Surgery Pestana Flashcards Preview

00Step 2 > Surgery Pestana > Flashcards

Flashcards in Surgery Pestana Deck (675):

which pts do not require an airway placed

fully conscious and normal voice


which pts require an airway

going to lose airway soon:
-expanding hematoma (quick induction then intubate)
-subcutaneous air/tissue emphysema

need airway now:
-gurgly noises
-spinal cord injury (airway needed first)
-facial trauma (cricothyroidotomy


what does subcutaneous air/tissue emphysema indicate?

signifies tracheobronchial injury


how do you manage tracheobronchial injury

intubate over fiberoptic bronchoscope


how do you you manage a pt with spinal cord injury and needing an airway

(pts will present with neck pain pro unable to move extremities)

establish airway first:
-nasotracheal over fiberoptic bronchoscope
-do not move/hyperextend neck
-do not pick CT/XR as first action


how do you evaluate breathing?

-pts are starting their own breathing motion
-both lungs are spontaneously inflating
-O₂ is being put into blood (O₂ sat)


how does a classic trauma shock pt present?

BP <90
tachy, poor quality pulse
diaphoretic, pale, cold, shivering, anxious
trauma scenario


what are the 3 conditions responsible for shock in trauma

pericardial tamponade


what is the most common cause of shock in trauma

hypovolemic hemorrhagic shock


where hypovolemic hemorrhagic shock present

>1.5L lost
not enough space in head
neck and arm bleeds are visible
pericardial sac --> tamponade + high CVP
pleural cavity --> seen on CXR
abdomen, pelvis, thighs can hide big bleeds (pelvic instability, femur fractures)

empty (non-distended) veins


how do you manage hypovolemic hemorrhagic shock

-ex lap

STOP BLEEDING before prioritizing resuscitation fluids, w/ exceptions
-"scoop and run" if you're near medical help and you know where bleeding is (direct finger pressure)

2 large-bore (16 gauge) peripheral IVs:
arms, ankles, femoral vein
-1-2 L balanced electrolyte soln (LR; sugar = osmotic diuresis = invalidate UOP)
-followed by blood as available

eventually monitored by pt response and UOP/CVP

last-resort access in child:
intraosseous cannulation in proximal tibia
-20mL/kg initial bolus


how do you identify pericardial tamponade in trauma setting

trauma to chest
DISTENDED VEINS; high CVP >20-25 (must be mentioned)


how do you manage trauma pericardial tamponade

it's based on clinical dx,
don't ask for CXR or blood gases

empty the pericardial sac (window, pericardiocentesis, decompression)

meanwhile, give fluid and blood
-heart is not failing, the ventricle just cant feel blood from the pressure buildup
-more blood = more to squeeze = somewhat improve status

fix the underlying problem:
-start w/ sternotomy if tamponade is the only problem


how do you identify tension pneumothorax in trauma setting

trauma to chest
-labored breathing/no breath sounds/tympany
-deviated trachea
-high CVP


how do you manage tension pneumothorax

based on clinical dx,
don't ask for CXR, CT, or blood gases

immediately decompress pleural space's pressure
-large bore needle in 2nd intercostal pleural space
-follow with chest tube on suction and water seal


what 3 things can cause shock in non-trauma setting



how does non-trauma bleeding shock happen

spontaneous; ruptured ulcer


how does cardiogenic shock happen

non-trauma setting:
-Myocardial infarction


how do you manage cardiogenic shock

Tx the MI

do not give fluids (this is intrinsic shock)


what is vasomotor shock

loss of peripheral vascular tone
-low CVP, low BP, tachy

-bee sting, penicillin allergy, spinal anesthesia)


how do you manage vasomotor shock

restore vascular tone that's been lost

(volume replacement does not hurt this pt)


which head traumas need to be taken to the OR vs ER?

-penetrating trauma (repair entry spot and control possible bleeding)
-comminuted depressed skull fracture

-linear skull fracture
-scalp laceration


what is required for every pt who has LOC

CT scan


what is indicated by:
ecchymosis in eyes or behind ear
clear fluid dripping from nose

basilar skull fracture


how are basilar skull fractures managed

evaluate airway
CT to look for potential hematoma
**also get cervical XR or CT head+neck to evaluate for neck injury, since this is big trauma

-the skull fracture itself doesn't need tx
-Abx are not indicated


what head injury is caused by BIG trauma (like highway car crash)

subdural hematoma


how does subdural hematoma present on CT

concave semilunar crescent shaped hematoma
midline structures may shift to opposite side


management of subdural hematoma?

(neurosurgeons do craniotomy/decompression if structures are shifted)

control ICP:
avoid fluid overload


what is prognosis of subdural hematoma

grim prognosis-
original trauma does a lot of damage


how does chronic subdural hematoma present

elderly and alcoholics
-brain shrinks, can easily rattle, and tear venous sinus

slow bleed
-ex. become senile over 3-4 weeks


how do you manage chronic subdural hematoma

decompress/evacuate the hematoma

memory loss will return to normal


how does epidural hematoma present in pt and on CT

2/2 trivial trauma (baseball bat)
pt will be completely normal between LOC (LUCID INTERVAL)
blown pupil on ipsilateral side of injury

biconvex/lens shape
midline structures shift to opposite side (especially w/ materializing sings)


how do you manage epidural hematoma

emergency craniotomy to evacuate the clot

excellent prognosis


what is a major concern of an acute hematoma?

CNS damage:
-the initial trauma's damage isn't fixable
-hematomas may push midline structures, which is fixed with surgery
-swelling frequently follows trauma and ICP (mostly a medical fix)


how does a diffuse axonal injury present in pt and on CT

trauma, coma, bilateral fixed pupils

-diffuse blurring of grey/white interface
-multiple small hemorrhages
-no single large hematoma or displaced midline structures


how do you manage diffuse axonal injury

no indication for surgery (no single large hematoma or displaced structures)

correct the high ICP without pushing the pt to dehydration


what are the absolute indications to go to the OR in neck trauma pts

any penetrating injury where pt is rapidly deteriorating
(low BP, not responding to fluids)

all GSW to middle neck
(asymptomatic stab to middle neck = observe)

any evidence of injury to important structures
(spitting up blood = tracheobronchial)
(hematoma = major vessel)


how do you manage upper neck trauma

need proximal and distal control before fixing
-difficult to operate
-angiogram to identify injury
-radiologist to embolize bleeding vessel


how do you manage base of neck trauma

Dx studies before operating
-arteriogram, esophagram, bronchoscopy, etc


what type of spinal cord injury presents with:
different sides/different functions
(R trauma = loss of proprioception on R; loss of pain on L)

AKA Brown Sequard Syndrome


what type of spinal cord injury presents with:
loss of motor, pain, temp on both sides distal to injury
with preservation of vibratory/positional sense

anterior cord syndrome


how does anterior cord syndrome happen

blow out of vertebral body
-spinal cord is posterior to vertebral body
-anterior section is damaged first
-posterior cord is preserved

can also be seen with vascular puppy injury


what spinal cord injury occurs with neck hyperextension

central cord lesion


how does central cord lesion present

neuro damage in UE
LE largely unaffected
(UE travels closer to center of cord)


what does some evidence suggest is helpful in improving outcome of spinal cord lesions?

high dose steroids ASAP


what are the bone clues of big chest trauma

first rib


what do you need to look for in major chest trauma

traumatic transection of aorta


how do you manage penetrating chest trauma

penetrating trauma rarely requires surgery in the chest

however, a blunt trauma can cause a penetrating trauma, like when a rib is broken and pierces lung to create a penetrating scenario


what are 3 things you need to consider with blunt chest trauma

pulmonary contusion
myocardial contusion
traumatic transection of aorta


what presents with "white out" lungs on CXR

pulmonary contusion


how do you determine if pulmonary contusion needs respirator, fluid restrictions/diuretic?

blood gases


how do you identify myocardial contusion

EKGs and cardiac enzyme monitoring

may be 2/2 sternal injury (tenderness, gritty bone-on-bone feeling by palp)


which portions of the aorta move where in a traumatic transection of the aorta 2/2 deceleration injury

ascending moves forward
descending stays put/stops

most of these pts die on scene


what tears in a small subset of aorta transection pts?

small subset of pts who don't die immediately get transection of intima/media with intact adventitia

a hematoma forms but is contained for several hours (asymptomatic)


what is the work up for traumatic transection of aorta

widened mediastinum = high suspicion (not diagnostic)

spiral CT

arteriogram if at least 1 of those 2 is positive


how does a pt develop pneumonia 2/2 rib fracture

elderly pt
hurts to breathe, avoids breathing, atelectasis, pneumonia


how do you manage rib fracture to prevent pneumonia

alleviate pain in a way that does not hinder breathing
-local anesthetic/nerve block that alleviates focal pain (Lidocaine)
-still allows pt to drive breathing

do not bind chest or prescribe heavy narcotics


what injury presents w/ large flap-like wound; sucking and air trapping with every breath

sucking chest wound


what happens to sucking chest wound if left untreated

pt will develop tension pneumo
(air trapping with every breath)


how do you manage sucking chest wound

occlusive dressing:
-vaseline gauze stuck to chest wall
-prevents air moving in during inspiration
-taped on 3 sides to push some air out during expiration


what injury presents w/ paradoxical breathing

flail chest

(caves in with inhalation; bulges with exhalation)


how do you manage flail chest

tx underlying pulmonary contusion
-fluid restriction and diuretics (sensitive to fluid overload)
-give colloid over crystalloid
-measure blood gases to watch for deterioration and intubate as needed
-need a preventative chest tube if you intubate

continue to monitor for less obvious injuries:
-MI, transection, etc


what presents with shock, distended neck veins, and no breath sounds

tension pneumothorax


how do you manage tension pneumo

needle for air escape


what presents with penetrating trauma, STABLE VITALS, no breath sounds?

plain pneumothorax


how do you manage plain pneumothorax

CXR first
-no need to rush with placing an emergency needle

then chest tube in 2nd intercostal space


what presents with penetrating trauma, SOB, stable vitals, no breath sounds at base, dull to percussion, faint/distant breath sounds at apex?



how do you manage hemothorax

CXR first
-pt is not actively dying; confirm hemothorax


where are most pts bleeding from in a hemothorax

most are bleeding from lung (a low pressure circuit)
-bleeding usually stops on its own (seldomly need to operate)


how do you manage a hemothorax

if there's penetration, there's risk of infection/empyema

chest tube to evacuate pleural space


how can you identify bleeding source in hemothorax

place a chest tube:

lung bleed = some bleeding that tapers in next hour

systemic bleed = significant bleed and hypotension (commonly intercostal)
-sums to 600cc in 6 hours
-need a thoracotomy to stop bleed


what does a large, single air/fluid level mean

need to manage both blood and air conditions in the lungs

begin with a chest tube


what does multiple air/fluid levels in chest mean

bowel in chest


how does bowel in chest present

traumatic rupture of diaphragm
always L side
need abdominal surgical correction
imaging shows NG tube tip curve up into the chest


what are 4 causes of air in chest

esophageal perforation
tension pneumo
major tracheobronchial injury
air embolism (rare)


what scenario would you connect w/ esophageal perforation

ex. pt had endoscopy and now has air in chest


how do you confirm dx of major trachobronchial injury

something has ripped in 2:
fiberoptic bronchoscopy to guide the airway/visualization to confirm dx


how would you get air embolism sudden death in post-trauma intubated pt


chest tube in pleural cavity
pt was previously hemodynamically stable
sudden cardiac arrest
injury to major bronchus and adjacent major vessel
respirator blows air into lung, leaks to vessel, travel to ventricle --> arrest


how would you get air embolism sudden death in an awake pt

major vein near SVC becomes open to air in awake pt
if it happens when pt is inhaling to give neg pressure, it may suck enough air into the ventricle to make it foam --> arrest

put pt in Trendelenburg L side down; tube to suck air; cardiac massage

many pts die


how does fat embolism present

severe trauma with long bone fractures
disorientation 12 hors later
petechial rash in axilla and neck
febrile, tachy
low platelets

