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158 Cards in this Set
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A 54 y/o man gives a hx of burning retrosternal pain and heartburn that is relieved shortly with antacids, but it seems to be getting worse. Next step? |
PPI, EGD,, pH monitoring
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What are atypical symptoms of GERD?
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Hoarseness, wheezing, laryngitis, reactive airway disease, recurrent pneumonia, and pulmonary fibrosis...due to pharyngeal reflux and silent aspiration.
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Pathophysiology of GERD
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incompetent LES
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Indications for surgical therapy for pts with GERD?
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Inability to tolerate PPI
Incomplete relief of symptoms Desire to discontinue meds Desiore for surgery |
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A pt with long standing GERD undergoes endoscopy which shows barretts esophagus and and esophagitis. Management?
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Nissen fundoplication:
360 wrap of the fundus of the stomach around the GE junction to create a valve effect. |
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A 44 y/o black male describes progressive dysphagia that began 3 months ago, with difficulty swallowing meat and has progressed to liquids. He has lost 30 pounds also. What is it? Next step?
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Esophageal carcinoma:
Barium swallow for obstruction, and GE location, then endoscopy w/ biopsy |
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A 47 y/o lady describes difficulty swallowing for many years. She says liquids are more difficult than solids, and she often has to situp and wait for foods to pass. Occasionally she regurgitates food. Dx? Next step?
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Achalasia:
Manometry for competency of LES |
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A 24 y/o man who has been drinking, vomits repeatedly, and then feels a severe wrenching epigastric pn of sudden onset. At the ER, he is diaphoretic, pale, has a fever, and leukocytosis. Next step?
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ABC's including chest tube, fluids, and IV antibiotics. Then gastrographin swallow. Then surgical repair.
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A 54 yr old man is admitted for SBO, due to adhesions from pervious abd surgery. Six hours after NG tube placement and IV fluids, he develops fever, leukocytosis, abd tenderness, and rebound tenderness. Next step?
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Probable strangulated obstruction...Emergent surgery
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A 54 yr old man is admitted for SBO. On PE a groin mass is noted and he explains that he used to push it back, but cant now. Dx? Next step?
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Incarcerated hernia, possibly strangulated if abnormal labs/vitals.
Fluid replacement, and urgent surgical intervention. |
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Why is fluid replacement important during SBO?
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Mechanical obstruction of the bowel results in accumulation of fluid in the bowel lumen and wall and extravasation into the peritoneal space. This leads to decreased intravascular volume and hypoperfusion of organs.Further, it may cause profound hypotension during anesthesia induction for surgery.`
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A 55 y/o women presents with protracted diarrhea. Her hx is positive for episodes of facial flushing and wheezing. A prominent JVP is noted in her neck? Dx? Next step?
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Carcinoid syndrome:
Serum 5-hydroxy-indoleacetic acid |
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20 y/o female presents with a 24hr hx of RLQ abd pn. She has a low grade fever, WBC of 12,000, hematuria, and pyuria. Next step?
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Ct scan
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A 59 y/o man is referred for eval because he has been fainting at his job. He is pale and gaunt, but otherwise his PE is remarkable only for 4+ occult blood. Hgb is 5. Dx? Tests? Txmt?
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Right colon Ca:
Conlonscopy with biopsy Blood transfusion and R hemicolectomy |
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A 56 yr old man has bloody bowel movements. The blood coats the outside of the stool, and he has been constipated, with narrowing of stool caliber. Dx? Tests?
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Ca of L colon:
Flexible sigmoidoscopy w/ biopsy is best bet |
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Premalignant polyps, in order of malignancy
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Familial polyposis, gardner's, villois adenoma, adenomatous polyps.
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A 27 y/o man is being treated with clindamycin and tobramycin for the past 8 days due to gangrenous appendicitis with perforation. He develops watery diarrhea and crampy abd pn with leukocytosis. Dx? Test? Txmt?
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Pseudomembranous colitis:
Stool cultures and proctosigmoidoscopy. IV metro or oral vanc and avoid lomotil. |
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A 59 y/o man is referred for eval because he has been fainting at his job. He is pale and gaunt, but otherwise his PE is remarkable only for 4+ occult blood. Hgb is 5. Dx? Tests? Txmt?
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Right colon Ca:
Conlonscopy with biopsy Blood transfusion and R hemicolectomy |
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A 56 yr old man has bloody bowel movements. The blood coats the outside of the stool, and he has been constipated, with narrowing of stool caliber. Dx? Tests?
