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414 Cards in this Set
- Front
- Back
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What is an abrasion?
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loss of epidermis and possibly dermis; possibility of ground in foreign bodies
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How are abrasions treated?
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neosporin, polysporin
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Is depth or length greater with a puncture wound?
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depth
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How are puncture wounds treated?
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do not close
irrigation if possible-->antibiotic-->cover |
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What happens with a crush wound and how should it be treated?
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compression of tissue
do neurovascular exam and allow to heal by secondary intention |
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What is an avulsion and how is it treated?
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partial or full thickness of epidermis ripped away from dermis
Tx: simple sutures |
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What are 6 types of lacerations?
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tidy
untidy flap stellate amputation degloving |
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What is the most common type of local anesthesia?
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lidocaine 1%
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What were the first anesthetics that we ever available and when are they used today?
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esters (still around in case pt has allergic rxn to amide)
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What are 3 types of amides that are used for local anesthesia?
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lidocaine
mepivacaine bupivacaine |
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What is the onset of action, duration of action, and max adult dose of lidocaine as a local anesthestic?
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rapid
60-120mins 4.5mg/kg |
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What is the onset of action, duration of action, and max adult dose of mepivacaine as a local anesthestic?
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fast
90-180mins 7mg/kg |
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What is the onset of action, duration of action, max adult dose, and an example of use of bupivacaine as a local anesthestic?
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slow
240-480mins 2mg/kg post-hernia surgery |
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What are the benefits to adding epinephrine to lidocaine for local anesthesia? (5)
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-prolongs half-life (b/c not being transported)
-vasoconstricion dec. drug clearance -inc. duration of action -dec. total required dosage -dec. bleeding (ex. scalp area-galea) |
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What 5 places of the body is epinephrine contraindicated and why?
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fingers
toes penis nose ears can vasoconstrict & cause necrosis |
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What does irrigation of a wound help remove? (4)
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debris
dirt bacteria devitalized material |
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What can a wound be irrigated with?
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sterile saline (via IV tubing)
antibiotic irrigation has not been found to significantly dec. infection rates |
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What is the minimum amount of saline that is used when irrigating a wound?
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50cc
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Devitalized fat has ___ times the infection of viable fat.
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2.5
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What does debridement do?
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removes devitalized, dirty tissue
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What are 3 types of wound closure methods?
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Dermabond
suturing stapling |
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What are 7 contraindications locations of Dermabond?
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tension wound
lower extremities joints hairy mucus >5cm long >5mm wide |
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What types of wounds is spliting used? (7)
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sutures over joints
finger laceration wrist laceration elbow laceration hand laceration plantar surface of feet very large lacerations |
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What does splinting do?
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immobilization of lymphatic channels
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What is the purpose of elevation of a wound? (2)
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limits edema
reduces throbbing |
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What ointments should not be used for wounds? (2)
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petroleum jelly (never)
corticosteroid cream (not recommended) |
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What are the typical wound infection rates in the ED?
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2-3% (except hands and feet may be more)
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Are systemic antibiotics always used for wounds?
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no (when wound is >10 bacteria per gram of tissue, infection will occur despite antibiotic Tx)
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What are 2 good antibiotic choices for "skin bugs"?
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Cipro
Augmentin |
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How long does it take before the final appearance of a scar should be judged?
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6-12months
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Where is the thyroid gland located?
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just below the cricoid cartilage in the anterior part of the neck
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What is the arterial supply of the thyroid?
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superior thyroid artery (1st branch off external carotid artery)
inferior thyroid artery (branch of thyrocervical trunk) |
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What is the venous supply of the thyroid?
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superior, inferior, and middle thyroid vein of each side
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What nerve supplies the only muscles that open the vocal cords?
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recurrent laryngeal nerves (just deep to thyroid gland)
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What is the most common thyroid abnormality seen in surgical patients?
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thyroid nodule
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What is the likelihood of a thyroid nodule being malignant?
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1-10%; more likely in younger men
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What sized thyroid nodule requires diagnostic workup?
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>1cm (10mm)
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Are TFTs helpful in distinguishing a benign fom malignant nodule?
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no
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What during Hx/PE would point more towards a malignancy of a thyroid nodule? (4)
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prior radiation exposure
FH vocal cord weakness/paralysis cervical lymphadenopathy |
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What are 4 diagnostic tests that can be done for a thyroid nodule?
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radionucleotide scanning (cold=hypofunctioning, more likely to be malignant)
US (cystic vs solid) FNA (performed on most palpable nodules; careful w/ results if any prior radiation) x-ray (stippled w/ calcium) |
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What is the most common thyroid malignancy?
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papillary carcinoma
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What are 4 types of thyroid carcinoma?
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papillary
folliculr medullary anaplastic |
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Which thyroid CA is generally slow growing and usually asymptomatic; usually presents in the 5th or 6th decades of life; may spread via lymphatics in the blood?
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follicular CA
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Which type of thyroid CA is slow growing and asymptomatic; many patients will present w/ cervical lymph node metastases?
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papillary
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What type of thyroid CA has a familial component, arises from parafollicular/C-cells, is associated with multiple endocrine neoplasia syndromes (MEN II), and the lesion is often detected by elevated calcitonin levels?
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medullary
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Which type of thyroid CA occurs in 4-8%, grows rapidly, invades adjacent tissues and often presents w/ vocal cord paralysis from recurrent laryngeal nerve involvement, and has a very poor prognosis?
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anaplastic
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What are the 3 types of differentiated thyroid CA?
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papillary
follicular medullary |
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What is the Tx for differentiated thyroid CA?
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total thyroidectomy
papillary >1.5cm follicular <1.5cm medullary <1.5cm |
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Why is a total thyroidectomy recommended in differentiated thyroid CA?
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b/c of recurrence of contralateral lobe
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How can the recurrence of thyroid CA on the contralateral lobe be assessed?
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serum thyroglobulin assay or radioiodine scan
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How are metastatic deposits of follicular and papillary CA treated after surgery?
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with iodine
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What are all patients w/ thyroid CA maintained indefinitely on?
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suppressive doses of thyroid hormone
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What levels should be measured as a tumor marker in patients w/ differentiated thyroid CA?
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thyroglobulin (usually high in pts w/ residual CA after thyroidectomy)
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Which thyroid CA is associated w/ high incidence of nodal involvement and what is the recommended Tx?
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medullary
bilateral central neck node clean out |
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When is an ipsilateral modified radical neck dissection needed for medullary thryoid CA?
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primary tumors >1.5cm in diameter and when central neck nodes are involved
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What are the indications for a subtotal thyroidectomy? (4)
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very large/multinodular goiter w/ low radioactive iodine uptake
hyperthyroidism pregnant women Tx psychologicall/mentally incompetent |
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How is undifferentiated thyroid CA treated? (3)
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total thryoidectomy (RND)
radiation chemotherapy |
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What happens with a radical neck dissection?
