UW Surgery Flashcards
Patient got in a car accident and has blunt abdominal trauma. You do a FAST exam (ultrasound) and it shows no pericardial effusion, but intraperitoneal fluid. Next best step?
Emergent laparotomy
(Do NOT do a CT scan- you don’t have that kind of time. They are bleeding internally in their abdomen area and you need to stop that bleeding with surgery ASAP)
Which bone tumor has a “soap-bubble” appearance?
Giant cell tumor
What is a cholesteatoma?
Mass of keratin debris in the middle ear—> conductive hearing loss
- Rinne: bone conduction> air conduction
- Weber: louder on affected side (bc the obstruction blocks out background noise)
Elderly patient has sensorineural hearing loss in left ear, feels off balance, loss of feeling on left face. Diagnosis?
**Sensorineural hearing loss=
Rinne: air conduction > bone conduction
Weber: louder on good ear side
Vestibular Schwannoma
-unilateral hearing loss with imbalance (CN 8 dysfunction) + decreased facial sensation (CN 7 dysfunction)
(“7 heaven and 8 gate” affects the cerebellarpontine angle and presses on CN 7 and 8)
Elderly woman has frequent urges for bowel movements and small-volume stools or mucus. When bearing down, a red mass with concentric rings protrudes through the anus and then retracts back. Diagnosis?
Rectal prolapse
- rectum protrudes through anal orifice
- it is associated with fecal incontinence, constipation, and/or mucus discharge
Risk factors for rectal prolapse?
How do we treat it?
Risk factors: vaginal delivery, pelvic surgery/ dysfunction, chronic constipation/ straining, and dementia or stroke
Treatment: high fiber diet, pelvic floor exercises, possibly surgical repair
Boy had an appendectomy 3 days ago. Now has jaundice, but LFTs and physical exam are normal. Most likely reason for his jaundice?
Gilbert syndrome
-decreased UGT conjugating activity in the liver during times of stress-> jaundice w/o symptoms
Does PE, atelectasis, and pleural effusion cause respiratory acidosis or alkalosis?
All cause respiratory alkalosis
Due to compensatory tachypnea (you start breathing rapidly to compensate for the thing causing you to be SOB)
How do you calculate A-a gradient? What number is normal?
A-a gradient= PAO2- PaO2 (oxygen in alveoli minus oxygen in the capillary…tells you how good the gas exchange is)
Normal A-a is <15
(Values increase with age, but >30 is a high A-a gradient no matter the age)
What is organomegaly?
Enlargement of organs
Woman has pain in LLQ. She hasn’t had a recent bowel movement, but is passing gas. She also has mild urinary urgency and positive leukocyte esterase but negative nitrites. Diagnosis?
Diverticulitis
Low fiber, high red meat diet, smoking—> parts of mucosa + go through muscularis propria of the bowel and protrude out—> outpouchings called diverticulosis—> they get inflamed—> diverticulitis
*bladder irritation can occur with diverticulitis due to the close proximity of the sigmoid colon
Is diverticulosis usually symptomatic?
No
Diverticulosis is usually asymptomatic, but 5-15% of patients develop diverticula bleeding or diverticulitis
Most common cause of lower extremity edema?
Venous valvular incompetence
Backflow of blood—> increased hydrostatic pressure—> fluid leakage out of capillaries into interstitial tissue
Patients with puncture wounds through the foot are at risk for osteomyelitis caused by what organsim?
Pseudomonas
Patient has abdominal pain and dissension. Has had watery diarrhea for several days, but no bowel movement since yesterday. Recently was hospitalized and treated for an ulcer. He has high WBC, fever, tachy, and X-ray shows dilation of the colon. Diagnosis?
C diff—> toxic megacolon (complication)
- recent antibiotics at the hospital for ulcer-> c diff w/ watery diarrhea
- symptoms of toxic megacolon: systemic toxicity (fever, low BP, tachy, lethargy), abdominal dissension and pain, leukocytosis, and large bowel dilation
- treatment: bowel rest, NG tube, aggressive c diff therapy (oral Vanco + Metronidazole)
Why do we hyperventilate patients (on a ventilator) with high ICP (intracranial pressure)?
Hyperventilation-> blow off more CO2-> less CO2 in blood (CO2= vasodilator of cerebral vasculature)-> cerebral vasoconstriction= dec cerebral blood flow= dec ICP
- key points:
(1) hyperventilate patients with ICP to reduce intracranial pressure
(2) decreased CO2 in blood= decreased cerebral blood flow= decreased ICP
Old man has lower abdominal pain, loss of appetite, and constipation. This morning, he had sudden, severe lower abdominal pain that gradually involved the whole abdomen and vomiting. He has a fever, decreased bowel sounds, grading, rebound tenderness. Diagnosis?
Diverticulitis-> diverticulum perforation
-common symptoms of diverticulitis: vague lower abdominal pain, anorexia, constipation
- all this + fever and peritonitis (guarding and rebound tenderness)= diverticular perforation
- free air can be seen on abdominal imaging (X-ray, CT)
How does diverticular perforation present?
You get the symptoms of diverticulitis (vague lower abdominal pain, anorexia, constipation) + fever and peritonitis (guarding, rebound tenderness)
*MORE SPECIFICALLY:
Moment of perforation—> sudden, severe pain (plus or minor vomiting, lightheadedness, or syncope)
After perforation to 2 hrs—> less pain as the inflamed organ decompresses
> 2 hrs after perforation—> generalized, constant pain due to peritonitis (plus or minus sepsis)
**free air can be seen on abdominal imaging (X-ray, CT) from the perforation
Patient presents with osteoarthritis in his knees. What is your first approach to treatment?
Recommend exercise (quadriceps strengthening exercises) *to take pressure off the joint and protect the articular cartilage from further stress
*if exercise/ weight loss fails to improve symptoms, then try NSAIDs. If that fails, then try corticosteroid injections (short-term relief). If all else fails, surgery (knee replacement).
What is Wells criteria used to predict?
The probability of PE
- If PE is likely (>4 points), do CTA (CT angiogram of pulmonary vessels) or V/Q scan if the patient has renal failure and can’t handle the contrast.
- If PE is unlikely (<4 points), you can do a D-dimer if you want to be sure you can rule it out (PE excluded if D-dimer <500)
50 year old guy is fatigued, lost 15 lb in the last month w/o dieting, and has tenderness in the epigastrium. He is a smoker. Fell and hit his head last month. Diagnosis?
Pancreatic adenocarcinoma
*don’t be distracted by falling on his head! Smoker w/ cancer symptoms and epigastric pain= pancreatic cancer
**other class symptoms of pancreatic cancer: painless jaundice (or epigastric abdominal pain worse at night) and migratory thrombophlebitis (Trousseau sign)
What imaging test can you do to diagnose pancreatic cancer?
If jaundice (suggesting pancreatic head tumor)—> ultrasound
If no jaundice (suggesting pancreatic body/ tail tumor)—> CT scan
Boy has fever, earache, sore throat that he can barley open. Right tonsil is enlarged and uvula deviated to the left. Rapid strep test is negative. Diagnosis?
Peritonsillar abscess
- Symptoms: fever + sore throat + earache
- Exam findings: trismus (jaw muscle spasms), muffled voice, enlarged tonsil w/ deviated uvula going the over direction
- Treatment: aspiration or incision and drainage + antibiotics (cover group A strep and respiratory anaerobes)
20 year old guy has had multiple joint dislocations, easy bruising, poor wound healing. He is normal height with no heart problems. Most likely diagnosis?
Ehlers-Danlos syndrome
Joint hyper mobility, multiple joint dislocations, poor wound healing, associated with mitral valve prolapse
In cervical spine trauma (patient fell and landed on neck), paralysis of what is your main concern?
The diaphragm
- the diaphragm is innervated by C3-C5 (“C3, C4, C5 keeps the diaphragm alive!”), so if injury occurs at these roots, patients may have immediate diaphragmatic paralysis
- if patient is injured below C5, a delayed diaphragmatic paralysis may occur due to ascending edema
*signs to look for: Hypercapnic respiratory failure and use of accessory muscles (intubate!)
Normal leukocyte (WBC) count?
4,500- 11,000 (4.5- 11k)
Elderly man has nausea, early satiety, unexplained weight loss, abdominal dissension, can’t eat solid food w/o vomiting. You hear a succussion splash listening to his stomach. K+ is low, bicarb is high, glucose is very high. Diagnosis?
PANCREATIC ADENOCARCINOMA
- early satiety, intractable N/V, weight loss-> gastric outlet obstruction (can be cancer- 80%, peptic ulcer dz, bezoar, gastric polyps, etc.). In this case, pancreatic cancer is invading the duodenum
- succussion splash= “splash” heard on abdominal auscultation when rocking the patient back and forth at the hips- suggests retained food in stomach
- new-onset diabetes in an old person suggests pancreatic cancer (the pancreas stops producing adequate insulin)
- K+ is low and bicarb high (metabolic alkalosis) due to vomiting (loss of H+, Cl-, K+ from the stomach-> alkalosis and hypOkalemia)
What is a gastric bezoar?
Solid mass of indigestible material (hair, foreign objects) that can cause blockage
*rare, most people will have an underlying motility disorder (gastroparesis) or prior gastric surgery
Most common cause of esophageal perforation?
Having an endoscopy done
If a tube is going down your esophagus, there is risk that the tube will perforate the esophagus if not done right
A patient had an upper GI endoscopy with biopsy for suspected esophageal cancer. 4 hours later, he has substernal pain radiating to the back, SOB, and a new pleural effusion. What is the diagnosis, how do we confirm the diagnosis, and how will we treat?
ESOPHAGEAL PERFORATION (due to the endoscopy with biopsy) —> chest/ back pain, systemic inflammatory response, and pleural effusion due to leaked esophageal contents
Confirm with ESOPHAGOGRAPHY WITH WATER-SOLUBLE CONTRAST- the best way to confirm esophageal perforation (can see the contrast escape the perf)
Treat with EMERGENT SURGERY (debridement and repair)
Man in ED has a COPD exacerbation. He is intubated on mechanical ventilation and a central venous catheter is placed in the right subclavian to give IV antibiotics. He keeps desaturating.
Now his BP is low, he is tachy. Breath sounds are decreased on the right, trachea is deviated left, neck veins distended. What do you do?
Needle thoracostomy
He had a tension pneumothorax (air in right pleural space-> dec right lung sounds and trachea is deviated left bc air from the outside pushes the trachea in the opposite direction)
-This is a complication of central line placement (from the right subclavian, you can knick the right lung)
What is normal calcium?