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Ca of L colon:
Flexible sigmoidoscopy w/ biopsy is best bet |
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Premalignant polyps, in order of malignancy
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Familial polyposis, gardner's, villois adenoma, adenomatous polyps.
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A 27 y/o man is being treated with clindamycin and tobramycin for the past 8 days due to gangrenous appendicitis with perforation. He develops watery diarrhea and crampy abd pn with leukocytosis. Dx? Test? Txmt?
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Pseudomembranous colitis:
Stool cultures and proctosigmoidoscopy. IV metro or oral vanc and avoid lomotil. |
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What are the general recommendations for Colon Ca screening?
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Colonoscopy every 10 yrs starting at age 50. With the presence of a polyp, shortened to every 3 yrs, until polyps are gone, then every 5 yrs after that.
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What is the appropriate txmt for a person with cancer of the cecum T3N1
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Right hemicolectomy and postop chemo with (FOLFOX4) 5-FU, leucorvin, and oxaliplatin.
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When should people with FAP begin screening for colon ca
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Flexible sigmoidoscopy every 1-2 yrs beginning at age 10-12
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What is the txmt for appendicitis complicated by abscess or phlegmon?
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IV antibiotics, and CT guided drainage, followed by appendectomy sseveral weeks later.
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A 24 yr old male presents with colicky umbilical and RLQ pn of 24 hrs duration. He complains of anorexia and nausea and his temp is 36.7. Dx?
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Gastroenteritis...not appendicitis becuase the pn is not intermittent.
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A 14 yr old boy presents with RLQ pn of two days duration. He states that he has been ill for the past 10 days with cough, runny nose, and fever. However, over the past 12 hrs the pt has been slowly improving, WBC is 11,000 and ua is normal. CT scan is negative. Plan?
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Mesenteric adenitis...dc home to fu with doctor.
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A nonhealing anal fissure or ulceration anywhere along the GI tract should alert the physician to?
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Crohns
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A 60 yr old man known to have hemorrhoids reports bright red blood in the toilet paper after evacuation. Dx? Managment?
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Internal hemorrhoids:
Proctosigmoidoscopic exam to rule out CA and diet changes. |
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A 23 y/o presents with extreme pn upon defecation and blood streaks on the outside of the stool. Because of the pn, she avoids having bowel movements, and when she does this it becomes more hard and painful. PE cannot be done, as it hurts to even have her cheeks spread. Management?
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1st you must examine under anesthesia!!! Then prescribe Sitz baths. bulking agents, stool softeners, and topical nitroglycerin ointment...surgery is lateral internal sphincerotomy
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A 28 yr old male is brought to the office by his mother. Beginning 3 months ago, he has had 3 operations for a perianal fisula, but after each one the area not healed and has become bigger. He now has multiple unhealing ulcers, fissures all around the anus, with purulent dx. Dx? Plan?
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Crohns (most likely) or malignancy(check for palpable mass)
Sigmoioscopy with biopsy |
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A 55 y/o HIV positive man, has a fungating mass growing out of his anus, and rock hard, enlarged lymph nodes on both groins. He has lost a lot of weight, and looks emaciated. Dx? Txmt?
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Squamous cell carcinoma of the anus
Nigro protocol of pre-operative chemo and radiation. |
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A 62 yr old man complains of perianal discomfort and reports that there are streaks of fecal soiling in his underwear. Four months ago he had a perirectal abscess drained surgically. PE shows a perianal opening in the skin, and a tract going to the inside of the anal canal. Brownish purulent discharge can be expressed. Dx? Plan?
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Fisulo in ano:
Rule out CA 1st with proctosigmoidoscopy! then fistulotomy. |
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Fistulo-in-ano are the end result of?
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perianall abscesses that have been drained
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Grade the hemorrhoids
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Grade I: hemorrhoids
Grade II: Hemorrhoids that spontaneously reduce Grade III: Hemorrhoids that prolapse and need manual reduction. Grade IV: Nonreducible |
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At what grade should hemorrhoids undergo hemorrhoidectomy?
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3 or 4
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Differential dx of anal fissure should include?
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Crohns(nonhealing), ulcerated hemorrhoid, or malignancy.
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Rule that an internal opening of an anal fissure is found via its location. A fistula located anterior track straight to dentate line. Posterior fistulas track in a curved line toward the psoterior commisure of the anal canal
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Goodsalls rule
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A 33 yr old man vomits a large amount of bright red blood. What is the general area of concern? Test?
