General Surgery

Small bowel obstruction

is most commonly caused by surgical adhesions. Patients will present with diffuse abdominal pain, nausea, and vomiting. While intravenous fluids and bowel rest are important in management, the most important step is decompressing the digestive system with the placement of a nasogastric tube. In the management of small bowel obstructions, rehydration with intravenous fluids is an important step. The vomiting and lack of intake by mouth cause the patient to develop a metabolic alkalosis along with volume depletion. Aside from surgical adhesions, the two next most common causes of small bowel obstruction are malignancy and hernia. Malignancy can be either primary, which is relatively uncommon, or metastatic. If a patient has history or evidence of a malignancy and a small bowel obstruction, metastatic disease must always be considered as a cause for the obstruction. Physical examination findings include abdominal distention, diffuse tenderness to palpation, and high-pitched, hyperactive bowel sounds. The best diagnostic test for a small bowel obstruction is upright and lateral abdominal radiographs. Upright radiograph will show air distended bowel loops that have a classic "stacked coin" appearance. Lateral radiograph will exhibit air fluid levels in the bowel loops. Small bowel obstruction is a blockage of the lumen of the small intestine. It is most commonly caused by postoperative adhesions, but may also be caused by hernias and tumors. It typically presents with abdominal pain and profuse vomiting. Examination may reveal high-pitched bowel sounds and abdominal distension, similar to that seen in sigmoid volvulus. Diagnosis is with upright plain radiograph demonstrating dilated loops of small bowel with air-fluid levels. CT scan is used if plain films are equivocal. Partial obstruction is managed expectantly with nasogastric decompression. Surgery is indicated for complete obstruction and if there is peritonitis or signs of bowel strangulation.

Rhabdomyolysis

is an acute necrosis of the skeletal muscle that occurs during crush injury, prolonged immobilization, drug toxicities, and hypothermia. It is associated with myoglobinuria and elevated creatine kinase (released from damaged muscle cells). Acute kidney injury (acute tubular necrosis) can result due to hypovolemia and the toxic effects of filtering excessive myoglobin. Hyperkalemia and hyperphosphatemia are also commonly associated with rhabdomyolysis, as high quantities of these electrolytes are released from the damaged myocytes. Treatment involves vigorous fluid resuscitation and correction of electrolyte abnormalities.

Legg-Calve-Perthes Disease

is an idiopathic avascular necrosis of the hip that affects children between the ages of 4 and 10. It often presents with insidious unilateral hip pain, restricted range of motion, and a limp. Diagnosis is clinical with support of radiographs and MRI. Treatment is conservative with activity restriction, stretching, and NSAIDs. Surgery is indicated if conservative treatment is unsuccessful. Legg-Calve-Perthes disease is a condition that occurs in young boys and is marked by avascular necrosis of the proximal femoral epiphysis. Legg-Calve-Perthes disease, or avascular necrosis of the proximal femoral epiphysis, is an uncommon condition of unknown etiology that occurs most often in obese boys between the ages of 4 and 10 years old. Unlike slipped capital femoral epiphysis, this condition presents only in a chronic fashion with no history of any trauma, even that of a minor nature. Patients present with a limp characterized as an antalgic gait, and with hip, groin, and/or anterior thigh pain. Physical examination will reveal limited passive motion of the affected hip joint, as well as limited abduction and internal rotation. Diagnosis can be made using hip radiographs, which will reveal increased density of the femoral head epiphysis and varying degrees of deformity of the femoral head. Treatment can either be supportive or surgical. In younger patients, and in those who maintain good alignment of the femoral head and neck, supportive therapy with anti-inflammatory medications and activity restriction is sufficient. In those patients with significant deformity or motion restriction, surgical intervention is necessary to correct the abnormality.

Otitis externa

is an infection of the external auditory canal. Risk factors include swimming, use of hearing aids (or other obstructive ear device), and a history of psoriasis. It is most commonly caused by Pseudomonas aeruginosa, Proteus mirabilis, and Aspergillus fumigatus. Patients present with pain in the ear canal. In patients with diabetes or those who are immunocompromised, malignant otitis externa can develop, which is a life-threatening osteomyelitis of the base of the skull (look for foul-smelling discharge from the ear). Ofloxacin is the treatment of choice for otitis externa. Topical treatment is recommended.

Bacterial tracheitis

is an infection of the soft tissues of the larynx. The most common etiologies are Staphylococcus aureus and Streptococcus pneumoniae. Patients commonly present with cough, stridor (inspiratory or expiratory), and respiratory distress. Drooling is uncommon. Direct laryngoscopy is necessary to confirm the diagnosis, demonstrating tracheal exudates and inflammation. Treatment is with airway management and antibiotics.

Systemic lupus erythematosus (SLE)

is an inflammatory autoimmune disorder that commonly affects multiple organ systems. SLE can also cause dysphagia due to esophageal hypomotility, stricture, esophageal spasm, or esophageal candidiasis. Patients would be unlikely to have iron-deficiency anemia. They can have anemia of chronic inflammation, with peripheral smear demonstrating normocytic, normochromic anemia. The mnemonic to remember is MD SOAP 'N HAIR: malar rash, discoid rash, serositis, oral ulcer, arthritis, photosensitivity, neurologic abnormality, hematologic abnormality, anti-nuclear antibody (ANA) positivity, immunologic abnormality, renal disease.

Anaplastic thyroid cancer

is an undifferentiated carcinoma. The typical presentation is an older patient with a long history of goiter who develops a rapid increase in thyroid size that is associated with vocal cord paralysis or dysphagia. From a prognosis standpoint, it is the worst thyroid cancer diagnosis, as it has a very poor prognosis. It is unresponsive to all treatment modalities and is commonly managed with palliative care.

Bladder cancer

is another common cause of gross hematuria, also occurring more commonly in men and in smokers. In contrast to renal cell carcinoma, patients with bladder cancer typically have painless hematuria. Remember that patients with renal cell carcinoma will have the triad of flank pain, hematuria, and palpable flank mass.

Delayed hemolytic transfusion reaction

is caused by a previous sensitization to red blood cell alloantigens (from pregnancy, previous blood transfusion, or transplantation). Patients develop a low-grade fever and a declining hematocrit two to ten days after receiving a blood transfusion.

Subdural hematoma

is characterized by the accumulation of blood beneath the dura mater but above the arachnoid. Usually resulting from rupture of the bridging veins that penetrate the dura mater, SDH is categorized according to location and size, and as acute (presenting within 2 days of injury), subacute (presenting 3 to 14 days post injury), or chronic (presenting more than 15 days after the injury, or other inciting event). A key risk factor for SDH is the use of blood-thinning agents, namely warfarin, which functions by inhibiting vitamin K-dependent coagulation factors. Given to many patients with atrial fibrillation (AF), warfarin must be dosed high enough to reduce the risk of embolism and stroke (the risks for which are particularly high in individuals above age 80 with AF), but not so high as to increase the risk of hemorrhage substantially. To optimize warfarin dosing accordingly, the international normalized ratio (INR) is monitored and should be maintained in the range of 2 to 3. The mechanism leading to SDH involves shearing of the bridging veins due to acceleration of brain tissue while the fixed dural structures remain stationary. While this normally requires high impact on the skull with rapid acceleration, the amount of impact required is usually lower in older people; this is because the bridging veins often are already stretched because of brain atrophy, so a chronic or subacute SDH can occur despite no history of major trauma. Presentation of a chronic SDH can include any of a variety of neurologic symptoms, including headache, altered consciousness, motor deficits (occurring on the side of the body contralateral to the injured side of the brain), cognitive dysfunction, memory loss, aphasia (impaired speech), personality change, and difficulties in balance. While it may be tempting to link a positive Romberg test with an earlier fall, balance disturbances can result from an SDH as easily as they can cause one.

Zollinger-Ellison syndrome

is characterized by the presence of a pancreatic gastrinoma and commonly presents as acid reflux that is refractory to adequate treatment. Patients typically have numerous shallow-based gastric and duodenal ulcers. Patients may also experience voluminous diarrhea secondary to the larger-than-normal volume of gastric secretion. Gastrinomas are the pathology that produce Zollinger-Ellison syndrome. Gastrinomas are most frequently found as pancreatic masses. These masses produce significant quantities of gastrin, which in turn stimulate gastric acid hypersecretion. This hypersecretion leads to peptic ulcer disease, which is classically not responsive to typical medical treatments for acid reflux. Patients typically develop multiple shallow-based gastric ulcers as well as shallow-based ulcers in the first two portions of the duodenum. Patients also experience voluminous diarrhea secondary to the increased volume of gastric secretions. Patients with multiple endocrine neoplasia, type 1 often have gastrinomas as part of their disease process. Gastrinomas are not often seen in other variations of multiple endocrine neoplasia. The gastrinomas that occur in patients with multiple endocrine neoplasia, type 1 are typically benign, while those that occur as an independent lesion are more often malignant. Patients with gastrinoma and subsequent peptic ulcer disease may experience complications, notably hemorrhage or perforation. Laboratory analysis will reveal a markedly elevated serum gastrin concentration in the setting of hypersecretion of gastric acid. Gastrinomas can be visualized on CT scan, and are usually seen in the pancreas. Treatment includes medical control of symptoms with histamine 2-receptor blockers and proton pump inhibitors and, ultimately, surgical resection of the gastrinoma.

