Surgery Pestana Flashcards Preview

00Step 2 > Surgery Pestana > Flashcards

Flashcards in Surgery Pestana Deck (675):
1

which pts do not require an airway placed

fully conscious and normal voice

2

which pts require an airway

going to lose airway soon:
-expanding hematoma (quick induction then intubate)
-subcutaneous air/tissue emphysema

need airway now:
-unconscious
-gurgly noises
-spinal cord injury (airway needed first)
-facial trauma (cricothyroidotomy

3

what does subcutaneous air/tissue emphysema indicate?

signifies tracheobronchial injury

4

how do you manage tracheobronchial injury

intubate over fiberoptic bronchoscope

5

how do you you manage a pt with spinal cord injury and needing an airway

(pts will present with neck pain pro unable to move extremities)

establish airway first:
-nasotracheal over fiberoptic bronchoscope
-do not move/hyperextend neck
-do not pick CT/XR as first action

6

how do you evaluate breathing?

-pts are starting their own breathing motion
-both lungs are spontaneously inflating
-O₂ is being put into blood (O₂ sat)

7

how does a classic trauma shock pt present?

BP <90
tachy, poor quality pulse
diaphoretic, pale, cold, shivering, anxious
trauma scenario

8

what are the 3 conditions responsible for shock in trauma

bleeding
pericardial tamponade

9

what is the most common cause of shock in trauma

hypovolemic hemorrhagic shock
"bleeding"

10

where hypovolemic hemorrhagic shock present

>1.5L lost
not enough space in head
neck and arm bleeds are visible
pericardial sac --> tamponade + high CVP
pleural cavity --> seen on CXR
abdomen, pelvis, thighs can hide big bleeds (pelvic instability, femur fractures)

empty (non-distended) veins

11

how do you manage hypovolemic hemorrhagic shock

Emergency:
-ex lap

STOP BLEEDING before prioritizing resuscitation fluids, w/ exceptions
-"scoop and run" if you're near medical help and you know where bleeding is (direct finger pressure)

2 large-bore (16 gauge) peripheral IVs:
arms, ankles, femoral vein
-1-2 L balanced electrolyte soln (LR; sugar = osmotic diuresis = invalidate UOP)
-followed by blood as available

eventually monitored by pt response and UOP/CVP

last-resort access in child:
intraosseous cannulation in proximal tibia
-20mL/kg initial bolus

12

how do you identify pericardial tamponade in trauma setting

trauma to chest
DISTENDED VEINS; high CVP >20-25 (must be mentioned)
pt is BREATHING FINE

13

how do you manage trauma pericardial tamponade

it's based on clinical dx,
don't ask for CXR or blood gases

empty the pericardial sac (window, pericardiocentesis, decompression)

meanwhile, give fluid and blood
-heart is not failing, the ventricle just cant feel blood from the pressure buildup
-more blood = more to squeeze = somewhat improve status

fix the underlying problem:
-start w/ sternotomy if tamponade is the only problem

14

how do you identify tension pneumothorax in trauma setting

trauma to chest
DISTENDED VEINS AND BREATHING DIFFICULTY
-labored breathing/no breath sounds/tympany
-deviated trachea
-high CVP

15

how do you manage tension pneumothorax

based on clinical dx,
don't ask for CXR, CT, or blood gases

immediately decompress pleural space's pressure
-large bore needle in 2nd intercostal pleural space
-follow with chest tube on suction and water seal

16

what 3 things can cause shock in non-trauma setting

bleeding
cardiogenic
vasomotor

17

how does non-trauma bleeding shock happen

spontaneous; ruptured ulcer

18

how does cardiogenic shock happen

non-trauma setting:
-Myocardial infarction
-high CVP; DISTENDED NECK VEINS

19

how do you manage cardiogenic shock

Tx the MI

do not give fluids (this is intrinsic shock)

20

what is vasomotor shock

loss of peripheral vascular tone
-low CVP, low BP, tachy
-WARM AND FLUSHED

anaphylaxis
-bee sting, penicillin allergy, spinal anesthesia)

21

how do you manage vasomotor shock

vasoconstrictors
restore vascular tone that's been lost

(volume replacement does not hurt this pt)

22

which head traumas need to be taken to the OR vs ER?

OR:
-penetrating trauma (repair entry spot and control possible bleeding)
-comminuted depressed skull fracture

ER/Other:
-blunt
-linear skull fracture
-scalp laceration

23

what is required for every pt who has LOC

CT scan

24

what is indicated by:
ecchymosis in eyes or behind ear
clear fluid dripping from nose

basilar skull fracture

25

how are basilar skull fractures managed

evaluate airway
CT to look for potential hematoma
**also get cervical XR or CT head+neck to evaluate for neck injury, since this is big trauma

-the skull fracture itself doesn't need tx
-Abx are not indicated

26

what head injury is caused by BIG trauma (like highway car crash)

subdural hematoma

27

how does subdural hematoma present on CT

concave semilunar crescent shaped hematoma
midline structures may shift to opposite side

28

management of subdural hematoma?

(neurosurgeons do craniotomy/decompression if structures are shifted)

control ICP:
hyperventilation
avoid fluid overload

29

what is prognosis of subdural hematoma

grim prognosis-
original trauma does a lot of damage

30

how does chronic subdural hematoma present

elderly and alcoholics
-brain shrinks, can easily rattle, and tear venous sinus

slow bleed
-ex. become senile over 3-4 weeks

31

how do you manage chronic subdural hematoma

decompress/evacuate the hematoma

memory loss will return to normal

32

how does epidural hematoma present in pt and on CT

2/2 trivial trauma (baseball bat)
pt will be completely normal between LOC (LUCID INTERVAL)
blown pupil on ipsilateral side of injury

CT:
biconvex/lens shape
midline structures shift to opposite side (especially w/ materializing sings)

33

how do you manage epidural hematoma

emergency craniotomy to evacuate the clot

excellent prognosis

34

what is a major concern of an acute hematoma?

CNS damage:
-the initial trauma's damage isn't fixable
-hematomas may push midline structures, which is fixed with surgery
-swelling frequently follows trauma and ICP (mostly a medical fix)

35

how does a diffuse axonal injury present in pt and on CT

trauma, coma, bilateral fixed pupils

CT:
-diffuse blurring of grey/white interface
-multiple small hemorrhages
-no single large hematoma or displaced midline structures

36

how do you manage diffuse axonal injury

no indication for surgery (no single large hematoma or displaced structures)

correct the high ICP without pushing the pt to dehydration

37

what are the absolute indications to go to the OR in neck trauma pts

any penetrating injury where pt is rapidly deteriorating
(low BP, not responding to fluids)

all GSW to middle neck
(asymptomatic stab to middle neck = observe)

any evidence of injury to important structures
(spitting up blood = tracheobronchial)
(hematoma = major vessel)

38

how do you manage upper neck trauma

need proximal and distal control before fixing
-difficult to operate
-angiogram to identify injury
-radiologist to embolize bleeding vessel

39

how do you manage base of neck trauma

Dx studies before operating
-arteriogram, esophagram, bronchoscopy, etc

40

what type of spinal cord injury presents with:
different sides/different functions
(R trauma = loss of proprioception on R; loss of pain on L)

Hemisection
AKA Brown Sequard Syndrome

41

what type of spinal cord injury presents with:
loss of motor, pain, temp on both sides distal to injury
with preservation of vibratory/positional sense

anterior cord syndrome

42

how does anterior cord syndrome happen

blow out of vertebral body
-spinal cord is posterior to vertebral body
-anterior section is damaged first
-posterior cord is preserved

can also be seen with vascular puppy injury

43

what spinal cord injury occurs with neck hyperextension

central cord lesion

44

how does central cord lesion present

neuro damage in UE
LE largely unaffected
(UE travels closer to center of cord)

45

what does some evidence suggest is helpful in improving outcome of spinal cord lesions?

high dose steroids ASAP

46

what are the bone clues of big chest trauma

sternum
first rib
scapula

47

what do you need to look for in major chest trauma

traumatic transection of aorta

48

how do you manage penetrating chest trauma

penetrating trauma rarely requires surgery in the chest

however, a blunt trauma can cause a penetrating trauma, like when a rib is broken and pierces lung to create a penetrating scenario

49

what are 3 things you need to consider with blunt chest trauma

pulmonary contusion
myocardial contusion
traumatic transection of aorta

50

what presents with "white out" lungs on CXR

pulmonary contusion

51

how do you determine if pulmonary contusion needs respirator, fluid restrictions/diuretic?

blood gases

52

how do you identify myocardial contusion

EKGs and cardiac enzyme monitoring

may be 2/2 sternal injury (tenderness, gritty bone-on-bone feeling by palp)

53

which portions of the aorta move where in a traumatic transection of the aorta 2/2 deceleration injury

ascending moves forward
descending stays put/stops

most of these pts die on scene

54

what tears in a small subset of aorta transection pts?

small subset of pts who don't die immediately get transection of intima/media with intact adventitia

a hematoma forms but is contained for several hours (asymptomatic)

55

what is the work up for traumatic transection of aorta

widened mediastinum = high suspicion (not diagnostic)

spiral CT

arteriogram if at least 1 of those 2 is positive

56

how does a pt develop pneumonia 2/2 rib fracture

elderly pt
hurts to breathe, avoids breathing, atelectasis, pneumonia

57

how do you manage rib fracture to prevent pneumonia

alleviate pain in a way that does not hinder breathing
-local anesthetic/nerve block that alleviates focal pain (Lidocaine)
-still allows pt to drive breathing

do not bind chest or prescribe heavy narcotics

58

what injury presents w/ large flap-like wound; sucking and air trapping with every breath

sucking chest wound

59

what happens to sucking chest wound if left untreated

pt will develop tension pneumo
(air trapping with every breath)

60

how do you manage sucking chest wound

occlusive dressing:
-vaseline gauze stuck to chest wall
-prevents air moving in during inspiration
-taped on 3 sides to push some air out during expiration

61

what injury presents w/ paradoxical breathing

flail chest

(caves in with inhalation; bulges with exhalation)

62

how do you manage flail chest

tx underlying pulmonary contusion
-fluid restriction and diuretics (sensitive to fluid overload)
-give colloid over crystalloid
-measure blood gases to watch for deterioration and intubate as needed
-need a preventative chest tube if you intubate

continue to monitor for less obvious injuries:
-MI, transection, etc

63

what presents with shock, distended neck veins, and no breath sounds

tension pneumothorax

64

how do you manage tension pneumo

needle for air escape

65

what presents with penetrating trauma, STABLE VITALS, no breath sounds?

plain pneumothorax

66

how do you manage plain pneumothorax

CXR first
-no need to rush with placing an emergency needle

then chest tube in 2nd intercostal space

67

what presents with penetrating trauma, SOB, stable vitals, no breath sounds at base, dull to percussion, faint/distant breath sounds at apex?

hemothorax

68

how do you manage hemothorax

CXR first
-pt is not actively dying; confirm hemothorax

69

where are most pts bleeding from in a hemothorax

most are bleeding from lung (a low pressure circuit)
-bleeding usually stops on its own (seldomly need to operate)

70

how do you manage a hemothorax

if there's penetration, there's risk of infection/empyema

chest tube to evacuate pleural space

71

how can you identify bleeding source in hemothorax

place a chest tube:

lung bleed = some bleeding that tapers in next hour

systemic bleed = significant bleed and hypotension (commonly intercostal)
-sums to 600cc in 6 hours
-need a thoracotomy to stop bleed

72

what does a large, single air/fluid level mean

need to manage both blood and air conditions in the lungs

begin with a chest tube

73

what does multiple air/fluid levels in chest mean

bowel in chest

74

how does bowel in chest present

traumatic rupture of diaphragm
always L side
need abdominal surgical correction
imaging shows NG tube tip curve up into the chest

75

what are 4 causes of air in chest

esophageal perforation
tension pneumo
major tracheobronchial injury
air embolism (rare)

76

what scenario would you connect w/ esophageal perforation

ex. pt had endoscopy and now has air in chest

77

how do you confirm dx of major trachobronchial injury

something has ripped in 2:
fiberoptic bronchoscopy to guide the airway/visualization to confirm dx

78

how would you get air embolism sudden death in post-trauma intubated pt

rare

chest tube in pleural cavity
pt was previously hemodynamically stable
sudden cardiac arrest
injury to major bronchus and adjacent major vessel
respirator blows air into lung, leaks to vessel, travel to ventricle --> arrest

