Surg

45yo, ED for abd pain of 2d duration - progressively increasing, constant, epigastric w/radiation to back; n/v/anorexia - 3-4 alc/d; no tobacco/drugs - 100.9F, BP 116/78, HR 104, RR 22, O2 97%/RA, Ht 5'11", wt 194lb, BMI 27.2; normal heart sounds - BL decrease lung sounds at bases; Abd mild distension, decreased bowel sounds, epigastric tenderness - Hct 37%, WBC 12.5K, BUN 44, Cr 1.6, Amylase 4415, Lipase 5636 [5-70] ***finding indicating worst prognosis [Abd signs, BUN, BMI, Hct, Serum Lipase]

BUN - indication of at least 1 organ system failure concurrent w/acute severe pancreatitis

43yo, construction worker in ED after 20ft fall w/severe chest pain; BP 136/92, HR 120; CXR in pic ***likely Dx?

Blunt Thoracic Aortic Injury [assoc w/rapid deceleration] - CXR: widened mediastinum, abnormal aortic contour, L-side effusion from aortic bleed into thorax - incomplete tear may have normal or hypertensive BP, and be initially stable - CTA confirmation if hemodynamically stable; TEE for unstable/hypotensive

67yo, ED for 5d hx LLQ abd pain, nausea, poor appetite; Hx chronic constipation but having 2-3 loose, nonbloody BM/d - 3y prior admitted for similar episode; Hx hysterectomy, BL salpingo-oophorectomy 15y prior - 101.8F, BP 122/82, HR 98; moderate disomfort from pain, no position of relief - LLQ tenderness/guarding w/o rebound; palpable tender mass; L-side tenderness w/rectal/pelvic exams; stool (-) occult blood; WBC 16.5K ***next step Dx?

CT Abdomen for apparent acute diverticulitis

51yo, ED following tennis ball to L eye - Hx htn [lisinopril], BP 168/96, HR 100, RR 20 - L periorbital bruising/edema, PERRLA; well-demarcated, small subconjunctival hemorrhage medial to L iris - intact/full EOM w/pain in L eye testing ***next step mgmt?

CT orbits and facial bones indicated in blunt trauma to eye - presenting with Sx of orbital injury [painful EOM, decreased visual acuity]

59yo, ED after falling in yard striking chest on a brick causing severe R upper chest pain; no head hit/LOC - Hx CABG 1y ago; BP 90/62, HR 118, RR 20, 96% O2 on room air; diaphoretic - swelling, bruising, tenderness to palp over R clavical and upper chest; normal heart/lung sounds; abd soft NT/ND - admin IV fluid >> BP 110/64, HR 100; ECG: sinus tachycardia; CXR in pic ***next step?

CT scan chest - apparent clavicular fracture >> subclavian vessels at risk - responded to fluids >> CT to further evaluate possible intrathoracic injury

65yo, 4wk hx weakness and vauge postprandial epigastric pain; no meds/conditions - smokes 1pk/d, occasional alcohol intake; (+) occult blood; antral ulcer evident on EGD - 4/7 biopsies of ulcer marging consistent w/adenocarcinoma ***next step?

CT scan for staging/mets - prognosis/treatment determined by staging at diagnosis

62yo, ED from rehab for sudden-onset dyspnea w/nonproductive cough; acute onset while trying to get out of bed - no fever, hemoptysis, wheezing, palpitations, leg pain, or LE edema - Knee replacement 2wk prior for degen jt dz - Hx PUD from NSAIDs, htn, T2DM; some alcohol intake socially, no tobacco - 100.4F, BP 130/80, HR 110, RR 22, 91% O2 on room air; sinus tachycardia on ECG, normal CXR, normal leukocytes ***next step?

CTA chest to evaluate pulmonary embolism - indicated in postop period [2wk after surg], w/sudden-onset dysnpea, nonprod cough, tachycardia, and mild hypoxia - Rx: early, effective anticoagulation reduces mortality [Abs CI: hemorrhagic stroke, massive GI bleed] - PUD may increase bleeding risk, so CTA confirms dx

49yo, PACU after cardiac ablation for symptomatic afib experiencing chest pain/SOB - started while resting, rapidly worsening - BP 72/32, HR 140, RR 30, O2 92% on room air - diaphoretic, distressed, distant heart sounds, distended JV; lungs clear to ausc BL - ECG: tachycardia, low-amp QRS complexes ***hemodynamic changes?

Cardiac Tamponade d/t bleeding into pericardial space after ablation - Increased PCWP, Decreased cardiac index, Increased SVR, Increased RA-P - indiacted by Beck Triad [hotn, JVD, distant heart sounds] + low-amp QRS

2yo, ED w/refusal to walk; returned from Arizona vacay 3d prior; no injuries but had cough/rhinorrhea prior to trip - limping on running, knee started hurting after leaving daycare yesterday, relieved by cold compress - today refused to walk, no conditions/meds; UTD vax - 101F, skin over L knee warm/edematous; no abrasions, resists passive ROM - aspiration: synovial fluid WBC 53K; cultured and admitted for IV vanco >> continued fever/refusal to walk 2 days ***next abx added to regimen?

Ceftriaxone for apparent Septic Athritis - knee pain, warmth, erythema, restricted ROM, synovial WBC >50K - typically staph aureus [or other G+] >> vancomycin >> if continued sx broaden abx to include G- pathogens w/ceftriaxone and target based on culture

45yo M, ED for L wrist pain after fall [Forward FOOSH]; applied ice w/no improvement in pain/swelling - Hx Celiac dz, Htn, Hypothyroidism [TH supp]; no tobacco, alcohol, rec drugs, allergies; BMI 20 - "dinner-fork" deformity of L wrist [pic], swollen, tender to palpation, intact sensation and can move all fingers ***1o RF of bone fracture in this patient?

Celiac Disease - malabsorption of vitamin D >> 2o hyperparathyroidism >> osteopenia, osteoporosis, osteomalacia - Sx: bone pain, muscle weakness, impaired ambulation - Rx: adequate calcium/Vit D supplementation, periodic DXA bone density scans

54yo w/R shoulder/arm pain of 3wk duration, onset after a few hours of golf - R arm weakness, especially lifting heavy objects; no prior conditions/meds - spasm of cervical paraspinal muscles; mild weakness in R elbow flexion, decreased R biceps reflex - pain improves with R arm lifted w/hand on top of head ***likely Dx?

Cervical Radiculopathy at C6 - nerve root cmpression from disk herniation or progressive spinal spondylosis - pain in neck/UE, sensory/motor deficits, diminished - shoulder abduction relief test >> reduces tension on impinged root - mild: conservative mgmt [NSAID, PT]; worsening: MRI/surgery

76yo, followup for recent CABG [9d prior, internal thoracic artery harvest] - abundant, yellow wound discharge from lower end of midsternal surgical wound - no chest pain, dyspnea, fevers, abd sweling - Hx Htn, T2DM; afebrile; normal vitals; sternum stable to palpation - swelling/soft tissue separation at lower wound w/copious discharge ***next step?

Chest/Sternal Imaging - differentiate soft tissue dehiscence vs sternal dehiscence to determine clinical course

72y follow-up after recent Dx 4.2cm adenocarcinoma of cecum [R hemicolectomy] w/no CT evidence of metastasis - histo indicates tumor only involved sub/mucosa and achieved clear margins w/o LN involvement - Hx Htn, Obesity; 99F, BP 140/80, HR 80; normal heart/lungs; well-healed surgical scar, abd soft NT/ND ***recommended follow-up surveillance?

Colonoscopy 1y - localized resection, limited to superficial layers, no mets = stage I - adenocarcinoma can have recurrence, faster onset neoplasia >> 1y then every 3-5y

76yo w/multi-infarct dementia, ED for cough and low-grade fever; treated twice in last year for pneumonia; 6mo of difficulty swallowing w/occasional regurg of undigested food - lengthy Hx htn, chronic afib; BMI 22; 101.3F, BP 150/95, HR 102, RR 16 - foul-smelling breath, fluctuant mass in left neck; crackles of R lung base >> admitted, sputum and blood cultures, admin abx >> improvement sx ***next step?

Contrast Esophagography to look for Zenker Diverticulum

46yo, worsening LE tingling and numbness; difficulty walking [esp at night], and hair loss - gastric bypass 5y prior, loss of 30kg; was on multivitamin but now only supplements zinc - Gait ataxia w/loss of vib/position sense in feet, (+) Romberg, mild LE edema, scattered skin depigmentation, fragile hair - microcytic anemia, leukopenia ***likely deficiency?

Copper - brittle hair, skin depigmentation, neuro deficit [ataxia, peripheral neuropathy, Romberg], Anemia, osteoporosis - assoc w/malabsorption from gastric surgery, chronic malabsorptive disorders [IBD/celiac], excessive zinc ingestion [competes for absorption - Cu: cofactor for many enzymes >> protein synthesis, cell division, iron absorption, CNS function [neuro sx present up to years after insult; may look like SCD or B12 def] - Dx: low serum copper and ceruloplasmin - Rx: copper supp, dc zinc

75yo w/Alzheimer dementia presents w/lable BP and worsening agitation - admit 4d prior for R hip replacement following traumatic fall and hip fracture - post-op complicated by agitation treated w/haloperidol; continued agitation/confusion - SBP 120-170, fever 101.6, HR 120, RR 22, 97% O2 on room air; not oriented to place/person; drooling/diaphoretic - normal heart/lung sounds, abd soft NT/ND, clean operative site; increased UE/LE muscle tone, tremor, DTR 2+, no Babinski - WBC 15K [80% neutrophils; 15% L], Urinalysis w/moderate blood, no nitrites/bacteria, 1-2WBC/hpf, 1-2RBC/hpf ***likely cause?

Decreased Central Dopaminergic Activity d/t post-op delirium treated w/antipsychotic [haloperidol] yielding Neuroleptic Malignant Syndrome - Sx: muscle rigidity, AMS, autonomic dysregulation [BP, HR, diaphoresis], fever; sustained contraction can cause elevated CK and myoglobinuria, +/- leukocytosis w/left shift

39yo, accidentally cut L index finger w/sharp knife 20min ago while cooking - immediately washed thoroughly and applied pressure on way to hospital; normal vitals; UTD tetanus - 2cm laceration w/slow active bleeding, no obvious FB; normal DIP/PIP a/pROM - digital block w/1% lido + NaBicarb before irrigation/repair ***benefit of adding sodium bicarbonate to anesthetic?

Decreasing pain during injection - lidocaine solution is acidic >> causes pain itself on injection >> buffering w/bicarb reduces acidity-related injection pain - also may convert more of anestheti to its uncharged/active form increasing the onset of analgesia ***compare to adding epinephrine to LA for vasoconstriction [to reduce bleeding in wound repair, decreasing systemic absorption preventing toxicity, and prolonging duration of action to local site]; epi CI for those w/risk of digital ischemia [PAD, Raynaud]

73yo, hospitalized following emergent L transmetatarsal amputation - Hx chronic, nonhealing foot ulcers from poorly-controlled DM; PAD - admitted 2d prior for wet gangrene/cellulitis w/fever, hotn, AMS - surrogate decision maker [son] consented amputation - now stabilized w/IV abx, opioid pain meds, and TE prophylaxis - Vascular surgeon proposes revascularization procedure, denied by patient ***next step?

Determine patient decision-making capacity - understands condition, ability to express choice, appreciation of consequences of +/- treatment, ability to provide reasoning for decision

48yo, crushed bt 2 cars pinning legs/abdomen - BP 74/32, HR 118, LE deformity, severe pelvic tenderness - multiple pelvic fractures, femur shaft fx - admin 4L IV fluid, 4u pckt RBC >> BP 106/58, HR 104; urgent operative fixation of pelvis/femur fx planned - Hct 26%, Plt 90K; Coag: PT 18, INR 1.6, aPTT 45, plasma fibrinogen 300 [150-400], D-dimer 100 [<400] ***cause of coagulation abnormalities?

Dilutional effect of large-volume resuscitation - packed RBCs restore volume and O2 capacity, but have minimal clotting factors and platelets - INR >1.5 or Plt <50K requires platelet replacement [FFP, platelet, whole blood]

50yo in PACU w/sudden onset severe nausea and R flank pain - following total abd hysterectomy and tumor debulking for metastatic ovarian cancer, complicated by bleeding/ureteral laceration - Hgb 6.8 >> 10min ago recieved pkt red cell transfusion - current status: pain, oozing IV site, fever, BP 90/50, HR 130, RR 26; tachycardia w/weak pulse, dark red urine in foley ***necessary for dx?

Direct Coombs to determine acute hemolytic transfusion reaction [ABO incompatability, intravascular hemolysis] - features: onset minutes-24h post-transfusion w/fever, chills, hypotension, hemoglobinuria, flank pain - other signs of intravascular hemolysis: ↑ LDH + ind bili; (+) direct Coombs - complications: Acute Renal Failure, DIC

20yo, ED w/fever, worsening abd/flank pain after direct blow to central upper abd during tackle in football practice; sat out rest of practive; nausea w/o emesis/d - no chronic conditions, 102.9F, BP 100/64, HR 112, RR 18 - normal heart/lung sounds; abd diffusely tender w/guarding oevr epigastrium; free air evident on imaging ***likely Dx?

Duodenal Tear

56yo w/pain, redness, and swelling of R arm; recent dx of unresectabla lung cancer - recieved 1st chemo through R-sided PICC 2wk prior - 98.4F, BP 130/80, HR 78, RR 14; normal O2 sat; no PICC discharge ***next step?

Duplex Ultrasonography - UE catheters assoc w/increased risk of UE-DVT [endothelial trauma on insertion or w/improper positioning of catheter tip] - higher risk w/PICC than IJV/subclavian line because longer distance through narrower vein - typically onset w/i 7-14d PICC insertion w/swelling +/- pain/erythema

56yo, hospitalized for recurrent chest pain; admitted 3d prior for 1d hx precordial chest pain - eval showed acute MI >> placed LAD drug-eluting stent >> resolution of sx - today presenting w/sharp chest pain radiating to L shoulder, position of comfort sitting up; no orthopnea or palpitations - Meds: aspirin, prasugrel, metoprolol, rosuvastatin - 99F, BP 122/70, HR 101/regular - no murmurs, lungs CATB, ECG: sinus tachy, widespread PR-seg depression ***next step?

Echocardigraphy to assess peri-infarction Pericarditis

50yo, routine physical; 5y prior mechanical aortic valve replacement following endocarditis - compliant warfarin anticoagulant regimen, lifetime nonsmoker, UTD vax - 2/4 diastolic murmur at LSB, best heard w/breath-hold at expiration - INR 2.9 5d ago ***next step mgmt?

Echocardiography to assess prosthetic valve dysfunction [PVD] - auscultatory findings consistent w/valvular aortic regurgitation; PVD indicated d/t recent replacement - Sx general: new murmur, macroangiopathic hemolytic anemia, HF signs, thromboembolism - Dx: Echocardiography to visualize valve and surrounding anatomy >> transvalvular regurgitation [cusp degen; likely bioprosthetic], paravalvular leak [annular degen/IE; likely mechanical], valvular obx/stenosis [thrombus]

68yo F w/groin bulge of 2mo duration; reducible, painless, BMI 34 - Hx htn, COPD, long time smoker - 2cm mass below R ing lig, med to femoral artery, tympanitic to percussion ***next step?

Elective Surgical Repair: presenting w/classic femoral hernia; common in older women w/RFs - nontender, painless groin bulge below inguinal ligament, medial to femoral artery, nonpulsatile; worsens w/increased abd pressure, decreased laying down - may be tympanic if bowel loop present - RF: chronic cough [CODP], constipation, smoking - complications: incarceration + strangulation of affected bowel [vs inguinal hernias that pass through larger orifice, less common complications] - Rx: elective surgical repair

21yo, fall hitting L-head on rock, no LOC; over 30min onset HA and vomits twice; no chronic conditions/meds - BP 136/90, HR 68; drowsy but oriented, swelling/tenderness over L frontoparietal region ***likely evident on CT?

Epidural Hematoma - traumatic head injury w/worsening mental status in mintes; frontoparietal swelling >> likely involving tear of middle meningeal artery >> accumulates blood between dura mater/skull - often fx of Pterion: jx frontal, parietal, temporal, sphenoid bones; usually younger adults - +/- lucid interval [20-50%] following LOC - CT: hyperdense biconvex lesion [lemon]

58yo, urgent care for 2wk hx ulcer on bottom of R foot; no injury; "dime-sized"; noticed wet sock - cleaned w/antiseptics, applied topical abx >> no healing - no pain, surrounding redness, fever, chills; Hx htn [unmanaged]; ibuprofen for occasional back pain; 30pkyr smoker; 1-2 beers/d; warhouse worker always on feet - 98F, BP 156/98, HR 88, BMI 32; feet warm/dry - 2cm, nontender ulcer on sole just below head of 1st MT; scant discharge, necrotic tissue at base, bone probe negative ***mechanism to Dx underlying cause of foot ulcer?

Hemoglobin A1c

45yo, mild L foot pain and difficulty walking over several months, recently started using a cane and ankle brace - Hx T1DM, Htn, Hypercholesterolemia - significantly deformed L ankle and mildly deformed L foot; full/symmetric distal pulses - XR L foot/ankle w/wt-bearing: osseous fragmentation, new bone formation, sclerosis [see pic] ***likely cause?

Impaired sensation and joint proprioception [Charcot/neuropathic arthropathy] - Acute: inflamm, erthema, edema 1-2d after minor trauma [soft tissue swelling on XR] - Chronic: bone deformities evident on XR w/osseous frag, new bone, subluxation/disloation of mid/hind foot; loss of MT heads; osteopenia/osteolysis >> neuropathic ulcers, arch collapse, callus

19yo G1P0, 34wk gestation; admitted for preeclampsia w/severe features - no chronic conditions/meds; 98F, BP 170/110, HR 80, RR 16 - admin mag sulfate bolus >> fetal HR becomes bradycardic [90s] >> rushed to OR for emergency C-section under general anesthesia - after intubation: 103F, BP 180/110, HR 130, RR 30, difficult to ventilate, rigid ***cause of acute decompensation in surgery?

Malignant Hyperthermia [MH]

68yo w/3d mild oral pain localized to L lower jaw, assoc w/gum swelling - loose molar extracted 3wk prior, site never healed completely - Hx Osteoporosis [Ca/Vit D, zolendronic acid], no tobacco/alcohol, normal vitals - Exam: gingival eedema, erythema surrounding area of exposed bone at L lower jaw ***likely Dx?

Osteonecrosis - rare bisphosphonate AE

28yo, evaluating L testicular mass of 2mo duration, with increasing size - no pain or wt loss, otherwise healthy/no symptoms; no tobacco, alcohol, illicit drugs; normal vitals - Abd soft NT/ND w/o palpable masses; hard, painless nodule noted in L testicle; no inguinal lymphadenopathy - Scrotal US: solid, hypoechoic 5cm mass ***next step?

Radical Iguinal Orchiectomy for apparent testicular cancer - solid, hard, nontender testicular mass; MC solid-organ malignancy of men 15-35 - usually UL nodule, painless +/- dull ache of lower abd/perineum

Symptomatic 40yo, following laparoscopic Nissen fundoplication - nausea, early satiety, epigastric discomfort, postprandial bloating, wt loss; no apparent obx ***next step?

Scintigraphic Gastric Emptying Scan: to evaluate iatrogenic gastroparesis - mech: accidental damage to vagus nerve - other potential NF complications: dysphagia, gas-bloat

6yo; annual wellness check; normal vitals, no fam hx; appropriate ht/wt - abd mass palpated in RUQ; unremarkable LFTs, bili, ALK - US shows CBD cyst, confirmed on MRCP ***next step?

Surgery now to prevent malignancy

28yo, ED following MVC as restrained driver; awake w/left chest pain and vague abd discomfort - BP 114/74, HR 112, chest/abd ecchymoses and tenderness in seatbelt distribution; equal BL breath sounds, normal heart sounds - FAST negative for FAF; CT: thickened proximal small bowel and small mesenteric hematoma - hospitalized for monitoring/supportive care >> next 24h develops worse pain, n/v, abd tenderness w/guarding [see repeat CT] ***next step?

Surgical Exploration - updated CT shows intraperitoneal free air, assoc w/perforated viscus

24yo, ED for extensive burns after being soaked in gasoline and lit on fire [>65% BSA] - intubated at seen, unk med hx, 99.7F, BP 117/70, HR 135; O2 96% on 40%FiO2 mech-vent - intubated/sedated, deep partial/full-thickness burns to face, neck, chest, upper/lower back; deep and superficial burns to all extremities - admin IV fluids, admit ICU >> 24h later high peak pressure alarm on ventilator, lungs difficult to vent, increasingly hypotensive; CTAB, normal heart, abd soft NTND; no infiltrates/consolidation on CXR ***next step?

