Michael Wray

General Surgery - ComQuest

Hemoptysis: “massive hemoptysis” is >500mL expectorated blood over 24 hours. Or 100mL/hr. MC causes are TB, bronchiectasis, and lung abscess. Initial
management is hemodynamic stabilization. Then put lung in dependent position, and flexible bronchoscopy. (Diagnostic and therapeutic). Many
methods such as balloon tamponade, iced saline lavage, topical epi, laser therapy during bronchoscopy. Aterialography/embolization if bronch fails.
Nephrolithiasis: Presents with intermittent flank pain, crampy/sharp, N/V, hematuria, radiates to groin, urinary frequency. Treat with ketorolac/NSAID therapy
initially, first line imaging is non-contrast CT. Use a strainer for analysis. If it doesn’t pass, do shockwave lithotripsy.
Cellulitis: Infection of the dermis and subcue tissue. MC due to gram-positive cocci. (Staph aureus, GAS). Diabetes have increased risk of lower leg cellulitis due
to weaker immune system and venous insufficiency. If it is purulent cellulitis, need to be covered for MRSA. If mild without systemic symptoms, can
be controlled with orals; clindamycin, TMP/SMX, linezolid, doxy/tetracyclines. If systemic (fever, hypotension), need IV vancomycin. If non-purulent,
can be treated with MSSA dicloxacillin, cephalexin, clindamycin.
Post-op fevers: Day 5: commonly caused by wound infections. Usually contained within subcue tissue. Will complain of incisional site pain. PE may show
incisional erythema/edema, possible exudative drainage. Can culture swab to diagnose. TX is with drainage of the wound, leaving wound packed
open. Atelectasis is no longer considered a cause of post-op fever. Can be seen on x-ray. Have patient mobilize, deep breathing, cough.
Days 2-5: PNA or UTI is common causes during this time frame.
NEC: Necrotizing enterocolitis. Commonly associated with premature infants and starting formula feeding early on. Some association with PDA. High mortality,
can cause perforation. Presents with new onset feeding intolerance, distension, declining platelets, abdominal erythema, vomiting. If perforation
occurs, emergent surgery indicated. X-ray can show air in the bowel wall (pneumatosis intestinalis). Free air pocket under diaphragm = perforation.
Essentially: NEC: Discontinue enteral feeds, place an NG tube, start IV fluids and antibiotics. If free air is present, they need emergent surgery.
Perforation surgery includes laparoscopy or primary peritoneal drain. (Medical: Commonly used Ampicillin, Gentamicin, metronidazole).
S/p colonoscopy: Normally air insufflated into colon to help distend lumen/provide visualization. If the colon perforates during the procedure/after can cause
abdominal distension with significant abdominal pain. Distension + pain is perforation until proven otherwise. Can have dyspnea, SOB, hypotension.
Can have shoulder pain from diaphragm irritation. X-ray shows subdiaphragmatic air. TX IV fluids, antibiotics, and surgery for perforation repair.
Pancreatitis: Epigastric pain, N/V, unable to tolerate anything PO. MC cause is gallstones, then alcohol abuse. Gallstone may present with normal LFTs, but has
high association with elevated LFTs as well (mainly ALT as opposed to AST). Gallstones #1, associated with obesity. Look for history of alcoholism.
Look for hypotension, tachypnea, hypoxia, hypocalcemia, hypoglycemia to determine severity. Other causes: hyperTG, hyperCa2+, thiazides.
CT can look for complications such as pseudocyst/necrotizing pancreatitis. TX is with bowel rest, NPO, IV fluids.
Chronic mesenteric ischemia: Seen in elderly population with history of vascular disease (DM, HTN, atherosclerosis). Presents with abdominal pain ~1hr after
eating due to increase metabolic demand with decreased vascular supply. Subsides over a couple hours. Can lead to significant weight loss/food
fear. (Gastric CA presents with early satiety, wt loss, not pain). DX with angiography of vessels with narrowing/insufficiency. TX is revascularization
with angioplasty or surgical vascular reconstruction.
Gastroparesis: Seen most often in patients with DM due to glycosylation of the nerves controlling the stomach. Presents with intractable nausea and vomiting,
inability to tolerate foods, mild/moderate abdominal pain, early satiety. Commonly seen with coexisting DM and diabetic autonopathy. DX is
confirmed with scintigraphic emptying study, demonstrating retention of radiolabeled low-fat egg white meal. >605 at 2hrs or >10% at 4 hours.
Other causes: CMV, HIV, EBV, opoids, clonidine, CCBs, TCAs, surgeries, stroke, MS.
AAA: Asymptomatic or presents as pulsating mass. One time ultrasound recommended in any male that has ever smoked at 65-75 to screen. If it is >5.5cm,
elective surgical repair is indicated. If less than 5.5cm, follow up US. (4-5.4cm, q6-12months. If less than 4cm, q2-3 years). Surgical tx is with open
repair vs. endovascular repair. Endovascular has less mortality, but less definitive. Repair also indicated if >0.5cm increase in 6months.
CMV colitis: MC seen in HIV patients with CD4 <50. Can manifest as colitis, esophagitis, enteritis, retinitis, or large painful ulcers of oropharynx or anus.
Presents with abdominal pain, weight loss, anorexia, fatigue, diarrhea. Tenesmus and hematochezia can be present. Will see colonic ulcerations.
Pathologic tissue shows intranuclear/cytoplasmic inclusions. TX with ganciclovir/foscarnet. (MAC is <CD50 as well, prophylaxis with azithromycin).
Celiac disease: Due to abnormal immunologic response against gluten. Presents with watery diarrhea, steatorrhea, weight loss, distension, weakness, muscle
wasting, flatulence, foul stools. Malabsorption can occur, vitamin deficiencies, B12 deficiency/folate. Megaloblastic anemia. Associated with
dermatitis herpetiformis-papulovesicular rash of extensors, scalp, neck. ComplicationsOsteomalacia/osteoporosis (VitD), depression, arthritis, iron
deficiency, IgA nephropathy. TX avoid gluten.
Crohns: Can affect any part of GI tract. Presents with crampy abdominal pain, low-grade fevers, non-bloody diarrhea, heme-positive stool. Perianal disease
demonstrating fissures, fistulas, abscesses commonly seen. Colonoscopy shows skip lesions, transmural inflammation, fistulas, ulcerations, strictures.
Endocarditis: Presents with fever, new systolic murmur, rash, skin changes, janeway lesions (red maculopapular lesions, palms/soles), splinter hemorrhages,
roth spots (retinal hemorrhages), patehechial rash, osler nodes (tender subcue papules) on pads of fingers. DX with blood cultures for bacteremia
and transesophageal echo (to see vegetations). MC cause is staph auereus in IV drug abuses, strep viridans in already damaged valves, strep mitis
from dental flora. Strep bovis is associated with colon cancer.
Epidural hematoma: May have initial loss of consciousness with transient regain in mentation, then return to ALOC. Due to rupture of middle meningeal
artery. Confined by suture lines, causes a biconvex hyperintense lesion. TX is surgical intervention with craniotomy and evacuation. (SDH is crescent)
Compression fracture: Vertebral compression fx MC type of fx associated with osteoporosis. MC location is mid-thoracic region, due to mild trauma, such as
coughing, sudden bending, lifting, falling from standing height. Often asymptomatic. If symptomatic, first line treatment is NSAIDs/Tylenol. Opiates
can considered in acute presentation. Watch renal function with NSAIDs. Nasal calcitonin has some efficacy in poor response to oral analgesia. Used
over 2-4 weeks before transitioning to bisphosphonate therapy. Vertebroplasty is generally reserved for treatment failure with conservative therapy
or if patient has pathologic fractures from multiple myeloma.
Multiple myeloma: Clonal plasma cell malignancy. Presents as bone pain worse with movement. Often associate with renal failure, proteinuria, hypercalcemia.
Spine and ribs most affected. Lesions with MM are lytic as opposed to blastic lesions of prostate cancer. Can see light chains in the urine/bence jones
protein. Also an M spike of IgG on electrophoresis. X-rays show “punched out” appearance of bone.
Prostate cancer: Older males. Presents with urinary complaints/obstruction, hesitancy, inability to void. May complain of bone pain due to sclerotic/blastic
lesions to the bone, usually worse at night (opposed to MM which is worse with activity).
Gout: Precipitation of monosodium urate crystals in the joint space. Negatively birefringent. S/S: swelling, erythema, effusion, limited ROM, severe pain. Risk
factors are surgery volume depletion, trauma, alcohol use, high meat/seafoods. First line therapy is NSAIDs > Colchicine > Steroids.
Colchicine is contraindicated in liver disease or being on other drugs that use P450 system. Side effects of abdominal pain, vomiting, diarrhea.
Prophylaxis is with Allopurinol, fuboxestat, probenecid (none used in the acute presentation). Usually started after 2 attacks.
 Michael Wray
Acute arterial occlusion: Acute limb ischemia often caused by embolus from elsewhere. Risk factors of obesity, atherosclerosis, previous MI, afib. Femoral,
popliteal, and pedal arteries most commonly affected. Presents with pulseless, change in color, pain, pallor, cold extremity. Absence of pulses is
diagnostic. TX is with emergent surgical revascularization. If the extremity was viable (with a pulse, no change in color, do heparin + arteriography).
Sialolithiasis: Presents with local pain and swelling, generally under tongue, in location of submandibular gland, when pt is trying to eat. Due to a stone in a
salivary gland. Pain subsides 1hr after eating. Can be felt on PE as a pebble sized hard mass on floor of mouth. DX can be made with intraoral
radiographs or sialography and CT. TX is aimed at extracting stone, can be done by serial dilation of the duct and expelling stone.
Ischemic colitis: Presents with abdominal pain, particularly LLQ with bloody diarrhea. Often due to post-op after abdominal aortic repair due to
occlusion/partial occlusion of blood flow through IMA to the rectosigmoid colon. Any portion can be affected, but mainly rectosigmoid. DX with
sigmoidoscopy to examine mucosa, can appear edematous/hemorrhagic. TX with bowel rest, IV fluids, antibitics. If it is necrotic (septic/peritoneal
signs), then bowel resection will be needed.
Dumping syndrome: MC occurs after gastric bypass/bariatric surgery. Bypass allows for increased transit of food contents into small intestine. Causes a rapid
solute load with massive fluid shift into small intestinedumping syndrome. Early or late forms. Early form presents with N/V, diarrhea, bloating,
diaphoresis, tachycardia, lightheadedness 15-30min after. Late is caused by rapid release of insulin in response to CHO load, 1-3hrs after, presents
similar to hypoglycemia, weakness, diaphoresis, dizziness.
Small bowel obstruction: MC causes are surgical adhesions, malignancy/recurrent, hernia. Presents with acuter onset abdominal pain, distension, N/V.
Abdomen will be distended with hyperactive/high-pitched bowel sounds (initially), diffuse tenderness. Best test is upright and lateral abdominal
radiographs showing air-distended loops of small bowel with classic stacked coin look and air fluid levels. TX is nasogastric tube placement to
decompress, IV fluids, bowel rest. If it is caused by malignancy, surgical intervention needed.
Zenker’s diverticulum: Outpouching of esophageal mucosa that develops at the pharyngoesophageal junction. It develops insidiously in older patients.
Presents with dysphagia, HALITOSIS, regurgitation of undigested food. Dx confirmed with barium esophagogram demonstrating
dilation/outpouching in the esophagus. TX is with surgical diverticulectomy. (EGD can cause perforation in ZD)
Often occurs in the posterior pharynx and proximal esophagus in the area of the Killian triangle.
Acute blood loss anemia: Commonly due to surgery/trauma, but can be due to any acute hemorrhage (s/p stent placement on anticoagulants, variceal bleeds,
diverticulosis, etc). Initial hgb/hct are almost normal, low reticulocyte count. As fluids are given, hgb will drop due to intravascular dilution.
Acute anemia typically normocytic as well. (Anemia of chronic disease also normocytic/low retic, look for chronic inflammatory disease/high ferritin).
Insulinoma: Neuroendocrine tumor of pancreas of beta-cells. Presents with S/S hypoglycemia (Diaphoresis, N/V, blurry vision, confusion, weakness, tremor).
Long-standing insulinoma patients have hypoglycemia unawareness, whereby they adapt to chronically low serum glucose, no sxs until it’s severe.
Labs are important to distinguish from factitious. Insulinoma will have high insulin, c-peptide, and proinsulin. Whereas exogenous will have low c/pro.
Osteosarcoma: MC primary bone malignancy. Mostly in children. Affects metaphysis of long bones. Most notably the distal femur/proximal humerus.
Presents with dull pain, improves initially, then reoccurs .Can have fevers, chills, weight loss, soft-tissue mass. X-ray shows sunburst pattern.
Diagnosis requires BIOPSY. MRI can show extent of lesion/mets. TX is with chemo/surgical excision.
ASD: S/S may not present until adulthood. May complain of fatigue, dyspnea, or asymptomatic. Presents with systolic ejection murmur over left sternum with
FIXED SPLIT S2 (Due to shunting of blood from L to R atrium, causing increased right ventricular volume/preload, eventually causes pulmonary
hypertension). DX with echo. TX is with surgical ductal closure.
VSD: MC heart defect. Often asymptomatic if defect is small. Presents with holosystolic murmur. Murmur is louder with smaller defects, less loud with larger
defects. Large defects can cause pulmonary vascular congestion and right heart failure. Small defects usually left alone.
Pancreatic CA: 4th leading cause of cancer death due to advanced stage at diagnosis. MC presents with jaundice, weight loss, and epigastric pain. Occasionally
presents with palpable mass. Courvoisier’s sign is a palpable gallbladder, associated with pancreatic cancer of the head causing obstruction with
bile flow backing up. Alk phos and CA19-9 will be elevated, but not specific. TX if lesion is <4cm is whipple/pancreaticoduodenectomy + chemo.
Carpal tunnel syndrome: Presents with tingling/pain in the wrist and first three digits. First line therapy for mild/moderate is wrist splitting, especially at night.
Epidural spinal cord compression: Usually from cord compression from spinal tumor/metastatic disease. First step is high dose IV steroids, then MRI.