About 8.5-10
What’s normal glucose?
70-110 (fasting)
<120 (2 hrs postprandial/ after food)
*in the hospital, we’re okay with it being higher like to 180
Lady with central obesity and moon face, lupus on Prednisone, and T2DM on Metformin has an elective hysterectomy for uterine fibroids. Post-op she has nausea/ vomiting, diffuse abdominal pain, BP drops. BUN and Cr are high, glucose is low. Cause of her symptoms?
Adrenal insufficiency
She has Cushing’s features (central obesity and moon face) and is on chronic glucocorticoids (Prednisone for SLE)—> suppresses hypothalamus-pituitary-adrenal axis. These patients may not respond well to acute stressors (surgery) and need higher doses of glucocorticoids (cortisol) during these times.
*Normally adrenal glands make: G-> mineralcorticoids (aldosterone) F-> glucocorticoids (cortisol) R-> sex hormones (androgens) In adrenal gland insufficiency, they’re not working to make aldosterone + cortisol (*lack of aldosterone can-> hypOnatremia and Hyperkalemia). Treat with IV hydrocortisone or dexamethasone (give them back what they’re lacking) and fluid support.
What’s costovertebral angle tenderness?
CVA tenderness!
Lateral to vertebrae, below rib cage
Flank pain radiating to the groin + hematuria is classic for what?
Nephrolithiasis (kidney stone)/ ureteral stone
Patient has a ureteral stone <1 cm. What medication can you give to help with passage of the stone?
Tamsulosin, or similar alpha 1 antagonist
*Alpha-1 causes urinary sphincter contraction-> urinary retention
Block alpha-1-> urinary sphincter relaxation-> decreases ureteral pressure, facilitating stone passage
**drugs like Bethanacol (anticholinergic that treats urinary retention/ helps you pee) would not work bc the receptors are in the bladder, but not the ureters
**also give hydration and pain meds (analgesics)
Patient with hx of GERD on Ranitidine has been having trouble swallowing. His has bad breath, sometimes regurgitates food, and his voice is “gurgly.” Diagnosis?
Zenker diverticulum
Spasm/ poor relaxation of cricopharyngeal muscles during swallowing (usually in an old man)—> false diverticulum (outpouching of mucosa in esophageal wall)—> food gets stuck in the pouch—> bad breath, regurg of food, dysphasia, voice change
What does halitosis mean?
Bad breath
May be due to retained food in a Zenker diverticulum, for example
How do you diagnose and treat Zenker diverticulum?
Diagnose: swallow study
Treat: surgery (circiopharyngeus muscle is divided and diverticulum is either removed (diverticulectomy) or combined with the esophageal lumen (diverticulotomy))
What is hemobilia?
Bleeding in the biliary tree (blood mixes with bile)
*typically seen following abdominal surgery or trauma
Alcoholic guy with hx of chronic dyspepsia (indigestion) is vomiting blood. 3 days ago he got a upper GI endoscopy and abdominal U/S done. The endoscopy showed esophagitis and gastritis. The U/S showed liver enlargement and gallstones. He has AST of 100 and ALT of 50.
Why is he vomiting blood?
Mallory-Weiss tear
(Longitudinal mucosal tear at the GE junction)
*note: AST:ALT > 2:1 indicates alcoholic hepatitis
He keeps vomiting, so makes sense that this caused an esophageal tear-> bleeding
*NOT esophageal rupture (Boorhave), as this would present with air in mediastinum, chest pain, maybe pleural effusion
*NOT ruptured esophageal varices, as this would have shown up on the endoscopy 3 days ago
Mallory-Weiss tear vs. Boerhaave syndrome?
Mallory-Weiss: longitudinal tear at GE junction of esophagus due to sudden increase in intraabdominal pressure- severe vomiting/ rethcing (alcoholics, bulemics), abdominal trauma, or hiatal hernia
Can lead to…
Boerhaave syndrome: rupture of esophagus (can also be caused as a complication of endoscopy and will cause subcutaneous emphysema/ air under chest, maybe pleural effusion)
Old guy with mid-epigastric abdominal pain with N/V. Travels to China a lot, recently lost weight. Has hepatomegaly. Labs show microcytic anemia, low albumin, high alk phos, and high ALT > AST. Diagnosis?
Gastric cancer
- Chinese people have increased risk for GI cancer (salty MSG-filled food)
- The microcytic anemia= iron deficiency anemia (from GI bleed- tumor vessels ooze into gastric lumen)
- Hepatomegaly and high liver enzymes explained by Mets to liver
What is the one and only major modifiable risk factor that affects the severity and progression of Crohn disease?
Smoking
Man has severe, constant anal pain and low-grade fever. He has a history of constipation and anoreceptive sex. There’s a mass near the anal orifice. Diagnosis?
Perianal abscess
(Bacterial infection of anal crypt gland)
- Both constipation and anal sex are risk factors
- Treat with incision and drainage to avoid progression to a fistula
Football player got tackled. Immediately after, had abdominal discomfort and nausea. BP is 90/60, HR 120, RR 25. FAST exam reveals intraperitoneal free fluid.
What is probably going on?
Splenic laceration
*spleen= most commonly injured organ in blunt abdominal trauma
Besides high-fiber diet, stool softeners, Sitz baths, how can you medically manage anal fissures?
Topical Lidocaine (pain relief) and topical vasodilators like Nifedipine/ CCB or Nitroglycerin (decrease pressure in and increase blood flow to area to promote healing)
*If refractory (medical management fails), then do surgery (lateral sphincterotomy, fissure excision)
Best test for diagnosing acute diverticulitis (usually presents as LLQ pain + leukocytosis, fever)?
CT scan of the abdomen
Diagnostic test for IBD (Crohn’s and UC)?
Colonoscopy with biopsies
(Crohn’s would show transmural inflammation, cobblestone appearance, skip lesions. Ulcerative Colitis would show continuous ulcerations and pseudo polyps of the distal colon/ rectum)
What is fecal calprotectin?
A stool marker for inflammatory diarrhea
*can check it to confirm an IBD flare, for example
What diet do we recommend for irritable bowel syndrome (IBS) patients?
Low FODMAP diet (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, And Polyols)
*Basically- don’t eat too many simple sugars that are poorly absorbed in the small intestine
4 week old boy has pale stool for 1 week. His eyes are jaundiced and he has high total bilirubin. Hepatic ultrasound shows no gallbladder, but enlarged liver. Diagnosis?
Biliary atresia
(Fibrosis of extrahepatic bile ducts)
- Usually present at 2-8 weeks
- Total and DIRECT bilirubin will be high
- GGT (gamma-glutamyl transpeptidase) and alk phos will be high from bile duct destruction
- Reticulocyte count in normal, since there’s no hemolysis going on
**Although you may think hemolytic disease of the newborn, this would not explain the absent gallbladder and pale stools
What is a barium enema?
X-ray of the colon with contrast dye
*can use it for diagnosis of diverticulosis (not diverticulitis bc the dye can further irritate the inflamed colon!), etc.
Guy has duodenal and jejunal ulcers, revealed on GI endoscopy. He presents with burning epigastric pain and watery diarrhea that floats. Occult blood and stool fat is positive. Diagnosis?
ZE (Zollinger-Ellison) syndrome= gastrin-secreting tumor in pancreas or duodenum —> excess release of stomach acid—> multiple ulcers + inactivation of pancreatic enzymes (bc normally the basic environment of the duodenum activates them)—> malabsorption and diarrhea
Guy had an episode of pancreatitis 5 weeks ago. Now he comes in with abdominal dissension and nausea/ vomiting. CT shows a round, well-circumscribed thing. Diagnosis and treatment?
Pancreatic pseudocyst (encapsulated area of fluid/ tissue/ debris that causes an inflammatory response)
Endoscopic drainage (you do this only for patients with bad symptoms from it)
How do you treat patients with asymptomatic gallstones?
You don’t!
*Only 20% of patients with gallstones get symptoms
Initial treatment for hemorrhoids?
Recommend a high-fiber diet (30 grams of fiber/ day), hydration, reduction in fat and alcohol intake, regular exercise
Can also give stool softeners (*remember that chronic constipation/ straining is why you get bleeding hemorrhoids in the first place)
50 y.o. foreigner guy with fatigue and back pain. Albumin is low, ALT is high, alk phos and alpha-fetoprotein (AFP) are crazy high. Spine imaging shows multiple blastic + lytic lesions in vertebrae. Diagnosis?
Hepatocellular carcinoma (HCC) that metastasized to the spine
*High AFP means HCC or testicular cancer (HCC more likely due to the fact that he’s from another country where hep B and C are more prominent and has high liver enzymes too)
Old lady with hx of heartburn and smoking has epigastric abdominal pain that is constant, worse with eating. Upper GI endoscopy shows esophagitis. Abdominal U/S shows gallstones but no wall thickening or ductal dilation, can’t see pancreas well due to gas. What test do you order next?
CT of the abdomen
(you need to see that pancreas—she may have pancreatic cancer!)
- smoking + epigastric pain in an old person—> be suspicious of pancreatic cancer. CT is the 1st line test to check for it.
- she has normal labs and no dilation of the bile ducts, so not likely to be a gallbladder pathology.
Lady comes in with bloating and diarrhea. She had a gastric bypass surgery 2 years ago. Most likely diagnosis?
SIBO (small intestinal bacterial overgrowth)
- common complication of gastric bypass surgery—the blind loop of intestine can allow for excessive bacterial growth (conditions that alter intestinal motility like DM can also cause this)
- often causes nutritional deficiencies, including vit B12-> macrocytic anemia
Guy presents with unintentional weight loss. Fecal occult blood testing is positive. He has hepatomegaly and U/S shows a liver lesion. Labs show microcytic anemia, high total bili, and high alk phos. What’s going on?
Colon cancer that metastasized to the liver
Middle aged woman is having intermittent RUQ and epigastric abdominal pain radiating to the back associated with N/V. Labs are normal. Next best step?
Get an abdominal Ultrasound
- This sounds like biliary colic and a RUQ U/S is the first test for gallstones (cholecystitis)!
- Would show gallbladder wall thickening, edema, pericholecystic fluid aka fluid around the gallbladder
Patient with CAD has sudden-onset severe epigastric pain associated with N/V. Got an ultrasound 2 weeks ago which showed gallstones. Has fever and guarding. CXR shows free air under the diaphragm. Most likely diagnosis?