Thoracic Escharotomy - full-thickness circumferential burns forming eschar + soft tissue edema = impaired chest wall exursion [constriction, lungs cannot expand fully] - added pressure from ventilation w/o chest wall accomodation yields high peak pressure and hypotension

24yo, ED w/vision disturbance - Hx AS, had severe pain/redness in both eyes a month ago, treated for anterior uveitis [predisone drops] that resolved in 1wk - no follow up, but continued w/glucocorticoid drops - recently has needed more light to read, and seen halos around lights while driving at night - nomal vitals, normal ocular and fundoscopic exam, normal neuro exam ***next step?

Tonometry - Implicates glucocorticoid-induced elevation in IOP [may preceed open-angle glaucoma]

35yo w/1wk hx excruciating pain on defecation w/BRBPR - no change in stool caliber, Hx chronic constipation, no meds, no tobacco/alc/drugs - normal vitals, abd soft w/normal bowel sounds; rectal exam shows posterior mucosal tear of anus and skin tag ***appropriate next step w/stool softeners and sitz baths?

Topical Lidocaine and Nifedipine for anal fissures

72yo plumber w/chronic knee pain discussing options - 10y of PT and GC injections, becoming less effective to control pain; now uses cane w/ambulation and can only walk 2 blocks before it's unbearable - Hx T2DM, Htn, depression; BP 130/78, HR 80, BMI 26 - R knee stiff/swollen w/o erythema; tenderness at medial/lateral joint lines, (+) patellar grind; stable to varus/valgus; limited p/aROM from pain - XR: bicompartmental joint space narrowing w/multiple osteophytes ***best treatment option?

Total Knee Arthroplasty for OA - (1) conservative: wt loss, regular moderate activtiy, NSAIDs, strengthen quads - (2) injectable glucocorticoids or hyaluronic acid - (3) total knee arthroplasty if failed nonsugical interventions

18yo, ED w/severe v/d and dizziness onset this morning - 2d prior nasal bleeding that required anterior packing in ED; no recent sick contacts, Hx asthma/allergic rhinitis - FDLNMP 3wk ago; no tobacco, alc, rec drugs - 102F, BP 90/60 supine, 66/45 standing, HR 120, RR 23; alert but restless, nasal packing in R nare - diffuse, confluent erythematous macules on trunk and extremities, oropharynx is hyperemic - Plt 55K; WBC 9.5K [30% bands] ***likely Dx?

Toxic Shock Syndrome from retained nasal packing

6yo at clinic for knee pain arising 4d prior after first gymnastics class; no relief w/massage/acetaminophen - onset of limp 2d ago, no chronic conditions/meds, 50%ile ht, 75%ile wt; temp 100.2F - limits wt-bearing on rights side while walking; supine R hip held flexed w/knee lateral; limited R hip IR/extension - knee full ROM; WBC 11K, CRP 8 [<10]; US hips: small, BL effusions ***likely Dx?

Transient Synovitis - often child [3-8y], self-limiting, inflammatory hip condition; possibly postviral or posttraumatic - Sx: well-appearing w/acute hip pain or referred knee pain; often normal knee exam, hip held flexed, abducted, ER - limping and wt-bearing; norml CRP/WBC; often uni/bilateral effusions on US - conservative mgmt: NSAIDs; resolve in days/weeks

30yo, ED w/scrotal pain; initially sharp along R groin yesterday after lifting weights - no relief w/warm bath and rest, pain returned w/nausea; ibuprofen ineffective - worsened overnight; difficulty walking this morning, vomited twice - Hx: umbilical hernia repair [2yo], no meds; BP 142/90, HR 110, resp 20 - marked swelling, induration, erythema of R hemiscrotum; US: R testicle 2x larger, heterogenous echotexture, small hydrocele ***cause of presentation? [bowel protrusion through wkness, dilated pampiniform plexus, malignant testis neoplasm, persistent processus vaginalis, twisting of spermatic cord]

Twisting of Spermatic Cord [Testicular Torsion] - abrupt-onset severe scrotal pain, testicular swelling, heterogenous texture [necrosis sign] w/small hydrocele - mech: insufficient fixation of testis to tunica vaginalis >> testicular hypermobility >> twisting of spermatic cord, ischemia, necrosis - Dx: doppler US >> need urgent urologic evaluation [>12h ischemia can yield nonviability]

Preoperative Testing [chart]

Unnecessary in young patients w/unremarkable history and negative review of systems and normal physical exam - no symptoms suggesting impaired functional capacity = no need for further testing/imaging

42yo, 3mo burning, substernal chest pain after meals; OTC antacids w/partial relief - UGI endoscopy: mucosal irregularity and ulceration and LES, biopsied - 4h after procedure: worsening substernal pain radiating to back w/mild SOB; HR 120, resp 34; CXR: small L pleural effusion ***confirm dx?

water-soluble contrast esophagogram: to evaluate esophageal perforation [EP] - MCC EP: endoscopy >> sx: severe chest pain, back pain, pleural effusion, pneumomediastinum/thorax, tachycardia, tachypnea - Dx: esophagogram to visualize perforation [barium is 2nd line to water contrast d/t inflamm response] - Rx: emergency surgical consult [prevent mediastinitis, septic shock, death]

45yo, restrained driver in MVC smashing leg against front console, required extication from vehicle; put in C-collar, admin IV fluids en route - BP 138/92, HR 105, RR 14; alert/oriented w/significant leg pain; CTAB, no chest tenderness, normal heart sounds; Abd soft NT/ND; no pelvic tenderness - R lower leg grossly deformed; exposed broken tibia; capillary refill <2s both feet; XR: comminuted tib-fib fx ***(1) other imaging required? >> (2) if positive for injury, additional studies?

(1) CT cervical spine required for all high-energy mechanism injuries; leg fracture might just be distracting - other indication: neuro deficit, spinal tenderness, AMS, intoxication (2)CT thoracic/lumbar spine if cervical scan shows S&S of single level vertebral fracture following blunt trauma, need to assess the entire spine

51yo colon cancer screening determination - normal BMs, no bleeding signs or unexpected wt loss; Hx htn, mother w/colon cancer at 80y - prior colonoscopy: 2 small [8mm] hyperplastic polyps removed ***next step mgmt?

10y repeat colonoscopy for average risk patient - hyperplastic polyps common/non-neoplastic, low-risk when <1cm; typically rectosigmoid - high-risk fam hx would have 1st-deg relative CRC <60y [5y repeat colon]

50yo, preventive visit w/PCP; no chest pain/SOB but some occasional L posterior calg pain when walking - sometimes leg cramping at rest; Hx diet-controlled DM and hypertension, no medication - hospitalized 2y ago for chest pain, cardiac stress test negative w/no recurrence - 30pkyr smoker, no alc/drugs; father died suddenly 60yo, mother stroke in 70s - BP 138/92, HR 88, BMI 28, normal heart/lungs exam - BL palpable pulses popliteal, dorsalis pedis, post tibial - ECG normal sinus rhythm, HbA1c 7.2% ***next step?

ABI [ankle-brachial index] - has RF of atherosclerosis, symptoms indicative of intermittent claudication - ABI should confirm PAD, it's noninvasive, and inexpensive screening

19yo w/painful nexk swelling; noticed lump 1wk prior, progressive enlargement and pain; intermitent fevers up to 103F - pet groomer, no travel hx, no prior conditions or meds - large, tender, firm, lobulated mass on L neck, erythematous overlying skin, normal oropharyngeal exam - CT: diffuse L cervical lymphadenopathy, inflamm changes [pic] ***next step in mgmt?

ABX [Azithromycin] for cervical lymphadenitis >> acute/unilateral likely staph aureus or strep; subacute/chronic usually atypical pathogen [MTB, toxo, Francis, Bartonella] - pet groomer: higher risk B. henselae >> tender, erythematous LA proximal to inoculation up to >5cm +/- fever; azithro recommeded d/t risk of dissemination in 15% [most resolve spontaneously w/i 4mo] - Penicillin V for strep isn't indicated bc that's usually d/t oropharyngeal infection/inflammation - TB would be indicated w/travel hx or IC - mono is typically BL w/pharyngitis

17yo w/R shoulder pain at urgent care; onset after hitting shoulder on ground in rugby tackle - no gross deformity, adduction across torso elicits pain over superior shoulder - normal neck/elbow sensation/ROM; BL radial pulses 2+, normal XR R shoulder/clavicle ***likely dx?

AC joint Sprain - (+) crossbody test

30yo, ED for worsening R-sided HA over last 6mo - 30min ago: R temporal HA at rest, gradually worsened to severe pain in minutes, nausea + vomiting episode; now somnolent and difficult to rouse - no other conditions, normal eval for military enlistment 1y ago; 98.6F, BP 150/90, HR 64, RR 14 - withdraws all extremities from painful stimuli, increased L-side DTR; no neck rigidity ***likely underlying cause of condition?

AVM [arteriovenous malformation] ruptured >> intracerebral hemorrhage [ICH] - unilateral HA w/n/v and decreased LOC suggest ICH, progression minutes to hours w/expansion - young age and history of unilateral HA suggests AVM rupture; classically congenital w/presentation/Dx <40yo after an ICH [other sx: recurrent HA, seizure, focal neuro deficit from compression]

56yo, ED for L hand pain starting 2h prior after feeling a sharp bite while reaching into a large pipe - Hx htn; BP 88/60, HR 118, RR 22 - 2 puncture wounds distal to L wrist on exam w/persistent oozing; pronounced swelling and ecchymosis up to middle of upper arm - significant pain w/passive movement, intact sensation, capillary refill decreased in all 4 extremities equally ***best initial treatment?

Admin Crotalidae Polyvalent Immune Fab - snakebite >> need antivenom - Sx: local tissue tox, coag abnormalities, neuro/myotoxicity, cardiovascular collapse, shock - labs: CBC, CK, PT/PTT, INR, fibrinogen; monitor swelling, ecchymosis, symptom progression - antivenom has anaphylaxis risk >> only admin for pronounced sx, abnormal coag oozing], CV compromise and send to ICU [otherwise obsere 12-24h for delayed toxicity]

36yo, abd hysterectomy for symptomatic uterine fibroids - Hx unremarkable, normal preop CBC, serum chem, and coag studies; no intraop complications, minimal blood loss - postop morphine via pt-controlled analgesia, IV 5% dextrose in 0.45% saline >> next day has increasing global HA, severe nausea, and confusion - 98.1F, BP 110/70, HR 88, RR 14; 24h urine output 1600mL - lethargic, disoriented on exam; mild incisional tenderness, decreased bowel sounds; no focal wkness/sensory deficit - Na 119, K 3.7, Cr 0.5, Gluc 78 ***appropriate fluid intervention?

Admin IV Hypertonic [3%] Saline - presenting w/symptomatic/acute hyponatremia ppt by combination of hypotonic [0.45%] saline and post-op SIADH release [stimulated by stress, pain, nausea] - low tonicity >> water into brain cells >> swelling, cerebral edema >> symptoms of elevated ICP [n, malaise, HA, confusion >> seizure, coma, resp arrest] - acute <48h, elevated ICP Sx + Na <130 [Rx: hypertonic 3% saline] - chronic >48h, better tolerated so no hypertonic saline unless Na <120 and/or severe Sx or concurrent intracranial pathology [masses/stroke] - hypertonic saline infusion admin rate of 4-6mEq/L over several hours to prevent herniation [max 8mEq/L in 24h to prevent osmotic demyelination syndrome]

66yo, ED w/low back and L hip pain after trippng and falling backwards at work, landing on left side; no head injury or LOC - BP 149/90, HR 105, RR 18; L paraspinal lumbar area and hip tender to palpation; intact neurovascular exam; see XR ***next step?

Admit for Surgical Repair of femoral neck fracture >> ORIF or hemiarthroplasty

80yo, fatigue, 10lb wt loss; Hx BPH [tamsulosin], CAD, Htn - no tobacco, 2 shots whiskey daily, vegetarian, normal vitals - nodular prostate and inguinal lymphadenopathy; PSA 25 [<4.5]; prostate biopsy reveals adenocarcinoma ***greatest RF in this pt? [age, alc, BPH, tamsulosin, vegetarian]

Advanced Age - 2nd MC malignancy in men; increasing prevalence w/aging [30-80% >70yo]

50yo w/recent cirrhosis dx in hospital for elective UGI endoscopy to evaluate esophageal varices - ↑LFTs, +HCV serology for chronic hepatitis - abd imaging: mild ascites, nodular liver, splenomegaly - Benzocaine topical anesthesia, sedation via midazolam and fentanyl - O2 sat decrease to 85% in procedure, no improvement w/face mask supplementation >> bluish lips/fingertips, normal lung/heart sounds - urgent labs: Hct 39%, ABG pH 7.39, PaO2 142, PaCO2 34, O2 sat 99 ***cause of decrease in saturation?

Altered State of Hemoglobin [Fe]: acquired methemoglobinemia from anesthetic - assoc: topical anesthetic [benzocaine], dapsone, nitrates [infants] >> oxidize Hgb so it cannot bind O2 - remaining normal Hgb increases O2 affinity [less delivery] >> false elevation of saturation based on PaO2 [not Hgb binding] - cyanosis w/10% Hgb altered, >20% yields hypoxemia sx [HA, lethargy], >50% severe [AMS, seizure, resp depression, death] - Rx: d/c agent, admin methylene blue [reducing agent]

45yo, ED w/3wk episode of fever, malaise, cough productive of foul-smelling/purulent sputum - hospitalized 6wk prior for head injury in MVC requiring brief nitubation; discharged 4wk ago - no tobacco, alcohol, illicit drugs - 102F, BP 120/74, HR 110, RR 14; Hgb12.5, WBC 18K; see CXR [pic], sputum cultures obtained ***next step?

Ampicillin-Sulbactam Empiric therapy - subacute fever, malaise, leukocytosis, productive/foul-smelling sputum cough, cavitary lung infiltrate w/air-fluid level >> indicative of lung abscess - likely oropharyngeal anaerobic flora aspirated while unconscious [head injury], takes 7-14d to evolve into necrotic infection - empiric rx: ampi-sulb [or carbapenem] bc good pulmonary penetration, action against anaerobes

58yo, ED w/1wk hx fever, chills, cough w/foul-smelling sputum; night sweats, anorexia, fatigue - unstable housing, smokes, alcohol intake, poor dentition - R-side crackles, high WBC, hyponatremia; chest imaging [pic] ***likely cause of current condition?

Anaerobic bacterial infection: lung abscess - consistent w/alcohol use, foul-odor sputum, fever, leukocytosis, and cavitary infiltrate w/air-fluid level - MC: aspirated oropharyngeal anaerobes d/t dysphagia/impaired consciousness [alc abuse, seizure]; greatest risk w/poor dentition or gingival disease - slow-growth causes onset arising over 1-2wk; often occur w/hyponatremia d/t SIADH - Rx: empiric abx [Amp/sulbac 1st line; Clinda for allergy to B-lac only dt C diff risk]; no improvement >> surgery

25yo following motocycle collision w/R knee pain; severe pain and marked swelling; wt-bearing, but "giving out" - notably difficult walking down stairs - XR: avulsion fracture of anterolateral tibial plateau ***Dx revealed on MRI?

Anterior Cruciate Ligament Tear: - instability, especially notable going down stairs - Segond Fx: avulsion fx of anterolateral tibial plateau; 75% occur w/ACL tears - Dx: MRI gold-standard, PE w/(+) Lachman/Ant Drawer

62yo, worsening skin lesions; admitted 6d after elective CABG for extensive CAD - uncomplicated surgery, extubated day 2 - yesterday: red patches arose on abd >> now purple lesions today - Hx: NSTEMI, T2DM, htn, htg - low dose SQ heparin for DVT prophylaxis, no oral anticoagulation - patchy rales on lung auscultation; large purple/black patches in periumbilical region surrounded by erythema ***likely underlying cause of skin changes?

Antibodies against platelet component [d/t type 2 heparin-induced thrombocytopenia, HIT] - Sx: heparin >5d prior and: 50%+ reduction from baseline, art/venous thrombosis, necrotic lesions at injection site, acute systemic anaphylactic rx after admin - Dx: Serotonin Release assay; start rx before confirmed - Rx: stop heparin products, start direct thrombin inhibitor [argatroban, etc.] or fondaparinux [synth pentasacch] - mech: Heparin causes platelet factor 4 [PF4] conformation change >> HIT antibodies form against now-exposed neoantigen on platelet surface >> platelet aggregation/consumption and prothrombotic state

18yo, ED w/severe chest pain; onset 1h ago, sharp, constant - dx primary amenorrhea; immigrated 2y prior; no adequate childhood medical care - BP 166/92, HR 103, 4'8"; moderate discomfort; no JVD, lungs CTAB; systolic ejection murmur - micrognathia, cubitus valgus, scoliosis; ECG: sinus tachy w/o ST-seg changes ***likely cause of sx?

Aortic Dissection assoc w/Turner syndrome [XO]

38yo w/exertional dyspnea of 6mo duration; decreased exercise capacity compared to year prior - chronic low back pain [ibuprofen, naproxen], intermittent BL heel pain; lifetime nonsmoker, no alcohol intake; no fam hx early CV/lung disease - 5'10", 167.6lb, BMI 23; impaired spinal mobility, limited cheset expansion, max apical impulse dispalced to left **likely Dx?

Aortic Regurgitation assoc w/Ankylosing Spondylitis

24yo, ED for 1wk RLQ abd pain exacerbated by motion, w/radiation to back over last 2d - started w/2 episodes vomiting, now decreased appetite - no increased urinary freq; Hx asthma, GERD; trip to Mexico for 5d 1mo prior [no GI issues then]; Fam Hx Colon Cancer in mother 49yo - 100.8F, BP 122/78, HR 109 - passive ext R hip in L lat decubitus causes significant abd pain - WBC 16K, Hgb 14.2, Plt 400K, K 4.5, Cr 1.0 ***likely Dx?

Appendiceal Abscess - delayed presentation of appendicitis [>5d] assoc w/rupture and contained abscess - anterior palpation may not be indicative; deeper signs more informative [psoas, obturator, rectal exam] - manage w/IV abx, bowel rest, +/- perQ drainage before surgery [up to 6-8wk later if not emergent] to prevent very high post-op complication rate

15yo, ED w/abd pain of 24h duration, diffuse, severe, stabbing; assoc freq bilious emesis, cannot tolerate oral intake - last BM 24h ago, minimal flatus since; nausea, anorexia, intermittent abd pain for 6mo - emigrated from indonesia 4wk ago; 99.7F, BP 112/78, HR 110, RR 12; abd diffusely tender/distended, no guarding/rebound; high pitch bowel sounds - Hgb 10.5, Plt 455K, WBC 13.8K [60N, 20L, 15E]; Na 142, K 3.3, Cr 1.2 - Abd XR: small bowel dilation, air-fluidi levels w/o pneumobilia ***etiology?

Ascariasis - apparent SBO w/peripheral eosinophilia, recent emigration from endemic region [Asia, Afr, S Amer] - +/- pulmonary sx, intestinal more common 1-2mo/nonspecific; adult worms cause lumen obx - Albendazole/Mebendazole; NG suction, fluid/electrolyte repletion

68yo w/R knee pain/swelling; 3d prior on knees for floor replacement, next day knee became red and painful - 100F, BP 130/80, HR 92; anterior R knee erythema/warmth - 5cm, tender, fluctuant swelling just anterior to patella; intact ROM w/mild pain at ends of E/F - pedal pulses 2+ BL, intact sensation, normal gait ***next step?

Aspirate Bursal Fluid >> septic bursitis - prepatellar bursa: fluid-filled synovial sac that alleviates friction bt patella and skin - infection extended from local cellulitis; probably G+ skin flora like SA, increased ri in IC [like diabetes] - send fluid for cell count, Gram stain, culture, and crystal analysis to differentiate from other bursitis - Rx: systemic Abx +/- drainage

67yo, ED w/worsening L foot pain involving entire foot [most severe at forefoot]; initially mild, but progressively worse over day - arising day prior while lying in bed; no relief with dangling foot over edge of bed [effective alleviating prior episodes] - heat pack, OTC pain = no relief; Hx htn, hyperlipidemia; smoke 1-2pk/d - BP 146/90, HR 90; bilateral LL skin shiny/hairless, L foot mottled/cooler; nonpalpable pulses BL [R detected on doppler]; L cap refill 4-5s; difficulty moving L foot/toes ***likely cause of new symptoms?

