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Uworld Surgery-shelf > Aortic & Peripheral Artery Disease > Flashcards

Aortic & Peripheral Artery Disease Flashcards

1
Q

PAD

A
  1. Acute Limb ischemia in the setting of chronic PAD often occurs less dramatically than in patient with WITHOUT PAD. Emergency intervention is necessary (embolectomy, thrombolysis, & endovascular)
  2. ABI index to confirm presence of PAD ( >1.3 = calcified & incompressible vessel; 1 = normal; <0.6= claudication; <0.4= ischemia/reset pain)
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2
Q

Lower extremely arterial injury

A
  1. Hard signs of vascular injury includes ( pulsatile bleeding, bruits/thrills, hematoma at site of injury, & distal ischemia/absent of pulses/cool extremely) require urgent surgical exploration of the wound
  2. Soft signs of vascular injury includes (history of hemorrhage, no pulses, bone injury & neurologic abnormality) require injured extremity index (ABI), CT scan/angiography, or Duplex doppler US.
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3
Q

Atrial fibrillation

A

Irregularly irregular

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4
Q

Premature ventricular complex (PVC)

A

Widen QRS

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5
Q

Ventricular aneurysm

A

ST elevation

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6
Q

Ischemia

A
  1. ST elevation
  2. ST depression
  3. Inverted T wave
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7
Q

Infraction

A

Q wave

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8
Q

Pericarditis

A

ST elevation throughout leads

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9
Q

Right Bundle Branch Block (RBBB)

A
  1. Wide QRS

2. R-R in V1 or V2

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10
Q

Left Bundle Branch Block (LBBB)

A
  1. Wide QRS

2. R-R in V5 or V6

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11
Q

Aortic dissection

A

Sign:

  1. Tearing chest pain that radiates to the back/neck/abdomen
  2. Asymmetrical pulses between arms/ Hypotension/ aortic regurgitation
  3. X-ray shows: widened mediastinum ( widened cardiac silhouette) & pleural effusion (due to hemothorax)
  4. CT scan: intimal flap (double aortic lumen) (CTA)
  5. Episodes of syncope (> 20mm Hg variation in SPB between arms)

Treatment:

  1. Medical (Sodium nitroprusside, Beta blockers, morphine)
  2. Emergent surgical repair for ascending dissection

Risk factor:

  1. HTN
  2. Connective tissue disease (Marfan syndrome)
  3. Cocaine use
  4. BLUNT AORTIC INJURY (incomplete rupture= tear of intima/ tear of intima & media/ psuedocoarctation; complete rupture)

Complication:

  1. Stroke
  2. Aortic regurgitation
  3. Pericaridal effusion/temponade
  4. MI

DIAGNOSIS:

  1. CTA (stable) —> MR-A (more time consuming)
  2. TEE (unstable patient & with kidney disease)

Types:
1. Type A: ascending aorta dissection that rupture in pericardial space & lead to pericardial temponade & cardiogenic shock (signs: chest pain, syncope, stroke, MI, hypotension, aortic regurgitation, asymmetrical pulses/ upper extremity)

Associated with:
1. Turner syndrome ( bicuspid aortic valve/ aortic coarctation & HTN)

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12
Q

Pulmonary embolism

A

Sign:

  1. Chest pain (pleuritic) with Hypotension & JVD
  2. Tachycardia
  3. SOB
  4. Elevated D-dimer
  5. Pleural effusion
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13
Q

Blunt thoracic aortic injury (BTAI)

A

Causes:
1. Blunt chest trauma (car accident, fall from heights)

Sign:
1. Incomplete rupture
*tear to intima
*tear to intima & media
*psuedocoarctation (upper extremity HTN & lower
extremity hypotension)
2. Complete rupture

Symptoms:

  1. Upper extremity HTN/lower extremity hypotension
  2. Hoarseness of voice (compression on recurrent laryngeal nerve)

Initial diagnosis:
1. Chest x-ray: widen mediastinum & left-sided hemothorax (effusion) & abnormal aortic contour

Confirm diagnosis:

  1. Stable patient: CT angiography (CTA)
  2. Unstable patient/hypotension: Transesophaheal Echocardiography (TEE)
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14
Q

Indication of amputation

A

Signs:

  1. Non-revascularizable limb ischemia
  2. Unsalvageable soft-tissue damage
  3. Life-threatening infection (infected gangrene)

Example:
1. Patient with PAD & gangrene with signs of infection —> perform amputation to remove infectious source & prevent sepsis

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15
Q

AAA rupture

A

Risk factor associated with AAA:

  1. Smoking
  2. Advanced age >60
  3. male
  4. HTN
  5. History of atherosclerosis

*note: uncontrolled diabetes does not contribute to AAA

Sign:

  1. Abdominal pulsatile mass
  2. Hypotension
  3. Bruits/ tenderness between epigastrium/periumbilicus

Symptoms:

  1. Abdominal/flank/back/groin pain
  2. Ecchymosis (hematoma) at flank
  3. limb ischemia
  4. Pulsatile mass

Investigation:

  1. X-ray: perivertebral aortic calcification (extensive atherosclerosis)

Diagnosis:

  1. Abdominal U/S = unstable
  2. Abdominal CT = stable

Treatment:
1. Surgical repair (endovascular)

*Note: bowel ischemia/infraction is a complication of AAA repair

Note:

  1. Femoral & popliteal aneurysms are associated with AAA —> present as pulsatile mass that compress (nerve/vein) & lead to thrombosis & ischemia
  2. Ruptured AAA: acute onset of severe abdominal or flank pain + syncope +pulsatile abdominal mass + flank/abdominal hematoma
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16
Q

Leriche syndrome (aortoiliac occlusion)

A

Sign:

  1. Claudication of buttocks, hip, thigh
  2. Absent of femoral pulse + symmetric atrophy of lower extremity muscles (due to ischemia)
  3. Impotence
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17
Q

Ankylosing spondylitis

A
  1. Associated with aortic regurgitation

Sign of AS:

  1. Chronic back pain
  2. Impaired spinal mobility
  3. Bilateral heal pain
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18
Q

Shock

A

Tachycardia + hypotension

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19
Q

Central venous pressure (CVP) measured by central venous catheter

A
  1. Pressure at the superior vena cava, where the tip of catheter is located
  2. Equal to the right-atrial pressure = preload

Note:

  1. Low CVP (LOW PRELOAD)—> hypovolemic or distributive shock
  2. High CVP (high preload) —> cardiogenic & obstructive

Note:

  1. Hypovolemic shock = hemorrhage
  2. Distributive shock = anaphylaxis
  3. Cardiogenic shock = Blunt cardiac injury
  4. Obstructive shock = cardiac tamponade, PE, pneumothorax
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20
Q

Cardiovascular contraindication to pregnancy

A
  1. Symptomatic mitral stenosis
  2. Symptomatic aortic stenosis
  3. Symptomatic heart failure with LVEF <30%
  4. Pulmonary arterial hypertension
  5. Bicuspid aortic valve with ascending aorta enlargement >50mm

Hemodynamic changes:

  1. Increase in blood volume up to 50% increase in CO by second trimester
  2. Stenotic valvular disease poorly tolerated than regurg. Disease.

Treatment:
1. Percutaneous mitral intervention should be performed prior to pregnancy

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21
Q

infective endocarditis

A

Heart failure is leading cause of death in patient with infective endocarditis
(Acute heart failure —> aortic/mitral regurg. )

Signs of Infective endocarditis:

  1. Fever
  2. Leukocytosis
  3. Mitral valve vegetation

Sign of heart failure:

  1. SOB
  2. Pulmonary edema
  3. Bilateral lower extremity edema
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22
Q

Left ventricular outflow tract obstruction (LVOT) in hypertrophic cardiomyopathy

A

Standing & valsalva strain phase:

  1. Decrease LV volume
  2. Worsen obstruction & accentuate murmur

Squatting & leg raises & handgrip:

  1. Increase LV volume
  2. Lessens obstruction & decrease murmur

Treatment:

  1. High LV end diastolic blood volume (preload) is improved by hydration & low heart rate & avoid venous dilator (nitroglycin)
  2. High LV end systolic blood volume is improved by low stroke volume & low contractility
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23
Q

Mitral regurgitation

A
  1. Mitral valve repair is recommended in patients with Ejection fraction of 30%-60%, asymptomatic, or symptomatic
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24
Q

Arteriovenous fistula & hemodialysis

A
  1. Access between cephalic vein & radial artery
  2. The fistula forms an enlarged vein, which serves as an access point (for hemodialysis) & facilitates adequate blood flow to/from the hemodialysis machine
  3. AV fistula can lead to hemodynamic changes
    • decrease afterload (by decreasing SVR)
    • increase preload (increasing RAP; venous return)
    • increase CO (by decrease SVR & increase venous Return)
  4. Marked changes in these parameters can lead to high-output heart failure

Note:

  1. An AV-fistula allows blood to bypass the high-resistance systemic capillaries, resulting in decreased systemic vascular resistance (afterload), increased venous reture (preload), & increased cardiac output.
  2. A large AV-fistula can lead to high-output heart failure
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25
Q

Primary adrenal insufficiency (adrenal crisis) (hypoaldosteronism)

A

Def:
1. Autoimmune destruction of all 3 layers of adrenal cortex ( aldosterone, cortisol, & androgen)

Sign:

  1. Hypotension & shock
  2. N/V & abdominal pain
  3. Fatigue, Fever & generalized weakness, weight loss
  4. Lab: hyponatremia & hypoglycemia & peripheral eosinophilia

Adrenal crisis:
1. Caused by surgery, endoscopy, infection, injury —> manifist as hypotension & shock that are refractory to volume resuscitation & poorly responding to vasopressor

Treatment:

  1. Hydrocortisone
  2. Dexamethasone
  3. Rapid IV volume repletion
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26
Q

Mitral valve stenosis

A

Sign:

  1. Progressive SOB with exertion —> can be at rest
  2. Swelling ankles
  3. Diastolic murmur that rumble
  4. Normal LV diastolic pressure; increased pulmonary pressure

Signs:

  1. Increase CVP (increase preload)
    * JVD
    * Hepatomegaly
    * Lower extremity edema
  2. Increase PCWP
    * Orthopnea
    * Paroxysmal nocturnal dyspnea
    * hemoptysis
  3. Decrease CO
    * dyspnea
    * fatigue
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27
Q

Malignant pericardial effusion

A
  1. Large & prone to recurrence
  2. Acute management includes: pericardiocentesis
  3. They require prevention of re-accumulation, either by pericardial window or prolonged catheter drainage.
  4. Metastasis from breast, lung, GI

Note:

  1. Malignancy (lung cancer) is a common cause of pericardial effusion, appears in chest X-ray as enlarged cardiac silhouette with clear lung.
  2. Echocardiography is used to confirm the diagnosis, evaluate for sign of subacute tamponade, & guide pericardiocentesis
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28
Q

Blunt chest trauma/Injury

A
  1. Hemodynamic unstable
    * resuscitation
    * evaluation ( chest X-ray, eFAST, ECG
    * Ex: chest tube for pneumothorax
    * operating room
  2. Hemodynamic stable
    * chest x-ray, eFAST, ECG, CT scan
    * Normal= discharge
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29
Q

Cardiac temponade

A

Sign:

  1. Increased PCWP
  2. Decreased CO
  3. Increased SVR
  4. Increased RAP
  5. Can develop after coronary artery disease

Diagnosis:
1. Urgent echocardiography should be performed in patient with suspected cardiac tamponade for definitive management

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30
Q

Central venous catheter (CVC)

A
  1. To administer medications (pressors, or hypertonic saline) or difficult vascular access, or need for long term medication (chemo)
  2. Preferred entry point: internal jugular vein & subclavian (assisted by U/S and landmarks)
  3. Tip of catheter is ideally placed in superior vena cava, & avoid placement at smaller vessels (subclavian, jagular or azygous)
    * predispose to venous perforation & lung puncture (lead to pneumothorax) & myocardial perforation (lead to pericardial tamponade)
  4. Portable chest x-ray is performed immediately following CVC to recognized mis-placed catheter
    • correct location: angle between trachea & mainstem bronchus
  5. Do not try more than 3 times !!!!!!
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31
Q

Pleural effusion

A

Manage pleural effusion:

  1. Conservative therapy (observation): Small + after 1-2 days of coronary artery bypass + no respiratory symptoms
  2. Chest tube insertion/ thoracocentesis/fluid analysis: large + symptomatic pleural effusion
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32
Q

Echocardiography

A
  1. To diagnose prosthetic valve dysfunction ( either, stenotic, regurgitation, Infective endocarditis)
  2. Allow visualization of the valve & surrounding anatomy
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33
Q

Exercise stress test

A
  1. To assess stable angina ( chest pain with exertion & improves with rest)
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34
Q

Dehiscence can lead to mediastinitis

A

Types:

  1. Soft tissue (muscle, skin) dehiscence : require local wound care or debridement followed by primary closure.
  2. Sternal dehiscence: is surgical emergency & require sternal re-wiring to prevent cardiac trauma.

