Surgery

Front 1

what is distributive shock

Back 1

shock where vasodilation
so drop in SVR
- septic shock
- anaphal
- neurogenic

Front 2

Drug treatment
- septic shock (distributive)
- anaph (distrib)

Back 2

Septic shock: fluids, NE (levafed)
Anap : epi, intub, diphenhyd, steroids
neuro : see low BP and low HR, fluids, dopamine or dobutamine

Front 3

SIRS
sepsis
s shock

Back 3

SIRS : meetsSIRS crit (under 50% infected)
Sepsis : SIRS + infected likley
severe sepsis: organ dysfx but fluid responsive
septic shock: non resp fluids

Front 4

cardiogenic shock ?
CO SVR

Back 4

low CO
high SVR high wedge
cold clammy skin (skin vessels clamp)
high JVD
If only iso R heart failure just give fluids to inc preload.

Front 5

wedge measures

Back 5

nml wedge 6 - 12 mmHg
floats down PArt
pulm cap bed pressure
L Atrial
L Vent end Diastolic OR PRE-LOAD so increases with pump failure

Front 6

Cardiac output CO
? nml ?
? how measure
? clinical

Back 6

nml 4 - 8 mmHg
CO = SV x HR
measure with Swn Ganz thermodilution
In MI low SV and low CO, in hemmorr no preload, no SV, no CO.
Increase CO: inc contractility, inc HR, inc preload, dec afterload.

Front 7

SVR
clinical comparison

Back 7

SVR / Body surface area = SVRIndex
nml SVRI 1500 - 2400
SVR vas resist over sys circ aka afterload
low in distrib shovk,
high in cardiogenic and hypovol shock as vasoconstriction

Front 8

shock with
low wedge
low CO
high SVR

Back 8

hypovolemic

Front 9

shock with
high wedge
low CO
high SVR

Back 9

cardiogenic

Front 10

shock with
low / nml wedge
high CO
low SVR

Back 10

distributive shock

Front 11

Pressors

Back 11

NE : strong A2 vasoconst, some B1 HR , ++ SVR +CO, USE sepsis

EPI : strong B1, A1 vasoconst, ++ SVR, Use snaph, Arrest

Phenylephrine : A1 vasoconst, Sepsic, neuro, hypo2/2 anesthesia

Na nitroprusside : dilates AandV, dec pre and afterload, USE : heart failure with low CO

DOPAMINE
int dose 5-10 ug/kg/min "Cardiac dose"
+ DA-R, + heart-R, some A1 to + CO in cardioshock
high dose 10-10 ug/kg/min
DA, B1, ++ A1 vasocon, ++ SVR to treat cardio or septic shock.

dobutamine +B1 B2 to +CO dec SVR to treat cardiogenic shock

milnerone: phosph dioester inhib

Front 12

ABG vent pulm

ventilation mode to wean / liberate
vent

Back 12

pressure support often used with IMV

pressure support is set pressure delivered with each breath pt takes (boost)

* liberation is taking off vent and may not require weaning first (now not on vents long so lung muscles dont get weak)
* taking out ET tube = extubation
* removing tracheostomy tube = decannulation

Front 13

ABG vent ICU pulm

what is assist control vent ?

Back 13

CMV or assist control

* every breath has same volume or pressure, time

if pat initiates breath by themselves, they get the full tidal volume given.

Front 14

ABG pulm ICU

what is IMV vent

Back 14

* spont breathes are allowed between mandatory breaths

* when pt inintiates breath, vent gives pressure support
but vol of breath determ by pt effort

Front 15

ABG pulm ICU

PEEP
- uses
- SE

Back 15

PEEP/ CPAP
- elevated end expir pressure
- keep alveoli open
LEVELS :
* min 5 mm H2O
* ARDS 10-20 cm H2O
* COPD 5-10 cm H@)
- use CHF, ARDS
** -SE hypotension as decreases PRE-LOAD

Front 16

acid base state that keeps patient on a vent ?

Back 16

alkalosis as H+ stimulates resp.

Front 17

AMPLE

Back 17

allegies
meds / mech of injury
past med hx / pregnant
LAST MEAL
EVENTS surrounding mech of injury

Front 18

trauma recusiation
amt urine adequete

Back 18

adults 0.5 ml/kg/hr ~ 30 ml/hr
child over 1 : 1 ml/kg/hr
child under 1 : 2 ml/kg/hr

Front 19

head face fracture changes in acute trauma mgt

Back 19

no NGT tube, use OGT tube

Front 20

what is 3 to 1 rule

Back 20

3 crystaloids vol to 1 vol blood loss

Front 21

blood vol in adult ?

Back 21

blood 7 % adult wt
70 kg adult 4.9 L blood
Kid 8-9% weight

Transfuse:
loss half blood volume
GIVE FFP when
rise PT, PTT to 1.5 nml
fibronogen under 100]
GIVE PLTS when under 50-17K

Front 22

After chest tube for hemothorax
indications for thoracotomy

Back 22

1,500 cc drainage from tube at placement
200 ml/hr for 4 hours
decomp after intitial stablization

~ 25% hemothorax pts have pneunon also

Front 23

sucking chest wound

Back 23

lung collapse on inspiration
init treatment cover with occlusive dressing sealed on 3 sides

Front 24

seal belt sign

Back 24

lower ant abdom wall
- perf bladder / bowel
- chance fx a lumbar distraction fracture

Front 25

blood around umbilicus

Back 25

Cullen sign
peri umbilical bruise
hemmor
intraperitondeal hemm

Front 26

Cullen sign

Back 26

peri umbilical bruise
hemmor
intraperitondeal hemm
peritoneal viscera: liver, spleen, stomach, sm bowel, sig tranv colon

Front 27

grey turners sign

Back 27

flank hemm ( bet ant post axill folds)
retroperitonfeal hemm

retroper organs
most duod, panc, kidneys, ureters, desc and asc colon , Abd aorta, IVC , renal and splenic vessels

Front 28

Kehr sign

Back 28

refer pain left shoulder or neck due to splenic supture
worse in trendelenberg or with LUQ palpation

Front 29

FAST looks at what 4 sites

Back 29

morrisons pouch RUQ liver - kidney
splenorenal recess LUQ
pouch douglas above rectum
for hemopericardium : sub xiphoid and parasternal

Front 30

When DPL

Back 30

unstable
sens for hemoperitoneum
questionable FAST
hollow organ injuries
Negatives: 1% risk injury, false postives, no good retroperitoneum
Must place foley and decompress stomach first.

Front 31

Amer Burn Assoc criteria admid burn center

Back 31

Under 10 yrs or Over 50
2nd 3rd degree > 10%

other ages 0ver 20%

FT burns over 5 % any age
elec incl lightening
inhal injury or other trauma too

Front 32

fluid lyte requirements in 24 hours

Back 32

per 24 hours you need
Per kg and Per 70 kg person
water 35 ml/kg -> 2,100 ml per 70 kg
K 1 mEq/kg -> 30 mEq
Chl 1.5 mEq/kg -_ 45 mEq
Na 1-2 mEq/kg -> 30-60 mEq

Front 33

Fluid lyte losses daily
urine
sweat
resp
stool
Na and K
chl

Back 33

Fluid lyte losses daily
urine 25-30 ml/kg/day-> 1,200-1,500 ml
sweat 200-400 ml, Has 40 mEq of Na, Cl per liter
resp 500-700 ml
stool 100 - 200 ml , from colon has mainly potassium 65 mEq liter

LYTe losses
Na and K 100 mEq
Chl 150 mEq

Physiol resp hypovolemia :
save Na and fluid via renin, aldo, ADH, vasoconst ANGII and symp, low UOP, first tachycardia, then hypotension.

Front 34

? third spacing and fluid shifts post op

Back 34

edema or fluid to interstitim
Happens in ileus when fluid leaves bowel post-op.
Then day 3 post-op fluid returns intra vascularly and can cause fluid overload.
So switch to hypotonic fluid and slow wIV rate.

Front 35

surgical cause metabolic acidosis

Back 35

loss bicarb : diarr , ileus, fistula of pancreas or sm bowel so loss of fluid , CA inhibotors
Anion Gap Met Acidosis :
SALUD
starvation (ketoacids)
alcohol
lactic acidosis (ischemia, necrotic tissue)
Uremia (renal failure)
DKA

Front 36

surg cause hypochloremic alkalosis

Back 36

NGT suction
loss stomach HCL vomiting

Front 37

cause
resp acidosis

Back 37

pain
PTX
hypovent CNS depress
airway obst

Front 38

acid/base with NGT suctioning

Back 38

hypochlor hypocalcemic met alkalosis

RX: IVF, Cl/K replacement

Front 39

Normal daily secretions
bile
gastric
pancreas
Sm bowel
saliva

Back 39

Normal daily secretions
bile 1000 ml / 24 hrs
gastric 2000 ml
pancreas 600 ml
Sm bowel 3000 ml
saliva 1500 ml
almost all secns are reabsorbed
REMEMBER BGS (alphabetically) and !L, 2L, 3L

Front 40

fluid to replace
gastric NGT suction :
duod bile and panc :
sm bowel ileostomy :
colon diarr :
post op p lap :

Back 40

fluid to replace
gastric NGT suction : D5 1/2 NS + 20KCL
duod bile and panc : LR +/- bicarb
sm bowel ileostomy : LR
colon diarr : LR +/- bicarnb
post op p lap : LR for 24-36 hrs then main

Front 41

what lyte causes or worsens ileus

Back 41

* low K
it also worsen dig toxicity
it can be caused by low mg

also low Na

Front 42

# 1 cause post op of low Na

Back 42

fluid overload

Front 43

how treat hyper mg

Back 43

hyper mg is over 2.5
treat ca gluconate IV
Sx:
resp failure, CNS depression, depressed DTR
CAUSES in sx:
TPN, renal failure, over IV hydration

Front 44

ICU glucose goal

Back 44

80-110

Front 45

Top causes low plts in sx pt post op

Back 45

sepsis
H2 blockers
hep
massive transf
DIC abx spurriius
swn ganz
Under 20K spont bleed
Need over 50K for surgery

Front 46

body fluid composition in lytes
hint compare to lyte's conc in plasma

Back 46

saliva
Na 10 K 26 Cl 10 HCO3 30
gastric
na 60 K 10 cl 130 HCO3 0
ileal (like plasma)
Na 140 K 5 Cl 104 Hco3 30
panc (high bicarb)
Na 140 K 5 Cl 75 HCO3 115
colon (K ++ higher plasma, and bicar)
Na 60 K 30 Cl 40 HCO3 40

Front 47

recus fluid lyte compositions

Back 47

LR
Na 130 K4 Cl 109 HCO3 28
NS
Na 154 K 0 Cl 154 HCO3 40
1/2 NS
Na 77 K 0 Cl 77 Hco3 0
M/6 lactate
Na 167 K0 Cl0 HCO3 167
3% hypertonic saline
Na 513 K0 Cl 513 HCO3 0

Front 48

Back 48

adynamic ileus

Front 49

aneurysm rupture

Back 49

aneurysm rupture

Front 50

RUQ pain
vomiting
kid

Back 50

Appendicolith

Front 51

atel L lung due to asthma

Back 51

atel L lung due to asthma

Front 52

Where ? atel vs PNA

Back 52

Atel LUL

Front 53

What ?

Back 53

cavitary breast cancer

Front 54

What ?

Back 54

cecum cancer

Front 55

What ?

Back 55

esophagus cancer

Front 56

baby
trouble breathing
common congen malform

Back 56

C CAM

Front 57

What ?

Back 57

cavitary cancer

Front 58

Back 58

abscess cavity

Front 59

Back 59

co arc aorta
figure 3 sign

Front 60

Back 60

Colon polyps
GI

Front 61

What ?

Back 61

diverticula

Front 62

Back 62

diverticulitis

Front 63

congenital defect baby
cyanotic

Back 63

Ebsteins

Front 64

problem ?

Back 64

free air under diaph

Front 65

watery diarrhea that is smelly
gut pain
no fever

Back 65

giardia

Front 66

lung Ct
person feels fine

Back 66

lung harartoma

Front 67

newborn 36 weeks
had to be intubated

Back 67

hyaline mmb dz

Front 68

What is going on ?
person cant breath post trauma

Back 68

hydro pneumo thorax

Front 69

patient with nephrotic syndrome
gut scan

Back 69

hypoalbumenemia
I made up scenario for image

Front 70

name stone

Back 70

jackstone calculus

Front 71

type of fx

Back 71

jones fx

Front 72

gut pain
no stool

Back 72

localized ileus LUQ

Front 73

HIV gut pain

Back 73

lymphoma gut

Front 74

kid
bloody diarrhea

Back 74

meckels diverticula

Front 75

type of fx

Back 75

monteggia fx

Front 76

Back 76

non cardio edema

Front 77

Back 77

rib osteochrondroma

Front 78

person losing weight
hoarse voice

Back 78

pancoast tumor

Front 79

shot in butt
so do BE

Back 79

rectum perf

GI

Front 80

patient post cardiac surgery
SOB

Back 80

pericardial effusion
" water bottle sign "

Front 81

what sx do they need ?

Back 81

gall bladder removal as have
porcelain GB and risk cancer

Front 82

What do you need to do ?

Back 82

Tension PTX
Needle to chest

Front 83

What is happening ?

Back 83

Tension PTX

Front 84

pat with JVD
SOB
ascites maybe
old guy

Back 84

Pulm HTN

Front 85

chronic lung disease
post surgery on leg fx
Now acutely SOB

Back 85

lung infarct

Front 86

had hodkins as a teen

Back 86

radiation fibrosis

Front 87

problems pooping

Back 87

rectal cancer

Front 88

Back 88

SBO
sm bowel obst

GI

Front 89

gut pain
hands abn tight
face skin tight

Back 89

scleroderma

Front 90

50 YO male
small scrape to toe
now red and hot

Back 90

septic arthritis

Front 91

chronic episodes of watery diarr starting as child
skin lesions
anemia

Back 91

sprue celiac dz

The BEnema shows :
spicules
edema
ulcers
biopsy : blunted villa and crypt hyperplasia

Front 92

cough blood
was in jail

Back 92

TB

Front 93

young women, on OCP, RUQ pain.

Back 93

On ultrasound, hepatic adenoma can be seen as round smooth-surfaced mass, slightly more echogenic than surrounding liver.
Ans image is CT with Figure 1. Computed tomographic scan of abdomen showing large intraparenchymal hematoma in the liver measuring 7.5 X 7.5 X 10 cm. Seen also is large subcapsular hemorrhage with evidence of hemoperitoneum.

Front 94

female, RUQ pain

Back 94

CT FNHyperplasia : stellate scar, lobulated intrahepatic lesions with central lucency (scar).

Front 95

liver mass ?

Back 95

Hemangiomas enhance in BOTH art and venous phases just as bright as aorta.
LEFT: rimenhancement in breast metastasis.
RIGHT: nodular discontinuous enhancement in hemangioma.

The enhancement of a hemangioma starts peripheral .
It is nodular or globular and discontinuous.
Rim enhancement is continuous peripheral enhancement and is never hemangioma.
Rim enhancement is a feature of malignant lesions, especially metastases.

Front 96

diastasis recti ?

Back 96

DIASTSIS RECTI is not a hernia. Although often confused and at times mis-diagnosed as an epigastric hernia, which it is not, these abdominal wall protrusions occur due to a widened band of non-contractile fascia or tendon normally present between the rectus musles. There is no defect or true hernia present in a normal Diastaasis Recti. Since this fascia does not contract as does normal adjacent muscle, when individuals with DR strain (e.g., do a sit-up), an elongated bulge in the upper abdomen, tappered at each end will appear. This non-tender bulge extends from just below the breast bone, down to the navel. Unlike Epigastric Hernias, a Diastasis Recti is not localized along the linea alba line, but involves the entire space between the breast bone and the navel. They are likened to a narrow foorball in shape. There is no pain associated with this bulge and it is not apparent when standing or walking, but is evident only when straining (sit ups). This is a variant of normal anatomy and Diastasis Recti is not a hernia. Surgery is not indicated for this condition and we disuade ill-advised attempts at surgical correction.

Front 97

name groin triangles ( 3 )

Back 97

MEDIAL TRIANGLE aka Hesselbach's, Hessert) is bounded by the inguinal ligament, the lateral border of the rectus muscle and the deep epigastric vessels.
LATERAL triangle is bounded by the deep epigastric vessels medially, and by the inguinal ligament laterally to a variable point approximately halfway between the deep inguinal ring and the anterior iliac spine (the lowest point on the inguinal ligament that the internal oblique and tranversus abdominus muscles are fused). The superior boundary is a line connecting that point on the inguinal ligament to the medial reach of the deep epigastric vessels.

Front 98

Back 98

femoral hernia
medial to femoral vessels
under inguinal lig

Another kind hernia
Coopers hernia : thru fem canal and tracking into scrotum and labia majus

Front 99

whats spigelian hernia

Back 99

Front 100

Back 100

Front 101

Back 101

direct ?

Front 102

old man hernia
he's a smoker

Back 102

Direct inguinal hernia

men. Rare to strangulate. Does not go into scrotum.

Thru transversalis fascia _> post to inguinal canal not in canal.
MEDIAL to inf epi vessels.

RF: men with chronic cough (smokers), and BPH(strain to pee).

Front 103

hasselbach s triangle borders

Back 103

epigastric vessels
inguinal ligament / Pouparts (from int oblique)

DIRECT hernia goes thru Hess. Triangle
lat border rectus sheath

Front 104

organs in inguinal hernia in boys and girls ?

Back 104

boys sm int
girls ovary/Ftube
can see Littre : meckels
adrenal rest

Front 105

sliding hernia =
pantaloon hernia =

Back 105

hernia sac partly made by wall of viscus organ like bladder or stomach

pantaloon = both direct and indirect as starddles inf epigastric vessels

Front 106

types lumbar hernia

Back 106

petits rare, inf lumbar triangle
Borders: iliac crest, ext obliq anterioraly, lat dorsi posteriorly

grynfelts rare, sup lumbar triangle

Front 107

hernia next to an ostomy

Back 107

parastomal hernia

Front 108

richeters hernia

Back 108

only on part of bowel sidewall in hernia sac

Front 109

type diaph hernia

Back 109

morgagni : anterior parasternal

bochdalek : thru post diaph often on left 'de lk' on the left

Front 110

hernia with meckels
or appendix

Back 110

meckels : littre
rupture appendix : Amyand's

Front 111

most common hernia ?
most likley to strangulate ?

Back 111

indirect inguinal hernia
5% all men
most common in men and women
strangulate : femoral > indirect > direct

Front 112

indications for lap hernia repair ?
when never use mesh ?

Back 112

bilat inguinal
recurring
need to resume full activity soon
no mesh if infection risk higher

Front 113

femoral hernia
who ?
how fix ?

Back 113

femoral hernia rarest, 5% all
but 85% of these women.
MEDIA to inguinal ligament
1/3 incarcerate
Repair with McVey using Coopers ligament, mesh plug repair

Front 114

women multiparous
recent weight loss
Howship Romburg sign : hip flexed, ext rotated and abducted and you feel mass

Back 114

obturator hernia, rare

Front 115

omphacele

Back 115

midline
more likley assoc other defects
can see malrotation
on umbilicus with cord on sac
can have liver
Rx: Ng decompress, IV abx and IVF, later sx

Front 116

gastroschisis

Back 116

no sac
off to side
get fluid and lyte abn
uncommon to see assoc abn except for intest atresia
umbilicus on skin to left of gasro sac

Front 117

child umbil hernia ?

Back 117

repair if 2 cm at age 4 to 5
use pants in vest method to close defect in linea alba

Front 118

femoral canal borders ?

Back 118

MED " lacunar ligament / Gimbernat
LAT : fem vein
ANT : ing ligament
Post : Coopers lig / pectineal lig

hernia goes thru fem ring

Front 119

Patient coming to have sx for indirect hernia needs what pre-op ?

Back 119

rectal exam
COLONOSCOPY !!
they may be straining due to colon cancer.

Front 120

trauma
rib fractures

Back 120

if rib 1 and 2 look for great vessel inj
Rx consv, rest , pain mgt

Front 121

PTX

Back 121

tube thoracotomy
if fail to reexpand consider injury to trachebronch tree

Front 122

how dx trauma aortic rupture

Back 122

CXR loss of knob**, apical cap, deviated NG tube, HEMOmediastinum.
CT angio
TEE
Gold is aortagram not CT Angio but most use CT Angio

Front 123

blunt cardiac injury presentation ?

Back 123

40% with arrhythmia
45% cardiogenic shock
15% anatomic defects (most die pre-hosp)

Front 124

treat bleeding liver

Back 124

first in trauma bleeding liver
pack liver
then can try pringle where compress proper hepatic artery between on finger in epipolic foramen/winslow and another anterior to free edge of lesser omentum.

Front 125

flail chest treatment

Back 125

first do thoracocentesis to R/O PTX, hemothorax.
Then if no early response early ETT.
LAter on can use intercostal blocks for pain.

