Shared Flashcard Set

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Surgery Case Files
Cases 52-56
202
Medical
Professional
09/20/2012

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Cards

Term
What diagnostic tests can you get to diagnose lumbar prolapsed nucleus pulposus?
Definition
MRI or myelography; plain x ray may shownarrowing of the intervertebral space
Term
At what level is herniated puplposes most common?
Definition
L4-5 level or L5-S1 level
Term
What is the difference between mechanical backache and back sprains?
Definition
backcageare usually chronic and may result in a long-term debilitating illness without any definite or demonstrable cause; back sprains are usually associated with minor trauma producing ligamentous or muscular injury
Term
What is cauda equina syndrome?
Definition
compression of the sacral nerve bundle which forms the end of the spinal cord, with symptoms of bladder or bowel dysfunciton and/or pain or weakness in the legs. This disorder should be diagnosed at an early stage to avoid permanent injury
Term
What complications associated with osteo and rheumatoid arthritis are associated with chronic back pain>
Definition
ankylosing spondylitis, spinal stenosis, spondylolisthesis
Term
What degenerative changes can cause compression of nerves emanating from the spinal cord?
Definition
herniation of nucleus pulposis, protrusion of osteophytes
Term
What are the characteristic symptoms of nerve compression in the back?
Definition
pain radiating to buttock, posterior thigh or calf; coughing, sneezing, or straining increases pain; other exacerbating factors are bending, sitting, and getting in and out of a vehicle whereas lying flat characteristically relieves pain;
Term
What are the PE findings for patients with spinal compression?
Definition
paravertebral muscles are often in spasm, loss of normal lumbar lordosis, straight leg raising is limited on teh side of the lesion, dorosiflexion of foot exacerbates, may be tenderness to palpation of the central canal or buttock; sensory and muscular weakness may be present along appropriate dermatomes,
Term
If you suspect herniated disk what else should be in your differential?
Definition
fracture, joint subluxation, tumors of the bone, joint, or meninges; abscess; arachnoiditis; ankylosing spondylitis
Term
What is first line conservative treatment for back pain?
Definition
bed rest, application of heat pads or ice packs, NSAIDs, and muscle relaxants and/or physical therapy; back brace or corset may help
Term
What are the indications for surgical decompression of herniated disk?
Definition
development of an acute disabling neurologic deficit (bladder dysfunction) or intractable severe pain; a large trial failed to show superior efficacy of surgery versus conservative therapy
Term
What does surgery for a herniated disk entail?
Definition
laminectomy and removal of the protruding disk; if several disk spaces are involved, posterior spinal usion in addition to removal of the disks may be indicated
Term
What are some techniques under review for herniated disk?
Definition
dissolution of the disk by the injection of chemicals, steroid injections for short term relief
Term
What does HIDA scan stand for?
Definition
hepatoiminodiacetic acid scan
Term
What is the differential diagnosis for neonatal jaundice?
Definition
neonatal hepatitis; toxoplasmosis, other agents, ,rubella, CMV, HSV (TORCH), metabolic diseases (alpha 1 antitrypsin deficiency, cystic fibrosis, etc.), biliary atresia and choledochal cyst
Term
When does physiologic jaundice typically occur?
Definition
typically is evident by day 2 to 3 and resolves by day 5 to 7 of life; does not persist for more than two weeks
Term
At what time is surgical correction for biliary atresia typically performed?
Definition
before 8 weeks of age (12 weeks maximum)
Term
How common is neonatal jaundice?
Definition
60% of term infants and 80% of preterm infants
Term
How should you evaluate neonatal jaundice that seems inconsistent with physiologic jaundice?
Definition
abdominal ultrasound, HIDA scan, percutaneous liver biopsy; if the imaging studies do not rule out biliary atresia, then operative exploration with intraoperative cholangiogram is indicated
Term
How do you treat a choledochal cyst?
Definition
cyst excision and hepaticojejunostomy, where a limb of the jejunum is attached to the bifurcating hepatic ducts at their confluence
Term
What is the term for biliary hypoplasia?
Definition
alagille syndrome
Term
How do you treat alagille syndrome?
Definition
choleretics
Term
What are the clinical findings associated with biliary hypoplasia?
Definition
cardiovascular, spinal, eye abnormalities, and jaundice common
Term
What medical treatment can cause conjugated hyperbilirubinemia in the new born?
