Surgery UWORLD Questions

39 yo woman + pins and needles around mouth for 2-3 weeks + sometimes same in feet + muscle cramps + vitals normal + calcium is 6.5 (normal 8-10) and phosphorus is 5.8 (normal 3-4.5) Diagnosis?

decreased secretion of PTH. this Pt has hypocalcemia and hyperphosphatemia, consistent with hypoPTH. Hypocalcemia presents with perioral paresthesias, muscle cramps, tetany, carpopedal spasms and seizures. Sometimes QT prolongation. HypoPTH is caused by: (1) post-surgery, (2) post-thyroidectomy, (3) autoimmune (4) congeinital digeorge (5) defective calcium sensort (6) wilson's, neck irradiation

32 yo woman + LLQ pain

diverticulitis

Breast Cancer Treatment

doxorubicin, cyclophosphamide and paclitaxel. Remember, that *doxorubicin* causes CHF in a dose dependent and irreversible way. So get echos to assess heart status. If HER2/Neu+ we use *traztuzumab*. Traz causes reversible heart failure. If Her2nu negative, we use *Bevalizumab*. ER/PR+ we can use SERNs (tamoxofen, Raloxifine). *Raloxifine* isn't as effective, but has no risk of DVTs or endometrial cancer. If postmenopausal use aromatase inhibitors. If BRCA12 should get prophylactic bilarteral mastectomy and ovaries out

40 yo man + ED + 1 week progressive abdominal discomfort, distension, nausea + 2 days of vomiting + 6 weeks ago episode of acute pancreatitis + heavy drinker who stopped 6 weeks ago, afer hospital + vitals stable + epigastric fullness and tenderness _ present bowel signs + no reboud + labs normal + CT shows large fluid filled mass Next step?

endoscopic drainage of what is mst likely a pancreatic pseudocyst, a walled off cyst containing pancreatic enzymes. If they rupture, will leak amylase. W/o symptoms, watch and wait. Otherwise endoscopic drainage.

63 yo man + urgent care + 4 hours severe, diffuse, constant abdominal pain + pne episode non-bloody vomiting + vitals stable + air under the diaphragm + positive rebound tenderness + on warfarin with an INR of 2.1 Initial treatment?

fresh frozen plasma to correct his warfarin-induced anticoagulation to rpepare for an emergent laporatomy. other preps include NG tube decompression, IV fluids and antibiotics

62 yo man + confusion, lethargy, reduced urine output + 5 days ago 20% surface area burn + inhalation injury (house caught fire) + 3rd degree burns on legs that have progressed to full thickness necrosis + blood glucose 230 platelets 80K leukocytes 16K Diagnosis?

gram negative sepsis. Burns are a feeding ground for infection, immediatly after burn, staph aureus from hair folicles and sweat glands. >5 days, gram negatives such as pseudomonas or fungi such as candida. You often do not have fever with burn wound sepsis. willl have severe tachypnea, oliguria, hyperglycemia, thrombocytopenia, AMS

35 yo man + ED + severe abdominal pain for 4 hours + began perimbilical shifted to RLQ + nausea + vomiting + fever (102 F) Next step?

lap appy Acute appendicitis is a clinical diagnosis and does not require imaging before going to surgery

Cardiac Murmurs

o Mitral Stenosis: rheumatic heart disease. Diastolic murmur at cardiac apex. Rumbling murmur with opening snap. The earlier the snap, the worse the murmur. Can dilate ventricle and cause CHF, AFib. Diagnose with echo. Treat medically or balloon valveotomy. May eventually need to be replaced. o Mitral Regurgitation: due to endocarditis or infarction (papillary muscle/corda tendinae from MI). systolic murmur @ cardiac apex radiating to the axilla. It is holosystolic. Diagnose with echo. Replace the valve. o Aortic Stenosis: usually due to age-related calcification, in old men with CAD. They will often have chest pain, syncope, CHF. 2nd IC space right sternal border, crescendo-decrescendo systolic murmur, radiates to carotids. Diagnos with echo. Replace the valve; can do operation without opening chest?. Bicuspid valves are major risk factor. o Aortic Regurgitation: caused by infection, infarction or aortic dissection. Usually presents acutely and these patients usually die. Can also present chronically, with amurmur. Diastolic, 4th IC space @ left sternal border. Decrescendo, blowing murmur. Diagnose with echo and replace valve. Must also consider doing a cabbage

Localizing abdominal pain

o RUQ: lung, diaphragm, liver, gallbladder o LUQ: lung, diaphragm, spleen o RLQ: kidneys, ureter, ovaries, testes, colon/appendix o LLQ: kidneys, ureter, colon/diverticulum o Suprapubic: bladder, uterus o Epigastric: heart, aorta, esophagus, pancreas, stomach

46 yo man + 2 days postop upper abdominal hernia repair + tachypnea +tachycardia + no chest pain + no fever + decreased breath sounds at right lung base + abdominal distension w/ diffuse tenderness and no rebound + CXR showing dense opacity at right lung base What would you expect his blood gas to show?

ph 7.49, pO2 70 pCO2 27 This Pt has postop atelectasis due to airway obstruction from retained airway secretions, decreased lung compliance, post op pain, meds that interfere with deep breathing Becomes most severe in the 2nd postop night and can last up to 5 days As compensation for the hypoxemia, Pts hyperventilate and develop a respiratory alkalosis

45 yo woman + ED + 4 hours of severe abdominal pain + nausea + bilious vomiting + several weeks of episodic periodic epigastric/RUQ pain and nausea + fever + +history of NSAID and alcohol use + renderness, guarding, rigidity + stool guaiac test is positive Next step?

upright xray of chest and abdomen. Pt has perforataed viscus due to peptic ulcers. look for free air under diaphragm.

What is the timeline for causes of postop fever?

*0-2 hours*: prior trauma/infection, blood products, malignant hyperthermia *24 hours - 1 week*: nosocomial infections, surgical site infection (SSI) due to GAS or C. perfinigens, MI, PE, DVT *1 week - 1 month*: SSI due to other organisms, catheter site infection, C. diff, drug fever, PE, DVT *>1 month*: viral infection, SSI due to indolent organisms

84 yo man + ED + severe back pain + syncope + gross hematuria + SOB + 72/55 + HR 112/min + PulseOx 92% + ST depression Diagnosis?

*AAA rupture* the massive blood loss can compress retroperitoneal structures such as the bladder. This compression can rupture the veins in the bladder, causing hematuria.

72 yo man + repair of infrarenal aortic aneurysm + cephalospirin prophylaxis POD#1 complains of progressive abdominal pain and bloody diarrhea Temp is 101 F, BP 110/65, HR is 110/min RR 22/min Abdomen mildly distended, tender in LLQ w/o rebound Femoral pulses full White count 12,000 diagnosis?

*Bowel ischemia* While repairing a AAA you have compromised colonic perfusion due to loss of IMA. The left and sigmoid colon are particularly vulnerable to ischemic insult. Presentation is abdominal pain, bloody diarrhea with fever early in the postop period Should have checked the sigmoid colon perfusion

12 yo boy + ED + postprandial colicky abdominal pain + bilious vomiting + fell into handlebar of bike 2 days ago + epigastric tenderness + dilated stomach with scant distal gas + amylase 91 total bilirubin 1.3 Diagnosis?

*Duodenal hematoma*. More common in kids and have a delayed presentation (24-36 hours) after a blunt abdominal trauma that compresses the duodenum against the spinal cord. The blood collects w/in the walls of the duodenum, causing complete/partial obstruction. Diagnosis is CT. NG tube to decompress and parenteral nutrition. If this fails, considuer surgery or percutaneous drainage

Causes of post-op GI fistula?

*FETID* - resect the fistula or do a diversion. F: foreign body; surgeon left something in there E: Epithelialization T: Tumor I: irradiation, inflamed, inflammatory bowel D: distal obstruction

40 yo femae + ED + MVC + hit head against windshield + alert + PERL + bruise over forehead but no tenderness + bruise on thigh + knee extension markedly reduced + decreased sensation on right thigh and leg What nerve was injured?

