SURGERY EOR EXAMS, PRACTICE EXAMS AND STUDY GUIDE EXAMS, Exams of Nursing

Download SURGERY EOR EXAMS, PRACTICE EXAMS AND STUDY GUIDE EXAMS and more Exams Nursing in PDF only on Docsity! SURGERY EOR EXAMS, PRACTICE EXAMS AND STUDY GUIDE EXAMS WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS ALL IN ONE 2024 NEWEST ALREADY GRADED A+ What is the treatment for colonic obstruction? Surgical treatment? IVF, NGT decompression, careful observation Surgical: acute colonic obstruction with cecal diameter greater than 12cm __________is the rotation of the large intestine on the axis formed by the mesentery. colonic volvulus 70% of colonic volvulus occur in the _____. 30% of colonic volvulus occur in the _____. sigmoid colon; cecum On abdominal series or barium enema, what is the classic appearance of a volvulus? birds beak or funnel The treatment for __________is rectal tube insertion for signmoid volvulus or emergent laparotomy if suspected perforation or cecal volvulus. colonic volvulus A _______is an obstruction of the perianal glands. Cryptoglandular in origin. Presents with perianal pain and swelling, spontaneous drainage of purulent material. What are the cardinal signs? Treatment? perianal abscess; pain, fever, redness, swelling, loss of function; I&D What is Goodsall's rule? anterior-opening fistulas tend to follow a simple direct course while posterior-opening fistulas may follow a devious, curving path with some even being horseshoe-shaped before opening in the posterior midline. ______are painful linear tears in the lining of the anal canal. Frequently posterior. CP: dramatic pain with defecation and blood streaked stool, recent diarrhea or trauma to the area. Anal fissures _______is intussusception of a full thickness portion of the rectum through the anal opening. Often occurs in thin, asthenic women. 4-20cm of rectum. Rectal prolapse (procidentia) What is the presentation of a rectal prolapse? rectal pain, mild bleeding, mucous discharge, and a wet anus ______are vascular cushions in the anal canal. Disease is accompanied by constipation, increased pelvic pressure, portal hypertension, and excessive diarrhea. Hemorrhoids Hemorrhoid grading: Grade I = Grade II = Grade III = Grade IV = Grade I = no prolapse, bulge in anal canal lumen Grade II = prolapse upon defecation but spontaneously reduce Grade III = prolapse upon defecation - manually reducable Grade IV = prolapsed and cannot be manually reduced ________are when peritoneal sac and potentially peritoneal contents protrude through a weakness or defect in the muscle or fascia of the abdominal wall. Hernias _______hernias account for 96% of all groin hernias. Indirect are more common and presents how? Inguinal; protrusion into the scrotum In a _____inguinal hernia, peritoneal contents come directly through the abdominal wall and occur within Hesselbachs triangle. direct What is Hesselbach's Triangle? inguinal ligament, inferior epigastric vessels, and the lateral border of the rectus muscle ________hernias are typically small, less than 1cm defect in the abdominal wall due to incomplete umbilical closure. More common in females. Umbilical Contraindications for surgery for lung cancer: STOP IT superior vena cava syndrome, supraclavicular node metastasis, scalene node metastasis, tracheal carina involvement, oat cell carcinoma, pulm fx tests shows FEV<1, myocardial infarction, tumor elsewhere A _________ is a collection of fluid (pleural fluid, blood, pus) within the pleural cavity. Causes: pulmonary infex, CHF, SLE or RA, pancreatitis, trauma, PE, renal dz, cirrhosis, malignancy, postpericardiotomy syndrome pleural effusion What are physical s/s of a pleural effusion? SOB, CP, decreased tactile fremitus, asymmetrical chest expansion, egophony, pleural friction rub On physical exam, a pleural effusion reveals___and___. Evaluation with thoracentesis w cytology. percussion on side with air and dull on side with fluid. A ____is diagnostic to acquire pleural fluid for analysis, usually pleural effusion. What are the risks? Thoracentesis; pneumothorax, injury to lung, intraabdominal injury, pain, bleeding With a thoracentesis, a patient should _____as the catheter/needle is withdrawn. exhale A needle decompression converts a _______to a pneumothorax. Where should the needle be inserted? tension pneumothorax; between 2 and 3 rib, midclavicular line over the top of the 3rd rib With a needle decompression, after you hear the rush of air, what should be placed over the catheter? a flutter valve A ______is a tube inserted into pleural space for drainage of fluid and air. Where should it be placed? 4th or 5th intercostal space; tube should pass over top of rib due to neurovascular bundle What are some complications of inserting a chest tube? puncture of liver or spleen, bleeding, cardiac puncture A ________is when air builds up in the pleural space and is unable to escape -- results in collapse of lung on affected side and pressure on mediastinum. With inhalation, the lung collapses further. There is no place for the air to escape. pneumothorax What are some s/s of pneumothorax? trachea pushed to opposite side; absent breath sounds on affected side What is the tx of pneumothorax? ABC's; oxygen, treat for shock, needle decompression of affected side, patient will need chest tube A _______is necessary when an emergent airway is required...extensive orofacial trauma preventing laryngoscopy, upper airway obstruction , unsuccessful endotracheal intubation Cricothyroidotomy What anatomic location should a cricothyroidotomy be performed? Between cricoid and thyroid cartilage The most common cause of post operative pneumonia or in hospital/ICU is ________. gram negative bacteria [Neisseria meningitidis, Pseudomonas aeruginosa] In community acquire pneumonia, what type of organisms is the most common cause? gram positive bacteria [Streptococcus pneumoniae & Staphylococcus aureus] If patient is supine, PNA most commonly involves which lobe____if supine or _________if patient is sitting/semirecumbant. RUL, RLL If a patient presents with slurred speech, what neurological problem is in your d/d? CVA or brain tumor If your patient presents with a motor and/or sensory loss, what is your imaging study of choice? CT scan -- test of choice to evaluate cervical spine Signs of ___are upon auscultation of the carotid and subclavian arteries -- reveals audible bruit in the neck. What is the diagnostic study of choice? carotid disease; Doppler ultrasound A ______is head trauma results in blood below the arachnoid membrane and above the pia. Most often supratentorial (contains the cerebrum). Subarachnoid hemorrhage What are the three most common causes of subarachnoid hemorrhage? 1 - trauma 2 - ruptured berry aneurysms 3 - AVM - arteriovenous malformations A ______is a secular outpouching of vessels in the circle of willis, usually at bifurcations). berry aneurysm A _____is a congenital abnormality of the vasculature with connections between arterial and venous circulations without interposed capillary network. AVM - arteriovenous malformations How does a patient with a SAH present? "worst headache of my life" -- positive Kernig and Brudzinski sign What is the difference between nuchal rigidity, Kernig's, and Brudzinski's signs? nuchal rigidity - neck stiffness when bending neck forward Kernig's - inability to straighten the leg when the hip is flexed at a 90 degree angle Brudzinski's - when the examiner flexes the patient's neck, knees, and hips at the same time What is part of the work-up of SAH? CT scan and arteriogram (to look for aneurysms or AVMs) The most common cause of morbidity and mortality with a SAH is _____. vasospasm -- other complications are brain edema (increased ICP) and rebleeding What is the treatment for SAH? --Nimodipine CCB for vasospasm --surgical metal clipping for aneurysm (alternative is balloon occlusion or coil embolization) --AVM: pre op embolization -- for surgically inaccessible lesions, radiosurgery A ______is bleeding into the brain parenchyma. Prognosis poor. Dx w CT. intracerebral hemorrhage These are _____indications for intracerebral hemorrhage are CNIII palsy (oculomotor nerve) and progressive alteration of consciousness. 2/3 present with coma, lateral gaze preference, aphasia, homonymous hemianopsia. surgical ______is blood collection under the dura. Caused by tearing of "bridging" veins that pass through the space between. The cortical surface and the dural venous sinuses or injury to the brain surface with resultant bleeding from cortical vessels. Subdural hemorrhage What are the CT finding of a subdural hemorrhage? Treatment? CT findings = curved, crescent shaped hematoma (sUbdural = cUrved) Treatment = reduce mass effect usually by craniotomy with clot evacuation A ________is a collection of blood between the skull and dura. Usually in association with skull fracture as bone fragments lacerate meningeal arteries. What artery is most commonly affected? epidural hematoma; middle meningeal artery What are the CT findings with epidural hematoma? _______pain is usually secondary to inflammation with secondary edema and distention of the prostatic capsule. Pain is poorly localized -- frequency associated with irritative sx such as frequency, dysuria, and in prostatic edema Prostatic ______pain primarily arises from w/in the scrotum and is usually secondary to acute epididymitis, torsion, or testicular appendices. Testicular ________is usually related to noninflammatory conditions such as a hydrocele, varicocele, and pain is characterized as dull, heavy sensation in testes that does not radiate. Chronic scrotal pain ____pain is acute, scrotum is red and warm to touch. Relief with elevation of the testis of the appropriate side. Epididymal Testicular carcinoma are most typically what type of tumors? malignant germ cell tumors (either seminomatous 35% or nonseminomatous 65%) or non germ cell tumors (rare and usually benign) What is the s/s of testicular carcinoma? What is the diagnostic study of choice? painless firm mass inside the testis; scrotal u/s What are the tumor markers for testicular carcinoma? B-hcg, alpha fetoprotein, lactic dehydrogenase What age do patients usually present with testicular carcinoma? What is the surgical treatment? age 18-40; inguinal orchiectomy with retro peritoneal lymph node dissection A _____is a embryonic tumor of renal origin. Ave age of dx is 2-4 years old. S/S: abdominal mass; Dx: abdominal/chest CT; Tx: radical resection of affected kidney Wilm's Tumor A associated abnormality with a Wilm's tumor is ___________syndrome ie. a umbilical defect, macroglossia, gigantism, neurofibromatosis, horseshoe kidney. beckwith Wiedemann Think Wilms=beckwith Wiedemann The second most common urologic malignancy is _____. 90% have _______carcinoma. Remaining cases are squamous or adenocarcinoma. bladder carcinoma; transitional cell carcinoma What are the s/s of bladder cancer? painless hematuria, with or without irritative symptoms, frequency bladder Treatment varies according to stage: Stage O: bladder chemo Stage A: Trans-urethral resection of the bladder (TURB) Stage B&C: radical cystectomy, node dissection, removal of prostate/uterus/ovaries/anterior vaginal wall, urinary diversion Stage D: superficial, isolate tumor, apical with 3cm margin from any orifices _________cancer is the most common neoplasm after skin cancer. 2nd most common cause of death due to cancer. Cause unknown. More than 75% of men have this on autopsy. Prostate Annual screening for prostate cancer should be performed for all men >____and black men >____. What lab should be drawn for screening? 