Surgery/GI Flashcards

Question

volvulus

Answer 1

insidious sx onset in adults - ascending colon and sigmoid colon - transition point usu in cecum or sigmoid tx - proctosigmoid exam, leave rectal tube in

Answer 2

**RUQ pain** --\> US - cholesterol gallstones - with increased estrogen or with decreased enterohepatic recycling (cholesterol saturates) - asymptomatic - no treatment (only 20% of pts with asx gallstones will develop sxs within 15yrs) - gallstones with biliary colic (pain is due to gallstone pressing against opening of cystic duct) - elective lap chole, possible usodeoxycholic acid in poor surgical candidates - complicated gallstone disease (acute chole, choledocho, gallstone pancreatitis) - cholecystectomy within 72hrs - acute chole - obstruction of cystic duct by gallstone - note: sxs often subside in a few days with volume resuscitation, abx, and pain meds. **However, early cholecystectomy has better outcomes** than delayed cholecystectomy (after 7d) - fenofibrate can contribute to gallstone formation **choledocholithiasis** - stone in CBD (CBD dilation) - RUQ pain, jaundice (due to biliary obstruction), elevated direct bili, transaminitis - ERCP + sphincterotomy **gallstone ileus** - due to biliary-enteric fistula, sxs intermittent over several days, pneumobilia (air in biliary tree) and dilated loops of bowel - sxs are intermittent because - stone causes tumbling obstruction --\> eventually lodges in ileum - will have hyperactive bowel sounds - confirm dx by abd CT - tx is removal of stone and chole (at some point)

Answer 3

acute cholecystitis - RUQ pain, fever, leukocytosis - complications - ...abscess, chronic cholecystitis - tx - NPO, IV abx, analgesia - lap chole shortly after hospitalization - perform immediately in cases of perforation or gangrene emphysematous cholecystitis - risk factors - gallstone, DM, vascular compromise (of cystic artery), immunosuppression - px - ...crepitus in abd wall adjacent to gallbladder - dx - air-fluid levels in GB, cultures with gas-forming bac (Clostridium, E coli), unconjugated hyperbili (because of Clostridium-induced hemolysis) - tx - **emergent chole**, BSAbx with clostridium coverage (ampicillin-sulbactam) - complications - gangrene and perforation chronic cholecystitis - porcelain gallbladder --\> increased for gallbladder carcinoma - cholecystectomy is considered

Answer 4

cause is biliary stasis - bile duct obstruction from gallstones, malignancy, stenosis Charcot: 1) RUQ pain, 2) jaundice, 3) fever Reynolds: + hypotension, AMS significantly elevated alk phos and conjugated bili bile duct dilation on US or CT tx - abx coverage of enteric bacteria, biliary drainage by ERCP within 24-48hrs

Answer 5

body has large stores of B12, minimal stores of folate - b12 storage = 3-5 yrs both B12 and folate are involved in DNA synthesis - deficiency will affect cells with rapid turnover - will see macrocytic anemia, low/nl retics, pancytopenia, hyperhomocysteinemia - also elevated MMA levels in B12 deficiency - causes of both - malnutrition - causes of B12 deficiency - intestinal bacterial overgrowth (competes for the B12), pernicious anemia myelodysplasia will also have macrocytic anemia with pancytopenia - but neutrophils will by hypogranulated and hyposegmented

Answer 6

c11p15 --\> gene that encodes ILGF2 physical exam - fetal macrosomia, hemihyperplasia, macroglossia rapid growth until late childhood - omphalochele/umb hernia - will close by age 5 - monitor newborns for hypoglycemia - occurs due to fetal hyperinsulinemia - complications - Wilms tumor, hepatoblastoma - surveil with AFP and abd/renal US through adolescence note - pts with isolated hemihyerplasia are at increased risk for Wilms tumor and hepatoblastoma...

Answer 7

age 15-30, M, obese, sedentary lifestyles issue is an infected hair follicle in the intergluteal region --\> abscess, sinus tract --\> recurrent abscesses

Answer 8

abx implicated - clinda, FQs, penicillins, and cephalosporins - PPIs change colonic microbiome - increases risk of C diff proliferation (note the spores are acid resistant) - C diff carriage is 8-15% and extensive proliferation is required to reach exotoxin levels that are pathogenic get stool studies (PCR for toxin) - pt with negative studies may require sigmoidoscopy or colonoscopy with bx - bacterial toxins --\> apoptosis of colonic cells, loss of tight junctions tx with oral metro or vanc - mild-mod = WBC \< 15K, Cr \< 1.5x baseline - metro - severe = WBC \> 15K, Cr \> 1.5x baseline, serum albumin \<3 g/dl - oral vanc - if pt has an ileus --\> add IV metro and switch to rectal vanc - if pt develops WBC \> 20K, lactate \>2.2, toxic megacolon, or severe ileus --\> subtotal colectomy or diverting loop ileostomy with colonic lavage - fidaxomicin can also be used - note: IV vanc is not excreted into the colon (that is why it is not used)

Answer 9

no symptoms in between vomiting episodes, no underlying condition often fhx of migraines (CVS is thought to be related to abd migraine) for kids - 2/3 will outgrow sxs in 5-10yrs - can give sumatriptan for kids with fhx of migraines

Answer 10

Lynch, AD: CRC, endometrial cancer, ovarian cancer - defect in mismatch repair gene - early screening via colonoscopy and embx - ppx hysterectomy and BSO at age 40 FAP: CRC, desmoids, osteomas, brain tumors - side note - rectum is usually spared VHL, AD: hemangioblastomas, RCC, pheo MEN1, AD (adenomas): parathyroid adenomas, pituitary adenomas, pancreatic adenomas MEN2, AD: medullary thyroid cancer, pheo, parathyroid hyperplasia

Answer 11

type 1 cysts are most common - extrahepatic single cystic dilatation of the bile duct px - triad of pain, jaundice (obstructive cholestasis), and palpable mass - majority present at \< 10 yrs, infants can present with jaundice and acholic stools - adults present with vague epigastric pain/RUQ pain/cholangitis dx - US, ERCP if obstruction is suspected tx - surgical resection to relieve obstruction and prevent malignant transformation

Answer 12

hepatic steatosis - occurs due to increased transport of FFA from adipose to liver, decreased oxidation of FF in liver, and decreased clearance of FFA from liver (decreased VLDL production) - cause = peripheral insulin resistance --\> increased peripheral lipolysis and hepatic uptake of Fas - normally insulin decreases lipolysis in adipose cells px - mostly asx, metabolic syndrome, AST:ALT \< 1, hyperechoic texture on US tx - diet, exercise, and bariatric surgery if BMI \> 35 - safe to continue statin therapy in these patients note on AST and ALT - AST is in liver, heart, kidney, and skeletal muscule - ALT is in reduced quantities in other tissues but is predominantly in liver - more specific for hepatocyte injury (and usually more elevated in liver disease, except for alcoholic liver disease)

Answer 13

precipitating factors - drugs (sedatives, narcotics), hypovolemia, hypokalemia or metabolic alkalosis (acid-base problems), increased N load (GI bleeding), infection, TIPS - note - UGIB will present with **elevated BUN and nl Cr** tx - correct precipitating cause and decrease blood ammonia concentration (lactulose, rifaximin) - lactulose --\> metabolized to short-chain fatty acids by colonic bacteria --\> acidifies colon --\> ammonia becomes charged and trapped in stool

Answer 14

alcohol or gallstones - rarely drug-induced - valproate, diuretics, ACEi, IBD drugs, immunosuppressants, HIV meds, abx like metro and tet - drug-induced pancreatitis is usually mild - hypertriglyceridemia \>1000 mg/dL (xanthomas on exam) - infections - CMV, legionella, aspergillus - iatrogenic - post-ERCP, ischemic/atheroembolic dx - 2/below - acute epigastric pain radiating to back - (get first) amylase or lipase \>3 ULN - amylase rises 6-12hrs (remains elevated for 3-5d), lipase rises 4-8 hrs (remains elevated for 8-14d) - (next) abnormalities in imaging Imaging - CT NOT required to dx pancreatitis, but it will show - swelling of pancreas, peri-pancreatic fluid, and fat-stranding - or RUQ US if you suspect biliary pancreatitis - ALT\>150 suggests biliary pancreatitis (also look at BMI, alk phos) Treatment - SUPPORTIVE (attacks are usu self-limited, resolve in 4-7d), IVFs, NPO - for gallstone pancreatitis - early lap chole - ERCP if pt has cholangitis, visible CBD obstruction, or increasing LFTs - note - ppx abx are **not** used (unless there is a necrotizing infection) severe disease = pancreatitis with failure of 1 organ - pancreatic enzymes enter vascular system, SIRS --\> increased vascular permeability - fever, tachy, hypotension - dyspnea, tachypnea, basilar crackles - abd tenderness or distention - Cullens (periumbilical), Grey-Turner - associated with: age \>75, obesity, alcoholism, CRP \>150 at 48hrs, rising BUN/Cr in first 48hrs, CXR with pulm infiltrates or pleural effusion, CT with necrosis and extrapancreatic inflammation - complications - pseudocyst, peripancreatic fluid collection, necrotizing pancreatitis, ARDS, ARF, GI bleed acute hemorrhagic pancreatitis - daily CTs to monitor for **abscess development** (this is a common pathway to death) **pancreatic pseudocyst** - complications - spont infection, duodenal/biliary obstruction, pseudoaneurysm (due to digestion of adjacent vessels), pancreatic ascites, pleural effusion - no sxs - symptomatic therapy, NPO - sig sxs, size \> 6cm, older (\> 6wk), infection, pseudocyst, pseudoaneurysm - endoscopic drainage others - pancreatic abscess/necrosis, pleural effusion, ileus, ARDS

Answer 15

80% sporadic, 20% MEN1 (check PTH, ionized ca, prolactin) - located in duodenum or pancreas uncontrolled gastrin secretion --\> parietal cell hyperplasia --\> excessive production of gastric acid px - chronic diarrhea (inactivation of pancreatic enzymes and injury to mucosal brush border) and weight loss when do you suspect a gastrinoma? - thickened gastric folds, multiple peptic ulcers, refractory ulcers, ulcers in the jejunum (gastric acid cant be fully neutralized in the duodenum) suspected gastrinoma 1) check serum gastrin level off PPI therapy for 1 week - level \>1000 pg/mL is diagnostic - check gastric pH to make sure that achlorhydria (failure of gastric acid secretion is not the cause of elevated gastrin) - \<110 rules it out - for 110-1000 pg/mL, get secretin stimulation test - normal G cells are inhibited by secretin (but secretin will stimulate gastrinoma cells) - last ditch effort - calcium infusion study, calcium can lead to increased serum gastrin levels in gastrinoma pts 2) EGD (ulcers and thickened gastric folds) 3) CT/MRI and somatostatin receptor scintigraphy for tumor localization resection is the treatment of choice for primary pancreatic neuroendocrine tumors (insulinoma, glucagonoma, VIPoma) - insulinoma - reactive hypoglycemia (after meals)... - glucagonoma - by serum glucagon levels - VIPoma - VIP levels, somatostatin scintigraphy to localize - for these tumors - get CT to locate tumor

