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91 Cards in this Set

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contraindications to surgery
absolute: Diabetic Coma, DKA
poor nutrition: albumin <3, transferrin <200, weight loss>20%
severe liver failure: bili>2, PT>16, ammonia>150, or encephalopathy
smoker: stop smoking 8wks prior to surgery
Goldman's Index
greatest risks for surgery
1) CHF, then MI w/i 6mo, arrythmia, age>70, emergent surgery, AS
meds to stop:
aspirin, NSAIDs, vit E (2wks)
warfarin (5d) - drop INR to < 1.5 (can use vitK)
take 1/2 morning dose of insulin, if diabetic

CKD on dialysis: dialysis 24 hrs pre-op
BUN>100
increased risk of post op bleeding 2/2 uremic platelet dysfunction -> nl platelets but prolonged bleeding time
vent settings: assist control, pressure support, CPAP, PEEP
assist control: set TV and rate but if pt takes a breath, vent gives the volume

pressure support: patient rules rate but a boost of pressure is given (8-20) -> important for weaning

CPAP: pt must breathe on own but + pressure given all the time

PEEP: pressure given at the end of cycle to keep alveoli open (5-20)
non-gap metabolic acidosis
diarrhea, diuretic, RTA
metabolic alkalosis - > next step?
check urine Cl

if <20, vomiting/NG, antacids, diuretics
if >20, Conn's, bartter's, gittelmans
sodium abnormalities
signs of Ca and K abnormalities
decreased Ca: numbness, AMS, prolonged QT interval, Chovstek's sign
increased Ca: stones, bones, psychiatric moans

decreased K: paralysis, ileus, U waves (give K, max 40meq/hr)
increased K: seizures, cardiac instability, prolonged QRS and PR (CBBIGKDDrop)
Fluids and Nutrition
maintenance IVFs -> D5 1/2NS + 20KCl
up to 10kg -> 100ml/kg/d
next 10kg -> 50ml/kg/d
all above 20 -> 20ml/kg/d

enteral feeds are best: keeps gut mucosa intact and prevents bacterial translocation

TPN: indicated if gut can't absorb nutrients 2/2 physical or functional loss
- risks = acalculus cholecystitis, hyperglycemia, liver dysfunction, zinc deficiency, other lyte problems
pt coming out of burning house with confusion, headache, and cherry red skin
check carboxyhemoglobin (pulse ox is worthless)
treat with 100% O2; hyperbaric if CO-Hb is highly elevated
Clotting and bleeding
burn w/u and tx
electrical burn - 1st step?
EKG, if abnl or +LOC, 48hrs of telemetry
burn -> what to check?
urine dipstick, if positive, but microscopic exam negative for RBC -> myoglobinuria, ATN

K+ (cells break)

compartment syndrome -> criteria = 5Ps or compartment pressure > 30mmHg ---> may require fasciotomy at bedside
shock: type, causes, PE, swan ganz, tx
neck trauma according to zones
tx for extraperitoneal extravasation
best rest + foley
Which ortho trauma fractures go directly to the OR?
depressed skull fx
severely displaced or angulated fx
any open fx (sticking out bone needs cleaning w/in 6hrs)
femoral neck or intertrochanteric fx
common fx

shoulder pain s/p seizure or electrical shock
arm outwardly rotated & numbness over deltoid
old lady FOOSH, distal radius displaced
young person FOOSH, anatomic snuff box tender
"I swear I punched a wall"
clavicle most commonly broken where?
shoulder pain s/p seizure or electrical shock: posterior shoulder dislocation

arm outwardly rotated & numbness over deltoid: anterior shoulder dislocation

old lady FOOSH, distal radius displaced: colle's fracture

young person FOOSH, anato...
shoulder pain s/p seizure or electrical shock: posterior shoulder dislocation

arm outwardly rotated & numbness over deltoid: anterior shoulder dislocation

old lady FOOSH, distal radius displaced: colle's fracture

young person FOOSH, anatomic snuff box tender: scaphoid fx

"I swear I punched a wall": metacarpal neck fx "boxer's fx". may need K wire

clavicle most commonly broken where? between middle and distal 1/3s; needs figure of 8 device
ortho tx

