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122 Cards in this Set

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When is a gun shot wound ASSUMED to involve both the thoracic and peritoneal cavity?
Any penetrating injury below the level of the nipples has great potential to involve the abdomen through the diaphragm and is assumed to involve both cavities until proven otherwise.

This requires an exploratory laparotomy in UNstable patients. A focused assessment with sonography for trauma (FAST) can be done prior to laparotomy bc it has a high sensitivity and specificity for detecting hemoperitoneum, pericardial effusion, and intraperitoneal fluid.
What should be suspected in a motorcycle accident pt that presents with blood at the urethral meatus, a HIGH riding prostate, scrotal hematoma, INability to void despite sensing an urge to void, and a palpably distended bladder?
posterior urethral (consists of the prostatic and membranous urethra) injury - commonly associated with fractures of the pelvis.
How may an anterior urethral injury present?
After blunt trauma to the perineum (saddle injuries) or instrumentation of the urethra. Findings may include perineal tenderness or hematoma, a NORMAL prostate and bleeding from the urethra. Patients may NOT complain of inability to urinate and delayed presentations may be complicated by sepsis secondary to extravasation of urine into the scrotum, perineum, and/or abdominal wall.
Why should a pregnancy test be performed in any woman of childbearing age before ordering diagnostic tests such as X-rays or CT scans?
Due to fetal exposure of ionizing radiation. During the first 14 dyas after conception, it can cause death of the fetus or the UNdamaged survival. After the first 14 days of conception, it can lead to developmental defects but usually not death.
Classic presentation of intraductal papilloma?
intermittent bloody discharge from ONE nipple - this is a benign breast disease in which masses are generally not appreciated as the abnormality is small, soft, and located directly beneath the nipple.
Most characteristic finding in Paget's dz of the breast?
eczematous changes of the nipple.

note: discharge from the nipple can also occur.
What is Ludwig's angina?
An infection of the submandibular and sublingual glands classically arising from an infected 2nd/3rd mandibular molar. Organisms usually include Streptococcus and anaerobes (anaerobes may cuase crepitus due to gas formation).

Note: Asphyxiation is the most common cause of death so monitor pts for respiratory difficulty and intubate if necessary.

ABX and removal of infected tooth is treatment of choice.
ALL hemodynamically UNstable pts with penetrating ABDOMINAL trauma must undergo _________?
immediate exploratory laparotomy to diagnose and treat the source of bleeding as wel as diagnose and treat perforation of any abdominal viscus in an effort to prevent sepsis.

Note: This should NOT be delayed for a focused trauma whereas FAST can be done before laparotomy in cases of penetrating thoracic trauma below the level of the nipple.
What are the first and second most likely organ to be damaged in blunt abdominal trauma?
1st - spleen
2nd - liver
Evaluation of palpable breast abnormalities in pts under the age of 30 years?
ultrasound
Evaluation of palpable breast abnormalities in pts over the age of 30 years?
ultrasound AND mammogram.
When to perform needle aspiration vs. core biopsy of a breast mass?
1) AFTER imaging to find suspicion of malignancy
2) needle aspiration in woman under the age of 30 with a SIMPLE cyst.
3) all other masses suspicious for malignancy require a core biopsy.
Appropriate management for hemodynamically UNstable victim of a MVC with suspected BLUNT abdominal trauma?
cervical spine immobilization, IV hydration, FAST, and a positive FAST is indication for urgent laparotomy.
Up to 50% of postgastrectomy pts may experience this complication?
dumping syndrome - rapid emptying of hypERtonic gastric content into the duodenum and small intestine leading to the fluid shift from intravascular space to the small intestine, release of intestinal vasoactive polypeptides, and stimulation of autonomic reflexes.
Treatment for dumping syndrome?
Initially dietary modifications are helpful to control symptoms and problem diminishes over time. In resistant cases, ocreotide (a somatostatin analogue) should be tried. Reconstructive surgery is reserved for intractable cases.
What is nursemaid elbow?
Common injury amont preschool children that is the result of subluxation of head of radius at elbow joint. Injury can occur innocently from swinging a young child by the arms or pulling a child's arm while in a hurry. Children are usually NOT in distress at presentation but would cry at any attempt to flex the elbow or supinate the forearm.