Sigmoid volvulus: More common with advancing age/debilitated patients/psychiatric illness. Decreased colonic motility might be predisposing factor. It is due
to torsion of sigmoid colon leading to large bowel obstruction. Sigmoid presents in elderly with abdominal pain, distension, CONSTIPATION,
palpable abdominal mass, (sometimes in LLQ). DX can be made with plain film with dilated sigmoid colon, lacking haustral markings, looks like a
coffee bean. TX is with sigmoidoscopy and rectal tube placement. Surgery if peritonitis/gangrene suspected (mesosigmoidopexy).
(Volvulus can also present with high pitched/tinkling bowel sounds like SBO, but SBO is predominately vomiting, whereas volvus is constipation).
Cecal volvulus: Results from twisting of the cecum and portion of ileum, around it’s mesentery. Presents with colicky RLQ pain, N/V, constipation, distension.
Patients are usually 30-50 years old (compared to elderly patients for sigmoid/nursing home). Colic type cramping pain secondary to volvulus.
Rectal vault devoid of stool. X-ray shows large dilated loop of bowel, loss of haustration, originating from RLQ. Barium enema to confirm dx. Enema
appears as a bird beak. TX with IV fluids, colonoscopy decompression, surgical resection of affected bowel segment to prevent reoccurrence.
Angle-closure glaucoma: Ocular emergency, requires urgent treatment. Caused by blockage of aqueous humor outflow from posterior to anterior chamber of
eye. Asians at higher risk. Acute attack often happens in low light conditions. Presents with sudden onset, N/V, HA, vision changes, cloudy cornea,
painful eye with conjunctival erythema. Confirmed by visualization of the angle under slip lamp (goniscopy). Tonometry can demonstrated elevated
pressures.
Neuroblastoma: MC intra-abdominal malignancy of childhood. Arises from neural crest tissue of adrenal medulla or sympthathetic ganglia. Presents with
abdominal pain, hypertension (catecholamines), diarrhea (VIP), and a firm, fixed abdominal mass. Can have fever, weight loss, bone pain. REtrobular
mets cause proptosis, unilateral horner syndrome. Can also see opsoclonus-myoclonus “dancing eyes dancing feet”. DX with ultrasound. See
calcifications on imaging and CROSSES MIDLINE. Can diagnose with biopsy or getting serum/urine catecholamines.
Wilms tumor: Second MC abdominal tumor from renal parenchyma. Usually incidentally found. Can be found as firm, smooth mass, RARELY crosses midline.
Hypertension and hematuria can be seen. Mets to lungs. TX with surgical resection + chemo.
Intracerebral hemorrhage: Type of hemorrhagic stroke, bleeding into cerebral parenchyma. Risks: chronic HTN, smoking, obesity, diabetes. Presents with HA,
N/V focal neurologic deficits developing over minutes to hours. Confirmed with CT showing signal hyperintensity. Manangement is primarily medical
depending on site/size. Admit to ICU for BP control. HTN leads to weak penetrating vessels in the deep brain. MC sites are thalamus and putamen.
Thalamus stroke presents with downward medial gaze and impaired upward gaze with contralateral sensorimotor deficit. Goal systolic BP is 180.
Do not lower BP too aggressively, as it may disrupt perfusion to rest of the brain.
Ampula of vader carcinoma: Ampulla is a projection into the duodenum. Best test to diagnose carcinoma of ampulla is ERCP. Can visualize and take a biopsy.
 Michael Wray
Dupuytren contracture: Slow progressive disorder of the hands. Leads to thickened palmar fascia and results in contracture of the hand. Unknown etiology.
Presents with nodular/thick cords of the palm and flexion contractions of 4th and 5th digit. Surgery is indicated for functional impairment or >30
degrees of flexion deformity. MC in white males, increased risk with smoking, alcoholism, DM, repetitive hand movements. Collegenease has been
approved for people who do not want surgery. Glucocorticoid injections can be used for mild cases for pain.
Hepatic abscess: Presents with fever, RUQ pain, fatigue. CT scan confirms diagnosis of peripherally enhancing lesion within liver parenchyma. Big risk factor is
recent infection. Often due to direct extension from ascending cholangitis and seeding from diverticulitis or appendicitis from portal vein spread.
TX is antibiotics with percutaneous or surgical drainage.
Post-op fever: 5 Ws. Wind (Atelectasis 1-2d), Water (UTI, 3-5d), Walking (DV, 4-6d). Wound (infection 5-7d), Wonder drugs (drug fever, days 7+)
Cricothyroidotomy: Used after intubation failure (endotracheal edema, etc). (Surgical cric in adults, needle cric in kids). (ETT > LMA > Cric)

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Diverticulitis: Inflammation of colonic diverticulum. Presents with LLQ pain and fevers. Risk factors are low-fiber diet, softer stool puts weak spots in colonic
lumen, while high fiber diet can protect against getting tics, but not recommended during acute flare. TX is fluids, bowel rest, generally clear liquid
diet, metronidazole and ciprofloxacin or amox/clav and Cipro or tmp/smx. Patients that are hemodynamically unstable (or microperf vs. abscess)
need admission and IV antibiotics. Recurrent diverticulitis may need resection of the colon.
Erbs palsy: Damage to the superior trunk C5-C6. (C7 is middle. C8-T1 is inferior trunk (klumpkeys)). Arm is medially rotated, hangs by side, hand pronated.
Nerves affected are suprascapular, MSK, and axillary nerves. Loss of innervation to biceps, deltoid, brachialis. DX with NCStudy or EMG.
TX is often with PT then surgery if refractory to conservative treatment. Mechanism commonly due to direct injury/trauma to plexus.
Klumpkeys palsy: Damage to inferior trunk C8-T1. Arm makes a claw hand with flexed digits. Commonly from upper limb being pulled superiorly quickly.
Neck zones: Horizontal zones of the neck. Zone 1 is from clavicles up to cricoid cartilage. Zone 2 is cartilage to jaw. Zone 3 is jaw and up (below ear essentially)
Zone 2 penetrating injuries MC (knife wounds, etc). Requires emergent surgery. Zone 1 requires CT angiogram. Zone 3 requires CT with contrast.
Blunt abdominal injury: Lower abdomen: Can cause urethral trauma. Appearance of blood at the urethral meatus and high riding prostate are concern for
urethral injury. Need retrograde urethrogram. This has to be done before placement of urinary catheter. Urethrogram will cause contrast
extravasation if injury is present. Treatment requires surgical repair by urethrocystoscopically. May need temporary suprapubic cath.
Epididymitis: Bacterial infection of the epididymis. Presents with scrotal pain, erythema, swelling, edema, fever, leukocytosis. Will worse over days.
Treatment is with antibiotics and analgesia. Risk factors are non-barrier sexual activity.
Testicular cancer: Presents as painless solid scrotal mask. Biggest risk factor is cryptorchidism. Initial workup is ultrasound + tumor markers of hcg, AFP, etc.
MC site is metastatic disease to retroperitoneal lymph nodes/periaortic. Abdominal/pelvic CT required to evaluate for mets. TX is with excisional
biopsy/radical inguinal orchiectomy.
Temporal arteritis: White females >50. Giant cell vasculitis. Can include aorta/extracranial branches. S/S: Fatigue, myalgias, headache, jaw claudication, vision
loss from optic neuritis, must be treated with high dose steroids. Gold standard for diagnosis is temporal artery biopsy. TX: high dose steroids.
Bacterial sinusitis: Suspect bacterial over viral after 7-10 days of symptoms, double sickening, purulent nasal drainage, 102 fever. First line is amox-clavulanate.
Get CT if atbx treatment failure or severe HA/diplopia/periorbital edema/visual acuity changes, or symptoms >12 weeks. Doxy for pen allergic.
Pituitary microadenoma: Less than 10mm. When asymptomatic, only need to get an endocrine panel (prolactin only). Monitor with prolactin levels.
Anterior medialstinal masses: Usually from the “Ts” ectopic thyroid tissue, thymma, teratoma, or terrible lymphoma.
Thymoma: Anterior mediastinal mass, well known for causing myasthenia gravis-autoimmune Ab against post-synaptic ACh receptors. Presents with muscular
weakness after use with rest improving symptoms. Often associated with diplopia and bulbar/dysphagia symptoms. Do excisional biopsy.
Pinealoma: MC type of tumor associated with parinaud syndrome a range of ocular motion abnormalities, most notably upward gaze paralysis and setting sun
appearance of the eyes. Downward gaze preference. Can have S/S of increased ICP, HA, n/v, blurred vision. TX with surgical removal w/w/o chemo.
Pregnant DVT: or PE. First line therapy is LMWH heparins. LMWH has been shown to be better alternative to unfractioned heparin.
MC in the LLE/left iliac vein due to external compression from uterus. Diagnose with compression ultrasound.
Brain tumors: Presents with progressively worsening symptoms of headache, worse in morning, blurred vision, papilledema, unprovoked vomiting, seizures.
Primary biliary cirrhosis: Autoimmune disease that results in destruction of interlobular bile ducts within the liver. Without treatment, cirrhosis and liver failure
results. Presents with cholestasis, pruritus, hyperpigmentation, hepatomegaly, fatigue. Diagnosis made based on elevated alk phosphatase and
anti-mitochondrial antibodies. Biopsy will show cholangitis and destruction of bile ducts, supportive, but not required for diagnosis (if neg AMA).
Usually a liver biopsy is done after to determine the amount of damage to the bile ducts.
Primary sclerosing cholangitis: Presents also with cholestatic liver pattern, however, there is no hyperpigementaiton. It is commonly associated with ulcerative
colitis (Also primary biliary cirrhosis is more associated with middle aged females).
Celiac disease: immunologic response to gluten. Results in chronic diarrhea, malaborsption. Can cause megaloblastic anemia. Presents with non-bloody
diarrhea, steatorrhea, weight loss, distension, weakness, wasting, flatulence, fatigue, foul stools. Dermatitis herpetiformis is associated. Patients have
IgA endomesial antibody positivity and IgA tissue transglutaminase antibody. TX with gluten avoidance.
Craniopharyngioma: Rare, benign epithelial mixed solid-cystic calcified sellar masses. Remnants from rathkes pouch. Bimodal age. Commonly presents with
increases intracerebral pressure of the optic chiasm and HA/N/V. Children commonly have growth failure due to hypothyroid/hypoGH. MRI to dx.
Commonly presents in children. Treatment is with surgical resection.
Medulloblastoma: MC malignant brain tumor in children. In cerebellum. Presents with HA, vomiting, AMS, ataxia, gait instability. DX MRI with
midline/paramedian mass within cerebellum. Confirm with pathologic analysis.
Hypocalcemia: Common complication s/p total thyroidectomy. PTH can drop post-op causes hypocalcemia. Presents with perioral numbness and muscle
spasms. Will have positive Chvostek sign and trousseau sign.

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Bells Palsy: Idiopathic paresis of the face. Commonly unilateral full facial palsy, including the forehead. Often has altered taste sensation and can have
associated ear pain, lacrimation (poor eye closing, need for eye drops due to possible corneal abrasion). Bilateral causes are rare, usually due to lyme
disease, GBS, leukemia, sarcoidosis, trauma, mono. Tx is with prednisone/steroids. Antiviral drugs have no benefit.
Bacterial peritonitis: Commonly presents with fever, ascites, AMS. Due to infection of the ascites fluid without clear intra-abdominal source. Thought to be due
to bacterial translocation across bowels. Patients with ascites, fevers, AMS have spontaneous peritonitis until proven otherwise. US can diagnose
ascites, but paracentesis is required. Showing ANC>250, or +ascetic fluid culture without secondary source. TX IV antibiotics.
Facial trauma: In patients with severe facial trauma, the best airway to obtain is an emergent cricothyroidotomy (not tracheostomy, which requires OR).
Orotracheal/nasotracheal is relatively contraindicated due to likely failure. After cric, trache tube can be placed after dilating the hole.
Pancoast tumor: Tumor of the apex of the lung, can initially present with upper extremity weakness, pain, and atrophy due to damage to brachial plexus.
Sympathetic ganglia can be affected, causing horner’s syndrome (anhidrosis, miosis, ptosis, enophthalmosis). Next step is chest x-ray/CT of thorax.
 Michael Wray
Follow up bronch often done for histo. Usually SCC or adenocarcinoma. Large association with smoking. TX is radiotherapy and resection.
Tumor markers: CEA is found in colorectal cancer cells, but also many cells through body and is non-specific. A baseline is usually gotten and tracked after colon
cancer removal. CEA is colon cancer. AFP is hepatocellular. CA-125 monitors ovarian cancer. CA19-9 monitors pancreatic cancer progression.
Subdural hemorrhage: Blood between dura and arachnoid membrane. Caused by traumatic rupture of bridging veins. Symptoms vary from mild headache to
coma. Dilated ipsilateral pupil and contralateral hemiparesis may be present if there is brain herniation. Can be acute/sub/chronic forms. Acute
within 24 hours. Subacute is up to two weeks. Chronic after two weeks. Surgical evacuation indicated if hematoma >10m or midline shift >5mm,
regardless of GCS. SDH more common in elderly due to larger space/atrophy. Or alcoholics have increased risk and in child abuse.
Splenectomy: Spleen has MO that phagocytose opsonized bacteria and senescent RBCs. Lack of spleen increases risks for infection with H flu, N meningitidis,
strep pneumo. (Aka an adult can present with epiglottitis). Vaccination recommended for all three in patients s/p splenectomy.
The most common cause of post-splenectomy sepsis is strep pneumo.
Sigmoid volvulus: Associated with elderly, nursing homes, constipation, dementia, abdominal pain, distension, constipation. Due to elongation of sigmoid
from chronic constipation, greater tendency to become free moving around it’s mesentery. X-ray will show large loop of bowel originating from LLQ.
TX is decompression with colonoscope/sigmoidoscope with surgical resection of affected bowel.
Coarctation: Congenital narrowing of thoracic aorta distal to origination of left subclavian. Thought to be of abnormal migration of tissue. With severe
obstruction, there will be cyanosis distal to obstruction (in the LE) with normal UE perfusion. Patients will have upper extremity hypertension
compared to lower extremities. Can have decreased or absent femoral pulses. Rib notching from collaterals. DX with echo. TX with surgical repair.