Atherosclerotic Plaque Disruption >> PAD [peripheral artery disease] - RF of PAD: smoking, htn, hyperlipidemia, symptoms usually alleviated w/dangling, shiny/hairless legs - mech: peripheral artery atherosclerosis >> plaque disruption >> thrombosis, acute-on-chronic limb ischemia - vs acute limb ischemia: Acute has 6Ps and more rapid onset; acute-on-chronic has slower onset from preexisting collateral supply that forms in chronic atherosclerosis [until overcome by acute status]

64yo w/urinary urgency, straining to urinate, sensation of incomplete bladder evacuation, and frequent nocturia of several months duration - no dysuria, fever, chills, abd/perineal pain, or penile discharge - had similar episodes prior relieved by TURP 5y ago - no othe conditions/meds; normal vitals and PE - DRE: normal sphincter tone, NT prostate, urine dipstick negative for blood, leukocyte esterase, or nitrites ***likely Dx?

BPH: benign prostatic hyperplasia - TURP leaves remaining tissue >> if no hormonal adjunctive then leftover prostate continues growth and BPH can recur

50yo, evaluation of white patch on buccal mucosa, present 2mo w/o pain, itching, or bleeding - no chronic conditions/meds; 1pk/d smoker for 30y, no alcohol use; normal vitals - see pic; lesion cannot be wiped away; oral exam shows several teeth w/crowns, no regional lymphadenopathy ***next step?

Biopsy lesion for assessment of Leukoplakia >> benign, premalignant, or malignant - benign: risk reduction counseling, regular examination +/- repeat biopsies if changes are observed - premalig: consider surgical excision

35yo, hospital burn unit w/abd distension and intolerance of enteral feedings - admitted 6d prior for electrical flash injury burning 40% total BSA - had 2 of 3 planned surgeries [burn excision/grafting], still intubated on mechanical ventialtion - doing well w/enteral feeding until last 24h >> onset high gastric residual volume and progressive abd distension - 102.4F, BP 112/60, HR 110, O2 97 on minimal vent setting [w/FiO2 35%] - dressings clean on exam, normal heart/lung sounds; abd distended, soft, tympanitic, decreased bowel sounds ***next step?

Blood Cultures + Empiric Abx - for apparent burn wound sepsis >> Sx overlap w/hypermetabolic state - note: fever, vial sign changes [tachycardia/pnea, refractory hotn], lab abnormalities, organ hypoperfusion/dysfx - new-onset enteral feeding intolerance may reflect splanchnic hypoperfusion

67yo, ED w/n/v, increasing abd pain over 3h; discharged 4wk prior after inpt admission for acute MI - Hx: T2DM, Htn, hypercholesterolemia, PUD; quit smoking 2y ago, no alcohol/illicit drugs - 100F, BP 150/90, HR 110/irregular, RR 22; severe distress from pain; chest clear to ausc - decreased bowel sounds, diffuse abd tenderness [esp LRQ], no peripheral edema - Na 140, Cl 100, Bicarb 14, BUN 25, Cr 1.1, Gluc 185; Amylase 275, Lipase 80 [0-160]; normal urinalysis ***likely Dx?

Bowel Ischemia [Acute Mesenteric Ischemia] - Assoc cardiac embolic events from afib, valvular disease, aneurysms; thrombosis from PAD or low CO states - this pt prob had LV thrombus from recent MI that embolized to mesenteric artery - Sx: sudden-onset severe periumbilical pain out of proportion to exam findings; +/- leukocytosis, elevated Hgb, elevated amylase, metabolic acidosis [lactate or low bicarb] - signs of infarct require immediate op eval, otherwise confirm via CTA - Rx: open embolectomy w/vascular bypass or endovascular thrombolysis

45yo, postop day 3 n/v after total abd hysterectomy for symptomatic uterine fibroids, complicated by ureter injury w/stent placement - adv to clear liquid diet day 2, had some nausea; since then had several vomiting episodes [no hematemesis] - no flatus or BM since surgery; see XR [pic] - 99F, BP 130/80, HR 80; mild abd distension, decreased bowel sounds, incision tender w/o erythema/discharge - Hgb 10.8, Plt 300K, WBC 11K; Na 130, K 3.1, BUN 22, Cr 1.1, Gluc 140, Mg 1.9 ***next step after IV fluids?

Bowel Rest, Serial Examination for postop Ileus - may look like SBO, but there is uniform dilation and decreased bowel sounds

39yo w/persistent R-sided breasst pain of 2mo duration; no trauma or change in activity - no chronic medical conditions, only med is OC; FDLNM 2wk prior - FamHx: female paternal cousin BC 58yo - dense breast tissue bilaterally; R breast localized tenderness lateral to areola [9o'clock]; no skin changes or axillary lymphadenopathy ***next step?

Breast Imaging - unilateral breast pain w/no mass requires imaging - malignant risk features: unilateral, persistent/noncyclic pain, focal pain/tenderness [+/- mass] - vs: physiologic pain: bilateral, diffuse, cyclic [only image if mass]

25yo, ED for several episodes of hemoptysis over last 2h - no chronic conditions/meds; never smoked, normal vitatls, BMI 27, normal lung exam - CT chest w/contrast reveals 3.2cm avidly-enhancing homogenous mass [see pic] w/endobronchial component at L hilum ***likely Dx?

Bronchial Carcinoid Tumor - MC lung canecr in kids/YA, nonsmoking - neuroendocrine malignancy derived from Kulchitsky cells [enterochromaffin] in bronchial epithelium - typically arise from proximal airway, causing bronchial obx or bleeding - Dx: CT w/contrast showing avid ehancement [highly vascular] w/endobronchial component d/t extension into lumen; homogenous or calcifications; confirm dx w/bronchoscopy/biopsy

22yo farmer, ED after tractor ran over chest; intubated in field d/t respiratory distress - BP 74/40, HR 132, 84% O2 on 100% FiO2 - L tracheal deviation, absent R lung sounds >> R chest tube placed >> normalizes BP/puls oximetry - bruising over anterior chest, crackling of neck/skin on palpation; normal heart sounds; Abd soft NTND - CXR: confirms ET/chest tube placements, multiple rib fx, R pneumothorax, pneumomediastinum, subcutaneous emphysema - 2h later chest tube drainage system has persistent air leakage despite adequate seals ***next step?

Bronchoscopy to evaluate tracheobronchial injury allowing air to escape w/each breath outside the lungs [pleural, mediastinal, subQ]

28yo primigravid; 40wk gestation; hospitalized for labor induction; no conditions, uncomplicated pregnancy - admin intravaginal misoprostol for cervical ripening, IV oxytocin >> onset progressive uterine contractions - pt-controlled bupivacaine admin for pain control via epidural >> 20min later experiences perioral numbness, metallic taste, and tinnitus w/anxiety and palpitations - BP 150/86, HR 110; normal DTR, no clonus; generalized tonic-clonic seizure during exam ***cause of seizure?

Bupivacaine Systemic Toxicity - d/t inadvertant insertion of epidural catheter into epidural vasculature >> rapid systemic absorption >> CNS overactivity +/- seizure and cardiovascular collapse - Rx: cessation, benzo for seizure, supportive care

12yo, intermittent dark urine and exertional fatigue of 2wk duration - 1yr prior: mechanical replacement of bicuspid aortic valve, on daily warfarin - mild fever, BP 110/64, HR 98, resp 16; normal cardiac exam, normal abd exam, no edema - urinalysis: spec grav 1.020, no protein, blood 3+, no leuk/bacteria, WBC/RBC both 1-2/hpf, no casts/crystals ***next step?

CBC - dark urine indicates heme positivity, but since few urinary RBCs present, likely myo/hemoglobinuria >> since no myalgia [rhabdo], and mechanical AV: likely hemoglobinuria from prosthetic valve shearing of RBCs causing intravascular hemolysis - free hemoglobin exceeds capacity of serum haptoglobin and resorption at PCT >> yields red/brown urine and positive blood on urine dipstick, but only 0-2 RBC/hpf [negative for hematuria] - next step is CBC to confirm and assess severity of anemia from hemolysis >> ↓hapto, ↑LDH/retic, and schistocytes on smear

52yo, lap chole for recurrent biliary colic >> uneventful surgery, observed in PACU and sent home - 3d later: return to ED w/persistent abd pain/nausea - on acetaminophen/hydrocodone q6h; 100F, BP 120/68, HR 104 - PE shows intact incisions, no erythema, or discharge - mild generalized tenderness, some guarding; WBC 16K, normal electrolytes and bilirubin - XR: generalized distension of small and large bowel, stool in distal colon, intraperitoneal free air ***next step?

CT Abd w/oral contrast to look for leakage from bowel injury since pt is stable - if pt had frank peritonitis >> straight to surgical reexploration

19yo, MVC 1h prior [rollover, seatbelt/airbag deployed]; alert, abd pain - BP 110/70, HR 106, RR 16, lungs CTAB, chest wall NT, normal heart sounds, abd ND w/LUQ tenderness; no gross limb deformity - FAST: free fluid in left subphrenic space ***next step?

CT Abd/Pelvis to assess source of hemorrhage [free fluid] on FAST exam following blunt abd trauma [BAT] - suspect splenic injury + hemodynamically stable >> confirm on CT >>> unstable rush to exploratory laparotomy

34yo, ED for snowmobile accident; thrown 9.8ft away, dazed several minutes w/o LOC; wearing helmet - presents w/L mid-back pain, BP130/76, HR 98; CTAB lungs, normal heart sounds, abd sft NT/ND - no areas of spinal tenderness or step-offs; L CVA tender to palpation; FAST negative, normal chest/pelvic XR - clear/painless urine sample: 11-25 RBC/hpf; normal CBC, electrolytes, Cr ***nest step?

CT Abd/Pelvis w/contrast indicated for blunt trauma w/potential renal injury [CVA tenderness, hematuria] - could also present w/flank pain, retroperitoneal bleeding +/- flank ecchymosis or hemodynamic instability - Multiphase contrast: NC, arterial, coticomedullary, excretory

40yo in ED w/RLQ pain radiating to R groin - onset 7d prior, increasing slowly since; fever/anorexia - 2wk prior: treated for furunculosis of R thigh; Hx T1DM managed w/insulin - abd tenderness in RLQ w/deep palpation, no rebound/gaurding - increased pain w/R hip extension, decreased w/flexion - Hgb 10.9, WBC 13.5K, Plt 450K ***next step evaluation/mgmt?

CT Abd/Pelvis: consistent w/Psoas Abscess [PA] - Sx: subacute fever, abd/flank pain +/- radiation to groin/hip; anorexia/wt loss; Psoas sign [worse on hip ext] - Dx: CT abd/pelvis, leukocytosis, elevated inflamm markers, blood/abscess cultures [guide abx] - Rx: drainage, broad-spec abx >> PA typically derived from infection w/hematologic seeding or direct extension of infection; elevated risk w/HIV, IVDU, diabetes, Crohn Dz

55yo, ED after falling from 20ft leaning over 2nd story roof; braced fall on arms/legs, body hit pavement full force - severe chest/back pain; BP 162/90 in L arm, HR 118, resp 24 - alert but scared, hoarse voice, symmetric/reactive pupils, midline trachea, normal breath sounds and heart sounds - bruising over sternum, tender to palpation, superficial abrasions to palms/knees, LE cool to touch, diminished pulses bilaterally ***confirm Dx?

CT Angiography of Chest - blunt thoracic aortic injury assoc w/rapid deceleration [typically at aortic isthmus bt mobile asc/fixed desc aorta - surviving pt likely has partial tear >> present similar to aortic dissection - pseudocoarctation impedes distal flow [proximal htn, diminished LE pulse], expansion proximally [compress L rec laryngeal n] - Dx: CTA chest: highly sens/spec for thoracic aorta injury [TEE good but needs experienced user, TTE more user friendly but doesn't visualize well] >> will also need surgical evaluation

11yo, ED for persistent vomiting; first episode 12h prior, last 4h unable to keep down liquids - nausea/epigastric discomfort, but no fever, abd distension, diarrhea - competitive gymast, fell striking abdomen on beam yesterday - 98F, BP 106/72, HR 110, RR 18, normal heart/lung sounds; abd scaphoid w/linear bruising across epigastrium - palpation elicits tenderness w/o guarding, rigidity, or rebound - upright C/Abd XR normal w/o free air; FAST normal ***next step?

CT abdomen for concern of duodenal hematoma d/t blunt abd trauma [BAT] - compression of duodenum against vertebral column injuring submucosal/muscularis vessels >> hematoma formation/expansion over 24-48h >> progressive duodenal obstruction - CT: homogenous density - Rx: bowel rest, NG decompression, parenteral nutrition, serial CT/US

65yo, 4wk progressive abd pain, constant, worse w/eating [anorexia, wt loss]; Hx heartburn [OTC meds] - 4wk of omeprazole w/o improvement; 10pkyr hx smoking but quit a few yeas ago; normal vitals, BMI 34 - epigastric tenderness, neg stool occult blood, normal serum/liver labs - UGI endoscopy: mild esophagitis, no gastritis; Abd US: 2 large gallstones, no GB thickening, pericholecystic fluid, or ductal dilation; pancreas poory visualized from gas ***next step?

CT abdomen to assess Pancrease for mass/inflammation - pancreatic cancer signs: smoking hx, alcohol abuse; progressive/constantt epigastric pain +/- rad to flank/back; pain worse w/eating and supine, better in curled position - wt loss, jaundice, nausea common

26yo, ED w/6wk hx intermittent lower abd pain w/cramps, rectal urgency, bloody diarrhea, nausea, and decreased appetite; increased severity in last 2d - no travel or recent abx hx; 101F, BP 90/50, HR 130, RR 15 - lethargic, ill-appearing, decreased bowel sounds; Abd distended, tympanic, diffusely tender, no rebound/rigidity - rectal exam: tenderness, mucus mixed w/blood in vault - Hgb 10.2, WBC 31.6K, Plt 398K - Admin IV fluids >> BP 104/58, HR 108 ***next step?

CT scan Abdomen to assess IBD yielding apparent toxic megacolon

65yo w/2wk hx dysuria and turbid urine, air bubbles present while urinating - no fever, hematuria, hematochezia, wt loss, pelvic/flank pain - Hx BPH causing straining w/urination and weak stream [undergoing treatment] - 4wk prior: ED visit for persistent LLQ pain d/t acute diverticulitis - today: 98.7F, BP 132/84, HR 72; Abd soft/mild tender LLQ; DRE w/smooth, enlarged NT prostate - normal serum labs; Urinalysis: WBC/Bacteria [culture: E. coli, Proteus, Kleb pneumo] ***next step in dx?

CT scan w/rectal contrast to look for Colovesical Fistula d/t prior diverticulitis episode - Sx: fecaluria, pneumaturia [typically at end of urination], recurrent UTI - also assoc w/Crohn dz and colorectal malignancy - Dx: oral/rectal contrast Abd CT w/subsequent colonoscopy to r/o malignancy

34yo, chronic pelvic pain/dyspareunia from endometriosis >> elective endometriosis laparoscopic resection under general anesthesia; prolonged procedure d/t excessive pelvic adhesions - moderate blood loss in surgery >> large-volume isotonic saline infusion - see pre/post-op serum chemistries/ABG in pic ***source of acid-base imbalance?

Chloride-Bicarb Ionic Shift dt metabolic acidosis mediated by excess saline infusion yielding nonanion gap metabolic acidosis - Cl/Bicarb are the predominant anions readily exchanged between fluid compartments to maintain electronegative balance - excess normal saline [NaCl] >> elevated intravascular Cl- >> drives intracellular shifting of Bicarb >> less Bicarb in bloodstream means lower pH blood

75yo, ED w/2d abd pain/nausea; nursing facility w/severe chronic conditions - mild fever, distended abd w/diffuse tenderness, no rigidity/rebound - see XR ***major RF of condition? [chronic constipation, colonic hypermotility, electrolyte abnormality, NSAIDs, recent abx use]

Chronic Constipation: yielding Sigmoid Volvulus - RF: colonic dysmotility [neuro], sigmoid colon redundancy [dilation/elongation from chronic constipation] - Twisting of sigmoid colon around its mesentery causes closed-loop obstruction - continued gas formation by bacteria expands obstructed loop >> slow/progressive distension/discomfort +/- loss of appetitie, n/v, obstipation

29yo new office pt; overall feels well but 4-5 loose BM daily w/mild, cramping abd pain; no wt changes, blood, vomiting, rashes, joint pain - Hx Crohn Dz [ileocolectomy 3y ago; on adalimumab, azathioprine], T2DM, morbid obesity, GAD - frequent fast food diet, minimal fruit/veg/whole wheat bread intake; 15yr smoking cigarettes and marijuana - 99F, BP 132/89, HR 80, RR 12, BMI 41; normal oropharyngeal exam, normal heart/lung sounds ***strongest association w/CD progression?

Cigarette Smoking - only major modifiable risk factor affecting severity and progression of Crohn disease - assoc: increased hospitalizations, intestinal surgery, biologic therapy failure - other RF: young at dx [<30yo], extensive anatomic involvement, perianal disease, deep ulcerations, strictures, fistulization, prior intestinal surgery

70yo, ED w/severe L wrist pain after falling; no head hit or other injury - Hx: htn, osteoporosis, normal vitals - L wrist: bruised, swollen, diffusely tender to palpation, intact skin - radial pulse absent, delayed finger capillary refill; XR pic ***next step?

Closed Reduction in ED: for Colles fracture - left distal radius and ulna fractures w/severe displacement of distal radius proximally/dorsally - classically FOOSH in elderly, RF: osteoporosis - neurovascular exam dt compression/injury risk to radial artery and median nerve [absent pulse, delayed cap refill] >> deficits indicate need for immediate reduction to restore normal arterial alignment

64yo, elective L inguinal hernia repair; present several years w/recent increase in size and discomfort affecting ADLs - Hx Htn, hyperlipid, C-section; no tobacco/alc/drugs - nonmesh open hernia repair w/no intraop complications >> discharge instructions to limit strenuous activity ***what provides max tensile strength to pt wound?

Collagen cross-linking

58yo, ED w/wrist pain after fall [forward FOOSH] - gross deformity [see pic], extensive swelling/bruising, normal distal pulse and capillary refill, gradual paresthesia onset in ED ***Classic Fracture? Impacted Function?

Colles Fracture affecting median nerve distal to injury - Sx: pain, swelling, dinner fork deformity, +/- neurovascular compromise - dorsal displacement of distal radius >> median nerve compression >> s/s carpal tunnel paresthesia, impaired thumb abduction, +/- paresthesia of anterolateral hand if cut br affected

28yo w/painful breast mass noted during last menstrual period, size unchanged, no skin changes or nipple discharge - palpable 3cm mass in R breast at 5o'clock; soft, mobile, tender - US: single, thin-walled, fluid-filled cyst - FNA to aspirate fluid: clear, light yellow >> mass still visible on US/palpable ***next step?

Core Needle Biopsy - painful palpable breast mass, PE/hx can't eval cancer >> need imaging - US preferred <30yo: symptomatic cysts use FNA >> persistent after aspiration indicates core needle biopsy ***if nonbloody AND mass/symptoms resolve no need for further exploration

65yo, 3d progressive R flank pain, 4wk dysuria and urinary frequency - Hx CAD, htn; father died prostate cancer - 98.8F, BP 130/86, HR 82, RR 16; Abd soft NTND, no suprapubic tenderness, mild R CVA tenderness - normal external genitalia, no discharge, mildly enlarged prostate w/o nodules or tenderness on rectal exam - Cr 1.5; Urinalysis: moderate blood [RBC 30-40/hpf], no bacteria/casts/dysmomrphic cells; negative gram stain, no culture growth - Abd US: R-side hydronephrosis, normal L kidney/uter ***next step?

Cystoscopy for suspected bladder cancer - hydronephrosis, acute flank pain, hematuria, voiding sx [dysuria, freq] - RF: chronic carcinogen exposure [envi, smoking] - typically >40yo, painless hematuria w/o evidence of infection, GN, nephrolith - Cystoscopy gold standard to directly visualize bladder wall and biopsy; Abd CT for staging

38yo, 6wk progressive R hip pain, localizes to R groin, present at rest, worsens w/wt-bearing - Hx sarcoidosis [extended course oral glucocorticoids] - BP 156/86, round face, fullness to supraclavicular area - abd/int rotation of femur aggravate pain - less strength in proximal thigh, normal reflexes, no sensory deficit - no major abnormality on XR ***likely cause of pain?