Septic arthritis of the hip

is most commonly seen in children < 3 years of age. It is most often caused by Staphylococcus aureus infection. Look for an ill-appearing, febrile child with significant hip pain. Next step is intravenous antibiotics and drainage of the joint. If the diagnosis is uncertain, next step would be an ultrasound-guided needle aspiration of the hip joint and fluid culture.

Anaphylaxis

is most commonly seen in patients who are IgA deficient. Immediately (seconds to minutes) after receiving blood products, the patient will develop signs of anaphylaxis, including hypotension, angioedema, and respiratory distress. This is a life-threatening emergency.

Retropharyngeal abscess

is most commonly seen in young children. It has become less common due to antibiotic treatment of streptococcal pharyngitis. The abscess develops in the retropharyngeal space and presents with dysphagia, odynophagia, muffled voice, drooling, fever, globus sensation, tenderness when moving the larynx from side to side (the "rock" sign), and a cri du canard (quacking sound). Diagnosis is established based on clinical findings and plain radiography of the neck. Treatment is with high-dose antibiotics and immediate surgical drainage if the patient has respiratory compromise. If diagnosed early, antibiotics alone may prevent progression to airway compromise and preclude the need for surgical drainage of the abscess.

Transjugular intrahepatic portosystemic shunt (TIPS)

is the creation of a connection between the hepatic vein and intrahepatic portion of the portal vein using noninvasive, angiographic techniques. This channel decreases the resistance in the portal system in patients who have portal hypertension. TIPS is most commonly indicated for patients with portal hypertension who develop recurrent variceal bleeding despite optimal medical and endoscopic therapy, and for patients with refractory ascites and hepatorenal syndrome.

Retrograde urethrography

is the diagnostic test of choice to evaluate urethral injury. Posterior urethral injuries are most commonly caused by pelvic fractures sustained during a motor vehicle collision, especially those that allow for superior displacement of the bladder and prostate (e.g., fractures involving all four pubic rami). Male patients present with blood at the meatus of the penis, gross hematuria, inability to void, and ecchymoses over the pelvis and genitals. Suprapubic tenderness would not be present. Physical examination classically reveals a "high-riding" or absent prostate. A retrograde urethrogram is usually done prior to a cystogram when injury is suspected to avoid injuring the urethra further during the cystogram. However, a urethrogram cannot substitute for a cystogram and does not provide the diagnosis of bladder rupture.

Diverticulitis

is the inflammation of a colonic diverticulum, causing left lower quadrant pain and fevers. Treatment consists of two important components: fluids and antibiotics. Patients take a clear liquid diet to provide bowel rest for the inflamed colon while maintaining adequate hydration. Antibiotic therapy must consist of anaerobic and gram-negative coverage, which are the common enteric flora. The most common oral drugs used are metronidazole or amoxicillin clavulanate for anaerobic coverage and ciprofloxacin or trimethoprim-sulfamethoxazole for gram-negative coverage. Diverticulitis begins when patients form small outpouchings, or diverticula, off of their colon. Diverticula occur in patients who eat a typically low-fiber diet, as softer stool puts pressure on weak spots in the colonic lumen. While a high-fiber diet is important in the protection against forming diverticula, a high-fiber diet is generally avoided in the setting of diverticulitis. Bowel rest is required to allow proper healing of inflamed diverticula, and patients are encouraged to maintain a clear liquid diet in the initial days following diagnosis. Patients can be treated as an outpatient, as long as they can tolerate an adequate amount of fluids by mouth. Patients who are not tolerating fluids by mouth or who appear hemodynamically unstable require hospital admission and intravenous hydration and antibiotics, covering gram-negative and anaerobic bacteria. In patients with recurrent episodes of diverticulitis, surgical resection of the colonic segment containing the diverticula may eventually be necessary to decrease the risk of colonic perforation. Inflammation in an already weakened portion of the colonic wall predisposes patients with diverticulitis to perforation.

Osteosarcoma

is the most common primary bone malignancy, especially of children, but may occur in adults as well. These lesions commonly occur in the metaphysis of long bones, most notably in the distal femur and proximal humerus. Patients present with dull pain that sometimes may present after an injury. The pain may improve initially but will recur. Patients rarely have systemic symptoms, notably fever, chills, or weight loss. Physical examination will reveal a tender palpable soft tissue mass in the affected area. Radiograph will reveal a destructive bone lesion with reactive cortical bone growth and a classical "sunburst" appearance. Bone biopsy is required to confirm the diagnosis. MRIs are often done to further detail the mass and stage the lesion. Treatment requires chemotherapy and surgical excision. associated with RB1 gene= retinoblastoma, and the TP53 gen, which is linked to Li Fraumeni syndrome

Acute appendicitis

is the most common surgical complication of pregnancy. Acute appendicitis in a pregnant patient may cause new-onset right lower quadrant pain/tenderness, nausea, vomiting, diarrhea, rectal tenderness, fever and leukocytosis with a left shift. Pregnant patients are less likely than non-pregnant patients to have the classic presentation of appendicitis (periumbilical abdominal pain which migrates to the right lower quadrant, anorexia, nausea, and vomiting). Abdominal tenderness can be in the mid to upper right quadrant due to migration of the appendix during pregnancy. Leukocytosis can be a normal finding in pregnancy, potentially obscuring the diagnosis of appendicitis. Perforation of the appendix is more common in pregnant patients than nonpregnant patients due to delays in diagnosis and a general reluctance to operate on pregnant women. Definitive treatment with appendectomy should not be delayed. Abdominal CT scan is used to diagnose appendicitis in a non-pregnant patient for whom the diagnosis is uncertain. In pregnant patients, the fetal risks associated with radiation exposure limit its use especially during the period of organogenesis in the first trimester. It is a back-up diagnostic option in pregnant patients when ultrasound is non-diagnostic and MRI is not available.

Papillary thyroid cancer

is the most common type of thyroid cancer. It is a carcinoma involving the thyroid epithelial cells. It typically presents with a painless thyroid nodule discovered on physical examination. It presents less commonly with new-onset hoarseness or dysphagia. The most common risk factor is ionizing radiation as a child. Treatment is with thyroidectomy(Primary treatment), radioactive iodine, and thyroid-stimulating hormone (TSH) suppression therapy (levothyroxine). Prognosis is excellent.

Febrile nonhemolytic transfusion reaction

is the most common type of transfusion reaction. It is caused by cytokines that are generated during the storage of blood products. Look for a patient who develops fever, chills, and mild dyspnea one to six hours after receiving blood or platelet transfusion.

Intravenous pyelography

is used to identify renal trauma. It is most commonly used in cases of suspected ureteral injury when CT scan is non-diagnostic or the patient is too unstable to receive a CT scan. In cases of hemodynamic instability, however, the primary concern is getting the patient to the operating room for hemorrhage control as soon as possible. A patient with renal trauma will have both hematuria (gross or microscopic) and flank tenderness.

Chronic subdural hematoma

like acute subdural hematoma, occurs from the rupture of bridging veins between the dura and arachnoid membrane. Unlike patients with acute subdural hematoma, those with chronic subdural hematoma do not usually have a history of head trauma. This also occurs more frequently in elderly and alcoholic patients. Patients usually present with headache, confusion, seizure, or unilateral weakness. Diagnosis is made using CT scan, and will show a hypodense, cresent-shaped lesion that may contain small bright areas, representing more acute areas of bleeding. Treatment usually requires craniotomy for surgical drainage. typically occurs in elderly patients or alcoholics with no history of head trauma. These patients present with headache or change in mental status. The atrophy of brain tissue that occurs with age or alcohol abuse, allows for the stretching of bridging veins between the dura and arachnoid layers. These can tear easily and lead to hematoma formation with minimal trauma. Physical examination may reveal focal neurologic deficits and altered mental status. Diagnosis is made with CT scan of the head, which will reveal a crescent-shaped, hypodense lesion that is not maintained within cranial suture lines but will not cross the midline. Treatment often requires surgical evacuation of the hematoma.

