High Yield Surgery Compatible Version
High Yield Surgery Compatible Version
• If PaO2 is high? decrease FiO2 Patient is getting too much oxygen free radical risk!
Hypervolem
ic
– ↑volume ↓Na: CHF, nephrotic, cirrotic
Hypovolemi
c
– ↑volume ↓ Na: diuretics or vomiting + free water
Euvolemic
– Nl volume ↓Na: SIADH, Addisons, hypothyroidism.
– Treatment? Fluid restriction & diruetics
– If hypovolemic? Normal Saline
– When to use 3% saline? Symptomatic (Seizures), < 110
Rate is .5-1
meq pe hour
– What would you worry about? Central Pontine Myolinolysis.
• ↑Na = Loss of water
– Treatment? Replace w/ D5W or hypotonic fluid
– What would you worry about? cerebral
edema.
Other Electrolyte Abnormalities
• Numbness, Chvostek or Troussaeu, prolonged
QT interval. ↓Ca
• Bones, stones, groans, psycho. Shortened QT
interval. ↑Ca
• Paralysis, ileus, ST depression, U waves.↓K
– Treatment? give K (kidneys!), max 40mEq/hr
• Peaked T waves, prolonged PR and QRS, sine
waves. ↑K
– Treatment? Give Ca-gluconate then insulin + glc,
kayexalate, albuterol and sodium
bicarb. Last resort = dialysis
Fluid and Nutrition
• Maintenance IVFs D51/2NS + 20KCl (if peeing)
– Up to 10kg s 100mL/kg/day
– Next 10 kgs 50mL/kg/day
– All above 20 20mL/kg/day
• Enteral Feeds are best keep gut mucosa in tact
and prevent bacterial translocation.
• TPN is indicated if gut can’t absorb nutrients 2/2
physical or fxnal loss.
– Risks = *acalculus cholecystitis*, hyperglycemia, liver
dysfxn, *zinc deficiency*, other ‘lyte probs
Erythematus but not peeling Burn Stats to affect nerves
Loss of integrety (starting to peel)
www.readykor.com/docs/burns_files/burns9.jpg
http://emedicine.medscape.com/arti
http://en.wikipedia.org/wiki cle/769193-media
1st degree /Burn
Silver
• Doesn’t penetrate eschar and can cause
Sulfadiazine
leukopenia? Not best for third degree burns
• Penetrates eschar but hurts like hell? Mafenide Best for third
degree burns
broncoscope
– If huge facial trauma, blood obscures oral and
nasal airway, & GCS of 7? cricothyroidotomy
• Breathing-
– So you intubated your patient… next best step?
Check bilateral breath sounds
– If decr on the left?Accidantely hypoventilating
Head Trauma
• GCS eyes 4, motor 6, verbal 5
tumj.tums.ac.ir
uiowa.edu
prep4usmle.com
• Common fractures-
– Shoulder pain s/p seizure or electrical shock Post. shoulder dislocation
Axillary nerve injury
– Arm outwardly rotated, & numbness over deltoid. Ant. shoulder dislocation
– old lady FOOSH, distal radius displaced. Colle’s fracture
– young person FOOSH, anatomic snuff box tender. Scaphoid fracture
– “I swear I just punched a wall…” Metacarpal neck fracture “Boxer’s
fracture”. May need K wire
– Clavicle most commonly broken where? Between middle and distal 1/3s.
Need figure of 8 device
Ortho Trauma X-rays
www.meddean.luc.edu
Work up of a Solitary Lung Nodule
• 1st step = Find an old CXR to compare!
• Characteristics of benign nodules:
– Popcorn calcification = hamartoma (most common)
– Concentric calcification = old granuloma
– Pt < 40, <3cm, well circumscribed
– Tx? CXR or CT scans q2mo to look for growth
• Characteristics of malignant nodules:
http://emedicine.medscape.com/
article/356271-media
• Acid reflux pain after eating, when laying down- Hiatal Hernia
– Type 1 = Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs.
– Type 2 =Paraesophageal. Abd pain, obstruction, strangulation needs surgery.
• MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids- Gastric Ulcers
Double-contrast barium swallow- punched out lesion w/ reg margins.
– Work up =
EGD w/ bx can tell H. pylori, malign, benign.
– Surgery if-
Lesion persists after 12wks of treatment.
• Gastric Cancer- Adeno most common. Esp in Japan
– Krukenberg Gastric CA ovaries Blummer’s Shelf Mets felt on DRE RECTAL EXAM
Virchow’s node L supraclav fossa Sister Mary Joseph Umbilical node
– Lymphoma- HIV MALT-lymphoma- H. pylori Txt with abx
• Randoms-
Foamy pee
– Mentriers = protein losing enteropathy, enlarged rugae.
– Gastric Varices = splenic vein thrombosis. Chronic pancreatitis
– Dieulafoy’s = massive hematemesis mucosal artery erodes into
stomach
Duodenum
Mid epigastric
– Consider w/ L lower rib fx and intra abd hemorrhage. Can have Kehr’s
sign (irritates L diaphragm). Left shoulder pain due to irritation in l dia[hragm
Appendix
• pain in umbilical area RLQ, n/v.
perf. Appendicitis
– Go to surgery if: Clinical picture is convincing.
– If perforated/abscess? drain, abx (to cover e.coli & bacteriodes),
and do interval appendectomy
• Carcinoid Tumor- #1 site: Appendix!
– Carcinoid syndrome sxs? Diarrhea, Wheezing.
