Surgery Flashcards
What do you need to worry about regarding the heart before surgery?
1. Decompensated HF (EF < 35%)These people have a 75% chance of dying2. MI 40% chance of dying 3 months post MI6% chance at 6 months
What do you use to evaluate someone for surgery?
Goldman IndexThe more points you have, the worse off the person is
What are some things that give you a lot of points in Goldman Index
JVD - EF <35%Recent MI
What should you start with when working someone up for surgery?
EKGBut if a CAD or HF patientDo Echo & stress --> if there is issue do stent or CABG and then wait 6 months and reevaluate
What is more important in surgery: ventilation or oxygenation?
VentilationBecause you can always turn up O2 but poor ventilation will result in increased CO2
What patients need a pulmonary evaluation?
SmokersCOPD/AsthmaILDDx: PFT & ABGLooking for low O2 or high CO2
If low O2 how do you fix?
Give O2inhalers
When should you tell a patient to stop smoking before a procedure?
8 weeks before procedureSmoking cessation causes increased bronchial secretions for a while
What scores do you monitor for the Liver?
Meld Score & Child-Pugh
How are you going to monitor synthetic function of liver?
Albumin --> decreasedPT/PTT --> absentBilirubin --> increasedAscites & encephalopathy
What if you have any one of these liver issues?
40% chance of deathIf 5 --> 100% chance of deathSo in this case outside of a liver transplant these patients do not get a liver transplant
Why is nutrition important for surgery?
Healing after surgery
Who are at risk?
Those that lost 20% of body weight in last 3 monthsAlbumin <3Fail skin anergy test (checking if enough protein)
How do you distinguish if low albumin is due to poor nutrition or liver disease?
Check pre-albumin and CRP (other proteins)If both of these are also low --> then albumin is low and you don't have enough protein in body
What conditions are absolutely contraindicated for surgery?
Diabetic Ketoacidosis
What are the 5 causes for a post-op fever?
Wonder DrugsWindWaterWalkingWound
What is the most likely Dx if fever occurs DURING surgery?
Malignant Hyperthermia
What do you do?
No time to make DxGive them high flow O2, Dantrolene, cool off
What if the fever occurs RIGHT AFTER the surgery?
Bacteremia Going to need to make Dx via blood culture
What is Tx going to be?
ABX (broad spectrum)
What if someone develops a fever POD #1?
Usually a product of atelectasis (WIND)Dx: via CXR (want to rule out PNA)
What is atelectasis?
collapsed lung --> decreased lung volumeCan be due to accumulation of pharyngeal secretions, tongue protruding posteriorly into pharynx, airway tissue edema, or residual anesthetic effectsMore common after abdominal or thoracoabdominal procedures
What are other causes?
Pain and changes in lung compliance â> can cause impaired cough and shallow breathingShallow inhalations â> limit recruitment of alveoli at lung basesWeak cough â> predisposes to mucus pluggingLeads to hypoxia â> increased ventilation â> low PCO2
When is it most likely to occur
POD 2-5
What is ABG?
Compesation for hypoxemia --> hyperventilate to blow off Co2So result will be pH 7.49, O2 70mmHg, CO2 27 mmHg
How can you prevent this?
Inspiratory muscle training, Forced expiration techniques
What if someone develops POD #2?
PNA (fever, cough) - WINDCXR: consolidationTx: Broad spectrum ABX (Vanco & Pip-Tazo
How do you want to treat these 2 conditions?
Incentive spirometry and get them out of bed
What if fever develops POD #3?
UTIDx: U/A & Urine CultureTx: ABXTake out foley as soon as you can to prevent this
What if fever develops POD #5?
DVT/PEDx: U/STx: Heparin/Warfarin bridgePrevent this by LMWH and also make them walk around
What other methods can be used to decrease postoperative PNA?
Encourage lung expansion viaincentive spirometry (most effecting)deep breathing exercisesContinuous positive airway pressure (CPAP) --> more costly and more complications, used on patients who develop pulmonary complications in spite of incentive spirometryIntermittent positive pressure breathing
What if fever develops POD #7?
Cellulitis- WOUNDDx: U/S (will be negative)Tx: ABXKeep wound sterile to prevent this
If a DVT develops how long should you treat?
At least 3 months of treatment General treatment is unfractionated heparin with warfarinHeparin is continued for 4-5 days until the INR is at therapeutic levelsNormally it is recommended to start all patients with anticoagulation 48-72 hours after surgery
What anticoagulation should be used if a patient has renal disease?
WarfarinLWMH not recommended as they are metabolized by kidney and cause increased bleeding risk
What if fever develops POD #10-14?
Abscess - WOUNDU/S + for abscessNeed to go back to OR for incision drainage
What can occur 10 days after laproscopic appendectomy and present with RUQ pain, fever, leukocytosis, and pulmonary manifestations (SOB, hiccups, right sided effusion)?
Subphrenic Abcess due to infectionDx: CT scan of abdomenTx: Drainage and IV ABX
What are some differentials to consider in someone having post op chest pain?
MI, PE, something elseGet EKG and troponins for MIGet U/S and spiral CT for PE
What if it is MI?
PCI heparinCannot use tPA
What if it is PE?
Heparin bridge with Warfarin
What else can be a differential for chest pain post op?
1. Altered Mental StatusMight be issues with electrolytes (Na+ & Ca2+)2. Sundowning (elderly)Tx: atypical antipsychotics3. Hypoxemia (PE, PNA)ARDS is most important ---> will need PEEP and O2 support4. Delerium TremensGive Benzos
What can be another post op issue?
Decreased urine output1. Figure out if there is urge to void and bladder is full --> most likely obstruction
What if no urge to urinate?
Might be renal failure --> monitor if there is any urine outputIf no output --> most likely mechanical (kinked foley)But if some output, but not a lot --> looking at actual renal disease --> need to figure out if intrinsic or pre-renalGive them fluid to seeIf output increases --> only thing they needed was more fluidIf output does not change --> intrinsic renal disease
What can be another post op issue?
Abdominal DistensionConsider Ileus, Obstruction, and Ogulvie
What is ileus?
Just functional No stool, no flatusDx: KUBSmall and large bowel both dilatedTx: Fluids, K+, get them to move
What are some causes for prolonged postoperative ileus?
Increased splanchnic nerve sympathetic toneLocal release of inflammatory mediatorsPostoperative opiate analgesic use
What is obstruction?
Person in which you suspected ileus but by day 5 still no bowel movement or flatusDx: Upright erect KUBTx: NG tube and surgery again
What is ogulvie syndrome?
A distractor question since this is also functionalImpacts only the colon and elderly Large bowel and colon will be distendedTx: decompression
What are some post operative complications of wounds?
Dehiscense --> failure of fascia Wound is not open but underneath the fascial planes are not closed wellsPatient will end up with herniaSerosanguinus drainage (Salmon colored)Tx: Binders & reduce straining, eventual re-operation Prevent this from turning into an evisceration
What is another problem?
EviscerationFailure of whole woundFascia and skin breaks downLoops of bowel will pop outHappens because patient strains or stands up way too soonTx: Back to OR EMERGENTLY . Apply warm saline dressings to keep everything moistNEVER push it back in because you don't want that exposed bowel back in peritoneum
What is another problem?
FistulaTracts between 2 thingsThings that cause it:Foreign bodyEpithelializationTumorIradiation, inflammed or inflammatory bowelDistal obstructionTx: remove or resect fistula
What is pre-hepatic bilirubin?
Primarily unconjugated
What can be intrahepatic liver dysfunction?
GeneticHepatitis
What can obstructive jaundice present as?
Gall stonesCancer
What happens when you have an obstruction? (post hepatic juandice)
Can be painful --> gallstonesElevation of conjugated billirubinBile is stored in gallbladder --> can form a stone and then get pushed out and obstruct biliary treeCan result in dilation of biliary tree and inflammation of gallbladder
How will patient present?
Elevated temperatureElevated WBC+ Murphy sign Dx: RUQ U/S, best test is MRCPTx: ERCP
What will result in thin gallbladder walls and massively dilated biliary ducts?
Cancer in biliary tree No inflammation because not acuteNo pain, no murphys
How do you Dx?
RUQ U/SBest test is MRCPTx: Endoscopic U/S with biopsy or ERCP with biopsy
How will this present?
Painless Jaundice --> direct bilirubin can be elevatedClay colored stools --> bilirubin gives stool its colorWeight lossAlso distended gallbladder thats palpable and nonpainful
What is buzzword for pancreatic cancer?
Migratory thrombophlebitis Can also present with painless jaundice and CT scan shows pancreatic massDx: Endoscopic U/S
How do you Dx?
Endoscopic U/S
What are signs of pancreatic cancer?
Epigastric abdominal pain that is insidious and worse at nightWeight losssignificant smoking historyUsually presents with jaundice and steatorrhea
What are other features?
Mean age of Dx is 55Very high mortality rate --> frequently diagnoses at relatively late stages70% orginiate at head of pancreas
How do you tx?
Whipple procedureIf cancer is at head of pancreas --> remove head of pancreas, duodenum, gallbladder, common bile duct, proximal jejunum, and distal stomachDue to common blood supply
What presents with history of alcohol use with recent episode of pancreatitis but currently presents as abdominal distention, N/V, with CT scan showing a round, well-circumscribed encapsulated fluid collection in pancreatic bed?
Pancreatic pseudocyst Surrounded by thick fibrous capsule --> contains enzyme rich fluid, tissue, and debris
How do you Tx?
If minimal symptoms --> expectant managementIf significant symptoms --> endoscopic drainage
What is pathopneumonic for Primary Biliary Cholingitis?
"beads on a string" on MRCPIncreased risk for cholangiocarcinomaDx: Best is ERCPTx: Resection of cancer
What if you see nothing on CT scan for painless jaundice?
Think ampulla of vater cancer+ FOBT- colonoscopy Dx: ERCP with biopsyTx: Resection
What causes GERD?
Weakened LESAcid reflux --> esophagus gets burnedRetrosternal burning chest painWorse when laying flat and eating spicy foodsBetter when sitting up and antacidsShould be no alarm symptomsLifestyle + PPI
What if there are alarm systems or failure of lifestyle + PPI after 4-6 weeks?
Need to do EGD with biopsyTo make sure no cancer
How do you treat Barrett's esophagus?
High dose PPI
Can you do surgery for GERD?
YesNissen FundoplicationBefore you do this you want to be sure that this person has GERDBest test for GERD: 24 hour pH monitor
What is achalasia?
LES wont relaxPatients will complain of knot or ball of food stuck at GE junctionDx: Barium swallow will show birds beak esophagusWhats best test? Manometry
What is best Tx?
MyotomyRemove muscle of LES
Where does SCC occur?
Upper 1/3 of esophagusDue to drinking hot liquids or smoking
Where does adenocarcinoma occur?
Lower 1/3 of esophagusRelated to GERD
How will esophageal cancer present?
Dysphagia
How do you Dx?
Barium SwallowEndoscopy with biopsy to confirm Dx
What is a Mallory-Weiss tear?
Superficial tear of mucosa of esophagusSelf limiting GI bleedIn someone that vomitsTx this like a GI bleed until you know for sure its Mallory Weiss
What is Boorhave's syndrome?
Spontaneous rupture of esophagus that typically occurs after foreceful emesisTransmural tearHole in esophagus = air in mediastinum
How do you Dx?
Gastrograffin swallowIf negative --> do barium swallowIf negative --> do endoscopy
How does small bowel obstruction occur?
1. Adhesions (most common cause in people who have had abdominal surgery before)2. Hernias Everything distal to obstruction works fine, will continue to empty and have flatusBut as progression everything proximal can't get any further --> results in obstipationWill get abdominal distention as gas and fluid build up before point of obstruction
How will patient present?
Colicky abdominal painSo pain that only occurs when the peristalsis reaches the point of obstruction and goes away when it passes that pointMight cause sound of borborygmi --> means complete obstruction
What is the first diagnostic step?
1. Upright abdominal film (KUB) Looking for air fluid levels2. F/U with CT scan w/ oral contrastIf no contrast material makes it to rectum, complete obstruction
What if SBO is incomplete? (contrast reaches rectum)
Conservative management --> watch and wait
What if complete?
Go to surgery ASAPSometimes they are poor surgical candidates and watch and wait is still an option --> NG tube, IV fluids, and monitor K+ for 3 days to see if they get betterIf not --> surgeryIf they become peritoneal --> then immediate surgery
Why is a complete SBO bad?
Risk of impending ischemia, strangulation, and necrosis Do emergency abdominal explorationAlso have pain, fever, hemodynamic instability, guarding, leukocytosis, and metabolic acidosis Delay can lead to perforation
Which hernia goes directly through the muscle?
Direct HerniaThrough transversalisAdult males
What is the hernia that is common in babies that goes through inguinal ring?
Indirect HerniaGoes into scrotumMale babies
What is a femoral hernia?
FemalesUnder inguinal ligamentWill see in leg or thigh
What is Ventral Hernia?
IatrogenicFailure of fascia to close in post op patient
How do Hernias present?
Abdominal bulgeNeed to do physical exam to figure out which type it is
What is a reducible hernia?
Can push it back through the muscle
What is an incarcerated hernia?
Non-reducibleStuck between muscle nowAt risk for strangulation where blood supply to that piece of bowel can be cut offNeeds treatment but not immediateNeeds urgent surgical repair
What is strangulated hernia?
Peritoneal signsEMERGENT surgery
What presents with a soft, non-tender bulge covered by skin that protrudes with increased abdominal pressure in a newborn infant?
