Surgery Boost Exam

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After initiation of clopidogrel, what is the functional test that can be done to determine clopidogrel responsiveness?

Functional testing using a P2Y12 assay can be used to determine if the patient is a poor metabolizer of the drug.

What is the most common complication of peptic ulcer disease?

GI bleeding is the most common complication and is estimated to occur in approximately 15% of patients.

Which scalpel blade is the best for performing an incision and drainage?

#11 blade

Acute Respiratory and Metabolic Acidosis and Alkalosis

(Normal ABG values pH:7.35 - 7.45; PaCO2: 35 - 45; HCO3: 22 - 26) Respiratory Acidosis pH: < 7.35; PaCO2: > 45; HCO3: Normal Respiratory Alkalosis pH: > 7.45; PaCO2: < 35; HCO3: Normal Metabolic Acidosis pH: < 7.35; PaCO2: Normal; HCO3: < 22 Metabolic Alkalosis pH: > 7.45; PaCO2: Normal; HCO3: > 26 Metabolic alkalosis would be the most likely acid-base disturbance to develop postoperatively in this patient presentation. Volume contraction combined with gastric fluid loss is the most common cause. During this type of surgery, aggressive third-spacing of fluid into the peritoneal cavity, as well as the intestinal lumen, is the cause of volume contraction. Postoperatively, nasogastric decompression of the stomach causes acid loss. As the stomach works to replenish hydrochloric acid, bicarbonate (HCO3-) is released into the serum. The patient also loses potassium from the gastric fluid during nasogastric suctioning. The combination of the volume contraction and the postoperative measures causes a hypochloremic, hypokalemic metabolic alkalosis. Metabolic acidosis (A) postoperatively is most common in situations of large blood loss or resuscitation causing lactic acidosis and reduced end-organ oxygenation. Respiratory acidosis (C) in the postoperative patient is typically secondary to hypoventilation from respiratory depression. This can often be attributed to narcotic medications or excessive sedation. Respiratory alkalosis (D) occurs in patients who have undergone upper abdominal or thoracic surgery and are taking shallow breaths to avoid incisional pain. This causes hypocarbia and hypokalemia.

What is the most common late complication from gastric bypass?

Anemia.

What dietary aspects can increase the risk of gallstones?

Intake of large amounts of cholesterol and other fats.

Of all smoking cessation aids, which has the highest cessation success rate?

Varenicline.

What is the goal INR in a patient anticoagulated with warfarin due to a mechanical heart valve?

2.5-3.5

What is the name of a major theory delineating the pathogenesis of venous thromboembolism consisting of venous stasis, vascular injury, and hypercoagulable state?

Virchow's triad.

What types of blood studies may be appropriate in a patient presenting with abdominal pain and altered bowel habits?

A complete blood count should be obtained for all symptomatic patients. The erythrocyte sedimentation rate, thyroid-stimulating hormone level, and electrolyte levels are also useful in patients with altered bowel habits..

What is the most common cause of large bowel obstruction in adults?

A malignant tumor.

What is the "Rule of W"?

A mnemonic for common causes of postoperative fever in the order in which they occur: wind (atelectasis), water (UTI), wound (infection), walking (venous thromboembolic disease), and wonder drug (drug fever).

What is Courvoisier's sign?

A palpable gallbladder in a patient with painless jaundice, which represents an obstructing pancreatic or biliary neoplasm until proven otherwise.

Cutaneous Absecess

A skin abscess is a collection of pus in the dermis or subcutaneous space. Risk factors for abscess formation are skin barrier disruption due to trauma, skin inflammation, edema due to impaired lymphatic drainage or venous insufficiency, obesity, and immunosuppression (HIV or diabetes). Patients usually complain of skin redness, edema, warmth, spontaneous drainage, and they may also present with fever. Physical exam reveals a fluctuant erythematous mass. Diagnosis is made based on clinical presentation and exam findings. Culture with susceptibility should be obtained of purulent drainage to direct antibiotic therapy. The most common cause of abscess is Staphylococcus aureus (methicillin-susceptible or methicillin-resistant) infection. Patients with a drainable abscess should undergo incision and drainage. Antibiotic therapy in addition to incision and drainage is recommended for patients with any of the following factors present: single abscess ≥ 2 cm, multiple lesions, extensive surrounding cellulitis, immunosuppression, systemic signs of toxicity, or inadequate response to incision and drainage alone. Antibiotic therapy should cover MRSA infection; appropriate options include clindamycin, trimethoprim/sulfamethoxazole, and tetracyclines (doxycycline or minocycline). Complete blood count with differential (A) may reveal leukocytosis, and erythrocyte sedimentation rate (ESR) (D) may be elevated in a patient with an abscess, but these tests are not sensitive or specific for the diagnosis. Complete metabolic panel (B) provides information about key electrolytes, renal function, and hepatic function, but would be of little value when evaluating an abscess.

Cutaneous Abscess

A skin abscess is a pocket of pus and debris within the skin. Abscesses can occur from minor or major skin injuries. The most common cause of skin abscess is Staphylococcus aureus infection, which can be methicillin-susceptible or methicillin-resistant. Patients present with skin erythema, warmth, pain, and sometimes with spontaneous, purulent drainage. Exam usually reveals a fluctuant erythematous nodule. Diagnosis is made by characteristic symptoms and exam findings. Patients with a fluctuant abscess should be treated with incision and drainage. Culture with susceptibility should be obtained of the drainage to guide antibiotic therapy. Patients should be treated with antibiotic therapy in addition to incision and drainage if they have any of the following risks: a single abscess ≥ 2 cm, multiple abscesses, extensive surrounding cellulitis, systemic signs of toxicity, immunosuppression, or an inadequate response to drainage alone. Antibiotic therapy should cover methicillin-resistant S. aureus infection. Appropriate oral therapies are clindamycin, trimethoprim/sulfamethoxazole, or tetracyclines (doxycycline or minocycline). Physical exam commonly reveals edema (A), erythema (B), and warmth (D) for patients who have cellulitis or a skin abscess, but fluctuance is only indicative of a skin abscess.

What two pleural and serum laboratory values are part of Light's criteria?

Lactate dehydrogenase and protein.

Opioid Use Disorder

Abuse of prescription medication, illegal medications (heroin) Maintenance medications with opioids agonist or opioid antagonist Counseling, substance use treatment, support groups Monitor for withdrawal State prescription monitoring Opioid use disorder can involve the misuse of prescribed opioid medications, use of diverted opioid medications, or the use of illicitly obtained heroin. Risk factors for the misuse of prescribed opioid analgesics include a prior history of substance use disorder, certain demographic features (e.g., younger age), more severe pain, and co-occurring mental health disorders. Opioids can be used orally, intravenously, intranasally, or smoked. Physical examination may reveal track marks, which are calluses and scars which follow the course of a subcutaneous vein and are often found on the backs of the hands, the antecubital fossae, on the legs, or on the neck. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) the diagnosis of opioid use disorder requires a problematic pattern of opioid use which causes clinically significant impairment or distress as manifested by two or more of the following within a 12-month period: opioids taken in larger amounts or over a longer period than was intended, persistent desire to control opioid use, a great deal of time spent on obtaining, using, or recovering from opioids, strong desire to use opioids, recurrent opioid use resulting in a failure to fulfill major role obligations and continuing to use despite the problems caused, important activities given up because of opioid use, recurrent use in physically hazardous situations, continued opioid use despite knowledge of its negative effects, tolerance, and withdrawal. Urine drug screen can be used to detect metabolites of morphine and heroin for one to three days after last use, but in chronic users it may be detected longer. Treatment often involves the use of opioid agonists to suppress craving and withdrawal symptoms and to block the acute effects of other opioids. For patients with mild opioid use disorder who are post-withdrawal, an opioid antagonist, such as naltrexone, is often used for maintenance treatment to prevent relapse. For patients who are actively using opioids, buprenorphine, a partial mu-opioid agonist, is often used as a first-line treatment. Additionally, methadone, a long-acting opioid agonist which binds to and occupies mu-opioid receptors, can also be used. Patients with known opioid use disorder on methadone should be advised to continue the use of methadone, including on the day of surgery to avoid precipitating withdrawal. For this reason, it is advised to continue chronic narcotics on the day of surgery. Avoid any use of methadone one week prior to surgery (A) is not appropriate and would increase the patient's chances of withdrawal. Start benzodiazepines to avoid the risks of withdrawal (C) is not advised in a patient receiving methadone maintenance treatment as this can increase the risk of death. Transition the patient from methadone maintenance to buprenorphine (D) is not advisable, as patients with physiologic opioid dependence who are transitioned directly from methadone maintenance to buprenorphine may experience acute opioid withdrawal syndrome.

What is the preferred treatment of urticaria?

Acute urticaria is often self-limited, however, in cases that require treatment, antihistamines are preferred.

What are the components of Ranson criteria that are assessed at admission?

Age, white blood cell count, blood glucose, lactate dehydrogenase, and AST.

Respiratory Alkalosis

Alkalosis can result in hypokalemia and an intracellular acidosis from the shift of potassium from the serum into the intracellular space. In acidotic states, potassium is exchanged from the intracellular space for hydrogen ions causing an increase in serum potassium. In alkalotic states, the opposite occurs as potassium leaves the extracellular space in exchange for hydrogen ions. The same occurs with ionized calcium, causing decreased levels in the serum in alkalotic states. Hypokalemia and hypocalcemia can cause paresthesias, carpopedal spasm, and tetany. Hypocalcemia, not hypercalcemia (A), occurs with alkalosis. Hypomagnesemia, and not hypermagnesemia (B) typically coincides with hypokalemia. When a patient is found to have low potassium levels, a magnesium level should also be assessed. Hyponatremia (D) may occur in a respiratory alkalosis but it is a rare finding.

What are three tumor markers that should be assessed in cases of suspected testicular cancer?

Alpha-fetoprotein (AFP), the beta subunit of human chorionic gonadotropin (beta-hCG), and lactate dehydrogenase (LDH).

Heart Failure Staging/Classification

American Heart Association/American College of Cardiology staging: Stage A: high risk without symptoms/disease Stage B: structural disease without sx Stage C: structural disease + sx Stage D: refractory heart failure New York Heart Association classification: I: asymptomatic II: sx with ordinary activity III: asymptomatic only at rest IV: sx at rest Heart failure is a common syndrome caused by anything that impairs the ability of the ventricles to fill with or eject blood. It may be due to systolic dysfunction (reduced ejection fraction) or due to diastolic dysfunction (preserved ejection fraction). Risk factors for heart failure are ischemic cardiomyopathy, hypertension, myocardial infarction, obesity, and left ventricular hypertrophy. Patients may present with dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and lower extremity edema. Physical exam usually reveals evidence of volume overload, such as pulmonary congestion, peripheral edema, and elevated jugular venous pressure. Initial blood analysis may reveal impaired renal function, hyponatremia, and elevated brain natriuretic peptide (BNP), depending on the cause of heart failure. Most patients have an abnormal electrocardiogram, and an echocardiogram can help identify potential causes. Heart failure is diagnosed clinically. It may be prevented with risk factor reduction and early detection of asymptomatic patients with left ventricular ejection fraction ≤ 40% because effective therapy can delay symptom onset. Goals of therapy are symptom improvement and reduced mortality. Both goals can be accomplished with angiotensin-converting enzyme inhibitors, beta-blockers, hydralazine plus nitrates, angiotensin receptor neprilysin inhibitors, and aldosterone antagonists. Diuretics, angiotensin receptor blockers, and digoxin may also be useful to reduce symptoms. Some patients may benefit from an implantable cardioverter-defibrillator or cardiac resynchronization therapy. Duplex ultrasonography (B) of the lower extremities is used to evaluate venous disorders, such as venous insufficiency, venous stenosis, venous reflux, and deep vein thrombosis (DVT). Venous disease typically does cause lower extremity edema but usually does not lead to dyspnea. A helical chest computed tomography (CT) (C) is the diagnostic study of choice for suspected pulmonary embolism (PE). Patients with a PE may present with dyspnea on exertion and at rest and tachycardia, but generally do not show evidence of volume overload. Thoracentesis (D) is the best diagnostic and therapeutic intervention for a patient with a pleural effusion, which is usually identified on chest X-ray. Patients with a pleural effusion may also present with dyspnea but will have variable decreased breath sounds on auscultation depending on the size of the effusion.

What is Graves' disease?

An autoimmune condition associated with hyperthyroidism that is caused by autoantibodies to the thyrotropin receptor (TRAb) that activate the receptor, thereby stimulating thyroid hormone synthesis and secretion and thyroid growth.

Adrenal tumor surgery approach

An open transabdominal approach is typically used for resection of any adrenal tumor when malignancy is suspected. The open approach allows for greater visualization of the surrounding structures and resection of the surrounding lymph nodes. The open approach also allows for resection of adjacent structures should this be necessary if abnormalities are discovered during the surgery. Minimally invasive techniques, such as laparoscopic techniques, have been associated with reduced blood loss and length of stay, fewer intraoperative complications, and quicker recovery than open approaches, however, when malignancy is known or suspected, the increased visualization and access to adjacent structures makes the open approach optimal. Minimally invasive techniques are the preferred method for benign adrenal tumors. Laparoscopic transabdominal (A) and posterior retroperitoneoscopic (C) approaches are both minimally invasive techniques and do not allow the visualization of or access to adjacent structures. The retroperitoneal approach (D) is not preferred because of the increased risk of subcostal neuropathy and lumbar hernias, as well as the increased amount of incisional pain from cutting through the latissimus dorsi muscle.

What are the clinical features of Löfgren syndrome?

Combination of erythema nodosum, hilar adenopathy, migratory polyarthralgia, and fever, which, when present, has a 95 percent diagnostic specificity for sarcoidosis.

Ischemic Stroke

Anterior cerebral artery: frontal lobe dysfunction, apraxia, contralateral paralysis (lower > upper) Middle cerebral artery: contralateral paralysis (upper > lower), aphasia Posterior cerebral artery and VBI: LOC, nausea/vomiting, CN dysfunction, ataxia, visual agnosia Rule out hypoglycemia CT reveals loss of grey-white interface, acute hypodensity Thrombolytics The patient above has signs and symptoms concerning for acute stroke, which requires prompt imaging with non-contrast brain CT, or alternatively, a brain magnetic resonance imaging (MRI). Head CT is the preferred imaging because of widespread availability and rapid scan times. The purpose of neuroimaging is to quickly identify hemorrhagic stroke, evaluate the extent of damage, and attempt to identify the vascular etiology of the stroke. Patients who are admitted for stroke workup will often have a number of imaging studies performed for these purposes, however, the initial study must be sufficient in ruling out hemorrhagic stroke in a timely fashion. A brain CT provides limited information about ischemic strokes but is a rapid way to rule out hemorrhagic stroke and may also show signs of early infarct. This information guides stroke management and determines if fibrinolytic therapy is an option for patients with acute ischemic stroke. Carotid ultrasound (A) is used in the workup of ischemic strokes to evaluate extracranial artherosclerotic disease that may have embolized to the brain. It is done after the patient is stabilized and has had neuroimaging to rule out hemorrhagic stroke. Echocardiogram (B) is done as part of the workup for ischemic stroke, however, it is not urgently performed. Echocardiogram is able to identify a potential cardiac source of the emboli from intracardiac thrombus, tumors, and valve vegetations. It is also used to check for a patent foramen ovale which can allow a systemic venous clot to pass from the right to left side of the heart and subsequently travel to the brain. Magnetic resonance angiography of the vertebral arteries (C) is useful for detecting vascular stenosis or clots, however, does not provide images for the entire brain, which must be obtained early in the workup to rule out hemorrhagic stroke. It may be used as part of the workup for patients presenting with signs and symptoms concerning for posterior circulation stroke.

The decrescendo diastolic murmur at the right sternal border heard with aortic dissection is characteristic of what type of valvular abnormality?

Aortic regurgitation.

What is the primary cause of appendicitis?

Appendiceal obstruction.

What is the mechanism of action of aspirin?

Aspirin inhibits the enzyme cyclooxygenase (COX) which is responsible for the conversion of arachidonic acid to prostaglandin and thromboxane, resulting in the antiplatelet, anti-inflammatory, and analgesic properties of aspirin.

Asthma

Asthma: airway inflammation + bronchial hyperresponsiveness + reversible airflow obstruction PEF < 50%: severe exacerbation Classifications Treatments Bronchospasm is a common postoperative complication. Patients may present with dyspnea, wheezing, chest tightness, tachypnea, or hypercapnia. Bronchospasm may be caused by exacerbation of a chronic lung condition (COPD, asthma), aspiration, histamine release due to medications, or due to trachea stimulation from secretions, suctioning, or endotracheal intubation. Therapy should be directed at the underlying cause. Short-acting beta-2 agonists like albuterol, a bronchodilator, are first-line therapy for bronchospasm in an asthmatic patient. Apixaban (B) is a direct factor Xa inhibitor indicated for thromboembolism prevention or treatment. Patients who suffer a pulmonary embolism (PE) after surgery may present with acute-onset pleuritic chest pain, shortness of breath, or tachycardia. Computed tomography (CT) is sensitive for PE and is first-line imaging. Levofloxacin (C) is a first-line antibiotic indicated for hospital-acquired pneumonia. Patients may present with fever, cough, tachypnea, tachycardia, or shortness of breath. Lung auscultation typically reveals crackles and chest radiograph usually reveals an infiltrate. Oxygen (D) supplementation with nasal cannula or intubation is indicated for acute respiratory failure, hypoxia, and hypoxemia.

Carotid Endarterectomy (CEA)

Asymptomatic internal carotid artery stenosis of 60 to 99 percent Symptomatic carotid stenosis of 70 to 99 percent and a life expectancy of at least five years Treat with aspirin, statin, BP control and lifestyle changes Carotid endarterectomy is recommended for management of patients with symptomatic carotid artery disease and 70-99% occlusion whose perioperative morbidity and mortality risk is less than six percent. Patients should have a carotid plaque that is surgically accessible, no previous endarterectomy, and no risk factors for a greater increase in morbidity and mortality from surgery. Symptomatic carotid artery disease can manifest as transient ischemic attacks and cerebrovascular accidents. Patients may be worked up for carotid artery disease if they have risk factors, history of cerebrovascular events, or if they are discovered to have physical examination findings concerning for the disease, such as carotid bruits on auscultation. For diagnosis, cerebral angiography is the gold standard test. Carotid duplex ultrasound and angiography using MRI or CT can also be used for diagnostic work-up. For management of carotid artery disease, carotid endarterectomy (CEA) and carotid angioplasty and stenting can be performed. Stenting is used in carotid lesions that are not easily accessible with surgery, patients with a previous endarterectomy, or comorbidities that put patients at increased risk of complications from surgery. Medical management includes antiplatelet therapy and initiation of statin therapy. Carotid stenting (B) is incorrect, as this patient has symptomatic carotid artery disease that is easily surgically accessible and meets criteria for endarterectomy, which would be the preferred treatment choice based on his history. Carotid angioplasty and stenting is preferred in patients that have a carotid lesion with poor surgical accessibility, previous endarterectomy, or other concerning comorbidities. Endovascular coiling (C) is a type of endovascular embolization used to close off and prevent blood flow to an aneurysm. Initiate heparin to bridge to warfarin (D) is incorrect, as this patient meets criteria for surgical procedure to reduce his risk of stroke.

Inguinal Hernias

Bimodal: < 1 and > 40 Direct:Protrudes directly through Hesselbach triangle and medial to the inferior epigastric artery (IEA) Bulge decreases upon reclining Indirect:Most common type Protrudes through internal ring, lateral to IEA Medial to IEA: Direct; Lateral to IEA: Indirect (MDs don't LIe) Strangulation risk: indirect > direct Nonreducible hernia: emergent surgery consultation Surgical repair is required to treat a strangulated hernia. Hernias are described by location, etiology (congenital or acquired), and as reducible, incarcerated (unable to be reduced) or strangulated (loss of blood supply). Additionally, groin hernias (the most common type) are also described as femoral, direct (protrudes medial to the epigastric artery), or indirect (protrudes lateral to the epigastric artery through the inguinal canal). An incarcerated hernia greatly increases the risk of strangulation, loss of viable bowel tissue, and potentially perforation with spillage of bowel contents into the peritoneal cavity. Symptoms of strangulation include tenderness, pain, abdominal distension, nausea, vomiting, erythema over the hernia site, fever, and peritonitis. Strangulation is a surgical emergency and there should be no delays to definitive surgical treatment. Uncomplicated hernias may be managed without surgery, however, all femoral hernias should be surgically treated, as they have a high risk of incarceration and strangulation. The most common imaging test for groin hernias is ultrasound, however, computed tomography is sometimes obtained and can evaluate for complications. Analgesia and antibiotics (A) are part of the treatment for strangulated hernias. However, surgery is required as definitive treatment. Manual reduction (B) is contraindicated in patients exhibiting evidence of strangulation. Attempts at reduction of a strangulated hernia greatly increase the risk of perforating the affected bowel segment. Truss application (D) to a strangulated hernia is also contraindicated, as it requires reduction. A truss may be placed over a reduced hernia but may cause strangulation if it is inappropriately applied.

What are the components of quadruple therapy for H. pylori?

Bismuth subsalicylate, metronidazole, tetracycline, and a proton pump inhibitor.

How does an ileus or pseudo-obstruction differ in presentation from an acute bowel obstruction?

Both conditions present with abdominal distention, however, colicky abdominal pain is typically absent and patients may not have nausea or emesis with an ileus or pseudo-obstruction.

Revised Cardiac Risk Index for Pre-Operative Risk

CHF CKD High Risk Procedure Insulin Use Ischemic Heart Disease TIA/CVA A preoperative chest radiograph should be obtained in patients with COPD and increasing respiratory symptoms, decreasing exercise tolerance, or new lung auscultation findings on exam to rule out an active infection and heart failure. A preoperative CXR may also be helpful in patients with known cardiopulmonary disease and patients over 50 years old prior to high-risk procedures, such as upper abdominal, aortic, esophageal, and thoracic surgery. Preoperative CXR provides little benefit in identifying healthy patients at risk for perioperative complications and is not indicated in the majority of patients undergoing elective procedures. Measurement of pulse oximetry is indicated for all patients, but arterial blood gases (A) are only indicated if there is a resting SpO2 < 95% or severe pulmonary function test abnormalities. Chest computed tomography (B) is indicated to evaluate a patient with suspected interstitial lung disease, pulmonary embolism, or malignancy. For patients with a suspected COPD exacerbation or infiltrate, a CXR is more timely, less expensive, and exposes the patient to less radiation than a CT. Pulmonary function tests (D) are only indicated if exam alone does not reveal if baseline pulmonary function is optimal and for all patients undergoing lung resection. Typically PFTs simply confirm the clinical impression of disease severity.

Revised Cardiac Risk Index for Pre-Operative Risk

CHF CKD High Risk Procedure Insulin Use Ischemic Heart Disease TIA/CVA Functional capacity, or cardiac functional status, is an important indicator of postoperative cardiac complication risk, and it should be assessed at the initial preoperative evaluation. Poor functional capacity is associated with increased cardiac complications in noncardiac surgery. A patient's functional capacity is expressed in metabolic equivalents (1 MET equals 3.5 mL O2 uptake/kg per minute, which is the resting oxygen uptake in the seated position). Self-care, the ability to complete activities of daily living (ADLs), vacuuming, walking 2 mph, and writing are examples of poor functional capacity (less than 4 METs). The ability to walk up a flight of stairs, walk 4 mph, walking a golf course, doing yard work, and cycling are examples of moderate functional capacity (4-10 METs). Jogging, playing singles tennis, swimming, and skiing are examples of excellent functional capacity (greater than 10 METs). One specific indicator of increased risk of postoperative cardiopulmonary complications is the inability to climb two flights of stairs or walk four blocks. Documenting 4-7 METs (A) or 7-10 METs (B) indicates moderate functional capacity. Documenting greater than 10 METs (C) indicates excellent functional capacity.

What are the components of the CHA2DS2 VASc score?

CHF, Hypertension, Age ≥ 75 years (2 points), Diabetes, previous Stroke, TIA, or thromboembolic event (2 points), Vascular disease, Age 65-74 years, Sex category female.

What are erosions or ulcers occurring in the sac of a hiatal hernia called?

Cameron lesions.

What is the most useful serum marker for pancreatic cancer?

Carbohydrate antigen 19-9 (CA 19-9).

Patients are at a greater risk for possible stroke as a complication of which surgical procedure for carotid artery stenosis?

Carotid artery stenting.

Primary Hyperparathyroidism

Causes: parathyroid adenoma > gland hyperplasia, cancer ↑ PTH, ↑ Ca, ↓ phosphorus ↑ Ca → "stones, bones, groans, psychiatric overtones" Only curative rx: parathyroidectomy Parathyroid hormone levels can be monitored during a parathyroidectomy to ensure that the adenoma and any other parathyroid glands causing the hyperparathyroidism have been appropriately excised. Parathyroid hormone has a short half-life of three to five minutes and thus can be measured throughout the surgery at appropriate time intervals (such as pre-operatively, time of adenoma excision, five minutes after excision, 10 minutes after excision). Primary hyperparathyroidism often affects women more than men. The most common causes include parathyroid adenoma, parathyroid hyperplasia, or possible cancer. Presenting signs and symptoms usually encompass the phrase, "bones, stones, abdominal groans, and psychic moans", referring to arthralgias, kidney stones, anemia, weight loss, nausea, vomiting, constipation, depression, disorientation, and psychosis. Patients are typically found to have hypercalcemia, hypophosphatemia, and elevated parathyroid hormone levels on laboratory testing. Treatment is surgical resection of the hypersecreting parathyroid gland. For patients that are not candidates for surgery, treatment focuses on bisphosphonates, calcimimetics, and avoiding factors that may increase calcium levels. Serum calcium level (B) is incorrect as drawing calcium levels intraoperatively would not be an accurate measure of whether the hypersecreting parathyroid gland had been removed and the half-life would not be short enough to prove useful during surgery. Serum phosphate level (C) is incorrect, as it would not be measured repeatedly intraoperatively to determine whether or not the offending parathyroid gland had been removed. Urine calcium excretion level (D) would not be appropriate to measure intraoperatively as it would not be an accurate assessment of whether or not the hyperparathyroidism has been resolved.

