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Surgery #2
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110
Archaeology
1st Grade
11/06/2010

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Cards

Term

What three symptoms typically characterize carpal tunnel syndrome?

 

what nerve is compressed?

Definition

pain, paresthesia and numbness

 

median nerve compressed

Term
What are risk factors for developing carpal tunnel syndrome?
Definition

displaced distal radius fracture

lipomas arising within the carpal tunnel

repeptitive mechanicl stress

Term

where do patients with carpal tunnel usually complain of pain?

when is pain worse?

 

ie. what areas specifically

Definition

thumb

index and long finger and the radial half of the ring finger

 

pain wakes them up at night and exacerbated by repetitive use of hand

 

 

Term
What is non surgical and surgical tx for carpal tunnel syndrome?
Definition

Non surg: nighttime splint of the wrist in neutral position to reduce carpal tunnel pressures

 

oral antinflam drugs to reduce synovitis

diuretics to reduce edema

corticosteroid injections

 

Surgical management: surgical release of the transverse carpal ligament

Term

What is usually mechanism of injury for olecranon fracture?

 

What type of studies do you want to get? what would you find?

Definition

fall on outstretched hand with a strong contraction of the triceps

 

lateral and AP of the elbow: may find ant and posterior fat pad signs of a hemarthrosis and highly suggestive of fracture

Term
What are non surg and surg tx for olecranon fracture?
Definition

non surg: if non displaced-long arm cast

 

surg: if comminuted or displaced or both; K wire and tension band construct

Term

Who is at risk for fat embolism syndrome?

 

What are symptoms (3)

Definition

people who have fracture of long bone or joint replacement

 

sxs: neurologic dysfunction, respiratory insufficiency, and petechiae of the axillae, chest, and proximal arms

Term

How do you diagnose fat embolism syndrome?

 

When does it occur after injury?

 

What labs may help you confirm? (3)

Definition
Fat embolism syndrome characteristically begins 12–72 hours after injury but may be delayed for several days. The diagnosis is clinical. The finding of fat droplets in sputum and urine is common after trauma and is not specific. Decreased hematocrit, thrombocytopenia, and other changes in coagulation parameters are usually seen.
Term
Where do you place thoracostomy tube in pt with pneumothorax?
Definition
should be placed in the fourth intercostal space in the midaxillary line
Term
What is immediate treatment for tension pneumo?
Definition
 immediate decompression of the affected pleural space by placement of an angiocath in the second intercostal space at the midclavicular line
Term

What is an empyema?

 

What are the three types?

Definition

accumulation of purulent material in the pleural space

 

three types:

1)exudative/acute phase: pleural fluid

2)fibrinopurulent/transitional: increase in WBC

3)organizing/chronic phase: viscous fluid and organized pleural peel

Term

What is the most common cause of empyema? second most common?

 

what are pathogens?

Definition

bacterial pneumonia

 

second most common: complication from surgical procedures on the lung, mediastinum or esophagus

 

pathogens: staphylococci, streptococci, and anaerobic organisms

Term

How do you diagnose an empyema?

 

what's the test of choice to differentiate empyema from lung abscess?

Definition

aspirating pus from pleural space

 

requires immed drainage

 

CT scan helps to differentiate

Term
What are the four major types of lung cancer?
Definition

adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and small cellcarcinoma

Term
Where are the lung cancers located?
Definition

adenocarcinoma (most common):peripheral

 

small cell carcinoma (second most common): central

 

large cell: peripheral and metastacise quickly

Term

How do you start diagnose lung carcinoma?

 

How do you stage lung cancer?

 

What is the most common surgical procedure performed?

Definition

chest radiograph

 

stage with CT

 

Bronchial biopsy, brushings, and washing are used to make the histologic diagnosis of a lung cancer.

 

procedure: lobectomy

Term
What is the second most common mediastinal mass and the most common lesion of the ant mediastinum?
Definition
thymoma
Term
What is associated with thymomas?
Definition
myasthenia gravis: weakness and fatigue of skeletal muscles
Term
What is primary therapy for thymomas?
Definition

complete surgical resection whenever possible

 

adjunctive radiation therapy shoudl be done for stage II and III disease

 

 

chemo for stage IV

Term

How do you diagnose a thymoma?

 

where are they found in mediastinum?

