basal cell carcinoma- 75%

squamous cell carcinoma- 20%

melanoma

raised, slightly pigmented skin lesions

ulcerative/exudative

chronic scab

itching

what is it?

how do u diagnose a squamous cell carcinoma?

What is the tx?

diagnose: 

small lesion: <1 cm- excise with .5 cm margin

large lesion: >1 cm: resect with 1 to 2 cm margins of normal tissue (may require skin graft/flap)

size

grade: 

ie. I: <25% undifferentiated cells

IV: greater than 75% undifferentiated cells

slow growing skin mass (chronic, scaly); scab; ulceration, without without pigmentation

often described as "pearl"-like

seborrheic: benign pigmented lesion in the elderly

actinic: premalignant skin lesion from sun exposure-surgical removal needed

soft tissue tumor of hands or feet

They are cystic structures filled with a mucinous fluid but without a synovial or epithelial lining

one that is relatively new (<12 hours) and has minimal contamination

when the skin has been violated by shearing forces and underlying tissue has been undermined and elevated, creating a flap or total loss of skin

the flap or avulsed tissue is composed of skin with or without underlying fat and muscle

second gen cephalosporin

broad spectrum PNC

combo of fluroquinolone and anerobic coverage with flagyl

afebrile

normal WBC count

regained GI function

laparoscopic: used when there is concern over the viability of the tissue at the appendicial base

open: done through a muscle splitting incision cented on McBurney's point in the RLQ

post operative wound infection

pelvic abscess: common- particularly when frank perforation

fecal fistula

Name the procedure:

a transverse or oblique incision is made, usually over Mcburney's point (a  point btw 11/2 and 2 inches superomedial to the ASIS, on a straight line joining that process and the umbilicus, where pressure elicits tenderness in....

wound infection

pelvic abscess

enterocutaneous fistula

pyelphlebitis

appendiceal perforation

acute or chronic cholecystitis

cholellithiasis

choledocholithiasis

lymphoid hyperplasia, fecalith

rare: parasite, foreign body, tumor

name this:

pain upon internal rotation of the leg with the hip and knee flexed; 

obturator sign

seen in pts with pelvic appendicitis

Name this sign:

Pain elicited by extending the hip with the knee in full extension or by flexing the hip against resistance

psoas sign

Seen with retrocecal appendicitis

point one third from the ASIS to the umbilicus

often the pt of maximal tenderness

CBC: increase WBC (>10,000 per mm)

UA: to r/o pyelonephritis or renal calculus

in acute appendicitis pain usually comes then vomiting

gastroenteritis: vomiting then pain

if perforated: IV fluid resucitation and prompt appendectomy

all pus is drained with post op abx continued for 3-7 days

wound is left open in most cases of perf after closing the fascia (heals by secondary intention or delayed primary closure)

usually tripple abx

amp/cipro/clinda

OR

ZOsyn (broad spectrum PNC)

US and CT have >90% accuracy

Typical CT findings: “edematous appendix with periappendiceal fat stranding”

US is operator dependent and visualizes only one area, but is cheaper, faster and portable

Name the skin prep:

§  Effective against Gram + and most Gram – organisms

§  NEVER use near eyes/ears (can cause deafness)

§  Blood/Pus DO NOT interfere

Name the skin prep:

§  Effective against Gram + and some Gram – organisms

§  Blood/Pus/Serum DO interfere

§  Is readily absorbed through open skin, so keep away from burns / rashes / large wounds

§  Looks like milk

Name the skin prep:

§  Works against Gram + and Gram –

§  Effective against Fungi / Viruses / Protozoa / Yeast

Name the skin prep:

§  Weak germicidal action and easily breaks down

§  Mechanism of action is mechanical – bubbles of O2 loosen dead tissue and bacterial pockets

§  DON’T use on new forming epithelium

§  ALWAYS rinse off with NSS

Name this skin prep:

§  Doesn’t effect spores or viruses at all

§  Inactivated by soap

Name the skin prep:

§  Effective against most pathogenic bacteria but erratic against Fungi / Viruses / Yeast

§  Will dry the skin, damage new epithelium and sting

catgut

polyglycolic acid

polyglyconate

polydioxanone

monocryl

silk

nylon

polyesther

polypropylene

prolene

steel

aspirin,warfarin, NSAIDS

thienopyridines (clopidogrel or ticlopidine)

some hypoglycemic agents

How (MOA) / When / Where / Why did the injury occur?

•            Ask about

•            Allergies

•            Tetanus and Immunization hx

•            Bleeding tendencies

•            Any prior tx of the wound before coming to the office

•            Estimated blood loss

A well-nourished pt should have a 7 to 10 day energy and protein reserve and should be able to tolerate the additional ntdt demands due to surgery. 

