Surgery: Subspecialty Flashcards by David Felipe Ortiz Paredes

Patient with hypertension and hypokalemia.

Aldo:renin > 20
Failed salt suppression test

Dx, next step, tx?

Primary hyperaldo (Conn’s)

Next step: CT/MRI and Adrenal vein sampling

Tx: resection

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Old man with atherosclerosis, or young woman with fibromuscular dysplasia who has Hypertension and Hypokalemia.

Aldo:renin < 10

Dx, next step, tx?

Renal Artery Stenosis

Next step: U/S doppler and Angiogram

Tx:

For old patient: ACE-I, ARBs, or aldo antagonist (e.g., spironolactone)
For young patient: stent

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Paroxysms of BP elevation, Headache, Palpitations, Perspire (transpiration).

Dx, next step, tx?

Pheochromocytoma

Next steps:

Urinary vanillylmandelic acid (VMA)
Unrianry metanephrines
CT scan/MRI
Adrenal vein sampling

Tx:

First alfa blockade
Then beta blockade
Then resection

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Patient with

Hypertension
DM
Women
Buffalo hump
Purple striae
Moon facies

Next step?

Next steps:

24 hr free urine cortisol
Low dose dexamethasone test (low then high)

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Patient with Hypertension, DM, Women, Buffalo hump, Purple striae, Moon facies .

High 24 hr free urine cortisol
Failed low dose dexamethasone test

Dx, Nex steps?

Cushing’s syndrome

Next step: ACTH levels

“low then high:” low dose DST –> ACTHen –> high dose DST

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Patient with Hypertension, DM, Women, Buffalo hump, Purple striae, Moon facies .

High 24 hr free urine cortisol
Failed low dose dexamethasone test
Low ACTH

Dx, Nex steps, tx?

Adrenal tumor

Nex steps: MRI/CT scan

Tx: resect

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Patient with Hypertension, DM, Women, Buffalo hump, Purple striae, Moon facies .

High 24 hr free urine cortisol
Failed low dose dexamethasone test
High ACTH

Dx, Nex steps?

High dose dexamethasone test

“low then high:” low dose DST –> ACTHen –> high dose DST

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Patient with Hypertension, DM, Women, Buffalo hump, Purple striae, Moon facies .

High 24 hr free urine cortisol
Failed low dose dexamethasone test
High ACTH
High cortiso after high dose dexamethasone test (failed)

Dx, Nex steps?

Ectopic ACTH production (pananeoplastic sd)

Next steps: CT of lung, abdomen, pelvis

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Patient with Hypertension, DM, Women, Buffalo hump, Purple striae, Moon facies .

High 24 hr free urine cortisol
Failed low dose dexamethasone test
High ACTH
Low cortisol after high dose dexamethasone test

Dx, Nex steps, tx?

Cushing’s disease

Next steps: MRI or CT abdomen

Tx: resection

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Torso HTN
Legs hypotension
Claudication
Warm upper extremities, cold lower extremities
Rib-notching (because of collaterals are formed)

Dx, Nex steps, tx?

Coarctation of aorta

Dx: angiogram

Tx: resect and reanastomose

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Old, male with CAD, Chest pain, CHF, Syncope.

Systolic murmur crescendo-decrescendo murmur at the 2nd space-right sternal border (improves with valsava, worsens with leg raise). Radiated to carotids

Dx, next step, tx?

Aortic Stenosis

Dx: Echo

Tx: replacement + CABG

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Holosystolic murmur at the apex, improves with Valsalva, radiates to the axial.

Dx, possible cause, next step, tx?

Mitral Regurgitation

Cause: Infection (endocarditis), infraction (papilary muscle/chordae tendinae rupture)

Dx: Echo

Tx: Replacement

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Cardiogenic shock, flash pulmonary edema, chest pain.

Rumbling, blowing decrescendo diastolic murmur at the 4th intercostal space-left sternal border

Dx, next step, tx?

Aortic Regurgitation

Dx: Echo

Tx: Replacement + CABG

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Young patient with CHF, AFibv.

Diastolic murmur on the apex “rumbling with opening snap”

Dx, possible cause, next step, tx?

Mitral Stenosis

Cause: Rheumatic disease

Dx: Echo

Tx: Balloon valvuloplasty (unique), then replacement

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Diference between valve types

Bovine (organic)

Last < 10 yrs
No anticoagulation needed

Mechanical

Last 10–20 yrs
Need anticoagulation (warfarin, target INR 2.5–3.5)

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Obese patient, HTN, DM, smoker, high cholesterol with Substernal pain, Worse with exercise, Improve with nitroglycerin or rest.