Esophageal foreign bodies: Most pass without complications, but those that become lodged in esophagus present with dysphagia, odynophagia, excessive
drooling, and will need emergent endoscopy. Other indications are airway compromise or disks shaped/watch batteries. Look for
crepitus/swelling/erythema of subcue tissue to demonstrate perforation. Usually DX with x-ray, CT if it’s non-radiopaque.
Acute urinary retention: Mainly males secondary to BPH. Presents with inability to void, suprapubic pain, restlessness. If severe enough can cause N/V. Can feel
distended bladder with tenderness. Can cause acute renal insufficiency secondary to obstruction. Tx with urinary foley cath placement. (Decompress
BPH determined by uniformly enlarged smooth prostate. Subrapubic cath not needed, foley will work.
AVNRT/SVT: MC form of SVT: Presents with dizzy, dyspnea, palpitations. First line therapy is Valsalva/carotid massage or amiodarone. But if unstable, they
need electrical cardioversion.
Bezoar: Foreign body in the stomach resulting from accumulation of ingested material most commonly hair (trichobezoar) veggie matter (phytobezoar) and
medications. Risk include trichophagia, vagotomy, pylrooplasty/gastric surgeries. Presents with insidious cramping abdominal pain, nausea, satiety,
anorexia, weight loss, halitosis. GI bleeding can occur. DX with endoscopy. TX with chemical dissolution (Coca-cola gastric lavage), surgery, or endo
Nec Fasc: Life-threatening tissue infection of subcue tissue and fascia, leads to necrosis and systemic toxicity. POlymicrobial. Risks include DM, alcoholism, PVD,
IV drug abuse. Presents with severe pain out of proportion to PE, tachycardia out of proportion to fever. Affected site often has expanding erythema
and appears swollen. CT/MRI to diagnose demonstrating fascial thickening, edema, subcue gas. TX emergent surgical exploration and debridement.
(Suspect in people with prior wound that becomes infected and is refractory to antibiotic therapy. Remember fasciotomy is for compartment synd).
Acute MR: Commonly presents 12-48hrs s/p inferior wall MI secondary topapillary muscle rupture. Presents with acute pulmonary edema, JVD, (acute HF).
Blowing systolic murmur at the apex with associated S4 gallop. DX with TEE showing regurgitant blood flow through MV during systole.
Acute AR: MC a complication of infective endocarditis or dissection. Presents with SOB, hypotension, tachycardia, new onset blowing diastolic murmur.
AS: Presents with exertional dyspnea, angina, lightheadedness, dizziness with exertion, syncope. Systolic ejection murmur, radiates to carotids. DX TEE, +LVH
ZES: Caused by gastrin-secreting neuroendocrine tumor of the pancreas. Gastrin stimulates excessive gastric acid and then ulcers. Presents with gastric
ulcerations refractory to treatment. Often with associated diarrhea. Liver is MC site of metastatic spread. Can diagnose with serum gastrin level,
often >1000pg. Get CT for tumor localization, TX with high dose PPI and tumor resection. (Secretin stim test is next best if serum gastrin not dx).

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Afib RVR: Treatment of choice is diltiazem or verapamil or a beta blocker (metoprolol, propranolol, esmolol) all for rate control. However, if patients are on a
CCB or BB, then pharmacologic cardioversion is necessary with amiodarone.
Dog bites: Hands are most common. Treatment is with copious irrigation, debridement of devitalized tissue, removal of foreign bodies. Simple lacerations to
face are closed and given antibiotic prophylaxis. Deep wounds involving muscle require surgical consultation. Teatnus prophylaxis should be given.
Prophylaxis with antibiotics given with wounds involving face, genitals, puncture wounds that are deep, especially cat bites, wounds with crush
injury, wounds with venous/lymphatic damage, wounds of hands/feet, those that are close relationship to bone, immunocompromised, wounds that
need sx repair. Generally dog bite wounds to extremities are left often. Amox/clav is choice for all bite wounds.
Varicosities: Greater saph is the MC involved varicose vein. Caused by venous valve incompetence that results in venous pooling in the LE. Presents with
aching pain, heaviness, or burning pain in LE worse after prolonged standing. DX clinically. TX initially is compression in no ulcers present. If ulcers or
thromboplhelbitis are present, endovascular ablation is standard of care.
Retinal detachment: Separation between neurosensory retina and underlying retinal pigment epithelium. MC type represents a full thickness retinal tear or
hole that is MC seen in older age. Myopia and cataract surgery are risk factors. Presents with floaters, flashing lights, peripheral field defects, or
central vision defects or “black curtain falling over vision”. Can diagnose with funduscopic or ultrasound. TX laser photocoagulation.
Age macular degen: Central vision loss with sparing of peripheral vision. Dry and wet types. Dry is gradual central loss uni vs. bilat. Wet is acute onset visual
distortion or an acute loss of central vision. Dry type shows yellow drusen spots. Wet shows subreitnal fluid/hemorrhage.
Retinal vein occlusion: Sudden onset painless vision loss due to primary venous thrombus.
Otosclerosis: Presents with bilateral hearing loss in a patient in a third decade of life with PE findings consistent with conductive hearing loss. Will have fam hx.
Speech recognition is diminished, but paradoxically better in crowded rooms. AD pattern. PE shows red blush on TM (Schwartze sign).
Cholesteatoma: Desquamated epithelial cell collection I nmiddle ear or mastoid. Primary lesion or complication of TM perforation. Presents with hearing loss,
dizziness and otorrhea. DX visualized keratinized collection on otomicroscopy.
Schwannoma: Benign tumor that develops from schwann cells in CN8. Has no known genetic risk factors when unilateral, but bilateral is NF2 associated.
Presents with hearing loss and tinnitus. Get hearing test to to screen. MRI can be used to definitively diagnose.
Slipped-cap-fem: Common in male adolescents during growth spurt. Presents with groin and anterior thigh pain as well as a limp. Classic finding is external
rotation of the affected hip joint at rest. Femoral epiphysis shears off, leaves proximal femur end within acetabulum and allows femoral neck to
displace usually anterior and lateral. Can occur chronically or after traumatic event. DX with x-ray showing ice cream cone slip. TX surgical pins.
Ewings sarcoma: 2nd MC childhood bone tumor after osteosarcoma. Affects the diaphyseal regions of long bones. Bone pain is common along with fever and
weight loss. Recent trauma can bring on the dx. X-ray shows periosteal elevation, concentric bony layers (onion skinning), and mottling. MRI
necessary to determine tumor margins. Bone biopsy to determine diagnosis. Hx shows roud blue cells with hyperchromatic nuceli. TX sx, rad, chemo.
 Michael Wray
(Osteosarcoma usually does not have fever/wt loss and presents to metaphyseal portion of bone).
Colon cancer: MC occurs in people >50. Symptoms depend on location of lesion. Sigmoid colon presents with constipation, pencil/thin stools. (Sigmoid more
common than descending). Ascending presents with anemia, +blood in stool. Descending presents with large bowel obstructions, pain and
distension and constipation, but can have frank blood. (Sigmoid > ascending > transverse > descending). Overall left obstructs, right occult bleeds.
Keloids: Occurs as an abnormal response to cutaneous injury that is MC seen in blacks. Scar-like lesions develop due to abnormal wound healing from
overproduction of ECM proteins and dermal fibroblasts, causing hypertrophic scarring. Can be cause by any skin insult. First line therapy is with
intralesional corticosteroids (triamcinolone).
Aortic Stenosis TX: younger patients can tolerate increasing AS without symptoms, generally managed with serial US until EF is below 50% and are
symptomatic. Elderly that are symptomatic with an EF <50% require aortic valve replacement. (Usually exertional symptoms).
Fat embolism: Most often caused by long bone fractures. Occurs 24-72 hours after event. Presents with hypoxemia, AMS, petechial rash, tachypnea, SOB.
Caused by fatty globules from marrow or disrupted adipose entering blood stream, traveling to lungs. Prevention is aimed at early immobilization

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and correcting of fractures. Methylprednisone can be used to prevent. TX is supportive. Patients usually fully recover.
Intracranial pressure: Causes of elevated pressure are tumors, trauma, cerebral edema, hemorrhage, hydrocephalus, hepatic encephalopathy, impaired venous
outflow. Tx is with elevation of bed, HYPERventilation, IV mannitol. Symptoms of ICP are HA, N/V, AMS along with Cushings triad of bradycardia,
respiratory depression, and HTN. The reason hyperventilation is used because it will blow off CO2, causing cerebral vasoconstriction, reducing
cerebral pressure. Normal ICP <15mmHg. Goal Is <20 ICP with cerebral perfusion pressure >60mmHg.
Legg-Calve-Perth: AKA avascular necrosis of femoral epiphysis. Usually presents in younger children 4-10 years old. It is usually idiopathic and presents
insidiously without any prior trauma. Patients will present with antalgic gait/limp/groin and hip pain. Have limited passive ROM. Limited abduction
and internal rotation. X-ray will show it. TX for pts with good alignment is activity limitation and NSAIDs. Others need surgery.
Anal fissures: Linear lacerations MC occur in posterior anal mideline caused by local trauma. Risk factors are chronic constipation, chronic diarrhea, anal sex or
vaginal delivery. Presents with bright red bleeding and/or severe rectal pain. TX is with topical nitroglycerin to reduce pressure/vasodilate to heal.
Temporal arteritis: Inflammation of external carotid artery from vasculitis. MC seen in association with polymyalgia rheumatic who are >50 years old. Has
associated vision loss secondary to transient ischemia to the retina, choroid, or optic nerve. Immediate high dose IV steroids will help with vision loss.
Lung abscess: MC a complication of anaerobic aspiration pneumonia, classically from an alcoholic with poor dentition that fell asleep while drinking that
aspirates. S/S of foul smelling sputum, fevers, chills, weight loss, night seats. DX with x-ray showing cavitary lesion with air fluid level. Treatment is
antibiotics, usually clindamycin. (Unlike other abscesses, lung abscess usually do not need aspiration or surgery).
Cauda equine syndrome: Compression syndrome of the spinal cord caused by disk herniation, spinal hemorrhage, epidural abscess, tumor, etc. Occurs at level
of lumbar spine. Presents with urinary retention/incontinence, paresthesia, weakness in legs. Associated fever can point to abscess. Treatment is
with surgical decompression. Even if abscess is present, if neurologic deficits, they need surgery.
Skin abscess: Infections within the dermis that usually begin as superficial cellulitis/folliculitis. Becomes walled off, collects purulent material. Risk factors are
DM, immune compromise, local trauma. PE sows raised erythematous fluctuant lesion that is very tender. Can have or not have surrounding
cellulitis. Definitive treatment is incision and drainage with subsequent antibiotics.
FAP: AD condition, characterized by usually >100 adenomatous colorectal polyps. Can have polyps present within duodenum or fundic gland polyps within the
stomach. Genetics can show APC mutation. Gardener syndrome is a subset of FAP that presents with polpys plus desmoid tumors (CT tumors)
osteomas of mandible/skull and sebaceous cysts. Turcot syndrome presents with medulloblastoma and polyps. Treatment is with prophylactic
colectomy around age 20. Because 100% progress to CRC.
Peutz-Jeghers: AD condition. Characterized by hamatomatous polyps throughout the GI tract and mucocutaneous pigmentation. Presents with hematochezia,
abdominal pain, obstruction, intussusception. Increased risk for CRC. Need endoscopies q2-3 years. CA-124 to screen for sex cord neoplasms.
Mammograms starting at 25.
Thyroglossal duct cyst: Presents as a congenital midline neck mass typically painless that elevated with swallowing and protrusion of tongue
(pathognomonic). Remnant of thyroglossal duct tract. DX with CT scan showing well circumscribed, heterogenous cstic mass near hyoid bone.
MC complication is infection. However, increased risk of thyroid cancerin the cyst. TX with sistrunk procedure: Cyst and mid-hyoid are resected.
PAD: Chronic atherosclerotic disease causes blockage of lower extremities. Risks are smoking, hyperlipidemia, HTN, DM. Commonly presents with intermittent
claudication due to transient ischemia from hypoperfusion. Cramping pain relieved with rest. Can also have shiny hairless skin distal to obstruction
along with reduce pulses. Most common site is superficial femoral artery producing upper 2/3s calf cramping pain with diminished popliteal pulses.
Esophageal SCC: Strong association with smoking and alcoholism. MC primary malignancy of esophagus. Presents with progressive dysphagia, weight loss,
odynophagia, regurgitation. Barium esophagram shows distal obstructing mass. Upper endoscopy can visualize and biopsy. TX is surgical resection +
Chemo and rad, but often advanced and thus palliative.
Esophageal adenocarcinoma: 2nd MC esophageal malignancy. Due to prolonged exposure to gastric acids/intestinal metaplasia/Barretts. Similar presentation.
Burns: Look for facial burns, singed facial hairs, burns to lips/mouth, soot in pharynx, circumferential neck burns. If so, the paitent needs to be intubated due to
flash edema causing airway compromise. Threshold for intubation in burn patients is low. Watch for compartment syndrome with circumferential
Thyroidectomy complication: Damage to the recurrent laryngeal nerve. Unilateral is hoarse voice. Bilateral can cause vocal cord paralysis, unable to protect
airway, and need for tracheostomy. Also can see hypocalcemia secondary to removal of parathyroid glands.
CT screen: For patients with 30 pack year history of smoking, including those who quit within 15 years, requires yearly CT screen ages 55-79.
US screen: Indicated for males who have ever smoked, after age 65. If aneurysm less than 3.5cm is present, do q3 screens.
Scoliosis tx: In teenagers/adolescents, observation is done for Cobb angles <20 degrees and repeated x-ray in 6-9m. If >5degrees progression  brace.
Or bracing is done with a cobb angle >30-40. Bracing IS NOT done in skeletally mature patients. Spinal fusion at >50 degrees.
Thyroid nodule: First step is measuring TSH. If normal or elevated, thyroid ultrasound is indicated. FNA is needed if >1cm solid hypo, iso/hyperechoic >1.5 or
mixed cyst/solid >2cm. History of head/neck radiation is 0.5cm. If TSH is LOW (aka hyperthyroid), thyroid scintigraphy is indicated as the nodule is
likely hyperfunctioning and rarely malignant. Purely cystic nodules do not need FNA. Monitor with ultrasound and PEs.