CXR shows bilateral fat infiltrate


how do you manage fat embolism

respiratory support and blood gas monitoring


what are the 3 circumstances where ex lap is required

every GSW to abdomen (below nipple line)

stab wound with clear penetration into abdominal cavity

penetrating or blunt trauma where pt develops acute abdomen


what is the prep process for ex lap

indwelling catheter

large bore venous lines

broad spectrum Abx


what are cons of diagnostic peritoneal lavage

invasive: cut belly + catheter

only gives yes/no; doesn't give origin, or whether or not bleeding will stop naturally

vignette must say pt is hemodynamically unstable / needing resuscitation***
otherwise, you'd get a CT


what are the pros of emergent CT scan

excellent to see presence of blood and source of bleeding


however, if pt is in shock/crashing, cannot leave ER to get CT scan
---must be hemodynamically stable (otherwise,get a DPL)


how is a splenic laceration/ rupture handled

surgeons will do everything possible to repair rather than remove a spleen, esp in children


when is a splenectomy (vs spleen repair) indicated

shattered beyond repair

other critical life-threatening injuries that require time/attention


what changes in a pt's immune status after a splenectomy

pt now needs immunizations against encapsulated bacteria to prevent sepsis
-pneumovax for pneumococcus
-immunize for H influenza meningococcus


when should you suspect a coagulopathy in an abdominal trauma pt

multi-trauma pt requiring massive blood transfusions
>10-12 units of blood

blood oozing from all dissected surfaces and IV sites

hypothermia + acidosis


how should you manage blood oozing from dissected surfaces and IV sites

pt has a coagulopathy

ideally, you'd do labs to determine what factor the pt needs,
but there's no time

shotgun approach:
give FFP and plt bags


what is pt's temp when oozing blood from IV sites?

nl core temperature


how do you handle a coagulopathy with hypothermia + acidosis

stop operation ASAP

give FFP and plts

pack all areas that are bleeding

rewarm and tx the coagulopathy before resuming operation


what is dx for surgical pt with abdominal wall edges that cannot be closed without tension

abdominal compartment syndrome

pt usually has lengthy ex lap procedure for multi-trauma abdomen
tension cutting through sutures, hypoxia, renal failure


what is the complication of pulling closed an abdomen w/ compartment syndrome

pulling closed --> unable to bleed, perfuse kidneys --> kidney failure


how is abdominal compartment syndrome managed

temporary closure w/ plastic or mesh stapled around opening


how can you identify a pelvic fracture

bleeding helped by fluids

pelvic hematoma

nearby viscera injury
-rectum and urinary bladder
-vagina (F)
-urethra (M)


how do you manage a pelvic hematoma

leave alone if not expanding


how can you evaluate a pelvic fracture

proctoscopic / pelvic exam


how do you manage a pelvic fracture

difficult to stop pelvic bleeding- unable to reach it easily in the OR


what is the hallmark of urological injury

trauma with hematuria


where could the blood be coming from in a urological injury

kidney, bladder, or urethra (M)


what does this story hint at as a source of urological bleed:

broken ribs with no fractured pelvis; flank injury

Kidney injury as source of bleeding


how do you manage kidney injury

a retrograde cystogram will be nl

CT scan next

most blunt kidney injuries don't require surgical repair
-RARE possible AV fistula development --> overload circulation --> HF --> bruit


what does this story hint at as a source of urological bleed:

pelvic fracture; blood at meatus; resistance from foley

bladder injury


where will dye appear on cystogram in a dome vs base/trigone of bladder injury

dome: dye will be seen in picture

base/trigone: dye will extravasate posterior/extraperitoneal; dye will not be seen
--you need a 2nd picture to identify this leak


what does this story hint at as a source of urological bleed:

blood in meatus

bladder or urethra injury


what is the next step when blood in meatus has been found

retrograde urethrogram w/ dye to find source of bleed: either bladder or urethra

do NOT place foley w/ evidence of potential urethral injury


what does this story hint at as a source of urological bleed:

high-riding prostate; sensation of needing to urinate but cannot

posterior urethra injury


how should you work up microhematuria in an adult vs pediatric pt

adult: inconsequential
big trauma justifies microhematuria

pediatric, esp w/ small trauma:
hematuria may be first sign of congenital abnormality or urinary tract
--need further studies


what should you order in a scrotal hematoma

sonogram to evaluate testicles


what injury results from "slip in shower" story

penile shaft hematoma


what is the complication in a penile shaft hematoma

fracture of the tunica albugenia / corpora cavernosa


how do you manage penile shaft hematoma

prompt surgical repair is indicated


what injury do you suspect in penetrating injury traveling antero-medial thigh

femoral artery/vein


how do you manage a femoral artery/vein injury

arteriogram, even if pt has normal pulses

hematoma needs immediate surgical exporation


what should you focus on first if pt has a combined vasculature, nerve, and bony injury

greatest urgency is vascular
--repair/recovery is very technical

however, you should set the bones first
--repair requires violent maneuvers that could undo your intricate vascular repair

nerve repair last


when and where is compartment syndrome likely to happen

likely to happen after prolonged ischemia --> reperfusion

most likely in the forearm and lower leg
--potentially permanently disabling


extent of GSW damage based on type of gun?

bigger bullet = more damage

low velocity <1500 ft/sec = injury limited to path of bullet
(civilian weapon)

high velocity >3000 ft/sec = E is dispersed into tissue; creates column of destruction; large exit wound
(hunting rifle, ex.)
likely needs debridement and amputation


what lab value makes you suspect a crush injury

myoglobinemia / myoglobinuria

--crush injury frees up myoglobin into blood --> kidney --> renal failure


how should you manage a crush injury

IV fluids, osmotic diuretics to protect kidneys

monitor serum K (released from crushed muscle cells)

possible fasciotomy 2/2 compartment syndrome


what are 3 types of thermal burns

confined environment burn

circumferential burn

small patch burn


what should you think of with a confined environment burn

think respiratory burn (chemical burn of upper respiratory tract)


how do you manage an upper respiratory burn

confirm dx with fiberoptic bronchoscopy

monitor with blood gases
---only tx is via respiratory support (no steroids, Abx, or airway)

tx w/ 100% O₂ (shortens the life of carboxyhemoglobin)


what should you suspect in a dry, white, 3rd degree burn called

circumferential burn


what happens in a circumferential burn

fluid escapes circulation and becomes trapped as edema

cuts off circulation to extremity


how do you manage circumferential burn

monitor circulation in that extremity
(pulse, cap refill, Doppler)

Escharotomy to enable skin to swell
--can do at bedside (skin is already anesthetized and contaminated)
--if the burn is on the trunk: escharotomy at breast plate w/ 4 cuts


what happens in a small patch burn

swelling underneath can easily push up eschar
--nothing happens


which burn is "the gift that keeps on giving"

chemical burn
--will continue to burn until chemical is removed
--eliminate the chemical ASAP


how do you manage a chemical burn

acid (battery) or alkaline (Drain-O) is the same

do not play chemist
remove clothing
running water for 30 min before going to ER

--exception: drinking liquid plumber (you can't drink water for 30min)
--play chemist a little bit


what should a pt immediately do after swallowing alkali substance

give diluted vinegar, orange/lemon juice


what should a pt immediately do after swallowing acid substance

give milk, egg whites, antacids


what is the concern with electrical burn

far more tissue destruction than what initially appears
--bone and muscles are readily cooked, even if exterior skin doesn't look that bad


how do you manage electrical burn

extensive surgical debridement
potentially amputation
monitor for myoglobinemia
look for vertebral compression fractures


what are 2 long-term sequelae in electrical burns

long-term sequelae of cataracts and demyelination


what are 2 burns suspicious for child abuse

bilateral burns on buttocks w/ moist blisters (2nd degree)

glove pattern of hand/foot being immersed in boiling water


what is the initial tx for burn victims

need vicious fluid resuscitation for ~2 days
--estimation formulas are used
--judge the adequacy based on UOP and CVP


what is the modified Parkland formula for adult surface area burns

Rule of 9s x 11 = 99%

9% head
9% each UE
9% x 4 in trunk (2 in front; 2 in back)
9% x 2 in each LE (1 in front; 1 in back)


what is the Parkland formula for child surface area burns

two 9%'s in head

trunk and UE's are same as adult
9% x 4 trunk
9% in each UE

three 9%'s total for LE


what is the modified Parkland formula to calculate fluid resuscitation

(Body weight kg) x (%burned up to 50%) x (A factor)

A factor = 2-4 for adults; 4-6 for peds

being burned >50% means you're already losing fluid at a max rate

#cc's of balanced electrolyte soln (LR) pt needs in the first 24 hours


how should you distribute the cc's of an electrolyte soln in a burn pt

give half in first 8 hours; other half over 16 hrs

pts typically cannot eat/drink; so give additional 2L for maintenance fluids


why should you not give a sugar fluid to burn pts

the osmotic diuresis invalidates UOP values


how do you manage resuscitation in burn pt on day 2 and 3?

day 2: typically needs ~half of first day fluids

day 3: trapped fluid tends to go back to pt; may see extensive diuresis


what is a good initial rate rule for fluid resuscitation

~1000/hr for >20% burn initially;
then monitor UOP to adjust


what is the normal UOP for fluid resuscitation

nl UOP is ~1cc/kg/hr, but anywhere between 0.5 -2x that is acceptable

(70kg M should produce 35-140 cc/hr)


what is the basic management for burn care

standard tetanus prophylaxis
suitable cleaning of areas; OR for cross-debridement
topical burn care (no parenteral Abx)
IV pain meds (cannot be subQ)
intensive nutritional support (GI tract; high calorie; high Nitrogen)
rehab beginning on Day 1 (function, not survival, is endpoint)

graft areas that did not regenerate after 2-3 weeks
or, take pt to OR on Day 1 if severe burn is isolated and can easily be grafted
--save time, money, pain/suffering


what are the 3 types of topical burn care depending on pt presentation (standard, severe, eyes)

standard: silver sulfadiazine
--soothing white paste; works well against bacterial infection

deep penetration w/ thick eschar or involved cartilage: mafenide acetate
--painful; can produce acidosis

near eyes: triple Abx ointment


how do you manage a bite from a provoked domestic dog

tetany prophylaxis

dog is presumably vaccinated and provoked, so has low risk of rabies
--no rabies prophylaxis needed
--vet puts animal under observation to look for rabies indication


how do you manage a wild animal (ex. coyote) bite w/ animal brought back alive

can kill animal to examine its brain and look for sings of rabies +/- rabies prophylaxis for bite victim


how do you manage bat attack w/o animal to examine

rabies prophylaxis

includes immunoglobulin + vaccine


what is the description of a venomous rattlesnake

elliptical eyes fixed behind nostrils, big fangs, rattles


how do you manage a snake bite, depending on timing and pt presentation

up to 1/3 of bites do not inject venom, even in a venomous snake

in ER 1 hr after bite; no local plain, swelling, or discoloration = no venom
--tx: wound cleaning, tetanus prophylaxis, observation

in ER 1 hr after bite; local pain, edema, ecchymosis = venom
--tx: anti-venom in large doses
at least 5 vials; maybe 10-20
venom has to do with size of envenomation, NOT size of pt
immediately type and cross (venom eventually interferes)
Coag studies and renal/liver function tests
surgical excision is rarely needed

do not:
cut/excise bite area
elevate extremity
give sterods


how do you tx anaphylaxis 2/2 bee sting

(wheezing, hypotension, purulent rash)

tx: 1/2 to 1/3 cc EPI
remove stinger carefully


how does a black widow spider bite present

black spider w/ red hourglass
pt has N/V; severe muscle cramps


how do you tx black widow spider bite

Tx: IV Calcium gluconate +/- muscle relaxants


how does a brown recluse spider bite present

hurts when it happens; develop an ulcer overnight; dead skin w/ halo of erythema


how do you tx brown recluse spider bite

Tx: local excision of ulcer
get rid of venom
may need skin graft


how do you tx human bite / punch in the face?

