Surgery - NMS/Pestana/pretest
A newborn baby is found on physical exam to have an imperforate anus.
"VACTER": vertebral, anal, cardiac, TE and renal/radial look for a fistula nearby (to the vagina in little girls, to the perineum in little boys), which will help determine the level of the blind pouch
Fluid resusc in burns. How much? Monitor what? when would you give extra fluid? when does rehab start?
4cc per Kg. of body weight per percentage of BSA burned (up to 50%). Give LR. First 1/2 in 8 hrs, second 1/2 in next 16. CVP and hourly urinary output. Keep the former below 15 or 20, aim for 1 cc per Kg body weight per hour for the latter Circumstances where additional fluid is needed (aiming for urinary output of two cc per Kg per hour, instead of one): electrical burns, patients who get escharotomy. day one.
A patient with progressive jaundice which has been present for four weeks is found to have a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase was twice normal value couple of weeks ago, and now is about six times the upper limit of normal.
A "generic" example of obstructive jaundice. Next move? - Sonogram, looking for dilated intrahepatic ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a finding of gallstones.
An 18 year old woman has a 4cm, fluctuant round mass on the side of her neck, just beneath and in front of the sternomastoid. She reports that it has been there at least 10 years, although she thinks that it has become somewhat larger in the last year or two. A CT scan shows the mass to be cystic.
A branchial cleft cyst. Management: Elective surgical removal.
A 23 year old lady describes exquisite pain with defecation and blood streaks on the outside of the stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even "spread her cheeks" to look at the anus for fear of precipitating the pain.
A classical description of anal fissure. Management: cancer still has to be ruled out. Examination under anesthesia is the correct answer. If you are asked what to do next, the currently favored surgical approach is a lateral internal sphincterotomy.
A 59 year old man arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on her hair and a robe over her nightgown. He has abdominal pain that began about one hour ago, and is now generalized, constant and extremely severe. He lies motionless in the stretcher, is diaphoretic and has shallow, rapid breathing. His abdomen is rigid, very tender to deep palpation, and has guarding and rebound tenderness in all quadrants.
Acute abdomen. He has generalized acute peritonitis. Management: The acute abdomen does not need a precise diagnosis to proceed with surgical exploration. Lower lobe pneumonia and myocardial infarction to have to be ruled out with chest X-Ray and EKG, and it would be nice to have a normal amylase...but the best answer is prompt ex lap.
A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began three days ago. The pain was colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. She has temperature spikes to 104 and 105, with chills. Her WBC is 22, 000, with a shift to the left. Her bilirubin is 5 and she has an alkaline phosphatase of 2,000 (about 20 times normal). She has had episodes of colicky pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.
Acute ascending cholangitis. Further test?: The diagnosis is already clear. Sonogram might confirm dilated ducts. Management: This is an emergency decompression of the biliary tract. To achieve the latter ERCP is the first choice, but PTC (percutaneous transhepatic cholangiogram) is another option.
A 43 year old obese lady, mother of six children, has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky at first, radiated to the right shoulder and around towards the back, and was accompanied by nausea and vomiting. For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the past, brought about by ingestion of fatty food, but they all had been of brief duration and relented spontaneously or with anticholinergic medications.
Acute cholecystitis. How is the diagnosis made? - Sonogram should be the first choice. If equivocal, an "HIDA" scan (radionuclide excretion scan). Medical management in most cases will "cool down" the process. Surgery will follow.
A 72 year old man has a history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best heard at the second intercostal space and along the left sternal border.
Aortic stenosis. Management: echocardiogram. Surgical valvular replacement is indicated if there is a gradient of more than 50 mm.Hg., or at the first indication of congestive heart failure, angina or syncope.
On the first post-operative day after an open cholecystectomy, a patient has a temperature of 101.
Atelectasis. Management: Listen to the chest, chest X-Ray, encourage deep breathing and coughing.
During a school physical exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited.
Atrial septal defect. Management: Echocardiography to establish the diagnosis. Surgical closure of the defect. Closure by way of catheterization is still experimental.
A 54 year old obese man gives a history of burning retrosternal pain and "heartburn" that is brought about by bending over, wearing tight clothing or lying flat in bed at night. He gets symptomatic relief from antiacids, but the disease process seems to be progressing since it started several years ago. Endoscopy shows severe peptic esophagitis and Barrett's esophagus.
Barrett's is premalignant. Surgery would be recommended, probably a Nissen Fundoplication.
An 8 week old baby is brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses, serology is negative for hepatitis and sweat test is normal.
Biliary atresia (narrowing of bile duct). Management: HIDA scan, percutaneous liver biopsy and exploratory laparotomy.