Disruption of bone vasculature: suggests osteonecrosis [avascular necrosis] of femoral head d/t chronic glucocorticoid use - long-term GC >> affects osteocytes, abnormal plasma lipids may cause microemboli - osteonecrosis >> bone/marrow infarct >> abnormal bone remodeling and trabecular thinning/collapse [gradual] - @femoral head: groin/thigh/buttock pain worse w/activity, ↓ROM [esp abd/int rot], pain at rest, joint instability - early XR may appear normal >> MRI more sensitive

Pt on involuntary psych hold, laceration w/no active bleeding - refuses recommended irrigation and closure to get more sleep ***response?

Don't perform procedure, reassess when pt less sedated - informed consent - on involuntary hold, but still has decisional capacity and wound is non-emergent >> still has right to refuse non-life-threatening injury treatment

10yo, ED w/post-prandial abd pain and bilious emesis - 2d prior abrupt bicycle injury slamming into handlebar, followed by abd pain that improved the next few hours - normal vitals, epigastric tenderness, no rigidity/rebound, normal bowel sounds - US: no intraperitoneal fluid; Abd XR: gastric dilation, scant distal gas - Hgb 13.8, WBC 8K, Tot bili 1.3, Amylase 91 ***likely Dx?

Duodenal Hematoma d/t blunt abd trauma - often delayed presentation of postprandial abd pain and sx of proximal small-bowel obx [bilious emesis, gastric dilation, scant distal gas] - mech: rapid compression of duodenum against vertebral column injuring BVs of submucosal/muscularis layers >> bleeding/hematoma >> expansion in 24-48h can obstruct duodenal lumen - confirm on CT; Rx: bowel rest, NG decompression, parenteral nutrition [persistent/weeks may require perQ drainage or surgery]

73yo, ED after found fallen on floor; L hip pain, does not recall moments before fall - has felt "sick" a few days w/SOB, cough, intermittent palpitations - Hx T2DM, Htn, COPD, BPH - 99.1F, BP 118/76, HR 116, RR 24, 95% O2 on 2L per NC - alert/oriented, no sign head injury; breath sounds decreased at R lung base, crackles at L lung base - L LE shortened/ER; normal CBC, gluc, serum chem, coag panels; see XR pelvis [pic] ***next step?

ECG, Cardiac Markers, CXR - Apparent L femoral neck fracture requiring surgical repair - several unstable medical conditions present in this patient >> need more extensive preop evaluation of possible arrhythmia, pneumonia, pleural effusion, etc. - should not delay repair >72h

20y M, follow-up shoulder dislocation - Hx multiple joint dislocations since childhood, easy bruising, poor wound healing - 176cm height, 70kg wt; normal vitals; several wide/atrophic scars present on both UE - Echo: normal aortic root size and LVF, no valve abnormalities ***likely Dx?

EDS [Ehlers-Danlos Syndrome]; compare to Marfan in pic - some features: joint hypermobility/laxity, skin hyperextensibility, tissue fragility, poor wound healing

52yo, intermittent RUQ pain/nausea; Hx obesity/gallstones [cholecystectomy 1y prior] - pain in R subcostal region lasting 30-60min; had similar episodes before surgery - tot bili 2.1, direct bili 1.2, ALK 185, AST 84, ALT 72 - Abd US: mild dilation of CBD, pancreas normal ***next step?

ERCP [endoscopic retrograde cholangiopancreatography] - for Post-cholecystectomy syndrome: persistent precholecystectomy sx attributable to biliary [bile duct] or extrabiliary [PUD, IBS, pancreatitis, CAD] causes - yields persistent abd pain, dyspepsia

64yo, hx uncontrolled htn, ED w/8h chest pain - ECG: normal sinus w/ST-elevation of anterior leads >> PCI via R femoral artery: complete occlusion of LAD >> stent placed and started on medical therapy >> 6d later: sudden onset L leg pain, cold/mottled, no swelling; bilateral palpable femoral pulses, but L pedal pulse absent [R present] ***Diagnostic to consider next?

Echocardiography: to evaluate LV aneurysm/thrombus - pt presenting with Acute Limb Ischemia [ALI] d/t arterial occlusion assoc w/thrombosis/embolism >> anterior STEMIs from LAD have highest risk of LV aneurysm formation [esp w/delayed reperfusion - pt had 8h symptoms before intervention] >> can yield stasis of blood from low EF >> LV thrombus >> embolization causing stroke or ALI - Rx: immediate ALI response [heparin, vascular surg consult] + TTE [transthoracic echo] to assess LV aneurysm or residual thrombus [may affect anticoag mgmt]

28yo, ED after concrete slab fell on legs at construction site, trapping pt from waist down for 15min; no head/upper torso injury or LOC - BP 140/90, HR 110, heart and BL lung sounds normal; abd soft NT/ND; obvious deformities/abrasions to both LL - XR: multiple BL LE fractures >> admin succinylcholine for RSI ***succy has greatest risk of what? [hint: not MH]

Electrolyte derangement yielding cardiac arrhythmia - depolarizing NM blocker binds postsyn ACh receptors triggering Na influx and K efflux >> may cause severe hyperkalemia in some pts yielding life-threatening arrhythmia - esp at risk after skeletal muscle crush injury from rhabdomyolosis K-release and upregulated ACh-receptors - other RF: burn injury, disuse muscle atrophy, denervation [upregulation of AChR] - alt RSI: non-depolarizing agents [curoniums]

63yo w/COPD; ED for 3d of increasing dyspnea [ran out of maintenance and rescue inhalers] - initially only w/exertion, now present at rest w/wheezing and nonproductive cough - CXR: lung hyperinflation w/o infiltrates - admitted w/no response to therapy >> intubated >> mech vent for worsening hypercapnia and increased work breathing ***Prevent VAP?

Elevate head of bed 45* - VAP RFs: acid suppression, supine, pooled subglottic secretions, paralysis/excess sedation, excess movement on intubation, frequent ventilator circuit changtes - VAP: pneumonia onset 48h after endotrachea intubation; assoc w/aspiration of oropharyngeal/gastric microbes

65yo, ED w/6h bilateral leg wkness/tingling, 2d new-onset LBP - Hx obesity, degenerative disc dz, hysterectomy for uterine cancer [15y prior]; spinal tenderness T6 - LE strength 3/5, UE 5/5; DTR brisk in LE - MRI: multilevel DDD, fluid collection spanning T6-8 ***next step?

Emergency Laminectomy and Decompression for apparent spinal epidural abscess [see chart] - bacterial infection of epidural space, tendes to affect multiple adjacent levels >> compression of spinal cord leads to neuro deficits - Emergency: Empiric Abx [staph/strep/GNB coverage] + Surgical Decompression [laminectomy] - lack of immediate rx >> rapid progression to permanent paralysis or death

16yo, ED for eye injury; 1h prior shot in face by paintball w/o eye protection >> immediate pain and difficulty seeing - no chronic medica conditions; 99F, periorbital edema and acchymosis w/proptosis of L eye - palpation of L-eye has rock-hard induration; visual acuity 20/100 [vs 20/20 on R]; relative afferent pupillary defect in L eye ***next step?

Emergency Orbital Decompression for Orbital compartment syndrome - rapidly increasing IOP can cause ischemia of optic nerve/globe causing permanent vision damage if uncorrected

58yo, increasing leakage of fluid from abd incision 5d after total abd hysterectomy and bilateral salpingo-oophorectomy for ovarian cancer - fluid leakage and bulging at incision when walking today - BP 144/92, HR 88, BMI 50, no rebound/guarding - vertical midline incision: surrounding erythema, large amount seeping serosanguineous fluid - removed staples >> protrusion of fatty tissue, loop of bowel between rectus abdominus mm >> moist dressing over wound ***next step?

Emergency Surgery for evisceration [deep wound post-op complication] - Deep wound dehiscence: involving rectus fascia; evisceration, heavy drainage; typically 1-2wk after surgery [up to 30d] >> need emergency surgery to prevent further herniation and strangulation - superficial wound dehischence: separation of skin/subQ tissue, intact rectus fascia; typically 1wk post op; +/- seroma >> mgmt: careful dressing changes; conservative

43yo, ED for 24h of increasing pain in lower abd, scrotum, and perineaum w/malaise and nausea - no abd surgery or recent perianal/scrotal trauma - Hx morbid obesity, htn, T2DM, hypercholesterol, HFpEF - 103.5F, BP 80/60, HR 112, RR 18; 96% O2 on room air; BMI 47 - ill/uncomfortable appearance, no JVD, lungs CTAB, normal heart sounds - skin over lower abd, scrotum, perineum is tender, erythematous, swollen w/crepitus; mild BL LE edema - WBC 27.8K [20% bands]; bicarb 18, Cr 1.7, Gluc 280; INR 1.4 ***next step after blood cultures and IV fluid/abx?

Emergent Surgery for apparent Fournier Gangrene [life-threatening necrotizing fasciitis +/- progression to sepsis/death] - rapid-onset skin infection of lowe abd, scrotum, perineum >> crepitus, systemic sx [hotn, fever, leukocytosis] - often polymicrobial colonic/urogenital organisms entering cutaneous breakdown of perianal/genital region - RF: poorly controlled DM, obesity - requires early surgical exploration and debridement [>20% still die during hospitalization]

70yo, ED w/8h hx R groin pain, n/v; Hx ESRD [3x/wk hemodialysis, last was 24 ago] - 102.2F, BP 92/58, HR 114; 6cm firm, tender, R inguinal mass; lungs clear BL, trace BL LE edema - Hgb 10, Plt 240K, WBC 17K [80% N]; Na 136, K 5.8, Cl 104, Bicarb 22, BUN 36, Cr 3.6 - normal ECG, IV fluid/abx started ***next step?

Emergent surgery w/intraoperative potassium monitoring - Apparent strangulated inguinal hernia w/signs of sepsis - hyperkalemia [>5.5] can be exacerbated in surgery >> emergency preop ECG >> no ECG changes: immediate surgery w/intraop monitoring >> presetn changes: short hemodialysis first if possible

45yo w/HIV, ED for increasing SOB, L-side chest pain, chills, and productive cough; onset 1wk ago - initially felt like flu sx, day 3 started coughing up gren phlegm and dev chest pain - pain worsens on deep inspiration or cough; CD4 count unknown; smoke cigs/drinks regularly - 102F, BP 110/70, HR 110, RR 26; poor dentition, decreased sounds over L lung base, see CXR ***likely cause of symptoms?

Empyema - complicated parapneumonic effusion - elevated risk in IC - require prolonged [2-4wk] abx and drainage [chest tube]

34yo, rural ED after rescued from burning building, trapped for prolonged period - presents w/HA/dizziness; 98.6F, BP 90/60, HR 100, RR 26; O2 100% on nonrebreather; awake/alert - diffuse oropharyngeal mucosal blisters; mild wheezing; deep partial/full-thickness burns to 45% BSA [face, neck, extremities]; circumferential deep partial to L lower arm - present radial pulses, Abd soft NTND, blood carboxyhgb 35%; IV fluid resuscitation initiated ***next step?

Endotracheal Intubation - burn injury: 1st stabilize airway/breathing >> 100% O2 for presumed CO-poisoning, early inhalation injury assessment [thermal airway injury may cause progressive airway edema] - w/this pt need endotracheal intubation before it potentially becomes difficult/impossible from edema

40yo w/hx HOCM undergoing elective hysterectomy under GA for large, symptomatic uterine fibroids and blood loss anemia - mild dyspnea w/mod exercise, on metoprolol -BP 120/80, HR 65, clear lungs, midsystolic murmur, no JVD or peripheral edema ***recommended during anesthesia to prevent perioperative complications?

Ensure adequate IV hydration - HOCM >> dynamic LV outflow tract obx worsened by low volume >> require hemodynamic optimization to prevent occurrence - basically adequate hydration + avoid venodilators - beta blockers beneficial to lengthen diastolic filling time

32yo, ED w/intense, midline chest pain and diaphoresis of 4h duration; prior to onset had nausea and recurrent vomiting after returning from a party - Hx: HIV, alcohol use disorder, alcoholic hepatitis; uses cocaine regularly, noncompliant w/meds - 101F, BP 100/60, HR 120, RR 28, injected conjunctivae and BL pupil dilation - diminished L breath sounds, normal heart sounds; CXR: widened mediastinum and L-pleural effusion; ECG tachycardia; pleural fluid: yellow, high amylase ***likely dx?

Esophageal Perforation

35yo, Hx IVDU, ED w/R-side weakness of 2h duration; night sweats/malaise for 7d - 102F, BP 122/76, HR 112, RR 18; 3/5 strength on right - MRI w/diffusion and MRA head/neck >> distal, small single infarct of MCA; no large vessel occlusion - TEE: mobile vegetation on aortic valve w/mild regurg - cultures obtained and IV abx initiated ***next step?

Evaluate for Aortic Valve Surgery - acute cardioembolic stroke d/t native valve infective endocarditis [IE] >> elevated risk of TIA/stroke from septic embolism [commonly to MCA] - thrombolytics contraindicated [vs regular ischemic stroke] d/t increased rate of intracerebral hemorrhage >> Mgmt: Abx + eval for surgery

62yo, L forearm pigmented lesion arising 4mo prior w/occasional itching, initially thought were freckles from golfing in summer - Hx psoriasis, htn, mild COPD; quit smoking 5y ago, 2-3 glass wine/week - 5mm dark brown lesion on dorsal surface of distal L forearm; smooth border w/small eccentric nodule; multiple scattered, flat, light brown lesions on nose, cheeks, dorsal hands ***next step for forearm lesion?

Excisional Biopsy for suspicion of malignant melanoma

10d M; ED for persistet bilious vomiting for 10h+; irritable and refuses feeeding; last BM 24h ago - vaginal birth, no pre/neonatal complications; Apgar 8 and 9; 100.2F, BP 66/36, HR 176 - lethargic, fontanelles open/flat, neck supple; abd firm/distented w/hypoactive bowel sounds, tender to palpation, normal rectal tone, stool in rectal vault, (+) occult blood - see XR [pic] ***next step?

Exploratory Laparotomy for suspicion of Midgut Volvulus - classically w/bilious emesis, potential for necrosis and rapid clinical decline [GI bleed, hypovolemic/septic shock, peritonitis/perf] - dilated bowel loops on XR w/normal rectal examination - hemodynamically stable: Dx gold-standard is upper GI series w/contrast; Unstable/peritoneal signs [this pt]: exploratory laparotomy

53yo, ED w/incr SOB and R-pleuritic chest pain of 10d duration - 5d prior abx from urgent care for pneumonia, w/no change in condition; smokes pk/d, 2-3beer/d - fever, HR 104, resp 18, no JVD, dull to percussion over R lung base - CXR: large, looculated R pleural fluid ***likely pleural fluid findings?

Exudative: bacterial pneumonia yielding pleural effusion >> persistent invasion may yield complicated effusion/empyema >> continued symptoms despite abx +/- loculation [walled off pleural fluid]; thoracentesis shows exudative effusion [criteria below] - ↓ glucose [<60]: consumption by neut/bacteria - ↓ pH [<7.2]: anaerobic gluc consumption - ↑ Protein: ↑ vascular permeability, cell destruction

27yo, ED for severe L hand pain after accidentally injececting index finger w/pain from an industrial sprayer at work yesterday - initially just localized soreness, awoke inthe middle of the night w/severe pain - no chronic conditions, vax UTD including tetanus - BP 144/86, HR 100, RR 18; 99F; L index finger, hand, and forearm swollen; 4mm puncture wound near PIP - tenderness along flexor surface, passive finger extension elicits severe pain radiating up arm - cap refill <2s in hand and all digits ***next step?

Fascriotomy, Debridement in OR for acute compartment syndrome secondary to high-pressure injection injury - initially sore/innocuous punture wound >> unseen internal damage, chemical irritation, inflammation >> extensive cellular necrosis, inflamm, edema +/- infection from bacterial inoculation - requires immediate surgical debridement and fasciotomy

24yo, breast lump, unsure duration but recently became more noticeable w/exercise >> pulling/tugging sensation - regular menses [26d interval, 2d heavy flow, 2d light flow]; FDLMP 3wk prior; sexually active [combined est/progest OC] - avid runner, wears sports bra daily; FamHx: paternal aunt BC 62yo - ovoid 4cm mass in superior outer quadrant of R breast; firm, nontender, mobile ***likely Dx?

Fibroadenoma [see pic for ddx] - isolated palpable mass >> ovoid, firm, mobile - MC <30yo, sensitive to estrogen fluctuation [increased E = increased growth, more noticeable prior to menses or initiation of combined OC] - small, well-circumscribed, mobile; typically upper/outer quadrant; no skin/nipple changes

Management/Evaluation of Fibroadenoma [vs other palpable breast masses]

Fibroadenoma: solitary palpable mass >> US sufficient to determine benign/cystic or solid/potentially malignant mass +/- mammography to further eval malignant-appearing mass

19yo, recurrent HA; occurring for years but recently worsened; last several hours, remit spontaneously or w/OTC acetaminophen - no n/v, abd pain, sweating, fever; recently had high BP check at pharmacy; no other conditions/meds - Fam Hx: htn, diabetes - BP 170/100, HR 80, RR 14; full/symmetric peripheral pulses; systolic bruit heard under R ear ***cause of htn?

Fibromuscular Dysplasia >> secondary hypertension - systemic noninflammatory disease of renal and internal carotid arteries >> arterial stenosis, aneurysm, dissection - 2o htn from renal artery stenosis >> 2o hyperaldosteronism

25yo, ED for abd pain, n/v; onset 2mo prior, intermittent RLQ pain; now diffuse, severe, unremitting - 2d ago bilious vomiting w/o hematemesis, melena, hematochezia, diarrhea, wt loss - no BM in 2d, but frequently passes flatus - Hx Crohn disease w/ileal involvement [infliximab, never had surgery]; pain relief w/OTC analgesics, no narcotics - smokes 3-4 cig/d, no alc/drugs - 99.5F, BP 134/78, HR 95, RR 18; Abd distended, tympanic, tender to palpation w/o rebound/guarding ***likely explanation?

Fibrotic Intestinal Stricture: causing SBO - complication of CD w/poorly controlled severe inflammation - increase risk of uncontrolled inflamm in smokers, <30yo - Sx SBO: bilious vomiting, severe abd pain, partial [gas no stool] or complete [neither] obx; abd distension, high-pitch/tympanic bowel sounds - may require surgical resection depending on length/location of stricture

4mo boy w/noisy breathing; harsh sound w/cry at 2wk old, gotten louder the last month, esp on back, improves w/tummy time or when held upright - no labored breathing or cyanosis; occasional spit-up after feeds, 60%ile wt; born full term no complications - inspiratory stridor when supine, improved prone; normal exam otherwise ***confirmation of likely Dx?

Flexible fiberoptic laryngoscopy to assess Laryngomalacia - chronic stridor in infants from "floppy" supraglottic structures that collapse on inpiration - onset in neonatal pd, loudest at 4-8mo >> inspiratory stridor worse in supine position, exacerbated by feeding or URI - on scope: omega-shaped epiglottis and collapse fo structures - improvement w/GERD treatment; spontaneous resolution by 18mo

80yo, ED w/2d fever, productive cough, SOB; HR 102, resp 20 - hx htn, CAD, asc aortic aneurysm, aortic insufficiency; 30pkyr recent ex-smoker - R-side lung crackles, early diastolic murmur; ↑WBC, CXR: R upper lobe infiltrates ***ABX contraindicated? >> amoxicillin, azithromycin, ceftriaxone, doxycycline, or levofloxacin

Fluoroquinolones [-floxacin] >> d/t hx aortic aneurysm [collagen-related AE: AA rupture, Achilles rupture, retinal detachment] - all these meds are options to treat community-acquired pneumonia - Aortic Aneurysm rupture risk: known history, or substantial risk [Marfan, EDS, adv atherosclerosis, uncontrolled htn] ***other AE: encephalopathy, peripheral neuropathy, prolonged QT

66yo, ED for worsening abd pain of 1wk duration; vague LLQ discomfort, nausea, anorexia, constipation - today: sudden severe lower abd pain w/light-headedness and vomiting >> initially improved then gradually intensified involving entire abdomen - Hx CAD, remote appendectomy; 100.9F, BP 110/54, HR 108, RR 20; alert/cooperative but uncomfortable - normal heart/lungs, diminished bowel sounds; abd diffusely tender w/guarding/rebound ***likely on Abd imaging?

