosis… what to do?

A

stop surgery, pack, and come back later

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66
Q

abdominal compartment syndrome

A

fluids and blood given during prolonged laparotomies –> cannot close at the end

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67
Q

how to avoid abdominal compartment syndrome?

A

cover with absorbable mesh or non absorbable plastic

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68
Q

POD2 s/p abdominal surgery: distension, retention sutures cutting through tissues, hypoxia (inability to breathe), renal failure from pressure on vena cava

A

abdominal compartment syndrome

tx by opening abdomen and placing temporary cover

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69
Q

how to tx pelvic hematomas

A

leave alone if not expanding

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70
Q

in pelvic fx, look for associated injuries….

A
  • rectum
  • bladder
  • vagina in women
  • urethra in men
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71
Q

how to manage significant bleeding in pelvic fxs

A
  • replace blood
  • external fixation
  • arteriographic emoblization
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72
Q

what does abdominal trauma + blood in urine mean?

A

urologic injury

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73
Q

gross hematuria must be investigated (T or F)

A

T

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74
Q

what to do with microscopic hematuria

  • asymptomatic adult
  • children
A
  • asymptomatic adult- no workup

- children- investigate and look for congenital anomalies

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75
Q

what to do with penetrating urologic injuries?

A

surgically explored and repaired

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76
Q

scrotal hematoma, pelvic fx, blood at meatus, high riding prostate… what is this?

A

urethral injury (men)

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77
Q

urologic injury- wants to void but not able to indicates _____ injury

A

posterior uretrhal

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78
Q

what to do with suspected urethral injury?

A

DO NOT INSERT FOLEY

-do a RUG

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79
Q

how to tx urethral injuries?

  • anterior
  • posterior
A
  • anterior- surgery

- posterior- suprapubic drainage and delayed repair

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80
Q

how to dx bladder injuries

A

retrograde cystogram

post-void films

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81
Q

how to tx bladder injuries

A

surgery + suprapubic cystostomy

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82
Q

what to do with kidney injuries

A

-assess with CT, manage w/o surgery

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83
Q

potential sequelae of renal injuries

A
  • AV fistula –> CHF

- renal artery stenosis –> renovascular HTN

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84
Q

what to do with scrotal hematomas

A
  • assess with sonogram

- no specific intervention needed unless testicle is ruptured

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85
Q

large penile shaft hematoma after vigorous intercourse… what is it and what do you do?

A
  • penis fx

- emergency surgical repair

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86
Q

penetrating injuries of extremities

  • not near major vessel
  • near major vessel, asymptomatic
  • obvious vascular injury
A
  • not near major vessel- tetanus
  • near major vessel, asymptomatic- arteriogram
  • obvious vascular injury- surgery
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87
Q

what order to repair?
bone
vascular
nerve

A

bone
vascular
nerve
+ fasciotomy

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88
Q

what’s the concern in crush injuries?

A

myoglobinemia
myoglobinuria
renal failure
compartment syndrome

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89
Q

how to prevent renal failure in crush injury?

A

vigorous fluids, osmotic diuretics, alkalinize the urine

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90
Q

how to tx chemical burns?

A

IRRIGATE!

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91
Q

how to tx high voltage electrical burns

A
  • may need debridement/amputation
  • fluids, osmotic diuretics
  • assess for ortho injuries
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92
Q

late complications of electrical burns (2)

A

cataracts

demyelinization syndromes

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93
Q

respiratory burn dx and treatment

A
  • dx with bronchoscopy
  • monitor blood gases to determine ventilator use
  • monitor carboxyhemoglobin –> if elevated, give 100% O2
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94
Q

rule of 9s

A

head- 1
trunk- 4
UE- 1 each
LE- 2 each

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95
Q

Parkland formula

A

Day 1: body weight (kg) x % burn (up to 50) x 4 cc RL + 2000 cc D5W
-infuse 1/2 first 8 hours, infuse 1/2 next 16 hours
Day 2: Half of the above. May use colloid

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96
Q

simple fluid maintenance for burns

A
  • start with 1000 mL/hr of LR on anyone with burns >20%

- adjust according to urine output (1-2 mL/kg/hr)

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97
Q

rules of 9s to babies

A

give one 9 from legs to head

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98
Q

leathery, dry, gray skin

A

3rd degree burn in adults

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99
Q

deep bright red babies

A

3rd degree burn in babies

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100
Q

burn fluid resuscitation for babies

A

4-6 mL/kg/%, use initial rate of 20 mL/kg/hr if burn exceeds 20% of body surface

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101
Q

burn care

A
  • tetanus
  • topical agents- silver (standard), mafenide (deep penetration)
  • IV pain meds
  • NG suction
  • after 1-2 days, intensive nutritional support
  • after 2-3 weeks, graft
  • rehab
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102
Q

when to do early excision and grafting

A

-limited burns (<20%) that are 3rd degree

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103
Q

all animal bites require what tx?

A

tetanus prophylaxis

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104
Q

bit by a provoked dog… what do you do?

A

observe the dog

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105
Q

bit by an unprovoked dog or wild animal… what do you do?

A 
kill animal and examine brain OR
rabies prophylaxis (immunoglobulin plus vaccine)
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106
Q

signs of snake envenomation

A

severe local pain
swelling
discoloration

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107
Q

what to do with envenomation

A
  • draw blood: type and crossmatch, coats, liver and renal fnc
  • tx with antivenin
  • no surgical excision or fasciotomy
  • splint extremity during transportation
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108
Q

black widow bite

A

N/V, severe generalized muscle cramps

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109
Q

how to tx black widow bite

A

IV Ca gluconate, muscle relaxants

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110
Q

brown recluse bite

A

skin ulcer with necrotic center and surrounding erythema

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111
Q

how to tx brown recluse bite

A

dabsone, maybe surgical excision and skin grafting later on

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112
Q

how to tx human bites

A

dirtiest bite of all…

  • extensive irrigation and deridement i nthe OR
  • specialized ortho care
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113
Q

uneven gluteal folds, easy to dislocate posteriorly and return to normal with click and snapping

A

developmental dysplasia of the hips

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114
Q

how to dx developmental dysplasia of the hips?

A

physical exam

if PE is equivocal, then do US

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115
Q

tx of developmental dysplasia of the hips

A

abduction splinting with pavlik harness for 6 months

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116
Q

hip pathology can show up with knee pain (T/F)

A

T

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117
Q

6 year old with insidious onset of limping, decreased hip motion, hip/knee pain, antalgic gait, guarded passive motion of the hip

A

legg perches disease

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118
Q

how to dx legg perthes

A

AP and lateal hip xrays

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119
Q

how to tx legg perthes

A

casting and crutches

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120
Q

avascular necrosis of the capital femoral epiphysis (aka ________)

A

legg perthes dz

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121
Q

legg perthes dz is an emergency (T/F)

A

F

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122
Q

chubby 13 y/o boy with groin/knee pain, limping, affected sole points toward other foot, limited hip motion, hip eternally rotate when it’s flexed

A

slipped capital femoral epiphysis

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123
Q

slipped capital femoral epiphysis is an orthopedic emergency (T/F)

A

T

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124
Q

how to dx slipped capital femoral epiphysis

A

xrays

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125
Q

how to tx slipped capital femoral epiphysis

A

surgical pinning of femoral head

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126
Q

septic hip is an orthopedic emergency (T/F)

A

T

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127
Q

toddler with febrile illness then refuse to move hip, hip is flexed, slight abduction, external rotation, elevated ESR

A

septic hip

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128
Q

how to dx septic hip

A

aspiration

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129
Q

how to tx septic hip

A

open drainage

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130
Q

little kid with febrile illness –> severe localized pain in a bone

A

acute hematogenous osteomyelitis

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131
Q

how to dx acute hematogenous osteomyelitis

A

bone scan; X-ray will not show it for a few weeks

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132
Q

how to tx acute hematogenous osteomyelitis

A

abx

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133
Q

varum is normal at what age?

A

up to age 3

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134
Q

persistent genu varum is most commonly what and what is the treatment?

A

Blount disease; tx with surgery

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135
Q

valgus is normal at what age?

A

age 4-8

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136
Q

teens with persistent pain over tibial tubercle, worse with quadriceps contraction
localized pain, no knee swelling

A

osgod-schlatter disease

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137
Q

how to tx osgood schlatter disease

A

cast 4-6 weeks

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138
Q

when is club foot seen?

A

at birth

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139
Q

how to tx club foot

A
  • serial plaster casts correcting the adduction, hind foot varus, and equinus
  • 50% are corrected but 50% need surgery at age 8-12 months
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140
Q

what kind of patient do you normally find with scoliosis?

A

teen girl

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141
Q

most common finding in scoliosis

A

thoracic spine curved to the right

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142
Q

how to dx scoliosis

A

look from behind as she bends over

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143
Q

scoliosis complications (2)

A

cosmetic deformity

lung function

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144
Q

how to tx scoliosis

A

bracing, may require surgery

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145
Q

degrees of angulation of fxs that would be unacceptable in adults may be okay when reduced and immobilized in children (T/F/)

A

T

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146
Q

areas where children have issues healing bone (2)

A
  • supracondylar fxs of humerus

- fxs involving the growth plate

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147
Q

hyperextension of elbow due to falling on extended arm may cause what fx?

A

-supracondylar fx of humerus

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148
Q

what do you worry about with supracondylar fx of humerus

A

vessel or nerve injury –> volkmann’s contracture

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149
Q

how to tx supracondylar fx of humerus?

A
  • casting or traction
  • monitor vascular/nerve integrity
  • monitor for compartment syndrome
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150
Q

how to tx fractures of the growth plate

A
  • if epiphyses and growth plate are in one piece –> closed reduction
  • if growth plate is in 2 pieces –> ORIF to ensure alignment
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151
Q

primary malignant bone tumors are diseases of old people (T/F)

A

F

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152
Q

persistent low grade pain, sunburst and periosteal onion skinning on X-ray

A

primary malignant bone tumor

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153
Q

most common primary malignant bone tumor, age 10-25, usually around the knee

A

osteogenic sarcoma

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154
Q

second most common primary malignant bone tumor, age 5-15, diaphyses of long bones

A

ewing sarcoma

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155
Q

most malignant bone tumors in adults are metastatic

  • _______ in women
  • _______ in men
A

breast

prostate

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156
Q

how to dx metastatic bone tumors in adults

A

bone scan more sensitive –> if positive, get xrays

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157
Q

old men, fatigue, anemia, localized pain on several bones

A

multiple myeloma

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158
Q

X-rays show punched out lytic lesions, bence-jones in urine, abnormal immunoglobulins in blood

A

multiple myeloma

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159
Q

how to tx multiple myeloma

A

chemo

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160
Q

firm and died growth of soft tissue mass

A

soft tissue sarcoma

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161
Q

how to dx and tx soft tissue sarcoma

A

dx with MRI then incisional biopsy

tx with very wide local excision, XRT, chemo

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162
Q

X-rays looking for suspected fxs should include ___ views

A

2

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163
Q

clavicular fxs are treated with

A
  • place arm in a sling

- fixation for young women with displaced fxs for cosmetic reasons

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164
Q

arm is adducted and externally rotated

A

anterior shoulder dislocation

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165
Q

ant shoulder dislocation may injure what?

A

axillary nerve

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166
Q

how to dx shoulder dislocations

A

axially view or scapular lateral view xrays

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167
Q

posterior shoulder dislocations are _____ and are caused by ____ and _____

A

rare, seizure, electricity

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168
Q

arm is adducted and internally rotated

A

posterior shoulder dislocation

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169
Q

FOOSH in old woman, dinner fork deformity (dorsally displaced and angulated fx of distal radius)

A

colles fx

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170
Q

how to tx colles fx

A

close reduction and cast

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171
Q

diaphyseal fx of proximal ulna, with anterior dislocation of radial head

A

monteggia fx

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172
Q

fx of radius, with dorsal dislocation of radioulnar joint

A

galeazzi fx

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173
Q

how to tx monteggia and galeazzi fxs

A

ORIF of broken bone, closed reduction of dislocated bone

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174
Q

FOOSH in young adult, tenderness in anatomic snuff box

A

scaphoid fx

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175
Q

how to tx scaphoid fx

A
  • if non displaced and negative X-ray, thumb spica

- if displaced and angulated, ORIF

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176
Q

how to tx metacarpal neck fx (boxer’s fx)

A
  • mild displacement/angulation: close reduction and ulnar gutter splint
  • severe displacement/angulation: kirschner wire or plate fixation
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177
Q

hip fx happen to _____ who _______. Their leg is ______ and _______

A

old women who fall

shortened and externally rotated

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178
Q

femoral neck fxs are at high risk for _________

A

avascular necrosis of femoral head

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179
Q

how to tx intertrochanteric fx

A

open reduction and pinning, post op anticoagulation

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180
Q

how to tx femoral shaft fx

A
  • intramedullary rod fixation

- if open, ortho emergency! tx w/in 6 hours

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181
Q

complications of femoral shaft fx

A
  • may cause hypovolemic shock

- fat embolism

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182
Q

tx knee collateral ligament injuries with _______

A
  • hinged cast for isolated injuries

- surgery for several torn ligaments

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183
Q

valgus

A

medial injury

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184
Q

varus

A

lateral injury

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185
Q

how to tx ACL injury

A
  • immobilization, rehab for sedentary pts

- arthroscopic reconstruction for athletes

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186
Q

what imaging is used to dx knee injuries?