A 24 year old man spends the night cruising bars and drinking heavily. In the wee hours of the morning he is quite drunk and starts vomiting repeatedly. Eventually he has a particularly violent episode of vomiting and he feels a very severe, wrenching epigastric and low sternal pain of sudden onset. On arrival at the E.R. one hour later he still has the pain, he is diaphoretic, has fever and leukocytosis and looks quite ill.
Boerhave's syndrome. How do you confirm the diagnosis? - gastrograffin/barium swallow Treatment: Emergency surgical repair. Prognosis depends on time elapsed between perforation and treatment.
A 23 year old man develops severe headache, seizures and projectile vomiting over a period of two weeks. He has low grade fever, and was recently treated for acute otitis media and mastoiditis.
Brain abscess. Signs and symptoms suggestive of brain tumor that develop in a couple of weeks with fever and an obvious source on infection, spell out abscess. Management: CT to see it. Then the abscess has to be resected by the neurosurgeons.
A 56 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times the upper limit of normal. He has lost 20 pounds over the past two months, and has a persistent, nagging mild pain deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of the pancreas. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder.
Cancer of the had of the pancreas. Terrible prognosis. How do clinch the diagnosis?: CAT scan -which may show the mass in the head of the pancreas; then ERCP -which will probably show obstruction of both common duct and pancreatic duct.
A 72 year old man has lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several months, and of vague epigastric discomfort for the past 3 weeks.
Cancer of the stomach. How do you diagnose it? - Endoscopy and biopsies.
middle aged lady, multiple episodes of sinusitis. six days ago you started her on decongestants and oral antibiotics for what you diagnoses as frontal and ethmoid sinusitis. Now she tells you over the phone that ever since she woke up this morning, she has been seeing double.
Cavernous sinus thrombosis, or orbital cellulitis. emergency. She needs immediate hospitalization, high dose IV antibiotic treatment and surgical drainage of the paranasal sinuses or the orbit. CT is needed too.
A 72 year old man has been known for years to have a wide pulse pressure and a blowing, high- pitched, diastolic heart murmur best heard at the second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation.
Chronic aortic insufficiency. Management: Aortic valve replacement.
A newborn baby is noted to be tachypneic, cyanotic and grunting. The abdomen is scaphoid and there are bowel sounds heard over the left chest. An X-Ray confirms that there is bowel in the left thorax. Shortly thereafter, the baby develops significant hypoxia and acidosis.
Congenital diaphragmatic hernia. Management: The main problem is the hypoplastic lung. It is better to wait 36 to 48 hours to do surgery to allow transition from fetal circulation to newborn circulation. Meanwhile keep the kid alive with endotracheal intubation, hyperventilation (careful not to blow up the other lung), sedation and NG suction.
A 12 year old boy is short for his age, has bitemporal hemianopsia and has a calcified lesion above the sella in X-Rays of the head.
Craniopharyngioma. Get MRI to dx then do pituitary surgery.
A 6 year old child has a mushy, fluid filled mass at the base of the neck, that has been noted for several years. The mass is about 6 cm. in diameter, occupies most of the supraclavicular area and seems by physical exam to go deeper into the neck and chest.
Cystic hygroma. Management: Get a CT scan to see how deep this thing goes. They can extend down into the chest and mediastinum. Surgical removal will eventually be done.
A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to it's present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
Cystosarcoma Phyllodes (has leaf like projections). Large, bulky masses/cysts Management: Tissue diagnosis is needed (some of these become outright malignant sarcomas), given the size best done with core or incisional biopsy. Margin-free resection will follow.
A 74 year old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after it's onset. His blood pressure is 220/100, he has unequal pulses in the upper extremities and he has a wide mediastinum on chest X-Ray. Electrocardiogram and cardiac enzymes show that he does not have a myocardial infarction.
Dissecting aneurysm of the thoracic aorta. Management: Arteriogram first, but the forces that dissected the vessel plus the force of the dye injection could further shear the aorta, thus study is done with beta blockers or IV nitrates to lower blood pressure. If the aneurysm is in the ascending aorta, emergency surgery will be done. If it is in the descending, intensive therapy (in the ICU) for HTN.
An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation.
Fibroadenoma. How is the diagnosis made? - FNA (fine needle aspirate for cytology). If not, core biopsy or if it is the only choice, excisional biopsy. Reassurance alone would not be a good choice! Mammogram alone is not the way to go, either. Mammogram is primarily for screening, not for diagnosis. At age 18, mammograms are useless (breast too dense). Sonogram is the only imaging technique suitable for the very young breast.
A 56 year old alcoholic male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight thorugh to the back, and is extremely severe. He has a serum amylase of 800, WBC of 18,000 blood glucose of 150, serum calcium of 6.5 and a hematocrit of 40. He is given IV fluids and kept NPO with NG sution. By the next morning, his hematocrit has dropped to 30 the serum calcium has remained below 7 in spite of calcium administration, his BUN has gone up to 32 and he has developed metabolic acidosis and a low arterial PO2.
