WiseMD Modules 2 Flashcards
45 yo F p/w periumbilical colicky pain and abdominal distention x2d, N/V, no stool/flatus x48h
- PSH: appendectomy at 14 yo
- BS: rare and high pitched
- PE: rebound on deep palpation
- WBC 15k
- plain film: dilated proximal small bowel w/ pneumatosis
(a) Dx
(b) Mgmt
(a) Dx = SBO
(b) Next step = NG tube, IV fluids, exploratory laparotomy
- surgery indicated since signs of peritonitis (rebound) and pneumatosis are concerning for bowel necrosis
- also indication for surgery = leukocytosis
Describe the transition epithelium makes at the dentate line and how this correlates to which type of hemorrohoids bleed
Dentate line = where rectal columnar mucosa meets squamous epithelium
-squamous epithelium is like skin, wouldn’t just spontaneously bleed = why external hemorrhoids are less likely to bleed
70 yo M w/ 15mins of weakness and paralysis of right arm w/ difficulty speaking
- similar episode 3 days ago, both times syptoms resolved
- PE: b/l carotid bruits
(a) Next step?
(b) Dx
(a) Next step = carotid duplex ultrasound
(b) Dx = TIAs, use US as first line b/c noninvasive way of diagnosing carotid stenosis/occlusion
-not recommended to use contrast (for contrast CTA) w/in first 24 hrs after onset of neurologic symptoms
First step in management for TIA
TIA management
First step = carotid ultrasound
-get that first before MRA/MRI
-anticoagulation is NOT recommended for tx of TIA
What are you looking for during rectal exam when suspecting SBO?
- presence or absence of stool (if there’s stool they’re probably not obstructed)
- guiac positivity
- masses
White count expected in
(a) Acute appendicitis
(b) Perforated appendicitis
White count seen in
(a) Acute appendicitis = can be normal, often mild-moderately elevated to 12-15k
(b) Perforated appendicitis = crazy high like 18-20
Three physical exam signs indicative of acute appendicitis
Acute appendicitis on physical exam
- Rosving’s = pain in RLQ when pressure applied to LLQ
- Obturator sign = bend right leg at knee and rotate, exacerbates pain
- Psoas sign = pt rolls away, pull straight leg away behind the pt which exacerbates pain
Post-op management of exploratory laparotomy for SBO
- Give IV fluids
- remove NG tube when output is less than 200-250 cc/shift
- can start PO fluids once the pt passes gas
80 yo F p/w 2 days of abdominal distention and obstipation
- no h/o previous surgeries
- Plain abdominal film: distended, coffee-bean loop of bowel w/ haustral markings in RUQ
Dx
Dx = sigmoid volvulus
-give away is the coffee bean sign
Haustral markings => you know it’s large bowel, distention and severe constipation (obstipation) => large bowel obstruction
One of the etiologies of mechanical LBO is volvulus
Narrowest part of an airway in a 6 yo
Cricothyroid junction- so a cricothyroidotomy is contraindicated in young children for emergency airway access
Needle jet ventilation and eventual tracheostomy in young children who need emergency surgical airway
What are you feeling for on the digital portion of a rectal exam?