Perforated peptic ulcer
- CAD means the patient is prob taking Aspirin, which blocks GI protective prostaglandins-> inc risk for peptic ulcer dz
- air under the diaphragm (pneumoperitoneum) is concerning for perforated viscus (a perfed organ- in this case, due to full-thickness erosion of an ulcer through the stomach or duodenal wall)
- a perforated gut-> peritonitis (tenderness w/ guarding), risk of sepsis! Surgery is indicated immediately
What is acute cholecystitis?
Inflammation and distention of the gallbladder due to a gallstone obstructing the cystic duct
*typical symptoms: RUQ pain, fever, leukocytosis (high WBC count)
When do you need to do a HIDA scan for gallstone work-up?
When a RUQ ultrasound is inconclusive
How do you treat patients with acute cholecystitis (gallstone in cystic duct-> RUQ pain, fever, high WBC count)?
Laparoscopic cholecystectomy within 72 hrs
A patient has acute cholecystitis (gallstone lodged in cystic duct-> RUQ pain + fever + high WBCs). Has been taking fenofibrate for hypertriglyceridemia.
Should you do surgery and take out the gallbladder, or discontinue the fibrate and see how it goes?
Do surgery to take out the gallbladder (cholecystectomy within 72 hrs)
*although fibrates can contribute to the formation of gallstones, having symptomatic gallstones is indication for surgery
Man with Crohn’s disease presents with RLQ-> diffuse abdominal pain associated with nausea and bilious vomiting. Abdomen is distended. He is passing gas, but has not had a bowel movement in 2 days. Most likely diagnosis?
Small bowel obstruction (SBO) due to fibrotic intestinal stricture
*strictures are a complication of Crohn’s disease (severe inflammation)
(Stricture= abnormal narrowing of intestine)
Guy has nausea, vomiting, early satiety. 3 weeks ago he drank acid in a suicide attempt. There is succession splash on the epigastrium. Diagnosis?
Pyloric stricture (gastric outlet obstruction)
*succession splash= sloshing sound on auscultation that means there’s retained gas/ fluid in the stomach
What does anasarca mean?
Generalized swelling
Abdominal dissension and shifting dullness means what?
Ascites
Bloody ascites can be due to what 2 causes?
- Trauma from a paracentesis (needle drainage of ascites fluid, this bleeding resolves on its own)
- Underlying malignancy (like hepatocellular carcinoma- tumor growth disrupts nearby blood vessels)
**if cancer is a concern, do abdominal imaging, measure AFP (revised in HCC), and cytologic analysis of the ascitic fluid
Guy has a CABG (coronary artery bypass graft). 3 days later has worsening retrosternal pain. He has a fever, tachycardia, tachypnea.
EKG: a-fib with RVR
CXR: widened mediastinum
Echo: pericardial fluid
Labs: low Hb, high WBC’s and platelets, high Cr, high CPK.
What’s going on?
Acute mediastinitis
- complication from cardiac surgery due to intraoperative wound contamination
- presents with fever + chest pain + leukocytosis + mediastinal widening on CXR
- treat with drainage, surgical debridement, and prolonged antibiotic therapy (*despite treatment, there’s a 10-15% death rate with this complication)
Lady had a gastric bypass surgery 5 years ago and only takes zinc, no other vitamins. She’s having lower extremity weakness and numbness, gait ataxia, loss of vibration/ position sense, hair loss, hypochromic microcytic anemia. Deficiency?
Copper deficiency
- occurs in patients with gastric bypass, chronic malabsorption, or zinc excess (competes with copper for absorption in the GI tract)
- symptoms are similar to vitamin B12 deficiency + hypochromic microcytic anemia, hair loss, skin depigmentation, hepatosplenomegaly, edema, and osteoporosis
- diagnose w/ low serum copper and ceruloplasmin (copper-carrying enzyme)
- treat with copper supplements and discontinuation of zinc
Patient has left-sided facial numbness for 1 month. Also has been having headaches, nasal congestion, left ear fullness. He has fluid behind tympanic membrane, soft-tissue mass in the nasopharynx, and palpable cervical lymph nodes. Diagnosis?
Nasopharyngeal carcinoma
- tumor associated with EBV, in China
- tumor obstructs nasopharynx—> nasal congestion/ nosebleeds, headache, facial numbness (invades para-cavernous sinus), and/or ear infection (invades Eustachian tube), spreads to cervical lymph nodes
Patient had a severe trauma requiring surgery. 2 days later he has decreased urine output and oozing from his venipuncture sites. What’s going on?
DIC (disseminated Intravascular coagulation)
- Seen after severe trauma, sepsis, malignancy, Ob/gyn complications (due to exposure of tissue factor and release of procoagulant proteins/ phospholipids)
- *Would have prolonged PT and PTT, thrombocytopenia (low platelets since they’re used up)
- Inappropriate activation of the coagulation cascade (coag factors and platelets get used up where they shouldn’t be, so bleeding happens from IV sites and mucosal surfaces)
- Organ failure may also be seen (ex: bleeding out so lack of blood to kidneys-> reduced urine output despite fluids given)
Man with history of retinoblastoma has left knee pain and swelling. X-ray shows lytic lesion of the femur surrounded by concentric layers of reactive bone. Diagnosis?
Osteosarcoma
- Retinoblastoma is associated with osteosarcoma
- Concentric layers of reactive bone= sunburst pattern
- lifting of periosteum (outer layer of bone)
What is adhesive capsulitis?
“Frozen shoulder”
-fibrosis and contracture of the glenohumeral joint capsule-> decreased passive range of motion
Woman has epigastric pain radiating to the back with N/V. Alk phos, ALT, AST, amylase, lipase are all elevated.
You do an U/S, which shows gallstones (no wall thickening). You give pain meds, IV fluids, make her NPO. Enzymes down-trend.
Next step?
Cholecystectomy
(take the gallbladder out now that she’s stable to prevent another episode of gallbladder pancreatitis)
*would do ERCP to relieve the obstruction if the patient had cholangitis, CBD obstruction/ dilation, or increasing LFT’s
ALT> 150 is suggestive of what pathology?
Gallstone pancreatitis
*some studies have shown this has a 95% positive predictive value for predicting gallstone pancreatitis (also expect elevated LFTs, alk phos, and lipase)
When is a HIDA scan indicated?
When UltraSound is inconclusive (need this extra test to determine if there’s cholecystitis)
Marathon runner comes in for right knee pain. It is sharp on the lateral side of the knee. She has full range of motion, but an area of tenderness 2cm proximal to the right lateral joint line. Diagnosis?
IT (iliotibial) band syndrome
- overuse injury-> poorly localized lateral knee pain, esp with flexion of the knee
- NOT lateral meniscus injury- this is caused by acute trauma rather than overuse-> catching, popping, or locking of the knee with movement
How does celiac disease increase risk for bone fracture?
Celiac disease—> malabsorption of fat-soluble vitamins (A, K, E, and D)—> low vitamin D= low calcium—> secondary hyperparathyroidism (PTH will rise to try to compensate and raise calcium levels)—> more breakdown of bone
Is hyper- or hypothyroidism a risk factor for osteoporosis?
Hyperthyroidism
Everything is sped up so there is increased bone turnover
Which kidney stones are high pH, which are low pH?
HIGH pH: calcium or ammonium magnesium phosphate (struvite)
LOW pH: uric acid or cysteine
Patient who fell and got cut on thigh 2 days ago comes in due to severe pain in that thigh and leg. He has a fever, BP of 80/60 (improves w/ fluids), and HR of 105. He has swelling, tenderness to palpation, and CT shows air in the deep tissue. Diagnosis?
Necrotizing fasciitis
- presents with pain out of proportion, signs of tissue necrosis (crepitus, purulent/ pus drainage, or CT showing gas in deep tissues), and systemic signs (hypotension)
- most commonly from group A strep
- requires antibiotics + surgical debridement
Best IV fluid to give burn victims?
Lactated Ringers
Isotonic balanced solution, meaning it contains near-physiologic levels of chloride, potassium, and calcium
The testes should descend by what age (if not, do orchiopexy which is surgery to bring the testes down into the scrotum)?
6 months
*orchiopexy is indicated after this point to reduce complications associated with cryptorchidism (undescended testicles) such as testicular torsion, infertility, and testicular malignancy
Patient fell on outstretched hand. Since then has had wrist pain (worse w/ radial deviation) and swelling at the dorsum of the wrist. X-ray shows no fracture. Next step?
CT or MRI to confirm fracture OR Repeat X-ray in 7-10 days
*X-ray at the time of injury has a low specificity for scaphoid fracture. Repeat the X-ray so the inflammation shows up (cost effective) or do MRI (faster, may allow for earlier return to normal activity)
Is aspiration more likely to occur in the right or left lung lobe?
Right lobe (right bronchus is more vertical than the left, so aspiration is more likely down this tube)
*if sitting/ standing, will go to right lower lobe. If laying down, will go to posterior right upper or lower lobe (depends on gravity).
60 year old lady presents with a mildly itchy lesion on her forearm that she noticed 4 mo ago. It is smooth with an eccentric nodule. She has a bunch of freckles in the area. Next step?
Excisional biopsy
*A mole is suspicious for melanoma if it appears different from other (“ugly duckling sign”), itches or bleeds, or develops nodularity. (Does not have to meet at least one of the ABCDE criteria: Asymmetry, Border irregularity, Color variation, Diameter >6mm, or Evolving)
What type of biopsy should you do if you are concerned about melanoma?
If lesion is small or suspicion for melanoma is high—> Wide excisional biopsy
If lesion is large or suspicion for melanoma is low—> Punch biopsy
**never do a shave biopsy for suspected melanoma—checking for depth of invasion is important!
30 year old lady has a femur fracture repaired with surgery. While recovering, she becomes agitated with tremor. Has fever, HTN, tachycardia, tachypnea. Labs significant for high BUN, Cr, and creatinine kinase. Diagnosis and treatment?
Thyroid storm
Treatment:
- Beta-blockers like Propanolol (block sympathetic effects and conversion of T4-> active T3)
- PTU (block TH synthesis and conversion of T4-> active T3)
- Glucocorticoids (block conversion of T4-> active T3)
- life-threatening thyrotoxicosis triggered by surgery (or trauma, childbirth, infection, etc.)
- symptoms: tachy, arrhythmias, HTN, high fever, tremor, altered mental status
*high CK, BUN, Cr possibly due to rhabdo (which would cause intrinsic AKI from myoglobinuria) (not sure?)