He has hemorrhagic pancreatitis. In fact, he is in deep trouble, with at least eight of Ranson's criteria predicting 80 to 100% mortality. What do you do? Very intensive support will be needed, but death commonly occurs from pancreatic abscesses that need to be drained as soon as they appear. Thus serial CT scans will be required.
54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with the colicky pain, and X- Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen. Six hours after being hospitalized and placed on nasogastric suction and I.V. fluids, he develops fever, leukocytosis, abdominal tenderness and rebound tenderness.
He has strangulated obstruction: i.e., a loop of bowel is dying -or dead- from compression of the mesenteric blood supply. What does he need? - Emergency surgery.
A two month old baby boy is brought in because of chronic constipation. The kid has abdominal distention, and plain X-Rays show gas in dilated loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool and flatus, with remarkable improvement of the distention.
Hirschsprungs's disease (aganglionic megacolon) How do you diagnose it? - Barium enema will define the normal-looking aganglionic distal colon and the abnormal-looking thickness biopsy of the rectal mucosa.
Your distant cousins that you have not seen for years visit you and brag about their beautiful baby with "huge, shiny eyes". They show you a picture that indeed proves their assertion (or the exam booklet will have such a picture).
Huge eyes in babies can be congenital glaucoma. Tearing will indeed make them shine all the time. If undiagnosed, blindness will ensue. tx is surgery.
A 45 year old lady comes to your office for a "regular checkup". On repeated determinations you confirm the fact that she is hypertensive. When she was in your office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium concentration of 2.1 mEq/L. The lady is taking no medications of any kind.
Hyperaldosteronism. Possibly adenoma. How is the diagnosis made? - aldosterone and renin levels. If confirmatory (aldo high, renin low) proceed with determinations lying down and sitting up, to differentiate hyperplasia (not surgical) from adenoma (surgical). Treat the first with aldactone. (hyperplasia will inc aldo levels with standing from sitting.) Pursue the second with imaging studies (CT scan or MRI) and surgery.
A 3 week old first-born, full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in it, follows each feeding and the baby is hungry and eager to eat again after he vomits. He looks somewhat dehydrated and has visible gastric peristaltic waves and a palpable "olive size" mass in the right upper quadrant.
Hypertrophic pyloric stenosis. Management: Check electrolytes: hypokalemic, hypochloremic metabolic alkalosis may have developed. Correct it, rehydrate and do Ramsted Pyloromyotomy.
A 7 year old boy passes a large bloody bowel movement.
In this age group, Meckel's diverticulum leads the list. How is the diagnosis made? - By radioactively labeled technetium scan (not the one that tags reds cells, but the one that identifies gastric mucosa).
A 55 year old man has an upper G.I. endoscopy done as an outpatient to check on the progress of medical therapy for gastric ulcer. Six hours after the procedure, he returns complaining of severe, constant, retrosternal pain that began shortly after he went home. He looks prostrate, very ill, is diaphoretic, has a temperature of 104 and respiratory rate of 30.
Instrumental perforation of the esophagus. How do you confirm the diagnosis? - gastrograffin/barium swallow Treatment: Emergency surgical repair. Prognosis depends on time elapsed between perforation and treatment.
A patient involved in a high speed automobile collision has multiple injuries, including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that there is gross hematuria, and retrograde cystogram is normal.
Lower injuries have been ruled out. The blood has to be coming from the kidneys. How is the diagnosis made? - CT scan. Further management: the rule is that traumatic hematuria does not need surgery even if the kidney is smashed. They operate only if the renal pedicle is avulsed or the patient is exsanguinating.
A 45 year old lady with a history of a recent tooth infection shows up with a huge, hot, red, tender, fluctuant mass occupying the left lower side of her face and upper neck, including the underside of the mouth. The mass pushes up the floor of the mouth on that side. She is febrile.
Ludwigs' Angina. (An abscess of the floor of the mouth) Management: Tracheostomy and incision drainage of the abscess.
A 66 year old man presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder. Except for the dilated ducts, CT scan is unremarkable. ERCP shows a narrow area in the distal common duct, and a normal pancreatic duct.
Malignant, but lucky: probably cholangiocarcinoma at the lower end of the common duct. He could be cured with a pancreatoduodenectomy (Whipple operation). Next move: get brushings of the common duct for cytological diagnosis.
A 66 year old man presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times the upper limit of normal. He has lost 10 pounds over the past two months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin walled gallbladder.
Malignant, silent, obstructive jaundice. A distended gallbladder is an ominous sign: when stones are the source of the problem, the gallbladder is thick-walled, non-pliable. What do you do next? - You already have the sonogram. Next move is CAT scan and ERCP.