Free air in peritoneal cavity - suspicion of acute diverticulitis w/subsequent diverticular perforation yielding peritonitis +/- sepsis/shock - free air will be visible on imaging [upright XR or CT]

68yo w/L eye vision loss; hx adv ovarian cancer [combo chemo], admit to hospital w/small bowel obx [lap/resection, 14d prior] - complication: anastomotic leak [TPN, pip/tazo] - 2d progressive blurring of vision and floaters, fever; reduced L eye visual acuity, fundo: fluffy, yellow-white chorioretinal lesions w/ill-defined borders - no central venous catheter or abd incision abnormalities ***cause of ocular symptoms?

Fungal Endophthalmitis: candidal infection dt invasion of retina/fluid chambers [hematogenous dissemination to choroid from existing distant fungemia - RF: indwelling central catheter, TPN, broad-spec abx, GI surgery, IC [chemo in this pt] - typically in hospitalized pt, or after recent eye surg - Sx: unilateral floaters/vision loss, rarely pain; +/- fever - Candida-specific: fluffy, yellow-white, mound-like lesions w/indistinct borders - Dx: vitreous fluid sample/culture [blood culture usually neg]; Rx: systemic antifungal, +/- vitrectomy/vitreous injection

59yo, routine visit w/o symptoms, no documented conditions or medications - no travel, no tobacco/alc/illicit drugs - BP 120/70, HR 88, RR 14; firm, nontender RUQ mass [see CT], unremarkable labs ***at risk of?

Gallbladder Adenocarcinoma - "porcelain GB" d/t chronic choolecystitis, may be asymptomatic , have RUQ pain, or NT RUQ mass on examination

16yo w/new-onset jaundice; admitted 24h prior for emergent appedenctomy and drainage/irrigation of peritoneal cavity for perforated appendicitis - no chronic conditions, on IV morphine and Pip-Tazo; no blood products - 100.6F, BP 118/80, HF 98; mild scleral icterus, normal heart/lung exam; mildly tender laparotomy site, no drain, no rigidity/rebound - Hgb 14.4, Plt 160K, WBC 11.5K; tot bili 3.3, direct 0.3, ALK 70, AST 27, ALT 24 ***likely Dx?

Gilbert Syndrome >> Deficiency of hepatic UDP gluconyltransferase - indirect hyperbilirubinemia

65yo, ED for abd pain, nausea for 1d - Hx ESRD from adv diabetic nephropathy [home peritoneal dialysis] - kidneys make little urine, regular BMs - 100.9F, BP 150/84, HR 108/regular, RR 20; normal heart/lung exam; Abd diffusely tender; normal dialysis catheter site; WBC 12K ***next step?

Gram stain/Culture Peritoneal Fluid

40yo, sore throat onset 2mo prior, worsens w/swallowing, dysphagia to solids, worsening halitosis - no med hx, nonsmoker, no alc, long-term monogamous but several prior partners - mild dental dz but otherwise normal nasal and oral examination - oropharyngeal: enlarged, firm R tonsil [2cm ulceration]; 2 enlarged, firm, fixed, NT LN on R ***likely cause?

HPV >> consistent w/HNSCC [head/neck sq cell carcinoma] - RF: older age, tobacco/alc use, poor dentition; HPV+ HNSCC assoc w/younger pts w/multiple sexual partners [instead of tobacco]; MC HPV16 [in vax] - Sx: enlarged, firm neck mass w/ulcerated tonsillar lesion +/- pharyngitis, dysphagia, halitosis

25yo, ED for pain/swelling of R ear after several blows to ear in wrestling match - no LOC/HA/neck pain/hearing loss; BP 110/55, HR 84, RR 14; R ear red, swollen, w/auricular hematoma - normal tympanic membrane w/o hemotympanum, normal auditory canal, no mastoid erythema or tenderness, no facial symptoms, normal neuro ***next step?

Hematoma Evacuation [drainage]

24yo Indian man in ED w/3d LUQ abd pain arising after returning to US from visiting family in India - no fever, palp, n/v/; no regular tobacco/alc use but had a drink on the flight home to help sleep - 99F, BP 120/80, HR 96, RR 16, 97% O2 on room air - normal PE w/LUQ tenderness [no rigidity/rebound]; no LE edema or rashes - Hgb 14, reticulocytes 2.5%, Plt 220K, WBC 10.4K; indirect bili 1.7 - Abd US: normal liver, slightly enlarged spleen w/hypoechoic wedge [likely infarct] ***method to diagnose underlying condition?

Hemoglobin Electrophoresis - Presentation consistent w/Sickle Cell Trait [normal Hgb, mild intravascular hemolysis, no prior pain crises >> not SCD] - Assoc Cent/S Amer, Caribbean, ME, Medit, India - Generally asymptomatic carriers of gene, can be ppt by stressors >> high altitude, dehydration [alcohol], etc - ppt can lead to ischemic infarct, vasoocclusive pain - Dx: Hgb Elecrophoresis

55yo, ED for rectal pain; started abruptly yesterday w/BM, now excruciating - no fever, abd pain, hematochexia, wt loss; Hx chronic constipation - 99.5F, BP 155/90, HR 105, RR 12; Abd soft NTND - rectal exam: exquisitely tender, purplish mass just below dentate line ***next step?

Hemorrhoidectomy

55yo, progressive abd distension over 2mo; clothes no longer fit - 99.5F, BP 152/87, HR 80, RR 18; abd grossly enlarged but NT/ND; shifting dulness; trace pitting edema BL LE - paracentesis: bloody ascitic fluid; repeat another site w/same result ***likely underlying condition?

Hepatocellular Carcinoma - bloody ascites: typically localized trauma from paracentesis and self-limited >> persistence on several repeats suggest malignancy destroying peritoneal BVs - HCC: MC malignant cause of bloody ascites >> RF: cirrhosis [MCC], chronic HBV, envi [aflatoxin]; less common from distal metastasis - Dx: contrast-enhanced CT, elevated AFP, cytology of ascitic fluid

36yo, Upper/Lower enndoscopy to evaluate abd pain, anorexia, nausea, and intermittent vom/diarrhea of several months duration - additional fatigue and 22lb wt loss; unrevealing imaging; no other conditions/meds - no tobacco, alcohol, illicit drugs, or allergies - PE normal w/mild diffuse abd tenderness - admin propofol for induction >> rapidly hypotensive within minutes; 100F, BP 66/40, HR 108, RR 20, O2 95% on room air; no wheezing/rash, normal heart/lung sounds - hypotension remains w/IV fluid bolus and epinephrine admin - rapid labs: Hgb 13, Plt 200K, WBC 8200 [N 60%, E 12%, L 28%]; Na 130, K 4.9, Cl 98, Bicarb 20, Cr 0.8, Gluc 64 ***likely cause of cardiovascular collapse?

Hypoaldosteronism from Primary Adrenal Insufficiency [PAI] >> adrenal crisis - Sx: fatigue, wt loss, abd pain, anorxia, GI disturbance - mech: AI-destruction of all 3 adrenal cortex layers >> deficient aldosterone, cortisol/GC, androgens >> hyponatremia, hypoglycemia, peripheral eosinophilia [not suppressed by CS] >>> acute stressor [surgery, endoscopy, injury, infection, etc] ppt Adrenal Crisis >> primarily d/t hypoaldosteronism >> yielding hotn refractory to fluid resuscitation and vasopressors - Rx: rapid volume repletion + GC replacement [dexamethsone > hydrocortisone], followed by mineralocorticoid [fludrocortisone] for later sodium-retention

62yo, ED for acute R-side HA, ocular pain, nausea onset while watching TV after dinner; cold compress and acetaminophen ineffective; called ambulance after decrease in vision of R eye - uncomfortable w/episodic retching; R eye conjunctival flushin, R pupil mid-dilated and nonreactive to light ***next step?

IV Acetazolamide for Angle-closure glaucoma - mech: decreased aqueous outflow >> increased IOP [Rx: reduce IOP]

45yo, ED for L groin/abd pain w/n/v - Hx SLE, Htn, glucocorticoid-induced hyperglycemia - Central obesity, skin striae, nonreducible tender mass of L groin - CT Abd shows L femoral hernia containing bowel segment and small dilated bowel loops - Ex Lap for resection of obstruted loop and hernia repair - no intraop complications >> hotn in PACU, remains <90/60 despite several fluid bolus ***next step?

IV Hydrocortisone for Acute Adrenal Insufficiency/Crisis - acute stressor in setting of chronic AI secondary to HPA axis suppresion by long-term glucocorticoids

44yo, 2mo low-grade fever, abd pain, and intermittent bloody diarrhea; pain dramatically increased in last 48h - no meds/allergies; lost 10lb in 8wk; no travel hx - 102F, BP 102/70, HR 118, RR 22; pale/dry mucous membranes; abd distension and diffuse tenderness - Hgb 9.5, WBC 16K, neg HIV; XR in pic ***intervention indicated?

IV Methylprednisolone - for apparent IBD-induced toxic megacolon w/risk of colonic perforation - typically w/in 3y of disease onset - mech: pathologic colonic dilation from mucosal inflammation - Rx: IV corticosteroids [1st line] anti-inflamm; other: supportive [IVF, electrolytes], broad-spec abx, bowel res, decompression; +/- colectomy if severe/refractory

65yo; follow-up for subacromial corticosteroid injection for R-sided rotator cuff tear 10d prior - tendinopathy confirmed via US before injection - had mild improvement initially, 2d ago pain worsened and now experiencing generalized body ache and fatigue - Hx T2DM, gout; 100.2F, BP 130/85, HR 109 - mild swelling on lateral R shoulder; ROM limited in multiple axes by pain [worse than before injection] ***next step?

Image-guided aspiration for apparent iatrogenic Septic Bursitis - likely dt introduction of skin flora w/penetration of subacromial bursa [staph aur, strep pyo] - Sx: worsening pain, redness, swelling, systemic sx onset several days after procedure [vs steroid-induced chemical synovitis w/resolution in 48h]

54yo, 30pkyr smoker; lap chole after episode of biliary pancreatitis - 3d postop: mild hypoxemia [90% O2 room air]; 98F, BP 130/80, HR 90, RR 22; decreased lung sounds BL bases - ABG: pH 7.44, pO2 64, pCO2 34 ***cause of observed findings?

Impaired cough and shallow breathing - Atelectasis: Hypoxia >> elevate RR >> low pCO2 - prevention: adequate pain control, deep-breathing exercise, directed coughing, early mobilization, incentive spirometry

67yo, awaiting clearance for elective AAA repair; no cough, SOB, chest pain - Hx CAD, DM, Htn; no tobacco/alc/drugs - BP 120/76, HR 60, RR 14; no abnormalities on exam except epigastric pulsations ***what would help prevent post-op pneumonia?

Incentive spirometry - encourage lung expansion to prevent atelectasis >> incentive spirometry most effective and 1st line [also deep breathing, continuous positive airway pressure, and intermittent positive pressure breathing]

22yo, hit in face w/basketball yielding bleeding from both sides of nose ~10min, halted w/pressure; now cannot breath through nose - Hx allergic rhinitis [oral antihistamines] - 98.6F, BP 110/70, HR 70, RR 14; O2 99% on room air - bruising over nose, under eyes; anterior rhinoscopy shows no bleeding; soft/fluctuant swelling of septum bilaterally; no blood in oropharynx ***next step?

Incise and Drain Nasal Septum d/t septal hematoma - nasal traum w/subsequent nasal obx and fluctuant swelling; accum blood between perichondrium and septal cartilage - complications: [rare], untreated >> rapid infection [2-3d] w/septal abscess; avascular necrosis of septal cartilage

42yo, ED for worsening anal pain over 2d; initially only w/defecation, now constant/severe - anal pruritus w/o drainage, hx constipation [hard stools every 3-4d, lots of laxatives] - bisexual and anoreceptive intercourse - 100.4F, BP 120/80, HR 85; erythematous/tender 1cm fluctuant mass near anal orifice w/induration of overlying skin ***likely cause of condition?

Infection of occluded anal crypt gland: perianal abscess - quick formation, assoc constipation and anoreceptive intercourse - Rx w/incision drainage to avoid progression to anorectal fistula

40yo, ED for 2wk fever, malaise, weakness, and unintentional 5lb wt loss - last 4d onset L-side chest/upper Abd pain - Hx asymp MVP; wife treated for URI 3wk prior; travels frequently to Mexico for work; 20pkyr smoker, no alc - 103F, BP 120/70, HR 96, RR 16; decreased breath sounds L lower field [dull to perc]; 2/6 systolic murmur apex - WBC 27K [60% N, bands 15%], Hgb 13, Plt 250K; imaging: L-pleural effusion, splenomegaly w/splenic fluid collection ***likely underlying Dx?

Infective Endocarditis typical cause of splenic abscess [see chart for others]

42yo, G3P3; L breast pain/swelling worsening over a few weeks; stoppred breastfeeding 2mo prior; onset swelling/pain 1mo ago [Dx Mastitis, Rx Abx, resolved sx] - worsening Sx again 2wk ago; Hx T2DM [metformin] - BMI 46.6, 99.7F, BP 110/68, HR 88, RR 18 - L breast diffusely warm, erythematous, thickened skin dimpling; normal R breast ***likely Dx?

Inflammatory Breast Carcinoma - warm, erythematous, skin dimpling, painful/rapid onset w/o improvement on abx - other sx: itching, palpable mss, nipple changes [flatten/retraction], axillary lymphadenopthy [mets in 20% at dx] - Dx: mammogram + US breast/nodes, biopsy confirmation

35yo, core needle biopsy for suspicious, asymptomatic thyroid nodule; normal TSH - post-procedure expanding hematoma at site; no personal/fam hx bleeding/easy bruising ***likely Dx [of bleeding]?

Insufficient Hemostasis

18yo, ED after fall, hit left chest on coffee table while playing VR game - moderate L-chest pain, worse on inspiration; lightheaded; shallow breathing - BP 88/50, HR 122, resp 28; no JVD; midline trachea - intact chest wall, bruised, tender to palpation, diminished breath sounds at L lung base [dull to percussion] ***likely cause of condition?

Intercostal Vessel Injury d/t rib fracture, causing hemothorax - suggested by symptomatic hypotension, tachycardia, flat jugular veins [hypovolemic shock] following blunt chest trauma - MCC hemothorax: large vessel [aorta, hilar aa/vv], small intrathoracic structures [intercostal, lung parenchyma] - Rx: tube thoracostomy

42yo w/bloody discharge from right nipple; no breast pain, swelling, or trauma; stopped breastfeeding 3mo prior - no prior mammography, no chronic conditions - normal appearing/symmetric breasts on exam; manual pressure to R nipple elicits bloody discharge - firm, ill-defined 2cm mass palpable in lower-outer quadrant of R breast, overyling skin retraction; no LA BL ***likely Dx? [abscess, galactocele, intraductal papilloma, invasive ductal carcinoma, mammary duct ectasia]

Invasive Ductal Carcinoma: see pic for signs - intraductal papilloma would not have an associated palpable breast mass

77yo, noticed skin lesion a few weeks prior that had rapid and painful growth - 3wk since has becoem smaller and less painful again ***likely Dx?

Keratoacanthoma - rapidly enlarging nodule w/ulceration and central keratin plug - frequent regression/resolution - MC in fair-skinned in areas of UV exposure or prior trauma - typically benign, but small risk of malignant transformation [SCC] >> biopsy

62yo, ED w/2d R knee pain/swelling - Hx pain w/physical activtiy [NSAIDs], this episode more severe/persistent - Hx htn, T2DM, CKD, diabetic foot ulcers - fever, BP 142/84, HR 104, knee swollen, warm, red, limited ROM - XR: subcutaneous edema, joint effusion, degenerative change - Arthrocentesis: 5mL cloudy fluid, leuks 55K [95% PMNs], no bacteria or crystals - took cultures and started empirin abx ***other additional intervention for mgmt?

Knee irrigation + drainage :consistent w/septic arthritis - RF: preexisting joint disease [pain, degerative change on XR], IC status [DM] - presenting w/more acute/severe pain, fever, synovitis, - joint aspiration w/cloudiness, WBC w/PMN predominance; Gram stain would confirm dx - Rx: start w/ IV abx + immediate drainage and irrigation to reduce bacterial load [via arthroscopy

35yo, ED after house fire w/50% body burns, FTB arms/legs, soot in nose/mouth, disorientation - 95F, BP 80/58, HR 156, RR 35, O2 67% on room air - IV access, intubation/sedattion, cleaned wounds, topical abx over burns ***fluid mgmt for next 24h?

Lactated Ringer Solution [LR] - LR preferred for burn injuries to help maintain pH

19yo, ED w/abd pain; intermittent, onset in yoga this morning; vomited twice - no chronic conditions or meds; copper IUD, sexually active; FDLNMP 2wk prior; HR 104, BP 130/80 - diffuse lower abd tenderness [L > R], no rebound/guarding - pelvic US: complex L adnexal mass w/absent doppler flow, free fluid in posterior cul-de-sac of pelvis ***next step?

Laparoscopy for Ovarian torsion - Sx: sudden-onset unilateral pelvic pain, n/v, +/- palpable adnexal mass [evident on US w/absent doppler flow] - Rx: laparoscopy w/detorsion, ovarian cystectomy, oophorectomy if necrotic/malignancy - RF: ovarian mass, reproductive age, infertility rx w/ovulation induction

6yo w/limp; onset 2mo prior as dull ache in left knee w/intermittent limp [urgent care visit showws normal labs/imaging of knee/hip] - no worse pain, but limp is constant; no assoc joint/muscle pains; relatively well aside from brief URI 2wk prior - Hx recurrent ear infections [tympanostomy tubes 2y ago]; no daily meds, UTD vax - 98.8F, BP 95/65, HR 80, RR 16, BMI 60; well-appearing alert child - ROM of L hip limited, esp IR/Abduction ***likely Dx?

Legg-Calve-Perthes disease [LCP]; AKA osteonecrosis of femoral head - antalgic gait, dull/chronoic LE pain w/insidious onset - Dx requires serial imaging

55yo, chronic pain in buttock, hip, thighs; aching present bilaterally in legs w/walking - 30pkyr smoker, several comorbidities/meds - decreased BL femoral, popliteal, and dorsalis pedis pulses ***additional symptoms?

Leriche Syndrome >> above Sx + impotence - BL hip/thigh/buttock claudication - absent/diminished pulses [typically symmetric atrophy of LE from chronic ischemia] - Impotence in men - RF: men w/atherosclerosis predisposition >> smokers [ddx: osteoarthritis]

12yo, ED for R ankle pain/swelling after landing awkwardly from skateboard, non-weightbearing since injury - diffuse swelling, limited ROM, no visible gross deformity; BL intact distal pulses and sensation; XR [pic] shows fx of distal tibia ***at risk for what complications?

Limb-Length Discrepancy: SH III epiphyseal fx - fx of growth plate suggested by growth plate widening >> potential growth plate arrest - other comp: physeal bars, premature OA, decreased ROM

24yo, ATV rollover trauma, BP 82/50, HR 128, resp 24; alert; see injuries below, persistent hypotension despite fluid resuscitation - abd: distended, diffuse tenderness; intraperitoneal free fluid on US - chest wall bruising; rib fx R8-9 + L4 ***liekly source of hypotension?

Liver Laceration: blood loss >> hypovolemic shock >> hypotension + tachycardia - BAT [blunt abd trauma] triage: FAST exam for free fluid >> hemodynamically unstable and sings of free fluid need exploratory laparotomy

35yo, emergency cholecystectomy yesterday, now having seizures; surgery uneventful but pt became gradually restless - Hx gastritis [omeprazole], heroin use in 20s - 99F, BP 145/92, HR 114, RR 18, diaphoresis, tremors, no sign of incision inflammation, normal biliary drainage - Na 137, K 4, Cl 101, Bicarb 24, BUN 12, Cr 1, Gluc 104; Hgb 14, WBC 9K; PT 20s, aPTT 38s; AST 242, ALT 118 ***Appropriate therapy?

Lorazepam for alcohol withdrawal syndrome - indicated by seizure, diaphoresis, tremors, elevated pulse/BP after admission,and 2:1 AST:ALT ratio - DoC = Benzodiazepine [consider liver dysfx >> prolonged PT, eleavted LFTs >> prefer phase II glucuronidation metabolism over phase I CYP450 oxidation]

67yo, hospitalized for elective R knee arthroplasty for OA - Hx Htn, T2DM, CAD; on clopidogrel antiplt [stopped 5d before surgery] - performed under anesthesia via epidural and femoral nerve block w/o intraop complications - pt-controlled analgesia provided post-op and prophylactic enoxaparin started 12h after surgery - pt has difficulty urinating, low back pain, and numbness in legs; some tenderness at epidural catheter sit - weakness of R plantar flexion/dorsiflexion, decreased sensation to anterior thigh/leg bilaterally ***next step?

