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Clinical Vignette
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Dx?
|
Labs? Imaging?
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1st LineTx or Tx of Choice?
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1. 40 yo ? s/p lap chole, POD 1, T 101.2 during AM rounds
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Atelectasis = MCC fever POD 1
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2. 48 yo ? s/p ventral hernia repair, POD 6, c/o RLE being red, swelling, tender, & painful
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DVT
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Duplex U/S
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3. 68 yo ?, + tobacco, sudden onset unilat blindness
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Retinal artery embolization
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Carotid Doppler
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4. 27yo s/p craniopharygeoma removal, POD 4, Na 128, asx
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SIADH
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H2O restriction
If sxs, use hypertonic saline
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5. 28 yo trauma pt s/p ex lap w/ stomach repair, POD 3, bleeding from IV sites, studies show ↓ plt, ↑ fibrin split products
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DIC
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Tx underlying cz (here, sepsis)
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6. 56 yo ? POD 14 s/p colon resection, 2d h/o diarrhea, 3 diff abx for intra-abd abscess
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Pseudomembranous colitis d/t C. difficile
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Exotoxin A in stool
|
p.o. metronidazole or vancomycin
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7. post-op or trauma pt, BP 90/60, low U/O, ↑ HR, hypovol
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IVF
Anyone who is ↓ BP, ↑ HR, ↓ U/O, answer is fluids
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8. 32 yo ? fatigue x 3d, HR 130, T 103, BP 88/50, warm, well-perfused extremities on exam
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S. aureus
Septic shock (low BP, warm extremities)
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Blood culture
|
1st tx: fluids/pressors (any low BP)
Def tx: IV abx
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9. 47 yo ? 18-hr h/o hi fever, fatigue, PE shows bite on arm, red streak ↑ arm, pain out of proportion to PE
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Nec fasciitis, MCC Grp A Strep, 40% = polymicrobial
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IV abx, surgical debridement in OR
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10. 84 yo ?, tx for AAA, t 102, painful urination, dementia
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UTI, common cz of delirium in older hospitalized patients
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UA
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11. 48 yo ? undergoing elective hernia repair, receives gen anesthesia à ↑ HR, T 103, rigid
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Malignant hyperthermia
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IV dantrolene, stop surgery, take pt to PACU, cancel case
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12. 48 yo ? swollen b/l Les, ulcer on medial malleolus
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Venous insufficiency (ulcer on top or lat part of foot à a. insuff)
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13. MC type of hernia in ?
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Indirect > (femoral ? > ?)
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14. 40 yo GERD, freq vomiting, heartburn, UGI shows paraesophageal hiatal hernia
|
Surgery
If hiatal hernia à med rx
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15. 28 yo ? s/p MVA, gasping, BP 80/50, ↓ breath sounds on L
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T PTX
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Needle thoracostomy
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16. 28 yo ? s/p chest wound, paradoxical rib mov’t, sucking sound
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Flail chest = open PTX = sucking chest wound
|
Intubation with + P intubation; in field, occlusive dressing taped on 3 sides
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17. 35 yo ? s/p SW to heart, ↓ heart sounds, 9 cm JVD (Beck’s triad)
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Cardiac tamponade
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Pericardiocentesis
|
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18. 48 yo ? fell off of his bike, c/o pelvic pain, blood at the urethral meatus, high-riding prostate
|
Traumatic injury to the bladder or urethra
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Retrograde urethrogram
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19. 11 yo kid fell off play gym, mult facial fractures, gasping for air
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Intubate with orogastric tube Never use NG tube with facial fractures (may go into brain)
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20. 35 yo ? acute foot pain, s/p vascular surg, 18hrs postop, has pain on passive mov’t, out of proportion to the exam, tense extremity
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Compartment syndrome
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4 compartment fasciotomy
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21. 19 yo kid s/p MVA. CXR shows widened mediastinum
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Aortogram
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22. 35 yo ? s/p motorcycle accident, 2 pelvic fx, BP 80/50, not responding to fluids
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Placement of external fixator (or placement of masked trousers)
Do not do surg w/pelvic fx’s à use above tx, stop venous bleeding)
|
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23. Neck zones: I & III à need imaging before surg
Zone II à can go straight to OR for surg exploration (see Surg Recall for good pic)
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24. 3:1 Resuscitation Rule: use 3 L crystalloid for every 1 L blood loss, use LR or NS for resuscitation
|
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25. MC injured organ in blunt trauma
|
Spleen
|
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26. Burn pt w/20% TBSA burn (whole RUE + LUE): how much fluid should u give in 1st 24 hrs?
