For a patient with a first-time DVT with a clearly reversible inciting incident (surgery) ___ should be started.
Heparin should be started as the patient transitions to > 3 months of warfarin therapy with goal INR 2-3
* Start anticoagulation in hemodynamically stable patient 48-72 hours after surgery w/o any sig risk of bleeding or other complication
Pt presents with trismus (inability to open the mouth normally) and limited cervical neck extension common in patients with ___.
Retropharyngeal abscess
- CT scan neck/lateral x-ray neck
- tx: IV broad spectrum abx and urgent drainage of the abscess avoid spread to mediastinum
Herpangina is caused by ___ results in formation of vesicles on the tonsils and soft palate, occurs in children, Causes sore throat, fever, and pain with swallowing.
Coxsackie A virus
GCS scale
What are methods that can be used post op to INC FRC and prevent atelectasis in the immediate postoperative period?
- Chest physiotherapy
- Incentive spirometry
- Coughing
- Frequent repositioning/early ambulation (INC FRC by 20-35%)
If a patient develops a whistling noise during respiration following rhinoplasty, one should suspect ___ likely resulting from a septal hematoma.
septal perforation
__ are by far the most common cause of small bowel obstruction. Causes?
Adhesions
- congenital in children (Ladd's bands)
- abdominal operations or inflammatory processes
High-energy, rapid deceleration trauma to the chest commonly causes ___ injury.
Aortic
- aortic rupture death is immediate
- widened mediastinum and L sided hemothorax are classic CXR signs
- confirm dx via CT scan
Clinical presentation:
- Fever
- RUQ pain
- N/V
- Crepitus in abd wall adjacent to gallbladder
Air-fluid levels in gallbladder, gas in gallbladder wall
Emphysematous cholecystitis
- Cultures with gas-forming Clostridium, E.coli
- Unconjugated hyperbilirubinemia, mildly elevated aminotransferases
Tx emphysematous cholecystitis.
Emergent cholecystectomy
Broad-Spectrum abx with Clostridium coverage (ampicillin-sulbactam)
Risk factors for emphysematous cholecystitis.
Vascular compromise (obstruction of stenosis of cystic artery)
Immunosuppression (DM)
Gallstones
Clinical presentation:
- Early satiety
- N/V
- Wt loss
- Pt ingested acid 3 months ago
Pyloric stricture
- gastric outlet obstruction (hear a succussion splash retained gastric material > 3 hours after meal)
Causes of gastric outlet obstruction.
- Gastric malignancy
- PUD
- Crohns disease
- Strictures (pyloric stenosis) 2/2 to caustic agent ingestion
- Gastric bezoars
___ is characterized by anterior knee pain, tenderness, erythema, and localized swelling common in occupations requiring receptive kneeling.
Prepatellar bursitis
- Staph aureus can infect the bursa via penetrating trauma, repetitive friction, or extension from local cellulitis
- dx confirmed with cell count and gram stain of bursal fruit
- tx drainage and systemic abxs
___ causes chest pain that is classically described as sudden, tearing, and radiating to the back. ___ is the most common predisposing factor.
Aortic dissection
- HTN
* can also have aortic regurgitation (early diastolic decrescendo murmur) due to the aortic dissection involving the aortic root
N/V
Abd distention
Obstipation
Hypoactive bowel sounds
Abx x-ray shows uniformly distended, gas-filled loops of both small and large intestines
Ileus
- abd sx can also be due to retroperitoneal/abd hemorrhage or inflammation, intestinal ischemia, electrolyte abnormalities
- tx: bowel rest, supportive care, and tx of secondary causes
Complications of supracondylar fractures of humerus.
- Brachial artery injury
- Median never injury
- Cubitus varus deformity
- Compartment syndrome, Volkmann ischemic contracture
*fall on an outstretched hand
* most common fractures in pediatric population
___ is the treatment of choice for sphincter of oddi dysfunction.
ERCP with sphincterotomy
___ innervates the muscles of the anterior compartment of the thighs, responsible for knee extension and hip flexion. ___ sensation to the anterior thigh and medial leg via saphenous branch.
Femoral nerve
Interventions for lowering ICP
Measurement of tissue pressure is diagnostic for compartment syndrome with compartment pressure > ___ mmHg.
30 mmHg or delta pressure < 20-30 mmHg
Blunt abd trauma often causes ___ injury which can present with delayed onset of hypotension, left shoulder pain, LUQ abd pain.
Next step in diagnosing?
