SURGERY
UWorld Step 2 Tables and Images (Subject)
Table of Contents
Cardiovascular System
Aortic and peripheral artery diseases
Ankylosing spondylitis
Aortic aneurysm
Evaluation of suspected unstable abdominal aortic aneurysm
Aortic dissection
Turner syndrome
Blunt thoracic aortic injury
Thoracic aortic injury
Compartment syndrome
Gunshot injury
Informed consent
Peripheral vascular disease
Cardiac arrhythmias and syncope
11
11
11
12
13
14
15
16
17
17
18
18
19
19
Acute limb ischemia
19
Coronary heart disease
20
Local vascular complications of cardiac catheterization
Myocardial infarction
20
21
Heart failure and shock
22
Adrenal insufficiency
Anaphylaxis
22
23
Miscellaneous
24
Ehlers danlos syndrome
24
Myopericardial diseases
25
Acute pericarditis
Blunt thoracic trauma
Blunt chest trauma
Cardiac tamponade
Pericardial effusion
25
25
26
27
28
Valvular heart diseases
Aortic stenosis
Atrial myxoma
Endocarditis
Mechanical valve
Mitral regurgitation
Mitral stenosis
Pulmonary stenosis
Tricuspid regurgitation JVP waveform
Dual chamber pacemaker
Ear, Nose & Throat (ENT)
Disorders of the ear, nose, and throat
Acute parotitis
Branchial cleft cysts
Cerebrospinal fluid rhinorrhea
Ear trauma
Epiglottitis
29
29
29
29
30
30
31
32
32
33
34
34
34
35
35
36
36
Referred otalgia
Nasopharyngeal carcinoma
Anatomy of lateral wall
Osteonecrosis
Otosclerosis
Management of suspected peritonsillar abscess
Recurrent respiratory papillomatosis
Deep neck space anatomy
Parotid tumor compressing facial nerve
Thyroglobulin used as a tumor marker
Vestibular schwannoma
Endocrine, Diabetes & Metabolism
Diabetes mellitus
Diabetes mellitus
Peripheral neuropathy
Endocrine tumors
Pheochromocytoma
Hypothalamus and pituitary disorders
Acromegaly
Prolactin & amenorrhea
Miscellaneous
Hypercalcemia
Diagnosis of hypercalcemia
Hyperparathyroidism
Hyponatremia
Normal structure and function of endocrine glands
38
38
39
39
40
41
42
43
44
45
45
46
46
46
46
47
47
48
48
49
49
49
50
51
52
52
Hypocalcemia
52
Thyroid disorders
53
Euthyroid sick syndrome
Hyperthyroidism
Evaluation of thyroid nodules
Gastrointestinal & Nutrition
53
53
54
55
Biliary tract disorders
55
Cholangiocarcinoma
Cholecystitis
Hemobilia
Porcelain gallbladder
55
55
57
58
Congenital and developmental anomalies
Tracheoesophageal fistula
Umbilical hernia
Disorders of nutrition
Bariatric surgery
Dumping syndrome
Obesity
Small intestinal bacterial overgrowth
Zinc deficiency
Gastroesophageal disorders
Esophageal cancer
58
58
59
59
59
60
60
61
61
62
62
Esophageal rupture
Esophagitis
Variceal hemorrhage bleed algorithm
Gastroparesis
Hiatal hernia
Mallory-weiss syndrome
Pneumoperitoneum on upright chest x-ray
Zenker diverticulum
Hepatic disorders
62
63
64
65
65
66
66
67
70
Biliary atresia
Liver laceration
Focal nodular hyperplasia
Hepatic adenomas
Hereditary hyperbilirubinemias
Liver abscess
Primary Sclerosing Cholangitis
70
71
71
72
72
73
73
Intestinal and colorectal disorders
74
Anal fissure
Management of suspected appendicitis
Intraperitoneal free air on abdominal CT scan
Blunt abdominal trauma
Bowel obstruction
Chronic diarrhea
Management of Clostridioides difficile infection
Colonic ischemia
Colorectal polyps and cancer
Diverticular disease
Diverticulitis
Fecal incontinence
Fistula in ano
Age-based evaluation of occult gastrointestinal bleeding
Hemorrhoids
Incisional hernia
Inflammatory bowel disease
Toxic megacolon
Mesenteric ischemia
Ogilvie syndrome
Paralytic ileus
Complicated small-bowel obstruction with perforation
Rectal prolapse
Volvulus
Cecal volvulus
Miscellaneous
Groin hernias
Ovarian cancer
Subdiaphragmatic free air on upright chest x-ray
Polyarteritis nodosa
Psoas abscess
Retroperitoneal hematoma
Spleen rupture
Evisceration
Pancreatic disorders
74
75
76
76
77
77
78
78
79
79
80
81
81
82
83
85
85
87
87
88
88
90
90
91
91
92
92
93
93
94
94
95
95
95
96
Acute pancreatitis
Pancreatic pseudocyst
Ascites
Chronic pancreatitis
Compartment syndrome
Tumors of the GI tract
Colorectal cancer screening
Colorectal polyps and cancer
Staging of gastric adenocarcinoma
Pancreatic cancer
Pancreatic and biliary duct system
Approach to hyperbilirubinemia in adults
Zollinger ellison syndrome
Suspected gastrinoma
96
97
98
99
100
100
100
101
101
101
103
104
105
105
General Principles
106
Miscellaneous
106
Penetrating abdominal trauma
Perioperative medical management
Surgical wound infection
Thermal burn
Traumatic brain injury
Hematology & Oncology
Hemostasis and thrombosis
DIC
Heparin induced thrombocytopenia
Rectus sheath hematoma
Venous thromboembolism
Treatment of deep venous thrombosis
Principles of oncology
Mediastinal Compartments, Structures, & Masses
Spinal cord compression
106
107
107
108
108
109
109
109
110
110
111
112
113
113
114
Transfusion medicine
114
Blood transfusion
Hypovolemic shock
114
115
Infectious Diseases
Antimicrobial drugs
Animal and human bite injuries
Lymphangitis
Bacterial infections
Acute diarrhea
Animal and human bite injuries
Endocarditis
Evaluation of suspected ventilator-associated pneumonia
Necrotizing soft tissue infections
Timeline of cause of postoperative fever
Septic arthritis
Surgical wound infection
Toxic shock syndrome
Vibrio vulnificus
116
116
116
116
117
117
117
118
119
120
120
121
121
122
122
Miscellaneous
123
Splenectomy
123
Parasitic and helminthic infections
Echinococcosis
Liver abscess
Male Reproductive System
Disorders of the male reproductive system
Benign prostatic hyperplasia
Transurethral resection of the prostate (TURP)
Benign prostatic hyperplasia (BPH)
Cryptorchidism
Epididymitis
Penile anatomy
Priapism
Prostate cancer
Prostatitis
Testicular cancer
Testicular torsion
Varicocele
Miscellaneous (Multisystem)
Miscellaneous
Shoulder dislocation
Nervous System
Anesthesia/pharmacotherapy
Delirium
Cerebrovascular disease
Hemorrhagic stroke
Initial management of stroke
Congenital and developmental anomalies
Malignant hyperthemia
Neurofibromatosis
123
123
124
125
125
125
125
126
126
127
127
128
128
129
129
130
131
132
132
132
133
133
133
134
134
135
135
135
135
Disorders of peripheral nerves and muscles
136
Management of unilateral facial weakness
Carpal tunnel syndrome
Femoral nerve
Axillary nerve injury
136
137
138
139
Neurodegenerative disorders and dementias
Normal pressure hydrocephalus
Spinal cord disorders
Anterior cord syndrome
Cauda equina syndrome
Central cord syndrome
Cervical myelopathy
Cervical spondylosis
Epidural abscess
Spinal epidural abscess
Radiculopathy
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139
140
140
141
142
142
143
144
145
146
Facet dislocation
Autonomic dysreflexia
Syringomyelia
Traumatic brain injuries
147
148
149
150
Types of brain herniation
Inferior rectus entrapment
Acute subdural hematoma
Traumatic brain injury
150
151
152
152
Tumors of the nervous system
153
Meningioma
Pituitary apoplexy
Ophthalmology
Disorders of the eye and associated structures
153
154
155
155
Cataract
Endophthalmitis
Endopthalmitis
Glaucoma
Glaucoma pathophysiology
Hyperthyroidism
Ocular trauma
Management of corneal abrasion
Eye irrigation devices
155
156
157
157
158
159
159
161
162
Poisoning & Environmental Exposure
163
Environmental exposure
163
Accidental hypothermia
Insect bites and stings
Snake bite
Thermal burn
Escharotomy
163
163
164
164
165
Pulmonary & Critical Care
Cancer and pulmonary/mediastinal masses
Carcinoid tumors
Lung cancer
Lung nodule
Congenital and developmental anomalies
Diaphragmatic rupture
166
166
166
166
167
167
167
Critical care and trauma medicine
168
ARDS
Acute respiratory failure
Blunt thoracic trauma
Flail chest
Diaphragmatic hernia
Rib fractures with hemothorax
Evaluation of hemoptysis
Penetrating neck trauma
Pneumothorax
Pulmonary contusion
Respiratory acidosis
Thermal burn
168
168
169
169
170
171
172
173
173
175
175
177
Interstitial pulmonary and other systemic disorders
Atelectasis
Interstitial lung disease
Miscellaneous
Foreign body aspiration
Lung transplantation
Pulmonary infections
Ludwig angina
Aspiration pneumonia
Cytomegalovirus
Healthcare associated pneumonia
Pathogenesis of ventilator-associated pneumonia (VAP)
Lung abscess
Parapneumonic effusion & Empyema
Pulmonary vascular and cardiopulmonary disease
Av malformation
Fat embolism
Diagnostic strategy in suspected pulmonary embolism
Approach to patient with suspected pulmonary embolism
Transfusion related acute lung injury
Renal, Urinary Systems & Electrolytes
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177
179
179
179
180
181
181
182
183
183
184
185
185
186
186
187
187
188
189
190
Acute kidney injury
190
Prerenal azotemia
190
Chronic kidney disease
191
Renal osteodystrophy
Renal artery stenosis
191
192
Cystic kidney diseases
193
Polycystic kidney disease
Renal cysts
Fluid, electrolytes, and acid-base
Metabolic acidosis
Metabolic alkalosis
Respiratory alkalosis
Neoplasms and trauma of the kidneys and urinary tract
Bladder cancer
Male urogenital anatomy
Renal cell carcinoma
Nephrolithiasis, hematuria, and urinary tract obstruction
Renal calculi
Management of ureteral stones
Renal vein thrombosis
Urinary incontinence/retention, GU infection
Urinary tract obstruction
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194
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195
196
196
197
197
199
199
200
201
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201
Rheumatology/Orthopedics & Sports
202
Arthritis and spondyloarthropathies
202
Bursitis
Lateral knee
202
203
Management of osteoarthritis
Osteoarthritis (knee)
Hip osteoarthritis
Septic arthritis
Bone tumors and tumor-like lesions
Giant cell tumor of bone
Ganglion cyst
Myositis ossificans
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205
206
206
207
207
208
208
Bone, joint, and soft tissue injuries and infections
209
Acromioclavicular injuries
Acute pain
Adhesive capsulitis
Amputation
Ottawa ankle rules
Anorexia nervosa
Baker cyst
Bursitis
Clavicle fracture
Colles fracture
De Quervain tendinopathy
Dupuytren's contracture
Hip fracture
Posterior hip dislocation
Femoral neck fracture
Clinical features of femoral neck fracture
Iliotibial band syndrome
Posterior knee dislocation
Knee trauma
Medial collateral ligament injury
Neurogenic arthropathy
Pathogenesis of neuropathic (Charcot) arthropathy
Osteomyelitis
Osteonecrosis
Osteoporosis
Patellar dislocation
Patellofemoral pain syndrome (PFPS)
Open book pelvic fracture
Plantar fascitis
Rotator cuff
Distal tibial physeal fracture (Salter-Harris type III)
Scaphoid avascular necrosis
Stress fractures
Complications of supracondylar fracture
Buckle fracture
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219
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221
222
223
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225
226
226
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231
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234
Congenital and developmental anomalies
Ganglion cyst
Slipped Capital Femoral Epiphysis
235
235
235
Metabolic bone disorders
236
Osteonecrosis
Tarsal tunnel syndrome
236
236
Miscellaneous
Anterior thigh anatomy
237
237
Spinal/peripheral nerve disorders and back pain
Back pain
Spinal deformity
Vertebral compression fracture
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238
239
240
Cardiovascular System
Aortic and peripheral artery diseases
ANKYLOSING SPONDYLITIS
Ankylosing spondylitis
Inflammatory back
pain
•
•
•
•
Insidious onset at age <40
Symptoms >3 months
Relieved with exercise but not rest
Nocturnal pain
Examination findings
•
•
•
•
•
Arthritis (sacroiliitis)
Reduced chest expansion & spinal mobility
Enthesitis (tenderness at tendon insertion
sites)
Dactylitis (swelling of fingers & toes)
Uveitis
Complications
•
•
•
Osteoporosis/vertebral fractures
Aortic regurgitation
Cauda equina syndrome
Laboratory
•
•
Elevated ESR & CRP
HLA-B27 association
Imaging
•
X-ray of sacroiliac joints
•
MRI of sacroiliac joints
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
AORTIC ANEURYSM
Abdominal aortic aneurysm
Risk factors
•
•
•
Advanced age (eg, >60)
Smoking, male sex, hypertension
History of atherosclerosis or CTD
Clinical
presentation
•
•
Mostly asymptomatic
Rapid expansion
–
Dull abdominal/back pain
–
Distal embolization
Rupture
–
Sudden, severe abdominal/back pain ±
shock
–
Umbilical/flank hematoma
•
Management
•
•
•
Smoking cessation
Elective repair for size >5.5 cm (asymptomatic)
Urgent repair for symptomatic & HD stable
patients
•
Emergency repair for symptomatic & HD unstable
patients
CTD = connective tissue disease; HD = hemodynamically.
Evaluation of suspected unstable abdominal aortic aneurysm
AORTIC DISSECTION
Acute aortic dissection
Clinical
presentation
•
•
•
Diagnosis
•
•
•
Treatment
History of HTN, genetic disorder (eg, Marfan
syndrome)
Severe, sharp, tearing chest or back pain
>20 mm Hg difference in SBP between arms
ECG: normal or nonspecific ST- & T-wave
changes
Chest x-ray: mediastinal widening
CT angiography or TEE for definitive diagnosis
•
•
•
•
Pain control (eg, morphine)
Intravenous beta blockers (eg, esmolol)
± Sodium nitroprusside (if SBP >120 mm Hg)
Emergent surgical repair for ascending
dissection
HTN = hypertension; SBP = systolic blood pressure; TEE = transesophageal
echocardiogram.
Acute aortic dissection
Clinical features
•
•
•
Complications
due to extension
(involved
structure)
•
•
•
•
History of HTN*, Marfan syndrome, cocaine use
Severe, sharp, tearing chest or back pain
± >20 mm Hg variation in SBP between arms
Stroke (carotid artery)
Acute aortic regurgitation (aortic root/valve)
Horner syndrome (carotid sympathetic plexus)
Myocardial ischemia/infarction (coronary artery
ostia)
•
Pericardial effusion/tamponade (pericardium)
•
Hemothorax (pleural cavity)
•
Renal injury (renal arteries)
•
Abdominal pain (mesenteric arteries)
•
Lower extremity paraplegia (spinal arteries)
HTN = hypertension; SBP = systolic blood pressure.
*
Strongest overall risk factor.
Acute aortic dissection
Clinical features
•
•
•
Complications
due to extension
(involved
structure)
•
•
•
•
History of HTN*, Marfan syndrome, cocaine use
Severe, sharp, tearing chest or back pain
± >20 mm Hg variation in SBP between arms
Stroke (carotid artery)
Acute aortic regurgitation (aortic root/valve)
Horner syndrome (carotid sympathetic plexus)
Myocardial ischemia/infarction (coronary artery
ostia)
•
Pericardial effusion/tamponade (pericardium)
•
Hemothorax (pleural cavity)
•
Renal injury (renal arteries)
•
Abdominal pain (mesenteric arteries)
•
Lower extremity paraplegia (spinal arteries)
HTN = hypertension; SBP = systolic blood pressure.
*
Strongest overall risk factor.
Turner syndrome
Blunt thoracic aortic injury
Thoracic aortic injury
COMPARTMENT SYNDROME
Clinical features of compartment syndrome
Common
•
•
•
•
Pain out of proportion to injury
Pain ↑ on passive stretch
Rapidly increasing & tense swelling
Paresthesia (early)
Uncommon
•
•
•
•
↓ Sensation
Motor weakness (within hours)
Paralysis (late)
↓ Distal pulses (uncommon)
GUNSHOT INJURY
Extremity vascular trauma
Clinical manifestations
Hard signs
•
•
•
•
Observed pulsatile bleeding
Presence of bruit/thrill over injury
Expanding hematoma
Signs of distal ischemia
Soft signs
Evaluation
•
History of hemorrhage
•
Diminished pulses
•
Bony injury
•
Neurologic abnormality
If hard signs or hemodynamic instability
•
Surgical exploration
Otherwise
•
•
•
Injured extremity index
CT scan or conventional angiography
Duplex Doppler ultrasonography
Preconditions
•
•
Competency
Voluntariness
Disclosure of key facts
•
•
•
•
Diagnosis
Proposed treatment or procedure
Alternate treatment options (medical,
surgical)
Risks/benefits of proposed treatment &
alternatives
–
Common complications
–
Rare but major complications
Risks of refusing treatment
•
•
•
Role of residents & medical students
Anticipated additional procedures
Financial conflicts
INFORMED CONSENT
Elements of informed consent
•
Other disclosures if
applicable
PERIPHERAL VASCULAR DISEASE
Ankle-brachial index
ABI = SBP of dorsalis pedis or posterior tibial artery ÷ SBP of brachial artery
≤0.9
Diagnostic of peripheral artery disease
0.91-1.3
Normal
>1.3
Suggests calcified & uncompressible vessels*
*Other testing should be considered.
ABI = ankle-brachial index; SBP = systolic blood pressure.
Cardiac arrhythmias and syncope
ACUTE LIMB ISCHEMIA
Acute limb ischemia
Etiology
Clinical
features
Management
•
Cardiac/arterial embolus (eg, AF, LV thrombus, IE)
•
Arterial thrombosis (eg, PAD)
•
Iatrogenic/blunt trauma
6 Ps of acute limb ischemia
•
•
•
•
•
•
Pain
Pallor
Paresthesia
Pulselessness
Poikilothermia (cool extremity)
Paralysis (late)
•
Anticoagulation (eg, heparin)
•
Thrombolysis vs surgery
AF = atrial fibrillation; IE = infective endocarditis; LV = left ventricular; PAD =
peripheral artery disease.
Coronary heart disease
Local vascular complications of cardiac catheterization
MYOCARDIAL INFARCTION
Mechanical complications of acute myocardial infarction
Complication
Time
course
Involved Clinical
coronary findings
artery
Papillary
muscle
rupture/
dysfunction
Acute
or
within
3-5
days
RCA
•
•
•
Interventricular Acute
septum
or
rupture
within
3-5
days
Free wall
rupture
Left ventricular
aneurysm
LAD
(apical
septal)
or RCA
(basal
septal)
•
•
•
Within LAD
5 days*
or up
to 2
weeks
•
•
Up to
LAD
several
months
•
•
•
•
Echocardiography
findings
Severe MR
Severe
pulmonary
edema,
respiratory
distress
New early
systolic
murmur
Hypotension/
cardiogenic
shock
Left-to-right
Chest pain
ventricular
New
shunt**
holosystolic
murmur
Hypotension/
cardiogenic
shock
Chest pain
Distant heart
sounds
Shock, rapid
progression
to cardiac
arrest
Pericardial
effusion with
tamponade
Heart failure
Angina
Ventricular
arrhythmias
Thin & dyskinetic
myocardial wall
*50% occur with 5 days.
**Right heart catheterization shows step up in O2 concentration from right atrium
to right ventricle.
LAD = left anterior descending; MR = mitral regurgitation; RCA = right coronary
artery.
Left ventricular aneurysm
Etiology
•
Scar tissue deposition following transmural MI
Clinical
presentation
•
•
•
Several months following MI
Heart failure & angina
Ventricular arrhythmia (eg, ventricular
tachycardia)
Systemic embolization (eg, stroke)
•
Diagnosis
•
•
ECG: Persistent ST elevation, deep Q waves
Echocardiograph: Thin and dyskinetic myocardial
wall
MI = myocardial infarction.
Heart failure and shock
ADRENAL INSUFFICIENCY
Acute adrenal insufficiency (adrenal crisis)
Etiology
•
•
•
Adrenal hemorrhage or infarction
Illness/injury/surgery in patient with chronic AI
Pituitary apoplexy
Clinical features
•
•
•
Hypotension & shock
Nausea, vomiting, abdominal pain
Fever, generalized weakness
Treatment
•
•
AI = adrenal insufficiency.
Hydrocortisone or dexamethasone
Rapid intravenous volume repletion
ANAPHYLAXIS
Hemodynamic measurements in shock
Parameter
Hypovolemic
shock
Cardiogenic
shock
Obstructive
shock
Distributive
CVP
(right-sided
preload)
↓
↑
↑
↓
PCWP
(left-sided
preload)
↓
↑
↓*
↓
Cardiac
index
(LV output)
↓
↓
↓
↑**
SVR
(afterload)
↑
↑
↑
↓
SvO2
↓
↓
↓
↑**
shock
*In tamponade, left-sided preload is decreased, but measured PCWP is
paradoxically increased due to external compression by pericardial fluid.
**Cardiac index & SvO2 are usually decreased in neurogenic shock due to
impaired sympathetic reflexes.
CVP = central venous pressure; LV = left ventricular; PCWP = pulmonary
capillary wedge pressure; SvO2 = mixed venous oxygen saturation; SVR =
systemic vascular resistance.
Miscellaneous
EHLERS DANLOS SYNDROME
Clinical features of Ehlers-Danlos & Marfan syndromes
Classic Ehlers-Danlos
Skin
•
Transparent &
hyperextensible
Easy bruising, poor
healing
Velvety with atrophy
& scarring
•
No features other
than striae
•
•
•
•
Joint hypermobility
Pectus excavatum
Scoliosis
High, arched palate
•
•
Joint hypermobility
Pectus excavatum
or carinatum
Scoliosis
Tall with long
extremities
•
Mitral valve prolapse
•
•
•
Musculoskeletal
Cardiac
Marfan
•
•
•
Other
•
•
Genetics
•
•
Abdominal &
inguinal hernias
Uterine prolapse
•
COL5A1 & COL5A2
mutation
Autosomal dominant
•
•
•
Progressive aortic
root dilation
Mitral valve
prolapse
Lens & retinal
detachment
Spontaneous
pneumothorax
FBN1 mutation
Autosomal
dominant
Myopericardial diseases
ACUTE PERICARDITIS
Post–cardiac injury syndrome
Causes
•
•
•
Myocardial infarction (ie, Dressler syndrome)
Cardiac surgery or trauma
Percutaneous coronary intervention
Clinical
features
•
•
•
•
Latent period of several weeks to months
Pleuritic chest pain, fever, leukocytosis
Chest x-ray: pleural effusion ± enlarged cardiac silhouette
Echocardiography: pericardial effusion
Treatment
•
•
NSAID (usually high-dose aspirin) ± colchicine
Corticosteroids in refractory disease
Prognosis
•
•
Usually self-limited disease course
May cause chronic/recurrent disease leading to
constrictive pericarditis
NSAID = nonsteroidal anti-inflammatory drug.