*Femoral nerve*, which is responsible for knee extension, hip flexion and sensation of anterior thigh and medial leg *Obturator* controls adduction of thigh and sensation over medial thigh *Tibial* controls flexion of knee and toes, plantar flexion of too and sensation to leg and plantar foot

16 yo boy + 3 days post-appy + mild scleral icterus + total bilirubin of 3.3 direct bilirubin 0.4 alk phos 70 Diagnosis?

*Gilbert Syndrome*, an inherited disorder of bilirubin conjugation. Presents as mild jaundice precipitated by stress (infeciton, fasting, surgery, vigerous exercise). Elevated indirect bilirubin is the only lab abnormality. No treatment is indicated

75 yo man w/ PMH of prostate cancer, type 2 diabetes, hypertension, high cholesterol, recently quit smoking. has surgical repair of a large AAA. Postop develops LLQ pain + bloody diarrhea + low grade fever + gross blood on rectal exam. CT scan shows thickening of the colon at the rectosigmoid junction. Colonoscopy shows ulcerations in the same area. What is the cause of his symptoms?

*Ischemic colitis* a common complicaation of vascular surgery. Thickening of and air in the bowel wall on CT is a specific sign. Colonoscopy shows cyanpotic mucosa and hemorrhagic mucosa. The major risk factors are age and atherosclerotic disease.

82 yo woman in the ED presenting w/ severe abdominal pain + vomiting + 5 days nausea and decreased appetite + bloating + cramps + PMH of diabetes, HTN, MVP, OA, gallstones, constipation, diverticulitis (2 yo) Vitals: 99 F + 108/68 + HR 106/min + RR 20/min PE: abdomen is soft but distended w/ hyperactive bowel sounds Labs: leukocyte count of 11,000, mildly elevated liver enzymes Abdominal xray shows dilated loops of small bowel and air in intrahepatic bile ducts Diagnosis?

*Mechanical bowel obstruction* , specifically *gallstone ileus* as indicated by the pneumobilia (air in biliary tree) and a history of gallstones The gallstone entered the small bowel through a biliary-enteric fistula. It "tumbles" through causing intermittent abdominal pain and vomiting until it lodges in the *ileum*, the narrowest part of the bowel, a few days later. CT will show gallbladder wall thickening, pneumobilia and an obstructing stone. Treatment is to surgically remove the stone via ERCP and then, usually later, the gallbladder

37 yo man + acute onset intense periumbilical abdominal pain + nausea + vomiting + 2 bowel movements since pain began + +n decreased bowel sounds + Hx of alcohol and heroin abuse Admitted 4 days ago for acute bacterial endocartitis w/ staph and mitral valve vegetations + treate with IV vancomycin Abdominal xray shows no free air or obstruction Diagnosis?

*Mesenteric ischemia*: Presents w/ rapid onset periumbilical pain out of proportion to exam findings and late hematochezia. If it progresses can lead to bowel infarction with focal pain, peritoneal signs, rectal bleeding and sepsis This pt has the major risk factor of an embolic source, namely mitral vegetations that could be flicked off into circulation. Labs: elevated amylase and phosphate. Metabolic acidosis w/ elevated lactate Diagnosis: CT or mesenteric angiography

46 yo man presents to the ED after a fall during a bike race. 1 minute of LOC + severe back/abdominal pain + CT scan of head shows no intracranial bleeding + CT scan of abdomen shows small retroperitoneal bleed and splenic lac + lumbar film shows L2 compression wedge fracture; a brace is placed. On hopsital day 3 Pt complains of mild diffuse abdominal pain and nausea. Abdomen is distended _ tympanic + mildly tender w/o rebounding or guarding. Bowel sounds are absent. Xray shows dilated bowel loops What is the diagnosis?

*Paralytic Ileus* Dilated gas-filled loops of bowel without a transition point. An obstruction would have a transition point.

23 yo male + ED + unrestrained driver MVA + unresponsive and intubated at scene + 2 L normal saline + BP 80/40 HR 120 + responsive to stimuli + pupils normal + neck veins distended + bruises on anterior chest and upper abdomen + cxr shows small left sided pelural effusion Diagnosis?

*Pericardial tamponade*: this Pt is hypotensive despite receiving 2 L normal saline. Blunt chest trauma w/ persistant venous distension, tachycardia and hypotension despite aggresive fluid resucitation should make you think of cardiac tamponade X CXR wiull show normal cardiac silhouette w/o tension pneumo

23 yo man presents to the ED for restrained passenger MVC + multiple organ injury + critical condition BP 90/60 + HR 130/min + RR 30/min Confused, AMS, pupils reactive, responds to pain Cool extermeties, decreased cap refill, open wound in RLE w/ sig blood loss What is the first indicator of hypovolemia?

*Pulse rate,* i.e. tachycardia. Tachycardia and peripheral vascular constriction are the first physiologic changes in response to hypovolemia in an attempt to correct the BP BP and cap refil will remain normal until you lose around 30% (1500 ml) of your volume

54 yo man + ED + restrained driver MVA + resucciatated with 2 L normal saline + 78/54 + HR 126 facial lacs, anterior chest wall and abdominal wall acchymoses abdomen is mildly tender w/o distension no pelvic tenderness US shows free fluid in the periodenal What will you find on laparotomy?

*Splenic laceration* due to blunt abdominal trauma, a common injury with MVA

74 yo man w/ PSH of coronary artery bypass 2 months ago gets elective AAA repair. Given prophylactic ABX, 2 units packed RBCs during surgery 1 hour after surgery, fever (1010.3 F) and chills, BP of 130/76, HR 90/min, RR 16/min Abdomen is mildly tender and not red, lungs are clear Has a foley and right subclavian central line (venous) What is causing the fever?

*Transfusion reaction*, which usually occurs w/in 1-6 hours of transfusion and can cause immediate postop fever.

54 yo man + right ankle edema + heaviness/cramping of right leg worse at end of day + swelling is better in the morning + PMH of hypertension treated with atenolol + PE is unremarkable + doppler shows no evidence of thrombosis. What is the most likely cause of edema?

*Venous valve incompetence*. this is a typical presentation of *varicose veins*; unilateral lower extremity swelling that worsens with use and improves with elevation (sleep). The incompetence causes an increase in capillary hydrostatic pressure and loss of fluid from the intravascular space into the interstitium. the kidneys view this as fluid loss and retain salt and water, worsening the edema.

55 yo Asian immigrent + recent onset neck swelling + episodes of epistaxis + no trauma + history of smoking, drinking, recurrent bacterial sinusitis, syphilis + mass in nasa cavity bipsied as an undifferentiated carcinoma What is a risk factor for this canceR?

*Viral infection*. This is nasopharyngeal carcinoma (NPX) an SCC. Usually metastatic by the time it causes symptoms. Strongly associated with EBV infection and even EBV titer levels. Also associated with smoking and chronic nitrosamine consumption (salted fish). More common in mediteranean and far eastern people

Causes of postop fever

*Wind*: something in the lungs, usually either atelectasis on POD #1 or pneumonia on POD #2 *Water*: UTI. Usually POD #3 *Walking*: DVT/PE. POD #5 *Wound*: Cellulitis POD #7 and abscess POD #10-14 *Wonder Drugs*: bad drug reaction, including malignant hyperthermia, which occurs immediately post-op.

88 yo man w/ severe right calf pain several hours after a right femoral artery embolectomy. Pain is burning, posterior. PMH of AFib and HTN, ischemic stroke, bleedign duodenal ulcer, diabetes, diabetic nephropathy PE: 160/70 HR 100/min and irregular. Right calf is swollen, tense, very tender. Pain is worsened with passive extension of right knee. Peripheral pulses are intact in both extremities. Diagnosis?