ortho surgeons take to OR for massive irrigation and debridement to prevent bad infection
--could destroy joint


what is dx in newborn with uneven gluteal folds; hip can easily be dislocated posteriorly w/ jerk/click

developmental dysplasia of hip


what is the concern with developmental dysplasia of hip

permanent disability if not recognized early
--femoral heads can grow outside of socket


how do you dx and manage developmental dysplasia of hip

Dx w/ PE or sonogram
--XR in newborn is not helpful (not enough calcification)

manage: abduction splinting w/ pelvic harness; or double diapers


what is dx in ~6yo w/ insidious development of limping w/ decreased hip motion
+/- ipsilateral knee pain

avascular necrosis of capital femoral epiphysis


how do you dx and manage avascular necrosis

dx w/ XR

manage: controversial; some use casting/crutches


what is dx in ~13yo M, often overweight, with groin pain, limping, inverted foot; limited hip motion;
as hip is flexed, leg goes into external rotation and cannot be rotated internally

slipped capital femoral epiphysis


how do you dx and manage slipped capital femoral epiphysis

dx w/ hip XR

manage: ortho emergency
pin femoral head into position so it does not die


what is dx in ~toddler with febrile illness, then acute hematogenous osteomyelitis

septic hip


how do you dx and manage septic hip

dx w/ radio nuclear bone scan (not CT)
--XR takes too long to show osteomyelitis

mange: Abx


what age is bow legged normal

(genu varum)
normal up to 3yo

do not prescribe ortho braces/casts etc


how do you treat genu varum after 3yo?

pt likely has Bowen's disease if bow-legged persists past 3yo

needs surgical correction


what age is knock knee'd normal

(genu valgus)
normal up to 8yo

co not prescribe ortho braces/casts etc


what does knee pain w/o swelling generally indicate

intrinsic knee problem


what is dx and tx of tibial tubercle pain aggravated w/ quad contraction

osteochondrosis of tibial tubercle
AKA Osgood-Schlatter disease

Tx: immobilization of knee; extension cast 4-6 weeks


what is dx of baby born w/ both feet turned inward

club foot
AKA congenital talipes equinovarus

adduction of forefoot
inversion of foot
flexion of ankle
internal rotation of tibia


how do you manage club foot

serial plaster casts beginning in neonatal period
--start most distal and move proximally

50% respond in 6mo and don't require surgery
--do surgery <1yo before they're ready to walk


what is dx in ~F w/ curved spine; hump in thorax when bending forward in premenstrual growth spurt yrs


S-form is seen lateral in progression
progresses as long as skeletal maturity has not yet been reached


how do you manage scoliosis

corsets and casts +/- surgery until skeletal maturity

consider possible limited pulmonary function


what are "pros" of a childhood vs adult fracture

most have better outcome than adults- more plastic
faster healing and capacity for remoodeling- grow back straight


what are 2 bad childhood fractures


growth plate involvement


what is the concern w/ childhood elbow fracture

high risk of neovascular compromise
--monitor w/ cap filling; Doppler, pulse, etc for vascular supply


what is the fracture in elbow fracture

supracondylar fracture of humerus
--distal fracture displaced posteriorly


what is needed with childhood fracture involving growth plate

precise re-alignment is needed
--open reduction and internal fixation is best


what type of bone tumor has a sharply demarcated edge that distinguishes it from the rest of bone (boundary)

benign bone tumor


what type of bone tumor has fuzzy/ill-defined edge between tumor and bone

malignant bone tumor


what are the 2 buzzwords for malignant bone tumors on radiology

"sunburst" pattern (fuzzy demarcation edge)

periosteal onion-skinning (tumor is growing fast and displacing periosteum from bone; new layer of bone that gets displaced again)


what is the presentation of 2 childhood bone tumors:
osteogenic sarcoma vs Ewing sarcoma

osteogenic sarcoma:
around the knee (lower femur/ upper tibia)

Ewing sarcoma:
younger children
around diaphysis/shaft of bone


how do you manage malignant bone tumors

refer to specialized ortho surgeon
do not do anything invasive to this pt


what are most adult bone tumors (primary or metastatic?)



what is the most common primary malignant bone tumor in adults

multiple myeloma


what is dx in pt who is old, anemic, multiple bones involved; Benz Jones protein in urine; abnl immunoglobins

multiple myeloma


how do you tx multiple myeloma

chemo usually


what is a pathologic fracture and what does it signify

fracture 2/2 trivial event

signifies metastatic tumor presence


what does XR show on pathologic fracture

XR shows lytic lesion (eating bone) vs plastic lesion (growth of bone)


where do you assume bone metastasis in a male vs female

male: assume to be metastatic from lung

female: assume to be metastatic from breast


what fracture commonly occurs in osteoporosis

vertebral compression fractures

all others need some sort of trauma


what is generic dx of an older pt with soft issue mass that grows, hard, fixed


(don't know if it's lipo, fibro, chondro, rhabdo - sarcoma yet


how do you dx sarcoma


do not do invasive maneuver
-doc who discovers the tumor should not be doing the biopsy
-pt requires large tissue sample and open bx from a specialist


what imaging should you get for a fracture

XR at 90 degrees to each other;
include the obvious and suspicious fracture sites


how do you manage clavicle fracture

spint w/ figure 8 device for 4-6 weeks to retract shoulders


what is the buzzword for colles fracture

dinner fork shaped, painful wrist


what does XR show for colles fracture

dorsally displaced dorsally angulated fracture of distal radius;
small fracture of ulnar head

(dinner fork wrist)


how do you tx colles fracture

closed reduction and long arm cast

(dinner fork wrist)


what type of fracture gives you a broken ulna and a dislocated radius

Monteggia fracture

diaphysial fracture of proximal ulna with anterior dislocation of radial head


how does one typically get a Monteggia fracture

protecting with outstretched forearm

(broken ulna; dislocated radius)


what type of fracture gives you a broken radius and dislocated ulna

Galeazzi fracture


how should you cast a Galeazzi fracture

in supinated form

(broken radius; dislocated ulna)


what is the general rule for fixing broken bones and dislocated bones, respectively

open reduction/internal fixation for the broken bone

closed reduction for the dislocated bone


what bone is commonly fractured with FOOSH, wrist pain, tender to palp over anatomic snuff box

scaphoid bone

XR will be negative for 3 weeks, so clinical dx is useful


how do you manage scaphoid bone fracture

needs thumb spiker cast (not displaced)


what does a XR showing an adulated fracture of scaphoid notorious for

high rate of non-union/delayed healing (displaced)

this requires open/internal fixation


what is commonly fractured with a closed fist hit

fracture of 4th/5th metacarpal neck


how do you manage the 4th/5th metacarpal neck fracture (closed fist hit)

management depends on degree of angulation, displacement, or rotary malalignment

mild: closed reduction and ulnar gutter splint

severe: wire plate fixation


which should dislocation is most common

anterior dislocation


what is dx for pt presenting holding arm close to body; rotated out as if to shake hands; numb in deltoid

anterior shoulder dislocation


how do you dx and tx anterior shoulder dislocation

dx: AP/lateral XR

tx: reduction


what is dx for pt presenting with arm held close to body; internally rotated

posterior dislocation of shoulder


how do you dx and tx posterior shoulder dislocation

difficult to dx; may have history of small clinic visit + pain meds that aren't helping
(may occur when all muscles in body contract at same time- electrical burn, epileptic seizure, etc)

dx: axillary or scapular/lateral XR

tx: reduction


what is dx in shortened and externally rotated leg

broken hip


what is concern in femoral neck fracture

the fracture will likely kill femoral head 2/2 tenuous blood supply

if this occurs in an elderly pt, they'll be immobilized, pneumonia, and die


how do you tx femoral neck fracture

OR to remove femoral head and replace w/ metal prosthesis


how do you tx intertrochanteric fracture

open reduction and pinning

immobilization and anti-coag (esp in elderly pts at risk for DVT)


how do you tx/manage femoral shaft fracture

intramedullary rod fixation

monitor for hypovolemic shock
monitor for fat embolism (low pO2)
--resp support to improve oxygenation


what is likely dx in pt who has h/o repetitive use of bone beyond toleration; localized tibia pain in specific area of bone

stress fracture


how do you dx and tx stress fracture

XR is nl until later on

tx: cast


what should you suspect hours after cast alignment when pt c/o persistent pain, tight muscle compartments, extreme pain with passive extension of toes

compartment syndrome

severe disability if not recognized


how do you tx compartment syndrome in legs

emergency fasciotomy in all compartments (4 in legs) with 2 skin incisions


what is dx in out of shape pt who over-exerts, hears a loud pop; can initially move, but then progresses to being unable to move

achilles tendon rupture


how do you tx achilles tendon rupture

casting in equinus position (pt on tip toes to not stretch tendon) for several months

open surgical repair for faster healing


what is dx in pt who falls on inverted/everted foot

malleoli fracture

it doesn't matter which way they fall; both malleoli will be broken


how do you manage malleoli fracture, depending on what XR shows

XR shows good position fracture: casting

XR shows displaced fractures: open reduction and internal fixation for proper ankle healing


what is dx in pt with medial knee pain/swelling
passive abduction elicits pain
positive valgus stress test

medial collateral ligament injury


which direction can you bend knee in MCL injury

can bend leg further in direction of broken ligament (medial) without limited motion


what is dx in pt with lateral knee pain/welling
passive adduction elicits pain
positive varus stress test

lateral collateral ligament injury


how do you treat MCL/LCL injuries

hinge cast if that's the only problem

otherwise, surgical repair


what is dx in positive anterior drawer test

Anterior cruciate ligament tear


what is dx in positive posterior drawer test

posterior cruciate ligament tear


which imaging confirms a ligament tear



how do you manage knee ligament tear

immobilization and rehab for sedentary pts

athletes: arthroscopic reconstruction for quick healing


what is dx in pt with catching and locking of knee that limits its motion; click when forcefully extended

meniscus injury


how do you dx meniscus injury

XR is nl
difficult to dx
may have h/o small clinic visit with unhelpful tx

MRI shows meniscal tear


how do you tx meniscus tear

arthroscopic repair
try to save as much meniscus as possible to avoid degenerative arthritis


how do you manage pt with cast and compartment syndrome

always remove cast immediately if pt presents with pain under recently placed cast
---do not select analgesics or XR to confirm bone placement


what are pulses in compartment syndrome

presence of pulses does NOT rule out compartment syndrome


what is the buzzword for compartment syndrome

severe pain with passive extension


how do you manage exposed bone

OR, clean, cover, close bones within 6 hours
to avoid infection, osteomyelitis


what is dx in pt who hit dashboard with knees

posterior dislocation of hip

drives the femur out of the socket backwards


how do you manage posterior hip dislocation

reduction ASAP to prevent femoral head necrosis


what is likely dx in pt who stepped on rusty nail --> swollen dusky foot w/ gas crepitus 2-3 days later

gas gangrene


how do you manage gas gangrene

requires extensive debridement +/- amputation

immediate tx:
large doses IV penicillin
surgical debridement (bugs feed on dead tissue)
hyperbaric O₂ to deactivate toxin

life threatening soft tissue infection
--can happen to anyone (vs an infection mostly happening in an immunocompromised/diabetic pt)


how do you evaluate nerve symptoms in a bone injury

reduce fracture and re-evalutate nerve function
(ex humeral fracture could damage radial nerve)

you could trap nerve when splinting bones and cause nerve symptoms
--need open reduction to unwrap nerve


what artery is damaged with posterior dislocation of knee

popliteal artery


how do you manage popliteal artery damage

immediate reduction of posteriorly dislocated knee w/ Doppler, pulses, arteriogram studies

feeble collateral circulation could cause damage --> leg loss


what is dx in pt who falls and lands on feet

compression fracture of thoracic and lumbar spine


what should you also check in a pt with facial trauma

check cervical spine


what should you look for in pt with dashboard MVC injury

XR hip in MVC to evaluate a posterior dislocation of femur


what is dx in pt with numbness/tingling in hand, esp at night, esp hanging hand limply, esp pressing on carpal tunnel or pericostal

carpal tunnel syndrome


what nerve distribution is involved with carpal tunnel syndrome

median nerve distribution (radial 3.5 fingers)


how do you dx and manage carpal tunnel syndrome

dx: XR including carpal tunnel views

tx: splints and anti-inflammatories
---do not inject steroids
---pt may need electromyography +/- surgery


what is dx in pt with finger acutely flexed; unable to extend; painful snap; almost exclusively F

trigger finger


how do you manage trigger finger

steroid injections


what is dx in pt with painful radial wrist and 1st dorsal compartment; pain w/ flexion and simultaneous thumb extension

deQuervain's tendosynovitis


what are 2 unique actions that elicit pain in a pt with deQuervain's tendosynovitis

pain w/ holding baby head

pain w/ holding thumb inside closed fist and forcing wrist into ulnar deviation


how do you tx deQuervain's tendosynovitis

steroid injections


what is dx in pt with contracted hand; can no longer be extended; palmar fascial nodules palpated; commonly in Scandinavian M or chronic alcoholic