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Upper GI. From the nose to ligament of Trietz.
Endoscopy |
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A 33 yr old male presents with vomiting large amounts of blood. His bp is 90/70, pulse of 120, and he is diaphoretic. Next step?
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1. ABC's
2.Fluid resuscitation 3.NG tube (1st diagnostic move) 4.. Labs 5. endoscopy |
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In a person vomiting large amounts of blood, what is the txmt for thrombocytopenia and coagulopathy?
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platelets
fresh frozen plasma |
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vomiting large amounts of blood. His bp is 90/70, pulse of 120, and he is diaphoretic. What is the 1st DIAGNOSTIC move?
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NG tube:
If blood is present, it determines there is bleeding from upper gi...nose to ligament of trietz |
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A man has 3 large bowel bloody bowel movements, made up of dark red blood. He is pale, diaphoretic, and has a bp of 90/70, pulse of 120. Next step? Next diagnostic step?
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Same as bloody vomitus:
1. Fluids 2. NG tube 3. labs 3. endoscopy |
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What is the preferred choice of therapy for an alcoholic with acute bleeding esophageal varices
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endoscopic sclerotherapy
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A 7 yr old boy passes a large bloody bowel movement. Dx? Test?
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Meckel's diverticulum:
Technetium scan that tags gastric mucosa(not rbc's). |
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A 33 yr old has 3 bloody bowel movements made up of dark red blood. He is diaphoretic, pale, bp 90-70, pulse 120. An NG tube returns clear, green fluid without blood. Dx? Next step?
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lower GI bleed. No blood or bile, exonerates the area down to the ligament of trietz.
Emergency Angiogram |
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A 72 yr old man has 3 large bloody bowel movements that he describes as made up entirely of dark red blood. The last one was 3 days ago. He is pale, but vital signs are normal. An NG tube returns clear, green fluid. Plan?
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The clear fluid is meaningless, because he is not bleeding now. Further, the involved area could have been anywhere...Do EGD and colonoscopy first, because the bleeding has stopped and hes stable!
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Most common cause of upper GI bleed
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duodenal ulcer 25%
gastric ulcer 20% & gastric erosions 20% malory weiss 15% |
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Causes of lower GI bleeding over 50
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diverticulosis, cancer, angiodysplasia
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A 41 yr old hsa been in the ICU for 2 wks due to hemorrhagic pancreatitis. He has been in septic shcok and respiratory failure several times.10 minutes ago, he vomited a large amount of bright red blood. Dx? Plan? Txmt?
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Stress ulcer
EGD angiographic embolization of left gastric artery |
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A 72 yr old man presents to the ER with abd pn and bloody stools. His past medical hx is significant for diabetes, heart disease, and hypertension. His bp is 90/60, pulse of 120. Temp is 38.8. Palpation reveals LUQ and LLQ pn. Diagnostic test?
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CT scan for schemic colitis
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Has great specificity for identifying lower GI bleeding?
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mesenteric angiography:
Bleeding rate of 0.5-1.0 ml/min |
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66 yr woman with a hx of passing several maroon colored stools earlier in the day. She complains of feeling lightheaded. Her initial bp is 100/85 and HR of 90. The pts bp improves with initial fluids. An NG tube was placed and revealed clear, bilious fluids. During the 4 hrs of observation, the pt remains stable without further bloody stools. Next appropriate step?
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Colonoscopy
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Pt arrives with painless hematochezia over the last 24 hrs. Pt has a hx of previous abdominal aorta vascular reconstruction following aneurysm. Dx?
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Aortoenteric fistula
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A 75 yr old develops hematochezia and presents with bp 90/60 and HR of 120. His vital signs improve slightly with crystalloid and packed rbc's. Next steps in management?
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NG tube, proctosigmoidoscopy, tagged RBC scan, then mesenteric angiography if bleeding is not localized with others.
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Highly sensitive for lower gi bleeding as low as 0.1ml/min, but may not localize, thus it is used as initial screen before angiography
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tagged rbc scan
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Management of acute pancreatitis? Dx?
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NPO, NG tube, IV fluids
Serum and urinary amylase and lipase, and CT scan. |
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A 43 yr old male develops extreme abd pn suddenly. He has a rigid abd, lies motionless on the table, has no bowel sounds. Xray shows free air under the diaphragm. Dx? Plan?
