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174 Cards in this Set

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What are the cardiology/heart association risks for surgery?
high risk: unstable/severe angina, MI in the last 7-30 days, decompensated CHF, bad arrhythmias (ventricular or uncontrolled supraventricular), really bad valves, grade 2/3 block.

Moderate: Mild angina, any previous MI, compensated CHF, DM.

Mild: uncontrolled HTN, old, LVH, LBBB, afib, stroke.
what are the advantages of the different kinds of anesthesia?
local = safest, fewest systemic complications. risk = not good pain control.

spinal = fewer RESPIRATORY complications than general. risk is in people without good hearts or vessels, who can't increase CO to compensate.

general: good anesthesia/amnesia, high liklihood of respiratory complications.
what do you do with insulin dependent diabetics who need surgery? what if a wound is present?
make sure BG before surgery is <250: if above, give 2/3 morning NPH and regular insulin. if <150, give 1/2 the morning dose. generally favor more than less sugar.

but don't operate if bg > 250 or <100.

any wound on any person, even if not near the site of surgery, needs to be addressed before surgery - it increases the chance of post-op infection. inspect diabetics well.
why would you think twice about laparoscopy in someone with severe COPD?
retained CO2 increases risk of post-op complications, and you're blasting it in.

open procedures might be safer.
renal failure pt gets surgery - what are the big risks and what can you do about it? what might sudden hypotension be caused by in a transplant patient?
dialysis close to surgery good to minimize uremia and platelet dysfunction (remember transfusing platelets doesn't help - need to ddAVP and FFP. can also use estrogen).

transplant pt with sudden hypotension might be from glucocorticoid withdrawl and adrenala crisis - need to give cortisone.
for what heart conditions do you not need abx prophylaxis to prevent endocarditis?
mitral prolapse without regurg, repaired ASD/VSD, previous CABG, pacemakers.

note that rheumatic disease, prosthetic valves, previous endocarditis, hypertrophic cardiomyopathy...need ABx.
how do you replace estimated blood loss? how do fluid requirements change after surgery?
3:1 replacement fluid to EBL. don't forget to replace the urine volume too.

post-surgery, third spaced fluid returns to the vasculature - so MUST REDUCE IVF otherwise you'll put the patient into edema.
if you pull out an IV and pus comes out, what is it and what do you do?
supprative phlebitis - remove IV and the vein also. IV abs and an open wound are required as well.
what gram stain finding would confirm clostridium, and how do you treat it?
G+ spore forming rods.

high dose PenG can do it.

remember perfinges causes gas gangrene and necrotizing fasciitis.
if you have a wound infection and don't want to simply let it heal by secondary intention, what are the options?
skin graft over it - need less than 10^5 bacteria in the bed. this minimizes contraction and speeds healing.

delayed primary intention - suture the wound closed, if few bacteria, good granulation tissue, and the edges look viable.
clean, clean contaminated, and contaminated wounds - how do you close them?
if clean (hernia, breast) = normal closure.

if clean contamintated (bowel prep with enterostomy) = regular closure, <10% risk of infection.

if contaminated most LEAVE OPEN. maybe delayed primary intention if good granulation tissue/viable edges persist.
describe what anterior vs. posterior shoulder dislocations look like:
anterior dislocation = most common. arm slight abducted, externally rotated.

posterior - happens in seizures and electrocution. arm against chest (adducted) and internally rotated.
what population do you expect to see seringomyelia in (not arnold chiari) and what does it look like?
post-spinal cord injury patients, sometimes years later.

usually in upper arm area, affects fibers that cross like spinothalamics (pain temperature) and motor (so see weakness/wasting). "cape like distribution" often mentioned.

eval with MRI.
someone has a TIA. How do you work them up?

What if they have some degree of stenosis in their carotids - what do you do?
make sure to listen to the carotids for bruits and to the heart for any murmurs (worry about emboli), as well as a full neuro exam.

do a duplex scan of the carotids: if >70% occlusion, endarderectomy preferred over medical management.
if you have a femoral artery embolous, what should you do?

what's the weird complication to remembr?
balloon catheter embolectomy, take it out.

frequently can get COMPARTMENT SYNDROME afterwards, sometimes manifested by pain and limited ROM.

this is due to reprofusion injury - muscles get edema from flushing toxins through them.

need to then do fasciotomy.
if someone's on warfarin and needs emergency surgery, what do you do?

what level of patelets are acceptable for emergency surgery?
restore clotting factors by giving FFP - note that giving vitamin K would allow synthesis of new factors, but it takes too long.

platelets >50k are alright to work with.
what are the rules for tetanus shots post trauma?
only time to give TIG is you didn't get all your childhood shots AND have big dirty wound.

for people who've had all their shots, use the kind of wound and 5 or 10 yrs to decide if they need booster: if cleanish wound, okay to give nothing if last TT was 10 yrs ago.
if dirty, okay to give nothing if last TT was <5 yrs ago.

if you didn't get all your shots as a kid: all wounds result in giving TT, if really dirty, give TIG.
AAA - when do you repair them?
if >5cm, general agreement that it's okay to operate if generally healthy and expected to live >2 yrs.

remember these pts are extremely susceptible to fluid shifts post-op, with fluid returning from the 3rd space and causing pulmonary edema.
if someone has a repaired AAA with graft and a long time later has upper GI bleed, what happened?
aorto-enteric fistula: the graft eroded into the gut.

need surgery to replace graft and repair gut - high mortality.
Pt has a PE that you treat successfully with heparin. Then the pt has another despite being anticoagulated. what do you do?
place greenfield filter in the IVC. and check platets - might have HIT and needs to be taken off heparin/bridged to coumadin.

greenfields also used in pts who need to be anticiagulated for PE prophylaxis but who have bleeding problems suddenly.
if someone perfs their appendix and doesn't realize it, then comes in for general pain later on, what might you find on exam?
might have a pelvic abscess, and it's often felt in the rectovessicular pouch (of douglas) - so finger in butt.

also might have defication problems from irritation of the distal colon

probably white count and mild temperature too.
what's anterior cord syndrome? rx?
blunt trauma patients get it - damage to the front of the cord causing loss of the corticospinal (motor) and spinothalamic (pain/temperature) tracts.