Splenic injury
- abdominal CT with IV contrast to dx
- persistent hemodynamic instability require urgent laparotomy
Postoperative pulmonary complications
___ can occur as a local vascular complication of cardiac catherization, and often presents with sudden hemodynamic instability and IL flank and back pain (flat neck veins, tachy, hypotension, and back pain)
Retroperitoneal hematoma
- dx: non contrast CT scan of abdomen and pelvis or abdominal US
- tx: supportive with bed rest, intensive monitoring, and IV fluids and/or blood transfusion
- post catherization patients are advised to avoid strenuous activity or
The next step in mgt of a suspected scaphoid fracture includes ___ for 7-10 days followed by repeating x-rays.
Thumb spica
- if pt cannot tolerate the immobilization then CT scan or MRI of the wrist
The differential diagnosis of an anterior mediastinal mass includes the "4T's"?
Thymoma
Teratoma (germ cell tumors)
Thyroid neoplasm
Terrible lymphoma
Among possible traumatic bladder injury, only a intraperitoneal rupture of the bladder __ could, by itself, cause chemical peritonitis.
Bladder dome
- covered by the peritoneum, can permit leakage of urine into peritoneum
Arterial occlusion of an extremity will cause pain, pulseless, pallor, paresthesias, and paralysis in the affected limb. ___ classically causes sudden-onset seven pain and asymmetric pulslessness.
Embolic occlusion
- originate from the heart either from the ventricles following an MI or from atria from a.fib
All hemodynamically unstable patients with sharp penetrating abdominal trauma and gunshot wounds that are believed to have entered the peritoneum must be treated with ___.
Exploratory laparotomy
- prevent dev. sepsis resulting from hollow organ perforation and prevent exsanguinating hemorrhage
Complicated diverticulitis refers to diverticulitis associated with an ___.
Abscess
Perforation
Obstruction
Fistula formation
fluid collection < 3 cm => tx IV abxs and observation, sx for worsening sxs
> 3cm => CT guided percutaneous drainage
Ischemic colitis
- RF
- Clinical features
- Dx
- Mgt
___ is indicated for circumferential full-thickness burns of an extremity with dead tissue causing significant edema and constriction of the vascular supply and DEC peripheral pulses.
Escharotomy
- a pressure of 25-40 mmHg threshold for escharotomy
- look for perfusion after escharotomy if not improved may need fasciotomy
Tetanus prophylaxis
Small bowel obstruction versus ileus
Pancreatic adenocarcinoma
Common causes of hemoptysis
Evaluation of hemoptysis
Patients with blunt abdominal trauma should undergo initial evaluation by ___ to evaluate for intraperitoneal hemorrhage.
FAST exam
+ exam require emergent ex-lap
Clinical signs of compartment syndrome.
- Deep pain out of proportion to the injury
- Pulselessness
- Paresthesias
- Cyanosis
- Pallor of the affected extremity
Indication for escharotomy a compartment pressure ___ mmHg.
Compartment pressure > 30 mmHg
Acute shoulder pain after forceful abduction and external rotation at the glenohumeral joint suggest an ___ dislocation, which may cause injury to the ___ nerve and artery.
Anterior shoulder
Axillary nerve + artery
__ is more common on the left side because the right side tends to be protected by the liver. Pts have respiratory distress and can have deviation of the mediastinal contents to the opposite side.
Diaphragmatic rupture
- elevation hemidiaphram on the CXR
- NGT in the pulmonary cavity is diagnostic on CXR
For hemodynamically unstable patients in whom blunt abdominal trauma is suspected, ___ should be initiated, followed by ___. If exam reveals intraperitoneal blood, the patient should then undergo ___.
IV fluids
US exam
Laparotomy for surgical repair
Fever, chills, and deep abdominal pain suggest ___.
Retroperitoneal abscess
- pancreatic contusion, crush injury, laceration
- Abd CT can often detect resolution of the injury but may be missed by initial CT
- untreated pancreatic injury can lead to retroperitoneal abscess or pseudocyst
- tx: percutaneous
__ and ___ are possible early complications of operation on the abdominal aorta such as AAA repair.
Bowel ischemia + infarction
- inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of the IMA during aortic graft placement
___ can occur following cardiac sx and presents with fever, CP, leukocytosis, and mediastinal widening on CXR. It is a serious condition requiring ___.
