1 Surgery Flashcards
1
Q
What signs differentiate pericardial tamponade from tension pneumothorax?
A
In pericardial tamponade there is no respiratory distress. In tension pneumothorax there is severe respiratory distress, one side of the chest has no breath sounds and is hyperresonant to percussion, and there is tracheal deviation.
2
Q
What is the initial treatment of hypovolemic shock?
A
Volume replacement with 2 L of Ringer lactate (without dextrose), and followed by PRBCs until urinary output 0.5–2 ml/kg/h, while not exceeding CVP of 15 mm Hg.
3
Q
What is the management of pericardial tamponade?
A
Evacuation of the pericardial sac by pericardiocentesis, tube, pericardial window, or open thoracotomy. Fluid and blood administration. The diagnosis is clinical (if diagnosis is unclear sonogram may be used).
4
Q
What are the signs of cardiogenic shock?
A
Hypotension with high CVP (distended veins). Cardiogenic shock is caused by massive myocardial damage (myocardial infarction or myocarditis). Treat with circulatory support.
5
Q
What are the signs of vasomotor shock?
A
Vasomotor shock is seen in anaphylactic reactions and high spinal cord transection or high spinal anesthetic. Circulatory collapse in a flushed, pink and warm” patient. CVP is low (flat veins). Treatment is fluids vasoconstrictors.”
6
Q
What is the treatment of linear skull fractures?
A
Linear skull fractures are not treated if closed. Open fractures require wound closure. Operative treatment is required if the fracture is comminuted or depressed.
7
Q
What is the treatment of head trauma with unconsciousness?
A
Head trauma with unconsciousness requires a CT for intracranial hematomas. If negative and no neurologic deficits, patients can go home if family will wake them up frequently during next 24 h.
8
Q
What are the signs of a fracture affecting the base of the skull?
A
Raccoon, eyes, rhinorrhea, otorrhea or ecchymosis behind ear. Cervical spine should be assessed with a CT. If the patient was unconscious, a CT of head is ordered to rule out intracranial bleeding.
9
Q
What factors cause neurologic damage from trauma?
A
The initial blow, subsequent development of a hematoma that displaces the midline structures, and development of increased intracranial pressure. Surgery can relieve hematoma, and medical measures can prevent increased ICP.
10
Q
What is the presentation of acute epidural hematoma?
A
Modest trauma to head causes unconsciousness, lucid interval, gradual lapse into coma again, fixed dilated pupil on side of hematoma, then contralateral hemiparesis with decerebrate posture. CT: lens–shaped hematoma. Craniotomy.
11
Q
What is the presentation of acute subdural hematoma?
A
Severe trauma and unconsciousness. The patient is usually not fully awake at any point, and the neurologic damage is severe. CT scan shows a semilunar, crescent–shaped hematoma.
12
Q
What is the treatment of subdural hematoma?
A
If midline structures are deviated, craniotomy is beneficial. If there is no deviation, therapy is ICP monitoring, elevate head, hyperventilate, and give mannitol or furosemide. Avoid over diuresis. Hypothermia will reduce brain oxygen demand.
13
Q
What is diffuse axonal injury?
A
Occurs in more severe trauma. CT shows diffuse blurring of gray– white matter interface and punctate hemorrhages. There is no role for surgery unless there is a hematoma. Therapy is directed at preventing increased intracranial pressure.
14
Q
What is chronic subdural hematoma?
A
Occurs in elderly or in alcoholics. A shrunken brain is injured by minor trauma, tearing the venous sinuses. Mental function deteriorates as a hematoma forms. CT is diagnostic, and treatment is evacuation.
15
Q
What is the management of penetrating trauma to the neck?
A
Requires surgical exploration if there is an expanding hematoma, deteriorating vitals, or esophageal or tracheal injury (coughing, hemoptysis). Severe gunshot wounds of the middle zone of the neck are always explored.
16
Q
What is the treatment of gunshot wounds to the upper neck zone?
A
Arteriographic diagnosis and management is preferred; for gunshot wounds to base of neck, arteriography, esophagogram (water–soluble), esophagoscopy, and bronchoscopy help determine the surgical approach.
17
Q
What are the signs of spinal hemisection (Brown–Sequard syndrome)?
A
Usually caused by a knife blade, causing paralysis and loss of proprioception distal to the injury on the injury side and loss of pain perception distal to the injury on the other side.
18
Q
What is the anterior cord syndrome?
A
Usually caused by burst fractures of the vertebral bodies. There is loss of motor function and loss of pain and temperature sensation on both sides distal to the injury. There is preservation of vibratory and positional sense.
19
Q
What is central cord syndrome?
A
Occurs in the elderly with forced hyperextension of the neck after a rear–end collision. There is paralysis and burning pain in the upper extremities, with preservation of function in the lower extremities.
20
Q
What is the management of spinal cord injuries?
A
Precise diagnosis of cord injury is with magnetic resonance imaging. High–dose corticosteroids immediately after the injury.
21
Q
What is a pneumothorax?
A
Results from penetrating trauma (broken rib or penetrating weapon). Moderate shortness of breath, unilateral absence of breath sounds, hyperresonance to percussion. X–ray, chest tube (upper, anterior), connect to underwater seal.
22
Q
What is the presentation of hemothorax?
A
Results from penetrating trauma. Affected side will be dull to percussion. Diagnosed by chest x–ray.
23
Q
What is the treatment of hemothorax?
A
Chest tube placed low. Bleeding will usually stop spontaneously. Surgery is indicated if 1,500 ml or more is removed when the chest tube is inserted, or if >600 ml of blood drains out over 6 hours.
24
Q
What is the management of severe blunt trauma to the chest?
A
Monitor with blood gases and chest x–rays to detect developing pulmonary contusion; check cardiac enzymes (troponins) and electrocardiogram to detect myocardial contusion. Traumatic transection of the aorta should be sought.
25
What is a sucking chest wound?
Characterized by a flap over a wound that sucks air with inspiration and closes during expiration. Tension pneumothorax develops. An occlusive dressing should be applied, which allows air out (tape on three sides) but not in.
26
What is the presentation of flail chest?
Multiple rib fractures allow a segment of the chest wall to cave in during inspiration and bulge out during expiration (paradoxic breathing).
27
What is the treatment of flail chest?
The underlying pulmonary contusion is sensitive to fluid overload, thus treatment includes fluid restriction, use of colloids (plasma or albumin), and diuretics. If a ventilator is needed, bilateral chest tubes are placed to prevent tension pneumothorax.
28
What is the presentation of pulmonary contusion?
Occurs after chest trauma with deteriorating blood gases and white out" of the lungs on chest x–ray. It can appear up to 48 hours after the injury. Treatment is fluid restriction colloids diuretics and blood gas monitoring."
29
What is the presentation of myocardial contusion?
Sternal fractures. ECG shows diffuse ST changes or T wave inversion. Troponins are specific. Treat arrhythmias.
30
What is the presentation of traumatic rupture of the aorta?
Occurs at junction of arch and descending aorta after deceleration injury. Asymptomatic until hematoma ruptures and causes death. X–ray shows wide mediastinum; transesophageal echocardiography, spiral CT, or MRI angiography.
31
What is the presentation of traumatic rupture of the trachea or major bronchus?
Subcutaneous emphysema in upper chest and lower neck, or a large air leak from a chest tube. X–ray shows of air in tissues, and fiberoptic bronchoscopy identifies the lesion and allows intubation beyond the lesion. Surgical repair.
32
What is the differential diagnosis of subcutaneous emphysema?
Rupture of the trachea, rupture of the esophagus (after endoscopy), and tension pneumothorax.
33
What is the presentation of air embolism?
Occurs when subclavian vein is opened to air (CVP disconnected). Sudden collapse and cardiac arrest. Immediate management includes positioning left side down. Prevented by using Trendelenburg when great veins are to be entered.
34
What is the presentation of fat embolism?
Respiratory distress after long bone fractures with petechial rashes in axillae/neck; fever, tachycardia, low platelets; hypoxemia, bilateral patchy infiltrates. Fat droplets in the urine. Treatment: respiratory support.
35
What is the management of gunshot wounds to the abdomen?
Exploratory laparotomy for repair of intraabdominal injuries. Low caliber gunshot wounds involving the right upper quadrant are managed with conservative therapy with close followup of clinical signs and serial abdominal CTs.
36
What is the management of stab wounds?
If penetration has occurred (protruding viscera) or if hemodynamic instability or signs of peritoneal irritation develop, exploratory laparotomy is mandatory. Otherwise, digital exploration of the wound may be sufficient.
37
What is the management of blunt trauma to the abdomen?
Exploratory laparotomy if there are signs of peritoneal irritation or signs of internal bleeding shock, low CVP, with no obvious external source of blood loss.
38
What are the signs of internal bleeding in a patient with blunt trauma?
Drop in blood pressure, with tachycardia, low CVP, and low urinary output; a cold, pale, anxious patient who is shivering, thirsty, and perspiring profusely. Signs of shock occur when 25 to 30% of blood volume is acutely lost (1,500 ml in an adult).
39
How is blunt trauma intraabdominal bleeding diagnosed?
CT shows blood or injury to liver or spleen. Patients with minor injuries who respond to fluid resuscitation do not need surgery. The patient with major injuries and vital signs that do not improve with fluid resuscitation requires surgery.
40
How is intraabdominal bleeding diagnosed in hemodynamically unstable, blunt trauma patients?
Sonogram is done in the ER or operating room to determine if there is blood in the peritoneal cavity. If ultrasound is positive, exploratory laparotomy is indicated.
41
What is the treatment of intraoperative coagulopathy during prolonged abdominal surgery for multiple trauma with multiple transfusions?
Empiric treatment with platelet packs and fresh–frozen plasma.
42
What is the presentation of the abdominal compartment syndrome?
Occurs when large volume of fluids and blood have been given during prolonged laparotomies; tissues are swollen and abdominal wound cannot be closed without excessive tension. A temporary cover is placed over the abdominal contents.
43
What is the management of pelvic fractures with hematoma bleeding?
Diagnosis is based on hypovolemic shock with a pelvic fracture and a large pelvic hematoma. External fixation is the best way to diminish the bleeding. For arterial bleeding, arteriographic embolization is effective.
44
What is the management of urologic injuries?
Penetrating urologic injuries are surgically explored and repaired. Blunt injuries may affect the kidney after lower rib fractures, or they may affect the bladder or urethra after a pelvic fracture.
45
What are the signs of urethral injury?
Occurs in men with pelvic fracture. Blood in meatus, scrotal hematoma. Sensation of bladder fullness with inability to avoid, and a high–riding" prostate. Foley should not be inserted but a retrograde urethrogram should be done."
46
What is the management of bladder injuries?
Usually associated with pelvic fracture. Diagnosed by retrograde cystogram. Postvoid contrast films may demonstrate extraperitoneal leaks at the base of the bladder. Management is surgical repair with a suprapubic cystostomy.
47
What is the management of renal injuries secondary to blunt trauma?
Usually associated with lower rib fractures. Assessment is by CT scan. Surgical intervention is usually not necessary. Renal artery stenosis caused by trauma may lead to renovascular hypertension.
48
What is the management of scrotal hematomas?
Scrotal hematomas can become large, but do not need specific intervention unless a sonogram shows that the testicle is ruptured.
49
What is the management of fracture of the penis?
Fracture of corpora cavernosa or fracture of tunica albuginea occurs to erect penis during vigorous intercourse. Pain and a penile hematoma. Emergency surgical repair is required to prevent impotence caused by arteriovenous shunts.
50
What is the management of penetrating injuries of the extremities?
When no vessels in vicinity of injury: tetanus prophylaxis, cleaning. If penetration is near a vessel: Doppler or arteriograms are done. If there are absent distal pulses or expanding hematoma: exploration, repair, fasciotomy.
51
What is the management of Crushing injuries to the extremities?
May cause hyperkalemia, myoglobinemia, myoglobinuria, renal failure, compartment syndrome. Fluids, osmotic diuretics, alkalinization of the urine, and fasciotomy may be required for crush injuries.
52
What is the presentation of high–voltage electrical burns?
Severe muscle damage. Myoglobinemia–myoglobinuric–renal failure (fluids, mannitol; alkalinize urine), posterior dislocation of shoulder, compression fractures of vertebral bodies, cataracts, demyelinization.