Answer 16

performed when a pt has ascites that does not respond to medical therapy OR has active/recurrent variceal bleeding even after appropriate treatment with upper endoscopy

Answer 17

cause - upper esophageal sphincter dysfunction and esophageal dysmotility dx - barium esophagram, esophageal manometry - side note - oral contrast in a pt with a hx of aspiration is associated with a risk of pneumonitis, but do this regardless because benefits \> risks management - open/endoscopic surgery, cricopharygneal myotomy complications - tracheal compression, ulceration with bleeding, regurgitation, and pulm aspiration

Answer 18

may have RUQ pain - pain may precede onset of vesicular rash - consider shingles in pts with recent cancer (and chemo)

Answer 19

bile is stored in upper small bowel during fasting for the first few wks-mo - diarrhea because of insufficient bile acid absorption by terminal ileum

Answer 20

**SBO** - hx of surgery, distention and INCreased bowel sounds (but will progress to absent bowel sounds, esp if bowel is ischemic), small bowel dilation (with no large bowel dilation) - will have return of bowel functional temporarily post-op - proximal v.s. mid/distal - proximal obstructions - early vomiting, abd discomfort, abnormal contrast filling on XR - distal - colicky abd pain, delayed vomiting, abd distention, constipation-obstipation - simple (luminal obstruction) v.s. strangulated (loss of blood supply) - partial v.s complete - partial - air in colon - complete - transition point, no air in colon - complications - ischemia/necrosis, bowel perf - tx - bowel rest, NG suction, IVFs - surgical exploration when you are concerned about risk of ischemia, strangulation, and necrosis (signs are fever, hemodynamic instability, metabolic acidosis) **ileus** - recent surgery - hrs-d - hypoK --\> what causes hypoK - GI losses, loops/excess aldosterone, correction of DKA (K rapidly moves into cells) - med induced - morphine (- pancreatitis) - possible distension, REDuced bowel sounds - small and large bowel dilation with no transition point - some degree of ileus occurs following most abdominal procedures, due to increased splanchnic nerve tone (peritoneal irritation) and inflammatory mediator release - however ileus of \>3-5d post-op is prolonged post-op ileus - techniques to prevent post-op ileus - epidural anesthesia, MIS, judicious peri-op use of IVFs (minimize GI edema) **Ogilvie** = paralytic ileus of the colon - massively dilated colon in elderly, sedentary post-op pts 1) fluid and electrolyte correction 2) colonoscopy to suck out air and place a long rectal tube

Answer 21

focal nodular hyperplasia (benign) - anomalous arteries - arterial flow and central scar on imaging hepatic adenoma - benign epithelial tumor - long-term OCPs, anabolic androgen use, pregnancy - possible hemorrhage (so needle bx is not recommended) or malignant transformation hepatic angiosarcoma - rare - older men who have been exposed to toxins (vinyl chloride gas, arsenic compounds, thorium dioxide) regenerative nodules - acute or chronic liver injury HCC - B symptoms, chronic hepatitis or cirrhosis, elevated AFP - mass often with satellite lesions liver mets - multiple (**or can be solitary**, look at hx) - most commonly secondary to GI malignancies (portal system) = colon cancer - often silent until pressure on liver capsule or obstruction of biliary tree causes sxs - LFTs may be normal hydatid cysts - Echinococcus tapeworm infections - southwest - exposure to sheep and dogs entamoeba - tx with metro

Answer 22

pancreatic insufficiency - ..CF bile-salt related - Crohns, bacterial overgrowth (due to surgical blind loop or motility disorders like scleroderma), PBC, PSC, surgical resection of ileum (at least 60-100 cm) impaired intestinal surface epithelium - celiac disease, AIDs enteropathy, giardia other - Whipple disease, ZES, meds

Answer 23

mechanical obstruction - post-prandial pain, vomiting, early satiety - causes - malignancy, PUD, Crohns, strictures (pyloric stenosis) - physical exam will elicit abdominal succussion splash (auscultation maneuver) initial management - NG suction, IVFs, endoscopy for definitive dx

Answer 24

endoscopy is the most common cause - with severe vomiting - occurs when pt is resisting vomiting reflex px - ... Hammans sign (crunching sound on chest auscultation) dx - CXR or CT scan will show wide mediastinum, pneumomediastinum, pneumothorax, pleural effusion (late) - can see esophageal wall thickening, mediastinal air-fluid level on CT - gastrin esophagram tx - NPO, abx, IV PPI - surgical repair (for significant leak with SIRS) **Mallory-Weiss** tear associated with alcohol use and hiatal hernia - bleeding stops spontaneously in 90% of pts - for ongoing bleeding - endoscopic electrocoagulation or local epi injection

Answer 25

work-up - orophargyneal dysphagia (difficulty initiating swallowing + cough, choking, nasal regurg) - videofluoroscopic modified barium swallow (swallow study) - stroke, dementia, oropharyngeal malignancy, NM disorder (myasthenia) - px with aspiration pneumonia - esophageal dysphagia - solids + liquids --\> motility disorder - 1) barium swallow, 2) manometry - solids then progressing to liquids --\> mechanical obstruction - hx of prior radiation, caustic injury, stricture, or surgery for esophageal/larygneal cancer - if yes barium swallow then egd - if no --\> EGD - in general - alarm sxs --\> proceed straight to EGD achalasia - dysphagia to solids and liquids - mild weight loss - chest pain and heartburn (many pts are initially diagnosed with GERD) - dx by \*manometry\* - loss of peristalsis in the distal esophagus with lack of LES relaxation; barium esophagram - tx - EGD to exclude malignancy, lap myotomy, **pneumatic balloon dilation** (other options include botox, nitrates, CCBs) pseudoachalasia - due to esophageal cancer - sxs are usu more rapid onset and associated with weight loss - risk factors for squamous cell (anywhere) - tobacco, alcohol - risk factors for adeno (distal) - Barrett's, GERD , smoking, obesity - classically presents with dysphagia to solids (bread, meat), chest pain, weight loss - CXR will show narrowing of distal esophagus - barium swallow prior to EGD for cancers - to prevent inadvertent perf - get EGD and CT for staging - differentiate by EGD (with bx) - achalasia - normal mucosa, easy to pass endoscope through LES (unlike in malignancy) globus sensation - no abnormalities on barium swallow polymyositis - affects upper third of esophagus (striated muscle) - also other sxs of weakness (difficulty climbing stairs)

Answer 26

**Crohns** - more women, smoking risk factor - non-bloody diarrhea (if diarrhea is bloody, it is colitis), oral ulcers, arthritis, uveitis, scleritis, erythema nodosum, \*lung disease\* - mouth to anus - rectum spared, skip lesions, perianal disease (skin tags, fistulas) - **transmural** inflammation, linear mucosal ulcerations, cobblestoning, creeping fat, noncaseating granulomas - intestinal complications - fistulas, strictures (bowel obstructions), abscesses - treat with - 5-ASA, corticosteroids, biologics - things on differentials - TB enteritis **UC** - males, A. Jews, bimodal distribution - mucosal and submucosal inflammation, erythema and friable mucosa - pseudopolyps - crypt abscesses - other manifestations - arthritis, uveitis, episcleritis, erythema nodosum - complications - toxic megacolon, **primary sclerosing cholangitis**, erythema nodosum, pyoderma gangrenosum (looks like necrotic skin infection), spondyloarthritis - start screening for CRC 8-10 after disease dx toxic megacolon - inflammation limited to colonic mucosa in UC - however subset of pts have inflammation that extends to smooth muscle layers --\> muscle paralysis --\> colonic dilation - usu occurs early in the disease - will see systemic toxicity - dx - abd xray and 3/following: temp \>39, pulse \>120, WBC \> 10.5, anemia - abd xray - will see dilated colon (**haustra markings that dont cross the entire lumen**), right colon \> 6cm - note - small bowel will look like stacked coins - medical EMERGENCY --\> colonic perf - tx - IVFs, BS abx, bowel rest, corticosteroids, surgery if unresponsive to medical management - DONT give opioids - because they have antimotility effects and can promote colonic perforation **PSC** - frequently asx or present with chronic fatigue and pruritis - inflammation of intra and extrahepatic bile ducts - onion skin connective tissue pattern and lymphocytic infiltration on liver bx (but this is not necessary for dx) - pos pANCA - ERCP/MRCP will confirm diagnosis - complications - biliary stricture, cholangitis and cholelithiasis, cholangiocarcinoma, cholestasis (ADEK deficiency, osteoporosis), colon cancer

Answer 27

elevated LFTs, hepatomegaly, increased liver echogenicity, pos HCV virus antibodies, and elevated HCV RNA chronic HCV is frequently asx HCV management strategies are to prevent further liver damage - alcohol avoidance, give HAV and HBV vaccines (-instead of starting an anti-viral agent) also evaluate these pts to determine presence of cirrhosis, etc. - if pts have cirrhosis (shrunken liver, TCP, coagulopathy, ascites) - start diuretic

Answer 28

anorexia, \*liver pain\*, jaundice, leukocytosis (predominantly neutrophils), decreased albumin if malnourished... LFTs elevated, AST:ALT 2, \<300 IU/L - GGT elevated - ferritin - acute phase reactant, elevated - leukocytosis abd imaging may show fatty liver for these pts - have them discontinue alcohol (and drug use) and repeat LFTs in 6 mo - if transaminitis persists - then pt has chronic alcoholic liver disease - test for hemochromatosis, viral hep, and fatty liver for treatment of acute AH - quit drinking, supportive therapy - prednisolone used to treat severe cases - fever, abd pain, jaundice, N&V