before doing scan, give HIGH DOSE STEROIDS to prevent inflammation, then MRI/CT scan.
in a multi-organ trauma pt in the ICU, what do you get worried about if they show a white count and some abdominal findings? signs of it?
acalculous cholecystitis - for some reason ICU patients get this all the time, and usually they can't tell you about it.

signs include pericholycistic fluid, thickening of galbladder wall.

need to cholecystOTOMY (remove infected fluid) followed by cholecystectomy after they're healthy enough.
what do you for patients who fail medical therapy for GERD?

what about barrett's esophagus?
10% fail and are surgery candidates - first get manometry to ensure the DES is working, then do NISSIN procedure (finduplication)

if barrett's esophagus, need biopsy to see if dysplasia present. Mild/Moderate dysplasia can be treated medically and re-evaluated every 2 yrs with EGD

if high grade, need to resect esophagus.
what's ludwig angina?
infected tooth leads to swelling of the submandibular area and can get bad enough to suffocate.

pts often homeless, and are drooling.

need Abx and removal of tooth.
if PUD fails medical management (ppi + metro + clinda), what do you do?
surgery: HSV = highly selective vagotomy, or vagotomy + pyloroplasty (V+P).

don't forget to measure serum gastrin levels: if you have refractory PUD or recurrent disease, might have zollinger-ellison.
if someone presents with super bad epigastric pain and involuntary guarding, after getting basic labs, what test should you order?
upright CXR/obstructive series, looking for free-air under the diaphragm: if present = perforation and go to the OR.
Pt in the ICU gets upper GI bleed, as many do due to stress ulcers. What do you do?
no matter how bad, get IVs started and give fluids, then PPi, type/cross, then UPPER ENDOSCOPY to find out exactly what is bleeding.
what's the treatment for someone having esophogeal varices bleeding?
assume cirrhosis and portal HTN: replace missing liver-derived clotting factors w/ vitamin K and FFP, lower portal HTN with OCTREOTIDE (somatostatin) and vasopressin.

sclerosing endocscopic procedure.
pt has a fib after a major surgery. what happened?
fluid overload in the lungs led to temporary CHF - give diuretics.
if DCIS diagnosed by core bx, what do you do?

what about LCIS?

atypical ductal hyperplasia?
need surgery: if diffuse, simple mastectomy/reconstruction.

DCIS: note that if it's the COMEDO VARIETY, need to add in sentinel node bx: 30% of these, even if DCIS on bx, are actually in invasive, and 4% are in the axilla already.

LCIS: not so bad. if by a known benign mass, leave along with 6mo biopsies. if around calcifications, consider open biopsy and remove.

atypical ductal hyperplasia: kinda like DCIS but with a higher risk of current/future cancer: remove lesion (needle guided excision).
what if you palpate a mass on exam? what do you do?
if 35-60 year old lady, get diagnostic mammo/U/S, then core bx, then remove/treat as appropriate.
what do you do with a young woman with a 14cm breast tumor?
probably phyllodes tumor: these are sometimes malignant, sometimes not. remove with big margins.
what do you do about nipple discharge? What characteristics make you less/more worried?
bilateral lactation, clear/milky, and production from multiple ducts are all good signs.

blood, coming from a single duct, is bad.

in the later case, good idea to CANULIZE the duct and remove the duct/duct system...it's probably an INTRADUCTAL PAPILLOMA and those have a small chance of becoming malignant.
describe the staging of breast cancer:
T: 0-2cm = T1. 2-5 = T2 5+ = T3. Extension into the pec or skin = T4.

N: mets to no nodes = 0 mets to movable axillary nodes = N1 Mets to matted, fixed axillary nodes = N2.

M = yes or no mets.

Stage 1 = T1 N0 M0
Stage IIa = either T1 N1 or T2 N0
Stage IIb = T2 N1 or T3 NO
Stage IIIa = T1 N2, T2 N2, T3 N1, T1 N2.

Stage IIIb = T4 with any N, no M.

Stage 4 = any M.
pt post lap chole is having lots of pain. what do you do?
repeat UQ ultrasound and a HIDA scan. HIDA = hepatoimmunodiacetic acid scan.

worry is a biliary leak: HIDA is secreted into the bile (as long as the T bili <8) and, if you don't see anything, follow pt.

if you do see a collection of dye, then there's a leak - must do ERCP and drain leak/repair.
what finding on abdominal ultrasound might hint at cholangiocarcinoma? study you should do
painless jaundice and a finding of dilated intrahepatic bile ducts (with normal extrahepatic ducts).

percutaneous intrahepatic cholangiography is the best test for cholangiocarcinoma.
1.guy has pancreatitis caused by stones. what do you do?

1. what if a guy has pancreatitis and then decompensates with massive organ failure?
1.treat like regular pancreatitis: NPO, IV hydration, pain control.

once the amylase goes down, proceed with the lap cholecystectomy.

2. decompensation - probably severe necrotizing pancreatitis. expect that he's going to get ARDS. fluid recuessitate in the ICU.

if he gets sepsis signs, this is probably a pancreatic abscess - need to suck out fluid for dx and then drain.
how do you manage pseudocyst? how does it present?
someone with pancreatitis that doesn't crash or get better, with amylase staying up.

don't do much - continue NPO and pain meds, start TPN 'cause it's going to take awhile.

if it persists >6 weeks, then do surgery to remove. this is because it takes this long for a good capsule so that it can be removed.
work up a solid liver mass on u/s:

what do you do with hepatic adenomas?
don't just blindly biopsy: this could be hemangioma which will bleed.
do labeled RBC test to see if it's hemangioma - if so, stop...usually no need to resect.

CT scan = hemangioma if it contrast shows "peripheral outlining" - no malignant potential, don't biopsy, just sit on it.

if doesn't light up, could be cancer - do biopsy.

hepatic adenomas usually come from OCP use - d/c and see if they persist. if they shrink, leave alone.

if persist, remove - these can eventually turn cancerous. note that biopsying them also causes bleeding. they RUPTURE.

don't forget that focal nodular hyperplasia = benign, no malignant potential, not connected to OCP's, leave alone.
how about liver abscesses?
1. if ameobic, no surgery - treat with metronidazole

2. if pyogenic (arterial spread from IV drug abuse) - lots of small ones, just do IV abx. if one big abscess, drain percutaneously.
with prolonged vomiting, what happens to your electrolytes?
contraction alkalosis with hypokalemia:

vomiting up H+, Cl-, and Na+: you end up alkalotic (low H+) - so cells transfer out H+ in exchange for K+.

also, the kidney ups aldosterone to retain Na+ and secrete K.
how do you treat small bowel obstruction?
if isolated (generalized tenderness with no focal point, no acidosis/leukocytosis/fever) - NG tube decompression and IV rehydration is usually enough.