– When do they happen? When mets to liver. (1st pass metabolism)
– What else to look out for? Diarrhea, Dementia, Dermatitis
^ Lose niacin because rey[to Phan
is depleted
– If >2cm, @ base of appendix, or
w/ + nodes Hemicolectomy
– Otherwise Appendectomy is good enough
Bowel Obstruction
• Small Bowel Obstruction-
– Suspect in hernia, prior GI surgery (adhesions), cancer,
intussusception, IBD.
– Sxs are pain, constipation, obstipation, vomiting.
– 1st test is upright CXR to look for free air. CT can show point of
obstruction.
– Tx w/ IVF, NG tube. Do surgery if peritoneal signs, Incr WBC, no
improvement w/in 48hrs.
• Volvulus- either cecal or sigmoid
– Decompression from below if not strangulated. Otherwise, need
surgical removal and colostomy.
• Post-Op Ileus-
– Also consider if hypoK (make sure to replete), opiates.
– See dilated loops of small bowel w/ air-fluid level.
– Do surgery for perforation. Give lactulose/erythromycin.
• Ogilvie’s syndrome- Peimqeily secum.
http://emedicine.medscape.co
http://emedicine.medscape.com/article/7 m/article/774045-
74045-diagnlearningradiology.comosis diagnlearningradiology.comosis learningradiology.com
Hernias
• Umbilical- in kiddos, close spontaneously by age 2. In
adults: 2/2 obesity, ascites or pregnancy.
• Indirect Inguinal- MC through inguinal ring (lat to
epigastric vessles) in spermatic cord. R>L, more often
congenital (patent proc vaginals)
• Direct Inguinal- through Hasselbeck’s triangle
(med to epigastric vessles), more often acquired
weakness.
• Femoral- more common in women.
• Tx- emergent surgical repair if incarcerated to
avoid strangulation. Elective if reducible.
Inflammatory Bowel Disease
• Involves terminal ileum? Crohn’s. Mimics appendicitis. Fe deficiency.
• Continuous involving rectum? UC. Rarely ileal backwash but never higher
• Incr risk for Primary UC. PSC leads to higher risk of cholangioCA
Sclerosing Cholangitis?
• Fistulae likely? Crohn’s. Give metronidazole.
• Granulomas on biopsy? Crohn’s.
• Transmural inflammation? Crohn’s.
• Cured by colectomy? UC.
• Smokers have lower risk? UC. Smokers have higher risk for Crohn’s.
• Highest risk of colon cancer? UC. Another reason for colectomy.
• Associated w/ p-ANCA? UC.
Treatment = ASA, sulfasalzine to maintain remission. Corticosteroids to induce
remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine,
6MP and methotrexate for severe dz.
IBD Images & Complications
commons.wikimedia.org
medinfo.ufl.edu/~bms5191/gi/images/cd1a.jpg
http://www.ajronline.org/cgi/con
tent-nw/full/188/6/1604/FIG20
studenthealth.co.uk
Diverticular Disease
• Diverticulosis-
– False diverticulae (only outpocketings of mucosa)
– Occur 2/2 low fiber diet in areas of weakness where blood
vessels penetrate bleed
– Complications are bleeding, obstruction, diverticulitis
• Diverticulitis-
– Diverticulum becomes obstructed and forms
abscess/perforates
– LLQ pain, either constipation or diarrhea,
– Look for free air, CT is best imaging to
evaluate for abscess. No Barium enema!
– Tx w/ NPO, NG suction, IVF, broad spec abx & pain control. www.meddean.luc.edu/.../GI/Diverticulit
is2.jpg
endo/exogenous estrogen.
• DCIS-
– Either excision w/ clear margins or simple mastectomy if multiple
lesions (no node sampling) + adjuvant RT.
• LCIS-
– More often bilateral. Consider bilateral mastectomy only if +FH,
hormone sensitive, or prior hx of breast cancer
• Infiltrating ductal/lobular carcinoma-
– If small and away from nipple, can do lumpectomy w/ ax node
sampling. Adjuvant RT. Chemo if node +. Tamoxifen or Raloxifen if ER +
– Modified radical mastectomy w/ ax node sampling w/o adjuvant RT
gives same prognosis.
• Paget’s Dz-
– Looks like eczema of the nipple. Do mammogram to find the mass.
• Inflammatory-
– Red, hot, swollen breast. Orange peal skin. Nipple retratction.
riversideonline.com
Skin Cancer
• Basal Cell Carcinoma-
– Shave or punch bx then surgical removal (Mohs)
• Squamous Cell Carcinoma-
– AK is precursor lesion (tx w/ 5FU or excision) or http://emedicine.medscape.com/article/
keratoacanthoma. 276624-media
Umbilical Hernia
• Defect in the midline. No
bowel present.
– Assoc w/ other disorders? Assoc w/ congenital hypo-
– Treatment? thyroidism. (also big tongue)
images.suite101.com/617141_c
om_picture067.jpg
Repair not needed unless persists past age 2 or 3.
A vomiting baby
• 4wk old infant w/ non-
Pyloric Stenosis
bileous vomiting and
palpable “olive”
– Metabolic complications? Hypochloremic, metabolic alkalosis
– Tx? Immediate surg referral for myotomy
• 2wk old infant w/ bileous
Intestinal Atresia
vomiting. The pregnancy Or Annular Pancreas
was complicated by poly-
hydramnios.
– Assoc w/? Down Syndrome (esp duodenal) Learningradiology.com