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e****0
发帖数: 678 | 1 在清理我的USMLE文件， 觉得删掉有点可惜
上传DROPBOX会被改密码， 发这里吧。 | b********r
发帖数: 87 | 2 在哪？^_^
Calendar别拍我，本来已经走了，看到emma这儿有要紧的东西，我得赶紧记下来^_^
Emma说的也都是金玉良言哪... | e****0
发帖数: 678 | | b********r
发帖数: 87 | | e****0
发帖数: 678 | 5 • Compartment syndrome
Severe pain worsened on passive range of motion
Pressure can be measured using a needle and pressure transducing
catheter system.
Pressure > 30 mmHg cessation of blood flow through the
capillaries.
• stress fracture
2nd, 3rd, 4th metatarsal are managed conservatively.
5th metatarsal such as Jones fracture needs surgical
intervention.
• Colonic diverticula are most common in the sigmoid colon,
although most diverticula that bleed are in the right colon.
• Medial collateral ligaments.
Bracing and early ambulation is the preferred treatment
Surgery is rarely necessary.
• Dumping syndrome
Postgastrectomy complication
Patho
Rapid emptying of hypertonic gastric content
The fluids shift from intravascular space to the small intestine
Release of intestinal vasoactive polypeptides
Stimulatation of autonomic reflexes.
Treatment
Dietary changes—small and frequent meals and avoidance of
simple CHO
In resistant cases—octreotide or reconstructive surgery should
be tried.
• Necrotizing infections
Cellulitis
Group A strep is more common. | e****0
发帖数: 678 | 6 • Glasgow coma scale
EYE OPENING
Spontaneous 4
To verbal command 3
To pain 2
none 1
VERBAL RESPONSE
Oriented 5
Disoriented/confused 4
Inappropriated words 3
Incomprehensible sounds 2
none 1
MOTOR RESPONSE
obeys 6
localizes 5
withdraws 4
Flexion posturing (Decorticate) 3
Extension Posturing (Decerebrate) 2
None 1 | J*********4
发帖数: 1274 | | e****0
发帖数: 678 | 8 • Exaggerated deep tendon reflexes can be seen in lock in syndrome.
• Non bleeding varices are managed with nonselective beta-
adrenergic antagonists, such as propranolol.
• Sclerotherapy, endoscopic band ligation, and surgery are
indicated after a patient has a first episode of variceal bleeding.
• TIPS is a last resort in variceal bleeding unresponsive to
medical and endoscopic intervention.
• Ischemic colitis
CT—thickening of eth bowel wall
Colonoscopy—a discrete segment of cyanotic mucosa with
hemorrhagic ulcerations
• Radiation proctitis
Diarrhea, rectal bleeding, tenesmus and incontinence
Stricture and fistulae
• Hip fracture
Intracapsular fracture Extracapsular fracture
Femoral head and neck Intertrochanteric and subtrochanteric
Higher chance of avascular necrosis Greater need for implant devices(
nails and rods)
• Current evidence shows that neither skin nor skeletal traction
relieves pain in hip fracture or improve the quality of surgical hip
reduction.
• Boerhaave syndrome
Chest X ray is the first test
Left pleural effusion
Pneumomediastinum
Pneumothorax
Water-soluble esophagram is the test of choice.
Primary closure of esophagus and drainage of mediastinum must be
done within 6 hours to prevent development of mediastinitis.
Endoscopy is avoided if there is concern for esophageal rupture
because the insufflated air or the tip of the endoscope can further extend
the rupture.
• Moyamoya disease
• Torus palatines
Benign bony growth located on the midline suture of hard palate
More common in younger, women, Asians
The thin epithelium overlying the bony growth tends to ulcerate
with normal trauma of the oral cavity and heal slowly due to a poor vascular
supply
No treatment is required unless the growth becomes symptomatic
or interferes with speech or eating.
