Surgery > Pestana > Flashcards

Pestana Flashcards

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1
Q

Do you deal with airway first or spine injury first?

A

airway

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2
Q

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

A
  • orotracheal w/o moving head

- nasotracheal over bronchoscope

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3
Q

Airway management options in maxillofacial injuries? (2)

A
  • cricothyroidectomy

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

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4
Q

How to assess breathing?

A
  • breath sounds on both sides

- pulse ox

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5
Q

Causes of shock in trauma setting (3)

A
  • bleeding
  • pericardial tamponade
  • tension ptx
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6
Q

Treatment of hemorrhagic shock

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

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

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7
Q

trauma preferred route of resuscitation

A
  • 2 16-gauge peripheral IVs

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

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8
Q

Which 2 trauma things are clinical diagnoses?

A

pericardial tamponade and tension ptx

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9
Q

management of pericardial tamponade?

A

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

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10
Q

management of tension ptx?

A
  • clinical diagnosis

- needle or tube decompression then chest tube

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11
Q

management of cardiogenic shock? what should you NOT do?

A
  • circulatory support

- DO NOT GIVE FLUID OR BLOOD

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12
Q

vasomotor shock presentation and management?

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

management of penetrating head trauma?

A

-requires surgical intervention

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14
Q

management of skull fxs?

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

mgt of head trauma and unconscious?

A

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

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16
Q

signs of basal skull fx? (4)

A

raccoon eyes, rhinorrhea, otorrhea, ecchymosis behind the ear

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17
Q

tx of basal skull fx?

A

-cspine imaging, no abx

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18
Q

3 ways trauma can cause neurologic damage

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

acute epidural hematoma presentation, dx, and tx

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

acute subdural hematoma presentation, dx, and tx

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

diffuse axonal injury presentation, dx, and tx

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

chronic subdural hematoma presentation, dx, and tx

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

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

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

gunshot to upper neck zone.. what to do?