Acute mediastinitis
- drainage, sx debridement, and prolonged antibiotic therapy
___ is recommended for medically stable patients who recover from acute pancreatitis and are surgical candidates.
Early cholecystectomy
- reduce the risk of recurrent gallstone pancreatitis
- ALT > 150 = gallstone pancreatitis
In patients with traumatic spinal cord injuries, ___ placement can assess for urinary retention and prevent acute bladder distention and damage.
Urinary catheter
Clinical features of pneumothorax
Any penetrating wound below the 4th intercostal space (level of the nipples) is considered to involve the abdomen and requires ___.
exploratory laparotomy in unstable patients
Management of blunt abdominal trauma in hemodynamically unstable patients.
Parotid surgery involving the deep lobe of the parotid gland carries significant risk of ___ nerve palsy resulting in ___.
Facial nerve palsy
- facial droop unilateral
Transtentorial herniation of the parahippocampal uncus can occur in significant head trauma and leads to ___.
- IL hemiparesis (compression CL crus cerebri)
- IL mydriasis and strabismus (CN III)
- CL hemianopsia (PCA compression)
- Altered mentation (reticular formation)
The first step in the tx of acute variceal bleeding is ___.
Establish vascular access with 2
large bore IV needles
or a central line
then control bleeding with vasoconstrictors terlipressin, octeotide, or somatostatin
__ can develop after a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement. Pt has jaundice and elevated alkaline phosphatase.
Postoperative cholestasis
Timeline of cause of postoperative fever.
Fever > 100.4 (> 38 C)
Colicky abd pain
Vomiting
Inability to pass flatus or stool
Hyperactive BS
Distended & tympanic abdomen
Dx.
Complications.
Tx.
Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests ___ rupture.
Tracheobronchial rupture
- pneumomediastinum and subcutaneous emphysema (palpable crepitus below the skin)
- confirm with high res CT scan, operative repair is indicated
Management of gallstones
Anal fissures clinical presentation and tx.
Acute pain and swelling of the midline sacrococcygeal skin and SQ tissues are most commonly due to ___.
Pilonidal disease
- infection of a dermal sinus tract originating over the coccyx
Classic signs of ___ include blood in the urethral meatus, inability to void and high-riding prostate on DRE.
Posterior urethral injury
- retrograde urethrogram prior to foley cath
- foley cath contraindicated in pts suspected of having urethral injury
Cause of primary hypoparathyroidism?
1. Post-surgical (MCC)
2. Autoimmune (MC not surgical syndrome)
3. Congenital absence or maldevelopment of the parathyroid gland (DiGeorge syndrome)
4. Defective calcium-sensing receptor on the parathyroid gland
5. Non-autoimmune destruction of the parath
Dumping syndrome
Suspect a patient has splenic trauma and is hemodynamically stable, responds to fluids (SBP > 100 mmHg) what is the next step?
Abdominal CT scan
___ is most common in patient of Mediterranean and Far Eastern descent strongly associated with EBV infection.
Nasopharyngeal carcinoma
Immunologic blood transfusion reactions
Tracheal deviation to the opposite side
Hyper-expanded chest with DEC movt with respiration
INC percussion note
Elevated CVP
Dx.
Tx.
Tension pneumothorax
- emergency needle thoracostomy in the 2nd intercostal space in the mid-clavicular line
Tx of MCL tears.
Surgery rarely necessary for MCL tears, bracing and early ambulation is the preferred treatment
Pts who presents with appendicitis > 5 days after the onset of sxs have a high incidence of perforation with ___ formation. Tx.
Abscess - typically contained
- CT confirm the diagnosis
- pt is stable may be treated with IVF, abxs, bowel rest, and interval appendectomy (in 6-8 weeks)
___ occurs in critically ill patients. Imaging studies show gallbladder wall thickening and distention and pericholecystic fluid.
Acalculous cholecystitis
- due to cholestasis and gallbladder ischemia leading to secondary infection by enteric organisms and resultant edema and necrosis of the gallbladder
tx: Abxs followed by percutaneous cholecystostomy under radiologic guidance, fol
Ankle-brachial index interpretation.
___ is a noninvasive test that is highly sensitive and specific for PAD in symptomatic patients. It is the preferred first step to confirm the diagnosis in most cases.
ABI
___ should be the prime objective in the mgt of rib fractures as it will allow proper ventilation and prevent atelectasis and pneumonia.
Pain relief
- opiates or NSAIDs
- intercostal nerve blocks with long-acting local anesthetics (pain relief but does carry risk of pneumothorax)
Pt presents with penile fracture next best step?