Dupuytren's contracture


how do you tx Dupuytren's contracture

surgery to free up fascia


what is dx in pt with abscess in pulp of index finger w/ throbbing pain, fever



what is concern in pt with felon

pulp of finger has fascial trabeculae made for closed spaces

swelling --> necrosis


how do you tx felon

immediate surgical decompression


what is dx in pt with injury of ulnar collateral ligament of thumb

Game Keeper's thumb


what is PE in game keeper's thumb

collateral laxity at 4th metacarpal phalangeal joint from thumb jam

can be dsyfunctional/painful --> arthritis


what activity commonly causes Game Keeper's thumb

(thumb jam)


how do you tx game keeper's thumb

casting for opportunity to heal


what is dx in pt with injury to flexor tendon, for example when grabbing another person's shirt

jersey finger


what is PE in jersey finger

distal phalanx of ring finger doesn't flex with others when making a fist


how do you manage jersey finger



what is dx in pt with injury to extensor tendon; for ex when playing volleyball

mallet finger


what is PE in mallet finger

distal phalanx cannot extend; tip of finger remains bent down; looks like hammer/mallet


how do you manage mallet finger



how do you manage a severed finger

clean severed finger with sterile saline
wrap in saline-moistened gauze
place in plastic bag
then on bed of ice


what is prognosis for severed fingers

replantation of severed extremities is done only for very distal parts

nerve regneration is limited, and replanting a denervated part is not useful


what is dx in pt who has vague back pain that turns into "electrical shock" down the leg; severe back pain when lifting heavy objects; aggravated by sneezing, coughing, ambulating, or straining; pt will keep legs flexed to avoid pain

lumbar disc hernia


how do you dx lumbar disc hernia

straight leg raise test produces excruciating pain


what is dx in pt who has vague back pain

disc bulge (discogenic pain)

the disc bulge pushes anterior spinal ligament to cause the vague back pain


what is pathogenesis of lumbar disc hernia

first you have a disc bulge that pushes anterior spinal ligament, producing vague back pain
then, a sudden/violent motion will herniate disc
compresses nerve root
gives you severe neurogenic root pain ("electric shock")


where is disc herniation located if pain radiates to big toe vs little toe

pain radiating to big toe = L4/L5

pain radiating to little toe = L5/S1


how do you dx and manage a herniated disc, including 2 exceptions?

dx with MRI image (two soft tissue structures: disc and nerve)

bed rest for 3 weeks

2 exceptions:
--neurosurgical intervention if there's progressive weakness
--sphincter defects are an emergency (rectum, bladder, etc); likely permanent if not quickly reversed


what is dx in pt with "herniated disc" symptoms + distended bladder, flaccid retrosphincter, and perianal saddle anesthesia

cauda equina syndrome


how do you manage cauda equina syndrome

surgical emergency


what is dx in young M (20s-30s) with chronic progressive back pain that improves with activity (worse in the morning)

Ankylosing spondylitis


what imaging goes with ankylosing spondylitis

eventually shows bamboo spine


how do you manage ankylosing spondylitis

anti-inflammatories and PT


what ulcer commonly presents:
pressure point, usually foot
classically the heel or 1st metatarsal
painless (neuropathy)

diabetic ulcer


why do diabetic ulcers not heal wel

ulcer develops and does not heal due to poor peripheral vascular supply


what is management of diabetic ulcer

control diabetes, stay in bed, keep leg horizontal

most diabetics suffer amputation; however, healing is possible


what ulcer commonly presents:
atherosclerotic disease causing ulcer at tip of toe- blue/pulseless

ischemic ulcer


how do you manage ischemic ulcers, depending on vessel size

big vessel: surgery, bypass big vessels

small vessel: surgery does not help

take BP at certain points to determine pressure gradient/blockage (or Doppler)
--no pressure gradient = no single point that can be bypassed; not a surgical candidate
--pressure gradient = next do an arteriogram for obstruction details


what ulcer commonly presents:
above medial malleolus in hyper pigmented, edematous skin;
varicose veins

venous insufficiency ulcer


how do you manage venous insufficiency ulcer

provide support so peripheral superficial veins are not engorged with blood

stockings, compression, stiff support, possible varicose vein surgery


what cancer commonly develops in longstanding site of chronic irritation

squamous cell carcinoma


what is this a classic story for:
chronic draining sinus in lower leg for years since osteomyelitis; but recently developed indolent, dirty ulcer with heaped up edges

squamous cell carcinoma


what is this a classic story for:
chronic shallow ulcerations at burn scar site that heal/break down, but recently developed indolent dirty ulcer w/ heaped up edges that are not getting smaller

squamous cell carcinoma


how do you dx and manage squamous cell carcinoma

biopsy of edge of ulcer where heaped up edge is

treat with wide resection and skin grafting


what is dx in chronic inflammation of plantar fascia pulling, leading to bony spur

plantar fasciitis


what presents with sharp heel pain with every strike on the ground; worse in the AM; with a bony spur matching pain site on XR and tenderness over bony spur on PE

plantar fasciitis


how do you manage plantar fasciitis

supportive analgesics
rigged devices of stepping (NOT excision of the bony spur)

it usually goes away 1-2yrs


what is dx in F wearing high heel/pointed shoes or a Cowboy wearing pointed boots
w/ pain from prolonged standing/walking; PE will be very tender on 3rd interspace

Morton's neuroma


what nerve is inflamed in Morton's neuroma

common digital nerve

(pointed shoes)


what is management of Morton's neuroma

conservative management

wear better shoes

excision of neuroma


what is dx in pt with red, painful swelling of 1st metatarsal joint



how do you dx and manage gout

dx: serum uric acid level or uric acid crystals in joint fluid

manage: medical (colchicine, allopurinol, probenecid)


what cardiac risk factors need to be considered in a pre-op assessment

EF <35% = high risk of intraoperative MI

Goldman's findings- high operative risk for non-cardiac surgery:
--age, chronically bedridden, emergency operation, major body cavity, recent MI, A-fib, premature ventricular beats, JVD

CHF (JVD), esp in elective surgery

recent MI, esp <6mo ago

Angina + AAA


what is your mortality risk in a non-cardiac operation with a recent MI vs non-recent MI

MI <6mo ago = 40% mortality

MI >6mo ago = 6% mortality


what should be done first in a pt with angina and AAA to improve operative cardiac risk

coronary revascularization before AAA repair


how do you assess an operative pt's pulmonary risk

smoking and ability to ventilate (vs oxygenate)

quantify with blood gases (high pCO2) or pulm studies (FEV1 = ability to ventilate)


what value does FEV1 represent

ability to ventilate


how can you reduce an operative pt's pulm risk prior to surgery

cessation of smoking for 8 weeks

incentive respiratory therapy (PT, expectorants, IS, humidified air)

1st week of cessation = bronchorrhea and mucus secretions


how do you assess a surgical pt's hepatic risk

liver function is important for anesthetic operation

high Bil due to hepatocellular dysfunction = high risk
---can operate if high Bil is due to obstruction/hemolysis

high PT
low serum Alb
high ammonia


how do you assess a surgical pt's nutritional risk

unable to eat / weight loss = malnutrition

serum Alb <3

allergy to skin test antigens

serum transferrin level <200

brief prior, intense nutritional support can lower operative mortality; preferably 7-10 days


what must be done for DKA pts before an operation

cannot operate in DKA

need to rehydrate pt; no coma; begin to fix acidosis; lower blood glucose first


what is dx in pt who develops intraoperative fever shortly after onset of general anesthesia >104

malignant hyperthermia


what is pathology of malignant hyperthermia

congenital absence of enzyme needed to break down succinylcholine, so you generate heat from muscle activity


what do lab values look like in pt with malignant hyperthermia

fever >104
metabolic acidosis


how do you treat malignant hyperthermia

IV dantrolene (different MOA than succinylcholine) to stop muscle activity

100% O₂
cooling blankets
correct the acidosis
monitor for myoglobinemia/uria and treat accordingly


how do you assess surgical pt's aspiration risk

prefer to prevent vs treat

can kill pt or cause chemical injury to bronchial tree--> failure

NPO before elective surgeries
--give pts anti-acids pre-op


how do you manage aspiration once it's happened

bronchoscopy to lavage and remove particulate matter

bronchodilators and respiratory support


how might an intraoperative pneumothorax happen

giving a pt positive pressure ventilation and a bleb breaks --> one way valve into pleural space


what values indicate an intraoperative pneumothorax

BP decreases as CVP increases


how can you manage an intraoperative pneumothorax

surgeon can poke a hole in the diaphragm w/ needle

place a chest tube at end of procedure


what is dx in pt with post-op fever immediately after surgery



how do you manage post-op bacteremia

blood cultures x 3

empiric Abx


what are the 4 W's in the ddx of post-op fever (actually 6)

Wonder Where
Wonder drugs


go through "wind" post op fever

♣ POD1: Inability to ventilate; atelectasis
• Tx: improve ventilation, breathing, coughing, IS, chest drainage
• Bronchoscopy rarely needed

♣ If continues to ~POD3 --> pneumonia
• Tx: CXR, Abx, sputum cultures


go through "water" post op fever

♣ POD3: Urinary Tract Infection
• Dx: urinalysis


go through "walking" post op fever

• Could do Doppler studies of deep vein flow restrictions


go through "wound" post op fever

♣ POD7: Wound infection
• Only erythema = Abx
• Pus = needs to be drained
o Sonogram helps


go through "wonder where" and "wonder drugs" post op fever

Wonder where:
♣ POD10: Deep abscess infection
• Subphrenic, subhepatic, or pelvic abscess
• CT or sonogram to visualize

Wonder drugs:
♣ Potential cause when everything else has been ruled out


what are the 2 big things on your ddx for post-op chest pain

MI POD 1-2
PE POD 5-7


how do you dx and manage post-op MI

dx: EKG, cardiac enzymes; usually POD 1-2

cannot lyse clots in a fresh post-op pt
have to treat the complications of MI but without blood thinners


what is seen in a preoperative MI

ST depression, T wave flattening; commonly 2/2 hypotension

dx: CK, CK-MB isoenzyme


how does post-op PE present

POD 5-7
sudden severe SOB and pleuritic chest pain; prominent veins, anxious, diaphoretic, tachy


how do you dx post op PE

ABGs show hypoxemia and hypocapnia
--cannot get O₂ into blood, but pt is also hyperventilating
--all areas that are perfused are ventilated; hypocapnia/hypocarbia is classic