MOST SMALL BOWEL OBSTRUCTIONS RESOLVE ON THEIR OWN.

note that focal tenderness, leukocytosis, acidosis, fever = DO SURGERY.
how do you evaluate someone you suspect of ischemic bowel?
if mild findings, can do sigmoidiscopy - though this doesn't rule anything out. if positive and pt stable, can do abdominal angiogram.

also can do revascularization surgery to repair blood supply - though if the patient improves on own, probably transient event that's likely to recur.
how do you manage someone with crohn's and evidence of small intestine obstruction?

what if there's a fistula seen on CT?
probably a stricture: treat it like anybody else with bowel obstruction.

if no focal tenderness, leukocytosis, fevers...bowel rest, IV hydration, maybe TPN. only consider surgery if persists for several weeks.

even if there are fistula, same deal. no surgery unless indicated clinically.
what surveillance is needed for people with inflammatory bowel disease?
UC causes colon cancer - they need colonoscopies every 1-2 years after >10 years of living with it.

this has to include random biopsies, 'cause their cancers don't always start out as polyps.

crohn's can cause cancer, but not as frequently. note that crohn's in the colon has a bad prognosis and is hard to control with 5-aminosalysilic acid.
someone with UC has painful, distended abdomen. what might be wrong? Rx?
toxic megacolon - treatment is like for small bowel obsturction: decompression, TPN, IV hydration. Probably add steroids.

note that if the pt. perfs, need to remove whole colon (the rest is probably trashed too) - make hartmann pouch so they can poop.
what if while doing an apendectomy you find a little yellow tumor in it?
it's a carcinoid: if it's in the tip and <2cm, remove appendix and you're done.

if it's at the base of the appendix (at the cecum) and >2cm, that suggests it's a malignant carcinoid and you have to do a colectomy.

either way, get a urinary 5-HIAA and serum serotonin level - these are good predictors of malignancy.
what's the management for divercitulitis? what if it comes back?
bowel rest, IV hydration, NOT morphine (increases intraluminal pressure) - meperedine is preferred.

if it recurs, plan resection - wait 'till recovered.

remember not to do colonoscopy while inflamed.
old lady has sudden and massive GI bleeding. what diagnoses are most likely, and what do you do?
IV access and 2 liters, NG TUBE and decompression (remember acute upper GI bleed can present as anus bleeding).

probably bleeding diverticula, ectasia.

note that these usually stop bleeding on their own, but have to be worked up with colonoscopy once things settle down. could be cancer.
Thyroid FNA shows follicular cells. what do you do?

what about hurthel cells?
this is indeterminate - remember follicular cancer is well-differentiated into follicles, and histo can't tell them apart.

need to do at least lobectomy and look for Ca: if positive, remove rest of thyroid.

Hurthle cells = adenoma or low grade cancer, do lobectomy. same deal.
how do you work up primary hyperparathyroidism?


how do you manage hypercalcemia? what are the other things that cause it? treatment?
high PTH level usually with high Ca+ and low phosphate.

almost always a parathyroid ADENOMA causing it - but you still have to do surgery to remove.

cut into the neck, find all 4 glands, remove the adenoma. Can do SETAMIBI scan to just find the adenoma and remove it.

hypercalcemia management: must figure out what's causing it. remember mets to bones can do it, thiazide diuretics, multiple myeloma, sarcoid, RCC, lung SQUAMOUS CELL Ca (secretes PTH-l)

treatment = REHYDRATE (Ca+ = diuresis) and give lasix, also bisphosphonates.
Thyroid FNA shows follicular cells. what do you do?

what about hurthel cells?
this is indeterminate - remember follicular cancer is well-differentiated into follicles, and histo can't tell them apart.

need to do at least lobectomy and look for Ca: if positive, remove rest of thyroid.

Hurthle cells = adenoma or low grade cancer, do lobectomy. same deal.
how do you work up primary hyperparathyroidism?


how do you manage hypercalcemia? what are the other things that cause it? treatment?
high PTH level usually with high Ca+ and low phosphate.

almost always a parathyroid ADENOMA causing it - but you still have to do surgery to remove.

cut into the neck, find all 4 glands, remove the adenoma. Can do SETAMIBI scan to just find the adenoma and remove it.

hypercalcemia management: must figure out what's causing it. remember mets to bones can do it, thiazide diuretics, multiple myeloma, sarcoid, RCC, lung SQUAMOUS CELL Ca (secretes PTH-l)

treatment = REHYDRATE (Ca+ = diuresis) and give lasix.
why might the renal service consult surgery for an ESRD patient? When should this happen?
to remove the parathyroid glands.

ESRD = retain phos, which binds Ca+, which induces parathyroid glands to make tons of PTH, which trash the bones. If fails medical management, might have to remove glands.

usually leave a little (50g) of tissue behind, usually transplanted into the arm.
atropine-like side effects
TCAs
what cancer is associated with epistaxis and otitis media? risk?
NPC - nasopharyngeal carcinoma. it's squamous cell usually.

weird risk factor is EBV- find it in asians/mediteranians. Can use EBV to track disease course.

Usually metistatic when discovered.
Trauma patient has elevated left diaphragm on x-ray. What might have happened?
diaphragmatic hernia from abdominal trauma. Hitting belly = high pressure, forces diaphragm up. Right side is protected by liver, so left side ruptures.

Bowel ends up in the chest cavity, which might not show up on X-ray.

Can get mediastinal deviation away from defect (to right).
when talking about someone on a vent, what's the RQ?
respiratory quotient - comparing Co2 made to O2 sucked in.

>1 = hard to ween off vent. Some reason, they're breaking down mostly carbs.

0.8 = using mostly proteins
0.7 = using mostly fatty acids.

