Emma Holliday Surgery lectures

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Absoulte contrindications to surgery

diabetic coma and DKA

Other contraindications to surgery

poor nutrition – ——albumin < 3,, ——transferrin < 200 ——weight loss of total body < 20% Lever failure – High bili, Pt > 16 ammonia > 150 SMoker – stop 6-8 wks prior

Meds to stop prior to surgery

aspirin NSAIDS vit E ( 2 weeks)

If have CKD what do you do 24 hrs proior to surgery

diayllsis 24 hours prior

What post surgical complication would you worry about with the BUN &gt; 100

Platlet dysfunction and bleeding

What would the labs show for uremia induced platlet dysfunction

Normal platlets but prolonged bleeding time


You get a set TV. therfore if the patient starts the breath they get the full volume


Pt determines the rate but a boost of pressure is given for each breath


Pt must breath on their own but prssure is given all the time


– pressure delivered at the end of the cycle to help th avelooi open VERY important top help in ARDS

What would you change on a vent if : PaCO2 is Hihg and pH is low

increase Rate or TV

What would you change on a vent if : Paco2 is low and Ph is high

decrease rate OR TV

IF Hco2 is low and pCO2 is low
what is the cuase and what do you check next

Metabolic acidosis next check anion gap – ( Na- [cl+ hco3])

Causes of metabolic acidosis With a HIgh anion gap

M-methanol U- uremia D- DKA P-propylene gylcol I-iron, isoniazid -L – lactic acidosis E- etholnol S- Siacylic acid

Causes of metabolic acidosis With a normall anion gap

diarrhea, diuretics RTA I< II, IV

If HCO3 is high and PCO2 is high and cl- in the urine is &lt; 20

Vomiting/NG tube antacids, diuretics

If HCO3 is high and PCO2 is high and cl- in the urine is &gt; 20

Conns Bartters Gittlemans

then you have low sodium when do you use 3% Na iv

when the patient is symptomatic with seizures or sodium is below 110

complication of correctio of hyponatermia too quickly

Centeral pontine myoliinolysis

If you ahve an increase in total body sodium what do you replace with and what is a complication

replace with D5 or hypoteonic fluid risk of cerebral brain edema

Numbness chvostek, or troussaeus sign or Prolonged Qt interval

Decrease Ca2+

Bone pain, kidney stones, Abdominal discomfort from constipation, Depression anexity trouble sleeping anorexiaOR shortened QT

Increased Ca2+

Paraylsis, Ileus, ST depression U waves
Cause and Treatment ?

Cause decrease K and treatment Give K max 40 mEq/hr

Peaked T waves ( generalized) prolonged PR and QRS waves

Cause – give Ca gluconate then insulin + glucose and kayexalate albuterol and sodium bicarb….. last resort is diaylsis

Maintenacne IVF equation

$: 2;1 0-10 kg – 4ml/kg/hr 10-20 – 2 ml/kg/hr all above 20kg: 1ml/kg/hr

Complication of TPN

Acalculus cholecystitis hyperglycemia liver dysfuxn, zinc def. lyte prob

If someone hasa circumferential burn

consider escharotmy

If someone has signed nose hairs wheezing and soot in mouth

Bad intubation – low threshold

Patient with confusion and cherry red skin

CO – best test is carboxy hb – DONT use pulse Ox

HYPER-Clotting. In the elderly

CAcner especiially pancreatic

Hyper- Clotting and Edema Htn and foamy pee

nephrotic syndrom

HYPER- Clotting in a young person with a + Family hx

factor V leiden

If you have AtIII def what medicatio will not work on the clots


HYper- clotting and a young women with a PMH of spontenous abortions

Lupus anticoagulant

Post Op HYper Clotting decrease in Plt

HIT – if heparin was given w/in 5-14 days

How do you treat HIT

leparudin and agatroban

Bleeding problem with an isolated decrease in Pltss


Normal PLts but increase in bleeding time and Ptt

von willibrands disease

Low Plts, Increase PT, PTT BT Low Fibrinogen, high D dimer and schistocytes

DIC!!! caused by Gram – sepsis carcinomatosis and OB stuff.

RULE of 9 for burns Adults Vs children

Adults- 9 for each Arm, 9 for the head, 18 front, 18 back, 1 genitals, 18 for each leg Babies- 18 for the head, 0 for each arm, 18 front and 18 back and 1 genitals and 14 legs

Parkland forumla adults and babies
and how fast do you give the voluem

adults : KG %BSA 3-4 Kids : Kg %BSA 2-4 – this gives you a value in Ml and you give 1/2 over the 1st 8 hrs and rest over the next 16hrs

How do you abx to Burn patients


Silver sulfadiazine

Doesnt penetrate eschar and can cause leukopenia


Penetrates eschar but hurts like helpp

silver nitrate

Doesnt penetrate Eschar and causes hypoK and HypoNa

Chemical burn 1st step

irrigate > 30 min

Electrical burn
1st test and then amangement

1st test: Get and EKG to check for arrthymias managment: check for myogliobinuria and ATN Check K levels from cell lysis Monitor limb temperature for compartment syndrome – criteria – 5 P and pressure > 30mmhg

When a smoker is coming out of anesthetics do you want to keep their pulse ox at 100

No because smokers and Co2 retainers need the low oxygen for the respiratory drive

Goldmans risk what is the MOST important Risk

CHF- check EF < 35% NO SURGERY for you

Goldmans risk what is the Second MOST important Risk

MI w/in 6 mon EKG-> stress test–> cardiac cath –> revasc.