• Scaphoid fracture
Proximal fracture fragment avascular necrosis
X ray with wrist in full pronation and ulnar deviation
Spica cast 7-10 days and repeat X ray
• Orotracheal intubation with rapid sequence intubation (RSI)
For unstable and apneic pt
• Nasotracheal intubation
Blind procedure
Require pt to be spontaneously breathing.
Contraindicated in apneic/hyponeic pts.
• Needle cricothyroidotomy
Excellent airway in children
Not suitable in adults due to risk of CO2 retention
• Tracheostomy
No longer a first option
Surgical cricothyroidotomy is preferred but should be converted
to formal tracheostomy in 5-7 days of prolonged airway is needed.
Prolonged cricothyroidotomy has a high incidence of tracheal
stenosis.
• Morton neuroma
Mulder sign—simutabneously palpating this space and squeezing
the metatarsal joints.
• Nasopharyngeal carcinoma
EBV
Smoking
Chronic nitrosamine consumption (diet rich in salted fish)
• Hematochezia
Bight red blood in the stool
Lower GI bleeding (distal to Ligament of Treitz)
Severe hematochezia
(Lower GI bleed)
Supportive
therapy
And initial
evaluation
NG tube
aspiration
NO blood, +Bile positive
blood,+/- Bile
Colonoscopy upper
endoscopy
+ source -- source unable to be done
Treat accordingly
No
Pt stops bleeding arteriogram+/-
nuclear scan first or surgery
Yes
Small bowel studies
• Circumcision is the treatment of choice for phimosis,
paraphimosis and zoon’s balanitis.
• The diaphgram can rise as high as the fourth thoracic dermatome
on the right and fifth thoracic dermatome on the left on expiration and go
down to the twelfth thoracic dermatome on both sides on inspiration.
• FAST—focused assessment with sonography for trauma
Hemopertoneum
Pericardial effusion
Intraperitoneal fluid
• Hamman sign (esophageal emphysema)
Characteristic crunching sound on auscultation of the heart due
to mediastinal emphysema
• SBO
Partial SBO—NG and OB
Complete SB—surgical correction.
CX—ischemic necrosis, perforation, lactate acidosis.
• Volvulus
BE
Sigmoidoscopy
Anterior shoulder dislocation Posterior shoulder dislocation
cause Direct blow
Fall on an outstretched arm seizure
Arms abducted and externally rotated Adducted and internally rotated
Prominence of the acromion with a abnormal subacromial space.
Fullness of anterior shoulder
Axillary nerve and artery
(deltoid and teres minor) Flattening of the anterior shoulder
Prominent coracoids process
X ray Light bulb sign
Widened join space> 6 mm
Trough line sign
management Closed reduction
Trough line sign
Two parallel cortical bone lines on the medial aspect of the
humeral head.
• Rotator cuff tear
Tendons of supraspinatus, infraspinatus, teres minor and
subscapularis
Supraspinatus is most commonly injuried
Drop arm test—
The arm is abducted passively to greater than 90 degrees, and
the pt is then asked to lower the arm slowly.
Pt will be unable to lower the arm smoothly and it will appear
to drop rapidly from near 90 degree position.
• Popeye sign
Rupture of the tendon of the long head of the biceps
Biceps muscle belly becomes prominent in the mid upper arm.
Weakness with supination is prominent
Forearm flexion is preserved.
• Magnesium toxicity
N/V/D, muscular weakness, absent DTRs.
• Acute mediastinitis
Complication of cardiac surgery
Due to intraoperative wound contamination
s/s: fever, tachycardia, CP, leukocytosis, wound drainage
CXR—widened mediastinum
Treatment
Drainage
Surgical debridement with immediate closure
Prolonged ABX therapy.
Mortality 10-50%
• AFIB post CABG
Self limited with resolution < 24 hours
Anticoagulation and /or cardioversion if > 24 hours.
