Medical Terminology and Anatomy Quiz, Exams of General Surgery

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Surgery I/II Comprehensive Review __________________________ is a state of controlled temporary loss of sensation or awareness that is induced for medical purposes - ANS Anesthesia What are the 3 main goals for anesthesia? - ANS 1) Achieve surgical goal 2) provide least amount of risk to PT 3) Patient comfort What are the three different types of Anesthesia? - ANS General, Regional, Intravenous This type of anesthesia suppresses CNS activity and results in unconsciousness and total lack of sensation - ANS General Anesthesia This type of anesthesia blocks transmission of nerve impulses from certain parts of the body - ANS Regional anesthesia This type of anesthesia suppresses the CNS to a lesser degree and inhibits anxiety and long-term memory creatin - ANS Intravenous anesthesia What are 3 examples of regional Anesthesia? - ANS epidural, spinal, nerve block What 4 factors determine what type of anesthesia a patient will receive? - ANS 1) type of operation 2) patient status/condition 3) surgeon choice 4) patient choice The goal of anesthesia providers is to ______________________ or _____________________ control of a patient's airway - ANS maintain, gain Intravenous sedation has a fast onset, and can avoid the ______________________ phase of anesthesia - ANS excitatory This condition is caused by a severe reaction to general anesthesia causing muscle rigidity and extremely high fevers - ANS Malignant hyperthermia What is the treatment for malignant hyperthermia? - ANS Rapidly cool the patient and administer Dantrolene What medication should be given immediately to a patient that is suffering from malignant hyperthermia? - ANS Dantrolene List 5 complications that could occur because of anesthesia - ANS aspiration, death, airway issues, hypothermia, malignant hyperthermia _______________________ refers to the loss of memories including facts, information, and experiences - ANS amnesia _______________________ is characterized by varied degrees of decreased mental status from anxiolysis to complete unconsciousness - ANS anxiolysis/hypnosis The perception of pain is also known as _________________________ - ANS analgesia A reaction to a noxious stimulus can be __________________, ___________________, or ______________________ - ANS mechanical, chemical, thermal Give an example of a narcotic - ANS Fentanyl Fentanyl is an example of what type of drug? - ANS narcotic Propofol is an example of a ______________________ agent - ANS induction agent Give an example of an induction agent - ANS Propofol Succinylcholine is an example of a ______________________________ - ANS muscle relaxant With the exception of infants and emergent surgery, every patient should be advised NPO after _____________________ - ANS midnight Aspiration can lead to ____________________________ - ANS severe pneumonia interventions to reduce the risk of aspiration of food, liquids, and/or secretions during the swallowing process - ANS Aspiration precautions The state in which body temperature is within the "normal" range - ANS Normothermia __________________________ complications are the most common cause of postop morbidity - ANS pulmonary What are the 3 most common causes of pulmonary edema? - ANS Cirrhosis, CHF, Renal failure ___________________________ is the leading cause of morbidity and mortality in the perioperative period - ANS Ischemic heart disease What is the most common pre-existing disease? - ANS Hypertension A diabetic patient should have a blood glucose level of no higher than ________________________ before surgery - ANS 140 A normal ECG is good for up to how long? - ANS 6 months An ECG is good for up to how long if any risk or patient status changes? - ANS 3 months How long before surgery should coumadin be discontinued? - ANS 5 days How long before surgery should NSAIDS be discontinued? - ANS 2 days For most surgeries _____________________ should be held - ANS diuretics _________________________ inhibitors decrease the breakdown of epinephrine and norepinephrine - ANS monoamine oxidase _________________________ should not be taken 7 days prior to surgery - ANS diet pills ASA 1 indicates that the patient is ___________________________ - ANS Healthy ASA 2 indicates that the patient has a ________________________________ - ANS Mild systemic disease ASA 3 indicates that the patient has a ___________________________________________ - ANS severe systemic disease that is non-life threatening ASA 4 indicates that a patient has a _______________________________________________________ - ANS severe systemic disease that is a constant threat to life ASA 5 indicates that the patient is _____________________________________________ - ANS not expected to live more than 24 hours without operation ASA 6 indicates that the patient is an ___________________________________________ - ANS organ donor There (ARE/ ARE NOT) absolute contraindications to surgery - ANS ARE NOT In Patients with Diabetes ______________ levels should be in an acceptable range before starting surgery - ANS A1C In a Patient with type II Diabetes Mellitus oral hypoglycemics should be held ___________________ hours before surgery - ANS 24 Before surgery a Type II diabetic can be given a 5% glucose infusion, also known as ______________ - ANS D5 Often times Type I diabetics will be administered _________________ during surgery as needed - ANS Insulin After surgery, the physical trauma, along with emotional and psychological stress lead to increases of _______________________ and _________________________ - ANS Epinephrine, Cortisol _________________________ may also increase blood sugar levels - ANS infections Current recommendations are to maintain the perioperative glucose level between _________- _________ mg/dL, even in patients not previously diagnosed as being diabetic - ANS 80-150 If a diabetic patient has a blood glucose of below 150 mg/dL, then how many units of insulin should they receive? - ANS none If a patient has a blood glucose between 150-200 mg/dL, then how many units of insulin should they receive? - ANS 4 units If a patient has a blood glucose between 201-250 mg/dL, then how many units of insulin should they receive? - ANS 8 units If a patient has a blood glucose between 251-300 mg/dL, then how many units of insulin should they receive? - ANS 10 units If a patient has a blood glucose between 301-350 mg/dL, then how many units of insulin should they receive? - ANS 12 units If a patient has a blood glucose level of greater than 400 mg/dL, then how much insulin should they receive? - ANS 20 units What should be the next lab value you look at when a low potassium is noted? - ANS Magnesium If a patient is volume overloaded, then you would expect them to have _________________________ (what would this do to sodium?) - ANS hyponatremia What is an uncommon cause of a fever of unknown origin that always needs to be in the differential? - ANS DVT What are the 5 W's of fever that always need to be considered? - ANS Wind, Water, Walking, Wound, Wonder drugs What are the 3 components of Virchow's Triad? - ANS Endothelial injury, Venous stasis, Hypercoagulability abnormally swollen, twisted veins with defective valves; most often seen in the legs - ANS Varicose Veins Patients with Varicose veins have an increased risk to develop ________________________, if they are not moving and mobile - ANS DVT's Many patients are ____________________ for some period of time before surgery - ANS NPO During a procedure patients often times lose blood and fluid through _____________________ and _____________________ - ANS evaporation, losses _________________________ is a definite post operative issue and requires careful consideration - ANS Volume status _______________________ is one of the first things that will tell you what is going on with a patient - ANS Urine output What does anesthesia do to the appetite? - ANS Suppresses it Malnourished patients typically have prolonged _______________________________ - ANS healing times (True/False) Malnourishment does not affect healing - ANS False Malnourished patients have increased _____________________ and _________________________ - ANS morbidity, mortality __________________________ and _______________________ levels are vital for healing - ANS albumin, protein ___________________________ is the accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury - ANS Third spacing What is PCM? - ANS Protein calorie malnutrition Where does most absorption occur in the body? - ANS Small bowels How do narcotics effect the bowels? - ANS Slows down bowel movements What is a pro of a jejunostomy? - ANS allows for more precise calorie counts What receptors do narcotics block in the intestines? - ANS MU opioid receptors the partial or complete blockage of the small and/or large intestine is known as a ______________________ - ANS Ileus If a patient has an Ileus, what will their bowel sounds sound like? - ANS nothing When checking the bowels, always remember to check ______________________________ - ANS all four quadrants What are the 5 Ps of surgery? - ANS Pee (urine), pacing (walking), puffing (spirometer), partaking (eating), pooting (passing gas) If a patient has an Ileus, they can be given supplements _______________________, also known as __________________ - ANS intravenously, TPN What does TPN stand for? - ANS total parenteral nutrition What are the problems with Total parenteral nutrition? - ANS not sustainable for long periods of time, patient