V/Q scan only works if lungs are otherwise normal

spiral CT


what lab values distinguish PE vs respiratory failure

hypocapnia/hypocarbia (classic)
--all areas that are perfused are ventilated

respiratory failure:
hypoxemia and hypercarbia
--cannot get O₂ in and CO₂ out of blood


how do you manage post-op PE

anti-coagulation to prevent new clots (Heparin)
--lungs will lyse the existing clot

vena cava filter if the pt has experienced a PE while on anti-coagulators


what is the ddx for disorientation

post-op hypoxia

drug overdose; hypoglycemia


Delirium tremens

Acute water intoxication

diabetes insipidus

ammonium intoxication


what is initial work-up of post-op disorientation

check ABGs for pulmonary insufficiency --> hypoxia
--inadequate brain oxygenation


what should be an initial thought of pt in ER in coma

possible drug overdose, hypoglycemia (insulin)
--inject with 50% dextrose


what is the classic story for an ARDS pt

classically in a long, complicated post-op pt
--good chance that sepsis is present


what is the work-up for post-op ARDS

CT scan to look for source/drainage


what will you see in post-op ARDS

pulmonary infiltrates, low pO2, no evidence of CHF


how do you manage post-op ARDS

mechanical respiration support and PEEP; max 40% O₂ long-term

PEEP: allow some degree of hypercapnia to not push more than necessary


what is dx in post-op alcoholic who is disoriented, combative, hallucinating

delirium tremens


how do you manage delirium tremens

IV 5% alcohol and 5% dextrose

psychiatrists disagree- tx addiction w/ non-addictive agent


what is likely dx in pt who is hours post-op with confusion, lethargy, HA, grand mal seizures, and coma

acute water intoxication

their 5% dextrose in water infusion was running way too high
(a large fluid that does not include Na --> water retention)


what will pt get with acute water intoxication

SIADH (metabolic response to trauma)


how do you dx acute water intoxication

serum Na concentration is low (water retention is diluting Na)


how do you manage acute water intoxication

high morbidity and mortality scenario

carefully administer hypertonic saline
-- acute hyponatremia + CNS symptoms = brain has not adapted
--acceptable to use hypertonic saline


what is dx in pt hours post-op who is lethargic, confused, comatose
with high UOP despite normal IV fluid rate

Diabetes insipidus


what is pathology of diabetes insipidus

inability to produce ADH

(surgery was ~near pituitary; transient interference)


how do you diagnose diabetes insipidus

serum Na concentration is high (losing water in urine)


how do you manage diabetes insipidus

rapidly reverse with several liters of D5W or diluted 1/3 to 1/4 normal saline

or ADH absorption via nasal mucosa


what is dx in pt with liver failure and delirium

ammonium intoxication


how might a pt with ammonium intoxication present with labs

liver failure:
cirrhotic, hypokalemic alkalosis, high CO, low PVR


bleeding varices (belly full of blood)


what is pathogenesis of ammonium intoxication

pt has hepatic failure/ delirium, and is bleeding from varices (belly full of blood)

blood from GI tract is absorbing ammonium
liver cannot convert it to ammonia


how do you manage ammonium intoxication

clean out bowel with enemas
locally acting Abx to rid the ammonium source


what is the story of a pt with post-op urinary retention

needs to void but unable
palpable suprapubic mass dull to percussion


how do you manage post-op urinary retention

catheter into bladder to empty

if you need to do it 2 or 3 times, some docs will leave in an indwelling catheter

or a prophylactic catheter (common/predictable problem)


what is the likely dx in a pt with zero UOP

mechanical problem-
plugged/kinked catheter


what are the 2 possibilities of a pt with oliguria (low UOP with normal vital signs)

pt is either behind on fluids or in acute renal failure


walk through the 3 tests to distinguish between behind on fluids vs Acute Renal Failure

bolus 500cc IV NS over 10-20min
--pt behind on fluids will increase UOP
--pt in renal failure is already making max UOP; the bolus won't improve UOP

measure urine Na
--pt behind on fluids (dehydration) Na conc <20mEq/L (good kidneys; they're holding onto fluid via Na retention)
--pt in renal failure will have urinary Na conc >40mEq/L (bad kidneys; making plasma filtrate; cannot change Na conc)

fractional excretion of Na
--Dehydration <1
--Renal failure >1


how do you manage a dehydrated pt vs a renal failure pt with oliguria

dehydrated: fluid administration

renal failure: fluid restriction


what are 3 things on the ddx for post-op abdominal distension

post-op paralytic ileus
mechanical obstruction
Ogilvie syndrome


what is dx in pt with ~POD4 abdominal distension w/o pain; no bowel sounds/flatus vs ~POD6-8

POD4 = post-op paralytic ileus
POD6-8 = mechanical obstruction


what does XR show in post-op paralytic ileus

dilated Small bowel loops w/o air-fluid levels


what lab abnormality can perpetuate a paralytic ileus



what does barium study show in a paralytic ileus vs obstruction

inject 30cc via NG tube:

paralytic ileus: barium goes to colon

obstruction: barium stops moving


how do you manage a post-op mechanical obsturction

re-operation to fix adhesions/anastamotic defect


what is likely dx in pt with ~POD5 abdominal distension; tense, but not tender; and occasional bowel sounds; typically elderly M who isn't active, then further immobilized from surgery

Ogilvie syndrome


what does XR in Ogilvie syndrome show

massively distended colon w/ a few distended small bowel loops


what is management of Ogilvie syndrome

--suck out gas that's diluting the colon
--rule out cancer of the colon
--long rectal tube left in place for continued gas exit

rarely, a cecostomy or colonostomy is needed


what is dx in pt with salmon-colored clear fluid soaking wound dressings, and what is that fluid

wound dehiscence

peritoneal fluid


what causes wound dehiscence

deeper layers of surgery have failed to heal before skin heals


how do you manage wound dehiscence

careful protection of wound
keep in bed; don't move
tape the wound together; use abdominal binders

later: re-operate to prevent vental hernia (non-emergency)


what is the concern with wound dehiscence

could turn into evisceration
--wound opens and small bowel falls out
--emergency; high morbidity/mortality


how do you manage evisceration following wound dehiscence

pt back to bed, cover bowel w/ moist dressings soaked in warm saline
--rush to OR for immediate closure
--do not allow bowel to dry out
--avoid hypothermia


what is dx in pt with ~POD7 fever and red, hot, tender wound

wound infection


how do you manage wound infection caused by either cellulitis or abscess

cellulitis: Abx directed toward nl skin flora
Abscess: drainage (check via sonogram)


what is dx in pt with luminal content leaking through belly and afebrile



describe fistula fluid from proximal GI tract

high volume 2-3 L /day

causes a fluid/electrolye/nutirition problem because the fluid has digestive enzymes digesting the abdominal wall


how do you manage proximal GI fistula

maintenance fluids and replacement electrolytes (LR)

nutritional replacement distal to fistula (NPO)

protection of abdominal wall; do not let fluid soak dressing; protect skin


describe fistula fluid from distal GI tract

low fluid / nutritional absorption /enzymes

non-life threateningn


what happens with most GI fistulas 2/2 anastomosis

most heal unless something is preventing closure


what would cause fistula closure prevention

foreign body
Irradiated tissue
Distal obstruction

requires surgical intervention


describe epithelialization in a GI fistula

granulation tissue grows from conduit while epithelium is migrating from inside the lumen

long and narrow hole = granulation tissue will win and fill epithelium

short and wide hole = epithelialization; hole will not close


what is likely dx in pt with hypernatremia (water loss) 2/2 surgery acutely



how do you manage acute DI

diluted fluid to replenish loss with several liters of D5W, 1/3 to 1/4 NS +/- ADH

every 3mEq that serum Na is above 140 represents ~1L water lost


what is likely dx in pt who is awake/alert but hypernatremia (dehydrated)

chronic hypernatremia
-selectively lost water
-developed hypernatremia over ~days, so the brain has adapted (normal mentation)


how do you manage chronic hypernatremia

reverse the volume loss over ~hrs to improve hemodynamics/kidneys

correct the hypertonicity over ~days
using 5L D5 1/2 NS
--fluid that's neither as diluted as D5W nor as concentrated as NS
--rapid correction of volume and ~modest/safe impact on tonicity


what is likely dx in pt with hyponatremia (water gain_ 2/2 rapid drip of Na-free soln during an inappropriate ADH response to trauma

acute water intoxication

every cell is swollen, including the brain
--> comatose


how do you manage acute water intoxication

hypertonic 3-5% Saline in small quantities



what is likely dx in pt who is alert/awake but hyponatremia (water retention)

chronic hyponatremia

too much ADH

hyponatremia has developed over ~days, so brain has adapted (normal mentation)


how do you manage chronic hyponatremia

slow correction of serum Na
--water restriction (cannot take away the excess ADH in the body)
--meds to counteract ADH effects

a rapid correction would cause central pontine lysis of myelin


what is pathogenesis in "loss of hypertonic fluids" or "selective loss of Na"

doesn't realistically happen- no mechanism to selectively lose Na to cause chronic hyponatremia

first, the pt begins losing isotonic fluids via vomiting (Na-containing, but still isotonic)
--the initial insult is dehydration w/o tonicity change

several days --> volume depletion; pt is likely unable to eat/drink, so cannot replace fluids being lost
--body is eager to retain fluids at this point

pt drinks Na-free fluid (water/soda vs HCO3/Na) --> production of free water
--body is willing to sacrifice tonicity to retain volume
--fluid drank is stained
--does not correct vol depletion; you've created a tonicity gradient, so the water ends up in cells but with a low serum Na due to retaining water and losing isotonic fluids

the pt lost isotonic fluid then eventually retained water --> hyponatremia


how do you manage chronic hyponatremia

slowly correct the hyponatremia with rapid correction of volume replenishment

use isotonic fluids to rapidly correct the volume and slowly correct tonicity

NS: when pt is alkalotic (vomiting gastric acid and juice)
LR: when pt is acidotic (vomiting small bowel content, bile, pancreatic juice, alkaline fluids)


how do you manage severe DKA

insulin + IV fluids + K


what is the rationale for giving K to a DKA pt

pt is acidotic
--excessive H+ in blood is pushed into cells in exchange for K being brought out of cells

high K in blood is seen by the kidneys, so kidney puts K into urine

when you correct the pt's acidosis, the H+ goes back into the blood, and K tries to go back into cells
--> profound hypokalemia


what is the normal safe upper limit of K administration in a normal vs DKA pt

normal pt:
10 mEq/hr = 24 mEq/day

DKA pt :
20 mEq/hr = 480 mEq/day


what lab abnormality are you likely to see after a crush injury


adding K to the blood via:
--crushed/killed cells
--blood transfusions (hemolysis in the blood bank as blood ages)
--acidosis with H+ moving into cells


how do you manage dangerous hyperkalemia 2/2 crush injury

dangerous hyperkalemia >6

hemodialysis (long process)

50% glucose and insulin to create momentary anabolic phase (K into cells)

GI tract to remove K (NG suction)- not effective
--Kayaxolate resins: exchange Na for K in lower GI