So descending order: carbs, proteins, fats. CPF.
what's the basic management for someone you suspect of having increased ICP?
head of bed up, mannitol, and HYPERVENTILATION (blow off Co2 = brain vasoconstricts = decrease cerebral perfusion).
what's a big brown melanoma spot on the face called?
lentigo maligna melanoma: has a better prognosis. old people get this and it tends to spread outward, rather than down.

preceded by hutchinson's freckle.
what are the 3 kinds of inguinal hernias and where do they go?
indirect inguinal hernia: this goes into the spermatic cord, which is medial to the inferior epigastric vessels, anterior to inguinal ligament.

direct = push through wall medial to inferior epigastrics, anterior to the inguinal ligament.

femoral: posterior to the inguinal ligament, medial to the femoral vein/artery.
dude has hematochezia but nothing but diverticuolosis on lower endoscopy. what next?
techtnium-99 labeled RBC scintiography: this can find the site of any random bleeding, including angiodysplasia or let you know where the bleeding diverticuli is .
Hb under 7 is an indication for blood transfusion.

what about acute bleeding?
>1500cc blood loss = 25-30% of blood volume = give transfusion.
what do you do for urethral injuries?
posterior injury = high riding prostate, bleedy penis. DO NOT PASS FOLEY

for all cases of suspected urethral damage, need to to RETROGRADE URETHROGRAM to evluate extent of damage.

passing foley = make things worse.
is it ever okay to not insert a chest tube for a pneumothorax?
if it's a small one and is asymptomatic, it can be observed.

note that if the patient has to go to the OR or be on a mechanical vent, you have to do the chest tube: positive pressure ventilation will blow out and make small pneumothoraces worse.
what does a widened mediastinum on xray mean? what do you do?
worry is aorta injury. note that portable AP magnifies mediastinum and is unreliable - if pt stable, better to get a formap PA X-ray.

note that a hazy knob or descending aorta are also hints of aortic injury.

need to do aortic angiography or do CT scan to eval aorta, if damaged = go to OR.
trauma patient with clear chest, abdomen, and no broken femur - where's the bleed? what do you do?
probably pelvis - go to angiography where they can embolize branches of the bleeding internal iliac. Reduction/external fixation of the pelvis also helps.
how do you evaluate spleen laceration, and what do you do?
CT scan.

If unstable and have spleen injury, take to OR.

If stable, grade injury: 3 or below, OK to watch

4 or 5, take to OR (even if stable).

If remove spleen, give pneumoccous, meningocccous, and H. flu vaccines.
What are the components of standing?
The components of standing are:

[1] Injury;

[2] Causation;

[3] Redressability;

[4] No standing to assert others’ rights, unless Π himself is injured and (a) 3rd parties find it difficult to assert their own rights, or
(b) Π’s injury adversely affects his relationship w/ 3rd parties;

[5] Associational Standing;

[6] No citizenship/taxpayer standing, except taxpayers have standing to challenge government expenditures as violating the Establishment Clause
how do you control cerebral salt wasting?
comes from ADH outflow after brain injury = make concentrated urine, dilute out serum sodium.

hypoosmolar plasma = brain cells relatively hypertonic, pull in fluid, make edema, make situation worse.

Rx = FLUID RESTRICTION.

also consider giving hypertonic saline (3%) - though it has to be slow.

correcting hypotension too fast = central pontine myelinolysis.
other than carbon monoxide, what can happen to burn patients in a closed room? what do you do about it?
methemoglobin - making of ferric 3+ fe from ferrous 2+, shifting Hb curve left.

treatment is methyline blue.

note that pulse ox won't tell you anything - need ABGs to see this.
say you operate on a messed up arm. post surgery the pt has tons of pain and the arm is kinda white. pulses intact.

what's wrong, what do you do?
this is compartment syndrome: note it won't cut off pulses.

just screws with the low pressures system of arterial flow into venules.

need to gague pressure: >30mmHg = fasciotomy.
what's the connection between crohn's and renal stones?
any fat malabsorption syndrome = hyperoxylaturia.

when gut can't absorb fat, it can't absorb calcium: calcium washed out into poop.

Ca normally binds oxylate to keep it from being aborbed.

lowering fat absorption = increasing oxylate absorption = more kidney stones.
what's the first step in someone who's having non-traumatic massive hemoptysis? note that they have a lung nodule too.
don't do CT scan first to figure out diagnosis - have to do bronchoscopy to find the source of bleeding and stop it.

risk is asphyxiation.
low levels of what electrolyte mimics calcium? how do you tell apart?
magnesium - low levels cause tetany.

hypomagnesemia affects the heart like hypercalcemia does - so check an EKG.

note that low Mg can also cause you to waste phosphorus, so expect this to be low as well.
hemolytic transfusion reaction - how do you treat it?
recognize it by screwed up bleeding and finding more Hb in the urine.

Hypotension happens rapidly - so GIVE LOTS OF FLUIDS

then give MANNITOL - osmotic diuresis prevents the degraded RBC membranes from clogging up the glomeruli.
Normal saline and lactated ringers - how do they affect body pH? What's in them?
Normalsaline = 154 mEq of both Na+ and Cl-, which is hypertonic slightly. pH is around 4.5 and giving a lot causes OVERLOAD ACIDOSIS (opposite of contraction alkalosis).

Lactated fingers is 130 mEq sodium, has a little potassium and calcium, and doesn't change blood pH very much.
what happens to sodium, potassium, temperature, and sugar in addison's?
retain potassium, loose sodium.

low blood sugar.

INCREASE temperature.
go through the phases of wound healing:
inflammatory (first 2 days), proliferative (up to 2 weeks), remodeling (years).

inflammatory = neutrophils coming in and secreting stuff. Monocytes come in day 2 and secrete chemotactics (TNF/PDGF).

