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Key: Underlined = Main concept Blue = Helpful Hints

Surgery
PP = Pathophysiology S/S= Signs/Symptoms RF= Risk Factor CST: Corticosteroids

Methylnaltrexone: alleviates obstruction from stool impaction due to chronic opioids

Metoclopramide (oral): alleviates gastroparesis

Anesthesia
1. Etomidate
1. SE: Inhibits 11B-hydroxylase leading to adrenal insufficiency
2. Halothane
1. SE: Acute liver failure due to hepatotoxic intermediary compounds
3. Succinylcholine
1. SE: Upregulation of PostACh-R in skeletal muscle trauma, Burn injury, Stroke, GB—Life-threatening Hyperkalemia
2. Alternative: Nondepolarizing neuromuscular blocking agents: Vecuronium, Rocuronium
4. Propofol
1. SE: Severe hypotension due to myocardial depression
5. Nitrous Oxide
1. SE: Inactivated B12—inhibition of methionine synthase = neurotoxicity in setting of preexisting B12 deficiency
6. Atelectasis (Severe ALI): General anesthesia reduces FRC
1. Mucus plugging
1. Subsegmental atelectasis may lead to obstruction and inflammation—> large airway obstruction and segmental collapse
2. Mediastinal shifting toward opacification (vs. opposite in pleural effusion) to occupy vacant space
3. Smoking
2. Low-grade fever and mild respiratory insufficiency
7. Emergence
1. Transition from general anesthesia to consciousness
2. Delayed Emergence from Anesthesia hypoactive state persists >30-60min
1. Failure to achieve consciousness within expected window of last anesthetic
2. Causes
1. Hypoventilation due to medicine effect—low pH, high CO2, low pO2, bradypnea, bradycardia
1. Especially in patient with “alcohol and polysubstance abuse”
2. Tx: Ventilatory support
2. Metabolic: hyper/hypoglycemia, hyper/hypothermia, liver disease
3. Neurologic: intraoperative stroke, postictal state seizure, elevated ICP
3. Emergence delirium: hyperactive; in operating room or after initial normal emergence
1. Common in children and adults after abdominal/breast surgery or psychiatric history (PTSD)
2. Tx: Reassurance, reorientation and observation
8. Spinal Epidural Anesthesia
1. Local anesthetic: Bupivacaine
1. Local anesthetic causes systemic toxicity if injected into epidural vasculature and enters maternal circulation
2. Initially blocks inhibitory neural pathways—CNS overactivity
1. Perioral numbness, metallic taste, tinnitus
2. Generalized tonic-clonic seizures
3. CV sympathetic activation (tachycardia, hypertension) and risk of fulminant cardiovascular collapse
3. Management: Drug cessation, BZD for seizure control and supportive
9. Spinal Epidural Abscess (SEA)
1. S. aureus
2. Cause
1. Hematogenous spread of distant infection (cellulitis, joint/bone)
2. Contiguous spread from adjacent (vertebral osteomyelitis)
3. Direct inoculation during spinal/epidural anesthesia
3. Fever, Focal/severe back pain, Neurological deficits
1. Neuro deficits (infections affect multiple spinal levels): focal pain—nerve root pain—motor weakness, sensory changes, bowel/bladder dysregulation—
paralysis
2. Progressive neurological impairment due to direct spinal cord compression, thrombophlebitis of draining venous plexus and interruption of arterial blood
supply
4. Dx: High ESR, Blood and culture, MRI spine —MRI provides visualization of infection extent
5. Tx: Broad spectrum Abx, Aspiration
10. Spinal Epidural Hematoma
1. Complication of neuraxial anesthesia, lumbar puncture, spinal surgery
2. More common in older adults taking antithrombotic medications
3. Presentation: Slowly progressive motor and sensory dysfunction, localized back pain; bowel/bladder dysfunction
4. Management: Urgent MRI and Neurosurgical decompression
11. Laparoscopic intervention and CO2 insufflation
1. CO2 insufflation creates space for surgical maneuvering and camera visibility
1. Peritoneal stretch receptors sense increase in intraabdominal pressure and trigger increased vagal tone
2. S/S: Severe bradycardia, AV block and sometimes asystole

Imaging/Procedures
CT
1. Abdominopelvic: Cecal volvulus
2. Chest Angio: sensitive and specific for thoracic aortic injury

Ultrasound
1. FAST
2. eFAST: extended focused assessment with sonography
3. TEE: Thoracic aorta (but experienced person, done in OR)
Preferred in renal insufficiency or hemodynamically unstable pt vs. CTA
4. TTE: Does not visualize thoracic aorta (more posterior, closer to esophagus)

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Thoracostomy: minimally invasive procedure in which a thin plastic tube is inserted into the pleural space
Thoracotomy: cut is made between the ribs to see and reach the lungs or other organs in the chest or thorax

GENERAL
Pre-Op Evaluation
5. General
1. BB not recommended if not already on medication list; increase risk of cerebral ischemic events
2. Dobutamine stress test: sensitive for perioperative cardiac complications
3. Renal dysfunction: best to assess using 24-hr collection; serum Cr in elderly with low muscle mass unreliable
4. Neuroaxial anesthesia: less cognitive dysfunction than general anesthesia
6. CVD Assessment
1. Male >45yo, HTN, DM (= CAD), Cholesterol <— 4 RF
1. Adjust BP meds, daily finger glucose + insulin adjusted, EKG + Stress test, Echo (if murmur)
2. Use pharmacological stress test if patient cannot walk
2. Previous hx Cardiac disease
1. EKG, Stress test (ischemic coronary disease), Echo (structural disease and assess EF)
3. No hx Cardiac disease
1. EKG only
7. Pulmonary Assessment
1. Lung disease hx—PFT for vital capacities
2. Quit smoking 6-8wk prior, replace with nicotine patch
8. Renal Assessment
1. Hydrate adequately to prevent hypoperfusion
2. Fluids before surgery
3. Dialyze 24hrs prior
9. Anticoagulation
1. Transition
2. Bridge
1. Oral to IV (Warfarin to Heparin for prosthetic valves)
3. Platelet Inhibition
1. Reversible: Dipyridamole, Cilastazol, NSAIDs
2. Irreversbile: ASA, Clopidogrel, Ticlopidine, Prasugrel
4. Stent dual therapy with ASA and Clopidrogel
1. Bare-metal: 6 months
2. Drug-eluting: 12 months
5. Warfarin
1. Post valve
6. CHAD2 (risk of stroke due to atrial fibrillation)
1. CHF (1pt), HTN systolic >160 (1pt), >75yo (1pt), prior CVA (2pt) High: 5-6, Mod: 3-4, Low: 0-2
7. NOACs *Stroke and embolic complications post A fib, DVT and PE tx, DVT prevention + High CHAD2 score*
1. Thrombin-I:
1. Dabigatran: Not in RF, Reversal—> hemodialysis
2. F10a-I:
1. Rivaroxaban: Not in RF, Increased levels in Liver Failure, Assess levels—>PT
1. Interactions: Antifungal, Protease Inhibitors, Rifampin
2. Apixaban
3. Less drug interactions with other medications
4. CI: pregnant or breastfeeding
10. Prophylactic Antibiotics
1. Clean procedure (without infection or viscus entry): Gram (+) coverage
1. 1st/2nd gen Cephalosporin: Cefazolin/Ceftoxitin
2. (In Penicillin allergy) Vancomycin, Clindamycin
2. Clean-contaminated

Post-Op
1. General
1. Ventricular diastolic dysfunction major causes of perioperative cardiac mortality due to intravascular volume and pressure fluctuations
2. Incisional pain
1. Postop incisional pain in the absence of infection, fluid collection and wound dehiscence is managed with observation and reassurance
2. Normal healing involves mild induration and diffuse tenderness to deep palpation over the incision
3. Respiratory management
1. Incentive spirometry most useful in preventing postop pneumonia
2. Vs. CPAP (only used in patients with pulmonary complications despite incentive spirometry)
4. Sinus Tachycardia seen with
1. Pain and Anxiety
2. Paroxysmal Sympathetic Hyperactivity

Post-Op Fever

100.4-101.3/38.0 to 38.5

1. #1 cause: Atelectasis
2. Risk of septic complications—Spillage of colonic contents > stomach or small bowel contents
3. Source control + Abx therapy
4. Abdominal Surgery
1. GI dysfunction post GI surgery indicates intra-abdominal infectious complications
2. Work-up
1. GIT broad-spectrum antimicrobial therapy
2. CT: inflammatory changes without abscesses, intra-abdominal abscess, percutaneous drainage
Complications
~Assume intra-abdominal or surgical site infection in febrile postoperative patient unless proven otherwise~
3. Deep Surgical Space infection
1. Intra-abdominal abscess—> Secondary peritonitis, Tertiary peritonitis, Deep surgical space abscess
2. CT scan evaluation and drained under CT guidance
3. Abx

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4. Secondary peritonitis
1. Spillage of endogenous microbes into peritoneal cavity following visceral perforation
2. Affected by size of microbes, timing of dx and tx, effect of microbes on growth of other microbes, host defense
3. Antibiotic therapy + source control (each not ineffective individually)
4. Uncontrolled
1. Recurrent Secondary Peritonitis
1. Inappropriate or inadequate duration of antimicrobial therapy
2. Give additional microbial therapy or adjust regimen
2. Tertiary Peritonitis
1. Diminished host peritoneal response
2. S. epidermidis, Enterococus faecalis or Candida
3. Intra-abdominal abscess
1. Host compartmentalizing process with fibrin, omental containment and ileus of SI to localize infection
2. Resultant loculated, infected inflammatory fluid cannot be eliminated by host trans-lymphatic clearance
3. If immunocompromised pt (taking CST): initiate broad-spectrum antibiotics as well
4. Sizable abscess: surgical or percutaneous drainage
5. Surgical site infection
~High risk of infection with Smoking~ LV Aneurysm
1. Superficial Surgical Site infection
1. Soft tissue of surgical site, above fascia
2. Wound exploration and drainage + Abx if cellulitis or immunocompromised patient
2. Deep Surgical Site infection
1. Fascia and muscles
2. CT to rule out deep surgical space infection
5. Post-Op Acute Respiratory Insufficiency (below in Lung Trauma)

CVS
POST MI
1. LV Aneurysm (several months post-MI)
1. Persistent ST elevation and deep Q waves, LV enlargement, Dyskinetic wall motion leading to heart failure
2. Necrosed myocardium is replaced with fibrous scar—convexity of LV wall—impaired ejection fraction
3. Complications
1. Heart failure (pulmonary edema)
2. Ventricular arrhythmia
3. Systemic embolization due to mural thrombus inside aneurysm
4. Dx: Echo—thinned and dyskinetic myocardial wall
2. Pericarditis
1. Peri-infarction (post-MI)
1. Echo to establish presence and severity of pericardial effusion
2. Pain control: Acetaminophen (NSAIDS avoided for 7days due to free wall rupture
risk)
OTHER
2. Cardiac Surgery Complication
1. Acute Mediastinitis
1. Deep tissue infection post cardiovascular surgery
2. S/S
1. Fever, chest pain, leukocytosis
2. Intraoperative wound contamination
3. CXR: Mediastinal widening
3. Dx
1. Chest and sternal imaging
1. Especially if there is copious drainage from sternal wound in the absence of classical symptoms
4. Tx: Surgical debridement, Prolonged Abx, drainage
2. Sternal Dehiscence
1. Separation of bone edges of the sternum
2. S/S: Chest wall instability and ‘clicking’ with chest movement Artery of Adamkiewicz: injury
3. Dx: Displaced sternal wire or palpable rocking/clicking of sternum during thoracoabdominal
4. Management: Urgent surgical exploration and sternal fixation aorta aneurysm repair can
cause Spinal cord ischemia
3. Acute Adrenal Insufficiency (PAI)
1. Acute stressors trigger adrenal crisis due to autoimmune destruction of all 3 layers
2. S/S
1. Shock
2. Severe hypotension refractory to initial volume resuscitation
1. Mainly due to Mineralocorticoid deficiency
2. Exacerbated by Glucocorticoid deficiency because cortisol needed to potentiate alpha-1 stimulation on peripheral vascular tone
3. Hyponatremia (hypovolemia-induced ADH secretion)
4. Hypoglycemia (cortisol deficiency)
5. Peripheral eosinophilia (eosinophils normally inhibited by corticosteroids)
3. Tx: Rapid volume repletion, Hydrocortisone or Dexamethasone
1. Glucocortic: Dexamethasone preferred cause does not interfere with plasmas cortisol level needed to confirm dx
2. Mineralocortic: Fludrocortisone requires several days to exert sodium-retaining effects, thus started after initial tx
4. Secondary PAI: Only Cortisol deficient
1. Patients on chronic glucocorticoid therapy can develop Hypothalamic-Pituitary-Adrenal axis suppression
2. Pituitary cannot secrete ACTH when needed
3. Tx: Hydrocortisone
4. Abdominal Aortic Aneurysm
1. Enlargement of abdominal aorta diameter to >3cm
2. RF: >60yo, Smokers, Male, Hx Atherosclerosis or Connective tissue disease
3. Anterior
1. Direct leakage into peritoneum and rapid hemodynamic instability and shock
4. Posterior
1. Proximal: Back pain “L1-L4 spinal level pain”, abdominal pain, flank pain
2. Distal: Lower abdominal pain, groin pan
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3. Leakage into retroperitoneum = Delayed onset of hemodynamic instability
5.S/S
1. Few symptoms until AAA significantly expands or ruptures, commonly
1. Acute onset severe abdominal or flank pain
2. Syncope, pulsatile abdominal mass, flank or umbilical hematoma
3. CXR: Prevertebral aortic calcifications due to extensive atherosclerosis
2. Distal ischemia due to embolization of thrombus or of atherosclerotic debris from aneurysm
3. High-output heart failure due to erosion of AAA into Vena Cava (aortocaval fistula)
6. Dx
1. HD Stable: CT abdomen
1. AAA identified—Medical optimization and repair
2. HD Unstable
1. Known AAA—Emergency repair
2. Unknown AAA: FAST scan
1. AAA identified—Emergency repair
7. Management
1. Smoking cessation
1. Disrupts arterial wall elastin matrix via stimulation of enhanced protease activity, chronic inflammation and smooth muscle dysfunction
2. Labetalol: Nonselective a-1 and B-1 blocker—decreases HR, Contractility and Vascular resistance
3. Elective repair >5.5 cm
4. Urgent repair for symptomatic and HD stable Ascending Thoracic
5. Emergency repair for symptomatic and HD unstable Aortic Aneurysm
8. Screening
1. 1-time Abdominal Ultrasound for men 45-75yo with smoking history A: Ascending
9. Association D: Descending
1. Peripheral Artery Aneurysms
1. Hallmark: Pulsatile groin mass below inguinal ligament
2. Mass can compress adjacent structures and cause thrombosis and ischemia
3. Commonly involved: Femoral artery, Popliteal artery
5. Acute Aortic Dissection
1. History of
1. HTN
2. Marfan Syndrome
3. Turner Syndrome
1. Aortic dissection risk increased further with pregnancy
4. Cocaine may cause rapid and transient hypertension leading to aortic dissection in young pt
1. Sudden onset, severe chest pain and pleural effusion due to hemothorax
2. S/S
1. >20 mmHg variation in SBP between arms
2. Severe, sharp, tearing chest pain or back pain
3. Elevated D-dimer (non specific)
4. Type A: Ascending
1. Aortic rupture into pericardial space and hemopericardium
2. Rapidly progresses to Cardiac Tamponade and Cardiogenic Shock
3. Surgical Emergency
~Intraoperative TEE performed to identify additional abnormalities—aortic root/valve damage or tamponade~
5. Type B: Descending
3. Dx
1. ~1st~ CTA: intimal flap or double aortic lumen
1. HD Stable patient with no renal dysfunction
2. TEE
1. HD Unstable or renal insufficiency
2. Note: TTE cannot visualize parts of aorta wall
3. MRA
1. Time-consuming, gadolinium-contrast needed
2. Avoided in kidney disease due to risk of nephrogenic systemic fibrosis
4. CXR: Widened cardiac silhouette, pericardial effusion
4. Tx
1. Pain control—Morphine
2. IV BB (Esmolol) +/- Sodium Nitroprusside (if SBP >120mmHg)
5. Complications
1. Stroke (carotid artery)
2. Acute Aortic Regurgitation (aortic root/valve)
3. Horner Syndrome (carotid sympathetic plexus)
4. Myocardial ischemia/infarction (coronary artery ostia)
5. Pericardial effusion/tamponade (pericardium)
6. Hemothorax (pleural cavity)
7. Renal injury (renal arteries)
8. Abdominal pain (mesenteric arteries)
9. Lower extremity paraplegia (spinal arteries)
6. Cardiac Catheterization
1. Complication: Retroperitoneal Hematoma
1. Sudden hemodynamic instability and ipsilateral flank/back pain "diaphoretic and clammy”
2. Dx: Non-contrast CT of abdomen and pelvis or Ultrasound
7. Central Venous Catheter
1. Confirm tip placement with CXR prior to catheter use
2. Complications occur in 15% cases
1. Small veins—Venous perforation; increased DVT risk (Preoperative LMWH)
2. Lung puncture—Pneumothorax or Myocardial perforation causing Pericardial Tamponade
8. Tricuspid Regurgitation
1. Hallmark: Prominent V waves
2. RF
1. Implantable pacemaker, Cardioverter-defibrillator
1. Transvenous led placement through triscuspid valve can damage triscuspid valve leaflets
2. RV lead passes through SVC into RA and then through Tricuspid valve

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2. Left HF leading to RV Overload—Tricuspid annular dilation and tethering of chord tendineae, both restrict adequate closure
S/S 3.
1. Right HF: Pulsatile tender hepatomegaly, abdominal distention with ascites
2. Right ventricular heave and holosystolic murmur at L Sternal border
3. Murmur intensifies with increased RV Preload (deep inspiration, leg raise)
4. Dx
1. Echo
9. Mitral Stenosis
1. Pregnancy: Percutaneous mitral intervention followed by pregnancy
1. Increase in CO and BV associated with pregnancy can be poorly tolerated in valvular disease
CV Contraindications to Pregnancy
Symptomatic MS, AS, HF with LVEF <30% Pericardial Effusion
Pulmonary Artery HTN, Bicuspid AV with ascending aorta enlargement >50mm
10. Pericardial Effusion
1. Etiology
1. Common Primary tumors: Lung, Breast, GIT, Lymphoma, Melanoma
2. Possible initial manifestation
2. S/S
1. Progressive dyspnea, chest fullness, fatigue
2. ECG: Low QRS voltage +/- electrical alternans
3. CXR: Enlarged cardiac silhouette and clear lung
4. Echo: Large effusion +/- signs of tamponade (RA collapse)
3. Tx
1. Acute: Pericardiocentesis, Cytologic fluid analysis
1. Pericardial Effusion & Cardiac Tamponade —> Emergency Pericardiocentesis
2. Recurrence prevention: Drainage
1. Catheter
2. Pericardial window: Surgical removal of a part of pericardium to allow fluid drainage into pleural or peritoneal cavity
11. Pleural Effusion
1. Usually Left-sided
2. Due to
1. Body’s reaction to surgical incision into pleura
2. Disruption of mediastinal lymphatic channels
3. Cardiac cooling
4. Postoperative Pericarditis
3. S/S
1. Decreased breath sounds in affected lung region
4. Management
1. Post-cardiac surgery managed conservatively with observation only
1. Small to moderate size and not enlarging
2. Early onset, within Day 1 or 2
3. No associated respiratory symptoms
2. Actively investigated and treated
1. Above criteria not present
2. Risk of hemothorax, central line erosion into pleural space, mediastinitis, chylothorax, MI with HF
12. Perioperative MI
1. Common in patients undergoing noncardiogenic surgery
2. RF
1. Intraoperative hemorrhage requiring blood transfusion (reduced oxygen delivery to myocardium)
3. S/S
1. Lack chest pain due to postoperative pain control
2. LV impaired contractility and low LV Stroke Volume due to significant infarction
3. Dyspnea and hypoxemia due to pulmonary edema
4. Low Cardiac Index (CO adjusted per body surface area)
1. Hypotension and compensatory peripheral vasoconstriction and increased SVR
2. Low tissue perfusion signals tissues to extract more oxygen from blood, causing decreased mixed venous oxygen saturation
5. Elevated PCWP due to elevated LV pressure back flowing into LA and lungs
13. Purulent Pericarditis
1. Hematogenous spread of S. aureus
2. RF: Chronic hemodialysis (fluid shifts and bacteremia)
3. Complication: Pericardial effusion
1. Distant heart sounds, low-voltage QRS complexes, enlarged cardiac silhouette with clear lung fields
4. Dx: Urgent Echocardiography-guided Pericardiocentesis
1. Echo can identify pericarditis but cannot differentiate if it is purulent or not
2. Pericardiocentesis confirms diagnosis and treats

Wound
1. Deep (fascial) Wound Dehiscences
1. Exposure of herniation (evisceration) of intraabdominal organs (bowels)—> possible strangulation
2. Altered mental status can be sign of hemorrhagic shock due to intrabdominal bleeding “dressing soaked with blood”
3. Require emergency surgery (2)
2. Dressing
1. 1st: Wet-to-dry for infected wounds or those with devitalized tissue or slough
1. Wet with saline, adheres to wound as gauze dries, removal debrides devitalized tissue
2. 2nd: Moisture-retaining once granulation tissue appears
1. Wound heals faster and promotes reepithelization

Pulmonary & Critical

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CAUSES OF HYPOXEMIA Examples A-a gradient Correct with supplem O2

Reduced PiO2 High altitude Normal Yes

CNS depression
Hypoventilation Normal Yes
Morbid obesity

Diffusion limitation Emphysema, ILD Increased Yes

V/Q mismatch Small PE, lobar pneumonia Increased Yes

Large intrapulmonary shunt Diffuse pulmonary edema (ARDS) Increased No + decreased lung compliance