Congenital Umbilical HerniaIncomplete closure of abdominal muscles around umbilical ring at birthCan be reduced easily --> very low risk of incarceration and strangulationIf small --> will most likely close spontaneouslyIf large (>1.5cm) surgery by age 5
How does appendicitis occur?
Fecalith forms across appendix --> infection sets up behind it --> swollen and inflamedPeriumbilical pain --> will go away and return at McBurneys pointDx: CT scan while prepping OR (not needed)Tx: Surgery
If patient has a lot of clinical signs of appendicitis like umbilical pain that travelled to RUQ and rovsing sign, is imaging needed before surgery?
No because further delay can just lead to complications if you have great suspicionBut in patients who do not have obvious signs --> get imaging like CT or US
What presents with a delayed presentation with a longer duration of symptoms (>5 days) of apendicitis?
Appendiceal rupture with a contained abscessNeed to do maneuvers like psoas sign and obturater signVery high complication rate
What is carcinoid cancer?
neuroendocrine tumor that secretes serotoninHas mets to liver in order to work since this breaks down serotoninSerotonin causes flushing, wheezing, and diarrheaRight sided cardiac fibrosis Dx: 5-HIAA in urine, then CT scan to identify tumorsTx: resect
How does pancreatitis present?
Epigastric abdominal pain --> will bore through to the back and positional Digestive enzymes that are supposed to digest food end up digesting pancreas which hurts a lotDx: Lipase and AmylaseTx: NPO, IV fluids, pain control
When do you get CT scan?
If you suspect it but enzymes are negativeIf someone looks septic after 5 days --> fever & leukocytosis --> might be abscess --> operateOr after Tx and they have early satiety, weight loss, and abd pain on F/U --> pseudocyst --> drain if complicatedSomeone who is sick as shit and hypotensive --> necrotizing pancreatitis
What is the medical term for gallstones?
cholelithiasis
What are other presentations of pancreatitis?
Midepigastric pain, nausea, vomitingElevated amylase & lipaseIf no alcohol use and elevated liver enzymes --> most likely due to gallstonesALT >150 has 95% predictive value for diagnosing gallstone pancreatitisIncreased risk for recurrent attacks of pancreatitis so elective cholecystectomy is tx of choice
What are the different types of gallstones?
1. Cholesterol stones --> green (5 F's)Fat, Female, Forty, and Fertile2. Pigmented --> BlackCome from hemolysis
How will patient present?
Colicky abdominal pain in RUQ that radiates to shoulderGets worse with fatty food when gallbladder contracts
How do you Dx?
RUQ U/STx: Cholecystectomy done electively
What is it called when gallstone pops out and ends up in cystic duct?
CholecystitisGallbladder gets big and inflamedInflammation and distension of gallbladderYou will have pericholecystic fluid, thickened gallbladder wall
How will patient present
constant abd pain because this is inflammatory+ Murphy signFever & Leukocytosis
How do you Dx?
RUQ U/SIf this doesn't show you what you want but you still suspect this --> get HIDA scanTx: NPO, IV fluids, IV ABX ....Cholecystectomy
When should you get cholecystectomy?
within 72 hours --> reduces disease duration, time of hospitalization, and mortality
What happens if the stone goes even further and ends up in the common bile duct?
Choledocholithiasis Dilation of ductObstructive Painful JaundiceCan end up causing pancreatitis or hepatitis
How do you Dx?
RUQ U/S --> looking for dilated ducts due to obstructionTx: ERCP and ABXCan do cholecystectomy electively later
What is cholangitis?
Dilated ducts, gallstones in gallbladder, obstructing stoneVery similarBut now you have stagnant fluid --> infection that ascends biliary treeGallstone in common bile duct
How will patient present?
Charcot's Triad --> RUQ pain, Painful jaundice, FeverJAUNDICEElevations in alk phos and CB
How do you Dx?
RUQ U/S --> dilated ductsTx: ERCP EMERGENTLY and give ABX while you get them thereThen go to cholecystectomy urgently
Which ABX?
Cipro and MetroAmp-Genta-MetroPip Tazo is wrong on test
How might you detect colon cancer?
Asymptomatic ScreenPostmenopausal man with iron deficiency anemiaChange in caliber of stool (pencil thin), alternating bowel habits, constipation, and weight loss
What is specific about right sided cancers?
Loose stool
Left sided cancer?
Firmer stools with obstructive symptoms
What if you suspect colon cancer?
colonoscopy
What if you find cancer?
Need CT scan to stageChemo
What if you see thousands of polyps?
FAPPremalignant when 18 but cancerous when adultTx: Prophylactic colectomy (take out colon)
What if you just find one polyp?
See if its a good polyp or badGood --> pedunculated, small, and tubular on biopsyBad --> villous, sessile, large
What is UC?
Inflammatory Bowel Disease that affects superficial mucosa of colonPresents: bloody bowel movements, rectal pain, weight lossDx: colonoscopy --> continuous inflamed rectum through colonTx: Treat medically until 8 years after Dx --> Change of malignant transformation goes very high --> need to be screened every yearNeed a prophylactic colonectomy
What about Chrons disease?
Not seen by surgeonTransmuralPatient usually presents with fistula Tx: fistulotomy ...use medications instead to prevent this
What are hemorrhoids?
Internal --> Bleed but no painExternal --> Pain but no blood Dx: visual inspectionTx: Banding internal hemorrhoids to stop bleeding, resecting external hemorrhoidsStart with creams though
What is caused by a tight anal sphincter?
Anal FissurePresent: Pain on defecation that will last for HOURSDx: you can see the fissureTx: Surgery --> lateral internal sphincterotomy First try nitroglycerin paste, surgery if no releif
What does Uworld say about anal fissures?
Longitudinal tears in anal canal distal to the dentate line --> most common at posterior midlineSpasm of sphincter contributes to the pain and creates tension.Can see bloody stoolAre related to chronic constipation --> high anal pressures and passage of hard stools
What can be common here?
Patients holding stool due to pain --> exacerbates constipationCan be accompanied by skin tags
What are Tx options?
Dietary mods --> high fiberStool softenerSitz baths --> increase blood flow to injured muscosaTopical anesthetics --> lidocaineTopical Vasodilators (nifedipine) --> can reduce pressure and increase blood flow to anal sphincter
What if Tx fails?
Surgical intervention --> gradual dilation for wider anus But this can lead to fecal incontinence and possible recurrent fissures
What is a pilo nidal cyst
Abscessed hair follicle that becomes infectedNeed a hairy butt to get itTx: incision and drainage --> Operating room to resect cyst
What are the 3 types of pain?
somatic, visceral, neuropathic
What do you do about anal cancer?
HPV --> causes SCCPatient someone who has anal receptive sexDx: Anal PapTx: Chemo & radiation --> pretty effective
What is the issue in somatic?
Problem with tissue itself Usually involves skin and you can pinpoint it exactly
What is visceral pain?
Visceral organs have no pain receptorsRefer pain to site of embryological originNo actual pain receptors but the organs do feel the stretch and obstruction which will cause pain
What are the different forms of visceral pain?
1. Obstructive --> colicky - peristalsis on obstruction causes painNo fever, no leukocytosis Ex) Cholelithiasis, Nephrolithiasis2. Inflammatory Pain --> constant painFever and possible leukocytosis, writhing in agonyEx) Cholecystitis, pyelonephritis 3. Perforation --> Sick as shit, constant pain, any movement causes painWill see free air on XrayEx) PUD, cancer, trauma4. Ischemic pain --> pain out of proportion, no peritoneal signs, belly is softEx) CAD, a fib,
What is neuropathic pain?
Damage to nerve, which is causing the painBurning/pins and needles like diabetic neuropathy
What is stage 1 of ulcer?
Non blanching erythemaOnly epidermis
What is stage 2?
Epi and dermisNot to fascia
Stage 3?
Fascia
Stage 4?
Muscle and bone
What is a diabetic ulcer?
Microvascular changesStocking glove fashionWont feel pain, will damage skin --> ulcerTx: control blood glucose, elevate legs
What are 3 ways that someone can get breast cancer?
1. Exposure to estrogen2. Radiation3. Genes (BRCA)
What is compression ulcers?
Path: Pressure points like through sitting on somethingBedridden or wheelchair bound patientsTx: roll person every 2 hours, cushions
Screening
Mammogram is gold standardAge 50 and then every 2 yearsWhats the BEST method? -- MRI - only use in people are very high risk
What are arterial insufficiency ulcers?
Peripheral vascular diseaseHairless legs, shiny skin, absent pulsesUlcers farthest away from blood supply, tips of toesDx: arterial U/S, angiogramTx: Stent/ bypass
What is venous stasis ulcers?
Problem getting blood outEdema (CHF, cirrhosis etc)Stasis dermatitisHyperpigmentationCan get indurated if long enoughInduration on medial malleolus is classicTx: Compression stockings, elevate legs, diuretics
What is marjolin ulcer?
SCC (that usually arises in a burn wound)Ulcer with sinus tract or ulcer that heals and then breaks down over and overIncreased risk of metastasis Dx: biopsyTx: resection
Dx?
Mammogram and then core biopsy
What are different ways of presentation?
Asymptomatic screensBreast lumpObvious breast cancer (skin dimpling, fixed axillary nodes, large breast mass)
What do you do if someone finds a lump?
<30: wait a few menstrual cycles If still there --> get U/S (distinguished between mass and cystIf mass --> get FNA --> can be blood, pus, or fluidCan't get mammogram <30, breasts too dense
How do you Tx?
Local: radiation & surgeryDo SLNB (sentinal lymph node biopsy) ... if axillary lymph nodes + --> then do axillary lymp node resectionSystemic: Chemo (doxorubicin, cyclophosphamide, paclitaxel & targeted therapyTargeted --> if HER2/NEU + --> tratuzamabHer2Neu - --> BevalizumabER/PR + --> SERMDoxorubicin and tratuzumab cause CHF
When you do an initial assessment on someone, what do you want to look at?
AirwayBreathingCirculation
What indicates a patent airway?
Speak full sentences without pausingNo accessory muscle useBilateral breath sounds
What indicates an urgent airway?
Expanding Hematoma Hearing cutaneous emphysema
What indicates an emergent airway?
Someone who is apneic --> not breathingGurgling/gasping
What are you assessing when you look at breathing?
Ventilation (CO2) --> measure via ABGOxygenation (O2) --> measure via Pulse oximeter
What are you assessing when looking at circulation?
To see if someone is in shockSystolic BP <90 (MAP<65)Urinary Output < 0.5 /hrPale cool and diaphoretic
What can hypotension be due to?
Hemorrhage (low volume)Obstruction --> tension pneumothorax & cardiac tamponadeBoth obstruct blood flow to RV
What happens in hemorrhage?
Patient is losing bloodFlat neck veins, normal heart and lungsDx: FAST (Ultrasound)Tx: apply pressure and go to OROn your way to OR --> IV fluids & blood
What happens in tension pneumothorax?
Peritoneal space between chest wall and lung is filled with air --> Crushes the IVCNo blood return to heart --> JVDNormal heart, decreased breath sounds, hyper-resonance Tracheal deviation away Tx: Needle Decompression (trying to undo pressure on IVC)
What happens in pericardial tamponade?
Blood around pericardium --> can compress right heart, prevent entry of blood into heartJVD, distant heart sounds, hypotension --> Beck's TriadNormal lung soundsTx: Pericardiocentesis
How does basilar skull fracture present?
Raccoon eyes (hematomas around eyes)Hematoma behind earOtorrhea & rhinorrhea
What is the most common brain hematoma in children?
Epidural hematoma Result of a traumatic brain injury following blow to skull
Which bone usually gets fractured?
Sphenoid boneTearing of middle meningeal artery
How will patient present?
Brief LOCLucid interval and then deteriorate againIncreased ICP --> Headache, N/V, AMS
What do you see on CT scan?
Biconvex lens lesion that does not cross suture linesBleeding is between dura mater and skullMid-line shift is possible (uncal herniation) -- dilation of pupil on ipsilateral side of lesionTx: Emergent neurosurgical hematoma evacuation
What is cerebral angiography used for?
Identifying cerebral aneurysms and AV malformations
What is an ACUTE subdural hematoma?
Young patientMassive trauma (80 mph car crash)LOC, no lucid intervalCrescent shaped hematomaTx: Reduce ICP --> hyperventilate, elevate head, mannitol
What is chronic subdural hematoma?
Older patient, alcohol --> shrunken brainsShearing of bridging veinsCrescent shaped hematomaMinor trauma like fallsBleeding worsens over time and worsening of status over days to weeksCT scan to Dx, Craniotomy to Tx
What is cerebral contusion?
Bruise of brain tissue from coup/contre-coup injuries
What is concussion?
Setting of a sports injuryLOC, retrograde amnesiaCT scan = normalTx: go home on observation
What is diffuse axonal injury?
Angular trauma Traumatic acceleration/deceleration shearing forces Diffusely damage axons in brainLOC, comaCT scan = Gray white matter blurringBasically dead
What are the 3 zones of the neck? OLD WAY
Zone III, II, and IZone III is highest --> arteriesArteriogramZone II: middle --> artery, trachea, esophagus Surgery Zone I: lowest --> artery, trachea, esophagus Artereogram, esophogram, bronchoscopy
What is the first thing you do if patient comes in with penetrating neck injury? NEW WAY
Ask if patient is stableIf unstable --> OR (Hard signs present)If stable --> determine if symptomaticIf symptomatic --> get CT angiogram --> if negative you observeIf + --> go to OR (soft signs present)If asymptomatic --> just observe
What are hard signs?