·       Albumin

·       Total Lymphocyte Count

·       Prealbumin

·       Transferrin

·       Retinal Binding Protein

·       Carnitine

o   More nitrogen is consumed than is excreted

o   Body is building more tissue than it is breaking down (Anabolism)

o   Occurs during:  Growth / Healing / Pregnancy

o   Less nitrogen is consumed than is excreted

o   Body is breaking down more protein than it is building (Catabolism)

o   Occurs during:  Illness / Stress / Inadequate intake

Gut associated lymphoid tissue

reason why you should use the gut!--enteral feeding when you can 

hypophosphatemia

There is a sudden increase in insulin levels which leads to an increased cellular uptake of phosphate.  

juice with no pulp

broth

tea

gelatin

milk 

ice cream

nutritional supplements

low fiber

avoid vegetables

recommended

no dietary restrictions

low fat

low Na

carb controlled

1800, 2000, 2200, 2400

What supplement does the following:

fuels the immune system

essential precursor to protein synthesis

enhanced wound healing is observed

Name the nutritional supplement:

substrate in fast growing cells

stimulates proliferation of fibroblasts

major AA lost during tissue injury

Name the nutritional supplement:

anti inflammatory agent

stimulate T-cell and natural killer cells

Name the nutritional supplement:

aids in wound healing

essential in collagen synthesis, intracellular matrix of bone, skin and blood vessel walls and ct tissue

Name the nutritional supplement:

Need is increased during cell proliferation

don't give this to cancer paitent bc we dont' want to help the cancer proliferate.

torsion of the spermatic cord, resulting in venous outflow obstruction

and subsequent arterial occlusion causing infarction of the testicle

what could it be:

acute onset of scrotal pain usually after vigorous activity or minor trauma

surgical expoloration

U/S (solid mass)

Doppler flow study

cold Tc99m scan (nuclear study)

What is the treatment for testicular torsion?

when should this be performed?

surgical detorsion and bilateral orchioplexy to the scrotum

should be performed within 6 hours for best results

dentition

cervical spine mobility

airway examination

factors affecting ease of ventilation

can visualize the faucial pillars, soft palate

35% will have difficult intubation

can ONLY visualize the soft palate

most will have difficulty intubating

This procedure involves making an incision in hte eardrum, usually to initiatially drain pus from the middle ear OR to create an opening in which a tympanostomy (ventilating) tube can be inserted.

What is this procedure?

Preop meds:

What do you stop? How many days before surgery?

What do you continue?

diuretics stop before stugery

Digoxin should be continued for a fib but stopped if for CHF (why? dig toxicity is difficult to treat and hard to stop intraop)

NSAIDS stopped 10 days before surgery

Insulin-typically given in half the usual preop dose in conjunction with the establishment of a glucose containing IV

What are three benzos used as preop meds

What are two opiods used for preop?

benzos:

midazolam (most freq used)

lorazepam

diazepam

Opiods:

fentanyl

morphine

What is it called when you can't retract the foreskin of a penis to view the glans?

What is it called when there is an inability to reduce a previously retracted foreskin?

What can happen if there is paraphimosis?

What's the tx/how do you fix paraphimosis?

With prolonged retraction, lymphedema of the prepuce exacerbates the condition and increases the circumferential pressure of the shaft proximal to the glans.

Manual reduction can usually be accomplished using the index fingers to pull the prepuce distally while pushing the glans into the prepuce. If this measure fails, the preputial cicatrix may be incised (dorsal slit) and the foreskin reduced with relative ease. Circumcision may be performed as an elective procedure once the edema has subsided.

high animal protein diet

extremes of calcium ingestion

decreased fluid intake 

sedentary lifestyle

excess oxalate consumption (ice tea, chocolate, and greens)

renal tubular acidosis (type I)

hyperparathyroidism

abrupt onset of sharp, cramping pain in the flankwith possible radiation to the groin or genitalia.

What's this called?

What is the best method for looking at kidney stones?

What is another way? How do stones appear?

CT without contrast

KUB: 90% of stones are radiopaque

uteropelvic junction

pelvic brim as the stone passes over the iliac vessels

ureterovesical junction

How can you treat uric acid stones?

What can you do as preventative measure?

alkalinization of urine through oral therapy

Preventative: give citrate containing alkalinizing agents

What meds can you give for hypercalciuria?

What preventive measures do you give pts?

low doses of HCTZ

increase fluid intake to several liters a day

mod calcium, low salt, low purine diet

What are indications for extracorpeal shock wave lithotripsy?

what are contraindications?

for renal stones as large as 2 cm

contraindications: pregnancy, coagulopathy, uncontrolled HTN or active infection

What's a normal PSA?

What is worrisome as far as increase/year

normal is 4.0 ng/mL

worrisome: >.75 ng/mL/year

prostate cancer

benign prostatic hyperplasia

prostatis

cystitis

presence of foley

urinary retention

What may you feel when doing DRE (prostate focused) that is consistent with advanced carcinoma?

What else do you look for on PE?

DRE: prostate feels hard, nodular

rest of PE: looking for signs of metastases: lower extremity weakness, decreased sensation, bowel and bladder dysfunction

What diagnostic tool is used to image the prostate and measure the size?

