surgery Flashcards
ecg changes in SAH
ST elevation
SAH investigations:
within 6hr= CT head
if -ve –> no LP
If >6hr –> CT head then if -ve LP
SAH LP result
xanthochromia
mastectomy wide local excusuin criteria (3)
what is needed after wide local excision? (1)
Matectomy:
- multifocal tumor, central tumor
- large lesion in small breast
- DCIS> 4cm
Wide Local excusion
- solitary lesion
- peripheral tumor
- small lesion in large breast
- DCIS<4
ALWYAS RADIOTHERAPY Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds
Hormonal therapy breast cancer (1)
biological therapy (1)
Tamoxifen = PRE- and PERI-menopausal women. Aromatase inhibitors such as anastrozole are used = POST MENOPAUSE
trastuzumab (Herceptin) - HER 2 +ve
ASA I–> V I
ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension, mild lung disease
ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled Diabetes Mellitus/Hypertension, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history (>3 months) of Myocardial infarction, Cerebrovascular accidents
ASA IV A patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): recent (< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA V= not expected to survive e.g. AAA rupture
ASA VI= brain dead
Renal stone:
when to watchful wait? (1)
when shock wave? (1)
when shock wave OR ureteroscopy? (1)
when percutaneous nephrolithotomy?
Renal stones
watchful waiting if < 5mm and asymptomatic
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
> 20 mm percutaneous nephrolithotomy
Uretic stones
shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy
Uriteric obstruction due to stones –> management=
decompression (an emergency)
Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.
management of ureteric stones:
calcium (6)
oxalate stones (2)
uric stones (2)
Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
high fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate may be beneficial NICE
thiazides diuretics (increase distal tubular calcium resorption)
Oxalate stones
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
Uric acid stones
allopurinol
urinary alkalinization e.g. oral bicarbonate
Bious vomiting in neonates: (age, diagnosis and treament)
duodenal atresia
few hours after birth
AXS+ double bubbl
duodenoduodenostomy
Bious vomiting in neonates: (age, diagnosis and treament) malrotation with volvulus
malrotation
3-7 days after birth
upper GI –> DJ flexure medial placed or USS abnormal sotation
LADD procedure
Bious vomiting in neonates: (age, diagnosis and treament) jejunal / ileul atresia
within 24hr birth
AXR air level
laparotomy with resection
Bious vomiting in neonates: (age, diagnosis and treament)
meconium ileum
24-48hr
AXR fluid levels, sweat test= CF
surgical deompression
Bious vomiting in neonates: (age, diagnosis and treament)
necrotising enterocolitis
second week of life
dilated bowel loops AXR
pneumatosis
conservative , laparotomy if worsening
investigation for prostate cancer if PSA raised
Multiparametric MRI
Incarcerated vs strangulated hernia
INCARCERATED = non reducible but OKAY
STRANGULATED= DYING ( EMERGANCY)
femoral vs inguinal hernia
inferolateral to the pubic tubercle, from inguinal hernias which are supermedial to the pubic tubercle
Femoral: Given the small size of the femoral ring, a cough impulse is often absent.
management BPH
- watchful waiting
-alpha-1 antagonists (tamsulosin, alfuzosin - 5 alpha- reductase inhibits (finasteride)
5 alpha-reductase inhibitors e.g. finasteride:
how do they work? (1)
how long do they take to work (1)
block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression
unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months
5 alpha-reductase inhibitors e.g. finasteride:
adverse effects
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
peripheral vascular disease management medical (2)
if severe (2)
when to amputate (1)
other licensed drugs (2)
clopidogrel and atorvastatin
if severe:
endovascular revascularization
percutaenous transluminal angioplasty +/- stent placement
endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
surgical revascularization
surgical bypass with an autologous vein or prosthetic material
endarterectomy
open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease
Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.
Drugs licensed for use in peripheral arterial disease (PAD) include:
naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE
What is the most appropriate stoma to create which will allow this whilst being easiest to reverse in the future?
loop ileostomy
Ileostomy vs colostomy
Ileostomy: R iliac fossa, spouted, liquid
Colostomy: varied location, flushed, solid
CT head within 1 hr
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
When to give steroids pre surgery
As a rule of thumb:
Minor procedure under local: no supplementation required
Moderate procedure: 50mg hydrocortisone before induction and 25mg every 8h for 24h
Major surgery: 100mg hydrocortisone before induction and 50mg every 8h for 24h, thereafter halving dose every 24h until maintenance dose reached.
Fasting/ oral fluids pre surgery
Oral fluids:
patients having surgery may drink clear fluids until 2 hours before their operation
drinking clear fluids before the operation can help reduce headaches, nausea and vomiting afterwards
clear fluids are water, fruit juice without pulp, coffee or tea without milk and ice lollies
Patients are generally advised to fast from non-clear liquids/food for at least 6 hours before surgery.