is vulnerable for infections Often times patients are asked to clean with this before elective surgeries to help prevent risk of infection - ANS Hibiclens If a patient has cardiac problems and they are sent to the floor, they MUST be on _______________________ - ANS Telemetry In a patient with renal disease what two lab values should you always look at? - ANS BUN, Creatinine A prior history of _____________________ increases mortality in patients with cardiac disease - ANS AMI (acute myocardial infarction) What is the most common pulmonary issue that you will often see? - ANS COPD The best way to treat pneumonia is with ___________________________ - ANS antibiotics Patient presents to the clinic with a fever of 102.7 F, with complaints of thick sputum and congestion. Patient states that they had an elective surgery done 7 days ago and has not felt well since returning home. On CBC you note a WBC count of 20,000 with noted bandemia. With this information and the CXR provided, what could be the possible diagnosis for this patient? - ANS Pneumonia What is the #1 cause of ventilator associated pneumonia? - ANS Pseudomonas aeruginosa What is the most common cause of pneumonia in a Cystic Fibrosis patient? - ANS Pseudomonas aeruginosa What is the treatment for a pleural effusion? - ANS Thoracentesis What does pneumonia of the lungs sound like on stethoscope? - ANS crackling ________________________ cuts involve the epidermis, dermis, fat, fascia, and exposed bone - ANS Full thickness What layer of the skin do superficial cuts penetrate to? - ANS epidermis What layers of the skin do partial thickness cuts penetrate? - ANS Both epidermis and dermis How would you close a wound that you know has no chance of possible infection? - ANS simple interrupted closer How would you close a wound that you know has a high potential for infection? - ANS less interrupted suture Healing takes place from the ____________________ layers outwards - ANS internal secondary closure meANS that you are going to let the wound __________________________ on its own - ANS granulate How long does the inflammatory phase last during the process of healing? - ANS wound onset through day 4 How long does the proliferative phase last during the process of healing? - ANS day 4 through week 2-6 How long does the maturation phase of wound healing typically last? - ANS up to 18 months after wound closure Clinical studies have shown that wounds maintained in a _______________ environment have lower infection rates and heal more quickly - ANS moist _________________________ levels impair white blood cell function - ANS blood glucose _________________________ slows metabolism - ANS hydration What does pain cause the body to do? - ANS vasoconstrict the vessels _________________________________ depresses the immune system - ANS corticosteroids Often times patients that take corticosteroids on a regular basis will have very ____________________ tissues - ANS thin What is the difference between a wound being contaminated and a wound being dirty? - ANS Contaminated meANS that the wound isn't infected but has a high probability of becoming infected. Dirty meANS that the wound is already infected (purulent contamination) What would be the best treatment for a dirty wound? - ANS Wound vac What would be the best way to close a contaminated wound? - ANS secondary closure a thick layer of dead tissue and tissue fluid that develops over a deep burn area is known as a ______________________ - ANS Eschar What is the best thing to clean wounds with in the ER? - ANS Soap and water This is a wound dressing that starts out moist and then over time dries out and can be useful in debridement of the wound - ANS Wet to Dry wound dressing What is the major benefit of using Hydrocolloid wound dressings? - ANS Good for tough to reach areas (heels, elbows) A patient with Chronic Diabetes Mellitus comes into the clinic with complaints of foot pain. On examination it is clear that the patient has a diabetic foot ulcer. What type would dressing would be appropriate for this situation? - ANS Hydrocolloid dressing What areas of the body could potentially be hard to dress areas for wounds? - ANS elbows, heels What is Hydrogel best used for? - ANS low exudate, shallow wounds If a patient has a dry wound, that needs some moisture then what would be the ideal wound dressing? - ANS Hydrogel What is a major benefit of Alginate wound dressings? - ANS they help to debride the wound Alginates are good for ______________ to _________________ exudate wounds? - ANS moderate, high What type of wound dressing is commonly used after surgery? - ANS Foam dressing Transparent dressings are also known as ___________________________ - ANS Tegaderm If a wound needed to be hydrated and debrided, what would be the ideal dressing? - ANS alginate dressing The 5-year mortality rate for a lower extremity amputation is around _____________% - ANS 74 What is Dakin? - ANS 10% mixture of Clorox used to clean wounds Water constitutes about _________-_________% of the total weight of the body - ANS 50-60 What is the main extracellular cation? - ANS Sodium What is the main intracellular cation? - ANS Potassium What are the main anions or the extracellular fluid? - ANS bicarbonate, chloride What are the main anions of the intracellular fluid? - ANS phosphate, sulfate What is the main cation in the plasma? - ANS sodium What percentage of body weight has to be lost to be considered in Severe dehydration? - ANS 9% If a patient has a body weight loss of 3%, this is considered _______________________ - ANS mild dehydration If a patient has a body weight loss of 6%, this is considered _________________________ - ANS moderate dehydration If a patient has body weight loss of 9% or more, this is considered _______________________________ - ANS severe dehydration How do you calculate volume deficit? - ANS weight x (percent dehydration) x 1iter /24 What are the 3 components of fluid management? - ANS 1) Maintenance 2) Resuscitation 3) Replacement ____________________, _____________________, _____________________, and _________________________ all exacerbate hypervolemia in the surgical patient - ANS heart failure, liver disease, renal disease, malnutrition What are the three types of crystalloid fluids? - ANS hypertonic, isotonic, hypotonic What concentration of sodium do hypertonic solutions contain? - ANS high When would be an appropriate time to administer a hypertonic saline solution? - ANS intercranial pressure Which saline is good for fluid maintenance and replacing free water deficit? - ANS hypotonic saline What lab value are nephrologists concerned with when trying to determine if a patient needs dialysis or not? - ANS potassium What is contained in lactated ringers? - ANS potassium, bicarbonate When listening to the lungs of a hypervolemic patient, what do you think you would hear? - ANS crackling and gurgling What is the main principle in fluid management? - ANS maintaining tissue perfusion What fluid type is the closest physiologically in serum to the plasma? - ANS normal saline What is the main component in normal saline? - ANS sodium chloride what effects do colloids have on the heart? - ANS increases heart rate by pulling fluids into the intravascular space If a patient's symptoms are caused by anemia, don't worry about fluids, give them __________________________ - ANS blood Condition caused by Demyelination of central pons. Due to electrolyte abnormalities, particularly hyponatremia, that are rapidly corrected. - ANS Central pontine myelinolysis (CPM) how many percent NaCl is normal saline? - ANS 0.9% How many percent NaCl is half-normal saline? - ANS 0.45% How many percent NaCl is quarter-normal saline? - ANS 0.225% What is the benefit of D5 normal saline? - ANS provides calories while patient is NPO What type of colloid works well for acidotic patients? - ANS Lactated ringers __________________________ pull fluid into the vascular space - ANS colloids A patient has an acute GI bleed and they are hypotensive and tachycardic. Which of the following would be the best supplement to this patient? a) lactated ringers b) blood c) Colloids d) Normal saline - ANS At what level do we want to keep hemoglobin? - ANS >10 What is the ratio of hemoglobin to hematocrit? - ANS 1:3 Remember most sodium issues are _______________________issues - ANS water What does the body secrete in response to pain, nausea, vomiting, opiate administration, and positive pressure ventilation? - ANS ADH What are some signs and symptoms of hyponatremia (4)? - ANS seizures, coma, mental status changes, cramping In what kind of patients is pseudohyponatremia commonly seen? - ANS diabetic patients with severe hyperglycemia In a patient with pseudohyponatremia, what will sodium and glucose levels look like? - ANS sodium- low glucose- high ____________________________is characterized by an elevated sodium level due to loss of free water - ANS hypernatremia What is the normal range for Potassium? - ANS 3.5-4.5 What is the first thing you need to check when a patient is suspected of hyperkalemia? - ANS EKG What are good topical treatments for Actinic Keratosis? - ANS 5-Flurouracil, Imiquimod What is the problem with a wide excision? - ANS scarring What is the first line treatment for Bowen's disease? - ANS Moh's Surgery What is the first line treatment for an invasive squamous cell carcinoma? - ANS Moh's Surgery What is the Sentinel node? - ANS 1st node that drains a tumor What is the best way to find the Sentinel node? - ANS Inject dye into the tumor and see which