atrial septal defect

worsening dyspnea; parasternal heave; pulmonic systolic ejection murmur; splits2; A fib, RVH, high rv o2 sat; ostium secundum present in adulthood (fossaovalis); eisenmenger syndrome; ostium prium (av valves, down syndrome;childhood failure) sinus venous (higher in septum anomalous pulmonary return)females; common in adults; emboli, arrythmia, fight heart failure, phtn (primum)

patch; cathertization; primu needmitral repair and sinus needprosthesis; contra in hemostable,pulhtn; eisenmenger (heart failure)

coarctation of aorta

nosebleeds; latesystolic ejection in interscapular; weak lower extremity pulses,strong upper extremity; rib notching; children may have proximal to ligamentumand open PDA with no BP differences; HTN in adolescents, headaches;claudication, dyanosis; males, bicuspid aorta, turner, VSD

HTN control, endocarditis abx(nafcilin) angio, resectin ofstenosis

tetralogy of fallot

syncopal episdoes; squatting relieves symptoms (decrfeases r->L shunt byincreasing PVR) cyanotic blue spells; clubbing, systolic thrill (VSD) systolicmurmur (pulm stenosis); high hb hct low o2; smalll heart pointed up, dimishedpulm vascularity; overrding large aorta; common

oxygen, morphine, beta blockers;cath--> surg; vsd closure; shuntfrom pulm to subclavian/thoracicaorta; phtn has to be monitored

tracheoesophagealfistula

neonate; aspiration, not feeding right; polyhydraminos; gas in stomach, bariuminto trachea/bronchi; usually esophageal atresia as well; radigraph showsesophageal pouch; methylene blue visualization during joint broncho andendoscopy PERSISTENT COUGH due to the recurrent aspiration

infant warmer, head up , abx foraspiration, npo with suction;ablation of fistual and anastomosisas necessary

pyloric stenosis

vomtting after meals; projectile a few weeks old, fine at first; olive like mass RUQ;metabolic alkalosis with hypochloremia; narrowing on enema; hypertrophy ofpyloric muscle; NO metabolism possibly genetic/familial; scadinavian first bornmales;

correct fluids/electrolytes; ramstedtpyloromyotomy

small bowel obstruction

crampy pain, vomitting, distension, constipation/blockage, progression of pain, hxof abdominal surg, distended ab, dry, high pitched bowel; fluid sequester elevateshematocrit; intrinsic (ascaris) extrinsic (bowel ring) intraluminal leiomyooma;ischemia and necrosis due to impaired blood flow; adhesions, bulges, cancer,less air on imaging; fluids, ng tube, foley, laparotomy

large bowel obstruction

abdominal pain, nausea, vomitting, obstipation, distension; abdominal surgery hx;distension visible on xray; colonc cancer, sigmoid diverticulitis, volvulus; boweledema/ischemia above obstruction--> perforation, death

fluids, abx, gastric decompression(colonoscopic) transverse/sigmoidcolonostomy, cecostomy, hartmanprocedure

pheochromocytoma

facial flushing, severe headaches, episodic palpitations, perspiration, obstipation,weight loss; htn, catecholamines elevated, clonidine fails, high glucose,vanillylmandelic acid; chromafinncells; acth can be secreted; VHL, NF, MEN II;clonidine suppression fails

phenoxybenzamine/prazosin withsalt to maintain volume; add beta toprevent arrythmia, resection; CHF,mets, cardiomyopathy

thyroid cancer

anterior portion of neck, painradiotherapyto neck hx, hard solitary mass; palpablelymphnodes, normal TFT; FNA, psmamomma bodies, cold on scan; papillarymost common (psmammoa bodies),

thyroidectomy; radical neck iflymphnodes involved, radioactiveiodine except Medullary

boerhaave

alcoholism, chest pain, vomitting, tearing chest pain, SOB; tachy hyperten, subQcrepitus, chest pain worse with flexion and swallowing; AST>ALT, widemediastinum, subq air in neck, fluid level in pleural

abx (staph, strep,pseudo,bacteroides); closure with drainage,post 24 hours ligation with j tubefeedings

achalasia

difficulty swallowing solids and liquids, weight loss, regurgitation, slowprogression, bad breath; low albumin, ANA neg, dilation of esophagus, LEShypertonic with high resting pressure, inadequate LES relaxation, beak onswallow; impairment of inhibitin of auerbach with LES impariment; Cardiospasmabsence of peristaltic contractions

nitrates/CCB, balloon dilation,botulinum injection; hellercardiomyotomy (reflux ) risk ofcancer

diverticulitisLLQ pain, low fiber diet; tachy, fever, guarding, occult stool; bowel dilation; highintraluminal pressure with bleeding, older,

