Surgery

Complete rectal prolapse: A mucosal or full thickness layer of rectal tissue slides through
the anal opening. Usually associated w/ conditions causing an increased intraabd P like
constipation, BP, and C!P". Presents w/ pain in anal area, rectal bleed, protruding
rectal mass. #f unctreated, strangulation and gangrene of the peolapsed mucosa is
possible. $his is a surgical emergency.
Painless testicular mass: always suspect malignancy. %hould e&amine w/ scrotal U% and
measure serum tumor markers. A better procedure is a radical inguinal orchiectomy 'can
do histological analysis of the tumor(.
)CC of oral lesions in elderly is trauma 'esp dentures(. Pt who wears dentures has a
lesion in their mouth: try not wearing dentures for a couple weeks. #f lesion persists, then
consider malignancy 'do a biopsy(. !therwise its ok.
%tress fractures: usually see in ppl with e&cessi*e running or training. $here is pain w/
acti*ity, which impro*es with rest. $here is tenderness and swelling locally o*er the
fracture site. !ften, plain films are unre*ealing for the first +,- weeks after the in.ury.
)/# or technetium bone scans are *ery sensiti*e. /& is generally w/ conser*ati*e
treatment. 0uts stop all acti*ity for -,1 weeks, and gradually return to acti*ity.
Anal abscess: present w/ se*ere, constant pain with possible fe*er. 2&am shows
reythematous, indurated skin or a lfuctuant mass o*er the perianal or ischiorectal space. #
and " is 3%!). #n pt w/ "), immunosuprpession, or e&tensi*e cellulitis, should also
gi*e ab&. 456 of pt with anal abscess will go on to de*elop a fistula. Presents as a
persistent abscess despite drainage. 3istulas usually need surgery.
Pancreatic cyst: Presence of it without any h& of pancreatitis should be considered
malignant until pro*en otherwise. $his is especially true if cyst is loculated in appearance
on C$. !therwise, it could .ust be a simple cyst. #f loculated, should do surgical resection.
%ilicone breast implant: )ain complications are with capsular contracture which causes
pain and shape distortion. /upture is another common one, which could re7uire remo*al
of the implant. !therwise, though, there is no e*idence tosuggest an increased risk of any
other disorder. %ilicone also has no harmful effects on a de*eloping fetus. #t also doesn8t
increase any risk of anything with breast feeding. Babies can be breast fed as normal.
Capsular contraction might interfere with mammogram, but in general silicone doesn8t
interfere with mammograms. Ppl with implants should still continue at regular inter*als.
"esmoid tumor: locally aggressi*e neoplasms aarising from muscle. 9ocally in*asi*e, so
only causes local complications. Present as minimally painful or painless, slow growing
masses o*er a part of the body. "& with tissue biopsy. /& is surgical resection. $here is a
high rate of local recurrence, so look for old scars from pre*ious remo*als.
Asymptomatic :allstones: )ost pt with these will ne*er e&perience symptoms. !ften,
risks of therapy might e&ceed ebenfit. Can .ust obser*e. Ursodeo&ycholic acid is
indicated for pt with mild symptoms and small cholesterol stones. 456 efficacy, but can
cause diarrhea.
;aricocele: dilation of pampiniform ple&us 'responsible for keeping testes cooler than
rest of body(. Presents as a mass 'looks like worms in a bag(, not tender, not fluctuant,
and warm. #t8s warm because the temperature within the testes has gone up. $hus, if you
don8t treat it, the temp will rise too high and cause the testicle to atrophy. / is with
surgery.
Bilateral *aricocele: if pt present w/ this, consider proceese that cause #;C obstruction
'clot, tumor(. C$ abd would be good 3%!) to look for mass obstruction. Also consider
blockage in pt with *aricocele which doesn8t disappear in the supine position, or right
*aricocele 'most *aricocele are 9 sided(.
Breast mass in pt < =4 yo: )ost likely benign. %till, ned a full workup. Benign cysts are
most prominent .ust before the start of a menstrual cycle, and regress after menstrual
period is o*er. !ther features suggesti*e of cyst include: smooth, soft, mobile, round. A
diffuse nodularoity in the cyst is likely fibrocystic disease. 3>A biopsy should be done
with easily palpable cystic masses. #f you get blood, send for cytology. #f not, .ust
ree&amine in ? month to see if mass regressed at all. )ass that goes away doesn8t need
further e*al. U% might be useful to distinguish cyst from solid mass. Also +
nd
option if pt
doesn8t want 3>A.