MRI Lumbosacral spine to evaluate Spinal Epidural Hematoma [SEH] - potential complication of neuraxial anesthesia [epidural], lumbar punction, spinal surg; esp common in older adults on antithrombotics - other RF: coagulopathies, spinal abnormalities, osteoporosis - mech: bleeding in spinal canal >> SC compression >> progressive motor and sensory dysfunction at affected level [requires urgent decompression via laminectomy]

22yo, intermittent R knee pain increasing over 8wk - started while playing soccer regularly; moderate pain w/"catching" of knee while walking - occaisionally unable to completely extend knees; initially swelled several days w/slow resolution, but unable to keep up with prior activity level d/t pain - full ROM, no erythema, warmth, swelling, no lig laxity on varus/valgus or ant/post traction - w/knee in Int/Ext rotation, flexion and extension elicits moderate pain and crepitus; normal XR ***next step?

MRI of Knee to evaluate meniscal tear - provocative Thessaly/McMurray on examination

36yo, lump in R-breast; no pain, galactorrhea, HA, wt changes; regular menses [last ended 2d prior] - no chronic conditions, nullgravida - Fam Hx: grandma breast cancer 76yo [died 78yo] - 2cm firm, round mass in upper/outer quadrant of R breast, no papable nodes; unremarkable PE ***next step?

Mammography

20yo, ED w/severe R knee pain following football tackle; non-weightbearing R leg - BP 142/90, HR 108, RR 18; R knee swollen, deformed, bruised; lower leg warm/soft, palpable dorsalis pedal pulse - lateral XR: posterior dislocation >> immediate reduction under sedation ***next step?

Measure ABI [ankle-brachial index] - confirm vascular supply intact - popliteal artery and neurovascular at risk w/posterior knee dislocation [ischemia could require above-knee amputation] - normal pulse palpation + ABI >0.9 excludes significant vascular injury; lack of either or clinical ischemic signs requires emergent imaging [CTA] and vascular consult

74yo, ED w/worsening lethargy, abd pain, distension; preceded by several days of watery diarrhea and no BM in last 24h - Hx Htn, MI, AFib, stroke w/hemiplegia; recent hospitalization for infected pressure ulcer - 101.8F, BP 106/60, HR 118, ill-appearing, somnolent, dry mucous membranes; abd distended and diffuse tenderness, decreased bowel sounds - WBC 18K, serum K 3.2, XR in pic ***likely cause?

Microbial toxin-induced colonic inflammation - C. diff colitis >> toxic megacolon - severe systemic toxicity, abd distension/pain, leukoytosis, large bowel dilation on XR - RF: adv age, recent hospitalization, abx - Rx: bowel rest, NG tube, aggressive abx; dc agents that impair GI motility

26yo, fever/chills, blood culture w/G+ cocci in clusters; echo shows mobile density on posterior mitral leaflet - day 3 in hospital: SOB, inability to lie flat; bibasilar crackles, 2/6 holosystolic murmur at apex ***likely also present on repeat echo? [LA size, LV size, LVEF]

Mitral Regurgitation - LA normal, LV normal, normal/inc LVEF - meets modified Duke criteria of IE w/acute MR as a complication - acute MR >> sudden large-volume backflow from LV to LA yields low-grade murmur - LA/LV stretch is minimal bc not enough time to accomodate elevated pressures >> transferred to pulmonary circulation [SOB/crackles]

23yo, R leg pain after below-knee amputation 4mo prior for nonsalvageable devascularization of the R foot following motorcycle collisino - severe, persistent postoperative pain, shooting quality toward absent extremity - worsens on urination/defecation; normal vitals - R LE shows well-healed scar, adequate soft tissue padding over distal stump [NT to palpation/percuss] - full/nonpainful ROM at spine, hip, knee ***next step?

Multimodal Pain Regimen involving pharmacologic and adjuvant therapies for apparent phantom limb pain [PLP] - common among 50-85% amputees, increased risk w/severe pre/postoperative pain - usually neuropathic [shooting/burning] in nature, +/- seemingly unrelated innocuous triggers [urination/defecation] - Pharm: antidepressant, antiepileptic, NMDA-antagonist, analgesics - Adjuvant: biofeedback, CBT, mirror therapy w/residual limb

72yo, intermittent lower abd discomfort for several months; frequent BM urges daily w/small-volume stools or mucus only and sense of incomplete evacuation - Abd soft, NT/ND; DRE normal rectal tone, empty vault - bearing down >> erythematous mass w/concentric rings protrudes through anus, spontaneous retraction ***strongest RF?

Multiple Childbirths - weakening of pelvic floor

24yo, ED w/eye pain and swelling following altercation while intoxicated - double vision on attempt to gaze upward, L face swollen, tender, echymotic, normal visual acuity, cannot look up w/L eye - CT in pic ***cause of diplopia?

Muscle Entrapment [Inferior rectus] - assoc w/blunt traum to globe yielding "blowout" fracture - this CT shows orbital floor fracture w/some orbital fat entrapment near inferior rectus location >> likely restricting globe to downward position - prolonged entrapment has risk of ischemia, fibrosis, pemanent dysfunction; emergent specialist consult

62yo w/partial pancreatectomy for exocrine pancreatic cancer, surgery complicated by excess peripancreatic bleeding requiring surgical hemostasis - receives pckt red cell transfusion and IV normal saline - extubated in ICU; several morphine doses for pain control >> 12h later decreased O2 sat [87% on 4L nasal cannula] - BL basal crackles, abd mild distension and decreased bowel sounds; pulm artery catheter low, high PCWP ***etiology?

Myocardial infarction >> cardiogenic shock

newborn in ED for coughing, difficulty feeding; born at home 3h prior via spontaneous vaginal delivery - mother: 24yo, primigravida, pt coughed/vomited after attempt breastfeeding; no prenatal care; hx rec drug use halted in pregnancy - 98.6F, HR 120, RR 50, O2 95% room air; Ballard score indicates 37wk gestation at birth, wt 25%ile, length 50%ile; coughing fit on attempt to feed 10mL formula - coarse breath sounds BL w/intercostal retractions; grade 2/6 systolic murmur at upper LSB ***next step?

NG tube placement to assess tracheoesophageal fistula w/esophageal atresia

38yo, ED w/severe painand swelling of L leg; fell 2d prior yielding mildly painful abrasion of posterior L thigh - steadily worsened since, now unbearable pain; pain/redness spread to involve buttock and proximal calf; now has fever/chills - 102.7F, BP 82/60, HR 104, RR 18; PE: swollen L thigh, moderate erythema over L proximal thigh/buttock; distal thigh and buttock tender to palpation, loss of touch sensation over proximal thigh - BP improves w/IV fluids, see CT ***likely Dx?

Necrotizing Fasciitis

30yo, progressively worsening sore throat of 6d duration - started bilaterally, worsened on left; difficulty swallowing, fever, chills starting yesterday - no cough, chest pain, dyspnea, or new sexual encounters - muffled voice; moderate trismus; no tonsillar exudates, but soft palate above left tonsil is swollen w/uvular deviation to R - enlarged, tender cervical LN on left ***next step in addition to abx?

Needle Peritonsillar Aspiration for suspected PTA [peritonsillar abscess] - indicated by symptom onset and progression; typically arising from tonsillitis/pharyngitis >> cellulitis/phlegmon >> pus collects in abscess - induces CL uvula deviation, muffled "hot potato" voice, and trismus [from pterygoid mm inflamm], +/- regional lymphadenopathy - Rx [and confirm Dx]: needle aspiration/incision + drainage w/abx [cover Group A Strep + resp anaerobes] >> untreated can be fatal if extends to parapharyngeal space or involves carotid sheath

48yo, ED for sudden-onset R flank pain of 6h duration - Hx Psoasis present on both knees [Vit d topical, beclomethasone] - normal vitals, abd soft NTND, present bowel sounds - Abd US: 3mm stone in R ureter, severeal in GB; normal liver/CBD, GB ND, no pericholecystic fluid/tenderness - admin analgesia and IV fluids >> passes ureteral stone in a few hours via urination ***next step in gallstone mgmt?

No Rx at this time - uncomplicated, asymptomatic; incidental finding - not advised unless onset biliary colic, or increased risk of GB carcinoma or hemolytic disesase [SCD]

83yo w/ Alzheimer's and progressive dementia; brought in by daughter for skin lesion - noticed while bathing, slow enlargement; no itching/pain [see pic] ***next step?

No additional testing: likely seborrheic keratosis [SK] - asymptomatic or mildly pruritic, well-demarcated, waxy or verrucous [papillated] surface - often raised surface, abrupt border, distinct tan/brown/black pigmentation - typically >50yo, numerous over time >>> Leser-Trelat sign: explosive onset of multiple pruritic SKs assoc w/internal malignancy

57yo, preop eval for arthroscopic meniscectomy under GA - normal ADL, but restricted exercise from knee locking - no chest pain, palp, dyspnea, light-headedness - Hx htn, dyslipidemia; 61yo sis had CABG; 30pkyr ex-smoker [5y] - BMI 29, BP 138/82, HR 68, resp 16, no JVD, normal CP exam; Cr 1 ***next diagnostic for preop mgmt?

No further testing - CV risk assessment for non-cardiac surgery - RCRI scoring based on risk predictors >> intermediate-risk procedure w/no pt-specific risks = 0 [no further testing necessary] - see chart for specific indicators

60yo, poorly controlled T2DM, ED w/worsening perianal pain - febrile, hotn, tachycardia; tender/swelling at perianal/gluteal region, dusky overlying skin, palpable crepitus - WBC 27K, CT shows edema of glut/perineal subQ w/free gas - IVF/Abx + surgical debridement of necrotic tissue - w/in hours: increasing dyspnea, hypoxemia; CXR shows new BL lung infiltrates; echo shows hyperdynamic LV w/o valve disease ***current pulmonary condition [from pic]?

No hypoxemia correction w/O2; low lung compliance, high A-a gradient [D] - ARDS d/t sepsis from necrotizing fasciitis >> inflammation >> capillary leak + diffuse pulmonary edema - edematous fluid fills alveoli causing collapse [low/zero ventilation, V] = severe V/Q mismatch >> hypoxemia uncorrected w/O2; impaired diffuse yields the high A-a gradient; fluid collection in interstitium stiffens lungs causing lower compliance

36yo hospitalized for MVC causing concussion, fx right femur >> planned ORIF - BP 150/90, HR 70, O2 98% on room air, BMI 24 - Hgb 12.7, Na 140, K 3.8, Bicarb 24, Cl 104, Gluc 145, BUN 22, Cr 1.2, Ca 9.1; fingerstick Gluc 156, HbA1c 5.5% ***next step for glucose management?

None: Stress Hyperglycemia - just a transient BG elevation caused by metabolic stress in pt w/o previous diabetes - common w/sepsis, burns, major trauma, hemorrhage - mech: stress >> hella cortisol + catecholamines >> more free glucose release - severe elevation [>180] may requireshort-acting insulin correction

1yo boy w/DS, follow up to ED visit for abd pain >> bowel intussusception w/spontaneous resolution; discharged home, no return of pain - 6mo old had similar episode; meds include ferrous sulfate supplement for mild iron deficiency anemia - 99.1F, abd normal bowel sounds, NT/ND ***other indicated studies?

Nuclear Scintigraphy - 25% have pathologic lead point >> sus: recurrent episodes, atypical site, atypical age, rectal bleeding despite reduction - MCC pathologic lead point is Meckel diverticulum >> nuclear scan w/99mTp dx

36yo, post-op incisional pain [1wk prior hysterectomy] - heparin in surgery [dc w/ambulation] - 1wk of incisional pain + light vaginal bleeding; pulling sensation L of incision worsens w/Valsalva - no sign of infection/incision compromise/defects - Hgb 9, WBC 10K ***next step?

Obervation + Reassurance - 1wk post-op pain: main concern is wound complication [esp w/ obesity, ↑intra-ab P] >> eval infection, fluid collection [seroma/hematoma], wound dehiscence - pt is afebrile, normal leukocytes, normal PE/healing >> no further evaluation necessary - fever/rebound would require pelvic US or CT abd/pelvis - superficial wound dehiscence would require incisional exploration and packing, or removal of fluid if there is subcutaneous collection - superficial cellulitis would require oral abx; more severe inf +/- debridement and IV abx

1mo, large birthmark on R face/scalp >> now more raised and bright red - no bleeding/oozing, normal vital signs/growth parameters; no abnormalities evident on head MRI or echocardiography ***appropriate therapy?

Oral Propranolol for Infantile Hemangioma - typically arise days-weeks after birth >> 0-6mo proliferation >> >6mo involution - Rx: observation, Beta-blocker for higher-risk features [large/facial/segmental/rapid-growing; periorbital c/vision impairment; hepatic c/HOHF; subglottic c/airway obx] >>> BB = vasoconstriction = limit growth, promote regression

76yo, admit following 2wk cough, increasing SOB, R-sided chest pain, and fever; 6.6lb wt loss - Hx T2DM, htn, Alzheimer dementia - 102.4F, BP 102/68, HR 112, RR 24; decreased breath sounds and dullness to percussion on R - WBC 22K [85% N], Hgb 10.5; CXR: moderate pleural effusion; R-lat decub XR: effusion is free flowing, R-lower lobe infiltrate - Thoracentesis: 750mL foul-smelling, turbid fluid ***likely underlying organism?

Oral streptococci and anaerobes - Empyema, sourced from aspirated anaerobic oral flora [polymicrobial] - may begin as uncomplicated pneumonia w/gradual presentation of empyema

75yo; office evaluation of R hip pain of several months duratiton, progressively worsening and now causes difficulty putting on shoes/socks - used to walk 2mi daily, now needs cane for 1/2mi; Hx htn, BMI 32, see XR ***likely cause of hip pain?

Osteoarthritis - chronic joint pain, worse on activity and weight-bearing; loss of joint space, periarticular osteophytes, sclerosis of acetabular surface - progressive destruction of articular cartilage >> pain of groin, buttock, lateral hip, may radiate to loewr thigh - decreased rotational ROM w/o synovitis sx [red/warm]

21yo, requesting opioid refill for new-onset L hip pain; onset 3wk prior initially just with wtbearing, progressed to presence at rest and overnight - no hx trauma; Hx SCD w/acute pain crisis hospitalizations [last 3mo prior]; been self-medicating w/pain meds from last visit - other meds: regular folic acid, hydroxyurea; 1 female sexual partner, no alcohol/tobacco/drugs - 99F, BP 100/70, HR 80, RR 16; no local tenderness; L hip restricted Abd/IR; XR/ESR normal ***likely Dx?

Osteonecrosis of Proximal Femur - common w/SCD d/t disruption of microcirculation of bones [sickling], and increased intraosseous pressure d/t bone marrow hyperplasia

45yo, 1wk R hip pain - Hx htn, stage 4 CKD; lisinopril, amlodipine, multivitamin - normal vitals; pain w/internal/external rotation; XR: nondisplaced R femoral neck fx and BL subperiosteal resorption ***appropriate diagnostic test next?

PT Hormone Level - assessing renal osteodystrophy >> secondary hyperparathyroidism

19yo, ED w/persistent abd pain following previous vist 3d prior after falling while biking - no LOC, hit handle bars and flipped landing on back - last visit trauma workup: negative CT chest/abd/pelvis - now returning w/persistent upper abd discomfort, nausea, 1 episode of nonbilious emesis; 100F, BP 104/62, HR 108; lungs CTAB, normal heart sounds - ecchymosis across upper abd, tender to palpation w/voluntary guarding; decreased bowel sounds - US: large amt free fluid in upper abd ***likely cause?

Pancreatic Duct Injury from blunt abd trauma - rapid compression of fixed retroperitoneal pancreas against vertebral column - may not have immediate signs of trauma

54yo, progressive fatigue and frequent loose stools; voluminous, foul-smelling, difficult to flush - 20lb wt loss in 6mo, hospitalized several times for epigastric pain radiating to back w/n/v - currently has intermittent episodes of similar pain for 15-30min intervals after meals - 98.6F, BP 118/80, HR 78, BMI 19.5 ***what may improve symptoms?

Pancreatic Enzyme Supplementation - Apparent steatorrhea, likely d/t chronic pancreatitis from long-standing alcohol abuse in this patient

46yo, ED after fall during downhill bicycle race; LOC ~1min and severe back/abd pain; no med hx - CT head: no incracranial bleed; CT abd: small retoperitoneal hemorrhage, renal lac - Lumbar XR: compression wedge fx t L2 [place brace] - day 3: mild, diffuse abd pain/nausea, abd distended, tympanic, mildly tender w/o rebound/guarding; absent bowel sounds; upright XR in pic ***likely Dx?

Paralytic Ileus - commonly after abd surgery, also w/retroperitoneal or abd hemorrhage, intraabd inflamm, intestinal ischemia, electrolyte abnormalities - uniformly dilated, gas-filled loops of bowel w/no transition point [vs obsruction]

68yo, 10y hx ESRD from diabetic and hypertensive nephropathy [on intermittent hemodialysis] - Meds: losartan, metoprolol, amlodipine, short/long-acting insulin, epoetin alpha - stopped calcium acetate and calcitriol therapy 3mo ago d/t elevated serum calcium - Ca 10.8, Phos 5.1, Albumin 3.8, PTH intact 760 ***likely cause of elevated Ca?

Parathyroid Hyperplasia: tertiary hyperparathyroidsm d/t long-standing ESRD - very high PTH, hypercalcemia, hyperphosphatemia [despite dc Ca/calcitriol therapies]

60yo, laparotomy for intestinal obx secondary to post-op adhesions from cholecystectomy 2y prior - Hx T2DM, hypothyroid, htn - postop day 3: intense pain around wound; 101F, BP 121/76, HR 100, RR 16; Gluc 312 - wound: abundant cloudy-gray discharge, duscky, friable subQ tissue, decreased sensation at wound edges ***next step mgmt?

Parenteral Abx and Urgent Surgical Debridement for apparent necrotizing surgical site infection - pain, edema, erythema beyond site; systemic sx; an/paresthesia at edges; purulent "dishwater" discharge; subQ gas/crepitus - Assoc Diabetes, often polymicrobial - require urgent surgical exploration and debridement of necrotic tissue; adj: broad-spec abx, hydration, tight glycemic control

14yo, ED for acute R knee pain; gymnast, landed awkwardly while dismounting balance beam, faling to ground after hearing audible pop on landing; unable to straighten knee - 98F, BP 120/70, HR 88, RR 16, BMI 17; normal heart/lungs - R knee held in flexed position, decreased ROM, significant medial swelling/tenderness; large, painful, immobile deformity on lateral aspect - palpation of anterior aspect reveals divot over trochlea and minimal pain over tibial tuberosity ***likely Dx?

Patella dislocation

62yo, ED for R knee pain/swelling after falling while walking up a flight of stairs; difficulty walking after - Hx Htn, T2DM, ESRD [hemodialysis] - BP 162/97, HR 94, BMI 52; R knee shows large effusion; cannot keep leg straight while flexing at hip; intact pROM - XR in pic ***likely Dx?

Patellar Tendon Rupture - note especially inability to actively extend knee against gravity or maintain straight leg while flexing hip - high-riding patella on XR - assoc: sudden, forceful contraction of quadriceps; increased risk in those w/tendinous fragility [ex. CKD]

38yo, firm, 3cm mass w/ill-defined margins in upper-outer quadrant of L breast - enlarged LN in L axilla; FNA shows adenocarcinoma - L modified mastectomy w/axillary node dissection [levels I/II] ***muscle used to distinguish levels of axillary nodes?

Pectoralis Minor - level I: lat/inferior to pec minor - level II: posterior to pec minor - level III: med/superior to pec minor

34yo w/3mo intermittent dizziness; sudden episodes of vertigo and nausea that resolve <1min - occur w/lifting heavy weights, riding in an elevator, after sneezing; no HA/ear pain but sometimes hard to hear from R ear - Hx bicycle collision 4mo ago; PE normal ears and tympanic membranes; no weakness/sensory loss - No nystagmus at rest, but is provoked with symptoms during Valsalva maneuver ***likely Dx?

Perilymphatic fistula: complication of head injury or barotrauma >> leakage of endolymph from semicircular canals/cochlea into surrounding tissues - causes progressive sensorineural hearing loss, episodic vertigo w/nystagmus

27yo, recent onset R knee pain arising 2wk prior while training for triathlon - sharp, medial; continuous but exacerbated by exercise w/partial improvement on ice/rest - normal vitals, localized tenderness at medial tibia below knee joint, no redness/warmth; no pain on valgus stress; normal gait; no abnormalities on XR ***likely dx?