BLUNT THORACIC TRAUMA
Blunt cardiac injury
Pathophysiology
•
Rapid deceleration or direct blow to the
precordium → shearing, compression, abrupt
pressure change
Clinical
spectrum
•
•
•
•
Arrythmia ranging from asymptomatic (eg, PVCs) to
fatal (eg, VFib)
Acute coronary syndrome from coronary dissection
or thrombosis
Myocardial dysfunction ("myocardial contusion")
Ruptured valve, septum, or ventricular wall
Cardiac tamponade
•
•
ECG
Echocardiogram
•
Confirmatory
testing
PVCs = premature ventricular contractions; VFib = ventricular fibrillation.
Central venous pressure in different types of shock
Shock
Hypovolemic
Distributive
Obstructive
Cardiogenic
CVP
↓
↓
↑
↑
↓ Systemic
vascular
resistance
↑ Back
pressure from
obstructed
cardiac filling
↑ Back
pressure from
forward pump
failure
Mechanism ↓
Intravascular
volume
CVP = central venous pressure.
Blunt chest trauma
CARDIAC TAMPONADE
Cardiac tamponade
Etiology
•
•
Blood in pericardial space (eg, LV rupture, cardiac
surgery)
Pericardial effusion (eg, malignancy, infection, uremia)
Clinical
signs
•
•
Beck triad: hypotension, JVD, ↓ heart sounds
Pulsus paradoxus: SBP ↓ >10 mm Hg during inspiration
Diagnosis
•
•
•
ECG: low-voltage QRS complex, electrical alternans
Chest x-ray: enlarged cardiac silhouette,* clear lungs
Echocardiography: right atrial & ventricular collapse, IVC
plethora
Treatment
•
Intravenous fluids to increase right-sided preload
•
Drainage via pericardiocentesis or pericardial window
*Subacute but not acute tamponade.
IVC = inferior vena cava; JVD = jugular venous distension; LV = left ventricular;
SBP = systolic blood pressure.
Characteristics of cardiac tamponade
Rapidity of fluid
accumulation
Acute
Subacute
Minutes to hours
Days to weeks
Clinical signs
Beck triad: hypotension, JVD, muffled heart sounds
Pulsus paradoxus (>10 mm Hg decrease in SBP with
inspiration)
Effusion volume
100-200 mL
1-2 L
Chest x-ray findings
Normal cardiac
silhouette
Enlarged, globular cardiac
silhouette
JVD = jugular venous distension; SBP = systolic blood pressure.
PERICARDIAL EFFUSION
Malignant pericardial effusion
Etiology
•
•
Clinical
features
•
•
•
•
Treatment
•
Common primary tumors: lung, breast, GI tract,
lymphoma, melanoma
May be initial manifestation of malignancy or recurrence
Progressive dyspnea, chest fullness, fatigue
ECG: ↓ QRS voltage ± electrical alternans
CXR: enlarged cardiac silhouette & clear lung fields
Echo: large effusion ± signs of tamponade (eg, right atrial
collapse)
Acute management: pericardiocentesis, cytologic fluid
analysis
•
Prevention of recurrence: prolonged drainage (eg,
catheter, pericardial window)
CXR = chest x-ray; echo = echocardiography; GI = gastrointestinal.
Purulent pericardial effusion
Etiology
•
•
•
Hematogenous or direct intrathoracic spread
Risk factors: immunosuppression, hemodialysis, recent
thoracic surgery/trauma
Organisms: Staphylococcus aureus (most common),
Streptococcus pneumoniae, Salmonella, Candida
Clinical
features
•
•
•
Acute presentation, patients often appear severely ill
Fevers, chills, chest pain (pleuritic or nonpleuritic)
Can be rapidly fatal
Diagnosis
•
ECG: tachycardia, diffuse ST-segment elevation, ± lowvoltage QRS complexes
CXR: enlarged cardiac silhouette & clear lung fields
Echocardiography: pericardial effusion
Cytology: turbid fluid with ↑ WBCs (neutrophil
predominant), ↑ protein, ↓ glucose
•
•
•
Treatment
•
Intravenous antibiotics + pericardial drainage
CXR = chest x-ray; WBCs = white blood cells.
Valvular heart diseases
AORTIC STENOSIS
Valve replacement in aortic stenosis
Severe AS criteria
•
•
Aortic jet velocity ≥4.0 m/sec, or
Mean transvalvular pressure gradient
≥40 mm Hg
•
Valve area usually ≤1.0 cm2 but not
required
Severe AS & ≥1 of the following:
Indications for valve
replacement
•
Onset of symptoms (eg, angina,
syncope)
•
Left ventricular ejection fraction <50%
•
Undergoing other cardiac surgery (eg,
CABG)
AS = aortic stenosis; CABG = coronary artery bypass grafting.
ATRIAL MYXOMA
Cardiac myxoma
Tumor characteristics
•
Benign neoplasm, 80% located in left atrium
Clinical features
•
Position-dependent mitral valve obstruction
–
Middiastolic murmur
–
Dyspnea, lightheadedness, syncope
Embolization of tumor fragments (eg,
stroke)
Constitutional symptoms (eg, fever, weight
loss)
•
•
Diagnosis &
management
•
Echocardiography & prompt surgical
resection
ENDOCARDITIS
Common surgical indications in infectious endocarditis
•
Acute heart failure (eg, aortic/mitral valve regurgitation)
•
Extension of infection (eg, abscess, fistula, heart block)
•
Difficult-to-eradicate organism (eg, fungus, MDR pathogen)
•
Persistent bacteremia on antibiotics
•
Large vegetation/persistent septic emboli
MDR = multidrug-resistant.
MECHANICAL VALVE
Prosthetic valve dysfunction
Types & causes
•
Transvalvular regurgitation (cusp
degeneration)
Paravalvular leak (annular degeneration, IE)
Valvular obstruction/stenosis (valve
thrombus)
•
•
Clinical
manifestations
•
•
•
New murmur (regurgitant or stenotic)
Macroangiopathic hemolytic anemia
Heart failure symptoms, thromboembolism
Diagnosis
•
Echocardiography
IE = infective endocarditis.
MITRAL REGURGITATION
Surgical indications for severe chronic mitral valve regurgitation
Primary MR
•
•
Surgery if LVEF 30%-60% (regardless of symptoms)
Consider surgery if successful valve repair* is highly
likely:
–
Asymptomatic & LVEF >60%
–
Symptomatic & LVEF <30%
Secondary MR
•
Medical management, valve surgery rarely
indicated
*When possible, durable valve repair is favored over replacement because
replacement necessitates lifelong anticoagulation & repeat replacement is
often needed after ~10 yr.
LVEF = left ventricular ejection fraction; MR = mitral regurgitation.
Hemodynamic changes in mitral regurgitation
Acute MR
Compensated
Decompensated
chronic MR
chronic MR
Preload
↑↑
↑
↑
Afterload
↓
No change
↑
Contractile function
No change
No change
↓
Ejection fraction
↑↑
↑
↓
Forward stroke volume
↓
No change
↓
MR = mitral regurgitation.
MITRAL STENOSIS
Cardiovascular contraindications to pregnancy
Highest risk
conditions*
•
•
•
•
•
Symptomatic mitral stenosis
Symptomatic aortic stenosis
Symptomatic heart failure with LVEF ˂30%
Pulmonary arterial hypertension
Bicuspid AV with ascending aorta enlargement
>50 mm
* Pregnancy contraindicated unless condition is corrected.
AV = aortic valve; LVEF = left ventricular ejection fraction.
Mitral stenosis
PULMONARY STENOSIS
Pulmonic valve stenosis
Etiology
•
•
Congenital (usually isolated defect)
Rarely acquired (eg, carcinoid)
Clinical
presentation
•
•
•
Severe: Right-sided heart failure in childhood
Mild: Symptoms (eg, dyspnea) in early
adulthood
Crescendo-decrescendo murmur (↑ on
inspiration)
Systolic ejection click & widened split of S2
Diagnosis
•
Echocardiography
Treatment
•
•
Percutaneous balloon valvulotomy (preferred)
Surgical repair in some cases
•
Tricuspid regurgitation JVP waveform
Dual chamber pacemaker
Ear, Nose & Throat (ENT)
Disorders of the ear, nose, and throat
ACUTE PAROTITIS
Suppurative parotitis
Risk factors
•
•
•
•
Elderly, dehydrated, postsurgical
Decreased oral intake (eg, NPO perioperatively)
Medications (eg, anticholinergics)
Obstruction (eg, calculi, neoplasm)
Clinical
presentation
•
•
Firm, erythematous pre/postauricular swelling
Exquisite tenderness exacerbated by chewing
and palpation
Trismus, systemic findings (eg, fever, chills)
Elevated serum amylase without pancreatitis
•
•
Management
•
•
•
•
•
Ultrasound or CT scan (eg, ductal obstruction,
abscess)
Hydration, oral hygiene
Antibiotics
Massage (ie, milking pus out of gland)
Sialagogues
BRANCHIAL CLEFT CYSTS
Pediatric neck masses
Thyroglossal duct
cyst
Midline
•
•
•
Dermoid cyst
Midline
•
•
•
Branchial cleft cyst
Lateral
•
•
Tract between foramen cecum &
base of anterior neck
Cystic, moves with swallowing or
tongue protrusion
Often presents after upper
respiratory tract infection
Cystic mass with trapped epithelial
debris
Occurs along embryologic fusion
planes
No displacement with tongue
protrusion
Tract may extend to the tonsillar
fossa (2nd branchial arch) or
pyriform recess (3rd branchial arch)
Anterior to the sternocleidomastoid
muscle
Reactive
adenopathy
Lateral
•
•
Firm, often tender
Multiple nodules
Mycobacterium
avium
lymphadenitis
Lateral
•
•
•
Necrotic lymph node
Violaceous discoloration of skin
Frequent fistula formation
Cystic hygroma
Posterior
•
Dilated lymphatic vessels
CEREBROSPINAL FLUID RHINORRHEA
Cerebrospinal fluid rhinorrhea
Etiology
•
•
•
Accidental trauma (most common)
Surgical trauma (eg, sinus surgery)
Nontraumatic (eg, elevated intracranial pressure)
Clinical
presentation
•
Unilateral watery rhinorrhea with salty or metallic
taste
Possible complication: meningitis
•
Evaluation
•
•
•
Management
Test for CSF-specific proteins (β-2 transferrin, β-trace
protein)
Imaging (with intrathecal contrast)
Endoscopy (± intrathecal fluorescein dye)
•
Bed rest, head of bed elevation, avoidance of straining
•
Lumbar drain placement
•
Surgical repair
CSF = cerebral spinal fluid.
EAR TRAUMA
Auricular hematoma
Risk
•
Contact sports injury (eg, wrestling, martial arts)
Clinical features
•
Tender, fluctuant blood collection on anterior pinna
Treatment
•
•
Immediate incision & drainage
Pressure dressing
Complications
•
•
•
Cauliflower ear (fibrocartilage overgrowth)
Bacterial superinfection
Reaccumulation of hematoma
factors
EPIGLOTTITIS
Infectious epiglottitis
Epidemiology
•
•
Streptococcus pneumoniae, Haemophilus influenzae
Risk reduced with H influenzae vaccination
Clinical
•
•
•
•
•
Rapidly progressive & life-threatening
Fever, sore throat, drooling, muffled voice
Airway obstruction (stridor, dyspnea)
Pooled oropharynx secretions
Laryngotracheal tenderness
Diagnosis
•
•
Direct visualization
Imaging (lateral neck x-ray)
Treatment
•
•
Early artificial airway (if needed)
Intravenous antibiotics (ceftriaxone plus vancomycin)
Septal hematoma
Referred otalgia
NASOPHARYNGEAL CARCINOMA
Nasopharyngeal carcinoma
Epidemiology
•
•
•
Endemic to Asia
Linked with Epstein-Barr virus reactivation
Risk factors: Diet (salty fish), smoking, genetics
Manifestations
•
•
•
Obstruction: Nasal congestion, epistaxis, headache
Mass effect: Cranial nerve palsy, otitis media
Spread: Neck mass (cervical lymphadenopathy)
Diagnosis
•
Endoscope-guided biopsy
Treatment
•
•
Radiation therapy
Chemotherapy
Anatomy of lateral wall
OSTEONECROSIS
Bisphosphonate-related osteonecrosis of the jaw
Risk
factors
•
•
•
•
High-dose, parenteral bisphosphonates
Dental procedures (eg, extractions, implants)
Concurrent glucocorticoid use
Concurrent or previous malignancy
Clinical
features
•
•
•
Chronic, indolent symptoms
Mild pain, swelling
Exposed bone, loosening of teeth, pathologic fractures
Management
•
•
•
Oral hygiene
Antibacterial rinses
Antibiotics and debridement as needed
OTOSCLEROSIS
Interpretation of Rinne & Weber tests
Rinne result
Weber result
Normal
AC > BC in both ears
Midline
Conductive
hearing loss
BC > AC in affected ear, AC Lateralizes to affected ear
> BC in unaffected ear
Sensorineural
hearing loss
AC > BC in both ears
Mixed hearing loss
BC > AC in affected ear, AC Lateralizes to unaffected
> BC in unaffected ear
ear, away from affected ear
Lateralizes to unaffected
ear, away from affected ear
AC = air conduction; BC = bone conduction.
Otosclerosis
Epidemiology
•
•
•
Younger (early to mid-30s) Caucasian patients
More common in women
Autosomal dominant with incomplete
penetrance
Pathophysiology
•
Imbalance of bone resorption & deposition →
stiffening of stapes
Clinical
manifestations
•
•
•
Progressive conductive hearing loss
Paradoxical improvement in speech
discrimination in noisy environments
± Reddish hue behind tympanic membrane
•
•
Amplification (eg, hearing aids)
Surgery (eg, stapes reconstruction)
Management
Management of suspected peritonsillar abscess
Recurrent respiratory papillomatosis
Deep neck space anatomy
Parotid tumor compressing facial nerve
Thyroglobulin used as a tumor marker
VESTIBULAR SCHWANNOMA
Vestibular schwannoma (acoustic neuroma)
Epidemiology
•
•
Median age 50
Usually unilateral (bilateral associated
with neurofibromatosis type 2)
Clinical manifestations &
pathophysiology
•
Sensorineural hearing loss & imbalance
(CN VIII Schwann cell tumor)
± Facial numbness &/or paralysis (CN V &
VII compression)
•
Diagnostic studies
•
•
Audiogram
MRI with contrast of internal auditory
canal
Management
•
Observation (eg, small tumors, minimal
symptoms, older or infirm patients)
Surgery
Radiation therapy
•
•
Endocrine, Diabetes & Metabolism
Diabetes mellitus
DIABETES MELLITUS
Stress hyperglycemia
Presentation
•
Transient hyperglycemia without preexisting diabetes
Risk factors
•
•
•
•
Intensive care unit admission
Fever, sepsis, severe infection
Major trauma/hemorrhage
Hypoxia
Treatment
•
•
Minimization of glucose in intravenous fluids
Insulin to maintain blood glucose at 140-180 mg/dL
PERIPHERAL NEUROPATHY
Diabetic foot ulcers
Risk factors
•
•
•
•
Chronically uncontrolled diabetes
Diabetic neuropathy (decreased protective sensation)
Foot deformity & small muscle atrophy
End-stage renal disease/dialysis
Presentation
•
Plantar surface under pressure points (eg, bony
prominences)
Painless ulcer
"Punched out" appearance with necrotic base
Often with adjacent callus
•
•
•
Endocrine tumors
PHEOCHROMOCYTOMA
Von Hippel-Lindau disease
Etiology
•
•
Mutation in the VHL tumor suppressor gene on
chromosome 3
Autosomal dominant inheritance
Manifestations
•
•
•
Cerebellar & retinal hemangioblastomas
Pheochromocytoma
Renal cell carcinoma (clear cell subtype)
Management
•
Surveillance for associated malignancies
–
Eye/retinal examination
–
Plasma or urine metanephrines
–
MRI of the brain & spine
–
MRI of the abdomen
Tumor resection
•
Pheochromocytoma
Indications for
testing
•
•
•
Classic triad: episodic headache, sweating &
tachycardia
Resistant HTN or HTN accompanied by
unexplained ↑ glucose
Family history or familial syndrome (eg, MEN2,
NF1, VHL)
Diagnostic approach
•
•
Urine or plasma metanephrine levels
Confirmatory abdominal imaging for ↑
metanephrines
Notable features
•
10% bilateral, 10% extraadrenal, 10%
malignant
Management
•
Preoperative alpha blockade prior to beta
blockade
•
Laparoscopic or open surgical resection
HTN = hypertension; MEN2 = multiple endocrine neoplasia type 2; NF1 =
neurofibromatosis type 1; VHL = von Hippel-Lindau syndrome.
Hypothalamus and pituitary disorders
ACROMEGALY
Clinical features of acromegaly
Local tumor
effect
Headache, visual field defects, cranial nerve defects
Musculoskeletal
Gigantism, frontal bossing, malocclusion of jaw,
macrognathia, arthritis, carpal tunnel syndrome,
enlargement of hands/feet
Skin
Skin thickening, hyperhidrosis (odor), skin tags
Cardiovascular
Cardiomyopathy, hypertension, heart failure
Respiratory
Sleep apnea
Gastrointestinal
Colon polyps/cancer, diverticulosis
Endocrine
Galactorrhea, hypogonadism, diabetes mellitus,
hypertriglyceridemia
Additional
features
Enlarged tongue, thyroid, salivary glands, liver, spleen,
kidney, prostate
Prolactin & amenorrhea
Miscellaneous
HYPERCALCEMIA
corrected calcium = measured calcium + 0.8 × (4 – albumin)
12.1 + 0.8 × (4 – 3) = 12.1 + 0.8 = 12.9 mg/dL
Diagnosis of hypercalcemia
HYPERPARATHYROIDISM
Primary hyperparathyroidism
Etiology
•
•
Symptoms
•
•
•
Diagnostic
findings
•
•
•
Indications for
parathyroidectomy
•
•
•
Parathyroid adenoma (most common),
hyperplasia,
carcinoma
Increased risk in MEN types 1 & 2A
Asymptomatic (most common)
Mild, nonspecific symptoms (eg, fatigue,
constipation)
Abdominal pain, renal stones, bone pain,
neuropsychiatric
symptoms
Hypercalcemia
Elevated or inappropriately normal PTH
Elevated 24-hour urinary calcium excretion
Age <50
Symptomatic hypercalcemia
Complications: Osteoporosis (T-score <−2.5,
fragility
fracture), nephrolithiasis/calcinosis, CKD (GFR
<60 mL/min)
•
Elevated risk of complications: Calcium
>1 mg/dL above
normal, urinary calcium excretion >400 mg/day
CKD = chronic kidney disease; GFR = glomerular filtration rate; MEN = multiple
endocrine neoplasia; PTH = parathyroid hormone.
Tertiary hyperparathyroidism
Risk factors
•
Longstanding chronic kidney disease/end-stage
renal disease
Chronic hypocalcemia, hyperphosphatemia
Pathogenesis
•
•
Parathyroid hyperplasia
Loss of feedback inhibition of PTH by calcium
Laboratory
diagnosis
•
•
•
Very high PTH
Mild/moderate hypercalcemia
Hyperphosphatemia
Treatment
•
•
Usually refractory to medical therapy
•
Parathyroidectomy is often needed
PTH = parathyroid hormone.
HYPONATREMIA
Syndrome of inappropriate antidiuretic hormone
Etiologies
•
•
•
•
•
Clinical features
•
•
•
Laboratory findings
•
•
•
•
CNS disturbance (eg, stroke, hemorrhage,
trauma)
Medications (eg, carbamazepine, SSRIs, NSAIDs)
Lung disease (eg, pneumonia)
Ectopic ADH secretion (eg, small cell lung
cancer)
Pain &/or nausea
Mild/moderate hyponatremia: nausea,
forgetfulness
Severe hyponatremia: seizures, coma
Euvolemia (eg, moist mucous membranes, no
edema, no JVD)
Hyponatremia
Serum osmolality <275 mOsm/kg H2O
(hypotonic)
Urine osmolality >100 mOsm/kg H2O
Urine sodium >40 mEq/L
Management
•
Fluid restriction ± salt tablets
•
Hypertonic (3%) saline for severe hyponatremia
ADH = antidiuretic hormone; JVD = jugular venous distension; NSAIDs =
nonsteroidal anti-inflammatory drugs; SSRIs = selective serotonin reuptake
inhibitors.
Normal structure and function of endocrine glands
HYPOCALCEMIA
Acute hypocalcemia
Causes
•
•
•
•
•
•
Neck surgery (parathyroidectomy)
Pancreatitis
Sepsis
Tumor lysis syndrome
Acute alkalosis
Chelation: blood (citrate) transfusion, EDTA,
foscarnet
Clinical
features
•
•
•
•
•
Muscle cramps
Chvostek & Trousseau signs
Paresthesias
Hyperreflexia/tetany
Seizures
Treatment
•
IV calcium gluconate/chloride
EDTA = ethylenediaminetetraacetic acid; IV = intravenous.
Thyroid disorders
EUTHYROID SICK SYNDROME
Euthyroid sick syndrome (low T3 syndrome)
Risk factors
•
•
•
Severe acute illness
ICU admission
High-dose glucocorticoid therapy
Pathophysiology
•
•
High circulating levels of glucocorticoids and
inflammatory cytokines (eg, tumor necrosis factor,
interferon alpha)
Decreased peripheral conversion of T4 to T3
Diagnostic
testing
•
•
Early: Low T3, normal TSH & T4
Late: Low T3, TSH & T4
Management
•
•
Observe without treatment
Follow-up testing when patient has returned to
baseline health
ICU = intensive care unit.
HYPERTHYROIDISM
Clinical features of thyroid storm
Precipitating
factors
•
•
•
Thyroid or nonthyroidal surgery
Acute illness (eg, trauma, infection), childbirth
Acute iodine load (eg, iodine contrast)
Clinical
presentation
•
•
Fever as high as 40-41.1 C (104-106 F)
Tachycardia, hypertension, congestive heart failure,
cardiac arrhythmias (eg, atrial fibrillation)
Agitation, delirium, seizure, coma
Goiter, lid lag, tremor, warm & moist skin
Nausea, vomiting, diarrhea, jaundice
•
•
•
Treatment
•
β blocker (eg, propranolol) to ↓ adrenergic
manifestations
•
PTU followed by iodine solution (SSKI) to ↓
hormone synthesis & release
•
Glucocorticoids (eg, hydrocortisone) to ↓
peripheral T4 to T3 conversion & improve
vasomotor stability
•
Identify trigger & treat, supportive care
PTU = propylthiouracil; SSKI = potassium iodide; T3 = triiodothyronine; T4 =
thyroxine.
