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1379 Cards in this Set
- Front
- Back
Comminuted fracture
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Results in more than 2 bone fragments (vs. simple fracture)
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Colles' fracture and cause
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Distal radius fracture, usually from falling on outstretched handSmith's fracture
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Smith's fracture
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Reverse Colles, from falling on dorsum of hand
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Jones' fracture
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Fracture at base of 5th metatarsal diaphysis
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Bennett's fracture
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Fracture-dislocation of base of 1st metacarpal w/ disruption of carpometacarpal join
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Boxer's fracture
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Fracture of metacarpal neck, classically of 5th metacarpal
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Monteggia fracture
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Fracture of proximal third of ulna with dislocation of radial head
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Pott's fracture
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Fracture of distal fibula
|
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Which dislocation needs to be reduced on the xray table, and to prevent what?
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Hip dislocation, to prevent avascular necrosis
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What 2 structures are at risk with a humeral fracture?
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Radial nerve
Brachial artery |
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Chief concern with tibial fractures
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Associated compartment syndrome
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Pain in the anatomic snuff box indicates
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Fracture of scaphoid bone
|
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Contracture of the forearm flexors might indicate
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Wokmann's contracture: final sequela of forearm compartment syndrome as fibrous tissue replaces dead muscle
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Most common site of compartment syndrome and why
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Calf: 4 compartments (anterior, lateral, deep posterior, superficial posterior)
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Pain, paresthesia, paralysis after a fracture
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Worry about compartment syndrome!
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Structures at risk with shoulder dislocation (2)
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Axillary nerve and artery
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Structures at risk with elbow dislocation (3)
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Brachial arter, ulnar nerve, median nerve
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Most common cause of hip dislocation
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MVA
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Structures at risk with hip dislocation (2)
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Sciatic nerve, blood supply to femoral head (--> avascular necrosis)
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Structures at risk with knee dislocation (5)
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Popliteal artery and vein, peroneal nerve, ACL, PCL
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Management of knee dislocation
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Arteriogram (may need arterial repair) and immediate attempt at relocation (don't want to xray), then ligamentous repair
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What is McMurray's sign?
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Medial tenderness of knee w/ flexion and internal rotation of knee: indicates medial meniscus tear
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Unhappy triad
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ACL, MCL, and medial meniscus tear
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Test for intact Achilles tendon
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Thompson's test: squeeze gastrocnemius; should result in plantar flexion of the foot
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What is turf toe?
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Hyperextension of great toe due to tear of tendon of flexor hallucis brevis, seen in football players
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Another name of exercise-induced anterior compartment syndrome/hypertension
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Shin splints
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What is a heel spur?
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Plantar fasciitis w/ abnormal bone growth in the plantar fascia
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What is Marjolin's ulcer?
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Squamous cell carcinoma that arises in a chronic sinus from osteomyelitis
|
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DDx of possible bone tumor
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1) Mets
2) Primary bone tumor 3) Metabolic disorder (e.g. hyperparathyroidism) 4) Infection |
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Sclerotic bone reaction in a tumor often indicates
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Tumor is benign
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Bone tumor with sunburst pattern
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Osteosarcoma
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Bone tumoor with ground glass lytic lesions
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Fibrous dysplasia
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Bone tumor with onion skinning
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Ewing's sarcoma
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How can Ewing's sarcoma mimic the appearance of osteomyelitis?
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Bone cysts
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Unicameral bone cyst
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Fluid-filled cyst in proximal humerus of kids
|
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Presentation and treatment of unicameral bone cyst
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Asymptomatic until pathologic fracture
Steroid injections |
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Aneurysmal bone cyst
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Hemorrhagic lesion, locally destructive by expansile growth but doesn't metastasize
|
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Presentation and Rx of aneurysmal bone cyst
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Pain and swelling
Curettage and bone grafting |
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Bouchard's vs. Heberden's nodes
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OA
Enlarged PIP vs. DIP joints |
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Rx for degenerative (OA or post-traumatic) arthritis
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NSAIDs only for acute flares, local
|
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Pannus
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Inflammatory exudate overlying synovial cells inside the joint
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Charcot's joint
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Arthritic joint from peripheral neuropathy
|
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What does the Salter-Harris classification describe, and what does it indicate risk of?
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Fractures in children involving physis and how much
Potential growth arrest |
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Rx for congenital hip dislocation
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Pavlik harness (maintains hip reduction w/ hips flexed)
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Indications for surgery for scoliosis
|
Respiratory compromise
Rapid progression Curves >40 degrees Failure of brace |
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What is Legg-Calve-Perthes disease?
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Idiopathic avascular necrosis of femoral head in kids
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What occurs in SCFE?
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Migration of proximal femoral epiphysis anteriorly on the metaphysis in kids
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What is Blount's disease?
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Idiopathic varus bowing of tibia
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Varus vs. valgus
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Varus is bow-legged
Valgus is knock-kneed |
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What is Osgood-Schaltter's disease?
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Apophysitis of tibial tubercle due to repeated powerful contractions of the quads
|
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Spinal anesthesia is risky in which pts
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CAD, low EF, valvular disease, diabetic peripheral neuropathy
|
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What are the risks of spinal anesthesia
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Pts who cannot vasoconstrict peripherally or increase CO appropriately: may become hypotension due to the vasodilation caused by spinal anesthesia
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How long must aspirin or NSAIDs be d/c prior to surgery
|
ASA 1 wk
NSAIDs 2 days (due to how long they effect platelets) |
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Common preop tests to consider, depending on risks
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CBC, chem panel, LFTs, pt/ptt/plts, urinalysis, ECG, CXR
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Management of pt found to be anemic before surgery
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Postpone surgery and investigate anemia
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Fractures with worst prognosis for future growth
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Those that extend through the growth plate (can form bony bridges that disrupt later growth)
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Nerve possibly injured by transverse humeral fracture
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Radial nerve
|
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Injury to radial nerve at wrist would cause
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Sensory deficits (only more proximal would affect motor function)
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Advantage of open fractures reductions
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Shorter period of immobilization
|
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Disadvantages of open fracture reductions (3)
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Increased trauma at at fracture site
Infection risk Delay in bone healing & possible non-union b/c disrupts clots/ hematomas helpful in healing |
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Dislocation of the radial head w/ fracture of proximal third of the ulna
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Monteggia's deformity
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Posterior shoulder dislocation may be from
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Seizure
|
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Common fracture from falling on outstretched hand
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Navicular bone fracture
|
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Pain in anatomic snuff box
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Navicular bone fracture
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Recovery time for navicular bone fracture
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Immobilization of wrist for 16wks-6mo
|
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Osteitis fibrosa cystica is associated with
|
hyperparathyroidism
|
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Increased bone density is seen in
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Oteopetrosis
|
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Another name for Paget's disease
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Osteitis deformans
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Most common site of osteosarcoma
|
Distal femur
|
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Rx for osteosarcoma
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Combo chemo + surgical resection
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Severe bone pain relieved by ASA
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Osteoid osteoma
|
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Round-cell type tumor on diaphysis of long bones
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Ewing's sarcoma
|
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Nasopharyngeal carcinoma is associated with
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EBV
|
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Management of severe facial trauma
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Stabilize C-spine, intubate or tracheostomy if needed, CT, nasal packing to control hemorrhage, can delay repair if needed
|
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Rx for SCC of the nasopharynx
|
Radiation; radial neck dissection if LN mets
|
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Rx for SCC of the oropharynx
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Surgery and/or radiation
|
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Rx for SCC of the hypopharynx
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Surgery (often + radiation) and radial neck dissection
|
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Pleomorphic salivary gland adenomas
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Rubbery, slow growing, potentially malignant, high recurrence, lips/tongue/palate
|
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First branchial cleft fistula opens where and dissection may damage which nerve
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External auditory canal
Facial |
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Second branchial cleft fistula opens where, passes where, and is adjacent to which nerve
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Posterolateral pharynx (below tonsillar fossa)
Passes btwn carotid bifurcation Adjacent to hypoglossal nerve |
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Painless nodule along lateral border of SCM
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Branchial cleft anomaly
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Rx for branchial cleft anomalies
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Surgical excision
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Common complication of tongue cancer (2)
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Tongue deviation from involvement of hypoglossal nerve
Decreased sensation from involvement of lingual nerve |
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Painless swelling in midline of neck that moves with swallowing or tongue protusion
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Thryoglossal duct cyst
|
|
Course of thyroglossal duct cysts
|
Retention of epithelial tract between thyroid and its embryo origin at base of tongue
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Rx for thryoglossal duct cyst
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Surgical resection (often includes hyoid bone) due to risk of infection/ progressive enlargement (and recurrence if only excise)
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When does buccal carcinoma usually present and why?
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Late (mandibular or amxillary involvement, cervical mets) because of lack of symptoms
|
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3 reasons for postponing surgery
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Glucose >250, active infection (cellulitis, PNA, UTI, etc.) diastolic BP >110
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Why are beta-blockers not held before surgery?
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High rate of rebound HTN if they are
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Abstaining from smoking for how long is required to decrease postoperative respiratory morbidity?
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6-8wks
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Laparoscopy is contraindicated in which pts?
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Poor pulm function/ severe COPD pts (b/c it increases CO2 absorption into the blood which requires increased excretion and therefore increased pulmonary work)
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5 factors used to predict risk for cardiac complications after vascular surgery
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Q waves on ECG
Hx of ventricular ectopy that requires Rx Hx of angina DM that requires Rx >70yo |
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Most common cause of death after LE revascularization is?
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MI
|
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What does Child's classification measure?
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Hepatic reserve/ liver function and therefore likelihood of mortality with surgery
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What are the 5 parts of Child's classification
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Bili, albumin, ascites, encephalopathy, nutrition
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Management of an ulcerated hernia
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Expedited surgery, as ulcers are often due to pressure necrosis, which increases the risk of rupture and has a mortality rate of 10-40%
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What is a cause of oozing blood in a pt with CKD undergoing surgery?
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Uremia --> platelet dysfunction
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What is the management of platelet dysfunction due to uremia, and what won't help?
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Transfusing platelets won't help
Desmopressin, FFP, estrogen, postop hemodialysis |
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What types of procedures need Abx prophylaxis for pts with high risk cardiac conditions (e.g. prosthetic heart valves)
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Dental work, GI or GU surgery, lung surgery
|
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What type of Abx prophylaxis is used?
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Amox for dental/ upper respiratory tract procedures
Amp and gent for GI and GU procedures |
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What complication should be monitored for in pts undergoing a bowel prep?
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Dehydration
|
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Management of a breast lump with negative mammography
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Still biopsy!
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Which histological pattern for DCIS is most concerning for malignancy?
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Comedo: up to 30% contain invasive carcinoma
|
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Rx for LCIS
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Close observation: mammography every 6mo
|
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Management of sclerosing adenosis vs. atypical ductal hyperplasia
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Sclerosing adenosis can usually be observed; ADH should be excised
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Management of breast lump in a woman <30yo
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Usually ultrasound first (to determine if cystic), then mammogram
|
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Dietary changes for fibrocystic breast disease
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Decrease caffeine
Vita E supplement |
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What is a phyllodes tumor?
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Usually a large fibroadenoma (giant cell fibroadenoma) with variable malignant potential and occasional ulceration of overlying skin
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Management of bilateral clear discharge
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Observation, usually associated with fibrocystic disease or subareolar duct ectasia
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Management of unilateral bloody discharge
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Surgical biopsy; usually due to intraductal papilloma, but small risk of carcinoma
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Metastatic work-up for breast cancer
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CXR for lung and bone mets
Liver enzymes |
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Breast cancer histo subtype with worst prognosis
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Inflammatory carcinoma
|
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What is peau d'orange and what does it indicate?
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Edema of the skin overlying the mass; tumor invasion of local dermal lymphatics (worse prognosis)
|
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What does a palpable supraclavicular LN indicate?
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Stage IV disease with distant mets: unresectable and incurable
|
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Why is a crusted nipple lesion concerning?
|
Could be Paget's disease of the breast, 95% of which are asociated with an underlying carcinoma
|
|
Two arteries that supply the breast
|
Internal mammary
Lateral thoracic |
|
What distinguishes a modified radical mastectomy?
|
Spares the pectoralis major
|
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What is a sentinel node?
|
Node that first receives lymphatic drainage from the tumor
|
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Which patients should not have lumpectomy + radiation?
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Those who are not candidates for radiation: CT disease or prior radiation to the chest/ breasts
|
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Contraindications to breast reconstruction
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Primary lesions involving the chest wall, extensive local or regional disease, or stage III or IV cancer
|
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Which women with breast cancer need adjuvant chemo?
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Tumor >2cm or >Stage 1, especially if ER negative
|
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Which women with breast cancer need neoadjuvant chemo?
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Stage III (to shrink tumor before surgery); usually not Stage IV since will only get palliative radiation/chemo
|
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Likely diagnosis of a nodule in the suture line of a women with a history of breast cancer?
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Local recurrence
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Likely diagnosis of a mammographic abnormality in the contralateral breast of a women with a history of breast cancer?
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New primary cancer
|
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Management of elevated LFTs of a women with a history of breast cancer?
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Contrast CT to evaluate for liver mets
|
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Management of pathologic fracture?
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Orthopedic repair +} postop radiation (controls cancer but doesn't inhibit fracture union)
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Likely diagnosis of a coma in a women with a history of breast cancer?
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Hypercalcemia (from bony mets and PTHrp)
|
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Likely diagnosis and management of decreased sensation/movement in one leg in a women with a history of breast cancer?
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Surgical emergency: may be extradural mets to the spine
Steroids, cord decompression, and radiation |
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Rx for mastitis
|
Warm compresses + Abx (staph and strep coverage)
|
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Management of gynecomastia in adolescents
|
Usually spontaneously regresses
|
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Need to replete every 1ml of EBL with how much isotonic fluid?
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3ml
|
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Why do IVF requirements decrease during the recovery period?
|
Pts begin to mobilize fluid from third space accumulation as they regain GI function
|
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Normal urine output
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0.5-1ml/kg/hr
|
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How to distinguish type of postobstructive diuresis (pathologic concentrating defect vs. osmotic diuresis)
|
Low osmolality: concentrating defect
High osmolality: osmotic diuresis |
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Postop fever
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PNA, URI, UTI, DVT, drug-related, indwelling IVs
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Most common cause of postop fever
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Atelectasis
|
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Rx for atelectasis
|
Vigorous pulmonary toilet and incentive spirometry (NOT antibiotics)
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What does a fluctuant postop wound indicate, and what is the management?
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Fluid collection: remove staples and drain pus; culture fluid and irrigate
|
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Drop of pus on skin at venipuncture exit site
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Suppurative phlebitis (infected thrombus in vein and around indwelling cathether)
|
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Rx for suppurative phlebitis
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Remove catheter and excise the infected vein + IV Abx
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Intestinal contents draining from wound
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Small bowel fistula
|
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Causes of small bowel fistula
|
Leak at jejunostomy insertion site
Breakdown of small bowel anastomosis Missed enterotomy |
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Management of small bowel fistula
|
If signs of peritonitis: operative reexploration
If not, CT to r/o intra-abdominal collection (which would need to be drained), and then monitor drainage + NPO |
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Factors associated with failure of fistula to heal
|
Foreign body in wound
Radiation damage to area Infection or IBD Epithelialization of fistulous tract Neoplasm Distal bowel obstruction |
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Concern with very high postop fever
|
Clostridium infection (gas-forming organism: G+, spore forming)
|
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Signs of clostridium infection
|
Discharge with foul odor/color, crepitus (from gas produced by anaerobes), cellulitis (gas gangrene)
|
|
Rx for clostridium infection
|
High-dose penicillin G + debridement + hyperbaric oxygen therapy + tetanus immunization
|
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Ddx for hemoptysis
|
Malignancy, bronchitis, PNA, TB, PE
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What does "T" indicate on GCS?
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Intubated
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Goals for CPP and ICP?
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<70 and <20
|
|
GBM is a tumor of what type of cells?
|
Glial cells
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Which skull fractures require surgery, and when?
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Depressed (if >1cm inward) or compound (when bone and overlying skin are broken)
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Management of CSF draining from ears/nose
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Observe, surgical repair of dura if >14 days
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Management of xanthrochromia
|
4 vessel cerebral angiogram to assess for cerebral aneurysm + Rx to counteract vasospasm + BP control + anticonvulsant therapy
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Compression of CNS --> fixed/dilated pupil is usually due to?
|
Herniation
|
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Rx of Schwannomas
|
Excision
|
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What is a countrecoup lesion?
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Contusion on opposite side of head from injury (as compared to a coup lesion)
|
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Most frequent sites of cerebral contusion
|
Orbital surface of frontal lobes and anterior portion of temporal lobes
|
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Rx for substantial contusion
|
Anti-convulsants
|
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Rx for meningiomas
|
Usually benign
Resection 10% recurrence |
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Rx for subdural hematoma
|
Drainage of hematoma thru burr hole; formal craniotomy may be required if fluid reaccumulates
|
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Significant contusions are usually associated with
|
Loss of consciousness
|
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Excruciating headache, stiff neck, photophobia
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Subarachnoid hemorrhage
|
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When is surgery for VSD indicated (3)?
|
CHF, pulmonary vascular resistance, or if still open at 5yo
|
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Cause of imperforate anus
|
Failure of descent of urorectal septum
|
|
How is imperforate anus distinguished as high or low?
|
Based on whether rectum ends below or above level of levator ani complex
|
|
In females, high imperforate anus often occurs with
|
Persistent cloaca
|
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Rx for high vs. low and outcomes
|
Low: perineal operation
High: pull-thru procedure required, lower likelihood of continence |
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Rx for Hirschsprung's
|
Colostomy decompression
|
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Cause of jejunoileal atresia
|
Mesenteric vascular accident during intrauterine growth
|
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Rx for jejunoileal atresia
|
Resection of primary anastamosis
|
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Most common type of intussusception
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Ileocolic
|
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Rx for intussusception
|
Barium enema, unless has bloody mucous or peritonitis or systemic toxicity: then needs surgery
|
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Rx for annular pancreas
|
Bypass procedure (duodenoduodenostomy)
|
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Presentation similar to acute appendicitis
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Inflamed Meckel's diverticula
|
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When should a Meckel's diverticula be removed?