Definition

diagnose with CT

 

found in ant mediastinum

 

they are primary tumors

Term
What is Ludwig's angina?
Definition
uncommon, life-threatening condition characterized by cellulitis involving the submental, sublingual, and submandibular spaces. The source of the infection is odontogenic and spreads rapidly. The infection is usually polymicrobial with aerobic and anaerobic gram-positive cocci and gram-negative rods
Term

Patient presents with painful neck swelling and edema of the floor of mouth, often leading to elevation and displacement of the tongue. Pt has hot potatoe voice. palpation of the floor of mouth reveals woody edema.

 

What is it?

How do you treat?

Definition

Ludwig's angina--clinical diagnosis/ CT can be used but not needed

 

primary treatment should be centered on airway maintenance with early involvement of anesthesiology and otolaryngology physicians. Intubation is often anatomically difficult, and tracheotomy under local anesthesia is often the preferred method of ensuring a patent airway

 

benefit of intravenous dexamthosone and nebulized epi to aid with temporizing the airway and transnasal intubatio

Term

What is this:

 

when an eardrum becomes markedly retracted, usually in the posterosuperior area (the pars flacidda)

Definition
cholesteatoma--acquired
Term

What is diagnostic tool to look for cholesteatoma?

 

What is tx?

Definition

CT of the temporal bone

 

tx: srugeron on the eardrum, middle ear and mastoid

Term
What are indications for tympanostomy tube?
Definition

frequently occuring AOM (three or more infections over a 6 month period OR three or more infections over 12 months), persistent middle ear effesuion with conductive hearing loss or complicatiosn of OM

 

most tubes come out on their own

Term
Where are tympanostomy tubes placed?
Definition

placed in the anteroinfefrior aspect of the tympanic membrane

 

allows for more consistent path for middle ear ventilation

Term
What causes 80% of the cases of primary hyperparathyroidism?
Definition

solitary adenoma: collection of chief cells surrounded by normal tissue

 

usually found in only one parathyroid gland

Term
Who is most at risk for hyperparathyroidism?
Definition

women

postmenopausal women

Term
What questions about PMH do you want to ask someone you suspect as hyperparathyroidism?
Definition

bone disease, kidney stones, nephrocalcinosis, hypercalciuria, peptic ulcer disease, HTN, endocrinopathies, radiation therapy as child

 

Meds: HCTZ, lithium, vit a and d

Term

What labs tests are diagnostic of hyperparathyroidism?

 

What is tx?

 

what is major complication from surgery?

Definition

hypercalcemia with elevated PTH

 

tx: parathyroidectomy is the only curative tx

 

major complication: hypocalcemia

Term
What's the most common endocrine tumor of the pancreas?
Definition
insulinoma
Term

What is whipple's triad?

 

what is it assoc with?

Definition

fasting hypoglycemia that induces sxs, blood glucose levels <50 and relief of sxs after glucose administration

 

assoc with insulinoma

Term
How do you diagnose insulinoma?
Definition

72 hour fasting insulin levels greater than 25 microunits/mL in the face of hypoglycemia and an insulin to glucose ratio greater than 0.4 after an overnight fast

 

Proinsulin and C-peptide are usually elevated

Term

What type of surgery can be done for small or large insulinoma?

 

What type of meds are helpful?

Definition

small benign insulinomas: enucleation

 

large lesions: distal pancreatectomy or pancreaticodudoenectomy

 

meds: diazoxide, thiazide diuretics and octreotide for pts with unresectable or residual disease

Term
What occurs during hypovolemic shock?
Definition
this form of shock is caused by a reduction of circulating blood volume to a point below that necessary to continue adequate tissue perfusion
Term
What are two reasons that may cause hypovolemic shock?
Definition
loss of whole blood from hemorrhage or from loss of plasma volume due to processes that cause sequestration of large volumes of fluid outside of the intravascular space, or due to gut losses of fluid as in gastric outlet or severe diarrhea
Term
What's the best way to assess blood loss?
Definition
measure metabolic acidosis
Term
What type of IVF do you give someone in hypovolemic shock?
Definition
crystalloid infusion
Term
What are early vs late findings of hypovolemic shock?
Definition

early: orthostatic hypotension, mild tachycardia, anxiety, diaphoresis, vasoconstriction (decreased pulse pressure with increased diastolic pressure)

 

late: changed mental status, decreased BP, marked tachycardia

Term
What is the most common vital sign change associated with early hypovolemic shock?
Definition
tachycardia
Term
What hormones are produced in the ant pituitary gland? (5)
Definition

ACTH

FSH/LH

Prolactin

GH

TSH

Term
What hormone is produced in the post pituitary gland?
Definition
Antidiuretic hormone
Term
Most hyperfunctioning pituitary tumors are ______.
Definition
prolactinomas
Term

What may you see in small prolactinomas? ie. physical exam

 

large prolactinomas??