Ankylosing spondylitis: MC involves joints of axial spine, producing pain and limited ROM. Typically presents in 20-30s, more common in males. First line
therapy is NSAIDs (indomethacin often used). Anti-TNFalpha drugs are second line after NSAID failure (Ertanecept > Adalimumab/infliximab)
Sulfasalazine is third line. Surgery is last line. DO NOT use steroids, worsens joint disease.
Presents with inflammatory back pain and anterior uveitis. Pain improves with exercise, does not improve with rest.
Child abuse fractures: Metaphyseal corner fractures, sternum, scapula, vertebrae SP, bilateral long bone fx, skull fx, rib fx. Get skeletal survey if <2y/o.
 Michael Wray
Crohns: Inflammatory bowel disease can affect any part of GI system. Presents with crampy abdominal pain, low fevers, non-bloody diarrhea but hemepositive
stool. Perianal (not same as periretal) disease can demonstrate fissures, fistulas, or abscesse. DX confirmed with colonoscopy. Causes transmural
inflammation, skip lesions, ulcerations, strictures. Terminal ileum most common.
Hepatocellular carcinoma: Aggressive tumor that occurs in setting of HCV, HBV, and cirrhosis. Other risks are hereditary hemochromatosis, aflatoxin exposure
(mycotoxin found in some grains). Usually diagnosed late with wt loss, satiety, ascites, encephalopathy, jaundice, variceal bleeding. DX with imaging
and serum AP. Biopsy rarely needed. Treatment is with mass resection. Or if they have poor function/portal HTN, they need transplant.
Nec fasc: Polymicrobial can often present after cut. Presents in a wound with grey border, surrounded by significant erythema and edema with SEVERE PAIN.
Exam will show undermining of surrounding skin “putting a q-tip through underneath the skin”. TX is with antibiotics and surgical debridement.
Achalasia: Presents with dysphagia to solids and liquids. Due to increased LES resting pressure. DX with barium esophagram. TX is pneumatic dilation.
MC complication is GERD with most severe complication being perforation.
Rib fractures: Worse in elderly due to 2nd respiratory compromise. Can get PNA from inadequate ventilation. Consider intercostal nerve block before narcotics.
Hemorrhoids: Internal from vascular plexus of subepithelail AV connections between superior rectal artery and veins. External originate from inferior
hemorrhoid plexus in anal canal below dentate line. Symptomatic hemorrhoids can cause rectal bleeding, pain with defecation, anal pruritus. Internal
hemorrhoids require endoscopy of some type. Do colonoscopy over anoscopy if patient has rectal bleeding, especially if >50.
Transitional cell carcinoma: Cigarette smoking is one of MC risk factors for this bladder CA due to ROS. Other risks, dye, arsenic, chronic cystitis, HPV, pelvic
radiation, cyclophosphamide, thiazolidinediones, and shciztosomiasis. Presents with painless hematuria. DX with cystoscopy, biopsy and histo.
Infantile hemangioma: MC vascular tumor of childhood. Usually apparent in first few days of life as solitary, raised, crimson round lesions. They undergo
growth for the first year and start the involution phase after 1 year of age. Most resolve. TX is with observation initially. Ulceration is a complication.
Ulcerated hemangiomas are treated with propranolol and wound care. (Or propranolol for very large lesions).
Pheochromocytoma: Definitive treatment is surgical resection, but pts must be prepared with phenoxybenzamine, THEN beta-blockers to avoid HTN crisis
Presents with paroxysmal HTN, HA, sweating, tachycardia. DX with urine/plasma catecholamines. Follow up CT/MRI for extent. TX above.
Ascending cholangitis: Fever, jaundice, RUQ pain (Charcot). Confusion, hypotension for (Reynolds pentad). Can see elevated LFTs, bilirubin, CRP, WBC.
Obtain blood cultures, do ERCP to drain biliary tract. If charcot triad absent, do an ultrasound to see if stone present, ERCP to follow.
Hepatic encephalopathy: Characterized by brain edema and cognitive dysfunction. Occurs in sever liver damage due to inability to detoxify neurotoxic
substances that arise from gut. Precipitating events are GI bleeding, infections, constipation, hypokalemia, volume depletion, hypoxic states, kidney
failure. Treatment is lactulose. Works by acidifying GI tract, which favors formation of NH4 from hydrogen ion and ammonia. Stays in GI tract. poop.
Anal SCC: Increased risk with anal intercourse, HIV, condyloma acuminate. Presents with rectal bleeding, fungating mass on PE. Hard inguinal lymph nodes are
commonly palpated. First diagnostic step is biopsy of anal lesion. Staging involves CT or CT/MRI and PET.
Cerebellar hemorrhage: Presents with HA, N/V, vertigo, ataxia, imbalance. DX with non-con CT.. In general intracerebral hemorrhage Tx involves Bp control
with a goal of 140-180 systolic (permissive HTN). Cerebellar hemorrhages respond well to decompression and hematoma evacuation.
Ventriculostomy can be used if blood extends into enlarging ventricles/hydrocephalus.
Basilar skull fracture: Presents with hemotympanum, periorbital ecchymosis (raccoon eyes), and bruising behind ear (battle sign). Dura mater tears can cause
otorrhea or rhinorrhea from CSF leaking.
VTE prophylaxis: Risks are increasing age, prior TE, malignancy, obesity, hypercoagulation, medical comorbidities/heart disease, infection. (Older than 75, hx of
VTE, malignancy, fractures of HIP/PELVIS/LEG) should undergo LWMH or unfracitoned heparin. It is also indicated in total hip/knee replacements.
LMWH is generally preferred, but if patient has renal insufficiency, use UFH. Absolute CI: ICH, stroke, neuro sx within 2mo, eye surg, pregnancy, HIT.
Pneumatic compression: Used if contraindications to anticoagulation or low risk patients ( not bed bound, no CA, no hx of VTE).
Avascular necrosis: Caused by chronic corticosteroid use, chronic alcohol consumption, SLE, gout, Gaucher, sickle cell. Prox/distal femur heads are most
commonly affected. Presents with groin/buttock pain, worse with walking, exquisitely tender joint, limited ROM, pain with abduction and IR. First
step is x-ray. MRI is definitive diagnosis. Can see crescent sign or double line sign showing hypervascular granulation tx. Tx: pain + surgery/decomp.
Hypertensive emergency: blood pressure >180/120 with end-organ damage. First line therapy is usually nitroprusside. Can be lebatalol, but watch for
bradycardia or asthma. Hydralazine mainly used in pregnant patients. Get a CT scan for any neurologic deficits. Only lower 25% in 2hrs, 160/100 6hr
Tricuspid atresia: Two types, 1 with normal great vessels, 2 with transposed vessels. Often presents with associated VSD. Tricuspid atresia causes Right
ATRIAL hypertrophy, decreased pulm vascular markings, tall peaked P waves. Treat with PGE1 to keep ductus open then surgery.
TOF: MC cyanotic. Pulmonary artery stenosis, VSD, rightward aorta deviation, right VENTRICULAR hypertrophy (not right atrial). IF severe, presents as neonate,
but usually presents as moderate with tet spells. DX echo. TX surg.
TAVR: Abnormal emptying of pulmonary veins (O2 rich) blood into right atrium instead of left atrium. Causing mixing of systemic/pulmonary venous blood.
Presents with mild cyanosis. Prone to respiratory infecitons. Right axis deviation.
Truncus arteriosus: Single great artery arising from heart due to failure of common truncus to divide into pulmonary artery and aorta. VSD always present.
Causes increased pulmonary blood flow. Usually have systolic ejection click, loud S2, systolic thrill. Mild cyanosis and heart failure sxs.
HA DX: CT indicated for sudden onset HA, suspected hemorrhage, focal neurologic signs, AMS, HIV, or patients older than 50 years old.
MRI is indicated for patients with new onset headache with history of cancer (mets from NSCLC, melanoma, breast, RCC, CRC).
RCC: Presents with hematuria, flank pain, abdominal mass (rarely all three). Risk in cigarette smokers. MC type is clear cell carcinoma. Common
paraneoplastic manifestations: HTN, hypercalcemia, erythrocytosis from EPO. DX with CT scan. Local lesions TX with radical nephrectomy.
ADPCKD: Causes cysts to develop in the kidneys bilaterally and invariably causes hypertension in patients. Kidneys become cystic and become palpable over
time. Usually present 30-40s with HTN/flank pain. Possible hematuria. DX can be made with US or CT scan. TX is with anti-HTN therapy with eventual
dialysis and probable need for transplant. Associated with cerebral Barry aneurysms in anterior circulation. DX with CTA/MRA.
Thrombosed hemorrhoid: Typically presents as a protruding blue/purple mass from the rectum with severe pain. TX is surgical exicison, clot evacuation.
Although most resolve spontaneously, so if a patient is improving, then don’t do surgery.
Chronic pancreatitis: Characterized by chronic epigastric pain, radiates to back, steatorrhea, malabsorption, weight loss, pancreatic calcifications. Patient at
HIGHEST RISK FOR DEVELOPING DIABETS and pancreatic adenocarcinoma. Others: psuedocysts, pleural effusion, splenic thrombosis, adenocarc.
Squamous cell CA: 2nd MC skin cancer. Presents in sun damaged skin. MC areas are sun exposure. Face/nose. Seen as erythematous nodule/papule with
central ulceration, often bleeding easy. Look for other areas of actinic keratosis. Locally invasive. Can met to nearby lymph nodes.
Meniscal tear: Commonly from twisting the knee with planted foot. May have pain initially with locking/catching/giving out. Large tears cause effusion.
PE shows joint line tenderness. Clicking during full passive F/E with IR/EX (McMurray). Can DX with MRI (“gold standard is arthroscopy”)
Pericardial effusion: Can present with tamponade. Hypotension, JVD, muffled heart sounds (becks triad). Pulsus paradoxus. TX: immediate pericardialcentesis.
 Michael Wray
ACL: connects to posterior lateral femoral condyle to anterior tibia. Prevents anterior translation normally. ACL commonly occurs from twisting injury while
planted (valgus conact). Presents with a pop sound and joint instability. Lachman test is very specific. Flex to 20-30d and pull tibia anteriorly for lax.
Melanoma TX: Breslow is the thickness of melanoma. Thickness of 1-2mm requires 1-2cm margins. (<1mm = 1cm) (2-4mm = 2cm).
Globe rupture: Of the eye. Usually traumatic. Presents with acute onset blurry vision and pain s/p orbital trauma. Look for subconjunctival hemorrhage with
obvious signs of glove rupture (extruding contents from globe/eye). Definitive treatment is urgent surgical repair (atbx, eye shield, fluids).
Avoid any manipulation of the eye and do not use any eye drops/eye drugs/fluorescein.
Sestamibi scan: Nuclear medicine study that allows visualization of hyperactive parathyroid glands. Lights up more brightly. Indicating adenoma. Used to
localize the adenoma prior to surgery for hyperparathyroidism to make it less invasive.
Inguinal hernia: Indirect is MC hernia. Risks are males, age >40, prior hernia, intra-abdominal pressure, constipation, chronic coughing.
Indirect usually from congenital defect. Processus vaginalis fails to close. Indirect is lateral to inferior epigastric. Palpated on TIP of finger.
Direct is medial to inferior epigastrics, palpated on SIDE/pulp of finger. Protrudes through hesselbach triangle.
Endocarditis: Infective type. Fevers, chills, septic emboli, new onset murmur IV druggers present with tricuspid regurg. Diagnose with echocardiogram.
Do echo before antibiotics. Need blood cultures as well. Major criteria includes +Blood cultures and echo showing valve mass/infection.
Traumatic aortic rupture: MC caused by sudden acceleration-deceleration injures. Such as MVA. Can present with chest pain, intrascapular back pain, SOB. If
aortic injury suspected get chest x-ray showing widened mediastinum, then get CT scan of the chest. If UNSTABLE, get thoracotomy.
SCFE: Characterized by displaced femoral head, leads to changes in hip function. Often due to rapid bone growth at growth plate. Causes instability. Look for
obese male, 11-13, developing limp. DX with radiographs. TX is operative stabilization surgery. Untreated can develop osteonecrosis.
Legg-calve-perth: Idiopathic avascular necrosis between 4-10. Presents insidious unilateral hip pain, limp, restricted motion. DX with x-ray and MRI.TX is
activity restriction, stretching +NSAIDs.
C. Diff: Very mild c. diff, tx is with metronidazole. Moderate or severe is with oral vancomycin (Temps >101, wbc >15k, hypotension, ileus, toxic megacolon).
Blunt abdominal trauma: Hypotension and tachycardia. Fluid bolus is first line. But get ultrasound for FAST exam. MC injured is the spleen with the liver
second. Look for seatbelt sign to indicate intraabdominal trauma. FAST exam follows primary survery to determine presence of hemorrhage. If FAST
is unequivocal, peritoneal lavage can be used. If unstable with hemorrhage ID’d, do laparotomy. If no hemorrhage, no laparotomy.
Carotid dissection: Division of internal carotid with formation of a false lumen and intramural hematoma. Can occur with any trauma. Presents with unilateral
headache/neck pain, ipsilateral HORNERS syndrome. Causes for SNS fiber stretching. Can cause cerebral vascular ischemia causing contralateral
hemiparesis. Get MRI to confirm diagnosis.
Vertebral artery dissection: Presents with suboccpital headache, back of nec pain. Commonly seems like MSK pain. Cerebral ischemia can develop also, but
usually affects posterior circulation, causing N/V, vertigo, dysphagia, unsteady gait. Can also see horners.
Hepatic adenoma: Benign liver lesion that has significant response to hormone. Classically a female on OCPs. Can have RUQ pain. Most asymptomatic.
Biggest risk is spontaneous hemorrhage. Small amount transform into hepatocellular carcinoma. Can dx US, but MRI best test showing vasc/intense
Focal nodular hyperplasia: of liver. Benign. No cancer association. Found in young women, but no hormonal response. Look for stellate scar imaging.
SBO: Presents as abdominal distension, pain, N/V, tympanic abdomen, hyperactive/tinkling bowel sounds. INITIAL test is with x-ray upright and lateral.
Will show stacked coin appearance of bowel. MC caused by surgical adhesions, malignancy, hernia. TX: bowel rest, NG tube, IV fluids.