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Only if symptomatic (obstructed, etc.)
|
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Where is a congenital diaphragmatic hernia and what does it cause?
|
Posterolateral
Respiratory distress from pulmonary hypoplasia |
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Rx for congenital diaphragmatic hernia
|
Stabilize pulmonary HTN crisis medically or with extracorporeal membrane oxygenation prior to attempting repair
|
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Initial Rx for hyponatremia
|
Free water restriction, then hypertonic saline (slowly, if needed)
|
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2 common causes of postop hyponatremia
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Stimulation of ADH and excessive water administration in first few days postop
|
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Pts with ileal resection are at risk for what type of kidney stones?
|
Calcium oxalate (w/o an ileum, unabsorbed fatty acids reach the colon and combine with calcium, leaving oxalate to be absorbed and excreted in the kidney)
|
|
Mg deficiency in common in which pts?
|
Malnourished and large GI fluid losses
|
|
Guidelines for prophylactic Abx for colon resections
|
Single dose <1hr before case (cefazolin), same as always; redose for long cases based on half-life
Bowel prep + oral Abx effective against aerobes and anaerobes as well |
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Preop cardiac workup for pt with risk factors
|
EKG + stress test (exercise or, if can't tolerate it, pharmacological)
|
|
Hypochloremic, hypokalemic metabolic alkalosis is also known as
|
Contraction alkalosis
|
|
Rx for contraction alkalosis
|
Volume repletion with NS + K is usually enough to correct the alkalosis
|
|
Rx for HIT
|
Stop heparin, start lepirudin, transition to warfarin when plts >100,000
|
|
When do you need a platelet transfusion for HIT?
|
Never: HIT promotes thrombosis, not hemorrhage
|
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Significant postop bleeding
|
Presume failed surgical control of blood vessels
|
|
When do most periop MIs occur?
|
3rd post op day when third space fluids return to circulation, increasing preload and O2 demand
|
|
Management of acute mesenteric ischemia with and without peritoneal signs
|
With: emergent XL
Without: angiography, then celiotomy once diagnosis of arterial occlusion or bowel infarction made |
|
Prolonged aPTT likely indicates
|
von Willebrand's disease
|
|
Diagnostic test for von Willebrand's disease
|
Lack of platelet aggregation with addition of ristocetin
|
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Management of pt with vWD who needs surgery
|
Transfusion of cryoprecipitate (which provides vWF and increases F VIII)
|
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Management of polycythemia vera pt who needs surgery
|
Emergent: FFP infusion
Elective: delay until hematocrit/ plts are normalized (can use alkylating agents) |
|
When large amts of banked blood are transfused, pts become deficient in what clotting factors?
|
V and VIII (as well as platelets)
|
|
Postop bowel function: timing for return to normal and initiation of enteral feeding
|
Small bowel: within hrs
Stomach: within 24 hrs Colon: 3-4 days Can institute enteral feeding w/in 24hrs safely |
|
3 electrolyte consequences of refeeding syndrome
|
Hypokalemia, hypomagnesemia, hypophosphatemia (as electrolytes are shifted back intracellularly)
|
|
3 other complications of TPN
|
Hyperglycemia
Hyperchloremic acidosis Volume overload --> CHF |
|
Fever, hypotension, lethargy, hypoglycemia, hyperkalemia after steroid taper
|
Adrenal insufficiency
|
|
Rx for adrenal crisis
|
IV steroids (dexamethasone), volume resuscitation
|
|
When should transfusion with FFP be given?
|
On call to the OR
|
|
Factors that predispose to fistula formation and may prevent closure
|
Foreign body
Radiation Inflammation Epithelialization of the tract Neoplasm Distal obstruction Steroids |
|
Fever, chills, hypotension, oliguria, pain at IV site
|
Hemolytic tranfusion reactions (due to reaction of recipient Abs against transfused antigens)
|
|
Management of pt with hemophilia A who needs surgery
|
If severe disease: e-aminocaproic acid (AMICAR; inhibits fibrinolysis) and desmopressin (DDAVP, increases VIII and vWF)
If mild: DDAVP alone |
|
Why can FFP not be used successfully in hemophiliacs?
|
Factor levels are too low; need cryo or recombinant factos
|
|
NSAIDs can cause ___ dysfunction
|
Platelet
|
|
Potential vitamin deficiency syndromes from gastrectomy and Bilroth II procedure
|
Megaloblastic anemia (decreased intrinsic factor)
Microcytic anemia (iron deficiency from decreased uptake in duodenum) Osteoporosis (decreased calcium absorption from duodenum/jejunum) Steatorrhea (fat malabsorpion) |
|
Diagnostic test for suspected ureteral injury (intraop and postop)
|
Intraop: methylene blue administration
Postop: CT to see hydronephrosis or fluid collection (urinoma), then IV pyelogram |
|
Tingling sensation and muscle cramps after thyroid surgery
|
Hypocalcemia, likely short-term due to transient ischemia of parathyroid gland
|
|
Rx for symptomatic hypocalcemia
|
IV calcium infusion (or oral if only mild symptoms); Vitamin D if persistent
|
|
Massive transfusion is associated with what electrolyte abnormality?
|
Hypocalcemia 2/2 chelation with citrate in banked blood
|
|
Numbness, Chvostek's sign, and prolonged QT
|
Hypocalcemia
|
|
Best fluid replacement for enteric losses
|
Ringer's lactate
|
|
Rx for hyperkalemia
|
Kayexalate (to bind it)
Sodium bicarb, dextrose, insulin (all to shift it intracellularly) Calcium gluconate (to counteract myocardial effects) |
|
Best drainage system and location to minimize wound infections
|
Closed drainage system that exits skin away from surgical incision
|
|
When epithelialization is delayed beyond 3 wks, the incidence of ? increases
|
Hypertrophic scarring
|
|
Ex of epidermal burn
|
Sunburn
|
|
Why are superficial partial thickness burns painful?
|
Exposed superficial nerves
|
|
What leads to healing of superficial partial thickness burns?
|
Regeneration of epidermis from keratinocytes w/in sweat glands and hair follicles (areas with more will heal more quickly)
|
|
Rx for superficial partial thickness burns and why?
|
Antimicrobial creams and occlusive dressings (epithelialization is faster in a moist environment)
|
|
Rx for deep partial thickness wounds
|
Excise to a viable depth and then skin graft, esp if in cosmetic location since healing is slow and associated with contraction
|
|
Rx for full thickness injuries
|
All should be excised and grafted unless <1cm and no compromise of function, b/c all regenerative elements have been destroyed
|
|
When is the best time to graft burns?
|
Within 5 days of injury to minimize blood loss
|
|
Ideal skin covering choice?
|
Split skin autograft from unburnt areas
|
|
Alopecia, poor wound healing, night blindness, anosmia, neuritis, skin rashes
|
Zinc deficiency
|
|
Excessive diarrhea may lead to a ___ deficiency
|
Zinc
|
|
Cardiomyopathy may be due to a ___ deficiency
|
Selenium
|
|
Pts on long-term TPN may develop this deficiency w/ hyperglycemia, peripheral neuropathy, and encephalopathy
|
Chromium
|
|
Potential abnormality following administration of large volumes of normal saline
|
Non anion-gap metabolic acidosis (due to increased chloride concentrations)
|
|
Both LR and NS are both __ (acidic/alkalotic) w/ respect to plasma
|
Acidic
pH of LR is 6.5 pH of NS is 4.5 |
|
Two good situations for NS and for LR
|
NS: vomiting or significant nasogastric suction losses (b/c pt will have tendency toward metabolic alkalosis)
LR: replacing GI losses and correcting ECF deficits |
|
3 indications for a vena caval filter
|
- Anticoagulation contraindication/ failure
- Free-floating venous clot - Chronic PE complicated by pulm HTN |
|
Earliest signs of sepsis
|
Altered mental status, flushed skin, tachypnea --> respiratory alkalosis
|
|
Body's response to stress causes
|
Increased CO
Hyperglycemia Peripheral vasodilation Decreased arteriovenous oxygen difference (from decreased peripheral use of O2) |
|
Rx for hemolytic transfusion reaction
|
- Fluid resuscitation
- Foley for diagnosis and monitoring of Rx - Mannitol to induce diuresis (so can clear hemolyzed red cell membranes and avoid renal damage) - Alkalinization of urine to prevent Hb clumping |
|
Surgery for C. diff colitis
|
Subtotal colectomy with end ileostomy
|
|
Caloric requirements for 70kg man who is:
Nml Postop Septic Multiple trauma/ventilated Major burn |
Nml: 1450
Postop: 1500 Septic: 2000 Multiple trauma/ventilated: 2500 Major burn: 3000 |
|
Bleeding from trach
|
Bleeding from tracheoinnominate artery fistula
|
|
Management of tracheoinnominate artery fistula
|
If still bleeding: stop (inflate balloon or compress)
Once bleeding stopped: fiberoptic exploration in the OR |
|
Criteria for extubation
|
Negative inspiratory force >-20
Weaned to 5cm H2O PEEP Minute ventilation <10L/min RR <20/min Rapid shallow breathing index btwn 60 and 105 |
|
What is the rapid shallow breathing index?
|
Ratio of RR to tidal volume
|
|
Anesthetic not to use in SBO operations and why
|
Nitrous oxide, b/c is less dense than air so may cause distension of air-filled spaces
|
|
Changes in ARDS
|
Hypoxemia
Decreased compliance Decreased FRC Alveolar collapse from leakage of protein-rich fluid |
|
Oxygen dissociation curve shifts (right/left) indicate?
|
Right: increased tissue oxygen uptake
Left: decreased tissue oxygen uptake |
|
Do the following conditions shift the oxygen dissociation curve R or L?
Acidosis Increased PaCO2 Increased temp Increased 2,3-DPG Chronic lung diseases Banked blood |
All right except banked blood (b/c low in 2,3-DPG)
Chronic lung diseases shift it right via an increase in 2,3-DPG due to chronic hypoxia |
|
Dopamine at low doses
|
Vasodilation of renal/mesenteric vessels and peripheral vasoconstriction, redirecting blood to kidneys/bowels
|
|
Dopamine at high doses
|
Increases HR, CO, BP and causes peripheral vasoconstriction
|
|
Dopamine at all doses
|
Increases diastolic BP and coronary blood flow
|
|
Best pressor choice for cardiogenic shock
|
Dobutamine (positive inotrope and vasodilates, but minimal chronotropic effect so only mild increase in O2 demand)
|
|
Reversal of epidural opiates
|
IV (not epidural) maloxone
|
|
Cardiac index =
|
CO/BSA
|
|
Rx for acalculous cholecystitis
|
Percutaneous drainage
|
|
Hemodynamics in postop septic shock (early)
|
Increased CO, decreased SVR, normal central pressures
|
|
Rx for postop septic shock
|
Fluids, pressors, Abx (against gram negative rods and anaerobes, esp after bowel surgery), laparotomy and drainage of intraabdominal abscess when identified/ if pt stable
|
|
Indications for cholecystectomy in asymptomatic pts
|
Immunocompromised
Porcelain gallbladder (calcified) Gallstones >3cm (associated w/ dev't of gallbladder carcinoma) |
|
Why is an intraop cholangiogram often performed in cholecystectomies?
|
To r/o common bile duct stones
|
|
2 major complications of a cholecystectomy
|
Injury to the common duct (--> chronic biliary strictures, infection, and cirrhosis)
Injury to hepatic artery (--> hepatic ischemia or bile duct ischemia and stricture) |
|
Most common bacteria in cholecystitis
|
E coli, enterobacter, klebsiella, enterococcus
|
|
Antibiotics for cholecystitis
|
2nd generation cephalosporin preop and for 24hrs postop
|
|
When is lap chole indicated in cholecystitis?
|
Within 48-72hrs
|
|
Symptomatic cholelithiasis + elevated bili or elevated LFTs
|
Suspect common bile duct obstruction
|
|
When is removal of common duct stones not necessary?
|
If they're smaller than 3mm
|
|
Management of symptomatic cholelithiasis or gallstone pancreatitis in pregnancy
|
Pain meds and hydration
If needed, cholecystectomy (ideally in 2nd trimester) or ERCP |
|
Management of cholecystitis + elevated amylase
|
Cholangiogram (and cholecystectomy) is mandatory with biliary pancreatitis
|
|
Cholecystitis + severe symptomatic pancreatitis
|
Delay cholecystectomy
|
|
Ddx for very high fever, gallstones, and hypotensive
|
Acute cholecystitis, cholangitis, empyema of gall bladder, or pericholecystic abscess
|
|
Management of suppurative cholangitis
|
Emergent ERCP with sphincterotomy, decompression of biliary tree, stone removal
|
|
What causes a palpable gallbladder?
|
Inflamed gallbladder with omentum attached
|
|
Management of palpable gallbladder?
|
Emergent cholecystectomy due to high rupture risk
|
|
What is an emphysematous gallbladder?
|
Air in the wall due to gas-forming organism that has invaded the tissues
|
|
Management of emphysematous gallbladder
|
Urgent surgery
|
|
Jaundice, fever, and RUQ pain/tenderness
|
Acute (or ascending) cholangitis
|
|
Management of acute cholangitis
|
Resuscitation, Abx, US of biliary tree
If obstruction or dilation of CBD seen, then ERCP and biliary decompression |
|
Name for a common duct stone occurring w/in 2yrs of a cholecystectomy
|
Retained stone
|
|
Management of biliary stricture
|
Surgical exploration and bypass of stricture usually w/ choledochojejunostomy
|
|
What two tests should be done in a pt with fever or pain after a lap chole?
|
Abdominal ultrasound and hepatobiliary nuclide scan (HIDA scan: hepatoiminodiacetic acid) looking for infection or biliary leak
|
|
How does the gallbladder look on a HIDA scan in a pt with acute cholecystitis?
|
Doesn't visualize
|
|
Management of postop biliary leak identified on HIDA scan
|
ERCP to define anatomy
If large collection: biliary drainage w/ temporary stent placed during ERCP |
|
Tender lymph nodes in the groin
|
Lymphadenitis (or, lower likelihood, malignancy)
|
|
Tender testicle (acte vs. gradual)
|
Acute: torsion of testis
Gradual: viral ochitis or epididymitis |
|
Hernia pt with N/V/abdominal distention
|
Incarcerated/ strangulated hernia
|
|
Hernia pt w/ fever, leukocytosis, and acidosis
|
Strangulated segment of bowel
|
|
Most hernia repairs involve attaching which two structures?
|
Transversalis fascia to either inguinal ligament or periosteum of pubic ramus
|
|
Most common hernia repair type
|
Lichtenstein repair (prosthetic mesh approximates superior abdominal wall structures to inguinal ligament)
|
|
Advtg of mesh?
|
Avoids creating tension on fascial structures, lessening postop pain and recurrence
|
|
Nerves at risk of injury in hernia repair
|
Genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous
|
|
Pediatric hernias represent a
|
Persistent patent processus vaginalis, NOT an abdominal wall defect/ defect in floor of inguinal canal
|
|
Sliding hernias may involve which other structures herniating?
|
Bladder, cecum, or sigmoid colon
|
|
When are ventral hernias difficult to repair?
|
Inadequate tissue strength, insufficient tissue, infection, or poor nutrition
|
|
Management of a perforated duodenal ulcer
|
Emergent celiotomy and ulcer closure
If no Hx of PUD, can close ulcer w/ omental patch; if long-standing disease, antrectomy w/ truncal vagotom |
|
Postop postprandial weakness, sweating, lightheadedness, crampy abdominal pain, diarrhea
|
Dumping syndrome
|
|
When should dumping syndrome symptoms abate?
|
Within 3mo of surgery
|
|
Mechanism of omeprazole
|
Irreversabily inhibits H+/K+ ATPase in gastric parietal cells
|
|
Management of ITP w/:
Plts >30,000 Plts <30,000 Active bleeding Refractory |
Observe
Prednisone (+/- IVIG) Plt transfusion Splenectomy |
|
Management of appendical adenocarcinoma
|
R hemicolectomy
|
|
Management of achalasia
|
Calcium channel blockers or long-acting nitrates; endoscopic dilation; Botox injection
|
|
Pts with achalasia are at increased risk of
|
Squamous cell carcinoma
|
|
Which symptoms improve in UC pts after total proctocolectom?
|
Peripheral arthritis, ankylosing spondylitis
|
|
Indications for UC surgery
|
Toxic megacolon, fulminant colitis, high grade dysplasia/carcinioma, definitive management of intractable disease (need end ileostom yas well)
|
|
Pancreatic fluid collection 4-6wks after acute pancreatitis
|
Pancreatic pseudocyst
|
|
Rx for pancreatic pseudocyst or pancreatic abscess
|
Percutaneous catheter drainage w/ Abx
|
|
CEA and amylase levels in pancreatic malignancy
|
High and low
|
|
Conditions associated w/ familial autonomous polyposis
|
Colon cancer
Fundic gland hyperplasia in stomach Premalignant polyps in duodenum and perampullary region Extraintestinal malignancies Retroperitoneal and abdominal wall desmoid tumors Benign osteomas |
|
Most frequent serious complication of end colostomes
|
Parastomal herniation
|
|
Cause of parastomal herniation
|
Stoma placed lateral to, rather than thru, rectus muscle
|
|
Management of parastomal herniation
|
If symptomatic, needs operative relocation
|
|
Prolapse occurs most frequently w/ what type of colostomy?
|
Transverse loop colostomy
|
|
Management of transverse loop colostomy prolapse
|
Restoration of intestinal continuity or converstion to end colostomy
|
|
Contraindication for pancreatic cancer excision
|
Involvement of superior mesenteric artery
|
|
Management of variceal bleed
|
Fluisd, octreotide or vasopressin to decrease splanchnic blood flow, beta-blockers for long term prevention
|
|
Surgical option for recurrent bleeding varices
|
TIPS (transjugular intrahepatic portosystemic shunt)
|
|
2 classes and 4 types of ulcers
|
Acid associated (II: body of stomach + duodenum; III: prepyloric)
Not acid associated (I: body or lesser curvature; IV: GE junction) |
|
Surgical indications for ulcers
|
Hemorrhage, perforation, refractory to medical Rx, inability to r/o malignancy
|
|
What surgery is required for ulcers?
|
Billroth I or II, + vagotomy if ulcer is a Type II or III (i.e. acid-associated)
|
|
Billroth I reconstruction
|
Distal gastrectomy w/ gastroduodenostomy
|
|
Billroth II reconstruction
|
Distal gastrectom w/ gastrojejunostomy
|
|
What is a Klatskin tumor?
|
Cholangiocarcinoma
|
|
DDx of biliary obstruction (5)
|
Pancreatic head cancer, periampullary carcinoma, cholangiocarcinoma, stricture of CBD, CBD stone impacted in ampulla
|
|
2 types of pts who often get CBD strictures
|
Chronic alcoholics w/ chronic pancreatitis
Pts w/ prior biliary surgery |
|
What is a "double duct" sign?
|
Dilated CBD and pancreatic duct due to narrowing of distal CBD
|
|
Option for surgical palliation in pts w/ unresectable pancreatic cancer, and what it helps avoid
|
Biliary and gastric bypass
Prevents gastric outlet or duodenal obstruction and bile duct obstruction |
|
Dilated intrahepatic ducts (intrahepatic obstruction) but no dilation of the CBD (extrahepatic obstruction)
|
Cholangiocarcinoma
|
|
Where are cholangiocarcinomas located?
|
At the bifurcation of the hepatic ducts
|
|
ERCP or this alternative test can be used to identify the tumor especially if high in the bile duct
|
Percutaneous transhepatic cholangiography
|
|
Rx for cholangiocarcinoma
|
If primary tumor only, excision (5 yr survival still only 15%)
If unresectable, palliative stenting (5% 5yr survival) No role for chemo/radiation |
|
Biliary cancer with best cure rate
|
Ampullary adenocarcinoma
|
|
Resection method for ampullary adenocarcinoma
|
Whipple
|
|
Why is lap chole not a suitable option for malignant gallbladder adenocarcinoma?
|
Need open to remove hepatic tissue (common direct spread to the liver)
|
|
Management of calcified (porcelain) gallbladder and why
|
Chole b/c of 50% association with adenocarcinoma
|
|
What test is necessary to ensure not missing other potential diagnoses in a pt with suspected pancreatitis
|
Obstructive abdominal series (rule out perforated ulcer w/ free air, etc.)
|
|
Pancreatitis + severe deterioration and hypotension
|
Severe necrotizing pancreatitis
|
|
Two criteria systems for pancreatitis
|
Ranson criteria or APACHE II
|
|
Pt recovering from percutaneous pancreatic abscess drainage when suddenly becomes hypotensive and drainage becomes bloody
|
Erosion of cathether or abscess into a major artery (diagnose w/ angiography; control w/ embolization)
|
|
Management of elderly pt with suspected pancreatitis
|
Abdominal CT b/c of concern for other pathologies (mesenteric ischemia and volvulus)
|
|
Management of hepatic mets found during colectomy for colon cancer?
|
Wedge resection
|
|
Hernias are defects in what?
|
Transversalis fascia
|
|
Air in biliary tract of nonseptic pt?
|
Biliary enteric fistula
|
|
Complication of biliary enteric fistula
|
Gallstone ileus (stone into duodenum causes SBO at distal ileum)
|
|
Colonic syndrome w/o malignant potential and why not
|
Peutz-Jeghers (intestinal polyposis and melanin spots on oral mucosa), b/c are hamartomas
|
|
Management of gallstone ileus
|
Ileotomy, removal of stone, cholecystectomy (or interval chole if too inflamed at time of op)
|
|
Surgical indications for diverticular disease
|
Hemorrhage, recurrent diverticulitis, intractable to medical Rx, complicated diverticulitis (perforated +/- abscess and fistula)
|
|
Rx for diverticular abscess
|
Percutaneous drainage then definitive resectional therapy
|
|
Rx for perforated diverticulitis
|
Hartmann's procedure (sigmoid resection w/ end colostomy and rectal stump) or sigmoid resection, anastomosis, and diverting loop ileostomy
|
|
Rx for biliary dyskinesia
|
Cholecystectomy
|
|
Rx for gallbladder polyp
|
<1cm: observe w/ serial US
Suspected carcionma: chole w/ intraop frozen section |
|
Management of acalculous cholecystitis
|
Abx and perc chole tubes until inflammation has resolved, then lap chole
|
|
Appendicitis presentation in the elderly (+anticoag, trauma, or sudden muscular exertion) plus mass on CT
|
Hematoma of rectus sheath: conservative management
|
|
Acute pancreatitis that won't resolve
|
Pancreatic pseudocyst
|
|
Diagnostic test and management of pancreatic pseudocyst
|
CT
NPO, TPN, observe; if not improved w/in 6wks, cystogastrostomy to drain fluid into GI tract (+biopsy to r/o cancer) |
|
Management of simple hepatic cyst
|
Observe; if persistently symptomatic, aspiration and then sclerosant or excision
|
|
Multilocular cyst in liver w/ calcifications (and management)
|
Suspect echinoccal cyst from GI parasite: need operative sterilization and excision
|
|
Hepatic abscess
|
IV antibiotics and CT-guided drainage
|
|
Amebic hepatic abscess
|
Metronidazole, no surgery
|
|
DDx for solid liver lesion
|
Hemangioma, focal nodular hyperplasia, hepatic adenoma, mets, HCC
|
|
Pts with hepatic adenoma usually have a history of?
|
OCP use
|
|
How to diagnose a hemangioma?