Investigate:
1. CT scan of chest

Management:

  1. Surgical debridement
  2. Tissue culture (require for identifying proper AB)
  3. Empiric IV antibiotics

Note:

  1. Mediastinitis is a complication of cardiovascular surgery.
  2. Lead to infection of deep tissue + systemic symptoms (fever, tachycardia) + chest pain + chest wall edema/crepitus (feel crackle with palpation)+ purulent discharge
  3. Copious drainage from sternal wound —> require Chest imaging (CT) —-> shows fluid collection
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35
Q

Left ventricular aneurysm

A
  1. Is a late complication (several months) of transmural MI
  2. Sign: deep Q wave & elevated ST segment (ECG)
  3. Diagnosis via echocardiogram (thin & dyskinetic myocardial wall)
  4. Progressive left ventricular enlargement & dyskinetic wall motion leading to heart failure (JVD, pulmonary crackles)/angina/systemic embolization
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36
Q

Hemorrhagic shock

A

Signs:

  1. Hypotension
  2. Tachycardia
  3. Diaphoresis
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37
Q

Blunt chest trauma

A
  1. Hemodynamic stable
    (Abnormal finding on evaluation, chest x-ray, ECG)
  2. Hemodynamic unstable
    (Resuscitation & evaluation via eFAST, chest CT scan, ECG). —> REQUIRES: thoracotomy
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38
Q

Avascular necrosis (osteonecrosis, aseptic necrosis) of the femoral head

A
  • osteonecrosis is common with Sickle cell disease
    1. Reduced perfusion of the femoral head & collapse of periarticular bone

Sign:

  1. Hip pain/ reduced range of motion
  2. Groin pain on weight bearing
  3. Pain on hip abduction & internal rotation
  4. No erythema, swelling, or point tenderness
  5. Normal WBCs, ESR, CRP
  6. Crescent sign seen at later stage in MRI
  7. X-ray: subchondral lucency & loss of the normal spherical contour of the femoral head
  8. X-ray: joint space is preserved & no osteophyte
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39
Q

Osteomyelitis (hematogenous)

A
  • associated with Staph. Aurues & salmonella in children

Signs:

  1. Fever
  2. Fatigue
  3. Elevated ESR, CPR
  4. Bone tenderness, swelling, erythema , pain

Diagnosis
1. X-ray shows tissue swelling & periosteal elevation

Treatment :

  1. Surgical debridement
  2. Antibiotics
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40
Q

Slipped capital femoral epiphysis (SCFE)

A
  • Associated with obesity & adolescence (obese teenager) (limited hip flexion & internal rotation)

Sign:

  1. Dull hip Pain
  2. Altered gait
  3. Referred knee pain
  4. Limited internal rotation of the hip
  5. Complication: avascular necrosis & osteoarthritis
  6. Symptoms: foot to point laterally, & thigh abduction & external rotation with passive hip flexion
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41
Q

Femoral neck fracture or inter-trochanter hip fracture

A
  1. Common in elderly after an acute fall

Signs following a fall:

  1. Leg shortened, abducted (gluteal medius) & externally rotated (iliopsoas)
  2. Severe pain on range of motion
  3. X-ray: shortening & angulation of femoral neck

Also with :
1. Anterior hip dislocation which occurs with severe trauma ( e.g., industrial accident, motor vehicle collision-MVC)

Diagnosis:
1. X-ray

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42
Q

Hip fracture

A
  1. Intra-capsular (femoral head or neck): less echymosis & high avascular necrosis
  2. Extra-capsular (trochanteric or subtrochanteric): high risk of displacement & visible ecchymosis

Treatment:
1. Surgical correction: open reduction with internal fixation

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43
Q

Posterior hip dislocation

A
  1. Associated with axial force on the femur (dashboard injury)

Signs:

  1. Adduction
  2. Internal rotation at the hip
  3. Neurologic manifistation due to involvement of sciatic nerve (impaired dorsiflexion)

Treatment:
1. Requires reduction within 6 hours of injury

Complication:
1. Osteonecrosis of the femoral head (ONFH) due to delayed reduction

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44
Q

Paget disease leads to osteosarcoma

A
  1. Paget disease is associated with bone remodeling & increase risk of osteosarcoma

Prevalence:

  1. In children: osteosarcoma develops in metaphysis of long bone
  2. In adults >40: osteosarcoma develops at sites of damaged bones

Signs of osteosarcoma (distal femur):

  1. Codman triangle (periosteal elevation)
  2. Sunburst periosteal reaction
  3. Moth-eaten lytic lesions (destructive bone lesion)
  4. Pain + soft tissue swelling + hallmarks
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45
Q

Lyme arthritis

A
  1. Associated with borrelia burgdorferi infection

Signs:

  1. Mono-articular arthritis of the knee
  2. Develops after months/years after tick exposure
  3. Erosion of joint cartilage or bone
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46
Q

Osteoarthritis

A

Symptoms:

  1. Joint pain worse with activity & weight-bearing
  2. Pain radiates to groin, thigh, buttocks and lateral hip region
  3. No synovitis (no warmth, no redness)
  4. Brief stiffness with prolonged rest

Signs:

  1. Inflammatory destruction of articular cartilage, often involves several joints (knee, hip)
  2. Imaging: shows thickening of subchondral bone, joint space narrowing & formation of osteophytes

Affects:

  1. Hip
  2. Knee
  3. Hands, (rarely elbow)

Signs:

  1. Osteophytes
  2. Joint space narrowing
  3. Subcondrial sclerosis
  4. Subcondrial cysts

Treatment:

  1. Non-pharm: exercise, weight loss
  2. If symptoms persist: Topical or oral NSAIDs (duloxetin, tramadol, topical capsaicin) or injectable glucocorticoids
  3. If symptoms persist, surgery (total knee arthroplasty) or chronic pain management (nonsurgical candidates)
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47
Q

Stress fracture

A

Signs:

  1. Overuse injury to bone caused by repetitive stress (running on pavement)
  2. Associated with peroisteal elevation (codman triangle), cortical thickening (with fracture line) & sclerosis
  3. Rare in femur
  4. Common in tibia & fibula
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48
Q

Septic bursitis

A

Note:

  1. During a joint or brusal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as a worsening pain several days following the procedure.
  2. Diagnostic aspiration of the joint or bursa is necessary to assess for infection

Associated with:
1. Injection of medication (corticosteroid) in the bursa region with introduction of staph. Aureus/strept.pyrogen) into deep structure

Signs: (several days after injection/procedure)

  1. Painful + localized bursal swelling with erythema & warmth
  2. Fever + chills + myalgias
  3. Septic brusitis can develop into septic arthritis

Treatment:
1. Image-guided (U/S) aspiration

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49
Q

Acute pain management in patients with opioid use disorder

A

Pain control: (open fracture & poly-trauma)

  1. Maximize non-opioid medication (acetaminophen & NSAIDS & ketorolac)
  2. Use regional anasthesia
  3. For severe pain: Add IV short-acting opioids as needed (morophine) (short period 3-5 days)
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50
Q

Osteoid osteoma (OO) = benign bone-forming tumor

A

Signs: (occurs in adolescence boys)

  1. Proximal femur & spine
  2. Pain: (worse at night, relieved by NSAIDS, unrelated to activity) = usually back pain
  3. No systemic symptoms
  4. X-ray: small, round lucency
  5. Treatment: NSAID, monitor for spontaneous resolution
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51
Q

Ankylosis spondylitis

A

Signs:

  1. Chronic, progressive back pain (worse with rest & at night)
  2. Pain improved with activity
  3. Spinal stiffness (bamboo-pattern spine)
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52
Q

Vertebral disc herniation

A

Signs:

  1. Nerve root compression result in back pain
  2. Acute pain, radicular, worse with flexion
  3. Associated with abnormal sensory & motor findings
  4. Positive straight-leg raising test (radicular pain from 30-60 degree indicates sciatic nerve root compression)
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53
Q

Pre-patellar-bursitis

A
  1. Associated with occupation requiring repetitive kneeling (landscaping/ gardening, plumbing)

Sign:

  1. Acute knee pain & tenderness
  2. Localized Swelling anterior to patella
  3. Erythema

Diagnosis:

  1. Bursal fluid Aspiration (cell count, gram stain, & culture)
  2. No infection: treat with NSAIDs
  3. Infection: drainage + antibiotics
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54
Q

Patellar fracture

A

Signs: (fall from heights)

  1. Acute swelling
  2. Tenderness
  3. Inability to extend knee
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55
Q

Infectious (septic) arthritis

A

Signs:

  1. Acute pain
  2. Joint effusion
  3. Fever
  4. Swelling involves joint space
  5. Pain with active & passive motion
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56
Q

Patellar tendinitis

A

Signs:

  1. Episodic pain at the inferior patella & patellar tendon
  2. Seen in athletes in jumping sports or occupation with repetitive, forceful knee extension
  3. X-ray: thickening of the patellar tendon
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57
Q

Spondylolisthesis

A
  1. Associated with anterior slippage of vertebral body ( L5 slips over S1) due to bilateral defects of the pars interarticularis (spondylolysis)
  2. Repetitive back extension & rotation (gymnastics, divers) & adolescence growth spur

Signs:

  1. Low back pain that is worse with lumbar extension
  2. Radiculopathy as slippage progress (compress on spine; radiating pain, numbness, weakness)
  3. Palpable step-off present !
  4. X-ray: lumbar visible at lateral view

Treatment:

  1. Modify activity
  2. Neurologic deficits >90 days (obtain MRI of spine & surgical consultation)
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58
Q

Spondylolysis

A
  1. Associated with fracture of the pars interarticularis due to overuse injury (unilateral or bilateral)
  2. Bilateral injury leads to spondylolisthesis
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59
Q

Risk factor of avascular necrosis (osteonecrosis)

A

Risk factors:

  1. Femoral head or neck fracture
  2. Hip anterior dislocation
  3. Glucocorticoids
  4. Alcohol
  5. Sickle cell disease
  6. Systemic lupus erythematous

Signs:

  1. Chronic groin pain
  2. Decrease range of motion
  3. X-ray shows: flattening/collapse of femoral head & patchy sclerosis
  4. MRI: can be used if x-ray is not diagnostic: shows boundary between normal & ischemic bone
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60
Q

Displaced supracondylar fracture of the humerus

A

Sign:

  1. Fall on outstretched hand
  2. Hold injury arm on flexed position & winces when touched & not moving arm
  3. Posterior displacement of the distal humerus fragment
  4. entrap of brachial artery & median nerve by the anteriorly displaced proximal humerus
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61
Q

Radial head subluxation (nursemaid’s elbow)

A
  1. Common in pre-school children
  2. Caused by swinging or pulling a child by the arm

Sign:

  1. Hold arm in pronation against chest
  2. Avoid any movement

Treatment:
1. Closed reduction by forearm hyper-pronation (hear a pop indicates successful reduction)

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62
Q

Colles fracture (distal radius fracture; dinner-fork deformity)

A
  1. Associated with fall on outstretched hand & common in elderly
  2. Can compress
    * radial artery (lead to absent pulse, delayed capillary refill)
    * median nerve (lead to acute carpal tunnel syndrome

Signs:

  1. Severe wrist pain
  2. Bruised & swollen

Treatment:
1. Closed reduction in the ED

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63
Q

Post-amputation pain

A

Types:

  1. Acute stump pain (tissue/nerve injury + severe pain lasts 1-3 weeks)
  2. Ischemic pain ( swelling & skin discoloration + wound breakdown)
  3. Post-traumatic neuroma ( weeks-months after amputation + altered local sensation + decrease pain with anesthetic injection)
  4. phantom limb pain (usually within 1 week + intermittent cramp/ burning felt in distal limb)
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64
Q

Tophaceous gout

A
  1. Affects the olecranon bursa
  2. Gout can affect the superficial bursea (olecranon & prepatellar)

Causing:

  1. Acute bursitis: painful + inflammation changes+ Erythema, warmth, swelling
  2. Chronic bursitis: no pain+ large, rounded, fluctuant swelling/effusion
  3. Bursal tophus: no pain+ slowly enlarging, hard mass + chronic inflammation that leads to + bone erosion/overhanging edges of cortical bone

Risk factor for tophus formation:

  1. Gout
  2. Chronic kidney disease
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65
Q

Osteosarcoma

A
  1. Bone malignancy in adolescence (affects femur)
  2. Or as malignant transformation due to paget disease in adults > 65 (affects axial skeleton)

Signs:
1. X-ray shows: periosteal reaction results in sunburst or codman triangle (destruction of trabecular & cortical bone with formation of new periosteal bone)

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66
Q

Fat embolism syndrome (FES)

A
  1. Occurs 24-72 hours after inciting event ( fracture, orthopedic surgery, pancreatitis)
  2. Release fat into venous circulation
  3. Lead to cerebral embolism

Signs:

  1. Triads (respiratory distress, neurologic dysfunction/confusion, & petechial rash)
    * obstruction of pulmonary circulation: tachypnea, hypoxemia,
    * obstruction of cerebral circulation: confusion, visual field defect, unilateral arm weakness

Treatment:

  1. Immobilization of fracture
  2. Supportive care (mechanical ventilation)
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67
Q

Signs of traumatic arterial injury

A

Hard signs ( require immediate surgery)

  1. Distal limb ischemia (paralysis, pain, pallor, poikilothermy)
  2. Absent distal pulse
  3. Active hemorrhage & rapidly expanding hematoma
  4. Bruit or thrill at site of injury

Soft signs ( require further imaging)

  1. Diminished distal pulse
  2. Unexpected HTN
  3. Stable hematoma
  4. Documented hemorrhage at time of injury
  5. Associated neurologic deficit

Note:

  1. Presence of hard sign after rib fracture indicates arterial injury & require immediate surgical intervention
  2. Presence of soft sign after rib fracture suggest arterial injury have occurred & require further imaging ( CT angiogram)
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68
Q

Clavicle fracture

A
  1. Middle third of clavicle overlies the brachial plexus & subclavian artery/vein in the thoracic outlet
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69
Q

Greenstick fracture (radius) (distal forearm fracture)

A
  1. Common in children
  2. Typically occur after a fall on outstretched hand
  3. Because children have strong periosteum, fracture is limited in one bone (radius)

Sign:

  1. Pain
  2. Swelling
  3. Limited range of motion

Treatment:

  1. Immobilization
  2. No long term complication
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70
Q

Buckle fracture (incomplete radial fracture)

A
  1. Common in children
  2. Occurs in the distal radius &/or ulna due to fall on outstretched hand
  3. X-ray is diagnostic & shows tiny bulging/bending of the bony cortex

Sign:

  1. Pain over fractured area
  2. Tenderness over fractured area
  3. Limited range of motion (impaired thumb movement due to radial injury)
  4. No swelling

Treatment:

  1. Pain control
  2. Heal within few weeks without complication
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71
Q