Peritonitis, IV fluids, NPO, abx(cipro + metro); colonoscopy;surgical abscess (if no drainage)peritonitis, fistula, obstruction,failure of med, recurrence

pseudocyst pancreas

epigastric, fever, nausea, vomitting, hx of pancreatitis; immotile mass in epigastricarea; leuko, elevated blood sugar, amylase, lipase, fluid mass on US; infectioncause abscess; trauma in children, surgery and alcohol;

let them grow to 6cm and mature 6weeks; anastomosis to internaldrainage; necrosis or abscess =immediate surg (percutaneousdrainage; less than 6cm usuallyregress; internal septation or noinflammation may be tumor

pancreatitis

improvement with fetal position, leaning forward; worse deep breathing; tenderdistended abdomen some guarding ecchymoses; hypocalcemic signs; highamylase and lipase; Ranson (age 55, ldh350, ast250; at 48 hours 10% hct drop,5% increase in bun, calcium 4, fluid sequester inferior middle rectal hemmorhoids;paraumbilical--> inf gastric (caput); varices only ones that bleed for real

hemodynamic stability;sclerotherapyoctrotide/vasopressin, balloontamponade (blakemore tube);surgical shunts, tranjugularintrahpeatic portosystemic shunt

acute choly

fat fair forty fertile; N/V, scapular pain, guarding, palpable, murphy sign;leukocytosis, alk phos and bilir elevated; thickened gallbladder, pericholecysticfluid, sonographic murphy; gallstones; ischemia, necrosis, perforation; browninfections; acalculous in severe burns parenteral nutrition;

surgery in frist 72 hours; ifnot npong tube, iv fluids abx with electivecholy a month later; if perforation orempyema then emergent chole;ercp to remove just stones,cholecystomy in high riskcandidates; gangrenous inelderly/diabetics appears benign;ascending cholangitis

anal fissure

tearing rectal pain straining and hard stool, constipation; spincter spasm,ulceration of mucosa, sentinel tag; hypertrophic papilla; minimal bleeding butintense pain

stool softeners, fiber, analgesics,sitz bath, suppository; refractorychronic lateral internspincterotomy;asses for chron or biopsy forcancer

fissure

intermittent foul smelling purulent anal discharge; through opening in skin; analcrypt with communication to skin, usually secondary to abscess; posterior onescurve and anterior are straight

rectosigmoidoscopy, assess area;barium enema; fistulographydelineates; surgery neededbecause of scarring; fistulotomy,fistulectomy, suture and fibrosis;IBD and HIV no surgery

appendicitismigrating pain from midline to RLQ. anrexia, tachy, mcburney point tender,rebound, psoas, obturator, rovsing, leuko, bhcg neg; ct and US;

emergent surgery/ no abxanalgesics; post op ampicillin,gentamicin, metornidazole; walledof abscess drain thenappendectomy later

rectal cancer

dislocated shoulder

falling backward sideways on hand, deformity of shoulder; loss of countour;depression under acromion (sulcus sign), palpate humerus underaxilla; limitedROM; check deltoid and hand for neurovascular; AP/oblique, axillary views;forced abduction/ex rotation; humeral fx (hill sachs) glenoid fx (bankart); posteriorcannot ex rotate, coracoid is prominent, anterior is flat, shock and seizures;capsular tear recurrent

r/o fx, sooner reduction better;kocher (90 degress, external rotatetraction and then adduct andinternal rotate) xray to check;immobilize for 3 weeks, in younger

dupuytren

cant extend 5th fingers; alcoholism and cirrhosis; familial; thickened palmar fasciawith bands contracting fingers; can involve feet and penis; hydantoin, olderalcoholics, diabetics, and post MI; earlier onset more severe

