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Surgery Oral Exam Review:
2005
CASE #1
Hx:
1. HPI of c/c (discharge, painful, etc.)
2. Fam hx-age at dx, # of 1st degree relatives, BRCA 1 or 2 genes
3. Prior mammogram or breast biopsy
4. Menstrual history (early menarche or late menopause)
5. Pregnancy history (1st preg after age 30 or nullparity are both RF’s)
6. Trauma to region - fat necrosis associated with hx of trauma.
7. Hx of HRT
PE:
1. Inspection- 3 positions. Look for asymmetry, dimpling, retraction, etc.
2. Palpate all 4 quadrants of breast and the nipple-areolar complex. Check for discharge.
3. Palpate axillary lymph nodes.
Labs: ?
Radiological Studies:
1. Ultrasound- better for younger women (<30) because they have greater amount of fibrous
tissue, which makes mammogram more difficult to interpret.
2. Mammogram - suspicious findings include micro-calcifications, mass, stellate/spiculated
patterns.
Ancillary Testing:
1. FNA-if the mass remains, the lesion recurs more than two times or bloody aspirate is
obtained, then you must do a biopsy. Dr. Baumann does not recommend doing FNA at
all.
2. Core biopsy
3. Mammotome biopsy - if non-palpable. You are using mammography to ensure that you
biopsy the lesion.
4. Open biopsy - incisional vs. excisional.
5. Needle loc biopsy
6. Sentinnel node biopsy
Differential Diagnosis:
1. DCIS 3. Invasive lobular ca. 5. Fibrocystic 7. Abscess 9.Ductal ectasia
2. Invasive ductal ca. 4. Fibroadenoma 6. Fat necrosis 8. Intraductal papilloma
Most likely Diagnosis: depends upon the history and histology. In general, I
think it is more than likely a pre-malignant/malignant mass.
Non-surgical Management:
1. If its not pre-malignant or malignant, you could just observe and proceed with prior
recommended screening.
2. If stage 4 breast ca - chemotherapy alone. CAF (cyclophosphamide, adriamycin,
fluorouracil) or CMF (methotrexate). Dr. Baumann also mentioned Taxol.
3. If fibroadenoma or fibrocystic change - just observe.
4. If LCIS - one option is to observe, or you could do a prophylactic bilateral mastectomy.
5. Most individuals with stage 2/3 cancer, also get adjuvant chemotherapy.
6. Only a few patients with stage 1 cancer will get adjuvant chemotherapy.
Surgical Management:
1. Lumpectomy with radiation (breast conservation therapy) - Stage 1-3.
2. Mastectomy (simple or modified radical) - Stage 1-3.
3. Axillary node dissection- if sentinel node biopsy is positive.
There is no survival benefit when doing a mastectomy vs. lumpectomy with radiation in patients
with stage 1-3 cancer. Survival/prognosis depends upon the stage.
Other useful points:
In general, a mass must be at least 1 cm to palpate on PE. ½ of breast cancer is located in the
upper outer quadrant. Mammogram screening recommendations include a first mammogram
between ages 35-40, mammogram every 1-2 years between ages 40-50, yearly mammograms
after age 50. Clinical breast exams are recommended every 2-3 years between ages 20-40 and
yearly after age 40. Self breast exams should be performed 1 weeks after menstrual period.
Pathology:
1. Inadequate specimen.
2. Benign.
3. Histological risk
a. Hyperplasia
b. Atypical hyperplasia
c. LCIS - this is a biopsy finding. It cannot be palpated on PE or seen on
mammography. LCIS increases your risk for breast ca. in both breasts and is a
marker for the development of invasive ductal carcinoma, not lobular carcinoma.
4. DCIS - premalignant disease.
5. Invasive cancer
a. Invasive ductal carcinoma
b. Invasive lobular carcinoma
c. Inflammatory breast carcinoma
Other:
Intraductal papilloma is the #1 cause of bloody nipple discharge.
Fibroadenoma - young girl with a solitary smooth, mobile lump.
Fat necrosis - post-traumatic.
Paget’s disease of the skin - indication that there is underlying breast ca.
Case # - 2
This patient would have the same history, physical, etc as the first patient.
Most likely diagnosis: Breast cancer.
This patient is older, has an abnormal mammogram and the lump is located in the upper outer
quadrant increasing the likelihood of cancer.
Stage 1-3 disease would warrant a lumpectomy with radiation or a mastectomy.
Stage 4 disease is treated with chemotherapy alone.
Case # - 3
This patient would have the same history, physical, etc. On physical exam, evaluate for a
subareolar mass and/or spontaneous nipple discharge.
Bloody nipple discharge is most likely going to be intraductal papilloma or breast ca. This
patient is 29 y.o and therefore is much more likely to have intraductal papilloma.
However, you should still get a mammogram because it is bloody discharge and the patient has a
family history of breast ca. Very unlikely to be breast ca. Patients who have a family history of
breast ca. should receive their 1st mammogram 10 years prior to the age at which the family
member was diagnosed.
Treatment: Excision of the affected duct.
Definitive diagnosis is by pathological evaluation of the resected specimen.
4. A 35 yo female presents with a 3x3cm mass in her right thyroid nodule.
Full History: focus on any previous radiation to neck, how rapidly did nodule develop, family history
of thyroid problems. Recent h/o viral URI?
Hyperthyroid symptoms: nervousness, fatigue, weight loss, tachycardia, goiter, pretibial myxedema,
tremor, heat intolerance, palpitations, fatigue, wt. Loss, dyspnea, weakness, increased appetite,
exopthalmos, thyroid bruit, amenorrhea, dec. libido, dec, fertility, HTN.
Hypothyroid Symptoms: fatigue, weight gain, cold intolerance, constipation, menorrhagia, dec
libido/fertility, bradycardia, dec. cardiac output, hypotension, SOB from pulmonary effusions, hair
loss, enlarged tongue, yellow skin.
Physical Exam: need complete exam, good thyroid eval for nodules. Note size, mobility, firmness,
quality/consistency, adherence of mass and if other lymphadenopathy….(worry about hard, fixed
gland with cervical lymph nodes)
Tests: Check TSH, Free T3, Free T4, antithyroglobulin and microsomal antibodies, ESR.
Do a FNA(fine needle aspiration) of nodule 1% false + rate and 5% false - rate
Benign (65%)-do US for sizing, check initial thyroglobulin level and follow this number over time.
Suspicious (15%)-get a I123 scan (85% will be cold nodules (cold nodules have 10-15% chance of
malignancy), 5% will be hot nodules (hot nodules have a 1% chance of malignancy)
-Surgery is indicated if serial T4 levels do not regress and bx is worrisome
Malignant (5%)-need surgery
Nondiagnositc (15%)
Cystic-drain completely (75% will be cured). If larger than 4cm or complex, or if it recurs after 3
attempts to drain, then evaluate in OR.
Differential dx: tyroiditis or cancer
Acute thyroidits-infections(s. pyogenes, s. aures, pneumococcus), unilateral neck pain and fever, skin
erythemia, euthryoid, dysphagia. Mostly spread through lymphatics from nearby infection. Pts often
have thyroglossal duct/cyst/fistula
Tx-IV antibiotics and surgical drainage
Subacute/DeQuervain’s thyroiditis- post-viral URI, more in females, fatigue, depression, neck pain,
fever, unilateral swelling of thyroid with erythemia, firm and tender thyroid, transient
hyperthyroidism then hypothyroid inc ESR.
Tx-self limited disease(w/in 6wks), manage pain with NSAIDs
Chronic/hashimoto’s thryoiditis: Autoimmune (inc risk with down’s, turners, familial Alzheimer’s
radiation therapy as kid), painless enlargement of thyroid, neck tightness, firm and rubbery gland, see
hypothyroidism other autoimmune disease. Have antithyroglobulin and microsomal antibodies, ab
against TSH receptor. In gland see follicular and Hurthle cell hyperplasia, lymphocytic and plasma
cell infiltrates
Tx: thyroid hormone, partial thyroidectomy of meds fail.
Riedel’s fibrosing thyroiditis: rare, benign inflammatory thyroid enlargement with fibrosis of thyroid,
have painless large thyroid, usually euthyroid, neck pain, possible airway compromise. Need an
open biopsy to r/o carcinoma or lymphoma.
Tx: isthmectomy if airway compromise, or medical tx with steroids
Cancer
Papillary(80-85%) inc, risk if had neck radiation. See in pts 30-40 F:M, 2:1, have painless mass,
dysphagia, dyspnea, hoarseness, euthryoid. To dx need FNA, CT or MRI to look for invasion. Mass
is multifocal, hard, white, with area of necrosis, cystic changes, papillary projections, pale abundant
cytoplasm, psammoma bodies with “orphan annie eyes”. Often spreads by lymphatics
TX: if minimal ca: lobectomy or isthmectomy
Other: total or near total thyroidectomy, if +LN do modified radial neck dissection. And
I131 ablation for pts with residual thyroid tissue or +LN.
Prognosis: worse for older age and those with distant mets, presence of +LN not affect prognosis.
Need post-op thyroid hormone replacement. 10 year survival 95%
Follicular CA(5-10%) see in 50s, and inc risk with dyshormonogenesis, F:M is 3:1. pts have painless
rubbery, encapsulated mass that is rarely hyperfunctional. FNA cannot be used for dx, need tissue
structure to dx, then CT/MRI to check invasion.
Spreads hematogenously (bone the most common distant site).
Tx: if <2cm do near total thyroidectomy or lobectomy and if >2cm then do total thyroidectomy.
For +LN do modified radical neck dissection, and can do I131 ablation for those with residual thyroid
or +LN.
Prognosis: worse than papillary, worse in older pts with distant mets, >4cm and high tumor grade.
Variant is the Hurthle cell tumor: bilateral, multifocal, spread to regional LN, arise from follicular
cells, mets by lymphatic>hematogenous. Tx same as follicular. 10year survival 70%.
Medullary CA(5-10%) assoc w/MEN in 30-40% of cases. Often pts 50-60yo and M:f 1.5:1. Painful
mass, dysphagia, dyspnea, hoarseness. Can dx by FNA (presence of amyloid is diagnostic) and
check immunohistochemistry for calcitonin. Often unilateral, in mid-upper lobes, arises from
C-cells, see sheets of cells, amyloid and collagen. Mets via lymphatics and locally.