A

arteriogram

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25
gunshot to base of neck
arteriogram, esophagogram, esophagoscopy, bronchoscopy --> maybe surgery
26
stab wounds to ___ and ____ zones of neck in asymptomatic patients can be safely observed
upper and middle
27
in blunt trauma to neck, get cspine xrays if ______ or _______
neuro deficits, cspine tenderness
28
clean cut injury (knife blade) to spinal cord paralysis and loss of proprioception ipsilateral loss of pain contralateral
brown-sequard
29
burst fractures of vertebral bodies associated with _____ (spinal cord issue)
anterior cord syndrome
30
loss of motor and pain/temp on both sides | intact vibratory and positional sense
anterior cord syndrome
31
forced hyperextension of neck (rear end collision) associated with ______ (spinal cord issue)
central cord syndreom
32
paralysis and burning pain in UE | LE are fine
central cord syndrome
33
how to dx and treat spinal cord injuries
dx with MRI | tx with high dose steroids immediately after injury
34
how to tx rib fracture in elderly?
local nerve block to prevent atelectasis and pneumonia
35
moderate SOB, no breath sides on one side, hyper resonant to percussion. what is it?
plain ptx
36
how to dx and treat ptx?
CXR, place CT
37
how to dx and tx hemothorax?
dx with CXR | tx with CT (low)
38
indications for thoracostomy in hemothorax?
>1500 mL drained initially OR | >600 mL drained in first 6 hours
39
sucking chest wound can cause _____
tension ptx
40
how to manage a sucking chest wound?
occlusive dressing that lets air out (taped on 3 sides)
41
how to tx pulmonary contusion?
fluid restriction colloids > crystalloids diuretics monitor blood gases
42
flail chest associated with what other injury?
pulm contusion | seek out aortic injury
43
if you need to intubate someone with flail chest, what should you do first?
chest tubes bilaterally to prevent tension ptx
44
presentation of pulmonary contusion
deteriorating blood gases "white out" of lungs may appear up to 48 hours after the event
45
how to manage myocardial contusion
- ECG monitoring - cardiac enzymes - tx the complications
46
which side does diaphragmatic rupture occur?
left side
47
how to evaluate traumatic diaphragm rupture?
laparoscopy
48
how to dx aortic injury in trauma
- suspicion- first rib/scapula/sternum fxs - normal mediastinum --> CT - widened mediastinum --> aortogram if inconclusive CT --> surgical repair
49
workup for rupture of trachea
CXR confirms air --> bronchoscopy and intubation --> surgical repair
50
ddx for subcutaneous emphysema (3)
- rupture of trachea - rupture of esophagus - tension ptx
51
sudden death in chest trauma patient who is intubated and mechanically ventilated. what is it?
air embolus
52
how to tx air embolus
trendelenberg with left side down | cardiac massage
53
clinical presentation of fat embolism
- petechial rashes in axilla and neck - fever, tachycardia, low pot - respiratory distress, hypoxemia, bilateral patchy infiltrates - tx with respiratory support
54
gunshot wound to abdomen…
needs exlap
55
indications for ex lap in stab wounds
- signs of clear penetration (ex. protruding viscera) - hemodynamic instability - peritoneal irritation
56
indications for ex lap in blunt trauma
- peritoneal irritation | - hemodynamically unstable internal bleeding
57
3 places 1500 mL blood can hide in the body
- abdomen - pelvis - thigh
58
best way to dx intra-abdominal bleeding?
CT scan
59
when to do CT scan? patient must be _____
hemo stable
60
if hemp unstable and source of bleeding is not clear, do a ____ or ______
DPL or FAST | -if either is positive, go to exlap
61
most common source of significant intra-abdominal bleeding in blunt abdominal trauma?
spleen
62
most common overall source of intra-abd bleeding in blunt and trauma?
liver
63
post-op splenectomy vaccines
pneumococcus H flu meningococcus
64
coagulopathy during surgery… what to do?
FFP and plts
65
coagulopathy + hypothermia + acidosis… what to do?
stop surgery, pack, and come back later
66
abdominal compartment syndrome
fluids and blood given during prolonged laparotomies --> cannot close at the end
67
how to avoid abdominal compartment syndrome?
cover with absorbable mesh or non absorbable plastic
68
POD2 s/p abdominal surgery: distension, retention sutures cutting through tissues, hypoxia (inability to breathe), renal failure from pressure on vena cava
abdominal compartment syndrome | tx by opening abdomen and placing temporary cover
69
how to tx pelvic hematomas
leave alone if not expanding
70
in pelvic fx, look for associated injuries….
- rectum - bladder - vagina in women - urethra in men
71
how to manage significant bleeding in pelvic fxs
- replace blood - external fixation - arteriographic emoblization
72
what does abdominal trauma + blood in urine mean?
urologic injury
73
gross hematuria must be investigated (T or F)
T
74
what to do with microscopic hematuria - asymptomatic adult - children
- asymptomatic adult- no workup | - children- investigate and look for congenital anomalies
75
what to do with penetrating urologic injuries?
surgically explored and repaired
76
scrotal hematoma, pelvic fx, blood at meatus, high riding prostate… what is this?
urethral injury (men)
77
urologic injury- wants to void but not able to indicates _____ injury
posterior uretrhal
78
what to do with suspected urethral injury?
DO NOT INSERT FOLEY | -do a RUG
79
how to tx urethral injuries? - anterior - posterior
- anterior- surgery | - posterior- suprapubic drainage and delayed repair
80
how to dx bladder injuries
retrograde cystogram | post-void films
81
how to tx bladder injuries
surgery + suprapubic cystostomy
82
what to do with kidney injuries
-assess with CT, manage w/o surgery
83
potential sequelae of renal injuries
- AV fistula --> CHF | - renal artery stenosis --> renovascular HTN
84
what to do with scrotal hematomas
- assess with sonogram | - no specific intervention needed unless testicle is ruptured
85
large penile shaft hematoma after vigorous intercourse… what is it and what do you do?
- penis fx | - emergency surgical repair
86
penetrating injuries of extremities - not near major vessel - near major vessel, asymptomatic - obvious vascular injury
- not near major vessel- tetanus - near major vessel, asymptomatic- arteriogram - obvious vascular injury- surgery
87
what order to repair? bone vascular nerve
bone vascular nerve + fasciotomy
88
what's the concern in crush injuries?
myoglobinemia myoglobinuria renal failure compartment syndrome
89
how to prevent renal failure in crush injury?
vigorous fluids, osmotic diuretics, alkalinize the urine
90
how to tx chemical burns?
IRRIGATE!
91
how to tx high voltage electrical burns
- may need debridement/amputation - fluids, osmotic diuretics - assess for ortho injuries
92
late complications of electrical burns (2)
cataracts | demyelinization syndromes
93
respiratory burn dx and treatment
- dx with bronchoscopy - monitor blood gases to determine ventilator use - monitor carboxyhemoglobin --> if elevated, give 100% O2
94
rule of 9s
head- 1 trunk- 4 UE- 1 each LE- 2 each
95
Parkland formula
Day 1: body weight (kg) x % burn (up to 50) x 4 cc RL + 2000 cc D5W -infuse 1/2 first 8 hours, infuse 1/2 next 16 hours Day 2: Half of the above. May use colloid
96
simple fluid maintenance for burns
- start with 1000 mL/hr of LR on anyone with burns >20% | - adjust according to urine output (1-2 mL/kg/hr)
97
rules of 9s to babies
give one 9 from legs to head
98
leathery, dry, gray skin
3rd degree burn in adults
99
deep bright red babies
3rd degree burn in babies
100
burn fluid resuscitation for babies
4-6 mL/kg/%, use initial rate of 20 mL/kg/hr if burn exceeds 20% of body surface
101
burn care
- tetanus - topical agents- silver (standard), mafenide (deep penetration) - IV pain meds - NG suction - after 1-2 days, intensive nutritional support - after 2-3 weeks, graft - rehab
102
when to do early excision and grafting
-limited burns (<20%) that are 3rd degree
103
all animal bites require what tx?
tetanus prophylaxis
104
bit by a provoked dog… what do you do?
observe the dog
105
bit by an unprovoked dog or wild animal… what do you do?
``` kill animal and examine brain OR rabies prophylaxis (immunoglobulin plus vaccine) ```
106
signs of snake envenomation
severe local pain swelling discoloration
107
what to do with envenomation
- draw blood: type and crossmatch, coats, liver and renal fnc - tx with antivenin - no surgical excision or fasciotomy - splint extremity during transportation
108
black widow bite
N/V, severe generalized muscle cramps
109
how to tx black widow bite
IV Ca gluconate, muscle relaxants
110
brown recluse bite
skin ulcer with necrotic center and surrounding erythema
111
how to tx brown recluse bite
dabsone, maybe surgical excision and skin grafting later on
112
how to tx human bites
dirtiest bite of all… - extensive irrigation and deridement i nthe OR - specialized ortho care
113
uneven gluteal folds, easy to dislocate posteriorly and return to normal with click and snapping
developmental dysplasia of the hips
114
how to dx developmental dysplasia of the hips?
physical exam | if PE is equivocal, then do US
115
tx of developmental dysplasia of the hips
abduction splinting with pavlik harness for 6 months
116
hip pathology can show up with knee pain (T/F)
T
117
6 year old with insidious onset of limping, decreased hip motion, hip/knee pain, antalgic gait, guarded passive motion of the hip
legg perches disease
118
how to dx legg perthes
AP and lateal hip xrays
119
how to tx legg perthes
casting and crutches
120
avascular necrosis of the capital femoral epiphysis (aka ________)
legg perthes dz
121
legg perthes dz is an emergency (T/F)
F
122
chubby 13 y/o boy with groin/knee pain, limping, affected sole points toward other foot, limited hip motion, hip eternally rotate when it's flexed
slipped capital femoral epiphysis
123
slipped capital femoral epiphysis is an orthopedic emergency (T/F)
T
124
how to dx slipped capital femoral epiphysis
xrays
125
how to tx slipped capital femoral epiphysis
surgical pinning of femoral head
126
septic hip is an orthopedic emergency (T/F)
T
127
toddler with febrile illness then refuse to move hip, hip is flexed, slight abduction, external rotation, elevated ESR
septic hip
128
how to dx septic hip
aspiration
129
how to tx septic hip
open drainage
130
little kid with febrile illness --> severe localized pain in a bone
acute hematogenous osteomyelitis
131
how to dx acute hematogenous osteomyelitis
bone scan; X-ray will not show it for a few weeks
132
how to tx acute hematogenous osteomyelitis
abx
133
varum is normal at what age?
up to age 3
134
persistent genu varum is most commonly what and what is the treatment?
Blount disease; tx with surgery
135
valgus is normal at what age?
age 4-8
136
teens with persistent pain over tibial tubercle, worse with quadriceps contraction localized pain, no knee swelling
osgod-schlatter disease
137
how to tx osgood schlatter disease
cast 4-6 weeks
138
when is club foot seen?
at birth
139
how to tx club foot
- serial plaster casts correcting the adduction, hind foot varus, and equinus - 50% are corrected but 50% need surgery at age 8-12 months
140
what kind of patient do you normally find with scoliosis?
teen girl
141
most common finding in scoliosis
thoracic spine curved to the right
142
how to dx scoliosis
look from behind as she bends over
143
scoliosis complications (2)
cosmetic deformity | lung function
144
how to tx scoliosis
bracing, may require surgery
145
degrees of angulation of fxs that would be unacceptable in adults may be okay when reduced and immobilized in children (T/F/)
T
146
areas where children have issues healing bone (2)
- supracondylar fxs of humerus | - fxs involving the growth plate
147
hyperextension of elbow due to falling on extended arm may cause what fx?
-supracondylar fx of humerus
148
what do you worry about with supracondylar fx of humerus
vessel or nerve injury --> volkmann's contracture
149
how to tx supracondylar fx of humerus?
- casting or traction - monitor vascular/nerve integrity - monitor for compartment syndrome
150
how to tx fractures of the growth plate
- if epiphyses and growth plate are in one piece --> closed reduction - if growth plate is in 2 pieces --> ORIF to ensure alignment
151
primary malignant bone tumors are diseases of old people (T/F)
F
152
persistent low grade pain, sunburst and periosteal onion skinning on X-ray
primary malignant bone tumor
153
most common primary malignant bone tumor, age 10-25, usually around the knee
osteogenic sarcoma
154
second most common primary malignant bone tumor, age 5-15, diaphyses of long bones
ewing sarcoma
155
most malignant bone tumors in adults are metastatic - _______ in women - _______ in men
breast | prostate
156
how to dx metastatic bone tumors in adults
bone scan more sensitive --> if positive, get xrays
157
old men, fatigue, anemia, localized pain on several bones
multiple myeloma
158
X-rays show punched out lytic lesions, bence-jones in urine, abnormal immunoglobulins in blood
multiple myeloma
159
how to tx multiple myeloma
chemo
160
firm and died growth of soft tissue mass
soft tissue sarcoma
161
how to dx and tx soft tissue sarcoma
dx with MRI then incisional biopsy | tx with very wide local excision, XRT, chemo
162
