UWorld - Surgery Flashcards
splenic infarction etiologies
splenic artery occlusion caused by hypercoagulable state, embolic disease or hemoglobinopathy
diagnostic testing for sickle cell trait
hemoglobin electrophoresis
first line treatment for open angle glaucoma
topical prostaglandin (latanoprost, bimatoprost)
initial sign of open angle glaucoma
elevated intraocular pressure
clinical presentation for transient synovitis
well appearing
afebrile or low grade fever
able to bear weight
diagnosis of transient synovitis
normal or mildly elevated WBCs, ESR, CRP
unilateral/bilateral joint effusion on US
dx of exclusion
clinical presentation of septic arthritis
ill-appearing
febrile
non-weight bearing
diagnosis of septic arthritis
moderately elevated WBCs, ESR, CRP
+/- positive blood cultures
unilateral joint effusion on US
synovial fluid WBCs >50k
common fibular nerve injury presentation
weakened dorsiflexion, decreased sensation of the right big toe
+/- decreased sensation of the lateral shin and decreased great toe extension
compressive nerve injury treatments
reassurance, physical therapy, continued mobilization
oral leukoplakia risk factors
tobacco and alcohol use
oral leukoplakia clinical features
painless white mucosal patch that cannot be wiped off
oral leukoplakia features that increase risk of cancer
nonhomogenous gross appearance, large size, dysplasia seen on biopsy
oral leukoplakia management
biopsy at diagnosis, risk factor modification, close monitoring, +/- surgical excision
common manifestations of brain tumors
headache, papilledema, unprovoked first seizure, focal deficits, cognitive dysfunction (impaired memory)
ascitic fluid characteristics
straw colored and clear typically
bloody - trauma or malignancy
cloudy - infection
milky/chylous - lymphatic disruption
Serum to ascites albumin gradient findings
> 1.1 portal htn caused by cirrhosis or heart failure
<1.1 no portal htn, could be malignancy, TB, or nephrotic syndrome
ascitic fluid total protein indications
< 2.5 cirrhosis
> 2.5 right sided heart failure
urinalysis blood count results in red/brown urine
3+ - hematuria
0-2 - hemoglobinuria (decreased Hgb and haptoglobin) or myoglobinuria (increased CK)
first step in hemolytic anemia workup
CBC w/ differential
common injuries in pelvic fractures
extraperitoneal bladder injuries (anterior bladder wall rupture)
etiology of suprapubic fullness and tenderness
anterior bladder wall rupture
Closed angle glaucoma clinical features
headache, ocular pain, nausea, decreased visual acuity, conjunctival redness, corneal opacity, fixed middilated pupil
Closed angle glaucoma diagnosis
tonometry to measure intraocular pressure and gonioscopy to measure corneal angle
Closed angle glaucoma treatment
topical therapy (timolol + pilocarpine + apraclonidine)
systemic therapy (acetazolamide +/- mannitol)
laser iridotomy
Fluoroquinolones adverse effects
Achilles tendon rupture, retinal detachment, aortic aneurysm rupture
Fluoroquinolones
levofloxacin, moxifloxacin, ciprofloxacin
porcelain gallbladder CT findings
calcium laden gallbladder wall with bluish color and brittle consistency
rimlike calcification in the area of the gallbladder with a central bile filled dark area
associated risks of porcelain gallbladder
gallbladder adenocarcinoma
first line recommendation for porcelain gallbladder
cholecystectomy
what is surgical subcutaneous emphysema
complication in which CO2 used for abdominal insufflation dissects into surrounding subcutaneous tissues
diagnosis of surgical subcutaneous emphysema
rule out more dangerous etiologies of subcutaneous emphysema by CXR (pneumothorax, tracheal rupture, esophageal perforation)
tricuspid regurgitation murmur
holosystolic murmur at the left lower sternal border
secondary tricuspid regurg cause
RV cavity enlargement in the setting of pressure overload
RV enlargement effects
tricuspid annular dilation and tethering of chordae tendinae
tricuspid regurg JVP waveform findings
prominent V waves
ICH presentation
unilateral headache, nausea, vomiting, decreased consciousness
common cause of ICH in young patients
arteriovenous malformation
implication of CXR with large opacification and mediastinal shift towards the side of the opacification
atelectasis due to airway obstruction (mucus, tumor, foreign body), not space occupying, mediastinum shifts towards empty space
implication of CXR with large opacification and mediastinal shift away the side of the opacification
pleural effusion, space occupying so pushes away
implication of CXR with large opacification and no mediastinal shift
multilobar pneumonia
factors increasing risk of mucus plugging
surgery under anesthesia, smoking
acute hemolytic transfusion reaction pathogenesis
ABO incompatibility and intravascular hemolysis
acute hemolytic transfusion reaction clinical findings
fever, chills, hypotension, hemoglobinuria and flank pain with onset within minutes to 24 hours of transfusion
acute hemolytic transfusion reaction laboratory findings
(+) direct Coombs test, hemolysis findings ( inc LDH and indirect bilirubin)
acute hemolytic transfusion reaction complications
acute kidney failure, DIC
intussusception pathogenesis