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Acute abd plus perforated viscus equals perforated duodenal ulcer usually.
Exploratory laparotomy(same thing as celiotomy). |
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Pt presents with extreme abd pn of sudden onset. He lies motionless on the stretcher and is diaphoretic with shallow, rapid breathing. His abd is rigid and he has guarding in all quadrants. Dx? Plan?
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Acute peritonitis
emergency exploratory laparotomy(same thing as celiotomy). |
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Management of acute pancreatitis? Dx?
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NPO, NG tube, IV fluids
Serum and urinary amylase and lipase, and CT scan. |
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A 43 yr old male develops extreme abd pn suddenly. He has a rigid abd, lies motionless on the table, has no bowel sounds. Xray shows free air under the diaphragm. Dx? Plan?
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Acute abd plus perforated viscus equals perforated duodenal ulcer usually.
Exploratory laparotomy(same thing as celiotomy). |
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Pt presents with extreme abd pn of sudden onset. He lies motionless on the stretcher and is diaphoretic with shallow, rapid breathing. His abd is rigid and he has guarding in all quadrants. Dx? Plan?
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Acute peritonitis
emergency exploratory laparotomy(same thing as celiotomy). |
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What type of gastric ulcer is most common? What type is combined with a duodenal ulcer? Which is seen with NSAID's?
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Type I: Lesser curvature
Type II: H pylori+acid hyper...also inc perforation and hemorrahge Type V: Anywhere in stomach |
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What type of histamine receptors are associated with gastric acid secretion?
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H2
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Txmt for H pylori?
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OAM, OMC, OAC
1-2 wks/BID |
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What are the indications for surgery in PUD
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Intractable pn, outlet obstruction, hemorrhage, perforation
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Re type I gastric ulcers associated with acid hypersecretion?
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No
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A 43 yr old obese, mother of 6, has severe RUQ pn that began 6 hrs ago. The pn was colicky at first and radiated towards the R shoulder. She also has had N/V. For the past 2 hrs, the pain has been constant. Her temp is 101, WBC is 16,000. Dx? Plan?
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Acute Cholecystitis:
Admit, NPO, IV fluids and antibiotics Sonogram, if eqiuvical then HIDA |
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Persistant abd pn, RUQ tenderness, leukocytosis
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Acute cholecystitis:
Sonogram for dx |
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Fever, intermittent RUQ pn, and jaundice are indicative of?
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Acute cholangitis:
Charcot triad of fever, RUQ pn, and jaundice |
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A 69 y/o man presents with confusion, abd pn, shaking chills, a temp of 94 and jaundice. An abd radiograph shows air in the biliary tree. Dx? Txmt?
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acute cholangitis:
IV antibiotics, fluids, supportive care, and Emergent ERCP |
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What US findings are suggestive of choledocholithiasis?
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Common bile duct of >5mm with elevated LFT's
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What findings on US can help distinguish acute vs chronic cholecystitis
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Thickened gallbladder wall or contracted gallbladder.
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A pt has ureteral colic. How is the diagnosis made?
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1. KUB plain film of the abd
2. Sonogram or intravenous pyelogram(IVP) |
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A 59 y/o lady has a hx of 3 prior episodes of LLQ pn for which she was briefly hospitalized and treated with antibiotics. She now has LLQ pn, fever, leukocytosis, and a palpable mass. Dx? Dx is made via? Plan?
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Acute diverticulitis:
CT scan NPO, antibiotics Elective sigmoid surgery for recurrent episodes like this lady. |
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An 82 y/o man develops severe colicky abd pn, distension, N/V. He has not passed gas or stool for 12 hrs. He has a tympanic bowel with hyperactive bowel sounds. Xray shows distended loops of small and large bowel, and a very large gas shadow in the RUQ and tapers to the LLQ as a parrots beak. Dx? Management?
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Volvulus:
Proctosigmoidoscopy will relieve obstruction. |
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CT findings with diverticulitis?
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Diverticula, colonic wall thickening, and mesenteric fat stranding.
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Txmt of abscesses associated with diverticulitis
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Small:
NPO, NG tube, IV Antibiotics Large: Surgery |
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A 72 y/o pt presents with LLQ abd pn of 5 days duration, N/V, and diarrhea. On PE he has mild tenderness to the left lower quadrant. His bp is 120/85, pulse 110, and he has a fever of 101.5. His WBC is 14,000. He has never had a similar episode. Txmt? At what pt would you consider surgery?
