Jr Surgery – De Virgilio question highlights

dysphagia/esophageal webs/iron def anemia
plummer vinson syndrome
diagnosis with barium esophagram

most common type of parotid gland tumor
pleomorphic adenoma
benign
but known risk of malignant transformation

most common site for foreign body obstruction in children younger than 1
larynx

most common site for foreign body obstruction in older children
trachea and Right mainstem bronchus

greater auricular nerve
branch of cervical plexus C2-C3
cutaneous sensation to lower portion of ear

brain abscesses
can be a rare complication of acute OM
fever/acute onset ha/ focal neuro findings/ seizure/obvious source
treat with open drainage by neurosurg

torus palatinus
bony benign mass located on hard palate
no associated malignant transformation/ no biopsy
reassurance

mastoiditis
days to weeks after AOM
displaced ear on affected side
confirm with CT scan

Ludwig’s angina
progressive cellulitis in floor of mouth – often involves submandibular space

malignant otitis externa – due to otomycosis
Aspergillus niger most common cause
intense fullness in ear and pruritis, gray exudate from affected ear
normal appearing TM

mgt of asymptomatic hyperparathyroidism
long standing hyperparathyroidism can lead to kidney injury and Osteoporosis
surgery is indicated if signs of reduced Cr Cl, osteoporosis, age <50, others

Sestamibi scanning
helps to localize involved gland in primary hyperparathyroidism
more accurate for single adenoma than for four gland hyperplasia

superior laryngeal nerve and parathyroid surgery
external branch of superior laryngeal nerve allows to sing in a high pitch

neck hematoma after neck surgery causing compromised airway … next steps:
immediately open neck wound at beside to decompress hematoma
take pt to OR emergently

characteristics of thyroid nodules that should be biopsied
greater than 1 cm
US characteristics that sugg malig: internal microcalcifications
history of growth

how to tell if pheochromocytoma is malignant
development of metastatic disease – recurrence in area that normally does not have any chromaffin tissue

paraneoplastic Polycythemia vera
classically assoc with:
pheochromocytoma
renal cell carcinoma
HCC
hemangioblastoma

MEN-2A
pheochromocytoma
hyperPTH
medullary thyroid cancer

management of pheochromocytoma
medical conditioning with alpha-blockade
then adrenalectomy

plasma markers of pheochromocytoma
plasma free metanephrine
plasma chromogranin A

thyroglossal duct cyst – management
elevates with tongue protrusion and swallowing
have a high rate of recurrent infections and small risk of progressing to malignancy
excision is indicated

steps in managing incidentally discovered adrenal mass
biochemical workup – determine if functional or nonfunctional

treatment of acalculous cholecystitis
BS abx
urgent perc cholecystotomy if pt critically ill, or cholecystectomy

gallstone pancreatitis key lab values
extremely high serum amylase
ALT greater than 3x Upper limit normal

persistent abd pain, fevers, nausea beyond a few days following lap choly — should raise suspicion of bile duct injury or bile leak — how to dx:
get CT scan to look for fluid collection
if large collection found – place perc drain
get HIDA scan next

gallbladder polyps management
usually incidental findings
vast majority are benign
polyps <10 mm can be observed > 10 mm should have lap choly

isolated gastric varices
associated with splenic vein thrombosis
should have splenectomy
does not lead to esophageal varices

porcelain gallbladder
associated with inc risk of gallbladder adenocarcinoma
patients should undergo surgical management with laparoscopic cholecystectomy

melanosis coli
secondary to laxative abuse
dark discoloration is a result of lipofuscin in macrophages

what can alter CEA levels
smoking up to 4h prior to checking levels can false elevate levels

management following finding tumor in removed appendix
if tumor less than 1 cm – appendectomy is appropriate management
if tumor larger than 1 cm and at base appendix or larger than or equal to 2 cm and located at tip of appendix — right hemicolectomy is indicated

sigmoid volvulus
closed loop obstruction
x-ray films – may show air filled closed loop of massively distended colon
most pts can be managed by colonoscopy // is colon already ischemic/gangrenous — urgent ex lap

cecal volvulus
due to failure of fixation of right colon – due to congenital malrotation
treatment is urgent right colectomy

colonoscopy regimen after UC dx:
risk of colon cancer is low in first 10 years but grows 1-2% per year after that. UC patients should begin getting screened 8 years after disease onset and continue getting screening every 1-2 years after that.
they should get random biopsies because cancer does not follow typical progression from polyp –> cancer

screening in FAP patients
if child has parent with mutation – gene testing
if positive – get flex sig at age 10
once polyp seen -get surgery to remove colon

how to confirm ischemic colitis
flexible sigmoidoscopy — will demonstrate inflamed, friable mucosa or full thickness necrosis
treatment – NPO, IVF, BS abx

solitary brain mass in gray-white junction with surrounding edema
most consistent with metastatic tumor

clearing cervical spine injuries in obtunded patients
with negative CT, should also get MRI before clearing them

components of GCS
eye opening
verbal response
motor response

interventions for increased ICP
– hypertonic saline will decrease cerebral edema
– mild hyperventilation to create hypocapnia — will cause vasoconstriction

diffuse axonal injury
minute punctate hemorrhages with blurring of gray-white junction
typical to have instantaneous loss of consciousness followed by PVS

posterior shoulder dislocation
rare
will present with adducted arm that is internally rotated
occur most often in patients who have generalized seizures or are electrocuted
regular AP xr’s will often miss dx, need to get axillary and lateral view radiographs