X-rays looking for suspected fxs should include ___ views
2
163
clavicular fxs are treated with
- place arm in a sling | - fixation for young women with displaced fxs for cosmetic reasons
164
arm is adducted and externally rotated
anterior shoulder dislocation
165
ant shoulder dislocation may injure what?
axillary nerve
166
how to dx shoulder dislocations
axially view or scapular lateral view xrays
167
posterior shoulder dislocations are _____ and are caused by ____ and _____
rare, seizure, electricity
168
arm is adducted and internally rotated
posterior shoulder dislocation
169
FOOSH in old woman, dinner fork deformity (dorsally displaced and angulated fx of distal radius)
colles fx
170
how to tx colles fx
close reduction and cast
171
diaphyseal fx of proximal ulna, with anterior dislocation of radial head
monteggia fx
172
fx of radius, with dorsal dislocation of radioulnar joint
galeazzi fx
173
how to tx monteggia and galeazzi fxs
ORIF of broken bone, closed reduction of dislocated bone
174
FOOSH in young adult, tenderness in anatomic snuff box
scaphoid fx
175
how to tx scaphoid fx
- if non displaced and negative X-ray, thumb spica | - if displaced and angulated, ORIF
176
how to tx metacarpal neck fx (boxer's fx)
- mild displacement/angulation: close reduction and ulnar gutter splint - severe displacement/angulation: kirschner wire or plate fixation
177
hip fx happen to _____ who _______. Their leg is ______ and _______
old women who fall | shortened and externally rotated
178
femoral neck fxs are at high risk for _________
avascular necrosis of femoral head
179
how to tx intertrochanteric fx
open reduction and pinning, post op anticoagulation
180
how to tx femoral shaft fx
- intramedullary rod fixation | - if open, ortho emergency! tx w/in 6 hours
181
complications of femoral shaft fx
- may cause hypovolemic shock | - fat embolism
182
tx knee collateral ligament injuries with _______
- hinged cast for isolated injuries | - surgery for several torn ligaments
183
valgus
medial injury
184
varus
lateral injury
185
how to tx ACL injury
- immobilization, rehab for sedentary pts | - arthroscopic reconstruction for athletes
186
what imaging is used to dx knee injuries?
MRI
187
pain and swelling, catching, locking, click
meniscal injury
188
how to tx meniscal tear
arthroscopic repair
189
TTP over specific point, normal xrays
stress fxs
190
how to tx stress fxs
cast, repeat X-rays in 2 weeks, crutches
191
how to tx tibia and fibula fxs in peds vs auto
- casting or intramedullary nailing | - monitor for compartment syndrome
192
out of shape middle age men, loud popping noise, limited plantar flexion, pain, swelling, limping
achilles rupture
193
how to tx achilles rupture
cast in equines position, surgery for quicker cure
194
what happens when ankle fx occurs?
both malleoli break
195
how to tx ankle fx
ORIF if displaced
196
2 common places for compartment syndrome
forearm, lower leg
197
pain, tight, TTP, excruciating pain with passive extension
compartment syndrome
198
how to tx compartment syndrome
emergency fasciotomy
199
knees hit dashboard, leg is shortened/adducted/internally rotated
posterior hip dislocation
200
how to tx posterior hip dislocation
emergency reduction to prevent avascular necrosis
201
deep penetrating dirty wound, pt looks sick/toxic, swollen, discolored, gas crepitation
gas gangrene
202
how to tx gas gangrene
IV penicillin, surgical debridement, hyperbaric O2
203
oblique fx of middle/distal humerus injures which nerve?
radial nerve
204
what to do if nerve paralysis develops/remains after reduction?
surgery
205
posterior knee dislocation can injure ____
popliteal artery
206
how to dx popliteal artery injury
pulses, doppler, arteriogram (if needed)
207
how to tx posterior knee dislocation
prompt reduction +/- prophylactic fasciotomy if revascularization is delayed
208
fall from height onto feet…. look for ____ and _____
foot/leg fxs | T or L spine fxs
209
head-on MVC…look for head, face, torso injuries but also ____ and _____
femoral head fx/dislocation | acetabular fx
210
facial fx and closed head injuries… look for _____
cspine issues
211
how to dx carpal tunnel
clinical (tap on median nerve), wrist X-ray to r/o other causes
212
how to tx carpal tunnel
splint, NSAIDs | may sometimes need surgery
213
finger is acutely flexed at night, "painful snap" if you try to forcibly extend it
trigger finger
214
how to tx trigger finger
steroid injection first | surgery as last resort
215
how to tx de quervain tenosynovitis
- splint and NSAID - steroid works best - rarely need surgery
216
old norwegian man, contracture of palm, palmar fascial nodules
dupuytren contracture
217
how to tx dupuytren contracture
surgery
218
fingertip pulp abscess due to penetrating injury
felon
219
how to tx felon
urgent surgical drainage
220
ulnar collateral ligament injury due to forced hyperextension of thumb
gamekeepr thumb while skiing
221
how to tx gamekeeper thumb
cast, b/c arthritis can result if untreated
222
jerseyfinger
flexor tendon injury 2/2 forceful extension of flexed finger, issue with flexing the distal phalanx
223
mallet finger
extensor tendon injury 2/2 forceful flexion of extended finger, issue with extending
224
how to tx jersey finger and malletfinger
splint
225
months of discogenic pain + sudden neurogenic pain 2/2 forced movement, can't ambulate, affected leg is flexed, pain with straight leg raise
lumbar disk herniation
226
how to dx lumbar disk herniation
MRI
227
how to tx lumbar disk herniation
bed rest
228
distended bladder, flaccid rectal sphincter, perineal saddle anesthesia…. what is it and what do you do?
cauda equina syndrome | -emergency surgery and immediate decompression
229
30-40 year old man with chronic back pain that is worse in the morning and improves with activity, "bamboo spine"
ankylosing spondylitis
230
how to tx ankylosing spondylitis
anti-inflam and PT
231
old person with progressive back pain that's worse at night and unrelieved by rest/position, weight loss
metastatic malignancy
232
how to dx metastatic malignancy of the bone
bone scan more sensitive early on, later on can see on xray
233
diabetic ulcers are 2/2 ______ and ________
neuropathy and microvascular disease
234
ulcers at tips of toes that are pale/dirty, absent pulses, trophic changes, claudication
arterial insufficiency ulcers
235
how to work up arterial insufficiency ulcers
doppler to look for pressure gradients --> arteriogram --> surgical revascularization
236
chronically edematous, indurated, hyper pigmented skin above medial malleolus, cellulitis, varicose veins
venous stasis ulcers
237
how to tx venous stasis ulcers
support stockings, ace and ages, inna boot, maybe surgery
238
marjolin ulcer
SCC in chronic leg ulcer
239
dirty, deep ulcer with heaped up tissue around the edges
marjolin ulcer
240
how to dx marjolin ulcer
biopsy
241
how to tx marjolin ulcer
wide local excision and skin grafting
242
old overweight ppl with sharp heel pain that's worse in the morning
plantar fasciitis
243
how to tx plantar fasciitis
do not excise bony spur | condition resolves spontaneously in 12-18 months
244
inflammation of common digital nerve at 3rd interspace, palpable tender spot assoc with high heels
morton neuroma
245
how to tx morton neuroma
analgesics, rarely surgical excision
246
sudden onset swelling, redness, pain at 1st MTP joint | middle age, obese pain
gout
247
acute tx for gout
indomethacin, colchicine
248
chronic tx for gout
allopurinol, probenicid
249
EF < 35% means what in terms of operative risk?
prohibitive for noncardiac operations!! | very high risk of MI and mortality
250
Goldman's index of cardiac risk factors (high to low)
``` JVD récent MI PVC or non-sinus rhythm age > 70 emergency surgery AS, poor medical condition, surgery in chest/abd ```
251
____ is the worst single finding predicting high cardiac risk. If possible, treat with ____, ____, _____, ______ beforehand
JVD | CCB, beta blockers, digitalis, diuretics
252
what to do if you need surgery and you had a recent MI?
wait 6 months | if you can't wait, admit to ICU the day before to optimize cardiac variables
253
what to do if pt has severe progressing angina right before surgery?
possibly do a coronary revascularization before the other operation
254
______ is the most common cause of increased pulmonary risk
smoking
255
what problem does smoking pose as a surgery risk factor
ventilation (not oxygenation) issues
256
if you're a smoker, what should you do before surgery?
- quit 8 weeks beforehand | - respiratory therapy
257
hepatic risk: 40% mortality if any of the (4) 80-85% morality if 3 of the (4)
bilirubin > 2 albumin < 3 PT > 16 encephalopathy
258
hepatic risk: | 80-85% mortality if any of these (3)
bilirubin > 4 albumin < 2 blood ammonia concentration > 150
259
lose 20% body weight over months albumin < 3 anergy to skin antigens serum transferrin < 200
this indicates severe nutritional depletion --> high operative risk!
260
what to do to optimize nutrition in those who are depleted
4-5 days of nutritional support via the gut before surgery
261
what about diabetic coma and surgery?
it's an absolute contraindication!!!!
262
what to do if pt is in diabetic coma and surgery needs to be done?
rehydrate urinary output partial correction of acidosis and hyperglycemia
263
abrupt onset of hyperthermia after succinylcholine or inhaled anesthetic
malignant hyperthermia
264
features of malignant hyperthermia
>104F, metabolic acidosis, hypercalcemia
265
tx of malignant hyperthermia
dantrolene, oxygen, cooling, correction of acidosis | watch for myoglobinuria
266
>104F fever and chills within 30-45 minutes of invasive procedure means ______ and you tx it with ______
bacteremia | blood cultures x 3, empiric abc
267
post op fever in the usual range caused by:
``` wind (atelectasis, pneumonia) water (UTI) walking (deep venous thrombophlebitis) wound (+/- deep abscess) wonder drugs ```
268
______ is the most common cause of fever on POD1. What do you do?
atelectasis | -r/o other causes, CXR, improve ventilation, bronchoscopy if needed
269
suspect ________ on day 3 if atelectasis hasn't resolved. What do you do?
pneumonia | -CXR, sputum cultures, abx
270
what to do if you suspect deep thrombophlebitis
doppler | anticoag with heparin
271
deep abscess post-op… dx and tx
dx with CT | tx with percutaneous drainage
272
intra-op MI commonly triggered by _______ and detected by ______
hypotension, ECG
273
post op MI - only 1/3 show up with ______ - dx with ________ - can't use _____ but can use ________
chest pain troponins can't use clot busters but can do emergency angioplasty and stent very high rate of mortality
274
________ happens on POD7 in elderly/immobilized pts
pulmonary embolus
275
sudden onset pleuritic pain, SOB, anxious, diaphoretic, tachycardic, JVD hypoxemia and hypocapnia
pulmonary embolus
276
how to dx pulmonary embolus
VQ scan or spiral CT
277
how to tx PE
heparin +/- IVC filter
278
aspiration can be lethal right away (T/F)
T
279
aspiration can lead to chemical injury and subsequent pulmonary failure/pneumonia. how do you prevent it?
NPO and antacids
280
how to tx aspiration. what do you not use?
lavage, bronchodilators, respiratory support | NOT steroids
281
pts with weakened or traumatized lungs who are then subjected to positive pressure ventilation during operation may develop ______
tension pnuemo
282
pt becomes difficult to bag, BP declines, CVP increases
tension ptx
283
post-op pt gets confused/disoriented. what's the first thing you suspect? what do you check?
hypoxia, perhaps secondary to sepsis | check blood gases, provide respiratory support
284
complicated post-op course often with sepsis, bilateral pulmonary infiltrates, hypoxia, no CHF
ARDS
285
how to tx ARDS
PEEP but minimize barotrauma | seek out source of sepsis
286
POD2-3: confused, hallucinations, combative
delirium tremens
287
how to tx DT?
alcohol or benzos
288
quick administration of D5W to pt with high ADH levels will cause...
hyponatremia
289
confusion, convulsions, coma, death are signs of ____
hyponatremia
290
how to tx hyponatremia
depends… small amounts of hypertonic saline osmotic diuretics
291
hypernatremia can cause...
confusion, lethargy, coma
292
surgical damage to posterior pituitary can cause...
hypernatremia due to diabetes insipidus
293
how to tx hypernatremia
D5 1/2 normal, D5 1/3 normal
294
cirrhotic patient with bleeding esophageal varices undergoes a portocaval shunt… they're at risk for _____ intoxication
ammonium
295
post op urinary retention is common; treat with _______ q6 hours and if prolonged place a _______
straight cath | foley catheter
296
zero urinary output is usually caused by ______
mechanical blockage
297
low urine output (<0.5mL/kg/hr) not due to shock typically is caused by 2 things
1. fluid deficit 2. acute renal failure differentiate between the two with: -fluid challenge- dehydrated pt increases output, renal failure pt does not increase output -urine Na 40 means renal failure
298
paralytic ileus can be prolonged by ____
hypokalemia
299
if ileus doesn't resolve by POD7, then suspect _______. Dx with __________ Tx with __________
SBO 2/2 adhesions dx with X-rays tx with re-operation
300
paralytic ileus of the colon after non-abdominal surgery (often elderly pts who are further immobilized) nontender abdominal distension, dilated colon on xray
