––––––––––––––––– CV ISSUES –––––––––––––––––
manage by sending fluid to lab, giving IV antibiotics,
Goldman’s index: cardiac risk factors in surgery – JVD
(#1), recent MI (#2), PVCs and arrhythmias, age >70,
emergency surgery, aortic stenosis
JVD: indicates CHF, #1 CV risk factor overall, give β-
blockers, Ca2+-channel blockers, digitalis, and
diuretics if possible before surgery
MI: previous MI increases risk of post-op MI, so
consult cards and order a stress test
MI within 30 days: very high risk, delay surgery
Family Hx of MI: get a concentrated cardiac FHx, EKG,
and exercise stress test to assess risk factors
↑cholesterol: increased risk of coronary artery
disease, but do not postpone surgery
Premature ventricular contractions: at risk of
arrhythmia due to ventricular dysfunction,
indicated for stress test and echo
Ejection fraction: SV/EDV; normal EF >67%, an
EF<35% increases risk of operative MI
Diabetes: should be NPO 8 hours before surgery,
administer IVF with D5, check glucose morning of
surgery; if glucose >250 → 2/3 of insulin, if glucose <250
→ 1/2 of insulin
Hyperglycemia: ideal glucose is 100-250, delay surgery
until glucose is under control
Diabetic coma: absolute contraindication to
surgery; give IVF, correct acidosis and glucose
hct: important to determine underlying cause of anemia,
consider possible colorectal cancer
hct: either hypovolemia or polycythemia; if hypovolemic →
delay until hydrated, if polycythemic
important to determine underlying cause
Obesity: higher risk of HTN, cardiovascular disease, post-
op atelectasis, type 2 diabetes, DVTs; require DVT
prophylaxis and aggressive post-op pulmonary care for
preventing atelectasis
HTN: diastolic BP >110 is high risk of CV complications, β-
blockers reduce overall risk
Atherosclerosis: can present as acute coronary
syndome or peripheral vascular disease, always
evaluate pt’s cardiac risk factors
CV evaluation: EKG (and compare to old EKG),
persantine thallium stress test, dobutamine echo
LBBB: indicates underlying ischemic heart disease
RBBB: indicates significant pulmonary disease, but can
be normal in up to 10% of pts
Previous CABG: decreases cardiac risk if performed 6
months to 5 years before surgery, effect on cardiac risk
unclear if >5 years Previous coronary angioplasty: high risk
(33%) of coronary restenosis, so stress test is indicated; if
angioplasty is recent, delay surgery for several weeks
Angina: indicates coronary artery disease, evaluate for
possible coronary revascularization
AFib: give anticoagulation and β-blockers, and
cardiovert them to normal sinus rhythm
Carotid bruit: indicates carotid stenosis; indicated for
CEA if high grade (>70%) stenosis
Previous stroke: order a carotid duplex study, in
order to assess the carotid arteries
Gangrenous toe: peripheral revascularization is
more urgent than a full cardiac work-up
––––––––––––– RESPIRATORY ISSUES ––––––––––––
Smoking: up to 6× risk for post-op complications due to
compromised ventilation, must quit smoking for 2 months
before surgery
COPD: give bronchodilators and try to improve
pulmonary status as much as possible
Severe COPD: very high risk for acute pulmonary
failure with surgery; teach patient about
incentive spirometry, give bronchodilators, and
mobilize post-op to prevent atelectasis
Green sputum: give oral antibiotics, and schedule
surgery after Tx is complete
Bloody sputum: indicates active infection or lung
cancer; requires a full work-up including CXR, CT scan,
and bronchoscopy
–––––––––––– HEPATOBILIARY ISSUES –––––––––––
Acute cholecystitis: presents as fever, RUQ pain, WBC>15;
get U/S → IVF, abx, lap chole w/in 72 hours
Child’s classification: stratifies risk of surgery in pts with
liver failure; measures 3 labs (albumin, bilirubin, PT) and 3
clinical findings (encephalopathy, ascites, nutrition)
Child’s group A: 0-5% mortality
Child’s group B: 10-15% mortality
Child’s group C: >25% mortality; not good surgical
candidates until Child’s status is improved
Alcohol use: delay surgery until pt has undergone
withdrawal, since post-op withdrawal syndrome has a
high risk of morbidity/mortality
Liver failure: make sure the pt is in a compensated state,
abstain from alcohol for 6-12 weeks, control ascites,
normalize nutrition status and coagulation factors
Pressure necrosis on hernia: high risk of rupture
with a high mortality rate, requires urgent repair
Delirium in liver failure: possible causes include CNS
abnormality, electrolyte imbalance, GI bleeding, sepsis,
or bacterial peritonitis; evaluate for mental status
change, and tap the ascites
Ascitic leakage: high risk of bacterial peritonitis;
and urgent hernia repair
Hemorrhoids: suspect portal HTN in pt with cirrhosis
+ hemorrhoids, high risk of hemorrhage
Malnutrition: indicated by recent weight loss (#1) or
albumin <3.0 (#2); give 7-10 days of pre-op nutritional
support ideally
––––––––––––––––– GU ISSUES –––––––––––––––––
Dysuria: get urinalysis and urine culture; if positive for
UTI, delay surgery until resolved
Chronic renal failure: delay surgery until pt is stable,
dialysis started, and any other problems resolved
CRF × K+ measurement: needs to be obtained
immediately before surgery, since CRF can result in
rapid electrolyte imbalances
CRF × operative bleeding: renal failure causes
platelet dysfunction secondary to uremia; give
desmopressin or FFP, but not platelets
CRF × operative hypotension: many possible causes,
consider glucocorticoid (aldosterone) deficiency in a
pt who has taken steroids before
Kidney transplant pt: require perioperative steroids
Post-op hyperkalemia: check EKG for peaked T waves,
Tx C BIG K DIe – calcium gluconate, bicarb-insulin-
glucose, kayexalate, and dialysis
–––––––––––––– VALVULAR ISSUES –––––––––––––
Mitral stenosis: elevated LA pressure can lead to cor
pulmonale (PH+RVH); management includes cards
consult, prophyactic abx for endocarditis, can go to
surgery if stable
Mitral stenosis × CHF: high risk of mortality; requires
extensive cardiac work-up, EKG, echo, and operative
monitoring of cardiac status
Aortic stenosis: Sx triad of angina, dyspnea, syncope, and
high possibility of sudden death; requires cardiac work-up
and operative monitoring
Endocarditis prophylaxis: recommended for GI
procedures, GU procedures, and HEENT procedures
Cardiomyopathy: high risk of arrhythmias, CHF, heart
failure, and sudden death; manage with cards consult
and full cardiac work-up
–––––––––––––––––– GI ISSUES –––––––––––––––––
Bowel prep: decreases fecal mass and bacterial
content in the colon → prevents colon surgery
GoLYTELY: an isotonic formula that causes no change in electrolyte or water balance; fluid
remains in colon and causes a “volume washout”
Fleet’s Phospho-Soda: a sugar-rich, hypertonic formula that works by drawing fluid into the GI tract; risks include dehydration, metabolic acidosis (loss of bicarb); avoid in diabetics
Magnesium citrate: an osmotic agent that draws fluid into GI tract (mag is poorly absorbed); risks include dehydration and hypermagnesemia; avoid in renal failure
–––––––––––––––– OTHER ISSUES –––––––––––––––
Anesthesia of choice: multiple factors involved, so
it’s best to consult an anesthesiologist
Local anesthesia: ↓systemic effects, ↑pain
Spinal anesthesia: ↓pulmonary complications,
↓control over cardiac or vascular mechanisms
General anesthesia: ↑physiologic control,
pulmonary complications, ↓HR/BP
Aspirin use: stop aspirin use 7-10 days prior to surgery, will affect platelet aggregation
NSAIDs use: stop NSAIDs 2 days prior, will affect platelet aggregation
Cellulitis: active infections are associated with higher risk of post-op wound infections; delay surgery until infection is resolved
––––––––––––––– POST-OP FLUIDS ––––––––––––––
Post-op fluid management: replace blood lost during
surgery + provide maintenance IVF + make up for fluid loss in
drains/NG tubes/fistulas
Surgical blood loss: replace in a 3:1 ratio with IVF
(e.g. replace 500mL blood loss with 1.5L NS or LR)
Maintenance IVF: administer D5½NS+KCl, using the
100/50/20 rule for daily fluid requirements, or 4/2/1 rule for
hourly fluids
Drains/NG tubes/fistulas: fluid loss should be
replaced milliliter for milliliter with regard to specific
electrolyte content
Third space: fluid sequestered into ISF due to
inflammation or injury, mobilized 3-5 days after
recovery → requires decrease in IVF rate
––––––––– OPERATIVE COMPLICATIONS ––––––––
Malignant hyperthermia: T>104 following
anesthesia w/ high risk of myoglobinuria; Tx
dantrolene, 100% O2, and cooling blankets
Bacteremia: T>104 and chills within 1 hour of an
invasive procedure; get blood Cx ×3 and start empiric
abx
Aspiration: complication of awake intubations; leads to
sudden death, chemical pneumonitis, or secondary
pneumonia
Aspiration management: prevent via NPO and antacids
before intubating, Tx BAL and bronchodilators (steroids
are useless)
Tension PTX: complication of intubation in weak or
traumatized lungs, presents as “difficulty to bag”,
progressive hypotension and JVD; Tx emergent needle
decompression + chest tube
complications; put pt on clears day before surgery, NPO at midnight, and give a cathartic agent
days for prevention
––––––––––– POST-OP COMPLICATIONS ––––––––––
Suppurative phlebitis: infected thrombus at site of
venipuncture; Tx remove catheter and surgical excision
Normal urine output: at least 0.5-1 mL/kg/hr
of infected vein to the first non-infected branch, leave
wound open, and give IV abx
Post-op urine retention: presents as a need to void, but
inability to do so; Tx straight cath at 6 shours post-op and
nd GI fistula: causes leakage of GI contents from wound site;
Foley after 2 straight cath
Tx NPO, TPN, and protect abdominal wall until body can
heal itself
UOP = 0: most likely a kinked or plugged Foley
Non-healing fistula: factors that prevent healing are
UOP < 0.5: either fluid deficit (bleeding out) or acute
FRIEND – foreign body, radiation, infection,
renal failure; give a bolus of 500mL IVF and if UOP
epithelialization, neoplasm, distal obstruction
responds, then it’s due to fluid deficit
Fistula × peritonitis: requires surgical exploration
Post-op hematuria: consider bladder overdistention,
cancer, infection, kidney stones, trauma, prostatitis, and
Fistula × abscess: requires percutaneous drainage
cyclophosphamide; get urology consult
Post-op chest pain: consider MI or massive PE
Post-op fever: consider the five Ws – wind (atelectasis
POD #1), water (UTI POD #3), walking (DVT POD #5),
MI: presents as chest pain +/-other classic signs; Dx CK-
wound infection (POD #7+), wonder drug (drug-
MB or troponin I, treat the complications
induced fever)
Massive PE: presents as chest pain, hypoxia, and
Atelectasis: partial lung collapse, Dx bilateral inspiratory
prominent JVD; Dx V-Q scan, Tx heparin → IVC filter if
crackles, prevent with pulmonary
PE recur while anticoagulated
toilet and incentive spirometry (can develop into
pneumonia on POD #3 if left untreated)
ARDS: presents as hypoxia due to septic shock, Tx
intubation w/ high PEEP and permissive hypercarbia, then
UTI: Dx urinalysis and urine Cx, Tx abx
look for source of sepsis
Urosepsis: UTI + septic shock; presents as cloudy
Delirium tremens: presents as hallucinations in an
urine, fever, hypotension, and ∆mental status; Dx
alcoholic POD #2-3, prevention is key and Tx is
urinalysis and urine Cx, Tx empiric abx + IVF
controversial (benzodiazepines if choice is given)
DVT: Dx doppler studies, Tx heparin
Hepatic encephalopathy: presents as coma in a liver failure
+
pt s/p TIPS due to NH4 toxicity
Wound infection: Dx examine wound site for
erythema and fluctuance; if cellulitis → abx only, if
Wound dehiscence: presents as salmon-colored fluid
abscess → drain pus and BID dressing changes
soaking dressings s/p open laparatomy POD #5; stabilize
wound site, surgical closure at a later date
IV infection: Tx remove catheter and inflammation
should resolve, all IV sites should be rotated every 4
Evisceration: dehiscence + intestines spilling out; keep pt
 ––––––––––––––– WOUND HEALING –––––––––––––
Prophylactic abx: recommended for any clean-

contaminated or contaminated procedures,

inPrimary
bed and intention:
cover bowel close
w/ approximation of wound
sterile dressings, emergency
insertion
surgical of prosthetic
closure material, immunosuppression,
necessary
edges via sutures or staples
or poor blood supply; give single dose 1 hour pre-op

––––––––––– FLUIDS & ELECTROLYTES ––––––––––

and single dose post-op
Primary intention timing: epithelialized by POD
Hypernatremia: every 3 Na+ over 140 indicates 1L water
#2,(e.g.
max Na + 146 =in2L5-7
collagen days,loss),
avoidpresents
weight-lifting
loss water as volume
depletion (slow) or altered MS (rapid); give D5½NS to
correct
for 4-6imbalance
weeks, complete healing by 6 months

Hyponatremia:
(only 60-80% ofdue to SIADH
original or isotonic fluid loss w/ free
strength)
water resorption, presents as coma and convusions; Tx
water restriction and LR/NS
Secondary intention: contamined wounds left open

Hypokalemia: due to diarrhea or vomiting, give K+ at a rate

to prevent abscess formation; granulation tissue
of <10 mEq/hr

forms first, then

Hyperkalemia: contraction
due via myofibroblasts,
to renal failure, aldosterone blockers,
or release from dead tissue (crush injury, ischemic bowel,
thenTx
etc.); finally
C BIGaKdelayed epithelialization
DIe – calcium gluconate, bicarb-insulin-
glucose, kayexalate, and dialysis
Third intention: wound initially left open, then
Metabolic acidosis: pH<7.4 + HCO3<24, Tx correct
underlying problem (e.g. afterwards
fluid resuscitation)
delayed primary closure

Metabolic alkalosis: pH>7.4 + HCO3>24, Tx KCl

Secondary/tertiary intention timing: much more
Respiratory acidosis: pH<7.4 + CO2>40 due to
delayed than healing
hypoventilation, by primaryventilation
Tx mechanical intention

Respiratory alkalosis:
Healing growth pH>7.4
factors: + CO
PDGF, 2<40 due
TGF-β, to EGF
FGF,
hyperventilation caused by pain, fever, sepsis or early
ARDS; Txknot:
correct underlying
Suture hard, knot-likeproblem
structure below wound

site; absorbable sutures will resolve with time, non-

absorbable sutures can be taken out under lido/epi

Stitch abscess: infected suture that intermittently

drains pus, should be taken out under lido/epi

Incisional hernia: presents as bulging at wound site

with increased abd pressure (e.g. coughing), needs

to be repaired surgically

Red/sensitive scar: assuming no wound infection, it

could be completely normal; observe for 6 months

––––––––––––––––
before considering LUNG
surgicalCANCERS
revision –––––––––––––– Malignant coin lesions: spiculations or 20+ pack-year Surgery contraindications: FEV1 <800mL,
Coin lesion: solitary pulmonary nodule on CXR; DDx smoking = primary lung cancer, multiple lesions = mediastinal LN involvement, distal metastases
primary lung cancer,
Hypertrophic scar:granuloma (TB or site
raised scar within fungal),
of incision; metastatic cancer; resection indicated
hamartoma, metastatic cancers SCLC staging: limited stage involves ipsilateral lung only,
observe until scar is stable, then steroids + excision Lung cancer management: first thing is always CXR extensive stage involves contralateral lung
Coin lesion management: first thing is always to get → if suspicious, sputum cytology and CT scan → if still
an older CXR for comparison studies →if suspicious, suspicious, bronchoscopy and mediastinoscopy w/ biopsy SCLC Tx: chemotherapy and radiation
Keloid:
sputumraised scar that
cytology and extends
CT scan beyond site of (“tissue is the issue”)
Pancoast tumor: superior sulcus tumor at the apex of the
incision;
Benign will
coingrow backcalcification
lesions: if excised = granuloma, bull’s- NSCLC staging: stage I is local, stage II involves hilar LN, lung; presents as Horner syndrome – ipsilateral ptosis,
eye shape, popcorn shape = hamartoma, air-crescent stage III involves distal LN, stage IV is metastatic cancer miosis, anhidrosis, flushing due to loss of sympathetic tone
sign = aspergilloma,
–––––––––––––– WOUNDSouthwest region =––––––––––––
INFECTION (invades superior cervical ganglia)
coccidioidomycosis, Ohio river valley = NSCLC Tx: stage I/II → first get spirometry and V/Q
histoplasmosis
Wound infection: red and tender area on incision scans to see if pt is a surgical candidate, then do Pancoast tumor Tx: two stages – irradiation for 6 weeks
pneumonectomy or sleeve lobectomy; stage III/IV to shrink tumor, then surgical resection
Indeterminate coin lesions: resection indicated →chemotherapy and radiation
site; Tx drainage and BID wet-to-dry dressing

changes, no antibiotics unless cellulitis is spreading

Post-infection management: observation is slow

Bronchial adenoma: tumors that arise from within
bronchi and cause obstruction; MC lung cancer in a
nonsmoker under 30 y/o, Sx hemoptysis and atelectasis,
Dx CT scan and bronchoscopy (beware of possibility of
bleeding)
Bronchial adenoma Tx: lobectomy is curative
Mesothelioma: cancer arising from pleural
mesothelium, shipyards and asbestos exposure are risk
factors, Dx CT scan shows thick pleural walls
Mesothelioma Px: not responsive to medical therapy,
most pts have <1 year to live w/o surgery
Mesothelioma Tx: extrapleural pneumonectomy is
curative, but high rate of morbidity/mortality
–––––––––––––––– LUNG DISEASES ––––––––––––––
Pleural effusion: fluid build-up in pleural space, cancer in
older pt until proven otherwise; DDx CHF, bronchogenic
carcinoma, mesothelioma, empyema, pneumonia, TB
effusions
Pleural effusion management: get thoracentesis
and culture pleural fluid, and a pleural biopsy
Spontaneous PTX: rupture of apical blebs in healthy young
people causes sudden chest pain and dyspnea; Tx
thoracostomy on water-seal drainage
Recurrent/persistent PTX: indicated for thorascopic
excision of blebs, and pleurodesis (either scraping or talc
application) causing pleural adhesions
Bilateral PTX: dangerous situation, indicated for
pleurodesis to prevent future recurrences
Empyema: collection of pus within pleural cavity;
presents with cough, fever, chest pain, and pleural
effusion on CT scan; MCC is Staph aureus
Empyema Tx: initiate appropriate antibiotics,
insert chest tube, evacuate pus collection, then
re-expand the lung
––––––––––––––– HEART DISEASES ––––––––––––––
Unstable angina: progressive ischemia of myocardium
resulting in increasing angina at rest and an ischemic
EKG pattern
Unstable angina management: cardiac catheter
and evaluate for potential revascularization, Tx
bypass or angioplasty
Ejection fraction: SV/EDV; normal EF is 67%, EF <50% is
abnormal, EF <35% is high-risk for operative MI
Coronary artery disease: blockage of coronary arteries,
high risk of sudden death due to ventricular arrhythmias;
Tx bypass or angioplasty
Left main disease: blockage of only LCA, worst Px
Three-vessel disease: blockage of LAD/RCA/LCX
Coronary artery bypass: open via median sternotomy,
isolate internal thoracic artery (best choice) or greater
saphenous vein, put on bypass and stop the heart, sew
grafts to arteries, restart the heart and close up
––––––––––– MEDIASTINAL DISEASES –––––––––––
CABG mortality: 3% overall, greater in high-risk
Anterior mediastinal mass: thymomas, lymphomas,
pts but they benefit the most from the surgery
teratomas, other metastatic germ cell neoplasms
Coronary angioplasty: insertion of stent to prolong
Thymoma: often presents with progressive muscle
patency of clogged coronary arteries, 33% rate of
weakness secondary to myasthenia gravis, Tx surgical
restenosis in 1 year
removal via median sternotomy
Cardioplegia solution: solution used to stop heart mid-
Lymphoma: Tx radiation and chemotherapy Teratoma:
diastole to protect it from ischemia and provide a
contains hair and teeth, Tx surgical
motionless field; often used with hypothermia to prolong
time of safe ischemia (up to 2.5 hours) Off-bypass
coronary surgery: grafting of ITA or GSV to coronary
arteries without bypass in order to avoid complications of
bypass (e.g. general inflammatory response); reserved for
high-risk pts
Dilated cardiomyopathy: dilation of myocardium causes
systolic dysfunction leading to progressive dyspnea and
fatigue, often preceded by viral URI
DCM Px: 1/3 recover, 1/3 stay the same, 1/3 die
DCM Tx: β-blockers will improve heart function,
but heart transplant is indicated (requires
chronic immunosuppression)
Heart transplant: remove donor heart and isolate in
hypothermic cardioplegia solution, remove recipient heart
on bypass, suture donor heart in recipient; MCC of death
are infection due to immunosuppression, and accelerated
coronary artery atherosclerosis
Constrictive pericarditis: presents as dyspnea,
hepatomegaly, and ascites due to diastolic failure; Dx
cardiac cath shows “square root sign”, Tx surgical
correction
––––––––––––– VALVULAR DISEASES ––––––––––––
Valvular disease management: first detected on
auscultation → get an echocardiogram
Valve replacement: mechanical valves (durable but
require anticoagulation) and porcine valves
(nonthrombogenic but will deteriorate over time)
Aortic stenosis: angina, dyspnea, syncope, and high risk of
sudden death; Dx harsh mid-systolic murmur, MCC is
congenital bicuspid aortic valve with dystrophic
calcification, Tx valve replacement when symptomatic
Aortic regurgitation: presents as loud, blowing diastolic
murmur and bounding pulses; if chronic → valve
replacement when symptomatic, if acute → emergent
valve replacement and long-term abx
Mitral stenosis: presents as dyspnea and fatigue, caused
by rheumatic fever, results in cor pulmonale (RVH+PH) and
AFib; Tx valve repair or replacement
Mitral regurgitation: presents as dyspnea and fatigue,
caused by MVP, Dx high-pitched holosystolic murmur; Tx
annuloplasty (preferred) or valve replacement
Mitral prolapse: eccentric closure of mitral leaflets;
common in women, precedes severe disease in men
 removal via median sternotomy
Middle mediastinal mass: lymphomas, bronchogenic cysts,
pericardial cysts
Neurilemoma: dumbbell-shaped tumor found adjacent to vertebral bodies, develops from nerves and nerve sheathes, Tx surgical removal via thoracotomy
–––––––––––––– CAROTID DISEASES –––––––––––––
Atherosclerosis: systemic disease that has multiple
manifestations (stroke, TIA, CAD, MI, mesenteric
ischemia, AAA, PVD); presence of any one of these
should raise suspicion for the others
Stroke: a neurologic deficit that doesn’t resolve
within 24 hours, Tx t-PA only within 3 hours
Stroke management: carotid duplex study, observation
for improvement; CEA is not indicated until pt has
stabilized
Transient ischemic attack: brief neurologic deficit that
fully resolves within 24 hours; due to thromboembolus
from internal carotid arteries
TIA management: physical exam (check carotid
bruids, neuro, cardiovascular) + carotid duplex; Tx
aspirin or carotid endarterectomy
TIA × amaurosis fugax: emboli from carotid travels to
retina causing transient blindness; Dx fundoscopic
exam reveals Hollenhorst plaque, a bright shiny spot in
a retinal artery
TIA × aphasia: emboli from left carotid travels to
speech center located in left hemisphere
CEA: indicated for >70% carotid stenosis with either
neurologic sx or asymptomatic bruits; complications
include 1-3% risk of perioperative stroke, or injury to facial,
vagus, or hypoglossal nerves
Post-CEA management: start aspirin, encourage
lifestyle modifications (e.g. diet and exercise, quit
smoking) since patient is still high-risk for MI
Asymptomatic carotid bruit: get a carotid duplex
study, indicated for CEA if >70% stenosis
–––––––––––– PERIPHERAL DISEASES –––––––––––
Subclavian steal syndrome: presents as nothing at rest,
but arm claudication and CNS sx with arm activity due to
subclavian artery atherosclerosis; Dx arteriogram, Tx
bypass surgery
Arterial embolus: presents as the 6 P’s – pain, pallor,
parasthesias, poikilothermia, pulselessness, paralysis; clot
source is usually Afib or recent MI
Embolus Tx: requires urgent revascularization within
6 hours; give heparin and go to OR for balloon
catheter embolectomy +/-fasciotomy
Embolus post-op: start warfarin for anti-coagulation,
then get CT scan or aortography to search for source
of emboli
Compartment syndrome: revascularization of acutely
ischemic limb results in ischemia-reperfusion injury,
causing muscle edema within fascial compartment and
the 6 P’s
Bronchogenic cysts: develop from foregut
remnants, Tx surgical removal via thoracotomy
Pericardial cysts: typical water bottle appearance, Tx
Compartment syndrome Tx: fasciotomy
Ankle-brachial index: ratio of BP in arm vs. leg; ABI
>1.0 is normal, ischemic ABI is 0.6-0.8 (claudication)
or 0.3-0.5 (rest pain)
Doppler tracing: normally triphasic due to systolic flow →
elastic recoil → diastolic flow; ischemic signal is either
biphasic (mild) or monophasic (severe)
Claudication: exercise-induced ischemia that causes
reversible calf pain, MCC is an atherosclerotic SFA
Claudication management: if mild → not indicated
for surgery, so exercise and lifestyle changes are
recommended; if severe → get Doppler tracing,
then arteriogram to localize
Claudication Px: 1/3 improve on a non-op exercise
program, 1/3 stay the same, 1/3 get worse
Aortoiliac stenosis: presents as triad of claudication
+ absent femoral pulse + impotence
Aortoiliac stenosis Tx: depends on case; bilateral loss
of femoral pulse → aortofemoral bypass graft, single
segment iliac stenosis → angioplasty, high risk pt →
lifestyle changes
Severe claudication: presents as claudication + rest pain or
foot ulcers, common in diabetics; get a vascular work-up
and arteriogram to determine level of occlusion, and
assess general medical status
SFA stenosis Tx: reverse GSV to SFA graft
Iliac stenosis Tx: surgical revascularization or
balloon dilation
SFA + iliac stenosis Tx: both of the above, either at the
same time or sequentially (iliac first)
SFA + popliteal stenosis Tx: femoropopliteal bypass
to the best artery continuous with the foot, failure
likely in distal and severe disease
Multiple obstructions Tx: reconstruction may not be
possible, limb amputation indicated
Bypass pre-op: 10% risk of MI, arrhythmias, or heart
failure; requires evaluation of cardiac status (get
dipyridamole-thallium scintigraphy to rule out CAD)
Pre-op reveals <30% ejection fraction: high risk of post-
op heart failure
Pre-op reveals CAD: cancel or delay surgery, perform a
less invasive procedure, pre-op CABG or PTCA, or
intensive intraoperative monitoring
Pre-op reveals recent MI: delay surgery for 3 mo
Bypass post-op: daily duplex studies to check for graft
stenosis, give aspirin, educate on lipid control and foot
care; MCC death is CAD
surgical removal via thoracotomy
Posterior mediastinal mass: neurogenic tumors (MCC
is neurilemoma)
Trash foot: post-op embolization of atherosclerotic
debris following bypass results in cyanotic toe; Tx
heparinization of clot and long-term aspirin use AAA:
presents as painless pulsatile abdominal mass;
management is getting ultrasound and CT scan, then
elective graft repair if aorta is >5 cm
AAA repair post-op: major fluid shifts (third-space loss
on POD#1/2, third-space mobilization on POD#3),
cardiac problems due to aortic clamping, and
impotence due to damage of hypogastric circulation or
autonomic nerves around IMA
Ruptured AAA: presents as pulsatile mass, back and
abdominal pain, and hypotension; if unstable → OR, if
stable → get CT scan or ultrasound, then OR
Ruptured AAA repair: clamp aorta at level of diaphragm
to stop bleeding, then proceed with repair; 80% risk of
death by bleeding out in the OR
AAA repair × bloody diarrhea: indicates ischemic colitis
due to interrupted IMA; Dx sigmoidoscopy, Tx bowel
rest if limited to mucosa, colectomy and colostomy if
full-thickness involvement
AAA repair × delayed fever: indicates vascular graft
infection via S. aureus or S. epidermidis; Dx CT scan,
Tx graft removal, debridement, and IV antibiotics
AAA repair × UGI bleed: indicates aortoduodenal
fistula, usually a small bleed followed 1-2 days later by
massive bleeding; Dx CT scan, Tx graft removal and GI
repair
Mesenteric ischemia: presents as postprandial abd pain,
weight loss, and multiple abd bruits due to
atherosclerosis of celiac trunk or SMA
Mesenteric ischemia management: Dx mesenteric
angiogram, Tx revascularization; follow-up with
aspirin and evaluation for other atherosclerotic
diseases
Aortic dissection: presents as acute onset tearing
chest/back pain due to severe HTN (200/140), CXR
shows widened mediastinum
Aortic dissection management: Dx MRI, spiral CT,
transesophageal echo, or arteriography; if ascending
aorta → go to OR for surgical repair, if descending
aorta → β-blockers
–––––––––––––– VENOUS DISEASES –––––––––––––
Deep venous thrombosis: presents as acute onset dull
leg pain, unilateral swelling, and Homans’ sign
DVT risk factors: Virchow’s triad – stasis,
endothelial damage, and hypercoagulability
DVT management: Dx duplex ultrasound, Tx
therapeutic heparin or LMWH, followed by long-term
warfarin therapy (follow INR)
Post-thrombotic syndrome: occurs in 10% of DVT pts, area due to chronic venous HTN
presents as severe leg edema and ulceration around ankle –––––––––––– ABDOMINAL DISEASES –––––––––––
Post-thrombotic syndrome management: prevention via chronic use of support hose, heal
ulcers if they’ve already developed