Emergent urethrogram
to assess for urethral injury as well as
emergent sx
to evacuate the hematoma and mend the torn tunica albuginea
Hemodynamic measurements in shock.
___ presents with painful swelling of the parotid gland that is aggravated by chewing. High fever, tender, swollen erythematous parotid gland. How can this be prevented? MCC?
Acute bacterial parotitis
- adequate fluid hydration and oral hygiene
- occurs in elderly most prone
- Staph aureus
SIRS criteria.
2/4 of the criteria
Temp > 38.5 (101.4F) or < 35 (95 F)
Pulse > 90
Resp > 20
WBC > 12,000, < 4000, > 10% bands
In patients with significant TBSA burns, the major cause of morbidity and mortality is ___. In the setting of adequate initial fluid resuscitation, ___ leading to sepsis and septic shock is the leading complication.
Hypovolemic shock
Bacterial infection (usually bronchopneumonia or burn wound infection Staph and Pseudomonas)
Sepsis vs Severe sepsis
SIRS with a known infection
Severe Sepsis (end-organ dysfunction)
- oliguria
- hypotension (SB < 90)
- thrombocytopenia (ptc < 80,000)
- metabolic acidosis
- hypoxemia
___ is a potential complication of thoracic aortic aneurysm surgery and presents with spinal shock (B/L flaccid paralysis and loss of P/T sensation below the level of spinal injury)
Anterior spinal cord infarction
- UMN signs (spasticity and hyperreflexia) develop over days to weeks
- vibration and proprioception preserved
Isolated duodenal hematoma most commonly occurs in children following blunt abdominal trauma. It is treated ___.
Conservatively with NG suction and parenteral nutrition
Oliguria (less than 400 cc /< 6cc/kg of urine output per day), azoetemia, and elevated BUN/creatinine ratio > 20:1 in the post-operative state most likely indicate acute pre-renal failure from ____, though ___ should first be ruled out. Tx.
Hypovolemia
- urinary catheter obstruction
- tx: IV fluid challenge
Patient with blunt abdominal trauma and shock assessed with FAST exam that is equivocal or inconclusive, next step?
Diagnostic peritoneal lavage (DPL)
- intraperitoneal hemorrhage
- aspiration 10 mL of peritoneal fluids shows blood, intraperitoneal injury is likely
Hypotension, tachy, flat neck veins, confusion, and cold extremities despite IV fluid resuscitation in a trauma patient indicates ____ shock.
Hypovolemic/hemorrhagic
An AAA can rupture into the retroperitoneum and create a ___ with the IVC leading to venous congestion in retroperitoneal structures (bladder).
Aortocaval fistula
- the fragile and distended veins in the bladder can rupture and cause gross hematuria
In a middle-aged adult, superficial unilateral hip pain that is exacerbated by external pressure to the upper lateral thigh (as when lying on the affected side in bed) suggests ____.
Trochanteric bursitis
Pt has a clavicular fracture should have a careful neurovascular exam via ___ to r/o brachial plexus and subclavian artery injury. Pt has a bruit heard and ___ is necessary to r/o injury to underlying vessel.
Angiogram
In a young patient who presents with a fleshy immobile mass on the midline hard palate, the most likely diagnosis is ____.
Torus palatinus
- no medical or sx therapy unless the growth is symptomatic or interferes with speech or eating
___ and ___ artery aneurysm are the most common peripheral artery aneurysm.
Popliteal and femoral
- pulsatile mass that can compress adjacent structures (nerves, veins) and can results in thrombosis and ischemia
When hemorrhage occurs, ___ and ___ are the first physiologic changes. These responses act to maintain the blood pressure within normal limits until severe blood loss has occurred.
Tachycardia
Peripheral vascular constriction
In case of amputation injury, amputated parts should be ___.
Wrapped in saline-moistened gauze, sealed in a plastic bag, placed on ice and brought to the ED with the patient
The presence of an extra-axial well-circumscribed or round homogeneously enhancing dural-based mass on MRI is strongly suggestive of a ___.
Meningioma
- tumor undergo calcification and can appear hyperdense on non-contrast head CT
- benign primary tumor
____ is characterized by the triad of B/L hip, thigh, and buttocks claudication, impotence and symmetric atrophy of the B/L LE due to chronic ischemia.
Aortoiliac occlusion (Leriche syndrome)
Meniscal tears
Etiology
Sxs
Exam
Dx
Mgt
Benign breast disease
___ single most important prognostic consideration in the tx of patients with breast cancer.
Tumor burden
- TNM staging
For a patient with a first-time DVT with a clearly reversible inciting incident (surgery) ___ should be started.
