- RUQ pain, fever, jaundice
- acute cholangitis
jaundice, fever, RUQ/biliary pain, mental status changes, hypotension
- progression from cholangitis to septic state, IV antibiotics, but if no improvement, decompress cystic biliary duct
- if amylase or transaminases are elevated, could be acute pancreatitis
What is the most common cause of unilateral serosanguinous discharge from the breast?
What is the confirmatory procedure?
- intraductal papilloma, breast cancer
What percentage of Stage II breast cancer patients have recurrance if only given locoregional control?
How long is anti estrogen therapy given to patients with estrogen/progesterone sensitive receptor tumors?
What is the hormonal therapy of choice for post menopausal women with estrogen sensitive tumors?
What is the proven advantage of neoadjuvant therapy in treating breast cancer?
Improvement in breast conservation rate and cosmetic results. No improvement in morbidity when compared to adjuvant therapy
What drug therapy is associated with the development of uterine cancer?
Do patients that are triple negative (ER neg, PR neg, HER2/neu neg) have a good prognosis?
What are two locoregional treatments and two systemic treatments for breast cancer?
- locoregional: surgery and radiation
- systemic: chemotherapy and antiestrogen therapy
In what percentage of GERD patients does PPI's provide relief?
What diagnostic tests do you run for GERD? Which is the best objective indicator of GERD? What is the best CLINICAL indicator of GERD?
- endoscopy, 24 hour pH monitoring, manometry, barium esophography
- commonly, not all four are done. But if a patient is not responding medically, it must be made certain that the symptoms are due to GERD and not something more serious (cancer, etc.)
- 24 hour pH monitory is the best OBJECTIVE indicator of GERD.
- response to PPI is the best CLINCIAL indicator of GERD.
What fraction of patients with esophageal ruptures present with pleural effusion?
3/4 present with pleural effusion. 2/3 have LEFT sided pleural effusions
What is the best initial test for esophageal rupture?
water soluble contrast (gastrograffin) esophagogram identifies ruptures in 90% of cases
What are the treatment principles for spontaneous esophageal rupture?
surgerical drainage, debridement, repair and diversion
how should skin lesions be evaluated?
- B: border irregularity
- C: color change
- D: diameter increase
- E: enlargement/elevation
What is the most common indication for intubation?
- altered mental status
- any sign that the airway is or will be compromised
A patient involved in severe automobile crash if fully awake and alert, but he has extensive facial fractures and is bleeding briskly into his airway, and his voice is masked by gurgling sounds.
How do you maintain an airway?
- Second best percutaneous tracheostomy
- NOT orotracheal route.
What is the typical picture of shock?
How do you treat it?
- diaphoretic, pale, cold, shivering, anxious, asking for a blanket and a drink of water, low blood pressure, fast weak pulse
- big bore IV lines, Foley catheter, IV antibiotics then fluid and blood administration
What are some causes of shock?
- pericardial tamponade
- tension pneumothorax
A 4-year-old child has been shot in the arm in a drive-by shooting. The site of bleeding has been controlled by local pressure, but he is hypotensive and tachycardic. Two attempts at starting peripheral IVs have been unsuccessful. What is the access of last resort in this age group and how much should be infused?
- intraosseous cannulation in the proximal tibia
- Ringer lactate, 20ml/kg of body weight
How would you distinguish shock from bleeding, pericardial tamponade, and a tension pneumothorax?
both pericardial tamponade and tension pneumothorax have distended neck veins.
tension pneumothorax also has respiratory distress, tracheal deviation, unilateral absent breath sounds and unilateral hyperresonance
How do you treat a suspected pericardial tamponade?
- 1) evacuate blood, either by pericardiocentsis, tap, tube or pericardial window
- 2) if positive, then thoracotomy then exploratory laparotomy
How do you treat a tension pneumothorax?
Immediate big bore IV needle or IV catheter place into pleural space, then chest tube
DO NOT choose x-ray as first step. Pt will die in xray!
How much blood must be lost to go into shock?
Can an intercranial bleed cause hypovolemic shock?
No, there's not enough space in the skull to accomodate the blood needed to go into shock.
How do you treat cardiogenic shock from massive MI?
verify high CVP, ECG, enzymes, coronary care unit, possible thrombolytics
DO NOT give fluid resiscitation.
If a patient has symptoms of shock but are warm and flushed, what kind of shock are they in?