50; 45; serum PSA - prostate specific antigen On DRE for prostate cancer, what is felt? rock hard nodule _______cell carcinoma is the most common urologic malignancy. Specifically what kind of cancer? Renal; adenocarcinoma What are the most common metastases sites for kidney cancer? What is the diagnostic study of choice? lungs and bone; CT scan What are the s/s of renal carcinoma? hematuria, flank pain, flank mass, possible complaints due to metastases sites (lung/bone) The surgical tx of renal carcinoma is radical nephrectomy. If the tumor is less than 4cm, what can be done? partial nephrectomy ______________is defined as presence of kidney damage (usually detected as urinary albumin >30mg/day) or decreased kidney fx (defined as estimated GFR <60 mL/min) for 3 or more months, irrespective of cause. Chronic kidney disease Dialysis is needed when approximately _____or more of kidney function is lost. 90% What are the indications for dialysis? AEIOU acidosis, excessive hyperkalemia, intractable volume overload (missed dialysis appointments), overdoses, uremia (sx of renal failure) Dialysis vascular access: _________is the preferred access method. Creates a direct connection between an artery and vein. Located under skin usually in lower arm. Created 2-4 months before it will be used. AV (arteriovenous) fistula Dialysis vascular access: _________is used when patients veins are not suitable for creating a fistula. Flexible rubber tube is used to create a path b/w artery and vein. Can be used 2 weeks after they are created. Possible narrowing of blood vessels and infection. Synthetic AV bridge graft Dialysis vascular access: _________uses a thin, flexible tube that is placed into a large vein (neck usually) -- can be used immediately. Highest infection risk and poorest function. Central venous catheter ______dialysis uses the peritoneum as a membrane across which fluids and dissolved substances are exchanged from the blood. Fluid introduced through a permanent tube in abdomen and flushed out either every night while patient sleeps or via regular exchanges throughout the day. Peritoneal Dialysis Most common causes of ___________disease are atherosclerosis of aorta and renal artery, and fibromuscular dysplasia. renal vascular disease; renovascular HTN less common causes are renal artery emboli, renal artery aneurysms, renal artery dissection, hypoplasia of renal arteries, and stenosis of the suprarenal aorta ______due to renal artery stenosis: results from kidneys response to decrease blood flow: renin is secreted, which acts on circulating angiotensinogen to form angiotensin I, which is converted to angiotensin II by ACE. This constricts arterioles, increases aldosterone secretion and promotes sodium retention. Hypertension Due to excess aldosterone, hypertension becomes volume dependent. Persistent elevation of ________is usually the only abnormal PE finding. diastolic pressure ________presents with flank pain, hematuria, pyelonephritis, previous stone passage, mod-severe renal pain, n/v, CVA tenderness. IV fluids and furosemide -- NOT thiazide diuretics (If from hyperplasia, then removing PTH except for 30mg tissue; If from adenoma, remove adenoma; If from carcinoma, remove carcinoma) The most common cause of hyperthyroidism is _________. What are three classic s/s of hyperthyroidism? Graves disease; hyperthyroidism, exophthalmos, and pretibial myxedema Hyperthyroidism is caused by circulating antibodies that stimulate _____receptors on follicular cells of the thyroid and cause deregulated production of thyroid hormones. Female to Male ratio?? TSH; Female:Male is 6:1 What is the medical therapy for hyperthyroidism? What is the most popular therapy? What is the surgical therapy? medical blockage with iodide, propranol, prophythiuracil (PTU), methimazole, Lugol's solution (potassium iodide); RADIOIODIDE ABLATION; bilateral subtotal thyroidectomy Thyroid nodules are evaluated using ____& _____. They are distinguished as being either hot or cold. What is the difference? Which is more likely to be malignant? FNA - fine needle aspiration & thyroid scan[injects radioactive dye] "cold" nodules: decreased radioactive iodine uptake "hot" nodules: increased radioactive iodine uptake cold nodules are more likely to be malignant (25%) ______is the most common cause of thyroid enlargement. Multinodular goiter Administration of thyroid hormone suppresses TSH secretion and up to half of benign thyroid nodules will _____. disappear ________disease is a toxic multinodular goiter. Plummer's disease What is the most popular type of thyroid carcinoma? Papillary carcinoma (80%) What are the 5 main types of thyroid carcinoma? papillary, follicular, medullary, Hurthle cell, anaplastic/undifferentiated An ______carcinoma presents with a failed dexamethasone suppression test, high cortisol, low ACTH. Tx: surgical excision. Adrenal carcinoma A ______is a tumor of the adrenal medulla and sympathetic ganglion (from chromaffin cell lines) that produces catecholamines. pheochromocytoma NE>E What are the classic s/s of a pheochromocytoma? palpitations, headache, episodic diaphoresis, HTN (most common sign!) Dx tests for pheochromocytoma Urine screen for VME (vanillylmandelic acid), metanephrine, epinephrine, norephinephrine Surgical treatment of pheochromocytoma? Possible perioperative complications? tumor resection with early ligation of venous drainage (lower possibility of catecholamine release); hypertensive crisis, hypotension w total removal of tumor, cardiac dysrhythmias Use __&___to evaluate breast malignancy? ultrasound and mammography Nipple Discharge duct ectasia (when lactiferous duct becomes clogged or blocked), abscess (tender fluctuant mass), blood discharge 10-15% of breast malignancy is unilateral ______ from a single duct. bloody discharge _____is a common benign breast tumor, late teens to early twenties, 1-3cm in size, fibrous stromal tissue and tissue clefts, FNA for dx. Fibroadenoma ______is the most common breast mass in women 40-50 years old. Screening mammogram, u/s, aspiration. Core-needle biopsy if complex on u/s. Breast cyst PE of breast exam should be in what 3 positions? sitting, supine, and leaning forward "akimbo" What are suspicious signs in a physical breast exam? skin dimpling, asymmetry, discoloration, edema, everted nipples wo rash or ulceration A ___________is recommended for tumors under 4cm. Post op radiation decreases to 30% recurrence rate. Lumpectomy Contraindications of lumpectomy (instead....simple/total mastectomy, modified radical mastectomy, axillary dissection, sentinel lymph node biopsy, breast reconstruction) dermal lymphatic involvement, diffuse or multiple tumors, unwillingness or inability to undergo radiation treatment, expectation of a poor cosmetic outcome Indications for chemotherapy node positive disease, tumors greater than 1cm Hormone therapy ie. ____decreases recurrence, contralateral breast cancer by 40% for estrogen positive tumors. tamoxifen Follow-up mammograms after breast cancer: Lumpectomy: bilateral mammogram 6 months after completing radiation therapy Radical mastectomy: annual contralateral mammogram PE: q 3-6 months for 3 years...then annually Pre-malignant breast cancers --atypical ductal & lobular hyperplasia --lobular hyperplasia --lobular carcinoma in situ (LCIS) Breast malignancies --ductal carcinoma in situ (non-invasive) DCIS --invasive ductal carcinoma --invasive lobular carcinoma --Paget disease of nipple Post-op drug eruptions: Anaphylaxis is the most severe form of immediate ______hypersensitivity. Characterized by s/s affecting multiple organ systems. (Pruritis, urticarial, angioedema, laryngeal edema, wheezing, nausea, vomiting, tachycardia, impending doom, occasionally shock) Tx? type I/IgE-mediated drug reaction; epinephrine Anaphylaxis: for bronchospasm not relieved with epinephrine, what can be used? Albuterol Itching/hives reaction only treatment? ______onset can also be used to prevent biphasic or protracted reactions but onset can take several hours H1 antihistamine like Cetirizine or Diphenhydramine; glucocorticoid ________is second most common drug eruption after exanthematous drug eruptions. Characterized by short lived swelling of the skin, oropharynx, or genitalia. Transient leakage of plasma from small blood vessels into surrounding connective tissue of the dermis resulting in wheals. --scaly plaques/papules - can look like psoriasis, eczema, others --resembles melanoma --least common, white to yellow patch w poorly defined borders Squamous cell carcinoma is aka _______disease if it is SCC in situ. A potentially invasive malignancy of keratinocytes in the skin or mucous membranes. Bowen's disease Squamous cell carcinoma presentation: flesh, pink, yellow, or red indurated papules, plaques, or nodules with scale. Can have ulcerations and erosions. Melanoma presentation: flat, raised, nodular, or ulcerated -- variable color -- consider in any new mole or a mole changing in shape, size, or color What is the ABCDE for melanoma? A - asymmetry B - border C - color D - diameter E - evolution The most common type of melanoma is ________. Asymmetric, flat, lesions >6mm, vary in color, lateral spread superficial spreading melanoma Nodular melanoma is most common where? Acral lentiginous melanoma is primarily? Nodular melanoma:: extremities Acral lentiginous hands, feet, and nails. MC in blacks and Asians. Amelanotic melanoma is innocent-appearing pink to red colored papules that enlarge to plaques and nodules. Scary. Which type of suture is good for maximizing wound eversion? vertical mattress Are Nylon, Prolene, Stainless Steel, and Silk sutures absorbable or non-absorbable? non-absorbable Are vicryl, monocryl, PDS (polydioxanone), chromic, and gut sutures absorbable or non-absorbable? absorbable Which suture is smaller: a 5.0 or a 3.0? a 5.0 How long does it take a wound to heal in the skin and mucosa? 5-7 days How long does it take a wound to heal in subcutaneous and peritoneum tissues? 7-14 days How long does it take a wound to heal affecting the fascia? 14-28 days What are some local and systemic factors that affect wound healing? Local: wound cleanliness, controlled bleeding, radiation, infection Systemic: nutrition, uncontrolled DM, medications, chronic illness, smoking, hypoxia What are the three stages of wound healing? inflammatory, epithelialization & neovascularization, tissue remodeling The ________stage of wound healing occurs in the first few days. The initial injury leads to the recruitment of inflammatory cells into the wound, once a clot forms in response to disrupted blood vessels. Complex interaction between local tissue mediators and cells that migrate to the wound. inflammatory The _______stage of wound healing results from the increase in cellular activity. Granulation tissue forms and depends on specific growth factors for further organization to occur in the completion of the healing process. Weeks to months. Epithelialization and neovascularization _________occurs over 6-12 months in which the wound contraction and tensile strength is achieved. Tissue Remodeling CDC Surgical Wound Classification: _________are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Operative incisional wounds, primarily closed or closed drainage. Clean wounds CDC Surgical Wound Classification: _________are operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and wo unusual contamination. Biliary tract, appendix, vagina, oropharynx are in this category. Clean-contaminated CDC Surgical Wound Classification: _________are open, fresh, accidental wounds, operations w major breaks in sterile technique or gross spillage from the GI tract, and incisions in which acute, nonpurulent inflammation is encountered. Contaminated CDC Surgical Wound Classification: _________ are old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. Dirty or infected IV Fluid -- What fluid should you NOT use with a brain injury because of worsening brain edema? no sugar!!!!!!!!!! What is the 421 rule for adult fluid replacement? 4mL/kg for first 10kg/hr 2ml/kg for second 10kg/hr 1ml/kg for each additional kg/hr Patients with GI loss or 3rd space losses may require a ______amount of saline to maintain volume balance. higher Normal replacement of fluids in surgical patients is _____mEg/kg of sodium and ______mEg/kg of potassium per day. 1mEg/kg of sodium; 0.5mEg/kg of potassium RANDOM FLASH CARDS NOW RANDOM FLASH CARDS NOW Potassium rule of thumb: 10meq of potassium is expected to raise a patient's potassium level by ____. 