physical therapy, night splinting,steroid shot, if no permananetchanges surgery can help;recurrence in 15%

hip fx

elderly fall, unable to bear weight on leg; pain in hip exaerbated with movement;leg ex rotate, shortened, adducted, positive logroll test, tenderness in groin;subcapital, transcervical an dextracapsular, intratrochanteric

best within 48 hours; nondisplacedstable impated may be medical ifcomorbidities; DVT prophylaxis;retinacular vessels of capsule needto be patent or avascular necrosis(intracapsular need arthroplasty)

osteosarcoma

pain and swelling lower extremity; dull aching pain, worse at night; nontenderfullness, no limits on ROM; ALK phos; sunburst knee with osteolytic metaphyseallesion; sclerosis from periosteal rxn, codman triangle ( new bone piece);retinablastoma with radiation hx; pain can be in different areas than tumor;teenagers, paget disease osteomyelitis

aggressive resection, radiation andchemo,

osteomyelitis

pain, tender, inability to bear weight, fever, malaise, hx of open injury;leukocytosis, inflammatory markers, staphylococcus, pus in bone; staph aureus,pseudomonas, salmonella; hematogenous spread; suppuratino with bone deathpus and sinus formation; involucrum around sequestrum

nafcillin and aminoglycoside X6weeks, with fever and esr/crpresolution, pus must be drained

radius fxfall on outstretched hand, dinner fork deformity, radial styloid no longer higher thnulnar, r/o compartment syndrome, n/v checks;

reduce and splint, cast a weeklater, intraarticular comminution,failure to to align, complartmentsyndrome,

herniated disc

severe acute back pain, radiation to but and worse with straining; heavy foot andnumbness on side of leg; tenderness, normal spncter no saddle, weak toe, diskherniatino on MRI, minor trauma, nerve compression, stenotic changes increasedrisk; s1/l5, vibrational stress smoking

bed rest, analgesia, traction;bladder bowel, muscle weakness,laminectomy or chemonucleolysis

Abdominal aorticaneurysm

sudden severe epigsatric pain; peripheral vascular disease hx, hypotension,tachy, pulsatile abdominal mass and bruit; intraluminal clot, free fluid and dilatedaorta on US and CT; athlersclerosis, age smoking, MI, pseudoaneurysm. canlead to renal colic

fluid resuscitation, osygen, blood,surgical reconstruction (ptfe dacronmeshes) unruptured can undergoelective repair and symptomaticshould as well. 5.5 cmasymptomatic too. 4-5.5 watchatleast once a year. beta blockersand stop smoking

carotid stenosiscarotid bruit; diabetic, hypercholesteremia, possible neuro signs (mini strokes);MRA can confirm; proximal and bifurcation, fibromuscular dysplasia, arteritis,

aspirin, risk factor,angioplasty/stenting; endarectomy>70%; 100% cant do surgery

claudication

smoker, pain on walking, calf pain resolving with rest; diabetes, diminishedpulses, femoral bruit; buerger test (foot pallor with elevation and red flushspreading) cool extremities, shiny skin, abi (0.4-.9); aortoiliac occlusive (leriche)buttock thigh claudication; angiogram can map

percutanous transluminalangioplasty, bypass surger

lung cancer

right shoulder pain, worsening, facial flusing, sweating; fatigue, weight loss,smoking history; diminished sounds, COPD, eye ptosis, miosis, enophthalmos;nonsmall cell; superior vena cava syndrome hoarseness pancoast syndrome(wasting, arm pain, reduced pulse, jugular vein distension horner due tosympathetic invasion)

radiotherapy portal determineslimited vs extensive; nsclc surgerymediastinocopy, lymph node brainwork up; pneumonectomy,lobectomy, resections, vats; chemoand radio for adjuvant small celland high risk

aortic disection

tearing chest pain; radiation to back , voice hoarseness; htn, tachy, blood in falselumen (between intima and media) trauamtic deceleration; a ascending, bdescending; mediastinal widending due to pooling of blood in false lumen;cocaine vascular disorders