Thin patient is losing weight and vomiting. Upper GI endoscopy with biopsy confirms gastric adenocarcinoma and he undergoes gastrojejunostomy. Post-operatively he tolerates tube feeding but get weaker and has episodes of V-tach. Phosphorus and potassium levels are low (down-trended).
Cause of worsening condition?
Refeeding syndrome
- this occurs when chronically malnourished people (anorexia nervosa, malignancy) are reintroduced to nutrients
- > glucose spike-> HUGE increase in insulin (body wants to store up all it can since it’s so deprived of calories)-> electrolyte imbalances (low phosphorus, low K+, low Mg)-> cardiac arrhythmias, rhabdo, seizures, death
Is it okay to give a fluoroquinolone to a patient with a history of AAA (ascending aortic aneurysm)?
NO
Fluoroquinolones increase collagen degradation-> aortic aneurysm rupture (also: Achilles’ tendon rupture and retinal detachment)
- avoid in patients with known aortic aneurysm or with risk factors (Marfans, Ehlers-Danlos, advanced atherosclerotic disease, uncontrolled HTN)
- *QT prolongation is another adverse affect
Treatment for ulcerative colitis (UC)?
5-aminosalicylic acid medications (5-ASA) (such as mesalamine, sulfasalazine, and balsalazide)
*Mesealamine enemas (suppositories that you push up the rectum) are preferred in patients with UC confided to the rectosigmoid. For more extensive dz, oral 5-ASA meds are recommended.
Man was stabbed in the chest. Breath sounds are absent on the right side and neck veins are distended. Next step?
Needle thoracostomy (make a small incision in chest wall for drainage, can place chest tube)
This is a tension pneumothorax
Air from injured lung comes into pleural space-> high intrathoracic pressure-> compresses vena cava-> backs up blood so that neck veins are distended but there’s less cardiac return
-there is also a mediastinal shift (trachea pushed away)
**do NOT do emergent thoracotomy (completely opening up chest)—this is a last resort to resuscitate a trauma or cardiac arrest patient
What is a buckle fracture?
An incomplete fracture involving only one side of the bone
15 year old hits his left chest hard against a coffee table. He has chest pain, worse with deep inspiration and feels lightheaded. BP is 85/50, HR 120, RR 28, jugular venous veins are flat. Breath sounds are diminished on the right. What structure was injured?
Most likely fractured ribs w/ intercostal vessel injury-> hemothorax (bleeding into pleural space)
*always think of intrathoracic hemorrhage when you have blunt chest trauma + hypovolemic shock! (His vitals show low BP, tachy, and he also has flat neck veins due to bleeding out)
Old man with history of renal transplant presents with rough, keratinized skin lesion. What skin cancer is this most likely to be?
Squamous cell carcinoma (SCC)
*remember that this is keratinized and ugly and is seen more often in people on chronic immunosuppressive therapy!
A man who previously used chewing tobacco has a white plaque on his tongue. It was biopsied before and was ok. Now it is thicker. Next step?
Biopsy it
-Evolving leukoplakia in the oral cavity requires biopsy (even if done before). Tobacco= no 1 risk factor for oral squamous cell carcinoma.
Lady has pain, itching, and red streaks on her arm. She also has tender palpable cord-like veins on the arm and upper chest. ROS is positive for heartburn and mild upper abdominal pain. Next step?
Get a CT of the abdomen
- This is describing migratory superficial thrombophlebitis aka Trousseau syndrome (superficial venous thrombosis at unusual sites like the arm and chest)
- Associated with PANCREATIC CA
Former alcoholic guy has foul-smelling stools that float, lost weight, multiple hospitalizations for epigastric pain radiating to the back with nausea/ vomiting. Lately, he’s having similar pain episodes after meals. Diagnosis? Treatment?
Chronic pancreatitis
Pancreatic enzyme supplementation
- pancreas is damaged (from recurrent pancreatitis and fibrosis)-> cannot make pancreatic enzymes to help digest-> malabsorption of fat-> steatorrhea (stools that float)
- postprandial (after eating) epigastric pain can become continuous
- give them the pancreatic enzymes they are missing to improve symptoms
Patient just underwent CABG (coronary artery bypass grafting). Now has a pleural effusion. What do you do?
Clinical observation only
(As long as it’s small to moderately sized, post-op day 1 or 2, and not associated with respiratory symptoms)
*About half of CABG patients develop a pleural effusion after (usually on the left). This is the body’s reaction to cutting into the pleura and disrupting lymphatic channels and such.
Guy with PMH of ulcerative colitis presents with RUQ pain, weight loss, jaundice, dark urine. AST, ALT, alk phos, and total bili are all really high. CT abdomen shows dilated intrahepatic ducts, normal common bile duct. CEA and CA 19-9 are high, AFP normal. Diagnosis?
Cholangiocarcinoma (cancer of the bile ducts)
- Remember that ulcerative colitis is associated with primary sclerosing cholangitis (inflammation/ fibrosis of intra and extrahepatic bile ducts), which increases risk for cholangiocarcinoma
- Presents with signs of biliary obstruction (RUQ pain, jaundice, dark urine) and weight loss is a sign of cancer
- bile duct obstruction (in this case from tumor)-> no bile going into duodenum and out into feces, more into blood and eventually to urine-> pale stools, dark urine
What is carcinoembryonic antigen?
CEA (tumor marker)
What is primary sclerosing cholangitis? What is it associated with? What does it increase risk for?
Inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts (*vs. primary biliary cholangitis, which is autoimmune destruction of the intraheptic bile ducts)
Associated with ulcerative colitis (UC) (90%)!
Having this means you’re at increased risk for cholangiocarcinoma (cancer of bile ducts)
When do you consult urology over a ureter stone (for evaluation of possible nephrostomy tube to drain backed up urine or ureteral stent placement)?
If there are signs of Urosepsis (fever, chills, tachy), AKI, complete obstruction
OR
Stone >10 mm
What medication can be used to facilitate passage of medium sized ureteral stones (6-10 mm)?
Alpha blockers (Tamsulosin)
*remember alpha-1 causes urinary retention and contracts the ureters. Block alpha-> dilate/ open up the ureters for easier passage of the stone
60 year old guy with PMH of HTN, IBS, and 30 pack-year smoking history comes into the ED with acute onset severe abdominal pain. He’s pale and drowsy. BP is 85/65, HR is 115. Abdomen is diffusely tender and has flank ecchymoses. Next step?
Abdominal ultrasound
- this sounds like AAA (abdominal aortic aneurysm)
- symptoms: severe abdominal/flank/groin pain, pulsatile mass, flank ecchymoses, limb ischemia
- you would get a CT abdomen instead of U/S if he were hemodynamically stable and you had time
1 year old boy has sudden-onset respiratory distress and wheezing while playing with his cousin. He has crackles and hyperresonance to percussion over the right lung. CXR shows right lung hyperexpansion with a left mediastinal shift. Likely diagnosis?
Foreign body aspiration
- use history! He’s a 1 year old playing legos
- aspiration occurs in right lung (right bronchus is more vertical, easier for stuff to go down)
- wheezing and decreased breath sounds on affected side are characteristic
- hyperresonance and hyperexpansion indicate air trapping (he can’t breathe well due to that lego prob causing some atelectasis/ collapsing some alveoli)
Boy is brought into the ED after a car accident. Has bruising and severe pain over the right chest. BP normal, HR tachy, RR 25. Requiring oxygen. Breath sounds decreased on right side. CXR shows patchy, irregular alveolar infiltrates on the right middle and lower lobes. Diagnosis?
Pulmonary contusion (Bruise on the lung due to chest trauma—since capillaries are damaged, blood and fluid accumulates in lung tissue and interferes with gas exchange, potentially leading to hypoxia)
*Tachycardia and high RR can be explained by pain and shallow breathing
**often associated with rib fractures (though kids have more elastic chest walls so they won’t always fracture ribs)
55 year old smoker presents with gross hematuria. He reports seeing blood clots in his urine at the end of the urinary stream. Denies fever, flank pain, weight loss. Most likely diagnosis?
Bladder disease (bladder cancer)
- painless hematuria (due to cancer blood vessel formation)
- you get total hematuria (blood during entire urinary stream) or terminal hematuria (blood just at end of urinary stream—if cancer is at neck/ bottom part of bladder)
- risk factors: smoking, male, >40
- *he doesn’t have weight loss, but that’s prob just bc we’re catching it early—get a cystoscopy for diagnosis!
What is cystoscopy?
Endoscopy of the bladder via the urethra
*use this to aid in diagnosis of bladder cancer, for example
“Peripancreatic fluid collection” refers to what?
Pancreatic pseudocyst (encapsulated fluid collection of the pancreas, a complication of pancreatitis)
A teardrop shaped pupil is suggestive of what?
A globe (eyeball) laceration/ perforation
Lady had an appendectomy 10 days ago, now presents with RUQ abdominal pain, fever, and SOB. Leukocytosis. Right lung sounds are decreased and CXR shows right pleural effusion. Most likely cause of all this?
Intra-abdominal abscess (specifically right subphrenic abscess—below the diaphragm in the region of the liver)
*Remember causes of post-op fever! “Wind, water, walking, wound”
Post-op day 1–> atelectasis
Post-op day 2-> pneumonia
Post-op day 3-> UTI
Post-op day 5-> DVT
Post-op day 7-> wound infection
Post-op day 10-15-> deep abscess (subphrenic, pelvic, subhepatic, etc.)
**intra-abdominal abscesses are often associated with pleural effusion
What are the causes of post-op fever? Name them all and their timeline!
“Wind, water, walking, wound” Post-op day 1–> atelectasis Post-op day 2-> pneumonia Post-op day 3-> UTI Post-op day 5-> DVT Post-op day 7-> wound infection Post-op day 10-15-> deep abscess (subphrenic, pelvic, subhepatic, etc.)
*”wonder drugs”= malignant hyperthermia (from halothane or succinylcholine) DURING surgery
What are the causes of post-op fever? Name them all and their timeline!
“Wind, water, walking, wound” Post-op day 1–> atelectasis Post-op day 2-> pneumonia Post-op day 3-> UTI Post-op day 5-> DVT Post-op day 7-> wound infection Post-op day 10-15-> deep abscess (subphrenic, pelvic, subhepatic, etc.)
*”wonder drugs”= malignant hyperthermia (from halothane or succinylcholine) DURING surgery
Lady has a CABG (coronary artery bypass grafting). 2 days later presents with patches on her abdomen. They were red but progressed to large purple/ black patches with surrounding erythema. Most likely cause?