Definition

small prolactinomas: hypogonadism

 

large prolactinomas: hypogonadism, headaches, visual compromise, loss of other hormone function

Term
What are signs of hyperprolactinemia in females?
Definition
amenorrhea, galactorrhea, infertility
Term
what type of visual loss is present in prolactinomas?
Definition
bitemporal hemianopsia
Term

What is the preferred tx for prolactinomas?

 

why?

 

What is second line tx?

Definition

dopamine agonisT: bromocriptine or cabergoline

 

why? inhibit the secretion and synthesis of PRL and impair lactotroph proliferation and growth 

 

second line tx: surgery

Term

What is the tx of choice for ACTH secreting hormone?

 

What do you need to give post operatively?

Definition

trans-sphenoidal adenoidectomy

 

post operatively: give glucocorticoid therapy for 1 year due to transient adrenal insufficiency

Term
What is the screening tool for Cushing's syndrome?
Definition

low dose dexamethasone suppression test

 

if the pt's cortisol level is not suppressed by this test and if the level of free cortisol in a 24 hr urine sample is elevated then you should test ACTH

Term

What does a normal or elevated ACTH level suggest?

 

What does a suppressed ACTH level suggest?

Definition

What does a normal or elevated ACTH level suggest? suggests ACTH dependant pituitary disease (Cushing's disease)

 

What does a suppressed ACTH level suggest? non ACTH dependant pituitary disease (Cushing's syndrome)

Term
GH secreting tumor can cause what?
Definition
acromegaly
Term

How can you screen for acromegaly?

 

what study should you get?

Definition

IGF-1 level

 

also imp to measure GH level after 100 g glucose

 

study: MRI with pituitary views: tumors are found to be macroadenomas

Term

What is first line therapy for pts with GH secreting tumor?

 

What is a common complication after surgery?

Definition

transspenoidal adenectomy

 

complication: hypopituitarism

Term
What's the difference between Cushing's syndrome vs Cushing's disease?
Definition

Cushing's disease: ACTH secreting tumor

 

Cushing's syndrome: cortisol producing adrenal adenoma

Term
What is the most common cause of Cushing's syndrome?
Definition
iatrogenic
Term
What are the signs/symptoms of Cushing's syndrome?
Definition

truncal obesity

hirsituism

"moon" fascies

acne

buffalo hump

purple striae

HTN

diabetes

weakness

depression

easy bruising

myopathy

Term
What is the low dose dexamethosaone suppression test?
Definition
dexamethasone is a synthetic cortisol that results in neg feedback on ACTH secretion and subsequent cortisol secretion in healthy patients. Pts with Cushing's syndrome do NOT suppress their cortisol secretion
Term
what is pheochromocytoma?
Definition
tumor of the adrenal medulla and sympathetic ganglion (from chromaffin cell lines) that produce catecholmines (NE>Epi)
Term
What are risk factors for developing pheochromocytoma?
Definition
MEN II FH, Von Recklinghausen disease, Von hippel Lindau disease
Term
What is the classic triad of pheochromocytoma?
Definition

palpitations

headache

episodic diaphoresis

 

also HTN (50%), pallor--causing flushing, anxiety, weight loss, tachycardia, hyperglyemcia

Term
What is medical treatment for pheochromocytoma?
Definition

phenoxybenzamine: increase intravascular volume with alpha blocker to sloow reduction in catecholmine induced vasoconstriction and resulting volume depletion

 

beta blockers also can be used

Term
What is the surgical tx for pheochromocytoma?
Definition
tumor resection with early litigation of venous drainage and minimal manipulation
Term
What is the treatment of choice for pheochromocytoma?
Definition
surgical resection of the tumor
Term

What type of lab tests do you do for pheochromocytoma?

 

what's specific? what's the least specific?

Definition

24 hour urine sample

 

looking at total catecholmines, metanephrine and vanillymandelic (VMA)

 

specific: elevated metanephrine

less specific: VMA

Term

What type of imaging studies can you do for pheochromocytoma?

 

When do you do the tests?

Definition

tests should be performed AFTER biochemical studies

 

MRI

Term

What's the difference btw direct and indirect inguinal hernias?

 

what are causes?

Definition

indirect inguinal: come through the internal inguinal ring and enter the inguinal canal

cause: lack of obliteration of the processus vaginalis during development; congential

 

Direct inguinal:  come through the posterior wall of the inguinal canal 

cause: defect of transversalis fascia

Term
What is the main etiologic factor in direct hernias?
Definition

any maneuver that increases the intrabdominal pressure such as freq heavy lifting

 

other: cig smoking, advanced age and chronic illness

Term
What are possible complications of an inguinal hernia?
Definition
strangulation or incarceration
Term

True or false:

 

Imaging studies are needed to diagnose an inguinal hernia.