An NSTEMI is Dx and he goes to the cath where 1–2 vessels are compromised

Next step?

Angioplasty (PCI) + Clopidogrel

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Obese patient, HTN, DM, smoker, high cholesterol with Substernal pain, Worse with exercise, Improve with nitroglycerin or rest.

An STEMI is Dx and he goes to the cath where left mainstem or 3+ vessels are compromised

Next step?

CABG

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HTN, DM, smoker, high cholesterol with Shiny shins, Loss of hair, ↓ pulses, ↓ temp.

Dx, next steps, tx and f/u?

Peripheral vascular disease

Next steps:

Ankle-brachial index (ABI)
Doppler
CT angiogram

Tx:

Above the knee or small lesion: Angioplasty/stent
Everything else: bypass

F/U: Medical treatment
BB/ACE-i, A1C< 7&, Smoking cessation, Statin, ASA or clopidogrel

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Interpretation of Ankle-brachial index (ABI) in PVD

1.0–1.4: normal
0.9–1.0: ambiguous –> follow up with exercise ABI
0.8–0.9: mild
0.4–0.8: moderate
< 0.4: severe

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Patient at the ER with Pulselessness, Pale, Pokolothermia (cold limb), Pain, Paresthesia, Paralysis.

Dx, next steps, tx and f/u?

Acute limp ischemia (ALI)

Next steps:

Doppler
Angiogram

Tx: Embolectomy, or tPA

F/U: What out for compartment syndrome after tx

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Male patient, older > 65, history of smoking, asx pulsatile mass, +/- back pain.

Dx, next step?

Abdominal aortic aneurysm (AAA)

Next step: U/S (screen men > 65; women > 65 with history of smoking)

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Tx of Abdominal aortic aneurysm (AAA)?

3–4 cm, Diagnosis, Screen q2y
4–5 cm, Worrisome, Screen q1y
5–5.4 cm, High Risk, Screen q6mo
> 5.5 cm, Danger, Operate (Endovascular aneurysm repair/open)
> 0.5 cm/6 mo, Danger, Operate (Endovascular aneurysm repair/open)

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Patient with tearing chest pain that radiates to the back, asymmetric BP between arms, widened mediastinum on CxR.

Dx, next step, tx?

Aortic dissection

Next step: CT angiogram
- MRI or TEE if CT angiogram can’t be done (e.g., CKD)

Tx:

Type A (ascending): operate (evaluate for aortic valve replacement)
Type B (descending): medical tx with IV beta-blockers

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Risk factors for aortic dissection

HTN, marfan, syphilis

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Causes of amblyopia

- Strabismus | - Congenital cataracts

Kid with light reflected differently between eyes (not at the center) Dx, Tx?

Strabismus Patch the good eye, glasses

Causes of congenital cataracts

- TORCH infection | - Galactosemia

When performing the red reflex, instead of red you see white in a pediatric patient. Dx, tx, and associated problem?

Retinoblastoma Tx: surgical F/U: osteosarcoma

Pediatric patient in the neonatal unit with vascular growths on the retina. Dx. tx?

Retinopathy of prematurity Tx: laser ablation F/U: bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis

Newborn who received Ppx with drops of silver nitrate who develops non-purulent bilateral eye discharge. Dx?

Chemical conjunctivitis produced by silver nitrate. The ppx should be done with erythromycin

5 days old baby with purulent bilateral eye discharge. Dx, next steps, tx?

Gonorrhea Next steps: - Chocolate agar - PCR Tx: Ceftriaxona IM

10 days old baby with watery, then purulent, then bloody eye discharge. First unilateral, then bilateral. Dx, next steps, tx?

Chlamydia Next steps: - Chocolate agar - PCR Tx: Erythromycin PO

Patient who was watching a movie and after that has pain in the eye, eye pain, Headaches. On physical Rigid eyeball and Non-reactive dilated pupil. Dx, next step, tx?

Closed angle glaucoma Next step: measure eye pressure ``` Tx: Constrict pupil • Alfa-2 agonist drops • Beta blockers drops Diuretics Emergent surgery to realise pressure ``` F/U: NEVER GIVE ATROPINE

Patient who was inflammation around the eye and can move it. Dx?

periorbital cellulitis

Patient who was inflammation around the eye and can't move it. Dx, next step, tx?