Definition
TPN
Term
What causes inspissated bile syndrome?
Definition
hemolytic diseases or cystic fibrosis
Term
How do you treat inspissated bile syndrome?
Definition
intraoperative cholangiogram may be both diagnostic and therapeutic
Term
What are some causes of unconjugated hyperbilirubinemia?
Definition
hemolytic diseases, metabolic diseases, physiologic jaundice
Term
What are some causes of conjugated hyperbilirubinemia?
Definition
biliary atresia, choledochal cyst, biliary hypoplasia (alagille syndrome), total parenteral nutrition, inspissated bile syndrome, sepsis/infection
Term
Whatis a choledochal cyst?
Definition
congenital anatomic malformation of a bile duct, including cystic dilatation of the extrahepatic bile duct or the large intrahepatic bile duct
Term
What causes biliary atresia?
Definition
exact cause is unknown; various theories include viral infection or autoimmune process
Term
What does biliary atresia look like histologically?
Definition
inflammatory cells surrounding obliterated ductules
Term
What does biliary atresia look like grossly?
Definition
fibrosis of the entire extrahepatic biliary tree, followed by proximal duct fibrosis with distal duct patency
Term
What causes choledochal cysts?
Definition
unkown; widely held theory is that common bile duct and pancreatic duct share a common channel leading to retrograde reflux of pancreatic juice into the choledochus with subsequent cystic dilation
Term
How many types of choledochal cysts are there?
Definition
5
Term
How many types of choledochal cysts are there?
Definition
5
Term
What is the most common tyep of choledochal cyst?
Definition
fusiform or type I is 90%
Term
Prior to surgical treatment of biliary atresia, patients should be evaluated for what complications?
Definition
coagulation abnormalities, anemia, and hypoproteinemia
Term
How is biliary atresia corrected surgically?
Definition
kasai portoenterostomy= extrahepatic biliary tree is dissected up to the level of the portal plate; a roux-en-y limb of jejunum is attached to the porta in a retrocolic manner
Term
What are hte three main complications of the surgical management of biliary atresia?
Definition
cholangitis, cessation of bile flow, and portal hypertension
Term
What is the most common complication occuring after portoenterostomy for bile duct atresia?
Definition
cholangitis
Term
What are the symptoms of cholangitis?
Definition
charcot's triad= RUQ pain, fever, jaundice; reynold's pentad= AMS, shock
Term
What is the treatment for cholangitis?
Definition
intravenous antibiotics against gram negative organisms and steroids
Term
What is the survival rate for biliary atresia?
Definition
before the kasai procedure it was less than 5% at 12 months; with surgery 30-50% have good long term results; however ultimately only 20% who get surgery survive into adulthood without liver transplantation
Term
What factors affect outcome in patients with biliary atresia?
Definition
age, immediate bile flow (technically sound operation) and degree of parenchymal disease at diagnosis; the presence and size of ductules in the hilum are of controversial prognostic significance
Term
What percent of cases of biliary atresia have visible normally distended gallbladders?
Definition
10-15%
Term
After ___ days of life, portoenterostomy is rarely indicated.
Definition
120
Term
How do you treat patients with biliary atresia after they are 120 days old?
Definition
liver transplant
Term
What are known risk factors for squamous cell carcinoma?
Definition
caustic burns, alcohol consumption, tobacco smoking, and nitrate-and nitrate containing food
Term
What are the risk factors for esophageal adenocarcinoma?
Definition
GERD, western diet, and acid suppression medications
Term
How do you determine whether dysphagia due to a mass is due to a benign or malignant process?
Definition
rapid onset is suggestive of neoplasm
Term
How do you stage esophageal cancer?
Definition
endoscopic ultrasound and evluation for possible metastatic disease with CT of the chest and abdomen; in some institutions, PET CT has replaced standard CT as teh staging modality of choice
Term
Why is it improtant to differentiate between esophageal and stomach cancer?
Definition
they require different treatments so its important to get EGD, endoscopic ultrasound and CTs to pinpoint teh exact tumor location
Term
When evaluating a patient with esophageal cancer, its important to assess their...
Definition
nutritional status with quantification of weight loss, measurement of serum albumin level
Term
T/F Pts who can not swallow secondary to esophageal malignancy should get TPN.
Definition
false; they should get a g tube or j tube
Term
How are GE junction adenocarcinomas classified?