Things that cause airway compromiseGurgling, stridor, loss of airwayExpanding hematoma, pulsitile bleeding, stroke, shock
What are soft signs?
Not as badDysphonia (difficulty speaking), Dysphagia, sub Q air, milder hard signs
What is rib fracture?
Caused by traumaPointy ribs can cause damage to chestPresent with chest pain, decreased breathingCan lead to PNA due to decreased breathing, goal is to get them to take bigger breaths Dx: chest XrayTx: Pain control to allow them to breathe
What is the preferred treatment in a rib fracture that has no evidence of internal organ injury? (no hypotension, chest wall deformity, abdominal pain, or pneumothorax)
Maintaining adequate ventilation Associated with significant pain which causes hypoventilation that can lead to atelectasis and PNA. Pain control is essential to allow patient to take deep breaths and cough adequately
What is a pneumothorax
Penetrating traumaDyspnea, hyper-resonance to percussion, decreased breath soundsDx: Vertical CXRTx: Thoracostomy chest tube placed high to allow air to leave
What is a hemothorax
Penetrating traumaDyspnea, pooling of blood at base of lungDullness to percussionTx: Thoracostomy chest tube placed low F/U: surgery depends on how much blood comes out (20cc/kilo at once)
How much blood is a hemithorax capable of holding?
50% of circulating blood volumeCan cause tracheal deviation to opposite sideReduced breath sounds and dullness to percussion
What is a sucking chest wound?
Penetrating wounds from outsideDyspneaWound allows air to enter each time you inhale, nothin on exhalation --> can lead to deadly tension pneumothoraxDx: visual but also get CXR due to traumaTx: Occlusive dressing to stop air entering
What is flail chest?
Huge blunt trauma + break 3 ribs in 2 different placesParadoxical motion on breathing --> flail segments move inward during inspiration and out on expirationDx: visual/CXRTx: Binders & weights
How can it present?
Respiratory distress and tachypnea with shallow breaths Respiratory failure can occur if this leads to pulmonary contusion with collection of edema and blood in alveoliPain control and supplemental O2 are early stepsIntubation with mechanical positive pressure ventilation is often required (MPPV)
What will you see with diaphragmatic tear?
abnormality of diaphragmatic shadowHerniation of abd contents into left pleural space --> causes compression of lungs and mediastinal deviation More common on left side since right side is protected by liver Tip of NG tube seen in left hemithorax
Will patients have symptoms right away?
May be a delayed presentationDelayed is associated with high morbidity and mortality and can increase risk of hernia formation and strangulation (30-70% due to strangulation of bowel)
What will imaging show?
Bowel loops in thoracic cavity and shifting of mediastinum to opposite sideCT scan is best
What is a pulmonary contusion?
Huge trauma to thorax --> parenchymal bruising of lungResults in intraalveolar hemorrhage and edemaPatient will present as completely normal on day 1 but will develop dyspneaDx: chest xray 24-48 hours later shows white outArterial blood gas --> hypoxemiaTx: PEEP, diuretics
What are symptoms?
Tachypnea, tachycardia, and hypoxiaRales and decreased breath soundsCXR: patchy alveolar infiltrate not restricted by anatomical borders
What is the management?
Supportive and pain controlPulmonary Hygiene --> nebulizer treatment, chest physiotherapy, and supplemental O2
How would ARDS present?
Can be a complication of pulmonary contusionOccurs 24-48 hours after trauma --> CXR --> bilateral patchy alveolar infiltrates
What is a myocardial contusion?
Huge traumaEssentially a heart attackDx: 12 lead EKG & TroponinsTx: CHF + Antiarrythmics
What is an aortic dissection?
Due to deceleration injuryCOMPLETE transection --> All of blood in heart ends up in chest --> most people with this dieIncomplete --> develop adventitial hematomaCXR: widened mediastinum DX: CT angiogramTx: emergent surgery
What if PCWP is slightly elevated at baseline and increases significantly after infusion of saline without much change in SBP?
Suggests elevated intracardiac filling pressures due to LV dysfunction Usually due to myocardial contusionMyocardial contusion can also present with cardiac arrhythmias, valvular septal or ventricular wall injuries, ventricular free wall rupture, pericardial tamponade, and death
How does it occur?
Fat enters venous circulation and causes mechanical disruption of capillary blood flow
What is the triad?
Respiratory distress, neuro dysfunction (confusion, visual field defects), and a petechial rash
How do you Tx?
Supportive --> 50% of patients require mechanical ventilation
Generally when it comes to abdominal trauma when should patient go to OR?
If injury penetrates peritoneum --> penetrating abdominal wound (not blunt abdominal trauma)On the test --> always the case with gunshot wounds
What are signs of blunt abdominal trauma?
seat belt signhypotension, rebound tenderness, abdominal guarding/distentionCo-existing femur fracture
How can blunt abdominal trauma lead to acute chemical peritonitis?
Spillage of blood, bowel contents, bile, pancreatic secretions, or urine into peritoneal cavity Causes diffuse abdominal pain and guarding
Will rupture of urethra lead to peritonitis?
No --> it is a extraperitoneal structureSo are anterior bladder wall and bladder neck
What can cause urine to spill into peritoneum?
Rupture of the dome of the bladder
How do you manage gun shot wound to abdomen?
Ex Lap --> surgeryAbd begins at T4 --> nipple line
What are indications for urgent exploratory laparotomy?
Hemodynamic instabilityPeritonitis (rebound tenderness, guarding)EviscerationBlood from NG tube or on rectal exam
How do you manage knife wound to abdomen?
Need to determine if knife penetrated peritoneumIf peritoneal signs, shock, or evisceration --> peritoneum was enteredIf superficial wound --> probe it to see if it enters peritoneum
What is first thing to do when someone comes in with blunt trauma to abdomen?
Do FASTIf + for blood --> ORCan do CT scanif + for blood or air --> OR
What if hemodynamically unstable?
Or have evidence of peritonitis or evisceration of any organ Do immediate exploratory laparotomy
Why is it so important to identify abdominal bleeding?
Has a large capacity to hold blood so it hides itself pretty wellThings like liver and spleen usually cause of bleedFor liver --> try to repair, if not may have to do lobectomy and repair bleeding lobeSpleen --> can generally salvage it --> can remove it though but need to vaccinate against encapsulated organisms
In blunt trauma, what if FAST is inconclusive and patient is unstable?
Diagnostic Peritoneal Lavage
How does ruptured diaphragm present?
Bowel sounds in chest --> bowel in chestStraight to OR
What can tip you off to a spleen injury?
Blunt abdominal trauma, left sided abdominal pain, and anemia Manifestations include hypotension, pleuritic chest pain, left abdominal wall bruising, LUQ tenderness, abdominal guarding Referred pain to shoulder via phrenic
How do you manage this?
FAST exam in hemodynamically stable patientIf normal FAST but high risk features like anemia or guarding --> get CT scan abdomen
When is exploratory laparotomy indicated?
Hemodynamically unstable patients with unequivocal FAST results OREmergency U/S or CT scan unavailableUrgent indicated in hemodynamically unstable with positive FAST
So if a patient is hemodynamically unstable how do you manage?
Resuscitation with IV fluids and FAST exam If FAST reveals free intraperitoneal fluid --> urgent laparotomy
What if patient is hemodynamically stable with FAST revealing intraperitoneal fluid?
CT scan of abdomenWill distinguish blood from urine and help quantify amount of blood
How does pelvic fracture present?
Enormous traumaDx: CT scanTx: no surgery, just external fixationAlso go looking for other injuries like urethra, rectum, vagina
What is gateway injury to urethral trauma?
Pelvic fractureHigh riding prostateBloody meatusDon't insert FoleyDx: retrograde urethrogram --> xray of lower GI tract during injection of radiopaque contrast into urethraNormal = contrast entering bladder uninterrupted
What are signs for a pelvic fracture?
Adducted and internally rotated LEPain in lower abdomen and groinBruising along scrotum and perineum
What are people with pelvic fracture at risk for?
Posterior urethral injury (PUI)Upward shifting bladder and prostate can lead to urethral tearing
What findings indicate a PUI?
Blood at urethral meatusInability to voidPerineal or scrotal hematomaHigh riding prostate on DRE
How does an extraperitoneal bladder injury (EPBI) present?
Contusion or rupture of neck of bladder wallYou get extravasation of urine into adjacent tissues --> localized pain in lower abdomen and pelvispelvic fracture is almost always presentgross hematuria usually present and also urinary retention (suprapubic fullness)
What are the different degree of burns?
1st degree --> sunburn (epidermis intact) eythema, warmth, and pain2nd degree --> partial thickness, broken epidermis. Increased pain, presence of blisters3rd degree --> full thickness, through the dermis. Muscle and burn exposed. Burned through skin entirely but no pain. Surrounded by 2nd degree
What is a chemical burn?
Alkali or acid Alkali is WAY worseIf on skin --> never buffer just irrigateIf ingest --> also never buffer or induce emesis, just monitor via serial exams (repeated CXR) and also endoscopy --> so you watch and wait and intervene surgically if something goes wrong
What is respiratory burn?
Gets hot stuff into respiratory tract like in fire or explosionsPeople respond with edema that might close off airwaySigns: stridor, soot at naresMonitor closely --> O2 and peak flowsDeterioration means intubateCan do bronchoscopy to ensure no edema --> if edema --> intubate
How should you manage burn injuries?
Identical to management of traumaManage airway, breathing, circulationHigh risk for respiratory compromise as progressive airway edema can occur --> reason why early intubation is often doneTreat initially with high flow oxygen if you can though
What are electrical burns?
Struck by lightening, touched high voltage wiresEntrance and exit woundCan cause arrythmiaBones can heat up and cause thermal burn of muscle next to them --> causing rhabdoNext step --> get CK level, CrTx: tx rhabdo with mannitol and IV fluidsMight also get posterior dislocation of shoulder via nerve conduction that contracts muscle with a very high force
What is circumferential burn?
Compromises blood supplyDx: is clinical and tx is by removing pressure via cutting the eschar
What is Parkland Formula?
Calculating body surface area to resuscitate these patientsEstimate of how much fluid someone is going to need in first 24 hours after a burn4 x kg x % body surface area burnedGive 50% of calculated fluid in first 8 hours, 50% in next 16 hours
What is the rule of 9's in an adult?
Head= 9%Chest = 18%Back= 18%UE= 18% (Right arm 9%, left arm 9%)LE=36% (Right leg 18%, left leg 18%)
What is the rule of 9's in an pediatric patient?
Head= 18%Chest = 18%Back= 18%UE= 18% (Right arm 9%, left arm 9%)LE=28% (Right leg 14%, left leg 14%)
How do you Tx burns?
Early movementEarly graftingControl PainTopical Abx
What can burns often lead to?
rapid development of intravascular volume depletion and shock due to both fluid loss and massive fluid shift into extracellular space
How do you Tx?
Aggressive fluid rescuscitation Isotonic crystalloids --> normal saline, lactated Ringer --> similar osmolality to blood
Why can burns lead to sepsis?
They disrupt skin barrier and create an avascular, immunologically poor, protein-rich substrate for growth and proliferation of bacteria and fungus
What organisms predominate immediately after a severe burn?
Gram positive (S Aureus)
What organisms predominate more than 5 days after a burn?
Gram negative (Pseudomonas Aeruginosa)
What are signs of burn wound sepsis?
Temperature <36.5 or >39Tachycardia >90/minTachypnea >30Hypotension <90 mmHgCan also lead to oliguria, unexplained hyperglycemia, and mental status changes
How do you Dx?
Quantitative wound culture and biopsy
What is concern with animal bite?
RabiesEspecially wild --> try to capture and kill it and examine brainIf domesticated --> most likely not rabies --> just observe animal
Which spider bites should you be aware of?
Black widow --> Black with red hourglass on bellyCauses abd pain, N/V --> like pancreatitisTx: IV calcium gluconateBrown Recluse --> Southern states (attic & old boxes)Little bit with ulcer that has necrotic center Tx: debride bite with skin graft
What is one of the most dangerous type of animal bites?
Cat bite Long sharp teeth and can inoculate their oral flora deep into skin reaching soft-tissue structuresWorse than dog or human bites
What if there are signs and symptoms of rabies
Give rabies immunoglobulin & vaccine
What do you care about when stung by a bee or wasp?
Anaphylaxis --> low BP and closing airwayTx: IM Epi, histamine blockers, and corticosteroidsIf no anaphylaxis, just remove pincer
Snake bites
Check for slit like eyes, cobra cowl, rattlerIf you don't see snake, use clues from skin changes --> erythema, pain out of proportionTx: antivenom if signs point to venomous bite
What is Tx?
Wound care like copious irrigationLeave wound open Give ABX: Amoxicillin ClavulanateThis covers both Pasteurella Multocida and other anaerobes
When should you receive a tetanus booster?
If last vaccine was > 5 years ago
When is observation and close follow up without using ABX going to be an option?
Human/Dog bites not located on hands, feet, or genitalia
What organism causes cat scratch disease?
Bartonella henselaeUse Azithromycin
Human bites?
Sex or fist fightTx: irrigate, leave open, Amox/clavTetanus if >5 years
Which alcohols do not cause AG?
ethanol & isopropyl (cleaners)Both have osmolar gapEthanol & isopropyl: Tx supportive
What problems can acetaminophen cause?
