Pestana Review
Everything you need to know for General Surgery Clinicals
TABLE OF CONTENTS
Title Page
Title Page
1. TRAUMA
A. Head Trauma
1.
– A 14-year-old boy is hit over the right side of the
head with a baseball bat. He loses
consciousness for a few minutes, but recovers promptly and continues to
play. One hour later he is found
unconscious in the locker room. His
right pupil is fixed and dilated.
What is it? –
Acute epidural hematoma (probably right side)
How is it
diagnosed? – CT scan
Treatment? –
Emergency surgical decompression (craniotomy).
Good prognosis if treated, fatal within hours if it is not.
2.
– A 32-year-old male is involved in a head-on,
high-speed automobile collision. He is
unconscious at the site, regains consciousness briefly during the ambulance
ride and arrives at the E.R. in deep coma, with a fixed, dilated right pupil.
What is it? –
Could be acute epidural hematoma, but acute subdural is better bet.
Diagnosis? – CT
scan. Also need to check cervical spine!
Treatment? –
Emergency craniotomy, poor prognosis because of brain injury.
3.
– A 77-year-old man becomes “senile” over a period of
three or four weeks. He used to be
active and managed all of his financial affairs. Now he stares at the wall, barely talks and
sleeps most of the day. His daughter
recalls that he fell from a horse about a week before the mental changes began.
What is it? –
Chronic subdural hematoma. (venous
bleeding, size 7 brain in size 8 skull)
How is
diagnosis made? – CT scan.
Treatment:
Surgical decompression (craniotomy).
Spectacular improvement expected.
4.
– A car hits a pedestrian. He arrives in the ER in coma. He has…(raccoon eyes… or clear fluid dripping
from the nose…or clear fluid dripping from the ear…or ecchymosis behind the
ear)…
What is it? –
Base of the skull fracture.
How is it
diagnosed? – CT scan. Needs cervical
spine X-Rays.
Implications
for therapy: needs neurosurgical consult, needs antibiotics.
B. Shock
5.
– A 45-year-old man is involved in a high-speed
automobile collision. He arrives at the
ER in coma, with fixed dilated pupils.
He has multiple other injuries (extremities, etc). His blood pressure is 70 over 50, with a
feeble pulse at a rate of 130. What is the reason for the low BP and high pulse
rate?
Point of the
question: It is not from neurological injury.
(Not enough room in the head for enough blood loss to cause shock). Look for answer of significant blood loss to
the outside (could be scalp laceration), or inside (abdomen, pelvic fractures).
6.
– A 22-year-old gang member arrives in the E.R. with
multiple guns shot wounds to the abdomen.
He is diaphoretic, pale, cold, shivering, anxious, asking for a blanket
and a drink of water. His blood pressure
is 60 over 40. His pulse rate is 150,
barely perceptible.
What is it? –
Hypovolemic shock
Management:
Several things at one: Big bore IV lines, Foley catheter and I.V.
antibiotics. Ideally exploratory lap immediately
for control of bleeding, and then fluid and blood administration. If O.R. not available, fluid resuscitation
while waiting for it.
7.
– A 22-year-old gang member arrives in the E.R. with
multiple gun shot wounds to the chest and abdomen. He is diaphoretic, pale, cold, shivering,
anxious, asking for a blanket and a drink of water. His blood pressure is 60 over 40. His pulse rate is 150, barely perceptible.
What is it? –
Hypovolemic shock still the best bet, but the inclusion of chest wounds raises
possibility of pericardial tamponade or tension pneumothorax. As a rule if significant findings are not
included in the vignette, they are not present.
Thus, as given this is still a vignette of hypovolemic shock, but you
may be offered in the answers the option of looking for the missing clinical
signs: distended neck veins (or a high measured CVP) would be common to both
tamponade and tension pneumo; and respiratory distress, tracheal deviation and
absent breath sounds on a hemithorax that is resonant to percussion would
specifically identify tension pneumothorax.
8.
– A 22-year-old gang member arrives in the E.R. with
multiple guns shot wounds to the chest and abdomen. He is diaphoretic, cold, shivering, anxious,
asking for a blanket and a drink of water.
His blood pressure is 60 over 40.
His pule rate is 150, barely perceptible. He has big distended veins in his neck and
forehead. He is breathing OK, has
bilateral breath sounds and no tracheal deviation.
What is it? –
Pericardial tamponade
Management: No
X-Rays needed, this is a clinical diagnosis!. Do Pericardial window. If positive, follow with thoracotomy, and
then exploratory lap.
9.
– Identical to the previous one, but with only a single
gunshot wound in the precordial area: when the location of the wound strongly
suggests pericardial tamponade, emergency thoracotomy might be done right away
without prior pericardial window.
10. –
A 22-year-old gang member arrives in the E.R. with multiple gun shot wounds to
the chest and abdomen. He has labored
breathing is cyanotic, diaphoretic, cold and shivering. His blood pressure is 60 over 40. His pulse rate is 150, barely
perceptible. He is in respiratory
distress, has big distended veins in his neck and forehead, his trachea is
deviated to the left, and the right side of his chest is tympantic, with no
breath sounds.
What is it? –
Tension pneumothorax.
Management:
Immediate big bore IV catheter placed into the right pleural space, followed by
chest tube to the right side, right away!
Watch out for trap that offers chest X-Ray as an option. This is a clinical diagnosis, and patient
needs that chest tube now. He will die
if sent to X-Ray. Exploratory lap
will follow.
11. –
A 72 year old man who lives alone calls 911 saying that he has severe chest pain. He cannot give a coherent history when picked
up by the EMT, and on arrival at the ER he is cold and diaphoretic and his
blood pressure is 80 over 65. He has an
irregular, feeble pulse at a rate of 130.
His neck and forehead veins are distended and he is short of breath.
What is it? –
Many findings similar to above cases, but no trauma, old man, chest pain: i.e.:
straightforward cardiogenic shock, from massive MI.
Management:
verify high CVP. EKG, enzymes, coronary care unit etc. Do not drown him with
enthusiastic fluid “resuscitation”, but use thrombolytic therapy if
offered.
12. –
A 17 year old girl is stun by a swarm of bees…or a man of whatever age breaks
out with hives after a penicillin infection…or a patient undergoing surgery
under spinal anesthetic…eventually develop BP of 75 over 25, pulse rate of 150,
but they look warm and flus rather than pale and cold. CVP is low.
What is it? –
Vasomotor shock (massive vasodilation, loss of vascular tone)
Management:
Vasoconstrictors. Volume replacement would
not hurt.
13. –
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on the
right. Resonant to percussion.
What is it? –
Plain pneumothorax.
How is
diagnosis verified? There is time to get
a chest X-Ray if the option if offered.
Treatment:
Chest tube to underwater seal and suction.
If given option for location, high in the pleural cavity.
14. –
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stale
vital signs. No breath sounds on at the
base on the right chest, faint distant breath sounds at the apex. Dull to percussion.
What is it? –
Sounds more like hemothorax.
How do we find
out? - Chest X-Ray
If confirmed,
treatment is chest tube on the right, at the base of the pleural cavity.
15. –
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on at the
base on the right chest, faint distant breath sounds at the apex. Dull to percussion. A chest tube placed at the right pleural base
recovers 120 cc of blood, drains another 20 c in the next hour.
Further
treatment: The point of this one is that most hemothoraxes do not need
exploratory surgery. Bleeding is from
lung parenchyma (low pressure), stops by itself. Chest tube is all that is needed. Key
clue: little blood retrieved, even less afterwards.
16. –
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has blood
pressure is 95 over 70, pulse rate of 100.
No breath sounds on at the base on the right chest, faint distant breath
sounds at the apex. Dull to percussion.
A chest tube placed at the right pleural base recovers 1250 cc of
blood…(or it could be only 450 cc at the outset, but followed by another 420 cc
in the next hour and so on).
Further
treatment: The rare exception who is bleeding from a systemic vessel (almost
invariably intercostal). Will need
thoracotomy to ligate the vessel.
17. –
A 25-year-old man is stabbed in the right chest. He is moderately short of breath, has stable
vital signs. No breath sounds on the
right. Resonant to percussion at the
apex of the right chest, dull at the base.