Definition
siewert classification
Term
Siewert classification type I=
Definition
located more than 1 cm above the GE junction
Term
Seiwert classification type II=
Definition
located within 1 cm proximal and 2 cm distal to the GE junction (surgical treatment would consist of esophagectomy with partial resection of the Ge junction)
Term
What is transthoracic esophagectomy?
Definition
resection traditionally done through an incision in the abdomen (or laparoscopic approach) and a separate incision through the right chest at approximately the level of the azygous vein and distal transection is usually at the level of the proximal stomach; the stomach is then brought into the mediastinum and anastomosed to the proximal esphagus
Term
What are the disadvantages ot a transthoracic esophagectomy?
Definition
anastomosis is in the mediastinum; high rate of pulmonary complications due to pain from incisions in both the chest and upper abdomen
Term
What is a transhiatal esophagectomy?
Definition
resection done through an abdominal incision and a cervical incision; through the abdomen= stomach is mobilized and the distal esophagus is dissected after enlargement of the hiatal opening; through the cervical= cervical esophagus is mobilized and the proximal throacic esophagus is dissected and the entire throacic esophagus and the proximal stomach are resected and the gastricconduit is brouht up through the posterior mediastinum and anastomosed to the cervical esophagus in the neck
Term
What are hte advantages of transhiatal esophagectomy?
Definition
reduction in pulmonary complications and reduced mortality and morbidity associated cervical anastomoticleaks
Term
What is the most common type of esophageal cancer?
Definition
squamous cell world wide; adenocarcinoma in north america
Term
Esophageal cancer is the __th leading cancer type.
Definition
6th
Term
T/F Esophageal cancer rates are rising.
Definition
true; incidence has increased sixfold over the past 25 years
Term
What is the overal prognosis for cancers of the esophagus and GE junction for all affectedpatients?
Definition
20% 5 yr survival rate
Term
What percent of patients presenting with esophageal cancers are eligible for surgical resection?
Definition
50%
Term
What kind of therapy is recommended for patients with resectable esophageal cancer?
Definition
surgery + chemo + radiation
Term
Tx esophageal cancer=
Definition
tumor cannot be assessed
Term
T0 esophageal cancer-
Definition
no evidence of tumor
Term
T1 esophageal cancer=
Definition
tumor invades lamina propria, muscularis mucosa, submucosa, but does not penetrate through the submucosa
Term
T2 esophageal cancer=
Definition
tumor invades into but not beyond the muscularis propria
Term
T3 esophageal cancer=
Definition
tumor invades periesophageal tissue but not adjacent structures
Term
What is T4 esophageal cancer?
Definition
tumor invasion of adjacent structures
Term
Nx esophageal cancer=
Definition
regional lymph nodes cannot be assessed
Term
N0 esophageal cancer=
Definition
no regional lymph node metastasis
Term
N1 esophageal cancer=
Definition
regional lymph node metastasis
Term
Mx esophageal cancer=
Definition
distant metastasis cannot be assessed
Term
M0 esophageal cancer=
Definition
no distant metastasis
Term
What is M1a esophageal cancer?
Definition
upper esophageal tumor with cervical LN mets; midthoracic tumor with mediastinal LN mets; lower thoracic lesion with celiac node metastasis
Term
What is M1b esophageal cancer?
Definition
upper lesion with mets to mediastinum or celiac lymphnodes; midthroacic lesion with mets to cervical or celiac nodes; lower thoracic lesion with mets to cervical or mediastinal lymphnodes
Term
What is stage 0 esophageal cancer?
Definition
Tis, N0, M0
Term
What is stage 1 esophageal cancer?
Definition
T1, N0, M0
Term
What is stage IIA esophageal cancer?
Definition
T2 or 3, N0 M0
Term
What is stage IIB esophageal cancer?
Definition
T1 or 2, N1, M0
Term
What is stage III esophageal cancer?
Definition
T3, N1, M0; T4, N0 or N1, M0
Term
What is stage IVA esophageal cancer?
Definition
any T, any N, M1a
Term
What is stage IVB esophageal cancer?
Definition
any T, any N, M1b
Term
5 yr survival of stage 0 esophageal cancer?
Definition
100%
Term
5y survival of stage 1 esophageal cancer=
Definition
75-80%
Term
5 yr survival of stage IIA esophageal cancer?