While trying to hook up illegally to cable TV, an unfortunate man comes in contact with a high tension electrical power line. He has an entrance burn wound in the upper outer thigh and an exit burn lower down on the same side.
Management: electrical burns are always much bigger than they appear to be. There is deep tissue destruction. The patient will require extensive surgical debridement, but there is also another item (more likely to be the point of the question): Myoglobinemia, leading to myoglobinuria and to renal failure. Patient needs lots of IV fluids, diuretics (osmotic if given that choice i.e. Mannitol), perhaps alkalinization of the urine.
A 54 year old man has had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate abdominal distention, and has not had a bowel movement or passed any gas for five days. He has high pitched, loud bowel sounds that coincide with colicky pain, and X-Rays that show distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory laparotomy for a gunshot wound of the abdomen.
Mechanical intestinal obstruction, due to adhesions. Management: Nasogastric suction, I.V. fluids and careful observation.
A three day old, full term baby is brought in because of feeding intolerance and bilious vomiting. X-Ray shows multiple dilated loops of small bowel and a "ground glass" appearance in the lower abdomen. The mother has cystic fibrosis.
Meconium ileus. Management: Gastrographin enema my be both diagnostic and therapeutic, so it is the obvious first choice.
A 69 year old man who smokes and drinks and has rotten teeth has a hard, fixed, 4 cm. mass in his neck. The mass is just medial and in front of the sternomastoid muscle, at the level of the upper notch of the Thyroid cartilage. It has been there for at least six months, and it is growing.
Metastatic squamous cell carcinoma to a jugular chain node, from a primary in the mucosa of the head and neck (oro-pharyngeal-laryngeal territory). Management: Don't biopsy the node! FNA is OK, but the best answer is to do a triple endoscopy (examination under anesthesia of the mouth, pharynx, larynx, esophagus and tracheobronchial tree).
A 35 year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis. She has had these progressive symptoms for about 5 years. She looks thin and cachectic, has atrial fibrillation and a low-pitched, rumbling distolic apical heart murmur. At age 15 she had rheumatic fever.
Mitral stenosis. Management: Start with echocardiogram. Eventually surgical mitral valve repair.
A 37 year old lady has a lumpectomy and axillary dissection for a 3 cm. infiltrating ductal carcinoma. The pathologist reports clear surgical margins and metastatic cancer in four out of 17 axillary nodes.
Next - More extensive tumors need adjuvant systemic therapy, and the rule is that premenopausal women get chemotherapy and postmenopausal women get hormonal therapy. This is one clear one for chemotherapy.
A 57 year old alcoholic male is being treated for acute hemorrhagic pancreatitis. He was in the intensive care unit fore one week, required chest tubes for pleural effusion, and was on a respirator for several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease he begins to spike fever and to demonstrate leukocytosis.
Pancreatic abscess. How do we confirm it? - CT scan. What does he need? - Drainage.
A 49 year old alcoholic male presents with ill-defined upper abdominal discomfort and early satiety. On physical exam he has a large epigastric mass that is deep within the abdomen, and actually hard to define. He was discharged from the hospital 5 weeks ago, after successful treatment for acute pancreatitis.
Pancreatic pseudocyst. Management: You could diagnose it on the cheap with a sonogram, but CT scan is probably the best choice. It will need to be drained, and the radiologist will do it with CT guidance. An older option was to operate and anastomose the pseudocyst to the GI tract.
A 62 year old man with cirrhosis of the liver and ascites, presents with generalized abdominal pain that started 12 hours ago. He now has moderate tenderness over the entire abdomen, with some guarding and equivocal rebound. He has mild fever and leukocytosis.
Peritonitis in the cirrhotic with ascites, or the child with nephrosis and ascites, could be primary peritonitis - which does not need surgery - rather than the garden-variety acute peritonitis secondary to an intra-abdominal catastrophe that requires emergency operation. How is the diagnosis made? - Cultures of the ascitic fluid will yield a single organism. Treatment will be with the appropriate antibiotics.
A 33 year old lady is undergoing a diagnostic work-up because she appears to have Cushing's syndrome. Chest X-Ray shows a central, 3 cm. round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung.
Radiation and chemotherapy. Small cell lung cancer is not treated with surgery, and thus we have no need to determine FEV1 or nodal status.
A 23 year old lady has had severe hypertension for two years, and she does not respond well to the usual medical treatment for that condition. A bruit can be faintly heard over her upper abdomen.
Renovascular hypertension due to fibromuscular dysplasia. arteriogram may precede surgical correction
A white, fat, female, aged 40 and mother of five children gives a history of repeated episodes of right upper quadrant abdominal pain brougth about by the ingestions of fatty foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right shoulder and around to the back, and is accompanied by nausea and occasional vomiting. This time she had a shaking chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the epigastrium and right upper quadrant. Laboratory determinations show a bilirubin of 3.5, an alkaline phosphatase 5 times normal and a serum amylase 3 times normal value.