Proliferative phase beings. Fibroblasts come in day 2 and make type III collagen, which peaks at a couple weeks

Then spend the next year turning type III into type 1
pt has a subdural hematoma, but no midline shift and no focal neural deficits. how do you control?
NO SURGERY - this is medicine. hyperventilation, mannitol, etc. Problem now isn't hematoma expanding, it's the edema that follows.
35 year old lady has bloody boob discharge - probably intraductal papilloma. what do you do?
do mammogram first - if it's negative, probably papilloma. can watch or remove for symptomatic cure.
Loa loa tx
diethylcarbamazine
what's the workup for someone with known hemorrhoids who has rectal bleeding?
flex sig or colonoscopy - don't assume that they DON'T have colon cancer.

butt bleeding an older person is cancer until proven othrewise.
what's the workup for someone with bright red blood coming out of butt and they're kinda getting unstable?
first, stabilize. then figure out what's bleeding.

drop NG tube: if you get bile and no blood, you've cleared the area between the nose and the ligament of trietz.

lower endoscopy is hard with blood (for some reason it's fine when it's upper) - angiography or tagged RBC scan is the way to go.

note that the NG tube trick only works if you're sure the patient is CURRENTLY bleeding. waiting a day and trying won't give you any information. if it's stopped, have to do upper/lower endoscopies.
what if a 7 year old kid starts crapping blood? dx?
probably meckle's diverticulium.

dx = technicium scan (NOT THE RBC ONE).
if a post-menopausal woman has a parathyroid adenoma, what should you give them (assuming they don't get surgery/)
estrogen - having the parathyroid around will raise serum Ca++ by leeching bones - so you'll get osteoperosis faster.
for the 4 kinds of surgeries (clean, clean contaminated, contaminated, and dirty) - what are the liklihoods of post-op infection?
clean = 1%

clean contaminated = 1-5% (non-perfed appendix)

contaminated = gun shot through gut with spillage, but no yet infected = 10-15%

dirty = significant dead tissue or already infected = 30-35%
old diabetic man, post op day one, gets confused. what do you do first?
give O2 and get ABG's: biggest post op risk of confusion is hypoxia secondary to atelectasis.

do the finger stick later.
what's osgood shatler disease?
see in kids: knee disorder. pain in knees, especially prox. tibia where patella inserts.

due because kids use quads a lot but insertion point isn't ossified yet, so it microtears.

rx = ice and rest, they grow out of it.
other than colon cancer, with what malignancy is ulcerative colitis connected to?
cholanciocarcinoma.

remember that UC causes sclerosing cholangitis which causes cholangiocarcinoma.
how dehydrated is someone with a sodium of 153, and what should you replace it with?
half normal saline for replacement. only use normal saline for hyponatremia and acute blood loss replacement.

every 3 above normal = 1 liter down.

so this is about 2 liters down.
young lady has follicular carcinoma of the thyroid. what do you do? remove whole lobe? both lobes?
both lobes, then give radioactive iodine.

follicular carcinoma doesn't uptake iodine as well as regular thyroid, so can't give radioactive iodine until the regular thyroid is removed.

then give it.
what's subclavian steal?
subclavian artery usually has low resistance: if it gets stenotic PROXIMAL TO THE VERTEBRAL, resistance goes up.

the redudant blood supply to the brain gets stolen via reverse flow through the vertebrals and/or carotids to the arm.

so get neurological symptoms when using the arms, and probably arm claudication.

treat with angioplasty/stent in the narrowed subclavian section
Cerebral salt wasting patient, post head trauma, has low sodium. what do you do?
Fluid restriction first. Don't give fluids - they'll just retain the water and pee out the salt, making things worse.

then diuretics-.

then demelocycline or lithium (ADH antagonists).
how do anal fissures present, where are they, and how do you treat them?
Posterior at 6 o'clock 90% of the time.

they are really painful with little bleeding.

they are DISTAL to the dentate line (closer to the butthole)

Rx = WASH - sitz baths, analgesics, stool softeners, high fiber diet. If last >6 weeks, surgery. = lateral sphincterotomy

Note that hemmorhoids usually bleed more and are easily seen on proctoscopy.
how does someone who's vomiting a lot end up with hyponatremia?
you're vomiting up stomach contents which have a sodium concentration close to plasma.

patients at home replace their fluid with water that has no sodium.

so you end up diluting out what's left.
what do you do if a pt who just had an ex lap has peritoneal fluid coming out of the wound but no sign of infection and no intestines falling out?
this is a dehissence without evisceration.

okay to bind up the belly and repair when it's convenient - no need for emergency surgery. note that the patient should stay on back, nothing that causes valsalva.
old guy notes some bleeding when wiping. anoscopy shows hemorrhoids that don't look thrombosed or too bad. what next?
colonoscopy! bleeding can always be from cancer - don't be fooled by someone taking anticoagulants. everybody needs one.
what's the pringle manuver?
clamping the hepato-duodenal ligament, which contains the hepatic arteries (L/R) and the portal vein.

note that it also contains the common bile duct.
how do you treat prostitis?
same bugs that cause UTI's - but because of the prostate capsule, need long term treatment. Bactrim or floroquinolones for several weeks.
if you find a prostate nodule, what do you do?
need biopsy to determine the GLEESON score
how do you treat epididymidis? what causes?
causes in young men = sexual = gonorrhea/chlamydia.
anbitiobitcs + elevation = prescription.

old dudes = gram negative rods along with prostititis. again, antibiotics.
what's the typical presentation of a meckle's diverticulum? treatment?
in a kid, random painless ass bleeding.

technicium 99 scan = meckle scan. remember rule of 2's: it's within 2 feet of the iliocecal valve, 2% of population has one, and it has 2 mucosa (gastric and colonic).

the scan looks for GASTRIC mucosa.

if simple painless bleeding, all you have to do is chop it off.

if it's complicated, need to chop off part of the healthy intestine as well.
Hernia exam: direct vs. indirect. Where do you feel the bulge? Where's the defect?
in a direct hernia, the bowel does NOT come through the internal ring, but can come out the external ring. It's due to weakness of the posterior inguinal canal wall, which is made of the transversalis fascia.

Exam = finger in external ring, valsalva, feel the hernia on the LATERAL aspect of the finger.