53
What is the management of respiratory burns?
Burns around mouth or soot in throat. Diagnosis with fiberoptic bronchoscopy; blood gases. Intubation should be done if there is an inadequate airway. If carboxyhemoglobin is elevated, 100% oxygen will aid in removal.
54
What is the management of circumferential burns of the extremities?
Impaired blood supply because edema accumulates underneath the eschar. Circumferential burns of the chest may interfere with breathing. Escharotomies (no need for anesthesia) will provide immediate relief.
55
How is the extent of burns in the adult estimated?
Rule of nines." The head and each of the upper extremities are assigned 9% of body surface each. Each lower extremity is assigned two 9% units and the trunk is given four units of 9% each. Second– and third–degree burns are counted."
56
How are fluid requirements estimated for burns?
Parkland formula: kg weight x % burn x 4 ml = RL (without dextrose) required for first 24 h, half should be infused in first 8 h; other half in next 16 h. 2,000 ml of 5% D5W for maintenance. Urinary output should be 1–2 ml/kg/h.
57
How does the estimation of fluid requirements in burned babies differ from the adult?
Babies have larger heads and smaller legs; thus rule of nines" assigns two 9's to head and both legs share a total of three 9's. Babies need proportionally more fluid than adult; 4 to 6 ml/kg/%. Rate is 20 ml/kg/h if \>20%."
58
What is the management of burn injuries?
Tetanus, cleaning, silver sulfadiazine. Burns near eyes are covered with triple antibiotic. Pain medication IV. After 1 day of NG suction, intensive nutritional support is provided via gut. After 3 weeks, areas that have not regenerated are grafted.
59
What is the management of dog bites that are provoked?
If the dog was petted while eating or teased, no rabies prophylaxis is required, other than observation of the dog for developing signs of rabies. Tetanus prophylaxis.
60
What is the management of unprovoked dog bites or bites from wild animals?
The animal can be killed and the brain examined for signs of rabies. If the animal is not available, rabies prophylaxis should consist of immunoglobulin plus vaccine. Tetanus prophylaxis should be given.
61
What are the signs of snake envenomation?
30% of snake bitten are not envenomated. Signs of envenomation are severe local pain, swelling, discoloration within 30 min of bite. If present, draw blood for typing/cross, coagulation studies, liver/renal function.
62
What is the management of snakebites?
Treatment is antivenom, at least five vials. Surgical excision of the bite site or fasciotomy are rarely needed. Splint the extremity during transportation. Sucking out venom, wrapping with ice, and tourniquets are contraindicated.
63
What is the management of bee stings?
Bees kill many more people than snakes because of anaphylactic reactions. Wheezing, rash, hypotension caused by vasomotor shock (pink and warm" shock). Epinephrine 0.3 to 0.5 ml of 1:1000 solution. Stingers removed by scraping."
64
What is the management of black widow spider bites?
Black with a red hourglass on the abdomen. The bite causes nausea, vomiting, and severe generalized muscle cramps. The antidote is IV calcium gluconate and a muscle relaxant.
65
What is the management of brown recluse spider bites?
A skin ulcer develops the next day, with a necrotic center and a surrounding halo of erythema. Dapsone. Surgical excision and skin grafting may be needed.
66
What is osteogenic sarcoma?
The most common primary malignant bone tumor. 25 years old, usually around the knee (lower femur or upper tibia). Sunburst" pattern on x–rays."
67
What is Ewing sarcoma?
Second most common primary malignant bone tumor; it affects younger children (5 to 15), grows in the diaphyses of long bones. A typical onion skinning" pattern is seen on x–rays."
68
What is the most common malignant bone tumor in adults?
Most malignant bone tumors in adults are metastatic from the breast in women or from prostate in men. Bone scan is more sensitive than x–rays (but not specific – if positive, should follow with x–rays). Lytic lesions may cause fractures.
69
What is the presentation of multiple myeloma?
Elderly men with fatigue, anemia, pain of bones. X–rays show multiple, punched–out lytic lesions. Bence–Jones protein in urine and abnormal immunoglobulins in blood by immunoelectrophoresis. Treated with chemotherapy.
70
What are soft tissue sarcomas?
Soft tissue mass that relentlessly grows over several months anywhere in the body. Firm, fixed to surrounding structures. Metastasize to lungs, but not to lymph nodes. MRI. Incisional biopsy with wide local excision, radiation, chemotherapy.
71
What is the treatment of clavicular fractures?
Typically at the junction of middle and distal thirds. Treated with a figure–of–eight device for 4 to 6 weeks.
72
What is the presentation of anterior dislocation of the shoulder?
Most common shoulder dislocation. Hold arm close to body but rotated outward as if they were going to shake hands. Numbness in a small area over deltoid from stretching of axillary nerve. AP and lateral x–rays are diagnostic.
73
What is the presentation of posterior shoulder dislocation?
Rarely occurs after severe uncoordinated muscle contractions, such as an epileptic seizure or electrical burn. The arm is held close to the body, internally rotated. Axillary x–ray views or scapular lateral views are needed.
74
What is the presentation of Colles fracture?
Distal radius fracture from a fall on outstretched hand in elderly osteoporotic women. Deformed and painful wrist looks like a dinner fork." Dorsally displaced dorsally angulated fracture of the distal radius. Close reduction and long arm casting."
75
What is the presentation of Monteggia fracture?
Results from direct blow to the ulna. Diaphyseal fracture of the proximal ulna with anterior dislocation of the radial head.
76
What is the presentation of Galeazzi fracture?
The distal third of the radius receives a direct blow and is fractured; dorsal dislocation of the distal radioulnar joint. Treatment is open reduction and internal fixation of the radius, and closed reduction of the radioulnar joint.
77
What is the presentation of fracture of the scaphoid (carpal navicular)?
Young adult who falls on an outstretched hand. Wrist pain. Tender anatomic snuff box. X–rays are negative, but a thumb Spica cast is indicated. If displaced and angulated fracture, open reduction and internal fixation are needed.
78
What is the presentation of metacarpal neck fractures?
Typically the fourth or fifth metacarpal. Happen when a closed fist hits a hard surface. The hand is swollen and tender. X–rays are diagnostic. Close reduction and ulnar gutter splint for mild cases; Kirschner wire or fixation for malalignment.
79
What is the presentation of hip fractures?
Elderly who sustain a fall and have hip pain. The affected leg is shortened and externally rotated.
80
What is the presentation of femoral neck fractures?
Femoral neck fractures compromise the blood supply of the femoral head if displaced. Treatment is a femoral head prosthesis.
81
What is the treatment of intertrochanteric fracture?
Open reduction and pinning. Immobilization is high risk for deep venous thrombosis and pulmonary emboli. Post–op anticoagulation is recommended.
82
What is the treatment of femoral shaft fractures?
Intramedullary rod fixation. May cause significant internal blood loss. Open fractures require operative cleaning and closure within 6 hours. Multiple fractures may lead to the fat embolism syndrome.
83
What is the presentation of collateral knee ligament injuries?
Caused by sideways impact to knee. Lateral impact tears medial ligaments. With the knee flexed, passive abduction or adduction will allow displacement. Isolated injuries are treated with a hinged cast. When several ligaments torn, surgical repair needed.
84
What is the presentation of anterior cruciate ligament tears?
Anterior cruciate ligament injuries are more common than posterior. With knee flexed, leg can be pulled anteriorly (anterior drawer test). MRI. Sedentary patients treated with immobilization; athletes require arthroscopic reconstruction.
85
What are meniscal tears?
Pain and swelling after a knee injury, and may cause a catching and locking that limits knee motion, and a click" when knee is extended. MRI. Arthroscopic repair may save the meniscus. Meniscectomy leads to arthritis."
86
What are tibial stress fractures?
Seen in young men subjected to forced marches. Tenderness to palpation over a very specific point on the bone, but x–rays are initially normal. Treat with a cast on crutches, and repeat the x–rays in 2 weeks.
87
What is the presentation of rupture of the Achilles tendon?
Middle–age men after severe strain. A loud popping noise is heard, followed by falling and clutching of the ankle. Pain, swelling, and limping. Palpation of the tendon reveals a gap. Surgery achieves a rapid cure.
88
What is the presentation of compartment syndrome?
Most frequently occurs in the forearm and lower leg. Caused by prolonged ischemia followed by reperfusion; crushing injuries. Tender and tight to palpation. Pulses may be normal. Emergency fasciotomy. Pain under a cast requires removing cast.
89
What is the presentation of posterior dislocation of the hip?
Occurs when the femur is driven backward, such as in a head–on car collision. Hip pain and lies with the leg shortened, adducted, and internally rotated (in a broken hip the leg is also shortened, but it is externally rotated). Emergency reduction.
90
What is the presentation of gas gangrene?
Occurs with deep, penetrating, contaminated wounds, after 3 days the patient becomes toxic and moribund. The site is tender, swollen, discolored, and gas crepitation. Treatment is penicillin, debridement, and hyperbaric oxygen.
91
What nerve is often injured by fractures of the humerus?
Radial nerve injury can be injured in oblique fractures of the middle to distal thirds of the humerus. If nerve paralysis develops, the nerve is entrapped and surgical exploration is required.
92
What artery is often injured by posterior dislocations of the knee?
Popliteal artery injuries can occur in posterior dislocations of the knee. Check pulses, Doppler studies, and arteriogram. Prompt reduction will minimize vascular compromise. Prophylactic fasciotomy if significant leg ischemia.
93
What is the treatment of carpal tunnel syndrome?
Wrist x–rays (including carpal tunnel view) should be done to rule out other causes. Initial treatment is splints and antiinflammatory agents. If surgery is needed, electromyography should be done first.
94
What is the presentation of trigger finger?
Occurs in women who wake up at night with an acutely flexed finger, and are unable to extend it unless they pull. Treatment is steroid injection; surgery.
95
What is the presentation of De Quervain tenosynovitis?
Occurs in young mothers who force their hand into wrist flexion and thumb extension to hold the baby's head. Pain along the radial side of the wrist and the first dorsal compartment. Treatment is splinting, NSAIDs; steroid injection. Surgery rarely.
96
What is the presentation of Dupuytren contracture?
Occurs in older men of Norwegian ancestry with contracture of the palm and palmar fascial nodules. Surgery is the only effective treatment.
97
What is a finger felon?
Abscess in the pulp of a fingertip caused by a penetrating injury. Throbbing pain, abscess, fever. Treatment is surgical drainage.
98
What is the presentation of gamekeeper thumb?
Injury of the ulnar collateral ligament caused by forced hyperextension of the thumb. Collateral laxity at the thumb–metacarpophalangeal joint causes joint dysfunctional and pain leading to arthritis. Casting is usually done.
99
What is Jersey finger?
Injury to the flexor tendon sustained when the flexed finger is forcefully extended. The distal phalanx of the injured finger does not flex with the others.
100
What is Mallet finger?
The extended finger is forcefully flexed, and the extensor tendon is ruptured. The tip of the affected finger remains flexed when the hand is extended, resembling a mallet. Treatment is splinting.
101
What is the management of traumatically amputated digits?
The amputated digit should be wrapped in a saline–moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice.
102
What is the presentation of lumbar disk herniation?
Occurs at L4–L5 or L5–S1. Peak age is 45–46 years. Vague aching pain before sudden severe pain precipitated by a forced movement.Electrical shock that shoots down the leg." Cannot ambulate affected leg is flexed. Straight leg–raising test. MRI."
103
What is the treatment of lumbar disk herniation?
Bedrest. Pain control with nerve blocks. Surgical intervention is needed if progressive weakness and emergency surgery is required if cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal saddle anesthesia).
104
What is the presentation of cauda equina syndrome?
Distended bladder, flaccid rectal sphincter, perineal saddle anesthesia. Surgical emergency requiring immediate decompression.
105
What is the presentation of ankylosing spondylitis?
Occurs in young men in thirties or early forties with chronic back pain, morning stiffness. Pain is worse at rest, improves with activity. Symptoms are progressive. X–rays: bamboo spine." Associated HLA B–27 antigen. Treatment: NSAIDs physical therapy."
106
What are the signs of metastatic spine malignancy?