What treatment for acute urinary retention can cause transient hypotension, hematuria, and postobstructive diuresis?

Decompression by catheterization.

Angina

Chest pain/pressure on exertion/stress that is relieved by rest Consider non-cardiac causes Diagnosis is made by stress test Management lifestyle modifications, beta blockers, calcium channel blockers, nitrates Angina pectoris is chest pain or discomfort attributed to myocardial ischemia, which occurs when myocardial oxygen demand exceeds oxygen supply. Oxygen demand is increased with physical exertion, mental stress, tachycardia, hypertension, and ventricular hypertrophy, all of which can lead to myocardial ischemia. Patients with angina classically present with chest pressure, tightness, or heaviness in the middle or left side of the chest that is preceded by exertion, lasts for minutes, and is relieved by rest. Some patients may also present with exertional shortness of breath, nausea, diaphoresis, dizziness, or fatigue. Patients usually have risk factors for coronary artery disease (family history, advancing age, hypertension, dyslipidemia, diabetes mellitus, chronic kidney disease, cigarette smoking). Electrocardiogram obtained when chest discomfort is present may reveal J point or ST segment depression indicative of subendocardial ischemia or the ECG may be normal. Further evaluation with stress testing and cardiac catheterization may be indicated to determine prognosis and to guide therapy. Pectoralis major strain (B) would not cause dyspnea or dizziness. Pulmonary embolism (C) is obstruction of the pulmonary arterial vasculature by thrombus. Patients usually complain of pleuritic chest pain, dyspnea, and tachycardia. Classic ECG findings are S1Q3T3 (deep S wave in lead I, Q wave in lead III, and inverted T wave in lead III), although sinus tachycardia is the most common ECG abnormality. ST elevation myocardial infarction (D) is irreversible myocardial death due to ischemia. Patients are symptomatic at presentation. Diagnostic ECG findings include ST segment elevation in the distribution of the affected artery.

Which complication is most likely to caused by the antibiotic Clindamycin ?

Clostridium difficile infection.

Which medication is a vitamin K antagonist?

Coumadin, which is used as an anticoagulant.

What is the gold standard for diagnosing and staging of bladder cancer?

Cystoscopy with biopsy.

Orthostatic Hypotension

Decrease in systolic blood pressure 20 Decrease in diastolic blood pressure 10 Inadequate physiologic response to postural changes Orthostatic hypotension is characterized by a significant drop in blood pressure upon standing. It can result in dizziness, syncope or, in severe cases, angina or stroke. The first-line management is removal of medications that cause orthostatic hypotension. Doxazosin, an alpha-adrenergic antagonist, is a common offending agent. Other medication classes that cause this problem are antihypertensive medications, nitrates, and antidepressants. Lifestyle management, such as arising slowly, not overheating, staying well hydrated, and raising the head of the bed are also ways of managing orthostatic hypotension. Decreasing salt intake (A), discontinuing erythropoietin (C), and discontinuing fludrocortisone (D) will all have the effect of lowering blood pressure. Treating orthostatic hypotension includes increasing salt and water intake. In patients that continue to be symptomatic despite non-pharmacologic measures, fludrocortisone can be used as monotherapy. Patients with both anemia and orthostatic hypotension should begin a trial of erythropoietin.

Orthostatic Hypotension

Decrease in systolic blood pressure 20 Decrease in diastolic blood pressure 10 Inadequate physiologic response to postural changes Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20 mm Hg, or in diastolic blood pressure of at least 10 mm Hg, upon sitting or standing. The major causes of orthostatic hypotension are drug effects (antihypertensives, antidepressants), decreased intravascular volume, primary or secondary autonomic insufficiency, aging, and alcohol consumption. Syncope due to orthostatic hypotension frequently occurs due to a posture change from supine to erect. Treatment includes removing the offending agent, maintaining euvolemia, or with fludrocortisone. Causes of transient loss of consciousness resulting in syncope can be classified as reflex syncope, orthostatic syncope, cardiac dysrhythmias, or structural cardiopulmonary disease. History and exam should also consider conditions that mimic syncope, like seizures, sleep disturbances, accidental falls, and certain psychiatric conditions (conversion reactions). The workup for syncope should include a detailed history, physical exam, and review of an electrocardiogram. Patients with orthostatic hypotension should arise slowly, maintain adequate hydration, and avoid straining in hot weather to minimize symptoms. Medical management may be indicated for patients with symptoms inadequately controlled with nonpharmacologic management alone. Aortic stenosis (A) is a thickened and stiff aortic valve. Typical symptoms are dyspnea, angina, and syncope. Exam usually reveals a systolic blowing murmur at the right sternal border and diagnosis is made by echocardiogram. A cardiac dysrhythmia (B) may lead to syncope if the heart rate is too slow or too fast to maintain adequate cardiac output. The most common dysrhythmias that lead to syncope are AV block, cardiac pauses, ventricular tachydysrhythmias, ventricular bigeminy, and supraventricular tachydysrhythmias. All of these dysrhythmias would be diagnosed by an abnormal ECG. Vasovagal syncope (D), or the common faint, is a type of reflex syncope. It occurs when neural reflexes modify blood pressure and heart rate inappropriately. Classic prodromal symptoms include nausea, diaphoresis, a warm or cold sensation, and blurred vision. Symptoms are classically triggered by emotional stress, painful or noxious stimuli, fear of bodily injury, prolonged standing, heat exposure, or after physical exertion.

What is the operative incidence for a patient with Crohn's disease?

Depending on the anatomic site of disease, the probability of surgery is 78% and 90% after 20 and 30 years of disease symptoms, respectively.

What is the optimal timing for cholecystectomy following an acute presentation of cholecystitis?

Depending on the stabilization of the patient, earlier surgery within 48-72 hours of diagnosis is recommended to avoid complications.

Hemoptysis

Diastolic murmur: mitral stenosis Sudden SOB, CP: PE Trauma: pulmonary contusion Immunodeficiency, immigrant: TB Hx of TB or sarcoidosis: aspergilloma Renal dysfunction: Goodpasture's syndrome or Granulomatosis with Polyangiitis (GPA, Wegener's) Hx of tobacco use, weight loss: malignancy Massive hemoptysis: ≥ 100 mL/hour or ≥ 500 mL over 24-hours Massive hemoptysis rx: patient in bleeding side down position, mainstem bronchus intubation Hemoptysis is the expectoration of blood. Hemoptysis can be massive (≥ 500 mL) or simply blood-tinged sputum. The most common cause of massive hemoptysis is bleeding from a bronchial artery. Airway diseases like bronchitis, bronchiectasis, and bronchogenic carcinoma are the most common sources of hemoptysis in developed countries. A directed physical exam should include examination of sputum at bedside, evaluation for signs of respiratory distress (tachypnea, tachycardia, use of accessory muscles, or cyanosis), auscultation of heart and lungs, and examination of the extremities for edema. Initial laboratory analysis should include hemoglobin and hematocrit to evaluate the severity of bleeding and white blood cell count for possible infectious etiology. The most important initial diagnostic study for all patients with hemoptysis is a chest radiograph, which can identify a site and cause of bleeding in some cases or may reveal an abnormality that guides further testing. Risk for lung malignancy increases with increasing age, cigarette smoking, and longer duration of hemoptysis, and should be considered when ordering imaging beyond chest radiography. For patients who present with estimated blood loss < 30 mL, a likely benign infectious cause, no risk factors for malignancy, and a normal chest radiograph, it is reasonable to manage hemoptysis with observation for recurrence. High-resolution chest tomography (B) and magnetic resonance imaging (D) reveal more information about the lungs than a chest radiograph, but the chest radiograph still provides a lot of information with much lower radiation than CT, has lower cost and is easier to obtain than CT and MRI. Lung biopsy (C) would be used for histologic evaluation of interstitial lung disease, mass, or adenopathy found on radiographic evaluation.

Why is recurrent ulceration a risk after surgery?

Directly related to the surgical procedure, ulcers after partial gastric resection typically develop at the site of anastomosis. Ulcers may also occur due to incomplete vagotomy, inadequate drainage, retained antrum, and persistent H. pylori infection.

Dyspepsia

Dyspepsia is a common symptom that can be defined as either excessive postprandial fullness, early satiation, or epigastric pain or burning. It can be due to a secondary etiology, such as gastroesophageal reflux disease (GERD) or peptic ulcer disease, but is most commonly functional, or idiopathic. History and exam should focus on identifying alarm features of gastroesophageal malignancy, such as unintentional weight loss, progressive dysphagia, odynophagia, persistent vomiting, gross gastrointestinal bleeding, palpable mass or lymphadenopathy, family history of upper gastrointestinal malignancy, and unexplained iron-deficiency anemia. Physical exam may reveal epigastric tenderness to palpation. Initial laboratory analysis should investigate potential iron-deficiency anemia and rule out metabolic disorders that can cause dyspepsia, such as diabetes or hypercalcemia. Patients should be tested and treated for Helicobacter pylori. The need for esophagogastroduodenoscopy (EGD) depends on a patient's age and clinical presentation. EGD should be performed when patients < 60 years of age present with clinically significant weight loss, rapidly progressive alarm features, overt gastrointestinal bleeding, or if more than one alarm feature is present. EGD should be performed on all patients ≥ 60 years of age with new dyspepsia. Over-the-counter calcium carbonate therapy (A) can provide fast-acting and short-term symptomatic dyspepsia relief, but proton-pump inhibitors are more likely to be effective and provide longer lasting relief. Lack of response to calcium carbonate therapy does not raise any alarm for malignancy. Male sex (B) is a risk factor for Barrett esophagus but does not independently indicate a need for EGD. Patients with gastroesophageal reflux disease (GERD) often complain of worsened heartburn or water brash at night (D), which occurs due to increased acid reflux into the esophagus subsequent to esophageal sphincter incompetence while lying supine. Not all patients with GERD require EGD.

What is the appropriate approach to managing patients with asymptomatic pilonidal disease?

Education on hygiene and monitoring for signs of infection, without pursuing surgical interventions, is generally recommended for patients with asymptomatic pilonidal disease.

What is the best initial cardiac test during preoperative evaluation?

Electrocardiogram

Which gastrointestinal procedure is often associated with the development of acute pancreatitis?

Endoscopic retrograde cholangiopancreatography (ERCP).

What physical exam findings are present in Courvoisier sign?

Enlarged, painless gallbladder on palpation and jaundice.

What type of intracranial hematoma does not cross suture lines?

Epidural hematoma.

Where is pain associated with pancreatitis most commonly located?

Epigastrium.

At what age should individuals with Lynch syndrome begin colorectal cancer screening via colonoscopy?

Every one to two years beginning at age 20 to 25 years, or two to five years prior to the earliest age of colorectal cancer diagnosis in the family, whichever comes first.

How often should average-risk individuals have a colonoscopy to screen for colorectal cancer if their initial screening is negative?

Every ten years.

How often should a patient with Barrett esophagus without any dysplasia undergo surveillance EGD?

Every three to five years.

Post-procedure Nausea/Vomiting Risk Factors

Expected use of post procedure opioids Female Gender Non-smoker Patient age Previous history of post-procedure nausea/vomiting Previous history of motion sickness Type of anesthesia Type and duration of surgery Postoperative nausea and vomiting is a common postoperative complication within the first 24 hours after surgery. The following neurotransmitters mediate nausea and vomiting: muscarinic, dopamine, histamine, serotonin, and neurokinin. Risk factors for postoperative nausea and vomiting are existing nausea and vomiting prior to surgery, female gender, history of previous postoperative nausea and vomiting or motion sickness, nonsmoking status, increasing age, history of chemotherapy-induced nausea and vomiting, general anesthesia, longer duration of anesthesia, and opioid administration. A simplified risk score created by Apfel, et al. can be used to determine which prophylactic interventions are required. The risk score includes the following risk factors: female gender, nonsmoking status, history of motion sickness or postoperative nausea and vomiting, and expected postoperative opioid administration. Adults with four risk factors are considered high risk for developing postoperative nausea and vomiting and they should receive at least three interventions to attempt to prevent symptoms. Possible interventions include antiemetics, acupuncture, anesthesia modification, and using non-opioid pain management. Antiemetic choices include transdermal scopolamine, dexamethasone, ondansetron, prochlorperazine, and droperidol. Postoperative nausea and vomiting is a hospital discharge criteria so prevention and quick treatment is critical. Discontinuing her hormonal contraceptive (A) would not have any effect on the development of postoperative nausea and vomiting, although women do commonly experience nausea and vomiting as a side effect when they begin taking a hormonal contraceptive. History of postoperative nausea and vomiting is not a contraindication to elective surgery, so there is no need to dissuade her from undergoing the surgery (B). Opioid administration (C) is a class effect risk factor for postoperative nausea and vomiting; the risk does not seem to be substantially lower with any one opioid medication.

Which clotting factor is decreased in patients with hemophilia A?

Factor VIII.

What is the cause of ophthalmopathy in Graves' disease?

Fibroblast proliferation, deposition of glycosaminoglycans, and inflammation of the extraocular muscles, orbital fat, and connective tissue.

Thermal Burn

Fire: obtain CO levels Industrial fire: suspect CN toxicity Superficial: similar to sunburn Superficial partial: red, painful, blisters Deep partial: white, leathery, painless Full-thickness: charred, insensate ABCs and consider intubating early Rule of 9s Parkland formula: 4 mL x Wt (kg) x % total BSA burned; 50% given in first 8 hours, remainder over 16 hours Target urine output: 0.5 - 1 mL/kg/h in adults; 1 - 2 mL/kg/h in children Consider escharotomy for circumferential and full-thickness burns Fluid resuscitation with Ringer's lactate solution is the most important initial intervention for severely burned patients after removal of the source of the burn and ensuring adequate airway and breathing. The progression of assessment and treatment follows the ABCDE model (airway, breathing, circulation, disability, environment/exposure). The most widely used fluid resuscitation protocol is the Parkland formula, which recommends 4 mL of Ringer's lactate solution for every percent of body surface burned (second and third-degree burns) multiplied by the patient's weight in kilograms. Half of the result of the formula is to be given in the first eight hours, with the rest being administered over the remaining 16 hours. In adults, the rule of 9 is often used to estimate burn surface area: one percent for the perineum, nine percent for each arm and the head, 18 percent for each leg, and a total of 36 percent for the entire torso and abdomen. Alternatively, the patient's palm is approximately equal to one percent of the patient's body surface area. Great care must be taken to prevent over-resuscitation. Therefore, a target for adequate resuscitation after the initial treatment is a urine output of 0.5 mL per kilogram of weight per hour for adults (1-2 mL/kg per hour in children weighing less than 30 kg and 0.5-1 mL/kg per hour if over 30 kg). In addition to fluid resuscitation, early treatment with topical antibiotics, non-stick dressings held in place with tube gauze, pain medications, anxiety medication, tetanus prophylaxis, and stress ulcer prophylaxis are indicated. Escharotomy is indicated for eschar restricting airway, ventilation, or causing ischemia. The American Burn Society has published criteria for burn center transfer, which includes any full thickness burn, or burns affecting the face, genitalia, perineum, hands, feet, or any major joint. Bullae should never be aspirated, and are instead left in place until they rupture and then may be debrided. Escharotomy (A) may be indicated if the airway or ventilation is restricted or if ischemia results but is not the most important initial treatment for severe burns. Cardiovascular collapse can occur more quickly than restrictive or constrictive eschar formation. Prophylactic antibiotic infusion (B) is not generally recommended. Topical antibiotics are recommended and should be applied early. Transfer to a burn center (D) is indicated for any patient with a severe burn, however, it is not the most important initial treatment.

What is first-line pharmacotherapy for orthostatic hypotension?

Fludrocortisone.

What is another name for necrotizing fasciitis of the perineum?

Fournier's gangrene.

Where does the majority of colonic bleeding occur?

From the right side of the colon (unlike diverticulitis which primarily affects the left side of the colon).

What is the most common cause of inherited unconjugated hyperbilirubinemia?

Gilbert syndrome.

Blood Transfusions - Hospitalized patient

Goal Hb 7-8 g/dL Use the least amount of blood products necessary Consider transfusing one unit at a time Follow the patient clinically and monitor for response and possible transfusion reactions Red blood cell transfusions are given to raise the hemoglobin level in patients with anemia or to replace losses after acute bleeding episodes. The patient above has acute blood loss anemia as a result of intraoperative blood loss related to her surgical procedure. Red blood cell transfusions are available as packed red blood cells or as whole blood. The major difference is that most or all of the plasma has been removed from the packed red blood cell transfusions resulting in a smaller volume than whole blood. This is generally preferred over transfusing whole blood to minimize volume overload. Fresh frozen plasma (A), known as FFP, is a blood product that is collected by separating the plasma from the blood cells. It contains all soluble plasma proteins and clotting factors. FFP is indicated for the reversal of an elevated international normalized ratio for patients taking a vitamin K antagonist, patients with vitamin K deficiency, for replacement of coagulation factors in patients with deficiencies, and as a part of massive transfusion protocols. Platelet transfusion (B) is indicated in the treatment of active bleeding or prophylaxis for bleeding in patients with low platelet counts, platelet function defects, and in patients who are receiving a large number of red blood cell transfusions. Sodium chloride 0.9% infusion (D) is an isotonic crystalloid solution which may be used for volume resuscitation in hypovolemic patients. The patient above is anemic secondary to intraoperative blood loss and requires transfusion of red blood cells.

What is the term used to describe ecchymosis of the flank in patients with acute pancreatitis?

Grey Turner sign.

Cardiac output is the product of what?

Heart rate multiplied by stroke volume.

What treatment is typically used as a last resort for lowering serum potassium?

Hemodialysis.

Lynch Syndrome

Hereditary non-polyposis colorectal cancer (HNPCC) Patient with a family history of cancers Most common inherited colorectal cancer Increased risk of other cancers Most commonly caused by an autosomal dominant genetic defect Management includes genetic testing Lynch syndrome is an autosomal dominant disorder and the most common inherited colorectal cancer susceptibility syndrome. Individuals with Lynch syndrome are also at increased risk for endometrial cancer, as well as several other malignancies including cancers of the ovary, renal pelvis, ureter, stomach, small bowel, bile duct, skin (sebaceous neoplasms), and brain (gliomas). Colorectal cancers in Lynch syndrome differ from sporadic colorectal cancers in that they are predominantly right-sided in location. The transition from adenoma to carcinoma progresses much more rapidly in Lynch syndrome as compared with sporadic colorectal cancers. Lynch syndrome should be suspected in patients with synchronous or metachronous colorectal cancer, colorectal cancer prior to the age of 50 years, multiple Lynch syndrome associated cancers, and in cases of familial clustering of Lynch syndrome associated cancers. Surgical management consists of total colectomy with ileorectal anastomosis and annual endoscopic surveillance of the remaining rectum. Women undergoing surgery for colorectal cancer should be offered concurrent prophylactic hysterectomy and bilateral salpingo-oophorectomy. Aspirin significantly reduces the incidence of cancer in Lynch syndrome. However, further studies are needed to identify the optimal dose. Birt-Hogg-Dube syndrome (A) is an inherited syndrome in which affected individuals are at risk for the development of bilateral, multifocal kidney cancer, as well as various dermatologic and pulmonary lesions. Ehlers-Danlos syndrome (B) is due to inherited alterations in genes affecting the synthesis and processing of different forms of collagen and is characterized by several features, including skin hyperextensibility, joint hypermobility, and tissue fragility. Li-Fraumeni syndrome (C) is a cancer predisposition syndrome associated with germline abnormalities of the TP53 gene and is manifested by a tendency to develop various malignancies at an unusual age, including breast cancer, sarcomas, brain tumors, and adrenocortical carcinomas.

Schatzki rings are almost always associated with what other upper gastrointestinal pathology?

Hiatal hernia.

What type of diet are patients started on during the alpha-adrenergic blockade preoperative preparation for pheochromocytoma resection?

High-sodium diet.

What Hinchey stages typically preclude colonic resection and reanastomosis?

Hinchey stages III (purulent peritonitis) and IV (fecal peritonitis) generally preclude reanastomosis at the time of surgery, therefore a Hartmann procedure is required.

What complication of a parathyroidectomy is characterized by severe hypocalcemia?

Hungry bone syndrome.

What is the most common cause of respiratory alkalosis?

Hyperventilation

What additional symptoms may be present in a patient with suppurative cholangitis?

Hypotension and mental status changes.

Respiratory Acidosis

Hypoventilation is the most likely cause out of the above choices for primary respiratory acidosis. Hypoventilation, with resultant hypercapnia, can be secondary to brain stem injury, neuromuscular disease, opiates, or ventilator dysfunction. Other causes include chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary embolism, or aspirated foreign body. Hypoventilation causes carbon dioxide retention, or hypercapnia, which leads to acidemia by increasing the formation of carbonic acid. An arterial blood gas (ABG) will demonstrate a decreased pH and an increased PaCO2 level. If bicarbonate is normal, then the kidneys are not compensating by retaining bicarbonate to increase the pH. Treatment includes identifying the cause and treating the underlying disorder. Diuretic treatment (A) will cause a metabolic alkalosis from a loss of hydrogen ions through the kidneys. Increased intracranial pressure (C) may cause hyperventilation which leads to respiratory alkalosis. Recent packed red blood cell transfusion (D) can cause a gain in HCO3- which can cause a metabolic alkalosis.

HIDA Scan

In a cholescintigraphy scan, an injected radioisotope is excreted by the liver into the biliary system. Normally, the gallbladder concentrates the isotope and is visualized; however, nonvisualization suggests cystic duct obstruction, which is highly specific for acute cholecystitis. A cholescintigraphy scan is useful when the pretest probability is high and the ultrasound is nondiagnostic. Abdominal X-ray (A) is incorrect as only 10-15% of gallstones contain enough calcium to appear on this study. It is also unable to evaluate for wall thickness, pericholecystic fluid or dilation of the common bile duct. A complete blood count (C) may show leukocytosis (12 x 109/L - 15 x 109/L) and liver function tests (D) will typically be normal. It is uncommon to see significant increases in lipase, amylase, or other liver function indices unless there are associated complications, such as pancreatitis and choledocholithiasis. Both of these laboratory tests are nonspecific and can not be used to confirm the diagnosis of cholecystitis.

What is the first-line treatment for acute ischemic stroke?

In eligible patients, first-line treatment is fibrinolytic therapy with alteplase.

When is surgery considered appropriate for patients with peptic ulcer disease?

In patients with ulcers > 3 cm in size (due to the high rate of complications and the high rate of failure with medical treatment), in patients with complications resulting from ulcers (bleeding, perforation or obstruction) or those refractory to medical therapy.

Where are small bowel carcinoid tumors most commonly found?

In the ileum.

What is the treatment of a ventilated patient with lab values that demonstrate an acute respiratory acidosis?

Increase alveolar minute ventilation.

Hypotension secondary to adrenal insufficiency

Intravenous hydrocortisone (50 to 100 mg) is administered to prevent hypotension secondary to adrenal insufficiency in a patient undergoing unilateral or bilateral adrenalectomy. Adrenal glands regulate cortisol and aldosterone which effects sodium and potassium balance and water retention. Adrenal insufficiency manifests as muscle weakness, fatigue, vomiting, abdominal pain, and hypotension. An adrenal crisis typically is caused by a stressor such as an injury, illness, or surgery. Patients in adrenal crisis are at risk of developing shock and, ultimately, at risk for death. If a patient has a cortisol-secreting tumor and then undergoes surgical resection of the tumor and the adrenal gland, the possibility of adrenal crisis is increased from the sudden drop in serum cortisol levels. Dobutamine (A) is the drug choice for cardiogenic shock in patients who have low cardiac output. Fludrocortisone (B) is an oral mineralocorticoid medication. It is typically used in conjunction with a glucocorticoid to treat chronic adrenal insufficiency and helps prevent sodium loss, volume depletion, and hyperkalemia. It is not used in the acute phase of treatment as it takes days to become effective. This is also not the best choice since the patient will be unable to take any oral medications during or immediately after surgery. Vasopressin (D) raises blood pressure by vasoconstriction and increasing free water retention. This is used in patients with diabetes insipidus and vasodilatory shock.

What is vitamin B12 bound to before traveling through the intestine and being absorbed in the terminal ileum?

Intrinsic factor.

What are two commonly used medications that can turn stool black?

Iron supplements and bismuth-containing products (such as bismuth subsalicylate).

What role does von Willebrand factor play in primary hemostasis?

It binds to both platelets and endothelial components, forming an adhesive bridge between platelets and vascular subendothelial structures at sites of endothelial injury.

What is the Wells score?

It is a clinical pretest probability score to risk-stratify patients into low, moderate, and high-risk categories for a deep vein thrombosis.

What is the name of an enlarged ovary caused by peritoneal spread of gastric carcinoma?

Krukenberg's tumor.

Which ECG leads are involved in inferior wall ischemia?