Heparin should be started as the patient transitions to > 3 months of warfarin therapy with goal INR 2-3
* Start anticoagulation in hemodynamically stable patient 48-72 hours after surgery w/o any sig risk of bleeding or other complication
Pt presents with trismus (inability to open the mouth normally) and limited cervical neck extension common in patients with ___.
Retropharyngeal abscess
- CT scan neck/lateral x-ray neck
- tx: IV broad spectrum abx and urgent drainage of the abscess avoid spread to mediastinum
Herpangina is caused by ___ results in formation of vesicles on the tonsils and soft palate, occurs in children, Causes sore throat, fever, and pain with swallowing.
Coxsackie A virus
GCS scale
What are methods that can be used post op to INC FRC and prevent atelectasis in the immediate postoperative period?
- Chest physiotherapy
- Incentive spirometry
- Coughing
- Frequent repositioning/early ambulation (INC FRC by 20-35%)
If a patient develops a whistling noise during respiration following rhinoplasty, one should suspect ___ likely resulting from a septal hematoma.
septal perforation
__ are by far the most common cause of small bowel obstruction. Causes?
Adhesions
- congenital in children (Ladd's bands)
- abdominal operations or inflammatory processes
High-energy, rapid deceleration trauma to the chest commonly causes ___ injury.
Aortic
- aortic rupture death is immediate
- widened mediastinum and L sided hemothorax are classic CXR signs
- confirm dx via CT scan
Clinical presentation:
- Fever
- RUQ pain
- N/V
- Crepitus in abd wall adjacent to gallbladder
Air-fluid levels in gallbladder, gas in gallbladder wall
Emphysematous cholecystitis
- Cultures with gas-forming Clostridium, E.coli
- Unconjugated hyperbilirubinemia, mildly elevated aminotransferases
Tx emphysematous cholecystitis.
Emergent cholecystectomy
Broad-Spectrum abx with Clostridium coverage (ampicillin-sulbactam)
Risk factors for emphysematous cholecystitis.
Vascular compromise (obstruction of stenosis of cystic artery)
Immunosuppression (DM)
Gallstones
Clinical presentation:
- Early satiety
- N/V
- Wt loss
- Pt ingested acid 3 months ago
Pyloric stricture
- gastric outlet obstruction (hear a succussion splash retained gastric material > 3 hours after meal)
Causes of gastric outlet obstruction.
- Gastric malignancy
- PUD
- Crohns disease
- Strictures (pyloric stenosis) 2/2 to caustic agent ingestion
- Gastric bezoars
___ is characterized by anterior knee pain, tenderness, erythema, and localized swelling common in occupations requiring receptive kneeling.
Prepatellar bursitis
- Staph aureus can infect the bursa via penetrating trauma, repetitive friction, or extension from local cellulitis
- dx confirmed with cell count and gram stain of bursal fruit
- tx drainage and systemic abxs
___ causes chest pain that is classically described as sudden, tearing, and radiating to the back. ___ is the most common predisposing factor.
Aortic dissection
- HTN
* can also have aortic regurgitation (early diastolic decrescendo murmur) due to the aortic dissection involving the aortic root
N/V
Abd distention
Obstipation
Hypoactive bowel sounds
Abx x-ray shows uniformly distended, gas-filled loops of both small and large intestines
Ileus
- abd sx can also be due to retroperitoneal/abd hemorrhage or inflammation, intestinal ischemia, electrolyte abnormalities
- tx: bowel rest, supportive care, and tx of secondary causes
Complications of supracondylar fractures of humerus.
- Brachial artery injury
- Median never injury
- Cubitus varus deformity
- Compartment syndrome, Volkmann ischemic contracture
*fall on an outstretched hand
* most common fractures in pediatric population
___ is the treatment of choice for sphincter of oddi dysfunction.
ERCP with sphincterotomy
___ innervates the muscles of the anterior compartment of the thighs, responsible for knee extension and hip flexion. ___ sensation to the anterior thigh and medial leg via saphenous branch.
Femoral nerve
Interventions for lowering ICP
Measurement of tissue pressure is diagnostic for compartment syndrome with compartment pressure > ___ mmHg.
30 mmHg or delta pressure < 20-30 mmHg
Blunt abd trauma often causes ___ injury which can present with delayed onset of hypotension, left shoulder pain, LUQ abd pain.
Next step in diagnosing?