79

how would you get air embolism sudden death in an awake pt

major vein near SVC becomes open to air in awake pt
if it happens when pt is inhaling to give neg pressure, it may suck enough air into the ventricle to make it foam --> arrest

put pt in Trendelenburg L side down; tube to suck air; cardiac massage

many pts die

80

how does fat embolism present

severe trauma with long bone fractures
disorientation 12 hors later
petechial rash in axilla and neck
febrile, tachy
RESPIRATORY DISTRESS and hypoxemia
low platelets

CXR shows bilateral fat infiltrate

81

how do you manage fat embolism

respiratory support and blood gas monitoring

82

what are the 3 circumstances where ex lap is required

every GSW to abdomen (below nipple line)

stab wound with clear penetration into abdominal cavity

penetrating or blunt trauma where pt develops acute abdomen

83

what is the prep process for ex lap

indwelling catheter

large bore venous lines

broad spectrum Abx

84

what are cons of diagnostic peritoneal lavage

invasive: cut belly + catheter

only gives yes/no; doesn't give origin, or whether or not bleeding will stop naturally


vignette must say pt is hemodynamically unstable / needing resuscitation***
otherwise, you'd get a CT

85

what are the pros of emergent CT scan

excellent to see presence of blood and source of bleeding

noninvasive

however, if pt is in shock/crashing, cannot leave ER to get CT scan
---must be hemodynamically stable (otherwise,get a DPL)

86

how is a splenic laceration/ rupture handled

surgeons will do everything possible to repair rather than remove a spleen, esp in children

87

when is a splenectomy (vs spleen repair) indicated

shattered beyond repair

other critical life-threatening injuries that require time/attention

88

what changes in a pt's immune status after a splenectomy

pt now needs immunizations against encapsulated bacteria to prevent sepsis
-pneumovax for pneumococcus
-immunize for H influenza meningococcus

89

when should you suspect a coagulopathy in an abdominal trauma pt

multi-trauma pt requiring massive blood transfusions
>10-12 units of blood

blood oozing from all dissected surfaces and IV sites

hypothermia + acidosis

90

how should you manage blood oozing from dissected surfaces and IV sites

pt has a coagulopathy

ideally, you'd do labs to determine what factor the pt needs,
but there's no time

shotgun approach:
give FFP and plt bags

91

what is pt's temp when oozing blood from IV sites?

nl core temperature

92

how do you handle a coagulopathy with hypothermia + acidosis

stop operation ASAP

give FFP and plts

pack all areas that are bleeding

rewarm and tx the coagulopathy before resuming operation

93

what is dx for surgical pt with abdominal wall edges that cannot be closed without tension

abdominal compartment syndrome

pt usually has lengthy ex lap procedure for multi-trauma abdomen
tension cutting through sutures, hypoxia, renal failure

94

what is the complication of pulling closed an abdomen w/ compartment syndrome

pulling closed --> unable to bleed, perfuse kidneys --> kidney failure

95

how is abdominal compartment syndrome managed

temporary closure w/ plastic or mesh stapled around opening

96

how can you identify a pelvic fracture

bleeding helped by fluids

pelvic hematoma

nearby viscera injury
-rectum and urinary bladder
-vagina (F)
-urethra (M)

97

how do you manage a pelvic hematoma

leave alone if not expanding

98

how can you evaluate a pelvic fracture

proctoscopic / pelvic exam

99

how do you manage a pelvic fracture

difficult to stop pelvic bleeding- unable to reach it easily in the OR

100

what is the hallmark of urological injury

trauma with hematuria

101

where could the blood be coming from in a urological injury

kidney, bladder, or urethra (M)

102

what does this story hint at as a source of urological bleed:

broken ribs with no fractured pelvis; flank injury

Kidney injury as source of bleeding

103

how do you manage kidney injury

a retrograde cystogram will be nl

CT scan next

most blunt kidney injuries don't require surgical repair
-RARE possible AV fistula development --> overload circulation --> HF --> bruit

104

what does this story hint at as a source of urological bleed:

pelvic fracture; blood at meatus; resistance from foley

bladder injury

105

where will dye appear on cystogram in a dome vs base/trigone of bladder injury

dome: dye will be seen in picture

base/trigone: dye will extravasate posterior/extraperitoneal; dye will not be seen
--you need a 2nd picture to identify this leak

106

what does this story hint at as a source of urological bleed:

blood in meatus

bladder or urethra injury

107

what is the next step when blood in meatus has been found

retrograde urethrogram w/ dye to find source of bleed: either bladder or urethra

do NOT place foley w/ evidence of potential urethral injury

108

what does this story hint at as a source of urological bleed:

high-riding prostate; sensation of needing to urinate but cannot

posterior urethra injury

109

how should you work up microhematuria in an adult vs pediatric pt

adult: inconsequential
big trauma justifies microhematuria

pediatric, esp w/ small trauma:
hematuria may be first sign of congenital abnormality or urinary tract
--need further studies

110

what should you order in a scrotal hematoma

sonogram to evaluate testicles

111

what injury results from "slip in shower" story

penile shaft hematoma

112

what is the complication in a penile shaft hematoma

fracture of the tunica albugenia / corpora cavernosa

113

how do you manage penile shaft hematoma

prompt surgical repair is indicated

114

what injury do you suspect in penetrating injury traveling antero-medial thigh

femoral artery/vein

115

how do you manage a femoral artery/vein injury

arteriogram, even if pt has normal pulses

hematoma needs immediate surgical exporation

116

what should you focus on first if pt has a combined vasculature, nerve, and bony injury

greatest urgency is vascular
--repair/recovery is very technical

however, you should set the bones first
--repair requires violent maneuvers that could undo your intricate vascular repair

nerve repair last

117

when and where is compartment syndrome likely to happen

likely to happen after prolonged ischemia --> reperfusion

most likely in the forearm and lower leg
--potentially permanently disabling

118

extent of GSW damage based on type of gun?

bigger bullet = more damage

low velocity <1500 ft/sec = injury limited to path of bullet
(civilian weapon)

high velocity >3000 ft/sec = E is dispersed into tissue; creates column of destruction; large exit wound
(hunting rifle, ex.)
likely needs debridement and amputation

119

what lab value makes you suspect a crush injury

myoglobinemia / myoglobinuria

--crush injury frees up myoglobin into blood --> kidney --> renal failure

120

how should you manage a crush injury

IV fluids, osmotic diuretics to protect kidneys

monitor serum K (released from crushed muscle cells)

possible fasciotomy 2/2 compartment syndrome

121

what are 3 types of thermal burns

confined environment burn

circumferential burn

small patch burn

122

what should you think of with a confined environment burn

think respiratory burn (chemical burn of upper respiratory tract)

123

how do you manage an upper respiratory burn

confirm dx with fiberoptic bronchoscopy

monitor with blood gases
---only tx is via respiratory support (no steroids, Abx, or airway)

tx w/ 100% O₂ (shortens the life of carboxyhemoglobin)

124

what should you suspect in a dry, white, 3rd degree burn called

circumferential burn

125

what happens in a circumferential burn

fluid escapes circulation and becomes trapped as edema

cuts off circulation to extremity

126

how do you manage circumferential burn

monitor circulation in that extremity
(pulse, cap refill, Doppler)

Escharotomy to enable skin to swell
--can do at bedside (skin is already anesthetized and contaminated)
--if the burn is on the trunk: escharotomy at breast plate w/ 4 cuts

127

what happens in a small patch burn

swelling underneath can easily push up eschar
--nothing happens

128

which burn is "the gift that keeps on giving"

chemical burn
--will continue to burn until chemical is removed
--eliminate the chemical ASAP

129

how do you manage a chemical burn

acid (battery) or alkaline (Drain-O) is the same

do not play chemist
remove clothing
running water for 30 min before going to ER

--exception: drinking liquid plumber (you can't drink water for 30min)
--play chemist a little bit

130

what should a pt immediately do after swallowing alkali substance

give diluted vinegar, orange/lemon juice

131

what should a pt immediately do after swallowing acid substance

give milk, egg whites, antacids

132

what is the concern with electrical burn

far more tissue destruction than what initially appears
--bone and muscles are readily cooked, even if exterior skin doesn't look that bad

133

how do you manage electrical burn

extensive surgical debridement
potentially amputation
monitor for myoglobinemia
look for vertebral compression fractures

134

what are 2 long-term sequelae in electrical burns

long-term sequelae of cataracts and demyelination

135

what are 2 burns suspicious for child abuse

bilateral burns on buttocks w/ moist blisters (2nd degree)

glove pattern of hand/foot being immersed in boiling water

136

what is the initial tx for burn victims

need vicious fluid resuscitation for ~2 days
--estimation formulas are used
--judge the adequacy based on UOP and CVP

137

what is the modified Parkland formula for adult surface area burns

Rule of 9s x 11 = 99%

9% head
9% each UE
9% x 4 in trunk (2 in front; 2 in back)
9% x 2 in each LE (1 in front; 1 in back)

138

what is the Parkland formula for child surface area burns

two 9%'s in head

trunk and UE's are same as adult
9% x 4 trunk
9% in each UE

three 9%'s total for LE

139

what is the modified Parkland formula to calculate fluid resuscitation

(Body weight kg) x (%burned up to 50%) x (A factor)

A factor = 2-4 for adults; 4-6 for peds


being burned >50% means you're already losing fluid at a max rate

#cc's of balanced electrolyte soln (LR) pt needs in the first 24 hours

140

how should you distribute the cc's of an electrolyte soln in a burn pt

give half in first 8 hours; other half over 16 hrs

pts typically cannot eat/drink; so give additional 2L for maintenance fluids

141

why should you not give a sugar fluid to burn pts

the osmotic diuresis invalidates UOP values

142

how do you manage resuscitation in burn pt on day 2 and 3?

day 2: typically needs ~half of first day fluids

day 3: trapped fluid tends to go back to pt; may see extensive diuresis

143

what is a good initial rate rule for fluid resuscitation

~1000/hr for >20% burn initially;
then monitor UOP to adjust

144

what is the normal UOP for fluid resuscitation

nl UOP is ~1cc/kg/hr, but anywhere between 0.5 -2x that is acceptable

(70kg M should produce 35-140 cc/hr)

145

what is the basic management for burn care

standard tetanus prophylaxis
suitable cleaning of areas; OR for cross-debridement
topical burn care (no parenteral Abx)
IV pain meds (cannot be subQ)
intensive nutritional support (GI tract; high calorie; high Nitrogen)
rehab beginning on Day 1 (function, not survival, is endpoint)

graft areas that did not regenerate after 2-3 weeks
or, take pt to OR on Day 1 if severe burn is isolated and can easily be grafted
--save time, money, pain/suffering

146

what are the 3 types of topical burn care depending on pt presentation (standard, severe, eyes)

standard: silver sulfadiazine
--soothing white paste; works well against bacterial infection

deep penetration w/ thick eschar or involved cartilage: mafenide acetate
--painful; can produce acidosis

near eyes: triple Abx ointment

147

how do you manage a bite from a provoked domestic dog

tetany prophylaxis

dog is presumably vaccinated and provoked, so has low risk of rabies
--no rabies prophylaxis needed
--vet puts animal under observation to look for rabies indication

148

how do you manage a wild animal (ex. coyote) bite w/ animal brought back alive

can kill animal to examine its brain and look for sings of rabies +/- rabies prophylaxis for bite victim

149

how do you manage bat attack w/o animal to examine

rabies prophylaxis

includes immunoglobulin + vaccine

150

what is the description of a venomous rattlesnake

elliptical eyes fixed behind nostrils, big fangs, rattles

151

how do you manage a snake bite, depending on timing and pt presentation

up to 1/3 of bites do not inject venom, even in a venomous snake

in ER 1 hr after bite; no local plain, swelling, or discoloration = no venom
--tx: wound cleaning, tetanus prophylaxis, observation

in ER 1 hr after bite; local pain, edema, ecchymosis = venom
--tx: anti-venom in large doses
at least 5 vials; maybe 10-20
venom has to do with size of envenomation, NOT size of pt
immediately type and cross (venom eventually interferes)
Coag studies and renal/liver function tests
surgical excision is rarely needed

do not:
cut/excise bite area
elevate extremity
fasciotomy
give sterods

152

how do you tx anaphylaxis 2/2 bee sting

(wheezing, hypotension, purulent rash)

tx: 1/2 to 1/3 cc EPI
remove stinger carefully

153

how does a black widow spider bite present

black spider w/ red hourglass
pt has N/V; severe muscle cramps

154

how do you tx black widow spider bite

Tx: IV Calcium gluconate +/- muscle relaxants

155

how does a brown recluse spider bite present

hurts when it happens; develop an ulcer overnight; dead skin w/ halo of erythema

156

how do you tx brown recluse spider bite

Tx: local excision of ulcer
get rid of venom
may need skin graft

157

how do you tx human bite / punch in the face?