Definition
35-40%
Term
5 yr survival of stage IIB esophageal cancer
Definition
25-30%
Term
5 yr survival of stage III esophageal cancer?
Definition
10-15%
Term
5 yr survival of stage IVA esophageal cancer?
Definition
0%
Term
5 yr survival of stage IVB esophageal cancer?
Definition
0%
Term
Do you use chemo for esophageal cancer?
Definition
good evidence for use of pre and post op chemo in tx of patients with adeno carcinoma of the esophagus and stomach but not for squamous cell
Term
Wht is palliative therapy for esophageal cancer?
Definition
relieving dysphagia and prevent bleeding, perforation and tracheoesopahgeal fistula formation
Term
What are the different types of palliative treatmentsfor dysphagia of esophageal cancer?
Definition
endoscopic therapy (laser, stent placemnt, photocoagulation), radiation therapy (external beam or intraluminal), chemotherapy, and feeding tube placement
Term
What are the advantages to endosocpic stent placement for palliation of esopaheal cancer?
Definition
rapid relief, treatment of choice for tracheoesophageal fistula, easy outpt procedure
Term
What are hte disadvantages of endoscopic stent placement?
Definition
recurrence due to stent migration, tumor overgrowth; GERD; increased risk of late hemorrhage
Term
What are hte advantages of using photodynamic therapy and Nd:YAG laser for esophageal cancer palliation?
Definition
works well with exophytic lesions; generally low complication rates
Term
What are the disadvantages to photodynamic therapy and Nd:YAG laser?
Definition
often available in specialized centers; repeat tx every 4 to 8 weeks
Term
What are hte advantages to single dose brachiotherapy?
Definition
long dterm dysphagia improvement is better than stent placement; longterm quality of life was better when compared with stent; lowerrate of hemorrhage than stent
Term
What are the disadvantages of palliative chemo for obstruction secondayr to esophageal carcinoma?
Definition
response to obstruction is variable therefore, additional treatment is for obstruction may be needed; relief from obstruction may be delayed
Term
What can renal U/S tell you?
Definition
renal sie and number, urinary obstruction, renal vascular obstruction, and tumor infiltration
Term
How do you stage renal disease?
Definition
assessment fo cr clearance allows for estimation of GFR to stage renal disease
Term
Half of the mortality of renal pts is due to complications of...
Definition
cardiovascular problems
Term
Why should renal pts get echos?
Definition
because LVH is common in renal patients and echo can diagnose uremic pericarditis and pericardial effusion
Term
At what GFR should you hemodialyse?
Definition
less than 15 mL/min/1.73
Term
What is the definition of CRF?
Definition
kidney damage of greater than 3 months duration and/or GRF less than 60 mL/min /1.73m2
Term
Stage I CRF=
Definition
kidney damage with normal or increased GFR(>90)
Term
What is stage II CRF?
Definition
kidney damage with mild decrease in GFR (60-89)
Term
What is stage III CRF?
Definition
moderate decrease in GFR (30-59)
Term
What is stage IV CRF?
Definition
severe decrease in GFR (15-29); predialysis day
Term
What is stage V CRF?
Definition
kidney fialure (GFR less than 15), indication for chronic dialysis usually
Term
How do you alter diets of patients with CRF?
Definition
K restriction if GFR is approaching 20 to avoid hyperkalemia; prevent hyperparathyroidism by dietary phosphate restriction, phosphate binder adinistration at meal time, syntehtic 1,25 dihydroxy vitamin D, and subtotal parathyroidectomy if needed
Term
What are the leading causes of LVH in pts with renal failure?
Definition
anemia and HTN
Term
What are the effects of uremia on the body?
Definition
immunodeficiency state that is not reversible with hemodialysis, uremic encephalopathy, uremic peripheral neuropathy, uremic autonomic neuropathy producing postural hypotension and hypotension during dialysis, uremic platelet dysfunction
Term
THe immunodeficiency state produced by uremia puts pts at greater risk for what kinds of infections?
Definition
bacterial, viral, and mycobacterial infections and anergic states
Term
Hemodialysis involves two spaces divided by a semipermeable membrane where blood passes through one side of the membrane and _____ passes on the other side.
Definition
dialysate
Term
What kind of access is needed for dialysis?
Definition
large bore venous catheters through which blood can be drawn off at a high rate (350-400 mL/min) through one lumen and returned through a separate lumen
Term
What are the different classifications of HD catheters?