Leads II, III, and aVF.

What are the three primary locations of internal hemorrhoids?

Left lateral, right anterior, and right posterior.

What is the term used to describe a rigid stomach from extensive malignancy?

Linitis plastica.

What is the pathophysiology behind a contraction alkalosis?

Losses of large volumes of fluids high in sodium and low in bicarbonate.

Which test is contraindicated in a patient that is suspected to have a subdural hematoma?

Lumbar puncture due to increased risk of brain herniation.

What bone is typically affected in patients with basal cell nevus syndrome who have bone cysts?

Mandible.

Which type of thyroid cancer is most commonly associated with multiple endocrine neoplasia type 2?

Medullary thyroid cancer.

In a patient with iron deficiency anemia, what will the peripheral blood smear reveal?

Microcytic hypochromic red blood cells.

What is the typical abdominal exam finding in a child with intussusception?

Mid to upper right-sided sausage-shaped mass.

What are the components of MONA therapy?

Morphine, Oxygen, Nitroglycerin, and Aspirin.

Esophageal Stricture

Most common cause: GERD Progressive dysphagia Barium swallow (initial), endoscopy Surgery, high-dose PPIs Esophageal or peptic strictures are benign and describe esophageal narrowing or tightening. The most common cause of peptic strictures is long-standing gastric reflux. The strictures usually form at the gastroesophageal junction as part of the healing process of ulcerative esophagitis and narrow the esophageal lumen. Patients typically complain of slowly progressive solid food dysphagia, regurgitation, and episodic food impaction. Patients complaining of esophageal dysphagia should undergo upper endoscopy. Endoscopy allows for direct visualization of the gastric mucosa to determine the etiology, and biopsy during endoscopy can rule out malignancy. Peptic strictures are managed with dilation during endoscopy and acid-suppressive therapy with proton-pump inhibitors to prevent recurrence. Barium esophagram (A) should only be performed as the initial test for a patient with esophageal dysphagia if the patient has a history or symptoms of a proximal esophageal lesion (e.g., Zenker's diverticulum, surgery for laryngeal or esophageal cancer), or if the patient has a known complex stricture from radiation therapy or caustic ingestion. Upper endoscopy is not the first-line test in such patients because the associated blind intubation may increase the risk of proximal esophageal perforation. Esophageal manometry (B) should be performed when an esophageal motility disorder like achalasia is suspected. Achalasia typically causes progressive dysphagia of solids as well as liquids. Soft tissue neck ultrasound (C) would provide low-cost and radiation-free imaging of the thyroid, lymph nodes, and dermatologic masses, but would not provide diagnostic imaging of the interior of the esophagus.

Esophageal Stricture

Most common cause: GERD Progressive dysphagia Barium swallow (initial), endoscopy Surgery, high-dose PPIs Esophageal or peptic strictures most commonly form due to long-standing acid reflux, but may also be due to radiation exposure or eosinophilic esophagitis. The strictures usually form at the gastroesophageal junction as part of the healing process of ulcerative esophagitis and narrow the esophageal lumen. Peptic strictures are benign and are managed with dilation and acid-suppressive therapy with proton pump inhibitors to prevent recurrence. Proton pump inhibitors irreversibly block the hydrogen/potassium adenosine triphosphatase enzyme system of the gastric parietal cells, which blocks hydrogen ion secretion into the gastric lumen and, therefore, blocks gastric acid secretion. Proton pump inhibitors should be administered 30 to 60 minutes before the first meal of the day for maximal effectiveness. Amoxicillin and clarithromycin (A) are antibiotics that are part of triple therapy for Helicobacter pylori infection. Antibiotics would not provide any long-term relief from acid reflux not due to Helicobacter pylori infection, and therefore would not prevent recurrence of peptic strictures. Histamine-2 receptor antagonists (B) have limited efficacy in patients with erosive esophagitis and are ineffective in patients with severe esophagitis. Histamine-2 receptor antagonists are not an effective maintenance therapy for acid reflux because patients develop tachyphylaxis within six weeks of starting therapy. Nonsteroidal anti-inflammatory drugs (NSAIDS) (C) inhibit the cyclooxygenase enzymes, which prevents protective gastric prostaglandin synthesis. This frequently leads to mucosal damage and acid reflux, which would worsen peptic strictures.

Tobacco Use/Cessation

Motivational Interviewing Nicotine replacement Bupropion (avoid with seizure or eating disorders) Varenicline Consider combination therapy Current cigarette smokers have a higher risk of postoperative complications, including pulmonary, neurological and wound complications, general infections, general morbidity, and ICU admission. Smoking cessation prior to surgery may reduce the risk of postoperative complications, and the longer the period of cessation the better. Current cigarette smokers should be encouraged to quit smoking immediately preoperatively. Pharmacotherapy attempts to reduce nicotine withdrawal symptoms to make it easier to quit smoking. Pharmacotherapy with nicotine replacement therapy, bupropion, or varenicline increases smoking cessation rates and decreases postoperative complications. Bupropion blocks the reuptake of dopamine and norepinephrine to reduce the rewarding aspects of cigarette smoking. Varenicline does appear to be safe for patients with psychiatric or cardiovascular illness, although there were initial concerns about these populations. Varenicline can also aid in smoking cessation. If surgery is imminent, nicotine replacement therapy is preferred due to its rapid onset. Buspirone (B) is serotonin and dopamine reuptake inhibitor indicated for anxiety treatment. Buspirone is commonly confused with bupropion hydrochloride, a norepinephrine and dopamine reuptake inhibitor indicated for depression, seasonal affective disorder, attention deficit hyperactivity disorder, and smoking cessation. Sertraline (C) is a selective serotonin reuptake inhibitor indicated for depression, obsessive-compulsive disorder, panic disorder, premenstrual dysphoric disorder, post-traumatic stress disorder, and social anxiety disorder. Sertraline has not been effective for smoking cessation. Venlafaxine (D) is a serotonin and norepinephrine reuptake inhibitor indicated for depression, general anxiety disorder, social anxiety disorder, and panic disorder. Venlafaxine has not been effective for smoking cessation, but may be confused with varenicline.

What familial disorders are associated with adrenal pheochromocytoma?

Multiple endocrine neoplasia type 2 (MEN2), von Hippel-Lindau (VHL) syndrome, and neurofibromatosis type 1 (NF1).

What are the findings of atypical anal fissures?

Multiple, off midline, large, irregular.

After a nasogastric tube is placed, what measures should be taken to assess the rate of bleeding?

Nasogastric lavage.

What are the most common side effects of dopamine agonists used to treat hyperprolactinemia?

Nausea and postural hypotension.

What is the most common side effect of varenicline?

Nausea.

Nephrotic Syndrome

PE will show pitting edema Labs will show proteinuria > 3.5 g/24 hr, hyperlipidemia, hypercoagulability (renal vein thrombosis), fatty casts Comments: Minimal change disease: children, preceded by URI, rx: steroids Focal segmental glomerulosclerosis: African-Americans, HIV/IVDA Membranous nephropathy: Caucasians, HBV, HCV, SLE, gold, penicillamine, malignancy Peripheral and periorbital edema are commonly seen in patients with nephrotic syndrome. Factors causing these symptoms are sodium retention and hypoalbuminemia which leads to fluid retention. Laboratory results show proteinuria > 3.5 g/day. Peripheral edema is generally seen in the lower extremities as those areas are where excess interstitial water will collect in an ambulatory patient. In a non-ambulatory patient, the fluid will collect around the sacrum. Because fluid is influenced by posture, weight loss or weight gain is another way to monitor edema or the efficacy of diuretic therapy in these patients. Pitting edema that results from excess interstitial fluid collection in an ambulatory patient will be seen in the hands (A), lower legs (B), or upper legs (D) as fluid pools in the peripheral extremities.

What is the most important initial step in suspected tension pneumothorax?

Needle decompression.

What medication is given in patients with subarachnoid hemorrhage to prevent vasospasm and subsequent mortality?

Nimodipine (calcium channel blocker).

What is the initial adjuvant immunotherapy used for patients with melanoma with lymph node involvement?

Nivolumab.

Are opioid analgesics always detected on a standard urine drug screen?

No, opioid analgesics like oxycodone require specific tests for detection.

Do patients with diverticula need to avoid eating popcorn and nuts to prevent diverticulitis?

No. Consumption of popcorn and nuts is not associated with increased risk of diverticulitis.

What histologic findings are consistent with Staphylococcus aureus?

Non-motile Gram-positive cocci in grape-like clusters.

What over-the-counter medication can exacerbate edema in patients with underlying heart failure or cirrhosis by increasing renal sodium reabsorption in response to the inhibition of renal vasodilatory prostaglandins?

Nonsteroidal anti-inflammatory drugs.

What is another name for hypertensive peristalsis?

Nutcracker esophagus.

What is the mechanism of action of ondansetron?

Ondansetron is a serotonin receptor antagonist.

Thyroid Carcinoma

PE will show a solitary hard nodule Labs will show normal thyroid function, cold nodule Diagnosis is made by Initial: US Confirmation: Fine needle biopsy Comments: Papillary - most common, least aggressive Anaplastic - least common, most aggressive Medullary - associated with MEN2, calcitonin can be used as a tumor marker Observation with routine assessment is the recommended treatment strategy for a hyperfunctioning nodule without thyrotoxicosis or risk factors for malignancy. The American Thyroid Association recommends all thyroid nodules be assessed with ultrasound and a thyroid function test. If the ultrasound has no concerning features and thyroid testing shows a decreased thyroid-stimulating hormone (TSH) level, radionuclide testing is recommended. Hyperfunctioning (hot) nodules are rarely malignant, and if the size is stable and there is no concerning history (childhood radiation therapy, multiple endocrine neoplasia) or concerning sonographic features, no further cytological testing is required. Fine-needle aspiration is recommended based on patient history, hypofunctioning (cold) nodules, and elevated thyroid-stimulating hormone with sonographic features that suggest potential malignancy, which include: cervical lymph node abnormalities, microcalcifications, height greater than width, hypoechoic component, spiculation, or extrathyroidal extension. Fine needle aspiration (A) is not necessary for a single, small, hyperfunctioning thyroid nodule with no concerning features on ultrasound. Radioactive iodine (C) may be used for ablation of certain types of thyroid cancers and to ablate thyrotoxic nodules causing symptoms of hyperthyroidism. It is not used when thyroid function is normal. Thyroidectomy (D) may be performed when nodules are excessively large and cause symptoms (voice change, swallowing problems), when multiple nodules are present or are recurrent, when cancer is confirmed, or if suspicious nodules have inconclusive pathology.

Thyroid Carcinoma

PE will show a solitary hard nodule Labs will show normal thyroid function, cold nodule Diagnosis is made by Initial: US Confirmation: Fine needle biopsy Comments: Papillary - most common, least aggressive Anaplastic - least common, most aggressive Medullary - associated with MEN2, calcitonin can be used as a tumor marker Papillary thyroid cancer is the most common type of thyroid cancer and typically the least aggressive. It is associated with psammoma bodies on fine needle aspiration. Thyroid cancer commonly affects women more than men. Risk of cancer increases in patients with previous radiation to the head or neck and familial tumor syndromes, such as multiple endocrine neoplasia (MEN) type 2. Presenting symptoms include neck swelling, single nodule, hoarse voice, and difficulty swallowing. Thyroid function tests and ultrasound are often the initial tests during diagnostic work-up. If a nodule meets certain sonographic criteria (hypoechoic, irregular margins, microcalcifications, taller-than-wide shape, rim calcifications, extrathyroid extension) or the patient has a positive family history of thyroid disease in the setting of normal or elevated thyroid stimulating hormone (TSH), a fine needle aspiration of the nodule should be performed. In patients with decreased TSH, a radionuclide thyroid scan should be performed to determine whether or not the nodule is functioning. Treatment includes surgical resection of the nodule with total thyroidectomy or thyroid lobectomy. Post-operatively, patients should be managed for hypothyroidism with levothyroxine. In certain types of thyroid cancer and residual disease, patients may receive radioiodine therapy. Complications of thyroid surgery include infection, hematoma of the neck, hypocalcemia, and recurrent laryngeal nerve injury. Anaplastic thyroid cancer (A) may show a combination of spindle cells, pleomorphic giant cells, or squamous cells on fine needle aspiration. It is typically the most aggressive type of thyroid cancer. Benign thyroid nodule (B) is incorrect due to the suspicious ultrasound results and presence of psammoma bodies on histology. Benign thyroid nodules can include adenoma, hyperplastic nodules, and goiters. Follicular thyroid cancer (C) includes microfollicular and macrofollicular nodules. Nuclear atypia and Hürthle cell lesions may be found on fine needle aspiration.

Urticaria

PE will show transient blanching, edematous papules, and plaques Most commonly caused by an IgE mediated reaction to an allergen Treatment: supportive care, antihistamines, glucocorticoids (if associated with angioedema) Urticaria, commonly known as hives or wheals, is an inflammatory skin reaction that is thought to occur as a result of mast cells releasing multiple mediators including histamines and vasodilatory mediators upon activation. Common precipitants include heat, cold, exercise, water, food ingestion, insect sting, or infection. Urticaria is characterized by circumscribed, raised, erythematous plaques with central pallor that vary in size and shape. Lesions are intensely pruritic, typically arise within minutes to hours, and resolve within twenty-four hours. Bullous pemphigoid (A) is an autoimmune blistering disorder of the skin and mucous membranes. Lesions may start as plaques resembling urticaria or dermatitis, however, in most cases go on to develop blisters. Bullous pemphigoid primarily occurs in the older population. Contact dermatitis (B) is an inflammatory reaction to an allergen or irritant exposure that also results in a pruritic rash. However, the rash is characterized by erythematous papules with or without vesicles. The lesions are also located around the area of allergen or irritant contact. Erythema infectiosum (C), also known as fifth disease, is a viral exanthem associated with parvovirus B19 infection. It is characterized by a mild febrile illness with associated erythematous malar rash and relative circumoral pallor ("slapped cheek" appearance), followed by a lacy-appearing rash over the extremities and trunk. It most commonly occurs in children.

Urticaria

PE will show transient blanching, edematous papules, and plaques Most commonly caused by an IgE mediated reaction to an allergen Treatment: supportive care, antihistamines, glucocorticoids (if associated with angioedema) Urticaria, or hives, are intensely pruritic, erythematous plaques which can be accompanied by angioedema, which is swelling deeper in the skin. It is mediated by cutaneous mast cells and basophils which release multiple mediators including histamine. A trigger may be identifiable, such as a drug, food ingestion, insect sting, or infection, but often the cause is unknown. Immunoglobulin E (IgE)-mediated, type I immediate allergic reactions often involve urticaria and typically occur within minutes to two hours after exposure to the inciting agent. Drugs that are commonly associated with an IgE-mediated allergic reaction are cephalosporins, such as cefotetan, and penicillins. Direct mast cell activation causes urticaria due to mast cell degranulation through a non-IgE-mediated mechanism and is commonly attributed to narcotics, muscle relaxants, vancomycin, and radiocontrast media. Urticarial lesions are circumscribed, raised, erythematous plaques, often with central pallor. They are intensely itchy and symptoms are often more severe at night. Individual lesions are transient, appearing and evolving over minutes to hours and subsequently disappearing within 24 hours. Any area of the body can be affected. If a specific trigger is suspected, serum testing for allergen-specific immunoglobulin E antibodies can be performed. Further work-up is often deferred to an allergist/immunologist. First-line therapy is administration of second-generation H1 antihistamines, such as cetirizine and loratadine. Alternative therapy includes the first-generation H1 antihistamines, which tend to be more sedating, such as diphenhydramine or hydroxyzine. For patients who are suspected of having an allergic etiology causing new-onset urticaria, referral to an allergy specialist is often warranted and evaluation regarding the need of an epinephrine auto-injector should be done. Contact dermatitis (B) is a dermatitis which arises from direct skin exposure to a substance and can be further broken down as allergic dermatitis and irritant dermatitis. Lesions are erythematous papular lesions often with areas of vesiculation which are distributed in the areas of direct contact. A drug eruption (C) is a cutaneous drug reaction which closely mimics viral exanthems but occurs in association with a medication. It is also known as a morbilliform drug eruption. The lesions can be pruritic and often begin as small macules or papules that become larger and confluent with time, but the lesions are persistent, unlike with urticaria. Urticarial vasculitis (D) should be considered in patients with individual lesions which are painful, long-lasting (i.e., longer than 24-36 hours), and are purpuric or ecchymotic.

Pleural Effusion

PE will show ↓ breath sounds + dull percussion + ↓ tactile fremitus CXR will show blunting of the costophrenic angle Most commonly caused by: Transudate: heart failure Exudate: infection > malignancy, PE Comments: Light criteria are used to differentiate between transudative and exudative effusions A pleural effusion is the accumulation of fluid in the pleural space. Effusions can be either transudative or exudative. Transudates are due to an imbalance in oncotic pressure. The most common cause of a transudate is congestive heart failure. Exudates are usually due to pleural and lung inflammation or from impaired pleural lymphatic drainage. Exudates can occur due to a wide variety of pulmonary or systemic pathology, most notably malignancy. A new pleural effusion is an indication for diagnostic thoracentesis. Therapy is directed at the underlying etiology. Echocardiogram (A) uses ultrasonography to evaluate the size of the hearts chambers, the valves, and blood flow through the heart. While this patient may have new onset of congestive heart failure and echocardiogram would be part of the workup, the best first step is to confirm that the effusion is a transudate with thoracentesis. Magnetic resonance imaging (MRI) of the chest (B) can show a pleural effusion, but cannot definitively characterize the contents of the effusion like an analysis with thoracentesis. Pericardiocentesis (C) can be diagnostic and therapeutic for patients with cardiac tamponade or pericardial effusion but is not indicated for a pleural effusion.

What is the most common form of thyroid cancer?

Papillary thyroid cancer.

Pyloric Stenosis

Patient will be 2-8 weeks of age Complaining of nonbilious projectile vomiting after feeding and early satiety PE will show RUQ olive-like mass (hypertrophied pylorus) Labs will show hypochloremic hypokalemic metabolic alkalosis Diagnosis is made by ultrasound or UGI series (string sign) Treatment is surgical Abdominal ultrasound is the diagnostic study of choice in detecting pyloric stenosis. Pyloric stenosis is a disorder of young infants caused by hypertrophy of the pylorus, which can progress to near-complete obstruction of the gastric outlet, leading to forceful vomiting. It is more common in male patients than female patients and in infants born preterm. The etiology is unclear, though likely multifactorial, including predisposition and environmental factors. Environmental factors include maternal smoking, bottle feeding, and use of macrolide antibiotics. Symptoms typically present between two weeks and two months of age. Patients develop immediate postprandial vomiting that is nonbilious and forceful. Infants then demand to be re-fed soon afterward. Physical examination reveals a palpable "olive" at the lateral edge of the rectus abdominis in the right upper quadrant of the abdomen. Abdominal ultrasound evaluates pyloric muscle thickness, pyloric muscle length, and pyloric diameter. Definitive management of pyloric stenosis is surgery. An abdominal X-ray (A) is useful in patients who present with abdominal distention or high-pitched bowel sounds suggesting intestinal obstruction. It is not helpful in diagnosing pyloric stenosis. Patients with intestinal obstruction would typically present with bilious vomiting. A barium swallow (C) evaluation is generally used only if the physical examination and ultrasonography are nondiagnostic. The classic signs seen on barium study include an elongated pyloric canal, two thin tracks of barium along the pyloric canal created by compressed pyloric mucosa, a tapered point ending the pyloric canal, and a prepyloric bulge of barium. Barium studies should be avoided, if possible, due to radiation exposure. An upper endoscopy (D) is reserved for patients in whom other imaging modalities are inconclusive. It may also be used to evaluate for other gastrointestinal disorders. Endoscopy is useful for obtaining tissue samples.

Pyloric Stenosis

Patient will be 2-8 weeks of age Complaining of nonbilious projectile vomiting after feeding and early satiety PE will show RUQ olive-like mass (hypertrophied pylorus) Labs will show hypochloremic hypokalemic metabolic alkalosis Diagnosis is made by ultrasound or UGI series (string sign) Treatment is surgical Infantile hypertrophic pyloric stenosis is progressive hypertrophy of the pylorus which leads to near complete gastric outlet obstruction. Infantile hypertrophic pyloric stenosis is thought to occur due to genetic predisposition and multiple environmental factors. It typically occurs between three and five weeks of age and very rarely after 12 weeks of age. The classic presentation is forceful nonbilious vomiting (often described as "projectile vomiting") immediately after eating. The infant usually appears hungry. Exam may reveal a firm olive-like mass in the epigastrium or right upper quadrant. The infant should be evaluated for signs of dehydration, including obtaining an electrolyte panel, a complete blood count (CBC), and venous pH. Affected infants may have normal blood analysis results, or they may have a hypochloremic alkalosis. Abdominal ultrasound (US) usually establishes the diagnosis and reveals increased pyloric muscle thickness, length, and diameter. First-line therapy is surgical pyloromyotomy. Since ultrasonography can establish the suspected diagnosis, CT (A) would expose the infant to unnecessary radiation and is also a costlier option. A histamine-2 blocker (C) is commonly prescribed for infantile gastric reflux but would not provide any relief for pyloric stenosis. A hydrostatic or pneumatic enema (D) is first-line therapy for intussusception, which is the most common abdominal emergency in children age six months through two years of age. The classic presentation of intussusception is severe, intermittent abdominal cramping episodes which progress in frequency and severity, nonbilious and then bilious vomiting, and currant jelly-appearing bloody stools.

Hemophilia A

Patient will be a child Complaining of easy bruising or hemarthroses Labs will show increased PTT Most commonly caused by X-linked recessive factor VIII (8) deficiency Hemophilia A is a deficiency of factor VIII, a clotting factor in the intrinsic pathway. An X-linked genetic mutation causes the deficiency, and therefore mainly males are affected. Since von Willebrand factor (VWF) is a carrier protein for factor VIII, a VWF deficiency can lead to low levels of factor VIII as well. Patients with hemophilia A usually have a history of soft tissue, joint, or urinary tract bleeding beginning in childhood. Desmopressin (DDAVP) is an analog of vasopressin (antidiuretic hormone) which promotes factor VIII and VWF release from storage pools. In the setting of mild bleeding or mild hemophilia, a presurgical DDAVP test dose can determine whether DDAVP is effective at raising the factor VIII level in an individual. This should be done at least one week prior to surgery because tachyphylaxis can occur. Fresh frozen plasma (FFP) (B) contains all of the coagulation factors and is indicated in the management of major bleeding associated with warfarin anticoagulation or vitamin K deficiency, or in the setting of liver disease or disseminated intravascular coagulation resulting in deficiency of several coagulation factors. If factor VIII replacement is required for patients with hemophilia A, that specific factor can be replaced without all of the additional factors in FFP. Protamine sulfate (C) can be given for urgent heparin reversal but would not prevent bleeding due to factor VIII deficiency. Vitamin K (D) can be given to reverse coumadin-associated major bleeding in patients with a supratherapeutic INR, since coumadin is a vitamin K antagonist. Vitamin K would not prevent or treat bleeding due to factor VIII deficiency.

Gastric Carcinoma

Patient will be a man With a history of H. pylori infection Complaining of loss of appetite, unintentional weight loss PE will show left supraclavicular node (Virchow's node), left axillary node (Irish node), periumbilical node (Sister Mary Joseph's node) Comments: Adenocarcinoma is most common Disease encasement of the hepatic artery is considered an indicator of unresectability of gastric cancer. Gastric cancer is typically surgically resected along with regional lymph nodes with complete disease eradication representing the best chance for positive outcomes. During gastric and lymph node resection, complete abdominal exploration should occur. Indicators of unresectability include vascular involvement of the aorta, hepatic artery, or proximal splenic artery. Distant metastases are also an indicator of unresectability, although locoregional metastases are not always unresectable. Lymph nodes that are located in the aorto-caval region, in the porta hepatis, or behind the pancreas are also considered unresectable. Distal splenic artery involvement (B) is not an indicator of unresectability since that artery can be resected en bloc. Lesions in the distal two-thirds of the stomach (C) are best surgically treated with a partial gastrectomy. Locoregional lymph node metastases (D) are typically geographically distant to the tumor. Unless the lymph nodes involved are at the head of the pancreas or necessitate a Whipple procedure, this does not indicate unresectability.

Colorectal Cancer

Second leading cause of death Third most common cancer in men and women Adenocarcinoma Risk factors: age, IBD, adenomatous polyps, FAP, HNPCC Rectosigmoid > ascending > descending Left-sided cancer: tends to obstruct Right-sided cancer: tends to bleed Iron deficiency anemia Colonoscopy CEA Unintentional weight loss is an alarm symptom which may raise suspicion for colon cancer if present along with a change in bowel habits. Additional alarm symptoms to consider when obtaining a history in a patient presenting with diarrhea, constipation, or any change in bowel habits include recent onset, recurrent vomiting, hematochezia or melena, significant abdominal pain, change in stool caliber, fever, back pain, saddle anesthesia, leg weakness or numbness, or difficulty urinating. Bloating sensation (A) may occur with overeating, especially rich and fatty foods, irritable bowel syndrome, or a defecatory disorder. An increased appetite (B) can be due to a period of growth; an endocrinologic condition such as diabetes, hyperthyroidism, or Graves' disease; or in certain emotional or psychiatric conditions as a response to stress, anxiety, or depression. Intermittent nausea (C) may be caused by gastroparesis, viral gastroenteritis, or intestinal obstruction.