#f you ha*e a mass which is solid, too small, or cannot be felt, U% is probably the best "&
to see if you ned a biopsy or not.
Cryptorchidism 'undescended tests(: )a.ority of cases resol*e spontaneously by first
se*eral )!>$% of life. /isk of malignant transformation is increased, and remains so
e*en after orchipe&y 'surgery(. !rchipe&y should be done before + years of age, and as
early as 1 months. #f untreated, complications of undescended testes include decreased
fertility, increased risk of torsion, inguinal hernia, and malignant transformation.
!rchipe&y doesn8t help w/ malignancy too much, but does help pre*ent torsion and
infertility.
P%A: normal range is < -. #f @ -, should refer to urologist for a biopsy. P%A is ok for
screening, but onlny biopsy can r/o cancer. +56 of pt with @ +5 P%A ha*e cancer. Cutoff
*alue was reduced to - to increase sensiti*ity.
$ransurethral /esection of the prostate: management of BP. )C complication is
retrograde e.aculation. Urinary incontinence and erectile dysfunction are complications of
radical prostatectomy 'used for /& of early prostate cancer(. $hese complications aren8t
problems with $U/P.
#f you do a $U/P/biopsy/cytology and diagnose Prostate cancer, suprapubic resectionof
the prostate is accepted therapy. Also do a lymph node resection.
;aricose ;eins: *isible, palpable *eins of the legs. Usually asymptomatic, but might
complain of cramping, hea*iness, fatigue, and swelling. %ymptoms worse w/ prolonged
standing, and impro*e with leg ele*ation. 3%!) is conser*ati*e: .ust leg ele*ation and
compression stockings. %clerotherapy is used for pt who ha*e failed =,1 months of
conser*ati*e /&. Aou8re basically damagint 'sclerosing( the *ein, pre*enting further *ein
filling.
Peripheral ;ascular "isease: Present w/ pain with walking. /elie*ed ith rest. ;arious C;
risk factors probably present. "iminished distal pulses. #ncreased pallor w/ ele*ation of
limb. Can "& with AB#. "i*ide the lower e&tremity %BP by the brachial %BP. >ormal
AB# is ?,?.= 'At ankle, %BP should be higher than in the arm d/t gra*ity(. AB# < 5.B is a
good cutoff for clinically significant P;". AB# < 5.- usually means there is ischemia.
Besat conser*ati*e /& for P;" is cliostaCol 'P"2 inhibitor which inhibits platelet
aggregation, also direct arterial *asodilator(.Can be safely taken w/ aspirin and
clopidogrel.
Comple& /egional Pain %yndrome: criteria are presence of an initiating e*ent or cause of
immobiliCation, continuing pain, allodynia 'pain w/ normally nonpainful stimulus(,
e*idence of edema, or change in skin blood flow, and absence of other conditions. Dhat
happens is that after the initial e*ent, the sympathetic system acti*ates in order'normal(.
owe*er, the sympathetic acti*ity doesn8t go away, and keeps going, e*entually leading
to *ascular compromise 'ischemia, atropht(. Pheno&ybenCamine 'a,blocker( is good since
it curtails sympathetic acti*ity.
#f some disease process causes 9A", and the 9A" doesn8t resol*e along with the
disease, then should be concerned about a lymphoma. Can be the first clinical sign of a
lymphoma. %hould get a biopsy.
"umping syndrome: After gastrectomy, food and li7uid passes through the stomach into
the .e.unum too fastr, laeidng to abd pain, diarrhea, >/; after eating. "yspnea and
diCCiness might e*en happen. Usually change to a high protein diet w/ small fre7uent
feedings will help.
/ectal cancer: the surgery always has a risk of messing up the spincter. Best type of
cancer which will probably allow a sphincter sparing surgery is a pro&imal node E cancer.
Dith these you can do a lower anterior resection 'w/ chemo E radiation(. "istal rectal
cancers may be treated either with local resection 'sphincter sparing( or abdomino,
perineal resection 'e&tensi*e radical operation(. 9ocation of the tumor is a big part of
whether sphincter can be sa*ed.
Porcelain gallbladder: Ca salts deposit in the wall of a chronically inflamed gallbladder.