Heparin-induced thrombocytopenia (HIT)
- You can assume heparin was given since she underwent CABG
- This is describing skin necrosis at the abdominal site where the patient is getting subcutaneous injections of heparin
*HIT= bad reaction to heparin where it binds platelet factor 4 (hep-PF4) and antibodies are made against this complex. The antibodies destroy platelets (thrombocytopenia) and stick platelets together (clotting in the setting of anticoagulation).
18 year old with recent nasal packing presents with vomiting, diarrhea, dizziness. Temp 102, BP 90/60 laying, 65/45 standing, HR 120, RR 23. She has erythematous macules on her trunk and extremities and inc neutrophils. Diagnosis?
Toxic shock syndrome (due to nasal packing)
- Staph a.-> toxic shock syndrome toxin-1 release (superantigen)-> T-cell activation and massive cytokine release-> widespread vasodilation-> hypotension (tachy in attempt to compensate)
- Other symptoms: sunburn rash, vomiting, diarrhea, inc neutrophils
What kind of rash do you get in meningococcemia?
Petechial rash
Patient has a right internal jugular catheter placed during surgery. After the catheter is removed post-operatively, he gets rapid-onset SOB. He’s in respiratory distress and jugular veins are distended. What happened?
Venous air embolism (VAE)
- Veins are susceptible to VAE due to their relatively low hydrostatic pressure (more collapsible). The VAE travels to the RV or further to the pulm arterioles, where it can cause obstructive shock and cardiac arrest.
- think of this in a patient with sudden-onset respiratory distress after removal of a central venous catheter
Old man with PMH of esophageal achalasia (has dysphasia and self-induces vomiting to relieve choking) presents with fever, back pain, and chest pain. CXR shows left pleural effusion. Diagnosis?
Esophageal perforation (Boerhaave syndrome)
- chest/back pain, fever, pleural effusion (from esophageal contents leaking into pleural space) in the setting of self-induced vomiting points to esophageal perf
- emergent surgery!
Lady is seen 3 days after surgery. Has abdominal distention, has not passed gas, decreased bowel sounds. X-ray shows uniformly dilated bowel loops. Diagnosis?
Post-op ileus (bowel paralysis)
*vs SBO- X-ray would show transition point (the obstruction) and dilated small bowel proximal/ leading up to that point
35 year old guy with PMH of sarcoidosis (on glucocorticoids) has progressive right hip and groin pain worse with weight bearing, aBduction, and internal rotation. On exam, he has a round face and fullness in the supraclavicular area (neck, above the clavicles). X-ray is normal. Most likely cause of hip pain?
Avascular necrosis aka osteonecrosis (disruption of bone vasculature)
- this is a complication of long-term glucocorticoid use
- > progressive hip pain, reduced range of motion, joint instability
*X-ray is normal in the first few months—MRI is more sensitive
**his moon face and buffalo hump neck are signs of Cushing’s, which support chronic glucocorticoid use
Patient with Crohn’s disease s/p small bowel resection (on TPN) presents with RUQ pain. U/S shows gallstones. Most likely cause of the gallstones?
Gallbladder stasis
Normal person: eat food-> CCK release-> gallbladder contraction
Person on TPN (total parenteral nutrition): IV nutrients-> directly delivered to bloodstream and does not go down GI tract, so no CCK release or gallbladder contraction-> promotes formation of bile sludge and gallstones
Patient presents with colicky RUQ pain, vomiting, melena for 1 day. Had a liver biopsy a week ago and diagnosed with nonalcoholic steatohepatitis (fatty liver). Labs show low Hb, high platelets, high WBCs, high total bili. Diagnosis?
Hemobilia (bleeding into the biliary tract)
- complication of recent liver biopsy
- this upper GI bleed explains the melena, low Hb, reactive thrombocytosis
- leukocytosis due to inflammation
- high total bili due to bile duct obstruction (blood is obstructing the bile ducts, so bile backs up rather than being emptied into the GI tract)
*note: liver abscess can occur after a liver biopsy and present with RUQ pain, leukocytosis, hyperbili if compressing biliary tree—but would NOT have upper GI bleed and would have fever too
College student presents with severe retrosternal and upper abdominal pain. He recently was drinking alcohol and vomited several times. He has a fever, hypotension, tachycardia. On exam, he has palpable crepitus in the suprasternal notch, heart RRR, lungs CTAB. Diagnosis?
Esophageal perforation (Boerhaave syndrome)
- the leaked GI contents cause a systemic inflammatory response (fever, tachy) that can quickly progress to septic shock and death
- confirm diagnosis with esophagography (barium swallow test) or CT scan w/ water-soluble contrast
- give IV antibiotics and PPIs (acid would further irritate) and get an emergency surgical consult for debridement and repair!
**vs Mallory-Weiss partial-thickness esophageal tear (assoc w/ hematemesis, do upper GI endoscopy to confirm, give PPI/ acid suppression, and most heal on their own)
Guy gets into car crash and has surgery for repair of a complicated tibial fracture. A day later, has more pain in his leg despite morphine. Pain is worse w/ passive movement and also has a “pins and needle” sensation and sensory loss between the big and second toe. Pulses intact. Next step?
Go to OR for fasciotomy (fascia is cut to relieve pressure and restore circulation)
This is compartment syndrome!
- caused by trauma, prolonged compression of an extremity, or after revascularization of an ischemic limb (inc pressure in compartment of leg-> impaired perfusion-> severe pain, necrosis of muscle cells, nerve injury)
- presents with excruciating pain worse w/ passive movement
- paresthesia from sensory nerve ischemia and intact pulses are early findings (though there’s variability in associated signs/ symptoms)
How is DVT diagnosed?
Doppler ultrasonography
35 year old lady presents with sudden abdominal pain (RLQ-> now diffuse) and shoulder pain. Recently hospitalized for DVT (on Warfarin). Last menstrual period 3 wks ago. BP is 80/40, HR 120. On exam, abdomen is rigid w/ guarding. Labs significant for low Hct. Diagnosis?
Ruptured ovarian cyst
-on Warfarin-> hemoperitoneum (internal bleeding in abdomen) from ruptured ovarian cyst-> hemodynamic instability (BP is low w/ tachy) and low hematocrit
- NOT ovarian torsion bc that presents with sudden lower abdominal pain but not an acute abdomen on exam + drop in Hct
- NOT ruptured ectopic pregnancy (last period 3 wks ago, so unlikely)
Which quadrant usually hurts in diverticulitis?
LLQ
What are the 3 indications for bariatric surgery?
- BMI >40
- BMI >35 with comorbidity (T2DM, HTN, OSA, etc.)
- BMI >30 with resistant T2DM or metabolic syndrome
- Check that they’ve already tried weight loss by diet and exercise, check psych history and readiness to change, and review cardiac and pulm risk factors for surgery
- *Patient does not have to try weight-loss meds first, though that is an option
55 year old man presents with abdominal discomfort and distention since this morning. Yesterday he drank heavily, fell and hit his abdomen. He cannot pee. Has positive fluid wave on exam. WBCs, BUN, and Cr are elevated (liver studies normal). Diagnosis?
Bladder rupture
- abdominal trauma (hit abdomen after drinking and prob had a full bladder)-> intraperitoneal bladder rupture-> urine leaks into peritoneal cavity-> abdominal distention and ascites (inc BUN and Cr from peritoneal reabsorption)
- peritonitis (guarding + rebound tenderness) doesn’t always happen bc urine is sterile (and he’s got alcohol in his system masking pain)
- this is NOT a cirrhosis picture (it’s too acute + liver studies were normal + that wouldn’t explain his inability to pee)
Guy with stab wound has successful surgical repair of small intestinal lacerations. As he’s being transferred to recovery unit, BP is 160/90, HR 130, RR 9. One hour later BP drops to 110/60, HR drops to 70, RR drops to 7. ABG shows low pH, high CO2, low O2. Explanation?
Delayed emergence (return to consciousness) from anesthesia (>15 min) -due to drug effect, metabolic disorder, or neurologic disorder (often multifactorial)
*ABG shows hypoxic respiratory failure due to hypOventilation (low pH, high CO2, low O2). This along with bradycardia (low HR) and bradypnea (low RR) suggest prolonged medication effect
70 year old man with PMH of HF (on diuretics) had watery diarrhea after eating at McDonalds. It got better until yesterday, when his bowel movements stopped. He has abdominal discomfort and distention. Abdominal CT shows colonic dilation with non-dilated small bowel. WBC count normal, C diff testing negative. Diagnosis?
Ogilvie syndrome
“Paralytic ileus of the colon”
-recent diarrhea (from foodborne gastroenteritis)+ diuretics-> electrolyte imbalance (hypokalemia)-> colon ileus (since K+ is needed to move the gut)
- treat w/ bowel rest (NPO) and rectal tube to decompress/ drain out feces so they don’t back up and lead to perf
- *can also give Neostigmine if ready to perf (cecal diameter >12cm) (AChE inhibitor-> more AChe= more PNS rest and DIGEST so helps get the poop out)
How do you treat Basal Cell Carcinoma (BCC) on the face?
Mohs microsurgery
*if not on the face (not a cosmetically sensitive area), can do electrodessication and curettage or generic surgical excision
What is the management for ureteral stones based on size? When do you consult urology?
Medical management: oral hydration, pain control, tell patient to strain their urine
<5mm-> pass spontaneously
6-10mm-> alpha-blockers can help them pass
>10mm-> consult urology
Also consult urology if patient has refractory pain, anuria (can’t pee), AKI, or signs of urosepsis
Diabetic has a foot ulcer. You can palpate the bone with a probe. Next step?
Bone biopsy
When the ulcer is so deep you can feel the bone the risk of osteomyelitis is much greater!
Patient has COPD exacerbation and is treated with inhaled bronchodilators, systemic glucocorticoids, empiric antibiotics, and intubation w/ mechanical ventilation. 1 hr later he has hypoxemia w/ elevated peak and plateau pressures. Breath sounds decreased on the right. Diagnosis?
Pneumothorax
Mechanical ventilation (positive pressure ventilation)-> pulmonary barotrauma-> alveolar rupture-> pneumothorax (air in pleural space) *this is a complication of mechanical ventilation and COPD’ers are at higher risk due to already having hyperinflation/ air trapping and blebs that can rupture
-rapid-onset hypoxemia, dec breath sounds on affected side, inc peak pressure (more resistance to air flow from the ventilator), and inc plateau pressure (dec compliance/ ability to expand)
**don’t confuse alveolar rupture-> pneumothorax with alveolar collapse-> atelectasis.
Treatment for pneumothorax?