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removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible superiorly to the clavicle inferiorly, the medial border of the strap muscles anteriorly, and the anterior border of the trapezius muscle posteriorly
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What happens with sequelae of spinal accessory nerve sacrifice?
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shoulder drop on side that spinal accessory nerve was taken
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What happens with bilateral internal jugular vein ligation?
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facial edema b/c of poor drainage from head; can get blindness, laryngoedema, & death
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Before thyroid surgery, what is given for toxic goiter until the pt becomes euthyroid?
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PTU
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What is given 10-15 days prior to thyroid surgery to decrease vascularity?
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2gtts of potassium iodide solution (Lugol's iodine solution)
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What are possible post-op complications of thyroid surgery? (7)
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bleeding (hematoma)
voice change respiratory problems dysphagia injury to parathyroids hypothyroidism unsightly scars |
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Damage to what nerve can result in paralysis of the vocal cords?
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recurrent laryngeal nerve
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Why may respiratory problems occur after thyroid surgery?
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expanding hematoma
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What does excision of both recurrent laryngeal nerves require?
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urgent tracheostomy
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What are the S/S that occur with injury to the parathyroids from thyroid removal?
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low blood calcium w/ tingling in the feet, hands, and around the mouth; severe cases have spasm of the fingers/hands; generally transient but may need long term calcium and vitamin D replacement
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What is the prevalence of unsightly scars from a thyroidectomy?
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<1%
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What is the blood supply for the parathyroid glands?
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inferior thyroid arteries
venous drainage through thyroid plexus |
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What are the parathyroid glands responsible for?
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synthesis of PTH; PTH & vitamin D play critical role in calcium homeostasis (inc renal calcium)
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What is primary hyperparathyroidism due to?
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solitary adenoma (80%)-calcium feedback loop is lost
4-gland hyperplasia-inc # of PTH secreting cells present (chief cells) |
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What are the assoicated conditions of primary hyperparathyroidism? (3)
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bones
stones abdominal groans |
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What do the labs for primary hyperparathyroidism show?
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hypercalcemia
elevated PTH 24h urine calcium rate slightly elevate |
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What are the deletirious effects of hypercalcemia on the CV system?
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HTN
LVH calcification (mitral/aortic valve dz) |
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What imaging studies are used for primary hyperparathyroidism?
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US
CT MR scintigraphy technetium 99m sestamibi scanning |
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What is the only curative Tx for PHPT?
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parathyroidectomy
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What are the possible indications for surgery in pts with PHPT? (6)
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elevated serum Ca >12mg/dL
marked hypercalciuria (>400mg/24h) overt manifestation reduced bone density reduced CrCl age <50yrs |
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What happens post-operatively for PHPT?
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not outpatient surgery
monitor serum Ca levels calcitriol 1ug/day |
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What are the possible complications of PHPT? (2)
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bleeding
recurrence |
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What is secondary hyperparathyroidism mostly due to?
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renal failure
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What are 5 benign breast conditions?
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fibrocystic breasts
fibroadenoma nipple discharge breast abscess augmented breasts |
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What ages is fibrocystic breast condition most common and what is the causative agent?
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30-50
estrogen |
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What are the S/S of fibrocystic breasts? (5)
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painful
multiple bilateral fluctuation (cyclic) pain/size larger pre-menstrual |
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How are suspicious fibrocystic breast lesions handled?
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FNA and if no resolution --> excision
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Who do fibroadenomas commonly occur in and what is the Tx?
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young (20yo) females
rule out CA using FNA or excision |
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How are fibroadenomas of the breast characterized? (6)
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nontender
round rubbery discrete movable 1-5cm |
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What are 3 causes of nipple discharge?
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duct ectasia (clogged milk duct)
intraductal papilloma (dilation of milk duct) CA |
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If anyone with nipple discharge is questionable, then what do they get?
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mammography
US to determine cystic vs solid |
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What condition has unilateral spontaneous serous or serosanguinous nipple discharge?
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duct ectasia
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What does bloody nipple discharge raise suspicions of?
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malignancy (however generally not)
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What 2 conditions may have milky nipple discharge?
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hyperprolactinemia
hypothyroidism |
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If purulent nipple discharge occurs in small children, then what condition is suspected?
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mastitis
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What are the S/S of a breast abscess and what is the causative organism?
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nursing mothers experience erythema, pain, and induration around the breast
Staph aureus |
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What is the early Tx of breast abscess?
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dicloxacillin or oxacillin PO (moms can continue breast feeding)
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If a breast abscess progresses to infection with systemic signs, then what is the Tx?
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surgical drainage (pump)
discontinue nursing |
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If a breast abscess/infection does not go away with antibiotics, then what may you be thinking?
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Paget's dz
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What conditions may occur with augmented breasts?
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capsulitis (scar around implant)
rupture (rare) |
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Is breast CA risk increased with augmented breasts?
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NO, but more difficult to find
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What are the risk factors for breast cancer? (13)
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nulliparous or delayed child birth
FH personal Hx white AA increasing developed countries (not Japan) older age BRCA1/BRCA2 mutation endometrial CA proliferative fibrocystic dz CA in opposite breast early menarch (<12yo) late menopause (>50yo) |
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What is generally the age for male breast CA and what is the prognosis?
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>50yo
poor prognosis |
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What are the early findings of breast CA?
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single
nontender firm/hard ill-defined margins palpable lymph nodes OR pos. mammogram w/ no palpable mass |
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What is the 1st and 2nd common locations for breast cancer?
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upper outer quadrant (tail of spence) 45%
nipple 25% |
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What are the advanced findings of breast CA? (7)
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skin/nipple retraction
axillary lymphadenopathy breast enlargement erythema edema pain mass fixed to chest wall |
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What are the late findings of breast CA? (4)
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ulceration
supraclavicular lymphadenopathy (stage IV) arm edema metastases |
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What the 4 common locations that breast cancer metastases to?
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bone
lung liver brain |
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When should self breast exams be done?
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monthly 2wks after menses
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When should clinician breast exams be done?
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every 2-3yrs ages 20-40
yearly >40yo |
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When should mammograms be done?
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every 1-2yrs ages 40-50
yearly >50yo *unless has a FH then 10 years earlier |
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What are the lab findings of breast CA?
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ESR-disseminated CA
serum alk phos (liver/bone mets) hypercalcemia-advanced CA tumor markers |
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What are the tumor markers that can be helpful post-surgery to see if there is a recurrence of breast CA, but are not diagnostic? (3)
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CEA
CA-15-3 CA-27-29 |
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What types of diagnostic testing can be done for breast CA? (6)
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US
FNA (w/ palpable lesion) large-needle/core biopsy (w/ palpable lesion) sterotactic core needle biopsy (nonpalpable lesion) mammographic localization biopsy open excisional biopsy (after FNA if still suspicious) |
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What are the steps for clinically malignant breast CA in a premenopausal woman AND not clinically malignant breast CA in a post-menopausal woman (both w/ palpable mass)? (4)
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mammogram
biopsy (FNA/excisional) pre-op counseling definitive procedure |
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What are the 2 most common types of breast CA?