*soft tissue swelling*, i.e. compartment syndrome, specifically ischemia-reperfusion syndrome. Measure the tissue pressure; if it is >30 mm Hg probably compartment syndrome.

What are 5 common causes of shoulder pain?

1. *Rotator Cuff tendinopathy*: pain with abduction and external rotation. Normal ROM. Positive Neer and Hawkins 2. *Rotator Cuff tear*: weakness with external rotation. in Pts above the age of 40 3. *Adhesive Capsulitis* (frozen shoulder): decreased ROM, more stiff than painful 4. *Biceps Tendinopathy/Rupture*: anterior shoulder pain. pain on lifting, carrying, overhead reaching 5. *Glenonumeral Osteoarthritis*: trauma. anterior/deep shoulder paon. decreased passive abduction and external rotation

What are the 3 most common causes of shock in the trauma setting?

1. Hypovooemic hemorrhage. Will have low CVP and empty veins 2. Pericardial tamponade. Will have trauma to chest, high cvp, distended head/neck veins, *no* respiratory distress 3. Tension pneumo. Same as above but with resp distress

42 yo man + MVC + hemo stable + bruises on anterior chest wall and abdomen + 8th rib fracture + no other pathology found on imaging Given IV fluids and analgesics. 8 hours later LUQ pain + left shoulder pain + mild nausea + hypotensive (90/60) + tachycardic + 96% O2 + vesicular breath sounds + fluids bring BP up to 102/65 What test will diagnoise?

Abdominal CT with IV contrast to look for a *splenic injury*, which can have a delayed presentation. The left shoulder pain is due to diaphragmatic irritation (Kehr sign) Persistant hemodynamic instability would warrant ExLap

A woman with SLE undergoes total hysterectmy. On postop day 1 she develops nausea, vomiting, dizziness, diffuse abdominal pain, hypotension (85/50) and tachycardia, round face, biffalo hump and central obesity. She is also hyponatremic and hyperkalemic What is causing this?

Acute adrenal insufficiency, which can be triggered by acute illness or surgery in those with either underlying adrenal insufficiency or long term glucocorticoid therapy (i.e. SLE) Treatment is hydrocortisone or dexamethason and high-flox IV fluids

36 yo woman + ED + fever (102.2 F) + sore throat + 4 days ago swalloed fish bone + difficulty swallowing + neck pain/stiffness + air-fluid levels in prevertebral soft tissues Pt is at risk for what?

Acute necrotizinf mediastinitis. This Pt has a retropharyngeal abscess. This area drains directly to the superior mediastinum. Spread to the carotid sheath can cause thrombbosis of IJ and CNs 9-12

73 yo man + laparotomy for intestinal obstruction + postop day 8 develops pain and swelling on the left angle of jaw at the parotid + fever (102 F) What could have prevented this complication?

Adequate fluid intake and oral hygiene. This Pt has *acute bacterial parotitis*. This occurs in dehydrated old people postop. Usually caused by *staph aureus*.

55 yo woman + ED + slipped and fell down flight of stairs + no head trauma + no LOC + upper back and right sided chest pain + vitals are stable + rapid shallow breaths + 6th rib fracture but no pneumothorax + right basilar atelectasis Next step?

Adequete analgesia. It is the most important for a non-complicated rib fracture because these patients tend to hypoventilate because it hurts to breathe. This can lead to atelectasis and pneumonia. For extensive rib fractrures, epidural is first line. Intercostal blocks can be helpful but must be careful not to cause a pneumothorax

35 yo man + deep left leg laceration from rusty barbed wire + wound is bleeding w/0 pus + last tDap was 12 years ago Next step?

Administer tetanus-diptheria toxoid vaccine severe/dirty wound + booster > 5 years ago = tDap clean wound + booster > 10 years ago = tDap severe/dirty wound + no/unclear immuniization = tatanus Ig

16 yo boy + ED + fell on hand + left shoulder and hand pain + heard a crunch and intense shoulder pain + bruising and papable gap in clavicle + loud bruit beneath clavicle + xray shows mid-clavicular fracture with displacement Next step?

Angiogram to assess the status of the subclavian vein. Should also do a focused neuro exam to assess the brachial plexus This is a classic mode of injury for clavicle fracture. Fractures of the distal 1/3 may require open reduction and internal fixation to prevent nonunion.

43 yo man + ED + schizoaffective disorder + fell from 3rd floor of building + pointing to chest asking for help + 137/91 120 Diagnosis?

Aortic injury Must screen via CXR. look for widened mediastinum and enlarged aortic arch

44 yo man + MVA + unresponsive + hypotensive + large bruises over chest wall + collapsed neck veins + decreased breath sounds on left due to large hemothorax Diagnosis?

Aortic injury (need a CXR to get this question right. Be able to recognize?) High energy blunt rapid deceleration is a common cause of aortic injury. CXR will show widened ediastinum and a left sided hemothorax. Immediate surgical repair is mandated

29 yo man + ED + persistent green vomiting and crampy, diffuse, progressive abdominal pain for 24 hours + no fever + BP sitting 116/75 standing 94/65 + abdomen distended + hyperactive bowel sounds + tympany + tender + potassium 3.1 What is likely in this Pt's history?

Appendectomy 6 months ago. This is small bowel obstruction. He is hypokalemic and dehydratred/ Will show dilated loops on xray. If a strangulated obstruciton, peritonial signs and shock (if late presentaiton) Adhesions are the most common cause of obstruction, as in this case. Congenital in children (Ladd's bands) and due to abdominal surgery in adults

24 yo man + ED + 1 week abdominal pain + RLQ + worse with motion + radiates to back + vomiting + anorexia + mexica 1 month ago + passive extension of right hip in left lateral decubitus causes pain Labs: WBC 16,000 Hb 14.2 Platelets 520,000 K+ 4.5 Creatinine 1 Diagnosis?

Appendiceal abscess This Pt has a positive psoas sign, indicating an abscess. The RLQ pain is consistent with appendicitis. It probably ruptured and formed an abscess. If clinically stable, do not operate on these Pts right away. Give IV antibiotics, bowel rest and return in 6-8 weeks for elective appenectomy (interval appendectomy)

27 yo man blocks BBall shot and has severe pain in shouder + ED + resists internal rotation + what nerve is injured?

Axillary nerve. Anterior dislocation of humeral head at the glenhumerol joint. paralysis of deltoid and teres minor and loss of sensation over lateral upper arm.

24 yo man + MVC + severe upper back pain + BP 115/78 HR 55 RR 16 + weakness and decreased pain sensation in both legs, proprioception intact + CXR, CT spine and abdomen ordered Next step?

Bladder catheterization. This can assess for urinary retention and prevent acute bladder distension and damage

53 yo man + occasional red urine for 3 mnths + turns red at end of voiding + small clots in urine + no fever, weight loss, flank pain + chronic back pain + smokes + 99.5 F and 160/90 + UA shows only blood Cause of symptoms?

Bladder disease Hematuria at the beginning of voiding suggest urethral injury and at the end of coidiong sugests bladder or prostate innury. Total hematuria suggests kidney or ureter Clots are not usually seen with renal injury. Clots suggest bleeding in the vladder or ureter and is concerning for urothelial cancer, which should be evaluated via cystoscopy

31 yo man + motorcycle accident + lower abdomen/pelvis injuries + diffuse abdominal pain + dull left shoulder pain + 110/80 92 16 + ROM intact + tenderness and gaurding What injury is likely to be seen on CT?

Bladder dome rupture. This Pt's has signs of an acute abdomen, which can be caused by peritoneal irritation via blood, bile, pancreatic secretions, bowel contents, or, as in this case, urine. The left shoulder pain is likely to be referred pain from diaphragmatic irritation. Note: anterior bladder wall, bladder neck, kidney and urethra are all largely extraperitoneal structures and would not cause an acute abdomen

68 yo man + coloerctal surgery for diverticulitis + postop not urinating + BUN 82 + creatinine 2.3 Next step?