Indirect hernia = defect in the internal ring. Exam = feel bulge on the tip of the finger.
what's ogilvie syndrome, and how do you fix it?
old people who don't move who get non-abdominal surgery. AKA 'acute megacolon' - you'll see large distension in the cecum.

treatment is conservative (NG tube, NPO) most of the time. also NEOSTIGMINE to increase motility - note this causes bradycardia and bronchoconstriction
PSA levels. What can you do if between 4 and 10? what if under four but suspicious?
under 4, can consider serial PSAs to look at velocity (increase): if >0.75 = suspicious.

if between 4 and 10, can do U/S to eval If suspicious, do free% (free = good, bound = bad).

can also do PSA density: compare amount of PSA to the volume of the prostate. If high = bad (big prostates make lots of PSA, little prostates with cancer make lots of PSA).
describe the webber test:
this is where you put the tuning fork midline on the skull.

in neural hearing loss, the patient will hear the sound best in the good ear.

in conductive hearing loss (anywhere before the choclea) the sound will be louder in the BAD EAR: this is because conductive loss will eliminate background noise, but you still have the sound being piped directly into the choclea through the skull, so it'll sound louder.
what's the thing to do with someone who has RA before they get surgery that's kinda abnormal?
cervical spine X-ray.

remember RA for some reason causes C1-C2 instability (lazy ligaments) which can make traumatic cord injury possible during intubation.
what's the treatment for carpal tunnel (suspected)?
remember they get parasthesias.

first is x-ray to rule out other causes of hand stuff.

then anti-inflammatories.

then to do surgery, but before this, to do electromyography.
the typical causes of post-op fever: when do they happen?
day 1 = atelectasis.

day 3 = UTI

day 5+ = DVT

days 7-10= wound infection, abscess.
Guy breaks his femur and there are decreased pulses. The bone is displaced. What comes first?
ANGIOGRAPHY happens before setting the bone any time you have disruption in the vascular supply.

this is because bleeding can be controlled with embolization in extermities.
what if someone has typical symptoms of non-complicated biliary colic (URQ pain after food, no fevers/white count) but U/S says they have no gallstones? eval?
this is biliary dyskinesia: the galbladder isn't contracting properly

test = HIDA scan after CCK administration - you'll see an ejection fraction out of the galbladder of <50%
someone has a hot thyroid adenoma. how do you prove and treat it?
do the radionucleotide uptake scan, look for free t4, then remove it (after giving them beta blockers)
If a kid has a TE fistula, what else do you do?
look for VACTER: vertebral, anal, cardiac, TE fistula, radial/renal stuff. X-ray gets most stuff, get echo and do physical exam for anus, U/S for renal.
GI abnormalities in a newborn - what might you get asked?
bilious vomiting in a newborn = bad. if double bubble, could be duodenal atresia or annular pancreas. with complete obstruction, either way you're going to do surgery.

if similar picture but there's air in the distal colon, could be partial version of above OR MALROTATION = super emergency: do contrast enema or gastrograffin to see it.

if air fluid levels more distally, could be random intestinal atresia from vascular abnormality in utero. surgery.

SO : complete obstruction = surgery to see it. Partial = enema/gastrograffin study
what's the typical baby presentation of intusucception and what do you do?
currant jelly stools, colicky pain.

barium enema is theraputic and diagnostic.
kid has big mushy mass along the supraclavicular region. what is it and what do you do?
cystic hygroma. do CT scan to see how big, then remove.
what's the management for a 20 something with a painless enlarge neck lymph node?
if it's the only one, give it time: recheck in a few weeks. if it went away, it was inflammatory. if it didn't, it's probably cancer, but waiting didn't make anything worse.

if there are other big ones, night sweats, etc...then it's lymphoma.
an older guy who smokes and drinks has a hard growing lymph node in the neck. what do you do?
DON'T BIOPSY. This could be squamous cell spread from anywhere, probably head/neck cancer. Maybe FNA okay.

triple endoscopy = esophagus, tracheo/bronchoscopy, and look at the larynx/pharynx to find the primary.
old guy has a parotid mass. what do you do?
REFER - never biopsy head masses. These have to be done by the ENT's in a special way.
someone has leg claudication. when should you operate, and how do you eval?
it's palliative - it doesn't decrease mortality, so no reason to do early surgery if someone can tolerate it.

if it interferes with life, can do surgery.

ABI followed by angiography followed by surgery.
dude with known kidney stone develops fever, WBC count. what next?
emergency - obstruction with infection = super bad. decompress with nephrostomy tube while giving huge amounts of antibiotics.
what is low ureter implantation?
only seen in girls. one ureter inserts into the vagina (in boys with this, low still puts it above sphincter).

little girls with normal urge and ability to go on command, but leak.

do physical exam, IVP if not obvious, then surgical repair.
what do you typically see in cases of dumping syndrome?
GI complaints with diarrhea AND vasomotor problems (flushing, sweating).

happens post-vagotomy.
femoral, tibial, common peroneal: generally what structure do they innervate? sensation?
tibial = all posterior leg. the posterior thigh (knee flexion) and the posterior lower leg (plantar flexion) as well as flexion of the toes.

Femoral = quadracepts as well as sensation of anterior thigh, and medial thigh/leg

common peroneal: divides into the superficial and deep. these innervate the anterior lower leg, sensation to the anterior lower leg, and the dorsum of the foot.
what do you do for someone with LCIS?
this isn't a marker of current cancer (like atypical hyperplasia) - just a risk of future cancer.

likely tamoxifen prophylaxis, if a candidate, as well as 6 month mammos, MRI, clinical exams.
when do you have to intubate someone, based on GCS scale?
only for "SEVERE" which is 8 and below.

mod = 9-12
light = 13-15
what's the management of acute hypercalcemia?
HYDRATION and lasix. high calcium usually goes with dehydration, and lasix will help pee it out.

Calcitonin can be used in difficult cases.
what's the inguinal triangle, and why does it matter for hernias?

what makes the floor of the inguinal canal?

nerves in danger?
hesselbach's: medial border = rectus.

superior border = epigastrics

inferior border = inguinal ligament (which is aponeurosis of ext. oblique, connecting ASIS to the pubis). Direct hernias push through this.

floor of inguinal canal = transversalis

nerves in danger: ilioinguinal (runs on top of cord)

genital branch of the genitofemoral (in cord).
what are the major arteries of the leg?
aorta gives off the iliacs. don't care about the internal iliac, follow the external. it becomes the femoral artery.

femoral artery gives off deep femoral and SUPERFICIAL FEMORAL (SFA)

this becomes the popliteal, then after going behind the knee, TRIfucrates into the anterior tibial, posterior tibial, and peroneal.

the tibials hook up again to become the dorsalis pedis.

remember that most claudication is the result of SFA thrombosis behind the sartorius muscle, so FEM-POP bypass it.
TNM of colon cancer:
T1 = invades into submucosa
T2 = invades into muscularis
T3 = THROUGH muscularis
T4 = through serosa: A= perfs visceral peritoneium, B = perfs adjacent structure.