Definition

False

 

you can use a herniography if there was an inconclusive exam or pits with unexplained groin pain, but not necessary

Term
What are the three types of surgeries for inguinal hernias?
Definition

1. anterior or inguinal canal approach

2. posterior or preperitoneal approach

3. posterior laparoscopic technique

Term
What's the difference between primary and secondary spontaneous pneumothorax?
Definition

primary: result of a ruptured bleb, most commonly at the apices of the upper lobes- usually yound adults, cigarette smothers

 

secondary: older (45 to 65) with underlying pulomary disease OR neoplasms or TB

Term
What is an anal fissure?
Definition
small tears in the anoderm typically in pos midline
Term
What type of anal fissure should raise suspicion of Crohn's disease?
Definition
any fissure off the midline
Term
Do you do any lab tests or imaging for anal fissures?
Definition
NOPE
Term
What is the best form of initial tx for anal fissures?
Definition
correcting the constipation with high fiber diet, increased liquid intake and the addition of a bulking agent and a stool softener
Term
What type of initial tx should be done for chronic anal fissures?
Definition
nitroglycerin paste- believed to be improving blood supply--applied twice  day to anal opening
Term
When should surgical options be explored for anal fissures?
Definition

when conservative tx have failed

 

you should do a lateral internal spincterotomy

 

can be done under local, spinal or general anesthesia

Term
What's the difference between internal and external hemorrhoids?
Definition

internal hemorrhoids: found above dentate line

 

external hemorrhoids: found below the dentate line

Term
What is nonsurg tx for hip pain due to arthritis or other disorders?
Definition

can or crutch to reduce joint loading forces

 

physical therapy- to improve flexibility and restore strength and ROM

 

Meds: Tylenol and NSAIDS, Cox 2 inhibitors and non acetylated salicylates

Term
What are options for hip surgery? (4)
Definition

arthroscopy

arthrodensis

osteotomy

arthroplasty

Term
When should pt get a hip arthrocopy?
Definition
limited to the management of labrum tears, loose bodies and chondral defects
Term
When is it indicated to get hip arthodesis?
Definition

in young pts with advanced unilateral hip arthritis

 

ipsilateral knee involvement, spine disorders and bilateral hip disease are relative contraindications

Term
Who is the ideal candidate for pelvic and femoral osteotomies?
Definition
a young, active pt who has hip pain secondary to acetabular dysplasia but does NOT have degenerative hip arthritis
Term
What are complications of hip arthroscopy?
Definition
neuropraxias of the hip and pudendal nerves
Term
What muscles comprise the rotator cuff muscles?
Definition

supraspinatus

infraspinatus

teres minor 

subscapularis

Term
What is the tx for rotator cuff tear?
Definition

symptomatic pain relief

 

later: if poor muscular function--surgical repair may be indicated

Term
What is tx for biceps tendon rupture?
Definition
Surgical treatment of proximal ruptures, if indicated, is usually reserved for patients less than 40 years old. Open surgical repair leaves a long scar and usually does not completely restore the underlying anatomy. The coiled-up distal end of the tendon is usually found beneath the attachment of the pectoralis major. A correlation exists between proximal biceps tendon rupture and rotator cuff tears in middle-age and older athletes (more than 50 years old). Rupture of the distal biceps tendon often warrants surgical repair because of loss of forearm flexion and supination strength. In this case, the tendon is usually found approximately 5–6 cm above the elbow joint, and care must be taken to avoid damage to the lateral antebrachial cutaneous nerve.
Term
When is it indicated to get a tonsillectomy?
Definition

frequent (chronic) tonsilitis

 

tonsilar hypertrophy

 

child who had had three or more episodes of tonsilitis a year  for more than 2 rs is candidate

Term

What are the two main reasons for having an adenoidectomy?

 

 

Definition

1. for improved nasal airway

2. adjunct tx for child with frew otitis media (adenoids are thought to harbor pathogens that predispose to infections)

 

 

Term

Patients usually present with fever, painful sore throat, halitosis, and dysphagia.

 

What could it be?