ATN: Type of acute kidney injury in which there is damage to renal tubules. MC caused by hypotension or nephrotoxicity. Look for oliguria <20mL/hr or anuria
with or without uremia. Dx with oliguria, creatinine, elevated FENa, dark brown casts. Uremia includes encephalopathy, slurred speech, asterixis,
seizure, coma, neuropathies, cardiomyopathies, non-STElevation pericarditis, anemia, bleeding, anorexia, hyperkalemia. Rapidly rising hypkeralemia
can cause peaked T-waves, AMS, shortened QT. Give calcium gluconate, insulin, glucose, get dialysis.
Laryngeal cancer: Think of hoarseness, sore throat, EAR PAIN, odynophagia, weight loss. Almost always squamous cell carcinoma. Risks are smoking/alcohol.
DX with biopsy during laryngoscopy. Stage with CT or MRI after biopsy. If advanced get PET.
Cavernous sinus thrombosis: Bacterial infection located in dural sinus. Commonly seeded from sinusitis/facial infections. Presents with sharp headache, vision
changes, fever, ophtalmoplegia, ptosis, chemosis, and periorbital edema. Pass from facial veins and pterygoid plexus via ophthalmic veins. DX with

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HR-orbital CT showing thick walls, increased enhancement, enlarged cavernous sinus. TX antibiotics. CN6 affected first.
Malignant hyperthermia: An anesthetic reaction usually to halothanes or succinylcholine. Leads to tachycardia, hypercapnia, muscular rigidity, rhabdomyolysis,
and eventual hyperthermia. TX: Stop the anesthesia, give dantrolene, terminate procedure.
Myasthenia gravis: Autoimmune neuromuscular ridsroder. S/S intermittent variable weakness among muscle groups including ocular and bulbar muscles,
limbs, and breathing. Typically worse after use/end of day. Recent infection/antibiotics can trigger onsent of disease or symptoms. Due to
destruction of ACH receptors in NMJ. DX is clinically and with ACH receptor antibiodies. Tensilon/edrophonium test is older. TX with mild disease is
with pyridostigmine. Get a CT as well to check for thymoma, remove it if so. IF severe myastenic crisis, intubate, do plasmaphoresis and IVIG.
Chronic mesenteric ischemia: Vascular insufficiency of intestine that progresses slowly over time. S/S: Post-prandial abdominal pain, food fear, weight loss. TX
is with mesenteric artery bypass/stent placement.
Dx pancreatitis: Obvious clinical s/s. If lipase is 3x normal limit, diagnosed. IF less than 3x limit, but suspected, get CT scan.
Prostate CA mets: Back pain after a history of prostate cancer with elevated PSA is metastatic bone disease. Get tech-99 scan, then x-ray.
Esophageal varices: Associated with cirrhosis and end-stage liver disease, secondary to chronic portal HTN. Can present with hematemesis, hemodynamic
compromise. Start with IV fluids, endoscopic sclerotherapy or band ligation. Octreotide can decrease portal pressure in conjunction with endoscopic
therapy. After TWO failed attempts with endoscopic therapy, do a TIPS procedure in poor surgical candidates. Balloon tamponade is a temporary
measure for local hemostasis while salvage therapy is being considered. TIPs and post-caval shunts are salvage therapy. Do TIPS in poor surgical pts.
Lynch: HNPCC. Presents with change in stool consistency, frequency, hematochezia not related to anal conditions. Usually have family members with early CRC.
Get colonoscopy. Will show adenomatous polyps early on, which mutate faster than normal adenomatous polyps. Other associated cancers
endometrial >> ovarian/breast, renal, gastric, biliary. Confirmed with DNA testing showing microsatellite instability in DNA mismatch repair genes.
If positive, get colonoscopy every year starting at 25 or 5 years before diagnosis of family member.
PE: Can present with SOB, pleuritic CP, tachycardia. Saddle embolus/large embolus presents with elevated JPV, RV dysfunction, tricuspid regurgitation. Risks
are immobilization, recent surgery, stroke, paralysis, immbolity, malignancy, hx of VTE. If patient is in shock, get transthoracic echo. If not in shock,
get CT scan of chest. With shock, do tPA unless contraindicated (ICP, brain tumor, intracranial surgery w/in 2mo, internal bleeding hx 6mo, hx of
hemorrhagic stroke, HTN, thrombocytopenia, etc). Then do pulmonary embolectomy if tPA contraindicated.
Acoustic neuroma: Unilateral hearing loss of high frequency sounds, loss of balance, tinnitus, ear pressure. It is sensoneural loss I affected ear. Weber
lateralizes to contralateralear. Rinne test is positive inboth ears (positive Rinne is normal, aka AC > BC). DX MRI.TX: eliminating tumor.
 Michael Wray
Laryngopharyngeal reflux: caused by acid reflux in to laryngopharynx, causing irritation of larynx/hypopharynx. Presents with hoarseness, chronic cough,
globus sensation, throat clearing. Look for obese males as well, but often do not have GERD. LPR and GERD are separate due to LES incompetence.
DX with clinical suspicion and nasolaryngoscopy with posterior laryngeal erythema and vocal fold edeam. TX is behavior change + PPIs.
Diffuse esophageal spasm: Causes painful abnormal esophageal contractions with normal function of LES. Classically a young female with episodic substernal
chest pain and dysphagia to both solid/liquids. Barium esophagram shows corkscrew/alternating esophagus.Manometry shows uncoordinated
contractions. ACS must be ruled out in people at risk.
Thyroid storm: Rare. Usually seen in patients with unrecognized thyroid disease (hyper). Can be precipitated by surgery, trauma, parturition, infections.
Thyrotoxic state causes delirium, agitation, tachycardia, eyelid lag, tremors, diaphoresis, goiter. Tx is with propranolol, hydrocortisone, PTU
(preferred over methamizole). Also PTU is less in breast milk in pregnancy for post-partum thyrotoxicosis. Then iodine is given ONE HOUR after PTU
treatment (If given immediately, can make more thyroid hormone, if give 1hr s/p PTU, blocks release of thyroid hormone).
Toxic megacolon: Severe dilation of the colon, often from ulcerative colitis. Causes systemic toxicity, fever, tachycardia, hypotension, leukocytosis, bloody stool
Segment of colon appears dilated, hallmark loss of haustral markings on x-ray. Can also occur in c. diff. TX: IVF, ATBX, NGT, TPN.
Airway FB: Presents usually in children with non-productive cough, sudden onset, unilateral wheezing and hyperinflation. Treat with rigid bronchoscopy.
“Back blows” are indicated when there is acute airway compromise (fully clogged by FB).
Subphrenic abscess: Presents with LUQ pain with radiation of pain to the left shoulder. DX with clinical presentation and CT scan. MC from intra-abdominal
surgery such as post-splenectomy/gastrectomy. Usually develops 1-3 weeks after. Phrenic nerve causes shoulder pain. Fevers, leukocytosis.
TX: percutaneous drainage.
Cocaine STEMI: TX is with aspirin, NTG, morphine, oxygen, diltiazem, BZD (diazepam), and getting percutaneous coronary intervention (stenting).
Presents with tachycardia, HTN, dilated pupils, restless, hyperemic nasal mucosa. Cocaine ischemia MC cardiac complication due to vasoconstriction.
Von willebrand disease Sx: Usually patients will have history of menorrhagia classically. Labs will show prolonged aPTT due to loss of factor 8 activity since vWF
carries factor 8. Type 1 is loss of amount of vWF. Type 2 is a crappy version of vWF, thus their vWF can be normal, but not work as well.
Desmopressin (DDAVP) is the prophylactic drug of choice before surgery.
Ludwigs angina: Subacute neck pain, submandibular swelling, stridor, fever, trismus, pooling of oral secretions, elevation of the tongue, poor dentition. Causes
swelling and can cause closure of the airway. MC caused by Strep viridans and oral anaerobes (peptostreptococcus, fusobacterium, bacteriodes).
Usually traverses from a dental infection from poor dentition. Can lead to need for ETT. CT scan is test of choice. It is cellulitis, not an abscess.
Tension pneumothorax: Presents with JVD, hypotension, decreased breath sounds unilaterally. Chest x-ray shows contralateral tracheal deviation,
hyperlucency of lung field on ipsilateral side. Start with needle decompression then put in chest tube.
CT screening of chest: Needs 30 pack yea history, even with quitting up to 15 years ago. Ages 55-79.
Abdominal US screen: Any history of smoking in males 65-75. One time.
Bacterial prostatitis: Usually from urethral/bladder migration to prostate via prostatic duct. Typically appear ill with dysuria, frequency, pelvic/perineal pain,
fever, PE shows warm boggy edematous prostate. Do a gentle DRE because it can trigger bacteremia with too much stimulation. Gram stain +
culture. TX: with TMP/SMX or ciprofloxacin.
Bariatric surgery: BMI >40 or BMI >35 with comorbid disease (DM, HTN, hyperlipidemia, OSA) in which lifestyle changes have not helped. MC surgery is sleeve
gastrectomy which is restrictive. Roux-En-y gastric bypass is restrictive and malsorption. Produce average weight loss of 30-35%. Need
supplementation of vitamin D, calcium, folate, vitamin B12.
Cholecystitis tx: Very first step with confirmed cholecystitis is IV antibiotics, then lap chole.
Priapism: Erection lasting longer than four hours in absence of sexual stimulation. Medial emergency because it can become ischemic. Ischemic priapism needs
to be differentiated from non-ischemia by corpora cavernosa blood gas analysis or ultrasound. Ischemic is black blood with hypoxemia, hypercarbia
and acidosis. Next best step is aspiration and irrigation of corpora cavernosa. 2nd line is phenylephrine injection. Observe for non-ischemic priapism
Oligive syndrome: Acute colonic pseudo obstruction (Colon obstruction without mechanical cause. Usually 3-5d after surgery. Treat with conservative therapy
first: Bowel rest, fluids, gastric and rectal tubes. Also tx underlying condition. If it continues with <12cm dilation, no severe pain, can do
conservative care. If >12cm dilation/severe pain/no improve can do neostigmine. Colonoscopic decompression is second line.
Aortic dissection: Tear in aortic intima with hemorrhage into aortic media. Risks are chronic HTN, vasculitis, disorders of collagen synthesis (Marfan/Ehlers).
Two types, A and B. A is ascending aorta and B is descending. A requires emergent surgical repair. B dissections are uncomplicated distal dissections
involving thoracic aorta. Usually managed with blood pressure control alone. Surgery indicated with persistent pain, uncontrolled HTN, occlusion of
branch vessel (renal), or leaking/rupture. Address ABCs at first. If medically stable, get CT angio. Obtain ECG as well (before CT). First line for BP
control here are beta-blockers (labetalol).
Carotid stenosis: Development of fibrofatty plaques within internal carotid artery. Results in stenosis. Fragments of plaques can dislodge, causing TIAs. Causes
intermittent focal neurologic deficits, lasting less than 24hrs. With focal deficits, they require CT scan. TX is indicated with carotid endcardectomy for
symptomatic patients with 60% stenosis or >70% asymptomatic.
Sickle cell disease: Increased risk of infections due to splenic dysfunction/autosplenectomy secondary to microinfarcts. Increases risk to encapsulated
organisms. Strep, H flu. Salmonella. Increases risk of osteomyelitis from salmonella. Need to differentiate from basoocclusive crisis. Both present
with bone pain, fever, elevated WBC, however longer duration and single site more likely osteomyelitis. Femur, tibia, humerus, MC sites. Staph
aureus MC cause in NON-sickle, salmonella MC cause typically in sickle cell. Pseudomonas is MC cause from puncture wounds.
Boerhaave: Esophageal perforation secondary to vomiting. Emergent condition. Quick diagnosis is important. Presents with severe retrosternal chest/upper
abdominal pain, usually after vomiting. More often in alcoholic patients or after heavy drinking. Can be confused with pancreatitis as amylase can
be elevated as well in Boerhaave. Due to contents leaking into mediastinum, may have fever, tachycardia, dyspnea, shock. Emergent surgery needed.
Diagnosis is with DIATRIZOIC ACID esophagram (Gastrogaffin) because barium turns into a “chalky” substance if it gets into mediastinum.
Gastrogaffin would be used anytime any GI tract perforation would be suspected (even colon). Barium only used if intact.
Strangulated vs. incarcerated: Strangulated rfers to hernia with blood supply that has been cut off. Incarcerated hernias are NOT reducible-emergent surgery.
Strangulation is usually extremely tender and painful. Can have N/V with it. Also surgical emergency, do not attempt to reduce these ones.
Femoral hernia: More common in females due to pelvis. Presents inferior to inguinal ligament and medial to femoral artery.
Delirium: Characterized by change in cognition; confusion, AMS, impaired attention, agitation, disorientation, memory deficits, perceptual changes. Typically
develops over hours to days. Has many causes including ICU, infection, sepsis, recent surgery. TX is with low-dose haloperidol.
HyperPTH treatment: Usually from adenoma. Presents with hypercalcemia (stones, bones, groans, psychiatric overtones). Definitive treatment is
parathyroidectomy, localized with sestamibi scan. Symptomatic patients should get surgery. Asymptomatic with any; serum Ca >1.0 above normal,
 Michael Wray
CrClerance of <60, bone density <-2.5, fragility fracture, should all get surgery. Otherwise if poor surgical candidate/does not want surgery, can use
dronates or cinacaletc.
Peptic ulcer disease: Occurs with disruption of gastric/duodenal mucosa. Leads to erosion and ulceration. Two MC causes are H pylori and NSAIDs. S/S of
epigastric pain along with GERD symptoms, metallic taste, post-prandial burning, chest pain, globus. EGD is indicated in patients with upper GI
symptoms (pain and nausea) who fail empiric PPI therapy OR paitents >55 years old. EGD also indicated with alarm features (weight loss,
hematemesis, dysphagia, odynophagia, IDA, LAD, mass, jaundice).
AAA monitoring: If it’s 3-4cm, do q2-3 year ultrasounds. If it’s 4-5ish, do yearly. If over 5 do q6months. Operate at 5.5cm.