A

MRI

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187
Q

pain and swelling, catching, locking, click

A

meniscal injury

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188
Q

how to tx meniscal tear

A

arthroscopic repair

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189
Q

TTP over specific point, normal xrays

A

stress fxs

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190
Q

how to tx stress fxs

A

cast, repeat X-rays in 2 weeks, crutches

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191
Q

how to tx tibia and fibula fxs in peds vs auto

A
  • casting or intramedullary nailing

- monitor for compartment syndrome

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192
Q

out of shape middle age men, loud popping noise, limited plantar flexion, pain, swelling, limping

A

achilles rupture

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193
Q

how to tx achilles rupture

A

cast in equines position, surgery for quicker cure

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194
Q

what happens when ankle fx occurs?

A

both malleoli break

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195
Q

how to tx ankle fx

A

ORIF if displaced

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196
Q

2 common places for compartment syndrome

A

forearm, lower leg

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197
Q

pain, tight, TTP, excruciating pain with passive extension

A

compartment syndrome

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198
Q

how to tx compartment syndrome

A

emergency fasciotomy

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199
Q

knees hit dashboard, leg is shortened/adducted/internally rotated

A

posterior hip dislocation

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200
Q

how to tx posterior hip dislocation

A

emergency reduction to prevent avascular necrosis

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201
Q

deep penetrating dirty wound, pt looks sick/toxic, swollen, discolored, gas crepitation

A

gas gangrene

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202
Q

how to tx gas gangrene

A

IV penicillin, surgical debridement, hyperbaric O2

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203
Q

oblique fx of middle/distal humerus injures which nerve?

A

radial nerve

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204
Q

what to do if nerve paralysis develops/remains after reduction?

A

surgery

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205
Q

posterior knee dislocation can injure ____

A

popliteal artery

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206
Q

how to dx popliteal artery injury

A

pulses, doppler, arteriogram (if needed)

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207
Q

how to tx posterior knee dislocation

A

prompt reduction +/- prophylactic fasciotomy if revascularization is delayed

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208
Q

fall from height onto feet…. look for ____ and _____

A

foot/leg fxs

T or L spine fxs

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209
Q

head-on MVC…look for head, face, torso injuries but also ____ and _____

A

femoral head fx/dislocation

acetabular fx

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210
Q

facial fx and closed head injuries… look for _____

A

cspine issues

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211
Q

how to dx carpal tunnel

A

clinical (tap on median nerve), wrist X-ray to r/o other causes

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212
Q

how to tx carpal tunnel

A

splint, NSAIDs

may sometimes need surgery

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213
Q

finger is acutely flexed at night, “painful snap” if you try to forcibly extend it

A

trigger finger

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214
Q

how to tx trigger finger

A

steroid injection first

surgery as last resort

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215
Q

how to tx de quervain tenosynovitis

A
  • splint and NSAID
  • steroid works best
  • rarely need surgery
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216
Q

old norwegian man, contracture of palm, palmar fascial nodules

A

dupuytren contracture

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217
Q

how to tx dupuytren contracture

A

surgery

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218
Q

fingertip pulp abscess due to penetrating injury

A

felon

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219
Q

how to tx felon

A

urgent surgical drainage

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220
Q

ulnar collateral ligament injury due to forced hyperextension of thumb

A

gamekeepr thumb while skiing

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221
Q

how to tx gamekeeper thumb

A

cast, b/c arthritis can result if untreated

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222
Q

jerseyfinger

A

flexor tendon injury 2/2 forceful extension of flexed finger, issue with flexing the distal phalanx

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223
Q

mallet finger

A

extensor tendon injury 2/2 forceful flexion of extended finger, issue with extending

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224
Q

how to tx jersey finger and malletfinger

A

splint

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225
Q

months of discogenic pain + sudden neurogenic pain 2/2 forced movement, can’t ambulate, affected leg is flexed, pain with straight leg raise

A

lumbar disk herniation

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226
Q

how to dx lumbar disk herniation

A

MRI

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227
Q

how to tx lumbar disk herniation

A

bed rest

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228
Q

distended bladder, flaccid rectal sphincter, perineal saddle anesthesia…. what is it and what do you do?

A

cauda equina syndrome

-emergency surgery and immediate decompression

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229
Q

30-40 year old man with chronic back pain that is worse in the morning and improves with activity, “bamboo spine”

A

ankylosing spondylitis

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230
Q

how to tx ankylosing spondylitis

A

anti-inflam and PT

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231
Q

old person with progressive back pain that’s worse at night and unrelieved by rest/position, weight loss

A

metastatic malignancy

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232
Q

how to dx metastatic malignancy of the bone

A

bone scan more sensitive early on, later on can see on xray

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233
Q

diabetic ulcers are 2/2 ______ and ________

A

neuropathy and microvascular disease

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234
Q

ulcers at tips of toes that are pale/dirty, absent pulses, trophic changes, claudication

A

arterial insufficiency ulcers

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235
Q

how to work up arterial insufficiency ulcers

A

doppler to look for pressure gradients –> arteriogram –> surgical revascularization

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236
Q

chronically edematous, indurated, hyper pigmented skin above medial malleolus, cellulitis, varicose veins

A

venous stasis ulcers

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237
Q

how to tx venous stasis ulcers

A

support stockings, ace and ages, inna boot, maybe surgery

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238
Q

marjolin ulcer

A

SCC in chronic leg ulcer

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239
Q

dirty, deep ulcer with heaped up tissue around the edges

A

marjolin ulcer

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240
Q

how to dx marjolin ulcer

A

biopsy

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241
Q

how to tx marjolin ulcer

A

wide local excision and skin grafting

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242
Q

old overweight ppl with sharp heel pain that’s worse in the morning

A

plantar fasciitis

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243
Q

how to tx plantar fasciitis

A

do not excise bony spur

condition resolves spontaneously in 12-18 months

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244
Q

inflammation of common digital nerve at 3rd interspace, palpable tender spot assoc with high heels

A

morton neuroma

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245
Q

how to tx morton neuroma

A

analgesics, rarely surgical excision

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246
Q

sudden onset swelling, redness, pain at 1st MTP joint

middle age, obese pain

A

gout

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247
Q

acute tx for gout

A

indomethacin, colchicine

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248
Q

chronic tx for gout

A

allopurinol, probenicid

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249
Q

EF < 35% means what in terms of operative risk?

A

prohibitive for noncardiac operations!!

very high risk of MI and mortality

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250
Q

Goldman’s index of cardiac risk factors (high to low)

A 
JVD
récent MI
PVC or non-sinus rhythm
age > 70
emergency surgery
AS, poor medical condition, surgery in chest/abd
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251
Q

____ is the worst single finding predicting high cardiac risk. If possible, treat with ____, ____, _____, ______ beforehand

A

JVD

CCB, beta blockers, digitalis, diuretics

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252
Q

what to do if you need surgery and you had a recent MI?

A

wait 6 months

if you can’t wait, admit to ICU the day before to optimize cardiac variables

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253
Q

what to do if pt has severe progressing angina right before surgery?

A

possibly do a coronary revascularization before the other operation

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254
Q

______ is the most common cause of increased pulmonary risk

A

smoking

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255
Q

what problem does smoking pose as a surgery risk factor

A

ventilation (not oxygenation) issues

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256
Q

if you’re a smoker, what should you do before surgery?

A
  • quit 8 weeks beforehand

- respiratory therapy

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257
Q

hepatic risk:
40% mortality if any of the (4)
80-85% morality if 3 of the (4)

A

bilirubin > 2
albumin < 3
PT > 16
encephalopathy

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258
Q

hepatic risk:

80-85% mortality if any of these (3)

A

bilirubin > 4
albumin < 2
blood ammonia concentration > 150

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259
Q

lose 20% body weight over months
albumin < 3
anergy to skin antigens
serum transferrin < 200

A

this indicates severe nutritional depletion –> high operative risk!

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260
Q

what to do to optimize nutrition in those who are depleted

A

4-5 days of nutritional support via the gut before surgery

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261
Q

what about diabetic coma and surgery?

A

it’s an absolute contraindication!!!!

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262
Q

what to do if pt is in diabetic coma and surgery needs to be done?

A

rehydrate
urinary output
partial correction of acidosis and hyperglycemia

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263
Q

abrupt onset of hyperthermia after succinylcholine or inhaled anesthetic

A

malignant hyperthermia

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264
Q

features of malignant hyperthermia

A

> 104F, metabolic acidosis, hypercalcemia

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265
Q

tx of malignant hyperthermia

A

dantrolene, oxygen, cooling, correction of acidosis

watch for myoglobinuria

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266
Q

> 104F fever and chills within 30-45 minutes of invasive procedure means ______ and you tx it with ______

A

bacteremia

blood cultures x 3, empiric abc

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267
Q

post op fever in the usual range caused by:

A 
wind (atelectasis, pneumonia)
water (UTI)
walking (deep venous thrombophlebitis) 
wound (+/- deep abscess)
wonder drugs
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268
Q

______ is the most common cause of fever on POD1. What do you do?

A

atelectasis

-r/o other causes, CXR, improve ventilation, bronchoscopy if needed

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269
Q

suspect ________ on day 3 if atelectasis hasn’t resolved. What do you do?

A

pneumonia

-CXR, sputum cultures, abx

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270
Q

what to do if you suspect deep thrombophlebitis

A

doppler

anticoag with heparin

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271
Q

deep abscess post-op… dx and tx

A

dx with CT

tx with percutaneous drainage

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272
Q

intra-op MI commonly triggered by _______ and detected by ______

A

hypotension, ECG

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273
Q

post op MI

  • only 1/3 show up with ______
  • dx with ________
  • can’t use _____ but can use ________
A

chest pain
troponins
can’t use clot busters but can do emergency angioplasty and stent
very high rate of mortality

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274
Q

________ happens on POD7 in elderly/immobilized pts

A

pulmonary embolus

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275
Q

sudden onset pleuritic pain, SOB, anxious, diaphoretic, tachycardic, JVD
hypoxemia and hypocapnia

A

pulmonary embolus

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276
Q

how to dx pulmonary embolus

A

VQ scan or spiral CT

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277
Q

how to tx PE

A

heparin +/- IVC filter

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278
Q

aspiration can be lethal right away (T/F)

A

T

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279
Q

aspiration can lead to chemical injury and subsequent pulmonary failure/pneumonia. how do you prevent it?

A

NPO and antacids

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280
Q

how to tx aspiration. what do you not use?

A

lavage, bronchodilators, respiratory support

NOT steroids

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281
Q

pts with weakened or traumatized lungs who are then subjected to positive pressure ventilation during operation may develop ______

A

tension pnuemo

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282
Q

pt becomes difficult to bag, BP declines, CVP increases

A

tension ptx

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283
Q

post-op pt gets confused/disoriented. what’s the first thing you suspect? what do you check?

A

hypoxia, perhaps secondary to sepsis

check blood gases, provide respiratory support

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284
Q

complicated post-op course often with sepsis, bilateral pulmonary infiltrates, hypoxia, no CHF

A

ARDS

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285
Q

how to tx ARDS

A

PEEP but minimize barotrauma

seek out source of sepsis

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286
Q

POD2-3: confused, hallucinations, combative

A

delirium tremens

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287
Q

how to tx DT?