node lights up first with dye Axillary node dissections can lead a patient to have _______________________ in the arms - ANS lymphadema What is the major red flag of a mole when determining whether or not it is cancerous or not? - ANS Evolution Of the following which is the most predictive for melanoma based on physical examination? a) Color of the lesion b) Asymmetry of the lesion c) Diameter of the lesion d) Evolution of the lesion - ANS d) Evolution What is the key test to diagnose a lesion as cancerous? - ANS tissue biopsy What is the TNM system of staging? - ANS Tumor, Nodes, Metastasis What is the 5-year survival rate for all patients with Melanoma? - ANS 92% If melanoma is caught in the EARLY stages, what is the 5-year survival rate? - ANS 99% Once melanoma has spread to the lymph nodes, what is the 5-year survival rate? - ANS 63% If melanoma spreads to other parts of the body, what is the 5-year survival rate? - ANS 20% ____________________________ is a condition characterized by a disorder of the apocrine glands - ANS Hidradenitis What condition can be seen in this picture? - ANS Hidradenitis What is the best treatment for Hidradenitis? - ANS Clindamycin What is the first line surgical treatment for Hidradenitis? - ANS Wide excision Which of the following has the fastest healing rate? a) skin grafting b) secondary closure c) tertiary closure d) delayed suture - ANS a) skin grafting This disease is commonly associated with inflammatory bowel disease. rheumatoid arthritis, or hematologic immunities - ANS Pyoderma gangrenosum What condition can be seen in this picture? - ANS Pyoderma gangrenosum What is the treatment for Pyoderma gangrenosum? - ANS Immunomodulators What are the 5 P's of Pyoderma Gangrenosum? - ANS Painful, Progressive, Purple, Pre-tibial, Pathergy What medications most commonly cause Steven-Johnson syndrome or TEN (4)? - ANS anti- psychotics, seizure medications, sulfur drugs, penicillin's fibrosis of connective tissue in the skin, fascia, muscle, or joint capsule that prevents normal mobility of the related tissue or joint - ANS contracture Contaminated or infected wounds should be allowed to heal by ________________________ or __________________________ - ANS secondary intention, delayed primary closure What is a major clinical finding of someone with radiation injuries? - ANS permanent hyperpigmentation What percentage of dog bites typically become infected? - ANS 10% What percentage of cat bites typically become infected? - ANS 80% What microbe is the most likely cause of infection after a dog bite? - ANS Pasteurella What microbe is the most likely cause of infection after a cat scratch? - ANS Bartonella Henselae What is the best treatment for a patient with acid burns? - ANS constant irrigation/emollients How long should you run saline or distilled water over a burn from an acidic solution? - ANS 30 minutes How long should you run saline or distilled water over a burn from an alkaline solution? - ANS 2 hours What is the treatment for a high-pressure injection injury? - ANS surgery (surgical consultation) What can be seen in this picture? - ANS hemangioma What is the appearance of seborrheic keratosis? - ANS turtle shell, "stuck on" appearance What is the first line treatment for seborrheic keratosis? - ANS liquid nitrogen Artery 2 - ANS Maxillary artery Artery 3 - ANS Posterior auricular artery Artery 4 - ANS Occipital artery Artery 5 - ANS Facial artery Artery 6 - ANS Lingual artery Artery 7 - ANS Ascending pharyngeal artery Artery 8 - ANS Superior thyroid artery What are the 5 branches of the facial nerve? - ANS Temporal, Zygomatic, Buccal, Mandibular, Cervical What is the saying to remember the arteries of the neck? - ANS Samford Always Loves Free Open Parking for My Students What is the 1st branch off the external carotid? - ANS Superior thyroid What is the 2nd branch off the external carotid? - ANS Ascending pharyngeal What is the 3rd branch off the external carotid? - ANS Lingual What is the 4th branch off the external carotid? - ANS Facial What is the 5th branch off the external carotid? - ANS Occipital If a patient is suffering from hoarseness after a surgery in the neck region, what most likely occurred? - ANS The recurrent Laryngeal nerve most likely got hit What is the saying to remember whether or not cranial nerves are sensory, motor, or both? - ANS Some Say Marry Money But My Brother Says Big Brains Matter More Is the hypoglossal nerve sensory, motor, or both? - ANS motor What provides sensation to the anterior 2/3 of the tongue? - ANS facial nerve What provides sensation to the posterior 1/3 of the tongue? - ANS Glossopharyngeal nerve If the patient has trouble protruding the tongue, what nerve is most likely damaged? - ANS Hypoglossal nerve What MUST you remember to do after draining a cauliflower ear? - ANS Pressure wrap it What is the most common origin of an anterior epistaxis? - ANS Kiesselbachs Plexus What is the most common origin of a posterior epistaxis? - ANS Woodruff's plexus A patient presents to the clinic with a nosebleed that he says has been constant for the last 2 hours. He states that this has never happened before. Though the patient is bleeding from the nose, he says he also feels as if he is swallowing blood. What plexus is most likely the cause of this episode? a) Woodruff plexus b) Kiesselbach's plexus c) anterior plexus d) myenteric plexus - ANS a) Woodruff's plexus What are two great treatments for an anterior nosebleed? - ANS Rhino rocket, silver nitrite stick What artery provides blood flow to Woodruff's plexus? - ANS Sphenopalatine artery What 3 arteries provide blood flow to Kiesselbach's plexus? - ANS Superior labial artery, anterior/posterior ethmoid artery What is the best treatment for a posterior epistaxis? - ANS double barrel balloon or surgery What should you never do to a patient with a posterior epistaxis? - ANS SEND THEM HOME If a patient is given a rhino rocket or double barrel balloon to stop epistaxis, what medication should they always be sent home with? - ANS Keflex What foreign body must always be taken out of a patients nose/nasal cavity and ears? - ANS Button battery What medication should a patient with the atopic triad of Asthma, allergies, and eczema not receive? - ANS Aspirin A patient comes in with a unilateral foul Rhinorrhea, what is the most likely cause? - ANS nasal foreign body In what 3 situations would a tonsillectomy be indicated? - ANS 1) 7 episodes within one year 2) five episodes each the last 2 years 3) 3 episodes per year for 3 successive years What type of tumor represent about 1-3% of sudden sensorineural hearing loss? - ANS acoustic neuroma What would be the most sensitive test to diagnose an acoustic neuroma? - ANS MRI A 55-year-old patient presents to the clinic with complaints of dizziness and imbalance. The patient also complains or unilateral high-frequency sensorineural hearing loss. On examination the patient shows no signs of sinusitis or vertigo. What could be a possible diagnosis for this patient? - ANS Acoustic Neuroma (Vestibular Schwannoma) What is the difference between Leukoplakia and Thrush? - ANS Leukoplakia will not scrape off, Thrush can be scraped off What is the first line diagnostic for a patient suspected of a head or neck cancer? - ANS CT head/neck w/ IV contrast Left supraclavicular node enlargement from metastatic carcinoma of the stomach - ANS Virchow's node (TRUE/FALSE) A flexible laryngoscopy can assess the esophagus and trachea? - ANS False What is the TNM staging system? - ANS Tumor, Nodes, Metastasis If a patient has a squamous cell carcinoma of the neck, what would be the surgical treatment of choice? - ANS radical neck dissection What is the best surgical treatment for a patient with a severe laryngeal cancer? - ANS laryngectomy Where is the most common gland for salivary cancer to form? - ANS Parotid glands _____________________________ is the leading cause of death worldwide - ANS Cardiovascular disease Structure 1 - ANS Right Coronary Artery (RCA) Structure 2 - ANS Right marginal artery Structure 3 - ANS left coronary artery (LCA) Structure 4 - ANS Left marginal artery Structure 5 - ANS Left anterior descending artery (LAD) What artery supplies the right atrium and right ventricle? - ANS Right coronary artery What structures does the right coronary artery supply? - ANS right atrium/right ventricle What artery supplies the right ventricle and apex of the heart? - ANS right marginal artery What structures does the Right marginal artery supply? - ANS right ventricle and apex of heart What artery supplies the left atrium and left ventricle? - ANS Left circumflex artery What structures does the left circumflex artery supply? - ANS Left atrium/Left ventricle What structures does the Left anterior descending artery supply (LAD)? - ANS right ventricle, left ventricle, interventricular septum What artery supplies the left ventricle? - ANS Left marginal artery Vein 1 - ANS Great cardiac vein Vein 2 - ANS Left marginal vein Vein 3 - ANS Left posterior ventricular vein Vein 4 - ANS Coronary sinus Vein 5 - ANS Small cardiac vein Vein 6 - ANS Middle cardiac vein What is the first thing you should do if a patient comes in with chest pain? - ANS EKG What is the first you should do if a patient is having an MI? - ANS CATH LAB/Angiography If you are on call and a patient presents having a heart attack and you have no CATH lab, what should you do next? - ANS tPA (tissue plasminogen activator)- acts as a clot buster An _______________________ is when no oxygenated blood makes it to the