She passed a common duct stone and had a transient episode of cholangitis (the shaking chill, the high phosphatase) and a bit of biliary pancreatitis (the high amylase). US to confirm gallstones. Cholecystectomy after she is better. if she deteriorates, stone may be impacted at ampulla of Vater and need ERCP.
A 47 year old lady describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to swallow than solids, and she has learned to sit up straight and wait for the fluids to "make it through". Occasionally she regurgitates large amounts of undigested food.
Sounds like achalasia (incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus) How do you make the diagnosis? - Manometry studies.
A 54 year old right handed laborer notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. What really concerned him, though, is that in the last few episodes he also experienced transitory vertigo, blurred vision and difficulty articulating his speech. Angiogram demonstrates retrograde flow through the vertebral artery.
Subclavian steal syndrome (prox stenosis with supply coming from stolen blood from vertebral arteries). Claudication of the arm with posterior brain neurological symptoms is classical. Management: angiogram -> vasc surg.
A 62 year old man describes severe epigastric and substernal pain that he can not characterize well. There is a history suggestive of gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly negative.
The question here is whether retrosternal pain is due to acid reflux or not. The test that you do is an acid perfusion (Bernstein) test, that reproduces the pain when the lower esophagus is irrigated with an acid solution.
A 49 year old has a firm, 2cm. mass in the right breast that has been present for 3 months.
This could be anything. Age is the best determinant for Cancer of the breast. If 72, cancer. At 22, benign. Management: You have to have tissue. Core biopsy is OK, but if negative you don't stop there: only excisional biopsy will rule out cancer.
A 42 year old man has suffered from chronic ulcerative colitis for 20 years. For the past 12 hours he has had severe abdominal pain, temperature of 104 and leukocytosis. He looks ill, and "toxic". His abdomen is tender particularly in the epigastric area, and he has muscle guarding and rebound. X-Rays show a massively distended transverse colon, and there is gas within the wall of the colon.
Toxic megacolon. Management: Emergency surgery for the toxic megacolon, but other indications for surgery include: chronic malnutrition, "intractability" and risk of developing cancer. The involved colon has to be removed, and that always includes the rectum.
Within eight hours after birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted and the baby is taken to X-Ray to have a "babygram" done. The film shows the tube coiled back upon itself in the upper chest. There is air in the gastrointestinal tract.
Tracheo-esophageal fistula, the most common type (type C) with proximal blind esophageal pouch and distal TE fistula. first, rule out the associated anomalies ("VACTER": vertebral, anal, cardiac, TE and renal/radial). The vertebral and radial will be seen in the same X-ray you already took, you need echo for the heart, sonogram for the kidneys and physical exam for the anus. Then off to surgery.
A six year old boy has been stumbling around the house and complaining of severe morning headaches for the past several months. While waiting in the office to be seen, he assumes the knee-chest position as he holds his head. Neurological exam demonstrates truncal ataxia.
Tumor of the posterior fosa. Most brain tumors in children are located there, and cerebellar function is affected. Management: MRI, neurosurgery.
On the third post-operative day after an open cholecystectomy, a patient develops a temperature of 101.
Urinary tract infection. Management: Urinalysis, Urinary culture, appropriate antibiotics.
An 82 year old man develops severe abdominal distension, nausea, vomiting and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours. He has a tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and large bowel, and a very large gas shadow that is located in the right upper quadrant and tapers towards the left lower quadrant with the shape of a parrot's beak.
Volvulus of the sigmoid. Management: Proctosigmoidoscopy should relieve the obstruction. Rectal tube is another option. Eventually surgery to prevent recurrences could be considered.
A motorcycle daredevil attempts to jump over the 12 fountains in front of Caesar's Palace Hotel in Las Vegas. As he leaves the ramp at very high speed his motorcycle turns sideways and he hits the retaining wall at the other end, literally like a rag doll. At the Er. he is found to be remarkably stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left first rib and widened mediastinum.
What is it? - Actually a real case. Classical for traumatic rupture of the aorta: King size trauma, fracture of a hard-to-break bone (it could first rib, scapula or sternum) and the tell-tale hint of widened mediastinum How is the diagnosis made? - Arteriogram (aortogram). Treatment: Emergency surgical repair.
A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it looks to her like "some kind of skin condition" that has not improved or gone away with a variety of lotions and ointments.
What is it? - Another sneaky way for cancer of the breast to show up. If you get this one in an extended matching set, the answer is Paget's disease of the breast-which is a cancer under the areola. Management: A full thickness punch biopsy of the skin would be OK, but core biopsy or incisional biopsy of the tissue underneath would be OK also.