Treatment of choice is a closed reducton by flexion and supination of the forearm.
Classic presentation of biliary colic (2dry to gallstones)?
Pain exacerbated by fatty meals that resolves completely btn episodes. Fever and leukocytosis are NOT present.

Note: occurs when gallbladder becomes distended as it contracts against an obstructed cystic duct. subsequent gallbladder relaxation allows the stone to fall back from the duct causing the pain to resolve completely.
Suspect what in a pt with a fleshy immobile mass on the midline of the hard palate?
torus palatinus - no medical or surgical therapy needed unless growth becomes symptomatic or interferes with speech or eating.
What are clues to a meniscal tear versus a ligamentous tear of the knee?
Both are often associated with a distinctly recalled acute knee injury and a "popping" sensation. Subsequent joint swelling develops GRADUALLY often not noticed until 24 hours later in meniscal tears. In contrast, rapid joint swelling due to hemarthrosis is common in ligamentous tears (bc ligaments ahve a greater vascular supply).
Most appropriate next step in management of a pt suspected to have a tension pneumothorax?
needle thoracostomy (even before a CT scan of the chest and fluid resuscitation).
Difference btn diverticulosis and diverticulits?
diverticulosis - painLESS bleeding

diverticulitis - abdominal pain and infectious symptoms but NO bleeding
Test of choice to evaluate suspected esophageal perforation?
water-soluble contrast esophagram - preferred over barium since barium tends to induce a granulomatous response. However, a leak can be difficult to see with water-soluble contrast, so a small amount of diluted barium might be needed to diagnose perforation, usually withOUT ill consequence.

If perforation is present - primary closure of esophagus and drainage of mediastinum must be attmepted within 6 hours to prevent development of mediastinitis.
What does a CXR frequently demonstrate in suspected esophageal perforation?
pleural effusion, pneumomediastinum, and/or pneumothorax.
What should be suspected with a triad of bilateral hip/thigh/buttock claudication, impotence and symmetric atrophy of the bilateral lower extremities?
Aortoiliac occlusion (Leriche syndrome) due to chronic ischemia.

Note: in the absence of impotence, an alternate diagnosis should be sought. Men with a predisposition for atherosclerosis such as smokers are at the greatest risk of this condition.
Assessment of the ______ is important when attempting to wean pts from mechanical ventilation, especially in patients with preexisting lung disease.
Respiratory quotient (RQ) to determine if there is overfeeding with carbohydrates leading to excessive CO2 production. This can make weaning off mechanical ventilation more challenging.

Note: a steady state RQ close to 1.0 indicates predominant oxidation of carbohydrates and net lipogenesis. The RQ for protein and lipid as sole sources of energy are 0.8 and 0.7, respectively.
Characterized by avascular necrosis of the femoral head and typically presents in children 4-10 years of age with insidious-onset hip or knee pain and an antalgic gait (limping)?
Legg Calves Perthes dz - idiopathic in nature. PE shows marked limitation of internal rotation and ABduction at the hip joint.

Treatment is aimed at maintaining placement of the femoral head within the acetabulum so that it may heal in the proper shape and position. This can be accomplished with splints or surgery.
How can diagnosis of a fat embolism be confirmed?
presence of fat droplets in urine or presence of intra-arterial fat globules on fundoscopy.
What may be needed after decompression with needle thoracostomy of a tension pneumothorax?
Subsequent tube thoracostomy to maintain lung expansion.

In a pt who remains hemodynamically UNstable, suspect pericardial tamponade.
Suspect what if a CT brain scan shows numerous minute punctate hemorrhages with blurring of grey-white interface?
diffuse axonal injury - clinical features are out of proportion to CT findings. Pt loses consciousness instantaneously and later develops persistent vegetative state.
What is required after central line placement and why?
CXR confirmation of catheter tip location after placement and absence of iatrogenic pneumothorax and hemothorax - complications occur in 1-5% of cases.