Usually gallstones are also present. %ee the Ca on a plain film, but C$ is what is used to
confirm the diagnosis. Ppl with porcelain gallbladder ha*e higher risk of gallbladder
cancer, so an electi*e cholecystectomy is recommended.
%ubphrenic Abscess: usually de*elops ?-,+? days aftrer abd surgery. Presents w/
swinging fe*er, leukocytosis 'abscess(. Cough and shoulder tip pain may also be present.
Abd U% is a good test for d& this.
#nguinal ernias: $hese do not resol*e with age, with high risk of potential compliations.
"irect hernias are d/t musclear weakness of abd wall, and are rare in infants, more likely
seen in elderly age group. #nguinial hernias in pediatric pt should be repaired A%AP.
3emoral ernia: much higher risk of strangulation compared to inguinal hernia. $hus,
should get surgery if you e*er notice a femoral hernia.
/alo&ifene: %2/) 'selecti*e for bone( to impro*e bone mineral density. #ncreased risk
of ";$ and P2, so should be d/c F+ hours before surgery.
)C9 in.ury: tenderness and pain along medial .oint line. Usually in*ol*es *algus
'abductor( stress to a partially fle&ed knee with fi&ed foot. $here is pain with *algus
stress of the knee. #n.ury happens with force from a leteral to medial direction.
AC9 in.ury: Usually happens after a cutting mo*ement, non,contact deceleration, or
hypere&tension. Poppig sound might be present. P2 shows pain with doing a anterior
drawer or 9achman maneu*er.
PC9 in.ury: little pain or alteration in /!), but posterior drawer test is positi*e.
Uncommon. "/t a posteriorly directed force on a fle&ed knee. Alternati*ely, can happen
in a pt who falls on a fle&ed knee with the foot in plantar fle&ion. Gnee doesn8t appear
7uite as unstable as in AC9 in.uries.
$esticular cancer: suspect in any pt with h& of painless scrotal swelling. Gey P2 to do is
transillumination. #f mass illuminates, likely ot be a hydocele. 3%!) is scrotal U% to
differentiate intra and e&tra testicular lesion. Cysts or fluid filled mases are unlikely to be
cancerous. #f you see something odd on U%, do a C$ of abd and pel*is. )easure afp and
b,hcg. #f test results make cancer likely, do a radical inguinal orchiectomy to get
histological analysis. $esticular cancer has good prognosis if d& and treated early."ont do
a testicular biopsy/3>A since this might disseminate cancer cells.
Glinefelter syndrome '-F HHA( is associated w/ higher risk of breast cancer. #n fact, this
is the strongest known /3 for male breast cancer '45& normal men(. %ome features
include hypogonadism, low testosterone, and gynecomastia.
/etrosternal :oiter: can cause compressi*e symptoms. #odine deficiency is a /3. Usually
these are multinodular. %hould do surgery to remo*e.
Bile salt induced diarrhea: commonly seen after cholecystectomy. /emo*al of gall
bladder causes a shift to secondary bile acids, which are more likely to cause diarrhea.
Cholestyramine is good /&, as it can ind bile acids.
2pididymitis: can be associated with a unilateral hydrocle 'confuse for testicular mass(.
Dith this infection, there is a testicular pain and tenderness. >o *oiding symptoms are
present, and UA is normal. )CC is Chlamydia. Cremasteric refle& is intact. Prehn8s sign
'decrease in pain on testicular ele*ation( is usually positi*e. "o transillumination to see if
an enlarging mass is hydrocele or malignancy.
:astric bypass surgery 'or e7ui*alent bariatric( is recommende for pt w// B)# @ -5, or
serious co,e&isitng medical problems or a markedly decreased 7uality of life.
!rchitis: presents as sudden onset of fe*er, se*ere scrotal pain, and swelling. 2specially
be on lookout for it in mumps pt.
Cla*icle 3racture: ;ery common. Criteria for return to sacti*ity is a .udgement call. Can
do lower body e&cercises if no in.uries there. Dhen shoulder pain resol*e, can do gentle
pendulum e&cercises for shoulder motion. :enerally, can return to acti*ities is ok after pt
has achie*ed the following. Painless, full, acti*e /!). >ear normal strength. 2*idence
of bridging callus. Usually happens within 1 weeks in younger pt.
$hyroglossal duct cyst: Presents w/ midline neck mas that mo*es w/ protrusion of tongue.
