surgery mix UWQ: july 6th 2021 Flashcards
acute diverticulitis
uncomplicated
vs
complicated
with abscess formation:
< 3 cm
> 3cm
sym?
dx?
rx?
Sym: !!!! LLQ pain Fever, N/V leukocytosis -> urinary urgency, freq, dysuria -> bladder irritation ( inflamed sigmoid colon)
—-> CONSTIPATION, LLQ pain , fever , ILEUS!!!!
dx: Abd CT scan ( oral + IV contrast)
- -> inc inf in pericolic fat
-> presence of diverticula, bowel wall thickening, soft tissue masses (eg, phlegmons), and pericolic fluid collection suggesting abscess.
- uncomplicated: bowel rest , oral AB, observe
- -> in hosp: IV ab : elderly, ICP, high fever / WBC , comorbidites - complicated: with ABSCESS fluid collection
<3 cm : IV ab + observe
> 3 cm :
Ab + CT-guided percutaneous drainage
—-> if sym NOT controlled in few days: Surgery drainage + debridment
comp: abscess, ob, fistula, perforation
** SIGMOIDOSCOPY / COLONOSCOPY contra : cause PERFORATION!!!!
Zinc def?
- > Alopecia
- > Pustular skin rash (perioral region & extremities)
- > Hypogonadism
- > Impaired wound healing
- > Impaired taste
- > Immune dysfunction
selenium def?
- > Thyroid dysfunction
- > Cardiomyopathy
- > Immune dysfunction
OA ( osteoarthritis)
rx steps :
–> deg articular cartilage
dx: XR
asso w/ HEMOCHROMATOSIS
step 1: weight loss + reg exercise
step 2: NSAIDS ( diclofenac, tramadol, duloxetine, topcial capsaicin)
–> injectable glucocorticoids / hyaluronic acids
step 3: surgery : total knee arthroplasty
RESP acidosis
Ph < 7.35
PaCO2 > 40
High PaCO2 and low PaO2 levels
- -> alveolar hypoventilation
etio: rx induced , OSA, obesity, NMD
-> although an elevated PaCO2 alone: 50-80 mm Hg, is sufficient
calc A-a gradient: PAO2 - PaO2 = 76 - X =>
< 15 Normal A-a
> 30 A-a : elevated!!
elev A-a:
etio:
- > V/Q mismatch: Pul Embolism
- > pleural effusion
- > atelectasis
- > pul edema
ureterolithiasis
urology consult ?
sym:
- > urosepsis
- >anuria
- >acute kidney injury, or refractory pain.
-> large kidney stones (≥10 mm in diameter) unlikely to pass without additional intervention (eg, lithotripsy)
- > unable to pass stone s/p 4-6 wks
- > uncontrolled pain
Perianal abscess
sym?
rx?
–> Occlusion of an anal crypt gland —-> bacterial infection and PERIANAL abscess formation.
sym:
- > tender, FLUCTUANT, ERYTHEMATOUS MASSES -> FEVER and progressively worsening pain
comp:
- –> anorectal fistulae
RF:
- > Anoreceptive intercourse
- > chronic constipation
rx: incision + drainage —> Ab ind: dec fistula formation, dec abscess recurrence
- > sys illness : fever, cellulitis
- > inc risk of severe inf ( DM, ICP)
Anal fissures
sym?
dx?
- —> over-stretching and tearing of the anal mucosa
- -> inc rectal pressure and local trauma
sym:
- > Tearing pain is associated with bowel movements
- > small amounts of hematochezia when wiping
dx:
endoanal u/s
dx: sx
*** NO fever , fluctuant mass, constant pain
External hemorrhoids
originate BELOW the dentate line
- > thrombosis surrounding skin : inflamed and edematous
- > exquisite PAIN and tenderness.
HIT
rx?
dx?
stop all heparin + LMWH stop!!
switch to: direct thromib inhibitor
- > Argatroban
- > fondaparinux
dx: serotonin release assay : functional assay of the blood
Pediatric / adults
acute / chronic osteomyelitis
sym?
dx?
rx?
- –> hematogenous : metaphysis of long bones.
- –> S. aureus MCC
etio: IV Drug users
sym: chronic > 6 wks insidious w/ minimal sym
- —-> SINUS TRACT: persistent draining wound
- > fever, refusal to bear weight
- > point tenderness over the affected bone area !!!
eg. Back , limp
dx:
- >Elevated ESR > 100 !!
- > CRP, CBC, B/C
acute: XR: often normal, MRI
-> chronic XR : lytic lesion w/ loss of cortical + trabecular bone , sclerosis , periosteal thickening!
Definitive:
GS: Bone biopsy/culture !!!
MRI ( sensitive dx) :
-> + prone -to -bone test
Rx:
-> Sx DEBRIBEMENT first +
Antistaphylococcal antibiotic (eg, vancomycin)
** need to debridement 1st : be4 surgical fixation
slipped capital femoral epiphysis
sym?
Displacement of the proximal femoral physis
- > OBESE adolescent boys
- > chronic dull hip (or referred knee) pain and a limp
*** AFEBRILE with limited internal rotation of the hip
Ewing sacroma ?
- > malignant degeneration of bone @ femoral DIAPHYSIS
- -> ONION SKIN appearance.
sym:
- > localized pain and swelling
- > over weeks to months
- > often worse at night.
rotator cuff tendinopathy (RCT)
sym?
repetitive activity above shoulder height:: SUPRASPINATUS muscle
-> subacromial bursa + tendon of long head biceps
sym:
- > Pain with abduction, external rotation
- > Subacromial tenderness
- > Normal ROM!!
- > positive impingement tests (eg, Neer, Hawkins)
Adhesive capsulitis (frozen shoulder?
- > Decreased passive & active ROM
- > Stiffness ± pain
femoral hernia
rx?
–> displacement of abd or pelvic contents through a widened or laxed femoral ring
(medial to the femoral artery and lateral to the inguinal ligament).
—> BELOW inguinal ligament
–> elderly women
sym: nonpulsatile mass groin
- > worsens with inc abd pressure (eg, standing, Valsalva maneuver, coughing)
- > imp with dec abd pressure
comp:
- > substantial risk of incarceration (trapping of abdominal/pelvic contents within the hernia)
- > strangulation (constriction of blood flow with subsequent ischemia/necrosis).
rx:
- > asx femoral hernias : elective sx repair
inguinal hernia
rx?
-> hernia ABOVE inguinal lig
: lower risk incareration + strangulation : wider orifice
rx: ASX: reassurance + watch
HNSCC : mucousal head + neck SCC
dx/
-> smoking
sym:
- > referred otalgia : N9, 10
- > TMJ dx
- > cervical LAD
dx: flexible laryngopharyngoscopy
Euthyroid sick syndrome (low T3 syndrome)
sym?
RF:
- > Severe acute illness
- > ICU admission
- > High-dose steroids rx
patho:
High circulating levels of steorids and inflammatory cytokines (eg, TNF, Interferon
-> dec peripheral conversion of
T4 —> T3
dx:
Early: Low total + free T3 : dec conversion
-> normal TSH & T4
Late: Low T3, TSH & T4
—> rT3 inc !
Recovery pt: transient inc TSH
–> f/u testing delay till return baseline health
NEXUS [National Emergency X-Radiography Utilization Study] low-risk criteria).
Any 1 of the following is ind: cervical CT ?
- > Neurologic deficit
- > Spinal tenderness
- > AMS
- > Intoxication
- > Distracting injury
eg.
- > high-energy mechanism of injury (eg, high-speed motor vehicle collision)
- > fall ≥3 m [10 ft]
- > trauma causing concomitant closed-head injury
Chest TRAUMA :
primary survey ?
- portable chest and pelvic x-rays
- Focused Assessment with Sonography for Trauma (FAST)
+ ECG
+ cardioecho (TEE) : continous monitor 24-48 hrs s/p : det life threatening arrythmia - chest CT imaging
- cervical CT ( if indicated)
single vertebral fracture ( cervical)
f/u dx?
–> indication to image the entire spine : thoracic + lumbar spine !!!
-> risk of a second, noncontiguous vertebral fracture is as high as 20%!!!
thoracolumbar spine ( TLS) : focal pain/ sign of injury ( brusing , stepp -off)
- > neuro deficit
- > AMS
- > high energy mech trauma
*** cervical radiculopathy ( nerve root compression!!!)
nerve conduction study
ind?
-> localize the site of Peripheral nerve injury/compression
(eg, carpal tunnel),
to direct treatment (eg, carpal tunnel release)
Valve replacement in aortic stenosis
?
- Severe AS criteria:
- > Aortic jet velocity ≥4.0 m/sec, or
- > Mean transvalvular pressure gradient ≥40 mm Hg
- > Valve area usually ≤1.0 cm2 but not req
ind valve replacement:
-> Severe AS & ≥1 of the following:
-> Onset of symptoms (eg, angina, syncope)
LVEF <50%
—> inc risk of sudden cardiac death !!