Answer 29

**angiodysplasia** - painless GI bleeding (maroon stools), venous and low volume - pts with anemia/gross or occult bleeding can be treated with cautery during endoscopy - increased incidence after age 60, most common in the R colon - more frequent in pts with advanced renal dz and vW disease (maybe because of tendency to bleed in these diseases) - may also be more common in pts with AS - possibly due to acquired vW deficiency (turbulent valve space) - angiodysplasia can be missed on colonoscopy - due to poor bowel prep **colon cancer** - microcytic anemia **diverticulOSIS** - arterial bleeding --\> BRBPR, painless - most common cause of lower GI bleeding in adults - deformation in the colonic wall can cause weakness in associated arterial supply --\> bleed - diverticulosis is more common in sigmoid, bleeding more common in R colon - confirmed with colonoscopy - *most cases will resolve spontaneously* - strongly associated with chronic constipation --\> acute diverticular complications are lower in inds with high fiber intake - seeds and nut = myth **ischemic colitis** - abd pain --\> rectal bleeding/bloody diarrhea in 24hrs **hemorrhoids** - rarely cause massive bleeding **active bleeding per rectum** - first exclude upper GI bleed 1) bleeding hemorrhoids - anoscopy 2) \>2 mL/hr - angiogram (may allow for angiographic embolization) 3) \<0.5 mL/min - wait for bleeding to stop --\> colonoscopy 4) 0.5-2 - tagged red cell study for past blood per rectum - young - get EGD - old - EGD and colonscopy

Answer 30

definitive dx? cirrhosis by liver bx jaundice, hyperestrinism (spider angiomata, gynecomastia, loss of sexual hair, testicular atrophy, palmar erythema), ecchymosis and edema (hepatic synthetic dysfunction), portal HTN (esophageal varices, splenomegalcy, ascites, caput medusa, anorectal varices) - cirrhosis can cause direct gonadal injury, HPA dysfunction, and increased estradiol - liver also synthesizes thyroid-binding proteins - total T3 and T4 will be reduced (but free levels are unchanged) - can have parotid gland enlargement - due to fatty infiltration compensated cirrhosis - asx or non-specific sxs - uncompensated - jaundice, prurits, upper GU bleeding, ascites, hepatic encephalopathy if you dx someone with alcoholic liver disease - check for potential complications - varices (EGD), HCC (screening US every 6 mo) complications - variceal hemorrhage - non-selective b-blockers and annual EGD - ascites - dietary Na restriction, diuretics, paracentesis, quit drinking - hepatic encephalopathy - id cause, lactulose - chronic PVT presents as variceal bleeding - acute PVT - sudden-onset abdominal pain pts with small varices + risk factors for bleeding, or medium-large varices - primary ppx - non-selective b-blocker = propranolol or nadalol (reduces portal blood flow and portal pressure) (or endoscopic variceal ligation in patients with contraindications) TIPS in pts with refractory ascites or varices

Answer 31

dehydrated post-op patients and elderly are most prone S. aureus adequate fluid hydration and oral hygiene pre- and post-op will prevent this complication

Answer 32

peri-op b-blockers in pts with CAD decreases likelihood of myocardial ischemia peri-op MI is due to hypotension - will usu not present with chest pain

Answer 33

give routine for pts undergoing abdominal surgery

Answer 34

**thoracic aneurysm** - definitive dx by \*MR angio\*/CT angio - ascending - repair with surgery - descending - repair with HTN control (ICU) **abd aneurysm** is \>3cm - involves all aortal layers and does not create and intimal flap or false lumen (unlike thoracic aortic aneurysms) **AAA rupture** - blood can collect into adventitial layer, rupture can occur into peritoneum or retroperitonuem - sxs - abd pain/back pain and hypotension (syncope) - CT only in stable pts, OR for unstable pts - AAA can rupture into retroperitoneum and create and aortocaval fistual --\> venous congestion in bladder --\> gross hematuria complications following repair - for thoracic aortic aneurysm - anterior spinal cord syndrome - because anterior spinal artery is dependent on thoracic aorta blood, px will be \*bilateral\* flaccid paralysis and impaired pain/temp sensation - late complication from AAA repair is aortoenteric fistula - duodenum..

Answer 35

due to twisting force with the foot fixed or degeneration of meniscal cartilage (older) - pts will generally report a popping sound, followed by acute pain - meniscus tear = crepitus, locking, cathcing - associated sxs - reduced extension, sensation of instability - late knee effusion (which will become apparent after a few hours) medial meniscus injury is more common than lateral injury dx - xray will be normal in young pts (sometimes exam will be normal, but use clinical suspicion) --\> confirm with MRI or arthroscopy tx - mild sxs, older pts - rest, NSAIDs, and activity modification - persistent sxs (3-4wks), impaired activity - surgery, to reduce risk of further joint injury

Answer 36

ACL - forceful hyperextension of knee - will have effusion and hemarthrosis patellofemoral pain syndrome = chronic anterior knee pain - pts present with pain worsened by activity or prolonged sitting (in flexion) - may have crepitus with motion of patella, pain is reproduced during knee extension (patellofemoral compression test) - tx - exercises to stretch and strengthen the thigh muscles patellar tendonitis = jumpers knee - anterior knee pain and tenderness tibial plateau fracture - pt will be unable to bear weight on that knee patellar fracture - inability to extend knee pes anerinus syndrome - pain and tenderness at anterior medial knee (distal to joint line) - strongly associated with diabetes

Answer 37

**immediate** - prior trauma/infection - blood products - mal hyperthermia (...metabolic acidosis, hypercalcemia, muscle rigidity) - bacteremia - 30-45min classically **5Ws** - atelectasis, pneumonia, UTI, DVT, wound infection, deep abscess **POD1d-1wk** - nosocomial infections - S epi will be from central line, enteric orgs will be associated with foley - VAP - after 48hrs of being on ventilator - surgical site infection due to group A strep or clostridium - non-infectious - MI, PE, DVT (doppler) **POD1wk-1mo** - surgical site infection due to other orgs - C diff - drug fever - DOE, occurs 1-2 wks after mediation administration, often accompanied by rash and peripheral eosinophilia (drugs implicated are anticonvulsants, abx, allopurinol) - PE/DVT **POD1mo and more** - viral infections (from blood products) - infective endocarditis - surgical site infection due to indolent orgs - note on necrotizing SSI - DM, polymicrobial - pain, edema, or erythema spreading beyond the surgical site - systemic signs (SIRS) - paresthesia or anesthesia at edges of the wound - dishwater drainage - subQ crepitus --\> EARLY surgical exploration (to prevent nec fasc) **reactions to blood products** - febrile nonhemolytic transfusion reaction - small amounts pf cytokines in PRBC bag (due to plasma or leukocyte debris) --\> transient fevers, chills, malaise within 1-6hrs after transfusion - acute hemolytic reaction - TRALI

Answer 38

common features - POOP, pain on passive stretch, rapidly increasing and tense swelling, parasthesia - uncommon - decreased sensation, motor weakness, paralysis (late), decreased distal pulses - when will you see this? - ischemia-reperfusion syndrome - also with lower extremity embolectomy - circumferential eschar - constricts venous and lymphatic drainage... - dx by compartment pressure \> 30 mm HG - if compartment pressures are improving - pts may be observed - pts with elevated pressures and no signs of improvement --\> fasciotomy **v.s an embolism** - absent pulses, pallor of affected limb, lack of local swelling **v.s. DVT** - vague aching pain (rather than this exquisite pain)

Answer 39

more common on L some pts (esp kids) will have no sxs initially - will px mo-yrs later with vague chest pain (due to expansion of diaphragmatic defect and herniation of abdominal organs) CXR - abdominal contents in thorax, shifting of mediastinum - may see NG tube in thorax - but CT is more sensitive so get CT if CXR is unrevealing

Answer 40

each hemithorax is capable of holding up to 50% of circulating blood volume - massive hemothorax is \>1.5L or 600 mL/6hrs - most common cause of massive hemothorax are traumatic lac to lung parenchyma, damage to **intercostal** or internal mammary artery

Answer 41

lobar or segmental collapse --\> decreased lung volume - decreased FRC? - will hear decreased breath sounds in that section post-op atelectasis - accumulation of pharyngeal secretions, tongue prolapsing into pharynx, airway tissue edema, residual anesthetic effects, splinting - low pO2 (small-airway mucus plugging) and low pCO2 (fast shallow breathing) - loss of lung volume - side note - in this regard, intercostal nerve blocks have shown success in reducing post-op pulm complications ABG - pt will be hypoxemia due to lung collapse and V/Q mismatch - low PaO2 - pt will hyperventilate due to hypoxemia - low PaCO2

Answer 42

atelectasis, bronchospasm or exacerbation of chronic lung disease, prolonged mechanical ventilation risk factors - age \>50, emergency surgery or surgery longer than 3hrs, HF, COPD, poor general health (ASA \>2) pre-op strategies - smoking cessation 8wks pre-op - note on smoking - issue with ventilation = **high PCO2**, low FEV1 - no issue with oxygenation - sx control of COPD (pre-op glucocorticoids) - tx of respiratory infections prior to surgery - pt education of pulm toilet post-op strategies - pulm toilet, epidural instead of opioids, PEEP

Answer 43

1) place 2 large bore IVs - volume resus, IV octreotide (leads to splanchnic vasoconstriction and decreased portal flow), abx (ppx abx for pts with cirrhosis, to prevent SBP) urgent endoscopic therapy with band ligation or sclerotherapy - if no further bleeding - start b-blocker and endoscopic band ligation 1-2 wks later - if continued bleeding - balloon tamponade (eponymed tubes) temporarily --\> TIPS/shunt - if early rebleeding - repeat endoscopic therapy --\> recurrent hemorrhage --\> TIPS/shunt in approx 50% of variceal bleeding - **hemorrhage ceases on its own** - in other UGIB - this rate is 90% side note - current guidelines suggest keeping **hgb \>9** in variceal hemorrhage

Answer 44

**oliguria \<500 mL/24hrs** decreased renal perfusion - true volume depletion - decreased EABV - heart failure, cirrhosis - displacement of intravascular fluid - sepsis, pancreatitis - renal artery stenosis - afferent arteriole vasoconstriction - NSAIDs features - increase in serum Cr (50% from baseline), decreased UOP - BUN/Cr \>20:1 - BUN increases because it is passively reabsorbed during the active reabsorption of Na and water - FeNa \<1% treat by restoring renal perfusion - give bolus of saline

Answer 45

b-lactam abx - cause acute interstitial nephritis - will see WBC on UA and a skin rash if blood flow drops too much --\> acute tubular necrosis

Answer 46

soft scrotal mass (bag of worms) - more common on L side - left spermatic vein drains into left renal vein (passes in between the SMA and aorta) - can be compressed beneath SMA - v.s. the R spermatic vein - drains directly into IVC - R-sided varicoceles are rare and can be a sign of malignant compression or thrombosis - can cause elevated scrotal temps --\> subfertility, testicular atrophy - US - retrograde venous flow, tortuous, anechoic tubules adjacent to testis - dilation of pampiniform plexus veins - tx - gonadal vein ligation - boys and young men with testicular atrophy - scrotal support and NSAIDs - for men who dont desire children other testicular masses - spermatocele - painless mass at superior pole of testis - testicular cancer- painless mass, almost always malignant - tx by radical orchiectomy, metastatic dz responsive to radiation or platinum-based chemo - hydrocele