TX: sporadic MTC tx with total tyhroidectomy and median lymph node dissection, modified neck
dissection if lateral nodes positive. (poor I131 uptake)
Prognosis: 10 year survival 50-70%.
Anaplastic: 1% inc risk if prior dx of well-differentiated thyroid ca, or iodine deficiency. See in ages
60-70, with M:F 1.5:1. rapidly enlarging neck mass, neck pain, dysphonia, dysphagia, hard fixed LN.
Dx by FNA. See macroinvasion, sheets of heterogeneous cells, giant cells, spindle cells. It is very
aggressive. 50% have pulmonary mets at dx.
Tx: if small do total thyroidectomy +/- external beam radiation, if airway compromise do
debulking surgery and tracheostomy.
Prognosis: poor median survival 4-5months. Most stage IV at presentation.
Remember to follow Ca level after thyroid surgery, b/c damage to parathyriods
5. 45yo male presents to pcp for f/u after recently being hospitalized for a renal calculus. His ca was
found to be 14.5. he was feeling fatigued chronically but otherwise has no complaints.
History: complete. Check hypercalcemic sx-kidney stones, bone pain, pathologic fx, n/v,
constipation, pancreatitis, PVD, lethargy, confusion, depression, paranoia, gout, wt loss, HTN,
polyuria, polydypsia.
Physical exam-complete
DDx of hypercalcemia=CHIMPANZEES
Ca overdose
Hyperparathyroid, hyperthyroid, hypocalciuric hypocalcemia
Immobility
Mets, milk-alkli syndrome
Pagets disease of bone
Addison’s
Neoplasm(colon, lung, breast, prostate, multiple myloma)
Zollinger Ellison syndrome-check gastrin levels
Excessive Vit D/A
Sarcoid-see if secrete acth
Tests: ionized calcium, total calcium, phosphorous, (get Chem-7), Alk phos, TSH, free T3/4,
Look at CT/MRI to check for malignancy, CXR, mammogram…
Primary hyperparathyroidism- 85% are adenomas, 10% are four gland hyperplasias, and cancer <1%.
Have overproduction of PTH causing increased absorption of ca from intestine, inc. vit D3 production
in kidney, and dec. renal ca excretion, inc. excretion of phosphate and increased break down of bone
by osteoclasts(bone resorption)
Tx: initial tx of hypercalcemia by IVF, furosemide(never thiazides!), antiarrythmics if needed.
If solitary adenoma-solitary parathyroidectomy, can bx other glands if enlarged
If multiple gland hyperplasia- do 3 ½ gland parathyroidectomy and re-implant ruminant in forearm or
SCM muscle.
Secondary hyperparathyroidism-from chronic renal failure or intestinal malabsorption that causes
hypocalcemia with appropriate increase in PTH. Get bone pain from renal osteodystrophy and
pruitus, but often asymptomatic.
Tx: in renal failure, restrict phosphorous intake, treat with phosphate binders and ca/vit-D
supplements. Adjust dialysate to maximize ca and minimize albumen.
Tertiary: autonomously functioning parathyroid glands resistant to negative feedback. Usually short
lived, if persistent, need surgery(31/2 gland parathyroidectomy).
Parathyroid cancer: 40-50% have a PALPABLE firm, fixed mass, an extremely high calcium, high
PTH, and high Alkaline phosphatase, bone disease, renal insufficiency, and renal stones
Need to biopsy-path shows pale white, adherent mass, with a thick fibrous capsule and septa, and
histo shows enlarged hyperchromic nuclei and varied nuclear size. A common tumor marker is human
chorionic gonadotrophin.
Tx: en bloc surgical resection of mass and surround structures, ipsilateral thyroid lobectomy, regional
LN, and post-op external radiation therapy and chemo usually not beneficial. 5 yr survival 70%
Post-op complications of parathryoidectomy:
Recurrent laryngeal nerve injury(hoarseness if unilateral or airway obstruction if bilateral)
Neck hematoma
Hypocalcemia(perioral tingling, paresthesia, +chvostek’s sign, +Trousseaus sign, tetany)
Superior laryngeal nerve injury
“hungry bone syndrome”-severe hypocalcemia seen after surgical correction of HPTH as chronically
ca deprived bones aggressively absorb ca.
6. A 65 year old pt comes to VA b/c of mass in his left neck. On exam he has a 2x2 cm hard but
mobile mass in anterior jugular chain. He has no other adenopathy.
History: smoking, alcohol, dysphagia, odynophagia, hoarseness, stridor, globus(feel like have lump in
throat), speck d/o, referred ear pain (cn V IX X)
Physical: do full head and neck exam,
Tests: direct laryngoscopy, CT/MRI to look for primary, FNA for tissue diagnosis, bx contraindicated
b/c it adversely affects survival if cancer.
DDx:Inflammatory: cervical lymphadenitis, cat scratch disease, infectious mono, infection
Congenital: thyroglossal duct cyst(midline, elevates with tongue protrusion), branchial clefts(lateral),
dermoid cyst(midline, submental), hemangioma, cystic hygroma.
Neoplastic-primary or metastatic(hodgkins/nonhodgkins lymphoma), squamous cell ca.
Tx: surgical excision for congenital or neoplastic(radical and modified neck dissection)
Radical neck dissection: removal of all nodes from clavicle to mandible, SCM, Submandibular gland,
tail of parotid, IJ vein, digastric muscle, stylohyoid, omohyoid, fascia in ant/post triangles, cn XI, and
cervical plexus sensory nerves.
Do this when clinically + nodes that likely contain ca, clinically - nodes in neck, but high
probability of mets from primary tumor elsewhere, a fixed cervical mass that is respectable
Contraindications: distant mets, fixation to structure that cannot be removed, low neck mass.
Usual etiology in adults is cancer
CASE # 7 (Esophagus)
Hx:
1. 55 yo male 5. 5 lb weight loss in 3 weeks
2. chronic EtOH use
3. difficulty swallowing
4. food gets stuck in mid chest, needs to drink to let it pass
PE:
1. Cachetic
2. Supraclavicular lymphadenopathy
3. May be entirely normal if early in disease
Labs:
1. LFTs (liver mets)
Radiological Studies:
1. UGI- localizes tumor 3.Transesophageal US
2. EGD- obtains biopsy, assesses resectability 4. Barium swallow
5. CT chest/abdomen
Ancillary Testing:
1. CXR (lung metastasis or hilar LAD) 2. bone scan (bone mets)
Differential Diagnosis:
1. Esophageal carcinoma 4. Diffuse esophageal spasm 7. Foreign body
2. Benign stricture 5. Lymphoma 8. Inflammation
3. Achalasia 6. GERD 9. Extrinsic compression
Most likely Diagnosis:
Esophageal carcinoma (squamous cell cancer in most of esophagus or adenocarcinoma at GE
junction)
Non-surgical Management:
1. Radiation
2. Chemotherapy
Surgical Management:
1. Total thoracic esophagectomy with gastric pull-up or colon interposition
2. Endoscopic laser therapy
3. Endoscopic dilatation and stent placement
4. Placement of gastrostomy or jejunostomy tube
Other useful points:
Most common in 6th decade, men>women, etiologic factors: tobacco, EtOH, diets high in
nitrites or nitrosamines, GE reflux, Barrett’s esophagus, achalasia, chronic esophagitis,
Plummer-Vinson syndrome, see Recall pg 604 for staging
CASE # 8 (Esophagus)
Hx:
1. 49 yo male 4. obesity
2. polish sausage stuck in chest 5. mild chest discomfort
3. dysphagia 6. heartburn
PE:
1. obese pt.
Labs:
1. CBC
2. LFTs
Radiological Studies:
1. Barium swallow
2. EGD (must evaluate for malignany)
Ancillary Testing:
1. CXR
2. bone scan
Differential Diagnosis:
1. Benign stricture 3. Extrinsic compression 5. Esophageal diverticula
2. Diffuse esophageal spasm 4. Esophageal CA 6. Achalasia
Most likely Diagnosis:
Benign stricture (inflammation due to long-standing GERD)
Non-surgical Management:
1. Adjust/change medications for GERD (antacids, H2 antagonists, PPIs)
Surgical Management:
1. Endoscopic dilatation (with polish saugagectomy???)
2. Esophagectomy with colon interposition or gastric pull-up
Other useful points:
Etiologic factors: long-standing GERD, radiation esophagitis, infectious esophagitis, corrosive
esophagitis, subsequent to scleropathy for bleeding ulcers; most feared complication of dilatation
is esophageal rupture
CASE # 9 (Esophagus)
Hx:
1. 40 yo female
2. chronic heartburn, occurs late at night and wakes her up at night
PE:
1. Normal appearing female
Labs:
1. CBC
2. Cardiac enzymes
Radiological Studies:
1. Barium swallow (assess severity, look for anatomical cause)
2. EGD (evaluate mucosa, obtain biopsies)
Ancillary Testing:
1. Continuous pH monitoring 3. EKG
2. Esophageal motility study
Differential Diagnosis:
1. GERD 3. Hiatal hernia 5. Benign stricture
2. Barrett’s esophagus 4. Gastric outlet obstruction 6. Angina/CAD
Most likely Diagnosis:
GERD (chronic)
Non-surgical Management:
1. H2 antagonists, Antacids, PPIs , metoclopramide
2. Smoking cessation
3. Sleep w/ head of bed elevated
4. Small, multiple meals
Surgical Management:
1. Nissen (lap or open)- wrap fundus all the way around esophagus
2. Belsy Mark IV- wrap is not all the way around
3. Hill- tighten arcuate ligament around esophagus and tack stomach to diaphragm
4. Lap Toupet- less wrap used with decreased esophageal motility
Other useful points:
Etiologic factors: decreased LES tone or esophageal motility, hiatal hernia, gastric outlet
obstruction, NGT; complications that require surgery: failure of medical therapy, esophageal
strictures, progressive pulmonary insufficiency secondary to nocturnal aspiration, Barrett’s
esophagus
CASE # 10
#1 is a primary survey- initial assessment and resuscitation of the vital signs.