-> Undergoing other cardiac surgery (eg, CABG)
** ASX AS: serial echocardio : normal LVEF
Crohn disease or ileal resection
gallstone formation?
TPN / prolong fasting:
—> gallbladder STASIS : absent of CCK release + NO GB contraction
- –> predisposes to gallstone formation + bile sludging
- —-> cholecystitis
—> slowing GB emptying
-> dec enterohepatic recycling of BA : inc conc bilirubin conjugated + total ca in gb
hemolytic anemia
pigment stone formation?
-> inc RBC dest: inc amt heme req degradation to bilirubin
ADPKD
rx?
vasopressin -2 recetor antagonist ( tolvaptan) : slow progression
- > ACEI
- > hemodialysis , renal transplant
vertebral compression fracture
etio?
sym?
comp?
–> elder pt > 65 yo
etio:
- > Trauma
- > Osteoporosis!!
- > osteomalacia
- > Bone metastases
- > Metabolic (eg, hyperparathyroidism)
- > Paget disease
Sym:
- Acute:
- > Low back pain & dec spinal mobility
- > Pain increasing with standing, walking, lying on back, persist at night
- > Tenderness at affected level!! - Chronic/gradual:
-> Painless
Progressive kyphosis
-> Loss of stature
Complications
inc risk for future fractures
-> Hyperkyphosis
—> leading to protuberant abdomen, early satiety, weight loss, decreased respiratory capacity
dx: plain XR
Ligamentous back sprain?
-> pain is usually relieved with rest,
- > tenderness would be seen in the paraspinal tissues !!
- *** rather than at the midline.
Disc degeneration?
can lead to
–> acute disc herniation
low back pain, but the pain is usually chronic
- > worsens with activity
- > relieved with rest.
colovesical fistula
sym?
dx?
etio:
- > connection between the colon and bladder
- > complication of acute diverticulitis/ CD/ Cancer
moa:
- > direct extension ruptured diverticulum or erosion of a diverticular abscess into the bladder.
sym:
-> fecaluria (stool in the urine)
- > pneumaturia (AIR in the urine) : occurs at the end of urination as the gas collects at the top of the bladder
- > mix aerobics
dx: Abd CT with oral / rectal contrast
- > NOT IV
- —> contrast mat in bladder with thickened colonic + vesticular walls
- > colonoscopy rxm f/u ca
rx: sx
Emphysematous pyelonephritis ?
-> pyelonephritis due to a gas-producing infection
RF: diabetes
sym: abrupt or gradual onset of FEVER, chills, flank or abdominal pain, and N/V
Sigmoid volvulus
RF?
sym?
dx?
rx?
RF:
- > Sigmoid colon redundancy: chronic constipation
- > Colonic dysmotility (eg, underlying neuro dx)
sym:
-> Slowly progressive abd discomfort/distension ± ob symptoms
-> abd distended & tympanitic to percussion
dx:
X-ray: dilated, inverted, U-shaped loop of colon (coffee bean sign)
CT scan: dilated sigmoid colon, mesenteric twisting (whirl sign)
rx:
-> w/o peritonitis/ perforation : Endoscopic detorsion (eg, flexible sigmoidoscopy) & elective sigmoid colectomy
-> perforation/peritonitis +: ER sigmoid colectomy :
*** laxative rx / manual disimpaction contra: inc risk perforation !!
** NG decompression : bowel rest: rx/ SBO !!!
vit K def?
- > aq bleeding dx: fat soluble vit
- > role in hemostasis : cofactor enz carboxylation of glutamic acid residues on PT complex pn.
etio:
- > inadeq dietary intake
- > alcoholic: depletes F2,7, 9, 10 pn c, s
- > intestinal malabsorption
- > hepatocellular disease causing loss of storage sites.
—> liver normally store a 30-day supply —> acutely ill person with underlying liver dx deficient in 7-10 days.
lab: inc PT, PTT
Hypersplenism
sym?
- > cirrhosis
- > portal hypertension
- > splenomegaly.
Splenic seq:
-> thrombocytopenia, .
compartment syndrome
common sym?
uncommon sym?
–> ACUTE LIMB ISCHEMIA -reperfusion syn: inc inc pressure W/IN enclosed fascial space , limit perfusion of muscle + nerve tix !!!!
etio:
- > long bone fracture
- > prolonged compression on ext
- > EMBOLISM: cardiac / intraarterial thrombus !!!
Common:
6 P’s
ASX pt w/o PAOD:
- > PAIN out of proportion to injury
- > PAIN ↑ on PASSIVE STRETCH
- > Rapidly inc & tense swelling ( edema
- > PARESTHESIA (early) !!!
Uncommon:
- > ↓ Sensation
- > Motor wkness (within hours)
- > Paralysis (late)
- > ↓ Distal pulses (uncommon)
dx:
- > needle manometry:
- —-> delta pressure : DBP - compartment pressure < 30 mmHg : STRONG SUGGEST CS!!!!
Definitive rx:
–> URGET fasciotomy!!
Polyarteritis nodosa
patho?
sym?
dx?
asso: hepatitis B/C (IC)
- > Fibrinoid necrosis of arterial wall → luminal narrowing & thrombosis → tix ischemia
-> int/ext elastic lamina damage → microaneurysm formation → rupture & bleeding
Sym:
- > Constitutional: fever, WL, malaise
- > Skin: nodules, livedo reticularis, ulcers, purpura
- > Renal: HTN, RF, arterial aneurysms!!
- > Nervous: HA, seizures, mononeuritis multiplex
- > GI: mesenteric ischemia/infarction
- > MSK: myalgias, arthritis
Dx:
- > Negative ANCA & ANA
- > Angiography: microaneurysms & seg/distal narrowing!!!!
- > tix biopsy: nongranulomatous transmural inf
Septic arthritis
RF?
RF:
- > Abnormal joint (eg, RA, prosthetic joint)
- > Age >80
- > Diabetes
- > IV drug abuse
- > alcoholism
sym: Acute monarthritis: -> hot, swollen, dec ROM -> Fever -> elev ESR & CRP
dx: plain XR B/C Synovial fluid analysis: leukocytosis (>50,000/mm3) -> Gram stain, culture
rx:
- > Joint drainage: needle aspiration !!!
- > arthroscopy (eg, hip, shoulder),
- > open arthrotomy
- > IV antibiotics
acute gallstone pancreatitis
rx?
Amylase + lipase elev
-> ALT > 150 U/L !!!!
- > Early cholecystectomy is rxm for med stable patients who recover from acute pancreatitis + surgical candidates.
- –> markedly reduce the risk of recurrent gallstone pancreatitis
gallstone pancreatitis who have cholangitis,
dx?
—> ERCP rxm in gallstone pancreatitis : cholangitis
- -> visible CBD dilation/ob
- > Inc liver enz levels.
ERCP allows for cannulation and sphincterotomy in an attempt to relieve the obstruction.
HIDA usage for?
hepatobiliary iminodiacetic acid (HIDA) scan : nuclear tracer that is excreted in bile.
-> Failure to visualize the tracer in the gb suggests ob.
HIDA can be used for evaluating cholecystitis in patients with indeterminate ultrasound findings.
greater trochanteric pain syndrome (GTPS) : trochanteric bursitis
RF?
sym?
dx?
rx?
RF:
- > Age ≥50
- > Women > men
- > Obesity
- > Low back & lower ext disorders (eg, scoliosis, osteoarthritis, plantar fasciitis)
sym:
- > Chronic lateral hip pain
- > Pain worse with hip flexion or lying on affected side
dx:
- > Focal tenderness over trochanter
- > XR to r/o hip joint pathology
-> u/s: degeneration of tendons, tendinosis
rx:
- > Exercise, PT, activity modification
- > NSAIDS
- > Steroids injection !!
Large-voln isotonic
crystalloid resuscitation
se?
Hemorrhagic shock: hypotension, tachycardia, cool extremitis
- hemodilution clotting factors + pt : inc coagulopathy
- hypothermia:
room temp fluid are cooler than body temp - Hypotension
- acidosis: rapid NS admin –> non-AG hyperchloremic met acidosis
- inc mortality: lethal triad: hypothermia, acidosis, coagulopathy
- inc risk ARDS: pul leakage + diffuse pul edema
Unilateral diaphragmatic paralysis
etio?
sym?
dx?
etio:
- > Phrenic nerve (C3-5) injury (eg, cardiac surgery, trauma, radiation therapy, compressive tumor)
- > Viral inf (eg, HZS, polio)
- > sys neuro dx (eg, ALS, GBS)
- > Idiopathic
Sym:
- > ASX @ rest
- > Dyspnea on exertion
- > Orthopnea
dx:
Fluoroscopic “sniff” test (paradoxical movement of the diaphragm seen during brisk inspiration)
laryngeal papillomas
recurrent resp papillomatoisis ( RRP)
etio?
sym?
dx?
etio: HPV 6, 11
Constant (≥1 month) or progressive hoarseness
dx: laryngoscopy
- –> irregular, exophytic growths in CLUSTERS on the surfaces of his VC
- > warty or grapelike
- > dark-red punctate areas corresponding to BV
comp: airway ob
rx: medical: interferon, cidofovir ( limited efficacy)
- > sx debridement
Polyps and nodules in VC?
chronic irritation vocal abuse
-> both POLYS and nodules : SMOOTH edges , NOT form in clusters !!
varicocele
sym?
u/s?
rx?
sym:
Soft scrotal mass ("bag of worms")
↓ In supine position
↑ With standing/Valsalva maneuvers
---> Subfertility !!