• Postpericardiotomy syndrome
s/s—fever, leukocytosis, tachycardia, CP
autoimmune and occurs a few weeks following a pericardium
incision
NSAIDS or steroids
Intervention for lowering ICP mechanism
Head elevation Increase venous outflow from the head
sedation Decreased metabolic demand and control of HTN
IV mannitol Extraction of free water oout of the brain tissue
osmotic dieresis.
hypervetilation CO2 washout, leading to cerebral vasoconatrition
• Trochanteric bursitis
Inflammation of bursa surrounding the insertion of the gluteus
medius onto the femus greater trochanter
Pain with pressure applied, external rotation or resisted
abduction.
• Leriche syndrome
Aortoiliac peripheral vascular disease
Pain is exercise-induced and relieved by rest.
• Hip OA—internal rotation of hip worsens pain.
• Meniscal injury
Knee function Join line tenderness
Loss of smooth flexion or extension
Inability to move forward and backward while squatting
Effusion
Provocative tests Thessaly test: pain or locking with
internal and external rotation of the knee while standing on one leg with
the knee flexed to 20 degrees
McMurray test: painful click with passive flexion and extension
of the knee with the examiner’s thumb and index finger placed on the medial
and lateral joint lines
Apley test: pain with pressing the heel toward the floor while
internally and externally rotating the foot with knee flexed to 90 degrees
• Oxalate absorption in increased in crohn disease and all other dx
causing fat malabsorption.
Under normal circumstances, calcium binds oxalate in the gut and
prevents its absorption
Fat malabsorption, calcium is bound by fat leaving oxalate
unbound and free to be absorbed into the blood.
• Medial meniscal tear
Mcmurray sign
Palpable or audible snap occurring while slowly extending the
leg at the knee from full flexion while simultaneously applying tibial
torsion.
A bucket handle tear leads to locking of the knee join during
terminal extension.
• Anterior cruciate ligament
Lachman’s test
Anterior drawer test
Pivot test.
• Posterior cruciate ligament
Dashboard injury
Posterior drawer, reverse pivot test and posterior sag test.
• Medial collateral ligament
Valgus stress test
• Lateral collateral ligament
Varus stress test.
• Acute appendicitis
If s/s> 5 days, phlegmon with an abscess that has walled off.
Managed with IV ABX, Bowel rest, delayed appendectomy weeks later.
• Legg-Calve-Perthes disease
Idiopathic avascular necrosis of the femoral capital epiphysis
Boys 5-10
s/s : hip, groin, knee pain plus an antalgic gait
treatment—OB and bracing
• slipped capital femoral epiphysis
the metaphysic and proximal femur slip relative to the
epiphyseal plate
the capital femoral epiphysis remains structurally intact
within the acetabulum.
Obese adolescent male
• Osteomyelitis in child
Hematogenous seeding by S. Aureus
The infection tends to affect the metaphysic, with epiphyseal
sparing.
• Bleeding
parameter I II III IV
Blood loss <15%
(750ml) 15-30%
(750-1500 ml) 30-40%
(1500-2000ml) >40%
(>2000ml)
HR >72 100-120 >120 >140
BP normal Slightly decreased Markedly decreased Markedly
decreased
Cap. refill normal May be delayed delayed Markedly delayed
U.O (cc/hr) >30 20-30 5-15 <5
CNS symptoms normal anxious confused lethargic
• Acalculous cholecystitis
Treatment
ABX followed by percutaneous cholecystostomy under radiologic
guidance
Cholecystectomy when medical condition stabilized
• The artery of adamkiewicz
Most prominent thoracic radicular artery and arises from aorta
to supply the ASA in T 9-12 region.
Emergent MRI for Dx and Tx with supportive care and lumbar
drains to reduce spinal pressure.
• Lumbar plexopathy
Asymmetrical focal weakness with numbness and parethesis.
Weakness of hip flexion and knee extension
• Diffuse axonal injury
Rotational forces that affect the brain areas where the density
difference is the maximum.
s/s are out of proportion with CT scan findings.
• Developmental dysplasia of the hip (DDH)
s/s
Caucasian race
Female gender
First born child
Breech position
Family history
Barlow and ortolani tests
Which act to dislocate and relocate affected infants’ hips.