Chest X-Ray shows one single, large air-fluid level.
What is it? –
Hemo-pneumothorax. Chest tube, surgery
only if bleeding a lot.
18. –
A 33-year-old lady is involved in a high-speed automobile collision. She arrives at the E.R. gasping for breath,
cyanotic at the lips, with flaring nostrils.
There are bruises over both sides of the chest, and tenderness
suggestive of multiple fractured ribs.
Blood pressure is 60 over 45.
Pulse rate 160, feeble. She has
distended neck and forehead veins, is diaphoretic. Left hemithorax has no breath sounds, is
tympanitic to percussion.
What is it? – A
variation on an old theme: classic picture for tension pneumothorax…but Where
is the penetrating trauma? : The
fractured rubs can act as a penetrating weapon.
Management:
chest tube to the left right away! Do not fall for the option of getting
X-Rays first, but you need them later to rule out wide mediastinum (aortic
rupture).
19. –
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is in moderate
respiratory distress. She has multiple
bruises over the chest, and multiple site of point tenderness over the
ribs. X-Rays show multiple rib fractures
on both sides. On closer observation it
is noted that a segment of the chest wall on the left side caves in when she
inhales, and bulges out when she exhales.
What is it? –
Classical physical diagnosis finding of paradoxical breathing, leading to
classical diagnosis of flail chest. She
is at high risk for other injuries.
Management:
Rule out other injuries (aortic rupture, abdominal injuries) The real problem is flail chest is the
underlying pulmonary-contusion, for which the treatment is controversial,
including fluid restriction, diuretics, use of colloid rather than crystalloid
fluids when needed, and respiratory support.
The probable wrong alternatives will revolve around various ways of
mechanically stabilizing the part of the chest wall that moves the wrong
way…because that used to be what was believed in the past.
Further
management: if other injuries require that she go to the OR, prophylactic
bilateral chest tubes because she is at high risk to develop tension
pneumothorax when under the positive pressure breathing of the anesthetic.
20. –
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing
well. She has multiple bruises over the
chest and multiple sites of point tenderness over the ribs. X-Rays show multiple rib fractures on both
sides, but the lung parenchyma is clear and both lungs are expanded. Two days later her lungs “white out” on
X-Rays and se is in respiratory distress.
What is it? –
Pulmonary contusion. It does not always
show up right away, may become evident one or two days after the trauma.
Management:
Fluid restriction (using colloid), diuretics, respiratory support. The later is key, with intubation, mechanical
ventilation and PEEP if needed.
21. –
A 54-year-old lady crashes her car against a telephone pole at high speed. On arrival at the E.R. she is breathing
well. She has multiple bruises over the
chest, and is exquisitely tender over the sternum at a point where there is a
crunching feeling of crepitation elicited by palpation.
What is it? –
Obviously a sternal fracture…but the point is that she is at high risk for
myocardial contusion and for traumatic rupture of the aorta.
Further tests:
as you would do for a MI : EKG, cardiac enzymes, but the real important ones
would be CT scan, transesophageal echo or arteriogram looking for aortic
rupture.
22. –
A 53-year-old man is involved in a high-speed automobile collision. He has moderate respiratory distress. Physical exam shows no breath sounds over the
entire left chest. Percussion is
unremarkable. Chest X-Ray shows air fluid
levels in the left chest.
What is it? –
Classical for traumatic diaphragmatic rupture.
It is always on the left.
Further test?
Not really needed. A nasogastric tube
curling up into the left chest might be an added tid bit.
Management:
Surgical repair.
23. –
A motorcycle daredevil attempts to jump over the 12 fountains in front of
Caesar’s Palace Hotel in Las Vegas. As
he leaves the ramp at very high speed his motorcycle turns sideways and he hits
the retaining wall at the other end, literally like a rag doll. At the Er. he is found to be remarkably
stable, although he has multiple extremity fractures. A chest X-Ray shows fracture of the left
first rib and widened mediastinum.
What is it? –
Actually a real case. Classical for
traumatic rupture of the aorta: King size trauma, fracture of a hard-to-break
bone (it could first rib, scapula or sternum) and the tell-tale hint of widened
mediastinum
How is the
diagnosis made? – Arteriogram (aortogram).
Treatment:
Emergency surgical repair.
24. –
A 34-year-old lady suffers severe blunt trauma in a car accident. She has multiple injuries to her extremities,
has head trauma and has a pneumothorax on the left. Shortly after initial examination it is noted
that she is developing progressive subcutaneous emphysema all over her upper
chest and lower neck.
What is it? –
Traumatic rupture of the trachea or major bronchus.
Additional
findings: Chest X-Ray would confirm the presence of air in the tissues.
Management:
Fiberoptic bronchoscopy to confirm diagnosis and level of injury and to secure
an airway. Surgical repair after that.
C. Abdominal Trauma
25. –
A 26-year-old lady has been involved in a car wreck. She has fractures in upper extremities,
facial lacerations and no other obvious injuries. Chest X-Ray is normal. Shortly thereafter she develops hypotension,
tachycardia and dropping hematocrit. Her
CVP is low.
What is it? –
Obviously blood loss, but the question is where. The answer is easy: it has to be in the
abdomen. To go into hypovolemic shock
one has to lose 25 to 30% of blood volume, which in the average size adult will
be nearly a liter and a half (25 to 30% of 4.5 to 5 liters). In the absence of external hemorrhage (scalp
lacerations can bleed that much), the bleeding has to be internal. That much blood can not fit inside the head,
and would not go un-noticed in the neck (huge hematoma) or chest (X-Rays can
spot anything above 150 cc). Only
massive pelvic fractures, multiple femur fractures or intra-abdominal bleeding
can accommodate that much blood. The
first two would be obvious in physical exam and X-Rays. The belly can be silent. Thus the belly is invariably the place to
look for that hidden blood.
How is it
diagnosed? - We have a choice here. The old, invasive way was the diagnostic
peritoneal lavage. The newer,
non-invasive ways are the CAT scan or sonogram.
CT scan is best, but it can not be done in the patient who is
“crashing”. (the X-Ray department is a
never-never land where patients die unattended). Try to gage from the question whether the
patient is stable –do CT scan, or literally dying on your hands, in which case
diagnostic peritoneal lavage or sonogram is done in the E.R.
Eventual
therapy: most likely finding will be ruptured spleen. If stable, observation with serial CT scans
will follow. If not, exploratory
laparotomy.
26. –
A 19 year old gang member is shot in the abdomen with a 38 caliber
revolver. The entry wound is in the
epigastrium, to the left of the midline.
The bullet is lodged in the psoas muscle on the right. He is hemodynamically stable, the abdomen is
moderately tender.
Management: No
diagnostic tests are needed. A penetrating
wound of the abdomen gets exploratory laparotomy every time. Only hidden trap you might get in the
question relates to preparations prior to surgery: an indwelling bladder
catheter, a big bore venous line for fluid administration and a dose of broad
spectrum antibiotics.
27. –
A 19 year old gang member is shot once with a 38 caliber revolver. The entry wound is in the left mid-clavicular
line, two inches below the nipple. The
bullet is lodged in the left paraspinal muscles. He is hemodynamically stable, but he is drunk
and combative and physical exam Is difficult to do.
What is it? –
The point here is to remind you of the boundaries of the abdomen: although this
sounds like a chest wound, it is also abdominal. The belly begins at the nipple line. The chest does not end at the nipple line,
though. Belly and chest are not stacked
up like pancakes: they are separated by a dome.
This fellow needs all the stuff for a penetrating chest wound (chest
X-Ray, chest tube if needed), plus the exploratory lap.
28. –
A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest
wall. Chest X-Ray shows fractures of the
8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a
pulse rate of 128.
What is it? –
This one is a classic: ruptured spleen.
We already went over the business of where blood can hide, the abdomen
is the place, but within the belly the most fragile solid organ that gives
clinically significant bleeding is the spleen. (The liver is actually more likely to be the
site of bleeding when CT scans are done on patients with blunt abdominal
trauma, but often the bleeding from the liver is not clinically
significant). In the absence of other
clues, clinically significant hidden intra-abdominal bleeding comes from a
ruptured spleen. This case is actually
full of other clues that point to the spleen.