0.1 points When surgeons talk about classic "breast cancer", what form are they specifically talking about? invasive ductal carcinoma Why is DCIS noninvasive? because it does not penetrate the basement membrane With breast cancer, what is the one specific case when chemotherapy is not necessary? IN ALL OTHER CASES, CHEMOTHERAPY IS DONE! A sliding hernia contains ____organs. intra-abdominal An ___hernia is common in thin, elderly women, SBO from herniation into the obturator canal. obturator A _____hernia contains a Meckel's diverticulum. Littre A Richter hernia is when a portion of bowel protrudes, the lumen is patent, what is the result? usually gangrenous necrosis A _____is a bulge and weakness of the linea alba, no actual herniation. diastasis recti What is the most common type of lung cancer? Non-Small cell 85 % ie. adenocarcinoma (35%) squamous (30%) large cell (10%) Lung Adenocarcinoma usually occurs at the _____. periphery Lung Squamous cell carcinoma usually occurs _____. What is this cancer associated with? Patients may present with hypercalcemia, Pancoast's syndrome, and hypertrophic pulmonary osteoarthropathy centrally; associated with smoking, NO oat cell appearance Lung Small cell carcinoma is usually located where? What is it associated with? What is the classic appearance? centrally; associated with smoking; oat cell appearance Lung_______carcinoma is associated with paraneoplastic syndromes small cell _______syndrome presents with flushing, diarrhea, and palpitations. Elevated 5-HIAA levels Carcinoid 50% of carcinoids are found where? The rest are found throughout the GI tract. appendix Thyroid cancer: ______is the most common, good prognosis, painless single nodule, ground glass appearance. Psammona bodies Papillary Thyroid cancer: ______has a poor prognosis, can metastasize to lungs/bones, iodine is used with unresectable or gross disease Follicular Thyroid cancer: ________is often familial, produces calcitonin and is known to metastasize early to surrounding lymph nodes. Medullary Thyroid cancer: _______is common in the elderly, poor prognosis, rapidly enlarging neck mass. Anaplastic/Lyphoma From highest inflammatory reaction to lowest inflammatory reaction, rank the following suture types: silk, chromic gut, nylon. highest - silk then chromic gut, then nylon Which type of suture loses tensile strength in ~8 weeks? Polydioxanone What percentage of liver tumors are malignant? 95% Cirrhosis, alcoholism, aflatoxins, smoking are all predisposing factors for ________. hepatomas (hepatocellular carcinoma) _______is a specific marker for hepatoma. alpha-fetoprotein The Child-Turcotte-Pugh Scoring system for cirrhosis - class C (possible B) may not......... tolerate a liver resection _______is the most important anesthetic complication. Anesthesia causes an uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove CO2, and regulative body temperature. Malignant hyperthermia If patient is hyperkalemic (normal range 3.8-5.0), how should you treat the patient? treat with glucose/insulin, and calcium +/-bicarb _______is the reversing agent for opiods. Naloxone _______is the reversing agent for benzodiazipines. Flumazenil What is the best indicator used to monitor nutritional status? prealbumin - every 2-3 days Intervention: _________require central access and indicated when no enteral feeding for > 7 days. TPN - total peripheral nutrition The _________is the most important part of the history before surgery. cardiac history -- history of MI, unstable angina, valvular disease In patients with known cardiac disease, aggressive intraoperative lowering of myocardial oxygen demand with ____ has been shown in RCT's to improve outcomes and should be used. beta blockers When accessing cardiac disease prior to surgery, what is the most important thing to access? aortic stenosis -- crescendo diastolic rumble at apex Guidelines for the use of antibiotics include administration within _______ of surgery and redosing after 4 hours. What is the abx of choice? 1 hour Abx of choice: cefazolin for all except colorectal then cefazolin/metronidazole Pre-op -- Metabolic disease/syndrome -- what are the 5 criteria? 3/5 to diagnose: 1 - diabetes 2 - central obesity 3 - HTN 4 - high serum triglycerrides 5 - low HDL levels ______should be monitored before surgery bc it is a stimulant and vasoconstrictor -- can lead to severe tachycardia Cocaine Pre-Op -- What are the indications for EKG and CXR? EKG - men >40, women>50, known CAD, DM, or HTN CXR - age >50, known cardiac or pulmonary disease Hypervolemic, Euvolemic, Hypovolemic What are the two most common treatments for hyponatremia? Other less common treatment? salt tabs and fluid restriction; vasopressin receptor antagonist in SIADH, CHF, and cirrhosis Hypernatremia is almost always due to _______. Therefore, what is the treatment? dehydration; rehydrate! What s/s can result in a hyperkalemic patient? cardiac arrhythmias (tall peaked T waves) and weakness If the potassium level is above 6meq/L or the patient has EKG changes, what treatments can lower K temporarily? calcium gluconate, sodium bicarbonate, insulin and glucose, kayexalate (takes longer to be effective) ______&______ is extremely effective in decreasing potassium. Dialysis and furosemide Hypokalemia is usually due to ________, hypomagnesemia, alkalosis, high aldosterone levels. How is it treated? potassium loss; replacement must be slow!!! Mild loss: oral KCl supplements or K containing foods Severe loss: IV supplementation - rate 10mEg/hr Causes of ________are VITAMIN D METABOLIC DISORDERS, abnormal PTH function, primary hyperparathyroidism, Lithium, malignancy, disorders related to high bone turnover rates (hyperthyroidism, prolonged immobilization, thiazide use, vit A intoxication, Pagets dz of bone, multiple myeloma), renal failure hypercalcemia How should hypercalcemia be treated? fluid and diuretics, bisphosphonates, and calcitonin _______is usually caused by ineffective PTH (chronic renal failure, absent active vit D, ineffective active vit D, pseudohypoparathyroidism), deficient PTH. Hypocalcemia How should hypocalcemia be treated? intravenous calcium gluconate, Tums Increased CO2, hypoventilation, or decreased pH is aka ___. respiratory acidosis Decreased CO2, hyperventilation, or increased pH is aka ___. respiratory alkalosis Increased H+ or HCO3 loss, DKA, lactic acidosis is aka ___. metabolic acidosis Loss of H+ is aka ________. metabolic alkalosis The d/d of post op ___________can be MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection, pneumo/chyle/hemothorax, or gastritis. chest pain Who classically gets silent MI's? diabetics How should syncope be initially evaluated? It is important to distinguish syncope from cardiac arrest from other nonsyncopal conditions causing LOC Syncope d/d: Prodrome or aura usually associated with ____. seizures (as is loss of continence) Cardiac syncope's onset is usually ____without a prodrome. Monitor vitals regularly, EKG, orthostatic challenge, neuro exam etc. sudden In a surgery patient with dyspnea on exertion, what should be ruled out? PE or pneumothorax What are some chronic dyspnea on exertion causes? asthma, COPD, interstitial lung disease, myocardial dysfunction, obesity What are some acute dyspnea on exertion causes? angioedema, anaphylaxis, foreign objects, airway trauma, pulmonary infection, pleural effusion, peritonitis/ruptured viscous, bowel obstruction __________is pain, cramping, or both of the lower extremity (usually calf muscle) after walking a specific distance; then resolves for a specific amount of time while standing. Claudication What is claudication associated with? peripheral vascular occlusion D/D of lower extremity claudication? neurogenic/nerve entrapment/discs, arthritis, coartation of the aorta, popliteal artery syndrome, neuromas, anemia, diabetic neuropathy pain A _________is an abnormal dilation of an artery. Involve all layers of the arterial wall. aneurysm At what size is surgical repair of aneurysm recommended? 5.5 cm 95% of aneurysms are associated with ___________. atheroschlerosis -- other causes are trauma, infection, syphilis, & Marfan's syndrome What is the classic triad of s/s related to ruptured AAA? abdominal pain, pulsatile abdominal mass, hypotension Where does the aorta bifurcate? At the level of umbilicus Because the ________is often sacrificed during AAA repair, colonic ischemia can occur. IMA - inferior mesenteric artery _______is a separation of the walls of the aorta from an intimal tear and disease of the tunica media; a false lumen is formed and a "reentry" tear may occur, resulting in a "double barrel" aorta. Aortic dissection Explain the DeBakey classifications (Type 1,2, & 3) of aortic dissections. DeBakey Type 1 - ascending & descending aorta DeBakey Type 2 - ascending aorta DeBakey Type 3 - descending aorta Explain the Stanford classifications of aortic dissections. Type A -- ascending +/- descending aorta Type B - descending aorta What is the most common cause of aortic dissection. HTN! __________most often occur in saphenous veins and are caused by incompetent valves from damage or venous dilation, AV fistula, congenital venous malformations. Varicose veins What are some treatment options for varicose veins? compression stockings, leg elevation, venous ablation, sclerotherapy, great saphenous vein stripping ___________is obstruction of left subclavian artery. S/S: upper extremity claudication and upper extremity blood pressure discrepancy. Tx: surgical bypass or endovascular stent Subclavian steal syndrome _________is stenosis of renal artery which results in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the renin-angiotensin-aldosterone system. S/S - diastolic HTN, A-gram is diagnostic. Renal artery stenosis _________is a vasospasm of the digital arteries with color changes of the digits. Usually initiated by cold or emotion. Raynaud's phenomenon ________is arteritis of the aorta and aortic branches resulting in stenosis/occlusion/aneurysms. Takayasu's arteritis _________aka thromboangiitis obliterans; occlusion of vessels of hands and feet. Seen in young MEN WHO SMOKE. Buerger's disease Anemia is evaluated by measuring ________. MCV - mean corpuscular volume MCV >100 is aka ____. MCV 80-100 is aka ___. MCV <80 is aka ___. MCV >100 is macrocytic. MCV 80-100 is normocytic. MCV <80 is microcytic. What are the most common causes of macrocytic, normocytic, and microcytic anema? Macrocytic -- B12 def, folate def, EtOH, HIV drugs Normocytic -- anemia of chronic disease Microcytic -- GI loss, menstruation The normal Hemoglobin for an adult male and female is: The normal Hematocrit for an adult male and female is: Hemoglobin - male=13.5-17.5 female=12-16 Hematocrit - male & female=~40% The d/d for ________is gastric cancer, gastroenteritis, influenza, pneumonia, infectious disease illness. anorexia The d/d for ________is gastric cancer, bowel obstruction, increased intracranial pressure, pregnancy, migraine, IBS, malignancy, appendicitis, cholecystitis, cholelithiasis, PUD, UTI... nausea/vomiting The d/d for ____is jaundice of newborn, hyperbilirubinemia, cholelithiasis, small bowel adenocarcinoma, pancreatic carcinoma, pancreatic pseudocyst. jaundice The d/d for _____is upper GI bleed, esophageal or gastric varices, gastritis, malignancy etc. hematemesis The d/d for ________infectious pathology, colorectal carcinoma, bowel obstruction, diverticular disease, volvulus, dietary. diarrhea, constipation, opstipation The d/d for ________is diverticulosis, diverticulitis, colon polyps, colorectal carcinoma, UC, Chron's, cancer, hemorrhoids. melena, hematochezia The d/d of ________is hiatal hernia, GERD, PUD, Barrett's, cholecystitis. heartburn, dyspepsia What are some causative agents of esophageal strictures? GERD, iatrogenic, long term NG tubes, caustic agents {lye, over cleaners, drain cleaners, batteries} Treat shallow esophageal ulcers with _______, and use ____for moderate or deep ulcers. Upper GI at 10-14 days. corticosteroids, antibiotics If an esophageal stricture develops, treat with what? What about in severe cases? dilation with Maloney dilator or balloon catheter. In severe cases, esophagectomy with colon interposition or gastric pull up After esophageal stricture, because of risk of esophageal squamous cancer, what should be done to screen more regularly (every other year)? endoscopies _________is the most common type of esophageal cancer at the GE junction in the US. Adenocarcinoma ________is the most common type of esophageal cancer worldwide. squamous cell carcinoma What are the 5 factors related to esophageal cancer? tobacco, alcohol, GE reflux, barrett's esophagus, radiation Esophageal cancer is most common in what sex, age, ethnicity? 