myocardium, causing the tissue to die - ANS Infarction How long do you typically have to start tPA in a patient having an MI? - ANS 90 minutes What are two ways that the coronary arteries can be accessed? - ANS 1) radial artery 2) femoral artery _____________________________ disease 100% needs bypass surgery - ANS multiple vessel If a patient has a single vessel disease, what would be the most appropriate treatment? - ANS Stint Before an angiogram is performed, what are two less invasive tests that can be done to assure that the patient does indeed need the arteriogram? - ANS 1) stress test 2) nuclear medicine test __________________________ refers to the decrease contractile function of the left ventricle - ANS Hypokinesis _____________________ is absent myocardial contractility (little movement of ventricle) - ANS Akinesis ____________________________ is a paradoxical, outward movement during systole causing intraventricular "shunting" of blood flow between systole and diastole. - ANS Dyskinesis _____________________________ and _______________________ are Always indications for BYPASS - ANS Multivessel disease, Left main disease (True/False) Graphs can be stinted? - ANS True An infection in the mediastinum is known as _______________________________, This is a big deal after CABG! - ANS Mediastinitis What device can be used to remove an unwanted or potentially harmful part of a conduit during a CABG procedure? - ANS Hegar Dilator When harvesting the radial artery as a conduit for bypass, which arm is it taken out of? - ANS Patients non-dominant arm A ________________________is a catheter-based surgical device that is used to ligate and disable venous valves. It is often used by vascular surgeons to perform in-situ bypasses of the lower extremity arteries and also used during CABG procedures - ANS Valvulatome What is the Most Commonly used conduit for CABG? - ANS Greater Saphenous vein What is the longest vein in the body? - ANS Greater Saphenous vein What is the BEST conduit to use for CABG? - ANS Internal Mammary artery What are patency rates for vein grafts in a 10-year period? - ANS 50-60% How long can the Internal Mammary artery typically be used before it needs to be replaced? - ANS 20 years What medications can be used to inhibit spasming of the internal mammary artery during surgical resection? - ANS calcium channel blockers What technique must be used to surgically resect the internal mammary artery? - ANS No touch technique Hold long are Saphenous vein grafts normally good for? - ANS 10-12 years The ________________________________ is used to assess collateral blood flow to the hands, generally in preparation for a procedure that has the potential to disrupt blood flow in either the radial or the ulnar artery. - ANS Allen's test How long are radial vein grafts normally good for when used for bypass? - ANS 4-5 years The _______________________________ returns oxygenated blood back to the bypass machine - ANS Arterial cannula The ____________________________ drains deoxygenated blood into the bypass machine - ANS Venous Cannula When a solution is introduced into the aortic root (with an aortic cross-clamp on the distal aorta to limit systemic circulation), this is called _________________________________ - ANS Antegrade cardioplegia When a solution is introduced into the coronary sinus, it is called _________________________________ - ANS Retrograde Cardioplegia When preparing the vein or artery for anastomosis always make sure the edges are _____________________ and _____________________ - ANS clean, crisp When positioning the graft, ALWAYS make sure that there is no _________________________ or ______________________ - ANS tension, twisting When taking the patient off bypass _______________________________ is used to reverse heparin - ANS Protamine Sulfate If a patient is still bleeding after bypass surgery, what lab value could you check to see their coagulation levels? - ANS Activated Coagulation Time (ACT) What procedure could be done to buy a transplant patient a little more time? - ANS LVAD ____________________________ is imperative to prevent retained blood in the pleural and pericardial spaces postoperatively - ANS Adequate evacuation capacity How long do patients normally stay in the CVICU after undergoing CABG? - ANS 24-48 Hours Where will patients normally go if they are doing well after 24-48 hours after having a CABG? - ANS step down floor (walking, incentive spirometry, etc.) How long does it normally take for a patient to return home after undergoing a CABG procedure if there are no setbacks? - ANS 4-7 days When a patient returns home from the hospital after a CABG, what should they avoid doing? - ANS 1) lifting heavy objects for at least 2 weeks 2) Do not drive What is a good supplement to give a patient who just underwent a CABG procedure who is a smoker? - ANS Nicotine patches What valves close during S1? - ANS Tricuspid valve and Bicuspid valve What valves close during S2? - ANS Pulmonary Semi-lunar valve and Aortic valve ________________________ go from high pressure to low pressure - ANS Shunts What is shunting? - ANS Moving from high pressure to low pressure What can be seen in this picture? - ANS Shunt What is an ASD? - ANS Atrial septal defect Any sound that occurs between the S1 and S2 heart sounds is known as a _____________________________________ - ANS systolic murmur Anything sound that occurs after the S1 and S2 heart sounds is known as a ________________________________ - ANS diastolic murmur What is Transposition of the great arteries? - ANS Aorta arises from the pulmonary semi-lunar valve (right ventricle), Pulmonary trunk arises from the aortic valve (left ventricle) What is the predominant clinical finding of a patient with transposition of the great arteries? - ANS Congestive heart failure What is the treatment for a translocation of the great arteries? - ANS Mustard procedure or Arterial switch procedure Describe the Mustard procedure for repairing a transposition of the great arteries - ANS A baffle is placed into the inferior and superior vena cava, which then runs through the Atrial septal defect (ASD) and allows unoxygenated blood to be pushed through the aortic valve by the left ventricle and to the lungs for oxygenation. The blood then returns to the right atrium and goes through the tricuspid valve into the right ventricle, where the oxygenated blood can be pushed out to the systemic circulation What is the gold standard for treatment of translocation of the great arteries? - ANS Arterial switch procedure What is the most common cause of reintervention in a patient with a translocation of the great arteries? - ANS pulmonary stenosis What causes Truncus Arteriosus? - ANS This is caused by the Aorta and the Pulmonary trunk never dividing from one another. What operation can be seen in this picture? What condition is this associated with? - ANS Mustard's procedure, Translocation of the great arteries What are the 3 characteristics of Truncus arteriosus? - ANS 1) VSD 2) Single truncal valve 3) Common ventricular outflow tract What is the treatment for Truncus Arteriosus? - ANS Rastelli procedure w/patch What condition can be seen in this picture? What is the most definitive surgical treatment? - ANS Truncus Arteriosus, Rastelli procedure w/patch What is TAPVC? - ANS Total anomalous pulmonary venous connections ______________________________ is a congenital heart disease where all of the pulmonary veins drain directly or indirectly into the right atrium - ANS TAPVC What is the most definitive treatment for a patient with Total Anomalous pulmonary venous connections? - ANS anastomosis of the pulmonary veins to the left atrium _____________________________ is a form of congenital heart disease whereby there is a complete absence of the tricuspid valve - ANS Tricuspid Atresia What condition can be seen in this picture? What is the most definitive treatment? - ANS Total anomalous pulmonary venous connections (TAPVC), Anastomosis pf the pulmonary veins to the left atrium What causes Tricuspid Atresia? - ANS This condition is caused by the absence of the tricuspid valve. This leads to the formation of a hypoplastic right ventricle. How can you treat a patient with Tricuspid Atresia? - ANS Bypass the right side of the heart by connecting the SVC/IVC to the pulmonary arteries, which then allows unoxygenated blood to be sent to the lungs for Oxygenation. Patch the ASD underdevelopment of the left side of the heart, usually resulting in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta is known as ____________________________________ - ANS Hypoplastic Left Heart Syndrome What condition can be seen in this picture? - ANS Hypoplastic left heart syndrome What is the 3-step process to treat Hypoplastic left heart syndrome? - ANS 1) Norwood procedure 2) Glenn procedure 3) Fontan Procedure What is the most common Acyanotic heart defect in patients older than 20 years old? - ANS Atrial septal defects (ASD) What is the most common type of ASD? - ANS Ostium Secundum Where is the most common place for an ASD to occur? - ANS Fossa Ovalis A fixed split S2 sound is indicative of what type of heart defect? - ANS Atrial septal defect (ASD) A patient presents to the clinic with complaints of being easily fatigued and the inability to exercise like normal. Being the good PA you are, you decide to give her heart a listen. On examination you hear a fixed split S2 sound. Based off the symptoms and finding on examination, what is the most likely cause for her symptoms? Where is the most likely spot