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High Yield Surgery Emma Holiday Ramahi PP

Terms in this set (407)

Absolute contraindications to surgery
Diabetic coma
DKA
Poor nutrition contraindications to surgery
Albumin <3
Transferrin <200
Weight loss <20%
Contraindications to surgery due to severe liver failure
Bili >2
PT >16
Ammonia >150
Encephalopathy
Contraindications to the smoker
Stop smoking 8 weeks prior
If a CO2 retainer, go easy on the O2 in the post-op period; can suppress respiratory drive
Goldman's index
Tells you who is at greatest risk for surgery
#1 on Goldman index
CHF
Check EF. If <35% no surgery
#2 on Goldman index
MI w/in 6 months
Check: EKG --> stress test --> cardiac cath --> revasc
Other factors of Goldman's index
Arrhythmia
Old >70
Emergent?
AS, poor medical condition, surgery in chest/abd
Late systolic, crescendo decrescendo murmur that radiates to carotids
Increases with squatting
Decreases with decreased preload
Aortic stenosis
Meds to stop prior to surgery
Aspirin
NSAIDs
Vitamin E (2 weeks)
Warfarin (5 days) - drop INR to <1.5 (can use vit K)
Take half the morning dose of insulin if diabetic
If CKD in dialysis...
Dialyze 24 hours post-op
Why do we check the BUN and Creatinine? What is the worry if BUN >100?
Increased risk of post-op bleeding due to uremic platelet dysfunction
What would you expect on coag panel if BUN>100?
Normal platelets, prolonged bleeding time
Explain Assist control vent
Set TV and rate but if pt takes a breath, vent gives the volume
Explain Pressure support vent
Important for weaning

Pt rules rate but a boost of pressure is given
Explain CPAP vent
Pt must breath on own but + pressure given all the time
Explain PEEP vent
Pressure given at the end of each cycle to keep the alveoli open
*Used in ARDS and CHF
Best test to evaluate management of pt on vent?
ABG
If pt on vent has low PaO2?
Increase FiO2
If pt on vent has high PaO2?
Decrease FiO2
If PaCO2 is low (pH is high) in pt on vent?
Decrease rate or TV
If PaCO2 is high (pH is low) in pt on vent?
Increase rate or TV
Which is more efficient to change? Rate or TV?
TV is more efficient to change
*Remember minute ventilation equation and dead space
If pH <7.4, and HCO2 is high and pCO2 is high?
Respiratory acidosis
If pH <7.4 and HCO2 is low and pCO2 is low?
Metabolic acidosis
After pH, HCO2, and pCO2, check anion gap (Na - [Cl + HCO3]). What is the normal anion gap?
8-12
Causes of Gap acidosis
MUDPILES
Methanol, Uremia, DKA, Paracetamol, Paraldehyde, Isoniazid, Lactic Acidosis, Ethanol, Ethylene glycol, Salicyclates
Causes of non-gap acidosis
HARD ASS
Hyperalimentation, Acetazolamide, RTA, Diarrhea, Diuretic, Addisons, Small bowel Fistula, Spironolactone
RTAs (I<II, IV)
If pH >7.4 and HCO3 is low and pCO2 is low?
Respiratory alkalosis
If pH >7.4 and HCO3 is high and pCO2 is high? What do you check next?
Metabolic alkalosis. Next, check urine [Cl]...
If pH>7.4, HCO3 high, pCO2 high, and urine Cl <20 what could cause this?
Vomiting
NG
Antacids
Diuretics
If pH>7.4, HCO3 high, pCO2 high, and urine Cl >20 what could cause this?
Conn's (1* hyperaldosteronism. Low Renin, high BP, poor vision, headaches)
Bartter's (low K+, alkalosis, hypotension, defect in thick LOH)
Gittlemans (Low K+ low Mag, Decreased excretion of Calcium/hypocalciuria)
Decreased sodium is usually due to ______ water. What do you check?
Gain of water. Check volume status.
Increased volume
Decreased sodium
Causes:
CHF
Nephrotic
Cirrhotic
Increased volume
decreased sodium
Causes:
Diuretics
Vomiting
Free weater
NL volume
Decreased sodium
Causes:
SIADH
Addisons
Hypothyroidism
Treatment for low sodium
Fluid restriction and diuretics
Tx for low sodium and hypovolemic?
Normal saline
When to use 3% saline in low sodium patients?
Symptomatic (seizures)
<110
When replacing with saline, what do you need to worry about?
Central pontine myelinolysis
Increased sodium is due to _____ water
Loss of water
Treatment for high sodium
Replace w/D5W or hypotonic fluid
What would you worry about when replacing sodium
Cerebral edema
Numbness, Chvostek or Troussaeu, prolonged
QT interval
Decreased calcium
Bones, stones, groans, psycho. Shortened QT
interval.
Increased calcium
Paralysis, ileus, ST depression, U waves.
Cause?
Treatment?
Decreased potassium

Tx: give K, max 40mEq/hour
Peaked T waves, prolonged PR and QRS, sine waves.
Cause?
Treatment?
Increased potassium

Tx: give calcium gluconate then insulin + glucose, kayexalate, albuterol, and sodium bicarbonate
Last resort: Dialysis
Maintenance IVFs
D51/2NS + 20KCl (if peeing)
- Up to 10kgs: 100mL/kg/day
- Next 10 kgs: 50mL/kg/day
- All above 20: 20mL/kg/day
Enteral feeds
Feeds that keep gut mucosa in tact and prevent bacterial translocation
TPN indications? Risks?
Indicated if gut can't absorb nutrients 2/2 physical or fxnal loss.
Risks = acalculus cholecystitis, hyperglycemia, liver dysfxn, zinc deficiency, other 'lyte probs
Tx for circumferential burns
Consider escharotomy
Physical cues for low threshold of intubation
Look for singed nose hairs, wheezing, soot in nose/mouth
Pt with confusion, HA, cherry red skin...
Cause?
Best test?
Carbon Monoxide poisoning
Check carboxy Hb (pulse ox = worthless)
Pt with confusion, HA, cherry red skin...
Tx?
100% O2 (hyperbaric if CO-Hb really high)
Clotting in old people
Sign of?
Cancer
Clotting with edema, HTN, foamy pee
Nephrotic syndrome
Clotting in a young person w/+FH
Factor V leiden
Whats special about ATIII deficiency?
Heparin wont work
Clotting in woman w/multiple SABs
Lupus anticoagulant
Clotting post-op, decreased platelets, clots
HIT (If heparin within 5-14 days)
Tx for HIT
Lepirudin, argatroban
Isolated decrease in platelets
DX?
ITP
Normal platelets but increased bleeding time and PTT
Dx?
vWD
Low platelets, increased PT/PTT/BT, low fibrinogen, high D dimer, and schistocytes
Dx?
DIC (Caused by gram sepsis, carcinomatosis, OB stuff)
Rule of 9s
Parkland formula
Adults: Kg x % BSA x 3-4
Kids: Kg x % BSA x 2-4