Answer 47

at home - IRRIGATION airway - supraglottic airway is very susceptible to direct thermal injury --\> edema and blistering - subglottic airway is protected from injury by reflexive closure of vocal cords upon exposure to extremely hot air - **all burn pts should be given high-flow O2** - maintain a low threshold for intubation increased metabolic rate - due to release of inflammatory mediators - increased basal temp, tachycardia and tachypnea, hyperglycemia steroids are contraindicated in burn pts - steroids are diabetogenic and immunosuppresive and burn pts are already prone to metabolic derrangements and immunosuppression infections - immediately after a severe burn - gram pos organisms dominate - after 5d - gram negative or fungi dominate (pseudomonas, candida) - burn wound sepsis - partial-thickness injury turns into full-thickness injury, temp changes, tachycardia, tachypnea, refractory hypotension, oliguria, unexplained hyperglycemia, TCP, and AMS - quantitative wound culture and bx for histopathology - treat with BS iv abx (pip/tazo, carbapenem), MRSA (vanc), MDR pseudomonal coverage (AG) - local wound care and debridement other things - tetanus - silver sulfadiazine = standard - if thick eschar, cartilage - mafenide acetate - triple abx near eye

Answer 48

mittelschmerz - unilateral, mid-cycle pain prior to ovulation - pain lasts hrs-d ectopic - what was date of last menses? ovarian torsion - sudden-onset, severe, unilateral lower abd pain, N&V - unilateral tender adnexal mass on examination ruptured ovarian cyst - sudden-onset, severe, unilateral lower abd pain immediately following strenous/sexual activity - pelvic free fluid or hemoperitoneum - signs of hemoperitoneum - severe, diffuse abdominal pain, pleuritic chest pain, shoulder pain, peritoneal signs - for unstable pt with hemoperitoneum - ovarian cyst surgery PID - fever, chills, vaginal discharge, lower abdominal pain and CMT +/- tubo-ovarian abscess

Answer 49

umbilical hernia - spont resolution by age 5 - due to incomplete closure of abd muscles round umbilical ring - most commonly associated with AA, premies, Ehlers-Danlos, Beckwith-Wiedemann, hypothyroidism - note - spontaneous closure is less likely for hernias \> 1.5cm umbilical granuloma - appears after the umbilical cord has separated - tx - silver nitrate gastrochisis - defect to the R of the cord insertion - immediate surgery after birth - will require TPN for sometime because bowel will be angry, matted omphalocele - umbilical cord inserts at apex of defect - immediate surgery after brith

Answer 50

pathophys - non-occlusive, occurs in watershed areas - splenic flexure (SMA and IMA) and rectosigmoid (between sigmoid and superior rectal) - underlying atherosclerotic disease/thrombus (...recent MI, infective endocarditis emboli) = small bowel ischemia - low blood flow - post-AAA repair - adverse effect can be minimize by checking sigmoid colon perfusion following placement of aortic graft px - mod abd pain and tenderness, urge to defecate, hematochezia, diarrhea, leukocytosis, lactic acidosis (low bicarb) - elevated amylase and phosphate dx - CT will show colonic wall thickening and fat stranding - mesenteric angio if dx unclear - EGD will was edematous and friable mucosa management - IVFs and bowel rest, abx, anticoag to limit clot expansion (if pt is not actively bleeding) - immediate operative eval if evidence of bowel infarct - embolectomy w/ bypass or endovascular thrombolysis - colonic resection if necrosis develops **v.s. chronic mesenteric ischemia** - epigastric pain shortly after eating (blood is shunted away from intestines to feed the stomach) - atherosclerosis - smoking, dyslipidemia - food aversion, abdominal bruit in 50% of pts - get CT angio - tx - risk reduction, nutritional support, and endovascular or open surgical revascularization

Answer 51

claudication - no need to work-up if it does not disrupt pt's lifestyle for severe, disabling claudication: SBP of ankle artery (DP or PT)/SBP of brachial artery ABI should be used for initial diagnosis of PAD - high sensitivity and specificity \<0.90 - abnormal --\> CT angio or MRI angio 0.91-1.30 - normal (or small vessel disease that is not amenable to surgery) \>1.30 - suggestive of calcified and uncompressible vessels - consider additional studies intermittent claudication --\> rest pain - rest pain = pain at night, pain relieved by gravity (dangling legs off bed), **shiny atrophic skin without hair**, no peripheral pulses

Answer 52

one of the most common intra-abdominal complications of BAT signs - hypotension, pleuritic CP, left abd wall bruising or tenderness, abd guarding pts who are hemodynamically stable - FAST --\> if negative FAST --\> CT for pts with high risk features - pts with AMS - proceed directly to CT if operative intervention is required - every effort is made to SAVE the spleen note - if someone has mono (fever, sore throat, spleen will be enlarged), there is a greater risk of splenic injury encapsulated bacteria - S. pneumoniae, Hib, N. meningitidis, E. Coli, Salmonella, Klebsiella, Group B streptococci

Answer 53

psoas abscess - fever, abd/flank pain that radiates to the groin - abdominal pain with hip extension (psoas sign) - risk factors - HIV, IVDA, DM, crohns disease - can be direct (even from diverticulitis) or hematologic seeding - get CT abd/pelvis and BC and abscess cultures - tx - drainage, broad spectrum abx - note psoas abscess is on the differential for **fever of unknown origin**

Answer 54

often causes bloody stools - usu presents for the first time within the first of treatment

Answer 55

because of diaphragm movement during inspiration and expiration - any penetrating injury **below the nipple line** has the potential to involve the abdomen - infact it is thought to involve the thorax and abdomen until proven otherwise - for a hemodynamically unstable pt --\> ex lap (even if there is no peritoneal fluid on fast exam) - for a stable pt and fast negative - get CT

Answer 56

place urinary cath - to assess for urinary RT and prevent possible bladder injury (from acute distention)

Answer 57

place limb/digit in sterile, saline moistened gauze and in a plastic bag --\> place the bag on ice

Answer 58

most common in individual 15-40 - arise due to repetitive stress and inflammation

Answer 59

Rovsing sign - RLQ pain with deep palpation of LLQ for pts with classical presentation --\> lap appy - for pts where dx is unclear - CT or US to confirm dx - pts with appendicitis who have had sxs for \>5d usu have phlegmon with abscess (phlegmon = localized area of acute inflammation of the soft tissues) - IV abx, bowel rest, and delayed appendectomy (6-8wks later, because presently the appendix will be inflamed, infection, friable) - these pts will present without peritoneal signs, instead they may have pos psoas sign mesenteric adenitis - RLQ pain, guarding, tenderness - can be mistaken for appendicitis - get CT

Answer 60

scenario - fall pre-hospital - spinal immobilization, careful helmet removal, airway oxygenation ED - orotracheal intubaion - RSI if pt is unconscious pts who are breathing but need ventilatory support - cervical stabilization unless it interferes with intubation - CT Cspine - monitor for neurogenic shock when would you get CT c-spine - basilar skull fracture, blunt neck trauma, facial fracture, CHI

Answer 61

nasotracheal intubation - blind procedure - contraindicated in apneic/hypopneic pts - also contraindicated in basillar skull fracture as these fractures may have cribiform plate disruption (tube could enter brain) subQ emphysema - fiberoptic bronchoscope cric is FAST - needle cric - not ideal in pts with head injury (these pts may require hyperventilation to treat intracranial HTN) - cric has risk of CO2 retention - surgical crich - prolonged use of cric has a high incidence of tracheal stenosis surgical tracheostomy, formal tracheostomy

Answer 62

more common in males, most common inherited disorder of bilirubin glucuronidation AR or AD - decreased UDP-glucuronosyltransferase activity --\> increased UCB px - intermittent mild jaundice provoked by stress only lab abnormality will be unconjugated hyperbilirubinemia - Hgb will be normal - NO evidence of hemolysis tx - reassurance and supportive care

Answer 63

critically ill hospitalized pts - severe trauma or recent surgery, prolonged fasting/TPN, critical illness (mechanical vent) - likely due to cholestasis and gallbladder ischemia --\> secondary infection **unexplained fever, leukocytosis**, elevated LFTs and bili (but normal results dont exclude the dx), RUQ pain - jaundice and RUQ pain are less common dx - US - will see thickened gallbladder wall with distention, pericholecystic fluid - get HIDA or CT if needed tx - perc cholecystostomy and chole after pt's medical condition improves - enteric abx coverage complications - sepsis, death, gangrene, perf, emphysematous cholecystitis (cholecystitis with clostridium)

Answer 64

LFTs x25 ULN anorexia, N&V B = sex **in order of appearance** 1) HBsAg 2) IgM anti-HBc - same time as when clinical sxs develop and transaminitis occurs 3) window period = IgM anti-HBc, HBV DNA (lag time between disappearance of HBsAg and appearance of anti-HBs) 4) after window period, recovery phase - anti-HBs, IgG anti-HBc, anti-HBe (only time when you'll see this), HBV DNA - so for acute hepB infection - check for HBsAg and IgM anti-HBc - note - HBeAg is a good level of infectivity - get hep B virus DNA in patients with chronic hep B - to determine candidacy for anti-virals pos HbsAg - sign of immunization chronic carrier - pos HBsAG and IgG anti-HBc (for \>6 mo) resolved HBV infection - anti-HBs, anti-HBc

Answer 65

get UA for hemodynamically stable pts --\> contrast CT to id and stage renal trauma unstable pts --\> IV pyelogram --\> surgery - note - most renal injuries can be managed non-operatively

Answer 66

leukocytes count will be \>1000 (but not as high as in a septic joint \>50K) \<3mo onset - acute pain, wound infection or breakdown - S aureus, gram negative rods (pseudomonas), anaerobes 3-12 mo - chronic joint pain, implant loosening, sinus tract formation - S. epi, propionibacterium, enterococci \>12 mo - acute sx in previously asx joint, recent infection at distant site (UTI) - S. aureus, gram negative rods, b-hemolytic strep

Answer 67

O2 delivery doesnt become deficient until Hgb \< 7g/dL DDAVP increases factor 8 levels (indirectly) - give pre-op to patients with hemophilia A plts \>**50K** will provide adequate hemostasis for most procedures