A

alcohol or benzos

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288
Q

quick administration of D5W to pt with high ADH levels will cause…

A

hyponatremia

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289
Q

confusion, convulsions, coma, death are signs of ____

A

hyponatremia

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290
Q

how to tx hyponatremia

A

depends…
small amounts of hypertonic saline
osmotic diuretics

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291
Q

hypernatremia can cause…

A

confusion, lethargy, coma

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292
Q

surgical damage to posterior pituitary can cause…

A

hypernatremia due to diabetes insipidus

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293
Q

how to tx hypernatremia

A

D5 1/2 normal, D5 1/3 normal

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294
Q

cirrhotic patient with bleeding esophageal varices undergoes a portocaval shunt… they’re at risk for _____ intoxication

A

ammonium

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295
Q

post op urinary retention is common; treat with _______ q6 hours and if prolonged place a _______

A

straight cath

foley catheter

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296
Q

zero urinary output is usually caused by ______

A

mechanical blockage

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297
Q

low urine output (<0.5mL/kg/hr) not due to shock typically is caused by 2 things

A
  1. fluid deficit
  2. acute renal failure

differentiate between the two with:
-fluid challenge- dehydrated pt increases output, renal failure pt does not increase output
-urine Na
40 means renal failure

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298
Q

paralytic ileus can be prolonged by ____

A

hypokalemia

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299
Q

if ileus doesn’t resolve by POD7, then suspect _______.
Dx with __________
Tx with __________

A

SBO 2/2 adhesions
dx with X-rays
tx with re-operation

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300
Q

paralytic ileus of the colon after non-abdominal surgery (often elderly pts who are further immobilized)
nontender abdominal distension, dilated colon on xray

A

ogilvie syndrome

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301
Q

how to tx ogilvie syndrome

A

colonoscopy, leave in long rectal tube

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302
Q

salmon colored fluid coming from wound on POD5 how to tx?

A

wound dehiscence

tx by taping and then re-operating

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303
Q

skin opens up and and contents rush out. how to tx?

A

evisceration

-keep pt in bed, cover bowel in sterile dressings soaked in warm saline –> emergency closure in the OR

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304
Q

how to manage GI tract fistulas

A
  • incomplete emptying can lead to sepsis
  • complete emptying can result in fluid/electrolyte/nutrition loss, erosion of belly wall
  • distal colon = ok
  • low volume high GI fistula = manageable
  • high volume high GI fistula = daunting
  • tx with fluid and electrolyte, nutrition, protect nfo abdominal wall (ostomy bags, suction)
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305
Q

hypernatremia: every ____ that Na is above _____ presents _____ of lost water

A

every 3 mEq/L that Na is above 140 represents 1L of lost water

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306
Q

if hypernatremia happens slowly, tx with

A

D5 1/2 NS

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307
Q

if hypernatremia happens quickly, tx with

A

D5 1/3 NS or D5W

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308
Q

2 kinds of hyponatremia:
isovolemic
hypovolemic

A

isovolemic- SIADH
hypovolemic- retaining water b/c they’re losing isotonic from their GI tract and isotonic fluid is not being given as a replacement

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309
Q

rapid development of hyponatremia (neuro sxs), tx with

A

hypertonic saline

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310
Q

slow development of hyponatremia (no neuro sxs), tx with

A

water restriction

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311
Q

hyponatremia in a hypovolemic pt, tx with

A

isotonic fluids

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312
Q

2 ways to develop hypokalemia:

A
  1. slow loss from GI tract or urine (loop diuretics, aldosterone)
  2. K moves into cells after correction of DKA
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313
Q

how to tx hypokalemia

A

replace the K

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314
Q

2 ways to develop hyperkalemia

A
  1. slow- kidney can’t excrete K (renal failure, aldosterone antagonists)
  2. fast- K dumped from cells after crush injuries, tissue death, acidosis
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315
Q

how to tx hyperkalemia

A

calcium
hemodialysis
insulin and dextrose
kayexelate

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316
Q

when you correct acidosis, you should also replace ____

A

K

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317
Q

precursors of bicarb

A

lactate, acetate

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318
Q

how to tx metabolic alkalosis

A

give KCl

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319
Q

when clinical dx of GERD is uncertain, do this…

A

monitor pH and correlate reflux with sxs

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320
Q
  • overweight person with burning retrosternal pain
  • worse with bending over, tight clothes, lying flat
  • relieved by antacids
A

GERD

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321
Q

with long term reflux, you worry about ____ and ______

thus, you do this test

A
  • esophagitis and barrett’s esophagus

- endoscopy and biopsy

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322
Q

tx for GERD

A
  • meds

- surgery if meds fail, complications (ulcer, stenosis), or dysplastic changes

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323
Q

what surgery can you do for GERD

A

laprascopic nissen fundoplication

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324
Q

GERD pre-op studies

A

pH monitoring, manometry, barium swallow, gastric emptying study, endoscopy and bx

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325
Q

crushing pain with swallowing

A

uncoordinated massive contraction

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326
Q

dysphagia of solids and liquids, sitting up helps

A

achalasia

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327
Q

achalasia is more common in men (t/f)

A

F

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328
Q

occasional regurgitation of undigested food

A

achalasia

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329
Q

X-ray shows mega-esophagus, manometry shows increased LES tone

A

achalasia

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330
Q

tx for achalasia

A

repeated dilations or heller myotomy

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331
Q

how to dx esophageal motility issues

A

barium swallow then manometry

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332
Q

dysphagia of solids –> liquids –> saliva
weight loss
hematemesis

A

esophageal cancer

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333
Q

2 types of esophageal cancer

  1. ________in men with smoking and drinking
  2. ________ in ppl with GERD
A
  • SCC

- adenocarcinoma

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334
Q

how to dx esophageal cancer

A

Ba swallow –> endoscopy and bx

335
Q

how to assess esophageal cancer operability

A

CT

336
Q

prolonged forceful vomiting, bright red blood

A

mallory weiss tear

337
Q

how to dx and tx mallory weiss tear

A

dx with endoscopy

tx with laser if it doesn’t stop bleeding on its own

338
Q

prolonged vomiting leading to continuous, severe, epigastric and low sternal pain followed by fever, leukocytosis, sick looking

A

boerhaave

339
Q

emphysema in lower neck of someone vomiting

A

boerhaave

340
Q

how to dx and tx boerhaave

A

dx with contrast swallow

tx with emergency surgery

341
Q

______________ is the most common reason for esophageal perforation

A

instrumental perforation (ie. endoscopy)

342
Q

elderly, weight loss, anorexia, vague epigastric distress, early satiety, hematemesis

A

gastric adenocarcinoma or gastric lymphoma

343
Q

how to dx and tx gastric adenocarcinoma

A
  • dx with endo/bx

- tx with surgery after assessing operability with CT

344
Q

how to dx and tx gastric lymphoma

A
  • dx with endo/bx
  • tx with chemo/XRT; surgery is only for potential of perforation
  • tx MALToma with H Pylori eradication
345
Q

most common cause of mechanical intestinal obstruction

A

adhesions

346
Q

colicky abd pain, protracted vomiting, abd distension, high pitched BS, obstipation

A

mechanical obstruction

347
Q

how to dx obstruction

A

X-ray shows distended loops with air fluid levels

348
Q

how to tx obstruction

A

NPO, NG tube, IV fluids, watch for strangulation (fever, leukocytosis, constant pain, peritonitis, sepsis)
-if strangulation occurs –> emergency surgery

349
Q

all incarcerated hernias should be surgically repaired (more or less) (t/f)

A

T

  • emergently after proper rehydration if strangulated
  • electively if reducible and viable bowel
350
Q

diarrhea, face flushing, wheezing, right heart valve damage

A

carcinoid syndrome

351
Q

when does carcinoid syndrome occur? what tumor and where is it?

A

small bowel carcinoid tumor with liver mets

352
Q

how to dx carcinoid syndrome

A

24 hour urine hydroxyindolacetic acid collection

353
Q

anorexia –> vague umbilical pain –> sharp, severe, constant RLQ pain; tenderness, guarding, rebound
+/- fever and leukocytosis

A

appendicitis

354
Q

how to dx appendicitis

A

CT

355
Q

how to tx appendicitis

A

emergency appendectomy

356
Q

anemia for no good reason, occult blood in stool

A

right colon cancer

357
Q

how to dx right colon cancer

A

colonoscopy and bx

358
Q

how to tx right colon cancer

A

right hemicolectomy

359
Q

blood on outside of bowel movements, constipation, narrow caliber stools

A

left colon cancer

360
Q

how to dx left colon cancer

A

proctosigmoidoscopy and bx +/- CT scan for operability

361
Q

how to tx left colon cancer

A

surgery +/- chemo/XRT

362
Q 
chance for malignancy: 
FAP
peutz jegher
hyperplastic
inflammatory
villous adenoma
adenomatous polyp 
juvenile
A

FAP > villous adenoma > adenomatous polyp

benign: juvenile, Peutz Jegher, inflammatory, hyperplastic

363
Q

UC is managed _________ until any of the following:

  • greater than 20 years
  • nutritional issues
  • multiple hospitalizations
  • high dose steroids/immunosuppressants
  • toxic megacolon

at that point, ________________

A
  • medically

- remove affected colon + rectal mucosa

364
Q

watery diarrhea, crampy abd pain, fever, leukocytosis

A

c diff pseudomembranous colitis

365
Q

how to dx c diff

A

stool toxin, endoscopy, culture

366
Q

how to tx c diff

A

D/C abx
do not use anti-diarrheal medication
metronidazole, vancomycin, fecal transplant

367
Q

abdominal pain, fever, leukocytosis, epigastric tenderness, massively distended transverse colon on X-rays, gas in the wall of the colon

A

toxic megacolon

368
Q

all anorectal disease should be ruled out for cancer by proper physical exam even when clinical presentation suggests a benign process (T/F)

A

T

369
Q

hemorrhoids:
__________ –> bleeding, itchy, may be painful. tx with rubber band ligation
__________ –> painful. may need to tx with surgery

A

internal

external

370
Q

young woman, pain with defecation, blood streaks on stool, may avoid BMs and get constipated

A

anal fissure

371
Q

where do anal fissures tend to occur?

A

posterior midline

372
Q

how to tx anal fissure

A

stool softeners, nitroglycerin, local botox, forceful dilation, lateral internal sphincterotomy

373
Q

fissure, fistula, ulceration fails to heal/gets worse after surgical intervention

A

Crohn’s disease in the anal area

374
Q

febrile, perirectal pain (can’t sit or have BMs)

A

ischiorectal (perirectal) abscess

lateral to anus

375
Q

how to tx ischiorectal abscess

A

I and D, r/o cancer

watch closely for necrotizing infection in the diabetic pt

376
Q

patients with drained ischiorectal abscess end up with fecal soiling, occasional perineal discomfort, opening lateral to anus, cordlike tract with expressible discharge

A

fistula in ano

377
Q

how to tx fistula in ano

A

r/o tumor

tx with fistulotomy

378
Q

HIV + homosexuals with fun gating mass growing out of anus, palpable metastatic inguinal nodes

A

SCC of the anus

379
Q

how to dx and tx SCC of the anus

A

dx with bx

tx with chemo/XRT followed by surgery

380
Q

3/4 of GI bleeds are from ________

1/4 of GI bleeds are from _____ or _______

A
  • upper GI

- colon or rectum

381
Q

colon bleeding pretty much only occurs in _________

possible causes include (4)

A

old ppl

angiodysplasia, polyps, diverticulosis, cancer

382
Q

young person with GI bleed is most likely ________ whereas old person with GI bleed is from _______

A

upper GI

anywhere

383
Q

vomiting blod or blood suctioned by NG tube tells you it’s a(n) ________. what do you do next?

A

upper GI bleed

you do an UGI endoscopy

384
Q

melena tells you what? what should you do next?

A

it’s most likely UGI

you should do an UGI endoscopy

385
Q

red blood per rectum comes from _________

A

anywhere!

386
Q

algorithm for red blood per rectum… this is long!

A

drop an NG tube

  • if blood in NG tube –> upper endoscopy
  • if no blood and non bilious –> UGI endoscopy b/c duodenum could still be the source

if you exclude an UGI..

