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116 Cards in this Set
- Front
- Back
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DDx for carpal tunnel syndrome
r/o how? |
gx
arthritis r/o w/ radiographs |
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what conditions is carpal tunnel syndrome related to
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DM
myxedema hyperthyroid acromegaly pregnancy lipomas bony abnormalities hematomas |
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what is Charcot's triad associated with
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ascending cholangitis
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what is Charcot's triad
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fever
jaundice RUQ pain |
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what is ascending cholangitis
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infx of bile duct --> sepsis and multiorgan failure
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tx for ascending cholangitis
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ABx and supportive care
ERCP decompression of CBD |
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what is the best way to dx stones in GB?
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U/S (98-99% sensitivity)
not the best way to dx stones in CBD, only 50% are visualized |
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what is ERCP
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way to visulaize CBD
can also perform sphincterotomy of duo to clear stones treats cholelithiasis and choledocolithiasis |
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dx of choledocolithiasis
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dilated CBD on U/S
>5mm diamter and increased LFTs |
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how to manage a pt w gal;stones and pancreatitis
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wait for pancreas to resolve itself, then perform cholecystectomy
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causes of LGI bleeds if >40 yo
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diverticulosis
angiodysplasia neoplasm (all are painless) |
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dx of LGI bleed + pain
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ischemic bowel
IBD intussusception ruptured AAA |
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how to localize LGI bleed
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colonoscopy
mesenteric angiography RBC scan |
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cause of overt LGI bleed in children
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meckel's diverticulum
IBD polyps |
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cause of overt LGI bleed in 20-60 yo
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diverticulitis
neoplasm IBD |
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cause of overt LGI bleed in >60 yo
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divertic
angiodysplasia neoplasm |
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what is RBC scan
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used to dx bleeding if >.1 ml/min
won't always localize bleeding accurately do 1st then follow with mesenteric angiography |
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advantage of mesenteric angiography
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.5-1.0 ml/min in order to be visualized... can see faster bleeds
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common causes of overt LGI bleeds in children
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Meckel's diverticulum
IBD polyps |
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common causes of LGI bleeds in 20-60 yo
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IBD
noeplasm diverticulosis |
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common causes of LGI bleeds in >60 yo
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neoplasm
diverticulosis angiodysplasia |
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when are maroon colored stools seen?
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LGI bleeds without rectum/anus involvment
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features of a rectal bleed
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formed stool streaked with blood , or fresh blood at the end of a BM
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what is mortality in head injury with hypoxia and hypotension?
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75%
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how much is mortality increased in hypoxia?
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2x
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how to tx increased intracranial pressure?
what precautions must be taken? |
hyperventilation and mannitol (but must be done cautiously since hyperven --> cerebral vasoconstriction)
it is helpful, however, b/c it makes room for expanding lesion, but can lead to cerebral ischemia if prolonged don't give mannitol unless pts are adequately hydrated |
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which type of hematoma (subdural or epidural) is more common
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subdural
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what does sluggish pupil dilation indicate
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early sign of temporal lobe hernaition
CN III gets compressed against tentorium herniation 90% of the time is on the same side as the pupil abnormality |
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1st step in managing SBO
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fluid resusc
NGT place Foley to assess fluid response |
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complications of SBO
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strangulation
bowel necrosis sepsis vomiting --> aspiration pneumonitis intravasc fluid loss --> prerenal azotemia and acute renal insuff |
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why is SBO so painful
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severe bowel distention --> venous congestion, decreased bowel perf, necrosis
bowel ischemia 2/2 strangulation |
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what is an ileus
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distention from non-obstructive causes
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gallstone ileus
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mechanical obstruction of SB b/c of large gallstone in bowel lumen
intermitt bowel obstruction for several days until stone lodges in distal small bowel --> complete obstruction |
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causes of SBO in child
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hernia
malrotation intussusception meconium ileus Meckel's divertic intestinal atresia |
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causes of SBO in adult
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tumor
hernia adhesions crohn's dz gallstone ileus |
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presentation of SBO
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passage of intestinal lumenal contents --> cramplike abdominal pain
n/v (bilious) BM occurs with start of obstruction/pain (b/c of incresaed peristalsis) no gas/BM |
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association of BM with SBO
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usually BM at very start of obstruction, followed by increasdd peristalsis and
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dx if there is stool on DRE of pt with SBO
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ileus, NOT mechanical obstruction
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what is early post-op SBO
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sx that occur <40d following surgery
results from narrowed lumen, exact cause not known |
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w/u for post-op SBO
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CT to r/o infx
exact cause not needed |
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tx for post-op SBO
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supportive care
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cause of chronic mesenteric ischemia
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occlussion of 2/3 BV
Dz also seen in 3rd as well |
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Dx of chronic mesenteric ischemia
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if no ATH, use arteriograpyhy
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tx for chronic mesenteric ischemia
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revasc with antegrade aortomesenteric bypass/perivisceral aortic endarterectomy
angioplasty retrograde bypass from iliac artery |
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when to operate on acute mesenteric ischemia
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this is a surgical emergency!