ogilvie syndrome
301
how to tx ogilvie syndrome
colonoscopy, leave in long rectal tube
302
salmon colored fluid coming from wound on POD5 how to tx?
wound dehiscence | tx by taping and then re-operating
303
skin opens up and and contents rush out. how to tx?
evisceration | -keep pt in bed, cover bowel in sterile dressings soaked in warm saline --> emergency closure in the OR
304
how to manage GI tract fistulas
- incomplete emptying can lead to sepsis - complete emptying can result in fluid/electrolyte/nutrition loss, erosion of belly wall - distal colon = ok - low volume high GI fistula = manageable - high volume high GI fistula = daunting - tx with fluid and electrolyte, nutrition, protect nfo abdominal wall (ostomy bags, suction)
305
hypernatremia: every ____ that Na is above _____ presents _____ of lost water
every 3 mEq/L that Na is above 140 represents 1L of lost water
306
if hypernatremia happens slowly, tx with
D5 1/2 NS
307
if hypernatremia happens quickly, tx with
D5 1/3 NS or D5W
308
2 kinds of hyponatremia: isovolemic hypovolemic
isovolemic- SIADH hypovolemic- retaining water b/c they're losing isotonic from their GI tract and isotonic fluid is not being given as a replacement
309
rapid development of hyponatremia (neuro sxs), tx with
hypertonic saline
310
slow development of hyponatremia (no neuro sxs), tx with
water restriction
311
hyponatremia in a hypovolemic pt, tx with
isotonic fluids
312
2 ways to develop hypokalemia:
1. slow loss from GI tract or urine (loop diuretics, aldosterone) 2. K moves into cells after correction of DKA
313
how to tx hypokalemia
replace the K
314
2 ways to develop hyperkalemia
1. slow- kidney can't excrete K (renal failure, aldosterone antagonists) 2. fast- K dumped from cells after crush injuries, tissue death, acidosis
315
how to tx hyperkalemia
calcium hemodialysis insulin and dextrose kayexelate
316
when you correct acidosis, you should also replace ____
K
317
precursors of bicarb
lactate, acetate
318
how to tx metabolic alkalosis
give KCl
319
when clinical dx of GERD is uncertain, do this...
monitor pH and correlate reflux with sxs
320
- overweight person with burning retrosternal pain - worse with bending over, tight clothes, lying flat - relieved by antacids
GERD
321
with long term reflux, you worry about ____ and ______ | thus, you do this test
- esophagitis and barrett's esophagus | - endoscopy and biopsy
322
tx for GERD
- meds | - surgery if meds fail, complications (ulcer, stenosis), or dysplastic changes
323
what surgery can you do for GERD
laprascopic nissen fundoplication
324
GERD pre-op studies
pH monitoring, manometry, barium swallow, gastric emptying study, endoscopy and bx
325
crushing pain with swallowing
uncoordinated massive contraction
326
dysphagia of solids and liquids, sitting up helps
achalasia
327
achalasia is more common in men (t/f)
F
328
occasional regurgitation of undigested food
achalasia
329
X-ray shows mega-esophagus, manometry shows increased LES tone
achalasia
330
tx for achalasia
repeated dilations or heller myotomy
331
how to dx esophageal motility issues
barium swallow then manometry
332
dysphagia of solids --> liquids --> saliva weight loss hematemesis
esophageal cancer
333
2 types of esophageal cancer 1. ________in men with smoking and drinking 2. ________ in ppl with GERD
- SCC | - adenocarcinoma
334
how to dx esophageal cancer
Ba swallow --> endoscopy and bx
335
how to assess esophageal cancer operability
CT
336
prolonged forceful vomiting, bright red blood
mallory weiss tear
337
how to dx and tx mallory weiss tear
dx with endoscopy | tx with laser if it doesn't stop bleeding on its own
338
prolonged vomiting leading to continuous, severe, epigastric and low sternal pain followed by fever, leukocytosis, sick looking
boerhaave
339
emphysema in lower neck of someone vomiting
boerhaave
340
how to dx and tx boerhaave
dx with contrast swallow | tx with emergency surgery
341
______________ is the most common reason for esophageal perforation
instrumental perforation (ie. endoscopy)
342
elderly, weight loss, anorexia, vague epigastric distress, early satiety, hematemesis
gastric adenocarcinoma or gastric lymphoma
343
how to dx and tx gastric adenocarcinoma
- dx with endo/bx | - tx with surgery after assessing operability with CT
344
how to dx and tx gastric lymphoma
- dx with endo/bx - tx with chemo/XRT; surgery is only for potential of perforation - tx MALToma with H Pylori eradication
345
most common cause of mechanical intestinal obstruction
adhesions
346
colicky abd pain, protracted vomiting, abd distension, high pitched BS, obstipation
mechanical obstruction
347
how to dx obstruction
X-ray shows distended loops with air fluid levels
348
how to tx obstruction
NPO, NG tube, IV fluids, watch for strangulation (fever, leukocytosis, constant pain, peritonitis, sepsis) -if strangulation occurs --> emergency surgery
349
all incarcerated hernias should be surgically repaired (more or less) (t/f)
T - emergently after proper rehydration if strangulated - electively if reducible and viable bowel
350
diarrhea, face flushing, wheezing, right heart valve damage
carcinoid syndrome
351
when does carcinoid syndrome occur? what tumor and where is it?
small bowel carcinoid tumor with liver mets
352
how to dx carcinoid syndrome
24 hour urine hydroxyindolacetic acid collection
353
anorexia --> vague umbilical pain --> sharp, severe, constant RLQ pain; tenderness, guarding, rebound +/- fever and leukocytosis
appendicitis
354
how to dx appendicitis
CT
355
how to tx appendicitis
emergency appendectomy
356
anemia for no good reason, occult blood in stool
right colon cancer
357
how to dx right colon cancer
colonoscopy and bx
358
how to tx right colon cancer
right hemicolectomy
359
blood on outside of bowel movements, constipation, narrow caliber stools
left colon cancer
360
how to dx left colon cancer
proctosigmoidoscopy and bx +/- CT scan for operability
361
how to tx left colon cancer
surgery +/- chemo/XRT
362
``` chance for malignancy: FAP peutz jegher hyperplastic inflammatory villous adenoma adenomatous polyp juvenile ```
FAP > villous adenoma > adenomatous polyp benign: juvenile, Peutz Jegher, inflammatory, hyperplastic
363
UC is managed _________ until any of the following: - greater than 20 years - nutritional issues - multiple hospitalizations - high dose steroids/immunosuppressants - toxic megacolon at that point, ________________
- medically | - remove affected colon + rectal mucosa
364
watery diarrhea, crampy abd pain, fever, leukocytosis
c diff pseudomembranous colitis
365
how to dx c diff
stool toxin, endoscopy, culture
366
how to tx c diff
D/C abx do not use anti-diarrheal medication metronidazole, vancomycin, fecal transplant
367
abdominal pain, fever, leukocytosis, epigastric tenderness, massively distended transverse colon on X-rays, gas in the wall of the colon
toxic megacolon
368
all anorectal disease should be ruled out for cancer by proper physical exam even when clinical presentation suggests a benign process (T/F)
T
369
hemorrhoids: __________ --> bleeding, itchy, may be painful. tx with rubber band ligation __________ --> painful. may need to tx with surgery
internal | external
370
young woman, pain with defecation, blood streaks on stool, may avoid BMs and get constipated
anal fissure
371
where do anal fissures tend to occur?
posterior midline
372
how to tx anal fissure
stool softeners, nitroglycerin, local botox, forceful dilation, lateral internal sphincterotomy
373
fissure, fistula, ulceration fails to heal/gets worse after surgical intervention
Crohn's disease in the anal area
374
febrile, perirectal pain (can't sit or have BMs)
ischiorectal (perirectal) abscess | lateral to anus
375
how to tx ischiorectal abscess
I and D, r/o cancer | watch closely for necrotizing infection in the diabetic pt
376
patients with drained ischiorectal abscess end up with fecal soiling, occasional perineal discomfort, opening lateral to anus, cordlike tract with expressible discharge
fistula in ano
377
how to tx fistula in ano
r/o tumor | tx with fistulotomy
378
HIV + homosexuals with fun gating mass growing out of anus, palpable metastatic inguinal nodes
SCC of the anus
379
how to dx and tx SCC of the anus
dx with bx | tx with chemo/XRT followed by surgery
380
3/4 of GI bleeds are from ________ | 1/4 of GI bleeds are from _____ or _______
- upper GI | - colon or rectum
381
colon bleeding pretty much only occurs in _________ | possible causes include (4)
old ppl | angiodysplasia, polyps, diverticulosis, cancer
382
young person with GI bleed is most likely ________ whereas old person with GI bleed is from _______
upper GI | anywhere
383
vomiting blod or blood suctioned by NG tube tells you it's a(n) ________. what do you do next?
upper GI bleed | you do an UGI endoscopy
384
melena tells you what? what should you do next?
it's most likely UGI | you should do an UGI endoscopy
385
red blood per rectum comes from _________
anywhere!
386
algorithm for red blood per rectum… this is long!
drop an NG tube - if blood in NG tube --> upper endoscopy - if no blood and non bilious --> UGI endoscopy b/c duodenum could still be the source if you exclude an UGI.. - exclude bleeding hemorrhoids with anoscopy - rate of bleeding > 2 mL/min --> angiogram +/- embolization - rate of bleeding < 0.5 mL/min -> wait for bleeding to stop and then do a colonoscopy - in between rate --> tagged red cell study - puddles --> angiogram - no puddles --> plan for subsequent colonoscopy - pt often stops bleeding before you even finish the study… with that being said, this may guide hemicolectomy in the future
387
history of blood per rectum but no active bleeding…. young person old person
young- UGI | old- UGI and LGI endoscopy
388
blood per rectum in child is _______________. do this to work it up
meckels diverticulum | technetium scan
389
massive UGI in trauma, stress, complicated post-op pts most likely due to _____ ________
stress ulcers
390
how to dx stress ulcers
endoscopy
391
how to tx stress ulcers
angio embolization; avoid by maintaining pH above 4
392
- most common source of visceral perforation - sudden onset constant, generalized, severe abd pain - doesn't want to move, tenderness, guarding, rebound, silent
perfed peptic ulcer
393
how to dx perforated peptic ulcer
CXR- free air under diaphragm
394
how to tx perforated peptic ulcer
emergency surgery
395
sudden onset of colicky pain; patent moves constantly, few physical findings limited to local area
acute abd pain caused by obstruction
396
gradual onset, constant, ill-defined then localizes, typical radiation patterns -peritoneal irritation in affected area, fever, leukocytosis
inflammatory process
397
____________ processes are the only ones that combine severe abdominal pain with blood in the gut lumen
ischemic
398
child with nephrosis and ascites | adult with ascites and mild generalized acute abdomen
primary peritonitis
399
how to work up primary peritonitis
culture ascitic fluid --> one organism --> tx with abx, not surgery
400
how to treat generalized acute abdomen
ex lap | -r/o primary peritonitis, MI, lower lobe pneumonia, PE, pancreatitis, urinary stones
401
alcoholic with acute upper abd pain; constant, epigastric, radiating straight to the back; N/V
acute pancreatitis
402
how to dx acute pancreatitis
amylase or lipase +/- CT
403
how to tx acute pancreatitis
NPO, NG suction, IVF
404
sudden onset colicky flank pain radiating to groin, urinary urgency and frequency, microhematuria
ureteral stones
405
how to dx ureteral stones
plain X-rays or noncontrast CT
406
acute abd pain in LLQ, fever, leukocytosis, peritoneal irritation in LLQ
acute diverticulitis
407
how to dx acute diverticulitis
CT
408
how to tx acute diverticulitis
NPO, IVF, abx, emergency surgery if it doesn't get better
409
intestinal obstruction, severe abd distension, parrot beak on xrays
volvulus of the sigmoid in old ppl
410
how to tx volvulus in old ppl
proctosigmoidoscopic exam, leave in rectal tube | recurrent cases treated with elective sigmoid resection
411
afib, récent MI, acute pain, GI bleeding, acidosis, sepsis
mesenteric ischemia
412
how to tx mesenteric ischemia if caught early
arteriogram and embolectomy
413
vague RUQ discomfort, weight loss, alpha-fetoprotein in ppl with cirrhosis
this is hepatocellular carcinoma
414
how to dx hepatocellular carcinoma
CT scan
415
how to tx hepatocellular carcinoma
surgical resection
416
which are more common? liver mets vs. primary liver cancer
liver mets
417
how to dx and tx liver cancer
dx with CT | tx with resection or radio-ablation
418
how monitor colon cancer recurrence
CEA
419
OCP use, massive bleeding
hepatic adenoma
420
how to dx hepatic adenoma
CT
421
how to tx hepatic adenoma
emergency surgery
422
- complication of biliary tract disease (acute ascending cholangitis) - fever, leukocytosis, tender liver
pyogenic liver abscess
423
how to dx and tx pyogenic liver abscess
dx with sonogram, CT | tx with percutaneous drainage
424
mexican man with tender liver, fever, leukocytosis, elevated ALP
amebic abscess
425
how to dx and tx amebic abscess
dx with serology but begin empiric tx based on clinical suspicion
426
increased indirect bilirubin only no bile in the urine Tbili 6-8
hemolytic anemia
427