|
Labeled RBC scan
|
|
Indications for surgical removal of benign liver mass
|
Symptomatic, risk of spontaneous rupture, uncertainty of diagnosis
|
|
Why is biopsy not performed when hemangioma or hepatadenoma are suspected but uncertain diagnoses?
|
High risk of bleeding
|
|
Management of hepatic adenoma?
|
Stop OCPs
|
|
Why must persistent or large hepatic adenomas be resected?
|
Risk of rupture or of development into HCC
|
|
When do hepatic adenomas have the highest risk of rupture?
|
During pregnancy
|
|
What is Bowen's disease?
|
Squamous cell carcinoma in situ
|
|
Melanoma location with worst prognosis
|
Face or trunk
|
|
Additional primary melanomas occur in what percentage of pts?
|
5%
|
|
Which melanoma pts need adjuvant therapy, and what does it consist of?
|
Stage III and IV
Interferon or dacarbazine Possibly radiation |
|
Management of large macular brown lesion on cheek
|
Lentigo maligna (Hutchinson freckle): monitor closely, remove if changing b/c is a precursor to lentigo malignant melanoma
|
|
Management of subungal melanoma
|
Biopsy requires excision of portion of nail in continuity w/ lesion; reexcision following diagnosis involves amputation at DIP
|
|
Prognosis for anal melanoma
|
As with other mucosal melanomas, mortality is near 100% at 5 years
|
|
Firm, painless mass that is larger than most benign tumors
|
Sarcoma
|
|
Fibrosarcoma and lymphangiosarcoma are associated w/ what two exposures?
|
Fibrosarcoma: therapeutic radiation
Lymphangiosarcoma: axillary lympadenectomy |
|
Management of suspected sarcoma
|
Excision biopsy if <3cm
Incisional biopsy if >3cm NO FNA |
|
Poor prognostic indicators in sarcoma
|
Mitoses, degree of necrosis, >15cm, symptomatic
|
|
Which pts need met workup, what does it consist of, and most common locations for mets
|
All! (22% have mets at presentation)
CT, MRI, CXR Liver, lung, bone, brain |
|
Surgical option for sarcoma
|
Extensive: often total resection of tissue compartment or amputation of extremity
|
|
Best adjuvant therapy for sarcoma
|
Radiation
|
|
Management of sarcoma recurrence in the lung
|
Thoracic wedge resection (one of the whom tumors in which excision of pulmonary mets can result in long-term disease-free survival)
Same with liver mets |
|
7 factors that slow wound healing
|
Malnutrition
Diabetes Jaundice Uremia Steroids Chemo Smoking |
|
Why can pts not do heavy lifting for 6wks postop?
|
Collagen production and cross-linking are still occurring, so not yet at full tensile strength, prone to injury/disruption
|
|
Hard knot-like structure underneath surgical wound
|
Likely a suture knot: should resolve if was absorbable suture, otherwise can be removed under local anesthesia once wound is fully healed
|
|
What is healing by third intention?
|
Delayed primary closure
|
|
Erythema and some pus drainage around wound 3mo postop
|
Stitch abscess
|
|
Management of a stitch abscess
|
Explore opening w/ hemostat and remove suture under local anesthesia
|
|
Management of postop ventral hernia thru wound
|
Surgery
|
|
How long should a wound be observed for before considering revision for its appearance?
|
6mo
|
|
Management of hypertrophic scar
|
Steroid injections and local pressure dressings
Revision usually not appropriate as are likely to recur |
|
Raised hypertrophic scar that is spreading outside immediate area of incision
|
Keloid (same as treatment for hypertrophic)
|
|
Management of wound infection
|
Drainage and debridement; usually don't require Abx (only if cellulitis spreading despite drainage)
|
|
2 types of wounds that heal by secondary intention
|
Wounds that are intentionally left open
Wounds that become infected and require opening in immediate postop period |
|
What is the process of a graft revascularizing from granulation tissue called?
|
Inosculation
|
|
What is the advantage of split thickness skin grafts for wounds?
|
Reduce wound contraction by 60%
|
|
Disadvantage of skin grafts
|
More susceptible to trauma than normal skin
|
|
What is required for the skin graft to attach successfully?
|
Bacterial count on granulation bed must be <10^5 bacteria/gram of tissue
|
|
Four categories of wounds
|
Clean, clean-contaminated, contaminated, infected
|
|
Management of contaminated wound
|
Leave open to heal by secondary infection, treat with saline-soaked gauze
|
|
Definition of a clean wound
|
No entry made into GI, respiratory, or GU tracts and no active infection
|
|
Definition of clean-contaminated wound
|
There is entry into GI, resp, or GU tract but it is prepared both mechanically and antibacterially (e.g. bowel prep before surgery)
|
|
Need for prophylactic Abx for clean, clean-contaminated, and contaminated
|
Clean: none
Clean-contaminated: single preop and postop dose |
|
4 situations in which prophy Abx are indicated
|
Exposure to bacteria
Prosthetic material Immunosuppression Poor bloody supply |
|
When should prophy Abx be given?
|
1 hr preop
Postop: multiply half-life of drug by 1-2.5 |
|
Prophy Abx of choice
|
Amox (or amp if IV)
Pen-allergic: clinda or cephalexin (or cefazolin if IV) |
|
Rx for amebic liver abscess
|
Metronidazole
|
|
Rx for pyogenic liver abscess
|
Perc drainage + Abx against G- and anaerobes
|
|
Best diagnostic test to determine treatment for sliding hiatal hernia?
|
Flexible endoscopy to look for esophagitis
|
|
1st test when extrahepatic biliary obstruction is suspected?
|
EUS
|
|
Increased SGOT and SGPT indicate
|
Hepatocellular disease
|
|
Increased alk phos indicates
|
Biliary obstruction
|
|
Obese/hirsute man with painful fluctuant mass btwn gluteal clefts
|
Infected pilonidal cyst
|
|
Hematochezia, fever, abd pain
|
Ischemic colitis
|
|
Management of ischemic colitis vs. acute mesenteric ischemia
|
Expectant (IVF, bowel rest, supportive) vs. surgery
|
|
Pts who undergo major colon resections undergo what change in their bowel habits?
|
None, usually; lots of reserve capacity for water absorption
|
|
Pts who undergo major colon resections undergo what change in their bowel habits?
|
None, usually; lots of reserve capacity for water absorption
|
|
Work-up of rectal cancer
|
Rigid proctoscopy (to assess distance of lesion from anal verge); barium enema or colonoscopy to r/o other lesions; CT abd/pelvis for mets; MRI for extent of local invasion; endorectal US for depth of invasion
|
|
Where are most dietary carbs absorbed?
|
Duodenum (even in short gut syndrome is in residual jejunum)
All of milk except fat absorbed in duodenum |
|
Rx for hepatic adenomas <4cm vs. >4cm
|
OCP cessation vs. surgical resection b/c of risk of rupture/hemorrhage
|
|
Management of acute hemorrhage from L-sided portal HTN (gastric varices + splenic or portal vein thrombosis w/o cirrhosis)
|
Splenectomy
|
|
Management of hepatic focal nodular hyperplasia
|
Nothing
|
|
Acute appendicitis presentation but w/ terminal ileum edema/fibrinopurulent exudate in OR
|
Regional enteritis; in kids, just do appy
|
|
Management of iatrogenic injury of CBD --> biliary stricture
|
End-to-side choledochojejunostomy (Roux-en-Y) performed over a stent
|
|
Acute intestinal radiation injury is manifested by
|
Diarrhea or GI bleeding
|
|
Chronic intestinal radiation injury causes ___ and can lead to these clinical problems
|
Progressive vasculitis and fibrosis
Malabsorption, ulceration, fistulization, or perforation |
|
4 things that inhibit intestinal motility
|
Sympathetics: drugs, hormones, emotions (fear)
Gastrin |
|
Factor that stimulates intestinal motility
|
Parasyms: acetylcholine
|
|
Best test for diagnosis of gastrinoma
|
Secretin stimulation test
|
|
Another name for gastrinoma
|
Zollinger-Ellison syndrome
|
|
Most common location of a gastrinoma
|
"Gastrinoma triangle" : duodenum, junction of neck/body and pancreas, and junction of cystic and common bile duct
|
|
Expected fluid/electrolyte status in SBO
|
Dehydration from vomiting and poor oral intake
Contraction alkalosis with hypokalemia (due to loss of H+, Na+, and Cl-) |
|
Concern with SBO and heme-positive stool in rectum
|
Obstructing tumor or ischemic bowel
|
|
Management of SBO due to inguinal hernia
|
Urgent repair and relief of bowel obstruction due to risk of strangulation
|
|
Most common tumor that metastasizes to the intestine
|
Melanoma
|
|
Indications for surgical exploration with SBO
|
Localized abdominal tenderness, fever, tachy, leukocytosis, metabolic acidosis (high risk for strangulation)
|
|
2 operative management choices for pt with SBO with uncertain bowel viability
|
Resect and anastamose
OR Second look operation 24hrs later |
|
Greatest risk associated w/ enterotomy
|
Postop leak and development of small bowel fistula
|
|
3 causes of abdominal distention other than SBO
|
Ileus, air swallowing, constipation
|
|
Diagnostic tests for suspected ischemic bowel
|
Sigmoidoscopy
Mesenteric angiogram (to determine whether candidate for surgical revascularization) |
|
Long-term medical Rx after surgical revascularization
|
ASA
|
|
Management if full-thickness necrosis found on sigmoidoscopy
|
Exploration and resection (vs. mucosal ischemia only, can observe closely)
|
|
Long-term management of pt with necrosis from ligament of Treitz to transverse colon
|
Can resect, esp in younger pt, but will have short bowel syndrome and need chronic TPN/ small bowel transplant
|
|
Most common location for Crohn's
|
Ileocolic
|
|
Thickened bowel wall with fibrous strictures and deep fissures
|
Crohn's
|
|
Epithelial ulceration and crypt abscesses
|
UC
|
|
Noncaseating granulomas or mesenteric lmphadenopathy can both indicate this type of IBD
|
Crohn's
|
|
Focal aphthous ulcers can indicate this type of IBD
|
Crohn's (whereas general ulceration is usually UC)
|
|
What is the "string sign" and what does it indicate?
|
Narrowing of terminal ileum from edema: Crohn's
|
|
Rx for acute disease vs. prevention in UC
|
Steroids for acute
5-aminosalicylic acid for prevention of relapse |
|
Drug for perianal Crohn's
|
Metronidazole
|
|
Problems associated w/ resection of the terminal ileum
|
Poor reabsorption of bile acids and vita B12 --> diarrhea, malabsorption, oxalate stones, B12 deficiency
|
|
Rx for Crohn's disease of the rectum
|
Can use 5-acetylsalicylic acid
|
|
Screening recommendations for UC of pancolitis vs. L-colon only
|
Colonoscopy every 1-2yrs beginning after 8yrs of disease vs. after 10yrs of disease
|
|
Why are random biopsies during colonoscopy necessary in UC?
|
Colon cancer of UC doesn't always follow sequence of polyp --> cancer
|
|
Fever, blood-tinged diarrhea, and pain on defecation after a total proctocolectomy w/ ileal pouch- anal anastamosis
|
Pouchitis
|
|
Rx for pouchitis
|
Metronidazole
|
|
Pt with UC, abdominal pain, distention, fever, and bloody diarrhea
|
Worry about toxic megacolon
|
|
Diagnostic test for toxic megacolon
|
Abdominal series (v. dilated colon w/ mucosal edema and w/o signs of abscess or perforation); often also a CT to r/o abscess or perf
|
|
Rx for toxic megacolon
|
If stable: NGT, NPO, TPN, IVF, broad spectrum Abx, high-dose IV steroids
|
|
Suspected toxic megacolon + free air on upright CXR
|
Perforation! Immediate OR
|
|
Air in wall of colon on XR
|
Impending perforation, likely OR!
|
|
PEX manuever that must always be done when appendicitis is suspected?
|
Rectal exam to detect pain in the right pelvis from retrocecal appendicitis
|
|
Appendicitis like presentation + dysuria/urinary WBCs
|
Possibly uncomplicated UTI, but also possibly appendiceal abscess in continuity w/ bladder
|
|
Abd pain + urinary RBCs too numerous to count
|
Severe UTI or kidney stone
|
|
Pregnant woman with RUQ pain
|
Worry about appendicits (appendix has been shifted)
|
|
Surgical management of perforated appendicitis w/ localized abscess
|
Appy + incise, drain, and irrigaet abscess; leave closed drain in abscess draining to outside; close muscle but leave skin open
|
|
Suspected appendicitis with small yellow firm mass at TIP of appendix
|
Carcinoid tumor (if not spread, just needs routine appy)
|
|
Suspected appendicitis with larger yellow firm mass at BASE of appendix
|
Needs excision; if >2cm or at base, suggestive of malignancy and indication for R colectomy
|
|
Diagnostic tests needed after carcinoid tumor diagnosed on path
|
Baseline urinary 5-hydroxyindoleacetic acid (5-HIAA) and serum serotonin level (carcinoid determinants of malignancy involve mostly biological behavior of tumor)
|
|
Management of postop pelvic abscess
|
Drain w/ perc catheter if possible, other open surgical drainage (or transrectal/ transvaginal drainage)
|
|
Colonoscopy screening for pts with first degree relative w/ CRC or adenomatous polyp?
|
Starts at 40yo (or 10yrs prior to relative's diagnosis?)
|
|
Colonoscopy screening for pts with FH of FAP?
|
Genetic counseling, yearly flex sig
Colectomy once polyps discovered |
|
Colonoscopy screening for pts with FH of HNPCC?
|
Genetic testing and colonoscopy every 1-2yrs beginning at age 20yo, yearly beginning at 40yo
|
|
Colonoscopy screening for pts w/ Hx of large or multiple adenomatous polyps that were remoevd?
|
Colonoscopy 3yrs after removal
|
|
Colonoscopy screening for pts with Hx of CRC
|
Colonoscopy 1yr after initial op, screening at 3yrs and then 5yr intervals
|
|
CEA measurement indications after CRC
|
Every 2-3mo for 2yrs (detects 80% of recurernces)
|
|
Surgical management for external vs. internal hemorrhoids
|
External: excision
Internal: excision or banding |
|
Any hemorrhoids w/ bleeding need what?
|
Colonoscopy to r/o colon cancer
|
|
2 types of polyps
|
Pedunculated (on a stalk)
Sessile (flush w/ mucosa) |
|
F/u after polypectomy
|
Repeat colonoscopy after 3-6mo to ensure sucessful removal and then surveillance colonoscopy every 3yrs
|
|
Management of carcinoma in head sv. stalk of pedunculated polyp
|
Head: polypectomy only
Stalk (esp if margin <2cm, poorly differentiated, or vascular/lymphatic invasion): may require bowel resection in addition to polypectomy |
|
Staging studies for colon cancer
|
CXR
CEA LFTs |
|
Most common presenting symptoms of R or L-sided colon cancer
|
Pain/mass
|
|
Most common presenting symptoms of sigmoid colon cancer
|
Pain or bowel complaints
|
|
Most common presenting symptoms of rectal cancer
|
Bowel complaints or bleeding
|
|
Prep before bowel surgery (3 parts)
|
- Bowel prep (polyethylene glycol or mag citrate)
- Oral nonabsorbed Abx (to decrease colonic bacteria) - Single preop dose of 2nd generation cephalosporin (to decrease wound infections) |
|
Specific places to explore for colon cancer mets
|
Small bowel mesentery, peritoneal surface, diaphragm, liver
|
|
Postop management after colon cancer surgery
|
NPO w/ IVF until bowel function returns; d/c when tolerating food
|
|
Colon cancer prognosis worse for these types of tumors (4)
|
Mucus-producing
Signet ring cell tumors Tumors p/w bowel perf Tumors w/ venous or perineural invasion |
|
What types of adjuvant chemo are used in colon cancer pts and for what stage?
|
Stage III
5-FU and leucovorin or levamisole |
|
Screening f/u after colon cancer
|
Repeat colonoscopy at 6mo then 12mo intervals + frequent monitoring of CXR, CEA, and LFTs
|
|
Management of colon cancer + large liver lesion
|
Large liver lesions shouldn't be resected at tmie of surgery
|
|
Feculent vomiting postop from colectomy ddx (2)
|
Leakaeg from anastomosis --> persistent ileus
Mechanical obstruction |
|
Cause of feculent material draining from inferior wound
|
Anastomotic leak that is spontaneously draining to skin; should close with NPO and IVF; need CT scan to determine if there is undrained collection
|
|
Diagnosis and management of distended colon
|
Likely sigmoid or cecal volvulus
Proctosigmoidoscopy first to eval for/hopefully treat sigmoid volvulus; if negative, emergent celiotomy for presumed cecal volvulus (risk of rupture in 1-2hrs) |
|
Common additional site of liver cysts
|
Lung
|
|
2 equivalent management options for echinococcal liver infections
|
Surgical drainage
Albendazole/mebendazole + perc drainage |
|
2 causes of feculent vomiting after colectomy
|
- Leakage from anastomosis --> persistent ileus
- Mechanical obstruction due to adhesions, hernia, or obstructed anastamosis |
|
Management of feculent material draining from inferior aspect of colostomy wound
|
Likely due to anastomotic leak
NPO, IVF, usually will self-close |
|
Pt 6mo s/p colostomy for colon cancer returning w abd pain, constipation, small stools
|
Concern for anastomotic recurrence of cancer or stricture at anastomosis
|
|
Rectal carcinomas spread to which lymphatic nodes?
|
Internal iliac
Sacral Inferior mesenteric Inguinal (if <5cm from anal verge) |
|
Type of resection necessary for rectal cancer >5cm above anal verge vs. <5cm
|
>5cm, can do anterior resection
<5cm, need abdominoperineal resection due to margins including sphincter |
|
Which rectal cancers require postop chemo?
|
Stage III (regional LNs) or high-risk stage II
|
|
Which rectal cancer pts receive preop radiation?
|
Those with large/bulky tumors
|
|
2 alternatives to colostomy for rectal carcinoma
|
Sphincter-preserving proctectomy or local resection
|
|
Pelvic pain after rectal cancer
|
Early postop: operative nerve injury or infection
Later: need to r/o local recurrence w/ CT pelvis |
|
Which hepatic mets are unresectable?
|
Multiple lesiosn in both lobes, lesions intimate w/ vascular structures or invading local structures, or lesions in cirrhotic livers
|
|
Most common cause of anal cancer and presenting symptoms
|
SCC
Bleeding, drainage, pain, pruritis |
|
Where does anal cancer metastasize to?
|
Inguinal LNs (also superior rectal LNs)
|
|
Staging w/u for anal cancer
|
CT and transrectal US
|
|
3 treatment regimens for anal cancer depending on location of lesion:
- Superficial, small, mobile - Large w/o extension or LNs - + LNs |
- Local excision alone
- Nigro protocol: chemo (5-FU, mitomycin C) and radiation, then resection only if there's biopsy-proven residual cancer - Chemoradiation, then radical resection |
|
Pain med to be avoided in diverticulitis
|
Morphine (b/c increases intracolonic pressure)
|
|
Management of 2nd episode of diverticulitis
|
Elective resection 4-6wks after inflammation has resolved (b/c risk of significant complication (perf, abscess) increases w/ each recurrence)
|
|
What is required before surgery for diverticulitis?
|
Preop or intraop colonoscopy to identify region w/ diverticula
|
|
Diverticulitis w/ patient deteriorating
|
Free perforation or intra-abdominal abscess
|
|
Eval for suspected perf/abscess from diverticulitis
|
CT
|
|
Management of diverticulitis abscess
|
CT-guided needle insertion of catheter in collection
|
|
What is Ogilvie syndrome?
|
Pseudo-obstruction: massive cecal and colonic dilation in absence of mechanical obstruction
|
|
Management of Ogilvie syndrome?
|
D/c narcotics/ anticholinergics; endoscopic colonic decompression if dilation >10cm; surgery if perforation or ischemia suspected
|
|
Cause of Zenker's diverticulum
|
Premature contraction of cricopharyngeal muscle on swallowing --> partial obstruction
|
|
Symptoms of Zenker's
|
Dysphagia, regurgitation, recurrent aspiration PNA
|
|
Diagnosis and treatment of Zenker's
|
Barium swallow
Diverticulectomy w/ cricopharyngeal myotomy |
|
RUQ pain, jaundice, GI bleeding
|
Quincke triad for hemobilia
|
|
Causes of hemobilia
|
Iatrogenic (from percutaneous liver procedures), anticoagulation, gallstones, parasitic infection, neoplasm
|
|
Diagnosis and treatment of hemobilia
|
Angiography/ endoscopy
Angiographic embolization if intrahepatic Surgery if bleeding from extrahepatic bile ducts or gallbladder |
|
Noncaseating granulomas are associated with this type of IBD
|
Crohn's
|
|
IBD w/ crypt abscess
|
UC
|
|
Sensation of voided air with urination
|
Pneumaturia, e.g. from colovesical fistula
|
|
Most common type of fistula due to diverticulitis
|
Colovesical fistula
|
|
Most common cause of rapid lower GI bleeding
|
Bleeding diverticula and vascular ectasias
|
|
Rx for vascular ectasia
|
Coagulation w/ monopolar current
|
|
Why are diverticula associated w/ bleeding?