Elderly with progressive back pain worse at night, unrelieved by rest or position. Weight loss. X–rays lytic breast cancer metastases at pedicles in women; blastic metastases from prostate in men. Bone scan is a more sensitive. MRI.
107
What are diabetic ulcers?
Located at pressure points (heel, metatarsal head, tip of toes, necrotic base with some granulation); caused by neuropathy, and microvascular disease. Healing may occur with control of diabetes, cleaning, leg elevation.
108
What are arterial insufficiency ulcers?
Affect feet, tip of toes. Pale base without granulation tissue. Absent pulses, trophic changes, claudication, rest pain. Doppler demonstrates pressure gradient. Absence of a pressure gradient indicates microvascular disease.
109
What are venous stasis ulcers?
Develop in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus. Painless with granulating bed. Varicose veins. Treatment is support stockings, Ace bandages, Unna boot. Vein stripping, grafting of the ulcer.
110
What is the presentation of Marjolin ulcer?
Squamous cell carcinoma of skin, developing in a chronic leg ulcer. A dirty–looking, deeper ulcer develops at the site, with heaped up tissue growth around the edges. Biopsy is diagnostic. Wide local excision and skin grafting.
111
What is the presentation of plantar fasciitis?
Common problem of older, overweight patients with sharp heel pain when walking. The pain is worse in the mornings. X–rays show a bony spur. Tenderness to palpation over spur. Spontaneous resolution in 12–18 months. Treatment is symptomatic.
112
What is the presentation of Morton neuroma?
Inflammation of common digital nerve at the third interspace, between the third and fourth toes. The neuroma is palpable and very tender. Caused by pointed, high heel shoes that force the toes together. Management: analgesics and wide shoes.
113
What is the presentation of gout?
Swelling, redness, pain of sudden onset at first metatarsal–phalangeal joint in a middle–age, obese man with high uric acid. Uric acid crystals in joint fluid.
114
What is the treatment of gout?
Treatment for the acute attack is indomethacin and colchicine. Allopurinol and probenecid for chronic control.
115
What cardiac ejection fraction is a contraindication to surgery?
Ejection fraction under 35% (normal is 55%) is a prohibitive cardiac risk for noncardiac operations. Mortality would be 55–90%.
116
What is Goldman's index of cardiac risk?
11 points for JVD, 10 points for recent MI, 7 points for PVCs or arrhythmia, 5 points for age \>70, 4 points emergency surgery, 3 points for aortic stenosis, poor medical condition, or chest/abdomen surgery. Risk is 1% with total of 5.
117
What is the presurgical management of long–term smokers?
Smokers have a high PCO2, low forced expiratory volume in 1 second. Cessation of smoking for 8 weeks and intensive respiratory therapy should precede surgery.
118
What are hepatic risk factors for surgery?
40% mortality with either bilirubin above 2, albumin below 3, PT \>16, or encephalopathy. 85% mortality if three of the above are present, or with either bilirubin\>4, albumin 150 mg/dl.
119
What are the signs of severe nutritional depletion?
Loss of 20% of body weight over months, serum albumin below 3, anergy to skin antigens, or serum transferrin level of less than 200 mg/dl. 5–10 days of preoperative nutritional support will reduce surgical risk.
120
What is the presentation of malignant hyperthermia?
Develops after onset of anesthetic (halothane or succinylcholine). T \>104 F. Metabolic acidosis, hypercalcemia, myoglobinuria.. Family history. Treatment: dantrolene, oxygen, correction of acidosis, and cooling blankets.
121
What are the causes of postoperative fever?
Fever in the range 101 –103 F is caused by atelectasis, pneumonia, urinary tract infection, deep venous thrombophlebitis, wound infection, or abscesses.
122
What is atelectasis?
Most common cause of post–op fever on the first day. Rule out other causes by auscultating, x–ray, deep breathing and coughing, postural drainage, incentive spirometry. Bronchoscopy for severe cases.
123
When does pneumonia develop after surgery?
Pneumonia may develop after 3 days if atelectasis is present. Fever. Chest x–ray shows infiltrates. Sputum cultures. Treat with appropriate antibiotics.
124
When does urinary tract infection cause fever after surgery?
Urinary tract infection causes fever starting on post op day 3. Urinalysis, urinary cultures. Treat with antibiotics.
125
When does deep vein thrombophlebitis cause fever after surgery?
Produces fever starting on post operative day 5. Doppler study of deep leg and pelvic veins is the best diagnostic modality. Anticoagulate with heparin.
126
When does wound infection cause fever after surgery?
Wound infection produces fever on post op day 7. Erythema, warmth, and tenderness. Treat with antibiotics if there is only cellulitis. Open and drain the wound if there is an abscess. A sonogram may be used to evaluate for abscess.
127
When do deep abscesses cause fever after surgery?
Subphrenic, pelvic, or subhepatic cause fever around post operative days 10–15. CT scan is diagnostic. Percutaneous radiologically guided drainage is therapeutic.
128
When do pulmonary emboli occur after surgery?
Pulmonary emboli occur on post op day 7 in elderly/immobilized. Sudden pleuritic pain, dyspnea, anxiety, diaphoresis, tachycardia, distended neck veins. Hypoxemia, hypocapnia. Spiral CT. After diagnosis, start heparin.
129
What is the presentation of adult respiratory distress syndrome?
Seen in patients with a complicated post–op course, often complicated by sepsis. There are bilateral pulmonary infiltrates and hypoxia with no evidence of congestive heart failure.
130
What is the presentation of delirium tremens?
Delirium tremens is common in alcoholics. Confusion, hallucinations, combative behavior on second or third postoperative day. IV benzodiazepines are the therapy for delirium tremens.
131
What are the complications of hyponatremia?
Induced by excessive hypotonic IV fluids (D5W) in a postoperative patient with high levels of antidiuretic hormone caused by trauma. Confusion, seizures, coma, death. Treatment is hypertonic saline (500 ml of 3%).
132
What are the complications of hypernatremia?
Confusion, lethargy, and coma if rapidly induced by unreplaced water loss. May be caused by surgical damage to the posterior pituitary with unrecognized diabetes insipidus. Replacement of fluid deficit with D5 1/2 NS.
133
What is the cause of zero urinary output after surgery?
Zero urinary output typically is caused by a mechanical problem, rather than a renal cause. Zero urinary output is often caused by a plugged or kinked Foley catheter.
134
What is the evaluation of low urinary output after surgery?
Urinary output 40 mEq/L in RF. Fractional excretion of Na \>1 in RF.
135
What is paralytic ileus?
Occurs in the first few days after abdominal surgery. Bowel sounds are absent, there is no passage of gas. Mild distension, no pain.
136
What are the x–ray signs of small bowel obstruction?
Early mechanical bowel obstruction is caused by adhesions. X–rays will show dilated loops of small bowel and air–fluid levels. CT scan shows a transition point between proximal dilated bowel and distal collapsed bowel at site of obstruction.
137
What is the presentation of Ogilvie syndrome?
Paralytic ileus of colon in elderly, sedentary. Abdominal distention. X–rays: dilated colon. Colonoscopy decompress colon, and rules out a mechanical cause of the obstruction, such as cancer of the colon. Long rectal tube.
138
What is the presentation of wound dehiscence?
Occurs around fifth post–op day after laparotomy. Wound may appear intact, but salmon–colored" peritoneal fluid is soaks dressings.Wound should be taped securely abdomen should be bound. Reoperation at a later date to correct a ventral hernia."
139
What is the presentation of evisceration?
A wound dehiscence where the skin opens up and the abdominal contents escape when the patient coughs, strains, or gets out of bed. The bowel should be covered with large sterile dressings soaked with warm saline. Emergency abdominal closure.
140
What is the treatment of hypernatremia?
Loss of water (or other hypotonic fluids) and hypertonicity. Every 3 mEq/L that the serum sodium concentration is above 140, represents 1 L of water lost. Therapy requires volume repletion with NS, then 1/2 NS.
141
What is the treatment of hyponatremia?
Water has been retained. Rapid hyponatremia requires 3% hypertonic saline. In slowly developing hyponatremia, therapy is water restriction. In hypovolemic, dehydrated losing GI fluids, volume restoration with NS will correct hypovolemia.
142
What are the causes of hypokalemia?
Develops when potassium is lost from the GI tract or urine (loop diuretics, or excessive aldosterone). Hypokalemia develops very rapidly when K moves into cells when diabetic ketoacidosis corrected. Therapy is potassium. Max IV K is 10 mEq/h.
143
What are the causes of hyperkalemia?
Occurs slowly in renal failure, and occurs rapidly in crushing injuries, acidosis. Therapy is 50% dextrose and insulin, exchange resins, IV calcium, and dialysis.
144
What are the causes of metabolic acidosis?
Excessive acids (DKA, lactic acidosis), loss of bicarbonate GI, or inability of kidney to eliminate acids (RF). pH is low (10).
145
What is the most common cause of metabolic alkalosis?
Occurs from loss of acidic gastric fluid. There is a high blood pH (\>7.4), high serum bicarbonate (\>25). An increased intake of KCl (between 5 to 10 mEq/h) will usually allow the kidney to correct the problem.
146
What is the most common cause of respiratory acidosis?
Impaired ventilation causes acidosis. Abnormal hyperventilation causes alkalosis. Pco2 is low in alkalosis, high in acidosis with abnormal pH of the blood. Therapy: ventilation in acidosis.
147
What are the symptoms of gastroesophageal reflux?
Overweight individual with burning retrosternal pain and heartburn" that is exacerbated by bending over or lying flat in bed and relieved by the ingestion of antacids or H2 blockers. Barrett esophagus may develop. Endoscopy biopsies."
148
What are the indications for surgical treatment of hiatal hernia?
Laparoscopic Nissen fundoplication for gastroesophageal reflux is indicated for ulceration, stenosis, or dysplastic changes.
149
What is the evaluation of hiatal hernia?
pH monitoring, endoscopic biopsies. Lower esophageal sphincter weakness is measured by manometry. Stomach emptying is assessed by emptying study. Esophagogastric junction is determinated by barium swallow.
150
What is the presentation of achalasia?
More common in women. Dysphagia is worse for liquids; regurgitation of undigested food. X– rays show megaesophagus. Manometry is diagnostic. Treatment is dilatations or myotomy.
151
What are the signs of cancer of the esophagus?
Dysphagia of solids, then soft foods, liquids, and finally saliva. Weight loss. Squamous cell carcinoma occurs in male smokers/drinkers. Adenocarcinoma is seen with gastroesophageal reflux. Most are treated with palliative surgery.
152
What is the presentation of a Mallory Weiss tear?
Occurs after prolonged, forceful vomiting. Bright red blood. Endoscopy establishes diagnosis and allows photocoagulation (laser).
153
What is the presentation of Boerhaave syndrome?
Prolonged, forceful vomiting leads to esophageal perforation. Epigastric/sternal pain of sudden onset, followed by fever, leukocytosis, and a septic appearance. Contrast (Gastrografin swallow, barium if negative) is diagnostic.
154
What are the signs of instrumental perforation of the esophagus?
Epigastric and low sternal pain after completion of endoscopy. Emphysema in the lower neck. Instrumentation is the most common cause of esophageal perforation. Contrast studies and prompt repair are indicated.
155
What is the presentation of gastric adenocarcinoma?
More common in the elderly with anorexia, weight loss, vague epigastric pain or early satiety, hematemesis. Endoscopy and biopsies. CT scan assesses operability. Surgery is the best therapy.
156
What is the presentation of gastric lymphoma?
Anorexia, weight loss, early satiety. Treatment: chemotherapy or radiotherapy. Surgery is done if perforation. Low–grade lymphomatoid transformation (MALTOMA) can be reversed by eradication of H. pylori.
157
What are the signs of small bowel obstruction?
Caused by adhesions from a prior laparotomy. Colicky abdominal pain, vomiting, abdominal distention, and no passage of gas or feces. High–pitched bowel sounds coincide with pain. X–ray: distended loops of small bowel, with air–fluid.
158
What is the treatment of small bowel obstruction?
NPO, NG suction, and IV fluids. Spontaneous resolution may occur.
159
What are the signs of strangulated obstruction?