First negotiate
the diagnostic dilemma: if he responds promptly to fluid administration, and
does not require blood, go for the CT scan.
Further management in that case may well be continued observation with
serial CT scans. If he is “crashing”, he
will need the peritoneal lavage or sonogram followed by exploratory laparotomy.
29. –
A 27 year old intoxicated man smashes his car against a tree. He is tender over the left lower chest
wall. Chest X-Ray shows fractures of the
8th, 9th and 10th ribs on the left. He has a blood pressure of 85 over 68 and a
pulse rate of 128, which do not respond satisfactorily to fluid and blood
administration. He has a positive
peritoneal lavage and at exploratory laparotomy a ruptured spleen is found.
What is the
issue here? – You are unlikely to be asked technical surgical questions, but
when dealing with a ruptured spleen an effort will be made to repair it rather
than remove it. In children the effort
will be even greater. But if the
vignette says that the spleen had to come out, then further management includes
administration of pneumovax and some would also immunize for hemophilus
influenza B and Meningococcus.
30. –
A 31 year old lady smashes her car against a wall. She has multiple injuries including upper and
lower extremity fractures. Her blood
pressure is 75 over 55, with a pulse rate of 110. On physical exam she has a tender abdomen,
with guarding and rebound on all quadrants.
What is it? –
Blood in the belly is not always, “silent”.
It can elicit peritoneal reaction.
When it does, you put two and two together and do not need fancy
diagnostic tests. Furthermore, blood is
not the only thing that can be loose in the belly after trauma: intestinal
contents can spill over from ruptured hollow viscus…and that calls for repair
also. The question here would be what to
do, and the answer would be exploratory lap.
31. –
A 31 year old lady smashes her car against a wall. Hollow viscera will spill their
contents. Of ten they both happen, but
one can exist without the other. Here
there is not evidence of blood loss, but plenty of clues to suggest that “evil
fluid” is loose in the belly.
What will she
need? - Exploratory lap, and repair of
the injuries.
D. Urological Trauma
32. –
A patient involved in a high speed automobile collision has multiple injuries,
including a pelvic fracture. On physical
exam there is blood in the meatus.
What is it? –
The vignette will be longer, but the point is that pelvic fracture plus blood
in the meatus means either bladder or urethral injury. Evaluation starts with a retrograde
urethrogram because urethral injury would be compounded by insertion of a Foley
catheter.
33. –
A 19 year old male is involved in a severe automobile accident. Among many other injuries he has a pelvic
fracture. He has blood in the meatus,
scrotal hematoma and the sensation that he wants to urinate but can not do
it. Rectal exam shows a “high riding
prostate”.
What is
it? - This is a more complete
description of a posterior urethral injury.
How is the
diagnosis made? - You already know:
retrograde urethrogram
Management:
They will not ask you, but these get a suprapubic catheter, and the repair is
delayed 6 months.
34. –
A 19 year old male is involved in a motorcycle accident. Among many other injuries he has a pelvic
fracture. He has blood in the meatus and
scrotal hematoma. Retrograde urethrogram
shows an anterior urethral injury.
A variation of
the above theme. The only difference is
that anterior urethral injuries are repaired right away.
35. –
A patient involved in a high speed automobile collision has multiple injuries,
including a pelvic fracture. Insertion
of a Foley catheter shows that there is gross hematuria.
What is it? –
Presumably there was no blood in the meatus to warn against the insertion of an
indwelling catheter, and since the latter was accomplished without problem, the
urethra must be intact. That leaves us
with bladder injury.
Assessment will
require retrograde cystogram.
36. –
A patient involved in a high speed automobile collision has multiple injuries,
including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that
there is gross hematuria, and retrograde cystogram is normal.
What is it? –
Lower injuries have been ruled out. The
blood has to be coming from the kidneys.
How is the
diagnosis made? – CT scan.
Further
management: They will not ask you for fine-judgment surgical decisions, but the
rule is that traumatic hematuria does not need surgery even if the kidney is
smashed.
They operate
only if the renal pedicle is avulsed or the patient is exsanguinating.
37. –
A patient involved in a high speed automobile collision has multiple injuries,
including rib fractures and abdominal contusions. Insertion of a Foley catheter shows that
there is hematuria, and retrograde cystogram is normal. CT scan shows renal injuries that do not
require surgery. Six weeks later the
patient develops acute shortness of breath and a flank bruit.
38. –
A 35 year old male is about to be discharged from the hospital where he was
under observation for multiple blunt trauma sustained in a car wreck. It is then discovered that he has microscopic
hematuria.
Management:
Gross traumatic hematuria in the adult always has to be investigated.
39. –
A 4 year old falls from his tricycle. In
the ensuing evaluation he is found to have microscopic hematuria.
Management:
This one is here to contrast it with the previous one. Microhematuria in kids needs to be
investigated, as it often signifies congenital anomalies…particularly if the
magnitude of the trauma does not justify the bleeding. Start with sonogram.
40. –
A 14 year old boy slides down a banister, not realizing that there is a big
knob at the end of it. He smashes the
scrotum and comes in to the E.R. with a scrotal hematoma the size of a
grapefruit.
What is it? –
The issue in scrotal hematomas is whether the testicle is ruptured or not.
How is the
diagnosis made? – Sonogram will tell.
Management: If
ruptured, surgery will be needed. If
intact, only symptomatic treatment.
41. –
A 41 year old male presents to the E.R. reporting that he slipped in the shower
and injured his penis. Exam reveals a
large penile shaft hematoma with normal appearing glans.
What is it? – A
classical description of fracture of the tunica albuginea…including the usual
cover story given by the patient. These
always happen during sexual intercourse with woman on top…but patient will not
say so.
Management:
this is one of the few urological emergencies.
Surgical repair is needed.
E. Burns
42. –
You get a phone call from a frantic mother.
Her 7 year old girl spilled Drano all over her arms and legs. You can hear the girl screaming in pain in
the background.
Management: The
point of this question is that chemical injuries – particularly alkalis-need
copious, immediate, profuse irrigation.
Instruct the mother to do so right at home with tap water, for at least
30 minutes before rushing the girl to the E.R.
43. –
While trying to hook up illegally to cable TV, an unfortunate man comes in
contact with a high tension electrical power line. He has an entrance burn wound in the upper
outer thigh and an exit burn lower down on the same side.
Management: The
issue here is that electrical burns are always much bigger than they appear to
be. There is deep tissue
destruction. The patient will require
extensive surgical debridement, but there is also another item (more likely to
be the point of the question): Myoglobinemia, leading to myoglobinuria and to
renal failure. Patient needs lots of IV
fluids, diuretics (osmotic if given that choice i.e. Mannitol), perhaps
alkalinization of the urine.
44. –
A man is rescued by firemen from a burning building. On admission it is noted that he has burns
around the mouth and nose, and the inside of his mouth and throat look like the
inside of a chimney.
What is it? –
The issue here is respiratory burns, i.e.: smoke inhalation producing a
chemical burn of the tracheobronchial tree.
It happens with flame burns in an enclosed space. The burns in the face are an additional clue
that most patients will not have.
Diagnosis is
made with bronchoscopy.
Management
revolves around respiratory support.
45. –
A patient has suffered third degree burns to both of his arms when his shirt
caught on fire while lighting the back yard barbecue. The burned areas are dry, white, leatherly
anesthetic, and circumferential all around arms and forearms.
What is it? –
You are meant to recognize the problem posed by circumferential burns: The
leatherly eschar will not expand, while the are under the burn will develop
massive edema, thus circulation will be cut off. (Or in the case of circumferential burns of
the chest, breathing will be compromised).
Note that if the fire was in the open space of the backyard, respiratory
burn is not an issue.
Management:
Compulsive monitoring of peripheral pulses and capillary filling.
Escharotomies
at the bedside at the first sign of compromised circulation.