The catheter tip should lie in the superior vena cava so should be located PROXIMAL to the cardiac silhouette or proximal to the angle btn the trachea and the right mainstem bronchus.
When is a CT brain scan withOUT hospitalization for frequent neurologic examinations in a patient that presents with mild traumatic brain injury adequate?
in mild-to-moderate traumatic brain injury where there are NO focal neurological signs, seizure, prolonged loss of consciousness, and evident skull fracture.
The femoral nerve innervates:
the MUSCLES responsible for knee extension and hip flexion. SENSATION to the ANTERIOR THIGH and MEDIAL LEG (via the saphenous branch).
The obturator nerve innervates:
Muscles that control ADDuction of the thigh and SENSATION to MEDIAL thigh.
The common peroneal (superficial and deep peroneal) nerve innervates:
Muscles of the anterior and lateral LEG and SENSATION to the anterolateral LEG and DORSUM of foot.
Following a splenectomy, pts should be vaccinated against?
S. pneumoniae, N. meningitidis, and H. influenzae. Pneumococcal vaccine requires boosters every 5 years.
FE Na < 1 indicates?
pre-renal azotemia
FE Na > 1 indicates?
intrinsic renal disease
BUN/Cr > 20:1 indicates?
pre renal azotemia
Next step in management of a post-op pt in suspected acute pre-renal failure from hypovolemia (oliguria, azotemia, and elev BUN/Cr)?
1) R/o urinary catheter obstruction
2) IV fluid challenge
What should be suspected in a pt with hypOtension and a pulsatile abdominal mass?

What is the management?
Ruptured abdominal aoritc aneurysm unless proven otherwise.

No imaging studies are indicated. Immediately begin laparotomy for repair of aneurysm.
Hypoxemia, respiratory ALKALOSIS, and abnormal CXR within the first 48 hours of surgery is usually due to ___________
post-operative atelectasis
Atelectasis of the right lower lobe will appear on CXR as ___________?
a triangular opacity with the medial aspect pressing against the right heart border and obscuring the pulmonary artery - bc with collapse it retracts inferiorly and medially.
Most effective prevention for post-operative pulmonary complications including atelectasis?
post-op breathing exercises, incentive spirometry, and forced expiration techniques.
Reversal of warfarin anticoagulation can be RAPIDLY achieved using?
fresh frozen plasma which restores the vitamin K-dependent clotting factors.

note: vitamin K administration for reversal is not appropriate in emergency situations because it depends on the SYNTHESIS of new vitamin K-dependent clotting factors by the liver which takes time.
Platelet counts of _________ provide adequate hemostasis for most invasive procedures.
> 50,000/mm3
Most common peripheral artery aneurysm?
popliteal and femoral artery - can compress adjacent structures (nerves, veins), and can result in thrombosis and ischemia. They are frequently associated with abdominal aortic aneurysms.
What should be suspected in a pt with spastic lower extremity paraplegia, pelvic organ dysfunction, and loss of temperature and pain sensation over the lower extremities but preservation of vibratory and proprioceptive sensation AFTER abdominal aortic surgery?
anterolateral spinal cord ischemia due to diminished flow in the artery of Adamkiewicz (arising from the aorta). Vibratory and proprioceptive sensation remains intact bc posterior circulation of the spinal cord is not affected.
What should be suspected in a pt that holds their arm ADducted and internally rotated after a tonic-clonic sizure?
posterior dislocation of the shoulder (glenohumeral joint).

Management is closed reduction.
Mechanism of compartment syndrome?
Caused by direct trauma (hemorrhage), prolonged compression of an extremity or after revascularization of an acutely ischemic limb.