Abdominal compartment syndrome: Defined as intra-abdominal HTN causing organ dysfunction MC occurs from aggressive IVF resuscitation (severe buns,
trauma with blood loss, abdominal surgery, pancreatitis, sepsis). Typically very sick. Presents with oliguria, anuria, hypotension, tachycardia,
peripheral edema. TENSE DISTENSION of abdomen. Diagnosis with intravesicular bladder pressure. >12mmHg + organ dysfunction = ACS.
CMV esophagitis: MC from immunosuppressed with HIV or solid organ transplant, leukemia, lymphoma. CD4 count less than 100. S/S: severe odynophagia and
dysphagia, substernal CP. EGD shows shallow ulcerations and erosions + intranuclear inclusions. Tx with ganciclovir.
HSV esophagitis: Similar to above, but presents with volcano like ulcerations. Biopsy shows ground glass nuclei/eosinophilic inclusions. TX: acyclovir.
CMV is more linear and deeper.
Trash foot: Complication following revascularization surgery secondary to PAD. Due to disloged atherosclerotic plaque into smaller artery. Causes a toe/part of
foot to become poorly perfused/dusky with intense pain followed by lack of sensation. As long as pulses in the foot are preserved (such as just toe), it
will spontaneously resolve.
Triquetral fracture: 2nd MC carpal bone fracture with FOOSH. Presents with pain, swelling, decreased ROM of ulnar side of bone. TX: wrist immobilization.
Fight bites: AKA closed first injuries. MC from punching someone, getting knuckle cuts. Often pts lie and say a different story. Look for 3-5mm lacerations of
dorsal MCP joints. Gest infected quicky. If erythematous, draining purulent fluid, cellulitic, they need surgical debridement/exploration.
Otherwise if wound is NOT infected acutely, do atbx, irrigation, and do not close. Get Tdap and x-ray for FB.
Scleroderma: Systemic sclerosis and Vasculopathy. Can affect any portion of GI tract. Presents with GERD, stricture formation, esophageal stricture, dysphagia,
dysfunctional esophageal motility, Raynaud’s phenomenon, and sausage digits. Manometry can eval motility problems, barium for stricture.
Multiple myeloma: MC presents with bone pain. Starts with low back that is worse with movement (contrasted to metastatic disease which is worse at night).
Can metastasize to the skull with punched out lesions of the skull. Lytic. Can have hypercalcemia and renal dysfunction. M protein. >10% plasma
cells. First line therapy is with systemic chemotherapy, then marrow xplant depending comorbidities. DX requires bone marrow biopsy.

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Acute angle closure glaucoma: Acute condition presenting with a red and painful eye 2/2 rise in intraocular pressure. Often occurs following dilation for eye
exam or going into dark area. Due to being given cycloplegic drops. Presents with a red painful eye, corneal hazing, blurry vision, N/V/ HA.
DX with intraocular pressure. TX aimed at lowering IOP with constriction. Timolol and pilocarpine relieve obstruction. Acetazolamide lowers IOP.
Primary CNS lymphoma: Found in AIDS. MC Presents with focal neuro deficits (hemiparesis, aphasia, blurred vision, depression, apathy, hallucinations,
personality changes). Look for constitutional symptoms to help differentiate from toxo since they are both ring enhancing lesions. Need to
diagnose patient with stereotactic brain biopsy.
BCC: Pearly, flesh-colored lesion, often with ulceration and/or telangiectasias. Next best step is biopsy. Facial lesions get excision/Mohs.
Pancreatic pseudocyst: Common complication of pancreatitis when enzymes wall off by pocket of fibrosis. Typically presents after improving pancreatitis
with return of abdominal pain, bloating, anorexia. (Pseudocyst since wall is fibrotic, not epithelial). CT scan shows pocket of fluid. TX with close
monitoring, analgesia, fluids. Eventual catheter drainage may be needed if it does not resolve spontaneously.
Mesenteric ischemia: Presents with severe abdominal pain, N/V, bloody diarrhea. Look for hx of diabetes/CHF/atherosclerosis/afib. Abdominal exam will show
only mild tenderness/not impressive. Usually first step is CTA of the abdomen. TX is with IVF and atbx. If embolus is cause, get embolectomy. If low
flow is cause, use papaverine to reverse splanchnic vasoconstriction to restore meenteric flow. If abdomen becomes rigid/change in mentation,
usually means necrotic bowel, needs surgical excision.
Pulmonary mass/nodule tx: Look for comparison radiology. If intermediate 8+mm, but less than 30mm, get FGT-PET or biopsy. If >30mm, do VATS.
Small nodules 4-8mm followed with serial CT scan. New onset large >30mm with hx of smoking/>60years old, do VATs due to high risk malignancy.
Epistaxis: MC from anterior nares from kiesselbach plexus where four arteries come together. Risks are trauma, nasal picking, low humidity, dryness, uses
meds for rhinitis, HTN. First line is compression for 15 minutes. If that fails, inspect for anterior vs. posterior. Then try topical cocaine and
cauterization. If cauterization fails, use anterior packing with nasal tampon.
Papillary thyroid CA: Well differentiated type of cancer. Can dx with FNA showing, intranuclear cytoplasmic inclusions (orphan anni), calcified (psammoma
bodies), abundant cytoplasm, large pale nucleus. MC thyroid cancer. Can present with dysphagia/hoarseness. MC risk is ionizing radiation as a child.
TX with thyroidectomy, radioactive iodine, and TSH suppression.
Anaplastic type: Elderly, goiter, undifferentiated, rapid increase in size of goiter with vocal paralysis/dysphagia.
Empyema: Purulent fluid collection in the parietal space. MC complication of pneumonia. Other causes: trauma, GI perf, hemothorax infection. Risks are
alcoholism, dementia, HIV, organ transplant. Presents with sxs of PNA (fever, cough, CP, fatigue), weight losss night sweats. PE shows egophony,
decreased breath sounds, decreased tactile fremitus, dullness to percussion. Imaging shows pleural thickening. Need to get a thoracentesis glucose
<40, pH <7.1, LDH >1000. TX with tube IVF, atbx, tube thoracostoma, VATS if not successful.
VIPoma: Neuroendocrine tumor of pancreas. Secretes VIP. Causes profuse watery diarrhea with resultant volume depletion, hypokalemia, hypochlorhydria. CT
scan will often show distal pancreatic mass. Treatment begins with octreotide for sxs control. Pancreatic resection and liver resection for mets.
Cryptorchidism: Condition which testicles remains in inguinal canal/abdominal cavity. Testes need to descend by 6mo or they will not descend. They need to
undergo orchiplexy if they do not descend due to risk of testicular carcinoma.
Retinoblastoma: Intraocular malignancy of childhood. Often unilateral, can be bilateral. Presents with leukocoria on red light reflex exam. Associated with
leiomyosarcoma, malignant melanoma, osteosarcoma
Brocas: Have non-fluent broken speech, poor repetition. Comprehension is preserved. Located in inferior gyrus of frontal lobe.
Hallmark is inability to speak in grammatically correct complete sentences. Written affected. They know what they want to say, unable to articulate.
Wernicke: Patients can speak rapidly and fluently, but what they say does not make sense. Poor comprehension and poor repetition.
Scaphoid fracture: One of most common carpal fractures after FOOSH. Presents with radial/dorsal hand pain. Non-displaced is treated with immobilization
with a short arm thumb spica cast. >1mm displacement associated with non-union and subsequent osteonecrosis need surgery.
 Michael Wray
Hodgkin lymphoma: Can present as an anterior mediastinal mass. Four Ts (Thymoma, teratoma, ectopic thyroid tissue, terrible lymphoma). Presents commonly
in younger adults. Painless enlarged supraclavicular or cervical LN. Can cause local compressive symptoms, dysphagia, dyspnea with b symptoms
fever, night sweats, weight loss. Biopsy can make diagnosis with Reed-sternberg cells. Stage with CT scans. TX with chemo sometimes radiation.
Pleomorphic adenoma (parotid): Benign mixed parotid tumor, MC tumor of salivary gland. Vast occur in superficial portion. Presents with facial fullness,
painless mass in front of ear. DX with FNA. TX with superficial parotidectomy.
Gastroschisis: Congenital abdominal wall defect. Occurs to right side of umbilicus that allows for the extrusion of small bowel, large bowel, stomach/repro
organs. Do NOT have protective covering/sac (like omphalocele does). DX is clinical or with prenatal US. TX is urgent surgery with silo device.
Focal nodular hyperplasia: Commonly occurs in young women, similar to other benign liver lesions. No malignant or hemorrhagic potential. Usually
asymptomatic. Becomes painful when large. PE and labs are normal. MRI contrast is ideal imaging. May resemble hypervascular/hyperintense lesion
of hepatic adenoma, but is distinguished by central stellate scar. Surgical resection only needed if painful.
Fibrous capsule/necrosis = HCC. Macrovesicular steatosis = NAFLD. Brown pedunculated spongy interior= hemangioma. Soft yellow = adenoma.
Hepatic adenoma: Common benign epithelial tumor. MC occur in young females on OCPs. Commonly solitary, hypervascular. Often in right lobe.
Can become symptomatic with RUQ pain, epigastric pain. DX with ultrasound showing well demarcated hyperechoic lesion. If lesion is >5cm then
surgical resection is treatment of choice. Otherwise if smaller, can stop OCPs.
RCC vs. urothelial: Renal usually presents with flank pain, hematuria, flank mass. Urothelial usually presents with painless hematuria (DX with cystoscopy).
Liver transplant: Indicated in patients with hepatic cirrhosis who develop severe intractable pruritus/bilirubin higher than 10mg/dl.
Neurogenic claudication: Due to lumbar spinal stenosis. Causes canal narrowing with increased intracanal pressure. Caused by spondylosis, disc degeneration,
s-listhesis, spinal tumor. Presents with mild back pain, bilateral lower extremity pain with walking/standing. IMPROVES WITH LEANING FORWARD.
TX is conservative with NSAIDs, epidural steroids. Surgical decompression for severe symptoms.
Acoustic neuroma: Look for gradual sensorineural hearing loss with tinnitus, ataxia. Risks are NF2, exposure to loud noise, childhood radiation. Start with
audiometry test followed by MRI.
General Surgery - ComBank
Testicular cancer: Presents with painless swelling, can present as “firm fixed tunica albuginea with rubbery enlargement”. MC solid malignant tumor in men
20-35. It is either germ cell or non. Germ cell accounts for 95%. Risks are cryptorchidism, klinefelters. Presumre cancer with mass or rubbery firm
lump. Can have heaviness or dull ache. Sometimes can produce beta-hCG causing hyperparathyroidism. US is test of choice. Cystic/fluid masses are
unlikely to be cancerous. Solid is more likely. Seminoma = +Beta-hCG in ~20%, NO AFP. Choriocarcinoma = hCG ALWAYS elevated, VERY high.
Leydig usually older males 40-50. Produce androgens/estrogens causing feminization/virilization (Gyno, libido, erectile dysfunction, precious puberty)
Sertoli: Rare cause of cancer. No known tumor markers. Associated with peutz-jeghers/Carney syndrome.
Yolk-sac: Known as endodermal sinus tumors. MC in prepubertal males. Elevated AFP. >100.
TX: Non-metastatic disease: radical inguinal orchiectomy.
Hydrocele: Another non-painful mass, but NOT firm or rubbery. Has POSITIVE transillumination.
Developmental dysplasia of hip: Can present with asymmetric gluteal folds, loss of gross motor milestones, but normal other milestones. Limited abduction.
Positive Galeazzi sign (shortened femur comparing knee heights) and classically orlani barlow (LACK sensitivity after three months), thus can confirm
diagnosis with ultrasound if less than 6months. Risk factors are breechpresentations. DDH causes flexion and adduction due to capsular laxity.
DDH is actually a spectrum of acetabular laxity due to excessive force on acetabulum and posterior aspect of hip joint. Can cause muscle contractures
TX: under 6 months is with Pavlik harness. >6mo is with hip arthrography, percutaneous adductor, closed reduction, spica. 3 rd line is open reduction.
Le forte fractures: Fractures of the midface with instability. Forte 1: only maxilla involved. Forte 2: Maxilla and nasal bridge movement. Forte 3: most serious
type, complete craniofacial disjunction, involves maxilla, zygoma, nasal bones, and even cranial base. Often cause airway compromise form blood.
Sigmoid volvulus: Occurs in elderly debilitated nursing home patients. Usually hx of dementia/neuropsychiatric impairment. Presents with constipation >
abdominal distension > nausea > vomiting. X-ray shows coffee bean sign or bent inner tube with birds beak appearing towards LLQ.
Hypocalcemia signs: Chovstek sign seen with facial tapping around 6, facial nerve ischemia. Troussae sign, BP cuff, 7, due to ulnar/median nerve necrosis
HypoCa2 is serum Ca less than 8.5 or ionized less than 4.4 Presents with paresthesia, tetany, seizures, QT prolongation, muscle spasm.
TX is with IV calcium gluconate. Calcium chloride can cause tissue necrosis. Often seen s/p thyroidectomy with accidental parathyroidectomy.
Carpal fractures: MC is scaphoid (78%) then triquetrum (13%). Usually due to FOOSH, forced hyperextension + radial deviation causing direct forces to scaphoid
Location of scaphoid fracture on the bone important due to blood supply, can get osteonecrosis due to loss of supply. (Enters distally).
Thus, proximal fractures can undergo non-union/avascular necrosis. Most fractures occur through the middle of scaphoid (waist). 30% risk of AVN.
Presents with snuffbox tenderness, swelling, limited ROM. Often missed, can cause degenerative wrist disease with collapsed wrist.
TX: Displaced >1mm, non-displaced <1mm. NON-displaced: thumb spica cast for several months depending on location of fracture. Long arm for two
weeks, then short arm spica for several months. (3-5 less if distal, more if proximal). CT scan most sensitive to determine if union/healing occurred.
Pancreatitis: Acute inflammation of pancreas. Many causes; obstruction, alcohol, smoking, hypertriglyceridemia, post-ERCP procedure. Presents with epigastric
pain radiating to the back, pain relieved by sitting up/forward. N/V. Grey turner = flank ecchymosis, Cullen is umbilical ecchymosis, both signify
possible hemorrhagic necrosis of the pancreas. Fox sign is retroperitoneal blood leaking down to inguinal ligament area causing ecchymosis.