-increased indirect and direct bilirubin -very increased transaminases, somewhat increase ALP what is it? what to do next?
heptocellular jaundice | work up for hepatitis
428
-increased indirect and direct bilirubin -somewhat increased transaminases, very increased ALP what is it? what to do next?
obstructive jaundice sonogram: - stones- stones in non-dilated gallbladder OR - malignancy- large thin walled and distended gallbladder (courvoisier terrier sign)
429
obese fecund 40F with high ALP, dilated ducts, non dilated gallbladder full of stones
obstructive jaundice due to stones
430
how to work up and tx obstructive jaundice due to stones
sonogram ERCP (confirm dx, sphincterotomy, remove CBD stone) cholecystectomy
431
how to work up obstructive jaundice due to tumor
sonogram shows dilated gallbladder --> CT - if CT positive --> percutaneous bx - if CT negative --> ERCP
432
malignant obstructive jaundice + anemia and blood in stool | what is it and how do we dx it?
ampullary cancer | dx with endoscopy
433
ampullary and lower common duct cancers have better prognosis than pancreatic cancer (t/f)
T
434
how to tx asyptomatic gallstones
we don't
435
temporary stone in cystic duct causing RUQ colicky pain radiating to right shoulder or back, fatty food, N/V, no systemic signs
biliary colic
436
how to dx and tx biliary colic
dx with US | tx with elective cholecystectomy
437
constant pain, fever, leukocytosis, peritoneal irritation in RUQ
acute cholecystitis
438
how to dx and tx acute cholecystitis
- dx with US (thick walled gallbladder with pericholecystic fluid) - tx with NG, NPO, IVF, abc --> interval cholecystectomy - if no response --> emergent chole - if very sick and not fit for surgery --> emergency percutaneous transhepatic cholesystostomy
439
stones in CBD, partial obstruction, ascending infection | -high temps, chills, very high WBCs all indicate sepsis
ascending cholangitis
440
charcot's triad
jaundice, fever, RUQ pain for ascending cholangitis
441
breast ca operability is based on _____ not _______
local extent, not metastases
442
adjuvant systemic therapy should follow breast ca surgery in virtually all patients (t/f)
T
443
persistent headache or back pain in woman with h/o breast ca suggests _____. what do you do?
metastases | -get head CT and bone scan
444
weight loss, palpitations, heat intolerance, moist skin, hyperactive person, tachycardia, a fib
hyperthyroidism
445
how to work up thyroid nodule in hyperthyroid pt
- get TSH (low) and/or T4 levels (high) - nuclear scan - if just nodule is the source, remove that lobe - if whole thyroid is the source, then do radioactive iodine ablation
446
key finding in ascending cholangitis is _________
high ALP
446
obstructive jaundice w/o ascending cholangitis can occur when _____________
stones produce complete biliary obstruction rather than partial obstruction
446
biliary pancreatitis
stones in ampulla, often pass spontaneously | US shows stones in the gallbladder
446
how to tx biliary pancreatitis
NPO, IVF, NG --> elective chole | -if conservative therapy doesn't work, then do ERCP and sphincterotomy
446
acute pancreatitis most often caused by _______ or ________
gallstones or alcohol
446
2 late complications of acute pancreatitis
pancreatic pseudocyst | chronic pancreatitis
446
acute edematous pancreatitis has this key finding
elevated hct
446
natural history of acute edematous pancreatitis
resolves after bowel rest (NPO, NG, IVF)
446
starts as edematous pancreatitis but with low hct
hemorrhagic pancreatitis
446
what makes hemorrhagic pancreatitis more likely?
Ranson's criteria - high WBC - high glucose - low Ca - high BUN, metabolic acidosis, low pO2
446
how to tx hemorrhagic pancreatitis
- requires ICU support | - anticipate and drain pancreatic abscesses ASAP (daily CT scans)
446
persistent fever and leukocytosis 10 days after onset of pancreatitis
pancreatic abscess
446
how to dx and tx pancreatic abscess
dx wit hCT | tx with percutaneous drainage
446
early satiety, vague discomfort, deep palpable mass 5 weeks after pancreatic injury
pancreatic pseudocyst
446
how to dx and tx pancreatic pseudocyst
dx with US or CT | tx by observing for 6 weeks with serial US --> if not resolved, then drain it
446
steatorrhea, DM, constant epigastric pain resistant to therapy
chronic pancreatitis
446
how to tx chronic pancreatitis
- insulin - pancreatic enzymes - perhaps ERCP and operations may help but this is a pretty terrible disease to have
446
in breast disease, if the presentation suggests benign disease then you don't have to worry about cancer (t/f)
F
446
inoperable breast CA is treated with ________. so are mets
chemo
446
obstructive jaundice w/o ascending cholangitis can occur when _____________
stones produce complete biliary obstruction rather than partial obstruction
446
how to tx chronic pancreatitis
- insulin - pancreatic enzymes - perhaps ERCP and operations may help but this is a pretty terrible disease to have
446
key finding in ascending cholangitis is _________
high ALP
446
how to tx ascending cholangitis
IV abx, emergency decompression of common duct (ERCP, PTC, surgery) --> eventual cholecystectomy
446
obstructive jaundice w/o ascending cholangitis can occur when _____________
stones produce complete biliary obstruction rather than partial obstruction
446
biliary pancreatitis
stones in ampulla, often pass spontaneously | US shows stones in the gallbladder
446
how to tx biliary pancreatitis
NPO, IVF, NG --> elective chole | -if conservative therapy doesn't work, then do ERCP and sphincterotomy
446
acute pancreatitis most often caused by _______ or ________
gallstones or alcohol
446
2 late complications of acute pancreatitis
pancreatic pseudocyst | chronic pancreatitis
446
acute edematous pancreatitis has this key finding
elevated hct
446
natural history of acute edematous pancreatitis
resolves after bowel rest (NPO, NG, IVF)
446
starts as edematous pancreatitis but with low hct
hemorrhagic pancreatitis
446
what makes hemorrhagic pancreatitis more likely?
Ranson's criteria - high WBC - high glucose - low Ca - high BUN, metabolic acidosis, low pO2
446
how to tx hemorrhagic pancreatitis
- requires ICU support | - anticipate and drain pancreatic abscesses ASAP (daily CT scans)
446
persistent fever and leukocytosis 10 days after onset of pancreatitis
pancreatic abscess
446
how to dx and tx pancreatic abscess
dx wit hCT | tx with percutaneous drainage
446
early satiety, vague discomfort, deep palpable mass 5 weeks after pancreatic injury
pancreatic pseudocyst
446
how to dx and tx pancreatic pseudocyst
dx with US or CT | tx by observing for 6 weeks with serial US --> if not resolved, then drain it
446
steatorrhea, DM, constant epigastric pain resistant to therapy
chronic pancreatitis
446
all abdominal hernias should be electively repaired to avoid the risk of intestinal obstruction and strangulation (t/f)
T | exception: umbilical in pts < 2, esophageal sliding hiatal hernia
446
in breast disease, if the presentation suggests benign disease then you don't have to worry about cancer (t/f)
F
446
mammography screening starts at age ____
40
446
mammograms should precede ____ in all women > ____ years
biopsy | 30
446
young woman with firm rubbery breast mass that moves easily
fibroadenoma
446
how to dx and tx fibroadenoma of the breast
dx with FNA or US | tx with optional surgical excision
446
very young teens with rapidly growing breast mass
giant juvenile fibroadenoma
446
how to tx giant juvenile fibroadenoma
removal to avoid deformity
446
late 20s, grow slowly to be large and distorting but are not invading or fixed
cystosarcoma phyllodes
446
how to work up cystosarcoma phyllodes
core or incisional bx and removal (2/2 malignancy potential)
446
age 30-40, bilateral breast tenderness related to the cycle, multiple lumps come and go
mammary dysplasia
446
how to work up mammary dysplasia
- if no dominant mass, mammogram - if dominant mass, aspiration (not FNA) - if clear fluid and mass goes away, do nothing - if mass persists or recurs after aspiration, formal bx - if bloody fluid, send cytology
446
young women with bloody nipple discharge
intraductal papilloma
446
how to work up intraductal papilloma
mammogram, galactogram to guide resection
446
breast abscess in the lactating woman. how to tx?
I&D and bx the wall
446
if you suspect breast cancer (which you should!!!)… this is the pathway you go down
- 40s or 50s- mammogram, core bx, incisional bx | - 60s or 70s- mammogram, core bx, incisional bx, excisional bx
446
a history of trauma rules out breast cancer (t/f)
F
446
ill defined fixed mass, retraction of overlying skin, "orange peel" skin, recent retraction of nipple, eczematous lesions of areola, reddish orange peel skin over the mass
inflammatory cancer
446
what about breast cancer during pregnancy
no XRT no chemo in 1st trimester surgery ok
446
small peripheral tumor in large breast. what's the tx?
lumpectomy, axillary sampling, post-op XRT | less desirable is modified radical mastectomy
446
what's the standard form of breast cancer
infiltrating ductal carcinoma
446
which breast cancer needs pre-op chemo?
inflammatory cancer
446
breast CA: lobular, medullary, mutinous have slightly (better/worse) prognosis compared to infiltrating ductal carcinoma
better
446
breast: can't metastasize, high incidence of recurrence after local excision
DCIS
446
txs for DCIS
- multicentric lesions --> total simple mastectomy | - lesion confined to one quarter of breast --> lumpectomy and XRT
446
if breast CA is estrogen receptor positive, treatments are: ______ for premenopausal ______ for post-menopausal
tamoxifen for pre | anastrozole for post
446
inoperable breast CA is treated with ________. so are mets
chemo
446
_____ is favored as adjuvant for breast CA.
chemo
446
hormonal therapy alone might be okay for old frail women (T/F)
T
446
work up for thyroid nodules in euthyroid pt
FNA - if benign, then follow - if malignant or in determinant, do thyroid lobectomy +/- further surgery
446
thyroid nodules in hyperthyroid patients are suspicious for cancer (t/f)
F | these are almost never cancer
446
how to tx ascending cholangitis
IV abx, emergency decompression of common duct (ERCP, PTC, surgery) --> eventual cholecystectomy
446
biliary pancreatitis
stones in ampulla, often pass spontaneously | US shows stones in the gallbladder
446
how to tx biliary pancreatitis
NPO, IVF, NG --> elective chole | -if conservative therapy doesn't work, then do ERCP and sphincterotomy
446
acute pancreatitis most often caused by _______ or ________
gallstones or alcohol
446
2 late complications of acute pancreatitis
pancreatic pseudocyst | chronic pancreatitis
446
acute edematous pancreatitis has this key finding
elevated hct
446
natural history of acute edematous pancreatitis
resolves after bowel rest (NPO, NG, IVF)
446
starts as edematous pancreatitis but with low hct
hemorrhagic pancreatitis
446
what makes hemorrhagic pancreatitis more likely?
Ranson's criteria - high WBC - high glucose - low Ca - high BUN, metabolic acidosis, low pO2
446
how to tx hemorrhagic pancreatitis
- requires ICU support | - anticipate and drain pancreatic abscesses ASAP (daily CT scans)
446
persistent fever and leukocytosis 10 days after onset of pancreatitis
pancreatic abscess
446
how to dx and tx pancreatic abscess
dx wit hCT | tx with percutaneous drainage
446
early satiety, vague discomfort, deep palpable mass 5 weeks after pancreatic injury
pancreatic pseudocyst
446
how to dx and tx pancreatic pseudocyst
dx with US or CT | tx by observing for 6 weeks with serial US --> if not resolved, then drain it
446
steatorrhea, DM, constant epigastric pain resistant to therapy
chronic pancreatitis
446
how to tx chronic pancreatitis
- insulin - pancreatic enzymes - perhaps ERCP and operations may help but this is a pretty terrible disease to have
446
all abdominal hernias should be electively repaired to avoid the risk of intestinal obstruction and strangulation (t/f)
T | exception: umbilical in pts < 2, esophageal sliding hiatal hernia
446
mammography screening starts at age ____
40
446
mammograms should precede ____ in all women > ____ years
biopsy | 30
446
young woman with firm rubbery breast mass that moves easily
fibroadenoma
446
how to dx and tx fibroadenoma of the breast
dx with FNA or US | tx with optional surgical excision
446
very young teens with rapidly growing breast mass
giant juvenile fibroadenoma
446
how to tx giant juvenile fibroadenoma
removal to avoid deformity
446
late 20s, grow slowly to be large and distorting but are not invading or fixed
cystosarcoma phyllodes
446
how to work up cystosarcoma phyllodes
core or incisional bx and removal (2/2 malignancy potential)
446
age 30-40, bilateral breast tenderness related to the cycle, multiple lumps come and go
mammary dysplasia
446
how to work up mammary dysplasia
- if no dominant mass, mammogram - if dominant mass, aspiration (not FNA) - if clear fluid and mass goes away, do nothing - if mass persists or recurs after aspiration, formal bx - if bloody fluid, send cytology
446
young women with bloody nipple discharge
intraductal papilloma
446
how to work up intraductal papilloma
mammogram, galactogram to guide resection
446
breast abscess in the lactating woman. how to tx?
I&D and bx the wall
446
if you suspect breast cancer (which you should!!!)… this is the pathway you go down
