random Flashcards
pts w trochanteric bursitis complain of pain when
- presssure applied eg sleeping on side
- external rotation (glut med)
- resisted abduction (glut med)
bursa where glut med knserts into greater femoral trochanter
leriche syndrome
erectile dysfunction caused by aortoiliac peripheral vascular disease
femoral n supplies sensation to
hip joint
anterior and medial thigh
pain in superiolateral thigh conducted by what nerves
lateral femoral cutaneous, iliohypogastric
nerves
what is a furuncle
a hair follicular abscess, a boil, usually caused by coag + staph aureus
why is nasal septum succeptible to injury and perf
becuase blood supply to septal cartilage is poor and limited to diffusion from mucosa
6 causes of basal septal perf
nose picking sarcoid w gpa syphillis tb cocaine
how does nasal septal perf present
whistling w respiration
tf
phys exam of mesenteric ischemia is often relatively normal despite excruciating pain
t
dumping syndrome symptoms incidence pathogenesis initial tx
- 20-30 min postprand, ab pain n/v/d, hypot tachyc, diz conf diaph fatigue
- ~50% incid post gastrectomy
- pylorus absence or dysfunc, dumping hypertonic into sb, pulls in fluid, stims ANS and vasoactive peptides
- small freq meals, complex carbs, finer and protein. few may benefit from trial of octreotide or reconstructive sx
VIP effects
heart contractility vasodilation glycogenolysis lowers arterial blood pressure relaxes smooth muscle of trachea, stomach and gall bladder.
octreotide moa
blocks
GH, glucagon, insulin, LH, VIP
like somatostatin
dx dumping syndrome
clinical dx.
-20-30 min postprand, ab pain n/v/d, hypot tachyc, diz conf diaph fatigue
-~50% incid post gastrectomy
upper gi xr or gastric emptying study can help dx if uncertain but usually not necessary
top 2 most common peripheral artery aneurysms
#1 popliteal #2 femoral
how can femoral artery aneurysm cause anterior thigh pain?
by compressing the femoral nerve which runs lateral to the artery
which is more lateral, femoral artery or nerve?
femoral nerve is lateral to artery
when does pulmonary contusion present and what are sympx?
v24 hours after blunt thoracic trauma
tachyp, tachyc, hypoxia
pulmonary contusion on cxr or cct
patchy alveolar infiltrates NOT RESTRICTED BY ANATOMIC BORDERS e.g. NONLOBULAR/IRREGULAR
tx pulmonary contusion
pain control
nebs, chest PT for lung hygiene
O2, ventilatory support as needed
tf
pulmonary contusion always assoc w rib fractures
f
may or may not
tf
pulmonary contusion can present 2 hours after trauma
t
usually within minutes but up to 24 hours after blunt trauma
tf
ARDS can present 2 hours after blunt chest trauma
f
usually 24-48 hours after
pulmonary contusion can present in v24 hours and can turn into ARDS however
classic clinical picture (sympx) of fat embolism from long bone fracture
tachyp tachyc hypot AMS thrombocytopenia petechiae
what is flail chest
fx of 3+ consecutive ribs in 2 places each
creating detached segment of chest wall
that moves paradoxically compared to the rest of the chest wall with respiration
at what age is it a risk for oa
^50yo
can start thinking oa…
espec if prior joint injury or ligament abnorm
initial mgmt oa
weight loss regular moderate exercise simple analgesics (acetaminophen) pt then home pt quad strengthening (lose strength w age, disuse 22 pain, -- abnormal loading, accelerated articular damage)
tf
arthroscopic lavage and debridement effective for oa
f
rct’s show ineffective
(2016 uworld)
pes anserinus pain syndrome
aka anserine bursitis
point tenderness medial knee just distal to joint line, oft exacerbated by contact w opposite knee when lying on side
most freq mechanism of knee meniscal injury
twisting trauma
acute/subacute knee joint line tenderness and catching sensation on extension
meniscal injury
moa for mcl injury
from lateral
severe valgus stress
or twisting
these may mask laxity on valgus stress test in mcl injury
swelling
muscle spasm
tf
acute effusion/hemarthrosis is common in mcl injury
f
not unless acl inj too
most sns test for dx of mcl tear and when used
mri
reserved for surgical candidates
but uncomplicated usually managed w rice and analg analgesics
rice in context of sports med