Gastric Carcinoma

Patient will be a man With a history of H. pylori infection Complaining of loss of appetite, unintentional weight loss PE will show left supraclavicular node (Virchow's node), left axillary node (Irish node), periumbilical node (Sister Mary Joseph's node) Comments: Adenocarcinoma is most common Gastric cancer is the third leading cause of global cancer mortality and the leading cause of infection-associated cancer death. Histologically, it is most often adenocarcinoma. Risk factors include smoking, chronic Helicobacter pylori infection, a diet high in salt, and obesity. Most patients with gastric cancer already have advanced incurable disease at the time of presentation. Weight loss and persistent epigastric abdominal pain are the most common symptoms at initial diagnosis. Dysphagia may be present in patients with cancers arising in the proximal stomach. Physical exam may reveal a palpable abdominal mass. Tumor extension or spread may cause left supraclavicular adenopathy, called a Virchow's node, a periumbilical nodule, called Sister Mary Joseph's node, or a left axillary node, called an Irish node. Upper gastrointestinal endoscopy with biopsy is the diagnostic study of choice. Treatment depends on staging. Duodenal ulcers (A) typically cause epigastric abdominal pain that occurs one to two hours after eating and may awaken the patient at night. Patients may complain of dyspepsia and symptoms may improve with eating. Physical exam is often absent of findings unless there is associated gastrointestinal bleeding or complications, such as perforation. Esophageal cancer (B) presents with progressive solid food dysphagia accompanied by weight loss. Patients may also notice retrosternal discomfort or a burning sensation. A palpable umbilical node is not common. Upper endoscopy with biopsy is diagnostic. Treatment involves surgery with or without adjuvant radiation or chemotherapy. Gastric ulcers (D) result in defect in the gastric wall. Patients complain of dyspepsia that worsens with eating and early satiety. Physical exam is typically absent of specific findings.

Testicular Cancer

Patient will be a man 20 - 35-years-old Complaining of a testicular lump PE will show painless, hard, fixed mass Labs will show increased beta-hCG, alpha-fetoprotein (AFP), or lactate dehydrogenase (LDH) Diagnosis starts with ultrasound Comments: Most common risk factor: cryptorchidism The initial diagnosis of testicular cancer is by trans-scrotal ultrasound. An ultrasound will confirm the presence of a mass and rule out benign processes such as hydrocele or epididymitis. Painless testicular mass is the most common presentation of testicular cancer. Gynecomastia may also be present. It is most commonly seen in young men between 15 and 35 years of age and is the most common cancer in males of this age. Initial treatment is radical orchiectomy. Biopsy will determine the need for adjuvant therapy as well as the type of neoplasm. The most common type of testicular carcinoma is a seminomatous germ cell tumors. CT scan of the abdomen and pelvis (A) can be used in imaging testicular cancer but there is a 20 to 30% chance of under-staging lesions by this method and it is not the initial diagnostic tool. Needle biopsy (B) is not used in testicular cancer as, once an ultrasound confirms the presence of a mass, inguinal radical orchiectomy is performed, which confirms the tumor histology as well as size and presence of invasion. While serum tumor markers (C) may be elevated due to testicular cancer, they are not used for initial diagnosis but are used to monitor for residual or recurrent disease.

Pilonidal Cyst

Patient will be a man younger than 40 Complaining of a painful area by his buttocks PE will show painful, fluctuant area at the sacrococcygeal cleft Treatment is surgical drainage This patient is presenting with symptoms of chronic pilonidal disease, for which the definitive treatment requires surgical excision of all sinus tracts. Pilonidal disease occurs when the skin and subcutaneous tissue at or near the upper region of the natal cleft of the buttocks becomes infected, often in the setting of ongoing inflammation and damage of local hair follicles. This problem is most common in young adults and often occurs in patients with sedentary occupations, obesity, or a positive family history. Patient presentations can range from asymptomatic to chronic pain and drainage. Acute abscess formation can also occur. Pilonidal disease is a clinical diagnosis that does not require any imaging or laboratory procedures. The role of antibiotics (A) is typically limited to causes of pilonidal disease that are complicated by superimposed cellulitis, a condition not suggested by this patient's presentation. Daily gentle washing with an antibacterial cleanser (B) is a helpful suggestion for patients with hidradenitis suppurativa, which is sometimes confused with pilonidal disease. However, it would not be helpful in a case of pilonidal disease. Incision and drainage (C) is necessary in the setting of an acute pilonidal abscess, but is not the definitive step in management due to high recurrence rates after incision and drainage treatment alone.

Megaloblastic Anemia

Patient will be a vegan or alcoholic Complaining of fatigue, weakness PE will show pallor, glossitis Labs will show MCV > 100 and hypersegmented neutrophils Most commonly caused by vitamin B12 (Cobalamin), folate deficiency, direct ethanol toxicity Comments: only vitamin B12 deficiency results in neurological symptoms A history of a partial gastrectomy would put this patient at risk for vitamin B12 or folate deficiency. Vitamin B12 and folate deficiencies can cause a megaloblastic anemia. Physical exam findings in these patients could include changes in oral mucosal cells, or glossitis. Patients may also complain of a loss of appetite, fatigue, or diarrhea. If vitamin B12 deficiency is present, neurologic symptoms begin with peripheral neuropathy that can cause paresthesias. If these progress, patients can have difficulty with balance or proprioception. Severe chronic vitamin B12 deficiency can cause memory disturbance and decreased vibratory sensation. Symptoms of folate deficiency are similar to vitamin B12 deficiency; however, patients do not get neurologic symptoms if the folic acid deficiency is isolated and there is not a concurrent vitamin B12 deficiency. A megaloblastic anemia (as shown by an elevated mean corpuscular volume) will be present with a reduced reticulocyte count. Serum cobalamin levels will be decreased in a patient with vitamin B12 deficiency anemia. Folate levels will be decreased in a patient with folate deficiency anemia. Common causes of vitamin B12 deficiency include lack of intrinsic factor (pernicious anemia), strict vegan diets, or post surgical gastrectomy. Folate deficiencies are typically caused by a lack of dietary intake. Treatment includes supplementation. Beta-thalassemia trait, chronic kidney disease, and ulcerative colitis (A, B, and D) will all typically cause a microcytic anemia. The abnormal hemoglobin with beta thalassemia causes red blood cells to be smaller. Chronic inflammation associated with inflammatory bowel disease results in reduced iron uptake in the gut and a resulting microcytosis. With chronic kidney disease, erythropoietin is reduced and subsequently red blood cell mass is decreased.

Acute Pancreatitis

Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting PE will show flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs will show elevated lipase (best) and amylase Ranson criteria and APACHE II are used to predict the severity (Note: they are difficult to apply and have limitations) Most commonly caused by gallstones > alcohol Treatment is IV fluids, analgesics Comments: Pancreatic pseudocyst complication in adults Ecchymosis of the flanks, also referred to as Grey-Turner sign, is a physical examination finding consistent with retroperitoneal bleeding (a complication of necrotic pancreatitis). Acute pancreatitis is an inflammation of the pancreas most commonly precipitated by gallbladder disease, alcohol use, high triglycerides, infection, smoking, medications, vascular disease, and pregnancy. The inflammation results in elevated pancreatic enzymes. Patients commonly complain of epigastric pain that radiates to the back and worsens when lying supine. Pain is often associated with nausea and vomiting. In severe cases, patients may have fever, hypotension, jaundice, and ecchymosis of the flanks (Grey-Turner sign) or periumbilicus (Cullen's sign), concerning for retroperitoneal bleeding. Pancreatic enzymes (lipase and amylase) are elevated three times or greater than normal in patients with acute pancreatitis. Ultrasound can be used to look for gallstones and CT scan is used to evaluate for pancreatic enlargement, necrosis, and possible mass. Oral intake should be delayed in patients while managing symptoms with intravenous fluids, antiemetics, and analgesics. When infection or sepsis is suspected, antibiotics should be initiated. If an underlying condition, such as gallstones, is identified as the cause, surgical intervention such as laparoscopic cholecystectomy or Endoscopic Retrograde Cholangiopancreatography (ERCP). Complications of acute pancreatitis include pseudocyst, necrosis of the pancreas, sepsis, and death. Improvement in pain when lying supine (B) is incorrect, as patients with acute pancreatitis often report worsening of pain when lying supine. Pain relief typically occurs when leaning forward or assuming the fetal position. Melena (C) would be seen in a patient presenting with upper gastrointestinal bleeding, such as from a peptic ulcer disease. While a peptic ulcer may cause hypotension, epigastric pain, nausea, vomiting, and tachycardia, it would not present with the increased pancreatic enzymes. Pain radiating to the left scapula (D) is commonly associated with disorders of the spleen. Patients with pancreatitis as a result of gallbladder disease may experience referred pain to the right shoulder.

Varicose Veins

Patient will be a woman Complaining of a dull ache in her legs after prolonged standing PE will show dilated, elongated subcutaneous veins Diagnosis is made by duplex ultrasound Treatment is leg elevation and compression stockings Varicose veins are dilated, tortuous subcutaneous veins most commonly appearing on the lower extremities. They may result from superficial veins with incompetent valves that reflux, leading to blood pooling in the legs and dilation of the small and delicate subcutaneous veins. Common risk factors include obesity, advanced age, family history, prolonged standing, sedentary lifestyle, pregnancy, prior venous thrombosis or trauma. Patients with varicose veins may be asymptomatic or may present with pain, leg heaviness or aching, swelling, dry skin, tightness, skin irritation, muscle cramps, and itching. Clinical signs may include dilated veins, edema, lipodermatosclerosis (a fibrosing dermatitis of the subcutaneous tissue), or ulceration. First-line treatment is with conservative measures including leg elevation, compression stockings, and exercise. If conservative measures have failed, the next step in treatment is with vein ablation. There are multiple types of vein ablation which include sclerotherapy, laser therapy, endovenous ablation, and surgical excision of the vein. The type of vein ablation used depends on the number, size, and location of the varicose veins. Anticoagulation (A) is indicated for the treatment of blood clots but is not a part of the treatment for varicose veins. Compression therapy (B), such as compression bandages or stockings, are conservative treatment options that should be offered as first-line therapy for varicose veins, however, this patient has already failed conservative measures. Diuretics (C) are not used for the treatment of varicose veins.

Irritable Bowel Syndrome

Patient will be a woman With a history of constipation alternating with diarrhea Complaining of abdominal discomfort which is relieved with bowel movements Diagnosis is made by Rome criteria Treatment is symptomatic - dietary management and drugs Diagnosing a patient who presents with altered bowel habits can be challenging. History and physical examination is the most valuable initial diagnostic tool to assess the patient presenting with altered bowel habits. Irritable bowel syndrome is one of the most common gastrointestinal illnesses and is characterized by abdominal pain and altered bowel habits (diarrhea, constipation, or both) in the absence of any organic cause. It is typically a diagnosis of exclusion based on history and physical and several negative diagnostic studies. Abdominal ultrasonography (A) uses sound waves to produce pictures of structures within the abdomen. It is used to assist in diagnosing pain or distention and to evaluate the kidneys, liver, gallbladder, pancreas, spleen, and abdominal aorta. Flexible sigmoidoscopy (B) provides an internal exam of the lower part of the large intestine, allowing inspection of the rectum and sigmoid colon. No psychometric screening (D) tools have a high enough specificity or sensitivity to warrant use for diagnosis. If necessary, a full psychosocial evaluation may be recommended. All of these are additional diagnostic studies, and therefore none would be the best initial diagnostic tool for assessing a patient with altered bowel habits.

Spontaneous Pneumothorax

Patient will be a young, tall, thin, man PE will show decreased breath sounds, decreased fremitus, hyperresonance to percussion CXR will show the absence of lung markings along lung periphery Treatment is: < 20% in a healthy patient: observation with oxygen administration > 20%: chest tube thoracostomy The best initial test to diagnose a spontaneous pneumothorax is a chest X-ray. Pneumothorax is the presence of gas in the pleural space. A primary spontaneous pneumothorax occurs without an inciting cause and in the absence of attributable lung pathology or trauma, whereas a secondary pneumothorax is caused by some underlying condition or injury. Symptoms of pneumothorax include dyspnea, cough, chest pain, and anxiety, but can include shock, tracheal deviation (away from the affected hemithorax), jugular venous distension, and cardiovascular collapse if a tension pneumothorax has occurred. Males are more commonly affected than females. Tall, thin individuals have a higher incidence of spontaneous pneumothorax, as do smokers. Diseases such as chronic obstructive pulmonary disease, Marfan syndrome, Birt-Hogg-Dubé syndrome, and alpha-1 antitrypsin deficiency also predispose to spontaneous pneumothorax. Diagnosis is usually made with a standing or lateral decubitus chest X-ray, however, a loculated or small pneumothorax may be more easily seen with computed tomography, which is the most sensitive and specific radiographic examination. Treatment is conservative if the pneumothorax is small. A large or significantly symptomatic pneumothorax may require either aspiration or tube thoracostomy. If no resolution is noted, or if the pneumothorax is recurrent, surgery may be indicated (video-assisted thoracoscopic surgery, thoracotomy). Additionally, supplemental oxygen is often used as it increases the rate of gas resorption from the pneumothorax. Arterial blood gas (A) testing may be part of the initial workup, but it is not confirmatory. Chest CT (B) is the most sensitive and specific study, however, it is often unnecessary in primary spontaneous pneumothorax. If there is persistence or recurrence of pneumothorax, a chest CT is the best imaging modality to assess for secondary causes and aid in preoperative evaluation. A ventilation-perfusion scan (D) can be used in the evaluation of patients with signs and symptoms concerning for pulmonary embolism but is limited by the number of indeterminate results.

Sarcoidosis

Patient will be an African-American woman Labs will show hypercalcemia and elevated serum ACE CXR will show bilateral hilar adenopathy Biopsy will show noncaseating granulomas Treatment is steroids Comments: Lupus pernio (chronic, violaceous, raised plaques and nodules commonly found on the cheeks, nose, and around the eyes) is pathognomonic for sarcoidosis and is the most specific physical exam finding in this disease Sarcoidosis is a granulomatous disorder which affects multiple organ systems. The etiology is unknown and is pathologically characterized by the presence of noncaseating granulomas in the involved organs. It most commonly affects young adults, typically presenting between the ages of 20 and 60 years. Initial presentation is most often one or more of the following: bilateral hilar adenopathy, pulmonary reticular opacities, skin, joint, or eye lesions. Sarcoidosis most commonly involves the lungs, with many patients presenting with cough, dyspnea, and chest pain. Systemic symptoms such as fatigue, malaise, fever, and weight loss are often present. Skin lesions are also common and may be present around tattoos or scars. Approximately one-half of cases will be detected in asymptomatic patients, due to incidental chest radiographic abnormalities. A comprehensive evaluation should be done on patients with suspected sarcoidosis and should include chest radiography, pulmonary function tests, electrocardiogram, ophthalmologic exam, and tuberculin skin test. Serum markers include an elevated angiotensin-converting enzyme level. Pulmonary imaging is important, starting with a chest radiograph and often followed up by high-resolution computed tomography. The classic radiographic finding in a patient with sarcoidosis is bilateral hilar adenopathy, which may occur in combination with parenchymal opacities. Diagnosis requires a combination of clinical and radiographic manifestations, exclusion of other diseases with similar presentations, and histopathologic detection of noncaseating granulomas. Biopsy is indicated in most cases of suspected sarcoidosis, with accessible peripheral lesions being preferred. Treatment is not required for asymptomatic patients. For patients with more severe lung involvement, treatment generally involves glucocorticoids, either inhaled or systemic. Asthma (A) classically presents with symptoms of wheezing, cough which is often worse at night, and shortness of breath. Pulmonary function tests are critical in the diagnosis and chest radiographs are typically normal in patients with asthma in the absence of comorbid illness. Obstructive sleep apnea (B) is most commonly diagnosed in patients with snoring and daytime sleepiness. Polysomnography or home sleep apnea testing is required for diagnosis. Lung cancer (C) commonly presents with cough, hemoptysis, dyspnea, and chest pain, often in a patient with a history of smoking cigarettes. Chest radiographs may demonstrate a new or enlarging focal lesion, pleural effusion, pleural nodularity, or enlarged hilar or paratracheal nodes.

Cholelithiasis/Choledocholithiasis

Patient will be an obese woman 40 - 50-years-old Complaining of slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal Diagnosis is made by ultrasound Most commonly made of cholesterol Treatment is observation or cholecystectomy Choledocholithiasis is the presence of a gallstone in the common bile duct. The most common cause is passage of a stone from the gallbladder into the common bile duct, where obstruction occurs. Rarely, stone formation may occur in the common bile duct (primary choledocholithiasis), usually as a result of a parasitic infection of the biliary system. Right upper quadrant abdominal pain, nausea, and vomiting are common symptoms. Tenderness to palpation of the right upper quadrant and epigastrium is a common sign. Jaundice may be noted. Lab analysis may reveal elevated alanine aminotransferase, aspartate aminotransferase, bilirubin, alkaline phosphatase, and gamma-glutamyl transferase. Transabdominal ultrasound is recommended as an initial exam. Common bile duct stones are often not directly visualized on ultrasound, however, common bile duct dilation may be seen, suggesting distal occlusion. Additional tests may include magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, or intraoperative cholangiography. Stone retrieval via ERCP is the most common treatment, with subsequent cholecystectomy recommended. Cholecystectomy with intraoperative cholangiography may also be used to both remove the gallbladder, as well as facilitate passage of a common bile duct stone or sludge. Complications of choledocholithiasis include cholangitis, cholecystitis, sepsis, liver failure, cirrhosis, and pancreatitis. Cholangitis (A) is an infection of the biliary system and is more likely to present with fever, jaundice, right upper quadrant pain (Charcot's triad), hypotension, and possibly cognitive alterations (Reynold's pentad). Cholelithiasis (C) is the presence of gallstones in the gallbladder and may be symptomatic with intermittent biliary colic or asymptomatic. The patient in this scenario had no gallstones on ultrasound. It is important to note that the diagnosis of choledocholithiasis does not require concurrent cholelithiasis. Perihepatitis (D) is inflammation of Glisson's capsule, which surrounds the liver, and is a complication of pelvic inflammatory disease. It often presents as right upper quadrant tenderness and pain concurrent with signs and symptoms of pelvic inflammatory disease.

Cholelithiasis/Choledocholithiasis

Patient will be an obese woman 40 - 50-years-old Complaining of slowly resolving right upper quadrant pain that begins suddenly after eating a fatty or large meal Diagnosis is made by ultrasound Most commonly made of cholesterol Treatment is observation or cholecystectomy Symptomatic cholelithiasis presents as pain in the epigastrium or right upper quadrant that is sudden in onset with radiation to the inferior border of the right scapula. Pain can be severe and cyclic and is typically associated with nausea and vomiting. During an acute attack, the right upper quadrant may be tender, and the patient may guard against abdominal examination. Symptoms typically resolve spontaneously after a few hours. Acute mesenteric ischemia (A) presents with an abrupt onset of acute severe abdominal pain that is out of proportion to the fairly benign physical examination. Acute mesenteric ischemia is life-threatening and typically occurs in patients with a history of arterial thrombosis or systemic embolization. Acute pancreatitis is characterized as acute knife-like epigastric pain with radiation to the flank. Irritation to the left hemidiaphragm may also cause radiation to the left shoulder. Nausea, vomiting, and retching are severe. Patients appear ill and tachycardia and hypotension may be present due to hypovolemia. Small bowel obstruction (C) presents variably depending on the location of the obstruction. Proximal obstruction presents with abdominal pain and repeated, unrelieved vomiting. Tachycardia is often present due to dehydration. Distal obstruction presents with periumbilical or diffuse, cramping abdominal pain. Vomiting may occur and become feculent. Abdominal distention is significant. Early in the obstruction, bowel sounds are hyperactive with gurgles and high-pitched tinkles; however, as the obstruction progresses, bowel sounds become hypoactive suggesting a loss of intestinal tone.

Cholecystitis

Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs) Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula) Diagnosis is made by:Initial - USGold standard - HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy Hypoactive bowel sounds are an indicator that a perforation has occurred. Other symptoms include high fever, systemic signs of toxicity (tachycardia and increased respiratory rate), and increased abdominal pain with rebound tenderness. A coarse cough (A) is not a complication of biliary system conditions. Jaundice (C) is a yellowing of the skin. It is unusual early in the course of acute cholecystitis but may occur when edema and inflammatory changes affect the bile ducts. Nausea and vomiting (D) are common in cholecystitis but not specific to perforation.

Cholecystitis

Patient will be an overweight (Fat),Fertile,Female in her Forties (4Fs) Complaining of colicky, steadily increasing RUQ or epigastric pain after eating fatty foods PE will show Murphy sign, Boas sign (hyperaesthesia (increased or altered sensitivity) below the right scapula) Diagnosis is made by:Initial - USGold standard - HIDA Most commonly caused by obstruction by a gallstone Treatment is cholecystectomy Murphy's sign is a sharp increase in tenderness in the right upper quadrant with inspiratory effort. When positive, Murphy's sign increases the likelihood of acute cholecystitis threefold. Additional physical exam findings in cholecystitis include moderate to severe right upper quadrant tenderness, guarding, fever, and mild jaundice. Courvoisier's sign (A) is painless jaundice associated with a palpable distended gallbladder, which signals obstruction secondary to a biliary or pancreatic head tumor. McMurray's sign (B) is a palpable click or pop over the lateral joint line of the knee indicating a tear of the medial meniscus. Rovsing sign (D) is pain in the right lower quadrant during left-sided pressure, which may indicate appendicitis.

Basal Cell Carcinoma (BCC)

Patient will be complaining of a painless slow growing lesion on the face, ears, or neck PE will show pearly papule with rolled borders and telangiectasia Diagnosis is made by shave biopsy Histology: atypical basal cells with blue-staining nuclei Most common type of skin cancer Treatment is surgical excision - Mohs Prevention includes sunscreen/UV light protection Basal cell carcinoma is a common skin cancer arising from the basal layers of the epidermis and its appendages. Basal cell carcinoma is particularly common in fair-skinned populations but very uncommon in darker-skinned populations. The most important environmental cause of basal cell carcinoma is sun exposure, with childhood exposure more important than exposure during adult life. Other established risk factors include chronic arsenic exposure, radiation therapy, long-term immunosuppressive therapy, and the basal cell nevus syndrome. The primary approach to prevention of basal cell carcinoma is protection from sun exposure. Approximately 70 percent of basal cell carcinomas occur on the face. Nodular basal cell carcinomas account for 60 percent of cases. These lesions characteristically are a pink or flesh-colored papule that has a pearly or translucent quality. A telangiectatic vessel is frequently seen within the papule. It may be described as having a "rolled" border. Ulceration may be present. Biopsy is needed to establish diagnosis. Treatment depends on risk of recurrence but centers around surgical excision. Melanoma (B) is the most serious form of skin cancer and the sixth most common cancer in North America. It presents as a pigmented lesion with one or more features suggestive of melanoma, including asymmetry, irregular borders, variegated color, and diameter > 6 mm. These features have been included in the widely adopted ABCDE checklist, where "E" stands for evolution, or a change in size, color, or shape. This is the most important clinical criterion for the diagnosis of melanoma. Diagnosis is confirmed with biopsy. Treatment is surgical excision. Molluscum contagiosum (C) is a poxvirus that causes a chronic localized infection, consisting of flesh-colored, dome-shaped papules on the skin. It is common in childhood but also occurs in healthy adolescents and adults, often as a sexually transmitted disease or in relation to participation in contact sports. Lesions are often found to have a shiny surface and a central indentation or umbilication. Diagnosis is often made clinically by the characteristic appearance of the lesion, though histologic examination can confirm diagnosis. The lesions will resolve spontaneously or can be treated with cryotherapy or curettage in certain cases. Squamous cell carcinoma (D) typically presents as erythematous papules, plaques, or nodules. Hyperkeratosis, ulceration, or hyperpigmentation may also be present. It can develop on any cutaneous surface with the head and neck the most common locations. Biopsy is necessary to confirm the diagnosis. Treatment involves surgical resection.

Diverticulitis

Patient will be complaining of abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits PE will show localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT scan Treatment is abx Abdominal CT with contrast is most likely to confirm the presence of diverticulitis. Diverticula are outpouchings of the gastrointestinal tract and can occur at any level from the esophagus to the rectum. Diverticula are usually asymptomatic until they become inflamed or bleed. The most common presentation of diverticulitis is left lower quadrant pain and tenderness, as the most commonly affected area is the sigmoid and descending colon. Asian patients may present with symptoms on the right side, corresponding to a higher prevalence of cecal diverticula. Fever may be present, especially if perforation or abscess occurs, as well as constipation or diarrhea. Diagnosis is suggested by the history, physical, and leukocytosis, but is confirmed with an abdominal CT scan with oral and IV contrast. CT can also evaluate for abscesses, perforation, fistula, obstruction, and ileus. Magnetic resonance imaging may be used instead of CT but is more expensive and time-consuming. Abdominal X-ray may reveal complications of diverticulitis, such as ileus, obstruction, or pneumoperitoneum. Graded compression ultrasound may also be used but is operator dependent and has limited ability to evaluate for other causes of pain. The Hinchey classification can outline severity of disease and assist in choosing the best treatment. The American Gastroenterological Association guidelines recommend selective use of antibiotics, such as a combination of metronidazole and ciprofloxacin, or moxifloxacin as monotherapy. A clear liquid diet, with gradual advancement after symptom improvement, may be recommended in uncomplicated disease. Severe symptoms, recurrent diverticulitis, or significant complications may require hospital admission, IV antibiotics, bowel rest, percutaneous abscess drainage, and potentially surgery. Complications include peritonitis, ileus, bowel obstruction, abscess, bowel perforation, fistula, bleeding, and sepsis. All patients should have a colonoscopy after symptoms resolve unless a colonoscopy was performed within the last year. A nut or popcorn-free diet is no longer routinely recommended. Abdominal X-ray (B) cannot directly visualize diverticula and only reveals complications. Colonoscopy (C) is not recommended during an acute bout of diverticulitis, as the risk for perforation is greater. However, approximately eight weeks after the acute phase has resolved, a colonoscopy is indicated if one has not been performed within the previous year. Pelvic ultrasound (D) is useful in the evaluation of the reproductive and genitourinary organs but not the intestines or stomach.