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causes of acute mesenteric ischemia
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embolism in SMA or celiac artery
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which part of the small intestines is spared in acute mesenteric ischemia? why?
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prox jejunum b/c of collaterals
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tx for acute mesenteric ischemia
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embolectomy
2nd-look laparotomy should also be done if bowel doesn't appear viable |
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when should a AAA be repaired
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5cm
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#1 cause of morbidity and mortality in AAA repair
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cardiac complications
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how should AAA found on physical exam be confirmed
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CT scan
don't use arteriography b/c it just shows the lumen of BV, can't dx aneurysm from this, although it will help to plan the operation |
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what are the 2 types of AAA repairs
benefits of each |
EVAR (endovascular aneurysm repair) - pts with copd, obesity, malig, etc get more protection from rupture with EVAR
open repair - stood the test of time, est as a tx |
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disadvantages to EvAR
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rquire imaging f/u every 3-6 mos
pt mortality of 2-3% |
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presentation of AAA rupture
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back pain
pulsaltile mass hypotension |
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management of acute pancreatitis
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resuscitative measures/supp O2
monitor cardio-pulm status CT abdomen |
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complications of acute pancreatitis
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hemorrhage
necrosis fluid collection infx pleural effusion --> pulm/renal probs |
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process of infected pancreatic necrosis
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2/2 infx by bowel organisms
occurs w/i first few weeks of onset |
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pancreatic abscess cause and tx
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accumulation of pus and infectious debris
tx with surgical drainage |
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tx of infectious pancreatic pseudocyst
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percutaneous/operative drainage
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Ranson's criteria seen on admission
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WBC >16,000
glucose >200 age > 55yo AST >250 LDH >350 |
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Ranson's criteria following 48 hrs
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HCt fall by 10%
Ca <8 BUN increase of 5 fluid requirement >6 L base excess of >4 P02 <60 |
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value of Ranson's criteria
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more criteria have more severe dz and increased risk of comlication and death
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what indicates severe acute pancreatitis
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necrosis of pancreas
50% have inx and increased microvasc permeability --> increased volume los decreased perfusion of kidneys, lungs, etc |
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when should a contrast-enhanced CT of the pancreas be done?
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if pancreatitis dx is in question
if no improvement in 3-5 days severe pancreatitis based on ranson score (looking for necrosis) |
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what, if seen on CT, wouldu indicate severe dz and increased risk of complications
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2+ extrapancreatic fluid collections or necrosis of >50% of pancreas
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management of necrotizing pancreatitis
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50% of time, complicate by infx, so must adminster proph ABx when necrosis is confirmed on CT
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how should gallstone pancreatitis be treated?