Vasomotor shock, massive vasodilation, loss of vascular tone
Manage with vasoconstrictors and fluids may help
How do you remove a weapon that is embedded in a patient?
Surgically, NOT in the ER
What do you do for a closed, non comminuted, non depressed skull fracture? What if it was open? What if it was comminuted or depressed?
- if they are asymptomatic, leave it alone
- if open, clean and close
- if comminuted or depressed, OR for cleaning, repair and possible craniotomy
Everyone who got hit in the head and lost conciousness gets a
ecchymosis around the eyes (raccoon eyes), clear fluid dripping out of his nose or ear, or ecchymosis behind the ear is indicative of
basal skull fracture, get CT of head and cervical spine
Nothing will be done about the basal skull fracture and the CSF leak will stop on it's own
A man involved in a high-speed, head-on automobile collision is in a coma. He has never had any lateralizing signs, and CT scan shows a small crescent shaped hematoma, but there is no deviation of the midline structures.
Subdural hematoma, but without lateralizing signs and evidence of displacement of midline structures, surger has little to offer.
- Control ICP: head elevation, hyperventilation, avoidance of fluid overload. Mannitol and furosemide
- lowering ICP is not ultimate goal, preserving brain perfusion is
A man has been shot in the neck and his blood pressure is rapidly deteriorating.
Any penetrating neck wound with an unstable patient need immediate surgical exploration.
If in the middle of the neck and there are alarming symptoms (hematoma, spitting up blood), need immediate surgical exploration, even if the patient is stable.
A young man is shot in the upper part of the neck. Evaluation of the entrance and exit wounds indicates that the trajectory is all above the level of the angle of the mandible. I steady trickle of blood flows from both wounds, and does not seem to respond to local pressure. The patient is drunk and combative but seems to be otherwise stable.
Angiography for diagnosis and potentially for embolization
No trachea, no esophagus damage possible. Only pharynx damage possible, which is inconsequential. Vascular injury is most important, but hard to get to surgically.
A young man suffers a GSW to the base ofhis neck. The entrance and exit wounds are above the clavicles but below the cricoid cartilage. He is hemodynamically stable.
Even if patient is stable: angiography, soluble-contrast esophagogram (followed by barium if negative), esophagoscopy, and bronchoscopy
Precise diagnosis helps plan the surgery and approach
A pateint in a car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss of pain and temperature sensation on both sides distal to the injury, while showing preservation of vibratory sense and position.
- Anterior cord syndrome
- CT for bones, MRI for spinal cord, high dose corticosteroids
An elderly man is involved in a rear-end automobile collision in which he hyerextends his neck. He develops paralysis and burning pain on both upper extremities while maintaining good motor function in his legs.
- Central cord syndrome
- CT for bone, MRI for cord, high dose corticosteroids
When would a hemothorax require a thoracotomy?
If little blood retrieved, DO NOT need surgery. If >1,000-1,500ml recovered, need to ligate or if the sum over 6 hours is > 600ml.
A worker has been injured at an explosion in a factory. He has multiple cuts and lacerations from flying debris, and he is obviously short of breath. The paramedics at the scene of the accident ascertain that he has a large, flaplike wound in the chest wall, about 5 cm in diameter, andhe sucks air through it with every inspiratory effort.
sucking chest wound, taping dressing on three sides, chest tube once in hospital
What is the diagnosis if the patient has paradoxical breathing? How do you manage it?
- Flail chest
- Management: fluid restriction for pulmonar contusion, colloids (not crystalloids) if fluid needed, diuretic, close monitoring of blood gases. If blood gases deteriorate, place on respirator and bilat chest tubes (to prevent tension pneumothoraxes)
- Monitor next 48 hours for pulmonary or myocardial contusion, repeated chest x-rays, blood gases, ekgs, and troponins
traumatic transection of the aorta diag with spiral CT scan. Also get x-ray. If mediastinum is wide on x-ray and CT is nondiagnostic, then get arteriogram
How do you manage pulmonary treatment?
fluid restriction, diuretics, respiratory support (intubation, mech ventilation, PEEP)
How to manage a sternal fracture?
high risk for myocardial contusion and traumatic rupture of aorta
diagnose and treat a myocardial contusion as an MI: ECG, troponins, control arrhythmias, spiral CT and chest X-ray
A patient is in high speed automobile collision. He has a moderate respiratory distress. Physical examination show no breath sounds over the entire left chest. Percussion is unremarkable. Chest x-ray shows multiple air fluid levels in the chest.
traumatic diaphragmatic rupture. ALWAYS on left
What are signs of traumatic rupture of the aorta?