posterior shoulder dislocation
anterior shoulder dislocation
colle's fx
scaphoid fx
metacarpal neck fx "boxer's fx" may need k wire
shoulder pain s/p seizure or electrical shock
arm outwardly rotated & numbness over deltoid
old lady FOOSH, distal radius displaced
young person FOOSH, anatomic snuff box tender
"I swear I punched a wall"
clavicle most commonly broken where?
shoulder pain s/p seizure or electrical shock
arm outwardly rotated & numbness over deltoid
old lady FOOSH, distal radius displaced
young person FOOSH, anatomic snuff box tender
"I swear I punched a wall"
clavicle most commonly broken where?
pressure ulcers caused by what?
impaired blood flow -> ischemia

don't cx -> bheck CBC and blood cx
can do tissue bx to r/o marjolin's ulcer (ulcerated squamous cell CA)
best prevention is turning q2hrs
pleural effusions: differentiating between transudative and exudative
lung abscess
usually 2/2 aspiration (drunk, elderly, enteral feesd)
- most often in posterior upper or superior lower lobes
- tx initially w/ antibx -> IV PCN or clinda
- indications for surgery = abx fail, abscess >6cm, or if empyema present
characteristics of benign nodules
popcorn calcifications -> hamartoma (most common)
concentric calcifications -> old granuloma
age<40, well circumscribed, <3cm

CXR and CT q2mo to look for growth
characteristics of malignant nodules
risk factors (smoker, old), eccentric calcifications, >3cm

remove nodule (with bronch if central, open lung resection if peripheral)
ARDS dx
bilateral pulmonary infiltrates on CXR
PCWP < 18 (excludes cardiac source)
P/F < 200 (P/F < 300 indicates acute lung injury)

tx: mechanical ventilation with PEEP
more lung findings
murmur buzzwords
murmur buzzwords
dysphagia with hot/cold liquids and CP feeling like an MI + no regurg
esophageal spasm
gastric varices: how to manage hypovolemic shock vs stable
stable: treat with nonselective beta blocker (propranolol)

hypovolemic shock: endscopic sclerotherapy or banding, balloon tamponade, octreotide/somatostatin
gastric ulcers: w/u and tx
w/u: double contrast barium swallow to identify any punched out ulcers, endoscopy with bx to identify H. pylori, benign vs malignant

surgery if lesion persists after 12wks tx
gastric CA+ different metastases
adeno most common (particularly in Japan)

Krukenberg: ovaries
Sister Mary Joseph: umbilical
Virchow: L supraclavicular
lymphoma
MALT-lymphoma (h. pylori)
blummer's shelf: mets felt on DRE
duodenal ulcers: dx and tx

if ulcer doesn't resolve, then what?
<45yo can do trial of H2 or PPI

dx: blood, stool or breath test for H. pylori, best test is EGD bc can also evaluate CA

H.pylori tx: clarithromycin, amoxicillin, metronidazole, PPI

if ulcer doesn't resolve, think of zollinger ellison -> secretin stimulation test looking for inappropriately elevated gastrin

tx: surgical resection of tumor (if part of MEN1)
pancreatic adenocarcinoma
usually don't have sx until advanced.

if in head of pancreas,
coursevoir's sign -> large, nontender gallbadder, itching, jaundice

trousseu's sign -> migratory thrombophlebitis
Insulinoma: sx + labs
sx (sweat, tremor, hunger, seizures), blood glucose < 45, responds to glucagon administration

labs: increase insulin, c-peptide, and pro-insulin
Glucagonoma: sx?
hyperglycemia, diarrhea, weight loss

characteristic necrolytic migratory erythema
VIPoma
watery diarrhea, hypoK, dehydration, flushing

looks like carcinoid syndrome
octreotide to help sx
Somatostatinoma
commonly malignant, observe steatorrhea, malabsorption from malfunctioning exocrine pancreas
shock liver labs
AST &ALT high s/p hemorrhage, surgery, or sepsis
TIPS
relieves portal HTN but worsens hepatic encephalopathy

tx with lactulose to help rid body of ammonia
hepatocellular carcinoma risks + dx + tx
chronic hep B > hep C. cirrhosis for any reason, plus aflatoxin or carbon tetrachloride

dx with high AFP, CT/MRI

tx: surgically remove solitary mass or use rads/cryoablation for palliation of multiple
women on OCP with hemorrhagic shock
hepatic adenoma -> palpable abd mass or spontaneous rupture

dx with U/S or MRI

tx: d/c OCPs; resect if large or pregnancy is desired
RUQ pain, profuse sweating and rigors, palpable liver
entamoeba histolytica