  • exclude bleeding hemorrhoids with anoscopy
  • rate of bleeding > 2 mL/min –> angiogram +/- embolization
  • rate of bleeding < 0.5 mL/min -> wait for bleeding to stop and then do a colonoscopy
  • in between rate –> tagged red cell study
    • puddles –> angiogram
    • no puddles –> plan for subsequent colonoscopy
    • pt often stops bleeding before you even finish the study… with that being said, this may guide hemicolectomy in the future
387
Q

history of blood per rectum but no active bleeding….
young person
old person

A

young- UGI

old- UGI and LGI endoscopy

388
Q

blood per rectum in child is _______________. do this to work it up

A

meckels diverticulum

technetium scan

389
Q

massive UGI in trauma, stress, complicated post-op pts most likely due to _____ ________

A

stress ulcers

390
Q

how to dx stress ulcers

A

endoscopy

391
Q

how to tx stress ulcers

A

angio embolization; avoid by maintaining pH above 4

392
Q
  • most common source of visceral perforation
  • sudden onset constant, generalized, severe abd pain
  • doesn’t want to move, tenderness, guarding, rebound, silent
A

perfed peptic ulcer

393
Q

how to dx perforated peptic ulcer

A

CXR- free air under diaphragm

394
Q

how to tx perforated peptic ulcer

A

emergency surgery

395
Q

sudden onset of colicky pain; patent moves constantly, few physical findings limited to local area

A

acute abd pain caused by obstruction

396
Q

gradual onset, constant, ill-defined then localizes, typical radiation patterns
-peritoneal irritation in affected area, fever, leukocytosis

A

inflammatory process

397
Q

____________ processes are the only ones that combine severe abdominal pain with blood in the gut lumen

A

ischemic

398
Q

child with nephrosis and ascites

adult with ascites and mild generalized acute abdomen

A

primary peritonitis

399
Q

how to work up primary peritonitis

A

culture ascitic fluid –> one organism –> tx with abx, not surgery

400
Q

how to treat generalized acute abdomen

A

ex lap

-r/o primary peritonitis, MI, lower lobe pneumonia, PE, pancreatitis, urinary stones

401
Q

alcoholic with acute upper abd pain; constant, epigastric, radiating straight to the back; N/V

A

acute pancreatitis

402
Q

how to dx acute pancreatitis

A

amylase or lipase +/- CT

403
Q

how to tx acute pancreatitis

A

NPO, NG suction, IVF

404
Q

sudden onset colicky flank pain radiating to groin, urinary urgency and frequency, microhematuria

A

ureteral stones

405
Q

how to dx ureteral stones

A

plain X-rays or noncontrast CT

406
Q

acute abd pain in LLQ, fever, leukocytosis, peritoneal irritation in LLQ

A

acute diverticulitis

407
Q

how to dx acute diverticulitis

A

CT

408
Q

how to tx acute diverticulitis

A

NPO, IVF, abx, emergency surgery if it doesn’t get better

409
Q

intestinal obstruction, severe abd distension, parrot beak on xrays

A

volvulus of the sigmoid in old ppl

410
Q

how to tx volvulus in old ppl

A

proctosigmoidoscopic exam, leave in rectal tube

recurrent cases treated with elective sigmoid resection

411
Q

afib, récent MI, acute pain, GI bleeding, acidosis, sepsis

A

mesenteric ischemia

412
Q

how to tx mesenteric ischemia if caught early

A

arteriogram and embolectomy

413
Q

vague RUQ discomfort, weight loss, alpha-fetoprotein in ppl with cirrhosis

A

this is hepatocellular carcinoma

414
Q

how to dx hepatocellular carcinoma

A

CT scan

415
Q

how to tx hepatocellular carcinoma

A

surgical resection

416
Q

which are more common? liver mets vs. primary liver cancer

A

liver mets

417
Q

how to dx and tx liver cancer

A

dx with CT

tx with resection or radio-ablation

418
Q

how monitor colon cancer recurrence

A

CEA

419
Q

OCP use, massive bleeding

A

hepatic adenoma

420
Q

how to dx hepatic adenoma

A

CT

421
Q

how to tx hepatic adenoma

A

emergency surgery

422
Q
  • complication of biliary tract disease (acute ascending cholangitis)
  • fever, leukocytosis, tender liver
A

pyogenic liver abscess

423
Q

how to dx and tx pyogenic liver abscess

A

dx with sonogram, CT

tx with percutaneous drainage

424
Q

mexican man with tender liver, fever, leukocytosis, elevated ALP

A

amebic abscess

425
Q

how to dx and tx amebic abscess

A

dx with serology but begin empiric tx based on clinical suspicion

426
Q

increased indirect bilirubin only
no bile in the urine
Tbili 6-8

A

hemolytic anemia

427
Q

-increased indirect and direct bilirubin
-very increased transaminases, somewhat increase ALP
what is it? what to do next?

A

heptocellular jaundice

work up for hepatitis

428
Q

-increased indirect and direct bilirubin
-somewhat increased transaminases, very increased ALP
what is it? what to do next?

A

obstructive jaundice

sonogram:
- stones- stones in non-dilated gallbladder OR
- malignancy- large thin walled and distended gallbladder (courvoisier terrier sign)

429
Q

obese fecund 40F with high ALP, dilated ducts, non dilated gallbladder full of stones

A

obstructive jaundice due to stones

430
Q

how to work up and tx obstructive jaundice due to stones

A

sonogram
ERCP (confirm dx, sphincterotomy, remove CBD stone)
cholecystectomy

431
Q

how to work up obstructive jaundice due to tumor

A

sonogram shows dilated gallbladder –> CT

  • if CT positive –> percutaneous bx
  • if CT negative –> ERCP
432
Q

malignant obstructive jaundice + anemia and blood in stool

what is it and how do we dx it?

A

ampullary cancer

dx with endoscopy

433
Q

ampullary and lower common duct cancers have better prognosis than pancreatic cancer (t/f)

A

T

434
Q

how to tx asyptomatic gallstones

A

we don’t

435
Q

temporary stone in cystic duct causing RUQ colicky pain radiating to right shoulder or back, fatty food, N/V, no systemic signs

A

biliary colic

436
Q

how to dx and tx biliary colic

A

dx with US

tx with elective cholecystectomy

437
Q

constant pain, fever, leukocytosis, peritoneal irritation in RUQ

A

acute cholecystitis

438
Q

how to dx and tx acute cholecystitis

A
  • dx with US (thick walled gallbladder with pericholecystic fluid)
  • tx with NG, NPO, IVF, abc –> interval cholecystectomy
  • if no response –> emergent chole
  • if very sick and not fit for surgery –> emergency percutaneous transhepatic cholesystostomy
439
Q

stones in CBD, partial obstruction, ascending infection

-high temps, chills, very high WBCs all indicate sepsis

A

ascending cholangitis

440
Q

charcot’s triad

A

jaundice, fever, RUQ pain for ascending cholangitis

441
Q

breast ca operability is based on _____ not _______

A

local extent, not metastases

442
Q

adjuvant systemic therapy should follow breast ca surgery in virtually all patients (t/f)

A

T

443
Q

persistent headache or back pain in woman with h/o breast ca suggests _____. what do you do?

A

metastases

-get head CT and bone scan

444
Q

weight loss, palpitations, heat intolerance, moist skin, hyperactive person, tachycardia, a fib

A

hyperthyroidism

445
Q

how to work up thyroid nodule in hyperthyroid pt

A
  • get TSH (low) and/or T4 levels (high)
  • nuclear scan
    • if just nodule is the source, remove that lobe
    • if whole thyroid is the source, then do radioactive iodine ablation
446
Q

key finding in ascending cholangitis is _________

A

high ALP

446
Q

obstructive jaundice w/o ascending cholangitis can occur when _____________

A

stones produce complete biliary obstruction rather than partial obstruction

446
Q

biliary pancreatitis

A

stones in ampulla, often pass spontaneously

US shows stones in the gallbladder

446
Q

how to tx biliary pancreatitis

A

NPO, IVF, NG –> elective chole

-if conservative therapy doesn’t work, then do ERCP and sphincterotomy

446
Q

acute pancreatitis most often caused by _______ or ________

A

gallstones or alcohol

446
Q

2 late complications of acute pancreatitis

A

pancreatic pseudocyst

chronic pancreatitis

446
Q

acute edematous pancreatitis has this key finding

A

elevated hct

446
Q

natural history of acute edematous pancreatitis

A

resolves after bowel rest (NPO, NG, IVF)

446
Q

starts as edematous pancreatitis but with low hct

A

hemorrhagic pancreatitis

446
Q

what makes hemorrhagic pancreatitis more likely?

A

Ranson’s criteria

  • high WBC
  • high glucose
  • low Ca
  • high BUN, metabolic acidosis, low pO2
446
Q

how to tx hemorrhagic pancreatitis

A
  • requires ICU support

- anticipate and drain pancreatic abscesses ASAP (daily CT scans)

446
Q

persistent fever and leukocytosis 10 days after onset of pancreatitis

A

pancreatic abscess

446
Q

how to dx and tx pancreatic abscess

A

dx wit hCT

tx with percutaneous drainage

446
Q

early satiety, vague discomfort, deep palpable mass 5 weeks after pancreatic injury

A

pancreatic pseudocyst

446
Q

how to dx and tx pancreatic pseudocyst

A

dx with US or CT

tx by observing for 6 weeks with serial US –> if not resolved, then drain it

446
Q

steatorrhea, DM, constant epigastric pain resistant to therapy

A

chronic pancreatitis

446
Q

how to tx chronic pancreatitis

A
  • insulin
  • pancreatic enzymes
  • perhaps ERCP and operations may help but this is a pretty terrible disease to have
446
Q

in breast disease, if the presentation suggests benign disease then you don’t have to worry about cancer (t/f)

A

F

446
Q

inoperable breast CA is treated with ________. so are mets

A

chemo

446
Q

obstructive jaundice w/o ascending cholangitis can occur when _____________

A

stones produce complete biliary obstruction rather than partial obstruction

446
Q

how to tx chronic pancreatitis

A
  • insulin
  • pancreatic enzymes
  • perhaps ERCP and operations may help but this is a pretty terrible disease to have
446
Q

key finding in ascending cholangitis is _________

A

high ALP

446
Q

how to tx ascending cholangitis

A

IV abx, emergency decompression of common duct (ERCP, PTC, surgery) –> eventual cholecystectomy

446
Q

obstructive jaundice w/o ascending cholangitis can occur when _____________

A

stones produce complete biliary obstruction rather than partial obstruction

446
Q

biliary pancreatitis

A

stones in ampulla, often pass spontaneously

US shows stones in the gallbladder

446
Q

how to tx biliary pancreatitis

A

NPO, IVF, NG –> elective chole

-if conservative therapy doesn’t work, then do ERCP and sphincterotomy

446
Q

acute pancreatitis most often caused by _______ or ________

A

gallstones or alcohol

446
Q

2 late complications of acute pancreatitis

A

pancreatic pseudocyst

chronic pancreatitis

446
Q

acute edematous pancreatitis has this key finding

A

elevated hct

446
Q

natural history of acute edematous pancreatitis

A

resolves after bowel rest (NPO, NG, IVF)

446
Q

starts as edematous pancreatitis but with low hct

A

hemorrhagic pancreatitis

446
Q

what makes hemorrhagic pancreatitis more likely?

A

Ranson’s criteria

  • high WBC
  • high glucose
  • low Ca
  • high BUN, metabolic acidosis, low pO2
446
Q

how to tx hemorrhagic pancreatitis

A
  • requires ICU support

- anticipate and drain pancreatic abscesses ASAP (daily CT scans)

446
Q

persistent fever and leukocytosis 10 days after onset of pancreatitis

A

pancreatic abscess

446
Q

how to dx and tx pancreatic abscess

A

dx wit hCT

tx with percutaneous drainage

446
Q

early satiety, vague discomfort, deep palpable mass 5 weeks after pancreatic injury

A

pancreatic pseudocyst

446
Q

how to dx and tx pancreatic pseudocyst

A

dx with US or CT

tx by observing for 6 weeks with serial US –> if not resolved, then drain it

446
Q

steatorrhea, DM, constant epigastric pain resistant to therapy

A

chronic pancreatitis

446
Q

all abdominal hernias should be electively repaired to avoid the risk of intestinal obstruction and strangulation (t/f)

A

T

exception: umbilical in pts < 2, esophageal sliding hiatal hernia

446
Q

in breast disease, if the presentation suggests benign disease then you don’t have to worry about cancer (t/f)

A

F

446
Q

mammography screening starts at age ____

A

40

446
Q

mammograms should precede ____ in all women > ____ years

A

biopsy

30

446
Q

young woman with firm rubbery breast mass that moves easily

A

fibroadenoma

446
Q

how to dx and tx fibroadenoma of the breast

A

dx with FNA or US

tx with optional surgical excision

446
Q

very young teens with rapidly growing breast mass

A

giant juvenile fibroadenoma

446
Q

how to tx giant juvenile fibroadenoma

A

removal to avoid deformity

446
Q

late 20s, grow slowly to be large and distorting but are not invading or fixed

A

cystosarcoma phyllodes

446
Q

how to work up cystosarcoma phyllodes

A

core or incisional bx and removal (2/2 malignancy potential)

446
Q

age 30-40, bilateral breast tenderness related to the cycle, multiple lumps come and go

A

mammary dysplasia

446
Q

how to work up mammary dysplasia

A
  • if no dominant mass, mammogram
  • if dominant mass, aspiration (not FNA)
    • if clear fluid and mass goes away, do nothing
    • if mass persists or recurs after aspiration, formal bx
    • if bloody fluid, send cytology
446
Q

young women with bloody nipple discharge

A

intraductal papilloma

446
Q

how to work up intraductal papilloma

A

mammogram, galactogram to guide resection

446
Q

breast abscess in the lactating woman. how to tx?