Answer 68

tetany, seizures, LONG QT - Chvostek sign, Trousseau sign (carpopedal spasm upon inflation of blood pressure cuff) **primary** - post-surgical - most common cause, takes a modest decrease to cause sxs - automimmune primary hypoparathyroidism - congenital absence of parathyroid glands (DiGeorge syndrome) - defective Ca-sensing receptor on parathyroid glands - non-autoimmune destruction of parathyroid gland due to infiltrative diseases (hemochromatosis, Wilson disease, neck irradiation) **secondary:** insufficient Ca intake --\> secondary hyperparathyroidism --\> increased PTH and hyperplasia of parathyroids --\> increased Ca and increased renal phosphate loss (hypophosphatemia) **tertiary:** due to chronic renal disease (very increased PTH --\> increased Ca) other reasons - CYP450 inducers (phenytoin, carbamazepine, rifampin) cause vitamin D deficiency by degrading vitamin D into inactive metabolites - kidneys convert 25-OH-D to 1,25-OH-D - note - serum phosphorous is low in vitamin D deficiency - precipitation of Ca with phosphate - renal failure, rhabdo, phosphate administration **PTH actions** - bone - long-term indirect action on osteoclasts --\> increased Ca and phosphate - kidney - increased Ca reabsorption and phosphate excretion vitamin D - increased Ca and phosphate absorption from gut and kidney

Answer 69

can be seen post-thyroidectomy - can also see hyponatremia

Answer 70

local vascular complications at the cath site are the most common complications - bleeding - hematoma - localized or with retroperitoneal extension (back pain) - arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula cholesterol emboli - s/p cardiac cath - pts who have risk factors for aortic atherosclerosis - signs and sxs - livedo reticularis, blue toe syndrome, AKI, pancreatitis, mesenteric ischemia

Answer 71

benign bony growth - thought to be due to genetic and environmental factors - more common in younger pts, women, and Asian surgery indicated for sx pts

Answer 72

4Ts: thymomas, teratoma, thyroid neoplasm, terrible lymphoma teratoma - Ca deposition (tooth), fat - note - for seminoma, only bhCG will be elevated

Answer 73

va**L**gus = applying **lateral stress** MRI is the most sensitive test but reserved for pts being considered for surgical intervention - uncomplicated MCL tears can be managed non-operatively (RICE)

Answer 74

UPPER gi bleed - PUD, gastritis, esophagitis, Mallory-Weiss tear give anti-secretory medication (PPI)

Answer 75

retropharyngeal compartment - infection in this compartment drains to superior mediastinum - spread to the carotid sheath --\> thrombosis of IJ and deficits of CN 9-12 - extension through danger space (two fascias) --\> posterior mediastinum and diaphgram - acute necrotizing mediastinitis - fever, chest pain, dyspnea, odynophagia, requires urgent surgical intervention paranasal sinus infection --\> bone --\> subdural empyema infected molar --\> Ludwig angina - bilateral cellulitis of submandibular and sublingual spaces - AIRWAY - infection in central face area --\> cavernous sinus thrombosis - occurs due to valveless facial venous system nasal furunculosis is potentially life threatening as it can spread to cavernous sinus - px = diplopia, facial pain, fever - **EMERGENCY** - dx with MRI, tx with early IV abx, and drain affected paranasal sinuses

Answer 76

complication of cardiac surgery - due to intra-op wound contamination px - within 14d post-op, fever, tachy, chest pain, leukocytosis, sternal wound drainage (or purulence) - widened mediastinum tx - surgical debridement with immediate closure and prolonged abx therapy other things post-cardiac surgery - afib is common - self-limited, rate control with b-blockers or amiodarone is best - anticoagulation and/or cardioversion reserved for patients with atrial fib \>24hrs post - pericardiotomy syndrome - fever, leukocytosis, tachy, and chest pain - autoimmune, occurs few wks following procedure where incision was made into pericardium - NSAIDs to treat (any) pericardial inflammation)

Answer 77

majority of duodenal ulcers are cause by H pylori infection and NSAIDs - if H pylori is likely - start eradication triple therapy (PPI, amox, clarithro) dx - EGD tx - NG suction, IVFs, broad spectrum abx, \*\*IV PPI\*\* - for stable pts with Hgb \< 7 - give PRBC - transfuse at Hgb \<9 for pts with ACS - for pts with active bleeding and hypovolemia - transfuse at higher Hgb levels

Answer 78

acute - only takes 100-200mL to compromise hemodynamics, cardiac silhouette may appear normal chronic processes (malignancy, renal failure) cause slow accumulation of pericardial fluid - 1-L before intrapericardial reaches a critical point - globular cardiac silhoutte

Answer 79

**rotator cuff impingement or tendinopathy** - *pain* with abduction, external rotation - normal ROM, positive impingement tests **rotator cuff tear** - \*weakness\* with external rotation, age \>40 - weakness with above motions, drop arm test (drop below horizontal) - passive ROM is preserved - FOOSH - drop arm test - supraspinatus is commonly injured due to degeneration of tendon with age and impingement between humerus and acromion (during ABduction) **adhesive capsulitis** - stiffness \> pain - can be due to rotator cuff tendinopathy, subacromial bursitis, paralytic stroke, DM, humeral head fracture - reduction in passive and active ROM **biceps tendinopathy/rupture** - *anterior* should pain, weakness is less common **glenohumeral osteoarthritis** - *trauma*, gradual onset of shoulder pain - decreased active and passive ROM

Answer 80

sxs - abd pain, diarrhea, nausea - hypotension, tachycardia - dizziness/confusion, fatigue, diaphoresis - 12-30 min after meals common postgastrectomy - 50% of pts - due to loss of normal action of the pyloric sphincter due to injury or surgical bypass - \*rapid emptying\* of hypertonic gastric contents - causes fluid shifts from intravascular space to SI = hypotension, stimulation of autonomic reflexes, release of intestinal vasoactive polypeptides initial management - small frequent meals - replace simple sugars with complex carbs - incorporate high fiber and protein-rich foods - drink fluids in between meals (not during meals)

Answer 81

acute diverticulitis - inflammation due to microperforation of diverticulum LLQ abd pain, fever, N&V, ileus (peritoneal irritation) - can have urinary signs from an inflamed sigmoid colon - dx - abd CT (oral and IV contrast) uncomplicated (75%) - can be managed outpatient with bowel rest, oral abx, observation - hospitalization recommended if pt is elderly, immunosuppressed, severe comorbidities, or high fever/WBCs complicated (25%) - abscess, perf, obstruction, or fistula formation - fluid collection \<3cm - tx with IV abx and obs - fluid collection \>3cm - CT-guided perc drainage --\> surgical drainage and debridement recommended if sxs dont improve by 5d on your differential - epiploic appendigitis

Answer 82

intracapsular - femoral neck and head - higher risk of avascular necrosis extracapsular - intertrochanteric, subtrochanteric - greater need for implant devices - requires immobilization - high risk of DVT and PE, recommend post-op anticoagulation in general - operate asap - may delay surgery up to \*72hrs\* if need to address an unstable medical comorbidity (do skeletal traction in the meantime) - need medical stability prior to operating

Answer 83

nutritional deficiencies scurvy - signs arise w/i 3 mo of deficiency - follicular hemorrhage, bleeding gums, arthralgias, weakness, impaired wound healing - vasomotor instability if severe/prolonged - dx by serum ascorbic acid level - tx - oral/injectable vitamin C (sxs resolve w/i days), watch for tox (abd pain, diarrhea, nausea)

Answer 84

1) give crystalloid (it is cheaper than albumin) - 500-1000mL boluses to achieve SBP \>90 2) vasopressors - dopamine 3) IV hydrocortisone other randoms - hemodialysis if: uremia, fluid overload, major electrolyte abnormalities - bicarb if severe acute acidosis (pH \<7.2)

Answer 85

initial hematuria (urethra issue) - urethritis, trauma (cath) total hematuria (kidney) - renal mass, glomerulonephritis, urolithiasis, PKD, pyelo, urothelial cancer, trauma - renal cell carcinoma - tx is surgery terminal hematuria (bladder issue) - urothelial cancer, cystitis, urolithiasis, BPH, prostate cancer - clots suggest bleeding in bladder or ureters (get cystoscopy) - cancer of bladder - SMOKING most cases of hematuria are benign - 1) CT scan, 2) cystoscopy

Answer 86

complications are common - 1/4 may need revision - dissatisfaction, nasal obstruction, epistaxis - septal hematoma (or abscess) --\> septal perf - whistling noise

Answer 87

guarding, rigidity, reduced bowel sounds, rebound tenderness = perforated viscus complications - subphrenic abscess (rare)

Answer 88

impairs to laryngeal defenses --\> aspiration of gastric contents, hypoventilation sux (rapid on/off)- depolarizing NM blocker, binds to postsynaptic AchR --\> influx of Na and efflux of K --\> temp paralysis - contraindicated in crush injury - pt can be at risk for life-threatening cardiac arrhythmia due to severe hyperkalemia (use roc instead) - side note - post-syn AchR upregulated in skeletal muscle injury (burn, disuse muscle atrophy, and denervation also have this) etomidate - inhibits 11b-hydroxylase --\> adrenal insuffiency - elderly and critically ill are most susceptible NO - inactivates B12, problems for pts with pre-existing B12 def propofol - severe hypotension (due to myocardial depression)

Answer 89

following major thoracic trauma acute circulatory failure (hypotension, SOB) and neuro signs (stroke type signs) immediate management - cardiac massage

Answer 90

indications for urgent ex lap - hemodynamic instability - peritonitis - evisceration - blood from NG tube or on DRE no indications for urgent ex lap --\> locally explore wound and get eFAST (to asses for pneumo- and hemothorax) penetrating neck trauma - surgical exploration IF expanding hematoma, deteriorating vital signs, or signs of esophageal/tracheal injury - upper zone - arteriography - base of neck - arteriography, esophagram, esophagoscopy, bronchoscopy penetrating urologic injury is surgically explored

Answer 91

hard signs --\> surgical exploration - observed pulsatile bleeding - bruit/thrill over the injury - expanding hematoma - signs of distal ischemia (absent pulses, cool extremity) soft signs - hx of hemorrhage, diminished pulses, bony injury, neuro abnormality --\> injured extremity index (\<0.9 is ABnormal) --\> CT/CT angio, doppler

Answer 92

hypovolemic shock drop in blood pressure occurs when 25-30% of blood volume has been lost if you mechanically ventilate someone in hypovolemic shock --\> increase intrathoracic pressure --\> collapse of venous system, loss of RV preload

Answer 93

primary v secondary (underlying lung disease) - small (\<2cm) - observe and supplemental O2 (enhances the speed of reabsorption!, though this is disputed and dependent on surgeons) - large and stable - needle aspiration (stable) or chest tube (unstable) if lung fails to re-expand (\<90% expansion) and persistent air leak is present - place one-way valve, blood patch, or VATs - recurrence - VATS pleurodesis or chemical pleurodesis