Definition
tonsilitis
Term
What do you see on PE for pt with tonsilitis?
Definition
On physical examination, the acute tonsillitis patient has erythematous tonsils, purulent tonsillar exudate, and anterior cervical lymphadenopathy.
Term
What is tx for tonsilitis?
Definition
7–10 day course of penicillin or a comparable cephalosporin
Term
What is surgery for chronic sinusitis?
Definition
endoscopic sinus surgery
Term
what is the mainstay imaging test for valvular heart disease?
Definition
two dimensional echocardiography with Doppler and color flow imaging- can be done transthoracic or transesophageal
Term
What can a two dimensional echocardiography with Doppler show?
Definition

describe the anatomic appearance of all the valves

can calculate the functional surface area of the valves based on flow and velocity of flow through the valve, can evaluate for chamber hypertrophy or dilation, can assess biventricular function and can estimate pulmonary artery pressures. 

Term
What type of tests would you want to do in pt with valvular disease?
Definition

ECG

CBC to identify anemia

BUN and creatinine for renal problems

liver function tests: with suspected RHG

blood cultures if suspected endocarditis

albumin for nutrional status

Term
What are the most common causes of valvular aortic stenosis?
Definition
rheumatic fever, senile calcific degeneration, calciforic aortic stenosis, and stenosis of a congenitally bicuspid aortic valve.
Term

What is the normal surface area for an aortic valve?

 

When is it a significant problem?

Definition

should be 3-4 cm squared

 

significant problem if < 1 cm squared

 

if > 1 cm squared- can be monitored with 6 to 12 month examinations and echocardiogram

Term
Who is a aortic stenosis candidate for surgical intervention?
Definition

pts with <0.75 cm sqaured valve area and or valvular gradient <50 mmHg and sxs of AS

 

asymptomatic pts with critical AS who show evidence of LV dysfunction or exercise intolerance also should be considered

Term
What are the surgical options for aortic stenosis? (3)
Definition

balloon valvuloplasty: poor long term

 

ultrasonic decalcification of the valve: usually results in valvular insufficiency and restenosis

 

valve replacement:most durable outcome

Term
What's medical tx for aortic regurg?
Definition

afterload reduction

 

ACE inhinitor

diuretic use to reduce volume overload

 

pt tx of arrythmia

Term
What elements of the heart are important to consider when thinking about mitral stenosis?
Definition

papillary msucles

LV wall

chordae tendinae

annulus

valve leaflets

Term
What is the tx for mitral stenosis?
Definition

diuretic therapy to treat pulmonary edema

tx of atrial or ventricular arrythmias

anticoag if afib

Term
What are the two primary causes of renovascular hypertension?
Definition

Atherosclerosis of the aorta and renal artery (two thirds of cases) and fibromuscular dysplasia

Term

Pt presents with the following: asymptomatic, but irritability, headache, and emotional depression are seen. Persistent elevation of the diastolic pressure is usually the only abnormal physical finding. A bruit is frequently audible to one or both sides of the midline in the flank or upper abdomen. 

What could it be?

What test do you want to do?

What is tx?

Definition

renovascular htn

 

duplex ultrasound scanning

 

tx: if medical tx works then surgery no needed. If not: Percutaneous transluminal angioplasty and stenting is the preferred procedure for most patients 

Term
Who are pts most at risk for wound dehiscence?
Definition
diabetes mellitus, uremia, immunosuppression, jaundice, sepsis, hypoalbuminemia, and cancer; in obese patients; and in those receiving corticosteroids.
Term

When does wound dehiscence most commonly occur?

 

What is the first sign of wound dehiscence? what will pts describe?

Definition

during days 5-8 when strength of wound is at a minimum

 

 The first sign of dehiscence is discharge of serosanguineous fluid from the wound or, in some cases, sudden evisceration. The patient often describes a popping sensation associated with severe coughing or retching

Term

What do you give pt preoperatively if they gave GI reflux?

 

What preop meds do you want to stop before surgery? (5)

 

How many weeks prior to surgery should you stop smoking?

Definition

What do you give pt preoperatively if they gave GI reflux? prevacid

 

What preop meds do you want to stop before surgery? oral hypoglycemics, antidepressants, Coumadin, ASA, plavix

 

How many weeks prior to surgery should you stop smoking? 8 weeks prior

Term
What are the American Society of Anesthesiologists scale? I-V
Definition

I: healthy individual with no systemic disease undergoig elective surgery

 

II: individual with one systemic disease, well controlled

 

III: individual with multiple systemic diseases or well-controlled major systemic diseases

 

IV: individual with severe incapacitating disease, poorly controlled of end-stage

 

V: pt in imminent danger of death

 

Term
What are major risk factors for PE in surgical pt---think MOIST!
Definition

M: malignancy

O: orthopedics

I: immobility

S: surgery

T: trauma

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