Front 126

emergency airway on person who shot self in face

Back 126

midface injury emergency airway
cricothyROTOMY - needle/percutaneous or surgical
Needle thry cricothyroid membrane

Using nasal or oral airway can push blood into trachea

Front 127

face injury and loss of upgaze ?
muscle

Back 127

injury sup rectus muscle or occ inf oblique

Front 128

blunt trauma pericardial tamponade is due to what

Back 128

rupture of myocrdium
or Cor art lacteration

Front 129

trauma
becks triad ?

Back 129

muffled heart sounds
JVdistension
hypotension
Signs of pericardial tamponade

Front 130

which pentrating chest wounds req abdom exploration

Back 130

below nipples or tip scapula

Front 131

patient
diff blod pressures in blood and feet
pulsatile left supraclavicular hematoma
left hemotjorax over 500 ml
What is gonna happen ?

Back 131

imment completion of
traumatic rupture of aorta
- falls over 12 feet
- head on collision
- tbone collision
9% pts have nml CXR
GOld is thoracic aortagram
TREAT with beta blocker keep systolic under 120 mmHg

Front 132

Kehr signs ?

Back 132

pain left shoulder due to diaph irritation from splenic injury

Front 133

Vicryl

Back 133

absorbable
braided
loss strength at 2 weeks
gone at 4 weeks
synthetic

Front 134

silk

Back 134

braided
non absorbable

Front 135

prolene

Back 135

non absorbable
Used: hernia, vas anast

Front 136

monocryl

Back 136

Absorbable
monofilament

Front 137

vert vs hor mattress stirch

Back 137

Question showed a horizontal mattress :
hor mattress
parallell to wound

ABOVE is
vert mattress :
everts, perp to wound

Front 138

Back 138

Fig. 4. Transverse and transverse-oblique Incisions. A. Kocher incision. B. Transverse Incision. C. Rockey-Davis incision. D. Maylard incision. E. Pfannenstiel incision

Front 139

Back 139

kocher subcostal for gb open sx

Front 140

Back 140

The incision may be continued across the midline into a double Kocher incision or roof top approach (Chevron Incision) (Figure 6), which provides excellent access to the upper abdomen particularly in those with a broad costal margin (Chute et al, 1968; Brooks et al, 1999). This is useful in carrying out total gastrectomy, operations for renovascular hypertension, total oesophagectomy, liver transplantation, extensive hepatic resections, and bilateral adrenalectomy etc (Chino & Thomas, 1985; Pinson et al, 1995; Miyazaki et al, 2001).

Front 141

Back 141

mcburney
1/3 from ant sup il spine to umbilicus
for appy

Front 142

bassini hernia repair

Back 142

Figure 13. Modified Bassini. The posterior wall is not opened. Sutures placed between the transversus arch aponeurosis and conjoint tendon to the inguinal ligament create tension on the tissues approximated.

Needs relaxing incision.

Front 143

lichenstein hernia sx
shouldice canada

Back 143

tension free with mesh
shouldice : imbrication uses 4 layers muscles, conjoint to inguinal

Front 144

Potassium is over 6.5

Back 144

Why :
alkalosis
Rx: Ca
Bicarb
dialysis
insulin and dextrose
albuterol
lasix
kayexolate

Front 145

ileus,weak, tetany
N/V
paresthesia

RF: diuertics, some abx, steroids, alkalosis, diarr, intestinal fistula, NG aspiration, vomit, insulin, amphotericin

Back 145

Potassium under 3.5
ECH flat t waves u waves,
Rapid Tx, IV KCl IV
Max periph 10 mEq hr
try treating low mg

Front 146

seizure confusion
stpor
pulm edema or periph edema
tremor
paralysis
RF innadequete hydration, diuersism Vomit, diarr, tachypnea, TPN

Back 146

Hypernatremia Na 135 - 145
TReat D5W 1/4 NS or 1/2 NS
slowly hydrate

If over do it
SEIZUURES not cental pontine myelosis !!

Front 147

Treating hypernatremia to fast causes what ?

Back 147

seizures

Front 148

treating hyponatremia too fast causes ?

Back 148

central pontine myelosis

Front 149

seixure coma
N/V
ileus
lethary confusion weakness

Back 149

low Na
Can be hypovol, euvol, hypervol
Post op usually vol overload.

Front 150

SIADH what about Na level ?

Back 150

SIADH Sodium level is always down here
LOW

Front 151

acute treamtent hypercalcemic crisis
what are ecg signs

Back 151

1. vol expand with NS
2. diuresis furosimide.
ECG short QT, prolong PR

Front 152

hypoalbuminemia
- how calculate Ca level in
- surg causes

Back 152

(measure alb level) x 0.08 then add this to measured Ca level
surg causes : short bowel
intest bypass, sepsis, pancreatitis
ECG: prolonged QT and ST,
TREAT: Ca gluconate IV.

Front 153

high blood glucose

low

Back 153

high sx cause: DM, infection, TPN, drugs, drawing over site, somat-oma, glucoma

low:liver failure, ad insuff, gastrojejunostomy

Front 154

labs to assess O2 delivery

Back 154

* SvO2 : = mixed venous oxy sat which is O2 in blood of RV or pulm art so indirect measure supply and demand.
* lactic acid
* ph
* base deficit

Front 155

frank starling curve

Back 155

CO increases with increasing preload up to a point.

Front 156

In ARDS what do want vent to be

Back 156

LOW TIDAL volume so 6 cc/kg ideal body weight

Front 157

cause CO2 retention

Back 157

hypovent
inc dead space
inc CO production (hypermetabolic state)

Front 158

bad SE PEEP

Back 158

dec COutput
esp with hypovolemia
dec compliance with high PEEP
barotrauma
fluid retention
high ICP

Front 159

nml ph and Pco2 values

Back 159

ph 7.35 to 7.45
PCO2 35 - 45

35-45 rule

Front 160

liver cyst
high eosinophils
cyst may have calcified walls

Back 160

NEVER ASPIRATE
hydatid cyst
echoncoccus from sheep, cat dog travel
usually asympto, incidental finding
Rx: albenadole then resect

Front 161

liver cyst
anchony
fever high WBCs high LFTs
guatmalan homosexual veteran alcoholic now living in VA institution
W/U
what is it ?
treat ?

Back 161

Amoebic abscess "anchovy paste"
w/u ct or us
SEROLOGY
Bug is entamoeba from intestine
Rx first with Iv metro. Do not drain in OR unless do not resolve or super infected with bacteria

Front 162

liver cyst
high WBCs high LFTs
#1 cause

Back 162

pyogenic
treat IV antibiotics and
percutaneous drainage with U/S and CT drainage
No OR unless multi and loculated.

Front 163

things that are in right lobe

Back 163

cysts congenital many small ones
cysts hyatid from echinococcus
cavernous hemangioma right posterior

Front 164

how can you tell
liver adenoma from FNH

Back 164

USe tc-99 study
And FNH uptakes sulfer

Front 165

treatment FNH ?

Back 165

resect only if symptomatic

Front 166

treatment adenoma ?

Back 166

resect all

Front 167

Diverticulitis scan of choice

Back 167

abdom CT
never colonscope or enema

Front 168

When to operate diverticulitis

Back 168

Under 40
not better in 72 hours with antibiotics
immunocompromised patients
2 or more episodes have electie resection later
Complicated diverticulitis :
abscess, perf with peritonitis,

Front 169

diverticulitis surgery

Back 169

* primary anast if no poop leak
* if pt hemo unstale, hartman, colostomy, close rectal stump. later on re anastmosis
* if just local perf with abscess try antibtoics or percut drainage and later surgery

Front 170

how work up if fistual from divertic

Back 170

barium enema, ct, sigscope
cystoscope
vag exam

Front 171

most common gi fistula

Back 171

bowel bladder from diverticulitis

Front 172

surgery nutrition
respitory quotient
what can be done to decrease CO2 production/retention in patient on a vent ?

Back 172

increase fat decrease carbo calories given.

Front 173

serum markers of nutrition in order of timingq

Back 173

prealbumin t1/2 2-3 days
transf 8-9 days
albumin 14-20 days
total kymoh count
anergy
retinol binding ptn 12 hrs

Front 174

vit a def ?
chromium

Back 174

no vit a : poor wound heal
no chromium : diabetic state

Front 175

pt TPN
poor wound healing
alopecia
dermatitis
taste disorder

Back 175

zinc def

Front 176

patient on TPN
dry flaky skin
alopecia

Back 176

fatty acid def

Front 177

state of shock ?
HR 130
RR 31
BP 80/50
confused

Back 177

class III
30-40%

Front 178

state of shock ?
mild anxiety
normal vital signs

Back 178

class I hemmorage
under 15% blood loss

Front 179

state of shock ?
BP 110/50
HR 105
RR 24

Back 179

class II
15 - 30 % blood loss
nml systolic BP
decreased pulse pressure
tachycardia
tachypnea
anxiety

Front 180

state of shock ?
HR 145
BP 70/50
RR 36
confused lethargic
no urine output

Back 180

class IV
over 40 %

Front 181

dypnea rales
pulsus alternans (pulse increased with greater filling after weak pulse)
loud P2 part of S2
gallop
hypotension
low CO
low UOP

Back 181

cardiogenic shock

Front 182

post injury thrown from car
hypotension
bradycardia

Back 182

neurogenic shock

Front 183

bacteria that cause infection in wound in first 24 hours

Back 183

strep
closotridium

Front 184

what does abscess look like on CT

Back 184

only post op on day 7, takes that long.
fluid in fibrous rind. gas in fluid collection.

Front 185

name

Back 185

diverticulosis
thick mural wall grey narrow contrast in lumen
black dot is gas in wall which is wall abscess

Front 186

steroids
- vit to help healing ?
- what stage of healing ?

Back 186

vit a helps corticosteroids pts
helps inflammation stage

Front 187

how long do you hold ASA

Back 187

10 days

Front 188

spinal anesthesia
where ?
SE?

Back 188

thecal
SE urine retention
hypotentsion (neurogenic shock)

Front 189

regional anesthesia

Back 189

spinal afferant from region
like radial nerve block
lido
bupivocaine/marcaine

Front 190

rapid seq anesthesia steps

Back 190

pre ox and short acting induction agent ( prop, midozolam, Na thiopenta)

muscle relax
cricoid pressure
intubate
inhalation anesthetic

RApid to dec risk of aspiration !

Front 191

Contraindication to Succ choline

Back 191

burns
NM trauma or paralyzing diseases
eye trauma (it inc eye pressure)
or increased ICP

(it inc K)

Front 192

lidocaine
- signs of OD
-why add Na bicarb to lido

Back 192

- signs toxicity : tinnitus, perioral numb, metal taste, blur vision, muscle twitch, drowsy as large overdose (10 mcg/ml) seizure, coma, respa rrest, LOC, apnea

- bicarb dec burning as lido is acidic

Note, it wont work in abscess

Front 193

CI nitrous oxide

Back 193

PTX
SBO

Front 194

why can you get low BP from morphine ?
SE mepiridine ?
How treat low RR from both ?

Back 194

histamine
mepiridine SE : like morphine but less phinter spasm, but normepiridine seizure and tachycardia

Use naloxine for low RR from both.

Front 195

epidural anesthsia
advantage
SE

Back 195

epidural
Advantage : no dec cough reflex
SE: ORTHOSTATIC hypotension
dec motor fx, urine retention, remove foley after epidural cath removed or likely urine retention

Front 196

vasc

Back 196

Terminology
Several different terms are used for the chronic symptoms that can occur after a deep vein thrombosis:

1. Venous stasis syndrome
2. Postthrombotic syndrome
3. Venous insufficiency syndrome
4. Postphlebitic syndrome

These terms all describe the same symptom complex.

What is it? Clots in the deep veins (DVT) lead to an obstruction of blood outflow from the legs or the arms back to the heart. When the body tries to heal from these clots the valves in the veins are often damaged. However, functioning valves are needed to prevent blood from pooling in the legs. Following a DVT the obstruction of the vein and the destruction of valves lead to impaired blood flow from the extremities back to the heart.

If a vein is completely blocked, neighboring smaller veins may enlarge to bypass the obstruction. These bypassing veins are called collaterals and can get quite large, particularly in the pelvis and abdomen in patients with thrombosis of the big vein in the abdomen (= inferior vena cava). Such collaterals can sometimes be seen as prominent veins underneath the skin. If good collaterals have formed, symptoms of leg swelling and pain are often not present or are only mild. However, in some patients collaterals do not get all that big and can not carry all the blood needed to drain the legs or arms; this then leads to chronic arm or leg swelling, pressure and pain.

Who develops it?

Patients who have had a DVT may or may not develop the venous stasis syndrome. Typically, the more extensive the DVT was, the more severe the syndrome will be. However, this is not always so: patients who have had very extensive acute DVTs with severe acute symptoms may recover completely and may not be left with any chronic symptoms. Approximately 60 % of patients will recover from a leg DVT without any residual symptoms. 40 % of patients will have some degree of postthrombotic syndrome, ca. 4 % of patients severe symptoms. The symptoms of postthrombotic syndrome usually occur within the first 6 months, may be up to 2 years after the clot. If a patient has done well for ½ - 2 years after the clot it is highly unlikely that he/she will develop the postthrombotic syndrome.

In patients with arm DVT postthrombotic syndrome develops in approximately 15 % of patients. Patients with DVT of larger veins, i.e. those in the shoulder and upper chest area (in medial terms "axillosubclavian DVT") and left-over clot (residual thrombosis) appear to be at particular risk for postthrombotic syndrome, whereas arm clots associated with catheters are at lower risk.

Little is known as to who will develop chronic symptoms and who won't. However, it is known, that patients with DVT who wear daily compression stockings (see below) for several month after the acute DVT will develop significantly less venous stasis syndrome. It is, therefore, important to wear individually fitted compression stockings if there is any leg swelling, beginning within days of the diagnosis of the acute DVT. They are typically worn for several months, if not years.

Symptoms

* chronic leg swelling
* chronic (or waxing) pain
* diffuse aching
* leg heaviness
* leg tiredness
* leg cramping
* dark skin pigmentation (=postthrombotic pigmentation; figure)
* hardening of the skin
* skin dryness
* formation of varicose veins
* skin ulcer (stasis ulcer)

Front 197

vasc
Name ?
Pt has heart dz, DM, smokes

Back 197

venous stasis ulcer
Loc : medial malleolus
Assoc : skin changes with statis dermatitis like thick scaly skin, pigementation,

Characteristics

• Ruddy color base

• Surrounding skin is reddened or brown

• Shallow depth

• Irregular wound margins

• Moderate to heavy exudate

• Pitting or non-pitting edema

• Skin temperature is warm to the touch (normal)

• Granulation tissue is present

• Infection is not common

• Minimal pain (unless infected)

• Peripheral pulses are present and palpable

• Capillary refill is normal

• Usually located near the ankle or lower calf

Front 198

vasc

Pt is a
smoker,
high fat/chol diet
HTN, heart dz, DM, obese,
RA

Back 198

Chronic art insuff :

- tissue necrosis and / or ulceration
- Pulselessness
- Painful ulceration
bullet
- Small, punctate ulcers well circumscribed
- Cool or Cold skin
- cap refill over 3 secs
bullet
- shiny, thin, dry skin and
Loss of digital and pedal hair

Location : top of the foot.
smaller arterial vessels is more difficult to address.

Front 199

name mallipati class

Back 199

A class I see fauces, ant post pillars, uvual
B class II palate, fauces, base uvual
C class III palate, only base of uvula
D class IV cant see palate

Front 200

Pre-Op finding on cardiac auscultation linked to ischemia, MI, sudden death ?

Back 200

aortic stenosis
thrill over R sternal border
cresendo-descc SYSTOLIC 2nd R intercostal space murmur, radiates to carotids
L V heave of lift from LV hypertrophy

Need CXR, ECG, echo, maybe cath as need operation for new valve.
SX: Syncope, angina, dypnea

Front 201

CV
Aortic stenosis indicaton for repair

Back 201

symptoms
OR
valve Xsxn area under 0.75 cm2 and/or gradient over 50 mmHg

Note: loud murmur sign of big gradient or big LV

Front 202

cv
mech vs non valve

Back 202

mech durable but need life anticoag

Front 203

what is + stress test pre-op ?
what is a bad echo ?

Back 203

ST depression over 0.2 mV
poor response HR to low BP or stress

echo bad : aoric stenosis, or EF under 35%
echo sens but not very specific
REVERSIBLE defects more concerning

Front 204

Risk of MI in non cardiac sx

Back 204

GOldman
High : h or EG evidence infact, angina, or angio CAD, prior CABG
Intermed : evidence non heart atheroscledfosis
Low no clinical athersclerosis but high RF profile
negibible : low Rf profile

Numbers:
no prior MI 0.1-0.6
Mi in lat 6 months : 4%
prior cabg 1.2

Front 205

CHF
CAD
valve
need endocarditits prohy

Back 205

CHF: risk P edema
CAD : 3x risk death, if need CABG first wait 30 days, death in 3 days asympto MI
Valve: Aortic stenosis under 1 cm and gradient over 50 mmHg, do echo, maybe new valve first
endocarditis : mod risk hypertrophic myppathy, Tet, fake valve

Front 206

treat post op urine retention

Back 206

- ensure fluid rescus
- straight cath twice 6 hrs apart, then foley if no pee
- can try prazozin or penoxybenzomeine

Front 207

stages of guts return to action

Back 207

sm int
stomach
colon

Front 208

plt needs
how much a bump with one unit ?

Back 208

normal over 150 k
unlikley to bleed 100-150k
20-50 possible excess sx bleeding
10-20k spon muscosal and curt bleed
under 10 k spont bleed and in GI

one plt unit bumpps 5 - 10k

Front 209

nutr
labs indicate malnutrition ?
inc sx risk ?

Back 209

alb under 3
trans under 150

under 80% IBW or over 120% IBW
recent change over 10%

Front 210

real time to be NPO pre-op

Back 210

To dec risk aspiration with intubation
- solids 6-8 hrs
- fluids 2-3 hrs

Front 211

when hold warf pre op

Back 211

3 choices :
- avoid 3 days pre, start again POD#2
- admit preop , change to hep and hold few hrs preop
- change LMW heparin

Front 212

thyroid meds

Back 212

give thyroid replacements on day of sx, ok to hold post-op a day pr 2 as t1/2 7 days.

thyroid antagonist hold on day of sx

Front 213

wound healing
what impairs collagen stage

Back 213

vit c def
ptn calorie malnut

Front 214

classic example of delayed primary closure of surgical wound ?

Back 214

ruptured pus full appendix
- close periotoneumm fasica and give abx
- use secondary intention as wound dirty and risk infection HIGh
- sub cut tissues not sutured until 3 to 5 days later

Front 215

- magic number for wound infection risk
- type of pressure inn OR

Back 215

> 10 5 microorgs dose
- postive pressure
- sterile parts of body: lower Resp, upper urinary

Front 216

sm bowel bugs
normal flora

Back 216

strep
enterbacteria
bacteriodes
very low lactobacilli

Front 217

lg bowel bugs
normal flora

Back 217

bacteriodes
enterobacter ( ecoli, kleb, salm)
s aureus,
clost

Front 218

lower urinary tract
normal flora

Back 218

staph epi
strep
diptheriods
gram neg rods

Front 219

patient
post mastectomy skin flap
swelling

Back 219

seroma as lymph channels disrupted
aspirate (unless it is in groin) and place drain
do inc risk infection as feed bugs

Front 220

patient with incisional hernia
abd pain, N, V

Back 220

OR ASAP
may strang bowel
repair fascia +/- mesh
no mesh if infected

Front 221

when is tape CI

Back 221

active bleeding
complex surface perimeum

tape >> staples > sutures

Front 222

calcium and ph

Back 222

acidosis increases ionized fraction
alkalosis, hyperventilation, decreases it

Front 223

nutrition
Harris vs Fick for calorie requirements

Back 223

Basal Energy expenditure
Harris : estimates BEE
Fick catheter equation if have swan ganz: (SaO2-SvO2) xCOxHbx95.18

Males 25 kcal/kg/day
females BEE 22 kcal/kg/day

KIDS do not use Harris for REE
Use kilocal/kg for age using chart of RDA

-------
post op : x 1.3
trauma/sepsis/burn x 1.6-2
fever : 12% inc per degree C

Front 224

vasc

wound
STAGES OF decub ulcers

Back 224

Front 225

neck injury zones

Back 225

triangles :
anterior and posterior

anterior has three zones
I : below cricoid
III above angle mandible

posterior : not much above spin acc nerve, below it subclavian vein, plexus, apices lung

treatment:
if intubate and no airway:
may have laryngtracheal separation and you are in false lumen.
So, tracheostomy.
CAreful of pneumonhemoPTX at apices lungs. If suspect, and need central line, use femoral or opposite side.
Never blind probe neck.
Go to OR** zone II with expanding hematoma,
and SQ emphy, trachea dev, change voice quality, air bubbles in wound,
Subclavian injury: put IVs in legs or opposite arm.

Front 226

"sacral sparing"

Back 226

voluntary anal sphinter intact or voluntary toe flex, perianal sensation

sign of incomplete cord injury

But sacral reflexes may be preserved in complete transection

Front 227

determines ICP ?
What is CPP ?
indication to moniter ICP in trauma ?