Ringers lactate or normal saline

Give 1/2 over the first 8 hours and the rest over next 16 hours
What type of Antibiotics for burn patients
no PO or IV antibiotics, only topical to avoid resistance
Which Abx doesn't penetrate eschar and can cause leukopenia
Silver sulfadiazine
Which Abx penetrates eschar, but hurts like hell
Mafenide
Doesn't penetrate eschar and causes hypoK and hypoNa
Silver nitrate
Chemical burn, what to do?
Irrigate >30 min prior to ER
Electrical Burn, best 1st step?
EKG
Electrical Burn, abnormal EKG or LOC:
Next step?
48 hrs of telemetry
If urine dipstick + for blood but microscopic exam is negative for RBCs in burn pt?
Myoglobinuria (ATN)
Rhabdo
If urine dipstick + for blood but microscopic exam is negative for RBCs in burn pt?
Then what do you check?
K+ (lysis of intracellular contents)
If affected extremity is extremely tender, numb, white, cold with barely dopplerable pulses?
Compartment syndrome
Criteria for compartment syndrome
5P's or pressure >30mmHg
Pain, palor, pulselessness, poikilothermia, parasthesia
Treatment for compartment syndrome
Fasciotomy at bedside
If trauma pt comes in unconscious
First step?
Intubate
If GCS <8
First step?
Intubate
If guy stung by bee, developing stridor and tripod posturing
First Step?
Intubate
If guy stabbed in the neck, crackly sounds w/palpating anterior neck tissues?
First step?
Fiberoptic bronchoscope
Careful intubation
If guy stabbed in the neck, GCS = 15, expanding mass in lateral neck?
First Step?
Intubate
If huge facial trauma, blood obscures oral and nasal airway, & GCS of 7?
Cricothyroidotomy
Do not intubate if no clear airway
So you intubated your patient... next best step?
Check b/l breath sounds
If intubated and decreased lung sounds on left?
Intubated right mainstem bronchus
Pull back
What do do when intubated and decreased lung sounds on left?
Pull back ET tube
What do do when intubated and decreased lung sounds on left?
Next step?
Check pulse ox
Keep >90%
Traumatic aortic injury
Treatment for Traumatic Aortic Injury
surgery ASAP to perform reconstruction with a clip
Pneumothorax
Physical Exam findings for Pneumothorax
decreased breath sounds on the effected side
hyperressonance to percussion
If tension pneumo= JVD and tracheal displacement away from effected side
Hemothorax
Physical exam findings in hemothorax
decreased breath sounds, dullness to percussion
treatment for hemothorax and when to go to OR
Tx: chest tube
go to OR if there is high output=>1.5L after chest tube insertion or >200cc/hr in the first 4 hours
Pulmonary contusion
causes and treatment for pulmonary contusion
causes: rib fracture, MVA, trauma
Tx: pulmonary toilet and pain management
A patient has inward mvmt of the right ribcage upon inspiration.
Dx?
Flail chest.
>3 consecutive rib fractures
A patient has inward mvmt of the right ribcage upon inspiration. Dx Fail Chest
Tx
O2 and pain control
A patient has confusion, petechial rash in chest, axilla and neck and acute SOB.
Dx?
Fat embolism
A patient has confusion, petechial rash in chest, axilla and neck and acute SOB.
When to suspect?
After long bone fracture
A patient dies suddenly after a 3rd year medical student removes a central line.
Dx?
Air embolism
Other causes of Air Embolism other than 3rd medical student
Lung trauma
Vent use
During heart vessel surgery
Any Patient that is hypotensive, tachycardic
Worry about shock
If flat neck veins and normal CVP, hypotensive, tachycardia
Hypovolemic/hemorrhagic
Hypotensive, tachycardic pt with flat neck veins and normal CVP. Next best step?
2 large bore peripheral IV 2L NS or LR over 20 minutes followed by blood
If muffled <3 sounds, JVD, electrical alternans, pulsus paradoxus?
Pericardial tamponade
If muffled <3 sounds, JVD, electrical alternans, pulsus paradoxus?
Dx?
Confirmatory test?
Pericardial tamponade
FAST scan
If muffled <3 sounds, JVD, electrical alternans, pulsus paradoxus?
Dx? Confirmatory test?
Treatment?
Pericardial tamponade, FAST scan
Needle decompression, pericardial window or median sternotomy
IF decreased BS on one side, tracheal deviation AWAY from collapsed lung?
Tension pneumothorax
IF decreased BS on one side, tracheal deviation AWAY from collapsed lung?
Next best step?
Needle decompression followed by chest tube
Don't do a CXR!
Hypovolemic shock: Causes, PE, PCWP, SVR, CO, treatment?
Vasogenic shock: no PO or IV antibiotics, only topical
Neurogenic shock: no PO or IV antibiotics, only topical
Cardiocompression shock: no PO or IV antibiotics, only topical
Cardiogenic shock: no PO or IV antibiotics, only topical
Causes of ICP
Hematoma
Edema
Tumor
Sx of increased ICP
HA
Projectile Vomiting
Altered mental status
Tx for elevated ICP
Elevate HOB, hyperventilation to pCO2 28-32, give mannitol (watch renal fxn)
Surgical intervention for ICP
Ventriculostomy
Penetrating trauma above angle of mandible. Zone? Tx?
Zone 3
Aortography and triple endoscopy
Penetrating trauma between angle of mandible to cricoid. Zone? Tx?
Zone 2
2D doppler +/- exploratory surgery
Penetrating trauma below the cricoid. Zone? Tx?
Zone 1
Aortography
IF GSW to the abdomen?
Ex lap
Plus tetanus prophylaxis
If stab wound and pt is unstable, with rebound tenderness and rigidity, or w/evisceration
Ex lap
Plus tetanus prophylaxis
Treatments:
Extraperitoneal extravasation?
Intraperitoneal extravasation?
Extra-bed rest and foley
Intra-ex-lap and surgical repair
FAST exam
DPL if FAST is equivocal
Ex lap if either are positive
IF stab sound but patient is stable
If blunt abdominal trauma pt with hypotension/tachycardia
Next step?
Ex lap
CXR w/ air under diaphragm. Next best step?
Do not pass go, go directly to exploratory laparotomy
Blunt Abdominal Trauma:
If stable, next stable?
Abdominal CT
Blunt Abdominal Trauma:
If unstable, next step?
Ex-lap
Blunt Abdominal Trauma: if stable and...
If lower rib fx plus bleeding into abdomen
Suspect?
Spleen or liver lac
Blunt Abdominal Trauma: if stable and...
IF lower rib fx plus hematuria
Suspect?
Kidney lac
Blunt Abdominal Trauma: if stable and...
If Kehr sign (what is Kehr sign)and viscera in thorax on CXR
Diaphragm rupture
Kehr's sign-pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classic symptom of a ruptured spleen. May result from diaphragmatic or peridiaphragmatic lesions, renal calculi, splenic injury or ruptured ectopic pregnancy. Kehr's sign is a classic example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the collarbone. This is because the supraclavicular nerves have the same cervical nerves origin as the phrenic nerve, C3 and C4.
Blunt Abdominal Trauma: if stable and...
IF handlebar sign
Pancreatic rupture
Blunt Abdominal Trauma: if stable and...
IF stable with epigastric pain?
Best test?
Abdominal CT
Blunt Abdominal Trauma: if stable and...
Stable with epigastric pain..