Avascular bone necrosis

A
  1. In children, is associated with the hip ( Legg-Calve-Perthes disease)
  2. Signs: chronic joint pain & decrease of motion
  3. X-ray: subchondral fracture & flattened, collapsed epiphysis
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72
Q

Greater trochanter pain syndrome (trochanteric bursitis)

A

Risk factors:

  1. Women
  2. Age > 50
  3. Obesity
  4. Low back or lower extremity disorders ( scoliosis, osteoarthritis, planter fasciitis)

Signs:

  1. Chronic lateral hip pain
  2. Pain is worse with hip flexion or lying on affected side

Diagnosis:

  1. Focal tenderness over trochanter
  2. X-ray to rule out hip joint pathology
  3. U/S shows degeneration of tendons or tendonitis

Treatment:

  1. Activity modification
  2. NSAIDS
  3. Local Corticosteroid injection
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73
Q

Salter harris type III ( juvenile Tillaux fracture)

A
  1. Common in adolescence
  2. Fracture of the distal tibial epiphysis & lateral physis (growth plate)
  3. Injury to physis can lead to growth arrest & lead to persistence limb-length discrepancy
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74
Q

Pes anserinus pain syndrome (anserine brusitis)

A

Pes anserinus : (attached point at medial knee)

  1. Semitendenous tendon
  2. Gracilis tendon
  3. Sartorious tendon

Sign:

  1. Medial knee pain
  2. Overuse, abnormal gait, trauma
  3. Pain at antero-medial tibia/ tenderness over the medial tibial chondyle or just below the joint line

Management:

  1. Quadriceps strengthening exercise
  2. NSAIDs
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75
Q

Hip fracture due to fall & development of MI

A
  1. Older patients with hip fracture should undergo definitive surgical correction as soon as possible.
  2. Surgery may be delayed up to 72 hours to evaluate surgical risk & insure medical stability

Management:

  1. ECG
  2. Cardiac markers
  3. Chest X-ray
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76
Q

Leg- calve-perthes disease

A
  1. Idiopathic avascular necrosis

Signs:

  1. Children 3-12
  2. Hip pain + limp + avoid weight bearing on affected limb
  3. Limited abduction + internal rotation
  4. Positive trendelenburg sign
  5. X-ray: femoral head flattening, fragmented, sclerosis
  6. MRI: avascular necrosis of femoral head
  7. Treatment: surgical repair
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77
Q

Ganglionic cyst

A

Is a connective tissue out-pouching, arising from tendon sheaths, joint capsule, or bursea

Signs:

  1. Round, Mobile, Non-tender, firm cyst on dorsal of wrist
  2. Transilluminate light
  3. Intact grip strength

Treatment:

  1. Observation: asymptomatic cyst- spontaneous resolve
  2. Needle aspiration: recurrence
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78
Q

Plantar fasciitis

A
  1. Degeneration of planter aponeurosis (& its insertion at calcaneus due to overuse)
  2. Heel pain with standing or walking

Signs:

  1. Heel pain + worse with walking/standing & weight bearing
  2. Pain elicited with dorsiflexion of toes
  3. X-ray shows heel spurs

Treatment:
1. Padded heal insert

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79
Q

Phantom limb pain (PLP)

A
  1. Common following extremity amputation

Signs:

  1. Shooting/burning pain at area that has been amputated
  2. Pain is worse with urination/defecation

Treatment:
1. Multimodal pain control regimen (pharmacology & therapeutic)

  • Antidepressant (tricyclic), anti-epileptic (gabapentin), NMDA antagonist (ketamine), analgesics (acetaminophen, opioids)
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80
Q

Deep vein thrombosis (DVT)

A
  1. Evaluate with duplex ultrasonography

2. Pain & swelling at effected lower extremity

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81
Q

Post-traumatic neuroma

A
  1. Regrowth of nerve fibers into tangled mass of unmylienated nerve endings

Sings:

  1. Pain relieved with local anesthesia injection
  2. Pain is exacerbated with palpation or percussion
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82
Q

Lumbosacral radiculopathy (L5, S1)

A
  1. Shooting pain radiates to foot
  2. Associated with back pain
  3. Symptoms exacerbated with range of motion testing (straight leg raising test)
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83
Q

Acute glenohumoral dislocation

A
  1. Blow to abducted/raised arm (play basketball)
  2. Fall on outstretched hand
  3. Violent muscle contraction (seizure)

Sign:

  1. Anterior dislocation: arm held in abducted/external rotation. Anterior prominence of humeral head
  2. Posterior dislocation: arm held in adducted/internal rotation. Loss of anterior contour, prominence of coracoid & acromion.

Manage:

  1. Close reduction, surgical repair
  2. Immobilization, progressive rehabilitation

Complication:

  1. Fracture (glenoid, proximal humerus, clavicle)
  2. Rotator cuff injury
  3. Recurrence dislocation
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84
Q

Osteomyelitis vs septic arthritis

A
  1. Osteomyelitis: due to contamination of an open fracture fragment or contagious extension from a local wound. Infection of the bone. Infection of the end of long bone.
  2. Septic arthritis: traumatic contamination by a penetrating wound. Infection of the cartilage, synovial fluid. Infection of the joint.
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85
Q

Compartment syndrome

A

Caused by:

  1. Trauma
  2. Prolonged compression
  3. Reperfusion after revascularization of acute ischemic limb

Signs:

Early (common)

  1. Pain out of proportion to injury
  2. Pain increase with passive stretch
  3. Rapidly increasing & tense swelling
  4. Paresthesia (pins & needle)

Late (uncommon):

  1. Decrease sensation
  2. Motor weakness (within hours)
  3. Paralysis (late)
  4. Decrease distal pulses

Treatment:

  1. Needle Manometry to measure pressure (< 30 mmHg)
  2. Fasciotomy (surgery)
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86
Q

Cellulitis

A

Early signs:
1. Pain, redness, swelling, heat

Late sign:

  1. Redness travels
  2. Pain is worsen
  3. More swelling & skin is tight

Manage:

  1. Elevate leg
  2. Ice pack
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87
Q

Tarsal tunnel syndrome

A
  1. Posterior tibial nerve compression beneath the flexor retinaculum in the medial ankle.

Signs:

  1. Burning pain or numbness in the posteromedial ankle, heel, sole & toes (sharp, shooting pain,pins / needle pain
  2. Elicited by tapping on the nerve (Tinel sign)
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88
Q

Giant cell tumor

A
  1. Benign tumor, but locally destructive
  2. Common in epiphysis of long bone
  3. Occur in young adults or older adults with paget disease

Sign:

  1. Progressive pain
  2. Swelling, stiffness
  3. Maybe, pulmonary metastasis or malignant transformation

Diagnosis:
1. X-ray/ CT/MRI + Biopsy: soap-bubble appearance = eccentric lytic bone lesion + multi-nucleated giant cells (osteoclast interspersed with sheets of mononuclear stromal cells)

Treatment:

  1. Surgery (intra-lesional curettage or excision)
  2. To shrink the tumor = denosumab against RANKL
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89
Q

Myositis ossificans

A
  1. Heterotropic bone formation

Sign:

  1. Intramuscular mass with pain, swelling/induration
  2. Days to weeks following injury
  3. Quadriceps & brachialis
  4. Labs: elevated alkaline phosphatase, ESR, CRP
  5. X-ray: periosteal bone reaction, calcification with radiolucent center

Management:

  1. ROM exercise & NSAID (indomethacin)
  2. Surgical excision
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90
Q

Intra-peritoneal bladder rupture (at dome)

A

Signs:

  1. Blunt lower abdominal trauma
  2. Inability to void (urine go to peritoneal space)
  3. Abdominal distention with ascites ( increase abdominal girth + dull percussion with fluid wave)
  4. Elevated BUN & Creatinine ( due to peritoneal reabsorption)
  5. Acute onset
  6. Positive FAST for intra-peritoneal fee-fluid
  7. Chemical peritonitis

Diagnosis:
1. Retrograde cystography

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91
Q

Severe cirrhosis (alcoholic liver disease)

A

Signs:

  1. Ascites ( abdominal girth + dull percussion with fluid wave)
  2. Low serum albumin
  3. Progressive pattern of ascites symptoms
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92
Q

Acute kidney injury

A
  1. Develop from rhabdomyolysis (short term alcohol intoxication + long term alcohol abuse)

Signs:

  1. Elevated BUN & Creatinine
  2. No ascites
  3. Dark urine
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93
Q

Perforation

A
  1. Systemic inflammatory response ( fever, tachycardia)

2. Peritonitis (abdominal rigidity)

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94
Q

Splenic injury ( laceration ) due to blunt abdominal trauma

A

Signs:

  1. Abdominal distention
  2. Hemorrhagic shock ( tachycardia + hypotension)
  3. LUQ pain
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95
Q

Evaluation of blood in urine (red urine)

A
  1. Urinalysis
    = > 3 RBC/hpf : hematuria
    = 0-2 RBC/hpf : hemoglobinuria (intravascular hemolysis + decrease Hb &haptoglobin) or myoglobinuria (rhabdomyolysis + increase CK+ muscle ache)
  2. CBC: to assess severity of anemia/fatigue
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96
Q

Glomerulonephritis

A

Signs:

  1. HTN
  2. Proteinuria
  3. Urinary RBC casts

Diagnose:
1. Serum complement level

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97
Q

Infection (UTI)

A

Sign:

  1. Dysuria
  2. Pyuria

Diagnosis:
1. Urine culture

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98
Q

Prosthetic valve

A

Signs:

  1. Infective endocarditis
  2. Fever
  3. New murmur
  4. Maybe hematuria & proteinuria ( due to IE- associated acute kidney injury)
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99
Q

Posterior Urethral injury (male)

A
  1. Caused by pelvic fracture (signs: adducted, internally rotated, & perineal bruising)

Signs:

  1. Blood in the urethral meatus
  2. High-riding prostate
  3. Inability to void
  4. Perineal bruising

Diagnosis:
1. Retrograde urethrography (diagnosed via extravasation of contrast from urethra)

Treatment:
1. Temporary urinary diversion via supra-pubic catheter, followed by delayed repair

Note:
1. Never start with catheterization because it can convert urethral tear into laceration

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100
Q

Anterior urethral injury (male)

A

Sign:

  1. Penile fracture
  2. Straddle injury

Treatment:
1. Repaired urgently within 24 hours

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101
Q

Renal or peri-nephritic abscess

A

Signs:

  1. Insidious flank pain
  2. Systemic symptoms (fever, fatigue, diaphoresis, weight loss)
  3. Urinalysis (pyuria, bacteriuria, proteinuria)
  4. History of UTI or extra-renal infection (bacteremia)

Diagnosis:
1. CT or US: enlarged kidney with central, hypo-dense fluid collection

Treatment:

  1. Antibiotics
  2. Percutaneous drainage
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102
Q

Acute interstitial nephritis

A
  1. Can cause acute kidney injury
  2. Caused by drugs: methicillin, NSAIDs, rifampin

Signs:

  1. Fever
  2. Rash
  3. Pyuria
  4. Urine eosinophilia with WBC casts

Treatment:
1. Resolves spontaneously

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103
Q

Acute papillary necrosis

A
  1. Causes AKI

Signs:

  1. Fever
  2. Flank pain
  3. Hematuria
  4. History of analgesic overuse or sickle cell anemia
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104
Q

Renal cell carcinoma

A

Signs:

  1. Weight loss
  2. Fever
  3. Anemia
  4. Hematuria
  5. Flank pain/mass
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105
Q

Renal tuberculosis

A
  1. Due to hematogenous spread of miliary tuberculosis
  2. Lead to abscess formation or glomerulonephritis

Signs:

  1. Pyuria (WBC)
  2. Hematuria (RBC)
  3. Urinary casts
  4. Lower UTI symptoms
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106
Q

Pre-renal acute kidney injury (AKI)

A
  1. No underlying kidney disease
  2. Caused by intravascular volume depletion (due to preoperative infection or intra-operative blood loss)

Signs:

  1. Decrease urine output (oliguria < 500mL)
  2. Increase BUN:CR ratio (20:1)
  3. Increase serum creatinine (due to volume depletion = decrease renal perfusion =decrease GFR)
  4. Unremarkable urine sediment (absent of casts, cell, or protein)
  5. Tachycardia, hypotension

Treatment:
1. Intravenous isotonic fluid (normal saline) to restore renal perfusion

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107
Q

Volume overload

A
  1. JVD
  2. Lung crackles
  3. Pulmonary edema
  4. Hypoxia
  • note:
    1. Similar to recurrent flash pulmonary edema (with no lower extremity edema)
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108
Q

Renal artery stenosis (RAS) (Reno-vascular disease)

A
  1. HTN-related symptoms
  2. Severe HTN & recurrent flash pulmonary edema (JVD & pulmonary crackles, without lower extremity edema) suggest RAS
  3. Associated symptoms include: chronic kidney disease, secondary hyper-aldosteronism (hypo-kalemia, elevated serum bicarbonate)

Signs:

  1. Asymmetrical renal size (>1.5 cm)
  2. Abdominal bruits
  3. Unexplained rise in serum creatinine (>30%) after starting ACE inhibitor or ARBs
  4. Urinalysis is bland
  5. Imaging (renal ultrasound with doppler): unexplained atrophic kidney
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109
Q

Post-operative urinary retention

A
  1. Urine retention is a common post-operative complication
  2. Risk factor: (male, elderly, hernia repair, joint arthroplasty, anorectal operation, prolonged anesthesia, excessive fluid administration, use of opioid, anti-cholinergic)

Signs:

  1. Hypertension
  2. Tachycardia
  3. Supra-pubic discomfort/fullness (elicit with palpation)

Diagnose:

  1. Portable bladder ultrasound
  2. Urinary catheterization performed if (> 600 mL on U/S)
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110
Q

Anterior bladder wall rupture

A

Sign:

  1. Gross hematuria
  2. Supra-pubic pain/tenderness
  3. Inability to void
  4. Negative FAST for intra-peritoneal fee-fluid
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111
Q

Hydronephrosis

A
  1. Swelling of one or 2 kidneys due to inability to drain urine & urine build up
  2. Causing dilation of renal pelvis
  3. Indicates urinary obstruction
  4. Treat with: ureteral stent placement
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112
Q

Posterior urethral valves (PUV)

A
  1. Newborn + abdominal distention + poor urine output + respiratory distress (oligohydromnias = subsequent lung hypoplasia)
  2. Diagnosis: renal/bladder US
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113
Q

Evaluation of acute kidney injury

A

Evidence of volume depletion:

Yes; Improve with IV-fluid (yes; pre-renal)
No; Urinalysis & microscopy (normal; exclude renal obstruction; post-renal)

abnormal; (intrinsic)

  1. hematuria +/- proteinuria (evaluate for glomerulonephritis; inflammation)
  2. Pyuria ( evaluate for Acute Interstitial Nephritis; antibiotics)
  3. Granular casts (muddy brown) +/- epithelial cells (evaluate for acute tubular necrosis; intraoperative hypotension )
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114
Q

Varicocele

A

Primary:

  1. Compression of left renal vein between SMA & Aorta
  2. Incompetent venous valve
  3. Presentation: Bag of warms mass; pubertal onset; left-sided; decompression when supine
  4. Management: reassurance & observation

Secondary:

  1. Extrinsic compression of IVC (renal or retroperitoneal mass)
  2. Venous thrombus lead to venous compression
  3. Presentation: bag of warms; pre-pubertal onset; right-sided; persists when supine
  4. Management: Abdominal US
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115
Q

Testicular cancer

A
  1. Male; 15-35 years
  2. Present with painless, & firm testicular mass
  3. Management: surgical orchiectomy
  4. Avoid biopsy due to tumor seeding
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116
Q

Epididymitis

A
  1. Infectious case of scrotal swelling & pain

2. Management: urine culture

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117
Q

Bladder cancer

A
  1. Present with: old patient + hydronephrosis + painless hematuria + voiding symptoms
  2. Diagnosis: cystoscopy + biopsy + CT abdomen (staging)

Notes:

  1. Hydronephrosis: associated with flank pain + increase creatinine level
  2. Voiding symptoms: dysuria + frequency
  3. Hematuria: due to tumor growth+ new vessels bleeding
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118
Q

Acute hyponatremia (<48 hrs)

A
  • risk of brain herniation (cellular swelling, & cerebral edema)

Signs:

  • sodium <130 mEq/L
  • signs of elevated intracranial pressure (ICP) (headache, N, confusion)

Treated:
- hypertonic 3% saline

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119
Q

Acute adrenal insufficiency

A

Signs:

  • hyponatremia
  • hyperkalemia
  • severe hypotension
  • confusion
  • N/V
  • weakness

Treatment:

  • dexamethasone
  • hydrocortisone
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120
Q

Hydronephrosis

A

Signs:

  • N/V
  • HTN
  • unilateral flank pain
  • initially relieved by pain killer
  • Normal Creatinine level
  • later, causes costovertebral angle tenderness + non/radiating back pain

Occurs with:
-ureter injury after hysterectomy

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121
Q

Pyelonephritis

A

Signs:

  • costoveretebral angle tenderness
  • fever
  • chills
  • elevated creatinine level

Occurs with:
- complication of foley catheter

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122
Q

Nephrolithiasis

A

Signs:

  • unilateral back pain, radiates to groin
  • N/V
  • Hematuria
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123
Q

Urethral stricture (fibrotic narrowing)

A

Signs:

  • urine retention
  • decrease spraying stream
  • incomplete emptying of bladder
  • post-void residual volume is high

Diagnosis:
- urethrography

Treatment:

  • urethral dilation
  • urethroplasty
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124
Q

CT abdomen / pelvis

A

-for renal injury

Signs:

  • flank pain with ecchymosis
  • Costo-vertebral tenderness
  • hematuria
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125
Q

Polycystic kidney disease (Autosomal dominant)

A

Signs:

  • HTN
  • Hematuria
  • recurrent flank pain
  • 30-40 ages

Diagnosis:
- U/S shows multiple cysts in kidney

Treatment:
-supportive (vasopressin-2 receptor antagonist: Tolvaptan; slow disease progression)

126
Q

Chronic kidney disease (decrease GFR)

A

Results in:

  • decrease 1.25 DH vitamin D = decrease Ca
  • decrease phosphate filtration = increase Phosphate

Causes:
- Increase PTH (secondary hyperparathyrodism)

Output:
-inadequate treatment: osteitis fibrosa cystica (a form of renal osteodystrophy) ( high PTH, High bone turnover, decrease mineralization with fibrosis, increase fracture risk)

  • excessive treatment: adynamic bone disease ( low PTH, low bone turnover, decrease cellularity & mineralization, increase fracture risk)
  • optimal treatment: normal bone turnover

Note:
- femoral fracture in CKD raise suspicion for secondary hyperparathyrodism

127
Q

Lung abscess

A

Sign:

  • alcohol use
  • foul smelling sputum
  • Fever
  • Leukocytosis
  • cavity infiltrate with air-fluid level
  • fever, night sweat, weight loss, cough with putrid sputum

Caused by:

  • aspiration of (oropharangeal) anaerobic bacteria
  • due to periods of swallowing difficulty & LOC (ALCOHOL USE)

Diagnosis:

  • CT
  • X-ray
  • shows consolidation (inflammatory exudate & edema)
  • abscess (air-fluid level)

Treatment:
-ampicillin-sulbactam

128
Q

Acute lung rejection

A

Signs:

  • fever
  • cough
  • dyspnea

Confirmed:
- chest x-ray: shows perihilar opacities & interstitial edema

Diagnosis:

  • lavage
  • biopsy

Treatment:
- high dose glucocorticoid

129
Q

Hemothorax vs tension pneumothorax vs diaphragm rupture vs lung atelectasis vs lung contusion vs flail chest vs fat emboli vs myocardial contusion

A

Hemothorax:

  • hypotension - tachycardia -tachypnea
  • decreased (diminished) breath sound
  • dullness on percussion
  • contralateral tracheal deviation
  • treat: tube thoracotomy

Tension pneumothorax:

  • hypotension - tachycardia -tachypnea
  • absent breath sound
  • hyper-resonance on percussion
  • contralateral tracheal deviation
  • air leakage into mediastinum & pleural space

Diaphragm rupture:

  • no hypotension -no tachycardia
  • Decrease breath sound
  • Tracheal deviation
  • diagnosis: visualize with (intra-thoracic nasogastric tube)

Lung atelectasis (alveolar collapse) & lung contusion (alveolar edema)

  • tachycardia -tachypnea -no hypotension
  • decrease breath sound
  • dullness to percuss

Flail chest:

  • tachypnea -hypoxia
  • respiratory distress
  • impaired generation of negative (intrathoracic) inspiratory pressure
  • tidal volume decrease & work of breathing increase (become fatigue & develops respiratory failure = requires mechanical ventilation)
  • requires mechanical positive pressure ventilation
  • lead to lung contusion, atelectasis, hypoxia (due to poor ventilation )
  • fracture of > 3 adjacent ribs in > 2 positions

Fat emboli:

  • associated with long bones
  • occlude pulmonary capillaries & lead to hypoxia
  • associated with neurological deficits
  • occurs within 24-72 hours
  • signs: 1. Respiratory distress; 2. Neurological deficits; 3. Rash

Myocardial contusion:
- result in cardiogenic pulmonary edema & hypoxia

130
Q

Venous air embolism (VAE)

A

-Develops after removal of central venous catheter (CVC)

Signs:

  • respiratory distress
  • ventilation/perfusion mismatch
  • hypoxemia
  • obstructive shock
  • cardiac arrest

Management:

  • left lateral decubitus or left lateral trendelnburg (left lateral decubitus with head down) = traps the VAE into lateral wall of the right ventricle = prevent right ventricle outflow tract obstruction
  • high flow oxygen = shrink VAE as it allow absorption of nitrogen
131
Q

Sleeping position and clinical correlation

A

Prone:
- for atelectasis

Supine:
-arterial air embolism (prevent travel to brain)

Left lateral decubitus:
- venous air embolism (help VAE to move to lateral wall of right ventricle & prevent RVOTO

Right lateral decubitus: (Normal)
- encourage movement of air into right ventricle outflow tract to pulmonary

Semi-recumbent
-lower risk for ventilator acquired pneumonia in incubated patients in mechanical ventilation

132
Q

Post-operative pneumonia

A

Prevention:

  1. Incentive spirometry
  2. Deep breathing exercise
  3. Continuous positive airway pressure (expensive)
133
Q

Hemodynamic measures in shock

A
  1. PCWP: left sided preload
  2. CI: LV output
  3. SVR: afterload
  4. CVP: right-sided preload
  5. SvO2:

Hypovolemic shock: (increase ejection fraction)

  1. PCWP: low
  2. CI: low
  3. SVR: high
  4. CVP: low
  5. SvO2: low

Cardiogenic shock: (myocardial contusion)

  1. PCWP: high
  2. CI: low
  3. SVR: high
  4. CVP: high
  5. SvO2: low

Obstructive shock:

  1. PCWP: low
  2. CI: low
  3. SVR: high
  4. CVP: high
  5. SvO2: low

Distributive shock:

  1. PCWP: low
  2. CI: high
  3. SVR: low
  4. CVP: low
  5. SvO2: high
134
Q

Hypovolemic shock & mechanical ventilation & sedatives

A
  • positive pressure mechanical ventilation causes acute increase in the intra-thoracic pressure
  • in case of hypovolemic shock ( decrease CVP): initiation of mechanical ventilation can cause acute loss of right-ventricular preload, loss of Cardiac output & cardiac arrest.
  • sedatives can lead to relax of venous vessels & loss of venous return (hypotension)
135
Q

Isolated rib fracture

A

Causes:

  1. Shallow breathing
  2. Atelectasis (increase risk for pneumonia)

Manage:

  1. Adequate analgesia
  2. Pulmonary toilet
  3. Incentive spirometry
136
Q

Septic shock

A

Signs:

  • hypotension
  • tachycardia
  • fever
  • low urine output

Caused by:
-pneumonia

Manage:

  1. restore adequate tissue perfusion + identify underlying infection —> via: Crystalloid (1. lactate ringer (IV); 2. Normal saline 0.9%)
  2. Continuously monitor patient to prevent volume overload ( pulmonary edema, hypoxia, or until pressure is not improved)
  3. Next step, use Norepinephrine (vasopressor) to improve perfusion.
137
Q

Isotonic solution (0.9%)

A
  • used in case of metabolic acidosis that is developed due to lactic acidosis (tissue hypoperfusion)
138
Q

Acute respiratory distress syndrome (ARDS)

A

Types of lung injury:

  1. Direct: pneumonia or inhalation
  2. Indirect: sepsis, pancreatitis, or trauma

Signs:

  1. Within 1 week
  2. X-ray shows bilateral alveolar opacities
  3. Exclusion of cardiac failure or volume overload

Diagnosis:

  1. ECG
  2. Troponin I
  3. B-type natriuretic peptide
  4. Bedside TTE
139
Q

Lung cancer

A

Bronchial carcinoid tumors:

  1. Young + nonsmoker
  2. Airway obstruction ( dyspnea + wheezing + post-obstructive pneumonia) or hemoptysis
  3. Mass with an endobronchial component

Small cell carcinoma

  1. Former or active heavy smoker
  2. Bulky hilar or mediastinal mass

Squamous cell carcinoma:

  1. Former or active heavy smoker
  2. Central cavitation (heterogenous density) due to tumor necrosis
140
Q

Diaphragmatic paralysis

A

Caused by:

  1. Phrenic nerve injury (surgery)
  2. Viral ( Herpes zoster, poliomyelitis)
  3. Neurological ( ALS, GBS)

Signs:

  • dyspnea on exertion
  • orthopnea
  • paradoxical breathing movement (abdomen moving inward during inspiration)

Diagnosis:
-paradoxical movement of diaphragm/abdomen during brisk inspiration (fluoroscopic sniff test) (abdomen goes inward instead of outward during inspiration)

141
Q

Aspiration pneumonia with subsequent lung abscess

A

Caused by:

  • impaired consciousness (alcohol, drug, seizure)
  • swallowing difficulty (Parkinson disease)

Signs:

  • Systemic system
  • cough (yellow sputum)
  • x-ray: cavity infiltrate

Note:
- similar to lung cancer, however , in cancer no yellow sputum

142
Q

Ludwig angina

A

-cellulitis of submandibular & sublingual spaces

Signs:
- airway obstruction ( drooling, tripod position, can’t lay flat)

143
Q

Chemical pneumonitis

A
  • within minutes to hours after aspiration of gastric acid that burns the lower respiratory tract

Treat:

  • supportively
  • oropharyngeal suction
144
Q

Bacterial aspiration pneumonia

A
  1. Within days to weeks after aspiration of oropharyngeal or gastric microbes

Treat:
1. Antibiotics

145
Q

Massive pulmonary embolism

A

Signs:

  • hypotension
  • right heart strain = right bundle branch block
  • JVD

Diagnosis:
-CT angiography

Immediate death occurs

146
Q

Rib fracture location & associate injuries

A

1-3 ribs: subclavian, brachial plexus, mediastinal vessels (aorta)

3-6: cardiovascular

9-12 ribs: intraabdominal: liver, spleen, kidney (11-12) —> detected via CT scan of abdomen (with contrast to visualize blush/extravasation) in hemodynamically stable patient (SBP >90)

147
Q

Pulmonary embolism

A

Signs:

  • sudden dyspnea
  • tachycardia
  • nonproductive cough
  • mild hypoxia

Diagnosis:

  • CT angiography (stable)
  • TTE (unstable; massive PE with syncope, shock)

Manage:

  • IVC filter
  • anticoagulation
148
Q

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) (HHT)

A

Signs:

  • hemoptysis
  • epistaxis
  • pulmonary bruits
  • nodular lung lesions
  • anemia (iron deficiency; microcytic)

Lead to:

  • mucocutaneous telangiectasia
  • visceral organ Arteriovenous malformation

Diagnosis:
-x-ray: smooth & well-circumscribed nodular opacities

Treatment:
- pulmonary angiography followed by embolization (induces the blood to clot and block the flow of blood)

  • AFTER 1-3 months, CT scan is performed to ensure complete blockage of pulmonary AVM
149
Q

Tracheo-bronchial injury

A
  • in patients with thoracic trauma & extensive extra-pulmonary air (chest tube with persistent large air leak)

Signs:

  • tension pneumothorax ( hypotension, deviated trachea, absent breath sound)
  • crepitus ( crackling of the neck & chest skin)

Diagnosis:

  • bronchoscopy
  • operative repair
150
Q

Post-operative atelectasis

A
  • seen on day 2 after a surgery and up to day 5.
  • result from shallow breathing & weak cough due to pain

Signs:

  • hypoxemia (low PO2)
  • respiratory alkalosis

Prevent with:

  • deep breathing exercise
  • incentive spirometry
  • adequate pain control
  • directed coughing
  • early mobilization

Manage:

  • CPAP (continuous positive airway pressure) to help open collapsed alveoli
  • atelectasis due to large mucus plugging requires (bronchoscopy)
151
Q

Following lung resection surgery

A

Predictor:

  • FEV1
  • diffuse lung carbon monoxide (DLCO)
152
Q

Acute hemolytic transfusion reaction (AHTR)

A

-develop within minutes to hours

Signs:

  • fever
  • hypotension
  • flank pain
  • hemoglobinuria
  • DIC

Diagnosis:
-Coombs test

153
Q

Spontaneous pneumomediastinum

A

-tall, thin adolescent boy with asthma

Signs:

  • acute chest pain
  • SOB
  • cough
  • subcutaneous emphysema (crepitus, crackles in the neck and skin of chest)
  • hamman sign

Diagnosis:
-x-ray: mediastinal gas

Manage:

  • rest
  • analgesia
  • avoid valsalva maneuver
154
Q

Post-transplant lymphproliferative disorder (PTLD)

A
  • occurs after receiving an organ transplant
  • triggered by immunosuppressive medication (impairs cytotoxic T-cells, that lead to uncheck viral pathogens in donor tissue)
155
Q

Management of patients with burns

A

Steps:
- administer 100% oxygen

  • early assessment of airways
  • indicators of inhalation injury/oropharyngeal blistering = perform endotracheal intubation

** for stable patient: fibroptic laryngoscopy to visualize airways

156
Q

Hemorrhagic shock

A

Signs:

  • hypotension
  • tachycardia
  • decrease capillary refill
  • narrow pulse pressure (cool extremity)

Manage:
- 1:1:1 ratio of packed RBC + FFP + Platelets (to reduce coagulopathy)

  • adjunct: antifibrolytic agent (within 3 hours) or topical hemostatic agent (kaolin-impregnated sponge, fibrin sealant dressing; to control external bleeding)
157
Q

Clinical feature of type 2 heparin-induced thrombocytopenia ( HIT)

A

Signs appear after 5 days of using heparin:

Signs:

  • decrease platelet by 50%
  • narcotic skin lesion at site of heparin injection
  • arterial or venous thrombosis
  • acute systemic reaction (anaphylactoid) after heparin

Diagnosis:
- serotonin release assay

Manage:

  • stop heparin
  • use direct thrombin inhibitor (argatroban; delay blood clotting) or fondaparinux (synthetic pentasaccharide)

-Warfarin can be used after platelet rise > 150,000, because if used as initial management it can lead to thrombus formation due to lowering protein C

158
Q

Transfusion reaction associated with hypotension

A

Anaphylaxis:

  • Within seconds-minutes
  • signs: shock, respiratory distress, angioedema/utecaria (rash)
  • caused by: IgA antibodies
  • manage: epinephrine, anti-histamine

Acute hemolysis:

  • within minutes-hours (1 hr)
  • signs: fever, hypotension, flank pain, hemoglobinuria, DIC
  • Caused by: ABO incompatibility
  • positive Coombs test

Urticarial:

  • within hours (2-3 hours)
  • sign: urticaria
  • caused by IgE against blood components

Febrile non-hemolytic:

  • within hours (1-6hrs)
  • signs: fever, chills
  • caused by: cytokine accumulation during blood storage

Transfusion-related acute lung injury: (TRALI)

  • within minutes-hours (6 hrs)
  • signs: respiratory distress (hypoxia, SOB), pulmonary edema, pulmonary infiltrates
  • caused by: donor anti-leukocytes antibodies
  • Manage: respiratory supportive care + transfusion stop

Bacterial sepsis:

  • within minutes-hours
  • signs: fever, chills, septic shock, DIC
  • Caused by: bacterial contamination of donor product

Delayed hemolytic:

  • within days to weeks
  • signs: asymptomatic, hemolytic anemia, positive Coombs test, positive new antibody screen
  • caused by: anamnestic antibody respond

Graft vs host reaction:

  • within weeks
  • sign: rash, fever, GI symptoms, pancytopenia
  • caused by: donor T-lymphocytes
159
Q

Disseminated intravascular coagulation (DIC)

A

Question:

  • decrease urine output
  • oozing from IV site

Sign:

  • bleeding
  • hypotension, tachycardia (hemodynamic unstable)
  • acute kidney & liver injury

Causes:

  • sepsis
  • severe traumatic injury
  • malignancy
  • obstetric complication

Pathophysiology:

  • procoagulant excessively trigger coagulation cascade
  • formation of fibrin or platelet rich thrombi & fibrinolysis
  • bleeding & organ damage (kidney, lung)

Laboratory:

  • increase D-dimer
  • increase PT & PTT time (consumption of coagulation factor)
  • decrease fibrinogen
  • decrease platelet ( thrombocytopenia )
  • hemolytic anemia (schistocytes)
160
Q

Acquired methoglobinemia

A
  • anesthesia agent oxidize iron in hemoglobin (altered hemoglobin state)

Sign:

  • hypoxia ( pulse oximetry 85%) (bluish discoloration of lips/fingertip)
  • large oxygen saturation gap
161
Q

Bacterial pneumonia

A
  • causes plueral effusion
  • types:
    1) uncomplicated: small, sterile, resolve with antibiotics
    2) complicated (empyema): frank pus/bacteria, requires drainage via chest tube, and antibiotics
162
Q

Mucus plugging

A

-lead to large-volume atelectasis (lung collapse) due to airway obstruction.

Sign:

  • absent of breath sound
  • dullness to percuss

Diagnosis:
-x-ray: opacification of the affected lung area & mediastinal shifting towards the side of atelectasis

163
Q

Peripheral Inserted central catheter (PICC)

A
  • lead to upper extremity deep venous thrombosis

Signs:
-arm swelling, pain, erythema

Diagnosis:
-duplex U/S

Manage:
-3 months of anti-coagulation

164
Q

Hemorrhagic shock (blood transfusion)

A

Management:

1) women of childbearing or young girls: group O-RH D negative blood
2) women past childbearing & men: group O-RH D positive blood

While waiting for type-specific blood

165
Q

Lethal triad in trauma patient

A

1) hypothermia
2) coagulopathy
3) acidosis

166
Q

Large-volume crystalloid resuscitation

A
  • increase coagulopathy
  • increase hypothermia
  • increase mortality in patients
  • balance crystalloid use: maintain a blood pressure that is sufficient for tissue perfusion
167
Q

Acute pulmonary embolism

A

Signs:

  • right sided chest pain (pleuritic in nature)
  • signs of VTE risk factors ( travel, surgery, swelling calf, OCP)

Diagnosis:
- CT pulmonary angiography

168
Q

Spontaneous pneumothorax

A

Feature:

  • no previous history of lung disease
  • thin, young men
  • history of cystic fibrosis, COPD, smoking, marfan syndrome, thoracic endometriosis

Sign:

  • chest pain, dyspnea
  • decrease breath sound, decrease chest movement
  • hyper-resonance to percussion

Imaging:

  • visceral pleural line
  • absent lung markings beyond pleural edge

Management:

  • small (<2 cm): observation & oxygen administration
  • large & stable: large bore needle aspiration (14 or 18) or chest tube
169
Q

Tension pneumothorax

A

Feature:

  • life-threatening
  • due to trauma or mechanical ventilation

Sign:

  • chest pain, dyspnea
  • decrease breath sound, decrease chest movement
  • hyper-resonance to percussion
  • hemodynamic instability
  • tracheal deviation away from affected side

Imaging:

  • visceral pleural line
  • absent lung marking beyond pleural edge
  • contralateral mediastinal shift
  • ipsilateral hemi-diaphragm flattening

Management:
- urgent needle decompression or chest tube placement

170
Q

Head & neck squamous cell carcinoma (

A
  • associated with alcohol & smoking

Sign:
- palpable cervical lymph node

Diagnosis:
-laryngopharyngoscopy

171
Q

Hemothorax

A
  • bleeding > 1500 ml

Management:

  • tube thoracotomy
  • emergent thoracotomy for extreme bleeding (>2000ml) or continuous need for blood transfusion to maintain hemodynamic stability
172
Q

Ventilator-associated pneumonia

A
  • develops > 48 hours after endotracheal intubation
  • caused by: aspiration of microorganism from oropharynx or stomach into pulmonary parenchyma (caused by leakage around the cuff) (due to supine position or movement of tube)

Management:

  • head of bed is elevated to 30-45 degree
  • suction of subglottic secretion
  • minimize tube movement
  • limit use of gastric acid inhibitors (PPI, antacid..)
173
Q

Rectus sheath hematoma

A
  • occur due to rupture of inferior epigastric artery from blunt trauma or forceful abdominal contraction (severe coughing)
  • associated with patient receiving anti-coagulation drugs

Sign:

  • acute abdominal pain
  • palpable abdominal wall mass (does not move with movement)
  • anemia
  • leukocytosis

Diagnosis:
-abdominal CT

Management:

  • stable: conservatively (serial CBC test, reversal of anticoagulation)
  • unstable (shock) : angiography with embolization
174
Q

Anterior mediastinal mass

A

Types:

  • thymoma
  • teratoma (& other germ cell tumor)
  • lymphoma
  • thyroid neoplasm

thymoma

  • middle-aged patients
  • paraneoplastic syndrome ( Myasthenia Gravis; Abnormal anti-acetylcholine receptor antibodies; ptosis)
  • normal AFP & Beta-hCG

teratoma (& other germ cell tumor)
-elevated AFP & Beta-hCG

lymphoma

  • fever, weight loss, night sweat
  • normal AFP & Beta-hCG

thyroid neoplasm

Seminoma:

  • elevated Beta-hCG
  • normal AFP
175
Q

Breast mass

A

Signs:

  • unilateral
  • firm
  • fixed
  • causing nipple retraction

Diagnosis:

  1. Mammogram or U/s
  2. Biopsy
176
Q

Acute graft vs host disease

A
  • caused by donor T-lymphocytes attacking host antigens
  • occurs within 100 days of transplant

Sign:

  • rash
  • abdominal pain
  • profuse, watery diarrhea
  • Hepatobiliary inflammation
177
Q

Vitamin k deficiency

A
  • associated with coagulation factors (2, 7,9,10)

- cause bleeding due to coagulation factors deficiency

178
Q

Vitamin C deficiency

A
  • cause bleeding due to vessel fragility
179
Q

Hemophilia A

A
  • associated with coagulation factor 8
180
Q

Anti-platelet dysfunction

A
  • caused by aspirin

- associated with Von Willebrand disease

181
Q

Horner syndrome

A

Sign:
-ipsilateral ptosis, miosis, anhidrosis

Associated with Pancoast (superior pulmonary sulcus tumor) tumor :

  • shoulder pain
  • Horner syndrome
  • neurologic deficit (C8-T2) (atrophy/numbness of hand muscle)
  • supraclavicular lymphadenopathy
  • weight loss

Diagnosis:

  • chest x-ray: mass in the lung apex (superior portion) (at superior sulcus)
  • staging (TNM)
  • biopsy
182
Q

Exudative effusion

A

Analysis:

  • pleural protein/serum protein >0.5
  • pleural LDH/serum LDH >0.6
  • Pleural LDH > 2/3 upper limit of normal for serum LDH

Etiology:

  • empyema ( purulent fluid, neutrophil-predominant, + gram stain/ culture)
  • chylothorax ( milky white fluid, increase triglycerides)
  • malignancy ( abnormal cytology)
  • TB (+ acid-fast bacterial stain/culture

Caused by:

  • increase capillary permeability
  • disruption of thoracic duct (drainage)
  • direct leakage of chyle/ lymphatic fluid into pleural cavity (chylothorax)

Management of chylothorax:

  • drainage via thoracentesis
  • drainage via chest tube placement
  • limitation of dietary fat
  • thoracic duct ligation
183
Q

Pulmonary contusion

A

-occurs 24 hours after thoracic trauma

Signs:

  • tachypnea
  • tachycardia
  • hypoxia
  • rales or decrease breathing sound
  • CT or X-ray: irregular, non-lobular infiltrates (alveolar edema: ground-glass opacities)

Manage:

  • pain control
  • pulmonary hygiene ( incentive spirometry, Chest physio)
  • oxygen & ventilation
184
Q

Blunt thoracic trauma

A
  • injure the lung
  • causing alveolar edema & hemorrhage (that is worsened by resuscitation)
  • lead to dyspnea, tachycardia, hypoxemia
185
Q

Mediastinal compartment, structure & masses

A

Anterior compartment:

  • structures: thymus, lymph node
  • masses:
    1) thymoma
    2) lymphoma
    3) germ cell tumors ( teratoma, seminoma, & nonseminoma)
    4) thyroid tissue (ectopic, substernal goiter)