Diverticulitis

Patient will be complaining of abdominal pain that is localized to the left lower quadrant, fever, nausea, vomiting, and a change in bowel habits PE will show localized guarding, rigidity, and rebound tenderness Diagnosis is made by CT scan Treatment is abx Diverticulitis is generally considered to be due to microperforation of a diverticulum. Left lower quadrant abdominal pain is the most common complaint in patients with acute diverticulitis. The pain is usually constant and a low-grade fever may be present. Physical exam reveals tenderness to palpation with localized guarding. Complications such as abscess, obstruction, perforation, or fistula may develop. Abdominal computed tomography scan is the diagnostic study of choice in patients presenting with signs and symptoms concerning for diverticulitis. Imaging may reveal localized bowel wall thickening, an increase in soft tissue density within the pericolonic fat, and the presence of colonic diverticula. Acute uncomplicated diverticulitis can be treated nonoperatively in most patients. Patients are typically treated with oral antibiotics, such as ciprofloxacin plus metronidazole, for seven to 10 days. Surgery is indicated in patients with complicated diverticulitis. Left upper quadrant (B) abdominal pain can be caused by splenic etiologies. Patients with left upper quadrant pain should be evaluated for splenomegaly and other disorders of the spleen. Ultrasound or computed tomography are useful in diagnostic evaluation. Right lower quadrant (C) abdominal pain is most often seen in patients with acute appendicitis. Ultrasound or computed tomography are useful in diagnosis. Subacute right lower quadrant pain with diarrhea is a classic presentation of ileal Crohn's disease. Right upper quadrant (D) abdominal pain is most often due to the liver or biliary tree. The pain may radiate to the back or shoulder. The most common causes include biliary colic, cholangitis, or cholecystitis. Abdominal ultrasound and laboratory evaluation should be done to determine the etiology.

Subarachnoid Hemorrhage

Patient will be complaining of abrupt onset of "worst headache of their life" or "thunderclap" headache Diagnosis is made by noncontrast CT scan. Blood will appear white in color on the CT If CT negative, and suspicion high, lumbar puncture Most commonly caused by a ruptured aneurysm Hunt & Hess classification classifies severity of subarachnoid hemorrhage to predict mortality Treatment is supportive and nimodipine (decreases vasospasm) Hemoglobin degradation products (xanthochromia) are found in the cerebrospinal fluid of a patient with a subarachnoid hemorrhage. A subarachnoid hemorrhage is most commonly caused by a ruptured saccular aneurysm. Patients often present complaining of a sudden onset of "worst headache of my life", typically in the setting of physical exertion. Patients can also experience loss of consciousness, nausea, vomiting, and meningeal signs. Noncontrast head CT scan should be the initial diagnostic study. Lumbar puncture is performed in the setting of a negative CT scan, but strong suspicion of subarachnoid hemorrhage. Severity of subarachnoid hemorrhage is based on the Hunt and Hess grading system. Complications include vasospasm, rebleeding, seizures, hydrocephalus, and death. Treatment includes antihypertensives, antiepileptics, and aneurysm management. Decreased opening pressure (A) is incorrect, as the opening pressure in a patient with a subarachnoid hemorrhage would have an increased opening pressure. Decreased protein (B) is incorrect. A patient with a subarachnoid hemorrhage would likely have increased protein due to the presence of blood products in the cerebrospinal fluid. Elevated glucose (C) is incorrect, as glucose fluctuations in cerebrospinal fluid are typically attributed to infection. A patient with a severe subarachnoid hemorrhage may be found to have decreased glucose in the cerebrospinal fluid sample.

Crohn Disease

Patient will be complaining of chronic nonbloody diarrhea, crampy abdominal pain, and weight loss PE will show aphthous ulcers, anal fissures, perirectal abscesses, anorectal fistulas Labs will show ASCA positive, p-ANCA negative Diagnosis is made by colonoscopy Colonoscopy will show skip lesions, cobblestone mucosa, transmural inflammation Surgery will not be curative Comments: Can occur anywhere on GI tract from mouth to anus Initial treatment for uncomplicated Crohn's disease is immunosuppressant therapy. If this is not effective, surgery may be required, especially for complications of perforation, hemorrhage, and toxic colitis. The distinction between Crohn's disease and ulcerative colitis is important as chronic treatment approaches vary. Resection is strongly recommended for ulcerative colitis patients who are young, have frequent recurrence, or are steroid-dependent. Avoidance of surgery is desired in patients with Crohn's disease due to the natural history of recurrence. Indications for surgery in both Crohn's disease and ulcerative colitis include intractable or fulminant disease, massive hemorrhage, colonic obstruction, cancer prophylaxis, colon dysplasia, or cancer. Indications for surgery specific to ulcerative colitis include toxic megacolon, colonic perforation, or extracolonic disease. Indications for surgery specific to Crohn's disease include stricture and obstruction, refractory fistula, abscess, or perianal disease unresponsive to medical therapy. Antibiotics (A) have no role in the treatment of inflammatory bowel disease unless there are associated complications, such as perforation or abscess formation. Chemotherapy (B) treatment strategies would be reserved for oncology patients with subsequent inflammatory bowel disease. Watchful waiting (D) with repeat ileocolonoscopy in six to 12 months would be indicated in asymptomatic patients who were found to have Crohn's disease incidentally on routine colonoscopy.

Hemorrhoids

Patient will be complaining of discomfort and itching in the anal regionIf thrombosed may also complain of pain PE will show:Internal - proximal to the dentate lineExternal - distal to the dentate line Treatment is lifestyle modifications, sitz baths, analgesic creams, or surgical excision Grade III hemorrhoids prolapse out of the anal canal with defecation or straining and require manual reduction. Hemorrhoids arise from a plexus or cushion of dilated arteriovenous channels and connective tissue. Patients with hemorrhoids present with complaints of bleeding, anal pruritus, prolapse, and pain due to thrombosis. Treatment is typically conservative, though surgical options are available for thrombosed hemorrhoids. Grade I (A) hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Grade II (B) hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade IV (D) hemorrhoids are irreducible and may strangulate.

Acute Pancreatitis

Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting PE will show flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs will show elevated lipase (best) and amylase Ranson criteria and APACHE II are used to predict the severity (Note: they are difficult to apply and have limitations) Most commonly caused by gallstones > alcohol Treatment is IV fluids, analgesics Comments: Pancreatic pseudocyst complication in adults Acute pancreatitis is most commonly caused by gallstones and by chronic excessive alcohol consumption. Affected patients generally present with severe acute-onset epigastric abdominal pain which often radiates to the back, as well as nausea and vomiting. A typical physical examination finding is epigastric tenderness on palpation. The most specific blood analysis abnormality is serum lipase elevated three times greater than the upper limit of normal. Serum amylase is usually also elevated but is less specific. The diagnosis of acute pancreatitis requires at least two of the following three criteria: (1) acute severe epigastric abdominal pain; (2) a serum lipase or amylase elevated greater than three times the upper limit of normal; (3) characteristic findings of acute pancreatitis on imaging (contrast-enhanced computed tomography, magnetic resonance imaging, or transabdominal ultrasonography). Once the diagnosis is made, the etiology should be identified and treated. The Ranson criteria can help predict the severity of illness. Typical treatment is supportive care with fluid resuscitation, pain control, and limiting oral food feedings. Elevated ALT (A) and AST (C) are signs of hepatic impairment, which can occur due to conditions such as gallstone obstruction, acetaminophen toxicity, viral hepatitis, and mushroom toxicity. Elevated amylase (B) greater than three times the upper limit of normal is a common finding in acute pancreatitis but is less specific than lipase, and has a shorter half-life than lipase.

Acute Pancreatitis

Patient will be complaining of epigastric pain radiating to the back, nausea, and vomiting PE will show flank ecchymosis (Grey Turner sign), umbilical ecchymosis (Cullen sign) Labs will show elevated lipase (best) and amylase Ranson criteria and APACHE II are used to predict the severity (Note: they are difficult to apply and have limitations) Most commonly caused by gallstones > alcohol Treatment is IV fluids, analgesics Comments: Pancreatic pseudocyst complication in adults Acute pancreatitis typically presents with acute onset of persistent, severe epigastric abdominal pain that often radiates to the back. Common causes of acute pancreatitis include mechanical ampullary obstruction with gallstones, alcohol abuse, and hypertriglyceridemia. Physical exam may reveal epigastric and left upper quadrant discomfort on palpation as well as abdominal distention and hypoactive bowel sounds. Other signs and symptoms include fever, tachypnea, and vomiting. Ecchymosis of the periumbilical region or flank may be present due to retroperitoneal bleeding associated with pancreatic necrosis. Diagnosis of acute pancreatitis requires the presence of two of the following three criteria: acute onset of persistent, severe, epigastric pain radiating to the back, elevation in serum lipase three times or greater than the upper limit of normal, and diffuse enlargement of the pancreas on contrast-enhanced abdominal computed tomography or magnetic resonance imaging. Initial management includes fluid resuscitation, pain control, and nutritional support. Acute cholecystitis (A) presents with abdominal pain most commonly in the right upper quadrant or epigastric region radiating to the right shoulder or back. Physical exam may reveal increased discomfort with palpation of the right upper quadrant and associated inspiratory arrest (Murphy's sign). Elevation of lipase greater than three times the upper limit of normal is not associated with cholecystitis. Patients with acute hepatitis (B) present with right upper quadrant pain, anorexia, and general malaise. Dark urine, acholic stool, jaundice, and pruritus may also be present. Scleral icterus and tender hepatomegaly may be seen on physical examination. Laboratory evaluation reveals normal amylase and lipase but liver transaminases will be elevated. Patients presenting with mesenteric ischemia (D) complain of pain that is out of proportion to findings on physical exam. Amylase and lipase elevations are much less marked in patients with mesenteric ischemia. Bowel wall thickening and gas in the bowel wall (pneumatosis intestinalis) may be seen on computed tomography of the abdomen.

Appendicitis

Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) Diagnosis is made by CT (adults), ultrasound (pediatric or pregnant patients), MRI (pregnant patients with nondiagnostic ultrasound) Most commonly caused by fecalith Treatment is surgery A single dose of cefotetan 2 g intravenously is recommended for preoperative administration for prophylaxis against infection. This is given to prevent intra-abdominal and wound infections. The targeted florae represent those that are found within the colon. In acute appendicitis without perforation, only a single dose within 60 minutes of the initial incision is indicated. Antibiotics are not indicated postoperatively in these uncomplicated cases of appendicitis. In patients with a penicillin or cephalosporin allergy, the recommended antibiotic regimen is clindamycin and one of the following: ciprofloxacin, levofloxacin, gentamicin, or aztreonam. A single dose of metronidazole (B) is not effective at covering gram-negative aerobic bacteria. It is better for gram-negative anaerobic coverage. Ertapenem (C) can be used as a single drug regimen in perforated appendicitis, however, this regimen is used for at least five days. Levofloxacin and metronidazole (D) provide good broad-spectrum coverage in cases of perforated appendicitis but is not indicated in nonperforated cases.

Appendicitis

Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) Diagnosis is made by CT (adults), ultrasound (pediatric or pregnant patients), MRI (pregnant patients with nondiagnostic ultrasound) Most commonly caused by fecalith Treatment is surgery Appendicitis occurs due to nonspecific obstruction of the appendiceal lumen. It is the most common indication for emergent abdominal surgery in childhood. The classic presentation is periumbilical pain which migrates to the right lower quadrant, worsened pain with movement, anorexia, and vomiting. Exam typically reveals right lower quadrant tenderness, signs of peritoneal irritation (rebound tenderness, guarding), and fever. Ultrasonography and CT are the most useful imaging modalities for diagnosis, although a surgeon should be consulted prior to ordering imaging when a child presents with classic signs and symptoms.. Patients with appendicitis without perforation or gangrene should undergo appendectomy. Children who do have perforation or gangrene should also receive postoperative IV antibiotics. This patient should not be admitted for IV antibiotic therapy (A) because the outcome is not as reliable as prompt appendectomy. Timely appendectomy is a curative and safe procedure for most children. There is some new evidence to suggest that nonoperative treatment of appendicitis can be a safe option for select children. Abdominal and pelvic CT (C) is not necessary in this patient with a classic presentation of acute appendicitis. CT involves significant radiation exposure and is much more expensive than the recommended first-line imaging study, which is ultrasonography. Ultrasound prior to consulting a surgeon is only recommended in patients with atypical presentation. Sending the patient home with supportive care (D) would be inappropriate and could prove fatal with progression of untreated appendicitis. Supportive care would be appropriate for self-limiting illnesses such as viral gastroenteritis.

Appendicitis

Patient will be complaining of fever, pain that began periumbilical then moved to RLQ, nausea, and anorexia PE will show Psoas sign (RLQ pain on extension of right hip), Obturator sign (RLQ pain on internal rotation of flexed right hip), Rovsing sign (right lower quadrant pain when the left lower quadrant is palpated) Diagnosis is made by CT (adults), ultrasound (pediatric or pregnant patients), MRI (pregnant patients with nondiagnostic ultrasound) Most commonly caused by fecalith Treatment is surgery Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower quadrant. It is indicative of right-sided local peritoneal irritation in patients with appendicitis. Abdominal pain is the most common symptom of appendicitis. Patients also can present with a constellation of symptoms, including fever, anorexia, and nausea and vomiting. The abdominal pain will typically start in the periumbilical region before migrating to the right lower quadrant. Physical exam findings may aid in diagnosis, however, abdominal computed tomography scan is used to confirm. Treatment is appendectomy. McBurney's point tenderness (A) is described as maximal tenderness at the point one-third of the distance from the anterior superior iliac spine to the umbilicus. The obturator sign (B) is associated with a pelvic appendix. Right lower quadrant pain is elicited when the clinician flexes the patient's right hip and knee and then internally rotates the right hip. The psoas sign (C) is associated with a retrocecal appendix. Passive right hip extension causes right lower quadrant pain.

Nephrolithiasis

Patient will be complaining of flank pain radiating to groin PE will show a patient that won't lay still and hematuria Diagnosis is made by helical CT Most commonly caused by calcium oxalate Struvite: staghorn calculi, urease producing bacteria Uric acid: radiolUcent on xray, gout Cystine: children with metabolic diseases Most common location is the ureterovesiclular junction (UVJ) Treatment is: < 5 mm: likely to pass spontaneously > 8 mm or hydronephrosis: unlikely to pass, lithotripsy Nephrolithiasis refers to calculi in the kidneys. Risk factors for development of nephrolithiasis include: prior nephrolithiasis, family history, low fluid intake, persistently acidic urine, and frequent upper urinary tract infections. Patients are typically asymptomatic until inflammation or ureteral obstruction occurs. Patients may present with the classic symptoms of flank pain radiating to the groin, nausea and vomiting, and hematuria. Patients are often restless and physical examination may reveal mild costovertebral angle tenderness. Eighty percent of patients with nephrolithiasis form calcium stones. The other main types include uric acid, struvite, and cystine stones. Computed tomography of the abdomen and pelvis without contrast is the preferred exam for most adults with suspected nephrolithiasis. Calcium and struvite stones are radiopaque while cystine and uric acid stones are radiolucent. Many patients with acute renal colic can be managed conservatively with pain medication and hydration until the stone passes. Patients should be instructed to strain their urine in order to analyze the stone makeup to better plan preventive therapy. Diverticulitis (A) typically presents with left lower quadrant abdominal pain, fever, nausea and vomiting. In addition, focal abdominal tenderness is characteristic of diverticulitis but not nephrolithiasis. Dysmenorrhea (B) can rarely present with flank pain. The pain typically begins just before or concurrent with the onset of menses. Dysmenorrhea is diagnosed after other disorders are excluded. Pyelonephritis (D) frequently presents with flank pain, fever, dysuria, urinary urgency and frequency, and pyuria. Patients often have significant costovertebral tenderness. Fever is uncommon in patients with nephrolithiasis unless there is associated infection.

Hypothyroidism

Patient will be complaining of generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain PE will show periorbital edema, dry skin and coarse brittle hair Labs will show high TSH and low free T4, antithyroid peroxidase and antithyroglobulin autoantibodies Most commonly caused by Hashimoto's thyroiditis Treatment is levothyroxine Comments: Takes about 6 weeks to see treatment effects. Monitor TSH Hashimoto's: Risk factor for non-Hodgkin lymphoma Graves' disease is the most common cause of hyperthyroidism. It is an autoimmune disorder resulting from thyroid-stimulating hormone receptor antibodies, which stimulate thyroid gland growth, thyroid hormone synthesis, and thyroid hormone release. Risk factors for the development of Graves' disease include stressful life events, relatively high iodine intake, and several drugs including lithium, interferon alfa, and alemtuzumab. Clinical manifestations include weight loss, heat intolerance, tremor, palpitations, anxiety, increased frequency of bowel movements, and shortness of breath. Exam findings often include a diffuse goiter, stare and lid lag, increased heart rate, systolic hypertension, and hyperglycemia. Findings specific to Graves' disease include pretibial myxedema and ophthalmopathy, which manifest as proptosis (exophthalmos), impairment of eye-muscle function, and periorbital and conjunctival edema. Laboratory tests reveal a low thyroid-stimulating hormone, with a greater elevation in serum triiodothyronine (T3) than in serum thyroxine (T4). The diagnosis may be apparent on presentation and with laboratory values, in which case no additional testing is needed. However, if the diagnosis is not apparent based on the clinical presentation, additional diagnostic testing can be done. Thyrotropin receptor antibodies can be measured first, and if positive, confirm the diagnosis of Graves' disease. If negative, the use of radioactive iodine uptake can aid in the diagnosis and would show normal or high radioiodine uptake. Treatment first involves symptom control with a beta blocker, like atenolol, to alleviate symptoms caused by increased beta-adrenergic tone (e.g., palpitations, tachycardia, tremors, anxiety, heat intolerance). For patients with significant symptoms and risk for complications of hyperthyroidism, a thionamide is also used, with methimazole being the primary drug used, except during the first trimester of pregnancy where propylthiouracil (PTU) is preferred. Radioiodine ablation and surgery are also alternatives to antithyroid drugs. Surgery is acceptable in specific clinical scenarios, especially in patients with signs or symptoms of upper airway obstruction or severe dysphagia and moderate-to-severe Graves' ophthalmopathy which can be exacerbated by radioiodine therapy. Patients who have a total thyroidectomy should receive thyroid replacement hormone prior to discharge and should be monitored for signs and symptoms of hypothyroidism (e.g., cold intolerance, fatigue, weight gain, and elevated thyroid-stimulating hormone) such as the patient above is experiencing. Hypocalcemia (A) is a complication after total thyroidectomy, due to the removal of one or more parathyroid glands during surgery. Symptoms would include muscle twitching, carpopedal spasm, and perioral paresthesias. Prophylaxis is often given to patients with calcium and calcitriol. Myxedema coma (C) is caused by severe hypothyroidism leading to decreased mental status and hypothermia. Recurrent hyperthyroidism (D) can occur in patients with subtotal thyroidectomy, but not in a patient with a total thyroidectomy.

Diverticulosis

Patient with a history of high dietary consumption of red meat, low dietary fiber, sedentary lifestyle, BMI > 25 kg/m2, and cigarette smoking Complaining of painless hematochezia Diagnosis is made by colonoscopy Comments: Most common cause of significant lower gastrointestinal bleeding Diverticular disease can result in diverticular bleeding, diverticulitis, or segmental colitis. Diverticula are sacs that form in weak areas of the colon wall where the vasa recta penetrate the muscle layer. Diverticula formation is related to pressure, colonic wall tension, and the bowel wall radius. The sigmoid colon is the site of the highest pressure since it is the segment with the smallest diameter, which results in the majority of diverticula formation in this part of the colon. Diverticula may still form in the ascending (A), descending (B), and transverse (D) colon segments, but there is less pressure in those areas due to the larger diameter than in the sigmoid colon, resulting in less diverticular formation.

Peptic Ulcer Disease

Patient will be complaining of gnawing epigastric painDuodenal ulcer: pain is alleviated by ingesting food (mnemonic: DUDe give me food)Gastric ulcer: pain is exacerbated by ingesting food Diagnosis is confirmed by endoscopy Diagnosis of H. pylori infection is made by H. pylori fecal antigen or urea breath test Most commonly caused by H. pylori infection or nonsteroidal anti-inflammatory use Comments: Most common cause of upper GI bleed Increases risk of perforation Peptic ulcer disease (PUD) is the most common cause of upper gastrointestinal (GI) bleeds. PUD is associated with two major causes: Helicobacter pylori infection and regular use of nonsteroidal anti-inflammatory drugs (NSAIDs). In the case above, the patient reported taking ibuprofen daily, which places her at risk for developing peptic ulcer disease. Patients with bleeding caused by peptic ulcer disease may present with nausea, hematemesis or melena. Hematemesis is the term used to describe red blood or coffee-ground emesis. Hematemesis is a sign of an upper GI bleed, such as peptic ulcer disease, that originates proximal to the ligament of Treitz. Patients who present with coffee-ground emesis are more likely to be experiencing a slow or limited bleed, while those presenting with frank bloody emesis are more likely to have moderate to severe bleeding. Melena is black, tarry stool that is most commonly seen with upper GI bleeding, however, it may be due to the bleeding from the small bowel or right colon. The patient above presented with a history of hematemesis and melena which would most likely indicate an upper GI source as the etiology of her bleed. Hematochezia, or bright red blood per rectum, is most commonly indicative of a lower GI bleed, although it may occur with massive upper GI bleeding. Diverticular bleed (A) is the most common cause of lower GI bleeding and it originates in the colon which is distal to the ligament of Treitz. Patients with lower GI bleeding may present with hematochezia or melena, however, lower GI bleeds are not associated with hematemesis. Mallory-Weiss syndrome (B) is characterized by longitudinal mucosal lacerations (intramural dissections) of the esophagus or proximal stomach secondary to repeated or forceful retching. This history was not reported by the patient above making this diagnosis less likely. Variceal bleed (D) originates from varices in the esophagus or proximal stomach that have developed as a result of portal hypertension. This can be difficult to distinguish from peptic ulcer disease in a patient presenting with upper GI bleeding. However, the patient above denied a history of liver disease or ethanol use, which would place variceal bleeding lower on the differential diagnosis. In addition, a patient with variceal bleeding is more likely to describe the emesis as red blood rather than coffee-ground in appearance. In any case of upper GI bleed, endoscopy is the preferred diagnostic tool for definitive diagnosis of the etiology.

Peptic Ulcer Disease

Pheochromocytoma

Patient will be complaining of headaches, diaphoresis, tremors, and vision changes PE will show hypertension Diagnosis is made by assay of urinary catecholamines and metanephrines, and plasma metanephrine levels Most commonly caused by catecholamine-secreting tumor located in the adrenal glands Treatment is surgery, α-blocker (ie phentolamine, phenoxybenzamine) prior to β-blockade to prevent unopposed alpha agonism Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla. Although they can occur at any age, they most commonly present between the ages of 30 to 49 and occur equally between men and women. While the majority of pheochromocytomas are benign, approximately 10% are malignant. The symptoms of pheochromocytomas are caused by tumoral hypersecretion of one or more of the following catecholamines: norepinephrine, epinephrine, and dopamine. The classic triad of symptoms consists of episodic headache, sweating, and tachycardia. Paroxysmal hypertension is found in one-half of patients, with the remaining having primary hypertension. Other symptoms include forceful palpitations, tremor, pallor, dyspnea, generalized weakness, and panic attack-type symptoms. Diagnosis is typically made by measurements of urinary and plasma fractionated metanephrines and catecholamines. A 24-hour urinary fractionated metanephrines and catecholamines test is indicated if there is a low index of suspicion, while a plasma fractionated metanephrines test is the preferred testing if there is a high index of suspicion. In patients with positive biochemical testing, radiological evaluation to locate the tumor is done with either computed tomography or magnetic resonance imaging of the abdomen and pelvis. Treatment with an alpha-adrenergic blocker, such as phenoxybenzamine, is started first to control blood pressure and expand the contracted blood volume. This is continued for 10-14 days preoperatively. Side effects of phenoxybenzamine include orthostasis, nasal stuffiness, marked fatigue, and in men it can cause retrograde ejaculation. After adequate alpha-adrenergic blockade is achieved, beta-adrenergic blockade is initiated, usually with propranolol. Laparoscopic adrenalectomy is the procedure of choice, although surgical removal of even a benign tumor does not always lead to long-term cure of the pheochromocytoma or hypertension. For this reason, long-term monitoring is indicated in all patients, with annual biochemical screening recommended for most patients. Adrenalectomy (A) is the procedure of choice in patients with solitary intra-adrenal pheochromocytoma without malignant features. This is done after preoperative preparation with medications to control blood pressure and heart rate is initiated. High sodium diet (B) of greater than 5000 mg daily is started on the second or third day of alpha-adrenergic blockade to oppose the catecholamine-induced volume contraction and the orthostasis associated with alpha-adrenergic blockade. Propranolol (D), which is a beta-adrenergic blocker, is initiated after adequate alpha-adrenergic blockade has been achieved. It should never be started first, as blockade of vasodilatory peripheral beta-adrenergic receptors with unopposed alpha-adrenergic receptor stimulation can lead to an elevation in blood pressure.