DX
Ultrasound in pt < 4 months
X ray in pt > 4 months
Tx
Hip (Pavlik) harness
Spica cast
Surgery.
• Diaphragmatic rupture
DX
Barium swallow or CT scan with oral contrast
Tx—surgery.
• CO poisoning
> 3% in nonsmoker and > 15% in smoker
Pulse oximetry is unreliable and may appear normal since it
cannot differentiate COHB ad HB
Tx
Decrease half life of CO from nearly 5 hours in RA to 1-2 hours
• Anterior cord syndrome
Total loss of motor function below the level of lesion with loss
of pain and temperature on both sides below the lesion.
• Central cord syndrome
Burning pain and paralysis in upper extremities with relative
sparing of lower extremities
Eldly secondary to forced hyperextension type of injury to the
neck.
• Intraabdominal abscess
CT scan is DX
• Nursemaid elbow
First extend and distract elbow
Next supinate the forearm
Hyperflex the elbow with your thumb over the radial haed in
order to feel the reduction as it occurs.
• Patellar tendonitis
Chronic overuse
Jumper’s knee
Point tenderness over proximal patellar tendon.
• Anserine bursa
Underlies the conjointed tendon of the gracilis abd
semitendinosus muscles.
• Duodenal hematoma
Seen children
Resolve spontaneously in 1-2 weeks
DX- CT with oral contrast
Best treated conservatively.
TX—NG suction and parenteral nutrition
Sx may be considered if fails.
• Edema, stasis dermatitis and venous ulcerations result from lower
extremity insufficiency due to valve imcompetence
Loss of fluid, plasma protein, and RBC->Hemosiderin deposition
Xerosis is the most common early finding
Lipodermatosclerosis and ulcerations are late disease.
• Ruptured AAA can be confirmed by Ultrasound
• Fat embolism
Petechial rash
DX can be confirmed by presence of fat droplets in urine or
presence of intra-arterial fat globules on fundoscopy.
X ray—increasing diffuse bilateral pulmonary infiltrates within
24-48 hours of onset of clinical finding.
TX-prompt respiratory support
Use of heparin, steroids, LMW dextran is controversial.
• AAA
A diameter > 3 cm at the level of renal arteries
Unlike thoracic aortic aneurysm, an AAA involves all aorta
layers and does not create an intimal flap or false lumen
An AAA can rupture into the retroperitoneum and create an
aortocaval fistula with IVC, leading to venous congestion in retroperitoneal
structures ( bladder)
The fragile and distended veins in the bladder can rupture and
cause gross hematuria.
• Posterior urethral injury
Retrograde urethrogram should be the first step
Most injury are treated with urinary diversion via a suprapubic
catheter while primary injury and a/c hematoma are allowed to heal
• Bladder injury
Retrograde cytogram with post void films.
• Mastitis
Most common—S.aureus
Tx—dicloxacillin, cephalosporins
• Mallory-weiss tear
Incomplete mucosal tear
Self limiting hematemesis.
• Paralytic ileus
Caused by an exaggerated intestinal reaction after abd surgery
Due to a disruption of the normal neurologic and motor control
of GI tract.
Absent BS with gaseous distension of both the small and large
bowels indicated a paralytic ileus
• Acute colonic pseudoobstruction
Result from trauma
N,abd pain/distension, hyperactive BS
Abd X ray—a massively dilated colon without significant small
bowel dilation.
• Gallstone
Ultrasound is preferred than CT
• Carbachol –stimulation contraction of the bowel musculature and
Oddi sphincter.
• Osteosarcoma
Most common primary malignancy of bone
Males in second decade
Metaphyses of long bone
Bone pain without systemic s/s or pathological fracture.
ESR is normal while serum ALP is elevated
• Ewing’s sarcoma
Most common in second decade
Neuroectodermal
Systemic s/s—fever, malaise, weight loss
• Nasal septal perforation
A whistling noise heard during respiration.