IF retroperitoneal fluid is found
Suspect?
Consider duodenal rupture
Pelvic trauma:
If hypotensive, tachycardic
FAST and DPL to r/o bleeding in abdominal cavity
Pelvic trauma:
Can bleed out into pelvis.
Consider?
Next step if stable. Not stable?
Consider internal vs. external
Stop bleeding by fixing fx internal if stable, external if not.
Pelvic trauma:
If blood at the urethral meatus and a high riding prostate?
Consider pelvic fracture w/urethral or bladder injury
NO FOLEY
Pelvic trauma:
Next best test? (if blood at urethral meatus)
Retrograde urethrogram (NOT FOLEY)
Pelvic trauma:
If urethra is normal?
Next step?
Retrograde cystogram to evaluate bladder
Pelvic trauma:
What are you looking for on retrograde cystogram?
Check for extravasation of dye
Take 2 views to ID trigone injury
If extraperitoneal extravasation, tx?
Bed rest
Foley
If intraperitoneal extravasation, tx?
Ex lap
Surgical repair
Fractures that go to the OR (4)
- Depressed skullfx
- Severely displaced or angulated fx
- Any open fx (sticking out bone needs cleaning)
- Femoral neck or intertrochanteric fx
Shoulder pain s/p seizure or electrical shock
Posterior shoulder dislocation
Arm outwardly rotated, & numbness over deltoid-nerve injured?
Dx?
Anterior shoulder dislocation
Axillary n.
old lady FOOSH, distal radius displaced
Colle's fracture
young person FOOSH, anatomic snuff box, tender
Scaphoid fracture
"I swear I just punched a wall...
Metacarpal neck fracture/Boxer's fracture
May need K wire
Clavicle most commonly broken where?
Between middle and distal 1/3s, need figure of 8 device
Depressed skull fracture
Colles fracture
Scaphoid fracture
clavicle fracture
femoral neck facture
intertrochanteric fracture
Fever on POD #1
MCC, low fever, and non-productive cough?
Dx?
Tx?
Atalectasis
Dx: CXR, see B/L lower lobe fluffy infiltrates
Tx: mobilization and incentive spirometry
Fever on POD #1
High fever (to 104!!), very ill appearing.
Necrotizing fasciitis
High fever (to 104!!), very ill appearing.
Pattern of spread?
In subQ along Scarpa's fascia.
High fever (to 104!!), very ill appearing.
Common bugs?
GABHS or clostridium perfringens
High fever (to 104!!), very ill appearing.
Tx?
IV PCN, Go to OR and debride skin until it bleeds
Fever on POD #1
High fever (>104!!) muscle rigidity.
Malignant hyperthermia
High fever (>104!!) muscle rigidity.
Caused by (drug)?
Succ or Halothane
High fever (>104!!) muscle rigidity.
Genetic defect?
Ryanodine receptor gene defect
High fever (>104!!) muscle rigidity.
Treatment?
Dantrolene Na (blockes RYR and decreased intracellular calcium
Fever on POD #3-5-
Fever, productive cough, diaphoresis
Pneumonia
Fever, productive cough, diaphoresis
Tx?
Check sputum sample for culture, cover w/moxi to cover strep pneuma in the mean time
Fever on POD #3-5-Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley.
UTI
Fever on POD #3-5-Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley.
Next best test?
UA (nitrite and LE) and culture
Fever on POD #3-5-Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley.
Tx?
Change foley and treat w/wide spectrum antibiotics until culture returns
Fever > POD 7- pain and tenderness at IV site?
Dx and Tx?
Central line infection
Tx: Do blood cultures from the line, pull it, abx to cover staph
Fever > POD 7-pain at incision site, edema, induration, but not drainage?
Dx and Tx?
Cellulitis
Tx: do blood cultures and start abx
Fever > POD 7-pain at incision site, induration WITH drainage?
Dx and Tx?
Simple wound infection
Tx: open wound and repack, no abx necessary
Fever > POD 7-pain w/salmon colored fluid from incision?
Dx and Tx?
Dehiscence
Tx: surgical emergency, go to OR, IV, abx, primary closure of fascia
Fever > POD 7-unexplained fever?
Dx and Tx?
Abdominal abscess
Dx: CT with oral, IV and rectal contrast to find it, diagnostic lap
Tx: drain it! percutaneously, IR guided, or surgically
Fever > POD 7-
Dx and Tx? Randoms?
Thyrotoxicosis
Thrombophlebitis
Adrenal insufficiency
Lymphangitis
Sepsis
Pressure ulcers. Cause. Next best step. Try to rule out what? Best prevention?
Caused by impaired blood flow ischemia
- Don't culture will just get skin flora. Check CBC and blood cultures. Can mean bacteremia or osteomyelitis.
- Can do tissue biopsy to rule out Marjolin's ulcer
- Best prevention is turning q 2hrs
Pressure ulcers: skin intact but red. Blanches w/ pressure. Stage? Tx?
Stage 1. Get special mattress, barrier protection
Pressure ulcers: blister or break in the dermis. Stage? Tx?
Stage 2. Get special mattress, barrier protection
Pressure ulcers: SubQ destruction into the muscle. Stage? Tx?
Stage 3. Get flap reconstruction surgery
*Before surgery, albumen must be >3.5 and bacterial load must be <100K
Pressure ulcers: involvement of joint or bone. Stage? Tx?
Stage 4. Get flap reconstruction surgery
*Before surgery, albumen must be >3.5 and bacterial load must be <100K
See fluid >1cm on lat decubitus --> thoracentesis
Pleural effusions
Transudative causes of pleural effusions (3)
CHF, nephrotic, cirrhotic
Pleural effusion with transudate and low pleural glucose. Dx?
RA
Pleural effusion with transudate and high lymphocytes.
Tuberculosis
Pleural effusion with bloody transudate?
Malignant or PE
Exudative pleural effusion
Likely parapneumonic, cancer, etc
SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardus
Aortic stenosis
Complicated PE. Criteria? Tx?
+ gram or culture of effusion
pH <7.2
Insert chest tube for drainage
Light's criteria
Transudative if:
LDH <200
LDH eff/serum <0.6
Protein eff/serum <0.5