rest ice compression elevation can add analg usually too
tf
effusion/hemarthrosis expected w acl tear
t
acute, often dramatic
obvious on physical exam
tf
lcl inj uncommon
t
may see w high velocity trauma
structure often inj w mcl
and how to know if it is
medial miniscus
small effusion, locking catching crepitus
jumper’s knee
aka
describe
physical exam findings
patellar tendonitis
chronic overuse inj
anterior knee lain and tenderness
no ligamentous stress test abnorms
tf
tibial plateu fx pts can weight bear
f
tf
most mcl tear pts managed operatively
f
nonop rice analg if uncomplicated
if comp sx candidate get mri
ankle brachial index
higher systolic dorsalis pedis or post tib / higher systolic brachial
v.9 abnormal, diagnostic of occlusive PAD w 90%sn 95%sp in symptomatic pt
.9-1.3 normal
^1.3 calcified non-compressible arteries consider further vascular studies
dx occlusive pad in pt w sx of intermittent claudication (eg leg cramps w activity)
abi ankle brachial index
higher systolic dorsalis pedis or post tib / higher systolic brachial
v.9 abnormal, diagnostic of occlusive PAD w 90%sn 95%sp in symptomatic pt
.9-1.3 normal
^1.3 calcified non-compressible arteries consider further vascular studies
when and how to screen for aaa
abd us
men 65-75 w hx of smoking
or anyone w suspicious sx but that not considered “screening”
when to typically consider arterial us
to locate affected segment when considering interventional procedure in pt w PAD already diagnosed by ABI (v.9)
(abi mot sn and sp for diagnosis lf pad)
psoas abscess
pres
dx
tx
ab pain radiating to groin inc w exten (psoas sign) dec w flex subacute fev anorex weight loss ct ap ab pelv leuk inflam markers... esr crp? blood and abscess cx drain and broad spec anx
ab pain radiating to groin think…
psoas abscess
pathogenesis of psoas abscess
hematologic seeding from distant infection
or
direct extension of nearby intraabdominal imf (diverticulitis, bertebral osteomyelitis)
risk factors for psoas abscess
crohn’s
ivdu
hiv
dm
tf
psoas anscess should be considered on ddx for fev of unknown origin
t
deep infection typically presents w ab/flank lain radiating to groin but sx may be nin-specific - subacute fev anorexia weight loss - so include on ddx for fuo
psoas sign
ab pain on hip ext
imaging to xx osoas abscess
ct ap (ab pelv)
tf
us to dx psoas abscess
f
poor sn due to deep location, overlying bowel gas
tf
psoas abscess is on posterior abdominal wall
t
hlepful abdominal imaging for bowel obstruction free air renal calculi foreign bodies
xr
tf
recent furunculosis a risk for psoas abscess
t
psoas abscess can result from hematogenois spread from distant infection
when to get colonoscopy for psoas abscess
when source otherwise unexplained
tf
appendicitis can cause positive psoas sign
t
Retrocecal appendicitis can
(ab pain w hip ext)
septic hip vs psoas abscess
s and s
septic hip has pain on FLEXION and usually inflammatory signs of erythema or warmth
describe blood supply to scaphoid
radial a courses ant to radius
superficial palmar branch gives off palmar scaphoid branch to distal pole
dorsal carpal branch gives off dorsal scaphoid branch enters distal pole and proceeds to proximal pole
and other radial branches continue over and under the thumb metacarpal
most common carpal bone fx
scaphoid
common mechanism of scaphoid fx
foosh causing axial compression or wrist hyperextension
tendons of anatomical snuff box
medially extensor pollicis longus
laterally abductor pollicus longus and extensor pollicis brevis
origins insertions of extensor pollicis longus and brevis
epl
o mid ulna
i base of dist phalanx thumb dorsally
epb
o radius and interosseous mem
i base of proximal phalanx thumb dorsally
tf
scaphoid fx evident on xr immediately
tish fish
t if displaced (operate)
f if compressede or nondisplaced may not be apparent for 7-10days so consider ct or mri to confirm or immediate thumb spica w repeat xr 7-10DAYS to confirm/ro fx and eval for osteonecrosis (DON’T just spica 6 wks w/o confirming fx, prolonged casting ci in soft tissue injury)
tf
corticosteroid inj indicated for fx pain
F
can impede fx healing
(ortho use for joint inflammation or bursitis..)