• Nasal furunculosis
Staphy
Life threatening as it can spread the cavernous sinus
• Scaphoid fracture
If nondisplaced (<2mm of displacement and no angulation). Spica
cast with X ray in 7-10 days or immediate advanced CT
If displaced, open reduction and internal fixation.
•
Palpable breast mass
< 30 yrs
> 30 yrs
Ultrasonogram
Mammogram &
Ultrasonogram
Simple cyst complex cyst/Mass
Suspicious for malignancy
(solid mass)
Needle aspiration Image guided
core biopsy
(if pt desired) core biopsy
If > 30 yrs, typically the mammogram is performed first to help
in targeting the abnormal location for the ultrasound.
• CVP line tip should lie in the SVC
• Hydroceles
Most hydroceles will resolve spontaneously by age of 12 months
Surgery needed if it does not resolve due to risk of inguinal
hernia.
• Volkmann’s ischemia contracture is the final sequel of
compartment syndrome in which the dead muscle has been replaced with fibrous
tissue.
• Reflex sympathetic dystrophy
A vague painful condition seen as a sequel of infection or
trauma which may be minor.
Pain, hyperesthesia and tenderness, which are out of propotion
to the physical findings.
Sudeck’s atrophy is a radiographic term for spotty rarefaction
seen in pt with reflex sympathetic dystrophy.
• A psoas sign suggestive of a psoas abscess, which is a known
complication of perforated appendix.
• Aortoenteric fistula is a rare and late complication where the
duodenum erodes into the proximal part of the aortic graft.
• Bowel ischemia and infarction are possible early complication of
operation on the abdominal aorta, such as AAA repair.
Time of latest Td Booster Minor and clean wound More severe or dirty
wound
unimmunized Td only Td and TIG
>10 years Td only Td and TIG
< 10 years none Td if latest booster given > 5 years ago.
< 5 year, on need for either
5-10 years , only Td for severe wound. No TIG
> 10 years. Severe wound Td+TIG, clean wound Td.
ABX—PCN +Metronidazole.
• Clavicle fracture
Shoulder is displaced inferiorly and posteriorly
Careful neurovascular examination to rule out injury to the
underlying brachial plexus and subclavian injury.
Middle third of clavicle
Most common
Nonoperatively with a brace, rest, and ice
Distal third of the clavicle
Open reduction and internal fixation
• Popliteal and femoral artery aneurysm are the most common
peripheral artery aneurysm, a/c with AAA.
• Central cord syndrome
Result from hyperextension injuries
Weakness in the upper extremities
Local pain and temperature defict.
Tensor fascia lata spans Iliac crest to the fascia lata Hip abduction
and knee extension
Psoas major Transverse processes to lesser trochanter Flex and
laterally rotate the thigh
Quadrates lumborum Iliac crest to the 12th rib and transverse processes
of first 4 Lumbar vertebrae Rib cage fixation and lateral flexion of the
trunk
The quadriceps femoris Extension legs
Rectus femoris Hip flexor
• SCC
SCC arising within chronic wounds tend to exhibit more
aggressive behavior.
Marjolin ulcers
SCC arising within Burn wounds
• BCC
Pearly telangiectatis papules with a central rodent ulceratioin
• Slipped capital femoral epiphysis
The femoral head slips posteriorly and medially relative to the
femoral neck.
s/s knee pain (referred pain), external rotation
a frog-leg, lateral view X ray of hip is Dx
Tx—surgery pinning
Corrective osteotomy can cause avascular necrosis and might not
correct the exact anatomic deformity. They are usually undertaken later in
treatment if a pt experience persistent pain and limited RPM after initial
repair and attempted rehab.
• Chest nodule
Solitary pulmonary nodule
On routine chest X ray
Chest CT
Has benign feature indeterminate or suspicious for malignancy
Serial CT scans to monitor further
investigation with biopsy or PET scan.
• CT 0.5mm vs Xray 5mm
• Respiratory quotient
The steady ratio of CO2 produced to O2 consumed per unit time.
Not affected by FiO2, but affected by the difference in O2
content of arterial and venous blood.