- 40s or 50s- mammogram, core bx, incisional bx | - 60s or 70s- mammogram, core bx, incisional bx, excisional bx
446
a history of trauma rules out breast cancer (t/f)
F
446
ill defined fixed mass, retraction of overlying skin, "orange peel" skin, recent retraction of nipple, eczematous lesions of areola, reddish orange peel skin over the mass
inflammatory cancer
446
what about breast cancer during pregnancy
no XRT no chemo in 1st trimester surgery ok
446
small peripheral tumor in large breast. what's the tx?
lumpectomy, axillary sampling, post-op XRT | less desirable is modified radical mastectomy
446
what's the standard form of breast cancer
infiltrating ductal carcinoma
446
which breast cancer needs pre-op chemo?
inflammatory cancer
446
breast CA: lobular, medullary, mutinous have slightly (better/worse) prognosis compared to infiltrating ductal carcinoma
better
446
breast: can't metastasize, high incidence of recurrence after local excision
DCIS
446
txs for DCIS
- multicentric lesions --> total simple mastectomy | - lesion confined to one quarter of breast --> lumpectomy and XRT
446
if breast CA is estrogen receptor positive, treatments are: ______ for premenopausal ______ for post-menopausal
tamoxifen for pre | anastrozole for post
446
breast ca operability is based on _____ not _______
local extent, not metastases
446
adjuvant systemic therapy should follow breast ca surgery in virtually all patients (t/f)
T
446
_____ is favored as adjuvant for breast CA.
chemo
446
hormonal therapy alone might be okay for old frail women (T/F)
T
446
persistent headache or back pain in woman with h/o breast ca suggests _____. what do you do?
metastases | -get head CT and bone scan
446
work up for thyroid nodules in euthyroid pt
FNA - if benign, then follow - if malignant or in determinant, do thyroid lobectomy +/- further surgery
446
thyroid nodules in hyperthyroid patients are suspicious for cancer (t/f)
F | these are almost never cancer
446
weight loss, palpitations, heat intolerance, moist skin, hyperactive person, tachycardia, a fib
hyperthyroidism
446
how to work up thyroid nodule in hyperthyroid pt
- get TSH (low) and/or T4 levels (high) - nuclear scan - if just nodule is the source, remove that lobe - if whole thyroid is the source, then do radioactive iodine ablation
446
what is lateral aberrant thyroid?
tissue removed from jugular chain and looks like normal thyroid is metastases from a follicular cancer… look for the primary tumor
446
high Ca on routine blood tests (not stones, bones, abd groans)
hyperparathyroidism
446
to work up high incidental Ca
- repeat Ca - look for low PO4 - r/o cancer - get PTH levels - do elective intervention --> oftentimes, it's a single adenoma that can be removed and result in a cure
483
round hairy face, supraclavicular fat pads, obese trunk, thin extremities, osteoporosis, DM, HTN, mental instability
Cushing
484
how to dx Cushing
low dose dex suppression test -if suppression, no dz -if no suppression, measure 24 hour fine cortisol -if urine cortisol elevated, do high dose suppression test if there's suppression on the high dose, then it's a pituitary micro adenoma - if not suppression at either dose, then adrenal adenoma - MRI for pituitary, CT scan for adrenal
485
how to tx cushing
surgical resection
486
virulent, resistant and extensive peptic ulcer disease
ZES
487
how to dx and tx ZES
- dx: measure gastrin, CT scan | - tx: surgical resection, omeprazole helps with metastatic disease
488
low blood sugar during fasting
insulinoma or self administration of insulin
489
how to differentiate insulinoma vs. self administration of insulin
- insulinoma, high insulin and high c peptide | - self administration, high insulin and low c peptide
490
how to dx and tx insulinoma
CT and surgery
491
devastating hyper secretion of insulin in the new born… what is it and how to treat?
nesidioblastosis | treat with 95% pancreatectomy
492
resistant severe migratory necrolytic dermatitis in patients with mild DM, anemia, glossitis, stomatitis
glucagonoma
493
how to dx and tx glucagonoma
- dx with glucagon assay and CT - tx with resection - if inoperable, tx with somatostatin and streptozocin
494
hypokalemia in hypertensive pt not on diuretics, modest hypernatremia, metabolic alkalosis -high aldo, low renin
primary hyperldosteronism
495
how to differentiate primary hyperaldosteronism caused by adenoma vs. hyperplasia and how to tx each
- hyperplasia = appropriate postural changes (more aldo when upright) --> tx medically - adenoma = inappropriate response --> adrenal CT and surgery
496
thin hyperactive women with pounding headache, perspiration, palpitations, pallor, high BP
pheochromocytoma
497
how to dx and tx pheochromocytoma
- measure 24 hour urine VMA or metanephrine (more specific) - CT scan - tx with surgery that's prepared with alpha-blockers
498
young pts with HTN in arms and normal BP in legs | CXR shows rib scalloping
coarctation of aorta
499
how to dx and tx coarctation of aorta
CT or MRA | correct with surgery
500
- young women with fibromuscular dysplasia - old men with arteriosclerotic disease - resistant HTN, bruit over flank or upper abdomen
renovascular HTN
501
how to dx and tx renovascular HTN
- scanning and doppler of renal vessels, arteriogram - tx - young women- balloon dilation and stunting - old men- may or may not treat it
502
excessive salivation, choking during feeding, coiled NG tube
esophageal atresia
503
if normal gas pattern in bowel (in the setting of esophageal atresia), that means….
blind esophagus + fistula between lower esophagus and tracheobronchial tree
504
what is VACTER
``` vertebral anal cardiac tracheal esophageal renal radial ```
505
how to tx esophageal atresia
- first, r/o VACTER - tx with primary surgical repair - if surgery has to be delayed, perform gastrostomy to prevent acid reflux to lungs
506
what to do in the case of imperforate anus
- look for fistula and repair soon-ish - if no fistula, do colostomy (high rectal pouch) or primary repair (low rectal pouch) - determine level of pouch with upside down X-rays
507
bowel in chest on the left side of infant
congenital diaphragmatic hernia
508
how to tx congenital diaphragmatic hernia
- delay repair 3-4 days to allow hypo plastic lungs to mature - if babies are in respiratory distress --> intubation, low pressure ventilation, sedation, NG suction (may require ECMO)
509
abd wall defect (2) and how to tx ___________: unprotected defect with angry bowel to cord's right ___________: protected normal looking bowel at the cord
gastroschisis omphalocele -tx: -small defect --> primary repair -large defect --> construct silo and stuff bowels back slowly -gastroschisis babies need TPN for 1 month
510
abd wall defect over pubis with red bladder mucosa, wet and shining with urine… what is it and how to tx
bladder exstrophy | -transfer and repair immediately within 1-2 days
511
is green vomiting in a new born good?
NO
512
green vomit + double bubble sign = (3) things
duodenal atresia- just double bubble annular pancreas- just double bubble malrotation (most serious)- double bubble and normal bowel gas beyond it
513
green vomit and normal gas pattern beyond the double bubble
malrotation
514
how to dx and and tx malrotation
- dx with contrast enema or upper GI (less safe, more reliable) - tx with surgery
515
green vomit and multiple air fluid levels (no double bubble)
intestinal atresia
516
when premature infants are first fed, they get feeding intolerance, abd distention, rapidly falling plt count
necrotizing enterocolitis
517
how to tx necrotizing enterocolitis
- stop feeding, give abc, IV fluids and nutrition - surgery if : - abd wall erythema - air in biliary tree - intestinal pneumatosis - pneumoperitoneum
518
feeding intolerance, bilious vomiting dilated loops of small bowel, ground glass in lower abd mother has CF
meconium ileus
519
how to dx and tx meconium ileus
dx and tx with gastrografin enema | -you would see a microcolon and inspissated pellets of meconium in terminal ileum
520
- 1st born boys, non bilious projectile vomiting after each feeding but eager to eat after vomiting - dehydrated, visible gastric peristaltic waves, palpable "olive sized" mass in RUQ - week 3
hypertrophic pyloric stenosis
521
how to tx hypertrophic pyloric stenosis
rehydration, correct hypochloremic hypokalemic metabolic alkalosis --> then do a Ramstedt pyloromyotomy
522
- increasing jaundice (conjugated) | - 6-8 weeks
biliary atresia
523
how to work up biliary atresia
- r/o other problems with serologies and sweat test - 1 week of phenobarbital stimulation --> HIDA scan --> if no bile in duodenum, surgical exploration - 1/3 get long lasting results, 1/3 need liver transplant later, 1/3 need liver transplant now
524
chronic constipation rectal exam --> relief of distention xray: distended proximal colon + "normal looking" distal colon
hirschsprung disease
525
how to dx and tx hirschsprung disease
dx with full thickness bx of rectal mucosa | tx with surgery
526
- 6-12 months - chubby healthy looking kid with colicky abd pain that makes them double up; lasts 1 min then kid looks happy again - vague mass on right side, "empty" RLQ, currant jelly stools
intussusception
527
how to dx and tx intussusception
- dx and tx with barium/air enema | - if that doesn't work, then do surgery
528
- subdural hematoma + retinal hemorrhages - many fx in diff bones at diff stages of healing - all scalding burns, esp both buttocks
child abuse signs
529
lower GI bleeding in kids most often caused by _________ how to dx it?
meckel's diverticulum | dx with radioisotope scan
530
stridor, respiratory distress with hyperextended position, difficulty swallowing
vascular rings around tracheobronchial tree
531
stridor, respiratory distress only
tracheomalacia
532
how to dx and tx vascular rings
- dx with barium swallow and bronchoscopy | - tx with surgical division of aortic arch
533
what do you do if someone has morphologic cardiac anomalies?
give them abx prophylaxis for subacute bacterial endocarditis workup always begins with CXR and echo
534
murmur, overloaded pulmonary circulation, long term damage to pulmonary vasculature
left to right shunts
535
- low pressure, low volume shunt - faint pulmonary flow systolic murmur, fixed split S2, frequent colds - how to dx and tx
ASD - dx with echo - tx with surgical closure
536
small restrictive VSD low in the septum… what to do?
few sxs, close spontaneously | observe and give SBE prophylaxis
537
- failure to thrive in first few months - loud pansystolic murmur at left sternal border, increased pulmonary vascular markings on CXR - how to dx and tx
VSD high in the membranous septum | -dx with echo, tx with surgery
538
- sxs in first few days of life - bounding peripheral pulses, continuous machinery like murmur - how to dx and tx?
PDA - dx with echo - tx - premature babies not in CHF --> close with indomethacin - babies who don't close, already in failure, or full term babies --> surgical division or coil embolization
539
murmur, decreased vascular lung markings, cyanosis
right to left shunts
540
- small for age, bluish hue in ops and fingers, clubbing, spells of cyanosis relieved by squatting - systolic mumur in left 3rd intercostal space, small heart, diminished lung markings, ECG signs of RVH - how to dx and tx
tetralogy of fallout - dx with echo - tx with surgery
541
- severe trouble early on - kept alive by ASD, VSD, and/or PDA - 1-2 day old with cyanosis - how to dx and tx
transposition of the great vessels - dx with echo - tx with surgery
542
- angina, exertional syncopal episodes | - harsh midsystolic murmur at right 2nd space
aortic stenosis
543
how to dx and tx aortic stenosis
-echo --> surgical valve replacement if gradient > 50, CHF, angina, or syncope
544
-wide pulse pressure, blowing high pitched diastole murmur in 2nd space
chronic aortic insufficiency
545
how to dx and tx chronic aortic insufficiency
- follow with medical therapy | - valve replacement if echo shows LV dilatation
546
-endocarditis in drug addicts who suddenly develop CHF and new loud diastolic murmur at 2nd space
acute aortic insufficiency
547
how to tx acute aortic insufficiency
emergency valve replacement and long term abx
548
- rheumatic fever in the past - dyspnea on exertion, orthopnea, PND, cough, hemoptysis - low pitched rumbling diastolic apical murmur - -> progress to be thin, cachectic, a fib
mitral stenosis
549
how to dx and tx mitral stenosis
echo --> worse sxs require MV repair
550
- valvular prolapse, exertional dyspnea, orthopnea, afib | - apical high pitched holosystolic murmur radiating to axilla and back
mitral regurgitation
551
how to tx mitral regurgitation
echo --> annuloplasty (valve repair)
552
what to do with progressive unstable disabling angina
cardiac cath - intervene if at least 1 vessel has 70% stenosis and there is a good distal vessel - should still have good ventricular function - simple or single vessel --> stent - complex or triple vessel --> CABG
553
dyspnea on exertion, hepatomegaly, ascites, square root sign, equalization of pressures on cath how to tx?
chronic constrictive pericarditis | tx with surgery
554
what do you do if you find a coin lesion of CXR
look for an old CXR to compare
555
what is the initial workup for suspected lung cancer
CXR --> sputum cytology and CT scan