DVT prophylaxis: indicated if pt is at risk for DVT; includes leg compression devices and subcutaneous low-dose heparin

DVT prophylaxis for hip fx: fondaparinux and leg compression devices

Pulmonary embolus: presents as acute onset chest pain, dyspnea, and hyperventilation (↓PCO2), due to DVT embolization into lung → wedge-shaped area of lung infarction, S1Q3T3 on EKG

PE management: get EKG to rule out MI, ABGs (shows ↓PCO2), CXR, and pulse oximeter; mismatch on a V/Q scan is diagnostic, Tx identical to DVT Tx

Recurrent PE: due to failure of heparin therapy; indicated for IVC interruption with a metal filter

Anticoagulation: therapeutic/high-dose heparin or LMWH for Tx DVT/PE, low-dose for prophylaxis; IVC filters when anticoagulation fails or is contra-indicated

Anticoagulation × HIT: rare heparin side-effects include thrombocytopenia and paradoxical arterial clots, d/c heparin immediately

Anticoagulation × skin necroses: rare side-effect of warfarin therapy, start warfarin along with heparin to prevent this from happening

Anticoagulation × UGI bleed: life-threatening condition that requires immediate d/c, give pt a metal filter instead for PE prophylaxis

Phlegmasia cerulea dolens: presents as acute onset leg edema with pain and cyanosis due to venous outflow obstruction, high risk of nerve damage and venous gangrene

PCD management: elevate leg and immediate anticoagulation, then order duplex ultrasound and pelvic CT scan to confirm the Dx

–––––––––– OTHER VASCULAR DISEASES –––––––––

Temporal arteritis: presents as severe, unilateral headache, visual changes, and nodularity of temporal artery; give high-dose steroids right away to prevent blindness

–––––––––––– ESOPHAGEAL CANCERS –––––––––––
Dysphagia: management includes barium swallow and
esophagoscopy w/ biopsy; DDx achalasia, Zenker
diverticulum, esophageal cancers, strictures
Esophageal cancer: SCC in upper 2/3 due to cigs and
EtOH, adenocarcinoma in lower 1/3 due to Barrett’s, Sx
progressive dysphagia and weight loss
EC management: esophagoscopy and biopsy, then
staging via endoscopic ultrasound and CT scan, then
specific Tx
EC staging: stage I invades submucosa only, stage II
invades muscularis +/-LN, stage III invades adventitia +
adjacent structures, stage IV is metastatic
EC prevalence: adeno MC in US, SCC elsewhere
EC Tx: upper 1/3 – chemo and radiation only; middle 1/3
– chemo and radiation to shrink the tumor, then
esophagectomy; lower 1/3 – esophagectomy and
proximal gastrectomy; never operate on stage IV
cancer
Advanced esophageal cancer: Sx severe dysphagia and
chronic cough (due to aspiration from TE fistula),
management is palliative care b/c surgery won’t help
––––––––––– ESOPHAGEAL DISEASES –––––––––––
Traction diverticulum: diverticulum at middle
esophagus due to LN traction, indicates cancer
Esophageal motility disorders: achalasia (only one
treated surgically), nutcracker esophagus, spasms,
hypertensive LES
Achalasia: hypertonic and non-relaxing LES w/ poorly
relaxing esophagus, Sx dysphagia of liquids > solids
Achalasia management: Dx bird’s beak on barium
swallow and ↑LES pressure on manometry, Tx Heller
myotomy
Nutcracker esophagus: painful swallowing due to high
amplitude action potentials, Tx nifedipine
Diffuse esophageal spasms: uncoordinated 3°
peristalsis, Tx medically
Hypertensive LES: high LES pressure at baseline but
relaxes with swallow, Tx medically
Acute epigastric pain: DDx acute pancreatitis, GERD, PUD
(gastric ulcers or duodenal ulcers), cholelithiasis,
gastroenteritis Pain × PMHx: gallstones or alcoholism =
acute pancreatitis (order amylase/lipase levels), NSAIDs or
steroid use = PUD
Esophageal varices: present as UGIB due to portal HTN,
often alongside coagulopathy (liver failure)
Mallory-Weiss syndrome: presents as UGIB due to
retching lacerating the lower esophagus, bleeding
usually stops spontaneously
Boerhaave syndrome: presents as epigastric pain and
fever due to retching perforating the esophagus; Dx
contrast swallow, Tx emergent surgical repair
Instrumental perforation: presents as retrosternal pain,
fever, and pneumomediastinum s/p upper GI
endoscopy; Dx contrast swallow, Tx surgical repair
GERD: presents as heartburn, regurgitation,
waterbrash (sour taste), dysphagia, cough
GERD Tx: PPIs → if it persists after six weeks, do
EGD w/ biopsy to see what’s going on
Normal EGD: PPIs or elective lap Nissen
Esophagitis: multiple, nonulcerating erosions in
stomach; mild to moderate esophagitis → PPIs for 8-
12 weeks, severe esophagitis → lap Nissen,
uncontrollable bleeding esophagitis → subtotal
gastrectomy
Barrett esophagus: intestinal metaplasia of
esophageal epithelium; no dysplasia → Tx PPIs or lap
Nissen; low-grade dysplasia → Tx lap Nissen + annual
surveillance; high-grade dysplasia → Tx
esophagectomy

Zenker diverticulum: pulsion diverticulum that
develops at upper esophagus due to abnormal
coordination of cricopharyngeal constriction; Sx
dysphagia, regurgitation, and bad breath
Zenker management: Dx barium swallow, Tx
cricopharyngeus myotomy
EV management: band the bleeding varices, correct
any coagulopathy, IV octreotide to lower portal
pressure → if bleeding continues, repeat endoscopic
banding → if bleeding continues, TIPS or gastric
balloon tamponade
EV follow-up: β-blockers to lessen chance of
rebleeding; good liver function → elective TIPS, bad
liver function → liver transplant
Lap Nissen fundoplication: wraps fundus of stomach
around LES to keep it in abdominal cavity (must check for
intact esophageal peristalsis first); contra-indicated in
morbidly obese (gastric bypass instead)
Hiatal hernia: hernia from abdominal cavity, through
diaphragm, into chest cavity
Type 1 hiatal hernia: sliding hernia, risk of reflux
 esophagitis, Tx PPIs
Type 2 hiatal hernia: paraesophageal hernia, risk of
incarceration/strangulation, Tx surgical repair
Type 3 hiatal hernia: presence of both types 1+2, Tx
surgical repair
–––––––– GASTRIC/DUODENAL DISEASES ––––––––
Peptic ulcer disease: gastric ulcers, duodenal ulcers
PUD surgery indications: intractability,
perforation, obstruction, bleeding
Duodenal ulcers: caused by ↑acid secretion; most
commonly in 1st part of duodenum, DU in 2nd-4th part
indicates Zollinger-Ellison syndrome (gastrinoma)
DU types: posterior ulcers bleed due to gastro
duodenal artery, anterior ulcers perforate
DU Tx: triple therapy → if ulcer persists, surgery is
indicated (HSV > TV+P >> TV+A), also get serum gastrin
levels to rule out Z-E syndrome
––––––––––––– GB/BILIARY DISEASES ––––––––––––
Biliary disease progression: cholelithiasis → biliary colic
→ acute cholecystitis; choledocholithiasis → ascending
cholangitis or gallstone pancreatitis
Cholelithiasis: presents as nausea, vomiting, RUQ pain
w/o fever; only 15-20% are symptomatic
Cholelithiasis in pregnancy: manage non-op if
possible (hydration and pain meds), elective lap
chole can be done after delivery
Biliary colic: fatty meal → CCK release → gall bladder
contraction against non-lodged stone resulting in transient
RUQ pain for <6 hours; labs are usually normal if episode
has passed
Cholecystitis: presents as fever, WBC>15, RUQ pain >6
hours; MC bacteria are E. coli, Bacteroides fragilis,
Klebsiella, Enterococcus
Cholecystitis management: Dx abdominal U/S, order
CBC and LFTs, Tx lap chole within 72 hrs
Cholecystitis in elderly: elderly pts respond to
sepsis with hypothermia and ↓WBC
Cholecystitis antibiotics: ciprofloxacin (Cipro) and
metronidazole (Flagyl) to cover GNR and
anaerobes; abx not indicated for cholelithiasis
Cholecystectomy indications: symptomatic
cholelithiasis, acute cholecystitis, and cholangitis; do
not operate on asx stones
Cholecystectomy complications: nicking the CBD
(jaundice) or right hepatic artery (hepatitis)
Post-op biliary leak: presents as Charcot’s triad; get
an U/S and HIDA scan → Tx biliary drainage and
temporary stent during ERCP
Post-op obstruction: presents as Charcot’s triad due to
stricture or retained stone; get an U/S and HIDA scan →
Tx biliary drainage and choledochojejunostomy
Choledocholithiasis: presents as transient jaundice and
Perforated DU: CXR shows free air under diaphragm;
use omentum to patch the ulcer (Graham patch),
then stop acid w/ PPIs or HSV
Perforated DU × sepsis: complete Graham patch as
soon as possible, give PPIs and IV abx, then monitor in
ICU and plan surgery for a later date
Bleeding DU: due to posterior ulceration into GDA; Tx
oversew the ulcer, then stop acid w/ PPIs
Gastric ulcers: caused by ↓mucosal protection; type I
– lesser curvature at incisure, type II – duodenum and
stomach, type III – pylorus, type IV – GE junction
GU Tx: PPIs → if ulcer persists after six weeks, do
endoscopy and multiple marginal biopsies for possibility
of gastric cancer; if ulcer persists after 18 weeks, surgery
is indicated
GU surgery: wedge resection or distal gastrectomy
(due to possibility of cancer), TV+P for types II and III
due to ↑acid production
Bleeding GU: Tx excision rather than oversewing
↑alk phos; Dx U/S shows dilated bile ducts +/ERCP, Tx lap
chole w/ CBD exploration
Acute cholangitis: presents as Charcot’s triad
(jaundice, fever, RUQ pain) or Reynold’s pentad
(shock, ∆MS) due to choledocholithiasis
Acute cholangitis management: IVF, antibiotics, and
U/S → ERCP to decompress biliary tree → finally lap
chole w/ CBD exploration
GB polyps: <2 cm observe, >2 cm take it out due to risk
of adenocarcinoma
GB adenocarcinoma: presents as mass in GB fossa; Dx CT
scan, Tx open chole + hilar LN resection + liver resection w/
negative margins
Porcelain GB: dystrophic calcification of GB has 50% risk of
adenocarcinoma, take it out
–––––––––––––––––– JAUNDICE –––––––––––––––––
Jaundice: elevated bilirubin and yellowing of skin; three
types – hemolytic, obstructive, hepatocellular
Hemolytic jaundice: ↑bilirubin (direct <20%), search for
what’s killing the RBCs
Hepatocellular jaundice: ↑bilirubin (direct 20-50%) and
↑AST/ALT, consider HBV/HCV and alcoholism
Obstructive jaundice: ↑bilirubin (direct >50%) and
↑alk phos, caused by CBD stones and cancers
Painless jaundice: caused by biliary obstructive tumors
(ampullary cancer, duodenal cancer,
cholangiocarcinoma, pancreatic adenocarcinoma)
Painless jaundice management: Dx CT scan then
ERCP, Tx Whipple if no mets or local invasion
Painless jaundice × occult bleed: indicates ampullary
cancer, get CT scan then Whipple
–––––––––––– PANCREATIC DISEASES –––––––––––
Pancreatic head mass: check for metastases, then
Gastric cancers: lymphoma, adenocarcinoma, GIST
(e.g. sarcomas and lipomas)
Gastric adenocarcinoma: often spreads to left
supraclavicular (Virchow’s) node and ovaries; Tx
proximal → total gastrectomy, if distal → distal
gastrectomy w/ anastomosis; take out D1 LN at lesser
curvature
Linitis plastica: infiltrating carcinoma with desmoplastic
reaction causing stomach to look fixed and rigid; Tx
total gastrectomy w/ splenectomy
Gastric lymphoma: first determine cancer stage (CT
scan, LN biopsy, and bone marrow Bx); Tx partial
thickness → radiation, full thickness → surgical
resection
GIST: any soft tissue tumor of stomach; Tx wedge
resection w/ 1 cm negative margins (no LN)
Gastric varices: present as UGIB due to portal HTN, Tx
uncontrollable bleeding w/ TIPS or splenectomy instead
of banding
perform Whipple if no mets
Pancreatic adenocarcinoma: presents as obstructive
jaundice, get a CT scan; cancer in head → Tx Whipple, in
body or tail → distal pancreatectomy, mets or local invasion
→ palliative care (no surgery)
Acute pancreatitis: presents as epigastric pain boring
through to the back w/ ↑lipase/amylase; amylase
levels do not correlate with severity
Pancreatitis causes: I GET SMASHED – Idiopathic,
Gallstones (#1), EtOH (#2), Trauma, Steroids, Mumps,
Autoimmune, Scorpion sting, Hypertriglyceridemia (#3),
Hypercalcemia, ERCP, Drugs
Edematous pancreatitis: get amylase/lipase, then NPO,
IVF, pain meds
Hemorrhagic pancreatitis: presents as MSOF, ARDS,
and hemodynamic instability; send to ICU for
resuscitation and serial CTs
Ischemic pancreatitis: Dx no blood flow to pancreas
on contrast CT, Tx IV abx and resection
Gallstone pancreatitis: if amylase returns to normal →
lap chole + cholangiogram; if complicated → ERCP to
remove stone
Pancreatic abscess: presents as septic shock 2 weeks after
acute pancreatitis; Dx dynamic CT scan, Tx perc drain +
antibiotics
Pseudocyst: abdominal pain and early satiety 5 weeks after
acute pancreatitis, Tx cystogastrostomy only if it’s
symptomatic and has been present for 6+ weeks (must get
Bx w/ frozen epithelial section and see no epithelial lining
before the ostomy since epithelium indicates cancer)
Chronic pancreatitis: presents as constant epigastric pain,
steatorrhea, and diabetes in a chronic alcoholic; Tx insulin
and pancreatic enzyme replacement
––––––––––––––– LIVER DISEASES ––––––––––––––
Liver cyst: simple cyst, leave it alone
Echinococcal cyst: multilocular cyst w/ calcified walls due
to parasite Echinococcus granulosus; inject hypertonic
saline inside cyst and carefully excise it
Liver abscess: multiple/small bacterial abscesses → IV
antibiotics; single/large bacterial abscess → perc drain;
amebic abscess (Mexicans) → metronidazole
Liver cancers: hepatic adenoma, focal nodular
hyperplasia, hemangioma, hepatoma
––––––––––– SMALL BOWEL DISEASES –––––––––––
Small bowel obstruction: presents as colicky abd pain,
nausea/vomiting, and constipation; MCC are adhesions
from previous surgery and hernias
SBO management: get KUB → Dx air-fluid levels and
dilated loops; Tx NPO, NG suction, IVF, and initially
observation
SBO × electrolyte imbalance: “hypokalemic,
hypochloremic metabolic alkalosis” due to emesis
SBO × bloody diarrhea: indicates obstructive tumor
or ischemic bowel; Dx sigmoidoscopy → observe if
mucosal, resection if full-thickness
SBO × flatus: indicates partial SBO since gas can get
through, more likely to resolve w/o surgery
SBO × diarrhea: indicates partial SBO due to fecal
impaction and severe constipation
SBO × inguinal hernia: requires urgent hernia
repair to relieve strangulation
SBO × melanoma: melanoma is the MC tumor that
metastasizes to intestine, surgery indicated
since these don’t resolve spontaneously
SBO × other cancers: surgery indicated since these
don’t resolve spontaneously
SBO × peritonitis: presents as rebound tenderness,
↑WBC, fever, or metabolic acidosis due to necrotic
bowel; indicated for ex lap
SBO × adhesions: indicated for ex lap → lysis of
adhesions
SBO × closed loop obstruction: usually due to adhesive
band occluding two segments of bowel; indicated for
ex lap → lysis of adhesions,
resection of any dead bowel, and “second look”
operation if bowel viability is indeterminate
SBO × pneumoperitoneum: indicates perforation due
to ischemic or overdistended bowel; indicated for ex
lap → dead bowel resection
Nicked bowel during LOA: small hole → primary
repair, large or multiple holes → bowel resection; high
risk of leakage and EC fistula formation
Uncertain about SBO: get an upper GI series w/ small
bowel follow-through, barium contrast will stop at site of
obstruction if SBO exists
Mesenteric ischemia: presents as postprandial abd pain,
weight loss, SBO, and multiple abd bruits usually due to
atherosclerosis of celiac trunk or SMA
Hepatic adenoma: often presents as hypovolemic shock
and distended abdomen, related to OCPs and anabolic
steroid abuse; Tx d/c OCP → if it persists, resect due to
possibility of rupture
FNH: Dx central stellate scar or sunburst pattern on CT
scan, no OCP relationship, leave alone even if
symptomatic
Hemangioma: leave alone even if symptomatic, never
spontaneously rupture, do not needle biopsy due to
Mesenteric ischemia management: Dx mesenteric
angiogram, Tx revascularization; follow-up with
aspirin and evaluation for other atherosclerotic
diseases Mesenteric ischemia × peritonitis: presents
as rebound tenderness, ↑WBC, fever, or metabolic
acidosis due to necrotic bowel; ex lap indicated
Mesenteric ischemia × AFib: indicates emboli
shooting from left atrium to celiac trunk or SMA
Mesenteric ischemia × ↑hct: polycythemia due to
severe dehydration requires IV fluid resuscitation
Mesenteric ischemia × CHF: ischemia may be
secondary to a low-flow, nonocclusive state;
indicated for mesenteric vasodilation and improve
cardiac output
Mesenteric ischemia × aortic dissection: dissected
aorta can occlude mesenteric vessels; Dx
angiography, Tx surgical repair
Mesenteric ischemia × ↓BP: either ischemic bowel
causing septic shock, or hypotension causing low-flow,
nonocclusive ischemia
Left colon necrosis: bowel resection → anastomosis if
stable, otherwise colostomy and Hartmann pouch
Long segment necrosis: bowel resection → small bowel
syndrome requiring chronic TPN or transplant
Short segment necrosis: bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Small punctate necroses: indicates multiple small
emboli or low-flow state; bowel resection →
anastomosis, “second look” operation if bowel
viability is indeterminate
Bowel ischemia but no necrosis: try to revascularize the
bowel via removing or bypassing the occlusion
Low-flow but no necrosis: non-op management of
hemodynamic status, surgery should be avoided
––––––– INFLAMMATORY BOWEL DISEASE –––––––
Inflammatory bowel disease: Crohn’s disease and
ulcerative colitis; presents as crampy abdominal pain,
bloody diarrhea, and recent weight loss
IBD management: colonoscopy to determine if it’s
UC, Crohn’s, or something else → abdominal CT scan
for confirmation of IBD
Crohn’s disease: inflammatory disease involving full GI tract
with skip lesions (terminal ileum is MC site), Bx shows full
thickness + noncaseating granulomas + creeping fat, Dx
terminal ileum string sign on CT scan
possibility of rupture
Hepatoma: presents as vague RUQ pain and mass
related to HBV/HCV and cirrhosis w/ ↑αFP; Dx CT scan
then Tx resection w/ negative margins indicated as long
as there’s no mets
Portal HTN: Sx esophageal varices, caput medusa,
hemorrhoids; Tx TIPS (connect portal vein to hepatic
vein to relieve pressure) as a “bridge to liver txp”
Crohn’s management: IV steroids and 5-ASA
(sulfsalazine) for acute flare-ups
Crohn’s × SBO: due to stenotic terminal ileum;
manage with NPO, TPN, and observation → if it fails
to resolve, surgical stricturoplasty indicated
Crohn’s × perianal disease: metronidazole
Crohn’s × rectal disease: rare, indicated for subtotal
colectomy and ileostomy
Ulcerative colitis: inflammatory disease involving
rectum and continuous proximal extension, Bx shows
mucosal involvement + crypt abscesses +
pseudopolyps, Dx lead pipe sign on CT scan
UC management: IV steroids and 5-ASA (sulfsalazine) for
acute flare-ups, annual colonoscopy for possibility of
cancer
UC × severe dysplasia: total proctocolectomy, ileal
pouch formation, and ileo-anal anastomosis; no further
cancer surveillance needed
Pouchitis: presents as fever, bloody diarrhea, and pain
on defecation s/p ileal pouch formation for UC; Tx
metronidazole
Toxic megacolon: presents as fever, bloody diarrhea, pain,
and abdominal distention in a pt w/ UC
TM management: get KUB for confirmation, then NPO,
IVF, NG suction, IV steroids and abx; improves → no
surgery, stays the same or gets worse → surgery
necessary
TM × perforation: shows free air on upright CXR,
indicated for total colectomy and ileostomy w/
Hartmann pouch
TM × impending perforation: shows pneumatosis on CT
scan, indicated for surgery (see above)
––––––––––––––– APPENDICITIS –––––––––––––––
Appendicitis: presents as RLQ pain, low grade fever and
leukocytosis; MCC lymphoid hyperplasia
Appendicitis management: get CT scan or U/S (U/S is
cheaper); if uncomplicated → app’y, if abscess
(↑↑fever/↑↑WBC) → perc drain, interval app’y
Appendicitis in kids: children with appendicitis
present more often with a ruptured appendix
Appendicitis in elderly: older pts usually don’t
have classic presentation of appendicitis, but
rather vague abdominal complaints, sepsis, altered
MS, or failure to thrive
 RLQ pain × h/o gastroenteritis: could be appendicitis
Diverticulitis complications: abscess (Tx perc drain),
FAP pts should always get upper endoscopy and
but likely gastroenteritis
obstructions, fistula (pneumaturia or fecaluria, Tx
Appendicitis in pregnancy:
remove the duodenal polyps enlarged uterus can push
appendix upwards → RUQ pain; appy can be
performed safely w/o risk to mom or child
surgical separation of colon from bladder)