N: N1 = 1-3 regional LN. N2 = 4 or more LN. N3 = regional nodes near MAJOR VESSEL.

stage 1 = T1/2
stage 2 = T3/T4
Stage 3 = any T with LN's
Stage 4 = any M.
Thyroid FNA shows "cellular" result - what is this, and what do you do?
remember follicular and hurthle cell can't usually be separated from adenoma/carcinima as seen on FNA.

so, check TSH. If it's LOW (hyperthyroidism), check it with radioactive scintography: if it's cold, remove thyroid.

if you get cellular result and TSH is HIGH or normal (low thyroid) - remove it, no need for scintography.
what's ALI and when does it come on, what are the criteria, what do you do?

when do you intubate someone?
Acute lung injury: usually within a few days of a trauma.

must have pulmonary infiltrates, wedge pressure <18, ACUTE onset, PaO2:Fi02 <300

treatment is appropriate respiratory support, from supplemental O2 to intubation.

note that this is MILD ARDS: PaO2:Fi02 <200 = ards.

intubation: if can't maintain Pa02 of 60 or pulse ox of 91% on non-rebreather 02, need to intubate.
someone immediately post-op abdominal surgery has a fascial dehissence. what do you do?
immediate surgery IF: impending enterocutaneous fistula, impending evisceration, untreated deep infections.

if everything is stable, generally use local wound care and repair the incisional hernia, when it later develops.

note that repair of an INCISIONAL HERNIA has a MUCH HIGHER INFECTION RATE than for typical ventral/inguinal hernias (due to the probably present comobrid conditions that led to the hernia in the first place).
when do you do surgery for diverticulitis? do you use colostomy?
if it's complicated (ruptured) or this is the 4th bout.

colostomy is good if the patient is hemodynamically unstable or spilling poop into the abdomen - leave a hartmann's and fix it later.

if they're stable, can reconnect immediately.
someone comes in with pretty bad pancreatitis and doesn't get better in a few days. what do you do?
get a CT scan - if there's necrosis, start IMIPINEM - it penetrates the pancreas and prevents INFECTED necrosis. If they crash, do surgery.

if infection occurs, go to surgery

remember if it's caused by a gallstone, remove the gallbladder before discharge.

percutaneous drainage is for infected pseudocysts.
someone has high calcium. what are the hints that it's a parathyroid adenoma? blood test?
the chloride:phosphorus ratio of 33:1. note that high PTH will inhibit bicarb resorption (so get a little acidodic) and to maintain neutrality, chloride is re-absorbed, so it'll be a little high.

high calcium from cancer won't have the high Cl.

also can do a PTH test: if primary, it'll be high. if due to cancer, PTH will be SUPPRESSED (the PTH like hormone made by lung cancers isn't detected by the test).

need to treat due to effects of high Ca+ on cardiovascular system (calcification, HTN, LVH)

surgery if Ca+ >11.5.

to do surgery, need to find glands -U/S of SESTAMIBI scan.
what do you do with thymomas in myasthenia gravis?
remove them - they're "semi-malignant" - and it often improves MG symptoms.

note that tissue diagnosis is often more trouble than it's worth - get CT scan and remove.
what blood tests should you run on everybody with an adrenal incidentaloma?

what scan do you do for pheos?
1. 24 hr urine VMA
2. bmp for K+, aldosterone:renin
3. O/N dexamethasone suppression

remember lung cancers often go to the adrenals.

only do FNA on the mass if it's under <4cm - you're going to remove anything bigger anyway, so it won't change management.

pheo scan = MIBG. remember to alpha block before surgery.
removing spleen for ITP - what are the indications? what do you do first?
try not to do it in kids, their risk of sepsis is higher and their ITP sometimes resolves.

pts should try medicine first - steroids, IVIG, plasmapharesis. If symptomatic for >1 yr on medicine, do surgery.

must get BONE MARROW ASPIRATE first to make sure they have normal/high megakaryocytes (should be making lots to replace those missing if bone marrow is normal, and ITP is a diagnosis of exclusion).

don't forget vaccines for h. flu, meningococcous, and pneumococcous.
when do you get worried about yellow babies, and what tests do you do? specifically if conjugated?

risks of procedure?
2 weeks still yellow = bad. workup = TORCH organisms, U/S, HIDA. Could be choledochal cyst.

remember if it's hemolysis, coombs test will be +.

common screwups = failure of bile to flow, cholangitis, and portal HTN.

only 20% make it to adulthood without liver transplant.
esophogeal cancer - what is done? how do you stage and do surgery?
need EUS - esophogeal ultrasonography is a great way to get both T and N staging.

if can't cure, pallative procedures can be done to stop dysphagia (like putting in stents)
diabetic guy has a foot with a painful area with red area. what might it be?

how do you find osteomyelitis?
soft tissue infection vs. charcot foot.

can do X-ray for osteomyelitis (and should do it on any new diabetic foot ulcer) but it can take awhile to show up - radioactive bone scan might be the way to go.
what do you about SCFE?
immediate surgical pinning. remember that slipped femoral epyphisis happens to fat boys.

legg calve perthis (avascular necrosis) is usually the one that's managed with weird traction things.
workup hyponatremia:
hypovolemic: these are renal losses (like aldosterone deficiency) vs. non renal losses. Renal losses = FeNa:1%, urine Na+ >20. non renal = opposite.

euvolemic: SIADH vs. crazy psychogenic polydypsia.
SIADH = urine osms >100 (maybe like normal plasma), Urine Na+ >20 (maybe high...remember ADH resorbs free water, increasing urine salt concentration).
Primary polydypsia: urine osm <100 (desperately diluting urine.