IV Ca administration: highly effective and protective of myocardium while waiting for hemodialysis


run through metabolic acidosis with pH 7.1
pCO2 36
Na 138
Cl 98
HCO3 15

look at pH = acidosis
look at pCO2; low = hyperventilating to try to compensate by breathing faster and removing CO₂ and therefore acid

either excessive production of acids, insufficient buffering from HCO3 loss, or inability of kidney to make necessary adjustments
--renal acidosis takes several days to develop
--HCO3 loss: biliary fistula, pancreatic fistula ostomy output, diarrhea
--high H+ production: pt is in a low-flow state (shock, hypotension, not perfusing well, cells using anaerobic metabolism with high lactic acid levels)


how do you manage metabolic acidosis with pH 7.1
pCO2 36
Na 138
Cl 98
HCO3 15

correct the underlying problem

this pt needs rehydration to correct the low-flow state so the pt can correct the acidosis
--fluid that doesn't compound the existing acidosis
--use LR, a primary volume expander, which also contains a little HCO3

giving HCO3 or a precursor (like acetate/lactate) does not address the volume problem
--give HCO3 if pt is losing HCO3 via fistula and doesn't have enough to buffer
--do not give NaHCO3: it makes a ppt


run through hypochloremic metabolic alkalosis 2/2 loss of acid gastric juice

protracted vomiting of clear gastric contents ~days

need to rehydrate and also correct the metabolic alkalosis
--rarely, provide hydrogen NH4Cl or HCl diluted in amino acid solution (buffers)


how do you manage hypochloremic metabolic alkalosis 2/2 loss of gastric acid and juice

help the kidney correct the problem

kidney can: bring in NaCl, NaHCO3, or exchange Na/K or Na/H

pt is alkalotic in this scenario (H+ depleted)
--do not want to put H+ into urine or retrieve HCO3-

want to: bring in NaCl or exchange Na for K
--give generous KCl to retrieve Na without using HCO3/H+
--only works if pt has functioning kidneys


when should you use pH monitoring to evaluate esophagus

use in pain that cannot be well characterized and cannot be timed


how can you dx reflux with pH monitoring

if pain coincides w/ low pH: reflux


when do you use manometry to evaluate esophagus

use if pt has horrible pain w/ every swallow; uncoordinated contractions


what is dx in pt who has burning, retrosternal pain and heartburn w/ bending, tight clothes, lying flat;
symptomatic relief with antacids, seems to be progressive; present ~yrs



how do you dx GERD

endoscopy and biopsy to determine extent of damage


how do you manage severe peptic esophagitis

surgery is indicated if there's progression despite strict adherence to PPI meds


how do you manage Barret's esophagus

this is pre-malignant
--a Nissen fundoplication only helps with acid reflux

you need intensive treatment directed at acid
--PPIs can take care of histological damage, but high doses are required for a long time
--may create a carcinoid tumor 2/2 PPI from long-term achlorhydria


what is the purpose of each study before esophageal surgery
-gastric emptying study
-barium swallow

endoscopy: evaluate extent of mucosal damage

manometry: evaluate motility

gastric emptying study: evaluate for pyloric obstruction

barium swallow: evaluate location of LE sphincter and GE junction


what is dx of pt with difficulty swallowing liquids > solids

achalasia of esophagus


what type of problem is achalasia

functional/motility problem


which esophageal problem starts with difficulty swallowing solids

mechanical problem


what is this a classic story for:
middle aged F who sits up straight when eating; has regurgitation of undigested food, like finding food on a pillow



how do you dx achalasia

manometry to assess motility
--establishes that LE sphincter doesn't relax

(Barium swallow/ endoscopy would both show mega-esophagus, but not the nature of the problem)


how do you manage achalasia

treat medically with repeat dilations

or surgery with Heller myotomy


which esophageal cancer classically develops with history of smoking, drinking, and black race

squamous cell carcinoma


which esophageal cancer classically develops with long-standing GERD

progresses from Barrett's esophagus


how do you dx cancer of esophagus

first, Barium swallow to visualize tumor and amount of lumen left to avoid perforation

then CT to determine surgical candidacy

Endoscopy and biopsy

Trans-hiatal esophageestomy for short-term palliation


what is tear in mucosa of esophagus 2/2 repeated vomiting and profuse bright red blood

Mallory Weiss Tear


how do you dx Mallory Weiss tear

endoscopy to visualize bleeding point


how do you manage Mallory Weiss tear

photocoagulation to stop bleeding


what is perforation of lower esophagus 2/2 repeated/forceful vomiting with sudden onset of wrenching epigastric pain and lower sternal pain; diaphoretic, febrile, and WBC count

Boerhaave syndrome (rare)


how do you manage Boerhaave syndrome

prognosis depends on timing of dx/tx

begin with gastrographing swallow (water-soluble solution)
--bad quality pictures, but safe if the fluid extravasates (vs harmful high-quality Barium swallow)

Negative gastrography --> Ba swallow study

immediate surgical repair of perforation


what is dx in pt with severe, constant, retrosternal pain ~hrs after GI endoscopy;
febrile, diaphoretic, subQ emphysema

instrumental perforation of esophagus


how do you manage instrumental perforation of esophagus

begin w/ gastrographing swallow
--positive --> surgical repair
--negative --> Ba swallow

Abx and overnight watching if the tear is very small

if the perforation was made ~3 days ago, you need to do an esophageal derivation in the neck (cannot repair now with all of the inflammation)
--derivation at GE junction; and eventual esophageal repalcement


what is likely dx in older pt with weight loss, anorexia, and epigastric discomfort

stomach malignancy


how do you manage a suspected stomach cancer

endoscopy and biopsy
--you don't need a Barium swallow because there's enough lumen to not require a safety roadmap

if the biopsy shows cancer,
do a CT scan to determine if it's resectable,
then surgery


what is likely dx in pt with protracted colicky abdominal pain; vomiting, hyperactive bowel sounds; progressive distension

mechanical obstruction of small bowel


what will XR show in mechanical small bowel obstruction

distended bowel loops and air-fluid levels


what is most likely causes of mechanical bowel obstruction

2/2 previous surgery adhesions


how do you initially manage mechanical small bowel obstruction

since the SB has avoided falling into adhesion trap in the past, it is likely that the bowel can un-trap itself

manage w/ NG suction, NPO, IV fluids, and wait to let the bowel extricate itself


how do you manage a partial vs complete small bowel obstruction

typically willing to wait 24 hours before taking to the OR

typically willing to wait 3-5 days

monitor pt for deadly complication:
bowel becomes wedged/compromised/strangulated
--pt will have early fever/WBC --> constant pain/peritoneal --> peritonitis --> septic shock
--immediate OR if pt begins to develop these signs


what is dx in pt with SB obstruction + growing mass that's no longer reducible

strangulated/incarcerated hernia


how do you manage strangulated/incarcerated hernia

--esp if discolored/strangulated/fever/WBC

operate electively, even if not strangulated, to indefinitely fix problem


what is likely dx in pt with protracted diarrhea, bizarre h/o flushing face, expiratory wheezing, prominent JVD?

carcinoid syndrome/tumor


where is carcinoid tumor likely to be

in small bowel / ileum


why does a carcinoid tumor produce its particular symptoms

carcinoid tumor is serotonin-producing

serotonin is normally deactivated in the liver, but if the pt has liver mets, the serotonin may dump into IVC --> systemic serotonin
--R heart damage (JVD)
--lungs can deactivate serotonin, so L heart is protected


how do you dx carcinoid tumor

serum 5-HIAA (byproduct of serotonin breakdown)


how do you manage carcinoid tumor

remove primary tumor

treat/remove liver mets

tends to be slow growing, so any palliative effort is helpful


what is likely dx in young adult w/ anorexia, vague periumbilcial pain --> sharp, severe, constant, well-localized RLQ pain with guarding/rebound tenderness

acute appendicitis


what will pt labs look like in acute appendicitis

mild fever w/ WBC count

L shift neutrophilia


how do you dx acute appendicitis

based on clinical presentation;
additional lab tests aren't necessary


how do you manage acute appendicitis in a pt before vs after perforation

before: emergency appendectomy

after perforation: appendectomy; ICU with prolonged post-op care


what are 98% of colon cancers

adenocarcinomas (grow out of mucosa)
--can impinge along lumen or bleed


how do you dx colon cancer

endoscopy and biopsy

start with flexible sigmoidoscopy to evaluate L sided cancer (any doc can do)

then do a full-length colonoscopy for R/L sided cancer
(done by surgeon doing the full colonoscopy)


how do you manage colon cancer

blood transfusions

CT scan to assess OR candidacy

cancers are often multi-centric



what is dx in classic pt with anemia + occult blood in stool

R sided olon cancer


why is impingement unlikely in R sided colon cancer

liquid feces + larger lumen


what is dx in classic pt with change in bowel habits, constipation, and change in caliber/shape of stool ("toothpaste"); with blood visibly surrounding already-solid feces

L sided colon cancer


what should you think with villous adenoma in rectum and adenomatous polyps in the descending/sigmoid colon

most likely to be malignant:
a pre-malignant condition of Familial polyposis (Gardner's syndrome)
--it's ~100% predictive to progress to cancer
--should do proctocolectomy

next most likely to be malignant: villous adenoma
--50% progress to cancer
--should do resection

next most likely: adenomatous polyp:
--remove, often endoscopically
--surgery if sessile

no malignant potential: Juvenile polyps, Peutz Jehgers, or inflammatory/hyperplastic polyps
--no surgery is necessary


what are the indications for surgery in chronic ulcerative colitis

>20 yrs of UC = risk of malignancy

low weight
many hospitalizations (interfering with nutritional status or lifestyle of pt)

needing long-term steroids to control disease

toxic megacolon (abdominal pain, fever, distended transverse colon)


what determines need for surgery in ulcerative colitis

surgery depends on extent of disease
-rectal mucosa will always be removed
-ileoanal anastomosis or ileostomy


what is likely dx in pt with watery diarrhea, crampy pain, febrile, WBC, and usually told specific Abx treatment (esp taking clindamycin)

pseudomembranous enterocolitis 2/2 Clostridium difficile


how do you dx pseudomembranous colitis 2/2 C diff

stool cultures (takes time)

proctosigmoid scope exam (helpful if disease is severe)

best: toxin in stool with kit (rapid)


how do you manage pseudomembranous colitis 2/2 C diff

stop offending Abx

do not use anti-diarrheal (keeps toxin in GI)

some docs prefer vancomycin or metronidazole or replenish normal flora


what does the management of anal/rectal problems always begin with

always begin with r/o cancer
--never prescribe meds over the phone

do rectal exam and proctosigmoid exam to r/o cancer


what is likely dx in BRB after bowel movement; painless

internal hemorrhoids


how do you manage internal hemorrhoids

rubber band ligation or laser/destruction


what is likely dx in painful perianal area w/o blood

external hemorrhoids


how do you manage external hemorrhoids

formal operation w/ anesthesia


what is dx in pt w/ severe pain with defecation and blood streaks, causing them to avoid BMs and not allow a PE

anal fissure


what is anal fissure thought to be caused by

thought to be 2/2 tight sprinter tone, causing limited blood supply, and unable to heal the tears


what is management of anal fissure

first examine pt to r/o cancer
--likely have to do under anesthesia since pt might refuse a painful PE

manage conservatively:
--stool softeners and topical agents
--nitroglycerin cream to relax sphincter

surgical management:
--lateral internal sphinterotomy, forceful dilation, Botox injections to paralyze sphincter


what should you suspect in a pt w/ h/o operation making a perianal fistula worse, causing an unsealing ulcer and purulence

Crohn's disease affecting the anus


how should you manage crohn's disease affecting the anus

rectal endoscopy exam to r/o necrotic cancer


what is likely dx in pt saying it's painful to sit or have BM, fever/chills; hot, tender, red defluction mass between anus and ischial tuberoscity

anorectal abscess


how should you manage anorectal abscess

r/o cancer or a fun gating tumor

drain all abscess with I&Ds


what should you think in a diabetic/immunocompromised pt with an anorectal abscess

if pt is diabetic/immunocompromised: the abscesses tend to be the beginning of necrotizing fasciitis
--treat with close F/U over next few hours to monitor the development of a soft tissue infection


when will an anal fistula develop

only in pts who have previously had ischial rectal abscess drainage

the abscess bacteria comes from anal crypts of the anal canal
drained through skin of perineum
epithelial migration
tract formation


how will an anal fistula pt present

pt must have previously had an ischial rectal abscess drainage

fecal streaks soiling underwear

PE shows perianal opening in skin and cord-like tract palpated from opening to inside


how do you manage anal fistula

r/o cancer

then surgery to to unroof the fistula so granulation tissue can fill in the tunnel


what is dx in blood coating the outside of stool + changed bowel habits

sigmoid adenocarcinoma


where does sigmoid adenocarcinoma metastasize to

metastasis only to Lymph nodes inside abdomen


what is dx more likely in an HIV+/homosexual pt (no viral connection)
grows close to anal canal opening; often felt as mass protruding from anus

squamous cell carcinoma of anus


where does squamous cell carcinoma of anus metastasize to

metastasizes to lymph nodes inside abdomen (like sigmoid adenocarcinoma),


how do you dx and manage squamous cell carcinoma of anus

dx: biopsy the mass

manage: best to first shrink before surgery
--Nigro protocol: combo of chemo + radiation
--+/- resection if necessary


where are pts likely to be bleeding from in a GI bleed, statistically

75% pts are bleeding from upper GI
(nose to Ligament of Trietz in duodenum)