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ductal
lobular invasive in situ |
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When are most breast cancers found?
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invasive ductal
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What is the #2 cause of morbidity/mortality in women?
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breast CA
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What are 4 types of imaging that can be done for metastases?
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plain chest film
CT scan (throax, brain, abdomen) bone scan PET scan (lymphatics) |
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What is the lymph node progression for breast CA?
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neighboring
axillary supraclavicular |
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What is stage 0 of breast CA?
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carcinoma in situ (can be ductal or lobular)
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What does stage 1 of breast CA involve?
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tumor confined to the breast
node negative |
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What does stage 2 of breast CA involve?
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tumor spread to ipsilateral axillary nodes
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What does stage 3 of breast CA involve?
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tumor spreads to superficial structures of chest wall
involvement of internal mammary lymph nodes |
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What does stage 4 of breast CA involve?
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metastases
supraclavicular lymph nodes |
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What are the 2 breast CA hormone receptors sites? Do they have a better or worse prognosis? How is this type of CA treated?
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estrogen, progesterone
better Tamoxifen (blocks estrogen receptors) |
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Which stages of breast CA are curative? Palliative?
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I/II-curative
III-may be curative, but generally palliative IV-palliative |
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What are 2 types of breast conserving therapy for breast CA?
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Partial mastectomy (lumpectomy with margins) & axillary node dissection
Modified radical mastectomy (total mastectomy & axillary node dissection) |
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What are the NIH current recommendations for stage II/III breast CA?
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partial mastectomy & axillary node dissection (only 20% of women choose this)
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What is the standard therapy (75%) for stage II/III breast CA?
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modified radical mastectomy & sentinel node biopsy
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What are 3 complications due to mastectomy?
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wound infection
wound edge necrosis seroma |
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What are 5 complications of axillary lymph node dissection?
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hypoesthesia
winged scapula frozen shoulder lymphedema wound infection |
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If a pt has a mother, sister, or daughter with breast CA then she has a ___ times risk of having it. However, if she has FH plus BRCA1/BRCA2 gene mutation then she has a ___ times risk.
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2
3 |
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What is the most common cause of all cancer-related deaths in both men and women in the United States?
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lung CA
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What are the 3 common risk factors for lung CA?
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tobacco smoking (85% of cases)
asbestos exposure (squamous & small cell) radon/isotopes exposure |
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In what location is lung CA most common?
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right upper lobes
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What are the associated CA risks with lung CA? (5)
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upper resp. tract
oral cavity esophagus bladder kidney |
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How does lung CA spread? (7)
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visceral/parietal pleura
chest wall great vessels pericardium diaphragm esophagus vertebral column |
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What are the common sites of metastasis for lung CA? (9)
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lymph nodes
liver bone brain adrenal pancreas kidney soft tissue myocardium |
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What are the 3 types of lung CA?
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non-small cell (80%)
small cell (15-20%) bronchial gland (5%) |
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What are the 4 types of non-small cell lung CA?
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squamous cell (20%)
adenocarcinoma (30%) adenosquamous large cell |
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Which type of lung CA is 2/3rds central, near hilum, 1/3rd peripheral, has a slower growth rate and metastasis that other lung tumors and may present w/ hemoptysis earlier than other types?
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squamous cell
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Which type of lung CA is classified as acinar, papillary, or bronchoalveolar, and the majority are peripheral?
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adenocarcinoma
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Which type of non-small cell lung CA is more agressive than the others and has a low survival rate?
|
adenosquamous
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What is the least common non-small cell lung CA and is peripheral?
|
large cell
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Which type of lung cancer is centrally located, agressive, metastasizes early, and are the most resistant to combined-modality Tx?
|
small cell (oat cell)
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Which type of lung CA is actually malignant "carcinoid tumors" that are located centrally in proximal airways?
|
bronchial gland adenomas
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Which type of lung CA is susceptible to pancoast tumors (Horner's syndrome)?
|
SCC
large cell |
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What happens with Horner's syndrome (lung CA)?
|
Invasion of the
paravertebral sympathetic chain and stellate ganglion. -Miosis -Slight ptosis -Anhydrosis |
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What happens with superior vena cava syndrome (lung CA)?
|
SVC relatively collapsable
-JVD -HA -swelling |
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What is the clinical presentation of central lung tumors? (5)
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chronic cough
hemoptysis respiratory difficulty pain pneumonia |
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What is the clinical presentation of peripheral lung tumors? (6)
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cough?
*chest wall pain pleural effusions pulmonary abscess Horner's syndrome Pancoast's syndrome |
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How can a definitive diagnosis be made (>90%) for lung cancer?
|
bronchoscopy (central) then biopsy
FNA (peripheral) |
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What diagnostics are used to work-up lung CA? (6)
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bronchoscopy
FNA CT (contrast for mediastinum) PET (lymph nodes) alk phos bone scan |
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Which type of lung CA uses TNM staging?
|
non-small cell CA
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What does each T1 for TNM staging for lung CA represent?
|
</= 3cm w/out invasion
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What does each T2 for TNM staging for lung CA represent?
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>3cm or invasion of visceral pleural or collapse of less than entire lung or at least 2cm from carina
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What does each T3 for TNM staging for lung CA represent?
|
invasion of chest wall
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What does each T4 for TNM staging for lung CA represent?
|
invasion of mediastinum+ (heart, great vessels, windpipe, esophagus, spine, etc.)
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What does each N0 for TNM staging for lung CA represent?
|
no nodal involvement
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What does each N1 for TNM staging for lung CA represent?
|
spread to lymph nodes w/in same lung as primary CA
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What does each N2 for TNM staging for lung CA represent?
|
spread to lymph nodes in the middle of the chest b/t the lungs but on the same side as primary CA
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What does each N3 for TNM staging for lung CA represent?
|
spread to lymph nodes in the middle of the chest b/t the lungs on the opposite side from the primary CA OR to supraclavicular lymph nodes
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What does each M0 for TNM staging for lung CA represent?
|
no spread outside the chest or to another lobe of the lung
|
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What does each M1 for TNM staging for lung CA represent?
|
distant spread present, including spread outside the chest, to a different lobe of the lung, or the the opposite lung
|
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How is the T stage for TNM staging of lung CA diagnosed?
|
broncoscopy/FNA
CT |
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How is the N stage for TNM staging of lung CA diagnosed?
|
palpation/PE
lymph node biopsy PET |
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How is the M stage for TNM staging of lung CA diagnosed?
|
CT
alk phos bone scan |
|
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What does stage IA/IB of lung CA include?
|
T1/T2 tumors, no nodes, no metastases
|
|
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What does stage IIA/IIB/IIIA/IIIB of lung CA include?
|
tumors, nodes, no metastases
|
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What does stage IV of lung CA include?
|
tumor, nodes, metastases
|
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What stage is early lung cancer w/o mediastinal involvement?
|
stage I/II
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What stage is locally advanced lung CA?