Choledocolithiasis: Presence of gallstones within CBT. Most are asymptomatic with biliary colic and jaundice. RUQ/epigastric/substernal pain with radiation to
right shoulder. Can last an hour. Cholestatic pattern on liver test. Afebrile without leukocytosis. Can have palpable gallbladder (courvoisiers sign).
Cholelithiasis: Presence of gallstones. Three types. Cholesterol with obesity, diabetes, multiple pregnancies, Crohns. Pigment is from hemolysis and alcoholic
cirrhosis or some infections. Biliary colic can occur with pain occurring after meals with radiation to right shoulder. Lasts around one hour. Although
many episodes are nocturnal and not associated with eating. Often labs are normal with Cholelithiasis.
Anticholinergic syndrome: Anticholinergics commonly used in OR, can cause facial flushing, urinary retention, QRS widening, dry mucus membranes, fever,
AMS, mydriasis. They’re often used to counteract post-operative bradycardia that can be seen with reversal of neuromuscular blockade during
general anesthesia. Glcopyrrolate and atropine are the most common reversal agents, sometimes scopolamine pre-op, causing cholinergic blockade
(increasing sympathetic input to the heart to reserve bradycardia). TX of anti-cholinergic syndrome is with cholinesterase inhibitors, mainly

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physostigmine.
Ethylene glycol toxicity: Presents with ataxia, hallucinations, siezures, “sweet breath”, kussmaul respirations due to severe metabolic acidosis. Can be treated
with ethanol (saturates ADH) or dialysis (removes directly) or fomepizol (competitively inhibits ADH).
Organophosphate poisoning: Usually due to insecticides. SXS: Salivation, lacrimation, urination, defecation N/V/D, paralysis, ALOC. TX with pralidoxime and
atropine (competitive antagonist at muscarinic cholinergic receptors both PNS and CNS).
 Michael Wray
Bet-blocker toxicity: Presents with hypotension, hypoglycemia, pulmonary edema. Can treat it with both glucagon or atropine.
Breast lump: In a female less than 30, get ultrasound before mammogram. >30 get mammogram. If lesion is cystic/fluid filled, get FNA. If solid mass then get
core needle biopsy. Pregnancy does not change this management. Fibroadenoma most common in 15-35. If benign features, can be left in place.
Unprovoked DVT: If a patient has an unprovoked proximal DVT (or PE). They should continue anticoagulation indefinitely. Due to high risk of recurrence.
Anticoagulation/anti-platelet drugs: Heparin and LMWHs bind to anti-thrombin III, which is a potent inhibitor of coagulation cascade. It lyses thrombin and
factor Xa. Plavix/aspirin: ASA inhibits thromboxane A2, used in normal platelet aggregation. Plavix inhibits aggregation by inhibiting ADP.
Coumadin: Inhibits vitamin K dependent factors 2, 7, 9, 10 and protein C/S (which are both actually anticoagulating factors)
Pagets of the breast: Presents between 50 and 60 with eczema like eruption of nipple and areola with yellow exudate. It is scaly, raw, vesicular, or ulcerated
lesion that begins at the nipple, spreads to areola. Usually unilateral. Can have burning pain/pruritus. Underlying breast cancer is found in 85% of
cases. Usually from extension of DCIS. Get bilateral mammography.
Kidney transplant: LEFT kidney preferred over right kidney due to longer renal vein. (IVC lies to the right side of arota, aka needs longer vein).
Pilonidal abscess: Develops due to hair follicle and inflammation where pores in the natal cleft open up and become infected. Can have mild to severe pain in
the intergluteal region with sitting/activities. Associated with fevers. No specific images or labs. PE shows a tender mass or sinus draining
mucoid/purulent/bloody fluid with hair embedded specifically along natal cleft. TX with excision and drainage. No atbx needed unless cellulitic.
ZES: Caused by non-beta islet gastric secreting neuroendocrine tumor, AKA gastrionoma. Arises from pancreas or duodenum. Tumor secretes gastrin,
stimulates acid secreting parietal and enterochromaffin-like cells of stomach. Causes GI mucosal ulceration, leading to reflux, heart burn, weight
loss, GI bleeds, watery diarrhea, refractory to PPI therapy. 90% develop peptic ulcers, usually small <1cm. Has associated with MEN1 syndrome.
(look for family hx of hypercalcemia (PTH)). Can diagnose with gastric 10x normal, but most have gastrin < 10x normal, need further evaluation.
If gastric not dx (not >10x nml), then get secretin stimulation: Baseline gastric obtained, bolus of secretin given after overnight fast. Serum gastrin
then measured at 2,5,10,30 minutes. Increase of >120pg is considered positive. (This is paradoxical in ZES, secretin normally inhibits gastrin).
Location and staging should be done with CT or MRI plus somatostatin receptor scintigraphy. If not mets, do a primary tumor resection.
If positive for MEN1, then they need medical therapy with octreotide.
GI adenocarcinoma: Esophageal presents with progressive dysphagia. Usually to liquids then solids. Can have epigastric pain, fatigue, weight loss, hoarseness.
GERD is biggest risk factor. GERD  barrets  adenocarcinoma. Remember that squamous cell results from irritation (smoking, alcohol).
Subacromial bursitis: Common cause of shoulder pain. Often poorly localized. Present around acromium. Complain of shoulder pain that is worst with
overhead activities, such as combing hair. May awaken at night. PE might show positive Neer sign and Hawkins test. TX is with NSAIDs, ice, rest,
physical therapy. Can do sub-acromial steroid injections if conservative therapy fails. (Subacromial used over > intra-articular injections).
Proliferative DM retinopathy: Characterized by neovascularization of iris and vitreous hemorrhages, which indicate more severe disease. May complain of
haziness, floaters, blurry vision, specks. BEST treatment is laser photocoagulation. Entire retina is burned with laser, spares macula.
Degenerative hip disease: Often from OA. Patient will develop gradual onset pain that fails conservative NSAID, rest, etc therapy. X-ray shows significant joint
space narrowing with osteophyte development. If conservative therapy fails, total hip arthroplasty of affected hip is indicated. Bilateral not
indicated unless both symptomatic.
LGIB: Lower GI bleed originates distal ligament of Treitz. MC cause is diverticulosis. Other causes are polyps, tumors, meckels, angiodysplasia (has random
association with aortic stenosis), colitis, and infectious diarrhea. Diverticulosis often presents as painless rectal bleeding. Can be copious. Etiology
from colonic outpouching, which erode into a vascular bed. (Tic usually occurs where vasa recta penetrate wall). More common in constipation.
Brisk upper GI bleeding can also cause hematochezia, but israre. Blood takes about 8hours to turn to melena/black.
Bladder diverticulum: Outpouchings from the bladder wall caused by herniation of mucosa through the muscular bladder wall. May be primary/acquired.
Size varies greatly. Acquired MC from; bladder outlet obstruction, neurogenic bladder, congenitally weak detrusor, s/p urologic surgery. BPH is a
common cause of bladder outlet obstruction from compressed prostatic urethra. Increases backflow pressure into bladder  diverticulum.
Can cause urinary stasis with urinary frequency and hematuria. Increases risk of bladder stone formation and malignancy (Transitional cell CA).
Diagnose with voiding cystourethrography. Fills bladder with radiocontrast through foley, x-rays taken, pt voids under fluoroscopy.
Hemorrhoids: Often cause PAINLESS blood per rectum (if internal, or painful if external). Usually on tissue, not mixed in with stool. Incidence increases at 45-
65. Often presents with rectal bleeding with defecation. Rectal exam can be negative if internal. Get anoscopy if no alarm symptoms are present
that might warrant a colonoscopy.
ACL injury: injured most frequently in sports, but also from non-contact twisting such as tibia externally rotated with foot outward with valgus force. Direct
impact can cause tears. ACL normally prevents anterior translation. 4.5x more common in females than males. Presents with a pop, giving way,
decreased ROM, acute onset edema (opposed to meniscus which is over hours to days). Hemearthrosis quickly develops. Has antalgic gait with
quadriceps avoidance gait. PE shows effusion, joint line tenderness, ecchymosis. Best test is Lachman >> anterior drawer. TX: For young patients,
kids, active adults, treatment is with pre-surgical PT, bracing, and then ACL reconstruction.
Prostatism: Syndrome caused by urinary outlet obstruction. S/S: Urinary frequency, urgency, nocturia. Can be because of BPH, but need to rule out prostate
cancer. PSA is often obtained. DRE usually done looking for nodules, asymmetry, or induration. If DRE is normal, but PSA is >10, they need urology
referral with US guided rectal biopsy of prostate. Tumors are graded by the Gleason score. Max of 5, min of 1 for each sample, x2. 2-4 usually
contained in transitional zone. 5-7 more advanced, 8-10 is aggressive advanced tumors, unlikely to be cured.
Large bowel obstruction: Presents as abdominal pain, distension, nausea, constipation. MC causes are tumor first, then volvulus, diverticular dz, other dz.
Parkland formula: Is %BSA of burns x weight (kg) x 4 ml/Kg. It is the fluid given over 24 hours. Remember that arms are 4.5% each side. Leg is 9% each side.
Chest is 9% and abdomen is 9% per side. The most usefuil way to monitor fluid status is urine. Burns cause diffuse swelling and edema which can
limit BP usefulness along with catecholamine release from the burns, despite intravascular depletion.
De Quervains: AKA stenosing tenosynvovitis of abductor pollicus longus and extensor pollicus brevis, but more often involves the APL. Seen in construction
workers and servers. It is MC in females and has an assosciation with RA. Presents with pain and tenderness at radial styloid near anatomical
snuffbox. Can be diagnosed with finklestein test which is grasping thumb and abducting toward the ulna. + is with increased pain. Initial treatment is
with NSAIDs, splinting. Then corticosteroid injections. Lastly surgery if conservative therapy fails with release of the APL.
Cecal vs. sigmoid volvulus: Tidbit of sigmoid volvulus will have loss of haufstra on imaging, whereas cecal volvulus retains the haufstra.
Cecal volvulus usually managed with surgery due to reoccurrence. Sigmoid usually with flexible sigmoidoscopy.
Pleomorphic adenoma: MC BENIGN salivary gland tumor. Presents as slow growing and just causes local irritation. CT shows well demarcated homogenous
appearing tumor in pre-auricular space in the parotid gland. Warthin tumor is 2nd MC benign tumor, but is much less common. If patients present
with facial nerve symptoms, then it is likely a malignant tumor such as mucoepidermoid carcinoma.
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Hemorrhoids: Located in submucosal layer in rectum. Arise from dilated AV channels. Internal are proximal to dentate line and arise from superior
hemorrhoidal veins. External arise distal to dentate line. Risk factors; age, pregnancy, diarrhea, constipation, pelvic tumors, straining. Caused by
hypertrophy/increased spincter tone, deterooation of tissue around veins or abnormal distinction of veins. SXS of anal pruritis, prolapse, bleeding.
External hemorrhoids are typically pain, internal are not unless they prolapse or strangulate.
Anal fissure: Tear in the anal canal caused by recurrent passage of hard stool. Have severe pain with defecation. The posterior anal commissure is poorly
perfused and pain is often a result of ischemia and internal sphincter spasm. Most fissures occur in posterior midline, a fissure off midline is
suggestive of Crohns, infection, or cancer.
Urethral injury: Often from blunt force trauma/MVA. Can be divided in anterior/posterior types. Anterior usually presents with stable patient with
penile/perineal pain, hematuria, blood at meatus. Posterior is more severe and involves perineal hematoma, high riding prostate on DRE. Usually
have undergone significant trauma. Although most posterior injuries are very ill, they get CTs anyway, but best test is retrograde urethrogram. Do
NOT place foley in suspected urethral injury. Anterior injury more common with straddle/direct injury. Posterior more common with high
speed/severe trauma. Pelvic fractures can contribute to posterior urethral injury. TX is with placement of suprapubic catheter. Surgical fixation is
delayed to allow reduction of hematoma. Deecreases incidence of complications such as ED/impotence.
Trigger finger: Type of stenosing tenosynovitis, commonly over age 45, especially diabetics. Presents as a palm nodule, usually at MCP over index or ring
finger. Pts have a catching sensation, locking in flexed position. MC from the A1 pulley. TX is conservative with splinting and stretching, THEN
corticosteroids, THEN A1 release.
CMV esophagitis: All esophagitis presents similary with dysphagia, odynophagia, reflux, N/V, fevers, weight loss. Severity varies. CMV is a severe type with
severe pain and dysphagia. Ulcers are longitudinal. Treatment is with ganciclovir and starting/optimizing ART. CMV will also affect other areas such
as abdominal pain, distension, constipation or watery diarrhea. Candida presents with white plaque. HSV presents with volcano-like ulcers.
HIT: Heparin induced thrombocytopenia. Occurs in 5% of patients treated with heparin products for 5 or more days. Risk of developing HIT is highest in surgical
pts, especially s/p bypass. DX with plt count <150k or 50% decrease in previous avg. Ruling out other causes. Reversal of thrombocytopenia after
cessation. Can DX with heparin induced platelet antibodies (sensitive) and serotonin release assay (specific). Most serious complication is
thrombosis, both venous and arterial. Must switch to lepirudin or argatroban. Get plts about 100k, then transition to Coumadin.
Caused by antibodies against platelet factor 4 (PF4). Bind to heparin-PF4 then bind to Fc-gamma receptors, releasing prothrombotic particles.
Ascending cholangitis: Or acute cholangitis. Presents with RUQ pain, jaundice, fever (Charcot triad), AMS, hypotension (Reynolds pentad). MC caused by stone
in the CBT (choledocolithiasis). Labs show increased WBC, LFTs, and biliary obstruction (increased direct bilirubin). ERCP is best test to confirm dx of
ascending cholangitis. Percutaneous transhepatic cholangiography is also acceptable.
Hemorrhoid treatment: Rubber band ligation: used for grade II or III INTERNAL hemorrhoids/hemorrhoids that protrude out from anus. Excision: Used for
thrombosed hemorrhoids. Hemorrhoidectomy: If patient does not respond to conservative therapy or if strangulated, severe prolapse, or very lage
anal tags. Medical management: Used initially for grade 1 internal and non-thrombosed EXTERNAL hemorrhoids.