RLQ pain × dysuria: indicates appendicits, UTI, or

RLQ pain ×abscess
appendiceal R pelvic tenderness:
next to bladderlikely retrocecal

HNPCC:
RLQ pain × ∆MLH
minimalordysuria:
∆MSH mismatch repair genes →
likely appendicitis
appendicitis, go to the OR
––––––––––– LARGE BOWEL DISEASES ––––––––––
RLQ pain × hematuria: indicates severe UTI or a
microsatellite instability, Tx total abdominal
kidney stone

RLQ pain × h/o PID: could be appendicitis, recurrent PID,

orcolectomy + ileorectal
an ectopic; anastomosis
PID confirmed by cervical or adnexal
RLQ pain or
tenderness, × BPH Sx:discharge
cervical likely bladder
(getoutlet obstruction
gyn consult and
Pseudomembranous
stain discharge) colitis: watery diarrhea and

due to enlarged prostate, Tx Foley catheter

↑↑WBC due to clindamycin-related C. diff overgrowth;
Colon cancer recurrence: f/u with colonoscopy, CEA

Dx stool toxin or colonoscopy, Tx stop clindamycin

marker, CXR for lung mets, and LFTs for liver mets
RLQ pain × h/o IBD: IBD can present similarly to
and start metronidazole or vancomycin

appendicitis, get colonoscopy and CT scan and

–––––––––––– ANORECTAL DISEASES –––––––––––

manage appropriately
Colon cancer screening: anyone above 50 y/o should

get yearly fecal occult blood test (flex sig and

All anorectal diseases: first step in management is to
RLQ pain × crampy pain/diarrhea: indicates IBD,
colonoscopy also used, but less commonly)
scope and rule out cancer
constipation, or cancer rather than appendicitis

Polyps: tubular/pedunculated have a stalk,

Hemorrhoids: presents as blood streaks in stool and
RLQ pain × corticosteroids: steroids can mask all Sx
sessile/villous are flattened; progression from polyp
extreme pain (external); Tx scope to r/o cancer →
of inflammation, be cautious since most steroid pts
to cancer takes ~10 years
fiber/stool softeners → if it keeps bleeding, excision
won’t present until perforation occurs

or banding

Pedunculated polyp: polypectomy w/ biopsy →

App’y findings: inflamed appendix, perforated

if dysplasia is not localized to head of polyp, then
Non-healing hemorrhoids: indicates anal canal
appendix, normal appendix, inflamed cecum,
segmental colectomy
cancer; Tx chemoradiation (5-FU) → APR if it
fecalith, carcinoid tumor, other tumors

persists or recurs

Sessile polyp: biopsy → if any high grade

Inflamed appendix: take it out

dysplasia, then colectomy
LAR vs. APR: LAR is low anterior resection (high in

rectum), APR is abdominoperineal resection (low in

Normal appendix: take it out anyways unless
Benign polyps: juvenile, Peutz-Jeghers,
rectum)
cecum is inflamed, check other areas for
inflammatory, hyperplastic; leave these alone
 –––––––––––––– THYROID DISEASES–––––––––––––
Papillary cancer Tx: total thyroidectomy w/
DiGeorge syndrome: congenital absence of both 3rd

central LN excisionGI→
–––––––––––––––– modified ––––––––––––––––
BLEEDING radical neck Hematemesis: bloody vomiting, always UGIB Melena: coffee ground blood in stool, usually UGIB but
and 4th branchial pouches → hypocalcemia, thymic can also be from ascending colon
Thyroid embryology: derivative of foramen cecum
dissection if LN are positive for cancer
Hematochezia: BRBPR, can be either UGIB or LGIB; NG tube aspirate/lavage → LGIB if –blood/+bile, UGIB if +blood, indeterminate if –blood/–bile
aplasia
UGIB:
fromGI
thebleeding proximal
base of the tongueto Ligament of Treitz, management is EGD

UGIB in ICU pt: most likely a stress ulcer

LGIB: GI bleeding distal to Ligament of Treitz, 85% stop spontaneously; MCC are AVM, diverticulosis, and colon cancer
Follicular cancer: endemic to iodine-deficient
PTH:
LGIBsecreted from chief
management: mustcells; threesite
localize functions –
of bleeding w/ tagged RBCs (<1 cc/min) or angiography (>1 cc/min); if not currently bleeding, get upper and lower endoscopy since localization
Thyroglossal
won’t help duct cyst: remnant of thyroglossal
regions, hematogenous spread, 2nd best Px
renal ↑Ca++/↓P, bone ↑Ca++/↑P, stimulates 1α
LGIB
duct assurgery
a mobileindications:“hemodynamic
midline neck mass, Dx at 1-2 instability
yo despite transfusion”, loss of 4-6 units in 24 hrs or 8-10 units in 48 hrs

LGIB scenario: GI bleed stops spontaneously → get colonoscopy to determine cause and rule out possibility of colon cancer → coagulate if AVM, leave alone if diverticulosis
hydroxylase to activate vitamin D for indirect GI
due to neck fat, Tx Sistrunk operation (take out
Follicular cancerunstable
LGIB scenario: Tx: hemilobectomy BRBPR, no imaging to localize site of bleeding → total colectomy since 85% of bleeding is from the colon
with biopsy
patient, massive
resorption of Ca++
cyst,
LGIBtrunk, andindicates
in kids: medial portion of hyoid
Meckel’s bone) Dx
diverticulum,
because 80% are benign adenomas and 20% are
technetium uptake into ectopic gastric mucosa

Dx tagged RBCs: sensitive for LGIB at 0.1 cc/min, but not specific for localizing site of LGIB; bladder always lights up first so ignore that part
malignant carcinomas, total thyroidectomy if Bx
DxOsteitis fibrosa
angiogram: cystica:
less rapid,
sensitive forpainful
LGIB atloss
1.0 of bone but more specific for localizing site of LGIB; allows for smaller LGI resection in surgery if necessary
cc/min,
Thyroid nodule management: first get TSH levels →
reveals malignant carcinoma
––––––––––––– OTHER GI DISEASES ––––––––––––
due to HPTH-“moth eaten skull”
if euthyroid, get FNA for cancer Dx; otherwise, work
Sigmoid volvulus: twisting of sigmoid colon around mesentery results in closed-loop obstruction; Tx
“detorse” the colon via rigid scope and rectal tube,
then elective sigmoid colectomy
up for hypo-or hyperthyroidism
Medullary cancer: AD inheritance with MEN2A/2B
Cecal volvulus: twisting of cecum; Tx right
Calciphylaxis: calcium deposition in soft tissue due
colectomy since detorsion usually won’t work

syndromes, Δret proto-oncogene, both lymphatic

Ogilvie’s syndrome: pseudoobstruction and massive colon dilation w/o mechanical obstruction; Tx endoscopic decompression or neostigmine if >11 cm due to possibility of cecal perforation
to HPTH
Risk of malignancy: solid nodules, cold nodules
and hematogenous
Constipation: spread,
do a rectal Bx amyloid
exam to makedeposits,
sure stool
isn’t impacted, then give enemas from below
(lack of radioiodine uptake), size > 1.5 cm
3rd best parathyroid
Missing Px glands: check thymus (MC location/15%), up and down neck, open carotid Metastatic glucagonoma: give somatostatin and streptozocin since surgery is
Multiple
sheath, myeloma: punched-out
retro-esophageal lesionsgroove,
area, esophageal of boneand
dueinside the thyroid gland itself
contraindicated
Median sternotomy: only indicated if pt is in a life-threatening hypercalcemic crisis
Nesidioblastosis: presents as hypersecretion of insulin in a newborn; Tx 95%
–––––– MULTIPLE ENDOCRINE NEOPLASIA ––––––
to a B-cell neoplasm pancreatectomy
Colloid nodule: benign nodule, manage medically
Medullary
MEN1 cancer
(Wermer): Tx: total
pituitary thyroidectomy
adenoma, for endocrine cancer (MC gastrinoma),
pancreatic
–––––––––– OTHER ENDOCRINE DISEASES –––––––––
parathyroid hyperplasia
Pituitary adenoma: prolactinoma (#1), null cell tumor (#2), ACTH (#3), GH (#4); may
MEN1 Tx: excise parathyroid first since hypercalcemia can cause ↑gastrin levels; if Z-E can’t be
both cancer and ret+ →prophylaxis w/ central since
LN MEN gastrinomas are multifocal present as bitemporal hemianopsia ◐◑ due to optic chiasm compression
controlled w/ PPIs total gastrectomy
Hypercalcemia Sx: kidney stones, painful bones,
Hyperthyroidism. Graves’ disease (most common), Prolactinoma: presents with galactorrhea and amenorrhea, Tx bromocriptine
excision
MEN2A → modified
(Sipple): radical neck
parathyroid dissection
hyperplasia, if LN
pheochromocytoma, thyroid medullary cancer
abdominal groans (peptic ulcers, pancreatitis,
toxic adenoma (#2), toxic multinodular goiter (#3) Null cell tumor. doesn’t secrete anything
MEN2B: pheochromocytoma, thyroid medullary cancer, mucosal neuromas, Marfanoid
are positive for cancer
habitus
cholelithiasis), psychic overtones (↓mental status) Cushing syndrome: presents as truncal obesity, abd striae, buffalo hump,
Graves’ disease (diffuse toxic goiter): auto- hyperglycemia, osteoporosis, HTN, and immunosuppression due to ↑cortisol
Anaplastic
MEN2A/2Bcancer: rare,pheochromocytoma
Tx: excise worst Px first since it can be life-threatening
Hypercalcemia DDx: parathyroid adenoma (MCC
immune disease due to IgG against TSH-R causing Cushing causes: MCC is exogenous steroid use; intrinsic causes include pituitary
Gastrinoma: give PPIs → if acid persists, get serum gastrin levels → <200 absent, >500 present,
adenoma, adrenal adenoma, and ectopic secretion of ACTH
200-500 indeterminate and requires secretin stimulation test
Pituitary Cushing: due to ↑ACTH secretion, suppressable by high dose
→outpatient), metastases
if paradoxical ↑gastrin tow/
bone (MCC present
secretin, inpatient)→ get CT scan to localize and cut it out
exophthalmos, pretibial myxedema, and dexamethasone; Dx MRI, Tx transsphenoid hypophysectomy
Anaplastic cancer Tx: palliative (e.g.
VIPoma. presents as “rice water” diarrhea-get CT
Adrenal Cushing: due to ↑cortisol secretion (causes ↓ACTH); Dx CT scan, Tx
scan to localize and cut it out
hyperthyroidism; more common in women adrenalectomy
tracheostomy)
Insulinoma: presents as
1° HPTH: ↑PTH/↑Ca hypoglycemia, Dx ↑C
++/↓P, most sensitive test is Cl:P Ectopic Cushing: due to ↑ACTH secretion usually from SCLC, not suppressable
peptide levels or monitored fasting (to see if they’re “faking it”)-get CT scan and cut it out
by high dose dexa