A

I&D and bx the wall

446
Q

if you suspect breast cancer (which you should!!!)… this is the pathway you go down

A
  • 40s or 50s- mammogram, core bx, incisional bx

- 60s or 70s- mammogram, core bx, incisional bx, excisional bx

446
Q

a history of trauma rules out breast cancer (t/f)

A

F

446
Q

ill defined fixed mass, retraction of overlying skin, “orange peel” skin, recent retraction of nipple, eczematous lesions of areola, reddish orange peel skin over the mass

A

inflammatory cancer

446
Q

what about breast cancer during pregnancy

A

no XRT
no chemo in 1st trimester
surgery ok

446
Q

small peripheral tumor in large breast. what’s the tx?

A

lumpectomy, axillary sampling, post-op XRT

less desirable is modified radical mastectomy

446
Q

what’s the standard form of breast cancer

A

infiltrating ductal carcinoma

446
Q

which breast cancer needs pre-op chemo?

A

inflammatory cancer

446
Q

breast CA: lobular, medullary, mutinous have slightly (better/worse) prognosis compared to infiltrating ductal carcinoma

A

better

446
Q

breast: can’t metastasize, high incidence of recurrence after local excision

A

DCIS

446
Q

txs for DCIS

A
  • multicentric lesions –> total simple mastectomy

- lesion confined to one quarter of breast –> lumpectomy and XRT

446
Q

if breast CA is estrogen receptor positive, treatments are:
______ for premenopausal
______ for post-menopausal

A

tamoxifen for pre

anastrozole for post

446
Q

inoperable breast CA is treated with ________. so are mets

A

chemo

446
Q

_____ is favored as adjuvant for breast CA.

A

chemo

446
Q

hormonal therapy alone might be okay for old frail women (T/F)

A

T

446
Q

work up for thyroid nodules in euthyroid pt

A

FNA

  • if benign, then follow
  • if malignant or in determinant, do thyroid lobectomy +/- further surgery
446
Q

thyroid nodules in hyperthyroid patients are suspicious for cancer (t/f)

A

F

these are almost never cancer

446
Q

how to tx ascending cholangitis

A

IV abx, emergency decompression of common duct (ERCP, PTC, surgery) –> eventual cholecystectomy

446
Q

biliary pancreatitis

A

stones in ampulla, often pass spontaneously

US shows stones in the gallbladder

446
Q

how to tx biliary pancreatitis

A

NPO, IVF, NG –> elective chole

-if conservative therapy doesn’t work, then do ERCP and sphincterotomy

446
Q

acute pancreatitis most often caused by _______ or ________

A

gallstones or alcohol

446
Q

2 late complications of acute pancreatitis

A

pancreatic pseudocyst

chronic pancreatitis

446
Q

acute edematous pancreatitis has this key finding

A

elevated hct

446
Q

natural history of acute edematous pancreatitis

A

resolves after bowel rest (NPO, NG, IVF)

446
Q

starts as edematous pancreatitis but with low hct

A

hemorrhagic pancreatitis

446
Q

what makes hemorrhagic pancreatitis more likely?

A

Ranson’s criteria

  • high WBC
  • high glucose
  • low Ca
  • high BUN, metabolic acidosis, low pO2
446
Q

how to tx hemorrhagic pancreatitis

A
  • requires ICU support

- anticipate and drain pancreatic abscesses ASAP (daily CT scans)

446
Q

persistent fever and leukocytosis 10 days after onset of pancreatitis

A

pancreatic abscess

446
Q

how to dx and tx pancreatic abscess

A

dx wit hCT

tx with percutaneous drainage

446
Q

early satiety, vague discomfort, deep palpable mass 5 weeks after pancreatic injury

A

pancreatic pseudocyst

446
Q

how to dx and tx pancreatic pseudocyst

A

dx with US or CT

tx by observing for 6 weeks with serial US –> if not resolved, then drain it

446
Q

steatorrhea, DM, constant epigastric pain resistant to therapy

A

chronic pancreatitis

446
Q

how to tx chronic pancreatitis

A
  • insulin
  • pancreatic enzymes
  • perhaps ERCP and operations may help but this is a pretty terrible disease to have
446
Q

all abdominal hernias should be electively repaired to avoid the risk of intestinal obstruction and strangulation (t/f)

A

T

exception: umbilical in pts < 2, esophageal sliding hiatal hernia

446
Q

mammography screening starts at age ____

A

40

446
Q

mammograms should precede ____ in all women > ____ years

A

biopsy

30

446
Q

young woman with firm rubbery breast mass that moves easily

A

fibroadenoma

446
Q

how to dx and tx fibroadenoma of the breast

A

dx with FNA or US

tx with optional surgical excision

446
Q

very young teens with rapidly growing breast mass

A

giant juvenile fibroadenoma

446
Q

how to tx giant juvenile fibroadenoma

A

removal to avoid deformity

446
Q

late 20s, grow slowly to be large and distorting but are not invading or fixed

A

cystosarcoma phyllodes

446
Q

how to work up cystosarcoma phyllodes

A

core or incisional bx and removal (2/2 malignancy potential)

446
Q

age 30-40, bilateral breast tenderness related to the cycle, multiple lumps come and go

A

mammary dysplasia

446
Q

how to work up mammary dysplasia

A
  • if no dominant mass, mammogram
  • if dominant mass, aspiration (not FNA)
    • if clear fluid and mass goes away, do nothing
    • if mass persists or recurs after aspiration, formal bx
    • if bloody fluid, send cytology
446
Q

young women with bloody nipple discharge

A

intraductal papilloma

446
Q

how to work up intraductal papilloma

A

mammogram, galactogram to guide resection

446
Q

breast abscess in the lactating woman. how to tx?

A

I&D and bx the wall

446
Q

if you suspect breast cancer (which you should!!!)… this is the pathway you go down

A
  • 40s or 50s- mammogram, core bx, incisional bx

- 60s or 70s- mammogram, core bx, incisional bx, excisional bx

446
Q

a history of trauma rules out breast cancer (t/f)

A

F

446
Q

ill defined fixed mass, retraction of overlying skin, “orange peel” skin, recent retraction of nipple, eczematous lesions of areola, reddish orange peel skin over the mass

A

inflammatory cancer

446
Q

what about breast cancer during pregnancy

A

no XRT
no chemo in 1st trimester
surgery ok

446
Q

small peripheral tumor in large breast. what’s the tx?

A

lumpectomy, axillary sampling, post-op XRT

less desirable is modified radical mastectomy

446
Q

what’s the standard form of breast cancer

A

infiltrating ductal carcinoma

446
Q

which breast cancer needs pre-op chemo?

A

inflammatory cancer

446
Q

breast CA: lobular, medullary, mutinous have slightly (better/worse) prognosis compared to infiltrating ductal carcinoma

A

better

446
Q

breast: can’t metastasize, high incidence of recurrence after local excision

A

DCIS

446
Q

txs for DCIS

A
  • multicentric lesions –> total simple mastectomy

- lesion confined to one quarter of breast –> lumpectomy and XRT

446
Q

if breast CA is estrogen receptor positive, treatments are:
______ for premenopausal
______ for post-menopausal

A

tamoxifen for pre

anastrozole for post

446
Q

breast ca operability is based on _____ not _______

A

local extent, not metastases

446
Q

adjuvant systemic therapy should follow breast ca surgery in virtually all patients (t/f)

A

T

446
Q

_____ is favored as adjuvant for breast CA.

A

chemo

446
Q

hormonal therapy alone might be okay for old frail women (T/F)

A

T

446
Q

persistent headache or back pain in woman with h/o breast ca suggests _____. what do you do?

A

metastases

-get head CT and bone scan

446
Q

work up for thyroid nodules in euthyroid pt

A

FNA

  • if benign, then follow
  • if malignant or in determinant, do thyroid lobectomy +/- further surgery
446
Q

thyroid nodules in hyperthyroid patients are suspicious for cancer (t/f)

A

F

these are almost never cancer

446
Q

weight loss, palpitations, heat intolerance, moist skin, hyperactive person, tachycardia, a fib

A

hyperthyroidism

446
Q

how to work up thyroid nodule in hyperthyroid pt

A
  • get TSH (low) and/or T4 levels (high)
  • nuclear scan
    • if just nodule is the source, remove that lobe
    • if whole thyroid is the source, then do radioactive iodine ablation
446
Q

what is lateral aberrant thyroid?

A

tissue removed from jugular chain and looks like normal thyroid is metastases from a follicular cancer… look for the primary tumor

446
Q

high Ca on routine blood tests (not stones, bones, abd groans)

A

hyperparathyroidism

446
Q

to work up high incidental Ca

A
  • repeat Ca
  • look for low PO4
  • r/o cancer
  • get PTH levels
  • do elective intervention –> oftentimes, it’s a single adenoma that can be removed and result in a cure
483
Q

round hairy face, supraclavicular fat pads, obese trunk, thin extremities, osteoporosis, DM, HTN, mental instability

A

Cushing

484
Q

how to dx Cushing

A

low dose dex suppression test
-if suppression, no dz
-if no suppression, measure 24 hour fine cortisol
-if urine cortisol elevated, do high dose suppression test
if there’s suppression on the high dose, then it’s a pituitary micro adenoma

  • if not suppression at either dose, then adrenal adenoma
  • MRI for pituitary, CT scan for adrenal
485
Q

how to tx cushing

A

surgical resection

486
Q

virulent, resistant and extensive peptic ulcer disease

A

ZES

487
Q

how to dx and tx ZES

A
  • dx: measure gastrin, CT scan

- tx: surgical resection, omeprazole helps with metastatic disease

488
Q

low blood sugar during fasting

A

insulinoma or self administration of insulin

489
Q

how to differentiate insulinoma vs. self administration of insulin

A
  • insulinoma, high insulin and high c peptide

- self administration, high insulin and low c peptide

490
Q

how to dx and tx insulinoma

A

CT and surgery

491
Q

devastating hyper secretion of insulin in the new born… what is it and how to treat?

A

nesidioblastosis

treat with 95% pancreatectomy

492
Q

resistant severe migratory necrolytic dermatitis in patients with mild DM, anemia, glossitis, stomatitis

A

glucagonoma

493
Q

how to dx and tx glucagonoma

A
  • dx with glucagon assay and CT
  • tx with resection
  • if inoperable, tx with somatostatin and streptozocin
494
Q

hypokalemia in hypertensive pt not on diuretics, modest hypernatremia, metabolic alkalosis
-high aldo, low renin

A

primary hyperldosteronism

495
Q

how to differentiate primary hyperaldosteronism caused by adenoma vs. hyperplasia and how to tx each

A
  • hyperplasia = appropriate postural changes (more aldo when upright) –> tx medically
  • adenoma = inappropriate response –> adrenal CT and surgery
496
Q

thin hyperactive women with pounding headache, perspiration, palpitations, pallor, high BP

A

pheochromocytoma

497
Q

how to dx and tx pheochromocytoma

A
  • measure 24 hour urine VMA or metanephrine (more specific)
  • CT scan
  • tx with surgery that’s prepared with alpha-blockers
498
Q

young pts with HTN in arms and normal BP in legs

CXR shows rib scalloping

A

coarctation of aorta

499
Q

how to dx and tx coarctation of aorta

A

CT or MRA

correct with surgery

500
Q
  • young women with fibromuscular dysplasia
  • old men with arteriosclerotic disease
  • resistant HTN, bruit over flank or upper abdomen
A

renovascular HTN

501
Q

how to dx and tx renovascular HTN

A
  • scanning and doppler of renal vessels, arteriogram
  • tx
    • young women- balloon dilation and stunting
    • old men- may or may not treat it
502
Q

excessive salivation, choking during feeding, coiled NG tube

A

esophageal atresia

503
Q

if normal gas pattern in bowel (in the setting of esophageal atresia), that means….