Drug induced lung injuryCan cause elevation of liver enzymesTx: N-Acetylcystine
Which alcohols cause an anion gap when ingested?
ethylene glycol (antifreeze can cause renal failure) and methanol (moonshine can cause blindness)Both have osmolar gapBoth Tx with Fomepizol
What problems does salicylates cause? (aspirin)
Early on --> tinnitus, N/V, vertigo, resp alkalosis Late: AG acidosis Tx: alkalization of urine
What is a TE fistula?
Combination of atresia and fistulaatresia means blind pouch --> in this case does not connect to stomachMight be a fistula between trachea and esophagus though which will allow access to lungs
How will baby present?
Gurgling & coughing due to connection between food hole and air holeDx: Pass NG tube that will coil that will be seen on XrayTx: SurgeryBut before surgery you need to consider VACTERL syndrome
What is a part of this VACTERL syndrome?
Imperforate Anus2 varieties:Mild form --> most of GI tract is almost up to the imperforate segment Severe: Bowel is very distant from anal openingPatient will present without a puttholeDx: Cross table XrayTx: Surgical --> if mild fix now, if severe let baby growAlso do colostomy and reverse it before toilet training
What is gastroschisis?
Occurs to the right of midlineBowel all over the place without a membraneTx: Silo
What if you have only double bubble sign alone?
Either duodenal atresia or annular pancreasTx: surgery for both
What is necrotizing enterocolitis?
Disease of premature infantsBloody bowel movementSeen on first feeding--> feeding intoleranceDx: Xray --> air in wall of intestine pneumatosis intestinalisTx: Immediate bowel rest , total parenteral nutrition, IV ABXF/U: Surgery
What is omphalocele?
Contained sac of bowel with membranemidlineTx: Silo
What is extrophy of the bladder?
Bladder out in midlineNo bowel hereKey words --> wet, shining, redTx: surgical repair in 1-2 days
What is a congenital diaphragmatic hernia?
Hole in diaphragm --> bowel in chest --> always on LEFTScaphoid AbdomenBowel sounds in chestDx: Xray --> bowel in chestTx: Surgical repair --> usually delayed to allow fetal lung to develop first --> usually intubated
What are the different types of biliary emesis?
Obstruction is distal to where gallbladder biliary tree connects to duodenumDx: XRay --> double bubbleAll cause green emesis
What if you have a double bubble and also gas distally?
MalrotationLife threatening --> can cut off vascular supplyDx: contrast enema or upper GI study which can both TxTx: Surgery to untwist bowl before necrosis
What if you have a double bubble and multiple air fluid levels?
Intestinal Atresia Caused by in utero infarcts --> multiple areas are obstructedUsually when mom uses cocaineTx: Remove areas of intestine that are atretic
What is a meconium plug?
Effectively means cystic fibrosis Patient will present with failure to pass meconium and biliary emesis Dx: Xray --> gas filled plug, Water soluble contrast edema is both diagnostic and TxTx: water soluble contrast enema, Tx cystic fibrosis
What is intussusception?
Age 6-12 monthsHealthy looking kid with episodes of colicky abdominal pain which makes them double up and squat --> lasts 1 minuteCaused by telescoping of bowelsausage shaped mass currant jelly stool
How do you Dx?
Air contrast enema is both diagnostic and therapeutic
What is Hirshsprung's disease?
Failure of inhibitory neurons to migrate to distal colonNo Auerbach Plexus, No myenteric PlexusExplosive diarrhea on digital rectal examSymptom is chronic constipation2 presentations:1. Failure to pass meconium in first 24 hours2. Will reach toddler age and then have trouble with overflow incontinence
What will you see on Xray?
Dilated proximal colon and then a transition point to a normal colon to anusNormal looking colon is the bad one!!
How do you Dx?
If failure to pass meconium --> contrast enemaIf you are toddler --> do anal manometry Best test is Biopsy Tx: surgery
What is pyloric stenosis?
Age 3 weeks - firstborn maleIs a gastric outlet obstructionNon-bilious projectile vomiting --> still hungrypalpable olive-size mass
What is biliary atresia?
Failure to form or early destruction of extrahepatic biliary tree --> can't get rid of CBPresents with direct hyperbilirubinemia at 6-8 weeks oldDx: U/S hows no ducts...phenobarbital HIDA scan is best way to make dxTx: surgery to cut out atretic segment
How do you approach someone with a thyroid nodule?
Determine if it is active (TSH shuts off)If low TSH, low risk noduleGet radioactive iodine uptake --> if hot means its a hyper-functioning nodule --> Tx with methamizole or PTU and then resection
How do you Dx?
U/S --> will show donut signTx: surgery --> pyelomyotomyAlso need to make sure there is no electrolyte abnormalities --> hypochloremic hypokalemic metabolic alkalosis --> give fluids and replace electrolytes
What if the radioactive iodine had shown a non-functioning nodule?
Risk for cancerDo FNA
What is choanal atresia?
Problem with getting air from nose to pharynxTurn blue when feeding, snoring babyDx: catheter fails to passTx: surgery
What if the TSH is elevated or normal?
You know that the nodule is not hyperfunctioningThis is a high risk noduleGet U/S --> looking at size (> 1cm is considered large) --> high risk for cancerget FNAIf < 1cm --> small and observe
What does aldosterone do?
Increases reabsorption of Na+ in collecting duct at expense of K+Done under influence of kidney via Renin
How does Renal Artery Stenosis occur?
Old man --> atherosclerosisYoung woman --> fibromuscular dysplasia Present with HTN and hypokalemiaFlow to kidney is low so body thinks its volume downDx: Aldo: Renin ratio <10 b/c both elevated. U/S doppler, angiogramTx: stent for old man
What happens after FNA?
1. Obvious cancer --> Cut out2. Not cancer --> watch and wait every 6 months3. Not sure --> immediately repeat biopsy
What does a gastrinoma produce?
GastrinStimulates parietal cells to make HClPatient will present with virulent ulcers and diarrheaDx: Gastrin level, if only small elevation also do a secretin test (secretin should turn off parietal cells, should be elevated too)How do you find the cancer --> CT scanTx: cut it out as it can cause a malignant transformation
What is an insulinoma?
Secretes insulinPresent with hypoglycemia even in fastingDx: insulin level, C peptide (increased if coming from own pancreas), sulfoneurea screenCT scanResect
What is a glucagonoma?
migratory necrolitic dermatitisDx: glucagon level (elevated)CT scanResect
What is a left to right shunt caused by?
A holeIncreased blood flow to pulmonary artery --> oxygenated blood --> increased pulmonary arterial pressures --> increase pulmonary arterial resistance --> pulmonary HTNRight heart will hypertrophy and become stronger then left --> leads to Eissenminger syndrome --> will lead to reversal of shunt --> will not become cyanoticAll left sided shunts are non cyanotic --> baby is not blue Consist of ASD, VSD, and PDA
What presents with hypertension and hypokalemia?
Hyperaldosteronism Primary Hyperaldosteronism (Conn Syndrome) --> Dx: Aldo: Renin ratio > 20. F/U with salt suppression test (no suppression of aldosterone)Do CT/MRI, adrenal vein sampling to figure out which gland it isTx: resection
What is ASD?
Hole between 2 atriumsVery minor low pressure low volume shuntFrom LA --> RA --> extra blood in Pulmonary ArteryDx: any age --> Fixed split S2EchocardiogramTx: close hole
What is VSD?
Hole between ventriclesBlood going back into pulmonary arteryAssociated with down syndromePatient present at age <1 year old --> might be asymptomatic and very loud or quiet but very symptomatic (failure to thrive)Dx: echoTx: depends on how bad --> if asymptomatic you can wait 1 year to go away. IF CHF --> surgery
What is PDA
Defect between Pulmonary artery and aorta --> connection persists beyond birthOxygenated blood from aorta going into pulmonary arterySymptomatic in first few days of life --> bounding peripheral pulsesmachine gun murmur
Dx/Tx?
EchoClosure via indomethacin
What are R --> L shunts?
More than just a holeAre accompanied by some sort of catastrophic failureDecreased pulmonary flow --> less blood being oxygenatedBlue cyanotic babiesWill die if not treated
What is tetralogy of fallot?
Endocardial cushion defectAge 5-6 --> bluish hinge to lips and tips of fingersWill have tet spells --> better on squatting --> increases venous return and increase SVR to increase blood flow into pulmonary artery rather than overriding aortaAlso associated with down syndrome
What are the 4 pieces?
1. VSD2. Overriding Aorta3. Pulmonary Stenosis4. RVHSo aorta pushes aside the pulmonary arteryRV pumps deoxygenated blood into aorta and into circulationDeoxygenated also entering pulmonary system --> blood returning into LA is oxygenatedRV hypertrophies
How do you Dx?
CXR showing boot shaped heartTx: surgery
What is transposition of great vessels?
Occurs in moms who have diabetesWill end up with 2 independent systems1. RA --> RV --> aorta --> vena cava (never sees oxygen)2. LA --> LV --> PA --> PV (never sees periphery but remains oxygenated constantly)Only way baby is surviving in womb is via PDA
How does patient present?
Blue baby first dayDies if you do nothingDx: echoTx: surgery & Prostaglandins to keep patent ductus open
What is coarctation of the aorta?
Narrowing of the aorta in the area of the ductus arteriosus --> distal to great vessels so blood easily can go to UEProblem going to LE HTN in UE, hypotension in LEDx: echoTx: surgery
What is aortic stenosis?
Problem with calcificationEssentially atherosclerosis --> present in old men with CAD
Where is it heard best?
2nd ICS, Right sternal borderCrescendo-decrescendoSystolicRadiates to carotids
How do you Dx/Tx?
Dx: EchoTx: Replacement
What is mitral regurgitation?
Due to infection or infarction (papillary muscle ruptures or chordae tendinae ruptures
Where is it heard best?
ApexHolosystolicRadiates to axilla
Dx?
EchoTx: replacement
What is aortic regurgitation?
Infection, infarction, or dissectionAcute presentationDiastolic--> 4th ICS, left sternal borderDecrescendo blowing murmur
What is mitral stenosis?
Rheumatic Heart DiseaseDiastolic at cardiac apexRumbling with opening snap
Dx?
EchoReplacement
Dx?
EchoTx: Medical Tx, Balloon valvotomy, eventually replaced
What is abdominal aortic aneurysm?
Product of atherosclerosis Old guy >65 who is a smokerWill get asymptomatic pulsatile mass or tender mass with back painDx: U/STx: >3.5 is an aneurysm and screen every year>5 or growing at rate >0.5 cm every 6 months --> surgery
How does rupture present?
Acute onset severe back pain, syncope, and hypotension Usually is diameter >3cm at level of renal arteries is DxOnly about 50% of patients survive to reach hospital
Which population should be screened for AAA?
Men age 65-75 with history of smoking
Where will the blood go?
peritoneal cavity or retroperitoneum Requires urgent surgery CT scan only done in stable patientsSurgery or ruptured aneurysm is very high morbidity and mortality
How does dissection present?
Due to HTNTearing chest pain that radiates to backAsymmetric BP arm to armWidened mediastinum
What is a Type A dissection?
Occurs in aorta PRIOR to great vessels
What is Type B dissection?
Occurs after great vessels
What can be a complication of thoracic aortic aneurysm?
Anterior spinal cord syndrome --> due to spinal cord infarctionAbrupt bilateral flaccid paralysis & loss of P&TVibration and proprioception preserved
What presents in a smoker with a small pulsatile mass in right groin area around thigh with thigh pain?
Femoral artery aneurysmThigh pain is due to compression of femoral nerve that runs lateral to arteryIs the second most common peripheral artery aneurysm after popliteal
What makes someone more prone to a dissection?
Marfan's, Syphilis
How do you Dx?
CT angiogramTx: Type A --> operateType B --> treat medically, get BP and HR down via BB's
What is peripheral vascular disease?
Essentially CADRisk factors: HTN, DM, SmokingPresents with leg claudication or when change in position
What can be seen on physical exam?
Shiny shinsLoss of hair, decreased pulses, cooler temps
Dx?
ABI<0.4 is severe0.4-0.8 is moderateU/S with dopplerCT angiogramTx: angioplasty/stenting (above knee) or bypass (below knee)Meds: Cilostosol & pentoxyphyline
If patient has multiple risk factors for atherosclerosis and symptoms of intermittent claudication of LE what is best next step?
ABIratio of resting systolic BP at ankle : systolic brachial BP
What ABI is considered diagnostic?
<.9Occlusive PAD
What is pathology of acute limb ischemia?
Cholesterol embolism after cathEmbolism - a fibThrombus - peripheral vascular disease
How does patient present?
Pulseless, pail, poikolothermia, pain, parasthesias, paralysis
Dx:
U/S doppler, angiogramTx: Embolectomy, tPA
What is amblyopia?
Develop cortical blindness --> occurs only during development (first 6 or 7 years of life)Either through strabismus or cortical cataractsFaced with 2 overlapping images, brain will suppress oneSuppressed eye can become blindNo treatment, just prevent by treating underlying illness
What is strabismus?
Lazy eyeIt is congenital and needs to be treated with surgery by 6 months --> prevent amblyopiaIf child develops this later in infancy --> problem is with refraction and corrective glasses will resolve issue
What are congenital cataracts?
1. Born with it --> TORCH infection2. Developed later --> inborn error of metabolism Will look cloudy/milky white in front of eyeTx: Resection
What presents with cloudy/milky white in back of eye?