Hypervolemic: CHF vs. renal failure. CHF = FeNA<1%, urine Na+ <10.
what do you do for choledocol cysts?
these are cysts of the extra-hepatic ducts (inta = caroli's disease).

all require surgery as they are PRE-MALIGNANT: choledocojujenostomy
what do you do about carcinoid tumors in the appendix?
if <2cm, just remove appendix and done.

if >2cm, need to do R. hemicolectomy.

also rules about where in the appendix it is?
hepatic mass - what's the scan for a hemangioma, and what do you do about it?
labeled RBC scan is gold standard for hemangioma. if positive, do nothing - leave them alone. no malignant potential.

if you do the scan and it's negative, then you can proceed to biopsy - it's hard to tell focal nodular hyperplasia from HCC.

remember adenomas in women can be treated with trial quitting OCP's - but if they don't resolve, remove.
what's the most common cause for sudden massive epigastric bleeding in a kid, and what do you do?
esophogeal varices - this is usually due to pre-hepatic portal vein thrombosis, sometimes from an non-obliterated umbilical vein infection.

usually self imited, but somatostatin/tamponade can be used.
how can you tell between epididymitis and testicular torsion, and what do you do?
epididymitis tends to be relieved by elevation of testis, torsion doesn't. also, epididymitis typically has discharge and inflammatory cells in the semen, happens in sexually active men

torsion = surgery. orchiplexy has to be done on BOTH testicles
what's osteitis fibrosa cystica, osteomalacia, and osteitis deformans?
osteitis fibrosa cystica = what you get from hyperparathyroidism. sometimes causes brown tumors = little hemorrhagic cysts.

osteomalacia = vitamin D problem, either from liver or kidneys - need to replace it.

osteitis defomrnas = paget's disease. remember this has high alk phos.
de queverian tendenosynovitis vs. duptryen's contracture: which is which?
duptryen's = scandanavian men with palpable nodules.

de quervian = women, radial side of the wrist, no deformity.
what do you do for someone who just perffed a diverticulitis and now has some free fluid?
depends on how stable they are - if they're stable, can sit on them with Abx and percutaneously drain the fluid later.

if they're really sick, need to remove the colon and drain them intra-operatively.
Adult volvolus - what's the xray sign, what do you do?
the twist causes a 'bird beak' - passing an endoscope through can fix it. kinda like intususcpetion in kids.
how are the neck zones divided?
1 = up to crycoid

2 = crycoid to angle of jaw

3 = jaw to the head

for zone 1 and 3, get CT angiogram before going to the OR.
Thyroglossal duct cysts vs. branchial cleft cysts - dofferene?
thyroglossal duct cysts ELEVATE with protrusion of tongue.

branchial cleft cysts are lateral.
how is aortic dissection managed?
beta blockers.

if it's proximal or ascending aorta, immediate surgery.

if it's after the left subclavian comes off, medical management can be attempted.
Axillary nerve, radial nerve, ulnar nerve - what are the typical causes of injury and how do they present? Musculocutaneous?
axillary nerve - think anterior shoulder dislocations. deltoid paralysis.

radial = think crutches, humeral MID-SHAFT. Radial = wRist drop.

Ulnar = think medial epicondyle of the elbow. claw hand.

Musculocutaneous = biceps motor, forearm sensory
if someone has outflow tract obstruction by swollen prostate, what do you do?
depends on why - if BPH, put in foley.

if prostaitits (boggy, tender prostate) = suprapubic catheter (foley will cause sepsis).
What's a furnicle, carbuncle?
Furnicle is an abscess - usually cause by follicuilitis.

when this auto-innoculates all around it, get big gross carbuncle.
Guy has pheo signs and symptoms. How can you know, without scan, if the pheo's in the adrenals or extra-adrenal?
adrenal is the ONLY place you can make epinephrine. All pheos could make nor-epi.

so if you find both norepi and epi degredation products, it has to be adrenals.
When are you allowed to do a gastric bypass?
BMI >40, or >35 with severe comorbidities (pickwickian or deadly apnea).
someone has upper GI bleeding, just showed up. they're stable. what's the first step to figure out what's wrong?
NG tube - get the stomach contents out and aspirate until it's not bloody anymore. then EGD to see what's wrong.

if still bleeding, EGD again.
someone's got claudication and a low ABI. You're working them up for possible surgery. What are the next tests to get?
PVR's first - pulse volume recordings - these are doppler studies at several arterial levels down the leg to create a flow/volume graph.

then angiogram - either traditional, CTA, MRA
how do you treat angry hemorrhoids?
day 3 is the cutoff - if they're inflamed, if you get to them before 3rd day complaint, okay to I+D.

after that, they'll get acutely better on their own.

long term - surgery, laser good.

only rubber band INTERNAL hemorrhoids.
what's mirizzi syndrome?
big stone in the cystic duct gets lodged, inflamed, big enough to compress the adjacent common bild duct.

see hepatic duct/intrahepatic duct dilitation and tapering of the CBD.
what's the different presentation of meniscal tears vs. ligament tears?
meniscus = pop sound, swelling over the next day.

ligaments torn will cause immediate swelling (hemearthrosis due to lots of vessels in the ligament).
what's the diagnostic screen for esophogeal perf?
water-soluble swallow study. NO EGD - the insuffluation will make the pneumomediastinum worse.
Parkland formula for burs is...?
4ml X kg body weight X % burned, not in percent. so if 36% burned, and 50kg, it's 4 x 50 x 36. this is deficit - so give half in the first 8 hours, and the other half over the next 16.

don't forget maintenance fluids too.
thioridazone, chlorpromazine - what are the famous side effects?
thioRidazone = Retinal pigmentation
.
Chlorpromazone = jaundice/photosensitivity.
what are the schizo time frames? what are the good/bad prognostic features?
<1 mo = acute psychotic disorder

1-6 mo = schizophreniform

>6 mo = schizophrenia

good signs: late onset, family hx of MOOD disorders, married, good support

bad signs: fam hx of schizophrenia, early onset, no reason, single
If you put in a chest tube in a trauma patient, how do you know if you need to do a throracotomy?
>1000 to 1500cc blood out immediately, or >600cc in 6 hours. This is an indication that the bleeding is arterial and not likely to stop on its own.
what are the indiciations to intubate a burn pt?
any resp symptoms = cough, stridor, horseness, dyspnea. Don't do bronch, don' do x-ray...immediately intubate.