|
stage IIIA/B
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What stage is metastatic lung CA?
|
stage IV
|
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What is limited small cell carcinoma of the lung?
|
dz limited to ipsilateral hemithorax
|
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What is extensive small cell carcinoma of the lung?
|
dz extending beyond the thorax, below the diaphragm, or in the brain
|
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How is small cell carcinoma treated?
|
generally palliative
chemo & radiation |
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What is the 5 years survival of lung CA?
|
<15%
|
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How is stage I/II lung CA treated?
|
surgery alone (lumpectomy or wedge resection)
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How is stage IIIA lung CA treated? (3)
|
pre-op chemo/chemoradiation
surgery post-op radiation |
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How is stage IIIB lung CA treated?
|
surgically unsectable dz
radiation w/ or w/out chemo |
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How is stage IV lung CA treated?
|
chemo alone
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What are the absolute contraindications to lung surgery? (6)
|
MI w/in 3mo
SVC syndome bilateral endobronchial tumor contralateral N3 malignant pleural effusion distant metastases |
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What should non-small cell CA limited to the thorax undergo to exclude N2 mediastinal lymph nodes?
|
mediastinoscopy (endoscopic evaluation of mediastinum through suprasternal incision)
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What is the standard of care for early or locally advanced non-small cell lung CA?
|
lobectomy
-1 cm margin of normal proximal bronchus -Hilar LN specimens are sent off to pathology intra-op to exclude need for pneumonectomy |
|
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What is inserted after lung surgery until it adheres again?
|
chest tube
pleur-evac |
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What is included in the post-op management of lung surgery? (5)
|
permanent loss of breath sounds
loss of lung markings on CXR chest tube turn, cough, deep breathing Lovenox/compression stockings |
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What is the wall suction for a chest tube generally set on so that the tube can overcome resistance whithout sucking up against chest wall?
|
20cm
|
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What are the 3 parts of the the Pleur-Evac and three bottle system?
|
suction
water seal drainage collection |
|
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What are the complications that may occur after lung surgery? (6)
|
Cardiac arrhythmias
Hemorrhage Infection (empyema) Bronchopleural fistula Respiratory insufficiency Pulmonary embolism |
|
|
What may advanced metastatic non-small cell CA that is solitary brain or adrenal metastasis benefit from?
|
pre-op chemo and radiotherapy followed by surgery
|
|
|
What foreign bodies warrant endoscopy or GI consult? (7)
|
sharp/elongated objects
multiple foreign bodies button batteries evidence of perforation airway compromise presence of FB >24h child w/ nickel/quarter @ level of cricopharyngeal muscle |
|
|
What is the hospital admission % average for patients >65yo?
|
60%
|
|
|
On x-ray, how can you tell whether a coin is in the trachea or esophagus?
|
trachea-high sagital position
esophagus-anterior/posterior position |
|
|
What is visceral pain caused by?
|
stretching of fibers innervating the walls or capsules of hollow or solid organs
|
|
|
What does localized peritonitis develop?
|
rigidity
rebound |
|
|
Where is parietal/somatic pain localized?
|
to the dermatome directly overlying the site of the painful stimulus
|
|
|
What are patterns of referred pain based upon?
|
developmental embryology
|
|
|
What conditions do you think of with "abrupt, excruciating" abdominal pain? (6)
|
*ureteral colic
*ruptured aortic aneurysm *MI perforated ulcer biliary colic mesenteric ischemia |
|
|
What conditions do you think of with "rapid onset of severe, constant" abdominal pain? (5)
|
*acute pancreatitis
*strangulated bowel ectopic pregnancy ruptured aortic aneurysm mesenteric thrombosis |
|
|
What conditions do you think of with "gradual, steady" abdominal pain? (7)
|
*appendicitis
*diverticulitis PUD acute cholecystitis acute cholangitis acute hepatitis acute salpingitis |
|
|
What conditions do you think of with "intermittent, colicky with pain free period" abdominal pain? (3)
|
gallbladder
small bowel obstruction IBD |
|
|
Where may biliary pain radiate to?
|
inferior scapula
|
|
|
Where may renal pain radiate to?
|
groin/testicles
|
|
|
What conditions do you think of with rapidly progressive (w/in 1-2hrs) abdominal pain?
|
cholecystitis
pancreatitis SBO mesenteric ischemia colic |
|
|
What conditions do you think of with gradual (over several hours) abdominal pain?
|
appendicitis
incarcerated hernia distal SBO PUD GU/GYN condition |
|
|
What are 4 specific GI symptoms?
|
jaundice (hepatobiliary)
heamatochezia hematemasis hematuria (ureteral colic) |
|
|
Do you think about a medical or surgical condition if a pt experiences abdominal pain THEN N/V?
|
surgical (severe abdominal pains may last as long as 6 hours)
|
|
|
Do you think about a medical or surgical condition if a pt experiences N/V THEN abdominal pain?
|
medical
|
|
|
What drug class can mask abdominal S/S?
|
corticosteroids
|
|
|
What are 10 systemic signs that may occur with "acute abdomen"?
|
fever
chills rigors AMS rebound dec urine output pallor tachycardia tachypnea dec BP (last sign) |
|
|
Where is "punch tenderness" of the abdomen assessed?
|
costal areas
costovertebral areas |
|
|
What are 5 special exam signs for the abdomen?
|
Murphy
Psoas Obrutator Rovsing Chandelier |
|
|
What blood studies may be done to work-up abdominal pain? (9)
|
CBC with differential
Serum Electrolytes Urea Creatinine Arterial Blood Gases Serum Amylase LFT Clotting studies UA with Micro |
|
|
What are the PE findings of a perforated viscus (abdomen)? (5)
|
tense abdomen
loss of liver dullness guarding rigidity diminished BS (late) |
|
|
What are the PE findings of peritonitis? (5)
|
motionless
cough & rebound tenderness guarding rigidity absent BS (late) |
|
|
What are the PE findings of an inflamed mass or abscess (abdomen)? (5)
|
tender mass
punch tenderness Murphy psoas obturator |
|
|
What are the PE findings of an intestinal obstruction? (5)
|
distention
visible peristalsis diffuse pain w/out rebound tenderness hernia/rectal mass |
|
|
What are the PE findings of an ischemic or strangulated bowel?
|
pain out of proportion to PE findings
|
|
|
What are the PE findings of bleeding (abdomen)? (6)
|
pallor
shock distention pulsatile (aneurysm) tender mass (ectopic) rectal bleeding |
|
|
What 3 films are included in an acute abdominal series?
|
supine/flat
PA upright left lateral decubitus OR upright |
|
|
Which imaging study is indicated for intra-abdominal ischemia?
|
angiography
|
|
|
What type of imaging study needs to be ordered before any GI contrast study?
|
angiography
|
|
|
What contrast needs to be given if there is suspicion of a perforation?
|
gastrografin (however, be careful b/c don't want pt to aspirate this)
|
|
|
What are 2 commonly ordered contrast x-ray studies of the abdomen?