Bolus of IV fluids. This is probably AKI due to hypovolemia and poor renal perfusion. Correct hypovolumeia by giving fluids and change Foley catheter to make sure the problem is not mechanical (clogged or kinked). Then give IV fluids

67 yo man + ED + nausea, vomiting, abdominal pain for 3 hours + hospitilized for MI 4 weeks ago + PMH diabetes, htn, cholesterol, peptic ulcer + 100 F 150/90 110 22 + chest is clear + bowel sounds decreased + RLQ tenderness + amylase is 275 + bicarb 14 Diagnosis?

Bowel ischemia (acute mesenteric ischemia) A common cause of this is an embolus the heart following an MI (mural thrombus) Will have pain out of proportion, megtabolic acidosis, elevated lactate, Hb and amylase and leukocytosis

7 yo boy + ED + fell on outstretched hand + cannot move arm + ecchymosis and swelling above elbow + hplds arm in flexion + xray shows displaced and angulated supracondylar fracture of humerus What is Pt at risk for?

Brachial artery injury or injury of the median nerve This would result in loss of brachial and radial pulses

(see above) ECG is normal. Pt is given O2 What would have prevented postop atelectasis?

Breathing exercises and incentive spirometry Also make sure to quit smoking at leat 8 weeks prior to surgery (secreitons)

34 yo man + high speed MVA + intubated at scene + decreased right breath sounds + hypotensive + chest tube is placed on right side + subcutaneous emphsema Hours later cxr shows air in pleural space and pneumomediastinum Diagnosis?

Bronchial rupture This Pt suffered a rapid deceleration chest trauma (steering wheel hitting chest) and should have gotten a CXR much earlier. He has pneumothorax despite chest tube. This is probably due to tracheobornchial tree perforation, usually the right main bronchus Must surgically repair

Pt presents with hemptysis seruous enough that he is hypotensive at 105/61 w/ HR 102 + intubated + blood fills endotracheal tube Next step?

Bronchoscopy. Pts with significant hemoptysis hsould be placed with bleeding lung in dependent (lateral) position). Bronchoscopy can identfy the site of bleeding and provide suction as well as cauterization.

12 yo boy + ED + MVC two months ago + left-sided chest pain + decreased air entry in lower left lung base + xray shows opaque density Next step?

CT of chest and abdomen. This Pt has bowel loops in his chest consistent with diaphragmatic ruture. Learn to read these xrays

40 yo man + ED + RLQ pain radiates to groin for 7 days + fever (101.9) + anaorexia + 2 weeks ago had treatment for furunculosis of thigh + no masses + no rebound or gaurding + hip extension worsens, + flexion improvees pain Next step?

CT scan of abdomen and pelvis This Pt may have a psoas abcess. The PE findings are sort of specific (wrse with extension) must be drained and abx

76 yo man + substernal chest pain + PMH hypertension, hyperlipid, diabetes, diverticular bleed 2 years ago Cardiac cath shows 70% left main coronary artery stenosis + 90% proximal LAD stenois and 80% right cor artery stenosis 5 hrs after cath, BP drops to 75/60 + HR 120 + diaphoretic + SOB + clammy + flat neck veins 1 L saline raises BP to 96/60 Next step?

CT scan of abdomen and pelvis w/o contrast This Pt is presenting with signs of a retroperitoneal hematoma due to complication of the cardiac cath. Treatment is supportive care, intensive monitoring, IV fluids and/or blood transfusion

34 yo man + exlap for gunshot wound + received 5 units packed RBCs during surgery + incentive spirometry and ampicillin/sulbactam postop Postop day 6 develops fever (101.7 F) + heart and lung normal + wound is fine + abdomen is fine + has a central line and a Foley + cultures shows coag negative staph What is cause of fever?

Catheter (central line) associated infeciton. Coag neg staph is usually staph epidermidis, normal skin flora, and was probably caused by the central line

38 yo woman + RUQ pain with nausea and vomiting for 12 hrs + Hx of this folllowing fatty foods + abdominal US shows gallstones, thickened gallbladder wall w/ edema and normal common bile duct Best next step?

Choly w/in 72 hours This Pt qualifies for "complicated gallbladder disease" due to acute cholecystitsi and gallstones and leukocytosis

27 yo man + ED + MVC + BP 112/92 HR 122 RR 20 + bruises on anterior chest wall and abdomen + breath sounds decreased at left lung base + xray shows NG tube in chest Cause of respiratory distress?

Diaphragmatic injury (rupture). Usually on the left side because the right side is protected by the liver. Will have deviation of mediastinum to the right and elevation of the diaphragm on the left side. CXR showing NG tube in chest is diagnostic

59 yo man + postop for gasterctomy for perforated ulcer 3 weeks ago + abx postop + npw has intermittent diarrhea and abdominal cramps for 10 days + episodes asssociated with nausea, weakness, palpitations, light headedness and diaphoresis and occur 25-30 minutes after eating Next step?

Diet modification. This Pt has dumping syndrome, which is the rapid emptying of hypertonic gastric contents. Manage with small/frequent meals, replace simple sugars with complex carbs and eat high fiber and protein rich foods.

18 yo man + scrotal mass + increases in size when standing + soft mass + increases with valsalva + decreases in supine + does not transilluminate Diagnosis?

Dilation of the pampinoform plexus, i.e. a variocele. this is the bag of worms mass. NSAIDs are helpful, as is surgeyr. Neplasia does not have significant postural changes (fixed).

45 yo woman + elective choly for gallstones + surgery does not relieve the pain + US and ERCP shows normal bile ducts and pancreas + ALP is 450 and total bilirubin is 1.6 + sphincter of Oddi manometry shows elevated pressures What is treatment?

ERCP sphincterotomy Post choly pain is due to sphincter of Odd dysfunction or common bile duct stones.

10 yo boy + progressive lethargy + hit in head with basevall 4 hours ago + no LOC but "dazed" + nausea and vomiting 30 minutes ago + somnolent + CT scan shows large (lens) shaped bleed displacing the midline Next step?

Emergent neurosurgical evacuation. This is a *epidural hematoma*, most likely due to fracture of the sphenoid bone and a tear in the middle meningeal artery. This is the classic "lucid interval." It is a biconvex shape that does not cross suture lines

59 yo woman + ED + RUQ pain + nausea/vomiting + fever (102 F) since yesterday + PMH htn, CAD, diabetes + leukocytes 18.3K + BUN 28 + alk phos 93 Imaging shows distended gallbladder with gas in gallbladder wall and lumen, but not the biliary tree Diagnosis?

Emphysematous cholecystitis, a life-threatening form of acute cholecystitis due to infection with gas-forming bacteria (clostridium, e. coli). Predisposing facotrs include diabetes, vascular compromise and gallstones. Crepitus is suually present. must watch out for gangrene and perforation. Diagnosis is confirmed with air-fluid levels in the gallbladder, gas in the gallbladder walll and sometime pneumobilia. requires emergent cholecystectomy and abx, usually with ampicillin-sulbactam

34 yo man + ED + burning building + 98.6 F BP 90/60 HR 100 RR 28 + 2nd and 3rd degree burns over 15% of body + oropharynx has erythema and blisters + lungs are clear + abdomen soft + blood carboxyHb is 20% Next step?

Endotracheal intubation. He has signs of thermal inhalation injury, which warrants early intubtion to prevent edema from closing off the airway. Other signs of thermal inhalaltion injury: burns on face, singed eybrows, oropharyngeal carbon deposits, carbon in sputum, stridor, carboxyHb >10%, history of confinement in burning building

12 yo boy + ED + progressive headache + drowsiness + fell fo bike and hit head + LOC + several hours later headache, vomit, somnolent + BP 140/86 HR 66 + bruise over right temporal + falling asleep Diagnosis?