Chest tube
Allow the air to escape from the pleural space and the lungs to re-expand
Woman gets into a car crash and has multiple rib fractures and liver laceration. She undergoes surgery and has blood transfusions. Postoperatively she develops hypOcalcemia (numbness, tingling around lips, Trousseau sign w/ the BP cuff). Why?
Her hypocalcemia is due to the blood transfusions (given that she had liver lacerations)
- there is citrate in transfused blood that binds up calcium
- normal liver: this does NOT cause hypocalcemia bc the liver rapidly metabolizes/ breaks down the citrate
- bad liver: this can cause hypOcalcemia bc the liver isn’t breaking down citrate as well-> more citrate remains to bind up that calcium-> dec levels in the blood
In general, how do you manage uncomplicated vs complicated diverticulitis?
Uncomplicated diverticulitis- bowel rest, oral antibiotics, observation
(IV antibiotics if old, immunosuppressed, bad leukocytosis, comorbidities)
Complicated diverticulitis (assoc w/ abscess)-
<3 cm-> IV antibiotics and observation
4+ cm-> CT-guided percutaneous drainage (*if this fails then surgical drainage)
Girl ‘pops’ her knee when practicing gymnastics. Now she can’t straighten her right knee. It is swollen and tender on the medial side. The lateral side has a large, painful deformity. The anterior knee has a divot over the trochlea and little pain over the tibial tuberosity. Most likely diagnosis?
Patella dislocation
- common in young athletes after quick, lateral movements on a flexed knee
- exam shows reduced range of motion and lateral displacement of the patella out of the trochlea
What are the 3 components to the GCS (Glasgow Coma Scale) to assess neuro function of a patient (and whether or not they require intubation to secure their airway)?
- Eye opening
- Verbal response
- Motor response
Patient who recently underwent Roux-en-Y gastric bypass surgery presents with epigastric abdominal pain, fever/ chills, and SOB. He also is tachycardic has a WBC count with lots of neutrophils. Next step?
Abdominal CT w/ oral contrast
This is concerning for anastomotic leak (complication of gastric bypass surgery, GI contents leak into peritoneum)
-fever, abdominal pain, tachycardia within 1 wk
*requires urgent surgical repair
How high do you expect lipase to be in pancreatitis?
> 3x the upper limit of normal
Lady has fever/ chills, dysphasia, and drooling. The floor of the mouth is swollen, submandibular area is tender, and there is palpable crepitus. Where did the infection most likely originate?
In the teeth roots
This is Ludwig angina (cellulitis of the submandibular space/ floor of mouth)
-occurs from dental infections
*treat with IV antibiotics (ampicillin-sulbactam, clindamycin, etc.) and removal of inciting tooth
What is angioplasty?
Surgically unblocking a blood vessel
Man is stabbed in the neck. He’s awake and alert, talking normally but short of breath. He has no breath sounds over his right hemithorax. Do you intubate at this time?
No
You evaluated the ABCs (airway, breathing, circulation). He’s talking and breathing, can maintain his own airway. No expanding hematoma or emphysema in the neck, so no need for intubation at this time.
Patient goes into shock. Septic shock is assumed and antibiotics + steroid bolus (to decrease the massive vasodilatory inflammatory response) are given. Patient responds well but a couple hrs later goes back into shock and dies. What happened?
Adrenal insufficiency (lack of aldosterone + cortisol) -he bled into and destroyed adrenal glands
*Initially presents like septic shock, responds well to steroid bolus since it’s due to lack of steroid (cortisol). Think of this in patients who respond to shock treatment at first but then relapse.
Man is hit over the head in a robbery and suffers a closed linear skull fracture, confirmed by CT. He has some pain, but was never unconscious and he remembers the event. There’s no open wound or hematomas. Next step?
Send him home
Linear skull fractures are left alone if closed! (If open, go to OR)
Man in car crash goes into a coma. Pupils are fixed and dilated. CT shows crescent-shaped intracranial hematoma hugging the inside of the skull. Diagnosis and approach to management?
Acute subdural hematoma (poor prognosis)
Lower the ICP (intracranial pressure) to prevent further damage at this point
(Head elevation, hyperventilate, hypertonic saline or mannitol, HTN treatment)
Guy gets stabbed in the back on the right. Presents with paralysis on the right, loss of proprioception on the right, loss of pain on the left. Diagnosis?
Hemisection of the spinal cord (Brown-Sequard)
-loss of ipsilateral motor (CST) and proprioception/ vibration (DC-ML), controlateral pain/ temp (STT)
State the presentation for the following spinal cord injuries:
- Hemisection (Brown-Sequard)
- Anterior cord syndrome
- Central cord syndrome
- Hemisection (Brown-Sequard)- loss of ipsilateral motor and proprioception/ vibration, loss of controlateral pain/ temp below the level of the lesion
- Anterior cord syndrome- loss of motor + pain/ temp on both sides below the level of the lesion
- Central cord syndrome- loss of pain/ temp on both sides in the upper extremities
* ”cape-like distribution”
* can be due to hyperextension of neck (ex: car crash)
* can also cause paralysis and burning in upper extremities
How do you manage a rib fracture?
Intercostal nerve block and analgesia (pain meds) by epidural catheter
-control the pain, otherwise pain-> hypoventilation (hurts to breathe, so patient will take shallow breaths)-> atelectasis (collapse of alveoli)-> pneumonia (alveolar collapse allows for mucus plug formation and inc chance of infection)
Man who had car crash has several rib fractures. At the time of admission, his lungs are clear on CXR. Two days later, CXR shows “white out” and he has low O2, high CO2. Most likely diagnosis?
Pulmonary contusion (bruising)
*looks like ARDS but follows chest trauma (the lungs took a big blow and are bruised up/ capillaries bursted, impairing breathing function)
Guy has a gunshot wound to the abdomen. He is hemodynamically stable, just tender when you press on the abdomen. What do you do to assess the extent of his intraabdominal injuries?
Exploratory laparotomy
Required in gunshot wounds to abdomen!
Man got into a car accident and has a pelvic fracture with blood at the meatus (urethral opening) and scrotal hematoma. His urologic work-up should begin with what?
Retrograde urethrogram
Guy with gunshot wound to thigh has bullet embedded in his muscles. The entry wound is cleaned. What else does he need?
Tetanus prophylaxis
*removal of the bullet is not necessary
Lady has a cumferential burn to her arm from her shirt catching on fire as she roasted marshmallows. What will you need to continue to monitor in her?
Peripheral pulses and capillary filling
-the concern in a circumferential burn in cut off blood supply!
Lady has a 3rd degree burn to thigh from a hot iron that fell on her lap. She would be a good candidate to be treated with what?
Immediate excision and grafting
-this is for limited (only in one area) 3rd degree burns
Newborn baby with hip that can be easily dislocated and put back in place. Diagnosis?
Developmental dysplasia of the hip
Ball and socket hip joint didn’t form properly…may require hip brace for 6 mo or so
4 year old kid breaks her humerus. AP (anterior/ posterior) and lateral X-rays show an angulated bone break. Surgery needed?
No (can do closed reduction to ‘set’/ align the bone—even though it’s angulated, meaning it’s displaced/ not lined up to the point where the bone fragments are pointed different directions)
Open reduction surgery is almost never the answer in kids—they have softer, flexible bones that easily heal back to normal. Where kids get into trouble and need surgery is when the fracture affects the growth plate.
Man suffers multiple femur fractures from a motorcycle accident. He is in the ICU with respiratory failure, on a respirator. Though he was conscious, he suddenly goes into coma. A MRI brain shows “star-field pattern.” Diagnosis?
Fat embolism that reached the brain
Fat embolism: long bone fracture-> petechial rash, fever, tachy, low platelet count-> respiratory distress (low oxygen, patchy infiltrates)-> if fat droplets reach brain, coma + star-field MRI pattern
Patient breaks his tibia and fibula, treated with closed reduction and casting. The patient has increasing pain so the cast is removed to examine the leg. Calf muscles are tight and pain is crazy high on passive movement. Diagnosis and treatment?
Compartment syndrome
Fasciotomy (surgically remove the fascia to relieve the pressure built up in the leg)
Guy landed from 2 stories and landed on his feet. He broke both calcanei (heel bones). In real life, you’ll probably pan-scan this trauma guy to make sure you don’t miss anything, but what is the test answer of imaging to do (your priority of what to look at)?
X-ray thoracic and lumbar spine
If fall from height and land on feet, need to look at the lumbar spine in line of that incredible upward force
What is a Felon?
Fingertip abscess
What is Gamekeeper’s finger?
Injury of the ulnar collateral ligament due to forced hyper-extension of the thumb
What is Jersey finger?
When you close your fist, finger is stuck up (cannot flex)
Mallet finger vs. Trigger finger.
In both, when you open up a fist, the finger is stuck down (can’t extend)
(*in Trigger finger if you forcefully extend it with the other hand, you hear a pop)
Difference is: Mallet finger is a sports injury, Trigger finger is an inflammatory problem
Guy has a dirty looking ulcer w/ heaped up tissue edges. The injury has broken down and healed many times over years. Now looks different and is getting larger. What is this and how to diagnose?
Marjolin ulcer
Biopsy the ulcer edge
What are 4 signs of nutritional depletion and when can you do surgery on these folks?
- Lost 20% or more of body weight
- Albumin <3
- Anergy to skin antigens (lack of protein-> can’t make Ig)
- Transferin <200
Do 7-10 days (or at least 4-5 days) of pre-op nutritional support before surgery
Post-op MI is often triggered by what?
Hypotension
(Blood loss-> low BP-> if already stenosis in coronary arteries and now you have general low blood flow to heart, the heart can suffer an MI)
Cirrhosis patient with portacaval shunt shunt (for bleeding esophageal varices) has neurologic deterioration. Why?
Portacaval shunt (shunt between portal vein-> IVC) is the same idea as TIPS (shunt between portal vein-> hepatic vein). Since all the liver vessels (where detoxification happens) are being bypassed, ammonium can build up in the blood and lead to hepatic encephalopathy.
*This is a treatment that helps severe cirrhosis patients since the blood skips over the liver which is failing, so it prevents further portal HTN/ backing up of fluid…but a side effect is increased likelihood of hepatic encephalopathy.
Treatment for post-op GI fistula?