%ometimes, the ectopic tissue on the cyst is the only functional tissue a pt has, so need to
do imaging to look for a normal thyroid before surgery to make sure pt will still ha*e
thyroid function. C$ scan is good. 3>A usually not needed. $hese cysts ha*e a high
chance of being infected.
Dith elderly ppl, think about whther to take them to surgery or not: #f there are no
benefits from surgery, don8t do it. Consider the pt8s functional status and other
comorbidities. #f a pt is bedridden, benefit might be minimal. Pain alone is not a good
indication for surgery, since you can manage pain w/ meds.
Acute arterial occlusion: 9imb ischemia will ha*e 4 P8s 'pallor, pain, pulselessness,
paresthesia, paralysis(. Usually d/t embolus from distal source, trauma to artery, or acute
thrombosis d/t pre*iously diseased *essel. %udden onset of symptoms in asymptomatic pt
is likely embolus. Usually emboli are from the heart, but can also be from peripheries.
3%!) is to do an embolectomy, then you should do histology on the embolus to find out
where it came from. #f it came from heart do an echo.
Atrial my&oma: most common primary cardiac tumor. !ften in the 9A. Can be friable,
leading to emboliCation. Can also present with sudden onset of heart issues 'heart failure,
afib in a young pt(. )ight ha*e some mitral *al*e signs 'diastolic murmur( if big enough.
"& with echo. /& is e&cise the mass A%AP to reduce risk of embolus.
#ndication for surgery of shoulder fracture: compound fracture, distal comminuted
fracture, multiple trauma, or se*ere displacement .eopardiCing skin integrity. !therwise,
.ust a sling or figure of I brace is good enough.
Acute mesenteric ischemia: presents w/ acute onset of se*er abd pain which has a P2 that
doesn8t match the se*erity of of the pain. )etabolic acidosisis also present. $his
presentation is mesenteric ischemia until pro*en otherwise. /adiology might all be
normal. )CC is superior mesenteric a. d/t thrombosis, embolus, or *asospasm. )ust treat
promptly. #f untreated, bowle infarction, sepsis, and death could happen.
!steoperosis can heppn in men too, especially male @ 15 yo. Age is the single most
important /3 for osteoperosis and osteoporotic bone fracture. %teroid, anti,androgens,
and anticon*ulsants may also predispose pt to osteo.
%caphoid fracture: classically, falling on an outstretched hand. $he hypere&tension and
radial de*iation of the wrist causes it. $here is se*ere loss in /!) of the wrist, as well as
se*ere pain and stiffness. Pt with a nondisplaced scaphoid fracture can ha*e normal
radiographs for up to + weeks after a traumatic incident. C$ should bene&t step if you
suspect it highly but plain filsm are negati*e. /& for uncomplicated, undisplaced
scaphoid fractures are immobiliCation in thumb cast w/ wrist in radial de*iation. )C
complication of scaphoid fractures is nonunion. !ther one is a*ascular necrosis. >on
union is more common.
%crotal $rauma: U% utility is contro*ersial. >romal U% shouldn8t preclude surgical
e&ploration if there are ob*ious concerns on physical e&am. #t8s important to minimiCe
chance that pt will need orchiectomy.
Parathyroidectomy: After surgery, serum Ca can fall, and symptoms of hypoCa could
actually de*elop. $hese include perioral numbness, cramps, positi*e Ch*ostek sign
'contraction of facial muscles on tapping the angel of the .aw( Dhate*er signs happen
from this are bilaterally symmetrical. $his effect is called hungry bone syndrome. $he
sudden drop in P$ causes all the Ca to shift from the serum into the bone, causing
hypoCa symptoms. Usually de*elops +,- days postop.
Bell8s Palsy: unilateral facial asymmetry. Usually recent U/#. $his is a lower motor
neuron in*ol*ement of the facial ner*e.
Acute compartment syndrome: ischemic tissue damage d/t ele*ated P in enclosed
compartments of legs or forearm. #n the 92, the cause is usually a traumatic e*ent 'tibial
fracture(. Any crush in.ury could also cause it. Presents as pain out of proportion to e&tent
of in.ury. Pain with passi*e muscle fle&ion and tightness and weakness are other early
signs. %ensory is usually affected earlier than motor. "ecreased *ibration sense, + pt
discrimination, and numbness. #f untreated, there is paralysis and absent pulses later on.