Epidural Hematoma. lucid interval and temporal injury. Requires emergent evacuation

34 yo man + ED + gunshot + obtunded + vomited + BP 85/43 + HR 126 + received 3 L normal saline in route Entry is 6th IC space anteriorly lateral to midclavicular line Exit is 7th IC space posteriorly Pt is intubated + xray shows hazy opacities at left lung base + US shows no fluid Next step?

Exploratory laparotomy Any penetrating injury below the 4th IC space (level of nipples) is considured to involve the abdomen and requires exlap unless Pt is stable. This Pt is hypotensive and obstunded = very unstable

28 yo man + MVC + pain in right pelvis and lower abdomen + BP 120/80 HR 104 + fulness in suprapubic w/o rigidity or rebound + no blood in urethral meatus or rectal vault + xray shows right pubic ramus fracture + foley is placed and there is immediate return of frank blood + pelvic binder applied What other injuries will be seen on CT?

Extraperitoneal bladder injury, i.e. either contusion or rupture of the neck, anterior wall or anterolateral wall of the bladder. This will cause urine to leak into local tissues and cause localized pain. This is very common in pelvic fracture. Will present with localized pain, gross hematuria. urinary retention (suprapubic fullness). There will *not* be peritoneal signs

54 yo man + ED + unrestrained driver high speed MVC + vitals stable + facial lacs + urises on anterior chest and abdomen + obtunded What is a compnent of GCS?

Eye opening. GCS assesses ability to open eyes, motor response, verbal response. More?

36 yo man + firm non-tender swelling in right cheek + had the same thing 2 years ago, which was found to be a tumor and removed + preauricular fullness Repeat surgery is at risk for what complication?

Facial droop. This Pt has recurrent *parotid neoplasm*. The facial nerve travels through the parotid, between its two lobes. This Pt most likely had a partial parotid excision and now requires full excission and if the facial nerve is involved in the tumor, it too must be removed.

18 yo woman + 9 weeks gestation + ED + open fracture of tibia and fibula + severe dyspnea and confusion + non-palpable petechiae in upper body Diagnosis?

Fat embolism

73 yo man + right anterior thigh pain + worse with walking + PMH of stable angina, HTN, high cholesterol, COPD, smokes, drinks Small pulsatile mass in right groin Diagnosis?

Femoral artery aneurysm. Pain is due to compression of nerves. Must also assess for AAA

22 yo man + ED for MVC + RR 40 100/60 120 after receiving 2 L normal saline + receives bilateral chest tubes and is intubated + bilateral coarse breath sounds + CXR shows ___ Diagnosis?

Flail chest. CXR shows multiple rib fractures and?

64 yo man + restrained driver in T-bone MVC + LOC + left chest and leg pain + BP 94/61 HR 117 pulseox 96% + bilateral breath sounds + abdomen diffusely tender + pbvious deformity and tenderness of left thigh Next step?

Focused bedside ultrasound (FAST). He has an obvious source of bleeding, abdominal tenderness and his chest checks out. He should first get fluids then, if alert get FASt, if altered mental status get serial abdominal exams +/- CT scan. If he was bleeding into his thigh it would be more obvious

24 yo man + ED + ATV accident + alert + BP 82/61 HR 122 RR 24 + scalp lac + PERL + bruising on chest wall and abdomen + abdomen is distended with rebound tenderness + absent bowel sounds + rib fractures + no pneumothorax + hypotensive after receiving 2 L IV fluids What is cause of sustained hypotension?

Hepatic laceration. May also have right shoulder pain due to phrenic nerve irritation. Should get a FAST to assess for bleeding and if positive, an exlap. Liver and spleen lacerations are much, much more common than aorta injuries in blunt trauma

39 yo woman + postop thyroidectomy for Graves + anxiety + muscle cramps + poor sleep + prolonged QT interval + HR 82 BP 142/85 + take lansoprazole for GERD Diagnosis?

Hypocalcemia due to hypoPTH, a common complication of thyroidectomy. Pt will also have elevated phosphate and normal renal function. May also have tetany (contractions) of lip, face, extremeties and even seizures and QT prolongation

55 yo man + ED + gunshot wound to abdomen + surgical repair + postop day 4 waxing/waning fever, tachypnea, SOB + fever of 104 F BP 90/60 HR 110 RR 22 + AMS + right lung base crackles + pH of 7.23 + low bicarb (16) What is the next step after antibiotics?

IV 0.9% saline. This Pt has a postop penumonia that is devloping into septic shock. IV normal saline is first step along with antibiotics to treat the pneumonia

54 yo man + 30 pack year history + lap choly after an episode of biliary pancreatitis POD3 hypoxemic with decreased breath sounds at the bases pH = 7.44 pO2 = 64 pCO2 = 34 What is causing this?

Impaired cough and shallow breathing causing atelectasis. These shallow inhalations leads to low pO2, which triggers an increase in RR and you end up blowing off too much CO2, causing a resp. alkalosis Most common on POD 2-3 Treat/prevent with directed coughing, incentive spirometry

55 yo man + chronic pain in butt, hip and thigh muslces + le ache associated with walking + smokes + decreased femoral, popliteal, dorsalis pedis pulses What other symtpom does this Pt likely have?

Impotence. This Pt is suffering for *Leriche Syndrome*< or arterial pcclusions at the bifurcation of the aoprta. It is associated with atherosclerosis. Impotence is almost always present. Will also have symmetric atrophy of bilateral lower extremeties due to chronic ischemia

67 yo man + medical clearance for elective AAA repair + denies cough, SOB, chest pain + PMH of CAD, diabetes, htn + does not smoke, drink + BP 120/76 HR 60 RR 14 + PE is normal What would best prevent postop pneumonia in this Pt?

Incentive spirometry Promoting lung expansion helps prevent postop pneumonia. Deep breathing exercises. continuous positive airway pressure have been shown to help but incentive spirometry is first line

65 yo man + right shoulder pain for few weeks + house painter + pain when lifts arm above head + smokes, arthritis + vitals stable flexes arm, thumb pointed down, shrug shoulder + @ 60 degrees flexion pain begins Diagnosis?

Inflammation of rotator cuff tendons (tendinopathy). Presents with subactue pain on abduction. This inflammmation causes impingement syndrome, which is when the humeral head and acromian come together and compress the soft tissue structures. Pt is at increased risk for rotator cuff tear This PE maneuver is called the Neer test

56 yo man + ED + massive hematemesis + PMH of peptic ulcer, esophogeal varices due to alcoholic cirrhosis + 37.6 C 102/58 112 23 Next step?

Insert two large bore IVs. This is a pretty classic example of variceal bleeding. The first step is aggressive fluid resuscitation and then protect the airway and gastric decompression via NG aspiration to prevent aspirating. Then control the bleeding. 50% are self-limitng. Those that aren't, first five a vasoconstrictor such as terlipressin (vasopressin), ocreotide or somatostatin. Usually do not need to operate urgently.

64 yo man + PMG of CAD, PVS gets coronary artery bypass surgery + postop hypotension corrected with fluids followed by abdominal pain and bloody diarrhea + 100 F 110/60 1110 20 + lactic acid elevated What will see on CT abdomen?

Ischemic colitis in the splenic flexure. Usually follows an episode of hypotension and affects the watershed areas of splenic flexure and rectosigmoid junction. CT scan will show thickened bowel wall. Colonoscopy confirms diagnosis.

55 yo woman + ED + acute onset midepigastric pain that radiates to back + nausea/vomiting + PMH of htn + does not drink or smoke + vitals stable + no rebound or guarding + US shows gallstones w/o wall thickening + admitted and given IVF, NPO, analgesia + recovers rapidly and enzymes begin to trend down Next step?

Lap choley. This Pt had an acute attack of gallstone pancreatitis, as evidence by *ALTs >150* and elevated lipase/amylase. Treatment is to stabilize them and then remove the gallbladder "early"

23 yo man + gunshot RUQ abdomen + BP 60/p HR 136 + breath sounds clear + abdomen distended + bowel sounds decreqased Best next step?