Orbital Cellulitis Next step: CT scan Tx: surgical drainage + Abx F/U: If DM/DKA consider mucormycotic and treat with amphotericin B

Patient who refers seeing floaters and then a curtain over vision. No pain in the eyer Dx?

Retinal Detachment

Patient who refers curtain over vision that comes a goes. No pain in the eye. Dx?

Amorousis fugax (sign of retinal artery occlusion

Patient who refers curtain over vision. No pain in the eye. On physyucal no other FND are seen. In fundoscopy you see Cherry red spots in the fovea Dx, tx?

Retinal A. Occlusion Tx: - Intraarterial tPA - Hyperventilation

Chronic progressive loss of central vision. On fundoscopy you see hemorrhages or fluid. Dx?

Wet Macular degeneration

Chronic progressive loss of central vision. On fundoscopy you see pigment changes. Dx, tx?

Macular degeneration Tx: supportive care, no specific tx

Patient who was asx and suddenly develops the worst headache of his life. A few days ago he had a headaches wich resolved with pain medications. Dx, next steps?

Subarachnoid hemorrhage Next steps: - Non-contrast CT scan showing bleeding within the meninges but not in the cerebral tissue - Lumbar puncture (LP) if CT is negative despite high suspicion: Xanthochromia (yellowish CSF) - CT angiogram/ MR angiogram/angiography

Patient who was asx and suddenly develops the worst headache of his life. A few days ago he had a headaches wich resolved with pain medications. Non-contrast CT scan showing bleeding within the meninges but not in the cerebral tissue Tx?

Subarachnoid hemorrhage ``` Bleeding control o BP < 140/90 with IV BB or CCB o Coil or clipping Hydrocephalus o Serial LP o VP shunt Seizures ppx (e.g., levetiracetam) ↓ ICP o Hypertonic solutions like mannitol o Elevate head of bed o Hyperventilate  Late complications (5–7 d) Vasospasm ppx with CCB ``` F/U: CT scan to evaluate changes in hemorrhage