telescoping of one bowel segment into adjacent segment (most often ileocecal) causing bowel edema, ischemia and eventually necrosis most commonly in 6mo-3yr
intussusception risk factors
hypertrophy of intestinal Peyer patches from recent viral illness or pathologic lead point (i.e. Meckel diverticulum, HSP (Henoch-Schonlein purpura), intestinal tumor)
intussusception clinical presentation
sudden intermittent abdominal pain and vomiting, sausage shaped mass in right abdomen, currant jelly stools, and lethargy or altered mental status
intussusception diagnosis and management
dx: target sign on US
pneumatic/air or saline enema, surgical intervention for failed enema reduction or signs of peritonitis
next step to evaluate a pathologic lead point in intussusception
Meckel scan/nuclear scintigraphy/99 technetium pertechnetate scan
Roux-en-Y gastric bypass surgery complications
anastomotic leak from breakdown of gastrojejunal or jejunojejunal anastomosis causing leakage of GI contents into the peritoneum
clinical signs of anastomotic leak
fever, abd pain, tachypnea, tachycardia
Diagnosis and management of anastomotic leak
oral contrast-enhanced abdominal CT scan followed by urgent surgical repair
bowel perforation diagnosis and management
upright x-ray of chest and abdomen
surgical consultation and intervention
septic bursitis risk factors
local cellulitis, abrasions, or penetrating trauma
bursal instrumentation/injection or prior inflammation
immunocompromised patients
septic bursitis presentation
painful localized bursal swelling with erythema and warmth
+/- fever, chills, myalgias
septic bursitis diagnosis treatment
aspiration and culture
systemic abx +/- drainage
tonsillar herniation signs
brainstem compression signs (irregular respirations, unconsciousness), fixed midposition pupils due to disruption of sympathetic and parasympathetic innervation
uncal herniation signs
brainstem compression signs (irregular respirations, unconsciousness), ipsilateral fixed and dilated pupil due to compression of the ipsilateral oculomotor nerve and parasympathetic fibers
subfalcine herniation signs
NO pupillary involvement or brainstem compression
contralateral leg weakness due to ipsilateral ACA compression
Posttransplantation lymphoproliferative disorder pathogenesis
immunosuppression following solid-organ or stem cell transplantation leading to suppressed cytotoxic t-cell immunosurveillance and unchecked viral replication promoting immortalizd lymphocytes or plasma cells
commonly caused by EBV but can also be caused by other human herpesviruses
Posttransplantation lymphoproliferative disorder manifestations
fever, lymphadenopathy, hepatosplenomegaly, leukopenia, masses in nonlymphatic tissue
Posttransplantation lymphoproliferative disorder diagnosis
high viral titers, biopsy evidence of lymphoid or plasma cell proliferation
Posttransplantation lymphoproliferative disorder treatment
reduce immunosuppression, b-cell immunotherapy, EBV titer monitoring
malignant hyperthermia epidemiology
genetic mutation alters control of intracellular calcium and is triggered by volatile anesthetics, succinylcholine, excessive heat
malignant hyperthermia manifestations
masseter muscle/generalized rigidity, sinus tachycardia, hypercarbia, rhabdo, hyperkalemia, hyperthermia
malignant hyperthermia treatment
respiratory/ventilatory support, immediate cessation of causative anesthetic, dantrolene
supracondylar fracture presentation
fall onto outstretched arm, pain, swelling, limited range of motion
supracondylar fracture diagnostic findings
x-ray with posterior fat pad (occult), fracture line, or displacement of humerus
supracondylar fracture treatment
nondisplaced - long arm splint & sling
displaced - surgical reduction & pinning
supracondylar fracture complications
neurovascular injury and compartment syndrome
signs suspicious for compartment syndrome in supracondylar fx
increased swelling and pain
signs suspicious for neurovascular injury in supracondylar fx
brachial artery - diminished distal pulses
median nerve - transient motor or sensory loss due to stretching of nerve
spinal epidural hematoma signs
slowly progressive motor and sensory dysfunction in the distribution of the nerve root +/- cauda equina syndrome
localized back pain
spinal epidural hematoma management
urgent MRI of spine and urgent decompression via laminectomy
C5 Cervical radiculopathy (reflex affected, sensory loss, and weakness locations)
reflex - biceps
sensory loss - lateral upper arm
weakness - shoulder abduction and elbow flexion
C6 Cervical radiculopathy (reflex affected, sensory loss, and weakness locations)
reflex - biceps, brachioradialis
sensory loss - thumb and index finger
weakness - elbow flexion, forearm pronation/supination, wrist extension
C7 Cervical radiculopathy (reflex affected, sensory loss, and weakness locations)
reflex - triceps
sensory loss - dorsal forearm, middle finger
weakness - elbow extension, wrist flexion, finger extension
C8 Cervical radiculopathy (reflex affected, sensory loss, and weakness locations)
reflex - finger flexors
sensory loss - ring and little fingers
weakness - finger flexion and extension, thumb flexion and abduction
T1 Cervical radiculopathy (reflex affected, sensory loss, and weakness locations)
reflex - finger flexors
sensory loss - medial forearm