Laparotomy All hemodynamically unstable Pts with penetratign abdominal trauma must get immediate ex lap to diagnose and treat the source of bleeding and/or perforation

31 yo man + unrestrained passenger in MVC + 3 L normal saline + O2 via nasal cannula + BP 85/55 HR 120 RR 30 + neck veins are flat + trachea shifted to right + absent left breath sounds and dullness to percussion Diagnosis?

Left hemothorax caused by blunt chest trauma Most common causes are laceration of lung parenchyma or damage to intercostal artery or internal mammary artery Treat w/ chest tube?

23 yo man + ED + unrestrained driver MVC + unresponsive and intubated at scene + 2.5 L normal saline before reaching ED + BP 70/30 HR 120 + PERL + responsive to stimuli + bruises ver chest and abdomen + flat neck veins + cold extremeties Diagnosis?

Loss of intravascular volume (hypovolemic shock) Cardiogenic shock would have JVD, not flat veins Cardiac tamponade restricts cardiac filling but also has JVD

34 yo man + ICU + motercycle accident + CT shows brain swelling but no hematoma + hospital day 2 placed ventriculostomy for ICP monitoring + day 3 ICP is high How might hyperventilation help in this situation?

Lowers ICP by causing a drop in paCO2 (blowing off to much CO2). This indicates that the brain has more than enough O2 and the body responds by vasoconstriction to shunt blood away, lowering cerebral blood flow and thus ICP

23 yo man + urgent care + knee injury playing basketball + tenderness at medial joint line + abduction (valgus) test shows left knee laxity Diagnosis?

MCL injury

22 yo man + 4 weeks of right knee pain + sensation of "catching" while walking + unable to extend knee + no ligament weakness is found on exam and no pain is elicited by any movement Next step?

MRI of the knee to look for a meniscus tear. Patients have a popping sensation at time of injury and sense of catching afterwards. Usually we treat with rest and NSAIDs but young patients who have persistant symptoms can have surgery.

23 yo man + right wrist pain + landed on outstertched hand + swelling over dorsum of wrist + tenderness over first metacarpal + pain with radial deviation of wrist + no fracture on radiograph Next step?

MRI of wrist and forearm because we are worried about scaphoid avascular necrosis and nonunion. 1st metacarpal = thumb = anatomic snuffbox. Will not show up on xray for 7-10 days. The wrist can also be immobilized in a thumb spica cast for 7-10 days, followed by repeat imaging to evaluate for osteonecrosis

30 yo woman + knee injury + felt popping sensation + internal rotation elicits locking sensation and pain Diagnosis?

Medial meniscus tear, usually due to twisting injury with foot fixed. Reduced extension, instability, effusion Comfirm with MRI or arthroscopy

21 yo AA man + ED + 6 weeks of progressive SOB and cough + wheezes at night + has to sit up to relieve chest discomfort + CT shows mediastinal chest mass compressing the trachea + alpha-fetoprotein and beta-HCG are elevated Diagnosis?

Mixed germ cell tumor (teratoma of the 4 Ts of anterior mediastinal masses). AFP is normal in seminoma. both are elvated in mixed germ cell tumor

42 yo woman + 4 days post-choley + mild diffuse abdominal discomfort + npt farted + Whats the most likely cause?

Morphine. prolonged postop ileus = nausea, abdominal discomfort, obstipation, hypoactive bowel sounds

53 yo man + MVC unrestrained driver + unresponsive + intubated at scene + BP 70/30 HR 100 + responsive to stimuli + PERL + bruises on anterior chest and upper abdomen + trachea is midline + pulm cap pressure 14 + normal saline raises wedge pressure to 22 and BP to 75/30 and HR to 123 Diagnosis?

Myocardial contusion. Should get an emergent echocardiogram. Elevated wedge pressure that elevates after fluids points to LV dysfunction most likely caused by myocardial contusion

23 yo woman + 4 weeks whistling noise while breathing + rhinoplasty a few months ago Diagnosis?

Nasal septal perforation, most likely from a septal hematoma

38 yo woman + ED + severe pain/swelling in left leg + 2 days ago fell playing soccer and suffered a minor abrasion + gotten worse + currently unbearably painful + thigh is red + pain has spread to butt and calf + fatigue, fever (102.7 F) and chills + BP 82/60 HR 104 RR 18 + CT scan shows air in the deep tissue Diagnosis?

Necrotizing fasciitis. Pain out of proportion to exam is a key finding. Crepitus. Rpaidly spreading. strep pyogenes, staph aureus, clostridium Surgical debridement and abx

65 yo man w/ COPD presents to ED + progressive dyspnea + productive cough + fever of 2 days + 101.8 F 122/74 110 32 93% + he is intubated and a central line is placed in right subclavian + given abx, steroids, bronchodilators Pt gets worse, desats to 83% and BP 80/50 + trachea deviated to left + absent right breath sounds + neck veins distended Next step?

Needle thoracostomy to relieve what is likely a *tension pneumothorax* caused by the central line placement. This Pt is extremely unstable to start with needle and then do an emergency chest tube (thoracostomy)

23 yo man + MVC + leg fractures + abdominal bruising + scalp lacerations + SOB + 95/60 HR 120 + cervical collar + IV access + 1 L fluids + on way to hospital becomes drowsy and weak on right side of body + BP 160/90 HR 50 What nerve is compromised?

Oculomotor nerve. This Pt probably has an uncal herniation secondary to right-sided epidural hematoma (lucid interval) due to MMA rupture and hematoma that compresses the temporal lobe, raising ICP. The uncus of the temporal lobe then herniates through the tentorium and compresses the: *ipsilateral oculomotor nerve*: mydriasis, ptosis, down and out gaze, strabismus due to unopposed trochlear and abducens *ipsilateral posterior cerebral artery*: contralateral homonymous hemianopsia due to ischemia of the visual cortex *contralateral cerebral peduncle*: ipsilateral hemiparesis *reticular formation*: AMS, coma

25 yo man + ED + fell 6 meters (20 feet) off a latter + received crystalloid on route + comatose on arrival + BP 92/45 HR 127 RR 6 pulseox 86% + depressed temporal skull fracture + no significant neck edema Next step?

Orotracheal intubation. Despite most likely having a cervical spine fracture, it is still possible to intubate as long as you manually stabilize th head.

54 yo woman + wrist pain 3 days after fall on her palm + tenderness over dorsoradial wrisrt lateral to tendon of extensor pollicus longus (anatomic snuffbox) + radigraph shows line across the scaphoid What complicaiton should you watch for?

Osteonecrosis of the proximal segment Monitor via serial xray

54 yo man + fatigue + tires easily + going to bed early + constant gnawing abdominal pain + lost 15 lbs in the last month + two moinths ago fell and hit head + smokes + tenderness and fullness in epigastrium Diagnosis?

Pancreatic cancer, most likely adenocarcinoma. Presents with cosntant gnawing apigastric pain that is worse at night, anorexia with weight loss, hainduce, migratory thrombophlebitis and steatorrhea' Smoking is a major risk factor

33 yo man + bike crash + abdomen hit handlebars + vitals stable + upper abdominal bruising + CT scan normal + sent home + 1 week later fever + chills + shakes + anorexia + deep abdominal pain Diagnosis?

Pancreatic laceration. The triad of fever, chills and deep abdominal pain suggest retroperitoneal abscess. The blunt trauma compressed the pancreas against the spinal cord. Pancreatic injury takes time to show up on CT and *serial CTs* are needed to detect it. Do not get amylase levels for trauma. Pancreatic acbscess requires immediate percutaenous drainage, culture of the drained fluid and surgical debridement.

60 yo man w/ PMH of diabetes, HTN, hypothyroid gets laparotomy for intestinal obstruction + postop day 3 intense pain at surgical site + fever (101 F) + gray discharge from wound + friable tissue + glucose at 312 Next step

Parenteral antibiotics and urgent surgical debridement. This Pt has necrotizing surgical site infection. Signs include parethesia or anesthesia at the edges of the wound and a purulent, cloudy-gray discharge, often termed "dishwater drainage," and crepitus. Necrotizing infections are more common in diabetics and are often polymicrobial. Early surgical expoloration and debridement is the most important step.