Pheochromocytoma

Patient will be complaining of headaches, diaphoresis, tremors, and vision changes PE will show hypertension Diagnosis is made by assay of urinary catecholamines and metanephrines, and plasma metanephrine levels Most commonly caused by catecholamine-secreting tumor located in the adrenal glands Treatment is surgery, α-blocker (ie phentolamine, phenoxybenzamine) prior to β-blockade to prevent unopposed alpha agonism Plasma fractionated metanephrines would be the initial biochemical test performed for a patient who is considered high risk for a pheochromocytoma (family history, familial tumor syndrome, history of previously resected pheochromocytoma, or presence of adrenal mass found incidentally). Pheochromocytoma is a neuroendocrine catecholamine-secreting tumor typically found on the adrenal gland. These types of tumors are often associated with familial tumor disorders, such as multiple endocrine neoplasia type 2 (MEN2) and von Hippel-Lindau (VHL) syndrome. The triad associated with pheochromocytoma include palpitations or tachycardia, episodic headaches, and diaphoresis. Patients have a history of hypertension. The majority of tumors are located on the adrenal gland. Patients in whom a pheochromocytoma is suspected, who have a positive family history, or who have an adrenal mass found incidentally, should be tested for the disease. Prior to diagnostic studies, any possible offending drug should be discontinued. In patients who are low risk for a pheochromocytoma, 24-hour urine fractionated metanephrines and catecholamines should be the first biochemical test. After a positive biochemical test, patients should be evaluated via imaging (either CT scan or MRI) to locate the catecholamine-secreting tumor. Genetic testing may also be indicated if a familial disorder is suspected. Treatment includes surgical resection of the pheochromocytoma preceded by a preoperative α-adrenergic blockade using phenoxybenzamine and β-adrenergic blockade using a β-blocker such as propranolol to maintain cardiovascular and hemodynamic stability during surgery. 24-hour urine fractionated metanephrines and catecholamines (A) is incorrect as this patient is at high risk of a pheochromocytoma given his family history. A 24-hour urine fractionated metanephrines and catecholamines test would be performed in a patient who is at low risk for a pheochromocytoma. CT scan (B) would not be the initial test in this patient as the initial biochemical test should be performed prior to imaging studies in patients where pheochromocytoma is the suspected diagnosis. Genetic testing (C) is indicated in patients with a positive family history of familial genetic disorders (such as MEN2, von-Hippel-Lindau syndrome, or neurofibromatosis type 1) or whose imaging results are suggestive of a familial disorder.

Pheochromocytoma

Hyperthyroidism

Patient will be complaining of heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE will show hyperreflexia, goiter, exophthalmos, pretibial edema Labs will show low TSH and high freeT4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Treatment is methimazole or PTU Comments:Propylthiouracil (PTU) if Pregnant Hyperthyroidism is a condition of an overactive thyroid which results in an excess production of the main thyroid hormones, thyroxine (T4) and triiodothyronine (T3). Signs and symptoms of hyperthyroidism may include anxiety, weakness, tremors, tachycardia/palpitations, heat intolerance, increased perspiration, and weight loss. The workup for patients with clinical presentation concerning for hyperthyroidism starts with checking the thyroid-stimulating hormone (TSH) level. Regulation of the thyroid hormone occurs through a negative feedback system between the hypothalamus, pituitary gland, and thyroid gland. When supply of thyroid hormone is low, the hypothalamus releases thyrotropin-releasing hormone (TRH) which signals the pituitary gland to release TSH. TSH then signals the thyroid gland follicular cells to produce and release thyroid hormones (T3 and T4). Patients with hyperthyroidism have a low TSH because the hypothalamus recognizes there is too much thyroid hormone circulating throughout the system and decreases the signal for thyroid hormone production. When a TSH value is abnormal, the next step is to check levels of serum free T3 and T4. One or both of these hormone levels will be elevated in hyperthyroidism. ACTH stimulation test (A) is used to diagnose adrenal insufficiency and to distinguish whether the condition is a result of a primary (adrenal gland), secondary (pituitary gland), or tertiary (hypothalamus) defect. Comprehensive metabolic panel (B) is a laboratory test that includes the following serum levels: sodium, potassium, chloride, carbon dioxide, BUN, creatinine, glucose, calcium, total protein, albumin, and liver function tests (ALT, AST, bilirubin, alkaline phosphatase). None of these labs are used to diagnose hyperthyroidism. Plasma cortisol level (C) may be used as part of the workup for adrenal insufficiency, however it is not useful in the diagnosis of hyperthyroidism.

Hyperthyroidism tremor

Complications of Gastric Bypass

Patient will be complaining of increasing fatigue, headaches, irritability, and dry skin PE will show mild pallor, atrophic glossitis, cheilosis, and koilonychia Can lead to deficiencies in: Water-soluble vitamins (vitamins B1, B12, folate, and vitamin C) Fat-soluble vitamins (Vitamins A, D, E, and K) Minerals (calcium, copper, iron, selenium, and zinc) Treatment is life-long micronutrient supplementation Vitamin C supplements also aid in the absorption of iron Comments: Acute complications include dumping syndrome (severe nausea, abdominal cramping, and light-headedness that occur approximately thirty minutes after eating when restarting normal diet) Life-long micronutrient supplementation is required for patients who undergo Roux-en-Y gastric bypass. The Roux-en-Y procedure involves a significant or total bypass of the stomach and duodenum, and usually leads to deficiencies in water-soluble vitamins (vitamins B1, B12, folate, and vitamin C), fat-soluble vitamins (Vitamins A, D, E, and K), and minerals (calcium, copper, iron, selenium, and zinc) if supplements are not taken. Dosing of micronutrients is based on many factors, including serum levels, medications, comorbidities, dietary intake, tolerances, and specific needs, and therefore must be tailored to individual patients. The frequency of routine testing is based on the discretion of the surgeon, however, symptoms of micronutrient deficiency should prompt additional assessment. Macronutrient intake is staged, with progressive intake of the amount of food and consistency from liquid to regular. Total caloric intake is also based on individual needs. Cholestyramine (A) is not routinely indicated after bariatric surgery. It may be used in the treatment of pruritus induced by liver failure, cholestasis, or diarrhea caused by bile acids (post-cholecystectomy syndrome, Crohn's disease). H2 antagonist (B) therapy is not routinely indicated after bariatric surgery. A liquid diet (C) is part of the early diet after bariatric surgery but is not routinely indicated for long-term nutrition.

Peripheral Artery Disease

Patient will be complaining of pain in the affected extremity related to activity (intermittent claudication) PE will show cool extremity with absent or diminished pulses Diagnosis is made by ankle-brachial index (ABI)If limb is threatened - contrast arteriography (gold standard) Most commonly caused by atherosclerotic disease The patient above presented with a history and exam findings consistent with peripheral artery disease (PAD), a disorder characterized by narrowing of the peripheral arteries as a result of atherosclerosis. PAD often involves the arteries providing flow to the lower extremities. Atherosclerosis develops from endothelial dysfunction, inflammation, and development of lipid and fibrin plaques within the arterial walls. This process is influenced by a variety of risk factors including tobacco abuse, hypertension, diabetes mellitus, and hyperlipidemia. A common presentation of PAD is intermittent claudication (leg pain that occurs with exercise and improves with rest), however symptoms may progress to leg pain at rest, skin ulceration, and loss of a limb in severe cases. Physical exam may show skin changes (loss of hair, skin atrophy or shiny skin, cool temperature, pale color, or ulceration), weak lower extremity pulses, and decreased sensation. Diagnosis is made with an ankle-brachial index (ABI) test which is calculated by dividing the systolic blood pressure of the ankle by the systolic blood pressure of the brachial artery. An ABI value of ≤0.9 is diagnostic of PAD. Treatment of PAD includes anti-platelet agents such as aspirin or clopidogrel which should be used for all patients with PAD who have no contraindications. Other first-line treatments are aimed at aggressive risk factor modification including complete tobacco cessation, exercise, antihypertensives, statin, and diabetes management. Cilostazol, a phosphodiesterase inhibitor, may also be beneficial in reducing intermittent claudication and improving exercise tolerance for patients with PAD. Anticoagulation (A) is not routinely used as a treatment for lower extremity peripheral artery disease because no benefit has been found over aspirin and the risk of bleeding is higher. Anticoagulation may be indicated following certain types of revascularization procedures, however it would not be used as initial therapy. Hormone replacement therapy (C) has not been found to improve symptoms of claudication and is not recommended for the treatment of peripheral artery disease. Revascularization (D) is used to restore perfusion that has been compromised by peripheral artery disease. It is performed with either endovascular or surgical techniques depending on the extent and location of the disease. It is indicated for the treatment of PAD in the following circumstances: persistent symptoms despite medical therapy, ischemic pain at rest, ulcerations as a result of poor perfusion, and cases where loss of a limb is a concern due to severely compromised blood flow. Although it is an important part of the management of PAD, it is not regarded as first-line treatment.

Cellulitis

Patient will be complaining of pain, redness, swelling PE will show tenderness, erythema with poorly demarcated borders, lymphedema Most commonly caused by group A Streptococcus, Streptococcus pyogenes, or Staph aureus Cellulitis is a skin infection caused by bacterial entry into a break in the skin. Cellulitis is more common in middle-aged and elderly patients. Risk factors for cellulitis are skin barrier disruption due to trauma, skin inflammation, edema due to impaired lymphatic drainage or venous insufficiency, obesity, and immunosuppression (HIV or diabetes). Patients usually present with skin erythema, edema, and warmth, and may present with fever. Cellulitis is almost always unilateral. Diagnosis is based on clinical presentation. Culture and susceptibility testing should be obtained of the purulent material. The most common cause of purulent cellulitis is Staphylococcus aureus. Empiric therapy (pending culture results) should be an agent that covers infection due to methicillin-resistant S. aureus (MRSA). Appropriate therapeutic options include clindamycin, trimethoprim/sulfamethoxazole, or tetracyclines (doxycycline or minocycline). Cephalexin (A) is a first-generation cephalosporin effective against Gram-positive and some Gram-negative bacteria including MSSA, but not MRSA. Cephalexin is indicated in non-purulent cellulitis infection. Ciprofloxacin (B) is a broad-spectrum fluoroquinolone effective against Gram-positive and Gram-negative bacteria including methicillin-susceptible S. aureus (MSSA), but not MRSA. Piperacillin-tazobactam (C) is a broad-spectrum beta-lactam effective against Gram-positive bacteria including MSSA and Gram-negative bacteria including Pseudomonas aeruginosa, but not MRSA.

Cellulitis

Patient will be complaining of pain, redness, swelling PE will show tenderness, erythema with poorly demarcated borders, lymphedema Most commonly caused by group A Streptococcus, Streptococcus pyogenes, or Staph aureus Cellulitis, a type of surgical site infection, is defined as an inflammatory condition of the skin and underlying subcutaneous tissue due to bacterial entry through a breach in the skin barrier. Surgical site infections are defined as infections related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery. Risk factors for surgical site infection include cigarette smoking, older age, obesity, malnutrition, diabetes, and immunosuppressive therapy. The highest rates of surgical site infections occur after abdominal surgery, followed by coronary bypass surgery, cesarean section, vascular surgery, and joint prosthesis. The average wound infection has an incubation period of 5-7 days. Clinical manifestations include localized erythema, induration, warmth, and pain at the incision site. Additionally, purulent wound drainage and separation of the wound may occur. Systemic signs of infection include a fever and leukocytosis. Diagnosis is clinical. Treatment depends on the extent of infection at the surgical site. Wound infections associated with cellulitis only, such as in the case above, can be treated with a course of antibiotics without open drainage. If an abscess is present, drainage is indicated. If fascial disruption is suspected in the setting of wound infection, then drainage and repair is performed in the operating room. Wounds that have opened can be closed after the infection has cleared and granulation tissue is apparent or can be allowed to heal by secondary intention. Severe infections often require empiric treatment using a broad-spectrum antibiotic with coverage of gram-positive cocci while also considering expected flora at the side of the operation. Wound cultures help guide more definitive antibiotic selection. An abscess (A) is a collection of pus within the dermis or subcutaneous space, which manifests as a painful, fluctuant, erythematous nodule, with or without surrounding cellulitis. Hematoma (C) is a collection of blood, which usually results from failure of primary hemostasis. It usually appears a few days after surgery and manifests as swelling, pain, or bloody drainage from the wound. Seroma (D) is a collection of serum under the skin or in the subcutaneous space. It can also cause the incision to separate, predisposes the wound to infection, and manifests as swelling, pain, and thin, clear or blood-tinged drainage.

Anal Fissure

Patient will be complaining of rectal pain and bleeding which occurs with or shortly after defecation PE will show fissure located in the posterior midline Diagnosis is made by visual inspection Treatment is stool softeners, protective ointments, sitz baths Comments: If fissures are located laterally, search for pathologic etiologies Fiber is one of the first-line supportive measures recommended for typical anal fissures (single posterior or anterior fissure with no evidence of Crohn's disease). Anal fissures result from a high anal pressure secondary to the passage of a hard stool. The goal of fiber supplementation is to prevent constipation and hard bowel movements which will cause further damage and prevent healing of the existing anal fissure. The recommended daily dietary fiber intake is 20-35 grams. For patients who continue to have hard stools despite adequate fiber intake, stool softeners or laxatives may be beneficial. Topical analgesics such as 2% lidocaine jelly and sitz baths are also recommended. Topical vasodilators such as nifedipine or nitroglycerin are often used along with these supportive measures for treatment of anal fissures. Lateral internal sphincterotomy (B) is a surgical option offered to patients who fail medical therapy treatment. Although cure of anal fissures is higher with surgery than conservative measures, patients are first given a trial with medical therapy due to the risks and complications associated with surgery which include fecal incontinence. Metronidazole (C) is an antibiotic used in the treatment of anal fissures that are a complication of Crohn's disease. It is not used for typical anal fissures. Oral nifedipine (D) is a calcium-channel blocker that may decrease anal sphincter spasms leading to healing of the fissure. Nifedipine can be used as a second-line treatment for patients who have failed first-line treatments and are not surgical candidates or elect to not pursue surgery. Side effects of nifedipine may include flushing, headaches, and lower extremity swelling.

Acute Cholangitis

Patient will be complaining of right upper quadrant pain, jaundice, fever (Charcot triad) Diagnosis is made by RUQ ultrasound, CT scan, or ERCP (gold standard) Most commonly caused by choledocholithiasis leading to bacterial infection, E. coli Treatment is antibiotics, definitive treatment is ERCP with antibiotics typically an adjunct Comments: Charcot triad + hypotension and AMS = Reynolds pentad, acute obstruction Acute cholangitis most commonly occurs due to biliary tract obstruction, stasis, and infection. The most common causes of obstruction are biliary calculi, benign stenosis, and malignancy. Cholangitis is also a common complication of stent placement for malignant biliary obstruction. The infection usually ascends from the duodenum. Classic presentation is fever, jaundice, and abdominal pain (Charcot's triad), although most affected patients present only with abdominal pain and fever. Blood analysis usually reveals an elevated white blood cell count with neutrophilia and a cholestatic pattern of elevated liver enzymes: alkaline phosphatase, gamma-glutamyl transpeptidase (GGT), and bilirubin. Diagnosis of acute cholangitis should be suspected if a patient has fever, shaking chills, or laboratory evidence of an inflammatory response, in addition to abdominal pain, jaundice, or abnormal liver chemistries. Definitive diagnosis can be made when a patient meets the previous criteria and also has biliary dilation or evidence of an etiology (e.g., stricture, stone, stent) on transabdominal ultrasonography (US). Blood cultures and cultures from bile or stents should be obtained on all patients to help guide antibiotic therapy. Endoscopic retrograde cholangiopancreatography (ERCP) confirms the diagnosis of acute cholangitis and enables biliary drainage, which can be a life-saving intervention. Patients suspected of having acute cholangitis should be admitted to the hospital to monitor and treat sepsis, provide empiric and then tailored antibiotic therapy, and establish biliary drainage. Since patients who develop acute cholangitis due to gallstones or benign stenosis are at high risk for recurrence, cholecystectomy and surgical repair, respectively, are generally recommended. Esophagogastroduodenoscopy (EGD) (B), or upper endoscopy, examines the esophagus, stomach, and duodenum. Therapeutic procedures such as esophageal dilatation can be performed via EGD, but biliary drainage cannot. Laparoscopic cholecystectomy (C) is indicated for symptomatic gallstone disease and may ultimately prevent cholangitis recurrence, but would not provide the necessary biliary drainage for acute cholangitis. Laparoscopic herniorrhaphy (D) is indicated for symptomatic hernia or a hernia at increased risk for strangulation, but plays no role in acute cholangitis management.

Iron Deficiency Anemia

Patient will be complaining of weakness, dizziness, and fatigue PE will show pallor, tachycardia, atrophic glossitis or koilonychia (spoon nails) Labs will show microcytic, hypochromic red blood cells. Decreased serum iron level, an increase in the total iron binding capacity (TIBC), and decreased serum ferritin levels Comments: the most common cause of microcytic anemia Iron deficiency anemia is a common problem encountered in the adult population, affecting over 12 percent of the world's population. Populations at greatest risk of iron deficiency include pregnant women and older adults (i.e., age greater than 65 years). The major causes of iron deficiency anemia are decreased dietary intake, reduced absorption, and blood loss. In the United States, most causes of iron deficiency anemia are attributed to either overt or occult blood loss. Overt bleeding includes traumatic hemorrhage, hematemesis or melena, hemoptysis, menorrhagia, pregnancy and delivery, and hematuria. Other causes of blood loss that are commonly overlooked include frequent blood donation, excessive diagnostic blood testing, underestimation of the degree of menorrhagia, and occult bleeding (e.g., gastrointestinal losses, hemolysis with urinary losses). Additionally, prior bariatric surgery, such as a Roux-en-Y procedure, increases the risk iron deficiency anemia. Clinical manifestations of adults with iron deficiency are primarily due to anemia and include fatigue, weakness, headache, irritability, exercise intolerance, exertional dyspnea, vertigo, and angina pectoris. Examination often reveals pallor, dry or rough skin, atrophic glossitis with loss of tongue papillae, cheilosis, and koilonychia (i.e., spoon nails). In the early stages of iron deficiency anemia, the complete blood count may be normal, however, as it progresses, the red blood cell count, hemoglobin and hematocrit, absolute reticulocyte count, and mean corpuscular volume will be decreased. Other laboratory evaluation includes iron studies, of which ferritin is the most useful test. Iron studies show a low serum iron level, an increased serum transferrin and total iron-binding capacity, a low transferrin saturation level, and a low ferritin level. A thorough evaluation should be done to identify possible causes of the deficiency, which may require additional testing such as endoscopy, especially in patients who are ≥ 50 years old, and those who fail to respond to iron repletion. Regardless of the presence of symptoms, all patients with iron deficiency with or without anemia should be treated. Treatment often involves oral iron due to ease of administration, but some cases may warrant intravenous iron such as ongoing blood loss, issues with adequate absorption (e.g., after gastric or bariatric surgery), and intolerable gastrointestinal side effects with oral iron. Effective treatment of iron deficiency results in normalization of the hemoglobin level in six to eight weeks. Intramuscular iron (A) is available and does raise the iron level but is painful, stains the buttocks, and has variable absorption. Oral iron (C) is not appropriate in the setting of prior bariatric surgery given the reduced absorption and increased risk of gastrointestinal side effects in these patients. Red blood cell transfusion (D) is reserved for patients who are hemodynamically unstable due to active bleeding or when there is evidence of ischemia secondary to severe anemia (e.g., symptoms of myocardial ischemia).

Iron Deficiency Anemia

Patient will be complaining of weakness, dizziness, and fatigue PE will show pallor, tachycardia, atrophic glossitis or koilonychia (spoon nails) Labs will show microcytic, hypochromic red blood cells. Decreased serum iron level, an increase in the total iron binding capacity (TIBC), and decreased serum ferritin levels Comments: the most common cause of microcytic anemia Iron deficiency is extremely common. Women of childbearing age, children, and people living in low-income countries are at higher risk. The most common causes of iron deficiency are poor dietary consumption, poor absorption, and blood loss. Iron is consumed and then bound to transferrin to produce hemoglobin and red blood cells (RBCs). Low serum iron results in low serum ferritin (an intracellular protein which stores iron) and increased serum transferrin (a protein that transports iron). The total iron binding capacity (TIBC) is an indirect measurement of transferrin and increases as the body attempts to compensate for the iron deficiency. Hemoglobin, hematocrit, RBC count, and the mean corpuscular volume (MCV) decrease as the deficiency progresses. Patients usually present with fatigue, weakness, exercise intolerance, irritability, headache, exertional dyspnea, vertigo, or angina pectoris. Some patients present with pagophagia (pica for ice), which is specific for iron deficiency. Physical exam may be normal or may reveal pallor, dry skin, blue sclerae, atrophic glossitis, cheilosis, or koilonychia (spoon nails). Typical findings on blood analysis are diagnostic. Iron deficiency requires iron administration and identification of the underlying cause. Endoscopy is indicated for possible occult gastrointestinal bleeding in adults without an apparent source of blood loss. A presumptive diagnosis may be made in women with heavy menstrual periods or during pregnancy, and these patients should have a rapid and complete resolution of anemia and associated symptoms with iron supplementation. Beta thalassemia (A) is caused by a mutation in one or both beta globin genes. Beta thalassemia major is the most severe form. Patients typically present in infancy with pallor, jaundice, irritability, failure to thrive, and profound anemia requiring lifelong transfusions. Pernicious anemia (C) is an autoimmune condition which causes autoantibodies to prevent vitamin B12 and intrinsic factor complex formation, which leads to vitamin B12 deficiency and a megaloblastic anemia. Affected patients may present with fatigue and neurologic abnormalities (symmetric peripheral neuropathy). Polycythemia vera (D) is characterized by an increased red blood cell mass. The disease may be found incidentally, but some patients present with aquagenic pruritus, symptoms of thrombosis, or facial plethora.

Subdural Hematoma

Patient will be elderly or alcoholic With a history of a fall or traumatic head injury Complaining of headache, mental status changes, seizures, or focal deficits Diagnosis is made by non-contrast CT, will appear as crescent-shaped hematoma Most commonly caused by rupture of the bridging veins Management includes neurosurgical consultation Subdural hematoma is an intracranial venous hemorrhage that often results after trauma causing the emissary veins to tear. Such an injury results in bleeding between the dura mater and the arachnoid membrane. The risk of subdural hematoma is greater in patients who are elderly or abuse alcohol due to the associated brain atrophy. Subdural hematoma can be acute, subacute, or chronic, depending on the time of onset. The injury is typically associated with a steady neurological decline to coma and may be associated with focal neurological deficits. CT scan of the head is often the first test performed, however, MRI of the brain has been shown to be more sensitive in the diagnosis of subdural hematoma. On CT scan, the hematoma will often appear crescent shaped. Treatment involves evacuating the bleeding through craniotomy, burr hole trephination, or decompressive craniectomy. Reversing anticoagulation is necessary in patients on anticoagulants who are in need of surgery. Complications include elevated intracranial pressure, brain herniation, permanent brain injury, and death. Subarachnoid hemorrhage (D) is incorrect, as it commonly presents with a severe headache and blood in the arachnoid and ventricular spaces on CT scan of the head. Epidural hematoma (A) is incorrect, as it commonly presents as a lenticular shaped hematoma on CT scan of the head. Ischemic stroke (B) is incorrect, as it would not be associated with hemorrhage noted on CT scan and a thrombotic or embolic event would be less likely in a patient anticoagulated with warfarin.

Venous Insufficiency

Patient will be obese, pregnant or older With a history of prolonged standing, family history of venous insufficiency Complaining of leg edema PE will show skin changes, ulceration, edema, varicose veins Imaging will show valvular abnormalities Diagnosis is made by history, physical exam Most commonly caused by valvular abnormalities Treatment is leg elevation, compression therapy, ulcer care, ablation Venous stasis ulcers can develop due to deep vein thrombosis or venous valvular incompetence. Risk factors for chronic venous disease are advancing age, family history of venous disease, increased body mass index, smoking, a history of lower extremity trauma, prior venous thrombosis, and pregnancy. Venous ulcers occur most commonly on the medial and lateral malleoli. Patients may complain of a dull pain. Exam typically reveals a beefy, red, granulated wound bed with surrounding hyperpigmentation, erythema, scaling, weeping, and crusting. Chronic venous disease may cause a brown or light blue discoloration to the anterior shins. Venous ulcers are diagnosed clinically. Basic wound care and compression therapies are the cornerstones of treatment. An abscess (A) is a collection of pus which is generally painful, red, and warm, and exam usually reveals a fluctuant, erythematous mass. Cellulitis (B) is an area of erythematous, edematous skin due to bacterial infection. Cellulitis generally does not cause any open wounds. A pressure injury (C) is a localized area of damaged skin or underlying tissue, usually over a bony prominence, due to pressure or shear force.