25% of pts are bleeding from distal GI tract
(mainly colon)


which location of bleed is common in younger vs older pts

upper GI: common in younger pts

lower GI: common in older pts (except hemorrhoids)
--elderly = equal opportunity bleeders


what are 5 things possibly causing a lower GI bleed

hemorrhoids, polyp, cancer, angiodysplasia, diverticulosis


what does vomiting blood tell you

upper GI bleed


how do you identify upper GI bleed site

endoscopy easily identifies an upper GI bleed site
--blood goes away as soon as you pass lesion


how do you manage upper GI bleed

stop bleeding with photocoagulation


what does a GI bleed with an NG tube w/ clear green fluid w/o blood mean

the fluid contains bile; you've sampled the duodenum
you can r/o it as a source of bleeding


what does a GI bleed with an NG tube w/ clear white fluid w/o blood mean

you can r/o the tip of the nose to the pylorus as a source of bleeding
--could still be in duodenum


when is a lower endoscopy/colonoscopy not helpful in locating a GI bleed

if the pt is presently and significantly bleeding
--it's too bloody distal to the lesion


what imaging is helpful to r/o hemorrhoids



what imaging is helpful in >=2cc/min GI bleeding



how do you calculate the extent of GI bleeding

calculate how often you're perfusing to keep stable vitals

2cc/min = 120cc/hr = every 4 hours a unit of blood is required

<5cc/min = every 16 hours a unit of blood is required (no arteriogram)


when can you perform a colonoscopy to evaluate a small bleed <5cc/min

after bleeding as stopped


what study can be done to evaluate "in-between" bleeds of 0.5-2cc/min

tagged RBC study


who does a tagged RBC study work to show where GI bleed is

can give rough indication of which side for hemicolectomy

some docs always order this before an arteriogram

some docs skip this and go straight to arteriogram
--pt has stopped bleeding by the time you get results back
--no guarantee the arteriogram will work, though


what imaging is helpful if the pt last bled 2 days ago from GI bleed

double endoscopy

(tagged RBC or arteiogram is useless)


what is dx in young child w/ bloody BM

Meckel's diverticulum


what test can you do to dx Meckel's diverticulum

radioactively labeled Technetium scan to identify gastric mucosa


what is dx in pt with multiple shallow furiously bleeding ulcers in gastric mucosa 2/2 complicated ICU course

stress ulcers


how do you dx and manage stress ulcers

dx: endoscopy

prefer to prevent vs tx
--ICU pts get H2 blockers, antacids, or both

radiologic angiogram to selectively catheterize stomach blood supply (L gastric artery)


what is the generic/broad ddx of acute abdominal pain

inflammatory process


what classically presents as sudden onset, constant severe pain that is GENERALIZED

abdominal perforation


what is the most common abdominal perforation

duodenal ulcer perforation


what is dx in pt who lies motionless to avoid pain in abdomen and PE elicits extreme peritoneal irritation (pain to palp, guarding, rebound tenderness); and absent bowel sounds

abdominal perforation


how do you manage abdominal perforation

r/o other things before arriving at perforation

first: CXR to r/o lower lobe pneumonia

EKG for coronary ischemia

plain abdominal XR for free air perforation, ureteral stone

amylase for pancreatitis

then, immediate ex lap


what is classic dx for sudden onset of pain, colicky, that is localized w/ associated radiation

abdominal obstruction

stone in ureter, cystic duct, common duct, or small bowel lumen


what is dx in pt who is moving around looking for positional comfort and PE localizes to the problem



what is most likely in female, fat, forty, fertile

gall stones

stones could be asymptomatic
low rate of conversion --> symptomatic


what is typical PE in biliary tract disease

severe RUQ colicky pain that radiates to R shoulder towards back, N/V that turns into constant pain

PE will show tender to palp, guarding/rebound
mild fever and WBC


what is abdominal pain that quickly resolves with OTC meds, often 2/2 fatty foods; and no residual findings after pain subsides

biliary colic

no residual findings afters stone falls back


how do you manage biliary colic

cholecystectomy to prevent further episodes


what is abdominal pain that persists to constant, localized pain with fever and WBCs;

acute cholecystitis


how do you dx acute cholecystitis

sonogram to show stones
thickened gallbladder wall
pericholecystic fluid

rarely, and inconclusive US will cause you to do a HIDA scan

HIDA scan shows bile flow NOT in the gallbladder


how do you manage acute cholecystitis

anticholinergics do not resolve symptoms

typically tx w/ medical management, including NG suction, NPO, Abx, and IV fluids

then do an elective cholecystectomy


what is likely dx in pt with abdominal pain and highly elevated Alkaline Phosphatase

Ascending cholangitis

(pt will be very sick- high 104 fever, high WBC)


what causes ascending cholangitis

partial obstruction from a stone that allows an ascending infection


how do you manage ascending cholantigis


IV Abx, hospitalization, decompress biliary tract with ERCP
catheter above the stone to drain the duct; percutaneous PTC


how does a stone cause acute pancreatitis

stone stuck at ampulla of Vater

occludes both common bile duct and pancreatic duct


what is dx in pt with sudden onset flank pain, radiates to thigh/scrotum; and microhematuria

ureteral stone


how do you dx ureteral stone

IV pyelogram, sonogram, CT scan


what is dx in elderly pt w/ abdominal distension, N/V, no flatus/BM, tympanic abdomen, and hyperactive bowel sounds

sigmoid volvulus


what does sigmoid volvulus XR show

distended loops w/ air fluid levels and "bird beak" sign


how do you manage sigmoid volvulus

proctosigmoid exam
try to untwist bowel and leave long rectal tube to prevent coil

surgery may be indicated


what is likely dx in elderly pt w/ A fib or a recent MI now presenting with an acute abdomen

mesenteric iscemia


how does a recent MI or A fib cause mesenteric ischemia

embolus occluding SMA


how is the bowel affected in an SMA occlusion

distension up to transverse colon


what does a sick pt with acute abdomen and acidosis likely have

mesenteric ischemia that has progressed to a dead bowel


how do you manage mesenteric ischemia

ex lap to resect dead bowel

call vascular surgeon ASAP to try arteriogram to prevent irreversible necrosis


what is dx in pt with gradual onset of abdominal pain, which builds up to maximal intensity in 2-12 hrs; constant, and localized

some sort of inflammatory process


what generic dx will have an abdominal exam showing peritoneal, but localized; and likely signs of systemic inflammation (fever, WBC)

abdominal inflammatory process


what presents with ascites + vague acute abdomen

bacterial hematogenous peritoniits


how do you dx and manage bacterial hematogenous peritonitis

sample ascites for culture

then tx


what is dx in alcoholic pt with abdominal pain that radiates to back w/ N/V



how do you dx pancreatitis, depending on when pt presents

serum amylase/lipase if recent onset

urinary amylase/lipase if seeing the pt 3 days later


what is dx in pt with abdominal pain with: inflammatory mass; LLQ pain; pain building up to a constant, localized pain; with fever and WBC



what is the blood marker for HCC



what is alpha-fetoprotein a blood marker for



who gets HCC

only seen in pts who already have cirrhosis


what is the most common liver cancer in the US

metastatic cancer to the liver
20:1 metastatic in the US


where does liver mets likely come from

h/o colon cancer


what is blood marker for liver mets

carcinogenic antigen CEA


what is carcinogenic antigen (CEA) a blood marker for

liver mets


how do you manage liver cancer

CT to evaluate extent of tumor

attempt surgical resection or radioablation


what is commonly seen in females on chronic birth control

hepatic adenoma


what presents in a female on birth control with sudden abdominal pain that leads to faint, pale, tachy, hypotensive, and mildly distended/tender abdomen

hepatic adenoma

birth control can develop hepatic adenomas with tendency to bleed


how do you dx and manage hepatic adenoma

dx w/ CT scan to show adenoma

tx with surgical resection
--not common and not an indication for a female to discontinue OCPs


what is likely dx in late-pregnancy female who suddenly experiences shock

visceral aneurysm of hepatic artery bleeding into abdomen


what type of liver abscess is a complication of biliary tract disease

pyogenic liver abscess


how do you manage pyogenic liver abscess

needs drainage (percutaneous)


what type of liver abscess will commonly present with a "Mexico connection", likely in a M

amoebic liver abscess


what do labs look like for amoebic liver abscess

fever, WBC, tender over liver, jaundice, elevated Alk phos


what will sonogram show in amoebic liver abscess

normal biliary tree and liver abscess


how do you dx and manage amoebic liver abscess

dx: serology (requires time for pt to develop antibodies)

empiric tx w/ metronidazole
drain if pt is not responding to Abx and the abscess is growing
do not draw pus to send to lab for growth; the amoeba grows from the wall of the abscess


what type of jaundice gives you:
mild 6-10 Bil elevation with almost ALL INDIRECT (not being processed by liver)

hemolytic jaundice


what is your work up geared toward with a mid Bil elevation that's almost all indirect

this is hemolytic jaundice, so you should direct your focus on what's destroying the RBCs


what type of jaundice gives you:
both high Bil's
very high transaminases
only modest elevation of Alk Phos

hepatocellular jaundice (hepatitis)


what should your work up be directed at with very high transaminases

identifying the type of hepatitis the pt has


what type of jaundice gives you:
classically both high Bil's (direct is high in early cases)
mildly high transaminases
very high alk phos

obstructive jaundice


what should your work up be directed at with very high alk phos

sonogram to identify where the obstruction is


what is the quick/obvious jaundice answer when labs show:

elevated Bil that is all indirect

very high transaminases

very high alk phos

indirect Bil = hemolytic jaundice

transaminases = hepatocellular

alk phos = obstructive


what type of obstruction occurs when the gallbladder is contracted, thick-walled, and full of stones

benign obstruction


what are the next steps after you identify a benign gallbladder obstruction

ERCP and sphincterotomy to retrieve stones

then cholecystectomy to prevent more stones


what type of obstruction occur when the gallbladder is nontender, distended, and thin-walled

malignant obstruction

cancer of the pancreas, common duct, or ampulla of Vater/hepatopancreatic duct


what is the next step after a malignant gallbladder obstruction has been identified

CT scan to determine cancer location


what type of pancreatic cancer will be symptomatic

pancreatic cx will be advanced if it's big enough to be symptomatic


what does a negative CT scan in a malignant gallbladder obstruction mean

a negative CT scan = small cancer of pancreatic head, cholangiocarcinoma, or ampulla of Vater carcinoma

next = ERCP


what gives you apple core appearance on ERCP



what are the next steps after dx cholangiocarcinoma

brushings to obtain cytologic confirmation

whipple procedure (relatively curable, vs pancreatic tumor)


what gives you a slightly anemic pt with blood in GI lumen and evidence of malignant gallbladder obstruction

ampullarf cancer


how do you manage ampullary cancer

CT scan will unlikely show this small cancer

endoscopy (not ERCP) to see the tumor, biopsy it, and confirm dx

easily resectable


what gives you evidence of malignant gallbladder obstruction, growing into retroperitoneum w/ milk pain deep to epigastrium and upper back; possibly w/ FHx

pancreatic head cancer


what are your next steps after suspecting pancreatic head cancer

first: sonogram

next: CT shows big cancer (big enough to be symptomatic)

percutaneous biopsy

palliative biopsy


what is dx in alcoholic pt with abdominal pain

acute pancreatitis


how do you dx acute pancreatitis

blood or urine amylase / lipase


when does serum vs urine elevation occur in acute pancreatitis with amylase / lipase

serum elevation occurs 12hrs - 2 days after onset of symptoms

urine elevation occurs 2- 5 days after onset of symptoms


what is dx when pt has plasma deposited around pancreas

benign edematous pancreatitis


how do you dx benign edematous pancreatitis

dx with a high Hct (hemoconcentrated blood)

plasma has been removed from the blood and deposited around the pancreas


how do you manage benign edematous pancreatitis

NPO, NG suction, IV fluids

pt will improve


which pancreatitis is diagnosed with a low Hct

Hemorrhagic pancreatitis (losing blood)


what is used to calculate the prognosis of hemorrhagic pancreatitis

Ranson's Criteria


what is happening with lab values in bad hemorrhagic pancreatitis

the Hct is continuing to drop
low serum Ca
high BUN
metabolic alkalosis
low pO2
high blood glucose


how do you treat hemorrhagic pancreatitis

intensive ICU support and expect lots of complications


what is concerning for oncoming death in hemorrhagic pancreatitis

pancreatitis abscess development often means death is coming

you have a destroyed, necrotic, hemorrhagic gland


what should be done daily to monitor hemorrhagic pancreatitis

daily CT scans to find the earliest indication of pus collection

drain the abscesses immediately as the only hope to survive


what is dx in pt with chronic epigastric pain that radiates to back for ~yrs.
pt may also have DM, steatorrhea, malnourishment, alcoholism
pt typically has no job, family, home, and frequents ER for pain control

chronic pancreatitis


what does XR show in chronic pancreatitis

upper abdominal Ca


why can amylase no longer be used in dx of pancreatitis in chronic pts

pt has a history of continuing to drink after alcoholic pancreatitis --> destroyed pancreas


how do you tx chronic pancreatitis

attempt to control DM, pancreatic enzymes for steatorrhea, but the pain isn't well treated