tx: metronidazole -> don't drain!
patient from mexico with RUQ pain and large liver cysts found on U/S
echinococcus

transmission: hydatic cyst parasite from dog feces
lab findings: eosinophilia, + casoni skin test
tx: albendazole and surgery to remove entire cyst
rupture -> anaphylaxis
vaccine ppx for post-splenectomy pts
S.pneumo, H. flu, and N. meningitidis
postop thrombocytosis post-splenectomy >1million
give aspirin
ITP
consider in isolated thrombocytopenia (bleeding gums, petechiae, nosebleeds)

decreased plt count, increased megakaryocytes in marroww
NO splenomegaly
tx with steroids 1st. if relapse, splenectomy
hereditary spherocytosis
see sx of hemolytic anemia (jaundice, elevated indirect bilirubin, LDH, decreased haptoglobin, elevated retic count) + spherocytes on smear and + osmotic fragility test.

prone to gallstones

tx with splenectomy (accessory spleen too)
# site for carcinoid tumor
appendix

sx: diarrhea, wheezing
happens when mets to liver (1st pass metabolism)
if greater than two cm, at base of appendix, or with positive nodes => hemicolectomy, otherwise just appendectomy
post op ileus
also consider if hypoK (make sure to replete), opiates
see dilated loops of small bowel with air-fluid levels
do surgery for perforation. give lactulose/erythromycin
umbilical hernia
in kids, close spontaneously by age 2; in adults, 2/2 obesity, ascites or pregnancy
smokers have higher risk for what? Crohns or UC
UC!
Crohns and UC tx
Crohn's: azathioprine, 6MP, and methotrexate

UC: ASA, sulfasalzine
erythema nodosum, pyoderma gangrenosum, PSC, migratory polyarthritis
Crohn's: erythema nodosum, migratory polyarthritis
UC: pyoderma gangrenosum, PSC, anklosing spondylitis, uveitis
diverticular dz
false diverticulae (only outpocketings of mucosa)
occur 2/2 low fiber diet in areas of weakness where blood vessels penetrate -> bleed
complications are bleeding, obstruction, diverticulosis

CT is best imaging to evaluate for abscess. no barium enema (bad if perforated)

Tx with NPO, NG suction, IVF, broad spectrum abx, and pain management
do colonoscopy 4-6 weeks later (need bleeding to be over)
surgery indicated if: multiple episodes, age <50?, elective better than emergency (can do primary anastomosis)
UC colonoscopy guidelines
needs colonoscopy 8-10yrs after dx
how to measure recurrence in colon cancer?
CEA
tx colorectal cancer
colon: remove affected segments and chemo if node positive

rectum: upper/middle 1/3 get a LAR (lower anterior resection), lower 1/3 gets an APR -> abdominoperineal resection (remove sphincter, permanent colostomy)
AAA screening
men 65-75 who have smoked should get an abdominal U/S

if <5cm and asymptomatic, monitor growth

surgery indicated if greater than 5cm or growing 4mm/yr
AAA postop complications
#1 cause of death: MI
bloody diarrhea: ischemic colitis
weakness, decreased pain with preserved vibration/proprioception: ASA syndrome

1-2yrs later if have brisk GI bleeding: aortoenteric fistula
chronic mesenteric ischemia
slow progressing stenosis (required stenosis of 2.5 vessels) -> celiac, SMA and IMA

severe midepigastric (MEG) pain after eating, food fear, and weight loss "pain out of proportion to exam"

dx: duplex or angiography

tx: aortomesenteric bypass or transaortic mesenteric endarterectomy
claudication peripheral artery dz
pain in butt, calf, thigh upon exertion
best test: ABI (nl >1)
claudication and ulcers: 0.4-0.8 -> use medical mgmt
limb ischemia -.2-0.4: surgery indicated
gangrene: <0.2 may require amputation
acute arterial occlusion: 5Ps -> no dopplerable pulses
tx: immediate heparin + prepare for surgery
surgery: (embolectomy or bypass) done w/in 6hrs to avoid loss
thrombolytics may be possible if no surgery <2wks, hemorrhagic stroke
complications: compartment syndrome during reperfusion period -> do fasciotomy watch for myoglobinuria
DVT/PE
DVT: tx with heparin, then overlap with warfarin for 5d, then continue warfarin for 3-6mo