Also leads to rhabdomyolysis which can lead to acute renal failure 'life threatening(. "&
it 7uickly by checking tissue pressure '@ =5 is positi*e(. $his is a surgical emergency.
Juickly r& with fasciotomy 'surgical decompression(.
%ometimes a cast can be causing a compartment syndrome. #f so, split the cast.
3at embolism: %ee after long bone or pel*ic fractures. %ee a triad of hypo&emia, neuro
abnormalities, and petechial rash. 2arly immobiliCation and operati*e fi&ation of
fractures reduces the chances of fat embolism.
A pt who suffers a traumatic in.ury should be gi*en narcotics for pain relief, e*en if they
were pre*iously addicted to pain meds.
2pidural Abscess: suspect in pt with fe*er as well as back pain. /3 is spinal surgery,
epidural in.ection, immunocompromised, and elderly. "& with cenhanced )/#. C$
myelogramis alternati*e. $hen, get cultures to guide ab& treatment. )CC is %. aureus.
%urgery within +- h is the most important /&.
Pulmonary Contusion: )C lung in.ury in pt with blunt chest trauma. Present with *arying
degrees of dyspnea, tachypnea, hypo&emia, and hemoptysis. P2 shows decreased breath
sounds o*er affected areas. CH/ can show homogenous opacification of the lung fields.
/& is supporti*e, and usually resol*es within =,4 days. $here is a risk for late onset
clinical deterioration, so should admit and minotor for ?,+ days. #f there is significant
in.ury, might ha*e to pro*ide mechanical *entilation until the lung in.ury heals.
3lail chest: Usually d/t + rib fractures in @ ? site. $here is increased work of breathing d/t
musclar pain and spasm. !ften there is hypo&ia. Present w/ tachypnea, shallow breathing,
ant chest bruising, and peripheral cyanosis.
Cardiac contusion: may lead to hemodynamic instability, but resp changes should not be
present.
#f a pt has breathing problems after you intubate them, check that the tube isn8t in the
right main stem bronchus. $here will be reduced lung e&pansion and hypo*entilation on
9 side of chest. #f you check the tube and pt still isn8t breathing, then likely a tension
pneumo. Besides resp stuff, there can be cardiac collapse too because the tension pneumo
could compress the heart. "o a needle decompression.
Pregnant person w/ appendicitis: Complications depend on which trimester. #n the first
trimesters, there can be abortion. #n the +
nd
, there can be premature deli*ery. #n the =
rd

trimester, if rupture of the appendi& happens, there could be peritonitis 'leading to fetal
death(, abscess formation, and pylephlebitis 'infectious thrombosis of the portal *eins(
/enal stones: presents w/ sudden onset of pain and hematuria. Pain is usually colicky
'wa& and wane( and has a wide range. Upper stones cause flank pain, and lower stones
cause groin pain. %tart w/ conser*ati*e management '#; hydration and pain control(. #f <
4 mm, stone usually passes spontaneously. @ I,?5 will need remo*al. /emo*al is
indicated if pt goes into A/3, has signs of urosepsis, or is pain doesn8t go away. =
methods of remo*al: schokwa*e lithotripsy, fle&ible ureteroscopy, and percutaneous
ureterolithotomy. %hockwa*e is prefereed for smaller stones < ?5. #f @ ?5, probablya need
fle&ible ureteroscopy.
Amputaed body parts:while transporting, make sure to keep it wrapped in saline
moistened sterile gauCe, and put #t in a sterile sealed plastic bag. >o need for ab& in the
solution. Use %aline >!$ 9/. !nce in the bag, put the bag on ice.
#ncreased #CP: triad of bradycardia, $>, and resp depression. 2arly signs are headache,
*omit, blurred *ision. 9ater on there is dilation of pupil, altered consciousness
decerebrate posturing, and hemiparesis d/t transtentorial herniatoin of brain tissue.
2*entually there will be resp arrest. 3%!) is to secure the airway incase of resp arrest.
>ote that hyper*entilating to lower the #CP is contra in pt with a $B# as well as acute
stroke.
Cardiac arrest d/t electrical in.ury: often in asystole. 2pinephrine can be used to re*ert the
asystole.
)eckel8s "i*erticulum: usually seen in kids < + yo, but can present in older ppl.
$echnetium scan will #" the di*erticulum, usually in /9J 'near ileocecal *al*e(. $he
technetium will concentrate in the parietal cells o fthe di*erticulum. Presents with acute
abd pain with rectal bleeding. !ther causes are #B" and appy.
