Surgery Flashcards
Intraabdominal pathology causing pain in one or both shoulders suggests what?
subdiagphragmatic peritonitis
Among the possible blunt traumatic bladder injuries, only an intraperitoneal rupture of the bladder dome could by itself, cause a chemical peritonitis.
where is the most common site of extraperitoneal bladder rupture?
bladder neck
Pancreatic cancer presentation
-combo of constant and gnawing epigastric pain that is frequently worse at night, anorexia w/ weight loss, and jaundice due to extrahepatic biliary obstruction (cholestatic picture of elevated alk phos. and direct bilirubin)
Distended neck veins
either pneumothorax or cardiac tamponade
tracheal deviation to the right
- LEFT sided pneumothorax/hemothorax
- RIGHT sided lung collapse
hypotension, tachypnea, tachycardia
tension pneumothorax
untreated tension pneumothorax
can lead to pulseless electrical activity and/or asystole
Patients who continue to remain hemodynamically unstable after needle decompression of pneumothorax?
have a FAST (focused assessment w/ Sonography for Trauma) exam to look for pericardial tamponade
what do the neck veins look like in a hemothorax?
collapsed
Tension pneumothorax
- presence of tachypnea, tachycardia, and distended neck veins, and tracheal deviation in pts w/ blunt or penetrating chest trauma
- pts w/ hemodynamic instability and suspected TP should have immediate needle thoracostomy prior to intubation, as positive ventilation following intubation usually exacerbates an existing pneumothorax
Clinical features of compartment syndrome
- pain out of proportion to injury
- pain increased on passive stretch
- rapidly increasing and tense swelling
- paresthesia (early)
- decreased sensation
- motor weakness (within hours)
- paralysis (late)
- decreased distal pulses (uncommon finding)
Ischemia-reperfusion syndrome
a form of compartment syndrome
- reperfusion of a limb following arterio-occlusive ischemia for longer than 4-6 hours can lead to intracellular and interstitial edema
- compartment syndrome may occur when edema causes the pressure within a muscular fascial compartment to rise above 30mmHg, leading to further ischemic injury
compartment syndrome pressures
- compartment pressure >30 mmHg or delta pressure (diastolic BP - compartment pressure) < 20-30 mmHg indicates significant CS.
- if compartment pressures are improving, pts may be closely observed. However, pts who have elevated compartment pressures and do not show rapid improvement require FASCIOTOMY
how can embolic occlusion be differentiated from compartment syndrome?
embolic occlusion will have absent pulses, pallor of affected limb, and lack of local swelling
Acute cholecystitis
- pain is predominantly in the upper abdomen and radiates to the tip of the right scapula or right shoulder
- Radioisotope (HIDA) scan is indicated in patients w/ acute cholecystitis when ultrasonography cannot definitively demonstrate obstruction at the neck of the gall bladder
when is exploratory laparotomy indicated?
when there is evidence of PERITONITIS (perforated viscus (free air under diaphragm), ruptured AAA, abdominal trauma, etc.)
-signs of guarding, rigidity, or rebound tenderness
Urinalysis in patients w/ urinary stones
-will show microscopic or gross hematuria in over 90% of cases
Ureteral calculi
- may cause flank or abdominal pain radiating to the perineum, often w/ nausea and vomiting
- a noncontrast spiral CT scan of the abdomen and pelvis is the imaging modality of choice to confirm the diagnosis
- Ultrasonography can be used if CT is unavailable or if the patient is pregnant to reduce radiation exposure
Intraductal papilloma
- intermittent bloody discharge from one nipple
- benign
- masses generally not appreciable because they are small, soft, and directly beneath the nipple
Paralytic (adynamic) ileus
- absent bowel sounds w/ gasseous distention of both the small and large bowels.
- classically follows abdominal surgery but can also occur in cases of retroperitoneal hemorrhage associated w/ vertebral fracture
Atelectasis
- one of the most common postoperative pulmonary complications and is usually due to airway obstruction from retained airway secretions, decreased lung compliance, postoperative pain, and meds that interfere w/ deep breathing
- ABG levels typically show hypoxemia, hypocapnia, and respiratory alkalosis
when does post-op atelectasis typically begin symptomatically?
2nd post-op day
what is the minimum duration of smoking cessation necessary prior to surgery to show a significant effect?
8 weeks
tracheobronchial tear
-dyspnea, hemoptysis, subcutaneous emphysema, Hamman sign (audible crepitus on cardiac auscultation) and sternal tenderness
absolute contraindication to lapraSCOPY?
-hemodynamic instability
For hemodynamically UNSTABLE pts in whom blunt abdominal trauma is suspected, fluid resuscitation should be initiated, followed by ultrasound exam (FAST). If ultrasound reveals intraperitoneal blood, the patient should then undergo urgent laparOTOMY for surgical repair.
.
A hemodynamically STABLE patient w/ intraperitoneal blood on US should undergo a CT scan of the abdomen w/ contrast. The surgeon can then select either laparotomy or admission and observation, based on the CT result.
.