Fluid replacement, nutritional support, protection of abdominal wall
(To avoid sepsis and keep patient alive while nature heals the fistula)
Patient is vomiting like crazy, dehydrated. Has low Cl, low K+, high bicarb. What fluid should you give?
NS (normal saline) with KCl
- vomit-> loss of HCl and K+. This explains the low Cl and K+ and the metabolic alkalosis.
- to treat hypokalemia, give back K+. Giving KCl will fix the low Cl and K+ problem.
Man with history of abdominal surgeries presents with colicky abdominal pain and distention and vomiting. Last bowel movement was 3 days ago and he is not passing gas. He has high-pitched bowel sounds. Diagnosis and initial management?
SBO (small bowel obstruction), likely due to adhesions from previous abdominal surgeries
NPO (bowel rest), NG tube, IV fluids
(Hope for spontaneous resolution and monitor for signs of strangulation)
Bright red blood on toilet paper, no pain. Likely diagnosis?
Internal hemorrhoids
LLQ abdominal pain, fever, leukocytosis. Diagnosis? What imaging do you want?
Diverticulitis
CT scan
Epigastric pain radiating to back. Really high lipase. Normal hematocrit. Diagnosis?
Acute edematous (inflammatory) pancreatitis
*normal hematocrit rules out hemorrhagic pancreatitis
How do you treat breast cancer in pregnancy?
The same way you treat breast cancer in non-pregnant women (biopsy, cut it out, etc.), with 2 exceptions:
- No radiation or hormonal manipulations
- No chemo in the FIRST trimester
Baby has bilious vomiting. X-rays show dilated loops of small bowel and “ground glass” appearance in lower abdomen. The baby’s mom has cystic fibrosis. What diagnostic test would be most appropriate for baby?
Gastrografin enema (to diagnose meconium ileus—baby prob has CF too and cannot pass meconium due to thick secretions)
*Gastrografin is an X-ray with contrast/ dye that is water-soluble, less irritating than Barium enema. This is both diagnostic of meconium ileus (will see pellets of meconium in terminal ileum) and therapeutic (draws fluid in, helping to dissolve the meconium pellets).
6 mo baby has stridor, crowing respiration, and respiratory distress. Additionally, he has difficulty swallowing. Bronchoscopy rules out tracheomalacia. Barium swallow shows extrinsic compression on the esophagus. Diagnosis and treatment?
Vascular ring (trachea and esophagus are encircled by a ring of abnormal blood vessels)
Surgical division of abnormal blood vessel
*presents similarly to tracheomalacia (soft/ underdeveloped tracheal rings that collapse on breathing) but there is ALSO difficulty swallowing (since the vascular ring encircles both the trachea and esophagus)
A lung cancer patient is evaluated for surgery to take out his right (bad) lung. He has a FEV1 of 1,000 and 60% of lung function comes from his affected right lung. Is he a surgical candidate?
NO
A minimum of FEV1=800mL is required!
If you do the math, after taking out his right (bad) lung, he has 40% lung function. So take 40% of his FEV1 of 1,000= 400mL. This is less than 800, so he would not be able to survive with just his left lung.
A fib patient has a clot thrown (emboli) to his leg. It is pulseless and he can’t move it. Treatment?
Embolectomy w/ fogarty catheter (used to surgically remove the emboli)
*if incomplete occlusion, may use fibrinolytics (clot busters)
How do you repair strabismus in kids?
Congenital—> surgical repair in 6 mo. (To avoid amblyopia where the brain turns off the competing signal and you go permanently blind in one eye)
Acquired—> eyeglasses (usually a refraction problem) *of patch the good eye to allow the bad eye to catch up
Girl has midline neck mass. Moves with pulling of the tongue. Diagnosis?
Thyroglossal duct cyst
(Remember, the thyroid in embryo migrates from the base of the tongue down to its usual position in the neck below thyroid cartilage and above the sternum. During this process, a fluid-filled cyst can form in the mid-neck.)
Smoker and drinker with rotten teeth complains of right earache that hasn’t gone away in 6 wks. On physical exam, he has otitis media on the right and induration in the right mouth area (where the right Eustachian tube opens into the pharynx). What diagnostic tool should you do?
Panendoscopy (triple endoscopy) and biopsies
-examine the pharynx/ larynx, upper trachea, and esophagus—this guy likely has squamous cell carcinoma of the mucosa
Guy has fractures to the face in a car accident. Cranial nerves all intact. Next day, he develops unilateral face paralysis. Why? What do you do?
This is facial nerve injury secondary to trauma (edema is compressing the nerve)
No treatment
Treatment for aortic stenosis vs. mitral stenosis?
Aortic stenosis-> valve replacement
Mitral stenosis-> clip it (mitral commissurotomy, which means surgeon is cutting out the calcium deposits/ scar tissue to open the stenotic mitral valve)
*why are these treatments different? Don’t know.
Before you decide on whether or not surgery would be curative for a lung cancer patient, what do you have to evaluate for?
Metastasis (figure out if it’s present to know the direction you have to go with your treatment)
Tearing chest pain radiating to the back, HTN, unequal pulses in upper extremities, wide mediastinum on CXR. Diagnosis?
Aortic dissection
Management for basal cell carcinoma (BCC)—if waxy, raised lesion? If ulcer?
Waxy, raised lesion—> excised
Ulcer—> biopsy the edge
Can you delay surgery for a baby with a congenital cataract?
No—do it ASAP to avoid amblyopia (where brain turns off competing signals, resulting in permanent loss of vision in one eye)
Girl has mass on side of neck in front of the SCM muscle. Diagnosis?
Branchial cleft cyst
Can form during development of head/ neck structures
Old man has unilateral sensory hearing loss. You may want to do an MRI to look for what?
Acoustic nerve neuroma (Schwannoma)
Lady who’s been treated for sinusitis has fever and woke up with severe pain in the middle of her face and double vision. Diagnosis?
Cavernous sinus thrombosis
- trapped infection (sinusitis) that irritates blood vessels-> clot forms (rare complication)
- Treat with IV antibiotics! and heparin/ anticoagulation (drainage of paranasal sinuses may or may not be indicated)
Man complains of “bolt of electricity” shooting down face. Brought on by touching the face and lasts 60 sec. Neuro exam is normal, but part of his face is unshaven because he fears touching that area. MRI ruled out lesions. Diagnosis and treatment?
Trigeminal neuralgia
Carbamazepine
Guy has testicular pain and fever. The testis is in the normal position but tender to palpation (especially palpation of the cord). Lifting the scrotum relieves the pain. Diagnosis and management?
Acute epididymitis
Do ultrasound (sonogram) and treat with antibiotics (<35 years get Ceftriaxone + Azithro or Doxy to cover Chlamydia/ Gonorrhea, >35 years get Ciprofloxacin to cover E. Coli)
Testicular torsion vs. acute epididymitis—
Fever? Position of testes? Does lifting scrotum relieve pain? Treatment?
Testicular torsion- no fever, testes “high riding with horizontal lie,” lifting scrotum does not relieve pain, treat with immediate surge
Acute epididymitis- fever, testes in normal position, lifting scrotum relieves pain, treat with antibiotics (<35 years get Ceftriaxone + Azithro or Doxy to cover Chlamydia/ Gonorrhea, >35 years get Ciprofloxacin to cover E. Coli)
Teenager goes on a beer-drinking binge for the first time in his life and shortly thereafter develops severe, colicky flank pain. This is classic for what?
Ureteropelvic junction (UPJ) obstruction
These patients already have some narrowing at the UPJ, but doesn’t cause a problem with normal peeing. Only causes a problem when they are peeing excessively (like after drinking), so that’s when it’s discovered. (*Same concept as angina doesn’t cause chest pain at rest, but does when exercising due to increased demand on the heart)
After orchiectomy (removal of testicle) for testicular cancer, what treatment do you do?
Platinum-based chemotherapy + radiation
How can you distinguish between impotence (inability to achieve erection) due to psychogenic factors or organic causes?
Still have nocturnal erections—> psychogenic
Sudden loss of erections—> trauma
Gradual loss of erections (could get receptions but didn’t last long-> poor quality erections-> no erections)—> arteriosclerosis, DM, etc.
How can you treat acute transplant rejection?
Steroid boluses
You are trying to do endotracheal intubation on a guy who suffered severe injuries from a car accident. You make multiple attempts, but he is bleeding into his nose and mouth and has gurgly, irregular breathing. 5 min passed. What should you do?
Cricothyroidotomy
Woman was stabbed in the chest with a knife. She has an entry wound at the left sternal border, 4th intercostal space. BP is 80/50, HR is 110, she is breathing normally. She is cold and sweaty and has distended neck veins. Next step?
Empty the pericardial sac (pericardiocentesis, pericardial window, tube, or open thoracotomy)
This is pericardial tamponade (hypotension, distended neck veins, distant heart sounds)
Patient was hit by a car. He has clear fluid leaking from his ear and a a dark bruise behind his ear over the mastoid area. What is probably going on?
Fracture of the base of the skull-> CSF leak
*image the neck (CT) and take to neurosurgery
What imaging should you do for a patient who got stabbed in the upper neck?
Arteriogram (X-ray w/ contrast to view vessels)
-your main concern is the carotid artery for upper neck injuries
Newborn baby has a testicle up in the canal rather than the scrotum but you can easily pull it down in place, it just doesn’t stay there. What do you do?
Reassure the parents he has a hyperactive cremasteric muscle (the muscle in the scrotal sac around the testes that moves the testes)
Patient was shot in the abdomen and has gross hematuria. How do you explore the penetrating urologic injuries?
Exploratory laparotomy
1 year old has an abdominal mass that moves up and down with respiration. What do you suspect and what do you want to measure?
Malignant tumor of the liver
Measure alpha fetoprotein (AFP)
*neuroblastoma of adrenal gland and Wilma tumor of kidney are NON-movable abdominal masses in kiddos
When you suspect breast cancer, what type of biopsy do you do?
Core biopsy
FNA wouldn’t give you a big enough sample
Girl spilled Liquid-Plumr all over her body and is screaming in pain. Mom calls and asks what to do. What advice do you give?
Put her in the shower for at least 30 min before bringing her to the ED
(Irrigate!)
What is the goal urinary output when giving fluids?
1-2 mL/kg/hr
Genu Varum and Genu Valgus are normal in what age groups?
Genu Varum (bow legs)- normal until age 3 Genu Valgus (knock knees)- normal between ages 4-8
70 year old lady picks up a heavy bag of groceries and breaks her arm from doing so. What do you suspect?