weakness - finger abduction and adduction
cervical radiculopathy management
NSAIDs and avoidance of provocative maneuvers
risk factors for mucosal head and neck squamous cell carcinoma
smoking, alcohol use, occupational exposure to welding fumes
prerenal acute kidney injury etiology
decreased renal perfusion due to volume depletion, decreased EABV (heart failure/cirrhosis), displacement of intravascular fluid (sepsis, pancreatitis), bilateral renal artery stenosis with ACE inhibition, or afferent arteriole vasoconstriction
prerenal acute kidney injury clinical features
increase in serum creatinine, decreased urine output, BUN/Creatinine ratio >20:1 , FeNa <1%, unremarkable urine sediment
prerenal acute kidney injury treatment
restoration of renal perfusion
prerenal acute kidney injury treatment
in absence of volume overload, intravenous isotonic fluid
greatest risk factor for prostate cancer
advanced age
clinical presentation of acute urinary retention
agitation, tachycardia, lower abdominal suprapubic tenderness
risk factors for acute urinary retention
male sex, advanced age, benign prostatic hyperplasia, neurologic disease, surgery
acute limb ischemia etiology
cardiac/arterial embolus, arterial thrombosis, iatrogenic/blunt trauma
acute limb ischemia management
anticoagulation and thrombolysis/surgery
pes anserinus pain syndrome presentation
medial knee pain and focal tenderness with no valgus stress test results
acute cholangitis clinical presentation
fever, jaundice, RUQ pain (Charcot triad), +/-hypotension, altered mental status
acute cholangitis diagnosis
cholestatic liver function abnormalities (increased direct bilirubin and alk phos, mildly increased aminotransferases)
biliary dilation on abdominal US or CT scan
acute cholangitis treatment
antibiotic coverage of enteric bacteria and biliary drainage by ERCP within 24-48 hours
warfarin induced anticoagulation reversal agent
prothrombin complex concentrate
fat embolism syndrome clinical presentation
respiratory distress, neurologic dysfunction, petechial rash
auricular hematoma treatment
immediate incision and drainage, pressure dressing
auricular hematoma complications
cauliflower ear (fibrocartilage overgrowth), bacterial superinfection and abscess, reaccumulation of hematoma
complications of Crohn disease
fibrotic stricture and small bowel obstruction
burn wound infection reduction mechanism
early excision of necrotic tissue and wound closure
acalculous cholecystitis risk factors
severe trauma or recent surgery, prolonged fasting or TPN, critical illness
acalculous cholecystitis clinical presentation
fever, RUQ pain, leukocytosis, +/- inc LFTs
uncommonly jaundice and RUQ mass
acalculous cholecystitis diagnosis
abdominal US, HIDA or CT scan
acalculous cholecystitis treatment
enteric antibiotic coverage, cholecystostomy for initial drainage, cholecystectomy
neuropathic (Charcot) arthropathy pathophysiology
repetitive bone and joint trauma due to impaired sensation/proprioception (diabetes mellitus, posterior column disease)
neuropathic (Charcot) arthropathy clinical manifestations (acute and chronic)
acute - inflammatory erythema, warmth, edema, minimal bone involvement (normal x-ray)
chronic - bone deformities, neuropathic ulcers, cellulitis, osteomyelitis)
neuropathic (Charcot) arthropathy management (acute and chronic)
acute - foot cast to reduce edema and offload weight bearing
chronic - orthotic footwear, infection management, surgical realignment
risk factor for osteosarcoma
paget disease of the bone
ischemic colitis presentation
abdominal pain, fever, leukocytosis, bloody diarrhea
infectious endocarditis surgery indications
heart failure from valve dysfunction, localized extension of infection, difficult pathogens, high risk of embolism
focal nodular hyperplasia buzzwords
anomalous arteries, arterial flow and central scar
hepatic adenoma
long term OCP use, hemorrhage, malignant transformation
hepatocellular carcinoma
systemic symptoms, chronic hepatitis and cirrhosis, elevated aFP
liver metastasis
single/multiple lesions, known extrahepatic malignancy
adult hip osteonecrosis clinical presentation
chronic/progressive groin/thigh/buttock pain, decreased range of motion/abduction/internal rotation
adult hip osteonecrosis pathogenesis
vascular occlusion, bone necrosis, trabecular thinning and collapse of femoral head
adult hip osteonecrosis risk factors
femoral head fracture, glucocorticoids, excessive alcohol use, sickle cell disease, systemic lupus erythematosus
adult hip osteonecrosis diagnostic findings
X-ray - loss of sphericity, subchondral sclerosis
MRI - serpiginous low intensity lines, bone marrow edema
perianal abscesses treatment
primary treatment - incision and drainage
secondary treatment - systemic antibiotic therapy for patients with systemic illness or increased risk of severe infection
indications for imaging in diabetic foot ulcers
deep, long standing, large, elevated ESR/CRP, adjacent soft tissue infection
hard signs of traumatic arterial injury
distal limb ischemia, absent pulses, active hemorrhage, bruit or thrill at site of injury
soft signs of traumatic arterial injury
diminished distal pulses, unexplained hypotension, stable hematoma, documented hemorrhage, neurologic deficit.