type b medical (beta blockers); typea repair, stenting of occlusion,grafting

melanoma

red hair, white, bleeding mole; color size shape changes; outdoor exposure; blackblue, reticulated, flecked lesion ; satellite lesions; actinic keratoses on forehead;lymphadenopathy; bone scan for metastases; blistering sunburns, genes; backand leg in women; superficial spreading, lentigo malina (elderly) acral lentignous(hands) nodular worse because of invasion

excisions; lymphnode dissection forsymptomatic SLN otherwise;chemo and radiation somewhateffective

necrotizing fascitis

painful swollen erythematous extremity; febril tachy; laceration with rash;diabetes; dark purple lesionsblisters, pain; crepitus; leukocytosis, cpk, acidotic;rapid spread along fascial planes; polymicrboial type 1 after procuedres,immunocompormised, diabetc PVD; type II monocrobial GAS, MRSA anytimeanywhere

exploration and debridement; abx,hydration, reexplration; fourniergangrene in groin and perianalrequiring cystoscopy, colostomy,orchiectomy

ICP

severe headaches, nausea vomitting; present in morning or lying down; gettingworse; ICP >20; cn palsies, papilledema, periorbital bruising, cushing triad (pulsepressure, brady, respiration) parinaud syndrome ( loss of upward gaze)

2* to stroke, ICH ASH,hydrocephalus; treat the cause;craniotomy, resection of tumor, csfshunting, blood clot evacuation;mannitol, steroids, hypervent,barbituates

head/neck cancer

painless hoarseness; tobacco/alcohol use; fiberoptic laryngoscopy erythematousnodular; squamous cell from head and neck; hpv family hx, p53 mutation; malesover 40

early radiation; resection forprogression; chemo; airwaycompromise (resection,tracheostomy

foreign body aspirationchild running with food, coughing, choking, wheezing, decreased breath sunds;air trapping and decreased air movement

removal (bronchoscopy) abx forpostobstructive

spinal cordcompression

cancer hx with severe back pain; extremity weakness; pain is excrucating, tenderto percussion; vast difference in unaffected limbs; prostate, breast, lung,

MRI; steroids (before dx); acutesurgical decompression; fusionmight be neecessary withlaminectomy; posterior safer butpossible instability; radiotherapyafter or inthose with mildcompression and no symptoms

hypovolemic shock

stab wound abdomen; hr tachy, hypotensive; cool clammy extremities; hb hctfalling, FAST positive for free fluid; 25% of blood in young healthy individualbefore serious signs (tachycardia!!); airway, 16 gauge access, crystalloid/bloodvolume infusion; central line or venous cutdown if need be; response confrims dxif not look for something else; vasoconstrictors are for bridging not cures

hypotension perfusion loss anddeath;

burns

fire and smoke inhalation; blisters, erythema with pain; leathery skin can be cool ,carboxyhemoglobin; asensate 3rd degree, painful 2nd degress; skin can continueto necrose for 72 hours.

silvadene, reconstructive surgery;very high fluid load 4ml X kg X %burned; heat lamps to avoidhyperthermia; circumferential burns(surgical release/escarotomy toalleviate swelling and occlusion)

Cervical spine injury

fall, headaches quadriparesis; RA weakness in all extremities; numbness in neck;c2 c6/7; c1/2 can be lethal, can also be unstable and compress; suspect inunconscious MVA

NEXUS (posterior midlinetenderness, intoxication, alert, focalneuro, painful distracting injury: cspine series; collar until cleared;atlantoaxial sublux in RA; highercan cause ascneding sensory lossand respiration impairment

subduralAMS, intoxicated; nonreactive pupil; withdrawal and xtension with pain; crescentblood on brain ct; bridge veins

acute changes with neuro deficitneeds emergent craniotomy(unreactive pupil) only smallcollections can be conservative

chest trauma

SOB, chest pain; MVA with wheel trauma; ecchymoses and flail chest; bonycrepitus; paradoxical breathing; multiple rib fx; pneumo, hemothorax, lungcontusions/laceration, cardac contusoin/tamponade, aortic dissectio, esophagealtear, bronchial tea diaphragmatic rupture; first rib thoracic spine sternum indicatehigh impact;