Large dead-space ventilation Massive PE, R-L intracardiac shunt Increased No

1. Unilateral Diaphragmatic Paralysis

1. Etiology: Phrenic nerve, Viral infection (Herpes, poliomyelitis), Neurologic (ALS, GBS), Idiopathic
2. Dyspnea upon exertion (not at rest); Orthopnea (gravity opposes chest wall and lung expansion in recumbent portion)
3. Dx: Paradoxical movement of diaphragm on brisk inspiration
2. AV Malformation
1. Hereditary hemorrhagic telangiectasia
1. Nasal telangiectasia cause recurrent epistaxis
2. Pulmonary AVMs cause hemoptysis
1. CXR: “Multifocal, well-circumscribed, smooth nodules”
2. Infrascapular murmur (continuous pulmonary bruit) due to turbulent flow of AVM
3. Diaphragmatic Hernia Diaphragmatic Hernia
1. Suspicion for diaphragmatic rupture in patient with prior blunt thorax-abdominal trauma and abnormal CXR
1. CXR: bowel loops in thorax, mediastinal shift
2. Delayed presentation: in children after progressive expansion and diaphragmatic injury
2. Dx: CT chest and abdomen
3. Surgical repair after CT; CT aids in operative approach (thoracotomy vs laparotomy)
4. Empyema pus in intrapleural space
1. MC due to aspiration pneumonia causing movement of anaerobic oral flora into the intrapleural space
2. S/S: Weight loss and symptoms of uncomplicated pneumonia; Moderate pleural effusion
3. Dx: Putrid or foul smelling pleural fluid is diagnostic
4. Lateral decubitus XR: free flowing effusion
5. Pneumothorax (More in Chest Trauma)
1. Spontaneous
1. Primary Spontaneous—History of lung disease; tall, thin men in early 20s
2. Secondary Spontaneous—Underlying lung disease
3. Signs/Symptoms
1. Chest pain, dyspnea
2. Decreased breath sounds, decreased chest movement
3. Hyperresonant to percussion
4. Imaging
1. Visceral pleural line
2. Absent lung markings beyond pleural edge
5. Management
1. Small <2cm: Observation, Oxygen
2. Large: Needle aspiration, Chest tube
2. Tension Pneumo (More under Chest trauma) Pancoast Tumor
1. Management: Urgent needle decompression or Chest tube
6. Lung Cancer
1. Superior pulmonary sulcus tumor
1. Malignant, arise in superior portion of lung; associated with smoking
2. Presentation
1. Invasion brachial plexus—Shoulder pain
2. Invasion sympathetic chain/cervical ganglion—Horner syndrome (Ipsi ptosis, miosis, exophthalmos & anhidrosis)
3. Invasion C8/T1 nerve roots —Arm pain (Weakness/atrophy intrinsic hand muscles, pain/paresthesia 4/5th digits)
4. Supraclavicular lymphadenopathy
5. Weight loss
3. Note: Superior sulcus in lung periphery, pulmonary symptoms not seen until later in disease
4. Dx: CXR
7. Lung Transplant
1. Infectious
1. Nosocomial
2. Infectious: CMV, PCP, Aspergillus
1. CMV: Acute, febrile, diffuse interstitial pneumonia
2. Immunological
1. Hyperacute: ABO mismatch
2. Acute (6mo): Cell/Ab mediated
1. Low-grade fever, hypoxemia, CXR—perihilar opacities and interstitial edema, small bilateral pleural effusion
1. Bronchoalveolar lavage and biopsy to rule out infection before giving high-dose glucocorticoids for ALTR
2. Biopsy: submucosal lymphocytic infiltrate, perivascular inflammation
3. Tx: Glucocorticoids
3. Chronic (mo-yrs): Graft structure fibrosis
4. Obstructive pattern on PFT
5. BAL to rule out infection
6. Biopsy: submucosal lymphocytic infiltrate, bronchiolitis obliterates
7. Tx: Supportive or Repeat transplant
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3. Postoperative
1. Surgical site: anastomotic dehiscence
2. Primary graft dysfunction: ARDS, ATN
8. Lung Resection Surgery
1. Best predictors of postop outcome: FEV1 and DLCO
9. Mechanical Ventilation
1. Positive Pressure: Causes acute increase in intrathoracic pressure which could cause collapse of IVC
1. In the setting of decreased CVP (hypovolemic shock), mechanical ventilation may cause acute loss of RV preload, loss of CO and Cardiac arrest
10. Ventilator-associated pneumonia ARDS requires Ventilation—>VA-Pneumonia—>May cause upper lobe Abscess
1. Confirmation requires identification of organism in lower respiratory tract
2. Reduce risk
1. Elevating head of bed to 30-45 degrees
2. Suctioning subglottic secretions
3. Limiting endotracheal tube movement
4. Avoiding gastric acid suppression (unless high risk of stress ulcers)

Infectious Disease
1. General
1. Avoid Fluoroquinolones in patients with aortic aneurysm due to risk of increased collagen degradation
1. I.e. Achilles tendon rupture, retinal detachment, aortic aneurysm rupture
2. Ludwig angina
1. Dental infection “teeth roots"—> Cellulitis of submandibular space, polymicrobial
2. S/S
1. Bilateral edema of submandibular and sublingual space
2. Airway compromise due to posterior displacement of the tongue—drooling, dysphagia, muffled voice
3. Floor of mouth elevated, displacing the tongue “woody/brawny” neck
3. Dx: CT neck
4. Tx: IV Abx—Ampicillin-sulbactam + Clindamycin
3. Sepsis
1. Scenario: Catheter-related bloodstream infection
1. Systemic signs of infection (fever, malaise chills) without localized symptoms because outer cuff prevents bacterial migration along exterior of the catheter
2. Signs of shock: lactic acidosis, confusion, hypotension
3. Prompt removal and Abx such as Vancomycin plus Ceftazidime for S. aureus and Coagulase-negative Staph
2. Scenario: Diabetic Foot
1. Lack of typical sepsis symptoms due to hyperglycemia induced leukocyte dysregulation/poor inflammatory cytokine response
2. Aggressive fluid resuscitation, broad-spectrum antibiotics within the hour after blood cultures (Pip-Tazo, Meropenem or Cefepim + Vanco for S. aureus)
4. Splenectomy
1. High risk of infection with encapsulated organisms—begin Amoxicillin-Clavulanate to avoid fulminant sepsis
2. Risk of infection with N. meningitides, H. flu, S. pneumo—Meningococcal vaccine, H flu type B vaccine, 13- and 23-valent pneumococcal vaccine, Yr influenza
vaccine

Esophagus Review Test 35

1. Epiglottitis (distal)
1. Lack uvula deviation and unilateral LAD
2. Initial management: emergency laryngoscopy
2. Foreign body ingestion
1. High risk of perforation and can be fatal
2. Immediate Endoscopic removal if an object is in esophagus, stomach or proximal duodenum
3. Peritonsillar abscess (near uvula)
1. Tonsillitis “tender cervical lymph nodes" complication, deviation of uvula and unilateral LAD
2. Initial management: Peritonsillar aspiration and IV antibiotics
4. Tracheoesophageal Fistula
1. TEF with esophageal atresia presents shortly after birth with copious oral secretions and choking, coughing and/or vomiting with feeding
1. Defective division of foregut into esophagus and trachea
2. Results in proximal esophageal pouch and fistula between distal trachea and esophagus
2. VACTERL association: Vertebral, Anal, Cardiac, TracheoEsophageal, Renal, Limb defects
1. Screening: Echo, Renal US
3. Dx: NG tube insertion reveals resistance at proximal esophageal pouch
5. Vascular Ring
1. Encircles trachea and esophagus
1. Compression of trachea may cause Stridor
2. Compression of esophagus may cause Dysphagia, Vomiting or Recurrent food impactions
2. Congenital vascular malformation
6. Zenker Diverticulum
1. Cricopharyngeal motor dysfunction—Increased intraluminal pressure above muscle leads to herniation
2. Association: GERD
3. Dx: Contrast esophagography
4. Tx: Cricopharyngeal myotomy +/- diverticulectomy
TRAUMA
7. Esophageal Perforation
1. Endoscopy (#1), Boerhaave, Infectious/pills/caustic Esophagitis
2. S/S
1. Hamman sign— crunching upon palpation of thorax due to subcutaneous emphysema
2. Pleural effusion with atypical (green) fluid
3. Dx: Esophagogram with water-soluble contrast reveals contrast leakage (barium is caustic to tissues)
1. CXR: Widened mediastinum, pneumomediastinum, pneumothorax, pleural effusion
1. Perforation allows GI contents to leak from esophagus into mediastinum (widened mediastinum)
2. And/or into pleural space (pleural effusion)
3. GI contents cause severe chest pain and inflammatory rsp that can quickly progress to septic shock
2. CT: Esophageal wall thickening, Mediastinal fluid collection
4. Complication: Boerhaave Syndrome
1. Full thickness tear, alcoholics, left posterolateral aspect of distal esophagus
2. Retrosternal chest pain, radiates to L shoulder
3. Upper Endoscopy, Alcoholics

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5. Complication: Mediastinitis
6. Tx: Surgical exploration with debridement of mediastinum and perforation closure
1. EP is life threatening that can progress to mediastinitis and septic shock
8. Mallory-Weiss: mucosal tear, GE junction
1. Hematemesis, Odynophagia
2. Alcoholics

Stomach
1. Gastrectomy
1. Complication: Dumping Syndrome
1. Rapid emptying of hypertonic gastric contents
2. GI (nausea, diarrhea, abdominal cramps) and Vasomotor (palpitations, diaphoresis) symptoms
3. Controlled with dietary medication and diminish over time
2. Roux-en-Y gastric bypass
1. Anastomotic leak: breakdown of either gastrojejunal or jeunojenunal anastomosis causing leak into peritoneum
2. 1st week of surgery, fever, abdominal pain, tachypnea, tachycardia
3. Complication
1. Fat solute vitamin deficiency (Vitamins A, D, E, K)
2. Vitamin C deficiency (~3months) = Scurvy
1. Poor post-op diet
2. Ecchymosis, petechia, poor wound healing, perifollicular hemorrhage, coiled hairs
3. Mild anemia due to blood vessel fragility and bleeding
4. Normal platelet count, PT, PTT
4. Management: Abdominal CT with oral contrast
3. Refeeding Syndrome
1. Alcoholic
1. Scenario: Chronically malnourished alcoholic becomes hyporeflexic and weak after dextrose fluid
2. Body utilizing anaerobic glycolysis and lactic acidosis—Reintroduction of carbs—insulin secretion—intracellular shift of PO4, K, Mg—increases PO4
utilization during glycolysis—PO4 depletion and failure of cellular energy metabolism
3. Causes muscle weakness, hyporeflexia, rhabdomyolysis, hemolysis, arrhythmias, CHF
4. Dx: Low serum Phosphorus levels
2. Chronic Malnourishment
1. Nutritional replenishment in chronically malnourished pt causes Hypophosphatemia, Muscle weakness, Arrhythmia,
Normal CXR
CHF
4. Retroperitoneal Hematoma Also a complication of cardiac catheterization
1. Due to Warfarin therapy
1. Back pain and signs of hemodynamic compromise (weakness, dizziness, anemia, tachycardia)
5. Stress Gastric Ulcer
1. RF: shock, sepsis, coagulopathy, mechanical ventilation, brain injury, burns, high-dose CST
2. Painless GI bleeding (worsening anemia with positive stool occult blood)
3. Tx: PPIs and close monitoring
6. Gastric Adenocarcinoma
1. Tumor staging: CT scan
7. Obesity
1. Bariatric Surgery Indication
1. BMI >40
2. BMI >35 and comorbidity (T2DM, HTN, OSA)
TRAUMA
8. Gastric Perforation Pneumoperitoneum
1. H. pylori, NSAIDs, burns, head injury, trauma, cancer
2. Smoking and alcohol slow ulcer healing
3. Presentation
1. Ulcer burrows through gastric mucosa and gastric acid leakage into abdomen causes peritonitis
2. Posterior stomach —> ulcer may cause pancreatitis “fries it”
3. Acute onset, severe pain, systemic inflammatory response, right shoulder pain due to phrenic n. irritation
4. Peritonitis: Guarding, rebound tenderness, abdominal rigidity
4. Initial test: Upright CXR shows air under diaphragm “pneumoperitoneum/subdiaphragmatic free air”
1. Air under diaphragm = bowel perforation
5. Accurate: CT
6. Tx: NPO, NG tube, BS Abx, IV fluids, Xlap and perforation repair
9. Hiatal Hernia
1. Gastric herniation into the thoracic cavity
1. N/V, Postprandial fulness, Dysphagia, Epigastric/chest pain
2. XR: retrocardiac opacity within thoracic cavity
3. Management: Asx don't require further workup
1. However GERD should be medically managed
2. GERD non responsive to PPI—Nissen fundoplication

Gallbladder
1. Gallstones Management
1. No symptoms: No treatment
2. Typical biliary colic: Elective laparoscopic cholecystectomy or Ursodeoxycholic acid if surgery not possible
1. Postprandial RUQ or epigastric pain, nausea, vomiting
2. Normal Vitals, WBC and Liver function studies
3. Imaging: Ultrasound
3. Complicated (Acute cholecystitis, Choledocholithiasis, Gallstone pancreatitis): Cholecystectomy 72hrs
4. Complication: Gallstone Ileus
1. Pneumobilia “air in intrahepatic bile duct”, hyperactive bowel sounds, dilated loops
2. Stone may cause intermittent “tumbling” obstruction as it advances causing mechanical bowel obstruction
3. Dx: Abdominal CT—GB wall thickening, pneumobilia, obstructing stone
2. Postcholecystectomy Syndrome
1. Persistent abdominal pain or dyspepsia after cholecystectomy
2. Causes: Biliary (retained CBD, Cystic duct stone) or Extra-biliary (Pancreatitis, Peptic Ulcer Disease)
3. Dx: US, ERCP

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3. Acute Cholecystitis
1. Complete obstruction of cystic duct with subsequent inflammation and infection
1. Fatty food ingestion causes GB contraction against obstructed cystic duct
2. Tissue behind duct obstruction becomes inflamed from stasis leading to bacterial overgrowth
3. Subsequent ischemic changes lead to gangrene and perforation, generalized peritonitis or well-circumscribed abscess
2. S/S
1. Radiates to R shoulder
2. Peritoneal signs
3. Murphy sign
3. Complication: Perforation of Gallbladder
4. Dx: US
5. Note: Uncomplicated cholecystitis can cause mild elevations in Transaminases, Total Serum Bilirubin from 1-4 and serum Amylase due to sludge or pus passage
through CBD (without bile duct or pancreatic disease). Alkaline Phosphatase is usually not elevated without associated Cholangitis or Choledocholithiasis
4. Emphysematous Cholecystitis
1. RF
1. DM, Vascular compromise, Immunosuppression
2. Presentation
1. Fever, RUQ pain, Gas in GB wall/surrounding tissue/hepatobiliary system
2. Gas forming Clostridium or E.coli infect damaged or ischemic tissue
3. Surgical emergency
4.
5. Biliary atresia
1. Initially well-appearing followed by jaundice and conjugated hyperbilirubinemia over the next 1-8 weeks
2. Dx: Ultrasound showing absent or abnormal gallbladder; gold standard is intra-operative cholangiogram showing biliary obstruction
3. Tx: Kasai procedure (hepatoportoenterostomy) or liver transplant; Biliary atresia is the most common indication for pediatric liver transplantation
4. Breast milk jaundice would present with unconjugated hyperbilirubinemia
6. Biliary Cyst
1. Presentation
1. Acute Cholangitis (Fever, RUQ pain, Obstructive jaundice, Cystic bile duct mass)
2. Asymptomatic, “Abdominal mass in RUQ, normal enzymes”
2. Complications
1. Cholangiocarcinoma, Acute Cholangitis, Pancreatitis, Stone formation Primary Sclerosing
3. Tx Cholangitis
1. Urgent biliary drainage via Endoscopic Sphincterotomy and drainage (ERCP)
1. Before surgical excision of cyst to reduce Cholangiocarcinoma risk
2. Cyst resection (to reduce malignancy risk)
3. +/- Roux-en-Y hepaticojejunostomy (biliary drainage)
7. Sphincter of Oddi Dysfunction
1. Recurrent, episodic pain in RUQ or epigastric region with corresponding increase in Aminotransferases and Alk phos
2. Precipitated by Opioid analgesics “worsened by pain medication” Opioid analgesics also associated with Constipation
3. CBD dilation in absence of stones
4. Dx: Sphincter of Oddi manometry
5. Tx: Sphincterotomy
8. Porcelain gallbladder
1. Calcified rim in GB wall with central bile-filled dark area
2. Chronic cholecystitis—> Porcelain GB —> GB Adenocarcinoma therefore cholecystectomy considered
9. Primary Sclerosing Cholangitis
1. Fibrosis and structuring of the medium and large intra-and extra hepatic bile ducts, promoting Cholestasis and Acute Cholangitis
2. Initially may only see Elevated Alkaline Phosphatase and Gamma-Glutamyl Transpeptidase
3. 90% associated with UC—> Perform Colonoscopy to rule out IBD
1. IBD and PSC patients have annual Colonoscopies due to Colon Cancer risk
4. Complications
1. Biliary stricture
2. Cholangitis or Cholelithiasis
3. Cholangiocarcinoma, Colon Cancer, Biliary Cancer
4. Cholestasis (Dec fat-soluble vitamins, Osteoporosis)
10. Cholangiocarcinoma
1. Occurs in pts with fibropolycystic liver disease or PBC from underlying UC
2. Subacute RUQ pain, Wt loss, Biliary obstruction, Cholestatic liver enzyme pattern, Dilation of intrahepatic or CBD
1. Late clinical attention once tumor has obstructed biliary drainage
2. Elevated Alk phos, normal transaminases
3. Vs. Hepatocellular carcinoma
1. Cholangio: Elevated CEA/CA 19-9, normal AFP
2. HCC: Normal CEA and CA-19, Elevated AFP
4. Dx: Endoscopic Ultrasound or ERCP
TRAUMA
11. Acute Cholangitis
1. Fever, Jaundice, RUQ pain +/- Hypotension, AMS
2. Elevated Direct bilirubin, Alkaline phosphatase, Biliary dilation on abdominal US or CT
3. Anion-gap metabolic acidosis due to lactic acidosis with severe sepsis
4. Tx: Abx, ERCP biliary drainage with 48hrs

Abdominal Compartment Syndrome

1. Increased in intraabdominal pressure causes organ dysfunction
2. RF
1. Massive fluid resuscitation (trauma, sepsis)
2. Major intrabdominal surgery or pathology (pancreatitis)
3. Intraabdominal fluid collection (bleeding, ascites)
3. Presentation
1. Tensed, distended abdomen
2. Inc CVP: Inc intraabdominal and intrathoracic pressure cause extrinsic venous compression
3. Dec Venous Return: Decreased Preload
1. Note: Typically CVP and Preload follow same direction; however here CVP is elevated due to external compression
(rather than increased intravenous volume) and Preload is decreased due to Vena Cava compression
2. Dec CO, Hypotension and Compensatory Tachycardia
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4. Dec Ventricular filling: Diaphragmatic elevation compresses heart
4. Tx
1. Avoid fluid over-resuscitation
2. Dec Intraabdominal volume: NG tube, Drain fluid
3. Inc Abdominal wall compliance: Sedation, Paralysis
4. Definitive: Surgical decompression

Occult GI Bleed
1. Unexplained Iron deficiency anemia +/- positive fecal occult blood test
2. 1st: Colonoscopy and upper endoscopy
1. Hemorrhoids do not preclude endoscopic evaluation

Liver
1. Solid Liver Masses
1. Focal Nodular Hyperplasia (young F): Anomalous arteries, arterial flow and central scar on imaging
1. Vs. Hepatic Adenoma: Not associated with oral contraceptives, increased arterial flow on imaging
2. Hepatic Adenoma (young and middle age F): Long term oral contraceptives)
1. Possible hemorrhage or malignant transformation
2. US: Well-demarcated hyperechoic lesion
3. Contrast CT: Early peripheral involvement (needle biopsy avoided due to bleeding risk)
4. Surgical excision preferred
3. Regenerative Nodules: Acute or Chronic liver injury (cirrhosis)
4. Hepatocellular Carcinoma: Systemic symptoms, Chronic hepatitis or cirrhosis, Elevated alpha-fetoprotein
1. Ascites
1. Persistently bloody ascites
2. MCC of Cirrhosis
1. Screening with Abdominal US every 6 months since patients maybe initially asymptomatic
5. Liver Metastasis: Single/multiple lesions; Known extrahepatic malignancy
1. MC malignancy of the liver
2. Commonly from Colorectal cancer or Pancreatic cancer (venous drainage through portal system)
3. Surgical resection of liver tumor and primary tumor can be curative
2. Gilbert Syndrome
1. Decreased hepatic glucoronyosyltransferase; mild jaundice due to stressors
2. Isolated Unconjugated Hyperbilirubinemia
3. Ischemic Hepatitis
1. Due to global hypoperfusion and/or hypoxemia
2. Zone 3 (centrilobular) necrosis
3. Severe aminotransferase elevations with bilirubin levels unaffected for few days
TRAUMA
4. Hepatic Laceration (Blunt Abdominal Trauma)
1. Hepatic Hematoma can lead to Hematobilia if a drain is not inserted during liver laceration repair

Pancreas
1. Pancreatic Cancer
1. Hx of smoking or alcohol abuse
2. Epigastric pain that is progressive and constant, worse with eating
3. Head: “Painless jaundice with dilation of common bile duct”
4. Body/Tail: “Painful without jaundice"
5. Dx: CT Abdomen especially if pancreas is not properly visualized by Abdominal ultrasound
2. Acute Pancreatitis
1. Alcohol
2. Gallstones
1. ALT >150 has 95% ppv for diagnosing gallstone pancreatitis
2. Elevated Liver enzymes, Amylase, Lipase
3. Early Cholecystectomy once current episode is resolved to prevent future bouts of gallstone pancreatitis
3. Severe Acute Pancreatitis
1. Failure of >1 organ system lasting >48hrs
2. Evidence of SIRS (Elevated Blood Urea Nitrogen or hematocrit) and Intravascular volume depletion
3. CXR: Pulmonary infiltrates, Pleural effusion (third spacing of fluid)
4. Abdominal CT: Severe pancreatic necrosis
4. Complication: Pseudocyst
1. Mature walled-off pancreatic fluid collections surrounded by thick fibrous capsule
1. Can leak amylase-rich fluid into circulation and increase serum amylase Pancreatic Pseudocyst
2. Complication: spontaneous infection, duodenal or biliary obstruction, pseudoaneurysm (digestion of adjacent vessels),
pancreatic ascites, pleural effusion
3. Management
1. Asymptomatic—Expectant (symptomatic therapy, NPO)
2. Symptomatic—Endoscopic drainage
TRAUMA
3. Pancreatitis
1. Retroperitoneal hemorrhage = flank bruising
2. Cullen sign (bruising around umbilicus) = hemorrhagic pancreatitis (or ruptured aortic aneurysm)
3. Radiates to back with N/V (- painless obstructive jaundice)
4. Serum amylase and lipase
5. Tx: Aggressive IV fluids and NPO until symptoms resolve (prevent enteric secretions from irritating organ)
6. Complication: 6-8wks post—> Pseudocyst
4. Pancreatic duct injury (Blunt Abdominal Trauma)
1. Upper abdomen (fixed, retroperitoneal pancreas) compressed against vertebral column
2. Difficult to diagnose initially—PE is nonspecific, enzymes levels don't rise and CT abdomen sensitivity is variable
3. Persistent abdominal discomfort/nausea, increasing amylase, peripancreatic fluid “free fluid in upper abdomen”

Spleen
TRAUMA
1. Splenic Laceration (Blunt Abdominal Trauma)

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1. Intrabdominal hemorrhage, shock, FAST finding—intraperitoneal fluid
2. (-) FAST does not rule out injury, FAST does not detect injury <200mL free fluid
3. Signs
1. Kehr sign: Pain in left shoulder
2. Balance sign: Dull percussion on Left and shifting dullness on Right

4. Injuries
1. Contusion
2. Subcapsular hematoma
3. Laceration
5. Management
1. HD unstable (+ frank peritonitis): Xlap
2. HD stable (+ or - FAST): CT Abdomen/Pelvis with contrast, observe with serial Hb and embolization