for this to occur in the heart? - ANS atrial septal defect (ASD), Fossa Ovalis What is a common finding when listening to a patient's heart that has an atrial septal defect? - ANS fixed split S2 sound What is the treatment for an ASD? - ANS intra-atrial patch What is the most common type of VSD? - ANS Perimembranous VSD A patient with this condition will have increased pulmonary artery pressure due to an unnoticed or untreated VSD. This can cause muscular hypertrophy of the media within the pulmonary arteries (pulmonary vascular disease) - ANS Eisenmenger's complex What is the treatment for a VSD? - ANS VSD PATCH ______________________________ is an abnormal connection between the pulmonary artery and the aorta - ANS Patent ductus arteriosus You are listening to a patient's heart and upon examination you hear a "machinery" like murmur. What is the most likely cause? - ANS Patent ductus arteriosus What is the diagnostic test of choice to diagnose Testicular Torsion? (TEST) - ANS Ultrasound *Will demonstrate decreased Blood flow* ________________________________ is a condition caused by the twisting of the Testis and the spermatic cord eventually resulting in ischemia - ANS Testicular torsion In what time period must a Testicular Torsion be fixed before significant damage occurs? (TEST) - ANS 6 hours List the Key diagnostic features of a patient with Testicular Torsion *These can help differentiate this condition from Epididymitis and Orchitis!* (TEST) - ANS 1) Tender, Enlarged, High riding testicle *Due to shortening of the spermatic cord* 2) (-) Prehn's sign 3) Absent Cremasteric reflex This condition is caused by a failure of either one or both testicles to descend into the scrotum - ANS Cryptorchidism What is a Bell Clapper deformity? - ANS This condition is caused when the testis sit horizontally instead of vertically in the scrotum Cryptorchidism is a very common development in ________________________________ - ANS Premature babies A patient presents to the clinic with complaints of a non-tender testicular mass on the right testicle. Ultrasound shows a solid mass concerning for malignancy of the testicle. Which of the following condition is most likely on the patients past medical history? A) History of Gonorrhea B) History of Chlamydia C) History of Cryptorchidism D) History of Epididymitis - ANS C) History of Cryptorchidism Where are Varicoceles most common to develop? (TEST) - ANS Left testicle This condition is caused by an inflammation of the Pampiniform Plexus - ANS Varicocele Varicoceles are caused by an inflammation of what structure? - ANS Pampiniform plexus *Due to increased venous pressure and venous stasis* What structure does the Right testicular vein empty into? - ANS Inferior Vena Cava (IVC) *Be suspicious for a mass or obstruction!* What structure does the Left testicular vein empty into? - ANS Renal vein List the Key diagnostic features of a patient with a Varicocele (TEST) - ANS 1) "Bag of worms" feeling on palpation *Mass distends or gets bigger when asked to cough or perform Valsalva maneuver* 2) (-) Transillumination test *NOTE: Hydroceles DO transilluminate!* A 46-year-old male presents to the clinic with complaints of testicular pain of the left teste. On examination of the left test, palpation is performed, and the teste has the feel of a bag of worms. Transillumination test is also performed and is (-). Based off the patient's signs and symptoms, what could be the possible diagnosis for this patient? - ANS Varicocele A ____________________________ refers to fluid accumulation between the visceral and parietal layer of the tunica vaginalis of the testis - ANS Hydrocele What causes a Hydrocele to form? - ANS Accumulation of fluid between the visceral and parietal layers of the tunica vaginalis and testis What is the Key diagnostic feature of a Hydrocele? *This will help differentiate this condition from a Varicocele!* (TEST) - ANS 1) (+) Transillumination test This condition is caused by a lack of space in the amniotic sac causing developmental abnormalities of the fetus - ANS Potter Sequence What causes a Potter Sequence to occur? (TEST) - ANS This condition is caused by a lack of space in the amniotic sac (Oligohydramnios) *Abnormalities such as a flattened face, widely separated eyes, low set ears, and limb abnormalities have been noted in this condition* List the signs and symptoms of Potter Sequence - ANS Pulmonary hypoplasia Oligohydramnios Twisted skin Twisted face Extremity deformities Renal agenesis ________________________________ is a genetic disease in which the kidneys become filled with hundreds of cysts, or fluid filled sacs, causing them to be larger than normal and to quit functioning over time - ANS Polycystic Kidney disease (PKD) What is the gold standard diagnostic for diagnosing Vesicoureteral reflux? (TEST) - ANS voiding cystourethrography (VCUG) This condition is often times caused by an obstruction in the path between the ureters and bladder which causes pressure to build up and a current of urine to push backwards from the bladder into the ureter and kidneys - ANS Vesicoureteral Reflux (VUR) List the signs and symptoms of Vesicoureteral Reflux (3) - ANS 1) Infection 2) Pyelonephritis *Inflammation of the kidneys* 3) Renal scarring What appearance do Uric Acid stones have on CT? - ANS Red-Brown appearance and appear Radiolucent What appearance do Struvite stones have on CT? *Infection stones* - ANS Dirty white with a "Staghorn" appearance What is the treatment for Renal stones? (4) - ANS 1) Pain reduction *1 of Dilaudid or 4 of morphine* 2) Potassium Citrate *Reduces stone formation* 3) Shockwave Lithotripsy 4) Surgery/Stent placement Where do Renal Cell carcinomas typically form? - ANS Typically form from the epithelial cells of the proximal convoluted tubule This structure surrounds the kidneys and perirenal fat, anchors the kidneys and limits infection from arising *Hurt brought this up* - ANS Gerota's fascia What is the diagnostic test of choice for diagnosing Renal cell carcinoma? - ANS CT What is the treatment for Renal Cell Carcinoma? - ANS Total or Partial nephrectomy *Don't respond well to chemotherapy or radiation* (True/False) Metastatic tumors of the kidneys are more common than primary renal tumors - ANS True *Most commonly the lung, stomach, and breast* What is the most common type of tumor to be involved in the collecting system of the kidneys? (TEST) - ANS Urothelial carcinoma (Transitional cell carcinoma) What is the diagnostic test of choice to diagnose Ureteral cancer? (TEST) - ANS CT Pyelography What is the treatment of choice for a Ureteral cancer? - ANS Nephroureterectomy What are the two most common types of Bladder cancer? What are the differences between each? - ANS 1) Urothelial Cell Carcinoma (Transitional cell carcinoma) *Majority of primary bladder tumors* 2) Non-Urothelial Cell Carcinoma *Occur from Urothelium but cells transition into Squamous cell and Adenocarcinomas* What is the most common form of bladder cancer in the United States? (TEST) - ANS Urothelial Cell carcinoma What is the most frequent risk factor for developing Urothelial Carcinoma? (TEST) - ANS Smoking What is the 2nd most common cause of Bladder Squamous cell carcinoma? *Hurt found this off a 2nd years EOR* - ANS Schistosoma Haematobium *Very common to develop in natives of Africa and Middle East* What is the diagnostic test of choice for diagnosing bladder cancer? - ANS Cystogram (Cystography) *CT used for staging purposes* What is the most common type of cancer to develop in the prostate? What area of the prostate is it most likely to develop? (TEST) - ANS Adenocarcinoma, Outer Peripheral zone What is the best initial test for diagnosing Prostate cancer? - ANS Transrectal ultrasound What is the most definitive treatment for Prostate cancer? - ANS Total (Radical) Prostatectomy What is the most common form of cancer to develop in males aged 15-35 years of age? (TEST) - ANS Testicular cancer List the signs and symptoms of Testicular cancer (4) - ANS 1) Small, firm painless mass 2) Swelling of testis 3) Dull pain in lower abdomen/testicles 4) Weight loss ____________________________ are germ cell tumors of the testes - ANS Seminomas *Made of germ cells that multiply without differentiating into other types of cells* What is the most common form of Testicular cancer? (TEST) - ANS Non-seminomatous tumors *Comprised of multiple cell types* What 2 lab values would be beneficial to check in patients with suspected Non-seminomatous testicular cancer? - ANS 1) Beta hCG 2) AFP *BhCG elevated in 60%, AFP in 70%* What are the treatment options for Testicular Cancer? (TEST) - ANS 1) Orchiectomy 2) Retroperitoneal lymph node resection *Stage 1, No mets, remove para-aortic nodes to renal vessels* 3) Systemic Chemotherapy (True/False) Biopsys should be performed in patients with suspected testicular cancer to confirm diagnosis - ANS False *This opens route for cancer cells to escape and metastasize* Which of the following would be the most positive in a patient with a Yolk Sac tumor of the testicles? A) AFP 2) Arms raised 3) Arms at sides What is the most reliable diagnostic tool for diagnosing and detecting breast cancer? (TEST) - ANS Mammogram What is the best initial test for diagnosing breast cancer? (TEST) - ANS Ultrasound What scoring system is used to stage breast cancer? List the different stages (TEST) - ANS BIRADS classification BIRADS 0- Further imaging needed, incomplete study BIRADS 1- No microcalcifications, mass, or asymmetry BIRADS 2- Benign finding (calcification, cyst, scar, or