A 65 year old West Texas farmer of Swedish ancestry has an indolent, raised, waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing over the past three years. There are no enlarged lymph nodes in the head and neck.
What is it? - Basal cell carcinoma. How is it diagnosed? - Full thickness biopsy at the edge of the lesion (punch or knife). Treatment: Surgical excision with clear margins, but conservative width.
A car hits a pedestrian. He arrives in the ER in coma. He has...(raccoon eyes... or clear fluid dripping from the nose...or clear fluid dripping from the ear...or ecchymosis behind the ear)...
What is it? - Base of the skull fracture. How is it diagnosed? - CT scan. Needs cervical spine X-Rays. Implications for therapy: needs neurosurgical consult, needs antibiotics.
A 77-year-old man becomes "senile" over a period of three or four weeks. He used to be active and managed all of his financial affairs. Now he stares at the wall, barely talks and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began.
What is it? - Chronic subdural hematoma. (venous bleeding, size 7 brain in size 8 skull) How is diagnosis made? - CT scan. Treatment: Surgical decompression (craniotomy). Spectacular improvement expected.
A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the entire left chest. Percussion is unremarkable. Chest X-Ray shows air fluid levels in the left chest.
What is it? - Classical for traumatic diaphragmatic rupture. It is always on the left. Further test? Not really needed. A nasogastric tube curling up into the left chest might be an added tid bit. Management: Surgical repair.
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate respiratory distress. She has multiple bruises over the chest, and multiple site of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides. On closer observation it is noted that a segment of the chest wall on the left side caves in when she inhales, and bulges out when she exhales.
What is it? - Classical physical diagnosis finding of paradoxical breathing, leading to classical diagnosis of flail chest. She is at high risk for other injuries. Management: Rule out other injuries (aortic rupture, abdominal injuries) The real problem is flail chest is the underlying pulmonary-contusion, for which the treatment is controversial, including fluid restriction, diuretics, use of colloid rather than crystalloid fluids when needed, and respiratory support. The probable wrong alternatives will revolve around various ways of mechanically stabilizing the part of the chest wall that moves the wrong way...because that used to be what was believed in the past. Further management: if other injuries require that she go to the OR, prophylactic bilateral chest tubes because she is at high risk to develop tension pneumothorax when under the positive pressure breathing of the anesthetic.
A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to "come and go" at different times in the menstrual cycle. Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks.
What is it? - Fibrocystic disease (cystic mastitis, mammary dysplasia), with a palpable cyst. Management: tissue diagnosis (i.e: biopsy) becomes impractical when there are lumps every month. *Aspiration of the cyst is the answer here*. If the mass goes away and the fluid aspirated is clear, that's all. -if bloody it goes to cytology. -if does not go away, or recurs she needs biopsy. Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only choice.
A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the abdomen. He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.
What is it? - Hypovolemic shock Management: Several things at one: Big bore IV lines, Foley catheter and I.V. antibiotics. Ideally exploratory lap immediately for control of bleeding, and then fluid and blood administration. If O.R. not available, fluid resuscitation while waiting for it.
A 41 year old man has been in the intensive care unit for two weeks, being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscesses, chest tubes for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. Ten minutes ago he vomited a large amount of bright red blood, and as you approach him he vomits again what looks like another pint of blood.
What is it? - In this setting, it has to be stress ulcer. Management: It should have been prevented by keeping the pH of the stomach above 4 with H2 blockers, antacids or both; but once the bleeding takes place the diagnosis is made as usual with endoscopy. Treatment may require angiographic embolization of the left gastric artery.
A 34 year old lady has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses.
What is it? - Intraductal papilloma. What is to be done? - the way to detect cancer that is not palpable is with a mammogram. That should be the first choice. If negative, one may still wish to find and resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or done as a retroareolar exploration.
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest, and is exquisitely tender over the sternum at a point where there is a crunching feeling of crepitation elicited by palpation.
What is it? - Obviously a sternal fracture...but the point is that she is at high risk for myocardial contusion and for traumatic rupture of the aorta. Further tests: as you would do for a MI : EKG, cardiac enzymes, but the real important ones would be CT scan, transesophageal echo or arteriogram looking for aortic rupture.
A 22-year-old gang member arrives in the E.R. with multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.
What is it? - Pericardial tamponade Management: No X-Rays needed, this is a clinical diagnosis!. Do Pericardial window. If positive, follow with thoracotomy, and then exploratory lap.
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable vital signs. No breath sounds on the right. Resonant to percussion.
What is it? - Plain pneumothorax. How is diagnosis verified? There is time to get a chest X-Ray if the option if offered. Treatment: Chest tube to underwater seal and suction. If given option for location, high in the pleural cavity.