Compromised blood supply causes fever, leukocytosis, constant pain, signs of peritoneal irritation, peritonitis and sepsis. Emergency surgery is required.
160
What is the presentation of carcinoid syndrome?
Small bowel carcinoid tumor with liver metastases with diarrhea, flushing of the face, wheezing, and right–sided heart valvular damage with prominent jugular venous pulse. Twenty–four–hour urinary collection for 5–hydroxyindolacetic acid is diagnostic.
161
What is the presentation appendicitis?
Anorexia, followed by periumbilical pain becomes sharp, severe, constant, localized to right lower quadrant. Tenderness, guarding, rebound on right below umbilicus. Fever, leukocytosis 10000, with neutrophilia, immature forms. CT: inflammed appendix.
162
What is the presentation of cancer of the right colon?
Presents with anemia (hypochromic, iron deficiency) in elderly. Stools will be 4+ for occult blood. Colonoscopy and biopsies are diagnostic. Treatment is right hemicolectomy.
163
What is the presentation of cancer of the left colon?
Blood–coated, narrow caliber stools, constipation. Proctosigmoidoscopic biopsies. Full colonoscopy to rule out a second primary. CT assesses operability and extent. Pre–op chemotherapy and radiation may be needed for large rectal cancers.
164
Which types of colonic polyps have a high probability of malignant degeneration?
Familial polyposis (and variants such as Gardner), villous adenoma, and adenomatous polyp. Polyps that are not premalignant include juvenile, Peutz–Jeghers, inflammatory, and hyperplastic polyps.
165
What are the indications for surgery for chronic ulcerative colitis?
Disease for \>20 years, severe interference with nutrition, multiple hospitalizations, high–dose steroids or immunosuppressants, or toxic megacolon (pain, fever, leukocytosis, epigastric tenderness, distended colon).
166
What is pseudomembranous enterocolitis?
Overgrowth of C difficile caused by antibiotics. Any antibiotic; clindamycin was first antibiotic described; cephalosporins are most common cause. Profuse, watery diarrhea, crampy pain, fever, leukocytosis. Diagnosis by toxin in stool.
167
What is the treatment of pseudomembranous enterocolitis?
Antibiotic should be discontinued. Metronidazole is the treatment of choice, with oral vancomycin is an alternate.
168
What are the signs of hemorrhoids?
Internal hemorrhoids are associated with bleeding, or external hemorrhoids are painful. Internal hemorrhoids can become painful and produce itching if prolapse occurs.
169
What is the treatment of internal hemorrhoids?
Treated with rubber band ligation. External hemorrhoids may need surgery if conservative treatment fails.
170
What are the signs of an anal fissure?
Severe pain with defecation; blood streaks on stools. Fissure is usually posterior, in midline. Treatment is stool softeners, topical nitroglycerin, local injection of botulin toxin, dilatation, or lateral internal sphincterotomy.
171
What are the anal manifestations of Crohn disease?
Often causes anal fissures, fistula, or small ulceration that fails to heal and gets worse after surgical interventions.
172
What is the presentation of ischiorectal abscess?
Fever with exquisite perirectal pain that prevents sitting or bowel movements. Rubor, dolor, calor, and tumor lateral to the anus between the rectum and the ischial tuberosity. Incision and drainage.
173
What is the presentation of fistula in ano?
Permanent tract develops after drainage of an ischiorectal abscess. Fecal soiling and perineal discomfort. Opening is lateral to the anus, a cordlike tract may be felt, and discharge may be expressed. Treat with fistulotomy.
174
What is the presentation of squamous cell carcinoma of the anus?
More common in HIV and homosexuals who practice anoreceptive sex. Fungating mass grows out of the anus; metastatic to inguinal nodes. Treatment with chemoradiation, followed by surgery.
175
What are the causes of lower gastrointestinal bleeding?
Colon angiodysplasia, polyps, diverticulosis, cancer, hemorrhoids. Elderly patients with anal bleeding usually have an upper GI tract source. The upper GI is the most common source of lower GI bleeding.
176
What is the most likely source of bloody emesis?
Vomiting blood always indicates a source within the upper GI (tip of the nose to the ligament of Treitz). A NG tube should be placed in a patient with bleeding per rectum. The next diagnostic test is upper GI endoscopy.
177
What is the evaluation of melena?
Black, tarry stools indicates digested blood, originating in the upper GI tract. Workup starts with upper GI endoscopy.
178
What is the diagnostic evaluation for red blood per rectum?
Red blood per rectum can be caused by upper or lower source. First pass an NG tube and aspirate gastric contents. If blood is retrieved, an upper source has been established (follow with upper endoscopy).
179
What is the diagnostic evaluation of red blood per rectum if the NG tube retrieves nonbilious fluid without blood?
If no blood is retrieved and fluid nonbilious, the nose to pylorus has been excluded. Upper endoscopy should follow. If no blood is recovered from NG tube and fluid is green (bile), an upper GI has been excluded.
180
What is the evaluation of active bleeding per rectum, when an upper GI source has been excluded?
Anoscopy for bleeding hemorrhoids. If hemorrhoids have been excluded and if bleeding \>2 mL/min, an angiogram should be done. If bleeding
181
What is the evaluation of patients with a recent history of blood per rectum who not actively bleeding at the time of presentation?
Start workup with upper GI endoscopy if they are young; elderly patients need an upper and a lower GI endoscopy at the same session.
182
What is the evaluation of blood per rectum in a child?
Usually caused by Meckel diverticulum. Workup is technetium scan, looking for the ectopic gastric mucosa.
183
What is the most common cause of massive upper GI bleeding in a multiple trauma or complicated post–op patient?
Stress ulcers. Endoscopy will confirm. Angiographic embolization is the best treatment.
184
What are the signs of acute abdominal pain caused by perforation?
Sudden, constant pain. Avoids movement, guarding. Signs of peritoneal irritation include tenderness, guarding, rebound, silent abdomen. Free air under diaphragm in upright x–rays. Perforated peptic ulcer is most common cause.
185
What are the signs of acute abdominal pain caused by obstruction?
Sudden onset of colicky pain. The patient moves constantly, seeking a position of comfort.
186
What disorder is uniquely characterized by severe abdominal pain with blood in the lumen of the gut?
Ischemic colitis.
187
What is the presentation of primary peritonitis?
Child with nephrosis and ascites, or an adult with cirrhotic ascites with a diffuse acute abdominal pain with equivocal physical findings, and fever and leukocytosis. Cultures of the ascitic fluid will yield a single organism. Treat with antibiotics.
188
What are the signs of acute pancreatitis?
Alcoholic with an upper, acute abdomen. Rapid onset over 2–3 h, with constant, epigastric pain, radiating straight through to back, with nausea, vomiting, retching. Increased amylase or lipase. CT shows pancreatic enlargement and inflammation.
189
What is the treatment of pancreatitis?
Nothing per oral, nasogastric suction, IV fluids.
190
What is the presentation of biliary tract disease?
Obese woman in her forties with multiple children and right upper quadrant abdominal pain.
191
What are the signs of ureteral stones?
Sudden onset of colicky flank pain radiating to inner thigh and scrotum/labia, urgency and frequency; microhematuria on urinalysis. Plain x–rays usually show the stone; CT scan is best diagnostic test.
192
What is the presentation of acute diverticulitis?
Inflammatory processes giving acute abdominal pain in the left lower quadrant. Elderly with fever, leukocytosis, peritoneal signs in left lower quadrant; tender mass. CT. Treatment: NPO, IV fluids, antibiotics. Surgery if no response to antibiotics; elec
193
What is the presentation of volvulus of the sigmoid?
Elderly with severe abdominal distention. X–rays: air–fluid levels small bowel, distended colon, air–filled loop in RUQ that tapers down toward LLQ (parrot's beak).
194
What is the treatment of volvulus of the sigmoid?
Rigid proctosigmoidoscope resolves problem. Rectal tube is left in place. Recurrences are treated with elective resection.
195
What are the signs of mesenteric ischemia?
Occurs in elderly with atrial fibrillation or a MI (thrombus in superior mesenteric artery) with an acute abdomen. Blood in the bowel lumen (the only condition of pain with GI bleeding), acidosis and sepsis. Treatment is supportive.
196
What is the presentation of hepatocellular carcinoma?
Hepatocellular carcinoma is seen only with cirrhosis. Vague right upper quadrant discomfort and weight loss. Blood marker is alpha–fetoprotein. CT scan will show location and extent. Treatment is resection.
197
What is the most common liver malignancy?
Metastatic cancer to the liver is more common than primary cancer of the liver by 20:1. If the primary malignancy is slow growing and the metastases are confined to one lobe, resection can be done. Radioablation.
198
What is the cause of hepatic adenomas?
Arise as a complication of birth control pills. Rupture and bleed massively inside the abdomen. CT scan is diagnostic.
199
What is the cause of pyogenic liver abscess?
Most often a complication of biliary tract disease, particularly acute, ascending cholangitis. Fever, leukocytosis, and a tender liver. Sonogram or CT scan is diagnostic. Percutaneous drainage is required.
200
What is the presentation of amebic abscess of the liver?
Recent immigrants; men from Mexico. Definitive diagnosis is by serology. Treated with metronidazole. Seldom requiring drainage.
201
What are the causes of jaundice in adults?
Jaundice may be hemolytic, hepatocellular, or obstructive.
202
What is the presentation of hemolytic jaundice?
Usually hyperbilirubinemia of 6 or 8, and all the elevated bilirubin is unconjugated (indirect), with no elevation of the direct, conjugated fraction. No bile in the urine. Workup should determine the cause of hemolysis.
203
What is the presentation of hepatocellular jaundice?
Elevation of direct and indirect bilirubin, and very high levels of transaminases, with modest elevation of the alkaline phosphatase. Hepatitis is the most common cause.
204
What is the presentation of obstructive jaundice?
Elevations of direct and indirect bilirubin, modest elevation of transaminases, very high alkaline phosphatase. Sonogram for dilatation of ducts, stones. In malignant obstruction, a large, gallbladder is identified (Courvoisier sign).
205
What is the presentation of obstructive jaundice caused by stones?
Obese, fecund woman in forties, high alkaline phosphatase, dilated ducts, gallbladder with stones. Endoscopic retrograde cholangiopancreatography confirms.
206
What is the treatment of obstructive jaundice caused by a gallstone?
Sphincterotomy to remove common duct stone followed by cholecystectomy.
207
What are the causes of obstructive jaundice caused by tumor?
Adenocarcinoma of the head of the pancreas, adenocarcinoma of the ampulla of Vater, or cholangiocarcinoma arising in the common duct.
208
What is the evaluation of obstructive jaundice?
Sonogram: dilated gallbladder. CT may reveal pancreatic cancer. If CT is negative, ERCP is next step. Ampullary cancers or cancers of common duct produce obstruction. Cholangiogram will show intrinsic tumors of duct or small pancreatic cancers.
209
What is biliary colic?
Stone occludes cystic duct. Colicky pain in RUQ, radiating to right shoulder/back, precipitated by fatty food. Nausea, vomiting. No peritoneal irritation or fever. Lasts 10–30 min. Sonogram gallstones. Elective cholecystectomy.
210
What is the presentation of acute cholecystitis?
Starts as a biliary colic, but the stone in the cystic duct causes an inflammatory process in the obstructed gallbladder. Pain constant; fever and leukocytosis; and peritoneal irritation in the right upper quadrant. Liver function tests are normal.
211
What are the ultrasound findings in choledococystis?
Sonogram shows gallstones, thick–walled gallbladder, and pericholecystic fluid. Rarely, a radionuclide scan (HIDA) is needed (shows uptake in the liver, common duct, and duodenum, but not in the occluded gallbladder).
212
What is the treatment of cholangitis?
NG suction, NPO, fluids, antibiotics. Elective cholecystectomy. If no response, emergency cholecystectomy is needed. Emergency percutaneous transhepatic cholecystostomy may be best temporizing option if surgical risk.
213
What is the presentation of acute ascending cholangitis?
Stones in common duct cause ascending infection. Patients are older and sicker. Temperature 104–105 F, with chills, very high WBC, sepsis. Hyperbilirubinemia, high alkaline phosphatase.
214
What is the treatment of acute cholangitis?