ABCDEF - Intubate if the GCS <8.
Place two 16 gauge peripheral IV’s, IVF- (bolus of isotonic fluid-either NS or LR), NGT, Foley,
T&C.
If patient’s vitals do not respond to IVF, give pRBC’s, if still don’t respond=OR
*Keep in mind that this patient may have associated trauma.
Hx: not available because the patient is non-verbal/impaired level of consciousness. However,
if possible, take an “AMPLE” history
PE:
1. Secondary Survey - a head to examination.
2. Especially pay attention to signs of liver disease/portal HTN - ie. ascites, caput medusae,
spider angiomata, palmar erythema, gynecomastia, splenomegaly, liver size?
Labs:
1. CBC
2. PT/PTT
3. Comprehensive metabolic panel (LFT’s, bilirubin, albumin, etc)
4. Alcohol level, UDS
Radiological Studies:
1. Upright CXR - rule out perforated peptic ulcer
Ancillary Testing:
1.EGD - most important. Don’t delay.
Differential Diagnosis:
1.Ruptured esoph. varice 2.PUD 3. Mallory Weiss 4.Gasritis 5.Other causes of UGIB
Most likely Diagnosis: Definitely ruptured esophageal varices.
Non-surgical Management:
1. Stop alcohol
2. Thiamine-prevent Wernicke encephalopathy.
3. Beta Blockers - protective against further episodes of rupture.
Surgical Management:
1. Sclerotherapy
2. Medications - vasopressin (add nitro to protect against MI), somatostatin
3. Balloon tamponade - Sengstaken-Blakemore balloon.
4. Ligation/banding
5. TIPS (transjugular intrahepatic portosystemic shunt)
6. Liver Transplant
Other useful points: Overall mortality of ruptured varices is 50%. 2/3 rule: 2/3 of patients with
cirrhosis will have portal hypertension, 2/3 of pts with portal hypertension will have varices, 2/3
of varices will bleed. Child’s classification estimates hepatic reserve and risk of operative
mortality in relationship to cirrhosis/portal hypertension. In a pt with varices, rupture only
accounts for 50% of the episodes of UGIB.
CASE # 11
Start with ABCDEF, etc.
Place two 16 gauge peripheral IV’s, give IVF’s - bolus of NS or LR,
NGT, Foley, T&C.
Hx:
1. HPI of c/c 6. Alcohol use or smoking
2. Prior episodes 7. Meds-NSAIDS,ASA,Steroids,Anticoag, Antacids
3. Hx of ulcers 8. Prior abdominal, cardiac, vascular surgeries
4. Prior EGD/colonoscopy
5. Did 1st vomit have blood (helps determine if Mallory weiss tear)
PE:
1. Abdominal exam - rule out peritoneal signs in the case of a perforated ulcer.
2. Heme positive stool? BRBPR (make sure to do a DRE on this pt)
Labs:
1. CBC
2. Alcohol level
3. Amylase/lipase-ie pancreatitis?
4. Comprehensive metabolic panel (including d. bili, alk phos, etc. gall stones?)
5. PT/PTT/INR
6. H. pylori workup - serology, urease breath test (not as important)
Radiological Studies:
1. Upright CXR -rule out perforated ulcer
2. UGI series (includes upright CXR, abdominal flat plate, upright abdominal x-ray)
Ancillary Testing:
1. EGD. If gastric ulcer seen -always biopsy.
2. Abdominal ultrasound - rule out free fluid, stones, pancreatitis, etc.
Differential Diagnosis:
1. PUD 3. Gastritis 5. Other causes of UGIB 7.Acute abdomen
2. Mallory Weiss 4. Varice rupture 6. Pancreatitis, gall stones (unlikely)
Most likely Diagnosis: Peptic ulcer disease
Non-surgical Management:
1. PPI, H2 blockers
2. Triple therapy - PPI, clarithromycin, flagyl). Other combinations work.
3. Behavioral modification - stop alcohol, NSAIDS, etc.
Surgical Management:
1. Vagotomy with pyloroplasty
2. Bilroth I
3. Bilroth II
Other useful points:
Operation if the patient requires >6 units of PRBC or > 3 units of PRBC’s to stabilize.
CASE # 12
Hx:
In my head, I am thinking of a person with RUQ pain with a history of ulcers. He is only 30
years old. In my differential would be peptic ulcer disease, cholelithiasis, hepatitis, gastritis,
etc. In my history, I would like to know the relationship of the pain to eating, if it is constant,
does it radiate, does it wake him up at night.
PE:
On PE, I would look for peritoneal signs including tenderness, rebound, guarding, etc. I would
try to localize the pain. If it is epigastric, I would lean toward gastric ulcers.
Labs:
CBC, Lytes, LFT, HDL, LDL, H. Pylori Antibodies.
Radiological Studies:
EGD, Biopsy of Ulcerated Lesions
Ancillary Testing:
Urease Breath Test for H. Pylori
Differential Diagnosis: See above
Most likely Diagnosis: PUD
Non-surgical Management:
1. PPI
2. Antacid
3. H2 Blocker
4. Triple Antibiotic Therapy if H. Pylori
Surgical Management:
1. Antrectomy for Type I and II ulcers
Type I is ulcer on lesser curvature of stomach
Type II is ulcer in stomach and duodenum (two places!)
Type III - prepyloric ulcer (three is pree!)
Type IV- Ulcer in gastric cardia ( heart has four chambers)
2. Highly selective vagotomy for Type III
3. Subtotal gastrectomy with Roux en Y esophagogastrojejunostomy for Type IV
4. Highly Selective vagotomy for Duodenal Ulcers
Other useful points:
Surgical Management only if medical management fails 12 weeks.
CASE # 13
Hx:
Tarry stools makes me think of bleeding. Epigastric pain and mass makes me think of cancer.
Weight Loss also. I would look in the history for the relation of any pain to food, how long it
has been going on, and other associated symptoms..
PE:
I would look for a mass that is palpable. I would also try to localize the pain. I would look for
Blumer’s shelf on rectal exam, Virchow’s node in left supraclavicular region, look for Sister
Mary Joseph’s nodule in umbilical region.
Labs:
CBC, lytes, LFTs, Guaiac
Radiological Studies:
1. Upper GI endoscopy
2. Abdominal CT Scan
Ancillary Testing:
Differential Diagnosis:
1. Gastric AdenoCA 3. Gastric Bezoar 5.
2. Gastric Lymphoma 4. 6.
Most likely Diagnosis: Gastric Adenocarcinoma
Non-surgical Management:
1. Radiation/CHemo
2.
3.
Surgical Management:
1. Resection if Bleeding
Other useful points:
CASE # 39
Hx: Patient presents with severe burns. The Chest represents 18%
BSA, Right arm is 9%, and Right Leg is 18%…so about 45%. Severe.
PE:
I want to make sure on physical exam that I perform the primary survey and a secondary survey.
I want to see how he is breathing, symmetrical or not. Is his trachea midline to rule out any
pneumothorax.
Labs:
1. CBC
2. Lytes
3. ABG.
4. Lactic acid
5. T&C
Radiological Studies:
I would get the usual trauma radiology studies, Lateral cervical, AP chest, AP pelvis
Non-surgical Management:
1. Dressings
2. Clean wounds
3.
Surgical Management:
1.escharotomy
2. debridement
3. skin grafting
14. Key points to the Hx: Past abdominal surgery (adhesions), N/V, bloating, crampy pain.
Questions to ask: Last BM (however, people can still have BM w/ a SBO because they
can shit out the stuff distal to the SBO). Meds (ie narcotics and anticholinergics). Past
medical history etc… On exam, listen for hyperactive bowel sounds, look and feel for
distension, look and feel for hernias. Labs: electrolytes (classically hypochloremic
hypokalemic alkalosis). Supine and upright AXRdilated loops of small bowel
without colonic distension but gas in colon and rectum and stepladder air-fluid levels.
In this case, it is most likely a mechanical obstruction from adhesions secondary to her
previous surgery. Keep in the differential the other big causes of SBO (hernias, cancer,
gallstone ileus). Treatment: NGT to decompress the bowel, IVF, NPO, keep an eye on
the lytes and check serial AXR. If the patient develops a fever, WBC, or tachycardia
OR for exploratory laparotomy.
15. Hx: Right groin pain with a right inguinal mass tells you it’s a hernia. Hernia-no big
deal, but this guy’s puking his guts out and c/o of distension. If you ask the guy how
long he’s had a bulge sticking out of his groin he’s probably going to say it’s been there
for a long time. Ask him if he used to be able to push it back it, he’ll probably say yes
but he can’t push it back in now and it hurts. So, we have a guy with an incarcerated
hernia causing a SBO. Do your physical exam and see if you can reduce the hernia. If
not, and you suspect you are dealing with an incarcerated hernia you need to do surgery
ASAP to prevent strangulation of the bowel.
16. Hx: Again, c/o N/V and distension. Brown vomit can be a clue that the vomitus is
coming from a place much more distal than the duodenum (bilious vomit). Make sure
the brown isn’t actually red or coffee-ground emesis (blood). So, 75 yo man with
brown vomit and distension. Ask if he’s able to keep any food down. Ask when his
last BM was or if he’s been passing gas. Ask if his stool has been bloody or tar colored
or if the caliber has changed. The physical will be the same as for the above-listen for
hyperactive sounds, look for distension, feel for hernias. Do a rectal if he answers yes
to any abnormal stool stuff. Let’s say we rule out hernia and adhesions (no past h/o
surgery) and we suspect a bowl obstruction. The top 3 causes of obstruction are
adhesions, hernias and cancer, so keep cancer in the back of your mind. Order lytes
and all that crap and AXR (supine and upright). For this case, I’m thinking the patient
will say he hasn’t had a bowel movement or gas for a time longer than usual
(obstipation). Then, AXR shows distended proximal colon, air fluid levels and no
distal rectal air. Compare this to AXR for number 14/15. So, obstipation and
distended colon with no rectal airthink large bowel obstruction. If this is how the
story unfolds at the oral exam (remember, it may be a case of SBO but I wanted to type
up a case of large bowel so you’d know how to work it up) then order a barium enema to
distinguish b/w ileus and pseudo-obstruction. The three most common causes of large
bowel obstruction are adenocarcinoma, diverticulitis and volvulus. Rule out
diverticulitis scarring by asking the typical questions for symptoms of diverticulitis or if
he’s ever been told he has diverticulosis/itis. He also didn’t c/o of any pain, which r/o
volvulus, which is associated with acute abd pain. So, again, the top 3 reasons for
obstrucion are adhesion, hernias and cancer. We’re thinking this is large bowel
obstruction, which can be caused by adenocarcinoma. Treatment: IVF, NGT, IV
antibiotics, surgery to relieve the obstruction (you don’t wait because NGT won’t
decompress the colon).