What is used to look for metastatic disease when PSA is greater than 20 ng/mL

What do you use when PSA is >10 or have tumor with high grade?

transrectal ultrasonagraphy

if PSA > 20: CT

if PSA>10 OR high tumor grade: radionuclide bone scan

all men >50

>40 if first degree family hx or AA pt

prostate gland

seminal vesicles

ampullae of the vasa deferentia

bilateral oriectomy

OR

LHRH agonists: decrease LH release from pituitary, which then decreases testosterone production in the testes

germ cell tumor foun din 95% of cases

two types:

1) seminomatous and nonseminomatous neoplasms

Who gets testicular cancer? ie. population

Is there a genetic/fam hx?

PMHx?

White males have high incidence than AA

Family hx significant

PMH of cryptorchidism: increase chances 40x

palpate testes for size, consistenc, tenderness and evidence of fixation

spermatic cord should be palpated for abnormal thickening

look  for signs of pleural effusion and check supraclavicular nodes

alpha fetoprotein may be elevated with embryonal carcinoma, teratocarcinoma or yolk sac tumor

beta HCG: embryonal carcinoma, choriocarcnoma or pure seminoma

LDH: non specific

**all these levels should be checked before radical orchiectomy bc if these markers don't decline at approp rates after surgery then there is metastatic disease

What is the major side effect of retroperitoneal lymph node dissection?

related to testicular cancer

What do you NOT clean lacerations with?

How should you clean lacerations

do NOT clean with betadine: inhibits normal healthy tissue

lacerations: H20 irrigation "the solution to pollution is dilution."

What is assessed in GCS?

What is scoring system?

eyes 

verbal resonse

motor

score btw 3-15

15 is best

3 is lowest

<9 indicates coma

<8 needs to be intubated

What is this called:

What is this called:

arms are rigidly extended and close to the body. Legs are rigidly extended and the feet are plantar flexed.

Subdural hematoma:

where is collection of blood?

What usually causes injury (ie. what type of vasculature)

collection of blood btw dura and brain surface

injury to cortical blood vessels or bridging veins

Usually underlying injury: contusions, lacerations, and hematomas

What is the most feared complication of surgery for subdural hematoma?

How do you usually control?

malignant brain swelling- can cause massive herniation of the brain through the crainotomy defect

how do you control: hyperventilation and mannitol

What is tx for chronic SDHs?

Who typically gets?

infants and elderly usually get after minor head trauma; due to tears in bridging beins, blood liquifies

surgical tx: craniotomy or burr hole draining

curved, crescent shaped hematoma

Where does blood collect in an epidural hematoma?

what age group are susceptible?

blood locatd in the temporal region btw the dura and the inner table of the skull

usually due to middle meningeal artery

usually seen in pts 20 and 40

These are signs of what type of fracture:

raccoon eyes

battle's sign

clear otorrhea or rhinorrhea

hemotympanum

What is normal ICP? 

What is a worrisome ICP?

btw 5 and 15 mm H20

worrisome if > 20

What is acute tx of seizures after head trauma?

What is seizure prophylaxis after severe head injury?

What is hydrocephalus?

What causes it?

abnormal condition consisting of an increased spaces volume of CSF along with distention of CSF

causes:

increased production of CSF

decreased absorption of CSF

obstriction of normal flow

What are signs/sxs of hydrocephalus?

How do you diagnose?

signs/sxs: signs of increased ICO: HA, nausea, vomiting, ataxia, increasing head circumference exceeding norms for age

diagnosis: CT, MRI, measurement of head circumference

How do you treat hydrocephalus?

What are possible complications?

tx: 1. remove obvious offenders

2. perform bypass obstruction with ventriculoperitoneal shunt of ventriculoatrial shunt

complications: blockage/shunt malfunction or infection

What are indications for surgery for skull fracture?

(5)

1. contaminanted wound requiring cleaning and debridement

2. devere deformity

3. impingement on cortex

4.open fracture

5. CSF leak

What is a intracerebral hemorrhage?

what causes?

bleeding into brain parenchyma

why?

HTN/atherosclerotic dease

Charcot-Bouchard aneurysms

other: coagulopathies, AVMs, amyloid angiopathy, bleeding into tumor, and trauma

two third occur in basal ganglia

putamen is structure most commonly affected

What could it be:

Contralteral hemiplegia and hemisensory deficits, lateral gaze preference, aphasia, and homonymous hemianopsia.

What diagnostic tool would you use?

intracerebral hemorrhage- most likely in putamen

diagnose: CT

What could this be:

severe headache

photophobia

neck stiffness

what is common cause?

SAH

cause: most common: trauma

spontaneous SAH are due to cerebral aneurysms

What determines tx for cerebral aneurysm?

(3)

location of aneurysm

age of pt

clinical grade

antiseizure prophylaxis

calcium channel blocker- helps with vasospasm

How do AVMs appear on studies?

What exactly are AVMs?

as "tangles" of vessels

AVMs consist of dilated arteries and veins within a capillary bed

Localized area of tissue necrosis that develops when a soft tissue is compressed between a bony prominence and an external surface.

What is this?

What causes it?

Decubitus ulcer

Excessive pressure causes capillary collapse and impedes the delivery of nutrients to body tissues. Pressure ulcer formation is accelerated in the presence of friction, shear forces, and moisture. immobility, altered activity levels, altered mental status, chronic conditions, and altered nutritional status