Plummer-Vinson

is characterized by the triad of dysphagia, cervical esophageal web, and iron-deficiency anemia. Digging Deeper: Patients with Plummer-Vinson syndrome commonly present with symptoms and signs of iron-deficiency anemia (severe fatigue, atrophic glossitis, koilonychia [spoon-shaped nails]) and dysphagia (worse for solids). Diagnosis is confirmed by demonstration of iron-deficiency anemia (serum ferritin less than 12 ng/mL) in addition to visualization of esophageal webs (using barium esophagogram or more commonly videofluoroscopy or esophagogastroduodenoscopy). Treatment is with endoscopic dilation of the esophageal web and iron repletion (which can also improve the esophageal web). Patients with Plummer-Vinson syndrome have an increased risk for squamous cell carcinoma of the esophagus and should be considered for annual surveillance with upper endoscopy.

Activated charcoal

is contraindicated because it can infiltrate the mucosa and cause further mucosal damage in cases of caustic ingestion. Also, it can obscure endoscopic visualization of the damage. Activated charcoal is correct for the majority of toxic ingestions and is the preferred method of gastrointestinal decontamination in children and adults. The greatest benefit is seen if it is administered within 1 hour of toxic ingestion. It should not be used in patients who have ingested caustic substances or hydrocarbons.

Hyperkalemia

is defined as a potassium concentration >5 mEq/L. Common causes are hemolysis, rhabdomyolysis, crush injuries, hyperglycemia, and acidosis (potassium ions shift from intracellular space to extracellular space). Patients will have nausea, vomiting, diarrhea, and neuromuscular weakness (similar to hypokalemia). EKG changes can help differentiate hypo- from hyperkalemia. Look for peaked T waves, shortened QT interval (early), and lengthening of PR interval and QRS duration (late and more severe hyperkalemia).

Liver transplantation

is indicated in patients with hepatic cirrhosis who develops severe or intractable pruritus and/or a bilirubin higher than 10 mg/dL.

Bariatric surgeries fall into two main categories:

restrictive and restrictive-malabsorptive. The most common restrictive procedure is laparoscopic sleeve gastrectomy. The most common restrictive-malabsorptive procedure is the Roux-en-Y gastric bypass. These procedures produce an average weight loss of 30% to 35% total body weight. The restrictive-malabsorptive procedures require post-operative supplementation with vitamin D, calcium, folate, iron, and vitamin B12. The restrictive procedures alone do not. rapid weight loss , promotes gallstone formation

Injury to the recurrent laryngeal nerve is a test favorite complication of...

thyroidectomy. Knowing the anatomy of the neck, and the potential structures that could be damaged during a procedure are important for test day. Injury to one recurrent laryngeal nerve will leave the patient with a hoarse voice.

What is the best step in management in a patient with new-onset headache who has a history of cancer?

Magnetic resonance imaging of the head appear as peripheral, circumscribed, enhancing lesions surrounded by vasogenic edema on MRI Brain metastases are most commonly seen in patients with a history of non-small cell lung cancer, melanoma, breast cancer, renal cell carcinoma, or colorectal cancer. Patients most commonly present with headache. There are several headache red flags that suggest the possibility that there might be a brain tumor; the ones to know are new onset (especially if older than 50 years of age), change in pattern, fever, focal neurologic signs, headache in children or elderly, and/or headaches worsened with exertion or Valsalva maneuver. In patients with these red flags, or in patients with a history of cancer, the next best step is magnetic resonance imaging of the head.

Pneumomediastinum & pneumopericardium

tracheobronchial rupture can cause progressive dyspnea and hypoxemia, CXR typically demonstrates evidence of air leakage from the tracheobronchial tree

Osteoid Osteoma

Radiolucent lesion in cortex of proximal femur, nocturnal pain relieved by aspirin

The acute abdomen is defined by...

a constellation of symptoms including severe, diffuse abdominal pain, guarding, and abdominal rigidity (peritoneal signs). The next best step in management of a patient with an "acute abdomen" is exploratory laparotomy to diagnose and treat the underlying condition. In patients with an acute abdomen, it is unnecessary to establish a definitive diagnosis before proceeding to surgery. These patients are sick and require prompt surgical treatment to treat the underlying cause. The case vignette is classic for perforated peptic ulcer. Look for a patient with a history of NSAID use who develops sudden, severe upper abdominal pain and peritoneal signs (abdominal pain with movement, involuntary abdominal guarding, rigid abdomen).

The best initial treatment of stable patients with intussusception is

air enema (pneumatic decompression of the bowel). Intussusception is defined as a telescoping of the bowel into itself. It occurs most commonly near the ileocecal junction. It classically presents with the triad of abdominal pain, bloody "currant jelly" stool, and a palpable sausage-shaped abdominal mass on examination. In a patient with intussusception, the first step is to identify whether or not there is a high likelihood of bowel perforation (look for tense, erythematous abdomen, fever, tachycardia, and hypotension). If there is evidence of bowel perforation, proceed to surgery. If the patient is clinically stable, the next best step in management is to confirm the diagnosis with ultrasonography. After diagnosis, treatment involves intravenous fluids, nasogastric tube placement, and non-operative reduction (air enema). Intussusception is defined as a telescoping of the bowel into itself. It is the most common cause of bowel obstruction in patients between the ages of 6 and 36 months. It occurs most commonly near the ileocecal junction. It classically presents with the triad of abdominal pain, bloody "currant jelly" stool, and a palpable sausage-shaped abdominal mass on examination. Diagnosis is suggested by the clinical picture and supported with either ultrasound or fluoroscopy. Treatment involves reduction with contrast or air enema. Surgery with manual reduction or resection and primary anastomosis may be required if patient is acutely ill. Intussusception has been associated with adenovirus infection, rotavirus vaccination, cystic fibrosis, and Henoch-Schönlein purpura. In approximately 25% of cases, there is a pathological lead point that triggers intussusception, dragging a segment of bowel into a distal segment of bowel. A lead point may be a polyp, tumor, hematoma, vascular malformation, or Meckel diverticulum. Symptoms usually occur in 15 to 20 minute intervals, becoming more frequent and severe with time. However, the presentation may be nonspecific with symptoms such as unexplained lethargy and altered mental status, which may be confused with sepsis.

The treatment of choice for infected clenched fist injuries is...

antibiotics followed by surgical exploration, irrigation, and debridement of the wound. Clenched fist injuries are also known as "fight bites." They occur most frequently when someone punches another person in the face and cuts their knuckles on the teeth of the target. Patients commonly fabricate a story as to how they cut their knuckles. However, the injury pattern is unmistakable, demonstrating 3- to 5-mm lacerations over the dorsal metacarpophalangeal joints. Human bite wounds are polymicrobial and can become quickly infected if not treated expediently. If the wound appears infected (erythematous, draining purulent fluid), the treatment is with antibiotics, followed by surgical exploration, irrigation, and debridement. If the wound is not infected, treatment is with irrigation and antibiotics without wound closure (dressing the wound, but leaving it open to heal by secondary intention). Plain radiography of the hand should always be obtained in these patients to identify embedded teeth or hair. Tetanus booster vaccine and human tetanus immune globulin should also be given if the patient has had less than three doses of tetanus toxoid in the past. If the patient has had three or more doses of tetanus toxoid in the past, a tetanus toxoid-containing vaccine should only be given if the last dose was given five or more years ago (tetanus immune globulin is not needed in these patients).

Pleomorphic adenomas

are benign mixed tumors of the parotid gland, and are the most common benign tumor of the salivary gland. The vast majority of these tumors occur in the superficial parotid gland. Patients commonly present with facial fullness or a painless mass in front of the ear. Diagnosis is suggested by clinical features and fine needle aspiration of the gland. Definitive treatment is with superficial parotidectomy.

Thyroglossal duct cysts

are the most common congenital midline neck masses and typically present as painless masses that elevate with swallowing or protrusion of the tongue (pathognomonic sign). A thyroglossal duct cyst is a remnant of the thyroglossal duct tract, the pathway that carries the early thyroid precursor (ventral diverticulum of the foramen cecum) to the base of the neck. The diagnosis of thyroglossal duct cyst is suggested by clinical features including a painless, firm, midline neck mass just below the hyoid bone (most commonly) that elevates with swallowing or protrusion of the tongue (due to the embryologic connection to the base of the tongue). Diagnosis is confirmed with CT scan demonstrating a well-circumscribed, heterogeneous, cystic mass near the hyoid bone. The most common complication includes infection; however, thyroid cancer can also occur within the cyst. Definitive treatment is with the Sistrunk procedure, whereby the cyst and midportion of the hyoid bone are resected.