46. –
A toddler is brought to the E.R. with burns on both of his buttocks. The areas are moist, have blisters and are
exquisitely painful to touch. The story
is that the kid accidentally pulled a pot of boiling water over himself.
What is it ? –
Burns, of course…but there are several issues: first, how deep. The description is classical for second
degree. (Note hat in kids third degree
is deep bright red, rather than white leatherly as in the adult). How did it really happen? Burns in kids always bring up the possibility
of child abuse, particularly if they have the distribution that you would
expect if you grabbed the kid by arms and legs and dunked him in a pot of
boiling water.
Management for
the burn is silvadene (silver sulphadiazine) cream. Management for the kid may require reporting
to authorities for child abuse.
47. –
An adult male who weight “X” Kgs.
Sustains second and third degree burns over ---whatever--- The burns
will be depicted in a drawing, indicating what is second degree (moist,
blisters, painful) and what is third degree (white, leatherly,
anesthetic). The question will be about
fluid resuscitation.
Management: -
Time to dust off the old formula: 4cc per Kg. of body weight per percentage of
burned are (up to 50). Percentage to be
calculated by the rule of nines: one nine each for head and arms, two nines for
each leg, four nines for the trunk. (In
kids the head is twice as big, the legs take up the slack). Give ringers lactate, pour it in so that half
of the calculated dose goes in during first 8 hours.
Lots of
additional questions could ensue from the basic burn vignette:
If the colloids
are to be used, give them in the second day (not the first).
Monitoring to
see if your calculation are correct: CVP and hourly urinary output. Keep the former below 15 or 20, aim for 1 cc
per Kg body weight per hour for the latter.
Circumstances
where additional fluid is needed (aiming for urinary output of two cc
per Kg per hour, instead of one): electrical burns, patients who get
escharotomy.
A classical
one, bound to be in the test somewhere: Patient was well resuscitated, had good
hemodynamic parameters but required a lot of fluid. On the third day he starts to pee out a
storm. What does that mean? : nothing.
You expect it. The fluid from the
burn edema is coming back to the circulation.
What to do for
the burn areas? After the obvious
cleansing, silvadene cream for most areas, sulphamyelon where deep penetration
is needed (cartilage, thick eschar), triple antibiotic ointment in the face
near the eyes (silvadene hurts the eyes).
Skin grafting
will ensue, but they will not ask about it ( too technical). However the emphasis on prevention may lead
to questions about the timing of rehabilitation: the answer is that
rehabilitation starts on day one.
48. –
A 42 year old lady drops her hot iron on her lap while doing the laundry. She comes in with the shape of the iron
clearly delineated on her upper thigh.
The area is white, dry, leatherly, anesthetic.
What is the
issue? - A current favorite of burn
treatment is the concept of early excision and grafting. After fluid resuscitation the typical burn
patient spends two weeks in the hospital consuming thousand of dollars of
health care every day, getting topical treatment to the burn areas and
intensive nutritional support in preparation for skin grafting. In most cases there is no alternative. But less extensive burns can be taken to the
O.R., excised and grafted on day one, saving tons of money. You will not be asked to provide the fine
judgement call for the borderline case that might be done that way, but the
vignette is a classical one where the decision is easy: very small and clearly
third degree.
Answer: Early
excision and grafting.
F. Bites
49. –
Let us end the trauma review with a classic.
A 22 year old gang leader comes to the E.R. with a small, 1 cm. deep
sharp cut over the knuckle of the right middle finger. He says he cut himself with a screwdriver
while fixing his car.
What is it? –
The description is classical for a human bite.
No, nobody actually bit him, he did it by punching someone in the
mouth…and getting cut with the teeth that were smashed by his fist. The imaginative cover story usually comes
with this kind of lesion. The point of
management is that human bites are bacteriological the dirtiest that one can
get. Rabies shots will not be needed,
but surgical exploration by an orthopedic surgeon will be required.
2. SKIN
SK.1. – A
65 year old West Texas farmer of Swedish ancestry has an indolent, raised,
waxy, 1.2 cm skin mass over the bridge of the nose that has been slowly growing
over the past three years. There are no
enlarged lymph nodes in the head and neck.
What is it? – Basal cell
carcinoma.
How is it diagnosed? - Full thickness biopsy at the edge of the
lesion (punch or knife).
Treatment: Surgical excision with
clear margins, but conservative width.
SK.2. – A 71 year old West Texas
farmer of Irish ancestry has a non-healing, idolent, punched out, clean looking
2 cm. ulcer over the left temple, that has been slowly becoming larger over the
past three years. There are no enlarged
lymph nodes in the head and neck.
What is it, and what needs to be
done? - Same as above. This is another way for basal cell carcinoma
to show up.
SK.3. – A blond, blue eyed, 69
year old sailor has a non-healing, indolent 1.5 cm. ulcer n the lower lip, that
has been present, and slowly enlarging for the past 8 months. He is a pipe moker, and he has no other
lesions or physical findings.
What is it? - Squamous cell carcinoma.
How is the diagnosis made? - Biopsy, as described before.
Treatment: he will need surgical
resection with wider (about 1 cm.) clear margins. Local radiation therapy is another option.
SK.4. – A red headed 23 year old
lady who worships the sun, and who happens to be full of freckles, consults you
for a skin lesion on her shoulder that concerns her. She has a pigmented lesion that is
asymetrical, with irregular borders, of different colors within the lesion, and
measuring 1.8 cms.
What is it? – The classical ABCD
that alerts you to melanoma or a forerunner (dysplastic nevus).
Management: full thickness biopsy
at the edge of the lesion, margin free local excision if superficial melanoma
(Clarks’ levels one or two, or under 0.75 mm), wide local excision with 2 or 3
cm. margin if deep melanoma.
SK.5. – A 35 year old blond, blue
eyed man left his native Minnesota at age 18, and has been living an idyllic
life as a crew member for a sailing yacht charter operation in the
Caribbean. He has multiple nevi all over
his body, but one of them has changed recently…
What is it? – Change in a
pigmented lesion is the other tip off to melanoma. It may be growth, or bleeding, or ulceration,
or change in color…whatever. Manage as
above.
SK.6. – A 44 year old man has
unequivocal signs of multiple liver metastasis, but no primary tumor has been
identified by multiple diagnostic studies of the abdomen and chest. The only abnormality in the physical exam is
a missing toe, which he says was removed at the age of 18 for a black tumor
under the toenail.
What is it? - A classical vignette for malignant melanoma
(the alternate version has a glass eye, and history of enucleation for a
tumor). No self-respecting malignant
tumor would have this time interval, but melanoma will.
SK.7. – A 32 year old gentleman had
a Clark’s level 5, 3.4 mm. Deep, melanoma removed from the middle of his back
three years ago. He now has…(a tumor in
a weird place, like his left ventricle, his duodenum, his ischiorectal
area…anywhere!).
The point of this vignette is
that invasive melanoma (it has to be deep) metastasizes to all the usual places
(lymph nodes plus liver-lung-brain-bone) but it is also the all-time-champion
in going to weird places where few other tumors dare to go.
3. BREAST
BR.1. – An 18 year old lady has a
firm, rubbery mass in the left breast that moves easily with palpation.
What is it? - Fibroadenoma.
How is the diagnosis made? - The underlying concern in all breast masses
is cancer. The only safe answer, even if
the presentation favors benign disease, is to get tissue diagnosis. In this case it should be done in the least
invasive way possible: If offered, FNA (fine needle aspirate for
cytology). If not, core biopsy or if it
is the only choice, excisional biopsy.
Reassurance alone would not be a good choice! Mammogram alone is not the way to go,
either. Mammogram is primarily for
screening, not for diagnosis. At age 18,
mammograms are useless (breast to dense).
Sonogram is the only imaging technique suitable for the very young
breast.
BR.2. – A 27 year old immigrant
from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and
slowly growing to it’s present size. The
mass is firm, rubbery, completely movable, is not attached to chest wall or to
overlying skin. There are no palpable
axillary nodes.
What is it? - Cystosarcoma Phyllodes.
Management: Tissue diagnosis is
needed (some of these become outright malignant sarcomas), given the size best
done with core or incisional biopsy.
Margin-free resection will follow.
