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.