|
4 * weight (kg) * % TBSA
Parkland formula
|
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27. 35 yo ? caught in house fire, charring around face, RR 20
|
Intubate, cric
|
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28. 68 yo couple comes in during the winter, warmed house w/oven à now unresponsive
|
CO poisoning
|
Carboxyhgb level
|
100% O2 via face mask or intubate w/100% O2
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29. 45 yo ? h/o PUD, 4 hrs h/o vomiting blood
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Endoscopy (EGD)
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30. 48 yo ? GERD, 4 hr h/o hematemesis
|
Grade III esophageal varices
|
EGD
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Sclerotherapy
|
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31. 48 yo ? fishing, drinking beer, non-painful vomiting, lg vol of blood; typical: massive, painless hematemesis after severe vomiting or retching
|
Mallory-Weiss tears
|
Watchful waiting b/c 85% MW tears stop on their own
If can’t control bleeding: balloon tamponade, endoscopic control of bleeding, gastrotomy & suture ligation
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32. Same patient as above, but w/severe chest pain; typical: severe substernal or L chest or shoulder pain after retching episode
|
Boarhaave’s syndrome
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UGI w/H2O soluble contrast e.g. Gastrografin
Ø Ba à mediastinitis!
|
Immediate surg: L thoracotomy, repair tear, drainage
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33. 60 yo ? constipation, no flatus x 2d, N/V, distended abd, hyperactive bowel sounds
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SBO
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KUB: dilated loops of small bowel
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1st line: NGT & Foley catheter
Def tx: ex lap, surg repair
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34. 6 yo non-painful rectal bleeding x 2d
|
MCC LGIB kids = Meckel’s diverticulum
|
Scan (technium?)
|
Surg
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35. 35 yo pg ? 18 hr h/o periumbilical pain, WBC 22, t 102
|
Appendicitis
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Surg no matter what trimester
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36. 55 yo RLQ pain, ↑ WBC, suspect appendicitis, do surgery. During the surgery, you see a hard mass at tip of the appendix that is yellowish and measures 1.5 cm
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Carcinoid syndrome
|
Continue w/appy
If > 2 cm or @ base of appy or cecum à R hemicolectomy
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37. 72 yo ? severe LLQ pain x 1d, F/C, T 102.5, BP 79/50
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Diverticulitis
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CT scan
If suspect perf à Ø colonoscopy or sigmoidoscopy
|
Can do colonoscopy if hemo stable
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38. 65yo ? no flatus or BM x 2 d, N/V, tense abdomen, LGI shows bird’s beak
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Sigmoid volvulus
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LGI shows bird’s beak
Plain film shows upside down U or “bent inner tube”
|
Flex sig—dx & rx
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39. same pt as above, upper GI shows cecal volvulus
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Surg, R hemicolectomy
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40. 19 yo painful BMs x 3 mo, sees blood on TP but not stool, exquisitely painful DRE
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Anal fissure
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1st line: stool softeners Ø surg
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41. 18 yo ? Crohn’s, sudden onset RLQ pain, suspect appendicitis, do surg. During surg, notice the terminal ileum = inflamed
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Finish appy, then close
|
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42. 45 yo ? postprandial RUQ pain, lasts several hours, colicky, had previous ep’s
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Biliary colic (cholelithiasis)
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U/S