IV antibiotics and emergency decompression of the common duct by ERCP or by percutaneous transhepatic cholecystectomy. Cholecystectomy.
215
What is the presentation of biliary pancreatitis?
Stones impacted in ampulla obstruct pancreatic and biliary ducts. Sonogram confirms gallstones in gallbladder.
216
What is the treatment of biliary pancreatitis?
Conservative treatment (NPO, NG suction, fluids) usually leads to improvement, elective cholecystectomy is done later. If stone does not pass, ERCP and sphincterotomy may be required.
217
What are the causes of acute pancreatitis?
Complication of gallstones, or in alcoholics. Acute pancreatitis may be edematous, hemorrhagic, or suppurative (pancreatic abscess). Late complications include pancreatic pseudocyst and chronic pancreatitis.
218
What is the presentation of acute pancreatitis?
Alcoholic or patient with gallstones with epigastric and midabdominal pain after a heavy meal or alcohol. Pain is constant, radiates to back, vomiting, and retching. Tenderness and mild rebound in the upper abdomen.
219
What are the laboratory abnormalities of pancreatitis?
Elevated serum amylase or lipase (early on) or urinary amylase or lipase (after 2 days) are diagnostic. The hematocrit is not decreased. Resolution usually follows a few days of pancreatic rest (NPO, NG suction, IV fluids).
220
What is acute hemorrhagic pancreatitis?
Pancreatitis with drop in hematocrit. Ranson's criteria at time of presentation are an elevated WBC, elevated glucose, low calcium. Blood urea nitrogen goes up, metabolic acidosis and low arterial PO2. Abscesses should be drained.
221
What is the presentation of pancreatic abscess?
Persistent fever and leukocytosis develop about 10 days after the onset of pancreatitis. CT will reveal the collection of pus, and percutaneous drainage is indicated.
222
What is the presentation of pancreatic pseudocyst?
Late sequela of acute pancreatitis or of pancreatic trauma. 5 weeks after the onset of pancreatitis. Collection of pancreatic fluid outside the pancreatic ducts. Pressure symptoms are early satiety, vague discomfort, a deep palpable mass.
223
What is the management of pancreatic pseudocyst?
Cysts 6 cm or cysts\>6 weeks are treated with drainage percutaneously or surgically into GI, or endoscopically into stomach.
224
What is the presentation of chronic pancreatitis?
Repeated episodes of pancreatitis (usually alcoholic), eventually developing calcified pancreas, steatorrhea, diabetes, and constant epigastric pain.
225
What is the treatment of chronic pancreatitis?
Diabetes,steatorrhea controlled with insulin and pancreatic enzymes, but the pain is resistant to most modalities of therapy. If ERCP shows obstruction and dilatation, operations that drain the pancreatic duct may be effective.
226
What is the management of abdominal hernias?
Abdominal hernias should be electively repaired to prevent obstruction and strangulation. Exceptions include umbilical hernias (close spontaneously) and esophageal sliding hiatal hernias.
227
At what age should mammogram screening begin?
Mammography should be started at age 40 (earlier if family history). Mammograms are not done before age 20 or during lactation, but mammograms can be done during pregnancy. Mammographically guided multiple core biopsies are the best method of biopsy.
228
What are fibroadenomas?
Occur in young women (late teens, early twenties) as a firm, rubbery mass that moves with palpation. Either fine–needle aspirate or sonogram establishs diagnosis. Removal is optional, although most women desire removal.
229
What are giant juvenile fibroadenomas?
Occur in very young adolescents; very rapid growth. Removal is needed to avoid deformity of the breast.
230
What is the presentation of cystosarcoma phyllodes?
Occurs in the late 20s and grow over many years, becoming very large, replacing and distorting the entire breast. No invasion. Most are benign, but may become malignant sarcomas. Core or incisional biopsy is needed and removal is mandatory.
231
What is the presentation of fibrocystic changes?
Cystic mastitis occurs in the thirties and forties (resolves with menopause), with bilateral tenderness related to menstrual cycle (worse in the last 2 weeks). If there is no dominant" or persistent mass mammogram is all that is needed."
232
What is the management of persistent cysts?
Aspiration is done. If clear fluid is obtained and the mass disappears, no further treatment is indicated. If the mass persists or recurs after aspiration, biopsy is required. If bloody fluid is aspirated, it should be sent for cytology.
233
What is the presentation of intraductal papilloma?
Occurs in young women (twenties to forties) with bloody nipple discharge. Mammogram is needed to identify potential lesions, but small papilloma are not visible. Galactogram may be diagnostic and guide surgical resection.
234
What is a breast abscess?
Occurs in lactating women. Incision and drainage is needed with biopsy of the abscess wall.
235
What are the signs of breast cancer?
Palpable breast mass. Elderly patient, ill–defined, fixed mass, retraction of overlying skin, retraction of the nipple, eczematoid lesions, reddish orange peel skin over the mass (inflammatory cancer), and palpable axillary nodes.
236
What is the diagnostic approach to breast cancer during pregnancy?
Diagnosed exactly as in non–pregnant women. Treated the same except for no radiotherapy during the pregnancy, and no chemotherapy during the first trimester.
237
What is the radiologic appearance of breast cancer on mammograms?
Irregular area of increased density with fine microcalcifications not present in previous study.
238
What is the treatment of resectable breast cancer?
Lumpectomy plus axillary sampling plus post–op radiation; or modified radical mastectomy. Lumpectomy can be offered only when the tumor is small, in a relatively large breast, away from nipple and areola.
239
What is the most common type of breast cancer?
Infiltrating ductal carcinoma is most common form of breast cancer. Inflammatory cancer is the only variant with much worse prognosis. Variants (lobular, medullary, mucinous) are treated same as infiltrating ductal cancer.
240
What is ductal carcinoma in situ?
Metastases are not possible thus no axillary sampling is needed. Total simple mastectomy is recommended for multicentric lesions throughout the breast, and lumpectomy followed by radiation is done the lesion is confined to one quarter of breast.
241
What are the indications for adjuvant chemotherapy for breast cancer?
Adjuvant systemic therapy should follow surgery. Chemotherapy in most cases; hormonal therapy is added if tumor is receptor positive. Premenopausal women receive tamoxifen, postmenopausal receive anastrozole.
242
What are the signs of breast cancer metastasis?
Persistent headache or back pain (with localized tenderness) in women who recently had breast cancer suggests metastasis. CT of brain for metastases and bone scan for bone metastases in the pedicles are indicated.
243
What is the evaluation of thyroid nodules?
Thyroid nodules in euthyroid patients are indicate cancer. If FNA is benign, observe for growth. If malignant or indeterminate results, follow with a thyroid lobectomy. Thyroidectomy for follicular cancers.
244
What is the likelihood ov cancer in a nodule in a patient who has symptoms of hyperthyroidism?
Thyroid nodules in hyperthyroid patients are never caused by cancer. Signs of hyperthyroidism: weight loss, ravenous appetite, palpitations, heat intolerance, moist skin, hyperactivity, tachycardia, atrial fibrillation. TSH is low.
245
What is the presentation of hyperparathyroidism?
Most commonly high serum calcium. Repeat calcium determinations, look for low phosphorus, and rule out bone metastases. If findings persist, do parathyroid hormone determination. 90% have single adenoma.
246
What are the signs of Cushing syndrome?
Round, ruddy, hairy face, buffalo hump, supraclavicular fat pads, obese trunk with abdominal stria, thin weak extremities. Osteoporosis, diabetes, hypertension, mental instability.
247
How is Cushing syndrome diagnosed?
Suppression with low dosage dexamethasone test rules out Cushing. If there is no suppression, 24–h urine cortisol is measured. If elevated, perform high–dose suppression test. Suppression of cortisol at a higher dose identifies pituitary microadenoma.
248
What diagnosis is suggested by a high–dose dexamethasone suppression test that shows no suppression?
No suppression identifies adrenal adenoma.
249
What is the presentation of gastrinoma?
Aggressive peptic ulcer disease, resistant to therapy (including eradication of pylori) and with multiple ulcers, ulcers extending beyond first portion of the duodenum; watery diarrhea.
250
What is the evaluation of gastrinomas?
Measure gastrin, locate the tumor with CT with contrast of pancreas. Remove the gastrinoma. Omeprazole helps with metastatic disease.
251
What is the presentation of insulinoma?
CNS symptoms because of hypoglycemia when the patient is fasting. Differentiated from reactive hypoglycemia (attacks occur after eating), and with self–administration of insulin (low C–peptide). CT (with contrast) of pancreas is done to locate tumor.
252
What is nesidioblastosis?
Hypersecretion of insulin in the newborn, requiring 95% pancreatectomy.
253
What is the presentation of glucagonoma?
Severe migratory necrolytic dermatitis, mild diabetes, anemia, glossitis, and stomatitis. Glucagon assay is diagnostic, CT scan is used to locate the tumor, resection is curative. Somatostatin and streptozocin can help metastatic, disease.
254
What are the causes of primary hyperaldosteronism?
Adenoma or hyperplasia of adrenal. Hypokalemia in a hypertensive female who is not on diuretics. Modest hypernatremia and metabolic alkalosis. Aldosterone levels are high, renin levels low. Adrenal CT localizes adenoma.
255
What is the presentation of pheochromocytoma?
Thin, hyperactive women with attacks of pounding headache, perspiration, palpitations, and pallor; extremely high blood pressure. The pressure may be normal when measured.
256
What is the laboratory evaluation of pheochromocytoma?
24–h urinary vanillylmandelic acid (false positives) or metanephrine (specific). CT of adrenals or radionuclide studies if looking for extraadrenal sites. Tumors are usually large. Surgery after control of hypertension with alpha–blockers.
257
What is the presentation of coarctation of the aorta?
Infants with HTN in arms, with normal pressure in the lower extremities. Chest x–ray shows scalloping of the ribs (erosion from large collateral intercostals). Spiral CT scan or MRI angiogram, arteriogram. Surgical correction is curative.
258
What is the presentation of renovascular hypertension?
In young women with fibromuscular dysplasia, or old men with arteriosclerotic occlusive disease. Hypertension is resistant to medications, and there is faint bruit over the flank or upper abdomen.
259
What is the evaluation of renovascular hypertension?
Doppler of the renal vessels. Arteriographic visualization is often needed. Therapy is balloon dilatation and stenting.
260
What is the presentation of esophageal atresia?
Excessive salivation after birth, or choking with first feed. NG tube coiled in upper chest. Normal gas pattern in bowel indicates the most common form in which there is a blind pouch upper esophagus and a fistula between lower esophagus and trachea.
261
What congenital disorder is associated with esophageal atresia?
Vertebral, anal, cardiac, tracheal, esophageal, renal, and radial [VACTER] constellation. The anus may be imperforate. Check x–ray for vertebral and radial anomalies, echocardiogram for cardiac anomalies, sonogram for renal anomalies.
262
What is the treatment of imperforated anus?
Colostomy is indicated for high rectal pouches, followed later by a repair; or a primary repair can be done if the blind pouch is almost at anus. Level of pouch is determined with x–rays taken upside down, with a metal marker taped to anus.
263
What is the presentation of congenital diaphragmatic hernia?
Always on left. Bowel will be up in chest. The hypoplastic lung retains fetal–type circulation. Repair must be delayed 3–4 days to allow maturation. Low–pressure ventilation, sedation, NG suction. Extracorporeal membrane oxygenation.
264
What is the presentation of gastroschisis?
Abdominal wall defect in middle of abdomen. In gastroschisis the cord is normal, the defect is to the right of the cord, there is no protective membrane.
265
What is an omphalocele?
Cord goes to the defect, which has a thin membrane under which normal bowel is visible with a slice of liver.
266
What is the treatment of gastroschisis?
Small defects can be closed primarily, but large defects require construction of a Silastic silo" to protect the bowel. The contents of the silo are then pressed into the belly. Complete closure can be done in about a week."
267
What is the presentation of exstrophy of the urinary bladder?
Abdominal wall defect over the pubis (which is not fused), with a medallion of red bladder mucosa. Repair can be done within the first 1 or 2 days of life.
268
What disorders cause green vomiting in the newborn?
Green vomiting and a double–bubble" are found in duodenal atresia annular pancreas or malrotation. Malrotation is diagnosed with contrast enema or upper GI. The first signs of malrotation can appear at any time within the first few weeks of life."
