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147 Cards in this Set

  • Front
  • Back
Basal Skull Fx Work Up
CT if in coma
C-Spine Injury!
nothing to do about fx
A man involved in a high-speed, head-on automobile collision is in coma. He has never had any lateralizing signs, and CT scan shows a small crescent- shaped hematoma, but there is no deviation of the midline structures.
Another subdural hematoma, but without lateralizing signs and evidence of displacement of the midline structures, surgery has little to offer. Management will probably be directed at controlling ICP
Penetrating wounds anywhere in the neck w/ unstable patient
immediate ex lap
Zone I of the neck
Thoracic Inlet to Cricoid Cartilage
Subclavian vessels, brachiocephalic veins, common carotid arteries, aortic arch, and jugular veins, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve roots.
Zone II of the neck
Cricoid cartilage to the angle of the mandible.
Carotid and vertebral arteries, jugular veins, pharynx, larynx, trachea, esophagus, and cervical spine and spinal cord.
Zone III of the neck
A angle of the mandible and the base of the skull.
salivary and parotid glands, esophagus, trachea, vertebral bodies, carotid arteries, jugular veins, and major nerves (including cranial nerves IX-XII), traverse this zone
Flail Chest. Next Step
1. R/O other injuries - abdominal and aortic rupture (CXR)
2. Pulmonary Contusion real problem. Monitor w/ ABG & support if needed - w/ b/l chest tubes if tubed (even in OR)
3. Don't need to stabalize flail portion
Pulonary Contusion Managment
1. Fluid restriction (using colloid), diuretics
2. Respiratory support. intubation, mechanical ventilation, and PEEP PRN
Aortic Rupture Next Step
1. CXR w/ wide mediastinum
2. Spiral CT
3. Aortogram if equivical
Air Embolism Managment
1. Cardiac Massage
2. Trendelenburg
3. Thoractomy
Posterior Urethral Injuries
Repair in 6 months
Anterior Urethral Injuries
Immediate Repair
Scrotal Hematoma Next Step
U/S for ruptured testicle
Crush Injury things to think about (2)
1. Rhabdo - diuresis, alkalinize
2. Compartment Syndrome - fasciotomy
Brown Recluse Spider
dabsone
Osteomyalities
BONE SCAN. x-rays take weeks to show. then abx
Varum (bow legs) after age 3
Blouts
Posterior Dislocation of Shoulder X-rays to order
axillary view or scapular lateral.
Hip Fracture
DVT/PE! Anticoagulate after surgery
Posterior Dislocation of the Hip
emergency because avascular necrosis
Carpul Tunnel Next Steps
1. wrist xrays to r/o other things
2. splints & antiinflammatories
De Quervain tenosynovitis
splints & antiinflammatories
Dupuytren contracture
contracted hand that can no longer be extended, Palmar fascia1 nodules
Felon
infection in pulp of finger. like a compartment syndrome
Gamekeepers Thumb
ulnar collateral ligament of the thumb. cast
When she makes a fist now, the distal phalanx of her ring finger does not flex with the others.
jersey finger (to the flexor),Splinting
Mallot Finger
Injury to extensor tendon. can't extend distal phalanx.
splint
Gout
Acute - indomethacin and colchicine.
Chronic- allopurinol or probenecid.
Post - op Confusion Next Steps
1. Hypoxia - ABG
2. Metabolic
3. DTs esp if 3-5 dys out
ARDS next steps
PEEP, allowing significant
hypercapnia, to minimize barotrauma.
R/O sepsis
Low UO post op
Urinary Na -
Dehydrated < 10-20 mEq
Kidney Damage > 40 meq
or FeNa in renal failure >1
SCC of anus
Biopsy & Nigro Protocol
LGI Bleed
> 2mL/min (1 U every 4 hours) angiogram
<0.5 ml/min colonoscopy
Tagged RBC in between
LGI Bleed w/o
1. r/o UGI Bleed w/ NGT
2. Hemorrhoids
3. RBC study if offered
Old melena no longer bleeding
NGT unhelpful do upper and lower endoscopies (most likely upper)
Chronic Pancreatitis if forced to pick test
ERCP
Ductal Carcinoma in situ on breast biopsy
No axillary sampling
lumpectomy + XRT or simple total mastectomy if multicentric lesions
Positive SLN or axilary dissection
Chemotherapy if young
Hormonal if old
Hot thyroid adenoma
Confirm hyperthyroidism by measuring free thyroxine (T4) or thyrotropin (TSH).Confirm source of the excessive hormone with radioactive iodine scan. Do surgery after beta-blocking.