Rectal tone, any palpable masses, any tenderness
-not feeling for hemorrhoids (most are way too small to feel)
Differentiate anoscope and proctoscope
Similar concept to gynecologic exam- anoscope looks into anus, while proctoscope goes further to assess entire length of the rectum
Post-op care for perirectal abscess drainage
(a) Symptomatic care
(b) Long term mornitoring
Post-op care for perirectal abscess drainage
(a) Symptoms after surgery are most commonly 2/2 levator ani spasms => sitz bath (literally submerge up to waist in warm water)
(b) Long term monitoring for anal fistula
List the causes of the two types of SBO
SBO: mechanical obstruction or motility issue
Mechanical obstruction: 60% adhesions, 20% tumor, 10% hernia, 5% Crohn’s
Functional obstruction = paralytic ileus
55 yo M w/ 15-yo burn wound that has recently changed and started increasing in drainage
Next step
Recent change in chronic wound needs biopsy- check for Marjolin’s ulcer = squamous cell carcinoma that develops in a chronic burn wound
40 yo F p/w 2d periumbilical colicky pain and abdominal distention, N/V, no stool/flatus x2d
PSH: hysterectomy
Dx and etiology
Adhesive small bowel obstruction
-if w/o surgical history, would consider other etiologies of SBO like tumor, hernia, Crohn’s
List the causes of the two types of LBO
LBO: mechanical obstruction or motility issue
Mechanical: color cancer, diverticulitis, volvulus
Functional = Ogilvie’s syndrome = colonic ileus
72 yo F p/w 2d vom and intermittent colicky abd pain
- distended abdomen, mildly tender
- 10 yr h/o postprandial upper abdominal pain
- high pitched and tinkling BS
- Plain film: branching air collections over liver w/ distended small bowel and decompressed colon
Dx
(a) Explain imaging
Dx = gallstone ileus
(a) Branching air collections over liver = portal venous air, complication of bowel obstruction
- typical of SBO 2/2 gallstone stuck at the ileo-cecal valve
65 yo F 18 hrs s/p l. carotid endarterectomy w/ left mouth droop when asked to smile
(a) Cause of facial droop
(b) Mgmt
(a) Injury to marginal mandibular branch of the left facial nerve
(b) Most likely 2/2 mechanical disruption of nerve in surgery, not due to permanent nerve damage => no further mgmt. needed
How the following change risk of anorectal disease
(a) Diabetes
(b) Cirrhosis
(c) HIV/AIDS
Diabetes and cirrhosis increase infection risk => increased risk anorectal abscess
HIV/AIDS increase risk for AIN and other noeplastic processes of the anorectal region
What to check at post-op f/u visit after lap appy
- wound site for wound infection
2. palpate for RLQ fullness to detect intraabdominal abscess
Perianal vs. perirectal abscess
(a) Clinical features
(b) Tx
Perianal abscess- small, no signs of surrounding cellulitis
-can be drained in the office, no need for abx
Perirectal abscess- significant surrounding cellulitis
-drain in the OR (b/c need a lot of anesthesia) and give post-op IV abx
2 complications of perirectal abscess drainage
Complication of drainage of perirectal abscess
- incontinence (esp to flatus) if abscess goes into rectal muscles
- development of fistula in-ano (abscess heals leaving opening btwn anus and skin)
Surgical indications for SBO
No prior abdominal surgery (only can medically manage SBOs 2/2 adhesions)
-febrile, leukocytosis, peritonitis, incarcerated hernia, primary SBO (tumor)
Or if medically managed but pt worsens or doesn’t improve w/in 2-5 days
Open vs. laparoscopic laparotomy for SBO management
Most of the time chose midline incision over laparoscopic b/c pt so distended that you can’t pump enough air into abdomen to visualize laparoscopically
Benefits of lap appy over oven appy
Decrease rate of infection, decreased pain, shorter LOS (faster recovery)
63 yo F p/w abdominal distention and obstipation x2 days, vomit x2
-2 mo h/o diffuse dull lower abdominal pain and change in bowel habits
Dx
Dx = colon cancer
-more of a chronic process causing obstruction
When to use allograft vs. autograft in wound healing
Autograft (self-graft) is permanent closure, but sometimes the burn surface area might be too much so you need to use cadeveric allograft which is temporary
23 yo F p/w crampy abd pain, N/V x2d
- similar episodes in the past which spontaneously resolve, no PSH
- +guiac test
Abdominal CT most likely to show what?
Inflammation of terminal ileum
SBO 2/2 Crohn’s disease, fits w/ symptoms/time line, repeat episodes, bloody stool
-terminal ileum = most common location in the GI tract affected by Crohn’s
81 yo M asymptomatic, found to have right carotid bruit
-Carotid duplex US shows >80% stenosis bilaterally of external carotids
Next step?