Splenic injury
- abdominal CT with IV contrast to dx
- persistent hemodynamic instability require urgent laparotomy
Postoperative pulmonary complications
___ can occur as a local vascular complication of cardiac catherization, and often presents with sudden hemodynamic instability and IL flank and back pain (flat neck veins, tachy, hypotension, and back pain)
Retroperitoneal hematoma
- dx: non contrast CT scan of abdomen and pelvis or abdominal US
- tx: supportive with bed rest, intensive monitoring, and IV fluids and/or blood transfusion
- post catherization patients are advised to avoid strenuous activity or
The next step in mgt of a suspected scaphoid fracture includes ___ for 7-10 days followed by repeating x-rays.
Thumb spica
- if pt cannot tolerate the immobilization then CT scan or MRI of the wrist
The differential diagnosis of an anterior mediastinal mass includes the "4T's"?
Thymoma
Teratoma (germ cell tumors)
Thyroid neoplasm
Terrible lymphoma
Among possible traumatic bladder injury, only a intraperitoneal rupture of the bladder __ could, by itself, cause chemical peritonitis.
Bladder dome
- covered by the peritoneum, can permit leakage of urine into peritoneum
Arterial occlusion of an extremity will cause pain, pulseless, pallor, paresthesias, and paralysis in the affected limb. ___ classically causes sudden-onset seven pain and asymmetric pulslessness.
Embolic occlusion
- originate from the heart either from the ventricles following an MI or from atria from a.fib
All hemodynamically unstable patients with sharp penetrating abdominal trauma and gunshot wounds that are believed to have entered the peritoneum must be treated with ___.
Exploratory laparotomy
- prevent dev. sepsis resulting from hollow organ perforation and prevent exsanguinating hemorrhage
Complicated diverticulitis refers to diverticulitis associated with an ___.
Abscess
Perforation
Obstruction
Fistula formation
fluid collection < 3 cm => tx IV abxs and observation, sx for worsening sxs
> 3cm => CT guided percutaneous drainage
Ischemic colitis
- RF
- Clinical features
- Dx
- Mgt
___ is indicated for circumferential full-thickness burns of an extremity with dead tissue causing significant edema and constriction of the vascular supply and DEC peripheral pulses.
Escharotomy
- a pressure of 25-40 mmHg threshold for escharotomy
- look for perfusion after escharotomy if not improved may need fasciotomy
Tetanus prophylaxis
Small bowel obstruction versus ileus
Pancreatic adenocarcinoma
Common causes of hemoptysis
Evaluation of hemoptysis
Patients with blunt abdominal trauma should undergo initial evaluation by ___ to evaluate for intraperitoneal hemorrhage.
FAST exam
+ exam require emergent ex-lap
Clinical signs of compartment syndrome.
- Deep pain out of proportion to the injury
- Pulselessness
- Paresthesias
- Cyanosis
- Pallor of the affected extremity
Indication for escharotomy a compartment pressure ___ mmHg.
Compartment pressure > 30 mmHg
Acute shoulder pain after forceful abduction and external rotation at the glenohumeral joint suggest an ___ dislocation, which may cause injury to the ___ nerve and artery.
Anterior shoulder
Axillary nerve + artery
__ is more common on the left side because the right side tends to be protected by the liver. Pts have respiratory distress and can have deviation of the mediastinal contents to the opposite side.
Diaphragmatic rupture
- elevation hemidiaphram on the CXR
- NGT in the pulmonary cavity is diagnostic on CXR
For hemodynamically unstable patients in whom blunt abdominal trauma is suspected, ___ should be initiated, followed by ___. If exam reveals intraperitoneal blood, the patient should then undergo ___.
IV fluids
US exam
Laparotomy for surgical repair
Fever, chills, and deep abdominal pain suggest ___.
Retroperitoneal abscess
- pancreatic contusion, crush injury, laceration
- Abd CT can often detect resolution of the injury but may be missed by initial CT
- untreated pancreatic injury can lead to retroperitoneal abscess or pseudocyst
- tx: percutaneous
__ and ___ are possible early complications of operation on the abdominal aorta such as AAA repair.
Bowel ischemia + infarction
- inadequate colonic collateral arterial perfusion to the left and sigmoid colon after loss of the IMA during aortic graft placement
___ can occur following cardiac sx and presents with fever, CP, leukocytosis, and mediastinal widening on CXR. It is a serious condition requiring ___.