Answer 94

local trauma, IBD, malignancy - spasm of sphincter contributes to the pain and creates tension across the wound most common at posterior anal midline - chronic fissure may have skin tag at distal end (sentinel pile) tx 1) high fiber, adequate fluids, stool softeners, sitz baths, topical anesthetics and vasodilators (CCBs, to reduce pressure and increase blood flow to anal sphincter) 2) surgery - lateral sphincterotomy and fissure excision

Answer 95

vulnerable to acute injury or chronic repetitive pressure - may become inflamed... - because they are located in exposed positions - active ROM reduced, passive nl housemaids knee = pre-patellar bursitis - bursitis is generally non-infectious - however this one is commonly due to S aureus (trauma, local cellulitis) aspirate and systemic abx (if pos gram stain)

Answer 96

1) popliteal artery aneurysm 2) femoral artery aneurysm - pulsatile mass in groin, thigh pain (due to compression of fem nerve) - may be associated with AAA

Answer 97

Hb catabolized --\> bili --\> UCB + albumin --\> hepatic artery - liver: conjugation by hepatic UDG enzyme --\> conjugated bilirubin **conjugation happens in the liver** - deconjugation in intestine by b-glucuronidase --\> 1) enterohepatic recycling of UCB, 2) excretion in feces and urine (urobilinogen) - UCB is tightly bound to albumin - so it will NOT be renally excreted - when you have excess UCB (hemolysis) --\> more conjugation --\> more excrete as urobilinogen (pos urobilinogen assay) - hepatic dysfunction (portosystemic shunt), biliary duct obstruction, storage defects - bilirubin will build up in plasma conjugated --\> check LFTs (will likely be a hepatobiliary problem because bilirubin conjugates are shunted into plasma when excretion into bile is slowed) 1) AST ALT are elevated - viral/autoimmune/toxin/drug-induced/ischemic/alcoholic hepatitis, hemochromatosis - autoimmune - pos ANA and anti-smooth muscle titers, give glucocorticoids 2) elevated alk phos (=cholestasis) - cholestasis of pregnancy, malignancy (pancreas or ampullary), cholangiocarcinoma, PBcholangitis, psc, choledocholithiasis - get US to assess hepatic parenchyma and biliary ducts (biliary dilatation is extrahepatic cholestasis) 3) normal LFTs - Dubin-Johnson, Rotors - Dubin-Johnson - decreased bilirubin excretion in bile canaliculi - Rotors - rare, benign, hereditary defect in hepatic secretion of conjugated bilirubin into biliary system **unconjugated** - overproduction - hemolysis (haptoglobin will be decreased) - reduced uptake - drugs, portosystemic shunt - conjugation defect - Gilbert's pattern of LFTs - elevated alk phos, normal transaminases - inherited bilirubin disorders - elevated transaminases, normal alk phos - liver issue - elevated alk phos \>\> transaminases - intrahepatic cholestasis, biliary obstruction

Answer 98

small bowel follow-through - detects stricture, obstruction, masses in the small bowel barium enema - detects strictures or inflammation (IBD)

Answer 99

monosaccharide - absorbed withOUT degradation by pancreatic or brush border enzymes - absorbed in proximal small bowel pts with proximal SI disease (celiacs) cant absorb d-xylose false-positive D-xylose test (decreased urinary excretion, normal absorption) can be seen in pts with delayed gastric emptying or impaired GFR - or with SIBO - because of bacterial fermentation of ingested D-xylose before it can be absorbed (rifaximin to kill bacteria)

Answer 100

chronic, intermittent epigastric pain and postprandial discomfort causes - NSAIDs, gastric/esophageal cancer, functional dyspepsia, GERD, PUD with H pylori (demographics! India) definitive dx by EGD - but only perform in pts \>55 or with alarm sxs (weight loss, bleeding, anemia, dysphagia, persistent vomiting)

Answer 101

immune-mediated destruction of \*intrahepatic\* bile ducts often middle aged women px with chronic fatigue, pruritis, - jaundice, hepatomegaly, cirrhosis - xanthomas, xanthelasmas - pos anti-mitochondrial antibody, severe hypercholesterolemia tx - ursodeoxycholic acid delays progression, liver transplantation for advanced disease complications - malabsorption and fat soluble vitamin deficiencies - metabolic bone disease - osteoporosis, osteomalacia - HCC

Answer 102

causes - blood - trauma, malignancy, rarely TB - milky - chylous, pancreatic - turbid - infection - straw color - benign **new onset ascites** - dx cirrhosis - labs, imaging, abd US to evaluate for splenomegaly or HCC - paracentesis for all pts with new-onset ascites - liver bx only if dx is unclear **characterizing ascitic fluid** neutrophils: \>250 means peritonitis (secondary or SBP) protein - high \>2.5 - CHF, constrictive pericarditis, peritoneal carcinomatosis, TB, Budd-Chiari, fungal - low \<2.5 - cirrhosis, nephrotic syndrome serum ascites albumin gradient - \>1.1 indicates portal HTN - cardiac ascites, cirrhosis, Budd-Chiari - \<1.1 indicates absence of portal HTN - TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome SBP - low grade-high grade temp (pts with cirrhosis after often hypothermic), abd pain/tenderness, AMS (connect the numbers test) - hypotension, hypothermia, paralytic ileus (dilated loops of bowel) with severe infection - due to bacterial translocation or hematogenous spread to liver and ascitic fluid - ascitic fluid: PMN \>250 and pos culture (often gram negatives, E coli, Klebsiella) - tx - empiric abx (cefotaxime), FQs for SBP ppx note - ascites separates the visceral and parietal peritoneal surfaces --\> wont have peritoneal signs even with perf viscus small portion of cirrhotics/pts with portal HTN have hepatic hydrothorax = pleural effusion due to ascites passing through defects in diaphragm - usually on R side due to less muscular hemidiaphragm - tx - salt restriction and diuretic administration - can do therapeutic thoracentesis for sx pts - **DONT use chest tube -** because it can result in large-volume protein, fluid, and electrolyte losses (and renal fialure) - definitive option - liver transplant

Answer 103

can be precipitated by emotional stress chest pain that is relieved by nitrates (can also give CCBs) - relax myocytes in esophagus get esophageal *manometry* - will show repetitive (non-peristaltic, high-amplitude simultaneous contractions in middle and lower esophagus) - spont or after ergonovine stimulation - esophagram will show corkscrew pattern - issue is dysfunction of inhibitory neurons

Answer 104

straight forward GERD - start empiric trial of PPI for 2 mo - refractory sxs --\> switch to different PPI or bid dosing - persistent sxs --\> consider EGD or esophageal pH monitoring men age \>50 with sxs for \>5yrs or cancer risk factors (tobacco use) or alarm sxs - EGD - either esophagitis or no esophagitis (pursue further work-up by esophageal manometry) - **alarm sxs** = melena, persistent vomiting, hematemesis, weight loss, anemia, dysphagia/odynophagia tx - lap nissen, radiofrequency ablation if there are severe dysplastic changes

Answer 105

AR hepatic copper accumulation --\> leak from damaged hepatocytes --\> deposits in BG and cornea px - hepatic, neuro sxs (parkinsonism), psychiatric changes decreased ceruloplasmin, increased urinary cu excretion tx - chelators, zinc (interferes cu absorption) - for pts with fulminant liver failure or drug-resistant disease - liver transplant

Answer 106

causes - diverticular disease, crohns, malignancy dx - abd ct with oral or rectal contrast (NOT IV) - colonoscopy to exclude malignancy

Answer 107

adenomas = neoplastic - findings that suggest greater risk of malignant transformation - villous features and high-grade dysplasia, large size, high number (3+), sessile

Answer 108

3Ds: dermatitis (on sun exposed areas), diarrhea (+loss of appetite), dementia (+mood changes) - note - chronic scaly rash (not hypersensitivity reaction) niacin is synthesized from trytophan - seen in populations that subsist primarily on corn products - can also be seen in malnourished, carcinoid syndrome, or Hartnup disease (disorder of trytophan absorption)

Answer 109

abdominal pain, vomiting, diarrhea + neuro symptoms (agitation, paresthesia, confusion) - may be triggered by isoniazid - but symptoms are episodic (rather than chronic)

Answer 110

in older patients - assume GI loss until proven otherwise - single fecal occult blood test is **not** sufficient to exclude GI bleeding - get colonoscopy and EGD - even if one fecal occult test is negative

Answer 111

neuroendocrine tumor skin flushing (85%), cutaneous telangiectasias, GI upset (secretory diarrhea), valvular lesions (R \> L), bronchospasm - other - niacin deficiency (pellagra) dx - elevated 24hr urinary excretion of 5HIAA - CT/MRI abd/pelvis to localize the tumor - octreotide scan to detect mets - echo - if there are sxs of heart disease tx - octreotide for symptomatic pts and prior to surgery and anesthesia - surgery for liver mets - mets to liver means that products are released directly into circulation (before being neutralized by liver)

Answer 112

multi-system illness commonly seen in white men, 40-60s GI - abd pain, diarrhea, malabsorption - migratory polyarthropathy, chronic cough, myocardial/valvular involvement, dementia - PAS pos material in LP

Answer 113

fatty acids in duodenum --\> stimulate endocrine cells to release CCK --\> CCK causes smooth muscle contractions of the GB and relaxation of the sphincter of Oddi vagus nerve also plays a role (hepatobiliary branches of the vagus?)