Glucagonoma: presents as new-onset diabetes and migratory rash from lower body upwards, Dx
Adrenal gland tumors: aldosteronoma, cortisoloma, sex hormone-secreting
ratio >33:1;
glucose causes
challenge include
test; 90%
get CT adenoma,
scan and cut9% hyper-
it out
Graves’ disease Tx: oral radioiodine (no surgical tumor, pheochromocytoma, incidentaloma
Thyroid lymphoma: associated w/ chronic
plasia, 1% carcinoma
risks) or surgery (won’t become hypothyroid)
Hashimoto’s thyroiditis, Tx radiation therapy
 –––––––––––– TRAUMA BREAST MANAGEMENT EVALUATION –––––––––––– –––––––––––
C-spine
––––––––injury:MALIGNANT suspected BREAST with neurological
DISEASES Sx, –––––––
Stab
Breast × cancer
hemiparesis: screening: suggests injuryself-exam,
monthly to the carotid
yearly
Breast cancer buzzwords:
Aldosteronoma: presentsfamily as ↑Na, history,
↓K, ↓H, ill-defined
↓renin; Dx CT scan for mass (if no mass present or Incidentaloma. make sure it’s not secreting
breast
↑renin,exam,
think yearly mammogram
RA stenosis), Tx if >40 y/o (earlier
adrenalectomy if
(adenoma) or aldactone (hyperplasia) hormones then work-up based on size; <5 cm → leave alone, >5 cm → resection +
radiological abnormalities, or
or fixed mass, skin or nipple retraction, peauC-spine tenderness;
artery; get angiogram and either vascular or check other organs since adrenals are common site of metastasis
there is a strong family Hx)
Evaluation
Cortisoloma.
d’orange, of trauma
nipple presents
eczema, pt:asprimary
andadrenal
palpablesurvey,
Cushing’s,get an
axillary Tx
LN
intubation
Breast mass
adrenalectomyrequires
on exam: extremefirst,caution
get mammogram to Aortic coarctation: presents as HTN in arms but normal BP in legs; get CXR
neurosurg
Breast cancer consult Tx: identical for all cancers (except (scalloping of ribs) then confirm w/ spiral CT, then surgical correction
“ample” Hx, secondary survey
characterize mass and rule out other masses →
Sex hormone-secreting tumor: Tx adrenalectomy
inflammatory, LCIS, DCIS); depends on cancer stage
get core needle biopsy → excisional biopsy if Renovascular HTN: presents as HTN + abd bruits, secondary to fibromuscular
Pheochromocytoma: presents with HA, HTN, palpitations, etc.; Dx 24 hour urinary VMA or dysplasia (young women) or atherosclerosis (old men) of the renal arteries; get a
metanephrines, Tx α-blockers (phenoxybenzamine) then β-blockers then adrenalectomy doppler of renal vessels, then either balloon dilation or surgical correction
needle inadequate
Stage I-II: lumpectomy w/ 1 cm
Priapism: indicates fresh spinal cord injury; checknegative margins
Intraoperative
Neck GSW: exploration hypotension:of neckgive IVF
is mandatory in zone
–––––––––––––––
Primary survey: SKIN initial CANCERS
evaluation of–––––––––––––––
trauma pt; Melanoma on face: Tx excision w/ smaller margins for Indirect hernia in kids: high incidence of bilaterality,
+ axillary
for cancers:
Skin LN
anal sphincter samping
basaltone, + post-op
bradycardia,
cell carcinoma radiation; or
and possibly
(50%), squamous cell
Abnormality on mammogram: ‘probably benign’ cosmetic purposes, consult plastic surgery repair is limited to high ligation of sac w/o abdominal
2, observe(25%),
carcinoma if stable in zonesmelanoma
malignant 1+3 (15%);
modified radical mastectomy
ABCDE – airway, breathing, circulation, disability
wall repair
→
management
follow-up;
neurogenic
is‘suspicious’
shock
full-thickness →incisional
core needle biopsy
biopsy,at border Melanoma in anus: all mucosal melanomas have bad
of the lesion prognosis, Tx APR w/ palpable LN excision Direct hernia: medial to inferior epigastric vessels, due
excisional biopsy if needle inadequate to weakening abdominal wall; more common in elderly
(neurological),
Basal cell carcinoma: environment/exposure
raised waxy lesion or non-healing
Stage III-IV: systemic chemotherapy Melanoma × SBO: presents as abd distention, nausea and
Breast
ulcer cancerface,
in upper riskdoesn’t
factors:spread;
family Hx (#1),excision
Tx local BRCA1 andw/ 1 vomiting due to metastatic melanoma in peritoneal cavity; Femoral hernia: below inguinal ligament into femoral
mmAxillary
Neck blunt
margins LNtrauma:
involvement: at riskTx chemotherapy
of carotid dissectionif pre
(Tx
Tx ex lap w/ excision triangle, more common in women, highest risk of
BRCA2 genes, old age
menopausal, tamoxifen if post-menopausal strangulation (50% of all strangulations)
–––––––––––––––
Squamous
MC breast cellmasses: HEAD
carcinoma: TRAUMA –––––––––––––––
non-healing
<25 fibroadenoma, ulcer
25-50infibro-
lower face,
anticoagulation) –––––––––––––––– SARCOMAS ––––––––––––––––
Breast to
spreads cancer
LN; Tx × or laryngeal
pregnancy:
local excision edema
work-up
w/ 1 cm (Txandintubation)
Tx is and LN
margins Sliding hernia: involves other viscera as part of the
Ample Hx: things
cystic change,
excision >50 to ask a trauma
infiltrating ductalpt –carcinoma
allergies,
hernia wall (e.g. bladder, cecum, sigmoid colon),
identical, except no chemo during 1st trimester Sarcomas: present as firm, painless masses; Px depends
important to recognize sliding hernias as not to injure
on size, grade, and distant metastases (no LN since
SCC risk factors: draining fistulas, arsenic any contained structures
and no radiation anytime; if stage III or IV, sarcomas spread hematogenously)
exposure
meds, previous illnesses, last meal, events
–––––––––– BENIGN BREAST DISEASES –––––––––
Head trauma evaluation: begin with primary survey Ventral hernia: hernia through incision site at linea alba; Tx
chemoradiation is essential and abortion may be Sarcoma management: Dx incisional biopsy parallel
–––––––––––––––
Keratoacanthoma: SPINAL
variantTRAUMA
of SCC that––––––––––––––
grows primary closure (small) or mesh repair (large)
surrounding to resection margins, chest CT for mets, Tx resection
rapidly andinjury then dies off spontaneously
(ABCs) → rapid neuro exam if stable →if any neuro
necessary w/ 1 cm negative margins
Fibroadenoma: firm, mobile, rubbery mass in young Rare hernia causes: anything that increases abdominal
Dysplastic nevus: atypical mole, precursor of malignant pressure – obesity, COPD, ascites, BPH causing bladder
High-grade sarcomas: Tx radical amputation w/
melanomas, requires close observation obstruction, constipation, ascites; these require
women; Dx FNA and U/S, Tx elective removal post-op radiation therapy
sx, get head CT and neurosurg consult further evaluation before surgery Hernia surgery
Breast cancer × men: work-up and Tx is identical
Spinal cord
Melanoma: injury
ABCDE management:irregular
– Asymmetric, get MRIBorders,
to look at types: open (Bassini, McVay, Shouldice, Lichtenstein),
Giant juvenile fibroadenoma: seen in teens with Sarcoma × lung mets: get chest CT to characterize
Secondary
different survey: full inspection of traumaPxptrelated to
Paget’s Colors,
disease:Diameter
presents as >5mm,
“crusty”Evolving;
nipple eczema, laparoscopic (TAPP, TEP)
rapid breast lesion and look for others → needle biopsy for
depth, highly growth;
metastatic Tx excision
and will be to avoid
foundbreast
in weird places
indicates underlying infiltrating ductal steroids
carcinoma confirmation → Tx thoracic wedge resection
spinal cord, then immediate high-dose Bassini repair: inguinal ligament to conjoint tendon,
deformity
following clearance of life-threatening issues,
Ulcerated melanoma: 1/3 reduction in survival high tension, fixes direct and indirect hernias
Rapid neuro exam: check pupils, cranial nerves, Sarcoma × liver mets: biopsy for confirmation → Tx
hepatic wedge resection or formal lobectomy
Depth <0.75 mm: Tx excision w/ 1 cm margin, McVay repair: Cooper’s ligament to conjoint tendon;
continual
good reassessment is necessary for changes
prognosis
Inflammatory cancer: resembles cellulitis w/ peau fixes direct, indirect, and femoral hernias
peripheral motor/sensory function, and rate level of
Phyllodes tumor: huge, benign tumors that distort
Hemisection syndrome: always due to stab
d’orange, “tumor cells
Depth 0.76-3.99 mm:inTxdermalexcision lymphatics”,
w/ 2 cm margin,Tx ––––––––––––––––– HERNIAS ––––––––––––––––– McVay repair w/ relaxing incision: cut transversus
the breast; Dx core or incisional biopsy since FNA is
palpable LN → removal, no palpable LN → abdominis aponeurosis to relax tension on sutures
requires pre-opvia
consciousness chemoGCS
sentinel LNTx
insufficient, biopsy
excision w/ elective removal Hernia surgery indications: all abdominal hernias due to
wounds in posterior neckw/ negative
area, presents margins
as ipsi
Airway: determine if airway is clear, quickest way to possibility of strangulation, except sliding esophageal Shouldice repair: inguinal ligament to reinforced
Depth >4 mm: Tx excision w/ 2 cm margin, hernias (Tx PPIs) and umbilical hernias in pts <2 yo (simple transversalis fascia in two layers
remove palpable LN, pt will likely die from mets observation)
DCML/motor loss and contra ACL loss
DCIS: Tx simple mastectomy
evaluate is to see if pt can talk; use intubation, Lichtenstein repair: tension-free repair w/ mesh; fixes
Fibrocystic change: multiple, bilateral lumps that
EDH: head
Melanoma × LNCTinvolvement:
shows convex remove lens hematoma;
regional LN, then Umbilical hernia management: <2cm watch, >2cm direct, indirect, and femoral hernias
complete staging for mets (CXR, CT scan, LFTs, brain MRI) fix, fix if it doesn’t regress before kindergarten
vary with menstrual cycle; if dominant or persistent regardless
cricothyroidotomy, or tracheostomy if obstructed TAPP and TEP: TransAbdominal PrePeritoneal and
LCIS: Tx careful observation or prophylactic bilateral
presents as×LOC
Melanoma →lucid interval
metastases: Tx radiation→LOC and→ Totally ExtraPeritoneal lap procedures; have steep
lump → aspiration → excisional biopsy if mass
Anterior cord(interferons)
chemotherapy syndrome: usually seen w/ Hernia × SBO: presents as abdominal distention,
simple mastectomy; not precancerous, but is a risk learning curve and unproven results
recurs or persists nausea, and vomiting due to incarcerated or
factor
Lentigo of
ipsilateral breast
maligna cancers
fixed/dilated
melanoma: pupil,superficial,
Tx craniotomy spreading strangulated hernia; Tx emergent hernia repair Hernia surgery complications: damage to genital branch
Sclerosing
melanoma onadenosis:
vertebral burst the face,Tx
fractures, careful
presents
good observation
as bilateral
prognosis or Tx
overall, of genitofemoral nerve, ilioinguinal, iliohypogastric, or
––––––––
Blunt trauma POST-SURGERY
to neck: COMPLICATIONS
consider possibility of –––––––
excision w/ narrow
prophylactic bilateralmargin
simple mastectomy; not Hernia × strangulation: presents as firm/tender lateral femoral cutaneous nerves causing pain and sensory
mass w/ fever, ↑WBC, metabolic acidosis; Tx defects
ALS/motor
Acral lentiginous loss but intact DCML
melanoma: melanoma on pale areas of emergent hernia repair
precancerous,
laryngeal edema butdeveloping
is a risk factorinto of cancers
airway
dark-skinned
Small head pts (sole
ipsilateral of feet,
nodule: localpalm of hand),
recurrence worst
until Hernia surgery post-op: avoid lifting for 6 weeks so
SDH: CT shows crescent moon hematoma,
prognosis due to depth Indirect hernia: through internal ring lateral to inferior incision site has time to regain strength
epigastrics vessels, due to patent processus vaginalis;
proven otherwise, work-up like
obstructionmelanoma: melanoma under fingernail orany other mass
Subungual most common hernia overall (even in women and
Atypical
high risk forductalbrainhyperplasia:
herniation; Tx Txhead
excision; not
elevation,
toenail, Tx DIP amputation elderly)
Central cord syndrome: usually seen w/ whiplash
HTX × hypotension: suspect blood loss in left chest, Thoracic blunt trauma: suspect HPTX, chest tube insertion on CXR, confirm w/ aortic angiography or chest CT →
precancerous,
indicated for leftbut chesthigh riskinsertion
tube of becoming a cancer
is indicated; emergent thoracotomy if >1.5L or >200mL/hr go to OR if transected
Contralateral
hyperventilate,
Thoracic GSW: GSW finding:
sedate, most likely
mannitol
is managed a new primary
+ furosemide
differently due to
blood is extracted from tube
(e.g. rear end collisions), presents
unpredictable path of bullets vs. knife, mark both as UE burning
Breathing: evaluate via lung auscultation, CXR, and Flail chest: presents w/ paradoxic chest wall
cancer, work-up
entrance/exit siteslikeandany getother
imagingmass
Aortic transection: presents as widened mediastinum movements due to multiple rib fx, suspect lung
Intraductal papilloma: presents as bloody nipple
pain and paralysis, but LE nerves intact
pulse oximetry
discharge; Tx galactogram/ductogram-guided
Diffuse axonal injury: head CT shows blurred
Elevated LFTs: indicates liver mets, get abd CT scan
excision (due to small risk of carcinoma)
 contusions and aortic transection; manage by
inserting bilateral chest tubes and serial ABGs
Pulmonary contusions: presents as deteriorating
ABGs and “white out” of lungs on CXR-Tx colloid
(not crystalloid) + diuretics + fluid restriction
Ruptured diaphragm: CXR reveals stomach in left
chest; rapid eval of non-abd injuries → go to OR
Ruptured trachea/bronchi: presents as continuous air
leak into chest tube and subcutaneous emphysema; go
to OR
Air embolus: presents as sudden death in an
intubated/respirator pt; management is immediate
Trendelenburg position + cardiac massage
Fat embolus: presents as RDS and petechiae in
neck/axilla due to bone marrow embolization from long
bone fx; management is respiratory support
––––––––––––– ABDOMINAL TRAUMA –––––––––––
Abdominal GSW: mandatory OR for ex lap for all GSW
below nipple level
Abdominal stab wound: mandatory OR if stab wound
penetrates peritoneum (e.g. protruding viscera,
peritonitis, hemodynamic instability); otherwise,
digital exploration and observation
Abdominal blunt trauma: mandatory OR if signs of
peritonitis or hemodynamic instability despite
transfusion; otherwise, CT scan can be done safely
before proceeding
Trauma × flat/nontender abd: observe if no mechanism,
imaging if mechanism exists
Trauma × severe abd pain: suspect peritoneal
irritation due to blood or intestinal contents, Dx FAST
or CT →indicated for ex lap if positive
Trauma × tire mark across abd: indicates severe
direct trauma, high suspicion of internal injury
Trauma × coma: abd imaging mandatory since
physical exam is impossible on a comatose pt
Trauma × perforated viscera: CXR reveals free air in
abdomen; rapid eval of non-abd injuries → repair
perforated viscera in the OR
Trauma × hypotensive w/o hemorrhage: indicated
for FAST or DPL → exlap inOR if positive; CT scan
inappropriate for unstable pts
Trauma × hypotensive w/ pelvic fx: suspect vascular
injury from branch of internal iliac, Dx FAST, Tx
control by embolization
↓CO/↑CVP: cardiogenic shock (e.g. CHF, MI, tension PTX,
pericardial tamponade)
Dx DPL/FAST: diagnostic peritoneal lavage (DPL) or
––––––––––––––––––– BURNS ––––––––––––––––––
Burn assessment: determine depth of burn, type of burn, and body surface area (%BSA)
burned
First-degree burns: epidermis only, painful
Second-degree burns: extends into dermis, causes pain and blistering, may
develop into third-degree burns w/o proper management
ultrasound (FAST) useful for quick Dx of internal free ––––––––– RETROPERITONEAL TRAUMA ––––––––
fluid → positive DPL/FAST is indicated for ex lap; may
be false negative in retroperitoneal injuries Retroperitoneal zones: central is zone 1, flank is zone
2, pelvis is zone 3
Dx CT scan: useful for stable pts, avoid in unstable or
severely injured pts Surgery indications: all zone 1 hematomas, zone 2 and 3
hematomas only if penetrating trauma
Splenic laceration: ex lap if unstable, preserve spleen if
possible to avoid post-splenectomy sepsis, avoid blood Zone 1 (central hematoma): may involve injury to
transfusion if possible, splenectomy requires vaccination major vascular structure, indicated for ex lap
for SHiN bacteria
Zone 2 (flank hematoma): no exploration warranted
Liver laceration: ex lap if unstable, observe if stable unless penetrating trauma, because peritoneum will
tamponade bleeding
Mesentery injury: difficult to detect on CT so mechanism
must evoke suspicion, co-exists with bowel injury since Zone 3 (pelvic hematoma): no exploration warranted
mesentery is tougher than bowel unless penetrating trauma, because peritoneum will
tamponade bleeding
Renal laceration: stable → angiography and planned
operative repair; unstable → IV pyelo to detect if two
kidneys present, then OR for nephrectomy
––––––––––––– UROLOGIC TRAUMA ––––––––––––
Hematoma in SMA region: suggests major injury to abd
Urologic surgery indications: all GSW, stab wounds, and
aorta, major aortic branches, pancreas, or duodenum;
other penetrating injuries
stable → angiography and assessment before operation,
unstable → urgent ex lap
Urethral injury: presents as blood on meatus, scrotal
hematoma, and “high-riding” prostate-get a retrograde
Pancreatic transection: mandatory ex lap; minor injury →
urethrogram and suprapubic catheter instead of Foley
debride and drain, major injury → resection of devitalized
(may compound injury)
pancreatic tissue and repair of duodenal injury
Bladder injury: associated w/ seatbelt trauma in adults;
Duodenal hematoma: common in kids hitting abd on bicycle
get a retrograde cystogram and post-void films, then
handlebars, hematoma causes GI obstruction; Tx NPO/IVF,
surgical repair
will resolve spontaneously in 5-7 days
Renal injury: associated w/ blunt trauma to back and lower
Blood in ex lap: stop bleeding by packing all four
rib fx; get CT scan, manage non-op if possible
quadrants with gauze packs → attack injuries in order of
severity and attempt hemostasis → inspect remainder of
Scrotal hematoma: manage non-op unless testicle is
abd contents and repair injuries
ruptured (seen on U/S)
Triad of death: acidosis, coagulopathy, hypothermia
Penis fx: associated w/ cowgirl sex; insert a
suprapubic catheter then repair surgically
Hemorrhage × hypothermia: can lead to
coagulopathy due to platelet dysfunction and
PT/PTT prolongation; rewarming indicated
–––––––––––––––– LIMB TRAUMA –––––––––––––––
Hemorrhage × low platelets: loss of platelets due to
hemorrhage puts pt at risk for coagulopathy; platelet Penetrating limb trauma: no vascular injury →give
transfusion indicated tetanus PPx and clean wound; vascular injury present →
arteriogram if stable, OR if unstable
Hemorrhage × metabolic acidosis: results from
decreased tissue perfusion causing lactic acidosis; Combined limb trauma: order of repair is bone first, then
crystalloid infusion indicated Hemorrhage × abd vascular repair, nerve last; fasciotomy required to prevent
distention: bleeding into abd cavity can lead to abd compartment syndrome
compartment syndrome, which can cause decreased
renal blood flow (oliguria) and dyspnea (elevated Limb GSW: may require extensive debridements and
diaphragm) amputation if unsalvageable
↓CO/↓CVP: hypovolemic shock, neurogenic shock Crushing limb trauma: high risk of myoglobinuria leading
(e.g. spinal cord trauma, anaphylaxis) to acute renal failure; Tx IV fluids + mannitol
+ acetazolamide to maintain a high urine output
Third-degree burns: full thickness, painless
Burn management: tetanus PPx, IV pain meds, topical agents (silver sulfadiazine is default,
mafenide acetate for deep penetration, triple abx ointment for the eyes)
Rule of 9’s: estimates %BSA burned; head and upper extremities are 9% each; anterior trunk,
posterior trunk, and lower extremities are 18% each; and perineum is the last 1%
Parkland formula: estimates fluid replacement in burn victims, LR volume = %BSA × kg ×
 4mL/kg; give 50%LR in first 8 hours, 50%LR in next 16 hours
Fluid for infants: 20 mL/kg if BSA>20%
Chemical burns: alkaline burns are worse than acids
Chemical burn management: massive tap water irrigation, don’t try acid-base
neutralization, except in ingestion – orange juice for alkali, milk for acids
Black widow spiders: present w/ severe muscle cramps, acute abdomen, and
nausea/vomiting; give IV calcium gluconate + muscle relaxants
Brown recluse spiders: present as an ulcerated lesion; excise ulcer and skin graft
Human bites: requires extensive irrigation and debridement due to high amounts of
bacteria

Electrical burns: may appear benign on surface, but masks large amounts of interior
––––––––––––––––– NUTRITION ––––––––––––––––
damage to muscles, nerves, and vessels; at risk of cardiac injury (arrhythmias) and muscle
injury (myoglobinuria)
TPN: indicated for nutrition when gut is nonfunctional or not availble, requires
personalization of formula for nutrition status
Electrical burn management: IV fluids + mannitol
+ acetazolamide to maintain a high urine output
TPN × fever: examine catheter site for infection, obtain cultures from catheter site and
blood; if –bacteria → change catheter site, if +bacteria
Inhalation burns: suspected with carbonaceous sputum, facial burns, singed
→ change catheter site and start antibiotics
facial/nasal hairs, hoarseness, etc. due to smoke inhalation
TPN × metabolic coma: hyperglycemic, hyperosmolar, nonketotic coma is commonly due
Inhalation burn management: confirm w/ fiberoptic bronchoscopy and order serial
to excessive osmolar diuresis in hyperglycemia
ABGs; high COHb levels → Tx 100% O2
TPN × elevated LFTs: very common (up to 30%), TPN can cause fatty liver, structural liver
Circumferential burns: rapidly become thick and contracted, causing restricted
damage, and even cirrhosis with prolonged TPN
ventilation in the chest and ischemia in extremities; Tx escharotomy
TPN × dry/scaly skin: indicates free fatty acid deficiency, Tx FFA administration
Scalding burns in kids: consider child abuse
Nitrogen in TPN: positive nitrogen balance is the goal, since negative nitrogen balance
Burns × methemoglobinemia: Sx chocolate-brown blood, central cyanosis of trunk,
indicates a catabolic state; severity of injury correlates with a higher amino acid
arrhythmias, seizures, coma; Dx ABGs (pulse ox is unreliable), Tx IV methylene blue
requirement

BEE: basal energy expenditure, equal to (body weight × 25 kcal/kg/day)

––––––––––––––– BITES & STINGS ––––––––––––––
Nondepleted pts: 1.2× BEE calories needed; good nutritional status before surgery
Bite management: all require tetanus PPx
Depleted pts: 1.2-1.5× BEE calories needed; malnourished before surgery
Dog bites: rabies PPx only required if bite was unprovoked and dog isn’t available for
brain Bx Snake bites. don’t always result in envenomation; if signs of venom evident Hypermetabolic pts: 1.5-2× BEE calories needed; severely stressed catabolic state due
(pain, swelling, discoloration) then draw blood for labs and Tx anti-venin to trauma, burns, sepsis, cancer, etc.

Bee stings: may present as anaphylactic shock (“warm and pink”) secondary to allergic Macronutrients: carbs (4 kcal/gm), protein (4 kcal/gm), fat (9 kcal/gm), etoh (7 kcal/gm)
response; Tx stinger removal and epinephrine

Spider bites: black widows have neurotoxins, brown recluses have necrotoxins
––––––––––––– PEDIATRIC SURGERY ––––––––––––
VACTERL syndrome: vertebral, anal atresia, cardiac, TE
fistula, esophageal atresia, renal, limbs (radius);
presence of any of these requires checking for the
others
Esophageal atresia: presents as excess salivation,
choking spells, coiling NG tube, and often a TE fistula;
Tx surgical repair (if delay is necessary, gastrostomy)
Anal atresia: high rectal pouch → colostomy then
delayed repair, low rectal pouch → repair, if anofistula
present → delay repair since further growth may
correct condition
Congenital diaphragmatic hernia: presents as RDS due
to hypoplastic left lung; Dx CXR shows bowel in left
chest, Tx intubation w/ low-pressure ventilation
Gastroschisis: midline hernia to left of umbilical cord
tearing through peritoneum; Tx closure if small, silo if
large, and TPN for a month since GI doesn’t work
Omphalocele: midline hernia through the cord with
peritoneal covering; Tx closure if small, silo if large
Biliary vomiting: indicates SBO distal to ampulla of Vater;
DDx duodenal atresia, intestinal atresia annular
pancreas, or malrotation
Malrotation: presents as biliary vomiting and double-
bubble on X-ray; Dx contrast enema or upper GI study,
Tx emergency surgical correction
Intestinal atresia: presents as biliary vomiting and
multiple air-fluid levels on X-ray, aka apple-peel atresia
due to vascular accident in utero
Necrotizing enterocolitis: presents as feeding intolerance,
abd distention, and ↓platelets in premies; Tx NPO, IVF,
TPN, IV abx → surgical repair if signs of intestinal
necrosis/perforation present
Pyloric stenosis: presents as non-bilious projectile
vomiting in first-born boys; Dx palpable epigastric olive,
Tx rehydration and pyloromyotomy
Biliary atresia: presents as progressive jaundice in a 1-2
month old due to lack of CBD; Dx HIDA scan +
phenobarbital (to stimulate GB contraction), Tx liver
transplant
Hirschsprung’s disease: presents as chronic constipation
due to lack of nerves in distal colon, rectal exam can
decompress bowel; Dx X-ray shows distended proximal
colon, Tx surgical pull-through
Intussusception: presents as colicky abd pain that lasts 1
minute then resolves, and currant jelly stools; Dx/Tx barium
or air enema (surgery if it doesn’t work)
Child abuse: presents as retinal hemorrhages, SDH,
multiple healed fx, and scalding burns; call child
protective services
Meckel’s diverticulum: presents as LGIB in a child, Dx
technetium uptake for ectopic gastric mucosa Vascular
rings: presents as stridor, RDS, crowing respiration, and
dysphagia in an infant due to compression of trachea
and esophagus; Dx barium swallow and bronchoscopy,
Tx surgical correction
Cardiac anomalies: all require prophylactic anti-
biotics for subacute bacterial endocarditis
L→R shunts: all present with murmurs and late-
onset cyanosis due to Eisenmenger syndrome
(pulmonary HTN reversing direction of shunt)
ASD: presents as low-grade systolic murmur, fixed S2,
and frequent colds; Dx echo, Tx surgery
VSD: presents as pansystolic harsh-sounding murmur
with failure to thrive; Dx echo, Tx surgery
PDA: presents with machinery-like murmur, often seen
with congenital rubella syndrome; Dx echo, Tx
indomethacin or surgery
R→L shunts: all present with murmurs and early- common in Turner syndrome, get CT scan to find
onset cyanosis extent of mass before surgical removal

Tetralogy of Fallot: presents as cyanosis and clubbing
in a 5 y/o child who squats for relief; Px determined by
degree of pulmonary stenosis, Dx echo shows RVH,
Tx surgery
Transposition of great vessels: presents as life-
threatening cyanosis in a newborn; Dx echo, Tx
surgery
LN DDx: cancers are large (>2 cm), painless, fixed,
insidious onset, unusual site; infectious LN are small (<2
cm), painful, rapid onset, mobile, normal site
Lymphomas: presents with multiple swollen LN, fever,
and night sweats; get excisional biopsy, then Tx chemo
Supraclavicular metastases: MC primary sites are
pancreas and stomach; get excisional biopsy for Dx

Head/neck SCC: presents as persistent hoarseness, painless

–––––––––––––– OPHTHALMOLOGY –––––––––––––
ulcer in floor of mouth, or unilateral earache; risk factors
are EtOH, smoking, and AIDS
Strabismus: misaligned eyes due to uncoordinated
extraocular muscles; Tx surgical extraocular muscle
SCC management: get triple endoscopy to look for
manipulation to prevent ambylopia
primary tumor → biopsy tumor → CT scan to
determine stage; Tx resection, radical neck dissection,
Amblyopia: vision impairment usually due to
cisplatin-based chemo
strabismus in kids, Tx eyepatch the good eye to
develop the impaired one
Acoustic neuroma: presents as unilateral deafness due to
Schwann cell proliferation on CN VIII, get MRI
Retinoblastoma: presents as a leukocoria in a baby, Tx
surgical enucleation (remove the eye)
Facial nerve tumor: presents as gradual-onset
unilateral facial paralysis (sudden-onset is Bell’s
Narrow-angle glaucoma: presents as severe eye pain,
palsy), get MRI
headache, “seeing halos around lights”, eye feels as hard
as a rock; Tx iridotomy (give pilocarpine, acetazolamide, or
Parotid tumors: present as masses around angle of
mannitol as first aid)
mandible, two types – pleomorphic adenomas (benign,
painless) and mucoepidermoid carcinomas (malignant,
Orbital cellulitis: presents as cellulitis of eyelids w/
painful)
fixed/dilated pupil and limited eye ROM; get CT scan then
drain the pus
Parotid tumor management: get FNA or formal
superficial parotidectomy (open biopsy contra-
Chemical burns of eye: irrigate w/ plain water ASAP, at
indicated due to CN VII)
hospital – irrigate w/ saline, remove corrosive particles,
and test pH before sending home; alkaline burns are
Foreign bodies: any toddler w/ unilateral ENT sx
worse than acid burns
(earache, rhinorrhea, wheezing) has a toy stuck in
there; do endoscopy under anesthesia to remove
Retinal detachment: presents as flashes and floaters, and a
dark curtain being pulled down over the eye;
Ludwig angina: abscess in floor of mouth due to
Tx emergency laser “spot welding”
tooth infection, Tx I&D and tracheostomy Bell’s palsy:
sudden CN VII paralysis for no evident reason, Tx
Amaurosis fugax: emboli from carotid travels to retina
antivirals immediately
causing transient blindness; Dx fundoscopic exam
reveals Hollenhorst plaque, a bright shiny spot in a retinal
artery Embolic occlusion of retinal artery: presents as
sudden unilateral loss of vision; Tx breathe into paper
bag and repeatedly press on eye to shake clot into a
more distal branch of retinal artery

––––––––––––– OTOLARYNGOLOGY ––––––––––––

Neck masses: three types – congenital, inflammatory,

neoplastic; differentiate via onset and resolution

Congenital neck masses: thyroglossal duct cyst

(midline), branchial cleft cyst (lateral), cystic
hygroma (base of neck)

Thyroglossal duct cyst: remnant of thyroglossal duct

as a mobile midline neck mass, Dx at 1-2 yo due to
neck fat, Tx Sistrunk operation (take out cyst, trunk,
and medial portion of hyoid bone)