AAA screening
single screening scan age 65
Diabetes and surgery: what do to about
- lantus
- hypoglycaemics e.g. SGLT2
Lantus: reduce by 20%
SGLT2- omit on day of surgery but otherwise as normal
Surgery requiring special preparation:
thread surgery
parathyroid surgery
sentinel node biopsy
surgery of thoracic duct
phaeochromocytoma
surgery for carcinoid tumours
colorectal cases
thyrotoxicosis
Thyroid surgery; vocal cord check.
Parathyroid surgery; consider methylene blue to identify gland.
Sentinel node biopsy; radioactive marker/ patent blue dye.
Surgery involving the thoracic duct; consider administration of cream.
Pheochromocytoma surgery; will need alpha and beta blockade.
Surgery for carcinoid tumours; will need covering with octreotide.
Colorectal cases; bowel preparation (especially left sided surgery)
Thyrotoxicosis; lugols iodine/ medical therapy.
AAA screeening
<3cm
3-4.4cm
4.5-5.4cm
>=5.5cm
<3cm= no action
2-4.4= 12 monthly rescan
4.5- 5.4= rescan every 3 months
>=5.5= refer within 2 weeks to vascular surgery
This is due to the classic presentation of a ‘lucid interval’ following head trauma, where the patient initially loses consciousness, regains it and appears well for a period of time before deteriorating again. E
typically occur when there is a tear in the middle meningeal artery, often following a skull fracture. The bleeding accumulates between the dura mater and the skull, leading to increased intracranial pressure and neurological deficits.
extradural
Suspected prostate cancer: what investigation not to do?
biopsy as –> spreads the tumor
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
hydrocele
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
Hydrocele:
when to do US?
to exclude any underlying cause such as a tumour
Local anesthetic toxicity:
treatment (1)
features (2)
IV 20% lipid emulsion
cardiovascular and neurological deterioration after local anaesthetic administration
doses of anaesthetic:
lignocaine
bupivacaine
prilocaine
Lignocaine 3mg/Kg 7mg/Kg
Bupivacaine 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
LARGER DOSE WITH ADRENALINE
investigations for venous insufficiency
venous duplex ultrasound
reasons to refer to secondary care for venous insufficiency
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
previous bleeding from varicose veins
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
when to refer hydroceles in babies
if there >1 year
PAD management
clopidogrel NOT aspirin
and statin 80mg
blood-stained nipple discharge
Duct papilloma
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Mammary duct ectasia
CTKUB contrast or non con contrast
non-contrast
fissure not responding to conservative treatment
spintcterotomy
risk factors for penile cancer
Human immunodeficiency virus infection
Human papillomavirus virus infection
Genital warts
Poor hygiene
Phimosis
Paraphimosis
Balanitis
Age >50
Surgery / metformin on day of surgery:
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein - what to do?
venous US of legs
Propofol - what else does it do other than anaesthetic
anti-emetic
BPH:
management
1st= alpha-1 antagonist (tamsulosin, alfuzosin)- decrease smooth muscle tone of the prostate and bladder
2nd= 5 alpha-reductase inhibitors e.g. finasteride (block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH)
may also decrease PSA concentrations by up to 50%
side-effects: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
Hernias in children:
Congenital inguinal hernia
Infantile umbilical hernia
Congenital inguinal hernia= repair surgically asap as risk of incarceration
Infantile umbilical hernia= The vast majority resolve without intervention before the age of 4-5 years
a collection of pancreatic fluid enclosed by fibrous or granulation tissue, which forms as a consequence of acute pancreatitis.
pseudocyst
(Often occurs 6 weeks post pancreatitis, located behind the stomach)
Pancreatitis complications:
- peripancreatic fluid collections
- pseudocysts
- pancreatic necrosis
- pancreatic abscess
- haemorrhage
- peripancreatic fluid collections: 25% of pancreatitis, fluid around pancreas. no fibrous/ granulation tissue
may –> psydocyst or abscess but don’t treat as may self resolve - pseudocysts: fibrous, collection behind stomach, occurs 4 weeks post pancreatitis, (retrograstric), 75% have persistent raised amylase. investigation with CT, ERCP, MRI or endoscopy USS
management= observe or treat with endoscopic or surgical cystogasatrostomy - pancreatic necrosis: try to manage conservatively. some will sample
- pancreatic abscess: collection of pus. NO necrosis. typically pseudocyst –> infected–> abscess. transgastric drainge
- haemorrhage: if infected necrosis –> vascular structure. –> Grey Turners sign
ARDS= systemic side effect
raised ICP- Cushings treat
hypertension, bradycardia, and irregular breathing
(often occurs late and is pre-terminal)
Often results from acceleration-deceleration trauma or a blow to the side of the head. occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
lucid interval
epidural haematoma (EXTRADURAL)
Head injury:
Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes.