Retinoblastoma --> RB geneNo red reflex --> all white retinaTx: Surgical F/U: Osteoblastoma
What is retinopathy of prematurity?
Premature infant with underdeveloped lungs --> give them FiO2This FiO2 can lead to eye issues --> growths on retina Tx: Laser AblationF/U: Bronchopulmonary Dysplasia
What is chemical conjunctivitis?
Silver Nitrate Onset within 24 hours non purulent
What is gonorrhea conjunctivitis?
Bilateral and purulent Td underlying gonorrhea
What is periorbital cellulitis?
Inflammation around eyeNeed to make sure patient can move eye (extraocular muscles intact)If they can --> periorbital cellulitis --> only need ABX
What is orbital cellulitis?
Can't move eyeDx: CT scan --> rule out abscessTx: Drain it and give ABXMedical emergency
What is retinal detachment?
Can be due to trauma like motor vehicle accident or hypertensive crisisComplains of floatersVeil or curtain over eye is severeTx: spot weld laserIf same symptoms but comes and goes --> not retinal detachment but amarosis fugax --> at risk for retinal artery occlusion
What are cataracts?
Caused by age and DiabetesChronic progressive vision lossNight time vision difficulty Dx: White spot on front of eyeTx: Remove cataract
What is a corneal abrasion?
Something getting into eyePain, red, tearyDx: Flouricin DyeTx: lots of irrigation
What is macular degeneration?
Wet (20%) vs Dry (80%)Chronically progressive --> lose central visionWet --> fluid/bloodDry --> Drusen/pigmentTx: Wet --> LaserDry --> nothing
What is retinal artery occlusion
Eye strokePainless acute loss of vision --> unilateralNo other focal neuro deficits cherry red spotTx: treat stroke --> tPACan also press hard on eye to try to shake the clot to a more distal location
What is greatest risk factor for skin cancer?
SunJobs: Navy, ships, outdoor labor (farmer, construction, landscape)Areas: Face, hands, back, shouldersPeople: fair skinned, fair haired
Which skin cancer does not metastasize but locally invades? (50%)
Basal cell carcinoma --> cancer of basal layerpearly lesion --> fails to heal, bleeds easilyDx: Excisional biopsy Punch is wrong answerTx: Face - Mohs surgery, Limb - excisional biopsy is adequate. Limb but aggressive - amputate
What are other features?
Typically form enlarging nodules in sun-exposed areasOften become keratinized or ulcerate with crusting and bleedingCan cause regional neuro symptoms (numbness, paresthesias)Especially common in patients with history of organ transplant and on immunosuppressive therapy
Which skin cancer can metastasize and also locally invades? (25%)
Squamous Cell CarcinomaMalignancy of keratinocytesWell defined red papule or non-healing ulcerLower lip --> most common malignancy of lip and affects lower lip 95% of the timeNO paraneoplastic syndrome
What are risk factors other than sunlight?
Fair skin tone, tobacco use, heavy alcohol use, chronic inflammation, and immunosuppression Prognosis is very good
Who should you suspect SCC in?
Patients with rough, scaly nodule or non healing, painless ulcer that develops in setting of a scar or chronic inflammatory lesionDx: skin biopsy
What are possible features for BCC?
Persistent open sore that bleeds, oozes, or crustsReddish patch Pearly or translucent nodule with pink colorElevated or rolled border with central ulcerationPale scar like area
What is Mohs surgery?
Used most often for face --> sequential removal of thin skin layers with microscopic inspection to confirm that margins have been cleared of malignant tissue
How do you treat low risk lesions on trunk or extremities?
Electrodessication and curettage (EC&D)
How do you Dx & Tx?
Same as BCC
Which cancer has no treatment and has waxing/waning course and needs to be diagnosed early?
MelanomaCancer of melanocytes - metastasizes and locally invadesCan be jet black lesion with no hair or ABCDEAsymmetricIrregular BordersDifferent ColorsDiameter > 5 mmEvolving
Dx & Tx?
Dx: Punch biopsy (large lesions or low suspicion)Excisional biopsy: (small, increased suspicion)Tx: <.5 mm --> excision1-2mm or 2-4 mm --> excision & Sentinal lymph node dissection if tracer is + >4 --> already metastasized so just chemo
What to look for if ABCDE is not met?
Ugly duckling sign --> if multiple pigmented lesions --> a lesion with an appearance that is substantially differentVertical growth --> palpable nodularity Itching or blood If melanoma suspected --> excisional biopsy
What is a subarachnoid hemorrhage?
Product of an aneurysm Usually a product of HTNPatient will present with thunderclap headache --> comes on suddenly Worst of their life
What can be some symptoms?
Headache & neck stiffnessFocal neuro deficits and even coma
How do you Dx?
Non-contrast CT scan of headYou are bleeding in meninges, not the brain itselfIf you confirm dx, also get MR/CT angiogram
How do you Tx?
Within 48 hours -->- control bleeding by keeping BP down-coil/clip-If hydrocephalus --> Serial LPs5-7 days --> -seizures --> prophylaxis-Increased ICP --> Mannitol, elevate head, hyperventilate
What in intraparenchymal hemorrhage?
Product of HTNPresent with focal neuro deficit, headache, N/VDx: CT scanTx: similar to SAH
What percentage of brain cancers are metastatic?
70%Lung, breast, and GI most commonMultiple lesions
What is unique about primary brain tumors?
30%Never metastasizeSingular
How will a patient with a brain tumor present?
Focal neuro deficit SeizureHeadacheN/V
How do you Dx?
MRI preferably with contrast > CT scanBiopsy Tx: Resection, radiation and/or chemoSeizure prophylaxis
What are the pituitary tumors?
Prolactinoma, acromegaly, craniopharyngeoma
What is a craniopharyngioma?
Asymptomatic --> occurs in kidsShort stature, bitemporal hemianopsiaCalcification of SellaYou can resect
What population generally has anterior fossa tumors?
AdultsPosteriors --> peds
What are some posterior fossa tumors?
Medulloblastoma, Ependymoma Both can present with obstructive hydrocephalus
What is a highly malignant tumor that seeds the arachnoid?
Medulloblastoma Spreads --> can get distal lesions in spinal cordTx: Surgery and radiation
What are 2 important tumors in anterior fossa?
Meningioma & Glioblastoma MultiformaMeningioma --> dura. Resect to cureGlioblastoma --> parenchyma (eating brain away)Dismal prognosis of <1 year, ring enhancing lesion, butterfly
Which tumor affects 4th ventricle and causes obstructive hydrocephalus?
Ependymoma Better in fetal position
What problems can you have at the level of the bladder?
Hematuria (nonglomerular)
What problems can you have at the level of the urethra?
Posterior urethral valvesHypo/Epi spadias
What problems can you have at the level of the ureters?
Uretero-pelvic junction obstructionUtetero-vesicular junction obstructionEctopic ureterVesiculo-ureter reflux
What problems can you have at the level of the kidney?
MalignancyWilms tumorHematuria (glomerular)
What do you need to consider in hematuria?
Do U/A to figure out if micro or macroIf micro --> self limiting. CT scan is indicated if there was traumaMacro --> frank hematuria. Do urine micro to investigate. -If RBC casts --> glomerular disease so make Dx with urinalysis and if you need it do kidney biopsy
What if you have normal RBCs and no casts?
Nonglomerular causes --> something with bladder most likelyDo ultrasound. Can do cystoscopy (colonocopy of bladder basically) vs. CT/MRI
what does VCUG (voidingcystourethrogram) show
If there is reflux or noDye is injected into bladder and you are seeing if it goes up into the ureters
What is usually first step here?
U/S --> shows hydronephrosis --> obstruction
What are last steps?
CT scan or cystoscopy --> to see if bleeding is in lumen or on top of kidneyCT scan --> trauma (contrast), stones (nonconstrast)cystoscopy --> intraluminal bleeding
What presents with baby not being able to get urine out of bladder on day 1 due to redundant tissue that causes post obstructive uropathy?
Posterior urethral valvesPatient will have oligohydramnios when getting prenatal care --> amniotic fluid is created by baby's urine and they can't get urine out
What will be the presentation?
No urinary output + distended bladder
What is first step in Dx?
U/S --> will show hydronephrosis. Also get VCUG to rule out refluxTx: catheter, surgery to fix anatomical problem
What is term for urethral opening on wrong area of penis?
Hypo/EpispadiasEpi --> dorsalHypo --> ventralNever circumcise --> will need to reconstruct
What presents with a narrow pelvic junction that causes no issues normally but can cause obstruction when there is increased flow?
Uteropelvic junction obstruction (UPJ)Problem is renal pelvis A problem if a lot of fluid is drunk --> colicky flank pain --> will spontaneously resolveUsually a teenager who has an alcohol binge --> causes increased diuresis
How do you Dx?
U/S --> hydronephrosisVSUG to rule out refluxTx: surgery and maybe a stent
What is an ectopic ureter?
1 good ureter --> goes to bladderthe other is doing whatever it wants --> abnormal one which implants anywhereIn boys --> always implants above sphincter so always asymptomaticIn girls --> normal function but other urether can implant below sphincter so she will be constantly leaking
How do you Dx?
U/S No HydroVSUG --> rule out refluxAlso do radionucleotide scan --> assess renal functionTx: Reimplant ureter
What presents with retrograde flow from bladder back into ureter?
Vesicoureteral refluxPatient is diagnosed via prenatal U/S
How will patient present?
Recurrent UTIs and pyelo
Dx?
U/S which will show hydroVSUG --> + refluxTx: surgery & ABX
What is prostate cancer a product of?
Testosterone --> 5 DHTOld men >70No longer doing asymptomatic screens since it is very manageable Will present with obstructive symptom of BPH
How is it diagnosed?
DRE --> Firm nodular prostateIf + get PSA --> then do biopsy wither transrectal or transurethralTx: resection = radiation Can use anti-androgens like flutamideGnRH analogs like leuprolideIf refractory can also do bilateral orchiectomy F/U with PSA
How do you Dx?
Can do U/SBest test is cystoscopy Tx: transuretheral resection then give BCG or chemoCan do a cystectomy
What is the most common subtype of bladder cancer?
transitional cell cancerAssociated with exposure with beta alanine dyesVery close correlation with smoking (even more than lung)usually presents with painless hematuriaCan also see obstructive symptoms
What is the most common subtype of testicular cancer?
Only germ cellPatients are young (18-35)Painless mass that will not transluminate
Dx?
U/S but don't do FNA biopsy because they are usually never benignJust cut it out asapThen find out what kind of cancer it is and then do chemo if its a seminomanonseminomas --> no chemo but use markers to follow them like AFP, b-HCG,
What is RCC?
Triad --> flank pain, palpable mass, and painless hematuriaonly 10% will present that way thoughMight see erythrocytosis --> paraneoplastic syndromeDx: CTTx: resect
What is the Dx when prostate enlarges and impedes urinary flow by impeding the urethra?
BPHPatient will be >50 with lower urinary tract symptoms like hesitancy, frequency, dribblingDRE --> smooth rubbery prostate
Dx?
U/A and Urine cultureTx: alpha blockers, 5-alpha reductase inhibitors like finasteride but takes longer to work
What causes ED?
Psych or organicInability to maintain erectionStress, vascular issue
Dx?
Night time Tunescense to see if there are nocturnal erectionsIf person breaks tape --> psych issue, need counseling or new partnerIf doesn't break --> its organicCan use PDE5 inhibitors, pumps, prosthesis
What is epididymitis?
Infection of epididymisIf <35 --> its an STD>55 = E coliPatient will have sudden scrotal painTestical in vertical lieTx: ABX
What is it called when testicle twists about its pedicle and compromises its own blood supply?
Testicular TorsionSpontaneous pain, horizontal liePain on elevationDx: U/S with doppler ---> no blood flowEmergency --> ORRegardless of whether blood supply returns --> do bilateral orchipexy where you anchor both down
What is close angle glaucoma?
Caused by pressure after dilation --> when pupil dilates fluid can't leavePresentation: patient enters low light situation that causes pupil to dilateIncreased pressure --> eye pain, headaches, rigid eye ballTx: decrease pressure by constricting pupil (alpha agonists and beta blockers & use laser to make hole) is medical emergencyF/U: never give atropine
What is prostatitis?
Bacterial v inflammatoryOld patient with pyeloDRE --> very tenderTx: never DRE againGet U/A and bacterial cultureTx: ABX
What is developmental dysplasia of the hip?
Occurs in newbornDo ortalani and barlow maneuvers --> will be a click
How will you Dx?
U/STx: put the kid in a Pavlik harness to line up joint and bones for about 6 months
What is Legg-Calve-Perthes disease?
Age 6Insidious onset of antalgic gait due to avascular necrosis of femoral epiphysisDx: xrayTx: cast it
What is slipped capital femoral epiphysis?
Occurs in kids going through growth spurt/fatteenagerIs orthopedic emergency --> complain of knee pain and noted to be limping
How do you Dx?
frog leg xrayTx: surgery to pin femoral head into place
What is a septic hip?
Orthopedic emergency toddler with febrile illness who refuse to move hipFever, leuko, high ESRDx: arthrocentesis --> >50,000 WBCTx: Drain and give ABX
What is transient synovitis?
Any ageHip pain after viral illness Can't bear weightTx: supportive care
What is Osgood-Schlatter disease?
teenage athletesKnee pain and tibial swelling--> aggravated by contraction of quads Tx: stop activity
What is scoliosis?