If the enema doesn’t show a mechanical obstruction, and you suspect
pseudo-obstruction (ogilvie syndrome) then place an NGT and rectal tube, IVF, d/c
narcotics and anticholinergics, mobilize patient, consider using neostigmine for
decompression. If peritoneal signs developexploratory lap with a cecostomy or loop
colostomy.
Please let me know if you don’t agree with any of the above information. This was just
my best guess using a few books. Good luck on the exams.
CASE # 17
Hx:
1. nausea 5.
2. mild abd pain 6.
3. vomit 7.
4. RLQ pain 8.
PE:
1. RLQ tenderness
2. Rigidity
3. Psoas sign
4. McBurney point
Labs:
1. CBC w/ WBC 10-18, PMN predominance, WBC > 18 => perforation
2.
3.
4.
Radiological Studies:
1. Abd CT 3. AXR
2. Abd US 4.
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1. Meckel’s diverticulum 3. cecum volvulus 5. acute appendicitis
2. intussusception 4. Crohn’s dz 6.
Most likely Diagnosis: acute appendicitis
Non-surgical Management:
1.
2.
3.
Surgical Management:
1. Appendectomy
2.
3.
4.
Other useful points:
Pain precedes vomiting. Pt does not want to eat
CASE # 18
Hx:
1. RLQ pain 5.
2. loss of appetite and nausea 6.
3. 7.
4. 8.
PE:
1. RLQ tenderness
2. Rigidity
3. Psoas sign
4. McBurney point
Labs:
1. CBC w/ WBC 10-18, PMN predominance, WBC > 18 => perforation
2.
3.
4.
Radiological Studies:
1. Abd CT 3. AXR
2. Abd US 4.
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1. Meckel’s diverticulum 3. cecum volvulus 5. acute appendicitis
2. intussusception 4. Crohn’s dz 6. PID, ruptured ectopic,
ovarian torsion
Most likely Diagnosis: acute appendicitis
Non-surgical Management:
1.
2.
3.
Surgical Management:
1. Appendectomy
2. If ruptured, fluid resuscitation, appendectomy, drained and Cx, post op antibiotic for 5-7
days
3.
4.
Other useful points:
Pain precedes vomiting. Pt does not want to eat. Risk of perforation 25% after 24hr of
onset of Sx, 50% after 36hr, and 75% after 48hr
CASE # 19
Hx:
1. constant LLQ pain 5. N/V
2. decreased stool caliber 6.
3. 101.5 temp 7.
4. 8.
PE:
1. Change of bowel habit
2. LLQ mass
3.
4.
Labs:
1. CBC w/ WBC increased
2.
3.
4.
Radiological Studies:
1. Abd CT (swollen bowel wall) 3. Avoid barium enema
2. AXR (ileus, distension, air-fluid levels, free air if perforated)
4. Avoid colonoscopy
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1. 3. 5.
2. 4. 6.
Most likely Diagnosis: diverticulitis
Non-surgical Management:
1. IV fluid
2. NPO, NGT
3. Broad-spectrum antibiotics
Surgical Management:
1. if obstruction, perforation, fistula, abscess, recurrent
2.
3.
4.
Other useful points:
CASE # 20
Hx:
1. LLQ discomfort 5.
2. generalized abd pain 6.
3. peritonitis 7.
4. 8.
PE:
1. Rebound tenderness
2. LLQ mass
3.
4.
Labs:
1. CBC w/ WBC increased
2.
3.
4.
Radiological Studies:
1. Abd CT (swollen bowel wall) 3. Avoid barium enema
2. AXR (ileus, distension, air-fluid levels, free air if perforated)
4. Avoid colonoscopy
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1. 3. 5.
2. 4. 6.
Most likely Diagnosis: diverticulitis w/ perforation
Non-surgical Management:
1. IV fluid resuscitation
2. NPO, NGT
3. Broad-spectrum antibiotics
Surgical Management:
1. if obstruction, perforation, fistula, abscess, recurrent
2.
3.
4.
Other useful points:
CASE # 21/22(colonic obstruction)...covers 24 also somewhat
Hx:
1.Age(increases w/ age>50) 4.Obstipation(no gas or stool passing)-passing gas in 8-12 hrs
is only partial obstruction-nonoperable condition
5.High pitch bowel sounds
2.Nausea/Vomiting 6. Medications-anticholinerics, sympathetics, narcotics decrease
GI motility
3.Cramping, abd pain 7. history/family histroy of colon ca/polyps
8. hight fat, low fiber diet
9. Prior melena, past H/O obstruction (volvulus)
10. h/o MI if operate
PE:
1.Distended abd
2.DRE
3.Fecal Occult blood testing(smack the ass!)
Labs:
1. CBC (anemia)
2. Lytes(check for imbalance leading to decreased motility)
3. WBC for infections
4.LFT-mets
5. CEA
6. Coags
Radiological Studies:
1.Supine/upright AXR (Shows Distended prox colon, air fluid levels, no distal rectal air) 2.
Barium enema (water soluble contrast-gastrogaffin)-Apple core filling defect for L. sisded CA;
Volvulus(kidney bean AXR, bird beak barium
3.Ct abd for tumors
4. CXR-check for free air, possible mets
Ancillary Testing:
1.Colonoscopy/sigmoidoscpy-evaluateentier colon and rectum for polyps, lesions(UC/crohns)
2.DRE
3. Transrectal Urethral Ulatrasound(TRUS), MRI,CT for depth of tumor invasion
Differential Diagnosis:
1. Adenocarcinoma (65%) Right vs Left side 2.scarring secondary to diverticulosis 3.
Volvulus 4. Ogilvie syndrome (pseudo obstruction 2nd to para/symp imbalance, lytes
imbalance, medications) %. Diverticulosis/Diverticulitis
Most likely Diagnosis: Case 21-Left sided colon Cancer(age, decreased stool caliber
Case 22- Volvulus/medication
Non-surgical Management:
1. NGT
2. correst fluid and lytes
3. Discontinue narcotics, monitor meds that decrease GI motility
4. Antibiotics if suspect perforation
5. Cancer-adjucant therapy- Duke C-5FU adn Levamisol or leucovorin
6. Rectal Ca-preop XRT if trnasmural add 5FU to radiosensitize
Surgical Management:
1.Surgical obstruction relief-emergency-Increased diameter-increased risk of perforation,
greatest at the cecum
2. Volvulus- Cecal-R. hemicolectlomy if vascular compromise and if rectal tube/sigmoidoscopy
or cecopexy doesnt relieve obstruction; Sigmoid vovlulus-sigmoidoscopy w/rectal tube insertion,
possible later elective resection due to hight recurrence rate
3. Emergent Laparotomy if strangulation or perforation suspected
4.Cancer-resect bowel 2 cm proximally and distally, lymph drainage
Other useful points:
-Colorectal Ca is 2nd most common cause of Ca deaths (behind lung)-at diagnosis, 10% insitu,
1/3 local Dz, 1/3 regional Dz, 20% mets; assoc. w/ microcytic anemia
R. sided-Occult bleeding w/ melena, anemia, weakness, wt loss, anorexia
L. sided-rectal bleeding, obstruction, change in bowel habits/caliber, wt loss, anorexia
Dukes Cancer Staging-A:limited to wall; B:Thru bowel wall but not to LN; C:Mets to regional
LN; D:distant mets
T1-invade submucosa T2-muscularis propria T3-subserosa, perirectal, or nonperitonealized
tissue T4-visceral peritneum, or direct invasion of other organs
N0-no nodes N1-1-3 pericolic/perirectal nodes N2->=4 LN N3-any Ln along course of named
vessel M0- no distant mets M1-distant mets
5 yr survival stage stage 1-72%, 2-54%, 3-39%, 4-rare; local recurrence after resection is 5-30%,
with total mesorectal excision-3.5%-recurrence may need pelvis exenteration
CASE # 34-Hernia
Hx:
1.prior hernia
2.prior abd surgery
3. abd mass(groin, umbilical)
4.increased intrabd pressure(COPD, frequent coughing, rectal straining, constipation,
weightlifing)
5. abd/groing trauma
6. worse at end of day, releived at night(lying down)
7. constipation/obstipation
8. if operate, h/o MI
9. many nonspecif discomfort, N/V, constipation abd pain, tenderness, fever
PE:
1.obesity
2. wall defect
3. standing cough
4.visualized mass
Labs:
1.CBC. lytes, coags if older
Radiological Studies: often not needed-clinical Dx is common
1. Ct abd
2. U/S
3. MRI
4. AXR
5. Herniography_axr with nonirritating contrast injected into hernial sac
Ancillary Testing: ?
Differential Diagnosis:
1.hernia-direct vs indirect
2.hydrocoele
3. Mass-lipoma, testiculare CA, abd wall mass, neoplasm
4.adenopathy
5 rectus sheath hematoma
Most likely Diagnosis:
Hernia- cant tell if direct or indirect until suregery
Non-surgical Management:
1. reduce manual
2. support devices
3. decrease straining through awareness
Surgical Management: generally all should be repaired surgically
1.herniotomy-cutting thru band of tissue constrictiing the strangulated hernia-ok for young and
muscular
2. herniorraphy
3.Lytle's repair-narrowing deep ring by suturing medial wall
4.Bassini, shouldice, Mcvay, Ogilvie
Other useful points: complications of surgery-ischemic orchitis w/ testicular atrophy,
neuralgia; recurrence is 1-3% over 10 yrs from excesive tension, deficient tissue, overlookee
hernia, more commona with direct hernia
Case # 23 new onset bld BM x2, 90/60, p 100, 75 y/o bright red bld per rectum
History: Lower GI Bleed. (bleeding distal to lig of Treitz)
DD: Diverticulosis, angiodysplasia >>> IBD, ischemic colitis, CA, anticoagulation therapy,
vulvulus, aortienteric fistula, meckel’s diverticulum
Symptoms: Painless vs painful BM, hematochezia/melena, anorexia, fatigue, syncope SOB and
shock
diverticulosis Angiodysplasia
Symptoms Large vol Bld Slow bleed
Painless painless
R side colon cecum ascending colon
>60 yrs old >60 yrs old
Fhx: Colon CA
Medication? Anticoag’s
Signs of Upper GI bleed: n/v etc..