Branchial cleft cyst: lateral mass at anterior edge of

SCM, may have a small opening and blind tract

Cystic hygroma: dilated lymphatic duct at base of neck,

CN VII trauma: sudden CN VII paralysis following facial
trauma, will resolve spontaneously
Cavernous sinus thrombosis: presents as diplopia in a pt
w/ sinusitis due to nerve (CN III/IV/VI) injury, Tx antibiotics,
CT scan, and drainage of abscess
Epistaxis: nosebleed has different causes and
management depending on pt’s age
Epistaxis × children: due to nosepicking, Tx local
pressure and phenylephrine nasal spray
Epistaxis × teens: either cocaine abuse and septal
perforation (requires packing) or juvenile
nasopharyngeal angiofibroma (surgical resection)
Epistaxis × elderly: due to HTN; requires packing, BP
control, and often surgical ligation of vessels
Vertigo: dizziness can be attributed to diseases of inner
ear or brain itself
Vertigo × inner ear: “room is spinning”, Tx
meclizine, phenergan, or diazepam
Vertigo × brain: “room is stable, but patient is
spinning”, do a neurologic work-up
––––––––––––––– NEUROSURGERY ––––––––––––––
CNS diseases: vascular (sudden onset), metabolic
(hours), infectious (days-weeks), tumors (months),
degenerative disease (years)
Vascular CNS diseases: TIA, ischemic stroke,
hemorrhagic stroke, subarachnoid hemorrhage
TIA: brief neurologic deficit that fully resolves within
24 hours; due to thromboembolus from internal
carotid arteries
TIA management: carotid duplex, then aspirin and
elective CEA (if >70% stenosis)
Ischemic stroke: a neurologic deficit that doesn’t
resolve within 24 hours due to thromboembolus from
internal carotid arteries, Tx t-PA within 3 hours,
otherwise observe and rehab
Hemorrhagic stroke: severe headache and
neurologic deficit that doesn’t resolve within 24
hours in uncontrolled HTN; Dx CT scan, Tx rehab and
control of HTN
SAH: “worst headache of my life” due to rupture
of Charcot-Bouchard aneurysm in lenticulostriate
arteries; Dx CT scan to confirm SAH, then arteriogram
to locate aneurysm, then surgical clipping
CNS abscess: presents as space-occupying lesions but
short-onset (weeks) and w/ nearby infections (otitis
media, mastoiditis); get CT scan then resect
CNS tumors: presents as space-occupying lesions and
progressive headache over months; get MRI then
resect (give mannitol, hyperventilate, and high-dose
steroids while waiting)
Frontal lobe tumors: present as disinhibition,
anosmia (CN I), ipsilateral blindness (CN II), and
contralateral papilledema
Craniopharyngioma: presents as GH deficit and
bitemporal hemianopsia ◐◑ in a kid, Dx calcified
lesion in sella turcica
Prolactinoma: presents as amenorrhea and
galactorrhea in a young woman, consider possibility
of MEN1 syndrome, Tx bromocriptine
Acromegaly: presents as huge hands, feet, tongue, and
jaws in a tall man due to ↑GH; Dx get somatomedin C
levels and MRI, then resection
Nelson syndrome: presents as bitemporal
hemianopsia ◐◑ and hyperpigmentation in an adult
due to pituitary microadenomas that grew to full size;
Dx MRI then Tx surgical resection
Pituitary apoplexy: presents with typical pituitary
adenoma sx, then sudden onset headache and CNS sx
due to bleeding into tumor; Dx MRI then emergent
steroid replacement
Pinealoma: presents as loss of upper gaze and
“sunset eyes” due to compression of vertical
gaze center in superior colliculi
Brain tumors in kids: present as cerebellar sx and
headaches relieved by knee-chest position, due to
posterior fossa lesions; Dx MRI, Tx resection
Spinal cord tumors: present as back pain in
someone who’s been treated for other cancers
(spine is a common site of mets); Dx MRI, Tx neuro-
surgical decompression
Neurogenic claudication: presents with pain on exertion
and relief with rest, but pain is position-dependent and
pulses are intact; Dx MRI, Tx neurosurgical decompression
Trigeminal neuralgia: severe facial pain lasting 60
seconds; Dx MRI to r/o organic cause, then Tx anti-
convulsants (radiofrequency ablation as backup)
Reflex sympathetic dystrophy: presents as severe pain
months after a crush injury w/ sympathetic overload
(cold, cyanotic, moist); Dx sympathetic block, Tx surgical
sympathectomy
–––––––––––––––––– UROLOGY –––––––––––––––––
Testicular torsion: presents as severe testicular pain
and “high riding testicle with horizontal lie” due to
twisting of the cord; Tx emergent surgical detorsion, then
orchiopexy (do not do any Dx tests)
Epididymitis: presents like testicular torsion but w/ fever,
pyuria, and cord is also tender; Dx U/S to rule out torsion,
then Tx antibiotics
Obstructive UTI: presents as sepsis (fever, chills, flank
pain) in someone passing a kidney stone; surgical
emergency that requires immediate decompression
(stent or perc nephrostomy) in addition to IV
antibiotics
Lower UTI: presents as dysuria and cloudy, stinky urine
but no fever, chills, or flank pain; common in young
women, give antibiotics
Pyelonephritis: UTI that has ascended to the kidneys,
presents with fever, chills, flank pain; Dx urologic work-up
and Tx antibiotics
Prostatitis: presents as fever, chills, dysuria, back pain,
and tender prostate on rectal exam; give antibiotics and
don’t do any more rectal exams
Urologic workup in kids: indicated for traumatic
hematuria and UTIs, since it may indicate congenital
abnormalities otherwise undiagnosed
Congenital malformations: posterior urethral valves,
hypospadias, epispadias, vesicoureteral reflex, low
implantation of ureter, ureteropelvic obstruction
Posterior urethral valves: presents as anuria in a
newborn boy; cathereterize to empty bladder, then
Dx voiding cystourethrogram, Tx resection
Hypospadias: presents as urethral opening on
ventral side of penis, never circumcise since prepuce
is needed for surgical correction
Epispadias: urethral opening on dorsal penis
VUR: presents as dysuria, fever, chills, and flank pain in
kids due to ascending UTI; give antibiotics and Dx IV
pyelo and voiding cystogram to look for reflux, long-
term abx until child “grows out of it”
Low implantation of ureter: asymptomatic in
boys, “wet with urine all the time” in girls b/c
ureter drips into vagina instead of bladder; Dx
physical exam or IV pyelo, Tx surgical correction
Ureteropelvic obstruction: usually asymptomatic, but
presents with colicky pain with large diuresis
(e;g; colicky pain following “beer drinking binge”)
Hematuria: always get IV pyelo (CT scan if allergic or poor
renal function) and cystoscopy to r/o cancers
Urologic cancers: renal cell carcinoma, transitional cell
carcinoma, prostatic cancer, testicular cancer
RCC: presents as hematuria, flank mass/pain, and
paraneoplastic syndromes (PAPER – PTHrP, ACTH,
prolactin, EPO, renin); get CT scan if suspected, Tx
surgical resection
Bladder TCC: presents as painless hematuria in
smokers; get IV pyelo and cystoscopy, then Tx
surgical resection, then lifelong f/u for high-rate of
local recurrence
Prostatic cancer: asymptomatic, detected as rock-hard
nodule on rectal exam; get U/S-guided needle biopsy, then
TURP or radiation therapy (Tx flutamide and leuprolide if
metastatic)
Testicular cancer: presents as painless testicular mass that doesn’t transilluminate; get radical orchiectomy w/ biopsy, then f/u αFP or βHCG for recurrence (Tx cisplatin or radiation if
metastatic)
BPH: presents as dribbing, nocturia, and difficulty voiding in an old man; put in Foley for 3 days, and Tx α-blockers (tamsuosin), 5αR-blockers (finasteride) +/-surgical prostate resection

Post-op urine retention: presents as a need to void, but inability to do so; Tx straight cath at 6 hours post-op and Foley after 2 nd straight cath

Stress incontinence: presents as urine leaking w/ abd pressure due to weakened pelvic floor in a multigravid woman; Tx surgical repair of pelvic floor

Kidney stones: presents as colicky flank pain and hematuria +/-radiation to inner thigh, Dx plain X-rays; Tx analgesics, fluids, and observation (<3 mm) or shockwave lithotripsy (>3 mm)

Impotence: two types – organic and psychogenic, management depends based on etiology

Psychogenic impotence: sudden onset w/o traumatic cause, specific to partner or situation; Tx psychotherapy

Organic impotence: sudden onset (trauma) or gradual onset (atherosclerosis, diabetes); first-line Tx is PDE5-blockers (sildenafil, Viagra)

–––––––––––– TRANSPLANT SURGERY –––––––––––

Transplant donors: almost everyone including brain-dead pts, Hep and HIV pts to each other, metastatic cancer pts for corneas

Transplant rejection: hyperacute (minutes), acute (days/months), chronic (years)

Hyperacute rejection: preformed ab’s against donor

organ causes vascular thrombosis within minutes; never seen since type-and-cross prevents this from happening

Acute rejection: HLA mismatch causes macrophage attack on donor tissue with lymphocytic infiltrate, confirmed by biopsy

Liver rejection: indicated by elevated LFTs, first step is to get U/S and Doppler to rule out biliary obstruction and vascular thrombosis

Heart rejection: indicated by progressive heart failure; management is getting routine ventricular biopsies and Tx steroid bolus + OKT3

Chronic rejection: gradual deterioration of organ function due to polymorphisms, irreversible and no Tx available

–––––––––––– PEDIATRIC DISEASES ––––––––––––

Congenital hip dysplasia: presents as uneven gluteal folds, Osteosarcoma: presents as low-grade knee pain in a 10-25 dislocation, following direct trauma to ulna
posterior dislocating hips (with “snapping”) in a newborn; Dx y/o, X-ray shows Codman’s triangle and sunburst appearance;
U/S since hip isn’t calcified for X-ray, Tx splinting
consult a specialist Galeazzi fx: diaphyseal fx of distal radius +
Avascular necrosis of femoral head: presents in a kid w/
ulnar dislocation, following direct trauma to
limping, hip pain, and limited hip ROM; Dx X-ray, Tx cast +
Ewing sarcoma: presents as low-grade epiphyseal pain in a radius
crutches
child, X-ray shows onion skinning, due to t(11;22); consult a
specialist Scaphoid fx: presents as wrist pain and
Hip dislocation: presents as a chubby kid limping due to
tender anatomic snuffbox in a young person
groin pain, hip has limited internal rotation; Dx X-ray, Tx pin
Metastatic bone cancers: usually from breast (lytic) and falling on outstretched hand; Tx thumb spica
femoral head back in place
prostate (blastic), causing bone pain and pathologic fx; Dx cast
bone scan, Tx chemoradiation
Septic hip: presents in toddlers who refuse to move hip
Metacarpal neck fx: presents as swollen and
following a septic illness; Dx hip aspiration unter anesthesia,
Multiple myeloma: plasma B-cell tumor results in CRAB – tender hand after punching a wall; Tx splint or
Tx perc drain
hyperCalcemia, Renal failure, Anemia, and Bone pain (X- plate
ray shows punched-out lesions); Dx urinary Bence-Jones
Osteomyelitis: presents in kids w/ severe localized bone
protein, Tx chemotherapy Hip fx: presents as shortened and externally
pain following a septic illness; Dx bone scan since X-ray will
rotated hip in an osteoporotic woman; Tx depends
be false negative, Tx antibiotics
on location of fx

Genu varum: aka bowlegs, <3 y/o observe since it’s normal,
>3 y/o surgical correction
Genu valgus: aka knock-knee, observation okay
Osgood-Schlatter disease: presents in teens w/ persistent
pain over tibial tubercle, aggravated by quad contraction;
Tx immobilization in cast
Club foot: presents as bilateral inverted feet in a
newborn; Tx serial plaster casts on adducted forefoot
→hindfoot varus → equinus
Scoliosis: laterally curved spine, common in teenage girls; Tx
spine brace until mature, surgery if severe
––––––––––––––– BONE TUMORS –––––––––––––––
–––––––––––– ORTHOPEDIC TRAUMA ––––––––––––
Femoral neck fx: may lead to avascular necrosis
of femoral head; Tx prosthetic replacement of
Fractures: all require 2 X-rays (90° from each other)
head
including joints above and below fractured bone;
anticoagulation of choice is fondaparinux + leg
Intertrochanteric fx: less likely to cause
compression devices
avascular necrosis; Tx ORIF
Clavicular fx: typically between mid-to-distal third of clavicle;
Femoral shaft fx: Tx intramedullary rod fixation,
Tx figure-of-eight device for 4-6 weeks Anterior shoulder
high risk of hypovolemic shock and fat
dislocation: presents w/ outward rotated arm + deltoid
embolisms
numbness due to axillary palsy
Knee injury: all severe knee injuries present w/
Posterior shoulder dislocation: rare, presents w/
swelling, and first step in management is an
internally rotated arm held close to body
MRI
Colles fx: distal radial fx in osteoporotic women falling
Unhappy triad: injury to ACL, MCL, and medial
on outstretched hand; Tx reduction + cast
meniscus following blow to lateral leg; Tx surgical
repair
Monteggia fx: diaphyseal fx of proximal ulna + radial
––––––– MENTAL STATUS EXAMINATION –––––––
Word salad: incoherent collection of words
Memory: controlled by temporal lobes; three

ACL tear: presents as swelling, pain, and positive Leg fx: common in pedestrian vs. car accidents; Tx cast Pain under cast: remove cast to examine Open fx:
anterior drawer sign; Dx MRI, Tx immobilization for easily reduced fx, intramedullary nailing otherwise, require cleaning and reduction within 6 hours to
main types – immediate, short-term (recent),
and rehab objective description of pt
Appearance: high risk of compartment syndrome prevent ischemia of distal limb
Clang associations: rhyming and punning (think
long-term
Meniscal(remote)
tear: presents as pain, swelling, and Achilles tendon rupture: presents as “popping noise” in ankle Gas gangrene: presents as tender, swollen, discolored
“clicking” of knee w/ forceful extension; Tx following exertion w/ pain and swelling; Tx cast or surgery wound site w/ crepitus following a penetrating injury;
Tx high-dose penicillin G, hyperbaric oxygen, and
hip-hop)
arthroscopic repair to salvage meniscus debridement
Ankle fx: common after falling on inverted or
Tibial stress fx:
Appearance presents as
buzzwords: localized
pupil size =tibial
drug pain
abusein a soldier everted foot; Tx ORIF
following a long march; Tx cast and f/u X-ray in 2 weeks
––––––––– ORTHOPEDIC EMERGENCIES –––––––––
Fund of knowledge: ask pt about simple facts
–––––––––––––––– PSYCHOSIS ––––––––––––––––
or withdrawal, bruises = abuse, needle
Psychosis: distortedabrupt
Thought blocking: perception of reality
cessation presenting as delusions, hallucinations, or severely disorganized thought/behavior
of speech
(e;g; “who is the current president?”)
marks/tracks = drug
Psychosis in abuse,
elderly: eroding
evaluate forenamel = w/ EEG
delirium
before idea is finished
Psychosis-exacerbating drugs:β-blockers,
bulimia, superficial
digoxin, steroids,cuts on arms = self-harm
anticholinergics

Concentration:
Delusion: ask ptbelief;
fixed, false to “spell
twoWORLD
types – forwards
bizarre (impossible) and nonbizarre (could be true)

Paranoid/persecution
Tangentiality: never gets delusion: irrational
to goal, keeps belief that one is being persecuted (e.g. CIA phone-tap)
breaking
and backwards” or do serial 7 test
Activity:
Delusionamount/type of motor
of reference: beliefmovement
that cues in
offexternal
on a tangent
environment are directed at individual

Delusion of control: thought insertion, thought withdrawal, and thought broadcasting are unique to SCZ

Delusion of grandeur: belief that one has

Abstraction:
superpowers,ask or
pt inflated
to interpret a proverb, and
self-esteem
Psychomotor agitation: excess, non-productive
Circumstantiality: overinclusion of trivial or
explain similarities
Delusion of guilt:between objects;
false belief thatlack
oneof
is
motor activity in
responsible orresponse
guilty fortosomething
inner tension
irrelevant details
abstraction →concrete thinking
Somatic delusion:
Psychomotor false belief
retardation: visiblethat one isof
slowing
infected or has
Perseveration: a certain
inability illness the topic, or
to change
Insight: pt’s awareness and understanding of his/her
thoughts,misinterpretation
Illusion: speech, movement of sensory stimulus
giving the same response to different questions
own problem
Hallucination: sensory
Tics: involuntary, perception
spasmodic motorw/o stimulus
movement
Thought content: what the pt thinks
Judgment:
Auditory pt’s ability to understand
hallucination: most common the outcome of
in schizophrenia, command hallucinations are specific AH that tell pt to do things

Visual hallucination: drug intoxication, drug/alcohol withdrawal, delirium, Lewy body dementia

his/her actions
Tactile hallucination:
Akathisia: cocaine
subjective feeling or amphetamine
of muscular tension
Poverty of thought
intoxication, vs. overabundance:
alcohol withdrawal too few

Olfactory
resulting hallucination:
in restlessness, seizure
pacing, disorder,
repeated must
sitting
or r/o
toomedical
many ideas expressed
conditions
–––––––––––––––– DIAGNOSIS ––––––––––––––––
and standing hallucination: r/o medical conditions SCZ phases: prodromal phase (prepsychotic decline in functioning), psychotic phase, residual phase (negative sx b/t episodes of
Gustatory
psychosis)

Delusions: fixed, false beliefs

DSM-IV: axis I – mental illnesses, axis II –personality
Stereotypic movements:
Schizophrenia repetitive, disorganized,
subtypes: paranoid, fixed pattern catatonic, residual, undifferentiated

d/oPSCZ: characterized
and mental by delusions
retardation, and AH/CH, deafness is a risk factor
axis III – medical
of physical action or speech (e.g. head banging)
Suicidal/homicidal ideation:
DSCZ: characterized thoughts about
by disorganized speech, behavior, and flat or inappropriate affect
conditions, axis IV – psychosocial stressors, axis V –

CSCZ: characterized by rigid posture, inappropriate or repetitive movements, echolalia/echopraxia, and waxy flexibility
wanting to kill self or others; assess by directly
global assessment of function (scale 0-100)
RSCZ: prominent negative sx (5 As – Anhedonia, flat Affect, Alogia, Avolition, poor Attention)
Tardive dyskinesia: involuntary choreoathetoid
asking about suicide, not just “do you want to
USCZ: doesn’t fulfill criteria for any other subtype
movements of head/limbs/trunk, due to
SCZ
hurtgender: men = women but men have earlier onset (20 y/o) than women (30 y/o), winter/early spring birthdays have ↑incidence (due to ↓sunlight →↓vit D)
yourself?”
! ≤30: criteria for hospitalization
prolonged use of antipsychotics

Phobias: persistent, irrational fears

Intelligence quotient: [IQ = 100 × (mental age /
SCZ prevalence: 1% overall, 10% siblings, 50% twins

Postpsychotic depression: major depressive episode after resolution of psychotic symptoms

Downward drift: ↑SCZ prevalence in lower socio

economic groups (can’t hold onto good jobs)

SCZ pathophysiology: ↑dopamine in mesolimbic pathway (positive sx), ↓dopamine in prefrontal ctx (negative sx); also ↑5-HT, ↑NE, ↓GABA, ↓glutamate

SCZ brain: diffuse cortical atrophy w/ enlarged ventricles

SCZ Px: good prognosis w/ later onset, good social support, positive sx, mood sx, acute onset, females,
↓relapses, and good premorbid function; 10% suicide

SCZ Tx: atypicals first-line, typicals second-line,

clozapine if other antipsychotics don’t work

Antipsychotic side-effects: EPS (parkinsonism, akathisia, dystonia), NMS, tardive dyskinesia, anti-HAM, metabolic syndrome, ↑prolactin, etc.

SCZ × bad family: increased relapse rate

–––––––– OTHER PSYCHOTIC DISORDERS ––––––––

SAD vs. mood disorders: SAD has 2 week period of psychotic sx w/o mood sx; worse Px than mood d/o

Paranoid/persecution delusions: irrational belief that one is being persecuted (e.g. CIA phone-tap)

Erotomaniac delusions: delusions regarding love

Jealous delusions: aka Othello syndrome,

delusions of unfaithfulness

Somatic delusion: false belief that one is infected or has a certain illness (e.g. parasitosis)

Delusional disorder Tx: psychotherapy (drugs ineffective)

–––––––––––––– SCHIZOPHRENIA –––––––––––––– related psychoses that are part of the personality d/o and not brief psychotic d/o
 –––––––––––––––––– MOOD ––––––––––––––––––

Mood: inner emotional state

Mood episode: distinct period of abnormal mood; includes major depressive, manic, hypomanic, and mixed episodes

Mood disorder: loss of control over mood and subsequent functional impairment; includes MDD, bipolar I/II, dysthymic, and cyclothymic disorders

–––––––––––––– MOOD EPISODES ––––––––––––––

Major depressive episode: 5/9 SIGECAPS (including depressed mood or anhedonia) for 2 weeks – depressed mood, Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor
activity, Suicidal ideation

Manic episode: 3/7 DIGFAST (4/7 if irritable mood) for 1 week – Distractibility, Insomnia, Grandiosity, FOI,
↑Activity, Speech pressured, Thoughtlessness

Hypomanic episode: 3/7 DIGFAST (4/7 if irritable mood) for 4+ days, no functional impairment or psychotic features (vs. manic episodes)

Mixed episode: 5/9 SIGECAPS + 3/7 DIGFAST for every day of 1 week

––––––––––––– MOOD DISORDERS –––––––––––––

MDD prevalence: 16.2% (25-50% in elderly)

MDD risk factors: stroke (30-50%, lasts 2 years), pancreatic cancer, loss of parent before age 11, genetics (70% in twins)

MDD × sleep: difficulty falling asleep, multiple awakenings, and early morning awakenings; hypersomnia characteristic of atypical depression

MDD etiology: monoamine hypothesis is most popular (↓5-HT/DA/NE), other causes include
↑cortisol, ↓thyroid, psychosocial and genetics

MDD brain: reduced frontal lobe blood flow and metabolism

MDD Px: 15% suicide, 30-40% alcoholism, only 50% receive Tx, 50-85% have another episode

MDD Dx: Beck depression inventory

MDD Tx: antidepressants ± psychotherapy; acute risk → hospitalization, elderly → use lower dose, unresponsive to drugs → add lithium or try ECT Antidepressants: all equally effective
and take 4-8 weeks for effect, SSRI/SNRI are first-line, maintain for 6-9 months

MDD in kids: presents as irritability and short temper, rather than sadness or depression

MDD in elderly: MC psychiatric disorder in elderly,

↑incidence s/p MI, stroke, and new admits to nursing homes

MDD subtypes: melancholic, atypical, catatonic, psychotic, postpartum, seasonal affective disorder

Melancholic depression: characterized by anhedonia, excess guilt, anorexia, early morning awakenings, and psychomotor disturbance

Atypical depression: characterized by hypersomnia, hyperphagia, reactive mood, leaden paralysis, hypersensitivity to rejection; Tx MAOIs

Catatonic depression: rare, characterized by catalepsy, purposeless movements, bizarre postures, and echolalia; Tx ECT

Psychotic depression: MDD + delusions or

hallucinations; Tx SSRI + antipsychotic

Postpartum major depression: onset within 4

weeks of delivery, resolves w/o meds
 DtD Tx: antidepressants ± CBT

DtD × psychosis: dysthymia can never have psychotic features, consider another diagnosis

Double depression: major depressive disorder + dysthymic disorder during residual periods

Kübler-Ross stages of grief: denial, anger, bargaining, depression, acceptance

Grief vs. depression: grief lasts <2 months and has illusions but no delusions, hallucinations, or SI

BI Tx: mood stabilizers (lithium ↓ suicidality, carbamazepine for rapid cyclers, valproate for kids <12); pregnant mania → atypicals, h/o postpartum mania → lithium PPx but c/i to
breastfeeding

BI × antidepressants: will flip into manic mode BII Tx: mood stabilizers (see BI)

Rapid cycling Tx: carbamazepine

CtD Tx: mood stabilizers (see BI)

Minor depressive disorder: 2-4/9 SIGECAPS w/ functional impairment, euthymic periods also seen (vs. dysthymic disorder), 20% progress to MDD

Suicide risk factors: SAD PERSONS – Sex (male), Age (<19 or >45), Depression, Previous attempt, EtOH or drugs, Rational thinking loss, Sickness, Organized plan, No spouse, Social support
loss

#1 suicide risk factor: previous attempt

–––––––––––––––––– ANXIETY –––––––––––––––––– Specific phobia Tx: CBT + desensitization is first-
line, BDZs and β-blockers help w/ autonomic sx Anxiety: subjective experience of fear and its sympathetic response (e.g.
↑HR, ↑BP, SOB, etc.)