Deformity of spineteenage girlUsually bent to rightCan lead to dyspnea --> restricts lung expansion
How do you Dx?
Adams test --> have her bend over --> + if one shoulder is higher than the otherTx: slow progression and reverse disease with brace or surgery
What are the 2 ped bone cancers?
Ewing SarcomaOsteogenic sarcoma
What is Ewing?
Translocation 11:22Age 5-15in the midshaft ---> diaphysis of long bonesonion skin appearance
What is osteosarcoma?
most common primary malignant tumor of bone10-25sunburst patternAssociated with retinoblastoma gene
How will both present?
Focal atraumatic bone painDx: Xray, MRI, biopsyTx: resectin
What do you need to consider in fracture of kids?
Heal and better prognosis compared to adultsSpecial places to do surgery are fractures of growth plate and supracondylar fracture of humerus
What causes carpal tunnel syndrome?
Compression of median nerve â> inner ages first 3 digitsInflammatory disorderPain, paresthesias, and eventually paralysis
Dx?
Dx: Phalen sign, Tinnel Sign, Thenar atrophy EMG Tx: Splint, NSAIDS, steroidsSurgery if all fails
What is Jersey finger?
A tear in one of the flexor tendons in the hand when caught in jerseyCan't flex that digit Tx: splinting, NSAIDS, steroidssurgery if fails
What is mallet finger?
Injury by ball that tears extensor tendonCan't extend digitTx: Same
What is Trigger finger?
stenosing tenosynovitisCan't extend â> will cause popTx: same
What is DeQuervain's tenosynovitis?
Thumb pain, tendinitisMom cradling baby or guy lifting lots of weight Dx: Fist, thumb, twist Tx: same, but can't do surgery here
What is Dupuytren's contracture?
Alcohols and Scandinavian menFascia balls up, can't extend fingersPalpable fasciae modules on palmTx: surgical
What is felon?
abscess in pulp of fingertip caused by neglected penetrating injuryPain, fever, leukocytosis Tx: Incision & drainage
What should you do after fracture?
2 Xrays â> perpendicular to each other Symptoms: Pain and swellingTx: Surgery: ORIF (open reduction internal fixation) â> open, angular, and comminuted Or Cast â> needs to be closed wound with close approximation Open skin â> OR emergency for washout
How does anterior shoulder dislocation present?
Any trauma Blow to abducted shoulder & externally rotated armMight have deltoid paresthesias due to axillary nerve and deltoid flatteningGet X-rayTx: Relocate and sling
Which nerve is most commonly injured here?
Axillary --> innervates teres minor and deltoidSensory to lateral shoulder
What is posterior dislocation?
Massive trauma, seizures, lightening strikesabducted but internally rotatedX-ray then relocate and sling
What is Colles fracture?
Old lady who falls on outstretched wrist Will fracture radius and ulna Dorsally displacedDx: x-ray tx: cast or surgery
What is a Monteggia fracture?
Fracture of the proximal third of the ulna with radial dislocationUpward block but downward blow
Dx?
X-raySurgery v cast
What is a Galeazzi fracture?
Distal radius fracture with dorsal dislocation of the distal radioulnar joint from direct blow to the radiusDownward block, upward blow x-ray, surgery vs cast
What is a scaphoid fracture?
usually results from a fall on the outstretched hand of a younger person. Because of a poor vascular supply, it has a high incidence of avascular necrosisPain at snuff box
Dx?
x-ray will be normalCast it anyway â> repeat x-ray will show fracture
What is Boxers fracture?
fracture of the 4th/5th metacarpalPunching a wall
What presents after blunt abdominal trauma most commonly in children resulting in epigastric pain and vomiting 24-36 hours later?
Duodenal hematomaCommon in children due to --> less abdominal adipose tissue, more pliable ribs, thinner abdominal wall musculature Blood collects between submucosal and muscular layers of duodenum --> partial or complete obstruction
Dx?
CT scanTx: resolves in 1-2 weeks. Decompress via nasogastric tube and nutritionSurgery if fails
What presents with RUQ tenderness, intra-peritoneal free fluid, hemodynamic instability, and abnormal blood counts after blunt abdominal trauma?
Liver lacerationEspecially if damage to right 8th and 9th ribsCan also have right shoulder pain due to irritation of phrenic nerve from hemorrhageAssess this with FAST
What presents with Fever, hemodynamic instability, and diminished bowel sounds with possible free air on CXR?
Small Bowel Perforation
What should all trauma patients be evaluated for?
Cardiorespiratory stability Also immobilize the spine until spinal injury is ruled outIf no obvious pelvic injury and blood at urethral meatus --> place urinary catheter to assess for urinary retention and prevent possible bladder injury
What if there is weakness or loss of sensation in extremities?
Suggests spinal cord injuryNeed to get imaging
When is IV atropine indicated?
Symptomatic bradycardia
When is NG tube indicated?
Bowel obstruction, enteral nutrition, and gastric lavage
What do you suspect in a patient with impaired abduction at shoulder after a fall?
Rotator Cuff Tear Rotator Cuff --> tendons of supraspinatus, infraspinatus, teres minor, and subscapularis supraspinatus most commonly injured --> degeneration of tendon with age
How will supraspinatus tear present?
weakness of abduction & external rotation (drop arm test)Age > 40Dx: MRI Tx: Surgery
What presents with subacute shoulder pain on ABDuction and external rotation with aubacromial tenderness and normal ROM with + impingement tests?
Rotator Cuff Tendinopathy Is a result of repetitive activity above shoulder heightImpingement can be demonstrated via Neer testIf untreated --> increased risk of rotator cuff tear
What is characterized by fibrosis and contracture of glenohumeral joint capsule with decreased passive ROM?
Adhesive capsulitis (Frozen Shoulder)
What produces sudden pain with an audible "pop" and visible bulge (Popeye sign) where the biceps muscle retracts into medial arm?
Rupture of tendon of long head of bicepsOccurs in forceful flexion of arm
What can be consequence of a fracture of the surgical neck of humerus?
Axillary nerve injury w/ paralysis of deltoid and teres minorSensory loss over lateral upper armBony tenderness, swelling, ecchymosis, or crepitus over fractureAlthough an abductor, deltoid weakness is best appreciated with extreme extension
Injury to which nerve causes weakness of serratus anterior with impairment in extreme abduction due to inability to rotate scapula upward?
Long thoracic nerveUsually due to penetrating trauma or medical procedures
What is a chronic growth on hard palate that is located on midline suture of hard palate?
Torus Palatius (TP)Benign bony growth More common in young patients, women, and asians Usually present for some time and is not tender and immobile
How are neoplasms of the mouth similar to this?
Not tender either and immobile but they are associated with history of tobacco or chronic alcohol use
What should you suspect in patient from another country with hemoptysis and lung infiltrate in upper lobe?
TuberculosisPut in complete respiratory isolation to avoid further exposure
How do you manage an episode of massive hemoptysis that is >600 mL of blood over 24 hours?
Bronchoscopy --> can localize bleed and provide suctioning ability Greatest danger in massive hemoptysis is asphyxiation due to the airway flooding with blood So establish an adequate patent airway
What can result in acute mesenteric ischemia?
Abrupt arterial occlusion from either:1. Cardiac Embolic Events: Afib, valvular disease, cardiovascular aneurysms 2. Acute thrombosis due to PAD or low CO
What presents with sudden onset SEVERE poorly localized midabdominal pain with N/V?
Acute Mesenteric IschemiaPain out of proportion to examLabs: leukocytosis, elevated hemoglobin, elevated amylase, and metabolic acidosis
What happens if it progresses to bowel infarction?
Focal pain, peritoneal signs, rectal bleeding, and sepsis
What is most likely diagnosis in a patient with abdominal pain after traumatic injury and abdominal xray revealing gas-filled loops of both small and large intestines and gastric dilations?
Paralytic ileusMost common after abdominal surgery but can also be seen in retroperitoneal/abdominal hemorrhage or inflammation, intestinal ischemia, and electrolyte abnormalities
What contributes to ileus?
increased splanchnic nerve sympathetic tone following irritation of peritoneumLocal release of inflammatory mediators, opioid analgesics
What are symptoms of ileus?
N/V, abdominal distension, failure to pass stool or flatus, hypoactive or absent bowel soundsCXR: dilated gas filled loops of bowel without transition pointTx: conservative with bowel rest, supportive care
How is this different from SBO?
Bowel distal to obstruction will not be distendedHyperactive "tinkling" bowel sounds
How does it present?
Severe hypotension, vomiting, abdominal pain, and feverUsually have hyperkalemia and hyponatremia due to mineralcorticoid insufficiency
What can result in acute adrenal insufficiency
Adrenal hemorrhage or acute illness
How should you Tx?
IV hydrocortisone or dexamethasone and aggressive fluid support
Which patients are at high risk?
Patients on long term glucocorticoid therapies who have cushingoid features (central obesity, moon facies)
In what situation does a penile fracture present?
Sudden onset severe pain in penis --> cracking sound with pain and rapid loss of erection during sex
What is mechanism?
Rupture of corpus cavernosum --> traumatic tear in tunica albuginea Tx: surgical
What is imaging used for testicular torsion?
Color doppler ultrasonography
What imaging might be indicated?
Retrograde Urethrogram --> if suspected uretheral injury Indications:-Blood at meatus-Hematuria-Dysuria-Urinary Retention
How does diverticulitis present?
Colonic diverticular inflammation --> LLQ pain, fever, and leukocytosis Can be uncomplicated or complicated
How do you treat uncomplicated?
Outpatient setting --> bowel rest, oral ABX, and observationMight have to hospitalize or give IV ABX if elderly, immunosuppressed, high fever, or leukocytosis
How is complicated diverticulitis treated?
Diverticulitis associated with an abscess --> perforation, obstruction, or fistula formationIf fluid collection >3cm --> treat with CT guided percutaneous drainage
Which patients are at high risk for aortic injury?
Rapid deceleration blunt chest traumaThere are no clinical findings specific for this but hypotension and evidence of external evidence of trauma with AMS is a indicator
What are most common reasons for aortic injury?
MVA and falls from >10 feetDx: Mediastinal widening most sensitive Deviation of trachea to right or depression of left mainstem bronchus also seen
What can indicate esophageal rupture?
pneumomediastinum and pleural effusion
How can it present?
widened mediastinumLarge left sided hemothorax, deviation of mediastinum to right and disruption of normal aortic contour
What are causes of terminal hematuria (blood at end of urinary stream)?
Suggests bleeding from prostate, bladder neck, or posterior urethraUrothelial cancerCystitisUrolithiasisBPHProstate Cancer
What can be causes for hematuria THROUGHOUT urinary stream?
Renal MassGlomerulonephritisUrolithiasisPolycystic Kidney DiseasePyelonephritisUrothelial CancerTrauma
What can suggest bleeding from bladder?
Terminal hematuriaClots on urineCan suggest urothelial cancer if risk factors of age >40, male, and history of smoking is presentDx: cystoscopy
What presents with abdominal/flank pain with microscopic or gross total hematuria along with occasional bulky mass on abdominal exam?
Polycystic Kidney DiseaseLeading heritable cause of renal disease in adults
What suggests urethral damage?
Initial hematuria
What is the first thing to do when patient has a cervical spine injury after fall?
Stabilize cervical spine and spine with backboard, rigid cervical collar, and lateral head supports Then assess airway --> cervical spine injuries can be associated with oral maxillofacial trauma, hemorrhage in retropharyngeal space, and significant airway and neck edema
What can be a possible complication of abdominal aortic aneurysm repair?
Bowel ischemia Due to inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of inferior mesenteric artery during aortic graft placement
How will the patient present?
Abdominal pain and bloody diarrheaFever and leukocytosis
What is the result when there is severe valgus stress (blow t lateral knee) or twisting?
Medial Collateral Ligament TearMay get local swelling, ecchymosis, and joint line tenderness at medial knee Dx: Appreciable laxity when leg is forced into abduction (valgus stress test)
Tx?
MRI is most sensitive for this but generally used if surgery is indicated Can be managed nonoperatively with RICE
What is the Glasgow Coma Scale?
Estimates severity of patient's neurological injury for triage.Is used to predict prognosis of coma, bacterial meningitis, traumatic brain injury, and subarachnoid hemorrhageMonitors ability to open eyes, motor response, and verbal responseNOT used to diagnose coma though
What is capillary refill a marker of?
Peripheral perfusion Normal is 3 secondsCan be delayed in hypotension and volume depletion
What presents with exaggerated DTRs, total paralysis of limbs, inability to speak but retained cognition and alertness and can only communicate with their eyes?
Locked-in SyndromeMimics coma but due to ischemic or hemorrhagic stroke of brainstem area
What should you suspect in a patient post CABG that has decreased BP, flat neck veins, and tender right groin at the puncture site that is improved with 1000mL of saline?
Retroperitoneal hematoma with bleeding at arterial access siteThis usually occurs within 12 hours of catheterizationPresents with localized discomfort/swelling at soft tissue, hemodynamic instability, ipsilateral flank/back pain
Dx:
CT scan w/o contrast
Tx?
Supportive with bed rest, intensive monitoring, and IV Fluids
In a patient with hypovolemia (flat neck veins), abdominal trauma (bruising, distension), and poor organ perfusion what is most likely reason?
Hypovolemic shock due to internal hemorrhageDecreased venous return to RA --> decreased CO
In a patient like this, what can positive pressure mechanical ventilation after intubation lead to?