Acoustic neuromas (also known as vestibular schwannomas)

arise from the vestibulocochlear nerve (cranial nerve VIII). Patients commonly present with unilateral hearing loss and tinnitus. Patients may also present with unsteadiness while walking. Always suspect acoustic neuroma in a patient with unilateral sensorineural hearing loss and tinnitus. Get audiometry (best initial screening test) followed by an MRI. Magnetic resonance imaging is the diagnostic test of choice for acoustic neuroma.

In a patient with ischemic priapism, prompt initiation of intravenous fluids, oxygenation, and pain management should be performed. The next best step in management is...

aspiration and irrigation of the corpora cavernosa. Priapism is an erection lasting longer than 4 hours in the absence of sexual stimulation. It is a medical emergency and requires prompt treatment to prevent irreversible damage. Ischemic priapism must be differentiated from non-ischemic priapism by corpora cavernosa blood gas analysis or ultrasonography because they are managed differently. Ischemic priapism will reveal black blood upon aspiration of the corpora cavernosa as well as hypoxemia, hypercarbia, and acidosis. Non-ischemic priapism will reveal red blood with normal oxygen, carbon dioxide, and pH. In ischemic priapism, ultrasound will demonstrate minimal or absent blood flow in the cavernosal arteries. In non-ischemic priapism, ultrasound will demonstrate high blood flow. Ischemic priapism is most commonly due to impaired relaxation of the cavernosal smooth muscle. Sickle cell disease and intracavernosal injections of papaverine (to achieve erection, although it's less commonly seen today) are risk factors. Non-ischemic priapism is most commonly due to a fistula between the cavernosal artery and the corpus cavernosum. Intracavernosal injection of phenylephrine is the correct choice after aspiration and irrigation of the corpora cavernosa in a patient with continued priapism. Surgical shunt is correct as a last resort in patients with ischemic priapism who failed management with aspiration, irrigation, and intracavernosal injection of phenylephrine. A surgical fistula is created between the corpus cavernosum and the corpus spongiosum, glans, or a penile vein.

In patients with a body mass index (BMI)> 40 kg/m2 or a BMI >35 kg/m2 who have a comorbid disease (type 2 diabetes mellitus, hypertension, hyperlipidemia, and obstructive sleep apnea) in whom lifestyle changes have been ineffective at decreasing weight, the next best step in management is...

bariatric surgery. Since these patients are at high-risk of obesity related complications, weight loss is more urgent.

A patient with hemotympanum (blood behind the tympanic membrane) associated with head trauma, has a...

basilar skull fracture until proven otherwise. Basilar skull fractures occur as a result of trauma. The hallmark signs include periorbital ecchymosis ("Raccoon eyes"), retroauricular or mastoid ecchymosis ("Battle sign"), and hemotympanum (dark purple or blue discoloration of the tympanic membrane). Raccoon eyes and battle sign typically occur one to three days after the traumatic event. Dura mater tears are often associated with basilar skull fractures and present with clear or blood-tinged cerebrospinal fluid leakage from the ear (otorrhea) or nose (rhinorrhea). Diagnosis is confirmed with non-contrast CT scan of the head. Basilar skull fractures are often managed conservatively with observation alone. CSF leakage from the ear typically stops without surgical intervention. CSF leakage from the nose more often requires surgical intervention to repair the torn dura mater. Prophylactic antibiotics are not recommended for the prevention of meningitis, as they may select for resistant organisms.

The canalith repositioning maneuver (Epley maneuver) is the treatment of choice for patients with...

benign paroxysmal positional vertigo. Benign paroxysmal positional vertigo is a condition that is caused by canalithiasis (calcium carbonate crystals) in the posterior semicircular canal that stimulates the hair cells when the head moves quickly (e.g., rolling over in bed), producing the classic symptoms of a spinning sensation (vertigo) that typically lasts less than 1 minute at a time. The symptoms wax and wane over time. Associated nausea and vomiting can also occur. With clinical suspicion, the diagnostic test of choice is the Dix-Hallpike maneuver. This is performed by having the patient lay down with the head to one side and then the patient is quickly assisted into the upright seated position. If there is horizontal nystagmus and the symptoms of vertigo are reproduced, the test is considered positive. The treatment of choice is the canalith repositioning maneuver (Epley maneuver), which is used to reposition the canaliths to prevent stimulation of the hair cells within the semicircular canals.

Acute epididymitis

can occur in adolescent or adult males, and typically is caused by pathogens of sexual origin or from pathogens of the urinary tract. Patients most typically present with unilateral testicular and epididymal swelling, as well as erythema of the surrounding scrotal skin. Patients often complain of fever and will also often have leukocytosis. Physical examination will reveal unilateral scrotal edema with associated erythema and tenderness to palpation. Ultrasound examination, which may be used to differentiate this condition from testicular torsion, will often show increased blood flow to the affected epididymis, as opposed to the decreased blood flow typically seen in testicular torsion. Treatment requires oral antibiotic therapy and outpatient management in most cases. In patients with high fevers or who appear to be hemodynamically unstable, hospital admission and intravenous antibiotic therapy may be necessary. Surgical intervention is rarely required for the management of acute epididymitis.

Inhaled glucocorticoid is the next best step in treatment for a patient with

chronic obstructive pulmonary disease who is already taking a long-acting bronchodilator.

Hypokalemia

classically presents with lower muscle weakness, cramps, ileus, and constipation. On electrocardiogram (EKG), look for T wave flattening, U waves after the T waves (most commonly in V4-V6), and ST segment depression and prolonged QT interval. Hypokalemia is defined as a potassium concentration <3.5 mEq/L. It is commonly caused by lower gastrointestinal fluid losses (diarrhea, vomiting, high ostomy output, high nasogastric tube output) or excessive diuresis. Early identification and potassium repletion is important because severe hypokalemia (<2.5 mEq/L) can cause cardiac arrhythmias, diaphragmatic weakness, paralysis, and rhabdomyolysis.

A pituitary adenoma that is less than 10 mm in size is

classified as a microadenoma. When asymptomatic and discovered incidentally on brain imaging, a pituitary microadenoma may be followed with prolactin levels which are part of the endocrine panel. The term concussion refers to a minor traumatic brain injury (TBI) resulting from rapid acceleration of the head when the head or another part of the body is jolted hard. Minor headaches and confusion are common symptoms of concussion and usually resolve within days to weeks, so long as the patient rests and avoids subsequent head injury. Derived from adenohypophyseal cells, pituitary adenomas are fairly common and account for 15% of primary intracranial neoplasia that are diagnosed. They are called microadenomas if under 10 mm in size, and macroadenomas if 10 mm or larger. Generally, only macroadenomas cause symptoms. In such cases, symptoms are related to pressure within the pituitary gland itself and on the nearby optic chiasm. Within the pituitary gland, the macroadenoma may produce excessive amounts of the hormone that is supposed to be produced by the particular cells that gave rise to it, while cells producing other pituitary hormones are destroyed. This leads to various endocrine pathologies, depending on which pituitary hormones are being secreted in excess and which are not being secreted at all. The workup for this begins with endocrine function panel and, in some cases, may require a biopsy. Pressure on the optic chiasm leads to visual field pathologies that should be assessed by a neuro-ophthalmologist. The visual field pathology most typical of a pituitary adenoma is bitemporal hemianopsia, the loss of the outer halves of both sides of the visual field. Additionally, headache is a very common symptom of pituitary macroadenoma. Tumor size should be monitored with serial MRI, but this is not indicated for incidental microadenomas. Often, symptomatic pituitary adenomas can be treated medically via administration of hormones and hormone antagonists. If these treatments fail, if patients cannot tolerate them or become refractory, or if the adenoma is very large, more aggressive treatments are indicated; the adenoma can be destroyed with radiation or it can be removed surgically.

Developmental Dysplasia of the hip (DDH)

encompasses a range of conditions in which there is abnormal development of the hip joint (proximal femur and acetabulum). The result is hip joint instability. Risk factors include female sex, age, breech positioning, and family history of DDH. Diagnosis is often made on routine physical examination with the Barlow maneuver (hip is dislocatable with posterolateral pressure) and the Ortolani maneuver (femoral head is reducible during abduction). In patients who have started to walk, DDH often presents with a painless limp. Palpable instability of the hip will likely be absent (starting around 4 months), as the muscles begin to reinforce and accommodate the displaced joint. Therefore, after 4 months of age, confirmation with radiographs is required. Treatment with fixation harness (Pavlik) or casting in infants is commonly effective. Significant deformity in older children can require surgery.

The next best step in management in a patient who ingested a strong acid or alkali solution is...

esophagogastroduodenoscopy (upper endoscopy) to evaluate the extent of esophageal and gastric damage.