|
See gallstones à def tx = cholecystectomy
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43. Same pt, RUQ pain, + t bili 8.2, d bili 8.8
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Choledocholithiasis
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ERCP
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ERCP, cholecystectomy 48 hrs later (allow bili to resolve)
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44. Same pt, RUQ pain, U/S shows gallstones, T 100.3, ↑ WBC
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Cholecystitis
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IV abx, then cholecystectomy in 48-72 hrs
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45. 56 yo ? c/o subjective fever (T 102.5), RUQ pain, yellow eyes (Charcot’s triad)
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Cholangitis
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IV abx, aggressive fluid resuscitation
Def tx: biliary decompression (ERCP or PTC), IV abx & IVF, then remove GB
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46. 72 yo ? no flatus or BM, tense belly, N/V, palpable mass RLQ, KUB shows hyperdense lesion in terminal ileum (gallstone) & air in the biliary tract
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Gallstone ileus
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KUB shows hyperdense lesion in terminal ileum (gallstone) & air in the biliary tract
|
Ex lap, enterotomy, remove stone, remove GB @ same time or delay if elderly
|
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47. 46 yo EtOH, severe epigastric pain x 1d, radiates to the back
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Acute pancreatitis
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NPO, IVF (if nec pancreatitis à abx)
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48. Same pt, c/o severe epigastric pain, jaundice, RUQ pain, gallstones
|
Gallstone pancreatitis
|
NPO, IVF,
1st line: ± ERCP
Def tx: remove GB
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49. 64 yo ? fatigue, wt loss, yellow eyes, t bili 20, nontender on exam, palpate RUQ mass (painless jaundice à Courvesier’s sign)
|
Malig in head of pancreas til proven otherwise
|
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50. MC BrCa?
|
Infiltrating ductal carcinoma
|
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51. 18 yo AAF blood nipple d/c
|
intraductal papilloma (usually young AAF)
|
Ductogram
|
Ductectomy
|
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52. 26 yo ? mass in R br x 6 wk, 1 cm, fully mobile
|
Fibroadenoma
|
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53. 22 yo ? hit w/ball in breast 1 wk ago, now has palpable breast nodule
|
Fat necrosis
|
Must do excisional bx even if – PMH, r/o Ca
|
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54. 56 yo ? b/l breast lumps x 3 wks, severely tender, greenish return on aspiration
|
MCC fibrocystic dz
Algorithm: 1) drain cyst. If disappears, you’re done. 2) If you get blood or it doesn’t go away send fluid for cytology and then you have to biopsy
|
Needle drainage of cyst
|
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55. 38 yo ? 3 wk h/o palpitations while walking, sweating, headaches, ↑ BP (classic triad)
|
Pheochromocytoma
|
Dx w/urine metanephrines
|
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|
56. 37 yo ? PMH GERD, comes in for the 4th time in 1 yr w/ severe heartburn & diarrhea
|
ZES
|
1st test: gastrin level Def dx: secretin stimulation test
|
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|
57. 18 yo s/p GSW to abd, splenectomy done, POD 9 has sudden fevers, septic shock pic
|
Strep pneumo b/c w/o spleen, can’t handle bac’s capsule
|
Prevent w/vaccinations before splenectomy
|
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|
58. 68 yo veteran (smoker), calf pain on walking, no rest pain
|
Claudication
|
Before surg pt w/PVD, order angiogram
|
Lifestyle ?’s
Surg indications: gangrene, rest pain, severe interference w/lifestyle
|
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|
59. 68 yo ? acute onset of lower extremity pain, leg paralyzed, pain on passive motion, numb
|
Suspect acute arterial embolism
|
IV heparin, then angiogram, then surg
6 hr window for arteriolar embolism!