Collapsed venous capacitance vessels & cut off venous return --> sudden loss of RV preloadCan lead to cardiac arrest This is due to acute increase in intrathoracic pressure !!!
What would you suspect in a patient with complain of hip pain when sleeping on affected side with pain localized to outer surface of thigh?
Trochanteric bursitisInflammation of bursa surrounding insertion of gluteus medius onto femur's greater trochanter Excessive frictional forces secondary to overuse, trauma, joint crystals, or infection are responsible
What presents with bone turnover that in accelerated in localized areas that leads to bone hypertrophy?
Paget's Disease of the BoneAffected bone is weak and prone to pathological fractures
What presents with Fever, RUQ pain, and gas in gallbladder wall?
Emphysematous cholecystitis --> life threatening form of acute cholecystitis Due to infection with gas forming bacteria --> clostridiumYou will have crepitus in abdominal wall adjacent to gallbaldder
What is Dx?
Imaging that demonstrates air-fluid levels in gallbladderTx: emergency cholecystectomy and broad spectrum ABX
What presents with intestinal obstruction due to a gallstone that has passed through a biliary-enteric fistula?
Gallstone ileusImaging --> pneumobilia and evidence of intestinal obstruction
What presents with stuttering episodes of N/V with pneumobilia (air in biliary tree), hyperactive bowel sounds, and dilated loops of bowel?
Gallstone IleusForm of mechanical small bowel obstructionOccurs when gallstone passes through a biliary-enteric fistula and into small bowel --> goes to ileocecal valveCan cause intermittent tumbling obstruction with diffuse abdominal pain and vomiting until it finally lodges in ileum Dx: CT scanTx: surgery to remove stone
What is associated with free air under the diaphragm?
PUD perforation
What is a Primary Spontaneous Pneumothorax?
Patients with no Hx of lung disease --> usually tall, thin men in early 20sOccurs due to rupture of subpleural blebsCommonly occurs at rest
How does patient present?
Dyspnea, hypoxemia, reduced chest excursion, reduced breath sounds on affected sideHyper-resonance to percussion
How do you Tx a small pneumothoraces?
If stable patient --> Obs and supplemental O2Stable but large pneumo --> decompression with large bore needle inserted in 2nd or 3rd ICSIF hemodynamically unstable --> emergent placement of a tube thoracostomy
What is the most common type of elbow fracture in children?
Supracondylar fracture of humerus Can cause posterior displacement of distal humerus fragmentMedian nerve and brachial artery can become entrapped by displaced bone
How can you monitor distal perfusion?
Brachial and radial artery pulsesTx: immobilization and analgesia
What kind of fracture can occur after repeated tension or compression without adequate rest and most commonly occurs in athletes or military recruits who suddenly increase their activity?
Nondisplaced stress fracture 2nd metarsal of foot is most commonly involved if it occurs in the footCan be managed conservatively with rest and simple analgesics because other surrounding metatarsals act as splints so nonunion is uncommon
What if fracture is of the 5th metatarsal?
Increased risk of non unionYou want to do more aggressive treatment with casting or internal fixation
What are more specifics about a stress fracture?
Especially common in women who have low caloric intake and hypomenorrhea/amenorrhea Can also be due to improper footwear, bio mechanical abnormalities, inadequate calcium/vitamin Dlocalized activity related pain, swelling, and point tenderness on palpation
What do you usually see on imaging?
Xrays usually NEGATIVE
What else can cause anterior leg pain that resembles a stress fracture?
Medial Tibial Stress Syndrome (Shin Splints)Diffuse area of tenderness not pointMore common in overweight individuals
What is the preffered way to establish airway?
Orotracheal intubation with rapid sequence intubation
What are signs of septic shock?
Fever, tachycardia, hypotension, and poor urine output
What are the goals of managing septic shock after securing airway?
Restoring adequate tissue perfusionIV 0.9% saline (crystalloid) --> used to improve systolic BP >90 mmHg (at which perfusion is considered adequate)Identifying underlying infection
What are indications to start urgent hemodialysis?
Uncompensated metabolic acidosisElectrolyte abnormalitiesUremiaVolume overload
What results in enlargement of central canal of spinal cord due to CSF retention that results in impaired strength and P/T sensation in UE?
Syringomyelia Whiplash is often inciting incident
What is a possible complication of cardiac surgery that presents with post-op fever, tachy, chest pain, leukocytosis, and sternal wound drainage/purulent discharge?
Acute Mediastinitis Due to intraoperative wound contamination
What will you see on CXR?
widened mediastinumDx: confirmed during surgery when pus is noted in mediastinum --> requires drainage , surgical debridement with immediate closure, and prolonged ABX
What is the mortality rate of mediastinitis?
10-50% even with appropriate Tx
What is a common complication within a few days of CABG that resolves in <24 hours/self-limited?
Atrial Fib
How should you handle an amputated body part?
Wrap in sterile gauze that is moistened with sterile saline and place in plastic bag and place on iceDon't let it freezeIncreases viability of amputated part for 24 hours
What presents after acute stressors and results in recurrent episodes of mild jaundice (scleral icterus) due to decreased activity of UDP-glucuronosyltransferase?
Gilbert SyndromeElevated unconjugated bilirubin with normal liver function testBENIGN condition
What presents with excruciating pain that is worsening on passive range of motion and presents with paresthesia from sensory nerve ischemia early and neuro deficits like sensory loss and motor weakness later?
Compartment SyndromeCaused by direct trauma or prolonged compression of an extremity or after revascularization of an acutely ischemic limb
How do you Dx?
Measuring compartment pressure in affected extremity Time to fasciotomy is most ciritical prognostic indicator and should be performed ASAP
What is acute compartment syndrome?
Excessive fluid accumulation in confined compartment of body part --> increase in pressure to the point where blood flow is severely impairedPain out of proportionTissue tension, pallor, and decreased sensation may also be presentIf not corrected, tissue ischemia and death will eventually occur
What can a circumferential, full thickness (3rd degree burn) lead to?
Constriction of venous and lymphatic drainage resulting in distal compartment syndrome
What presents with burning epigastric pain that is relieved by food?
Duodenal UlcerPain when lack of food buffer for acid secretion
What presents with a mediastinal mass with elevated AFP and B-HCG?
nonseminomatous germ cell tumor
What lab values are elevated in a seminomatous germ cell tumor?
Elevated B-HCGNormal AFP
What symptoms can indicate blunt genitourinary trauma?
Costovertebral pain and hematuriaDo a focused GU exam in addition to eval of abdomen and thoraxGet U/A and in patient with hematuria get a contrast enhanced CT of abdomen/pelvis to stage renal trauma
What condition is most commonly seen in severely ill patients that occurs due to cholestasis and gallbladder ischemia that leads to a secondary infection with resultant edema and necrosis of gallbladder?
Acalculous cholecystitis Gallbladder wall thickens and has distention with presence of pericholecystic fluidCan lead to sepsis and death if undetected
How do you Tx?
ABX followed by percutaneous cholecystostomy --> drainage of any associated abscesses
What can occur secondarily after previous breast cancer therapy that presents with skin lesion on arm?
Angiosarcoma --> rare malignant tumor of internal lining of blood vessels or lymphatic vesselsA major risk factor is radiation therapyLymph node resection is also a risk factor
How do people with this secondary angiosarcoma present?
multiple ecchymoses/purpuric masses on skin of breast, axilla, or upper arm 4-8 years after completion of breast cancer therapyThere can be metsGenerally poor prognosis
What can result from twisting force on fixed foot followed by a popping sound with acute pain that can result in reduced extension, instability, and knee effusion?
Tear of medial meniscusTenderness at joint line
Which injury results from forceful hyperextension of knee of noncontact torsional injury during deceleration?
ACL tearThere will be a pop, immediate knee pain and swellingAnterior laxity Dx: Lachman and Anterior drawer sign
What are the diagnostic tests?
Thessaly test McMurray testPalpable locking or catching when joint is rotated or extended while under loadUse MRI
What is the most sensitive test?
Lachman
How do you manage?
Older patients --> mild symptoms RICEYounger patients --> persistent symptoms --> surgery
What presents similar to meniscus tear but has no catching during extension or rotation?
MCL tearDx: valgus stress test
What are the most common malignancies in young men?
Testicular cancer, lymphoma, or leukemia
How can testicular cancer present?
Painless massBut minority of patients can have symptoms of mets --> retroperitoneal lymphadenopathy that can compress adjacent structures leading to lumbar back painMets to liver and lungsIf testicular mass is present do a scrotal U/S
What is ischemic colitis?
Acute abdominal pain, Lower GI bleed, and hypotensionFever, nausea, elevated lactic acid, & leukocytosis may also be present Is watershed ischemia that commonly involves splenic flexure & rectosigmoid junction
What can be a cause of this?
A vascular procedure like AAA repair
What can be seen on colonoscopy?
Segments of cyanotic mucosa and hemorrhagic ulcerations with sharp transition from affected to unaffected mucosa
What will you see on CT?
Thickened Bowel wallEdema and air in bowel wallColonoscopy: pale mucosa with petechia bleeding, bluish hemorrhagic nodulesTx: If colon resection not needed â> IV fluid & ABX
What presents with bilateral lower extremity edema and stasis dermatitis
Venous valvular incompetence --> results in pooling of venous blood Erythrocyte extravasation causes hemosiderin deposition and classic coloration of stasis dermatitis --> microvascular disease and ulceration
What is a sign of venous valve incompetence?
Unilateral LE edemaworsens when leg is moving, better on elevationThis is the most common cause of LE edemaAllows blood to pool --> increase in capillary hydrostatic pressure --> increased fluid into interstitial tissue
What is a synovial sac that alleviates friction at bony prominences and ligamentous attachments?
Bursa --> vulnerable to acute injury and chronic repetitive pressure and can even become inflamed due to infectionDue to them being in exposed positions --> pain and tenderness of bursitis may be exquisite Active ROM is decreased and painfulPassive ROM is normal
What condition is common in occupations requiring repetitive kneeling like concrete work, carpet laying, and plumbing?
Prepatellar Bursitis Acute pain and localized tendinitisOften due to S Aureus --> can infect bursa via penetrating trauma, repetitive friction, and extension from local cellulitisPatients usually treated with drainage and ABX
What presents with episodic pain and tenderness at the inferior patella and patellar tendon?
Patellar Tendonitis Usually seen in athletes
What are hard signs of extremity vascular trauma?
Pulsatile bleedingBruit/thrill over injuryExpanding hematomaSigns of distal ischemia
What are soft signs?
History of hemorrhageDiminished pulsesBony injuryNeuro abnormalities
What should you do if hard signs are present?
Immediate surgical explorationIf soft signs, do further testing like injured extremity index or CT scan
What presents with tenderness at anatomic snuff box which carries a significant risk of osteonecrosis because of blood supply that enters the distal pole and flows proximally?
Scaphoid fractureInitial x-rays can be normal --> so if suspected use CT scan or MRI to confirm Dx
How do you Tx?
Displaced fracture --> surgeryNondisplaced fracture --> wrist immobilization with cast
What 3 compartments of the brain influence intracranal pressure (ICP)?
Brain parenchymaCSFCerebral Blood Flow (CBF)
How can you change CBF in certain conditions when ICP is too high?
paCO2 is a potent regulator as paCO2 rises, so does blood flow so lowering paCO2 through hyperventilation results in vasoconstriction and a decreased in ICP in brain
What cranial nerve separates the 2 parotid glands and might need to be removed when dissecting a tumor of the parotid gland?
Facial nerveCan lead to unilateral facial droop
What presents with fever, hypotension, erythema, and swelling and pain that is out of proportion to exam?
Nec FascCT scan will show air in deep tissueIs a rapidly spreading infection that involves the subcutaneous fascia after trauma Group A strep is most commonGas production by microbes leads to air in soft tissues --> crepitus on exam
What happens if left untreated?
Rapid discoloration of affected side, purulent discharge, bullae, and necrosisTx: broad spectrum ABX and resection of necrotic tissue
What is an abscess?
Skin and soft tissue infections that are successfully limited by immune system and tissue barriers
What can be a complication after a knee arthroplasty?
Prosthetic Joint Infection (PJI) Leukocyte count usually elevated to >1000 but <50,000
What is infection is due to a virulent organism?
S Aureus, P. AeruginosaPresents within first 3 months after surgeryAcute pain, fever, leukocytosis, local signs of infection
What if infection is due to a less virulent organism?
Coagulase negative staph, Staph epidermidis Is delayed onset (3-12 months) --> presents with chronic pain, implant loosening, gait impairment, sinus tract formationUsually no fever or leukocytosis
How does a necrotizing surgical infection present?
Pain, edma, erythema that spreads beyond surgical siteSystemic signs like fever, hypotension, and tachyPurulent cloudy drainage (dishwater drainage)
What kind of patients are more susceptible to necrotizing infection?
Patients with diabetes Are usually polymicrobial
What if these infections involve fascial plane?
Emergencies --> develop ino necrotizing fasciitisNeed to do early surgical exploration to assess extent and do debridement along with ABX
When is surgical debridement required?
When infection penetrates deeper skin layers and adjacent tissue
What presents with fever, sore throat with difficulty swallowing, Trismus (spasm of jaw muscles), muffled hot potato voice, and swelling of peritonsillar tissues with deviation of uvula to CONTRALATERAL side?
Peritonsillar AbscessTx: needle aspiration or I & D + ABX
What presents with tonsillar erythema and exudates with tender anterior cervical nodes and palatal petechiae?