Diagnostic peritoneal lavage
-should be performed in any hemodynamically UNSTABLE patient w/ an equivocal or poor quality ultrasound exam (FAST).
the use of laparoSCOPY in cases of blunt abdominal trauma is debatable and hemodynamic instability is an absolute contraindication to laparoscopy
.
shock
any state that causes perfusion inadequate to meet the oxygen and nutrient demands of the tissues
hypotension, tachycardia, flat neck veins, confusion, and cold extremities despite IV fluid resuscitation in a trauma patient inidicates hypovolemic/hemorrhagic shock
.
Brachial artery injury
commonly injured in supra-condylar fracture of humerus, commonly seen in children
-ischemia (pain, pallor, pulselessness, paresthesia and pressure)
ulnar nerve injury
claw hand
-commonly associated w/ humeral fracture
Beck’s triad
Cardiac tamponade
-hypotension w/ pulsus paradoxus, jugular venous distension, and muffled heart sounds
tx for tension pneumothorax
-immediate needle thoracostomy in the second intercostal space at the midclavicular line
tx for all NONdisplaced scaphoid fractures (fractures w/ <2mm of displacement and no angulation)
-wrist immobilization for 6-10 weeks
The wrist should be immobilized in all proven or suspected scaphoid fractures due to the risk of nonunion. If the initial x-rays are negative in a patient w/ suspected scaphoid fracture, further management should be immobilization w/ subsequent x-ray in 7-10 days or immediate advanced imaging
.
perianal abscess
- presents w/ anal pain and a tender, erythematous bulge at the anal verge
- pain and swelling located superior to the anus over the coccyx in the middle postsacral intergluteal cleft
Suppurative hidradenitis
- multiple painful nodules and pustules of the axillea and groin
- lesions lead to sinus formation and fibrosis
- this along w/ pilonidal disease, dissecting folliculitis of the scalp and acne conglobata are members of the follicular occlusion tetrad
Bowen’s disease
- squamous cell carcinoma in situ of the skin
- typically presents as a thin erythematous plaque w/ well-defined irregular borders and an overlying scale or crust
Pilonidal disease
- acute pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues are most commonly due to pilonidal disease
- the acute presentation involves infection of a dermal sinus tract originating over the coccyx
“Popeye sign”
- seen in rupture of the tendon of long head of biceps
- biceps muscle belly becomes prominent in the mid upper arm
- weakness w/ supination is prominent and forearm flexion is typically preserved
injury to the long thoracic nerve
winged scapula due to paralysis of the serratus anterior muscles
-most common cause is iatrogenic injury during axillary lymphadenectomy
positive drop arm tests suggest what?
rotator cuff tear
Cushing’s reflex
- hypertension, bradycardia, and respiratory depression
- indicates elevated intracranial pressure
Transtentorial herniation of the parahippocampal uncus can occur during significant head trauma and leads to ipsilateral hemiparesis, ipsilateral mydriasis and strabismus, contralateral hemianopsia, and altered mentation.
.
Slipped capital femoral epiphysis
- typically occurs in obese, early-adolescent boys
- should be promptly treated w/ surgical pinning of the slipped epiphysis where it lies (in situ) in order to lessen the risks of avascular necrosis of the femoral head and chondrolysis
all patients with a clavicular fracture should have a careful neurovascular exam to rule out injury to the underlying brachial plexus and subclavian artery
.
Unilateral subacute hip pain in a male child coupled with a progressive antalgic gait, thigh muscle atrophy, decreased hip range of motion, and collapse of the ipsilateral femoral head on plain pelvic x-rays are findings suggestive of idiopathic avascular necrosis of the femoral capital epiphysis (Legg-Calve-Perthes disease).
.
Nasogastric tube indications
- bowel obstruction
- enteral nutrition
- gastric lavage
Pts w/ traumatic spinal cord injuries should first be hemodynamically stabilized and have proper airway management. An important next step is urinary catheter placement to assess for urinary retention and prevent bladder distention and damage.
.
A pregnancy test should be administered to any woman of childbearing age before performing any diagnostic tests such as x-rays or CT scans that involve ionizing radiation.
.
CT scan is the investigation of choice to diagnose an intraabdominal abscess. MSK infections such as osteomyelitis or abscess frequently result from hematogenous spread of organisms from another site, such as the skin. In such cases, S. aureus is the most common offending pathogen.
.
Blunt trauma to the upper abdomen can cause a pancreatic contusion, crush injury, laceration or transection. Pancreatic injuries may be missed by CT scan during the first six hours following trauma. An untreated pancreatic injury can later by complicated by a retroperitoneal abscess or pseudocyst.
.
young individual who presents w/ a fleshy immobile mass on the midline hard palate
- Torus Palatinus
- no medical or surgical therapy is required unless the growth becomes symptomatic or interferes w/ speech or eating
signs of tracheobronchial injury
hemoptysis, pneumomediastinum, and air leak even after chest tube placement
All hemodynamically unstable patients w/ penetrating abdominal trauma must undergo immediate exploratory laparotomy to diagnose and treat the source of bleeding, as well as to diagnose and treat perforation of any abdominal viscus in an effort to prevent sepsis.