- 1. big trauma
- 2. fracture of hard to break bone (first rib, scapula, sternum)
- 3. widened mediastinum
emergency surgical repair
What are the three things that can give thoracic subcutaneous emphysema?
- 1) rupture of the esophagus-usually after endoscopy
- 2) tension pneumothorax
- 3) traumatic rupture of the trachea of major bronchus
chest x-ray to confirm air in tissues
management: fiberoptic bronchoscopy to confirm diag and obtain an airway. surgical repair
Patient is shot with a revolver. The entry wound is in the epigastrium, to the left of the midline. The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is moderately tender.
- Penetrating GSW of abdomen=exploratory laparotomy
- Need: 1) indwelling bladder catheter 2) large-bore venous line 3) broad spectrum antibiotics
Patient is shot iwth a revolver. The entry wound is in the left mid-clavicular line, 2 inches below the nipple. The bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk and combative and physical examination is difficult to perform.
- Needs chest and abdoment management.
- Chest x-ray, chest tube if needed, exploratory laparotomy
During the performance of a supraclavicular node biopsy under local anesthesia, suddenly a hissing sound is heard and the patient drops dead.
sudden death=air embolism
26 year old female has been involved in mva. She has fractures in both upper extremities, facial lacerations, and no other obvious injuries. Chest x-ray is normal. Shortly thereafter she develops hypotension, tachycardia, and dropping hematocrit. Her CVP is low.
Only massive plevic fractures, multiple femur fractures, or intraabdominal bleeding can accommodate enough blood to go into hypovolemic shock. Abdomen is where to look for hidden bleeding.
If hemodynamically stable, CT. If not stable peritoneal lavage or sonogram in ER or OR.
What is the management for surgical removal of a spleen?
Pneumovax and immunization for H. influenza B and meningococcus
A 42 year old woman is in mva where the car crushes her. At eval in the ER it is determined by physical exam that she has a pelvic fracture. She arrive hypotensive and did not respond to fluid resuscitation. Hemodynamic parameters have continued to deteriorate. Sonogram performed at the ER shows no intraabdominal bleeding.
External fixation or arteriograhic embolization (only effective for arterial bleeding, not venous)
NOT surgical exploration
How can you tell an anterior urethral injury from a posterior urethral injury and how do you diagnos it?
Both will have pelvic fracture with blood at the meatus and scrotal hematoma. But posterior will have a high riding prostate with the feeling of needing to urinate but he can't.
diagnose with retrograde urethrogram
Patient has been involved in a mva. She has multiple injuries, including pelvic fracture. Insertion of Foley catheter reveals gross hematuria.
retrograde cystogram. If negative, must get another film after bladder is empty to see reptures of trigone that leak retroperitoneally.
A patient in mva has multiple injuries, including rib fractures and abdominal contusions (but no pelvic fracture). Insertion of a Foley catheter shows that there is gross hematuria.
Blood from kidneys
CT scan for diagnosis.
only operate if renal pedicle is avulsed or the patient is exsanguinating.
How does traumatic microhematuria differ in adults and children?
In adults, it does not need to be investigated. In children, it must be investigated by sonogram.
A young man is shot through the arm with a revolver. The path of the bullet goes right across the extremity, from the medial to lateral sides. He has a large hematoma in the inner aspect of the arm, no distal pulses, radial nerve palsy, and a shattered humerus. How do you manage?
- In this order: 1) fracture stabilization 2) vascular repair 3) nerve repair
- delay in restoring circulation will make a fasciotomy mandatory
A 6-year-old girl has her hand, forearm, and lower part of the arm caught in the wringers of an old-fashioned washing machine. The entire upper extremity looks bruised and battered, although pulses are normal and the bones are not broken.
What are the complications? How do you manage?
crushing injury: hyperkalemia, myoglobinemia-myoglobinuria-acute renal failure, delayed swelling may lead to compartment syndrome
Manage with fluids, osmotic diuretics and alkalinization of urine
What are some injuries that occur with electrical burns? How do you manage them?
posterior dislocation of shoulder, compression of vertebral bodies, development of cataracts, demyelinization syndromes
- myoglobinemia-myoglobinuria-renal failure
- lots of IV fluids, diuretics, alkalinization of urine
What does a third degree burn in a child and an adult look like?