Otherwise exudative.
Spontaneous pneumothorax. Suspect in what population? How to dx? Tx? Indications for surgery?
Subpleural bleb ruptures --> lung collapse
1. Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)
2. Dx w/ CXR, Tx w/ chest tube placement
3. Indications for surgery = ipsi or contra recurrence, bilateral, incomplete lung expansion, pilot, scuba, live in remote area, VATS, pleurodesis (bleo, iodine or talc)
Lung abscess. 2/2 to? Most often in what lobes? Tx? Indications for surgery?
Usually 2/2 aspiration (drunk, elderly, enteral feeds)
1. Most often in post upper or superior lower lobes
2. Tx initially w/abx --> IV PCN or clinda
3. Indications for surgery: abx fail, abscess >6cm, or if empyema present
Workup of a solitary lung nodule:
First step
Find old CXR to compare
Benign nodules: Characteristics? Tx?
Workup of a solitary lung nodule:
1. Popcorn calcification= hamartoma (MC)
2. Concentric calcification= old granuloma
3. Pt <40, <3cm, well circumscribed
4. Tx: CXR or CT scans q2mo to look for growth
Malignant nodules: Risk factors? Tx?
Workup of a solitary lung nodule:
1. If pt has risk factors (smoker, old), if >3cm, if calcification
2. Tx: remove the nodule (w/bronc if central, open lung biopsy if peripheral)
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Characteristics of effusion?
Exudative with high hyaluronidase
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Mc cancer in non-smokers
Adenocarcinoma
Occurs in scars of old pneumonia
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Location and mets
Peripheral cancer
Mets to liver, bone, brain and adrenals
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Pt with kidney stones, constipation, and malaise low PTH and central lung mass
Squamous cell carcinoma.
Paraneoplastic syndrome (high PTH-rP)
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Pt with shoulder pain, ptosis, constricted pupil, and facial edema
Superior sulcus syndrome from small cell carcinoma
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Pt with ptosis better after 1 minute of upward gaze?
Lambert Eaton Syndrome from small cell carcinoma
Ab to pre-syn Ca channels
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

Old smoker presenting w/Na=125, moist mucus membranes, no JVD
SIADH from small cell carcinoma
Produces euvolemic hyponatremia
Fluid restrict +/- 3% saline in <112
A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pnia or lung collapse.

CXR showing peripheral cavitation and CT showing distant mets
Large cell carcinoma
Causes of ARDS
Sepsis, gastric aspiration, trauma, low perfusion,
pancreatitis.
ARDS: Pathophys
1. Pathophys: inflammation --> impaired gas exchange, inflammatory mediator release, hypoxemia
Holosystolic murmur w/ late diastolic rumble in kiddos
VSD
Diagnosis of ARDS
a.) PaO2/FiO2 < 200 (<300 means acute lung injury)
b.) Bilateral alveolar infiltrates on CXR
c.) PCWP is <18 (means pulmonary edema is non-cardio
Tx for ARDS
Mechanical vent with PEEP
Rumbling diastolic murmur with an opening snap, LAE and A-fib
MS
SEM louder w/ valsalva, softer w/ squatting or handgrip.
HOCM
Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting
MVP
Holosystolic murmur radiates to axilla w/ LAE
MR
Bad breath and snacks in the morning
Tx: surgery
Zenker's diverticulum
Continuous machine like murmur-
PDA
Wide fixed and split S2-
ASD
Dysphagia worse w/hot and cold liquids + chest pain that feels like MI w/NO regurg. Dx? Tx?
Diffuse esophageal spasm
Tx: CCB or nitrates
Blowing diastolic murmur with widened pulse pressure and eponym parade.
AR
Epigastric pain worse after eating or when laying down cough wheeze, hoarse. Dx? Tx?
GERD
Dx: most sensitive test is 25 hour pH monitoring; do endoscopy if danger signs present
Tx: behavioral modifications 1st, then antacids, H2 block, PPI
T/F. Zenkers diverticulum only contains mucosa
False
Dysphagia to liquids and solids. Dx, tx, associations?
Achalasia
Tx: CCB, nitrates, botox, heller myotomy
Assoc: Chaga's dz and esophageal cancer
Indications for esophageal surgery?
Bleeding, stricture, Barrett's incompetent LES, max dose PPI w/still sx, or no want meds
If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase
Boerhaave's
If gross hematemesis unprovoked in a cirrhotic w/ pHTN.

Tx of choice?
Endoscopic sclerotherapy or banding

*Don't prophylactically band asymptomatic varies
Give BB
If progressive dysphagia/wgt loss. Smoker? Longstanding GERD? Next best step?
Squamous cell in smoker/drinkers in the middle 1/3
Adeno in people with long standing GERD in the distal 1/3

Endoscopic sclerotherapy or banding
*Don't prophylactically band asymptomatic varices. Give BB.
If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase

Next best test?
CXR, gastrograffin esophagram
NO ENDOSCOPY
If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase

Tx?
Surgical repair if full thickness
If gross hematemesis unprovoked in a cirrhotic w/ pHTN.
Gastric varices
If gross hematemesis unprovoked in a cirrhotic w/ pHTN.

If hypovolemic shock?
Do ABCs, NG lavage, medical tx w/ octreotide or SS. Balloon tamponade only if you need to stablize for transport
If progressive dysphagia/wgt loss.