ortho surgeons take to OR for massive irrigation and debridement to prevent bad infection
--could destroy joint

158

what is dx in newborn with uneven gluteal folds; hip can easily be dislocated posteriorly w/ jerk/click

developmental dysplasia of hip

159

what is the concern with developmental dysplasia of hip

permanent disability if not recognized early
--femoral heads can grow outside of socket

160

how do you dx and manage developmental dysplasia of hip

Dx w/ PE or sonogram
--XR in newborn is not helpful (not enough calcification)

manage: abduction splinting w/ pelvic harness; or double diapers

161

what is dx in ~6yo w/ insidious development of limping w/ decreased hip motion
+/- ipsilateral knee pain

avascular necrosis of capital femoral epiphysis

162

how do you dx and manage avascular necrosis

dx w/ XR

manage: controversial; some use casting/crutches

163

what is dx in ~13yo M, often overweight, with groin pain, limping, inverted foot; limited hip motion;
as hip is flexed, leg goes into external rotation and cannot be rotated internally

slipped capital femoral epiphysis

164

how do you dx and manage slipped capital femoral epiphysis

dx w/ hip XR

manage: ortho emergency
pin femoral head into position so it does not die

165

what is dx in ~toddler with febrile illness, then acute hematogenous osteomyelitis

septic hip

166

how do you dx and manage septic hip

dx w/ radio nuclear bone scan (not CT)
--XR takes too long to show osteomyelitis

mange: Abx

167

what age is bow legged normal

(genu varum)
normal up to 3yo

do not prescribe ortho braces/casts etc

168

how do you treat genu varum after 3yo?

pt likely has Bowen's disease if bow-legged persists past 3yo

needs surgical correction

169

what age is knock knee'd normal

(genu valgus)
normal up to 8yo

co not prescribe ortho braces/casts etc

170

what does knee pain w/o swelling generally indicate

intrinsic knee problem

171

what is dx and tx of tibial tubercle pain aggravated w/ quad contraction

osteochondrosis of tibial tubercle
AKA Osgood-Schlatter disease

Tx: immobilization of knee; extension cast 4-6 weeks

172

what is dx of baby born w/ both feet turned inward

club foot
AKA congenital talipes equinovarus

adduction of forefoot
inversion of foot
flexion of ankle
internal rotation of tibia

173

how do you manage club foot

serial plaster casts beginning in neonatal period
--start most distal and move proximally

50% respond in 6mo and don't require surgery
--do surgery <1yo before they're ready to walk

174

what is dx in ~F w/ curved spine; hump in thorax when bending forward in premenstrual growth spurt yrs

scoliosis

S-form is seen lateral in progression
progresses as long as skeletal maturity has not yet been reached

175

how do you manage scoliosis

corsets and casts +/- surgery until skeletal maturity

consider possible limited pulmonary function

176

what are "pros" of a childhood vs adult fracture

most have better outcome than adults- more plastic
faster healing and capacity for remoodeling- grow back straight

177

what are 2 bad childhood fractures

elbow

growth plate involvement

178

what is the concern w/ childhood elbow fracture

high risk of neovascular compromise
--monitor w/ cap filling; Doppler, pulse, etc for vascular supply

179

what is the fracture in elbow fracture

supracondylar fracture of humerus
--distal fracture displaced posteriorly

180

what is needed with childhood fracture involving growth plate

precise re-alignment is needed
--open reduction and internal fixation is best

181

what type of bone tumor has a sharply demarcated edge that distinguishes it from the rest of bone (boundary)

benign bone tumor

182

what type of bone tumor has fuzzy/ill-defined edge between tumor and bone

malignant bone tumor

183

what are the 2 buzzwords for malignant bone tumors on radiology

"sunburst" pattern (fuzzy demarcation edge)

periosteal onion-skinning (tumor is growing fast and displacing periosteum from bone; new layer of bone that gets displaced again)

184

what is the presentation of 2 childhood bone tumors:
osteogenic sarcoma vs Ewing sarcoma

osteogenic sarcoma:
10-25yo
around the knee (lower femur/ upper tibia)

Ewing sarcoma:
younger children
around diaphysis/shaft of bone

185

how do you manage malignant bone tumors

refer to specialized ortho surgeon
do not do anything invasive to this pt

186

what are most adult bone tumors (primary or metastatic?)

metastatic

187

what is the most common primary malignant bone tumor in adults

multiple myeloma

188

what is dx in pt who is old, anemic, multiple bones involved; Benz Jones protein in urine; abnl immunoglobins

multiple myeloma

189

how do you tx multiple myeloma

chemo usually

190

what is a pathologic fracture and what does it signify

fracture 2/2 trivial event

signifies metastatic tumor presence

191

what does XR show on pathologic fracture

XR shows lytic lesion (eating bone) vs plastic lesion (growth of bone)

192

where do you assume bone metastasis in a male vs female

male: assume to be metastatic from lung

female: assume to be metastatic from breast

193

what fracture commonly occurs in osteoporosis

vertebral compression fractures

all others need some sort of trauma

194

what is generic dx of an older pt with soft issue mass that grows, hard, fixed

sarcoma

(don't know if it's lipo, fibro, chondro, rhabdo - sarcoma yet

195

how do you dx sarcoma

MRI

do not do invasive maneuver
-doc who discovers the tumor should not be doing the biopsy
-pt requires large tissue sample and open bx from a specialist

196

what imaging should you get for a fracture

XR at 90 degrees to each other;
include the obvious and suspicious fracture sites

197

how do you manage clavicle fracture

spint w/ figure 8 device for 4-6 weeks to retract shoulders

198

what is the buzzword for colles fracture

dinner fork shaped, painful wrist

199

what does XR show for colles fracture

dorsally displaced dorsally angulated fracture of distal radius;
small fracture of ulnar head

(dinner fork wrist)

200

how do you tx colles fracture

closed reduction and long arm cast

(dinner fork wrist)

201

what type of fracture gives you a broken ulna and a dislocated radius

Monteggia fracture

diaphysial fracture of proximal ulna with anterior dislocation of radial head

202

how does one typically get a Monteggia fracture

protecting with outstretched forearm

(broken ulna; dislocated radius)

203

what type of fracture gives you a broken radius and dislocated ulna

Galeazzi fracture

204

how should you cast a Galeazzi fracture

in supinated form

(broken radius; dislocated ulna)

205

what is the general rule for fixing broken bones and dislocated bones, respectively

open reduction/internal fixation for the broken bone

closed reduction for the dislocated bone

206

what bone is commonly fractured with FOOSH, wrist pain, tender to palp over anatomic snuff box

scaphoid bone

XR will be negative for 3 weeks, so clinical dx is useful

207

how do you manage scaphoid bone fracture

needs thumb spiker cast (not displaced)

208

what does a XR showing an adulated fracture of scaphoid notorious for

high rate of non-union/delayed healing (displaced)

this requires open/internal fixation

209

what is commonly fractured with a closed fist hit

fracture of 4th/5th metacarpal neck

210

how do you manage the 4th/5th metacarpal neck fracture (closed fist hit)

management depends on degree of angulation, displacement, or rotary malalignment

mild: closed reduction and ulnar gutter splint

severe: wire plate fixation

211

which should dislocation is most common

anterior dislocation

212

what is dx for pt presenting holding arm close to body; rotated out as if to shake hands; numb in deltoid

anterior shoulder dislocation

213

how do you dx and tx anterior shoulder dislocation

dx: AP/lateral XR

tx: reduction

214

what is dx for pt presenting with arm held close to body; internally rotated

posterior dislocation of shoulder

215

how do you dx and tx posterior shoulder dislocation

difficult to dx; may have history of small clinic visit + pain meds that aren't helping
(may occur when all muscles in body contract at same time- electrical burn, epileptic seizure, etc)

dx: axillary or scapular/lateral XR

tx: reduction

216

what is dx in shortened and externally rotated leg

broken hip

217

what is concern in femoral neck fracture

the fracture will likely kill femoral head 2/2 tenuous blood supply

if this occurs in an elderly pt, they'll be immobilized, pneumonia, and die

218

how do you tx femoral neck fracture

OR to remove femoral head and replace w/ metal prosthesis

219

how do you tx intertrochanteric fracture

open reduction and pinning

immobilization and anti-coag (esp in elderly pts at risk for DVT)

220

how do you tx/manage femoral shaft fracture

intramedullary rod fixation

monitor for hypovolemic shock
monitor for fat embolism (low pO2)
--resp support to improve oxygenation

221

what is likely dx in pt who has h/o repetitive use of bone beyond toleration; localized tibia pain in specific area of bone

stress fracture

222

how do you dx and tx stress fracture

XR is nl until later on

tx: cast

223

what should you suspect hours after cast alignment when pt c/o persistent pain, tight muscle compartments, extreme pain with passive extension of toes

compartment syndrome

severe disability if not recognized

224

how do you tx compartment syndrome in legs

emergency fasciotomy in all compartments (4 in legs) with 2 skin incisions

225

what is dx in out of shape pt who over-exerts, hears a loud pop; can initially move, but then progresses to being unable to move

achilles tendon rupture

226

how do you tx achilles tendon rupture

casting in equinus position (pt on tip toes to not stretch tendon) for several months

open surgical repair for faster healing

227

what is dx in pt who falls on inverted/everted foot

malleoli fracture

it doesn't matter which way they fall; both malleoli will be broken

228

how do you manage malleoli fracture, depending on what XR shows

XR shows good position fracture: casting

XR shows displaced fractures: open reduction and internal fixation for proper ankle healing

229

what is dx in pt with medial knee pain/swelling
passive abduction elicits pain
positive valgus stress test

medial collateral ligament injury

230

which direction can you bend knee in MCL injury

can bend leg further in direction of broken ligament (medial) without limited motion

231

what is dx in pt with lateral knee pain/welling
passive adduction elicits pain
positive varus stress test

lateral collateral ligament injury

232

how do you treat MCL/LCL injuries

hinge cast if that's the only problem

otherwise, surgical repair

233

what is dx in positive anterior drawer test

Anterior cruciate ligament tear

234

what is dx in positive posterior drawer test

posterior cruciate ligament tear

235

which imaging confirms a ligament tear

MRI

236

how do you manage knee ligament tear

immobilization and rehab for sedentary pts

athletes: arthroscopic reconstruction for quick healing

237

what is dx in pt with catching and locking of knee that limits its motion; click when forcefully extended

meniscus injury

238

how do you dx meniscus injury

XR is nl
difficult to dx
may have h/o small clinic visit with unhelpful tx

MRI shows meniscal tear

239

how do you tx meniscus tear

arthroscopic repair
try to save as much meniscus as possible to avoid degenerative arthritis

240

how do you manage pt with cast and compartment syndrome

always remove cast immediately if pt presents with pain under recently placed cast
---do not select analgesics or XR to confirm bone placement

241

what are pulses in compartment syndrome

presence of pulses does NOT rule out compartment syndrome

242

what is the buzzword for compartment syndrome

severe pain with passive extension

243

how do you manage exposed bone

OR, clean, cover, close bones within 6 hours
to avoid infection, osteomyelitis

244

what is dx in pt who hit dashboard with knees

posterior dislocation of hip

drives the femur out of the socket backwards

245

how do you manage posterior hip dislocation

reduction ASAP to prevent femoral head necrosis

246

what is likely dx in pt who stepped on rusty nail --> swollen dusky foot w/ gas crepitus 2-3 days later

gas gangrene

247

how do you manage gas gangrene

requires extensive debridement +/- amputation

immediate tx:
large doses IV penicillin
surgical debridement (bugs feed on dead tissue)
hyperbaric O₂ to deactivate toxin


life threatening soft tissue infection
--can happen to anyone (vs an infection mostly happening in an immunocompromised/diabetic pt)

248

how do you evaluate nerve symptoms in a bone injury

reduce fracture and re-evalutate nerve function
(ex humeral fracture could damage radial nerve)

you could trap nerve when splinting bones and cause nerve symptoms
--need open reduction to unwrap nerve

249

what artery is damaged with posterior dislocation of knee

popliteal artery

250

how do you manage popliteal artery damage

immediate reduction of posteriorly dislocated knee w/ Doppler, pulses, arteriogram studies

feeble collateral circulation could cause damage --> leg loss

251

what is dx in pt who falls and lands on feet

compression fracture of thoracic and lumbar spine

252

what should you also check in a pt with facial trauma

check cervical spine

253

what should you look for in pt with dashboard MVC injury

XR hip in MVC to evaluate a posterior dislocation of femur

254

what is dx in pt with numbness/tingling in hand, esp at night, esp hanging hand limply, esp pressing on carpal tunnel or pericostal

carpal tunnel syndrome

255

what nerve distribution is involved with carpal tunnel syndrome

median nerve distribution (radial 3.5 fingers)