60s, male, black Treatment of _______with esophagectomy with gastric pull up or colon interposition. esophageal cancer ________is reflux of gastric contents into lower esophagus resulting from decreased fx of LES. Esophageal reflux Some causes of _______are decrease LES tone, decreased esophageal motility, hiatal hernia, gastric outlet obstruction, and NG tube. esophageal reflux Complications of esophageal reflux requiring surgery: failure of medical therapy, esophageal strictures, progressive pulmonary insufficiency secondary to documented nocturnal aspiration, barrett's esophagus Barrett's esophagus is replacement of lower esophageal squamous epithelium with columnar epithelium secondary to reflux. This is a ________malformation. pre-malignant ________is the most common esophageal diverticulum. Zenker's diverticulum What are the s/s of Zenker's diverticulum? Dx is made via ____. dysphagia, neck mass, halitosis, food regurgitation, heart burn; barium swallow What are the two treatment options for Zenker's diverticulum? diverticulectomy; cricopharyngeus myotomy if >2cm abscess, perforation, choledocholithiasis, cholecystenteric fistula formation, gallstone illeus What is the test of choice for cholecystitis? u/s -- then HIDA scan What labs are often elevated with cholecystitis? Choledocholithiasis? Cholangitis? Gallstone pancreatitis? cholecystitis: increased WBC and minor LFT abnormalities Choledocholithiasis: increased bilirubin & alkaline phosphatase Cholangitis: elevated serum bilirubin and transaminase levels, as well as leukocytosis Gallstone pancreatitis: elevations in serum amylase and lipase Gallstones (cholelithiasis) increase with age and in what specific population? Fat, Female, Forty, Fertile Biliary colic that lasts longer than 6 hours is often ____. cholelithiasis 15% of stones pass through the cystic duct and enter the common bile duct. Patient presents with RUQ abdominal pain, jaundice, light colored stools, and tea colored urine. This is aka ____. choledocholithiasis In choledocholithiasis, what study can be used to extract the stones? ERCP - endoscopic retrograde choloangeopancreatography _________is infection of the biliary tract. Cholangitis What is Charcot's triad? fever with chills, RUQ abdominal pain, jaundice What is Reynold's Pentad? Charcot's triad, hypotension, altered mental status What are some common causes of cholangitis? choledocholithiasis, stricture, neoplasm (usually ampullary carcinoma), extrinsic compression (pancreatic pseudocyst/pancreatitis), instrumentation of the bile ducts, biliary stent What are the most common causative organisms of cholangitis? gram negative - E Coli, Klebsiella, Pseudomonas, Enterobacter, Proteus, Serratia. Enterococci are the most common gram positive bacteria Anaerobes are less common The treatment of ________is with stone extraction and/or decompression, laparotomy with T tube placement, NPO, IVF, broad spectrum abx. cholangitis _________is a SBO from a large gallstone that has eroded through the gallbladder and into the duodenum/small bowel. Tx: removal of stone w possible cholecystectomy. Gallstone illeus Most gallstone carcinomas are ________(type of cancer.) adenocarcinoma _______is malignancy of the extrahepatic or intrahepatic ducts -- primary bile duct cancer. Management is whipple procedure. Cholangiocarcinoma _______is a calcified gallbladder. Removal required bc of strong association with gallbladder cancer. Porcelain gallbladder _______of the gallbladder is complete obstruction of the cystic duct by gallstone and filling of the gallbladder with fluid. Hydrops ________is inborn error in liver bilirubin uptake and glucuronyl transferase resulting in hyperbilirubinemia. Gilbert's syndrome _________is a palpable, NONTENDER gallbladder. Associated with cancer on head of pancreas. Courvoisier's gallbladder ______is common hepatic duct obstruction as a result of extrinsic obstruction from gallstone impacted in the cystic duct. Mirizzi's syndrome ______carcinoma is the most common primary malignancy of the liver -- accounts for 80% of all primary malignant liver tumors Hepatocellular carcinoma - can either be nonlamellar or lamellar Some associated risk factors of hepatocellular carcinoma are ___, ___, or ___. Hep B virus, aflatoxin, or cirrhosis S/S of hepatocellular carcinoma are: dull RUQ pain, hepatomegaly (classic: pain), abdominal mass, weight loss, portal HTN, ascites, jaundice, fever, splenomegaly Most is the most common site of liver metastases? lungs ____is a serious and painful condition in which pancreatic enzymes, which help digest fats/sugars, overreact and begin to digest the pancreatic tissue itself. Pancreatitis What are s/s of pancreatitis? non-crampy epigastric pain, variable character, radiation to LUQ/RUQ or back, pain alleviated by sitting or standing, n/v What is the most common cause of pancreatitis? alcoholism (others are high triglycerides, gallstones) In pancreatitis, the patient may present with fever, tachycardia, upper abdominal tenderness, and absent bowel sounds. Is amylase or lipase more specific for pancreatitis? lipase What is the study of choice for pancreatitis? CT scan A ____is a collection of tissue & fluids that forms on the pancreas, that is not surrounded with epithelial capsule like a true cyst would be. Usually the result of pancreatitis. Less likely to be cancerous that a true cyst. pancreatic pseudocyst A pancreatic pseudocyst is only dangerous if what happens? if it ruptures -- can present without symptoms or may cause hematemesis, fainting, weak and rapid heartbeat, abdominal pain What are two treatments for a pancreatic pseudocyst? pancreatic rest (NPO), surgical drainage Pancreatic ____ are sac-like pockets of fluid on or within your pancreas. May have no symptoms or persistant abdominal pain that may radiate to the back. cysts ___________is the 4th leading cause of cancer deaths in the US. Pancreatic carcinoma Risk factors of pancreatic carcinoma alcohol > 4/day, obesity, BRCA gene, DMII, FH, tobacco use Benign Small bowel tumors - _____tumors are asymptomatic, sexes equally affected, smaller, lack necrosis, lack invasive or metastatic behaviors, may cause mucosal ulceration, most common in jejunum. GIST's - benign gastrointestinal stromal tumors/leiomyomas Benign Small bowel tumors - _____are similar to GIST tumors but more common in males and in the duodenum and ileum. Lipomas Benign small bowel tumors - ______is occult bleeding, 5% of benign small bowel lesions, multiple lesions, Osler-Weber-Rendu syndrome, not visible on contrast studies, capsule endoscopy, ANGRIOGRAPHY is useful in the setting of active bleeding. Hemangiomas Benign small bowel tumors - _____is typically isolated and asymptomatic, bleeding or intussusception potential, multiple ones may be present in Peutz-Jeghers syndrome. Hamartomas Epithelial benign lesions of the small intestine are tubular and villous adenomas and asymptomatic brunner's gland adenoma. Which one is most likely to become malignant? villous adenomas For small bowel carcinoma, what decade is most common for diagnosis? It what type of patient should you have a high clinical suspicion of carcinoma? 6th decade; a patient with a SBO without prior abdominal surgery or hernia _______carcinoma from pre-existing benign adenoma is the most common malignancy after proctocolectomy in patients with familial polypoisis and require endoscopic surveillance. Duodenal _________represent 1/2 of all small intestine malignancies. The most common site is the duodenum. What is the surgical management? Adenocarcinomas; wide resection of the involved bowel with wide margins --- adjuvant therapy poor response -- low survival rate due to delayed/advance disease at diagnosis Carcinoid tumors are the most common endocrine tumors of the GI tract and arise from _________cells. What does extent of metastasis depend on? enterochromaffin cells or Kulchitsky cells; dependent on tumor size 40-50% of GI carcinoids originate where? in the appendix ________syndrome is often exhibited by episodic cutaneous flushing, bronchospasm, intestinal cramping, diarrhea, vasomotor instability, pellagra-like skin lesions, and right sided heart disease. What are triggers? Carcinoid; elaboration of serotonin by tumor (spontaneous, excitement, alcohol, anesthesia, tumor manipulation) The small bowel is the most common site of extranodal ____. The ileum is the most common site. Lymphoma Explain what MALT and GIST. What is the medical therapy for GIST tumors? MALT = mucosa-associated lymphoid tissue; GIST = malignant gastro-intestinal tumors; imatinab ______: patients are severely ill (toxic) and usually have one or more: inflammation involving the muscular coats, hypokalemia, opiod use, anticholinergic use, or barium enemia examination. S/S: severe bloody diarrhea. What is the emergent treatment? Toxic Megacolon -- put patients in knee-elbow position and use a rectal tube to help colon decompress In toxic megacolon, what does abdominal film or barium enema show? thickened bowel wall and dilated lumen Colorectal carcinoma is most common in ______&_______colon near the rectum. ______accounts for 95% of primary colon cancers. descending and sigmoid; adenocarcinoma What are some s/s for colorectal cancer? rectal bleeding, tenesmus, iron deficiency anemia, abdominal mass or pain, weakness, mets to liver and lung, change in stool quality of caliber [#1 reason for lg bowel obsrtuction] What predisposes a patient to colorectal cancer? Men - rectal cancer; Women - colon cancer; ulcerative colitis, polyps >40yo, - peak at 70s, famililar polyposis, garner's syndrome, hereditary nonpolyposis colon cancer, lymphogranuloma venereum What are some mild risk factors for colorectal cancer? diet, inactivity, obesity, smoking, race, and alcohol What are the screening recommendations for colorectal cancer? At what age should screening begin? At age 50 or age 40 for increased-risk patients: --yearly fecal occult blood test --flexible sigmoidoscopy every 5 years --colonoscopy every 10 years --double contrast barium enema every 5 years What increased testing should be performed on a high risk patient? genetic blood testing, UC or Chron's > 10 years requires annual screening Where is the most common site of distal metastases? liver Monitoring of the tumor marker ____ is useful in colorectal cancer. ________involvement is the most important prognostic variable. CEA (carcinoembryonic antigen); lymph node involvement ________is multiple acquired diverticula through the colon. What is the presentation? Diverticulosis; LLQ pain, rectal bleeding, alternating constipation and diarrhea _______is infection of one or more diverticula...typically from ____obstruction. Diverticulitis; fecaltih In diverticulitis, colonoscopy is not recommended. Why? possible perforation What is the acute treatment of diverticulitis? medical management -- IVF, bowel rest, IV abx After 2 hospitalizations from diverticulitis, what is recommended? elective sigmoid colectomy What is the treatment for a colovesical fistula? colectomy and primary bladder closure _______is a congenital anomaly -- a remnant of the embryonic vitelline/omphalomesenteric duct -- located w/in 2 feet of the ileocecal valve. Meckel's diverticulum What is the Meckel's diverticulum "rule of 2's"? 2 inches longs, located within 2 feet of the ileocecal valve, 2 times as common in males than females, 2% of the population, 2% symptomatic, 2 types of ectopic tissue -- gastric & pancreatic For Meckel's diverticulum patients, those presenting with malabsorption, impaction, perforation etc. are treated how? with surgical resection and/or small bowel resection What are the three most common causes of a small bowel obstruction? ABC's dx? lower esophageal webs/constrictions at squamocolumnar junctions MC associated w/ sliding hiatal hernias but also can be s/p corrosive injury schatzki ring test of choice is barium sallow tx: dilation esophageal varices are MC d/t? tx to prevent rebleeds? -cirrhosis as a complication of portal venous HTN -long term tx: 1. nonselective BB: propranolol, nadolol 1st line (reduces portal pressure) but not used in acute bleeds bc pt may already be hypovolemic 2. isosorbide: long acting nitrate (vasodilator) tx of an acute esophageal varices bleed? these have a 30-50% mortality rate w/ 1st bleed and 70% recurrence rate w/i 1st yr! 1. 2 large bore IV lines, IVF, +/- blood transfusion 2. endoscopic ligation is tx of choice 3. pharmacologic vasoconstrictors- octreotide 1st line (somatostatin analog), vasopressin 4. balloon tamponade 5. surgical decompression TIPS (transjugular intrahepatic portosystemic shunt) connects portal vein to hepatic vein to drain to IVC what is the tx for type I/sliding hiatal hernia vs type II/rolling hiatal hernias? -type I/sliding: (MC type 95%) tx: none except manage GERD it causes -type II/rolling: (paraesophageal) tx: surgical repair to avoid complications (strangulation) in comparing squamous cell vs adenocarcinoma of the esophagus, which is: -MC worldwide (90%) VS MC in the US -MC in upper 1/3 of esophagus VS lower 1/3 -RF of untreated GERD/barrett's VS tobacco/EtOH use, exposure to noxious stimuli, AA -squamous cell: MC worldwide (90%), upper 1/3, RF: tobacco/EtOH use, exposure to noxious stimuli, AA -adenocarcinoma: MC in US, lower 1/3, RF: untx'd GERD/barrett's what are the 2 most common causes of gastritis? how are they diagnosed and treated? 