Best first test?
Barium swallow, then endoscopy w/bx, then staging CT
If progressive dysphagia/wgt loss.
Esophageal carcinoma
Acid reflux pain after eating, when laying down
Hiatal hernia
Hiatal hernia: Type 1
Sliding hiatal hernia. 95% of hiatal hernias.
GE junction herniates into thorax >2cm above diaphragmatic hiatus
Worse for GERD
Tx sxs
Why should all Type 2 hiatal hernias be fixed?
volvulus risk
MEG pain worse w/eating, H. pylori, NSAIDs, steroids. Workup? Indications for surgery?
Gastric ulcers
1. Workup: double contrast barium swallow; punched out lesion with regular margins
2. Surgery if: EGD w/bx can tell H. pylori, malignant, benign, lesion persists after 12 weeks of treatment
Hiatal hernia: Type 2
Paraesophageal
Normal GEJ but stomach in chest
Abd pain, obstruction, strangulation
Needs surgery
Gastric cancer:
L supraclavicular fossa
Virchow's node
Gastric cancer:
HIV
Lymphoma
Gastric cancer: most common, especially in Japan?
Adenocarcinoma
Gastric cancer:
gastric carcinoma --> ovaries
Krukenberg
Gastric cancer:
Mets felt on DRE
Blummer's shelf
Gastric cancer treatable with antibiotics?
H. Pylori MALT lymphoma
Dieulafoy's
Massive hematemesis= mucosal artery erodes into stomach
Gastric cancer:
Umbilical node
Sister Mary Joseph node
What to suspect if MEG pain/ulcers don't resolve? Best test? Tx? What else to look for?
ZE syndrome
Best test: secreting stim test (find inappropr high gastrin
Tx: surgical resection of pancreatic/duodenal tumor
What else to look for: pituitary and parathyroid problems
Protein losing enteropathy
Enlarged rugae
Menetrier's
Gastric varices
Splenic vein thrombosis
MEG pain straight through to the back. MC etiologies? Dx? Tx? Bad prognostic factors? Complications?
Pancreatitis
MC etiologies: gallstones and EtOH
Dx: increased amylase and lipase; CT is best imaging test
Tx: NG suction, NPO, IV rehydration and observation
Bad prognostic factors: old, WBC>16K, Glc>200, LDH>350, AST>250, drop in HCT, decreased calcium, acidosis, hypox
Complications: pseudocyst (no cells), hemorrhage, abscess, ARDs
Duodenal ulcers. Presentation? Association? Dx? Tx?
MEG pain better w/eating
95% associated with H pylori
Healthy pts <45 can do trial of H2 block or PPI
Dx: blood, stool or breath test for H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer.
Tx: PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.
MC etiologies of pancreatitis
Gallstones, EtOH
A pt has bilious vomiting and post-prandial pain; recent lost 200 lbs. Path? Tx?
SMA syndrome
Path: 3rd part of duodenum compressed by AA and SMA
Tx: by restoring weight/nutrition, can do Roux-en-Y
How does insulinoma present?
Whipple's triad
Labs: increased insulin, C peptide increased, pro-insulin increased
hyperglycemia, diarrhea, weight loss, with associated rash
Glucagonoma
Rash: necrolytic migratory erythema
Chronic MEG pain, DM, malabsorption (steatorrhea). Dx? What can this cause?
Chronic pancreatitis
Can cause splenic vein thrombosis which leads to Gastric varices!
Large nontender GB, itching, and jaundice
Usually don't have sx until advanced; +Courvoisier's sign, may have trousseau's sign. Dx? Tx?
Adenocarcinoma (Exocrine pancreas)
Courvoisier's sign: If in head of pancreas
Trousseau's sign: migratory thrombophlebitis
Dx: EUS and FNA biopsy
Tx: with Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoneal mets
Somatistatinoma
Commonly malignant. see malabsorption,
steatorrhea, ect from exocrine pancreas malfxn
Whipple's triad
sxs (sweat, tremors, hunger, seizures) + BGL < 45 + sxs resolve w/ glc admin
RUQ pain back, n/v, fever, worse s/p fatty foods. Best first test? Tx?
Acute cholecystitis
1. Best first test: US
2. Tx: cholecystectomy, perc cholecystomy if unstable
Choledochal cysts. Type 1? Tx? Type 5? Tx?
Type 1: fusiform dilation of CBD
Tx: excision

Type 5: Caroli's dz
Carol's disease; cysts in intrahepatic ducts --> need liver transplant
Sxs: Watery diarrhea, hypokalemia, dehydration, flushing. Tx?
VIPoma- Looks similar to carcinoid syndrome.
Tx: octreotide can help sx
Cholangiocarcinoma. Risk factors? Tx?
Rare
RF: primary sclerosing cholangitis, liver flukes, and thorothrast exposure
Tx: surgery +/- radiation
RUQ pain, high bill, alk phase. Dx? Tx?
Choledocholithiasis
Dx: U/S will show CBD stone
Tx: chole +/- ERCP to remove stone
RUQ pain, fever, jaundice, ↓BP, AMS. Dx? Tx?
Ascending cholangitis
Tx: w/fluids and broad spectrum abx; ERCP and stone removal
Viral hepatitis AST, ALT?
AST > ALT high (1000s)
Cirrhosis and portal HTN. Tx?
1. Tx- SS and VP vasocontrict to decrease portal pressure, betablockers
also decrease portal pressure.
2. Don't need to treat esophageal varices prophyactically, but band/burn them once they bleed once.
3. TIPS relieves portal HTN but...worsens hepatic encephalopahty
4. Treat: lactulose, helps rid body of ammonia
Alcoholic hepatitis. AST? ALT?
AST = 2x ALT
Hepatocellular carcinoma. Risk factors? Dx? Tx?
1. RF: chronic hepB carrier >hepC; cirrhosis for any reason, plus aflatoxin or carbon tetrachloride
2. Dx: high AFP; CT/MRI
3. Tx: surgically remove solitary mass, use rads or cryoablation for palliation of multiple
Shock liver AST, ALT?
AST & ALT high s/p hemorrhage, surg, or sepsis
2nd MC benign liver tumor;
Focal nodular hyperplasia
W>M but less likely to rupture.
No tx needed
TIPS relieves portal HTN but...
worsens hepatic encephalopahty
Liver abscess
1. MC bugs?
2. Tx?
1. E. coli, bacteriodes, enterococcus
2. Surgical drainage and IV abx
Women on OCPpalpable abd mass or spontaneous rupture hemorrhagic
1. Dx?
2. Tx
Hepatic adnoma
1. US or MRI
2. D/C OCPs, resect if large or pregnancy is desired
RUQ pain, profouse sweating and rigors, palpable liver. Dx?
Tx?
Entamoeba histolytica