256

how do you dx and manage carpal tunnel syndrome

dx: XR including carpal tunnel views

tx: splints and anti-inflammatories
---do not inject steroids
---pt may need electromyography +/- surgery

257

what is dx in pt with finger acutely flexed; unable to extend; painful snap; almost exclusively F

trigger finger

258

how do you manage trigger finger

steroid injections

259

what is dx in pt with painful radial wrist and 1st dorsal compartment; pain w/ flexion and simultaneous thumb extension

deQuervain's tendosynovitis

260

what are 2 unique actions that elicit pain in a pt with deQuervain's tendosynovitis

pain w/ holding baby head

pain w/ holding thumb inside closed fist and forcing wrist into ulnar deviation

261

how do you tx deQuervain's tendosynovitis

steroid injections

262

what is dx in pt with contracted hand; can no longer be extended; palmar fascial nodules palpated; commonly in Scandinavian M or chronic alcoholic

Dupuytren's contracture

263

how do you tx Dupuytren's contracture

surgery to free up fascia

264

what is dx in pt with abscess in pulp of index finger w/ throbbing pain, fever

felon

265

what is concern in pt with felon

pulp of finger has fascial trabeculae made for closed spaces

swelling --> necrosis

266

how do you tx felon

immediate surgical decompression

267

what is dx in pt with injury of ulnar collateral ligament of thumb

Game Keeper's thumb

268

what is PE in game keeper's thumb

collateral laxity at 4th metacarpal phalangeal joint from thumb jam

can be dsyfunctional/painful --> arthritis

269

what activity commonly causes Game Keeper's thumb

skiing
(thumb jam)

270

how do you tx game keeper's thumb

casting for opportunity to heal

271

what is dx in pt with injury to flexor tendon, for example when grabbing another person's shirt

jersey finger

272

what is PE in jersey finger

distal phalanx of ring finger doesn't flex with others when making a fist

273

how do you manage jersey finger

splint

274

what is dx in pt with injury to extensor tendon; for ex when playing volleyball

mallet finger

275

what is PE in mallet finger

distal phalanx cannot extend; tip of finger remains bent down; looks like hammer/mallet

276

how do you manage mallet finger

splint

277

how do you manage a severed finger

clean severed finger with sterile saline
wrap in saline-moistened gauze
place in plastic bag
then on bed of ice

278

what is prognosis for severed fingers

replantation of severed extremities is done only for very distal parts

nerve regneration is limited, and replanting a denervated part is not useful

279

what is dx in pt who has vague back pain that turns into "electrical shock" down the leg; severe back pain when lifting heavy objects; aggravated by sneezing, coughing, ambulating, or straining; pt will keep legs flexed to avoid pain

lumbar disc hernia

280

how do you dx lumbar disc hernia

straight leg raise test produces excruciating pain

281

what is dx in pt who has vague back pain

disc bulge (discogenic pain)

the disc bulge pushes anterior spinal ligament to cause the vague back pain

282

what is pathogenesis of lumbar disc hernia

first you have a disc bulge that pushes anterior spinal ligament, producing vague back pain
then, a sudden/violent motion will herniate disc
compresses nerve root
gives you severe neurogenic root pain ("electric shock")

283

where is disc herniation located if pain radiates to big toe vs little toe

pain radiating to big toe = L4/L5

pain radiating to little toe = L5/S1

284

how do you dx and manage a herniated disc, including 2 exceptions?

dx with MRI image (two soft tissue structures: disc and nerve)

bed rest for 3 weeks

2 exceptions:
--neurosurgical intervention if there's progressive weakness
--sphincter defects are an emergency (rectum, bladder, etc); likely permanent if not quickly reversed

285

what is dx in pt with "herniated disc" symptoms + distended bladder, flaccid retrosphincter, and perianal saddle anesthesia

cauda equina syndrome

286

how do you manage cauda equina syndrome

surgical emergency

287

what is dx in young M (20s-30s) with chronic progressive back pain that improves with activity (worse in the morning)

Ankylosing spondylitis

288

what imaging goes with ankylosing spondylitis

eventually shows bamboo spine

289

how do you manage ankylosing spondylitis

anti-inflammatories and PT

290

what ulcer commonly presents:
pressure point, usually foot
classically the heel or 1st metatarsal
painless (neuropathy)

diabetic ulcer

291

why do diabetic ulcers not heal wel

ulcer develops and does not heal due to poor peripheral vascular supply

292

what is management of diabetic ulcer

control diabetes, stay in bed, keep leg horizontal

most diabetics suffer amputation; however, healing is possible

293

what ulcer commonly presents:
atherosclerotic disease causing ulcer at tip of toe- blue/pulseless

ischemic ulcer

294

how do you manage ischemic ulcers, depending on vessel size

big vessel: surgery, bypass big vessels

small vessel: surgery does not help

take BP at certain points to determine pressure gradient/blockage (or Doppler)
--no pressure gradient = no single point that can be bypassed; not a surgical candidate
--pressure gradient = next do an arteriogram for obstruction details

295

what ulcer commonly presents:
above medial malleolus in hyper pigmented, edematous skin;
cellulitis
varicose veins

venous insufficiency ulcer

296

how do you manage venous insufficiency ulcer

provide support so peripheral superficial veins are not engorged with blood

stockings, compression, stiff support, possible varicose vein surgery

297

what cancer commonly develops in longstanding site of chronic irritation

squamous cell carcinoma

298

what is this a classic story for:
chronic draining sinus in lower leg for years since osteomyelitis; but recently developed indolent, dirty ulcer with heaped up edges

squamous cell carcinoma

299

what is this a classic story for:
chronic shallow ulcerations at burn scar site that heal/break down, but recently developed indolent dirty ulcer w/ heaped up edges that are not getting smaller

squamous cell carcinoma

300

how do you dx and manage squamous cell carcinoma

biopsy of edge of ulcer where heaped up edge is

treat with wide resection and skin grafting

301

what is dx in chronic inflammation of plantar fascia pulling, leading to bony spur

plantar fasciitis

302

what presents with sharp heel pain with every strike on the ground; worse in the AM; with a bony spur matching pain site on XR and tenderness over bony spur on PE

plantar fasciitis

303

how do you manage plantar fasciitis

supportive analgesics
rigged devices of stepping (NOT excision of the bony spur)

it usually goes away 1-2yrs

304

what is dx in F wearing high heel/pointed shoes or a Cowboy wearing pointed boots
w/ pain from prolonged standing/walking; PE will be very tender on 3rd interspace

Morton's neuroma

305

what nerve is inflamed in Morton's neuroma

common digital nerve

(pointed shoes)

306

what is management of Morton's neuroma

conservative management

wear better shoes

excision of neuroma

307

what is dx in pt with red, painful swelling of 1st metatarsal joint

gout

308

how do you dx and manage gout

dx: serum uric acid level or uric acid crystals in joint fluid

manage: medical (colchicine, allopurinol, probenecid)

309

what cardiac risk factors need to be considered in a pre-op assessment

EF <35% = high risk of intraoperative MI

Goldman's findings- high operative risk for non-cardiac surgery:
--age, chronically bedridden, emergency operation, major body cavity, recent MI, A-fib, premature ventricular beats, JVD

CHF (JVD), esp in elective surgery

recent MI, esp <6mo ago

Angina + AAA

310

what is your mortality risk in a non-cardiac operation with a recent MI vs non-recent MI

MI <6mo ago = 40% mortality

MI >6mo ago = 6% mortality

311

what should be done first in a pt with angina and AAA to improve operative cardiac risk

coronary revascularization before AAA repair

312

how do you assess an operative pt's pulmonary risk

smoking and ability to ventilate (vs oxygenate)

quantify with blood gases (high pCO2) or pulm studies (FEV1 = ability to ventilate)

313

what value does FEV1 represent

ability to ventilate

314

how can you reduce an operative pt's pulm risk prior to surgery

cessation of smoking for 8 weeks

incentive respiratory therapy (PT, expectorants, IS, humidified air)

1st week of cessation = bronchorrhea and mucus secretions

315

how do you assess a surgical pt's hepatic risk

liver function is important for anesthetic operation

high Bil due to hepatocellular dysfunction = high risk
---can operate if high Bil is due to obstruction/hemolysis

high PT
low serum Alb
encephalopathy
high ammonia

316

how do you assess a surgical pt's nutritional risk

unable to eat / weight loss = malnutrition

serum Alb <3

allergy to skin test antigens

serum transferrin level <200

brief prior, intense nutritional support can lower operative mortality; preferably 7-10 days

317

what must be done for DKA pts before an operation

cannot operate in DKA

need to rehydrate pt; no coma; begin to fix acidosis; lower blood glucose first

318

what is dx in pt who develops intraoperative fever shortly after onset of general anesthesia >104

malignant hyperthermia

319

what is pathology of malignant hyperthermia

congenital absence of enzyme needed to break down succinylcholine, so you generate heat from muscle activity

320

what do lab values look like in pt with malignant hyperthermia

fever >104
metabolic acidosis
hypercalcemia
FHx

321

how do you treat malignant hyperthermia

IV dantrolene (different MOA than succinylcholine) to stop muscle activity

100% O₂
cooling blankets
correct the acidosis
monitor for myoglobinemia/uria and treat accordingly

322

how do you assess surgical pt's aspiration risk

prefer to prevent vs treat

can kill pt or cause chemical injury to bronchial tree--> failure

NPO before elective surgeries
--give pts anti-acids pre-op

323

how do you manage aspiration once it's happened

bronchoscopy to lavage and remove particulate matter

bronchodilators and respiratory support

324

how might an intraoperative pneumothorax happen

giving a pt positive pressure ventilation and a bleb breaks --> one way valve into pleural space

325

what values indicate an intraoperative pneumothorax

BP decreases as CVP increases

326

how can you manage an intraoperative pneumothorax

surgeon can poke a hole in the diaphragm w/ needle

place a chest tube at end of procedure

327

what is dx in pt with post-op fever immediately after surgery

bacteremia

328

how do you manage post-op bacteremia

blood cultures x 3

empiric Abx

329

what are the 4 W's in the ddx of post-op fever (actually 6)

Wind
Water
Walking
Wound
Wonder Where
Wonder drugs

330

go through "wind" post op fever

♣ POD1: Inability to ventilate; atelectasis
• Tx: improve ventilation, breathing, coughing, IS, chest drainage
• Bronchoscopy rarely needed

♣ If continues to ~POD3 --> pneumonia
• Tx: CXR, Abx, sputum cultures

331

go through "water" post op fever

♣ POD3: Urinary Tract Infection
• Dx: urinalysis

332

go through "walking" post op fever

♣ POD5: DVT
• Could do Doppler studies of deep vein flow restrictions

333

go through "wound" post op fever

♣ POD7: Wound infection
• Only erythema = Abx
• Pus = needs to be drained
o Sonogram helps

334

go through "wonder where" and "wonder drugs" post op fever

Wonder where:
♣ POD10: Deep abscess infection
• Subphrenic, subhepatic, or pelvic abscess
• CT or sonogram to visualize

Wonder drugs:
♣ Potential cause when everything else has been ruled out

335

what are the 2 big things on your ddx for post-op chest pain

MI POD 1-2
PE POD 5-7

336

how do you dx and manage post-op MI

dx: EKG, cardiac enzymes; usually POD 1-2

cannot lyse clots in a fresh post-op pt
have to treat the complications of MI but without blood thinners

337

what is seen in a preoperative MI

ST depression, T wave flattening; commonly 2/2 hypotension

dx: CK, CK-MB isoenzyme

338

how does post-op PE present

POD 5-7
sudden severe SOB and pleuritic chest pain; prominent veins, anxious, diaphoretic, tachy

339

how do you dx post op PE

ABGs show hypoxemia and hypocapnia
--cannot get O₂ into blood, but pt is also hyperventilating
--all areas that are perfused are ventilated; hypocapnia/hypocarbia is classic

V/Q scan only works if lungs are otherwise normal

spiral CT

340

what lab values distinguish PE vs respiratory failure

PE:
hypocapnia/hypocarbia (classic)
--all areas that are perfused are ventilated

respiratory failure:
hypoxemia and hypercarbia
--cannot get O₂ in and CO₂ out of blood

341

how do you manage post-op PE

anti-coagulation to prevent new clots (Heparin)
--lungs will lyse the existing clot

vena cava filter if the pt has experienced a PE while on anti-coagulators

342

what is the ddx for disorientation

post-op hypoxia

drug overdose; hypoglycemia

ARDS

Delirium tremens

Acute water intoxication

diabetes insipidus

ammonium intoxication

343

what is initial work-up of post-op disorientation

check ABGs for pulmonary insufficiency --> hypoxia
--inadequate brain oxygenation

