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116 Cards in this Set

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