Budd-chiari: Hepatic venous outflow obstruction due to occlusion of hepatic veins and/or adjacent IVC. Leads to hepatic ischemia and congestion. Often seen
in age 40s, females. S/S jaundice, ascites, variceal bleeding, hepatomegaly. All due to portal HTN from congestion. Can have acute RUQ pain and
fullness. Often suspect with liver failure with no other cause or peri-partum. Remember due to hepatic vein thrombosis. Also associated with
hypercoagulation, HCC, polycythemia, paroxysmal nocturnal hemoglobinuria. (vs. cirrhosis, which is NON painful).
Achilles tendon rupture: Causes sudden pain in superior heel. Positive Thompson test. Pain at gastroc insertion. Pain with/lack of plantarflexion.
Dissection classifications: Debakey 1: ascending, arch, descending. Debakey 2: confined to ascending. Debakey IIIa: descending distal to left subclav, proximal
to celiac. IIIb: thoracic and abdominal aorta, distal to left subclavian. Stanford A: ascending. Stanford B: descending (distal to subclavian).
Chronic steroid use and surgery: If patients are on daily steroids, make sure they increase the dose for surgery to avoid adrenal crisis.  Stress dosing.
Carotid endarterectomy: Indicated for symptomatic patients in 70-99%. CEA is contraindicated in ipsilateral 100% blockage, increased risk of CVA.
PND: Defective gene for PIG-A. Leads to CD55/59 deficiency (decay accelerating factor). Overactivation of complement system, increased sensitivity of RBCs to
complement in an acidotic state (during sleep, hemolysis will occur due to hypoventilation with increase in CO2 and subsequent transient respiratory
acidosis). Presents with episodic dark urine with first urine of day. Labs can show pancytopenia, IDA, DECreased levels of CD55/59. Most
common cause of death is thrombosis (Usually hepatic/mesenteric veins). TX: Acute flare can be treated with Prednisone or Eculizumab (anti-complement
MAB that targets CD5 pathway. Improves quality of life and symptoms and decreases hemolysis, but does not cure disease). Stem-cell bone marrow
transplant is the only curative therapy for this disease.
Riglers triad: Triad of gallstone ileus. Pneumobilia, small bowel obstruction, radiolucent gallstone. Due to ductal fistula to GI lumen, gallstone falls into tract.
Gallstoen ileus is a surgical emergency  Enterolithotomy. Stone removal through bowel. Also perform cholecystectomy and fistula closure.
Radiation therapy: Produced from two settings. X-rays and gamma rays. Ionizing radiation correlates with dose and amount of body surface area. Can cause
direct or indirect DNA injury through formation of hydroxyl free radicals. Most susceptibile tissues Lymphoid > marrow > GI mucosa > germinal
tissue. LEAST radiosensitive bone > brain > muscle > skin. (bone being least).
Succinylcholine: Depolarizing NM blocker with two phases. Depolarizing action can cause fasciculations, particularly in muscular patients. P1 is primarily the
paralytic effect. Involves keeping membrane potential above threshold so that is constantly depolarized. P2 involves a non-depolarizing blockage
where ACh is competitively antagonized. Onset is rapid, biphasic, has no refractory period. IMPORTANT SIDE EFFECT IS HYPERKALEMIA (potassium
efflux from cells). DO NOT use in burns, crush injuries, NM disease, or known hyperkalemia. Often associated with MH, treated with dantrolene.
Zenkers diverticulum: Presents with esophageal dysphagia, regurgitation, HALITOSIS, weight loss. Vomiting of undigested food occurs. Occurs due to
abnormal cricopharyngeal muscular activity that results increased mucosal pressure since weakest part of mucosa is posterior, pouch forms.
Delta pressure: Used for compart syndrome Difference between diastolic BP and measured compartment syndrome. Less than 30mmhg is need for fasciotomy.
Rule of nines: Remember each side of arm is 4.5% and each side of leg is 9%. Genitals are 1%. Chest 9%. Abd 9%. Back 18%.

UWORLD
Torus palatinus: Benign, bony growth on the hard palate. Presents as immobile, hard, bony growth in midline hard palate. Thought to be
genetic/environmental. More common in younger patients, women, Asians. It usually <2cm in size. Can increase in size throughout life.
Surgical removal can be done, but only if it’s problematic such as recurrent traumatic ulceration or fitting for dentures, etc.
Scaphoid fracture: MC carpal fractures. Frequently result from FOOSH injury. Causes axial compression + hyperextension. Scaphoid located proximal radial
wrist. Arterial supply from radial artery enters through foramina in bones distal pole before going to proximal pole. Can lead to avascular necrosis
 Michael Wray
and nonunion. Presents with painful anatomic snuffbox and radial deviation pain. X-ray has low initial sensitivity, put pt in thumb spica and have
repeat x-ray in 7-10 days. Wrist must be immobilized. Can consider MRI for earlier return to activity.
Fat emboli syndrome: MOA not 100%, but thought to be from fat entering system from either traumatic long bone rupture, ortho surg, or pancreatitis. Crosses
over in circulation to capillaries or it activates systemic inflammation/toic intermediates. Presents with respiratory distress, neurologic dysfunction,
and petechial rash. Low grade fever and subconjunctival hemorrhage can be seen. Chest x-ray often normal, but can start developing infiltrates
within 1-2 days. Diagnosis is clinical. TX is supportive, many need mechanical ventilation.
Acalculous cholecystitis: MC seen in severly ill patients (ICU, trauma, multiorgan failure, burns, sepsis, prolonged parenteral nutrition). Likely due to cholestasis
and GB ischemia leading to 2ndary infection by entering bugs. Causes edema and necrosis of GB. Can result in death. Need high degree of suspicion
since patients are usually very ill. Treatment is with percutaneous cholecystOSTOMY under radiologic guidance, THEN cholecystectomy once
patient stabilizes.
Prosthetic infections: Early onset <3m: Acute pain, fever, wound infection due to staph aureus, gram neg rods, anaerobes. Delayed onset 3-12mo: Presents
with chronic joint pain, implant loosening, sinus tracts, due to coagulase negative staph (epidermis), ppropionibacterium, enterococci.
Late onset >12m: Acute symptoms in previously asymptomatic joint. Recent infection elsewhere. Staph aureus, gram neg rods, beta-hemolytic strep.
Nec fasc: Due to strep pyogenes, staph aureus, clostridium perfringens, or polymicrobial. Bacteria spread rapidly through subcue tissue and deep fascia,
undermining the skin. MC involves extremities, perineal region. Often antecedent history of minor trauma. Erythema of overlying skin. Swelling and
edema. Severe pain out of proportion to exam. Systemic symptoms (fever, hypotension). TX: Requires surgical debridement + broad spectrum atbx.
Marjolin ulcer: This is essentially squamous cell carcinoma arises from burn wound scars/chronic burn drainage. SCC has a tendancy for UV burned skin, but
can also be seen in chronic wounds, burn scas, or inflamed skin. SCC arises from burn wound is known as Marjolin ulcer. SCC has also been seen
overlying focus of osteomyelitis, radiotherapy scars, venous ulcers. SCC within chronic wounds tends to be more aggressive.
Acute mesenteric ischemia: Presents with rapid onset periumbilical pain (severe) pain out of proportion to exam, hematochezia (late). Risk factors are
atherosclerosis (acute or chronic), EMBOLIC source (thrombus, vegetation (IE patient)), hypercoagulable states. Labs can show leukocytosis, elevated
amylase, phosphate, metabolic acidosis, lactic acidosis. DX with CTA or MR angiography.
Elevated ICP TX: Head elevation: increased venous outflow. Sedation: decreased metabolic demand/control of HTN. Mannitol: Extraction of free water from
brain tissue  osmotic diuresis. Hyperventilation: CO2 washoutcerebral vasoconstriction. Removal of CSF: Reduction in CSF volume/pressure.
Ischemic colitis: Due to non-occlusive watershed ischemia, underlying atherosclerotic disease, state of low blood flow (hypotension/hypovolemia). S/S of
moderate abdominal pain and tenderness, hematochezia, diarrhea, leukocytosis, lactic acidosis. DX with CT scan: colon wall thickening, fat stranding.
Endoscopy can show edematous friable mucosa. Management with IV fluids, bowel rest, atbxs, resection of necrotic bowel. The areas most
affected are splenic flexure (IMA and SMA anastomosis) and rectosigmoid junction (sigmoid and superior rectal aa.)
Gilbert syndrome: more common in males. MC inherited bilirubin glucuronidation problem. Due to UGT1A1 gene. AD/AR. Decreased UDP-gluctransferanse,
increases UNCONJUGATED bilirubin. S/S: Intermittent episodes of mild jaundice (scleral icterus). Provoked by stress, infection, fasting, exercise,
surgery. DX with unconjugated hyperbilirubinemia on repeat testing. Normal CBC, smear, reticulocytes. NORMAL AST/ALT/alk phos. NO TX.
Amputation preservation: Traumatic amputation should be treated as candidates for reimplantation. The amputated limb/digit should be wrapped in sterile
gauze, moistened with saline, placed in plastic bag. Should not be allowed to freeze. Can preserve the part for up to 24 hours.
Penile fracture: results from rupture of corpus cavernosum due to traumatic tear in the tunica albuginea (envelopes cavernosum). PF is MC caused by blunt
trauma during sex in erect state. Pts typically experience an audible snapping sensation, detumescence, minimal to severe pain. Hematoma forms
rapidly, causing bending of the shaft of penis at fracture site. DX is clinical. Urologic emergency, surgical treatment is mainstay, but only imaging
test commonly used is retrograde urethrogram in suspected urethral injury. (Does not always occur in PF; blood at meatus, hematuria, dysuria,
retention, inability to void).
Adrenal insufficiency: Adrenal crisis. Etiology: Adrenal hemorrhage/infarction, acute illness, surgery in patient with chronic adrenal insufficiency/long-term
glucocorticoid use. S/S: Hypotensive shock, N/V, abdominal pain, weakness, fever. TX: Hydrocortisone, dexamethasone.
(Remember that primary AI has loss of aldosterone, causes hyperkalemia and hyponatremia. Central/2 ndary can have mild hyponatremia).
Generally seen after 3 weeks of steroids on 20mg or more. 5-20mg puts them at risk, monitor closely. <5mg are not at risk of HPA suppression.
Blunt GU trauma: Rarely life threatening unless kidneys/renal vasculature involved. MC lesions are contusions, lacerations, renovascular lesions (pedicle
avulsion, renal artery dissection). Evaluation should include urinalysis for hematuria. STABLE patients with hematuria should get CT scan. If they’re
unstable, they need IV pyelography BEFORE surgical evaluation. Other tests; US for testicles, retrograde cystourethrogram (gross hematuria, meatus)
Pulmonary contusion: Present <24hours after blunt thoracic trauma. Tachypnea, tachycardia, hypoxia. Rales/decreased breath sounds. CT/x-ray shows patchy
alveolar infiltrate, NOT restricted by anatomical borders. Mgmt: pain control, pulmonary hygiene, supplemental O2/vent support.
Meningioma: Dural based massed, seen out outsides of brain/spinal cord. Usually a focal lesion that can be calcified. Well circumscribed. Can present with
increasingly painful headaches with progressive neurologic deficit (often seizures, but can see focal weakness). TX with complete resection.
Sphincter of Oddi dysfunction: Muscular valve controlling flow of bile and pancreatic juice into duodenum. SOD can develop following any inflammatory
process (s/p cholecystectomy, pancreatitis, other sx), encompasses 2 separate physiologic entities: dyskinesia and stenosis of oddi. Obstruction
results in bile retention—functional biliary disorder that mimics structural lesion with episode RUQ pain, elevated ALT/AST, alk phosphate, and
dilation of CBT. Opioid analgesics (morphine), may increase pain due to contraction of oddi. Sphincter manometry is gold standard for diagnosis.
Penetrating chest trauma: Abdominal structures can be involved all the way up to the T4 dermatome (nipple line) (because of expiration). If a patient is
hemodynamically unstable with penetrating chest trauma at this level, they need laparotomy.
Blunt vs. penetrating abdominal trauma: FAST exam is done first. If pt is hemodynamically unstable, they go to OR. If FAST inconclusive, do peritoneal lavage.
Bladder injury: Extraperitoneal bladder injury: Can be from contusion/rupture of the neck, anterior wall, or anterolateral wall of bladder (remember that the
dome of the bladder sits up against peritoneum). Bladder can rupture extra-peritoneal, causing localized irritation with pelvic pain/LQ pain. Pelvic
fracture is almost ALWAYS present with EPBI. Gross hematuria/urinary retention also seen. Intraperitoneal bladder rupture: occurs from dome of
bladder (superior and lateral bladder walls, abuts peritoneal space) rupture causes diffuse chemical peritonitis. Due to leakage of urine into
peritoneum. Pelvic fractures also less common with rupture.
Paralytic ileus: Often seen in patients following intraabdominal trauma/peritonitis. Presents with abdominal pain, constipation, N/V, absent bowel sounds.
Xray will show gas filled loops of small bowel and large bowel as well as gastric dilation. Ileus MC due to abd surgery, but can be seen from
peritonitis/inflammatory changes to abdomen. TX is supportive care, bowel rest, tx of secondary causes.
Diverticulitis: Due to colonic diverticular inflammation. Causes LLQ pain, fever, leukocytosis. CT can show inflammatory changes such as soft-tissue stranding
and colonic wall thickening. Classified as uncomplicated (75%) or complicated (25%). Uncomplicated pts can be discharged and managed with oral
 Michael Wray
atbx (metro + Cipro). Complicated (elderly, immunosuppressed, high fever/huge leukocytosis, significant comorbidities) need admission on IV
antibiotics. Complicated can also have abscess, obstruction, fistula or perforation. Fluid collection <3cm can be treated with IV atbx. >3cm needs CT
guided percutaneous drainage. If symptoms not controlled by day 5, they need surgical resection (or if they have fistula, peritonitis, obstruction,
recurrent diverticulitis).
Venous stasis: Caused by venous valvar incompetence with poling of venous blood, increasing pressures in post-capillary venules. This increases pressure,
damages capillaries, causes fluid loss, plasma protein leakage and RBCs into tissue. Causes hemosiderin deposition (classic brownish discoloration).
Inflammation and fibrin deposition occurs with PLT aggregation, causing microvascular disease with eventual venous ulceration.