PE: Hematochezia, positive hemoccult, abdominal tenderness, hypovolemic shock, orthostasis
Labs: CBC, Lytes BUN Cr, PT/PTT, Type and cross
Radiological/ancillary studies: 1) r/o Upper GI bleed- NGT/EGD
2) colonoscopy to localize slow to moderate bleeding
3) A-gram if large amount of active bleeding that can’t
be localized on colonoscopy
Slow bleeding: Radiolabled RBC: detect bleeding 0.1 ml/min or intermittent bleeding
A-gram: only detects bleeding if greater than 0.5-1.0 ml/min
Management (per Recall):
1)Hx/PE + Labs
2) NGT/EGD r/o Upper GI bleed
3) scope- identify bleed- non surgical stop bleed or colectomy
Can’t identify bleed - massive bld a-gram
Slow bld- labeled RBC
Surgical Management:
Initial management: IFV- LR or NS, PRBC as needed, Foley, NGT and d/c any aspirin -
consider stopping anticoag meds.
-80-90% stop bleeding with resuscitative measures only
-Emergent surgery only 10%
-Exploratory Lap with total colectomy and primary ileorectal anastamosis or total colectomy
with ileostomy
Nonsurgical Management: Ocetreotide, embolization, epinephrine injection during colonoscopy
to induce vasoconstriction, vasopressin causing vasoconstriction during A-gram, vasodestruction
with Etoh or sodium compound, coagulation/cautery via heat
Case # 24: Colorectal CA (adenocarcinoma most common)
Hx/PE: Fecal occult +, colonoscopy shows polyp-like mass in sigmoid and 1 cm polyp in
transverse colon
Signs/symptoms: Hematochezia, mucus tenesmus rectal mass
Right sided: Occult bleeding, melena anemia, weakness microcytic anemia
Left sided: Change in bowel habits, colicky pain obstruction, abd mass, gross red bld,
+n/v, constipation
Diet, family hx colon CA, hx IBD, Lynch Syndrome(HNPCC)
Labs: CBC, LFT’s CEA CBC lytes bun cr PT/PTT type and cross, UA
Radiographic: CT abd/Pelvis, CXR, CT head (mets)
Ancillary: Rectal exam, heme occult Sigmoid/Colonoscopy, barium enema(apple core filling
defect), endoscopy with bx,>>transrectal ultrasound, MRI
Staging Astler-Coller modified Dukes and TMN staging
Surgical management: Endoscopic resection if small, large sessile villous polyps = bowel
resection (at least 2 cm margins)
Resection dependent on location: R hemicolectomy-R side to mid transverse
L hemi- splenic flexure to Left colon, sigmoid colectomy- sigmoid and rectosigmoid, LAR (low
anterior resection)- Proximal rectum
APR(abd-peritneal resection) - Distal rectum
Nonsurgical /adjuvant: Dukes C: 5FU and leucovorin
Transmural + nodes: Pelvic radiation and 5 FU: preop-xrt
Case # 42 Pediatrics
Hx: 6 week old : Progressive Non bilious vomiting, progressive and becoming more severe
over several weeks DD: pyloric stenosis, milk allergy, increased IP, GERD, adrenal
insufficiency, uremia, mal rot, duod atresia, annular pancreas, duod web
1) pyloric stenosis- starts 3rd to 5th week of life/2weeks-2months
Non bilious vomit, progressive, projectile (+/-), hungry post vomit
**Hypochloremic/hypokalemic metabolic alkalosis
*****paradoxical aciduria
Fhx: 7% have affected parent, 1st born male (4:1 M:F)
PE: Olive mass mid epigastric, visible peristaltic wave, dehydration
Labs: Lytes
Radiographic: Ultrasound- elongated pyloric channel, thickened pyloric wall
Contrast: String sign- elongated pyloric channel
Shoulder sign- bulge of pyloric muscle into antrum
Double tract sign- parallel streaks of barium in narrow channel
Surgical treatment: Fredet-Ramstedt pyloromyotomy
Nonsurgical treatment: Correct fluid and electrolytes, acid base, D5 NS with KCL 3-5 mEq/kg
per first aid: D10 NS with 20 mEq of KCL per recall (vein of mayo crosses pylorus)
Case # 43 Pediatrics
Hx: 4 week old infant with bilious emesis, abdominal distension and bloody stools
DD:1)Malrotation with midgut volvulus (sudden onset bilious vomit)
Bilious vomiting in infant is malrotation until proven otherwise-recall
-cecum in RUQ
-ladd’s bands extend from normal cecum position across duodenum causing obstruction
-age: 75% 1-4 weeks old
2)intussusception (rare): 4-12 months of age (triad-bilious vomit, colicky abd pain and currant
jelly stool)
3)NEC- hx premature infants
PE: Mal rot. With midgut volvulus: acute onset bilious vomit, abd distention, lethargy, skin
mottling hypovolemia and bloody stool (late sign)
Labs: ?
Radiographic: Abd xray- distended loops of bowel proximal to volvulus, double bubble,
Upper GI with contrast-cut off in duodenum at volvulus
BE- abnormal position of cecum in upper abd.
Surgical management:
IV antibiotics, Fluid resus., emergent laparotomy Ladd’s Procedure, followed by second look
laparotomy 24 hrs postop if bowel is ischemic
Ladd’s procedure- counter clockwise rotation of midgut volvulus, split ladd’s bands, cut
peritoneal attachments to the cecum and ascending colon and appendectomy. Cecum is in LLQ
following Ladd’s procedure.
CASE #25 (anal fissure)
Hx:
1. Local trauma (constipation or excessive diarrhea)
2. Onset/duration of pain
3. Severity of pain (disproportionate to size of lesion); pain with defecation
4. Presence of bleeding (usually min. and bright red) in stool and/or on toilet tissue
5. Any prior history of recurrent anal fissures
6. PMH including any of the following: Crohn’s, anal cancer, sexually transmitted diseases,
UC, AIDS.
PE:
1. Markedly increased sphincter tone and extreme pain on digital examination
2. Visible tear upon gentle lateral retraction of anal tissue
3. In cases of chronic, recurrent anal fissures, classic triad of the following is pathognomonic:
a. external skin tag
b. fissure exposing internal sphincter fibers
c. hypertrophied anal papilla at the level of the dentate line
4. Presence of a sentinel pile (thickened mucosa/skin at the distal end of an anal fissure that
looks like a small hemorrhoid.
Ancillary Testing: colonoscopy in older individuals
Differential Diagnosis:
1. Anal fissure
2. Hemorrhoids
3. Any of the above diseases listed in #6 of the history
Most likely Diagnosis: Anal fissure
Non-surgical Management:
1. Sitz baths
2. Stool softeners
3. High fiber diet/ Increase fluid intake
4. Good anal hygiene
5. Mild, non-narcotic analgesic
Surgical Management:
1. Lateral internal sphincterotomy (LIS), in which a small portion of the internal sphincter is
cut, releasing the sphincter spasm, relieving pain, and allowing the fissure to heal. Small risk of
minor incontinence.
2. Forceful anal dilation (Lord procedure)-not done as commonly as LIS
Other useful points: Anal fissures are painful linear tears in the lining of the anal canal,
below the level of the dentate line. Most often located posteriorly in both sexes.
CASE #26
Hx:
1. Hx of ischiorectal abscess, Crohn’s disease, trauma, foreign body, TB, colorectal ca.
2. Recurrent or persistent anal drainage
3. History of “diaper rash”
4. itching
PE:
1. Goodsall’s rule used to help examiner predict the trajectory of the fistulous tract and probable
location of the internal anal opening.
-with the patient in the lithotomy or knee-chest position, an imaginary transverse line is
drawn through the anus. Fistulas originating anterior to the line will course straight ahead
and exit anteriorly. Those exiting posteriorly have a curved tract.
2. To find the internal rectal opening of an anorectal fistula, examiner may inject hydrogen
peroxide or methylene blue in external opening-then look for bubbles coming out of the
internal opening. The tract may also be identified by gently inserting a probe in the external
opening until the internal anal opening is found.
Diagnosis: 1. Bidigital rectal exam 2. Intrarectal ultrasound
Labs: CBC
Differential Diagnosis: 1. anal fistula 2. anorectal abscess
Most likely Diagnosis: Fistula in Ano
Non-surgical Management: never heal spontaneously; surgical correction is indicated to
eliminate the symptoms.
Surgical Management:
1. Fistulotomy (unroofing fistula tract and allowing to heal by secondary intention)
2. Wound care (routine sitz baths and dressing changes)
3. Seton placement if fistula is through the sphincter muscle.
(Heavy suture looped through the tract to keep it patent for drainage and to stimulate fibrosis.
Allows for continence after transection.)
Other useful points: An anorectal fistula is an abnormal communication between the anus (at the
level of the dentate line) and the perirectal skin. Usually the sequelae of anorectal infections, particularly
abscesses. Fistulas are named in relation to the sphincter mechanism.
1. Intersphincteric (70%): result of perianal abscess; fistula tract stays within intersphincteric plane.
2. Transsphincteric (25%): result of ischiorectal abscesses; fistula connects intersphincteric plane with
the ischiorectal fossa by perforating the external sphincter.
3. Suprasphincteric (4%): result of supralevator abscesses; fistula loops above the external sphincter to
penetrate the levator ani muscles.
4. Extrasphincteric (1%): bypass the anal canal and the sphincter mechanism and open high up in the
rectum.