BR.3. – A 35 year old lady has a
ten year history of tenderness in both breasts, related to menstrual cycle,
with multiple lumps on both breasts that seem to “come and go” at different
times in the menstrual cycle. Now has a
firm, round, 2 cm. mass that has not gone away for 6 weeks.
What is it? - Fibrocystic disease (cystic mastitis,
mammary dysplasia0, with a palpable cyst.
Management: tissue diagnosis
(i.e: biopsy) becomes impractical when there are lumps every month. Aspiration of the cyst is the answer
here. If the mass goes away and the
fluid aspirated is clear, that’s all. If
the fluid is bloody it goes to cytology.
If the mass does not go away, or recurs she needs biopsy. Answers that offer mammogram or sonogram in
addition to the aspiration would be OK, but not as the only choice.
BR.4. – A 34 year old lady has
been having bloody discharge from the right nipple, on and off for several
months. There are no palpable masses.
What is it? - Intraductal papilloma.
What is to be done? - The old concern over cancer is the issue,
and the way to detect cancer that is not palpable is with a mammogram. That should be the first choice. If negative, one may still wish to find an
resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or
done as a retroareolar exploration.
BR.5. – A 26 year old lactating
mother has cracks in the nipple and develops a fluctuating, red, hot, tender
mass in the breast, along with fever and leukocytosis.
What is it? - Sounds like an abscess…and in this setting
it is. However, only lactating
breasts are “entitled” to develop abscesses.
On anybody else, a breast abscess is a cancer until proven otherwise.
Management: Incision and drainage
is the Rx. For all abscesses, this one included. But, if an option includes drainage with
biopsy of the abscess wall, go for that one.
BR.6. – A 49 year old has a firm,
2cm. mass in the right breast, that has been present for 3 months.
What is it? - This could be anything. Age is the best determinant for Cancer of the
breast. If she had been 72, you go for
cancer. At 22, you favor benign. But they will not ask you what this is, they
will ask what do you do.
Management: You have to have
tissue. Core biopsy is OK, but if
negative you don’t stop there: only excisional biopsy will rule out cancer.
BR.7 and 8. – A 69 year old lady
has a 4 cm. hard mass in the right breast, with ill defined borders, movable
from the chest wall but not movable within the breast. The skin overlying the mass is retracted an
has an “orange peel” appearance…or the nipple became retracted six months ago.
What is it? - Classical cancer of the breast.
What do you do? - Establish the diagnosis with tissue, as
mentioned above.
BR.9. – A 72 year old lady has a
red, swollen breast. The skin over the
area looks like orange peel. She is not
particularly tender, and it is debatable whether the area is hot or not. She has no fever or leukocytosis.
What is it? - Another classic for cancer of the breast.
Management: Same as above: get
that tissue diagnosis (here a punch biopsy of the skin is an option. It probably is permeated with cancer).
BR.10. – A 62 year old lady has
an eczematoid lesion in the areola. It
has been present for 3 months and it looks to her like “some kind of skin
condition” that has not improved or gone away with a variety of lotions and
ointments.
What is it? - Another sneaky way for cancer of the breast
to show up. If you get this one in an
extended matching set, the answer is Paget’s disease of the breast-which is a
cancer under the areola.
Management: same as above: get
tissue! A full thickness punch biopsy of
the skin would be OK, but core biopsy or incisional biopsy of the tissue
underneath would be OK also.
BR.11. – A 42 year old lady hits
her breast with a broom handle while doing her housework. She noticed a lump in that area at the time,
and one week later the lump is still there.
She has a 3 cm. hard mass deep inside the affected breast, and some
superficial ecchymosis over the area.
What is it? - A classical trap for the unwary. It is cancer until proven otherwise. Trauma often brings the area to the attention
of the patient…but is not cause of the lump.
BR.12. – A 58 year old lady
discovers a mass in her right axilla.
She has a discreet, hard, movable, 2 cm. mass. Examination of her breast is negative, and
she has not enlarged lymph nodes elsewhere.
What is it? - A tough one, but another potential
presentation for cancer of the breast.
In a younger patient you would think lymphoma. It could still be lymphoma on her. She needs a mammogram (we are now looking for
an occult primary), and the node will eventually have to be biopsied.
BR.13. – A 60 year old lady has a
routine, screening mammogram. The
radiologist reports an irregular area of increased density, with fine
microcalcifications, that was not present two year ago on a previous mammogram.
What do you do? - You will not be asked to read X-Rays
(particularly mammograms), but you should recognize the description of a
malignant radiological image – which this one is. Thus, we go back to our old issue: we need
tissue diagnosis. In this case the first
attempt should be stereotactic radiologically guided core biopsy. If unsatisfactory, the next move would be
needle localized excisional biopsy.
BR.14. – A 44 year old lady has a
2 cm. palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal
carcinoma. The mass is freely movable
and her breast is of normal, rather generous size. She has no palpable axillary nodes.
The question is obviously what to
do. The standard option here is
segemental resection (lumpectomy), to be followed by radiation therapy to the remaining breast, as well as axillary
node dissection to help determine the need for adjuvant systemic therapy.
BR.15. – A 62 year old lady has a
4 cm. hard mass under the nipple and areola of her rather smallish left
breast. A core biopsy has established a
diagnosis of infiltrating ductal carcinoma.
There are no palpable axillary nodes.
Again, a management
question. Lumpectomy is an option only
when the tumor is small (in absolute terms and in relation to the breast) and
located where most of the breast can be spared.
A modified radical mastectomy is the choice here. Why go after the axillary nodes when they are
not palpable?: Because palpation is notoriously inaccurate in determining the
presence or absence of axillary metastasis.
BR.16. – A 44 year old lady shows
up in the Emergency Room because she is “bleeding from the breast”. Physical exam shows a huge, fungating,
ulcerated mass occupying the entire right breast, and firmly attached to the
chest wall. The patient maintains that
the mass has been present for only “a few weeks”, but a relative indicates that
it has been there at least two years, maybe longer.
What is it? – An all too frequent
tragic case of neglect and denial.
Obviously a far advanced cancer of the breast.
Management: the tissue diagnosis
is still needed, and either a core or an incisional biopsy is in order, but the
likely question here is what to do next.
This is an inoperable, and incurable as well…but palliation can be
offered. Chemotherapy is the first line
of treatment. In many cases the tumor
will shrink enough to become operable.
BR.17. – A 37 year old lady has a
lumpectomy and axillary dissection for a 3 cm. infiltrating ductal
carcinoma. The pathologist reports clear
surgical margins and metastatic cancer in four out of 17 axillary nodes.
The question here is what to do
next: Only very small tumors with negative nodes and very favorable
histological pattern are “cured” with surgery alone. More extensive tumors need adjuvant systemic
therapy, and the rule is that premenopausal women get chemotherapy and
postmenopausal women get hormonal therapy.
This is one clear one for chemotherapy.
BR.18. – A 66 year old lady has a
modified radical mastectomy for infiltrating ductal carcinoma of the
breast. The pathologist reports that
tumor measures 4 cm. in diameter and that 7 out of 22 axillary node are
positive for metastasis. The tumor is
estrogen and progesterone receptor positive.
A variation on the previous one,
but here a clear choice for hormonal therapy.
The agent uses is Tamoxifen.
BR. 19. – A 44 year old lady complains
bitterly of severe headaches that have been present for several weeks and have
not responded to the usual over-the-counter headache remedies. She is two years post-op. from modified
radical mastectomy for T3, N2, M0 cancer of the breast, and she had several
courses of post-op chemotherapy which she eventually discontinued because of
the side effects.
What is it? – A classic: severe
headaches in someone who a few years ago had extensive cancer of the breast
means brain mets until proven otherwise. Don’t get hung up on the TNM classification,
if the numbers are not 1 for the tumor and zero for the nodes and met, the
tumor is bad.
What do yo do? CT scan of the brain.
BR.20. – A 39 year old lady
completed her last course of postoperative adjuvant chemotherapy for breast
cancer six months ago. She comes to the
clinic complaining of constant back pain for about 3 weeks. She is tender to palpation over two well
circumscribed areas in the thoracic and lumbar spine.