Next step = observation and anti-platelet therapy
-key is EXTERNAL artery stenosis, which is not associated w/ significant risk of TIA/stroke
22 mo old boy p/w paroxysms of severe colicky abdominal discomfort
-plain film: dilated loops of small bowel
(a) Dx
(b) Next step
(a) Intussusception = loop of bowel going in and out of target point
(b) Next step for both diagnosis and therapeutic benefit = barium enema
80 yo Fs/p hip replacement p/w constipation and abdominal distention x4 days
Dx
Ortho procedure => pt probably on opioids = common cause of colonic ileus (Ogilvie’s syndrome)
= Functional etiology of LBO
TIA vs. CVA
(a) Clinically
(b) Imaging Findings
Transient ischemic attack
(a) Clinically symptoms are under 24 hrs, transient
(b) Ischemia, but NOT infarct
Cerebral vascular accident
(a) Symptoms persist over 24 hrs
(b) Infarction
70 yo M w/ 2hrs of right arm/leg weakness and speech difficulties
- symptoms slightly improved, but weakness still present
- b/l carotid bruits
Best next step
Next step = CT w/o contrast
-get CT w/o contrast to exclude evidence of bleed (r/o intracranial hemorrhage) before considering lytic therapy w/ tPA
Next step after suspecting sigmoid volvulus from history, physical, and abdominal plain film
Next step for sigmoid volvulus = sigmoidoscopy, then surgery after
-sigmoid volvulus requires decompression prior to definitive surgery to avoid recurrence
4 risks of ANY AND ALL SURGERIES
- bleeding
- infection
- recurrence of the problem
- injury to nearby structures
Briefly describe pathophysiology of acute appendicitis
Acute appendicitis develops due to appendiceal lumen obstruction (lymphatic hyperplasia, infection, IBD, etc)
- intestinal bacteria in the appendix multiple => WBC recruited => pus and increase in pressure
- then when intraluminal pressure overcomes venous pressure you get venous outflow obstruction => ischemia => gangrene/necrosis etc
Name the three structures in the carotid sheath
- carotid artery
- internal jugular vein
- vagus nerve
Complications to monitor for s/p exploratory laparotomy for SBO
Much higher complication if bowel had to be resected or anastamosed (b/c exposing outside to intraabdominal contents)
- intra-abdominal abscess POD5 of later
- anastamotic leak
65 yo F 2 hrs s/p carotid endarterectomy develops tense swelling of neck on side of surgical incision
-reports choking sensation and increasing SOB
Next step?
Immediately decompress the surgical wound
-relieve the hematoma before intubating (you won’t be able to intubate w/ all the blood in that area!)
Decompress wound from carotid endarterectomy by relieving all three layers (skin, superficial cervical fascia = platysma, deep cervical fascia)
60 yo M w/ lower abdominal pain and tenesmus x5d
- 2 previous episodes managed outpt
- h/o chronic constipation
- 100.8F
- LLQ tenderness w/ guarding w/o rebound
- WBC 12.4
(a) Dx
(b) Next step
(a) Dx = diverticulitis- often presents w/ low grade temp, LLQ pain and tenderness, and leukocytosis
- supported by previous episodes
(b) Next step = CT to confirm diagnosis and r/o other possibilities, also see if diverticulitis is complicated (ex: by perforation or abscess)
55 yo M w/ sudden inability to speak coherently
- knows what to say, but cannot find the words
- no weakness/numbness, no trauma
- BP 160/90
- can write coherently, but cannot find words to speak
(a) Name this condition
(b) Locate the cerebral defect
(a) Aphasia = inability to find the right words
(b) Aphasia caused by ischemia of the pt’s dominant hemisphere
For right handed pt: expect embolus to left anterior circulation
Pt p/w intense pain during defecation that lasts a for a few minutes after completion
Most likely dx
Anal fissure
- pain lasts 2/2 spasms of levator ani muscle
- intense pain => localizes issue to below the dentate line
36 yo M w/ 24h of diffuse abdominal pain, obstipation, N/V
- appendectomy at 5 yoa
- normal VS
- distended abdomen w/ high pitched BS and tympanic percussive sounds, TTP over all 4 quadrants
Most likely cause of obstruction?