-> Testicular atrophy!!
—> MC @ lt side: left spermatic vein drains into Lt Renal vein :vulnerable to compression by SMA + aorta
U/S:
- > Retrograde venous flow
- > Tortuous, anechoic tubules adjacent to testis
- > Dilation of PAMPINIFORM PLEXUS VEINS
rx:
- > Gonadal vein ligation (boys & young men with testicular atrophy)
- > Scrotal support & NSAIDs (older men who do not desire additional children)
hydrocele
fluid collection within the TUNICA VAGINALIS
–> it typically presents in NB as a painless scrotal swelling
->asso with an inc risk for testicular torsion: inadequate fixation of the lower pole of the testis to the tunica vaginalis.
acute MR
changes in cardiac?
- > IE
- > sudden-onset large-volume backflow of blood from LV –> LA
lack of time to adapt :
–> LA normal : back into lung: PUL edema ( bibasilar crackles)
- -> LV normal : inc LVEDP
- -> CO dec –> total SV inc
SV = EDV - ESV
EF = SV/ EDV
Acalculous cholecystitis
RF?
sym?
dx?
rx?
RF:
- > Severe trauma or recent surgery
- > Prolonged fasting or TPN
- > Critical illness (eg, sepsis, ICU)
Sym:
- > Fever, l-> eukocytosis, ↑ LFTs, -> RUQ pain
- > Jaundice & RUQ mass less common
dx:
- —> abd U/S (preferred)
- > HIDA or CT scan if needed
rx:
- > Enteric ab coverage
- -> Cholecystostomy for initial drainage
- > Cholecystectomy once clinically stable
Subphrenic abscess
Fever and abdominal pain.
–> pul sign: hiccups, SOB, rt side effusion
- > dev due to peritonitis (eg, perforated ulcer, appendicitis, abdominal surgery)
dx: CT scan abd
Acute pancreatitis
sym?
predicts worst prognosis?
- > unilateral, left pleural effusion and fever in severe cases.
- > RADIATES to the BACK but typically originates in the EPIGASTRIUM, not the chest, CONSTANT pain
Prognosis:
- > elev BUN> 20 / elev Cr > 1.8
- -> hct > 44%
- — > IV depletion
- > clx: SIRS, AMS
- —-> RR> 20 / Pco2 < 32
- —-> Leu > 12,000 / <4000
- —> temp > 38 / < 36
- —> pulse > 90/bmp
-> pt factors: older age, BMI > 30
- > XR: pul infiltrates, pleural effusion
- > abd CT: severe pancreatic necrosis
- —> 3rd spacing fluid
Boerhaave syndrome
sym?
etio:
- -> repeat vomiting
- -> endoscopy trauma
- -> esophagitis ( inf/ pills/ caustic)
- -> unilateral PLEURAL EFFUSION from leaked esophageal contents into mediastinum : AIR ( pnmediatrinum)
- ——-> CREPITUS suprasternal notch : Hamman sign ( crunchinig sign)
—> FULL THICKNESS !!
–> usually LEFT: intrinsic wkness left posterolat aspect distal intrathoracic esophagus
- > sys: fever , tachycardia
dx: Confirm with : ESOPHAGOGRAPHY : leak from perforation!!!!
or
CT scan using water-soluble contrast : widening mediastinum
rx:
ER surgical consultation.
Retroperitoneal hematoma
etio? sym? local comp? dx? rx?
etio: local vascular complication of cardiac catheterization
- -> anticoag w/ heparin / warfarin
—> w/in 12 hours of catheterization !!!
sym:
- > ipsilat flank or back pain !!
- > hypotension !!
- > tachycardia
- > flat neck veins
- –> bleeding from arterial access site ( retroperitoneal extension)
local comp:
- > AD
- > Acute thrombosis
- > pseudoaneurysm : tender , PULSTILE mass
-> AV fistula formation : CONTINOUS bruit + palpable thrill !!!
Dx;
- > confirmed with non-contrast CT scan of abdomen and pelvis
- > abd u/s
rx:
- > supportive with bed rest, intensive monitoring, and IVF and/or blood transfusion.
- –> RADIAL artery LESS complication
NG tube
ddx?
upper / lower GI bleeding
duodenal / gastric ulcer
dx?
rx?
acute abdomen (guarding, rebound tenderness) with subdiaphragmatic (intraperitoneal) free air
- -> NG tube decompression
- > IV fluid , AB
- > warfarin ind anticoag reversed: PROTHROMBIN complex concentrate ( PCC) Transient effects : vit K-dep cofactors
- > F2, 9 , 10 , c, s
alternate: FFP ( less effective )
** COLLOIDS: inc FFP + albumin : rx/ hepatorenal syn / SBP
** Blood transfusion Hbg < 7 g/ dl
** Pt infusion < 50,000
desompressin
rx>
mild Hemophilia A
- > prevent excessive bleeding
- > indirect inc F8 level –> cause vWF release from endothelial cells
acute urinary retention
RF?
sym?
sym:
- > agitation, tachycardia, and lower abdominal (suprapubic) tenderness 2 days following surgical repair of a hip fracture
RF:
- > Male sex (AUR rarely occurs in women)
- > Advanced age (~33% of men age >80 will develop AUR)
- > Hx BPH
- > Hx of neuro dx (eg, mild cognitive impairment)
- > Surgery (especially abd sx, pelvic sx, and joint arthroplasty)
–> opionds, anticholingerics ( amitriptyline)
dx: bladder u/s > 300 ml urine
rx: foley catheter
U/A : r/o UTI
Inflammatory breast carcinoma (IBC)
- -> aggressive breast cancer
- –> RAPID tumor growth + MTS
sym:
- > unilat breast rash, erythema, and skin edema
- > Peau d’orange
- > MTS disease (eg, axillary LAD!!!! )
Dx:
-> require core needle breast Bx + full-thickness skin punch Bx
breast mastitis ?
benign
- > focal inf, fever , NOT affect LAD
- > single breast affect
dx: u/s guide asp
dx: sx drainage
Ab
paralytic (adynamic) ileus
sym?
Etio:
- —> irritation and temp paralysis of abd SNS and PNS –> local release of inf mediators
- > opioid analgesic use.
dx: Clx
X-ray: GASTRIC DILATION and gas-filled loops of BOTH SMALL and LARGE intestines
—> NO transition point
sym:
- > N/V,
- > abd distension
- > failure to pass flatus or stool (obstipation)
- > hypoactive / ABSENT bowel sounds
RF:
-> abd sx s/p
s/p sx comp:
- > retroperitoneal / abd hemorrhage
- > intraabd inf ( pancreatitis)
- > int ischemia
- > electrolyte abnormal: hypoK + hypoPO4
Gastric outlet obstruction
dx?
- > XR: distended stomach
- > A succussion splash heard over the stomach
- > bowel sounds may be NORMAL or HYPERACTIVE.
SBO ( small bowel ob)
dx?
sym?
lab?
comp?
Bowel distal to the obstruction is NOT distended.
- > HYPERACTIVE “tinkling” bowel sounds
- > Peristaltic waves on the abdominal wall
strangulation
ob
lab:
vomiting:; hypokalemia
+ dehydration , orthostatis
etio:
adhesion :
-> LADD bands ( children)
-> adults: s/p abd sx
catheter-related bloodstream infection (CRBSI)
hemodialysis thru : tunneled dialysis catheter
high risk inf thrucatheter lumen into BS
sym:
- > sys inf (eg, fever, chills, malaise)
- > NO localizing manifest
- > Progressive: shock (eg, lactic acidosis, confusion, hypotension) can occur rapidly due to bacteremia.
rx: urgent B/C + AB ( VNC + ceftazidine) initiated w/o delay @!!!
–> REMOVE dialysis CATHETER !!
Chronic bacterial prostatitis
patho?
sym?
dx>
rx?
etio:
- > Young & middle-aged men
- > ↑ Risk with DM, smoking, urinary tract procedure
patho:
Coliforms enter from urethra via intraprostatic reflux
E.coli >75% causes
sym:
- > Recurrent UTI (with the same organism) !!!
- > +/- Prostatic tenderness & swelling ( PE often absent)
- > Pain with ejaculation
- > hx of Ab rx → transient imp
dx: Clx
- > Pyuria and bacteriuria on urinalysis
-> bact in prostatic fluid > bact in urine
rx:
Fluoroquinolones (eg, ciprofloxacin) for 6 wk ( prevent recurrence)
Chronic epididymitis
- > inf (eg, Neisseria gonorrhoeae, Chlamydia trachomatis) or autoimmune conditions.