High Ca / Low PO4 on test
1. PTH
2. sestamibi
Hyperaldosteronism
1. Renin: Aldo
Hyperplasia - appropriate response to postural changes (not surgical - aldactone)
Adenoma - no response to postural changes (Ct or MRI then surgery)
Coartation of Aorta W/U
Chest XRAY - scalloping of ribs
HTN 2/2 fibromuscular dysplasia rx
w/up with duplex or aortogram
since usually young
balloon dilation with stenting or surgery
Malrotation Presentation
DOuble bubble wtih normal gas pattern distal
Malrotation W/up
contrast enema or upper GI study (more reliable)
NEC
stop all feedings
broad abx
IVF and nutrition
Surgery if - abd erythema, pneumobilia, pneumoperitoneum
Biliary Atresia W/up
HIDA scan after 1 week of phenobarb
surgery
Orbital Cellulitis w/up
CT scan to assess exten with drainage
Sistrunk Operation
Thyroglossal duct cyst. Remove mass and track with medial segment of hyoid and some of tongue cecum
Unilateral Hearing Loss (adult)
Sensioneural assume aoustic neuroma and look for tumor w/ MRI
(if kid think foreign body)
Bell's
antivirals ?immediatly +/- steriods
A 72-year-old, hypertensive man, on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220 over 115 when seen in the ER. He says he began swallowing blood before it began to come out through the front of his nose.
epistaxis secondary to hypertension
Medical treatment to lower the blood pressure, but getting the ENT people there right away should also be part of the equation. Posterior packing is needed, emergency arterial ligation may be required.
A 57-year-old man seeks help for "dizziness." On further questioning he explains that he gets light-headed and unsteady, but the room is not spinning around.
Neurologic, probably vascular occlusive- but not inner ear. Direct your manage- ment and workup in that direction.
Prolactinoma
r/o pregnancy and hypothyroid
measure PrL
MRI
Bromocriptine or surgery if want baby or non responsive
Acromegaly
Somatomedin C/IGF1 determination (production stimulated by GH)
MRI
surgery or radiation
Pituitary Aproplexy Rx
Steroid Replacement
MRI or CT
A business executive who has been a T6 paraplegic for many years is held at a business meeting for several hours beyond the time when he would normally have done his in-and-out self catheterization of the urinary bladder. He develops a pounding headache, profuse perspiration, and bradycardia. His blood pressure is 220 over 120.
autonomic dysreflexia. Obviously his bladder needs to be emptied, but he also needs alpha-adrenergic blocking agents and may benefit from calcium-channel blockers (such as nifedipine).
Trigeminal Neuralgia
r/o organic lesions with MRI
Rx with anticonvulsants
UTI in a guy work up
DO NOT start with cystoscopy
start w/ IVP or US
IVP
don't do if renal function
first test for blood in pee
Bladder Cancer
IVP then cystoscopy
Contraindications to shock wave lithotripsy
pregnancy, bleeding issues, too big stones (cm)
Electrical Burns things to watch for
myoglobinuria
compartment syndrome
demylinating dx and cateracts
resperatory infections (after capillary damage)
Duodenal Hematoma
Coiled spring on upper GI
treat with observation.
drain if in there for another reason or obstructed > 2wks
Transfusion Reaction
stop transfusion
alkanize urine
fluids and mannitol
Transudate
pressure filtration with NORMAL capillary permeability
Exudate
inflammatory leaking b/c increased cap permealibity (exudata ~water)
Cardiogenic Shock
dobutamine
Neurogenic Shock
IVF then dopamine or phenylephrine
Septic Shock
ealry abx
norepi
Black Widow Spider
N/V, cramps
Ca glutamate +/- muscle relaxants
Brown Recluse Spider
skin ulcer w/ necrosis
Dapsone +/- surgerical excision
loss of ileum can lead to
increased oxalate (hyperabsorbed by colon)
von willibrand's treatment
CRYO to give back vWF
refeeding syndrome lytes
low PO4, Mg, K (insulin causes shift into cells)
Acute adrenal insufficiency
low glucose, K
change in MS, fever, CV collapse
rx - dex!