1. H. pylori MC- stool antigen or urea breath test; tx: triple therapy: "CAP" clarithromycin + amoxicillin + PPI or metronidazole if PCN allergic; if macrolide resistance suspected do quad therapy: PPI + bismuth subsalicylate + tetracycline + metronidazole 2. NSAIDs/ASA- clinically dx but EGD gold std; tx: acid suppression (PPI, H2RA, antacids) is a gastric or duodenal ulcer more associated with relief of epigastric pain (dyspepsia) with eating? which type always needs a Bx and endoscopic monitoring 2-3 mos later to r/o malignancy and document healing? -duodenal ulcer (area becomes more basic when you eat in preparation for acid/food later on); these are 4x more common that GUs -gastric ulcer bc higher risk of malignancy PPIs block the _______ pump of the ________ cell reducing acid secretion; taken _____ min before meals and can result in diarrhea, HA, hypomagnesemia, _____ deficiency, and hypocalcemia; which PPI causes CP450 inhibition? -H/K ATPase pump -parietal cells -30 min -B12 deficiency -omeprazole causes CP450 inhibition (can inc levels of theophyllin, warfarin, phenytoin, etc.) which H2RA/H2 blocker causes CP450 inhibition (can inc levels of theophyllin, warfarn, phenytoin, etc.) and can also cause anti-androgen s/e (gynecomastia, impotence, dec libido)? cimetidine/Tagamet what PUD tx is best for treating NSAID induced ulcers because it is a prostaglandin E1 analog that increases bicarb & mucus secretion? what pts is this drug contraindicated in? -misoprostol -CI: premenopausal women bc abortifacent and causes cervical ripening what PUD treatments are cytoprotective (forms viscous adhesive ulcer coating that promotes healing and protects stomach mucosa)? what s/e can they have? -bismuth compounds (pepto-bismol, kaopectate): also antibacterial; s/e: darkening of stool/tongue, constipation -sucralfate/Carafate: s/e: may reduce bioavailability of H2RA what is the MC type of gastric carcinoma? risk factors? s/sx? tx? -adenocarcinoma MC (90%) -stomach is MC site of extranodal non-hodgkin lymphoma -RF: H. pylori, foods containing nitrites/nitrates -s/sx: dyspepsia, wt loss, early satiety, IDA, supraclavicular LN (virchows), umbilical LN (sister mary joseph's) -tx: gastrectomy, chemo, XRT (prognosis poor) what are the 5 F's of RF for cholelithiasis? -fat -fair -female -forty -fertile what medicine can be used to dissolve gallstones in symptomatic cholelithiasis pts? ursodeoxycholic acid (Ursodiol) -but elective cholecystectomy usually done -in nonsymptomatic pts: observation choledocholithiasis is a gallstones stuck in the __________ duct whereas cholelithiasis is stuck in the __________ duct -choledocholithiasis: common bile duct -cholelithiasis: cystic duct what is the tx for choledocholithiasis? -ERCP w/ stone extraction (diagnostic and therapeutic) what are the s/sx's in charcot's triad and reynold's pentad for acute cholangitis? charcot's triad: 1. fever/chills 2. RUQ pain 3. jaudice reynold's pentad: 4. shock/hypotension 5. AMS what are the MC infectious agents seen in acute cholangitis and cholecystitis? what is the tx? -(gram neg organisms ascending from GI tract) E. coli MC, followed by Klebsiella, Enterococci -tx options: ampicillin/sulbactam, piperacillin/tazobactam, ceftriaxone/metronidazole, FQ/metronidazole, or ampicillin/gentamicin (-) HBsAg, (+)HBs Antibody, (+)IgG Anti-HBc, (-)HBeAg they had Hep B infection and now its resolved. (+) HBsAg, (-)HBs Antibody, (+)IgG Anti-HBc, (+)HBeAg chronic hep B infection; contagious; replicative *if they were to have -HBeAg and +anti-HBe that would mean they are in a nonreplicative state (+) HBsAg, (-)HBs Antibody, (+)IgM Anti-HBc, (+)HBeAg acute hepatitis infection, they are actively replicating. You need to bring them back to make sure they clear it (-) HBsAg, (+)HBs Antibody, (-)IgG Anti-HBc, (-)HBeAg vaccination (-) HBsAg, (-)HBs Antibody, (+)IgM Anti-HBc, (-)HBeAg latent, window period. Surface antigen is cleared, but we haven't mounted IgG yet. Still fighting core. They are still contagious what is the tx of acute and chronic hepB infxn? prevention? -acute: supportive -chronic: treat if inc ALT, inflammation on Bx, or (+)HBeAg (replicative state) w/ alpha-interferon 2b, lamivudine, adefovir, tenofovir, telbivudine, or entecavir; screening for HCC w/ serum AFP and US -prevention: hepB vaccine given at 0, 2, and 6 mos an elevated alpha-fetoprotein (AFP) is a tumor marker for? what are the risk factors for this cancer? tx? -hepatocellular carcinoma (HCC) -RF: hep B, C, D, cirrhosis, alflatoxin B1 exposure (produced from aspergillus spp) -tx: surgical resection or transplant if pt has severe cirrhosis what are the MC causes of cirrhosis? -EtOH MC -chronic viral hepatitis (B, C, D) -nonalcoholic fatty liver dz (obesity, DM, hyperTGemia) -hemochromatosis what is the tx of cirrhosis? 1. encephalopathy: (reduce ammonia) lactulose, abx (rifampin 1st line, neomycin), protein restriction 2. ascites: Na+ restriction, diuretics, paracentesis 3. pruritis: cholestyramine (bile acid sequestrant) 4. liver transplant: definitive + HCC screening w/ AFP & US what 5 values are taken into account for child-pugh classification of cirrhosis staging? total bili, serum albumin, PT INR, ascites, hepatic encephalopathy what are the most common causes of acute pancreatitis? 1. gallstones 2. EtOH abuse others: meds, malignancy, scorpion bite, trauma, CF, mumps in children acute pancreatitis is due to autodigestion of the pancreas by enzymes released from damaged __________ cells acinar cullen's sign (periumbilical ecchymosis) and grey turner's sign (flank ecchymosis) are associated with? acute pancreatitis (necrotizing and hemorrhagic) (the digestive enzymes have no only eroded the pancreas but surrounding vasculature = high risk for shock/hypotension) what lab values will be affected in acute pancreatitis? -leukocytosis -inc glucose (pancreas not producing insulin) -inc bilirubin (from gallstones) -inc triglycerides -inc lipase/amylase (lipase more specific) -inc AST/ALT (ALT more specific) -hypocalcemia (necrotic fat binds calcium) what is the tx of acute pancreatitis? "rest the pancreas", NPO, IV fluids, analgesia, broad spectrum abx if severe, ERCP if stone extraction needed what are MC causes for chronic pancreatitis? what clinical manifestations will occur? tx? -EtOH abuse (70%), idiopathic (15%), hypertriglyceridemia, CF in children -triad of pancreatic calcifications on AbXR, steatorrhea, and DM -tx: oral pancreatic enzyme replacement (amylase, lipase, protease helps w/ pain), EtOH abstinence, pain control a diverticula is an outpouching due to the herniation of ________ through the colon wall along natural opening at the ________ of the colon -herniation of mucosa -vasa recta what are common causes of diverticulosis? -low fiber diet -constipation -obesity what is the MC cause of lower GI bleeding (MC presenting as hematochezia)? diverticulosis (otherwise usually asymptomatic) dx/tx? fever, LLQ abd pain, inc WBCs, N/V, (+) guaiac, fecaliths obstruction, distention at sigmoid colon -diverticulitis -tx: clear liquid diet, abx (cipro or bactrim+metronidazole) which types of polyps have the highest risk for malignancy? -pseudopolyps -hyperplastic -tubular adenoma (adenomatous polyp) -tubulovillous (adenomatous polyp) -villous adenoma (adenomatous polyp) -pseudopolyps: benign- 2ndary to IBD (UC/crohn) -hyperplastic: low risk adenomatous polyps: higher risk -tubular adenoma (adenomatous polyp): nonpedunculated; MC adenomatous polyp and lowest risk of the 3 -tubulovillous (adenomatous polyp): intermediate risk -villous adenoma (adenomatous polyp): highest risk (think villians are bad!) colorectal cancer is the ____ MC cause of cancer related deaths in the US; it is an adenocarcinoma and its MC site of metastasis is ________ -3rd MC -liver (others: lungs, LNs) s. aureus -can tx w/ anti-motility agent like immodium, anti-inflammatory pepto bismol, and antiemetic what type of noninvasive infectious diarrhea (vomiting, voluminous, watery, - fecal/blood leukocytes) is MC caused by contaminated fried rice and is self-limiting? bacillus cereus -can tx w/ anti-motility agent like immodium, anti-inflammatory pepto bismol, and antiemetic Dx? noninvasive diarrhea, copious watery diarrhea, "rice water stools" grey, w/o fecal odor/blood/pus, rapid dehydration, transmitted via contaminated food & water and usually occurs in outbreaks during poor sanitation & overcrowding conditions in other countries; tx? dx: vibrio cholerae tx: fluid replacement is mainstay of tx, but if severe can give tetracyclines, FQs or macrolides to shorten length of disease what is the MC cause of traveler's diarrhea- a type of noninvasive infectious diarrhea (vomiting, voluminous, watery, - fecal/blood leukocytes) from unpeeled fruits and unsanitary drinking water/ice? tx? enterotoxigenic e. coli tx: fluids, bismuth, if severe FQ, bactrim, azithromycin what type of noninvasive infectious diarrhea (vomiting, voluminous, watery, - fecal/blood leukocytes) is usually iatrogenic following a course of abx (esp clindamycin) or chemotherapy and has very high leukocytosis, is aka pseudomembranous colitis, and can result in bowel perf and toxic mega colon? tx? dx: clostridium difficile tx: po metronidazole 1st line, vancomycin 2nd line unless severe dz vanc is 1st line what is the MC cause of bacterial enteritis? it is also the MC antecedant event in post-infectious Guillain- Barre syndrome; what causes it? campylobacter jejuni enteritis; undercooked poultry, dairy, water Dx? fever, HA, abdominal pain (may mimic acute appendicitis), diarrhea initially water then becomes bloody, on stool Cx "S, comma, or seagull shaped" organisms, MC from undercooked poultry; tx? dx: campylobacter jejuni tx: fluids/supportive but if severe erythromycin 1st line, followed by FQs or doxy Dx? high fever, lower abdominal pain, tenesmus, explosive watery diarrhea that becomes mucoid and bloody, febrile seizures in infants/young children, stool Cx showing fecal WBC/RBCs and CBC showing leukemoid rxn (>50,000 WBCs), sigmoidoscopy showing punctate areas of ulceration; tx? dx: shigella tx: fluids but if severe trimethoprim-sulfamethoxazole 1st line, FQs otherwise Dx? fever, abdominal pain, cramping, vomiting, mucus/bloody diarrhea, MC from poultry products, dairy, meat, eggs, exotic pets (reptiles, turtles), usually self-limited; tx? dx: salmonella (s. typhimurium) tx: fluids but if severe FQs, ceftriaxone, trimethoprim-sulfamethoxazole Dx? HA, constipation, pharyngitis, cough then crampy abdominal pain, diarrhea (pea soup stools), intractable fever, relative bradycardia, hepatosplenomegaly, blanching "rose spots" appear in 2nd week, usually from contaminated poultry or exotic pets (reptiles); tx? dx: salmonella (s. typhi) typhoid (enteric) fever tx: fluids + FQs Dx? watery diarrhea that progresses to bloody w/ crampy abdominal pain, vomiting, low grade or absent fever, usually from undercooked ground beef, unpasteurized milk/apple cider, day care centers, contaminated water; tx? dx: enterohemorrhagic e. coli tx: fluids/supportive but abx use controversial d/t inc incidence of hemolytic uremic syndrome in children Dx? fever, abdominal pain mimicking acute appendicitis (mesenteric adenitis, abd tenderness w/ guarding), from contaminated pork, milk, water, tofu; tx? dx: yersinia enterocolitica tx: fluid replacement but if severe FQs or trimethoprim-sulfamethoxazole Dx? frothy, greasy, foul diarrhea, after drinnking contaminated water from remote streams/wells; prevention? tx? dx: giardia lamblia (confirm w/ trophozoites/cysts in stool sample) prevention: boil H2O x1 min to kill cysts tx: fluids, metronidazole how is entamoeba histolytic contracted? complications? dx confirmation by? tx? -fecally contaminated soil/water via feco-oral route MC seen in developing nations -can result in GI colitis, dysentery (blood/mucus in stool), amebic liver abscess -confirm dx w/ stool ova & parasites -tx: metronidazole which is more acute, sharp and severe pain: parietal or visceral abdominal pain? parietal pain; visceral pain is slower, more gradual, dull, and aching feeling pain is parietal