|
Underlying vasa recta artery penetrating thru bowel wall
|
|
How to diagnose an ongoing GI bleed w/ negative upper and lower scopes
|
Technetium-labeled RBC scan or mesenteric angiography
|
|
When to use angiography vs.RCN scanning
|
Angiography in less stable pts
RBC scanning in more stable pts, can detect slower bleeds |
|
2 treatment options for bleeding discovered during angiography
|
Vasopressin into the vessel
Embolization |
|
Typical pt/ causes of sigmoid volvulus
|
Debilitated pts from nursing homes due to chronic laxative use, chronic illness, or dementia
|
|
Type of obstruction in sigmoid volvulus
|
Closed loop obstruction
|
|
Rx for sigmoid volvulus
|
Rigid proctosigmoidoscopy and placement of rectal tube
|
|
Definitive Rx for sigmoid volvulus
|
Sigmoid colectomy w/ colostomy or anastomosis
|
|
Rx for cecal volvulus
|
Urgent surgical treatment w/ detorsion alone, cecopexy, or right colectomy
|
|
3 treatment options for Ogilvie's syndrome w/ colon diameter >11-12cm (otherwise conservative Rx)
|
1) Endoscopic decompression
2) Neostigmine (increases colonic tone and counteracts dilation) 3) Surgical decompression |
|
Rx for rectal prolapse
|
Internal: high fiber diet
External w/ bleeding: surgery |
|
3 surgical options for prolapse
|
1) Rectopexy (no removal)
2) Transabdominal rectosigmoid resection 3) Perineal approach w/ removal and anastamosis |
|
Rx for anal fissures (conservative vs. more invasive)
|
Bulk agents/ softeners, sitz baths
If deep and chronic, lateral sphincterotomy +/- biopsy if suspicious for cancer |
|
What are anal fissures and what causes them?
|
Tears in the anoderm (--> painful BM, tenderness on palpation, blood on TP) due to repeated trauma from hard stools or IBD
|
|
Pain and drainage in sacrococcygeal area
|
Pilonidal abscess (infection in hair-containing sinus in sacrococcyx)
|
|
Rx for pilonidal abscesses
|
Unroof, remove all hair, leave open to heal by secondary intention
|
|
Most common complications of stomas
|
#1: leakage around the bag
Also parastomal herniation, bowel obstruction abscess, fistula formation |
|
What is a Hartmann pouch?
|
If distal bowel is closed and not brought to abdominal wall but rather dropped back into pelvis
|
|
Common indication for Hartmann pouch
|
Diverticulitis when bowel can't be safeul reconnected
|
|
Small intestine bleeding in a pt under 30
|
Meckel's diverticulum
|
|
Work-up for suspected Meckel's?
|
99m-Tc pertechnate scan
|
|
What type of tumor is a carcinoid tumor?
|
Apudoma
|
|
Congenital cystic dilation of the extrahepatic biliary duct?
|
Choledochal cyst
|
|
Management of choledochal cyst?
|
Complete resection of cyst (due to risk of malignant changes) and roux-en-y choledochojejunostomy
|
|
What is stress ulceration?
|
Acute gastric or duodenal erosive lesions following shock, sepsis, major surgery, trauma, or burns
|
|
Cause of stress ulceration?
|
NOT increased acid; may be ischemic damage to mucosa; often ulcers are in multiple places
|
|
Treatment of pancreatic pseudocyst?
|
Wait 6wks to allow for spontaneous resolution; then excise, externally drain, or internally drain into GI tract
|
|
Do pancreatic pseudocysts have malignant potential?
|
No, b/c have no epithelial lining
|
|
Complications of pseudocysts
|
Gastric outlet and extrahepatic biliary obstruction
Spontaneous rupture and hemorrhage |
|
What is a Diuelafoy's lesion?
|
Abnormally large submucosal artery that protrudes thru small, solitary mucosal defect 6cm distal to GEJ --> spontaneous bleeding
|
|
Rx for Diuelafoy's lesion?
|
Endoscopic
|
|
When is hemicolectomy needed for appendiceal carcinoid tumors?
|
If >2cm
|
|
Asthma, right heart valvular disease, flushing, hepatomegaly, diarrhea
|
Carcinoid syndrome
|
|
Indication for resection of a gallbladder polypoid lesion?
|
Clinical symptoms
|
|
Electrolyte abnormalities after pancreatectomy
|
Hypocalcemia
Hypophosphatemia Iron deficiency Pernicious anemia |
|
Characteristics of cecal diverticula?
|
Congenital
Solitary True diverticula (involve all layers of bowel wall) |
|
Management of liver hemangiomas?
|
Can usually observe; affected by hormones, but usually only hemorrhage iatrogenically (from attempted biopsy)
|
|
CEA is elevated in these pts w/o cancer
|
Smokers
|
|
High CEA indicates?
|
High likelihood liver involvement/ peritoneal spread
|
|
Management of Mallory Weiss tear?
|
If bleeding stopped: expectant
To control bleeding: balloon tamponade, endoscopic control, gastrostomy/oversewing, or vasopressin (but not in CAD pts) |
|
Types of gastric ulcers and which are acid-associated?
|
I (lesser curvature)
II (gastric and duodenal) III (pyloric) IV (juxtracardial) II and III are acid associated |
|
Rx for Type I ulcer
|
Antrectomy (+/- vagotomy)
|
|
Surgical Rx for type III ulcer?
|
Vagotomy and antrectomy
|
|
Surgical Rx for toxic megacolon?
|
Subtotal colectomy with end ileostomy
|
|
Rx for SCC of the anus refractory to Nigro protocol (chemo and XRT)?
|
Abdominal-perineal resection w/ permanent end colostomy
|
|
Rx for proximal and midrectal cancers?
|
Low anterior resection
|
|
Radiolucency under right hemidiaphragm indicates?
|
Pneumoperitoneum
|
|
Causes of pneumoperitoneum
|
Perforated diverticulum, perforated gastric ulcer, perforated transverse colon carcinoma, or strangulated hernia w/ necrotic bowel
|
|
Intestines in upside down U
|
Sigmoid volvulus
|
|
How does PEEP improve oxygenation?
|
Increasing FRC b ykeeping alveoli open at end of expiration
|
|
Potential negative effects of increased PEEP (3)
|
- Alveolar overdistention --> pneumothoraces
- Decreased venous return/CO - Increased minute ventilation requirements due to increased dead space ventilation |
|
Systemic hypotension, JVD, distant heart sounds
|
Beck's triad for cardiac tamponade
|
|
What is pulsus paradoxus?
|
Decrease in SBP by >10 at end of inspiration
|
|
Risk factors for eriop MI
|
Previous infarction, esp w/in 6mo
DOE Age >70 MR > 5 PVCs/min Tortuous or calcified aorta |
|
When should you not use epi w/ lidocaine?
|
Tissues supplied by end arteries (fingers/ toes, ears, nose, penis)
|
|
What can interfere with measurement of wedge pressure w/ Swan Ganz catheter?
|
PEEP or CPAP
|
|
Increased risk of periop stroke with?
|
History of stroke
|
|
What is the mortality from periop stroke?
|
High
|
|
PaCO2 levels are a reliable indicator of?
|
Adequacy of alveolar ventilation
|
|
Respiratory acidosis from hypercarbia
|
Alveolar hypoventilation
|
|
Hypoxemia with increased PCO2 is NOT
|
PE, pulmonary edema, PNA, or atelectasis (b/c those pts should be hyperventilating (decreased CO2) to improve oxygenation
|
|
Benefits of albumin vs. transferrin/acute phase reactants to eval nutritional status
|
Long life life (3 wks) vs. short (hrs), but not affected by intravascular volume
|
|
The physiologic goal of shivering is to ___, which causes ___
|
Generate heat to maintain core temp
Increases metabolism by 3-5x, which increases O2 consumption/ CO2 production, which is usually counterproductive in critically ill pts |
|
What should be administered preop in a pt with vWD?
|
Cryoprecipitate (provides both FVIII and vWF)
|
|
Best choice for stress ulcer prophylaxis
|
Sucralfate (better than antacids, which cause loss of acidic protection and G- overgrowth)
|
|
Procedure for tracheostomy
|
Skin incision below cricoid cartilage, strap muscles spared and retracted, thyroid isthmus divided if necessary, trachea entered at second tracheal ring
|
|
Rx for malignant hyperthermia
(3) |
Cessation of anesthesia, hyperventilation w/ 100% O2, IV dantrolene
|
|
Effect of PE on CVP
|
Increases by causing RV overload and increasing RAP
|
|
Renal failure with eosinophilia
|
Cholesterol atheroembolism
|
|
Hyperkalemia, hyponatremia, hypoglycemia, fever, weight loss, dehydration
|
Adrenocortical insufficiency (e.g. Addison's disease)
|
|
Why are antacids given before emergency intubation?
|
Risk of intubation, esp if don't know gastric contents
|
|
Rx for necrotizing fasciitis
|
Wide debridement
|
|
Passive rewarming is appropriate for which pts?
|
Mild hypothermia (between 34 and 36C)
|
|
Smoke inhalational injuries: cause, which lab value is elevated, mortality
|
Epithelial injury from chemical irritation
Carboxyhemoglobin Low in absence of cutaneous burns |
|
Which anesthetic can cause seizures?
|
Enflurane
|
|
Adjunct anesthetic that can cause hypotension if given in bolus
|
Morphine
|
|
Anesthetic with nephrotoxicity
|
Methoxyflurane
|
|
Complications of halothane
|
Hypotension, decreased CO
|
|
Anesthetic that can cause increased distension if used in a pt with bowel obstruction
|
Nitrous oxide
|
|
Hypertensive pt after carotid endarterectomy is at risk for ___, so needs this treatment and monitoring
|
- Hemorrhagic stroke
- Aggressive BP management with nitroglycerin or nitroprusside - Arterial cath for beat to beat monitoring of BP |
|
Indications for intracranial pressure monitoring (5)
|
Subarachnoid hemorrhage, hydrocephalus, postcraniotomy status, Reye's syndrome, blunt head trauma w/ repeated surgeries
|
|
A thrombin time measures the function of what?
|
Fibrinogen
|
|
Which nerve innervates the majority of the intrinsic hand muscles?
|
Ulnar nerve
|
|
Which nerve innervates the extensor muscle (and one other function)?
|
Radial nerve (also does forearm supination w/ musculocutaneous nerve)
|
|
Which inflammatory mediator is key to wound healing?
|
Monocytes (phagocystose + secrete GFs)
|
|
When in healing to fibroblasts appear?
|
Day 3
|
|
Which type of collagen predominates during proliferative phase of wound healing, and what is it replaced with?
|
Type III
Type I |
|
Lympangitic inflammatory streaking along extremities indicates infection with what type of bacteria, and what Abx are indicated?
|
Strep
Penicillin |
|
Cutaneous ulcers associated with IBD?
|
Pyoderma gangrenosum
|
|
Rx for pyoderma gangrenosum
|
Systemic steroids and immunosuppressants (e.g. cyclosporine)
|
|
Rx for frostbite (initial rewarming and overall)
|
Rapid warming in hot water (40-44C)
Elevation, Abx, tetanus toxoid, debridement of necrotic skin |
|
What are clean surgical wounds?
|
No part of respiratory, GI, or GU tract entered
|
|
3 causes of squamous cell carcinoma
|
Sun exposure, chronic ulcers or sinus tracts (draining osteomyelitis), history of radiation or thermal injury
|
|
Advantage/disadvantage of Mohs surgery
|
Improved cosmetic result, but longer time required (small increments with immediate frozen section analysis); no difference in outcomes
|
|
Where do the superficial and deep finger flexors insert and which has a common muscle belly?
|
Superficial: middle phalanx
Deep: distal phalanx; common muscle belly (so only superficial flexors can move finger when others are immobilized) |
|
Healing a tendon injury requries formation of a ___, requiring a balance between ____?
|
Tenoma, which tends to become adherent to surrounding sheath; need balance btwn avoiding adhesions w/ early mobilization and risk of rupturing unhealed tendon
|
|
Tendon repair of the hand is most difficult in which area?
|
Fibroosseous tunnels
|
|
When should devitalized tissue be excised in cases of severe burns?
|
Early, except w/ deep wounds of palms, soles, genitals, and face
Staged excision of deep partial-thickness or full thickness burns btwn 3 and 7 days after injury |
|
Topical therapy used for burns to delay colonization?
|
Silver sulfadiazine
|
|
Why can skin autograft not be placed over eschar?
|
Requires a vascular bed
|
|
When should longitudinal escharotomy be performed?
|
First sign of vascular compromise
|
|
Rare complication of silver nitrate
|
Methemoglobinemia
|
|
More common complication of silver nitrate
|
Hyponatremia and other electrolyte imbalances
|
|
Main complication with silver sulfadiazine
|
Neutropenia
|
|
Main complication with mafenide acetate
|
Metabolic acidosis 2/2 inhibition of carbonic anhydrase
|
|
Where is SCC of the lip usually found?
|
Lower lip (b/c of sun exposure)
|
|
When are early carpal tunnel syndromes often noticed?
|
Nocturnally
|
|
When does carpal tunnel often present in women?
|
During pregnancy, w/ recurrent symptoms during PMS in subsequent periods
|
|
What is responsible for wound contracture?
|
Fibroblasts with actin microfilaments
|
|
Initial Rx for leukoplakia
|
Oral hygiene, avoidance of alcohol/tobacco, avoidance of chronic irritation (e.g. ensuring dentures fit properly)
|
|
When does leukoplakia need biopsy?
|
Thick lesions
|
|
When are cleft lips/palates repaired?
|
Lip in first 3mo of life
Palate at 12-18mo |
|
What is a Marjolin's ulcer?
|
SCC that develops in a chronic wound such as a previous burn scar or sinus tract 2/2 osteo
|
|
Rx for Marjolin's ulcer
|
Surgical excision or amputation
|
|
What is the cause of compartment syndrome for burn pts?
|
Increased pressure 2/2 tissue edema and lack of elasticity of burnt skin (eschar)
|
|
Rx for compartment syndrome due to burns
|
Escharotomies of affected extremity
|
|
Which wounds should not be closed?
|
- Dirty or contaminated (e.g. animal bites)
- Trauma by puncture/gunshot or crush injury) - Older than 6hrs |
|
What prophylactic Abx should be used for bowel cases?
|
3rd generation cephalosporin (for G- coverage)
Clinda or metronidazole for anaerobic coverage |
|
Ulcer over medial malleolus, painless, and associated w/ brawny induration
|
Venous stasis ulcer
|
|
Most common location for diabetic ulcers
|
Plantar surface of foot
|
|
Most common location for ischemic ulcers
|
Dorsum of foot or 1st/5th toe
|
|
Rx for acute diaphragmatic rupture
|
Emergent ex lap
|
|
What is a seatbelt sign and how is it managed?
|
Abdominal wall ecchymosis from seatbelt
Observe for signs of enteric or mesenteric injury even if pt stables/tests negative |
|
When should you tape the chest for rib fracture and why?
|
Never! (compounds problem of inadequate ventilation)
|
|
Management for lower rib fractures
|
Imaging to assess for associated abd injuries, pain control, admit if respiratory probelms, will heal spontaneously
|
|
Organ most likely to be daamged in blunt abd trauma
|
Spleen
|
|
Rx for venous injury in hemodynamically unstable pts
|
Ligation, not repair (only repair if HDS, is a proximal vein, and there is also an arterial injury)
|
|
Rx for signs of arterial insufficiency w/ signs of neuro compromise in extremity (Ps)
|
Immediate op and repair
|
|
Eval for penetrating trauma below nipples
|
Diagnostic peritoneal lavage
|
|
Why is local wound exploration contraindicated in penetrating trauma to the chest?
|
Risk of creating pneumothorax
|
|
Insulin secretion in trauma pts is?
|
Increased
|
|
Rx for complete common bile duct transection
|
T-tube
W/ loss of tissue, choledochojejunostomy or cholecystojejunostomy |
|
Abd trauma w/ pain, RUQ mass, obstructive symptoms, and coiled spring appearance of duodenum
|
Duodenal hematoma
|
|
Rx for duodenal hematoma
|
NGT and observe
|
|
Rx for closed radial nerve palsy
|
Fracture reduction and observation, 90% will self resolve
|
|
First sign of increased ICP
|
Change in level of consciousness
|
|
Initial Rx for increased ICP w/ hypotension
|
Hyperventilation (mannitol or head elevation may exacerbation hypotension)
|
|
What is flail chest?
|
Paradoxical respiratory movement due to at least 2 fractures in each of 3 adjacent ribs
|
|
Rx for flail chest
|
Analgesia, chest physiotherapy
Mechanical ventilation only if respiratory compromise develops |
|
High carboxyhemoglobin levels indicate
|
Carbon monoxide poisoning
|
|
Rx for carbon monoxide poisoning (mild vs. severe) and for how long?
|
Mild: 100% O2
Severe (coma, respiratory failure): Hyperbaric chamber Either should last until carboxyhemoglobin levels are <10% |
|
Rx for single pelvic fracture in pelvic ring
|
Bed rest until HDS, then gentle ambulation
|
|
How does fluid resuscitation for electrical injury compare to that for thermal injury?
|
Can't use BSA b/c often deep tissue damage is worse than superficial; need massive amts of fluid
|
|
Electrical pts require f/u with what specialists?
|
Ophthalmologists (b/c of risk of cataract development)
|
|
Highest rate of vascular injury comes with this MSK injury
|
Knee dislocations (due to extreme force required to dislocate the joint)
|
|
Indications for thoracotomy after chest tube placement?
|
1500ml of blood on initial chest tube placement
OR Persistent bleeding at 200mL/hr for 4hrs or 100 mL/hr for 8hrs |
|
With subQ emphysema in the extremities, worry about
|
Necrotizing fasciitis
|
|
Rx for suspected clostridium infection
|
High dose penicillin G
|
|
Rx for myocardial contusion with normal ECG
|
Tele for 24hrs, no need for ICU, low risk of complications
|
|
Cellular changes during injury/sepsis (4)
|
- Gluconeogenesis
- Acute phase protein synthesis (fibrinogen, completement, haptoglobin, ferritin) - Decreased glutamine (is consumed) - Increased urinary nitrogen loss and peripheral release of aas (from accelerated protein breakdown) |
|
Diagnostic test for suspected penetrating injury to rectum
|
Sigmoidoscopy
|
|
Why is barium contraindicated in suspected penetrating injury to colon, and what should be used instead?
|
Spillage of barium mixed with feces into peritoneal cavity would increase likelihood of intraabdominal abscess
Water-soluble medium |
|
Rx for postop bile leak
|
ERCP with sphincterotomy and/or tenting
|
|
When is a bile leak a biliary fistula?
|
If drains >50cc/day for over 2 wks
|
|
When is a bile leak major, and what mangement does that warrant?
|
Early biliary drainage >300cc/day
Re-laparotomy and hepatico-jejunostomy |
|
What cannot be excluded following vascular trauma w/ ischemic changes despite palpable pulses?
|
Arterial injury
|
|
When do blowout orbital fractures require immediate operative intervention (4)?
|
- Extraocular muscle entrapment (e.g. inability to move eye in particular direction)
- Fracture >50% of orbital floor - Diplopia - Enophthalmos >2mm |
|
Management of blunt renal trauma?
|
Nonsurgical:
- Bedrest to decrease likelihood of secondary hemorrhage - Abx to reduce likelihood of infection w/in hematoma |
|
If urethral injury is suspected, what should be done prior to placing a Foley?
|
Retrograde urethrogram
|
|
Management of pt with urethral injury who cannot receive a Foley cath?
|
Suprapubic cath
|
|
3 complications of pancreatic injury
|
Fistula, pseudocyst, abscess
|
|
Most common cause of death in pts with pancreatic injury
|
Exsanguination from associated injury to major vascular structures
|
|
Management of penetrating pancreatic injur
|
Most just need simple drainage
|
|
How does a pneumatic antishock garment work?
|
Elevates BP by increasing peripheral vascular resistance
|
|
How should a pneumatic antishock garment be discontinued?
|
Very slowly to prevent sudden irreversible hypotension
|
|
Indications for ER thoracotomy
|
- Release cardiac tamponade in pts deteriorating radpily
- Cross-clamping of descending in aorta if can't maintain BP otherwise - Internal cardiac massage for pts w/ faint pulses/distant heart sounds and other resuscitation unsuccessful |
|
Rx for enterocutaneous fistulas
|
Bowel rest, TPN, correct electrolyte abnormalities
|
|
Complications of enterocutaneous fistulas
|
Fluid and electrolyte depletion, skin necrosis, malnutrition
|
|
Imaging study for pt with enterocutaneous fistula
|
Small-bowel follow through to determine location, relation to other organs, and whether there is distal obstruction
|
|
Which enterocutaneous fistulas are least likely to close?