6 P’s: pulselessness, pain, pallor, poikilothermia, , paresthesia,& paralysis
|
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|
60. 56 yo smoker, sudden onset abd pain, BP 90/40, palpate mass in abd, throbbing
|
Ruptured AAA (hypotension, palpable mass)
|
OR!
|
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|
61. Same pt w/nl VS, palpate abd mass
|
abd U/S or KUB
|
If AAA > 5 cm à OR
If < 5 cm à obs
|
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62. Same pt s/p AAA repair, POD 3, has abd LLQ pain, passes bloody stool
|
Sigmoid ischemia d/t ligation of IMA, usu presents 48-72 hrs postop AAA
|
Sigmoidoscopy (see dusky colon)
|
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|
63. 65 yo ? sudden onset abd pain, out of proportion to PE, maybe see afib
|
Acute mesenteric ischemia
|
Abd angiogram
|
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|
64. 70 yo ? vague abd pain w/ meals x 3 mo, wt loss b/c food fear
|
Chr mesenteric ischemia
|
Angiogram
|
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|
65. 7 yo ? T 103, appears toxic, leaning forward & drooling
|
Epiglottitis usu d/t H flu, but has ↓ b/c vaccine
|
No tongue blade exam!
|
OR, intubate?
|
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|
66. 22 yo ? red face & diarrhea. X 10d, asthma, RH calcification, suspect tumor
|
Carcinoid syndrome
|
5 HIAA level in urine
|
Seen w/mets to liver, any tumor escaping portal syst
|
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|
67. 47 yo ? c/o pain on swallowing, heartburn, UGI see bird’s beak
|
Achalasia
|
Bird’s beak on UGI
Def dx test: esophageal manometry, shows ↓ peristalsis, failure of LES to open
|
Antireflux meds (PPIs), then myotomy, remove LES
|
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|
68. 37 yo ? sudden tearing CP radiating to back, ≠ brachial BPs in arms
|
Aortic dissection
|
BP control 1st
If ascend dissection: surg excision & repair
If ≠ say ascend, assume descend: BP control
|
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|
69. 50 yo ? kidney transplant, 30 sec after clamps released, kidney turns blue
|
Hyperacute rejection
|
Immediately remove donor kidney
Pathophys: preformed Ab’s
|
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|
70. 16 yo ?, AMS, found down by friends, shoulder looks funny
|
Posterior shoulder dislocation
|
90% shoulder dislocations = anterior
|
d/t seizures or electrocution
|
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|
71. 18 yo football player hit on lateral aspect of knee. On exam, tibia can be displaced from knee (+ anterior drawer sign/Lachman’s test)
|
ACL tear
|
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|
72. Know classic distinctions between:
|
Osteosarcoma
Sunburst pattern
Pain at night
Most common
|
Ewing’s
onion skinning
constitutional symptoms
|
|||
|
73. Kid hit by baseball or bat, lucid interval, then LOC.
|
Epidural hematoma, middle meningeal artery rupture
|
CT: biconvex lens density
|
Low mortality
|
||
|
74. Elderly or alcoholic with 2 wk h/o acting weird after falling on ice
|
Subdural hematoma, bridging veins
|
CT head
|
Higher mortality
|
||
|
75. 25 yo ? sudden onset of worst headache of her life, photophobia
|
Subarachnoid hematoma
|
1st test: non-contrast CT head
|
MC d/t trauma > berry aneurysm rupture
|
||
|
76. 56 yo ? PMH HTN, sudden onset numbness in R face & L side paralysis
|
Intercerebral hemorrhage, int capsul of basal ganglia
|
MC d/t HTN
|
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|
77. 50 yo ? smoker 40 pack yr hx, 2 wk history painless hematuria
|
Bladder Ca
|
Cystoscopy (pick UA with cytology if offered)
|
|||
|
78. 22 yo ? college student, lump in testicle, painless
|
Seminoma (MC testicular Ca in young ?)