Penetrating in.ury to skull: Gnife should be remo*ed in the !/. Before doing this, get a
P$/PP$/blood group and crossmatch to ha*e spare blood ready. A couple reasons for this
are that remo*ing knife could cause bleeding in the *enous sinuses. Also, before going to
surgery, you want to make sure that the pt has no coagulopathies.
Consent for minors: Always need it, e&cept for some e&ceptions. $hese include
immediate care to pre*ent serious harm or death.
/upture of Achilles tendon: sometimes occurs after abrupt calf muscle contraction. $here
might be an audible snap. Usually happens in ppl who don8t perform e&ercise regularly.
Presents w/ se*ere calf pain and inability to stand up on the toes. $hompson test is for
Achilles rupture. Pt kneels on a chair or lies prone on e&am table w/ feet hanging o*er the
edge. Dhen you s7ueeCe calf muscle on normal side, foot will plantar fle&. !n affected
side, no foot response. /& with immediate immobiliCation of lower leg and surgical repair
of tendon.
Aortic in.ury is the )CC of sudde death in sterring wheel in.uries. Pt usually die at the
scene. /apid deceleration produces shearing force along aortic arch, and the aorta
ruptures.
Acute cholecystitis: gallbladder inflammation w/ steady /UJ pain, fe*er, and
leukocytosis. )CC is gallstones. Pain might radiate to the back or / shoulder. )urphy
sign E 'inspiratory arrest on palpation of gallbladder during deep inspiration(. U% is the
best initial "&. )C complication is gall bladder gangrene and perforation. $hus, all pt
withi acute chlecystitis should be admitted and supported. %upporti*e includes >P!,
analgesia, and #; antibiotics. Usually gi*e amp E gent for broad co*erage. $his reduces
risk of secondary infection.
Acalculus cholecystitis is seen # critically ill pt and elderly.
>eck trauma: airway must be secured with .aw lift to pre*ent further strain on the neck.
$etanus prophyla&is: #mmune globulin is indicated for contaminated wounds when
immuniCation status is unknown or when pt has < = doses of tetanus antito&in.
!nly tetanus antito&in is indicated if: pt has clean wound w/ unknown immuniCation
status. Pt has clean wound and has @ = doses of antito&in with last dose @ ?5 eyars ago. #f
wound is contaminated byt pt has gotten @= doses of antito&in within last 4 years.
$hus if a pt has a dirty wound, the only way he doesn8t get both the antito&in and immune
globulin is if he knows hes gotten @K = doses of antito&in within last 4 years.
Pt who do hip replacement are at higher risk for ;$2 leading to P2. #n pt getting this
surgery, need ro get prophylactic 9)D. 9)D is shown to be better than warfarin or
aspirin.
)orphine o*erdose post op: esp in opiate naL*e patients w/ renal insufficiency. Presents
as lethargy, miosis, resp depression, apnea. 3%!) is to secure the airway./& with
nalo&one.
;arious ner*e in.uries may happen during carotid endarterectomy: hypoglossal ner*e,
which presents as tongue de*iation. 3acial ner*e, presenting as asymmetric smile 'd/t
damage to the marginal mandibular branch(. Ansa hypoglossus ner*e, which inner*ates
strap muscles of the neck. #t can be sacrificed with impunity.
)CC sudden hyperglycemia is sepsis in pt getting surgery: %hould look for source of
infection 'a line, pneumonia, wound(. Another possibility is that #; infusion of $P> is
going too fast. >ote that during #; nutrition, bowel rest can happen, which leads to
degenerati*e changes in small mucosa .ust after a few days.
Post obstructi*e acute renal failure: can present as sudden inability to *oid urine. !one
cause is BP. #n this case need to do bladder decompression 7uickly to alle*iate pain and
a*oid further renal damage. /& is with urethral catheter with a foley catheter.
Animal bite: important fact is wild animal or not 'animal which has had shots(. >eed to
obser*e animal for signs of rabies. Usually, you want ot close the laceration 7uickly. Dith
hand bites, howe*er, there is high risk of subse7uent wound infection, so don8t close
those right away, and lea*e them open to drain and obser*e. !ther bites which shouldn8t
be closed include: pucture wound, cat/human bites, pt presenting muich later after the
bite. Cat/dog bites can be trested prophylatically with amo&/cla*.