Metformin important prior to surgery

YOU must stop because of lactitic acidosis

What is more effective for your patient to increase Rate or Volume ?

By increasing rate you are not increasing the amount of I2 to the aveoli by increasing TV you are increasing the effective oxygenation

Low sodium but signs of fluid retention

CHF, nephrotic cirrotic

DEcrease volume and decrease sodium

diureticcs or vomiting and free water

NOrmal volume but decrease in NA

SIADH ! addisons and hypothyroidism

When do you use hypotonic saline 5%

patient is symptomatic with seizures or sodium less then 110

Maintenacne IVF for daily requirments

up to 10Kg – 100ml/kg/day NExt 10 -> 50ml/kg/day All above 20 -> 20ml/kg/day

1st degree burn what layer of skin


Why dont you give IV or PO antibiotics to a burn victom

it breeds resisitance

If yo have low sodium what do you want to check

the serum osmolarity because high glucose makes the plasma look too dilute

What kills you in rhado!

The hyperkalemia

Patient is unconscious


If a guy is stabbed in the neck and there is subcutenous stridor then what to do

Use fibrooptic broncoscope to secure the airway

when do yo immeadatly brind a patietn to the OR

Upput is greater then 1500 ml when the tube is first placed or greater then 200ml/hr in the first 4 hours

If patient was inward mvmt of the right ribcage upon inspiration

FAIL chest > 3 consec rib fractures

Fail chest treatment

o2 and pain control ( NERVE BLOCK) – do not give morphine because it decreases repiratory drive

A patient is confused petechial rash in hte chest and axilla and neck with Acute SOB post Car accident multiple bone injuries

Fat embolism – mcc after long bone fracture s

A patient dies suddenly dies after a centeral line

AIR embolism

Causes of air embolism

lung trauma ( too much TV) , vent use, during heart vessel surgery

If the neck veins are flat and the CVP is normal what type of shock

Hypovolemic/ hemorraghic

After hypovolemic shock has been indentified whats the next best step

2 large bore iv-2L NS or LR over 20 min followed by the blood

If muffled heart sounds, Disteneded JVD, electracal alternas on EKG Pulsus paradoxus

pericardial tamponade

What test to confrim pericardial tamponade

FAST scan

Treatmetn for Pericardial tamponade

needle decompression pericardial window or median sternotomy

IF decrease breath sounds on one side tracheal deviation away from the collapsed lung

Tension pneumothorax You do not need to confrim – simply place the need and then a chest tube NO CXR nessisary

NEurogenic shock physical findings

Bradycardia, warm dry extremities NO relfexs or flaccid muscle tone. CAN HAVE hyponatermia and Hypokalemia d/t adrenal insufficency – give dexamethasone

Neurogenic shock swan ganz catheter pressures

Increase CO Systemic Vascular rsistance – decreases SVR PCWP- Decrease

Vasogenic physical exam

AMS!, Warm Dry extremities ( early) LATE APPEARSlike hypovolemic shock

Vasogenic swan ganz catheter pressures

PCWP decrease SVR decrease CO increase

Cuase of neurogenic shock

loss of sympathetic input there for dilatation of the vascular tone.

Physical presentation of cardiocompressive shock

hypotensive tackycardiac JVD decreased heart sounds normal breath sounds Pulsus paradoxcus

Cardiogenic shock physical exam

SOB ( pulmoary edema) clammy extremities rales b/l S3 pleural eddusion and decrease breath sounds ascities and peripheral edema

Cardiogenic pressure readings

PCWP – increase ( back up of blood) SVR increase CO decrease

Physical exam for hypovolemic shock

Hypotensive tackycardiac diaphoretic cool clammy extremites

Lung pressures

PCWP decrease SVR increase CO decrease

Increased ICP

Heachache, projectile vomiting and AMS ! also papilledema ( visual cahnges

What are the besd side treatments for increase ICP

Elevate HOB, Hyperventilate to ppCO2 28- 32 give mannitol watch renal failure

Surgical managmnt for head trauma and bleeding

Ventriculostomy – or BUrr hole

Zone 3 of the neck

ABOVE The angle of the mandible

WORK up for damage of zone 3 of the neck

AOrtography and triple endoscopy to make sure the trachea nd esophagus are still patetn

zone 2 neck location

Angle of the mandible to the cricoid

ZOne 2 work up for neck trauma

2d Doppler (vessels) and +/- exploraoty surgery

zone 1 location

below the cricoid

work up for zone 1 damage


IF Gun shot wound to the abdomen where for you go

OR immeadatly + tetnus prophaylaxis

If stab wound and patient is unstable with rebound tenderness and rigidy or evisceration

OR immeadatly + tetnus prophalaxis

If blunt ab trauma pt with hypotension/tachycardia

OR ex lap

If stab wound to the abdomen but patient is stable

FAST exam DPL ( diagnositc peritoneal lavage ) if FAST is equivocal EX lap if EITHER are postive

BAT + unstable vitals

OR immeadatly

BAT + hemodynamically stable next best step

CT Of the abdominal

BAT + hemodynamically stable + Ct shows Lower rib fracture and bleeding intothe abdomen

Spleen or liver laceration

BAT + hemodynamically stable + Ct shows Lower rib fracture and hematuria

Kidney laceration

BAT + hemodynamically stable + Ct shows Viscera in the chest aznd patient complains of shoulder pain – kehr sign

Diaphragmatic rupture

BAT + hemodynamically stable + Ct shows handler bar sign ( bruising in the mid epigastrium )