A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. Insertion of a Foley catheter shows that there is gross hematuria.
What is it? - Presumably there was no blood in the meatus to warn against the insertion of an indwelling catheter, and since the latter was accomplished without problem, the urethra must be intact. That leaves us with bladder injury. Assessment will require retrograde cystogram.
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing well. She has multiple bruises over the chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs "white out" on X- Rays and she is in respiratory distress.
What is it? - Pulmonary contusion. It does not always show up right away, may become evident one or two days after the trauma. Management: Fluid restriction (using colloid), diuretics, respiratory support. The latter is key, with intubation, mechanical ventilation and PEEP if needed.
A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest wall. Chest X-Ray shows fractures of the 8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a pulse rate of 128.
What is it? - This one is a classic: ruptured spleen. In the absence of other clues, clinically significant hidden intra-abdominal bleeding comes from a ruptured spleen. This case is actually full of other clues that point to the spleen. First negotiate the diagnostic dilemma: if he responds promptly to fluid administration, and does not require blood, go for the CT scan. Further management in that case may well be continued observation with serial CT scans. If he is "crashing", he will need the peritoneal lavage or sonogram followed by exploratory laparotomy.
A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked up by the EMT, and on arrival at the ER he is cold and diaphoretic and his blood pressure is 80 over 65. He has an irregular, feeble pulse at a rate of 130. His neck and forehead veins are distended and he is short of breath.
What is it? - cardiogenic shock, from massive MI. Management: verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with enthusiastic fluid "resuscitation", but use thrombolytic therapy if offered.
A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus, scrotal hematoma and the sensation that he wants to urinate but can not do it. Rectal exam shows a "high riding prostate".
What is it? - posterior urethral injury. How is the diagnosis made? - retrograde urethrogram Management: They will not ask you, but these get a suprapubic catheter, and the repair is delayed 6 months.
A 53 year old lady is in the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly after she left the movies where she watched a double feature. On further questioning, she reports seeing halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated, do not react to light, the corneas are cloudy and with a greenish hue, and the eyes feel "hard as a rock".
acute glaucoma. get to ophtho. diamox (acetazolamide), pilocarpine drops, or mannitol.
A 29 year old migrant worker from Mexico develops fever and leukocytosis, as well as tenderness over the liver when the area is percussed. He has mild jaundice and an elevated alkaline phosphatase. Sonogram of the right upper abdominal area shows a normal biliary tree, and an abscess in the liver.
amebic abscess...very common in Mexico. Management: Alone among abscesses, this one in most cases does not have to be drained, but can be effectively treated with Metronidazole. Get serology for amebic titers, but don't wait to tx. Don't fall for an option that suggests aspirating the pus and sending it for culture, you can not grow the ameba from the pus.
A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic fracture. He has blood in the meatus and scrotal hematoma. Retrograde urethrogram shows an anterior urethral injury
anterior urethral injury dx w/ retrograde urethrogram tx: repaired right away.
A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns copious amounts of bright red blood.
bleeding between the tip of the nose to the ligament of Treitz. How is the diagnosis made?: for all upper G.I. bleeding, start with endoscopy.
A 44 year old black man describes progressive dysphagia that began 3 months ago with difficulty swallowing meat, progressed to soft foods and is now evident for liquids as well. he locates the place where food "sticks" at the lower end of the sternum. He has lost 30 pounds of weight.
carcinoma of the esophagus. What do you do? - Barium swallow first, then endoscopy and biopsies. CT scan next.
On a routine pre-employment physical examination, a chest X-Ray is done on a 45 year old chronic smoker. A "coin lesion" is found in the upper lobe of the right lung.
get old CXR. if there, prob not cancer, follow w/ periodic CXRs. if not there, work up.
Half an hour after the first feed, a baby vomits greenish fluid. X-Ray shows a double bubble sign: a large air fluid level in the stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the duodenum, in loops that are not distended.
incomplete obstruction from duodenal stenosis, annular pancreas, or it could be malrotation. malrotation is an emergency. do contrast enema, if not diagnostic order a water-soluble (gastrographin) upper GI study.
A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram.
malignant radiological image. stereotactic radiologically guided core biopsy. If unsatisfactory, the next move would be needle localized excisional biopsy.
A 64 year old lady presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8 direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times the upper limit of normal. She is otherwise asymptomatic, but is found to be slightly anemic and to have positive occult blood in the stool. A sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended, thin walled gallbladder.
malignant, but also lucky. The coincidence of slowly bleeding into the GI tract at the same time that she develops obstructive jaundice points to an ampullary carcinoma, another malignancy that can be cured with radical surgery. Next move: Endoscopy.
