Pancreatic cancer
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Recent diagnosis of DM
Patient with symptoms of gnawing, constant epigastric pain and weight loss should get further
evaluation with CT scan of abdomen
Abdominal U/S is the initial evaluation of patients with painless jaundice, anorexia or weight loss
but it’s not the preferred modality for screening patient who have abdominal pain without
jaundice
Gastric cancer
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Present with epigastric pain and weight loss.
Friable tumor vessels can bleed into stomach lumen, leading to iron def. anemia. Metastasis to
liver can result in hepatomegaly and increase transaminases and alkaline phosphatase.
Workup starts with esophagogastroduodenoscopy to visualize the stomach
CT abdomen is then required to evaluate for metastatic disease
Depending on CT finding, additional staging procedures like laparoscopy, endoscopic U/S, chest
CT or PET
Patient with advanced disease are referred for palliative intervention such as laparotomy
Blunt abdominal trauma
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Rapid compression of the bowel during blunt abdominal trauma can cause perforated viscus.
When viscus perforation occurs within the retroperitoneum (duodenal tear), classic symptoms
and signs (fever, diffuse abdominal pain) may be delayed. Retroperitoneal free air may be
present on abdominal imaging
Back or flank pain may be present due to retroperitoneum inflammation
Vit K Def
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Due to inadequate dietary intake, intestinal malabsorption or hepatocellular disease. An acutely
ill patient with underlying liver disease can be deficient in 7-10 days. Labs show increase PT and
PTT
DIC show thrombocytopenia, increase PT and PTT, decrease fibrinogen and schistocytes on
smear
Von Willebrand show increase BT and PTT. PT is normal
Hemoptysis
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Massive is defined as >600ML over a 24hrs period or bleeding rate >100ML/hr.
Great danger is asphyxiation due to airway flooding with blood.
Initial Tx: establishing adequate patent airway, maintaining adequate ventilation and gas
exchange, and ensuring hemodynamic stability.
Place patient with bleeding lung in dependent position (lateral position)
Bronchoscopy is the initial procedure of choice in patient
Acute acalculous cholecystitis
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Acute inflammation of gallbladder in absence of gallstones.
Seen in hospitalized patients who are critically ill
Present with unexplained fever and diffuse or RUQ pain. You see jaundice, RUQ mass,
leukocytosis or abnormal LFT
Dx: U/S; if unclear do abdominal CT or cholescintigraphy (hepatobiliary iminodiacetic acid) scan
Empyema
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Bacterial pneumonia commonly causes a pleural effusion. Often the effusion is small, sterile and
resolves with antibiotics (uncomplicated). However, if bacteria persistently cross into the pleural
space, a complicated parapneumonic effusion or empyema can develop. Empyemas have frank
pus or bacteria (by gram stain) in the pleural space and require drainage (chest tube) in addition
to prolonged antibiotics
Sialadenosis
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Benign noninflammatory swelling of salivary glands. It result from overaccumulation of
secretory granules in acinar cells in patients with chronic alcohol use, bulimia or malnutrition
Can also result from fatty infiltration of glands in patients with diabetes mellitus or liver disease
Cirrhosis
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Patient with cirrhosis are unware until they develop complications such as hepatocellular
carcinoma that present with decompensated liver failure (ascites, jaundice, hypoalbuminemia),
weight loss and palpable liver lesion. AFP is usually elevated. Triple phase arterial contrast CT
scan of abdomen is diagnostic
Conductive hearing loss
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Caused by disorder of external auditory canal (cerumen impaction, otitis externa), tympanic
membrane (perforation), middle ear space (otitis media, cholesteatoma), or ossicular chain
(otosclerosis)
Otosclerosis results from an imbalance of bone resorption and deposition that leads to stiffening
and ultimately fixation of stapes. May progress during pregnancy and it is autosomal dominant.