Pancreatic rupture

BAT + hemodynamically stable + Ct shows retroperitoneal fluid

Consider duodenal ruptures

Pelvic trauma + Hypotensiive and tachycardia

Bleeding into the pelvic cavity – Use FAST AND DPL to r/o bleeding

Treatment for a pelvic fracture

IS to stabilize the pelvis with a large sheet and because it is a bowel remeber there is most likely two fracture points

IF Blood at the urethral meatus and high riding prostate

consider pelvic fracture with uretheral or bladder injugy – remeber you are preforming rectal exam at the same time as the spinal exam

IF suspected adamage to the urethreal meatus what is the next best test –

Retrograde urethrogram – not foley —-if normal then do retrograde cytogram to evaluate bladder — you are looking for extravastation ofthe sye and **you need to see 2 views to See trigone injury ****

IF you see extravastion on the retrograde uretherogram what isthe management
FOR Extraperitoneal
VS intraperitoneal

extraperitoneal – Bed rest and Foley intraperitoneal – ex-lap and surigal

What part of the bladder is the most susceptable to dsamge

The dome of the blader

Does this fracture go to the OR immeadatly or NOT ? Depressed skull fracture


Does this fracture go to the OR immeadatly or NOT ? Severely displaced or angulated Fx


Does this fracture go to the OR immeadatly or NOT ? Any Open fx ( sticking out bone needs cleaning)

GO to the OR

Does this fracture go to the OR immeadatly or NOT ? Femoral neck or intertrochanteric FX


Shoulder pain s/p seizure or electrical shock

posterior should dislocations

Arm extrnerally rotated and numbness over the deltoid

Anterior dislocation wiht damage to the axiallary nerve

Old lady feel on her wrist and the distal radius is aNTERIORLY displaced

Colle fracture aka dinner fork deformity

Young person fell on outstretched hand, tenderness on antomically snuffbox

scaphoid fracture X ray is normal at first wait ten days and repeat hiGH index of suspicion is important

Young man pouches a wall

metacarpel ( 4th and 5th) neck fracture may need a k wire

Clavical is most commonly fractured where

between the middle and the distal 1/3 need figure of 8 device

Fever on POD 1 with a low fever &lt;101 and non productive cough


How to diagnosis atelectasiss

CXR – look for bilateral lower lobe fluffy infiltrates

Treatment for post op atelectasis

MOVE Around and incentive spirometry

Fever to 104 on post OP day 1 + appearing very ill

Necrotizing fasciatius

HOw does post op necrotizing fascitits spread

Along Scarpa fascia in the SubQ region.

Common bugs that cause post op necrotizing fascitits

Strep and colstridium perfingenes

Trement for post op necrotizing fascitits

BAck tot he tOR and debride until it bleeds also IV antibiotics

POst op day one fever &gt; 104 and muscle rigidity

maligant hyperthermia

What drugs cause maligant hyperthermia

succyline choline or halothane

Genetic defect for MAligant hyperthermia

Ryanodine receptor –

Treatment for maligant hyperthermia

Dantrolene NA – it blokcs the RYR recptors and decreases the intracellular Ca

Fever on POD 3-5 with productive cough and diaphoresis

Pneumonia – get a sputum sample for culture cover with respiratory quinolone aka MOxi ( for strep pneumo )

Fever POD 3-5 with fever dysuria frequency urgency in a patient with a foley
WHat is it and howdo you confrim

UTI, Next best test is UA – Nitrite and LE and culture

Treatmetn for POD 3-5 fever d/t UTI

Change foley and treat with wide spectrum abx until culture returns

POD &amp; Fever pain and tenderness at the IV site:
Cuase and treatment

Centeral line infection Txt: 1st draw blood for cultures, then remove the line and then start IV abx especially for Staph

POD &amp; Fever &amp; pain at the incision site, with edema , induration BUT NO DRAINAGE

CELLULITUS txt Do blood culture and start antibiotics

POD &amp; Fever pain @ incision site induration with drainage

Simple wound infection Open wound and reack No abx necessary

POD &amp; Fever Pain at incision site with salmon coloured fluid leaking from the inscision

DHEISCENCE Txt – Surgical emergency Go to the OR IV abx primary closure of the fascia – this is an infection that has compromised the fascia

Unexplained fever on POD

Abdominal abscess – use a ct to scan fdor it with oral/iv / rectal contrast or if nothing diagnostic lap

Treatment for intrabdminal abscess



Thyroitoxicosis THrombophlebitis – Especially after a OB/GYN SURgery – Heparin + Abx Adrenal insufficency Lymphangitis sepsis

Cuases of pressure ulcers


Do you culture a pressure ulcer?

No because you will get skin flora – check CBC and blood cultures – if something found can be bactermeia or osteomyleitis

MARJOLIN ULCER how do you diagnosis

agressive ulcerating squamous cell cancer

How do you prevent pressure ulcers

– turning every 2 hours

Stages of presure ulcers

stage 1 – skin intact but red – BLANCHES with pressure Stage 2- Blister or break in the dermis Stage 3 – gets inot the sub q destruction into the muscles Stage 4 involvment of the joint or bone

Treatment for stage 1-2 pressure ulcer

no big deal – cream adn special matress and barrier protection

treatment for stage 3-4

SUrgery :get flap reconstruction before sugery make sure albumin ( nuitritional status) is 3-5 and bacteria load below 100k

PLeural effsion on a chest xray at what level must you do a thoracentesis

if you see 1cm of fluid on thoracentesis

Light criteria

IF Protein > 0.5 LDH > 0.6 ( or > 200) LDH greater 2/3 of the serum then excudative