sialadenosis
nontender bilateral enlargement of the parotid glands common in patients with chronic alcohol use, bulimia, malnutrition, diabetes, or liver disease
Legg-Calve-Perthes Disease pathogenesis
idiopathic avascular necrosis of the femur
Legg-Calve-Perthes Disease clinical features
boys aged 3-12 with a limp and insidious hip, thigh, or knee pain and restricted hip abduction and internal rotation along with positive trendelenburg sign
Legg-Calve-Perthes Disease diagnosis
x-ray normal in early stages but femoral head flattening, fragmentation and sclerosis in later stages
Legg-Calve-Perthes Disease treatment
non-weight bearing, splinting, possible surgical repair
keratoacanthoma
rapidly growing nodule with ulceration and keratin plug with spontaneous regression and resolution
keratoacanthoma clinical significance
may resemble or progress to squamous cell carcinoma
keratoacanthoma management
excisional biopsy and removal
rotator cuff impingement or tendinopathy
pain with abduction and external rotation, subacromial tenderness, normal ROM w/ positive impingement tests
rotator cuff tear
weakness and pain with abduction and external rotation
adhesive capsulitis
decreased passive and active range of motion with initial painful phase followed by stiffness more than pain
biceps tendinopathy/rupture
anterior shoulder pain with lifting, carrying or overhead reaching
refeeding syndrome
muscle weakness, arrhythmias, CHF, rhabdomyolysis and neurologic dysfunction caused by hypophosphatemia
angiodysplasias
tortuous, dilated, thin walled vessels lined by a layer of endothelium that commonly occur in individuals over 60
angiodysplasia risk factors
older age, end stage renal disease, aortic stenosis
acute pericarditis clinical features
pleuritic chest pain decreased while sitting, pericardial friction rub, ST segment elevation and PR segment depression
AAA risk factors
advanced age, SMOKING, male sex, hypertension, pmh of atherosclerosis or CTD
ASD clinical manifestations
wide fixd split S2, right sided volume overload , atrial arrhythmias with RBBB, pulmonary htn and right sided heart failure
prosthetic valve endocarditis diagnostic test of choice
transesophageal echocardiography
normal anion gap metabolic acidosis etiologies
diarrhea, renal tubular acidosis, excess saline, intestinal/pancreatic fistula, CAI and MRA diuretics
elevated anion gap metabolic acidosis etiologies
lactic acidosis, diabetic ketoacidosis, kidney failure, methanol/ethylene glycol, salicylate toxicity
rectal prolapse risk factors
women over the age of 40 with history of vaginal deliveries and multiparity, prior pelvic surgery, chronic constipation, diarrhea or straining, stroke/dementia, pelvic floor dysfunction
rectal prolapse clinical presentation
abdominal discomfort, straining or incomplete bowel evacuation, fecal incontinence, erythematous mass with concentric rings or radial invaginations
rectal prolapse management
fiber and fluid intake, pelvic floor muscle exercises, biofeedback therapy for fecal incontinence, surgical preferred for full thickness or debilitating symptoms
radial head subluxation mechanism
pull injury in young child, axial traction on forearm with extended elbow, annular ligament slips past radial head and becomes trapped in radiohumeral joint
radial head subluxation physical findings
arm held with extended elbow and pronated forearm, pain with movement, mild tenderness on radial head, no swelling/deformity/other tenderness
radial head subluxation management
hyperpronation of forearm or supination of forearm and flexion of elbow
suppurative parotitis clinical presentation
firm, erythematous pre/postauricular swelling, exquisite tenderness exacerbated by chewing and palpation, trismus systemic findings, elevated serum amylase
suppurative parotitis management
ultrasound or CT scan, hydration, oral hygiene, antibiotics, massage, sialagogues
ovarian torsion clinical presentation
sudden onset unilateral pelvic pain, nausea and vomiting, palpable adnexal mass
ovarian torsion US findings
adnexal mass with absent Doppler flow to ovary
ovarian torsion treatment
laparoscopy with detorsion, ovarian cystectomy, oophorectomy
osteoarthritis management
weight loss, moderate activity, NSAIDs, strengthening of the quadriceps muscles
sympathetic ophthalmia
autoimmune conditions where T cells become sensitized to eye antigens as a result of inflammation after ocular trauma
Candida endophthalmitis risk factors
indwelling central catheter, TPN, abx use, GI surgery and immunocompromise
Candida endophthalmitis manifestations
unilateral floaters and progressive vision loss, pain rare until late
steroid induced ocular hypertension symptoms
halos around lights, decreased visual acuity, eye pain, headache, corneal edema
steroid induced ocular hypertension management
monitoring to detect IOP, steroid cessation, topical anitglaucoma medications, laser trabeculoplasty or trabeculotomy
greenstick fracture
fracture that only involves one side of the bony cortex
greenstick fracture complications
none
greenstick fracture management
reduction and immobilizaton
C. Diff infection oral therapy
fidaxomicin and vancomycin
fulminant CDI abx therapy
oral vancomycin, IV metronidazole
Entamoeba histolytica clinical manifestations
colitis, liver abscess
complications - pleural effusion, rupture into peritoneum/pleural space
Entamoeba histolytica
single subcapsular, low density lesion
meniscal tear symptoms
acute popping sensation, catching locking, reduced range of motion, slow onset joint effusion
fat malabsorption effects on absorption