Evaluation of thyroid nodules
Gastrointestinal & Nutrition
Biliary tract disorders
CHOLANGIOCARCINOMA
Malignant biliary obstruction
Etiologies
•
•
•
Cholangiocarcinoma
Pancreatic/hepatocellular carcinoma
Metastasis (eg, colon, gastric)
Manifestations
•
•
•
•
•
Jaundice, pruritus, acholic stools, dark urine
Weight loss
RUQ pain
RUQ mass or hepatomegaly
↑ Direct bilirubin, ALP, GGT
Diagnosis
•
Serum tumor markers (CEA, CA-19, AFP)
•
Abdominal imaging (ultrasound, CT scan)
•
EUS or ERCP for tissue diagnosis if unclear
AFP = alpha-fetoprotein; ALP = alkaline phosphatase; CEA = carcinoembryonic
antigen; EUS = endoscopic ultrasound; ERCP = endoscopic retrograde
cholangiopancreatography; GGT = gamma-glutamyl transferase; RUQ = right
upper quadrant.
CHOLECYSTITIS
Acalculous cholecystitis
Risk factors
•
•
•
Severe trauma or recent surgery
Prolonged fasting or TPN
Critical illness (eg, sepsis, ICU)
Clinical presentation
•
•
Fever, leukocytosis, ↑ LFTs, RUQ pain
Jaundice & RUQ mass less common
Diagnosis
•
•
Abdominal ultrasound (preferred)
HIDA or CT scan if needed
Treatment
•
•
•
Enteric antibiotic coverage
Cholecystostomy for initial drainage
Cholecystectomy once clinically stable
ICU = intensive care unit; LFTs = liver function tests; RUQ = right upper
quadrant; TPN = total parenteral nutrition.
Emphysematous cholecystitis
Risk factors
•
•
•
Diabetes mellitus
Vascular compromise
Immunosuppression
Clinical
presentation
•
•
Fever, right upper quadrant pain, nausea/vomiting
Crepitus in abdominal wall adjacent to gallbladder
Diagnosis
•
•
Air-fluid levels in gallbladder, gas in gallbladder wall
Cultures with gas-forming Clostridium, Escherichia
coli
Unconjugated hyperbilirubinemia, mildly elevated
aminotransferases
•
Treatment
•
•
Emergency cholecystectomy
Broad-spectrum antibiotics with Clostridium
coverage (eg, piperacillin-tazobactam)
Management of gallstones
Gallstones without symptoms
•
No treatment required in most
patients
Gallstones with typical biliary
colic symptoms
•
•
Elective laparoscopic cholecystectomy
Possible ursodeoxycholic acid in poor
surgical candidates
Complicated gallstone
disease*
•
Cholecystectomy within 72 hr
*Acute cholecystitis, choledocholithiasis, gallstone pancreatitis.
Hemobilia
Porcelain gallbladder
Congenital and developmental anomalies
TRACHEOESOPHAGEAL FISTULA
Tracheoesophageal fistula with esophageal atresia
Pathogenesis
•
•
Defective division of foregut into esophagus & trachea
Most commonly results in proximal esophageal pouch
& fistula between distal trachea & esophagus
Clinical
features
•
•
•
Coughing, choking, vomiting with feeding
Excessive oral secretions
Commonly part of VACTERL association
Diagnosis
•
•
Inability to pass enteric tube into stomach
X-ray: enteric tube coiled in proximal esophagus
Management
•
•
Surgical correction
VACTERL screening: echocardiography, renal
ultrasound
VACTERL = Vertebral, Anal, Cardiac, TracheoEsophageal, Renal, Limb defects.
UMBILICAL HERNIA
Congenital umbilical hernia
Pathophysiology
•
Incomplete closure of abdominal muscles
Clinical features
•
•
•
Soft, nontender bulge at umbilicus
Protrudes with increased abdominal pressure
Typically reducible
Management
•
•
Observe for spontaneous closure
Elective surgery around age 5
Disorders of nutrition
BARIATRIC SURGERY
Vitamin C deficiency (scurvy)
Pathogenesis
•
•
Manifestations
•
•
•
•
Insufficient dietary intake (lack of citrus
fruits/vegetables)
–
Chronic alcohol/substance use, severe
malnutrition (eg, anorexia, restricted diet)
Impaired collagen production
Cutaneous:
–
Coiled hair, perifollicular hemorrhage
–
Petechiae, ecchymoses
–
Impaired wound healing
Mucosal: gingivitis with bleeding
Musculoskeletal (eg, periosteal hemorrhage):
arthralgia, limp
Constitutional: malaise, depression, vasomotor
instability
Laboratory
findings
•
•
Anemia (normocytic or microcytic)
Normal platelet count & coagulation studies
Treatment
•
Oral/injectable vitamin C (improvement within days
to weeks)
Toxicity (eg, abdominal pain, diarrhea) with
excessive supplementation
•
DUMPING SYNDROME
Dumping syndrome
Pathogenesis
•
•
Destruction or bypass of the pyloric sphincter
Rapid emptying of hypertonic gastric contents
Etiology
•
•
Esophageal/gastric resection or reconstruction
Vagal nerve injury (eg, Nissen fundoplication)
Symptoms
•
•
•
Abdominal pain, diarrhea, nausea
Hypotension/tachycardia
Dizziness/confusion, fatigue, diaphoresis
Timing
•
15-30 minutes after meals
Management
•
•
•
Clinical diagnosis
Small, frequent meals
Replacement of simple sugars with complex
carbohydrates
Incorporation of high-fiber & protein-rich foods
•
OBESITY
Preparation for bariatric surgery
Indications
•
•
•
Intake
assessment
•
BMI ≥40 kg/m2
BMI ≥35 kg/m2 with serious comorbidity (eg, T2DM,
hypertension, OSA)
BMI ≥30 kg/m2 with resistant T2DM or metabolic
syndrome
Review previous attempts at weight loss, diet, exercise
habits
•
Review psychiatric history, coping skills, readiness to
change
•
Review risk for cardiac (eg, CAD) and pulmonary (eg,
OSA) disease
CAD = coronary artery disease; OSA = obstructive sleep apnea; T2DM = type 2
diabetes mellitus.
SMALL INTESTINAL BACTERIAL OVERGROWTH
Small intestinal bacterial overgrowth
Risk factors
•
•
•
•
•
Anatomic abnormalities (eg, strictures, surgery, small
bowel diverticulosis)
Motility disorders (eg, diabetes mellitus,
scleroderma, opioid use)
Immunodeficiency (eg, IgA deficiency)
Chronic pancreatitis
Gastric hypochlorhydria, proton pump inhibitor use
Clinical
manifestations
•
•
•
•
Bloating, flatulence
Chronic watery diarrhea
Possible malabsorption
↓ Vitamin B12 (bacterial consumption), ↑ folate
(bacterial synthesis)
Diagnosis
•
•
Carbohydrate breath testing (lactulose or glucose)
Endoscopy with jejunal aspirate/culture
Treatment
•
Oral antibiotics (eg, rifaximin, ciprofloxacin,
doxycycline)
ZINC DEFICIENCY
Clinical manifestations of trace mineral deficiencies
Chromium
•
Impaired glucose control in diabetes
Copper
•
•
•
•
•
Brittle hair
Skin depigmentation
Neurologic dysfunction (eg, ataxia, peripheral
neuropathy)
Anemia
Osteoporosis
Iron
•
Microcytic anemia
Selenium
•
•
•
Thyroid dysfunction
Cardiomyopathy
Immune dysfunction
Zinc
•
•
•
•
•
•
Alopecia
Pustular skin rash (perioral region & extremities)
Hypogonadism
Impaired wound healing
Impaired taste
Immune dysfunction
Gastroesophageal disorders
ESOPHAGEAL CANCER
Esophageal cancer
Subtypes
•
•
Risk
factors
•
•
Symptoms
•
•
•
Adenocarcinoma
–
Distal esophagus, arises from Barrett esophagus
Squamous cell carcinoma
–
Most commonly proximal and mid esophagus
Uncontrolled gastroesophageal reflux, obesity, male
(adenocarcinoma)
Smoking, alcohol use, n-nitroso containing food
(squamous cell)
Progressive solid-food dysphagia
GI bleeding, iron deficiency anemia
Weight loss, aspiration
Diagnosis
•
Endoscopy with biopsy
•
CT (PET/CT) is used for staging (not initial diagnosis)
GI = gastrointestinal; PET = positron emission tomography.
ESOPHAGEAL RUPTURE
Esophageal perforation
Etiology
•
•
•
Instrumentation (eg, endoscopy), trauma
Effort rupture (Boerhaave syndrome)
Esophagitis (infectious/pills/caustic)
Clinical
presentation
•
Chest/back &/or epigastric pain, systemic signs (eg,
fever)
Crepitus, Hamman sign (crunching sound on
auscultation)
Pleural effusion with atypical (eg, green) fluid
•
•
Diagnosis
•
•
•
Management
•
•
Chest x-ray or CT scan: widened mediastinum,
pneumomediastinum, pneumothorax, pleural
effusion
CT scan: esophageal wall thickening, mediastinal
fluid collection
Esophagography with water-soluble contrast: leak
from perforation
NPO, IV antibiotics & proton pump inhibitors
Emergency surgical consultation
Characteristics of gastroesophageal mural injury
Etiology
Clinical
presentation
Mallory-Weiss syndrome
•
•
•
Forceful retching
Mucosal tear
Submucosal
venous or arterial
plexus bleeding
•
•
•
Forceful retching
Transmural tear
Spillage of esophageal
air/fluid into surrounding
tissues
•
Epigastric/back
pain
Hematemesis
(bright red or
coffee-ground)
Possible
hypovolemia
•
Chest/back/epigastric
pain
Crepitus, crunching
sound (Hamman sign)
Odynophagia, dyspnea,
fever, sepsis
Upper GI
endoscopy
confirms diagnosis
(& can treat
persistent
bleeding)
•
Acid suppression
Most heal
spontaneously
•
•
•
Studies
Management
Boerhaave syndrome
•
•
•
•
•
•
•
Chest x-ray:
pneumothorax,
pneumomediastinum,
pleural effusion
Esophagography or CT
scan with water-soluble
contrast confirms
diagnosis
Acid suppression,
antibiotics, NPO
Emergency surgical
consultation
GI = gastrointestinal.
ESOPHAGITIS
Eosinophilic esophagitis
Pathogenesis
&
epidemiology
•
Clinical
features
•
•
•
•
Dysphagia
Heartburn & epigastric pain
Regurgitation
Food impaction
Diagnosis
•
Endoscopy & esophageal biopsy (eosinophils:
≥15/hpf)
Exclusion of alternate diagnoses (eg, achalasia,
infection)
•
•
Treatment
Th2-mediated inflammatory response triggered
primarily by food antigen exposure
Comorbid atopic disease (asthma, eczema, food
allergies, allergic rhinitis) common
•
Elimination diet
•
Proton pump inhibitors
•
Topical glucocorticoids
Th2 = T-helper cell type 2.
Variceal hemorrhage bleed algorithm
GASTROPARESIS
Postoperative complications of Nissen fundoplication
Dysphagia
•
•
•
Gas-bloat
syndrome
•
•
•
Gastroparesis
Possibly caused by disruption of peristalsis due to
tightening of the LES
Symptoms develop within 12 weeks of surgery
Diagnosed clinically & usually self-resolves
Likely caused by gastric air trapping due to tightening
of the LES
Symptoms include bloating & inability to belch
Diagnosed clinically & usually resolves with
conservative management*
•
•
Caused by inadvertent vagal nerve injury
Symptoms: bloating, early satiety, postprandial
emesis, food aversion, weight loss
•
Diagnosed via gastric scintigraphy + EGD to rule out
obstruction
•
Managed with small, low-fat, low-fiber meals ±
promotility agents**
*Including simethicone & avoidance of carbonated beverages.
**Metoclopramide typically first-line.
EGD = esophagogastroduodenoscopy; LES = lower esophageal sphincter.
Hiatal hernia
MALLORY-WEISS SYNDROME
Mallory-Weiss tear
Etiology
•
•
Sudden increase in abdominal pressure
(eg, forceful retching)
Mucosal tear in esophagus or stomach (submucosal
arterial or venous plexus bleeding)
Risk factors: hiatal hernia, alcoholism
Clinical
presentation
•
•
•
Vomiting, retching
Hematemesis
Epigastric pain
Diagnosis
•
Longitudinal laceration on endoscopy
Treatment
•
•
Most heal spontaneously
Endoscopic therapy for persistent bleeding
•
Pneumoperitoneum on upright chest x-ray
ZENKER DIVERTICULUM
Zenker diverticulum
Pathophysiology
•
Impaired UES relaxation (cricopharyngeus muscle)
→ ↑ intraluminal pressure → herniation →
pseudodiverticulum
Clinical
manifestations
•
•
•
•
•
Age >60, more common in men
Insidious, progressive dysphagia
Halitosis, gurgling, or crepitus
Regurgitation of undigested food
Aspiration
Diagnosis
•
Swallow study with contrast esophagography
Treatment
•
Surgery: cricopharyngeal myotomy ±
diverticulectomy
UES = upper esophageal sphincter.
Zenker diverticulum
Zenker diverticulum
Hepatic disorders
BILIARY ATRESIA
Biliary atresia
Pathogenesis
•
Extrahepatic bile duct fibrosis
Clinical
findings
•
•
Asymptomatic at birth
Infants age 2-8 weeks:
–
Jaundice, acholic stools, dark urine
–
Hepatomegaly
Diagnostic
evaluation
•
•
Direct hyperbilirubinemia
Ultrasound:
–
Absent/abnormal gallbladder &/or CBD
Liver biopsy:
–
Intrahepatic bile duct proliferation
–
Portal tract inflammation & edema
–
Fibrosis
Intraoperative cholangiography (gold standard):
–
Biliary obstruction
•
•
Treatment
•
Surgical hepatoportoenterostomy (Kasai procedure)
•
Liver transplant
CBD = common bile duct.
Liver laceration
FOCAL NODULAR HYPERPLASIA
Solid liver masses
Focal nodular
hyperplasia
•
•
Associated with anomalous arteries
Arterial flow & central scar on imaging
Hepatic adenoma
•
•
Women on long-term oral contraceptives
Possible hemorrhage or malignant
transformation
Regenerative nodules
•
Acute or chronic liver injury (eg, cirrhosis)
Hepatocellular
carcinoma
•
•
•
Systemic symptoms
Chronic hepatitis or cirrhosis
Elevated ɑ fetoprotein
Liver metastasis
•
Single/multiple lesions
HEPATIC ADENOMAS
Hepatic adenoma
Epidemiology
•
•
Benign epithelial liver tumor
Primarily young women on oral contraception
Manifestations
•
•
Often asymptomatic (incidentally found)
Episodic right upper quadrant pain
Imaging
•
•
Solitary, solid lesion in right lobe of liver
Multiple lesions occasionally occur
Treatment
•
•
Asymptomatic & <5 cm – stop oral contraception
Symptomatic or >5 cm – surgical resection
Complications
•
•
Malignant transformation (~10%)
Rupture & hemorrhagic shock
HEREDITARY HYPERBILIRUBINEMIAS
Gilbert syndrome
Epidemiology
•
Most common inherited disorder of bilirubin
metabolism
Pathogenesis
•
↓ Hepatic UDP glucuronosyltransferase activity → ↓
conjugation of bilirubin
Clinical
findings
•
•
Recurrent episodes of mild jaundice
Provoked by stress (eg, febrile illness, fasting,
dehydration, vigorous exercise, menstruation,
surgery)
Diagnosis
•
•
•
↑ Unconjugated bilirubin (ie, indirect
hyperbilirubinemia)
Normal CBC, blood smear, reticulocyte count
Normal AST, ALT, alkaline phosphatase
•
Benign; no treatment required
Treatment
ALT = alanine aminotransferase; AST = aspartate aminotransferase; CBC =
complete blood count; UDP = uridine diphosphogluconurate.
Liver abscess
PRIMARY SCLEROSING CHOLANGITIS
Primary sclerosing cholangitis
Clinical features
•
•
•
Asymptomatic
Fatigue & pruritus
Associated with IBD, particularly UC (~90% of
patients)
Laboratory/imaging
•
Cholestatic liver injury (↑↑ alkaline
phosphatase, ↑ bilirubin)
Multifocal stricturing/dilation of intrahepatic
&/or extrahepatic bile ducts on cholangiography
•
Liver biopsy
•
Complications
•
•
•
Fibrous obliteration of small bile ducts, with
concentric replacement by connective tissue in
onion-skin pattern
Biliary stricture
Cholangitis or cholelithiasis
Cholangiocarcinoma, colon cancer, biliary
cancer
•
Cholestasis (eg, ↓ fat-soluble vitamins,
osteoporosis)
IBD = inflammatory bowel disease; UC = ulcerative colitis.
Intestinal and colorectal disorders
ANAL FISSURE
Anal fissures
Etiology
•
•
•
Local trauma (eg, constipation, prolonged diarrhea,
anal sex)
Inflammatory bowel disease (eg, Crohn disease)
Malignancy
Clinical
presentation
•
•
•
•
Pain with bowel movements
Bright red blood on toilet paper or stool surface
Most common at posterior anal midline
Chronic fissure may have skin tag at distal end
Treatment
•
•
•
•
High-fiber diet & adequate fluid intake
Stool softeners
Sitz baths
Topical anesthetics & vasodilators (eg, nifedipine,
nitroglycerin)
Management of suspected appendicitis
Intraperitoneal free air on abdominal CT scan
Blunt abdominal trauma
BOWEL OBSTRUCTION
Small bowel obstruction
Clinical
presentation
•
•
•
•
Diagnosis
•
•
•
Colicky abdominal pain, vomiting
Inability to pass flatus or stool if complete (no
obstipation if partial)
Hyperactive → absent bowel sounds
Distended & tympanitic abdomen
Dilated loops of bowel with air-fluid levels on
plain film or CT scan
Partial: air in colon
Complete: transition point (abrupt cutoff), no air
in colon
Complications
•
•
Ischemia/necrosis (strangulation)
Bowel perforation
Management
•
Bowel rest, nasogastric tube suction, intravenous
fluids
Surgical exploration for signs of complications
•
CHRONIC DIARRHEA
Bile acid diarrhea
Pathophysiology
•
Unresorbed bile acids spill into the colon, resulting
in mucosal irritation
–
Bile acid enters terminal ileum too rapidly
& overwhelms resorptive capacity (eg, post
cholecystectomy)
–
Ileal disease impairs bile absorption (eg,
Crohn disease, abdominal radiation
damage)
Clinical features
•
Secretory diarrhea (eg, fasting diarrhea, nocturnal
episodes)
Bloating, abdominal cramps
Unremarkable serum & stool studies
•
•
Treatment
•
Bile acid–binding resins (eg, cholestyramine,
colestipol)
Management of Clostridioides difficile infection
COLONIC ISCHEMIA
Colonic ischemia
Pathophysiology
•
•
•
Usually nonocclusive, “watershed” ischemia
Underlying atherosclerotic disease
State of low blood flow (eg, hypovolemia)
Clinical features
•
•
•
Moderate abdominal pain & tenderness
Hematochezia, diarrhea
Leukocytosis, lactic acidosis
Diagnosis
•
•
CT scan: Colonic wall thickening, fat stranding
Endoscopy: Edematous & friable mucosa
Management
•
•
•
Intravenous fluids & bowel rest
Antibiotics with enteric coverage
Colonic resection if necrosis develops
COLORECTAL POLYPS AND CANCER
Risk factors for colon cancer
Lifestyle factors
•
•
Frequent consumption of red/processed meat
Tobacco, alcohol use
Medical/family
history
•
Personal/family history of adenomatous polyps
or colon cancer
Inherited colon cancer syndromes (eg, familial
adenomatous polyposis, Lynch syndrome)
Ulcerative colitis
Diabetes/obesity
Prior abdominopelvic radiation
•
•
•
•
Protective factors
•
High-fiber diet
•
Aspirin/NSAID use
NSAID = nonsteroidal anti-inflammatory drug.
DIVERTICULAR DISEASE
Clinical features of colovesical fistula
Etiology
•
•
•
Diverticular disease (sigmoid most common)
Crohn disease
Malignancy (colon, bladder, pelvic organs)
Clinical
presentation
•
•
•
Pneumaturia (air in urine)
Fecaluria (stool in urine)
Recurrent urinary tract infections (mixed flora)
Diagnosis
•
CT scan of the abdomen with oral or rectal (not
intravenous) contrast
Colonoscopy to exclude colonic malignancy
•
Clinical features of acute diverticulitis
Clinical
presentation
•
•
•
Abdominal pain (usually left lower quadrant)
Fever, nausea & vomiting
Ileus (peritoneal irritation)
Diagnosis
•
CT scan of the abdomen (oral & intravenous
contrast)
Management
•
•
Bowel rest
Antibiotics (eg, ciprofloxacin, metronidazole)
Complications
•
Abscess, obstruction, fistula, perforation
Diverticulitis
FECAL INCONTINENCE
Radiation proctitis
Acute radiation proctitis
Chronic radiation proctitis
Postradiation
onset
•
≤8 weeks
•
>3 months to years
Pathogenesis
•
Direct mucosal
damage
•
Obliterative
endarteritis & chronic
mucosal ischemia
Submucosal fibrosis
•
Manifestations
•
•
Endoscopic
appearance
Management
•
•
•
•
Diarrhea, mucus
discharge,
tenesmus
Minimal bleeding
•
•
Severe bleeding
± Strictures with
constipation & rectal
pain
Severe erythema
Edema,
ulcerations
•
Multiple
telangiectasias
Mucosal pallor &
friability
Antidiarrheals (eg,
loperamide)
Butyrate enemas
•
•
•
Endoscopic thermal
coagulation
Sucralfate or
glucocorticoid
enemas
FISTULA IN ANO
Anorectal fistula (fistula in ano)
Causes
•
•
•
•
Perianal abscess
Crohn disease
Malignancy, radiation proctitis
Infection (eg, lymphogranuloma venereum)
Clinical
manifestations
•
•
•
Perirectal pain, discharge
Inflammatory papule/pustule
Palpable fistula tract
Management
•
Assess extent of fistula
–
Gentle probe
–
Imaging (endosonography, fistulogram,
MRI)
Surgery (eg, fistulotomy)
•
Age-based evaluation of occult gastrointestinal bleeding
HEMORRHOIDS
Anal & perianal masses
Rectal prolapse
•
•
Erythematous mass with concentric rings that
occurs with Valsalva
Mucus discharge, mild abdominal pain, mass
sensation
External
hemorrhoid
•
•
•
Dusky/purple lump or polyp
Associated itching, bleeding
Thrombosis: acute enlargement with pain
Internal
hemorrhoid
•
Intermittent itching, painless bleeding, leakage of
stool
Detected with digital rectal exam or anoscopy
(unless prolapsed)
•
Perianal abscess
•
•
•
Fluctuant mass/swelling with erythema
Fever
Gradual onset
Anogenital wart
•
•
•
Pink or flesh-colored papules, plaques, or
cauliflower-shaped masses
Chronic onset
Mild itching, bleeding
Anorectal cancer
•
•
•
Squamous cell carcinoma most common
Bleeding, pain
Ulcerating, enlarging mass
Skin tags
•
•
Small, flesh-colored papules
May represent external terminus of anal fissure
(sentinel tag)
External hemorrhoids
Pathophysiology
•
•
Hemorrhoidal venous plexus distension
Intravascular inflammation, which leads to
hemorrhoid thrombosis
Risk factors
•
•
Constipation, low-fiber diet, prolonged sitting
Pregnancy, advanced age
Presentation
•
Anal pruritus, bleeding, discharge of mucus, fecal
incontinence, sensation of fullness in anorectum
Thrombosis (severe anorectal pain)
Purple or blue bulge on examination
•
•
Management
•
Conservative management:
–
High-fiber diet, stool softeners, sitz baths
–
Topical analgesics, anti-inflammatories &
antispasmodics (eg, lidocaine,
glucocorticoid suppositories, nitroglycerin
cream)
Refractory or thrombosed hemorrhoids:
–
Conservative measures when mild
–
Hemorrhoidectomy when severe
–
Hemorrhoid incision with thrombus
removal for temporary relief
•
Initial management of hemorrhoids
Dietary factors
•
•
•
•
Increased fluid intake
Increased fiber intake (foods, fiber supplements)
Reduced fat intake
Moderation of alcohol intake
Behavioral factors
•
•
•
Limit time sitting on toilet (eg, 3 minutes)
Limit defecation to once daily
Avoid straining during defecation
Topical agents
•
•
•
Analgesics (eg, benzocaine)
Astringents (eg, witch hazel)
Hydrocortisone
INCISIONAL HERNIA
Incisional hernia
Pathogenesis
•
Breakdown of prior fascial closure
Risk factors
•
•
•
•
•
Obesity
Tobacco smoking
Poor wound healing (eg, immunosuppression,
malnutrition)
Vertical or midline incision
Surgical site infection
Clinical
features
•
•
•
Abdominal mass that enlarges with Valsalva
Palpable fascial edges in nonobese patients
Possible delayed presentation (months-years)
Diagnosis
•
•
Clinical
CT scan of abdomen
INFLAMMATORY BOWEL DISEASE
Classification & management of mild ulcerative colitis
Clinical features
•
•
<4 watery bowel movements per day
Hematochezia is rare or intermittent
Laboratory findings
•
•
No anemia
Normal ESR & CRP
Treatment
•
5-Aminosalicylic acid agents (eg, mesalamine,
sulfasalazine)
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
Inflammatory bowel disease subtype characteristics
Crohn disease
Involvement
•
•
•
Ulcerative colitis
Anywhere mouth to
anus (mostly ileum &
colon)
Perianal disease with
rectal sparing
Skip lesions
•
•
Rectum (always) &
colon
Continuous lesions
Microscopy
•
Noncaseating
granulomas
•
No granulomas
Gross
findings
•
Transmural
inflammation
Linear mucosal
ulcerations
Cobblestoning,
creeping fat
•
Mucosal &
submucosal
inflammation
Pseudopolyps
Abdominal pain (often
RLQ)
Watery diarrhea
(bloody if colitis)
•
•
•
Clinical
manifestations
•
•
Intestinal
complications
•
•
Fistulae, abscesses
Strictures (bowel
obstruction)
RLQ = right lower quadrant.