Adhesions
-don’t get confused by demographics (36 yo M) and think internal hernia, hernias only account for 5% of SBOs while adhesions (which can even be from minor surgeries) account for 60% SBO
Anterior vs. posterior cerebral ischemia symptoms
Which would be expected from carotid endarterectomy clot?
Clot from carotid –> middle meningeal artery –> end branch vessel anteriorly causing anterior symtpoms
Anterior symptoms: contralateral weakness, contralateral numbness, ipsilateral monocular blindness
vs. Posterior symptoms of diplopia (double vision), dysarthria (trouble w/ speech), ataxia, circumoral numbness
When can SBO be managed w/o surgery?
Only ppl who are candidates for medical surgery are those who you are saying cause is adhesions
=> if pt has no previous abdominal surgeries you can’t manage them medically!
Pt must be: afebrile, normal white count, no signs of peritonitis
Most common location for carotid body tumor?
(a) Appearance on MRA
(b) Mgmt
At the carotid bifurcation
(a) very vascular w/ abundant supply from external carotid artery
(b) Surgical resection
- Doesn’t respond to radiation, can’t just leave it b/c it tends to expand and cause mass effect
25 yo M w/ severe bloody diarrhea and abdominal pain x4 wks w/o f/c, obstipation x1d
- h/o 2 similar episodes tx outpatient
- PSH: appendectomy at age 12
- WBC 11.3, Hb 12
Dx
Dx = Crohn’s
- progressive symptoms w/ bloody stool in right age group
- adhesive SBO wouldn’t have bloody diarrhea (or chronic time course)
70 yo M 1 hr s/p left carotid endarterectomy develops RUE weakness
Next step
Next step = immediate re-exploration of carotid artery
- occlusion of LCA at endarterectomy site
- suspecting embolic event s/p endarterectomy = immediate surgical re-exploration
What would you expect to see on abdominal physical exam in a pt w/ SBO
(a) Inspection
(b) Auscultation
(c) Percussion
(d) Palpation
(a) Inspection- central distention, no visible masses, possible scars from previous surgeries
(b) Auscultation- really nonspecific findings, potentially hear high pitched rush (but really not a reliable finding)
(c) Tympanic/hyperresonant to percussion indicating air and not fluid in the bowel
(d) Palpation- mildly tender to palpation, but no guarding or masses/organomegaly
71 yo M s/p TIA, carotid duplex US showing over 80% stenosis of left internal carotid artery
Next step?
Next step = carotid endarterectomy b/c symptomatic and stenosis over 70%
-if asymptomatic, cutoff would be stenosis over 80%
70 yo M w/ several 10 minute episodes of transient blindness in left eye over 2 weeks
- Fundoscopic exam: yellow highly retractable debris in left eye
- carotid duplex US: >80% stenosis of internal carotids b/l
(a) Dx
(b) Next step?
(a) Dx = episodes of amaurosis fugax
- presence of Hollenhorst plaques (in retinal artery) on fundoscopic exam
(b) Next step = further characterization of the anatomy w/ CTA of head and neck
- also confirms degree of stenosis provided by US
Pre-op mgmt of acute appendicitis
- Start IV fluids
2. Start IV abx (often Cefoxitan)
60 yo F w/ incidental finding of left carotid bruit
-Carotid duplex US showed 50% stenosis of left internal carotid artery
Next step
Next step = anti-platelet therapy (ASA) w/ repeat duplex scan in 12 mo
-no indication for surgery given asymptomatic and less than 80% stenosis
Why is it indicated to do a UA on a pt in which you suspect SBO?
UTIs can cause paralytic ileus, which is a functional etiology of SBO
Technique used to ensure contrast is in the right place when assessing for acute appendicitis
1 hr post contrast ingestion- use scout radiograph (abdominal Xray) to ensure that the contrast is in the right colon
-need contrast to make structures visible, almost impossible to diagnose acute appendicitis w/o contrast