- > painful ejaculation and a small amt of pyuria.
- > focal tenderness over the epididymis (POSTERIOR TESTIS) !!!!!
Chronic urethritis ?
- > insufficient rx of N gonorrhoeae or C trachomatis
- > atypical STD (eg, Trichomonas vaginalis).
- > urethral discharge !!!!
peripheral ARTERIAL disease (PAD)
dx?
RF:
ATS: (diabetes, hypertension, and smoking)
-> intermittent claudication!!!
—> Arterial ulcer @ tips of digits ( less perfused) : cool , PALE skin with dermal ATROPHY , DIMINISHED PULSE , PAINFUL!!!!!
ABI: Ankle -Brachial Index = SBP dorsalis pedis / post tibial A / SBP brachial A
<0.9 : dx PAOD
0.91-1.3 : normal
> 1.3 : ca+ + uncompressible vessels
*** arterial U/S : less sensitive + specific than ABI for dx A+PAOD
Von Hippel-Lindau disease
Etio:
- > mut in the VHL TSG on Chrm 3
- > AD
- -> Asso with MEN 2A, 2B
sym:
1. Cerebellar & retinal hemangioblastomas
- Pheochromocytoma: inc production of CATECHOLAMINE OVERPRODUCTION!!!
- ->HA, palpitation, severe HTN - RCC (clear cell subtype)
rx: Surveillance for associated malignancies -> Eye/retinal exme -> Plasma or urine metanephrines -> MRI of the brain & spine -> MRI of the abdomen -> Tumor resection
BLUNT abd trauma
dx steps?
Hemo stable:
Peritonitis?
—–> rebound tenderness, rigidity
Yes–> LP , CT abd + Pelvis (CTAP) en route to OR
NO–> free fluid FAST?
- > Yes: CTAP !!!!
- > No: consider CTAB / abd series exam ( reg PE of abd)
- -> intraabd injury
Hemo UNstable: SBP < 90 mmHg
periotonitis?
Yes: LP !!!!
No: free fluid FAST?
-> yes: LP
-> No: consider CTAP / diagnostic peritoneal lavage / other etio hemorrhage
gastric adenocarcinoma
dx steps?
TNM needed
- endoscopy / bx : + adenoca
- CT scan abd + pelvis
3. PET/CT endoscopic u/s LP CT chest \+/- paracentesis / peritoneal lavage
rx:
limited stage: sx resection
adv stage: CMT +/- palliative sx
- *** H.pylori eradication rxm : MALT lymphoma
- -> need testing 1st
flail chest
sym?
pul contusion
- > occurs when fracture of ≥3 adjacent ribs in ≥2 locations
- > isolated chest wall seg that moves paradoxically to the remaining rib cage during resp.
- > generate neg intrathoracic pressure during inspiration : dec TV + inc work of breathing
- > dec Oxygenation
- -> resp failure
cardiac myoxmas?
arise LA
- > Fragments of the tumor can dislodge: sys embolization (eg, stroke, acute limb ischemia).
- > position-dep ob of the MV
- > middiastolic murmur
- > decreased CO (eg, dyspnea, syncope, LH).
Constitutional symptoms: produce cytokines IL-6: systemic inf (eg, fever, weight loss)
-> inc ESR
dx: cardioecho
rx: sx
Enteral nutrition
ind?
Naso/ orogastric feeding tube
EARLY nutritional support : prevent malnourishment + imp overall outcome
- –> optimal form of nutrition for critically ill patients + multiple clx benefits:
- –> red in inf ( pn)
- -> maintenance of gut integrity : prevent atrophy of gut + mucosa asso lym tix
when initiated early (ie, ≤48 hr).
-> red mortality
TPN ind?
TPN used in:
- –> pt with contra to EN
- > eg, intestinal discontinuity
- > prolonged ileus
–> early initiation may inc risk of inf
(eg, central line–asso BS infection)
-> prolonged ICU and hosp stays.
lower rib fractures
Rib 9-12
dx?
-> can injury : intraabdominal organs.
***viscus injuries: subdiaphragmatic free air on upright x-ray
-> SOLID organ (eg, liver, spleen, kidney) injuries: typically NOT visible on plain abd XR
Dx:
-> CT scan of the abdomen with IV contrast : better visualizes SOLID organs njury
“ BLUSH” extravasation at site bleeding
—> FAST u/s : also ok !
ribs 1-3
ribs 3-6
ribs 9-12
any level
damage organs ??
–> Ribs 1-3
Subclavian vessels, brachial plexus, mediastinal vessels (eg, aorta)
–> Ribs 3-6
CV
–> Ribs 9-12
Intraabdominal: liver (right), spleen (left), kidney (posterior ribs 11 & 12)
–> Any level:
Pulmonary
enlarging parotid gland neoplasm.
Cancer sign?
dx?
rx?
-> CN VII + CN V closely asso w/ the parotid gland.
- -> facial droop (CN VII dysfunction)
- -> facial numbness (CN V dysfunction) is very concerning for neural invasion due to malignant disease.!!!!
dx:
- -> CT/ MRI
- > U/S : enable fine needle asp bx
rx: sx resection w/ sparing N7
- > adjuvant rx
** originate in the submandibular gland or minor salivary glands –> higher likelihood of Ca.
HIT -2?
etio?
dx?
rx?
—> Heparin ind a conformational change in a platelet surface protein (platelet factor 4),
HIT : Pt Count drop > 50%
–> skin necrosis @ abd injection site
dx: immunoassay (only if high titer)
GS -> functional assay (eg, serotonin release assay
rx: stop heparin
- > anticoag: argatroban, fondaparinux
HCC
sym?
dx?
- > ascites (shifting abdominal dullness)
- > hypoalbuminemia
- > mildly elev LFT
- > thrombocytopenia
- > hyperbilirubinemia
——> cirrhosis.
RF:
alcohol abuse, chronic viral hepatitis, or nonalcoholic fatty liver disease
–> hx diabetes mellitus and obesity
sym: decomp LF
- > WL, cachexia (eg, TEMPORAL WASTING)
- > hepatomegaly
- > palpable liver nodule
lab: AFP elev 50% cases : cannot R/O as dx
- -> abd U/S: monitor free fluid, portal /hep vascular sys , liver mass
if liver mass:
-> triple phase arterial contrast CT scan abd dx!!
Polymicrobial pyogenic (bacterial) abscesses
sym?
asso with : jaundice
hydatid liver cyst
etio?
sym?
Echinococcus granulosis
- > RUQ pain, nausea, vomiting, and hepatomegaly.
- > fever is rare
Entamoeba histolytica
etio?
sym?
dx?
rx?
–> protozoan
sym: 90% ASX
- > colitis : diarrhea, bloody stool with mucus , abd pain
-> extraintestinal (liver, pleura, brain) illness
- -> live in or travel to developing countries.
- > fecal-oral , sex transmission
sym: Amebic liver abscess: --> RUQ pain -> fever, -> single subcapsular lesion in the right lobe !!!!
dx:
serology: Stool ova & parasites
- > stool antigen testing (colitis)
rx:
Metronidazole & intraluminal ab (eg, paromomycin)
CVC
f/u dx?
Int JV/ subclavian vein :
ideal loc @ lower SVC
comp:
- > tips placement in smaller veins comp: venous perforation !!
- > pnthorax
- > pericardial tamponade
- > myocardial peroration
-> CXR : omit complication
Cardiovascular contra to pregnancy
?
Highest risk conditions:
- > sym MS: worst condition
- —> decomp HF w/ elev LAP + Pul edema
- –> AF ( LA stretching )
- –> inc risk LA thromboembolism
- > sym AS
- > sym HF with LVEF ˂30%
- > Pul A HTN
- > Bicuspid AV with ascending aorta enlargement >50 mm
rx: percutaneous valve surgery PRIOR to pregnancy !!
*** B blockers: used only in MILD conditons
cardiogenic shock
lab?
acute MI
lab:
- > dec Cardiac index
- > inc PCWP !!! LA pressure elev
- > dec CO = SV x HR : HYPOTENSION
–> INC SVR
-> low Svo2 ( low tix perfusion signals tix to extract more O2 from blood = dec mix venous O2 sat)
RCC
sym:
- > unintentional WL!!
- > smoking history
- > hard flank mass !!
- > hematuria
- > paraneoplastic syn: inc ECTOPIC EPO production , hyperCa
dx: CT abd
PE
etio:
- > patients age >50; risk is greatest in former or current smokers
- > obesity, hypertension, and/or occupational exposure to toxic compounds (eg, asbestos).
Non-Hodgkin lymphoma
- > B symptoms (intermittent fever, night sweats, weight loss),
- > > 70% also causes painless peripheral LAD + HSM.
THyroid nodules in pregnancy
dx steps?