The next best step in management of a pregnant patient with signs of acute appendicitis is...

graded compression ultrasonography.

Suspect bladder injury following a blunt force accident if a patient has

gross hematuria and suprapubic tenderness. The test of choice to confirm a diagnosis of traumatic bladder rupture is retrograde cystography. While a retrograde urethrogram would usually be done prior to cystography to rule out urethral injury before doing cystography, a retrograde urethrogram does not allow for assessment of the bladder and cannot substitute for cystography to make the diagnosis. Intraperitoneal bladder rupture is most commonly caused by blunt abdominal trauma (usually from the seatbelt) in motor vehicle accidents. The most commonly injured area is the dome of the bladder. Extraperitoneal rupture occurs with pelvic fractures where shearing forces cause tears of the anterior bladder wall. Patients with bladder rupture present with suprapubic pain and gross hematuria. The diagnostic test of choice is retrograde cystography, where the bladder is filled with contrast and multiple films are taken to look for leaks.

The risk of venous thromboembolism (VTE) in patients undergoing surgery depends on numerous factors...

including increasing age, prior VTE in patient or family, malignancy, obesity, inherited or acquired hypercoagulability, and medical comorbidities including heart disease and infection. Patients with risk factors for VTE (older than 75, history of VTE, malignancy, fractures of the pelvis, hip, or leg) should receive low-molecular-weight heparin (LMWH) or unfractionated heparin. It is also indicated in patients undergoing high-risk surgeries (total hip replacement and knee replacement). For these patients, LMWH is generally preferred to unfractionated heparin due to proven efficacy; however, unfractionated heparin should be used in patients with renal disease because it is primarily metabolized in the liver and blood vessel endothelium, versus low-molecular-weight heparin, which is cleared primarily by the kidney. This can lead to increased accumulation of low-molecular-weight heparin in patients with chronic kidney disease, and an increased risk of major bleeding.

Medullary thyroid cancer

involves the parafollicular cells (C cells) of the thyroid. Medullary carcinomas predominantly secrete calcitonin and are more aggressive than papillary and follicular thyroid cancer. There is an association with multiple endocrine neoplasia (MEN) type 2a and 2b. The medullary thyroid cancer associated with MEN 2b is the most aggressive form, and that which is associated with MEN 2a is the least aggressive form. All patients with medullary thyroid cancer should be screened for the other endocrinopathies associated with MEN 2a (pheochromocytoma and hyperparathyroidism) and MEN 2b (pheochromocytoma and numerous mucosal neuromas). Treatment is with thyroidectomy and lymph node dissection. Patients should be monitored for recurrence of disease with measurements of serum calcitonin or carcinoembryonic antigen (CEA).

Transient Synovitis of the Hip

is a benign inflammatory condition that affects the hip joint. Look for unilateral hip or groin pain in an otherwise well-appearing afebrile child who had a recent upper respiratory tract infection. Diagnosis is clinical, and septic arthritis of the hip must be excluded. If white blood cells are < 12,000 cells/microliter, erythrocyte sedimentation rate is < 20 mm/hour, or C-reactive protein is < 2 mg/dL, septic arthritis is highly unlikely and the patient can be treated conservatively with non-steroidal anti-inflammatory drugs.

An epidural hematoma

is a collection of blood between the dura and the skull. It is caused by a forceful impact to the head which lacerates an artery in the dura. The classic clinical picture is loss of consciousness followed by a lucid interval. This is then followed by sudden decline in neurologic status and coma, as the brain begins to herniate. Diagnosis is made with computed tomography (CT) scan of the head and treatment involves either craniotomy with hemorrhage evacuation or conservative medical management if the hematoma is small in size. Epidural hematomas are most common in the adolescent age group, because the dura is not as firmly attached to the skull as in adults. Disruption of the middle meningeal artery by the temporal bone is the classic case. The sudden onset of decreased consciousness and coma is the result of the brain beginning to herniate as the intracerebral pressure increases. Uncal herniation is most commonly seen and results in ipsilateral cranial nerve III palsy and contralateral hemiparesis. Diagnosis is made with CT scan which demonstrates a lens-shaped hematoma. Prompt diagnosis and treatment often results in an excellent prognosis.

Renal cell carcinoma

is a solid renal parenchymal tumor that most commonly presents with the classic triad of flank pain, hematuria, and palpable flank mass. It appears more commonly in men and in cigarette smokers. Pathologically, the most common type of renal cell carcinoma is clear cell carcinoma. In general, paraneoplastic syndromes occur frequently in the setting of renal cell carcinoma. Common paraneoplastic manifestations include hypertension, hypercalcemia, and erythrocytosis. Patients may present with symptoms of metastasis, notably bone pain or dyspnea. Physical examination will classically reveal the presence of a palpable flank mass, though this is not always the case in practice. Diagnosis can be made using CT scan, which will reveal the presence of a renal mass. Treatment of locally-contained lesions is achieved by surgical radical nephrectomy.

Acute otitis media (AOM)

is a common problem seen in childhood. It is a bacterial infection of the middle ear that is usually precipitated by a blockage of the Eustachian tube during an acute upper respiratory tract infection. The most common pathogens causing AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Diagnosis is clinical, requiring bulging of the tympanic membrane, erythema of the tympanic membrane, and signs of middle ear effusion (bubbles or an air-fluid level behind the tympanic membrane, decreased mobility of the tympanic membrane, or white/yellow discoloration of the tympanic membrane). Children often pull on the affected ear(s) or on their hair. The pneumococcal conjugate vaccination helps prevent the development of AOM. Treatment: Amoxicillin is the first-line treatment for acute otitis media in patients without an allergy to beta-lactam antibiotics. Amoxicillin/clavulanate is the recommended treatment for patients who have failed amoxicillin therapy, and in patients who have received amoxicillin in the past 30 days, or who have concomitant purulent conjunctivitis (often caused by beta-lactam-resistant Haemophilus influenzae). Tympanocentesis is the next best step in a patient diagnosed with acute otitis media who has failed previous antibiotic therapy, is immunocompromised, or appears septic (hypotensive, tachycardic, and high fever). Tympanocentesis is used to determine the bacteriology and antibiotic susceptibility of the involved organism to better select the appropriate antibiotic treatment.

Mediastinitis

is a complication of cardiovascular surgery characterized by infection of the deep tissues; it classically present with systemic symptoms, chest pain, chest wall edema/crepitus, and purulent discharge. Any patient with copious drainage from the sternal wound should undergo chest imaging. Radiographic findings include fluid collections or pneumomediastinum Requires drainage, surgical debridement, and prolonged antibiotic therapy

Chronic obstructive pulmonary disease (COPD)

is a condition that is characterized by progressive airflow obstruction. Patients commonly present with dyspnea (especially with exertion but can occur at rest in severe cases). Chronic bronchitis and emphysema fall under the umbrella of COPD, and patients typically have symptoms of both conditions. Chronic bronchitis is a clinical diagnosis (daily productive cough for greater than 3 months over 2 consecutive years) and emphysema is a pathologic diagnosis (destruction and dilatation of air spaces in the lungs). Classically, chronic bronchitis presents with chronic cough productive of mucopurulent sputum; dyspnea is often mild. Patients are typically overweight and cyanotic ("blue bloaters"); peripheral edema is also common. Patients with emphysema present with severe dyspnea; cough is uncommon. Patients are typically thin ("pink puffers") due to the amount of energy it takes to breathe using accessory muscles of respiration. Initial treatment for COPD is with smoking cessation and short-acting bronchodilator (e.g., albuterol). A long-acting bronchodilator is added as symptoms progress. If patients remain symptomatic despite a long-acting bronchodilator, inhaled corticosteroid therapy should be initiated.

Branchial cleft cyst

is a congenital neck mass that is caused by failure of the pharyngobranchial ducts to obliterate during embryogenesis. They often present when they become infected (typically after upper respiratory tract infections). Location is usually at the anterior border of the sternocleidomastoid muscle. Patients should be treated with antibiotics (if infected), followed by surgical removal of the cyst and tract.

Dermoid cyst

is a congenital, midline neck mass that arises from epithelium that has been entrapped within deeper tissue during embryogenesis. They can also be seen at other sites in the head and neck (face and scalp). When they arise in the neck, they can be easily confused with thyroglossal duct cysts. The way to differentiate them is that dermoid cysts are typically more superficial and do not move with swallowing or protrusion of the tongue. Treatment is with surgical excision. is a type of epidermoid tumor that can occur anywhere in the central nervous system. They arise from retained epithelial cells during closure of the neural tube. They also commonly contain sebaceous glands and hair follicles. They most commonly arise in the fourth ventricle and most commonly present with headache. Rupture of the cyst can be fatal and presents with headache and seizures, most commonly. MRI demonstrates a hypodense lesion. Treatment is with surgical resection.