Pathological anxiety: inappropriate to situation and interferes w/ daily functioning

Anxiety NTs: ↑NE, ↓GABA/5-HT

–––––––––––– ANXIETY DISORDERS ––––––––––––

Anxiety disorders: panic disorder, agoraphobia, specific and social phobias, OCD, PTSD, ASD, GAD, anxiety 2/2 GMC or substance use

Anxiety d/o prevalence: 30% women > 19% men, more frequent in higher socioeconomic groups

Panic attack: peak in 10 min and last <25 min; 4 of the following PANICS – Palpitations, Abdominal distress, Numbness/nausea, Intense fear of death, Choking/chills/chest pain,
Sweating/shaking/SOB

PA risk factors: mitral valve Prolapse, Pulmonary embolus, Asthma, Angina, Anaphylaxis

PA management: order labs (TSH, metanephrine, B12, etc.) to r/o medical and substance causes

PD etiology: dysregulation of autonomic nervous system w/ NT imbalance (↑NE, ↓GABA/5-HT)

PD Tx: high-dose SSRI for 8-12 months + CBT, short-term BDZs for immediate relief of attacks

Common agoraphobias: bridges, crowds, buses, trains, open areas outside the home

Common specific phobias: animals, blood or needles, death, flying, heights, illness or injury

Specific phobia epidemiology: most common mental disorder in the US, women > men Common social phobias: public speaking, eating out, using public restrooms

Social phobia vs. shyness: shyness + impairment of daily function = social phobia

Social phobia Tx: SSRI (paroxetine) + CBT is first-line, BDZs and β-blockers help w/ performance anxiety

Obsession: intrusive, repetitive thought

Compulsion: ritualistic behavior

Obsessions of contamination: followed by excessive hand-washing or avoidance of feared contaminant

Obsessions of doubt: followed by repeated checking to avoid potential danger (e.g. turning off stove, locking the door)
 Obsessions of symmetry/order: compulsively slow performance of task

Intrusive thoughts: often sexual or violent thoughts → distress but no compulsion

Somatic obsessions: cause pts to view parts of their body, waste, or secretions as abnormal

OCD etiology: abnormal 5-HT regulation, associated w/ head injury, epilepsy, basal ganglia d/o, and postpartum conditions; onset triggered by stressful life event in 60% of pts

OCD epidemiology: 2.5% prevalence, frequently comorbid w/ ADHD and Tourette syndrome

OCD vs. OCPD: OCD is ego-dystonic (marked distress over sx), OCPD is ego-syntonic

OCD Tx: SSRI (fluvoxamine) is DOC, clomipramine is second line, last-resort is ECT or cingulotomy

ASD Tx: mobilize social supports

PTSD epidemiology: high MDD and substance abuse

PTSD Tx: SSRIs are DOC, β-blockers good for hyperarousal sx

GAD epidemiology: 45% prevalence, women > men; frequently comorbid w/ MDD, dysthymia, or other anxiety disorders

GAD Tx: CBT + drugs (SSRIs, buspirone,

venlafaxine)

GAD vs. phobias: anxiety is free-floating in GAD, rather than being fixed to specific situation

–––––––––– ADJUSTMENT DISORDERS ––––––––––

AD etiology: triggered by a non-life threatening psychosocial stressor

AD Tx: psychotherapy, should resolve in 6 months by definition

Adjustment vs. GAD: no stressor in GAD Adjustment vs. PTSD: life-threatening event in PTSD Adjustment vs. MDD: consider MDD if sx last over 6

months Adjustment vs. normal experience: adjustment has impaired level of social or occupational functioning
–––––––––– PERSONALITY DISORDERS –––––––––– social or occupational functioning, traits don’t SPD vs. AVPD: SPD want to be alone, AVPD want friends
Personality: stable, predictable emotional and but are too shy to make any
behavioral traits ––––––––––––––––– CLUSTER A –––––––––––––––––
SPD Tx: psychotherapy
Personality disorder: maladaptive, ego-syntonic
personality traits → functional impairment; 10-20%
prevalence

Cluster A: schizoid, schizotypal, paranoid;

↑association w/ psychotic disorders
Cluster B: antisocial, borderline, histrionic,
narcissistic; ↑association w/ mood disorders
Cluster C: avoidant, dependent, obsessive-
compulsive; ↑association w/ anxiety disorders
PD-NOS: passive-aggressive, depressive, sadistic, self-
defeating/masochistic
PPD defense mechanism: projection (attributing
inappropriate thoughts/emotions onto another)
PPD vs. social isolation: pts w/o social support system can
react w/ suspicion to others, DDx by getting collateral
regarding baseline
––––––––––––––––– CLUSTER B –––––––––––––––––
PPD Tx: psychotherapy

PD Tx: psychotherapy for all PDs except borderline (use

DBT) and antisocial ASPD epidemiology: ↑incidence in prisoners and poor
SPD defense mechanism: fantasy (imagination
used as an escape where others aren’t needed urban areas, high genetic component
Personality traits vs. PD: PDs show impairment of for emotional fulfillment)
ASPD vs. conduct disorder: conduct disorder if
<18 y/o, !SPD if ≥18 y/o
ASPD vs. drug abuse: antisocial behavior may be 2/2 drug
use, need to find out which came first
ASPD Tx: psychotherapy is useless; SSRIs and mood
stabilizers help w/ reducing aggression
BPD buzzwords: “best doctor ever”, multiple
meds don’t work, =5 allergies, h/o cutting
BPD epidemiology: women > men, high rate of
childhood sexual abuse, 10% suicide rate
BPD defense mechanism: splitting (people are all good or
bad, no in-betweens)
BPD Tx: dialectical behavior therapy (DBT) + setting
clear boundaries
HPD defense mechanism: regression (reverting back to
childlike behavior) and repression (unconsciously
avoiding bad thoughts)
HPD vs. BPD: HPD pts generally more functional; BPD pts
more likely to have MDD, brief psychotic episodes, and
attempt suicide
HPD Tx: psychotherapy + setting clear boundaries
–––––– SUBSTANCE ABUSE & DEPENDENCE ––––––
Abuse: 1/4 WILD for 1 year – Work/school/home
obligation failure, Interpersonal consequences,
Legal problems, Dangerous use
Dependence: 3/7 for 1 year – tolerance, withdrawal, time-
consuming, can’t cut down, ↓activities, use > intended
amount, use despite problems
Tolerance: need ↑amount to achieve same effect
Withdrawal: substance-specific syndrome due to
cesssation following heavy and prolonged use
Substance-use epidemiology: 17% prevalence, MC
substances are alcohol and nicotine, men > women
(think VA population)
Substance types: sedatives, stimulants, opioids,
hallucinogens
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs and
barbiturates), inhalants
Stimulants: strong – cocaine, amphetamines,
MDMA/MDEA; weak – caffeine, nicotine
Opioids: heroin, oxycodone, codeine,
dextromethorphan (cough syrup), morphine,
methadone, meperidine (Demerol)
NPD vs. ASPD: both characterized by exploiting
others, but NPD is for self-elevation and ASPD is for
material gain or subjugation of others
NPD Tx: psychotherapy ± group therapy to learn
empathy
––––––––––––––––– CLUSTER C –––––––––––––––––
AVPD vs. SPD: SPD want to be alone, AVPD want friends
but are too shy to make any
AVPD vs. social phobia: social phobia is a fear of
embarrassment, AVPD is more a fear of rejection
AVPD vs. DPD: both cling to relationships, but AVPD are
slow to get involved while DPD actively and aggressively
seek relationships
AVPD Tx: psychotherapy + assertiveness training
DPD defense mechanism: regression (reverting back to
childlike behavior)
DPD vs. AVPD: both cling to relationships, but AVPD are
slow to get involved while DPD actively and aggressively
seek relationships
DPD vs. BPD/HPD: DPD have long-lasting relationships w/
one person, BPD/HPD are unable to maintain a long-lasting
Hallucinogens: phencyclidine (PCP), ketamine,
psilocybin, mescaline, LSD, marijuana
––––––––––––––––– SEDATIVES –––––––––––––––––
Sedatives: alcohol, sedative-hypnotics (e.g. BDZs and
barbiturates), inhalants
Alcohol metabolism: alcohol + dehydrogenase →
acetaldehyde + dehydrogenase → acetic acid; common
cause of ↑anion gap metabolic acidosis
Alcohol intoxication: ↓fine motor control (BAL 2050),
↓judgment and coordination (50-100), ataxic gait and
balance (100-150), lethargy and amnesia (150-250),
possible coma and death (>300)
EtOH intoxication Dx: breathalyzer test, blood/urine
testing (more accurate); labs show
↑LFTs (AST:ALT >2, ↑GGT, ↑CDT) + ↑MCV
EtOH intoxication Tx: ABCs and banana bag; possible
injury → head CT, massive EtOH within past hour →
GI evacuation
relationship
DPD Tx: psychotherapy (especially groups and social
skills training)
OCPD epidemiology: men > women, oldest child
OCPD vs. OCD: OCD is ego-dystonic (marked
distress over sx), OCPD is ego-syntonic
OCPD vs. NPD: both involve achievement, but
OCPD loves the work and NPD loves the status
OCPD Tx: psychotherapy
–––––––––––––––––– PD-NOS ––––––––––––––––––
Passive-aggressive personality disorder: stubborn,
inefficient procrastinors that alternate between
compliance and defiance, make excuses and manipulate
others into doing their chores/errands
PAPD Tx: psychotherapy
Depressive personality disorder: chronically unhappy,
pessimistic, self-doubting, distressed, etc.
EtOH × H2-blockers: ↑EtOH levels
EtOH × sedative-hypnotics: respiratory depression →
death
EtOH × NSAIDs: GI bleeding
EtOH × acetaminophen/INH: hepatotoxicity EtOH ×
metronidazole/sulfa drugs: N/V
EtOH × pregnancy: fetal alcohol syndrome,
leading cause of MR/DD in US
Banana bag: thiamine + folate + MVI + MgSO4 + IVF
Alcohol withdrawal: starts in 6-24 hrs and lasts 1 wk; mild
sx = irritability, hand tremors, insomnia; moderate sx =
↑sympathetic activity; severe = DTs
Delirium tremens: delirium, VH/TH, gross tremor,
autonomic instability, seizures → 15-25% mortality
EtOH withdrawal Tx: BDZ taper, banana bag,
monitor sx w/ CIWA scale
Alcohol dependence: 2/4 CAGE – Cut down, Annoyed by
criticism, Guilty about drinking, Eye opener
EtOH dependence Tx: disulfiram (Antabuse)
blocks aldehyde DH → aversive reaction;
 naltrexone blocks opioid-R →↓cravings; Cocaine dependence Tx: psychotherapy, no FDA-
acamprosate →↑GABA/↓glu →↓cravings approved pharmacotherapy exists

Wernicke-Korsakoff syndrome: COAT RACK Cocaine withdrawal: aka crash, non-life threatening,
extreme exhaustion following coke binge, severe
Wernicke encephalopathy: acute thiamine deficiency depression → risk of suicide
→ reversible Confusion, Ophthalmoplegia (CN6 palsy),
Inhalant intoxication: perceptual disturbances, psychosis,
Ataxia, Thought disturbances; Tx IV thiamine Cocaine withdrawal Tx: refer to Narcotics Anonmyous,
N/V, euphoria, lethargy → stupor → coma
resolves w/o meds
Korsakoff psychosis: chronic thiamine deficiency
Inhalant OD: death 2/2 ↓RR or arrhythmias Inhalant
→ irreversible Retrograde /Anterograde amnesia,
Confabulations intoxication Tx: ABCs, identify solvent b/c some (e.g.

leaded gas) may require chelation

BDZs: ↑GABA frequency, used for anxiety
Barbiturates: ↑GABA duration, used as anesthetics
and antiepileptics, lower margin of safety vs. BDZs
Sedative-hypnotic intoxication: drowsiness, confusion,
slurred speech, incoordination, ataxia, etc.
SH intoxication Dx: +UDS for variable amount of
time
SH OD: respiratory depression → death, especially
when combined w/ EtOH
Inhalant withdrawal: rare
–––––––––––––––– STIMULANTS ––––––––––––––––
Stimulants: strong – cocaine, amphetamines,
MDMA/MDEA; weak – caffeine, nicotine
Cocaine intoxication: euphoria, ↑self-esteem,
↑sympathetic activity, TH, paranoia; possible death by
MI, stroke, seizure, arrhythmia, or ↓RR
Amphetamine intoxication: dilated pupils, ↑libido,
sweating, ↓RR, chest pain; heavy use → amphetamine
psychosis (mimics SCZ)
Amphetamine intoxication Dx: +UDS for 1-3 days
Amphetamine OD: hyperthermia, dehydration,
rhabdomyolysis → renal failure Amphetamine
intoxication Tx: IVF + electrolytes,
treat hyperthermia Chronic amphetamine use: acne +
meth mouth Amphetamine withdrawal: prolonged

Cocaine intoxication Dx: +UDS for 2-4 days

SH intoxication Tx: BDZs → flumazenil, barbiturates → depression
IV NaHCO3
Cocaine intoxication Tx: mild agitation/anxiety → BDZs,
severe agitation/psychosis → haloperidol, T>102 → ice
Sedative-hypnotic withdrawal: life-threatening,
bath or cooling blanket
presents similar to alcohol withdrawal; barbiturate
withdrawal has highest mortality rate of all drugs MDMA/MDEA × SSRI: serotonin syndrome
Cocaine × alcohol: cocaethylene metabolite has 24×
mortality vs. cocaine alone
SH withdrawal Tx: BDZ taper

Cocaine dependence: purely psychological

Caffeine intoxication: ↑sympathetic activity, anxiety, diuresis, insomnia, GI distress
Caffeine OD: tinnitus, severe agitation, and
arrhythmias (>1 g); seizures → death (>10 g)
Caffeine intoxication Tx: supportive care Caffeine withdrawal: headache, fatigue,
Opioid OD: classic triad RAM – Respiratory depression, Altered mental status, Miosis
Opioid intoxication Tx: ABCs, naloxone or naltrexone will help respiratory depression
but can precipitate withdrawal syndrome

irritability, drowsiness, mild depression Meperidine × MAOI: serotonin syndrome

Caffeine withdrawal Tx: self-resolves in 1 week Opioid withdrawal: violent yawning, dilated pupils, abdominal cramps, ↑secretions
(lacrimation, rhinorrhea, sweating, nausea/vomiting, diarrhea); not life-threatening

Opioid withdrawal Tx: moderate → CLIP – Clonidine, Loperamide, Ibuprofen,

Promethazine; severe → methadone or buprenorphine detox, monitor sx w/ COWS
Nicotine prevalence: 21%, MCC of preventable morbidity and mortality in US scale

Nicotine withdrawal: intense craving and dysphoria, anxiety, irritability, restlessness

–––––––––––––– HALLUCINOGENS ––––––––––––––

Nicotine withdrawal Tx: varenciline (Chantix) and buproprion (Zyban) are partial
Hallucinogen intoxication: perceptual changes, labile affect, dilated pupils,
nicotinic agonists; nicotine patch or gum
↑RR/↑BP/↑HR usually lasting 6-12 hrs

Nicotine × pregnancy: low birth weight and chronic pulmonary hypertension

Hallucinogen intoxication Tx: monitor closely,
agitated psychosis → BDZ or antipsychotics
–––––––––––––––––– OPIOIDS ––––––––––––––––––

Hallucinogen withdrawal: no withdrawal syndrome, but LSD flashbacks can occur due to
storage in fat

Opioid intoxication: respiratory depression, pupillary constriction (except Demerol →

Dilation), sedation, ↓pain, ↓GI motility PCP intoxication: RED DANES – Rage, Erythema, Dilated pupils, Delusions, Amnesia,
Nystagmus (vertical or rotary is pathognomonic), Excitation, Skin dryness
Opioid intoxication Dx: +UDS for 2-4 days; methadone and oxycodone are false
negatives, poppy seed bagels are false positive PCP intoxication Dx: +UDS for 3-8 days, labs show
↑CPK and ↑AST
 PCP OD: seizures, coma, possible death
PCP intoxication Tx: monitor closely; mild agitation/anxiety → lorazepam, severe
agitation or psychosis → haloperidol
Delirium
PCP withdrawal: no withdrawal syndrome, but flashbacks can occur due to storage
Dementia
inDefinition
body fat
waxing-and
impairment in
waning change in
memory and
Ketamine intoxication: tachycardia, tachypnea, hallucinations, and amnesia
¾.’. level of
other cognitive
consciousness
functions disorder: significant change in cognition from
Cognitive
previous level of functioning; two types – delirium and
dementia
––––––––––––––––– DELIRIUM –––––––––––––––––
Delirium risk factors: common in elderly, ICU pts, s/p
surgery pts, and cancer pts
Delirium management: r/o life-threatening
causes, then ID and Tx the underlying cause
Delirium causes: AEIOU TIPS – Alcohol/drug toxicity or
withdrawal, Electrolyte imbalance, Iatrogenic, Oxygen
hypoxia, Uremia/hepatic encephalopathy, Trauma,
Infection, Poison, Seizures, Stroke
Delirium × CVA/mass lesion: presents as focal
neuro sx (e.g. hemiparesis); Dx brain CT/MRI
Delirium × HTN encephalopathy: presents as ↑BP and
papilledema; Dx brain CT/MRI
Delirium × drug intoxication: presents as ↑HR and
dilated pupils; Dx urine toxicology screen
Delirium × meningitis: presents as fever, nuchal
rigidity, and photophobia; Dx lumbar puncture
Delirium × thyrotoxicosis: presents as ↑HR, tremor,
and thyromegaly; Dx TSH and T4 levels
Delirium × hepatic encephalopathy: due to
↑ammonia, Tx lactulose + neomycin
Sundowning: worsening of delirium at night
––––––––––––––––– DEMENTIA –––––––––––––––––
Dementia epidemiology: prevalence doubles every
5 years (1.5% at 60, 40% at 90)
Dementia management: r/o reversible causes
Dementia types: Alzheimer (#1), vascular (#2), Lewy body
(#3), Pick/FTD, HIV-associated, Huntington, Cruetzfeldt-
Marijuana intoxication: euphoria, red eyes, dry
mouth, munchies, anxiety, perceptual disturbances MJ intoxication Dx: +UDS for 3 days
(single use) to 4 weeks (heavy users)
MJ intoxication Tx: psychosocial interventions Chronic MJ use: respiratory sx +
gynecomastia Marijuana withdrawal: irritability, anxiety,
restlessness, depression, headaches, etc. MJ withdrawal Tx: supportive care
Jakob, normal pressure hydrocephalus Dementia × VD Tx: no effective cure; AChE-inhibitors and
hypothyroidism: reversible, presents as obesity, coarse antihypertensives can help
hair, constipation, and cold intolerance; Dx TSH and T4
levels VD × frontal lobe infarct: sx of schizophrenia,
depression, and bipolar I disorder
Dementia × ↓B12: presents as diminshed position and
vibration sensation; Dx B12 levels
Dementia × neurosyphilis: presents as diminshed
position and vibration sensation, and Argyll-Robertson
LBD Sx: presents as waxing-and-waning parkinsonism,
pupils (¯±±½»½²¯.³. °.. ²½³.¼’.
VH, and antipsychotic sensitivity
respond to light); Dx CSF FTA-ABS or VDRL levels
LBD Dx: onset of dementia within 12 mo of parkinsonism
Dementia × Wilson disease: presents as tremor,
LFTs, and Kayser-Fleischer corneal rings; Dx (after 12 mo of onset is Parkinson’s) LBD Tx: AChE-
inhibitors for VH, antiparkinsonians and psychostimulants
serum ceruloplasmin levels
for motor sx
Mini Mental State Exam (MMSE): screening test to Dx
dementia; 30 is perfect score, <25 is dementia
Pick/FTD Sx: profound changes in personality and social
conduct, disinhibition, hyperorality, hyper-sexuality; good
memory and language though
AD NTs: ↓ChAT →↓ACh synthesis
Pick/FTD brain: gross – marked atrophy of frontal and
AD etiology: amyloid cascade hypothesis – high risk
temporal lobes; microscopic – neuronal loss and
genes (presenilin I, presenilin II, APP, and apoE4)
¾À³²·.¾½.³ .½ ³x±³.. !β-amyloidosis
astrocytosis of cortical layer II
Pick/FTD Tx: anticholinergics and antidepressants help w/
AD Dx: diagnosis of exclusion, definitive diagnosis
behavior but not cognition
requires brain biopsy
AD brain: gross – diffuse atrophy with enlarged
ventricles and flattened sulci; microscopic – senile
plaques, neural plaques, and neurofibrillary tangles (not
specific to Alzheimer) HAD Sx: rapid decline in memory, cognition, behavior, and
motor skills; depression and social withdrawal also
AD Tx: AChE-inhibitors for mild-to-moderate AD common
(tacrine, donepezil, rivastigmine, galantamine),
NMDA antagonist for moderate-to-severe AD HAD Tx: HAART
(memantine)
Alzheimer × Down syndrome: trisomy 21 → triple apoE4
expression → inevitable Alzheimer by 40 y/o
HD Sx: chorea, apathy, depression, and dementia with
onset at 35-50 y/o, ↑rate of suicide
VD Dx: multiple small lacunar infarcts on CT scan, HD brain: atrophy of caudate nucleus
sensitive but not specific for vascular dementia
VD risk factors: previous stroke, diabetes, HTN
 PD Sx: early PD presents as TRAP – Tremor, Rigidity,
Akinesia, Postural instability; late PD presents as
Alzheimer-like dementia

PD brain: neuronal death in substantia nigra, senile

plaques, and neurofibrillary tangles

PD Tx: early PD → carbidopa + levodopa (Sinemet), late

PD → subthalamic nucleus deep brain stimulation;
antipsychotics will exacerbate dementia due to PD

Prion diseases: Creutzfeldt-Jakob disease, kuru,

Gerstmann-Straussler syndrome, fatal familial
insomnia, bovine spongiform encephalopathy CJD Sx:
rapidly progressive dementia, myoclonus (muscle
spasms), and personality changes
CJD Dx: probable – clinical picture + periodic
B3 (niacin) deficiency → 3 Ds – Diarrhea, Dermatitis,
generalized sharp waves on EEG; definitive –
spongiform change on brain biopsy Dementia

NPH Sx: 3 Ws – Wet (urinary incontinence), Wobbly

Herpes encephalopathy: involves temporal lobes
(gait apraxia), Wacky (dementia)

NPH Tx: CSF shunt to relieve pressure Pellagra: vitamin

––––––––––––– GEROPSYCHIATRY ––––––––––––– imbalance
Normal aging: ↓brain volume w/ enlarged ventricles,
↓muscle, ↑fat, ↓vision/hearing, minor forgetfulness
Elderly × MDD: MC psychiatric disorder in elderly, Sleep disturbance Tx: fix sleep hygiene, stop drinking, stop napping, fix underlying
incidence s/p MI, stroke, and new admits to nursing homes causes; hydroxyzine or trazodone are second-line

Pseudodementia Elderly × antidepressants: elderly are very sensitive to anticholinergic side-effects,

Dementia
Elderly × suicide: white elderly males have highest rate of successful suicides
Definition including dry mouth, constipation, blurry vision, etc.
MDD + cognitive
impairment in –––––––––– OTHER GERIATRIC ISSUES ––––––––––

defects due to Restraints: should be used as a last resort in non-emergency situations, consider pt health
memory and and safety
Pseudodementia Tx: supportive psychotherapy + low-dose antidepressants (SSRIs >
underlying use nortriptyline if TCA is preferred); depression + low appetite + insomnia →
TCAs/MAOIs, Medications: polypharmacy is common in elderly,
other cognitive
mirtazapine ↑side-effects due to ↓liver/kidney function and ↓lean body mass

depression Elderly abuse: 10% incidence, perpetrator is usually the caregiver of the victim; can be
functions physical, psychological, neglect, or exploitation (rarely sexual)
Onset
Nursing homes: provide care and rehab for both chronically ill and short-term care pts;
Dementia epidemiology: prevalence doubles 50% stay on permanently, 50% are d/c after a few months
every 5 years (1.5% at 60, 40% at 90)