Definition
temporary access (days), intermediate term access (weeks to months), or permanent access
Term
What are intermediate-term catheters for HD access like?
Definition
they contain a cuff barrier and subcutaneous tunneled portion which are barriers against containation by skin flora and are associated with lower cather related infections and complications than the temporary dialysis catheters
Term
What are the pros and cons of using the femoral vein for temporary dialysis access?
Definition
rapid and safe but associated with increased infections when left in for more then a few days
Term
What is the ideal site for either temporary or intermediate catheter insertion for HD for most patients?
Definition
internal jugular vein
Term
What are the pros and cons of using thesubclavian vein for temporary vascular access in dialysis patients?
Definition
shouldbe avoided because of the potential for thrombosis and stenosis which would affect venous return and copromise the success of future upper extremity arterial-venous fistulas on that side
Term
Name soe commonly constructed AVFs?
Definition
brescia-crimino fistula (radial artery to cephalic vein), brachial artery-cephalic vein fisula in the upper arm, brachial-basilic fistula in the upper arm
Term
What are the major limitations to AVF creation?
Definition
inadequate size and quality of the veins; because injuries to the vein can occur with blood draws and IV insertions, it isextreely important to preserve the upper extremity veins in any pt in whom long term dialysis is to be anticipated
Term
How long do AVFs needed before tehy are mature enough for dialysis?
Definition
approx 6 weeks
Term
What is the most commonly used material for AV grafts?
Definition
polytetrafouroethylene
Term
Which is better, an AVF or an AVG?
Definition
grafts are less desirable because of increased complications including infection and pseudointimal hyperplasia on the venous end of the graft-vein connection leading to graft thrombosis
Term
What are the pros and cons of peritoneal dialysis?
Definition
allows pts to ambulate and carry on some of the activities of daily living during dialysis but is done at home so ptsneed to be functional and capable of troubleshooting problems; also there is a risk of peritoneal infection and peritoneal dialysis catheter-related complications
Term
Which is better for survival rates, hemodialysis or kidney transplant?
Definition
kidneytransplant has an overal improved survival of 10 yrs
Term
What are the three most common causes of CRF treated by renal transplantation?
Definition
diabetes mellitus (27%), hypertension (20%), glomerular disease (21%)
Term
What is the ratio of people on waitlist for kidney transplant and number of kidneys transplanted?
Definition
4:1
Term
What is the median time on weight list for kidney transplant before recieving kidney?
Definition
39 months
Term
When are patients considered for renal transplantation?
Definition
when their GFR falls below 20 mL/min
Term
What preop testing should pts undergo before getting a kidney?
Definition
psychiatric eval to determine whether they are likely to comply with imunosuppressivetherapy; valuation to rule out urinary obstructive process and reflux as a cause of CFR and ABO/HLA typing. All patients are also evaluated for possible infections such as HIV, Hep B, hep C, CMV and syphilis
Term
Can patients with cancer be considered for renal transplant?
Definition
they need to be at least 2 years without evidence of disease prior to being considered for transplantation
Term
T/F Age is a contraindication to organ transplantation.
Definition
false; up to 20% of the pts on the kidney waitlist are over 65
Term
What are the two types of kidney transplants you can get and which is more common?
Definition
living donor transplantation (40%) and cadaveric transplantation (60%)
Term
Why does living donor transplantation have less complications than cadaveric transplantation?
Definition
overall better medical condition of the donors and short cold ischemia time
Term
What are the graft survival rates of living donor kidney transplants at 1, 5, and 10 yrs?
Definition
95%, 80%, 56%
Term
What type of patients do we get cadaveric organs from?
Definition
retrieved fro brain dead donors between the ages of 3 to60 yoa and without systemic degenerative diseases such as hypertensiona dn diabetes and history of a stroke; however, because of the shortage of organs, ECDs (expanded criteria donors)= older than 60 or between 50 and 60 with a stroke, hx ofHTN, diabetes or elevated Cr
Term
What are the survival rates of non ECD cadaveric kidney transplant at 1 and 5 yrs?
Definition
90%; 70%
Term
What are the survival rates of ECD cadaveric kidney transplants at 1 and 5 yrs?
Definition
81%, 53%
Term
T/F All patients who have renal transplants need immunosuppressive agents.