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Admit, NPO, IV fluids, IV antibiotics, and close observation.
If after 72 hrs, there has been no improvement, surgery may be needed. |
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A 59 yr old woman presents with complaints of pneumaturia(air in the urine) and recurrent UTI. She has a prior hx of diverticulitis 6 months ago. Test of choice? Dx?
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CT scan for colovesical fistula
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Most common cause of GI tract fistulas
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diverticulitis
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Sigmoid colectomy for diverticulitis is usually performed after how many bouts of diverticulitis?
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4
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What are the complications of diverticulitis
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Perforation w/ peritonitis
abscess obstruction fistula |
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A 66 yr old woman presents for eval of weight loss. She states that over the past 6 months she has lost 50 lbs. She states that she is unable to eat, due to significant abd pn after eating. thus, she has stopped eating. She denies any fever, N/V, malaise or constipation. her past medical hx is significant for hypertension and cardiac heart disease. PE shows bilateral carotid bruits, normal abd exam, and negative hemoccult. Her femoral pulses are diminished. Lab studies indicate normal CBC, and electrolytes, and UA. ECG is NSR. Dx? Test? Txmt?
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Mesenteric artery thrombosis:
Screening with duplex US Arteriography with lateral aortic projections Aortomesenteric bypass grafting |
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Gold standard test for definitive dx of mesenteric artery ischemia? Screening test?
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Arteriography with lateral aortic projections
Duplex US |
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A 66 yr old man is admitted to the CICU becuase of new onset AFIB. After 25 hrs, he devlops acute abd pn, distension, and peritonitis. The pt undergoes acute exploratory laparatomy w. resection of necrotic bowel. What is the most important post op txmt?
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Systemic heparinization
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A 69 yr old woman with cardiogenic shock following MI develops diffuse abd pn. On PE her bp is 85/50, pulse of 90, and she has a non-tender abd, cool extremities. Management?
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Dobutamine drip for low flow state related to poor LV function, and decreased mesenteric blood flow.
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A 53 yr old man with cirrhosis develops malaise, vague RUQ pn and 20lb weight loss. PE shows a palpable mass that seems to arise from the left lobe of the liver. Dx? Testing?
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hepatocellular carcinoma:
CT scan and AFP |
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A 53 yr old develops vague RUQ pn and a 20lb weight loss. Two yrs ago he had R hemicolectomy for ca, his CEA is 10x normal. Dx? Test? txmt?
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Liver mets from colon ca
CT scan chemo, because liver lobe resection is usually impossible with multiple lobes involved. |
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A 24 yr old lady develops moderate, generalized abd pn of sudden onset, and then faints. In the ER she is pale, diaphoretic, tachycardiac, and hypotensive. the abd is mildly distended and tender, and she has a hgb of 7. Her medical hx is only significant for birth control pills since 14. Dx? Test? txmt?
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Ruptured hepatic adenoma
CT scan Surgery |
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A 44 yr old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever, leukocytosis, and RUQ tenderness. Sonogram reveals liver abscess. Management?
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Percutaneous drainage
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A 29 yr old mexican immigrant develops fever, leukocytosis, as well as tenderness in the RUQ. he has mild jaundice, and elevated alk phos. Sonogram reveals normal biliary tree and abscess of the liver. Txmt?
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Metronidazole for amebic abscess
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A 19 yr old college student returns from a trip to cancun, and two weeks later develops malaise, wkns, and anorexia. A wk later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with indirect of 12 and direct of 5. His alk phos is mildly elevated, while the sgot and sgpt are very high. Dx? Testing?
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Hepatocellular jaundice due to probable hepatitis
Serologies!!! |
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A pt with progressive jaundice which has been present for four weeks is found to have a total bili of 22, 16 direct. The alk phos is 6x normal. Dx? Next step?
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Obstructive jaundice, most likely gallstones
Sonogram. then possibly ERCP. |
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A 66 yr old man presents with progressive jaundice which he 1st noticed 6 wks ago. he has a total bili of 22, 16 direct. Alk phos is elevated. Sonogram shows dilated intra and extra-hepatic ducts, and a thin, distended gallbladder wall. Dx? Next step?
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Malignant obstructive jaundice.
Distended, thin gallbladder is ominous sign. CT scan and ERCP |
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A 44 yr old lady is recovering from an episode of acute ascending cholangitis secondary to choledocholithiasis. She develops fever, leukocytosis, and RUQ tenderness. Sonogram reveals liver abscess. Management?