Acute mediastinitis
- drainage, sx debridement, and prolonged antibiotic therapy
___ is recommended for medically stable patients who recover from acute pancreatitis and are surgical candidates.
Early cholecystectomy
- reduce the risk of recurrent gallstone pancreatitis
- ALT > 150 = gallstone pancreatitis
In patients with traumatic spinal cord injuries, ___ placement can assess for urinary retention and prevent acute bladder distention and damage.
Urinary catheter
Clinical features of pneumothorax
Any penetrating wound below the 4th intercostal space (level of the nipples) is considered to involve the abdomen and requires ___.
exploratory laparotomy in unstable patients
Management of blunt abdominal trauma in hemodynamically unstable patients.
Parotid surgery involving the deep lobe of the parotid gland carries significant risk of ___ nerve palsy resulting in ___.
Facial nerve palsy
- facial droop unilateral
Transtentorial herniation of the parahippocampal uncus can occur in significant head trauma and leads to ___.
- IL hemiparesis (compression CL crus cerebri)
- IL mydriasis and strabismus (CN III)
- CL hemianopsia (PCA compression)
- Altered mentation (reticular formation)
The first step in the tx of acute variceal bleeding is ___.
Establish vascular access with 2
large bore IV needles
or a central line
then control bleeding with vasoconstrictors terlipressin, octeotide, or somatostatin
__ can develop after a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement. Pt has jaundice and elevated alkaline phosphatase.
Postoperative cholestasis
Timeline of cause of postoperative fever.
Fever > 100.4 (> 38 C)
Colicky abd pain
Vomiting
Inability to pass flatus or stool
Hyperactive BS
Distended & tympanic abdomen
Dx.
Complications.
Tx.
Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests ___ rupture.
Tracheobronchial rupture
- pneumomediastinum and subcutaneous emphysema (palpable crepitus below the skin)
- confirm with high res CT scan, operative repair is indicated
Management of gallstones
Anal fissures clinical presentation and tx.
Acute pain and swelling of the midline sacrococcygeal skin and SQ tissues are most commonly due to ___.
Pilonidal disease
- infection of a dermal sinus tract originating over the coccyx
Classic signs of ___ include blood in the urethral meatus, inability to void and high-riding prostate on DRE.
Posterior urethral injury
- retrograde urethrogram prior to foley cath
- foley cath contraindicated in pts suspected of having urethral injury
Cause of primary hypoparathyroidism?
1. Post-surgical (MCC)
2. Autoimmune (MC not surgical syndrome)
3. Congenital absence or maldevelopment of the parathyroid gland (DiGeorge syndrome)
4. Defective calcium-sensing receptor on the parathyroid gland
5. Non-autoimmune destruction of the parath
Dumping syndrome
Suspect a patient has splenic trauma and is hemodynamically stable, responds to fluids (SBP > 100 mmHg) what is the next step?
Abdominal CT scan
___ is most common in patient of Mediterranean and Far Eastern descent strongly associated with EBV infection.
Nasopharyngeal carcinoma
Immunologic blood transfusion reactions
Tracheal deviation to the opposite side
Hyper-expanded chest with DEC movt with respiration
INC percussion note
Elevated CVP
Dx.
Tx.
Tension pneumothorax
- emergency needle thoracostomy in the 2nd intercostal space in the mid-clavicular line
Tx of MCL tears.
Surgery rarely necessary for MCL tears, bracing and early ambulation is the preferred treatment
Pts who presents with appendicitis > 5 days after the onset of sxs have a high incidence of perforation with ___ formation. Tx.
Abscess - typically contained
- CT confirm the diagnosis
- pt is stable may be treated with IVF, abxs, bowel rest, and interval appendectomy (in 6-8 weeks)
___ occurs in critically ill patients. Imaging studies show gallbladder wall thickening and distention and pericholecystic fluid.
Acalculous cholecystitis
- due to cholestasis and gallbladder ischemia leading to secondary infection by enteric organisms and resultant edema and necrosis of the gallbladder
tx: Abxs followed by percutaneous cholecystostomy under radiologic guidance, fol
Ankle-brachial index interpretation.
___ is a noninvasive test that is highly sensitive and specific for PAD in symptomatic patients. It is the preferred first step to confirm the diagnosis in most cases.
ABI
___ should be the prime objective in the mgt of rib fractures as it will allow proper ventilation and prevent atelectasis and pneumonia.
Pain relief
- opiates or NSAIDs
- intercostal nerve blocks with long-acting local anesthetics (pain relief but does carry risk of pneumothorax)
Pt presents with penile fracture next best step?