•
•
Abdominal pain
(varying locations)
Bloody diarrhea
•
Toxic megacolon
Toxic megacolon
Pathophysiology
•
•
•
Colonic smooth muscle inflammation & paralysis
Complication of IBD or infectious colitis
↑ Risk with use of antimotility agents (eg,
loperamide) or opioids
Clinical features
•
Systemic toxicity (eg, fever, tachycardia,
hypotension)
Abdominal pain & distension following diarrheal
illness
•
Diagnosis
•
Treatment
•
•
•
Colonic dilation (>6 cm) on imaging
Bowel rest/decompression, antibiotics
Corticosteroids if IBD-associated
Surgery for perforation, peritonitis, clinical
deterioration
IBD = inflammatory bowel disease.
Toxic megacolon
MESENTERIC ISCHEMIA
Acute mesenteric ischemia
Presentation
•
•
•
Rapid onset of periumbilical pain (often severe)
Pain out of proportion to examination findings
Hematochezia (late complication)
Risk factors
•
•
•
Atherosclerosis (acute or chronic)
Embolic source (thrombus, cardiac vegetation)
Hypercoagulable disorders
Laboratory
•
•
•
Leukocytosis
Elevated amylase & phosphate levels
Metabolic acidosis (elevated lactate)
•
•
CT (preferred) or MR angiography
Mesenteric angiography if diagnosis is unclear
findings
Diagnosis
OGILVIE SYNDROME
Acute colonic pseudoobstruction (Ogilvie syndrome)
Etiologies
•
•
•
•
Major surgery, traumatic injury, severe infection
Electrolyte derangement (↓ K, ↓ Mg, ↓ Ca)
Medications (eg, opiates, anticholinergics)
Neurologic disorders (eg, dementia, stroke)
Clinical
findings
•
•
•
Abdominal distension, pain, obstipation, vomiting
Tympanic to percussion, ↓ bowel sounds
If perforation: guarding, rigidity, rebound tenderness
Imaging
•
•
X-ray: colonic dilation, normal haustra, nondilated
small bowel
CT scan: colonic dilation without anatomic obstruction
•
•
NPO, nasogastric/rectal tube decompression
Neostigmine if no improvement within 48 hr
Management
PARALYTIC ILEUS
SBO vs ileus
SBO
Clinical
features
X-ray
findings
•
•
•
•
•
•
Ileus
Nausea, vomiting
Obstipation
Acute abdomen
Hyperactive or absent
bowel sounds
Air fluid levels
Dilated proximal bowel,
collapsed distal bowel
•
Little/no air in
colon/rectum
SBO = small bowel obstruction.
•
•
•
•
•
•
•
Nausea ± vomiting
No flatus
Abdominal
distension
Decreased or absent
bowel sounds
No transition point
Dilated loops of
bowel
Air in colon/rectum
Small bowel obstruction vs ileus
Small bowel obstruction
Etiology
•
Prior surgery
(weeks to years)
Ileus
•
•
•
Abdominal
examination
•
•
Small bowel
dilation
Present
Present
Large bowel
dilation
Absent
Present
Distension
Increased bowel
sounds
Paralytic ileus
•
•
Recent surgery (hours
to days)
Metabolic (eg,
hypokalemia)
Medication induced
Possible distension
Reduced/absent
bowel sounds
Complicated small-bowel obstruction with perforation
RECTAL PROLAPSE
Rectal prolapse
Risk factors
•
•
•
•
•
Clinical
presentation
•
•
•
•
Management
•
•
Women age >40 with history of vaginal
deliveries/multiparity
Prior pelvic surgery
Chronic constipation, diarrhea, or straining
Stroke, dementia
Pelvic floor dysfunction or anatomic defects
Abdominal discomfort
Straining or incomplete bowel evacuation, fecal
incontinence
Digital maneuvers possibly required for defecation
Erythematous mass extending through anus with
concentric rings (full-thickness prolapse) or radial
invaginations (non–full-thickness prolapse)
Medical
–
Considered for non–full-thickness prolapse
–
Adequate fiber & fluid intake, pelvic floor
muscle exercises
–
Possible biofeedback therapy for fecal
incontinence
Surgical
–
Preferred for full-thickness or debilitating
symptoms (eg, fecal incontinence,
constipation, sensation of mass)
VOLVULUS
Sigmoid volvulus
Risk factors
•
•
Presentation
•
•
Imaging
•
•
Management
•
•
Sigmoid colon redundancy (eg, dilation/elongation
from chronic constipation)
Colonic dysmotility (eg, underlying neurologic disorder)
Slowly progressive abdominal discomfort/distension ±
obstructive symptoms (eg, nausea, emesis,
obstipation)
Abdomen distended & tympanitic to percussion
X-ray: dilated, inverted, U-shaped loop of colon (coffee
bean sign)
CT scan: dilated sigmoid colon, mesenteric twisting
(whirl sign)
Endoscopic detorsion (eg, flexible sigmoidoscopy) &
elective sigmoid colectomy
Emergency sigmoid colectomy if
perforation/peritonitis present
Cecal volvulus
Miscellaneous
Groin hernias
OVARIAN CANCER
Epithelial ovarian carcinoma
Clinical
presentation
•
•
Acute: shortness of breath, obstipation/constipation
with vomiting, abdominal distension
Subacute: pelvic/abdominal pain, bloating, early
satiety
Asymptomatic adnexal mass
Laboratory
findings
•
↑ CA-125
Ultrasound
findings
•
•
•
Solid mass
Thick septations
Ascites
Management
•
Exploratory laparotomy
•
Subdiaphragmatic free air on upright chest x-ray
POLYARTERITIS NODOSA
Polyarteritis nodosa
Pathophysiology
•
•
•
Clinical
features
•
•
•
•
•
•
Diagnosis
Correlation with underlying hepatitis B/C (immune
complexes)
Fibrinoid necrosis of arterial wall → luminal
narrowing & thrombosis → tissue ischemia
Internal/external elastic lamina damage →
microaneurysm formation → rupture & bleeding
Constitutional: fever, weight loss, malaise
Skin: nodules, livedo reticularis, ulcers, purpura
Renal: hypertension, renal insufficiency, arterial
aneurysms
Nervous: headache, seizures, mononeuritis
multiplex
Gastrointestinal: mesenteric ischemia/infarction
Musculoskeletal: myalgias, arthritis
•
•
Negative ANCA & ANA
Angiography: microaneurysms & segmental/distal
narrowing
•
Tissue biopsy: nongranulomatous transmural
inflammation
ANA = antinuclear antibodies; ANCA = antineutrophil cytoplasmic antibodies.
PSOAS ABSCESS
Psoas abscess
Clinical
presentation
•
•
•
Subacute fever & abdominal/flank pain that may
radiate to the groin or hip
Anorexia, weight loss
Abdominal pain with hip extension (psoas sign)
Diagnosis
•
•
•
CT scan of the abdomen & pelvis
Leukocytosis, elevated inflammatory markers
Blood & abscess cultures
Treatment
•
•
Drainage
Broad-spectrum antibiotics
Retroperitoneal hematoma
SPLEEN RUPTURE
Atraumatic splenic rupture
Risk factors
•
•
•
•
•
Hematologic malignancy (eg, leukemia,
lymphoma)
Infection (eg, CMV, EBV, malaria)
Inflammatory disease (eg, SLE, pancreatitis)
Splenic congestion (eg, cirrhosis, pregnancy)
Medications (eg, anticoagulation, G-CSF)
Clinical presentation
•
•
•
Diffuse or LUQ abdominal pain, peritonitis
Referred left shoulder pain (Kehr sign)
Hemodynamic instability
Diagnosis
•
•
Acute anemia
Intraperitoneal free fluid on imaging
Treatment
•
Catheter-based angioembolization (stable
patients)
•
Emergency splenectomy (unstable patients)
CMV = cytomegalovirus; EBV = Epstein-Barr virus; G-CSF = granulocytestimulating colony factor; LUQ = left upper quadrant; SLE = systemic lupus
erythematosus.
Evisceration
Pancreatic disorders
ACUTE PANCREATITIS
Acute pancreatitis
Etiology
•
Chronic alcohol use (~40%)
•
Gallstones (~40%)
•
Hypertriglyceridemia
•
Drugs (eg, azathioprine, valproic acid, thiazides)
•
Infections (eg, CMV, Legionella, Aspergillus)
•
Iatrogenic (post-ERCP, ischemic/atheroembolic)
Diagnosis (requires 2 of the follow)
Clinical
presentation
•
•
•
Acute epigastric pain radiating to the back
Amylase or lipase >3 times normal limit
Abnormalities on imaging consistent with
pancreatitis
Other findings
•
•
ALT level >150 U/L suggests gallstone pancreatitis
Severe disease: fever, tachypnea, hypoxemia,
hypotension
ALT = alanine aminotransferase; CMV = cytomegalovirus; ERCP = endoscopic
retrograde cholangiopancreatography.
Severe acute pancreatitis
Definition
•
Predictors
•
Acute pancreatitis with organ failure (eg, respiratory,
cardiovascular, renal) persisting >48 hr
Patient factors:
–
Older age (eg, age >55)
–
Comorbidities, including obesity (BMI >30 kg/m2)
•
Clinical findings:
–
Altered mental status
–
SIRS (eg, leukocytes >12,000/mm3, temperature
>38 C [100.4 F])
•
Laboratory findings of intravascular volume depletion:
–
↑ BUN (>20 mg/dL) and/or ↑ creatinine (>1.8
mg/dL)
–
↑ HCT (>44%)
•
Radiologic findings:
–
CXR: pulmonary infiltrates, pleural effusions
–
Abdominal CT scan: severe pancreatic necrosis
BUN = blood urea nitrogen; CXR = chest x-ray; HCT = hematocrit; SIRS =
systemic inflammatory response syndrome.
Pancreatic pseudocyst
ASCITES
Ascites fluid characteristics
Color
•
•
•
•
Bloody: trauma, malignancy, TB (rarely)
Milky: chylous
Turbid: possible infection
Straw color: likely more benign causes
Neutrophils
•
≥250/mm3: peritonitis (secondary or spontaneous
bacterial)
Total
protein
•
≥2.5 g/dL (high-protein ascites)
–
CHF, constrictive pericarditis, peritoneal
carcinomatosis, TB, Budd-Chiari syndrome,
fungal
<2.5 g/dL (low-protein ascites)
–
Cirrhosis, nephrotic syndrome
•
SAAG
•
≥1.1 g/dL (indicates portal hypertension)
–
Cardiac ascites, cirrhosis, Budd-Chiari syndrome
•
<1.1 g/dL (absence of portal hypertension)
–
TB, peritoneal carcinomatosis, pancreatic
ascites, nephrotic syndrome
CHF = congestive heart failure; SAAG = serum-ascites albumin gradient; TB =
tuberculosis.
CHRONIC PANCREATITIS
Exudative & transudative pleural effusions
Light criteria
Exudate
Transudate
Pleural protein/serum protein
>0.5
Exudate criteria not met
OR
Pleural LDH/serum LDH >0.6
OR
Pleural LDH >2/3 upper limit
of normal of serum LDH
Pathophysiology Inflammation
Common causes
Hydrostatic or oncotic
pressure
•
Infection (eg, TB,
•
Cirrhosis (hepatic
pneumonia)
hydrothorax)
•
Malignancy
•
Nephrotic
syndrome
•
Connective tissue
disease
•
Heart failure
•
Pulmonary embolism
•
Constrictive
pericarditis
•
Pancreatitis
•
Post-CABG
CABG = coronary artery bypass grafting; LDH = lactate dehydrogenase; TB =
tuberculosis.
Common causes of steatorrhea
Pancreatic
insufficiency
•
•
Chronic pancreatitis due to alcohol abuse,
cystic fibrosis, or autoimmune/hereditary
pancreatitis
Pancreatic cancer
Bile salt–related
•
•
•
•
•
Small-bowel Crohn disease
Bacterial overgrowth
Primary biliary cirrhosis
Primary sclerosing cholangitis
Surgical resection of ileum (at least 60-100 cm)
Impaired intestinal
surface epithelium
•
•
•
Celiac disease
AIDS enteropathy
Giardiasis
Other rare causes
•
•
•
Whipple disease
Zollinger-Ellison syndrome
Medication induced
COMPARTMENT SYNDROME
Abdominal compartment syndrome
Etiology
•
•
Clinical
manifestations
•
•
•
•
•
Management
↑ intraabdominal pressure causing organ
dysfunction
Risk factors: massive fluid resuscitation, major
intraabdominal surgery or pathology
Tense, distended abdomen
↑ ventilatory requirements (diaphragmatic
elevation, ↑ intrathoracic pressure)
↑ CVP (venous compression but ↓ venous return
& cardiac preload)
Hypotension, tachycardia (↓ venous return &
cardiac output)
↓ urine output (↓ intraabdominal organ
perfusion)
•
Temporizing measures:
–
Avoid over resuscitation with fluids
–
↓ intraabdominal volume (eg, NG tube)
–
↑ abdominal wall compliance (eg,
sedation)
•
Definitive management: surgical decompression
CVP = central venous pressure; NG = nasogastric.
Tumors of the GI tract
COLORECTAL CANCER SCREENING
Surveillance after colon cancer resection
Stage I
•
Colonoscopy in 1 yr & then every 3-5 yr
Stages II &
III
•
•
•
Colonoscopy in 1 yr & then every 3-5 yr
Periodic CEA testing
Annual CT scan of the chest, abdomen (± pelvis)
Stage IV
•
•
Individualize
Consider stage II/III strategy but more frequent CT
scans
CEA = carcinoembryonic antigen.
COLORECTAL POLYPS AND CANCER
Staging evaluation for rectal adenocarcinoma
Tumor markers
Carcinoembryonic antigen
Imaging
CT scan: chest, abdomen, pelvis
Endoscopy/direct visualization
Colonoscopy
Staging of gastric adenocarcinoma
PANCREATIC CANCER
Major risk factors for pancreatic cancer
Hereditary
•
•
•
First-degree relative with pancreatic cancer
Hereditary pancreatitis
Germline mutations (eg, BRCA1, BRCA2, PeutzJeghers syndrome)
Environmental
•
•
•
Cigarette smoking (most significant)
Obesity, low physical activity
Nonhereditary chronic pancreatitis
Pancreatic adenocarcinoma
Risk factors
•
•
•
•
Smoking
Hereditary pancreatitis
Nonhereditary chronic pancreatitis
Obesity & lack of physical activity
Clinical
presentation
•
Systemic symptoms (eg, weight loss, anorexia)
(>85%)
Abdominal pain/back pain (80%)
Jaundice (56%)
Recent-onset atypical diabetes mellitus
Unexplained migratory superficial
thrombophlebitis
Hepatomegaly & ascites with metastasis
•
•
•
•
•
Laboratory
studies
•
•
•
Cholestasis (↑ alkaline phosphatase & direct
bilirubin)
↑ Cancer-associated antigen 19-9 (not as a
screening test)
Abdominal ultrasound (if jaundiced) or CT scan (if
no jaundice)
Pancreatic adenocarcinoma
Risk factors
•
•
•
•
Smoking
Hereditary pancreatitis
Nonhereditary chronic pancreatitis
Obesity & lack of physical activity
Clinical
presentation
•
Systemic symptoms (eg, weight loss, anorexia)
(>85%)
Abdominal pain/back pain (80%)
Jaundice (56%)
Recent-onset atypical diabetes mellitus
Unexplained migratory superficial
thrombophlebitis
Hepatomegaly & ascites with metastasis
•
•
•
•
•
Laboratory
studies
•
•
•
Cholestasis (↑ alkaline phosphatase & direct
bilirubin)
↑ Cancer-associated antigen 19-9 (not as a
screening test)
Abdominal ultrasound (if jaundiced) or CT scan (if
no jaundice)
Pancreatic and biliary duct system
Approach to hyperbilirubinemia in adults
ZOLLINGER ELLISON SYNDROME
Zollinger-Ellison syndrome
Epidemiology
•
•
Age 20-50
80% Sporadic/20% MEN1
Clinical
features
•
•
•
Multiple & refractory peptic ulcers
Ulcers distal to duodenum
Chronic diarrhea
Diagnosis
•
Markedly elevated serum gastrin (>1,000 pg/mL) in
the presence of normal gastric acid (pH <4)
Workup
•
•
Endoscopy
CT scan/MRI & somatostatin receptor scintigraphy for
tumor localization
MEN1 = multiple endocrine neoplasia type 1.
Suspected gastrinoma
General Principles
Miscellaneous
Penetrating abdominal trauma
PERIOPERATIVE MEDICAL MANAGEMENT
Indications for select preoperative tests
ECG
•
•
History of coronary artery disease or
arrhythmia
Asymptomatic patients with risk of MACE ≥1%
Chest radiograph
•
•
History of cardiopulmonary disease
Undergoing upper abdominal/thoracic surgery
Hemoglobin
•
History of anemia, significant expected blood
loss
Undergoing major surgery
•
Coagulation &
platelets
•
•
Creatinine &
electrolytes
History of abnormal bleeding, anticoagulant
use
Liver disease, malignancy, planned spinal
anesthesia
•
History of kidney disease, cardiovascular risk
calculation
•
Predisposing medications (eg, diuretic, ACE
inhibitor, ARB)
ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker;
MACE = major adverse cardiovascular event.
SURGICAL WOUND INFECTION
Antibiotics for SSI prevention
Wound
classification
Procedure
Typical
examples
contaminants
Clean*
Cardiac, neurological,
orthopedic, vascular
Skin flora:
Streptococcus,
Staphylococcus
aureus &
coagulasenegative
staphylococci
1st-line:
cefazolin
Skin flora, gramnegative bacilli,
enterococci &
endogenous
flora of the
viscus
Based on
surgical site,
broader
coverage
often
indicated
Cleancontaminated**
Gastrointestinal,
genitourinary,
gynecologic/obstetric,
head & neck, thoracic
Antibiotic
prophylaxis
Alternatives:
vancomycin,
clindamycin
*Uninfected, uninflamed, the viscus is not entered.
**Viscus (eg, alimentary, genitourinary, respiratory systems) is entered under
controlled conditions.
SSI = surgical site infection.
THERMAL BURN
Intravenous fluids
Tonicity
Fluid type
Clinical use
Isotonic
0.9% (normal) saline
Volume resuscitation
(eg, hypovolemia, shock)
Lactated Ringer solution
Hypotonic
Albumin (5% or 25%)*
Volume replacement,
treatment of
SBP or HRS
Dextrose 5% in water**
Free water deficit
0.45% (half-normal) saline
Hypertonic
Dextrose 5% in 0.45% (halfnormal) saline**
Maintenance hydration
3% (hypertonic) saline
Severe, symptomatic
hyponatremia
HRS = hepatorenal syndrome; SBP = spontaneous bacterial peritonitis.
*Colloid solution; all other listed fluid types are crystalloid solutions.
**Dextrose 5% in water (initially slightly hypotonic) & dextrose 5% in 0.45%
saline (initially hypertonic) become markedly hypotonic due to metabolism of
glucose.
Traumatic brain injury
Hematology & Oncology
Hemostasis and thrombosis
DIC
Disseminated intravascular coagulation
Major causes
•
•
•
•
Sepsis
Severe traumatic injury
Malignancy
Obstetric complications
Pathophysiology
•
Procoagulant excessively triggers coagulation
cascade →
Formation of fibrin-/platelet-rich thrombi &
fibrinolysis →
Bleeding & organ damage (eg, kidneys, lungs)
•
•
Laboratory
findings
•
•
•
•
•
Thrombocytopenia
Prolonged PT & PTT
↓ Fibrinogen
↑ D-dimer
Microangiopathic hemolytic anemia
(schistocytes)
Acute vs chronic disseminated intravascular coagulation (DIC)
Common etiologies
Acute DIC
Chronic DIC
Sepsis
Malignancy (eg,
pancreatic)
Severe trauma
Obstetric
complications
Coagulation studies
Prolonged
Often normal
Platelets
Low
Often normal
Fibrinogen
Low
Often normal
D-dimer
High
High
Bleeding risk
Very high
Mildly increased
Thromboembolism
risk
Mildly increased
Very high
HEPARIN INDUCED THROMBOCYTOPENIA
Clinical features of type 2 heparin-induced thrombocytopenia
Clinical signs
Suspected with heparin exposure >5 days & any of the
following:
Diagnostic
evaluation
•
•
•
•
Platelet count reduction >50% from baseline
Arterial or venous thrombosis
Necrotic skin lesions at heparin injection sites
Acute systemic (anaphylactoid) reactions after
heparin
•
Serotonin release assay: gold standard confirmatory
test
Start treatment in suspected cases prior to
confirmatory tests
•
Therapy
•
•
Stop all heparin products
Start a direct thrombin inhibitor (eg, argatroban) or
fondaparinux (synthetic pentasaccharide)
RECTUS SHEATH HEMATOMA
Rectus sheath hematoma
Risk factors
•
•
•
Clinical
features
•
•
•
Management
•
Abdominal trauma, forceful abdominal contractions
(eg, coughing)
Anticoagulation
Older age, female sex
Acute-onset abdominal pain with palpable abdominal
mass
Blood loss anemia, leukocytosis
± Nausea, vomiting, fever
Hemodynamically stable: serial monitoring of CBC,
reverse anticoagulation and transfuse blood products
when appropriate
•
Unstable: angiography with embolization, surgical
ligation
CBC = complete blood count.