Answer 114

alcohol use, CF, ductal obstruction (malignancy, stones), autoimmune sx - chronic epigastric pain (intermittent, pain-free interval), malabsorption, DM - pain is relieved by sitting upright or leaning forward CT scan - calcifications, dilated ducts, enlarged pancreas treatment - pain management, alcohol and smoking cessation, frequent and small meals - enzymes based on sxs and stool fat content (sxs - bloating, diarrhea) secretin test - measures ability of pancreatic ducts to produce bicarb - good for diagnosing chronic pancreatitis

Answer 115

MALT also extranodal marginal zone B cell lymphomas H pylori - chronic inflammation from H pylori --\> stimulation of B and T cells in gastric lamina test for H pylori - early-stage MALT - H pylori eradication therapy (quadruple therapy) - more advanced dz or H pylor negative tumors - radiation, immuno, or chemo

Answer 116

risk factors - cigarette smoking, high salt intake, consumption of N-nitroso compounds (processed foods) - NSAIDs are protective - H pylori is a risk factor - eradication is recommended for pts with resectable disease to reduce risk of developing second cancer - pernicious anemia increases risk for gastric adenocarcinoma (and gastric carcinoid tumors)

Answer 117

pill esophagitis - tets, ASA, NSAIDs, bisphosphonates, KCl, Fe - typical sxs are **sudden-onset** odynophagia and retrosternal pain - most common in mid-esophagus (due to compression by the aortic arch or enlarged LA) - EGD - discrete ulcers with relatively normal appearing surrounding mucosa (though dx can be made clinically)

Answer 118

elevated alk phos and elevated GGT - likely biliary in origin (otherwise likely of bone origin) - get RUQ US and AMA - if AMA pos or abnormal hepatic parenchyma - get liver bx --\> if dilated bile ducts - get ERCP - if both normal - liver bx, ERCP, observation pos AMA = primary biliary cholangitis

Answer 119

most commonly seen in Asian-Americans colonic bacteria ferment lactose --\> bloating dx - lactose hydrogen breath test - rise in breath hydrogen level after ingestion of lactose - indicates bacterial carbohydrate metabolism diarrhea will have high osmotic gap due to unmetabolized lactose and organic acids - OG = 290 - [2(stool Na + stool K)] - stool pH will be acidic - due to fermentation products

Answer 120

1-2 small adenomatous polyps on colonoscopy - q5yrs FHx of adenomatous polyps or CRC - at 40 or 10 yrs before dx of affected relative - q5yrs IBD - UC or Crohns with colonic involvement - 8-10 yrs post-dx - q1-2 yrs = frequent surveillance - prophylactic colectomy if dysplasia is identified classic FAP (APC gene mutation) - sigmoidoscopies at age 10-12 - annual colonoscopies once colorectal adenomas are detected - usu proctocolectomy by early 20s HNPCC (Lynch syndrome) - age 20-25 - q1-2yrs

Answer 121

due to malignancy - cholangiocarcinoma, pancreatic or HCC, mets px - jaundice, pruritis, weight loss, acholic stools with dark urine - exam - normal or RUQ mass, tenderness, or hepatomegaly - labs - elevated direct bili, elevated alk phos and GGT, normal-elevated AST and ALT evaluation - abd imaging (US, CT) - MRCP or ERCP if imaging is nondiagnostic

Answer 122

cirrhosis, heart failure, DM, hypogonadism, arthritis

Answer 123

steatorrhea, ADEK and Fe deficiency associated with dermatitis herpetiformis - autoimmune, on extremities IgA, anti-TTG, and IgA anti-endomysial antibodies - however many pts with celiac disease have selective IgA deficiency! villus atrophy on bx

Answer 124

persistent abd pain or dyspepsia (nausea) post-op can be due to - retained CBD or cystic duct stone - bile duct injury (?) - note that bile ducts stricture so these injuries can be devastating - biliary dyskinesia - pancreatitis - PUD - CAD elevated alk phos, mildly abnormal serum aminotransferase, dilated CBD - 1) US, 2) ERCP

Answer 125

diarrhea, international travel (rural areas, developing countries, mtns), foul-smelling stools, bloating - contaminated water, fecal-oral route abd exam benign get stool antigen assay - can also look for oocysts and trophozoites in stool tx - metronidazole - but note - short course of cipro is empiric treatment for travelers diarrhea

Answer 126

travel abroad dx - ova and parasite stool tests invade biliary tree

Answer 127

bacteria from the colon are inappropriately present in the SI - DM, jejunocolonic fistula greasy diarrhea

Answer 128

**Cardiac** Goldman's index 1) JVD 2) recent MI (last 6 mo) 3) PVCs, non-sinus rhythm 4) age over 70 5) emergency surgery 6) AS 7) poor medical condition 8) surgery in chest/abd - goldmans is outdated, preferred method is assessing functional status **hepatic risk** - encephalopathy, albumin ascites, bili, INR **nutritional risk** - more than 20% body weight loss over couple mo (serum albumin \<3, anergy, serum transferrin \<200) - 4-5 d enteric feeds will fix the issue DKA is absolute contraindication to surgery

Answer 129

consider hypoxia DTs occur POD 2-3 - confused, hallucinations, combative

Answer 130

extremely common - esp after surgery in the lower abdomen, pelvis, perineum, or groin pt will often have dribbling - signs of overflow incontinence straight cath at 6hrs post-op with no voiding - indwelling foley after 2x or 3x straight caths

Answer 131

salmon colored fluid (peritoneal fluid) immediate concern - evisceration late issue - ventral hernia

Answer 132

cecal - blood per rectum rectal cancer - diarrhea (obstructed above) - 1) chemo, 2) surgery junction of ascending and sigmoid - bloating - note - colon cancer 1) surgery, 2) chemo

Answer 133

12 minimum

Answer 134

arterial embolization to leg (afib) --\> doppler to localize - incomplete occlusion - clot busters - complete occlusion - Fogarty catheter to remove embolism

Answer 135

basal cell (50%) - waxy, raised, or ulcer (pearly telangiectatic papules with central ulceration) - kills by relentless local invasion (rodent ulcer) (does not met) - timetable is yrs - resection - 1mm margin squamous cell carcinoma (25%) - associated with UV light and chronically wounded, scarred, or inflamed skin - SCC arising with burn = Marjolin ulcer - mets to LNs - timetable is mo melanoma - most lethal, ABCD (\>0.5 cm) E - prognosis and management by depth, lesions beyond 4 mm have terrible prognosis - disseminated melanoma - cant be cured, IFN improves survival time note - ulcers should be bx at edge, other things can be completely excised

Answer 136

amblyopia - vision impairment due to interference with processing of images by brain during first 6-7yrs - ex - strabismus - note true strabismus is present at birth and requires corrective surgery, strabismus that arises after birth can be fixed with corrective glasses glaucoma - acute angle closure = emergency - painful eye, headache - mid-dilated, nonreactive pupil, halos around lights, eye is hard as a rock, cornea is greenish hue - often Asian female who has been watching tv for a long time (pupil dilated for a long time) - - tx - acetazolamide, etc. orbital cellulitis = emergency - cellulitis + pupil is dilated and fixed and limited ROM, means there is pus in orbit - CT scan and drainage retinal detachment - floaters in eye and flashes of light - other clues - snowstorm, dark cloud at top of visual field - tx with emergency laser spot welding to protect remaining retina embolic occlusion of retinal artery - sudden loss of vision (damage becomes irr in 30 min) - recommendation - breath into paper bag and have someone press hard on eye and release (repeatedly) - idea is to vasodilate and shake clot into more distal location

Answer 137

thryoglossal duct cyst - surgical excision involves removing cyst, track, and attaching part of hyoid bone branchial cleft cysts - anterior edge of SCM, can have opening and blind tract onto skin cystic hygroma - supraclavicular area + deep chest - get CT prior to excision

Answer 138

recently discovered - will most likely be benign - f/u in 3-4wks - if persistently enlarged - have to rule out neoplasia lymphoma - remove node, chemo tx squamous cell carcinoma of mucosa - old men who drink, smoke and have rotten teeth, AIDS - other pxs - persistent hoarseness, persistent painless ulcer in floor of mouth, persistent unilateral earache - first sign will be a metastatic node in neck --\> panendoscopy to look for primary - CT to look for extent - can do FNA, NEVER do open bx - scar will make future surgery difficult

Answer 139

sensory hearing loss in one ear only, get MRI

Answer 140

most are pleomorphic adenomas - benign but have malignant potential hard parotid mass, painful, facial nerve paralysis - cancer superficial parotidectomy to excise - spares facial nerve - in malignant tumors - take nerve

Answer 141

treat with antivirals (and sometimes steroids)

Answer 142

little children - epistaxis, give phenylephrine spray and local pressure juvenile nasopharyngeal angiofibroma - surgical resection is mandatory - because it will eat away at nearby structures cocaine use - packing elderly and nose bleeds - posterior packing, may require surgical ligation

Answer 143

inner ear - room spinning, give **meclizine**, promethazine, diazepam brain - unsteady

Answer 144

diabetic complication, rocker bottom deformity, swelling - inflammation is the issue pulses are fine will have peripheral sensory neuropathy

Answer 145

TIA - IC stenosis (\>70%) or ulcerated plaque at carotid bifurcation - 1) Doppler hemorrhagic stroke - control HTN brain bleeds - if midline shift --\> surgery - acute subdural - work on lowering ICP - SAH - 1) CT first, 2) arteriogram to look for aneurysm brain cancer - approx 50% from lung elevated ICP (with a brain tumor) - tx with high dose steroids until you can surgically remove pituitary apoplexy - steroid replacement is necessary brain abscess - resection is required reflex sympathetic dystrophy (formerly called CRPS?) - develops after a crushing injury - doesnt respond to usual analgesics - extremity is cold, cyanotic, and moist - requires surgical sympathectomy

Answer 146

acute epididymitis - will present with fever and pyuria - \*get doppler to rule out testicular torsion\* obstruction + infection - IV abx, immediate decompression (?) erection longer than 4 hrs - drain blood from penis posterior urethral valves - voiding cystourethrogram to dx, surgery/endoscopy to tx VUR - consider in child with UTI, get voiding cystourethrogram, long term abx until child grows out of problem low implantation of ureter - issue in girls, ureter will leak urine (constantly) into vagina UPJ - renal/bladder system can empty normal amounts of urine, pt will present with colicky pain after a night of binge drinking... prostate cancer - dx by transrectal needle bx impotence due to chronic dz (arteriosclerosis) - viagra penile fracture - rupture of corpus cavernosum (tissue around urethra) due to traumatic tear in tunica albuginea (fibrous covering around entire penis) - crack, detumescence, variable pain, hematoma foramtion - urologic emergency - get RUG (because urethral injury is a common complication) - note other indications for RUG are blood at meatus, hematuria, dysuria, URT

Answer 147

1) CT scan 2) inflammatory diverticular mass 3) sigmoidoscopy to rule out cancer

Answer 148

hyperacute - vascular thrombosis in min, due to incompatbile ABO and lymphocytes (so pre-formed abs) acute - 5d-3mo, organ dysfunction, get bx - liver - usu technically problems cause an issue --\> get doppler to evaluate for biliary obstruction and vascular thrombosis - heart - routine bx (otherwise its becomes too late to intervene) - give steroid boluses - mediated by mononuclear macrophages and T lymphocytes (leukocytic infiltration) chronic - yrs, insidious organ loss - T- cell mediated (foreign mhc looks like a self mhc that is carrying an antigen) --\> intimal thickening and fibrosis of graft vessels) - no tx - get bx - to make sure it is not a delayed and treatable case of acute rejection

Answer 149

1) repair bone first 2) vascular - because this can be disrupted when you reduce a fracture 3) nerve