Muscles of extremities are encased in fascial compartments that do not allow for expanion of tissue. Hemorrhage/edema within these muscles causes increased pressure within the non-distensible fascial compartment and interferes with perfusion by disallowing passage of blood from the arterial system into the capillary beds of affected muscles. This eventually leads to necrosis.
Typical presentation of compartment syndrome and treatment?
severe pain, pain with passive range of motion, paresthesias as well as pallor and paresis of the affected limb. The presence of pulses does not rule out compartment syndrome.

Fasciotomy is the treatment and must be done urgently.
How can pressures in compartment syndrome be measured?
Using a needle and pressure transducing catheter system. Pressures over 30mmHg result in cessation of blood flow through the capillaries and need emergent fasciotomy.
The 5 W's:
Refer to common causes of post-operative fever (pneumonia, UTI, DVT, wound infection, and meds called "drug fever".

Wind (1-2 days postop)
Water (3-5 days postop)
Walking (4-6 days postop)
Wound (5-7 days postop)
Wonder drugs (>7 days)
organisms commonly involved in femoral catheter bacteremia?
cutaneous organisms such as staph but also gram-NEG enteric organisms.
Treatment for Acalculous cholecystitis in a critically ill pt?
antibiotics followed by percutaneous cholecystOStOMY under radiographic guidance. CholecystECTOMY with drainage should follow when medical condition stabilizes.

Dx is confirmed via imaging studies that show gallbladder distention, gall bladder wall thickening, and the presence of pericholecystic fluid.
What should be suspected in a pt with acute onset nausea, vomiting, abdominal pain, hypOglycemia, and hypOtension after a stressful event (e.g. surgical procedure) who is steroid-dependent?
adrenal insufficiency
Typical presentation of osteosarcoma (most common primary malignancy of bone.)
Usually presents during the second decade of life. Pt complains of persistent bone pain that may be worse at night but do NOT have systemic symptoms. Pain typically begins AFTER trauma. The ESR is normal while the serum ALP is ELEV. XR shows a destructive lesion and periosteal new bone formation with periosteal elevation (Codman's triangle). A spiculated "sunburst" pattern within the tumor may also be seen on XR.

Note: Ewing's is usually WITH systemic features such as fever, malaise, and weight loss. XR shows osteolytic lesion with onion-skin appearance.
What is anterior cord syndrome?
Associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of the lesion with loss of pain and temperature on both sides but INTACT proprioception.
What is central cord syndrome?
characterized by burning pain and paralysis in the UPPER extremities with relative SPARING of LOWER extremities. Commonly seen in elderly 2dry to forced hyperextension type of injury to the neck.
What is Brown Sequard Syndrome?
acute hemisection of cord and is characterized by IPSILATeral motoer AND proprioception loss and CONTRAlateral loss of pain all below the level of the lesion.
Suspect what with severe radicular pain with positive straight leg raising?
acute disk prolapse
What complicates 30-75% of cases of severe blunt chest trauma but may not become clinically evident immediately following an injury and often has initial radiographic studies that may be negative?
pulmonary contusion that causes direct physical injury to the underlying pulmonary parenchyma - pts typically develop hypoxia (driving hyperventilaiton) and respiratory distress hours later as pulmonary edema sets in. Administration of large volumes of IV fluid may hasten this process (i.e. hypoxemia worsened by intravascular volume expansion). CXR showd patchy, irregular alveolar infiltrates.
risk factors for developmental dysplasia of the hip?
Caucasian race, female gender, first born infants, breech position, and a positive family hx
Maneuvers used to screen for developmental dysplasia of the hip?
Barlow and ortolani - acts to dislocate and relocate affected infants' hips, respectively.
Next step in management if Barlow or Ortolani test is positive?
confirm diagnosis via:

ultrasound if <4 months old bc femoral head and acetabulum have not yet ossified, so plain xr are poorly capable of illustrating the pt's anatomy.

XR if >4 months.

Tx is use of a hip (Pavlik) harness, spica cast, or surgical reduction.
what should be suspected in a trauma setting where a pt presents with shock but has an ELEV CVP/PCWP (pulmonary capillary wedge pressure) OR hypotension fails to resolve after a bolus of IV fluids?
A diagnosis other than hypovolemia from blood loss.