implant) BIRADS 3- Equivocal finding (recommended 6 month follow up) *10% chance of malignancy BIRADS 4- Worrisome for malignancy (Biopsy recommended) *30% chance of malignancy BIRADS 5- Highly suggestive of malignancy (Biopsy indicated) *80% chance of malignancy BIRADS 6- Known malignancy Which BIRADS classifications warrant immediate biopsy? (TEST) - ANS BIRADS classification 4 or greater What are the most common benign lesions of the breast? (TEST) - ANS Fibrocystic breast *Commonly occur in women aged 30-50 years of age* Fibrocystic breast disease can be exacerbated by ______________________ and ______________________ - ANS Estrogen, Alcohol (True/False) Nipple drainage is relatively common in patients with Fibrocystic breast disease - ANS True What are the most common benign tumors of the breast? (TEST) - ANS Fibroadenomas What is a hallmark symptom of Fibrocystic breast disease? (TEST) - ANS Premenstrual breast pain *Pain that starts just before the beginning of the menstrual cycle* This condition is caused by small benign fibroepithelial papillary tumors within the lactiferous ducts of the breast - ANS Intraductal papilloma What is the most common cause of serous or bloody discharge from female breasts? (TEST) - ANS Intraductal Papilloma (True/False) Intraductal Papilloma is associated with a slightly increased risk for developing breast cancer - ANS True What is the diagnostic test of choice to diagnose Intraductal Papilloma's? (TEST) - ANS Galactogram *Most specific imaging, mammography is not typically used!* (True/False) Breastfeeding should stop during an episode of mastitis - ANS FALSE *DO NOT stop breastfeeding* This condition is caused by an inflammation of the breast parenchyma and leads to swollen, red, and painful areas of the breast to develop - ANS Mastitis *Most commonly caused by Staph Aureus* What is the most causative organism of Mastitis? (TEST) - ANS Staphylococcus aureus What is the most common type of cancer to develop in women? (TEST) - ANS Breast cancer What ratio of women will develop breast cancer in their lifetime? - ANS 1:8 List the risk factors for developing breast cancer (5) (TEST) - ANS 1) Alcohol use 2) Radiation exposure 3) Family history 4) Early menarche (under age 12), late menopause (over age 50) 5) No pregnancies or late pregnancies What percentage of patients with a BRCA 1 Mutation will develop breast cancer by the age of 70? (TEST) - ANS 50-65% *39% will also develop Ovarian cancer* List the signs and symptoms of breast cancer (4) - ANS 1) Hard, Fixed, painless lump or swelling 2) Axillary swelling 3) Dimpling (Peau D'orange spots) 4) Retraction of the nipple What is the most common malignant cancer of the breasts? (TEST) - ANS Ductal Carcinoma *80-90%* List the signs and symptoms of Paget's disease (3) - ANS 1) Itching 2) Burning 3) Superficial erosion of ulceration on the breast *Should always be considered in patients with mastitis* (TEST) - ANS Vaginal artery *Branches off of the Internal Iliac artery* Which two types of HPV are the most common to cause Cervical cancer? (TEST) - ANS HPV 16 and 18 At what age is screening recommended for Cervical cancer? How often? (TEST) - ANS Recommended to start at age 21 and screening should be done every 3 years with basic cytology What is the 2nd most common type of cancer to develop in women? (TEST) - ANS Cervical cancer What is the most common form of Cervical cancer? (TEST) - ANS Squamous cell carcinoma What are the possible treatment options for Cervical cancer? - ANS 1) Simple Hysterectomy *If fertility is not desired* 2) Radical Hysterectomy *For more invasive forms of cervical cancer* What is the gold standard diagnostic for screening for Cervical cancer? (TEST) - ANS PAP Smear What is the gold standard for examination for assessing dysplasia, carcinoma, and early invasive disease of the Cervix? (TEST) - ANS Colposcopy What procedure can be performed after Colposcopy to investigate further or even treat Cervical cancer patients? - ANS LEEP Procedure (Loop Electrical Excision Procedure) In patients with suspected Cervical cancer, what solution can be used to locate dysplastic cells and decrease the vascularity of the cervix? (TEST) - ANS Lugol's Solution *Will often times reveal a yellowish color of the cervix due to low glycogen stores in the cells* What is the most common benign tumor of the apocrine gland? (TEST) - ANS Hidradenoma What is the function of the Bartholin Glands? - ANS Secrete fluid to lubricate the vagina In a patient with a Bartholin Gland cyst, what organism is the most likely cause? (TEST) - ANS Neisseria Gonorrhea What are the treatment options for a Bartholin gland cyst? - ANS 1) Marsupialization 2) I/D with Word Catheter (True or False) Most Bartholin Gland cysts occur on the lower wall of the Bartholin gland - ANS True Where do the majority of Vaginal cancers occur? - ANS Labia Majora *Some in the Labia Minora* List the Risk factors for developing Vaginal cancer (3) (TEST) - ANS 1) Early 1st sexual intercourse 2) Smoking 3) Immunocompromised conditions *HIV infection* List the signs and symptoms of Vaginal cancer (3) - ANS 1) Vaginal bleeding *Especially in postmenopausal patients* 2) Vaginal discharge *Watery, blood tinged, foul smelling discharge* 3) Inguinal Adenopathy *Can be from STD's or cancer* What is the best diagnostic tool for diagnosing Vaginal cancer? (TEST) - ANS Colposcopy *Epithelium can be stained with Acetic acid solution to increase magnification* List each of the following for Vaginal Cancer staging (VAIN) VAIN 1 VAIN 2 VAIN 3 Carcinoma in Situ (TEST) - ANS VAIN 1: Lower one third of the epithelium contains cancer cells VAIN 2: Lower 2/3 of the epithelium contains cancer cells VAIN 3: Epithelium contains >2/3 of cancer cells *Carcinoma in Situ: Entire Epithelium contains cancer cells What is the treatment for Focal Vaginal Intraepithelial Neoplasia? (Focal VIN) - ANS 1) Wide excision 2) CO2 laser photoablation 3) Radical Hysterectomy and Vaginectomy *This is a removal of the whole uterus and vagina with associated lymph nodes* This condition is characterized by thinning of the epidermis and fibrosis of the dermis; presents as a white patch (leukoplakia) with parchment-like vulvar skin *Hurt mentioned this in class* - ANS Lichen Sclerosis *Has an association with the development of Vulvar cancers* List the signs and symptoms of Vulvar cancer (4) - ANS 1) Itchy Leukoplakia 2) Open sore that doesn't heal 3) Inguinal Adenopathy *Enlarged lymph nodes of the groin with pelvic pain* *Blocks estrogen receptors in the breast, but increases stimulation in uterus* 2) Postmenopausal estrogen therapy 3) Never having been pregnant 4) Polymenorrhea 5) Lynch syndrome What are the factors that are protective against Endometrial cancer? (3) (TEST) - ANS 1) Breastfeeding 2) Older at the time you gave birth 3) Hormonal Contraceptives List the Stages of Endometrial cancer Stage 1 Stage 2 Stage 3 Stage 4 (TEST) - ANS Stage 1: Carcinoma in the uterus Stage 2: Carcinoma spread to the Cervix Stage 3: Carcinoma outside of the uterus but within lesser pelvis Stage 4: Carcinoma beyond the pelvis How is Endometrial Cancer staged? - ANS Usually staged surgically with either Laparotomy or Laparoscopy What is definitive treatment option for Endometrial cancer? (TEST) - ANS Total Hysterectomy with Bilateral Salpingo-oopherectomy ______________________________ is a condition where cells that make up the endometrium migrate and implant themselves into other parts of the body - ANS Endometriosis List the signs and symptoms of Endometriosis (5) - ANS 1) Pelvic pain 2) Bleeding 3) Dysmenorrhea (painful menstruation) 4) Dyspareunia (painful sexual intercourse) 5) Dyschezia (pain with defecation) *Symptoms depend on location of endometrial cells* What is the diagnostic test of choice for diagnosing Endometriosis? (TEST) - ANS Laparoscopy *Confirm with Biopsy* What are the surgical treatment options for Endometriosis? - ANS 1) Surgical resection of Endometrial implants *If women wants to have children* 2) Hysterectomy and Oophorectomy with excision *If childbearing is completed or if pain is debilitating* In a patient with a suspected Ectopic pregnancy what is the initial diagnostic test of choice? (TEST) - ANS Transvaginal Ultrasound *Also get a Serum hCG and trend it, patients with Ectopic pregnancies will have continuous low measurements * hCG levels double every _________ days - ANS 2 What is the pharmacological treatment of choice for an ectopic pregnancy? - ANS Methotrexate *Remember surgical treatment is the most definitive treatment* What is the treatment for a patient with an Ectopic pregnancy that is Hemodynamically unstable? (TEST) - ANS Salpingectomy What appearance do Corpus Luteum cysts have on Ultrasound? - ANS Spider web appearance *Ring of Fire* List the signs and symptoms of a Tubo-Ovarian abscess (5) - ANS 1) Acute Lower abdominal pain 2) Fever/chills 3) Vaginal discharge 4) High WBC count 5) Abnormal Ultrasound What can be seen on ultrasound of a patient with a suspected Ovarian Torsion? (TEST) - ANS Enlarged ovary with little to no blood flow *Also can see "Whirlpool" sign in some cases* List the Risk factors for developing Ovarian Cancer (5) (TEST) - ANS 1) Postmenopausal 2) Endometriosis or PCOS 3) Never having been pregnant 4) BRCA1 Or BRCA2 mutations 5) Lynch syndrome What tumor marker is specifically helpful in diagnosing Ovarian Cancer? - ANS CA-125 *Usually will be >200 units/mL* What is the treatment for Ovarian Cancer? (TEST) - ANS 1) Total hysterectomy with bilateral