- serum TSH
- thyroid U/S
Thyroid nodules >1 cm + high-risk u/s :
——> fine-needle aspiration (FNA) biopsy.
- high risk u/s :
- > microcalcifications
- > irregular margins
- > internal vascularity
Thyroid nodules >2 cm :
ALL undergo FNA (unless they are cystic, as they have a low risk of malignancy).
- ** pregnancy women: AVOID Radioactive iodine!!!
- > congenital hypothyroidism
- > intellectual disability
- > increased risk of malignancy in the fetus.
**Thyroglobulin : tumor marker to monitor RECURRANCE s/p th yroid gland complete removed!
Scaphoid fractures
sym?
dx?
MC carpal bone fractures.
etio: falls onto an outstretched hand that cause axial compression or wrist hyperextension.
-> arterial supply to the scaphoid (from the radial artery)
causes AVASCULAR NECROSIS and nonunion.
dx: XR : low sensitivity
if neg : CT / MRI confirm
rx:
wrist can be immobilized briefly in a thumb spica splint
-> f/u repeat imaging in 7-10 days.
Type A dissections
sym?
rx?
–> ascending aorta and present with sudden-onset chest or back pain that is severe
- -> sharp or tearing.
- > pericardial effusion
- > inc 20% SBP upper ext
-> complicated by syncope, stroke, MI, or HF
dx:
CXR: widening mediaterial
ECG: normal, non-ST / T changes
!!!!! CT angiography/ TEE ( def dx): intimal flap!!
rx: !!! req ER sx intervention.
Type B Aortic dissections
not inv abd organ / thoracic ischemia
rx?
rx:
pain and blood pressure control.
celiac dx
rx?
rx:
- > loperamide and the low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols) diet
lab:
- > NO elev CRP
- > NO BLOODY stool on rectal exam
IBD
crohns dx/ UC
sym>
dx?
- > chronic diarrhea, abdominal pain, anemia
- > CD: fistulas, strictures, and abscesses
- > uncontrolled UC: toxic megacolon:
- —-> sym toxicity (eg, fever, tachycardia, hypotension)
- –> abd pain & distension+ diarrheal illness
------> dx: CT abd Colonic dilation (>6 cm) -> loss haustral pattern -> irregular pattern *** avoid colonoscopy to prevent perforation
lab:
- > elevated inflammatory markers (eg, CRP, ESR)
dx: colonoscopy with Bx
BZD w/drawal
sym?
rx?
worsening agitation, impaired attention, and disorientation following surgery
——-> delirium
chronic usage BZD: inhibitory effect via GABA receptors: sudden w/drawal —> excitatory state !!
—-> sym w/in 24-48 hrs !
-> can ind seizures
sym,
tremulousness, hallucinations, and elevated vital signs
rx; reinitiation BZD long acting agents , gradual taperd down over wk= mo
amputated part
rx?
-> transported by wrapping it in saline-moistened gauze, sealing it in a plastic bag, and placing the bag in a bath of ice water.
Cooling of the amputated part prolongs the window for replantation.: dec tix met + O2 demand
*** NOT submersion in water/ antiseptic soln : can injury digital vessels !!!
opioids se?
vs
metroclopramide
se?
prolong sx: ind ileus
opioids
se: dec GI motility and dx peristalsis
metoclopramide:
DA antagonist: promote motility effect!
periocardial effusion
/ cardiac tamponade
rx?
sym?
beck’s triad: hypotension, dilated neck vein, muffled Heart sound
rx; ER pericardiocentesis
Rupture of the left ventricular free wall ?
post-MI complication : acute / w/in 3-5 days
ANTERIOR MI ( left Ant descending A occlusion)
hemopericardium
- > pericardial tamponade : beck’s triad:
- —–> hypotension, jugular venous distension, distant heart sounds
-> rapidly progress to PEA + death
Papillary muscle rupture?
Acute or within 3-5 days
@ RCA
sym:
- > Severe pulmonary edema
- > New holosystolic murmur
dx: TEE/ TTE
echo:
-> Severe mitral regurgitation with flail leaflet
TB
rx steps ?
sym:
hemoptysis : massive > 600 ml/day / 100mh/hr
upper lobe inv
rx:
step 1 :: RESP ISOLATION pt till dx of TB can confirm / refuted by additional testing
step 2: bronchoscopy!!! for localized the bleeding + visualize
—>
adequate patent airway, placed pt with the bleeding lung in the dep position (lateral position) : avoid blood cxn in the airways of the opp lung.
- rx: balloon tamponade , electrocautery for bleeding
*** FFP : given when INR > 1.5 causing hemoptysis
Suppurative parotitis
rf?
sym?
rx?
RF:
- > Elderly, dehydrated, postsurgical
- > dec oral intake (eg, NPO perioperatively)
- > Medications (eg, antiach)
- > Obstruction (eg, calculi, neoplasm)
sym:
- > fever, leukocytosis
- > Firm, erythematous pre/postauricular swelling: S aureus oral flora retro-seeding to oral cavity
- > Exquisite tenderness exacerbated by chewing and palpation: fluid can be expressed
- > Trismus, systemic findings (eg, fever, chills)
lab:
elev serum amylase without pancreatitis
dx:
u/s or CT scan (eg, ductal obstruction, abscess)
rx: Hydration, oral hygiene ab Massage (ie, milking pus out of gland) Sialagogue
Extreme jaw opening (eg, during intubation)
sym?
anterior TMJ dislocation,
-> pain in the preauricular area and diff opening or closing the jaw.
** fever with leukocytosis would NOT be present.
Lemierre syndrome (LS)
sym?
dx?
- > severe life-threatening inf affects young ICP
- > caused by the GN anaerobic bacillus Fusobacterium necrophorum
- > a comp dental work or mastoiditis.
- > Bact inv lat pharyngeal space thru the lym sys + affects the neurovascular st
- -> IJV thrombosis and inf!!!!
sym:
- > prolonged duration of sore throat + high fever
- -> Pharyngitis
-> rigors, dysphagia, and neck pain and swelling SCM muscle
dx: B/C from blood / pus
- > airway management
- > AB
- > incision + drainage
Klebsiella pneumoniae?
GN rod
Rare cause of CAP
-> pn w/ thick “currant jelly” sputum in alcoholics or patients with diabetes.
Group A Streptococcus pyogenes?
bacterial pharyngitis.
- > tonsillar exudates are classically
- > NOT typically severely toxic-appearing.
AC joint sprain?
—> rugby, football injury
direct shoulder trauma , fall onto shoulder
Pain over AC joint
Passive shoulder ADDUCTION provokes pain ( cross body add test)
-> sig force applied to the lat or sup shoulder
dx:
XR : normal
rx: mild : AC Joint sprain : immobilization with sling
Pectoralis major strain ?
activities inv repetitive pushing movements,
eg. bench presses.
sym:
-> chest wall soreness rather than shoulder pain.
acute necrotizing pancreatitis
sym?
dx?
- > signs of sepsis (eg, fever, hypotension, tachycardia, confusion) days after being admitted
sym: inf causes uncontrolled release of pancreatic enzymes, —> autodigestion of the pancreatic parenchyma and peripancreatic tix
Dx;
- > CT abd : pancreatic edema and necrosis on CT
- > initial necrotic cxn is sterile
- > inf w/ enteric pathogens (eg, Escherichia coli, Pseudomonas, Enterococcus : 7-10 days s/p
rx: AB IV
- > aspiration
- > debridement ( endoscopic) : delayed till stabilize on ab
RA myelopathy
s/p intubation
se?
sym:
- > Neck pain radiating to occipital region
- > Slowly progress spastic quadriparesis
- > Painless sensory def in hands/ feet
- > resp dysfunction (eg, from vertebral artery compression)
Signs:
-> Protruding ant arch of atlas
-> Scoliosis with loss of cervical lordosis
-> UMN sign
eg, spastic paresis, hyperreflexia, Babinski sign
-> Hoffman sign: corticospinal lesion
dx;
MRI C1-2
rx: stiff sx collars + cervical fixation
Critical illness polyneuropathy
sym?
comp of sepsis
sym: axonal injury of the perip Nerve.
- > wkness after a prolonged stay in an ICU
- > peripheral nerve injury: hyporeflexia;
***UMN signs would NOT occur.
Malignant pericardial effusion
etio?
sym?
rx?
etio:
- > primary tumors: lung, breast, GI tract, lymphoma, melanoma
- > malignancy or recurrence!!!!
Sym:
prog dyspnea, chest fullness, fatigue
dx:
-> ECG: ↓ QRS voltage ± electrical alternans
> !!!! ECHOCARDIO: large effusion ± signs of tamponade (eg, right atrial collapse)
rx:
Acute: pericardiocentesis, cytologic fluid analysis
-> Prevention of recurrence: prolonged drainage (eg, catheter, pericardial window !!!! )
** colchicine + NSAIDS : rx/ viral / idopathic acute pericarditis !!!
+ rx/ pericardial effusion
Heart failure
sym?
rx?Malignant pericardial effusion
-> fatigue, dyspnea,
pul edema : crackles on lung
-> peripheral edema.