556
if sputum not + for lung cancer, then you need a ______
biopsy (bronchoscopic or percutaneous) | if these aren't successful, thoracotomy and wedge resection
557
how to tx small cell lung cancer
chemo and XRT (NO SURGERY!!)
558
what to do for central lung lesions vs. peripheral lung lesions?
central- pneumonectomy | peripheral- lobectomy
559
minimum FEV1 is what?
800
560
hilar mets can be removed with pneumonectomy (t/f)
T
561
nodal mets at carina or mediastinum can be surgically resected (t/f)
F
562
before considering surgery for lung cancer, what should you do?
figure out remaining FEV1 | get CT to look for mets
563
- coldness, tingling, muscle pain in arm + visual sxs and equilibrium issues - this occurs when you're moving your arm
subclavian steal syndrome (stenosis at origin of a subclavian artery --> blood reverses in vertebral artery)
564
how to dx and tx subclavian steal syndrome
- need both vascular and neuro sxs (vascular alone suggests thoracic outlet obstruction) - dx with arteriogram - tx with bypass
565
asymptomatic pulsatile abd mass | what is it and how to dx and tx
AAA -dx with US or CT < 4 cm --> observe > 6 cm --> repair
566
excruciating back pain in pt with AAA
retroperitoneal hematoma is forming, blowout into peritoneal cavity is about to happen --> emergency surgery!!!
567
tender AAA
rupture will happen soon --> immediate repair!
568
when do you do surgery for peripheral artery disease of the lower extremities
to relieve sxs to prevent impending necrosis NO prophylactic surgery
569
how to work up intermittent claudication
-if it doesn't bother the pt that much, no workup needed dx -duplex to look for pressure gradient -if there is a gradient, do arteriogram tx -can be stented or bypassed -repair proximal before distal -grafts near aorta (prosthetic), more distal grafts (saphenous vein)
570
cannot sleep due to pain in calf, sitting up and dangling leg helps but leg becomes deep purple -shiny, atrophic skin w/o hair, no peripheral pulses
rest pain | duplex --> arteriogram --> stent or surgery
571
sudden painful, pale, pulseless, paresthetic, paralytic, cold extremity
arterial embolization
572
how to dx and tx arterial embolization to extremities
doppler --> clot busters if early incomplete occlusion, embolectomy with fogarty for complete obstruction -fasciotomy if revascularization is delayed
573
poorly controlled HTN - sudden onset severe, tearing CP radiating to back and migrates down - unequal pulses in UE, wide mediastinum on CXR
aortic dissection
574
how to work up aortic dissection
- r/o MI with ECG and troops - dx with spiral CT - ascending aorta --> surgery - descending aorta --> control of HTN in the ICU
575
skin cancer epidemiology
BCC > SCC > melanoma
576
how to dx skin cancer
full thickness incisional (punch) bx at edge of lesion
577
-raised waxy lesion, unhealing ulcer on upper face -no mets, only local invasion how to tx?
BCC | -tx with local excision with negative margins
578
- nonhealing ulcer, lower lip/face | - metastasize to LN
SCC - tx with wider margins +/- node dissection - XRT is an option
579
asymmetric irregular borders, different colors, > 0.5 cm diameter how to tx
melanoma < 1 mm depth --> local excision 1-4 mm depth --> aggressive tx including node dissection > 4 mm depth --> terrible prognosis deeper lesions require wide margin excisions mets can go anywhere at any time!!! it's cray-cray
580
strabismus can resolve spontaneously (t/f)
F | must correct ASAP to prevent amblyopia
581
causes of amblyopia if not corrected in first 6-7 years
congenital cataracts | strabismus- light reflects from different areas of cornea
582
white pupil in a baby...
ophthalmologic emergency! | could be retinoblastoma
583
- severe eye pain, frontal headache starting in the evening, halos around lights - pupil is mid-dilated, not reactive to light, cloudy green cornea, eyes feel hard as a rock
acute angle closure glaucoma - tx with laser - if no ophthalmologist, tx with topical pilocarpine drops/CA inhibitors (-zolamides) and systemic diuretics
584
- angina, exertional syncopal episodes | - harsh midsystolic murmur at right 2nd space
aortic stenosis
585
how to dx and tx aortic stenosis
-echo --> surgical valve replacement if gradient > 50, CHF, angina, or syncope
586
-wide pulse pressure, blowing high pitched diastole murmur in 2nd space
chronic aortic insufficiency
587
how to dx and tx chronic aortic insufficiency
- follow with medical therapy | - valve replacement if echo shows LV dilatation
588
-endocarditis in drug addicts who suddenly develop CHF and new loud diastolic murmur at 2nd space
acute aortic insufficiency
589
how to tx acute aortic insufficiency
emergency valve replacement and long term abx
590
- rheumatic fever in the past - dyspnea on exertion, orthopnea, PND, cough, hemoptysis - low pitched rumbling diastolic apical murmur - -> progress to be thin, cachectic, a fib
mitral stenosis
591
how to dx and tx mitral stenosis
echo --> worse sxs require MV repair
592
- valvular prolapse, exertional dyspnea, orthopnea, afib | - apical high pitched holosystolic murmur radiating to axilla and back
mitral regurgitation
593
how to tx mitral regurgitation
echo --> annuloplasty (valve repair)
594
what to do with progressive unstable disabling angina
cardiac cath - intervene if at least 1 vessel has 70% stenosis and there is a good distal vessel - should still have good ventricular function - simple or single vessel --> stent - complex or triple vessel --> CABG
595
dyspnea on exertion, hepatomegaly, ascites, square root sign, equalization of pressures on cath how to tx?
chronic constrictive pericarditis | tx with surgery
596
what do you do if you find a coin lesion of CXR
look for an old CXR to compare
597
what is the initial workup for suspected lung cancer
CXR --> sputum cytology and CT scan
598
if sputum not + for lung cancer, then you need a ______
biopsy (bronchoscopic or percutaneous) | if these aren't successful, thoracotomy and wedge resection
599
how to tx small cell lung cancer
chemo and XRT (NO SURGERY!!)
600
what to do for central lung lesions vs. peripheral lung lesions?
central- pneumonectomy | peripheral- lobectomy
601
minimum FEV1 is what?
800
602
hilar mets can be removed with pneumonectomy (t/f)
T
603
nodal mets at carina or mediastinum can be surgically resected (t/f)
F
604
diplopia in pts with frontal or ethmoid sinusitis
cavernous sinus thrombosis | -admit, IV abx, CT, drainage
605
- coldness, tingling, muscle pain in arm + visual sxs and equilibrium issues - this occurs when you're moving your arm
subclavian steal syndrome (stenosis at origin of a subclavian artery --> blood reverses in vertebral artery)
606
how to dx and tx subclavian steal syndrome
- need both vascular and neuro sxs (vascular alone suggests thoracic outlet obstruction) - dx with arteriogram - tx with bypass
607
asymptomatic pulsatile abd mass | what is it and how to dx and tx
AAA -dx with US or CT < 4 cm --> observe > 6 cm --> repair
608
excruciating back pain in pt with AAA
retroperitoneal hematoma is forming, blowout into peritoneal cavity is about to happen --> emergency surgery!!!
609
tender AAA
rupture will happen soon --> immediate repair!
610
when do you do surgery for peripheral artery disease of the lower extremities
to relieve sxs to prevent impending necrosis NO prophylactic surgery
611
how to work up intermittent claudication
-if it doesn't bother the pt that much, no workup needed dx -duplex to look for pressure gradient -if there is a gradient, do arteriogram tx -can be stented or bypassed -repair proximal before distal -grafts near aorta (prosthetic), more distal grafts (saphenous vein)
612
cannot sleep due to pain in calf, sitting up and dangling leg helps but leg becomes deep purple -shiny, atrophic skin w/o hair, no peripheral pulses
rest pain | duplex --> arteriogram --> stent or surgery
613
sudden painful, pale, pulseless, paresthetic, paralytic, cold extremity
arterial embolization
614
how to dx and tx arterial embolization to extremities
doppler --> clot busters if early incomplete occlusion, embolectomy with fogarty for complete obstruction -fasciotomy if revascularization is delayed
615
poorly controlled HTN - sudden onset severe, tearing CP radiating to back and migrates down - unequal pulses in UE, wide mediastinum on CXR
aortic dissection
616
how to work up aortic dissection
- r/o MI with ECG and troops - dx with spiral CT - ascending aorta --> surgery - descending aorta --> control of HTN in the ICU
617
skin cancer epidemiology
BCC > SCC > melanoma
618
how to dx skin cancer
full thickness incisional (punch) bx at edge of lesion
619
-raised waxy lesion, unhealing ulcer on upper face -no mets, only local invasion how to tx?
BCC | -tx with local excision with negative margins
620
- nonhealing ulcer, lower lip/face | - metastasize to LN
SCC - tx with wider margins +/- node dissection - XRT is an option
621
asymmetric irregular borders, different colors, > 0.5 cm diameter how to tx
melanoma < 1 mm depth --> local excision 1-4 mm depth --> aggressive tx including node dissection > 4 mm depth --> terrible prognosis deeper lesions require wide margin excisions mets can go anywhere at any time!!! it's cray-cray
622
strabismus can resolve spontaneously (t/f)
F | must correct ASAP to prevent amblyopia
623
causes of amblyopia if not corrected in first 6-7 years
congenital cataracts | strabismus- light reflects from different areas of cornea
624
white pupil in a baby...
ophthalmologic emergency! | could be retinoblastoma
625
- severe eye pain, frontal headache starting in the evening, halos around lights - pupil is mid-dilated, not reactive to light, cloudy green cornea, eyes feel hard as a rock
acute angle closure glaucoma - tx with laser - if no ophthalmologist, tx with topical pilocarpine drops/CA inhibitors (-zolamides) and systemic diuretics
626
eyelids are hot, tender, red, swollen | -febrile, fixed, dilated pupils, limited EOMI, pus in the orbit
``` orbital cellulitis (ooh emergency) -emergency CT and drainage ```
627
what to do with chemical burns of the eye
massive irrigation with water for 30 min --> in ED, irrigate with saline and test pH
628
flashes of light, floaters, snow storm, dark cloud
retinal detachment- emergency! | -tx with laser spot welding
629
elderly with sudden loss of vision from one eye
embolic occlusion of retinal artery- emergency! | -breathe into paper bag, press and release on the eye --> vasodilator to shake clot into more distal location
630
what about diabetics and eyes?
type II need ophthalmologic evaluation | type I can wait a little
631
young men with sudden severe testicular pain | -fever, pyuria, testis is swollen and tender but in normal position, tender cord
acute epididymitis | -tx with abx and r/o torsion with US
632
neck mass at anterior edge of SCM | sometimes have opening and blind tract in the skin
brachial cleft cyst
633
mass at base of neck, large and mushy thing occupying supraclavicular area
cystic hygroma | -CT scan then surgical removal
634
recently enlarged LN are usually cancer (T/F)
F | do H&P and re-evaluate in 3-4 weeks
635
young person with multiple enlarged nodes, low grade fever, night sweats what is it, dx, tx
lymphoma dx with FNA, node removal and pathology tx with chemo
636
mets to the supraclavicular nodes usually come from where
lung or intraabdominal tumors
637
- old men who smoke, drink, have bad teeth and AIDS | - hoarseness, persistent painless ulcer in the floor of the mouth, persistent unilateral earache
SCC of head and neck - these often metastasize to nodes in the neck - dx with tripe endoscopy, bx, and CT - tx with resection, radical neck dissection, XRT, platinum chemo
638
adults with sensory hearing loss in one early only
acoustic nerve neuroma | dx with MRI
639
gradual unilateral facial nerve paralysis
facial nerve tumors | dx with MRI
640
parotid mass with no pain or facial nerve paralysis
pleomorphic parotid adenoma with chance for malignancy
641
parotid mass that is hard or painful
parotid cancer - can do FNA but DO NOT DO AN OPEN BIOPSY - tx and bx with parotidectomy (sparing facial nerve) - if tumor is malignant, sacrifice the nerve and do a graft
642
unilateral ENT problems in toddlers
foreign bodies | endoscopy under anesthesia
643
abscess of mouth floor due to bad tooth infection
Ludwig angina | -I&D but may need to intubate and trach
644
sudden paralysis of CNVII for no apparent reason
Bell palsy | early admin of antiviral medications
645
pt has normal facial nerve function at time of trauma but later, they have a facial nerve deficit
this is due to swelling and will resolve by itself
646
diplopia in pts with frontal or ethmoid sinusitis
cavernous sinus thrombosis | -admit, IV abx, CT, drainage
647
epistaxis in children
-due to nose picking -anterior septum phenylephrine spray, local pressure
648
epistaxis in teens
- cocaine - posterior packing - nasopharyngeal angiofibroma requires surgical resection
649
epistaxis in old ppl
- control BP - posterior packing - maybe surgical ligation
650
2 causes of dizziness and how to tx each one
inner ear -room is spinning --> meclizine, phenergan, diazepam brain -unsteady but room is stable --> neurologic workup
651
vascular neurologic issues are ____ in onset _____ have severe headache _____ have no headache