269
What is the presentation of intestinal atresia?
Green vomiting, but instead of a double bubble there are multiple air–fluid levels throughout the abdomen.
270
What is necrotizing enterocolitis?
Occurs in premature infants at the first feeding. There is feeding intolerance, abdominal distention, and a rapidly dropping platelet count (in babies, a sign of sepsis). Treatment: stop all feedings, broad–spectrum antibiotics, fluids, nutrition.
271
What are the indications for surgery in necrotizing enterocolitis?
Surgical intervention is required if they develop abdominal wall erythema, air in the portal vein, intestinal pneumatosis, or pneumoperitoneum (intestinal necrosis and perforation).
272
What is the presentation of meconium ileus?
Baby with cystic fibrosis, bilious vomiting. Multiple dilated loops of small bowel and a ground–glass appearance. Gastrografin enema is diagnostic (pellets of meconium in terminal ileum) and therapeutically dissolves the meconium pellets.
273
What is the presentation of hypertrophic pyloric stenosis?
Age 3 weeks in first–born boys with nonbilious projectile vomiting after feedings. The infant is hungry, dehydrated, with visible gastric peristaltic waves and a palpable olive–size mass in right upper quadrant. Sonogram is diagnostic.
274
What is the treatment of hypertrophic pyloric stenosis?
Therapy begins with rehydration and correction of the hypochloremic, hypokalemic metabolic alkalosis, followed by Ramstedt pyloromyotomy.
275
What is the presentation of biliary atresia?
Suspected in 6– to 8–week–old babies with persistent, increasing jaundice. Serologies, sweat test, HIDA scan after 1 week of phenobarbital. If no bile reaches the duodenum with phenobarbital stimulation, surgical exploration is needed.
276
What is the presentation of Hirschsprung disease?
Aganglionic megacolon may go undiagnosed. Failure to pass meconium, and constipation. X–rays: distended proximal colon,normal–looking" distal colon which is aganglionic. Full–thickness biopsy of rectal mucosa."
277
What is the presentation of intussusception?
6– to 12–month–old overweight, child with episodes of colicky abdominal pain. The pain lasts for about 1 minute. Vague mass on the right side of the abdomen and currant jelly" stools. Barium or air enema is both diagnostic and therapeutic."
278
What is the presentation of congenital vascular rings?
Stridor, respiratory distress with hyperextended position for breathing. Difficulty swallowing. Barium swallow: extrinsic compression from abnormal vessel. Bronchoscopy: segmental tracheal compression. Surgery divides aortic arch.
279
What is the presentation of aortic stenosis?
Angina and exertional syncope. Harsh midsystolic heart murmur at the right second intercostal space. Echocardiogram. Valvular replacement if there is a gradient \> 50 mm Hg, or at first indication of failure, angina, syncope.
280
What is the presentation of chronic aortic insufficiency?
Wide pulse pressure, blowing, high–pitched, diastolic heart murmur at second intercostal space and along the left lower sternal border. Valvular replacement at the first evidence on echocardiogram of LV dilatation.
281
What is the presentation of acute aortic insufficiency?
Endocarditis in young drug addicts may cause acute congestive heart failure and a new, loud diastolic murmur at the right second intercostal space. Treatment is valve replacement and long–term antibiotics.
282
What is the presentation of mitral stenosis?
Caused by rheumatic fever years before. Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, hemoptysis. Low–pitched, rumbling, diastolic, apical murmur. Cachectic; atrial fibrillation. Echocardiogram.
283
What is the treatment of mitral stenosis?
If symptoms: mitral commissurotomy or balloon valvuloplasty.
284
What is the presentation of mitral regurgitation?
Exertional dyspnea, orthopnea, and atrial fibrillation. Apical, high–pitched, holosystolic murmur that radiates to the axilla and back. If symptoms become disabling, annuloplasty is preferred over prosthetic replacement.
285
What is the presentation of coronary disease?
Middle– age sedentary man, with a family history, a history of smoking, type II diabetes, and hypercholesterolemia. Progressive, unstable, angina is an indicaton for cardiac catheterization and evaluation for revascularization.
286
What are the indications for intervention in coronary disease?
Intervention if \>70% stenosis, good distal vessel, and adequate ventricular function. Single vessel disease is treated with angioplasty/stent. Triple vessel disease is treated with coronary bypass using internal mammary.
287
What are the hemodynamic signs of left ventricular failure?
Cardiac output 20 suggests ventricular failure.
288
What is the presentation of chronic constrictive pericarditis?
Dyspnea on exertion, hepatomegaly, ascites. Catheterization shows square root sign equalization of pressures. Treatment is pericardectomy.
289
What is the treatment of small cell cancer of the lung?
Chemotherapy and radiation.
290
What is the most important factor in determining the operability of lung cancer?
Operability of lung cancer is predicated on residual function after resection. Central lesions require pneumonectomy. Peripheral lesions can be removed with lobectomy. A minimum FEV1 of 800 ml is needed after surgery.
291
What is subclavian steal syndrome?
Stenosis at origin of subclavian before takeoff of vertebral artery allows blood to reach arm. Exercise causes the arm to draw blood away from brain via vertebral artery, causing arm claudication, visual symptoms, disequilibrium.
292
What is the indication for repair of aortic aneurysms?
If the aneurysm 5–6 cm, the patient should have elective repair because chance of rupture is very high. A tender abdominal aortic aneurysm will rupture within a day, and immediate repair is indicated.
293
What is the presentation of ruptured aortic aneurysm?
Excruciating back pain with a large abdominal aortic aneurysm indicates that the aneurysm is leaking. Retroperitoneal hematoma is forming, and rupture into the peritoneal cavity will occur in minutes. Emergency surgery is required.
294
What are the signs of arteriosclerotic occlusive disease of the lower extremities?
First manifestation is pain brought about by walking and relieved by rest (intermittent claudication). If claudication does not interfere with patient's lifestyle, no evaluation is indicated. Cessation of smoking, exercise, cilostazol are beneficial.
295
What is the evaluation of atherosclerotic occlusive disease?
Disabling intermittent claudication is evaluated with Doppler. Arteriogram to identify stenosis. Short stenotic segments can be treated with angioplasty/stenting. Extensive disease requires saphenous vein grafts, sequential stents.
296
What is rest pain?
Pain in the calf that prevents sleep. Sitting up and dangling the leg over the edge of the bed relieves the pain. Shiny atrophic skin without hair, and no peripheral pulses.
297
What is the presentation of arterial embolic occlusion?
Occurs in atrial fibrillation or a MI (embolus from mural thrombus). Sudden painful, pale, poikilothermic, pulseless, paresthetic, paralytic extremity.
298
What is the treatment of arterial embolic occlusion?
Heparin should be initiated. Doppler will locate obstruction. Early occlusion may be treated with thrombolytics. Embolectomy with Fogarty catheter for complete obstructions. Fasciotomy should be added if muscle ischemia has occurred.
299
What is the presentation of dissecting aneurysm of the thoracic aorta?
Occurs in the poorly controlled hypertensive. Sudden, severe, tearing chest pain that radiates to back and migrates down. Unequal pulses in upper extremities. X–ray: wide mediastinum. Normal ECG and cardiac enzymes rule out MI. Spiral CT.
300
What is the treatment of dissecting aneurysms of the thoracic aorta?
Dissections of the ascending aorta are treated surgically, whereas those in the descending are managed medically with control of the hypertension.
301
What is the presentation of basal cell carcinoma?
Raised waxy lesion, or a nonhealing ulcer with a preference for the upper part of the face (above the lips). It does not metastasize, but can cause local invasion. Local excision with 1 mm margins is curative.
302
What is the presentation of squamous cell carcinoma of the skin?
Nonhealing ulcer with a preference for the lower lip (and below the lips); can metastasize to lymph nodes. Excision with 0.5 to 2 cm margin, and node dissection. Radiation treatment is another option.
303
What is the presentation of melanoma?
Originates in a pigmented lesion. Melanomas are asymmetric (A), have irregular borders (B), have different colors (C) within the lesion, and have a diameter (D) that exceeds 0.5 cm.
304
What is the treatment of melanoma?
Lesions 4 mm have a poor prognosis. Lesions between 1 and 4 mm benefit from chemotherapy, node dissection.
305
What is amblyopia?
Vision impairment from interference with processing of images during first 6 years. If strabismus is not corrected, there will be permanent cortical blindness. If vision is impeded by congenital cataract, amblyopia will develop.
306
What is the presentation of strabismus?
The reflection from a light comes from different areas of cornea in each eye. Strabismus should be surgically corrected when diagnosed to prevent the development of amblyopia.
307
What causes of a white pupil in a baby?
Retinoblastoma.
308
What is the presentation of acute angle closure glaucoma?
Severe eye pain or frontal headache, starting when pupils were dilated for several hours (watching TV in dark). Halos around lights. Pupil is mid–dilated and does not react to light, cornea is cloudy with a greenish hue, eye feels hard.
309
What is the treatment of angle closure glaucoma?
Iridoplasty in which a hole is made in iris to drain anterior chamber. Administer carbonic anhydrase inhibitor (Diamox), apply topical beta–blockers, alpha–2–selective adrenergic agonists. Mannitol and pilocarpine may also be used.
310
What is the presentation of orbital cellulitis?
Eyelids are warm, tender, red, and swollen; fever. The pupil is dilated and fixed, and the eye has limited motion. There is pus in the orbit. Emergency CT scan. Treatment is drainage.
311
What is the presentation of retinal detachment?
The patient sees flashes of light andfloaters or a snow storm" within the eye or a big dark cloud at top of his visual field. Emergency laser "spot welding" will protect the remaining retina."
312
What is the presentation of embolic occlusion of the retinal artery?
Elderly patient with sudden loss of vision from one eye. Treatment is having the patient breathe into a paper bag and apply repeatedly pressure to vasodilate and shake the clot into a more distal location.
313
What is a thyroglossal duct cyst?
Located on the midline, at the level of the hyoid bone, and is connected to the tongue; 1 or 2 cm in diameter. Treatment is removal of cyst, middle segment of hyoid bone, and track that leads to base of tongue.
314
What are branchial cleft cysts?
Located along the anterior edge of the sternomastoid muscle, several centimeters in diameter, and sometimes have a small opening in the skin overlying them.
315
What is the presentation of cystic hygroma?
Located at the base of the neck as a large, soft, ill–defined mass that occupies the entire supraclavicular area and extends deeper into the chest. Often extend into the mediastinum. CT scan is necessary before surgical removal.
316
What is the presentation of lymphoma?
Typically seen in young adults with multiple enlarged nodes, low fever, night sweats. Usually a node is excised for pathologic study to determine specific type of lymphoma.Treatment is chemotherapy.
317
What is the presentation of squamous cell carcinoma of the head and neck?
Elderly men who smoke, drink, and have dental decay; and patients with AIDS. First sign is metastatic node in neck. Panendoscopy for primary tumor. Treatment is resection, radical neck dissection, radiotherapy, and chemotherapy.
318
What is the presentation of acoustic nerve neuroma?
Suspected in an adult who has sensory hearing loss in one ear, but not the other. MRI is the best diagnostic modality.
319
What is the presentation of facial nerve tumors?
Gradual unilateral facial nerve paralysis affecting the forehead and the lower face. (sudden onset of facial paralysis suggests Bell palsy.) Gadolinium–enhanced MRI is the best diagnostic study.
320
What is the presentation of pleomorphic, parotid adenomas?
Painless, palpable, soft mass around angle of mandible. Benign but have potential for malignant degeneration.
321
What is the presentation of parotid gland cancer?
A hard, painful parotid mass or a mass with paralysis is most likely a parotid cancer.
322
What is the presentation of Ludwig angina?
Abscess of the floor of the mouth caused by a dental infection. Incision and drainage are done, but intubation and tracheostomy may also be needed.
323
What is the presentation of Bell palsy?
Sudden paralysis of the facial nerve. Treatment is acyclovir, famciclovir, or valacyclovir.
324
What is the presentation of cavernous sinus thrombosis?
Diplopia (from paralysis of extrinsic eye muscles) in a patient with frontal or ethmoid sinusitis. Requires hospitalization, IV antibiotics, CT scans, and drainage of the affected sinuses.