Transudative – with low pleural glucose

rheumatoid artitiris

transudative with high lyphocytes and adenosine deaminase


transudative with blood present

maligancy and pulmonary embolus

If exudative

parapneumonic or cancer

Complicated effusion for 3 reasons

Bacteria is present ph is < 7.2 Glucose is low

Sponentous penumothroax d/t ?

subpleural bleb in a tall thing young men Or asthma Or COPD empysema

Spontenous pneumothorax indications for surgery

Recurrance in the smae spot or aanywhere else If Bilateral, if there is incomlete lung expansion, If pilot, scuba diver or live in a remote area

Treatment for recurrant spontenous pneumothorax

Video assisted throcentesis or pleurodesis – bleo iodine or talc

Who gets lung abscess

Alcoholics, elderly demented or neuronal damage emtera; feeds

diagnossis of the lung abscess

Chest X ray with a air fluid interface

Treaetmetn of lung abscess

Abx – Penicillin or clinda mycin if abx fail then SURGERY

Abscess indications for surgery

abscess > 6 cm or if empyema is present or if abx fail

SLN with popcorn calcification

harmartoma – most common

concenteric calcification in an SLN

old granuloma

SLN but the Pt &lt; 40, &lt;3cm well circumscribed

Most likely benign and f/u with CT or Cxr in 2 months

SLN but pt is a smoker, or is the lesion is &gt;3cm or if calcification is spiculated

more liekly maligant and you will need to biopsy it

Physcial presentation of a patient with lung cancer

Weight loss, cough, dyspnea, hemoptysis, repeated lung collapse, repeated pneumonia ( from the obstruction) Clubbing

MC lung cancer isnon smokers femals and asians

adenocarcinoma occuring at the point of old scars ( can be from pneumonia) in the lungs

where does adenocarcinoma metasize tooo

metd to liver bone, brain and to the adrenals and can present with hypoaderenalism

Adenocarcinoma has what type of pleural effusions

Exudative and high hyaluronidase

Paitent presents with kidney stones, constipation, malaise LOW PTH and centeral lung mass

sQUAMOUS CELL CANCER paraneoplastic suyndrom pthrp low PO4 high Ca

Patient has shoulder pain ptois constricted pupil and facial edema

superior sulcus

XR shoing peripherial caviatio and CT whoing distant mets

LArge cell carcinoma

Patietn has euvolmeia but hyponatermia and hx of smoker

Siadh frmo small cell carcinom produces evolemia hyponatermia

Patiente has ptossis and it impoves after staring up for a long time

Lambert eatons syndrom from small cell carcinoma – binds to the Ca channel on the pre nerves

ARDS diagnosistc critear

Pao2/fio2 > 200 < 3000 means acute lung injury Bilateral alveolar infiltrates on CXR PCWP < 18 ( means that the edema is not cardiogenic )

SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvuset tardus

Aortic stenosis

SEM louder w/ valsalva, softer w/ squatting or handgrip.


Late systolic murmur w/ click louder w/ valsalvaand handgrip, softer w/ squatting

Mitral valve prolapse

Holosystolicmurmur radiates to axilla w/ LAE

Mitral regurgitation

Holosystolic murmur w/ late diastolic rumble in kiddos


Continuous machine like murmur-


Wide fixed and split S2-


Rumbling diastolic murmur with an opening snap, LAE and A-fib

Mitral stenosis

Blowing diastolic murmur with widened pulse pressure and Corrhamer pulse, quinkes, Water hammer

Aortic regurgitation

Patietne has new onset bad breath sometimes finds undigested food in their mouth

Zenkers diverticulum tx with surgery – it is a false divrticulum

Dysphagia to liquids an solids
what is themedical and surigcal treatment

MEdical treatment – CCB nitrates botox Surgical heller myotomy

What cancer is ass to achalasia

Esphogeal squamous cell cancer

Epigastric pain worse after lying down
CAn have cough wheeze or HOarse voice

GERD the other symptoms are abnormal presentation represenitng silent aspiration

Test for GERD

24 hour PH monitoring

When Do you do an endoscopic examination for gerd

Alarm signs – Bleeding

Dyphasgia WORSE to hot and cold liiquids chest pain that seems like an MI
no reguirgitation

DIffuse esophageal spasm

Indications for surgery in GERD

Strictures, refractory to medical managment

Acid reflux pain after eating, when laying down

Hiatal hernia

Hiatial hernia type 1

Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs.

Type 2 hiatal hernia

aesophageal. Abd pain, obstruction, strangulation needs surgery.

Mid esophageal pain worse when eating

Gastric ulcers

Test for gastric ulcers

UlcersDouble-contrast barium swallow-punched out lesion w/ reg margins. EGD w/ bx can tell H. pylori, malign, benign.

When do you preform surgery on the gastric ulcers

Lesion persists after 12wks of treatment.


Gastric cancer spreads to the ovaries

Virchows nodes

Left supraclavicular lymph node


MCC extra nodal site common in HIV patients

Blummer shlfs

Mets felt on DRE

Sister mary joseph node

mets to the umbilical node

Malt- oma

H. Pylori

Protein loosing enteropathy with foamy pee and enlarged stomach rug


Gastric varices

splenic thrombosis

Dieulafoy –

eorded vessel in the stomach causes massive stomach hematemesis

Mid epigastric pain that gets better with food

dueodenal ulcesr

which ulcer stomach or duodenal is most associated with h pylori


Treatment for h pylori

PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.