|
upper GI series
barium enema |
|
|
When is US useful for abdominal pain? (5)
|
pregnancy
cystic vs solid mass aortic aneurysm biliary dz renal dz |
|
|
What are the contrast allergies that need to be asked to pts before doing a CT?
|
shellfish
iodine |
|
|
What is an excellent modality for defining anatomy, inflammation, abnormal masses, and abscesses within the abdomen and the test of choice to visualize retroperitoneum?
|
CT
|
|
|
What are 5 risk factors for increased mortality from GI bleeding?
|
-Hemodynamic instability
-Repeated Hematemesis/Hematochezia -Failure to stop bleeding with Gastric Lavage ->60yo -Coexistent Organ System Disease |
|
|
What are the common causes of upper GI bleeding? (3)
|
PUD (H. pylori, NSAIDs)
erosive gastritis/esophagitis (GERD, alcohol, salicylates, NSAIDs) esophageal/gastric varices (from portal HTN-hepatic failure) |
|
|
What is included in the Hx for PUD?
|
buring, sharp, dull epigastric pain
relieved by food/milk/antacids nocturnal symptoms intermittent episodes |
|
|
What is found during PE of PUD?
|
epigastric tenderness
abdominal rigidity (perforation) occult/gross blood per rectum/NGT |
|
|
What is seen on upper endoscopy of PUD?
|
gastric ulcer w/ punched out ulcer base w/ whitish fibrinoid exudate
|
|
|
Where do most duodenal ulcers "live"?
|
just past the pyloric sphincter
|
|
|
What may be included in the S/S of gastritis? (7)
|
anorexia
nausea dyspepsia pain postprandial emesis rarely massive GI bleed H. pylori association |
|
|
What is the classic Hx of Mallory-Weiss syndrome?
|
repeated vomiting followed by bright red hematemesis
|
|
|
What is Mallory-Weiss syndrome caused by?
|
longitudinal mucosal tear in the cardio-esophageal region
|
|
|
What are 3 common causes of lower GI bleeds?
|
upper GI bleed
diverticulosis (painless) angiodysplasia (AV malformations) |
|
|
What is angiodysplasia usually associated with and who is it more commonly found in?
|
right colon
elderly w/ HTN and aortic stenosis |
|
|
What are 6 less common etiologies of lower GI bleeding?
|
Malignancy
IBD Polyps Infectious Gastroenteritis Meckel’s Diverticulum Hemorrhoids |
|
|
What is the "rule of 2's" for Meckel's Diverticulum? (5)
|
2% of population
2% symptomatic <2yo 2ft from ileocecal valve 2ft long |
|
|
What ancillary studies may be done for a GI bleed?
|
CBC (Hct may be normal b/c takes a while to show anemia)
electrolytes PT/PTT bleeding time LFTs ECG actue abdominal series |
|
|
What is the most accurate tool for an upper GI bleed?
|
endoscopy
|
|
|
Which type of imaging modality for upper GI bleeds must have brisk bleeding and is time consuming?
|
angiography
|
|
|
What specific tests are done for a lower GI bleed? (4)
|
anoscopy/proctosigmoidoscopy
colonscopy (definitive 75%) mesenteric angiography RBC tagged scinitigraphy (nuclear/radionuclide scan) |
|
|
When is a radionuclide scan done for a lower GI bleed?
|
if no bleeding site is found after DRE/anoscopy/sigmoidoscopy and there is rapid bleeding (prior to angiography) OR if no bleeding site is found after colonoscopy
|
|
|
What is the first evaluation to do with a lower GI bleed?
|
evaluate/rule out upper GI bleed
|
|
|
What may be included in the primary Tx plan for a GI bleed? (8)
|
ABCs (including 2 large bore IV’s)
Isotonic Crystalloid Infusion up to 2 liters-warmed Lab studies Blood Transfusion based on clinical picture Fresh Frozen Plasma or Vitamin K Platelet Infusion NGT NPO |
|
|
What is included in the Tx plan for eradication of H. pylori? (3)
|
PPI
Clarithromycin Amoxicillin (Metronidasole if PCN allergy) |
|
|
What meds may be used in the Tx for GI bleed?
|
PPI
Somatostatin Octreotide H2 blocker (Pepcid, Zantac) beta blocker |
|
|
Which med may is effective in preventing GI re-bleeding, transfusion, and surgery?
|
PPI
|
|
|
Which meds are effective in varices and PUD and reduce splanchnic blood flow and GI motility and inhibits acid secretion?
|
*Somatostatin
Octreotide |
|
|
Which med helps with portal HTN?
|
H2 blockers (Pepcid, Zantac)
|
|
|
What is included in the disposion of GI bleeds? (8)
|
Admission Criteria
Significant GI Hemorrhage Initial Hematocrit < 30 Initial SBP < 100 Bright Red Blood in NG Lavage Hx of cirrhosis or Ascitis on PE Hx of Vomiting Red Blood |
|
|
What are you thinking if there is presence of fever with vomiting?
|
infectious (bacterial, viral)
IBD |
|
|
If there is vomiting with radiation of pain to the chest then what are you thinking about?
|
acute MI
pneumonia |
|
|
If a pt is vomiting with radiation of pain to the back, then what is included in your DD? (3)
|
pancreatitis
aorta problem kidney dz |
|
|
What does a HA with vomiting suggest?
|
subarachnoid hemorrhage
|
|
|
What does vomiting during 1st trimester of pregnancy suggest?
|
hyperemesis gravidon (check hCG)
|
|
|
What does vomiting associated w/ HTN during 3rd trimester suggest?
|
pre-eclampsia
|
|
|
What does vomiting with a change in bowel movements suggest?
|
obstruction (peristalsis increased above point of obstruction; pain then vomiting-->surgical condition)
|
|
|
What does vomiting w/ associated PVD and abdominal pain suggest?
|
mesenteric ischemia
|
|
|
What is included in the broad DD of diarrhea and vomiting? (9)
|
Intracranial pathology
MI angina Toxic exposures Obstruction mesenteric ischemia ruptured cyst DKA adrenal insufficiency |
|
|
What labs/diagnostics may be indicated for diarrhea & vomiting? (12)
|
CBC
BUN Creatinine glucose lipase LFT blood culture urinalysis urine hCG acute abdominal series abdominal CT US (stones) |
|
|
What is the DOC for bacterial gastroenteritis?
|
Ciprofloxacin
|
|
|
What is a fecal leukocyte test used for?
|
bacterial etiology
|
|
|
What is a stool culture useful for? (4)
|
children
toxic patients diarrhea >3days immunocompromised |
|
|
When is a giardia stool antigen tested? (4)
|
HIV-infected patients
Hx of travelling to developed country backpacking Hx daycare exposure |
|
|
How is infectious diarrhea treated?
|
Cipro
antimotility agent (Immodium, Lomotil): do not prolong the course of infectious diarrhea |
|
|
When should an antimotility agent be avoided? (3)
|
bloody diarrhea
high fever systemic toxicity |
|
|
What are the 2 most common causes of actue pancreatitis?