Partial Gastrectomy + Billroth 2 nutrition changes
low Ca
steatorrhea
low B12
low Fe
Descending aortic dissection
b blocker + nitroprusside
surgery if end organ failure
chylothorax
low fat diet + drainage. if >500cc /day OR for ligation
Pheo blockade order
alpha first (1-3 wks preop) then beta
vWD work up
PTT MAYBE prolonged
increased bleeding time w/ nl platelet count
decreased ristocetin induced platelet aggregation
vWD treatment
DDAVP and F8 concentration
Low pitched Diastolic Rumble
Mitral Stenosis
harsh crescendo-decresendo systolic @ right 2 IC space
loader with squatting
softer w/ val salva
parvus et tardus
Aortic Stenosis
Diastolic decrescendo @ lft sternal border
Aortic Regurg
also waterhammer pulse and wide pulse pressure
Holosystolic at apex radiates to axilla w/ LAE
mitral regurg
midsystolic or late systolic clicks or murmur increased with valsalva and handgrip, softer with squatting
mitral prolapse
Anterior Mediastinal Mass
thymoma
lymphoma
teratoma
Middle Mediastinal Mass
bronchogenic cyst
pericardial cyst
Posterior Mediastinal Mass
neurogenic tumor
anti mitochrondrial antibodies
Primary biliary cirrhosis
fatigue and puritis
treat with urso
toxic megacolon rx
high dose roids and IV Abx
malignant hyperthermia rx
dantrolene& Ca if high K
Paget's Disease of bone
high Alk Phos
think arthritis, hearing loss, kidney stones, vision loss
Femoral n.
knee extension and hip flexion
Tibeal n.
knee flextion, planter flextion, digis
Obturator n.
adduction thigh
Fibular/Common Peraneal n.
divides into superficial and deep peroneal n.
ant and lateral leg muscles
Watery Diarrhea
Dehydration
Hypokalemia
Achlorhydia
VIPoma = Verner-Morrison Syn
rx octreotide then surgery
Human Bite
washout by orthO!
Low Ca EKG
long QT
MEN 1 gene
RENIN
MEN 2 gene
Ret
Elderly Clotting
Cancer
Edema HTN Foamy Pee
Nephrotic Syndrome
Young person clotting w/ FHx
Factor V Leiden
Antithrombin 3 Deficiency
Heparin not work
Post - op
Low platelets and clots
HIT
Rx - Lepirudin (direct thrombin inhibitor) or argatroban (direct thrombin inhibitor)
Isolated platelet drop
ITP
NOrmal plates w/ increased bleeding time & PTT
vWD
Low platelets, increased PT,PTT, BT, and D-dimers. Can see schistocytes
DIC
Gram - sepsis, carcinomatosis, OB stuff
Silver Sulfadiazine
doesn't penetrate eschar
leukopenia
Mafenide
penetrates eschar
hurts
Silver Nitrate
Doesn't penetrate eschar
hypoK
hypoNa
Electrical Burn 1st STEP
EKG
Handlebar Sign
Pancreatic Rupture
Malignant Hyperthermia
Dantrolene
Random causes of post-op fever to watch for
Thyrotoxicosis
Thrombophlebitis
Adrenal Insufficiency
Lymphangitis
Sepsis
Transudative Pleural Effusion Causes
CHF
Nephrotic
Cirrhotic
Pleural Effusion w/ low glu
RA
Pleural Effusion w/ high lymphocytes
TB
Pleural Effusion w/ blood
Malignant or Pulmonary Embolus
Exudative Pleural Effusion Causes
parapneumonic, cancer
Transudative Effusion If...(light's)
LDH<200
LDF effusion:serum <0.6
Protein effusion:serum<0.5
Lung Abscess
2/2 aspiration
1. PCN or clinda
surgery if abx fail, abscess >6cm, empyema
Paraneoplastic Syn from Lung CA
SCC
PTH-rp --> low PO4 high Ca
Pt w/ ptosis better after 1 min of upward gaze
Lambert Eaton from small cell CA
SIADH
small cell
rx fluid restiction
Peripheral cavitation and distant mets
LARGE cell CA
ARDS
PaO2/FiO2 < 200
Bilateral infiltrates on CXR
PCWP <18
HOCM
systolic louder w/ valsalva softer w/ squatting or handgrip
ASD
wide fixed and split S2
Mitral Stenosis
rumbiling diastolic w/ opening snap
LAE and Afib
Aortic Regurg
blowing diastolic w/ wide pulse pressure
aymptomatic varices
b blocker
ZE Syndrome w/up
Secretin stim test (inapropp high gastrin)
AST = 2x ALT
EtOH Hepatitis
AST>ALT in high 1000s
viral hepatitis
AST and ALT high s/p hemorrhage, surgery or sepsis
shock liver
Post splenectomy thrombocytosis > 1mil Rx?
ASA
perfed appy bugs to cover
E Coli
Bacteroides
SBO First Test
CXR for free air
Diverticulitis W/UP
CT for abscess
NO Barium Enema and NO scope
do colonoscopy 4-6 wks later
surgery if old, multiple episodes
Rectal Cancer
upper/mid 1/3 - LAR
lower 1/3 - APR
Laryngeal Cancer
Kids - laryngeal papilloma
Adults - SCC
Neonate not passing meconium dx (2!)
Meconium ileus
HIRSCHSPRUNG's
Occlusive Mesenteric Ischemia Rx
heparin
glucagon
intraarterial papavarine
laporotomy to remove clot