pain more localized or more referred? more localized because the skin overlying the area of parietal peritoneum is innervated by the same somatic nerve supply (so pain will be felt exactly where the peritonitis is!) where is visceral (organ) pain normally felt? more often in the midline bc of the bilateral sensory supply to the spinal cord; often presents as referred pain that is not well localized site of pain for appendicitis RLQ (starts periumbilical) site of pain for diverticulitis LLQ (sigmoid colon) esophageal rupture presenting in Mackler's triad of emesis, chest pain, neck/mediastinal emphysema/crunch from air filled tissues (Hamman's sign) Boerhaave syndrome what is a typical early sign of a SBO (small bowel obstruction) besides abdominal pain? recurrent vomiting of bile-stained fluid #1 cause = adhesions dx? tx? cramping abdominal pain, abdominal distention, vomiting, obstipation (absence of stool/flatus), hyperactive bowel sounds (tinks and visible peristalsis), air fluid levels in step ladder patter w/ dilated loops of bowel on abdominal XR -dx: small bowel obstruction -tx: NPO (bowel rest), IV fluids, bowel decompression via NG suction tube, if strangulated surgical intervention compare involuntary guarding with voluntary guarding involuntary guarding occurs when the muscle palpated remains rigid or board-like and means badness what diagnosis do you think of for an elderly or cardiac pt with severe unrelenting diffuse abdominal pain that is not made worse with palpation? ischemia (check for acidic pH and order visceral angiography) name the sign: acute pain in the L shoulder due to presence of blood or other irritants in peritoneal cavity when lying down and legs are elevated; seen with irritation of diaphragm from the phrenic nerve or to the L shoulder from a ruptured spleen Kehr's sign (referred pain) name the sign: radiating pain to the R shoulder (midback to R scapula) from gallbladder issues Boas sign (referred pain) name the sign: initial periumbilical pain that moves to RLQ (& palpation of LLQ elicits pain in RLQ) seen in appendicitis Rovsing's sign 2. symptomatic jaundice (kernicterus), inc indirect bili from absence of GT 3. asx jaundice, nml LFTs, inc direct bili, due to impaired hepatocyte excretion of conj. bili into bile 1. gilbert syndrome 2. crigler-najjar syndrome 3. dubin-johnson syndrome causes of melena vs hematochezia? -melena: bleeding (usually) above ligament of Treitz: PUD, varices, gastric carcinoma -hematochezia: diverticulitis, colon cancer, hemorrhoids Dx? infant <6 mos old, non-bilous vomiting/regurgitation that becomes projectile vomiting after feeding, dehydration, malnutrition, jaundice, olive-shaped non-tender mobile hard nodule in epigastric area, string sign on upper GI contrast; tx? dx: pyloric stenosis tx: rehydration and electrolyte replenishment & pyloromyotomy what is the diagnostic test of choice for pyloric stenosis? US showing thickening of pylorus -can also do an upper GI contrast which will show string sign (dye through narrowed channel) what type of acid-base disturbance will you see with pyloric stenosis? hypochloremic metabolic alkalosis what are the contents of a pancreatic pseudocyst? complications? fluid collections of pancreatic enzymes; can become infected and turn into an abscess, can rupture, can bleed, can cause bowel obstruction on duodenum pancreatic pseudocyst tx -internal drainage (tube to stomach or anastomosed to jejunum) if >6 cm or >6 wks -external drainage (through skin) if critically ill complications: infection, rupture, hemorrhage, bowel obstruction Ddx/tx? pt presents s/p acute pancreatitis 2 weeks ago with pain, fever, leukocytosis, elevated lipase/amylase, and a palpable mass over the epigastric/LUQ area -DDx: pancreatic pseudocyst vs pancreatic abscess; diagnose w/ CT scan a pt w/ severe acute pancreatitis that fails to improve a develops rising fever or recurrent symptoms after a period of recovery should be worked up for a pancreatic abscess *mortality rate of 20% tx of pancreatic abscess -drainage -Cx -broad spectrum abx -surgical debridement of necrotic tissues if necessary new onset DM in an older (50-60 y/o) pt who does not appear to be diabetic (not obese) should be worked up for pancreactic cancer what is the most common type of pancreatic cancer? ductal adenocarcinoma (>90%)- poorly differentiated (worse) migratory thrombophlebitis associated with malignancy is called? Trousseau syndrome/Trousseau's sign of malignancy (i.e. w/ pancreatic cancer) in what part of the pancreas is cancer normally located? head a palpable, nontender gallbladder in a jaundiced pt is called a ______ sign and is most often due to pancreatic cancer (or biliary cancer) Courvoisier sign what labs/PE findings may show up in a pancreatic ca. pt? elevated direct bilirubin, elevated alk phos, CEA, CA19-9, gray-clay colored stools, painless jaundice, pruritis, anorexia, Courvoisier's sign (palpable, nontender, distended GB), abdominal/back pain what is a great test to check for pancreatic ca. when nothing shows up on CT/US but you are really suspicious? ERCP (inj contrast directly into pancreatic duct) pancreaticoduodenectomy aka ? is very surgeon dependent when it comes to mortality rates whipple procedure what areas must be free of tumor for pancreatic cancer to be considered resectable? 1. hepatic a near origin of gastroduodenal a 2. SMA (under body of pancreas) 3. liver and regional LNs Dx? anorexia, periumbilical/epigastric pain followed by RLQ pain, nausea, vomiting, rebound tenderness, rigidity, guarding, pain when leg is raised against resistant; workup? tx? dx: appendicitis workup: US, CT, CBC w/ leukocytosis tx: appendectomy & sometimes broad spectrum abx if caught early and uncomplicated -other signs; Rovsings (RLQ pain from LLQ palpation), Obturator sign (RLQ pain w/ hip rotation), McBurney's pt tenderness (1/3 distance from ASIS to umbilicus), Psoas sign (described in scenario) while malignancies involving the small intestine are rare, they most commonly are what type? 1. adenocarcinoma (mostly in duodenum) 2. carcinoid (mostly in ileum) 3. lymphoma 4. sarcoma *increased risk if pt has HNPCC, Peutz-Jeghers syndrome, FAP, IBD- Crohn's dz, CF dx? nonobstructive colon dilation >6 cm + signs of systemic toxicity; causes? tx? -toxic megacolon -causes: UC, Crohn's, C. diff (pseudomembranous colitis), infectious, radiation, ischemic -tx: decompression where is volvulus (twisting of the bowel at its mesenteric attachment site) most common? tx? -MC: sigmoid and cecum -tx: endoscopic decompression initially and if failed, surgical correction what type of inguinal hernia protrudes at the internal inguinal ring and is lateral to the inferior epigastric artery (d/t persistent patent process vaginalis) presenting as intestines in the scrotal sac dx: indirect inguinal hernia (MC type) tx: manual reduction but usually surgical correction a direct inguinal hernia protrudes medial to the inferior epigastric artery in Hesselbach's triangle which borders are? RIP -Rectus abdominus (medial) -Inferior epigastric artery (lateral) -Poupart's/inguinal ligament (inferiorly) -this does NOT go into scrotum what type of hernia is MC seen in women? -stable angina: inc risk but okay to operate -unstable angina: high risk- needs further investigation and intervention prior to surgery who should patients with a h/o DM x5-10 years receive an EKG prior to elective procedures? -@5-10 yrs 60% have vascular pathology -after 20 years nearly all do what are some factor that increase peri/postoperative pulmonary complications? -smoking -asthma -obesity -COPD -prolonged OR time (3-4 hrs) -tracheal Intubation -thoracic or intra-abdominal surgery -age > 60 y/o -hypotension -acidosis -chronic bronchitis prevention of the MC postop pulmonary complication (atelectasis) can be prevented by? incentive spirometer and early mobilization to increase VC/FRC because smoking increases postop pulmonary complication risk by 2-4x, cessation should be encouraged ____ weeks before surgery (although compliance is rare) 6 weeks before perioperative AKI (acute kidney injury) is MC d/t? ATN (acute tubular necrosis) from intraoperative hypotension is CKD or ESRD a contraindication to surgery? no, just need to monitor fluids, electrolytes, HTN, hypotension very closely in an insulin dependent diabetic prior to surgery when should insulin be held? -rapid/short acting held when oral intake stops (NPO at midnight) -intermediate/long acting admnistered 2/3 the nml evening dose the night before surgery and half the nml morning dose morning of surgery when should oral anti-DM agents be stopped prior to surgery? -long acting stopped 48-72 hrs prior -short acting withheld night before or day of surgery what fluids should be given to a DM patient? how often is BS checked? what range should BS be? -continuous infusion of 5% dextrose to provide 10g of glucose/hr -Q6hrs intra/postoperatively -120-180 managed w/ sliding scale or continue IV insulin 1-3 units/hr what are the MC causes of adrenal (Addisonian) crisis? 1. abrupt withdrawal of glucocorticoids MC 2. a pt w/ Addison's dz, response to body stress (surgery, MI, trauma, vol loss, hypothermia, sepsis, hypolycemia, steroid withdrawal) and lack of nml 3 fold increase in cortisol that naturally occurs in healthy pts 3. bilateral adrenal infarction (usually d/t hemorrhage) what do 1° (Addison's dz) adrenal insufficiency pts need to have before and after surgical procedures? IV glucocorticoids (hydrocortisone) + IV fluids *dose 3x what they normally get bc the body's natural response to stress is a 3 fold increase in cortisol what is the MC initial presenting symptom of a pt in Addisonian crisis (acute adrenal insufficiency)? what will labs show? tx? shock, hypotension, or hypovolemia -other nonspecific sx's: abd pain, N/V, fever, weakness, lethargy, coma -labs: hyponatremia, hyperkalemia, hypoglycemia -tx: 1. IV NS unless hypoglycemic then 1/2 NS/D5 2. IV hydrocortisone 3. fludrocortisone (minieralocorticoid similar to aldosterone) 4. reversal of electrolyte abnormalities wounds heal by primary or secondary intention, meaning? -primary: edges are apposed (by sutures, steristrips, glue, staples) -secondary: edges left unapposed and packed with gauze until self closure without prophylaxis ___% of patients will experience postoperative venous thromboembolism 25% all surgical pts have all 3 risk factors in Virchows triad (stasis, hypercoagulability, endothelial injury) what medications are given for DVT prophylaxis in surgical pts? which has a higher risk of thrombocytopenia? when should these be initiated? -unfractionated heparin: potentiates antithrombin III's ability to activate factor Xa and inactivates thrombin (factor IIa); higher risk of heparin-induced thrombocytopenia than LMWH -low molecular weight heparin (enoxaparin/Lovenox SQ): potentiates antithrombin III's ability to activate factor Xa -start these 2-12 hrs prior to surgery and continued until pt is mobile or at discharge -adjunctively intermittent pneumatic compression (IPC) devices reduce DVTs at comparable rates (as well as early mobilization) what are the antidotes to heparin and warfarin toxicity? -heparin: protamine sulfate -warfarin: vitK when prescribing warfarin to take at home after a thrombotic event, when should the transition/bridging from heparin take place? the 2 drugs should overlap 5 days when should warfarin be discontinued prior to surgery? resumed? -5 days prior and if INR >1.5 day before surgery low dose oral vitK given -resume 12-24 hrs postop likely cause of post op fever on day 0-2? day 1-5? after day 5? -0-2: wind (lungs) -2-4 water (UTI, catheter related phlebitis, drug rxns) ->5: wound what are the best diagnostic studies to dx DVT? 1. venous duplex US- 1st line 2. D dimer- sensitive but not specific (can r/o a DVT if D dimer negative in Wells criteria <1 pts) 3. venography- gold std what are the tx options for DVT? anticoagulation (preventing further emboli) 1. unfractionated heparin (antithrombin III potentiator) monitor PTT 1.5-2.5 range; inc risk of HIT 2. LMWH (MOA ") both can cause s/e of thrombocytopenia; SQ inj; no need to monitor PTT 3. warfarin/Coumadin (inhibits vitK dependent coag factors 2, 7, 9, 10 and inhibits protein C & S) IVC filter (put a filter in the IVC to catch clots) what clinical features are counted for points in Well's criteria for DVT? 1 pt: -active cancer -immobilization of LE -bedridden for ≥4 days after surgery (& presents w/i 4 wks of surgery) -localized tenderness along deep vein -swelling of entire leg where TBW is 50% wt in W and 55% wt in M ex. 80kg.55(126-120)= 264mEq infusion rate = Na deficit/0.513/24 ex. 264/0.513/24 = 21 ml/hr x 24 hrs what medications can be used to treat severe non-acute hyponatremia over infusion of 3% saline? what pt's are these meds contraindicated in? what is a downside of using them over infusing saline? vasopressin antagonists (aka anti-ADH meds) 1. demeclocycline 300-600mg BID 2. tolvaptan 15mg QD -ESRD pts bc can cause nephrotoxicity -cannot control how fast they are metabolized by the body so could cause too rapid of an inc in Na level what are the s/sx's of hypernatremia? -change in consciousness, irritability, dizziness, weakness, orthostatic hypotension, dec skin turgor, dry mucous membranes *basically think: you're dehydrated how do you calculate the free water deficit to resuscitate hypernatremia pts? 1. 