|
alcohol (medical)
cholecystitis (surgical) |
|
|
What makes acute pancreatitis worse? Better?
|
worse-lying down
better-leaning forward |
|
|
What may be included in the Hx for acute pancreatitis? (6)
|
constant, boring pain
N/V adynamic ileus low grade fever tachycardia hypotension |
|
|
What may found on PE of acute pancreatitis? (5)
|
left pleural effusion
peritonitis Cullen's sign (umbilicus) Grey Turner's sign (flanks) shock? |
|
|
What labs are used with acute pancreatitis? (7)
|
amylase
*lipase CBC chemistries LFT (inc alk phos w/ biliary) UA hCG |
|
|
What imaging studies may be used for acute pancreatitis?
|
acute abdominal series (colon cut off sign)
US CT scan |
|
|
What are Ranson's Criteria for acute pancreatitis? (5)
|
Age > 55 years
Glucose > 200 WBC > 16000 SGOT > 250 LDH > 350 *extremely poor predictive value in the acute setting |
|
|
What are the helpful prognostic indicators for acute pancreatitis? (7)
|
Comorbid Conditions
Hypotension Tachycardia Hypoxia Oliguria Renal Insufficiency Hypocalcemia |
|
|
How is acute pancreatitis treated? (6)
|
*crystalloid IV fluid
O2 NPO NGT for active vomiting analgesics antiemetics further Tx/etiology |
|
|
What are the first 4 things you think about with a nonverbal acute poisoning patient?
|
hypoglycemia->50mL of dextrose
hypoxia->O2 opiods->Naloxone/Narcan Wernicke's->thiamine (w/ or prior to glucose) |
|
|
How is a nonverbal acute poisoning pt initially managed?
|
airway
breathing (ABG, pulse ox) circulation (large bore IV, labs, anion/osmolar gap) |
|
|
How is an anion gap calculated and what is normal?
|
(Na + K) - (Cl + HCO3)
12 +/- 2 meq/L |
|
|
What may cause a positive anion gap? (10)
|
methanol
uremia *DKA phenformin iron, INH, ibuprofen *lactate ethylene glycol (coolant) carbon monoxide, caffeine albuterol theophylline |
|
|
What is the calculation for osmolar gap and what is normal?
|
measured serum osmo - calculated osmo
</=10 |
|
|
Do alcoholics generally have a positive or negative osmolar gap? Anion gap?
|
both positive
|
|
|
If a pt has OD on TCA then what should be obtained?
|
serial EKG (make sure not suffering from bradycardia)
|
|
|
How are seizures of acute poisoning treated?
|
diazepam (if ineffective phenytoin)
|
|
|
How should a pt that inhaled poisons be decontaminated?
|
remove poison
O2 observe for hoarseness or singed nasal hairs |
|
|
How are contaminated eyes decontaminated?
|
irrigate, irrigate, irrigate
eye exam check pH |
|
|
How is contaminated skin decontaminated?
|
wash w/ soap/water
|
|
|
How are hydrofluoric acid burns (penetrate & corrosive) treated?
|
prompt immersion into ammonium salt solution OR 10% calcium gluconate solution; consult plastic surgery for finger involvement
|
|
|
*What are 6 choices for decontamination for ingested poisons?
|
Ipecac syrup (household use ONLY)
gastric lavage activated charcoal whole bowel irrigation alkalinization of urine dialysis |
|
|
What are the contraindications for syrup of Ipecac? (4)
|
caustic ingestion
hydrocarbons foreign bodies airway at risk for hours |
|
|
When should syrup of Ipecac not be given? (7)
|
pt <1yo
corrosives petroleum distillat-containing product pt lethargic/sluggish pt asleep pt comatose/unconscious pt convulsing |
|
|
When is gastic lavage performed on acute poisoning patients?
|
nonverbal pt
any pt w/ AMS who ingested substance w/in 1hr of arrival to ED |
|
|
What are 2 gastric lavage contraindications?
|
caustic substances
plain hydrocarbons |
|
|
What is activated charcoal used for with acute poisoning? (6)
|
ABCD
antimalarials aminophylline barbiturates/pentobarbital B-blockers carbamazepine dapsone |
|
|
*What are the exceptions to the use of activated charcoal for acute poisoning? (4)
|
iron
lithium lead alcohols |
|
|
What is given for whole bowel irrigation of acute poisoning?
|
polyethylene glycol electrolyte solution (GoLYTELY) via NG tube
|
|
|
What substances of acute poisoning is whole bowel irrigation used for? (5)
|
for substances not bound to activated charcoal:
heavy metals body packers iron lithium sustained/delayed release formulas |
|
|
What is GoLYTELY usely given with?
|
Metoclopramide (Reglan)
-avoid Phenothiazine agents as they slow gut transit |
|
|
What are 2 drugs that may respond to alkalinization of urine Tx for acute poisoning?
|
salicylate
phenobarbital |
|
|
What precaution needs to be taken with alkalinization of urine?
|
alkalosis may lead to hypokalemia which causes body to resorb K+ and excrete H+ which acidifies urine
|
|
|
What is the risk of acidificaiton of urine (perhaps for amphetamine poisoning)?
|
rhabdomyolysis induced ARF
|
|
|
What are 4 agents that dialysis may be used for Tx of acute poisoning if levels are really high?
|
salicylates
alcohols lithium theophylline |
|
|
What is the last resort of acute poisoning and what are 2 examples of reasons it may be used?
|
surgical decontamination
-iron pill may clump & stick to mucosa -body packers who do not clear w/in 24h |
|
|
What are 2 representative agents of opiods?
|
heroin
morphine |
|
|
What are the most common findings of an opiod toxidrome? (3)
|
CNS depression (coma)
miosis respiratory depression |
|
|
What is Tx plan for opiod toxidrome? (4)
|
ventilation
Narcan (Naloxone) activated charcoal 4-6h observation |
|
|
What are 2 representative agents of sympathomimetics?
|
cocaine
amphetamines |
|
|
What are the common findings of a pt that has a sympathomimetic toxidrome? (7)
|
mydriasis
HTN tachycardia diaphoresis dysrhythmias seizure hyperthermia |
|
|
What are the possible quinidine effects of cocaine?
|
wide QRS
prolonged QT interval |
|
|
How is a sympathomimetic toxidrome treated? (4)
|
Lorazepam (Ativan) OR Diazepam (Valium): tachycardia, HTN, seizures
MONA (cardiac ischemia) alkalinization of serum w/ sodium bicarb (tachdysrhythmias) Nitroprusside (HTN emergency) |
|
|
What are 2 representative agents of cholinergics?
|
organophosphate insecticides
carbamate insecticides |
|
|
What are the most common findings for a cholinergic toxidrome?
|
DUMBELS:
diarrhea urination miosis bronchorrhea excitation w/ muscle fasciculation anxiety lacrimation seizure Killer B's: bradycardia bronchospasm bronchorrhea |
|
|
How is a cholinergic toxidrome treated? (4)
|
decontamination
O2 atropine symptomatic relief Pralidoxime (2-PAM) |
|
|
What are 4 representative agents of anticholinergics?