Metronidazole
Patient from Mexico presents w/ RUQ and large liver cysts found on U/S
1. Mode of transmission?
2. Lab findings?
3. Tx?
Enchinococcus
1. Hydatic cyst paracyte from dog feces.
2. eosinophilia, +Casoni skin test
3. rupture anaphylaxis
albendazole and surgery to remove ENTIRE cyst,
See sxs of hemolytic anemia (jaundice, incr indir bili, LDH, decr haptoglobin, elevated retic count) + spherocytes on smear and +osmotic frag test. Prone to gallstones. Dx? Tx?
Hereditary spherocytosis
Tx: w/splenectomy (accessory spleen too).
Suspect in hernia, prior GI surgery (adhesions), cancer, intussusception, IBD. Sxs are pain, constipation, obstipation, vomiting. Dx? First test? Tx? Indications for surgery?
SBO
1st test is upright CXR to look for free air. CT can show point of obstruction.
Tx w/ IVF, NG tube. Do surgery if peritoneal signs, Incr WBC, no improvement w/in 48hrs.
Post-splenectomy
1. Post op thrombocytosis >1mil give aspirin.
2. Prophylactic PCN + S. pneumo, H. flu and N. meningitidis vaccines.
Consider in isolated thrombocytopenia (bleeding gums, petechiae, nosebleeds). Decr plt count, incr megakaryocytes in marrow. NO splenomegaly. Dx? Tx?
ITP
Tx w/ steroids 1st. If relapse splenectomy.
Types of volvulus. Tx?
Either cecal or sigmoid
Decompression from below if not strangulated. Otherwise, need
surgical removal and colostomy.
Consider w/ L lower rib fx and intra abd hemorrhage. Can have Kehr's sign (irritates L diaphragm). Dx?
Traumatic splenic rupture
Pain in umbilical area; RLQ, n/v perforation
1. Go to surgery if:
2. IF perforated/abscess
Appendicitis
1. Clinical picture is convincing
2. Drain, abx (to cover e.coli and bactericides, and do interval appendectomy)
Carcinoid syndrome #1 site? Sx? Tx?
Appendix
Sx: diarrhea, wheezing
When: mets to liver
Other sx: diarrhea, dementia, dermatitis
Tx
1. If >2cm @ base of appendix or w/+ nodes=hemicolectomy
2. Otherwise: appendectomy is good enough
Carcinoid tumor syndrome
Hernias: in kiddos, close spontaneously by age 2. In adults: 2/2 obesity, ascites or pregnancy.
Umbilical hernia
Hernias: MC; through inguinal ring (lat to epigastric vessles) in spermatic cord. R>L, more often congenital (patent proc vaginals)
Indirect inguinal hernia
Dilated loops of small bowel w/ air-fluid level, possible with hypoK and opiates. Dx? Tx?
Post-op ileus
Do surgery for perforation. Give lactulose/erythromycin.
Massive colonic distension in absence of any mechanical obstruction. Dx? Tx?
Ogilvie's syndrome.
If >10cm, need decompression w/ NG tube and neostigmine (watch for bradycardia) or colonoscopic decompression.
Hernias: through Hasselbeck's triangle (med to epigastric vessels), more often acquired weakness.
Direct inguinal hernia
Crohn's IBS. Criteria?
1. Mimics appendicitis (Fe deficiency)
2. Involves terminal ileum
3. Fistulae
4. Granulomas
5. Transmural inflammation
Ulcerative colitis IBS. Criteria?
1. Continuous involving rectum (Rarely ileal backwash but never higher)
2. Increased risk for primary sclerosing cholangitis
3. Cured by colectomy
4. Smokers have lower risk
5. Highest risk of colon cancer
6. Associated with p-ANCA
Hernias:
More common in women
Femoral hernia
Tx for hernias
Emergent surgical repair if incarcerated to avoid strangulation. Elective if reducible.
Treatment for IBS
ASA, sulfasalzine to maintain remission. Corticosteroids to induce remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine, 6MP and methotrexate for severe dz.
Diverticulosis. Path, 2/2 to? Complications?
1. False diverticulae
2. Occur 2/2 low fiber diet in areas of weakness where blood vessels penetrate --> bleed
3. Complications are bleeding, obstruction, diverticulitis
Diverticulitis. Path? Presentation? Dx? Tx? Surgery indications?
1. Diverticulum becomes obstructed and forms abscess/perforates
2. LLQ pain, either constipation or diarrhea,
3. Look for free air, CT is best imaging to
evaluate for abscess. No Barium enema!
4. Tx w/ NPO, NG suction, IVF, broad spec abx & pain control.
5. Do colonoscopy: 4-6 weeks later.
6. Surgery indicated if:
multiple episodes, age <50. Elective is better than emergency (can do primary anastamosis)
RF for colorectal cancer
AFP
Lynch syndrome
HNPCC
Gardners
Cowdens
Screening for AAA
men 65-75 who have ever smoked. Do abdominal U/S.
Sx of right sided cancer
Bleeding
Sx of left sided cancer
Obstruction
Sx of rectal cancer
Pain/fullness, bleeding/obstruction
Symptoms of AAA
Pulsatile abdominal mass
Workup for colorectal cancer
DRE
Transrectal ultrasound (Depth of invasion)
Colonoscopy!
CEA to measure recurrance
CT for staging
Tx for colon in colorectal cancer
Remove affected segments & chemo if node +
Tx for rectum in colorectal cancer
Upper/middle 1/3 get a LAR, lower 1/3 gets an APR (remove sphincter, permanent colostomy)
When is AAA surgery indicated?
>5cm, growing <4mm/yr
AAA rupture. Sx?
Sx: severe sudden abdomen, flank or back, shock, tender pulsatile mass.
50% die before reaching the hospital
When to tx AAA conservatively?
If <5cm and asymptomatic, monitor growth every 3-12mo.
Post-op complications:
#1 cause of death
MI
Post-op complications:
Bloody diarrhea
Ischemic colitis
Acute abdominal pain in a pt w/ A-fib subtherapeutic on warfarin or pt s/p high dose vasoconstrictors (shock, bypass). Dx? Workup? Tx?
Acute mesenteric ischemia
Work up is angiography (aorta and SMA/IMA)
Tx is embolectomy. If thrombus, or aortomesenteric bypass.
Thyroid nodule:
First step?
Check TSH
Post-op complications:
Weakness, decresaed pain w/preserved vibr, prop
ASA syndrome
Post-op complications:
1-2 years later if have brisk GI bleeding
Aortoenteric fistula
Benign thyroid nodule. Next step?
Leave it alone
Slow progressing stenosis (req stenosis of 2.5 vessels Celiac, SMA and IMA). Severe MEG pain after eating, food fear and weight loss. "Pain out of proportion to exam". Dx? Workup? Tx?
Chronic mesenteric ischemia
Dx w/ duplex or angiography.
Tx w/ aortomeseteric bypass or transaortic mesenteric endarterectomy.
Acute arterial occlusion (PAD). Tx? Surgery w/in how many hours? Tx? Complications?
5Ps, no dopplerable pulses
High risk after surgery
Tx: immediate heparin + prep for surgery
Surgery done w/in 6 hours to avoid loss
1. Thrombolytics may be possible: no sure in <2 weeks, hemorrhagic stroke
2. Complications: compartment syndrome during repercussion period --> do fasciotomy watch for myoglobinuria
DVT. Dx? Tx? Complications?
- Dx w/ Duplex U/S & also check for PE
- Tx w/ heparin, then overlap w/ warfarin for 5 days, then continue warfarin for 3-6mo.
- Complications- post-phlebotic syndrome = chronic valvular incompetence, cyanosis and edema
Claudication (PAD). Sx? Best test?
1. Sx: pain in butt, calf thigh upon exertion
2. Best test: ankle brachial index
3. Normal: >1
4. Claudication and ulcers: 0.4-0.8 use medical management
5. Limb ischemia: 0.2-0.4 surgery is indicated
6. Gangrene: <0.2 may require amputation
PE. Signs? If suspected, what is the best first step? Then? If it's life threatening? If you can't give chronic anticoagulation?
- Random signs = right heart strain on EKG, sinus tach, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2.
- If suspected, give heparin 1st! Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard.
