What three symptoms typically characterize carpal tunnel syndrome?

what nerve is compressed?

pain, paresthesia and numbness

median nerve compressed

displaced distal radius fracture

lipomas arising within the carpal tunnel

repeptitive mechanicl stress

where do patients with carpal tunnel usually complain of pain?

when is pain worse?

ie. what areas specifically

thumb

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

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

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

oral antinflam drugs to reduce synovitis

diuretics to reduce edema

corticosteroid injections

Surgical management: surgical release of the transverse carpal ligament

What is usually mechanism of injury for olecranon fracture?

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

fall on outstretched hand with a strong contraction of the triceps

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

non surg: if non displaced-long arm cast

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

Who is at risk for fat embolism syndrome?

What are symptoms (3)

people who have fracture of long bone or joint replacement

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

How do you diagnose fat embolism syndrome?

When does it occur after injury?

What labs may help you confirm? (3)

What is an empyema?

What are the three types?

accumulation of purulent material in the pleural space

three types:

1)exudative/acute phase: pleural fluid

2)fibrinopurulent/transitional: increase in WBC

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

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

what are pathogens?

bacterial pneumonia

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

pathogens: staphylococci, streptococci, and anaerobic organisms

How do you diagnose an empyema?

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

aspirating pus from pleural space

requires immed drainage

CT scan helps to differentiate

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

adenocarcinoma (most common):peripheral

small cell carcinoma (second most common): central

large cell: peripheral and metastacise quickly

How do you start diagnose lung carcinoma?

How do you stage lung cancer?

What is the most common surgical procedure performed?

chest radiograph

stage with CT

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

procedure: lobectomy

complete surgical resection whenever possible

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

chemo for stage IV

How do you diagnose a thymoma?

where are they found in mediastinum?

diagnose with CT

found in ant mediastinum

they are primary tumors

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

What is it?

How do you treat?

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

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

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

What is this:

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

What is diagnostic tool to look for cholesteatoma?

What is tx?

CT of the temporal bone

tx: srugeron on the eardrum, middle ear and mastoid

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

most tubes come out on their own

placed in the anteroinfefrior aspect of the tympanic membrane

allows for more consistent path for middle ear ventilation

solitary adenoma: collection of chief cells surrounded by normal tissue

usually found in only one parathyroid gland

women

postmenopausal women

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

Meds: HCTZ, lithium, vit a and d

What labs tests are diagnostic of hyperparathyroidism?

What is tx?

what is major complication from surgery?

hypercalcemia with elevated PTH

tx: parathyroidectomy is the only curative tx

major complication: hypocalcemia

What is whipple's triad?

what is it assoc with?

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

assoc with insulinoma

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

Proinsulin and C-peptide are usually elevated

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

What type of meds are helpful?

small benign insulinomas: enucleation

large lesions: distal pancreatectomy or pancreaticodudoenectomy

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

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

late: changed mental status, decreased BP, marked tachycardia

ACTH

FSH/LH

Prolactin

GH

TSH

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

large prolactinomas??

small prolactinomas: hypogonadism

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

What is the preferred tx for prolactinomas?

why?

What is second line tx?

dopamine agonisT: bromocriptine or cabergoline

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

second line tx: surgery

What is the tx of choice for ACTH secreting hormone?

What do you need to give post operatively?

trans-sphenoidal adenoidectomy

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

low dose dexamethasone suppression test

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

What does a normal or elevated ACTH level suggest?

What does a suppressed ACTH level suggest?

How can you screen for acromegaly?

what study should you get?

IGF-1 level

also imp to measure GH level after 100 g glucose

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

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

What is a common complication after surgery?

transspenoidal adenectomy

complication: hypopituitarism

Cushing's disease: ACTH secreting tumor

Cushing's syndrome: cortisol producing adrenal adenoma

truncal obesity

hirsituism

"moon" fascies

acne

buffalo hump

purple striae

HTN

diabetes

weakness

depression

easy bruising

myopathy

palpitations

headache

episodic diaphoresis

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

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

beta blockers also can be used

What type of lab tests do you do for pheochromocytoma?

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

24 hour urine sample

looking at total catecholmines, metanephrine and vanillymandelic (VMA)

specific: elevated metanephrine

less specific: VMA

What type of imaging studies can you do for pheochromocytoma?

When do you do the tests?

tests should be performed AFTER biochemical studies

MRI

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

what are causes?

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

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

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

cause: defect of transversalis fascia

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

other: cig smoking, advanced age and chronic illness

True or false:

Imaging studies are needed to diagnose an inguinal hernia.

False

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

1. anterior or inguinal canal approach

2. posterior or preperitoneal approach

3. posterior laparoscopic technique

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

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

when conservative tx have failed

you should do a lateral internal spincterotomy

can be done under local, spinal or general anesthesia

internal hemorrhoids: found above dentate line

external hemorrhoids: found below the dentate line

can or crutch to reduce joint loading forces

physical therapy- to improve flexibility and restore strength and ROM

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

arthroscopy

arthrodensis

osteotomy

arthroplasty

in young pts with advanced unilateral hip arthritis

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

supraspinatus

infraspinatus

teres minor 

subscapularis

symptomatic pain relief

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

frequent (chronic) tonsilitis

tonsilar hypertrophy

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

What are the two main reasons for having an adenoidectomy?

1. for improved nasal airway

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

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

What could it be?

describe the anatomic appearance of all the valves

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

ECG

CBC to identify anemia

BUN and creatinine for renal problems

liver function tests: with suspected RHG

blood cultures if suspected endocarditis

albumin for nutrional status

What is the normal surface area for an aortic valve?

When is it a significant problem?

should be 3-4 cm squared

significant problem if < 1 cm squared

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

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

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

balloon valvuloplasty: poor long term

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

valve replacement:most durable outcome

afterload reduction

ACE inhinitor

diuretic use to reduce volume overload

pt tx of arrythmia

papillary msucles

LV wall

chordae tendinae

annulus

valve leaflets

diuretic therapy to treat pulmonary edema

tx of atrial or ventricular arrythmias

anticoag if afib

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

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

What could it be?

What test do you want to do?

What is tx?

renovascular htn

duplex ultrasound scanning

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

When does wound dehiscence most commonly occur?

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

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

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

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

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

How many weeks prior to surgery should you stop smoking?

I: healthy individual with no systemic disease undergoig elective surgery

II: individual with one systemic disease, well controlled

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

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

V: pt in imminent danger of death

M: malignancy

O: orthopedics

I: immobility

S: surgery

T: trauma