tx scaphoid fx
if displaced on xr, operate
if compressede or nondisplaced may not be apparent for 7-10days on xr so consider ct or mri to confirm fx or immediate thumb spica w repeat xr 7-10DAYS to confirm/ro fx and eval for osteonecrosis (DON’T just spica 6 wks w/o confirming fx, prolonged casting ci in soft tissue injury)
normal shoulder rom w pos impimgement tests (neer, hawkins) suggests
rotator cuff impingement or tendonopathy
signs of rotator cuff impingement or tendonopathy
vs tear
full rom w pos hawkins neers impingement tests
pain w abduction er
subacromial tenderness
(suspect tear if above plus WEAK er or abductin, ^60, espec if hx of fall or trauma)
frozen shoulder
aka
signs
adhesive capsulitis
dec rom (pass and act)
more stiff than pain
Anterior shoulder pain think…
biceps tendinopathy/rupture
glenohumeral osteoarthritis
is it common
what causes it
not common
caused by past trauma usually
shoulder impingement syndrome refers to
compression of supraspinatus tendon and subacromial bursa between humeral head and acromion eg w flexion or abduction of humerus
tf
unadressed rotator cuff tendonopathy inc risk of tear
t
borders of retropharyngeal space
ant buccopharyngeal fascia and constrictor muscles
post alar fascia
comminicates w parapharyngeal (lateral pharyngeal) space laterally
life-threatening complication of retropharyngeal abscess
necrotizing mediastinitis
(fev cp dysp odyn urgent surg)
by draining within retropharyngeal space to superior mediastinum
or extension thru alar fascia to “danger space” (btw alar and prevertebral fasc) and drain inferiorly to posterior mediastinum down even to diaphragm
-can also extend to carotid sheath cause jug v thrombosis cnIX X XI XII deficits
ludwig angina
define
s and s
rapid progressing
bilateral cellulitis of
submandibular sublingual spaces from infected molar
fev dysphag odynophag drool
epidural abscess causes
- hematogenous spread eg from ivdu
- contiguous spread from osteomyelitis of vertebrae
- direct inoculation eg from epidural anesthesia
metabolic derangement in ischemic colitis
lactic acidosis (matabolic acidosis)
ct findings in ischemic colitis
thickened bowel wall
double halo sign
pneumatosis coli
severity and locality of ischemic colitis
usually moderate severity and
lateralizes to affected side
tf
ischemic colitis affected areas are sharply demarcated from unaffected
t
ischemic colitis mgmt
ivf
bowel rest
abx conservative mgmt usually
unless perf or bowel gangrene…
c diff s and s
fever ab pain non bloody watery diarrhea
(prob recent abx)
colonoscoply shows erythema edema occasional ulceration
colonoscopy findings of c diff inf
erythema edema occasional ulceration
rectal involvement of ischemic colitis vs ulcerative colitis
ischemic usually spares rectum due to collateral supply
uc always involves rectum…
colonoscopy findings in ischemic colitis
cyanotic mucosa and hemorrhagic ulcerations
normal serum albumin
3.5-5.5 g/dl
normal serum alk phos
30-115
30-100 male
45-115 female
normal serum ast and alt
8-40
normal serum amylase
25-125 u/L
pt recovers well from gallsone pancreatitis with suplortive ivf and pain control. what is next step?
cholecystectomy
to reduce risk of recurrent pancreatitis
(recommended for medically stable patients recovered from acute pamcreatitis)
antihypertensives commonly assoc w pancreatitis
thiazides
acei’s
when is ercp recommended for gallstone pamcreatitis
with cholangitis
bile duct obstruction/dilation
increasing liver enzymes
to relieve obstruction by cannulation or sphyncterotomy
HIDA scan aka
hepatobiliary iminodiacetic acid scan
visialization of nuclear tracer in bile
when to get hida scan
eval for cholecystitis in pts w indeterminate us findings
pt has biliary colic but no signs of gallstones on us
next step?