2 x BW (kg) = amt of D5W to run per hr 2. 2(Serum(Na)-140) = hours to run ex. 2(50kg) = 100mL D5W/hr 2(150-140) = 20 hrs to run ^ -correcting hyponatremia at a rate of ≤____ prevents demyelination -correcting hypernatremia at a rate of ≤____ prevents cerebral edema ≤0.5 mEq/L/hr in BOTH what is a good objective measure of fluid status? urine output- should be ~0.5ml/kg/hr how is % dehydration calculated? = (nml wt - ill wt)/nml wt x 100 mild dehydration is ____% and the signs are? 3% dry mucous membranes, inc thirst, slight dec urine output mod dehydration is ____% and the signs are? 6% dry mucous membranes, tachycardia, little to no urine output, lethargy, sunken eyes, dec skin turgor severe dehydration is ____% and the signs are? 9% or more dry mucous membranes, tachycardia, thready pulse, tachypnea, delayed cap refill, hypotension, mottled skin, cyanosis, coma, no urine output how is the volume deficit calculated? using the degree of dehydration (3, 6, or 9%) wt x 0.3/0.6/0.9 x 1L how is the maintenance fluid requirement (that you replace over 24-48hrs) calculated? if replacing over 24 hrs: (2500ml + volume deficit)/24 hrs = ___mL/hr if replacing over 48 hrs: (2x2500ml + volume deficit)/48 hrs = ___mL/hr electrolyte disorders dx? usually exertional, poorly localized substernal chest pain/pressure/burning/tightness that may radiate to the arm/teeth/lower jaw and is usually 1-5 min in duration (but by definition <30 min) and relieved by rest or nitroglycerin angina pectoris what are the diagnostic tests and findings for anginal ischemic heart disease? 1. EKG- ST depression +/- T wave inversion, LVH 2. stress test- (+) if ST depressions, hypo/hypertension, arrhythmias, and/or sx's 3. coronary angiography- definitive dx/gold std tx for angina pectoris? -surgical: PTCA (percutaneous transluminal coronary angioplasty) w/ stent (reduces restenosis by 30%) or CABG if L main artery is affected, symptomatic, critical stenosis >70%, 3 vessel dz, or EF <40% -medical: nitrates, BB (1st line for chronic mgmt), CCB (for Prinzmetal angina), ASA what conditions fall under the category of acute coronary syndrome? 1. unstable angina 2. non ST elevation myocardial infarction (NSTEMI) 3. ST elevation myocardial infarction (STEMI) what will the ECG and cardiac enzymes show in unstable angina vs. NSTEMI vs. STEMI? -UA: (subtotal occlusion) ST depression +/- T wave inversion; (-) cardiac enzymes -NSTEMI: (subtotal occlusion) ST depression +/- T wave inversion; (+) cardiac enzymes (cell death) -STEMI: (total occlusion) ST elevation; (+) cardiac enzymes (cell death) clinical manifestations of acute coronary syndrome? -retrosternal pressure/pain >30 min, not relieved with rest/nitrates -sympathetic stimulation: anxiety, diaphoresis, tachycardia/palps, N/V, dizziness -silent MI: in women, elderly, diabetics & obese pts -EKG changes what leads on an EKG represent the following areas of infarction when ST elevations/Q waves are seen? -anterior wall/septal (LAD) -lateral wall (L circumflex) -anterolateral (mid LAD or circumflex) -inferior (RCA) -posterior wall (RCA or circumflex) -anterior wall/septal: V1-4 -lateral wall: I, aVL, V5-6 -anterolateral: I, aVL, V4-6 (basically just add V4) -inferior: II, III, aVF -posterior wall: ST DEPRESSIONS instead in V1-2 what cardiac markers should you order to monitor for an MI? how often should you order them? how long after an AMI do these markers appear? peak? and return to baseline? -CK/CK-MB and troponin I & T -order 3 sets every 8 hours -CK/CK-MB appears 4-6 hrs after, peaks @ 12-24 hrs, and returns to baseline in 3-4 days -troponin appears 4-8 hrs after, peaks @ 12-24 hrs, and returns to baseline in 7-10 days what are the 2 parts of the tx approach to unstable angina or an NSTEMI? 1. antithrombotic therapy (anti-platelet drugs or anticoagulants) 2. adjunctive therapy (BB, nitrates, morphine, CCBs) what are the antithrombotic drugs used to treat unstable angina or an NSTEMI? Sudden severe, sharp chest/upper back pain w/ variation in bilateral UE pulse pressures >20mmHg, HTN, new onset aortic regurgitation aortic dissection Triad of aortic dissection [but only ~30% of pts] 1. Tearing/ripping abdominal pain through the back 2. Shock/hypotension 3. Pulsatile abdominal mass Impaired or absent blood flow to peripheral vessels=pulse deficit; weak or absent carotic, brachial, femoral pulse Aortic regurg heard along the Right sternal border Can see: grey turner's sign, cullen's sign [just like in acute pancreatitis] what diagnostic tests are used to evaluate aortic dissection? 1. CT w/ contrast- becoming 1st line 2. MRI angiography- gold std but time consuming if unstable 3. Transesophageal electrocardiogram- used if pt is unstable 4. CXR: widening of the mediastinum, pleural effusion 5. CT angiography what is the management for DeBakey Type I-III aortic dissections? -if involves ascending aorta: surgical mgmt -if descending aorta only w/ complications (vital organ involvement, impending rupture): surgical mgmt -if descending aorta w/o complications: esmolol or labetalol 1st line to get target SBP <120mmHg and pulse <60bpm in 20 min; sodium nitroprusside and nicardipine as needed s/sx of a peripheral venous dz + ulcer? tx? -leg pain -swelling worse w/ prolonged standing/sitting and improved w/ leg elevation/walking -stasis dermatitis (dryness, itching, scaling, weeping erosions) -brownish hyperpigmentation -medial malleolus -tx: compression (leg elevation, elastic stockings), wet to dry dressings, unna boot, edema control, if severe: skin grafting, hyperbaric oxygen a flapping tremor of the hand w/ wrist extension is called? d/t? asterixis from buildup of ammonia levels (dysfxning liver can't convert to urea anymore) what is on the DDx for a pt w/ tremors? -hypoglycemia -benign essential tremor (intentional tremor) -parkinson's disease (resting tremor) -multiple sclerosis (intentional tremor) -thyroid storm an benign familial essential tremor involves bilateral shaking of _________ worsening with _________ that is briefly relieved by _________; tx? -hands, forearms, head, neck or voice -worse w/ emotional stress and intentional mvmt -EtOH briefly relieves -tx: propranolol if severe or situational what is released to increase blood Ca2+ (via inc bone resorption & inc GI/kidney absorption)? what is released to decrease blood Ca2+ (via inc bone mineralization & dec GI/kidney absorption)? -hypocalcemia triggers and inc in PTH (increases osteoclastic activity & renal absorption) & vitD/calcitriol (increases GI absorption) to inc blood Ca2+ -hypercalcemia triggers and inc in calcitonin (tone down Ca2+) to dec blood Ca2+ what is the most common type of hyperparathyroidism? MC cause? is Ca2+ inc or dec? clinical manifestations? tx? -primary hyperparathyroidism -MC (80%) parathyroid adenoma, (15% parathyroid hyperplasia/enlargement, others: lithium, thiazides, MEN I (pituitary tumor, pancreatic tumor), MEN IIa (pheochromocytoma, medullary thyroid cancer); (MEN = multiple endocrine neoplasia) -Ca2+ is increased, phosphate will be dec -s/sx: of hypercalcemia (kidney stones, bone pain, abdominal groans/constipation, psychic moans, dec DTRs), shortened QT interval on EKG -tx: parathyroidectomy dx/tx? low Ca2+, high PTH, nml-low vitD, Trousseau's sign (inflation of BP cuff = carpal spasms), Chvostek's sign (facial spasm w/ tapping of facial nerve), inc DTRs, prolonged QT interval; MC cause? -dx: secondary hyperparathyroidism -tx: po Ca2+ and vitD (if severe IV calcium gluconate) -MC cause is CKD, others: severe Ca2+ or vitD deficiency dx/tx? low Ca2+, low PTH, inc phosphate, Trousseau's sign (inflation of BP cuff = carpal spasms), Chvostek's sign (facial spasm w/ tapping of facial nerve), inc DTRs, prolonged QT interval; MC causes? -dx: hypoparathyroidism -tx: po Ca2+ & vitD -MC causes: post-surgical (accidental damage after neck surgery) & autoimmune DDx? high Ca2+, low PTH hypercalcemia, PTH-indepedent DDx: -malignancy -lithium -thiazides -vitD excess treatment for severe/symptomatic hypercalcemia? s/sx: arrhythmias, kidney stones, constipation/ileus, dec DTRs, AMS -1st line: IV NS then furosemide -calcitonin & bisphosphonates may also be used -avoidance of HCTZ (increases Ca2+) no tx needed for mild hypercalcemia dx/tx? cold intolerance, wt gain, loss of outer 1/3 of eyebrow, dry skin, fatigue, memory loss, depression, constipation, bradycardia, dec CO, menorrhagia, goiter -hypothyroidism -Hashimoto's thyroiditis MC (autoimmune) in US (iron deficiency MC cause worldwide) -tx: levothyroxine (synthetic T4) dx? heat intolerance, wt loss, anxiety, weakness, diarrhea, tachycardia, palps, high out HF, irregular/absent periods; what is the MC cause? tx? -hyperthroidism (low TSH, high FT4/T3) -Graves dz (autoimmune) is 90% of all hyperthyroid d/o (+TSH receptor Ab) -tx: radioactive iodine ablation MC (destroys thyroid gland- will need synthetic replacement after), 1st line- methimazole (takes a few weeks to produce results so give a B-blocker like atenolol/propranolol for immediate effects (HTN/tachycardia)), 2nd line propylthiouracil (PTU) bc can cause severe hepatotoxicity; surgical resection another option what types of thyroid disorders are autoimmune? -Graves (HYPERthyroidism) +TSH receptor Ab (specific for Graves), +thyroid peroxidase Ab, +anti-TG Ab -Hashimotos (HYPOthyroidism) +thyroid peroxidase Ab, +anti-TG Ab what are the RFs for thyroid nodules? symptoms if nodule large enough? -RFs: extremes of age (very young or >60) & h/o head/neck irradiation -sx's: most are asx; if lrg enough: difficulty swallowing/breathing, neck/jaw/ear pain, hoarseness (if it compresses recurrent laryngeal nerve); most pts in euthyroid state what is the MC type of benign thyroid nodule? --invasive (involving muscular layers): radical cystectomy, chemo, XRT --recurrent: BCG (bacillus calmette-guerin) intravesicular vaccine to stimulate immune crossrxn w/ tumor antigens renal cell carcinoma makes up ____% of all tumors found in the kidney- dysplasia of the _________ cells; RFs? dx by? tx? -95% -proximal convoluted tubule cells (PCT) -RFs: smoking, dialysis, HTN, obesity, men -dx by: CT -tx: stage I-III: radical vs partial nephrectomy +/- immune therapy w/ interleukin-2 (these respond poorly to chemo/XRT) dx? male smoker comes in w/ hematuria, flank/abdominal pain, palpable mass, L-sided varicocele, HTN, and hypercalcemia -dx: renal cell carcinoma (confirm w/ CT) ALL of these are buzzwords nepholithiasis: MC causes? types of stones? which is MC? dx by? -causes: dec fluid intake MC, inc protein intake, meds, gout, hypercalcemia, UTIs (urea splitting organisms) -types of stones: 1. calcium oxalate & phosphate MC (80%) 2. uric acid: from high protein foods 3. struvite stones: (Mg ammonium phosphate stones) "staghorn calculi" from UTI organisms -dx by: noncontrast CT scan 1st dx/tx? sudden, constant back/flank pain over CVA radiating to groin/anteriorly + hematuria -dx: nephrolithiasis -tx: <5mm- 80% chance of spontaneous passage- IV fluids, analgesics, antiemetics, tamsulosin to relax smooth muscle of pathway >7mm- 20% chance of spontaneous passage- lithotripsy, uretoscopy +/- stent if obstructed or at risk kidney >10mm- percutaneous nephrolithotomy -if complete obstruction need to do US or CT to r/o hydronephrosis (can lead to dilation and rupture of ureters and irreversible kidney damage- although most recover) what type of kidney stones are related to each of the following urinary pHs: <5.0 (acidic)? 