If the shock was due to hypovolemia, the pulmonary capillary wedge pressure SHOULD be LOW. Further it should NOT become more elevated upon saline infusion.
When is a myocardial contusion suspected and how can it be confirmed?
Suspected with evidence of injury to the anterior chest and can be confirmed with positive cardiac markers and EKG changes (such as new left bundle branch block or dysrhthmia).
Central cord syndrome classically occurs with ____________ injuries in elderly patients with degenerative changes in the cervical spine (such as spondylosis).
hyperextension - such injuries cause selective damage to the CENTRAL portion of the anterior spinal cord affecting the corticospinal tracts and sometimes the lateral spinothalamic tract.
Characteristic neuro deficits in central cord syndrome?
Weakness more pronounced in the upper extremities than in the lower extremities (bc motor fibers serving the arms are nearer to the central part of the corticospanal tract).

Rarely, pts will also have a selective loss of pain and temperature sensation in the arms due to damage of the spinothalamic tract.
What are two scenarios where the risk of esophageal rupture (boerhaave syndrome) is fairly high?
1) most commonly following instrumentation of the esophagus
2) less commonly in pts with protracted vomiting who have been resisting the urge to vomit resulting in high intraabdominal pressures that are transmitted to the mediastinal esophagus. Rupture in these cases can result in pneumomediastinum that manifests as retrosternal pain and crepitus in the suprasternal notch.
What is Kehr sign?
irritation of the diaphragm caused by peritonitis which is referred to ipsilateral or bilateral shoulders by the C3-C5 phrenic nerve.
What intraperitoneal injuries can lead to a chemical peritonitis?
hemoperitoneum or spillage of bowel contents, bile, pancreatic secretions or urine.

Note: Among bladder injuries, only rupture of the badder DOME can cause peritonitis.
What is McMurray's sign?
refers to a palpable or audible snap occurring while slowly extending the leg at the knee from full fexion while simultaneously applying tibial torsion. Indicative of a medial meniscus tear.
Most appropriate management for a pt with suspected inflammatory breast cancer?
biopsy for histology and treatment depending on the findings of histology.
What is inflammatory breast cancer?
Uncommon form of breast cancer that presents ith an erythematous and edematous cutaneous plaque with a "peau d' orange" (orange peel) appearance overlying a breast mass. It is an aggressive tumor so MOST patients also have axillary lymphadenopathy and 25% have metastatic dz.

Note: nipple discharge in non-lactating women should always raise suspicion for breast cancer.
What should be suspected in a pt who presents with dull abdominal pain as well as hematochezia after repair of an AAA?
bowel ischemia - complicates 7% of procedures on the aortoiliac vessels and most commonly affects the distal LEFT colon. Colonoscopy shows a DISCRETE segment of cyanotic and ULCERated bowel.
General posterior column (of the spinal cord) functions?
fine touch, vibration, pressure, and proprioception
Most appropriate inital management if a neuro exam is suggestive of blunt spinal cord trauma?
immediate administration of high-dose intravenous steroids (methylprednisolone) within 8 hour so spinal cord injury has shown to provide significant and sustained motor/sensory neurological improvment.

Note: these pts will also need a CT and MRI of the spine to assess the extent of injuries but IV steroid administration should not be delayed for these imaging procedures.
All patients with a clavicular fracture should have a careful neurovascular examination to rule out injury to the underlying _________________ and __________________.
1) brachial plexus
2) subclavian artery

Note: suspected brachial plexus injuries can be further assessed with nerve conduction studies. suspected subclavian artery (may manifest as a bruit) can be furter assessed with an angiogram.
Presentation of pancreatic cancer?
insidiously with a combination of constant visceral epigastric pain radiating to the back, jaundice due to extrahepatic biliary obstruction (bc pancreatic cancer most commonly occurs in the head of the pancreas), and anorexia with weight loss.