A

blind esophagus + fistula between lower esophagus and tracheobronchial tree

504
Q

what is VACTER

A 
vertebral
anal
cardiac
tracheal
esophageal
renal
radial
505
Q

how to tx esophageal atresia

A
  • first, r/o VACTER
  • tx with primary surgical repair
    • if surgery has to be delayed, perform gastrostomy to prevent acid reflux to lungs
506
Q

what to do in the case of imperforate anus

A
  • look for fistula and repair soon-ish
  • if no fistula, do colostomy (high rectal pouch) or primary repair (low rectal pouch)
  • determine level of pouch with upside down X-rays
507
Q

bowel in chest on the left side of infant

A

congenital diaphragmatic hernia

508
Q

how to tx congenital diaphragmatic hernia

A
  • delay repair 3-4 days to allow hypo plastic lungs to mature
  • if babies are in respiratory distress –> intubation, low pressure ventilation, sedation, NG suction (may require ECMO)
509
Q

abd wall defect (2) and how to tx
___________: unprotected defect with angry bowel to cord’s right
___________: protected normal looking bowel at the cord

A

gastroschisis
omphalocele
-tx:
-small defect –> primary repair
-large defect –> construct silo and stuff bowels back slowly
-gastroschisis babies need TPN for 1 month

510
Q

abd wall defect over pubis with red bladder mucosa, wet and shining with urine… what is it and how to tx

A

bladder exstrophy

-transfer and repair immediately within 1-2 days

511
Q

is green vomiting in a new born good?

A

NO

512
Q

green vomit + double bubble sign = (3) things

A

duodenal atresia- just double bubble
annular pancreas- just double bubble
malrotation (most serious)- double bubble and normal bowel gas beyond it

513
Q

green vomit and normal gas pattern beyond the double bubble

A

malrotation

514
Q

how to dx and and tx malrotation

A
  • dx with contrast enema or upper GI (less safe, more reliable)
  • tx with surgery
515
Q

green vomit and multiple air fluid levels (no double bubble)

A

intestinal atresia

516
Q

when premature infants are first fed, they get feeding intolerance, abd distention, rapidly falling plt count

A

necrotizing enterocolitis

517
Q

how to tx necrotizing enterocolitis

A
  • stop feeding, give abc, IV fluids and nutrition
  • surgery if :
    • abd wall erythema
    • air in biliary tree
    • intestinal pneumatosis
    • pneumoperitoneum
518
Q

feeding intolerance, bilious vomiting
dilated loops of small bowel, ground glass in lower abd
mother has CF

A

meconium ileus

519
Q

how to dx and tx meconium ileus

A

dx and tx with gastrografin enema

-you would see a microcolon and inspissated pellets of meconium in terminal ileum

520
Q
  • 1st born boys, non bilious projectile vomiting after each feeding but eager to eat after vomiting
  • dehydrated, visible gastric peristaltic waves, palpable “olive sized” mass in RUQ
  • week 3
A

hypertrophic pyloric stenosis

521
Q

how to tx hypertrophic pyloric stenosis

A

rehydration, correct hypochloremic hypokalemic metabolic alkalosis –> then do a Ramstedt pyloromyotomy

522
Q
  • increasing jaundice (conjugated)

- 6-8 weeks

A

biliary atresia

523
Q

how to work up biliary atresia

A
  • r/o other problems with serologies and sweat test
  • 1 week of phenobarbital stimulation –> HIDA scan –> if no bile in duodenum, surgical exploration
  • 1/3 get long lasting results, 1/3 need liver transplant later, 1/3 need liver transplant now
524
Q

chronic constipation
rectal exam –> relief of distention
xray: distended proximal colon + “normal looking” distal colon

A

hirschsprung disease

525
Q

how to dx and tx hirschsprung disease

A

dx with full thickness bx of rectal mucosa

tx with surgery

526
Q
  • 6-12 months
  • chubby healthy looking kid with colicky abd pain that makes them double up; lasts 1 min then kid looks happy again
  • vague mass on right side, “empty” RLQ, currant jelly stools
A

intussusception

527
Q

how to dx and tx intussusception

A
  • dx and tx with barium/air enema

- if that doesn’t work, then do surgery

528
Q
  • subdural hematoma + retinal hemorrhages
  • many fx in diff bones at diff stages of healing
  • all scalding burns, esp both buttocks
A

child abuse signs

529
Q

lower GI bleeding in kids most often caused by _________ how to dx it?

A

meckel’s diverticulum

dx with radioisotope scan

530
Q

stridor, respiratory distress with hyperextended position, difficulty swallowing

A

vascular rings around tracheobronchial tree

531
Q

stridor, respiratory distress only

A

tracheomalacia

532
Q

how to dx and tx vascular rings

A
  • dx with barium swallow and bronchoscopy

- tx with surgical division of aortic arch

533
Q

what do you do if someone has morphologic cardiac anomalies?

A

give them abx prophylaxis for subacute bacterial endocarditis
workup always begins with CXR and echo

534
Q

murmur, overloaded pulmonary circulation, long term damage to pulmonary vasculature

A

left to right shunts

535
Q
  • low pressure, low volume shunt
  • faint pulmonary flow systolic murmur, fixed split S2, frequent colds
  • how to dx and tx
A

ASD

  • dx with echo
  • tx with surgical closure
536
Q

small restrictive VSD low in the septum… what to do?

A

few sxs, close spontaneously

observe and give SBE prophylaxis

537
Q
  • failure to thrive in first few months
  • loud pansystolic murmur at left sternal border, increased pulmonary vascular markings on CXR
  • how to dx and tx
A

VSD high in the membranous septum

-dx with echo, tx with surgery

538
Q
  • sxs in first few days of life
  • bounding peripheral pulses, continuous machinery like murmur
  • how to dx and tx?
A

PDA

  • dx with echo
  • tx
    • premature babies not in CHF –> close with indomethacin
    • babies who don’t close, already in failure, or full term babies –> surgical division or coil embolization
539
Q

murmur, decreased vascular lung markings, cyanosis

A

right to left shunts

540
Q
  • small for age, bluish hue in ops and fingers, clubbing, spells of cyanosis relieved by squatting
  • systolic mumur in left 3rd intercostal space, small heart, diminished lung markings, ECG signs of RVH
  • how to dx and tx
A

tetralogy of fallout

  • dx with echo
  • tx with surgery
541
Q
  • severe trouble early on
  • kept alive by ASD, VSD, and/or PDA
  • 1-2 day old with cyanosis
  • how to dx and tx
A

transposition of the great vessels

  • dx with echo
  • tx with surgery
542
Q
  • angina, exertional syncopal episodes

- harsh midsystolic murmur at right 2nd space

A

aortic stenosis

543
Q

how to dx and tx aortic stenosis

A

-echo –> surgical valve replacement if gradient > 50, CHF, angina, or syncope

544
Q

-wide pulse pressure, blowing high pitched diastole murmur in 2nd space

A

chronic aortic insufficiency

545
Q

how to dx and tx chronic aortic insufficiency

A
  • follow with medical therapy

- valve replacement if echo shows LV dilatation

546
Q

-endocarditis in drug addicts who suddenly develop CHF and new loud diastolic murmur at 2nd space

A

acute aortic insufficiency

547
Q

how to tx acute aortic insufficiency

A

emergency valve replacement and long term abx

548
Q
  • rheumatic fever in the past
  • dyspnea on exertion, orthopnea, PND, cough, hemoptysis
  • low pitched rumbling diastolic apical murmur
  • -> progress to be thin, cachectic, a fib
A

mitral stenosis

549
Q

how to dx and tx mitral stenosis

A

echo –> worse sxs require MV repair

550
Q
  • valvular prolapse, exertional dyspnea, orthopnea, afib

- apical high pitched holosystolic murmur radiating to axilla and back

A

mitral regurgitation

551
Q

how to tx mitral regurgitation

A

echo –> annuloplasty (valve repair)

552
Q

what to do with progressive unstable disabling angina

A

cardiac cath

  • intervene if at least 1 vessel has 70% stenosis and there is a good distal vessel
  • should still have good ventricular function
  • simple or single vessel –> stent
  • complex or triple vessel –> CABG
553
Q

dyspnea on exertion, hepatomegaly, ascites, square root sign, equalization of pressures on cath
how to tx?

A

chronic constrictive pericarditis

tx with surgery

554
Q

what do you do if you find a coin lesion of CXR

A

look for an old CXR to compare

555
Q

what is the initial workup for suspected lung cancer

A

CXR –> sputum cytology and CT scan

556
Q

if sputum not + for lung cancer, then you need a ______

A

biopsy (bronchoscopic or percutaneous)

if these aren’t successful, thoracotomy and wedge resection

557
Q

how to tx small cell lung cancer

A

chemo and XRT (NO SURGERY!!)

558
Q

what to do for central lung lesions vs. peripheral lung lesions?

A

central- pneumonectomy

peripheral- lobectomy

559
Q

minimum FEV1 is what?

A

800

560
Q

hilar mets can be removed with pneumonectomy (t/f)

A

T

561
Q

nodal mets at carina or mediastinum can be surgically resected (t/f)

A

F

562
Q

before considering surgery for lung cancer, what should you do?

A

figure out remaining FEV1

get CT to look for mets

563
Q
  • coldness, tingling, muscle pain in arm + visual sxs and equilibrium issues
  • this occurs when you’re moving your arm
A

subclavian steal syndrome (stenosis at origin of a subclavian artery –> blood reverses in vertebral artery)

564
Q

how to dx and tx subclavian steal syndrome

A
  • need both vascular and neuro sxs (vascular alone suggests thoracic outlet obstruction)
  • dx with arteriogram
  • tx with bypass
565
Q

asymptomatic pulsatile abd mass

what is it and how to dx and tx

A

AAA
-dx with US or CT
< 4 cm –> observe
> 6 cm –> repair

566
Q

excruciating back pain in pt with AAA

A

retroperitoneal hematoma is forming, blowout into peritoneal cavity is about to happen –> emergency surgery!!!

567
Q

tender AAA

A

rupture will happen soon –> immediate repair!

568
Q

when do you do surgery for peripheral artery disease of the lower extremities

A

to relieve sxs
to prevent impending necrosis
NO prophylactic surgery

569
Q

how to work up intermittent claudication

A

-if it doesn’t bother the pt that much, no workup needed
dx
-duplex to look for pressure gradient
-if there is a gradient, do arteriogram
tx
-can be stented or bypassed
-repair proximal before distal
-grafts near aorta (prosthetic), more distal grafts (saphenous vein)

570
Q

cannot sleep due to pain in calf, sitting up and dangling leg helps but leg becomes deep purple
-shiny, atrophic skin w/o hair, no peripheral pulses

A

rest pain

duplex –> arteriogram –> stent or surgery

571
Q

sudden painful, pale, pulseless, paresthetic, paralytic, cold extremity

A

arterial embolization

572
Q

how to dx and tx arterial embolization to extremities

A

doppler –> clot busters if early incomplete occlusion, embolectomy with fogarty for complete obstruction
-fasciotomy if revascularization is delayed

573
Q

poorly controlled HTN

  • sudden onset severe, tearing CP radiating to back and migrates down
  • unequal pulses in UE, wide mediastinum on CXR
A

aortic dissection

574
Q

how to work up aortic dissection

A
  • r/o MI with ECG and troops
  • dx with spiral CT
  • ascending aorta –> surgery
  • descending aorta –> control of HTN in the ICU
575
Q

skin cancer epidemiology

A

BCC > SCC > melanoma

576
Q

how to dx skin cancer

A

full thickness incisional (punch) bx at edge of lesion

577
Q

-raised waxy lesion, unhealing ulcer on upper face
-no mets, only local invasion
how to tx?