VENOUS THROMBOEMBOLISM
Modified Wells criteria for pretest probability
of deep venous thrombosis
Score 1 point for each feature
present
•
•
•
•
•
•
•
•
•
•
Total score for clinical
probability
•
•
•
Previously documented DVT
Active cancer
Recent immobilization of the legs
Recently bedridden >3 days
Localized tenderness along vein
distribution
Swollen leg
Calf swelling >3 cm compared to
other leg
Pitting edema
Collateral superficial nonvaricose
veins
Alternate diagnosis more likely (−2
points)
0 points = Low probability
1 or 2 points = Moderate probability
≥3 points = High probability
DVT = deep venous thrombosis.
Upper extremity deep venous thrombosis
Epidemiology
•
•
•
Central catheter or PICC line
Young, athletic males (spontaneous)
Thoracic outlet obstruction
Manifestations
•
•
•
•
Unilateral arm or forearm edema
Pain/heavy sensation
Erythema
Dilated subcutaneous collateral veins
Diagnosis
•
Doppler or duplex ultrasonography
Treatment
•
3 months of anticoagulation
PICC = peripherally inserted central catheter.
Upper extremity deep venous thrombosis
Risk factors
•
•
•
•
Central venous catheters
Repetitive arm motions (eg, baseball pitching)
Weight lifting
Malignancy
Manifestations
•
•
•
Acute arm edema, heaviness, pain & erythema
Dilated subcutaneous collateral veins in chest/upper
extremity
Pulmonary embolism
Diagnosis
•
Duplex or doppler ultrasonography
Treatment
•
•
3 months of anticoagulation
Thrombolysis (non–catheter-related)
Treatment of deep venous thrombosis
Principles of oncology
Mediastinal Compartments, Structures, & Masses
SPINAL CORD COMPRESSION
Spinal cord compression
Causes
•
•
•
Mechanical (eg, disc herniation, spinal stenosis)
Malignancy (eg, lung, breast, prostate cancers)
Infection (eg, epidural abscess)
Symptoms
•
•
Gradually worsening, severe back pain
Pain worse in recumbent position/at night
Physical
examination
•
Early signs
–
Symmetric extremity weakness
–
↓ Deep tendon reflexes
Late signs
–
↓ Rectal tone
–
↑ Deep tendon reflexes, bilateral Babinski
reflex
–
Paralysis
•
Management
•
•
•
Emergency MRI of the spine
Emergency surgical ± radiation oncology
consultation
Intravenous glucocorticoids (eg, malignancy) or
antibiotics (eg, infection)
Transfusion medicine
BLOOD TRANSFUSION
Transfusion reactions associated with hypotension
Reaction
Onset*
Cause
Clinical features
Anaphylaxis
Seconds
to
minutes
Recipient antiIgA antibodies
•
Shock,
angioedema/urticaria &
respiratory distress
Transfusionrelated acute
lung injury
Minutes
to hours
Donor
antileukocyte
antibodies
•
Respiratory distress &
noncardiogenic
pulmonary edema
Bilateral pulmonary
infiltrates
•
Acute
hemolysis
Minutes
to hours
ABO
incompatibility
•
Fever, flank pain,
hemoglobinuria & DIC
Bacterial
sepsis
Minutes
to hours
Bacterial
contamination
of donor
product
•
Fever, chills, septic
shock & DIC
*Time after transfusion initiation.
DIC = disseminated intravascular coagulation.
HYPOVOLEMIC SHOCK
Management of hemorrhage due to trauma
Control
bleeding
•
•
Control bleeding from any compressible site
Early transfer to location (trauma center, operating
room, angiography suite) for definitive care &
control of hemorrhage
Give blood
products early
•
•
Transfuse blood products early in resuscitation
Massive transfusion protocol*: ratio of 1:1:1
FFP/pRBCs/platelets to minimize risk of
coagulopathy
Limit use
of crystalloids
•
•
Limit to ~1 L if patient is hypotensive
Switch to blood products as soon as available
*Massive transfusion protocol likely required in patients with ≥2 of the
following: SBP ≤90 mm Hg, pulse ≥120/min, positive FAST examination, and
penetrating mechanism of injury.
FAST = Focused Assessment with Sonography for Trauma; FFP = fresh frozen
plasma; pRBCs = packed red blood cells; SBP = systolic blood pressure.
Infectious Diseases
Antimicrobial drugs
ANIMAL AND HUMAN BITE INJURIES
Cat bites
Microbiology
•
•
Pasteurella multocida
Anaerobic bacteria
Management
•
•
•
•
Copious irrigation & cleaning
Prophylactic amoxicillin/clavulanate
Tetanus booster as indicated
Avoid closure
LYMPHANGITIS
Lymphangitis
Epidemiology
•
•
Cutaneous injury → pathogen invasion of lymphatics
in deep dermis
Streptococcus pyogenes & MSSA
Manifestations
•
•
•
Tender, erythematous streaks proximal to wound
Regional tender lymphadenopathy (lymphadenitis)
Systemic symptoms (eg, fever, tachycardia)
Treatment
•
Cephalexin
MSSA = methicillin-sensitive Staphylococcus aureus.
Bacterial infections
ACUTE DIARRHEA
Clostridioides difficile colitis
Risk factors
•
Recent antibiotic use or hospitalization
•
•
•
•
Advanced age (>65)
Gastric acid suppression (eg, PPI, H2 blocker)
Underlying inflammatory bowel disease
Chemotherapy
Clinical
presentation
•
•
•
Profuse watery diarrhea
Leukocytosis (~15,000/mm3)
Fulminant colitis or toxic megacolon
Diagnosis
•
•
Stool PCR for C difficile genes*
Stool EIA for C difficile toxin & glutamate
dehydrogenase antigen
Infection
control
•
Hand hygiene with soap & water
•
Contact isolation
•
Sporicidal disinfectants (eg, bleach)
*Genes specific to toxigenic strains are assessed.
EIA = enzyme immunoassay; H2 = histamine-2 receptor; PPI = proton pump
inhibitor.
ANIMAL AND HUMAN BITE INJURIES
Clenched-fist bite injury ("fight bite")
Mechanism
•
•
Puncture through thin soft tissue overlying MCP joint
Enclosed bacterial proliferation under extensor
tendon & within joint capsule
Pathogens
•
Oral flora (eg, Eikenella corrodens, beta-lactamase–
producing anaerobes)
Skin flora (eg, streptococci, Staphylococcus aureus)
•
Clinical
features
•
•
Management
•
•
Small puncture wound appears minor initially; delay
in care common
Septic arthritis: joint pain, swelling,
erythema/warmth, restricted/painful ROM
Urgent surgical irrigation & debridement
Antibiotics (eg, ampicillin/sulbactam [IV],
amoxicillin/clavulanate [PO])
IV = intravenous; MCP = metacarpophalangeal; PO = orally; ROM = range of
motion.
ENDOCARDITIS
Clinical features of splenic abscess
Risk factors
•
•
•
•
•
Clinical
presentation
•
•
•
•
•
Treatment
•
•
Infection (eg, infective endocarditis) with
hematogenous spread
Hemoglobinopathy (eg, sickle cell disease)
Immunosuppression (eg, HIV)
Intravenous drug use
Trauma
Classic triad of fever, leukocytosis & left upperquadrant abdominal pain
Left-sided pleuritic chest pain with left pleural
effusion commonly seen
Possible splenomegaly
Most commonly due to Staphylococcus,
Streptococcus & Salmonella
Usually diagnosed by abdominal computed
tomography scan
Combination of broad-spectrum antibiotics &
splenectomy
Possible percutaneous drainage in poor surgical
candidates
Evaluation of suspected ventilator-associated pneumonia
NECROTIZING SOFT TISSUE INFECTIONS
Features of necrotizing fasciitis
Microbiology
•
•
•
•
Streptococcus pyogenes (group A Streptococcus)
Staphylococcus aureus
Clostridium perfringens
Polymicrobial
Pathogenesis
•
Bacteria spread rapidly through subcutaneous
tissue & deep fascia, undermining the skin
Most commonly involves the extremities &
perineal region
•
Clinical
manifestations
•
•
•
•
•
Often antecedent history of minor trauma
Erythema of overlying skin
Swelling & edema
Pain out of proportion to examination findings
Systemic symptoms (eg, fever & hypotension)
Treatment
•
Requires surgical debridement & broad-spectrum
antibiotics
Timeline of cause of postoperative fever
SEPTIC ARTHRITIS
Prosthetic joint infection
Time to
onset after
surgery
Early onset
Delayed onset
Late onset
<3 months
3-12 months
>12 months
Presentation
•
•
•
Acute pain
Wound
infection or
breakdown
Fever
•
•
•
Chronic joint pain
Implant loosening
Sinus tract
formation
•
•
Most
common
organisms
•
•
•
Staphylococcus
aureus
Gram-negative
rods
Anaerobes
•
•
•
Coagulasenegative
staphylococci
Propionibacterium
species
Enterococci
•
•
•
Acute
symptoms in
previously
asymptomatic
joint
Recent
infection at
distant site
Staphylococcus
aureus
Gram-negative
rods
Beta-hemolytic
streptococci
SURGICAL WOUND INFECTION
Risk of surgical site infection
Patient factors
•
•
•
•
•
•
Malnutrition/hypoalbuminemia, obesity
Glucocorticoids, immunosuppressive drugs,
chemotherapy, radiation
Smoking
Uncontrolled diabetes, peripheral artery disease,
venous insufficiency
Concurrent infection at another site
Advanced age
Procedural
factors
•
•
•
•
Emergency surgery
Surgery for malignancy
Open surgical approach
Inadequate site preparation & antibiotic prophylaxis
(as appropriate)
Personnel
factors
•
•
Inadequate hand hygiene
Inappropriate attire/gloving
TOXIC SHOCK SYNDROME
Clinical features of toxic shock syndrome
•
•
•
•
Fever usually >38.9 C (102 F)
Hypotension with systolic BP ≤90 mm Hg
Diffuse macular erythroderma
Skin desquamation, including palms & soles, 1-2 weeks after illness
onset
•
Multisystem involvement (3 or more systems)
–
Gastrointestinal (vomiting &/or diarrhea)
–
Muscular (severe myalgias or elevated creatine kinase)
–
Mucous membrane hyperemia
–
Renal (BUN or serum creatinine >1-2x upper limit of normal)
–
Hematologic (platelets <100,000/mm3)
–
Liver (ALT, AST & total bilirubin >2x upper limit of normal)
–
Central nervous system (altered mentation without focal
neurological signs)
ALT = alanine aminotransferase; AST = aspartate transaminase; BP = blood
pressure;
BUN = blood urea nitrogen.
VIBRIO VULNIFICUS
Vibrio vulnificus
Epidemiology
•
•
•
Gram-negative, free-living in marine environments
Ingestion (oysters) or wound infection
↑ Risk in those with liver disease* (cirrhosis,
hepatitis)
Manifestations
•
•
•
Rapidly progressive (often <12 hours)
Septicemia - septic shock, bullous lesions
Cellulitis - hemorrhagic bullae, necrotizing fasciitis
Diagnosis
•
Blood & wound cultures
Treatment
•
Empiric in those with likely illness as highly fatal
•
Intravenous ceftriaxone + doxycycline
*Hereditary hemochromatosis is particularly high risk as iron acts as a growth
catalyst.
Miscellaneous
SPLENECTOMY
Recommended vaccines for asplenic adult patients
Pneumococcus
•
•
Sequential PCV13 & PPSV23
Revaccination with PPSV23 5 years later &
at age 65
Haemophilus influenzae
•
1 dose Hib vaccine
Meningococcus
•
•
Meningococcal quadrivalent vaccine
Revaccinate every 5 years
Influenza
•
Inactivated influenza vaccine annually
Other vaccines
•
•
•
HAV
HBV
Tdap once as substitute for Td, then Td
every 10 years
HAV = hepatitis A vaccine; HBV = hepatitis B vaccine; Hib = Haemophilus
influenzae type B; PCV13 = 13-valent pneumococcal conjugate vaccine; PPSV23
= 23-valent pneumococcal polysaccharide vaccine; Td = tetanus-diphtheria
toxoid booster; Tdap = tetanus-diphtheria-acellular pertussis.
Parasitic and helminthic infections
ECHINOCOCCOSIS
Echinococcus granulosus
Epidemiology
•
•
•
Manifestations
•
•
•
Diagnosis
•
•
Treatment
Dog tapeworm (sheep intermediate host)
Rural, developing countries (eg, South America,
Middle East)
Humans are incidental hosts (egg ingestion)
Initially asymptomatic (often for years)
Liver cyst (most common)
–
Mass effect: RUQ pain, nausea, vomiting,
hepatomegaly
–
Rupture: fever, eosinophilia
Lung cyst: cough, chest pain, hemoptysis
Large, smooth hydatid cyst often with internal
septations on imaging
IgG E granulosus serology
•
Albendazole
•
Percutaneous therapy (>5 cm or septations)
•
Surgery (if rupture)
RUQ = right upper quadrant.
LIVER ABSCESS
Entamoeba histolytica
Risk factors
•
Resource-limited regions (contaminated food/water)
Clinical
manifestations
•
•
•
Most are asymptomatic
Colitis: prolonged bloody/mucoid diarrhea
Liver abscess: RUQ pain, fever
–
Complications: pleural effusion, rupture into
peritoneum/pleural space
Diagnosis
•
•
•
Stool PCR/antigen: preferred
Stool microscopy: low sensitivity
Serology*: useful for isolated liver abscess
Treatment
•
Metronidazole or tinidazole
PLUS
•
Intraluminal antibiotic (eg, paromomycin)
*Does not distinguish between prior & current infection.
RUQ = right upper quadrant.
Male Reproductive System
Disorders of the male reproductive system
BENIGN PROSTATIC HYPERPLASIA
Indications for cystoscopy
•
•
•
•
•
•
Gross hematuria with no evidence of glomerular disease or infection
Microscopic hematuria with no evidence of glomerular disease or
infection but increased risk for malignancy
Recurrent urinary tract infections
Obstructive symptoms with suspicion for stricture, stone
Irritative symptoms without urinary infection
Abnormal bladder imaging or urine cytology
Transurethral resection of the prostate (TURP)
Benign prostatic hyperplasia (BPH)
CRYPTORCHIDISM
Cryptorchidism
Risk factors
•
•
•
•
Prematurity
Small for gestational age
Low birth weight (<2.5 kg [5.5 lb])
Genetic disorders
Clinical features
•
•
Empty, hypoplastic, poorly rugated scrotum or
hemiscrotum
± Inguinal fullness
Treatment
•
Orchiopexy before age 1
Complications
•
•
•
•
Inguinal hernia
Testicular torsion
Subfertility
Testicular cancer
EPIDIDYMITIS
Acute epididymitis
Etiology
•
•
Age <35: sexually transmitted (chlamydia, gonorrhea)
Age >35: bladder outlet obstruction (coliform
bacteria)
Manifestations
•
•
•
•
Unilateral, posterior testicular pain
Epididymal edema
Pain improved with testicular elevation
Dysuria, frequency (with coliform infection)
Diagnosis
•
NAAT for chlamydia & gonorrhea
•
Urinalysis/culture
NAAT = nucleic acid amplification test.
Penile anatomy
PRIAPISM
Priapism
Pathogenesis
•
•
•
Impaired venous outflow from corpora cavernosa
Increased cavernosal pressure
Ischemia, hypoxia, acidosis
Causes/
risk factors
•
•
Autonomic dysfunction: spinal cord injury
Altered blood viscosity: sickle cell disease, blood
dyscrasias
Medications/drugs: phosphodiesterase inhibitors (eg,
sildenafil), trazodone, stimulants
•
Treatment
•
•
Aspiration, irrigation
Intracorporal alpha-1 adrenergic agonist (eg,
phenylephrine)
Priapism in sickle cell disease
Pathogenesis
•
•
Sickling of blood in corpora cavernosa
Increased viscosity & decreased venous outflow
Triggers
•
•
Physical factors: fever, cold, dehydration
Drugs/medications: cocaine, alcohol, testosterone
Treatment
•
•
Aspiration of blood from corpora cavernosa
Intracavernous injection of phenylephrine
PROSTATE CANCER
Comparison of benign prostatic hyperplasia & prostate cancer
BPH
Prostate cancer
Risk factors
•
Age >50
•
Age >40, African
American & family
history
Affected
part
•
Central portion
(transitional zone)
•
Usually peripheral
zone of prostate but can
be anywhere
Examination
•
Symmetrically
•
Asymmetrically
enlarged & smooth
enlarged, nodules &
prostate
firm prostate
•
Can have elevated
•
Markedly elevated PSA
PSA
BPH = benign prostatic hyperplasia; PSA = prostate-specific antigen.
PROSTATITIS
Chronic bacterial prostatitis
Epidemiology
•
•
Young & middle-aged men
↑ Risk with diabetes, smoking, urinary tract procedure
Pathogens
•
•
Coliforms enter from urethra via intraprostatic reflux
Escherichia coli causes >75% of cases
Presentation
•
Recurrent urinary tract infection (with the same
organism)
+/- Prostatic tenderness & swelling (often absent)
Pain with ejaculation
History of antibiotic treatment → transient
improvement
•
•
•
Diagnosis
•
•
Pyuria and bacteriuria on urinalysis
Bacteria in prostatic fluid > bacteria in urine
Treatment
•
Fluoroquinolones (eg, ciprofloxacin) for 6 weeks
TESTICULAR CANCER
Testicular cancer
Epidemiology
•
•
Age 15-35
Risk factors: family history, cryptorchidism
Manifestations
•
•
•
Unilateral, painless testicular nodule or swelling
Dull lower abdominal ache
Metastatic symptoms (eg, dyspnea, neck mass, low
back pain)
Diagnosis
•
•
•
•
Examination: firm, ovoid mass or unilateral swelling
Scrotal ultrasound
Tumor markers (AFP, β-hCG)
Staging imaging (CT scan, chest x-ray)
Treatment
•
Radical orchiectomy
•
Chemotherapy
•
Cure rate ~95%
AFP = alpha-fetoprotein.
Testicular cancer
Epidemiology
•
•
Age 15-35
Risk factors: family history, cryptorchidism
Types
•
•
Germ cell tumors (95%): seminomatous or
nonseminomatous (embryonal carcinoma, yolk sac,
choriocarcinoma, teratoma, mixed)
Sex cord–stromal tumors: Sertoli cell, Leydig cell
•
•
Unilateral, painless testicular mass
Dull ache in lower abdomen
Manifestations
Diagnosis
•
Examination: firm, ovoid mass
•
Elevated tumor markers (AFP, β-hCG, LDH)
•
Scrotal ultrasound
AFP = alpha-fetoprotein; LDH = lactate dehydrogenase.
Malignant testicular neoplasms
Germ
cell
(95%)
Seminoma
•
•
Retain features of spermatogenesis
β-hCG, AFP usually negative
Nonseminoma
•
≥1 partially differentiated cells: yolk sac,
embryonal carcinoma, teratoma, and/or
choriocarcinoma
β-hCG, AFP usually positive
Stromal
(5%)
Leydig
•
•
•
Sertoli
•
•
Often produces excessive estrogen
(gynecomastia) or testosterone (acne)
Can cause precocious puberty
Rare
Occasionally associated with excessive
estrogen secretion (eg, gynecomastia)
AFP = alpha-fetoprotein.
TESTICULAR TORSION
Testicular torsion
Epidemiology
•
Most common in adolescents
Clinical
features
•
•
•
•
•
Testicular, inguinal, abdominal pain
Nausea, vomiting
Horizontal testicular lie with elevated testicle
Absent cremasteric reflex
Swollen, erythematous scrotum
Imaging
•
No blood flow on scrotal ultrasound with Doppler
Management
•
Surgical detorsion & fixation with exploration of the
contralateral side
Manual detorsion (if immediate surgery is not
•
VARICOCELE
Varicocele
Clinical
presentation
•
•
•
Soft scrotal mass ("bag of worms")
–
↓ In supine position
–
↑ With standing/Valsalva maneuvers
Subfertility
Testicular atrophy
Ultrasound
findings
•
•
•
Retrograde venous flow
Tortuous, anechoic tubules adjacent to testis
Dilation of pampiniform plexus veins
Treatment
•
Gonadal vein ligation (boys & young men with
testicular atrophy)
•
Scrotal support & NSAIDs (older men who do not
desire additional children)
NSAIDs = nonsteroidal anti-inflammatory drugs.
Miscellaneous (Multisystem)
Miscellaneous
SHOULDER DISLOCATION
Acute glenohumeral dislocation
Mechanism
of injury
•
•
•
Blow to abducted/raised arm
Fall on outstretched hand
Violent muscle contraction (eg, seizure)
Clinical
features
•
•
Anterior dislocation: arm held in abduction/external
rotation, anterior prominence of humeral head
Posterior dislocation: arm held in adduction/internal
rotation, loss of anterior contour, prominence of
coracoid & acromion
Management
•
•
Closed reduction (uncomplicated), surgical repair
Immobilization & progressive rehabilitation
Complications
•
•
•
Fracture (glenoid, proximal humerus, clavicle)
Rotator cuff injury
Recurrent dislocation
Nervous System
Anesthesia/pharmacotherapy
DELIRIUM
Emergence from anesthesia
Normal
emergence
•
•
Transition from general anesthesia to consciousness
Most patients fully awake within 15 min of
extubation
Inadequate
emergence
•
Delayed emergence: hypoactive state, somnolence
persisting >30-60 min
Emergence delirium: hyperactive state, usually
manifests in the OR
Reassure & reorient: most cases are temporary & due
to anesthetic effects
Evaluate for serious underlying conditions (eg,
oxygenation, metabolic, or neurologic factors) &
causes of discomfort (eg, acute pain, bladder
distension)
•
•
•
OR = operating room.