Another classic association is migratory thrombophlebitis.
All forms of ARTERIAL occlusion (embolus, thrombosis, or trauma) in the extremities will cause what symptoms?
pain, diminshed pulses, pallor, COOLness to touch, neurological deficits, and muscle dysfunction in the affected extremity.

Note: arterial thrombosis symptoms have an insidious onset and pulses are usually diminshed BILATerally while in an embolus the onset is SUDDEN with SEVERE pain and ASYMMetric pulselessness.
How to distinguish a DVT from an arterial occlusion?
DVT causes pain and edema and is accompanied by WARMTH to touch. Pain is typically dull and aching in contrast to the sudden and severe pain seen in an arterial embolus. Also pulselessness is NOT a feature of DVT.
Signs and symptoms post-operative bowel ileus?
nausea, vomiting, abdominal distention, failure to pass flatus or stool, and hypOactive or absent bowel sounds on PE.

Note: hypERactive bowel sounds on PE is a sign of MECHANICAL bowel obstruction.
What contributes to defective bowel motility in ileus, especially in a post-op setting?
INCR splanchnic nerve sympathetic tone following violation of the peritoneum, local release of inflammatory mediators, and posoperative narcotics.

Note: opiates contribute to poor bowel motility by causing disordered peristalsis.
What is indicated by the finding of a tender, fluctuant mass palpable ONLY with the TIP of the examining finger on rectal examination of a MALE patient?
An abscess in the rectovesical pouch as the prostate is much more readily palpable.

Note: Acute ruptured appendicitis is a common cause of pelvic abscesses in men whereas gynecologic issues are more commonly the cause of pelvic abscesses in females.
Pelvic abscesses may cause the following symptoms?
fever, leukocytosis, painful defecation, and diarrhea (resulting from bowel irritation by the intraabdominal infection). Drainage of the abscess is the usual treatment in such cases.
Most important step in management of a suspected necrotizing surgical infection?
early surgical exploration to assess the extent of the process and debride the necrotized tissues.

Note: Antibiotics are also important, but S. aureus is a less frequent pathogen causing this condition. Also adequate hydration and glycemic control (in diabetics) is important. The discharge should also be cultured.
3 clues to diagnosis of a necrotizing surgical infection:
1) intensive pain in the wound accompanied by fever and tachycardia
2) decreased sensitivity at the edges of the wound
3) cloudy-gray discharge

Note: Diabetes is an important predisposing condition. Organisms usually include mixed gram-positive and gram-negative flora.
How should acute cholecystitis be managed?
INITIALLY with observation and supportive care (hydration, abx, and pain meds), followed by elective cholecystectomy within a few days of the SAME hospitalization. This results in better treatment outcomes.
When is an ERCP used?
It is reasonable to perform an ERCP if the patient has choledocholithiasis (a gallstone in the common bile duct causing CBD dilation). In such cases, sphincterotomy can help facilitate passage of stones.
When is a HIDA scan used?
used to diagnose gallbaladder obstruction if an ultrasound is not diagnostic. It uses a nuclear tracer that injected into the blood and collects in the gallbladder. If the tracer is not expelled from the gallbladder, an obstruction is diagnosed.
When is percutaneous transhepatic gallbladder drainage used?
to decompress the gallbladder in patients who are unstable or have a contrindication to surgical cholecystectomy.
Persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma suggests?
tracheobronchial rupture

Other findings include pneumomediastinum and subcutaneous emphysema.
What is the next step in management of a pt with a suspected urethral injury?
a retrograde urethrogram to confirm damage to the urethra and to determine the location of such damage within the urethra.

Most cases of urethral injury are treated with urinary diversion via a suprapubic catheter while the primary injury and associated hematomas are allowed to heal. AFter healing is complete, residual damage, such as urethral stricture is assessed and repaired.