|
Proximal small bowel fistulas (up to mi-ileum) w/ high output of fluid
|
|
Choice for repair of artery
|
End-to-end anastamosis if possible
If too much lost, use a vein graft |
|
Contraindications for nonoperative management of a splenic injury (2)
|
Indication of associated injury requiring operation (e.g. peritonitis)
Hemodynamically unstable pt or deteriorating |
|
4 criteria through which DPL can be positive (diagnostic peritoneal lavage)
|
>10cc gross blood initially
>100,000 RBC/ uL > 500 WBC / uL Elevated amylase, bili, or alk phos |
|
CXR indications of thoracic aortic injury
|
Widening of mediastinum
Loss of aortic knob Sternal or scapular fracture Multiple L rib fractures Massive L hemothorax |
|
PEX difference in pts in neurogenic vs. hypovolemic shock
|
Neurogenic: pts are warm and pink and usually bradycardic
Hypovolemic: pts are cold and clammy and usually tachycardic |
|
Abdominal compartment syndrome causes (5)
|
- Increased ICP/ decreased CPP (Due to decreased venous return)
- Decreased venous return/CO - Increased SVR - Increased peak airway pressures - Decreased RBF/GFR and liver function |
|
Rx for laryngeal obstruction
|
Cricothyroidotomy
|
|
Rx for pericardial tamponade
|
Subxiphoid, supradiaphragmatic incision and creation of pericardial window
|
|
Rx for an open pneumothorax
|
Occlusive dressing over defect; later thoracostomy tube (preferably thru separate incision) and formal closure of chest wall
|
|
Which cells produce TNF?
|
Monocytes/macrophages (present in G-shock and sepsis)
|
|
Paucity of bile ducts on liver bipsy years after transplant indicate
|
Chronic rejection
|
|
Rx for chronic liver rejection
|
Retransplantation
|
|
Rx for portal venous thrombosis early after transplant
|
XL and thrombectomy
|
|
Sequela of hepatic arterial thrombosis
|
Biliary strictures 2/2 ischemia
|
|
What is combined in a transplant cross match?
|
Donor lymphocytes w/ recipient serum
|
|
What is a cross match searching for, and why would those things be present?
|
Recipient Abs against donor HLA antigens
Not naturally present but acquired from pregnancy, blood transfusion, or prior transplant |
|
What does a positive cross match predict?
|
Transplantation will cause a hyperacute rejection
|
|
Shortly after receiving chemo, pt becomes febrile w/ hyperkalemia, hyperphosphatemia, and hypocalcemia
|
Tumor lysis syndrome
|
|
Which cells mediate tumor lysis syndrome?
|
Cytotoxic T cells
|
|
How does cyclosporine work?
|
Inhibits IL-2 production, so there is no expansion of cytotoxic T cells or production of antibodies
|
|
Conservative measures for renal failure pts not yet in need of emergent dialysis
|
<60g of protein/day
Limit fluids Kayexylate for hyperkalemia |
|
Best transplant matches
|
Living relative with 6 HLA matches > living relative with 0 HLA matches > cadaveric transplant
|
|
Most common cause of death within 1yr of cardiac transplant
|
Infection
|
|
Most common cause of death after 1yr of cardiac transplant
|
Accelerated graft arteriosclerosis
|
|
Presentation of hyperacute renal rejection
|
Swollen bluish oliguria
|
|
Histology of hyperacute renal rejection
|
Fibrin; platelet thrombosis; necrosis of glomerular tufts, renal arterioles, and small arteries
|
|
Rx for hyperacute renal rejection
|
Plasmapheresis and cyclophosphamide decrease antibody load, but no definitive treatment available
|
|
Main toxicity of cyclosporine
|
Nephrotoxicity
|
|
Matching criteria for cardiac transplants
|
Size and ABO compatability (cannot tissue-type like with renal transplants, b/c can only be protected by hypothermia for 4hr)
|
|
Increased Cr, decreased UOP, fever, tenderness 2mo after renal transplant
|
Acute rejection (1wk-3mo posttransplant)
|
|
Rx for acute renal rejection
|
Biopsy to confirm diagnosis, high dose steroids, anti-T-cell antibody (e.g. OKT3)
|
|
4 most common post-transplant viruses
|
CMV, EBV, VZV, Herpes viruses
|
|
CMV infection can cause
|
Ulceration and hemorrhage in GI tract
Pneumonitis, retinitis, encephalitis, pancreatitis |
|
Best and worst survival rate after liver transplant is for which pts?
|
Best: cholestatic liver disease
Worst: fulminant hepatic failure |
|
Rx for GVHD
|
More aggressive immunosuppression
|
|
Glucose and end-organ outcomes after pancreas transplant for T1DM
|
Normal serum glocuse and normal GTT
No reversal of diabetic retinopathy or reduction in ulcers/amputations Can prevent recurrence of nephropathy if combo w/ kidney transplant |
|
How long should presence of an extrahepatic malignancy defer liver transplant for?
|
2yrs after curative therapy
|
|
Contraindication to liver transplant
|
Alcohol use w/in 3mo
|
|
What is OKT3?
|
Monoclonal Ab against CD3 antigen complex on mature T cells
|
|
Severe complications of OKT3 (4)
|
Noncardiogenic pulmonary edema
Encephalopathy Aseptic meningitis Nephrotoxicity |
|
What is OKT3 used for (3)?
|
Rejection prophylaxis, acute rejection, induction therapy
|
|
Diagnostic test for enlarged cervical LNs
|
FNA (or open biopsy if lymphoma is suggested)
|
|
When should adjuvant chemo be started?
|
10-14 days after surgery, to allow for wound healing (unless there are compelling clinical indications for more urgent treatment)
|
|
Extravasation of chemo agents during IV administration may cause what?
|
Severe ulceration and sloughing
|
|
What can normalize wound healing when given with methotrexate?
|
Folinic acid
|
|
For which 4 tumor types is histologic grade closely correlated with stage/ prognosis?
|
Soft tissue sarcoma, transitional cell cancer of the bladder, astrocytoma, chondrosarcoma
|
|
Wilms tumor is associated with what 4 conditions and how often?
|
Aniridia, cryptorchidism, hemihypertrophy, hypospadias
10% |
|
Most common presentation of Wilms tumor
|
Asymptomatic mass (hematuria in less than half, hypertensive in just over half)
|
|
MEN 1 tumors
|
Pituitary, pancreatic, parathyroid
|
|
MEN 2A tumors
|
Hyperparathyroidism, pheochromocytoma, medullary thryoid cancer
|
|
MEN 2B tumors
|
Pheochromocytoma and mucosal neuromas, medullary thyroid cancer, gangliomas
|
|
Most common GI site for non Hodgkin's lymphoma?
|
Stomach
|
|
What are interferons?
|
Glycoproteins; products of virus-infected cells that inhibit viral replication
|
|
3 diseases that interferons are very effective in
|
Burkitt's lymphoma
Hairy cell leukemias (and other hematologic malignancies) Hep B and C |
|
Typical procedure for parotid carcinoma
|
Superficial parotidectomy w/ facial nerve preservation (may need deeper/loss of nerve if tumor is more involved) + regional node dissection (50% rate of occult mets)
|
|
Most common operative complication of chemotherapy?
|
Perirectal abscess
|
|
This condition carries an increased risk of testicular cancer
|
Cryptorchidism (even after surgical correction)
|
|
Procedure for testicular cancer
|
Inguinal orchiectomy + LN dissection if embryonal or teratoma
|
|
Why don't seminomas need LN dissection?
|
Very radiosensitive
|
|
Why don't choriocarcinomas need LN dissection
|
Very chemosensitive, often w/ pulm mets
|
|
Pheos are associated with these 4 syndromes
|
MEN 2A, MEN 2B, VHL, NF-1
|
|
What causes tissue death from radiation?
|
Both direct effect of xrays and indirect effect mediated by free radicals
|
|
Which cells are resistant to radiation?
|
Those deficient in oxygen
|
|
Cells in which phase of the cell cycle are most sensitive to radiation?
|
M phase
|
|
IL-2 is an effective drug for pts with which two metastatic diseases?
|
Metastatic melanoma and metastatic RCC
|
|
Complications of IL-2 treatment
|
Lymphocytosis, eosinophilia, fluid retention, fever, decrease in peripheral vascular resistance (is like septic shock)
|
|
Nitrates and nitrosamides are associated with what kind of cancer?
|
Stomach cancer
|
|
Excessive amts of dietary fat and fiber deficiency is associated with what kind of cancer?
|
Colorectal cancer (and pancreas, prostate, and uterine)
|
|
3 elements of the mainstay of immunosuppression for cardiac and renal transplants
|
Steroids
Calcineurin inhibitors (FK506 or cyclosporine) Antimitotic agents (azthioprine or mycophenylate mofetil) |
|
Should needles be capped or uncapped for HIV pts?
|
Always uncapped! Capping procedures are more dangerous
|
|
RET protooncogene is associated w?
|
MEN 2
|
|
PTEN tumor suppressor gene is associated w/?
|
Cowden disease (multiple harmartoma syndrome)
|
|
p16 tumor suppressor gene is associated w/?
|
Malignant melanoma
|
|
Which tumors are more likly to be ER+, BRCA1 associated or BRCA2?
|
BRCA 2
|
|
Which other cancers are associated with BRCA1?
|
Colon and prostate
|
|
Which other cancers are associated with BRCA2?
|
Gallbladder, bile duct, pancreatic, gastric, melanoma, prostate
|
|
Toxicity associated w/ cyclophosphamide
|
Hemorrhagic cystitis
|
|
Toxicity associated w/ bleomycin
|
Pulmonary fibrosis
|
|
Toxicity associated w/ vincristine
|
Peripheral and central neurotoxicity
|
|
Toxicity associated w/ cisplatin
|
Oto/neuro/nephrotoxicity
|
|
Toxicity associated w/ 5-FU
|
Mucositis, dermatitis, cerebellar dysfunction
|
|
4 posttransplant malignancy and the viruses associated with them?
|
Posttransplant lymphoproliferative disorder (enlarged LNs): EBV
HCC: HBV or HCV Kaposi's sarcoma: HHV8 Cervical cancer: HPV |
|
Rx for posttransplant lymphoproliferative disorder
|
Withdraw immunosuppression, antivirals, chemo, or monoclonal Abs
|
|
What is tertiary hyperparathyroidism?
|
Persistent hypercalcemia 2/2 autonomous parathyroid function after renal transplant (high calcium pre and posttransplant)
|
|
What is a Dukes C colon cancer?
|
AKA Stage III, indicates involves adjacent LNs
|
|
Mild increase in creatinine shortly after renal transplant likely indicates?
|
Nephrotoxicity from cyclosporine, hold it
|
|
Low WBC count after renal transplant likely indicates?
|
Bone marrow toxicity from azathioprine, hold it
|
|
Rx for renal transplant pt with CMV
|
High dose gancyclovir
|
|
Elevated Cr 3-6mo after transplant with vs. without fever and graft tenderness and Rx
|
With: likely rejection, start steroid burst and/or OKT3
Without: likely cyclosporine toxicity, hold it |
|
Rx for adrenal insufficiency
|
Exogenous steroids
|
|
Preop Rx for Addison's disease
|
Exogenous steroids
|
|
Best test for adrenal insufficiency?
|
ACTH stimulation test
|
|
Difference between adenoma and carcinoma on thyroid scan
|
High uptake (hot) for adenoma
Low uptake (cold) for carcinoma |
|
Swelling under incision, stridor, difficulty breathing after thyroidectomy and Rx
|
Wound hematoma: intubation, explore wound, evacuate hematoma, control bleeding
|
|
True or false: previous history of therapeutic radiation to breast is an absolutely contraindication to lumpectomy with XRT
|
True
|
|
Rx for inflammatory breast cancer
|
Surgery, chemo, and XRT
|
|
3 Rx options for prolactinomas
|
Asymptomatic: observe
Symptomatic: dopamine agents (e.g. bromocriptine) Refractory symptoms: surgery |
|
What is sestamibi scanning for?
|
Parathyroid problems
|
|
Labs in primary hyperparathyroidism (2 most imp for diagnosis)
|
Increased PTH with increased serum calcium
|
|
Hypercalcemia with low urinary calcium
|
Familial hypocalciuric hypercalcemia (vs. in primary hyperparathyroidism, urinary calcium should be high or nml)
|
|
Usual Rx for glucagonoma
|
Distal pancreatectomy
|
|
Rx for hyperglycemia in unresectable glucagonoma pts
|
Octreotide
|
|
When do adrenal adenomas need to be resected?
|
If they are functioning, nonfunctioning but >6m, or carcinoma suspected
|
|
Rx after adrenal surgery
|
Steroid replacement for 6-12mo postop, even if contralateral adrenal is normal
|
|
Radiation-induced thyroid cancer is usually what histo type?
|
Papillary
|
|
Rx for radiation-induced thyroid cancer
|
Near total or total thyroidectomy due to high incidence of bilateralityand more effective use of radioactive iodine postop
|
|
What % of pts with radiation history and thyroid nodule have cancer?
|
40%
|
|
Risk of invasive breast cancer after LCIS: what type, what location, and for how long?
|
Most commonly ductal carcinoma
Risk equivalent in both breasts, last indefinitely, not correlated to amt of LCIS |
|
Whorled pattern in breast mass on young girl?
|
Fibroadenoma
|
|
Work up for incidentally identified adrenal tumor (e.g. small incidentaloma) (4 things and what each is ruling out)
|
- Dexamethasone suppression test (to r/o Cushing's)
- 24hr urine collection to r/o pheo - Serum lytes and plasma renin/aldosterone to r/o aldosteronoma - MRI to r/o malignancy |
|
First therapy for hypercalcemia
|
Vigorous hydration to restore intrasvascular volume --> renal perfusion and increased urinary calcium excretion
|
|
What diuretics should be used in hypercalcemia?
|
Loop diurectics (Lasix); thiazides are contraindicated b/c cause pts to become hypercalcemic
|
|
Indications for surgery for asymptomatic primary hyperparathyroidism
|
<45yo
Markedly increased urine Ca Kidney stones Decreased Cr clearance Marked hypercalcemia Decreased bone mass |
|
Two causes of fat necrosis in the breast
|
Trauma
Prolonged pressure |
|
Fat necrosis is often confused with?
|
Breast cancer (although it doesn't increase the risk of carcinoma)
|
|
Diagnosis and treatment of fat necrosis
|
Excisional biopsy, once confirmed, then excision
|
|
45yo woman with HTN, hair development, and 7cm suprarenal
|
Functional adrenocortical tumor (functional indicates can secrete cortisol, androgens, estrogen, aldosterone, or multiple hormones)
|
|
What is Cushing's disease?
|
Pituitary tumor --> hypercortisolism --> bilateral adrenal hyperplasia
|
|
Rx for functional adrenocortical tumor
|
Resection
|
|
Adjuvant therapy for unresectable functional adrenocortical tumor
|
Mitotane
|
|
Preop treatment for pheo
|
Alpha blockade 1-3wks in advance (+ volume expansion)
Then add beta blockade (not alone b/c of risk of CV collapse) |
|
True or false: chemotherapy is contraindicated during pregnancy
|
False; only during first trimester, is generally safe during second and third trimesters
|
|
Nipple erosion and eczema
|
Paget's disease of the breast
|
|
Paget's disease with a mass
|
Likely an infiltrating ductal carcinoma
|
|
Rx for Paget's disease
|
Modified radical mastectomy (possibly less if no associated mass?)
|
|
Paradoxical rise in serum gastrin and IV secretin is diagnostic of what syndrome?
|
Zollinger Ellison syndrome
|
|
Rx for Zolllinger-Ellison syndrome
|
Distal pancreatectomy (where the gastrinoma mass usually is)
|
|
Which drugs are useful in Zollinger Ellison syndrome?
|
H2 blockers
|
|
Preop treatment before thyroidectomy for Graves disease to prevent postop thyroid storm
|
Medicate to euthyroid
10 days of Lugol's iodide solution, propylthiouracil, or methimazole |
|
Rx for thyroid storm
|
Beta blockade (e.g. propanolol)
|
|
Rx for primary hyperparathyroidism
|
Resection of usually solitary adenoma
|
|
Rx for parathyroid hyperplasia
|
Resection of 3 1/2 parathyroid glands; leave the rest and can reexplore if needed
Calcium and possibly Vita D supplementation afterward |
|
Rx for cystosarcoma phyllodes
|
Wde excision with adequate margins
|
|
What is Hurtle cell cancer and how does it usually behave?
|
Type of follicular thyroid cancer; often multifocal and bilateral, more likely to metastasize, higher mortality
|
|
Rx for Hurthle cell lesions?
|
Lobectomy if unilateral adenoma
Total thyroidectomy for carcinoma |
|
What test is not useful for Hurthle cell cancer and why?
|
FNA, b/c can't determine invasion
|
|
Amyloid deposits in the stroma of a thyroid tumor indicate?
|
Medullary carcinoma
|
|
Rx for follicular thyroid mass
|
Adenoma: lobectomy
Carcinoma or >4cm: total thyroidectomy |
|
12 signs of Cushing's syndrome
|
Truncal obesity
HTN Hirsutism Moon facies Proximal muscle wasting Ecchymoses Skin striae Osteoporosis DM Amenorrhea Growth retardation Immunosuppression |
|
What percent of gastrinomas/insulinomas are malignant?
|
50%/10%
|
|
What antibiotic is useful in unresectable malignant insulinoma?
|
Streptozotocin (controls symptoms by selectively destroying islet cells)
|
|
How do the characteristics of positive lymph nodes change the staging of breast cancer
|
Palpable lodes are only Stage II unless they are fixed or matted, then Stage III
|
|
What is desmoplasia/ a desmoplastic reaction?
|
Growth of fibrous or connective tissue, secondary to another insult (e.g. scar formation around a neoplasm or adhesions after abdominal surgery)
|
|
Rx for sclerosing adenosis
|
Nothing: is a benign lesion
|
|
Rx for LCIS
|
Twice yearly exams and yearly mammography; is not a precancerous lesion in itself, just predicts future risk of cancer but equal in both breasts
|
|
Which subtype of DCIS has the highest recurrence?
|
Comedo
|
|
Rx for stress urinary incontinence
|
Estrogen, pelvic floor exercises, timed voiding, or urethral sling surgery
|
|
Rx for urge incontinence
|
Anticholinergics, biofeedback, timed voiding
|
|
Cause of overflow incontinence
|
Bladder outlet obstruction
|
|
Cause and Rx for total incontinence (continuous leakage of urine)
|
Fistula
Surgery |
|
Hypospadias in the scrotal area is associated with these 2 other problems
|
Bilateral undescended testes
Infertility |
|
Where is hypospadias most commonly
|
Corona
|
|
Hypospadias in the corona is often associated with a?
|
Chordee (ventral curvature of penis)
|
|
Why would a pt not have hematuria with a kidney stone?
|
If completely occluding lumen of ureter
|
|
What % of kidney stones recur
|
50% within 5-10yrs
|
|
Initial Rx for kidney stones
|
Hydration and analgesics
|
|
Pathophys of testicular torsion
|
Abnormally narrowed testicular mesentery w/ tunica vaginalis surrounding testis and epididymis in bell clapper deformity
|
|
Testicular pain decreased w/ elevation
|
Prehn sign for epididymitis
|
|
Rx for testicular torsion
|
Bilateral orchiopexy
|
|
Which renal tumor can only be diagnosed on patho?
|
Oncocytoma
|
|
3 types of benign kidney lesions
|
Simple cysts, angiomyolipomas, oncocytomas
|
|
Rx for RCCs based on size
|
<4cm: partial nephrectomy
>4cm: radial nephrectomy (includes ipsilateral adernal gland and perirenal fat) |
|
How does prostate cancer spread?
|
Direct extension, lymphatics, blood vessels
|
|
Most common site of distant mets from prostate cancer?
|
Axial skeleton with osteoblastic bony lesions
|
|
Rx for prostate cancer with T1 masses in men >65yo?
|
Expectant management
|
|
Where in the gland does prostate cancer usually initiate?
|
Periphery
|
|
Risk factors for prostate cancer
|
FH, African American, diet
|
|
Surgical indications for BPH
|
Urinary retention refractory to medical Rx, upper tract dilation, renal insufficiency 2/2 outflow obstruction, bladder stones, recurrent UTIs
|
|
Rx for BPH
|
TURP
|
|
Postop problem with TURP
|
Hyponatremia due to hemodilution 2/2 absorption of irrigation fluid
|
|
Management of suspected ruptured urethra
|
Retrograde urethrogram
If complete disruption: suprapubic cath, delay repair 4-6mo (after which hematoma will be resolved) |
|
Rx for ureteral injury
|
Reconstruction (primary anastamosis vs. ureteroplasty)
|
|
Rx for ureteral injury if can't do immediate repair
|
Placement of stent w/ catheter into proximal ureteral stump and delayed reconstruction
|
|
Which kidney stones require further workup?