Cerebrovascular disease
HEMORRHAGIC STROKE
Cerebellar hemorrhage
Risk factors
•
•
•
Hypertension
Antithrombotic therapy (eg, warfarin, aspirin)
Cerebral amyloid angiopathy
Manifestations
•
•
•
Headache, nausea, vomiting
Ipsilateral ataxia, dysarthria, vertigo, nystagmus
Cranial neuropathies
Management
•
•
•
Reversal of anticoagulation
Blood pressure management
ICP management (eg, head of bed elevation,
mannitol)
•
Surgical decompression indicated with:
–
Hemorrhage >3 cm
–
Neurologic deterioration (eg, impaired
consciousness)
–
Brainstem compression, obstructive
hydrocephalus
ICP = intracranial pressure.
Initial management of stroke
Congenital and developmental anomalies
MALIGNANT HYPERTHEMIA
Malignant hyperthermia
Epidemiology
•
•
Genetic mutation alters control of intracellular
calcium
Triggered by volatile anesthetics, succinylcholine,
excessive heat
Manifestations
•
•
•
•
•
•
Masseter muscle/generalized rigidity
Sinus tachycardia
Hypercarbia resistant to increased minute ventilation
Rhabdomyolysis
Hyperkalemia
Hyperthermia (late manifestation)
Treatment
•
•
•
Respiratory/ventilatory support
Immediate cessation of causative anesthetic
Dantrolene
NEUROFIBROMATOSIS
Neurofibromatosis type II
Genetics
•
•
•
Autosomal dominant
NF2 gene on chromosome 22 encoding merlin (tumor
suppressor)
Variable expressivity, usually at age 20-30
Clinical
manifestations
•
•
•
•
•
Bilateral vestibular schwannomas
Intracranial meningiomas
Spinal tumors (eg, schwannomas, ependymomas)
Cataracts
Cutaneous tumors or skin plaques
Tumor
surveillance
•
•
•
Audiogram
Ophthalmologic evaluation
MRI of the brain & spine
Disorders of peripheral nerves and muscles
Management of unilateral facial weakness
CARPAL TUNNEL SYNDROME
Pathophysiology of carpal tunnel syndrome
Cause
Pathophysiologic features
Idiopathic/overuse
•
Swelling & fibrosis of tendons & soft tissue
Hypothyroidism
•
Soft tissue enlargement (mucopolysaccharides)
Diabetes mellitus
•
•
Soft tissue enlargement
Microvascular insufficiency & neovascularization
Rheumatoid
arthritis
•
Extrinsic compression from joint deformity
Pregnancy
•
Edema/fluid accumulation
End-stage
renal disease
•
•
Amyloid & calcium phosphate deposition
Access related (bleeding, venous hypertension
during HD, vascular steal)
Acromegaly
•
•
Tendon enlargement
Synovial edema
Gout
•
Compression from tophi
HD = hemodialysis.
Femoral nerve
Axillary nerve injury
Neurodegenerative disorders and dementias
NORMAL PRESSURE HYDROCEPHALUS
Normal pressure hydrocephalus
Clinical
features
•
•
•
•
•
Gait instability (wide-based) with frequent falls
Cognitive dysfunction
Urinary urgency/incontinence
Depressed affect (frontal lobe compression)
Upper motor neuron signs in lower extremities
Diagnosis
•
Marked improvement in gait with spinal fluid removal:
Miller Fisher (lumbar tap) test
Enlarged ventricles out of proportion to the underlying
brain atrophy on MRI
•
Treatment
•
Ventriculoperitoneal shunting
Spinal cord disorders
Anterior cord syndrome
CAUDA EQUINA SYNDROME
Conus medullaris
syndrome
Cauda equina syndrome
Vertebral
level
•
L1-L2
•
L2-sacrum
Spinal level
•
UMN: tracts of
lumbosacral cord
•
LMN: lumbosacral spinal
roots
Presentation
•
Severe low back
pain
Mild or absent
radicular pain
Bowel/bladder
dysfunction
•
Mild or absent low back
pain
Severe radicular pain
Bowel/bladder dysfunction
•
•
Physical
examination
•
•
•
Motor weakness
•
Motor weakness usually
usually
asymmetric
symmetric
•
Areflexia/hyporeflexia
•
Hyperreflexia,
•
Asymmetric saddle
UMN signs
numbness that may extend
•
Symmetric
to the leg
perianal
numbness
LMN = lower motor neuron; UMN = upper motor neuron.
Central cord syndrome
CERVICAL MYELOPATHY
Cervical myelopathy
•
•
Age >55
Degenerative cervical spine/discs → canal stenosis →
cord compression
•
•
•
•
•
Gait dysfunction - usually first
Extremity weakness & numbness
LMN signs (arms) - muscle atrophy, hyporeflexia
UMN signs (legs) - Babinski, hyperreflexia
↓ Proprioception/vibration/pain sensation
Diagnosis
•
•
MRI of cervical spine
CT myelogram
Treatment
•
•
Nonsurgical - immobilization
Surgical decompression
Epidemiology
Manifestations
LMN = lower motor neuron; UMN = upper motor neuron.
Cervical spondylosis
EPIDURAL ABSCESS
Spinal epidural abscess
Epidemiology
•
•
•
Manifestations
•
Staphylococcus aureus (65%)
Immunosuppression (HIV, diabetes, alcohol use, old
age)
Inoculating sources
–
Distant infection (eg, cellulitis, joint/bone)
–
Spinal procedure (eg, epidural catheter)
–
Injection drug use
•
Classic triad
–
Fever (~50%)
–
Focal/severe back pain
–
Neurologic findings (eg, motor/sensory
change, bowel/bladder dysfunction,
paralysis)
↑ Erythrocyte sedimentation rate
Diagnosis
•
•
MRI of the spine with contrast
Blood & aspirate cultures
Treatment
•
Broad-spectrum antibiotics (eg, vancomycin +
ceftriaxone)
Urgent aspiration/surgical decompression
•
Spinal epidural abscess
RADICULOPATHY
Features of cervical radiculopathy
Nerve
root
Reflex affected
Sensory loss*
Weakness
(Disc
space)
C5
•
Biceps
•
(C4-5)
C6
(C5-6)
•
•
Biceps
Brachioradialis
•
•
Lateral
upper
arm
•
Thumb
Index
finger
•
•
•
•
C7
•
Triceps
(C6-7)
C8
•
•
(C7T1)
T1
•
•
(T1-2)
Finger
flexors**
Finger
flexors**
•
•
Dorsal
forearm
Middle
finger
•
Ring &
little
fingers
•
Medial
forearm
•
•
•
•
Shoulder abduction
(deltoid)
Elbow flexion
(biceps)
Elbow flexion
(biceps)
Forearm
pronation/supination
(brachioradialis)
Wrist extension
Elbow extension
(triceps)
Wrist flexion
Finger extension
Finger flexion &
extension
Thumb flexion &
abduction
Finger abduction &
adduction
*In addition to neck/shoulder pain, radicular pain typically has a similar
distribution to sensory loss.
**Not typically evaluated clinically.
RHEUMATOID ARTHRITIS
Clinical features of RA cervical myelopathy
Symptoms
•
•
•
•
Signs
•
•
•
Neck pain radiating to occipital region
Slowly progressive spastic quadriparesis
Painless sensory deficits in hands or feet
Respiratory dysfunction (eg, from vertebral artery
compression)
Protruding anterior arch of atlas
Scoliosis with loss of cervical lordosis
Upper motor neuron signs (eg, spastic paresis,
hyperreflexia, Babinski sign)
•
Hoffman sign
RA = rheumatoid arthritis.
Facet dislocation
Autonomic dysreflexia
Syringomyelia
Traumatic brain injuries
Types of brain herniation
Inferior rectus entrapment
Acute subdural hematoma
TRAUMATIC BRAIN INJURY
Interventions to reduce intracranial pressure
↓ Brain
parenchymal
volume
•
Osmotic therapy (eg, hypertonic saline, mannitol)
to extract water
↓ Cerebral blood
volume
•
•
•
Head elevation to ↑ venous outflow
Sedation to ↓ metabolic demand
Hyperventilation to ↓ PaCO2, resulting in
vasoconstriction
↓ CSF volume
•
CSF removal (eg, external ventricular drain)
↑ Cranial volume
•
Decompressive craniectomy
CSF = cerebrospinal fluid.
Management of traumatic brain injury
Goal
Interventions
Maintain
CPP
(= MAP −
ICP)
•
•
Maintain MAP: isotonic fluids, vasopressor therapy
Reduce ICP: head elevation, sedation, osmotic therapy
(eg, hypertonic saline, mannitol), decompressive
interventions (eg, CSF removal, craniectomy)
Prevent
ICH
•
Antifibrinolytic therapy (ie, tranexamic acid) within first 3
hr
Reversal of preexisting anticoagulation
•
Other
measures
•
•
Prevent seizures (eg, levetiracetam, phenytoin)
Control blood glucose (eg, insulin to target 140-180
mg/dL glucose)
•
Maintain normothermia (eg, antipyretics, surface-cooling
devices)
CPP = cerebral perfusion pressure; CSF = cerebrospinal fluid; ICH = intracranial
hemorrhage; ICP = intracranial pressure; MAP = mean arterial pressure.
Tumors of the nervous system
Meningioma
PITUITARY APOPLEXY
Thunderclap headache
Clinical
features
Etiology
•
•
Sudden (maximum intensity <1 hr), severe headache
± Seizure, neurologic deficits, mental status
abnormality
•
± Nausea/vomiting
Most common:
•
Subarachnoid hemorrhage: hypertension, neck
stiffness
•
RCVS: recurrent episodes over days to weeks
Less common:
•
•
•
•
•
Evaluation
Pituitary apoplexy: ophthalmoplegia, visual field
defects, adrenal insufficiency
Cervical artery dissection: posterior headache, neck
pain
Cavernous sinus thrombosis: slower onset, proptosis,
fever (if septic)
Meningitis: slower onset, fever, neck pain & stiffness
PRES: subacute headache, hypertensive crisis
•
Immediate noncontrast CT scan of the head
•
Lumbar puncture
•
Expedited MRI of the head
PRES = posterior reversible encephalopathy syndrome; RCVS = reversible
cerebral vasoconstriction syndrome.
Ophthalmology
Disorders of the eye and associated structures
CATARACT
Ocular manifestations of HIV
Cataracts
•
•
•
Loss of acuity, glare, halos around lights
Opacification of lens, loss of red reflex
Surgery often required at early age
Cytomegalovirus retinitis
•
•
•
Unilateral, acute/subacute loss of vision
Fluffy or granular retinal lesions
Decreased risk with HAART
Herpes simplex keratitis
•
Acute unilateral ocular pain, redness,
tearing
Branching/dendritic corneal ulcers
•
Uveitis
•
•
•
Neuroophthalmic
complications
•
•
Pain, tearing, photophobia, decreased
acuity
Hyperemia, constricted pupil, hypopyon
Due to intraocular HIV replication or
secondary infection
Optic neuropathy
Motor palsies
HAART = highly active anti-retroviral therapy.
Cataract
ENDOPHTHALMITIS
Candida endophthalmitis
Epidemiology
•
•
•
Transient/persistent fungemia → hematogenous
dissemination to the choroid → invasion of the retina
& fluid chambers
Risk factors: indwelling central catheter, TPN, broadspectrum antibiotic use, gastrointestinal surgery &
immunocompromise
Most cases arise in hospitalized patients or in those
with recent eye surgery/trauma
Manifestations
•
•
•
Usually unilateral floaters & progressive vision loss
Pain rare until late in disease process
Fever may be absent & patient may otherwise feel
well
Diagnosis
•
•
Blood cultures (often negative)
Vitreous fluid sampling & culture
Treatment
•
•
Systemic antifungal therapy
Vitrectomy + vitreous injection (when fluid chamber
involved)
TPN = total parenteral nutrition.
ENDOPTHALMITIS
Bacterial endophthalmitis
Etiology
•
•
Bacterial infection of the aqueous humor &/or
vitreous
Risk factors: recent eye surgery (eg, cataract
extraction) or trauma
Clinical
features
•
•
•
Decreased vision ± eye discomfort (eg, "ache")
Conjunctival injection & edema
Purulent haziness or layering of leukocytes
(hypopyon) in anterior chamber
Diagnosis
•
•
Diagnosed clinically → ophthalmologic emergency
Can confirm diagnosis with Gram stain & culture of
vitreous
Treatment
•
•
Intravitreal injection of antibiotics
Vitrectomy for severe cases
GLAUCOMA
Angle-closure glaucoma
Clinical
features
•
•
Symptoms: headache, ocular pain, nausea, decreased
visual acuity
Signs: conjunctival redness; corneal opacity; fixed,
mid-dilated pupil
Diagnosis
•
•
Tonometry (measures intraocular pressure)
Gonioscopy (measures corneal angle)
Treatment
•
Topical therapy: multidrug topical therapy (eg,
timolol, pilocarpine, apraclonidine)
Systemic therapy: acetazolamide (consider mannitol)
Laser iridotomy
•
•
Glaucoma pathophysiology
HYPERTHYROIDISM
Clinical manifestations of Graves disease
General
Heat intolerance, weight loss, sweating
Eyes
Lid lag, proptosis, diplopia
Skin
Hair loss, infiltrative dermopathy (pretibial myxedema)
Cardiovascular
Tachycardia, hypertension, atrial fibrillation
Nails
Onycholysis, clubbing (acropachy)
Endocrine
Hyperglycemia, hypercalcemia, bone loss, menstrual
irregularities
Gastrointestinal Diarrhea
Neurology
Tremors, hyperreflexia, proximal muscle weakness
OCULAR TRAUMA
Corneal epithelial defects
Etiology
•
•
•
Trauma or foreign body
Contact lens use
Exposure (eg, incomplete lid closure)
Clinical
features
•
•
•
Severe eye pain
Foreign body sensation, ↑ tearing
Photophobia, reluctance to open eye
Evaluation
•
Penlight test: assess pupillary shape & function, inspect
for foreign body
Visual acuity
Fluorescein examination after above tests:
concentrated uptake indicates corneal epithelial defect
•
•
Orbital compartment syndrome
Pathophysiology
•
•
↑ Intraorbital pressure
Risk factors: trauma, coagulopathy, infection,
surgery
Clinical features
•
•
Acute eye pain
Diplopia, vision loss
Examination
•
•
•
•
•
Periorbital swelling, ecchymosis & tightness (eg,
hard eyelid)
Proptosis
Diffuse subconjunctival hemorrhage
Limited extraocular movements
Afferent pupillary defect
•
Emergency surgical decompression
findings
Management
Traumatic hyphema
Mechanism
•
•
Blunt ocular trauma (eg, baseball, paintball,
airbag deployment)
Penetrating trauma (less common)
Clinical
presentation
•
•
•
•
•
Vision loss
Eye pain
Photophobia
Layering of blood in the anterior chamber
Anisocoria (unequal pupils)
Initial
management
•
Ophthalmology consultation
–
Monitor intraocular pressure
–
Cycloplegic & glucocorticoid eye drops
Eye shield
Bed rest (elevate head)
•
•
Complications
•
•
•
Rebleeding
Intraocular hypertension → optic nerve atrophy
(glaucoma)
Permanent vision loss
Open globe injury
Risk factors
•
•
Blunt force trauma (rupture)
Penetrating trauma (laceration)
Clinical features
•
•
•
•
•
Extrusion of vitreous (eg, "gush" of fluid)
Eccentric or teardrop pupil
Decreased visual acuity
Relative afferent pupillary defect
Decreased intraocular pressure
Management
•
•
•
•
•
Emergency ophthalmology consultation
Eye shield
CT scan of eye
Intravenous antibiotics
Tetanus prophylaxis
Management of corneal abrasion
Eye irrigation devices
Poisoning & Environmental Exposure
Environmental exposure
ACCIDENTAL HYPOTHERMIA
Frostbite
Clinical
findings
•
•
•
Superficial pallor & anesthesia
Blistering, eschar formation
Deep tissue necrosis & mummification
Management
•
Rapid rewarming in water bath at 37-39 C (98.6-102.2
F)
Analgesia & wound care
Angiography or technetium-99m scan to assess for
thrombosis if rewarming is unsuccessful
Thrombolysis in severe, limb-threatening cases
•
•
•
INSECT BITES AND STINGS
Bites from Loxosceles reclusa (brown recluse)
Epidemiology
•
•
•
Southwestern, southern, midwestern United States
Dry, warm areas (eg, attics, basements)
Spider identification rare (initial bite usually painless)
Manifestations
•
Small erythematous papule that self-resolves (most
common)
Burning pain → blister → eschar/necrosis
–
Expands over days, heals over weeks
Systemic loxoscelism (eg, fever, hemolysis, DIC)
–
Uncommon; not correlated with lesion size
•
•
Management
•
Cleanse wound & apply ice (reduces phospholipase
activity)
•
No surgical débridement until lesion has stopped
growing
•
Supportive management for systemic loxoscelism
•
Update tetanus
DIC = disseminated intravascular coagulation.
SNAKE BITE
Snakebite envenomation
Clinical features
•
•
•
•
•
Effects due to venom toxins (may be delayed)
Tissue injury (eg, progression to necrosis)
Myotoxicity (eg, cardiovascular collapse)
Neurotoxicity
Coagulopathy
Management
•
•
•
•
Limb immobilization & wound management
Frequent coagulation studies
Antivenom if indicated (not given in mild cases due
to risk of life-threatening allergic reaction)
Observation for 12-24 hr
•
•
•
Unstable vital signs (eg, hypotension, tachypnea)
Rapidly progressing changes in wound
Abnormal coagulation studies
Antivenom
indications
THERMAL BURN
Hypermetabolic response in burn injury
Etiology
•
•
Clinical
features
•
•
•
•
Treatment
•
•
•
•
Moderate to severe burn injury (eg, inhalational, highvoltage electrical, TBSA >20%)
↑ Inflammatory mediators, which result in ↑
catecholamines, glucocorticoids & glucagon
Hyperdynamic circulatory response: tachycardia,
hypertension
↑ Gluconeogenesis & insulin resistance:
hyperglycemia
↑ Basal metabolic rate: ↑ basal body temperature
↑ Protein & lipid catabolism: ↑ lean muscle wasting
Early burn excision & grafting
Beta blockade (eg, propranolol)
Glycemic control (eg, insulin)
Nutritional support & anabolic steroid therapy (eg,
oxandrolone)
TBSA = total body surface area.
Escharotomy
Pulmonary & Critical Care
Cancer and pulmonary/mediastinal masses
CARCINOID TUMORS
Bronchial carcinoid tumor
Epidemiology
•
•
Manifestations
•
•
•
•
Diagnosis
•
•
Most common lung cancer in adolescents/young
adults
Neuroendocrine tumor derived from bronchial
Kulchitsky cells
Proximal airway obstruction (eg, dyspnea, wheezing,
cough)
Recurrent pneumonia distal to obstruction
Hemoptysis
Carcinoid syndrome less common than with midgut
carcinoid
Chest imaging: contrast enhanced (vascular) tumor
with endobronchial component
Bronchoscopy with biopsy
LUNG CANCER
Common manifestations of superior pulmonary sulcus tumor
•
•
•
•
•
Shoulder pain
Horner syndrome (invasion of paravertebral sympathetic chain/stellate
ganglion)
–
Ipsilateral ptosis, miosis, enophthalmos & anhidrosis
Neurologic symptoms in the arm (invasion of C8-T2 nerves)
–
Weakness/atrophy of intrinsic hand muscles
–
Pain/paresthesia of 4th/5th digits & medial arm/forearm
Supraclavicular lymphadenopathy
Weight loss
LUNG NODULE
Solitary pulmonary nodules
Factors increasing
malignant probability
•
Large size*
•
Advanced patient age
•
Female sex
•
Active or previous smoking
•
Family or personal history of lung cancer
•
Upper lobe location
•
Spiculated radiographic appearance
*Size >2 cm independently correlates with >50% malignant probability.
Congenital and developmental anomalies
Diaphragmatic rupture
Critical care and trauma medicine
ARDS
Acute respiratory distress syndrome: pathogenesis & diagnosis
Risk factors &
pathogenesis
•
•
Pathophysiology
•
•
•
Diagnosis
•
•
•
Direct (eg, pneumonia, inhalation) or indirect (eg,
sepsis, pancreatitis, trauma) lung injury
Inflammatory cell activation & ↑ permeability ↔
fluid & cytokine leakage into alveoli
↓ Lung compliance (alveolar flooding) → ↑ work
of breathing
Severe V/Q mismatch (intrapulmonary shunt) →
severe hypoxemia
↑ Hypoxic pulmonary vasoconstriction → ↑ RV
afterload & acute PHTN
New bilateral alveolar opacities within 1 week of
inciting insult
Edema not explained by cardiac failure or volume
overload
Hypoxemia with PaO2/FiO2 ≤300
PHTN = pulmonary hypertension; RV = right ventricular; V/Q =
ventilation/perfusion.
ACUTE RESPIRATORY FAILURE
Causes of hypoxemia
Examples
A-a
gradient
Corrects with
supplemental O2?
Reduced PiO2
High altitude
Normal
Yes
Hypoventilation
CNS depression,
morbid obesity
Normal
Yes
Diffusion limitation
Emphysema, ILD
Increased
Yes
V/Q mismatch*
Small PE, lobar
pneumonia
Increased
Yes
Large
intrapulmonary
shunt
Diffuse pulmonary
edema
Increased
No
Large dead-space
ventilation
Massive PE, rightto-left intracardiac
shunt
Increased
No
*Caused by localized dead-space ventilation and/or intrapulmonary shunting.
A-a gradient = alveolar-arterial oxygen gradient; ILD = interstitial lung disease;
PE = pulmonary embolism; PiO2 = partial pressure of inspired oxygen;
V/Q = ventilation/perfusion ratio.
BLUNT THORACIC TRAUMA
Rib fracture location & associated injuries
Location
Associated injuries
Ribs 1-3
Subclavian vessels, brachial plexus, mediastinal vessels (eg, aorta)
Ribs 3-6
Cardiovascular
Ribs 912
Intraabdominal: liver (right), spleen (left), kidney (posterior ribs 11
& 12)
Any
level
Pulmonary
Flail chest
Diaphragmatic hernia
Rib fractures with hemothorax
Evaluation of hemoptysis
PENETRATING NECK TRAUMA
Venous air embolism
Etiologies
•
•
•
Trauma, certain surgeries (eg, neurosurgical)
Central venous catheter manipulation
Barotrauma (eg, positive-pressure
ventilation)
Clinical
manifestations
•
•
Sudden-onset respiratory distress
Hypoxemia, obstructive shock, cardiac arrest
Management
•
•
Left lateral decubitus positioning
High-flow or hyperbaric oxygen
PNEUMOTHORAX
Pneumothorax
Spontaneous pneumothorax
Associated
features
•
•
Signs &
symptoms
•
•
•
Imaging
•
•
Primary: no preceding
event or lung disease;
often thin, young men
Secondary: underlying
lung disease (eg,
COPD, CF)
Chest pain, dyspnea
↓Breath sounds,
↓chest movement
Hyperresonant to
percussion
Visceral pleural line
Absent lung markings
beyond pleural edge
Tension pneumothorax
•
•
Same as spontaneous plus:
•
Hemodynamic
instability
•
Tracheal deviation
away from affected
side
Same as spontaneous plus:
•
•
Management
•
Life-threatening
Often due to trauma
or mechanical
ventilation
Contralateral
mediastinal shift
Ipsilateral
hemidiaphragm
flattening
Small (≤2 cm):
•
Urgent needle
observation & oxygen
decompression or
administration
chest tube
placement
•
Large & stable: needle
aspiration or chest
tube
CF = cystic fibrosis; COPD = chronic obstructive pulmonary disease.