.
femoral nerve
provides sensation to the anterior thigh and medial leg via the saphenous branch
Ludwig’s angina
- infection of the submandibular and sublingual glands
- the source of infection is most commonly an infected tooth, usually the second or third mandibular molar
- asphyxiation is the most common cause of death
colon cancer
- tends to present w/ chronic occult blood loss
- gross bleeding is less likely
- always a concern in patients w/ lower GI bleeding, although it is less common than is diverticulosis
ischemic colitis
- usually occurs in the setting of hypotension, vasculitis, or atherosclerotic disease
- pts have abdominal pain, fever, and vomiting
- bleeding occurs due to ischemia of the watershed ares of the colon, most commonly the splenic flexure
acute mesenteric thrombosis
- abdominal pain out of proportion of physical findings, nausea/vomiting, and bloody diarrhea due to mucosal sloughing
- pts have numerous atherosclerotic risk factors
Diverticulosis
- most common cause of lower GI hemorrhage in an elderly patient
- bleeding from diverticulosis is typically painless
- diverticulosis should be distinguished from diverticulitis, which is characterized by abdominal pain and infectious symptoms, usually w/o associated bleeding
tracheobronchial disruption
-may cause pneumothorax, mediastinal emphysema, and/or subcutaneous emphysema on chest x-ray
Laryngeal mask placement
-TEMPORARY measure to stabilize the patient until another airway can be established if orotracheal intubation fails
Nasotracheal intubation
- blind procedure that is CONTRAINDICATED in apneic/hypopneic patients
- its also contraindicated if the patient has a basilar skull fracture as such fractures are associated w/ a risk of cribriform plate disruption, which could lead to inadvertent intracranial passage of the tube
needle cricothyroidotomy
- risk of carbon dioxide retention makes it not ideal in pts w/ head injury who might require hyperventilation
- however, its preferred to surgical cricothyroidotomy in CHILDREN age <12 as it is easier to perform anatomically
Tracheostomy
- no longer a first option for establishing an airway due to its complications
- surgical cricothyroidotomy is preferred over surgical tracheostomy but should be converted to formal tracheostomy in 5-7 days if prolonged airway control is needed. Prolonged use of cricothyroidotomy has a high incidence of tracheal stenosis
Pts w/ cervical spine injuries require initial stabilization of the cervical spine. OROTRACHEAL INTUBATION w/ rapid-sequence intubation is preferred for establishing an airway in an apneic patient w/ a cervical spine injury
.
duodenal perforation
- usually presents w/ sudden-onset, diffuse abdominal pain
- abdomen is rigid on initial exam (becomes distended later) w/ signs of peritonitis
- imaging typically shows free air under the diaphragm
Mesenteric ischemia
- usually presents w/ sudden periumbilical abdominal pain out of proportion to exam findings
- risk factors include older age, atrial fibrillation, CHF, and atherosclerotic vascular disease
- CT shows focal or segmental bowel wall thickening, small bowel dilation, and mesenteric stranding
small-bowel obstruction
-abdominal distension, high-pitched hyperactive bowel sounds, dilated loops of bowel w/ air-fluid levels on imaging, and no or minimal air in the colon and rectum
Acalculous cholecystitis
- occurs in critically ill patients
- imaging studies show gallbladder wall thickening and distension and pericholecystic fluid
- the emergency tx of choice is antibiotics and percutaneous cholecystostomy, followed by cholecystectomy when the medical condition stabilizes
Pts w/ clinical signs of a scaphoid fracture following an injury likely to cause such a fracture should be presumed to have the fracture and have an initial x-ray. If the x-ray is negative, the next step is thumb immobilization in a spica cast and repeated x-rays in 7-10 days
.
anterior urethra injury
-perineal tenderness or hematoma, a normal prostate, and bleeding from the urethra
posterior urethral injury
- associated w/ pelvic fractures
- pts present w/ blood at the urethral meatus, a high riding prostate, scrotal hematoma, inability to void despite sensing an urge to void, and a palpably distended bladder
Atelectasis
- common post-op complication that results from shallow breathing and weak cough due to pain.
- its most common on post-op day 2 and 3 following abdominal or thoracoabdominal surgery.
- adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry decrease the incidence of post-op atelectasis
Diverticulosis
- most common cause of lower GI hemorrhage in an elderly patient
- typically painless
- should be distinguished from diverticulitis, which is characterized by abdominal pain and infectious symptoms, usually without associated bleeding
pneumoperitoneum
- air under the diaphragm indicates perforated viscus, which is a surgical emergency
- immediately obtain surgical consultation for emergent exploratory laparotomy
SIRS
having at least 2 of the following:
- Temp >38.5 or 90
- Resp >20
- WBC > 12,000, <4,000, or 10% bands
-it can occur in conditions such as pancreatitis, autoimmune disease, vasculitis, and burns
In pts w/ significant total body surface area burns, the major cause of morbidity and mortality is hypovolemic shock. In the setting of adequate initial fluid resuscitation, bacterial infection (usually bronchopneumonia or burn wound infection) leading to sepsis and septic shock is the leading complication.
.