#n digital in.uries, tendons are more likely to bein.ured than arteries, *eins, or ner*es.
"espite being on ";$ prophyla&is, sometimes ";$ can .ust happen anyways. #f you
suspect it, ;/J scan is the best initial test. ",dimer, although it has a high negati*e
predicti*e *alue, is not *ery useful. #t is almost always ele*ated in hospitaliCed patients
'esp recent surgery(. " dimmer would be more useful in a healthy pt who comes to 2"
with symptoms.
Cremasteric /efle& may be lost d/t diabetic neuropathy.
3emoral >er*e in.ury: uncommon. Present w/ weakness of the 7uad. Presents as unable
to e&tend the knee against resistance. %ensory loss o*er ant aspect and medial thigh is
common. %ensory loss also in medial shin and the arch of the fut. Gnee .erk is decreased
in amploitude or absent.
%ubarachnoid hemorrhage: constellation of sudden onset headache, nausea, and nuchal
rigidity. )ore specifically, a post. communicating artery aneurysm would also present w/
C>= palsy 'ptosis and anisocoria(. P#CA aneurysm would lead to ata&ia and bulbar
dysfunction.
Partial small bowel obstruction: can present with distended abd, increased bowel sounds,
Air fluid le*els on abd & ray, but there is still air in the distal colon. . 'obstructi*e series(.
Also there might be repeated *omiting. Because it8s only partial, can .ust obser*e and see
if it resol*es. #f it doesn8t resol*e, sugery is indicated.
#nhalation #n.ury: Can happen if e&posed to smoke. 9eads to supraglottic damage. $his
leads to edema in surrounding soft tissues, which narrows the airway. a*e a low
threshold for intubation.
Patellar tendon tear: )CC is sudden 7uadriceps contraction while the foot is firmly
planted. $here is patellar tendon or rupture leading to pain, swelling, difficulty in bearing
weight. Pt unable to perform acti*e e&tension of the leg and cannot passi*ely e&tend the
knee against gra*ity by themsel*es. %hould get surgery 7uickly, as waiting too long can
lead to muscle atrophy and contracture formation.
)eniscal tear: )CC is twisting force with foot fi&ed on ground. Use )c)urray8s
maneu*er to detect presence of tears. Pt is put in supine position with knee in ma&imum
fle&ion. $hen, e&ternally roatte tibia, and e&tend knee. #f there is audible click or pop then
is a E test.
$achycardia is the earliest sign of hypo*olemia.
igh risk factors for P2: pre*ious h& of ;$2, malignancy, orthopedic surgery, stroke, pt
with )#.
:enerally, 9)D is the prophyla&is of hoice. #f pt has had pre*ious )#, then gi*e full
dose therapeutic #; heparin.
Acute cholangitis: $riad of fe*er, /UJ and .aundice. /& with hydration, ;% monitoring,
and immediate ab& therapy. %hold get BC first, but a good empiric is amp E gent, or
monotherapy with imipenem or le*oflo&acin. Afterwards, schedule for an 2/CP. #f pt
doesn8t impro*e, need to do biliary compression 'done through 2/CP(. Datch out for
sepsis. #f pt also de*elops hypotension and confusion, pt has /eynold8s pentad, which has
456 mortality rate.
Abd gunshot wound: B46 of them need surgery. Presence of peritoneal signs is absolute
indication for urgent laparotomy. !ther absolute indications are hollow *iscus
perforation, hemodynamic compromise, hemo/pneumoperitoneum, diaphragmatic
lesions, and spinal cord in.ury.
!8"onohue8s unhappy triad: knee in.ury which includes AC9 tear, ) 'tibial( C9 in.ury,
and medial meniscal in.ury. )A$
"ifferentiating btw aortic dissection and )# in the acute setting: *ery similar
presentation, but some differenes in testing. CH/ might show mediastinal widening on
CH/. )ore accurately, a person ha*ing a )# who has acti*e chest pain would likely
ha*e an abnormal 2G:@ Aortic dissection has a normal 2G:.
Blunt cardiac in.ury: #f mild, only associated with transient arrhythmias. )ore se*ere can
lead to rupture of the *al*es, inter*entricular septum, or myocardium. 2G: is a good first
step. #f 2G: is normal in pt with mild/possible blunt cardiac in.ury, no further treatment
is needed.
Best initial test to confirm pneumothora& diagnosis is an AP upright chest film.