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Percutaneous drainage
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A 29 yr old mexican immigrant develops fever, leukocytosis, as well as tenderness in the RUQ. he has mild jaundice, and elevated alk phos. Sonogram reveals normal biliary tree and abscess of the liver. Txmt?
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Metronidazole for amebic abscess
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A 19 yr old college student returns from a trip to cancun, and two weeks later develops malaise, wkns, and anorexia. A wk later he notices jaundice. When he presents for evaluation his total bilirubin is 12, with indirect of 12 and direct of 5. His alk phos is mildly elevated, while the sgot and sgpt are very high. Dx? Testing?
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Hepatocellular jaundice due to probable hepatitis
Serologies!!! |
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A pt with progressive jaundice which has been present for four weeks is found to have a total bili of 22, 16 direct. The alk phos is 6x normal. Dx? Next step?
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Obstructive jaundice, most likely gallstones
Sonogram. then possibly ERCP. |
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A 66 yr old man presents with progressive jaundice which he 1st noticed 6 wks ago. he has a total bili of 22, 16 direct. Alk phos is elevated. Sonogram shows dilated intra and extra-hepatic ducts, and a thin, distended gallbladder wall. Dx? Next step?
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Malignant obstructive jaundice.
Distended, thin gallbladder is ominous sign. CT scan and ERCP |
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A person receives a biliary sonogram that shows intra- and extra-hepatic duct dilation with a distended then walled gallbladder. ERCP shows narrowing of the common bile duct. Dx? txmt?
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Cholangiocarcinoma
Whipple: pancreatoduodenectomy |
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A 64 year old lady presents with progressive jaundice. She has a total bilirubin of 12, direct 8, and elevated alk phos 10x above normal. She is otherwise asymptomatic, but is found to be slightly anemic and hemoccult is positive. A sonogram shows dilated intra and extrahepatic ducts with a thin, distended gallbladder. Dx? Next move? Txmt?
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Obstructive jaundice plus occult bleeding is worrisome for ampullary(of vater) carcinoma.
Endoscopy Pancreatoduodenectomy(Whipple) |
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A 56 yr old presents with progressive jaundice and weight loss. Bilirubin is 22, 16 direct, and alk phosphatase is 10x normal. He complains of a persistent nagging pn deep in his epigastrium that goes to his back. A sonogram shows dilated biliary tracts and a distended thin gallbladder. Dx? Next step?
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Pancreatic head carcinoma:
CT scan then ERCP, which will show obstruction of the common duct and pancreatic duct. |
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A 58 yr old woman presents with painless obstructive jaundice, pruritis, 20 lb weight loss, and recent onset of diabetes mellitus. Dx? Next step?
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Periampullary tumor:
US first to rule out gallbladder, then CT scan. |
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A periampullary tumor that invades what structure, is considered unresectable?
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SMA,
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What chemo drug has been shown effective in prolonging survival of pancreatic ca pts and other periampullary tumors
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gemcitabine
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Most common periampullary ca, and also the worst prognosis
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pancreatic ca...most commonly in the head.
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A 33 yr old has been dx with metastatic pancreatic ca. He has severe itching and hyperbilirubunemia. Best therapy?
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Endoscopic stent of biliary tree.
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A 58 yr old woman presents with painless obstructive jaundice, pruritis, 20 lb weight loss, and recent onset of diabetes mellitus. Dx? Next step?
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Periampullary tumor:
US first to rule out gallbladder, then CT scan. |
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A periampullary tumor that invades what structure, is considered unresectable?
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SMA,
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What chemo drug has been shown effective in prolonging survival of pancreatic ca pts and other periampullary tumors
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gemcitabine
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Most common periampullary ca, and also the worst prognosis
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pancreatic ca...most commonly in the head.
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A 33 yr old has been dx with metastatic pancreatic ca. He has severe itching and hyperbilirubunemia. Best therapy?
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Endoscopic stent of biliary tree.
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Txmt of pancreatitis
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NPO, NG tube, and IV fluids
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A 57 yr old man is being treated for hemorrhagic pancreatitis. He was in the ICU for one week, required chest tubes, and required a respirator for several days. Two weeks later he develops a fever and leukocytosis. Dx? management?