344

what should be an initial thought of pt in ER in coma

possible drug overdose, hypoglycemia (insulin)
--inject with 50% dextrose

345

what is the classic story for an ARDS pt

classically in a long, complicated post-op pt
--good chance that sepsis is present

346

what is the work-up for post-op ARDS

CT scan to look for source/drainage

347

what will you see in post-op ARDS

pulmonary infiltrates, low pO2, no evidence of CHF

348

how do you manage post-op ARDS

mechanical respiration support and PEEP; max 40% O₂ long-term

PEEP: allow some degree of hypercapnia to not push more than necessary

349

what is dx in post-op alcoholic who is disoriented, combative, hallucinating

delirium tremens

350

how do you manage delirium tremens

IV 5% alcohol and 5% dextrose

psychiatrists disagree- tx addiction w/ non-addictive agent

351

what is likely dx in pt who is hours post-op with confusion, lethargy, HA, grand mal seizures, and coma

acute water intoxication

their 5% dextrose in water infusion was running way too high
(a large fluid that does not include Na --> water retention)

352

what will pt get with acute water intoxication

SIADH (metabolic response to trauma)

353

how do you dx acute water intoxication

serum Na concentration is low (water retention is diluting Na)

354

how do you manage acute water intoxication

high morbidity and mortality scenario

carefully administer hypertonic saline
-- acute hyponatremia + CNS symptoms = brain has not adapted
--acceptable to use hypertonic saline

355

what is dx in pt hours post-op who is lethargic, confused, comatose
with high UOP despite normal IV fluid rate

Diabetes insipidus

356

what is pathology of diabetes insipidus

inability to produce ADH

(surgery was ~near pituitary; transient interference)

357

how do you diagnose diabetes insipidus

serum Na concentration is high (losing water in urine)

358

how do you manage diabetes insipidus

rapidly reverse with several liters of D5W or diluted 1/3 to 1/4 normal saline

or ADH absorption via nasal mucosa

359

what is dx in pt with liver failure and delirium

ammonium intoxication

360

how might a pt with ammonium intoxication present with labs

liver failure:
cirrhotic, hypokalemic alkalosis, high CO, low PVR

delirium

bleeding varices (belly full of blood)

361

what is pathogenesis of ammonium intoxication

pt has hepatic failure/ delirium, and is bleeding from varices (belly full of blood)

blood from GI tract is absorbing ammonium
liver cannot convert it to ammonia

362

how do you manage ammonium intoxication

clean out bowel with enemas
locally acting Abx to rid the ammonium source

363

what is the story of a pt with post-op urinary retention

needs to void but unable
palpable suprapubic mass dull to percussion

364

how do you manage post-op urinary retention

catheter into bladder to empty

if you need to do it 2 or 3 times, some docs will leave in an indwelling catheter

or a prophylactic catheter (common/predictable problem)

365

what is the likely dx in a pt with zero UOP

mechanical problem-
plugged/kinked catheter

366

what are the 2 possibilities of a pt with oliguria (low UOP with normal vital signs)

pt is either behind on fluids or in acute renal failure

367

walk through the 3 tests to distinguish between behind on fluids vs Acute Renal Failure

Test:
bolus 500cc IV NS over 10-20min
--pt behind on fluids will increase UOP
--pt in renal failure is already making max UOP; the bolus won't improve UOP

Test:
measure urine Na
--pt behind on fluids (dehydration) Na conc <20mEq/L (good kidneys; they're holding onto fluid via Na retention)
--pt in renal failure will have urinary Na conc >40mEq/L (bad kidneys; making plasma filtrate; cannot change Na conc)

TesT:
fractional excretion of Na
--Dehydration <1
--Renal failure >1

368

how do you manage a dehydrated pt vs a renal failure pt with oliguria

dehydrated: fluid administration

renal failure: fluid restriction

369

what are 3 things on the ddx for post-op abdominal distension

post-op paralytic ileus
mechanical obstruction
Ogilvie syndrome

370

what is dx in pt with ~POD4 abdominal distension w/o pain; no bowel sounds/flatus vs ~POD6-8

POD4 = post-op paralytic ileus
POD6-8 = mechanical obstruction

371

what does XR show in post-op paralytic ileus

dilated Small bowel loops w/o air-fluid levels

372

what lab abnormality can perpetuate a paralytic ileus

hypokalemia

373

what does barium study show in a paralytic ileus vs obstruction

inject 30cc via NG tube:

paralytic ileus: barium goes to colon

obstruction: barium stops moving

374

how do you manage a post-op mechanical obsturction

re-operation to fix adhesions/anastamotic defect

375

what is likely dx in pt with ~POD5 abdominal distension; tense, but not tender; and occasional bowel sounds; typically elderly M who isn't active, then further immobilized from surgery

Ogilvie syndrome

376

what does XR in Ogilvie syndrome show

massively distended colon w/ a few distended small bowel loops

377

what is management of Ogilvie syndrome

colonoscopy
--suck out gas that's diluting the colon
--rule out cancer of the colon
--long rectal tube left in place for continued gas exit

rarely, a cecostomy or colonostomy is needed

378

what is dx in pt with salmon-colored clear fluid soaking wound dressings, and what is that fluid

wound dehiscence

peritoneal fluid

379

what causes wound dehiscence

deeper layers of surgery have failed to heal before skin heals

380

how do you manage wound dehiscence

careful protection of wound
keep in bed; don't move
tape the wound together; use abdominal binders

later: re-operate to prevent vental hernia (non-emergency)

381

what is the concern with wound dehiscence

could turn into evisceration
--wound opens and small bowel falls out
--emergency; high morbidity/mortality

382

how do you manage evisceration following wound dehiscence

pt back to bed, cover bowel w/ moist dressings soaked in warm saline
--rush to OR for immediate closure
--do not allow bowel to dry out
--avoid hypothermia

383

what is dx in pt with ~POD7 fever and red, hot, tender wound

wound infection

384

how do you manage wound infection caused by either cellulitis or abscess

cellulitis: Abx directed toward nl skin flora
Abscess: drainage (check via sonogram)

385

what is dx in pt with luminal content leaking through belly and afebrile

fistula

386

describe fistula fluid from proximal GI tract

high volume 2-3 L /day

causes a fluid/electrolye/nutirition problem because the fluid has digestive enzymes digesting the abdominal wall

387

how do you manage proximal GI fistula

maintenance fluids and replacement electrolytes (LR)

nutritional replacement distal to fistula (NPO)

protection of abdominal wall; do not let fluid soak dressing; protect skin

388

describe fistula fluid from distal GI tract

low fluid / nutritional absorption /enzymes

non-life threateningn

389

what happens with most GI fistulas 2/2 anastomosis

most heal unless something is preventing closure

390

what would cause fistula closure prevention

"FETID"
foreign body
Epithelialization
Tumor
Infection
Irradiated tissue
IBD
Distal obstruction

requires surgical intervention

391

describe epithelialization in a GI fistula

granulation tissue grows from conduit while epithelium is migrating from inside the lumen

long and narrow hole = granulation tissue will win and fill epithelium

short and wide hole = epithelialization; hole will not close

392

what is likely dx in pt with hypernatremia (water loss) 2/2 surgery acutely

DI

393

how do you manage acute DI

diluted fluid to replenish loss with several liters of D5W, 1/3 to 1/4 NS +/- ADH

every 3mEq that serum Na is above 140 represents ~1L water lost

394

what is likely dx in pt who is awake/alert but hypernatremia (dehydrated)

chronic hypernatremia
-selectively lost water
-developed hypernatremia over ~days, so the brain has adapted (normal mentation)

395

how do you manage chronic hypernatremia

reverse the volume loss over ~hrs to improve hemodynamics/kidneys

correct the hypertonicity over ~days
using 5L D5 1/2 NS
--fluid that's neither as diluted as D5W nor as concentrated as NS
--rapid correction of volume and ~modest/safe impact on tonicity

396

what is likely dx in pt with hyponatremia (water gain_ 2/2 rapid drip of Na-free soln during an inappropriate ADH response to trauma

acute water intoxication

every cell is swollen, including the brain
--> comatose

397

how do you manage acute water intoxication

hypertonic 3-5% Saline in small quantities

mannitol

398

what is likely dx in pt who is alert/awake but hyponatremia (water retention)

chronic hyponatremia

too much ADH

hyponatremia has developed over ~days, so brain has adapted (normal mentation)

399

how do you manage chronic hyponatremia

slow correction of serum Na
--water restriction (cannot take away the excess ADH in the body)
--meds to counteract ADH effects

a rapid correction would cause central pontine lysis of myelin

400

what is pathogenesis in "loss of hypertonic fluids" or "selective loss of Na"

doesn't realistically happen- no mechanism to selectively lose Na to cause chronic hyponatremia

first, the pt begins losing isotonic fluids via vomiting (Na-containing, but still isotonic)
--the initial insult is dehydration w/o tonicity change

several days --> volume depletion; pt is likely unable to eat/drink, so cannot replace fluids being lost
--body is eager to retain fluids at this point

pt drinks Na-free fluid (water/soda vs HCO3/Na) --> production of free water
--body is willing to sacrifice tonicity to retain volume
--fluid drank is stained
--does not correct vol depletion; you've created a tonicity gradient, so the water ends up in cells but with a low serum Na due to retaining water and losing isotonic fluids

the pt lost isotonic fluid then eventually retained water --> hyponatremia

401

how do you manage chronic hyponatremia

slowly correct the hyponatremia with rapid correction of volume replenishment

use isotonic fluids to rapidly correct the volume and slowly correct tonicity

NS: when pt is alkalotic (vomiting gastric acid and juice)
LR: when pt is acidotic (vomiting small bowel content, bile, pancreatic juice, alkaline fluids)

402

how do you manage severe DKA

insulin + IV fluids + K

403

what is the rationale for giving K to a DKA pt

pt is acidotic
--excessive H+ in blood is pushed into cells in exchange for K being brought out of cells

high K in blood is seen by the kidneys, so kidney puts K into urine

when you correct the pt's acidosis, the H+ goes back into the blood, and K tries to go back into cells
--> profound hypokalemia

404

what is the normal safe upper limit of K administration in a normal vs DKA pt

normal pt:
10 mEq/hr = 24 mEq/day

DKA pt :
20 mEq/hr = 480 mEq/day

405

what lab abnormality are you likely to see after a crush injury

hyperkalemia

adding K to the blood via:
--crushed/killed cells
--blood transfusions (hemolysis in the blood bank as blood ages)
--acidosis with H+ moving into cells

406

how do you manage dangerous hyperkalemia 2/2 crush injury

dangerous hyperkalemia >6

hemodialysis (long process)

50% glucose and insulin to create momentary anabolic phase (K into cells)

GI tract to remove K (NG suction)- not effective
--Kayaxolate resins: exchange Na for K in lower GI

IV Ca administration: highly effective and protective of myocardium while waiting for hemodialysis

407

run through metabolic acidosis with pH 7.1
pCO2 36
Na 138
Cl 98
HCO3 15

look at pH = acidosis
look at pCO2; low = hyperventilating to try to compensate by breathing faster and removing CO₂ and therefore acid

causes:
either excessive production of acids, insufficient buffering from HCO3 loss, or inability of kidney to make necessary adjustments
--renal acidosis takes several days to develop
--HCO3 loss: biliary fistula, pancreatic fistula ostomy output, diarrhea
--high H+ production: pt is in a low-flow state (shock, hypotension, not perfusing well, cells using anaerobic metabolism with high lactic acid levels)

408

how do you manage metabolic acidosis with pH 7.1
pCO2 36
Na 138
Cl 98
HCO3 15

correct the underlying problem

this pt needs rehydration to correct the low-flow state so the pt can correct the acidosis
--fluid that doesn't compound the existing acidosis
--use LR, a primary volume expander, which also contains a little HCO3

giving HCO3 or a precursor (like acetate/lactate) does not address the volume problem
--give HCO3 if pt is losing HCO3 via fistula and doesn't have enough to buffer
--do not give NaHCO3: it makes a ppt

409

run through hypochloremic metabolic alkalosis 2/2 loss of acid gastric juice

protracted vomiting of clear gastric contents ~days

need to rehydrate and also correct the metabolic alkalosis
--rarely, provide hydrogen NH4Cl or HCl diluted in amino acid solution (buffers)

410

how do you manage hypochloremic metabolic alkalosis 2/2 loss of gastric acid and juice

help the kidney correct the problem

kidney can: bring in NaCl, NaHCO3, or exchange Na/K or Na/H

pt is alkalotic in this scenario (H+ depleted)
--do not want to put H+ into urine or retrieve HCO3-

want to: bring in NaCl or exchange Na for K
--give generous KCl to retrieve Na without using HCO3/H+
--only works if pt has functioning kidneys