Dementia types: Alzheimer (#1), vascular (#2), Lewy body (#3), Pick/FTD, HIV-associated,
Huntington, Cruetzfeldt-Jakob, normal pressure hydrocephalus

Dementia Tx: behavioral and environmental Tx preferred over pharmacotherapy (see

cognitive disorders for specifics)

Grief: aka bereavement, normal reaction to a major loss, does not present w/ SI or
disorganization

Kübler-Ross stages of grief: denial, anger,

bargaining, depression, acceptance BAD Tx: antidepressants ± psychotherapy; acute risk
→ hospitalization, unresponsive to drugs → ECT (safe and effective in elderly)

Elderly × alcohol abuse: elderly have ↓alcohol dehydrogenase →↑BAL w/ fewer

drinks; ↑CNS sensitivity to alcohol

Medical conditions worsened by alcohol: liver diseases, GI diseases, CV diseases, gout,

diabetes, depression, anxiety

Elderly × sleep: ↓sleep efficiency and ↓total sleep (↑stage 1-2, ↓stage 3-4, ↓REM latency,
↓total REM);
↑incidence of sleep disorders

Periodic leg movements: restless leg movements during sleep, due to dopamine
––––––––––– MENTAL RETARDATION ––––––––––– Fragile X syndrome: MC inherited form of MR/DD; X- Disruptive behavior disorders: includes oppositional
linked CGG trinucleotide expansion in FMR1 gene defiant disorder and conduct disorder
causes DSM-IV – Discontinued chromosomal staining,
MR/DD types: profound <25, severe 25-40, Shows anticipation, Males, Mental retardation,
moderate 40-55, mild 55-70 (intervals of 15) Macrognathia, Macroorchidism

MR/DD causes: 50% idiopathic, Down syndrome (MC

ODD Tx: individual psychotherapy + family involvement
genetic), Fragile X (MC inherited), fetal alcohol syndrome
(overall MCC); prenatal, perinatal, or postnatal pathology

Learning disorder types: reading disorder (MC),

TORCHES complex: perinatal infections than can lead
mathematics disorder, writing disorder
to MR/DD, includes Toxoplasmosis, Rubella, CMV,
CD in boys: cruelty to animals, fighting, stealing, fire-
Herpes simplex, Syphilis
Learning disorder Tx: remedial education
setting, vandalism CD in girls: lying, running away,
Prader-Willi syndrome: partial deletion of 15q →
–––––– DISRUPTIVE BEHAVIOR DISORDERS –––––– promiscuity
MR/DD, obesity, hypogonadism, almond eyes

CD Px: 40% of conduct d/o →ASPD CD Tx: multimodal
approach w/ family and teacher involvement
CD vs. ASPD: conduct disorder <18 y/o, ASPD ≥18 y/o
behavioral therapy can help w/ developing skills
Autism vs. deafness: toddler w/ ↓communication skills
needs hearing test to r/o deafness
Tourette prevalence: very rare; ↑rate of comorbid OCD
(40%) and ADHD (50%)
Tourette etiology: multifactorial, involves impaired
dopamine regulation in caudate nucleus

CD vs. ODD: unlike conduct disorder, ODD doesn’t Tourette Tx: risperidone and α2-agonists (clonidine,
involve physical aggression or violation of basic rights of guanfacine) are DOC; severe cases → typical
others antipsychotics, tics+OCD → SSRIs
Aspie Tx: supportive Tx similar to autism

CD vs. pyromania: pyromaniacs light things on fire due

to inner tension, not out of anger issues

Enuresis etiology: genetics, stress (MC), small bladder,

or ↓nocturnal ADH
Rett etiology:ΔMECP2 on X chromosome (only girls get
ADHD types: inattentive type, hyperactive-impulsive Enuresis Tx: DDAVP is DOC, imipramine is second-line
the disease, guys all die in utero)
type, combined type

Rett Px: cognitive development never progresses beyond

ADHD prevalence: boys > girls, >50% have comorbid
first year of life, ↑risk of sudden death
psychiatric diagnosis
Encopresis etiology: genetics, stress, lack of sphincter
Rett Tx: supportive care control, or constipation w/ overflow incontinence (MC)
ADHD Px: 50% go onto adulthood untreated

ADHD Tx: CNS stimulants are DOC w/ 75% success rate, Encopresis Tx: usually remits spontaneously,
second-line is atomoxetine and α2-agonists (clonidine, bowel catharsis + stool softeners if it doesn’t
guanfacine)
CDD prevalence: boys > girls, ↑rate of abnormal EEG and
ADHD vs. MR/DD: both struggle w/ academic seizures
performance, so differentiate via IQ tests
CDD Tx: supportive care CDD vs. Rett: similar loss of Mutism Tx: psychotherapy, behavioral therapy,
––– PERVASIVE DEVELOPMENTAL DISORDERS ––– previously acquired skills, but CDD has no ↓head growth or management of anxiety
hand wringing
Pervasive developmental disorders: includes autism,
Asperger, Rett, and childhood disintegrative d/o –––––––– OTHER PEDIATRIC DISORDERS ––––––––

Tic disorders: characterized by sudden, repetitive, SAD Px: risk factor for development of panic d/o or
involuntary movements (motor tics) or vocalizations agoraphobia as an adult
(vocal tics); one of few DSM-IV Dx that don’t require
significant distress as a qualifier SAD Tx: family therapy, CBT, low-dose
antidepressants
Autism prevalence: 70% meet criteria for MR/DD;
associated w/ fragile X syndrome, tuberous sclerosis, Coprolalia: repetitive speaking of obscene words
and seizures
Echolalia: exact repetition of words
Autism Px: most important predictors of adult
outcome are intelligence and communication Sexual abuse prevalence: 15-25%, perpetrator is
usually the child’s parent
Autism Tx: no cure, but remedial education and
–––––––––– DISSOCIATIVE DISORDERS ––––––––––
Dissociation: loss of memory, identity, or sense of self; often following trauma, may involve NE + glu

Abreaction: strong reaction pts get when retrieving traumatic memories

Dissociative disorders: dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization disorder, dissociative disorder NOS

DA epidemiology: MC dissociative disorder,

↑incidence of MDD and anxiety disorders

DA Tx: psychotherapy; most acute cases return to normal after min-days, lorazepam or amobarbital often used to help pt talk freely during interview

DA vs. dementia< D! can’t recall common personal

info but can remember obscure details, dementia can remember personal info but not obscure details

DF epidemiology: rare, usually follows stressful

life event or personal conflict
 DF Tx: same as DA

DF vs. DA< D! pts are aware of what they can’t seem to remember, DF don’t acknowledge the amnesia

DF vs. transient global amnesia: DA pts show loss of identity, global amnesia have difficulty with more recent events but identity remains intact

DID epidemiology: usually women w/ prior trauma (e.g. childhood sexual abuse); ↑incidence of MDD, anxiety, BPD, substance abuse, suicide

DID Tx: psychotherapy; worst Px of all dissociative disorders

DID DDx: DID-like sx may be seen in BPD, psychosis, or malingering (factitious disorder)

Depersonalization: feeling that one is falling apart, fragmenting, detached, not oneself, etc.

Derealization: feeling that the world is not real DPD epidemiology: women > men, severe stress is a risk factor, ↑incidence of MDD and anxiety disorders

DPD Tx: usually chronic, anxiety or MDD →

anxiolytics or SSRIs

DPD vs. normal stress: transient depersonalization is common during times of stress

Ataque de nervios: Puerto Rican culturally-bound trance disorder that consists of convulsive movements, fainting, crying, and visual problems

Ganser syndrome: giving of approximate answers

to simple questions (e=g= “how many legs do you have?”)
––––––––––––––––––– GAIN –––––––––––––––––––

Primary gain: internal motives (e.g. stress, anxiety) as the cause of symptoms

Secondary gain: external motives (e.g. attention, money, avoiding law) as the cause of symptoms

Münchhausen Sx: triad of 3 Ps – Peregrination, Pseudologia phantastica, Polysurgery

Münchhausen Tx: establish therapeutic alliance, avoid confrontation and unnecessary procedures

–––––––––– SOMATOFORM DISORDERS ––––––––––

Somatoform disorders: not consciously feigning symptoms, though no direct link to medical cause; 50% have comorbid anxiety d/o or MDD

Somatoform disorders × gender: women > men, except hypochondriasis where women = men

Somatization Px: chronic and debilitating, worse under stress

Somatization Tx: r/o potential medical causes, regularly scheduled visits w/ a single PCP who limits extensive medical work-ups

Somatization vs. conversion: somatization pts are

concerned over condition, conversion don’t care

Conversion Sx: commonly paralysis, blindness, mutism, parasthesias, seizures, globus hystericus

La belle indifference: apathy despite severity of condition

Conversion Tx: most spontaneously recover; if it persists → insight-oriented psychotherapy, hypnosis, or relaxation therapy

Conversion in elderly: high chance of real neuro deficit, get a neuro consult

Conversion × seizures: use EEG to differentiate between epileptic vs. nonepileptic seizures Conversion × neuropathy: consider multiple sclerosis

Hypochondriasis epidemiology: 80% have comorbid GAD or MDD (vs. 50% in other somatoform d/o), men = women (vs. women > men in other somatoform d/o)

Hypochondriasis Tx: regularly scheduled visits w/ a single PCP

Hypochondriasis vs. somatization: somatization pts have a long list of sx, hypochondriacs are worried about a specific disease

Hypochondriasis vs. BDD: hypochondriasis + about a specific body part = body dysmorphic disorder

BDD Tx: optional CBT ± SSRIs, avoid cosmetic procedures

Pain Tx: validate pt’s pain, moderate → biofeedback and relaxation techniques, severe → antidepressants (not analgesics)
–––––––– IMPULSE CONTROL DISORDERS ––––––––

Impulse control disorders: IED, kleptomania, pathological gambling, trichotillomania, pyromania

Core qualities: anxiety before act, repetitive or compulsive act in spite of consequences, lack of control during act, relief or satisfaction after act

IED Dx: ↓5-HIAA in CSF IED Tx: SSRIs + lithium + propanolol; individual psychotherapy is difficult and ineffective IED vs. amok: amok has amnesia and only in Asians

Klepto etiology: multifactorial but ↑ with stress;

↑incidence of OCD, mood disorders, and eating disorders (25% of bulimics are klepto)

Klepto Tx: insight-oriented psychotherapy + behavioral therapy + SSRIs; anecdotal evidence exists for naltrexone

Gambling etiology: multifactorial; ↑incidence of OCD, mood disorders, and anxiety disorders

Gambling Tx: Gamblers Anonymous is first-line, after 3 months of abstinence →insight-oriented psychotherapy, treat comorbid problems

Tricho etiology: multifactorial; ↑incidence of OCD/OCPD, borderline PD, and mood disorders

Tricho Tx: behavioral therapy + SSRIs, lithium, or antipsychotics

Pyro Tx: supervision + behavioral therapy + SSRIs

––––––––––––– EATING DISORDERS –––––––––––––

Eating disorders: anorexia nervosa, bulimia nervosa, binge-eating disorder (eating disorder NOS)

Anorexia subtypes: restrictive type doesn’t eat and has OCPD traits; binge/purge type binge eats followed by vomiting or exercising

Anorexia prevalence: 1%, most commonly in women in industrialized countries

Anorexia Px: 10% mortality due to starvation, suicide (57× normal rate), or cardiac failure

Anorexia Tx: food (behavioral therapy + family therapy + supervised weight-gain programs); excessive weight preoccupation →low-dose 2G antipsychotics, preprandial anxiety
→BDZs

Anorexia complications: BATCH – Bone loss (osteopenia/osteoporosis), Amenorrhea, ↓Thyroid, Constipation, Heart problems (cardiomyopathy, ACS, MVP, arrhythmias due to ↓K+)

Anorexia lab values: ↑cortisol, QTc, chol, BUN, GH;

↓RBC/WBC, LH/FSH, E/T, T4/T3, glucose

Anorexia × purging: contraction (hypokalemic, hypochloremic metabolic) alkalosis

Anorexia DDx: endocrine disorders, GI diseases, genetic disorders, cachexia (due to cancer/AIDS), MDD, bulimia

Anorexia vs. bulimia: both may binge and purge, but bulimics are normal weight and anorexics are <85%

Anorexia vs. MDD: both may refuse to eat, but anorexics starve in spite of a good appetite and MDD have poor appetite

Refeeding syndrome Tx: slow feedings and replace electrolytes

Bulimia subtypes: purging type involves vomiting, laxatives, enemas, or diuretics; nonpurging type involves excessive exercise or fasting

Bulimia prevalence: 1-4%, most commonly in women in industrialized countries

Bulimia Px: chronic and relapsing, but better Px than anorexia nervosa

Bulimia Tx: SSRIs (fluoxetine) + therapy (CBT); avoid buproprion which can ↓seizure threshold Bulimia complications: SPARKED – Sialadenosis, Petechiae, Aspirations, Arrhythmias due to
↓K+, Russell’s sign, Kleptomania (25%), Esophagitis, Edema, Dental erosions or caries

Russell’s sign: calloused knuckles due to hitting

incisor teeth when inducing the gag reflex

-
Bulimia lab values: vomiting →contraction alkalosis, laxatives →metabolic acidosis; ↑BUN, ↑HCO3 ,
↑amylase, ΔT4/T3, Δcortisol

Bulimia vs. binge-eating disorder: both like to binge, but bulimics try to control their weight afterwards

Binge-eating: excessive food intake within 2 hr period + sense of lack of control

BED Tx: psychotherapy + behavioral therapy + diet/exercise program; drugs can be used as an adjunct (stimulants, orlistat, sibutramine)
––––––––––––––––––– SLEEP –––––––––––––––––––

Normal sleep cycle: non-rapid eye movement sleep (stages 1-4) alternating w/ REM sleep every 90 min

NREM: deeper sleep progression through stages; stage 2 is tooth grinding, stage ¾ (delta sleep) is sleepwalking, bedwetting, and sleep terrors

REM: dreaming, loss of motor tone, erections, sympathetic activity (↑HR, ↑RR, ↑BP)

Sleep EEG waveforms: BATS Drink Blood – Beta (awake), Alpha (resting), Theta (1), Sleep spindles and K complexes (2), Delta (¾), Beta (REM)

Sleep disorders: dyssomnias and parasomnias

––––––––––––––– DYSSOMNIAS –––––––––––––––

Dyssomnias: ↑/↓ or altered timing of sleep

PI subtypes: sleep-onset insomnia (can’t go to sleep), sleep-maintenance insomnia (can’t stay asleep), sleep-offset insomnia (early morning awakenings), nonrestorative sleep (wake up still
tired)

PI etiology: usually poor sleep hygiene

PI Tx: fix sleep hygiene, Chronic insomnia → CBT, acute insomnia → long-term BDZs or non-BDZ hypnotics, insomnia + depression → trazodone

OSA etiology: repetitive upper airway collapse due to obesity and/or airway narrowing

OSA Tx: first-line is weight loss and exercise, second-line is CPAP or BiPAP, third-line is surgery

Narcolepsy etiology: loss of hypothalamic neurons that contain hypocretin, may have autoimmune component

Narcolepsy Tx: fix sleep hygiene, excess daytime sleepiness → stimulants (e.g. amphetamines, modafinil), cataplexy → sodium oxybate (GHB)

Circadian rhythm: sleep-wake cycle controlled by suprachiasmic nucleus (SCN) in the hypothalamus Delayed sleep phase disorder: sleep onset and awakening are delayed, but normal
duration/quality

DPSD Tx: bright light phototherapy in the

morning, melatonin in the evening

Advanced sleep phase disorder: sleep onset and awakening are early, but normal duration/quality

APSD Tx: bright light phototherapy in the evening

Shift-work disorder: sleep schedule is messed up due to nontraditional work hours

SWD Tx: avoid risk factors, severe → modafinil

Jet lag disorder: sleep schedule is messed up due to travel across multiple time zones

Jet lag Tx: resolves by itself 2-3 days after travel

––––––––––––––– PARASOMNIAS –––––––––––––––

Parasomnias: unusual sleep-related behaviors (e.g. movements, emotions, dreams, autonomic activity)

Sleepwalking etiology: unknown, usually not associated w/ any psychiatric problems

Sleepwalking Tx: ensure child safety and wait; refractory cases → BDZs (clonazepam) or TCAs

Sleep terror etiology: ↑comorbidity w/ restless leg syndrome and sleep-disordered breathing

Sleep terror Tx: ensure child safety and wait; refractory cases → BDZs (clonazepam)