Prune-belly syndrome, also known as Eagle-Barret syndrome,

is a disorder most commonly seen in male infants that is characterized by abnormally weak abdominal muscles, dilated ureters and bladder, and bilateral undescended testes. Pulmonary hypoplasia is a common comorbidity and is the major cause of mortality in these patients. is a disorder most commonly seen in male infants that is characterized by abnormally weak abdominal muscles, dilated ureters and bladder, and bilateral undescended testes. Physical examination reveals a wrinkled abdominal wall (prune-like). Pulmonary hypoplasia is a common comorbidity and is the major cause of mortality in these patients. Urethral dilatation can cause vesicoureteral reflux and predispose to urinary tract infections.

Slipped Capital Femoral Epiphysis (SCFE)

is a disorder that is characterized by a displaced femoral head that leads to a change in hip function. It is often due to the rapid bone growth at the growth plate (causing instability) associated with mechanical stress. Look for an obese afebrile male between the ages of 11 and 13 who develops a limp that is associated with aching pain of the hip, thigh, or knee. Diagnosis is confirmed with plain radiograph using the frog-leg lateral view. Treatment is with surgery.

Carotid artery dissection

is a division of the wall of the internal carotid artery with the formation of a false lumen and an intramural hematoma. It is most commonly a spontaneous event that occurs with little to no provocation. It can also develop in the setting of minor/major trauma. The classic presentation is unilateral headache and/or neck pain associated with an ipsilateral Horner's syndrome (ptosis, miosis, +/- anhidrosis). The Horner's syndrome is caused by stretching of the sympathetic nerve fibers that surround the internal carotid artery. Endothelial disruption can activate the clotting cascade causing thrombus formation with the potential for distal emobilization. Cerebrovascular ischemia seen in carotid artery dissections most commonly involves the middle cerebral artery circulation, resulting in contralateral hemiplegia (due to infarction of the posterior limb of the internal capsule) and sensory deficits that typically occur hours to days later. Patients with suspected carotid artery dissection should receive magnetic resonance angiography to confirm the diagnosis.

Achalasia

is a form of dysphagia, caused by absence of esophageal peristalsis in conjunction with increased lower esophageal sphincter tone. Diagnosis is made using a combination of barium esophagogram and esophageal manometry. The mainstay of treatment is pneumatic esophageal dilation. Achalasia presents as dysphagia to both solids and liquids. Patients often adapt their diet over time, and may not experience significant weight loss the way a patient with esophageal cancer would. They may also experience regurgitation of undigested food after meals. The exact cause for the development of achalasia is unknown, but it is characterized by the absence of esophageal peristalsis and increased tone of the lower esophageal sphincter. Once diagnosis is made, using barium esophagogram and esophageal manometry, there are few treatment options that are useful. The mainstay of treatment over time has been pneumatic esophageal dilation. This consists of endoscopic use of a balloon to dilate the lower esophageal sphincter. This is by far the most effective treatment modality available, and can be repeated over time as necessary. The most common complication of the procedure is development of gastroesophageal reflux, and the most dangerous complication, which rarely occurs, is esophageal perforation.

Chondrosarcoma

is a malignancy of cartilage cells and occurs most often in adulthood, in individuals in their 50s and 60s. It rarely occurs in children. They occur most often in the knees, pelvis, and shoulders. Radiographs will reveal cortical thickening and cartilage deposition. Biopsy of the lesion is used in combination with history and radiographic images to make a diagnosis. Treatment requires surgical excision and chemotherapy.

Temporal arteritis

is a medical emergency and management should begin with high-dose intravenous corticosteroids in any patient with visual loss suspected of having temporal arteritis. Look for jaw claudication, shoulder pain, throbbing headache, and an elevated ESR. Temporal arteritis is an inflammation of the external carotid artery system. It is most commonly seen in patients with polymyalgia rheumatica (shoulder and hip girdle pain) who are > 50 years of age. The etiology of visual loss in cases of temporal arteritis is transient ischemia to the retina, choroid, or optic nerve. Immediate high-dose intravenous glucocorticoids in patients with visual loss and suspected temporal arteritis helps prevent worsening of visual symptoms or loss of vision in the contralateral eye. Oral corticosteroids are the treatment of choice in patients with temporal arteritis who do not have visual symptoms.

Neoplastic epidural spinal cord compression

is a medical emergency and treatment must be initiated promptly to give the patient the best chance at neurologic recovery. Clues to the diagnosis are a history of cancer, weeks of back pain, plus new lower extremity weakness and loss of sensation in the saddle region of the legs. Bowel and bladder incontinence is an ominous late finding and does not occur in most patients. In patients with neurologic findings, the first step in management is intravenous high-dose corticosteroids (e.g., dexamethasone) to both relieve pain and reduce inflammation. Epidural spinal cord compression is most commonly a complication of metastatic cancer to the spine. Patients present with back pain that precedes the development of lower extremity weakness or paraplegia by several weeks. Patients also typically have pain that radiates to the thoracic dermatomes, commonly described as wrapping around the torso. Decreased sensation in the lower extremities, particularly the saddle area, is also common. Bowel incontinence and urinary retention are ominous late manifestations. Initial management is with high-dose corticosteroids (e.g., dexamethasone) to reduce the inflammation and edema, thereby, decreasing compression on the spinal cord. Definitive management with either surgical decompression and/or external beam radiation therapy would then follow. Due to the urgency of the matter, patients need to be given dexamethasone immediately - this is a relatively easy and noninvasive management that could make the difference between permanent paralysis and returning function of the lower extremities.

Cholestyramine

is a non-absorbable resin that binds bile acids in the intestinal tract. It is considered a first-line treatment for patients with moderate to severe pruritus due to cholestasis. However, in a patient with other complications of cirrhosis (e.g., spontaneous bacterial peritonitis or chronic fatigue and weakness), liver transplantation would be the most appropriate management.

Phentermine

is a pharmacologic treatment (catecholamine) for obesity. It is a stimulant that helps to suppress appetite, leading to weight loss. It is a drug that should be used only in the short-term (less than 12 months). It is contraindicated in patients with hypertension, hyperthyroidism, tachyarrhythmia, and glaucoma as this medicine will worsen these conditions.

Orlistat

is a pharmacologic treatment for obesity. It alters the digestion of fat by inhibiting pancreatic lipases, causing increased excretion of fecal fat. Orlistat causes modest reductions in body weight (3-4 kg). It is recommended for patients with BMI >30 kg/m2 or in patients with BMI >27 kg/m2 who have comorbid disease. This would be the correct choice in an overweight patient with a BMI <35 kg/m2 who has been unsuccessful with lifestyle changes. Side effects are predominately gastrointestinal complaints, including diarrhea and anal leakage.

Scleroderma

is a progressive disease that is characterized by systemic sclerosis and vasculopathy. Scleroderma can affect any portion of the gastrointestinal system, with the esophagus being the most commonly involved site. Patients can develop gastrointestinal reflux disease, stricture formation (secondary to reflux esophagitis), and dysfunctional esophageal motility. Manometry is the test of choice to evaluate for esophageal motility problems in these patients. Radiographic examination with barium swallow is helpful to identify esophageal stricture.

Bilateral recurrent laryngeal nerve injury

is a serious complication of thyroidectomy. As opposed to the hoarse voice that can occur with injury to a unilateral recurrent laryngeal nerve, bilateral injury can lead to vocal cord paralysis, inability to protect one's airway, and potential need for tracheostomy.

Follicular thyroid cancer

is a well-differentiated cancer. It usually presents as a cold thyroid nodule. Diagnosis cannot be made with fine-needle aspiration (FNA) because it can't distinguish benign adenoma from carcinoma. If FNA demonstrates a follicular tumor, the patient should undergo thyroidectomy so that evidence of capsular or vascular invasion can be determined (malignant). Treatment is with surgery, radioactive iodine, and TSH suppression therapy (levothyroxine).

Patent urachus

is an abnormal communication between the bladder and the umbilicus. Look for urine leaking from the umbilicus and recurrent urinary tract infections.