411

when should you use pH monitoring to evaluate esophagus

use in pain that cannot be well characterized and cannot be timed

412

how can you dx reflux with pH monitoring

if pain coincides w/ low pH: reflux

413

when do you use manometry to evaluate esophagus

use if pt has horrible pain w/ every swallow; uncoordinated contractions

414

what is dx in pt who has burning, retrosternal pain and heartburn w/ bending, tight clothes, lying flat;
symptomatic relief with antacids, seems to be progressive; present ~yrs

GERD

415

how do you dx GERD

endoscopy and biopsy to determine extent of damage

416

how do you manage severe peptic esophagitis

surgery is indicated if there's progression despite strict adherence to PPI meds

417

how do you manage Barret's esophagus

this is pre-malignant
--a Nissen fundoplication only helps with acid reflux

you need intensive treatment directed at acid
--PPIs can take care of histological damage, but high doses are required for a long time
--may create a carcinoid tumor 2/2 PPI from long-term achlorhydria

418

what is the purpose of each study before esophageal surgery
-endoscopy
-manometry
-gastric emptying study
-barium swallow

endoscopy: evaluate extent of mucosal damage

manometry: evaluate motility

gastric emptying study: evaluate for pyloric obstruction

barium swallow: evaluate location of LE sphincter and GE junction

419

what is dx of pt with difficulty swallowing liquids > solids

achalasia of esophagus

420

what type of problem is achalasia

functional/motility problem

421

which esophageal problem starts with difficulty swallowing solids

mechanical problem

422

what is this a classic story for:
middle aged F who sits up straight when eating; has regurgitation of undigested food, like finding food on a pillow

achalasia

423

how do you dx achalasia

manometry to assess motility
--establishes that LE sphincter doesn't relax

(Barium swallow/ endoscopy would both show mega-esophagus, but not the nature of the problem)

424

how do you manage achalasia

treat medically with repeat dilations

or surgery with Heller myotomy

425

which esophageal cancer classically develops with history of smoking, drinking, and black race

squamous cell carcinoma

426

which esophageal cancer classically develops with long-standing GERD

adenocarcinoma
progresses from Barrett's esophagus

427

how do you dx cancer of esophagus

first, Barium swallow to visualize tumor and amount of lumen left to avoid perforation

then CT to determine surgical candidacy

Endoscopy and biopsy

Trans-hiatal esophageestomy for short-term palliation

428

what is tear in mucosa of esophagus 2/2 repeated vomiting and profuse bright red blood

Mallory Weiss Tear

429

how do you dx Mallory Weiss tear

endoscopy to visualize bleeding point

430

how do you manage Mallory Weiss tear

photocoagulation to stop bleeding

431

what is perforation of lower esophagus 2/2 repeated/forceful vomiting with sudden onset of wrenching epigastric pain and lower sternal pain; diaphoretic, febrile, and WBC count

Boerhaave syndrome (rare)

432

how do you manage Boerhaave syndrome

prognosis depends on timing of dx/tx

begin with gastrographing swallow (water-soluble solution)
--bad quality pictures, but safe if the fluid extravasates (vs harmful high-quality Barium swallow)

Negative gastrography --> Ba swallow study

immediate surgical repair of perforation

433

what is dx in pt with severe, constant, retrosternal pain ~hrs after GI endoscopy;
febrile, diaphoretic, subQ emphysema

instrumental perforation of esophagus

434

how do you manage instrumental perforation of esophagus

begin w/ gastrographing swallow
--positive --> surgical repair
--negative --> Ba swallow

Abx and overnight watching if the tear is very small

if the perforation was made ~3 days ago, you need to do an esophageal derivation in the neck (cannot repair now with all of the inflammation)
--derivation at GE junction; and eventual esophageal repalcement

435

what is likely dx in older pt with weight loss, anorexia, and epigastric discomfort

stomach malignancy

436

how do you manage a suspected stomach cancer

endoscopy and biopsy
--you don't need a Barium swallow because there's enough lumen to not require a safety roadmap

if the biopsy shows cancer,
do a CT scan to determine if it's resectable,
then surgery

437

what is likely dx in pt with protracted colicky abdominal pain; vomiting, hyperactive bowel sounds; progressive distension

mechanical obstruction of small bowel

438

what will XR show in mechanical small bowel obstruction

distended bowel loops and air-fluid levels

439

what is most likely causes of mechanical bowel obstruction

2/2 previous surgery adhesions

440

how do you initially manage mechanical small bowel obstruction

since the SB has avoided falling into adhesion trap in the past, it is likely that the bowel can un-trap itself

manage w/ NG suction, NPO, IV fluids, and wait to let the bowel extricate itself

441

how do you manage a partial vs complete small bowel obstruction

complete:
typically willing to wait 24 hours before taking to the OR

partial:
typically willing to wait 3-5 days

monitor pt for deadly complication:
bowel becomes wedged/compromised/strangulated
--pt will have early fever/WBC --> constant pain/peritoneal --> peritonitis --> septic shock
--immediate OR if pt begins to develop these signs

442

what is dx in pt with SB obstruction + growing mass that's no longer reducible

strangulated/incarcerated hernia

443

how do you manage strangulated/incarcerated hernia

OR
--esp if discolored/strangulated/fever/WBC

operate electively, even if not strangulated, to indefinitely fix problem

444

what is likely dx in pt with protracted diarrhea, bizarre h/o flushing face, expiratory wheezing, prominent JVD?

carcinoid syndrome/tumor

445

where is carcinoid tumor likely to be

in small bowel / ileum

446

why does a carcinoid tumor produce its particular symptoms

carcinoid tumor is serotonin-producing

serotonin is normally deactivated in the liver, but if the pt has liver mets, the serotonin may dump into IVC --> systemic serotonin
--R heart damage (JVD)
--lungs can deactivate serotonin, so L heart is protected

447

how do you dx carcinoid tumor

serum 5-HIAA (byproduct of serotonin breakdown)

448

how do you manage carcinoid tumor

remove primary tumor

treat/remove liver mets

tends to be slow growing, so any palliative effort is helpful

449

what is likely dx in young adult w/ anorexia, vague periumbilcial pain --> sharp, severe, constant, well-localized RLQ pain with guarding/rebound tenderness

acute appendicitis

450

what will pt labs look like in acute appendicitis

mild fever w/ WBC count

L shift neutrophilia

451

how do you dx acute appendicitis

based on clinical presentation;
additional lab tests aren't necessary

452

how do you manage acute appendicitis in a pt before vs after perforation

before: emergency appendectomy

after perforation: appendectomy; ICU with prolonged post-op care

453

what are 98% of colon cancers

adenocarcinomas (grow out of mucosa)
--can impinge along lumen or bleed

454

how do you dx colon cancer

endoscopy and biopsy

start with flexible sigmoidoscopy to evaluate L sided cancer (any doc can do)

then do a full-length colonoscopy for R/L sided cancer
(done by surgeon doing the full colonoscopy)

455

how do you manage colon cancer

blood transfusions

CT scan to assess OR candidacy

cancers are often multi-centric

colectomy

456

what is dx in classic pt with anemia + occult blood in stool

R sided olon cancer

457

why is impingement unlikely in R sided colon cancer

liquid feces + larger lumen

458

what is dx in classic pt with change in bowel habits, constipation, and change in caliber/shape of stool ("toothpaste"); with blood visibly surrounding already-solid feces

L sided colon cancer

459

what should you think with villous adenoma in rectum and adenomatous polyps in the descending/sigmoid colon

most likely to be malignant:
a pre-malignant condition of Familial polyposis (Gardner's syndrome)
--it's ~100% predictive to progress to cancer
--should do proctocolectomy

next most likely to be malignant: villous adenoma
--50% progress to cancer
--should do resection

next most likely: adenomatous polyp:
--remove, often endoscopically
--surgery if sessile

no malignant potential: Juvenile polyps, Peutz Jehgers, or inflammatory/hyperplastic polyps
--no surgery is necessary

460

what are the indications for surgery in chronic ulcerative colitis

>20 yrs of UC = risk of malignancy

low weight
many hospitalizations (interfering with nutritional status or lifestyle of pt)

needing long-term steroids to control disease

toxic megacolon (abdominal pain, fever, distended transverse colon)
--emergency

461

what determines need for surgery in ulcerative colitis

surgery depends on extent of disease
-rectal mucosa will always be removed
-ileoanal anastomosis or ileostomy

462

what is likely dx in pt with watery diarrhea, crampy pain, febrile, WBC, and usually told specific Abx treatment (esp taking clindamycin)

pseudomembranous enterocolitis 2/2 Clostridium difficile

463

how do you dx pseudomembranous colitis 2/2 C diff

stool cultures (takes time)

proctosigmoid scope exam (helpful if disease is severe)

best: toxin in stool with kit (rapid)

464

how do you manage pseudomembranous colitis 2/2 C diff

stop offending Abx

do not use anti-diarrheal (keeps toxin in GI)

some docs prefer vancomycin or metronidazole or replenish normal flora

465

what does the management of anal/rectal problems always begin with

always begin with r/o cancer
--never prescribe meds over the phone

do rectal exam and proctosigmoid exam to r/o cancer

466

what is likely dx in BRB after bowel movement; painless

internal hemorrhoids

467

how do you manage internal hemorrhoids

rubber band ligation or laser/destruction

468

what is likely dx in painful perianal area w/o blood

external hemorrhoids

469

how do you manage external hemorrhoids

formal operation w/ anesthesia

470

what is dx in pt w/ severe pain with defecation and blood streaks, causing them to avoid BMs and not allow a PE

anal fissure

471

what is anal fissure thought to be caused by

thought to be 2/2 tight sprinter tone, causing limited blood supply, and unable to heal the tears

472

what is management of anal fissure

first examine pt to r/o cancer
--likely have to do under anesthesia since pt might refuse a painful PE

manage conservatively:
--stool softeners and topical agents
--nitroglycerin cream to relax sphincter

surgical management:
--lateral internal sphinterotomy, forceful dilation, Botox injections to paralyze sphincter

473

what should you suspect in a pt w/ h/o operation making a perianal fistula worse, causing an unsealing ulcer and purulence

Crohn's disease affecting the anus

474

how should you manage crohn's disease affecting the anus

rectal endoscopy exam to r/o necrotic cancer

475

what is likely dx in pt saying it's painful to sit or have BM, fever/chills; hot, tender, red defluction mass between anus and ischial tuberoscity

anorectal abscess

476

how should you manage anorectal abscess

r/o cancer or a fun gating tumor

drain all abscess with I&Ds

477

what should you think in a diabetic/immunocompromised pt with an anorectal abscess

if pt is diabetic/immunocompromised: the abscesses tend to be the beginning of necrotizing fasciitis
--treat with close F/U over next few hours to monitor the development of a soft tissue infection

478

when will an anal fistula develop

only in pts who have previously had ischial rectal abscess drainage

the abscess bacteria comes from anal crypts of the anal canal
drained through skin of perineum
epithelial migration
tract formation

479

how will an anal fistula pt present

pt must have previously had an ischial rectal abscess drainage

fecal streaks soiling underwear

PE shows perianal opening in skin and cord-like tract palpated from opening to inside

480

how do you manage anal fistula

r/o cancer

then surgery to to unroof the fistula so granulation tissue can fill in the tunnel

481

what is dx in blood coating the outside of stool + changed bowel habits

sigmoid adenocarcinoma

482

where does sigmoid adenocarcinoma metastasize to

metastasis only to Lymph nodes inside abdomen

483

what is dx more likely in an HIV+/homosexual pt (no viral connection)
grows close to anal canal opening; often felt as mass protruding from anus

squamous cell carcinoma of anus

484

where does squamous cell carcinoma of anus metastasize to

metastasizes to lymph nodes inside abdomen (like sigmoid adenocarcinoma),
but ALSO GROIN NODES

485

how do you dx and manage squamous cell carcinoma of anus

dx: biopsy the mass

manage: best to first shrink before surgery
--Nigro protocol: combo of chemo + radiation
--+/- resection if necessary

486

where are pts likely to be bleeding from in a GI bleed, statistically

75% pts are bleeding from upper GI
(nose to Ligament of Trietz in duodenum)

25% of pts are bleeding from distal GI tract
(mainly colon)

487

which location of bleed is common in younger vs older pts

upper GI: common in younger pts

lower GI: common in older pts (except hemorrhoids)
--elderly = equal opportunity bleeders