decreased recycling of bile salts and fatty acids, increased enteric absorption of oxalate
eosinophilic esophagitis clinical features
dysphagia, heartburn and epigastric pain, regurgitation, food impaction
eosinophilic esophagitis diagnosis
endoscopy and esophageal biopsy and exclusion of alternate diagnoses
eosinophilic esophagitis treatment
elimination diet, PPIs, topical glucocorticoids
muscle which distinguishes different levels of axillary lymph nodes
pec minor
liver abscess management
blood cultures, abx, percutaneous aspiration and drainage
splenic abscess risk factors
infection w/ hematogenous spread, hemoglobinopathy, immunosuppression, IV drug use, trauma
splenic abscess clinical presentation
fever, leukocytosis, LUQ abd pain, left pleuritic chest pain with left pleural effusion
TRALI treatment
respiratory supportive care
initial management of gastric adenocarcinoma
CT scan of abdomen and pelvis
otosclerosis clinical manifestations
progressive conducting hearing loss, paradoxical improvement in speech discrimination in noisy environments, reddish hue behind tympanic membrane
otosclerosis pathophysiology
imbalance of bone resorption and deposition leading to stiffening of the stapes
Heparin induced thrombocytopenia
heparin exposure within 5 days and platelet count reduction >50% from baseline, arterial and venous thrombosis, necrotic skin lesions, acute anaphylactoid reactions after heparin
otosclerosis management
amplification and surgery
cardiac effects of hypovolemic shock
decreased right ventricular preload
PJP pneumonia imaging
CXR with diffuse bilateral interstitial or alveolar infiltrates not large unilateral effusion
peripheral artery disease presentation
rest pain that improves with dangling, shiny hairless legs,
delayed emergence etiologies
drug effects that potentiate anesthetic effects, metabolic disorders, neurologic disorders
ways gout can affect superficial bursae
acute bursitis - erythema warmth and swelling
chronic bursitis - large rounded fluctuant effusion
bursal tophus - slowly enlarging hard mass +/- mild inflammatory changes
subphrenic abscess indications
RUQ pain, fever, leukocytosis, pulmonary manifestations
Heparin induced thrombocytopenia diagnostic evaluation
serotonin release assay but start treatment in all suspected cases
Heparin induced thrombocytopenia therapy
stop heparin, start direct thrombin inhibitor or fondaparinux
varicocele clinical presentation
soft scrotal mass decreased in supine and increased with standing/valsalva maneuvers, subfertility, testicular atrophy
varicocele ultrasound complications
infertility and testicular atrophy
varicocele US findings
retrograde venous flow, tortuous anechoic tubules adjacent to testis, dilation of pampiniform plexus veins
varicocele treatment
reassurance and observation, gonadal vein ligation for pain, atrophy or abnormal semen analysis
Zollinger Ellison Syndrome clinical features
multiple refractory peptic ulcers distal to the duodenum
Zollinger Ellison Syndrome diagnosis
markedly elevated serum gastrin in the presence of normal gastric acid
Zollinger Ellison Syndrome workup
endoscopy and CT scan/MRI and somatostatin receptor scintigraphy for tumor localization
septal hematoma complications
infection, septal abscess, avascular necrosis of septal cartilage
septal hematoma treatment
incision and drainage
Upper extremity deep venous thrombosis manifestations
unilateral arm or forearm edema, pain/heavy sensation, erythema, dilated subcutaneous collateral veins
Upper extremity deep venous thrombosis epidemiology
central catheter or PICC line, young athletic males, thoracic outlet obstruction
post traumatic neuroma
weeks to months after amputations, presents with focal tenderness and altered local sensation, decreased pain with anesthetic injection
hemobilia presentation
RUQ pain, jaundice, anemia, direct hyperbilirubinemia after liver biopsy
torus palatinus
benign bony growth located at the midline suture of the hard palate
hemodynamic changes in arteriovenous fistula
decreased afterload, increased preload, increased cardiac output
Esophageal perforation clinical presentation
Chest, back or epigastric pain, systemic signs, crepitus, pleural effusion with atypical fluid
esophageal perforation diagnosis
CXR or CT w/ widened mediastinum, pneumomediastinum, pneumothorax, and pleural effusion
CT scan: esophageal wall thickening and mediastinal fluid collection
esophageal perforation management
NPO, IVAbx, PPIs, surgical consultation
Esophageal perforation pleural fluid analysis
low pH, very high amylase
chromium deficiency
impaired glucose control
copper deficiency
brittle hair, skin depigmentation, neurologic dysfunction, anemia, osteoporosis
Selenium deficiency
thyroid dysfunction, cardiomyopathy, immune dysfunction
zinc deficiency
alopecia, pustular skin rash, hypogonadism, impaired wound healing, impaired taste, immune dysfunction
most important prognostic factor for breast cancer
tumor stage
dumping syndrome pathogenesis
destruction or bypass of pyloric sphincter
dumping syndrome etiology
esophageal gastric resection or reconstruction
dumping syndrome symptoms
abdominal pain, diarrhea, nausea, hypotension/tachycardia, dizziness/confusion, fatigue, diaphoresis
dumping syndrome timing
15-30 minutes after meals
dumping syndrome management
small frequent meals replacing simple sugars w/ complex carbohydrates and incorporation of high fiber and protein rich foods
pleural effusions that can be managed with observation
small to moderately sized, early onset, not associated with respiratory symptoms
pheochromocytoma management