Tx is hearing amplification or surgical reconstruction of stapes
Sensorineural hearing loss= meniere disease, aminoglycoside antibiotics, presbycusis, and
vestibular schwannoma
Intra-abdominal abscess
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Patients who receive a laparoscopic appendectomy are at much greater risk for intra-abdominal
abscess than those receiving laparotomy. Intra-abdominal abscess should be suspected when
fever, pain, vomiting return days after an abdominal operation
Boerhaave syndrome
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Esophageal perforation
Forceful retching increase intraesophageal pressure to cause full thickness effort rupture of
esophagus leading to efflux of esophageal fluid and air in mediastrinum. The leaked GI content
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cause chest/abd pain, fever. The leaked air (pneumomediastinum) may be palpated as
suprasternal crepitus (subcutaneous emphysema
Dx: esophagography or CT scan with water soluble contrast
Tx: IV antibitics and PPI, oral intake restricted and emergent surgical consultation
Mallory Weiss: mucosal tear; submucosal venous or arterial plexus bleeding giving you
hematemesis. Dx by upper GI endoscopy and most heal spontaneously
Spinal cord injury
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Central cord syndrome is common after whiplash type injuries in older adults with underlying
cervical spondylosis. Damage to the central cervical spinal cord causes upper extremity motor,
sensory, and reflex abnormalities; sacral (bowel/bladder) and lower extremity function is
generally preserved
Post-amputation pain
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Acute stump pain
o Tissue and nerve injury
o Severe pain lasting 1-3 weeks
Ischemic pain
o Swelling, skin discoloration
o Wound breakdown
o Decrease transcutaneous oxygen tension
Post traumatic neuroma
o Weeks to months after amputation
o Focal tenderness, altered local sensation
o Decrease pain with anesthetic injection
Phantom limb pain
o Onset within 1 week
o Increased risk in patients with severe acute pain
o Intermittent cramping, burning felt in distal limb
Pancreatic injury
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Persistent abdominal discomfort/tenderness
Persistent nausea/emesis
Increasing amylase over serial measurement
Peripancreatic fluid collection (due to pancreatic duct injury)
Cardiac tamponade
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Cardiac catheterization reveals elevated and equilibrated intracardiac diastolic pressures (right
atrial, right ventricular, and PCWP suggestive of left atrial pressure)
Urgent echocardiography should be performed for definitive diagnosis and management
Warfarin
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Patient on warfarin who require urgent surgery with high risk of bleeding or those experiencing
hemorrhage should get prothrombin complex concentrate and IV vitamin K. if unavailable
Give fresh frozen plasma
Liver abscess
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Entamoeba histolytica is a protozoan that cause colitis or extraintestinal (liver, pleura, brain)
illness in patients who live in or travel to developing countries. Amebic liver abscess has RUQ
pain, fever and a single subcapsular lesion in right lobe. Dx is made with serology
Renal artery stenosis
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Severe hypertension and recurrent flash pulm. Edema in setting of diffuse atherosclerosis
suggests Renal artery stenosis. Associated finding are CKD and evidence of secondary
hyperaldosteronism (hypokalemia, increase bicarbonate); urinalysis is bland and Dx is confirmed
with renal imaging (renal U/S with doppler)
Salter harris Fracture
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Aka juvenile tilaux fracture is characterized by fracture of distal tibial epiphysis and lateral physis
(growth plate) and occurs in adolescent when the physis is fused. Injury to growth plate can
cause growth arrest and lead to persistent limb length discrepancy.
Other complication are formation of physeal bars (bony bridges across the growth plate)
premature osteoarthritis and decrease range of motion
Scaphoid fracture
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Displaced scaphoid fracture should be considered for surgical intervention. Wrist immobilization
with a cast can be considered for nondisplaced fracture but patients should be monitored with
serial X-ray to rule out osteonecrosis of proximal segment and nonunion of the fracture
Basal cell carcinoma
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Appear as an enlarging fleshy nodule with ulceration.
Associated with sun exposure and is most common on face, neck and extremities
Osteomyelitis
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Diabetic foot infections are deep, long standing are polymicrobial with a mixture of grampositive (S. aureus, S. Pyogenes), gram-negative (Pesodomonas) and anaerobic organisms.
Underlying osteomyelitis is common due to contiguous spread from the wound
Urethral stricture
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Characterized by fibrotic narrowing of urethra and occurs in bulbar portion
Are idiopathic and secondary causes include urethral trauma (pelvic fracture, iatrogenic
instrumentation), infection (sexually transmitted urethritis) and radiotherapy
Can lead to urine retention, recurrent UTI, bladder stones
Patient have obstructive type voiding symptoms (weak urine stream, urinary spraying)
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Dx: elevated postvoid residual volume….voiding cystourethrogram or cystourethroscopy can
confirm the diagnosis
Tx: urethral dilation or surgical urethroplasty