- Tx w/ 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 anti-coagulation.
Thyroid nodule:
IF malignant?
Surgically excise and check pathology
Thyroid nodule: Low TSH. Next step?
Do RAIU to find the hot nodule
Excise or radioactive iodine
Thyroid nodule:
If normal TSH?
FNA
Thyroid nodule:
IF indeterminate?
Re-biopsy or check RAIU
Thyroid nodule:
If cold?
Surgically excise and check pathology
Thyroid nodule:
MC type, spreads via lymph, psammoma bodies
Papillary
Thyroid nodule:
Spreads via blood, must surgically excise whole thyroid!
Follicular
Thyroid nodule:
Assoc w/ MENII (look for pheo, hyperCa). Amyloid/calci
Medullary
Thyroid nodule:
80% mortality in 1st year.
Anaplastic
Pheochromocytoma: Presentation? Workup?
Features: high BP, catechol symptoms
Biochemical tests: urine and plasma free metanephrines
Cushing or silent Cushing syndrome: Presentation? Workup?
Features: Cushing symptoms or normal examination results
Biochemical tests: overnight 1mg dexamethasone test
Thyroid nodule:
Hashimoto's predisposes to it.
Thyroid lymphoma
If adrenal nodule >6cm or functional
Tx?
Surgical excision
Primary aldosteronism: Presentation? Workup?
Features: high BP, low K, low PRA
Biochemical tests: plasma aldosterone to renin ratio
Adrenocortical carcinoma: Presentation? Workup?
Features: virilzation or feminization
Biochemical tests: urine 17 ketosteroids
Typically comes from thyroidectomy
- Sxs are perioral numbness, Chvortek, Trousseau
Hypoparathyroidism
↓Ca+, ↑↑*PO4+, ↓*PTH
If adrenal nodule <5cm and non-functional?
Observe w/CT scans q6mo
Pituitary adenoma, parathyroid hyperplasia, pancreatic
islet cell tumor.
MEN1
parathryoid hyperplasia, medullary thyroid cancer, pheochromocytoma
MEN2a
Usually asymptomatic ↑Ca, but can present w/ kidney stones, abdominal or psychiatric sxs. Dx? Tx?
Hyperparathyroidism
- ↑Ca+, ↓↓*PO4+, ↑vitD, ↑*PTH+
- Dx w/ FNA of suspicious nodules. Can use Sestamibi scan.
- Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in forearm.
Good for eval dense breast tissue, evaluating nodes and determining recurrent cancer
- Best imaging for the young breast
MRI
Work up of a breast mass
1. Exicisional biopsy
2. Mammographically guided multiple core biopsies
medullary thyroid cancer, pheochromocytoma, Marfanoid
MEN2b
Testing that can tell if breast mass is solid or cystic
US
Good for determining fibroadenoma/cysto-sarcoma
phyllodes.
RF for breast cancer
Breast cancer:
BRCA1 or 2, person hx of breast cancer, nulliparity, endo/exogenous estrogen.
Workup of a breast mass:
Cells from cysts are from fluid
Aspiration of fluid
Workup of a breast mass: if cells comes from solid
FNA
Cysts are painful and change w/ menses. Fluid is typically green or straw colored. Dx? Tx?
Fibrocystic change
Tx: restrict caffeine, take vitamin E, wear a supportive bra
Breast cancer: DCIS Tx?
Either excision w/ clear margins or simple mastectomy if multiple
lesions (no node sampling) + adjuvant RT.
Breast cancer: LCIS Tx?
More often bilateral.
Consider bilateral mastectomy only if +FH, hormone sensitive, or prior hx of breast cancer
Infiltrating ductal/lobular carcinoma: Tx?
Breast cancer:
- If small and away from nipple, can do lumpectomy w/ ax node sampling. Adjuvant RT. Chemo if node +. Tamoxifen or Raloxifen if ER +
- Modified radical mastectomy w/ ax node sampling w/o adjuvant RT gives same prognosis.
Melanoma. Best prognosis? Most common? Poor prognosis? Tx?
- Superficial spreading (best prog, most common)
- Nodular (poor prog)
http://emedicine.medscape.com/article/1 101535-media
- Acrolintiginous (palms, soles, mucous membranes in darker
complected races).
- Lentigo Maligna (head and neck, good prog)
- Need full thickness biopsy b/c depth is #1 prog
- Tx w/ excision-1cm margin if <1mm thick,
2cm margin if 1-4mm thick, 3cm margin if >4mm
- High dose IFN or IL2 may help
Soft tissue sarcoma. Dx? Tx? Spreads to?
- Painless enlarging mass. (Don't confuse w/ bruised muscle.
- Dx w/ biopsy (NOT FNA). Excisional if <3cm otherwise incisional.
- Tx w/ wide, local excision or ampulation + RT.
- Spreads 1st to the lungs (hematogenously)can do
wedge resection if only met and primary is under control.
Paget's disease. Presentation? Workup?
Breast cancer:
Looks like eczema of the nipple. Do mammogram to find the mass.
Red, hot, swollen breast. Orange peal skin. Nipple retraction
Inflammatory breast cancer
Basal cell carcinoma of skin. Dx? Tx?
Shave or punch bx then surgical removal (Mohs)
Squamous cell carcinoma of skin. Dx? Tx?
- AK is precursor lesion (tx w/ 5FU or excision) or keratoacanthoma.
- Excisional bx at edge of lesion, then wide local excision.
- Can use rads for tough locations.
Hard round mass on extremity. Can occur in areas of chronic lymphedema
Fibrosarcoma/rhabdomyosarcoma/lyphangiosarcoma
Workup of neck mass present for 7 days
Inflammatory
Liposarcoma relation to lipoma?
99% DON'T come from lipoma
Workup up neck mass:
1st step
MCC is reactive node, so first step is to examine teeth, tonsils, etc for inflammatory lesion
Workup up neck mass:
If node is firm, rubbery and "B sxs" are present. Reed Sternberg cells. Dx? What is a good prognostic factor?
Hodgkins lymphoma. Lymphocyte predom is good prog factor.
Workup of neck mass present for 7 months
Cancer
Workup of neck mass present for 7 years
Congenital
Workup up neck mass:
If midline (mass moves). Dx? Tx?
Thyroglossal duct cyst
Tx: remove surgically
If you find a lesion that's still there in 2 week
FNA it
If node is firm, rubbery and "B sxs" are present
Excisional biopsy looking for lymphoma
Most frequent squamous cell in smokers and drinkers. Dx? Tx?
-Oral cancer
-Tx w/XRT or radical dissection
Workup up neck mass:
If node is firm, rubbery and "B sxs" are present. What are good prognostic factors for non-hodgkins lymphoma?
Nodular and well-dif are good prog factor.
Workup up neck mass:
Tx for Firm rubbery node with B symptoms
Staging CT, CXR, and laparotomy
Warthin's tumor aka? What nerve involved?
- Papillary cystadenoma lymphomatosum. Benign on parotid
gland.
- Can injure facial nerve (look for palsy sxs in ? Stem)
Workup up neck mass:
If anterior to SCM
Branchial cleft cyst
Workup up neck mass:
If spongy, diffuse and lateral to SCM
Cystic hygroma
MC malignant tumor of parotid gland
Mucoepidermoid carcinoma
Arises from duct. Causes pain and CNVII palsy
Laryngeal cancer. MC in kids? Adults? Tx?
- Laryngeal papilloma in kiddo w/ stridor or cough - Squamous cell in adults.
- Tx w/ laryngoscope laser or resection
MC salivary gland tumor.
Pleomorphic adenoma
- Usually on parotid. Benign but recurs
Baby is born w/ respiratory distress, scaphoid abdomen & this CXR.
1. Biggest concern?
2. Biggest treatment?
1. Pulmonary hypoplasia
2. If dx prenatally, plan delivery at place w/ECMO; let lungs mature 3-4 days then do surgery
1 wk old baby w/ bilious vomiting, draws up his legs, has abd distension.
Dx?
Pathophys?
Malrotation and volvulus (Ladds bands can kink duodenum)
Path: doesn't rotate 270 ccw around SMA
Baby is born w/ respiratory distress, scaphoid abdomen & this CXR.
CDH
A 3 day old newborn has still not passed meconium
Consider CF if FH
1. Meconium ileus
Dx and Tx: gastrograffin enema