Note: insertion of a Foley catheter is contraindicated as it can cause seeding of hematomas, laceration, or predispose to abscess formation.
Best management for air under the diaphragm (pneumoperitoneum)?
it is a surgical emergency - exploratory laparotomy to look for perforation of a viscus organ.
What treatment is recommended in all proven OR suspected scaphoid fractures?
wrist immobilization due to risk of nonunion - if initial XR is negative with a suspected scaphoid fracture, immobilization with subsequent XR in 7-10 days or immediate advanced imaging (CT scan) is recommended.
How should pts with a CLASSIC presentation of appendicitis be managed?
immediate operation to remove the inflamed appendix and prevent rupture.

Note: ABX should be given preoperatively in ALL cases and continued postoperatively if there is appendiceal rupture.
When is imaging with either a CT scan or ultrasound useful in pts with suspected appendicitis?
If they present atypically, especially in women of child bearing age or older adults. Pregnant women should be evaluated with an ultrasound to look for pelvic pathology.
How to manage a pt who presents with appendicitis symptoms for >5 days?
They usually have a phlegmon with an abscess that has walled off so should be managed conservatively with IV ABX, bowel rest, and delayed appendectomy to weeks later.
Mechanism of ischemia-reperfusion syndrome that can lead to compartment syndrome?
Following more than 4-6 hours of ischemia (from an embolus for example), tissues can suffer both intracellular and interstitial edema upon reperfusion. When the extremities are involved, this creates a risk for compartment syndrome bc of increased pressure within the enclosed fascial space. This causes even more ischemia of muscles and nerves.
Imaging modality of choice in a pt presenting with urinary calculi (presents as flank or abdominal pain radiating to the groin plus n/v; these pts are writhing in pain and unable to sit still unlike patients with an acute abdomen)?
NON-contrast spiral CT of the abdomen and pelvis.

Note: Ultrasound can be used in pregnancy to reduce radiation but can miss some small stones.
How to treat ileus caused by ureterolithiasis?
Treat the ureterolithiasis and ileus will resolve as a result.
If FAST and diagnostic peritoneal lavage are both negative in a hemodynamically UNSTABLE pt who has suffered blunt abdominal trauma, what is the next best step?
FAST and diagnostic peritoneal lavage helpful in establishing INTRAperitoneal bleeding. But in blunt abdominal trauma and pelvic fracture, RETROperitoneal bleeding must also be ruled out. Pelvic angiography to search for retroperitoneal bleeding is useful in both identifying the source of bleeding and embolizing the offending vessel.
What causes symptomatic hyperoxaluria (i.e. nephrolithiasis via oxalate stone formation)?
Increased oxalate absorption in the gut. Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In patients with fat malabsorption such as those with Crohn's disease, calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed into the bloodstream.

Fat malabsorption states also cause decreased bile salt reabsorption in the small intestine. Excess bile salts may damage the colonic mucosa and contribute to increased oxalate absorption.
What causes mastitis and what is the treatment?
Typically mastitis results from transmission of bacteria from the infant's nasopharynx to a fissure on the mother's nipple or areola. The most commonly isolated organism is S. aureus.

Treatment is with analgesics, antibiotics, and continued nursing from the affected breast (bc it has been shown to decrease the progression of mastitis to breast abscess).
classes of hemorrhagic shock
photo
How are non-bleeding esophageal and gastric varices managed?
nonselective beta-adrenergic antagonists such as propranolol - they reduce the risk of bleeding by up to half.
What is a portosystemic shunt and when is it used?
connects the portal venous system to the systemic venous system - can be accomplished surgically or with a TIPS procedure. These procedures are considereda LAST resort in variceal bleeding UNresponsive to medical AND endoscopic interventions (sclerotherapy/endoscopic band ligation).
What classifies diverticulitis as "complicated?"
abscess formation, perforation, obstruction, or fistula formation. Complicated cases account for 25% of divirticulitis cases.
How should diverticulitis complicated by an abscess be managed?
fluid collection < 3 cm: should be treated with IV antibiotics and observation, with surgery reserved for patients with worsening symptoms.

fluid collection > 3 cm: Percutaneous drainage under CT guidance should be tried first. If symptoms are not controlled by the 5th day, surgery for drainage and debridemen is the next step.