A

BCC

-tx with local excision with negative margins

578
Q
  • nonhealing ulcer, lower lip/face

- metastasize to LN

A

SCC

  • tx with wider margins +/- node dissection
  • XRT is an option
579
Q

asymmetric irregular borders, different colors, > 0.5 cm diameter
how to tx

A

melanoma
< 1 mm depth –> local excision
1-4 mm depth –> aggressive tx including node dissection
> 4 mm depth –> terrible prognosis
deeper lesions require wide margin excisions
mets can go anywhere at any time!!! it’s cray-cray

580
Q

strabismus can resolve spontaneously (t/f)

A

F

must correct ASAP to prevent amblyopia

581
Q

causes of amblyopia if not corrected in first 6-7 years

A

congenital cataracts

strabismus- light reflects from different areas of cornea

582
Q

white pupil in a baby…

A

ophthalmologic emergency!

could be retinoblastoma

583
Q
  • severe eye pain, frontal headache starting in the evening, halos around lights
  • pupil is mid-dilated, not reactive to light, cloudy green cornea, eyes feel hard as a rock
A

acute angle closure glaucoma

  • tx with laser
  • if no ophthalmologist, tx with topical pilocarpine drops/CA inhibitors (-zolamides) and systemic diuretics
584
Q
  • angina, exertional syncopal episodes

- harsh midsystolic murmur at right 2nd space

A

aortic stenosis

585
Q

how to dx and tx aortic stenosis

A

-echo –> surgical valve replacement if gradient > 50, CHF, angina, or syncope

586
Q

-wide pulse pressure, blowing high pitched diastole murmur in 2nd space

A

chronic aortic insufficiency

587
Q

how to dx and tx chronic aortic insufficiency

A
  • follow with medical therapy

- valve replacement if echo shows LV dilatation

588
Q

-endocarditis in drug addicts who suddenly develop CHF and new loud diastolic murmur at 2nd space

A

acute aortic insufficiency

589
Q

how to tx acute aortic insufficiency

A

emergency valve replacement and long term abx

590
Q
  • rheumatic fever in the past
  • dyspnea on exertion, orthopnea, PND, cough, hemoptysis
  • low pitched rumbling diastolic apical murmur
  • -> progress to be thin, cachectic, a fib
A

mitral stenosis

591
Q

how to dx and tx mitral stenosis

A

echo –> worse sxs require MV repair

592
Q
  • valvular prolapse, exertional dyspnea, orthopnea, afib

- apical high pitched holosystolic murmur radiating to axilla and back

A

mitral regurgitation

593
Q

how to tx mitral regurgitation

A

echo –> annuloplasty (valve repair)

594
Q

what to do with progressive unstable disabling angina

A

cardiac cath

  • intervene if at least 1 vessel has 70% stenosis and there is a good distal vessel
  • should still have good ventricular function
  • simple or single vessel –> stent
  • complex or triple vessel –> CABG
595
Q

dyspnea on exertion, hepatomegaly, ascites, square root sign, equalization of pressures on cath
how to tx?

A

chronic constrictive pericarditis

tx with surgery

596
Q

what do you do if you find a coin lesion of CXR

A

look for an old CXR to compare

597
Q

what is the initial workup for suspected lung cancer

A

CXR –> sputum cytology and CT scan

598
Q

if sputum not + for lung cancer, then you need a ______

A

biopsy (bronchoscopic or percutaneous)

if these aren’t successful, thoracotomy and wedge resection

599
Q

how to tx small cell lung cancer

A

chemo and XRT (NO SURGERY!!)

600
Q

what to do for central lung lesions vs. peripheral lung lesions?

A

central- pneumonectomy

peripheral- lobectomy

601
Q

minimum FEV1 is what?

A

800

602
Q

hilar mets can be removed with pneumonectomy (t/f)

A

T

603
Q

nodal mets at carina or mediastinum can be surgically resected (t/f)

A

F

604
Q

diplopia in pts with frontal or ethmoid sinusitis

A

cavernous sinus thrombosis

-admit, IV abx, CT, drainage

605
Q
  • coldness, tingling, muscle pain in arm + visual sxs and equilibrium issues
  • this occurs when you’re moving your arm
A

subclavian steal syndrome (stenosis at origin of a subclavian artery –> blood reverses in vertebral artery)

606
Q

how to dx and tx subclavian steal syndrome

A
  • need both vascular and neuro sxs (vascular alone suggests thoracic outlet obstruction)
  • dx with arteriogram
  • tx with bypass
607
Q

asymptomatic pulsatile abd mass

what is it and how to dx and tx

A

AAA
-dx with US or CT
< 4 cm –> observe
> 6 cm –> repair

608
Q

excruciating back pain in pt with AAA

A

retroperitoneal hematoma is forming, blowout into peritoneal cavity is about to happen –> emergency surgery!!!

609
Q

tender AAA

A

rupture will happen soon –> immediate repair!

610
Q

when do you do surgery for peripheral artery disease of the lower extremities

A

to relieve sxs
to prevent impending necrosis
NO prophylactic surgery

611
Q

how to work up intermittent claudication

A

-if it doesn’t bother the pt that much, no workup needed
dx
-duplex to look for pressure gradient
-if there is a gradient, do arteriogram
tx
-can be stented or bypassed
-repair proximal before distal
-grafts near aorta (prosthetic), more distal grafts (saphenous vein)

612
Q

cannot sleep due to pain in calf, sitting up and dangling leg helps but leg becomes deep purple
-shiny, atrophic skin w/o hair, no peripheral pulses

A

rest pain

duplex –> arteriogram –> stent or surgery

613
Q

sudden painful, pale, pulseless, paresthetic, paralytic, cold extremity

A

arterial embolization

614
Q

how to dx and tx arterial embolization to extremities

A

doppler –> clot busters if early incomplete occlusion, embolectomy with fogarty for complete obstruction
-fasciotomy if revascularization is delayed

615
Q

poorly controlled HTN

  • sudden onset severe, tearing CP radiating to back and migrates down
  • unequal pulses in UE, wide mediastinum on CXR
A

aortic dissection

616
Q

how to work up aortic dissection

A
  • r/o MI with ECG and troops
  • dx with spiral CT
  • ascending aorta –> surgery
  • descending aorta –> control of HTN in the ICU
617
Q

skin cancer epidemiology

A

BCC > SCC > melanoma

618
Q

how to dx skin cancer

A

full thickness incisional (punch) bx at edge of lesion

619
Q

-raised waxy lesion, unhealing ulcer on upper face
-no mets, only local invasion
how to tx?

A

BCC

-tx with local excision with negative margins

620
Q
  • nonhealing ulcer, lower lip/face

- metastasize to LN

A

SCC

  • tx with wider margins +/- node dissection
  • XRT is an option
621
Q

asymmetric irregular borders, different colors, > 0.5 cm diameter
how to tx

A

melanoma
< 1 mm depth –> local excision
1-4 mm depth –> aggressive tx including node dissection
> 4 mm depth –> terrible prognosis
deeper lesions require wide margin excisions
mets can go anywhere at any time!!! it’s cray-cray

622
Q

strabismus can resolve spontaneously (t/f)

A

F

must correct ASAP to prevent amblyopia

623
Q

causes of amblyopia if not corrected in first 6-7 years

A

congenital cataracts

strabismus- light reflects from different areas of cornea

624
Q

white pupil in a baby…

A

ophthalmologic emergency!

could be retinoblastoma

625
Q
  • severe eye pain, frontal headache starting in the evening, halos around lights
  • pupil is mid-dilated, not reactive to light, cloudy green cornea, eyes feel hard as a rock
A

acute angle closure glaucoma

  • tx with laser
  • if no ophthalmologist, tx with topical pilocarpine drops/CA inhibitors (-zolamides) and systemic diuretics
626
Q

eyelids are hot, tender, red, swollen

-febrile, fixed, dilated pupils, limited EOMI, pus in the orbit

A 
orbital cellulitis (ooh emergency)
-emergency CT and drainage
627
Q

what to do with chemical burns of the eye

A

massive irrigation with water for 30 min –> in ED, irrigate with saline and test pH

628
Q

flashes of light, floaters, snow storm, dark cloud

A

retinal detachment- emergency!

-tx with laser spot welding

629
Q

elderly with sudden loss of vision from one eye

A

embolic occlusion of retinal artery- emergency!

-breathe into paper bag, press and release on the eye –> vasodilator to shake clot into more distal location

630
Q

what about diabetics and eyes?

A

type II need ophthalmologic evaluation

type I can wait a little

631
Q

young men with sudden severe testicular pain

-fever, pyuria, testis is swollen and tender but in normal position, tender cord

A

acute epididymitis

-tx with abx and r/o torsion with US

632
Q

neck mass at anterior edge of SCM

sometimes have opening and blind tract in the skin

A

brachial cleft cyst

633
Q

mass at base of neck, large and mushy thing occupying supraclavicular area

A

cystic hygroma

-CT scan then surgical removal

634
Q

recently enlarged LN are usually cancer (T/F)

A

F

do H&P and re-evaluate in 3-4 weeks

635
Q

young person with multiple enlarged nodes, low grade fever, night sweats
what is it, dx, tx

A

lymphoma
dx with FNA, node removal and pathology
tx with chemo

636
Q

mets to the supraclavicular nodes usually come from where

A

lung or intraabdominal tumors

637
Q
  • old men who smoke, drink, have bad teeth and AIDS

- hoarseness, persistent painless ulcer in the floor of the mouth, persistent unilateral earache

A

SCC of head and neck

  • these often metastasize to nodes in the neck
  • dx with tripe endoscopy, bx, and CT
  • tx with resection, radical neck dissection, XRT, platinum chemo
638
Q

adults with sensory hearing loss in one early only

A

acoustic nerve neuroma

dx with MRI

639
Q

gradual unilateral facial nerve paralysis

A

facial nerve tumors

dx with MRI

640
Q

parotid mass with no pain or facial nerve paralysis

A

pleomorphic parotid adenoma with chance for malignancy

641
Q

parotid mass that is hard or painful

A

parotid cancer

  • can do FNA but DO NOT DO AN OPEN BIOPSY
  • tx and bx with parotidectomy (sparing facial nerve)
  • if tumor is malignant, sacrifice the nerve and do a graft
642
Q

unilateral ENT problems in toddlers

A

foreign bodies

endoscopy under anesthesia

643
Q

abscess of mouth floor due to bad tooth infection

A

Ludwig angina

-I&D but may need to intubate and trach

644
Q

sudden paralysis of CNVII for no apparent reason

A

Bell palsy

early admin of antiviral medications

645
Q

pt has normal facial nerve function at time of trauma but later, they have a facial nerve deficit

A

this is due to swelling and will resolve by itself

646
Q

diplopia in pts with frontal or ethmoid sinusitis

A

cavernous sinus thrombosis

-admit, IV abx, CT, drainage

647
Q

epistaxis in children

A

-due to nose picking
-anterior septum
phenylephrine spray, local pressure

648
Q

epistaxis in teens

A
  • cocaine
  • posterior packing
  • nasopharyngeal angiofibroma requires surgical resection
649
Q

epistaxis in old ppl

A
  • control BP
  • posterior packing
  • maybe surgical ligation
650
Q

2 causes of dizziness and how to tx each one

A

inner ear
-room is spinning –> meclizine, phenergan, diazepam
brain
-unsteady but room is stable –> neurologic workup

651
Q

vascular neurologic issues are ____ in onset
_____ have severe headache
_____ have no headache

A

sudden

  • hemorrhagic
  • occlusive
652
Q

constant, progressive, severe HA worse in the morning, blurred vision, papilledema, projectile vomiting, +/- focal deficits

A

brain tumor

653
Q

what to do about TIAs

A

duplex –> arteriogram if needed –> CEA

654
Q

sudden onset of neuro deficits w/o HA.. what is it and what’s the workup

A

ischemic stroke

  • assess with CT –> give tPA if there is no hemorrhage
  • tx with rehab
655
Q

uncontrolled HTN with sudden onset of severe HA and neuro deficits … what is it and how to approach ?

A

hemorrhagic stroke

-evaluate with CT and tx by controlling HTN and rehab

656
Q

sudden onset of the “worst headache of their life”
no neuro deficits
+/- meningeal irritation

A

subarachnoid hemorrhage from a berry aneurysm

-CT scan –> arteriogram –> embolize or clip

657
Q

bradycardia and HTN in the setting of brain tumor

A

Cushing reflex

658
Q

how to work up brain tumor

A

MRI –> surgery

-treat increased ICP with mannitol, hyperventilation, and high dose steroids

659
Q

inappropriate behavior, ipsilateral optic nerve atrophy, contralateral papilledema, anosmia

A

tumor at base of frontal lobe

660
Q

youngsters who are short for their age with bitemporal hemianopsia, calcified lesion above the sella

A

craniopharyngioma

661
Q

amenorrhea, galactorrhea in young women

what could it be and how to work it up?