CXR: cardiomegaly
rx: diuretics
posterior urethral injury (PUI)
sym?
dx?
Pelvic fracture
( perineal bruising), acc by blood at the urethral meatus
-> urethral tearing,MC @ bulbomembranous junction (transition point between the anterior and posterior urethra)
sym:
- > unable to void ( urethral discontinuity)
- > perineal brusing
- >high riding prostate @ DRE
dx:
- > retrograde urethrography!!! PRIOR any FOLEY insertion
-> XR urethral tract
Testicular torsion
sym?
dx?
rx?
epi:
MC in adolescents
Sym;
- > Testicular, inguinal, abd pain
- > N/V
- > Horizontal testicular lie with elev testicle
- > Absent cremasteric reflex!!
- > Swollen, erythematous scrotum
dx:
NO BF on scrotal u/s w/ Doppler
–> heterogeneous echotexture : necrosis testies
rx:
-> sx detorsion & fixation with exploration of the
contralateral side
-> Manual detorsion (if immediate surgery is not
available)
Renal vein thrombosis
RF?
sym?
dx?
rx?
—> loss of antithrombin III in urine : inc risk venous + arterial thrombosis
sym: :
- > hematuria, renovascular congestion, and flank pain
- > elev LDH, AKI
etio:
1. hypercoagulability
- > nephrotic syndrome, malignancy, OCP
2. voln depletion : infants
3. trauma.
dx: confirmed by CT or MR angiography: enlarge renal
- > renal venography.
rx:
- > anticoag
- > thrombolysis / thrombectomy ( AKI + )
renal infarction ?
etio: cardioembolic disease (eg, AF)
-> incomplete infarction and a WEDGE-shaped area of ischemia
sym:
-> abd pain + flank pain. -> acute inc in BP due to renin release
Auricular hematoma
RF?
sym?
rx?
comp?
RF:
Contact sports injury (eg, wrestling, martial arts)
Sym:
-> Tender, fluctuant blood collection on ant pinna
rx:
-> Immediate incision & drainage!!! cover P. aeruginosa
-> Pressure dressing
comp:
- > Cauliflower ear (fibrocartilage overgrowth)
- > bact suprainf!!!! s/p 2-3 days–> ABSCESS
- – > avascular necrosis outer ear cartilage
- > Reaccumulation of hematoma
Malignant biliary obstruction
etio?
sym?
dx?
etio:
- > Cholangiocarcinoma
- > Pancreatic/HCC
- > MTS (eg, colon, gastric)
sym: ->PAINLESS Jaundice, !!! -> pruritus, acholic stools, dark urine WL -> RUQ pain -> RUQ mass or hepatomegaly
lab:
-> elev ↑ Direct bilirubin, ALP, GGT
dx:
Serum tumor markers (CEA, CA-19, AFP)
- > Abd imaging (u/s , CT scan)
- > Endo U/S or ERCP for tissue dx if unclear
Acute choledocholithiasis
lab:
-> markedly elev ALP
sym:
-> acute-onset RUQ or epigastric pain
Chronic pancreatitis >
Recurrent Abd pain
-> fat malabsorption + steatorrhea.
lab: LFT Normal later on : elev bilirubin and ALP -> elev AMYLASE rich !! -> PH 7.35-7.5
comp:
- > fibrosis, stricture of the intrapancreatic portion of the bile duc
- –> pancreatic fistulas : disrupt pancreatic duct leak pancreatic digestive enz
rx: bowel rest
- > ercp w/ sphincterotomy + stent placement
- > refractory : percutaneous drainage / sx
clavicle
rx?
hard vs soft signs?
Signs of traumatic arterial injury HARD signs: (req immediate sx)!! -> Distal limb ischemia (eg, paralysis, pain, pallor, poikilothermy) -> ABSENT distal pulse -> Active hemorrhage or rapidly expanding hematoma -> Bruit or thrill at site of injury -----> rx: ER SX exploration!!!
Soft signs (req further imaging): -> DEC distal pulses -> Unexplained hypotension -> STABLE hematoma -> doc hemorrhage at time of injury -> asso neuro deficit
dx:
- –> CT angiography ( high sens + sp)
clavicle overlies the brachial plexus + subclavian A + V in the thoracic outlet.
Uncomp fractures of the middle 1/3 clavicle ?
vs
distal 1/3 clavicle
rx?
rx:
-> uncomp middle 1/3: figure 8 bandage
-> distal 1/3 : ORIF
*** upper ext venous duplex: venous thrombosis / ob : venous OB sign : edema / cyanosis
renal cyst
simple
vs
malignant
sym? rx?
simple cyst: common > 50 yr
SIMPLE: BENIGN
- > Thin, smooth, regular wall
- > Unilocular
- > No septae
- > Homogenous content
!!! -> Absence of contrast enhancement on CT/MRI
- > Usually asymptomatic
- –> No f/u needed
MALIGNANT:
- > Thick, irregular wall
- > Multilocular
- > Multiple septae, occasionally thick & CALCIFIED!
- > Heterogenous content (solid & cystic)
- >
- of contrast enhancement on CT/MRI
- > pain, hematuria, or hypertension
- —> req f/uimaging & urological evaluation
foreign body asp in NB?
sym: abrupt onset resp distress, cough , dspnea, hypoxia, wheezing
- > prolong exp phase
- > dec BS on affected side
- > hyperresonance
—> unresponsive to b-agonist
dx: rigid bronchoscopy confirm
xr: unilat lung hyperinflation with mediastinal shift towards UNAFFECTED side
- > atelectasis : comp bronchial ob
abd aortic aneurysm
MCC?
dx steps ?
enlarge AA > 3 cm
MCC: SMOKING
rupture common in > 5.5cm / rapid rate expansion > 1cm/yr
dx: ONE time U/S abd @ 65 - 75 with any SMOKING hx
Q) Hemo stable?
YES: CT abd
NO: U/S
rx:
small - moderate size ( 3.5 -5.5cm) AAA: lifestyle modify
large: sx repair
splenic abscess
sym?
comp?
dx?
rx?
-> life-threatening comp of bacteremia from a distant infection (eg, infective endocarditis, cholecystitis).
inc risk: ICP from HIV, hematologic malignancy, or diabetes mellitus.
sym:
-> persistent fever and LUQ pain (radiating to the back),
-> w/ or w/o SM
=-> Anorexia and WL
lab:
- > leukocytosis with left shift,
- > CXR: elev left hemidiaphragm (and/or left pleural effusion).
dx:
CT scan of the abdomen;
rx:
ab + splenectomy
Pancreatic pseudocyst
-> walled-off cxn of fluid around the pancreas —> pancreatitis,
sym:
ASX
-> occasionally become inf: fever + epigastric pain that radiates to the back
*** NO SM
brain injury damage to cortical areas
sym?
–> disrupted inhibition :
hyperactivity paroxysmal sym
—> trigger by ext stimuli ( bathing , reposition)
sym:
- > rapid-onset epi of tachycardia, HTN + tachypnea
-> fever and diaphoresis.
Pulmonary contusion
sym?
dx>
rx?
sym:
- > Present <24 hours after blunt thoracic trauma
- > Tachypnea, tachycardia, hypoxia
dx:
Rales or dec breath sounds
-> CT scan (most sensitive)
-> CXR with patchy, alveolar infiltrate not restricted by anatomical borders ( IRREGULAR, NON-LOBULAR INFILTRATES)
rx:
Pain control
Pulmonary hygiene (eg, incentive spirometry, chest PT)
Supplemental oxygen & ventilatory support
fat embolism
?
-> Tachypnea and hypoxemia in the femur fracture
sym:
- > NEURO abnormalities
- > PETECHIAE RASH, latency period of 12-72 hours after the initial injury.
testicular ca?
types:
- > Germ cell tumors (95%): seminomatous or nonseminomatous (embryonal carcinoma, yolk sac, choriocarcinoma, teratoma, mixed)
- > Sex cord–stromal tumors: Sertoli cell, Leydig cell
dx: PE: firm, ovoid mass -> elev tumor markers (AFP, β-hCG, LDH) -> Scrotal ultrasound Solid, hypoechoic lesion (seminoma) / lesion with cystic areas and ca+ (nonseminomatous germ cell tumor [NSGCT]).
rx: Radical inguinal orchiectomy
- –> Confirm the dx hx + definitive rx.
** NO bx : prevent seeding thru LN
bronchiolitis obliterans
(Chronic lung transplant rejection)
sym?
dx?
rx?
- > prog dyspnea, an ob pattern (ie, FEV1/FVC <70%)
- > no evidence of inf
- —-> months to yrs after transplant
—> chronic lymphocytic inf of the small airway submucosa,—> leads to ingrowth of fibromyxoid tix into the airway lumen
dx: PFT: consistent clx ob pattern on PFT.