Ulcers
LEG
1. Iliopsoas abscesses
1. Fever and lower abdominal/flank pain radiating to groin
2. “Psoas sign”: pain with hip extension
3. Dx: CT abdomen and pelvis
4. Tx: Drainage with Abx
2. Arterial Ulcer (painful)
1. Terminal arteries (tips of digits)
2. Cool, make skin, dermal atrophy, diminished pulses
3. Ankle-brachial Index
3. Vasculitic Ulcer (painful)
1. Cause: Cryoglobulinemia, Granulomatosis with Polyangiitis
2. Nonblanching petechiae or purpura
4. Venous Ulcer
1. Medial leg above malleolus
2. Edema and Stasis Dermatitis
3. Duplex Ultrasonography

FOOT
5. Neuropathic ulcers
1. Cause
1. #1 cause: Diabetic Mellitus —> Check HbA1c
2. ESRD
2. Repeated pressure, friction or trauma due to lack of sensation in local tissues; weight-bearing sites

Small Bowel
1. Ascariasis
1. Small bowel obstruction; may cause Jaundice via Bile duct obstruction
2. Peripheral Eosinophilia
3. Endemic regions: Asia, Africa, South America
4. Tx: Albendazole or Mobendazole
2. Groin hernia
1. Direct Inguinal
2. Indirect Inguinal
3. Femoral
1. Can lead to small bowel obstruction (SBO) due to small bowel herniation
1. High-pitched bowel sounds, distended loops of bowel with air-fluid levels
2. Incarceration (entrapment) may lead to strangulation (ischemia, necrosis)
2. Elective surgical repair due to risk of incarceration and strangulation
3. IBD
1. Skin complication: Erythema nodosum tender, anterior shin, delayed-type hypersensitivity reaction to antigen exposure
1. Bx: septal panniculitis without vasculitis
2. Presence correlates with degree of IBD
3. EN also seen in Sarcoidosis, Hodgkin lymphoma, Fungal, Viral Mono
2. Crohn
1. Associated with disease progression
1. Cigarette Smoking
2. Young age at diagnosis (<30yo), Strictures, Fistulization, Prior Surgery
2. 50% patients present with palpable abdominal mass in RLQ
3. Barium Xray: ”String sign”
3. UC
1. Yearly Colonoscopy due to Colon Cancer risk
2. 90% associated with PSC
4. Volvulus: Midgut Malrotation
1. Common cause of bilious emesis in infants, especially with other congenital anomalies (omphalocele)
2. Episodic, bilious, vomiting, abdominal pain
3. Tx: Surgical (Ladd procedure) to divide peritoneal bands and bowel reposition
5. Zollinger-Ellison Syndrome (Pancreas or duodenum)
1. Multiple duodenal ulcers refractory to treatment; ulcer distal to duodenum; associated with chronic diarrhea
2. Malabsorption due to excessive stomach acid production inactivating pancreatic enzymes
3. Excessive Gastrin—Parietal cell hyperplasia—Excessive Gastric acid
4. MEN1 association
5. Dx:
1. Elevated Gastrin in presence of acidic gastric pH
2. Endoscopy: ulcers, primary duodenal gastrinoma
3. After gastrinoma confirmation, screen for MEN1 with assays for PTH, Ionized Ca, Prolactin

TRAUMA

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6. Appendicitis
1. Severe symptoms due to peritonitis
2. Laparoscopic surgery
3. Rovsing: LLQ, Psoas: Hip extension, Obturator: IR thigh
4. Complication: Intra-abdominal abscess formation—Subphrenic abscess
1. Higher incidence with laparoscopic appendectomy than laparotomy
2. Recurrent fever and abdominal pain + fever, leukocytosis + pulmonary sx (SOB, R-sided effusion)
3. Several days post-operation
2. Complication: Gangrenous perforation
7. Duodenal tear
1. Rapid compression of bowel causes perforated viscus
2. Retroperitoneal viscus (i.e. duodenal, ascend/descend colon) has delayed symptoms of fever & diffuse abdominal pain
1. Gastric spillage initially sequestered away from intraperitoneal space
2. Back or flank pain due to retroperitoneal inflammation
3. Retroperitoneal free air on imaging
8. Laparoscopic Surgery
1. Risk: Bowel Injury
1. Persistent bowel pain, guarding, ileum (diminished bowel sounds, SI/LI distention), leukocytosis
2. Frank peritonitis—> Surgical exploration
3. Without frank peritonitis —> Abdominal CT with contrast to identify leak
9. Small Bowel Obstruction
1. Obstipation, hyperactive bowel sounds, diffuse unlocalized pain, Nausea, Vomiting, Abdominal bloating, Dilated loops of bowel
2. MCC: PMH of surgery can hint at adhesions (i.e. hysterectomy in elderly F)
1. Hernias, Crohn disease, Intussusception, Volvulus, Intestinal atresia, Carcinoid, Foreign body, Neoplasms
3. “Tinkling” sound: intestinal fluid and air under high pressure in bowel
4. Hypovolemia due to 3rd spacing
5. Dx
1. Hallmark: Elevated lactate with marked acidosis
2. Initial test: Abdominal x-ray shows multiple air-fluid levels with dilated loops of small bowel
3. Accurate: CT Abdomen shows transition zone from dilated loops of bowel with contrast to bowel with no contrast
6. Tx
1. NPO: prevent further bowel pressure increase
2. NG tube with suction: lower bowel pressure proximal to obstruction
3. Medical management: IV fluids to replace loss from 3rd spacing
4. Surgical: complete obstruction or lack of improvement with medical management
7. Type
1. Partial (small GI contents can pass)
2. Complete
8. Complication: Strangulated obstruction presents with peritoneal signs (rigidity, rebound tenderness) + shock
9. Complication: Incisional hernia
1. Palpable mass at the level of the incision due to breakdown of fascia (obesity is important factor)
10. Midgut volvulus—small bowel obstruction (1st month of life)
1. Bilious emesis
2. Rapid clinical deterioration due to intestinal ischemia and necrosis—GI bleeding, hypovolemic or septic shock, peritonitis due to intestinal perforation
3. Dx:
1. Hemodynamically unstable: Exploratory laparotomy
2. Hemodynamically stable: Upper GI series (X-rays with contrast material for visualization)
Colorectal
1. Colonoscopy
1. Regular 10-year interval: Hyperplastic polyps
2. Yearly: UC, PSC

Condition Bowel Sounds Additional

Diffuse abdominal tenderness

Peritonitis Absent
Rebound tenderness

Ischemic colitis Colonoscopy

Decreased Pain out of proportion, soft abdomen

Acute/Chronic mesenteric ischemia
CT Angio (- guarding, - rebound tenderness)

Hyperactive or Absent
Obstipation Postoperative adhesions
Small bowel obstruction
Imaging: Gas filled loops of SI (+Strangulation)
Little/no air in colon/rectum

Hypoactive or Absent
No flatus, Abdominal distention Retroperitoneal hemorrhage
Paralytic Ileus Imaging: gas filled loops of SI and LI Intrabdominal inflammation
Air in colon/rectum ~Especially for Prolonged Intestinal ischemia, Electrolyte imbalance
postop Ileus~
2. Volvulus
1. Cecal Volvulus
1. Cecum and ascending colon twist on mesentery—forming closed loop obstruction
1. Lumen of obstructed bowel expands due to gas formation from intraluminal bacteria
2. Slow progressive abdominal distention with nausea and vomiting
2. Younger, prior-self resolving episodes due to congenital mobile cecum (mesentery failed to fuse with parietal peritoneum)
3. Distended and tender abdomen (-) rigidity, XR—large, dilated loop of colon
4. Dx: Abdominopelvic CT Scan
5. Tx: Emergency laparotomy and resection of volvulized segment
2. Sigmoid Volvulus
1. RF

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1. Chronic constipation: chronic fecal overloading leads to dilation and elongation of sigmoid colon
2. Colon dysmotility (neurological, diabetic enteropathy): contribute to constipation
2. Tx: Endoscopic detorsion with flexible sigmoidoscopy; Emergency sigmoid colectomy if perforation/peritonitis
3. Ileocolic intussusception (prolapse of ileum into colon)
1. Self-resolving episodes of abdominal pain and vomiting
2. CXR: multiple, dilated small-bowel loops with air-fluid levels
4. Paralytic Ileus
1. Generalized, uniform distention, obstipation, hypoactive/absent bowel sounds, nausea, vomiting
2. RF: Electrolyte abnormalities (low Phosphate, low K) can cause muscle dysfunction, Retroperitoneal/
abdominal hemorrhage
3. Prolonged Postoperative Ileus
1. Delayed return of bowel function >72hrs after surgery
2. Abdominal distention (temporary bowel paralysis, gastric secretion backup and gas)
3. Imaging: Gas filled loops of SI and LI without transition point (vs. SBO)
4. Management: Conservative, bowel rest, serial examinations
5. Clostridioides difficile infection (CDI)
1. Surgical intervention: Toxic Megacolon
1. Diffuse dilation within normal anatomy (vs single dilated loop unlike cecal volvulus)
2. Toxic: fever, altered sensorium, bloody diarrhea
3. Peritonitis (absent bowel sounds, tender to palpation and release)—> Laparotomy
1. Indicates bowel perforation and definition indication for surgery exploration
4. Increased serum lactate
6. Chronic IBD: Toxic Megacolon
1. Imaging: CT Abdomen
2. Tx: IV glucocorticoids
7. Colorectal Cancer
1. Right-sided Adenocarcinoma
1. Obstructive symptoms uncommon due to larger lumen and liquid stools
2. Occult bleeding, Iron-deficiency anemia
2. Left-sided Adenocarcinoma Sigmoid Colon Adenocarcinoma
1. Unexpected wight loss; Disrupted stool flow leading to crampy/colicky pain; Red/maroon Hematochezia common due to proximity to anal verge
3. Rectal Tumors
1. Hematochezia or frank red blood; narrowed stools, tenesmus, mass sensation in rectum
TRAUMA
8. Ischemic Bowel Disease
1. Acute Mesenteric Ischemia
1. Pain out of proportion, soft abdomen (- guarding, - rebound tenderness)
2. Pain after eating due to increased oxygen requirement of bowel post muscular contraction + bloody diarrhea
3. Cardiac embolic events
1. #1 RF: Atrial fibrillation
2. Valvular disease: Infective Endocarditis
4. Initial: CT abdomen showing air in bowel wall
5. Accurate: Angiography to avoid perforation
6. Surgery: Emergent laparotomy to remove necrotic bowel
2. Ischemic Colitis post-surgery
1. Complication of vascular surgery, older patients have extensive atherosclerosis
2. Lower GI bleed after episode of hypotension with fever, nausea, elevated lactic acid
1. Watershed areas
1. Impaired blood flow between SMA and IMA—Splenic Flexure
2. Impaired blood flow between SMA and Sigmoid artery—Rectosigmoid junction
2. Moderate pain, bloody diarrhea
3. CT: thickening of bowel wall
4. Colonoscopy: cyanotic mucosa and hemorrhagic ulcerations, sharp transition from affected to unaffected region
5. Tx: IV fluids, Bowel rest, Abx (uncomplicated)
9. Abdominal Abscess
1. Tx: CT scan, incision and drainage
10. Acute Diverticulitis
1. Highly associated with constipation
2. Contraindicated: Endoscopy or barium enema and colonoscopy due to perforation risk
3. Complication: Abscess formation
4. Dx: CT with contrast (Oral and IV)
1. Increased inflammation in pericolic fat, diverticula, bowel wall thickening, soft tissue masses (phlegm’s) and pericolic fluid suggesting abscess
5. Tx: Medical if 1st, bowel resection if recurrent
1. Uncomplicated: Bowel rest, Abx, Observation
2. Complicated (abscess)
1. <3cm: IV Abx, Observation
2. >3cm: CT-guided Percutaneous Drainage
11. Colovesical Fistula
1. RF: Diverticular disease, Crohn Disease, Malignancy
1. Extension of ruptured diverticulum or erosion of diverticular abscess into bladder
2. Presentation: Pneumaturia “air bubbles while urinating”, Fecaluria, Recurrent UTI
3. Dx: Abdominal CT with oral or rectal contest (NOT IV)
1. Contrast media in the bladder confirms dx
4. Colonoscopy to exclude malignancy
12. Free perforation of GIT
1. In the setting of ongoing inflammation (diverticulitis), there’s a classic sequence
1. Sudden, severe pain (perforation + vomiting, lightheadedness)
2. Followed by temporary relief (decompression of inflamed organ)
3. And then generalized, constant pain (peritonitis + sepsis/septic shock)
2. Free perforation leads to colonic contents spilling into peritoneal cavity
3. Imaging: intraperitoneal free air
4. Tx: Surgical emergency with abdominal washout and resection of ruptured bowel segment
5. Vs. Diverticular microperforation
1. Contained, responds to medical management with Abx and Bowel rest
13. Fecal Incontinence

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1. Uncontrolled passage of fecal material for 1 month in >3yo
2. Dx:
1. Hx + flexible sigmoidoscopy or anasocopy
2. Accurate: anorectal manometry
3. Anatomic injury hx: endorectal manometry
3. Tx:
1. Medical: fiber
2. Biofeedback: control exercises and strengthening exercises, dextranomer/hyaluronic acid
3. Colorectal surgery
Rectum
Anal and Perianal Masses
1. Hemorrhoids
1. Internal Hemorrhoid
1. Intermittent itching, painless bleeding, leakage of took
2. DRE or anoscopy
2. External Hemorrhoid Thrombosis
1. Excruciating anorectal pain exacerbated by sitting, bluish-purple bulge at anal verge
2. Initial management: Sitz baths, Stool softeners, Topical anesthetics
3. Anogenital Wart
1. Pink/flesh colored papule, plaques, cauliflower-shaped mass; mild itching, bleeding
2. Chronic
4. Anorectal Cancer
1. Squamous Cell Carcinoma, bleeding, pain
2. Ulcerating, enlarging mass
5. Skin Tags
1. Small, flesh-colored papule
2. External terminus of anal fissure (sentinel tag)
6. Perianal Abscess
1. Fluctuant mass/swelling with erythema
2. Fever, gradual onset
7. Rectal Prolapse
1. Erythematous mass with concentric rings that occurs with Vasalva
2. Mucus drainage, mild abdominal pain, mass sensation

2. Anal Fissures
1. Pain and rectal bleeding on defecation; posterior anal midline; chronic fissure may have skin tag at distal end
2. Causes: Local trauma (constipation, prolonged diarrhea, sex), IBD (Crohn), Malignancy
3. Tx: Fiber and fluid, Sitz baths, Stool softeners, topical anesthetics and vasodilators (nifedipine, nitroglycerin)
1. Nifedipine causes topical vasodilation, reduces pressure, increased blood flow, facilitate healing
3. Fecal Incontinence
1. Acute Radiation Proctitis
1. Direct mucosal damage
2. Diarrhea, mucus discharge, tenesmus, minimal bleeding
3. Endoscopic: Severe erythema, Edema, Ulcerations
4. Management: Antidiarrheals (loperamide), Butyrate enemas
2. Chronic Radiation Proctitis
1. From pelvic radiation therapy —> Progressive rectal fibrosis
2. Obliterative endarteritis and submucosal fibrosis—anorectal stricture formation—reduced rectal compliance, constipation and fecal incontinence
3. Endoscopic: Chronic tissue hypoxia results in neovascularization and telangiectasia formation that causes hemorrhage
4. Management: Endoscopic thermal coagulation, Sucralfate or Glucocorticoid enemas
4. Rectal Prolapse
1. Intermittent protrusion of rectum (erythematous mass with concentric rings) through the anal orifice; associated fecal incontinence, constipation and mucous
discharge. F >40yo
2. RF: Multiparity, Vaginal delivery, Pelvic surgery, Pelvic floor dysfunction, Chronic constipation or straining, dementia and stroke
3. “Small volume stools or just mucous; incomplete evacuation”
5. Rectal Adenocarcinoma
1. Presentation
1. “Blood in stool, BRB on toilet paper, fhx of colon cancer, sigmoidoscopy shows fungating mass upper rectum”
2. Most appropriate prior to surgical treatment—Colonoscopy of entire colon
1. Sigmoidoscopy does not visualize R colon
2. Staging
1. Tumor markers: CEA
2. Imaging: CT chest, abdomen, pelvis
3. Endoscopy/direct visualization: Colonoscopy

Mineral Deficiency
1. Mineral Deficiency
Especially patients on parenteral nutrition
1. Chromium: Impaired glucose control in diabetic
2. Copper: Brittle hair, Skin depigmentation, Neurological (ataxia, peripheral neuropathy), Anemia, Osteoporosis
1. Hypochromic microcytic anemia (impaired iron absorption), Brittle hair
2. Skin depigmentation, Osteoporosis
3. Neurological dysfunction (ataxia, peripheral neuropathy similar to subacute combined degeneration fo B12 def)
4. Cause
1. Gastric surgery—bariatric surgery
2. Excessive Zinc—competes with copper
5. Dx
1. Low serum copper and ceruloplasmin levels
3. Iron: Microcytic anemia
4. Selenium: Thyroid dysfunction, CM, Immune dysfunction
5. Zinc (duodenum, jejunum): Hypogonadism, impaired taste, impaired wound healing, alopecia, skin rash with perianal involvement

Vitamins
1. Vitamin B3 (Niacin)

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2. Dermatitis, Diarrhea, Dementia, Hyperpigmented sun-exposed rash
3. Vitamin C Deficiency--Scurvy
1. Alcohol use disorder, Substance abuse disorder, Psychiatric illness
2. Follicular hyperkeratosis, Perifollicular hemorrhage, Ecchymosis, Petechiae
3. Gingivitis, Impaired wound healing
4. Dx: Plasma or leukocyte Vit C levels
2. Vitamin D
1. Toxicity: Hypercalcemia, Shortened QT Interval

Breast Cancer
1. Breast Pain
1. Unilateral: Persistent, focal pain/tenderness, noncyclic—> Mass: biopsy, No Mass: Imaging
2. Bilateral: Bilateral, diffuse, cyclical—> Mass: Breast imaging, No mass: Observe

Pediatrics
1. Hemoptysis (>600mL blood in 24hr)
1. Bronchoscopy best 1st step to identify site of bleeding
2. Maintain adequate patent airway, place bleeding lung in dependent position (lateral)
2. Cardiac shunting hints
1. Asymmetric septal hypertrophy: Hypertrophic CM
2. LV inflow obstruction: Mitral Stenosis
3. Right-to-Left flow: Eisenmenger
3. VSD
1. Left sternal border holosystolic murmur: L-R intracardiac shunting
2. Increased LA preload: L-R shunting—> RV volume overload —> increased LA preload —> RV and Left chamber enlargement —> Enlarged Left heart contour

TRAUMA
ABC
1. Airway
1. Patent—Full sentences, lack of accessory muscle use, bilateral breath sounds
2. Urgent—Expanding hematoma, cutaneous emphysema
3. Emergent—GCS <8, apnea, gurgling/gasping
1. Intervention
Facial trauma—> Cricothyroidotomy (done in ED), Tracheotomy (done in OR)
No facial trauma —> Orotracheal intubation
Cervical trauma—> Orotracheal intubation + flexible bronchoscopy
Esp in impending respiratory failure; rapidly performed and noncomplex
2. Breathing
1. Goal oxygen saturation >90%
2. Ventilation: CO2—> MV = TV x RR
1. PCO2 = ABG
2. Endotracheal CO2 = 40 to confirm endotracheal tube placement
3. Oxygenation: O2 —> PEEP, FiO2
1. PO2=ABG or SPO2
3. Circulation
1. Shock
1. SysBP <90 (MAP <65)
2. Urine Output <0.5cc/kg/hr
3. Pale, cool/warm, diaphoretic
4. Glasgow Coma Score

Shock HD instability despite fluid resuscitation

1. Workup
1. Diagnosis
1. Foley: urine output
1. Oliguria (in previously healthy kidneys) = <0.5cc/kg/hr
2. Serial arterial blood gas:
1. Acid base deficit
2. Lactate levels (global oxygen deficit or decreased clearance due to renal dysfunction)
3. Arterial catheterization: blood pressure
4. CVP and Echo: differentiate between hypovolemic and cardiogenic causes
1. CVP: Superior vena cava through internal jugular vein or subclavian vein
2. Echo: intravascular volume status plus regional wall/valvular abnormalities
2. Organ hypoperfusion
1. Brain—confusion, Kidney— inc BUN/Cr ratio, Liver—inc ALT/AST, Heart—Chest pain, SOB, Blood—Lactic acid
3. Initial treatment
1. Fluids
2. Antibiotics/Antifungal
4. Low urine output: 20mL/2-3hrs
2. Large Blood Loss “Floor and 4 more”
1. External bleeding “Floor”: Entire volume
2. Chest: 40% blood volume
3. Abdomen: Entire volume
4. Pelvis: Entire volume; Blood hidden within retroperitoneum
1. Pelvic fracture can cause tearing of thin-walled venous plexus (presacral, lumbar)
2. Pelvic Xray performed in adjunct to trauma primary survey for dearly detection
5. Thigh: 1-2L/Thigh
MAP = CO x SVR
CO = HR x SV

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HR
‣ Too fast, Too slow
SV
Preload
‣ Volume—Hemorrhage
‣ Obstruction—Tension Pneumothorax, Pericardial Tamponade
Contractility
‣ CHF, MI, Myocardial Contusion
*Above: Hypotension, Cold extremities (SVR increases in compensation, vasoconstriction, distal extremity blood cuts off)
*Below: Hypotension, Warm extremities (SVR decreased, vasodilation)
SVR
‣ Sepsis, Anaphylaxis, Anesthesia, Spinal Trauma

3. Hypovolemic—Decreased Intravascular Volume

Ongoing bleeding: initially respond to crystalloid resuscitation but subsequent drop in blood pressure—> Source control
Another cause of hypotension despite fluid resuscitation is Acute Adrenal Insufficiency (under CVS)
Do not believe initial normal hemoglobin, pt bleed whole blood so initial Hb and Hct do not drop immediately
1. Dehydration
2. Small LV cavity volume with ejection fraction of 75%
1. Initial decrease in preload and CO, followed by compensatory increase in SVR, HR and EF
3. Hemorrhage
1. Transfusion blood products: helps hypovolemia and improves oxygen carrying capacity
2. Large volume crystalloid resuscitation complication: hypothermia, acidosis, coagulopathy issues
1. Fluids temperature cooler than body, non-anion gap hyperchloremic metabolic acidosis, lethal triad
3. Pt <30yo and pt on BB do not exhibit tachycardia in response to hemorrhage until late in course
4. Intraperitoneal hemorrhage is of major concern due to lack of “visible” signs
1. Dx: FAST/US
2. Tx: Apply pressure on the way to OR; IVS, Type and Cross, IVF, Blood

4. Cardiogenic—Pump Failure: Intrinsic

EKG, Cardiac Troponin, Echo
Dobutamine: increased cardiac contractility and peripheral vasodilation to decreased left hear afterload
1. ACS
2. Cardiomyopathy
3. Perioperative MI
5. Cardiogenic—Pump Failure: Extrinsic (Obstructive)
Chest auscultation, CXR, Echo
1. Tamponade: pericardial pressure compromises venous return to right heart and hypotension
1. Broken ribs, knives or bullet wounds could injure pericardium (source)
2. Dx: FAST/Echo
3. Tx: Pericardiocentesis
2. Tension Pneumothorax: mediastinum shifts away from pneumothorax and kinks vena cava disrupting cardiac filling
1. Immediate Tx: Needle decompression to release pressure on IVC
2. Definitive Tx: Thoracostomy