DVT’s
- occur when Virchow’s triad (stasis, endothelial injury, and hypercoagulability) is present
- major surgery is a risk factor
- tx w/ heparin product acutely and warfarin for several months
- stable pts can be tx w/ anticoagulation as early as 48-72 hours after surgery
Dumping syndrome
- common postgastrectomy complication
- symptoms of postprandial abdominal cramps, weakness, light-headedness, and diaphoresis (usually diminish over time and dietary changes are helpful to control the symptoms)
- in resistant cases, octreotide should be tried
- reconstructive surgery is reserved for intractable cases
insulin-induced hypoglycemia
- can be triggered by autonomic activation such as surgery
- pts develop dizziness, diaphoresis, and fatigue
- pts do not usually develop nausea, vomiting, hypotension, and abdominal pain
Acute adrenal insufficiency
- potentially lethal postoperative complication
- features: nausea, vomiting, abdominal pain, hypoglycemia, and hypotension
- pts taking chronic glucocorticoids (ie. >20mg prednisone for >3 wks) may have glucocorticoid-induced suppression of the HPA axis and require stress-dose perioperative glucocorticoids.
A pregnancy test should be administered to any woman of childbearing age before performing any diagnostic tests such as x-rays or CT scans that involve ionizing radiation!
.
Anterior cord syndrome
- characterized by bilateral spastic motor paresis distal to the lesion
- usually due to occlusion of the anterior spinal artery
Brown-sequard syndrome
- hemisection of the cord, most often due to penetrating injury
- ipsilateral: weakness, spasticity, loss of vibration sense and proprioception
- contralateral: loss of pain and temperature sensation
Posterior cord syndrome
- associated w/ bilateral loss of vibratory and proprioceptive sensation, often w/ weakness, paresthesias, and urinary incontinence or retention
- may be due to multiple sclerosis and vascular disruption (vertebral artery dissection)
Central cord syndrome
- may result from hyperextension injury, particularly in elderly patients w/ spondylosis
- characterized by weakness that is more pronounced in the upper extremities than the lower and may be accompanied by a localized deficit in pain and temp sensation
Preeclampsia
-triad of hypertension, proteinuria, and edema
tx of eclampsia
- magnesium sulfate, oxygen, and antihypertensives
- however, delivery is the only definitive therapy
todd paralysis
-transient unilateral weakness following a tonic-clonic seizure that usually spontaneously resolves
radial nerve compression
-most commonly occurs in the forearm and results in hand weakness and decreased handgrip
Posterior shoulder dislocations
- commonly after electrocution or tonic-clonic seizure, w/ the patient holding the arm adducted and internally rotated
- radiographs show internal rotation of the humeral head w/ circular appearance (light bulb sign), widened joint space > 6mm (rim sign), or 2 parallel cortical bone lines on the medial aspect of the humeral head (trough line sign)
management of uncomplicated diverticulitis in stable pts?
-bowel rest, oral antibiotics, and observation
complicated diverticulitis
- refers to diverticulitis associated w/ an abscess, perforation, obstruction, or fistula formation
- fluid collection 3cm should initially be drained w/ CT guidance
- if the drain does not control symptoms by the 5th day, surgery for drainage and debridement is the next step
- surgery w/ sigmoid resection is generally reserved for pts w/ fistulas, perforation w/ peritonitis, obstruction, or recurrent attacks of diverticulitis
Lymphatic obstruction
- uncommon cause of edema
- may result from malignant obstruction of lymph nodes, lymph node resection, trauma, or filariasis
- classically affects the dorsa of the feet and causes marked thickening and rigidity of the skin
venous insufficiency (valvular incompetence)
- is the most common cause of lower extremity edema
- classically worsens throughout the day and resolves overnight when the patient is recumbent
achalasia
- esophageal stricture and dismotility
- presents w/ dysphagia
diabetic gastroparesis
-tends to occur in pts who have had diabetes for longer than a decade
Gastric outlet obstruction
- early satiety, nausea, nonbilious vomiting, and weight loss
- common causes: gastric malignancy, PUD, Crohn disease, strictures (w/ pyloric stenosis) secondary to ingestion of caustic agents, and gastric bezoars
- physical exam can show an abdominal succussion splash (retained gastric material > 3hrs after a meal will generate a splash sound and indicates the presence of a hollow viscus filled w/ both fluid and gas)
acid ingestion causes fibrosis 6-12 wks after the resolution of the acute injury. upper endoscopy is usually required to confirm the diagnosis, and tx is primarily surgical.
.
Fever, chills, and deep abdominal pain
-suggests a retroperitoneal abscess
Blunt trauma to the upper abdomen can cause pancreatic contusion, crush injury, laceration, or transection. Pancreatic injury may be missed by CT scan during the first 6 hours following trauma. An untreated pancreatic injury can later be complicated by a retroperitoneal abscess or pseudocyst.
.
esophageal rupture
- manifestations include pneumomediastinum and pleural effusion
- the diagnosis is confirmed w/ water-soluble contrast (gastrograffin)
myocardial contusion
- causes tachycardia, new bundle branch blocks, or arrhythmia
- sternal fracture is commonly seen
bronchial rupture
-pnuemothorax that does not resolve w/ chest tube placement, pneumomediastinum, and subcutaneous emphysema
Aortic injury
- high energy, blunt, deceleration trauma to the chest
- in pts w/ a contained rupture, a widened mediastinum, and left-sided hemothorax are commonly seen
Moving from supine to sitting can increase the Functional Residual Capacity by 20-35%. In normal adults, this can amount to several hundred cubic centimeters of lung volume. Increasing the FRC can help prevent post-op atelectasis.