488

what are 5 things possibly causing a lower GI bleed

hemorrhoids, polyp, cancer, angiodysplasia, diverticulosis

489

what does vomiting blood tell you

upper GI bleed

490

how do you identify upper GI bleed site

endoscopy easily identifies an upper GI bleed site
--blood goes away as soon as you pass lesion

491

how do you manage upper GI bleed

stop bleeding with photocoagulation

492

what does a GI bleed with an NG tube w/ clear green fluid w/o blood mean

the fluid contains bile; you've sampled the duodenum
you can r/o it as a source of bleeding

493

what does a GI bleed with an NG tube w/ clear white fluid w/o blood mean

you can r/o the tip of the nose to the pylorus as a source of bleeding
--could still be in duodenum

494

when is a lower endoscopy/colonoscopy not helpful in locating a GI bleed

if the pt is presently and significantly bleeding
--it's too bloody distal to the lesion

495

what imaging is helpful to r/o hemorrhoids

anoscopy

496

what imaging is helpful in >=2cc/min GI bleeding

arteriogram

497

how do you calculate the extent of GI bleeding

calculate how often you're perfusing to keep stable vitals

2cc/min = 120cc/hr = every 4 hours a unit of blood is required

<5cc/min = every 16 hours a unit of blood is required (no arteriogram)

498

when can you perform a colonoscopy to evaluate a small bleed <5cc/min

after bleeding as stopped

499

what study can be done to evaluate "in-between" bleeds of 0.5-2cc/min

tagged RBC study

500

who does a tagged RBC study work to show where GI bleed is

can give rough indication of which side for hemicolectomy

some docs always order this before an arteriogram

some docs skip this and go straight to arteriogram
--pt has stopped bleeding by the time you get results back
--no guarantee the arteriogram will work, though

501

what imaging is helpful if the pt last bled 2 days ago from GI bleed

double endoscopy

(tagged RBC or arteiogram is useless)

502

what is dx in young child w/ bloody BM

Meckel's diverticulum

503

what test can you do to dx Meckel's diverticulum

radioactively labeled Technetium scan to identify gastric mucosa

504

what is dx in pt with multiple shallow furiously bleeding ulcers in gastric mucosa 2/2 complicated ICU course

stress ulcers

505

how do you dx and manage stress ulcers

dx: endoscopy

prefer to prevent vs tx
--ICU pts get H2 blockers, antacids, or both

manage:
radiologic angiogram to selectively catheterize stomach blood supply (L gastric artery)

506

what is the generic/broad ddx of acute abdominal pain

perforation
obstruction
inflammatory process

507

what classically presents as sudden onset, constant severe pain that is GENERALIZED

abdominal perforation

508

what is the most common abdominal perforation

duodenal ulcer perforation

509

what is dx in pt who lies motionless to avoid pain in abdomen and PE elicits extreme peritoneal irritation (pain to palp, guarding, rebound tenderness); and absent bowel sounds

abdominal perforation

510

how do you manage abdominal perforation

r/o other things before arriving at perforation

first: CXR to r/o lower lobe pneumonia

EKG for coronary ischemia

plain abdominal XR for free air perforation, ureteral stone

amylase for pancreatitis


then, immediate ex lap

511

what is classic dx for sudden onset of pain, colicky, that is localized w/ associated radiation

abdominal obstruction

stone in ureter, cystic duct, common duct, or small bowel lumen

512

what is dx in pt who is moving around looking for positional comfort and PE localizes to the problem

obstruction

513

what is most likely in female, fat, forty, fertile

gall stones

stones could be asymptomatic
low rate of conversion --> symptomatic

514

what is typical PE in biliary tract disease

severe RUQ colicky pain that radiates to R shoulder towards back, N/V that turns into constant pain

PE will show tender to palp, guarding/rebound
mild fever and WBC

515

what is abdominal pain that quickly resolves with OTC meds, often 2/2 fatty foods; and no residual findings after pain subsides

biliary colic

no residual findings afters stone falls back

516

how do you manage biliary colic

cholecystectomy to prevent further episodes

517

what is abdominal pain that persists to constant, localized pain with fever and WBCs;

acute cholecystitis

518

how do you dx acute cholecystitis

sonogram to show stones
thickened gallbladder wall
pericholecystic fluid

rarely, and inconclusive US will cause you to do a HIDA scan

HIDA scan shows bile flow NOT in the gallbladder

519

how do you manage acute cholecystitis

anticholinergics do not resolve symptoms

typically tx w/ medical management, including NG suction, NPO, Abx, and IV fluids

then do an elective cholecystectomy

520

what is likely dx in pt with abdominal pain and highly elevated Alkaline Phosphatase

Ascending cholangitis

(pt will be very sick- high 104 fever, high WBC)

521

what causes ascending cholangitis

partial obstruction from a stone that allows an ascending infection

522

how do you manage ascending cholantigis

emergency

IV Abx, hospitalization, decompress biliary tract with ERCP
catheter above the stone to drain the duct; percutaneous PTC

523

how does a stone cause acute pancreatitis

stone stuck at ampulla of Vater

occludes both common bile duct and pancreatic duct

524

what is dx in pt with sudden onset flank pain, radiates to thigh/scrotum; and microhematuria

ureteral stone

525

how do you dx ureteral stone

IV pyelogram, sonogram, CT scan

526

what is dx in elderly pt w/ abdominal distension, N/V, no flatus/BM, tympanic abdomen, and hyperactive bowel sounds

sigmoid volvulus

527

what does sigmoid volvulus XR show

distended loops w/ air fluid levels and "bird beak" sign

528

how do you manage sigmoid volvulus

proctosigmoid exam
try to untwist bowel and leave long rectal tube to prevent coil

surgery may be indicated

529

what is likely dx in elderly pt w/ A fib or a recent MI now presenting with an acute abdomen

mesenteric iscemia

530

how does a recent MI or A fib cause mesenteric ischemia

embolus occluding SMA

531

how is the bowel affected in an SMA occlusion

distension up to transverse colon

532

what does a sick pt with acute abdomen and acidosis likely have

mesenteric ischemia that has progressed to a dead bowel

533

how do you manage mesenteric ischemia

ex lap to resect dead bowel

call vascular surgeon ASAP to try arteriogram to prevent irreversible necrosis

534

what is dx in pt with gradual onset of abdominal pain, which builds up to maximal intensity in 2-12 hrs; constant, and localized

some sort of inflammatory process

535

what generic dx will have an abdominal exam showing peritoneal, but localized; and likely signs of systemic inflammation (fever, WBC)

abdominal inflammatory process

536

what presents with ascites + vague acute abdomen

bacterial hematogenous peritoniits

537

how do you dx and manage bacterial hematogenous peritonitis

sample ascites for culture

then tx

538

what is dx in alcoholic pt with abdominal pain that radiates to back w/ N/V

pancreatitis

539

how do you dx pancreatitis, depending on when pt presents

serum amylase/lipase if recent onset

urinary amylase/lipase if seeing the pt 3 days later



540

what is dx in pt with abdominal pain with: inflammatory mass; LLQ pain; pain building up to a constant, localized pain; with fever and WBC

diverticulitis

541

what is the blood marker for HCC

alpha-fetoprotein

542

what is alpha-fetoprotein a blood marker for

HCC

543

who gets HCC

only seen in pts who already have cirrhosis

544

what is the most common liver cancer in the US

metastatic cancer to the liver
20:1 metastatic in the US

545

where does liver mets likely come from

h/o colon cancer

546

what is blood marker for liver mets

carcinogenic antigen CEA

547

what is carcinogenic antigen (CEA) a blood marker for

liver mets

548

how do you manage liver cancer

CT to evaluate extent of tumor

attempt surgical resection or radioablation

549

what is commonly seen in females on chronic birth control

hepatic adenoma

550

what presents in a female on birth control with sudden abdominal pain that leads to faint, pale, tachy, hypotensive, and mildly distended/tender abdomen

hepatic adenoma

birth control can develop hepatic adenomas with tendency to bleed

551

how do you dx and manage hepatic adenoma

dx w/ CT scan to show adenoma

tx with surgical resection
--not common and not an indication for a female to discontinue OCPs

552

what is likely dx in late-pregnancy female who suddenly experiences shock

visceral aneurysm of hepatic artery bleeding into abdomen

553

what type of liver abscess is a complication of biliary tract disease

pyogenic liver abscess

554

how do you manage pyogenic liver abscess

needs drainage (percutaneous)

555

what type of liver abscess will commonly present with a "Mexico connection", likely in a M

amoebic liver abscess

556

what do labs look like for amoebic liver abscess

fever, WBC, tender over liver, jaundice, elevated Alk phos

557

what will sonogram show in amoebic liver abscess

normal biliary tree and liver abscess

558

how do you dx and manage amoebic liver abscess

dx: serology (requires time for pt to develop antibodies)

manage:
empiric tx w/ metronidazole
drain if pt is not responding to Abx and the abscess is growing
do not draw pus to send to lab for growth; the amoeba grows from the wall of the abscess

559

what type of jaundice gives you:
mild 6-10 Bil elevation with almost ALL INDIRECT (not being processed by liver)

hemolytic jaundice

560

what is your work up geared toward with a mid Bil elevation that's almost all indirect

this is hemolytic jaundice, so you should direct your focus on what's destroying the RBCs

561

what type of jaundice gives you:
both high Bil's
very high transaminases
only modest elevation of Alk Phos

hepatocellular jaundice (hepatitis)

562

what should your work up be directed at with very high transaminases

identifying the type of hepatitis the pt has

563

what type of jaundice gives you:
classically both high Bil's (direct is high in early cases)
mildly high transaminases
very high alk phos

obstructive jaundice

564

what should your work up be directed at with very high alk phos

sonogram to identify where the obstruction is

565

what is the quick/obvious jaundice answer when labs show:

elevated Bil that is all indirect

very high transaminases

very high alk phos

indirect Bil = hemolytic jaundice

transaminases = hepatocellular

alk phos = obstructive

566

what type of obstruction occurs when the gallbladder is contracted, thick-walled, and full of stones

benign obstruction

567

what are the next steps after you identify a benign gallbladder obstruction

ERCP and sphincterotomy to retrieve stones

then cholecystectomy to prevent more stones

568

what type of obstruction occur when the gallbladder is nontender, distended, and thin-walled

malignant obstruction

cancer of the pancreas, common duct, or ampulla of Vater/hepatopancreatic duct

569

what is the next step after a malignant gallbladder obstruction has been identified

CT scan to determine cancer location

570

what type of pancreatic cancer will be symptomatic

pancreatic cx will be advanced if it's big enough to be symptomatic

571

what does a negative CT scan in a malignant gallbladder obstruction mean

a negative CT scan = small cancer of pancreatic head, cholangiocarcinoma, or ampulla of Vater carcinoma

next = ERCP

572

what gives you apple core appearance on ERCP

cholangiocarcinoma

573

what are the next steps after dx cholangiocarcinoma

brushings to obtain cytologic confirmation

whipple procedure (relatively curable, vs pancreatic tumor)

574

what gives you a slightly anemic pt with blood in GI lumen and evidence of malignant gallbladder obstruction

ampullarf cancer

575

how do you manage ampullary cancer

CT scan will unlikely show this small cancer

endoscopy (not ERCP) to see the tumor, biopsy it, and confirm dx

easily resectable

576

what gives you evidence of malignant gallbladder obstruction, growing into retroperitoneum w/ milk pain deep to epigastrium and upper back; possibly w/ FHx

pancreatic head cancer

577

what are your next steps after suspecting pancreatic head cancer

first: sonogram

next: CT shows big cancer (big enough to be symptomatic)

percutaneous biopsy

palliative biopsy

578

what is dx in alcoholic pt with abdominal pain

acute pancreatitis

579

how do you dx acute pancreatitis

blood or urine amylase / lipase

580

when does serum vs urine elevation occur in acute pancreatitis with amylase / lipase

serum elevation occurs 12hrs - 2 days after onset of symptoms

urine elevation occurs 2- 5 days after onset of symptoms

581

what is dx when pt has plasma deposited around pancreas

benign edematous pancreatitis

582

how do you dx benign edematous pancreatitis

dx with a high Hct (hemoconcentrated blood)

plasma has been removed from the blood and deposited around the pancreas

583

how do you manage benign edematous pancreatitis

NPO, NG suction, IV fluids

pt will improve

584

which pancreatitis is diagnosed with a low Hct

Hemorrhagic pancreatitis (losing blood)

585

what is used to calculate the prognosis of hemorrhagic pancreatitis

Ranson's Criteria

586

what is happening with lab values in bad hemorrhagic pancreatitis

the Hct is continuing to drop
low serum Ca
high BUN
metabolic alkalosis
low pO2
high blood glucose