|
>1cm (if <.5cm, likely to pass spontaneous): IV pyelogram
If high-grade obstruction, need nephrostomy or passage of ureteral stent |
|
Rx for cryptoorchidism
|
Inguinal orchiopexy before 1yo
|
|
To which LNs do seminomas usually metastasize?
|
Along regional lymhatic drainage pathways to iliac, aortic, and renal LNs
|
|
Rx for seminoma
|
Removal of affected testis
Sample LN (usually external iliacs) for mets; if present, radiation |
|
Best postop assessment of sigmoid viability?
|
Sigmoidoscopy
|
|
Repeated cellulitis in pt with unilateral LE swelling is due to?
|
Unilateral primary lymphedema
|
|
Pt s/p AAA repair now w/ severe L flank pain and bloody mucus per rectum
|
Ischemic colitis due to damage to IMA
|
|
Smokers often have isolated atherosclerosis in which LE artery?
|
Superficial femoral
|
|
Diabetics often have isolated atherosclerosis in which LE artery?
|
Tibioperoneal
|
|
Inability to dorsiflex toes may indicate
|
Anterior compartment syndrome
|
|
Acute arterial occlusion w/o collaterla inflow and rapid reperfusion of ischemic muscle may cause
|
Anterior compartment syndrome
|
|
Rx for claudication
|
Smoking cessation, weight loss, exercise; vasodilators don't help
|
|
How long is aspirin's antiplatelet effect?
|
7-10days
|
|
Mechanism of aspirin
|
Inhibits synthesis of thromboxane A2 and subsequent production of prostaglandins
|
|
Pt with angina and claudication who is now light-headed on exertion especially when working with his arms may have?
|
Subclavian steal syndrome
|
|
What is the subclavian steal syndrome?
|
Atherosclerotic occlusion of subclavian artery proximal to vertebral artery so that when involved arm (usually left) exercises, becomes relatively ischemia, causing reversal of flow thru the vertebral artery --> diminished flow to the brain
|
|
Rx for subclavian steal syndrome
|
Carotid-subclavian bypass or subclavian-carotid transposition (or dilation/stenting of artery)
|
|
Aortoiliac atherosclerotic occlusive disease causes what symptom?
|
Claudication of buttock and thigh
|
|
Bilateral stenosis or occlusion of what arteries can cause sexual impotence?
|
Hypogastric (internal iliac) arteries
|
|
Best predictor of periop ischemic cardiac eevnts for peripheral vascular surgery
|
Dipyridamole-thallium imaging (pts often can't undergo stress test)
|
|
Management of acute graft occlusion is with what med?
|
Urokinase (fewer allergic rxns than streptokinase)
|
|
% effectiveness of urokinase and reocclusion rate %
|
75% effective
20% reoccluded w/in 1yr (even if angioplasty or anastamotic revision performed; 50% w/o surgical revision) |
|
Rx for symptomatic popliteal aneurysm
|
Exclusion (ligation) and surgical bypass; can also terat asymptomatic pts if good surgical candidates
|
|
Cause of popliteal aneurysms and what else to look for
|
Atherosclerosis
Often bilateral and/or associated with extrapopliteal aneurysms |
|
Abdominal pain out of proportion to PEX?
|
Intestinal ischemia
|
|
Increased serum lactate may be associated with what arterial pathology?
|
Mesenteric ischemic
|
|
Management of pt with AAA and horshoe kidney
|
Preop arteriogram to define the likely unusual vascular anatomy
Retroperitoneal dissection and implantation of all renal arteries |
|
Immunocompromised pt with new murmur, fever, back pain, and enlarged saccular abdominal aorta below renal arteries
|
Mycotic aortic aneurysm
|
|
What is the cause of mycotic aortic aneurysms?
|
Infection w/ staph or salmonella
|
|
Rx for infrarenal mycotic aortic aneurysm
|
Axillofemoral bypass, excision of invovled aorta, grafting, Abx for 3-6mo
|
|
Best surgical option for rest claudication in otherwise healthy patient
|
Aortoefmoral bypass
|
|
Best surgical option for rest claudication in pt with many comorbidities
|
Extraanatomic bypass (femorofemoral or axillofemoral bypass)
|
|
Contraindication to femorofemoral bypass?
|
Bilateral iliac artery disease
|
|
Rx for empyema
|
Thoracotomy with decortication (to allow lung to reexpand) and antibiotics
|
|
Facial swelling and cyanosis on bending over
|
Superior vena cava syndrome
|
|
Top 2 causes of SVC syndrome
|
Bronchogenic carcinoma
Lymphoma |
|
Rx for SVC syndrome
|
Diuresis
Radiation and chemo for malignancy |
|
Rx for perforation of esophagus during endoscopy for pts w/ and w/o underlying esophageal problem
|
Without: thoracotomy w/ primary repair and drainage of mediastinum
With: thoracotomy with esophagectomy |
|
Rx for lung abscess
|
Prolonged Abx; if fails, percutaneous or surgical drainage
|
|
Rx for descending aortic dissection
|
Reduction in change in BP over change in time (dP/dT): beta blockade, then nitroprusside
|
|
Indications for operative intervention for descending aortic disection
|
End-organ failure, inadequate pain relief despite medical Rx, rupture, signs of impending rupture (increasing diameter or periaortic fluid)
|
|
Unilateral hip pain on outer surface of thigh, more painful with pressure (e.g. when sleeping)
|
Trochanteric bursitis
|
|
What is Paget's disease of the bone and what are pts predisposed to?
|
Osteitis deformans: accelerated bone turnover in localized areas --> focal bony hypertrophy
Bone is weak and prone to pathologic fractures |
|
How to distinguish trochanteric bursitis pain from that of hip OA?
|
Trochanteric: superficial
Hip OA: pain is deep within the joint, may be referred to inguinal area/ knee |
|
Which manuevers worsen trochanteric bursitis vs. hip OA?
|
TB: external rotation or resisted abduction
OA: internal rotation |
|
Peritoneal abdomen, bloody stool, N/V
|
Bowel infarction
|
|
Acute abdominal or back pain followed by syncope and eventually hypovolemic shock
|
AAA rupture
|
|
Where does the pain in acute renal colic start/ radiate to?
|
Unilateral flank pain, radiates to groin
|
|
Differentiate the swelling in a ligamentous knee injury vs. meniscal
|
Ligamentous: rapid from hemarthrosis
Meniscal: over 12-24hrs |
|
"Popping" sensation in knee likely indicates
|
Meniscal injury
|
|
Tenderness over medial knee in athlete or obese older woman w/out popping sensation
|
Anserine bursitis
|
|
2 most common complications from rhinoplasty
|
Nasal obstruction
Epistaxis |
|
Whistling noise after nasal surgery, and why pts are at risk for this complication
|
Nasal septal perforation (at risk b/c of poor blood supply: is cartilage)
|
|
Which pts are predisposed to nasal polyps
|
Asthma/ allergic disorders (due to chronic inflammation)
|
|
Symptom of nasal polyp and management
|
Chronic nasal obstruction
If symptomatic: surgical removal |
|
Pain, tenderness, and erythema within the nose
|
Nasal furuncuolosis 9from staphylococcal folliculitis)
|
|
Predisposing factors for nasal furunculosis
|
Nose picking or nasal hair plucking
|
|
Why is nasal furuncolosis life threatening?
|
Can spread to cavernous sinus
|
|
What are the two most common causes of postop nasal septal perforation?
|
Septal hematoma
Septal abscess (much less common) |
|
Most common iatrogenic cause of tension pnuemo
|
Subclavian central venous catheter placement
|
|
Malignant vs. benign breast calcifications
|
Malignant: microcalcs
Benign: coarse calcs |
|
Breast biopsy with fat globules and foamy histiocytes
|
Fat necrosis
|
|
One week after abdominal injury w/ negative CT pt has fever, shaking chills, and deep abdominal pain
|
Retroperitoneal abscess from pancreatic injury (wouldn't necessarily be diagnosed on initial CT, unlike many other injuries)
|
|
Trauma pt with gross hematuria
|
Suspect bladder injury
|
|
Diagnostic test for suspected bladder injury
|
Retrograde cystogram w/ post void films
|
|
First step in management of a pt with new-onset oliguria with a Foley
|
Change Foley to ensure not clogged (then fluids)
|
|
Pts with Crohn's are predisposed to what GU abnormality and why?
|
Nephrolithiasis
Fat malabsorption --> hyperoxaluria |
|
Struvite stones are often due to persistent infection by what bacteria?
|
Proteus
|
|
What are staghorn calculi?
|
Struvite stones that fill the entire renal pelvis
|
|
N/V, abd pain, hypoglycemia, and hypotension after stressful event (e.g. surgery)
|
Adrenal insufficiency
|
|
Which pts are particularly predisposed to this type of postop adrenal insufficiency?
|
Steroid-dependent pts
|
|
What is the cause of postop obstructive atelectasis?
|
Airway blockage --> retained air distal to occlusion (which is eventually reabsorbed); affected airway becomes airless and collapses
|
|
Compensation for hypoxemia due to postop atelectasis
|
Respiratory alkalosis (hyperventilation)
|
|
How far in advance of surgery is preop smoking cessation beneficial?
|
>8wks prior to surgery
If closer, actually have increased risk of postop pulm complications |
|
Unilateral bloody nipple discharge in perimenopausal woman with no other findings on PEX/imaging
|
Intraductal papilloma
|
|
Why are intraductal papillomas often not palpated/ visualized on imaging?
|
Small size (US can only detect >1cm) and beneath areola so difficult to palpate
|
|
Rx for unresponsive trauma pt who is still hypotensive after fluids
|
Emergent ex lap (suspect continued bleeding)
|
|
What is Legg-Calve-Perthes isease?
|
Avascular necrosis of femoral capital epiphysis
|
|
Radiologic difference between SCFE and Legg-Calve-Perthes
|
SCFE: femoral epiphysis is structurally intact w/in acetabulum, just misaligned
LCP: severe abnormalities of epiphysis/ avascular degeneration |
|
Hip pain w/ limp in young boy
|
With limp, most likely Legg-Calve-Perthes (I think?)
|
|
Child w/ limp and normal XRs
|
Transient synovitis of hip
|
|
Bowel sounds in ileus vs. SBO
|
Ileus: hypoactive/ absent
SBO: hyperactive ("tinkling") |
|
Cause of ileus after trauma
|
Retroperitoneal hemorrhage associated w/ vertebral fractures
|
|
High-riding prostate, scrotal hematoma, and inability to urinate is most likely due to what kind of urethral injury?
|
Posterior urethra (pelvic hematoma causes the high-riding prostate)
|
|
Which type of urethral injury is commonly associated w/ pelvic fracture
|
Posterior urethra
|
|
2 most common causes of anterior urethra injury
|
Blunt trauma to perineum (straddle injury)
Instrumentation of urethra |
|
How does intraperitoneal bladder rupture present?
|
Peritoneal signs on PEX
|
|
Multiple bony lesions with elevated alk phos
|
Paget's disease of the bone (osteitis deformans)
|
|
Paget's disease of the bone is associated with these three other conditions in the head
|
Increased head/hat size
CN palsies Hearing loss |
|
3 vaccines needed after splenectomy
|
S. pneumoniae, N. meninigitidis, H. influenzae
|
|
Common ortho injury after seizures and typical presentation
|
Posterior dislocation of shoulder
Pt holding arm adducted and internally rotated |
|
When is surgery indicated for GERD?
|
10-15% of pts with GERD refractory to medical therapy
|
|
Preop requirements for GERD surgery
|
EGD with biopsy and esophageal manometry (to demonstrate intact esophageal peristalsis)
|
|
Surgery of choice for GERD
|
Nissen fundoplication (restores GEJ and LES to normal intra-abdominal position and wraps stomach around distal esophagus to augment LES tone while preserving LES relaxation)
|
|
Surveillance for Barrett esophagus
|
Endoscopy and biopsies ever 18-24mo to determine if it has progressed to dysplasia
|
|
Rx for Barretts with severe dysplasia
|
Esophageal resection (high risk of occult adenocarcinoma)
|
|
4 types of hiatal hernia
|
Type I: GEJ above diaphragam
Type II: paraesophageal (stomach herniates into chest but GEJ in nml location) Type III: mixed, i.e. stomach herniates into chest + GEJ in chest Type IV: other abd contents in chest |
|
Why is a Type II hernia dangerous?
|
Risk for a gastric volvulus
|
|
Indications for surgery for H. pylori
|
Persistent ulcer after adequate treatment (8-12 wks of medical Rx with EGD showing persistent ulcer)
|
|
3 surgical options for H. pylori
|
1) Highly selective vagotomy (procedure of choice, despite recurrence risk)
2) Truncal vagotomy and pyloroplasty 3) Vagotomy and antrectomy (highest complication rate) |
|
What should always be done in cases of persistent ulcer?
|
Measure serum gastrin levels
|
|
Which types of ulcer are associated with low vs. high acid?
|
Types I and IV: low acid
Types II and III: high acid |
|
Where are the 4 types of gastric ulcers located?
|
Type I: lesser curvature
Type II: simultaneous duodenal ulcer Type III: prepyloric Type IV: gastric cardia/GEJ |
|
All gastric ulcers require this diagnostic test
|
Biopsy to rule out malignancy
|
|
Surgical options for gastric ulcers, based on type
|
Antrectomy
Add truncal vagotomy if type II or III (acid producing) |
|
How to stage gastric cancer
|
Abdominal explroation
|
|
Early gastric cancer surgical treatment
|
Distal subtotal gastrectomy
|
|
Which subtype of gastric carcinoma has teh best prognosis?
|
Intestinal
|
|
Resection of infiltrating gastric carcinoma includes?
|
Stomach, omentum, and perigastric LNs
|
|
What is linitis plastica?
|
Diffusely infiltratnig gastric carcinoma; involves all layers of stomach wall with marked desmoplastic reaction
|
|
Rx for linitis plastica
|
Total gastrectomy with splenectomy, though cure is rare
|
|
How does linitis plastica appear on biopsy?
|
Wall of stomach appears fixed and rigid
|
|
Cancer at the GEJ/proximal stomach has a better/worse prognosis than those in the antrum?
|
Worse
|
|
Surgical Rx for perforated ulcer
|
Close ulceration with Graham patch
If pt had previous ulcer symptoms/ treatment, should also do vagotomy and pyloroplasty |
|
Management of perfed ulcer that appears >12hrs ago
|
Quick closure and then monitor in ICU for sepsis with fluids, IV Abx, and omeprazole
|
|
Two drugs with gastric mucosal protective properties
|
Misoprostol (PGE1 analog)
Sucralfate (topical cytoprotective) |
|
What does an ulcer with a white base indicate?
|
How not bled recently, can observe
|
|
Management of ulcer visualized on endoscopy with clot and/or visible artery?
|
Endoscopic hemostasis
With visible artery and recent bleed, may need surgical intervention |
|
How does the endoscopic management of gastric vs. duodenal ulcers differ?
|
All gastric ulcers require biopsy!
|
|
3 management options for gastric varices
|
More recalcitrant than esophageal:
- Cyanoccrylate glue - TIPS - Splenectomy |
|
Gastritis and gastric varices in pt w/ history of chronic pancreatitis: diagnosis and management
|
May be due to splenic vein thrombosis --> left sided portal HTN
Splenectomy if bleeding is persistent |
|
Rx for esophageal varices
|
- FFP and Vita K
- Vasopressin or octreotide to lower portal pressure - Sclerotherapy/band ligation |
|
Multiple linear erosions in the gastric mucosa at the GEJ
|
Mallory Weiss Syndrome
|
|
Rx for persistent bleeding from Mallory Weiss Syndrome
|
Injection or electrocautery
|
|
Three heart infections associated with Reiter's syndrome (reactive arthritis)
|
Myocarditis, aortitis, pericarditis
|
|
4 conditions associated with HLA-B27
|
Reactive arthritis
Aortic regurg Pericarditis Ankylosing spondylitis |
|
Coughing up hair may indicate
|
Teratoma in connection with tracheobronchial tree
|
|
Which receptors do the following drugs act on, causing what effects?
Epi |
B1 and B2
|
|
Which receptors do the following drugs act on, causing what effects?
Norepi |
B1 and B2, at nerve synapses
|
|
Which receptors do the following drugs act on, causing what effects?
Isoproterenol |
Beta agonist --> vasodilator and chronotropic
|
|
Which receptors do the following drugs act on, causing what effects?
Dopamine |
Alpha-1 and dopamine receptors --> vasodilation
|
|
Which receptors do the following drugs act on, causing what effects?
Dobutamine |
Similar to dopamine as strong inotrope but minimal chronotropic action
|
|
Which receptors do the following drugs act on, causing what effects?
Milirinone/amrinone |
Vasodilation and inotropy via inhibition of phosphodiesterase
|
|
Which receptors do the following drugs act on, causing what effects?
Digitalis |
Inhibiits NaKATPase --> positive inotrope
|
|
Which receptors do the following drugs act on, causing what effects?
Nitroprusside vs. nitroglycerin |
Both are vasodilators
Nitroprusside: balanced arterial and venous dilation Nitroglycerian: more venous effects --> venous pooling |
|
Octreotide vs. vasopressin for bleeding esophageal varices
|
Octreotide is better b/c vasopressin has side effect of coronary vasoconstriction
|
|
Management for persistent esophageal variceal bleeding despite medical therapy (3)
|
Portosystemic shunt (high mortality)Balloon tamponade
TIPS procedure |
|
Long-term prevention of bleeding of esophageal varices
|
Beta blockers
|
|
Pt with fever, chills, night sweels, weight loss, and epigastric upset
|
Gastric lymphoma (constitutional symptoms + epigastric upset)
|
|
Rx for pts with mucosa-associated lymphoid tissue lymphoma in the stomach
|
H pylori eradication only; surgery if fail to respond (more advanced gastric lymphomas reuire surgery)
|
|
8 complications from central venous catheter placement
|
Arterial puncture
Pneumothorax Hemothorax Thrombosis Air embolism Sepsis Vascular perf Myocardial perf --> tamponade |
|
Where should a central venous catheter be on CXR?
|
Ideally in the SBC, but at least proximal to cardiac silhouette
|
|
First step in hip fractures from a fall in the elderly, once stabilized with pain control and DVT prophy
|
Determine the cause of the fall/ operative risk
|
|
Signs and symptoms of transtentorial herniation of the uncus
|
Ipsilateral hemiparesis
Ipsilateral mydriasis and strabismus Contralateral hemianopsia Altered mental status |
|
Pain in forefoot/ btwn 3rd and 4th toes and a clicking sensation when palpating while squeezing the metatarsal joints
|
Morton's neuroma (positive Mulder sign)
|
|
Rx for Morton neuroma
|
Metatarsal support w/ bar or padded shoe inserts (on both sides so even!) to decrease pressure on metatarsal head; surgery if fails conservative Rx
|
|
What is Boerhaave syndrome?
|
Esophageal perforation due to recurrent retching alone
|
|
Best test for diagnosing an esophageal perf
|
Water-soluble esophagram
|
|
Rx for esophageal perf
|
Primary closure and drainage of mediastinum w/in 6hrs to prevent mediastinitis
|
|
Rx for Legg-Calve-Perthes disease (idiopathic osteonecrosis of the femoral head)
|
Maintaining placement of femoral head w/in acetabulum so heals in proper shape/position (w/ splints or surgery)
|
|
Tachypnea, tachycardia, hypoxia, unilateral decreased breath sounds w/in 24hrs (or even minutes) of rib fracture
|
Pulmonary contusion
|
|
How to distinguish pulmonary contusion from ARDS?
|
ARDS takes 24-48 hrs to develop and is bilateral
|
|
Appendicitis like presentation, but 5 days duration and stable pt: diagnosis and management
|
Likely contained abscess
IVF, Abx, bowel rest, perc drainage if possible, appendectomy in 6-8wks |
|
Flexion of right hip against resistance elicits severe pain
|
Psoas sign: indicative of psoas abscess associated w/ appendicitis
|
|
Rx for apnea in pt with cervical spine injury
|
Orotracheal intubation w/ rapid sequence intubation (requires 4 people)
|
|
Why is needle cricothyroidotomy not useful in adults?
|
Risk of carbon dioxide retention
|
|
Congenital adhesions in children
|
Ladd's bands
|
|
Fever, urticaria, arthritis, nephritis
|
Serum sickness (immune complex reaction against heterologous proteins)
|
|
Burn pt with hyperglycemia, leukocytosis, tachypnea, and tachy
|
Sepsis (bronchopneumonia or bound wound infection)
|
|
Which wound pts need tetanus vaccine?