.
Brachial plexus injury
-common complication of neonatal clavicle fracture or high impact neck-shoulder trauma
structures most at risk in a supracondylar fracture of the humerus
-brachial artery and median nerve (both run in the antecubital fossa)
The immediate management of splenic trauma caused by blunt abdominal injury depends on the pts hemodynamic status and response to IV fluids. If the patient is initially hemodynamically unstable but improves w/ fluid administration, the best next step is to get an abdominal CT scan. If the patient is initially hemodynamically unstable but does NOT respond to IV fluids, an emergent exploratory laparotomy is required.
.
Acute appendicitis
- clinical diagnosis
- classic signs: migratory pain, nausea, vomiting, fever, leukocytosis, McBurney point tenderness, and Rovsing sign
- if classic presentation, pts should have an immediate appendectomy to prevent appendiceal rupture
- Imaging studies such as CT and US are useful for pts w/ NON-classic symptoms, equivocal findings on initial assessment, or delayed presentation
Esophageal perforation
- iatrogenic causes are not uncommon
- CXR frequently shows left sided pleural effusion, pneumomediastinum, and/or pneumothorax
- a water-soluble contrast should be used to diagnose (gastrograffin)
Respiratory quotient
- in a steady resting state, the RQ depends on the proportion of metabolic fuels being oxidized for ATP production.
- a steady state RQ close to 1.0 indicates predominant oxidation of carbohydrates and net lipogenesis
- the RQ for protein and lipid as sole sources of energy are 0.8 and 0.7, respectively.
Primary Hypoparathyroidism
- hypocalcemia and hyperphosphatemia in the presence of normal renal function
- causes include post-surgical, autoimmune and non-autoimmune parathyroid destruction, and defective calcium sensing receptors
Oliguria, azotemia, and an elevated BUN/creatinine ratio of > 20:1 in the post-op state most likely indicate acute pre-renal failure from hypovolemia, though urinary catheter obstruction should be ruled out first! The next step in the diagnosis/management of acute renal failure manifesting as oliguria or anuria is what?
-IV fluid challenge
Fibrocystic changes
- common in premenopausal females
- BILATERAL breast pain associated w/ cystic changes of the breasts
- benign, and symptoms VARY CLINICALLY W/ THE MENSTRUAL CYCLE
- lumpiness of the breasts is present
Fibroadenoma
- solitary breast lesion
- painless, firm, and mobile; averaging 2cm in size
- occurs most often in women ages 15-25
- benign
- do NOT change w/ the menstrual cycle
Ductal carcinoma in situ
- most common in POSTmenopausal women
- usually an incidental finding on mammography
- nipple discharge and breast mass are the most frequent complaints
- histologic diagnosis; ductal epithelium that do NOT penetrate the basement membrane
Paget’s disease of the breast
-form of breast cancer in which discharge from the nipple can occur, but eczematous changes of the nipple are most characteristic
Intraductal papilloma
- presents w/ intermittent bloody discharge from ONE nipple
- benign
- masses are generally not appreciated, as the abnormality is small, soft, and located directly beneath the nipple
Acute bacterial parotitis
- presents w/ painful swelling of the parotid gland that is aggravated by chewing
- high fever and a tender, swollen and erythematous parotid gland are common
- this post-op complication can be prevented w/ adequate fluid hydration and oral hygiene
- the most common infectious agent is Staph aureus
The timing of fever (immediate, acute, subacute, delayed) after surgery usually indicates the likely diagnosis. Febrile nonhemolytic transfusion rxn’s can occur within 1-6 hrs of transfusion and can cause immediate post-op fever in pts receiving blood during or after surgery. Other causes of immediate post-op fever include prior infection or trauma, inflammation due to surgery, malignant hyperthermia, and meds (annesthetics).
.
Untreated syphilis
- primary, secondary, and tertiary phases
- primary is characterized by the appearance of a painless chancre
- secondary has disseminated skin lesions, condylomata lata, and fever
- tertiary syphilis may be marked by ascending aortitis, tabes dorsalis, psychosis and tumors (gummas) of the skin, bone, and liver
Nasopharyngeal cancer
- most common in pts of Mediterranean and Far Eastern descent
- strongly associated w/ EBV infection
a patient who is hypotensive w/ abdominal pain and has a CT scan showing an enlarged aortic silhouette
- ruptured AAA
- the patient needs immediate surgery!
Pts w/ cervical spine injuries require initial stabilization of the cervical spine. Orotracheal intubation w/ rapid-sequence intubation is preferred for establishing an airway in an apneic patient w/ a cervical spine injury.
.