If the duodenal ulcers don’t resolve after therapy

COnsdier ZE

Test for zollinger ellsion syndorm

Secretin stim test – find high levels of gastrin

Treatment for zollinger ellison syndrome

Surgical resection of pancreatic/duodenal tumor

what other cancers if Zollinger elision associated with

pituitary and parathyroid as part of MEN 1

Bilious vomiting and post prandial pain – recently loss a lot of weight

SMA syndrom — Where the 3rd part of the duodenum is compressed against the aorta

How to treat SMA SYNDROME

restore nutrition and weight or ROUX-en-Y

Most common cause of pancreatitis

ETOH and gallstones

Bad prognostic factors for pancreatitis

AGE WBC > 16 Glc > 200 LDH > 350 AST> 250 Drop in HCT , Ca PH and hypoxia

Complication of pancreatitis

abscess, pseudocyts, hemorrhage ARDS Thrid spacing of fluid

Chronic pancreatitis presentations

Mid epigastric pain DM and Malabsorption

Chronic pancreatitis can cause

SPlenic vein thrombosis – gastric varices

Pancreatitis adenocarcinoma presentation

Large NON tender GB, Itching and jaundice – cousvioar signs

Trousseaus sign

migratory thrombophlebitis

DX pancreatic cancer


Surgical treatment w

WHIPPLES – and only if no mets are found

Presentations of Insulinoma

sxs (sweat, tremors, hunger, seizures) + BGL < 45 + sxs resolve w/ glc admin

Glucagonoma + rash!

Hyperglycemia, diarrhea, weight-loss With necrolytic migratory erthyema

Somatistainoma ( prognosis )

Commonly malignant. see malabsorption, steatorrhea, ectfrom exocrine pancreas malfxn


Water diarrhea, hypokalemia, dehydration and flushing – LOKS like a carcinoid tutor



Patient presents with RUQ pain with shoulder or back pain – N/v fever

Acute cholecystitis

Acute cholecystitis first test


Treatment for Acute cholecystitis

Removal of the gallbladder – perutenous drainage if unstable

RUQ pain with High bill and all phase


Choledocolithiasis dx

U/s will show the stone in the CBD

Choledocolithiasis txt

Might remove the gall bladder and +/- ERCP

RUQ PAin fever jaudice Low bp, ams

Reynold pentad-ascending chalnagititis Txt abx and ERCP

Choledocal Cysts type 1

Mild – fusiform dilation of the common bile duct – txt with excision

Cholecohal cyst type 4

aka carol disease intrahepatic duct cysts need liver transplant


klatskin tumor for the bile duct epithelium

Cholangiocarcinoma RF

Primary sclerosisng chlangitis ass with UC, Liver flukes, thorothrast exposure



If ALT is higher then AST but both are in 1000’s


AST &amp; ALT high s/p hemorrhage surgery ( cardiovascular ) or sepsis

SHOCK LIVER – hypotnension liver injurgy

cirrhosis and portal htn medical txt

somatostatin – vasocontrict to decrease portal pressure

Tips used to but might cause

relieves portal htn but can cause encephalopathy

txt with hepatic encephalopathy


RF for hepatocellular carcinoma

Chronic HEp B ( DNA VIRUS ) > hep C cirrhosis for any reason Aflatoxin or CCL4

Tumor marker for HCC

AFP it is high in 70%

If multiple masses for HCC
txt vs singular mass

Multiple is radiation and cryoablation Surgically remove singular

Women on OCP with a palpable abdominal mass or sponteous rupture -&gt; hemorrhagic shock

hepatic adenoma

hepatic adenoma DX


hepatic adenoma – Surgery needed when

refractory to treatment Large Women wasn’t to be pregnant

*2ndMC benign liver tumor. W&gt;M but less likely to rupture

Focal nodular hyperplasia

Focal nodular hyperplasia what shows up on CT

Stellate scar

Bacterial Abscess- liver

E. coli, bacteriodes, enterococcus. txt Drainage and IV antibiotics

RUQ pain, profuse sweating and rigours palpable liver

entamoeba histolytica

Txt of entamoeba histolytica

Metronidiazole —DONT DRAIN IT —

Patient from Mexico presents with ruq pain and large liver Cysts found on U/S

Enchinococcus – hydatic cyst parasite from dogs fees

Enchinococcus lab

esonipholia- + Casoni skin test

Enchinococcus txt

albendazole and surgery to remove the entire cyst if ruputure the patient dies

Post Splenectomy what do you check

platelets if high can give aspirin

Propholatic treatment post splenectomy

Prophylactic PCN + S. pneumo, H. flu and N. meningitidisvaccines.

ITP presentations

isolated thrombocytopenia – bleeding gums, petechiae and nosebleeds NO splenomegaly

IPT treatment

steroids if a relapse then surgery

IPT bone marrow findings

Increase megakaryocytes in the marrow

Hereditary sphereocytosis

– hemolytic anemia – increase indirect bilirubin Increase LDH Decrease Haptoglobine Elevated reticulocyte count

Traumatic splenic rupture

consider w/L lower rib fracture and kerhs sign

Appendix when do you go to surgery

high clinical suspicion

Would you go to surgery with abscess or perforation

no first drain abscess and txt with ABX then removes

number 1 site for carcinoid tumor


Carcinoid syndrom sxs

Flushing, wheezing and diarrhea ( it needs to mets to the liver or beyond)

IF carcinoid is &gt; 2cm at the base of the appendix or w/ + nodes


Vitamine deficient in carcinoid syndrom

niacin – needed for tryptophan Diarrhea dementia dermatitis

pain, constipation, obstipation, vomiting. sxs


When is surgery indicated

peritoneal signs, IncrWBC, no improvement w/in 48hrs.