Back 227

- monroe kelly
vol brain
vol blood
vol CSF
- CPP = MAP - ICP
- GCS under 9, altered LOC or unconc and muti trauma ir dec consc focal neuro abn

Front 228

Use of CN to localize injury in coma ?

Back 228

cornea reflex intact pons
gag intact upper medulla

CN6 palsy is often false localizing sign

Front 229

how remember which brain bleed is cresect ?

Back 229

sUbdural is cUrved like
cresent

Front 230

Rx SAH

Back 230

anti-conv and observe

Front 231

skull fx:
open and closed
which need OR

Back 231

depressed skull to OR if:
dirty for debriide, severe deform, ipinge brain, open fx, CSF leak

If open fx, abx, seiz prophy, surgery

Front 232

when to OR for spine fx

Back 232

unstable vertbra
incomplete injury extrinsic compression
spine hematoma

Front 233

patient post spine surgery
- bilateral loss pain and temp
- paraplegia
what part of cord ?
what happened ?

Back 233

Anterior cord syndrome
art adamawitz (enter L1 supply to T4)
or compression from FLEXION
- pain and temp (Sthal)
- paraplegia (CST)
still posterior cord so vibr, position

Front 234

man stabbed in back
left side paralysis
left side loss of virb and position
right side loss of pain and temo

Back 234

Brown Sequard syndrome
hemisection
ipsi motor
contra pain temp

stab, tumor,

Front 235

60 year old man has car crash
whiplash
walks ok
very weak hand shake

Back 235

central cord syndrome
pre-existing canal stenosis
like hyperextension

weaker in arms > legs
hands weaker than biceps

Front 236

if steroids are helpful, when

Back 236

non penetrating and within 8 hours
high dose methypred (30mg/kg over 25 min in hour 1) then continuous 5.4 mcg/kg/hr over next 23 hours

Front 237

Patient fell of ladder onto their head
OR
anvil fell on head
name fx ?
stable or not ?

Back 237

burst fx or jefferson fx
C1 fx of both sides of ring
unstable
from axial loading

Front 238

hyperextension injury

Back 238

hangman fracture
C2 (hangman C2, jefferson president so #1)
more stable meaning rarely spinal cord injury but treat all as unstable
The hangman´s fracture is located in the pedicles of C2, with C2 displacing anteriorly on C3 (Fig. 264-15). The fracture is caused by an extension mechanism and is seen in judicial hangings. Suicidal hangings do not usually cause the extreme hyperextension seen in judicial hangings and do not cause a hangman´s fracture. The same fracture is seen in motor vehicle and diving accidents where sudden hyperextension forces are applied in deceleration. Owing to the large diameter of the spinal canal at the level of C2, even displacement of C2 on C3 may not cause neurologic injury, and these patients may be neurologically intact. This injury is unstable and mandates immediate consultation.

Front 239

look at C2

Back 239

teardrop flexion fx
ant inf vert body chips off like teardrop
assoc with tear of post lig so often neuro injury too

Front 240

man shoveling snow, heard crunch in shoulder

Back 240

An avulsion of the spinous process of the lower cervical vertebrae, classically C7, is known as a clay-shoveler´s fracture (Fig. 264-7). Intense flexion against contracted posterior erector spinal muscles causes avulsion of the spinous process. An isolated clay shoveler´s fracture is mechanically stable. Conservative treatment with ice, analgesia, rest, and early referral is indicated

Front 241

Man fell
back pain
bruise on lower abdom wall

Back 241

chance fx = distraction of posterior part of vertebra usually lower lumbar, below cord, L1 or L2 (is some ant compression but minor vs post compression)
Originally most often caused by seat belts as hyperflexion injuries , now thorax crush or hyperflex.



· Seat belt injuries usually involve the lower thoracic and upper to mid lumbar spine (L1 and L2 most commonly)

· Chance fractures are hyperflexion injuries in which there is distraction of the posterior elements and impaction of the anterior components of the spine

o Compression component from hyperflexion is usually minor compared to distraction componento SIGN : BACK PAIN,
SEAT BELT BRUISE ANT ABDOM WALL

*** NEED ADB CT !!!!
rare is spine cord transection.
o Up to 50% serious blunt injury to internal organs : primarily the pancreas, duodenum and mesentery
0 children may not fx but intestinal and urinary bladder injuries
o fx is below cord end but can hit nerves so bowel and bladder signs
o die from gut injury

Front 242

rectal exam, feel step off

Back 242

coggeal fx, r/o rectal bleed
rx donut

Front 243

trauma
how dx pericardial tamponade

Back 243

GOLD : direct see via
subxiphoid window sm midline
if see injury, do median sternotomy.
Cut sac ant and parallel to phrenic N, stuff hole with foley baloon, use 3-0 non absorb sutures,
Keys:
tamponade relief, vol expland, correct adidosis, perfuse heart, avoid hypothermia

chamber injury :
LV 40% = RV
then RA 24%
LA tiny, 3%
Also: fast

Front 244

diaphragm holes ?

spine levels needed for diaph function ?

Back 244

"I 8 10 ECGs at 12"

I = I (IVC) @ 8th vertebra
ECG = esophagus at 10th vert
A is aorta, azygous, thoracic duct at 12th vert

T8 IVC
T9 esoph, vagus,
T12 aorta, thoracic duct, azygos vein

C3 thru 5 keeps you alive

Front 245

peritoneal or retro ?
liver

Back 245

peritoneal

Front 246

peritoneal or retro ?
spleen

Back 246

peritoneal

Front 247

peritoneal or retro ?
duod

Back 247

duod :
1-3rd parts retro
4th intra

Front 248

peritoneal or retro ?
kidney

Back 248

kidney ureter
retro

Front 249

peritoneal or retro ?
asc colon

Back 249

retro

Front 250

peritoneal or retro ?
trans colon

Back 250

peritoneal

Front 251

peritoneal or retro ?
desc colon

Back 251

retro

Front 252

peritoneal or retro ?
sigmoid colon

Back 252

peritoneal

Front 253

peritoneal or retro ?
sm bowel

Back 253

peritoneal

Front 254

peritoneal or retro ?
stomach

Back 254

peritoneal

Front 255

peritoneal or retro ?
pancreas

Back 255

retro

Front 256

peritoneal or retro ?
aorta

Back 256

retro

Front 257

peritoneal or retro ?
IVC

Back 257

retro

Front 258

peritoneal or retro ?
renal vessels

Back 258

retro

Front 259

peritoneal or retro ?
splanic vessels

Back 259

retro

Front 260

peritoneal or retro ?
iliac vessels

Back 260

NEITHER !
pelvic
like urethra, bladder
prosate
ovary
uterus

Front 261

peritoneal or retro ?
rectum

Back 261

neither
pelvic

Front 262

pt post trauma
neuro intact
peritonitis and guarding
what do they need ?

Back 262

trauma lap now.
no other w/u

Front 263

trauma
waht does CT miss

Back 263

diaph
colon
panc injury

Front 264

critieria ex lap

Back 264

stomach bleeding
periotoneal irritation
dipah injury
free air in gut
bladder rupture
rectal perf confirmed with sig scope
transabdom misslepath
------
+ DPL,abd trauma hemo unstable
evisceration, Ct see injury you can fix in OR, remove impaled thing

Front 265

trauma thor
reasonable w/o dipah injury

Back 265

cxr (at first nml in half)
upper GI
barium enema
U
s
CT
MRI
CAreful with NGT as esoph gets kinked.

Front 266

liver injury
-who might escape OR

Back 266

standard is OR
May try non-OR (~half):
-very few pentrating stab stable after CT/DPL
- try blunt more often
- clearly grade and see injury with CRT as grade III or less (hematoma subcapsular, hema parencyma under 75% or under 3 lobes, no vena cava or major hep vein injury, no avulsion
- no peritoneal signs
- no other inj needing lap
- no need blood tx

Mgt: serial hct Q4-6hrs
ReCt 2-3 days

Front 267

Pt post liver lac
Scenario A :
upper gi bleed
RUQ pain
+ fecal occult blood
jauncide
Scenario B:
draining bile over 50 mls/day for over 14 days

Back 267

A. hemobilia (1%)
try angioembolize
B. bile fisula, 7-10%, closes on own with drainage
C. also see hyperpyrexia for 3-5 days self lim

Front 268

kid with 9th rib fx
left neck/shoulder hurts when you push LUQ
Name w/u modality
What degree means go to OR ?

Back 268

spleen fx
CT great, prescise
If unstable, U/S for hemoperitoneum
No good: DPL, laparoscopy
Therapy: angio embolize if stable

hint of may of failing nonOR mgt: .
blush on CT

Grade III goes to OR : subcap hematomam over 50% area, or parenchyma over 5cm or expanding parenchymal hematoma, or lac over 3 cm or lac into vessels
or HILAR injury or devascularized spleen.
remove spleen if : "pulverized"
shock, otherwise repair/antomic resect.

Give pneumo vax day discharge.

Front 269

trauma to stomach , sm bowel , and perf
type of wound ?
Diagnosis ?

Back 269

- wound clean-contam in stomach, gut not dirty until term ileum really
- Dx:
Exam for peritonitis
DPL or laparoscopy
free air on CXR ! note it is CXR
Bad choices : CT false-neg
OR :
stab pylorus : pyloroplasty, stab body fix it.
Sm Bowel: most 1 anast, unless nasty then try 2nd look delay anast

Front 270

Kid 4 yr old
signs like SBO
gets CT/upper GI with water sol con

Back 270

See duod bruise
which in kids assoc abuse
Rx: NGT decom
TPN
reeval upper GI 1 week

Front 271

man 24 yr
shot in lg bowel
bleeding ALOT
Rx ?
What is lac to rectum ? anus ?

Back 271

OR ASAP, skip CT but may show free air, may miss specific injury.

If small perf try repair or small resxn with 1repair
CI to ANASt with hemmorage as #1 cause death exsang from other injurys or MOFS or sepsis.

Most rectal injury extra peritoneal, + bladder
Dx: DRE,
RIGID proctoscope (in OR) mandtory of path of knife or bullet thru pelvis

Rx: diverting proximal loop colostomy +/- distal limb closure and repair of perf,
end col muscus fisuta.
Can close colostomy in 3-4 mnths.

Anus injury : do sigmoid colostomy

Front 272

what can bleed if panc gets shot ?

Back 272

behind pancreas is :
IVC, aorta, L kidney, renal vein, splanic vein, spleinc Art, SMA,, SMV

lateral : spleen
medial : duod

Front 273

pancreas ducts anat

Back 273

Major duct joins CBD at ampulla where sphincer Oddi is. Then they dump to duod at ampulla Vater.

minpr duct is higher up.

Front 274

panc trauma
labs :
Dx
when take out pancreas ?

Back 274

- amylase
- dx:
CT : LESSER sac fluid, fluid spleic vein and panc body, retro bleed
ERCP, if stable or to eval mised injuries
Sx: Whipple or remove panc when duod or panc head devitalized.
with distal transxn: take out distal panc, tie ducts.
with prox transxn hard, try ext drain and stenting.

Front 275

trauma with flank pain and hematuria
OR
fluid responsive, distended abd, hypotensive, dec pulses LE, fluid on FAST, missles on KUB

Back 275

renal art injury
OR
contained hematoma vas injury
MGT vascular injuries:
recus, prep ct chin to thigh
warm, srtop bleeding,
if tamponaded get prox and distal control before opening hematoma.
if active hemm, get active contrl

Comps: vasoenteric fisula

Front 276

renal injury

Back 276

contusion : capsule intact, can have hematoma, IVP nml, CT can have edema or micro-leak contrast to renal parencyma; admit hx, no OR

lacL if minor and only cortex watch clolosely,

renal fracture/shattered kidney : OR ASAP. kidney rips off.

Front 277

airway for 10 year old
face shattered

Back 277

NEEDLE cricothyroidomy
a cricothy surgically CI in under 13 yolds

recall

Front 278

minor extra per bladder rupture

Back 278

foley drain and observe

if intraperio or large need OR closure

Front 279

seat belt sign :
3 injuries
(one is gut)

Back 279

sm bowel L2
pancreas

Front 280

blood in pelvis fx is A or V ?

Back 280

90% venous

Front 281

duod injury

Back 281

Duod injury : Dx with upper GI watersoluble con, CT MISSES so does DPL. 1-2nd part of duod more likley fatal
Sx:
1. Most 1 repair, try omentun patch, gastric diversion.
2. pyloric exclusion : close duod injury, staple off pylorus, gastrojejunostomy

Front 282

stable parasternal GSW

Back 282

CXR
FAST, chest tube, +/- Or for subxiph window

Front 283

in kids, a lab for abd injury

Back 283

ALT ASt

Front 284

Rx myoglobinuria

Back 284

HAM
hydrate IVf
Alkalinize urine with IV bicarb
mannitol diuresis

Front 285

change in fluids burn pts after 24 hrs

Back 285

colloid, D5W and 5% alb : need free water and have cap leak.

also in first 24 hrs never give glu

Front 286

What closes ductus arteriosus and what opens it ?

Back 286

closes it : indomethacin

Keeps patent : prostaglandin

In fetus desat blood goes thru it.

Front 287

arterial switch vs Rastelli ?

Back 287

transpostion of great arteries
egg heart
marked pulm congestion on cxr

TGA with VSD -> arterial switch before 2 wks old

TGA with VSD plus LV outflow obst -> palliative systemic pulm shunt, then Rastelli (aorta reroute internally over VSD, then PA attached to Rv externally)

TGA with septium: balloon septosomy of f ovale, then arterial switch.

Front 288

surgery for tet of fallot

Back 288

If ratio pulm art to aorta 1:3 one step

ratio under 1:3 2 step:
palliative enlarge stenotic outflow (blalock-taussig anast subclav to PA, wateston aortic-pulm anast, potts)
THEN corrective procedure.

Front 289

balloon dilation for ?

Back 289

pulm stenosis

Front 290

tricuspid atresia sx ?

Back 290

newborn emergency palliation enlg ASD/fovale or systmeic-pulm shunt

Then bidirectional Glenn then Fontan (cavopulm shunt)

Front 291

PDA
what drug ?
when sx ?

Back 291

PDA
indomethacin to close it
OR when : premie severe resp insiff refractory indo and then double ligate ductus watchful for L recurr laryngeal, larger kids get a coil in it.

infants get more risk endocarditits, pulm HTN

Front 292

when OR for VSD

Back 292

most close on own
patch if
* CHF not controlled with meds
* VSD not closed by 9 mnths old and pulm pressure 2/3 of systemic pressure
* if pulm and systemic flow is ovr 2:1 after 4 yrs old

Outcome : 1/3 regress pulm vasc resist, 1.3 same, 1/2 gradual dec

Front 293

eisenmenger rx

Back 293

only can try heart lung tx

Front 294

heart sx that can result in paralysis

Back 294

co-arc sx as cross clamp aorta
goal to keep occlusion under 20 min
distal aortic pressure over 50 mmHg

Front 295

norwood sx ?

Back 295

hypoplastic left heart
1. attach PA to arotic arch, resex atrial septum to mix blood
2. later take down shunt, connect atrial to PA via Glenn or fontan.

Front 296

neonatal GFR and urine

Back 296

GFR half that of adults
50 ml/min/m2
vs adult 100

urine conc 600 mOsm vs 1200 adults

Front 297

nutrition
stress sx hormones do what ?

Back 297

hypermetabolism
muscle breakdown faster than normal
more gluconeogenesis

Front 298

nutrition
where do you see muscle wasting in PE

Back 298

interossues fingers
quads
temporalis
also PE:
check lungs PNA, GI look for BS and periotonitis post op

Front 299

nutrition
What is total energy expediture ?

Back 299

TEE =
1. basal metabolic rate
2. phy activity ~ 10%, more vairable pt in health
3. diet induced thermogenesis (still goes in when TPN ! biochemical)

Front 300

nutrition
BMR depends on ?

Back 300

health
awake
fasting
body size
BODY composition
- lean body mass **
- fat mass
- free fat mass

** So not body wt is predictor. Danger is when obese person loses body wt in illness people don't feed as fast as 'dont look thin'. but person losing fat and LEAN body mass.

Front 301

nutrition
starving vs stress ptn needs

Back 301

stress:
inc ptn needs
more muscle ptn breakdown
more aa oxid
more ACR synth

Strav
dec ptn needs as metab adapts (slower)
dec gluconeogenesis
more ketone oxidation
ptn go to liver where deamin and then glu to brain for use.

Front 302

nutrition
where does nitrogen from ptn get elim ?

Back 302

urine
urea

Front 303

nutrition
carb use in stress vs starvation

Back 303

stress:
inc gluconeogensis
inc INSULIN resistance
inc plasma glu
inc energy needs

starvation:
less gluconeogensis
less energy needs (adapting)

Front 304

nutrition
nitrogen balence

Back 304

order 24 hr urine
1 g ptn intake has 0.16 g nitrogen
So if 40 g ptn in diet
40 g x 0.16 g nitrogen - urine nitrogen - 3g =

* For TPN use -3g as adjustment factor. can be a little bit neg, like 0.13ish as in crit ill not going to be + or zero exactly.

Front 305

acute abd davis lecture
pain poorly localized diffuse
assoc autonomic signs like:
-hypotension
- sweat
- N/V
-abd wall spasm
TYPE of PAIN
TYPE of CAUSE / ORGAN

Back 305

visceral pain
- organ with visceral peritonem cover
So capsule of organ stretching, distension
- chem irritation (gastric or panc enz)
- ischemia
- stretch of hollow viscus
(so NOT liver)

Front 306

acute abd davis lecture
Pain sharp , well localized

Back 306

somatic
arises near site pathology
- abd wall
- par peritoneum
- root mesentary
- dipahragm
via ff spinal nerves

Front 307

acute abd davis lecture
referred pain

teste

Back 307

kidney stone
pyelo

Front 308

acute abd davis lecture
referred pain

supraclavicular fossa / clav region

Back 308

dipahrgm

esp left with spleen when push LUQ

Front 309

acute abd davis lecture
referred pain

scapula

Back 309

gallstone

aneurysm (back)

Front 310

acute abd davis lecture
referred pain

back

Back 310

pancreas

abd aneurysm

Front 311

acute abd davis lecture

colicky pain ?

Back 311

comes and goes

from obst hollow viscus organ as peristalsis waves

Front 312

acute abd davis lecture

ulcer pain

Back 312

burning pentrating
sharp knife like perf ulcer

Front 313

acute abd davis lecture

cyst pain

Back 313

mid cycle mittleschmertz / graafian follicle

onset of menses : ruptured corpus luteum cyst

Front 314

acute abd davis lecture

peritonitis pt position

Back 314

knees and hip flexed

Front 315

acute abd davis lecture

tenderness types
rigidity ?

Back 315

direct : over inflam local or stretched capsule

rebound : from peritnoeal inflamm

crepitis : soft tiss infection (anar) , air leaving pleural space

Invol rigidity = from spasm of abd wall muscle, can be uni or bi, +/- tenderness

Front 316

acute abd davis lecture
percussion
- hyperresonance
- tenderness

Back 316

- bowel gas OR free air
- tender : infla local or general , distended capsule

Front 317

bowel sounds ranges

Back 317

Description

1. Bowel Sounds


Normal bowel sounds occur approx. every 5-10 seconds and have a high-pitched sound. If after 2 minutes no bowel sounds are heard, the statement “absent bowel sounds” may be made and suggest a paralytic ileus that is due to diffuse peritoneal irritation. Also borborygmi associated with hyperperistalsis which is common in early acute intestinal obstruction.

"hypoactive" is under 3-4 a minute

Front 318

succussion splash ?

Back 318

A succussion splash may be detected in a distended abdomen as a result of the presence of gas and fluid in an obstructed organ. The examiner applies the stethoscope over the patient’s abdomen while shaking the patient from side to side. The presence of sloshing sound generally indicates distention of the stomach or colon.

Front 319

liver span

Back 319

liver span
In the right midclavicular line, liver dullness should be 6 to 12 cm. In the midsternal line liver dullness should be 4 to 8 cm. Bates pg 366

Anonymous

The liver span should be 6-12 cm. in the MCL.

The liver span should be 4-8 cm in the midsternal line.

- Will decreased when there is free air in the abdomen, as from a perforated hollow viscus
-The span of liver dullness is increased when the liver is enlarged. Cirrhosis, hepatitis, venous congestion,malignancy. The span of liver dullness is decreased when the liver is small. It may also be decreased when free air is present below the diaphragm as from a perforated hollow viscus.. The span is usually greater in men and in tall people.
- A more common cause of overestimating liver size (false-positive measurement) is some form of chronic obstructive lung disease. This makes percussion of the upper border of the liver difficult. Obesity can cause problems in both percussion and palpation. Distention of the colon may obscure the lower liver dullness. This may result in understanding the size of the liver (false-negative measurement).

Front 320

psoas sign ?

Back 320

can also bring leg straight up Key is bring hip posterior.
FIGURE 1A. The psoas sign. Pain on passive extension of the right thigh. Patient lies on left side. Examiner extends patient's right thigh while applying counter resistance to the right hip (asterisk).

Front 321

what is this ?

Back 321

The obturator sign.
Pain on passive internal rotation of the flexed thigh. Examiner moves lower leg laterally while applying resistance to the lateral side of the knee (asterisk) resulting in internal rotation of the femur.