Note: surgery with sigmoid resection is generally reserved for patients with fistulas, perforation with peritonitis, obstruction, or recurrent attacks of diverticulitis.
Presentation of esophageal perforation?
sudden-onset, severe, unrelenting pain located retrosternally or in the neck, back, or abdomen. The pain is often exacerbated by swallowing.

More specific signs of esophageal perforation include subcutaneous emphysema in the neck or a characteristic crunching sound on auscultation of the heart due to mediastinal emphysema (Hamman's sign).

Note: CXR is rarely diagnostic; findings may include air in the paraspinal muscles, a widened mediastinum, pneumomediastinum, pneumothorax or pleural effusions.
Diagnostic study of choice for esophageal perforation?
gastrografin contrast esophagogram
Esophagitis is a condition that predisposes to esophageal _______________.
perforation
How to distinguish fat necrosis from breast cancer?
Fat necrosis can mimic breast cancer in its clinical and radiographic presentation as it commonly presents as a fixed mass with skin/nipple retraction, calcification on mammography, and appears solid on ultrasound.

However, calcifications in fat necrosis tend to be coarse (vs. microcalcifications in malignancy). Excisional, core, or fine-needle biopsy is diagnostic and will show fat globules and foamy histiocytes/macrophages in fat necrosis. No treatment is indicated for this self-limited condition.
Typical presentation of peripheral vascular disease?
claudication, erectile dysfunction, and other signs of vascular insufficiency such as skin changes. skin changes include atrophy, a shiny quality, loss of appendages such as hair follicles and a propensity for nonhealing wounds and ulceration.

The degree of vascular insufficiency is best assesed with the ankle-brachial pressure index (ABI or ABPI) resting AND post-exercise.
Classic mechanism of flail chest?
Occurs following fractures of numerous contiguous ribs in two or more locations. Due to severe pain, patients with flail chest take shallow breaths and compensate for the resulting hypoxemia with hyperventilation. Trauma severe enough to cause flail chest also typically causes a significant pulmonary contusion, which is regarded as the primary reason for respiratory distress wih such an injury. On examination, the isolated thoracic wall segment may exhibit paradoxical inward motin on inspiration, and outward movement on expiration.
Management of flail chest?
Pain control and supplemental oxygen are the most important early steps. Intubation with mechanical psitive pressure ventilation may also be required.
Findings suggestive of aortic injury with incomplete or contained rupture?
WIDENED mediastinum, large LEFT-sided hemothorax, deviation of the mediastinum to the RIGHT, and disruption of the normal aortic contour. In these cases diagnosis can be confirmed via CT scanning.

Note: In most cases of aortic injury/rupture, circulatory collapse and death are immediate sequelae.
Defintion of solitary pulmonary nodule?
a discrete lesion less than 3 cm in diameter surrounded completely by lung parenchyma and does not contact the pleura, hilum, or mediastinum. Additionally, there must not be any associated pleural effusion, adenopathy or atelectasis.
Likelihood of malignancy of a solitary pulmonary nodule is determined by?
1) Demographic data - risk increases with age and smoking
2) doubling time - lesions that take longer than 1.5 years to double are typically benign whereas those that double very rapidly (less than 30 days) are frequently infectious.
Best radiographic test for determination of malignancy of a solitary pulmonary nodule?
high-resolution CT scan - factors associated with malignancy include increasing size, irregular or spiculated margins, stippled or irregular calcifications, and cavitation with thickened walls.

Biopsy and culture may be used if CT is inconclusive.
What are the first physiological changes that accompany hemorrhage?
tachycardia and peripheral vascular constriction - both responses act to maintain blood pressure within normal limits until severe blood loss has occurred.
Scaphoid fractures are particularly concerning because?
the tenuous blood supply to the scaphoid makes the proximal fracture fragment vulnerable to avascular necrosis.