2. Hirschsprung's (DRE- explosion of poo, bx showing no ganglia is gold standard)
Baby is born w/ respiratory
distress w/ excess drooling.
TE fistula
Baby is born w/ respiratory
distress w/ excess drooling.
Best diagnostic test?
Place feeding tube, take X-ray, see it coiled in thorax
Defect lateral (usually R) of the midline, no sac
1. Associated with other disorders?
2. Complications?
Gastroschisis
1. Not usually
2. may be atretic or necrotic req removal; short gut syndrome
Defect in the midline. Covered by sac.
- Assoc w/ other disorders?
Omphalocele

Yes
Defect in the midline. No bowel present.
1. Associated with other disorders?
2. Tx?
Umbilical hernia
1. w/ congenital hypothyroidism. (also big tongue)
2. Repair not needed unless persists past age 2 or 3.
4wk old infant w/ non- bileous vomiting and palpable "olive"
1. Metabolic complications?
2. Tx?
Pyloric stenosis
1. Hypochloremic, metabolic alkalosis
2. Immediate surgery referral for myotomy
2wk old infant w/ bilious vomiting. The pregnancy was complicated by polyhydramnios.
Associated with?
Intestinal atresia

Down Syndrome (Especially duodenal)
A 2mo old baby has colicky abd pain and current jelly stool w/ a sausage shapend mass in the RUQ.
Dx and Tx: barium enema
Intussusception
BPH: Use anticholinergics? Medical tx? Surgical tx?
- Anticholinergics meds make it worse. foley for acute urinary
retention.
- Medical Tx 1st w/ tamsulosin or finasteride
- Surgical Tx w/ TURP (hyponatremia, retro-ejac)
A 5 day old former 33 weeker develops bloody diarrhea
1. What do you see on X-ray?
2. Treatment?
3. Risk factors?
Necrotizing enterocolitis
1. Pneumocystis intestinalis
2. NPO, TPN, antibiotics and resection of necrotic bowel
3. Premature gut, introduction of feeds, formula
Scrotal mass. Workup?
Transilluminate, U/S, excision! (don't bx). Know hormone markers!
Avascular necrosis: MC presentation in 4-5 yr olds? 12-13 yr olds? Adults?
- In kids: Leg-Calve-Perthe's dz in 4-5 y/o w/ a painless limp and SCFE in a 12-13 y/o w/ knee pain or sickle cell pts
- In adults: steroid use, s/p femur fracture.
Prostate cancer: Workup? Tx?
- Nodules on DRE or elevated/rising PSA means transrectal ultrasound and bx. Bone scan looks for blastic lesions.
Tx: w/surgery, radiation, leuprolide or flutamide.
Kidney stones. Best test? What size to let it pass? What size to do lithotripsy? When to do surgical removal?
CT is best test. If stone <5mm, hydrate and let it pass.
If >5mm, do shock wave lithotripsy. Surgical removal if >2cm.
Ewing's sarcoma: Where is it seen along bones? XR characteristics? Histology?
- Seen at diaphysis of long bones, night pain, fever & elevated ESR
- Lytic bone lesions, "onion skinning".
- Neuroendocrine (small blue) tumor
Testicular torsion. Presentation? Workup? Tx?
- Acute pain and swelling w/ high riding testis.
- Do STAT doppler U/Swill show no flow (contrast w/ epididymitis)
- Can surgically salvage if <6hrs. Do orchiopexy to BOTH testes.
Organ dysfunction (incr GGT or Cr depending on organ)
w/in 5days - 3mo. Workup? Tx?
- Acute rejection
- Due to T-lymphocytes.
- Technical problems common in Liver
- 1st check for biliary obstruction w/ U/S then check for thrombosis by Doppler.
- In heart, sxs come late, so check ventricular bx periodically.
- Tx w/ steroid bolus and antilymphocyte agent (OKT3)
Osteosarcoma: Where is it seen along bones? XR characteristics?
- Seen in distal femur, proximal tibia
@ metaphysis, around the knee
- Codman's triangle and Sunray appearance
Transplant rejection that occurs after years. Tx?
- Chronic rejection
- Due to T-lymphocytes.
- Can't treat it. Need re-transplantation.
Vascular thrombosis w/in minutes following transplant
- Hyperacute rejection
- Caused by preformed antibodies
No epi where?
fingers, nose, penis, toes
Epidural anesthesia (local + opioid). What does high block block?
"High block" blocks heart's SNS nerves and phrenic nerve.
Local (lidocaine)
Why give with epi?
Given to prevent systemic absorption numb tongue, seizures hypotension, bradycardia, arrhythmias
Merperidine: Adverse effects? Avoid in?
Norperidine metabolite can lower seizure threshold esp in pts w/ renal failure.
Anesthetic for ppl who can't be intubated. Contraindications?
Spinal subarachnoid anesthesia (bupivacaine)
Can't give if incr ICP or hypotensive.
Halothane: Adverse effects?
Can cause malignant hyperthermia (dantroline Na), liver toxicity.
Succinylcholine: Adverse effects?
Can cause malignant hyperthermia, hyperK (not for burn or crush victim)
Rocuronium: Adverse effects?
Sometimes allergic rxn in asthmatics
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