325
What are the causes of epistaxis?
Digital trauma causes bleeding from anterior septum. Cocaine abuse (septal perforation) or juvenile nasopharyngeal angiofibroma. Elderly and hypertensive nosebleeds can be life–threatening.
326
What is the treatment of epistaxis?
Phenylephrine spray and pressure controls bleeding. BP should be controlled; posterior packing. Surgical ligation of vessels may be necessary.
327
What are the causes of dizziness?
Dizziness may be caused by inner ear disease or cerebral disease. When the inner ear is the cause, the room spins. When the problem is in the brain, the patient is unsteady but the room is stable.
328
What is the treatment of peripheral vertigo?
Peripheral vertigo is treated with meclizine, Phenergan, or diazepam.
329
What is the presentation of ischemic stroke?
Sudden onset of neurologic deficits occurs without headache when the deficits are caused by an arterial occlusion.
330
What is the presentation of hemorrhagic stroke?
Neurologic deficit associated with very severe headache.
331
What is the presentation of brain tumors?
Constant, progressive, severe headache with neurologic deficits, worse in the mornings, developing over months. As ICP increases, blurred vision, projectile vomiting, and focal deficits develop.
332
What is the presentation of infectious neurologic problems, such as meningitis?
Infectious neurologic problems develop over days and there is an identifiable source of infection. Metabolic problems develop over hours to days and affect the entire CNS. Degenerative diseases develop over years.
333
What are transient ischemic attacks?
Sudden, transitory loss of neurologic function without headache which resolves without sequela. Most common origin is stenosis of internal carotid, or ulcerated plaque at carotid bifurcation. TIAs are predictors of stroke.
334
What is the evaluation of transient ischemic attack?
Duplex studies (sonogram plus Doppler) followed by arteriogram. Carotid endarterectomy is indicated if the lesions are found in the location that explains the neurologic symptoms.
335
What is the presentation of ischemic stroke?
Sudden onset with the neurologic deficits that last for more than 24 hours, leaving permanent sequela without headache. Ischemic strokes are not amenable to carotid endarterectomy
336
What is the evaluation of cerebrovascular accidents?
CT scan to rule out extensive infarcts or the presence of hemorrhage. Intravenous infusion of tissue–type plasminogen activator (t–PA) is best if started within 90 minutes up to 4 hours after the onset of symptoms.
337
What is the presentation of intracranial bleeding?
Hemorrhagic stroke occurs in uncontrolled hypertension with a sudden, severe headache, followed by neurologic deficits. CT is used to evaluate location and extent of hemorrhage, and therapy is directed at control of hypertension.
338
What is the presentation of subarachnoid bleeding from intracranial aneurysms?
Extremely severe headache of sudden onset (thunderclap"). Because the blood is in the subarachnoid space there may be no neurologic findings. Meningeal irritation and nuchal rigidity is present."
339
What is the treatment of subarachnoid hemorrhage?
CT should be done, looking for blood in subarachnoid space (spinal tap can identify blood that is not visible on CT), and follow with arteriogram to locate the aneurysm of the circle of Willis. Therapy is clipping of aneurysm.
340
What are the symptoms of brain tumors?
Progressively increasing headache for several months, worse in mornings, and signs of increased ICP: blurred vision, papilledema, projectile vomiting, bradycardia, hypertension (Cushing reflex). MRI has better detail for tumors.
341
What is the acute management of increased intracranial pressure caused by brain tumors?
Increased ICP is treated with high–dose dexamethasone, while awaiting surgical removal.
342
What are the signs of a tumor at the base of the frontal lobe?
Inappropriate behavior, optic nerve atrophy on the side of the tumor, contralateral papilledema, and anosmia (Foster–Kennedy syndrome).
343
What is the presentation of craniopharyngioma?
Occurs in children who are short for their age with bitemporal hemianopsia and a calcified lesion above the sella turcica.
344
What is the presentation of prolactinomas?
Amenorrhea and galactorrhea in young women. Diagnostic evaluation includes pregnancy test, thyroid function tests for hypothyroidism, prolactin level, and MRI of the sella.
345
What is the treatment of prolactinomas?
Therapy with bromocriptine is used in most cases. Transnasal, trans–sphenoidal surgical removal is reserved for patients who desire pregnancy, or who fail to respond to bromocriptine.
346
What is the presentation of acromegaly?
Large hands, feet, tongue, and jaws. Hypertension, diabetes, headache, and hats that no longer fit.
347
How is acromegaly diagnosed?
Somatomedin C and pituitary MRI. Surgical removal is preferred, but radiation is an option.
348
What is the presentation of pituitary apoplexy?
Bleeding into a pituitary tumor. Headache, visual loss, headache, followed by signs of compression of nearby structures by hematoma (deterioration of vision, bilateral optic nerve pallor), and pituitary destruction (stupor, hypotension).
349
What is the treatment of pituitary apoplexy?
Immediate steroid replacement and replacement of other pituitary hormones. MRI scan.
350
What are the signs of pineal gland tumors?
Loss of upper gaze and sunset eyes" (Parinaud syndrome)."
351
What is the most common location of brain tumors in children?
Tumors in children are most commonly located in the posterior fossa. Cerebellar symptoms (stumbling, truncal ataxia); children often assume the knee–chest position to relieve headache.
352
What is the presentation of brain abscesses?
Headache, signs of increased ICP: blurred vision, papilledema developing over 1–2 weeks. Fever and a source of the infection, such as otitis media or mastoiditis. CT is diagnostic. Drainage is required.
353
What is the presentation of spinal cord tumors?
Most tumors affecting the spinal cord are metastatic and extradural. Metastases may compress the cord directly, or may cause a vertebral fracture which compresses the cord. MRI is the best diagnostic modality for the spinal cord.
354
What is neurogenic claudication?
Occurs in elderly with pain caused by walking and relieved by rest. The patient can walk without pain when hunched over. Pain is not relieved by rest. Pain is relieved by bending over. The cause is spinal stenosis.
355
What is the presentation of trigeminal neuralgia?
Tic douloureux is severe, sharp, shooting, pain in face, triggered by touching cheek. Lasts 60 sec. Patients are in sixties, and have a normal neurologic exam. MRI rules out organic lesions. Anticonvulsants, radiofrequency ablation.
356
What is the presentation of reflex sympathetic dystrophy?
Several months after a crushing injury. Severe, constant, burning pain that does not respond to analgesics. Pain is aggravated by slight stimulation of area. Extremity is cold, cyanotic, moist. Sympathetic block is diagnostic. Treatment is sympathectomy.
357
What is the presentation of acute epididymitis?
Seen in sexually active young men with severe testicular pain of sudden onset. Fever, pyuria, swollen and tender testis in normal position. Spermatic cord is very tender. Ultrasound is done to exclude torsion.
358
What is the presentation of obstruction and infection of the urinary tract?
Destruction of the kidney may occur in a few hours with death from sepsis. A patient with a ureteral stone suddenly develops chills, fever spike (104 F), and flank pain.
359
What is the treatment of septic obstruction of the urinary tract?
IV antibiotics, immediate decompression of the urinary tract above the obstruction. Ureteral stent or percutaneous nephrostomy.
360
What is the presentation of acute bacterial prostatitis
Seen in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and a tender prostate. Antibiotics are indicated. Continued prostatic massage could lead to septic shock.
361
What is the presentation of posterior urethral valves?
Posterior urethral valves are most common reason a newborn boy can not urinate on first day. Catheterization is done. Voiding cystourethrogram is diagnostic, and endoscopic fulguration or resection will remove the valves.
362
What is the presentation of hypospadias?
The urethral opening is on the ventral side of the penis. Circumcision should never be done because the skin of the prepuce will be needed for the plastic reconstruction that will eventually be done.
363
What is the presentation of vesicoureteral reflux and infection?
Dysuria, frequency, low abdominal and perineal pain, flank pain, fever, chills in a child. Obtain a voiding cystogram looking for reflux. If reflux is found, long–term antibiotics are used for prevention.
364
What is the presentation of low implantation of a ureter?
Patient voids normally, but is constantly wet with urine (urine drips from low implanted ureter). If physical examination does not find the abnormal ureteral opening, IVP will demonstrate opening.
365
What is the presentation of ureteropelvic junction obstruction?
An anomaly at UPJ allows normal urinary output to flow without difficulty, but if a large diuresis occurs, the narrow area impairs flow, causing colicky flank pain.
366
What is the most common presentation of cancers of the kidney, ureter, and bladder?
Hematuria is the most common presentation for cancers of the kidney, ureter, or bladder. Most cases of hematuria are caused by benign disease.
367
What is the evaluation of hematuria?
Evaluation begins with a CT scan, looking for renal or ureteral tumors, and continues with cystoscopy, which rules out cancer of the bladder.
368
What is the presentation of renal cell carcinoma?
Hematuria, flank pain, and a flank mass. Hypercalcemia, erythrocytosis, and elevated liver enzymes. CT gives the best detail, showing the mass to be heterogenic solid tumor. Treatment is surgery.
369
What is the presentation of transitional cell cancer?
Hematuria, irritative voiding symptoms. Correlation with smoking. Diagnosis is by cystoscopy. Treatment is surgery and intravesical Bacillus Calmette–Guerin vaccine. High rate of recurrence requires follow–up.
370
What is the presentation of prostatic cancer?
Increases with age. Most asymptomatic. Detected by rectal exam (rock–hard nodule) and prostatic specific antigen. Surveillance stops at age 75. Transrectal needle biopsy. CT assess extent of disease.
371
What is the treatment of prostatic cancer?
Surgery and/or radiation. Widespread bone metastases respond for a few years to androgen ablation, surgical (orchiectomy) or luteinizing hormone–releasing hormone agonists, or antiandrogens (flutamide).
372
What is the presentation of testicular cancer?
Affects young men, in whom it presents as a painless testicular mass. Testicular tumors are almost always malignant.
373
What is the treatment of testicular cancer?
Radical orchiectomy. Blood samples for alpha–fetoprotein and beta– human chorionic gonadotropin. Lymph node dissection in some cases. Most testicular cancers are radiosensitive and chemosensitive.
374
What is the presentation of acute urinary retention?
Common in benign prostatic hypertrophy. Precipitated by antihistamines, nasal drops, high fluids. Bladder is palpable. Indwelling catheter should be placed. Therapy is alpha–blockers. 5–Alpha–reductase inhibitors for large prostates.
375
What is the surgical treatment of benign prostatic hyperplasia?
Minimally invasive laser heat to destroy prostatic tissue. Microwaves, radiofrequency energy, high–intensity ultrasound waves, high–voltage electrical energy. Transurethral resection of prostate (TURP) is rarely done.
376
What is the presentation of postoperative urinary retention?
Very common. The patient may not feel the need to void because of pain medication. Involuntary release of urine every few minutes. Distended bladder will be palpable. An indwelling bladder catheter is needed.
377
What is the presentation of stress urinary incontinence?
Common in middle–age multiparas. Leakage of small amounts of urine with intraabdominal pressure caused by sneezing, laughing, lifting. Incontinence does not occur at night. Weak pelvic floor with prolapsed bladder neck.
378
What is the presentation of nephrolithiasis?
Passage of ureteral stones produces colicky flank pain with radiation to inner thigh, labia/scrotum. Most are visible on x–rays or CT. Stones
379
What liver condition is associated with an elevated alpha–fetoprotein?
Hepatocellular carcinoma
380
What is the presentation of perforated peptic ulcer?
Sudden, severe abdominal pain radiating to back and shoulders, nausea, vomiting, rebound tenderness, guarding
381
What is the management of perforated peptic ulcer when free air is present under the diaphragm?
Surgery
382
How is severe upper gastrointestinal bleeding managed?
ABC's, IV fluids, nasogastric suction, gastric lavage with normal saline, blood transfusion
383
What is the treatment of gastrointestinal bleeding that does not respond to endoscopic treatment?
Surgery
384
What are the causes of upper GI bleeding?
Duodenal ulcer (40%), gastric ulcer (20%), gastritis (20%), varices (10%), Mallory–Weiss tear (10%)
385
What percentage of gastric tumors are malignant?
95% are carcinomas
386
What are the symptoms of gastric cancer?