repeat us 4 wks
can consider in pt w sx of biliary colic but no evidence of stones on initial us
tf
early cholecystectomy is indicated in all pts medically stable enough for surgery
t
pancreatic pseudocyst what is it signs and symptoms complications dx tx
- mature thick fibrous capsule walled-off pancreatic fluid collection of enzymes tissue debris (no necrosis)
- inc amylase from leak into serum
- spontaneous infection, duod or biliary obstruction, pseudoaneurusym from leaking eating weakening vessel walls, pamcreatic ascites, pleural effusion
- ct ab
- initial expectant mgmt (npo, sx tx) if min sx no compx… endoscopic drainage if sx compx do arise, + ivabx if infected
expected electrolyte disturbance in pt vomiting not eating or drinking
hypokalemic. .. loss of k in vomit
hypermatremic. .. dehydrated vomiting not eating drinking
different kinds of sbo’s and their presentations
proximal - early vomiting, ab pain
middle-distal - colicky ab pain, delayed vomiting, ab distention (dilated loops on xr), hyperactive bs, constipation
simple - luminal obstruction
strangulated - loss of blood supply, peritoneal rigidity rebound tenderness, shock fever tachyc leukocytosis
obstipation
complete constipation
tf
green vomit
indicates proximal small bowel obstruction
f
anywhere in small bowel - mid-distal sbo’s can cause green emesis too
by far the most common cause of sbo
adhesions
typically from prior abdominal surg #1 /inflammatory processes… can be congenital ladd’s bands in kids
ladd bands
fibrous connection of cecum to abdominal wall, can cause duodenal obstruction in intestinal malrotation
4 most common causes of melena in 28yo
pud
gastritis
esophagitis
mallory weis tear
(melena = bleed from above lig of trietz
weight loss can precipitate what ab vasc syndrome
superior sma syndrome
classic presentation of clavicle fx
immobile arm shoulder displaced inf post, supported by good arm, after fall onto outstretched hand or sports collision
why should careful neurological exam accompany all clavicle fractures
proximity to subclavian a (auscultate for bruit) and brachial plexus (clinical motor exam of hand)
where is the clavicle most commonly fractures
midline
tx clavicle fx
careful neurovascular exam (auscultate for subclavian a bruit, motor exam of limb for brachial plexus inj)
middle third brace ice rest early rom and strengthening to prevent rom loss
distal third may need orif as malunion a greater risk
incidence of bowel ischemia after abdominal aortic aneurysm repair
1-7%
usually left and sigmoid
from loss of ima after aortic grafting
if ischemic bowel after abdominal aorta surg, what part of bowel typically affected?
left and sigmoid colon
from lack of collateral after ima compromised
presentation of ischemic colon
ab pain
bloody diarrhea
sometimes fev leuk
how to minimize ischemic colon risk after abdominal aorta surgery
check sigmoid colon perfusion at conclusion of surgery
sigmoid most vulnerable to ischemia
when does c.diff develop relative to abx use
4-5 days after typically
voluminous watery diarrhea fever abdominal pain not bloody diarrhea
what bug?
c.diff
bloody purulent diarrhea w tenesmus
bug?
e.coli
shighella
(invasive diarrhea)
tf
bloody diarrhea is a typical feature of bowel perforation
f
bowel sounds in sbo
hyperactive initially,
progressing to hypoactive and absent if ischemia develops
tf
mild leukocytosis and amylase can be seen in sbo
t
tx sbo
ngt suction
ivf
iv nutrition
(uncomplicated)
if not responding completely to above but medically stable, can do small bowel follow thru to help diagnose partial obstruction
emergency surgical exploration
if complicated w signs of inc risk of ischemia strangulation necrosis (perf, death)
-pain character, fever, hemodynamic instability (tachyc hypot) guarding leukocytosis metabolic acidosis (eg low bicarb)
imaging choice for acute mesenteric ischemia
ct angiogray
what is meant by bowel “pseudoobstruction”
no identifiabe mechanical cause
normal total and direct bili
.1-1.0
0-.3
mechanism of duodenal hematoma
blunt abdominal trauma
pathogenesis of duodenal hematoma
usually blunt abdominal trauma compressing duodenum against vertebral column… blood collects between submucosal and muscular layers of duodenum causing partial or complete obstruction
in peds
due to thinner ab muscles and adipose tissue and more pliable ribs
duodenal hematoma path pres dx tx
usually blunt abdominal trauma compressing duodenum against vertebral column… blood collects between submucosal and muscular layers of duodenum causing partial or complete obstruction
in peds
due to thinner ab muscles and adipose tissue and more pliable ribs
classically present 24-36 hrs post bat w only prior sx of abdominal wall trauma now resolving but no clinical deterioration w epigastric pain and vomiting due to failure to pass gastric contents past expanding obstructing hematoma
dx CT ab
tx ng tube decompression, maybe npo w parenteral nutrition… usually resolve in 1-2 wks… maybe percutaneous or surgical drainage of hematoma if nonop management fails
signs and symptoms of
liver laceration
commonly from blunt abdominal trauma bat ruq ttp intraperitoneal free fluid hemodynamic instabiliity low blood count
frequency
presentation
of pancreatic psuedocyst after blunt abdominal trauma
rare but occcasional after bat
subacutely developed days to weeks after
nausea vomiting weight loss, palpable abdominal mass
tf
pyloric stenosis a common presentation in preadolescent child
f
usually nausea vomiting poor feeding in 1-month-old infant
fever hemodynamic instability diminished bowel sounds free intraperitoneal air on cxr subacutely after blunt abdominal trauma think...