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cholecystectomy after pancreatitis has resolved
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which ABx penetrate pancreas
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imipenem
cilistatin |
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Tx for carotid artery dz
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surgery should always be done on sx side 1st, if both are affected
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when should elective CEA be done
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if 60% stenosis is seen, unless pt is high risk
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what is complication o fCEA or medical management of carotid artery dz
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stroke can occur with either
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how is amt of stenosis determined in carotid artery dz
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US
if that is unclear, do MR angiogram, carotid angiogram or CT reconstruction angiogram |
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what are risk factors for CEA
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prior radiation to the neck
coronary artery stent recrrent coronary artery stenosis |
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what is a short term tx for carotid artery dz
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stent
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When should barium enema be used in dx diverticulitis
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never- there is sig risk involved with intraeritoneal leakage of barium
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dx of diverticulitis
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CT scan will show colonic wall thickening, mesenteric fat stranding
can see diverticulae |
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complications of diverticulitis
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perforation
abscess bowel obstruction fistula (#1 cause of fistulas in adults) |
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tx of abscesses from diverticulitis
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if small, ABx
if big, CT-guided drainage + ABx if no imrpovement after 72 hrs, surgery |
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if there is an increased risk of recurrence with diverticulitis, management?
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elective surgical resection with primary anastamosis even if prior flare-up was treated conservatively
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how should uncomplicated diverticulitis be treated?
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monitor hydration, give IV ABx, bowel rest and observation
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how should complicated diverticulitis be treated?
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surgical resection
colostommy closure of the rectal stump reanastomosis performed at a later date |
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what is fascial dehiscence?
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disruption of fascial closure within 3 days of operation, with or without operation
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complications of fascial dehiscence
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enterocutaneous fistula
evisceration incisional hernia |
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risk factors for fascial dehiscence
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failure of surgical technique, anesthetic relaxation
>70 yo DM infx malnutrition pulm dz |
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tx of fascial dehiscence
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wound care
elective repair of defect |
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time frame that fascial dehiscence is most likely to occur?
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up to 3 weeks following surgery, after that, fibrous scar formation has enough strengthh to prevent evisceration
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vitamins involved in wound healing
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vitamin c, a, b6 (collagen cross linking)
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tx of ptx
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tube thoracostomy/needle aspiration
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difference btwn primary and 2ndary spontaneous ptx
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1ary: from spont rupture of blebs
2ndary: from bullous emphysematous dz, CF, CA, PCP, necrotizing infx, copd |
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sx of tension ptx
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dyspnea
jvd decreased breath sounds increased resondance trachea shifts away from affected side |
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tx perf of duo ulcers
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if no h/o prior ulcers or + HP, omental patch closure and HP tx
if + h/o prior ulcers and - HP, highly selective vagotomy |
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tx of perf gastric ulcer
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+ closure of perf or excise/resect ulcer w 1ary repair or Billroth I/II
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tx of obstructing gastric ulcer
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antretomy and Whipple
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are H2 blockers or PPIs more effective in tx ulcers
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PPIs
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string sign
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seen in hypertrophic pyloric stenosis, showing narrowed pylorus
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stack of coins sign
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intestinal obstruction
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tx for intussusception
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radiographic reduction
if fails, open surgery |
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incision through previous scar- good or bad?
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good. promotes wound healing
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featuress of large bowel ischemia
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minimal pain
see thumbprinting on barium enema BVs are usually patent |
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when should a colectomy be done on a pt w UC
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10-20 yrs with dz... (after 10 yrs, CA risk increases 4x)
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complication of typhoid fever
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Peyer's patches bleed /perf in 2-3rd week following sx
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how to stop intractable bleeding
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use laparoscopic towels to pack abdomen
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what is seen on EKG of pt with high Mg?
how can it be reversed |
sim to increased K
CaCl2 |
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what is seen with low Na on EKG
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nothing
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what is seen with low K on EKG
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flattened T waves and U waves
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when is succussion splash seen in the abdomen
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any sort of obstruction
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what are the most common causes of pyloric obstruction
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duo ulcer
gastric CA |
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how is mild Na deficiency tx?
severe Na defic? |
fluid restriction
if CNS sx present, give hypertonic saline |
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how is ARDS monitored
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ABG
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surgery = physiological stress
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surgery = physiological stress
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benefits of enteral feeding
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preserves gut mucosal mass and nml gut flora
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benefits of parenteral feedings
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good for rapid administration
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what happens if TPN is suddenly DCd?
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rebound hypoglycemia, give D10W when TPN is suddennly DCd
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what does surgery do to fluid levels
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following surgery, increased cortisol levels --> increased sugar in serum --> increased urine output
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what TPN additive is good for liver encephalopathy
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lactulose
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how is AAA dx?
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U/S then CT scan to det true size
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