- child: bright red
- adult: white and leathery
treat with silvadene
What is the rule of 9's for adults? For children?
- Adult: head-9, torso-18 front, 18 back, leg-each 18, arm-each 9, genitalia/perineum-1
- children: head-18, torso-18 front, 18 back, leg-each 13, arm-each 9, genitalia/perineum-1
What is the Parkland Formula?
(4ml)(kg)(% burned)=amount of fluid needed for resuscitation + about 2L of 5% dextrose in water, first half given in first 8 hours, second half in next 16 hours
Day 2: (1/2) parkland amount, may also give colloids
estimated amounts. Maybe fine tuend according to hourly urinary output. Higher amounts are needed in patients who have respiratory burn, electrical burns or escharotomies
For children: 4-6 ml/kg/%
For burn wounds, fluid administration should be started at a rate of what?
Ringer lactat (w/o sugar) at 1,000ml/h
For children, the first hour should be 20 ml/kg
A 42-year old woman drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron clearly delineated on her upper thigh. The area is white, dry, leathery, anesthetic.
small third degree burn=early excision and grafting
A 6 year old child tries to pet a domestic dog while the dog is eating, and the child's hand is bitten by the dog.
- provoked attack, observe dog for development of rabies symptoms, if none, just tetanus prophylaxis and standard wound care.
- If bite on face/near brain, rabies treatment should be started and then discont if proved unneccessary.
What is the ideal hourly urinary output for burn patients?
at least 0.5 ml/kg/hour, ideally 1.0ml/kg/hour. 1-2 ml/kg/hour for electrical burns
During a hunting trip, a hunter is bitten on the leg by a rattlesnake. The patient arrives at the hospital 1 hour after the bite took place. Physical examination shows two fang marks about 2 cm apart, as well as local edema and ecchumotic discoloration. The area is very painful and tender to palpation.
- Draw blood for typing and crossmatch, coags, renal and liver function. ANTIVENIN: start with 5 vials, if symptoms are alarming 10 or even 20, dose IS NOT calculated on the basis of the size or age of patient
- Surgical excision of bite sit and fasciotomy are only needed in extremely severe cases.
Patient has been bitten by black widow spider. Patient has n/v and severe gen. muscle cramps.
IV calcium gluconate, muscle relaxants also help
Brown recluse spider bite
Dabsone. Local excision and skin grafting may be needed
A 22 year old gang leader comes to the ER with a small, 1 cm deep sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver while fixing his car.
human bite-surgical exploration by an orthopedic surgeon will be required
18 year old with a firm, rubbery, moveable mass in her breast
Fibroadenoma. FNA for biopsy, cure biopsy or excisional biopsy (usually do least invasive)
mammography is only for screening, not diagnosis. For very young breast, sonogram is best.
A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to it’s present size. The mass is firm, rubbery, completely movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
What is it? - Cystosarcoma Phyllodes.
Management: Tissue diagnosis is needed (some of these become outright malignant sarcomas), given the size best done with core or incisional biopsy. Margin-free resection will follow.
How do you manage acute glaucoma?
Diamox, pilocarpin drops, or Mannitol
A 59 year old, myopic gentleman reports “seeing flashes of light” at night, when his eyes are closed. Further questioning reveals that he also sees “floaters” during the day, that they number ten or twenty, and that he also sees a cloud at the top of his visual field.
retinal detachment, opthalomologic emergency
A 77 year old man suddenly loses sight from the right eye. He calls you on the phone 10 minutes after the onset of the problem. He reports no
other neurological symptoms.
embolic obstruction of the retinal artery
little can be done. ER immediately, breathe into paper bag, putting pressure on the eye and then releasing multiple times can help
In what order does the symptoms of acute appendicitis appear?
- 1) crampy epigastric pain
- 2) n/v
- 3) RLQ pain
A 77 year old man has a colonoscopy because of rectal bleeding. A villous adenoma is found in the rectum as well as several adenomatous polyps are identified in the sigmoid and descending colon.
premalignant polyps in descending order of malignant conversion: familial polyposis, Garner's, villous adenoma, adenomatous polyps.