Abdominal aortic aneurysms (AAA)

occur when there is a weakness in the aortic wall, causing it to expand. They are significantly more common in males than in females, and occur more often in individuals with vascular risk factors, primarily hypertension, hyperlipidemia, atherosclerotic disease, cigarette smoking, or diabetes mellitus. Patients may be asymptomatic or may present with a pulsatile mass in the abdomen. Patients rarely experience pain or weakness, but if the aneurysm ruptures, it can be life threatening. The diagnostic test of choice is abdominal ultrasound. Contrast CT scan can also be used to make the diagnosis, but is more costly and exposes the patient to radiation (unlike ultrasound). If an aneurysm is 5.5 cm or larger, surgical intervention should be planned, as there is a greater risk for spontaneous rupture at this size. The only reason to avoid surgery at this point is if an individual's life expectancy is less than two years. The other indications for surgery are if the aneurysm grows at a rate of greater than 0.5 cm per six months. If a AAA is smaller than 5.5 cm, it should be monitored at regular intervals. AAAs between 4.0 and 5.4 cm should be monitored every 6 to 12 months, while aneurysms smaller than 4.0 cm should be monitored every two to three years. Endovascular surgical exploration would be appropriate if an aneurysm was suspected to be ruptured, or was identified to be larger than 5.5 cm and needed to be repaired. Suspect a ruptured aneurysm in a patient with severe abdominal pain and severe hemodynamic instability, notably severe hypotension and tachycardia in the absence of trauma.

Acute subdural hematoma

occurs after head trauma, when the bridging veins between the dura and arachnoid layer of the meninges are ruptured. Elderly and alcoholic patients are at increased risk for this type of injury, as they suffer brain atrophy, causing the bridging veins to stretch. Acute subdural hematoma occurs from head trauma, either in acceleration-deceleration injury, or in elderly or alcoholic patients with atrophied brain tissue after a minor fall. Patients do not typically lose consciousness after the initial trauma, but will present with symptoms of increased intracranial pressure, notably headache, nausea, and vomiting, or with focal neurologic deficit. Diagnosis is made using CT scan, and typically shows a hyperintense, crescent-shaped lesion that will not cross the midline because of the falx. Acute subdural hematomas are not confined by cranial suture lines. Treatment can either be supportive, waiting for the hematoma to resorb on its own, or surgical, with evacuation of the hematoma. Those patients with rapidly expanding hematoma or those with focal neurologic deficits require surgical evacuation.

Peripheral artery disease

occurs as a result of atherosclerosis of the arteries of the lower extremity. Patients often present with claudication, or lower extremity exertional pain that is relieved by rest. The method of choice for diagnosing peripheral artery disease is the ankle-brachial index. The ankle-brachial index is the test of choice for diagnosing peripheral artery disease. It involves measuring the systolic arterial pressure of the brachial artery, as well as the systolic arterial pressure at the ankle using a Doppler device. The Doppler device allows one to assess the flow of blood through the arteries, and can even be used to find the locations of occlusion. A normal Doppler arterial wave is triphasic, and as artherosclerosis causes the arteries to become less compliant, the wave becomes bi, or even mono, phasic. An ankle-brachial index of 1.1-0.9 is normal. Anything less than that indicates some level of peripheral artery disease, with the lower the number, the more severe disease. An ankle-brachial index as low as 0.3 indicates patients who have tissue loss or may even be experiencing pain at rest.

Thyroid lymphoma

occurs in older patients with a history of chronic lymphocytic thyroiditis. Patients typically present with a rapidly enlarging mass associated with a history of goiter or a diagnosis of Hashimoto's thyroiditis. Patients can also experience neck pressure, hoarseness, and dysphagia. Definitive diagnosis requires open biopsy and tissue analysis demonstrating sheets of B-cell lymphocytes. Treatment is with radiation and chemotherapy. Surgery is not indicated.

Intraparenchymal hemorrhage

occurs most often in patients with head trauma or in patients that have arteriovenous malformations. These hemorrhages can occur anywhere within the brain parenchyma, and in trauma patients may present after a period of 24 hours in the area of previous contusion. Patients often present with focal neurologic deficit. Diagnosis is made using CT scan, which will show an area of intensity within the brain parenchyma. Patients with significant neurologic deficit or mass effect require surgical decompression of the hemorrhage.

Testicular torsion

occurs when the spermatic cord becomes twisted within the tunica vaginalis, and leads to sudden onset of severe testicular pain and swelling. In contrast to patients with acute epididymitis, patients will not often have a fever or leukocytosis. Physical examination will reveal significant scrotal edema, a high-riding testicle that is tender to palpation, and loss of the typically brisk cremasteric reflex. Treatment requires emergent surgical intervention to detorse the affected testicle and restore its blood supply. Testicular torsion occurs when the spermatic cord becomes twisted within the tunica vaginalis, and occurs most often in children and adolescent males, although it can occur at any age. Patients present with sudden onset of severe testicular pain followed by significant scrotal swelling. Patients will often report a distinct moment in time when the pain began, signifying the acute nature of the process. Physical examination will reveal significant scrotal edema, a high-riding testicle that is tender to palpation and elevation, and a loss of the usually brisk cremasteric reflex. If clinical presentation and physical examination are insufficient to make the diagnosis, ultrasound examination can be used. Ultrasound examination will reveal decreased blood flow to the affected testicle compared to the unaffected testicle. Treatment hinges on prompt surgical intervention to detorse the testis. This is crucial to restore blood supply to the testicle and to reduce the risk of necrosis. If surgical intervention occurs within 6 hours of the onset of symptoms, the affected testicle can often be preserved. Surgical intervention should never be delayed for ultrasound, however, to reduce the risk of necrosis. Along with detorsion, surgical intervention also includes fixation of both testes to the dartos fascia to reduce the risk of subsequent torsion. Orchiectomy is only performed when necrosis of the torsed testicle has occurred.

Needle aspiration is the treatment of choice for a...

peritonsillar abscess in cooperative patients. Incision and drainage is an acceptable treatment option for patients who cannot cooperate with needle aspiration. Tonsillectomy may be required in patients who have had recurrent peritonsillar abscesses or abscesses that have failed to resolve with other treatments. Peritonsillar abscess (PTA) is an infection of the space between the palatine tonsil and the parapharyngeal muscles. There is a collection of purulent material in the space which is commonly polymicrobial. Patients present with fever, drooling, trismus, odynophagia, and dysphagia. Physical examination reveals medial and lateral displacement of the palatine tonsil on the affected side and deviation of the uvula away from the site of infection. Patients also commonly have a muffled or "hot potato" voice. Treatment is with needle aspiration of the abscess. Diagnosis is clinical. An important global concept on the examination is to understand that all skin and soft tissue collections of purulent material within an abscess cavity will require drainage to cure.

Skeletal surveys are indicated in children less than 2 years of age for whom

physical abuse is suspected, children less than 5 years of age who have a questionable orthopedic fracture, and older children who cannot give a reliable history (e.g., intellectually impaired child). There are several orthopedic fractures that are particularly concerning for child abuse. These include metaphyseal corner fractures, fractures involving the sternum, scapula, or vertebral spinous processes, bilateral long bone fractures, skull fractures in a patient who is less than 18 months old, and rib fractures. Fractures that are less likely to be associated with child abuse include isolated long bone fractures, fractures of the clavicle, and skull fractures in patients greater than 18 months of age. Child abuse should also be suspected if there is inconsistency in the story, injuries that are attributed to siblings, injuries that are inconsistent with the mechanism of injury or developmental age of the child, and injuries that are unwitnessed.

Hepatic cirrhosis is the end result of ...

repeated hepatocellular injury that leads to hepatic fibrosis. The most common causes of hepatic cirrhosis are alcoholic liver disease and chronic hepatitis C infection. Liver transplantation is the only curative option. There are several indications for liver transplantation. Patients with liver cirrhosis who develop cholestatic liver disease as evidenced by severe or intractable pruritus, bilirubin higher than 10 mg/dL, progressive bone disease, or recurrent ascending cholangitis are candidates for liver transplantation. Also, patients with a serum albumin less than 3 g/dL, or a prothrombin time more than three seconds above the upper limit of normal, are also candidates for liver transplantation. Patients who develop complications of hepatic cirrhosis including severe or recurrent hepatic encephalopathy, refractory ascites, recurrent spontaneous bacterial peritonitis, recurrent esophageal variceal bleeding, severe chronic fatigue and weakness, worsening malnutrition, hepatorenal syndrome, or evidence of new small hepatocellular carcinoma are also candidates for liver transplantation. Absolute contraindications to liver transplantation include malignancy (other than small hepatocellular carcinoma), advanced cardiovascular or pulmonary disease (except for hepatopulmonary syndrome), and sepsis. Patients with hepatitis C infection should be treated with interferon and ribavirin to achieve a low viral load before transplantation is performed (to reduce the likelihood of infecting the transplanted liver).