|
opthalmic atropine
*TCA OTC antihistamines cold remedies |
|
|
What are the most common findings of an anticholinergic toxidrome?
|
blind
hot red dry mad TCA=cardiac, convulsions, coma |
|
|
How is an anticholinergic toxidrome treated? (3)
|
Diazepam/Valium (agitation, seizures)
activated charcoal if w/in 1h cardiac monitor x 6h |
|
|
What are 2 representative agents of hypoglycemia?
|
sulfonyureas
insulin |
|
|
What are the 4 most common findings of hypoglycemia?
|
AMS
diaphoresis tachycardia HTN |
|
|
What is the max daily dose of acetominophen?
|
7g (adults)
150mg/kg (children) |
|
|
What is a toxic dose of adult acetaminophen?
|
single acute ingestion of 140mg/kg
|
|
|
What 2 conditions is the margin of safety lower for acetaminophen?
|
chronic alcohol abusers
liver dz pts |
|
|
What happens shortly after ingestion of acetaminophen (up to 12h)?
|
no symptoms or anorexia/nausea
|
|
|
What are the clinical findings 24-48h after ingestion of acetaminophen? (4)
|
signs of hepatic necrosis?
nausea jaundice markedly elevated LFTs hepatic failure? |
|
|
How is the severity of acetaminophen toxicity estimated?
|
obtain a 4h post-ingestion acetaminophen serum concentration measurement and use the Rumack-Matthew nomogram to predict range of severity and whether or not to use Mucamix
|
|
|
What labs are used for acetaminophen poisoning? (7)
|
transaminase (AST & ALT rise in 24h & peak @ 48-72h; either one >1000=severe toxicity)
serum glucose PT bilirubin electrolytes creatinine |
|
|
How is acetaminophen toxicity treated? (5)
|
supportive care!
IV fluids oxygen cardiac monitor activated charcoal N-acetylcysteine (Mucamix) |
|
|
When is acetylcysteine given and what is it given with?
|
-if 4h level is >150 or 7.5g (toxic dose)
-w/in 12-16h, preferably 8-10h -do not delay Tx if levels unknown -dilute w/ citrus juice or soda |
|
|
What is the min acute toxic dose of salicylates? Severe toxicity?
|
150mg/kg
300-500mg/kg |
|
|
What does too much ASA interfere with? (2)
|
Kreb's cycle enzymes
hemostatic mechanisms |
|
|
What are the metabolic effects of severe salicylate toxicity?
|
metabolic acidosis w/ compensatory respiratory alkalosis
|
|
|
What are the early manifestations of salicylate toxicity? (5)
|
N/V
tinnitus listlessness hyperventilation |
|
|
Is acute renal failure common with salicylate toxicity?
|
no
|
|
|
How may the GI, hematologic, and dermatologic systems be affected by salicylate toxicity?
|
N/V
GI hemorrhage intestinal perforation pancreatitis hepatitis (chronic toxicity) prolonged PT & bleeding time dec platelet adhesiveness DIC (chonic toxicity) diaphoresis |
|
|
How often should serum salicylate levels be repeated?
|
every 2h until salicylate level falls
|
|
|
What does it mean if serum salicylate levels increase?
|
possibility that a sustained-release preparation was ingested OR concretion in GI tract has formed
|
|
|
What are the correlations of 6h postingestion levels of salicylates?
|
<50mg/dL->asymptomatic
51-110->mild/moderate toxicity 110-120->severe toxicity |
|
|
Do salicylate serum levels <6h postingestion rule out impending toxicity?
|
no b/c salicylates are in the absorption-distribution phase
|
|
|
What diagnostic tests may be used in salicylate toxicity?
|
*serum salicylate level
serum electrolytes BUN creatinine calcium magnesium glucose urinalysis CXR ECG (flattened T's, prolonged QT, U waves) |
|
|
How is salicylate toxicity managed?
|
endotracheal intubation
large bore IV activated charcoal LR or NS maintenance fluids to maintain urinary alkalinization (urine pH 7-7.5) correct hypokalemia do not force diuresis |
|
|
What is the best method for enhanced elimination of salicylates?
|
hemodialysis
-increases salicylate clearance, corrects acid-base disturbance, corrects fluid and electrolyte abnormalities |
|
|
What are the 3 recommendations for hemodialysis for salicylate toxicity?
|
severe intoxication
refractory/profound acidosis serum level >100 after acute dose or serum level >40-50 in chronic salicylism |
|
|
What are 3 severe manifestations of severe salicylate toxicity?
|
persistent neurological symptoms
pulmonary edema renal failure |
|
|
What do beta-1 receptors do?
|
reduce heart rate, blood pressure, myocardial contractility, and myocardial oxygen consumption
|
|
|
What do beta-2 receptors do?
|
inhibits glycogenolysis and gluconeogenesis
|
|
|
What may be included in the Hx of a beta-blocker toxicity patient? (11)
|
Dizzy
Headache Weakness Diaphoresis Slow Heart Rate Blurry Vision Wheezing SOB Chest Pain Confusion Comatose |
|
|
What may be seen on PE of a beta-blocker toxicity patient? (8)
|
Bradycardia
Hypotension Hypoglycemia CHF Pulmonary Edema Depressed Level of Consciousness Coma Bronchospasm |
|
|
What diagnostic tests may be used for beta-blocker toxicity?
|
CXR (pulmonary edema)
ECG: severe sinus bradycardia increased PR intervals loss of atrial activity atrioventricular junctional rhythm widening of the QRS complex atrioventricular block idioventricular rhythm asystole |
|
|
How is beta-blocker toxicity treated? (9)
|
ABCs
crystalloid & Trendelenburg position (hypotension) glucagon atropine (bardycardia) Isoproterenol (dec cardiac output) Dopamine (hypotension) gastric lavage (if w/in 1-2h) activated charcoal transcutaneous pacing? |
|
|
What are the 4 CV effects of CCB toxicity?
|
Peripheral vasodilatation
Negative chronotropy (dec HR) Negative inotropy (dec cardiac contractility) Negative dromotropy (dec cardiac conduction) |
|
|
What happens if CCB blocks insulin release from the pancreas and decrease free fatty acid utilization by the myocardium? (3)
|
hyperglycemia
lactic acidosis depressed cardiac contractility |
|
|
What % of people w/ cholelithiasis become symptomatic each year?
|
2%
|
|
|
Is surgery needed if cholelithiasis is asymptomatic?
|
no
|
|
|
What is the abnormal diameter of the common bile duct?
|
>1cm (10mm)
normal is 2-4mm and increases w/ age |
|
|
Describe colic? (7)
|
Minor recurrent symptomatic episodes
-Lasts for minutes to hours -Postprandial -Steady -N/V may occur -Epigastric, or right sided, even left sided pain -Every other possible GI symptom |
|
|
What are the S/S of acute cholecystitis?
|
RUQ pain/tenderness
fever elevated WBC's inflammatory changes on US |
|
|
What are 2 inflammatory changes that may show up on US of acute cholecystitis?
|
gallbladder wall thickening
pericholecystic fluid |
|
|
What S/S may occur w/ choledocholithiasis? (3)
|
jaundice
pancreatitis elevated LFT |
|
|
What is cholangitis?
|
bacterial infection of the bile ducts
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What is Charcots's triad for cholangitis?