Front 322

Diastasis recti ?

Back 322

Diastasis recti- separation of the rectus abdomenus muscle, contents bulge from to form a midline ridge. Repeated pregnancies, obesity, and chronic lung disease predispose to it. No clinical consequences.

Front 323

acute abd cope

abdom pain and constipation
inc distention
little to no vomiting

Back 323

lg bowel obstruction

Do plain film

before OR, rule out renal failure as uremia causes giant abd distention and vomit

Front 324

acute abd cope

male infant
screams
draws up legs
looks pale and ill

gets better

later on happens again

Back 324

intussecption

rectal exam : blood or mucus
rectal air enema

Front 325

acute abd cope
severe abd pain
collapse
ridgid wall

Back 325

visceral perf
usually stomach or duod

-often stomach ulcer erode
- can be gb perf or stercoral ulcer colon or rare app rupture

Front 326

acute abd cope
severe abd pain
collapse
ridgid wall

then ridgid board like abdomen
hr or 2 later pt looks and feels better bit still ridig wall

later inc HR, vomit, more distension

Back 326

perf gastric ulcer

pain by shoulder
has peritonitis
can see air under diaph

Front 327

acute abd cope

severe RUQ pain / tender and risgid

Back 327

acute cholecystitis
leaking duod ulcer
(exclude chest with CXR)

Front 328

acute abd cope
severe LUQ pain / tender and ridgid

Back 328

pancretitis
perf gastric ulcer
jej diverticulitis
spont spleen rupture
leak spelic A
acute perinephritis

Front 329

acute abd cope
LLQ

Back 329

app
leak duod ulcer
acutepanc
regional illeitis
infl ileocecal glands
infl meckels
cholecystitis w/ low gb
biliray pancreatitis

left iliac low left kidney left pyelitis or left pleurisy

Front 330

acute abd cope
RLQ

Back 330

diverticulitis
pericolitis around colon cancer
pelvic peritonitis spreading up

crohn's colitis

Front 331

acute abd cope
Barium usage
obstructions

Back 331

sm int PARTIAL obst
- xray first to r/o total obst, can miss partial, ok to give meal w/barium when symtoms, won't turn partial to full
Lg intestine
- NEVER barium as can complete a block
Colon obst
Barium ENEMA

Front 332

acute abd cope

w/u renal system
uretala colic

Back 332

* serious injury pt, think renal injury
- do IVPyelogram to confirm one good kidney before take out injured one

* plain film to show stone -> (if no stone shown ~15%) TRY U/S -> then IVP

* suspect uretal stone from acute pyenephrosis-> IVP

Front 333

acute abd cope

tell acute panc from acute cholecystitis
in crit ill

Back 333

radio scans
tc uptake by liver and goes to GB

in panc see uptake by GB usually

Front 334

acute abd cope

pt central epigastric pain
and

A. LUQ pain left side plural effusion
B. right side pleural effusion

Back 334

Pleural effusion seen with sub-diaph
inflamm processes , uni or bi

A. pancreatitis

B. perf ulcer

Do not tap unless want to test for amylase as unsure if from panc

Front 335

acute abd cope

role of u/s in appendicitis appy

Back 335

Graded compression u/s
less sensitive 85%
specificity 92%
- a thick wall appendix confirms ( over 6mm noncompressible appendix)
but abscense does not rule out

- useful in questionable case to r/o tubal, female gyne

Front 336

RLQ pain
25 yo

Back 336

appendix
+ CT for appy :
Use contrast
thicken wall
over 6 mm dilation of lumen
periappendiceal streaking (density in perimesentary fat)
see arrows
under 15% have fecolith xray only 30% obst czed by fecolith overall

CT with con : sens 95-98% and spec 83-90%

appy

Front 337

treatment
algo
appy

Back 337

Front 338

acute abd cope

best modalities for w/u
Choices : XRAY, Barium/GI, US, CT

Appy :
Perf :
Panc :
DiverticITIS :
CholecystITIS :
abscess :
intest Obst :
intest inflam :
int ischemia :
aor aneu :
aor rupture :
renal colic :
gyne :
- rupture follicle
- ectopic
- TuboOvAb

Back 338

best modalities for w/u
Choices : XRAY, Barium/GI, US, CT

Appy : CT -> US
Perf : XR GI > CT
Panc : CT > US > XR GI
DiverticITIS : CT > GI
CholecystITIS : HIDA US > CT > XR
abscess : CT > US
intest Obst : GI XR > CT
intest inflam : GI > CT > XR
int ischemia : CT ok
aor aneu : CT US
aor rupture : CT > US
renal colic : IVP > rest same
gyne : US > CT
- rupture follicle US
- ectopic US >> CT
- TuboOvAb US > CT

Page 60

Front 339

Order of exam in abdomen

Back 339

inspect
ausculate
palapte
percuss

Front 340

hernia exam in inguinal canal
which kind of hernia touches where on finger

Back 340

- your finger tip points lateral / to side and lateral to external ring ring
- indirect hernia : touches fingertip in inguinal canal
- direct : touches side of examiner finger as not in canal but bulging anterior to canal

Front 341

radiology
pat can't stand but want to see if air fluid level ,
what to do ?

Back 341

left lat decub
lay 20 min

(so stomach DOWN )

- air stomach : ok
- air sm int : adult abn and obst (baby ok)
- colon : shld habe no gas colon, rectum

Front 342

choledocholithiasis Rx

Back 342

ERCP spincterotomy
if fails, Sx

Front 343

bact cholangitis

Back 343

try iv abx , bil drainage , treat cause

Front 344

biliary tumors

Back 344

relieve mech obst
ERCP and stent
percut stent by rad
sx

Front 345

featuers of #1 GB cancer

Back 345

cholangiocarcinoma
adenoca of intra bile ducts
assoc stones
spreads vascular

NO link to HBV or cirrhosis

Front 346

cancer of extra hep bile ducts

Back 346

rare in US
#1 far east
realt flukes
also of ampulla vater
always adenocarc

present progessive relent obstructive jaundice

Front 347

CI to HIDA

Back 347

sig jaundice

Front 348

When use PTC and what it stands for ?

Back 348

percutaneus transhepatic chlangiogram
when can't do ERCP and want to try non-sx mgt

Front 349

what does panc make that eats it up ?

Back 349

Inactive as eat panc
tyypsinogen + by enterokinase in duod and then turns on others
chymotryp
proelastase
procarbozypepe
prophospholipase A


Active enz : don't autodigest panc
lipase
amylase
(panc no strach or fat)

Front 350

Dx chronic panc

Back 350

US : sensitive
CT : more sensitive duct dilate, Calcify
ERCP more sens as dz advanced, show ducts
MOST sensitive endoscope u/s

PET scan tells chr panc from panc cancer

alcoholics have Ca in 20-50% can go away with abstain

Front 351

Surg tx chr panc

Back 351

nerve block thorascopic
decomp - whipple, puestow
autoislet tx and total panc-ectomy endotherapy
ERCP stents

Front 352

nutrition
comps enteral

Back 352

aspiration
refeeding
bowel obst

Front 353

when use TPN ?
CI ?

Back 353

panc
crohn IBS
post op abd sx
fistula
short bowel syndrome

CI
life expect under 3 mnths
MOFS
sepsis
use TPN only 3 days
(gut works)

Front 354

blood to apapendix

Back 354

SMA to ileocolic to appedicular

Front 355

appy
fold of treves

Back 355

= inferior ileocecal fold
bloodless fold of treves

Front 356

how big is too big for appy ?
causes of obst ?

Back 356

- nml size 6 to 9 cm
- obst #1 lymphoid tissue (young adults), 30% fecolith, barium, ascarids

Front 357

Appy
order of symptoms

Back 357

!! key is abd pain before vomit !!
unlike gastro

Front 358

High Likilihood ratio appy

Low LR appy

Back 358

High LR
#1 RLQ pain
ridgidity
periumb -> RLQ pain
pain before vomit
psoas
Low LR fever, rebound,

Negative LR : unikley to be appy
no RLQ
had sim pain before

Front 359

appy
vs mesenteric adenitis

Back 359

mes ad
concurrent or prior URI
so nonGI symptoms

Front 360

Rx
appy perf

Back 360

peritoneal washout
Iv abx
leave skin open, reclose ~ 5 days
close fascia only

Front 361

appy
pregnant

Back 361

use us not ct
#1 sx emer in preg
1st tri
fetal mort 3-8% up to 30% with perf
RX: surg and risk premat labor 10-15%

Front 362

appy elderly

Back 362

late present as dont show peritoneal signs as soon

perf high 1/2
delay high WBC

Front 363

AIDS pts or on chemo
looks like appy

Back 363

think neutropenic colitis
OR
CMV bowel perf

Front 364

appy
#1 tumor and cause Rx

Back 364

carcinoids are 2/3 primary tumors
under 2 cm : remove appy
over 2 cm : right hemicolectomy

Front 365

branchial cleft vs thyroglossal cyst
which arches ?
sx must remove what ?

Back 365

thyroglossal must remove middle of hyoid bone.
most common is cleft 2

thyroglossal cyst can move with swallowing but doesn't have to

don't probe brachial arch cysts or can lead to infection

Front 366

what is it ?
Rx ?

Back 366

cystic hygroma
remove early or get sclerotic

Front 367

what is it ?
Rx ?

Back 367

thyroglossal cyst

Front 368

man 20 year old
pain periumbil and RLQ that is
intermittent and colicky
slightly high WBC
temo 98

DX

case files

Back 368

Not appy
as pain
INTERMITTENT and colicky

Front 369

What modality of w/u ?

Female sex active pain RLQ
WBC 12K fever 100

case files

A. Urine clean, exam right adnexal tenderness

B. Urine + WBCs, + RBCs

Back 369

A. likley pelvic so use u/s

B. likley not pelvic, (pyelo) so try Ct

To be SURE PID vs appy need laparoscopy

Front 370

appy
appendicitis
CT shows abscess

case files

Back 370

Interval appendectomy

for appendicitis comp w. abscess or phlegomon

1. 1st treat broad abx
2. CT guide drainage, resolve infection
3. sev weeks later take out app

Front 371

never use clinical obesrvcation if see any of what

case files

Back 371

limited use of
localized pain , fever, of high WBC already

maybe use in early appy w/o local signs as CT less good in early appy

Front 372

burr holes ?

Back 372

Rapid decline in consciousness
inc BP and low HR

try CT first ! that guides whatever neurosurg does

- never do blind ED craniotomy before CT
- can consider ventriculostomy / burr hole to release hematoma. If you don't have a CT you can put 6 holes in "woodpecker method"

Front 373

in blunt trauma what does CT pick up and miss ?

case files

Back 373

CT good for solid organs

poor at retroperitoneal
poor hollow viscus organs

Front 374

man 60 yr
h/o polyps removed
now gross positive hemeoccult
hgb 8.7 chronic
w/u ?



case files

Back 374

1. transfuse
2. needs EGD and colonoscopy
likely colon

Front 375

what is a abdominoperineal resection ?

Back 375

APR
For anal cancer that is low lying
- remove rectum and anal canal and sphinter
- leaves a permenent colostomy (on left)

Front 376

diverticulitis
- small absces
- lger
- not better in 72 hours
- are better in 72 hours
- OR ASAP

case files

Back 376

- - small mesenteric abscess can heal w/ abx
- lger pelvic abscesses need CT drainage
- not better in 72 hrs go to OR
- are better in 72 hrs may beed to return for elective sx
- OR ASAP if perf and peritoneal signs, hemounstable and so resetion and Hartmanss if no contamination can be orimary anastamosis

Front 377

repair divertucilar fistula

case files

Back 377

- resect sigmoid colon that is part of fisula
- excise fistulous tract
- repair/resect other organ

Front 378

what is a hartmann ?

Back 378

HArtmann
2 stage surgery for emergent sx for diverticlitis
first make colostomy
then later take it down

Front 379

fascial defect or incisional hernia at midline laparotomy site
when ?
who ?
treatment ?

case files

Back 379

When ? 3 weeks post op
RF : over 70 Yr, DM, malnutr, perioperative pulm dz
Treatment :
1. Eval for sepsis or evisc so do WBC
2. local wound care
3. later on elective repair of fascial defect / incisional hernia that will occur

Who needs OR asap : pts risk eviscerate, high WBC and fever, enterocutaneous fistula, uncontrolled sepsis

Who not to operate on if can help it : stable dehis, no bowel out, nasty abd you don't want to open

Front 380

incisional hernia ?
repair ?

Back 380

- can present 5 yrs post op
- avoid repair when occur as high wound infeciton rate and recurr rate so use mesh

Front 381

5 days pot op patient has 40 ml serosanguinous fluid from midline lap wound
- what to do ?

Back 381

open wound and eval fascia

infected wounds have up to 20% rate of incisional hernia / defect

Front 382

biliary colic vs acute cholecystitis vs cholecdocholitiasis

Back 382

b colic : intermittent , nml liver enz

acute cholecystitits : high WBC, stays painful, mild rise non specific liver enz

choledocholithisias : dilated common bile duct on U/S of over 5 mm and high liver enz

gallstone pancrease: if amylase and lipase high

Front 383

biliary colic vs acute cholecystitis vs cholecdocholitiasis

Back 383

b colic : intermittent , nml liver enz

acute cholecystitits : high WBC, stays painful, mild rise non specific liver enz

choledocholithisias : dilated common bile duct on U/S of over 5 mm and high liver enz

gallstone pancrease: if amylase and lipase high

Front 384

gallstone pancreatitis treatment

Back 384

- bowel rest and IV hydration
- during same hospitalization but after calm down (no jaundice) lap cholecystetomy as long as uncomp gallstone panc

Front 385

man presents with sudden painful groin mass
what to do ?

Back 385

sudden painful mass suggests incarceration
so OR before strangulates

Before OR
- IVF and fix lytes and try to reduce it

Front 386

- 80 year old women in nursing home lost several pounds over last mnths
- 3 days not eating, vomiting, this AM confused and very ill
- abd benign no scars,
mass on medial thigh

Dx

Back 386

Obturator hernia
XRay will show dilated small bowel

Rx :
FIRST recus and hydrate (altermed mental)
Then to OT urgent repair

Front 387

FNH what has good spec and sens ?

Back 387

Angiography

Front 388

liver tumors seen well on MRI ?

Back 388

On MRI
- high spec and sens for mets adeno and hemangioma
- low FNH unless see central scar, low hepato carcinoma, adenoma

Front 389

liver tumor seen well on CT ?

Back 389

hemangioma
mets

Front 390

angio is good for which liver tumors ?

Back 390

gold standards for hemangioma
and high for mets

Front 391

lap u/s good for which liver tumors ?

Back 391

gold standard for hepato carcinoma

when combo w. lap biopsy good for adenoma and met adenocarc

Front 392

biopsy which liver tumors ?

Back 392

mandatory got hepato carcinoma and mets adeno

helpful adenoma ,

rarely helpful in FNH (do angio)
CI hemangioma

Front 393

name 2 kinds pulm sequestration and treatment ?

Back 393

Intralobar :
presents with infection, has no pleura cover, CXR mass or air/fluid level
veins drain via pulm veins
Rx lobectomy

Extra-lobar
pleural covering
assoc diaph hernia
incidental finding CXR
venus via pulm vein or azygous vein

DX MRI

Must do aortigram? or somesthing to prove no vessels draining below dipah which can cause exsanguination if cut

Front 394

ruptured omphacele vs gastroschisis

Back 394

omphacele has intact umb cord at leve of abd wall

Front 395

lab bili findings indicating biliary atresia

Back 395

direct bili over 2 mg/dL
direct bili over 10% of bili of total bili

Front 396

4 month old infant jaundice direct bili 3 mg/dL

Back 396

correctible type : blind ending dialtion of c hep duct Use anast with Roux-en-Y loop jejeumum

non-correctable use : Kasai hepato portoenterostomy

post op tx prophy abx, phenobarb , liver transplantation

Kasai : A surgery performed on an infant with Biliary Atresia to allow bile to flow from the liver. In a Kasai the damaged ducts are removed and replaced with some of the infant’s own intestine. The small intestine is divided (Roux-en-Y) and a section is brought up to the liver. This connection may be inside or outside of the liver. The Kasai procedure is also called a hepatoportoenterostomy.

Front 397

kid with volvulus
CI barium enerma

Back 397

No enemia if periotontits, perf , profound shock

Rx volvulus :
treat dehyd
NG to decompress
hydrostatic decompression
barium enema
air enema

Front 398

meckels repair ?

Back 398

diver tic resection and transverse closure of enterostomy

Front 399

GI bleed lecture
NG aspirate finding
neg blood
pos bile
What next ? If this test neg, what next ?

Back 399

on test rules out U GI bleed
-> Do EGD
If neg ->
Tagged RBC scan ! (not colonoscopy as only see poo and blood)
If pos -> Angio to localize

Front 400

GI bleed lecture
How fast a bleed needed to see with Tagged RBC scan and angio ?

Back 400

Tagged scan : 0.1 cc/min
very sens but not specific to an area

Angio L 1 cc/min nad localizes to an area. Still do tagged RBC first and only if tagged pos go to angio.

Front 401

GI bleed lecture

NG aspirate
neg blood
neg bile

Back 401

can't rule out U gi bleed

Front 402

GI bleed lecture

+ blood
+ bile

Back 402

U GI bleed
Diff :
PUD gastric or duod (since bile)
dilauefoy
mall weiss

Front 403

GI bleed lecture

when might you go to OR without localizing lesion in GI bleed ?

incision ?

Back 403

hemo unstable (BP under 70) despite cont'd transfusion

NG negative so know its lower

4-5 units/24 hrs
8-10units/48 hrs

incision : lap
Sx : total abdominal colectomy
Risk as 15% bleeds from sm int can try seriel enterotomy (peek holes in sm bowel)
TEst answer: no 1 anast as that is slow and concerns about unpreped bowel and healing esp if left colon
But 85% stop bleeding on own

Front 404

GI bleed lecture

can angio be therapeutic ?

Back 404

Can use vasopressin to close vessel

Risk colon ischemia as no alot collateral vessels

Front 405

GI bleed lecture

First tag scan negative
Pt in ICU for moniter
BP drops now

What to do ?

Back 405

Re RBC tag scan.

Do not have to re-dye load as tagged cells last 24 hours.

Front 406

notes fluids kagen
drug that causes hyperkalemia

Back 406

pen G

Front 407

Treatment for hyperkalemia

Back 407

Glucose-insulin-bicarb :
- 50 cc D50
- 10-25 u reg insulin
- 1 amp NaHCO3

Ca gluconate 10% 50-100cc
Kayexalate 5-10 gm po QID
dialysis

Front 408

Treatment hypercalcemia

Back 408

NS and furosemide
mithramycin
chelating agents
steroids

Front 409

treatment hypocalceima

Back 409

ca chloride
ca gluconate
lecture notes

Front 410

treatment metabolic alkalosis

Back 410

ch replacement
potassium replacement
0.1 N HCL or ammonium chloride

lecture notes

Front 411

treatment resp acidosis

Back 411

mech ventilation

lecture notes

Front 412

treatment resp alklosis

Back 412

pain mgt
vent support CPAP/PEEP
search for sepsis

lecture notes

Front 413

Treatment
small cell lung cancer

Back 413

chemo (has fast mitotic rate) hafe regress
VS non-small cell only 5% regress with chemo

No sx

- central

Front 414

Lung CA
central

Back 414

Sentral
Small cell
Squamous

Front 415

lung ca
plain film
size ?

Back 415

size ? 0.8 to 1 CM diameter most malig nodules

Good features :

Bad features :

Front 416

chronic cough
dyspnea
syncope
headache
bloody nose
worse with leaning forward and upin AM awakening

Back 416

Superior vena cava syndrome blocks venous return

Front 417

hyponatremia
chronic cough
smoker

Back 417

SIADH
low serum osmol but no edema
due to AVP ectopic release

Front 418

treatment lung CA

nonsmall cell

Back 418

30-50% shrink with radiation
chemo doesn't work
Sx if under stage IIIA

Front 419

Types of tumor trachea and bronchi
- benign
- malig potential

bluprints , old version

Back 419

BENIGN
sq papillamoatosis HPV 6 11
angioma
fibroma
leioma
chrondma

MALIG POTENTIAL
br carcinoids (10% malig)
adenoid cystic carcinoma
mucoepidermoid

Front 420

lung ca nodules

- nodule that is stable for 2 yrs
- nodule new in last 2 months
- and clubbed fingers

Back 420

- nodule that is stable for 2 yrs -> needs no further eval

- nodule new in last 2 months -> unlikley to be malignant
- SPnodule with hypertrophic osteoarthy : 75% chance carcinoma

Front 421

lung ca nodules

no bony mets
no bulky contra lat mediastonal LN

Back 421

plain film first, may be enough

Front 422

lung ca nodules
when CT

Back 422

CT should inc liver and adrenal

better mediastinal LNs

Front 423

lung ca nodules or CA

when do bronch ?

When do TBNA ?

Back 423

Sentral masses
- small cell
- squamous

Options :
direct visualize and biopsy lesions , TBNA (transbronchial needle aspirate), washings

TBNA best for staging mediastinal LNs

Front 424

lung ca nodules or CA

When do trans thoracic needle biopsy ? TNB

When thoracocenesis ?