preoperative alpha blockade prior to beta blockade
diverticulitis intestinal symptoms
LLQ abd pain, nausea/vomiting, alteration in bowel habits
diverticulitis extraintestinal symptoms
mild urinary symptoms and sterile pyuria
first line treatment for colon cancer with spread to liver
surgical resection
contact lens abrasion treatment
topical antibiotics and follow up in 24 hours
Foreign body corneal abrasion treatment
removal by irrigation, topical antibiotic
zenker diverticulum treatment
cricopharyngeus myotomy
recommended treatment for FAP
prophylactic colectomy in teens to early 20s
superior pulmonary sulcus tumor manifestations
shoulder pain, Horner syndrome, neurologic symptoms in the arm, supraclavicular lymphadenopathy, weight loss
cause of sinus bradycardia and transient AV block intraoperatively
peritoneal stretching during insufflation of CO2 increases vagal tone
plantar fascitis symptoms
pain at plantar aspect of heel and hindfoot worsened with weight bearing
plantar fasciitis diagnosis
tenderness at insertion of plantar fascia, pain with dorsiflexion of toes, presence of heel spurs
plantar fasciitis treatment
activity modification, stretching and heel pads
L’hermitte sign
electric shock like pain with neck flexion
indications of l’hermitte sign
cervical spinal cord compression
hypercalcemia plus high PTH
primary hyperparathyrodism or lithium
hypercalcemia plus suppressed PTH causes
malignancy, vitamin D toxicity, milk-alkali syndrome, thyrotoxicosis, vit A toxicity, immobilization
toxic shock risk factors
tampon use, nasal packing, surgical/postpartum wound infection
toxic shock syndrome clinical features
fever, hypotension, macular rash, vomiting/diarrhea, altered mentation w/o focal signs, desquamation 1-3 weeks after onset
carotid artery dissection presentation
gradual onset hemiplegia, aphasia, neck pain, thunderclap headache
abx with broad spectrum against encapsulated organisms
Amoxicillin-clavulanate
sign of quadriceps tendon tears
low riding patella, palpable defect above the patella
sign of patellar tendon tears
high riding patella
hematoma vascular findings
+/- mass, no bruit
pseudoaneurysm vascular findings
bulging pulsatile mass, systolic bruit
arteriovenous fistula vascular findings
no mass, continuous bruit
avascular necrosis etiology
steroid use
alcohol use
SLE / antiphospholipid syndrome
hemoglobinopathy
infection
kidney transplant
decompression sickness
Gilbert Syndrome
Decreased UDP glucuronosyltransferase activity leads to decreased conjugation of bilirubin
Gilbert syndrome clinical findings
recurrent episodes of mild jaundice provoked by stress
Gilbert syndrome diagnosis
increased indirect bilirubin but normal CBC, blood smear, retic count, AST, ALT, Alk phos
prepatellar bursitis risk factors
occupations with frequent kneeling
hydatid cyst etiology
Ecchinococcus granulosus infection from close contact with dogs
hydatid cyst findings
eggshell calcificaiton of a hepatic cyst
acidosis level at which you transfuse with bicarbonate
<7.2
toxic megacolon pathophysiology
colonic smooth muscle inflammation and paralysis as a complication of IBD or infectious colitis
result of pheochromocytoma and anesthesia induction
catecholamine surge (hypertension, tachycardia, etc.)
toxic megacolon diagnosis
colonic dilation >6 cm on imaging
toxic megacolon treatment
bowel rest/decompression, corticosteroidds, surgery for perforation, peritonitis, or deterioration
seminoma features
beta hcg and afp negative, retain features of spermatogenesis
nonseminoma types of tumors
yolk sac, embryonal carcinoma, teratoma, choriocarcinoma
nonseminoma features
beta hcg, afp usually positive
leydig cell tumor features
exccessive estrogen or testosterone, can cause precocious puberty
first line treatment for invasive burn wound infection
pip-tazo/meropenem and vanco
hemodynamics of thyroid storm
reduced systemic vascular resistance, increased cardiac output, high venous oxygen content
hypermetabolic response in burn injury
tachycardia, hypertension, hyperglycemia, inc basal body temp, inc lean muscle wasting
traumatic carotid injuries mechanism
penetrating trauma, fall with object in mouth, neck manipulation
traumatic carotid injuries presentation
gradual onset hemiplegisa, aphasia, neck pain, thunderclap headache
best antibiotic for post splenectomy patients
amoxicillin clavulanate for encapsulated pathogen coverage
hemodynamic changes in cardiac tamponade
PCWP - increased
CI - decreased
SVR - increased
RAP - increased
pyogenic liver abscess presentation
fever, RUQ pain, hepatomegaly, leukocytosis, elevated liver enzymes, right sided pleural effusion
stress ulcer risk factors
shock, sepsis, coagulopathy, mechanical ventilation, traumatic spinal cord or brain injury, burns, high dose corticosteroids
radiation proctitis
obliterative endarteritis and submucosal fibrosis leading to anorectal stricture formation
clinical features of burn injury hypermetabolism
tachycardia, hypertension, hyperglycemia, increased basal body temp, lean muscle wasting
acute epithelial ovarian carcinoma presentation
shortness of breath, constipation with vomiting, abdominal distention
subacute epithelial ovarian carcinoma presentation
pelvic/abd pain, bloating, early satiety
management of venous air embolism
left lateral decubitus positioning, high flow oxygen
immediate management of pelvic fractures
pelvic binder
most common causes of deep infections following puncture wounds
staph aures, pseudomonas aeruginosa
polyarteritis nodosa pathophysiology
fibrinoid necrosis of arterial wall leads to luminal narrowing and thrombosis which causes ischemia