In a steady resting state, this ratio depends mainly on the
major fuel being oxidizing for ATP production.
RQ=1 indicates CHO is the major nutrients being oxidized
RQ=0.8 Protein
RQ=0.7 Fatty acids
The body utilize a combination of fuels, the normal RQ=0.8.
Assessment of the RQ is important when attempting to wean pt
from mechanical ventilator
As overfeeding of CHOexcessive CO2 production and make
weaning more challenging.
Sepsis. RQ<1
• Obturator nerve
Sensation over the medial thigh.
• A fetus exposed to ionizing radiation during the first 14 days
after conception either survives undamaged or is resorbed. Exposure after
the first 14 days can lead to developmental defects but usually not death.
• CN V3
Foramen ovale
Mastication muscles
Jaw asymmetry
• Strabismus
CN III,IV, VI
Brain stem lesion
• Long thoracic nerve
Breast cancer.
• Flail chest
Should be suspected in pt with blunt trauma who remains
tachypeic and hypotensive despite aggressive fluid resuscitation
Claasic X ray reveal multiple rib fractures overlying a lung
contusion.
• Atelectasis
Hypoxemia, respiratory alkalosis,
Smoking cessation > 8 weeks prior to elective surgery is a/c a
decreased risk of postoperative pulmonary complications.
Atelectasis is the major cause of FRC reduction
Supine to sitting will help and increase the FRC by 20-35%
• Legg-calve-perthes disease
Idiopathic osteonecrosis of the femoral head
4-10 years old males
Mild chronic pain of insidious onset in the hip or knee ,
antalgic gait.
Limitation of internal rotation and abduction at the hip joint
MRI and bone scan dx earlier
Tx—aimed at maintaining placement of the femoral head within
the acetabulum so that it may heal in the proper shape and position.—splint
or surgery.
• PEEPincreased intrathoracic pressure increased
right Atrial pressure and decreased systemic veinous return->acute
ventricular preload reduction decreased CO
• Diverticulitis
Uncomplicated diverticulitis
Pain, tender, fever, leukocytosis
CT soft tissue stranding and wall thickening
Management
1. Stable pt, outpt, bowel rest, oral ABX
2. Inpt, IV ABX if elderly, immunosuppressed, high fever,
Complicated pt
a/c abscess
o < 3cm can be treated with IV ABX
o >3cm
1. drain with CT guide
2. surgery and debridement if s/s not controlled by 5th day.
Perforation, obstruction, fistula, recurrent attacks
o Sigmoid resection
• Main causes of massive hemoptysis
The greatest danger is nor exsanguination but asphyxiation
1st step –intubate and place the bleeding lung on the dependent
position
2nd step –IVF and flexible bronchoscopy( visualize the lesion and
control the bleeding)
3rd step, pulmonary artery catheterization if persistent bleeding
despite bronchoscopy
4th step—urgent thoracotomy
Bronchitis
Bronchiectasis
Malignancy
TB
PNA
Lung abscess
Vasculitis
PE
• Urethral injury
Anterior urethral injury Posterior urethral injury
location Distal to the urogenital diaphragm Prostatic and membranous
urethra
injury Blunt trauma to the perineum (straddle injuries) or
instrumentation of the urethra. Fracture of the pelvis
s/s Perineal tenderness or hematoma
Normal prostate
Bleeding from the urethra
Delayed sepsis secondary to extravasation of urine into the scrotum,
perineum abd wall Suprapubic pain
High-riding prostate
Inability void
Blood at the urethral
Scrotal trauma
• Postoperative pulmonary complication
Risk factors
Smoking
Preexisting pulmonary disease
Age > 50
Thoracic or abd urgery
Surgery> 3 hours
Poor general health.
• Blunt traumaair emboli
Focal neurological defects, hemoptysis, circulatory arrest.
• Tracheobrochial perforation
Persistent pneumothorax despite the chest tube
Right main bronchus is most commonly
• The most reliable means of monitoring adequacy of circulation in
a circumferentially burned limb is serial examination using a Doppler
ultrasonogram flow meter.