5.5-6.8? >7.2 (alkaline)? which types are radiopaque on KUB? <5.0 (acidic)- uric acid 5.5-6.8- calcium oxalate & phosphate >7.2 (alkaline)- struvite radiopaque: struvite, calcium oxalate/phosphate what are the top causes of CKD? 1. DM MC 2. HTN 2nd 3. golumerulonephritis 4. PKD how is CKD detected on imaging? kidneys will atrophy and get smaller so this is done by measurement- renal US <9-10cm bilaterally *exception is diabetic nephropathy where kidneys get bigger what are the GFR ranges for the 5 stages of CKD? 1: >/=90 (nml GFR but kidney damage present) (ACR-albumin/Cr ratio <30) 2: 60-89 (ACR 30-300) 3: 30-59 (ACR >300) 4: 15-29 5: <15 (ESRD on dialysis in need of transplant) tx of CKD includes: 1. dietary mgmt by protein restriction to ____g/kg/day (unless malnourished or have nephrotic syndrome), salt restriction to ____g/day, & K+ restriction to <____mEq/day 2. renally dose adjust meds and avoid _________ and _________ 3. dialysis when GFR <____ml/min 4. transplant (shows _____ year graft survival rate) 5. manage complications (list 5) 1. 0.8g/kg/day protein; 2g/day salt; 60mEq/day K+ 2. magnesium (laxatives, antacids) and phosphorus 3. GFR <10ml/min 4. 15-20 year graft survival 5. HTN, CVD, renal osteodystrophy, anemia, hypoglycemia what is the MC complication of CKD? how is this managed? HTN- tx w/ ACEi/ARB (renal protective), HCTZ (diuretic) unless GFR <30 then loop diuretic besides HTN, what are the 4 other complications of CKD and their treatments? 1. CVD: mgmt- stop smoking (statins no benefit) 2. renal osteodystrophy (from 2ndary HPT osteoclast effects- mgmt- *control hyperphosphatemia w/ phosphate binders (calcium acetate, sevelamer), vit D (calcitriol) 3. normocytic, normochromic anemia: (d/t erythropoietin production dec; tx- FeSO4 or EPO shots when Hg<9g/dL) 4. hypoglycemia: d/c metformin in advanced CKD; insulin dose adj d/t dec renal elimination a pt w/ abdominal bruits, refractory HTN to at least 3 meds or AKI following initiation of an ACEi should be evaluated for? renal artery stenosis what are the MC causes of renal artery stenosis? what is the MC complication of RAS? -atherosclerosis in the elderly -fibromuscular dysplasia in women <50y -MC cause of 2ndary HTN how is renal artery stenosis diagnosed and treated? -dx by: renal arteriography (gold std) or CT, MRA US, captopril renography -tx: angioplasty w/ stent, ACEi/ARB to preserve renal blood flow (unless pt has bilateral dz or a solitary kidney then its CI) older male w/ urinary frequency, nocturia, urgency, hesitancy, weak/intermittent stream force, incomplete emptying; what needs to be done to make the diagnosis? tx? -dx: BPH 1. DRE- uniformly enlarged, firm, rubbery prostate 2. check PSA- inc levels in BPH 3. check urine cytology to screen for bladder cancer (BPH = inc risk) -tx: 1. observation 2. 5-alpha reductase inhibitors (finasteride & dutasteride) inhibit androgens suppressing prostate growth- long term benefit no immediate relief 3. alpha-1 blockers (tamsulosin) smooth muscle relaxation of prostate/bladder neck for immediate sx relief but no long term suppression of prostate growth; s/e: orthostatic HTN 4. TURP (transurethral resection of prostate) TIAs (transient ischemic attacks) are defined as transient episode of neurological deficits WITHOUT acute infarction w/ sx's lasting <____ (most resolving in 30-60 min) MC due to ________ <24hrs -MC d/t embolus (heart/afib, carotid, vertebrobasilar) or transient hypotension dx? amaurosis fugax "lamp shade down on one eye", weakness in the contralateral hand, sudden HA, speech changes, confusion dx/tx? sudden, "worst headache of my life", neck stiffness, photophobia, delirium, d/t arterial bleed from berry aneurysm (on circle of willis) rupture MC, or AVM -dx: subarachnoid hemorrhage -tx: supportive (bed rest, lower ICP- mannitol, hyperventilation, head elevation) + lower BP gradually w/ nicardipine, nimodipine, or labetalol) -w/u: if CT is negative can do LP (+ if xanthochromia (RBCs) and inc opening pressure) then 4 vessel angiography dx/tx? headache, N/V, +/- LOC, hemiplegia, hemiparesis, brain bleed d/t HTN, AVM, trauma, or amyloid in which LP is contraindication because may cause brain to herniate -dx: intracerebral hemorrhage -tx: gradual BP reduction (nicardipine, nimodipine, or labetalol), supportive, if ICP inc = mannitol, evacuation of hematoma if + mass effect community acquired pneumonia is most commonly caused by? if admitted to hospital, PNA occurs <___ hrs from admission; how does sputum appear? tx? -strep. pneumoniae (2nd MC is h. influenzae) -develops within 48 hrs of admission -sputum: rusty (blood-tinged) -tx: macrolide, doxycycline, B lactam, or broad spectrum FQ if severe or admitted hospital acquired pneumonia is most commonly caused by? if admitted to hospital, PNA occurs >___ hrs from admission; tx? -pseudomonas and MRSA -develops >48 hrs from admission -tx: anti-pseudomonal B lactam (piperacillin/tazobactam aka Zosyn or cefepime), anti-pseudomonal aminoglycoside or FQ; + vanc or linezolid if MRSA suspected, + levofloxacin or azithromycin if legionella suspected aspiration pneumonia tx? -need anaerobe coverage: -clindamycin, metronidazole or amoxicillin/clavulanic acid (augmentin) pts ages 2-64 should receive what pneumococcal vaccine? age 65? what do children receive? -Pneumovax (23) once -once at age 65 and then not indicated after that -children receive Prevnar 13 at 2, 4, 6, and 12-15 mos of age what causes of pneumonia are seen in patients with HIV? -pseudomonas aeruginosa (piperacillin/tazobactam, meropenem, doripenem, cefepime, ceftazidime, levo/ciprofloxacin, aminogl ycosides) -CMV -pneumocystis jirovecii (PCP) (fungal) (bactrim, dapsone, atovaquone, pentamidine) -histoplasma capsulatum (fungal) (itraconazole, amphotericin B) -cryptococcus neoformans (fungal) (fluconazole, amphotericin B) -atypical mycobacterium like MAC (macrolide, rifabutin) 1st line in bold what are factors that increase likelihood that a pulmonary nodule is malignant? -single nodule -size -older age -h/o smoking -family hx -female sex -prior malignancy -growth >2mm usually calcification and presence of fat in a pulmonary nodule is a sign of benign lesion (other signs: round, smooth, slow growth, cavitary) malignant signs: irregular, speculated shape, rapid growth (may double in 4 mos), cavitary with thickened walls a pt with a known primary cancer with multiple pulmonary nodules >___mm is of high suspicion for lung mets >5mm although GI tract is the MC site for carcinoid tumors, the 2nd MC is _______ lungs a rare neuroendocrine (enterochromaffin cell) lung tumor characterized by slow, well differentiated growth and low METS bronchial carcinoid tumor bronchial carcinoid tumors may secrete what subtances/hormones? -serotonin -ACTH -ADH -melanocyte stimulating hormone although usually asymptomatic, the follow s/sx's can occur with what kind of lung cancer? -wheezing/cough -recurrent PNA -hemoptysis -SIADH -diarrhea -flushing -tachycardia -hemodynamic instability -acidosis -on bronchoscopy a pinkish purple well-vascularized central tumor bronchial carcinoid tumors -class but rare: carcinoid syndrome: diarrhea d/t inc serotonin secretion; inc bradykinin/histamine: flushing, tachycardia, bronchoconstriction/wheezing, hemodynamic instability (hypotension), acidosis what is the tx/mgmt for bronchial carcinoid tumors? -surgical excision (often resistant to chemo/XRT) -octreotide reduces symptoms by decreasing secretion of active hormones what are the #1 and #2 MC causes of lung cancer/bronchogenic carcinoma? 1. smoking 2. asbestosis where do METS from lung cancer often go? -brain -bone -liver -lymph nodes -adrenals what are the 3 types of non-small cell lung cancers? these make up 85% of all lung cancers 1. adenocarincoma 35%- MC in smokers, women and nonsmokers; peripheral, gynecomastia 2. squamous cell 20%- central, cavitary lesions, hypercalcemia, pancoast syndrome (superior tumor causing thoracic outlet syndrome and horner's syndrome) 3. large cell (anaplastic) carcinoma 10%- very aggressive -recurrent PNA -hemoptysis -SIADH -diarrhea -flushing -tachycardia -hemodynamic instability -acidosis -on bronchoscopy a pinkish purple well-vascularized central tumor bronchial carcinoid tumors -class but rare: carcinoid syndrome: diarrhea d/t inc serotonin secretion; inc bradykinin/histamine: flushing, tachycardia, bronchoconstriction/wheezing, hemodynamic instability (hypotension), acidosis aspiration pneumonia tx? -need anaerobe coverage: -clindamycin, metronidazole or amoxicillin/clavulanic acid (augmentin) "walking pneumonia" is most commonly caused by? what else is seen on PE? workup? tx? -mycoplasma pneumoniae- seen in school-aged children, college students, and military recruits -ear pain, bullous myringitis, persisitent non-productive cough -w/u: PCR, serum cold agglutinin test & serology/enzyme immunoassays (serum or sputum Ab detection) -tx: macrolide or tetracycline pts ages 2-64 should receive what pneumococcal vaccine? age 65? what do children receive? -Pneumovax (23) once -once at age 65 and then not indicated after that -children receive Prevnar 13 at 2, 4, 6, and 12-15 mos of age aspiration pneumonia tx? -need anaerobe coverage: -clindamycin, metronidazole or amoxicillin/clavulanic acid (augmentin) _______is the most important anesthetic complication. Anesthesia causes an uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove CO2, and regulative body temperature. Malignant hyperthermia If patient is hyperkalemic (normal range 3.8-5.0), how should you treat the patient? treat with glucose/insulin, and calcium +/-bicarb _______is the reversing agent for opiods. Naloxone _______is the reversing agent for benzodiazipines. Flumazenil What is the best indicator used to monitor nutritional status? prealbumin - every 2-3 days Intervention: _________require central access and indicated when no enteral feeding for > 7 days. TPN - total peripheral nutrition The _________is the most important part of the history before surgery. cardiac history -- history of MI, unstable angina, valvular disease In patients with known cardiac disease, aggressive intraoperative lowering of myocardial oxygen demand with ____ has been shown in RCT's to improve outcomes and should be used. beta blockers When accessing cardiac disease prior to surgery, what is the most important thing to access? aortic stenosis -- crescendo diastolic rumble at apex Guidelines for the use of antibiotics include administration within _______ of surgery and redosing after 4 hours. What is the abx of choice? 1 hour Abx of choice: cefazolin for all except colorectal then cefazolin/metronidazole Pre-op -- Metabolic disease/syndrome -- what are the 5 criteria? 3/5 to diagnose: 1 - diabetes 2 - central obesity 3 - HTN 4 - high serum triglycerrides 5 - low HDL levels ______should be monitored before surgery bc it is a stimulant and vasoconstrictor -- can lead to severe tachycardia Cocaine Pre-Op -- What are the indications for EKG and CXR? EKG - men >40, women>50, known CAD, DM, or HTN CXR - age >50, known cardiac or pulmonary disease What are the 5 classic "W's" of post operative fever? W - wind (atelectasis) W - water (UTI) W - wound (wound infection) W - walking (DVT/thrombophlebitis) W - wonder drugs (drug fever) If the post op fever occurs within the first 24 hours of surgery, what is the most likely cause? wind/atelectasis If the post op fever occurs within days 3-5 post op, what is the most likely cause? water/UTI, catheter related phlebitis, pneumonia If the post op fever occurs within days 5-10 post op, what is the most likely cause? wound infection, pneumonia, abscess, infected hematoma, C diff colitis, anastomotic leak, DVT, peritoneal abscess, drug fever, PE, parotitis _______is the most common pathogen in wound infections and around foreign bodies. Staph aureus _______invades the inner ear and enteric tissues as well as the lung. Klebsiella ______organisms are often found together with anaerobes. Enteric organisms ie. enterobacteriaceae and enterococci Among the anaerobes, ___&___are often present in surgical infections and _____species are major pathogens in ischemic tissue. Bacteroides & Peptostreptococci; Clostridium ___&___are usually nonpathogenic surface contaminants but may be opportunistic. Some fungi and yeast cause abscesses in sinus tracts. Pseudomonas & Serratia History of recent surgery, trauma, cancer, prolonged immobilization, or oral contraceptive use increases the risk of ____. DVT - deep vein thrombosis What is Homan's sign? pain on passive dorsiflexion of ankle What is the test of choice for DVT? doppler ultrasound