elastic lamina damage leads to microaneurysm formation, rupture, and bleeding
what must be done before imaging in all women of childbearing age
pregnancy testing
imaging modality of choice for women with breast mass under the age of 30
ultrasonography
imaging modality of choice for women with breast mass over the age of 40
mammography
phantom limb pain syndrome treatment
multimodal pain regimen
staging evaluation for rectal adenocarcinoma
CEA, colonoscopy
meniscal tear examination results
tenderness of the joint line and pain or a click with provocative maneuvers
hypocalcemia causes
neck surgery (parathyroidectomy) or chelation from blood transfusion
hypocalcemia clinical features
muscle cramps, chvostek/trousseau signs, paresthesias, hyperreflexia, seizures
right sided colon tumor presentation
occult bleeding and iron deficiency anemia
left sided colon tumor presentation
crampy/colicky pain, constipation, hematochezia
perilymphatic fistulas
complication of head injury where endolymph leaks into surrounding tissues which causes progressive sensorineural hearing loss, episodic vertigo with nystagmus caused by pressure changes or loud noises
common complications of cholecystectomy
bile acid diarrhea
bile acid diarrhea treatment
bile acid binding resins (cholestyramine, colestipol, colesevelam)
opioid induced constipation first line therapy
osmotic and stimulant laxatives
adrenal crisis etiology
adrenal hemorrhage or infarction or pituitary apoplexy
clinical features of adrenal crisis
hypotension and shock, n/v/abd pain, fever, wekaness
adrenal crisis treatment
hydrocortisone or dexamethasone and IV volume repletion
SIBO clinical manifestations
bloating, flatulence, chronic watery diarrhea, malabsorption, decreased B12 and increased folate
SIBO diagnosis
carbohydrate breath testing , endoscopy with jejunal aspirate
SIBO treatment
abx
colovesical fistula clinical presentation
pneumaturia, fecaluria, recurrent urinary tract infections
colovesical fistula diagnosis
CT abd w/ oral or rectal contrast, colonoscopy to exclude malignancy
peripheral arterial disease diagnostics
ankle brachial index
trochanteric pain syndrome symptoms
chronic lateral hip pain worse with hip flexion or pressure
trochanteric pain syndrome diagnosis
focal tenderness over trochanter, x-ray to rule out hip joint pathology, US to find degeneration of tendons/tendinosis
trochanteric pain syndrome treatment
exercise, physical therapy, activity modification, NSAIDs, corticosteroid injections
flail chest
fracture of >3 adjacent ribs in >2 locations creates an isolated chest wall segment that moves paradoxically and increases work of breathing
lab signs of ischemic hepatitis
elevated AST/ALT with normal or delayed rise in bilirubin
when to consider pathologic causes of scoliosis
back pain, neurologic symptoms, rapidly progressive curvature or vertebral anomalies
recurrent respiratory papillomatosis causes
HPV subtypes 6 and 11
interventions that prevent VAPna
elevation of the head of the bed, suctioning secretions, limiting tub movement and avoiding gastric acid suppression
unicameral bone cyst diagnosis
well-defined lucent lesion arising from metaphysis with narrow transition zone and no periosteal reaction
homogenous cyst with enhancing rim
myositis ossificans causes
muscle injury, fracture, or surgery
stroke, TBI, spinal cord injury
myositis ossificans clinical presentation
intramuscular mass with pain, swelling/induration days to weeks following injury
myositis ossificans diagnosis
elevated alk phos, ESR, CRP
periosteal bone reaction, calcification with radiolucent center
myositis ossificans management
ROM exercise and NSAIDS, surgical excision
cause of decreased urinary force and incomplete emptying of bladder in young man
urethral stricture
post op complications of Nissen fundoplication
Dysphagia, gas bloat syndrome, gastroparesis
common cause of ludwig angina
dental infections
bronchial carcinoid tumor manifestations
proximal airway obstruction, recurrent pneumonias distal to obstruction, hemoptysis, carcinoid syndrome
bronchial carcinoid tumor diagnosis
contrast enhanced tumor with endobronchial component
most common cause of empyema
aspiration pneumonia leading to translocation of oral flora
first line therapy for IBD induced toxic megacolon
IV corticosteroids
transfusion protocols for hemorrhagic shock
1:1:1 ratio of fresh frozen plasma, pRBCs, and platelets
hiatal hernia findings
retrocardiac opacity with an air fluid level
ankylosing spondylitis exam findings
reduced chest expansion/spinal mobility, enthesitis, dactylitis, uveitis
ankylosing spondylitis complications
osteoporosis, vertebral fractures, aortic regurgitation, cauda equina
nonbacterial thrombotic endocarditis workup
hypercoagulable work up and investigation for malignancy
chemical pneumonitis onset timing
minutes to hours of exposure
chemical pneumonitis treatment
nothing, will resolve within 36 hours
acute lung transplant rejection timing
w/n 6 months of transplant
acute lung transplant rejection workup
BAL w/ biopsy to rule out infection
treatment of mild UC
mesalamine/sulfasalazine enemas
symptoms of cataracts
blurred vision, glare, halos around lights
predictors of severe acute pancreatitis
systemic inflammatory response syndrome symptoms or intravascular volume depletion
ileus x-ray findings
no transition point, dilated loops of bowel, air in colon/rectum
management of sigmoid volvulus
endoscopic detorsion and elective sigmoid colectomy
achilles tendon rupture physical exam test
calf squeeze test does not provoke movement, absent foot plantar flexion