ERCP to drain pancreatic duct

total pancreatectomy: usually die 2/2 extremely poorly controlled DM


what is dx in pt with ill-defined upper abdominal discomfort, early satiety, and h/o recent d/c from hospital for pancreatitis tx

pancreatic pseudocysts


what will PE show in pancreatic pseudocysts

large epigastric mass deep in the abdomen


what is dx in pt with vague upper abdominal discomfort, early satiny, and h/o recent MVC hitting the steering wheel

pancreatic pseudocysts


how long is the "incubation" period for pancreatic pseudocysts

typically ~5 weeks between trauma/pancreatitis and fluid collection/pressure


what causes pancreatic pseudocysts

trauma/pancreatitis leading to pancreatic juice leaking out of duct and collecting nearby


where is the classic collection site for pancreatic pseudocyst fluid

lesser sac


how do you dx pancreatic pseudocysts

sonogram or CT showing fluid collection


how do you manage pancreatic pseudocysts based on 4 outcomes

careful monitoring w/imaging for resolution

spontaneously resolve:
--go away within 6 weeks

deadly complications typically happen >6 weeks later
--rupture into peritoneal cavity --> massive fulminating peritonitis
--erode into major vessels --> bleeds and exsanguinate
--infected juice 2/2 arterial infection; pseudocyst--> pancreatic abscess --> death

endoscopic internal drainage by gastroscopy:
--create a cystogastrostomy that can drain it without a fistula (via perc drain)


what is the standard recommendation for any hernia

repair electively to prevent possible incarceration/strangulation of bowel


what is the exception for fixing hernias

umbilical hernia <2yo child

will resolve/close spontaneously


what is recommendation for sliding esophageal hernia

not an actual hernia;
not an indication for surgery itself,
but paraesophageal hernia is indicative for surgery


what does breast disease management always begin with

r/o cancer


what is the only way to certainly r/o or dx breast cancer

pathology report

clinical/radiology can only suspect cancer


what are the 5 types of breast biopsies from least to most invasive

least invasive:
FNA cells from mass, cytology

core biopsy: needle collects cores of tissue

mammotome to obtain bigger mass

incisional bx in the OR

most invasive:
excision biopsy (remove the entire suspicious mass)


what does the extent of breast biopsy depend on

depends on clinical suspicion


what is the most important factor for clinical suspicion of breast pathology



what method would you use in a young person vs middle-aged to r/o breast pathology

young: non-invasive r/o measures

middle aged: either a core biopsy or bigger biopsy; may not even stop until an excision biopsy is done


what should your clinical suspicion be in a female pt with recent trauma to breast

do not allow recent trauma to r/o potential dx of cancer by assuming it's fat necrosis or a hematoma

--still need mammogram and tissue sampling


what is the role of a mammogram

does not dx cancer of the breast
it detects potential/probable cancer that's too small to be palpated
--always done first is mass is found on exam in a F >30yo


what is description of irregularities suspicious for cancer

irregular density
no sharply demarcated borders
fine microcalcifications
recent finding (not present on mammogram ~2yrs ago)


what are 2 contraindications for mammogram

<20yo (dense breast tissue won't allow pathology visualization)

lactating (only see milk)


can you do a mammogram during pregnancy



what is dx in young F with rubbery mass; easily movable



what is the term for a quickly growing fibroadenoma

giant juvenile fibroadenoma


what is work up for fibroadenoma suspicion

FNA/sonogram to confirm dx of fibroadenoma

+/- remove mass depending on pt preference


what is dx in late 20s F with a mass, typically long history, grows big, remains movable; no axillary involvement

cystosarcoma phyllodes


what is management of cystosarcoma phyllodes

removal is mandatory; malignant potential


what is dx in 20-40yo F with painful cyclical lumps that come/go

fibrocystic disease: mammary dysplasia, cystic mastitis


how do you manage fibrocystic disease

mammogram for baseline picture and cyst visualization

if cyst becomes firm and doesn't go away with cycle:
--aspiration of cyst (not FNA) to remove cystic fluid
--retrieve clear fluid and mass disappears: you're done
--retrieve blood fluid: send for cytology
--if mass doesn't go away/quickly returns: needs formal tissue sampling/bx


what is dx in F with blood discharge from nipple w/o palpable masses

intraductal papilloma


what is a small benign tumor 2-3mm that grows inside breast duct

intraductal papilloma


how do you manage intraductal papilloma

need to r/o carcinoma possibility
--mammogram first
----lesion = probably cancer; need bx

can see with galactogram or retroareolar surgical exploration: remove that section of breast


what is the pt presentation that is only acceptable in a lactating F

crack in nipple with red, hot, tender mass in breast with fever and WBC

otherwise, assume it's cancer until proven benign


how do you manage a F with cracked nipple, red, hot, tender mass in breast with fever and WBC

r/o cancer, but no point in a mammogram if the F is lactating (only see milk)

need I&D, but also take small sample from the wall to path to r/o infected cancer


what are the 2 limitations of pregnancy and breast cancer

cannot give chemo in 1st trimester of pregnancy

cannot give radiation at any time during pregnancy (diagnostic XRs are ok)

not necessary to terminate pregnancy


what is dx in classic orange peel / retracted skin with red/swollen breast

inflammatory breast cancer


what is prognosis and management of inflammatory breast cancer


manage w/ mammogram, tissue sampling, pre-op chemoradiation


what is dx in F with hard mass under nipple causing nipple retraction

desmoplastic rxn of breast cancer


how do you manage desmoplastic rxn of breast cancer

mammogram, generous tissue sampling


what is dx of non-palpable eczematous lesion in areola of F not improved w/ lotions

Paget's disease of breast

it's infiltrative under areolar tissues


how do you manage Paget's disease of breast

mammogram, biopsy, then proceed


what is dx in mass in axilla; discrete, hard, movable, and a negative breast PE

breast cancer metastatic to axilla


how do you manage metastatic breast cancer to axilla

mammogram needed to show primary tumor; then proceed

if negative, biopsy and remove the axillary lymph node


how should you manage incidental micro calcifications off mammogram

tissue biopsy,
core biopsy by radiologist 8-12 samples
surgical removal w/ wire guidance for path


what are your management options for breast cancer after dx

lumpectomy + radiation

modified mastectomy

axillary sampling

also need to look for signs of systemic metastasis


when is lumpectomy + radiation indicated

relatively small cx compared to breast ratio and far from nipple
--also need axillary sampling


when is modified mastectomy indicated

relatively large cx compared to breast ratio or near the nipple
--includes axillary sampling
--no radiation necessary


how is axillary sampling conducted

different from axillary dissection

axillary sampling = sentinel node biopsy
--inject radioactive material into tumor; migrate via lymph; trapped by 1st LN --> biopsy that LN


what are the 2 breast cancers that call for a special management, and what is it

inflammatory carcinoma of breast
or Carcinoma in situ

pre-op radiation/chemo before surgical resection


how do you manage/ what should you suspect in h/o breast cancer w/ recent onset HAs

need CT san looking for brain mets
resect any resectable brain mets
TNM classification


how do you manage/ what should you suspect in h/o breast cancer w/ recent onset back pain

need radio bone scan (sensitive, not specific)
--positive --> XR to see it light up; or consider other causes (fracture; arthritis)

manage bone mets with radiation, ortho stabilization, braces, etc


what are 4 rules for systemic tx of breast cancer

any pt with positive axillary lymph nodes

premenopausal pts: prefer chemotherapy

postmenopausal pts: prefer hormonal therapy (Tamoxifen), esp if ER/PR positive

give chemo to everyone who already has obvious metastasis (liver, bone, brain)


how do you manage ductal carcinoma in situ

standard recommendation: simple total mastectomy
--offers 100% cure
--not yet capable of metastasis
--axillary examination is not needed


how do you manage thyroid masses based on biopsy results

negative: leave alone
positive: operate to remove tumor (most are benign)

indeterminate: operate


what is dx in pt who is losing weight, big appetite, heart palps, heat intolerance, thin, fidgety, diaphoretic, tachy

hyper functioning thyroid adenoma- "hot" --> hyperthyroidism


how do you dx and manage hyperthyroidism

high free T4 or low TSH

localize with radioactive iodine scan
--surgically resect the isolated area
--or radioactive iodine tx if whole thyroid lights up


what is dx in lateral mass near thyroid

metastasis from follicular carcinoma of thyroid that has completely replaced a lymph node


how do you manage metastatic follicular carcinoma of thyroid

thyroid scan to identify primary tumor
then surgery


what is dx in pt with high serum Ca and low serum P



how does hyperparathyroid pt present

"stones, bones, moans, psychiatric overtones"

cystic bone lesions
GI complains w/ pancreatitis
peptic ulcer


how do you dx hyperparathyroidism

verify primary hyperPTH with simultaneous high serum Ca


what are most hyperparathyroid conditions

90% are adenomas (vs hyperplasia)


how do you tx primary hyperparathyroidism

remove offending adenoma
--localize with Sestamibi, sonogram, CT scan prior to surgery

--high rate of conversion, so you should treat even if pt is asymptomatic


what is dx in pt who goes pretty --> monster (lolz)



what is dx in pt with round face, acne, hair, hump, supraclavicular fat pads, thin extremities, truncal centripetal obesity w/ striae



what should you think in a pt with HTN, DM, osteoporosis, amenorrhea, wide mood swings +/- psych service



how do you work up cushing

measure AM and MP cortisol (high; and no longer diurnal variation)

Dexamethasone tests


what is dx in pt whose cortisol is suppressed with small dose of dexamethasone

does not have Cushing's


what is dx in pt whose cortisol is not suppressed with low-dose dexamethasone


don't know location/cause yet
--could be pituitary adenoma --> both adrenals
--or adenoma in adrenal --> cortisol


what is dx in pt whose cortisol suppresses at high doses of dexamethasone

ACTH-secreting pituitary micro-adenoma


what is dx in pt whose cortisol does not suppress at high doses of dexamethasone

adrenal or extra-adrenal cortisol production


depending on your Dex results, what is your next step

MRI of pituitary or CT of adrenals
--remove the offender


what is dx in pt with gastronoma of pancreas or duodenum

Zollinger-Ellison syndrome


what is dx in pt with extremely virulent PUD that does not respond to normal therapy + watery diarrhea

Zollinger Ellison syndrome


what is work up up for Zollinger Ellison syndrome

measure serum gastrin
CT scan of pancreas/duodenum to see primary tumor
resect the gastronoma


what is ddx for hypoglycemia

terminal stage liver failure, retroperitoneal sarcoma


reactive hypoglycemia

injecting insulin


what is dx in pt who gets a hypoglycemic attack during fasting (skip breakfast; late for lunch)



what will labs be in insulinoma

endogenous insulin = high C peptide + high insulin


what is dx in pt who gets hypoglycemia attack after a big meal

reactive hypoglycemia (pancreas overreacts)


what are labs in reactive hyoglycemia

endogenous insulin - high C peptide + high insulin


what is dx in pt who gets hypoglycemia attack and has knowledge of how insulin works

injecting insulin

refer pt to psych to determine motivation of action


what will labs look like for a pt injecting insulin

exogenous insulin = low C peptide + high insulin