Middle compartment:

  • Structures: lymph node, pericardium, heart & great vessels, trachea & main bronchi, esophagus
  • masses:
    1) lymphadenopathy (sarcoidosis, lung cancer), lymphoma
    2) benign cystic masses ( pericardial cyst, bronchogenic cyst)
    3) vascular mass
    4) esophageal tumors

Posterior compartment:

  • structures: neural tissues, vertebrae, lymph node
  • masses:
    1) neurogenic tumors (schwannoma, neurofibroma), meningiocele
    2) spinal masses ( metastases)
    3) lymphoma
186
Q

Testicular cancer

A

Sign:

  • painless testicular mass
  • unilateral
  • dull achy lower abdomen

Diagnosis:

  • bilateral scrotal U/S
  • tumor markers (LDH, Beta hCG, AFP)
  • Radical inguinal orchiectomy (used to remove testicles with cancer)
187
Q

Chronic bacterial prostatitis

A
  • caused by e.coli or coliform bacteria

Signs:

  • urinary tract infection
  • painful ejaculation
  • prostatic tenderness (+/-)
  • young or middle-aged man
  • improves with short course of antibiotics (6 weeks of Fluoroquinolone/ciprofloxacin)
  • bacteria & pyuria in urine
188
Q

Acute epididymitis

A

Etiology:

  • less than 35 yrs: sexually transmitted (chlamydia, gonorrhea)
  • more than 35 yrs: bladder outlet obstruction (coliform bacteria; e.coli)

Signs:

  • unilateral, posterior testicular pain
  • epididymal edema
  • pain improves with testicular elevation
  • dysuria & frequency with (coliform infection)

Diagnosis:
-NAAT for chlamydia & gonorrhea (nucleic acid amplificatio
test)
-urinalysis/ culture

189
Q

Priapism

A

Sign:

  • prolonged & painful erection (more than 12 hours)
  • seen with hematologic disorders ( altered blood viscosity, sickle cell disease, CML, Thalassemia, multiple myeloma)

Diagnosis:
-CBC

Management:

  • aspirate blood from the corpora cavernosa
  • intracavernous injection of phenylephrine
190
Q

Benign prostatic hyperplasia

A

Signs:

  • urinary urgency
  • straining to urinate
  • sensation of incomplete bladder evacuation
  • frequent nocturia

MANAGEMENT:

1) alpha-blockers
2) 5-alpha reductase inhibitor
3) Phosphodiesterase type 5 inhibitor
5) TURP

Note:
- transurethral resection of the prostate (TURP) is performed to reduce the size of prostate, however, after years the remaining part of prostate tissue can grow back & and block bladder and lead to BPH.

191
Q

Acute bacterial prostatitis

A

Signs:

  • fever
  • dysuria
  • swollen prostate

Manage: (6 weeks course)

  • fluoroquinolone (levofloxacin)
  • Trimethoprim-sulfamethoxazole
192
Q

Varicocele

A

Sign:

  • soft scrotal mass (bag of warms)
  • increase with valsalva maneuver / standing
  • decrease with supine position
  • increase risk for: infertility & testicular atrophy (due to increase scrotal temp.)

Diagnosis:
-US: retrograde venous flow / dilation of pampiniform plexus vein (surrounding spermatic cord & testis)

Management:

1) boys/young men (with testicular atrophy/ change in semen) : gonadal vein ligation/embolization
2) older men (no desire for babies): scrotal support & NSAIDs

193
Q

Testicular torsion

A
  • common in adolescence
  • absent of fixation of testis to tunica vaginalis
  • caused by twisting of spermatic cord = lead to testicular necrosis

Sign:

  • testicular, abdominal & inguinal pain
  • N/V
  • horizontal testicular lie with elevated testicle (testicle in horizontal plane)
  • absent cremasteric reflex
  • swollen, erythematous scrotum
  • pain worse with scrotum elevated
  • scrotum does not transilluminate

Diagnosis:

  • scrotal U/S with doppler: no blood flow & reactive hydrocele
  • heterogenous echotexture ( testicular necrosis)

Management:

  • surgical detorsion & fixation + exploration of the contralateral side
  • manual detorsion (if immediate surgery not available)
194
Q

Fournier gangrene

A
  • acute necrotic infection of the scrotum; penis; or perineum

Signs:

  • crepitus in the perineum, scrotum & lower abdomen
  • fever & hypotension
  • leukocytosis, acidemia, renal insufficiency, coagulopathy

Management:

  • antibiotics
  • IV-fluid
  • emergent surgery: early exploratory-laparotomy & debridement
195
Q

Benign prostatic hyperplasia vs. prostatic cancer

A

BPH:

  • Risk factor: age>50
  • affected part: central portion (transitional zone)
  • examination:
    1. Symmetrical enlarged & smooth prostate
    2. Can have elevated Prostate-specific antigen (PSA)

Prostatic cancer:

  • risk factor: age > 40, African American, family history, diet high in meat/low in vegetables
  • affected part: peripheral portion
  • examination :
    1) asymmetrically enlarged, nodules & firm prostate
    2) markedly elevated PSA
196
Q

Peyronie disease (PD)

A
  • caused by blunt trauma to penis during sexual intercourse that lead to aberrant wound healing.
  • lead to fibrosis of tunica albuginea of the penis

Signs:

  • dorsal penile plaque (between glans/pubis)
  • pain & curvature with erection

Management:

  • reduce pain: NSAIDs
  • reduce fibrosis: pentoxifylline
  • increase collagenase: intra-lesional injection
  • refractory cases: surgery
197
Q

Management of patient with burns

A

Steps:

1) stabilization ( A,B,C)
2) resuscitation ( IV-fluid)
3) urethral catheter ( foley catheter) (urine-output)
4) copious irrigation
5) gentle gauze debridement of the affected area
6) topical antibiotics
7) non-stick dressing

198
Q

Acute pyelonephritis

A

Signs:

  • fever
  • costvertebral angle tenderness
  • leukocytosis
  • urine: pyuria, bacteriuria, hematuria
199
Q

Penile fracture

A
  • associated with crackling sound after sex with pain & rapid loss of erection

Signs:
- urethral injury ( blood at meatus, dysuria, urinary retention)

Diagnosis:
Retrograde urethrography

200
Q

Abdominal compartment syndrome

A

Caused by:

  • excessive fluid resuscitation
  • pathogen or surgery to intra-abdomen

Signs:

  • tense, distended abdomen
  • increase CVP ( venous compression, but decrease venous return & decrease CO)
  • Increase ventilatory requirement ( increase intrathoracic pressure, elevated diaphragm = compress lung= high pressure during ventilation= peak inspiratory pressure)
  • hypotension & tachycardia ( decrease venous return & decrease CO)
  • decease urine output ( decrease intraabdominal organ perfusion)

Diagnosis:
- measurement of bladder pressure via foley catheter= estimate intraabdominal pressure

Manage:

  • avoid over resuscitation with fluid
  • decrease intraabdominal volume ( NG tube)
  • increase intraabdominal compliance ( sedation)
  • surgical decompression if IAP is > 25 mmHg ( laparotomy without fascial closure, allowing for an open abdomen)
201
Q

Ischemic colitis

A

Signs:

  • abdominal pain
  • bleeding (hematochezia)
  • diarrhea
  • leukocytosis
  • lactic acidosis
  • hypotension

Diagnosis:

  • abdominal CT scan with contrast= thickened bowel with fat strand
  • confirmed by: colonoscopy

Management:

  • bowel rest + iv-fluid
  • antibiotics
  • colonic resection, if necrosis developed

Involved areas: “watershed area”

  • splenic flexure ( SMA/IMA)
  • Rectosigmoid junction ( Sigmoid artery & Superior rectal artery)
202
Q

Acute colonic pseudoobstruction (ogilvie syndrome)

A

Caused by:

  • electrolytes imbalance
  • surgery, neurologic disease, anticoagulation drugs
  • recent infection

Signs:

  • severe abdominal pain + distention
  • vomiting
  • obstipation

Diagnosis:

  • CT abdomen: colonic dilation without anatomic obstruction
  • x-ray: colonic dilation, normal haustra, non-dilated small bowel

Treatment:

  • Bowel rest
  • colonic decompression ( NG/rectal tube)
  • neostigmine (iv)
203
Q

Trousseau syndrome ( migratory superficial thrombophlebitis)

A
  • hypercoagulabe disorder
  • inflammation of the veins due to blood clot
  • associated with undiagnosed malignancy (occult visceral malignancy) (cancer): pancreas, lung, prostate, stomach, colon

Signs:
- thrombosis at unusual sites ( arm, chest)

Diagnosis:
- CT scan of abdomen

204
Q

Splenic abscess

A

Caused by:
-bacteremia from distant infection (infective endocarditis, cholecystitis)

Sign:

  • LUQ pain (may radiate to the back)
  • fever, chills
  • (+/-) splenomegaly

Diagnosis:

  • CT scan of the abdomen
  • x-ray: elevated hemi-diaphragm ( left pleural effusion)

Manage:

  • antibiotics
  • splenectomy ( patient fail percutaneous aspiration)
205
Q

Radiation proctitis (RP)

A
  • mucosal damage associated with pelvic radiation therapy

Acute RP:

  • present < 8 weeks post-radiation
  • diarrhea + tenesmus + mucus discharge

Chronic RP:

  • present months/years post-radiation
  • hematachezia, anemia, strictures

Diagnosis:
- colonoscopy: mucosal pallor, friability, telangiectasia confined to the rectum

206
Q

Zollinger-Ellison syndrome ( gastrin-producing tumor)

A

Signs:

  • multiple refractory ulcers ( usually distal to duodenum)
  • chronic diarrhea
  • elevated serum gastrin (> 1000) ( causes diarrhea & steatorrhea due to inactivation of pancreatic enzymes; fat malabsorption)

Diagnosis:

  • endoscopy (locate ulcer)
  • CT or MRI (identify pancreatic tumor or metastasis)
  • somatostatin receptor scintigraphy for tumor localization
207
Q

Polyarteritis nodosa (PAN)

A

Causes:
-inflammation, weakness, damage of arteries (lumen narrow & aneurysm —> organ ischemia & infraction due to decrease blood flow & thrombus formation)

  • associated with kidney ( renal infraction) , & GI (mesenteric ischemia, bowel perforation)

Signs:

  • loss of appetite
  • sudden weight loss
  • abdominal pain
  • excessive fatigue
  • fever
  • muscle & joint ache

Diagnosis:
-Angiography : arteries with micro-aneurysms, irregular luminal narrowing, & distal occlusion

208
Q

Zinc

A
  • absorbed in the duodenum & jejunum
  • malabsorption (crohn’s and celiac diseases), bowel resection, gastric bypass, or poor nutritional intake can prevent absorption of zinc
  • zinc associated with hair loss, and impaired tasting
209
Q

Steatorrhea (fat malabsorption)

A

Signs:
- voluminous, greasy, foul-smelling stool that are difficult to flush

Associated with:

  • chronic pancreatitis due to alcohol abuse
  • cystic fibrosis
  • autoimmune pancreatitis
  • pancreatic cancer
  • crohn’s disease (small bowel)
  • celiac disease
  • Zollinger-Ellison syndrome
  • Whipple disease

Management:
- pancreatic enzyme supplementation

210
Q

Mittelschmerz

A
  • unilateral, mid-cycle pain prior to ovulation
  • pain lasts hours to days
  • no need for U/S
211
Q

Ectopic pregnancy

A
  • amenorrhea, vaginal bleeding, abdomen/pelvic pain
  • elevated beta hCG
  • U/S: no intra-uterine pregnancy
  • treat: methotrexate
212
Q

Ovarian torsion

A
  • severe, sudden onset, unilateral, lower abdominal pain
  • N/V
  • unilateral, tender adnexal mass on examination
  • U/S: enlarged ovary with decreased blood flow/ absent blood flow/absent doppler flow
  • treat:
    1) laparoscopy with detorsion
    2) ovarian cystectomy (preserved ovaries)
    3) oophorectomy if necrosis or malignancy
213
Q

Ovarian cyst rupture

A
  • severe, sudden onset, unilateral, lower abdominal pain
  • associated with strenuous activity or sex
  • abdominal rigidity, guarding rebound tenderness, referred shoulder pain
  • U/S: pelvic free fluid (hemi-peritoneum)
  • treat: NSAID & observation (non-urgent)
214
Q

Pelvic inflammatory disease (PID)

A
  • fever, chills, vaginal discharge, abdomen/pelvic pain, cervical motion tenderness
  • U/S: +/- tuboovarian abscess
215
Q

Palpable breast mass

A

younger than 30 years:

  • U/S (+/-) mammogram
    1) simple cyst: needle aspiration if desire
    2) complex cyst/solid mass/irregular border: image-guided core biopsy

Older than 30 years:

  • mammogram (+/-) U/S
  • suspicious for malignancy: core biopsy
216
Q

Inflammatory breast cancer

A

Signs:

  • rapid in onset (within months) & aggressive & metastasis
  • painful
  • Enlarged lymph nodes (underarm)
  • retracted nipple/flattening
  • itching
  • edema, erythema, thickened skin dimpling & “orange-peel” breast

Diagnosis:

  • mammogram +/- U/S
  • biopsy (confirm diagnosis)
217
Q

Mastitis

A

Sign:

  • pain, erythema, warmth
  • fever
  • rapidly improved with antibiotics
  • involves women breast feeding
  • if not improved with antibiotics, evaluate patient for inflammatory breast cancer or breast abscess ( tender & fluctuant mass)
218
Q

Fat necrosis

A

Sign:

  • firm & irregular mass
  • no nipple discharge & skin/nipple retraction
  • history of trauma or surgery
  • local ecchymosis
  • calcification on mammogram
  • biopsy: fat globules & foamy histiocytes (macrophages)
  • reassurance & routine follow up
219
Q

Invasive ductal carcinoma

A

Signs:

  • firm & irregular mass
  • nipple discharge
  • nipple retraction
220
Q

Lobular breast carcinoma

A
221
Q

Benign Intra-ductal papilloma

A

Signs

  • nipple discharge (bloody or non-bloody)
  • no breast mass
  • unilateral

Diagnosis:

  • mammography +/- U/S
  • biopsy +/- excision
222
Q

Fibroadenoma

A

Sign:

  • firm, round & mobile mass
  • cyclic premenstrual tenderness ( feel pain before period)
  • age < 30
223
Q

Management of breast pain (mastalgia)

A

Cyclical, bilateral & diffused:

1) mass: imaging
2) no mass: observation

Non-cyclical, unilateral, focal

1) mass: biopsy, referral to breast surgeon
2) no mass: imaging
- normal: observe
- abnormal: biopsy

224
Q

Breast cysts (benign)

A

Simple cyst:

  • FNA for symptomatic: biopsy/imaging (bloody) & observation (non-bloody)
  • non-bloody cyst: biopsy/imaging (recurrent/persistent) & no additional management (for resolved cyst)

Complex cyst:
-biopsy

225
Q

Small bowel obstruction

A

Signs:

  • acute abdomen
  • hyperactive & absent bowl sound
  • N/V
  • obstipation

Diagnosis:

  • air fluid level
  • dilated proximal colon & collapsed distal colon
  • no air in rectum (colon)

Management:

  • bowel rest + NG decompression
  • emergency laparotomy ( to prevent bowel ischemia/perforation)
226
Q

Pectoralis minor

A
  • distinguish the surgical level of axillary lymph node during axillary lymph node dissection
227
Q

Hypermetabolic response to severe burn

A
  • arise within 5 days post injury

Signs:

  • tachycardia
  • hypertension
  • fever
  • hyperglycemia
228
Q

Frostbites

A
  • Signs of ischemia ( decrease capillary refill, grey color, sensory loss)
  • manage with warm water bath.
  • if refractory, Perform angiography or technetium-99 scintigraphy ( identify thrombosis)
229
Q

Brown recluse spider bite

A

Signs:

  • painful
  • burning sensation
  • deep skin ulcer that develops to necrosis & eschar
  • provide support wound care only + cold packs
230
Q

Venamous Snake-bite

A
  • systemic toxicity treat with: crotalidea polyvalent immune Fab
  • normal laboratory & mild symptoms: observation, frequent coagulation studies, wound evaluation
231
Q

Hypercalcemia

A
  • occurs in prolonged immobilization due to increase bone turnover
  • treat: bisphosphonate (reduce hypecalcemia & bone turn over)
232
Q

Stress hyperglycemia

A
  • increase blood glucose due to illness or injury

Mild elevation:
- no treatment

Massive elevation ( glucose > 180 or 200)

  • lead to mortality
  • treat: short acting insulin ( to lower glucose to 140-180)
233
Q

Evaluating thyroid nodules

A

Via TSH level & thyroid U/S

-High TSH: FNA

  • Low TSH: radioactive iodine scintigraphy ( radionuclide thyroid scan)
    1) hypo-functional (cold) or intermediate nodule: FNA
    2) hyper-functional (hot) nodule (not malignant) : treat hyperthyrodism
234
Q

Hypocalcemia

A
  • prolonged QT
  • hypoparathyrodism
  • post thyroidectomy
  • high-volume blood transfusion (due to chelation of ionized calcium by citrate in transfused blood; hepatic dysfunction causes decreased clearance of citrate by the liver)
  • signs: muscle cramp, anxiety, fatigue, poor sleep
  • treat: IV calcium gluconate/chloride
235
Q

Intravenous fluid

A

Isotonic

1) lactate ringer solution
- volume resuscitation ( hypovolemia, shock, burnt victim)

2) 0.9 % normal saline
- volume resuscitation ( hypovolemia, shock)
- don’t give to burnt victim = develop hyperchloremic metabolic acidosis

3) albumin (5% or 25%)
- volume replacement
- treatment of spontaneous bacterial peritonitis or hepatorenal syndrome

Hypotonic

1) dextrose 5% in water
- water deficit

2) 0.45% (half-normal) saline
- water deficit

3) dextrose 5% in 0.45% (half-normal) saline
- maintain hydration

Hypertonic

1) 3% (hypertonic) saline
- severe, symptomatic hyponatremia

236
Q

Syndrome of inapproperiate ADH

A

-desmopressin can act like an analogue to ADH

Signs:

  • mild hyponatremia: nausea & forgetfulness
  • severe hyponatremia: seizure, coma
  • euvolemia ( moist mucus membrane, no edema, no JVD)

Findings:

  • hyponatremia
  • serum osmolality (<275)
  • urine osmolality (>100)
  • urine sodium (>40)

Manage:

  • fluid resuscitation +/- salt tablet
  • severe hyponatremia: 3% (hypertonic) saline
237
Q

Indication for select pre-operative tests

A

1) ECG:
- history of coronary artery disease (CAD) or arrhythmia
- asymptomatic patients with risk of major adverse cardiovascular events (MACE >1%)

2) Chest radiograph:
- history of cardiopulmonary disease
- undergoing an upper abdominal/thoracic surgery

3) Hemoglobin
- history of anemia, & expected significant blood loss
- undergoing major surgery

4) Coagulation & platelets
- history of abnormal bleeding or anti-coagulant use
- liver disease, malignancy, planned spinal anesthesia

5) Creatinine & electrolytes
- history of kidney disease, cardiovascular-risk calculation
- use of medication ( ARB, ACE inhibitors, diuretic)

238
Q

Diabetic foot ulcer (causes neuropathic ulcers)

A

caused by:
- repeated pressure, friction or trauma

Risk factors:

  • uncontrolled diabetes ( measure hemoglobin A1c)
  • peripheral neuropathy ( loss of sensation)
  • foot deformities or muscle atrophy
  • End stage renal disease/ dialysis (ESRD)

Signs:

  • located at the sole of foot at high-pressure points
  • painless ulcer
  • punched out appearance with necrotic base
  • adjacent callus ( on pressure point, not painful, related to pressure)

Diagnosis:
- check hemoglobin A1c (controlled vs uncontrolled diabetes)

239
Q

Venous ulcer

A

Signs:

  • located at the shin of leg above malleolus
  • associated with edema & stasis dermatitis (venous eczema ; leak of blood from vein into skin)

Diagnosis:
-duplex U/S

240
Q

Penetrating abdominal trauma

A

Indication for immediate laparotomy:

  • hemodynamically unstable (systolic BP < 90)
  • peritonitis ( rigidity, rebound tenderness)
  • evisceration (externally exposed intestine)
  • impalement (+ remove necrotic tissue, hematoma, initiate negative pressure wound therapy)
  • penetration of peritoneum & significant organ damage

Note:
- eFAST: can be performed before just to confirm the need of laparotomy ( presence of free-fluid)

241
Q

Tracheobronchial rupture ( bronchial rupture) = rapid accumulation of pleural air in despite presence of chest tube

A

-air escape with each breath

Signs:

  • persistence pneumothorax
  • RAPID large air leak (+ decrease in oxygen saturation) despite tube thoracotomy
  • presence of air in pleural space (pneumothorax) + air under diaphragm (pneumomediastinum) + air trapped in tissue under skin (subcutaneous emphysema; crepitus)

Diagnosis:
-bronchoscopy

Manage:
- repair surgery

242
Q

Primary hyper-parathyrodism (PTH)

A

Etiology:

  • parathyroid adenoma
  • hyperplasia
  • carcinoma
  • MEN Type 1 & 2A

Symptoms:

  • constipation + fatigue
  • abdominal pain + renal stones+ bone pain

Diagnosis:

  • hypercalcemia
  • hypophosphatemia
  • elevated PTH
  • Increase 24-hours urinary calcium excretion

Indication for parathyroidectomy:

  • age <50
  • hypercalcemia with symptoms
  • with complications: osteoporosis, nephrolithiasis, impaired renal function- GFR<60)
243
Q

Pheochromocytoma

A

Signs:

  • pale + tachycardia+ hypertension occurrence after general anesthesia induction
  • catecholamine surge due to anesthesia
  • history of anxiety disorder, HTN, headache

Signs:

  • headache, sweating , tachycardia
  • resistance HTN or HTN + increased glucose
  • family history of MEN 2, NF1, VHL

Diagnosis:

  • urine or plasma metanephrine level
  • confirmatory abdominal imaging for increase metanephrine

Management:
- pre-operative alpha blocker (7-14 days before surgery), before beta-blocker ( 2-3 days before surgery) to prevent catecholamine surge
-laparoscopic or open surgery for surgical resection
-

244
Q

Adrenal crisis

A

Development of hypotension (SB <90) despite IV-fluid bolus during surgery

Etiology:

  • adrenal hemorrhage or infraction
  • illness, injury, surgery in patient with adrenal insufficiency
  • pituitary apoplexy

Signs:

  • hypotension +shock + hypoglycemia
  • N/V + abdominal pain
  • fever + generalized weakness

Treat with:

  • IV-hydrocortisone
  • IV- dexamethasome
  • rapid (aggressive) IV volume repletion
245
Q

Prolactin & amenorrhea

A

Hyperprolactinoma due to pituitary microadenoma

  • increase prolactin
  • inhibits GRH (Hypothalamus)
  • decrease FSH & LH (anterior pituitary)
  • decrease estrogen (ovaries)
  • amenorrhea, an-ovulation, menopausal symptoms, infertility

Signs:

  • hot flashes
  • vaginal dryness & atrophy
  • dyspareunia
  • prolonged estrogen deficiency leads to osteoporosis (bone loss)

Manage:
-dopamine agonist

246
Q

Hemorrhagic shock areas causing hemodynamic instability

A

1) floor
2) chest
3) abdomen
4) pelvis/retroperitoneum
5) thigh

247
Q

Papillary thyroid cancer

A

Signs:

  • (2) cm hypo-echoic nodules in one lobe of thyroid
  • no enlargement of lymph node
  • FNA biopsy: large cells with ground glass cytoplasm + pale nuclei containing inclusion bodies + central grooving consistent with papillary thyroid cancer

Management:

  • FNA biopsy
  • surgical resection (thyroidectomy)
  • if recurrence is expected:
    1) radioactive iodine ablation (kill remaining thyroid tissue after thyroidectomy)
    2) thyroid hormone
248
Q

Tertiary hyperparathyroidism

A

Risk factor:

  • chronic kidney disease (end stage renal disease-ESRD)
  • chronic hypocalcemia, hyperphosphatemia ( result in more secretion of PTH)

Pathogenesis:

  • parathyroid hyperplasia
  • loss of feedback inhibition on PTH by calcium

Signs:

  • increase calcium
  • increase phosphorous
  • increase increase PTH

Management:

  • refractory to medical therapy
  • parathyroidectomy
249
Q

Antibiotics prophylaxis for pre-operative surgery

A

Cardiac, neurological, orthopedic, vascular:

  • skin flora: gram positive: strep., staph.,
  • cefazolin (cephalosporin); vancomycin ; clindamycin

GI, genitourinary, gynecologic/obstetric, head/neck, thoracic:
- broader coverage

250
Q

Euthyroid sick syndrome ( low T3 syndrome)

A

-adaptive response to severe illness
Signs:
-EARLY: low T3, normal T4, normal TSH
-LATE: low T3, T4, TSH

Management:

  • observe without treatment
  • follow up testing when patient has returned to normal baseline
251
Q

Eosinophilic esophagitis

A

caused by:
- eosinophilic infiltration of the esophagus mucosa

Signs:

  • food dysphagia
  • refractory heartburn
  • regurgitation
  • food impaction

Diagnosis:

  • endoscopy & esophagus biopsy (eosinophil: >15)
  • rule out: achalasia, infection

Management:

  • elimination diet
  • PPI
  • Topical glucocorticoids
252
Q

Colovesical fistula

A
  • associated with diverticular disease, Crohn disease, malignancy
  • abnormal connection between colon & bladder

Signs:

  • pneumaturia (air in urine)
  • fecaluria (stool in urine)
  • recurrent urinary tract infection

Diagnosis:

  • CT scan of the abdomen with oral or rectal contrast
  • colonoscopy (exclude malignancy)

Management:
-surgical after resolution of infection

253
Q

Stress-induced ulcer

A
  • associated with ICU
  • risk factors: sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord/brain injury, burns, high-dose corticosteroids

Signs:

  • gross or occult GI bleeding (in stool)
  • anemia
254
Q

Requirement for bariatric surgery

A

Requirements:

1) BMI > 40
2) BMI >35 + comorbidity ( T2D, HTN, sleep apnea)
3) BMI > 30 + resistant T2D or metabolic syndrome

255
Q

Metastasis to liver

A
  • metastasis from: colon, pancreas, skin

Signs:

  • weight loss
  • anemia
  • hepatomegaly
  • cholestasis ( high bilirubin & Alkaline phosphatase)
  • normal liver function test
256
Q

Evaluation of bilious emesis in neonates ( meconium ileus vs. Hirschsprung disease vs. malrotation vs. duodenal atresia)

A

Bilious emesis

  • unstable (+ rigid abdomen): emergency laparotomy
  • stable: abdominal X-ray
    1) free-air: emergency laparotomy

2) dilated loops of bowel:
- increase rectal tone &/or delayed passage of meconium: contrast enema: (microcolon: meconium ileus) or (rectosigmoid transition zone: Hirschsprung disease)

  • normal rectal examination: upper GI series …….(+…)
    3) normal: upper GI series: right-sided ligament of trietz: malrotation
    4) double bubble sign: duodenal atresia

Note:
- malrotation with midgut volvulus causes intestinal perforation & necrosis, considered in patient with normal rectal examination & air-fluid level on x-ray.