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RUQ pain
Jaundice Fever and Chills |
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What is Reynold's Pentad for cholangitis?
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RUQ pain
Jaundice Fever and Chills delirium shock |
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What is the mainstay of Tx for biliary colic?
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cholecystectomy (vast majority done laparoscopically)
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What is the Tx plan for cholecystitis?
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may include admission
fluid/electrolytes Cefotetan cholecystetomy (may have to do open procedure) |
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What does the cystic artery 90% or the time branch off of?
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right hepatic artery
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What is a good landmark for the cystic artery?
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Calot's node
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How may ports are done for laparoscopic cholecystectomy? What is "clipped"? What type of imaging may be done intraoperatively?
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4
cystic artery & cystic duct cholangiogram |
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How is cholangitis treated?
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draingage of biliary tree by decompression; either percutaneous transhepatic from above or ERCP from below
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What is the Tx for common bile duct stones?
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-Pre-op ERCP or MRCP
-emergent evaluation if acutely ill -intra-op cholangiogram, common bile duct exploration, possible T-tube placement |
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What is gallbladder CA generally associated with?
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gallstones 70%
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What % of gallbladder CA pts are dead w/in one year?
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85%
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What may localized gallbladder carcinomas benefit from?
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wedge resection of liver and regional lymphadenectomy
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If pancreatitis is related to biliary dz then what Tx is needed?
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cholecystectomy
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What diagnostic test is used for pancreatic pseudocyst?
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CT
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What reason would a pseudocyst be drained?
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infection
symptomatic |
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How may internal drainage be done for a pseudocyst? (3)
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Cystgastrostomy
Cystduodenostomy Roux-en-Y jejunocystostomy |
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What is the Tx for a pancreatic abscess?
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operative debridement
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What is the overall mortality for pancreatic CA?
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close to 100% :(
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If a pt has painless jaundice then what should you be thinking about?
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possible pancreatic CA of the head (possibly better prognosis)
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What may be done for a distal pancreas tumor?
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lesion-Distal pancreatectomy
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What may be done for a proximal pancreas tumor? Describe it.
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Whipple procedure
-Pancreaticoduodenal resection with gastric or duodenal intestinal anastomosis -Biliary-enteric anastomosis -Pancreatic remnant to intestinal anastomosis |
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What are 3 possible post-op complications from a Whipple operation?
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pancreatic/bilary fistula
hemorrhage infection |
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Is primary or secondary/metastatic liver CA more common?
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secondary (20x more common)
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What is primary liver CA assoicated with? (3)
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chronic hep B/C
cirrhosis |
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What tumors may metastatic liver neoplasms come from? (8)
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*GI (colorectal)
breast lung GU ovary uterus melanoma sarcoma |
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What are intrahepatic primary liver tumors from? Extrahepatic sites?
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infiltration of portal venous system
hilar & celiac LN, lungs |
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What are the S/S of large primary liver tumors?
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epigastric/RUQ pain
may have R shoulder radiation weight loss jaundice (rare) hepatomegaly |
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What labs may be helpful for diagnosis of liver cancer?
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inc AST
inc ALT inc alk phos inc bilirubin hypoalbuminemia coagulopathy thrombocytopenia pos HBsAg or HCV antibody |
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What may be an omnious sign for liver cancer and what does it mean?
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elevated bilirubin (liver starting to fail)
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What are 3 types of imaging that may be used for liver cancer?
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CT with angiography
MR angiography triple phase, contrast enhanced helical CT scan |
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How is the diagnosis for liver CA made?
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CT guided liver biopsy
-Percutaneous core or needle aspiration biopsy (false negative rate 30 % in FNA) |
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When can liver CA be diagnosed w/out biopsy? (2)
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cirrhosis + hypervascular mass >2 cm on 2 imaging studies OR
positive alpha-fetoprotein level > 400 ng/mL |
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What is the Tx plan for liver CA pts?
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resection in selected patients without cirrhosis or in cirrhotics with preserved hepatic function
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What is the minimum criteria for liver CA resection? (2)
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dz confined to liver
dz amenable to complete resection western countries 25-30% are candidates for resection |
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Besides liver resection, what are 4 other Tx options for liver CA?
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Liver transplant
Ethanol injection Radiofrequency ablation Arterial embolization |
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When is resection of the liver most commonly indicated for liver CA pts? What is the 5 year survival?
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metastatic colorectal cancer
25-40% |
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What is small bowel obstruction most commonly caused by? Second most common? Other causes?
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*adhesions 70%
*hernias metastases tumor Crohn's |
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What are the S/S of small bowel obstruction?
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N/V
cramping, diffuse abdominal pain |
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What is found in complete bowel obstruction? What is the Tx?
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no air, obstipation
surgery, NG decompression -possibly a CT prior |
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What is found in parital bowel obstruction? What is the Tx?
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air in the rectum
bowel rest, NG tube, IV fluids, monitor/repeat films q4-6h |
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Does a small bowel obstruction cause dilation or constriction?
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dilation w/ air/fluid levels present
-sequestration of fluid |
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What is the main issue of small bowel obstruction?
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determining whether there is a gangrenous bowel
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What are 5 reasons for small bowel obstruction surgery?
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Elevated wbc
Fever Increasing pain Peritoneal signs Failure to improve by 48 hours |
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What is the most common malignant tumor of the small bowel? Where are they usually found?
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adenocarcinoma 50%
duodenum |
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What is the most common emergent surgical procedure?
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appendicitis
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What are the S/S of appendicitis? (3)
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pain
N/V anorexia |
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What are 4 special tests for appendicits?
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Dunphy
Rovsing Psoas Obturator |
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What is happening with appendicitis?
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fecolith
obstruction poor venous outflow inflammation arterial insufficiency necrosis |
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What % of the population gets appendicits?
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7%
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What imaging tests may be used for appendicits?
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CT w/ smaller cuts (97% specific, almost 100% sensitive)
US (85% sensitivity) |
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What found on x-ray is pathogneumonic for appendicitis?
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fecolith
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What is the Tx plan for appendicitis?
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prompt surgery with anitibiotic via a traditional vs laparoscopic approach
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What is the most common non obstetric surgical emergency during pregnancy?
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appendicitis
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What abdominal condition has "pain out of proportion to exam findings"?
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acute mesentreric ischemia
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How is mesenteric vascular dz diagnosed?
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CT and/or Arteriogram if no peritoneal signs
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What is the mortality rate of acute mesenteric ischemia?
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90%
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