6. Obstructive—PE
1. Blood flow obstruction between RA and Pulmonary capillaries

7. Distributive-Acute Vasodilation
Minimal response to fluid due to microvascular leak syndrome or excess vasodilation
1. Neurogenic: a1-agonist (phenylephrine)
1. Hyperreflexia and bilateral babinski
2. Septic: NE
1. Source control and minimize remote organ hypoperfusion
2. Fluid resuscitation —> NE —> Vasopressin—> CST + Antibiotics
3. Monitoring devices and diagnostic modalities if pt doesn’t respond to initial fluid resuscitation
3. Anaphylactic
1. Arterial vasodilation —> Decreased SVR
2. Venous vasodilation —> Decreased CVP, PCWP
4. Medications

Head Trauma
1. Work Up
1. Unconscious—Head CT no contrast—> Alert, oriented x3 —> go home
2. Increased ICP Tx—Elevated head, Hyperventilate (vasoC in arteriole, reduces cerebral BF), Mannitol (draw fluid into vasculature), Hypertonic Saline
2. Basilar Skull Fracture
1. Clear rhinorrhea/otorrhea in the setting of trauma is CSF leakage
3. Cervical Spine injury
1. High risk: CT no contrast immediately
1. High energy mechanism, trauma causing closed head injury
2. *Note: Evidence of single vertebral fracture (radiculopathy) is indication to scan entire spine
2. Low risk: CT non contrast if NEXUS criteria present
1. Neurologic deficit
2. Spinal tenderness
3. Altered mental status
4. Intoxication
5. Distracting injury (open tibia-fibula fracture)
3. No NEXUS criteria: Thorough neurological exam only
4. Epidural: LOC—Lucid interval—Die
1. Epidural “lens”—> Emergency craniotomy
5. Acute Subdural: LOC—Die
1. Decrease ICP (Elevate, Hyperventilate, Mannitol)
2. CT scan
6. Chronic Subdural
1. Sheared bridging veins—Elderly, EToH
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2. CT scan
3. Tx: Craniotomy reverses dementia
7. Concussion: LOC
1. Normal CT
2. GCS of 15: send home and observe
8. Diffuse Axonal Injury: LOC—Coma
1. Angular trauma (spinning)
2. CT scan: Grey/White blurring
Neck Trauma
1. Cervical Radiculopathy: nerve root compression, neck/arm pain with sensorimotor deficits
Shoulder abduction relief test: Symptom improvement when hand is on top of head is diagnostic and
therapeutic
Acute: Disk herniation Chronic: Spinal spondylosis
1. C5: Biceps—lateral upper arm—shoulder abduction, elbow flexion
2. C6: Biceps, Brachioradialis—thumb, index finger—forearm pron/supin, elbow flexion, wrist extension
Deficit follows dermatome (thumb, index) and myotome (elbow flexion) and not isolated to single nerve
Lateral flexion (cradling phone b/t head and shoulder) narrows ipsi neural foramina, worsening compression
3. C7: Triceps—dorsal forearm, middle finger—finger extension, elbow extension, wrist flexion
4. C8: Finger flexors—ring and little finger—fingerer flexion and extension, thumb flexion and abduction
5. T1: Finger flexors—medial forearm—finger abduction and adduction
6. Management: Provocative activity avoidance and NSAIDs and MRI if progressive pain
2. Hemisection/Brown-Sequard Syndrome
1. At the lesion: Ipsilat UMN loss (flaccid paralysis, no reflexes), Ipsilat Sensation loss, Contralat Pain and Temp loss
2. Below the lesion: Ipsilat LMN loss (spastic paralysis, inc reflexes, Babinski), Sensation loss, Pain and Temp loss
3. Cord Compression
1. Focal Neurologic Deficit: Erectile Dysfunction, Urinary/Bowel Incontinence, Edema
2. Dx: MRI
3. Tx: Dexamethasone
4. Complete Cord: Lose everything
1. At the lesion: LMN
2. Below the lesion: UMN
5. Anterior Cord
1. Loss Motor and Pain/Temperature
6. Central Cord
1. Syringomyelia: Loss Pain/Temp, Cape-like (Bilateral)
2. Elderly: Loss Pain/Temp, Motor, Cape-like
1. Due to rapid neck hyperextension
7. Posterior Cord
1. Loss sensation (Dorsal Columns)

Chest Trauma
Hemodynam Stable:
(-) High risk and (-) serious injuries: ECG, CXR
Abnormalities—Additional tests (CT scan)
(-) Abnormalities—Discharged with analgesics
High risk mechanism or Serious injury
Similar to Hemodynam Unstable
(ECG for Blunt Cardiac Injury, CXR, eFAST)

Hemodynam Unstable: Resuscitation and Evaluation (ECG, CXR, eFAST)

Stabilizing intervention (chest tube)
Additional tests for injuries missed at admission (CT scan)
Remain unstable (Operating room thoracotomy)

1. Clinical Approach
1. “What will kill the patient first”—Tension Pneumothorax, Massive Hemothorax, Cardiac Tamponade, Blunt Cardiac Injury, Thoracic Aorta disruption
2. #1 COD: Traumatic brain injury (More in Neurosurgery Bleeds)
3. #2 COD: Traumatic aorta rupture
2. Blunt Chest Trauma
1. CXR: identify pneumothorax, hemothorax, rib fractures, pulmonary contusion
1. “Widening of mediastinal structures”—possible thoracic aorta injury

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2. CT Angio: confirm above + assess blunt thoracic aorta injury
1. IV contrast
3. Considerations
1. ABCs first
2. IV lines, Blood specimen, Vital signs, Supplemental O2 >94-95%
3. Thoracostomy if pneumothorax suspected
1. Can be delayed with initial CXR until confirmatory CXR
2. If respiratory status worsen after thoracostomy—intubate and mechanical ventilation
4. Frequent re-asessment of cardiopulmonary status and Assessment of Common injuries

Injury Diagnosis Treatment Comment

Avoid other injures

Pain management; Goal—> Pain control
Rib fractures PE, CXR rib series Surgical plating if altered chest wall mechanics Epidural anesthesia to prevent hypoventilation and pulmonary
complications

Achieve full re-expansion

Pneumothorax PE, CXR Tube thoracostomy Consider tracheobronchial injury if failure to re-expand or persistent air leak

Tension
Pneumothorax CXR Diminished breath sounds and hypotension after intubation

Pulmonary contusion CT, CXR Support +/- intubation Ventilatory support on clinical grounds

Traumatic aortic CXR: widened mediastinum, loss of aortic knob, depressed L main
rupture CT Angio, TEE Open or Endovascular repair bronchus, NG tube R deviation
CT: intimal flap, periaortic hematoma

5. Cause of Instability post-blunt chest trauma

Injury Treatment

Blunt Cardiac Injury Supportive (ionotropes); Cardiac rupture surgery

Cardiac Tamponade Decompression, Exploration repair

Air Emboli Exploration, Repair

Injury to great vessels Exploration, Repair or Repair via Endovascular approach

Hemothorax Tube thoracotomy resuscitation, Possible exploration, Repair

Tension pneumothorax Tube thoracostomy, Needle decompression

3. Blunt Chest Trauma Conditions

1. Blunt Cardiac Injury
1. Significant cause of death following blunt trauma
2. Admission ECG
1. Abnormal ECG—monitoring for cardiac rhythm or pump abnormalities for 24hrs
1. May cause SVT (Pain and anxiety can cause sinus tachycardia but not SVT)
2. Traumatic Rupture of Aorta/Aortic Dissection
1. #2 COD in blunt trauma
2. Types
1. Complete Aortic rupture
1. Rapid exsanguination and death
2. Incomplete rupture examples
1. Secondary, false lumen similar to aortic dissection
2. Pseudocoarctation: Obstructive intimal flap or intramural hematoma that impeded blood flow
1. Proximal HTN, Distal Hypotension “diminished pulses”
3. Left Recurrent laryngeal nerve compression and hoarseness: Adventitia expansion
3. Incomplete rupture: Blunt Thoracic Aorta Injury (BTAI)
4. Signs
1. Widened mediastinum and pleural effusion (hemothorax—diminished breath sounds) present before hematoma forms (bleeding
containment)
2. Hemorrhagic shock
5. Systolic BP kept <100mmHg to prevent injury extension and rebleeding
6. Tx: Emergent operative repair
3. CXR
1. Left apical cap, mediastinal widening, obscured aortic knob, widening of paravertebral stripe
2. Downward deviation of L mainstem bronchus, R deviation NG tube

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3. Opacification of aorta-pulmonary window
4. Dx
1. Stable: CTA
2. Unstable: TEE (in the OR)
5. Tx
1. Conservative
2. Thoracic endo-vascular aortic repair (TEVARs)—lower rate of complications than open repair
3. Open repair
6. Note
1. All patients initially managed with controlled hypotension to maintain BP of 100mmHg
3. Rib Fractures
1. Pain and discomfort: Can lead to decreased respiratory efforts, splinting, decrease mobility (atelectasis,
hypoxia, pulmonary infections)
2. Left sided: Spleen injury
3. >2 ribs in >45yo: Increased morbidity and mortality
4. Pain control: Epidural catheter or patient controlled analgesia (PCA)
1. Adequate pain control leads to less complications (atelectasis, pneumonia)
4. Associated with Rib fractures
1. Hemothorax: Costophrenic angle blunting on CXR and CT —> Chest tube drainage + thoracotomy
1. Absent breath sounds, Dull to percussion, Pericardial effusion
2. CXR: opacification of ipsilateral hemothorax
1. Note: Ipsilateral opacification also occurs if endotracheal tube misplaced, however mediastinum shifts ipsilaterally to opacification (vs
contralaterally in hemothorax)
3. Surgery: Emergent thoracotomy
1. >1500mL initial output with chest tube
2. >200mL/h bloody output for 4 or more hrs
4. Retained hemothorax (following thoracostomy)
1. May develop empyema and fibrothorax
2. <300mL: safely observed; any larges ones are indicted for surgery
5. Hemothorax >1.5L blood, >200ml/hr for 4 hours
2. Pneumothorax (discussed below)
3. Sucking Chest Wound
4. Less Common
1. Scapular Fractures
2. Sternal Fractures
1. Isolated: managed outpatient
2. Multisystem: similar associations to rib fractures
5. Blunt Diaphragmatic Injury
1. More common on left
2. Associated with rib fractures
5. Flail Chest
1. Associated with rib fractures in more than 1 location; segment moves independently from rest
2. Hypoxia due to ineffective ventilation, pulmonary contusion and atelectasis
1. Impaired generation of negative intrathoracic pressure during inspiration and decreased dead space during expiration
2. Pulmonary contusion impairs oxygen diffusion
3. Fracture related pain causes respiratory splitting (decreased inspiratory effort) and bibasilar atelectasis
6. Myocardial Contusion
1. Huge trauma “heart attack”
2. Dx: 12-lead EKG, Troponins
3. Tx: CHF and Arrhythmia—MONABASH
4. Complication: Pericardial Tamponade—FAST scan
7. Cardiac Tamponade: Cardiac Echo —> Pericardiocentesis
1. No respiratory distress Vs. Tension pneumothorax (no breath sounds, tracheal deviation)
2. RF
1. Broken ribs, knives or bullet wounds could injure pericardium (source)
3. Acute
1. Effusion volume: 100-200mL
2. CXR: Normal
4. Subacute
1. Effusion volume: 1-2L
2. CXR: Enlarged, globular cardiac silhouette
5. S/S
1. Beck’s Triad: JVD, Hypotension, Pulsus paradoxus
2. Pericardial effusion
3. Elevation and equalization of intracardiac diastolic pressures—RA, RV, PCWP
1. Increasing pericardial pressure restricts diastolic filling of Right heart = Low CO and obstructive shock
2. Compression = High RA pressure and PCWP
4. Possible pleural effusion due to blood leaking from pericardium through small tear or lacerated lung parenchyma
6. Dx
1. FAST or Echo
7. Tx
1. 16 gauge needles for fluids
8. Pleural Effusion (More in CVS)
1. Parapneumonic: Fever and pleuritic pain despite antibiotics Glucose <60, Low pH (anaerobic), high protein
1. Uncomplicated: Negative culture
2. Complicated: Gross pus or bacteria
2. Empyema and compacted parapneumonic effusion require drainage + antibiotics
9. Pulmonary Contusion
1. Noncardiogenic pulmonary edema with leaky capillaries (similar to ARDS seen with sepsis)
2. Associated with rib fractures or flail chest involving overlying chest wall
3. Susceptible to capillary leakage and inflammatory injuries, made worse by pulmonary edema
1. Alveolar edema may appear as ground-glass opacities; Worsened by excessive fluids
4. CXR: Opacification, alveolar infiltrate not restricted by anatomical borders
5. CT: Irregular, non lobular infiltrates
10. Occult Pneumothorax

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1. Seen on CT but not on CXR
2. Positive-pressure ventilation patients more likely to require chest tube placement than those not on PPV
1. Thus, monitor and provide supplemental oxygen only if pt is not in respiratory distress
11. Pneumothorax: CXR —> Chest tube placement
1. Direct disruption of lung parenchyma or disruption of visceral pleura via rib penetration
2. Hyperresonance, decreased breath sounds, soft tissue crepitance
3. Small: O2 and monitor with repeat CXR
1. Monitoring important in patients with thoracostomy because simple pneumothorax may progress to tension pneumothorax
4. Large: Thoracostomy
1. Monitor for air leak and drainage volume
2. Commonly can remove tube around 48hrs
3. In case of persistent large air leak or failure of lung re-expansion—> strong possibility of traceobronchial injury—> requires surgery
5. Spontaneous pneumomediastinum
1. Severe coughing paroxysms increase intraalveolar pressure, cause leak into subcutaneous tissue (subcutaneous emphysema) and lead to spontaneous
pneumomediastinum
1. Hamman sign
2. RF: Asthma exacerbation, Respiratory infection, Tall/think adolescent boy
3. 1st step: CXR to confirm mediastinal gas and rule out pneumothorax
4. Tx: Rest, Analgesics; Avoid Vasalva
12. Tension pneumothorax: CXR —> Needle decompression + Chest tube
1. Cause: pleural bleb burst in smoker, trauma, mechanical ventilation
2. Increased in size that has decreased venous return to heart and potential for hypotension and cardiac arrest—“distended neck veins, obtunded patient”
1. High intrathoracic pressure compresses vena cava and impedes cardiac venous return
3. Signs/Symptoms (Obstructive Shock)
1. Hyperresonance, Decreased breath sounds (could occur post intubation in blunt chest injury pt), Hypotension
2. Contralat Trachea deviation
3. Ipsi diminished breath sounds, hemidiaphragm flattening
4. Management
1. Needle thoracostomy done before intubation due to exacerbation of TP with positive-pressure ventilation
2. Urgent needle decompression
5. Complication: Persistent Pneumothorax/Pneumomediastinum despite tube thoracostomy
1. Due to Bronchial Rupture (proximal)
1. “Reaccumulation of air in pleural space, pneumomediastinum and subcutaneous emphysema”
2. Rapid large air leak into chest-tube drainage and persistent pneumothorax/mediastinum
3. Dx: Bronchoscopy
4. Tx: Operative repair

Lung Trauma
1. T1 pneumocyte: gas exchange
2. T2 pneumocyte: replaced damaged cells, secrete surfactant
3. Excess fluid administration is major cause of respiratory distress in surgical patient
4. Failure to terminate fluid resuscitation in pts with hemorrhagic and septic shock increases pulmonary-related morbidity and mortality in ventilated patients
5. Postoperative Acute Respiratory Insufficiency Ddx
1. Acute Lung Injury
1. Acute onset, PaO2/FiO2 <300, bilateral nonsegmented infiltrates on CXR, ABG reveals moderate hypoxemia
2. Endothelial damage leads to microvasculature permeability, accumulation of extravascular lung water —> low lung volume and low lung compliance
1. Lung compliance further decreases due to sloughing of Type1 pneumocytes and decreased surfactant production by T2 pneumocytes
3. Subtype: Negative pressure pulmonary edema
1. Self-limited with supportive care (mechanical ventilation and fluids)
2. Forced inspiration against closed or narrowed airway “diffuse bilateral nonsegmental infiltrates, lack pneumothorax or plural effusion"
2. ARDS
1. Injury to pulmonary endothelial cells with intense inflammatory response
2. Interstitial and alveolar edema, loss of T2 pneumocytes, surfactant depletion, intra-alveolar hemorrhage, hyaline membrane deposition, eventual fibrosis
3. Aspiration pneumonitis—gastric contents directly irritate bronchial tree
1. Bronchoscopy to clear airway
2. Abx if pneumonia indicated RLL Atelectasis
4. Atypical pneumonia—incisional pain affects ability to clear mucus
1. Airway obstruction and ineffective bacteria clearance
2. Nosocomial organisms in hospital setting
5. Atelectasis (Severe ALI)
1. Mucus plugging
1. General anesthesia reduces FRC
1. Subsegmental atelectasis may lead to obstruction and inflammation—> large airway obstruction and segmental collapse
2. Mediastinal shifting toward opacification (vs. opposite in pleural effusion) to occupy vacant space
2. Smoking
2. Low-grade fever and mild respiratory insufficiency
6. Cardiogenic Pulmonary Edema
1. Left V dysfunction, fluid overload, pulmonary interstitial edema
2. Increase in interstitial water causes compression of bronchovascular structures, V/Q mismatch and worse hypoxia
7. PE
1. Acute-onset hypoxia, anxiety, tachypnea, hypocarbia
2. CXR: no significant abnormalities
3. Dx:
1. Stable: CTA
2. Unstable: TTE
1. Enlarged RV
4. Workup
ARDS “White-out”
1. Stabilize with oxygen and fluids—Evaluate for contraindications to anticoagulation
1. Yes—Diagnostic test for PE
1. (+) PE — IVC filter
2. (-) PE — None further
2. No—Clinical suspicion of PE with modified Wells criteria
1. PE unlikely — Diagnostic test for PE
1. (+) PE — Anticoagulation; Surgery or thrombolytics
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2. PE likely —Anticoagulation — Diagnostic test for PE
1. (-) PE — Stop anticoagulation
8. Pulmonary Contusion
1. Morbidity linked to direct parenchymal injury and bronchoalveolar hemorrhage—> V/Q mismatch, hypoxemia
2. Worsened by chest wall injury pain, leading to ATELECTASIS IN THE UNINVOLVED LUNG
9. Delayed Emergence from Anesthesia
1. Failure to achieve consciousness within expected window of last anesthetic
2. Causes
1. Hypoventilation due to medicine effect—low pH, high CO2, low pO2, bradypnea, bradycardia
1. Especially in patient with “alcohol and polysubstance abuse”
2. Tx: Ventilatory support
2. Metabolic: hyper/hypoglycemia, hyper/hypothermia, liver disease
3. Neurologic: intraoperative stroke, postictal state seizure, elevated ICP
10. Ventilator Bundle
1. Elevation of head of bed; Stress ulcer prophylaxis; DVT prophylaxis; Daily sedation interruption; Daily assessment of readiness for weaning and removal
from ventilatory support

11. Ventilator-Induced Lung Injury (VILI)

1. Positive-pressure-ventilation injury secondary to over-inflation, over distention, repetitive open and closing of alveoli. High oxygen delivery to lung can cause
oxygen free radical formation and hyperoxic injuries.
2. Changes: Low tidal volume (5-7 mL/kg), FiO2 <60% within 48-72hrs, PEEP to reduce atelectasis
12. Missed injuries within abdomen causing respiratory insufficiency

6. Respiratory Management
1. Severe Tachypnea and Tachycardia—> consider intubation and mechanical ventilation
2. Important to intubate and stabilize respiratory status while sorting out potential causes
1. If unable to maintain PaO2 of 60mmHg or O2 sat 91% with nonrebreathing O2 mask = significant A-a gradient
3. Noninvasive respiratory support
1. BIPAP mask provides some PEEP, higher oxygenation than conventional mask (Begin with CPAP, switch to BiPAP for better oxygenation and ventilation)
2. Caution: careful in individuals with atelectasis, fluid overload or pt at risk for aspiration
4. Mechanical Ventilation Modes
1. Conventional
1. Endotracheal tube—positive-pressure ventilation fills lungs with supratmospheric pressure
2. Creates positive transpulmonary pressure that ensures inflation of lungs
3. Exhalation is passive and occurs after release of positive pressure in the ventilator circuit
2. High-Frequency
1. Endotracheal tube—Small tidal volume (1mL/kg) at rate of 100-400 breaths/minute
2. Infants withs respiratory distress syndrome
3. Extracorporeal Life Support
1. Pt cardiopulmonary bypass—venovenous bypass circuit to remove CO2 and oxygenate blood
2. Neonates
7. Treatment
1. Diagnostic bronchoscopy with bronchoalveolar lavage
1. Immunocompromised (AIDS patient) with ARS and bilateral pulmonary infiltrates
2. Procedure used to identify possible opportunistic infecton
2. Sudden onset of respiratory distress post-op
1. Consider PE possibility, especially with hx of malignancy
1. O2, Doppler, CT Angio chest, Empiric Heparin
8. Negative impact
1. Positive pressure ventilation: causes VILI
2. Excess fluid in surgical patient: leading cause of respiratory distress
3. Failure to stop fluid resuscitation in hemorrhagic + septic shock: increases pulmonary morbidity and mortality in ventilated patient

Acute Lung Injury Atelactasis PE

Common Features

Findings CXR: B/l nonsegmental infiltrate PaO2/FiO2 <200 CXR: NORMAL Diminished breath sounds
PaO2/FiO2 <300 Segmental infiltrate Scattered rhonchi

Acute onset, Normal PCWP Decreased O2 exchange

Dec lung compliance/V Dec pulmonary compliance
Inc dead space ventilation Inc dead space ventilation

Abdominal Trauma Workup

HD Unstable: SBP <90mmHg CTAP: CT Abdomen and Pelvis

Peritonitis: Rigidity, Rebound tenderness Xlap: Laparotomy
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Evisceration: Externally exposed intestines DPL: Diagnostic Peritoneal Lavage
FAST: Intraperitoneal fluid

1. Abdominal trauma
1. Gunshot below nipple (T4), HD unstable/Peritonitis/Evisceration—>xlap
1. Diaphragm and Intraabdominal organs can rise to T4 dermatome
2. FAST not required for xlap because already has indication for xlap (HD unstable/Peritonitis/Evisceration)
2. Blunt Abdominal Trauma (BAT)
1. Frank peritonitis —> Xlap
2. HD Unstable
1. Peritonitis —> Xlap
(-) Peritonitis
2. (+) FAST—> Xlap
3. (-) FAST —> CTAP after resuscitation or DPL to find source
3. HD Stable
1. Peritonitis —> Xlap CTAP en route to OR
(-) Peritonitis
2. (+) FAST —> CTAP (identify source and manage non-operatively)
3. (-) FAST, high suspicion injury —> CTAP
4. (-) FASH, low suspicion injury —> Series abdominal exams, monitor closely,, IV fluids
CTAP: Hemodynamic stability required to prevent rapid deterioration in CT scanner
DPL: Bedside; considered in patients too HD unstable for CT

2. Abdominal Xray — Ileus

3. Upright CXR/KUB—free air under diaphragm (bowel perforation)
4. FAST scan/Ultrasound — intraabdominal
5. CT — retroperitoneal or splenic rupture

Burns
Colloid: Albumin, Crystalloid: Rest

Tonicity Fluid Type Clinical Use

0.9% (Normal) Saline Volume resuscitation

Isotonic
Lactated Ringer solution (Hypovolemia, Shock)

Albumin (5% or 25%) Volume replacement, Treatment of SBP or HRS

Dextrose 5% in Water
Hypotonic Free Water Deficit
0.45% (half normal) Saline

Dextrose 5% in 0.45% (half-normal) Saline) Maintenance hydration

Hypertonic 3% (Hypertonic) Saline Severe, Symptomatic Hyponatremia

Severe burn Patient: Lactate Ringers (buffer to maintain normal blood pH)
*Normal saline can cause Hyperchloremic Metabolic Acidosis and hypocoagulopathy
Parkland Formula: 4x(kg wt)x(% area) = mL
1. Accidental hypothermia
1. Initial management—rapid rewarming 98-102F
2. Persistent signs of tissue ischemia after frostbite—Angiography or Technetium-99m scintigraphy to assess benefit from thrombolysis
2. Burn wound infection
1. Vancomycin (Staph) + Pip/Tazo or Carbapenem (Meropenem)
3. Enteral nutrition asap (vs parenteral)
4. Endotracheal intubation
1. Early intubation to prevent upper airway obstruction by edema
5. High-voltage electrical injury
1. More damage to internal organs than outer skin
2. Complications: Acute compartment syndrome, Rhabdomyolysis, Heme pigment-induced acute kidney injury
6. Thermal Burn
1. Hypermetabolic response—Hyperdynamic circulatory response (Tachycardia, Hypertension)
2. Increased gluconeogenesis and insulin resistance
3. Increased protein and lipid catabolism—Elevated Basal body Temperature
7. Urethral catheterization
1. After initial stabilization, burn patients requiring aggressive fluid resuscitation should undergo urethral catheterization asap to maintain adequate urine output
2. Delay can lead to edema that obstructs visualization and catheterization of urethra
Note: Delay leads to airway edema/obstruction and urethral edema/obstruction—intubate and urethral catheter 1st!