Back 424

Diagnosis :
Chest CT with needle biospy
bronchoscopy plus/minus transtracheal biopsy (note with transtrachel needle biopsy can't see node as needle it, rely on CT scan from before of where it is. Endoscope better but only at a few centers. )

Excisional biopsy open vs thorascopic diagnostic but risks PTX. Can be therapeitic for small lesions, sol mets, prim cancer if cant have more major sx

TNB ?
-peripheral nodules
- Most CT guided
-sensitivty 70-100%

thorcocentesis
-TOC pulm effusion and suspect malignancy

Front 425

lung ca nodules or CA

single
nodule under 3 cm
intra parenchymal opacity
wel marginated

Back 425

= def of solitary pulmonary nodule

Most benign
- granuloma, haramtoma, intrapulm lymoh nodes

Some malig
- bronchogenic carcinoma
RF malignant :
- over 1 cm and even more if over 4 cm
- indistinct margins (corona radiata)
- document growth on FU plain film
- pt older
- male

Smoker over 50 YRs over 50% malig VS 5-10% malig overall.

Front 426

lung ca nodules or CA

small cell staging

Back 426

70% met at dx

2 stages
limited : one radiation portal
VS
extensive : the rest

Front 427

lung ca nodules or CA

non-small cell staging

Back 427

Work up to determine if sx possible

Chest CT (incl liver and adrenal for mets)

If malig pleural eff CI sx

TNM staging system

Front 428

lung ca nodules or CA
recall

lung areas where CA more often ?

Back 428

Right > left
upper > lower

Front 429

lung ca nodules or CA
recall
Sites of extra thoracic mets

Back 429

1. bone (vert bone pain)
2. liver
3. adrenal
4. kidney

Front 430

paraneo syndromes can also get with lung CA not just gut cancer ?

Back 430

acanthosis nigracans
thrombophlebitis
Also paraneo
cushing
SIADH
Eat Lam
cerbellar ataxia
hypertrophic osteoarthy

Front 431

tests to workup tumor or lung mass
recall

Back 431

- sputum cytology (diagnostic in 5-20%)
needle biopsy w. CT or floror guidance
broncho with brushings, biopsy or both
w or without mediastinoscope, scalene node biopsy, or open lung biopsy.

Front 432

lung CA

T3 and T4 stage ?

Adam online

Back 432

In T3, a tumor of any size has directly invaded any of the following:

* Chest wall
* Diaphragm
* Membrane covering organs and structures in the chest
* Outer wall of the membrane around the heart (pericardium)

In addition, one or more of the following conditions are present:

* The tumor is in the main airway, less than 2 cm away from the carina, but is not in the trachea (windpipe).
* The tumor is associated with a collapsed lung or swelling that blocks the entire lung.

In T4, the tumor has invaded any of the following:

* Area between the lungs (mediastinum)
* Heart
* Great vessels (the blood vessels that carry blood from the heart)
* Carina, trachea, or esophagus
* Main portion of the spine

In addition, one or both of the following occurs:

* Separate tumors are present in the same lobe
* The tumor is accompanied by an increased amount of fluid between the pleural membrane and the lung.

Front 433

lung CA and on biopsy :
- Only a few layers of cancer cells are detected within one local area. - The cancer has not grown through to the top lining in the lung

Back 433

Stage 0 or Carcinoma in Situ

Stage 0 or carcinoma in situ (Tis, N0, M0) are noninvasive cancers. Only a few layers of cancer cells are detected within one local area. The cancer has not grown through to the top lining in the lung and can be surgically removed. There is a high risk for development of a second tumor, however.

Treatment Options:

* Surgery, often a limited procedure, where only part of a lobe is removed from the lung.
* In patients who cannot be treated surgically, consider photodynamic therapy, cryotherapy, or brachytherapy.

Adam online

Front 434

lung CA treatments

Back 434

Treatment Options.

* Combination of two- or three-drug chemotherapies that include platinum-based drugs and newer drugs;
* Bevacizumab (Avastin) may be used for patients with non-squamous lung cancer, no spread to the brain, and who are not coughing up blood.
* External-beam radiation for symptom relief
* Paclitaxel, gemcitabine, or docetaxol are all additional drug options
* If metastasized cancer involves only one or two areas in the brain, it may respond to surgery followed by radiation to the brain.

Front 435

lung CA sx :

Back 435

# Mainstay lobestomy for central lesions

# for primary cancer that is re sectable and no CI, do node dissections.

The surgical removal of an entire lobe or parts of a lung is the primary treatment for eligible patients in the early stages of cancer. Recurrence is high after surgery, although the new tumor is often operable.
# Some patients with stage IIIA cancer may also benefit from surgery. The intent at this stage is to extend survival time, rather than cure the disease.

Wedge Resection or Segmentectomy. Wedge resection and segmentectomy remove only a small part of the lung. They preserve almost normal breathing function after the operation.

Lobectomy. Removal of one of the lobes of the lung is called lobectomy. The patient must have enough lung function to undergo this procedure. The patient has a 3 - 5% after this operation, with older patients having the highest risk.
Pneumonectomy. Pneumonectomy removes the entire lung. The patient has a 5 - 8% risk of death after this procedure. The oldest patients have the greatest risk, and they almost always have a recurrence.

Stage 1 and small, and old try VATS

Front 436

pt too sick or for sx and early stage and adequte lung function

Back 436

try radiation.

also palliative rad

Front 437

features sq lung CA ?

Back 437

Squamous
central in HILUS so
Pancoast
slow growth and late mets
assoc smoking

Front 438

adenocarc
lung CA features ?

Back 438

adeno
peripheral
rapid spread
hematog and nodal spread
assoc lung scarring

Front 439

small cell lung CA feautres ?

Back 439

Small cell
Sentral
highly malig
non operable usually

Front 440

LARGE CELL lung CA features ?

Back 440

large cell lung CA a subtype of non-small cell

usually peripheal
very malig

Front 441

lung Ca
diff between IIIa and III b and why it matters ?

Back 441

For NON SMALL cell

III a operate/resect if early IIIA, chemo +/- radio., 5yr surv ~ 20%
1. tumor in chest wall, diah, or mediasrinal pleura or pericardial sac AND + nodes in lung or ipsi hilum and NO mets T3N1M0
2. LN mets ipsi mediastinal or subcarinal nodes, NO Mets and NO mediastinal tumor invasion
T1-T3N2 M0


III b no operate but chemo and radiation (XRT)

Front 442

When chemo for lung CA

Back 442

induction chemo BEFORE sx for NON small cell CA inc survival

Front 443

lung CA
isolated brain mets ?

Back 443

sx resect

Front 444

CI to sx for lung CA

recall

Back 444

Sup vena cava syndrome
supra clav LN mets , scalene node mets , mets in other organs
trachea carina involved
small cell cancer

PFTs show FEV1 under 1 (as to remove lung must be over 1 to start as must be over 800 cc after sx to do well)

cardiac cripple or prior MI

Front 445

Post op FEV1 goal

Back 445

Post op FEDV1 over 800 cc

so pre op must be over 2 for pneumonectomy

If FEV1 under 2, try VQ scan

Front 446

wheezing
atelectasis
bronchoscope shows round red-yellow mass protrudeing into brochial lumen

Back 446

carcinoid tumor
slow growing
comnfused with asthma
Rx: lobeectomy with LN dissection
OR sleeve dissection of proximal (cut out bad ring of bronchus and anast ends) good prog if nodes negative

Front 447

Esophagus
why does it leak after anastomosis ?
What nerbe runs here ?

Back 447

no serosa , like distal rectum

nerve here is VAGUS

Front 448

esophagus thru what level in diaphragm

Back 448

esophagus thru T10

T8 IVC
T10 esophagus
T12 aorta

Front 449

name wrist bones ?
proximal row and distal row ?

Back 449

Some scaphoid
Lovers lunate
Try triquetrum
Positions pisiform
That Trapezium

Also the areticular disk between pisiform, ulnar bone and lunate which makes meniscus of wrist.
They trapezoid
Cant Capitate
Handle hamate

Front 450

muscles that extend wrist ?

Back 450

WRIST EXTENSORS
On posterior of wrist / dorsal side
RADIAL NERVE and all extrinsic muscles meaning attach to forearm not to within hand.
* Extensor Carpi Radialis Longus
* Extensor Carpi Radialis Brevis

FLEXOR GROUP

* Flexor Carpi Radialis
* Palmaris Longus
* Flexor Carpi Ulnaris
ROTATORS OF THE WRIST
* Pronator Teres
* Pronator Quadratus
* Supinator

Front 451

what is dequer wrist tenosynovitis ?

Back 451

de Quervain's tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB).

tendons run along radius

Sx : pain above thumb in wrist

diff : intersection syndrome , more medial

Front 452

name problem ?

hand

Back 452

ext tendon along top of finger rips off DIP

Rx splint for 6 weeks or else cant straighten finger out

(under side of finger is flexor tendon )

Front 453

name problem ?

hand

Back 453

tear in central slip of extensor hood

Front 454

chronic onset

Back 454

Cubital Tunnel Syndrome

ulnar nerve where it crosses the inside edge of the elbow. ( very similar to the pain that comes from hitting your funny bone).

It supplies feeling to the little finger and half the ring finger. It works the muscle that pulls the thumb into the palm of the hand, and it controls the small muscles (intrinsics) of the hand.


Causes
N actually stretches several millimeters when the elbow is bent. Sometimes the nerve will shift or even snap over the bony medial epicondyle. Over time, this can cause irritation.

pulling levers, reaching, or lifting. Constant direct pressure on the elbow over time may also lead to cubital tunnel syndrome. The nerve can be irritated from leaning on the elbow while you sit at a desk or from using the elbow rest during a long drive or while running machinery. OR The ulnar nerve can also be damaged from a blow to the cubital tunnel IN MEDIAL ELBOW

Front 455

hand nerve radial sensory ?

Back 455

radial nerve enters between superfic and deep extensor muscles in back of hand.

supplies extensors

Front 456

hand nerve ulnar ?

Back 456

ulnar :
passes between pisiform and hook of hamate and tunnel of guyon

supplies Flex carpi ulnaris and 1/2 F dig profundus

Front 457

hand nerve median ?

Back 457

enters carpal tunnel
to flexor muscles

Front 458

hypothenar muscle ?
nerve ?

hand

Back 458

hypothenar muscles are opposite hand

Ulnar nerve

- abductor digiti minimi
- flex digiti minimi
- opponoms digiti minimi

Front 459

hand injurys needing OR vs ER repair ?

Back 459

extensor : more ER

flexor : more OR

Front 460

flexor tendon of hand injury zones ?

Back 460

TENDON INJURIES

Flexor Tendons

The most common cause of flexor tendon injury is a laceration. Flexor tendon lacerations can be subtle; however, the careful examiner will identify these injuries. A classification system for flexor tendon injuries has been developed based on location, treatment considerations, and prognosis.



ZONE I

Extends from the insertion of FDS to the profundus tendon. Patients with these injuries lose flexion at the DIP. Retrieval of the proximal tendon is often difficult.



ZONE II

Involves the portion of the digital canal occupied by both FDS and FDP. The close proximity of these tendons makes it essential for exact repair with minimal operative trauma. This region is often referred to as “no man´s land” because of the frequent poor outcomes prior to the 1960s when improved repair techniques were developed. Lacerations in this zone are common, and partial lacerations are more common then complete.



ZONE III

Extends from the distal edge of the carpal tunnel to the proximal edge of the flexor sheath. The lumbrical muscles originate from FDP in this region. Outcomes are generally favorable.



ZONE IV

Involves the carpal tunnel and related structures. The area must be explored carefully because so many vital structures go through the carpal tunnel. Isolated injuries are the exception.



ZONE V

Involves injuries to tendons proximal to the carpal tunnel. Injuries here tend to be severe and often involve multiple tendons as well as the median or ulnar nerve. It is essential to search for all major structures.



A hand surgeon should repair flexor tendon lacerations. Primary repair should occur within 12 h. Secondary repair can occur up to 4 weeks after the injury.



Another type of flexor tendon injury is the avulsion of FDP from its insertion in the distal phalanx. This can occur from a grasping motion against high-speed resistance. The patient will be unable to flex the distal phalanx. Prognosis depends on the size of the bony fragment, the length of time from injury to repair, and the blood supply to the tendon.

Front 461

hand intrinsic muscle ?

Back 461

Median nerve :
- dorsal interossei : abduct finger
- palmer interosseu : adduct finger

lumbricals flex MCP and extend PIP, DIP use Median and Ulnar nerve

Ulnar for palmaris brevis for hand grip

Front 462

hand tests ?
- bend thumb tip ? flex pol longus
- bring thumb to side and back ? ext poll brevis and abd poll brevis
- raise thumb only while rest of hand is flat ? ext poll longus

Back 462

hand tests ?
- bend thumb tip ? flex pol longus
- bring thumb to side and back ? ext poll brevis and abd poll brevis

- make fist with little finger extended alone ? ext digiti minimi

Radial , extrnsic muscle (Extrensors)

Front 463

hand tests ?

- flex and ext a fist at wrist ? ext carpi radialis longus and brevis

- make fist with little finger extended alone ? ext digiti minimi

Back 463

hand tests ?

- flex and ext a fist at wrist ? ext carpi radialis longus and brevis

- make fist with little finger extended alone ? ext digiti minimi

Extensors are Radial

Front 464

name injury ?

Back 464

Felon :
tense in fingertip pad unlike whitlow where painful but soft pad.

Pad has fibrous septae so little room so gets tight and swollen.

Bugs : S. aureus, streptococci First-generation cephalosporin or anti-staphylococcal penicillin
Incision and drainage should be performed if infection is well established.
Oral antibiotic therapy usually is adequate.

Because the septa attach to the periosteum of the distal phalanx, spread of infection to the underlying bone can result in osteomyelitis.16

Front 465

Rx paronchyia ?

Back 465

7 days abx soaks, retract skin nail margin

If more extensive, unroll skin at base of nail and lat and ID at area of most pus and drain under dig block.

Front 466

breast CA

findings on prior breast biopsies assoc with breast CA ?

Back 466

aty hyperplasia
LCIS

Front 467

breast CA
and hormone meds ?

Back 467

combo HRT over 4 yrs
estrogen over 5 yrs
OCP slight inc and stops once stop OCP

Front 468

breast CA
percent biopsies showing CA ?

Back 468

20%

Front 469

breast CA

sens and spec mamm ?

Back 469

mamm
Screening : 80-95% sens IF so with breast exam
Also high specificity

Vs diagnostic if done with symptoms

Front 470

breast CA
sens and spec ultrasound ?

Back 470

US used only diagnostically NOT for screening

poor sens
good spec solid vs cyst
homo vs not

1st tool for young women

Front 471

breast CA

sens and spec MRI ?

Back 471

diagnostic use
high sens over 95%
low spec as sees lots of masses
useful in breast dense on mammogram
can use gadolin contrast

Front 472

breast CA

options palable mass ?

Back 472

FNA : give no tissue arch just cytology, at best 94% accurate sens for CA. ** 10% FALSE neg rate so can't r/o CA

Percut core biopsy 96% sens CA

excisional biospy 100% sens CA
incisional biospy Dx adv dz and inititate Rx

Front 473

breast CA
options non palp mass

Back 473

need imaging

stereotaxic core biopsy (mammogram guide) 96% sense CA

U/S guided core biospy 90-95% sens CA

needle localized excisional biospy (sx after needle placed mamm) 98% sens CA

Front 474

breast CA
screening recs ACS

Back 474

BSE monthly age 20
clinical breast exam per 3 yrs age 20-39, annually age 40
mamm age 40 yearly

Front 475

breast CA
what has Ca++ on mammo ?

Back 475

fibrocystic change
ductal hyperplasia
insitu carcinoma
invasive carcinoma

Front 476

breast CA nodes ?

Back 476

on clinical exam palpate :
supraclavicular
infraclavicular
thyroid involved in adv cases
axillary

Front 477

breast CA
Mammogram views ?

Back 477

Left
MLO medial lateral oblique
CC cranio caudal : top of muscle, and between breast and muscle should be lucent

Front 478

breast CA
breast CA ultrasound breast findings

Back 478

cysts should be in same place as tissue and often oblong in that plane

no echos in them (be homgen)

Front 479

breast CA

month after box falls of women
skin or nipple retraction
oil cyst in wall of breast

Back 479

fat necrosis

Rx follow by PE

Front 480

breast CA
women 35
well circum tumor
mobile mass

Back 480

women younger / Middle aged
more cellular vs fibroadenoma

RX: Wide local excision (recur locally)
If recur or large may need mastectomy.

Do not need LN removal even if malig cystosarc phyloide as don't met by lymph

Front 481

breast CA

what is LCIS ?

Back 481

marker for inc risk Breast CA
not itself pre malig
bilat and multicentric

Rx no sx

Front 482

breast CA

What is DCIS ?

Back 482

usually defined as mammogram changes, sometimes comedo mass

if any signs invasion managed as such

RX:
- lumpectomy and total br radiation post op
- total mastectomy

Front 483

breast CA

extended beyond BM
Rx ?

Back 483

= invasive carcinoma

remove breast plus mgt axillary LN mgt

Front 484

breast CA

stages I and II

Back 484

- lumpect axill LN dissection and total breast irrad post op
- mod rad mastect and rad sometimes and chemo sometimes

Front 485

who is poor candidate for lump and breast irradiation ?

Back 485

small breat / lg tumor
tumor over 4 cm
carcinoma behind nipple
multicentric DCIS or invasice
extensive ductal carcin in situ
compliance
scleriderma / SLE

Front 486

breast CA

read skin or peau d'orange

Back 486

stage III B or C
inflamm carcinoma

Rx chemo PRE - op = neoadjevant AND
modified rad mast (total mast and axill LN mgt)
then radiation afdter chemo as lots of local recurrence

Front 487

breast CA

axillary lymph nodes ?

DAngers of dissecton ?

Back 487

The surgical classification is used in axillary dissection for breast cancer.

CA spreads level 1 to 2 to 3 and 3 is worse.
- based on relationship to pec minor.

Level 1 nodes : lateral or side of pec minor (lateral, anterior and posterior nodes)

Level 2 consists of those nodes under pec minor : central nodes and some of the apical nodes.

Level 3 (medial to medial border of pec minir nad under clavicle) consists of those nodes beyond the superior border of pectoralis minor.

ROTTER's nodes :
between pec major and minor.

Axill and int mamm LN drain also.
It includes the remaining apical nodes and infraclavicular nodes.

Dangers of dissection :
damage axillary A and nerbe
seroma, lymphedema, rest shoulder mvt from scar contraction

Front 488

breast CA

mets ?

Back 488

via venous plexus Batson's
to spine

Front 489

breast CA

anatomy

nerve
veins

Back 489

long thoracic nerve is posterior -> serr ant -> wing scapula

mediaL pectoral N is really lateral to lat pect N as named based on brachial plexus -> pec maj and minor -> weak of these muscles

intercostobrachial N : anesh inner arm skin
thoracodorsal N -> lat dorsi -> cant push up from sitting
axill vein is superior and is most of vein drainage

Art :
- lat thoracic A and thoraco dorsal A to Axill A
- int mamm A perf and intercostal A

Front 490

breast CA

Cse 42 yr old
mass persists for 3 mnths
undiagnosed
FNA non- diagnostic
what to do ?

Back 490

FNA false neg 10% !! cant r/o cancer

Oberving not option if over 30.

Algo: Over 30 : U/S or FNA.
- fluid non bloody and mass resolves serial fu screening per guidelines
- mass persists/no fluid -> mammo or get tissue via FNA or needle biospy
----- dx made then treat
---- non diagnostic : get more tissue with excisional bx then treat and f/u

Front 491

breast CA

Case
20 yr firm mass
well circum non tender

Back 491

fibroadenoma til proven other
RF AA, smoker

Dx FNA and can observeif under 3 Cm

if FNA non dx, pt over 30 or symptoms MUST excise mass

Front 492

breast Ca

what is mondot's dx ?

Back 492

thrombophlebitis of lat thor or thoracoepi vein

RF trauma, sx, infection

Sx: pain axilla or upper breast and on PE feel a tender cord

Dx US gives clear dx

Tx ASA, wam compress, resolves 2-6 wks

if persist can try sx

Front 493

breast CA

you needle aspirate cyst and fluid is ____ what do you do ?

Back 493

- green or cloudy and single dom cyst ok to discard

- bloody sent to cytology

Front 494

peds sx

hirshsprung

Back 494

Front 495

peds sx

hirshsprung

Back 495

Front 496

gi sx

name condition

Back 496

cecal volvulus

Front 497

what sx is this for ?

gi sx

Back 497

achalasia

Front 498

gi sx
stomach

what is antrectomy ?

Back 498

see pic

Front 499

name sx and what it is for ?

gi sx

Back 499

APR
??

Front 500

gi sx

what is an ivor lewis ?

Back 500

Front 501

gi sx
peds sx

what is kasai ?

Back 501

i think for biliary atresia

Front 502

gi gb sx

describe lap chol and who can get one ?