sudden - hemorrhagic - occlusive
652
constant, progressive, severe HA worse in the morning, blurred vision, papilledema, projectile vomiting, +/- focal deficits
brain tumor
653
what to do about TIAs
duplex --> arteriogram if needed --> CEA
654
sudden onset of neuro deficits w/o HA.. what is it and what's the workup
ischemic stroke - assess with CT --> give tPA if there is no hemorrhage - tx with rehab
655
uncontrolled HTN with sudden onset of severe HA and neuro deficits … what is it and how to approach ?
hemorrhagic stroke | -evaluate with CT and tx by controlling HTN and rehab
656
sudden onset of the "worst headache of their life" no neuro deficits +/- meningeal irritation
subarachnoid hemorrhage from a berry aneurysm | -CT scan --> arteriogram --> embolize or clip
657
bradycardia and HTN in the setting of brain tumor
Cushing reflex
658
how to work up brain tumor
MRI --> surgery | -treat increased ICP with mannitol, hyperventilation, and high dose steroids
659
inappropriate behavior, ipsilateral optic nerve atrophy, contralateral papilledema, anosmia
tumor at base of frontal lobe
660
youngsters who are short for their age with bitemporal hemianopsia, calcified lesion above the sella
craniopharyngioma
661
amenorrhea, galactorrhea in young women | what could it be and how to work it up?
prolactinoma - r/o pregnancy and hypothyroidism - determine prolactin level - MRI the sella - tx with bromocriptine… if this doesn't work or if they want to get pregnant, then surgically remove it
662
- huge hands, feet, tongue, jaws | - HTN, DM, sweaty hands, HA, wedding bands and hats don't fit
acromegaly - workup with somatomedin C levels and pituitary MRI - tx with surgery but can also do XRT
663
person gets into accident b/c they have issues with peripheral vision they had a b/l adrenalectomy for Cushings years ago
this is bilateral hemianopsia caused by pituitary adenoma (Nelson syndrome) -MRI and resect
664
h/o pituitary tumor + acute HA, vision deterioration, bilateral pallor --> stupor and hypotension
pituitary apoplexy (bleeding and destruction of a pituitary tumor) - tx with steroid replacement and eventual replacement of other hormones - evaluate with MRI or CT
665
loss of upper gaze, "sunset eyes" (Parinaud syndrome)
pineal gland tumor
666
stumbling around, truncal ataxia, knee to chest position to relieve HA in children
posterior fossa tumor
667
brain tumor-like presentation in the setting of fever, otitis media/mastoiditis
brain abscess | -dx wit CT and tx with resection
668
most tumors affecting the spinal cord are ____ and ______
metastatic and extradural - they may fx the spine or compress the cord - dx with MRI - tx with neurosurgical decompression
669
pain when standing up straight, no pain if hunched over
neurogenic claudication | -MRI --> surgical decompression
670
sharp shooting pain the face caused by touching, unshaven area of the face
trigeminal neuralgia - get an MRI to r/o organic lesions - tx with anticonvulsant and if needed, radio frequency ablation
671
months after a crush injury, pt gets constant burning pain that's aggravated by the slightest stimulation -extremity is cold, cyanotic, and moist
reflex sympathetic dystrophy - dx with sympathetic block - tx with surgical sympathectomy
672
severe sudden testicular pain | -swollen testis, tender, "high riding" with "horizontal lie," nontender cord
testicular torsion | -immediate surgery + orchiopexy
673
young men with sudden severe testicular pain | -fever, pyuria, testis is swollen and tender but in normal position, tender cord
acute epididymitis | -tx with abx and r/o torsion with US
674
pt passing kidney stone suddenly has chills, fever spike and flank pain
obstruction and infection of urinary tract | -IV abx, immediate decompression of urinary tract with stent, nephrostomy, etc
675
urinary frequency, painful urination, small amounts of cloudy and smelly urine in women of repro age
- UTI (cystitis) - tx with empiric antimicrobial - for pyelonephritis and UTI in children or young men, get cultures and uro workup to r/o obstruction
676
what consists of a urinary workup?
IVP (kidney, collecting system, ureter, some bladder) CT for renal tumors US for dilation/obstruction cystoscopy for bladder mucosa
677
chills, high fever, n/V, flank pain
pyelonephritis | tx: admit, IV abx, IVP or sonogram
678
older men with chills, fever, dysuria, urinary frequency, diffuse low back pain, tender prostate on rectal exam
acute bacterial prostatitis | tx: IV abx, no more rectals
679
newborn boy not urinary (r/o metal stenosis)
posterior urethral valves - cath to empty the bladder - dx: voiding cystourethrogram - tx: endoscopic fulguration/resection
680
urethral opening on ventral penis
hypospadias | -do not circumcize b/c you need that tissue for reconstruction
681
always work up hematuria from trivial trauma and UTI in children (T/F)
T
682
child with burning on urination, frequency, low abd and perineal pain, flank pain, fevers, chills
vesicoureteral reflux and infection - tx: empiric abx --> cultured guided abx, IVP, voiding cystogram to look for reflux - if reflux is present, long term abx until child grows out of it
683
- girl feels need to void and voids normally at appropriate interval - BUT she is wet with urine all the time
low implantation of the ureter | -dx with PE, IVP --> tx with surgery
684
adolescent binge drinks and then gets colicky flank pain
ureteropelvic junction obstruction
685
most hematuria is ____ but work it up b/c most cancers of kidney and ureter and bladder present with hematuria
benign
686
hematuria workup
IVP/CT for renal or ureteral tumors | cystoscopy for bladder cancer
687
hematuria, flank pain, flank mass, hypercalcemia, erythrocytosis, elevated liver enzymes
renal cell carcinoma
688
how to dx and tx renal cell carcinoma
IVP- renal mass US- solid mass CT- heterogenic solid tumor if clinical picture suggests RCC, CT may be done first tx with surgery ONLY
689
hematuria, irritative voiding sxs, smoking history
bladder cancer
690
how to work up suspected bladder cancer
IVP --> cystoscopy tx with surgery, intravesical BCG high rate of recurrence means you need life long follow up
691
hard discrete nodule on DRE, elevated PSA
prostate cancer | -stop surveillance at age 75
692
how to dx and tx prostate cancer
-dx: transrectal needle bx -CT helps with planning tx -tx: surgery and/or XRT bone mets respond for androgen abalation
693
young men with painless testicular mass
testicular cancer
694
how to dx and tx testicular cancer
- bx with radical orchiectomy by inguinal route - take prep alpha fetoprotein and beta HCG blood samples for f/u - tx: maybe surgical LN dissection, most are sensitive to XRT and platinum chemo even when metastatic
695
men who have h/o BPH with palpable distended bladder
acute urinary retention - place indwelling catheter for 3 days - 1st line long term therapy = alba blockers - 5 alpha reductase inhibitors for very large glands - TURP rarely done
696
how to tx postop urinary retention
straight cath and then indwelling catheter
697
middle aged women with previous pregnancies who leak urine when they sneeze or laugh
stress incontinence | -tx with surgical repair of the pelvic floor
698
how to prevent kidney stones
drink water
699
most kidney stones are visible on X-ray (t/f)
T
700
common causes of pneumaturia (fistula between bladder and GI)
1. sigmoid colon- diverticulitis 2. sigmoid cancer 3. bladder cancer
701
how to work up pneumaturia
CT to see diverticular mass sigmoidoscopy to r/o cancer tx with surgery
702
how to tx organic impotence
viagra, vascular surgery, suction devices, prosthetic implants
703
the only absolute contraindication to organ donation is __________
HIV +
704
transplantation: __________ rejection vascular thrombosis occurring within minutes due to _______ prevent by _____ and ________
hyperacute preformed antibodies ABO matching and lymphocytotoxic crossmatch
705
transplantation: ______________ rejection signs of organ dysfunction at 5 days - 3 months liver: what do you do? heart: what do you do? treatment?
acute liver- r/o biliary obstruction by US and vascular thrombosis by doppler heart- routine ventricular bus at set intervals tx- steroid boluses, OKT3
706
transplantation: _____ rejection | - gradual insidious loss of organ function
chronic - no prevention, no tx - bx to r/o treatable acute rejection
707
someone comes to you with sxs of long standing GERD... what do you do?
tx the symptoms | recommend endoscopy and biopsy to assess their esophagus
708
what to do with Barrett's esophagus
``` medical management (esp if it hasn't already be instituted) fundoplication if dysplastic, then surgical resection ```
709
if you want to do a nissen fundoplication, you should do what first?
all the esophageal studies (swallow, endoscopy, biopsy, manometry, gastric emptying, etc)
710
how to dx achalasia
Ba swallow then manometry
711
you suspect esophageal cancer.. what do you do?
swallow --> endoscopy and biopsy --> CT to assess extent
712
mallory weiss tear. what do you do?
endoscopy +/- photocoagulation for dx and tx
713
esophageal perforation. what do you do?
dx with swallow | tx with emergency surgery
714
how to work up stomach cancer
endoscopy and biopsy --> CT
715
patient comes with a history suspicious for hemorrhoids, what do you do?
proctosigmoidoscopic exam!!! not home remedies b/c you must r/o cancer
716
if given choice, choose __________ for initial dx of left colon cancer
proctosigmoidoscopy then colonoscopy later on
717
fistula in ano... what do you do?
r/o cancer with proctosigmoidoscopy | then elective fistulotomy
718
GI bleeding upper GI bleed has been ruled out what do you do?
you can do the thing regarding bleeding rate... or it might be always safe to pick tagged red cell scan
719
a really sick patient (in the ICU) vomits up blood... what is it most likely and how to tx it?
stress ulcer dx and attempt to tx with endoscopy if that doesn't treat it, consider arterial embolization
720
how to dx acute cholecystitis
US | if US is equivocal, then get HIDA
721
eczematoid lesion of the areola
Paget's disease of the breast
722
punch biopsy in breast stuff only ok for ________ and _______ otherwise, you need incisional or excisional biopsy
Paget's disease | orange peel skin (inflammatory breast ca)
723
infiltrating ductal carcinoma near the nipple in a small breast
modified radical mastectomy (MRM) - no need for radiation - also the old unmodified radical mastectomy no longer done
724
other breast cancers besides the standard infiltrating ductal carcinoma: - lobular - inflammatory - others
lobular- higher incidence of b/l but not enough to do b/l mastectomy inflammatory- terrible prognosis others- tx it like infiltrating ductal carcinoma, slightly better prog than IDC
725
DCIS tx
if in one quadrant, lumpectomy + XRT | if multicentric, simple mastectomy
726
inoperable breast ca... what can you do?
chemo is preferred for palliation
727
woman has lumpectomy and axillary dissection for IDC... there are some positive LN. what do you do?
chemo as adjuvant therapy
728
patient with a h/o breast ca has bad headaches
do CT scan to look for mets | tx with high dose steroids and XRT
729
pt has a "hot" thyroid adenoma.. what do you do before surgery?
beta blocking
730
"lateral aberrant thyroid" is really __________
``` metastatic cancer (follicular carcinoma in the thyroid) do a thyroid scan and then tx with surgery ```
731
you suspect primary hyperparathyroidism... what do you do?
PTH levels scan to locate the adenoma surgery
732
patient presents with hyper-aldo sxs? what do you do?
get aldo and renin levels postural determinations to differentiate hyperplasia vs. adenoma hyperplasia- tx with aldactone adenoma- tx with CT/MRI and then surgery
733
how to work up coarctation of the aorta
CXR- rib scalloping spiral CT or MRA surgery
734
how to dx malrotation in peds
contrast enema- safe, less reliable | upper GI- not as safe, more reliable
735
baby with green vomit no double bubble multiple air fluid levels and distended loops of bowel
intestinal atresia
736
low cardiac index without high LVEDP indicates what?
you need to increase fluid intake
737
orbital cellulitis. what do you do?
emergency consult | CT and drainage
738
don't do open biopsies of _______ and ________
neck LN suspicious for SCC of head and neck
739
how to dx facial nerve tumor
gadolinium enhanced MRI
740
paraplegic holds their urine for a while and develops headache, perspiration, and bradycardia what is it and how to tx?
autonomic dysreflexia | tx: empty the bladder, alpha blockers, CCBs (nifedipine)
741
acute bacterial prostatitis | what do you NOT do??
rectal exam
742
uses octreotide
``` bleeding esophageal varices dumping syndrome carcinoid tumors high output fistula glucagonoma ```
743
posterior urethral valves. dx and tx?
dx: voiding cystourethrogram tx: surgical resection
744
hematuria from minor trauma in kids... what to do?
look for congenital anomalies | do sonogram +/- IVP
745
little boy with UTI
look for vesicoureteral reflux - do IVP and voiding cystogram - also, obviously give abx
746
UPJ obstruction | dx and tx?
dx: US tx: surgery
747
workup of painless hematuria in old person
CT and cystoscopy
748
pneumaturia.... what test do you get first?
CT
Surgery
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