|
U/S
|
Do excisional bx
|
||
|
79. Mom brings in 8 yo, had trouble breathing while playing
|
Foreign body aspiration
|
CXR
|
Remove foreign body w/rigid bronch
|
||
|
80. 2d infant, been on O2 since birth. On CXR see NGT is up in the chest (will be an x-ray picture
|
Congenital diaphragmatic hernia
|
Surg repair, usu on L
|
|||
|
81. 16 yo HS soccer kid, acute onset pain in scrotum, started 2 hrs ago
|
Testicular torsion
|
Doppler U/S
|
If 5-6 hrs: no time for U/S à OR for surg detorsion & b/l orchiopexy
If < 5-6 hrs, have time for U/S
|
||
|
82. Testicular torsion
Pain does not go away
Duplex U/S shows ↓ blood flow
Tx w/surg
|
Epididymitis
Friend’s sign: elevate scrotum, pain disappears
Duplex U/S shows ↑ blood flow
Tx w/abx
MCC < 40 yo = gonorrhea or Chlamydia; > 40 = E coli
|
||||
|
83. 5 wk old boy with non-bilious projectile vomiting x 2d, palpable mass in stomach
|
Pyloric stenosis
|
Abd U/S or pyloric U/S
|
Pyloromyotomy
|
||
|
84. 5d old infant with bilious, constant vomiting. KUB shows double bubble (may be an xray picture)
|
Duodenal atresia, assoc w/Down syndrome
|
KUB shows double bubble (may be an xray picture)
|
|||
|
85. 3d old boy has never passed meconium, distended abd
|
Hirschsprung’s dz
|
Def test: Rectal bx
|
Colectomy & anal pull-thru anastomosis
|
||
|
86. 2 mo old kid, sudden onset bilious vomiting, ~ bile
|
Midgut volvulus til proven otherwise
|
OR: ex lap, detorse volvulus
|
|||
|
87. Location, covering, associated diseases, organ involvement
|
Omphalocoele
|
Gastrochisis
|
|||
|
88. 6mo old, N/V, currant jelly stools. Palpable mass in RLQ. h/o URI 2 ws ago
|
Intussusception
|
Ba or air enema (dx & rx)
Surg if enema fails
|
|||
|
89. 4yo ? mom noticed abd mass on side while bathing, + hematuria
|
Wilm’s tumor
|
CT scan
(not IVP)
|
Surg, then chemo
|
||
|
90. 12yo ? passenger in MVA, chest hit dashboard. Upper epigastric pain, “coiled spring” appearance in upper epigastrium on CXR
|
Duodenal hematoma
|
CXR: “coiled spring” appearance in upper epigastrium
|
Obs
|
||
|
91. 18 month old with bubble through umbilicus
|
Umbilical hernia
|
Most resolve spontaneously by 4 yo, if > 4: surg repair
|
|||
|
92. 18yo ? been to the ER before with nosebleeds, this time nosebleed won’t stop w/packing
|
Juvenile nasopharyngeal angiofibroma
|
Pre-op embolization with angiography then go to OR
|
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|
93. 37yo ? severe abd pain, starts in back and radiates to groin, + hematuria
|
Kidney stone
(painful hematuria)
|
1st diagnostic test is KUB, then CT scan.
|
|||
|
94. 48yo smoker flank pain & hematuria, a mass overlying kidney on PE
|
Renal cell carcinoma
|
Diagnostic imaging test is CT scan
(not IVP)
|
|||
|
95. 27yo ? fell off bike, has wrist pain, tenderness in anatomic snuff box, no fx is visible on x-ray
|
Scaphoid fracture
|
Fx not necessarily seen on xray
|
Cast up to elbow anyway b/c hard to see, avascular necrosis of the scaphoid can occur
|
||
|
96. 38yo ? R wrist pain x 6 wks, pain/numbness worse at night
|
Carpal tunnel
|
1st tx: splinting
|
|||
|
97. 35yo ? heartburn x 2 yrs
|
GERD
|
1st test is endoscopy
If you see esophagitis, you want to get biopsy for Barrett’s
pH probe
|
|||