A three week old baby has had "trouble feeding" and is not quite growing well. he now has bilious vomiting and is brought in for evaluation. X-Ray shows a classical "double bubble", along with normal looking gas pattern in the rest of the bowel.
malrotation. can occur anytime. contrast enema to verify, then emergency surgery
A 52 year old lady has constant, severe back pain for two weeks. While working on her yard, she suddenly falls and can not get up again. When brought to the hospital she is paralyzed below the waist. Two years ago she had a mastectomy for cancer of the breast.
mets. most cord mets are extradural. MRI.
A 72 year old man had three large bowel movements that he describes as made up entirely of dark red blood. The last one was two days ago. He is pale, but has normal vital signs. A nasogastric tube returns clear, green fluid without blood
not bleeding now (clear asp). 3/4 of all GI bleeding is upper, and virtually all the causes of lower GI bleeding are diseases of the old: diverticulosis, polyps, cancer and angiodysplasias. How is the diagnosis made? - Angiography is not the first choice for slow bleeding or bleeding that has stopped. The first choice now is endoscopies, both upper and lower.
A newborn baby is noted to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver, and loops of normal looking bowel.
omphalocele. (abdominal wall defect in organs remain outside of the abdomen IN A SAC because of a defect in the development of the muscles of the abdominal wall). more congenital defects in these kids. surgery to fix. in gastroschisis the umbilical cord is not involved and the lesion is usually to the right of midline. there is also no sac. don't confuse with gastroschisis (defect in the anterior abdominal wall through which the abdominal contents freely protrude).
A 32 year old lady presents in the E.R. with swollen, red, hot, tender eyelids on the left eye. She has fever and leukocytosis. When prying the eyelids open, you can ascertain that her pupil is dilated and fixed and that she has very limited motion of that left eye.
orbital cellulitis ophtho emergency. CT scan to assess extent. surgical drainage.
A patient involved in a high speed automobile collision has multiple injuries, including a pelvic fracture. On physical exam there is blood in the meatus.
pelvic fracture plus blood in the meatus means either bladder or urethral injury. Evaluation starts with a retrograde urethrogram because urethral injury would be compounded by insertion of a Foley catheter.
A 22 year old lady notices an enlarged lymph node in her neck. The node is in the jugular can, measures about 1.5 cm, is not tender, and was discovered by the patient yesterday. The rest of the history and physical exam are unremarkable.
recheck in 3 weeks. if still there, investigate further.
A 33 year old man has had three large bowel movements that he describes as made up entirely of dark red blood. The last one was 20 minutes ago. He is diaphoretic, pale, has a blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns clear, green fluid without blood.
somewhere distal to the ligament of Treitz. lower endoscopy is notoriously difficult and unrewarding in massive bleeding. If he is bleeding at more than 2 cc per minute, emergency angiogram is the way to go.
A 39 year old lady presents to the ER with a history of a severe headache of sudden onset that she says is different and worse than any headache she has ever had before. She is given pain medication and sent home. She improves over the next few days, but ten days after the initial visit she again gets a sudden, severe and singular diffuse headache and she returns to the ER. This time she has some nuchal rigidity on physical exam.
subarachnoid bleeding from an intracranial aneurysm. The "sentinel bleed" that is not identified for what it is is a common feature. The "sudden, severe and singular" nature of the pain, are classics. And the nuchal rigidity betrays the presence of blood in the subarachnoid space. Diagnosis: We are looking for blood inside the head, thus start with CT. Angiograms will eventually follow, in preparation for surgery to clip the aneurysm.
A 52 year old man has right flank colicky pain of sudden onset, that radiates to the inner thigh and scrotum. There is microscopic hematuria.
ureteral colic. get a KUB, followed by an IVP or US.
A 44 year old man shows up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements are very painful, and has been having chills and fever. Physical examination shows a hot, tender, red, fluctuant mass between the anus and the ischial tuberosity.
very common problem: ischiorectal abscess. Management: The treatment for all abscesses is drainage. This one is no exception. But as always, cancer has to be ruled out. Thus the best option would be an answer that would offer examination under anesthesia and incision and drainage.
A 57 year old man seeks help for "dizziness". On further questioning he explains that he gets light headed and work-up in that direction.
vestibular apparatus problem. either symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup.
A 57 year old man seeks help for "dizziness". On further questioning, he explains that the room spins around him.
vestibular apparatus problem. either symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup.
A 22-year-old gang member arrives in the E.R. with a single gun shot wound to the precordial area. He is diaphoretic, cold, shivering, anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pule rate is 150, barely perceptible. He has big distended veins in his neck and forehead. He is breathing OK, has bilateral breath sounds and no tracheal deviation.
when the location of the wound strongly suggests pericardial tamponade, emergency thoracotomy might be done right away without prior pericardial window.