Risk factors include old age, alcoholism and anticoagulation.
Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness
Subdural
Muscle relaxants:
suxamethonium
Depolarising neuromuscular blocker
Inhibits action of acetylcholine at the neuromuscular junction
Degraded by plasma cholinesterase and acetylcholinesterase
Fastest onset and shortest duration of action of all muscle relaxants
Produces generalised muscular contraction prior to paralysis
Adverse effects include hyperkalaemia, malignant hyperthermia and lack of acetylcholinesterase
Hiatus hernia:
most sensitive test (1)
management (2)
barium swallow is the most sensitive test
given the nature of the symptoms many patients have an endoscopy first-line, with a hiatus hernia being found incidentally
MANAGEMENT:
all patients benefit from conservative management e.g. weight loss
medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias (Ie when stomach rgough a different hole in diaphragm)
Following a complete prostatectomy, what should the PSA upper limit be? (1)
for others? (4)
undetectable (<0.2ng/ml)
depends on age:
40–49 > 2.5
50–59 > 3.5
60–69 > 4.5
70–79 > 6.5
Acute limb ischaemia:
initial management (3)
definitive (5)
vascular review
IV heparin
IV opioids
intra-arterial thrombolysis
surgical embolectomy
angioplasty
bypass surgery
amputation: for patients with irreversible ischaemia
Surgery / sulfonylureas on day of surgery:
omit on the day of surgery
exception is morning surgery in patients who take BD - they can have the afternoon doseM
Metformin and surgery
metformin should be taken as usual on the day before and on the day of elective surgery. The exception is three times daily dosing, where the lunchtime dose should be omitted on the day of surgery.
% blood loos before BP drops in haemorrahge
30-40%
Class iii shock
VTE management post hip replacement
dalteparin (LMWH) 6 hr after surgery + TED stockings
Screening colon cancer
Screening kits are sent every 2 years to all patients aged 60-74 years in England, 50-74 years in Scotland.
anaesthetic agent causing laryngospasm
Thiopental
most common cause bladder cancer
SMOKING»_space;» aniline dyes
haemorrhoids that prolapse during bowel movements and require manual reduction: what grade
grade III
haemorrhoids that are permanently prolapsed and cannot be manually reduced back into the anal canal
Grade IV
haemorrhoids are those that prolapse during defecation but reduce spontaneously afterwards
Grade II
Abdominal wound dehiscence
saline impregnated gauze + IV broad-spectrum antibiotics
Priapism: investigations
Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.
Priapism: Rx
if >4 hr –> aspiration from cavernous and flush
If fails –>If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals.
If medical therapy fails then surgical options can be considered.
Non-ischaemic priapism is not a medical emergency and is normally suitable for observation as a first-line option.
Fibroadeoma; when to surgically remove
if >3cm
Testicular lump:
separate from the body of the testicle
found posterior to the testicle
Epididymal cysts
Associated conditions
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
Epididymal cysts: how to confirm diagnosis (1)
management (1)
US
Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts.
Epididymal cyst. vs hydrocele
Hydrocele and epididymal cysts are types of testicular lumps and swellings: Hydrocele is a swelling caused by fluid around the testicle. Epidydimal cysts are lumps caused by a collection of fluid in the epididymis, which is a long-coiled tube behind the testicles.
How is severity of pancreatitis defined?
presence of organ failure OR local complications
SAH:
management if stable?
Coiling of the aneurysm by an interventional radiologist
useful test of exocrine function in chronic pancreatits
faecal elastase
Anal tissue:
<1 week (3)
>1 week (3)
Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Management of a chronic anal fissure
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Burns:
Parkland formula
Volume = SA% x weight x 4ml
hernia superior and medial to the pubic tubercle
inguinal hernia
coffee-bean sign + bowel obstruction
Sigmoid Volvos
management: sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
caecal volvulus: management is usually operative. Right hemicolectomy is often needed
rectal tomour: most common operation
Anterior resection
BUT Rectal cancer on the anal verge → Abdomino-perineal excision of rectum
management for asymptomatic + reducible inguinal hernias
routine referral surgical repair
emergency colorectal surgery
In the emergency setting where the bowel has perforated the risk of an anastomosis is much greater, particularly when the anastomosis is colon-colon. In this situation, an end colostomy is often safer and can be reversed later. When resection of the sigmoid colon is performed and an end colostomy is fashioned the operation is referred to as a Hartmann’s procedure. Whilst left-sided resections are more risky, ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.