Complete small-bowel obstruction
- usually presents w/ nausea, vomiting, abdominal bloating, and dilated loops of bowel on abdominal x-ray
- adhesions, typically post-op, are the most common etiology
Ludwig’s angina
- infection of the submandibular and sublingual glands
- source of infection is most commonly an infected tooth, usually the second or third mandibular molar
- asphyxiation is the most common cause of death in this disease
Tenosynovitis
- inflammation of the tendon and its synovial sheath
- usually seen in hands and wrist joints following a bite or puncture wound
- pts have pain and tenderness along the tendon sheath, particularly w/ flexion and extension movements
morton neuroma
- mechanically induced degenerative neuropathy commonly seen in runners that presents w/ pain between the third and forth toes reproducible w/ palpation on physical exam
- tx is conservative, w/ bilateral shoe inserts
- surgery is reserved for pts who fail conservative tx
Acalculous cholecystitis
- occurs in critically ill patients
- clinical presentation may be similar to calculous cholecystitis, though assessment may be difficult due to the underlying illness
- imaging shows gallbladder wall thickening and distention and pericholecystic fluid
- the emergency tx of choice is antibiotics and percutaneous cholecystostomy, followed by cholecystectomy when the medical condition stabilizes
small bowel obstruction
-characterized by abdominal distention, high pitched hyperactive bowel sounds, dilated loops of bowel w/ air-fluid levels on imaging, and no or minimal air in the colon and rectum
CT findings of pancreatitis
-parenchymal enhancement w/ IV contrast, pseudocyst formation, or peripancreatic fluid collection
CT of mesenteric ischemia
-focal or segmental bowel wall thickening, small-bowel dilation, and mesenteric stranding
Palpable breast abnormalities in pts under the age of 30 are usually evaluated w/ US whereas those in pts over age of 30 are evaluated w/ mammogram and US. Palpable breast masses should generally have an imaging evaluation even if the findings are relatively benign on physical exam. Imaging evaluation is helpful both in characterizing the lesion as benign or malignant, and for guiding biopsy if needed.
.
Fractures of the middle third of the clavicle, which account for most clavicular fractures, are treated nonoperatively w/ a brace, rest, and ice. Fractures of the distal third of the clavicle may require open reduction and internal fixation to prevent nonunion. In cases managed nonoperatively, early range of motion and strengthening are recommended to prevent loss of motion at the shoulder.
.
All pts w/ a clavicular fracture should have a careful neurovascular exam to rule out injury to the underlying brachial plexus and subclavian artery.
.
Intraabdominal pathology causing pain in one or both shoulders suggests subdiaphragmatic peritonitis. Among the possible blunt traumatic bladder injuries, only an intraperitioneal rupture of the bladder DOME could, by itself, cause a chemical peritonitis.
.
mastitis
- typically occurs in younger lactating women
- pts should be treated w/ an antibiotic that covers Staph and should be encouraged to continue breastfeeding or breast pumping from the affected breast
Inflammatory breast cancer
- uncommon form of breast cancer that presents w/ an erythematous and edematous cutaneous plaque overlying a mass on the breast commonly w/ axillary lymphadenopathy
- 1/4 of pts w/ this condition will have metastatic disease at time of presentation
Nipple discharge in non-lactating women should always raise suspicion for breast cancer!
.
Pts w/ Crohn disease or any other small intestinal disorder resulting in fat malabsorption, are predisposed to hyperoxaluria. Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In pts w/ fat malabsorption, calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed into the bloodstream. All of this predisposes to oxalate kidney stone formation.
.
In burn victims, clinical indicators of thermal inhalation injury to the upper airway and/or smoke inhalation injury to the lungs include burns on the face, singing of the eyebrows, oropharyngeal inflammation/blistering, oropharyngeal carbon deposits, carbonaceous sputum, stridor, carboxyhemoglobin level > 10%, or hx of confinement in a burning building. The presence of one or more of these indicators warrants early intubation to prevent upper airway obstruction by edema.
.
Chest x-ray findings in acute cardiac tamponade
-typically reveal a normal cardiac silhouette w/o tension pneumothorax (only takes 100-200mL of fluid to cause tamponade acutely)
Torus palatinus
- young individual who presents w/ a fleshy immobile mass on the midline hard palate
- no medical or surgical therapy is required unless the growth becomes symptomatic or interferes w/ speech or eating
wrist immobilization is recommended in the tx of all NONdisplaced scaphoid fractures (fractures w/ < 2mm of displacement and no angulation).
.
Isolated duodenal hematoma
- most commonly occurs in children following blunt abdominal trauma
- it is treated conservatively w/ nasogastric suction and parenteral nutrition
- if conservative tx fails, then a focused laparotomy or a laparoscopic procedure to evacuate the hematoma is indicated
- most resolve spontaneously in 1-2 weeks
Diaphragmatic rupture
- should be suspected in pts w/ a history of blunt trauma/ motor vehicle accident, abnormal chest x-ray, left lower lung opacity, elevated hemidiaphragm, and mediastinal deviation
- children can have a delayed presentation w/ expansion of the diaphragmatic defect and herniation of abdominal organs (can be months or years after initial injury)
- Chest CT can confirm the diagnosis in pts w/ suggestive chest x-ray findings
Recurrent UTIs, particularly by Proteus species, predisposes to struvite stone formation. Struvite stones may eventually grow to fill the entire renal pelvis, at which point they are known as “staghorn” calculi
.