76 yo woman + ED + 2 days lower abdominal pain + mild fever (100.2) + sigmoid diverticula + started on ABX + 3 days later symptoms worsened and CT shows a 5 cm ring enhancing fluid collection in sigmoid Next step?

Percutaneous abscess drainage under CT guidance, which is first line treatment of complicated diverticulitis w/ abscess formation

16 yo boy in ED + sore throat and fever for 1 week + right neck pain + ear ache + fever of 102 F but otherwise stable + enlarged cervical nodes + pooling of saliva + large tonsil + uvular deviation Diagnosis?

Peritonsillar abscess. will also have muffled voice. Treatment is needle aspiration of incision and drainage, plus abx to cover GAS (strep)

31 yo man + pain/swelling over coccyx + appendectomy 2 years ago and acute pyelonephritis 1 year ago Diagnosis?

Pilonidal Disease (cyst). Most common in young men with a lot of body hair, especially butt hair. Usually midline. Treat by draining abscess and excising sinus tracts

What is the first thing to do when someone amputates a finger?

Place the amputated finger in saline moistened gauze in a plastic bag. Place the bag on a bed of ice and bring it (and the Pt) to the ED

34 yo woman + ICU for UTI and septic shock + IV fluids and abx + IJ catheter is placed What should be done after the central line is placed?

Portable chest xray to ensure the catheter is in the right place. You want the catheter tip in the SVC

63 yo man + ED + 2 days of right knee pain + cannot walk + no trauma + smokes, drinks + diabetes, htn, cholesterol, COPD + construction worker + mild fever (99 F) + swelling anterior to patella + passive range of motion normal Diagnosis?

Prepatellar bursitis, common in jobs with repetitive kneeling. Often caused by staph aureus. Confirm with aspiration of bursal fluid for cell count and gram stain. If negative, NSAIDs and rest. If positive drainage and abx

53 yo man + high speed MVC + bilateral chest pain + left leg pain + left femur fracture + blood gases show pH 7.45 pO2 81 pCO2 32 wedge pressure 10 2000 mL IV fluid challenge takes his pO2 to 76 and his wedge pressure to 12 + CXR shows bilateral lower lobe opacities + shortness of breath What is causing his shortness of breath?

Pulmonary contusion, which has hypoxdemia worsened by fluids (volume expansion) and patchy, irregular alveolar infiltrates on CXR. SOB may be a delayed presentaiton

12 yo boy + ED + MVC + no distress + tachypnea and tachycardia 2 hours after admission + other vitals stable + bruises on right side of chest + chest wall tender but no fractures + breath sounds decreased on right + CXR shows patchy, irregular alveolar infiltate on right middle/lower lobes pH=7.42 PaO2=60 PaCO2=32 Diagnosis?

Pulmonary contusion, which is parenchymal bruising of the lung that results in intraalveolar hemorrhage and edema. It presents in the first 24 hours after a blunt thoracic injury and often presents in the first few minutes with tachypnea, tachycardia and hypoxia. Pathcy, irregular alveolar infiltrate with hypoxemia and trauma is fairly indicitave. Management is supportive with pain control, pulmonary hygeine (nebulizer, chest physiotherapy) and supplemental oxygen

45 yo man from gautemala + persistant nausea + vomiting of partialy digested food for 1 month + lost 5 lbs in this time + early satiety with normal appetite + ingested acid in a suicide attempt 3 months ago + PUD controlled with antacids + drinks and smokes + vitals stable + abdominal exam shows succession splash on epigastrium Diagnosis?

Pyloric stricture, i.e. gastric outlet obstruction. This can be caused by cancer, PUD, Crohn's, strictures secondary to ingestion of caustic agents (as in this case_ and gastric bezoars. PE shows abdominal succession splash, which is elcitied by placing stethescope over upper abdomen (epigastrium) and rocking Pt @ hips. willl hear a splash. Acid ingestion takes 6-12 weeks to cause fibrosis. Upper endoscopy confirms diagnosis and treatment is surgery

34 yo man + midshaft humerus fracture + closed reduction and cast + 1 hr later numbness of left wrist and limited wrist extension Diagnosis?

Radial nerve injury

34 yo man + mexican immigrant + ED + coughing up a lot of bright red blood + BP 112/63 HR 97 RR 16 pulseox 96% + breath sounds audible and expiratory wheeze on right side + given IV fluids and O2 + CXR shows dense opacity in right upper lobe Next step?

Respiratory isolation. This Pt likely has TB until diagnosis is confirmed with acid-fast bacilli smear/culture or ruled ou

21 yo female military recruit + pain in right foot + began with activity, now also at rest + swelling, warmth, point tenderness over second metatarsal + films shopw hairline fracture of second metatarsal shaft Best next step?

Rest and analgesics This is a nondisplaced stress fracture and are common in people who see a sudden and drastic increase in activity. The 2nd metatarsal is most common site of injury. Treat with rest, analgesia, hard-soled shoe Bone scan and MRI are used if plain films are inconclusice Surgical intervention is resercved for fractures of 5th metatarsal

45 yo man + ED + MVC + unable to void + blood in urethral meatus + scrotal hematoma + BP 100/50 HR 100 RR 16 + high riding prostate Next step?

Retrograde urethrogram This Pt is a classic presentation of a posterior urethral injury, often associated with pelvic fracture. Do *not* insert a Foley before assessing urethral damage

34 yo man + ED + severe penis pain began during sex (wife on top) that began at orgasm + penis is swollen and deviated Next step?

Retrograde urethrogram followed by surgical exploration of the penis. This is a penis fracture, which is actually a torn tunica albugginea and the formation of a hematoma. Must first assess for urethral injury then evacuate the hematoma and repair the tear

22 yo man + MVC + surgery to repair left tibial fracture and popliteal artery injury + POD 1 has incresed leg pain + treated with IVF and morphine + POD 3 pain worse with passive movement and pins and neeedles + tense, tender swelling of left calf + sensory loss between big and 2nd toe + pulses intact Next step/

Return to OR for fasciotomy for compartment syndrome. Signs: pain out of proportion to injury, rapid tense swelling, paresthesia, can progress to sensation loss, weaknes, paralysis, decrease in distal pulses

25 yo man + ED + MVA + truck hit driver side + BP 110/66 + HR 120 + RR 34 + pulse ox 88% + trachea is midline + chest wall and abdominal bruises + breath sounds decreased at bilateral bases + badomen is soft, nontender, nondistended + deformity of left thigh What is causing the hypoxia?

Rib fractures causing flail chest. Basically it hurts so much to breath they take shallow breaths and chest moves in on inspiration.

43 yo man + right shoulder pain/weakness after falling on outstretched hand 2 days ago + when arms above shoulder, they drop rapidly at the midpoint Diagnosis?

Rotator cuff tear. This is a positive arm drop. Probably supraspinatous.

How di you determine how much fluid a burn Pt requires?

Rule of 9s: only for 2nd and 3rd degree. The front and back of the chest, abdomen and each leg gets 9. The head gets 9. Each arm in its entirety (front and back) is 9. This adds up to 99%. The remaining 1% is the genitalia. This calculated body surface area burnt Then, 4 * body weight * body surface area burnt = amount of fluid needed in first 24 hours. Give 50% in the 1st 8 hours and the 2nd 50% in the subsequent 16 hours.

35 yo woman + g2p2 + ED + abdominal pain started 6 hrs ago RLQ now is diffuse + started while playing tennis + pain in right shoulder + menses 3 weeks ago + recently stopped OCPs due to DVT + on warfarin + rebound and guarding Labs: Ht 22% WBC 9,000 Platelets 160,000 Diagnosis?