Bites
1. Clenched-fist bite injury “fight bite”
1. Puncture (tooth) through soft tissue overlying MCP joint, can result in septic arthritis (joint pain, erythema, swelling, fluctuant, painful range of motion)
2. All septic joints require drainage (larger joints are drained via arthrocentesis or arthroscopy, smaller ones via surgical irrigation and debridement)
3. IV antibiotics (ampicillin/sulbactam) after joint cultures, wound is left open to drain and heal by secondary intention
4. Tx: Urgent surgical irrigation and debridement and antibiotic therapy
2. Snake bite
1. Antivenom
1. Crotalidae polyvalent immune Fab—used with high risk only due to anaphylaxis risk

3. Spider bite
1. Loxosceles reclusa—brown recluse
1. Small, red papule that can form larger necrotic wound
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2. Complication: Necrosis and eschar
3. Found in warm, dry areas like attics, woodpiles, cellars
4. Most resolve with local wound care and cold packs (decrease venom phospholipases that cause tissue necrosis)

Social Sciences
1. Informed consent—conducted for all including those admitted under substance intoxication
1. Must include risk of refusing treatment, diagnosis, risks and benefits of treatment and treatment alternatives
2. Necessary if an incidental tumor is discovered
3. Exceptions
1. Life-saving procedure in an emergency, such as intubation
1. Patient oral refusal of procedure does not count unless all the other factors of informed consent are also discussed. Generally oral refusal after trauma
or shock might not be sufficient due to temporary lack of decision making capacity.
2. Additional procedure related to initial indication (unexpected ostomy necessary if profound enteric spillage)
2. Capacity for health decisions
1. Reassess incapacitated patients before health care decisions are made (i.e. patient who recently gained consciousness has to be reassessed before refusal for
treatment can be accepted)
3. Time-out and Site Verification
1. Preoperative Verification: of operative site and patient, should involve patient and 2 providers
2. Site Marking: surgeon marks sites
3. Final Time-out: prior to incision involving entire team

SUBSPECIALTY
CT Surgery
1. Ankylosing Spondylitis
1. Aortic regurgitation (chronic inflammation of valve)
2. Gunshot wound
1. Hard signs of vascular injury: pulsatile bleeding, bruits or thrills over injury, expanding hematoma, distal ischemia (absent pulses, cool extremities)
2. Soft signs of valvular injury: hx of hemorrhage, diminished pulses, bony injury, neuro abnormality
3. Management: Urgent surgical repair in presence of penetrating injury

Endocrine
1. Calcium
1. Hypercalcemia
1. Correct for albumin concentration/ionized calcium
1. Corrected Calcium = Measured Ca + 0.8 x (4-Albumin)
2. S/S: Nausea, Polyuria
3. Workup: PTH levels
1. High/Normal PTH (PTH-dependent)
1. Primary (or 3o) Hyperparathyroidism
2. Familial Hypocalciuric Hypercalcemia
3. Lithium
2. Low PTH (PTH-independent)
1. Malignancy
2. Vitamin D Toxicity (shortened QT interval)
3. Vitamin A Toxicity
4. Granulomatous disease
5. Thiazide use
6. Milk-alkali Syndrome
7. Prolonged Immobilization: Increased Osteoclast activity
1. Onset around 4 weeks; earlier onset (within 3 days) in renal insufficiency
2. Tx: Bisphosponates (inhibit Osteoblastic bone resorption and decrease bone loss)
2. Hypocalcemia
1. Cause
1. Hypoparathyroidism (neck surgery)
2. Pancreatitis
3. Sepsis
4. Tumor Lysis Syndrome
5. Acute Alkalosis
6. Chelation: Blood (citrate) transfusion, EDTA, Foscarnet
1. Citrate binds ionized Calcium especially in liver injury/disease (normally Citrate metabolized by liver)
2. S/S: Chvostek, Trousseau (forced wrist flexion), Paresthesias, Hyperreflexia, Seizures
3. Tx: IV Ca Gluconate/Chloride Ca gluconate also used to stabilize cardiac membranes in Hyperkalemia
2. Acromegaly
1. Excess Growth Hormone usually by Pituitary Somatotroph Adenoma
1. Enlarging adenoma may suppress other hormones (erectile dysfunction and low testosterone)
2. S/S: Joint involvement of axial and appendicular skeletons
1. Increased Hyperglycemia—Polyuria
2. Increased Metabolic rate—Hyperhidrosis
3. GH stimulates Insulin-like GF-1—Overgrowth tissues, bone, cartilage, visceral organs
4. Spinal involvement—Kyphoscoliosis
3. Xray:
1. Initially—Joint space widening
1. Excess GH causes hyperplasia of articular chondrocytes and synovial hypertrophy
2. Later—Osteoarthritis resemblance “osteophytes”
1. Cartilage degeneration
4. Tx:
1. Transsphenoidal surgery—minimize arthropathy in hypertrophic stages but cannot reverse degenerative changes

3. Pheochromocytoma
1. S/S

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1. Triad: Episodic headache, Sweating, Tachycardia
2. Resistant HTN or HTN with unexplained Elevated Glucose
3. FH: MEN2, NF1, VHL
4. 10% Bilateral, 10% Extraadrenal, 10% Malignant
2. Dx
1. Urine or Plasma Metanephrine levels
2. Confirmatory abdominal imaging for Elevated Metanephrine
3. Tx ~All Pheochromocytomas should undergo surgical resection due to catecholamine surges risk~
1. Preop Alpha blockade (1-2wks before surgery) prior to Beta blockade
1. Phenoxybenzamine (irreversible, nonselective alpha blocker)
2. Terazosin (selective, alpha-1 blocker)
3. Increased Na intake and hydration to avoid alpha-blockade resulting orthostasis and hypotension
2. Laparoscopic or open surgical resection

4. Diabetes
1. Stress Hyperglycemia (physiologic response to illness or injury)
1. Severe stress triggers Cortisol and Catecholamine release
1. Act on liver to increase Glycogenolysis and Gluconeogenesis, this can be enhanced by Glucagon
2. Tx
1. Mild elevations (140-180): No treatment
2. Marked elevation (>180): Short-acting insulin to target 140-180mg/dL
1. High glucose levels increase risk of mortality
2. Goal kept at 140-180mg/dL to minimize risk of insulin-induced hypoglycemia

5. Gynecomastia
1. Pseudogynecomastia: Chronic, excessive deposition of fat in breast without distinct margin
1. Tx: Weight loss
2. True: Margin of firm grandular tissue palpable and tender breast

ENT
EAR
1. Acoustic Neuroma: Affects CN 7 and CN8—Neural hearing loss, Tinnitus, Vertigo, Ataxia, Loss of taste in anterior tongue
2. Meniere Disease: Fluid overload in vestibulocochlear apparatus, Triad of Hearing loss, Tinnitus, Vertigo
3. Otosclerosis: Conductive hearing loss (no ataxia)

NOSE
1. Deviated Nasal Septum/Septal Perforation
1. Complication of rhinoplasty—septal hematoma—whistling noise during respiration
~Perforation also seen with Nose picking, Syphilis, TB, Intranasal Cocaine, Sarcoidosis and Wegener’s~
2. Epistaxis
1. Septal Hematoma
1. Presents as fluctuant swelling of nasal septum
2. Tx: 1st: Incise and Drain (Avoid complications of infection, septal perforation, nasal deformities)
1. Septal cartilage relieves all nutrients from perichondrium, hematoma can disrupt that and lead to avascular necrosis of septal cartilage
2. 2nd: Anterior nasal packing, ice packs and NSAIDs

LARYNX: EPIGLOTTIS, SUPRAGLOTTIS, VOCAL CORD, GLOTTIS, SUBGLOTTIS

1. Recurrent Respiratory Papillomatosis
1. HPV 6 and 11 vertical transmission
2. S/S: Hoarseness from finger-shaped growths on true vocal cords in young patient
3. Tx: Surgical Debridement
4. Complications: Voice problems, Airway obstruction, Repeated interventions
2. Squamous Papilloma
1. HPV
2. Wartlike proliferations, multiple, raised, finger-shaped lesions on vocal cords
3. Head and Neck SCC (HNSCC)
1. RF: HPV-16 in the absence of smoking/old age/poor dentition Decrease in smoking, but increase in HPV (+) HNSCC
1. HPV affects oropharynx possibly due higher content lymphatic tissue facilitating viral processing
2. S/S: Pharyngitis, Dysphagia, Halitosis
3. Management: Tonsil biopsy, HPV status, CT neck to characterize lesion and associated nodal metastasis
4. Laryngeal Squamous CC
1. RF: Smoking, Alcohol
2. S/S: Hoarseness, fungating mass
1. Persistent hoarseness (>30days) always evaluated by laryngoscopy for cancer evaluation
2. Referred Otalgia (CN9 or CN 10)
3. Hemoptysis: Tumor friability
4. Regional LN metastasis—> Cervical adenopathy

SALIVARY GLANDS

TONSILS
1. Tonsilloliths (Tonsil stones)
1. Toothpick related mucosal trauma
2. S/S: Concretions of food, cellular and bacterial debris

PARATHYROID
1. Hyperparathyroidism
1. Primary HPT (PHPT)
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1.
HyperCa, HypoPO4 HyperPTH
2.
Elevated PTH causes increased reabsorption of Ca from Distal Tubule, but net urinary Ca excretion is increased due to excess resorption of Ca from bones
3.
Cause: Parathyroid Adenoma (#1), Hyperplasia, Carcinoma; Increased risk in MEN 1 and 2A
4.
S/S: HyperCa symptoms (abdominal pain, renal stones, bone pain, neuropsychiatric symptoms)
5.
Parathyroidectomy Indications
1. <50yo, Symptomatic hypercalcemia
2. Complications: Osteoporosis, Nephrolithiasis/Calcinosis, CKD (GFR <60ml/min)
3. Elevated risk of Complications: Calcium >1 mg/dl above normal, Urinary Calcium excretion >400mg/day
2. Familial Hypocalciuric Hypercalcemia
1. HyperCa, HyperPTH, Low urinary Ca excretion )<100mg/24hr)
3. Secondary HPT
1. HyperPTH, HyperPO4, HypoCa
2. Cause: ESRD (Decreased excretion of PO4, Decreased activation of Vitamin D)
3. Complication: Can cause Renal Osteodystrophy due to excessive PTH
4. Tertiary HPT
1. RF: Longstanding CKD/ESRD, Chronic HypoCa, HyperPO4
2. PP
1. Parathyroid hyperplasia and loss of feedback inhibition of PTH by Calcium
2. CKD leads
1. Decreased 1,25-dihydroxyvitamin D activation—> Low Ca
2. Decreased GFR and inadequate clearance of PO4—> High PO4
3. Resulting PTH stimulation leads to High PTH levels = 2nd HPT
1. Long-standing CKD = Chronic PTH stimulation causes PT Hyperplasia
2. Leads to autonomous PTH secretion that is not suppressed by rising Ca levels due down regulation of Ca-sensing receptor and Vitamin D
receptor in PT gland
3. Leads to Tertiary HyperPT
3. Labs
1. Autonomous PTH—Very hight PTH
2. Bone mobilization—Mild/Moderate HyperCa
3. Renal PO4 retention—HyperPO4
4. Tx
1. Refractory to meds; Parathyroidectomy
5. Osteoporosis
1. Serum Ca, Vitamin D, Magnesium normal
2. However Low Vitamin D levels can cause Elevated PTH in the presence of Normal Serum Calcium
2. Hypoparathyroidism
~Low calcium and High Phosphorus in presence of Normal Renal function~
1. Causes
1. #1 Post-thyroidectomy
2. Autoimmune Parathyroid destruction
3. Defective Calcium-sensing Receptor
2. S/S: Hypocalcemia related
1. Initially asymptomatic
2. Nonspecific: Fatigue, Anxiety, Depression
3. Sever Hypocalcemia: Involuntary contractions of lips, face, extremities, seizures and QT Prolongation

THYROID
1. Thyroid Nodule
1. Small, hyperfunctioning nodules are rarely malignant and do not require FNA
2. Workup
1. Normal/Elevated TSH—FNA based on size and US findings
1. FNA
1. >1cm + high risk features (microcalcifications, irregular margins, internal vascularity)
2. >2cm noncystic
2. Low TSH—Radioactive Iodine Scintography
1. Hypofunctional/Cold—FNA based on size and US findings (higher risk of cancer)
2. Hyperfunctiona/Hot—Treat Hyperthyroidism
2. Thyroid Storm Life threatening
1. RF
1. Surgery
2. Acute illness
3. Acute iodine load
2. S/S
1. High fever 104-106, Tachycardia, Hypertension, CHF, Cardiac arrhythmia
2. Agitation, Delirium, Seizure, Coma, Goiter, Lid lag, Tremor, Warm/moist skin
3. N/V, Diarrhea, Jaundice
3. Tx
1. BB—decrease adrenergic response
2. PTU and iodine—decrease hormone synthesis and release
3. Glucocorticoids (Hydrocortisone)—decrease T4-T3 peripheral conversion and improve vasomotor stability
4. Supportive care
3. Euthyroid Sick Syndrome
1. RF: Severe acute illness, ICU admission, High-dose glucocorticoid therapy
2. PP
1. High circulating levels of Glucocorticoids and Inflammatory cytokines (TNF, INF-a)
2. Decreased T4-T3 peripheral conversion
3. Dx
1. Early: Low T3, Normal TSH, T4
2. Late: Low T3, TSH, T4
4. Management
1. Observe without treatment (Thyroid hormone supplementation not indicated)
2. Follow-up testing after patient has returned to baseline health
4. Cancer
1. Thyroglobulin (produced only by thyroid tissue), is used as a tumor marker post-thyroidectomy
1. Elevated levels indicate recurrence of malignancy

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2. MC: Papillary Empty-nuclei, psamomma bodies
1. Tx: Surgical resection
1. Recurrence suppressed by
1. Radioiodine ablation post resection
2. Thyroid replacement to suppress TSH secretion (prevent growth of residual/metastatic disease)
3. 2nd MC: Follicular Neoplastic cells invade capsule (vs. Follicular adenoma with no capsule invasion)
4. Family Hx: Medullary Thyroid Cancer (Parafollicular cells) Present with symptoms of Hypocalcemia
1. Serum Calcitonin measured for risk of metastasis and recurrence
2. Associations
1. 25% RET Proto-oncogene—MEN2 (MTC, Pheo, Parathyroid Hyperplasia 2A or Marfanoid habitus and Mucosal neuromas 2B)
5. Papillary Thyroid Cancer

Derm
1. Hidradenitis Suppurativa inflammation of apocrine sweat glands
1. RF
1. Smoking, Metabolic Syndrome (Obesity, Diabetes)
2. S/S
1. Painful, chronic, relapsing condition with inflamed nodules, subq abscesses, scarring
2. Sinus tract formation in intertriginous (axilla, anogenital, breast folds) areas
3. Tx
1. Prolonged Antibiotics
4. Complications
1. Depression and Suicide
2. Squamous CC skin
CANCER
2. Basal Cell Carcinoma
1. Tx
1. Low risk: <2cm, trunk or extremities
2. High risk: >1cm, face, neck, hands, feet, genitalia
1. Mohs Micrographic surgery (highest cure rate, preservation of normal tissue)
2. 1st line for non melanoma skin cancer with high recurrence
3. Squamous Cell Carcinoma
1. Tonsil ulcer in smoker
1. Tumor invasion—Sore throat, Odynophagia
2. Referred Otalgia or isolated neck mass due to regional lymph node spread
4. Melanoma

Heme/Onc
Iron
Transferrin (transports), TIBC (binding capacity) **inverse relationship
Ferritin

Hemolytic anemia: Indirect Bilirubin increased, Free Serum Haptoglobin reduced (binds free Hb from hemolysis), LDH increased

Blood Cell Deficiency

• All lineages: Bone Marrow issue
• Specific lineage
• Congenital Deficiency—DiGeorge (TC)
• Infection Specific—HIV (Lymphocytes)

1. Methemoglobinemia
1. Cause: Topical anesthetic/Benzocaine or Dapsone
1. Altered state of hemoglobin: oxidize Fe in Hb, leading to methemoglobin which cannot bind oxygen
2. Pulse ox is falsely elevated because it estimates based on PaO2 only, not on effective Hb-O2 binding
3. Hypoxia, SpO2<85% and large oxygen saturation gap (blood gas vs pulse oximetry)
4. Tx: Methylene Blue
RBC
Anemia
1. Microcytic
2. Macrocytic
3. Normocytic
1. Hemolytic
1. Sickle Cell Trait
1. Mild intravascular hemolysis (elevated reticulocyte count, indirect hyperbilirubinemia), normal Hb
2. Cause: stress due to flying at high altitude, dehydration from alcohol consumption can cause splenic infarct
3. Dx: Hb electrophoresis

Hyperproliferative
1. Decreased EPO
1. PV
2. Elevated EPO
1. Renal Cell Carcinoma
2. Chronic Lung Disease
3. High altitude
4. Chronic Carbon Monoxide Exposure
5. Sleep Apnea
6. R-L cardiac shunt
3. Treatment
1. Treat hypoxia cause

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2. Phlebotomy

WBC
1. Decreased—Immunodeficiency
2. Elevated—Hypersensitivity
3. Neutrophils
1. Dec: Drug toxicity, Chemo, Pancytopenia
2. Elevated: Acute Inflammation, Bacterial Infection, AML, CML
4. Lymphocytes
1. Dec: SCID (premature B and T cell death), Low AB production—X linked agammaglobulinemia, Common Variable Immunodeficiency, Selective IgA deficiency
2. Elevated: Chronic Inflammation, Fungal/Viral Infection, ALL, CLL
5. Basophils, Mast Cells, Eosinophils (Allergies)
1. Eosinophils Elevated: Collagen Vascular Disease, Parasitic infection, Neoplasia, Allergy, Asthma
6. Plasma Cells (terminally differentiated BC)
1. Multiple Myeloma: Primarily in bone
1. Bone destruction—> Hypercalcemia, bone pain, spinal cord compression, pathological fractures
2. Overproduction nonfunctional Ab—> Immunodeficiency, Elevated serum protein, Elevated urine protein (Bence Jones proteinuria which can cause renal
damage)
7. Leukemia: Bone Marrow
1. Proliferation of one lineage negatively affects other lineages—Anemia and Platelet dysfunction (spontaneous mucosal bleeding and easy bruising)
8. Lymphoma: Lymph Node, Spleen
1. Hodgkin’s: Reed-Sternberg cell
2. Non-Hodgkin’s (T or B cell)

Platelets and Coagulation

PT: Extrinsic (Warfarin)
PTT: Intrinsic (Heparin) “Hint” “Longer name, more factors”

1. Hypocoagulopathy—Decreased Platelets or Coagulation Factors, Decreased Platelet function Also caused by excessive crystalloid fluids
1. Presentation
1. Blood in urine: hematuria
2. Excessive bleeding menses: menorrhagia
3. Excessive bleeding in between cycles: metrorrhagia
2. Coagulation
1. Liver disease
2. Vitamine K deficiency
1. Cause: Acutely ill patient with liver disease hospitalized for 7-10 days
1. Elevated PT with PTT
2. “Patient did not receive any enteral nutrition”
3. Hemophilia A: F8
4. Hemophilia B: F9
5. VWF Disease: Decreased F8
3. Platelet Dysfunction
1. vWF Disease: platelets cannot bind vessel wall
1. Insufficient Hemostasis following tissue injury from biopsy: most common cause of postoperative hematoma in patients with no perusal or family
history of easy bleeding or bruising
2. Bernard-Soulier Syndrome: GP 1b-1X: platelets cannot bind vessel wall
3. Glanzmann’s Thrombasthenia: GP 2b/3a: platelets cannot bind fibrinogen
4. Decreased Platelet Count
1. Decreased Production (Bone Marrow issue)
1. Malignancy, Radiation, Drugs, Infection
2. Destruction/Loss
1. Infection, Drugs (Heparin, Alcohol, Quinidine)
2. Autoimmune: ITP
3. Inappropriate Aggregation
1. TTP/HUS: platelet aggregation and thrombus formation causes thrombocytopenia
1. Microvascular occlusion causes widespread ischemia
2. Fever, Purpura, AMS, Renal dysfunction, Hemolytic Anemia
3. Initial microvascular injury: autoimmune process, pregnancy, HIV/E.coli infection, cancer, drugs
4. Normal PT/PTT
5. HUS: Younger children, post-E.coli/Shigella
6. TTP: Fatal unless Plasmapheresis done to remove offending toxin and replace deficient serum factors
2. DIC
1. Cray cray bisch
2. Increased risk with severe trauma “Consumptive coagulopathy”
3. Oozing from venipuncture/surgical site and signs of organ damage (renal insufficiency)
4. Lab: Prolonged PT/PTT, High D-dimer, Low Fibrinogen, Low Platelets, Microangiopathic hemolytic anemia (schistocytes)
2. Hypercoagulopathy—Elevated Platelets or Deficiency Anti thrombotic (Protein C and S deficiency)
1. Pulmonary Emboli, Mesenteric Ischemia, Stroke
2. Protein C, S, Antithrombin3 deficiency
3. Factor V Leiden (F5 not inactivated by Protein C)
4. Anti-phospholipid Antibodies
5. Pregnancy
6. OCP
7. Heart Failure
8. Stasis—DVT (may lead to PE)
1. Source: Femoral vein IV drug abuse
1. Iliofemoral venous wall trauma, chemical irritation and infection
2. Source: Peripherally inserted central catheters
1. Arm swelling, erythema and pain
2. Dx: Duplex ultrasonography
3. Tx: 3 months of anticoagulation
Note: Vs. Superficial phlebitis (Caused by peripheral venous access, redness along peripheral vein; treat with NSAIDs and warm compresses)
3. IVC filter indications
1. Life-threatening bleeding episode with DVT and high-risk of PE