Sigmoid colon cancer resection
high anterior researction
Distal transverse, descending colon
Left hemicolectomy
Caecal, ascending or proximal transverse colon
Right hemicolectomy
An obese woman presents with an irregular lump on the lateral aspect of her right breast associated with skin tethering. Biopsy excludes a malignant cause.
Fat necrosis
GREEN NIPPLE DISCHARGE
Mammary duct ectasia
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis
A 35-year-old woman complains of ‘lumpy’ breasts. Her symptoms are worse in the premenstrual period.
Fibroadenosis
(fibrocystic disease, benign mammary dysplasia)
Unilaterally dilated
sluggish/ fixed
3rd nerve compression secondary to tentorial herniation
Tamoxifen is used to treat what breast cancer type
oestrogen receptor-positive breast cancer in pre-menopausal women
ulcer RELIEVED by eating
DUODENAL
Prevention of renal stones:
calcium (4)
oxalate (2)
uric acid (2)
Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population.
high fluid intake
add lemon juice to drinking water
avoid carbonated drinks
limit salt intake
potassium citrate may be beneficial NICE
thiazides diuretics (increase distal tubular calcium resorption)
Oxalate stones
cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion
Uric acid stones
allopurinol
urinary alkalinization e.g. oral bicarbonate
incarcerated vs strangulated hernia
strangulated= v sick
An incarcerated femoral hernia would present as a non-reducible mass inferolateral to the pubic tubercle. These hernias are at high risk of strangulation but they have not lost their blood supply yet. The sick appearance of the patient, accompanied by symptoms of necrosis such as vomiting and bloody stool indicates that strangulation has occurred.
Strangulated –> ischaemic + necrotic = BAD
finasteride how long to take to work for BPH (5 alpha-reductase inhibitors, 2nd line treatment )
Finasteride treatment of BPH may take 6 months before results are seen
prednisolone pre surgery: what to do
Hydrocortisone supplementation is required prior to surgery for patients taking prednisolone
TPN nutrition
The definitive option in those patients in whom enteral feeding is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is strongly phlebitic
Long term use is associated with fatty liver and deranged LFT’s
Breast cyst: what management
aspirated
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
varicose veins/chronic venous disease investigation of choice
Venous duplex ultrasound
Post defecatory rectal bleeding that is noted in the toilet pan and on toilet paper is
haemorrhoidst
topical steroids and anal fissure
NOT USED
While they may reduce inflammation and pain temporarily, they do not promote healing of the fissure
solitary anal ulcer
associated with constipation
most common cause of scrotal swellings seen in primary care.
where are they found?
epididymal cyst
found posterior to testicle, separate from testicle
useful test of exocrine function in chronic pancreatits
Faecal elastase
most commonly performed operation for rectal tumours, except in lower rectal tumours
Anterior resection
LOWER= lower rectal tumours which are excised using an abdomino-perineal excision of the rectum.
emergency perforation procedure–>
hartmanns
armature inhibitors adverse effects
OSTEOPOROSIS - DEXA scan when starting it
also
hot flushes
arthralgia, myalgia
insomnia
6 week baby - hydroceles
hydroceles are common in newborn males and often resolve spontaneously
if there >1 year then –> urology
how to assess severity of pancreatitis
SYSTEMIC or LOCAL complications
e.g. organ failure
used to detect accidental oesophageal intubation
Capnography
calcium stones- what medication helps
TIAZIDE (causes HYPERcalcaemia but LOW URINARY calcium)
A 10-day-old neonate presents with sudden onset bilious vomiting. These episodes of vomiting are occurring frequently. On examination, he has a swollen, firm abdomen, is pale and appears dehydrated. He has not passed stool in the last 48 hours. He was born at term and there were no complications around the time of his delivery.
malrotation (–>Ladds procedure)
US
desaturated as soon as ET tube placed
oesophageal intubation
management of caecal volvulus (less common that sigmoid with is treated with rigid sigmoidoscopy)
caecal volvulus: management is usually operative. Right hemicolectomy is often needed
breast cyst management
aspirate
Patients with long saphenous vein superficial thrombophlebitis should have
an ultrasound scan to exclude an underlying DVT
breast cancer screening referral
one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or
one first-degree male relative diagnosed with breast cancer at any age, or
one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or
two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or
one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or
three first-degree or second-degree relatives diagnosed with breast cancer at any age
head injury with dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
8 hr CT
head injury with any history of bleeding or clotting disorders including anticogulants
OR
65+
OR
more than 30 minutes’ retrograde amnesia of events immediately before the head injury
CT in 8 hr
1+ episode of vomiting CT
within 1 hr