587

how do you treat hemorrhagic pancreatitis

intensive ICU support and expect lots of complications

588

what is concerning for oncoming death in hemorrhagic pancreatitis

pancreatitis abscess development often means death is coming

you have a destroyed, necrotic, hemorrhagic gland

589

what should be done daily to monitor hemorrhagic pancreatitis

daily CT scans to find the earliest indication of pus collection

drain the abscesses immediately as the only hope to survive

590

what is dx in pt with chronic epigastric pain that radiates to back for ~yrs.
pt may also have DM, steatorrhea, malnourishment, alcoholism
pt typically has no job, family, home, and frequents ER for pain control

chronic pancreatitis

591

what does XR show in chronic pancreatitis

upper abdominal Ca

592

why can amylase no longer be used in dx of pancreatitis in chronic pts

pt has a history of continuing to drink after alcoholic pancreatitis --> destroyed pancreas

593

how do you tx chronic pancreatitis

attempt to control DM, pancreatic enzymes for steatorrhea, but the pain isn't well treated

ERCP to drain pancreatic duct

total pancreatectomy: usually die 2/2 extremely poorly controlled DM

594

what is dx in pt with ill-defined upper abdominal discomfort, early satiety, and h/o recent d/c from hospital for pancreatitis tx

pancreatic pseudocysts

595

what will PE show in pancreatic pseudocysts

large epigastric mass deep in the abdomen

596

what is dx in pt with vague upper abdominal discomfort, early satiny, and h/o recent MVC hitting the steering wheel

pancreatic pseudocysts

597

how long is the "incubation" period for pancreatic pseudocysts

typically ~5 weeks between trauma/pancreatitis and fluid collection/pressure

598

what causes pancreatic pseudocysts

trauma/pancreatitis leading to pancreatic juice leaking out of duct and collecting nearby

599

where is the classic collection site for pancreatic pseudocyst fluid

lesser sac

600

how do you dx pancreatic pseudocysts

sonogram or CT showing fluid collection

601

how do you manage pancreatic pseudocysts based on 4 outcomes

careful monitoring w/imaging for resolution

spontaneously resolve:
--go away within 6 weeks

deadly complications typically happen >6 weeks later
--rupture into peritoneal cavity --> massive fulminating peritonitis
--erode into major vessels --> bleeds and exsanguinate
--infected juice 2/2 arterial infection; pseudocyst--> pancreatic abscess --> death

endoscopic internal drainage by gastroscopy:
--create a cystogastrostomy that can drain it without a fistula (via perc drain)

602

what is the standard recommendation for any hernia

repair electively to prevent possible incarceration/strangulation of bowel

603

what is the exception for fixing hernias

umbilical hernia <2yo child

will resolve/close spontaneously

604

what is recommendation for sliding esophageal hernia

not an actual hernia;
not an indication for surgery itself,
but paraesophageal hernia is indicative for surgery

605

what does breast disease management always begin with

r/o cancer

606

what is the only way to certainly r/o or dx breast cancer

pathology report

clinical/radiology can only suspect cancer

607

what are the 5 types of breast biopsies from least to most invasive

least invasive:
FNA cells from mass, cytology

core biopsy: needle collects cores of tissue

mammotome to obtain bigger mass

incisional bx in the OR

most invasive:
excision biopsy (remove the entire suspicious mass)

608

what does the extent of breast biopsy depend on

depends on clinical suspicion

609

what is the most important factor for clinical suspicion of breast pathology

age

610

what method would you use in a young person vs middle-aged to r/o breast pathology

young: non-invasive r/o measures

middle aged: either a core biopsy or bigger biopsy; may not even stop until an excision biopsy is done

611

what should your clinical suspicion be in a female pt with recent trauma to breast

do not allow recent trauma to r/o potential dx of cancer by assuming it's fat necrosis or a hematoma

--still need mammogram and tissue sampling

612

what is the role of a mammogram

does not dx cancer of the breast
it detects potential/probable cancer that's too small to be palpated
--always done first is mass is found on exam in a F >30yo

613

what is description of irregularities suspicious for cancer

irregular density
no sharply demarcated borders
fine microcalcifications
recent finding (not present on mammogram ~2yrs ago)

614

what are 2 contraindications for mammogram

<20yo (dense breast tissue won't allow pathology visualization)

lactating (only see milk)

615

can you do a mammogram during pregnancy

YES!

616

what is dx in young F with rubbery mass; easily movable

fibroadenoma

617

what is the term for a quickly growing fibroadenoma

giant juvenile fibroadenoma

618

what is work up for fibroadenoma suspicion

FNA/sonogram to confirm dx of fibroadenoma

+/- remove mass depending on pt preference

619

what is dx in late 20s F with a mass, typically long history, grows big, remains movable; no axillary involvement

cystosarcoma phyllodes

620

what is management of cystosarcoma phyllodes

removal is mandatory; malignant potential

621

what is dx in 20-40yo F with painful cyclical lumps that come/go

fibrocystic disease: mammary dysplasia, cystic mastitis

622

how do you manage fibrocystic disease

mammogram for baseline picture and cyst visualization

if cyst becomes firm and doesn't go away with cycle:
--aspiration of cyst (not FNA) to remove cystic fluid
--retrieve clear fluid and mass disappears: you're done
--retrieve blood fluid: send for cytology
--if mass doesn't go away/quickly returns: needs formal tissue sampling/bx

623

what is dx in F with blood discharge from nipple w/o palpable masses

intraductal papilloma

624

what is a small benign tumor 2-3mm that grows inside breast duct

intraductal papilloma

625

how do you manage intraductal papilloma

need to r/o carcinoma possibility
--mammogram first
----lesion = probably cancer; need bx

can see with galactogram or retroareolar surgical exploration: remove that section of breast

626

what is the pt presentation that is only acceptable in a lactating F

crack in nipple with red, hot, tender mass in breast with fever and WBC

otherwise, assume it's cancer until proven benign

627

how do you manage a F with cracked nipple, red, hot, tender mass in breast with fever and WBC

r/o cancer, but no point in a mammogram if the F is lactating (only see milk)

need I&D, but also take small sample from the wall to path to r/o infected cancer

628

what are the 2 limitations of pregnancy and breast cancer

cannot give chemo in 1st trimester of pregnancy

cannot give radiation at any time during pregnancy (diagnostic XRs are ok)

not necessary to terminate pregnancy

629

what is dx in classic orange peel / retracted skin with red/swollen breast

inflammatory breast cancer

630

what is prognosis and management of inflammatory breast cancer

lethal

manage w/ mammogram, tissue sampling, pre-op chemoradiation

631

what is dx in F with hard mass under nipple causing nipple retraction

desmoplastic rxn of breast cancer

632

how do you manage desmoplastic rxn of breast cancer

mammogram, generous tissue sampling

633

what is dx of non-palpable eczematous lesion in areola of F not improved w/ lotions

Paget's disease of breast

it's infiltrative under areolar tissues

634

how do you manage Paget's disease of breast

mammogram, biopsy, then proceed

635

what is dx in mass in axilla; discrete, hard, movable, and a negative breast PE

breast cancer metastatic to axilla

636

how do you manage metastatic breast cancer to axilla

mammogram needed to show primary tumor; then proceed

if negative, biopsy and remove the axillary lymph node

637

how should you manage incidental micro calcifications off mammogram

tissue biopsy,
core biopsy by radiologist 8-12 samples
surgical removal w/ wire guidance for path

638

what are your management options for breast cancer after dx

lumpectomy + radiation

modified mastectomy

axillary sampling

also need to look for signs of systemic metastasis

639

when is lumpectomy + radiation indicated

relatively small cx compared to breast ratio and far from nipple
--also need axillary sampling

640

when is modified mastectomy indicated

relatively large cx compared to breast ratio or near the nipple
--includes axillary sampling
--no radiation necessary

641

how is axillary sampling conducted

different from axillary dissection

axillary sampling = sentinel node biopsy
--inject radioactive material into tumor; migrate via lymph; trapped by 1st LN --> biopsy that LN

642

what are the 2 breast cancers that call for a special management, and what is it

inflammatory carcinoma of breast
or Carcinoma in situ

pre-op radiation/chemo before surgical resection

643

how do you manage/ what should you suspect in h/o breast cancer w/ recent onset HAs

need CT san looking for brain mets
resect any resectable brain mets
TNM classification

644

how do you manage/ what should you suspect in h/o breast cancer w/ recent onset back pain

need radio bone scan (sensitive, not specific)
--positive --> XR to see it light up; or consider other causes (fracture; arthritis)

manage bone mets with radiation, ortho stabilization, braces, etc

645

what are 4 rules for systemic tx of breast cancer

any pt with positive axillary lymph nodes

premenopausal pts: prefer chemotherapy

postmenopausal pts: prefer hormonal therapy (Tamoxifen), esp if ER/PR positive

give chemo to everyone who already has obvious metastasis (liver, bone, brain)

646

how do you manage ductal carcinoma in situ

standard recommendation: simple total mastectomy
--offers 100% cure
--not yet capable of metastasis
--axillary examination is not needed

647

how do you manage thyroid masses based on biopsy results

negative: leave alone
positive: operate to remove tumor (most are benign)

indeterminate: operate

648

what is dx in pt who is losing weight, big appetite, heart palps, heat intolerance, thin, fidgety, diaphoretic, tachy

hyper functioning thyroid adenoma- "hot" --> hyperthyroidism

649

how do you dx and manage hyperthyroidism

high free T4 or low TSH

localize with radioactive iodine scan
--surgically resect the isolated area
--or radioactive iodine tx if whole thyroid lights up

650

what is dx in lateral mass near thyroid

metastasis from follicular carcinoma of thyroid that has completely replaced a lymph node

651

how do you manage metastatic follicular carcinoma of thyroid

thyroid scan to identify primary tumor
then surgery

652

what is dx in pt with high serum Ca and low serum P

hyperparathyroidism

653

how does hyperparathyroid pt present

"stones, bones, moans, psychiatric overtones"

nephrolithiasis
cystic bone lesions
GI complains w/ pancreatitis
peptic ulcer
constipation
psych

654

how do you dx hyperparathyroidism

verify primary hyperPTH with simultaneous high serum Ca

655

what are most hyperparathyroid conditions

90% are adenomas (vs hyperplasia)

656

how do you tx primary hyperparathyroidism

remove offending adenoma
--localize with Sestamibi, sonogram, CT scan prior to surgery

--high rate of conversion, so you should treat even if pt is asymptomatic

657

what is dx in pt who goes pretty --> monster (lolz)

cushing

658

what is dx in pt with round face, acne, hair, hump, supraclavicular fat pads, thin extremities, truncal centripetal obesity w/ striae

cushing

659

what should you think in a pt with HTN, DM, osteoporosis, amenorrhea, wide mood swings +/- psych service

cushing

660

how do you work up cushing

measure AM and MP cortisol (high; and no longer diurnal variation)

Dexamethasone tests

661

what is dx in pt whose cortisol is suppressed with small dose of dexamethasone

does not have Cushing's

662

what is dx in pt whose cortisol is not suppressed with low-dose dexamethasone

Cushing's

don't know location/cause yet
--could be pituitary adenoma --> both adrenals
--or adenoma in adrenal --> cortisol

663

what is dx in pt whose cortisol suppresses at high doses of dexamethasone

ACTH-secreting pituitary micro-adenoma

664

what is dx in pt whose cortisol does not suppress at high doses of dexamethasone

adrenal or extra-adrenal cortisol production

665

depending on your Dex results, what is your next step

MRI of pituitary or CT of adrenals
--remove the offender

666

what is dx in pt with gastronoma of pancreas or duodenum

Zollinger-Ellison syndrome

667

what is dx in pt with extremely virulent PUD that does not respond to normal therapy + watery diarrhea

Zollinger Ellison syndrome
--gastrinoma

668

what is work up up for Zollinger Ellison syndrome

measure serum gastrin
CT scan of pancreas/duodenum to see primary tumor
resect the gastronoma

669

what is ddx for hypoglycemia

terminal stage liver failure, retroperitoneal sarcoma

insulinoma

reactive hypoglycemia

injecting insulin

670

what is dx in pt who gets a hypoglycemic attack during fasting (skip breakfast; late for lunch)

insulinoma

671

what will labs be in insulinoma

endogenous insulin = high C peptide + high insulin

672

what is dx in pt who gets hypoglycemia attack after a big meal

reactive hypoglycemia (pancreas overreacts)

673

what are labs in reactive hyoglycemia

endogenous insulin - high C peptide + high insulin

674

what is dx in pt who gets hypoglycemia attack and has knowledge of how insulin works

injecting insulin

refer pt to psych to determine motivation of action

675

what will labs look like for a pt injecting insulin

exogenous insulin = low C peptide + high insulin