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Pancreatic abscess
CT scan and drainage |
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Postop Fever:
1st day 3rd day 4th day 7th day |
Atelectasis: CXR, spirometry
UTI: UA, urine cx, antibiotics DVT: Duplex US. Heparin Wound infection: I and D |
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An alcoholic complains of constant epigastric pn radiating to the back that he has had for several yrs. He has diabetes, steatorrhea, and calcifications in the upper abd on plain xray. Dx? Further test?
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Chronic pancreatitis:
ERCP |
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A 55 yr old lady presents with vague upper abd pn, early satiety, and a large but ill defined epigastric mass. Five weeks ago she was involved in an auto accident. Dx? Management
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Pseudocyst:
CT scan with CT guided drainage |
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What are most adrenal incidentalomas?
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nonfunctioning adenoma
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Specific signs and symptoms of what, should be sought in the hx and physical exam of a pt with an incidentaloma?
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catecholamines, aldosterone, cortisol, and androgens.
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Primary adrenal cortical carcinomas are rare and most of them are greater than what size?
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>6cm
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When is surgery recommended for people with an incidentaloma?
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Functioning adenoma
Non-functioning greater than 4cm Tumors less than 4cm that are enlarging |
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Most common tumor metastasizing to the adrenal gland is?
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lung carcinoma
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The pt with an adrenal incidentaloma, and a hx of malignancy should undergo what test?
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PET scan
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What confirmatory imaging test is usually obtained for pheochromocytoma because it has the highest specificity?
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Iodine-131 metaiodobenzylguanidine
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During surgery for pheochromocytoma, what precautions must be taken?
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There is a danger of fluctuations in bp, hr, and fluid balance.
Fluid replacement Foley catheter Central line IV nitroprusside for hypertension and esmolol for tachycardia Once removed, severe hypertension may occur and Neo-Synephrine is used. |
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A 3.5 cm adrenal mass was discovered incidentally on an abd CTscan obtained from a 62 yr old man with a previous hx of lung cancer. He is asymptomatic. Next step?
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functional assessment of adrenal mass:
24 hr urine VMA and metanephrine Serum renin and aldosterone K and Na levels Cortisol levels/dexamethasone suppression test |
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A 4 wk old girl develops severe jaundice. She was born at full term with no complications. The liver is palpable and firm, and lab evals show a bilirubin of 28, 24 direct, and elevated ALT, AST, and alk phos. Differential? Next steps?
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Neonatal jaundice:
Biliary atresia, TORCHES metabolic diseases Need TORCH/metabolic studies, abd US, and HIDA scan |
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3 main complications of surgical management for biliary atresia? Txmt?
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Cholangitis, cessation of bile flow, portal hypertension.
Cholangitis is the most frequent complication. IV antibiotics against gram negatives and steroids. |
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A 2 yr old male child is noted to have progressive jaundice. There is suspicion of biliary atresia. What study is the most definitive to dx biliary atresia
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intra-operative cholangiogram
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Initial txmt for post Kasai procedure cholangitis?
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corticosteroids and antibiotics
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What is the Kasai procedure?
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portoenterostomy for biliary atresia.
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Fulminant colitis is characterized by abd pn, fever, and sepsis, and is most often associated with? Most common site?
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UC
When there is colonic distention also present, this is toxic megacolon. Cecum |
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New medical txmt for UC
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infliximab:
anti TNF |
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A 38 y/o man falls off of a 15 foot ladder and undergoes open reduction and internal fixation of his femur. On postinjury day 2, he develops SOB, fever, hr of 120, and respiratory rate of 34. The pt appears anxious, and complains of difficulty breathing, but is not in pn. Auscultation of the chest reveals scattered rhonchi and diminished breath sounds. CBC shows ebc of 16,000and a hgb of 10.8. A CXR reveals bilateral nonsegmental pulmonary infiltrates. Next steps? Dx?
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Administer O2 and possible intubation of not improved.
Acute respiratory insufficiency caused by acute lung injury. |
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ALI requirements
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Acute
PaO2:FIO2 <300 bilateral infiltrates pulmonary capillary wedge pressure >18 |
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Clinical hallmarks of PE
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Acute hypoxia, with tachypnea and hypocarbia, without CXR findings
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Pathophysiology of ARDS
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An injury to the pulmonary endothelial cells leads to intense inflammation. Inhomogenous involvement of the lung occurs, with interstitial and alveolar edema, loss of type II pneumocytes, surfactant depletion, intra-alveolar hemorrhage, hyaline membrane deposition, and eventual fibrosis. This leads to severe hypoxia, decreased lung compliance, and increased dead space ventilation
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How is the adequacy of oxygenation determined in an individual? When would mechanical ventilation be required?