Pain, anorexia, weight loss
387
What are the risk factors for gastric cancer?
Age \>60, nitrites in diet, chronic gastritis
388
What is a Krukenberg tumor?
Metastases to the ovary of a gastrointestinal malignancy
389
What is a Virchow's node?
Metastases to the left supraclavicular fossa
390
List the risk factors for cholelithiasis
Fertile, fat, forty, female
391
What are the types of gallstones?
Cholesterol 75%, pigment stones 25%
392
What is the initial diagnostic test for cholelithiasis?
RUQ ultrasound
393
What are the complications of cholelithiasis?
Acute cholecystitis, choledocholithiasis, gallstone pancreatitis, gallstone ileus, cholangitis
394
What is acute cholecystitis?
Blockage of the cystic duct by an impacted stone, resulting in inflammation, infection, gangrene of gallbladder
395
What is Murphy's sign?
Inspiratory arrest upon deep palpation of RUQ in cholecystitis
396
What is the presentation of cholecystitis?
Fever, nausea, tender gallbladder, leukocytosis, referred right side subscapular pain
397
What test is indicated when acute cholecystitis is suspected, but the ultrasound is equivocal?
Hepatobiliary iminodiacetic acid (HIDA) scan. Failure to visualize the gallbladder is diagnostic of acute cholecystitis
398
How is acute cholecystitis treated?
IV fluids, antibiotics, cholecystectomy
399
How is choledocholithiasis treated?
Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and stone removal
400
What are the complications of choledocholithiasis?
Cholangitis, pancreatitis
401
What are the signs and symptoms of obstructive jaundice?
Jaundice, pruritus, dark urine, clay–colored stool, weight loss
402
RUQ pain, jaundice, fever/chills are part of what triad?
Charcot's triad of cholangitis
403
What is Courvoisier's sign?
Painless enlargement of the gallbladder, jaundice caused by cancer of the head of the pancreas
404
What are the common lab abnormalities in cholangitis?
Leukocytosis, elevated direct bilirubin, increased alkaline phosphatase (bile duct obstruction from inflammation)
405
What organism is the cause of cholangitis?
E coli
406
How is cholangitis treated?
IV fluids, antibiotics, endoscopic retrograde cholangiopancreatography with papillotomy
407
What disorder commonly occurs with sclerosing cholangitis?
Inflammatory bowel disease
408
What is the surgical procedure for distal cholangiocarcinoma?
Whipple procedure, consisting of pancreaticoduodenectomy
409
What are the causes of acute pancreatitis?
Gallstones, ethanol, ERCP, trauma, steroids, mumps and other viruses, autoimmune disorders, scorpion stings, hypertriglyceridemia, didanosine
410
What is Cullen's sign?
Periumbilical ecchymosis in hemorrhagic pancreatitis
411
What is Grey–Turner sign?
Flank ecchymoses in hemorrhagic pancreatitis
412
pancreatitis
Systemic inflammatory response syndrome, necrosis, pseudocyst, pancreatic ascites, fistula, cystic duct obstruction, intestinal obstruction
413
Name two signs of acute pancreatitis on abdominal x–ray
Sentinel loop of dilated bowel in LUQ next to inflamed pancreas. Colon cutoff sign: Distended transverse colon and absence of colonic gas distal to splenic flexure.
414
Severe pancreatitis should be evaluated by what radiologic study?
Abdominal CT
415
How should suspected gallstone pancreatitis be evaluated?
Ultrasound of RUQ for gallstones
416
Prognosis in acute pancreatitis is estimated by what criteria?
Ranson's criteria: 1–2 (
417
What are Ranson's criteria for acute pancreatitis at presentation?
Age \>55, WBC \>16,000, glucose \>200, AST \> 250, LDH \>350
418
What are Ranson's criteria for acute pancreatitis at 48 hours?
Base deficit \>4, increase in BUN \>5, fluid sequestration \>6 L, Ca2+ 10%, PaO2
419
List the four common laboratory abnormalities in acute pancreatitis
Hyperamylasemia within 24 h, hyperlipasemia within 72–96 h, hypocalcemia, glycosuria
420
What are the indications for drainage of a pancreatic pseudocyst?
Cyst \>6 cm for 6 weeks, or infection of the pseudocyst
421
What are five common causes of chronic pancreatitis?
Alcoholism, biliary tract disease, cystic fibrosis, hypercalcemia, pancreas divisum
422
How does a mass of the pancreatic head usually present?
Obstructive, painless jaundice, malabsorption, Courvoisier's gallbladder (enlarged, palpable gallbladder)
423
Name the serologic markers for pancreatic cancer
Carcinoembryonic antigen, CA 19–9
424
A tumor of the head of the pancreas should be treated with what surgical procedure?
Whipple procedure (pancreaticoduodenectomy)
425
What is the most common benign liver tumor?
Hemangioma
426
What is the most common primary liver cancer?
Hepatocellular carcinoma (hepatoma)
427
What is the most common type of liver cancer?
Metastatic cancer
428
Name the liver tumor that is associated with oral contraceptives and anabolic steroids.
Hepatic adenoma
429
How is hepatic adenoma treated?
Discontinuation of birth control pills and observation
430
What is the most common cause of parasitic liver abscesses?
Entamoeba histolytica
431
What is the sign of Pseudomonas aeruginosa infection of wounds and burns?
Fruity odor
432
What are the major risk factors for hepatocellular carcinoma?
Wilson's disease, alpha–1–antitrypsin deficiency, carcinogens, hemochromatosis, alcoholic cirrhosis, hepatitis B, hepatitis C
433
What are two factors that contribute to the formation of hernias?
Increased intraabdominal pressure (lifting, straining, cough, pregnancy, ascites, obesity) and congenital defects
434
What is an indirect inguinal hernia?
Inguinal hernia that protrudes from the peritoneal cavity lateral to the epigastric vessels
435
What is a direct inguinal hernia?
Inguinal hernia that protrudes from the peritoneal cavity medial to the epigastric vessels
436
What is a femoral hernia?
Hernia that protrudes through the femoral sheath in the femoral canal medial to the femoral vein
437
What is the name of the hernia that protrudes through esophageal hiatus?
Hiatal hernia
438
What type of hernia is incarcerated and only involves one side of th bowel wall?
Richter's hernia
439
What is the most common hernia in both males and females?
Indirect inguinal hernia; the hernia that protrudes from the peritoneal cavity lateral to the epigastric vessels
440
What type of hernia is more common in females than males?
Femoral hernia
441
What are the symptoms and signs of small bowel obstruction?
Abdominal discomfort or pain, nausea, vomiting, distension, cramping, high–pitched bowel sounds
442
Name the two most common causes of small bowel obstruction
Adhesions, hernias
443
How should adhesive small bowel obstruction be treated initially?
NPO, IV fluids, nasogastric suction
444
Name the signs of small bowel obstruction on abdominal x–ray
Distended bowel loops, air–fluid levels, paucity of gas in colon
445
What is the typical acid–base disturbance caused by small bowel obstruction?
Hypovolemic hypochloremic hypokalemic alkalosis caused by vomiting
446
What is the presentation of large bowel obstruction?
Cramping, abdominal pain, distention, nausea, feculent vomitus
447
List the three most common causes of large bowel obstruction
Colon cancer, diverticulitis, volvulus
448
Name the two most common causes of lower GI bleeding
Diverticulosis, angiodysplasia
449
Rectal cancer usually presents with what findings?
Hematochezia, tenesmus, incomplete evacuation of stool
450
After treatment of colon cancer, what marker should be followed?
Carcinoembryonic antigen
451
How does appendicitis classically present?
Periumbilical pain, followed by nausea and vomiting, anorexia; followed later by right lower quadrant pain
452
In patients with appendicitis, what is the chronological order in which pain, nausea, and vomiting occur?
Pain usually occurs before nausea and vomiting in appendicitis; however, in gastroenteritis, nausea and vomiting occur before pain.
453
What laboratory tests should be ordered for suspected appendicitis?
CBC, urinalysis, beta–hCG, radiographs of abdomen, chest x–ray, abdominal ultrasound
454
Ovarian causes of abdominal pain should be evaluated with what test?
Ultrasound
455
Where on the abdomen is McBurney's point?
Point of maximal tenderness located one–third of the distance from the anterior iliac spine to the umbilicus associated with appendicitis
456
When palpation of the left lower quadrant causes pain in the right lower quadrant, what sign is present?
Rovsing's sign associated with appendicitis
457
What is the obturator sign?
Pain on internal rotation of the leg with the hip and knee flexed, suggesting appendicitis
458
What is the management of abscess caused by appendicitis?
Percutaneous drainage, antibiotics, appendectomy in 6–8 weeks
459
What is the most common tumor of the appendix?
Carcinoid tumor
460
What substances do carcinoid tumors secrete?
Serotonin, histamine, prostaglandins
461
What is the second most common cause of cancer death in women?
Breast cancer
462
What area of the breast is the most common site of breast cancer?
Upper outer quadrant
463
List the classic symptoms and signs of breast cancer?
Mass, dimple, nipple retraction, nipple discharge, rash, edema, enlarged axillary lymph node
464
How should a nonpalpable, suspicious lesion on mammography be evaluated?
Stereotactic or needle localized excisional biopsy
465
What is the most common cause of bloody nipple discharge?
Intraductal papilloma
466
What is Paget's disease of the breast?
Invasion of epidermal layers of the skin near the nipple by tumor cells
467
What is mastitis?
Infection of the breast, usually caused by Staphylococcus aureus, associated with breast feeding
468
What is the treatment of breast fibroadenoma?
Observation or excisional biopsy
469
What is the treatment of breast mastitis?
Cephalexin (Keflex) or dicloxacillin and continued breast feeding
470
What is the treatment for breast ductal carcinoma in situ?
Lumpectomy plus radiotherapy or total simple mastectomy
471
What is the treatment for lobular carcinoma in situ?
Close follow–up or bilateral simple mastectomy in high–risk patients
472
What is the best treatment for invasive breast carcinoma?
Lumpectomy plus radiotherapy or modified radical mastectomy (chemotherapy optional for both); sentinel lymph node biopsy and axillary lymph node dissection.
473
What are the recommendations for breast cancer screening?
Monthly self–breast examinations, annual breast examinations by physician after 40 years old, annual mammograms after 40 years old.
474
List the major risk factors for peripheral vascular disease?
Smoking, diabetes
475
What are two common symptoms of peripheral vascular disease?
Intermittent claudication, ischemic rest pain
476
List the signs of peripheral vascular disease?
Absent pulses, atrophic skin changes (shiny skin, hair loss, thick toenails), dependent rubor, muscle atrophy, gangrene of skin
477
What is claudication?
Reproducible lower extremity pain, usually calves, exacerbated by walking and relieved by rest
478
What percentage of patients with leg claudication will lose a limb in 5 years?
5%. Claudication is not a limb–threatening condition
479
What is ischemic rest pain of the foot?
Severe foot pain at rest caused by peripheral vascular disease
480
How do patients with ischemic rest pain obtain partial pain relief?
Hanging the foot over the side of the bed in a dependent position
481
What is the prognosis for ischemic rest pain of the lower extremity?
Ischemic rest pain is limb–threatening because 85% of patients will lose the limb in 5 years
482
What test is the gold standard for diagnosis of peripheral vascular disease?
Arteriogram
483
Initial management of peripheral vascular disease consists of what conservative measures?
Smoking cessation, exercise, aspirin, clopidogrel (Plavix)
484
List the interventional options for peripheral vascular disease
Percutaneous transluminal angioplasty, surgical revascularization, amputation
485
When is surgery indicated for peripheral vascular disease?
Rest pain, loss of tissue, incapacitating claudication
486
Name the ?six P's? that indicate acute arterial occlusion
Pain, Pallor, Pulselessness, Paralysis, Poikilothermia (cold), Paresthesias
487
Acute arterial occlusion is most commonly cause by what cause?
Embolization, usually from the heart thrombi in 85%
488
What is the medical treatment for acute arterial occlusion?
Heparin
489
What is the treatment for compartment syndrome of an extremity?
Emergent fasciotomy
490
What are the five risk factors for abdominal aortic aneurysm?
Atherosclerosis, smoking, hypertension, age \>60 years, male gender