PE: if suspected, give heparin first. then w/u with V/Q scan, then spiral CT. pulm angio gold standard

tx with heparin warfarin overlap. use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke. surgical thrombectomy if life threatening. IVC filter if contraindications to chronic coagulation
w/u thyroid nodule
picture
w/u adrenal nodule
picture
hypoparathyroidism labs
decreased calcium, increased phosphate, decreased PTH (phosphate thrashing hormone)
multiple endocrine neoplasias
1: diamond -> pituitary, parathyroid, pancreas
2a: square -> parathyroid, pheo
2b: triangle -> medullary thyroid, pheo
breast cancer: what to do for DCIS, LCIS, infiltrating ductal/lobular CA, paget's, inflammatory
picture
sarcoma?
pic
w/u neck mass:
rule of 7s: 7 days = inflammatory, 7 mo = cancer, 7 yrs = congenital

MC reactive node so first check teeth, tonsils, etc for inflammatory lesion; if persists > 2wks, FNA!

if node if firm, rubbery and B sx present, think lymphoma

if midline: thryoglossal duct cyst, move tongue and mass will move -> remove surgically

if anterior to SCM: brachial cleft cyst

if spongy, diffuse and lateral to SCM, cystic hygroma (think Turners, downs, klinefelters)
oral CA tx
most frequently squamous cell; in smokers and drinkers

tx with XRT or radical dissection of jaw/neck
baby born with respiratory distress, scaphoid abdomen and CXR concerning for diaphragmatic hernia

biggest concern?
tx?
pulmonary hypoplasia

if dx prenatally, plan delivery at place with ECMO. let lungs mature 3-4d, then do surgery
baby born with respiratory distress and excessive drooling
TE-fistula

best diagnostic test: place feeding tube, take CXR, see it coiled in thorax
umbilical hernia a/w what?
congenital hypothyroidism (look for big tongue)

repair not needed unless persists past age 2 or 3
2wk old infant with bilious vomiting with pregnancy c/b polyhydramnios
intestinal atresia or annular pancreas (i guess malrotation/volvulus too?!)

a/w down syndrome (especially duodenal atresia)
3d newborn not passed meconium. DDx?
meconium ileus -> consider CF if +FH, gastrograffin enema is dx and tx

hirschprung's -> DRE -> explosion of poo; bx showing no ganglia is gold standard
5 day old former premie develops bloody diarrhea
necrotizing enterocolitis

XRAY: air in the wall
Tx: NPO, TPN, abx and resection of necrotic bowel
risk factors: premature gut, introduction of feeds, formula
2mo old baby with colicky abd pain and currant jelly stools with sausage shaped mass in RUQ
intussusception

- barium enema is dx and tx
BPH tx
medical: tamsulosin, finasteride
surgical tx: TURP
prostate CA tx
look at bone scan for blastic lesions

tx with surgery, radiation, leuprolide or flutamide
kidney stones guidelines
if stone < 5mm, hydrate and let it pass
if stone >5mm, do shock wave lithotripsy

surgical removal if >2cm
avascular necrosis
kids: leg-calve-perthe's dz in 4-5yo with a painless limp and SCFE in 12-13yo with knee pain or sickle cell pts

adults: steroid use, s/p femur fx
osteosarcoma
seen in distal femur, proximal tibia @metaphysis around the knee

codman's triangle and sunray apperance
ewing's sarcoma
- seen at diaphysis of long bones, night pain, fever and elevated ESR
- lytic bone lesions, onion skinning
- neuroendocrine (small blue) tumor
hyperacute, acute, chronic rejection tx
picture
lidocaine -> why administer with epinephrine?
to prevent systemic absorption -> numb tongue, seizures, hypotension, brady, arrythmias

no epi on the fingers, nose, penis, or toes!
General anesthesia: meperidine, succinylcholine, rocuronium, halothane
meperidine: can lower seizure threshold esp in pts with renal failure

succ: can cause malignant hyperthermia, hyperK (not for burn or crush victim)

rocuronium: sometimes allergic rxn in asthmatics

halothane: can cause malignant hyperthermia, liver toxicity
epidural (local + opioid)
if high block -> blocks heart's SNS nerves and phrenic nerve
spinal-subarachnoid (bupivicaine, etc)
for people who can't be intubated. can't give if increased ICP or hypotensive