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2. Anticoagulation failure (subsequent DVT while on anticoagulation)

Mass
1. Anterior Mediastinal Mass
1. MC: Thymoma
1. Myasthenia Gravis
2. Teratoma (and other germ cell tumors)
1. Elevated AFP and B-hCG: Nonseminoma (mixture of different cell types)
Note: Elevated B-hCG only: Seminoma
3. “Terrible” lymphoma
4. Thyroid neoplasm
2. Middle Mediastinal Mass (heart, great vessels, trachea, main bronchi, esophagus, pericardium, lymph node)
1. Bronchogenic cysts: congenital anomalous budding of the foregut, causes chest discomfort and respiratory symptoms
3. Posterior Mediastinal Mass
1. Neuroblastoma
4. Breast Mass
1. Mammography is the best initial imaging for Men and Women
5. Head & Neck Cancer
1. Squamous cell carcinoma in Cervical LN especially in smoker likely has mucosal head and neck primary site, requires examination of laryngopharyngeal mucosa
6. Posttransplantation lymphoproliferative disorder
1. Proliferation of immortal B-cells
2. Plasmocytic or lymphoid proliferation in those on high-dose immunosuppressive meds post-transplant
3. Most cases due to EBV: lymphadenopathy, hepatosplenomegaly, cytopenia, elevated EBV titers

Anticoagulation
1. Heparin-induced Thrombocytopenia (HIT): Antibodies against platelet component
1. Heparin exposure >5days and any of following:
1. Platelet reduction >50% from baseline
2. Arterial or venous thrombosis
3. Necrotic skin lesions at heparin injection site
4. Acute systemic (anaphylactic) reaction after heparin
2. Note skin lesions near subcutaneous insertion site
3. Dx: Serotonin release assay
4. Tx: Stop all Heparin productions, Start direct Thrombin-I/Argatorban or Fondaparinux
2. Rectus Sheath Hematoma
1. Acute abdominal pain with palpable abdominal mass, anemia, leukocytosis; rupture of inferior epigastric artery especially on patients taking anticoagulants
2. RF: Blunt trauma, forceful abdominal contractions as seen in severe coughing in asthma exacerbation
3. Presentation: “Tenderness lateral to umbilicus”, acute, palpable mass
4. Tx: Hemo stable (monitoring CBC, reverse anticoagulation, transfuse), Hemo unstable (angiography with embolization, surgical ligation)

Vascular
1. Blood Transfusion
REACTION
1. Anaphylactic (sec-min)
1. Recipient Anti-IgA directed against donor IgA
2. Angioedema, Hypotension, Respiratory wheezing, IgA-deficient recipient
2. Acute Hemolytic Transfusion reaction (24hrs onset)
1. Positive Coombs test: Antibody-coated red blood cells
2. ABO incompatibility, often clerical error
3. Hemolysis (inc LDH, inc indirect bilirubin)
4. Complications: Acute renal failure, DIC
1. Host antibodies attack donor antigens—massive rbc destruction—toxic hb buildup in kidney—renal tubular cell injury—acute renal failure
2. Flank pain, dark urine, fever, hemoglobinuria
3. Bronchoalveolar lavage and biopsy to rule out infection
5. Tx: Immediate cessation, aggressive IV fluids, supportive care
3. Febrile nonhemolytic (1-6hrs) most common
1. During blood storage, leukocytes release cytokines that when transfused cause transient fever, chills and malaise
2. Fever, chills
4. Urticarial (2-3hrs)
1. Recipient IgE against blood product component
5. Transfusion-related Acute lung injury (6hrs)
1. Donor anti-leukocyte antibodies: neutrophil activated by complement damage pulmonary microvasculature
2. Respiratory distress; Noncardiogenic pulmonary edema with bilateral pulmonary infiltrates (similar to ARDS seen in sepsis)
3. Tx: Discontinue transfusion and supportive care
6. Delayed Hemolytic (days-wks)
1. Anamnestic antibody response
2. Positive Coombs, Positive new Antibody screen
7. Graft vs Host (wks)
1. Donor T lymphocytes
2. Rash, Fever, GI symptoms, Pancytopenia
TRAUMA
8. Hemorrhagic Shock
1. Criteria (>2)
1. SBP <90 and HR >120, AMS, Delayed capillary refill = 30% circulating volume loss = Class 3 Hemorrhage
2. Bleeding from non-compressible site
2. Immediately provide Group O, Rh D-negative blood and transfuse type-specific blood later
3. To reduce risk of coagulopathy in massive transfusion, give in 1:1:1 FFP:Packed RBC:Platelets ratio
2. Acute Limb Ischemia
1. Chronic Peripheral Artery Disease (PAD)

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1.
HTN, Hyperlipidemia, Smoking
2.
Preexisting collateral circulation, therefore less dramatic presentation than in non-PAD
1. Lack classic 6Ps
2. Prolonged but not absent capillary refill
3. Diminished pulses in unaffected extremities, shiny hairless legs
4. 1st test: Ankle-brachial index (sensitive and specific): <0.9 is diagnostic
5. Amputation
1. Nonrevascularized limb ischemia
2. Unsalvageable soft-tissue damage (Trauma, Gangrene, Frostbite)
3. Lift-threatening infection (Infected Gangrene, Necrotizing soft-tissue infection)
2. Cardiac
1. Arterial embolus from Afib
2. LV thrombus
3. IE
3. Iatrogenic/blunt trauma
4. Anticoagulation started immediately: IV Heparin upon diagnosis to prevent thrombus formation
3. AV Malformation
1. Intracerebral Hemorrhage: Ruptured AV malformation before age 40
1. Artery directly anastomosing with vein leads to high-pressure system and aneurysm formation risk
2. Recurrent headaches, seizure, focal neurogenic deficit due to compression
3. Elevated ICP—headache, nausea/vomiting, altered mental status
2. Hereditary hemorrhagic telangiectasia
1. Nasal telangiectasia cause recurrent epistaxis
2. Pulmonary AVMs cause hemoptysis
1. CXR: “Multifocal, well-circumscribed, smooth nodules”
2. Infrascapular murmur (continuous pulmonary bruit) due to turbulent flow of AVM
3. Hemodialysis
1. Fistula forms enlarged vein and allows blood to bypass high-resistance capillaries
2. Decreased SVR (decreased afterload), Increased venous return (increased preload), increased CO
3. Complication: high output heart failure
4. Post-Cardiac Catheterization
1. Complication of vascular access during Femoral artery catheterization
1. Femoral vein inadvertently punctured during artery access—inadequate hemostatic post-procedure may cause persistent bleeding from arterial
puncture site into venous puncture site—leading to AVF
2. S/S
1. Mild localized pain and swelling, continuous bruit, palpable thrill over fistula site
5. Complications
1. Limb edema: Enlarge and cause venous hypertension
2. Limb ischemia: Redirection of arterial blood flow
3. High out HF: Blood returning to RA without passing through peripheral resistance

4. Cervical Artery Dissection

1. Cause
1. Penetrating Trauma
2. Fall with object in mouth: toothbrush, pencil
3. Neck manipulation: yoga, sports
2. Presentation
1. Gradual-onset hemiplegia Aphasia
Leriche Syndrome
2. Neck pain Thunderclap headache
3. Cervical internal carotid artery injury
1. Lateral and posterior to tonsillar pillars
2. Dissection or thrombus can extend into MCA and ACA—neck pain, thunderclap headache, ischemic stroke sx
3. Dx
1. CT or MRA
5. Peripheral Vascular Disease
1. Leriche Syndrome—Aortoiliac occlusion
1. Bilateral hip, thigh, buttock claudication
2. Absent/diminished femoral pules: symmetric atrophy of bilateral LE due to chronic ischemia
3. Impotence
6. Polyarteritis Nodosa
1. Fibrinoid Necrosis
1. Segmental, transmural inflammation of medium-sized vessels—luminal narrowing, thrombosis, organ ischemia
2. Internal/External elastic lamina damage
1. Micro-aneurysm formation—> rupture and bleeding
2. Kidneys (Renal infarction) and GI (Mesenteric ischemia, Bowel perforation)
3. Underlying Hep B/C
4. Angiography: multiple arteries with micro aneurysms, irregular luminal narrowing, distal occlusions “distal abrupt cutoffs”
5. Tissue biopsy: nongranulomatous transmural inflammation

Altered Mental Status

1. CT no contrast (AMS is part of NEXUS criteria)

Optho Adult
1. Atropine: dilates pupils; contraindicated in OAG because dilation causes angle narrowing and decreased outflow of aqueous humor
2. CA-I
1. Topical—Dorzolamide—OAG
2. Systemic—Acetazolamide—Acute angle-closure G (headache, ocular pain, vomiting, fixed/middilated pupil)
3. Latanoprost: treatment of OAG (chronic insidious onset of peripheral vision loss)
4. Cataracts
1. MC related to oxidative damage of lens with aging
2. Symptoms:
1. Progressive painless bilateral blurring of vision, bothersome glare, difficulty reading
3. Signs:
1. Opacification of the lens with chronic loss of visual acuity

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2. Decreased visualization of retinal detail
3. Glare and halos around bright light due to scattering of light in the lens
4. Loss of red reflex (later)
5. Visible cloudiness in the lens
4. Causes: Younger patients: DM, Trauma, Glucocorticoid use, Chronic HIV
5. Treatment: Surgical removal of lens and prosthetic lens implantation
5. Glaucoma
1. Angle-closure (ACG)
1. Narrowing or closure of anterior chamber angle causing decreased aqueous outflow and elevated IOP
2. Symptoms: Headache, ocular pain, nausea, decreased vision
3. Signs: Conjunctival redness, corneal opacity, fixed mid-dilated pupil
4. Dx: Tonometry, Gonioscopy (measures corneal angle)
5. Tx: Decreased IOP
1. Topical: Timolol (reduce aqueous production), Apraclonidine (reduction production, increase outlfow), Pilocarpine (ciliary m. contraction to open
trabecular meshwork at corneal angle)
2. Systemic: Acetazolamide (rapidly reduce aqueous production)
3. Laser iridotomy: definitive
2. Open-angle (OAG): Elevated IOP ~irreversible~
1. Insidious loss of peripheral vision due to atrophy of optic nerve head
1. “Optic disc rim thinning, increased cup/disc ratio” (later)
2. Elevated IOP due to topical or systemic glucocorticoids (Prednisolone)
1. GCs decreased outflow of aqueous humor via anterior chamber drainage channels
2. Also develop central blurriness due to corneal edema
2. Measuring IOP: Tonometry measures deformation of cornea in response to applied pressure
3. Tx: Decrease IOP
1. Topical Prostaglandin—latanoprost, bimatoprost—increase aqueous humor drainage through uveosclerer way
2. Topical BB—Timolol—caution in comorbid asthma patients
3. Laser trabeculoplasty
Cataracts Open Angle Glaucoma Angle Closure Glaucoma

Oxidative damage of lens, DM, GC Iris in right position Iris squeezed against the cornea blocking uveoscleral drains
use, Chronic HIV Uveoscleral drainage canals clear and trabecular meshwork
Trabecular meshwork not draining

Painless blurred vision Insidious gradual loss of peripheral vision Painful, vision loss, headache, nausea
Glare, halos around lights Central loss with GC use

Opacification of lens, decreased Enlargement of optic cup, central blurriness Conjunctival redness, corneal opacity, fixed mid-dilated
retinal detail pupil

Difficulty with night driving Near-miss MVA

6. Hyphema
1. Blood within anterior chamber commonly due to blunt force trauma to the eye
2. Spontaneous episodes due to VW Disease or Diabetes (microvascular disease)
7. Hypopyon
1. Layering of inflammatory cells in dependent portion of anterior chamber
2. Signs: Perilimbal injection/ciliary flush due to dilation of vasculature at junction of sclera and cornea
3. Conditions
1. Inflammatory: Anterior uveitis/iritis
2. Infectious: Endophthalmitis, Keratitis
8. Macular Degeneration
1. Decreased central vision acuity
2. Types
1. Atrophic (dry): slow vision loss with scotoma (blind spot)
2. Exudative/neovascular (wet): unilateral, aggressive vision loss that starts with straight line distortion
9. Myopia (nearsightedness)
1. Due to increased axial length of eye or corneal protrusion; causes refracted image focused anterior to retina
2. RF: Positive FH, East Asian decent
3. Complicaitons: Retinal detachment, Macular degeneration
10. Periorbital ecchymosis (raccoon eyes)
1. Orbital/skull fracture
11. Pterygium
1. Wedge-shaped proliferation of conjunctival tissue that expands from lateral aspects toward cornea
2. Chronic UV light exposure
12. Orbital floor fracture: Inferior rectus muscle entrapment—> vertical diplopia and restriction upward eye movement
13. Ocular Trauma
1. Open globe laceration (OGL)
1. Small, high velocity particles sent airborne
2. Symptoms: Foreign body sensation, pain, excessive tearing, decreased vision, extreme discomfort
3. Signs:
1. Globe deformity, extrusion of vitreous or iris or visible entry wound, peaked/teardrop pupil iris stretching
2. Asymmetric anterior chamber depth, loss of visual acuity or afferent pupillary response
3. Reduced intraocular pressure
4. Management
1. Eye shield, CT eye, IV Abx, Tetanus prophylaxis
2. Sympathetic ophthalmia: autoimmune, TC become sensitized to previously sequestered eye antigen
1. Decreased vision in uninjured eye and bilateral conjunctival erythema
2. Eyes and testes have immune privilege where inflammation is inhibited unless self-antigens are released into lymphatic system due to trauma
1. TC recognized antigens as foreign and mount inflammatory response against injured and uninjured eye
3. Tx: Injured eye is removed if injured eye is not expected to recover to prevent blindness
14. Uveitis
1. Acute Uveitis (intraocular inflammation): eye pain, redness, vision loss
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1. Associated with infection (herpes viruses), autoimmune (juvenile idiopathic arthritis)
15. Systemic
1. Graves
1. Ocular irritation, impaired extra ocular motion and proptosis
1. TRAB (TSH autoab) stimulate TH—TH increases catecholamine sensitivity—thyrotoxicosis causes sympathetic activation and contraction of superior
tarsal muscle—lid lag and retraction
2. TC activation and stimulation of orbital fibroblasts by TSH Autoantibodies causes orbital tissue expansion
2. Lamber-Eaton (paraneoplastic)
1. Diplopia, ptosis
3. Myasthenia Gravis (NMJ)
1. Autoantibodies against ACh-R on motor end plate
2. Fluctuating diplopia and ptosis
4. Diabetic Retinopathy: vascular proliferation with or without vitreous hemorrhage
1. Late findings: floaters, decreased visual acuity, focal visual field defects, acute monocular vision loss
5. Hypertensive Retinopathy: progressive arteriolar changes in retina
1. MC asymptomatic or monocular vision loss; symptoms due to retinal hemorrhage

Neurology
1. Delirum
1. Nonpharm Management preferred: Professional sitter
2. Cervical Myelopathy
1. Spinal cord and spinal nerve root compression
1. Myelopathic: UMN below the lesion
2. Radicular: LMN, pain in dermatomal/myotomal pattern, atrophy
3. Lhermitte sign: electric shock-like pain with neck flexion (also seen in MS, Transverse myelitis)
1. Activates ascending spinothalamic tracts
3. Spinal Cord Injury
1. Loss of spinal cord function—areflexia, anesthesia, paralysis, distended bladder
2. Lesions above T1 often cause neurogenic shock due to interruption of descending sympathetic fibers
1. Initial phase of massive sympathetic stimulation
1. Hypertension and tachycardia due to NE release from adrenals
2. Sympathetic tone plummets due to descending spinal tract injury
1. Brainstem—preganglionic sympathetic neurons in lateral horn of spinal cord at levels T1-L2
3. Unopposed parasympathetic stimulation carried by intact vagus nerve
1. Hypotension, bradycardia, hypothermia from peripheral vasodilation
3. Neurogenic shock lasts 1-5 weeks; patients with SC injury at increased risk for hypotension, bradycardia and hypothermia due to reduced sympathetic tone
4. LE Nerves
1. Ilioinguinal
1. Upper medial thigh and genital region
2. Obturator
1. Medial thigh compartment
3. Femoral Nerve
1. Hip flexion, Knee extension, sensation to anterior thigh and medial leg

Neurosurgery Bleeds
1. Herniation
1. Subfalcine: Ipsilateral ACA compression, contralateral leg weakness (lack pupillary or respiratory compromise)
1. Lateral ventricle compressed—disappears on image
2. Transtentorial/Uncal: Ipsilateral CN3 compression, ipsilateral fixed and dilated pupil
3. Tonsillar: Fixed, mid position pupils due to sympathetic and parasympathetic disruption
2. Diffuse Axonal Injury: Acceleration-deceleration or rotational shearing force on
1. MRI shows punctate hemorrhages in white matter, blurring of gray-white matter junction
1. May not be apparent on initial CT due to injury happening at microscopic level
2. Tx: Supportive, ICP management
3. Hemorrhagic Stroke
1. Cerebellar Hemorrhage
1. RF: Hypertension, Antithrombotic therapy, Cerebral Amyloid Angiopathy
2. Presentation
1. Headache, nausea, vomiting
2. Ipsi ataxia, dysarthria, vertigo, nystagmus
3. Cranial neuropathies
3. Imaging
1. CT: Posterior fossa hyperdensity
4. Management
1. Reverse anticoagulation
2. BP and ICP management
3. Urgent Surgical decompression > lumbar puncture to reduce ICP
4. Epidural Hematoma: Middel Meningeal artery, Frontotemporal region, Pterion region
1. Most patients are alert and do not lose consciousness
2. Hematoma expansion causes neurological decompensation: elevated ICP (headache, n/v, AMS)
5. Subdural Hematoma
1. “Acute on Chronic” hemorrhage
6. Subarachnoid Hemorrhage
1. Hallmark: blood layering cerebral sulci
2. CT shows hyper dense blood in basal cisterns (white hyperdense regions in brain parenchyma on noncontrast CT)
3. Nimodipine: improves outcome in aneurysmal SAH, causes cerebral vasodilation
7. Intracerebral Hemorrhage (ICH)
1. ABCs reassessed if rapid clinical deterioration—intubate and mechanically ventilate > discussion DNR/DNI
2. Cerebral Amyloid Angiopathy
1. Elderly patients with dementia
3. Ruptured AV malformation before age 40
1. Artery directly anastomosing with vein leads to high-pressure system and aneurysm formation risk
2. Recurrent headaches, seizure, focal neurogenic deficit due to compression
3. Elevated ICP—headache, nausea/vomiting, altered mental status

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8. Intraparenchymal Hemorrhage
9. Lacunar Infarct: Changes not immediately seen on CT due to small infarct size
10. Traumatic Brain Injury
1. Elevated ICP/Cushing Triad
1. Hypertension, Bradycardia, Irregular respiration
2. Prevent Intracranial hemorrhage (ICH)
1. Acute traumatic coagulopathy
1. Hypocoagulopathy from secondary coagulation factor deficiency (consumptive coagulopathy)
2. Hyperfibrinolysis can break down necessary clots and worsen existing ICH/TBI
3. Managed with antifibrinolytic therapy within 3 hours of injury for moderate TBI (GCS 9-12)—Tranexamic acid
3. Prevent ischemia by managing CPP (MAP-ICP)
1. MAP: Fluids and vasopressors
2. ICP: Determined by 3 distinct brain compartments
1. Brain parenchyma (80%)
1. Osmotic therapy: gradient draws water out of edematous brain tissue— Mannitol, Hypertonic saline
2. Hypertonic saline preferred over Mannitol (causes volume depletion)
2. Cerebral Blood volume (10%)
1. Head elevation (increased venous outflow)
2. Sedation (reduces cerebral metabolic demand and total cerebral blood flow/vol)—Propofol, midazolam
3. CSF
1. CSF drainage by External ventricular drain
2. *Note: Lumbar puncture avoided to prevent acute pressure gradient (high intracranial to low lumbar increased herniation risk)
4. Decompressive craniectomy
4. Other measures
1. Prevent seizures—Levetiracetam, Phenytoin
2. Control blood glucose
3. Maintain normothermia
5. Complication: Paroxysmal Sympathetic Hyperactivity (PSH)
1. Damage to cortical areas responsible for modulating and inhibiting lower sympathetic centers (hypothalamus, brainstem and spinal cord)
2. Presentation: Fever, diaphoresis, rapid-onset tachycardia, hypertension, tachypnea
3. Triggers: External stimuli—bathing, repositioning
4. Tx: Supportive, Opioids, GABA-agonist, a2-agonist

Neurosurgery Tumors
1. Solitary frontal lobe mass
1. Personality changes + headaches, increased ICP, unprovoked first seizure
2. Meningioma
1. Extra-axial well-circumscribed dural-based mass partially calcified
2. Presentation: headache, seizure, focal neuralgic deficits due to mass effect
3. Tx: complete surgical resection (benign)
3. Mesial Temporal lobe Sclerosis
1. MC cause of focal epilepsy
2. Preceded by distinct aura: epigastric uneasiness, olfactory hallucinations (lack elevated ICP)

Psychiatry
1. Alcohol
1. Withdrawal: 48-96hrs: Delirium tremens—Autonomic excitation
1. Delirium, hyperthermia, hypertension, tachycardia
2. Cocaine
1. Withdrawal: 12hrs
3. Malignant Hyperthermia (within 24 hrs)
1. Genetic mutation alters control of intracellular calcium
2. Triggered by succinylcholine, inhalation gases and excessive heat
1. Calcium accumulation causes muscle rigidity and increased cellular metabolism—>Hypercarbia resistant to increased minute Ventilation and Tachypnea
2. Sustained muscle contraction, Tachycardia, Myoglobinuria
3. Hyperthermia (later, sustained contractions generating more energy than can be dissipated)
3. Tx: Dantrolene
4. Neuroleptic Malignant Syndrome (few days)
1. #1 cause: Dopamine antagonism
1. Central dopamine receptor blockade in hypothalamus—autonomic dysregulation and hyperthermia
2. Nigrostriatal pathway—tremor, diffuse lead-pipe rigidity “increased muscle tone in all extremities”
2. Muscular rigidity, AMS, Autonomic dysregulation, Fever, Elevated creatinine kinase + renal failure
1. Sustained muscular contraction—muscle breakdown—inc CK and Myoglobinuria (UA+ for blood, but few rbc)
3. Agents
1. Haloperidol (antipsychotic), Promethazine (antiemetic), PD drug withdrawal
Similar