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Pulse oximetry or PaO2 on ABG:
Inability to maintain an oxygen sat of 91% on nonrebreather or PaO2 of 60mmhg |
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A 34 yr old woman is hospitalized for septic shock caused by toxic shock syndrome. A CXR is noted to have diffuse infiltrates in bilateral lung fields. What test would most likely differentiate ARDS from cardiogenic pulmonary edema
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Pulmonary capillary wedge pressure, would approximate the left ventricular end-diastolic pressure.
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Diagnostic bronchoscopy and bronchoalveolar lavage are recommended for what pts who develop acute fever, respiratory distress, and bilateral pulmonary infiltrates.
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Immunocompromised
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A 57 yr old woman develops an acute onset of respiratory distress 7 days following colectomy. The PE shows diminished breath sounds at the bases, and a cxr shows atelectasis. Most appropriate txmt?
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Supplemental O2, heparin, venous duplex scan, lung V/Q scan
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A 46 yr old man sustains multiple rib fx's after falling off a horse. One hr after arrival to ER, he continues to have severe CP, SOB, and tachypnea. His pulse is 125, 36 breaths/min, and pulse ox of 92%. His breath sounds are diminished on the left. Next step?
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CXR
his sat isnt quite low enough to warrant ET tube placement. |
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A 52 yr old woman presented with afib and an acute abd 8 days ago. She was taking to the operating room for exploratory laparotomy after initial eval suggested perforation of a hollow viscus. She required resection of an infarcted bowel, and a jejunal-colonic anastomosis was performed. On postop day 8 she began nutritional support through a feeding tube and began having watery diarrhea. Her PE was unremarkable and stool sample was analyzed and found negative for fecal leukocytes and C diff. Dx? Therapy?
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Short bowel syndrome:
Bowel rest and parental nutrition until bowel adaptation. |
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Individuals with less than how much small bowel may require permanent parental nutrition?
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60cm
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Most common causes of short bowel syndrome?
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Crohn disease and mesenteric infarction in adults and necrotizing enterocolitis and small bowel volvulus in infants
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A 2 month old preterm infant is noted by a neonatologist to have probable short bowel syndrome. Most likely cause?
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necrotizing enterocolitis
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A 40 yr old man underwent massive bowel resection secondary to SMA thrombosis, in which the entire small bowel was resected. Most appropriate txmt?
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Small bowel transplantation
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Role of the large bowel in NUTRITIONAL support
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short-chain fatty acids
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Most common place of crohns disease
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Terminal ileum and right colon
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Immunosuppressants used in crohns
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AZT and 6MP:
Bone marrow suppression, nausea, vomiting, rash anti-TNF...inflixamab |
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Initial txmt for crohn's? Initial testing?
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Antibacterials such as metronidazole and ciprofloxacin
Anti-inflammatories such as 5-ASA, and corticosteroids. CT scan and colonoscopy and SBFT contrast study for both colonic and small bowel involvement. |
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Crohn's pts often present with what secondary process?
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GI obstruction, that is due to subacute inflammation. Usually relieved medically to start, but chronic crohn's is usually fibrotic strictures requiring surgery.
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4 weeks following appendectomy for presumed acute appendicitis, a 23 yr old man returns to the ER with drainage of bile-stained fluid from his RLQ surgical site. The pt is afebrile and has been tolerating a normal diet. CT revealed postop inflammation and no abscess. A review of the pathology report from his previous appendectomy revealed involvement of the appendix with transmural inflammation and granulomatous changes. What is the most appropriate management?
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Infliximab
enterocutaneous fistula due to crohns. Fistulas close reported with inflixamib. |
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How is the hand splinted post op of CTS?
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Slight extension for 2 weeks
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Initial management of CTS?
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Nighttime splint and NSAID's
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A 54 yr old man presents with a hx of GERD, recent weight loss, and dysphagia. next step?
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Esophagoscopy (EGD) w/ biopsy, then possible ct scan for mets
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What is the appropriate txmt for a 455 yr old man with adenocarcinoma of the distal esophagus that penetrates to, but does not penetrate through the muscularis propria, provided that ct scan is negative for mets?
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Chemo with esophagectomy and postop chemo
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