|
Dirty wound w/ last dose >5yrs ago
Clean wound w/ last dose >10yrs ago |
|
Most common form of thyroid cancer following radiation
|
Papillary carcinoma
|
|
Management of pt with neck nodule with history of neck radiation
|
Proceed directly to thyroidectomy
|
|
Medullary thyroid cancer is associated with a mutation in which gene
|
RET
|
|
5 H&P findings that indicate that a neck nodule may be malignant
|
Hoarseness
Dyspnea Dysphagia Cervical LN enlargement Vocal cord paralysis |
|
Work-up of neck nodule
|
FNA
|
|
When should neck cysts be removed?
|
Large (>4cm) or recurs (to eliminate risk of malignancy)
|
|
Rx for a colloid nodule in the neck
|
Benign: medical thyroid suppression and f/u
|
|
Psammoma bodies indicate this type of thyroid cancer
|
Papillary
|
|
Amyloid deposits and calcitonin staining indicate this type of thyroid cancer
|
Medullary
|
|
Undifferentiated cells indicate this type of thyroid cancer, with this management
|
Anaplastic
Chemo and radiation |
|
Hurthle cells indicate this type of thyroid cancer, with this management
|
Adenoma or low-grade
Lobectomy |
|
Follicular cells indicate what diagnosis/management?
|
Nondiagnostic, but doesn't exclude cancer, so thyroid lobectomy indicated
|
|
Lymphocytic infiltrate indicates what diagnosis/ management
|
Lymphoma (Rx: radiation) or chronic lymphocytic thryoiditis (Rx: thyroid hormone replacement)
|
|
2 most common complications of thyroid surgery
|
Injury to recurrent laryngeal or external branch of superior laryngeal
Injury to parathyroid --> hypocalcemia |
|
Management of papillary cancer (2 subgroups of pts)
|
Previous H&N radiation: total thyroidectomy
No radiation Hx: limited thyroid lobectomy and isthmusectomy (or total thyroid if >1.5cm) |
|
Management of follicular thyroid cancer
|
Microinvasive: formal lobectomy and isthmusectomy
>4cm or clear cancer: total thyroidectomy |
|
What areas have a higher incidence of follicular thyroid cancer?
|
Iodine deficient areas
|
|
Primary means of spread of follicular cancer
|
Vascular
|
|
Management of medullary thyroid cancer
|
Total thyroidectomy
|
|
Histologic feature of medullary thyroid cancers
|
Hyperplasia of C cells (parafollicular) with amyloid
|
|
Which thyroid cancers utilize postop iodine-131 ablation
|
Follicular (always) and papillary (sometimes, + thyroid suppression w/ thyroid hormone)
|
|
Why does medullary cancer not require I-131/thyroid suppression postop?
|
Tumor arises from C cells
|
|
Postop monitoring of medullary cancer uses these two serum levels
|
Calcitonin
CEA |
|
Rx for parathyroid adenoma
|
Resection of involved gland; identification of other glands and biopsy of one to ensure normalcy
|
|
Rx for parathyroid carcinoma
|
Resection of all four glands
|
|
What is a sestamibi scan used for?
|
Preop demonstration of enlarged parathyroid glands to identify adenoma w/o need for idenftification of remaining glands (minimally invasive)
|
|
Most common site for "missing" parathyroid gland on exploration
|
Thymus
|
|
Common postop risk in parathyroidectomy pts
|
Tetany (from hypocalcemia)
|
|
What is Chvostek's sign?
|
Tap on facial nerve adjacent to ear --> spasm of orbicularis oris
|
|
When should asymptomatic hypercalcemia be explored
|
>11
|
|
Initial treatment for acute hypercalcemia (5 agents, in order)
|
1) Rehydration w/ normal saline
2) Furosemide 3) Mithramycin, calcitonin, glucocorticoids |
|
Why do pts with chronic frenal failure develop secondary hyperparathyroidism
|
Retain phosphate from decreased GFR; hyperphosphatemia --> hypocalcemia --> elevated PTH
|
|
Indications for surgical management of secondary hyperphosphatemia
|
Bone pain, intractable pruritus, ectopic calcifications in the soft tissues
|
|
What is calcium tachyphylaxis?
|
Ectopic calcifications in the soft tissues
|
|
Surgical management of secondary hyperphosphatemia
|
Removal of all but 50mg of parathyroid (possible transplant it to forearm)
|
|
Pt with hyperparathyroidism who suddenly develops uncontrollable HTN
|
Undiagnosed pheochromocytoma
|
|
Rx for uncontrolled HTN from pheo
|
Combo alpha and beta blockage
|
|
What is the 10% rule with pheos?
|
10% malignant
10% extraadrenal 10% produce epi 10% bilateral |
|
2 important principles in pheo resection
|
Minimize release of catecholamines with:
- Minimal manipulation of tumor - Ligation of all venous drainage before tumor manipulation |
|
Swollen tender thyroid gland
|
De Quervain's thyroiditis
|
|
Classically elevated lab test in thyroiditis
|
ESR
|
|
Histology of de Quervain's thyroiditis
|
Giant cell granulomas around degenerating thyroid follicles
|
|
Rx for de Quervain's thyroidits
|
Analgesics and aspirin; steroids in resistant cases
|
|
Rx for Hashimoto's thyroidits
|
Thyroid replacement and biopsy of all suspicious lesions (due to higher incidence of malignancy)
|
|
Zollinger-Ellison syndrome is associated with what familial syndrome?
|
MEN-1 (pancreatic endocrine tumor)
|
|
Typical localization of gastrinoma
|
Duodenum and head of pancreas (gastrinoma triangle)
|
|
Primary chemo agent used for tumor control of gastrinoma
|
Streptozocin
|
|
What is the Whipple triad and what tumor does it indicate?
|
Fasting hypoglycemia, symptomatic hypoglycemia, relief w/ glucose admin
Insulinoma |
|
Rx for unresectable insulinoma
|
Diazoxide (inhibitor of insulin release)
|
|
Rx for incidentally identified adrenal mass
|
>5cm: surgical excision (high likelihood of adrenal cortical carcinoma)
<5cm: observation (if normal catecholamines, cortisol, and K+) |
|
Most likely diagnosis with CXR appearance of:
popcorn |
Hamartoma
|
|
Most likely diagnosis with CXR appearance of:
bulls eye configuration |
Benign
|
|
Most likely diagnosis with CXR appearance of:
calcium-containing |
Granuloma (not malignant)
|
|
Diagnostic tests for CXR mass
|
CT and then needle biopsy
|
|
Main risk of needle biopsy
|
Pneumothorax
|
|
What doubling time favors malignant nodule?
|
5wks to 280 days
|
|
What does a low CT density number (<100) indicate
|
Favors malignant status
|
|
3 common cancers that metastasize to the lugn
|
Colorectal
Breast Renal |
|
Lung nodule associated w/ a dental abscess and with chest wall involvement
|
Actinomycosis
|
|
Lung nodule associated w/ chronic skin ulcers
|
Blastomycosis
|
|
Preop eval for pneumonectomy
|
Cardiac: EKG and echo (for EF and wall motion)
Lungs: PFTs, V/Q scan |
|
2 causes of a widened mediastinum
|
Aortic aneurysm
Hilar LAD |
|
What is the hilum and what does it contain
|
Pedicle that attaches lung to medistinal structuers
Pulm artery, pulm vein, main bronchus (bilaterally) |
|
What stage is lung fcancer with positive ipsilateral hilar LNs?
|
Stage II
|
|
What stage is lung fcancer with positive mediastinal LNs?
|
Stage III
|
|
Where is a Pancoast tumor located and what vessel produces that space?
|
Apex of the lung in the groove (superior sulcus) produced by the subclavian artery
|
|
Workup of lung nodule identified on CXR (4 pts)
|
CT
Possibly bronchoscopy and mediastinoscopy Needle biopsy |
|
Rx for Pancoast tumor
|
Irradiation for 6wks
Then surgical resection of involved chest wall and lung |
|
Hemoptysis in healthy young non-smoker
|
Most likely from bronchial adenoma (also consider TB)
|
|
Why do bronchial adenomas cause hemoptysis?
|
Vascular and arise within bronchi, often obstructing them (--> atelectasis)
|
|
2 types of bronchial adenomas
|
Carcinoid tumors
Adenocystic carcinomas |
|
Rx for bronchial adenoma
|
Lovectomy
|
|
Pleural effusion in 70yo
|
Cancer until proven otherwise, though most likely heart failure
|
|
Diagnostic test for pleural effusion not related to CHF
|
Thoracentesis and pleural biopsy
|
|
What is pleural fluid cultured for (in addition to looking for malignant cells)?
|
Bacteria, TB
|
|
Rx and likely prognosis for mesothelioma
|
Extrapleural pneumonectomy is the only potential cure; high mortality E
|
|
Etiology of spontaneous pneumo
|
Rupture of apical blebs
|
|
Two causes of rupture of apical blebs
|
Spontaneous
Strenuous activity |
|
What two signs indicate that a spontaneous pneumo is a tension pneumo?
|
Total lung collapse
Mediastinal shift |
|
How does a water seal for a chest tube function?
|
Maintains a negative pressure in pleural space and chest tube so that air and fluids may escape from the chest, and creates a one-way valve to prevent air and fluids from reentering the cavity
|
|
Rx for recurrent pneumothorax
|
Thoracoscopic excision of blebs and pleural abrasion (pleurodesis), which causes irritation --> adhesions
|
|
Which wound pts need tetanus IG?
|
<3 doses of tetanus vaccine or dirty wound with unknown immunization status
|
|
Management of pt with hypotension and possible aortic aneurysm
|
Explore in OR (+/- ultrasound for diagnosis, but no time for CT)
|
|
Unstable trauma pt with CXR showing widened mediastinum, large left hemothorax
|
Aortic injury
|
|
Causes of a psoas abscess
|
Not just appendicitis; also contiguous spread from nearby bone or bowel, or hematogenous spread from furuncles or other infection
|
|
Which part of the bone is associated osteosarcoma vs. Ewing's sarcoma?
|
Osteosarcoma: metaphyses (rapid bone growth)
Ewing's: diaphyses |
|
Osteolytic lesion with onion skin appearance
|
Ewing's sarcoma
|
|
"Sunburst" pattern or periosteal new bone formation w/ elevation (Codman's triangle)
|
Osteosarcoma
|
|
In which malignant bone tumor is alk phos elevated?
|
Osteosarcoma
|
|
Which malignant bone tumor has bone pain worse at night, often precipitated by trauma?
|
Osteosarcoma
|
|
Which malignant bone tumor is associated with systemic symptoms (fever, malaise, weight loss)?
|
Ewing's sarcoma
|
|
Soap bubble appearance of bone (due to osteolysis)
|
Osteoclastoma (giant cell tumor of bone)
|
|
DRE with tender, fluctuant mass palpable only w/ tip of finger
|
Pelvic abscess (in rectovesical pouch)
|
|
Presentation of pelvic abscess
|
Fever, leukocytosis, painful defecation, diarrhea (from bowel irritation)
|
|
Most common cause of pelvic abscess in men vs. women
|
Men: appendicitis
Women: gyne infection |
|
Rx for pelvic abscess
|
Drainage
|
|
Flaccid paralysis after vascular surgery
|
Spinal cord ischemia
|
|
Which part of the spinal cord is most vulnerable to infarction
|
Thoracic
|
|
Diagnostic test and Rx for postop spinal cord ischemia
|
MRI
Lumbar drains to reduce spinal pressure |
|
Fat embolism is often secondary to?
|
Long bone fracture
|
|
Few days after trauma w/ dyspnea, tachypnea, chest pain, hypoxemia worsened by fluids, and patchy alveolar infiltrates on CXR
|
Pulmonary contusion
|
|
Hx of PNA now with pleural effusion
|
Empyema
|
|
Why are empyemas often culture negative?
|
Previous treatment
|
|
When to suspect G- with empyema
|
Alcoholic, unconscious, recent op, pulmonary aspiration
|
|
Management of empyema (3)
|
Abx
Evacuate pus Reexpand lung (chest tube for last 2) |
|
Rx for loculated empyema
|
Thoracotomy and decortication
|
|
Three vessel disease indicates blockages in what three arteries?
|
Right main
LAD Circumflex |
|
Most common conduits used to bypass obstructed coronaries (2)
|
Greater saphenous vein grafts
Internal thoracic (mammary) artery (best patency) |
|
2 important components of cardiopulmonary bypass
|
Cardioplegia solution (enough potassium to stop heart)
Hypothermia |
|
Average mortality for CABG surgery
|
3%
|
|
Repair options for mitral valve stenosis
|
Commissurotomy (splitting commissures and reconstituting lumen w/ dilation)
|
|
Repair options for mitral regurg
|
Excising insufficent/redundant portions of leaflets and narrowing/reinforcing mitral annulus w/ annuloplasty ring
|
|
Option for mitral valve disease if repair isn't feasible
|
Prosthetic valve
|
|
Work-up of newly diagnosed aortic stenosis
|
Cardiac cath to determine status of coronary circulation (better outcomes of valve replacement if intact)
Carotid Doppler to r/o internal carotid obstruction |
|
Difference btwn mechnical (metal/plastic) and tissue valves
|
Mechanical require anticoagulation
Tissue deteriorate, require replacement at ~7yrs |
|
What causes a Zenker (pulsion/pharygneal) diverticulum
|
Abnormal uncoordinated constriction of cricopharygneal muscle during swallowing, which increases the pressure in this area of pharynx and forces out a pouch of mucosa covered by pharygneal muscle
|
|
What is another type of esophageal diverticulum and where is it?
|
Epiphrenic (near distal GEJ)
|
|
Etiology of achalasia
|
Loss of smooth muscle ganglionic cells of Auerbach's plexus and neuronal degeneration
|
|
Rx for achalasia (2)
|
Disruption of lower-esophageal high-pressure zone w/ dilation:
- Heller myotomy - Endoscopically w/ transesophageal pneumatic dilation (only 60% successful, vs 100% for Heller) |
|
Fever, dysphagia, odynophagia, drooling, and submandibular swelling w/ crepitus
|
Ludwig angina (rapidly progressive bilateral cellulitis of submandibular and sublingual spaces)
|
|
Cause of Ludwig angina and involved bugs
|
Infected mandibular molar
Strep and anerobes (--> crepitus) |
|
Management of Ludwig angina (3)
|
Abx, removal of infected tooth
Monitor for respiratory difficulty and intubate if necessary (asphyxiation is most common cause of death) |
|
Why is traumatic rupture of the diaphragm more common on the left?
|
Liver is protective on the right
|
|
Diagnostic tests for ruptured diaphragm
|
CXR raises suspicion
Barium swallow or CT w/ oral contrast are diagnostic |
|
Needle shaped crystals on UA
|
Uric acid stones
|
|
Why do uric acid stones need to be evaluated by CT or IV pyelography?
|
Radiolucent
|
|
Three components of GCS and their max points
|
MVE: Motor Response (6), Verbal Response (5), Eye Opening (4)
|
|
Rx for clot in the superficial femoral vein
|
Still heparin! Is actually a deep vein, is just the distal part of the femoral vein
|
|
Management of trauma pt with splenic injury on US (2 diff scenarios)
|
Unstable: emergent XL
Stable: CT to determine splenic injury and need for operative repair |
|
What is the final sequel of compartment syndrome
|
Volkmann's ischemic contracture (dead muscle has been replaced with fibrous tissue)
|
|
4 possible complications of diverticulitis
|
Abscess
Perforation Obstruction Fistula formation |
|
Rx for fluid collection/abscess formation after diverticulitis (dependent on size)
|
<3cm: IV Abx and observation
>3cm or worsening symptoms: CT-guided drainage; if unsuccessful, surgery for drainage and debridement |
|
Rx for diverticulitis w/ fistula, perforation, or obstruction
|
Sigmoid resection
|
|
Tenderness over a bony surface that is worse with palpation
|
Stress fracture
|
|
Burning, numbness, and aching of the distal plantar surface of the foot/ toes
|
Tarsal tunnel syndrome
|
|
Pain and tenderness particularly w/ flexion/extension of hand/wrist after a bite or puncture wounds
|
Tenosynovitis
|
|
Most common tumor of posterior mediastinum
|
Neurogenic tumors
|
|
Diagnostic test for neurogenic tumor, and what are you looking for?
|
CT scan
Determine whether tumor is present in spinal canal |
|
Management for neurogenic tumor in posterior mediastinum/spinal canal
|
Combined thoracic and neurosurg approach
|
|
2 most common tumors of the middle mediastinum
|
Lymphatic tumors
Various cysts |
|
Two most common type of middle mediastinal cysts
|
Bronchogenic
Pericardial (water bottle appearance) |
|
Management of mediastinal cysts
|
Removal due to potential inflammatory complications, i.e. fistula formation
|
|
Most likely histopath of esophageal cancer by location
|
Upper and middle third: squamous cell
Lower third: adeno |
|
Staging workup for esophageal cancer
|
EUS (for wall penetration and LNs), CT C/A for celiac LNs
|
|
Rx for cancer of the cervical and upper third of the esophagus
|
Irradiation (chemoradiation)
|
|
Rx for cancer in the middle third of esophagus
|
Neoadj rads/chemo hopefully to allow surgical resection
|
|
2 esophagectomy options
|
Transhiatal esophagectomy
Formal esophagectomy utilizing a neck anastamosis (gastroesophageal) |
|
Advt of a neck anastamosis
|
Can manage anastamosis leak easily, which is a common postop complication (10%)
|
|
Rx for cancer in the distal third of the esophagus
|
Esophagectomy and proximal gastrectomy
|
|
How can an esophageal carcinoma cause constant cough?
|
Chronic aspiration from tracheoesophageal fistula due to tumor erosion into the trachea
|
|
Rx for advanced esophageal cancer
|
Palliation with gastrostomy, esophageal stents, radiation, or palliative resection
|
|
Recurrence rate of TIA without treatment
|
40%
|
|
Periop stroke risk during carotid endarterectomy
|
1-3%
|
|
3 nerves at risk during carotid endarterectomy
|
Hypoglossal, vagus, marginal branch of facial
|
|
Med to send pts home on after carotid endarterectomy
|
ASA
|
|
Cause of amaurosis fugax
|
Emboli from carotid bifurcation --> internal carotid --> ophthalmic artery (first branch of ICA)
|
|
What is a Hollenhorst plaque
|
Portion of embolus seen on retinal exam as bright shiny spot in retinal artery
|
|
One extremity w/ absence of distal extremity pulses, cool and cyanotic, decreased sensation, weakness
|
Acute arterial embolus
|
|
Rx for acute arterial embolus
|
Heparin and immediate OR (better recovery with quicker revascularization)
|
|
Procedure used to treat acute arterial embolus
|
Balloon catheter embolectomy
|
|
Procedure done during embolectomy to ensure adequacy of procedure
|
Intraop arteriogram
|
|
Inability to dorsiflex foot + calf tenderness after embolectomy
|
Compartment syndrome
|
|
Cause of postop compartment syndrome
|
Ischemia-reperfusion injury (edema after reperfusion)
|
|
Long-term therapy after embolectomy
|
Chronic anticoagulation with warfarin
|
|
Hairless leg, loss of sensation, thin/shiny skin
|
Suggestive of chronic ischemia from peripheral vascular disease
|
|
Where is claudication pain most commonly located?
|
Calf
|
|
ABIs for normal, mild claudication, severe (multilevel occlusion), and rest pain/tissue loss
|
Normal: >0.9
Mild: 0.6-0.8 Severe: <0.5 Rest pain: <0.3 |
|
How does the Doppler wave form change with occlusive disease
|
Normal triphasic --> biphasic with moderate stenosis (less compliance) --> monophasic with severe stenosis
|
|
Unilateral absence of femoral pulse
|
Aortoiliac occlusive disease
|
|
Management of aortoiliac occlusive disease
|
Often surgery, as is generally more progressive than more peripheral occlusive disease
|
|
Surgical treatment for aortoiliac occlusive disease
|
Balloon dilation and/or stent placement or surgical revascularization
|
|
What is important to evaluate in a diabetic with peripheral vascular disease and a foot ulcer?
|
Whether bloody supply is sufficient to allow ulcer to heal; if not, will require revascularization
|
|
Arteriogram may demonstrate two patterns of occlusive disease
|
Inflow disease: inadequate blood blow into femoral artery (E.g. aortoiliac disease)
Outflow disease: single or multiple occlusions of leg arteries, esp superficial femoral or popliteal |
|
F/u and long-term management after vascular bypass surgery
|
Frequent duplex exams of graft
ASA, lipid control, foot care |
|
Impotence, calf/thigh pain on exertion and relieved by rest, smoker, absence LE pulses
|
Aortoiliac disease 2/2 atherosclerosis
|
|
What is Leriche syndrome?
|
Aortoiliac disease 2/2 atherosclerosis
|
|
When should arteriograms be performed for aortoiliac disease/ low extremity disease?