salpingo-oophorectomy 2) Paraaortic lymph node dissection 3) Omentectomy What is the most common germ cell tumor of the ovaries? (TEST) - ANS Teratomas List the stages of Ovarian Cancer Stage 1 Stage 2 Stage 3 What is the treatment for Penetrating Liver trauma if the patient is unstable? (TEST) - ANS 1) Clipping or suturing of bleeding vessels 2) Pack and Stack What is the most common cause of a ruptured diseased liver? - ANS Hepatic tumors What is the most common cause of a ruptured normal liver? - ANS 1) Pregnancy 2) HELLP Syndrome What is the leading cause of Primary Liver cancers worldwide? (TEST) - ANS Infection with Hepatitis B and C What tumor marker is sensitive for Liver cancer? - ANS AFP (alpha-fetoprotein) *Rise can also be seen in patients with testicular cancer* What is the diagnostic test of choice for diagnosing Liver cancer? - ANS CT *Initially will use ultrasound* What is the treatment for Malignant Hepatic tumors? - ANS 1) Surgical removal 2) Chemo/Radiation What is the most common primary tumor of the liver? (TEST) - ANS Hepatomas *80% of Liver cancers and at the time of diagnosis 70% have spread outside of the liver* What is the 2nd most common primary tumor of the Liver? (TEST) - ANS Cholangiocarcinoma *This is cancer occurring in the bile ducts* List the signs and symptoms of Cholangiocarcinoma (5) - ANS 1) RUQ pain 2) Boas sign (Referred pain to the right shoulder) 3) Hepatomegaly 4) Jaundice 5) Ascites What percentage of the Liver can be resected/removed and still be able to regenerate sufficiently for the patient to survive? - ANS 80% Which are more common Primary or Metastatic lesions of the Liver? - ANS Metastatic *20 times more common!* What is the most common benign tumor of the Liver? (TEST) - ANS Hemangiomas *Most commonly found as an incidental finding!* A 34-year-old male patient presents to the clinic with complaints of a vague abdominal pain that has been bothering him for 1 month. The patients past medical history is Non substantial. CT is performed and shows the appearance of a well demarcated mass on the right lobe of the liver. Excisional biopsy is performed, and the results show benign findings. What type of tumor does this patient most likely have? - ANS Hemangiomas What is the most common cause of Hepatic Adenomas in women? (TEST) - ANS OCP's A 23-year-old female presents to the clinic with complaints of vague abdominal pain over the last 2 weeks. She thinks it could be because of the new OCP's she was prescribed by her doctor. A CT scan is obtained and shows stellate scarring of the liver and afterwards biopsy is performed and shows a benign tumor. Based off these findings, what could be the possible diagnosis for this patient? - ANS Focal nodular Hyperplasia What is the most common cause of Portal Hypertension? (TEST) - ANS Cirrhosis *Accounts for 85% of all cases in the United States* What is the medical treatment option of choice for long term management of patients with Portal Hypertension? (TEST) - ANS 1st Line- Nadolol 2nd Line- Propranolol What is the treatment of choice for Esophageal Varices bleeding if the bleed can be visualized? What if the bleed cannot be visualized? - ANS Banding, Sclerotherapy What is the normal Portal pressure? - ANS 7-10 mmhg *Portal HTN averages around 20 mmhg* List the signs and symptoms of Portal Hypertension (6) - ANS 1) Scleral Icterus 2) Spider nevi 3) Jaundice 4) Caput medusa 5) Asterixis 6) Hematemesis What drug can be used to reduce encephalopathy in patients with high ammonia levels? - ANS Lactulose List the 3 places where the Systemic venous system and the Portal venous system connect (TEST) - ANS 1) Inferior portion of the esophagus 2) Superior portion of the Anus 3) Round ligament What are the possible treatment options for patients suffering from bleeding Esophageal Varices? (TEST) - ANS 1) Banding 2) Sclerotherapy 3) Octreotide 4) Balloon tamponade (Very rare but good to know) - ANS Thyroid IMA artery What artery supplies the main blood flow to the posterior aspect of the thyroid gland? (TEST) - ANS Inferior thyroid artery List the risk factors for developing Thyroid Cancer (4) - ANS 1) Prior radiation (head or neck) 2) Family history of thyroid cancer 3) Being >65 years of age 4) Being <20 years of age with nodules What lab value will typically be elevated in a patient with Medullary thyroid carcinoma? (TEST) - ANS Elevated Calcitonin levels *This is due to the effects on the C-Cells of the thyroid (These produce Calcitonin)* What is the initial diagnostic test of choice for detecting thyroid cancer? - ANS Ultrasound *This can be followed with Fine-needle aspiration or biopsy* If FNA (fine-needle aspiration) results show a high risk for malignancy, when should the next screening occur? - ANS Within 1 year *Both FNA and Ultrasound should be performed* If FNA (fine-needle aspiration) results show an intermediate risk for malignancy, when should the next screening occur? - ANS Within 12-24 months *Ultrasound should be performed* If FNA (fine-needle aspiration) results show a Low risk for malignancy, when should the next screening occur? - ANS Within 2 years *Ultrasound should be performed* List the signs and symptoms of Hyperthyroidism (5) - ANS 1) Weight loss 2) Increased appetite 3) Heat intolerance 4) Tachycardia 5) Anxiety List the possible treatment options for Hyperthyroidism (3) - ANS 1) Antithyroid drugs 2) Radioactive iodine 3) Thyroidectomy What is the most common medication used to treat patients with Hyperthyroidism? - ANS Methimazole *Propylthiouracil (PTU) is also used but is used less due to its possible side effects* List the indications to use Radioactive iodine to treat patient with Hyperthyroidism (4) (TEST) - ANS 1) Patients over 40 years of age with poor risk factors for surgery 2) Patients with recurrent Hyperthyroidism 3) Toxic multinodular goiter 4) Toxic adenoma Patients who undergo Radioiodine therapy should not come into close contact with women and young children for how long after the procedure? - ANS 3 days List the Indications for surgery in patients with Hyperthyroidism (6) - ANS 1) Large or Multinodular goiter 2) Suspicious malignant thyroid nodule 3) Ophthalmopathy (Graves disease) 4) Pregnancy or children 5) For women who wish to become pregnant within 1 year of treatment 6) Amiodarone induced hyperthyroidism (True/False) A thyroid nodule is more likely to be a cancer in a man than in a women - ANS True In patients with suspicious thyroid nodules what should be done? - ANS Ultrasound should be performed along with Fine needle aspiration *Needle biopsy is the most cost-effective diagnostic test, along with ultrasound* List what each of the following categories mean in terms of thyroid cancer staging (Bethesda system) Category I Category II Category III Category IV Category V Category VI - ANS Category I: Non-diagnostic/Unsatisfactory (1-4% chance of malignancy) Category II: Benign (0-3% chance of malignancy) Category III: Atypia or follicular lesion of undetermined significance (5-15% chance of malignancy) Category IV: Follicular neoplasm (15-30% chance of malignancy) Category V: Suspicion for malignancy (60-75% chance of malignancy) Category VI: Malignant (97-99% chance of malignancy) *Categories III and IV need follow up within 6-12 months* *Categories V and VI need surgical removal* (True/False) A Hot thyroid nodule is better to have than a Cold thyroid nodule - ANS True *Cold thyroid nodules have a cancer incidence of about 15-20%, whereas Hot thyroid nodules are rarely malignant* What group of patients are most commonly affected by Acute Thyroiditis? (TEST) - ANS 1) Elderly 2) Immunocompromised 3) Chronically ill What is the most common cause of Acute Thyroiditis? (TEST) - ANS Gram (+) bacteria (Staph and Strep) _______________________________ is an uncommon condition thought to be caused by a viral infection of the thyroid gland. The condition often occurs after a viral infection of the upper What will Calcium and Phosphate levels look like in a patient with Primary Hyperparathyroidism? (TEST) - ANS Elevated Calcium (Hypercalcemia) and Decreased Phosphate levels (Hypophosphatemia) What will Calcium and Phosphate levels look like in a patient with Secondary Hyperparathyroidism? (TEST) - ANS Decreased Calcium (Hypocalcemia) and Elevated Phosphate levels (Hyperphosphatemia) *This occurs due to the kidneys not properly filtering phosphate into the urine* What is the most common cause of Tertiary Hyperparathyroidism? (TEST) - ANS Chronic Kidney disease (CKD) *Most commonly occurs in patients who have had secondary hyperparathyroidism in the past* A high serum calcium and a low serum phosphate suggest what condition? (TEST) - ANS Hyperparathyroidism What is the definitive treatment for patients with Hyperparathyroidism? (TEST) - ANS Parathyroidectomy What is the #1 cause of Primary Hyperparathyroidism? (TEST) - ANS Parathyroid Adenoma An __________________________ is an abnormal protrusion of intra-abdominal tissue through a fascial defect in the abdominal wall - ANS External hernia (Abdominal hernia) Where is the most common area for hernias to develop? (TEST) - ANS Groin (Inguinal and Femoral hernias) *About 75% of hernias occur in this region* What structure lies between protrusion sites of direct and indirect inguinal hernias? (TEST) - ANS Inferior Epigastric vessels List the contributing factors to developing a Hernia (TEST) - ANS 1) Obesity 2) Heavy lifting 3) Coughing 4) COPD 5) Ascites 6) Family history of hernia 7) Prior surgery 8) Straining to defecate or urinate Which of the following IS NOT