•Post-Op Ileus-Radiography

– dilated small bowel loop through the entire small bowel Give lactulose or erthyromycin

Ogilvie syndrom

Dilation of the colon

What is the threshold of treatment for olive syndrome
what is the management and treatment

10 cm the need decompression with ng tube or colonoscope and neostigmine ( watch for bradycardia )

What is this

Small bowel obstruction as the divisions go allthe way through representing the Plecae of the small bowel

IS this a cecal or sigmoid volvulus – birds beak

This is a birds beak – cecal

IS this a cecal or sigmoid volvulus – coffee bean

Coffee bean the crease is the mesenteric artery – sigmoid

Umbilical hernia in a 1 year old what isthe advice given

They will close spontenously by age 2

what adults get umbilical hernia

obese ascites and pregnancy

indirect inguinal

THROUGH the inguinal ring and lat to the epigastric vessels R>L more often congential patent proc vaginals

Direct inguinal hernia

Hasselbacks triangle and medial to the epigastric vessels More often acquired weakness

Femoral hernia more common in

women & more common to strangulate

What iBD affects the terminal ileum


Which ibd mimics appendicitis


Which IBD can result in FE deficiency

Chrons – d/t ileitus

Continously involving the ileum

Uc, ( can have backwash iliititis

Increased risk of PSC and Cholangiocarcinoma


Often has fistulas and what is the medical management

Crohns Give metronidazole

Has granulomas on biopsy


Transmural inflammation


CURED by colectomy


Smokers have a decreased risk

UC, but smokers have an increased risk of Crohns

Associated with <b>p-ANCA</b>


Treatment for IBD

ASA, Sulfasalzine, corticosteroids to induce remission

Chrons disease txt

Give metranidazole for any ulcer or abscess azathioprine 6MP and methotrexate

lead pip colon xray

ulcertive colitis

String sign is

Pagets disease do mammogram to find the mass -dcis

Pyroderma gangersoum


Diverticular disease
and complications

2/2 to a low fiber diet complication of bleeding, obstruction and infection


Forms a abscess that can perforate

Whats the best test for diverticular disease ?

CT not barium enema

When is colonscopy recommended after diverticulosis

4-6 weeks

When is surgery indicated- for colorectal cancer

multiple episodes, age < 50, elective is always better then emergency

RF for colorectal cancer

FAP, Lynch syndrom HNPCC Gardners – soft tissue tumors Cowdens Turcots- Carnial tumors

Presentation of colorectal cancer Right sided cancer


Presentation of left sided cancer


RECTAL cancer presentation

PAin/fullness, bleeding/ obstruction

What work up is done for colorectal cancer

DRE, Transrectal ultrasound ( this is to determine depth of invasion and prognosis ) colonoscopy CEA measurements for recurrence CT for staging

Treatment for coloncancer

Remove the affected regions + chemo if nodes are postive

Treatment for rectal cancer -if upper/middle 1/3
if lower 1/3

-if upper and middle get lower anterior resection – if lower 1/3 get abdominal peritoneal resection – permanant colostomy

Screening FOR AAA

MEN 65- 75 who have ever smoked- screen with U/S

What type of AA do you treat conservatively

if < 5cm and asymptomatic monitor growth every 3-12 months

Surgery indicated 2 reasons

> 5 cm in women > 5.5cm men Growting > 4mm/yr

complications of aaa surgery

#1 cause of death MI Bloody diarrhea – ischemic colitis ASA syndrom -1-2 years later brisk GI bleeding- d/t aorticenteric fistula, – heamturia – aroticvesiclular fistula – Aortic caval fistula – with the IVC ( look for increase in venouse congestion)

Post AAA surgery <b>Weakness &amp; decreased pain sensation</b> w/ preserved vibratory and proprioception

Anterior spinal artery syndrom

Acute mesenteric ischmeia TXT

Surgical emergency – embolectomy – if thrombus Aortomesenteric bypass if plaque

WOrk up for acute mesenteric ischemia

angiography – most common place is the SMA

Presentation:acute abdominal pain in a pt with a-fib subtherapeutic on warfarin or pt s/p high dose vasoconstrictors


Chronic mesenteric ischemia

Slow progression stenosis – req stenosis of 2.5 vessels – celiac & SMA & IMA

Physical presentation- chronic mesentric ischemia

Mid epigastric pain after eating food fear and weight loss – PAIN is out of proportion to exam

For acute arterial occlusion when should surgery be preformed

within 6 hours of insult to avoid tissue damage

Complications of surgery for acute arterial occlusion

compartment syndrom 5p’s

For acute arterial occlusion if surgery is not an option then what medical management

thrombolytics watch for hemorrhagic stroke*

ABI of 0.4-0.8 + ulcers

Best medical managment

ABI of 0.2-0.4 + limb ischemia

Surgery is indicated

ABI &lt;0.2 + gangrene

may require amputation

How to diagnosis DVT

Duplex and US also check for PE

How to treat DVT

txt with heparin, then overlap w/ warfarin for 5 days then continue warfarin for 3-6 mons

Complications of a DVT

Post phlebotic syndrom = chronic valvular incompetence cyanosis and edema

PE the signs

EKG – signs of Right heart failure – sinus tachycardia CXR decreased vascular markings wedge infarct ABG- low Co2 and o2 – alkalosis

What txt is provided if you suspect a dvt

Give heparin 1st – then work up with V/q scan —- then spiral CT

What is the gold standard test for a PE

pulmonary angiography

Work up for a thyroid nodule
1st step check what level?
If level is Low ?
If normal ?
IF benign ?
If maligant?
If intermediate ?