Patient with hx of HTN who develops headache, n/v and FND. Non- contrast CT scan shows Intraparenchymal hemorrhage Tx?

``` ↓ ICP • Hypertonic solutions like mannitol • Elevate head of bed • Hyperventilate Craniotomy Evacuate the hematoma ``` F/U: CT scan to evaluate changes in hemorrhage and midline shifts

CT scan showing calcification of sella in a kid. Dx?

Craniopharyngioma

Patient with FND, Seizure, Headache worse in AM, Progressive N/V. CT scan shows calcified mass from the dura Dx, tx?

Meningioma | Tx: resection (curative)

Patient with FND, Seizure, Headache worse in AM, Progressive N/V. CT scan/ MRI ring enhancing lesion that crosses the midline Dx, tx?

Glioblastoma multiforme (bad prognosis) - Steroids (palliative) - Seizure ppx (e.g., lamotrigine, phenitoin, levetiracetam)

Old male with urinary obstructive sx (hesitancy, frequency, failure to empty). On DRE you feel a firm nodular prostate. PSA really elevated Dx, next step, tx?

Prostate Cancer Next step: Bx (transrectal vs transurethral) Tx: - Resection = radiotherapy = brachytherapy - Antiandrogens (e.g., flutamide) - GnRH analogs (e.g., leuprolide) - Orchiectomy F/U: PSA should decrease - If PSA↑= Antiandrogens - If PSA↑ and mets= radiation

Patient with painless hematuria. On U/S you see a mass on on the bladder. Most common type of this cancer, next step, tx?

Transitional cell carcinoma (bladder ca) Next step: - Cystoscopy (best) Tx: transurethral resection + intravesicular BCG/chemo (cisplatin) - If invasive= cystectomy

25 y-o male with a painless mass in testicle, which doesn't transilluminate. Dx, next step, tx?

Testicular Cancer Next step: - U/S - NEVER do Bx Tx: orchiectomy - If seminoma= Chemo (cisplatin)/radiation - If non-seminoma • Endodermal= follow-up with AFP • Choriocarcinoma= follow-up with bHCG • Teratoma= malignant in men!! (unlike in women)

Flank pain, Palpable mass and Painless hematuria. Dx, next step, tx?

Renal Cell Cancer Next step: CT scan (avoid Bx) Tx: nephrectomy - Chemo/radiation if mets

> 50 y-o male, Lower urinary track sx (hesitancy, dribbling, frequency, urgency, trouble emptying) DRE showing a smooth rubbery prostate. U/A and culture and negative Dx, next step, tx

BPH Next step: nothing, treat right away, no need of PSA or Bx Tx: - Open the urethra with alpha blockers (e.g., tamsulosin, doxazosin, terazosin) - Prevent prostate growth with 5-alpha reductase inhibitors (e.g., finasteride) - Transurethral resection of prostate (TURP)

Patient with sudden, spontaneous pain on testicule, horizontal lie of testicle, pain on elevation of testicle. Dx, next step, tx?

Testicular Torsion Dx: U/S doppler showing decrease vascular supply Tx: Untwist/orchidectomy + Bilateral orchidopexy

Patient with sudden, spontaneous pain on testicule, Vertical lie, Relief of pain on elevation. Dx, next step, tx?

Epididymitis Mext step: normal U/S doppler Tx: - If < 35: ceftriaxone + azithromycin - If > 35: ciprofloxacin

Old male with urgency, dysuria, frequency, fever, N/V. No CVA tenderness on physical exam, but really tender DRE.

Prostatitis Next step: U/A + Urinary culture Tx: - Don’t repeat the DRE - Bacterial: Abx - Inflammatory: NSAIDs

Colicky flank pain that radiates to the groin. Dx, next step, tx?

Kidney Stones Next steps: - U/A showing hematuria - Non-contrast CT scan - U/S if CT can’t be done o Tx: - < 0.5 cm: IVF + pain control - 0.5–0.7 cm: add medical treatment (tamsulosin, amlodipine) - 0.7–1.5 cm: stenting or lithotripsy - > 1.5 cm: surgery - Septic: nephrostomy

Patient with Pain, paresthesia, paralysis of first 3 digits. On physical worse sx with flexion of wrists, taping the nerve makes it worse. DX, TX?

Carpal Tunnel syndrome Tx: - Splinting and NSAIDs - Intraarticular steroids - Surgery (make an EMG before)

Patient who during a football game had an injury of the hand while graving the jersey of another person. The patient can’t flex the finger (can be flexed passively without resistance). Dx, tx?

Jersey Finger (tearing of the flexor tendon) Tx: splining + NSAIDs, intraarticular steroids, surgery

Patient who during a football game had an injury of the hand while graving the ball. The patient can’t extend the finger (can be extended passively without resistance). Dx, tx?

Mallet Finger (tearing of the extensor tendon) Tx: splining + NSAIDs, intraarticular steroids, surgery

Patient who can’t extend the finger (when extended passively there is resistance and a pop sound). Dx, tx?

Trigger Finger (stenosis tenosynovitis) Tx: splining + NSAIDs, intraarticular steroids, surgery

Patient with tumb pain. On physical pain is worse when he makes a fist with the thumb under the fingers and with ulnar deviation. Dx tx?

Dequervain's tenosynovitis Tx: splining + NSAIDs, intraarticular steroids (no surgery)

Patient with inability to extend, palpable fascia nodules on palm, palm in contraction. Dx, tx?

Dupuytren contracture Tx: surgery

Patient who had a penetratin injury on the pulp pf finger. He has a lot of pain and fever. Dx, tx?

Felon (abscess of the pulp of the finger producing a mini compartment syndrome) Tx: incision and drainage +/- antibiotics

Baby with persistent Clicky hip with barlow and ortolarni at 4 weeks. Dx, next step, tx?