A variation on the above
theme. Now bone mets, instead of brain
mets…at least until proven otherwise.
What do you do?: The most
sensitive test for bone mets is bone scan.
If positive, X-Rays are needed to rule out benign reasons for the scan
to “light up”.
4. OPTHALMOLOGY
A. Children
EY.1. – A two year old has a
huge, pedunculated lipoma hanging out from his right upper eyelid, and
obstructing his vision on that eye.
EY.2. – A one year old child is
suspected of having strabismus. You
verify that indeed the corneal reflection from a bright light in your examining
room comes from different places from each of his eyes.
What is the point of these
vignettes? - To remind you that the
brain “learns” to see what the eyes see during early infancy (up to about age
7). If one eye can not see (any kind of
obstruction) or the brain does not like what they see (double vision) the brain
will refuse to process the image and that cortical “blindness” will be
permanent (the concept of amblyopia).
Management: the problem has to be
surgically corrected as early as possible.
EY.3. – A young mother is
visiting your office for routine medical care.
She happens to have her 18 month old baby with her, and you happen to
notice that one of the pupils of the baby is white, while the other one is
black.
What is it? – An ophthalmological
and potentially life-and-death emergency.
A white pupil (leukocoria0 at this age can be retinoblastoma. This kid needs to see the ophthalmologist not
next week, but today or tomorrow. If it
turns out to be something more innocent, like a cataract, the kid still needs
it corrected to avoid amblyopia.
EY.4. – Your distant cousins that
you have not seen for years visit you and brag about their beautiful baby with
“huge, shiny eyes”. They show you a
picture that indeed proves their assertion (or the exam booklet will have such
a picture).
What is it? - Huge eyes in babies can be congenital
glaucoma. Tearing will indeed make them
shine all the time. If undiagnosed,
blindness will ensue.
B. Adults
EY.5. – A 53 year old lady is in
the ER complaining of extremely severe frontal headache. The pain started about one hour ago, shortly
after she left the movies where she watched a double feature. On further questioning, she reports seeing
halos around the lights in the parking lot when leaving the theater. On physical exam the pupils are mid-dilated,
do not react to light, the corneas are cloudy and with a greenish hue, and the
eyes feel “hard as a rock”.
What is it? - A classical description of acute
glaucoma. Not the most common type (most
are asymptomatic…but you can not write a vignette for those), but one that
requires immediate Rx.
Management: An ophthalmologist is needed right
away…but if you are put in a position to chose treatment, pick Diamox,
pilocarpin drops or Mannitol.
EY.6. – A 32 year old lady
presents in the E.R. with swollen, red, hot, tender eyelids on the left
eye. She has fever and
leukocytosis. When prying the eyelids
open, you can ascertain that her pupil is dilated and fixed and that she has
very limited motion of that left eye.
What is it? - Orbital cellulitis.
Management: Another
ophthalmological emergency that requires immediate consultation, but if asked
what to do, CT scan will be indicated to assess the extent of the orbital
infection and surgical drainage will follow.
EY.7. – A frantic mother reaches
you on the phone, reporting that her 10 year old boy accidentally splashed
Drano on his face and is screaming in pain complaining that his right eye hurts
terribly.
Management: We know that copious
irrigation is the main treatment for chemical burns. The point of this vignette is to remind you
that time is a key element. If the lady
is instructed to bring the boy to the ER, his eye will be cooked to a crisp by
the time he arrives. The correct answer
here is to instruct the mother to pry the eye open under the cold water tap at
home, and irrigate for about ½ hour before she brings the kid to the
hospital. You will do more irrigation at
the ER, remove solid matter, and eventually re-check pH before the kid goes
home.
EY.8. – A 59 year old, myopic
gentleman reports “seeing flashes of light” at night, when his eyes are
closed. Further questioning reveals that
he also sees “floaters” during the day, that they number ten or twenty, and
that he also sees a cloud at the top of his visual field.
What is it? - Retinal detachment. One or two floaters would not mean that. More than a dozen is an ominous sign, and
that “cloud” at the top of the visual field is hemorrhage settling at the
bottom of the eye.
Management: Another
ophthalmological emergency. The retina
specialist will use laser treatment to “spot weld” the retina back in place.
EY.9. – A 77 year old man
suddenly loses sight from the right eye.
He calls you on the phone 10 minutes after the onset of the
problem. He reports no other
neurological symptoms.
What is it? - Embolic occlusion of the retinal artery.
Management: Another
ophthalmological emergency…although little can be done for the problem. He has to get the ER instantly and it might
help for him to breathe into a paper bag on route, and have someone press hard
on his eye and release repeatedly.
EY.10. – A 55 year old man is
diagnosed with type two diabetes mellitus.
On questioning abut eye symptoms he reports that sometimes after a heavy
dinner the television becomes blurry and he has to squint to see it clearly.
What is it? - The blurry T.V. is no big deal: the lens
swells and shrinks in response to swings in blood sugar…the important point is
that he needs to start getting regular ophthalmological follow up for retinal
complications. It takes 10 or 20 years
for those to develop, but type 2 diabetes may have been present that long
before it was diagnosed.
5. GASTROINTESTINAL
TRACT
A. Esophagus
Gl.1. – A 54 year old obese man
gives a history of burning retrosternal pain and “heartburn” that is brought
about by bending over, wearing tight clothing or lying flat in bed at
night. He gets symptomatic relief from
antiacids, but the disease process seems to be progressing since it started
several years ago.
What is it? - Gastroesophageal reflux, of course (GERD).
Management: Thousands of cases
like this are handled with symptomatic medication and no fancy work-up, but the
academicians writing questions would want you to recommend endoscopy and
biopsies to assess the extent of esophagitis and potential complications.
Gl.2. – A 54 year old obese man
gives a history of burning retrosternal pain and “heartburn” that is brought
about by bending over, wearing tight clothing or lying flat in bed at
night. He gets symptomatic relief from
antiacids, but the disease process seems to be progressing since it started
several years ago. Endoscopy shows
severe peptic esophagitis and Barrett’s esophagus.
Management: Barrett’s is
premalignant. Surgery would be
recommended, probably a Nissen Fundoplication.
G.l.3 – A 62 year old man
describes severe epigastric and substernal pain that he can not characterize
well. There is a history suggestive of
gastroesophageal reflux, and EKG and cardiac enzymes have been repeatedly
negative.
What is it? - The question here is whether retrosternal
pain is due to acid reflux or not. The
test that you do is an acid perfusion (Bernstein) test, that reproduces the
pain when the lower esophagus is irrigated with an acid solution.
G.l.4. – A 44 year old black man
describes progressive dysphagia that began 3 months ago with difficulty
swallowing meat, progressed to soft foods and is now evident for liquids as
well. he locates the place where food
“sticks” at the lower end of the sternum.
He has lost 30 pounds of weight.
What is it? – A classic for
carcinoma of the esophagus.
What do you do? – Barium swallow
first, then endoscopy and biopsies. CT
scan next.
G.l.5. – A 47 year old lady
describes difficulty swallowing which she has had for many years. She says that liquids are more difficult to
swallow than solids, and she has learned to sit up straight and wait for the
fluids to “make it through”.
Occasionally she regurgitates large amounts of undigested food.
What is it? - Sounds like achalasia.
How do you make the
diagnosis? - Manometry studies.
G.l.6. – A 24 year old man spends
the night cruising bars and drinking heavily.
In the wee hours of the morning he is quite drunk and he starts vomiting
repeatedly. He initially brings up
gastric contents only, but eventually he vomits bright red blood.
What is it? - Mallory Weiss tear of the esophagogastric
junction.
Management: Endoscopy to
ascertain the diagnosis. Bleeding is
typically arterial and brisk, but self-limiting. Photocoagulation may be used if needed.
G.l.7. – A 24 year old man spends
the night cruising bars and drinking heavily.
In the wee hours of the morning he is quite drunk and starts vomiting
repeatedly. Eventually he has a particularly
violent episode of vomiting and he feels a very sever, wrenching epigastric and
low sternal pain of sudden onset. On
arrival at the E.R. one hour later he still has the pain, he is diaphoretic,
has fever and leukocytosis and looks quite ill.