Back 502

Front 503

what is this ?
s sx ?

Back 503

malrotation
sx emergency

Front 504

gi sx
what is this test and what does it show ?

Back 504

meckels scan

sx to take out not just meckels but also part of intestine near it as that is part that bleeds due to acid eating it.

Front 505

gi sx
panc

anat of panc

Back 505

Front 506

peds sx
lung
pulm seq
name 2 types

Back 506

Front 507

peds sx

how repair TEF ?

Back 507

Front 508

gi sx

types of stomas ?

Back 508

Front 509

gi sx
panc

descrive whipple

Back 509

Front 510

esoph
gi

name disorder

pic is pre and post procedure

Back 510

esoph atresia
Achalasia of the esophagus. Left: Moderately advanced achalasia. Note dilated body of esophagus and smoothly tapered lower portion. Right: Widely patent cardioesophageal region following cardiomyotomy (Heller procedure). (Reproduced, with permission, from Way LW [editor]: Current Surgical Diagnosis & Treatment, 10th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)

Front 511

esoph
gi

treatment for achalasia

Back 511

Surgical Myotomy

A modified Heller cardiomyotomy of the LES and cardia results in good to excellent symptomatic improvement in over 85% of patients. Because gastroesophageal reflux may develop in up to 20% of patients after myotomy, most surgeons also perform an antireflux procedure (fundoplication). Myotomy is now performed with a laparoscopic approach and is preferred to the open surgical approach. The low morbidity of laparoscopic surgery has led some experts to recommend it for initial treatment. In experienced hands, however, the initial efficacies of pneumatic dilation and laparoscopic myotomy are nearly equivalent.

Front 512

abg pulm icu

what O2 sat does the following equal :
30 mmHg ?
40 mmHg
60 mmHg

Back 512

30 mm Hg ~ 60% O2 sat
40 ~ 75% O2 sat
60 mm Hg ` 90% SaO2 2

Once PaO2 exceeds 70mmHg further increases do not necc increase O2 delivery.

Front 513

abg pulm icu

What is base excess ?

Back 513

non resp part of ABG
incl RBC buffering

nm is -2 to +2

Front 514

abg pulm icu
If the PH is decreased by 0.8 : what should happen to others for a balenced deficit ?

Calculate what PaCO2 should be for a pt with PH of :
7.40

Back 514

For 0.8 change in Ph

pa CO2 changes 10 mmHg

0.8 PH -> 10 in CO2 [ this is using HCO3 / PCO2]

Ph 7.40 -> PaCO2 40
Ph 7.32 -> PaCO2 50
7.48 -> CO2 30

Front 515

abg pulm icu

low ph : acidosis
high PaCO2 : retaining CO2
nl BE and HCO3

Back 515

uncompensated
resp acidosis

as BE and bicarb nml

like NM dz or lung dz or resp center depression

Rx treat cause, mech vent, buffers

Front 516

abg pulm icu

nml ph
high paCO2
high BE and HCO3

Back 516

comp resp acidosis
like NM dz or lung dz or resp center depression

Rx treat cause, mech vent, buffers

Front 517

ABG icu pulm

high ph
low pa CO2
nl BE and bicarb

Back 517

uncomp resp alk

Cx: resp center stim , iatrogenic

Rx: treat cause

Front 518

ABG icu pulm

nml ph
low pa CO2
low BE and bicarb

Back 518

comp resp alk

Cx: resp center stim , iatrogenic

Rx: treat cause

Front 519

ABG icu pulmarb

high ph
high HCO3
nml paCO2

Back 519

uncomp met alk

Cause : hypokalemia , NG suction / vomit, contraction alkalosis, admin bicarb, steroid therapy

Rx : treat caues, volume, diamox, NH4CL, arginine monohydochloride, HCL

Front 520

nml ph
high HCO3
high paCO2

Back 520

comp met alk

Cause : hypokalemia , NG suction / vomit, contraction alkalosis, admin bicarb, steroid therapy

Rx : treat caues, volume, diamox, NH4CL, arginine monohydochloride, HCL

Front 521

ABG pulm ICU

tidal volumes to use

Back 521

post op 8-12 ml/kg ideal BWt
restrictive lung dz 4 - 8 ml/kg
(ARDS 6 ml/kg)
obstrctive 8-10 ml/kg

Alveloar vent = tidal vol - dead space

Vent Ex = freq x tidal volume

Main determ tidal vol is ht not weight
Women 45.5 +2.3(ht inches -60)
Men 50+2.3(hr inches-60)

modify so airway press under 30 cm H2O

Front 522

ABG pulm icu

Failure to liberate from vent ?
WHEANS not

Back 522

Wheezes
heart dz
ELectrolyte (alkalosis)
Anx, airway probs, alkalosis
NM dz
sepsis, sedation
Nutri (over and under feeding)
Opiates, obesity
thyroid dz (RARE)

Front 523

ABG pulm icu

weaning readiness daily screen

Back 523

5crit
cough when suctioned
no contin pressors or sed infusion
PaO2/FIO@ over 200
PEEP <= 8 cm H2O
f/Tv under 105 for one minute ***
Ely author

If pass this go to SBT 30 mins

Front 524

ABG pulm icu

SBT is what

Back 524

resp rate > 35 for over 5 mins
spo2 under 90% over 30 secs
20% inc or dec HR for over 5 mins
SBP over 180 or under 90 for 60 consec seconds

Agit/diaph > baseline for over 5 minutes

Front 525

vasc
where is dorsalis pedis ?

Back 525

Proximal base of metatarsals 1 and 2.

the dorsalis pedis, posterior tibial and femoral pulses are not palpable 8.1%, 2.9% and 0.0% of the time respectively (McGee, 1998).

Absense of both DP corr to PAD though.

Front 526

vasc

ABI values nml and with rest pain ?

Back 526

1 nml
0.5 t0 7 claud
under or equal 0.3 ~ ischemic rest pain and gangrene

Front 527

suture class
Wound
classifications ER vs Or

Back 527

ER
aseptic -> clean (hair, sweat) _> contam (hair, gravel)
DIRTY : 4-8 hrs
infected is over 8 hrs
sloghing or granulating

OR

clean
clean-contam : hollow organ entered
infected : est infection going

Front 528

Suture class
size

is a 2-0 bigger or smaller than a 0 ?

Back 528

A 2-0 means 00

#2
#1
0
2-0 Or 00
3-0 or 000

Front 529

Suture class
suture type

these are what kind of sutures ?
silk
ethibond
mersilene
nurolone

Back 529

multi filiment

Front 530

Suture class
suture type

these are what kind of sutures ?

ethilon
prolene
stainless steel

Back 530

monofilament

Front 531

Suture class
suture type

these are what kind of sutures ?

plain gut
chromic gut
monocryl
PDS

Back 531

absorbable
monofilament

plain gut
chromic gut
monocryl ( 1-3 weeks)
PDS ( 3-6 mos)

Front 532

suture class
these are what kind of sutures ?
vicryl rapide
vicyl
panacryl

Back 532

multifilament absorbable

vicryl rapide (2 weeks)
vicyl (3-4 wks)
panacryl (3-6 mos)

Front 533

vasc

common site of leg clot PVD or claud ?

Back 533

Bifurcation COMMON femoral artery : where splits to profundi/deep and superficial

which is In Hunters canal

Front 534

vasc

bypass of plaque in femoral bifurc

- indications ?
- req to work ?

Back 534

Indications :

Req to work : inflow via aorta, ouflow via patent downstream popliteal A, and 'Runoff' or posterior art in back of leg at trifurc (post tib and peroneal) patent

Front 535

vasc

true vs false aneur ?
degf aneur

Back 535

true : dilation over 2x nl diameter ALL 3 layers

false/pseudo : not all 3 layers like hematoma with fibrous scar

Front 536

vasc

pt awakens at night
hurts in foot esp over front of foot

in this story what makes pain better ?

Back 536

REST PAIN

- distal metatarsals or front of foot
- better if hangs foot over edge of bed or walks over as
pain 2/2 ischemia

not like DM neuropathy

Front 537

vasc

calf pain when walk
better when stop and rest

Back 537

claudication
usually better after consist time of rest
chronic

Diff : neurogenic (nerve entrap ,shopping cart)
arthritis, co-arc aorta ?? , popliteal A syndrome ?? , chr compartment syn ?? , neuroma, anemia , DM neuro

Front 538

vasc
young man of 35
soldier
calf pain when walks
better when rests
diminished distal pulses observed with forced plantar- or dorsiflexion

Back 538

The popliteal artery entrapment syndrome
- rather uncommon pathology
-SSX : claudication and chronic leg ischemia
- The popliteal artery may be compressed behind the knee, due to congenital deformity of the muscles or tendon insertions of the popliteal space. This repetitive trauma may result in stenotic artery degeneration, complete artery occlusion or even formation of an aneurysm.
- One Rx : The patient was treated with myotomy of the medial head of the gastrocnemius muscle and concomitant endarterectomy of the popliteal artery. They later reported four more cases and claimed incidence of this pathology in patients younger than 30 years old with claudication was 40%.

Souce Wiki

Front 539

vasc
older guy of 65 with popliteal artery aneurysm
Important tests to do ?

Back 539

Need exam all arteries !
- as over half have aortic/iliac aneu !
- 3/4 have an aneu somewhere
- half bilat pop aneu

Dx pop aneur : PE -> A gram, U/s

Indication for ELECTIVE repair :
equal over 2 cm
INTRALuminal thrombus (atheroscler or rare bact infection etiol pop aneur)
art defomation

Front 540

vasc

Size of aneur indicating sx repair ?

Back 540

thoracic aorta 7 cm
abd aorta 5.5
iliac 4 cm
femoral 2.5
pop 2

Front 541

An 85-year-old woman with newly diagnosed metastatic non–small-cell lung cancer was admitted for pain control. Two days after admission, bluish discoloration of the left great toe was noted. Doppler ultrasonography revealed a left femoropopliteal deep-vein thrombosis. Anticoagulation with heparin was initiated, but there was progressive swelling and cyanosis of the leg (Panels A and B). The patient was referred for prophylactic placement of an inferior vena cava filter. Fluoroscopy revealed that the clot had extended into the left iliac vein and lower inferior vena cava. Filter placement was successful. However, despite continued intravenous anticoagulation and attempts at mechanical thrombectomy, the clinical findings progressed to venous gangrene.

Back 541

NEJM case and image :
Phlegmasia cerulea dolens
aka painful blue leg
is an uncommon severe form of deep venous thrombosis which results from extensive thrombotic occlusion of the major and the collateral veins of an extremity.
Sx:
SUDDEN SEVERE PAIN, swelling, CYANOSIS and EDEMA
SEQ !
- massive pulmonary embolism hig risk even under anticoagulation
- Foot gangrene
- An underlying malignancy in 50% of cases.

This phenomenon was discovered by Jonathan Towne, a vascular surgeon in Milwaukee, who was also the first to report the "white clot syndrome" (Now called HIT= Heparin induced thrombocytopenia). Two of their HIT patients developed Phlegmasia cerulea dolens that went on to become gangrenous

Other RF phlegmagsia :
hypercoagulable syndrome, surgery, trauma, ulcerative colitis, gastroenteritis, heart failure, mitral valve stenosis, vena caval filter insertion, and May-Thurner syndrome (compression of the left iliac vein by the right iliac artery). Pregnancy has often been associated with phlegmasia alba dolens, especially during the third trimester when the uterus is large enough to compress the left common iliac vein against the pelvic rim (ie, milk leg syndrome). Finally, 10% of patients with phlegmasia have no apparent risk factors.
source wiki NEJM

Front 542

An 85-year-old woman with newly diagnosed metastatic non–small-cell lung cancer was admitted for pain control. Two days after admission, bluish discoloration of the left great toe was noted. Doppler ultrasonography revealed a left femoropopliteal deep-vein thrombosis. Anticoagulation with heparin was initiated, but there was progressive swelling and cyanosis of the leg (Panels A and B). The patient was referred for prophylactic placement of an inferior vena cava filter. Fluoroscopy revealed that the clot had extended into the left iliac vein and lower inferior vena cava. Filter placement was successful. However, despite continued intravenous anticoagulation and attempts at mechanical thrombectomy, the clinical findings progressed to venous gangrene.

Back 542

NEJM case and image :
Phlegmasia cerulea dolens
aka painful blue leg

Etiol : SEVERE venous OUTFLOW obst due to thrombosis major and collateral vesels ->
the extensive venous clots lead to arterial impairment -> cyanosis

Main root hypercoag as thrombosis of vessels.

Sx:
SUDDEN SEVERE PAIN, swelling, CYANOSIS and EDEMA
SEQ !
- massive pulmonary embolism hig risk even under anticoagulation
- Foot gangrene
- An underlying malignancy in 50% of cases.

This phenomenon was discovered by Jonathan Towne, a vascular surgeon in Milwaukee, who was also the first to report the "white clot syndrome" (Now called HIT= Heparin induced thrombocytopenia). Two of their HIT patients developed Phlegmasia cerulea dolens that went on to become gangrenous

Other RF phlegmagsia :
hypercoagulable syndrome, surgery, trauma, ulcerative colitis, gastroenteritis, heart failure, mitral valve stenosis, vena caval filter insertion, and May-Thurner syndrome (compression of the left iliac vein by the right iliac artery). Pregnancy has often been associated with phlegmasia alba dolens, especially during the third trimester when the uterus is large enough to compress the left common iliac vein against the pelvic rim (ie, milk leg syndrome). Finally, 10% of patients with phlegmasia have no apparent risk factors.
source wiki NEJM

Front 543

vasc

30 yr old male smoker
black finger

Back 543

BUERGER
digit gangrene gets amp

Rx stop smoking
sympethectomy

Sx recall

Front 544

68 yr old

toes hurt swelling
started 4 days ago
PMH: HTN, afib on anti-HTN and warf

PE : sharp demarc at base toes
tender to touch, nml periph pulses legs, ABI nml

Back 544

Also known as "trashfoot," blue toe syndrome is an arterial embolic disorder. Thrombogenic and atherogenic sources for emboli need to be considered in the diagnostic work-up. Transthoracic echocardiogram was performed in this patient and was negative for vegetations or clots. Computed tomography scanning revealed no evidence of abdominal aortic aneurysm or atheromatous plaque.

A thrombogenic etiology initially seemed more likely in this patient, given his known atrial fibrillation, the distal location of the embolic event, and its simultaneous onset in adjacent toes. However, when review of laboratory values confirmed consistently therapeutic anticoagulation and no cardioembolic source was found on transthoracic echocardiogram, attention shifted toward a possible atherogenic source.

He was admitted on abx as w/u pended but stopped.
d/c pain meds.
outpt consult vasc sx to see if need amp but wait it out

Ref AAFP

Cellulitis
Erythema, edema, warmth, pain with or without fever

Cryoglobulinemia
Recurrent palpable purpura on lower extremities with or without arthralgias and renal disease

Warfarin skin necrosis Onset during first week of warfarin use in areas of adipose accumulation

Blue toe syndrome
Acute onset of painful cyanotic discoloration caused by embolism in a vascular distribution pattern

Front 545

vasc
45 year old male
also has ulcer on ankle

Back 545

Cryoglobulinemia may lead to purpuric or gangrenous lesions in the distal extremities, and its incidence is increasing recently because of its association with hepatitis C infection. Skin lesions from cryoglobulinemia typically would be more widespread and be unlikely to affect only two adjacent toes

Type 1 cryoglobulinemia is often associated with lymphoma.
Type 2 cryoglobulinemia is often associated with hepatitis C infection.

Symptoms may include a rash on the lower limbs, arthritis, nerve damage and tissue necrosis of affected areas.

Front 546

vasc
female
takayasu

Back 546

Pictured below is a close–up view of an angiogram of the left vertebral and subclavian arteries in a patient with Takayasu's arteritis. Note the narrowing and irregularities that occur at several sites, and the “corkscrew” configuration of one vessel segment near the junction of the two arteries. These changes, caused by inflammation in the blood vessel wall, sometimes cause complete blockage of the artery.

signs of occusive phase (after inflam systemic one)
- pain/claud limbs that occurs during repetitive activities, such as pain in the arm that occurs while using a handsaw
- The symptoms also include dizziness upon standing up, headaches, and visual problems.
- no palp pulses in the neck, elbow, wrist, or lower extremities
- “bruits”
- High blood pressure is common, but blood pressures taken in the arms may be read as falsely low if there is a narrowing of an artery high up in the arm.

Front 547

vasc

arteriogram pitfalls

Back 547

Prestudy : iodine, shellfish allergy, use under 200 cc

Dose-Independ rxns : asthma, laryngo edema, sasm, CV collapse

post-agram expanding hematoma : would be pulsitile, direct pressure 30 min then explore wound

vasc spasm : if dec pulses post-proc that are up to 1 hr ; of longer consider art injury or clot

Relative CIL coagulopathy, allergy contrast, shellfish allergy, renal insuff, dehydr, metformin within 48 hrs, CHF, rencent MI, CT dz like ehlers-danos

Orders to do pre-angio:
hold warf 3-4 days
hold metform pre Iodine contrast (ok before gadolin MRA)
correct coagpathy and low plts
clear liqs 8 hrs
hydrate
if entereing dirty area give abx
if h/o asthama etc give rxn prohy

Front 548

vasc

What is DSA ?

Back 548

dig substraction angio

USES contrast
inject dye vein or art
computer floroscope subst bones and soft tissue so only see art tree

Magnetic resonance imaging

see patent distal vessels with minimal flow, eval carotid bifur or Abd aorta.
NO CONTRAST uses gadolin

Front 549

vasc
imaging AAA ?

Back 549

spiral CT

Front 550

vasc
Doppler types

Back 550

doppler pulsed wave : flow velocity and resistance to flow

doppler color : flow direction and turbulence

nml doppler lower extremities : triphasic w. cardiac cycle

with stenosis changes to monophasic pattern of forward flow in systole only

(no more retro backwash with 1st pt diastole and low vel in late diastole)

Front 551

vasc
angiogram of aorta and head
when do you enter R vs left side ?

Back 551

You enter LEFT subclavian as reduces stroke risk. Can get to asc aorta w/o crossing R brachioceph and L comm carotid.

EXCEPTION: Use right if want to study asc aorta, R subclavian, R vertebral or coronary arteries or L is bad.

Note the three vessels taking off from the top of the arch from right to left:

* the brachiocephalic (AKA "innominate") artery
* the left common carotid artery
* the left subclavian artery

Front 552

vasc

name branches of ext carotid in head ?

Back 552

trick : ext carotid has no branches in head, branches in neck

Front 553

vasc radio

what is gadolinium

Back 553

Gd atomic number 64
solid lanthanide, solid mathal at RT

MRI : Because of their paramagnetic properties, solutions of organic gadolinium complexes and gadolinium compounds are used as intravenous MRI contrast agent to enhance images in medical magnetic resonance imaging, Ex, Magnevist. in the 3+ oxidation state, the metal has 7 unpaired f electrons. This causes water around the contrast agent to relax quickly, enhancing the quality of the MRI scan.
As contrast, dangerfor those with renal dz who cannot chelate it and then it become sunbound and . Cz skin rxn.

In X-ray, gadolinium emits green emahnce image.

Gadolinium oxyorthosilicate PET as scit to detect neutrons

Front 554

vasc
doing a balloon

PTC / PTA means what ?

Back 554

percut translum angioplasty

Indications :
SHORT (under 5 cm) NON-occluding lesions with less extensive atherosclerosis

athero, taka, fibromus dyspalsia, failure of graft

When gradient is more than 15-40 in artery or more than 3 in vein

Outcome : 5 yr patency 90% with 2nd inteventions too
radrecell p 274

Front 555

vasc
pt fails PTC what now ?

Back 555

repeat it
stent
percut atheroectomy
sx bypass
laser ablate

Front 556

vasc
stent graft is what ?
ind ?

Back 556

Ind : long seg of stenosis/occ so PTA (balloon less favorable) , ulcerated plaque, failed PTA (resid stenosis over 30/10 or dissection), recur

DEf: dacron/PTFE graft with self expanding metal frame, go via femoral usually for aortic diss/trauma/aneur

Need annual f/u CT or MRI

Front 557

vasc ICU

PICC line
CI

Back 557

CI
1. need line longer than 3-6 mnths
2. severe coaglopathy
3. central venous occ [realtive]
4. thrombophlebitis
5. bactremia

sites:
Arm basiclic, brachial, ceph
antecub fossa,

Comps :
thrombophebitis #1 3-10% check this
sepsis 1-3%

Front 558

vasc

what imaging favored for aneur

- pre-op : angio for branch vessels and pre-op
- follow over time :
- accurate to measure size :
- pt allergy contrast :
- MRI benefits:

Back 558

vasc

- pre-op : angio for branch vessels and pre-op, assesses mesenteric ischemia, HTN, renal dysfx, horsekidney and claud
- u/s to follow over time not for acute
- accurate to measure size : CT, MRI
- pt allergy contrast : MRI
- CT: wall thickness, loc and if leak or rupture
- MRI benefits: more detail about lumen and surface anat and relation to renal artery, acc size mesure, any place, contrast allergy, reproducible

Front 559

vasc

* CT : saccular anur shape, inflamm around it, breakdown of wall
* Loc : aorta > cerebral . mesentary > spleen > renal

Pt recently d/c from hospital

Back 559

MYCOTIC aneur

RF : bact endo, sepsis, IVDA , immcomp

Need sx as expand and rupture

Etiol: weak art wall at bfurc due to bacteria

Front 560

gi bleed
bleeding not seen well with tagged rbc or angio ?