SCFE
obese adolescent males
femoral head separates from neck and slips posteriorly, resulting in a limp and impaired internal rotation
treatment: operative stabilization

management of suspected scaphoid fracture
immobilize with thumb spica cast and re-image 7-10 days later
plain films typically unrevealing directly after injury

tinel’s test
percuss over median nerve at carpal tunnel

phalen’s test
patient place elbow on table and flex wrist for 60 s — parasthesias in median nerve distribution

Legg-Calve-Perthes = avascular necrosis of proximal femoral head
kids 4-10, more males
insidious onset of hip pain and limp
limitation in internal rotation of hip

suppurative tenosynovitis — 4 cardinal signs
flexor tendon sheath tenderness
fusiform swelling
pain with passive extension
semi-flexed posture of involved digit

tear in PCL
lower leg that sags on passive flexion of knee at 90 deg while patient is supine

duodenal atresia
would see no gas in small bowel

gastrochisis
no membrane covering
defect to right of midline
biggest worry before surgery is severe dehydration from insensible fluid losses.

transient tachypnea of newborn
self-limited and resolves within 1-2 days

gold standard imaging for pyloric stenosis
ultrasound

imaging/dx of midgut volvulus
upper GI study with oral contrast

PEEP
designed to keep alveoli open throughout respiratory cycle even during expiration
increases surface area for gas exchange
but high levels of PEEP will increase pressure within alveoli to dangerously high levels and cause barotrauma
PEEP should be maintained at or below 5 mm Hg

fetal posterior urethral valve
prevents fetus from passing urine via Urogenital tract
oligohydramnios

tracheomalacia
softness of tracheal cartilage
airway can collapse, especially when patient is supine

Class I, II, III, IV wounds
class I – clean – do not involve entering a organ or cavity known to harbor bacteria
class II – clean contaminated – aseptically made wound enters the alimentary/resp/GU tracts
Class III – contaminated- 2/2 trauma, breaks in sterile technique, gross spillage from GI tract
Class IV – dirty infected – wounds involving a pre-op infection or perf viscera

HIT
immune reaction to heparin-ptt complexes
hypercoaguable state
heparin should be stopped, pt started on direct thrombin inhibitor like argabatron

mgt of post-op pt with suspected PE
start IV heparin right away

ITP
autoAbs against ptts
consumptive process
ptt count <30K and bleeding symptoms, corticosteroids

mgt of necrotizing fascitis
blood cultures
BS abx
urgent surgical debridement

first step in mgt septic shock
aggressive IV fluid resusitation with NS or LR
NE first line pressor for septic shock

DVT’s more common in left leg than right
because right common iliac a often compresses the left common iliac vein

most common ECG in patients in PE
sinus tachycardia

ideal method for quickly reversing warfarin in pt with elevated INR
FFP!

seborrheic keratosis
– isolated SKs occur commonly in elderly
– suddent onset of multiple SKs (Lesar-Trelat sign) suggests underlying carcinoma of GI tract
most often gastric cancer

Nodular variant melanomas
grow vertically . absence of radial growth phase.
usually uniformly dark blue or black “berry-like” lesion that is mostly symmetric, elevated, and one color

Squamous cell carcinoma on skin
ulcerated, nodular mass without any telangiectasias

BCC
pearly white nodule with central ulcerated crater surrounded by dilated vessesl (telangiectasias)

actinic keratosis
is most common precancerous skin lesion
can progress to SCC

epigastric pain, dyspepesia – mgt
younger patients, can try PPI’s or test for h. pylori
if over 55 or with ALARM = Anemia, Loss of weight, Anorexia, Recent onset of prog symps, melena/hematemesis, swallowing probs: do Upper endoscopy to rule out gastric cancer

GIST
mass is submucosal – initial biopsy often negative
CT scan shows a well-circumscribed, homogenous mass
GOF mutation in c-KKIT
surgical resection, imatinib – TK inhibitor

patient comes in with massive UGI bleed or massive hemoptysis
need to intubate the patient! preserve the airway = first step

MALT lymphoma is strongly associated with
H. pylori
curable with antibiotics

mgt of pt presenting with possible esophageal perforation
should receive immediate IV fluids and antibiotics to treat sepsis
gastric decompression, mediastinal and pleural drainage, and primary repair of esophagus should occur after initial stabilization, ideally within 24 hours

management of patient after confirmed gastric adenocarcinoma
– do EUS to assist with TNM staging.
– then do CT of abdomen to look for distant mets and confirm that pt is surgical candidate
– then can do surgery with gastric resection, or if more advanced than stage 1B can also do chemo

initial mgt of nephrolithiasis
– IVF, pain control
– KUB + non-contrast CT abd/pelvis

testicle facts:
– blood supply
– testicular artery
– cremaster artery
– deferential artery off superior vesical

testicle facts:
– most common cause of testicular ischemia after inguinal hernia repair
injury to pampiniform plexus

testicle facts:
lymphatic drainage from testicle
periaortic nodes

mgt of: sudden onset of right sided varicocele
get CT abdomen
high suspicion for renal cell carcinoma that has invaded IVC

henoch-schonlein pupura
HSP: non-thrombocytopenic pupura
arthralgia
abdominal pain
intususseption
scrotal pain

infants born with cryptorchidism
have an increased risk of developing testicular cancer later in life
and lowering the testicle does not lower that risk
but it does help preserve fertility

Leydig cell tumors in testicle
assoc with precocious puberty
androgen producing tumors
rod-shaped Reinke crystals

patients found to have a popliteal a. aneurysm
should be screened with ultrasound for aneurysm in contralateral popliteal a, femoral a, and abdominal aorta

Leriche syndrome
1) buttock and thigh claudication
2) erectile dysfunction
3) absent femoral pulses
chronic progressive atherosclerosis of the distal aorta and proximal common iliac arteries that eventually occludes the aorta

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