What is it? – Boerhave’s
syndrome.
How do you confirm the
diagnosis? - Gastrographin swallow
Treatment: Emergency surgical
repair. Prognosis depends on time
elapsed between perforation and treatment.
G.l.8. – A 55 year old man has an
upper G.I. endoscopy done as an outpatient to check on the progress of medical
therapy for gastric ulcer. Six hours
after the procedure, he returns complaining of severe, constant, retrosternal
pain that began shortly after he went home.
He looks prostrate, very ill, is diaphoretic, has a temperature of 104
and respiratory rate of 30.
What is it? - Instrumental perforation of the esophagus.
Diagnosis and management as in
the previous case.
B. Stomach
G.l.9. – A 72 year old man has
lost 40 pounds of weight over a two or three month period. He gives a history of anorexia for several
months, and of vague epigastric discomfort for the past 3 weeks.
What is it? - Cancer of the stomach.
How do you diagnose it? –
Endoscopy and biopsies.
C. Small Bowel and Appendix
G.l.10. – A 54 year old man has
had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate
abdominal distention, and has not had a bowel movement or passed any gas for
five days. He has high pitched, loud
bowel sounds that coincide with colicky pain, and X-Rays that show distended
loops of small bowel and air-fluid levels.
Five years ago he had an exploratory laparotomy for a gunshot wound of
the abdomen.
What is it? - Mechanical intestinal obstruction, due to
adhesions.
Management: Nasogastric suction,
I.V. fluids and careful observation.
G.l.1 – A 54 year old man has had
colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate
abdominal distention, and has not had a bowel movement or passes any gas for
five days. He has high pitched, loud
bowel sounds that coincide with the colicky pain, and X-Rays that show
distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory
laparotomy for a gunshot wound of the abdomen.
What is it? – Mechanical
intestinal obstruction, due to adhesions.
Management; Nasogastric suction,
I.V. fluids and careful observation.
G.l.11. – A 54 year old man has
had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate
abdominal distention, and has not had a bowel movement or passed any gas for
five days. He has high pitched, loud
bowel sounds that coincide with the colicky pain, and X-Rays that show
distended loops of small bowel and air-fluid levels. Five years ago he had an exploratory
laparotomy for a gunshot wound of the abdomen.
Six hours after being hospitalized and placed on nasogastric suction and
I.V. fluids, he develops fever, leukocytosis, abdominal tenderness and rebound
tenderness.
What’s happening? - He has strangulated obstruction: i.e., a
loop of bowel is dying –or dead- from compression of the mesenteric blood
supply.
What does he need? - Emergency surgery.
G.l.12. – A 54 year old man has
had colicky abdominal pain and protracted vomiting for several days. He has developed progressive moderate
abdominal distention, and has not had a bowel movement or passed any gas for
five days. He has high pitched, loud
bowel sounds that coincide with the colicky pain, and X-Rays that show
distended loops of small bowel and air-fluid levels. On physical exam a groin mass is noted, and
he explains that he used to be able to “push it back” at will, but for the past
5 days has been unable to do so.
What is it? – Mechanical
intestinal obstruction, due to an incarcerated (potentially strangulated)
hernia.
Management: After suitable fluid
replacement needs urgent surgical intervention.
G.l.13. – A 55 year old lady is
being evaluated for protracted diarrhea.
On further questioning she gives a bizarre history of episodes of
flushing of the face, with expiratory wheezing.
A prominent jugular venous pulse is noted on her neck.
What is it? - Carcinoid syndrome.
How do you diagnose it? - Serum determinations of 5-hydroxy-indoleacetic
acid.
G.1.14. – A 22 year old man
develops vague periumbilical pain that several hours later becomes sharp,
severe, constant and well localized to the right lower quadrant of the
abdomen. On physical examination he has
abdominal tenderness, guarding and rebound to the right and below the
umbilicus. He has a temperature of 99.6
and a WBC of 12,500, with neutrophilia and immature forms.
What is it? – A classic for acute
appendicitis.
What does he need? – Exploratory
laparotomy and appendectomy.
D. Colon
G.l.15. – A 59 year old is referred for evaluation
because he has been fainting at his job where he operates heavy machinery. He is pale and gaunt, but otherwise his
physical exam is remarkable only 4+ occult blood in the stool. Lab studies show a hemogoblin of 5.
What is it? - Cancer of the right colon.
How is it diagnosed? - Colonoscopy and biopsies.
Treatment: Blood transfusions and
eventually right hemicolectomy.
G.l.16. – A 56 year old man has
bloody bowel movements. The blood coats
the outside of the stool, and has been constipated, and his stools have become
of narrow caliber.
What is it? - Cancer
of the distal, left side of the colon.
How is it diagnosed? - Endoscopy and biopsies. If given choices start with flexible sigmoidoscopy.
G.l.17. – A 77 year old man has a
colonoscopy because of rectal bleeding.
A villous adenoma is found in the rectum and several adenomatous polyps
are identified in the sigmoid and descending colon.
The issue with polyps is which
ones are pre-malignant, and thus need to be excised, and which ones are benign
and can be left alone. Premalignant
include, in descending order of malignant conversion: familial polyposis,
Gardner’s, villous adenoma and adenomatous polyps. Benign include juvenile, Peutz-Jeghers,
inflammatory and hyperplastic.
G.l.18. – A 42 year old man has
suffered from chronic ulcerative colitis for 20 years. He weights 90 pounds and has had at least 40
hospital admissions for exacerbations of the disease. Due to a recent relapse, he has been placed
on high dose steroids and immuran. For
the past 12 hours he has had severe abdominal pain, temperature of 104 and
leukocytosis. He looks ill, and “toxic”. His abdomen is tender particularly in the
epigastric area, and he has muscle guarding and rebound. X-Rays show a massively distended transverse
colon, and there is gas within the wall of the colon.
What is it? - Toxic megacolon.
Management: Emergency surgery for
the toxic megacolon, but the case illustrates many other indications for
surgery: chronic malnutrition, “intractability” and risk of developing
cancer. The involved colon has to be
removed, and that always includes the rectum.
G.l.19. – A 27 year man is
recovering from an appendectomy for gangrenous acute appendicitis with
perforation and periappendicular abscess.
He has been receiving Clindamycin and tobramycin for seven days. Eight hours ago he developed watery diarrhea,
crampy abdominal pain fever and leukocytosis.
What is it? - Pseudomembranous colitis from overgrowth of
Clostridium Difficile.
How do you diagnose it? - Eventually with stool cultures, but
proctosigmoidoscopy can show a typical picture before the cultures are
back. Stop the clindamycin, give either
Vancomycin or Metronidazole, and avoid lomotil.
E. Anorectal
Gl.20. – A 60 year old man known
to have hemorrhoids reports bright red blood in the toilet paper after
evacuation.
What is it? - Probably bleeding from internal
hemorrhoids.
Management: It is not reassurance
and hemorrhoid remedies prescribed by telephone. In all these cases, cancer of the rectum has
to be ruled out. The correct answer is
proctosigmoidoscopic examination.
G.l.21. – A 60 year old man known
to have hemorrhoids complains of anal itching and discomfort, particularly
towards the end of the day. He has
perianal pain when sitting down and finds himself sitting sideways to avoid the
discomfort. He is afebrile.
What is it? - External hemorrhoids.
Management: as above: rule out
cancer first!
G.l.22. – A 23 year old lady
describes exquisite pain with defecation and blood streaks on the outside of
the stools. Because of the pain she
avoids having bowel movements and when she finally does, the stools are hard
and even more painful. Physical
examination can not be done, as she refuses to allow anyone to even “spread her
cheeks” to look at the anus for fear of precipitating the pain.
What is it? - A classical description of anal fissure.
Management: Even though the
clinical picture is classical, cancer still has to be ruled out. Examination under anesthesia is the correct
answer. If you are asked what to do
next, the currently favored surgical approach is a lateral internal
sphincterotomy.
G.l.23. – A 28 year old male is
brought to the office by his mother.