• Kehr sign
Left shoulder pain referred from splenic hemorrhage irritating
the phrenic nerve and diaphgram
• Inflammatory breast carcinoma
Brawny ed ematous cutaneous plaque with a “peau d’ orange”
appearance overlying a breast mass.
• Anaphylaxis
Medical emergency
1st step—IM epinephrine, if s/s persistent, IV epinephrine
Steroids have no significant immediate effect but can prevent
relapse of severe reactions
• dopamine
low dose—dopamine -1 receptors to vasodilate and improve renal
flow
high dose—Beta-1 and alpha receptors to increase CO and
vasoconstriction.
• Splenectomy
Vaccine—S.Pneumoniae, N. Meningitidis H. Influenzae
Pneumococcal vaccine boosters are required every 5 years.
Fat necosis malignancy
A fixed mass with skin or nipple retraction
Calcification on mammography
Solid on ultrasonography
Coarse calcification microcalcification
Dx--Biopsy Fat globules and foamy histiocyte
Tx Self limited
• Pulmonary contusion
s/s first 24 hours
X ray—unilateral patchy irregular alveolar infiltrate
• ARDS 24-48 hours, bilateral lungs.
• Head injury
Traumatic head injury TBI Minor TBI Mild TBI Moderate TBI Severe
TBI <8
GCS 15 13-15 9-12
s/s normal Brief LOC,N/V,HA, Intracranial injury
Focal neurologicsign
Seizure
LOC
Skull fracture
Tx D/C w/o CT if monitored 24 hours at home CT CT CT
Mild to moderate pt, if CT is normal, can be D/C with monitor at
home
• Stress fracture
The tibia is the most common bone in the body to be affected by
stress fracture
Medial tibial stress syndrome
Shin splints with no tibial tenderness on palpition
Tx—rest
Anterior part of the middle third tibia in pt with jumping
sports
Poseriormedial of distal third tibia in runners.
• Flail chest
Pain control and supplemental O2 are the most important early
steps.
Intubation with PEEP is required
Posive pressure mechanical ventilation replaces the normal negative
intrapleural pressure during spontaneous ventilation with positive
intrapleural pressure.
• Without the chest tube, pneumothorax will worsen with positive
pressure ventilation.
• Uncus herniation
Ipsilateral hemiparesis
Ipsilateral mydrasis
Strabismus
Contralateral hemianopsia
AMS.
• Ludwig angina
Infection of the submandibular and sublingual glands
Rapidly progressive cellulitis
Due to infected tooth
Strep and anaerobes
Fever, dysphagia, odynophagia, drooling, posterior displacement
of tongue
Presence of anaerobes cause crepitus due to gas formation.
Asphyxiation is the most common cause of death
• Air under the diaphgram indicates perforated viscus , which is a
surgical emergency.
• VAP
Ventilator associated PNA
> 48 hours
Pseudomonas
• Massive hemothorax defined as > 1.5 L
• A tracheobronchial tear
Hamman sign—audible crepitus on cardiac auscultation
• Aortic injury
X ray
Widened mediastinum
Large left-sided hemothorax
Deviation of the mediasteum to the right or depression of the left
mainstem bronchus
and disruption of the normal aortic contour
DX—CT
TX—antihypertensive tx and OR
• Myocardial contusion
Tachycardia, new BBB or arrhythmia
• SIRS
Systemic inflammatory response syndrome
At least two of the four criteria
T > 38.5 (101.3) or < 35 (95)
P>90
R>20
WBC>12,000 <4000,or > 10% bands
Pancreatitis, autoimmune dx, vasculitis and burns.
SEPSIS (SIRS with a known infection)
• Burn
Hypermotabolic state
Hyperglycemia (insulin resistant)
Leukocytosis
Thrombosytopenia
Hyperthermia
Sepsis
Wound infection(staphy and pseudomona)
PNA
• DDAVP indirectly increases factor VIII levels by causing vWF
release from endothelial cells.