50% of patients with a perirectal abscess develop a fistula in ano after drainage.
CASE # 38
Hx:
1. Hx of any severe sunburns before age 18
2. Family history of skin cancer
3. Use of tanning beds or frequent sunbathing
PE:
1. ABCD’s (asymmetry, border irregularity, color variation, diameter)
2. Palpate for any lymphadenopathy
Labs:
1.LFT’s (mets)
Radiological Studies:
1.CXR (mets)
Differential Diagnosis:
1. Cutaneous melanoma 3. Compound nevi 5. Blue nevi
2. Junctional nevi 4. Intradermal nevi 6. Seborrheic keratosis
Most likely Diagnosis: malignant melanoma
Surgical Management:
1. excisional biopsy (at least 1cm margins of resection)
2. sentinel node biopsy
Other useful points:
*most common sites: skin, eye, anus
*prognosis determined by depth of invasion,
CASE # 27
Hx:
1.fevers? 5.High cholesterol
2. hx of gallstones? 6.hx of hepatitis
3. Sickle cell or any other heme disorder? 7. Fluke exposure
4. Age 8.
PE:
1. murphys sign
2. splenomegaly
3. abd tenderness
4.
Labs:
1. cbc/lytes
2. alk phos
3. liver enzymes
4. bilirubin direct and indirect
Radiological Studies:
1. ultrasound 3. HIDA scan
2. intra op cholangiogram 4.
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis: possible Obstrxn
1. Choledocholethiasis 3.pancreatits 5.hepatits
2. Ampula of vater dysfxn 4. cholangiocarcinoma
6.
Most likely Diagnosis:
Obstrxn due to choledocholethiasis
Non-surgical Management:
1. meds to dissolve stones
2.lithotripsy
3.
Surgical Management:
1.ERCP with papillotomy and basket/balloon retrieval of stones
2.Lap trancystic duct or trans common bile duct retrieval
3. Open common bile duct exploration
4.if accompanying cholecystitis, then do cholecystectomy
Other useful points:R/o odd balls, think of obstrxn as prehepatic,
intrahepatic, and posthepatic
CASE # 28
Hx:
1.hx of gallstones? 5. hx of alcoholism
2.hx of pancreatitis 6.hepatits?
3.pain after fatty meals? 7.
4.blood disorders? 8.
PE:
1.murphys sign
2.abd tenderness
3.
4.
Labs:
1.cbc/lytes
2.amylase/lipase
3.lfts
4.alk phos/ bili direct and indirect
Radiological Studies:
1.ultrasound 3.HIDA
2. CT scan 4.
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1.Pancreatic CA in head of pancreas 3.pancreatic psuedocyst
2. pancreatitis 4.cholangiocarcinoma 5. hepatic cancer
Most likely Diagnosis:
Pancreatic CA based on U/s
Non-surgical Management:
1.
2.
3.
Surgical Management:
1. resection by whipple procedure ifr resectable
2.if not respectable, treat obstrxn and palliative txt
3.
4.
Other useful points:
CASE # 29
Hx:
1. When did it start?
2. Is the pain worsened upon inspiration?
3. Is there pain in the pt's. right scapula?
4. Chills, fever?
PE:
1. Observation-- does the pt. appear jaundiced/icteric?
2. GI--RUQ tenderness? Murphy's sign?
3. Does the patient appear to have any mental status changes?
4.
Labs:
1. Does the pt. appear to be in shock?
2. WBC
3. AST/ALT/Alk Phos./Total and Direct BIlirubin
4. Bile cultures--enteric gram negatives(klebsiella, e-coli) and enterococcus,
Radiological Studies:
1. Ultasound--dilation of common and intrahepatic bile ducts
3. Percutaneous Transhepatic cholangiography--
2. ERCP
Differential Diagnosis:
1. cholecystitis
Most likely Diagnosis:
Cholangitis
Non-surgical Management:
1. NPO, IVF, IV Abx.
2. If pt. in shock, decompress bile duct and remove obstruction immediately by ERCP/PTC. If
unsuccessful, intraoperative decompression with T-tube placement.
Surgical Management:
1. Removal of any ductal gallstones and performing cholecystectomy if gallstones were present.
Other useful points:
Charcot's triad- ruq pain (aggravateed by inspiration causing referred pain to the right scapula), high fever (w/
shaking chills), and jaundice
Reynold's pentad - Charoct's triad + shock + altered mental status
CASE # 30-Cholecystitis
Hx:
1. association with food
2. risk of cholelithiasis -fat, female, forty, fertile, flatulent , familial, cystic fibrosis, hemoglobin
F (sickle cell disease)
3. fever, nausea, vomiting, chills,
4. pain > 3 hrs (for acute calculous cholecystitis)
PE:
1. ruq pain? does pain radiate?
2. murphy's sign ?
Labs:
1. leukocytosis
2. alk phos, alt, ast, amylase, total bilirubin
Radiological Studies:
1. ultrasound-gallbladder wall thickening > 4mm, pericholecystic fluid and stones (headlight
appearance of stones)
2. hida scan- most sensitive
Differential Diagnosis:
1. cholelithiasis
2. cholangitis
Most likely Diagnosis: acute calculous cholecystitis
Non-surgical Management:
1. npo, IVF, IV Abx, IV analgesia,
Surgical Management:
1. cholecystectomy withing 24-48 hours
there is a need to differentiate between acute calculous cholecystitis and acute acalculous
cholecystitis. given the history of female, forty, and food association, this is most likely
calculous.
CASE # 31-cholecystitis
Hx:
1. no association with food 5. Was the pt. recently in the ICU
with multiorgan failure
2. pain in ruq? 6. Did the pt. recently aquire any
major burns
3. is there radiation to right shoulder ? 7. Was or is the pt. on TPN
4. fever 8. Does the patient appear
jaundiced
PE:
1. ruq pain?
2. radiation to the rt. shoulder?
3. positive Murphy's sign?
Labs:
1. Leukocytosis, Alk Phos., ALT, AST, amylase, total bilirubin 3.
2. 4.
Radiology
1. Ultrasound 3. ERCP 5.HIDA Scan
2. CT 4. Percutaneous Transhepatic cholangiography
Differential Diagnosis:
1. cholangitis
2. acute calculous/acalculous cholecystitis 3. Liver abscess
Most likely Diagnosis:
cholecystitis...
Non-surgical Management:
1. npo, IVF, IV Abx., IV analgesics
2.
3.
Surgical Management:
1. cholecystectomy
2. Ultasound or CT guided percutaneous drainage (Liver abcess)
3. Percutaneous cholecystostomy
Other useful points:
Whose your baby daddy?
CASE # 32
Hx:
1. EtOH 50% 5. Drugs (antiviral)
2. Gallstones 30% 6. Hypercalcemia
3. Idiopathic 10% 7. Autimmune
4. Hypertriglycerides 8. Symptoms: epigastric pain radiating to back, N/V
PE:
1.Epigastric tenderness, decreased bowel sounds (ileus), fever, dehydration/shock
2. Cullen’s sign: periumbilical bluish discoloration
3. Grey turner’s sign: flank discoloration
4.Fox’s sign: ecchymosis of inguinal ligament (2-4 with hemorrhagic pancreatitis
Labs:
1.CBC, LFT’s, amylase, lipase, Ca, Chem 10, coags, serum lipids
2. Increased amylase, lipase, WBC
3.
4.
Radiological Studies:
1.AXR: sentinal loops-distention,air-fluid levels 3.
2.CT : psuedocyst, abscess, necrosis 4.
Ancillary Testing:
1. U/S: same as CT 3.
2. 4.
Differential Diagnosis: gastritis, PUD, perforated viscus, acute cholecystitis, SBO,
mesenteric ischemia, Ruptured AAA, biliary colic, inferior MI, pnuemonia
1. 3. 5.
2. 4. 6.
Most likely Diagnosis:
Non-surgical Management:
1. NPO, IVF, NGT if vomiting, TPN, H2 blocker, Demerol, not morphine(sphincter of Oddi
spasm)
2.
3.
Surgical Management:
1. psuedocyst: drainage (percutaneous or operative) amylase remains elevated
2.
3.
4.
Other useful points: Look at Ranson’s Criteria (prognosis)
CASE # 33
Hx:
1.Smoking, diabetes mellitus, heavy EtOH, chronic pancreatitis, coffee,benzidine, age >60
2. Symptoms: painless jaundice, wt. loss, ABD pain, anorexia
PE:
1.Courvoisier’s sign: palpable, nontender gallbladder
2.
3.
4.
Labs:
1.Increased direct bili, increased alk phos, increased LFT, CEA and CA 19-9(markers)
2.
3.
4.
Radiological Studies:
1.Abdominal CT, U/S, ERCP (cell brushing, r/o stones)
3.
2. 4.
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1. 3. 5.
2. 4. 6.
Most likely Diagnosis:
Non-surgical Management:
1.
2.
3.
Surgical Management:
1.Whipple for head tumor, distal pancreatectomy for body/tail
inoperability: vascular encasement (portal vein, SMV, SMA), and any distant METS
2.
3.
4.
Other useful points: Poor prognosis: 5% alive in 5 years
CASE # 40
Hx:
1.AMPLE history: allergies, meds, PMH, pregnancy, last meal, environment
PE:
1. Trauma exam
2.peripheral pulses, evaluate for compartment syndrome
3. loss of sensation
4.
Labs:
1.Trauma panel: CBC, lytes, bun/cre, coags, ua, tox screen, Etoh, b-HCG
2.
3.
4.
Radiological Studies:
1. Trauma x-rays: chest, pelvis, c-spine, lower extremity (joint above and below)
2. CT: ABD, Head
Ancillary Testing:
1. 3.
2. 4.
Differential Diagnosis:
1. 3. 5.
2. 4. 6.
Most likely Diagnosis:
Non-surgical Management:
1. Reduction of fracture under sedation, irrigation, antibiotics and tetanus prophylaxis
2.
3.
Surgical Management:
1. fix fracture: intramedullary rod
2.
3.
4.