Pes Anserinus Pain Syndrome - semitendinosus, gracilis, and sartorius tendons - medial knee pain w/focal tenderness assoc w/abnormal gait, overuse, or trauma - RF: obesity, DM, knee OA, angular deormity - pain in anteromedial tibia, no swelling, erythema, or induration - Rx: quadricep-strengthening exercises, NSAIDs - clinical Dx, imaging to r/o OA/other structural cause

34yo, erectile dysfunction; 2mo of pain and penile curvature w/erections making vaginal penetration dfficult - no urethral discharge or assoc sx - 1pk/d smoker; no alcohol/illicit drugs; 5 female partners - normal vitals and cardiopulm exam; abd soft NT/ND, no inguinal lymphadenopathy - palpable plaque present on dorsal penis halfway bt glans and pubis; normal scrotal/testicular exam ***likely Dx?

Peyronie disease - d/t formation of fibrous plaques [upreg TGF1] in tunica albuginea, reducing elasticity and expansion during erections - typically caus pain, curvature, plaques - Rx: NSAIDs, pentoxifylline to reduce fibrosis, intralesional collagenase injections; refractory = surgery

25yo, pain over intergluteal cleft present for several weeks; intermittent swelling w/mucoid discharge that recently became blood-tinged - no fever/chills, normal BMs, no urinary sx; appendectomy 2y prior - BMI 34, tender mass near tip of coccyx drains mucoid fluid w/pressure ***likely Dx?

Pilonidal Disease - classic: 15-30yo [M>F], obese, sedentary, deep gluteal cleft - Sx: painful, fluctuant mass 4-5cm cephalad to anus in intergluteal region; +/- mucoid, purulent, or bloody discharge; pain worsened by activites stretching overlying skin [bending down] - mech: edematous, infected hair follicle in intergluteal cleft becomes occluded >> infection spreads SQ forming abscess >> may rupture creating sinus tract - Rx: open closure preferred to prevent recurrence

75yo, ED w/severe back pain of 2d duration after vacuuming; sharp R-flank pain - Hx htn, stage 1 CKD; spinal tenderness at T10, no CVA tenderness ***after pain control, next step?

Plain XR spine - in this pt, consistent w/osteoporotic vertebral compression fracture [VCF] d/t minimal trauma - sharp/achy pain, may worsen w/Valsalva, position change, or spinal extension; classically midline pain, +/- radicular flank/upper abd referred pain - Dx: XR first, +/- MRI if neuro deficits; +/- DXA to evaluate severity of bone loss and chronic mgmt

64yo, ED w/chills, fever, flank pain, and lethargy of 2d duration - 102F, BP 100/60, HR 120; R CVA tenderness - WBC 16K, urinalysis: pyuria, many bacteria, (+) nitrites - ECG: sinus tachycardia - CVC to be placed for IV therapy and hemodynamic monitoring >> prepped/draped, needle inserted lateral to angle of L clavicle >> advance triple lume catheter to L subclavian v [each lumen flushd w/sterile saline after blood return]; sutured to skin, sterile dressing ***next step?

Portable Chest XR to confirm proper placement and potential injury - CVC tip in lower superior vena cava - risk of venous perforation in smaller vv, risk of pneumothorax from apical lung puncture; risk of MI/pericardial tamponade

52yo, tachypneic day 2 from uncomplicated upper abd ventral hernia repair - unremarkable postop course to this point, low dose mophine pain control - SOB w/o chest pain, occasional morning cough w/minimal sputum - Hx Htn, Hyperlipidemia; 15pkyr smoker - 98.1F, BP 123/79, HR 90, RR 28, BMI 32 - decreased breath sounds R lung base; normal heart sounds; abd distension and diffuse tenderness; clean/dry incisions; CXR: dense opacity at R lung base - ECG: sinuse rhythm, no ST or T changes; supp O2 started on nasal cannula ***ABG expectations before O2? Most effective prevention of condition?

Postoperative Atelectasis - thoracic/abd pain after surgery restricts chest expansion >> low TV >> basilar alveolar collapse; usually days 2-5 ABG: basic, normal O2, low CO2 - Hypoxemia >> intrapulmonary shunting >> VQ mismatch >> increase RR >> hyperventilation lowers CO2 >> increases pH [resp alk] Postoperative deep-breathing exercises

64yo in nursing home w/foot ulcer; CVA 3mo prior, residual hemiparesis w/contractures - hx: htn, DM, hypercholesterol, CAD, mild dementia - 98.9F, BP 142/63, HR 62; alert/oriented to person only; no focal neuro deficits; see pic for skin exam of L foot ulcerations ***likely cause of ulcers?

Pressure Necrosis: pressure (decubitus) ulcers - common at bony prominences >> sacrum, ischial tube, malleoli, heels, 1st/5th MT head - constant, unrelieved pressure >> necrosis of overlying skin/muscle d/t impeded soft tissue blood supply - RF: impaired mobility, mannutrition, AMS [dementia], decreased skin perfusion, reduced sensation - prevention: repositioning; rx: same + local wound care, pain control, nutritional support

68yo, CCU w/confusion/agitation 3d after CABG; uncompliated surgery other than transfusion for periop bleeding - initially difficulty weaning w/successful extubation postop day 2 - pain well-controlled w/IVmorphine, calm all day; evening onset anxiety and tried pulling IV - Hx T2DM, dyslipidemia, PAD; no alcohol intake - 98.8F, BP 138/86, HR 96, RR 18; O2 96% on room air - oriented to person only, hallucinating small animals in room, no focal weakness, normal labs ***best initial intervention to prevent self-harm?

Professional Bedside Sitter for postoperative delirium

76yo w/constipation; infrequent BM w/straining; intermittent fecal leakage and hematochezia, no melena or wt loss - Hx prostate cancer [external beam rad, brachytherapy 18mo ago]; no recurrence evidence on CT or PSA - 99.5F, BP 132/80, HR 80, RR 12; conjunctival pallor, normal heart/lungs, abd soft NT/ND - coclonoscopy: rectal pallor, areas of mucosal hemorrhage and telangiectasias; rest unremarkable ***contributing to symptoms?

Progressive Rectal Fibrosis

6yo, fever of 1wk duration; hx viral myocarditis [transplant 8mo ago]; pre-transplant panel negative for EBV/CMV - on IS meds; 100.6F, BP 102/74, HR 76, RR 22; normal heart sounds; all pulses 2+; lungs CTAB; BL enlarged anterior cervical LN - Hgb 10, Plt 180K, WBC 1900; LDH 412, EBV-PCR copies 95.5K/mL; CMV PCR neg - ECG: normal heart structure/fx, CT chest: BL scattered atelectasis and several enlarged mediastinal LN ***likely cause of sx?

Proliferation of Immortal B cells - lymphoproliferative disease secondary to EBV >> PTLD [post-transplant lymphoproliferative disorder]

36yo w/persistend pain and drainage from axillae last 2wk - 2y of intermittent pain/drainage, but would spontaneously resolve in past - axillae skin has become thickened, developed openings that intermittently drain malodorous, seropurulent material [see pic] - no fluctuance or lymphadenopathy ***appropriate initial therapy?

Prolonged Abx Therapy for Hidradenitis Suppurativa - chronic occlusion folliculitis of folliculopilosebaceous units, often of intertrginous areas - assoc smoking, obesity, T2DM - Rx: mild = topical clindamycin; mod = oral tetracycline; severe = TNFa inhibitors, surgical excision

36yo w/neck pain after lifting weights 2d prior; sudden onset neck/upper back pain - constant/dull pain and intermittent sharp pain w/neck movements that radiates to hand; tingling in L hand, no weakness or bladder/bowel dysfx - normal vitals; cervical paraspinal mm spasm; mildly decreased sensation to L digits 4/5, no other sensorimotor deficits; normal DTR ***next step?

Provocative activity avoidance, NSAIDs - apparent C8 cervical radiculopathy - most pt have gradual resolution w/symptom mgmt and avditance of provocative maneuvers

26yo, R heel pain/swelling after stepping on rusty nail at work 2wk prior; continued pain after OTC abx cream and oral acetaminophen - no Hx conditions/meds/allergies; smokes 2-3cig/d, occaisonal alcohol intake - 101F, BP 140/90, HR 84, RR 14; small puncture wound visible; R heel swollen, red, warm, tender - mild leukocytosis; XR: bone changes consistent w/osteomyelitis ***Likely organism?

Pseudomonas aeruginosa and Staphylococcus aureus MCC of deep infections from puncture wounds - PA esp through sole of shoe: warm, moist envi promotes growth - changes consistent w/osteomyelities take 2wk+ to arise - Rx: IV Abx [cipro, pip-tazo] and surgical debridement

10yo, ED for MVC trauma; negative for major injuries; significant bruising and severe pain over R chest - normal CXR, over next 6h dev worsening tachycardia and tachypnea requiring supp O2 - 98F, BP 110/66, HR 110, RR 24; breath sounds decreased on R; ABG on 6L O2 = pH 7.42, PaO2 60, PaCO2 32 - CXR: patchy, irregular alveolar infiltrates of R mid/lower lobes ***likely Dx?

Pulmonary Contusion d/t blunt thoracic trauma - parenchymal bruising yields alveolar hemorrhage and edema - tachypnea, hypoxemia, decreased breath sounds; +/- rib fractures; initial evaluation often negative - CT more sensitive, or repeat CXR w/patchy, irregular infiltrates

60yo, ED after found unresponsive at bottom of stairway - hemodynamically stable w/GCS 7, no other obvious injuries - head CCT no fx or large hematoma - intubated for airway protection; no improvement in mentation for several hours >> suspect diffuse axonal injury ***most suggestive neuroimaging to confirm Dx?

Punctate Hemorrhages in White Matter on MRI - DAI assoc w/accel-deceleration or rotational forces in blunt head trauma >> shearing of long, white matter tracts [axons] - may not be apparent on CT, more sensitive on MRI punctate hemorrhages in white matter w/blurring of gray-white interface [edema]

35yo, ED w/R knee pain after landing awkwardly from jump in rec football game; hear pop, felt immediate pain, cannot walk since - 1/2pk/d smoker; has a few beers on weekends - large effusion over R knee, evident on XR w/low-lying patella; no fractures noted; can bend knee but unable to straighten d/t weakness; no weight-bearing but no instability ***likely Dx?

Quadriceps tendon rupture - symptoms, activity, low-riding patella

54yo, ED w/BRBPR; passed 3 large, bloody stools in last 2d + mild abd cramps; no melena, fever, vomiting, wt changes - 12mo prior: radical hysterectomy + radiation therapy for cervical cancer - Hgb 9.8, Plt 325K, WBC 6K; BUN 17, Cr 0.8 - Colonoscopy: mucosal pallor, friability, telangiectasias confined to rectum ***likely Dx?

Radiation Proctitis: hematochezia w/hx radiation to area d/t damage of rectal epithelium [depends on intensity, duration, and type of radiation] - Acute: up to 8wk d/t direct mucosal damage >> diarrhea, tenesmus, mucus - Chronic: months-years d/t submucosal fibrosis and obliterative endarteritis >> tissue hypoxia >> neovascularization >> telangiectasias [bleeding, anemia, stricturing possible] - Rx: thermal coagulation, sucralfate, GC enema [acute: antidiarrheal, butyrate enema]

55yo, progressive limb weakness and difficulty walking; onset 4mo ago and increased since - no hx seizure/HA; Hx Hodgkin lymphoma [chemo, rad to neck/chest 20y ago] - professional dancer, teaches classes regularly; immigrant from India 10y prior - normal vitals; decreased muscle strength, increased muscle tone, 3+ DTR all limbs, BL (+) Babinski; normal sensory exam - MRI: 1.7cm well-defined, homogenously enhancing globular lesion compressing cervical spinal cord at C2 level ***most significant RF of current condition?

Radiation Therapy Exposure >> Cervical Spinal Meningioma - pic: MRI w/contrast - RF: older age, females, genetics [NF2, schwannomatosis], ionizing radiation [potential latency >20y]

24yo, 2wk progressive foot pain localized to L heel - worsen w/ambulation, now difficult; recreational runner, started marathon training 1mo prior - normal vitals, full/symmetric pedal pulses; normal ankle ROM; pain reproducible w/compression lateral/medially - normal forefoot ecam; no pain w/dorsi/plantar flexion of toes ***other management w/activity modification?

Radiologic imaging of foot - sounds like calcaneal stress fx from repetitive microtrauma [high-impact, running] - DDx plantar fasciitis, achilles tendinopathy, tarsal tunnel syndrome

40yo, establishing PCP, no major concerns/meds - smoked 1/4pk/d in 20s but quit; alc socially ~2/wk; normal vitals - oral lesions [pic]: firm, immobile, nontender, no neck lymphadenopathy; normal PE otherwise ***next step?

Reassurance - Mandibular Tori: benign oral lesions w/smooth mucosa, uniform pigmentation, no destruction, symmetry, slow/no growth

38yo w/postop difficulty walking; yesterday had laparoscopic vaginal hysterectomy w/midurethral sling for endometriosis and stress incontinence - surgery 4.5h, ~500mL blood loss; BMI 48; normal cardiopulmonary exam and bowel sounds - incisions intact/NT, patellar reflexes 2+ BL; weakened R foot dorsiflexion and pinpoint sensation of R big toe - preop Hgb 12.1, no1 9.9 ***next step?

Reassurance and PT - common fibular/peroneal n compression from lithotomy position against leg braces - transient effect, should resolve fully over next few weeks >> reassurance, PT, continued mobilization

54yo, ED w/cramping lower Abd pain, mild nausea, 2 episodes watery diarrhea - no fever, vomiting, urinary sx; father died AAA rupture; lifetime nonsmoker; normal vitals; see CT abd [pic] - GI sx resolve in 2h w/o intervention ***next step for renal finding in CT?

Reassurance: simple renal cyst - thin, smooth, regular wall, unilocular, no septae, homogenous, no contrast enhancement, asymptomatic - classically present >50yo, benign, often incidental finding

70yo seen for constipation; strains during defecation, stools hard and difficult to pass - dx local adv pancreatic adenocarcinoma 3mo ago, now undergoing chemo and on hydrocodone for pain - Hx T2DM w/peripheral neuropathy - normal vitals; epigastric tenderness on deep palpation; normal bowel sounds; no fecal impaction on rectal exam ***next step w/increasing fluid and soluble fiber intake?

Recommend scheduled stimulant laxative

40yo, htn follow-up [dx 6mo prior, controlled w/exercise/wt loss] - no meds, nonsmoker, few glasses of wine per week; mother w/osteoporosis [alendronate] - Na 140, K 4.0, Bicarb 25, Cl 101, Ca 11.8, Alb 4.0, Phos 2.2, Cr 1.2, 25-OHvitD 38 [25-80] - serum PTH 814pg/mL; 24h urine Ca 325mg [high], DXA w/normal bone density; renal US shows multiple small stones BL [<5mm] ***next step?

Referral for PT imaging and Parathyroidectomy d/t primary hyperparathyroidism - MCC: PT adenoma, hyperplasia, carcinoma [↑risk MEN1/2A] - Sx: usually asymp, mild/nonspecific, abd pain, renal stones, bone pain, neuropsych - Dx: Hypercalcemia, elevated/inappropriately normal PTH, elevated 24h urinary Ca excretion - indications for PTectomy: <50yo, symptomatic hypercalcemia, complications [Osteoporosis, nephrolithiasis/calcinosis, CKD], elevated risk of complications [Ca >1mg/dL above normal, urinary Ca 400mg/d]

65yo, sudden SOB, cannot lie flat from dyspnea; no chest pain; hospitalized 6mo prior w/similar episode that responded to diuretics - Hx htn, CAD, TIA; several PCI for stable angina; R carotid endarterectomy 2y ago - daily smoker, BP 210/100, HR 104, RR 22, 86% O2 on room air; distended neck veins, bilateral lung crackles, no edema - Hgb 13, Plt 240K, WBC 8200, K 3.1, Bicarb 30, BUN 30, Cr 2, Ca 8.4, Gluc 100 - LFTs: Prot 6, Alb 4.3, AST 12, ALT24 - Urinalysis: trace protein, glucose (-), Blood (-), WBC and RBC 1-2/hpf, no casts/crystals - no cardiac enzyme elevations; ECG: LVH; Echo: LVH, preserved EF, no wallmotion abnormalities - improves on diuresis and antihypertensive therapy ***next step?

Renal US w/Doppler to evaluate renovascular disease - diffuse atheroscerosis, recurrent flash pulmonary edema w/normal EF and no LE edema + severe htn suggests renal artery stenosis - mech: renal ischemia >> RAAS >> Na/H2O retention, vasoconstriction, htn

2d old boy in newborn nursery; estimated 40wk gestation to 26yo primigravida w/no prenatal care - been taking 30mL cow milk-based formula q3h since brith; appears uncomfortable; mother thinks he's dehydrated from spitting up during last few feeds, only 1 damp diaper and single stool since birth - birth wt 7lb 1o, now 7lb 3oz; 98.1F, HR 150, RR 66; 88% O2 on room air; diminished BL lung sounds; normal cardiac exam; Abd distension; intact urethral meatus - small sacral dimple w/intact skin overlies coccyx; skin warm/pink, CXR: diminished BL lung volumes, normal heart size; placed on supplemental O2 ***next step?

Renal/Bladder US to assess PUV [posterior urethral valves] - MCC urinary tract obx in newborn boys - Sx: Abd distension, poor urine output, respiratory distress; wt gain instead of loss [retained urine], normal cardiac exam - in utero: impaired urinary excretion >> oligohydramnios >> lung hypoplasia >> postnatal respiratory distress from diminished lung volumes - Dx: Renal/Bladder US w/dilated bladder and BL hydroureters/hydronephrosis >> abnormal US do voiding cystourethrogram [posterior urethral dilation supporst dx], confirm w/cystoscopy - Rx: bladder drainage, electrolyte correction, ablate PUV

56yo, increasing R arm swelling; admit 12h prior bc found unresponsive at bottom of stairs in home - traumatic subarachnoid hemorrhage and small subdural hematoma - R forearm swelling was noted, but no fx evident on XR and normal compartment pressures - blood ethanol 380 mg/dL [<50], WBC 15K; admit neuro ICU >> increased R forearm swelling - normal vitals, intubated/sedated; tense/swollen forearm w/mild erythema, no fluctuance, crepitus, streaking; grimaces w/R arm manipulation, normal pulses ***next step?

Request immediate surgical consult for acute compartment syndrome - can occur delayed from initial presentation >> need serial examination

30yo, admitted after motocycle collision; hemdynamically stable at presentation, but initial workup indicates liver lac - no chronic conditions/meds; 3-4 alcoholic drinks daily, 1pk/d smoker 10y - Hgb acute decrease overnight, pkt red cell ordered - 1h after start of infusion develops dyspnea and transfusion halted - 98.4F, BP 86/42, HR 110, RR 26; 88% O2 on room air - BL lung crackles, normal skin; CXR: BL pulm infiltrates ***next step to manage respiratory distress?

Respiratory Supportive Care - likely d/t TRALI >> usually also require ventilatory support - recovery in 24-48h, but mortality rate ~50% in critically ill patients

31yo, ED following motocycle collision w/direct blow to lower abd/pelvis - BP 110/80, HR 102, RR 18, intact airway, normal heart/lungs; CXR no fx - suprapubic tenderness w/bruising; pelvic XR widened pubic symphysis; FAST intraperitoneal free fluid; urine dipstick (+) blood ***next step?

Retrograde Cystography

45yo, ED after MVC; pain in lower abd and R groin; cannot move R LE from pain; fullness in suprapubic region - R LE adducted, flexed, IR; bruising to scrotum/perineum, blood at urethral meatus, testes nontender; high-riding prostate on DRE ***next step?

Retrograde Urethrography - likely pelvic fracture w/blood at urethral meatus and high-riding prostate suggests posterior urethral injury >> need retrograde urethrography - MC injury at bulbomembranous junction [of ant/post urethra] - extravasation of contrast on XR indivates urethral injury [complete PRIOR to catheterization attempt to prevent further injury]

70yo, ED w/weakness, dizziness, back pain; no n/v/d, chest pain, palpitations, SOB, urinary sx, or black stools - Hx DM, diabetic nephropathy/retinopathy, Htn, AFib, chronic leg cellulitis; on Warfarin for chronic anticoag - BP 120/70, HR 110/irregular; WBC 10.5K, Hgb 7, Plt 170K; see CT in pic ***likely Dx?