considered to be a contributing factor for developing hernias? A) Obesity B) Hypertension C) Ascites D) Previous surgical procedures E) Heavy lifting - ANS B) Hypertension A patient presents to the clinic with complaints of fever, nausea, and vomiting over the last 24 hours. The patient also complains of a vague abdominal pain near the groin. On physical examination of the patient a marked red area is noted near the inguinal canal with a large palpable bulge. Based off the patient's symptoms and physical exam findings, what could be the possible diagnosis for this patient? - ANS Strangulated hernia *Immediate surgical intervention is needed* What are the diagnostic tests of choice for diagnosing hernias? (TEST) - ANS CT Pelvis or Abdominal Ultrasound *Hurt didn't pick a clear favorite; they are mostly diagnosed by physical exam in most cases* What is one of the major differences between Indirect and Direct Inguinal hernias? (TEST) - ANS Direct: Lie medially to the inferior epigastric vessels Indirect: Lie laterally to the inferior epigastric vessels A __________________________ hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recumbent - ANS Reducible hernia A ___________________________ hernia is one whose contents cannot be returned to the abdomen, usually because they are trapped by the narrow neck - ANS Irreducible (Incarcerated) Hernia What is the difference between a Strangulated hernia an Incarcerated hernia? (TEST) - ANS Strangulated hernia: Vascular supply to the bowel is compromised! *Surgical emergency* Incarcerated hernia: Not able to be reduced but blood supply to the bowel IS NOT compromised! *Usually can be fixed surgically be elective repair* (True/False) The bigger the hernia in size the better - ANS True What is the most common type of Hernia? (TEST) - ANS Indirect Inguinal hernia What structures does an Indirect Inguinal hernia travel through? (TEST) - ANS Indirect inguinal hernias travel laterally to the inferior epigastric vessels and go through both the external (superficial) and internal (deep) inguinal rings into the scrotum Direct Inguinal hernias are caused by a defect in the ________________________________ - ANS Transversalis fascia *Weakens in the posterior wall of the inguinal ring* What structures make up the borders of Hesselbach's Triangle? (TEST) - ANS 1) Lateral border of the Rectus abdominis 2) Inguinal ligament 3) Inferior epigastric vessels List the predisposing factors for developing Umbilical hernias (TEST) - ANS 1) Stabilize the scapula with one hand 2) Grasp humeral head and move anteriorly and posteriorly *This tests the stability of the glenohumeral joints* What does a (+) Clunk test indicate? (TEST) - ANS Labrum tear What test can be used to assess the Acromioclavicular joint? (TEST) - ANS Crossover test *Shoulder adduction, pain with this suggests AC joint issue* How do you perform a Speed's Test? What is a (+) test indicative of? (TEST) - ANS 1) Have patient flex arm while palpating bicipital groove 2) Push down slightly on hand *(+) test is indicative of Biceps tendinitis* What physical exam test can be performed to diagnose thoracic outlet syndrome? - ANS Adson's test *This will show a compression of the subclavian artery by cervical rib or tight anterior scalene muscle, If radial pulse disappears this is a (+) test* What is the management for a grade I-III Acromioclavicular sprain? (TEST) - ANS Sling and rest What is the management for a grade IV-VI Acromioclavicular sprain? (TEST) - ANS Surgery *Patients with higher grade sprain will have trouble with abduction of the arm* List what each of the following mean in terms of Acromioclavicular Joint Sprains Grade I Grade II Grade III Grade IV Grade V Grade VI (TEST) - ANS Grade I: AC ligament sprain Grade II: AC ligament rupture with CC ligament sprain Grade III: Rupture of both AC and CC joints Grade IV: Posterior clavicular dislocation with rupture of AC Grade V: Rupture of AC and CC ligaments with rupture of trapezius and deltoid attachments Grade VI: Dislocation of clavicle inferior to coracoid process What kind of fracture can be seen in this image? - ANS Clavicle fracture *Relatively common accounting between 2% and 12% of all fractures* Which portion of the clavicle is most common to fracture? (TEST) - ANS Middle 3rd of clavicle What type of injury can be seen in this image? - ANS Sternoclavicular sprain *Absent radial pulse signifies a posterior dislocation* ______________________________ is an excessive translation of the joint (TEST) - ANS Subluxation A _______________________________ is a complete separation of the joint surface (TEST) - ANS Dislocation *50% of dislocations are of the shoulder* What type of dislocation can be seen in this image? (Be specific) (TEST) - ANS Anterior Shoulder dislocation *Humeral head is in axilla* What type of dislocation can be seen in this image? (Be specific) (TEST) - ANS Posterior shoulder dislocation *Light bulb sign* What is the difference in presentation in an Anterior and Posterior shoulder dislocation? (TEST) - ANS Anterior: Arm is usually abducted, externally rotated Posterior: Arm is adducted and internally rotated What is the diagnostic test of choice for diagnosing a Bankhart or SLAP lesion? (TEST) - ANS MRI What is the treatment for Bankhart or SLAP lesions? (TEST) - ANS Laparoscopic repair What can be seen in this image? - ANS Bankhart lesion *Typically form inferiorly to the labrum as compared to SLAP lesions* What can be seen in this image? - ANS SLAP lesion *Typically form superior to the labrum from anterior to posterior* Where do SLAP lesions typically occur? (TEST) - ANS Where the Biceps tendon attaches to the labrum What is the treatment for patients with Shoulder Impingement? (TEST) - ANS NSAIDS, Corticosteroids, Acromioplasty What is the most commonly injured muscle of the Rotator cuff? (TEST) - ANS Supraspinatus What tests will have (+) signs in a patient with a Supraspiatus injury? (TEST) - ANS 1) Empty can test 2) Drop arm test What is the treatment for Acute Olecranon Bursitis? (TEST) - ANS RICE, NSAIDS What is the treatment for a SEVERE case of Olecranon Bursitis? (TEST) - ANS Bursectomy What condition can be seen in this image? - ANS Olecranon Bursitis What is the treatment for a Chronic presentation of Olecranon Bursitis? (TEST) - ANS NSAIDS, Corticosteroid injections, Aspiration This condition is caused by microtrauma to the insertion of the common extensor tendon from repetitive forearm flexion and extension (TEST) - ANS Lateral Epicondylitis (Tennis elbow) What is the treatment for Lateral Epicondylitis? (TEST) - ANS RICE, NSAIDS, Corticosteroid injections, bracing and PT This condition is caused by microtrauma to the common flexor tendon from repetitive forceful extension and valgus torque (TEST) - ANS Medial Epicondylitis (Golfers elbow) What are the treatment options for Cubital Tunnel syndrome? (TEST) - ANS 1) RICE, NSAIDS, Corticosteroid injections 2) Surgical release, Nerve transposition List the signs and symptoms of Cubital tunnel syndrome (3) - ANS 1) (+) Tinel's sign 2) (+) Froment sign 3) Paresthesia's in the 4th and 5th digits What is the surgical treatment for a tear of the Ulnar Collateral ligament (UCL)? (TEST) - ANS Tommy John Surgery *Palmaris longus tendon is usually used as the rebuild ligament* Patients with a torn Ulnar Collateral Ligament (UCL) with have severe pain with (Valgus/Varus) Stress (TEST) - ANS Valgus stress Is an Anterior or Posterior Elbow dislocation more common? (TEST) - ANS Posterior *Always be alert of ulnar nerve injury or palsy* When should a neurovascular exam be performed in patients with an elbow dislocation? (TEST) - ANS Before and After reduction Elbow dislocations are often associated with what other type of fracture? (TEST) - ANS Radial head fracture What is the management for an Elbow dislocation? (TEST) - ANS Reduction and immobilization *Always obtain a secondary x-ray* What can be seen in this image? - ANS Elbow dislocation What type of fracture can be seen in this image? - ANS Intercondylar fracture *Posterior force driving olecranon into humerus and splitting the condyles* What is the treatment for an Intercondylar fracture? (TEST) - ANS Reduction with immobilization, +/- surgery What type of fracture can be seen in this image? - ANS Supracondylar humerus fracture *Typically caused by hyperextension force, Most common in children* What is the management of a supracondylar humerus fracture? (TEST) - ANS Non-displaced: Immobilization Displaced: Surgical fixation *These fractures need vigilant neurovascular monitoring* What can be seen in this image? - ANS Volkmann's contracture *Very commonly occur in patients with Supracondylar Humerus fractures!* What is the most commonly fractured bone of the elbow? (TEST) - ANS Radial head fracture *Typically occurs from FOOSH injury* What can be seen on x-ray of a patient with a Radial head fracture? (TEST) - ANS Fat pad sign This condition occurs when the radius slips out of place from where it normally attaches to the elbow joint. Very commonly occurs in children younger than 4 years of age! (TEST) - ANS Nursemaid elbow What is the treatment for Nursemaids elbow? (TEST) - ANS Reduction What type of fracture can be seen in this image? (TEST) - ANS Olecranon fracture *Patient will have triceps weakness* What is the treatment for a Posterior Sternoclavicular joint dislocation? (TEST) - ANS Emergent reduction *Could cause associated vascular compression or injury to the trachea, esophagus, or lungs* What is the treatment for Stage I-III AC joint injuries?