Benign Prostatic Hyperplasia (BPH)

Patient will be older Complaining of Hesitancy, Intermittence/Incontinence, Frequency/Fullness, Urgency, Nocturia (HI FUN) PE will show a smooth, firm and mobile prostate without any nodules or indurations Diagnosis is made by digital rectal exam Most commonly caused by stromal and epithelial cell growth in the transitional zone of the prostate Treatment is alpha-blockers, 5-reductase inhibitors, surgery (TURP) Alpha-1-adrenergic antagonists should be administered immediately at the time of catheterization to prevent the recurrence of early acute urinary retention due to benign prostatic hyperplasia (BPH). These medications, such as alfuzosin and tamsulosin, relieve the obstruction in the case of BPH by relaxing smooth muscle in the bladder neck, prostatic capsule, and prostatic urethra. Following removal of the catheter, voiding trials must be performed, as half of men with BPH will have a recurrence of acute urinary retention within one week. Alpha-1 adrenergic antagonists have been proven to decrease the incidence of early recurrence. They have also been shown to postpone the need for surgery in many patients. Surgery should be considered if a patient with BPH fails two voiding trials. 5-α-reductase inhibitors (A) are helpful in the prevention of long term risk of acute urinary retention, but must be used for a year to be beneficial so they are not used to prevent early recurrence of retention. They also decrease the need for surgery. Phosphodiesterase-5 inhibitors (C) and Prostaglandin E1 (D) are both medications used in patients with erectile dysfunction. They are not considered useful in the prevention or treatment of urinary retention.

Bladder Cancer

Patient will be older With a history of smoking Complaining of painless hematuria Diagnosis is made by cystoscopy Most common type is urothelial (transitional cell) carcinoma The most common symptom of bladder cancer is hematuria, either gross or microscopic, and is seen in the majority of cases. Irritative bladder symptoms may also be present but are less common. Smoking is the most common risk factor. Other risk factors include, industrial exposure to dyes, rubber, leather, infection, genetics and radiation/chemotherapy. A urinalysis is an important, inexpensive test that can be used to detect hematuria. Tumor markers, such as bladder tumor antigen (BTA), may also be used to screen for disease or monitor the condition. Once hematuria is detected, cytology, cystoscopy and CT scans are used to confirm the diagnosis. The gold standard for diagnosis is cystoscopy with biopsy. Transurethral resection is used to stage the tumor as well as being the initial treatment. Tumor stage will determine the follow-up therapy. Transitional cell carcinoma (urothelial) is the most common type of bladder cancer. Fever (A) may have many etiologies, but generally falls into three main categories: infection, connective tissue disease, or malignancy. It is not a symptom normally associated with bladder cancer. Suprapubic pain (C) is not a symptom of bladder cancer, but is associated with cystitis. Weight loss (D) may also have many etiologies such as hyperthyroidism, gastrointestinal causes, psychiatric causes, or malignancy, but it is not the most common symptom of bladder cancer.

Aortic Dissection

Patient will be older, usually male With a history of HTN, Marfan syndrome Complaining of sudden "ripping" or "tearing" CP radiating to back PE will show asymmetric pulses/BP CXR will show widened mediastinum Type A - involves ascending aorta Type B - involves only descending aorta Diagnosis is made by CT angiography or transesophageal echocardiogram (TEE) Treatment is reduce BP/HR, surgery (depending on dissection type) Aortic dissection is a relatively uncommon condition with high mortality that occurs due to a tear in the aortic intima and subsequent creation of a false lumen. Hypertension is the most important risk factor for aortic dissection. Other risk factors are genetically mediated collagen disorders (Marfan syndrome, Ehlers-Danlos syndrome), pre-existing aortic aneurysm, bicuspid aortic valve, aortic instrumentation or surgery, aortic coarctation, Turner syndrome, inflammatory diseases that cause vasculitis (giant cell arteritis, rheumatoid arthritis), pregnancy, and childbirth. Patients may present with acute onset of severe, sharp, knife-like pain in the middle of the chest radiating to the back. Exam may reveal a new decrescendo diastolic murmur along the right sternal border, a wide pulse pressure, and hypotension. The characteristic chest X-ray finding is a widened mediastinum. Computed tomography (CT) angiography can confirm the diagnosis and differentiate between ascending and descending dissection. Ascending aortic dissection is a surgical emergency due to high risk for life-threatening complications like aortic regurgitation, cardiac tamponade, stroke, frank rupture, and myocardial infarction. Descending aortic dissection can usually be managed medically with blood pressure control and imaging surveillance. Imaging surveillance (B) is commonly part of descending aortic dissection management but would not be appropriate for the more immediately life-threatening ascending aortic dissection. An oral beta-blocker (C) is also commonly part of long-term medical management for descending aortic dissection to aid in blood pressure control. Endovascular repair (D) is a surgical option for certain descending aortic dissection cases and is less invasive than open repair.

Aortic Dissection

Patient will be older, usually male With a history of HTN, Marfan syndrome Complaining of sudden "ripping" or "tearing" CP radiating to back PE will show asymmetric pulses/BP CXR will show widened mediastinum Type A - involves ascending aorta Type B - involves only descending aorta Diagnosis is made by CT angiography or transesophageal echocardiogram (TEE) Treatment is reduce BP/HR, surgery (depending on dissection type) Aortic dissection is a relatively uncommon condition with high mortality that occurs due to a tear in the aortic intima and subsequent creation of a false lumen. Hypertension is the most important risk factor for aortic dissection. Other risk factors are genetically mediated collagen disorders (Marfan syndrome, Ehlers-Danlos syndrome), pre-existing aortic aneurysm, bicuspid aortic valve, aortic instrumentation or surgery, aortic coarctation, Turner syndrome, inflammatory diseases that cause vasculitis (giant cell arteritis, rheumatoid arthritis), pregnancy, and childbirth. Patients present with acute onset of severe, sharp, knife-like pain in the middle of the chest radiating to the back. Exam may reveal a new decrescendo diastolic murmur along the right sternal border, a wide pulse pressure, and hypotension. The characteristic chest X-ray finding is a widened mediastinum. Computed tomography (CT) angiography can confirm the diagnosis and differentiate between ascending and descending dissection. Ascending aortic dissection is a surgical emergency. Descending aortic dissection can usually be managed medically with blood pressure control and imaging surveillance. Acute pericarditis (A) is inflammation of the pericardial sac which typically presents as pleuritic chest pain worsened by laying flat and improved by sitting up and leaning forward. Exam classically reveals a pericardial friction rub. Myocardial infarction (C) occurs due to lack of oxygenation to the myocardium. Patients may present with angina, shortness of breath, nausea, and diaphoresis, and ECG may reveal ST segment elevation. Pulmonary embolism (D) is the obstruction of the pulmonary arterial vasculature. Patients usually present with dyspnea, pleuritic chest pain, and tachycardia. ECG usually shows a sinus tachycardia, but the classic abnormality is SIQIIITIII (deep S wave in lead I, Q wave in lead III, and inverted T wave in lead III), although this is neither sensitive nor specific for PE.

Mallory-Weiss Syndrome

Patient will have a history of drinking alcohol and forceful vomiting Complaining of hematemesis Diagnosis is made by upper endoscopy Caused by an incomplete tear in the esophagus mucosa and proximal stomach Mallory-Weiss syndrome is characterized by longitudinal mucosal lacerations in the distal esophagus and proximal stomach that are usually associated with forceful retching. The lacerations often lead to bleeding from submucosal arteries presenting as hematemesis. Blood loss is typically small volume and self-limited. A sudden increase in intra-abdominal pressure caused by vomiting, straining at stool or lifting, coughing, or seizures often precipitates a Mallory-Weiss tear. A history of heavy alcohol use leading to vomiting is a common cause. Endoscopy is the diagnostic modality of choice to document the presence of a gastroesophageal tear. Most tears will heal spontaneously, however, endoscopic hemostatic therapy is the first-line therapy for actively bleeding lacerations. Duodenal ulcers (A) are a common cause of hematemesis. Risk factors for bleeding ulcers include Helicobacter pylori infection, use of nonsteroidal anti-inflammatory drugs, physiologic stress, and excess gastric acid. Patients may report dyspepsia and pain that occurs one to two hours after eating. Eating typically improves the pain. Esophageal varices (B) develop as a consequence of portal hypertension in patients with cirrhosis. Endoscopy is the diagnostic modality of choice for esophageal varices. Endoscopic band ligation is the standard treatment. Esophagitis (C) is seen in patients with a history of gastroesophageal reflux disease. Hematemesis is much more common than melena in patients with esophagitis. It is typically associated with a benign course compared to other causes of hematemesis.

Mallory-Weiss Syndrome

Patient will have a history of drinking alcohol and forceful vomiting Complaining of hematemesis Diagnosis is made by upper endoscopy Caused by an incomplete tear in the esophagus mucosa and proximal stomach Obtaining intravenous (IV) access is the most important first step in caring for a patient with gastrointestinal (GI) bleeding. Intravenous access allows blood to be drawn for a type and screen, coagulation studies, and determination of hematocrit and hemoglobin levels. It also allows for fluid resuscitation to maintain intravascular volume. Two large bore IV catheters should be used. A Mallory-Weiss tear is a tear in the esophageal mucosa often following forceful vomiting. Patients with a history of alcoholism are at greater risk for developing a Mallory-Weiss tear. Once the patient is stabilized, an esophagoduodenoscopy (EGD) can confirm the diagnosis and allows for treatment options if the bleeding has not resolved spontaneously. Epinephrine injection, embolization, or coagulation therapy can be used to stop the bleeding although most cases resolve spontaneously as the mucosa heals over 48 to 72 hours. Administering an antiemetic (A) is important to prevent further vomiting and subsequent worsening of the bleeding; however, this is not the most important first step in a patient that is actively bleeding and has the potential to become hemodynamically unstable. Placing a nasogastric tube (C) is advised after IV access is obtained to assess the amount and rate of bleeding and to help prevent any further emesis. Preparing the patient for an emergent upper endoscopy (D) may be necessary if the bleeding is severe and the patient requires the procedure; however, it is not the first step before obtaining IV access.

Melanoma

Patient will have fair skin With a history of severe blistering sunburns, a family history of melanoma, dysplastic nevus syndrome Complaining of an itching, tender lesion that won't heal PE will show ulceration and ABCDE A - Asymmetry B - Border irregularity C - Color variation D - Diameter E - Evolution Diagnosis is made by biopsy - excisional or punch Treatment is excision with adequate margins, interferon reduces recurrence Comments: Most important factor is depth A wide excision with a 1 cm wide margin of normal tissue is standard for melanoma that is less than 1 mm in thickness. The 1 cm wide margin should be measured in the short axis of the elliptical incision. The excised tissue should extend down to the deep fascia. Clinical trials have shown the recurrence rates for tumors of this depth with a 1 cm wide excision margin at less than 2 percent with an 87 percent overall survival rate with wide excision alone. Application of imiquimod (A) has been used to treat lentigo melanoma with some success but this treatment is still experimental. Mohs microsurgery (B) is currently being studied as a treatment option in lentigo melanoma and tumors in difficult areas to excise, however, this is also an experimental treatment option. A wide excision with a 2 cm margin of normal tissue (D) is used for tumors greater than 1 mm in thickness.

What is the mechanism of action of cilostazol, a medication used to relieve the symptoms of intermittent claudication?

Phosphodiesterase inhibitor.

Epidural Hematoma

Patient with a history of a head injury with a loss of consciousness followed by a lucid interval CT will show a biconvex opacity Most common artery ruptured is the middle meningeal artery Treatment is emergent evacuation Epidural hematoma presents as lenticular or lens-shaped collection of blood on CT scan between the skull and the dura mater. An epidural hematoma is an arterial bleed, most commonly coming from the middle meningeal artery following trauma to the skull (often resulting in a skull fracture). Patients with an epidural hematoma may have a history of loss of consciousness at the time of the trauma following by a lucid interval and then progressive neurological deterioration as the artery continues to bleed. Patients may experience headache, vomiting, confusion, seizures, and focal neurological deficits. As the hematoma enlarges, the intracranial pressure of the brain can increase leading to herniation of the brain and death. Patients with herniation may display a dilated pupil and Cushing's triad (hypertension, bradycardia, irregular respirations). CT scan of the head without contrast should be the initial diagnostic study, but MRI can also be used. Lumbar puncture is contraindicated due to the increased risk of brain herniation. This is a neurosurgical emergency. Craniotomy is performed to evacuate the hematoma and anticoagulation should be reversed in patients taking anticoagulants. Subarachnoid hemorrhage (C) is incorrect, as it often presents as "worst headache of my life" and is found to have blood present in the arachnoid space and ventricular spaces on CT scan. Subdural hematoma (D) is more common in elderly patients and typically have a crescent shaped collection of blood on CT scan. Hydrocephalus (B) is a buildup of cerebrospinal fluid in the subarachnoid spaces and ventricles. Ventricles would appear enlarged on CT scan.

von Willebrand Disease

Patient with a history of a parent with similar symptoms Complaining of mucosal hemorrhage or bleeding that is difficult to control Labs will show decreased factor VIII, prolonged bleeding time Treatment is desmopressin (DDAVP) Comments: Most common inherited bleeding disorder, autosomal dominant Von Willebrand disease (VWD) is the most common heritable bleeding disorder. An autosomal dominant mutation causes the deficiency in von Willebrand factor (VWF), which assists in hemostasis by bridging platelets with subendothelial factors at sites of injury as well as transporting factor VIII. Patients typically present with easy bruising, skin bleeding, and prolonged bleeding from mucosal surfaces. They may have a history of epistaxis longer than 10 minutes, heavy menstrual bleeding, and prolonged bleeding after dental surgeries or other procedures, including childbirth. Patients with a presentation suggesting VWD should have an initial laboratory analysis that consists of a complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), plasma VWF antigen, plasma VWF activity, and factor VIII activity. Patients with VWD usually have a low VWF antigen, low VWF activity or both and may have low factor VIII due to inability to bind to VWF, but the rest of the analysis is often normal. Patients who are actively bleeding may present with a normocytic anemia. Further testing to determine the specific type of VWD is indicated to direct therapy. Desmopressin (DDAVP) or replacement with VWF concentrate can be effective therapies for the most common types of VWD in the postsurgical setting. A hematologist should be consulted on recommended therapy prior to surgery in patients with known VWD. Factor VIII (B) and Factor IX (A) deficiency are both X-linked disorders, so women would only be symptomatic if both X chromosomes were affected. A typical family history would reveal only males with bleeding abnormalities and patients usually have soft tissue, joint, or urinary tract bleeding. Prothrombin time (PT) (C) measures the time it takes blood to clot when exposed to tissue factor, which is a test of the extrinsic coagulation pathway. PT may be prolonged due to anticoagulant use, vitamin K deficiency, liver disease resulting in low vitamin K production, disseminated intravascular coagulation, the presence of antiphospholipid antibodies which result in prothrombin (factor II) deficiency, or deficiency in one or more of the components of the extrinsic coagulation pathway. PT is not usually prolonged in patients with VWD.

von Willebrand Disease

Patient with a history of a parent with similar symptoms Complaining of mucosal hemorrhage or bleeding that is difficult to control Labs will show decreased factor VIII, prolonged bleeding time Treatment is desmopressin (DDAVP) Comments: Most common inherited bleeding disorder, autosomal dominant Von Willebrand disease is the most common inherited bleeding disorder, which results in a decreased level or an impairment in the action of von Willebrand factor. The most common type is type one, which is a partial, quantitative deficiency of von Willebrand factor with an autosomal dominant inheritance pattern. Many patients are asymptomatic and those who do have symptoms often experience easy bruising, skin bleeding, and prolonged bleeding from mucosal surfaces (e.g., oropharyngeal, gastrointestinal, uterine). Women may have a history of heavy menstrual bleeding and bleeding during the peripartum period. Laboratory testing often reveals a normal platelet count, a normal prothrombin time, and a normal activated partial thromboplastin time, although this can be prolonged depending on the degree of reduction of the factor VIII level. Initial screening tests include plasma von Willebrand factor (VWF) antigen, plasma VWF activity, and factor VIII activity. A VWF activity or antigen level of 30 international units/dL or less establishes a diagnosis of von Willebrand disease. If one of the initial screening tests is abnormal, then two specialized assays should be performed, the VWF multimer distribution using gel electrophoresis and the ristocetin-induced platelet aggregation test. These tests will determine the type of von Willebrand disease. A trial of desmopressin (DDAVP) should be performed to assess the clinical response prior to its actual need. Treatment using DDAVP depends on the type of von Willebrand disease but is generally limited to situations when bleeding occurs, like during minor surgery. For major bleeding and major surgery or those who fail to respond to DDAVP the use of a plasma-derived VWF concentrate or recombinant VWF is recommended. Hemophilia A (A) which is also known as factor VIII deficiency, is an X-linked recessive trait which results in a normal platelet count, normal prothrombin time, and an elevated activated partial thromboplastin time. Hemophilia B (B) which is also known as factor IX deficiency, is an X-linked recessive trait which results in normal platelet count and function, normal prothrombin time, increased activated partial thromboplastin time, a normal factor VIII level, and a decreased factor IX level. Thrombocytopenia (C) can be attributed to many causes, including immune-related thrombocytopenia, pregnancy, chronic liver disease, and certain medications. Laboratory testing reveals a low platelet count, normal prothrombin time, and a normal activated partial thromboplastin time.

Barrett Esophagus

Patient with a history of chronic reflux Diagnosis is made by upper endoscopy, biopsy Biopsy will show squamous to columnar epithelium and proximal shift in the squamocolumnar junction Treatment is proton pump inhibitors Comments: Increased risk for adenocarcinoma Dyspepsia or heartburn can be functional or a symptom of gastroesophageal reflux disease (GERD). Chronically uncontrolled or inadequately treated GERD leads to mucosal damage in the stratified squamous epithelium of the distal esophagus. The damaged mucosa is usually replaced by new squamous cells, but in some patients, the damage can lead to pathologic columnar metaplasia, which is diagnostic of Barrett esophagus. The reason for the pathologic metaplasia is unknown. The columnar epithelium is more resistant to reflux-induced damage, but it predisposes the patient to adenocarcinoma of the esophagus. First-line therapy for functional dyspepsia, GERD, and Barrett esophagus is a proton-pump inhibitor (PPI) and lifestyle changes, including weight loss, consuming smaller portions, and consuming less of the foods that induce symptoms. Some observational and in-vitro data suggest that aggressive anti-reflux therapy decreases the risk of malignant transformation. Atrophic squamous epithelium (A) is the pathologic histologic finding associated with atrophic vaginitis. The main histologic feature of celiac disease is increased intraepithelial lymphocytes (B) in the duodenum. Stratified squamous epithelium (D) is the normal histology of the distal esophagus.

Which approach is preferred in cases of a bilateral adrenalectomy?

Posterior retroperitoneoscopic.

Small Bowel Obstruction

Patient with a history of prior abdominal/pelvic surgery Complaining of bilious vomiting PE will show high pitched bowel sounds X-ray will show dilated bowel, air fluid levels, stack of coins or string of pearls sign Diagnosis is made by imaging Treatment is NGT, surgery Abdominal CT with contrast is most likely to confirm a small bowel obstruction as it has the highest sensitivity and specificity of the various imaging modalities listed. Additionally, a CT scan can identify complications, such as ischemia or perforation, localize the transition point, evaluate for malignancy, and rule out competing diagnoses, such as volvulus or intussusception. Often, an initial abdominal X-ray is obtained prior to CT evaluation and may show dilated loops of bowel with air-fluid levels or proximal dilation with a gasless distal bowel. Adjunctive tests include ultrasound, magnetic resonance enterography, and contrast X-rays. Symptoms of small bowel obstruction include nausea, vomiting, intermittent abdominal cramping, abdominal distension, constipation, and, if the obstruction is complete, obstipation with failure to pass flatus. Partial obstruction may be associated with hyperactive bowel sounds and high-pitched tinkles. Hypoactive bowel sounds or no bowel sounds may be noted if the obstruction is complete. Fever, tachycardia, and significant abdominal tenderness should raise concern for bowel perforation or strangulation. Treatment depends on the cause and severity of the obstruction but generally is non-operative with gastric decompression via a nasogastric tube, bowel rest, IV fluids, and replenishment of electrolytes. Definitive treatment is laparoscopy or laparotomy. Abdominal X-ray (B) is frequently the initial imaging modality to detect small bowel obstruction, but it has a significantly lower sensitivity and specificity compared to CT and therefore is less likely to establish the diagnosis. Abdominal ultrasound (C) may be ordered as an adjunctive assessment but is operator dependent and limited in ability to adequately visualize intestines. Colonoscopy (D) has no role in assessment of a small bowel obstruction but may be used as a temporary treatment of sigmoid volvulus or to reduce intussusception.

Small Bowel Obstruction

Arterial Embolism

Patient with a history of recent MI or atrial fibrillation Complaining of sudden onset of pain, pallor, paresthesias, pulselessness, paralysis, and pain out of proportion to exam (6 P's) Most common source is left heart Comments: Most common site is femoral artery bifurcation CTA of the pelvis with runoff is the recommended imaging modality in the assessment of acute arterial embolism that is not immediately limb-threatening, according to the American College of Radiology. Classically, the six Ps outline the presentation of arterial occlusion: paresthesia, pain, pallor, poikilothermia, reduced pulses, and paralysis. Late findings include paralysis, gangrene, and loss of sensation. A viable or marginally threatened limb is usually evaluated with CT, as this modality is rapid, accurate, and can give detail about smaller vessels and collateral blood flow, providing valuable information for interventional planning. The primary risk associated with CTA is contrast nephropathy. Digital subtraction angiography is the gold standard of diagnosing arterial occlusion and has the additional benefit of potential treatment at the time of assessment, however, availability often limits the use of this method. Treatment depends on etiology, location, severity, and health of the patient, but may include thrombolysis, stenting, thrombectomy, or surgery (bypass). D-dimer (B) testing is a useful evaluation for patients with a low probability of venous thromboembolism, however, it is not helpful to establish the diagnosis of acute arterial occlusion. Doppler ultrasound (C) is helpful in the initial evaluation to confirm blood flow but is not able to provide detailed information on the location of occlusion or collateral vessel patency and is highly operator-dependent. Magnetic resonance angiography of the pelvis with runoff (D) is an acceptable alternative to CTA, but it is time-consuming and not readily available in many places. Additionally, visualization of calcium deposits is fairly poor with magnetic resonance angiography, which may make surgical planning somewhat more difficult, as areas of heavy calcification are not ideal for bypass grafting.

Hyperkalemia

Patient with a history of renal failure, DKA, rhabdomyolysis, tumor lysis Complaining of lethargy, weakness, paralysis PE will show bradycardia, hypotension, cardiac dysrhythmia ECG will show peaked T waves, prolonged PR, wide QRS Treatment is calcium gluconate, insulin, albuterol, bicarbonate Ten percent calcium gluconate (1 g ) should be administered intravenously before any other medications are given to the patient. The most concerning and life-threatening effects of hyperkalemia are cardiac dysrhythmia and cardiac arrest. Patients with early cardiac manifestations of hyperkalemia will demonstrate peaked T waves on electrocardiogram (ECG). As the hyperkalemia worsens or persists, the P waves disappear on ECG and the QRS intervals progressively widen, resulting in significant worsening risk of cardiac dysrhythmia. Administering calcium gluconate to the patient with hyperkalemia does not affect serum potassium levels, however, it stabilizes the membrane potential of cardiac tissue and reduces the risk of cardiac arrest. Albuterol (A) does lower serum potassium levels by promoting cellular reuptake of the electrolyte but should not be administered as the first treatment because it does not stabilize cardiac tissue. Insulin with glucose (C) also promotes cellular reuptake of potassium and is administered to lower serum potassium; however, this is not the first step as it does not lower the risk of cardiac dysrhythmia. Sodium polystyrene (D) is administered to patients with hyperkalemia and works by promoting excretion of potassium, however, this does not have any protective effect on cardiac tissue. There is also evidence that sodium polystyrene is associated with increased morbidity and mortality and is not recommended by many clinicians.

Pancreatic Cancer

Patient with a history of smoking Complaining of abdominal/epigastric pain, painless jaundice, depression, and weight loss PE will show palpable nontender gallbladder (Courvoisier sign), migratory thrombophlebitis (Trousseaus syndrome) Labs will show CA 19-9 serum marker Most common type is adenocarcinoma Comments: Other PE signs: Palpable left supraclavicular lymph node (Virchows node), palpable nodule bulging into the umbilicus (Sister Mary Joseph sign) Pancreatic cancer is a highly lethal malignancy and is the fourth leading cause of cancer-related death in the United States. The most common type of pancreatic cancer is ductal adenocarcinoma. Most pancreatic cancers are localized to the head of the pancreas. It is rarely seen in patients before age 45 and the incidence is greater in males than females. Risk factors include a family history of pancreatic cancer, cigarette smoking, high body mass and lack of physical activity, and non-hereditary chronic pancreatitis. The most common symptoms at diagnosis are asthenia (i.e., abnormal physical weakness), weight loss, anorexia, abdominal pain, epigastric pain, dark urine, jaundice, nausea, and back pain. The most frequent signs include jaundice, hepatomegaly, right upper quadrant mass, cachexia, Courvoisier's sign (palpable, nontender distended gallbladder at the right costal margin), and epigastric mass. Common laboratory abnormalities include an elevated serum bilirubin and alkaline phosphatase levels, as well as the presence of mild anemia. First-line imaging includes abdominal computed tomography and transabdominal ultrasound. Abdominal computed tomography is preferred in patients with epigastric pain and weight loss, but no jaundice. Transabdominal ultrasound is preferred in patients who present with jaundice or in those patients suspected of having pancreatic cancer. If a pancreatic mass is present, the next step involves staging evaluation to determine resectability. Contrast-enhanced abdominal computed tomography, specifically triple-phase multidetector row computed tomography, is the preferred method to diagnose and stage pancreatic cancer. Complete surgical resection is the only potentially curative treatment modality for pancreatic cancer. Conventional pancreaticoduodenectomy (i.e., Whipple procedure) is the most common operation for pancreatic cancer involving the head or uncinate process, which includes removal of the pancreatic head, duodenum, first 15 cm of the jejunum, common bile duct, and gall bladder, as well as a partial gastrectomy. Unresectable disease can be treated with radiation therapy alone, chemoradiotherapy, or chemotherapy alone, although no standard treatment protocol exists. The prognosis of pancreatic cancer is poor even in those with potentially resectable disease. Echoendoscope-guided fine needle aspiration biopsy (B) is not required once pancreatic cancer is suspected on initial imaging studies. A preoperative biopsy may be recommended if a diagnosis of chronic or autoimmune pancreatitis is suspected based on age and clinical findings. Endoscopic retrograde cholangiopancreatogram (C) and magnetic resonance cholangiopancreatography (D) can be used to evaluate patients when initial abdominal computed tomography or transabdominal ultrasound does not display any mass lesion. Additionally, these two modalities are often preferred for patients in whom a high suspicion for choledocholithiasis exists.