Retroperitoneal hematoma
- can occur as a local vascular complication of cardiac catheterization, and often presents w/ sudden hemodynamic instability and ipsilateral flank or back pain
- diagnosis is confirmed w/ non-contrast CT scan of abdomen and pelvis or abdominal US
- Tx is usually supportive w/ bed rest, intensive monitoring, and IV fluids and/or blood transfusion
Dumping syndrome
- common postgastrectomy complication
- symptoms usually diminish over time and dietary changes are helpful to control the symptoms
- in resistant cases, octreotide should be tried
- reconstructive surgery is reserved for intractable cases
Any penetrating injury in the thorax below the level of the nipples has potential to also involve the abdomen through the diaphragm and is assumed to involve both compartments until proven otherwise.
.
Patients who are hemodynamically unstable, have evidence of peritonitis, or have evisceration of any organ need immediate exploratory laparotomy!
.
All pts w/ penetrating injury and evidence of peritonitis or unstable hemodynamics need immediate laparotomy.
.
Diagnostic peritoneal lavage
-done in hemodynamically UNSTABLE pts w/ BLUNT abdominal trauma and INCONCLUSIVE FAST exam
Bowel ischemia and infarction are possible early comlications of operation on the abdominal aorta, such as AAA repair.
.
Characterstic findings in syringomyelia
-decreased strength and diminished pain and temp sensation affecting the arms/hands or having a cape-like distribution, w/ preservation of dorsal column function (light touch, vibration, position sense)
Older pts w/ hip fracture should undergo definitive surgical correction as soon as reasonably possible. However, surgery may be delayed up to 72 hours to evaluate surgical risk and ensure medical stability.
.
Assessment of the Respiratory Quotient is important when attempting to wean pts from mechanical ventilation, as overfeeding, especially w/ carbohydrates, can cause excessive CO2 production and make weaning more challenging
.
Pain management and respiratory support are the priorities in the management of rib fractures. Oral agents, such as opiates and/or NSAIDs are most commonly used, but an intercostal nerve block w/ a long-acting local anesthetic can be used if oral or systemic analgesics are not sufficiently effective.
.
symptoms of ileus
-failure to pass stool or flatus, abdominal distention, nausea and/or vomiting, distended abdomen w/ tympany, and decreased or absent bowel sounds
management of ileus
-conservative, w/ bowel rest, supportive care, and treatment of any secondary causes of the ileus
Erosive gastritis
-complication of trauma but typically presents w/ abdominal discomfort, nausea, vomiting, and hematemesis
Acute colonic pseudoobstruction
- can result from trauma and presents w/ nausea, abdominal pain, abdominal distention, tympanic bowel sounds, and hyperactive bowel sounds
- abdominal films tends to show a massively dilated colon w/o significant small bowel dilation
Mesenteric ischemia
-typically caused by emboli or thrombosis of the arterial supply to the intestine and presents w/ sudden onset of abdominal pain out of proportion to the examination, nausea, vomiting, and nonspecific abdominal x-ray findings
small bowel obstruction
- the bowel distal to the obstruction will not be distended
- hyperactive “tinkling” bowel sounds are typically present on physical exam
- peristaltic waves on the abdominal wall can also be observed
Absent bowel sounds w/ gaseous distention of both the small and large bowels
- paralytic (adynamic) ileus
- classically follows abdominal surgery but can also occur in cases of retroperitoneal hemorrhage associated w/ vertebral fracture
Although FNA is the most accurate modality for assessing thyroid nodules measuring >1 cm, US and TSH are recommended first in patients w/o thyroid cancer risk factors to better differentiate which need FNA. However, FNA is indicated in all patients w/ thyroid cancer risk factors or suspicious US findings, even if the nodule is
.
Although the prevalence of thyroid nodules in the adult population is high, the majority are benign. TSH measurement and US are the FIRST steps in the evaluation. Radionuclide scan is indicated for pts w/ low TSH. Hot nodules are almost always benign and can be treated for hyperthyroidism. FNA is indicated for pts w/ normal or high TSH, cold nodules, thyroid cancer family hx, or suspicious US findings (hypoechoic, microcalcifications, internal vascularity).
.
Hyperkalemia tx
- medical emergency
- therapy involves 3 steps:
- membrane stabilization w/ calcium
- shifting potassium intracellularly
- decreasing the total body potassium content
- Insulin/glucose administration is the QUICKEST way to decrease the serum potassium concentration
major risk factors for pancreatic cancer
- first degree relative w/ pancreatic cancer
- hereditary pancreatitis
- germline mutations (BRCA1, BRCA2, Peutz-Jeghers syndrome)
- cigarette smoking (most significant)
- obesity, low physical activity
- nonhereditary chronic pancreatitis
chronic pancreatitis is associated w/ increased risk of pancreatic cancer!