Pneumothorax
PULMONARY CONTUSION
Pulmonary contusion
Clinical
features
•
•
Present <24 hours after blunt thoracic trauma
Tachypnea, tachycardia, hypoxia
Diagnosis
•
•
Rales or decreased breath sounds
CT scan (most sensitive) or CXR with patchy, alveolar
infiltrate not restricted by anatomical borders
Management
•
•
Pain control
Pulmonary hygiene (eg, incentive spirometry, chest
PT)
•
Supplemental oxygen & ventilatory support
CXR = chest x-ray; PT = physiotherapy.
RESPIRATORY ACIDOSIS
Unilateral diaphragmatic paralysis
Etiology
•
•
•
•
Phrenic nerve injury (eg, cardiac surgery, trauma, radiation
therapy, compressive tumor)
Viral infection (eg, herpes zoster, poliomyelitis)
Systemic neurologic disease (eg, ALS, GBS)
Idiopathic
Clinical
features
•
•
•
Typically asymptomatic at rest
Dyspnea on exertion
Orthopnea
Diagnosis
•
Fluoroscopic "sniff" test (paradoxical movement of the
diaphragm seen during brisk inspiration)
ALS = amyotrophic lateral sclerosis; GBS = Guillain-Barré syndrome.
Flail chest
THERMAL BURN
Inhalation injury
Pathophysiology
•
•
Upper airway thermal injury ± lower airway
chemical injury
Concomitant CO & cyanide poisoning common
Concerning
features
•
•
Historical: smoke exposure in enclosed space
Physical: singed hair, facial burns, carbonaceous
sputum, wheezing
Strong
indicators
of airway injury
•
•
Oropharyngeal blistering or edema
Retractions, respiratory distress, hypoxia
Management
•
•
100% oxygen to displace CO
Stable patients with concerning features but no
strong indicators: bedside fiberoptic laryngoscopy
Unstable patients or patients with strong
indicators: endotracheal intubation
•
CO = carbon monoxide.
Interstitial pulmonary and other systemic disorders
ATELECTASIS
Postoperative pulmonary complications
Complications
•
•
Atelectasis, bronchospasm, pneumonia
Prolonged ventilator requirement
Risk
factors
•
•
•
Age >50, active smoking
Underlying heart failure or obstructive lung disease
Emergency surgery or surgery duration >3 hr
Perioperative
prevention
•
•
•
Smoking cessation >4-8 weeks prior to surgery
Symptomatic control of underlying lung disease
Pain control, deep-breathing exercises, incentive
spirometry
Atelectasis
INTERSTITIAL LUNG DISEASE
Idiopathic pulmonary fibrosis
Pathophysiology
& risk factors
•
•
•
Clinical
presentation
•
•
•
Microscopic alveolar epithelial injury (smoking,
GERD, silent aspiration)
Inappropriate repair by fibrosis instead of
epithelial regeneration
Risk factors/demographics: male, age >60,
smoking, polymorphisms in genes regulating
epithelial regeneration & health
Chronic progressive dyspnea, nonproductive
cough, fatigue
Fine "Velcro" inspiratory crackles, digital clubbing
HRCT: UIP (subpleural honeycombing, reticular
opacities); PFTs: restrictive pattern
Management
•
Antifibrotic therapy (eg, pirfenidone, nintedanib)
•
Smoking cessation & treatment of GERD
•
Supplemental oxygen & pulmonary rehabilitation
•
Lung transplantation
GERD = gastroesophageal reflux disease; HRCT = high-resolution computed
tomography; PFT = pulmonary function test; UIP = usual interstitial pneumonia.
Miscellaneous
FOREIGN BODY ASPIRATION
Foreign body aspiration
Clinical
features
•
•
•
Sudden-onset cough, dyspnea
Cyanosis
± History of choking episode
Examination
findings
•
•
Wheezing &/or stridor
Focal area of diminished breath sounds
X-ray findings
•
•
•
•
Hyperinflation of affected side
Mediastinal shift toward unaffected side
Atelectasis if obstruction is complete
± Foreign body
Management
•
Rigid bronchoscopy
LUNG TRANSPLANTATION
Lung transplant rejection
Clinical
presentation
Acute
Chronic
(cell-mediated response)
(mixed cell-mediated
& antibody response)
•
•
≤6 months after
transplant
Asymptomatic or
fever, cough, dyspnea
•
•
•
Diagnosis
•
•
Management
•
BAL to rule out
infection
Biopsy: submucosal
lymphocytic infiltrate,
perivascular
inflammation
•
High-dose
glucocorticoids
•
•
•
Months to years
after transplant
Progressive cough &
dyspnea
History of acute
episodes
Obstructive pattern
on PFT
BAL to rule out
infection
Biopsy: submucosal
lymphocytic
infiltrate,
bronchiolitis
obliterans
Supportive
management
•
Possible repeat
transplant
BAL = bronchoalveolar lavage; PFT = pulmonary function testing.
Pulmonary infections
Ludwig angina
ASPIRATION PNEUMONIA
Aspiration: pneumonitis vs pneumonia
Chemical pneumonitis
Aspiration pneumonia
Cause
•
Inhalation of gastric
acid leads to direct
chemical injury of
bronchial & alveolar
epithelial cells
•
Inhalation of large
inoculate of
oropharyngeal or
gastric microbes
overwhelms host
pulmonary defenses
Onset
•
Sudden: within
minutes or hours
•
Indolent: a few days
to weeks
Manifestations
•
Abrupt-onset
dyspnea, cough,
hypoxemia
Low-grade fever
Diffuse
crackles/wheezes
Infiltrate in
dependent portion of
lung
•
•
Fever
Cough with putrid
sputum
Infiltrate in
dependent portion
of lung
Supportive care
Oropharyngeal
suction if event is
witnessed
•
•
•
•
Management
•
•
•
Antibiotics (eg,
ceftriaxone plus
azithromycin) that
target communityacquired
pneumonia
pathogens
CYTOMEGALOVIRUS
Major complications of solid organ transplantation
Infectious
•
•
Nosocomial infections (eg, hospital-acquired
pneumonia)
Opportunistic pathogens (eg, CMV, PCP, Aspergillus)
Immunologic
•
•
•
Hyperacute rejection: ABO mismatch
Acute rejection*: cell or antibody-mediated
Chronic rejection: fibrosis of graft structures (eg,
bronchiolitis obliterans of airways)
Postoperative
•
•
Surgical site: anastomotic dehiscence
Primary graft dysfunction: ARDS, ATN
Other
•
Drug toxicities: nephrotoxicity (calcineurin
inhibitors), osteoporosis (corticosteroids)
•
Malignancy: posttransplant lymphoproliferative
disorder (EBV)
*Acute cellular rejection is the most common type in the first 90 days but can
occur at any time after transplant.
ARDS = acute respiratory distress syndrome; ATN = acute tubular necrosis;
CMV = cytomegalovirus; EBV = Epstein-Barr virus; PCP = Pneumocystis jiroveci
pneumonia.
HEALTHCARE ASSOCIATED PNEUMONIA
Major risk factors for ventilator-associated pneumonia
•
Acid suppression (eg, PPI, H2R blocker, antacid)
•
Supine position
•
Pooled subglottic secretions
•
Paralysis & excessive sedation
•
Excessive patient movement while intubated
•
Frequent ventilator circuit changes
H2R = histamine-2 receptor; PPI = proton pump inhibitor.
Pathogenesis of ventilator-associated pneumonia (VAP)
LUNG ABSCESS
Lung abscess
Pathophysiology
•
•
•
Aspiration of oropharyngeal/gingival anaerobes
Risk factors: dysphagia, substance abuse, seizures
Pneumonitis → pneumonia → abscess/empyema
Manifestations
•
•
Subacute fever, night sweats, weight loss
Cough with putrid sputum
Diagnosis
•
•
Cavitary infiltrates with air-fluid levels
Cultures rarely useful
Treatment
•
•
Ampicillin-sulbactam, imipenem, meropenem
Alternate: clindamycin
PARAPNEUMONIC EFFUSION & EMPYEMA
Parapneumonic effusions
Uncomplicated
Complicated
Etiology
Sterile exudate in pleural
space
Bacterial invasion of
pleural space
Radiologic
appearance
Small to moderate & free
flowing
Moderate to large, free
flowing
or loculated
Pleural fluid
characteristics
Pleural fluid
Gram stain &
culture
Treatment
•
•
•
pH ≥7.2
Glucose ≥60 mg/dL
WBCs
≤50,000/mm3
•
LDH ≤1,000 units/L
Negative
•
•
•
pH <7.2
Glucose <60 mg/dL
WBCs
>50,000/mm3
•
LDH >1,000 units/L
Positive or negative*
Antibiotics
Antibiotics & drainage
*Gram stain & culture are often falsely negative due to low bacterial
count. Both are typically positive in empyema, which represents advanced
progression of a complicated effusion.
LDH = lactate dehydrogenase; WBC = white blood cell.
Empyema
Etiology
•
Bacterial invasion of pleural space resulting in
fibrinopurulent consolidation
Usually due to progression of a complicated
parapneumonic effusion
•
Common
organisms
•
•
Oral anaerobic bacteria (likely most common)
Streptococcus pneumoniae, Staphylococcus aureus
Clinical
features
•
Symptoms of pneumonia (eg, fever, dyspnea, pleuritic
chest pain)
Insidious presentation (eg, 1-2 weeks or more),
weight loss
Laboratory evidence of inflammation (eg,
leukocytosis, thrombocytosis)
•
•
Management*
•
Chest tube drainage when possible (ie, empyema is
free flowing)
•
Intrapleural fibrinolytic drugs (eg, tPA/DNase) may
assist drainage
•
Surgical decortication for highly fibrotic, loculated
effusions
*In addition to antibiotics.
tPA/DNase = tissue plasminogen activator/recombinant deoxyribonuclease.
Pulmonary vascular and cardiopulmonary disease
AV MALFORMATION
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu)
Vascular bed
Sequelae
CNS
•
•
Hemorrhagic CVA
Brain abscess: paradoxical bacterial embolization
across pulmonary AVM
Mucocutaneous
•
•
Oral & cutaneous telangiectasia
Recurrent epistaxis
Lung
•
•
Pulmonary AVM: hemoptysis
PAH: right-sided heart failure
GI
•
•
Chronic GI bleed
Liver: portal hypertension, high-output heart
failure
AVM = arteriovenous malformation; CVA = cerebrovascular accident; GI =
gastrointestinal; PAH = pulmonary arterial hypertension.
FAT EMBOLISM
Fat embolism syndrome
Etiology
•
•
•
Fracture of marrow-containing bone (eg, femur)
Orthopedic surgery
Pancreatitis
Clinical
presentation
•
•
24-72 hr following inciting event
Clinical triad
–
Respiratory distress
–
Neurologic dysfunction (eg, confusion)
–
Petechial rash
Diagnosis
•
Based on clinical presentation
Prevention
& treatment
•
•
Early immobilization of fracture
Supportive care (eg, mechanical ventilation)
Approach to patient with suspected pulmonary embolism
TRANSFUSION RELATED ACUTE LUNG INJURY
Acute respiratory failure due to transfusion
Feature
TRALI
TACO
Pulmonary symptoms
Acute dyspnea
Acute dyspnea
Chest x-ray
Diffuse bilateral
infiltrate
Diffuse bilateral
infiltrate
Jugular venous
distension
Absent
Present
Auscultation
Crackles/rales
Crackles/rales ± S3
Ejection fraction
Normal
Decreased
BNP
Normal
High
BNP = brain natriuretic peptide; TACO = transfusion-associated circulatory
overload; TRALI = transfusion-related acute lung injury.
Renal, Urinary Systems & Electrolytes
Acute kidney injury
PRERENAL AZOTEMIA
Prerenal acute kidney injury
Etiology
•
Decreased renal perfusion
–
True volume depletion
–
Decreased EABV (eg, heart failure, cirrhosis)
–
Displacement of intravascular fluid (eg, sepsis,
pancreatitis)
–
Bilateral renal artery stenosis with ACE
inhibition
–
Afferent arteriole vasoconstriction (eg,
NSAIDs)
Clinical
features
•
•
•
•
•
Increase in serum creatinine (eg, 50% from baseline)
Decreased urine output
Blood urea nitrogen/creatinine ratio >20:1
Fractional excretion of sodium <1%
Unremarkable ("bland") urine sediment
Treatment
•
Restoration of renal perfusion
EABV = effective arterial blood volume; NSAIDs = nonsteroidal antiinflammatory drugs.
Chronic kidney disease
Renal osteodystrophy
RENAL ARTERY STENOSIS
Fibromuscular dysplasia
Clinical presentation
•
•
•
90% women (in adults)
Internal carotid artery stenosis
–
Recurrent headache
–
Pulsatile tinnitus
–
Transient ischemic attack
–
Stroke
Renal artery stenosis
–
Secondary hypertension
–
Flank pain
Physical examination
•
•
Subauricular systolic bruit
Abdominal bruit
Diagnosis
•
•
Imaging preferred (eg, duplex US, CTA, MRA)
Catheter-based arteriography
Treatment
•
Antihypertensives (ACE inhibitors or ARBs 1st
line)
PTA
Surgery (if PTA unsuccessful)
•
•
ARB = angiotensin II receptor blocker; CTA = CT angiography; MRA = MR
angiography; PTA = percutaneous transluminal angioplasty; US =
ultrasonography.
Clinical clues to renovascular disease
HTN-related
symptoms
Supportive
evidence
•
Resistant HTN (uncontrolled despite 3-drug
regimen)
•
Malignant HTN (with end-organ damage)
•
Onset of severe HTN (>180/120 mm Hg) after age
55
•
Severe HTN with diffuse atherosclerosis
•
Recurrent flash pulmonary edema with severe
HTN
Physical examination
•
Asymmetric renal size (>1.5 cm)
•
Abdominal bruit
Laboratory results
•
Unexplained rise in serum creatinine (>30%) after
starting ACE inhibitors or ARBs
Imaging results
•
Unexplained atrophic kidney
ARBs = angiotensin II receptor blockers; HTN = hypertension.
Cystic kidney diseases
POLYCYSTIC KIDNEY DISEASE
Autosomal dominant polycystic kidney disease
Clinical
presentation
•
•
•
•
•
Most patients asymptomatic until age 30-40
Flank pain, hematuria
Hypertension
Palpable abdominal masses (usually bilateral)
Chronic kidney disease (CKD)
Extrarenal
features
•
•
•
•
•
Cerebral aneurysms
Hepatic & pancreatic cysts
Mitral valve prolapse, aortic regurgitation
Colonic diverticulosis
Ventral & inguinal hernias
Diagnosis
•
Ultrasonography showing multiple renal cysts
Management
•
Aggressive control of risk factors for CV & CKD
•
ACE inhibitors preferred for hypertension
•
Hemodialysis, renal transplant for ESRD
CV = cardiovascular; ESRD = end-stage renal disease.
RENAL CYSTS
Characteristics of renal cysts
Simple renal cyst
Malignant cystic mass
Thin, smooth, regular wall
Thick, irregular wall
Unilocular
Multilocular
No septae
Multiple septae, occasionally thick &
calcified
Homogenous content
Heterogenous content (solid & cystic)
Absence of contrast
enhancement on CT/MRI
Presence of contrast enhancement on
CT/MRI
Usually asymptomatic
May cause pain, hematuria, or hypertension
No follow-up needed
Requires follow-up imaging & urological
evaluation for malignancy
Fluid, electrolytes, and acid-base
METABOLIC ACIDOSIS
Metabolic acidosis
Type
Normal anion gap
Mechanism
•
Etiologies
•
•
Loss of bicarbonate
Elevated anion gap
•
Accumulation of
unmeasured acidic
compounds
Severe diarrhea
•
Lactic acidosis
Renal tubular
•
Diabetic ketoacidosis
acidosis
•
Renal failure (uremia)
•
Excess saline
•
Methanol, ethylene glycol
infusion
•
Salicylate toxicity
•
Intestinal or
pancreatic fistula
•
CAI & MRA
diuretics
CAI = carbonic anhydrase inhibitor; MRA = mineralocorticoid receptor
antagonist.
METABOLIC ALKALOSIS
Hypokalemic, hypochloremic metabolic alkalosis
Common
etiologies
•
•
Gastric suction or severe vomiting
Loop or thiazide diuretic overuse
Pathophysiology
•
•
•
Gastric or renal H+ losses initiate alkalosis
Volume depletion activates RAAS
↑ renal K+ & H+ losses cause hypokalemia &
worsen alkalosis
Relatively greater loss of Cl− than Na+ → profound
Cl− depletion
↓ Cl− impairs renal HCO3− excretion to
perpetuate alkalosis
•
•
Management
•
Remove or treat initiating factor
•
Cl− repletion with normal saline corrects alkalosis
RAAS = renin-angiotensin-aldosterone system.
RESPIRATORY ALKALOSIS
Common causes of primary acid-base disturbance
Metabolic acidosis
Elevated anion gap
•
•
•
•
Poor tissue perfusion (ie, lactic acidosis)
Diabetic ketoacidosis
Renal failure (ie, uremia)
Certain toxicities (eg, methanol, ethylene
glycol)
Normal anion gap
•
•
•
Severe diarrhea
Renal tubular acidosis
Excess normal saline infusion
Metabolic alkalosis
•
•
•
Nasogastric suctioning or severe vomiting
Diuretic overuse
Primary hyperaldosteronism
Respiratory acidosis
•
Central respiratory depression (eg, opioid
overdose)
OHS, neuromuscular weakness
Chronic obstructive pulmonary disease
(hypoventilation)
Respiratory alkalosis
•
•
•
Acute V/Q mismatch (eg, PE, pneumonia)
•
Anxiety, inadequate pain control
(hyperventilation)
•
High altitude, pregnancy
OHS = obesity hypoventilation syndrome; PE = pulmonary embolism;
V/Q = ventilation/perfusion.
Neoplasms and trauma of the kidneys and urinary tract
BLADDER CANCER
Bladder cancer
Epidemiology
•
•
>90% urothelial carcinoma
↑ Risk with smokers & exposure to industrial
carcinogens
Manifestations
•
•
•
Painless hematuria throughout micturition
Irritative voiding symptoms (eg, frequency, urgency,
dysuria)
Regional pain
Diagnosis
•
•
Flexible cystoscopy with biopsy (gold standard)
Urine cytology
Staging
•
•
TURBT
Upper urinary tract imaging (eg, IVP, MRI, CT)
Treatment
•
No muscle invasion: TURBT & intravesical
immunotherapy
•
Muscle invasion: radical cystectomy & systemic
chemotherapy
•
Metastatic: systemic chemotherapy &
immunotherapy
IVP = intravenous pyelogram; TURBT = transurethral resection of bladder
tumor.
Male urogenital anatomy
RENAL CELL CARCINOMA
Renal cell carcinoma
Epidemiology
•
•
Age >50
Risk ↑ with smoking, obesity, chemical exposure
Manifestations
•
•
•
•
•
Hematuria: microscopic or gross ± clots
Abdominal/flank mass
Flank pain
Left-sided varicocele that does not decompress
Paraneoplastic syndrome (eg, EPO production, ↑
calcium)
Diagnosis
•
•
EPO = erythropoietin.
Abdominal CT scan
Partial/complete nephrectomy (for histology)
Differential diagnosis of polycythemia
Primary (↓ EPO)
•
•
Secondary (normal/↑ EPO)
Polycythemia vera (JAK2
mutation)
EPO receptor mutations
•
•
•
•
•
Hypoxemia
–
Cardiopulmonary disease
–
Obstructive sleep apnea
–
High altitude
EPO-producing tumors (renal,
hepatic)
Congenital (high-affinity
hemoglobin)
Following renal transplantation
Androgen supplementation
EPO = erythropoietin.
Male urogenital anatomy
Nephrolithiasis, hematuria, and urinary tract obstruction
RENAL CALCULI
Struvite (magnesium ammonium phosphate) stones
Risk factors
•
•
Recurrent upper urinary tract infection
Urease-producing organisms (eg, Klebsiella, Proteus)
Pathogenesis
•
Hydrolysis of urea to yield ammonia:
Urea → 2 NH3 + CO2
NH3 + H2O → NH4+ + OH−
•
•
Increased urine pH
Precipitation of magnesium ammonium phosphate
salts
•
•
•
Large staghorn calculi
Fever, mild flank pain due to infection
Obstruction of collecting system & atrophy of renal
parenchyma
Clinical
features
Uric acid kidney stones
Risk factors
•
•
•
Pathophysiology
•
•
Increased uric acid excretion: Gout,
myeloproliferative disorders
Increased urine concentration: Hot, arid
climates; dehydration
Low urine pH: Chronic diarrhea (GI bicarbonate
loss), metabolic syndrome/diabetes mellitus
Acidic urine favors formation of uric acid
(insoluble) over urate (soluble)
Supersaturation of urine with uric acid
precipitates crystal formation
Clinical
characteristics
•
•
•
Radiolucent stones (not visible on x-ray)
Uric acid crystals on urine microscopy
Urine pH usually <5.5
Treatment
•
Alkalinization of urine (potassium citrate)
GI = gastrointestinal.
Management of ureteral stones
RENAL VEIN THROMBOSIS
Renal vein thrombosis
Risk factors
•
•
•
Hypercoagulability
–
Nephrotic syndrome
–
Malignancy (particularly renal)
–
OCP
Volume depletion (infants)
Trauma
Clinical features
•
•
•
•
Hematuria
Flank or abdominal pain
Elevated LDH ± AKI
Enlarged kidney on imaging
Diagnosis
•
•
CT or MR angiography
Renal venography
Treatment
•
Anticoagulation
•
Thrombolysis/thrombectomy (if AKI present)
AKI = acute kidney injury; LDH = lactate dehydrogenase; OCP = oral
contraceptive pills.
Urinary incontinence/retention, GU infection
URINARY TRACT OBSTRUCTION
Urethral stricture
Etiology
•
•
•
•
Male > female
Urethral trauma (eg, catheterization)
Urethritis
Radiotherapy
Symptoms
•
•
•
Weak or spraying stream
Incomplete emptying
Irritative voiding (eg, dysuria, frequency)
Complications
•
•
•
Acute urine retention
Recurrent urinary tract infection
Bladder stones
Diagnosis
•
•
•
Postvoid residual, uroflowmetry
Urethrography
Cystourethroscopy
Management
•
•
Dilation
Urethroplasty
Rheumatology/Orthopedics & Sports
Arthritis and spondyloarthropathies
BURSITIS
Septic bursitis
Risk factors
•
•
•
Presentation
•
•
Local cellulitis, abrasions, or penetrating trauma
Bursal instrumentation/injection, prior bursal
inflammation
Immunocompromised state
Painful, localized bursal swelling with erythema &
warmth
± Fever, chills, myalgias
Diagnosis
•
•
Consider diagnostic aspiration of bursal fluid
Consider x-ray (for suspected fracture, foreign body, or
osteomyelitis)
Treatment
•
•
Systemic antibiotics
Drainage in select cases
Lateral knee
Management of osteoarthritis
Osteoarthritis (knee)
Hip osteoarthritis
SEPTIC ARTHRITIS
Septic arthritis
Risk factors
•
•
•
•
Advanced age
Abnormal joint (eg, OA, RA, prosthetic joint)
Immunocompromise (eg, diabetes mellitus)
Bacteremia (eg, intravenous drug use)
Clinical features
•
•
•
Hot, swollen joint with ↓ ROM
Fever
↑ ESR & CRP
Diagnosis
•
Synovial fluid analysis
–
Leukocytosis (>50,000/mm3)
–
Gram stain (sensitivity ~30%-50%) & culture
Blood cultures
•
Initial
treatment
•
•
Intravenous antibiotics
Joint irrigation & drainage (eg, arthroscopy, open
arthrotomy)
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; OA =
osteoarthritis; RA = rheumatoid arthritis; ROM = range of motion.