delayed small bowel perforation
(eg from duodenal hematoma or mesenteric injury
w subsequent ischemia and necrosis)
severe burn w extensive scar and chronic non-healing wound, cancer to suspect is…
SCC squamous cell carcinoma
aka Marjolin ulcer when arising within burn wound
(usually assoc w UV exposure but also chronically wounded inflamed scarred skin)
define Marjolin ulcer
scc arising within burn wound
pathogenesis of SCC other than UV exposure
UV exposure most common,
but also arising within burn wound/chronically wounded inflamed scarred skin, overlying osteomyelitis, radiotherapy scar, or venous ulcer
-arising within chronic wound tends to be more aggressive so bx and early dx important to prevent mets
pearly telangiectatic papule, often w central ulceration
classic appearance of…
bcc basal cell carcinoma
classic appearance of basal cell carinoma
pearly telangiectatic papule, often w central ulceration
tf
melanoma likely to arise within scars and burns
f
assoc w sun exposure (like SCC)
but less likely than SCC to arise within scars or burns or chronically inflamed tissue
classic setting of kaposi sarcoma
and appearance
coinfection of HIV and HHV8
begin as papules and later plaques or nodules, color change from light brown to violet, often multiple lesions
tf
gilbert has a gender preference
t
male
most common inherited disorder of bilirubin glucuronidation
gilbert
pathogenesis of gilbert syndrome
AR or AD mut in UGT1A1 gene
dec UDP-glucuronyltransferase activity
inc unconjugated bilirubin
unconjugated vs conjugated disorders of bilirubin metabolism
u go crazy
(unconjugated gilber crijler najar)
c dr rogers
(conjugated dubin johnson rotors)
presentation of gilbert syndrome
intermittent mild otherwise asymptomatic jaundice
provoked by physiologic stress
(infection, fasting, exercise, surgery…)
dx gilbert syndrome
unconjugated hyperbilirubinemia
normal cbc, smear and retic count
normal ast alt alk phos
gilbert syndrome path pres dx tx
-AR or AD mut in UGT1A1 gene
dec UDP-glucuronyltransferase activity
inc unconjugated bilirubin
-intermittent mild otherwise asymptomatic jaundice
provoked by physiologic stress
(infection, fasting, exercise, surgery…)
-unconjugated hyperbilirubinemia
normal cbc, smear and retic count
normal ast alt alk phos
-educate pt and family re benign nature and inheritance pattern to avoid unnecessary worry or diagnostic tests in the future
presentation of acute viral hepatitis
anorexia
nausea vomiting
extremely elevated aminotransferases (^25x)
why are halothane and other halogenated anesthetics not recommended for adults
hepatotoxicity that can be either
mild - mild aminotransferase ele
severe - liver necrosis, fever, jaundice, grossly eleveated aminotransferases
iatrogenic biliary injury
most common setting
signs and symptoms
laparascopic cholecystectomy
jaundice fever epigastric pain
iatrogenic biliary injury
most common setting
signs and symptoms
laparascopic cholecystectomy
jaundice fever epigastric pain
what percentage of circulating blood volume can a hemithorax hold
about 50% of circulating blood
define massive hemothorax
most common causes
^1.5L
traumatic lung laceration
intercostal artery or internal mammary artery injury
hamman sign
audible crepitus on cardiac auscultation
eg w subcutaneous emphysema from tracheobronchial tear
hamman sign
audible crepitus on cardiac auscultation
eg w subcutaneous emphysema from tracheobronchial tear