Emergent urethrogram
to assess for urethral injury as well as
emergent sx
to evacuate the hematoma and mend the torn tunica albuginea
Hemodynamic measurements in shock.
___ presents with painful swelling of the parotid gland that is aggravated by chewing. High fever, tender, swollen erythematous parotid gland. How can this be prevented? MCC?
Acute bacterial parotitis
- adequate fluid hydration and oral hygiene
- occurs in elderly most prone
- Staph aureus
SIRS criteria.
2/4 of the criteria
Temp > 38.5 (101.4F) or < 35 (95 F)
Pulse > 90
Resp > 20
WBC > 12,000, < 4000, > 10% bands
In patients with significant TBSA burns, the major cause of morbidity and mortality is ___. In the setting of adequate initial fluid resuscitation, ___ leading to sepsis and septic shock is the leading complication.
Hypovolemic shock
Bacterial infection (usually bronchopneumonia or burn wound infection Staph and Pseudomonas)
Sepsis vs Severe sepsis
SIRS with a known infection
Severe Sepsis (end-organ dysfunction)
- oliguria
- hypotension (SB < 90)
- thrombocytopenia (ptc < 80,000)
- metabolic acidosis
- hypoxemia
___ is a potential complication of thoracic aortic aneurysm surgery and presents with spinal shock (B/L flaccid paralysis and loss of P/T sensation below the level of spinal injury)
Anterior spinal cord infarction
- UMN signs (spasticity and hyperreflexia) develop over days to weeks
- vibration and proprioception preserved
Isolated duodenal hematoma most commonly occurs in children following blunt abdominal trauma. It is treated ___.
Conservatively with NG suction and parenteral nutrition
Oliguria (less than 400 cc /< 6cc/kg of urine output per day), azoetemia, and elevated BUN/creatinine ratio > 20:1 in the post-operative state most likely indicate acute pre-renal failure from ____, though ___ should first be ruled out. Tx.
Hypovolemia
- urinary catheter obstruction
- tx: IV fluid challenge
Patient with blunt abdominal trauma and shock assessed with FAST exam that is equivocal or inconclusive, next step?
Diagnostic peritoneal lavage (DPL)
- intraperitoneal hemorrhage
- aspiration 10 mL of peritoneal fluids shows blood, intraperitoneal injury is likely
Hypotension, tachy, flat neck veins, confusion, and cold extremities despite IV fluid resuscitation in a trauma patient indicates ____ shock.
Hypovolemic/hemorrhagic
An AAA can rupture into the retroperitoneum and create a ___ with the IVC leading to venous congestion in retroperitoneal structures (bladder).
Aortocaval fistula
- the fragile and distended veins in the bladder can rupture and cause gross hematuria
In a middle-aged adult, superficial unilateral hip pain that is exacerbated by external pressure to the upper lateral thigh (as when lying on the affected side in bed) suggests ____.
Trochanteric bursitis
Pt has a clavicular fracture should have a careful neurovascular exam via ___ to r/o brachial plexus and subclavian artery injury. Pt has a bruit heard and ___ is necessary to r/o injury to underlying vessel.
Angiogram
In a young patient who presents with a fleshy immobile mass on the midline hard palate, the most likely diagnosis is ____.
Torus palatinus
- no medical or sx therapy unless the growth is symptomatic or interferes with speech or eating
___ and ___ artery aneurysm are the most common peripheral artery aneurysm.
Popliteal and femoral
- pulsatile mass that can compress adjacent structures (nerves, veins) and can results in thrombosis and ischemia
When hemorrhage occurs, ___ and ___ are the first physiologic changes. These responses act to maintain the blood pressure within normal limits until severe blood loss has occurred.
Tachycardia
Peripheral vascular constriction
In case of amputation injury, amputated parts should be ___.
Wrapped in saline-moistened gauze, sealed in a plastic bag, placed on ice and brought to the ED with the patient
The presence of an extra-axial well-circumscribed or round homogeneously enhancing dural-based mass on MRI is strongly suggestive of a ___.
Meningioma
- tumor undergo calcification and can appear hyperdense on non-contrast head CT
- benign primary tumor
____ is characterized by the triad of B/L hip, thigh, and buttocks claudication, impotence and symmetric atrophy of the B/L LE due to chronic ischemia.
Aortoiliac occlusion (Leriche syndrome)
Meniscal tears
Etiology
Sxs
Exam
Dx
Mgt
Benign breast disease
___ single most important prognostic consideration in the tx of patients with breast cancer.
Tumor burden
- TNM staging