Other useful points: complications-compartment syndrome, fat
embolism, osteomyelitis, rhabdomyolysis, avascular necrosis, malunion,
nonunion
Know the A,B,C’s Resuscitation first
CASE # 35
Hx:
1. HPI of c/c
2. Risk factors - HTN, cholesterol, CAD, smoking, DM, etc.
3. Heart dysrhythmias - especially atrial fibrillation.
4. History of bleeding/clotting abnormalities.
5. Prior cardiac, vascular surgeries.
6. Fam hx of stroke, CAD, etc.
PE:
1. Blood pressure and heart rate. Remember HTN is #1 risk factor for stroke and an irregular
rhythm is present in A. Fib, which is a major risk factor for embolic stroke.
2. Complete vascular exam-all peripheral pulses and check for abdom aortic aneurysm.
3. Bruits?
4. Heart examination
Labs:
1. CBC
2. PT/PTT/INR
Radiological Studies:
1. Carotid Doppler/US - this is the procedure of 1st choice.
2. A-gram - gold standard
3. Echocardiography
Ancillary Testing:
1. ECG -signs of atrial fibrillation or old MI
Differential Diagnosis:
1. TIA 3. RIND
2. Stroke 4. Subclavian steal syndrome
Most likely Diagnosis: TIA with amaurosis fugax.
Non-surgical Management:
1. Anti-platelet therapy - ASA, etc.
2. Statins
3. Control atrial fibrillation, hypertension, DM, etc.
Surgical Management:
1. CEA
2. Angioplasty with Stent = generally in the sicker patient. Not as much data.
Other useful points:
CEA is recommended in the asymptomatic patient with >60% stenosis.
CEA is recommended in the symptomatic patient with >50% stenosis.
Stroke = permanent deficits
RIND = neurological deficits that resolve between 24-72 hrs.
TIA = resolve within 24 hrs.
Subclavian steal syndrome = Upper extremity claudication and signs of vertebrobasilar
insufficiency.
CASE # 36
Hx:
1. Most of these patients are asymptomatic
2. HPI
3. Pain? (back, abdominal, flank). May be a vague epigastric discomfort.
4. Hx of atherosclerosis (CAD, HTN, Smoking, Cholesterol, etc.)
PE:
1. Pulsatile mass - usually above umbilicus and left of midline.
2. Complete peripheral vascular exam (pulses, bruits, etc.)
Labs:
1. CBC
2. PT/PTT/INR
Radiological Studies:
1. Ultrasound - used to follow abdominal aortic aneurysms more than to diagnose them.
2. CT of abdomen and pelvis
3. Angiogram - gold standard
4. Carotid Doppler/US - check if carotid disease. If present, may need to do CEA first.
5. Abdominal x-ray - may see some calcifications in eggshell pattern. Not as important.
Differential Diagnosis:
1. Abdominal aortic aneurysm 3. Dissection 5. MI
2. Pancreatitis 4. Mesenteric ischemia 6. Other
Most likely Diagnosis: Abdominal Aortic Aneurysm.
Non-surgical Management:
1. Control of risk factors - blood pressure, quit smoking, etc.
2. If not over 5 cm, you can observe with serial US examinations every 6 months.
Surgical Management:
1. Prosthetic graft placement
2. Stenting - not as much data.
Other useful points:
Surgery is indicated when the aneurysm is >5-5.5cm in diameter, ruptured, rapid growth (>5mm
in 6 months), if symptomatic (painful).
Risk factors for rupture = large aneurysm, increasing diameter, COPD, diastolic HTN
Triad for rupture = Pain, pulsatile mass, hypotension.
If ruptured, very high mortality (>50% operative mortality). Many don’t make it to the OR.
Aneurysm = 1.5-2 times the normal size (by definition)
95% of abdominal aortic aneurysms are infrarenal in location.
CASE # 37
Hx:
1. HPI of c/c
2. PMH - CAD, cholesterol, smoking, HTN, DM, etc.
3. History of vascular or cardiac surgery.
4. Erectile dysfunction? Leriche’s syndrome.
PE:
1. Blood pressure
2. Complete peripheral vascular examination - pulses, bruits, etc.
3. Inspection for skin changes - pigmentation, lack of hair, nail changes, ulcerations, etc.
Labs:
1.
Radiological Studies:
1. LE Doppler
2. Angiogram - gold standard
Ancillary Testing:
1. ABI (may be falsely elevated if calcification of arteries, DM, etc.)
a. Normal > or = 1.0
b. Claudication <0.6
c. Rest pain <0.4
2. PVR - pulse wave forms. Large wave forms suggest good collateral blood flow.
Differential Diagnosis:
1. Peripheral vascular disease 2. neurogenic claudication 3. arthritis 4. Popliteal artery
syndrome 5. Chronic compartment syndrome 6. Diabetic neuropathy 7. Other
Most likely Diagnosis: Patient with intermittent claudication, rest pain
and non-healing ulcer.
Non-surgical Management:
1. If only intermittent claudication- risk factor modification (smoking, BP, diet), antiplatelet
therapy, exercise, medications- Trental, lotions, etc.
Surgical Management:
Indications for surgery include rest pain, tissue necrosis, infection, severe claudication with
failed conservative management or significantly reduced quality of life.
1. Bypass graft.
2. PTA with stent.
3. Endarterectomy
Other useful points:
Risk of limb loss is 5% over 5 years in patient with only intermittent claudication and 50% at
some point in patients with rest pain.
Leriche’s syndrome - impotence, buttocks claudication, gluteal atrophy). Seen with aortoiliac
disease.
Arterial ulcers are frequently located on dorsal/lateral aspect of foot (metatarsal region).
Venous ulcers are frequently located just above medial malleolus.
CASE # 41
Hx:
1. Pain - site, radiation, shift, nature (type, freq, severity), onset, duration, variation with time, modifying
factors
2. Associated symptoms - anorexia, nausea, vomiting, bowel function, urinary symptoms
3. Gynecological history
4. Trauma
5. Past medical history and previous operations
6. Drugs
7. Last meal
PE:
1. Auscultation - bowel sounds, bruits
2. Percussion - rebound, bladder size, ascites, HSM
3. Palpation - soft/rigid, tenderness, guarding, rebound, organomegaly, mass present
4. Inspection - distension, scars, color, bruising, stigmata, visible peristalsis, dehydration
5. Vitals
6. Rectal/Vaginal exams
Labs:
1. Blood tests: CBC with diff, UA, LFTs, amylase/lipase, glucose,
2. Type and Screen
3. Pregnancy test
4. Blood cultures
Radiological Studies:
1. US 2. Upright CXR
3. AXR (upright and supine, cannot stand= left lat decub abd film)
4. CT
Ancillary Testing:
1. ECG
2. Peritoneal lavage in trauma
Differential Diagnosis: (By Quadrant)
RUQ
Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumor, gastritis, hepatic
abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis (especially
during preg), thoracic causes: (pleurisy/pneumonia), PE, pericarditis, MI (esp. inf. MI)
LUQ
PUD, perforated ulcer, gastritis, splenic dz/rupture, abscess, reflux, dissecting aortic aneurysm,
throracic causes, pyelonephritis, nephrolithiasis, hiatal hernia (strangulated paraesophageal
hernia), Boerhaave’s syndrome, Mallory-Weiss tear, splenic artery aneurysm
LLQ
Diverticulitis, sigmoid vulvulus, perforated colon, colon ca, UTI, SBO, IBD, nephrolithiasis,
pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gyn causes:
ectopic, PID, mittelschmerz, ovarian cyst, fibroid degeneration, endometriosis, gyn tumor,
torsion of cyst or fallopian tube
RLQ
Same as LLQ but especially appendicitis, also mesenteric lymphadenitis, cecal diverticulitis,
Meckel’s diverticulum, intussusception
Most likely Diagnosis:
Appendicitis
Non-surgical Causes:
RUQ: RLL pneumonia, biliary colic, cholangitis, hepatitis, Fitz-Hugh-Curtis
Midepigastric: non-perf ulcer, mi, esophagitis, PE, pancreatitis, shingles, rectus sheath hematoma
RLQ or LLQ: ureteral calculi, regional enteritis, IBD, PID, endometriosis, prostatitis,
mittleschmertz, UTI, ruptured ovarian cyst
LUQ: LLL pneumonia, gastritis, splenomegaly, splenic infarct
Diffuse: abd wall hematoma, black widow spider bite, Pb poisoning, addisonian crisis, sickle cell
crisis, DKA, diabetic gastropathy, opiate withdrawal, hemorrhagic dengue fever, nerve root
compression
Surgical Causes:
RUQ: perf duodenal ulcer, cholecystitis, hepatic abscess, retrocecal appendicitis, pregnant
appendicitis
RLQ: appendicitis, cecal diverticulitis, Meckel’s diverticulitis
LLQ: sigmoid diverticulitis, volvulus
LUQ: splenic rupture, splenic abscess
Diffuse: bowel obstruction, leaking aneurysm, mesenteric ischemia
Periumbilical: early appendicitis, referred pain of small bowel
Suprapubic: ectopic, ovarian torsion, tubo-ovarian abscess, psoas abscess, incarcerated groin
hernia
Other useful points:
Always check for preg in women of childbearing years, check position: motionless with knees
flexed for peritonitis and writhing, restless, can’t stay still for kidney stones, scrotal causes:
torsion, epididymitis, orchitis, hernias, referred pain from kidney stones and appendicitis, careful
with the elderly: comorbid dz, don’t tolerated intravasc volume loss, unusual presentation, may
not mount wbc count or fever, complaint incommensurate with severity of dz, 2% have mi and
abd pain
CASE #44
Hx:
Where is the pain, how long has pt had pain, recurrent episodes?, duration, how often, palliative,
provocative, makes it worse (breathing, lying flat, moving arms, moving neck), quality (burning,
pressing, crushing, dull, aching, throbbing, knife-like, sharp, constricting, sticking), at rest?, with
exertion? After eating?, moving arms?, with emotional strain?, while sleeping?, during sex?,
occur with (SOB, palpitations, N/V, cough, fever, hematemesis, hemoptysis, leg pain?)
PE:
Poor skin color, diaphoresis, tachypnea, and anxious expression alert the physician to a
potentially lethal process. Evaluate the meaning of the vital signs. Tachycardia is non-specific - it
can suggest shock, severe pain, or physical stress - but it serves to alert the physician.