|
Not until a decision to proceed with surgery has been made
|
|
3 treatment options for aortoiliac disease
|
Lifestyle modification, percutaneous transluminal angioplasty, aortobifemoral bypass
|
|
Percutaneous transluminal angioplasty vs. aortobifemoral bypass
|
PTA best for signle, short-segment iliac stenosis
Bypass best for bilateral loss of pulses/ occlusion of entire system |
|
Alternative to aortobifemoral bypass for high risk pt
|
Axillofemoral bypass graft
|
|
Painful, cyanotic big toe after revascularization
|
"Trash foot": atheroembolization of fibrin, platelets, or disloged atherosclerotic debris that has blocked small pedal or digital arteries during unclamping
|
|
Rx for trash foot
|
Heparinization followed by long-term antiplatelet therapy
|
|
Likelihood of a cardiac event during vascular surgery
|
Up to 10% for MI, arrhythmia, or heart failure in major vascular reconstruction
|
|
Method used to assess cardiac risk in pts w/ various backgrounds (3 categories)
|
Class III/IV CHF or EF <20%: coronary angiography
Asymptomatic: straight to surgery History of MI/moderate angina: DT scan |
|
How long should a vascular procedure be delayed after MI
|
At least 3mo
|
|
Eagle's criteria in prediction of periop cardiac morbidity (6)
|
>70yo
DM Angina Ventricular arrhythmia Q waves on preop EKG DT scan redistribution |
|
How fast, on average, do AAAs grow?
|
4mm/yr
|
|
Cause of erectile dysfunction after AAA repair
|
Interupption of hypogastric circulation or autonomic nerves on aorta
|
|
Rx for hypotensive pt with ruptured AAA
|
Straight to OR; no IVF first b/c could convert contained rupture into free intraperitoneal rupture
|
|
HDS patient with AAA and history of syncope/abdominal pain
|
CT scan; if AAA present, esp w/ nearby hematoma, to OR
|
|
Pt with postop ischemic colitis, sigmoidoscopy demonstrates limited to mucosa
|
Bowel rest, GI decompression, ABx, frequent rescoping
|
|
Pt with postop ischemic colitis, sigmoidoscopy demonstrates full thickness involvement
|
Resection of nonviable bowel and end colostomy
|
|
2mo after AAA repair pt is febrile with inflamed femoral incision
|
Vascular graft infection, usualyl from skin flora
|
|
Diagnostic test for suspected vascular graft infection
|
CT
|
|
Rx for vascular graft infection
|
Complete removal of graft, debridement of all infected tissues, revascularization by extra-anatomic bypass, long-term Abx
|
|
Pt with history of aortic surgery/vascular graft and new onset upper GI bleeding
|
Eval for aortoenteric fistula
|
|
Diagnostic test for aortoenteric fistula
|
CT abd or angiography
|
|
Rx for aortoenteric fistula
|
Removal of graft, repair of GI tract, extra-anatomic bypass
|
|
Abd pain, weight loss, intermittent diarrhea, multiple abdominal bruits
|
Chronic mesenteric ischemia
|
|
Diagnostic test for chronic mesenteric ischemia
|
Mesenteric arteriogram
|
|
Rx for chronic mesenteric ischemia
|
Revascularization using bypass graft from aorta
|
|
Tearing chest/back pain, diaphoresis, HTN
|
Aortic dissection
|
|
Rx for aortic dissection
|
Beta blockers unless invovl;es ascending aorta (requires surgery)
|
|
Why can warfarin be hypercoagulable early on?
|
Protein C deficiency
|
|
DVT pt with chronic, marked edema; skin ulceration around ankles; venous claudication
|
Postthrombotic syndrome due to chronic venous HTN in lower leg
|
|
Rx for postthrombotic syndrome
|
Chronic use of support hose (good prevention as well)
|
|
When do pts with a mild to moderate TBI need neuroimaging? (4 symptoms)
|
Brief LOC
Vomiting Headache Disorientation |
|
Difference btwn tibial stress fracture and medial tibial stress syndrome on exam
|
Latter (shin splints) have no tibial tenderness on palpation
|
|
What is the respiratory quotient (RQ)?
|
Ratio of CO2 produced to O2 consumed; assessment of metabolism
|
|
Causes of RQ of 0.8, 1.0, 1.05
|
0.8: high protein diet or sepsis
1.0: Largely carbohydrate diet 1.05: Mechanically ventilated pt |
|
Why is RQ imp in intubated pts?
|
High RQ can indicated overfeeding w/ carbs that --> excessive CO2 production which will make weaning more challenging, esp in pts with preexisting lung disease
|
|
Abd pain, bloody diarrhea, fever, and leukocytosis after AAA repair
|
Bowel ischemia
|
|
Acute rectal bleeding with blood that fills the toilet
|
Diverticulosis is most likely
|
|
Time line of development of postop infections
|
PNA (<2 days), UTI, DVT, wound infection, drug fever (>7 days)
|
|
2 most common causes of drug fever
|
Anticonvulsants
Bactrim |
|
How to differentiate pneumothorax from cardiac tamponade in pt with hypotension and JVD
|
Decreased breath sounds and mediastinal deviation in pneumothorax
|
|
Where to perform needle thoracostomy
|
2nd intercostal space in midclavicular line
|
|
Pneumomediastinum, subQ emphysema, and persistent pneumo despite chest tube placement
|
Bronchial rupture
|
|
Pt who cannot lower arm smoothly (drops rapidly from 90 degree position)
|
Rotator cuff tear
|
|
Hypotension and back pain after cardiac cath
|
Retroperitoneal bleeding
|
|
Chronic immobile hard mass on hard palate
|
Torus palatinus: congenital benign exostosis (bony growth)
|
|
When does torus palatinus need surgical correction?
|
Symptoms, interferes w/ speech or eating, or problems with fitting dentures
|
|
Pt with claudication signs but normal ABI
|
Exercise testing with repeat ABI
|
|
ABI <0.9 indicates how severe of an occlusion?
|
>50% in a major vessel
|
|
Which pts need a Td booster even if their last shot was within 10 yrs?
|
Dirty wound if shot >5yrs ago
|
|
Which patients need Td booster?
|
Last dose >10yrs ago
OR Severe or dirty wounds and last dose >5yrs ago |
|
Which pts need tetanus immunoglobin?
|
Unimmunized (or unknown)
OR Last Td >10yrs ago and dirty wound |
|
4 strategies for control of tetanus symptoms
|
Abx (metronidazole and penicillin)
Removal of unbound tetanospasmin (with TIG) Control muscle spasms Airway protection |
|
Causes of esophageal ulceration (6)
|
Instrumentation
High pressures from persistent vomiting Pill esophagitis Barrett's --> ulcer Infectious esophageal ulcer (Candida) Ingestion of caustic substance |
|
Diagnostic test and surgical option for suspected meniscal tear
|
MRI
Arthroscopy (or open surgery) |
|
Why are fractures of the 2nd, 3rd, and 4th metatarsals managed conservatively?
|
Surrounding metatarsals act as splints and nonunion is uncommon
|
|
Hypotension and tachycardia, but with a high PCWP that increases further with fluids
|
Cardiac shock, e.g. myocardial contusion
|
|
Abd pain radiating to groin, N/V, and soft abdomen
|
Renal colic from obstructed kidney stone
|
|
6 signs of necrotizing surgical infection
|
1) Intense pain in wound
2) Sepsis 3) Decreased sensitivity at wound edges 4) Cloudy gray discharge 5) Tense edema outside skin 6) SubQ gas w/ crepitus |
|
Which type of pts often get necrotizing infections postop?
|
Diabetics
|
|
Rx for postop necrotizing wound infection
|
Surgical exploration and debridement
|
|
Possible cause of cardiac arrest immediately after intubation in trauma pt
|
If pt is hypovolemic, the increase in intrathoracic pressure decreases venous return + venous dilation from sedatives --> cardiac arrest
|
|
How to prevent postop bacterial parotitis
|
Adequate hydration and oral hygiene
|
|
What is an abdominal succussion splash, and what does it indicate?
|
Auscultate upper abdomen and rock pt back and forth at hips; retained gastric material >3hrs --> splash sound
Indicates gastric outlet obstruction |
|
Causes of gastric outlet obstruction
|
Malignancy, PUD, Crohn's, strictures (2/2 ingestion of caustic agents), gastric bezoars
|
|
Pathophys of biliary colic
|
Ingestion of fatty meal --> gallbladder contraction --> gallstone pushed against cystic duct (stone falls back when GB relaxes)
|
|
Cause of abdominal pain referred to the shoulder
|
Peritonitis --> irritation of diaphragm
|
|
Region of the bladder most susceptible to injury, and region that is covered by peritoneum (thru which urine can leak into peritoneum)
|
Bladder dome
|
|
Most common site of extraperitoneal bladder rupture
|
Bladder neck
|
|
Management of suspected SBO with acidosis
|
Laparotomy
|
|
Management of duodenal obstruction 2/2 hematoma
|
NGT with parenteral nutrition until hematoma resolves (1-2wks)
|
|
Burning pain and paralysis in upper extremities only
|
Central cord syndrome
|
|
Which pts often develop central cord syndrome and from what injury?
|
Elderly pts 2/2 forced hyperextension of neck
|
|
Ipsilateral motor and proprioception loss and contralateral pain loss below level of lesion
|
Brown Sequard syndrome (hemisection of cord)
|
|
Loss of motor function below lesion level w/ loss of pain and temp on both sides below lesion (but maintain proprioception)
|
Anterior cord syndrome
|
|
Common cause of anterior cord syndrome and best diagnostic test for extent of neurologic damage
|
Burst fracture of vertebra
MRI |
|
Paraplegia, variable sensory loss, urinary and fecal incontinence
|
Cauda equine syndrome
|
|
Dose for prophylactic low dose heparin?
|
5000U SQH preop and q8-12postop
|
|
Most common ABG abnormality in PE
|
Decreased PCO2 due to hyperventilation
|
|
Management of a PE while on heparin therapy
|
Failure of anticoagulation --> IVC filter
|
|
Pt being anticoagulated w/ heparin for DVT who vomits 100ml of blood but is HDS
|
D/c systemic anticoagulation immediaetly; provide IVC filter
|
|
Woman with cervical cancer extending into pelvic wall w/ acute edematous, cyanotic, painful left leg
|
Phlegmasia cerulea dolens (inflammatory, cyanotic, painful): acute interruption of venous outflow from obstruction 2/2 pelvic malignancy (extreme ileocaval DVT)
|
|
Possible complication of phlegmasia cerulea dolens
|
Sensory and motor loss and possibly venous gangrene
|
|
Rx for phlegmasia cerulea dolens
|
Anticoagulation and leg elevation; monitor viability of tissue, rarely may require venous thrombectomy
|
|
Management of lack of gag reflex in trauma pt
|
Inspect airway digitally for foreign bodies
|
|
Blunt trauma to neck + hoarseness, change in voice, or stridor (most likely diagnosis + management)
|
Suspect laryngeal edema; need intubation befoer airway obstruction occurs
|
|
What GCS score is an indication for intubation?
|
8 (or less)
|
|
Common cause of simple pneumothorax in trauma pt
|
Rib fracture that lacerates visceral pleura and underlying lung parenchyma
|
|
When can a chest tube be removed?
|
Lung is fully inflated (on repeat CXR) and no further air leak is apparent
|
|
After insertion of chest tube, large amt of air leaks over next 6hrs and lung remains only partially inflated
|
Major airway injury (disruption of bronchus or trachea): requires thoracotomy and lung resection to repair injury
|
|
When can a pneumothorax be observed?
|
Small, not enlarging, no free fluid in pleural space, no other injuries, AND asymptomatic pt
|
|
Typical cause of tension pneumo
|
Lung lac that acts like one way valve (allows air to enter pelural space but prevents it from escaping --> increased positive pressure)
|
|
When do pneumothorax pts need needle thoracostomy before chest tube placement?
|
Tension pneumo (hypotensive)
|
|
Management of cardiac tamponade (initial and subsequent)
|
Subxiphoid pericardiodentesis (or pericardial US) or needle aspiration
To OR for pericardial window and to stop bleeding source |
|
How much blood loss is necessary before see tachycardia; how much before hypotension?
|
15% (750-1500ml)
30% (1500-2000ml) |
|
After how much blood loss do pts usually require transfusion?
|
30% (1500-2000ml)
|
|
Should you insert a central catheter on the same side or opposite side as a pneumothorax?
|
Same side; otherwise could develop one on opposite side as complication of insertion
|
|
Why doesn't a head injury usually cause hypotension?
|
Cushing reflex: maintains BP + pt becomes bradycardic
|
|
Concern with intubation of pt with possible cervical spine injury
|
Cannot tilt the head; need in-line traction to maintain cord alignment, or nasotracheal intubation
|
|
Trauma pt with priapism
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Suspect spinal cord injury
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5 signs of spinal cord injury in trauma pt (other than loss of motor function in extremities)
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Priapism
Loss of anal sphincter tone Loss of vasomotor tone Bradycardia Intestinal ileus |
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2 indications for thoracotomy based on chest tube output
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>1500ml initially
>200ml/hr for 3 hrs |
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Concern with stab wound below clavicle + hypotension (and management)
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Subclavian arterial or venous injury
Perform angiogram if pt stable; surgical exploration if not |
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Difference in management of gunshot wound vs. stab wound
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Unpredictable bullet path, so often need abdominal exploration if wound near abdomen
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Why is a portable CXR unrelaible for diagnosing thoracic aortic transection
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Tends to magnify mediastinum
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Diagnostic test for suspected aortic injury
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Aortic angiography (or CT of chest)
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When is a diagnostic peritoneal lavage most useful?
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Unclear diagnosis of abdominal injury and pt is hemodynamically unstable (is an alternative to FAST scan)
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Indications for surgical exploration on diagnostic peritoneal lavage?
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>10ml of blood on opening, >100,000 RBCs on lavage fluid
Vegetable matter Bile |
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Diagnostic test for suspected pelvic bleed
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Pelvic angiogram
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Most likely source of pelvic bleed and management
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Branch of internal iliac artery
Embolization |
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What is essential before removing a damaged kidney?
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Document presence of two kidsneys with IV pyelogram
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Management of a flank hematoma
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Often 2/2 renal parenchymal injury; can be observed in stable pts
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Management of blood on opening the peritoneum
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Pack all 4 quadrants with gauze to stop bleeding; attempt hemostasis one at a time
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Post cardiac surgery w/ fever, leukocytosis, tachy, chest pain, and sternal wound drainage
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Mediastinitis
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Rx for postop mediastinitis
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Drainage, surgical debridement, and prolonged Abx
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Unilateral LE edema that worsens while at work (e.g. when legs are dependent)
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Venous valve incompetence
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Damage to facial nerve causes what symptom
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Facial droop
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Anterior shoulder dislocation can damage which nerve?
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Axillary nerve
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Weakness worse in upper extremities
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Central cord syndrome
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Bilateral loss of vibratory and proprioceptive sensation
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Posterior cord syndrome
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Bilateral spastic motor paresis
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Anterior cord syndrome
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Anterior cord syndrome is due to occlusion of what artery?
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Vertebral artery
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Abx for mastitis
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Dicloxacillin or cephalosporins
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Tenderness in anatomic snuffbox likely indicates
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Scaphoid fracture
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Rx for scaphoid fracture
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Wrist immobilization for 6-10wks (if nondisplaced) due to risk of nonunion
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Lack of pain and temp sensation in upper extremities
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Syringomyelia
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Cause of syringomyelia
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Disruption of CSF drainage from central cord of spinal cord --> fluid filled cavity compressing neural tissue
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Pulsatile groin mass below inguinal ligament
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Femoral artery aneurysm
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Why do femoral artery aneurysms cause anterior thigh pain
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Compression of femoral nerve, which runs lateral to the artery
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Management of traumatic amputation in the field
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Limb/digit wrapped in sterile gauze, moistenized with sterile saline, placed in plastic bag on ice while transported to ED
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Confusion, wheezes, seizure post smoke inhalation
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Suspect CO poisoning
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Rx for suspected CO toxicity
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100% oxygen via nonrebreather facemask (hyperbaric oxygen if unresponsive)
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3 types of retroperitoneal hematoma and management of each
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Zone 1- central hematoma (abdominal exploration)
Zone 2- kidney (observe unless unstable) Zone 3- pelvic hematoma (explore only if from penetrating trauma to exclude vascular injury) |
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Blood behind tympanic membrane or ecchymosis in mastoid region/ around eyes
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Indicates basal skull fracture
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CSF leaking from ear or nose
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Indicates basal skull fracture
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Why does hypothermia lead to poor outcomes in trauma pts
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Coagulopathy from platelet dysfunction and prolongation of PT and PTT
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Pt with ongoing intraabdominal bleeding who has oliguria, abd distension, and difficulty respirating
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Worry about abdominal compartment syndrome
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If pt doesn't respond to fluid challenge, 2 ways to see if they are truly volume depleted
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CVP
PCWP if place Swan-Ganz cathether Both indicate hypovolemia if low |
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Previous stab injury now with SOB, tachy, murmur, JVD
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Traumatic arteriovenous fistula --> high output cardiac failure
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What is Branhma's sign?
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Occlusion of fistula --> drop of 10bpm in HR
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Management of flail chest
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Adequate ventilation (may need intubation), administration of O2, careful fluid balance to avoid pulmonary edema
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Management of hematoma after stab wound to the neck
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Surgical exploration
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When is a preop angiogram useful in pts with neck injuries?
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Wound in Zone 1 or 3 (below or avoid cricoid) and HDS pt
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Management of asymptomatic carotid injury or thrombosis
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Anticoagulation
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Parkland formula
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Volume of LR = %BSA burned x weight x 4ml/kg
Give 1/2 that volume over first 8hrs, second half over next 16hrs |
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When are topical Abx needed for burns, and what is commonly used?
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Deep wounds
Silver sulfadiazine |
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Burn pt with hematuria
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If RBCs seen in urine, pt has myoglobulinuria, at risk for ATN
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Management of myoglobulinuria
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Fluids, alkalinization of urine, osmotic diuresis
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Burn pt with chocolate brown blood, central cyanosis of trunk, or even seizures/coma
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Methemoglobinemia (iron in ferric (Fe3+) form, which can't bind O2)
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Management of methemoglobinemia
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IV methylene blue (hyperbaric oxygen in extreme cases)
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Work-up of electrical burn
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Potential interior damage, so: EKG, cardiac enzymes, maintain high urine ouput, alkalinize urine
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What should a patient on TPN's nitrogren balance be?
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Positive (esp if amlnourished or in severely catabolic state)
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Type of coma seen in TPN (3 descriptive words) and its cause
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Hyperglycemia, hyperosmolar, nonketotic 2/2 dehydration following excessive diuresis due to hyperglycemia
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Which organ is often damaged by TPN?
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Liver (fatty liver or structural damage; even cirrhosis over years)
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Asian immigrant with mass in posterior nasal cavity
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Nasopharyngeal carcinoma
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3 common presentations of nasopharyngeal cancer
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Recurrent otitis media
Recurrent epistaxis Nasal obstruction |
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Nasopharyngeal cancer is associated with these 3 risk factors
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EBV infection
Smoking Nitrosamine consumption |
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Best option to control bleeding in massive hemoptysis
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Intubation, place bleeding lung in dependent position, fluids, and:
Bronchoscopy |
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Definition of massive hemoptysis
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>100ml blood / 24hrs
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LUQ pain, hypotension, and left shoulder pain
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Splenic lac (shoulder pain is from splenic hemorrhage irritating the phrenic nerve and diaphragm: Kehr sign)
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Test for meniscus tear vs. MCL/LCL tear
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McMurray's for meniscus
Valgus/varus for ligaments |
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Injury from torsion of knee with foot planted; popping sound and severe pain at time of injury; slow swelling; locking during terminal extension
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Medial meniscus tear
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Management of suspected scaphoid fracture with normal imaging
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Thumb spica cast and reimage in 7 days
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Best diagnostic test for development dysplasia of the hip (2 groups)
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<4mo: ultrasound
>4mo: xray |
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Treatment options for resistant dumping syndrome (2)
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Octreotide or reconstructive surgery
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Dropping of contralateral pelvis when pt stands on one foot
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Trendelenburg sign
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Cause of Trendelenburg sign
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Weakness of gluteus medius and minimus (innervated by superior gluteal nerve)
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How to rapidly normalize INR
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FFP
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Which pts get acalculous cholecystitis?
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Chronically ill pts in ICU (multiorgan injury, trauma, severe burns, sepsis, TPN)
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Rx for critically ill pt with acalculous cholecystitis
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Percutaneous drainage and Abx
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Management of very classic appy presentation
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Emergent surgery (don't wait for CT)
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Management of SCFE
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Surgical pinning of the femoral head
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Where is the fluid collection in a hydrocele?
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Tunica vaginalis due to patent processus vaginalis
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When is surgical repair for a hydrocele indicated
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After 12mo due to risk of inguinal hernia
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