•1ststep? check TSH •If low? Do raiu to find the hot nodule – excise or radioactive I •If normal? FNA •If benign? Leave it alone •If malignant? Surgically excise •If indeterminate? re-biopsy or check RAIU •If cold? Surgiclaly excise and check pathology


MC type — spreads via lymph

papillary thyroid histology

psammoma bodies

Follicular how does it spread

spreads via the blood, must surgically excise whole thyroid

MEdullary what other test do you run

Look for MEN 2 pheo and hyperca

medullary histology

amyloid calcitonin


80% mortality in the 1st year

thyroid lymphoma

hashimotos predisposes to it

Work up for adrenal nodule

1: Check functional status – symptoms of a function tumor 2: if < 5 cm and non functional – observe with CT scans for q6mon if > 6cm or functional – if surgical excision

Clinical features of pheochromocytoma
and test

high blood pressure – sweating and weight loss Urine and plasma – metanephrines

Primary aldosteronism
symptoms and test

HIGH BP and Low K and High Na test : plasma aldosterone to renin ratio

adrenocortical carcinoma

Virilization or feminization URINE 17 ketosteroids

Cushing or silent cushing

Cushing symptoms or normal examination results test is dexamethasone

Patient with <b>perioral numbness</b> and chvortek and trousseau sign
what are the labs suspected

Hypoparathryoidism – after thyroidectomy decrease CA increase Po4 DEcrease Pth

Hyperparthyroidism presentation

Usually asymptomatic but increase in CA can present with stones, moans, bones ect. Increase Ca decrease Po4 increase vit D increase Pth


pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor.

MEN 2a

parathryoidhyperplasia, medullary thyroid cancer, pheochromocytoma

Men 2b

medullary thyroid cancer, pheochromocytoma, Marfanoid neuromucco- gangliomas

Work up for beast cancer

us to determine if it is solid or cystic

What type of breast tissue does MRI work on

good for dense breast tissue

IF a cystic mass is found what is the next step

aspiration of the fluid Send for cytology if it is bloody orhas recurred x2

IF a mass is solid


If cysts are painful and change with menses what is ir

Fibrocystic change – fluid is green or straw coloured -txt – restrict caffiene & chocolate take vit E and wear a supportive bar

RF for breast cancer

Brac 1 or 2 or hx of breast cancer in the family nulliparity endo/exogenous estrogen


Lumpectomy with clear margins or simple mastectomy if multiple lesions ( no NODES) + adjuvant RT

LCIS- lobular carcinoma in situ

Often bilateral – consider b/l mastectomy if FH+, Hormone senstive or prior hx of breast cancer

For infiltrating carcinoma that is small –

Can do lumpectomy with ax node biopsy + adjuvant _ chemo ( if the node +) + hormone therapy if + ______ OR ______ modified radical mastectomy with ax node sampling w/o adjuvant RT gives the same prognosis

Looks like eczema of the nipple

Pagets disease do mammogram to find the mass -dcis

Inflammaotry breast cancer

Red hot swollen breast – orange peel skin nipple retractione

Basal cell carcinom

Shave or punch biopsy then surgical remove

Squamous cell carcinoma what is the precursor lesion

aktinokeratosis or keratoacanthoma

Tx of squamous cell carcinoma

5FU or excision

Melanoma superifical spreading

Best prognosis most common


nodular poor prognosis


palms soles mucous membranes in darker complected races

Lentigo maligna

head and neck good prognosis

What is the prognosis factor for melanoma


TXT for melanoma –
for &lt; 1 mm thick
1-4 mm

< 1 mm thick -1 cm margin 1-4 mm 2 cm margin >4mm- 3 cm margin

Medical treatment of <b>melanoma</b>

high dose of IFN or IL2

Rules for time for the neck mass
7 days
7 months
7 years

7 days – inflammatory 7 months -cancer 7 years -congential

<b>Most common</b> neck lesion

Reactive node so the #1 step is to investigate for inflammatory lesions – tonsils and teeth

If neck node is firm rubbery and B sxs are present – whats the next step

excisional bx looking for lymphoma

Excisonal biopsy of the lymph node finds predominatly lymphocytes and reed sternberg cells

hodgkins lymphoma

If neck mass is <b>midlne</b> and moves when the <b>tongue is protrouded</b>

thyroglossal duct cysts move tongue and move the mass

IF the mass is <b>anterior to the SCM</b> &gt;

Brachial cleft cyst- can occur any where along the lenght of the SCM.

If spongy diffuse and lateral to the SCM

cystic hygroma – turners down, klinefelter

ORAL cancers MCC

Squamous cell cancer – seen in alcoholics and smokers Can present with unilateral hearing loss, a non healing ulcer in the base of the mouth especially in patients with poor dental hygeine txt with radial dissection

laryngeal cancer mcc in adults

squamous cell

Most common <b>laryngeal cancer</b> in kids with <b>stridor</b>

Laryngeal papilloma with stridor or cough

Pleomorphic adenoma

mc parotid gland tumor – Usually parotid benign but recurs-painless and mobile- cartilage and spithelium

Warthlin tumor

papillary cystadenoma lymphomatosum – itis a cystic lesion with a double layer of epithelium surronding a cystic space—–benign on parotid gland WATCH for 7th nerve damage

Mucoepidermoid carcinoma

MC malignant tumor arises from duct causes pain CNVII palsy painful mass has mucinous and squamous components