- > lung BX (eg, circumferential elastin rings in the airway lumen
- > Bronchoalveolar lavage r/o inf (eg, viral pneumonia),
Cerebellar hemorrhage
RF?
sym>
rx>
RF:
- > HTN
- > Antithrombotic therapy (eg, warfarin, aspirin)
- > Cerebral amyloid angiopathy
sym:
- > HA, N/V
- > ipsil ataxia, dysarthria, vertigo, nystagmus
- > Cranial neruopathies
rx:
- > Reversal of anticoagulation
- > BP rx
- > ICP management (eg, head of bed elev, mannitol)
SE rx decompression ind with:
- > Hemorrhage >3 cm
- > neuro deterioration (eg, impaired consciousness)!!!!
- > BS comp, ob hydrocephalus
Central cord syndrome
s/p whiplash-type injuries in older adults w/ underlying cervical spondylosis.
sym:
- > Damage to the central cervical SC –> Upper ext, sensory, and reflex abnormalities
- > sacral (eg, bowel/bladder)
!!!! -> LE function is generally preserved.
Postconcussion syndrome
sym?
HA, dizziness, cognitive impairment
eg, loss of concentration/memory
-> irritability, anxiety, and noise sensitivity.
avascular necrosis
osteonecrosis
sym?
- > long term steorids users
- > osteocytes / abd plasma lipid level : degenerate articular cartilage !!!
Bone + BM infarction
-> abnormal baone remodeling subseq : trabecular thinning + collapse mo- yrs later
dx: MRI
rotator cuff tear
sym?
rx?
inc risk?
Similar to rotator cuff tendinopathy
—> glenohumeral dislocation : fall on outstretched hand
Weakness with abduction & external rotation
-> intact sensation
Age >40
dx: DROP ARM TEST
MRI
rx: SX
inc risk:
- > fracture
- > recurrent dislocation !!! lig laxity overuse: multidirectional joint instability !!!!
** avascular necrosis + axillary A thrombosis : more asso with PROXIMAL HUMERUS FRACTURE : gradual
recurrent sialadenitis (salivary gland infection)
sym?
rx?
–> salivary stasis: retrograde seeding of BACTERIA (eg, S aureus, oral flora) in oral cavity.
- -> seen in elderly s/p or ob’ of the outflow duct
- -> exacerbated by eating + FEVER !!
@ submandibular gland : higher mucus content + duct travel against gravity : dec salivary flow
-> ca stone on CT scan
rx: NSAIDS , AB
hydration
-> otolaryngology
TMJ .?
epi pain exacerbated by eating with intervening ASX periods
—> NO FEVER
Angle-closure glaucoma
sym?
dx?
rx?
sym:
-> HA, ocular pain, N, dec VA
Signs:
-> conjunctival redness; corneal opacity; fixed, mid-dilated pupil !!!!!
dx:
- > Tonometry (measures IOP)
- > Gonioscopy (measures corneal angle)
rx:
-> Topical rx: multidrug topical therapy (eg, timolol, pilocarpine, apraclonidine)
- > sys rx: acetazolamide (consider mannitol)
- > Laser iridotomy
intracranial hemorrhage
eio?
Thalamic hemorrhage
etio:
1. cocaine use
dx: urine toxicology screen
- echocardio: IE / LA myxoma
- -> mix thrombotic / embolic + fever , WL, malaise , murmur
** carotid A stenosis: ischemic stroke : dec BF thru carotids / thrombus formation in stenotic area
refeeding syndrome
lab?
-> hypoPO4
-> hypoK
-> muscle wkness, + arrhythmias
-> seizure, paresthesia
after the initiation of tube feeding
reintro carbs (ie, tube feeding) —–> inc insulin secretion.
stimulates cellular uptake of electrolytes (ie, PO4, K, Mg ) and inc Po4 utilization during glycolysis
—-> PO4 dep : failure cellular energy met : massive fluid + electrolytes shifts
esophageal ca ?
Subtypes -> Adenoca: Distal eso: Barrett esophagus -> SCC mc @ proximal mid eso
RF:
-> Uncontrolled GERD, obesity, male (adenoca)
->Smoking, alcohol use, n-nitroso containing food (scc)
sym:
-> Progressive solid-food dysphagia
GI bleeding, IDA
-> WL, aspiration
dx:
- > Endoscopy with bx
- > CT (PET/CT) is used for staging (not initial dx) !!!!!
Left ventricular aneurysm
etio?
sym?
dx?
etio:
-> Scar necrotic tix deposition following transmural MI
sym:
-> Several MONTHS s/p MI ( LATE complication) !!!
- > HF & angina
- > Vent arrhythmia (eg, VT)
- > Sys embolization (eg, stroke)
dx:
-> ECG: PERSISTENT ST elev, DEEP Q waves
-> Echocardio: THIN + DYSKINETIC myocardial wall
spinal epidural hematoma
sym?
potential comp of neuraxial anesthesia (eg, epidural block), LP, or spinal sx
—> antithromboitic rx se
CAUDIA EQUINA SYN:
- -> slowly prog motor and sensory dysfunction
- > loc back pain; bowel and bladder dysfunction
rx: ER MRI and neurosurgical laminectomy.
Positive pressure vent
se?
pul barotrama -> alveolar reupture + pnthorax formation
inc risk:
COPD preexisting pul hyperventilation
–> bullea / blebs can rupture
eg. primary spontaneous pnthroax: tall, thin male
large pnthroax:
-> abrupt-onset tachycardia, tachypnea, hypoxemia, and dec / ABSENT BS on the AFFECTED side.
collapsed lung:
- > inc peak pressure
- > inc plateau pressure
rx: chest tube
Cytomegalovirus (CMV) pneumonitis
sym?
dx?
ppx?
- > acute, febrile, and diffuse pn
- > opp inf in the 1st yr s/p lung transplant.
- > reactivation of latent CMV from the donor lung or recipient leukocytes.
- > tix injury by CMV pneumonitis inc risk of graft rejection and dec survival.
dx: bronchoscopy + lung bx
ppx: valganciclovir
TMP-SMX
Li-Fraumeni syndrome
AD
- > alter p53 gene.
- > early onset of Ca: sarcomas, breast cancer, and adrenal carcinomas.
VHL dx?
- > mut VHL TSG chrm 3
- > AD
sym: HARP
-> Hemangioblastomas: CNS:
Cerebellar ( cerebral hemorrhage), retinal detachment
- > Angiomatosis: cavenous hemangioma in skin , mucosea, organs
- > RCC (clear cell subtype) : multiple cysts
- > Pheochromocytoma
Dx + rx: Eye/retinal examination Plasma or urine metanephrines MRI of the brain & spine MRI of the abdomen Tumor resection
Quadriceps tendon tears
sym?
–> sudden force contraction , deceleration from a fall / activities
- > prox to the patella in the rectus femoris tendon
- > patella rides LOW !!!!
- > an intact cxn to the tibia, with a palpable DEFECT ABOVE THE PATELLA
Patellar tendon tears
- > distal to the patella
- > patella rides HIGH, often with a palpable def below the patella
s/p pancreatic leak
lab?
pancreas drain output of pancreatic fluid:
- > LOSS of HCO3 !!
- > acc of unmeasured H+ cpd
——> hyperchloremic acidosis
Met acidosis NON-AG
etio:
- > Severe diarrhea
- > RTA
- > Excess saline infusion
- > Int/ pancreatic fistula
- > CAI & MRA diuretics
- ** high AG met acidosis:
- > acc of unmeasured ACIDIC cpd ( lactic acid, ketones ) in blood –> inc AG!!
otosclerosis ?
sym?
rx?
Imbalance of bone resorption & deposition → stiffening of stapes
AD
sym:
- > Progressive conductive hearing loss
- > paradoxical IMPROVE in NOISY enviro
- > ± Reddish hue behind tympanic mem
rx:
- > Amplification (eg, hearing aids)
- > sx (eg, stapes reconstruction)
presbycusis?
deg neuronal cell bodies
- > BIL sym SENSORINEURAL hearing loss
- > worsen with noise
Ménière disease?
-> inc fluid in cochlea
- > UNILATERAL hearing loss in young adults
- > autoimmune dx , GENETICS
-> episodic vertigo, hearing loss, aural fullness
Alport sym?
lamellated BM
- > hereditary SNHL (not CHL)
- > damage of the BM in the cochlea.
-> recurrent hematuria in childhood.
Team safety debriefings
?
collaborative discussions encouraging expression of safety-related concerns and actions in a specific sit
—-> Debriefings: used by high-reliability org to strengthen safety culture (shared commitment to safety goals) + continuous team learning.
blunt chest trauma
sym?
-> RAPID pnthroax reacc : declining oxy sat) + inc subcutaneous emphysema.
- > tracheobronchial injury : large quantity of air escapes with each breath
- > persistent pnthorax/ pnmediastinum
dx: bronchoscopy
- > high CT scan
rx: sx repair
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu)
syM?