stomal stenosis symptoms
nausea, postprandial vomiting, GERD, dysphagia following roux-en-y gastric bypass
stomal stenosis diagnosis and treatment
EGD
middle mediastinal masses
lymphadenopathy/lymphoma, benign cystic masses, vascular masses, esophageal tumors
posterior mediastinal masses
neurogenic tumors, spinal mets, lymphoma
causes of post op fever, 0-6 hours
tissue trauma, blood products, malignant hyperthermia
causes of post op fever, 24 hours - 1 week
nosocomial infections, SSI/catheter site infection, noninfectious
causes of post op fever, 1 wk - 1 mo
SSI/catheter site infection, C. diff, drug fever, PE/DVT
causes of post op fever, >1 mo
viral infections, SSI
priapism causes/risk factors
autonomic dysfunction, altered blood viscosity, medications/drugs
Massive PE presentation
patient with elevated thrombotic risk, sudden onset hypotension/syncope and acute RV strain ( RBBB, elevated JVP)
treatment for distal radius fractures
immediate reduction
hemodynamic alterations of mitral stenosis
elevated pulmonary artery pressures with normal left ventricular pressures (passive pulm htn)
popliteal cyst clinical presentation
asx bulge behind knee that diminishes with flexion, posterior knee pain, swelling, stiffness
popliteal cyst complications
venous compression, dissection into calf, and cyst rupture with arc of ecchymosis distal to the medial malleolus
acute epididymitis manifestations
unilateral posterior testicular pain, epididymal edema, pain improved with elevation, dysuria and frequency
chronic osteomyelitis diagnosis
probe to bone test, lytic lesions w/ loss of cortical and trabecular bone, surrounding sclerosis, periosteal thickening
chronic osteomyelitis management
surgical debridement, abx
signs of urethral injury
blood at the meatus, high riding prostate
testing for urethral injury
retrograde urethrography
first line abx for clean procedures
cefazolin, vancomycin, clindamycin
paroxysmal sympathetic hyperactivity effects
rapid onset tachycardia, hypertension and tachypnea
paroxysmal sympathetic hyperactivity cause
TBI and damage to lower sympathetic center inhibition
axillary nerve damage results
weakened shoulder abduction, sensory innervation to the lateral shoulder
polycystic kidney disease presentation
hypertension, hematuria, recurrent flank pain
ischemic colitis diagnosis
colonic wall thickening, fat stranding, edematous and friable mucosa
ischemic colitis pathophysiology
nonocclusive watershed ischemia from underlying atherosclerotic disease or state of low blood flow (vascular surgery)
most common type of damage in high voltage electrical injurites
severe damage to internal structures i.e. skeletal muscle necrosis leading to compartment syndrome, rhabdomyolysis annd pigment induced acute kidney injury
spontaneous pneumothorax signs and symptoms
chest pain, dyspnea, decreased breath sounds, decreased chest movement, hyperressonat to percussion
spontaneous pneumothorax management
small - observation w/ o2 administration
large and stable - needle aspiration or chest tube
arginine vasopressin deficiency
dysfunction of AVP producing neurons within the first days to week after pituitary manipulation
SIADH
uncontrolled release of AVP from neurons for several days after the procedure lasting up to a few weeks
ewing sarcoma evaluation
x-ray - central lytic lesion with moth eaten appearance and onion skinning
biopsy - small uniform round blue cells
signs of undiagnosed pancreatic injury
persistent abdominal discomfort or nausea, increasing amylase, peripancreatic fluid collection
tumor marker for thyroid cancer post thyroidectomy
thyroglobulin
left ventricular aneurysm clinical presentation
heart failure, angina, ventricular arrhythmia and systemic embolization
limb ischemia in asx patient cause
embolic arterial occlusion
pilonidal disease presenting symptoms
painful fluctuant mass cephalad to the anus in the intergluteal region with associated mucoid, purulent or bloody drainage
initial management of acute cholangitis
endoscopic sphincterotomy
hidradenitis suppurativa
chronic/recurrent lesions in intertriginous areas with painful nodules and draining abscesses, sinus tracts and scarring, or extensive sinus tracts and widespread disease
hidradenitis suppurativa treatment
prolonged antibiotic therapy, surgical excision only when severe
most common cause of post op hematoma in patients w/o family hx of easy bleeding or bruising
insufficient hemostasis
best management of gallstone pancreatitis
ERCP
indication for emergent thoracotomy
initial large volume of bloody output from chest tube or persistent hemorrhage
spondylolisthesis clinical features
low back pain worsened by extension, radiculopathy, palpable step off
spondylolisthesis management
activity modification, pain control, MRI of spine if neuro deficits or long standing symptoms
most common areas affected by ischemic colitis
splenic flexure and rectosigmoid junction
distal radius nerve damage
median nerve
median nerve compression symptoms
paresthesia of lateral 3.5 digits, impaired thumb abduction
first step in management of burn patients who require aggressive fluid resuscitation
urethral catheterization
biggest contributor to plantar foot ulcers in T2DM patients
sensory, autonomic and motor neuropathy
tarsal tunnel syndrome presentation
burning pain, numbness or paresthesia in the medial ankle, heel, sole and toes
tarsal tunnel syndrome management
activity modification, orthototics, NSAIDs, steroid injection
tarsal tunnel syndrome pathology
compression of posterior tibial nerve under the flexor retinaculum in the medial ankle