Baby born with respiratory distress scaphoid abdomen

Diaphragmatic hernia- always on the left

What is the biggest concern then the diaphragmatic hernia

Pulmonary hypoplasia

Best treatment for diaphrgamatic hernia

at delivery place ECMO. let lungs mature 3-4 days then do surgery

Baby is born with <b>respiratory distress</b> with <b>excess drooling</b>

te – fistula

Best test for fistula

Place feeding tube and take X ray and see it Coiled in the thorax

Gastroschisis has what elevated in amniotic fluid



Defect lateral usually Right of the midline — NO SAC – matted angry appearing bowel, child must remain TPN for 2 weeks

Complications with gastrochisis surgery

bowel may be atretic or nectotic and require removal – SHORT gut syndrome

OMphalceocele associated with

Edwards And patau and beckwidth widemen

Umbilical hernia what else is associated

congential hypothyroidism and big tongue

A vomiting baby 4 week old non bileous vomting and palpable olive

pyloric stenosis

metabolic complications of severe vomting

hypochloremic metabolic alkalosis

2 wk old infant with <b>bilious vomiting</b> the pregnancy was complicated by <b>polyhydramnios</b>

Intestinal atresia or annular pancreas both are associated with down syndorme intestinal aterisa have multiple air fluid levels annular pancrease has the double bubble sign.

1 wk old baby w/ bileous vomiting draws up his legs has abdominal distension

malrotation and volvulus — Ladd bands can kink the duodenum ( doesnt rotate 270 ccw around the sma )

3 day old newborn has still not passed meconium
what 2 things could it be

meconium ileus – consider Cystic fibrosis if FH + or gastrograffin enema is dx and tx ________ OR _________ Hirschaprung DRE explosion of poo bx showing no ganglia is gold standard

A new day old baby who was premature develops bloody diarrhea
what is it
what is on the X ray
risk factors

necrotizing enterocolitis XR findings = pneumocystis intestinalis ( air in the intestine walls) txt – NPO TPN antibiotics and resection of the nectotic bowel risk factors: premature gut, introduction feeds and formula

2month old baby has colicky ab pain and current jelly stool with a palpable mass in the RUQ

intussuception – barium enema is DX and TX– Dance sign – ( knees to chest )

What medications make BPH worse


how do you treat acute urinary retension


what is the best treatment BPH

medical tx 1st tamsulosin (a-1 blockers) or finasteride- Decreases the size of the prostate

TURP Syndrome:

Hyponatremia and water intoxication (symptoms resembling brain stroke in an elderly presenting patient) caused by an overload of fluid absorption (e.g. 3 to 4 Litres) from the open prostatic sinusoids during the procedure. This complication can lead to confusion, changes in mental status, vomiting, nausea, and even coma.

Prostate cancer

nodules on DRE or elevate/rising PSA means = trans rectal ultrasound and bx. tx with surgery radiation & leuprolide & flutamide


CT- without contrast

Kidney stone less then 5 mm

hydrate and pain killers to let pass

IF &gt; 5mmm

do shock wave lithotripsy


Surgical removal

Scrotal mass

transilumiante U/s and excision [never biopsy allows for seeding]

Testicular torsion

acute pain and swelling with high riding testies pain is excerbated by movment.

Testicular torsion Studies

STAT Doppler U/S (will show no flow ) contrast with epididymitis where flow is maintained

how much time to salvage testies- after testiclular torsion

6 hours

Avscular necrosis in a 4-10 ( mean age 7) year kid with a <b>painless limp</b>

leg calve perthe disease

Avascular necrosis in a kid 12-13

slipped capital femoral epiphyseals – the ball slipps off in a backward direction– Can present with Knee pain from the obturator nerve and look for an externally held passively in external rotation

Avascular necrosis in an adults

steroids and femur fracture ( look for a shortened an extrenally rotated foot)

where and what radiological sign

distal femur/proximal tibia/ at metaphysis around the knee codman triangle and sunburst apperance

Ewing sarcoma

seen at the disphysis of the long bones – night pain fever and elevated ESR

Ewing sarcoma radiological

lytic bone lesions – onion skinning (lytic); t 11:22, small round blue cell tumor

Hyperacute Rejection

Vascular thrombosis with in minutes Caused by preformed antibodies

Acute rejection

Organ dysfunction – INCREASED GGT in the liver or CR depending on organ w/ in 5 days – 3months

Acute rejection what cell is responsible

T lymphocytes

Technical problems common in the liver

1st biliary obstruction w u/S then check for thrombosis by doppler

Heart transplant complications

sx come late so check with ventricular bx periodically

How to treat the acute rejection

OKt3 antilymphocytic agent tx + steroid bolus

chronic rejection

occurs after yeas – d/t t-lypmhocytes cant treat

Where <b>cant</b> you get epi in the body

fingers, nose, Penis & Toes

Spinal subarachnoid –

bupivacine etc.


Local + opioid


Norperidine metabolite can lower seizure threshold especial in patients with renal failure


Can cause malignant hyperthermia, hyperK (not for burn or crush victim because of upregulation of receptors)


Sometimes allergic rxn in asthmatics


Can cause malignant hyperthermia (dantroline Na), liver toxicity.

Seminoma what marker is increase

placental alp

Yolk sac tumor aka endodermal sinus tumor

Increased AFP


increased HCG hematogenous mets to the brain


increased HCG adn AFP

Embryonal carcinoma

increased hcg

Superficial spreading melanoma

4th -6th decade of life and fiar skinned people trunk males legs – femals Long radial growth phase then verticle growth

Nodular melanoma

6th decade – 2nd MC 6th decade on trunk head and neck M>F NO radial growth

Letigo meligna

7th decade uncommon on face nose & cheek under the hutichens freckle acitinic background – chronic expose to the sun

Acral lentigous melanoma

Palms and soles of the feet and nail bed more rapid vertical phase

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