A

prolactinoma

  • r/o pregnancy and hypothyroidism
  • determine prolactin level
  • MRI the sella
  • tx with bromocriptine… if this doesn’t work or if they want to get pregnant, then surgically remove it
662
Q
  • huge hands, feet, tongue, jaws

- HTN, DM, sweaty hands, HA, wedding bands and hats don’t fit

A

acromegaly

  • workup with somatomedin C levels and pituitary MRI
  • tx with surgery but can also do XRT
663
Q

person gets into accident b/c they have issues with peripheral vision
they had a b/l adrenalectomy for Cushings years ago

A

this is bilateral hemianopsia caused by pituitary adenoma (Nelson syndrome)
-MRI and resect

664
Q

h/o pituitary tumor + acute HA, vision deterioration, bilateral pallor –> stupor and hypotension

A

pituitary apoplexy (bleeding and destruction of a pituitary tumor)

  • tx with steroid replacement and eventual replacement of other hormones
  • evaluate with MRI or CT
665
Q

loss of upper gaze, “sunset eyes” (Parinaud syndrome)

A

pineal gland tumor

666
Q

stumbling around, truncal ataxia, knee to chest position to relieve HA in children

A

posterior fossa tumor

667
Q

brain tumor-like presentation in the setting of fever, otitis media/mastoiditis

A

brain abscess

-dx wit CT and tx with resection

668
Q

most tumors affecting the spinal cord are ____ and ______

A

metastatic and extradural

  • they may fx the spine or compress the cord
  • dx with MRI
  • tx with neurosurgical decompression
669
Q

pain when standing up straight, no pain if hunched over

A

neurogenic claudication

-MRI –> surgical decompression

670
Q

sharp shooting pain the face caused by touching, unshaven area of the face

A

trigeminal neuralgia

  • get an MRI to r/o organic lesions
  • tx with anticonvulsant and if needed, radio frequency ablation
671
Q

months after a crush injury, pt gets constant burning pain that’s aggravated by the slightest stimulation
-extremity is cold, cyanotic, and moist

A

reflex sympathetic dystrophy

  • dx with sympathetic block
  • tx with surgical sympathectomy
672
Q

severe sudden testicular pain

-swollen testis, tender, “high riding” with “horizontal lie,” nontender cord

A

testicular torsion

-immediate surgery + orchiopexy

673
Q

young men with sudden severe testicular pain

-fever, pyuria, testis is swollen and tender but in normal position, tender cord

A

acute epididymitis

-tx with abx and r/o torsion with US

674
Q

pt passing kidney stone suddenly has chills, fever spike and flank pain

A

obstruction and infection of urinary tract

-IV abx, immediate decompression of urinary tract with stent, nephrostomy, etc

675
Q

urinary frequency, painful urination, small amounts of cloudy and smelly urine in women of repro age

A
  • UTI (cystitis)
  • tx with empiric antimicrobial
  • for pyelonephritis and UTI in children or young men, get cultures and uro workup to r/o obstruction
676
Q

what consists of a urinary workup?

A

IVP (kidney, collecting system, ureter, some bladder)
CT for renal tumors
US for dilation/obstruction
cystoscopy for bladder mucosa

677
Q

chills, high fever, n/V, flank pain

A

pyelonephritis

tx: admit, IV abx, IVP or sonogram

678
Q

older men with chills, fever, dysuria, urinary frequency, diffuse low back pain, tender prostate on rectal exam

A

acute bacterial prostatitis

tx: IV abx, no more rectals

679
Q

newborn boy not urinary (r/o metal stenosis)

A

posterior urethral valves

  • cath to empty the bladder
  • dx: voiding cystourethrogram
  • tx: endoscopic fulguration/resection
680
Q

urethral opening on ventral penis

A

hypospadias

-do not circumcize b/c you need that tissue for reconstruction

681
Q

always work up hematuria from trivial trauma and UTI in children (T/F)

A

T

682
Q

child with burning on urination, frequency, low abd and perineal pain, flank pain, fevers, chills

A

vesicoureteral reflux and infection

  • tx: empiric abx –> cultured guided abx, IVP, voiding cystogram to look for reflux
  • if reflux is present, long term abx until child grows out of it
683
Q
  • girl feels need to void and voids normally at appropriate interval
  • BUT she is wet with urine all the time
A

low implantation of the ureter

-dx with PE, IVP –> tx with surgery

684
Q

adolescent binge drinks and then gets colicky flank pain

A

ureteropelvic junction obstruction

685
Q

most hematuria is ____ but work it up b/c most cancers of kidney and ureter and bladder present with hematuria

A

benign

686
Q

hematuria workup

A

IVP/CT for renal or ureteral tumors

cystoscopy for bladder cancer

687
Q

hematuria, flank pain, flank mass, hypercalcemia, erythrocytosis, elevated liver enzymes

A

renal cell carcinoma

688
Q

how to dx and tx renal cell carcinoma

A

IVP- renal mass
US- solid mass
CT- heterogenic solid tumor

if clinical picture suggests RCC, CT may be done first
tx with surgery ONLY

689
Q

hematuria, irritative voiding sxs, smoking history

A

bladder cancer

690
Q

how to work up suspected bladder cancer

A

IVP –> cystoscopy
tx with surgery, intravesical BCG
high rate of recurrence means you need life long follow up

691
Q

hard discrete nodule on DRE, elevated PSA

A

prostate cancer

-stop surveillance at age 75

692
Q

how to dx and tx prostate cancer

A

-dx: transrectal needle bx
-CT helps with planning tx
-tx: surgery and/or XRT
bone mets respond for androgen abalation

693
Q

young men with painless testicular mass

A

testicular cancer

694
Q

how to dx and tx testicular cancer

A
  • bx with radical orchiectomy by inguinal route
  • take prep alpha fetoprotein and beta HCG blood samples for f/u
  • tx: maybe surgical LN dissection, most are sensitive to XRT and platinum chemo even when metastatic
695
Q

men who have h/o BPH with palpable distended bladder

A

acute urinary retention

  • place indwelling catheter for 3 days
  • 1st line long term therapy = alba blockers
  • 5 alpha reductase inhibitors for very large glands
  • TURP rarely done
696
Q

how to tx postop urinary retention

A

straight cath and then indwelling catheter

697
Q

middle aged women with previous pregnancies who leak urine when they sneeze or laugh

A

stress incontinence

-tx with surgical repair of the pelvic floor

698
Q

how to prevent kidney stones

A

drink water

699
Q

most kidney stones are visible on X-ray (t/f)

A

T

700
Q

common causes of pneumaturia (fistula between bladder and GI)

A
  1. sigmoid colon- diverticulitis
  2. sigmoid cancer
  3. bladder cancer
701
Q

how to work up pneumaturia

A

CT to see diverticular mass
sigmoidoscopy to r/o cancer
tx with surgery

702
Q

how to tx organic impotence

A

viagra, vascular surgery, suction devices, prosthetic implants

703
Q

the only absolute contraindication to organ donation is __________

A

HIV +

704
Q

transplantation: __________ rejection
vascular thrombosis occurring within minutes due to _______
prevent by _____ and ________

A

hyperacute
preformed antibodies
ABO matching and lymphocytotoxic crossmatch

705
Q

transplantation: ______________ rejection
signs of organ dysfunction at 5 days - 3 months
liver: what do you do?
heart: what do you do?
treatment?

A

acute
liver- r/o biliary obstruction by US and vascular thrombosis by doppler
heart- routine ventricular bus at set intervals
tx- steroid boluses, OKT3

706
Q

transplantation: _____ rejection

- gradual insidious loss of organ function

A

chronic

  • no prevention, no tx
  • bx to r/o treatable acute rejection
707
Q

someone comes to you with sxs of long standing GERD… what do you do?

A

tx the symptoms

recommend endoscopy and biopsy to assess their esophagus

708
Q

what to do with Barrett’s esophagus

A 
medical management (esp if it hasn't already be instituted)
fundoplication
if dysplastic, then surgical resection
709
Q

if you want to do a nissen fundoplication, you should do what first?

A

all the esophageal studies (swallow, endoscopy, biopsy, manometry, gastric emptying, etc)

710
Q

how to dx achalasia

A

Ba swallow then manometry

711
Q

you suspect esophageal cancer.. what do you do?

A

swallow –> endoscopy and biopsy –> CT to assess extent

712
Q

mallory weiss tear. what do you do?

A

endoscopy +/- photocoagulation for dx and tx

713
Q

esophageal perforation. what do you do?

A

dx with swallow

tx with emergency surgery

714
Q

how to work up stomach cancer

A

endoscopy and biopsy –> CT

715
Q

patient comes with a history suspicious for hemorrhoids, what do you do?

A

proctosigmoidoscopic exam!!! not home remedies b/c you must r/o cancer

716
Q

if given choice, choose __________ for initial dx of left colon cancer

A

proctosigmoidoscopy then colonoscopy later on

717
Q

fistula in ano… what do you do?

A

r/o cancer with proctosigmoidoscopy

then elective fistulotomy

718
Q

GI bleeding
upper GI bleed has been ruled out
what do you do?

A

you can do the thing regarding bleeding rate… or it might be always safe to pick tagged red cell scan

719
Q

a really sick patient (in the ICU) vomits up blood… what is it most likely and how to tx it?

A

stress ulcer
dx and attempt to tx with endoscopy
if that doesn’t treat it, consider arterial embolization

720
Q

how to dx acute cholecystitis

A

US

if US is equivocal, then get HIDA

721
Q

eczematoid lesion of the areola

A

Paget’s disease of the breast

722
Q

punch biopsy in breast stuff only ok for ________ and _______
otherwise, you need incisional or excisional biopsy

A

Paget’s disease

orange peel skin (inflammatory breast ca)

723
Q

infiltrating ductal carcinoma near the nipple in a small breast

A

modified radical mastectomy (MRM)

  • no need for radiation
  • also the old unmodified radical mastectomy no longer done
724
Q

other breast cancers besides the standard infiltrating ductal carcinoma:

  • lobular
  • inflammatory
  • others
A

lobular- higher incidence of b/l but not enough to do b/l mastectomy
inflammatory- terrible prognosis
others- tx it like infiltrating ductal carcinoma, slightly better prog than IDC

725
Q

DCIS tx

A

if in one quadrant, lumpectomy + XRT

if multicentric, simple mastectomy

726
Q

inoperable breast ca… what can you do?

A

chemo is preferred for palliation

727
Q

woman has lumpectomy and axillary dissection for IDC… there are some positive LN. what do you do?

A

chemo as adjuvant therapy

728
Q

patient with a h/o breast ca has bad headaches

A

do CT scan to look for mets

tx with high dose steroids and XRT

729
Q

pt has a “hot” thyroid adenoma.. what do you do before surgery?

A

beta blocking

730
Q

“lateral aberrant thyroid” is really __________

A 
metastatic cancer (follicular carcinoma in the thyroid)
do a thyroid scan and then tx with surgery
731
Q

you suspect primary hyperparathyroidism… what do you do?

A

PTH levels
scan to locate the adenoma
surgery

732
Q

patient presents with hyper-aldo sxs? what do you do?

A

get aldo and renin levels
postural determinations to differentiate hyperplasia vs. adenoma
hyperplasia- tx with aldactone
adenoma- tx with CT/MRI and then surgery

733
Q

how to work up coarctation of the aorta

A

CXR- rib scalloping
spiral CT or MRA
surgery

734
Q

how to dx malrotation in peds

A

contrast enema- safe, less reliable

upper GI- not as safe, more reliable

735
Q

baby with green vomit
no double bubble
multiple air fluid levels and distended loops of bowel

A

intestinal atresia

736
Q

low cardiac index without high LVEDP indicates what?

A

you need to increase fluid intake

737
Q

orbital cellulitis. what do you do?

A

emergency consult

CT and drainage

738
Q

don’t do open biopsies of _______ and ________

A

neck LN suspicious for SCC of head and neck

739
Q

how to dx facial nerve tumor

A

gadolinium enhanced MRI

740
Q

paraplegic holds their urine for a while and develops headache, perspiration, and bradycardia
what is it and how to tx?

A

autonomic dysreflexia

tx: empty the bladder, alpha blockers, CCBs (nifedipine)

741
Q

acute bacterial prostatitis

what do you NOT do??

A

rectal exam

742
Q

uses octreotide

A 
bleeding esophageal varices
dumping syndrome 
carcinoid tumors 
high output fistula
glucagonoma
743
Q

posterior urethral valves. dx and tx?

A

dx: voiding cystourethrogram
tx: surgical resection

744
Q

hematuria from minor trauma in kids… what to do?

A

look for congenital anomalies

do sonogram +/- IVP

745
Q

little boy with UTI

A

look for vesicoureteral reflux

  • do IVP and voiding cystogram
  • also, obviously give abx
746
Q

UPJ obstruction

dx and tx?

A

dx: US
tx: surgery

747
Q

workup of painless hematuria in old person

A

CT and cystoscopy

748
Q

pneumaturia…. what test do you get first?

A

CT

Surgery (5 decks)

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