Uncomplicated tonsillitis
What population is more likely to get this NPC?
People from southern china --> due to diet (salt-cured foods, early exposure to salted fish) & genetic predisposition
How does it present?
Obstructs nasopharynx and invades adjacent tissue --> nasal congestion with epistaxisHeadaches, cranial nerve palsies, otitis mediaEarly mets to cervical lymph nodes
What presents with neck pain, odynophagia, and fever following penetrating trauma to to posterior pharynx?
Retropharyngeal abscessInfection can drain into superior mediastinum and into "danger space" which can result in acute necrotizing mediastinitis
What cancer is Aflatoxin B1 associated with?
Hepatocellular Carcinoma
What can be a complication of thyroidectomy?
HypoparathyroidismWill lead to hypocalcemiaNonspecific symptoms --> fatigue, anxiety, and depressionSevere --> tetany involving lips, face, and extremities. Even seizuresQT prolongation
What presents with tortuous dilation of pampiniform plexus of veins surrounding spermatic cord and testis?
VaricocelePresents as a soft, irregular massIncreases in size with standing and valsalvaElevated scrotal temp, increase risk for infertility and testicular atrophy
Which side are varicoceles more common on?
left sideDue to left spermatic vein draining into left renal vein which is vulnerable to compression when it passes beneath SMA
What is a fluid filled cyst of head of epididymis that presents as painless mass at superior pole of testes?
spermatocele
What are peritoneal fluid filled collections between parietal and visceral layers of tunica vaginalis?
HydrocelesUsually asymptomatic but may present with painless scrotal swellingtransluminate
What is a central venous catheter used for?
Administration of critical care medications Preferred points are internal jugular vein and subclavian *Do portable chest xray after placement to make sure it is properly placed
What are complications of inappropriate catheter placement?
Venous perforationLung puncture --> pneumothorax
What presents with acute onset severe abdominal pain, fever, tachy, and signs of peritonitis?
Peptic ulcer perforationPeritonitis --> Guarding, rigidity, reduced bowel sounds, rebound tenderness
How do you Dx?
Upright x-ray of chest and abdomen --> will show free intraperitoneal air under diaphragm
What is a common complication after a gastrectomy that presents with GI symptoms (N/V, diarrhea, abdominal cramps) and vasomotor symptoms (palpitations, sweating)?
Dumping syndromeLoss of normal action of pyloric sphincter --> rapid emptying of contents into duodenum Pain and symptoms occur 15-30 minutes after meals
How do you manage?
Dietary modificationsFrequent, small mealsIncrease fiber
What is a fever immediately after surgery due to (within few hours)?
Prior infection or trauma, inflammation due to surgery, malignant hyperthermia, medications, blood products
What presents with fever, leukocytosis, and parotid inflammation with painful swelling of parotid glands that is aggravated by chewing shorty after surgery?
Acute bacterial parotitisMost prone: dehydrated & post-operative patientsTender, swollen and erythematous gland with purulent saliva from parotid ductUsually caused by staph aureus
How can you prevent this?
Adequate fluids & oral hygiene both pre and post op
What is enough for a diagnosis of solid testicular mass?
Painless hard mass in testicle + suggestive U/S
How do you address this?
Removal of testis and its associated cord (orchiectomy)Then testis and abnormal tissue present is examined under microscope to determine cancer typeAdditional surgery, radiation, or chemo might be indicated
Why is his method unique?
Tumor that we kill first and investigate laterBiopsies are done after resection
How can a rupture ovarian cyst present?
With hemiperitoneumPatients who are on anticoagulation can bleed intra-abdominally and become hemodynamically unstableLower quadrant tenderness with hemiperitoneum, diffuse abdominal rigidity with rebound and guarding
Which tumors are benign and undergo calcification and can lead to expanding intracranial neoplasm that can present with headache, seizure, and focal neuro deficits due to mass effect?
MeningiomasMore commonly found in middle age to elderly womenTreatment of choice is complete resection
What can present with severe, constant anal pain and low grade fever along with an indurated, erythematous mass near the anal orifice?
Perianal abscess Due to occlusion of anal crypt glandIf untreated --> can lead to anorectal fistulae
What are risk factors for this?
Anoreceptive intercourseConstipation
If there is subdiaphragmatic free air on xray what should patient immediately get?
Emergent laparotomy
If same patient is on warfarin what do you need to do?
Discontinue ASAP and give FFPB/c this will predispose patient to intraoperative and post-operative bleeding FFP is most rapid, Vitamin K too slow for emergent procedures
What can present after a noncardiac surgery with symptoms of low O2 sat, dyspnea, hypotension, and bilateral crackles?
Cardiogenic shock due to acute MICan lack chest pain due to postoperative pain controlSignificant infarction of LV --> impaired contractility and decrease in LV stroke volume Increased pressure in LV --> transmitted to lungs --> increase PCWPPulmonary edema --> dyspnea and hypoxemia with cracklesDecreased CO = hypotension
What can present with symptoms of gastric outlet obstruction that includes postprandial pain and vomiting of partially digested food with early satiety with history of acid ingestion?
Pyloric stricturesCan see abdominal succussion splash on PE --> retained gastric material for >3 hours after a meal generates a splash sound
How should you initially manage chronic joint pain and stiffness that is consistent with osteoarthritis of knee?
Lifestyle measures like weight loss and regular moderate activity You need to strengthen the quadriceps muscles to improve function and take pressure off knee
What about giving injections of glucocorticoids?
Usually no long term benefits and generally only recommended when noninvasive measures fail
How does Leriche syndrome present? (aortoiliac occlusion)
arterial occlusion at bifurcation of aorta into common iliac arteriesClassic triad:1. Bilateral hip, thigh, and buttock claudication2. Diminshed femoral pulses3. ImpotencePredisposition --> Men who have atherosclerosis and smoke
Is ankle swelling a finding of arterial occlusive disease?
NO --> more common in venous insufficiency
If there is blunt chest trauma what should be first diagnostic study?
CXRif it reveals pneumothorax and pneumomediastinum --> most likely tracheobronchial perforationDx: CT, bronchoscopy, or surgical explorationTx: Operative repair
If you have a whistling noise during respiration after a rhinoplasty, what is the most likely Dx?
Septal perforationMostly because septum has poor blood supply
Who tend to get nasal polyps?
Asthmatics and allergic disorders Can cause chronic nasal obstruction and should be surgically removed
What presents with gingival bleeding & recession, cutaneous findings like petechia, follicular hemorrhage, and impaired wound healing?
Scurvy --> Vitamin C deficiencyMost cases arise in setting of malnutrition --> frequently alcoholicsUsually occurs within 3 months
What follows a fall on an outstretched arm or direct blow to shoulder?
Clavicular fracture to middle third of boneUsually is supported by the other hand Shoulder on affected side is usually displaced both inferiorly and posteriorly
What do you do if you hear a bruit below clavicle?
Do a careful neurovascular exam due to its proximity to subclavian artery and brachial plexusTx: Non-operative with brace, rest, and ice
How does patellar dislocation usually occur?
Quick, lateral movements on a flexed kneeMight be a popping noise and severe painlateral displacement associated with tear of medial patellofemoral ligament
What will you see on examination?
Flexed knee with reduced ROMLateral displacement of patella Often reduces spontaneously
What presents in a patient with history of skin infection who presents with fever and abdominal pain that radiates to groin?
Psoas AbscessCan occur from hematologic seeding from distant infection or direct extension of intraabdominal infectionDeep abdominal palpation is required to elicit tenderness
What is the "psoas sign" that can sometimes be elicited for this condition?
Abdominal pain with hip extensionDx: CT scanTx: Drainage & ABX
Which nerve supplies muscles of posterior compartment of thigh, leg, and plantar muscles of foot?
Tibial NerveControl flexion of knee and digits and planterflexion of foot
Which nerve innervates medial compartment of thigh and controls ABDuction along with sensation over medial thigh?
Obturator Nerve
What muscles comprise the quads?
Rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
When can there be sudden, forceful contraction of the quads?
Deceleration from a fall or certain athletic activities
What are characteristics of a quad tear?
Patella rides low with palpable defect above patellaLarge knee effusion, audible pop, rapid swelling, inability to actively extend knee against gravity
How does a patellar tendon tear present?
patella rides highPalpable defect below patella
How does succinylcholine work?
Is depolarizing agent that works by binding to postsynaptic ACh receptors to trigger influx of sodium and efflux of potassium Causes temporary paralysis Rapid onset (45-60 seconds) & offset (6-10 minutes)
What can be a side effect?
Cardiac arrhythmia due to severe hyperkalemia
What is the most important first step in hematemesis in setting of a history of PUD and alcoholic cirrhosis?
At risk for rapid, life threatening upper GI bleeding Prompt fluid resuscitation is 1st stepAll patients with acute hemorrhage need vascular access with at least 2 large bore IV linesOnce patient is stable --> do upper endoscopy to identify and control source of hemorrhage
What presents with new onset diarrhea, fever, elevated WBC, recent ABX use, and mild abdominal tenderness?
C. difficile colitis More common in patients with recent hospitalization, advanced age, or ABX useDx: stool studies for toxin
What presents with subacute pain over midline sacrococcygeal with mucoid and bloody drainage?
Pilonidal DiseaseAffects ages 15-30 --> young, obese males with sedentary lifestylespainful, fluctuant mass 4-5cm cephalad to anus in intergluteal regionHas mucoid, purulent, or bloody discharge
What is cause of this?
When edematous, infected hair follicle in intergluteal region becomes occluded
How does retinal detachment present?
Retina pulls away from posterior portion of inner globePAINLESSBright flashes of lightShowers of floaters in affected eyeEventual progression to vision loss --> curtain being pulled over affected eye
What causes abrupt vision loss due to atherosclerotic embolus?
Central retinal artery occlusionOcular emergencyPainless, acute, unilateral vision lossRed lesion surrounded by pale retina
What is another ocular emergency that causes sudden loss of vision due to obstructed venous outflow which causes blood to leak out and obscure macula?
Central Retinal Vein Occlusion
Which injury typically develops in athletes that increase level of activity like for marathon that causes a popping sound and pain at superior heel?
Achilles tendon tear
Which test can confirm diagnosis?
Thompson testLack of plantarflexion when gastrocnemius is squeezed
When should you use an IVC filter to treat DVT?
When anticoagulation is absolutely contraindicatedIntracranial bleeding (stroke), recent surgery, active bleedingOr if failure of anticoagulation
What presents with painless, snapping, catching, or locking of one or more fingers during flexion of the affected digit?
Stenosing Flexor Tenosynovitis (Trigger Finger)Affects patients >45 yearsMore common in diabeticsFinger can usually become locked in flexed positionTender painful nodule
What is the name of carpal spasm that occurs during inflation of a blood pressure cuff above systolic pressure?
Trousseau Sign
What is name of twitching in face that begins after tapping facial nerve 2 cm anterior to the trigs of the ear?
Chvostek's sign
What presents with acute hepatic vein thrombosis that can result in centrilobular congestion and necrosis?
Budd Chiari Syndrome Rapidly progressive hepatomegaly, juandice, fever, severe RUQ pain, and abdominal distension, LE edema, and eventual liver failure
What is this associated with?
Hypercoagulable states, pregnancy, HCC, and polycythemia vera
What is the most important thing to monitor when giving fluid in burn patients?
Urine outputGoal is .5 mL/kg/hour so about 25ml in someone who is 50kgFluid intake should be adjusted to match this outputCare should be taken not to give excess IV fluid beyond what is needed because this can exacerbate pulmonary edema
How does sigmoid volvulus present?
Abdominal pain, N/V, constipationTwisting of the sigmoid colon on its mesentery causing large bowel obstruction and possible vascular compromiseOccurs in age 70
What is Graves disease?
Syndrome of hyperthyroidism, goiter, orbitopathy, and dermopathyCaused by autoantibodies to TSH receptor
How can amiodarone cause hyperthyroidism?
Structurally similar to T4 --> iodine rich compound
Why do you give a patient iodine?
It can prevent release of thyroid hormoneBut need to give at least 1 hour after the administration of drugs like PTU to make sure the iodine will not be used to make new thyroid hormone
What range should INR be maintained?
2-3INR > 3 can delay surgery due to increased risk of bleeding --> patient will get FFP or Vitamin K
What presents with scrotal swelling in pediatric patients with pain and blue mass on testicle
Torsion of testicular appendageCan result in ischemia and necrosis --> blue mass represents infarcted appendageBut this is a BENIGN condition that resolves with rest, NSAIDS, and scrotal support
How does Crohn's disease present?
Any location in GI tractSymptoms --> mouth sores, melena, or hematocheziaAbdominal pain, loss of bowel movementsFistulas, granulomas, skip lesions, cobblestoning
What presents with a well defined, mobile breast mass on PE with a well defined solid mass on US in a women age 15-35
Fibroadenoma --> benign solid tumorManaged with core needle biopsy or short term F/U in 3-6 months
When is fine needle aspiration indicated? (FNA)
When a mass is fluid filledA solid mass needs a core needle biopsy
Who benefits from carotid endarterectomy?
70-99% stenosisIf 100% stenosis, no benefit
What is a Le Fort I fracture?
Result of a direct facial blowInvolves only the maxilla at the level of nasal fossaCT of face is required for dx
What is Le Fort II fracture?
Maxilla, nasal bones, and medial aspects of orbits
What is a Le Fort III fracture?
Cause craniofacial disjunction in which the entire facial skeleton is completely detached from the base of the skull and suspended only by soft tissues.