Surgery or Rigidity, myoglobinuria, tachypnea,

Malignant Hyperthermia Within 24hrs
Surgical anesthesia tachycardia

Neuroleptic agent: Haloperidol, Rigidity, myoglobinuria, tachypnea,

Neuroleptic Malignant Syndrome Days
Fluphenazine tachycardia

Breast
Female <30: Ultrasound >30: Mammogram
*Ultrasound added to Mammogram for better characterization of mass
*Tissue biopsy to confirm diagnosis
Simple cyst: FNA doesn’t resolve—> Core biopsy
Complicated cyst: Core biopsy
1. Breast Cancer
1. Warning Signs
1. Nipple retraction: invasion of lactiferous ducts
2. Nipple scaling or ulceration: epidermal infiltration by neoplastic cells
3. Nipple discharge: intraductal tumor growth +/- necrosis
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4. Skin retraction: invasion of suspensory (cooper) ligaments
5. Peau d’orange: obstruction of dermal lymphatics
6. Fixed breast mass: invasion into adjacent breast tissue
7. Axillary lymphadenopathy: lymphatic spread to regional lymph nodes
2. Prognosis: Depends on tumor burden, identified via TNM staging
3. Noninvasive
1. Ductal Carcinoma in situ
2. Paget Disease: Unilateral bloody nipple discharge
1. Intraductal tumor growth or necrosis leads to nipple discharge; eczematous nipple or skin changes
3. Lobular Carcinoma in situ
4. Invasive
1. Invasive Ductal Carcinoma: Bloody discharge with breast mass
1. Suspensory ligament invasion: skin retraction
2. Invasive Lobular Carcinoma
3. Medullary Carcinoma
4. Inflammatory Carcinoma
1. Unilateral breast rash, erythema, edema, warmth, skin dimpling
2. Metastatic disease (axillary lymphadenopathy) common in initial presentation
1. Invasion of dermal lymphovascular spaces—lymphatic obstruction—diffusely enlarged best with skin edema and fine dimpling “peau d’orange”
2. Rapid tumor growth due to early lymphatic involvement
3. Aggressive treatment due to high rate of metastasis
3. Core needle biopsy and full-thickness skin punch biopsy necessary for diagnosis
2. Breast Conserving Therapy (BCT)
1. Step 1: Partial Mastectomy along with sentinel lymph node biopsy
2. Step 2: Removed tumor and border of surrounding tissue microscopically examined
1. Positive margins = Partial mastectomy/reexcision of involved margins “Ductal CIS present in lateral margins”
2. Negative margins = Tumor resection complete
3. Positive sentinel lymph node = Axillary lymph node dissection
4. Negative lymph node = Tumor resection complete
3. Step 3: Radiation therapy follow surgery after negative surgical margins obtained to reduce risk of locoregional recurrence
3. Benign Breast Disease
1. Palpable Breast Mass
1. Age <30: Ultrasound +/-Mammogram
1. Simple cyst: Needle aspiration
2. Complex cyst: Imaged-guided core biopsy
2. Age >30: Mammogram +/- Ultrasound
1. Malignancy suspicion: Core biopsy
2. Breast Cyst
1. Simple (thin-walled, fluid-filled = anechoic)
1. Asymptomatic: Observe
2. Tender: FNA
1. Nonbloody aspirate—cyst resolves: No additional management
2. Nonbloody aspirate—persistent: Core needle Biopsy
3. Bloody aspirate: Core needle Biopsy
2. Complex (thick-walled, solid)
1. Core needle Biopsy
3. Fibrocystic Changes
1. Multiple, diffuse nodulocystic masses
2. Cyclic premenstrual tenderness
4. Fibroadenoma
1. Solitary, firm, well-circumscribed, mobile mass in upper outer quadrant
2. Cyclic premenstrual tenderness
3. Sensitive to Estrogen “recently started estrogen/progestin contraceptives”
5. Fat Necrosis
1. After trauma/surgery
2. Firm, irregular mass
3. +/- Ecchymosis, skin/nipple retraction
4. Can mimic breast cancer in presentation: fixed mass with skin/nipple retraction, calcifications on mammogram
5. Entire mass excised due to calcifications and fixed irregular mass
6. Reassurance and routine follow-up after mass excision
6. Intraductal Papilloma: Bloody discharge without breast mass
1. Papillary tumor arising from breast duct lining
2. MCC of nipple discharge “serosanguineous discharge” without breast mass or lymphadenopathy
3. Mammography & Ultrasound, Biopsy +/- excision
1. Mammogram often normal due to low sensitivity for ductal pathology
2. Ultrasound may show dilated duct due to space-occupying papilloma
4. Vs. Invasive Ductal Carcinoma (bloody nipple discharge with breast mass)
7. Mammary Duct Ectasia: Green-brown, sticky discharge with subareolar mass
1. Subareolar ductal thickening and dilation
1. Ductal thickening clogs duct causing fluid buildup, overlying skin erythema and nipple pain
2. Inflammation and fibrosis can cause palpable breast mass with nipple discharge
8. Galactocele
1. Lactiferous duct blockage in first few months following breastfeeding cessation
9. Galactorrhea
1. Cause: Poorly controlled hypothyroidism leads to TRH release—> TSH and Prolactin release
1. Increased Prolactin may cause physiologic bilateral, milky nipple discharge
4. Combined Oral Contraceptives
1. May cause breast pain few months after initiation

Female Reproductive
1. Acute Abdominal/Pelvic Pain
1. Mittelschmerz (hrs-days): recurrent mild and unilateral mid-cycle pain prior to ovulation
2. Ectopic Pregnancy: Amenorrhea, abode pain, vaginal bleeding, (+) B-hCG
3. Ovarian Torsion: Sudden, severe, unilateral, nausea, vomiting, tender adnexal mass
1. US: Enlarged ovary with decreased or absent blood flow
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2. Associated inflammatory pelvic free fluid “free fluid in posterior cul-de-sac"
3. Emergent laparoscopy for detorsion
4. Ruptured Ovarian Cyst: Sudden, severe, unilateral pain following strenuous or sexual activity
1. US: Pelvic free fluid
2. Ovarian cysts are common in reproductive age women
1. Occur when fluid fills space of recently released follicle following ovulation
3. Significant intraabdominal bleeding seen in patients on anticoagulants
4. Phrenic nerve irritation may cause radiation to shoulder
5. Peritoneal signs: rigidity, rebound, guarding
6. Hemodynamic instability: hypotension, tachycardia
5. Pelvic Inflammatory Disease: Fever, chills, vaginal discharge, cervical motion tenderness
1. US: +/- Tuboovarian abscess

Pregnancy/Childbirth
1. Pregnancy test
1. Serum quantitative: 4 days of implantation
2. Urine: 1 week
3. Pelvic US required after positive test

Renal
1. Acid-Base
1. Metabolic Acidosis
1. Anion gap: Unmeasured acids
1. Compensation
1. Respiratory: Increased ventilation and CO2 removal
2. Metabolic: Increased HCO3 reabsorption and H excretion via Ammonium
1. HCO3 reabsorption leads to increased Urinary Cl excretion
2. H excreted in the form of ammonium or titratable acid, H2PO4 (only small amount can be excreted as free acid)
2. Nonanion gap: Loss of HCO3 = Hyperchloremic acidosis
~Inverse relationship between Cl and HCO3, readily exchanged to maintain electronegative balance~
1. Cause
1. Severe diarrhea, RTA, Intestinal/Pancreatic fistula
2. CAI, Mineralocorticoid-R antagonist diuretics
3. Infusion of excess normal saline
1. Cl-HCO3 ionic shift: Increased intravascular Cl drives intracellular shift of HCO3 to reduce serum HCO3, which decreases blood pH
2. Metabolic Alkalosis
1. Cause
1. Gastric suction or severe vomiting
2. Loop or Thiazide diuretic overuse
2. PP
1. H loss initiates alkalosis—volume depletion activates RAAS—increased renal K and H loss worsens alkalosis—greater loss of Cl than Na causes
profound Cl depletion—Low Cl impairs HCO3 excretion to perpetuate alkalosis
2. Elevated Serum HCO3, Low Serum Cl, Urine Cl, Urine Na (Aldosterone-mediated reabsorption)
3. Tx
1. Remove initiating factor
2. Cl repletion with normal saline corrects alkalosis
3. Respiratory Alkalosis
1. Acute V/Q mismatch
2. Anxiety, inadequate pain control—especially patients on opioids pre-surgery due to tolerance
3. High altitude, pregnancy
2. Cysts
1. Simple
1. Asymptomatic, thin, homogenous, no contrast enhancement
2. Tx: Reassurance only
2. Malignant
1. Multilocular, irregular walls, thickened septa, contrast enhancement
2. Tx: Removal
3. AD Polycystic Kidney Disease
1. Associated
1. Progressive Renal Dysfunction
2. Urinary Concentrating Defect (low urine SG)
3. Increased Circulating Vasopressin
1. Encourage renal cyst growth
2. Vasopressin-2 R Antagonist (Tolvaptan) may slow ADPKD progression
2. S/S
1. Asymptomatic until 30-40yo
2. Flank pain, Hematuria, Bilateral flank pain
3. Hypertension—early disease manifestation
3. Kidney Injury
1. Pre-renal: Intravascular volume depletion
1. Decreased renal perfusion leads to decreased GFR and Increased serum Creatinine
2. Kidneys increase water and Na resorption, increasing passive urea resorption —> Blood BUN/Cr >20:1
3. Oliguria (<500mL of urine 24hrs)
4. Tx: IV Isotonic fluid (normal saline)

4. Hyponatremia
1. Desmopressin-associated Hypotonic Hyponatremia
1. ADH analog (used for Diabetes Insipidus); Promotes release of vWF (used for heavy menses due to vWD)
2. Dx: Serum electrolytes
1. ADH mediated water retention and reabsorption—Hypotonic Hyponatremia
2. Concentrated Urine—High Urine Osmolality
3. Increased secretion of natriuretic peptides—High Urine Na
2. Symptomatic Hyponatremia
1. Cause: Hypotonic IV fluids (0.45% saline), Postoperative ADH (stimulated by pain, nausea, stress)

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2. S/S: Elevated ICP—nausea, malaise, headache, confusion
3. Management
1. Serum Na <130 with Elevated ICP symptoms—> Hypertonic 3% saline
1. Acute hyponatremia (present <48hr) is poorly tolerated and increases risk for herniation
2. Chronic hyponatremia (>48hrs) better tolerated, hypertonic saline only if Na <120
3. Goal: raise 4-6 mEq/L, maximum rate 8 mEq/L in 24hrs to prevent Osmotic Demyelination Syndrome

5. Red Urine Evaluation (positive dipstick)

1. UA: >3 RBC
1. Hematuria
1. Painful
2. Painless
1. Bladder Cancer
2. Renal Cell Carcinoma
3. ADPKD
2. UA: 0-2 RBC
1. Hemoglobinuria (free Hb in urine)
1. Intravascular hemolysis: Mechanical valve
1. Next step —> CBC to confirm and assess anemia
2. Low Hb and Haptoglobin
3. Elevated Lactate dehydrogenase, Reticulocytes, Schistocytes
2. Myoglobinuria (muscle aches)
1. Rhabdomyolysis
2. Elevated CK
6. Renal Calculi
1. S/S: Hematuria, Ureteral dilation (source of much of the pain)
2. Types
1. Oxalate
1. Increased absorption in intestinal diseases causing fat malabsorption: Crohn
2. Ca binds fat, oxalate unbound and freely absorbed in blood (normally Ca binds oxalate in gut)
2. Uric Acid
1. Increased uric acid excretion: Gout, Myeloproliferative disorders
2. Increased urine concentration: Hot, Dehydration
3. Low urine pH (pH <5.5): Chronic diarrhea, Metabolic syndrome/DM
~Acidic urine favors uric acid (insoluble) over urate (soluble) formation~
4. Tx: Alkalization of urine with Potassium Citrate
3. Management
1. Urologic Consultation: >10mm, Urosepsis (Fever, Chills), Anuria, AKI, Refractory pain
2. Alpha blockers: 6-10mm
3. Supportive: <5mm
7. Ureter Injury
1. Dx: IV Pyelogram
2. Complication: Post Hysterectomy Ureteral injury
1. Ureter accidentally sutured leading to partial or complete ureteral obstruction
2. Masked initially due to pain medications
3. S/S: Hydronephrosis from ureteral injury
1. Unilateral back pain, Nausea, Vomiting
2. Costovertebral angle tenderness
4. Dx: Renal Ultrasound
5. Tx: Suture removal
~Normal renal function because only 1 ureter affected~
8. Ureteropelvic junction
1. Calcifications from long term stent placement in elderly
2. Replace stent if patient fails surgery
9. Urinary Tract Infection
1. Complication: Renal and Perinephric abscess
1. Necrosis of infected tissue processes over time to cavity formation (insidious, ~12 days)
2. In the setting of urologic infection (Pyelonephritis, UTI)
3. RF
1. Uncontrolled DM, Tobacco, Nephrolithiasis, Vesicoureteral reflux, Neurogenic bladder
4. S/S
1. Systemic: Fever, Fatigue, Diaphoresis, Weight loss
2. Unilateral flank pain and palpable mass (due to location)
3. UA findings may be normal if abscess is not in contact with collecting ducts
5. Dx: CT or US
6. Tx: Abx, Percutaneous drainage
10. Cancer: Renal Cell Carcinoma
1. Older patients who smoke
2. S/S
1. Wt loss, Hematuria (invasion renal collecting system), Firm/nontender flank mass, Intermittent fever
2. L-sided varicocele that does not decompress
3. Paraneoplastic syndrome: EPO production, Elevated Ca
3. Dx: Abdomina CT, Partial Nephrectomy
TRAUMA
11. Flank pain, Ecchymosis, Costovertebral angle tenderness, Hematuria —> CT abdomen and pelvis

Bladder
1. Bladder Anterior Wall Rupture
1. S/S
1. Pelvic fracture: Pubic ramus fracture (bony fragment can puncture bladder wall)
2. Gross Hematuria
3. Suprapubic tenderness/pain
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4. Difficulty voiding—>Urine leaked from extraperitoneal bladder rupture stays in retropubic space
2. Bladder Dome Rupture (from Blunt abdominal trauma)
1. Blunt trauma causes bladder to rupture at the weakest point, the dome leading to intraperitoneal bladder rupture
2. S/S
1. Pelvic fracture: Widening of pubic symphysis
2. Hematuria
3. Suprapubic tenderness
4. Inability to void
5. Urinary ascites, Increased BUN and Cr
1. Diversion of urine from urinary tract into peritoneal cavity and increased peritoneal reabsorption of BUN/Cr
2. Peritonitis does not appear acutely because urine is sterile
3. Patients present after urine has accumulated in peritoneal cavity (~1day later)
3. Dx: Retrograde Cystography
1. Bladder filled with water-soluble contrast via foley and imaged with CT scan to confirm diagnosis
3. Urinary Retention
1. Acute Urinary Retention (AUR)
1. Elderly mean, especially in setting of BPH
2. RF: Opioids, Anticholinergics, Neurologic disease
3. Dx: Bladder Ultrasound
1. >300mL confirms diagnosis —> Foley catheter
2. Postoperative UR (POUR)
1. Suprapubic discomfort and bladder spasms, might by masked by residual anesthesia or analgesia
2. S/S: Hypertension and Tachycardia due to sympathetic stimulation (distended bladder is noxious stimuli)
3. Dx: Portable bladder scanner
1. >600mL —> urinary catheterization
4. Cancer
1. Adult >40yo with painless hematuria and no evidence of infection, glomerulonephritis or nephrolith require bladder cancer investigation
2. S/S
1. Acute unilateral flank pain due to hydronephrosis
2. Voiding symptoms (dysuria, frequency due to reduced bladder capacity)
3. Hematuria (painless, due to new blood vessels that bleed)
3. Dx: Urinary cystoscopy
1. Visualize bladder and remove suspicious lesions

Incontinence
Micturition

1) M Agonist—Bethanechol: +M3, Contract Detrusor, Empty Bladder

1) M Antagonist—Oxybutynin: -M3, Relax Detrusor, Lower overactivity

2) Sympat—Mirabegron: +B3, Relax Detrusor, Increase Capacity
3) A Agonist—Midodrine: +a1, Contract IUS, Improve Stress Incontinence

3)A-blocker—Tamsulosin: -a1, Relax Bladder neck/Prostate, Lower obstruction

Normal Pressure Hydrocephalus: Lack of Detrusor Cortical Inhibition

Detrusor: M3 (parasympathetic), B3 (sympathetic)

Internal Urethral Sphincter: a1 (sympathetic)
External Urethral Sphincter: S2-S4 Pudendal (Sacral nicotinic) Voluntary

IV. 2 Incontinence
1. Stress: Outlet incompetence (urethral hypermobility) or intrinsic sphincter deficiency pudendal n.
1. Leak with Increase in Intrabdominal pressure
1. Vaginal Delivery: Pudendal nerve injury—> EUS damage
2. Obesity
3. Prostate Surgery
4. Postmenopausal: Decrease in Estrogen—> Weak pelvic floor
5. Levator Ani damage—> Pelvic organ prolapse = Cystocele, Urethral hypermobility
2. (+) Bladder Stress Test
3. Treatment
1. Pelvic floor muscle strengthening: Target Levator Ani muscles (Illiococygeus, Pubococ,
Puborectalis)
2. Alpha agonist Midodrine: Contract IUS
3. SNRI Duloxetine: Increase EUS activity
2. Urge: Overactive detrusor leak on the way to bathroom, Early MS
1. Uninhibited Bladder Contraction
2. Wet or Dry
3. Treatment
1. M3 antagonist: Oxybutynin, Toleradine, Solifenacin, Dicyclomine
2. B3 agonist Mirabegron (Myrbetriq)
3. Overflow: Underachieve detrusor or outlet obstruction
1. Diabetes, BPH
2. Neurogenic Bladder (late MS) post S2-S4 injury
3. MS Demyelination lesion before S1
4. Increased Postvoid residual on Catheterization or Ultrasound
1. Noctural enuresis
2. Dribbling—> Recurrent UTI
5. Treatment
1. Alpha blockers (BPH): Tamsulosin
2. M2 agonist: Bethanechol
4. Urethral Stricture
1. Urethral trauma (catheterization), Urethritis, Radiotherapy
2. S/S
1. Weak or spraying stream
2. Incomplete emptying
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3. Irritative voiding (dysuria, frequency)
3. Complications
1. Acute urine retention
2. Recurrent UTI
3. Bladder stones
4. Dx
1. Postvoid residual, uroflowmetry
2. Urethrography (voiding cystourethrogram)
3. Cystourethroscopy
5. Management: Dilation, Urethroplasty
Male Reproductive
1. Fournier Gangrene
1. Life-threatening necrotizing fasciitis that progresses to sepsis and possible death
2. Cutaneous breakdowns in perianal or genital region allow portal entry for polymicrobial colonic/urogenital organisms
3. Spreads along subq fat via fascial planes, results in micro thrombi of cutaneous vessels and leads to skin gangrene
4. Greater risk in poorly controlled diabetes mellitus and obesity
5. Emergent surgery; >20% patients die during hospitalization

TESTES
1. Layers: Skin, Dartos m, External Spermatic fascia, Cremasteric m, Internal Spermatic fascia, Tunica Vaginalis (visceral and parietal) [peritoneal layers carried from
abdomen]

2. Epididymitis
1. <35yo: Chlamydia, Gonorrhea
2. >35yo: Bladder outlet obstruction (coliform bacteria)
3. Presentation: Normal cremasteric reflex, relief with testicle elevation (Prehn sign), posterior testicular pain, unilateral
4. Dx: NAAT for Chlamydia/Gonorrhea, UA/Culture
5. Tx: Abx Ceftriaxone + Doxycycline or Levofloxacin (enteric)
3. Hydrocele
1. Fluid collection between parietal and visceral layers of tunica vaginalis
2. “Persistent patent processus vaginalis”
3. Tx: Incision and drainage
4. Orchitis
5. Torsion
1. Presentation: Absent cremasteric reflex, horizontal testicular lie with elevated testicle, pain with testicle elevation
2. Referred pain to abdomen (due to descend during development)
3. Intermittent torsion: prior episodes that resolve without intervention
4. Imaging: No blood flow on scrotal ultrasound with Doppler
1. Reactive hydrocele may be visible on US
2. Heterogenous echotexture indicates testicular necrosis
5. 80% untreated torsions develop into nonviable testicle within 12 hours
6. Varicocele
1. Primary (L-sided)
1. Pubertal: Compression of L Renal vein between SMA and Aorta; Incompetent venous valves
2. Soft, irregular mass that increases in size with standing and vasalva; “ropy mass”
3. Reassurance and observation
4. Secondary (R-sided
1. Prepubertal: Extrinsic compression of IVC; Venous thrombus
2. Soft, coiled, scrotal mass that does not compress while supine
3. Dx: Abdominal Ultrasound (Risk of Wilms tumor)
2. Complication: Increased risk for infertility
7. Cancer
1. AFB, B-hCG, LDH
2. Metastasis: Retroperitoneal lymph nodes, Mediastinum
3. Types
1. 95% Germ Cell:
1. Seminoma: Retain features of spermatogenesis (Possible B-hCG elevation)
2. Nonseminoma (B-hCG, +AFP): Partially differentiated
1. Embryonal carcinoma
2. Yolk sac (AFP)
3. Choriocarcinoma (B-hCG)
4. Teratoma
2. Sex cord-Stomal:
1. Leydig: Excessive Estrogen (gynecomastia) or Testosterone (Acne); Precocious puberty
1. Estrogen/Testosterone lead to FSH and LH suppression
2. Sertoli: Excessive Estrogen (gynecomastia)
4. Painless testicular mass, dull ache in lower abdomen
5. Workup: Bilateral scrotal US, Serum tumor markers, Radical Inguinal Orchiectomy

PROSTATE
1. BPH
1. Symptoms
1. Irritative: Urgency, Frequency, Nocturia
2. Obstructive: Incomplete emptying, weak stream, intermittent stream, straining
2. Complication: Recurrence post-TURP
1. Leftover prostate tissue enlarges under influence of androgens
2. Alpha-blockers, 5-alpha reductase-I, PDE5-I or repeat TURP
3. Complication: Acute Pyelonephritis
1. Periurethral prostatic enlargement impinges urethra and prevents complete bladder evacuation—> High post-void residual volume
2. This allows fecal flora that have contaminated urinary tract to proliferate rather than be removed in urine
3. Bacterial ascent to kidney causes pyelonephritis: fever, costovertebral angle tenderness, leukocytosis

2. Prostatitis
1. Fever, dysuria, swollen/tender prostate
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2. Caused by coliform (E.coli) bacteria that contaminated the urethra and entered prostate via intraprostatic urinary reflux
3. Tx: TMP-SMX or Fluoroquinolone
4. Chronic Prostatitis
1. Young or middle-aged men who smoke or are diabetic
2. Recurrent UTI, painful ejaculation, prostatic tenderness but normal prostate exam
3. Transient improvement of symptoms with short courses of antibiotics
4. 6wks of Fluoroquinolones for eradication
3. Cancer
1. RF: Advanced Age (>70)
2. Metastasis: Bone, Spina (via Batson plexus, valveless veins)

URETHRA
1. Posterior Urethral injury
1. High-riding prostate; blood at the meatus; inability to void (urethral discontinuity)
2. Associated: Pelvic fracture (adducted and IR leg, perineal bruising)
1. Abrupt upward shifting of bladder can lead to urethral tearing, commonly at bulbomembranous junction
3. Dx: Retrograde urethrogram, KUB xray
1. Xray of urethral tract following radiopaque contrast injection through meatus
2. Extravasation of contrast from urethra is diagnostic
3. Urethrography preceded before foley insertion to prevent partial urethral tear becoming complete laceration
4. Tx: Supra-pubic pathetic if necessary (avoid foley catheter)