• Oliguria
< 400 ml or < 6ml /kg/day
Pre-renal Intrinsic renal
FEna<1 FEna>1
• Leriche syndrome
Aortoiliac occlusion
Triad—
bilateral hip, thigh and buttock claudication,
impotence ( always present)
symmetric atrophy of bilateral lower extremities
• Biliary colic
Occurs when the gallbladder becomes distended as it contracts
against an obstructed cystic duct.
Intermittent nature and related to meals as well as the absence
of fever.
• Intraductal papilloma
Benign
Perimenopausal
Unilateral bloody discharge
Situated beneath the areola
Difficult to palpate due to the small size and soft
Ultrasound maybe normal (only detect> 1cm)
• Fibrocytic
Premenopausal
Bilateral
Lumpiness
• Fibroadenoma
15-25
Benign
• Acute parotitis
Dehydration and eldery
Staphy.
• Varicocele
Most common at left side
Swelling the pampiniform plexus
Valsalva maneuver cause the mass to enlarge
• Spermatocele
Cystic dilation of the efferent ductules
Painless fluid filled cysts that contains sperm
On the superior pole of the testis in relation to the epididymis.
transilluminate.
• Pancreatic injury can be missed by CT during the first 6 hours &#
61664;
abscess
high mortality
TX—percutaneous drainage catheter, culture and surgical debridement.
pseudocyst.
• Small bowel injury is less likely after blunt trauma except the
duodenum
• The most common causes of infective aortic aneurysma—staphy and
salmonella
• Acute cholecystitis
Manage conservatively followed by cholecystectomy within 72
hours
Early cholecystectomy is better than delayed
• Fenofibrate gallstones
• Adhesion is by far the most common cause of SBO
Congenital in children—ladd’s bands
Surgery
• PAD
1st step—ABI with Doppler (the ratio of the SBP in the
posterior tibial and dorsalis pedis arteries over the SBP in the brachial
artery)
Ratio 1-1.3 normal
Ratio <0.9 highly sensitive and specific for > 50% occlusion
Ratio <0.4 limb ischemia
If normal ABIexercise ABI
After ABI,
Arterial duplex ultrasonography identify the vessels.
contrast arteriography can identify the occluded vessels.
Tx—ASA and cilostazol
• Post op fever
5W
Wind
Water
Walking
Wound
Wonder drugs—anticonvulsants and sulfa
• Cardiac tamponade
Acute chronic
100-200ml 1-2L
Chest X ray may be normal CXR—enlarged cardiac silhouette in a globular
shape
• Most pt with aortic rupture die in the field. Pt who survived
typically have an injury distal to the left subclavian artery that may be
contained within the mediastinum. This form of aortic injury causes
hypertension 9due to visceral afferent reflexes and a pseudocoarctation
syndrome)
• Pilonidal disease
Young males
Infection of a derma sinus tract
Tx—drainage of abscess and excision of sinus tract.
• Bowen disease—SCC in situ of skin
• Follicular occlusion tetrad
Suppurative hidradenitis
Pilonidal disease
Dissecting folliculitis of the scalp
Acne conglobata
• Compartment syndrome
The earliest s/s is severe pain out of propotion to the PE, and
pain is exacerbated by passive stretch of the muscle.
5 ps.
• Kehr sign
Abd pain that refers to the shoulder (causing peritonitis and
irritation of the diaphragm
Due the C3-5
• The most common site of extraperitoneal bladder rupture is the
bladder neck.
• Gastric outlet obstruction
Abd succession splash
Elicited by placing the stethoscope over the upper abd and rocking pt
back and forth at the hips
Retained gastric material > 3 hours after a meal
Endoscopy will Dx
• Acute afebrile nonhemolytic transfusion reaction
T increased > 1 degree with rigor
Immune –mediated phenomenon mediated by host AB that binds to
donor cells causing activation of completement components and release of
inflammatory cytokines
Tx—D/C bood
• Morton neuroma
A mechanically induced neuropathuc degeneration
Mulder sign
Tx—insets and surgery. | y***n
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