Bone cancer (most likely metastatic osteolytic cancer, like from breast cancer)
*this is a pathologic fracture- arm should not break from holding a bag of groceries! Most likely cancer. Although osteoporosis also means easy breaks, these folks usually fall (something a little more severe than just holding groceries) to get their fractures.
What do you suspect if hip is—
Internally rotated? Externally rotated?
Internally rotated hip—> dislocated
Externally rotated hip—> fractured
Old guy immigrant from Norwegian has a contracted right hand with palpable fascial nodules. Most likely diagnosis?
Dupuytren contracture
(Fascia under skin is thick/ tight, pulls on hand so you can’t fully extend the fingers. More common in Norwegian ancestry. Steroids or collagenase injections may help.)
What’s the BASIC cause/ progression of diabetic ulcers?
Diabetic neuropathy-> ulcer develops on pressure point-> fails to heal due to small vessel disease
There are 2 clinical findings and 3 laboratory findings to predict if a liver dz patient is a surgical candidate. What are they?
- Ascites
- Encephalopathy
- Albumin
- INR
- Bilirubin
20 year old guy is in the ICU recovering from a laparotomy for a gunshot wound. His CXR was initially normal, but he now has bilateral pulmonary infiltrates and PO2 of 65 while breathing 40% O2. Diagnosis?
ARDS (Acute Respiratory Distress Syndrome)
- ARDS is not always a “white out” of the lung—often shows up as BILATERAL patchy pulmonary infiltrates with sudden increase in oxygen requirements
- NOT pneumonia (he’s young so unlikely, only bad pneumonia will be bilateral, he has no other PNA symptoms, and ARDS is more likely following trauma)
A guy has a surgical laparotomy. 5 days later, is soaking his dressings with salmon-pink colored fluid. How do you manage this?
This is wound dehiscence (leaking peritoneal fluid, even though wound looks intact). Tape and bind the wound securely and plan on surgical reclosure (otherwise can progress to evisceration, where skin opens up and the GI tract literally comes out of the skin at surgical site).
What sided colon cancer is more likely to present as bloody napkin-ring stools?
Left-sided
(*vs. right-sided colon CA is more likely to involve anemia. The lumen is larger on the right, so less likely to cause obstruction-> thin stools)
What do you do with a liver abscess?
Drain it
Kid 2-5 years has an umbilical hernia. What do you do?
Nothing- they may heal on their own within this age group.
Lady with history of breast cancer presents with constant back pain. Physical exam reveals 2 areas in her thoracic spine tender to palpation. Next next and what diagnosis are you concerned about?
Do an MRI- concerned about metastasis of breast cancer to vertebrae
*persistent headache or back pain in a woman with breast cancer suggests metastasis (MRI is diagnostic)
Lady with peptic ulcer disease fails to get better with PPIs and H.Pylori treatment. She has 3 ulcers in the duodenum and watery diarrhea. Next step?
Measure serum gastrin (non-responsive gastric ulcers are suspicious for ZE syndrome/ gastrinoma!)
*Tumor in duodenum or pancreas-> too much gastric acid-> ulcers + inactivation of pancreatic enzymes-> malabsorptive, watery diarrhea
Differential diagnoses for bilious vomiting in a young one?
- Duodenal atresia
- Intestinal atresia
- Annular pancreas
- Malrotation
- Duodenal atresia- failure to recannalize-> duodenum closes off (“double bubble” sign)
- Intestinal atresia- vascular accident in utero/ disruption of SMA-> ischemic necrosis of fetal intestine-> bowel spirals up/ is narrowed/ blocked anywhere in intestine (“apple peel”, dilated loops of small bowel with air-fluid levels on X-ray)
- Annular pancreas- abnormal rotations of ventral pancreatic bud-> pancreas encircles around duodenum
- Malrotation- problem with midgut rotation during fetal development-> small intestine is positioned wrong/ clumped up on right side-> fibrous Ladd bands form and press on duodenum (can lead to Volvulus where intestine twists on itself)
What is duodenal atresia?
Duodenal atresia- failure to recannalize-> duodenum closes off (“double bubble” sign)
What is intestinal atresia?
Intestinal atresia- vascular accident in utero/ disruption of SMA-> ischemic necrosis of fetal intestine-> bowel spirals up/ is narrowed/ blocked anywhere in intestine (“apple peel”, dilated loops of small bowel with air-fluid levels on X-ray)
What is annular pancreas?
Annular pancreas- abnormal rotations of ventral pancreatic bud-> pancreas encircles around duodenum
What is malrotation?
Malrotation- problem with midgut rotation during fetal development-> small intestine is positioned wrong/ clumped up on right side-> fibrous Ladd bands form and press on duodenum (can lead to Volvulus where intestine twists on itself)
Baby has subdural hematoma and retinal hemorrhages. Diagnosis?
Shaken baby syndrome (call CPS)
What med can you give to close the PDA?
Indomethacin (an NSAID)
*Prostaglandins E1 and E2 kEEp the PDA open. NSAIDs close it.
Elderly man has SOB on exertion, hepatomegaly, and ascites. Balloon-tip catheter (Swan-Ganz) inserted in jugular vein shows “square root sign” (equal pressures in all 4 chambers of the heart). Diagnosis?
Chronic constrictive pericarditis
Old man presents with acute-onset excruciating back pain. BP is low. Has a pulsatile mass in the epigastrium. Diagnosis?
Rupturing AAA (abdominal aortic aneurysm)
30 year old lady with past surgical hx of removed of pigmented skin lesion presents with findings suggestive of heart dz. An echo is done and shows a solid tumor in the LV. Most likely diagnosis?
Metastatic melanoma
*Note that the most common heart tumor is metastasis (from melanoma). Primary cardiac tumors are: myoxoma (LA tumor in adults, presents with syncope) and rhabdomyoma (in kids, associated with Tuberous Sclerosis)
Seeing flashes and floaters. Diagnosis?
Retinal detachment
Little kid has a foul-smelling fluid running out of only one nostril. He resists physical exam. Mom says the nasal discharge has been present for one week. You suspect what?
Nasal foreign body (ex: he stuffed a lego up his nose)
Dizziness like the room is spinning is suggestive of what?
Inner ear pathology
40 year old man has been having right hemiparesis (weakness) and speech difficulty. The last couple of months, he’s also had bad headaches worse in the mornings. He has blurred vision and diplopia. His becomes hypertensive and bradycardic. What is the most likely diagnosis? Reason for spike in BP and drop in HR?
Brain cancer (morning headaches, weakness, speech difficulty, blurred vision, diplopia)
Cushing’s reflex (tumor presses on brain-> inc ICP-> dec cerebral blood flow-> body responsds to this by increasing BP to try to get more blood to the brain-> reflex Brady)
25 year old guy has otitis media and mastoiditis and is treated with antibiotics. 2 weeks later, he complains of headache, seizures, blurry vision, projectile vomiting. He’s had a fever the last week. Likely diagnosis? What diagnostic study will you do?
Brain abscess
Do a CT scan of the head
Newborn baby boy has not peed during his first 18 hrs of life. He has a normal urethral meatus and distended bladder. Most likely diagnosis?
Posterior urethral valves
Redundant tissue in the urethra obstructing urinary flow
Can PSA be normal in prostate cancer
YES
Lady has a 7-mm ureteral stone at the ureteropelvic junction, confirmed by CT. How would most urologists treat this patient?
Extracorporeal shock wave lithotripsy (ESWL)
(Like an x-ray machine that shoots beams at you to break up the stone and help it pass)
- it is >3mm, so unlikely to pass on its own
- other options: endoscopic retrograde basket extraction, endoscopic retrograde laser vaporization of the stone, and open surgical removal (but these are not preferred over ESWL unless patient is pregnant or has a stone so big it’s in the centimeters and needs surgery, etc.)
How do you manage a hemothorax?
Drain the blood (to prevent development of empyema)
Car crash victim has moderate respiratory distress. He has absent breath sounds on left hemithorax. CXR shows collapsed left lung and multiple air fluid levels filling the left pleural cavity. An NG tube reached the upper abdomen then curled up into the left chest. Diagnosis?
Left diaphragmatic rupture
*air-fluid levels in chest are consistent with bowel going up in chest through diaphragm hole
Automobile accident victim sustained multiple injuries. FAST exam confirms bleeding into the abdomen, so an exploratory laparotomy is done. He has so many injuries that the surgery takes a while and lots of lactated Ringers and packed RBCs had to be given during surgery. When the surgeon tried to close up his abdomen, the swollen edges will not easily come together. What should the surgeon do?
Provide temporary bowl coverage with an absorbable mesh (until swelling goes down and he can be closed up…this is abdominal compartment syndrome)
Lady has an ATV accident and is crushed. She suffers a pelvic fracture and Foley catheter recovers bloody urine. Best way to evaluate her urologic injury?
Retrograde cystogram including post-void films
(shoot contrast/ dye up the urethra and take a picture after the patient urinates—should see most the dye come out, helps you evaluate damage to urethra and bladder)
- it’s called “retrograde” cystogram bc the dye is injected up the urethra (opposite direction of pee going out the urethra)
- *cystoscopy is a camera put up the bladder- don’t go sticking cameras up people’s bladders (invasive) until you have a better idea of what’s going on
- *ultrasound of bladder may be helpful for showing fluid in pouch of Douglas, for example, but a cystogram is the best test here to track the fluid, see if it’s coming out of the bladder into the pelvis
Guy is shot in the upper thigh. Has an expanding hematoma under the entry wound and no pulses below the injury. Next step?
Surgical exploration and repair
*surgery is required if there is obvious vascular injury (absent pulses and/ or expanding hematoma)!
Patient has an animal bite. How do you decide whether to initiate Rabies prophylaxis?
Provoked dog bites (ex: little girl pulls on dog’s tail so dog bites)—> no rabies ppx indicated (but monitor the dog for signs of rabies)
*if bite is on the face, may consider starting rabies immunization (due to close proximity to brain) and discontinuing if dog shows no signs of having rabies
Unprovoked dog bites or wild animal bites—> kill animal and examine brain for rabies. If animal is not available, do rabies ppx (Ig + vaccine)!
Obese kid is limping and complaining of knee pain. Knee is normal on physical exam, but the kid has limited hip range of motion (and cannot be internally rotated). Diagnosis?
Slipped capital femoral epiphysis
-Ortho emergency (usually in a chubby pre-teen). X-ray to diagnose. Surgery to treat and pin femoral head back in place.