Ruptured ovarian cyst Decreased hematocrit indicates bleeding into the abdomen. Diagnos with pelvic ultrasound. If hemodynamically unstable, requires surgeyr

69 yo man w/ a PMH of htn, lipids, diabetes, CAD + hours after elective repair of descending thoracic aortic aneurysm w/ significant blood loss requiring multiple transfusions + weakness in both legs + urinary retention + flaccid paraplegia and loss of pain sensation in both legs + vibration intact + arms normal Diagnosis?

Spinal cord infarction, specifically of the anterior cord due to an anterior spinal artery insufficiency. The anterior spinal artery relies on the radicular arteries, which aries from the artery of adamkiewicz, which arises from the thoracic aorta. clamping the aorta during the repair decreased blood flow. Presents with abrupt onset bilateral flaccid paralysis and loss of pain/temp.In subsequent days-weeks develop spasticity and hyperreflexia. Will often have bowel/bladder dysfunction due to autonomic dysfunction

65 yo man + burn 4 years ago that got a skin graft + chronic draining wound that never closed + 6 weeks ago enlarging nodule at wound site that is painful and draining What is this nodule/

Sqaumous cell carcinoma. Often associated with sun exposure as well as chronicall wounded, scarred or inflamed skin. SCCs that arise from chronic wounds tend to be aggresive. This type of SCC is known as *marjolin ulcer*

65 yo man + ED + dull knee pain + total knee replacement 6 months ago + 99.2 F 120/60 90 + full range of motion + WBC 10,000 + synovial fluids shows 10,000 WBCs with 90% neutrophils What is the bug?

Staph epidermidis Staph aureus causes early onset (w/in 3 months) infection while epidermidis, along with staphylococci, propionibacterium, enterococci causes delayed onset (>3 months) Both types of infection require removal of the prosthesis

24 yo woman + 2 weeks of right leg pain + active dancer + practices 4-5 hours/day + dulll ache in right shin + point tenderness + xray normal Diagnosis?

Stress fracture of tibia. Middle of tibia in people who jump (dancers, BB) and lower 1/3 in runners. Treatment is rest

22 yo man + ED + sudden onset dyspnea 2 hours ago + improved since but right sided chest pain on inspiration + smokes and drinks + CXR shows small right apical pneumothorax Next step?

Supplemental oxygen. This Pt most likely has primary spontaneous pneumothorax. Happens in young, tall, thin men who smoke.

72 yo man + CABG + POD 3 dypnea + retrosternal pain + fever 101.5 F + irregularly irregular pulse + cloudy fluid in sternal wound drain + AFIb + x-ray showes widened mediastinum + echo shows pericardial fluid + WBC 16K Next step?

Surgical debridement of acute mediastinitis and abx.

55 yo woman + ED + worsening constant, throbbing headaches associated with nausea for 1 month + right-sided weakness + no photphobia, blurry vision + recently emigrated from mexico + right sided pronator drift + CT scan shows calcified dura based contrast enhancing round mass compressing left frontal lobe Next step?

Surgical resection of the brain mass, which is likely to be a meningioma. Thse are usually benign. Complete resection is curative.

35 yo man + impaired pain/temp in both arms + moderate wasting of hand muscles + light touch, vibration intact + whiplash car injury 7 years ago Diagnosis?

Syringomyelia. 3-4% of spinal cord injuries will develop post-traumatic syringomyelia months to years after the injury, which is often a whiplash injury. The injury causes CSF retention and enlargement of the central canal of the spinal cord, causing impaired strength and decreased pain/temp in the upper extermeties. MRI is used for diagnosis

25 yo man + mouth mass + been there for years + denies weight loss + in MVC years ago and had a concussion + non smoker, non drinker + 2X2 mass on hard palate that is bony hard What is the diagnosis?

This is likely *torus palaatinus*, a benign congenital bony growth midline on the hard palate. Usually non-tender. Only remove if interfering with eating, speaking, etc

35 yo man + excruciating pain of defecation for 1 week + bright red blood on surface of stool + history of chronic constipation + soft mucosal tear of anus and skin tag In addition to stool softeners and sitz baths what is best next step?

Topical lidocaine and nideipine This is a classic presentation of anal fissures. Treatment incluids increased fiber and fluids intakes as well as topical anethetics and vasodilators.

39 yo paleontologist + superficial right hip pain + can't sleep on it + PMH hypertension, hyperlipidemia + meds HCZ and statin + smokes Cause of pain?

Trochanteric bursitis This is inflammation of the bursa surrounding the insertion of the gluteus medius nto the femur's greater trochanter. Due to overuse. Pt describes it as superficial and worse with external pressure

newborn AA boy + bulge in abdomen + bigger when cires + soft swelling at umbilicus + reducible Diagnosis and treatment?

Umbilical hernia, observe for spontenous resolution. These usually close by the age of 5, do not cause pain and we do not operate until around 5 years of age

60 yo man w/ PMH of end-stage renal disease + ED + 2 days right calf pain, swelling, difficulty bearing weight + no chest pain, SOB, syncope + 4 weeks ago abx for hemicolectomy + 2 week hospital stay + vitals stable + right calf pain on dosriflexion of foot + US shows non-conpressible right femoral vein Next step?

Unfractionated heparin follosed by warfarin. This Pt has a DVT due to recent surgery. low molevular weight heparin (enoxaparin) and rivaroxaban are contraindicated due to his renal status. All Pts w/ a postop DVT require 3 months of anticoagulation, which can be started as early as 48-72 hours after surgery. Must do a heparin to warfarin bridge

62 yo man + ED + severe epigastric pain for 1 hour + episodic postprandial epigastric pain for few days + nause/vomiting + PMH HTN, diabetes, lipids, CAD + ibuprofen + ECG shows Q waves Next step?

Urgent exlap. On xray this Pt has free air in the peritoneum (pneumoperitoneaum) consistent with perforated peptic ulcer due to chronic NSAID use.

50 yo woman + ED + 2 days abdominal pain, nausea, vomiting + started as waves of pain, now constant + no bowel movement or fart for 3 days + 101.3 F 91/64 122 24 + 97% pulse ox + abdomen is distended, tympanic, tender + bowel sounds decreased + no stool in rectal vault + distended small bowel with air-fliuid level NG tube is placed, IV fluids and analgesics started. Next step?

Urgent surgical exploration Since this Pt is hypotensive w/ tachycardia, low bicarb indicating metabolic acidosis this Pt requires surgery

29 yo woman + ED + hot coffee on arm + full thickness burn + 3 days later worsening severe and aching pain/swelling on left arm + circumfurential eschar + hand is tense and tender Diagnosis?

Vascular compromise due to compartment syndrome.

28 yo man + ED + MVC + BP 90/50 HR 120 RR 30 + stuperous + bruises over extremeties and upper abdomen + neck veins flat + intubated + mechanical ventilation + cardiac arrest What could have prevented arrest?

Volume resusciatation. Postiive pressure mechanical ventilation increased intrathroacic pressure, which decreases venous return, something you absolutely do not want in a severely hypovolemic patient.

46 yo man + ED + PMVC + unresponsive + basilar skull fracture + brain contusion + fractured ribs 7-10 + R. hemopneumothroax +npelvic fracture Trasnfused, chest tube placed, pelvis stabilized + POD 5 minimaly responsive + diminished bowel sounds + facial grimace upon palpation of RUQ + NG aspiration shows retention of abdomina contents + CT shows gaseous distension of bowels with *no* air-fluids levels + gallbladder distened w/o gallstones + pericholecystic fluid Diangosis?

acalculous cholecystitis. seen in Pts w/ mutliorgan failrue, serious trauma, burns, basiclly very sick patients. need abx followd by percutaneous choley

50 yo man + checkip + occasional left posterior calf pain when walking, sometimes at rest + PMH diabetes and HTN w/ poor compliance + smokes + family history of MI and stroke + all peripheral pulses intact + A1c is 7.2% Next step?

ankle-brachial index to look for peripheral artery disease. ABI <0.90 is diagnostic of occlusive PAD