Developmental dysplasia of the hip (DDH) Next step: U/S (4 weeks) Tx: Harness

6 y-o patient with Insidious onset of antalgic walk . Dx, next step, tx?

Legg-Calve-Perthes (avascular necrosis) Next step: xR Tx: Cast

13 y-o patient in Growth spurt who is Fat and consults because of Nontraumatic joint pain. Dx, next step, tx?

Slip capital femoral epiphysis (SCFE) Next step: Frog-leg xR Tx: Surgery

Patient who can't bear weight, Fever, ↑WBC, ↑ESR, ↑CRP. Dx, next step, tx?

Septic Joint Next step: Arthrocentesis with > 50,000 WBC Tx: Drain + Abx

Patient with Hip pain after a viral illness who Can’t bear weight. Dx, tx?

Transient Synovitis Tx: Autoinflammatories

Teenage athlete with Knee pain and Tibial swelling. Dx, tx?

Osgood Schlatters (osteocondrosis) Tx: Stop exercise, or continue but they’ll have a palpable nodule

Teenage girl with and Positive Adam’s test. Dx, next step, tx?

Scoliosis Next step: xR Tx: - Brace can slow progression and prevent surgery - Surgery for severe cases

Pediatric patient with Focal, atraumatic bone pain. xR shows tumor in distal bone with sunburst pattern Dx, path, next step, tx?

Osteosarcoma Path: retinoblastoma gene Next steps: MRI, Bx Tx: resection

Pediatric patient with Focal, atraumatic bone pain. xR shows Tumor in mid-shaft of bone with onion-skin appearance Dx, path, next step, tx?

Ewing's Sarcoma Path: translocation 11, 22 Next steps: MRI, Bx Tx: resection

When is an o Open reduction and internal fixation (ORIF) indicated in a pediatric fracture?

- Open Fx - Comminuted Fx - Involvement of growth plate

Patient who had trauma on the shoulder and it's in adduction and externally rotated. Also he refers • Deltoid paresthesia. Dx?

Anterior Dislocations of shoulder

Patient who was on a car accident and now has the Shoulder in adduction and internally rotated. Dx?

Posterior dislocation of shoulder

Old Woman Falls onto an outstretched wrist. Wrist Fracture is dorsally displaced. Dx?

Collis fracture

A person was blocking upward from a downward blow. On xR you see Ulnar fracture and Radius dislocation. Dx?

Monteggia

A person was blocking downward from a downward blow . On xR you see Radius fracture and Ulnar dislocation. Dx?

Galleazzi

* Falls onto an outstretched wrist * Pain at the anatomic snuff box Dx?

Scaphoid fracture

Tx of hip fracture?

* Femoral head fx: Head prosthesis * Intertrocanteric fx: plates * Shaft: rods * Open: emergency washout * While the surgery is performed: traction

Patient who had posterior trauma on the knee and has anterior draw sign. Dx?

ACL rupture

Patient who had anterior trauma on the knee and has posterior draw sign. Dx?

PCL rupture

Patient who has knee pain and click on extension. Dx?

Meniscus injury

Patient who had ankle overeversion, has pain and swelling but can walk. Dx?

Sprain

Patient who had ankle overeversion, has pain and swelling and can't walk. Dx?

Fracture

Back pain that is exacerbated by standing and walking and relieved with sitting and hyperfl exion of the hips.

Spinal stenosis.

Joints in the hand affected in rheumatoid arthritis.

MCP and PIP joints; DIP joints are spared.

Joint pain and stiffness that worsen over the course of the day and are relieved by rest.

Osteoarthritis

Genetic disorder associated with multiple fractures and commonly mistaken for child abuse.

Osteogenesis imperfecta.

Hip and back pain along with stiffness that improves with activity over the course of the day and worsens at rest. Diagnostic test?

Suspect ankylosing spondylitis. Check HLA-B27.

Arthritis, conjunctivitis, and urethritis in young men. | Associated organisms?

Reactive (Reiter’s) arthritis. Associated with Campylobacter, Shigella, Salmonella, Chlamydia, and Ureaplasma.

A 55-year-old man has sudden, excruciating first MTP joint pain after a night of drinking red wine. Diagnosis, workup, and chronic treatment?

Gout. Joint fluid aspirate: Needle-shaped, negatively birefringent crystals Chronic treatment with allopurinol or probenecid.

Rhomboid-shaped, positively birefringent crystals on joint fluid aspirate.

Pseudogout.

An elderly woman presents with pain and stiffness of the shoulders and hips; she cannot lift her arms above her head. Labs show anemia and ↑ ESR.

Polymyalgia rheumatica.

An active 13-year-old boy has anterior knee pain. Diagnosis?

Osgood-Schlatter disease.

Bone is fractured in a fall on an outstretched hand.

Distal radius (Colles’ fracture).

Complication of scaphoid fracture.

Avascular necrosis.

Signs suggesting radial nerve damage with humeral fracture.

Wrist drop, loss of thumb abduction.

A young child presents with proximal muscle weakness, waddling gait, and pronounced calf muscles.

Duchenne muscular dystrophy.

A first-born female who was born in breech position is found to have asymmetric skin folds on her newborn exam. Diagnosis? Treatment?

Developmental dysplasia of the hip. If severe, consider a Pavlik harness to maintain abduction.

An 11-year-old obese African-American boy presents with sudden onset of limp pain. Diagnosis? Workup?

Slipped capital femoral epiphysis. AP and frog-leg lateral view.

The most common 1° malignant tumor of bone.

Multiple myeloma.

Surgery: Subspecialty Flashcards

(101 cards)