Answer 150

give calcium gluconate

Answer 151

**Legg-Calve-Perthes disease** - avascular necrosis of capital femoral epiphysis - age 6, limping, decreased hip motion, hip (or knee) pain - tx - by containing the femoral head in acetabulum by casting or crutches **slipped capital femoral epiphysis** - 13 yo M, lanky, limping, decreased hip motion, hip/knee pain - affected foot points in - pin back in place **septic joint** - wont move hip - aspiration and drainage acute hematogenous osteomyelitis - MRI gives prompt dx **others:** bowlegs - nl till age 3 knock knee - nl till 4-8 Osgood-Schlatter - RICE club foot - serial casting, achilles tenotomy scoliosis - bracing is used to arrest progression, severe cases may need surgery

Answer 152

fractures of growth plate (kids) - ORIF anterior shoulder dislocation - more common, "shaking hands" position Colles - FOOSH, dorsally angulated radius fracture Monteggia - ulnar fracture, anterior dislocation of radial head - Galeazzi is opp - ORIF for break, closed reduction for dislocation for both of these fractures rupture of achilles tendon - out of shape middle aged men who subject themselves to severe strain trigger finger, De Quervains (thumb) - steroid injection Dupuytren - steroid or collagenase gamekeeper thumb - injury UCL of thumb --\> cast jersey finger is opp of mallet finger

Answer 153

pathologic fracture - fracture with almost no force = mets MM - punched out lytic lesions sarcoma - require wide local excision and radiation &chemo, mets to lungs giant cell tumor of bone - soap bubble appearance, eccentric lytic area - benign, locally aggressive skeletal neoplasm seen in young adults - tumor contains cystic and hemorrhagic lesions osteoi osteoma - sclerotic, **cortical** lesion with central lucency - nighttime pain, pain unrelated to activity, and relieved by NSAIDs - tx - surgery

Answer 154

fall from height - check (L/T) spine herniated disk - will most likely resolve cauda equina syndrome - distended bladder (late), flaccid rectal sphincter, perineal saddle anesthesia - condus medularis is similar - but will have EARLY urinary and fecal incontinence

Answer 155

acute attack - indomethacin, colchicine chronic control - allopurinol and probenicid

Answer 156

if they dont drain out directly --\> sepsis if they drain freely (pt is afebrile with no signs of peritoneal irritation) - consequences are only fluid and electrolyte loss, nutritional depletion, and erosion and digestion of belly wall - high volume losses from high in GI tract - tx - give enteral nutrition (past the fistula), protect abd wall - fistula will heal on its own

Answer 157

in all anorectal disease - rule out cancer ischiorectal abscess - perirectal pain that prevents sitting - watch diabetics closely - can progress to necrotizing soft tissue infection fistula-in-ano - develops in some pts who have had an ischiorectal abscess drained - anal crypt --\> skin - fecal soiling - r/o necrotic and draining tumor treat with fistulotomy SqCC of anus - bx first - tx 1) chemoradiation, 2) surgery is there is residual tumor

Answer 158

need systemic therapy for systemic disease - so chemo for mets T tumor - T4 invasion of adjacent structures N M

Answer 159

most thyroid nodules are benign but have to work all up to exclude malignancy 1) US --\> 2) TSH/radionuclide scan --\> 3) FNA --\> ... - except follicular hot nodules are rarely malignant - toxic multinodular goiter - TSH-independent hyperfunctioning follicular cells **thyroiditis** - Hashimotos (autoimmune) - subacute (follows viral infection) - silent - associated with thyroid abs, can occur post-partum - Reidels - fibrosing **neoplasia** - autopsy, f-ed, pissed off, will present as a nodule (decreased I uptake in adenoma and carincoma) --\> get FNA - follicular adenoma - follicular carcinoma - FNA cant distinguish between follicular adenoma and carcinoma --\> partial thyroidectomy --\> total thyroidectomy if cancer - papillary carcinoma (80%) - old lady with exposure to ionizing radiation as a child - medullary carcinoma - C cells, aggressive --\> radical surgery - anaplastic (elderly, invades local structures...)

Answer 160

have to rule out cancer ALWAYS - lymph nodes! \<30 - US - simple breast cyst (can be quite painful) - posterior acoustic enhancement (fluid), no echogenic debris... - cystic fluid can reaccumulate so pt should f/u in 2-4 mo for repeat clinical breast examination - no recurrence or sx - annual visits screening MRI - cancer - and use it for women with increased risk of cancer (BRCA and their relatives, genetic syndrome, hx of radiation during ages 10-30 diagnostic mammography - DONT in women \< 30 (dense breast tissue prevents visualization, radiation risk) - diagnostic to evaluate risk - needle aspiration for breast mass - core bx if suspicious imaging (mammogram) - for complex cysts, masses, or recurring mass when would you image - unilateral breast discharge, bloody or serous d/c, or palpable lump or skin changes - mammo or US accordingly - nipple discharge that looks benign - UPT, TSH, prolactin, guaiac fibroadenoma - FNA or sonogram cystosarcoma phyllodes - grow over many years --\> distort entire breast, dont become fixed - core or incisional bx --\> removal mammary dysplasia (fibrocystic disease, cystic mastitis) - linked to estrogen cyst - aspirate --\> clear ok --\> recurs --\> get formal bx - bloody send for cytology - intraductal papilloma - get mammogram (though it will not show the mass) **treatment**: for resectable cancer (infiltrating ductal, DCIS, small lesions away from nipple/areola) - 1) lumpectomy, 2) radiotherapy - otherwise - total mastectomy (no need for radiation) - if LNs are not palpable - get sentinel node bx - if LNs are palpable - take them out - inoperable breast cancer - based on local extent --\> give chemo - follow every surgery with adjuvant chemo

Answer 161

esophageal atresia - rule out VACTER anomalies imperforate anus - look for fistula nearby - if fistula is present - can repair imperforate anus before potty training (otherwise repair immediately) green vomiting - double bubble - duodenal atresia, annular pancreas, malro - if there is a normal gas pattern beyond double bubble - malro is likely (malro is diagnosed with contrast enema) biliary atresia - **6-8 wk old babies** with progressive jaundice - normal work-up - 1) phenobarb (powerful choleretic), 2) hida scan neuroblastoma tracheomalacia - wheezing, stridor, dysphagia, hyperextension of neck - vascular ring that encircles trachea and esophagus - shown on barium swallow and bronchoscopy - surgery to divide (aortic) arches

Answer 162

ASD - low pressure, fixed S2, hx of frequent colds VSD (classically in membranous septum) - failure to thrive baby, loud pansystolic murmur PDA - machine like murmur Tet of Fallot transposition of great vessels - need ASD or some other connection --\> surgery AS - surgical valvular stenosis, replace if gradient is more than **50 mm Hg** (or other complications) acute aortic insufficiency - endocarditis --\> emergency valve replacement and abx mitral stenosis - acute rheumatic fever mitral regurg - holosystolic heart murmur, radiates to back and axilla

Answer 163

coin lesion 1) sputum cytology, 2) CT chest/abdomen to look for mets, 3) biopsy - operability is based on FEV1 remaining after the surgery \> 800 mL - sufficient FEV1 --\> look for mets (carinal and mediastinal mets preclude resection) - not surgical candidate - chemo and rads **small cell** = s tumors are associated with smoking, sentral, syndromes (paraneoplastic, ADH, ACTH, Eaton-Lambert) - small cell --\> chemo **non-small cell** - adenocarincoma - squamous cell - PTHrP - carcinoid tumor **screening guidelines** - low-dose chest CT annually in pts 55-80 who have a \>30-pack-yr smoking hx AND are currently smoking or quit in the past 15 yrs

Answer 164

CAD: intervention if one or more vessels have **70%** (or greater) stenosis and there is a good distal vessel - stenting or bypass subclavian steal syndrome - plaque at origin of subclavian--\> results in retrograde flow during times of exercise - AND posterior circulation neuro signs

Answer 165

hyponatremia (\<120) - check serum Na, serum osm, UA, physical exam - urine Na low (\<20) - primary polydypsia - urine Na high (\>20) - look at volume status - hypervolemic - cirrhosis, chf, nephrotic syndrome - euvolemic - siadh, adrenal insufficiency, hypothyroidism - hypovolemic - cerebral salt wasting, diarrhea, diruetics hypernatremia (\>145) - due to net loss of free water - large wound (burn), open abd, GI tract loses, lungs (humidifier air), kidneys - or due to net gain of sodium

Answer 166

insulin brings K into cells hypokalemia - weakness, constipation --\> frank muscle necrosis --\> ascending paralysis, arrhythmias are uncommon - due to renal loss, metabolic alkalosis, diarrhea - less often due to redistribution hyperkalemia (5.5) - fatigue, muscle weakness, flaccid paralysis, paresthesias, cardiac excitability (can lead to heart block and vfib) - impaired renal excretion (AKI), metabolic acidosis, rhabdo - tx - 1) ca gluconate to stabilize heart, 2) insulin to shift K into cells, 3) excrete K (lasix, hemodialysis)

Answer 167

entamoeba histolytica - abd pain, chronic diarrhea (bloody)

Answer 168

intraoperative hemorrhage (requiring blood transfusion) increases risk px - lack of chest pain, possibly because of peri-op pain control

Answer 169

px - fever, hypotension, pulm edema within 6 hrs of blood product administration

Answer 170

leukemoid reaction - WBC \> 50K, due to severe infection - leuk alk phos - high - mature neutrophil precursors v. s. CML - WBC \> 100K, Bcr-abl - low leuk alk phos - due to cytochemically abnormal neutrophils - less mature neutrophli precursors, absolute basophilia

Answer 171

bronze diabetes, transaminitis/hepatomegaly, hypogonadism, cardiomyopathy - MSK - arthralgia, arthropathy, **chondrocalcinosis** - pts with pseudogout should be elevaluated for seocndary causes - hyperparathryoidism, hypothyroidism, hemochromatosis - hemaochromatosis - get Fe studies, manage with serial phlebotomy - infections - increased susceptibility to Listeria, Vibrio vulnificus, Yernsinia enterocolitica

Answer 172

gastric bypass

Answer 173

acute liver failure --\> liver transplant - jargon note - ALF is acute liver injury in a pt without cirrhosis - triad of 1) elevated AST/ALT (1000s), 2) hepatic encephalopathy, 3) synthetic liver dysfunction (INR \> 1.5) - rising serum bili and PT - indicative of worsening ALF - cerebral edema is a potential complication --\> coma and brainstem herniation - acute renal insufficiency is common - esp with acetaminophen (because it is directly toxic to renal tubules) - as a note - signs of HE differentiates ALF from acute hepatitis

Answer 174

CA-UTI - bacteria properties - biofilm - avoid by clean intermittent cath - every 4-6 hrs compare to indwelling catheters - changed monthly - risks - increased UTI, stricture, bladder spasm other option - suprapubic tube placement

Surgery/GI Flashcards

(198 cards)