Back 560

gastric varices or esoph VENOUS bleeds seen better with Ct

Front 561

vasc gi
80 yr old man with afib, PVD, smoker.
severe abd pain after eating
weight loss
fear of food

Back 561

mesenteric ischemia
CHRONIC : only shows when all 3 branches occlude, Cz athero

ACUTE :
Cz emboli
thrombi
expanding aneur, hypotension, post-op

Dx: trad gold standard selective mesenteric angio but now using CTA and MRA. 3 vessels celiac and IMA and SMA.

Signs infracted bowel : gas in wall , thick wall, gas in portal vein (late sign), free air w. perf
On Benema : "thumb printing" from gas in wall

Rx: broad abx and agressive fluids. Lap and resect dead bowel. In 24 hrs can do re-look at bowel.

Can try angio for stent, lysis clot if localized dz, papaverdine given if see occlusion on aGram.

thrombectomy is possible but very risky.

UCV sx p59

Front 562

vasc

DVT gold stand dx

Back 562

venogram

acute : has menisucus, and tram tracks as contrast outlines thrombus

chronic : "linear filling defects" as syncytia or collaterals detours vessels

Front 563

vasc
bad aorto illiac dx
unilateral
Pt : elderly 85 year old , bad risk for comps from abd sx, had prior graft and it is infected

Back 563

aXILLo BI femoral graft as better than unilateral

Other extra-anatomic bypass :
best is femoral-femoral 5 yr patency 50-70%

Front 564

vasc
aorto femoral bypass VS aorta iliac bypass
ind ?

Back 564

aorto femoral better patency
90% 5 yr patency, 10yrs is 75%

Others : aorto-iliac endarterecomy if local and distal vessel nml

Front 565

vasc
pt has gangrene, rest pain, ulcers long term

Back 565

prob multisegment
poor life expectency
get venous and art ulcers

NonOp: no smoke, Meds: oentoxifylline and CILOSTAZOL

OP: revasc , fem-pop bypass with synthetic or saph vein and RSVG best patency

Endaterectomy not as useful as limited to sht lesions at adductor cancal or profunda origen

Front 566

vasc
left mild arm claud
arm fatigue

+/-
syncope attacks , vertigo, confusion, blind, dysartria,

PE: upper arm BP discrepency
bruit above clavicle

Back 566

subclavian steal
Dx w/ angio flow reversal in vertebral A.

When move ipsi arm (usually left) increased demand causes retro flow from vertebral Art "stealing" from vertebrobasilar circ.

PAtho : dec flow post cerebral A when blood goes retro to vert A to SCA

When OR:
incompac arm claud
hand emboli or to post cerebral circ
symptoms subclav steal
** fix carotid first if have both issues

Note: some pts only have arms sx not carotid.

OR: sx bypass or endovasc stent

Hint 566

(a) TOF sequence with a saturation band above the section demonstrates absence of signal in the left vertebral artery (arrow). (b) TOF sequence with a saturation band below the section demonstrates signal corresponding to retrograde flow in the left vertebral artery (arrow). (c) Coronal maximum intensity projection (MIP) image from contrast-enhanced MR angiographic study demonstrates occlusion of the proximal subclavian artery (arrow), with reconstitution distal to the origin of a patent left vertebral artery.

Front 567

vasc ortho
amp sites and why for ischemia ?

Back 567

BKA : isch up to med malleoli, CI if dead above ankle and likley to fail if no femoral pulse; with pop pulse 95% success w/o 82%

AKA : alderly and non amb, contractures at knee/hip

hip disartic : extensive leg ischem, prox gangrene, poor outcome for PVD

with sepsis use guillitine not flap

Front 568

vasc AAA

Back 568

75% asymto at dx
in pts 1 degree relative known AAA 11% risk so recc u/s screening

RF rupture DIASTOLIC HTN, lr at dx, COPD

Front 569

vasc
Have AAA and want to do repair ,
pre op

Back 569

* no h, nml ECG -> repair
* stable known CAD -> echo/dipy or thall and consider revasc before
* clin severe CAD -> Need Cor Art revasc before AAA repair unless percut
If get a CABG wait 4-6 weeks to fix AAA.

Front 570

vasc
AAA and COPD

Back 570

more risk rupture
try repair retroperitonreal
also bene's of this approach :
less adhesions, no interfere GI or GU, see suprarenal better

Front 571

vasc

AAA repair
pt 85
lots of co-morb

Back 571

try endovasc repair

Front 572

vasc

AAA repair
pt 85
lots of co-morb

Back 572

try endovasc repair

Front 573

vasc
AAA rupture presenting signs
A * pt has h/o AAA and unstable
VS
B * pt has no h/o AAA and stable

Back 573

A * GO to OR, no anesth until scapel in hand as anesth -> hypotension

B * CT then if needed OR

Comps of repair :
If reach hx alive mort 50%
renal failure 75%
isch colitis 5% bloody diarr, high wbc, perioitits
spinal cord ischemia

Front 574

vasc
DM vasc dz features

Back 574

lower down on leg (spares aortoiliac) hits smalller vessels
younger

Front 575

derm plastic melanoma CA
skin cancer staging

mets and work up ?

Back 575

bresLOW THICKness more accurate

Clark depth of invasion

spread to bone : bone scan
spread to liver : do u/s and CT nodular solid masses

Front 576

derm plastic CA

pre skkinv CA conditions

Back 576

2/3 melanoma de nov0
1/3 from pre malig conditions

Actinic keratosis -> sqaum cell

nevi super spreading

a marker of inc risk
congen nevi
dysplastic nevi

Front 577

derm plastic CA
ABCDE diameter that is bad
invasion level that needs prophy lymphadectomy ?

Back 577

over 6 cm ABCDE

under 0.75 mm invasion do not need prophy removal of LN. Can use sent node mapping.

Front 578

derm anal

obese woman , lots of cystic acne
job where sweats alot

1st stage "cold" lump in groin,rounded and hard, painful, fever, induration. Skin near it shiny and swollen

2nd stage "mature" : liquid green pus tracts open at sides of lump draining as multiple fistula tracts

Back 578

suppurative hidradenitis
SItes in males perianal, female areaola, axilla in females #1

cold stage : abx and compresses
warm : sx I&D

if chr and scarring can need sx wide excision of apocrine tissue

Front 579

abd liver

scan shows periph nodular enhancement

Back 579

FNH

Front 580

anal
chr anal fissures
treatment

Back 580

Sx :
hypertrophic papilla
anal ulcers , sentinal pile

Do sigscope for crohns

Rx: Lat internal sphincterotomy
biopsy ulcers for cancer

Front 581

anal
anal fistula

Back 581

sx : anal itching , d/c on underwear
Use Goodsalls rule to tell if form ant or post crypt

usually from anorectal abscess

W/U : Recto sig scope for term colon and rectum and usually bar enema

Can try fistulogram to define tract if needed

Nearly always need sx fistulectomy to unroof tract leaving in seton (piece of material) to cz fibrosis on purpose

CI sx are HIV and IBS

comps are injury to puborectalis czing incont

Front 582

colon CA
old man
alternate D and const
wt loss
dec stool caliber
occ red blood in stool

What side of colon ?

Back 582

More like in left colon :
rectum or sigmoid
apple core as spread circum so cz obstructive symptoms

Front 583

gi CA esoph

Pt : smoking man 75 yr Af Amer
Sx hard swallow, losing wt
Postive LN supra-clav on left (Virchows)
anemia,

Back 583

esoph CA
usually squamous which is in upper 2/3
spreads locally to mediastim easy, no serosa
Dx: endo with biopsies multiple times as lots false negs

Rx: If can be cured try Pre-op chemo and rad -> sx.
Otherwise try pall radio or chemo

VS adeno in lower 1/3 related Barretts

Front 584

abd biliary acute abd

pres of gallstone ileus

Back 584

elderly lady
h/o of 3 years of stomach upset / heart burn
presents obstipation / bowel obstruction
BUT no h/o sx, no hernias , no periotontis , nml liver tests

Radio : dilated jej loops and "FILLING DEFECT" which is where stone is so contrast can't fill it

Rx rapid lap sx and enterotomy

pics ucv p43

Front 585

gi
upper gi bleeds
endo shows bleeding peptic ulcers
Rx ?

Back 585

If bleeding active or see vessels at ulcer base : under endoscope use epi, polidocanol , cautery, laser sx.
Use IV PPI to reduce risk of re-bleeding.

Most common bleeders are duod ulcers, 40% :
vagotomy and pyloroplasty

For severe gastric ulcers occ gastrectomy

Front 586

gi
upper gi bleeds
endo shows hemmorg gastritis
rx ?

Back 586

ice lavage
and angiographic vasopressin

Front 587

abd gi obst
how does obst lead to perf ?

Back 587

* pressure builds up stream of block as air and fluid accum
* then pressure in lumen exceeds post-capillary venule pressure impairing blood flow
* bowel necrosis and ischemia

Front 588

abd gi
abd tympanic distended and tender
no ridgid or rebound tenderness
Bsounds high pitched and increased

Back 588

bowel obst
On KUB : string of beads of step ladder as air fluid levels above obst

Front 589

abd gi

causes bowel obst
which bowels ?

Back 589

adhesions, hernia, cancer
infants : hernia, intuss

volvulus : cecum or sig colon cz obs with less vomitingand of lg bowel ot sm bowel

75% is small bowel

Rx NPO, fluids, NG aspir and decomp, fix lyte and acid/base imbalence
Then lap and fix obst

Front 590

gi panc
what lies behind neck of panc ?

Back 590

SMV

Front 591

gi panc
panc - itis effect on gut ?
signs on films ?

Back 591

adynamic ileus
dehyd and shock
fluid shifts

AXR: sentinel loop** , colon cutoff

** sentinal loop most common sign on Abd xray. It is area of lg GI near area of inflammation so in panc it is jej and in appy can be RLQ.
u/s : phelgmon and panc necrosis

Front 592

gi panc abd
ranson admit

Back 592

GA LAW
georgia's law
glu over 200
age over 55
LDH over 350
AST over 250
WBC over 16,000

** not amylase or lipase

Front 593

gi panc abd
ranson less than 48 hrs

Back 593

C HObbs like calvin and hobbs
ca under 8
Hct drop 10%
O2 under 60
base deficit over 4
bun over 5 increase
seq over 6 L

Front 594

gi panc abd
* cause of panc and Ca
* % pts chr panc get panc ca

Back 594

high Ca -> panc so hyper PTH
2% get CA

Front 595

gi panc
treatment for chr panc when duct large/dilated and looks like chain of lakes

Back 595

Fig. 2A —Puestow procedure = lateral / longitud pancreatico-jejuno-ostomy
Diagram of anatomy after modified Puestow procedure. The pancreas is filleted to expose main duct from neck to tail, and ductal calculi are removed. Roux loop of jejunum is anastomosed to "capsule" of pancreas with direct drainage of main and secondary pancreatic ducts into lumen of jejunum over 8-10 cm segment. This procedure is best performed if main pancreatic duct is significantly (>6 mm) dilated.

Front 596

gi panc
to drain panc

Back 596

Duval :
partial drainage of panc to help pain

distal/caudal amp of panc which is a near total panc-ectomy
Developed on the basis of presumption that a single stricture of duct of Wirsung near the ampulla was responsible for the obstructive pathology and terminal drainage would treat the condition. It consists of a distal pancreatectomy with splenectomy and retrograde drainage of the main duct into a defunctioned jejunal loop (Fig. 1).

Front 597

gi panc
frey's

Back 597

for chr panc
* Ind : chr panc with comps liek cysts or still pain after puestow / lateral panc jej.
* CI in cancer as leaves behind panc head but does a core resection of head
* also saves duodenum

Front 598

gi panc
pt with acute panc but pain still there after ? 2 weeks
mild fever
wt loss
tender epigastrium and ileus

Back 598

Suspect panc pseudocyst
W/u amyylase/lip ,bili, CBC

See high SBS

US : fluid fillled mass and CT will show mult cysts

ERCP to tell if common or non-commun (connect to panc duct or not)

MUST biopsy cyst wall to rule out cystadenoCANCER (adenoma or carcinoma)

Comps include bleed into cyst

Rx wait 6 weeks to resolve, half do, before drain for walls to get thick to hold sutures

Drain : infeccted ones (percut drainage and IV abx) , over 5 cm, caldify wall or thick wall

Front 599

gi panc
cyst not sticking to stom or duod
(in which you take out part of that)

Back 599

roux en Y cysto-jejunoostomy and drain into roux limb jej

Front 600

gi ulcer
duod

males 35, burninf pain empty stomach
H pylori ?
ESt Dx ?
Ca ?
Who ?
r/o ?

Back 600

H pylori duod 70-90% vs stomach only 50-70

Loc : 1-2 cm from distal pylorus

Est Dx : endoscopy with antral biopsy 90% and does beyond duod, CLO test, serology, VS upper GI series only sees duod and 70-80% accurate

CA : rarely

Who ?
If multiple r/o Zoll-Ellison

Front 601

gi ulcer
med mgt and when do sx

Back 601

6-8 weeks med mgt :
PPI
cytprotective agents
treat h pylori : lansoprozole, amoxi, clarithro

Try sx if not better after 8 to 12 weeks

OR
bleeding that won't stop and trans over 6 units, usually with post ulcers and into gastduod ulcers

OR perf, more with anter and acute pain and free air

OR gastric outlet obst more duodo r near bulb

Front 602

trauma airway
emergent airway page
a trach falls out
what to do ?

Back 602

rookie move is to shove new trach in old hole, often get in wrong space.

FIRST : plain old endo tracheal intubation

Second : can't do ETT (airway cancer or Max-fac trauma that was cause for trach) use NG/cook/eschmarr into trach hole.
Then use this a guide to feed in new trach.

Front 603

Gi panc
tests for steattorhea ?

Back 603

fecal fat
fecal lactase

Front 604

gi panc
role of octreotide ?
AE ?

Back 604

convert high output fistula to low output fistula.

Will not close hole.
SE include cut off blood to spleen.

Front 605

CA syndromes
lynch ?

Back 605

lynch
hered non polyposisi coli
auto dom
CA stomach

DREbyrly age 40 + FOBS

Front 606

CA Gi stomach
RF ?

Back 606

Prior gastric sx (reflux of bile)
including partial gastrectomy
atrophic gastitis
pern anemia
h pylori

Front 607

Gi CA stomach
spread ?

Back 607

* drop mets to pelvis like to shelf above rectum (note : note drop mets as pieces to lumen)
* direct * lymph * hemat

So met w/u :
* CT abd + pelvis
* CXR chest and if + do CT chest
NO BONE scan and NO brain scan

Top distant mets are liver and lung

Source : Mont Reid Prof hr ITSessions

Front 608

chest thoracic lung
mediastinoscopy

Back 608

mainstay to eval cervical LN
Ind : stage lung CA or dx cause of hilar LN
Better than VATS
Have to sample nodes at 3 stations, ipsi and contra lateral paratracheal nodes levels 2,3,4 and subcarinal 7
Can access nodes AorPulm window.
AE: risk 1-2% bleed into chest req opening chest
Incision 1 finger above sternal notch

Front 609

Gi ulcer

define peptic ulcer disease

Back 609

includes ulcers in stomach and duod

Front 610

gi ulcer
what cells make acid ? loc ?
stimulus ?

Back 610

Parietal cells make acid and intrinsic factor
Body and fundus (NOT antrum even though sometimes remove this in sx)
+ gastrin from antrum via blood
+ Ach (vagus)
+ histamine H2 cephalic phase

Stim for gastrin ?
stretch
antrum stretch aa
gastric phase acid secn

Front 611

vasc
5 days post AFBG
1 loose BM
some red blood

Back 611

* concern for IMA mesenteric ischemia
* Dx sigmoidoscope / proctoscope
If see black spots it is real late and to to OR ASAP.

If this is negative do not need colonscope, it is not mes ischemia as IMA only up to ___ flexure and you see with sig-scope.

Front 612

vasc

10 year post AFBG
hemetemsis

Back 612

aorto enteric fistula

Front 613

derm CA
cancer
bulging red / black
local spots recur after excise

Back 613

merckel cel carcinoma
neuroendocrine tumor

do excision, LN excision
rad/chemo

f/u LN exams
has 50% local recur rate

stage 2 if regional nodes,
stage 3 if N1

Front 614

trauma
deaths are when ?

Back 614

golden hour : head injury, hemm shock ,
min to hours : exsang, PTX
14-21 days : "second hit" MOFS , sepsis

Front 615

peds gi embry

desc why mid gut volvulus using embry terms ?

Back 615

embry

midgut goes out umbil week 6
returns week 10 whilst spinning COUNTER clockwise 270 degrees SMA.

Abn rotation causes Ladds bands fixing at 2ND part DUOD and all of midgut hangs on SMA -> obst and vomit about day of life 2.

VERSUS
midgut volvulus when impair perfusion and SMA -> atresia or gangrene,


Foregut : 90 rotate celiac A
....hepatic divertic and panc buds
mid 270 CClock SMA
....
hind septates IMA




foregut rotates 90 degree

Front 616

peds gi embry

sm int "apple peel" appearence

Back 616

midgut fails to rotate properly as returns to gut,
impairs perfusion SMA -> necrosis/gangrene
-> atresia of sm int
"apple PEEL" appearence
no dorsal mesentary
affected gut spirals around vessel

Front 617

anat step 1
gi

abd divisions blood structures nerves

Back 617

foregut celiac tr , great splanchnic T5-9
...abd esoph, stomach, duod part, liver, GB, panc, spleen

midgut SMA lesser sphlancnic t10-11
....aftermaj duod papilla to 2/3 trans colon

hindgut IMA least sphlannic
... splenic flexure to anus

Front 618

gi cancer CA hemmorroids anat
anus anal canal rectum

nerves and blood to here ?

Back 618

ABOVE pectinate line ?
insensate and adenoCArcinoma
Visceral nerves
IMA : superior rectal A
vein sup rectal -> IM vein -> portal vein


Below ?
ext hemm painful and sqaum cancer
nerve : somatic
blood : inf rectal from internal pudendal A
Vein : inf rectal -> internal pudendal -> int iliac ->IVC

Front 619

peds gi

day 2

- polyhydram
- bile vomit and stomach distension

Back 619

duod atresia

failure to recanulate (unlike sm int atresia which is ischemia from failed midgut rotation and block SMA)

- polyhydram
- bile vomit and stomach distension

Front 620

gi
patient with ascites
esophageal varices
never drank alcohol
splenomegaly ?

UNrelated : hemm that alcoholics get, painful or not ?

Back 620

slpenic A clog ->
gastric vein varies only which are esophageal ones and in lower esophagus and drain to azygus

alcoholic hemm not painful as get internal ones, as sup rectal drains to portal and painless

Front 621

gi stom
where is antrum
body
fundus

Back 621

Front 622

gi
CCK
stimulus ?
inhibition ?
action ?

Back 622

made by : I cells duod and juj
Stim : Fatty acids and monoglyc , small pepetides, aa

and decreased by secretin and stomach ph under 1.5

ACtion: + GB contract, relax sph Oddi, + panc enz secn, i nhibit stom empting

Front 623

gi
secretin
source ?
stimulus ?
action ?

Back 623

source ? S cells duod
stimulus ? FAtty aids in duod, low ph in duod

action ? inc panc bicarb secn, inc bile production, dec stomach acid secn
action ?

Front 624

gi
K and colon ?
iron and duod ?

Back 624

K actively secretied by colon if excess K diet and stim by aldosterone

free heme iron absorbed by duod

Front 625

gi esoph
what is
esoph web
vs
schatzi ring

Back 625

a web is above arch and a muscosal fold in upper esoph and related to sq cancer esoph and post cricoid

VS
schatzi ring
ring musoca at squamocolumnar junction below aortic arch

Front 626

gi stom
2 kinds gastritis
A and B ?

Back 626

gastritis A Fundal
autoimmune reltd pern anemia, achlorhydria, and no Ifactor
90% antibodies par cells and 60% to IF


gastritis B due to H pylori , a "reactive like gastritis"
and most common and related to metaplasia

Front 627

gi stom esoph
anor
wt loss
anemia epigastric pain
left supraclav LN enlarged

Back 627

stomach Carcinoma CA
Sites: antrum and pylorus in 60%
RF hypochlor
nitromasmine diet
Histo : signet ring cells sign gastric carcinoma

Front 628

gi stom ulcer
with head trama
burns ?
become CA ?

Back 628

head cushing
burn curling

rare stomach ulcers -> CA
no duod ones

Front 629

gi CA
lymohoma found
what type usualy ?