Tachycardia is particularly likely with pulmonary embolism. Blood pressure should be checked
in both arms. A difference of over 20 mm Hg systolic suggests aortic dissection - and will be
present in about two thirds of cases. Hypotension may suggest massive PE or cardiac shock.
Fever may suggest pneumonia or mediastinitis as the cause of chest pain. Tachypnea may simply
reflect severity, or can suggest pulmonary embolism or hyperventilation.
evidence of atherosclerosis (or risk factors for ASVD). Note corneal lipid rings, narrowed
retinal arteries, and pigment and hair changes in the legs.
Evaluate the neck veins for distension. Check the carotids for quality of pulse, and for
bruits. The chest wall should be inspected for respiratory motion, respiratory retractions or
accessory muscle use, and precordial motion. Identify the apical impulse (PMI). Feel for tender
areas. Many older patients will have tenderness. Only if the tender area corresponds to the
location of the patient’s pain, palpation exactly reproduces the pain, and the history suggests
chest wall pain, should the physician diagnose musculoskeletal chest pain.
Check the lungs for rales, wheezes, and asymmetrical breath sounds. Asymmetry of breath
sounds may be found in about half of patients with spontaneous pneumothorax. However,
asymmetry also can be due to splinting of the painful side of the chest in other conditions that
cause pleuritic pain. Wheezing will most likely be due to underlying COPD, but can occur due to
heart failure (cardiac asthma) or pulmonary embolism.
Listen to the heart tones. Wide physiologic splitting of the second heart sound (splitting
wider with inspiration) can be found in right bundle branch block or in right ventricular
infarction. New paradoxical splitting is most often due to left bundle branch block, or anterior or
lateral infarction. A new fourth heart sound (preceding the first heart tone) can occur with angina
or infarction. An S3 (third heart tone) is more likely due to underlying heart failure.
A new murmur may be significant. Aortic regurgitation occurs in over half of patients with
aortic dissection. New mitral regurgitation can occur in patients with angina or infarction, and is
due to papillary muscle dysfunction.
The extremities should be examined for pulses, edema, calf tenderness, and signs of
atherosclerotic vessel disease. Absence of pedal pulses may occur in aortic dissection. Any
swelling of the legs, especially if unilateral, raises the odds of pulmonary embolism as the cause
of chest pain. Pulmonary embolism often occurs in patients with CHF.
(excerpted from Argyle, B., Chest Pain Simulator Computer Program Manual.
Mad Scientist Software, Alpine UT, 1996: http://www.madsci.com/manu/ches_gen.htm#40 )
Labs:
electrolytes, complete blood count, clotting studies (PT & PTT), and baseline CPK
ABG (for patients in obvious respiratory distress, patients who may have shock or sepsis,
patients in whom the diagnosis of PE can be ruled out by normal room air blood gases,
and patients with underlying lung disease who must have monitoring of oxygen therapy.
A normal arterial-alveolar diffusion gradient on room air gases essentially excludes
significant PE)
(If the pain is cardiac-compatible, it’s best to await the ECG before ordering blood gases,
if the gas analysis is not critical for early management of the patient. If the ECG shows
infarction and thrombolytics are given, bleeding may prove problematic at the arterial
puncture site)
Radiological Studies:
CXR (pneumothorax, pneumomediastinum (such as from esophageal rupture), pleural
effusion, or infiltrates. Subtle findings such as loss of lung volume or unilateral decrease
in vascular markings may suggest pulmonary embolism. Dissection of the aorta can cause
a wide mediastinum or aortic knob contour changes)
perfusion scan, arteriogram, and gallbladder ultrasound, are ordered based on clinical suspicion
Ancillary Testing:
EKG (for MI, PE, electrolyte abnormalities, CVA, dissection etc.)
Differential Diagnosis:
MI, angina, aortic dissection, PE, spontaneous pneumothorax, pericarditis, mitral valve prolapse,
pneumonia, GERD, esophagitis, esophageal spasm, shingles
Most likely Diagnosis:
PE= tachypnea, tachycardia, sudden onset, shortness of breath
( I also like this as a Dx because of scenario 45 that lists basically the same pt. but three days
post op which just adds to the Dx.) This could also be MI or unstable angina or spontaneous
pneumo but I tend toward PE, any suggestions would be appreciated.
Non-surgical Management:
Depends on possible condition:
MI- ASA, beta blocker, nitro, morphine
PE- O2, anticoagulation, pressers, thrombolytics
Esophageal spasm- CCB, nitrates, tricyclics, bo-tox, balloon dilation
GERD- PPIs, H2 blockade
Pneumonia- antibiotics, fluids
Mitral prolapse- prepare for surgery, endocarditis prophylaxis, beta blockers, aerobic exercise
Etc.
Surgical Management:
valve problems- valve replacement, valve reconstruction
Aortic dissection- partial/complete arch repair or reconstruction
Ischemic Heart Dz- CABG, stents, angioplasty
Aortic aneurysm- surgery only for rupture, elective for thoracic aneurysm >7cm, degen
aneurysm-replace entire aortic root, repair
Pericarditis- drainage, tube, sclerosing agent, pericardectomy, pericardial window (esp for
recurrent or debilitated pt)
PE- Inferior vena cava (IVC) interruption by the insertion of an IVC filter
(Greenfield filter) is indicated in the following settings:
o Patients with acute venous thromboembolism who have an absolute
contraindication to anticoagulant therapy, eg, recent surgery, hemorrhagic
stroke, or significant active or recent bleeding
o Patients with massive PE who survived but in whom recurrent embolism
will be invariably fatal
o Patients who have objectively documented recurrent venous
thromboembolism, adequate anticoagulant therapy notwithstanding
An ideal IVC filter should have the following characteristics:
o Easy and safe placement by percutaneous technique
o Biocompatible and mechanically stable
o Ability to trap emboli without causing occlusion of the vena cava
One large trial has shown that during the first 12 days after insertion of IVC
filters, significantly fewer patients had recurrent PE. However, following a 2-year
follow-up, no significant differences in survival rates existed between the 2
groups. Furthermore, significantly higher rates of recurrent DVT occurred among
patients who received an IVC filter. Other complications of IVC filters include
proximal migration of the filter into the right heart chambers and perforation of the
IVC.
Other useful points:
PE emphasized slightly assuming it is the correct Dx. I got lazy at the end and just copied and
pasted from Emedicine. But at least it’s a good source. Obviously this paper isn’t all inclusive
but maybe forces some recall and thinking to get through this case.
CASE # 46
Hx:
1. OPQRST 5. Hx of MI esp <6mo
2. CHF (RF for DVT) , JVD, edema 6. RF for MI (smoke, FH, Chol, prior MI)
3. colon CA? (hypercoag) 7. Activity
4. Heparinized? (no heparin vs. HIT) 8. cough, fever, etc (pneumonia, empyema)
PE:
1. hemoptysis (PE)
2. Homans sign (PE)
3.Loud pulmonic S2 (PE)
4.Diaphoretic, etc
5.non-regular rhythm (dsyrrhythmias)
Labs:
1.Troponins, CKmb
2.ABG-look for decreased PO2, AND decreased PCO2 (hypervent in PE, or MI)
3.
4.
Radiological Studies:
1. V/Q scan (gold standard for PE) 3.CXR (hyperlucent wedge in PE)
2. Spiral CT (quickest for PE) 4.CXR pneumonia/effusions
Ancillary Testing:
1. EKG (ST seg for MI, flipped T waves in PE)
3.
2. 4.
Differential Diagnosis:
1. MI 3. pneumonia 5.
2. PE 4. 6.
Most likely Diagnosis:
My pick =MI- most heart attacks occur b/w day 2-5, and present with dyspnea and dysrhthmias
(often w/o pain though). DVT still strong candidate, as has had likely CA (colectomy),
Post-Op, likely laying around, etc. Pneumonia/empyema out there, but has had intubation,
hospitalization, etc.
Non-surgical Management:
1. MI“BEMOAN”=beta blocker, morphine, O2, ASA, Nitrates.
2. Stable PE1. Make sure airway secure. 2. Therapeutic dose heparin followed by 3-6 mo
coumadin or Greenfield filter. (get Greenfield if get DVT/PE even on coumadin, or inability to
take coumadin
3. Unstable PE1. airway ok? 2.Consider thrombolytics and Trendelenburg operation
(pulmonary embolectomy).
4. Pneumonia/empyemaairway secure, antibiotics
Surgical Management:
1. MIcardiac cath, CABG
2.PETrendelenburg operation, catheter suction embolectomy
3. empyemaVATS w/decortication
4.
Other useful points:
Have fun with this one, there is really no telling where they could take you on this ride. I
recommend knowing Sx, Dx, Tx, etc for all three differentials here.
CASE # 47
Hx:
1.COPD? (lotsa O2 shuts off drive) 5. CHF? Lotsa fluids in OR? (pulm edema)
2. lung dz (pneumonia, etc) 6. extubated at appropriate time?
3. Pre-Op NPO? (aspirate) 7. asthma
4. Drug allergies (bronchospasm) 8. Chest pain, irreg rhythm
PE:
1. Breath sounds
2. JVD, edema
3. wheezing, stridor
4.mental status (still out of it and extubated)
Labs:
1. ABG
2.
3.
4.
Radiological Studies:
1. CXR (ptx, infiltrate, etc) 3.
2. CT if suspect PE 4.
Ancillary Testing:
1. EKG 3.
2. O2 sats 4.
Differential Diagnosis: (NO ORDER HERE)
1. PE 3. Early extubation 5. Aspiration pneumonitis
2. PTX 4. Asthma 6. O2 in COPD’r
7. Pulmonary edema
Most likely Diagnosis:
This will depend 100% on answers given to questions above.
Non-surgical Management:
1. Albuterol if wheezing
2. Chest PT
3. Suctioning
4. reintubation
5. Supplemental O2 or lack thereof
6. heparin if PE
7. BEMOAN (see #46) Tx if MI
Surgical Management:
1. Chest tube if PTX
2. See case 46 for PE surgery-trendelenburg operation
3. MIcath, CABG, etc
4.
Other useful points: Sorry so broad, but we need to think broad.