-> AD inv angiogenesis visceral organs
- CNS:
- > Hemorrhagic CVA
- > Brain abscess: paradoxical bact embolization across pul AVM - Mucocutaneous
- > Oral & cutaneous telangiectasia
- > Recurrent EPISTAXIS !!! - Lung
- > Pul AVM: anastomoses btwn pul A + Pul V: HEMOPTYSIS !!!!
- —> smooth nodules CXR: continuous pul bruits
- > PAH: RHF
- —> rx: pul angiography + embolization !!! - GI
Chronic GI bleed: IDA - Liver: portal HTN, high-output HF
GPA :
granulomatosis with polyangiitis (GPA)
—> necrotizing, small-vessel vasculitis
sym: resp tract, : Pul-renal syn.
- > upper airway inv: nasal septal necrosis and destructive sinusitis
- > lower airway inv: crackles, diffuse patchy infiltrative
- > renal : hematuria microscopic u/a
ESRD : CTS?
MC mononeuropathy ESRD on dialysis.
—> dialysis related amyloidosis
: formation beta -2 microglobulin
–> inc venous pressure during hemodialysis
blood tracking thru fascial plans into CT
-> dep CaPO4 : ischemia neuropathy
- > pain and paresthesia in the lat hand
- > sym: WORSEN during DIALYSIS and are more SEVERE in the arm with VASCULAR ASCESS.
Uremic polyneuropathy is
- > ESRD : progressive pain + paresthesia in the feet, not the hands.
- > uremia, the polyneuropathy typically resolves when dialysis is initiated.
ER SX ind in infectious endocarditis (IE)?
local / septic embolic comp
- Acute HF: aortic/MV regurgitation)
- Ext of inf (eg, abscess, fistula, heart block)
- Diff-to-eradicate organism (eg, fungus, MDR pathogen)
- Persistent bacteremia on ab
- Large vegetation/persistent septic emboli
- ** anticoagulation does NOT diminish the risk of septic embolization
- > inc risk of bleeding comp: NOT rxm
Ottawa ankle rules?
plain XR : ankle
ind
-> pain in the area of the malleolus in asso w/ either:
—-> pt tenderness over the POST margin or TIP of the malleolus
OR
—-> Inability to bear weight after the injury: 4 steps
dx: XR
rx: open fracute immediately orthopedic consult : evaluate Neuro impairment
Diabetes mellitus : neuropathic ulcers
dx?.
-> Repeated pressure, friction, or trauma due to lack of sensation in the local tissues.
@ weight-bearing sites on the sole of the foot
dx: HbA1c / fasting glc
venous insufficiency / ob?
- > Venous ulcers @ medial aspect of the leg ABOVE MALLEOUS
- > usually asso w/ edema and stasis dermatitis!!!
dx/ duplex U/S
atelectasis : bronchial mucus plug
- > trapped air molecules diff into the BS
- > NO add air can enter the ob airway: alveoli become devoid of matter and COLLAPSE! PULL TOWARDS
—-> dullness to percussion, absense BS
sym:
- > dyspnea, tachypnea, tachycardia , hypoxemia
-> CXR: OPACIFICATION of the affected lung area with mediastinal shifting toward the side of opacification
rx:
chest physiorx
-> large voln: bronchoscopy remove mucus plug
large pleural effusion?
- > large opacification CXR
- > effusion is occupying space, the mediastinum will be SHIFTED AWAY from the side of effusion (rather than toward)
Mallory-Weiss syndrome?
- > only PARTIAL-thickness tear
- > hematemesis (from submucosal plexus bleeding)
Pulmonic valve stenosis
HS?
Severe: RHF in childhood
Mild: Symptoms (eg, dyspnea) in early adulthood
—> Crescendo-decrescendo murmur (↑ on inspiration)
—> Systolic ejection click & WIDENED SPLIT of S2!!!!
ASD hs?
mid-systolic murmur : INC flow across the pulmonic valve;
-> S2 is widely split
with NO variation during respiration (WIDE and FIXED splitting)
epidural hematoma
(EH)
sym?
injury @ middle meningeal artery.
–> Rapid expansion of the EH can abruptly inc ICP !!!!
(eg, Cushing triad of HTN, bradycardia, and bradypnea),
- > herniation of the most medial portion of the TEMPORAL lobe (ie, uncus) through the tentorial notch.
sym: KERNOHAN PHENOMENON - > Ipsi FIXED and DILATED pupil from compression of the ipsilateral
- > CN 3: ptosis and a down-and-out position of the ipsilateral eye
- > Contralateral hemiparesis : ipslat cerebral peduncle of the midbrain,: injury descending corticospinal tracts
- > Contralateral homonymous hemianopsia with macular sparing from comp of the ipsilateral PCA
perilymphatic fistula
sym?
- > head trauma
- –> inner ear: endolymphatic fluid filled semicircular canals : vertigo + nystagmus
- –> cochlea hair cell damage : sensory hearing loss
sym:
–> episodic vertigo triggered by sudden pressure changes (eg, Valsalva maneuvers) or loud noises (Tullio phenomenon).
burn wound sepsis
se?
s/p burn HYPERMETABOLIC response :
- > hyperdynamic circulatory response: tachycardia >90, HTN
- > inc gluconeogenesis + insulin resistance : hyperglycemia
- > inc BMR :inc basal body temp > 39 / < 36.5
–> organ hypoperfusion / dysfunction : oliguria : new onset enteral feeding tolerance : splanchnic hypoperfusion : GI hypomotility + ILEUS
- > pn + lipid cat : inc lean muscle wasting
dx: B/C + wound cultre !!!!
rx: emp AB !!
insulin, grafting, beta blocker , steroids, nut suppost
abdominal compartment syndrome (ACS
sym?
–> intraabdominal HTN => organ dysfunction)
–> abd distension, + tense abd
blowout” eye fracture
sym?
dx?
comp?
rx?
Blunt trauma to the globe : rapid inc in pressure transmitted post into the orbit
dx: VA + EOM
CT scan
- —–> orbit floor fracture : entrapment INFERIOR RECTUS MUSCLE
- –> downward position, diplopia on upward gaze
- -> Normal VA !!!!
—> prolong comp: ischemia , fibrosis, permanent dysfunction
rx: sx w/in 24 hrs
orbital hematoma
sym?
-> facial trauma w/diplopia.
!!! -> MARKED DEC VA : pressure-ind ischemia of the optic nerve
dx:
CT scan intraorbital fluid rather than an orbital floor fracture.
Tibial stress fractures
sym?
-> repeated tension or compression w/o adeq rest
MC in: athletes or suddenly inc their activity.
- > female athlete triad :
- > low cal intake
- > hypomenorrhea/ amenorrhea
- > low bone density
sym: subacute, loc, activity-related pain;
- > swelling; POINT TENDERNESS on palp
dx:
XR are freq normal 1st 6 months
rx: dec Weight bearing 4-5 wks
interosseous ligaments (high ankle sprain) ?
acute antlat ankle pain,
-> rotational force on a dorsiflexed ankle.
common asso: fibular fracture.
Medial tibial stress syndrome (shin splints?
Diffuse area of tenderness (not pt tenderness)
sialadenosis
?
BENIGN, noninflammatory,
—> overacc of secretory granules in acinar cells (abnormal auto innervation)
- > nontender, bil enlargement of the parotid glands
- > NOT fluctuate , not asso with eating
etio: chroninc ETHO useage,
SM, malnutrition , bulimia
pleomorphic adenoma
sym?
benign salivary neoplasm that
sym:
- > painless enlargement of the parotid gland. UNILATERAL !!!! distinct mass
Salivary stones (sialolithiasis)
sym?
block the flow of saliva out of the duct —> swelling + inc fluid in the gland.
—> swelling usually fluctuating, painful, and asso with eating (which + saliva secretion).
Hepatic adenomas
?
benign liver tumors @ rt lobe liver in women
->asso with OCP !!! estrogen on hepatocyte
triphasic CT scan: centripetal enhancement ,
focal nodular hyperplasia (FNH)
benign regenerative liver nodule
-> women age 20-50.
sym:
ASX
-> well-circumscribed, solitary, <5 cm in size
-> central, stellate scar
-> large congenital arterial anomaly sends arterial branches to the periphery.
dx:
- > helical CT: hyperdense lesion : central scar !!!!!
Cerebrospinal fluid rhinorrhea
-> skull base fracture : cribiform plate, temp bone
sym:
Unilat watery rhinorrhea with salty or metallic taste
comp:
- > meningitis
dx:
Test for CSF-specific pn (β-2 transferrin, β-trace protein)
image: (with intrathecal contrast)
Endoscopy (± intrathecal fluorescein dye)
rx:
- > Bed rest, head of bed elev, avoidance of straining
- > Lumbar drain placement
- > sx repair
cocaine / nasal decongestants
sym?
vasoconstion BV
-> BIL (rather than unilateral)
-> rhinorrhea + severe “rebound” nasal congestion
eg, rhinitis medicamentosa).
exam:
- > swollen, erythematous turbinates.
- > Tissue dest from vasoconstriction : septal perforations) rather than at the skull base.