Retroperitoneal Hematoma - note displacement of R kidney on CT dt isodensity anterior to psoas - Hx anticoag + wk/dizzy, anemia, tachycardia >> suspect internal hemorrhage - RF of bleeding on Warfarin: diabetes, >60yo, htn, alcoholism - back pain consistent w/hemorrhage being retroperitoneal

22yo, MVC victim in prolonged surgery for L tibial fracture and popliteal artery injury - placed in knee immobilizer and admit to ICU - next day has increasing L leg pain, IV fluid + morphine >> worsening pain over 2h, notable w/ankle movement and pins and needles sensation of limb - tense, tender swelling of L calf, sensory loss between great/2nd toes, LE pulses palpable BL ***next step?

Return to OR for Fasciotomy for apparent compartment syndrome - pain out of proportion to injury, pain w/passive stretch, rapid increase/tense swelling, paresthesias - Less common: loss of sensation, motor weakness paralysis, loss of distal pulses

44yo; follow-up for shoulder injury evaluated at ED - 2wk prior: FOOSH injury at work; hospital XR indicated posterior GH dislocation w/o fx - dislocation successfully reduced under sedation, placed in sling and instructed to follow up in 2wk - still unable to abduct arm w/o pain/difficulty; no numbness, intact distal pulses/sensation, no shoulder asymmetry ***likely Dx?

Rotator Cuff Injury

63yo, R shoulder pain/weakness of 3d duration, onset w/fall onto side while moving boxes - partial relief from OTC analgesics and stretching, but persistent weakness - normal vitals, no visible deformity or bony tenderness - full pROM, limited aROM; significant weakness in abduction of R shoulder; intact sensation - passive abduction over head >> pt asked to slowly lower arm down >> at horizontal drops abruptly w/moderate sharp pain ***likely Dx?

Rotator Cuff Tear: likely supraspinatus based on drop-arm test

42yo, ED for diffuse abd pain; onset 6h prior while playing tennis - sudden onset RLQ >> became diffuse w/radiation to R shoulder - DVT 2mo prior and hospitalized >> dc OC, now on oral anticoagulant - FDLNMP 3wk ago; no tob/alc/drugs; 99F, BP 80/40, HR 118; rigid abdomen, diffuse tender, rebound/guarding - Hct 26%, Plt 160K, WBC 9K, BhCG <5 ***likely Dx?

Ruptured Ovarian Cyst [see ddx pic for hemoperitoneum] - ruptured cyst: female of repro age, likely after dc combined OC, fluid fills space of recently released follicle >> generally benign w/lower abd pain >> pt on anticoag can have signif bleeding [unilat lower abd >> diffuse >> shoulder rad >> hemodynamic instability requiring emergency surgery]

62yo, ED w/acute leg pain after recently starting exercise program - pain in R knee/posterior calf while walking on treadmill followed by swelling of calf/ankle - BP 166/88, BMI 41; Hx htn, T2DM, hypercholesterolemia - tenderness/induration at medial gastrocnemius head, pitting edema at ankle, crescent-shaped ecchymosis at medial malleolus ***cause of symptoms?

Ruptured Popliteal Cyst: assoc w/trauma or underlying joint disease - extrusion of synovial fluid from knee joint into gastroc/semimembranosus bursa >> excess fluid [as in OA/RA] and positive pressure in extension can enlarge cysts - rupture can follow strenuous exercise >> posterior knee/calf pain, tenderness, swelling [mimic DVT; r/o via US]; often w/crescent sign [arc of ecchymosis distal to med malleolus]

13yo, persistent R knee pain [dull, anterior 2mo duration] following basketball practices; 2d prior worsened after landing a jump at practice - pain now constant, no relief w/ibuprofen/ice; 75th %ile ht, 95th %ile wt - limps w/foot pointing laterally; no tenderness, erythema, swelling at knee - normal ant/posterior drawer, normal knee flex/ext, normal int/external rotation of tibia - limited R hip ROM, knee points lateral w/passive hip flexion ***likely dx?

SCFE - slipped capital femoral epiphysis - obesity in adolescents w/chronic hip +/- knee pain - dull hip pain + referred knee pain, altered gait, limited hip internal rotation w/lateral foot deviation on internal rotation - Dx: bilateral hip XR: posterior displacement of femoral head - Rx: non-wt bearing, surgical pinning - complications: avascular necrosis, osteoarthritis

62yo, increasing discomfort and bulge at R groin; previous dx direct inguinal hernia w/o repair - recent acute bronchitis w/incessant dry cough >> enlarging of hernia; no pain, n/v/constipation - Hx: hypothyroidism [levothyroxine], seasonal allergies, sinusitis [GC nasal spray]; smokes 1pk/d; normal vitals; BMI 24; NT/easily reducible groin mass ***plan for hernia repair >> what increases postop infection risk?

Smoking History

38yo, R-handed F, husband witnessed brief seizure - no seizure hx, HA for several weeks, husbands reports odd behavior for months - grown more socially withdrawn, loss of interest in activites, only speaks when addressed, impaired memory - lacking medical/psych Hx, no fam hx neuro dz - somnolent, wakes to voice, follows commands, PERRLA, BL papilledema, BL UE/LE normal strength ****likely on neuroimaging?

Solitary Mass of Frontal Lobe - brain tumors: classically asymp or minimal sx until ↑ICP-induced HA, if compressing optic nerve can cause papilledema - often w/unprovoked 1st time seizure, focal deficit, and cog dysfx - frontal lobe affects personality, language, motor, and executive fx >> disinhibition, impulsiveness, decreased motivation, abulia, anhedonia, etc.

46yo; tingling, numbness, weakness of L UE after vacation 1mo prior, assoc L shoulder and subscapular pain she attributed to sleeping on new bed - spends prolonged time working in office, sx worsen when cradling phone bt head/shoulder - Hx Hypothyroidism [levothyroxine]; normal vitals - loss of pinprick in L thumb/index; mild weakness in elbow flexion and biceps reflex decreased ***likely underlying cause?

Spinal nerve root compression: cervical radiculopathy

18yo, ED w/persistent pain after hard football tackle landing on abdomen, causing immediate abd discomfort and nausea - BP 92/64, HR 118, RR 24; alert/anxious-appearing; BL normal breath sounds; normal heart sounds - Abd mildly distended, diffusely tender; normal chest/pelvic XR; FAST shows intraperitoneal free fluid ***likely Dx with further evaluation?

Splenic Laceration d/t blunt abd trauma [BAT] - intraperitoneal free fluid on FAST, distended/tender abd >> indicate intraabd hemorrhage [typically spleen] - confirm via CT abd/pelvis w/IV contrast - hemodynamic instability requires ex lap +/- splenectomy; stable observation, Hgb, and emboliz

12yo boy w/progressive back pain starting several months prior; localized central lower back, notably during sports - last month has persisted in other activties w/radiation to buttocks and legs - no relief w/OTC analgesics, no fever, rash, other joint pain; mother has RA - 98F, BP 110/65, HR 80, RR 16; PE shows palpable step-off in lumbosacral area; pain reproducible on extenion, painless flexion, normal gait ***likely Dx?

Spondylolisthesis - defect of pars interarticularis

45yo screening colonoscopy; bowel prep w/laxatives, NOP 8h, normal preanesthesia exam; admin propofol sedation - turned supine to L lateral for difficult colonic intubation >> immediate large, nonparticulate, yellow emesis [oropharyngeal suction and transient O2 decrease] - after procedure reports burning, hoarseness, mild dyspnea; fine crackles in R lung [mild infiltrate evident on CXR in R lower lobe] ***likely outcome of pulmonary complication?

Spontaneous Resolution - vs pneumonia

66yo w/sore throat of 3mo duration; worsening pain, esp w/swallowing; not relieved w/personal mgmt of tonsil stones; ulcer on R tonsil bleeds w/touch - Hx COPD [several inhalers], 2pk/d smoker 50y; normal vitals; normal ear exam; poor dentition but no oral lesion - enlarged, firm R tonsil w/1cm ulceration and surrounding fibrinous debris; no cervical lymphadenopathy ***what is likely apparent on biopsy?

Squamous Cell Carcinoma [SCC] - indicated by long smoking history and ulcerated tonsillar lesion; assoc odynophagia from tumor invasion/inflamm - RF: >40yo, tobacco use, alcohol use, IC; younger/nonsmoker has HPV assoc

65yo, abnormal tonometry w/IOP of 28mmHg [norm 8-21] - thinning of optic disc rim, asymmetry of cup:disc bt eyes - Hx asthma [daily fluticasone/salmeterol, albuterol for symptoms] ***mgmt ocular condition?

Start Latanoprost: ophthalmic solution, 1st line to incrase outflow; topical prostaglandins [-prost] - next line: topical BB [timolol, caution in asthma] - pt has Open-Angle Glaucoma >> ↑ IOP [causes gradual peripheral vision loss - vs acute Close-Angle: systemic CAI [-zolamide] - note: inhaled GC unlikely to contribute, but systemic or topical GC may worsen OAG

65yo, ED for acute R flank pain onset 1h prior; vomited twice; pain 10/10, crampy, wax/wanes, no prior episode - occasionally passes "sand" in urine, Hx obesity, hyperlipidemia, htn, gout, claustrophobia - 98.6F, BP 160/100, HR 98, RR 16, BMI 54; excess abd weight, decreased bowel sounds; mild R flank tenderness - urinalysis: hematuria, pH 5; Abd US: R-side hydronephrosis and dilation of proximal ureter ***Likely Dx?

Supersaturation of Urine w/Uric Acid

72yo, CABG for severe CAD; extubated 2d postop [97.9F, BP 120/70, HR 80, RR 12] - day 3: dyspnea w/worsening retrosternal pain despite continuous morphine; 101.5F, BP 112/52, HR 125/irregulary irregular, RR 28; normal heart sounds - small volume cloudy fluid in sternal wound drain; AFib on ECG w/RVR; CXR shows widening mediastinum; Echo shows small volume pericardial fluid - Hgb 8.9, WBC 16.3K, Plt 512K, Cr 1.7, CPK 430 ***what will pt need?

Surgical Debridement and Abx - for apparent acute mediastinitis d/t intraoperative wound contamination [5% sternotomies] - Sx: <14d postop fever, tachycardia, chest pain, leukocytosis, sternal wound drainage, purulent discharge; CXR widened mediastinum - need drainage and surgical debridement w/immediate closure and prolonged abx [still 10-50% mortality]

65yo w/abnormal bowel habits; stools are pellet-like, difficult to pass despite increased fluid/fiber - frequent fecal incontinence, wears diaper in public - no bloody stools, wt loss, diarrhea, n/v; 5 vaginally-delivered children; active lifestyle, no med hx, UTD colon cancer screening and no polyps -98.6F, BP 138/76, HR 85, RR 13; normal heart/lung exam - 3cm, erythematous mass w/concentric rings protrudes from anal canal when bearing down; retracts when relaxed ***next step mgmt?

Surgical Repair: rectal prolapse from weakened pelvic floor

55yo, ED w/worsening HA and R-side weakness; HA started ~1mo prior, now continuous throbbing pain over L of head w/nausea - increasing difficulty using R arm/leg - recently emigrated from Mexico; retired seamstress, chronic tobacco use - Neuro exam: R-side pronator drift; non-contrast CT: calcified round extra-axial mass compressing L frontal lobe [pic] - mass likely dural based, homogenous enhancement on gadolinium MRI ***next step?

Surgical Resection of Meningioma - Sx/Imaging indicate intracranial neoplasm >> extra-axial well-circumscribed/round homogenous MRI enhancement suggests meningioma [often calcify, hyperdense on CT] - Generally benign primary brain tumor of meningothelial cells; typically in middle-age/elderly women - onset w/neuro signs, may cause mass effect if large enough - confirm Dx intraoperatively, Rx: complete resection

48yo, elective cholecystectomy for symptomatic cholelithiasis; hx htn/obesity; cefazolin preop prophylaxis; Foley catheter preop - laparoscopic approach swapped to open d/t difficult anatomy - 2h postop fever, awake, alert, mild pain; no physical signs of infection at central venous catheter or surgical site - elevated leukocytes [80% N] ***mgmt of postoperative fever?

Symptomatic treatment and Observation - immediate fever [w/in hours of operation] MC assoc w/tissue damage, lasting <3d and managed by symptoms and observation - other immediate: blood transfusion or drug rxn [would present w/hypotension and rash] - see chart for acute [1-7d], and subacute [7-28d] postop: typically bacterial

16yo, ED w/abd pain, sudden severe persistent RLQ pain/nausea - 3wk hx of intermittent episodes of pain after sporting events, relieved w/rest - sexually active w/1 partner and inconsistent condom use - currently mild fever, abd soft NT/ND, scrotal erythema/edema, R hemiscrotum tender to palpation [worse w/elevation], no transillumination ***likely cause of symptoms?

Testicular Torsion - adolescent w/recurrent abd pain/n after strenuous activity; tender/erythematous scrotum - often absent cremasteric reflex - Dx: clinical presentation, confirm via Doppler US - mech: insufficient fixation of testis to tunica vaginalis >> hypermobility to exercise, mild trauma, simple mvmts >> twisting of testis around spermatic cord >> obx/ischemia >> pain - vs epididymitis w/(+) Prehn sign: pain relief w/elevation of testis ***requires emergent urologic evaluation and detorsion

58yo, hard mass on posterior L elbow growing for last 3y - no fever, pain, wt loss, trauma; Hx htn, CKD, gout - 3x3cm nontender, hard mass under skin; elbow not warm, red, tender; Cr 1.7 - imaging shows 3cm soft tissue mass and bone erosions w/overhanging eedges of cortical bone at olecranon process ***condition explaining findings?

Tophaceous Gout of olecranon bursa - bursal tophus: slowly enlarging, hard mass, +/- inflamm changes - assoc: bone erosions, urate is radiolucent, but can become radiopaque when Ca ppt w/urate in tophus - RF: chronically untreated gout and CKD, chronic hyperuricemia can ppt urate nephropathy

24yo, ED for burning sensation in left eye arising yesterday after putting in contact lenses - worsening despite removal of lenses and uing saline drops; now w/excessive tearing and photophobia - no conditions/meds; normal vitals - L eye erythematotus/injected, clear anterior chamber; PERRLA, intact EOM - L eye stain fluoresccein and cobalt blue filtered light exam: small oval area of green uptake at 7o position of cornea ***next step?

Topical Abx for corneal abrasion - need pseudomonal coverage for contact-wearers >> fluoroquinolones [-floxacin] - no eyepatch, may cause further abrasion and infection risk - treat early to prevent progression to ulceration [+vision loss]

62yo, Hx NAFLD-related cirrhosis in ED w/worsening abd distension, pain, fatigue, and dyspnea - other Hx: GERD, htn; 98F, BP 112/77, HR 85, RR 16 - alert/oriented, no asterixis; abd distended w/shifting dullness and tenerness; 2+ pedal edema - labs: thrombocytopenia, mild PT elevation; normal CXR - Diagnostic paracentesis indicated >> discussed risk/benefits, got informed consent and start prep ***What is most essential during time-out called just before inserting needle?

Type of Procedure Being Performed - critical verifications: pt ID, procedure, location [w/site marking]

3yo, ED after swallowing watch battery ~1h prior; had smll coughing episode but has been able to drink and talk normally since - normal vitals, alert/comfortable, no drooling, clear posterior oropharynx, lungs CTAB, normal cardiac exam, abd soft NT/ND - AP CXR: radiopaque, circular object w/halo sign; see pic for lateral ***next step?

Upper GI Endoscopy for foreign body retrieval bc high-risk feature [battery = perf risk] - benign object would just do serial XR >> no intervention if moves distally; endoscopy if no transit

28yo, ICU following MVC, intubated - bladder injury, bilateral tib/fib open fx, complicated pelvic ring injury, ribs R 4-7 fx - 8d of daily surgeries requiring pt to stay upright/intubated until complete - day 9: 4h of increasing secretions, worsening oxygenation [increased vent FiO2 from 30 to 70%], new-onset tachycardia; fever, HR 125, resp 22; CXR: new R/L lower lobe lung infiltrates, L pleural effusion ***likely dx?

VAP: sus w/onset >48h after intubation, dt aspiration of oropharyngeal/gastric secretions - new pulmonary infiltrates, increased respiratory secretions, signs of worsened respiratory status, systemic signs of infection - sample LRT to confirm dx

62yo, hospitalized for elective CABG for worsening exertional angina and 3-vessel CAD - Hx Htn, T2DM, hyperlipid; no recent infections or abx recently - Hx severe penicillin allergy [anaphylactic shock] - BP 128/72, HR 78, lungs CTAB, normal heart sounds - normal preop blood counts, serum labs, coag ***appropriate preop abx prophylaxis?

Vancomycin for surgical site infection prevention - clean procedure: should be no infection or viscus entry >> classically skin flora >> G+ coverage via 1st/2nd gen cephalosporins [alt: vanco/clinda]

40yo, evaluation for hoarseness that arose 4mo prior; proressively become more raspy - no fever, pain, SOB, dysphagia - Hx: asthma/GERD; meds: budesonide, albuterol, omeprazole; 3-4cig/d; normal vitals - laryngoscopy: irregular exophytic growths in clusters on vocal cord surfaces; no malignant features on pathology ***likely underlying cause?

Viral Infection: HPV 6/11 - constant (1mo+) progressive hoarseness related to vocal cord lesions >> need laryngoscopy - irregular, exophytic growths in clusters consistent w/laryngeal papillomas d/t recurrent respiratory papillomatosis [RRP] - warty/grapelike, dark-red punctate areas corresponding to BVs - vertical transmission to infants; adults have reactivation from vertical transfer, or new exposure from sexual contact

47yo, knee pain after slipping 2wk prior and landing on knee; severe pain, large overlying bruise remains unhealed - 6mo prior Roux-en-Y gastric bypass for morbid obesity [lost 44lb]; no tobacco/alc; normal vitals - large ecchymosis over L knee; swollen, painful to palpation, limited ROM; smaller ecchymoses/petechiae on all 4 extremities - Hgb 11.4, Plt 375K, WBC 6.2K; Cr 0.8; Alb 2.9, tot bili 0.6, AST 22, ALT 14; PT 12s, INR 1.1 [normal], aPTT 31s - XR: large effusion w/o fx; arthrocentesis: brown fluid (+) xanthrochromia ***cause of pt manifestations?

Vitamin C Deficiency after bariatric surgery

64yo, ED for L ankle pain after sharp pain w/pivoting while playing tennis 2d prior - now has difficulty walking, stumbled on stairs yesterday - weightbearing but painful, diffuse ankle swelling; normal pulses/sensation in L foot; pROM normal; active plantar/dorsiflexion present - squeezing L calf while prone does not move L foot - XR: soft tissue swelling w/o fx ***likely most impaired active movement on physical exam?

Walking on Tiptoes of L Foot - d/t Achilles tendon rupture >> (-) calf-squeeze [Thompson] test, w/absent passive plantar flexion [active may still be present d/t accessory mm] >> accessory mm [soleus] insufficient for ambulation on tiptoes, so impaired on exam

42yo, Crohn Disease follow-up - Hx: partial ileal resection d/t stricture, several surgeries for enterocutaneous fistula - few weeks of parenteral nutrition, recent reintroduction of oral feeding - nonbloody diarrhea w/o fever or abd pain, food doesn't taste the same - patchy alopecia, crusting/pustular skin rash w/scaling and erythema around mouth and on extremities ***what dietary change or supplementation would improve condition?

Zinc Supplementation - zinc deficiency: hypogonadism, impaired wound healing, impaired taste, immune dysfunction; alopecia, skin rash w/erythematous pustules around body orifices and extremities - commonly assoc w/malabsorption [absorption at duodenum/jejunum], parenteral nutrition, bowel resection, gastric bypass, and poor nutritional intake

Pt w/apparent septic arthritis refuses diagnostic arthrocentesis - 19yo, has decision-making capacity, presented risk/benefits and alternative accomodation ***response?

allow them to leave, and counsel them to return whenever - autonomy

55yo, ED for RLQ pain d/t acute appendictis >> emergency appendectomy and admission - Hx Graves [methimazole, noncompliant] - 1d postop restless, tremulous, agitated, SOB; 102F, BP 210/110, HR 140; bibasilar lung crackles, sinus tachy ***likely hemodynamic parameters: CO, SVR, PCWP

elevated CO, decreased SVR, elevated PCWP - Thyroid Storm: excess thyroid hormone >> reduced SVR, elevated CO >> LV cannot keep up w/increased venous return causing backup to lungs [elevated PCWP] - hyperdynamic circulation w/increased venous return