257
Q

Chronic pancreatitis

A

Signs:

  • intermittent epigastric pain (radiate to the back) (worst with eating)
  • nausea
  • pancreatic atrophy & calcification
  • history of alcohol abuse

Management:
- provide pancreatic enzyme supplement (amylase, lipase, protease)

258
Q

Subphrenic abscess (intra-abdominal abscess)

A
  • accumulation of infected fluid between the diaphragm, liver, and spleen.
  • associated with infection after surgery (appendectomy, splenectomy)
  • should be suspected if fever & abdominal symptoms returns days after surgery

Signs:

  • RUQ pain
  • fever
  • leukocytosis
  • pulmonary manifistation ( hiccups, pleural effusion, SOB)

Diagnosis:
-CT (abdomen)

Management:

  • antibiotics
  • drainage
259
Q

Vascular ring (abnormal arch within aorta)

A

-encircle trachea or esophagus

Signs

  • compression of trachea presents with stridor
  • compression of esophagus presents with dysphagia, vomiting, recurrent food impaction
260
Q

Management of C. Difficile infection

A

Drugs:

1) vancomycin or fidaxomicin
- non/severe CDI ( symptoms: profuse watery diarrhea + abdominal pain)
- severe CDI (symptoms + leukocytosis >15,000 + Creatinine>1.5 )

2) Oral vancomycin & IV- metronidazole
- fulminant CDI ( severe CDI + either: hypotension/shock or illeus/megacolon)

3) Fecal microbiota transplantation or surgical intervention
- refractory CDI

261
Q

Enteral nutrition

A
  • used right away for patient with moderate to severe burn

- benefits: stop the hyper-metabolic state, maintain gut integrity, reduce rate of sepsis, decrease mortality

262
Q

Pilonidal disease

A

-associate with: males., age 15-30, obese, sedentary

Signs:

  • painful, fluctuant mass 4-5 cm in the intergluteal region
  • mucoid, purulent or blood drainage
263
Q

Primary sclerosing cholangitis (PSC)

A

Signs:

  • fatigue + pruritus
  • associated with ulcerative colitis

Laboratory/imaging:

  • cholangiography: dilated intrahepatic & extrahepatic bile duct
  • increase bilirubin & alkaline phosphatase
  • increase gamma-glutamyl transpeptidase

Lead to:

  • biliary stricture
  • cholangitis or cholelithiasis
  • cholangiocarcinoma
  • cholestasis

In patients with PSC:
- colonoscopy is performed to rule out associated Ulcerative colitis

  • annual colonoscopy is performed in patients with PSC+UC to monitor risk for colon cancer
264
Q

Perforated viscus

A
  • caused by duodenal ulcer = result in retroperitunium bleeding + free air
  • caused by kidney laceration or pancreatic trauma = delayed retroperitunium bleeding + free fluid
265
Q

Surveillance after colon cancer resection

A

Stage 1:
-colonoscopy after 1 year, than after 3-5 years

Stage 2/3:

  • colonoscopy after 1 year, than after 3-5 years
  • CEA testing
  • CT scan of chest, abdomen, pelvis

Stage 4:
- follow stage 2/3 + more frequent CT scan

266
Q

Perianal abscess

A

-associated with: constipation, intercourse
Sign:
- progressive worsening pain in anal region
- tender, fluctuant, erythematous mass + itching
- fever

267
Q

Colon cancer

A

Left sided:
-visible red bleeding with rectum

Right sided:
- occult bleeding + anemia

268
Q

Acute ischemic bowel

A
269
Q

Ischemic colitis

A
  • complication of vascular surgery
  • old
  • atherosclerosis
  • thickening of colonic wall
  • cyanotic mucosa + hemorrhagic ulceration
270
Q

Visceral hemorrhage management

A

1) 2 IV-access
2) resuscitation
3) IV- octreotide
4) antibiotics

Stop bleeding:

  • beta blocker
  • endoscopic band ligation (1-2 weeks later)

Continued bleeding:

  • balloon tamponade (temporary)
  • TIPS or shunt surgery

Early re-bleeding:

  • repeat endoscopy
  • recurrent bleeding
  • TIPS or Shunt
271
Q

Toxic megacolon

A
  • present in patients with inflammatory bowel disease (Crohn’s or UC) (low grade fever, abdominal pain, bloody diarrhea)

Treat:
- IV corticosteroid ( methylprednisolone)

272
Q

Acute pancreatitis

A
  • caused by alcohol or gallstone

- evaluate right upper quadrant by U/S

273
Q

Gallstone pancreatitis

A
  • suspected in patient with alanine aminotransferase > 150

- treat with: cholecystectomy

274
Q

Toxic megacolon

A

1) CT scan shows colonic dilation > 6 cm

2) systemic toxicity ( fever, leukocytosis, hemodynamic instability)

275
Q

Zenker diverticulum

A
  • foul smelling breath
  • mass in neck when palpate
  • recurrent pneumonia + dysphagia + regurgitation in elderly patient

Diagnosis:
-contrast esophagography

Treat:
- surgical (cricopharangeal myotomy +/- diverticulectomy)

276
Q

Esophagus perforation

A
  • pleural effusion with yellow exudate + high amylase content or green fluid or low pH
  • widened mediastinum

Diagnosis:

  • water-soluble contrast CT scan
  • esophogography
277
Q

Pancreatic psuedocyt

A
  • encapsulated area ( enzyme-rich fluid, tissue, debris) around fat stranding
  • previously diagnosed with acute pancreatitis

Treat:
- endoscopic drainage for symptomatic patient with abdominal pain , N/V, distention, discomfort

278
Q

Pyogenic liver abscess

A

Signs:

  • fever
  • leukocytosis
  • RUQ pain
  • altered liver function tests

Diagnosis:
-CT

Treat:

  • blood culture
  • antibiotics
  • drainage
  • aspiration
279
Q

Epidural hematoma

A

Signs:

  • tear of middle meningeal artery
  • skull fracture
  • young patient
  • elevated ICP ( headache, N/V, altered Mental status)
280
Q

Subdural hematoma

A

Signs:

  • tear of bridging veins
  • older patients or anti-thrombotic use
  • acute SDH: coma
  • chronic SDH: confusion + headache
281
Q

Subarchinoid hemorrhage

A

Signs:

  • Sudden &B severe thunderclap headache
  • loss of consciousness
  • Meningism ( headache, neck stiffness, photophobia, N/V)
282
Q

Emergence from anesthesia

A
  • most patient fully awake after 15 min

Residual effect of anesthesia leads to:

Delayed emergence:

  • hypoactive state
  • somnolence persisting > 30-60 min

Emergence delirium:
- hyperactive state

Treat:
- reassurance & reorient & observe : usually temporary & will resolve

283
Q

Copper (similar to effect of vitamin B12)

A

Signs:

  • hair loss or brittle
  • anemia or osteoporosis
  • ataxia
  • skin depigmentation
284
Q

In trauma of cervical spine

A

Manage:

  • spinal immobilization + removal of helmet
  • oxygen supplement

In hospital:

  • orotracheal intubation
  • in-line cervical stabilization
  • CT scan of cervical spine
285
Q

Spinal cord injury

A
  • high spinal cord injury (above C5) leads to hypercapnia respiratory failure due to diaphragm paralysis
  • high speed motor accident: expansion of airbag leads to hyperextension of the neck; injury to C5 (C5-C6) —> This makes you reconsider CT scan of the thoracic & lumbar spine (imaging the entire spine)
286
Q

Untreated anterior shoulder dislocation

A

Sign:

  • hand is abducted + externally rotated
  • cause injury to axillary nerve (innervated teres minor & deltoid muscles)

Result in:
- decrease abduction + decrease sensation at the lateral shoulder

287
Q

High-speed motor accident management

A

1) chest & pelvic x-ray
2) FAST
3) CT of cervical spine ( before doing surgery: irrigation, fixation, because patient might require orotracheal intubation & neck manipulation) —> evaluate cervical spine injury

288
Q

Traumatic carotid injury ( carotid artery dissection)

A

Caused by:

  • fall with object in mouth
  • neck manipulation

Signs:

  • aphasia (inability to speak or comprehend)
  • thunderclap headache
  • neck pain
  • gradual onset of hemiplegia
  • facial droop

Diagnosis:
- CT or MRI angiography

289
Q

Meningioma

A

Signs:

  • hyperdense & calcified mass at the dural space of frontal lobe
  • headache, seizure, focal weakness/numbness
  • middle-elderly aged women
  • benign

Treat:
- surgical resection

290
Q

Cuada equina syndrome can lead to spinal epidural hematoma

A
  • caused by epidural block, lumbar puncture, spinal surgery
  • common in older adult taking anti-thrombotic agents

Sings:

  • slowly progressive motor & sensory dysfunction
  • localized back pain
  • bowel & bladder retention

Manage:
-urgent MRI + DECOMPRESSION

291
Q

Stroke due to intracranial hemorrhage

A

Signs:

  • slurred speech
  • dizziness
  • weakness
  • continuous hemorrhage lead to brain herniation (midline shift on CT scan, decerebrate posturing)
  • brain herniation leads to respiratory failure (decrease ventilation)—> manage with intubate & mechanically ventilate
292
Q

Femoral nerve

A
  • hip flexion & knee extension (hf/ke)

- sensation to anterior thigh & medial leg

293
Q

Loss of spinal cord function (injury to descending spinal tract)

A

Signs: (long standing reduce of sympathetic tone)

  • hypotension + hypothermia (lack of peripheral vasoconstriction) + bradycardia
  • areflexia, anesthesia, paralysis, distended bladder
  • initial presentation: tachycardia/hypertension due to sympathetic stimulation (NE release)
294
Q

Thunderclap headache seen in

A
  • subdural hematoma
  • carotid dissection due to trauma
  • pituitary apoplexy (hemorrhage or acute ischemia of pituitary; associated with large adenoma; headache, nausea, mental status, hypotension, bilateral visual field defect, ophthalmoplegia )
  • severe-onset of headache + nausea + altered mental status
295
Q

Paroxysmal sympathetic hyperactivity (PSH)

A

Signs:

  • tachycardia, hypertension, tachypnea
  • fever, diaphoresis
  • associated with traumatic brain injury
  • lasts for 20-30 min
  • triggered by bathing, repositioning, or spontaneous
296
Q

Spinal cord compression (cervical myelopathy)

A

Signs:

  • weakness in upper & lower extremities
  • atrophy of hand (loss of grip)
  • neck stiffness + electric shock feeling when neck flexed (lhermitte sign)
  • hyperreflexia of leg
297
Q

Reduce ICP

A
  • mannitol or hypertonic saline
  • elevated head
  • sedation
  • hyperventilation
  • CSF removal
  • decompression craniectomy
298
Q

Orbital floor fracture (muscle entrapment)

A

Signs:

  • vertical diplopia
  • restrictive upward eye movement
299
Q

Malignant hyperthermia

A

Signs:

  • tachycardia
  • dyspnea
  • muscle rigidity
  • myoglobinuria ( brown urine found in foley catheter)
  • arise shortly after anesthesia induction
300
Q

Venous stasis ulcer

A

Signs:

  • brawny skin discoloration (hemosiderin deposition)
  • ulcer with well-vascularized granulation tissue (appears pink/red)

Scenario:

  • venous ulcer —> developed cellulitis —> managed with sntibiotics & wet to dry dressing (commonly used for wound that are infected, have been freshly derided, devitalized tissue) —> (gauze soaked in saline, applied to wound, let dry, upon removal of gauze from wound, it takes out the devitalized tissue)
  • when healthy granulation tissue forms, wet to dry dressing should be discontinued and substituted with (non-adherent, moisture-retaining dressing to promote healing)

Note:
- would should not be left open to air to let dry out; because moist wound heal faster than dry wound

301
Q

Diabetic foot ulcer

A
  • history of uncontrolled diabetes
  • loss of sensation (peripheral neuropathy)
  • colonized by many microbes, complicated by osteomyelitis

Diagnosis:

  • x-ray or MRI to assess for osteomyelitis
  • ulcer with (increase ESR or CRP) requires imaging
302
Q

Basal cell carcinoma

A

Risk factors:

  • fair skin
  • sun
  • radiation

Signs:

  • skin colored, pearly nodule, +/- rolled borders
  • telangiectasia appears
  • central ulceration, local invasion

Diagnosis:
- shave, punch, excisional biopsy

Treat:
- 1st: surgical excision with 4 mm margin + MOHs micrographic surgery (for face & high-risk of recurrence)

-2nd: topical FU, topical imiquimod, C & E

303
Q

Keratocanthoma

A

Signs:

  • rapidly growing nodules with ulceration & keratin plug
  • shows spontaneous regression/resolution
  • can progress to invasive squamous cell carcinoma

Manage:
- excisional biopsy with complete removal of lesion

304
Q

Melanoma

A

Signs: ( ABCDE)

  • asymmetry
  • border irregularity
  • color variation
  • diameter > 6 cm
  • evolving appearance over time

Management:
- excisional biopsy

305
Q

Pyoderma gangrenosum

A

Signs:

  • painful papules with discharge that progressively enlarge
  • refractory to antiseptics
  • women 40-60 years
  • associated with: IBD, rheumatoid arthritis, malignancy

Diagnosis:

  • exclusion of infection ulcer
  • skin biopsy: shows mixed inflammation (neutrophils)

Manage:
- local or systemic glucocorticoids

306
Q

Pressure necrosis

A

-prolonged pressure over bony prominence

307
Q

Secondary angiosarcoma due to radiation

A
  • purpuric nodules
  • purpuric patches without distinct border
    Diagnosis: lesion biopsy
308
Q

Infantile hemangioma

A
  • days to weeks after birth
  • bright red soft raised plaques

Manage:
- beta-blocker (oral)

309
Q

Squamous cell carcinoma

A
  • non-healing ulcer arise from chronic wound or scar
  • aggressive, recurrence, local invasion, metastasis

Diagnose:
-biopsy

310
Q

Alcohol withdrawal treatment

A
  • benzodiazepines

- for liver diseases: lorazepam

Uworld Surgery-shelf (1 decks)

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