Acute bacterial endocarditis

requires prompt and prolonged appropriate intravenous antibiotic therapy to eradicate the offending pathogen and decrease the risk of permanent damage to the affected cardiac valve. As the most common cause of bacterial endocarditis (particularly in intravenous drug users) is Staphylococcus aureus, the most appropriate treatment is intravenous vancomycin to cover for methicillin-resistant species, given daily over as many as 4 weeks. Bacterial endocarditis occurs as a result of bacteremia in patients who often have underlying heart valve damage, notably rheumatic heart disease. Intravenous drug users are at a particularly increased risk of developing bacterial endocarditis, most often of the tricuspid valve. The most common pathogen to cause bacterial endocarditis, particularly in intravenous drug users, is Staphylococcus aureus; but bacterial endocarditis can also be caused by other organisms, notably Streptococcus viridans and Enterococcus. Patients commonly present with fever, malaise, myalgias, new-onset heart murmur, and often some characteristic skin lesions. Patients may develop petechiae, 1-2 mm non-blanching red macules, which typically occur on the distal extremities. Splinter hemorrhages may occur under the finger and toenails, and Osler nodes, tender subcutaneous papules, can occur on the pads of the fingers. Janeway lesions, nontender erythematous macules, may occur on the soles of the feet and palms of the hands. Roth spots, or retinal hemorrhages, may be seen on funduscopic examination. The heart murmur associated with bacterial endocarditis is typically a systolic ejection murmur heard most prominently on the area of the chest wall associated with the affected heart valve. Diagnosis is made using a combination of history, physical examination, laboratory abnormalities, and the presence of vegetations on a heart valve, all comprised to make the Duke criteria. The most important diagnostic tests used in the diagnosis of bacterial endocarditis are blood culture and echocardiography. Blood cultures establish the presence of bacteremia with the offending pathogen and direct antibiotic therapy. Echocardiography is used to directly visualize the vegetation on the affected heart valve. Treatment requires appropriately-directed intravenous antibiotic therapy, typically for 4 weeks or more. It is important to treat bacterial endocarditis with an antibiotic effective against the offending pathogen, to ensure eradication of the offending pathogen.

An acute hemolytic transfusion reaction is seen in patients...

several minutes to hours after receiving an ABO incompatible blood transfusion. Look for hypotension, tachycardia, fever, flank pain, and myoglobinuria. A common complication of acute hemolytic transfusion reaction is disseminated intravascular coagulation (DIC). A common presenting sign is oozing of blood from venipuncture sites. An acute hemolytic transfusion reaction is caused by ABO blood incompatibility, most often the result of a clerical or procedural error, wherein the patient was given the wrong blood type. It results in destruction of host red blood cells due to preformed antibodies from the recipient blood. On labs, look for evidence of hemolysis (elevated indirect bilirubin, elevated lactate dehydrogenase, and decreased serum haptoglobin). Direct antiglobulin test (Coombs) will be positive (detects antibodies or complement bound to red blood cells). DIC is a relatively common complication of acute hemolytic reaction. DIC is a consumptive coagulopathy, producing both thrombosis and hemorrhage. The most common clinical signs are bleeding, kidney failure, and liver dysfunction.

Hemangiomas are the most common

solid benign liver lesions. They are often found incidentally on other imaging studies. Ultrasound studies will reveal a nonspecific, well-demarcated homogeneous mass, but this in itself is not diagnostic of hemangioma. MRI with contrast will reveal a smooth, well-demarcated homogeneous mass, with low intensity on T1 images and characteristically hyperintense on T2 images. Contrast added to the MRI will highlight the peripheral enhancement characteristic of hemangiomas. Hepatic hemangiomas are considered congenital malformations consisting of collections of endothelial-lined vascular caverns within fibrous tissue that grow over time. These lesions are most commonly found in the right lobe of the liver. They are found most commonly in women, and are often discovered incidentally on imaging studies done for other reasons. The most common symptom caused by hemangiomas is pain; however, this only occurs when lesions become large, often more than 8 cm. Right upper quadrant ultrasound will reveal a well-demarcated homogeneous hyperechoic mass; however, this configuration is not specific for hemangioma and further imaging is required. While both CT scan with contrast and MRI with contrast (choice C) can identify characteristics of hepatic hemangioma, MRI is a more specific test.

The most common caustic ingestion is with...

strong alkali solution (sodium or potassium hydroxide). Ingestions are commonly accidental in children under the age of 5 years, and intentional (often due to suicide attempt) in adolescents and adults. Alkali ingestions tend to damage the esophageal mucosa more than the stomach or duodenum, whereas acid ingestion preferentially damages the gastric mucosa. Strong alkali causes liquefactive necrosis. Patients present variably depending upon the amount of caustic ingestion, the length of time elapsed since ingestion, and the associated degree of gastrointestinal damage that has taken place. Common complaints include epigastric or retrosternal burning pain, dysphagia/odynophagia, and increased salivation. Patients can also have vomiting, hematemesis, or peritoneal signs (severe, diffuse abdominal pain, guarding, and abdominal rigidity) if there is gastrointestinal perforation. Shock can result if there is massive hemorrhage due to blood vessel erosion by the caustic solution. The next best step in management is upper endoscopy to identify the damage. Contraindications to upper endoscopy include hemodynamic instability, signs and symptoms of perforation or severe respiratory distress, or significant oropharyngeal edema. Emergent surgery is indicated if there is peritonitis, mediastinitis (severe retrosternal or back pain), or clinical signs of perforation (e.g., crepitus in the neck).

Squamous cell carcinoma of the esophagus

was once the most common primary malignancy of the esophagus (but being overtaken by adenocarcinoma). It has a strong correlation with cigarette smoking and alcohol abuse. Patients present with progressive dysphagia, often first having issues with bulky solids and progress to liquid dysphagia as the mass grows to further occlude the esophagus. Patients exhibit significant weight loss and oral intake decreases more and more over time. Patients may also complain of odynophagia or regurgitation. Barium esophagogram will show an obstructing mass, most commonly in the mid-esophagus. CT scan of the chest can give a more detailed characterization of the mass, and upper endoscopy will provide direct visualization and allow for biopsy. Treatment options consist of surgical resection, esophageal stent placement, chemotherapy, and radiation. If the cancer has become too advanced, these interventions may be palliative but can provide an increased quality of life for the patient. can also present with dysphagia, most commonly described as solid foods "sticking" in the throat. Patients also commonly present with weight loss and iron-deficiency anemia (due to chronic bleeding). The risk factors to know include smoking and alcohol consumption. Upper endoscopy is the first diagnostic step.

Bilateral external branch of the superior laryngeal nerve injury

will cause symptoms similar to that of unilateral external branch of the superior laryngeal nerve injury. Patients will experience increased pitch of the voice and difficulty raising the volume of their voice, not the hoarseness or vocal cord paralysis experienced with recurrent laryngeal nerve injury.

Unilateral external branch of the superior laryngeal nerve injury

will cause the patient to lose the higher ranges of vocal pitch, unlike the hoarseness caused by the injury to the recurrent laryngeal nerve. Patients with this injury may also have difficulty raising the volume of their voice. The external branch of the superior laryngeal nerve innervates the cricothyroid muscle.

Gastroschisis

would be correct if this patient had a congenital abdominal wall defect with extruding viscera that had no protective covering, located to the right of the umbilicus. The bowel appears thickened, matted, and edematous. Diagnosis is made during prenatal ultrasound or clinically at birth. is an extrusion of abdominal viscera (most commonly) and/or pelvic organs from an abdominal wall defect located to the right of the umbilicus. Gastroschisis is a congenital abdominal wall defect that occurs to the right of the umbilicus that allows for the extrusion of small bowel, large bowel, stomach and/or reproductive organs outside of the body. These organs do not have a translucent protective covering, as is seen with omphalocele. Diagnosis is made clinically at birth or by prenatal ultrasound demonstrating extrusion of abdominal viscera (and occasionally reproductive organs) from a defect in the abdominal wall. Treatment is with urgent surgery to reduce the extruded organ(s) back into the abdomen or pelvis. A staged approach to reduction with a "silo" device is most commonly used to slowly reduce the contents back into the abdominal cavity as edema subsides. Once reduction is achieved (5 to 7 days), the defect is closed.

Umbilical hernia

would be correct if this patient had a protrusion of abdominal contents through a central defect in the linea alba. The protrusion is typically asymptomatic and is covered by cutaneous tissue. Incarceration of bowel contents is a rare complication. Small umbical hernias (< 1 cm) generally close spontaneously by 4 years of age.

Post-transfusion purpura

would be correct in the patient who develops thrombocytopenia seven to ten days after transfusion of a platelet-containing product. Look for mucosal bleeding (epistaxis), petechiae, and superficial ecchymoses.