Pancreatic Cancer

Deep Vein Thrombosis (DVT)

Patient with a history of smoking, long-distance travel, surgery, oral contraceptives use Complaining of unilateral leg edema, leg pain, tenderness, and warmth Physical exam may show a positive Homans sign Diagnosis is made by ultrasound; Gold standard is venography Most commonly caused by stasis, hypercoagulable state, trauma (Virchow triad) Treatment is anticoagulation Warfarin is contraindicated in pregnancy Comments: Pretest probability by modified Wells score Deep vein thrombosis is a form of venous thromboembolism where a blood clot forms in one or more extremities. It occurs most commonly in the lower extremities. Signs and symptoms include redness, swelling, and pain of the affected extremity. Risk factors for deep vein thrombosis include recent surgery or trauma, splinting or casting of an extremity, active cancer within the last six months, recent immobilization or travel, and use of hormone replacement therapy, among others. For patients at low risk for deep vein thrombosis, it is acceptable to use a D-dimer blood test to rule out the diagnosis. For patients at high risk, such as this patient, the diagnostic test of choice is venous Doppler ultrasound, which will show restricted flow and lack of venous compression. Patients who have a confirmed deep vein thrombosis should be started on anticoagulants to prevent a pulmonary embolism, which can be potentially fatal. Ankle-brachial index (A) is a comparison of the systolic blood pressures at the ankles and upper arms. It is used as a noninvasive approach to test for arterial disease. D-dimer (B) is a blood test that measures fibrin degradation products and can be used to effectively rule out deep vein thrombosis in patients who are low risk. In patients who are high risk, D-dimer is not recommended and imaging should be pursued. Lower extremity MRI (D) with or without contrast may be used as an effective imaging modality for deep vein thrombosis, however, it is not considered to be first-line because of high cost, patient anxiety, and contrast-related complications.

Deep Vein Thrombosis (DVT)

Patient with a history of smoking, long-distance travel, surgery, oral contraceptives use Complaining of unilateral leg edema, leg pain, tenderness, and warmth Physical exam may show a positive Homans sign Diagnosis is made by ultrasound; Gold standard is venography Most commonly caused by stasis, hypercoagulable state, trauma (Virchow triad) Treatment is anticoagulation Warfarin is contraindicated in pregnancy Comments: Pretest probability by modified Wells score Doppler ultrasound is the diagnostic test of choice in patients with suspected deep vein thrombosis. Deep vein thrombosis and pulmonary embolism can cause fever in the postoperative patient and are more frequent in patients who are debilitated either by chronic medical problems or by recent surgery. Typically, patients will develop a deep vein thrombosis more than one week after surgery and present with pain and swelling of the affected extremity. Symptoms are usually unilateral. Risk factors for development of deep vein thrombosis include: history of immobilization, recent surgery, obesity, malignancy, and use of oral contraceptives. Physical examination will reveal dilated superficial veins, with unilateral edema, warmth, tenderness, and erythema. Doppler ultrasound will demonstrate non-compressibility of the imaged vein, indicating a thrombus. Anticoagulation is the mainstay of therapy for patients with acute deep vein thrombosis. Prevention strategies following surgery include ambulation and use of sequential compression devices. Computed tomography of the lower extremity (A) can usually identify a thrombus, though computed tomography has not been rigorously studied for the diagnosis of lower extremity deep vein thrombosis. The major disadvantage of computed tomography is the potential for contrast-related complications or contraindications. Contrast venography of the lower extremity (B) is invasive, expensive, and technically difficult to perform and interpret. It is also associated with complications including contrast-induced allergic reactions and renal insufficiency. D-dimer (C), a degradation product of cross-linked fibrin, is elevated in nearly all patients with acute deep vein thrombosis, however, it is nonspecific since elevated levels are found in many other conditions including malignancy, sepsis, recent surgery, and pregnancy.

What is the difference between primary and secondary stones in the common bile duct (choledocholithiasis)?

Primary stones are gallstones that form directly in the common bile ducts. Secondary stones are the result of stones passing from the gallbladder through the cystic duct, which is more common.

What two mechanisms can trigger urticaria due to nonsteroidal anti-inflammatory drugs?

Pseudoallergic reaction secondary to underlying abnormalities in arachidonic metabolism and IgE-mediated allergic reaction.

What Gram-negative bacteria most commonly cause burn wound infection?

Pseudomonas aeruginosa.

Which of the treatment options for Graves' disease can cause worsening orbitopathy?

Radioiodine ablation.

What is the name of the classical operation for infantile hypertrophic pyloric stenosis?

Ramstedt pyloromyotomy.

Atrial Fibrillation

Rate will be irregular Rhythm will be irregular Notable feature: No defined P waves Treatment Unstable: cardioversion Stable: rate control is mainstay (diltiazem, metoprolol) Comments: > 48 hours - anticoagulate for 21 days prior to cardioversion Determine the need for anticoagulation by using CHA2DS2-vasc score Most common sustained dysrhythmia in adults Atrial fibrillation is the most common sustained dysrhythmia and puts a patient at increased risk for a thromboembolic event, heart failure, hospitalization, and death. It is more prevalent in men with increasing age and occurs frequently in patients who binge drink alcohol. Established risk factors for atrial fibrillation are family history and existing chronic cardiopulmonary or renal disease. The most common underlying conditions in patients with atrial fibrillation are hypertension and coronary artery disease. The dysrhythmia ranges from self-limiting and paroxysmal to chronic and longstanding. Patients commonly complain of tachycardia, palpitations, fatigue, dyspnea, dizziness, lightheadedness, or reduced exercise capacity, but patients may be asymptomatic. Electrocardiogram is necessary for diagnosis. Characteristic ECG findings are "irregularly irregular" ventricular depolarizations (RR intervals) and an absence of distinct P waves. An echocardiogram is indicated for patients with atrial fibrillation to rule out valvular heart disease and to evaluate the size and function of the atria and ventricles. Management must address thromboembolic event prevention and the choice between a rhythm control or rate control strategy. Cardioversion is indicated for some patients. Atrial flutter (B) is a cardiac dysrhythmia characterized by rapid, regular atrial depolarizations at a rate of about 300 beats per minute. Symptoms are very similar to those of atrial fibrillation, but an ECG would reveal the definitive diagnostic features. Premature atrial contractions (C) occur when a supraventricular ectopic focus, rather than the sinoatrial node, activates the atrial myocardium. This causes a shorter distance between the previous sinus beat and the premature beat than the interval between two sinus beats. Patients may complain of palpitations or may be asymptomatic. Ventricular flutter (D) is a rapid monomorphic ventricular tachycardia with a typical rate around 300 beats per minute; ECG does not reveal any evidence of atrial contractions due to the rapid rate. Ventricular flutter results in significant hemodynamic compromise and rapidly progresses to ventricular fibrillation.

What are the most common risk factors for development of cholelithiasis in the presentation of abdominal pain?

Remembered as the "4 Fs", risk factors include fat (BMI > 30), female, fertile (one or more children), and forty (age > 40 years). Cholelithiasis can occur in younger patients with a positive family history and therefore "family" would replace "forty".

What type of hernia has only a portion of intestinal wall involved?

Richter hernias involve only the antimesenteric wall of the intestine.

What are the most common presenting signs of colorectal cancer?

Right-sided colon cancer typically presents with bleeding ranging from a positive fecal occult blood test to hematochezia, whereas left-sided colon cancer presents with changes in bowel habits due to the stool being more formed in the right colon.

Colorectal Cancer Screening (AAFP)

Routine: Fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at 50 until 75 1 relative with colon cancer: colonoscopy at 40 or 10 years earlier than the age at which relative diagnosed Familial adenomatous polyposis: sigmoidoscopy at age 12, then every 1-2 years Colorectal cancer is a very common cancer with a high mortality rate. In the United States, colorectal cancer is the third most common type of cancer and approximately one in three people with colorectal cancer die from the disease. The cause of colorectal cancer is multifactorial with genetics, diet, environment and inflammatory disease in the gastrointestinal tract all playing a role in its development. Clinical manifestations include nonspecific findings such as fatigue and weight loss in the early stages of the disease. Patients may also be asymptomatic and the disease is only diagnosed through screening. Later signs and symptoms include iron deficiency anemia, abdominal pain, rectal bleeding, change in bowel habits, hepatomegaly, ascites or a palpable abdominal mass. Definitive treatment is surgical. Colorectal screening is recommended due to the benefit that results from removing premalignant adenomas as well as removal of localized cancer, which may prevent cancer-related death. Screening for average-risk individuals should be offered to everyone starting at 50 years of age and discontinued when the lifespan of the individual is less than 10 years. There are a number of tests used to screen for colorectal cancer including colonoscopy (A) and fecal occult blood testing (B). Other options include flexible sigmoidoscopy, fecal immunochemical testing, and computed tomography colonography. Due to the importance of encouraging more people to participate in colorectal cancer screening, the United States Preventive Services Task Force does not give preference to one method of screening over the others. Colorectal cancer screening recommendations for high-risk individuals (D) vary depending on the risk factor, but generally involve screening before age 50 years, screening more frequently or screening specifically with colonoscopy.

Hypovolemic Shock

Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery or increased oxygen consumption. Shock can be classified into four categories which are distributive, cardiogenic, obstructive, and hypovolemic. Hypovolemic shock results from low intravascular volume within the body. This can be further classified as hemorrhagic shock related to blood loss, or nonhemorrhagic shock related to fluid loss. The patient above had a high normal hemoglobin which would suggest the cause is related to fluid loss. During surgical procedures, insensible losses are increased and, if not adequately replaced, patients can develop tachycardia, hypotension, and hypovolemic shock as a result of fluid depletion. Treatment of hypovolemic shock depends on the source of volume loss. In nonhemorrhagic shock, treatment is replacement of volume with intravenous fluids, typically in the form of crystalloid solutions. Treatment of hemorrhagic shock is with blood products. Cardiogenic shock (A) is due to intracardiac causes of cardiac pump failure that result in reduced cardiac output and inadequate tissue perfusion. It may be cardiomyopathic or due to a dysrhythmia or a mechanical abnormality. Distributive shock (B) results from vasodilation of peripheral blood vessels. There are multiple causes of distributive shock with the most common being septic shock. Other causes include neurogenic shock, anaphylactic shock, drug or toxin-induced shock, and endocrine shock. Obstructive shock (D) is caused by poor cardiac pump function (typically poor right ventricular output) as a result of extracardiac factors that are either mechanical (reduced venous return to the heart leading to poor cardiac output) or related to the pulmonary vasculature. Mechanical causes include pericardial tamponade, tension pneumothorax, constrictive pericarditis, and restrictive cardiomyopathy. Pulmonary vascular causes are pulmonary embolism and pulmonary hypertension.

The Stanford system differentiates aortic dissection based on ascending, type A, and descending, type B. What is the DeBakey system based on?

Site of origin of the dissection.

Chest Pain

Stable angina - Chest discomfort precipitated by activity but symptoms abate after rest Unstable angina - Ischemic symptoms suggestive of an acute coronary syndrome with or without ECG changes indicative of ischemia NSTEMI - Troponin elevation, ECG typically with ST depressions STEMI - Troponin elevation, ECG shows ST-segment elevation Angina is chest pain or discomfort attributed to myocardial ischemia, which occurs when myocardial oxygen demand exceeds oxygen supply. Physical exertion, mental stress, tachycardia, hypertension, and ventricular hypertrophy increase oxygen demand, and can therefore lead to myocardial ischemia. Patients with angina classically present with chest pressure, tightness, or heaviness in the middle or left side of the chest that is preceded by exertion and relieved by rest. The pain is usually difficult to locate, and patients usually indicate a diffuse area of discomfort. Angina usually lasts for five to fifteen minutes. Pain that lasts longer than that may be indicative of acute coronary syndrome. An electrocardiogram obtained when chest discomfort is present may reveal J point or ST segment depression indicative of subendocardial ischemia, but the ECG may also be normal. A constant pain for days (A) is atypical of angina because the discomfort is relieved with rest due to decreased oxygen demand. Pain localized with one finger (B) is also atypical of angina. Angina is a referred pain due to a neural reflex pathway via the thoracic and cranial nerves, which results in a diffuse discomfort rather than a specific painful spot. Pleuritic pain (C) is a sharp chest pain that occurs during inhalation and exhalation. It can occur in acute pericarditis, pulmonary embolism, pneumothorax, pneumonia, pleuritis, or rib trauma.

What stage pressure-induced soft tissue injury is characterized by intact skin with non-blanchable erythema?

Stage 1.

Pressure Ulcer

Stage I,II, III, IV Patient with impaired mobility Most common location is by bony prominence Risk factors: Malnutrition Management includes prevention, frequent turning, skin assessment at admission pressure-induced soft tissue injuries are localized areas of skin or soft tissue damage due to unrelieved pressure from an underlying bony prominence, usually due to immobility. Commonly affected areas include the sacrum, calcaneus, and ischium. Risk factors in addition to immobility are malnutrition, decreased perfusion, and sensory loss. Patients may present with pain and possible fever if there is associated infection. Physical exam findings vary depending on the severity of the injury; they may range from non-blanching erythema of intact skin to full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone. Treatment includes pressure redistribution with more frequent position changes and proper support surfaces, local wound care, pain management, and, if present, treatment of associated infections. An abscess (A) is a collection of pus in the skin or subcutaneous space. Patients present with an erythematous, tender, fluctuant mass. Cellulitis (B) is a skin infection from bacterial entry through a break in the skin. Patients present with localized skin erythema, edema, tenderness, and fever. Hemangiomas (C) are benign superficial collections of blood that usually present in newborns and usually enlarge for the first six to 12 months and then undergo spontaneous involution. They are nontender.

What is the most common dermatological manifestation of chronic venous insufficiency?

Stasis dermatitis.

Which non-invasive H. pylori test is sensitive, specific, and cost-effective enough for routine use?

Stool antigen testing

Patients with recurrent upper urinary tract infections due to urease-producing organisms are at risk of developing what type of stone?

Struvite stone.

Transient Ischemic Attack

Transient episode of neurological dysfunction without acute infarction 10% of TIA patients will have a stroke within 90 days Low-risk TIA (ABCD2 score < 4) or moderate to major ischemic stroke (National Institutes of Health Stroke Scale (NIHSS) > 3) Treatment with aspirin alone High-risk TIA (ABCD2 score ≥ 4) or minor ischemic stroke (NIHSS score ≤ 3) Begin with dual antiplatelet therapy (DAPT) for 21 days using aspirin plus clopidogrel ABCD2 score: predicts likelihood of subsequent stroke within 2 days Transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. Large artery low-flow TIAs are commonly associated with a tightly stenotic atherosclerotic lesion at the internal carotid artery origin or in the intracranial portion of the internal carotid artery which causes impairment of collateral flow from the circle of Willis to the middle or anterior cerebral artery. Low-flow TIAs are usually short-lived (minutes) and are often recurrent. Symptoms often include hand, arm, and face numbness and weakness together. Additionally, when the dominant hemisphere is affected, aphasic syndromes can occur. When the nondominant hemisphere is affected, neglect can occur. Brain imaging with magnetic resonance imaging or CT is indicated in all patients with suspected TIA. Additional imaging should be obtained to evaluate for large vessel occlusive disease, which is often done alongside initial imaging. Options include computed tomography angiography (CTA), magnetic resonance angiography (MRA), carotid duplex ultrasonography, and transcranial Doppler ultrasonography. Treatment is primarily focused on resolving the symptomatic carotid atherosclerotic disease. In patients with recently (within the previous four to six months) symptomatic carotid stenosis of 70 to 99 percent who have a life expectancy of at least five years, a carotid endarterectomy (CEA) is recommended. For patients with recently symptomatic carotid stenosis of 70 to 99 percent, carotid artery stenting (CAS) is preferred if any of the following conditions are present: carotid lesion that is not suitable for surgical access, radiation-induced stenosis, or clinically significant cardiac, pulmonary, or other disease that increases the risk of anesthesia and surgery. For patients with symptomatic carotid stenosis that is less than 50 percent, medical management with antithrombotic medications is recommended. For patients undergoing CEA, low-dose aspirin treatment should be started prior to the procedure and is continued for at least three months after CEA is done. Carotid revascularization is not recommended for patients with chronic total occlusion of the carotid artery. Clopidogrel (B) is used in combination with aspirin for dual antiplatelet therapy and can be used after carotid revascularization for long-term antiplatelet therapy. Dual antiplatelet therapy (C) is used in patients prior to undergoing carotid artery stenting. It includes both aspirin and clopidogrel. Warfarin sodium (D) is not indicated as part of the management of carotid revascularization. It is often used to manage cardioembolic stroke due to atrial fibrillation.

Abnormal Liver Tests

Take thorough history Discuss social history (drugs, travel, alcohol use) Review medication lists Review exposure history Labs may help suggest cause of liver disease depending on pattern A fractionated bilirubin test is important to establish the diagnosis of jaundice and provide further information on the etiology. Jaundice is a clinical manifestation of hyperbilirubinemia, which causes a yellow discoloration of the skin and sclerae, and requires a systematic approach to assessment. A total bilirubin level of 3 mg/dL or higher is generally sufficient to cause jaundice. Bilirubin is a byproduct of heme metabolism, which occurs in three phases: prehepatic, intrahepatic, and posthepatic. Prehepatic processes, such as red cell breakdown, hemolysis, erythropoiesis, hematoma resorption, and myoglobin breakdown, often result in unconjugated bilirubin or indirect bilirubin. Unconjugated bilirubin is fat soluble, however, the majority is bound to albumin in plasma, which prevents diffusion across the blood-brain barrier and kernicterus (bilirubin encephalopathy) in newborns. In the hepatic phase of bilirubin metabolism, conjugated bilirubin, or direct bilirubin, is formed by enzymatic binding to a sugar making it water soluble. Intrahepatic, or hepatocellular, causes of hyperbilirubinemia may be due to a number of causes ranging from autoimmune, to infectious (hepatitis), genetic defects involving conjugation (Gilbert syndrome, Crigler-Najjar syndrome), or pharmacologic. The posthepatic phase involves excretion of conjugated bilirubin into bile. Posthepatic causes of hyperbilirubinemia are usually related to biliary obstruction (cholelithiasis, choledocholithiasis, Mirizzi syndrome), but can also be infectious (cholecystitis, cholangitis), or secondary to neoplasm in or around the biliary tract. Further assessment with sonography, computed tomography, liver biopsy, and additional lab tests (Coombs test, blood film) aid to further determine etiology and treatment. Abdominal CT (A) and abdominal ultrasound (B) may be useful to assess posthepatic and some causes of intrahepatic jaundice but do not confirm a diagnosis of jaundice. Additionally, imaging is of limited value in unconjugated hyperbilirubinemia. A complete blood count (D) is useful for the assessment of anemia and may reveal leukocytosis if infection is present but does not confirm jaundice.

Which location do pancreatic tumors most often arise?

The head of the pancreas.

Why is isometric handgrip when standing effective in reducing symptoms of orthostatic hypotension?

The maneuver minimizes drops in blood pressure and cardiac output.

How is the New York Heart Association functional class 1 defined?

The patient is asymptomatic during ordinary activities and experiences no activity limitations as a result of his or her heart failure.

What is the most common limb artery to be affected by acute arterial occlusion?

The superficial femoral artery.

How does surgical approach (e.g., laparoscopic vs. open surgery) affect the rate of bowel obstruction?

There is no difference in the incidence of bowel obstruction based on the procedural approach specifically related to colorectal surgery. Incisional hernia and stoma formation in those experiencing open surgery does increase the risk of developing bowel obstruction.

Which drug class is known to frequently interfere with 24-hour urine fractionated metanephrines and catecholamines?

Tricyclic antidepressants.

What are the three most common causes of massive hemoptysis?

Tuberculosis, bronchiectasis, and lung abscess.

Hiatus Hernia

Type I: sliding Type II-IV: paraesophageal May have reflux symptoms Diagnose via endoscopy/ imaging Manage reflux, consider surgery if symptoms are not well controlled Paraesophageal hiatus hernia is a type of hiatus hernia that is described as herniation of a portion of the gastric fundus into the thoracic cavity through the phrenoesophageal membrane, a fascial membrane that is responsible for anchoring the esophagus to the diaphragm. There is also thought to be an abnormal laxity of the ligaments responsible for anchoring the stomach either as a result or cause of these hernias. Paraesophageal hiatal hernias can be further classified based on whether the gastroesophageal (GE) junction has also become displaced, and how much of the gastric fundus is involved in the hernia sac. In its most severe form, other organs may also herniate through, including the small intestine, colon, spleen, or pancreas. Paraesophageal hiatal hernias can be asymptomatic, but may also be associated with epigastric or postprandial fullness, nausea, and vomiting. Less commonly, they can be associated with gastroesophageal reflux disease (GERD) symptoms. Diagnosis may be made incidentally and can be seen on a barium swallow study, upper endoscopy, or high-resolution manometry. Treatment of paraesophageal hiatal hernias varies depending on the severity and may range from symptomatic treatment to surgical repair. Esophageal motility disorder (A) encompasses a group of conditions related to abnormal esophageal movement or contractions. Patients range from asymptomatic to presenting with complaints of dysphagia, chest pain, heartburn or reflux symptoms. Diagnosis is made in part by excluding other causes of the symptoms such as GERD because symptoms do not always correlate with the degree of dysmotility. After other conditions are excluded, a specific esophageal motility disorder diagnosis is made with esophageal manometry testing. Patients do not typically present with abdominal fullness and a barium swallow study in a patient with an esophageal motility disorder would not show herniation of the stomach as in the case above. Esophagitis (B) is a nonspecific term used to describe inflammation of the esophagus which is most commonly associated with GERD. Esophagitis is diagnosed with visualization of the esophagus on upper endoscopy and would not be seen on a barium swallow study. Sliding hiatus hernia (D) is another type of hiatus hernia that is described as displacement of the gastroesophageal junction above the diaphragmatic hiatus by greater than 2 cm. By definition, this type of hernia differs from paraesophageal hiatal hernias in that the stomach remains in its position. Patients with sliding hiatal hernias are most often asymptomatic, however, if they do have symptoms they are typically related to GERD (heartburn, regurgitation, and dysphagia). Sliding hiatal hernias are most often identified incidentally during the workup of GERD. Treatment is aimed at addressing the symptoms with diet, lifestyle modifications, and antacids.

Pituitary Tumors

Visual sx (bitemporal hemianopia (or hemianopsia)) Prolactinoma: (most common), amenorrhea, impotence Growth hormone tumor: gigantism (children), acromegaly (adults) ACTH secreting TSH secreting Nonfunctioning Diminished temporal vision, or bitemporal hemianopsia, is the most common visual complaint in patients with a pituitary mass. Lactotroph adenomas (prolactinomas) are pituitary masses that can lead to hypersecretion of prolactin. Symptoms include amenorrhea, galactorrhea, and headaches. Due to the location of the mass at the sella turcica, the tumor applies pressure on the optic chiasm of the optic nerve resulting in loss of vision in the temporal visual fields. Diagnostic studies include MRI, CT scan, and evaluation of hormone levels. First line treatment of patients with hyperprolactinemia should include dopamine agonists (cabergoline and bromocriptine). In women, estrogen therapy can also be used due to the associated hypogonadism. If dopamine agonists are unsuccessful, transphenoidal resection of the pituitary tumor should be considered. Aniscoria (A) is incorrect. While it is commonly associated with ocular conditions and intraocular tumors, it can be found in intracranial tumors that apply pressure on the oculomotor nerve. Pituitary tumors most commonly affect the optic nerve. Torsional diplopia (C) is a visual disturbance associated with trochlear nerve palsy, resulting in a tilting of objects due to the effect on the superior oblique muscle. Unilateral spatial neglect (D) is a lack of awareness of one side of the field of vision, commonly seen in cerebrovascular accidents affecting the non-dominant hemisphere of the brain

Which vitamin improves iron absorption when consumed at the same time?

Vitamin C.

In cases of acute, nonperforated appendicitis, how soon should appendectomy be performed?

Within 12 hours.

When should a patient have a preoperative antibiotic administered?

Within one hour prior to the first incision.

What nonpharmacologic treatment options can improve postoperative nausea and vomiting?

acupuncture and isopropyl alcohol inhalation.

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