Bone tumors and tumor-like lesions
Giant cell tumor of bone
Ganglion cyst
MYOSITIS OSSIFICANS
Myositis ossificans
Pathogenesis
•
Formation of lamellar bone in extraskeletal tissues
Causes &
risk factors
•
Traumatic: muscle injury, fracture, orthopedic
surgery (eg, arthroplasty)
Neurogenic: stroke, traumatic brain injury, spinal
cord injury
•
Clinical
presentation
•
•
•
Intramuscular mass with pain, swelling/induration
Days to weeks following injury
Quadriceps & brachialis most common
Diagnosis
•
Laboratory: elevated alkaline phosphatase, ESR, Creactive protein
X-ray: periosteal bone reaction, calcification with
radiolucent center
•
Management
•
ROM exercise & NSAIDs (eg, indomethacin)
•
Surgical excision
ESR = erythrocyte sedimentation rate; NSAIDs = nonsteroidal antiinflammatory drugs; ROM = range of motion.
Bone, joint, and soft tissue injuries and infections
ACROMIOCLAVICULAR INJURIES
Common causes of shoulder pain
Rotator cuff tendinopathy
•
•
Pain with abduction (overhead activities)
or external rotation
Strength preserved
Rotator cuff tear
•
•
Similar to rotator cuff tendinopathy
Weakness
Adhesive capsulitis (frozen
shoulder)
•
Decreased passive & active range of
shoulder motion
AC joint sprain
•
•
Pain over AC joint
Passive shoulder adduction provokes
pain
Biceps tendinopathy
•
Pain over bicipital groove
AC = acromioclavicular.
ACUTE PAIN
Acute pain management in patients with opioid use disorder
Environment
•
Supportive, nonjudgmental, shared decision-making
Withdrawal
prevention
•
Do not decrease or stop maintenance opioid (eg,
methadone, buprenorphine)
Analgesia
•
Maximize nonopioid medications (eg, acetaminophen,
NSAIDs)
•
Use regional anesthesia when possible
•
Add opioids only as needed (shared decision-making
required):
–
Patients with sustained remission are treated
as opioid naïve
–
Patients on maintenance may require higher
doses
–
Convert to oral as soon as possible with rapid
taper to baseline
–
Use for shortest period (3-5 days) if possible
NSAIDs = nonsteroidal anti-inflammatory drugs.
ADHESIVE CAPSULITIS
Adhesive capsulitis
Pathogenesis
•
•
•
Clinical
presentation
•
•
Glenohumeral capsule contracture
Idiopathic or secondary to shoulder injury (eg, rotator
cuff tear, surgery)
Risk factors: diabetes mellitus, hypothyroidism
Gradual onset, poorly localized shoulder pain &
stiffness
Decreased passive & active range of motion
Diagnosis
•
•
Clinical diagnosis
X-ray, MRI, ultrasound to rule out other causes
(eg, rotator cuff tendinitis, osteoarthritis)
Treatment
•
•
•
•
Range-of-motion exercises
Nonsteroidal anti-inflammatory drugs
Corticosteroid injection
Arthroscopic distension of joint capsule or surgical
release
Natural
history
•
•
Muscle atrophy of shoulder in advanced disease
Pain & stiffness may last years
AMPUTATION
Post-amputation pain
Acute stump pain
•
•
Tissue & nerve injury
Severe pain lasting 1-3 weeks
Ischemic pain
•
•
•
Swelling, skin discoloration
Wound breakdown
↓ Transcutaneous oxygen tension
Post-traumatic
neuroma
•
•
•
Weeks to months after amputation
Focal tenderness, altered local sensation
↓ Pain with anesthetic injection
Phantom limb pain
•
•
Onset usually within 1 week
Increased risk in patients with severe acute
pain
Intermittent cramping, burning felt in distal
limb
•
Ottawa ankle rules
ANOREXIA NERVOSA
Anorexia nervosa
Clinical
features
•
•
BMI <18.5 kg/m2
Fear of weight gain, distorted body image
Medical
complications
•
•
•
•
•
•
•
Decreased bone mineral density, osteoporosis
Amenorrhea
Lanugo, hair loss, dry skin
Gastroparesis, constipation
Enlarged parotid glands (if binge/purge type)
Hypotension, hypothermia, bradycardia
Cardiac atrophy, arrhythmias
BAKER CYST
Popliteal (Baker) cyst
Etiology
•
Extrusion of fluid from knee joint space into
semimembranosus/gastrocnemius bursa
Risk factors
•
•
Trauma (eg, meniscal tear)
Underlying joint disease (eg, osteoarthritis,
rheumatoid arthritis)
Clinical
presentation
•
Asymptomatic bulge behind knee that diminishes
with flexion
Posterior knee pain, swelling, stiffness
•
Complications
•
•
•
Venous compression (leg/ankle swelling)
Dissection into calf (erythema, edema, positive
Homans sign)
Cyst rupture (acute calf pain, warmth, erythema,
ecchymosis)
BURSITIS
Greater trochanteric pain syndrome (trochanteric bursitis)
Risk
factors
•
•
•
•
Age ≥50
Women > men
Obesity
Low back & lower extremity disorders (eg, scoliosis,
osteoarthritis, plantar fasciitis)
Symptoms
•
•
Chronic lateral hip pain
Pain worse with hip flexion or lying on affected side
Diagnosis
•
•
•
Focal tenderness over trochanter
X-ray to rule out hip joint pathology
Ultrasound: degeneration of tendons, tendinosis
Treatment
•
•
•
Exercise, physical therapy, activity modification
Nonsteroidal anti-inflammatory drugs
Corticosteroid injection
CLAVICLE FRACTURE
Signs of traumatic arterial injury
Hard signs
(require immediate
surgery)
Soft signs
(require further
imaging)
•
•
Distal limb ischemia (eg, paralysis, pain, pallor,
poikilothermy)
Absent distal pulse
Active hemorrhage or rapidly expanding
hematoma
Bruit or thrill at site of injury
•
•
•
•
•
Diminished distal pulses
Unexplained hypotension
Stable hematoma
Documented hemorrhage at time of injury
Associated neurologic deficit
•
•
Clavicle fracture
Colles fracture
De Quervain tendinopathy
DUPUYTREN'S CONTRACTURE
Dupuytren contracture
Risk factors
•
•
•
Male sex, age >50, family history
Diabetes mellitus
Tobacco & alcohol use
Clinical
presentation
•
Thickening of palmar fascia at the 3rd, 4th & 5th
digits
Discrete nodules along flexor tendons near distal
palmar crease
Decreased extension of digits
•
•
Treatment
•
•
•
•
Modification of hand tools (eg, cushion tape,
padded gloves)
Needle aponeurotomy
Intralesional glucocorticoid injection
Surgery for contractures or advanced disease
HIP FRACTURE
Femoral neck fracture
Clinical
presentation
•
Severe hip pain & inability to bear weight after a
fall
Risk factors: age >65, frailty, osteoporosis
Examination
findings
•
•
•
Shortened, externally rotated leg
Painful range of motion
Ecchymosis
X-ray findings
•
•
•
•
Disruption of cortical contour
External rotation of distal fragment (prominence
of lesser trochanter profile)
Shortening of neck
Lucency or hazy sclerosis at fracture plane
•
Open reduction/internal fixation or arthroplasty
Management
•
Posterior hip dislocation
Femoral neck fracture
Clinical features of femoral neck fracture
ILIOTIBIAL BAND SYNDROME
Common overuse injuries of the knee
Patellofemoral
syndrome
•
•
•
Poorly localized anterior pain
Pain with squatting
Common in runners, more common in women
Iliotibial band
syndrome
•
•
•
Poorly localized lateral pain
Tenderness at lateral femoral epicondyle with flexion
& extension
Common in runners, cyclists
Pes anserine
bursitis
•
•
•
Highly localized medial pain
Point tenderness at pes anserine bursa
Common with osteoarthritis, diabetes mellitus
Patellar
tendinopathy
•
•
Localized pain in inferior patella
Tenderness at tendon insertion at inferior patellar
margin
Common in jumping sports (eg, basketball, volleyball)
•
Prepatellar
bursitis
•
•
•
Anterior knee bogginess & tenderness
Propensity to secondary infection with
Staphylococcus aureus
Common in patients who work on their knees
("housemaid's knee")
Posterior knee dislocation
KNEE TRAUMA
Features of anterior cruciate ligament injury
Injury
mechanisms
•
•
Rapid deceleration or direction changes
Pivoting on lower extremity with foot planted
Symptoms
•
•
•
•
Pain: rapid onset, may be severe
A "popping" sensation at the time of injury
Significant swelling (effusion/hemarthrosis)
Joint instability
Examination
findings
•
Anterior laxity of tibia relative to femur (anterior
drawer test, Lachman test)
Diagnosis
•
Magnetic resonance imaging
Treatment
•
•
RICE (rest, ice, compression, elevation) measures
± Surgery
Special tests for knee examination
MCL injury
Valgus stress test
•
Stabilize lateral thigh; apply abduction force to lower leg
Laxity indicates MCL injury
ACL injury
Anterior drawer test
•
Patient supine with knee flexed
•
Grip proximal tibia with both hands & pull anteriorly
Lachman test
•
•
Place knee at 30 degrees flexion
Stabilize distal femur with 1 hand & pull proximal tibia
anteriorly with the other
Laxity of tibia indicates ACL injury
Meniscal
tear
Thessaly test
•
•
Patient stands on 1 leg with knee flexed 20 degrees
Patient then internally & externally rotates on flexed
knee
McMurray test
•
Passive knee flexion & extension while holding the knee
in internal or external rotation
Pain, clicking, or catching indicates meniscal tear
ACL = anterior cruciate ligament; MCL = medial collateral ligament.
Meniscal tears
Etiology
•
•
Younger patients: rotational force on planted foot
Older patients: degeneration of meniscal cartilage
Symptoms
•
•
•
Acute "popping" sensation
Catching, locking, reduced range of motion
Slow-onset joint effusion
Examination
•
•
Joint line tenderness
Pain or catching in provocative tests (Thessaly,
McMurray)
Diagnosis
•
•
MRI
Arthroscopy
Management
•
Mild symptoms, older patients: rest, activity
modification
Persistent symptoms, impaired activity: surgery
•
Medial collateral ligament injury
NEUROGENIC ARTHROPATHY
Neuropathic (Charcot) arthropathy
Pathophysiology &
causes
Repetitive bone & joint trauma due to impaired
sensation/ proprioception
•
•
Clinical
manifestations
Diabetes mellitus (most common)
Posterior column disease (eg, B12 deficiency,
tabes dorsalis)
Acute
•
•
Inflammatory erythema, warmth & edema of
the foot
Minimal bone involvement (x-rays often
normal)
Chronic
•
Management
•
Acute
•
Bone deformities (eg, subluxation, collapsed
arch, stress fracture)
Neuropathic ulcers, cellulitis, osteomyelitis
Foot cast to reduce edema & offload weight
bearing
Chronic
•
Orthotic footwear, infection management,
surgical realignment
Pathogenesis of neuropathic (Charcot) arthropathy
OSTEOMYELITIS
Chronic osteomyelitis
Mechanisms
•
•
•
Hematogenous seeding
Extension from infection in adjacent structure
Direct inoculation (eg, compound fracture, bite
wound)
Pathogens
•
•
•
Staphylococcus aureus (most common)
Coagulase-negative staphylococci
Polymicrobial
Risk factors
•
•
•
Surgical hardware/instrumentation
Diabetes
Impaired circulation or sensation in the limb
Clinical
features
•
•
•
Persistent pain, swelling, chronic wound
Sinus tract formation
Nonunion of fracture
Diagnosis
•
•
•
Positive probe-to-bone test
Imaging: lytic lesion with loss of cortical & trabecular
bone, surrounding sclerosis, periosteal thickening
Bone biopsy for culture
•
•
Surgical debridement
Antibiotics (prolonged course)
Management
Osteomyelitis in children
Pathogenesis
•
•
Hematogenous spread
Staphylococcus aureus most common cause
Clinical features
•
•
•
Fever, irritability
Limited function (eg, limp)
Bony tenderness, swelling
Diagnosis
•
•
•
•
Elevated ESR, CRP, WBC count
Blood culture
X-ray (often normal), MRI
Definitive: bone biopsy/culture
Treatment
•
Antistaphylococcal antibiotic (eg, vancomycin)
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; WBC = white
blood cell.
OSTEONECROSIS
Avascular necrosis
Etiology
•
•
•
•
•
•
•
•
Steroid use
Alcohol abuse
Systemic lupus erythematosus
Antiphospholipid syndrome
Hemoglobinopathies (eg, sickle cell)
Infections (eg, osteomyelitis, HIV)
Renal transplantation
Decompression sickness
Clinical manifestations
•
•
•
Groin pain on weight bearing
Pain on hip abduction & internal rotation
No erythema, swelling, or point tenderness
Laboratory findings
•
•
Normal white blood cell count
Normal ESR & CRP
Radiologic imaging
•
Crescent sign seen in advanced stage
•
MRI is most sensitive modality
CRP = C-reactive protein; ESR = erythrocyte sedimentation rate.
OSTEOPOROSIS
Secondary causes of osteoporosis
Endocrine
•
•
•
•
Hyperthyroidism
Hyperparathyroidism
Hypercortisolism
Hypogonadism
Metabolic/
nutritional
•
•
Calcium &/or vitamin D deficiency
Eating disorders
Gastrointestinal/
hepatic
•
•
Malabsorption (eg, celiac disease, Crohn disease)
Chronic liver disease
Renal
•
•
Chronic kidney disease
Renal tubular acidosis
Medications
•
•
•
Glucocorticoids
Phenytoin, carbamazepine
Proton pump inhibitors
Other
•
•
•
•
Inflammatory disorders (eg, rheumatoid arthritis)
Multiple myeloma
Alcohol use disorder
Immobilization
PATELLAR DISLOCATION
Patellar dislocation
Risk factors
•
•
•
•
•
Joint laxity
Misaligned lower extremity
Tight iliotibial band
Patellar subluxation
Competitive sports, dance, military training
Clinical
presentation
•
•
Quick, twisting motion around a flexed knee
Feeling of knee giving way, severe pain, popping
noise
Examination: lateral dislocation of patella,
decreased extension
•
Patellofemoral pain syndrome (PFPS)
Open book pelvic fracture
PLANTAR FASCITIS
Plantar fasciitis
Risk
factors
•
•
•
Pes planus
Obesity
Working or exercising on hard surfaces
Symptoms
•
•
Pain at plantar aspect of heel & hindfoot
Worse with weight bearing (especially after prolonged
rest)
Diagnosis
•
•
•
Tenderness at insertion of plantar fascia
Pain with dorsiflexion of toes
Presence of heel spurs on x-ray has low sensitivity &
specificity
Treatment
•
•
•
Activity modification
Stretching exercises
Heel pads/orthotics
ROTATOR CUFF
Rotator cuff tendinopathy & tear
Rotator cuff impingement
or tendinopathy
•
•
•
Pain with abduction, external rotation
Subacromial tenderness
Normal range of motion with positive
impingement tests (eg, Neer, Hawkins)
Rotator cuff tear
•
•
Similar to rotator cuff tendinopathy
Weakness with abduction & external
rotation
Age >40
•
Common causes of shoulder pain
Rotator cuff impingement
or tendinopathy
•
•
•
Pain with abduction, external rotation
Subacromial tenderness
Normal range of motion with positive
impingement tests (eg, Neer, Hawkins)
Rotator cuff tear
•
•
Similar to rotator cuff tendinopathy
Weakness with abduction & external
rotation
Age >40
•
Adhesive capsulitis
(frozen shoulder)
•
•
Biceps tendinopathy
or rupture
•
•
•
Glenohumeral
osteoarthritis
•
•
•
Decreased passive & active range of
motion
Stiffness ± pain
Anterior shoulder pain
Pain with lifting, carrying, or overhead
reaching
Weakness (less common)
Uncommon & usually caused by trauma
Gradual onset of anterior or deep
shoulder pain
Decreased active & passive abduction &
external rotation
Acute rotator cuff injury
Risk factors
•
•
Age >40
Acute glenohumeral dislocation
Clinical presentation
•
•
•
Lateral shoulder pain
Decreased active range of motion (eg,
abduction)
Positive drop arm test*
•
•
MRI
Ultrasound
Diagnosis
Management
•
Physical therapy
•
Consider surgical repair
*The arm is held in 90-degree abduction & released; inability to hold the arm
steady suggests a tear.
Distal tibial physeal fracture (Salter-Harris type III)
Scaphoid avascular necrosis
STRESS FRACTURES
Clinical features of stress fracture
Risk factors
•
•
•
Repetitive activities (eg, running, military marching)
Abrupt increase in physical activity volume & intensity
Low BMD from inadequate nutrition, malabsorption,
estrogen deficiency in women (eg, functional
hypothalamic amenorrhea)
Clinical
presentation
•
•
•
Insidious, gradual worsening onset of localized pain
Point tenderness at fracture site
Usually negative x-ray in the first 2-3 weeks
Management
•
•
Analgesia & reduced weight bearing
Referral to orthopedic surgeon for high-risk fracture
(eg, anterior tibial cortex, 5th metatarsal)
BMD = bone mineral density.
Differential diagnosis of heel pain
Plantar
fasciitis
•
•
Maximal pain on first stepping out of bed
Pain & tenderness at medial plantar heel, worse
with toe dorsiflexion
Achilles
tendinopathy
•
•
Posterior pain
Swelling & tenderness 2-6 cm proximal to
tendon insertion
Calcaneal stress
fracture
•
•
Pain that is worse with activity
Pain reproduced by medial-lateral squeezing of
the calcaneus
Tarsal tunnel
syndrome
•
Pain, paresthesia & numbness on the sole of the
foot
Percussion tenderness over the posterior tibial
nerve in the tarsal tunnel
•
Clinical features of stress fracture
Risk factors
•
•
•
Repetitive activities (eg, running, military marching)
Abrupt increase in physical activity volume & intensity
Low BMD from inadequate nutrition, malabsorption,
estrogen deficiency in women (eg, functional
hypothalamic amenorrhea)
Clinical
presentation
•
•
•
Insidious, gradual worsening onset of localized pain
Point tenderness at fracture site
Usually negative x-ray in the first 2-3 weeks
Management
•
•
Analgesia & reduced weight bearing
Referral to orthopedic surgeon for high-risk fracture
(eg, anterior tibial cortex, 5th metatarsal)
BMD = bone mineral density.
Complications of supracondylar fracture
Buckle fracture
Congenital and developmental anomalies
GANGLION CYST
Ganglion cyst
Pathophysiology
•
•
•
Mucoid degeneration of periarticular tissue
Herniation of connective tissue from joint capsule,
tendon sheath, bursae
Filled with clear/gelatinous fluid
Presentation
•
•
•
Wrist (most common), dorsal foot, knee
Rubbery, round, well-circumscribed cystic nodule
Transillumination positive
Treatment
•
•
•
Observation for asymptomatic cysts
Needle aspiration (recurrence common)
Surgical excision
Prognosis
•
Most resolve spontaneously
SLIPPED CAPITAL FEMORAL EPIPHYSIS
Slipped capital femoral epiphysis
Risk factors
•
•
Obesity
Adolescence
Clinical
presentation
•
•
•
•
Dull hip pain
Referred knee pain
Altered gait
Limited internal rotation of hip
Diagnosis
•
Posteriorly displaced femoral head on x-ray
Treatment
•
•
Non–weight bearing
Surgical pinning
Complications
•
•
Avascular necrosis
Osteoarthritis
Metabolic bone disorders
OSTEONECROSIS
Adult hip osteonecrosis (avascular necrosis)
Clinical
presentation
•
•
Chronic/progressive groin, thigh, buttock pain
Decreased ROM: abduction, internal rotation
Pathogenesis
•
•
Macro- or microvascular occlusion, bone necrosis
Trabecular thinning & collapse of femoral head
Risk factors
•
•
•
•
•
Femoral head fracture (arterial disruption)
Glucocorticoids
Excessive alcohol use
Sickle cell disease
Systemic lupus erythematosus
Diagnosis
•
X-ray (low sensitivity): subchondral sclerosis,
loss of sphericity
MRI: serpiginous low-intensity lines (T1 images);
bone marrow edema
•
ROM = range of motion.
TARSAL TUNNEL SYNDROME
Tarsal tunnel syndrome
Etiology
•
•
•
Trauma (fracture, dislocation)
Overuse injury (poor biomechanics)
Inflammatory disorder (eg, rheumatoid arthritis)
Pathology
•
Compression of posterior tibial nerve under the flexor
retinaculum in the medial ankle
Presentation
•
•
Burning pain, numbness, or paresthesia
Medial ankle, heel, sole, and toes
Diagnosis
•
•
Clinical presentation
Nerve conduction studies
Management
•
Activity modification
•
Orthotics
•
NSAIDs/corticosteroid injection
•
Surgical release (refractory cases)
NSAID = nonsteroidal anti-inflammatory drugs.
Miscellaneous
Anterior thigh anatomy
Spinal/peripheral nerve disorders and back pain
BACK PAIN
Causes of low back pain
Condition
Musculoskeletal Mechanical
(eg, muscle strain)
Clinical clues
•
•
Radiculopathy
(eg, herniated disc)
•
•
Normal neurologic
examination
Paraspinal tenderness
•
Radiation below the knee
Positive straight-leg raising
test
Neurologic deficits
Spinal stenosis
•
•
Pseudoclaudication
Relief with leaning forward
Compression
fracture
•
•
Osteoporosis
Onset following minor
trauma
Malignancy
Metastatic cancer
•
•
•
Age >50
Worse at night
Unrelieved with rest
Infectious
Osteomyelitis,
discitis, abscess
•
Recent infection or
intravenous drug use
Fever, spinal tenderness
•
Spinal deformity
VERTEBRAL COMPRESSION FRACTURE
Clinical features of vertebral compression fracture
Etiologies
Clinical
presentation
Complications
•
•
•
•
•
Acute
Trauma (often trivial)
Osteoporosis, osteomalacia
Bone metastases
Metabolic (eg, hyperparathyroidism)
Paget disease
•
Back pain & decreased spinal mobility
•
Pain increasing with standing, walking, lying on back
•
Referred pain to abdomen/flank
•
Spinal tenderness at affected level
Chronic/gradual
•
•
•
Painless
Progressive kyphosis
Loss of height
•
•
Increased risk for future fractures
Hyperkyphosis → protuberant abdomen, early satiety,
weight loss, decreased respiratory capacity