Definition
false; if the kidney is from an identical twin donor you don't need immunosuppresion
Term
What is the MOA of cyclosporin?
Definition
inhibits the calcineurin pathway and the production of IL-2
Term
What are some major side effects associated with cyclosporin?
Definition
gingival hyperplasia, hypertension, hyperkalemia, nephrotoxicity
Term
What is the MOA of tacrolimus?
Definition
calcineurin inhibitor causing inhibition of IL-2, IL-3, and IL-4 and gamma interferon production
Term
Which is more potent, tacrolimus or cyclosporin?
Definition
tacrolimus
Term
What are the side effects of tacrolimus?
Definition
nephrotoxicity, hypertension, hyperkalemia, hypomagnesemia, CNS symptoms (headaches, tremors, seizures) and insulin resistence
Term
What is the MOA of sirolimus?
Definition
a T cell inhibitor that acts through a pathway that is different from the calcineurin pathway
Term
What is another name for sirolimus?
Definition
rapamycin
Term
What are the side effects of sirolimus?
Definition
less nephrotoxic than cyclosporine and tacrolimus but can cause thrombocytopenia, hyperlipidemia and poor wound healing
Term
What is Imuran?
Definition
azathioprine
Term
What is the MOA of mycophenolate mofetil?
Definition
inhibitor of B and T cell proliferation
Term
What is the MOA of azathioprine?
Definition
inhibits B and T cell proliferation
Term
MMF is often combined with...
Definition
cyclosporine
Term
When is azathioprine used?
Definition
substitued for MMF when intolerance develops
Term
What is OKT3?
Definition
monoclonal murine antibiotdy agains the CD3 receptor complex on T cells
Term
When acuteorgan transplant rejections are resistant to steroid induction, what is the next line of therapy?
Definition
antilymphocytic antibiodies
Term
What percent of people get a cute graft rejetion during the first few weeks to months after tranplantation?
Definition
10-20%
Term
What are the side effects of prolonged antilymphocytic therapy?
Definition
serious viral infections, thrombocytopenia, and leukopenia
Term
What are the symptoms of acute graft rejection?
Definition
fever, malaise, hypertension, oliguria, increase in serum creatinine, and tenderness and swelling over the transplanted kidney
Term
What percent of patients developsome form of infection during the first year after tranplant?
Definition
30-60%
Term
What is the most common type of infection in the first month following transplantation?
Definition
bacterial
Term
What are the most common types of infections seen after the first month post transplant?
Definition
CMV, PCP, aspergillosis, toxoplasmosis, cryptococcosis, nodardiosis, and blastomycosis
Term
What kind of prophylactic antimicrobial can be given to pts post transplant?
Definition
TMP-SMX for the first 6 months after transplant to decrease risk of PCP
Term
Post-transplant immune suppression increases your risk of malignancy by...
Definition
3-14x
Term
What kinds of neoplasms are common post transplant?
Definition
viral associated neoplasms, squamous cell carcinoma (HPV), kaposi sarcoma (EBV), non-hodgkin lymphoma (EBV), and hepatocellular carcinoma (hep B and C), lymphoma or post-transplant lymphoproliferative disorders are the most common post transplant malignancies and the occurence is related to the intensity and duration of anti T cell therapy
Term
If a patient post transplant starts having lymphoproliferative disorder approaching malignancy, what should you do?
Definition
decrease immuno suppression meds because they may cause regression of the lymphoproliferation
Term
What do you call the chronic fibrotic changes and accelerated loss of renal functions that occurs in transplanted kidneys?
Definition
chronic allograft nephropathy
Term
What lab results suggest chronic allograft nephropathy?
Definition
pogressive increase in serum Cr, proteinuria,a nd microscopic hematuria; confirm with biopsy
Term
What is the treatment for chronic allograft nephropathy?
Definition
there is no effective treatment but generally immunosuppressive treatemtn is gradually tappered to limit nephrotoxicity associatedwith calcineurin inhibitors
Term
T/F UTIs are common causes of infection after kidney transplantation.
Definition
bacterial infections are high on the list of possible infections within the first 4 weeks after transplantation
Term
What are the initial tests and initial clinical management of patients with a diabetic foot ulcer?
Definition
biopsy the wound for culture and send blood for culture; obtain xrays of the foot to look for charcot neuroarthropathy and/or osteomyelitis; the patietn should be put on bed rest, IV antibiotics, and strict glycemic control
Term
Inital evaluation of a foot ulcer can made with what criteria?
