Critical Care

Question 1

Acute abdomen

Path:

Answer 1

RUQ: Cholecystitis , Pyelonephritis , Ureteric colic , Hepatitis, Pneumonia

Epigastric: Peptic ulcer dz, Cholecystitis, Pancreatitis, Myocardial infarction

LUQ: Gastric ulcer, Pyelonephritis, Ureteric colic, Pneumonia

RLQ: Appendicitis, Ureteric colic, Inguinal hernia, IBD, UTI, Gynecological, Testicular torsion

Periumbilical: Small bowel obstruction, Large bowel obstruction, Appendicitis, Abdominal aortic aneurysm

LLQ: Diverticulitis, Ureteric colic, Inguinal hernia, IBD, UTI, Gynecological, Testicular torsion

Question 2

Acute adrenal insufficiency 
Path:
Pt:
Dx:
Tx:

Answer 2

Path: Sudden worsening of adrenal insufficiency due to stress-> surgery, trauma, volume loss, hypothermia, MI, fever, sepsis, hypoglycemia, steroid withdrawal
Abrupt withdrawal of glucocorticoids (MC cause)
Previously undiagnosed Addison’s disease subject to stress
Exacerbation of known Addison’s disease-> did not increase glucocorticoid during stress
Bilateral adrenal infarction (usually 2/2 hemorrhage)

Pt: Shock-> hypotension, hypovolemia

Dx: 
BMP: hypo Na, hyper K, hypoglycemia 
Cortisol levels 
ACTH
CBC

Tx:

• IVF: normal saline (D5NS if hypoglycemic) to correct hypotension and hypovolemia
• Glucocorticoids: IV hydrocortisone (if known Addison’s) or Dexamethasone (if undiagnosed)
• Reversal of electrolyte disturbances: hypo Na, hyper K, hypoglycemia, hyper Ca
• Fludrocortisone- synthetic mineralocorticoid (similar to aldosterone)

Question 3

Adrenal insufficiency lab values 
CRH
ACTH
Cortisol
CRH stimulation test (ACTH response)
Aldosterone
Renin

Answer 3

Primary- Adrenal
CRH: High
ACTH: HIGH
Cortisol: LOW
CRH stimulation test (ACTH response): High ACTH
Aldosterone: Low
Renin: High

Secondary- Pituitary 
CRH: High
ACTH: LOW
Cortisol: LOW
CRH stimulation test (ACTH response): Absent/low ACTH
Aldosterone: Low
Renin: Normal/low

Tertiary-Hypothalamus 
CRH: Low
ACTH: Low
Cortisol: Low
CRH stimulation test (ACTH response): exaggerated,prolonged
Aldosterone: Low
Renin: Normal/low

Question 4

GI Bleed Path:

Answer 4

Upper GI:

• Mallory-Weiss tear
• Peptic ulcer dz
• Gastritis
• Gastric cancer
• Esophageal varices

Lower GI:

• Colon cancer
• Diverticular bleed
• Hemorrhoids
• Anal fissure
• IBD

Question 5

Gastric Cancer
Path:
Pt:
Dx:
Tx:

Answer 5

Path:
One of the MC worldwide cancers, more common in developing countries, M>W
Risks: diet, obesity, smoking, H pylori, EBV, gastric surgery & radiation, blood type A, family Hx
Protective: fruits, vegetables, fibers, NSAIDs, reproductive hormones

Pt: Early stages- asx. Often dx late w/ incurable disease
Occult GI bleed w/ or w/o iron deficiency anemia, melena, hematemesis, weight loss, abdominal pain, nausea, dysphagia
PE: possible palpable mass, enlarged lymph nodes, ascites

Dx: EDG & bx
Barium studies (UGI)- poor distensibility of stomach (linitis plastica gastric cancer)
CT/PET/EUS- staging of disease and possible metastasis

Tx:
Endoscopic resection 
Surgery (gastrectomy with lymph node resection ) 
Chemotherapy 
Radiation therapy

Question 6

Acute Glaucoma 
Path:
Pt:
Dx:
Tx:

Answer 6

Path: Increased intraocular pressure 2/2 to obstruction of aqueous humor drainage via the canal of Schlemm
Increased posterior chamber pressure or pupillary dilation-> narrowing of anterior chamber-> canal of schlemm obstruction

Pt: Ocular pain, N/V, unilateral blurred vision, halos around lights, conjunctival injections, cloudy cornea, mid-dilated nonreactive pupil
Elevated intraocular pressure (>30 mmHg)

Dx:
Inc intraocular pressure by tonometry-> >/=21mmHg
“Cupping” of optic nerve on fundoscopy

Tx:
Decrease aqueous humor production: PO or IV acetazolamide, topical timolol (BB) and apraclonidine (alpha agonist)

Miosis-pupil constriction (inc aqueous humor outflow)- topical pilocarpine 1 hour after the start of treatment, 2 doses 15 mins apart

Adjuncts- hyper-osmotic agents (IV mannitol), 2 hours after initiation of treatment if not adequately controlled

Ophthalmology consult-> definitive laser iridotomy