Benign include: juvenile, Peutz-Jeugers, inflammatory and hyperplastic
A 60 year old man with hemmorrhoids reports bright red blood in toilet paper after evacuation
Proctosigmoidoscopic exam, must rule out CA
Cannot just reassure over the telephone and prescribe steroids
A 23 year old lady complains of exquisite pain while defecating and blood streaks on the outside of the stool. Because of the pain, she tries to avoid BM. When she does it is painful and the stool is hard. PE is refused because she refuses anyone to examine her for fear of precipitating the pain
Anal fissure. exam under anesthesia, lateral internal sphinterotomy to rule out CA
A 28 year old male has had multiple surgeries for perianal fistulas. The wounds have not healed and there are multiple ulcers and fistulas with purulent discharge. No masses are palpable.
Generally, perianal area heals well because of good blood supply. If it doesn't think Crohn's. Must rule out CA. Biopsy will rule out CA and diagnose for Crohn's.
A 55 year old HIV positive male has a funginating mass growing out of his anus and rock hard lymph nodes in his groin. He has lost a lot of weight and looks emaciated and ill.
squamous cell carcinoma of the anus. Biopsy funginating mass and eventual pre-operative radiation and chemotherapy
A 33 year old male has three BM that he describes as being made up entirely of dark red blood. The last one was 20 minutes ago. He is pale and diaphoretic and has a blood pressure of 90/70 and HR of 110.
- First diagnostic move is to place a nasogastric tube.
- If patient is CURRENTLY bleeding: If the nasogastric tube returns blood, he could be bleeding from the tip of the nose to the ligament of trietz. If NG tube returns bile, bleeding is beyond ligament of Trietz.
If bleeding more than 2cc/min, emergency angiogram
A 72 year old male has had two BM that he states is made up entirely of dark red blood. The last one was two days ago. He is pale and has normal vital signs. nasogastic tube returns clear, bilious fluid.
Not currently bleeding. can't tell anything from NG tube. Do upper and lower endoscopies. angiography is NOT the choice since he's not currently bleeding.
3/4 of GI bleeding is from the upper GI. Lower GI bleeing is from diseases of the old: diverticulosis, polyps, CA, angiodysplasias.
A 7 year old boy passes a large bloody BM.
- In this age group, Meckel's diverticulum.
- Diagnose by radioactively labled technetium scan that identifies gastic mucosa.
a 52 year old man has right flank colicky pain of sudden onset that radiates to inner thigh and scrotum. There is microscopic hematuria.
- Uretal colick
- diagnose by x-ray KUB, sonogram or Intravenuous pyelogram (IVP)
What are the four kinds of melanoma and what are their prognoses?
- 1) superficial spreading-slow, good prognosis comparatively
- 2) nodular sclerosing-aggressive vertical growth, poor prognosis
- 3)lentigo maligna-good prognosis
- 4)acral lentiginous-AA, Asians and Hispanics-palms of hands, feet and nail beds-poor prognosis
Sunscreen protects against UVB while _______ or ________ protects against UVA
titanium, zinc oxide
What is the primary therapy for malignant melanoma and nodal involvement? What is the primary treatment for Stage III malig melanoma? What is the primary treatment for Stage IV malig melanoma?
- Interferon 2A
What are the common causes of bowel obstruction in a child? In an adult?
- hernia, meckel's diverticulum, malrotation, meconium, atresia, intussusception, ileus
- hernia, gallstone disease, tumor, adhensions, Crohn's disease
What is the initial treatment for a suspected small bowel obstruction?
NG tube to decompress stomach, fluid resuscitation, Foley catheter to monitor response to fluids, exploratory laprascopy
Can you get leukocytosis with small bowel obstructions?
Yes. Usually resolve with therapy. Persisten leukocytosis may be indicative of complications
A 34 year old woman comes in with a 6 month history of numbness and pain in her right hand that wakes her up at night. She states the thumb is especially affected. She reports she's starting to drop things that she is holding in her right hand. She denies a hx of trauma, exposure to heavy metals, or family history of MS. The only medication she's taking is an oral hypoglycemic agent.
- Carpel tunnel's syndrome, classic symptoms flaring up at night
- Median n compression
- night time splint and NSAIDs
What conditions are associated with carpel tunnel's syndrome?
hypothyroidism, hyperthyroidism, pregnancy, diabetes mellitus, acromegaly
What is the difference between biliary colic and cholecystitis? How do you manage each?
both have abdominal pain and gallstones, but cholecystitis has leukocytosis and thickened gallbladder wall.
- treat biliary colic with just elective cholecystectomy
- treat cholecystitis is hospital admission, IV antibiotics and cholecystectomy, common organisms found are e. coli, klebsiella, proteus, strep feacalis