PENIS
1. Penile Fracture
1. If there is urethral injury (blood at the meatus, dysuria, urinary retention)—> Retrograde Urethrography prior to surgery. If urethral injury is confirmed, urethra
repair also happens at time of surgery.
2. Peyronies Disease
1. Fibrosis of tunica albuginea (TGF-1 upregulation) restricts tissue expansion and flexibility during erections
2. Penile pain, curvature, dorsal nodules/plaques
3. Priapism
1. Erection
1. Is via parasympathetic-dilation of cavernous arteries, increased blood flow into corpora cavernous; however this
compresses emissary veins against tunica albuginea blocking blood outflow
2. Subsequent sympathetic stimulation constricts arterial inflow, induces cavernosal smooth muscle contraction and
blood exits corpora via emissary veins leading to detumescence
3. Persistent inflow or obstructed outflow leads to priapism
2. Causes
1. Autonomic dysfunction: Spinal cord injury
2. Altered blood viscosity: Sickle Cell Disease, Blood Dyscrasias (CML)
1. CML Hints: Hepatosplenomegaly suggests heme malignancy —> Order a Complete Blood Count
2. Sickle Cell: Aspiration of blood from corpora cavernosa, then intracavernous phenylephrine injection
1. Blood gas analysis reveals ischemic pattern with acidosis, hypoxemia and hypercarbia
3. Meds that alter autonomic/vascular tone: PDE-5 inhibitors, Trazodone, Cocaine
3. Treatment
1. Aspiration, irrigation
2. Intracorporal a1 agonist: Phenylephrine

Urology Peds
1. Posterior Urethral Valves
1. Bladder distention, decreased urine output, respiratory distress—due to OLIGOHYDRAMINOS AND LUNG HYPOPLASIA
2. Dx: Renal and bladder ultrasound and then voiding cystourethrogram
3. Tx: Bladder drainage, ablation of PUV

ORTHO
1. Compartment Syndrome Pain minimally relieved with opioids/analgesics
1. Features
1. (Early) Paresthesia
2. Pain: unrelieved by medication
3. Pressure: casts fit too tightly
4. Pallor
5. Pulselessness: uncommon
6. Poikilothermia
7. (Late) Paralysis: lost of motor activity
2. Causes
1. Ischemia-Reperfusion Syndrome
1. Following reperfusion of an acutely ischemic limb
2. “Calf pain after femoral artery embolectomy”
2. Full thickness burn can cause eschar formation that restricts venous and lymphatic drainage
3. Dx: Measuring Compartment Pressures
1. Delta pressure (Diastolic BP) <30mmhg
4. Tx: Fasciotomy or escharotomy

Bone Tumor
BENIGN
1. Giant Cell Tumor
1. Epiphysis
2. Local pain and swelling
3. Pulmonary metastasis and malignant transformation
4. Dx: Biopsy—multinucleated giant cells
5. Tx: Surgery, Denosumab (Ab against RANKL which is overexposed in stromal cells)
2. Osteoid Osteoma
1. Small, round lucency
2. Noctural pain relieved by NSAIDs
MALIGNANT
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1. Ewing Sarcoma
1. Osteolytic lesion with periosteal reaction that produces layers of reactive bone, “onion skin” appearance
2. Tender—Metaphysis: Osteosarcoma (13-16yo or >40yo previous bone damage)
1. Inherited genetic mutation to RB1 gene—Retinoblastoma and TP53 gene—Li Fraumeni Syndrome
2. Sunburst periosteal reaction “lytic lesion with ill-defined margins on femoral condyle, surrounded by concentric layers of reactive bone”
3. Alkaline phosphatase and lactate dehydrogenase elevated from turnover of damaged osteocytes
4. Older generation—Osteogenic sarcomatous transformation at sites of bone overgrowth (Paget’s disease)
1. “Medullary and cortical bone destruction, periosteal elevation”

OTHER
1. Myositis Ossificans
1. Formation of lamellar bone in extra-skeletal tissue (Heterotopic bone formation)
2. Intramuscular mobile mass with pain and swelling/induration days/weeks following trauma
1. Increased bone morphogenic proteins lead to in-migration of spindle stem cells that mature into fibroblasts, chondrocytes and osteocytes resulting in
cartilage and metaplastic bone formation
2. “Increased thigh circumference and decreased range of motion”
3. Most commonly in Quadriceps and Brachialis
4. Labs: Elevated Alkaline phosphatase, ESR, C-reactive protein
5. Xray: Periosteal bone reaction, calcification with radiolucent center
2. Osteitis Fibrosa Cystica
1. Advanced Hyperparathyroidism
2. Increased resorption in cortical bone with subperiosteal thinning and cystic degeneration

Ortho Neck/UE
Vascular Injury
Soft Signs: Diminished pulses, unexplained hypotension, stable hematoma Hard Signs: Distal limb ischemia, absent pules, active hemorrhage, bruit/thrill at injury site

1. Shoulder Pain Causes

1. Rotator Cuff Tendinopathy
1. Pain with Abduction or IR
2. Strength Preserved
3. Normal ROM with positive impingement tests (Neer, Hawkins)
4. Neer: Shoulder IR and forearm pronated
2. Rotator Cuff Tear (Similar RC Tendinopathy)
1. Weakness, sensory preserved
2. Shoulder pain and difficulty with abduction
3. Positive Drop arm test —> Supraspinatus most commonly injured
1. Degeneration of tendons with age and repeated ischemia due to impingement between humerus and acromion
2. Loss of smooth adduction near horizontal plane
4. Dx: MRI
3. Adhesive Capsulitis (Frozen Shoulder)
1. Contracture of Glenohumeral joint capsule
2. Decreased Active and Passive ROM in multiple planes
3. Muscle atrophy of shoulder in severe cases; pain and stiffness over numerous years
4. Management: Range of motion exercises, NSAIDs, Corticosteroids
4. AC Joint Sprain
1. Pain over AC joint
2. Passive Shoulder Abduction provokes pain
3. “Adduction across torso elicits pain over superior lateral shoulder”
4. Xray: Assess degree of sprain and evaluate for concomitant clavicular or humeral fracture
5. Biceps Tendinopathy
1. Pain over Bicipital Groove
2. Long head of Biceps Tendon rupture
1. Sudden pain, “pop”, visible bulge “Popeye sign” where muscle retracts not medial arm
6. Acute Glenohumeral dislocation
1. Displacement of humeral head in relation to coracoid process and glenoid
2. Increased risk of recurrent dislocation due to labral tears, ligamentous laxity due to overuse and multidirectional joint instability
3. Axillary nerve injury (teres minor and deltoid paralysis)—shoulder abduction weakness
7. Humeral Neck Fracture
1. Axillary Nerve injury—Deltoid paralysis (extreme extension), Teres Minor paralysis, Sensory loss over lateral upper arm
2. Bony tenderness, swelling, ecchymosis, crepitus over fracture
8. Long Thoracic Nerve Injury
1. Serratus Anterior—Extreme Abduction impairment (>90), unable to rotate scapula inward
2. Penetrating trauma or medical procedures (chest tube placement)
9. Lower Brachial Trunk Injury (C8-T1)
1. Klumpke Palsy: Sudden upward traction on the arm
2. Ulnar nerve distribution: Hypothenar and Interosseous muscles impaired, “Claw hand” deformity
2. Chronic Olecranon Bursitis
1. Synovial fluid accumulation within the bursa due to repetitive friction
2. Round, fluctuant swelling (not a hard mass)
3. Clavicle Fracture
1. Minor blunt chest trauma patients can have serious intrathoracic injury (subclavian vessel injury)
2. CT scan chest to evaluate for intrathoracic injuries
3. CT angiogram if soft signs of vascular injury; immediate surgery if hards signs
4. Subclavian Steal Syndrome
1. Subclavian artery stenosed proximal to Vertebral artery
2. Movement of affected UE causes reversal of blood flow from Vertebral a. —> Subclavian artery
3. Causes Vertebrobasilar Insufficiency: Dizziness, Vertigo, Imbalance
4. Dx: Measuring BP in both arms, >15mmHg difference confirms diagnosis
5. Upper Extremity Long bone fracture
1. Midshaft Fracture
1. Open reduction and surgical exploration: Open fractures, Neurovascular compromise, Significant displacement
2. Closed reduction with arm immobilization: Isolated mid shaft fracture treated nonsurgically
2. Buckle Fracture (children)
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1. Distal radius or ulna due to fall on outstretched hand; incomplete fracture
1. Cortices “buckle” without breaking and become displaced
2. Dx: Xray—Bulging of bony cortex
3. Heal within few weeks without complication
3. Supracondylar Humerus Fracture
1. Damage: Median nerve, Brachial artery
2. Complication: Compartment Syndrome—increased swelling and pain unresponsive to analgesics

Ortho Hand
1. Colles Fracture
1. Distal radius fracture
2. Acute Carpal Tunnel Syndrome
1. Median nerve compression: paresthesia of lateral 3 1/2 digits and impaired thumb abduction
3. Proximal to Tunnel—Palmar Cutaneous branch of Median nerve
1. Decreased sensation over anterolateral hand
2. Dupuytren Contracture
1. Progressive Palmar Fascia Fibrosis—puckering of skin and fibrotic nodule and cord formation along flexor tendons
2. Contractures limit Extension at MCP and PIP
3. Dx: Clinical, no imaging
3. Ganglion Cyst
1. Mobile, nontender swellings on dorsal surface of wrist
2. Dx: transillumination (no treatment required)
3. Tx: Observation
4. High-Pressure injection injury
1. Injected material can spread into hand and forearm, lead to tissue ischemia, necrosis and compartment syndrome
2. Due to high risk of amputation, surgical debridement and fasciotomy should be performed immediately
3. Complication: Compartment Syndrome

Ortho LE
1. Back Pain
1. Acute: <4 wks Meniscus
1. Moderate activity, NSAIDs or Acetaminophen
2. Subacute (4-12wks), Chronic (>12wks)
1. Intermittent NSAIDs/Acetaminophen
2. Exercise therapy
3. TCA or Duloxetine
3. Secondary prevention
1. Exercise therapy, Education
2. Knee: Audible “pop” diagnosis
Anterior Cruciate L: ACL Posterior Cruciate L Meniscal tear Medial Collateral L: MCL Lateral Collateral L

Presentation Twisting movement LE Hyperextension Pivoting on flexed knee Twisting

Rapid pain, swelling with Blow to Anterior Proximal with foot planted Blow to lateral knee
hemarthrosis Tibia (Valgus stress)

Exam Anterior translation of Little pain or ROM Mild effusion Swelling, Muscle spasm
tibia on femur alteration vs. ACrucLig Joint line tenderness Preserved ROM

Management MRI MRI

RICE +/- surgery

Pop Acute Pop Subacute or Chronic

locking or popping

Tests Anterior Drawer Thessaly (IR, ER) Valgus Test (apply

Lachman McMurray (Knee flexion) abduction force)
3. Knee Dislocation
1. Patellar Dislocation
1. Quick, lateral movement on flexed knee; Lateral dislocation is most common “large, immobile deformity”
2. RF: <20yo, Joint laxity, LE malalignment, Patellar subluxation
3. Exam: Reduced ROM, Lateral displacement of patella out of trochlea (depression at anterior knee)
4. Ankylosing Spondylitis
1. Relieved with exercise, not rest
2. Complications
1. Aortic regurgitation—> Compensatory eccentric hypertrophy
2. Enthesitis (tenderness at tendon insertion site)
3. HLA-B27; Xray of sacroiliac joint
5. Arthritis
1. Septic Arthritis
1. Acute knee pain, warmth, erythema, restricted ROM, >50K WBC
2. S. aureus: Vancomycin
1. Add broad-spectrum Abx (Ceftriaxone) if symptoms don’t improve with Vancomycin to cover Gram(-) joint pathogens like Kingella kingae
3. Management
1. IV Abx, drainage
2. Serial knee aspiration required to completely clear the infection
2. Osteoarthritis
1. Xray: Loss of normal joint space, periarticular osteophytes, sclerosis of acetabular surface
2. Initial Management: Wt loss, regular activity, topical/oral NSAIDs, Quadricep strengthening exercises
3. Severe cases: Total knee arthroplasty
3. Rheumatoid Arthritis
6. Bursitis
1. Tophaceous Gout (hard mass)
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1. Chronic inflammation in surrounding soft tissue and bones
2. Results in erosions and overhanging edges of cortical bone on imaging
2. Pes Anserinus Pain
1. Localized pain and tenderness over medial tibial condyle and just below the joint line
2. Can be due to abnormal gait, overuse or trauma
3. Management: Quadriceps strengthening and NSAIDs
3. Trochanteric Bursitis: Greater Trochanteric Pain Syndrome
1. Lateral hip pain and tenderness over grater trochanter during flexion
2. Dx: Xray to rule out hip joint pathology US: degeneration of tendons, tendinosis
3. Initially: Heat, Activity medication, NSAIDS
4. Persistent: Local CST injection
4. Septic Bursitis or Septic Arthritis
1. Prepatellar bursa
2. Due to superficial abrasions from working while kneeling
1. S. aureus; higher risk in immunocompromised (Diabetic)
3. Due to introduction of skin flora during joint or burial aspiration or injection
1. “Subacromial corticosteroid injection”, pain several days post-injection
2. Note: Steroid-induced chemical synovitis occurs rapidly and resolves within 48hrs
4. Imaged guided aspiration necessary to assess for infection (Xray useful in concurrent fracture)
5. Tx: Abx
7. Baker cyst
1. Excess fluid from OA or RA
2. Fluid extrusion from knee joint space into semimembranosus/gastrocemius bursa
3. Rupture “Crescent shaped patch of ecchymosis at medial malleolus and acute pain”
1. Tenderness at medial gastrocnemius
8. Knee Dislocation
1. Dashboard injury
2. Knee is swollen and grossly deformed
3. Posterior Dislocation
1. Measurement of ankle-brachial index necessary after stabilizing to asses for popliteal artery injury
2. Normal pulses and ABI >0.9 excludes clinically significant vascular injury
9. Hip Dislocation
1. Anterior
1. External Rotation (“leg fans out, toes point outward”) and Shortening of leg due to Psoas and Iliacus contraction
2. Posterior
1. Knee strikes dashboard while Hip is Flexed and Abducted
2. Leg is Internally Rotated, Shortened, Adducted
3. Sciatic Nerve injury
1. Sciatic: Weakness of Knee Flexion
2. Common Fibular: Weakness of Ankle Dorsiflexion
3. Tibial: Decreased Ankle Reflex
4. Arterial injury with Avascular necrosis of Femoral head (Osteonecrosis of the femoral head ONFH)
5. Management
1. Without fracture: Closed reduction
2. Fracture: Open/Operative reduction
10. Hip Fracture
1. Intracapsular: Femoral Neck Fracture
1. Elderly, hip pain after fall, External Rotation due to Psoas and Iliacus contraction
2. Femoral neck has thin periosteum and tenuous blood supply can be disrupted by injury
3. Xray: Shortened femoral neck, disruption of normal cortical contour, irregular lucency at fracture plane
4. Complications: Secondary instability, Malunion
5. Immediate Surgical repair
2. Intracapsular: Femoral Head Fracture
3. Extracapsular: Intertrochanteric Hip Fracture
1. Shortened and Externally Rotation of leg
4. Extracapsular: Subtrochanteric Hip Fracture
Note: Clear for surgical intervention in elderly with ECG, Cardiac markers, CXR, surgery may be delayed by 72hrs
11. Pelvis Fracture
1. Pelvic ring disruption can lead to life-threatening hemorrhage from vascular injury (thin-walled presacral or lumbar venous plexus) and cause expanded pelvic
volume and bleeding into retroperitoneum
2. Pelvic binder application can decrease pelvic volume and promote tamponade of bleeding
12. Neuoropathic pain due to Amputation
1. Multimodal pain regimen
2. Unrelated, innocuous triggers (urination, defecation)
3. Neuroma formation
1. Due to transection of nerve fibers; cause local pressure that can complicate fittings for amputational prosthetics
2. Tx: Excision
13. Osteomyelitis
1. Chronic osteomyelitis may cause fracture nonunion
1. Intermittent pain and swelling
2. Sinus tract formation—persistently draining wound
2. Management
1. Bone biopsy and surgical debridement
3. Complication: Chronic Diabetic foot
1. May be minimally symptomatic (Fever, pain, elevated ESR, sinus tract drainage)
2. If bone is palpated with a proper, risk of osteomyelitis is increased—> Biopsy and culture to confirm diagnosis
4. Complication: Plantar Puncture

14. Osteoporosis
1. Young or Middle-aged Man: Secondary Cause
1. Celiac Disease: Bone loss common due to Vitamin D malabsorption
2. Serum Ca, Vitamin D, Magnesium normal
1. However Low Vitamin D levels can cause Elevated PTH (=Hyperparathyroidism) in the presence of Normal Serum Calcium
15. Osteonecrosis (Avascular Necrosis)
1. Chronic groin pain worsened with activity and decreased ROM in Abduction and IR

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2. Disruption of bone vasculature:
1. Macro or Microvascular occlusion cause bone necrosis
2. Bone and bone marrow infarction leads to trabecular thinning and collapse of femoral head
3. RF
1. Femoral head fracture (arterial disruption)—> Posterior Hip Dislocation
2. Glucocorticoids
3. Excessive alcohol use: proportionate to amount and duration of use
4. Sickle Cell Disease
1. Normal findings on X-ray
2. Occlusion of end arteries supplying femoral head causes necrosis & collapse of periarticular bone and cartilage
5. Systemic Lupus Erythematosus
4. Dx
1. Xray (low sensitivity): subchondral sclerosis, loss of sphericity “flattening and patchy sclerosis” of femoral head
2. MRI: serpiginous low-intensity lines, bone marrow edema
16. Salter-Harris III Fracture (children)
1. Distal tibial epiphysis and lateral physis (growth plate) fracture; occurs in adolescents when physis is partially fused
2. Injury to growth plate can cause growth arrest and lead to persistent limb-length discrepancy
17. Shin Splints
1. Overweight, resemble stress fracture but diffuse area of tenderness
2. Medial tibial stress syndrome
18. Stress Fracture
1. Repetitive movement “dancer”
2. Female athlete triad: low caloric intake, hypomenorrhea/amenorrhea, low bone density
3. Point tenderness at fracture site, “hairline fracture”
4. Possible negative xray frist 6wks
5. 2nd-4th metatarsal fracture management: Rest and Analgesics

Ortho Foot
1. Heel Pain differential diagnosis
1. Plantar fasciitis—medial plantar heel, worse with dorsiflexion
1. Maximum pain in morning—inflammation and degeneration of plantar aponeurosis
1. Chronic overuse and repetitive micro trauma to aponeurosis and its insertion point at calcaneus
2. Heel spurs—calcifications in proximal plantar fascia (not sensitive or specific)
3. Tenderness at insertion of plantar fascia at calcaneus = anteromedial heel
2. “Direct pressure to bottom of heal elicits pain”
3. Tx: Heel inserts
2. Achilles tendinopathy—posterior pain
1. Swelling and tenderness proximal to tendon insertion
1. Positive Thompson test/Calf squeeze test: Absence of plantarflexion
2. Complete rupture leads to impaired ability to walk on tips of the toes
3. Calcaneal stress fracture—medial/lateral squeezing of calcaneus, overuse injury to bone
1. Worse with activity
2. Dx: Xray or MRI
4. Tarsal tunnel syndrome—posterior tibial nerve in tarsal tunnel
1. Pain, paresthesia and numbness of sole of the foot
2. (+) Tinel sign
2. Ankle Trauma
1. Xray ankle: tenderness posterior margin or tip of medial/lateral malleolus, unable bear weight 4 steps
2. Xray foot: tenderness navicular, 5th metatarsal base, unable bear weight 4 steps
3. Brace
1. Anterior Talofibular ligament: tenderness distal to lateral malleolus
1. Lateral ankle sprain due to inversion, imaging not necessary
3. Charcot Joint (Neurogenic arthropathy)
1. Diabetic Neuropathy, Peripheral Neuropathy (B12 deficiency), SC injury, Syringomyelia, Tabes Dorsalis
2. Abnormal LE sensation and proprioception—altered weight bearing, mechanical stresses, recurrent trauma
3. Exam: Foot deformity due to Nerve damage
4. Xray: Bone destruction, osteophyte formation and loss of joint spaces Findings similar to Osteoarthritis

Ortho Peds UE
1. Greenstick Fracture
1. Common due to strong periosteum which limits fracture line extending through width of bone
2. Tx: Immobilization to prevent refracture, no long-term complications expected
2. Radial Head Subluxation
1. Arm held Extended and Pronated
2. Tx: Hyperpronation or Supination of forearm and flexion of elbow

Ortho Peds LE
1. Legg-Calve-Perthes Disease (idiopathic necrosis of femur)
1. Decreased Abduction and IR
2. Antalgic gait: avoid weight bearing on affected side due to pain
3. Diagnosis requires high index of suspicion; initial X-rays may be normal
4. Sclerosis of femoral head with flattening and fragmentation
5. Atrophy of quadriceps and gluteal muscles
1. Positive Trendenlenburg signs
6. Tx: Avoid weight bearing activities and splinting or surgery
2. Osgood-Schlatter Disease (osteochondritis of tibial tubercle)
1. Chronic anterior knee pain; tenderness over tibial tubercle
2. Inflammation and fragmentation of tibial tubercle
3. Slipped Capital Femoral Epiphysis
1. Chronic, progressive pain of hip, groin or knee; worse with activity; obese pre-teen/teen
2. Decreased Abduction and IR (externally rotated foot)
3. Atrophy of quadriceps and gluteal muscles
1. Positive Trendenlenburg signs
4. Bilateral Hip Xray
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5. Dx: Anterolateral and Superior displacement of epiphysis from metaphysis confirms diagnosis
1. Excessive shearing at growth plate (proximal femoral epiphysis) weakens growth and gives appearance of posteriorly displaced femoral head
4. Transient Synovitis
1. Children 3-8yr, self-limiting inflammatory hip condition
2. Limp, Hip pain, Pain referred to knee
3. Small, bilateral hip effusions
5. Tibial Shaft Fractures
1. Toddler’s fractures <3yo; following twisting motion during minor fall
2. Pain, Limp and refusal to bear wight
3. Hairline fracture
4. No additional workup needed besides limb immobilization and pain control

Medial Temporal Lobe Sclerosis

Random Hints:
Fever, Leukocytosis, Costovertebral angle tenderness —> Acute Pyelonephritis
Fever, Leukocytosis, LLQ pain —> Diverticulitis —> CT

Hypotension, Tachycardia —> Shock signs

Hypertension, Bradycardia, Irregular respiration —> Cushing Triad of Elevated ICP

Atherosclerosis, Leukocytosis, Lactic acidosis —> Mesenteric ischemia —> Celiotomy (Surgical incision of abdomen)

Rule out Esophagus cancer (Solid dysphagia, >50yo, Smoker) —> EGD
Rule out Colon cancer —> Colonoscopy
CT for staging

GB Disease
Normal ALT/AST: Rule out Liver Disease
No Wt loss/Painless Jaundice: Rule out Pancreatic Cancer

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