.
pancreatic secretin test
- directly measures the ability of pancreatic ductal cells to produce bicarb
- used for diagnosing chronic pancreatitis
Pancreatic cancer
- should be suspected in pts w/ a hx of chronic pancreatitis who develop abdominal pain and weight loss
- US of the abdomen is useful to exclude biliary obstruction in pts WITH JAUNDICE
- CT w/ contrast of the abdomen is preferred for patients WITHOUT JAUNDICE
metoclopramide
- dopamine antagonist w/ promotility effects
- increases esophageal sphincter contraction and enhances gastric emptying
post-op ileus
- follows most surgeries where the peritoneal cavity is entered
- morphine and other opiates compound this problem by decreasing GI motility
Patients w/ ulcerative colitis are at increased risk of what? (besides colon cancer)
- primary sclerosing cholangitis (PSC)
- an elevated alk phos in a patient w/ UC should raise suspicions for PSC, but there is no routine screening recommended to prevent PSC
- studies suggest that pts w/ UC and PSC have 5 times greater risk of developing colon cancer than those w/ UC alone
Ulcerative colitis
- causes bloody diarrhea, tenesmus, and cramping as well as weight loss and anemia in severe cases
- potential extraintestinal manifestations include PSC, uveitis, erythema nodosum and spondyloarthropathy
- severe complications include toxic megacolon and colon cancer
- routine surveillance w/ yearly colonoscopies is recommended for patients w/ UC beginning 8-10 years after diagnosis for prevention and/or early detection of colon cancer
colloid solutions
- (albumin)
- used in burns or conditions accompanied by hypoproteinemia
Elderly pts are particularly predisposed to dehydration after even minor insults (a minor febrile illness, etc.). Know the classic signs of dehydration (dry mucosa, marginally high values for hematocrit and serum electrolytes, BUN/Cr ratio >20). The tx is administration of IV sodium containing crystalloid solutions (NS).
.
Zollinger-Ellison syndrome
- most commonly caused by gastrin-producing pancreatic tumor
- uncontrolled gastrin secretion causes parietal cell hyperplasia and stomach acid production is significantly increased
- multiple duodenal ulcers are typical, and a jejunal ulcer is almost pathognomic
- steatorrhea may develop because increased production of stomach acid inactivates pancreatic enzymes
Chronic hepatitis C
- can be asymptomatic or present w/ fatigue and nonspecific symptoms (arthralgias, myalgias)
- pts usually have waxing and waning elevations in transaminase levels
- extrahepatic sequelae can include essential mixed cryoglobulinemia, porphyria cutanea tarda, and membranoproliferative glomerulonephritis
Varicoceles
- tortuous dilation of the pampiniform venous plexus surrounding the spermatic cord and testis in the scrotum
- usually result from left renal venous compression between the aorta and SMA
- Exam shows a soft left-sided scrotal mass (“bag of worms”) that worsens w/ standing and Valsalva maneuvers but regresses when the patient is supine
- it does NOT transilluminate
Hypothyroidism
- can cause additional metabolic abnormalities such as hyperlipidemia, hyponatremia, and asymptomatic elevations of CK and serum transaminases
- most patients have hypercholesterolemia alone (due to decreased low-density lipoprotein surface receptors and/or decreased LDL receptor activity) or combined w/ hypertriglyceridemia (due to decreased lipoprotein lipase activity)
Nephritic glomerulonephritis
- usually presents w urinary sediment containing RBCs, occasional WBCs, and red cell or mixed cellular casts
- edema in these pts is due primarily to decreased GFR and retention of sodium and water by the kidneys
Adrenal insufficiency (Addison’s disease)
- characterized by nonspecific symptoms and signs including anorexia, fatigue, GI complaints, weight loss, and hypotension
- hyponatremia is the most common associated electrolyte abnormality
- hyperkalemia is also common
Peripheral artery aneurysm
- manifests as a pulsatile mass that can compress adjacent structures (nerves, veins), and can result in thrombosis and ischemia
- popliteal and femoral artery aneurysms are the most common peripheral artery aneurysms
- they are frequently associated w/ abdominal aortic aneurysms
Hemolytic uremic syndrome
-suspect HUS in a child who has recently recovered from a diarrheal illness and presents w/ acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia, and characteristic peripheral smear finding of schistocytes
Primary hyperaldosteronism (Conn’s syndrome)
- causes hypertension, mild hypernatremia, hypokalemia, and metabolic alkalosis
- suggested by a low renin and elevated aldosterone levels
most common cause of asymptomatic elevation of alkaline phosphatase in an elderly patient
- Paget’s disease of bone (osteitis deformans)
- pts w/ this condition are typically asymptomatic at the time of diagnosis; the diagnosis is made by incidentally finding an isolated elevated alk phos on routine lab testing
Choriocarcinoma
- metastatic form of gestational trophoblastic disease
- may occur after molar pregnancy or normal gestation, and the lungs are the most frequent site of metastatic spread
- suspect choriocarcinoma in any postpartum woman w/ pulmonary symptoms and multiple nodules on CXR
- an elevated b-hCG help confirm the diagnosis
Mitral regurgitation
- holosystolic murmur heard best at the apex w/ radiation to the axilla
- features include: exertional dyspnea, fatigue, atrial fibrillation, and signs of heart failure
Reentrant ventricular arrhythmias (eg ventricular fibrillation) are the most common cause of sudden cardiac arrest in the immediate post-infarction period in pts w/ acute myocardial infarction
.