Nightmare etiology: seen in >50% PTSD pts

Nightmare Tx: image rehearsal therapy (IRT), severe → antidepressants

RBD etiology: unknown, usually in senior males

RBD Tx: clonazepam, ensure safety

Restless leg syndrome: irresistable urge to move one’s legs while going to sleep-caused by pregnancy, anemia, renal failure, or other metabolic d/o
Periodic limb movement disorder: aka nocturnal myoclonus, frequent limb movement during sleep
–––––––––––– NORMAL SEXUALITY ––––––––––––
Sexual response cycle: desire to EXPLORE – desire,
EXcitement, PLateau, Orgasm, REsolution
Refractory period: post-resolution period in
which men can’t reexperience orgasm
Sex × male aging: desire unchanged but requires
↑stimulation and time to orgasm, ↓intensity of
ejaculation, ↑refractory period
Sex × female aging: desire unchanged but ↓estrogen levels
→vaginal dryness and thinning
Sex × drugs: ↑libido – cocaine, amphetamines, marijuana,
and acute alcohol use; ↓libido – narcotics and chronic
alcohol use
Sex × NTs: DA ↑libido, 5-HT inhibits sexual function
Sex × hormones: testosterone ↑libido, progesterone
↓libido, postmenopausal ↓estrogen levels →vaginal dryness
and thinning
––––––––––––– SEXUAL DISORDERS –––––––––––––
Sexual disorders: problems involving any stage of sexual
response cycle or pain during intercourse, not due to
substance use or GMC
MC sexual disorders: premature ejaculation and 2° ED in
men, HSDD and orgasmic disorder in women
HSDD Tx: hormone replacement therapy
ED Tx: PDE5-inhibitors (sildenafil) or alprostadil injection
are first-line; vacuum pumps, surgical tube insertion, or
constrictive rings
ED vs. psychological condition: men w/ psych condition
can get it up at other times (e.g. other partners,
––––––––––––– FREUD’S THEORIES –––––––––––––
Topographic theory: mind is composed of three types
of thoughts – conscious, preconscious, and
unconscious
Conscious thoughts: current thoughts and 2° process
thinking (logical, mature, organized, etc.)
Preconscious thoughts: memories that are not
immediately aware but easy to recall
Unconscious thoughts: repressed thoughts that
are out of one’s awareness, involves 1° process
masturbating, morning wood) Male OD Tx: gradually
progress from extravaginal ejaculation (via masturbation)
to intravaginal
Female OD Tx: masturbation ± vibrator
Dyspareunia Tx: gradual desensitization to achieve
intercourse (muscle relaxation →erotic massage →sexual
intercourse)
Vaginismus: involuntary muscle contraction of outer 1/3 of
vagina during insertion; ↑incidence in higher socioeconomic
groups and strict religious upbringing
Vaginismus Tx: manual dilation
Homosexual × depression: consider MDD or adjustment d/o
due to conflict w/ societal values; homosexuality is not a
disorder
Homosexual × prepuberty: same-sex exploratory activities
are common in prepubescent kids and
don’t signify latent homosexuality
Transsexuality Tx: therapy, family involvement for
younger pts, possibly sex reassignment
Transsexual vs. transvestite: transsexuals identify with the
other sex, transvestites like to wear other gender’s
vestments (clothing)
–––––––––––––––– PARAPHILIAS ––––––––––––––––
MC paraphilias: pedophilia, voyeurism, exhibitionism
Pedophilia: getting turned on by kids <13 y/o,
thinking (primitive and pleasure-seeking)
Structural theory: mind is composed of three
identities – id, ego, and super-ego
Id: primitive; involves sexual/aggressive urges and 1°
process thinking
Ego: realistic; mediates id, super-ego, and external
environment using defense mechanisms
Super-ego: idealistic; represents morals, society, and
parental teaching
pedophile must be >16 y/o and at least 5 years
older than the child
Frotteurism: sexual pleasure from touching or
rubbing up against a nonconsenting person
Voyeurism: watching unsuspecting nude people
for sexual pleasure
Exhibitionism: exposing self to others
Masochism: sexual excitement from being hurt or
humiliated
Fetishism: sexual preference for inanimate
objects (e;g; women’s shoes)
Transvestic fetishism: sexual gratification in men
from wearing women’s clothing
Necrophilia: sexual pleasure from f-ing a corpse
Telephone scatologia: sexual excitement from
calling unsuspecting women and having phone
sex with them
Paraphilia Px: good prognosis w/ self-referral (vs.
police arrest), sense of guilt, and low frequency of
behavior
Paraphilia Tx: insight-oriented psychotherapy
+ aversion therapy; antiandrogens for
refractory hypersexual paraphilias in men
Paraphilia vs. normal fantasy: occasional fantasies
are normal if <6 months and don’t interfere w/ daily
functioning
Transvestic fetishism vs. homosexuality: dressing up
as a woman doesn’t mean you’re turned on by men
–––––– TREATMENT OF SEXUAL DISORDERS ––––––
Sexual disorder Tx: psychotherapy, medications,
and mechanical therapy all play a role
Psychotherapy: dual sex therapy for marriage or
couple issues, behavioral therapy for
maladaptive behaviors, hypnosis for anxiety
Pharmacotherapy: (see specific disorders)
Mechanical therapy: (see specific disorders)
Sadism: sexual excitement from hurting or Premature
ejaculation Tx: SSRIs or TCAs can humiliating others
prolong time to ejaculation
Normal development: id is present at birth, ego
develops after birth, superego begins at age 6
––––––––––– DEFENSE MECHANISMS –––––––––––
Defense mechanisms: used by ego to mediate id, super-
ego, and external environment; three types – mature,
neurotic, and immature
Mature defenses: mature women wear a SASH –
Sublimation, Altruism, Suppression, Humor
 Sublimation: satisfying socially objectionable
impulses in an acceptable manner
Altruism: performing acts that benefit others to feel
better about oneself
Suppression: consciously avoiding unacceptable
impulse or emotion (vs. repression)
Humor: using comedy to express thoughts or
feelings w/o discomfort to self or others
Neurotic defenses: RIDICulous – Rationalization, Reaction
formation, Repression, Intellectualization, Displacement,
Isolation of affect, Controlling
Rationalization: making reassuring but incorrect
explanations for outcome or behavior
Reaction formation: doing the exact opposite of an
unacceptable impulse
Repression: unconsciously avoiding unacceptable
impulse or emotion (vs. suppression)
Intellectualization: using excessive abstract thinking to
avoid experiencing disturbing feelings
Displacement: redirecting thoughts or feelings
about one thing onto something more tolerable
Isolation of affect: separation of an unpleasant
idea from the feelings it evokes
Controlling: regulating aspects of external
environment to relieve anxiety
Immature defenses: acting out, denial, distortion,
fantasy, regression, passive aggression, projection,
projective identification, splitting, undoing
Acting out: giving into an impulse, even if it’s
socially inappropriate
Denial: not accepting reality that is too painful,
first stage of Kubler-Ross grief model
Distortion: grossly reshaping external reality to
suit inner needs
Fantasy: substituting fantasy for reality to resolve inner
conflicts; characteristic of schizoid PD
Regression: reverting back to childlike behavior;
characteristic of histrionic PD and dependent PD
Passive aggression: nonconfrontational
expression of aggression towards others
Boundaries and triangles: boundaries between family members may be too rigid or permeable; triangles are two family members against a third
Couples therapy types: conjoint therapy (see couple together), concurrent therapy (see both separately), collaborative therapy (one therapist per pt), four-way therapy (all of the above)
––––––––––– NEUROTRANSMITTERS –––––––––––
Anti-H2: sedation, weight gain
Anti-A1: orthostatic hypotension, sexual dysfunction
Anti-M: dry mouth, blurry vision, constipation, urinary
retention, exacerbates Alzheimer disease
Anti-D2: anti-psychosis, EPS, ↑prolactin
Projection: attributing one’s inappropriate
thoughts or emotions onto another (e.g. stealing from a
friend you suspect is stealing from you)
Learning theory: behaviors can be learned by
conditioning, and extinguished by deconditioning
Projective identification: attributing one’s
inappropriate thoughts onto another, then
Classical conditioning: stimulus can eventually evoke a
identifying with the countertransference
conditioned response (e;g; Pavlov’s dog)
Splitting: labelling people as all good or all bad;
Operant conditioning: uses positive (rewards) or
characteristic of borderline PD
negative reinforcement (removing an aversive
stimulus) to encourage behavior
Undoing: attempting to reverse a situation by
adopting a new behavior
Systematic desensitization: pt uses relaxation
techniques while being exposed to increasing doses
of anxiety-provoking stimuli
–––––––––––––– PSYCHOANALYSIS ––––––––––––––
Flooding and implosion: pt is exposed to real
Split treatment: one psychiatrist provides (flooding) or imagined (implosion) anxiety-provoking
medication, another provides the therapy stimuli and not allowed to withdraw until he/she
feels calm and in control
Aversion therapy: uses punishment to discourage
behavior (e.g. electric shock)
Token economy: rewards (tokens) given after
Psychoanalysis techniques: free association, dream
specific behaviors for positive reinforcement
interpretation, therapeutic alliance, interpretation of
transference
Biofeedback: vital signs given to pts as they try to
mentally control physiological states
Free association: pt says whatever comes to mind
Negative reinforcement vs. aversion therapy: negative
Dream interpretation: dreams represent conflict
reinforcement removes aversive stimulus to encourage
between urges and fears, interpret for resolution
behavior, aversion therapy adds an aversive stimulus to
discourage behavior
Therapeutic alliance: bond between pt and therapist
Transference: pt projects unconscious feelings onto
doctor (e.g. therapist seen as father figure)
Countertransference: doctor projects unconscious
feelings onto pt (e.g. all antisocial pts are malingering for
benzos)
Brief dynamic therapy: like psychoanalysis but briefer
and face-to-face instead of lying on a couch
Interpersonal therapy: focuses on development
of social skills
Peer led group therapy: no therapist (e.g. AA)
Supportive therapy: focuses on helping pt feel safe
during a difficult time, builds up healthy defense
mechanisms, not insight-oriented
–––––––––– OTHER PSYCHOTHERAPIES ––––––––––
Anti-5-HT1c: weight gain Anti-HAM side-effects: TCAs and low-potency anti-
psychotics can cause anti-H2, anti-α1, anti-M
5-HT2: agitation, akathisia
Serotonin syndrome: ↑5-HT →fever, confusion,
5-HT3: diarrhea, nausea/vomiting flushing, sweats, tremor, hypertonicity, rhabdo-
myolysis → renal failure, death
Serotonin syndrome combos: SSRI+MAOI, SSRI+OTC
––––––––––––––– SIDE-EFFECTS –––––––––––––––
 cough medicine, SSRI+linezolid, MAOI+meperidine,
MAOI+MDMA/MDEA
Serotonin syndrome Tx: cyproheptadine or BDZ,
avoid taking within 5 weeks of each other
Hypertensive crisis: MAOI+tyramines or sympatho-
mimetics can cause ↑NE/↑epi (severe HTN)
Extrapyramidal side-effects: high-potency typical
antipsychotics can cause Parkinsonism, akathisia, and
dystonia within days
EPS Tx: acute dystonia →benztropine or
diphenhydramine, akathisia →β-blockers or BDZ,
Parkinsonism → levodopa or amantadine
Tardive dyskinesia: high-potency typical anti-psychotics
can cause choreoathetosis of mouth and tongue after
years of use
TD Tx: irreversible, so monitor sx with AIMS (abnormal
involuntary movement scale)
Withdrawal dyskinesia: tendency for TD to
temporarily increase following d/c antipsychotic
Hyperprolactinemia: high-potency antipsychotics and
risperidone can ↑prolactin (galactorrhea, amenorrhea,
↓libido, infertility), due to ↓dopamine in tuberoinfundibular
pathway
Neuroleptic malignant syndrome: all antipsychotics can
cause FALTER – Fever, Autonomic instability,
Leukocytosis, Tremor, Elevated CPK, “lead pipe” Rigidity;
mortality rate is 20%
NMS Tx: dantrolene or bromocriptine
Metabolic syndrome: atypical antipsychotics can
↑BP, ↑insulin, ↑body fat, ↑risk of CAD/stroke/diabetes;
switch to typical antipsychotic if pt is at risk CYP450: liver
enzymes that metabolize drugs; CYP450 inducers ↓drug
levels, CYP450 inhibitors
↑drug levels
CYP450 inducers: smoking, carbamazepine,
barbiturates, St; John’s wort
CYP450 inhibitors: fluvoxamine, fluoxetine,
paroxetine, duloxetine, sertraline
Teratogenic drugs: TCAs (fetal limb defects), VPA
(neural tube defects), lithium (Ebstein’s anomaly),
BDZs (cleft palate + FAS facies)
––––––––––––– ANTIDEPRESSANTS –––––––––––––
sensitivity) and thioridazine (retinal pigmentation → night
blindness)
Mid-potency: midrange properties; includes
loxapine (↑seizures), thiothixene (ocular
pigmentation), trifluoperazine (↓anxiety), and
perphenazine
High potency: ↑EPS and TD, ↓anti-HAM;
includes haloperidol, fluphenazine, pimozide
Atypical side-effects: weight gain, DKA, metabolic
Antidepressants: SSRIs, TCAs, MAOIs, and atypicals; all 2° vs. 3° TCAs: tertiary are more anticholinergic and
have similar efficacy but differ in side-effect profile, require sedating, and more lethal in OD; secondary are active
3-4 week trial to take effect, none cause elation or have metabolites of tertiary amines
abuse potential
Imipramine (Tofranil): Tx enuresis
Withdrawal phenomenon: dizziness, headache, N/V,
insomnia, malaise after stopping most antidepressant Amitriptyline (Elavil): strong anticholinergic side-effects
use; may require tapering
Clomipramine (Anafranil): very sedating, Tx OCD
Doxepin (Sinequan): very sedating, useful as a sleep
aid in low doses
SSRI side-effects: sexual dysfunction, GI distress,
serotonin syndrome, black box for suicidality Nortriptyline (Pamelor, Aventyl): fewest anti-HAM
side-effects
SSRI × sexual dysfunction: switch to bupropion
Desipramine (Norpramin): more activating, less
sedating, least anticholinergic
Fluoxetine (Prozac): longest T½ (fewest withdrawal sx)
Amoxapine (Asendin): metabolite of loxapine, only
Sertraline (Zoloft): highest GI distress
antidepressant that can cause EPS
Paroxetine (Paxil): shortest T½ (highest withdrawal
Maprotiline (Ludiomil): ↑rate of seizures,
sx), most anticholinergic side-effects
arrhythmias, and fatality w/ OD
Fluvoxamine (Luvox): Tx OCD
Citalopram (Celexa): fewest drug interactions,
fewest sexual side-effects
Escitalopram (Lexapro): L-enantiomer of citalopram, MAOI side-effects: serotonin syndrome (MAOI+ SSRI
even fewer side-effects but more $$$ within 5 weeks), HTN crisis (MAOI+tyramine)
Venlafaxine (Effexor): SNRI, ↑↑BP
–––––––––––––– ANTIPSYCHOTICS ––––––––––––––
Desvenlafaxine (Pristiq): SNRI, active metabolite of
venlafaxine, more $$$
Antipsychotics: typical (1G) and atypical (2G) are both
good for positive psychotic sx, but atypicals are better for
Duloxetine (Cymbalta): SNRI, good for painful
negative psychotic sx
diabetic neuropathy, more $$$
Depot antipsychotics: long-acting decanoate forms ideal
Buproprion (Wellbutrin): no sexual side-effects,
for noncompliant psychotic pts; includes haloperidol,
contraindicated with seizures and eating disorders (↑risk
fluphenazine, risperidone, paliperidone
of seizures)
Typical vs. atypicals: typicals have more EPS, tardive
Trazodone (Desyrel): can cause sedation and
dyskinesia, anti-HAM, and lethality in OD due to QTc
priapism (Tx epi injection into penis)
prolongation; atypicals have more weight gain, DKA, and
metabolic syndrome
Nefazodone (Serzone): can cause sedation, black box
for hepatotoxicity Mirtazapine (Remeron): can cause
weight-gain and sedation
Typical side-effects: EPS (parkinsonism + akathisia +
dystonia), ↑prolactin, anti-HAM, tardive dyskinesia (1%
annual incidence), NMS
TCA side-effects: anti-HAM + 3 Cs – Cardiotoxicity (↑QTc), Low potency: ↑anti-HAM, ↓EPS and TD; includes
Convulsions, Coma; lots of interactions (highly protein chlorpromazine (corneal pigmentation + photo
bound) and lethal in OD
syndrome (monitor weight and lipids) Olanzapine (Zyprexa): ↑weight gain
Clozapine (Clozaril): ↓suicide but ↑weight gain, Ziprasidone (Geodon): ↓weight gain
seizures, agranulocytosis (requires weekly WBC
counts), R-sided obstipation Aripiprazole (Abilify): #1 for akathisia (Tx βblockers or
BDZ)
Risperidone (Risperdal): #1 for ↑prolactin and
dystonic reactions Ziprasidone doesn’t work: pt wasn’t eating, food is
required to activate Geodon in the body
Paliperidone (Invega): metabolite of risperidone
Quetiapine (Seroquel): can cause sedation and
––––––––––––– MOOD STABILIZERS –––––––––––––
orthostatic hypotension
Mood stabilizers: Tx acute mania and prevent relapses
of manic episodes, includes lithium and
anticonvulsants (valproic acid, lamotrigine,
carbamazepine)
Li+ side-effects: LMNOP – Lithium causes
Movement (tremors →Tx propanolol),
Nephrogenic DI, Narrow TI (0.6-1.2),
hypOthyroidism (Tx Synthroid), Pregnancy
problems (Ebstein’s anomaly)
Li+ level factors: NSAIDs (↑ except aspirin),
dehydration (↑), salt deprivation (↑), sweating (↑),
renal failure (↑), diuretics (↑)
Lithium overdose: if blood level >4.0, hemodialysis
Lithium duration: maintain use for 1 year following single
episode, maintain for lifetime if 3+ relapses
Lithium × HTN: Tx Ca2+-channel blockers
––––––––––––– ANTICONVULSANTS –––––––––––––
Carbamazepine (Tegretol): good for rapid-cycling
bipolar disorder and trigeminal neuralgia; takes 5-7 days
for onset and requires CBC/LFT monitoring
CBZ side-effects: BATHS – Blood dyscrasias, P450
Autoinduction, Teratogenic, Hepatotoxic, Stevens-
Johnson syndrome
Valproic acid (Depakote): requires CBC/LFT/VPA
monitoring
VPA side-effects: 4 Fs – Fat (weight gain), Farts (GI
distress), Fatal hepatotoxicity, Fetal teratogen (neural
tube defects)
Lamotrigine (Lamictal): can ↓VPA levels, causes
Stevens-Johnson syndrome so raise levels slowly
Topiramate (Topamax): causes weight loss, cognitive
slowing (aka Dopamax), kidney stones
Gabapentin (Neurontin): good for chronic pain
Oxcarbazepine (Trileptal): rarely used
Pregabalin (Lyrica): rarely used
Tiagabine (Gabatril): rarely used
–––––––––––––––– ANXIOLYTICS ––––––––––––––––
Anxiolytics: benzodiazepines, barbiturates, and non-
benzodiazepine hypnotics/anxiolytics
BDZ overdose: give flumazenil
Non-liver metabolized BDZ: LOT – Lorazepam, ECT method: pt put under general anesthesia and
Oxazepam, Temazepam muscle relaxant, then electrodes induce a seizure;
efficacy based on length of postictal suppression
Long-acting BDZ: T½ >20 hrs; includes diazepam
(Valium) and clonazepam (Klonopin) ECT side-effects: amnesia (MC), headaches, muscle
soreness, confusion
Intermediate-acting BDZ: T½ 6-20 hrs; includes alprazolam
(Xanax), lorazepam (Ativan), oxazepam (Serax), and ECT electrodes: bilateral electrodes ↓number of
temazepam (Restoril) sessions but ↑amnesia and confusion
Short-acting BDZ: T½ <6 hrs; includes triazolam (Halcion) ECT efficacy: 75%
and midazolam (Versed), used mainly in medical and
surgical settings ECT c/i: recent MI, anything w/ possibility of
hemorrhagic stroke (raised ICP, aneurysms, bleeding
d/o, BBB distruption)
Barbiturate overdose: Tx IV NaHCO3
Chloral hydrate (Somnote): sedative, rarely used due to
tolerance/depedence and liver toxicity
Ramelteon (Rozerem): melatonin MT-2/3 agonist used
for sedation, no tolerance/depedence
Buspirone (BuSpar): 5-HT1A partial agonist given for
anxiety, useful in alcoholics (no EtOH potentiation like
BDZ)
Diphenhydramine (Benadryl): antihistamine given for
sedation, ↑anticholinergic side-effects
Hydroxyzine (Atarax): antihistamine given for
anxiety, ↑anticholinergic side-effects
Propanolol:β-blocker used to Tx panic attacks,
performance anxiety, and akathisia
––––––––––––––– OTHER DRUGS –––––––––––––––
Amphetamines (Dexedrine, Adderall): schedule II (↑abuse
potential), monitor BP and watch for weight loss, insomnia
Methylphenidate (Ritalin, Concerta): schedule II (↑abuse
potential), monitor BP/CBC/LFTs and watch for weight
loss, insomnia
Atomoxetine (Stattera): ↓appetite suppression and
insomnia, but ↑hepatotoxicity and SI in adolescents
Modafanil (Provigil): used in narcolepsy
Memantine (Namenda): NMDA blocker used for
moderate-severe Alzheimer disease
–––––––––––– OTHER TREATMENTS ––––––––––––
Electroconvulsive therapy: Tx refractory depression; 8-12
sessions given 3/week then monthly ECT to prevent
relapse; safe for pregnant and elderly
Deep brain stimulation: Tx chronic pain, Parkinson’s disease, tremor, and dystonia

DBS method: implant device in brain that sends regular electrical impulses to specific regions, high risk of surgical complications
Repetitive transcranial magnetic stimulation: noninvasive method to excite neurons via electromagnetic induction, Tx psychiatric conditions but modest effects at best

rTMS side-effects: rare seizures, discomfort at the delivery site

Light therapy: Tx seasonal affective disorder

––––––––––––––– LEGAL ISSUES ––––––––––––––– Mental disability: inability to meet personal, social, or occupational demands due to
Forensic psychiatry: psychiatry + legal issues mental impairment

Legal issues: two types – criminal if being charged with a crime, civil if other rights are th th
Competence: legal term for pt’s ability to make informed treatment decisions; 6 + 14
violated
amendments require competence to stand trial

Standard of care: skill level and knowledge base of the average psychiatrist
th
6
Negligence: practicing below standard of care amendment: right to counsel and to confront witnesses

Malpractice: act of being negligent as a doctor; must meet the 4 Ds – Deviation 14th
(neglect) from Duty that was the Direct cause of Damage
amendment: right to due process of law
Damages: reward for malpractice case, includes compensatory damages (financial
reimbursement) and punitive damages (money awarded to punish the doctor) Conviction: judgment of guilty in a criminal case; requires both actus reus (evil deed)
and mens rea (evil intent)
Confidentiality: nondisclosure of information except to another authorized person
Insanity defense: if someone is declared legally insane, they are not criminally responsible
Exceptions: COPS – Child abuse, Other staff involved in pt’s care, Potential harm to for the act
others, Subpoena, Suicidality (i.e. not guilty by reason of insanity, NGRI)

Tarasoff duty: legal obligation to breach patient confidentiality and warn potential Insanity defense standards: M’Naghten rules,
victims about a pt who may physically harm them American Law Institute (ALI) model, Durham test

Child abuse: doctors are required to contact child protective services, lawyers are not M’Naghten Rules: person does not understand
what he was doing or its wrongfulness
Informed consent: pt knowingly and voluntarily agrees to a treatment or procedure;
includes 4 Rs – Reason for Tx, Risks and benefits, Reasonable alternatives, and Refused ALI Model: person could not appreciate right
Tx consequences from wrong or could not control his/her actions
(aka “irresistible impulse” test)
Exceptions: medical emergencies, suicide or homicide prevention, unemancipated
minors receiving obstetric care, STD Tx, or substance abuse Tx Durham Test: person’s criminal act has resulted
from mental illness
Emancipated minors: do not need parental consent to make medical decisions; minors are
emancipated if self-supporting, military, married, or have children Violence risk assessment: h/o violence (#1 factor), h/o impulsivity, specific threat w/ a
plan, psychiatric illness, substance abuse
Capacity vs. competence: both refer to pt’s ability to
make informed treatment decisions, but capacity is a medical term and competence is a
legal term
––––––––––––––– OTHER ISSUES –––––––––––––––

Decisional capacity: task specific

Expert witness standards: evidence must be accepted by appropriate scientific
community (Frye 1923), and judge decides if evidence is based on relevant and reliable
Guardian: appointed to make treatment decisions for incompetent pts
science (Daubert 1993)

Voluntary admission: pt checks self into psych ward, may not have the right to be
Malingering: feigning or exaggerating sx for secondary gain (e.g. money, drugs, avoiding
discharged immediately upon request
work)

Involuntary admission: pt checked in for potential harm or inability to provide for basic
Malingering buzzwords: ASPD, h/o substance
needs; supported by legal principles of police power and parens patriae
Parens patriae: protecting citizens who can’t care abuse, “doctor shopping”, textbook description
for themselves of illness, symptomatic only when observed

Child forensic psychiatry: involves child custody, child abuse/neglect, termination of

parental rights
––––––––––– DISABILITY & INSANITY –––––––––––

Correctional psychiatry: involves balancing confidentiality vs. violence

Mental impairment: loss or derangement of a mental function
–––––––– EXAMINATION AND DIAGNOSIS ––––––––
Prevention: PDR – 1° is Prevention, 2° is Detecting
disease, 3° is Reduction of disability
Circumlocution: substitution of a word or
description for a word that can’t be recalled (e;g; “that
Police power: protecting citizens from each other
thing you write with”) Abuse vs. dependence: inability to quit despite
knowledge of harm best indicates dependence over
Tangentiality vs. circumstantiality: tangentiality never abuse
comes back to original topic, circumstantiality eventually
does Verbigeration: repetitive, meaningless talking
Glossolalia: ability to speak a new language suddenly Hamilton Depression Scale: used to measure
depressive sx
––––––– SUBSTANCE-RELATED DISORDERS ––––––– Nasal
––––––––––– PSYCHOTIC DISORDERS –––––––––––
best interest
Pt refuses tx: respect pt wishes, unless it puts others at
risk (e.g. infx) → requires involunary admit

Dementia praecox: another name for SCZ
Psychogenic polydipsia: SCZ pt drinks too much
water causing hyponatremia (Na+ <135)
SCZ brain: diffuse atrophy with decreased size of
hippocampus, parahippocampal gyrus, amygdala
Koro: Asian pt believes that his penis is shrinking and will
disappear causing his death
Amok: sudden unprovoked outbursts of violence of
which the person has no recollection (think “to run
amok”)
Brain fag: headache, fatigue, and visual disturbances in
African male students
Ataque de nervios: Puerto Rican trance d/o with
convulsions, fainting, crying, and visual problems
Mal de ojo: Mediterranean “evil eye”
Sangue dormido: Portugese d/o with numbness, tremors,
paralysis, convulsions, stroke, heart attack
septum erythema: cocaine abuse Rotary or vertical
nystagmus: PCP abuse Injected eyes: marijuana (cannabis)
abuse
––––––––––– COGNITIVE DISORDERS –––––––––––
Delirium Dx: abnormal EEG Dementia Dx: MRI Multiple
sclerosis brain: multiple plaques of frontal
white matter
Pseudoseizure: resembles seizure but normal EEG
Localized amnesia: memory loss surrounding a
discrete period of time
Selective amnesia: inability to recall certain aspects of an
event
–––––––––– PSYCHOPHARMACOLOGY ––––––––––
Placebos: 33% efficacy for depression Antidepressants: 70%
Parents refuse tx for minor: nonemergent and not fatal
→ respect parent wishes; nonemergent but potentially
fatal → get court order; emergent → proceed w/ tx;
one parent agrees → proceed w/ tx
Kid w/ imaginary friends: completely normal
Teen w/ behavioral changes: get urine tox screen
Pt requests medical records: give it to them
Relative requests dx not be revealed to pt: ask relative
about reasoning, since pt has right to know
Family disagrees w/ advance directives: discuss
situation w/ family, if unresolved after meeting → call
ethics committee
Pregnant woman vs. fetus: woman has right to
refuse tx, even if it puts the fetus at risk
Depressed pt: ask about suicidal ideation

Dhat: anxiety and hypochondriasis regarding semen
discharge
Windigo: Native American d/o regarding possession by a
demon that murders and eats human flesh
efficacy for depression ECT: 75% efficacy for depression NE:
synthesized in locus ceruleus 5-HT: synthesized in raphe
nucleus DA: synthesized in substantia nigra ACh:

Autoscopic psychosis: VH of transparent phantom of synthesized in nucleus accumbens

one’s own body, aka doppleganger

–––––––––––––––––– ETHICS ––––––––––––––––––

Capgras syndrome: delusion that friends/family have been
Suicidal pt: admit to inpatient care (against will if
replaced by identical impostors
necessary)

Lycanthropy: delusion that one is a werewolf (or

Homicidal pt: admit to inpatient care
another animal)

Psychotic pt: acknowledge pt’s distress

Cotard syndrome: delusion that one has lost
everything, including one’s internal organs
Angry pt: encourage discussion about what’s
Kluver-Bucy syndrome: presents as docility, hyperphagia,
bothering the pt
hypersexuality, and disinhibition due to bilateral amygdala
lesions
Inappropriate pt: respond firmly but politely, remain
professional

––––––––––––– MOOD DISORDERS –––––––––––––
Postpartum blues: 20-40%, dysthymia that lasts <2
weeks, resolves spontaneously
Postpartum depression: 10-15%, resembles MDD
Postpartum psychosis: 0.1%, a subtype of bipolar
disorder, admit into inpatient care →Tx anti-psychotic
+ antidepressant
Bipolar disorder: 25% among relatives, average age of
onset is 30 y/o
Anorexic pt: admit to inpatient care if <75% ideal body
weight and/or medical complications
Abused pt: ask about abuse in an empathetic, open-
ended question
Suspected child abuse: complete a thorough
physical exam, then get X-rays, then call child
protective services if necessary
Breaking bad news: set the stage and assess pt’s
comprehension, then deliver news in empathetic
manner

Porphyria: presents as psychotic or manic sx + Medical error: admit the mistake and apologize
abdominal pain → get urinary porphobilinogen
Colleague makes medical error: always act in pt’s