Back 629

non hodkins lymphoma large cell diffuse
If immunosp could be primary lymph of sm int

MALToma more slow prog related to h pylori and may regress with abx

Front 630

tropical sprue

Back 630

related licing tropics , vietna, P rico
like celiac but not better with no gluten and ALL of sm bowel
relate dto toxogenic e coli

Front 631

gi
man
malabsorb
LN adeno
joint pain

Back 631

whipple dz
Rare PAS+ bug bacilla trophery whippelli
macros in lamnia propia

Front 632

gi bleed
loc most bleeds angiodysplasia

Back 632

lg bowel
esp
cecum

Front 633

gi CA
peutz
what type polyps they get ?

Back 633

harartoma so not premalignant and in all of GI tract

Front 634

gi ca

dental abn
tumor in jaw with soft tissue and bone in it
as teen colon polyps

Back 634

gardner syndrome

colon polyps and
desmoid tumors : have soft tissue and bone and often in mandible

risk colon CA 100%

Front 635

gi liver
portal HTN

ascites with
high ptn
VS
low ptn

Back 635

portal HTN
ascites with
high ptn / exudate :
Budd chiari (pancreatitis)

low ptn transudate
cirrhosis

Front 636

ascites gi liver

high ptn
exudate

Back 636

peritonitis or CA in peritoneum
portal HTN and panc or Budd Chairi
hypothyroid
lymph obst

Front 637

ascites gi liver

low ptn transudate

Back 637

cirrhosis
....hypo ptn emia

nephrotic syndrome
.....hypoalbuminemia

CHF
consti pericarditis / R heart failure

Front 638

gi
acute
tachycardia
fever
jaundice
shock ileus
high amylase (lipase high after 3 days)
high leukocytes

Back 638

acute hemmoragic pancreatitis

Front 639

gi peds
biliary atresia
extra vs intra hepatic

Back 639

extra hepatic
first weeks of life
jaundice , dark urine, light stool, hepatosplenomegaloy

intrahepatic
sometimes related to alpha1antitryp def
infancy presentation
cholestiatis, itching, growth retardation, high serum lipids
ictrus when bili at 2

Front 640

gi peds
neonatal hepatitis

Back 640

50% idio
30% alpha 1 anti tryp
rest TORCH, viral, metabolic,
extra hep bil atresia

Front 641

gi liver
women of 40
itchy , xanthomas
high alk phos
what is dz ? what specific tests ?

Back 641

prim bil cirrhosis
anti mitco ab in over 90%
high chol

On ERCP : see biliary tree

VS secondary biliary cirr see bile lakes due to stasis
histo path : granulomas destroy bile ducts

Front 642

gi liver

man with diarrhea
pale stool and dark urine

Back 642

pri sclerosing cholangitis
pANCA
ERCP : "beading" as alt structure and dilate and dz in extra and larer intra-hep ducts

Front 643

gi liver
women 20-40 yr old
anorexia
malab , fatigue, abd distension,
dark urine and itch
LFT and bili high

Back 643

high IgG and ANA

AUTOIMMUNR hep
relap and remit course
retd autothyroid and sjorgens
have chr anemia and high ESR

Front 644

gi liver
bad cancer liver related to vinyl chloride ?

Back 644

angiosarcoma

Front 645

peds gi liver CA
child
hepatomegaly
vomit and diarr
wt loss
high AFP

Back 645

hepatoblastoma
maligmant

Front 646

gi liver CA
assoc with hepatocell CA ?

Back 646

ascites
wt loss fever
POLYCYTEMIA
HYPOGLYCEMIA
50-90% HIGH AFP
death from bleed or liver failure.
mets often 1st to lungs via hematos portal and IVC.

Front 647

gi liver
lab signs
fulm metabolic hepatitis

Back 647

hypo glycemia
high amm
low K
low cacemia
acid base abn
coag abn

Front 648

endo thyroid

pecent people pyramidal lobe ?

Back 648

75-80% goes UP from isthmus

Front 649

endo thyroid

percent ppl pyramidal lobe thyroid ?

Back 649

75-80%
it goes UP from middle isthmus bridge

Front 650

endo thyroid

Back 650

2 arteries :
Superior thyroid artery from EXTernal carotid
Inferior thyroid A from subclavian thrycervical trunk
sometimes Ima from aortic arch or innomicate A

Veins (3)
superior thy V -> interal jug
middle thyroid V to in jug
inferior thy vein to brachiocepgalic

Front 651

endo thyroid

hyperthyroidism
A. scan show diffuse uptake ?
B. scan shows multiple nodules hot ?

Back 651

A. graves and TOC radioabltion

B. Toxic multinod goiter and recc surgery (radio less successful and med less less effective)
.... if one nodule nodule or lobectomy
.....multi nodules ..lobetomy or contraleteral subtotal lobectomy

Front 652

endo thyroid
when sx for grave's ?

Back 652

TOC is radioablation
Sx when can't do radioablate
...pregnant
...young

First get patient euthyroid with PTU/methamozol and b blockers
Is an immediate cure VS radio take 2 months

Front 653

endo thyroid

post subtotal thyroidectomy
pt with distoriented fever tachy
vomit and diarr

Back 653

thyroid storm

Best avoided by being euthy w/ drugs pre-op

Rx
fluids
PTU/meth
b blockers
NaI or lugols
hydropcrotisone
cooling blanket
(and with subtotal can get persistant hyperthyroid)

Front 654

endo thyroid
female
unilateral neck pain
thyroglossal duct cyst perhaps or goiter
fever
EUTHYROID
dysphagia

Back 654

thyroiditis
Rx IV abx , sx drainage

RF thyroglossal duct and/or goiter

bugsL come via lymphs, staph, streppyogenes, pnem coccs

Front 655

endo thyroid
female
HYPERTHYROID
post URI
tired, sad, neck pain and fever
unil lat sweling thyroid and over it is red firm tender thyroid

Back 655

subacute deQuervain

get transient hyperthy then hypothyroid

Rx: it is self limited
pain rx with NSAIDS

Front 656

endo thyroid
Pt alz / downs / fam hx thyroid dz

painless enlargement of thyroid
ab present
euthyroid or 20% at diag hypothyroid
Rx ?

Back 656

hashimoto's AI thyroiditis
see cell hyperplasia

Rx thyroid hormone and often goiter regresses

if no regessino of goiter
partial thyroidectomy

Front 657

endo thyroid
reidels fibrosis replaces thyroid and isthmus

Back 657

if airway issue can do
isthmectomy
othewise med tx with steroids

Front 658

endo thyroid
percent thy single masses that care malignant ?
FNA rates false + and - ?

Back 658

15% malignant
false + rate 1%
false - 5%

FNA less reliable if h/o radiation so try OR biopsy

Front 659

endo thyroid
role of u/s ?

Back 659

tells if multiple nodules

If FNA benign can use u/s to follow size and thryglob levels to track over time.

Front 660

endo thyroid

FNA of nodule is " suspicous" what next ?

If "malignant "

Back 660

usually follicular (incl huethle cell)
Do I 123 scan
85% will be cold and those are 10-20% malignant

FNA "malignant"
surgery


5% are hot and 1% malignant

Front 661

endo thyroid

cyst what to do ?
what cysts go to OR ?

Back 661

drain it completely

GO to OR for eval and biopsy if :
over 4 cm or complex
recur after 3 drainage tries

Front 662

endo thyroid
role of uptake scans for nodules ?

Back 662

less use now with FNA

if FNA benign -> watch with u/s and labs

If FNA malig -> OR

Only if FNA suspiscius might you use scan

Front 663

Endo thyroid
After thyroid sx
A pt is hoarse
B pt has airway obst
C deeper and quieter voice ,

Back 663

A unilat recur laryngeal cut
B bilat recur laryn cut
C superior laryn cut

Front 664

Endo thyroid
TRH vs TSH
Synthyroid,

Back 664

A2
Endo thyroid
TRH from hypo
TSH from ANT pit
Synthyoid = thyroixine = T4
T12 is 7 days,

Front 665

Endo thyroid
Nodule Multiple non diagnositic FNA
Low TSH
What test next ? ,

Back 665

A3 I123 scan

Front 666

,Endo thyroid
Nodule
Thyrotoxicosis
Low TSH
What test ?

Back 666

I123 scan

Front 667

Endo thyroid
When sx for multi nod goiter ?

Back 667

cannot rule out CA (1% multi nod are malignant)
Compressive symptoms
Cosmetic

Front 668

Endo thyroid
ho radiation
nodule
neg FNA
what to do ?

Back 668

most remove nodule

Front 669

Endo thyroid
Pt has gardner’s
Had neck irradiation for hodkins
Now had thyroid nodule
What kind of CA are you worried about ? ,

Back 669

Papillary

Front 670

Endo thyroid
How pap thyroid CA spread ?

Back 670

P Papillary means Palpable Lymph nodes
Lymph to cervi nodes, and slowly
LN + not related to prognosis really,

Front 671

Endo thyroid
papaillary thyroud CA
Under 1.5 cm
No ho radioation to neck
Rx ? ,

Back 671

Thyroid lobectomy and isthectomy
Neat total thyroidmectomy
Total thyroidmectomy
Post-op thyroid meds to suppress TSH,

Front 672

Endo thyroid
Thyroid pap CA
Over 1.5 cm
Bilat
+ Cerv node mets,
OR ho neck rad
Rx ?,

Back 672

Total thyroidectomy
Post-op thyroid meds to suppress TSH
(if + lat nodes need mod rad uni neck dissection)
(if + cerv nodes need central neck dissection),

Front 673

Endo thyroid
What is “lateral palpable cervical LN” ? ,

A11 a misnomer, it is pap CA of thyroid

Back 673

Rx with modified uni neck dissection,

Front 674

Endo thyroid
Post op fu pap CA thyroid

Back 674

Use Thy hormone to suppress TSH
Scan with I123 for mets outside thyroid area,

Front 675

endo thyroid
spread of follicular CA ?
what percent of CA ?

Back 675

follicular os 10% thyroid CA

spread hematogenous -> often to bone.

F's
follicular
far away mets : blood and to bone
Female 3:1
FNA ...NOT
favorable

rubbery and encapsulated
50% 10 yr survival

Cannot dx invasiveness by FNA as need to tell if into capsule or vessels.

Front 676

endo thyroid
follicular CA thyroid RX ?

Back 676

thyroidectomy TOTAL
post-op I123 scan

Front 677

what is huerthle cells CA thyroid ?

Back 677

a type of CA from follicle cells
5% total
NO UPTAKE OF iodine

FNA can tell cells but not maignancy

Mets via lymphs
Rx total thyroidectomy

Front 678

endo thyroid
meduLLRY

Back 678

5% TOTAL
M's
medullarly
MEN II
aMyloid makes calcitonin
Median LN dissection if LN involved Modified neck dissection if lateral modes +

does spreads lymoh and hemetog

POOR Iodine upake

Front 679

endo thyroid CA
meduLLRY survival

Back 679

if found from screening fam members w. calcitonin 10 yr survival is 95%

if when CA palpable under 20%

Front 680

endo thyroid CA
medullary rx ?

Back 680

total thyroidectomy
PLUS
median lymph mode dissection
if lat nodes+ then modified neck dissection

Front 681

endo thyroid CA

anaplastic CA

what does it arise from often ?

Back 681

areise from follicular CA
Very poor Iodine uptake
dx FNA
Rx: small tumors total thyoidectomy +/- ext beam xray
lg tumors debulking sx and trach

Front 682

endo thyroid CA

what if comprimise blood to parathyroids during sx ?

Back 682

can move parathroids to autograft into sternocleaido mastoid m or forearm

also post op in all thyroid sx check Ca levels.

Front 683

endo thyroid CA

post -op thyroid sx pat has dyspnea ?

Back 683

hematoma

bilat cut recurrnet laryngeal nerve

Front 684

endo pth
number pts with 3 pth glands ?
5 ?
embryo sup and inf pth glands ?
blood ?

Back 684

10% pts have 3 PTH glands
5% have 5 and often by thynus

sup PTH glands from 4th phar pouch
inf pth gland from 3rd pouch (careful, couner intuituve)

blood ? inferior thyroid Art and 80% ppl have this Art only give blood to all 4 pth glands

Front 685

endo pth
role of pth

Back 685

INCREASE serum Ca
..bone breakdown, gi absorb, resorb renal,
decrease serum phosphate
....renal exrete

Front 686

endo pth
how image pth glands

Back 686

sestamibi scan

Front 687

endo adrenal
after a bilat adrenal ectomy in 60's
pt now has pigemented skin
maybe visual disturbances
amenorhea

Back 687

Nelsons syndrome
due to excess ACTH and MSH

Can treat with pituatary ablation surgically trans-sphenoidal

Front 688

gi rectal
what is a stercoral ulcer ?

Back 688

fecal impaction leading to perf and ulcer -> sepsis and req emergent laparoromy

Front 689

gi
stomach
treatment of post vagotomy diarrhea

Back 689

cholestyrameine as it is partly due to unabsorbed bile salts

if that fails consider sx reversal part of sm int to prolong transit time and inc absorbtive capacity

Front 690

gi rectal
incontinence work up

Back 690

anal manometry : pressures of sph

endoanal u/s : more acureate vs manometry, detects occultlesions

pelvis floor EM<G to tell anat vs neurogenic probs like childbirth pudendal N injury

and to predit likley success of sx repair a pudendeal nerve terminal motpr latency

Front 691

gi CA
sequence genes colorectal CA

Back 691

APC loss or mutation
loss DNA methylation
Ras mutation
loss DCC Gene
loss of p53

Front 692

gi syndrome
pt gi polyps
alopecia
nail dystrophy
hyperpigmentation

Back 692

cronkite-canada
minimal malig potential

Front 693

gi CA syndromes
peutz jeugers get what cancers

Back 693

panc
breast
lung
ovasry
uterus

Front 694

CA gi syndrome
lynch I vs II

Back 694

Lynch I
mult polyps, R side colon cancer

Lynch II
same as I but also extra-colion CA like uterus, ovary, cervex, breast

Front 695

desc blood to spleen

Back 695

vein: splenic vein joins SMA to portal vein

Art: splenic off celiac tr
some by sht gastric which are off and L gastroepiploic

Front 696

spleen
splenolegaly vs hypersplenism

Back 696

splenomegaly = physically big spleen, see in 2% nml people as when can feel it. Nml function

hypersplenism = one kind of splenomegaly where big AND increased FUNCTION
#1 cause = portal HTN ;
- primary, rare, females, idio, DOExcl
- seconday: hemolysis, ITP, TTP, neoplasm/MDS, inflamm states,
seconday includes congestive splenomegaly : portal HTN, cirrhosis (60% get splenomegaly, 15% hypersplenism) , splenic vein thrombosis, CHF, infection,

Front 697

spleen
young woman
bleeding
mennorrhagia
easy bruise mucosal bleeding
petechia

Back 697

ITP
Rx 1st steroids , inc PLTs in 3-7 days.
Sx when steroids fails (yrs) and TCP recurs.

Front 698

spleen
arthritis
eye issues
smear Howell jowell bodies
pappelheimers (iron)
acanthrocytes
heinz bodies

Dz?
Rx?

Back 698

hyposplenism
sickle
IBS
collagen vasc
AI dxz

Rx? prophy encapsuled bugs

Note: this is a FUNCTIONAL hyposplenism and spleen can be physically lg, sm, normal.

Front 699

25 year old male
cyclic fever
wt loss
sup vena cava syndrome

Back 699

hodkins lymphoma
Reed sternberg cells

stage: clinical vs laparoscopy
spleen can be primary site.
starts localized and regional.
lap staging : liver, splenectomy(2), LN samples (3), iliac crest (4)


For 2 consider radiation alone otherwise chemorad.

Front 700

spleen
systemic s/s at dx
men
SVC

Back 700

non hodkins
chemo
limited role of splenectomy

Front 701

spleen
man over 50
abd full due to big spleen
brusing as low plts
infections low wbc
wt loss, weak,
LITTLE LYMPHADENOPATHY

Back 701

HAIRY CELL

LITTLE LYMPHADENOPATHY unlike CLL

cells in red pulp of spleen.

Def Dx by BM bx

RX: alpha interferon w/ 80% response rate

splenectomy for symptoms from abd fulness from it, canimprove cell counts and dec risk of hemmorage

Front 702

spleen
man
60's
big LN
big spleen due to AI hemo anemia
hepatomegaly
smear: leukocytosis immature leuks

Back 702

CLL
chemorad
remove spleen : just helps symptoms not prolong life

Front 703

BIG spleen common finding
BM has ++ cells
smear myelos and fibros
alk phos low in bad cells

Back 703

CML
phili chromo
Rx chemo and for some w./ symptoms can remove spleen which helps symptoms but not lifespan

Front 704

spleen
tumors

Back 704

most common non lymphoid
hemangioma : risk rupture, plt seq, dx and rx splectomy

haram,toma : incidental, can be cysticsolid, clin insig, need splenectomy to dx

Lymphanioma as with liver angioma and those in body , removing spleen dx and rx

Front 705

spleen

mucosal bleeding
guicac pos stool
TTP on CBC

Back 705

ITP DOExcl
rx steroids, or IvIG if severe
can remove spleen to prevent recur

Front 706

spleen
one unit plts inc plt count how much
?

Back 706

10,000

Front 707

etiology TTP

Back 707

hemo anemia from abn VWF multimers in vesssels

RF: infection like HIV , OI57, CA, AI, pregnancy,

Front 708

scenario : HIV man 27, fever, changing mental status, hematuria or rising BUN
CBC : pancytopenia or low rbc

Back 708

TTP
hemo anemia from abn VWF multimers in vesssels

Front 709

spleen
rx TTP

Back 709

never give plts
plasma pheresis daily untli plt count nml

or give FFP if no pheresis possible

can give RBCS if symp from anemia

treat cranail bleeds

Front 710

spleen
Pt [ infection, hematoma, IVDA)
fever
chills
LUQ tender and guarding
+/- palp spleen

U/S lg spllen with areas of lucency

CT: area of lower attenuation

Back 710

Rx
usually splenectomy
or if lg solitary juztracapsular abscess try percut drainage

Front 711

spleen
function ?

Back 711

stores 33% plts
filters RBCS
makes opsonins : tuftsins, properdin
makes IgM
site phagocytosis

** does NOT stores RBCs in humans

Front 712

spleen
pt had motorcycle acc
2 weeks later presents shock and abd pain

s/sx
hemoperitoneum
Kehrs sign
LUQ pain

Test to Diag ?

Back 712

delayed splenic rupture
from subcap hematoma or psueudo anuer

Diag splenic rupture :
stable pts -> CT
unstable --> u/s or DPL

Front 713

spleen
treat splenic rupture ?

Back 713

Non OR :
stable pt
isolated spleen injury
no hilar involvement
not complete rupture

UNSTABLE pt
DPL/FAST and then laporatomy with removal of sleeen ( splenorrhaphy) or splenectomy.

Select pts embolization.

Front 714

Eponym sign for what ?
1. Localisation of trauma in the upper abdomen.
2. Demonstration of internal bleeding.
3. Spread, localized and fixated dullness in the left flank also when changing position.

Back 714

Ballance's sign

Associated persons:
Sir Charles Alfred Ballance

Description:

A trias of clinical signs of rupture of the spleen in abdominal trauma:

1. Localisation of trauma in the upper abdomen.
2. Demonstration of internal bleeding.
3. *** LUQ DULLNESS TO PERCUSSION Spread, localized and fixated dullness in the left flank also when changing position.

Front 715

spleen

what is splennoraphy ?

Back 715

means a spleen salvage op:

wrap with vicrl mesh
topical hemostasis agents
partial splectomy

Front 716

post splen comps

Back 716

thromboCYTOSIS

subpherenic abscess
atelectaisis
pancreattitis
gastric dilation
OPPS :
--adults under 1%
--vs kids 1-2% with 50% mortality

Front 717

spleen
post splennectomy pts
presents
fever lethargy cold and URI

Back 717

Can be OPPS
and mortality of 50%
#1 bug S pna
Neis men, H flu


PRophy: IMMEDIATE PENNY for all minor infections and illness and medical carefor major illness and fever

Front 718

spleen
when vax pts for splenectomy

Back 718

preop best
or 2 weeks post op

Front 719

spleen
changes in labs postp spleeen ectomy

Back 719

WBC inc 50% over BL
MARKED THROMBOCYTOSIS
RBC smear abn : pappen, Howell, Heniz

Front 720

ACLS
After shock ?
If pulse ?

Back 720

CPR after shock
If pulse -> check BP

Front 721

ACLS
No pulse / cardiac arrest
(Even if see ECG tracing)

Back 721

CPR until AED

Front 722

ACLS
asystole

Back 722

ECG gain/senstivity up, leads ok
epi, no shock
atropine 1 mg leapfrog with epi

Front 723

ACLS
V fib and V tach

Back 723

shock shock epi
amiodarone 300 mg then 150 mg

OR

lidocaine 1 mg/kg then 1/2 @ 5-10 minute interals

Front 724

ACLS
PEA

Back 724

epi , no shock

atropine 1 mg if brady rhythm

Front 725

ob neonate
new baby has fingers like this.
likly diag ?

Back 725

Tri 18
Edwards
characteristically clenched overlapping fingers seen in the image are highly specific for trisomy 18 (Edwards syndrome). Microcephaly, microphthalmia, malformed ears, micrognathia or retrognathia, microstomia, and other congenital malformations are also associated with this disorder.