Definition
PEDIS= perfusion, extent, depth,infection, sensation
Term
What should you send to the lab to determine whether a wound is infected?
Definition
tissue biopsy of the wound, NOT a swab (because all wounds are colonized but not necessarily infected)
Term
What are the most common pathogens involved in diabetic foot infections?
Definition
staph aureus and beta hemolytic strep
Term
What is appropriateinitial empiric therapy of diabetic foot ulcer?
Definition
amoxicililn-clavulanic acid, ciprofloxacin, cephazolin, and vancomycin
Term
How long should you treat diabetic foot ulcers with antibiotics?
Definition
no good range has been determined but a reasonable range would be between 7 and 14 days
Term
Why is it important to control blood sugars in pts with diabetic foot ulcers?
Definition
hyperglycemia contributs to leukocyte dysfunction and compromised host response to infections
Term
When might you give 4 to 6 weeks of antibiotic therapy to a person with a diabetic foot ulcer?
Definition
if their xray shows degenerative changes that could be osteomyelitis vs. charcot's arthropathy
Term
What local wound care is needed for diabetic foot ulcers?
Definition
sharp debridement, larval therapy with medicinal maggots, topical agent applications, and in some cases the local infections associated with abscesses would require surgical drainage oand minor amputations; contact casting to offload pressure from the wound site
Term
Once healing of a foot ulcer is completed the pt should be thoroughlyexamined for contributory conditions such as...
Definition
limited joint mobility of the foot and ankle, calluses, bunions, hammer toes, claw toes
Term
What is charcot's neuroarthropathy?
Definition
noninfective bone and joint destruction that occurs in well perfused an insensate foot; thought to be caused by repetitive trauma to an insensate portion of teh foot
Term
What does charcot's neuroarthropathy look likeradiographically?
Definition
extensive bone and joint destruction, fragmentation, and remodeling
Term
What is the clinical presentaiton of acute Charcot neuroparthropthy?
Definition
soft tissue swelling, soft tissue erythema and increased local skin temp; can be very difficult to differentiate clinically from foot infections and osteoyelitis
Term
How does diabetic neuropathy predispose to foot ulcers?
Definition
muscle atrophy, altered biomechanics, and foot deformities, sensory neuropathy that increases susceptibility to injuries, autonoic neuropathy leading to decreased sweating, skin dryness, cracks, and increases susceptibility to infections
Term
"diabetic foot" refers to a nuber of pathologic conditions encountered in this pt population including=
Definition
diabetic neuropathy, ischemic vascular disease, Charcot neuroarthropathy, skin ulceration, soft tissue infections and osteomyelitis
Term
What is the lifetie risk of foot ulcer in a diabetic?
Definition
25%
Term
What percent of nontraumatic foot amputations are due to diabetic foot ulcers?
Definition
80%%
Term
Pts at low risk for diabetic foot ulcer=
Definition
normal sensation and pulses; annual foot exam
Term
Moderate risk for diabetic foot ulcer=
Definition
pts with enuropathy or absence of uplses should get exams and maintenence care every 3 to 6 months
Term
pts at high risk for diabetic foot ulcers=
Definition
neuroapthy or abscence of pulses in addition to foot defority, skin changes or prior history of ulcers; need evaluation every 1 to 3 months
Term
What are signs associated with a foot ulcer that indicate deeper infection?
Definition
pain, induration and wound drainage
Term
What signs with diabetic foot ulcer suggest osteomyelitis?
Definition
pain, deeper ulcers, elevated leukocyte count
Term
WHat is a helpful radiographic study used to diagnose acute osteomyelitis?
Definition
radionuclide scan with gallium
Term
Why are diabetic patients less likely to have calf claudication?
Definition
arterial occlusion occurs at the tibial-peroneal arteries so they get foot claudication but because of sensory neuropathy this may go unnoticed
Term
How can you assess blood flow to distal extremities?
Definition
measurement of ABI's, TBIs and duplex ultrasonography
Term
Why are ABIs falsely elevated in diabetics?
Definition
calcifications of tibial vessels
Term
What is teh best way to surgically revascularize diabetic pts with poor peripheral perfusion?
Definition
open vascular reconstruction because there is increased frequency of ultiple level occlusivedisease and tibial level occlusive disease
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