Beginning four months ago he has had three operations, done elsewhere,
for a perianal fistula, but after each one the area has not healed, but
actually the surgical wounds have become bigger. He now has multiple unhealing ulcers, fissures
all around the anus, with purulent discharge.
There are no palpable masses.
What is it? - Another classic. The perianal area has fantastic blood supply
and heals beautifully even though feces bathe the wounds. When it does not, you immediately think of
Crohn’s disease.
Management: You still have to
rule out malignancy. A proper
examination with biopsies is needed. The
biopsies should diagnose Crohn’s.
G.l.24. – A 44 year old man shows
up in the E.R. at 11 PM with exquisite perianal pain. He can not sit down, reports that bowel movements
are very painful, and has been having chills and fever. Physical examination shows a hot, tender,
red, fluctuant mass between the anus and the ischial tuberosity.
What is it? - Another very common problem: ischiorectal
abscess.
Management: The treatment for all
abscesses is drainage. This one si no
exception. But as always, cancer has to
be ruled out. Thus the best option would
be an answer that would offer examination under anesthesia and incision and
drainage.
G.l.25. – A 62 year old man complains
of perianal discomfort, and reports that there are streaks of fecal soiling in
his underwear. Four months ago he had a
perirectal abscess drained surgically.
Physical exam shows a perianal opening in the skin, and a cord-liked
tract can be palpated going from the opening towards the inside of the anal
canal. Browninsh purulent discharge can
be expressed from the tract.
What is it? - A pretty good description of a fistula in
ano.
Management: First rule out cancer
with proctosigmoidoscopy. Then schedule
elective fistulotomy.
G.l.26. – A 55-year old, HIV
positive man, has a fungating mass growing out of the anus, and rock hard,
enlarged lymph nodes on both groins. He
has lost a lot of weight, and looks emaciated and ill.
What is it? - Squamous cell carcinoma of the anus.
How to diagnose it? - Biopsies of the fungating mass.
Eventual treatment: Nigro
protocol of pre-operative chemotherapy and radiation.
F. GI Bleeding
G.l.27. – A 33 year old man
vomits a large amount of bright red blood.
What is it? - Pretty skimpy vignette, but you can already
define the territory where the bleeding is taking place: from the tip of the
nose to the ligament of Treitz.
How is the diagnosis made?: for
all upper G.I. bleeding, start with endoscopy.
G.l.28. – A 33 year old man has
had three large bowel movements that he describes as made up entirely of dark
red blood. The last one was 20 minutes
ago. He is diaphoretic, pale, has a blood
pressure of 90 over 70 and a pulse rate of 110.
The point of the vignette is that
something needs to be done to define the area from which he is bleeding. With the available information it could be
from anywhere in the G.I. tract. The first
diagnostic move here is to place a nasogastric tube.
G.l.29. – A 33 year old man has
had three large bowel movements that he describes as made up entirely of dark
red blood. The last one was 20 minutes
ago. He is daphoretic, pale, has a blood
pressure of 90 over 70 and a pulse rate of 110.
A nasogastric tube returns copius amounts of bright red blood.
What is it? - Same as if he had been vomiting blood.
G.l.30. – A 33 year old man has
had three large bowel movements that he describes as made up entirely of dark
red blood. The last one was 20 minutes
ago. He is diaphoretic, pale, has a
blood pressure of 90 over 70 and a pulse rate of 110. A nasogastric tube returns clear, green fluid
without blood.
What is it? - If the NG tube had returned blood, the
boundaries would have been tip of the nose to ligament of Treitz. Clear fluid, without pile, would have
exonerated the area down to the pylorus, and if there is bile in the aspirate,
down to the ligament of Treitz…provided you are sure that the patient is
bleeding now. That’s the case
here. So, he is bleeding from somewhere distal
to the ligament of Treitz. Further
definition of the actual site is no longer within reach of upper endoscopy, and
lower endoscopy is notoriously difficult and unrewarding in massive bleeding. If he is bleeding at more than 2 cc. per
minute, emergency angiogram is the way to go.
G.l.31. – A 72 year old man had
three large bowel movements that he describes as made up entirely of dark red
blood. The last one was two days
ago. He is pale, but has normal vital
signs. A nasogastric tube returns clear,
green fluid without blood.
What is it? - The clear aspirate is meaningless because
he is not bleeding right now. So the
guilty territory can be anywhere from the tip of the nose to the anal canal. Across the board, ¾ of all GI bleeding is
upper, and virtually all the causes of lower GI bleeding are diseases of the
old: diverticulosis, polyps, cancer and angiodysplasias. So, is old, the overall preponderance of
upper is balanced by the concentration of lower causes in old people…so it
could be anywhere.
How is the diagnosis made? - Angiography is not the first choice
for slow bleeding or bleeding that has stopped.
The first choice now is endoscopies, both upper and lower.
G.l.32. – A 7 year old boy passes
a large bloody bowel movement.
What is it? - In this age group, Meckel’s diverticulum
leads the list.
How is the diagnosis made? - By radioactively labeled technetium scan
(not the one that tags reds cells, but the one that identifies gastric mucosa).
G.l.33. – A 41 year old man has
been in the intensive care unit for two weeks, being treated for idiopathic
hemorrhagic pancreatitis. He has had
several percutaneous drainage procedures for pancreatic abscesses, chest tubes
for pleural effusions, and bronchoscopies for atelectasis. He has been in and out of septic shock and
respiratory failure several times. Ten
minutes ago he vomited a large amount of bright red blood, and as you approach
him he vomits again what looks like another pint of blood.
What is it? - In this setting, it has to be stress ulcer.
Management: It should have been
prevented by keeping the pH of the stomach above 4 with H2 blockers, antiacids
or both; but once the bleeding takes place the diagnosis is made as usual with
endoscopy. Treatment will be difficult,
and it may require angiographic embolization of the left gastric artery.
G. Acute Abdomen
G.l.34. – A 59 year old man
arrives in the E.R. at 2 AM, accompanied by his wife who is wearing curlers on
her hair and a robe over her nightgown.
He has abdominal pain that began about one hour ago, and is now
generalized, constant and extremely severe.
He lies motionless in the stretcher, is diaphoretic and has shallow,
rapid breathing. His abdomen is rigid, very
tender to deep palpation, and has guarding and rebound tenderness in all quadrants.
What is it? - Sort
of a generic picture of acute abdomen.
The time and circumstances attest to the severity and rapid onset of the
problem. The physical findings are
impressive. He has generalized acute
peritonitis.
Management: The acute abdomen does not need a precise
diagnosis to proceed with surgical exploration.
Lower lobe pneumonia and myocardial infarction to have to be ruled out
with chest X-Ray and EKG, and it would be nice to have a normal amylase…but the
best answer for this vignette should be prompt emergency exploratory
laparotomy.
G.l.35. – A 62 year old man with
cirrhosis of the liver and ascitis, presents with generalized abdominal pain
that started 12 hours ago. He now has
moderate tenderness over the entire abdomen, with some guarding and equivocal
rebound. He has mild fever and
leukocytosis.
What is it? - Peritonitis in the cirrhotic with ascitis,
or the child with nephrosis and ascitis, could be primary peritonitis – which
does not need surgery – rather than the garden-variety acute peritonitis
secondary to an intraabdominal catastrophe that requires emergency operation.
How is the diagnosis made? - Cultures of the ascitic fluid will yield a
single organism.
Treatment will be with the
appropriate antibiotics.
G.l.36. – A 43 year old man
develops excruciating abdominal pain at 8:18 PM. When seen in the E.R. at 8:50 PM, he has a
rigid abdomen, lies motionless in the examining table, has no bowel sounds and
is obviously in great pain, which he describes as constant. X-Ray shows free air under the diaphragms.
What is it? - Acute abdomen plus perforated viscus equals
perforated duodenal ulcer in most cases.
Although I am exaggerating the “sudden onset” by giving the exact
minute, vignettes of perforated peptic ulcer will have a pretty sharp time of
onset.
What needs to be done? - Emergency exploratory laparotomy.
G.l.37. – A 44 year old alcoholic
male presents with severe epigastric pain that began shortly after a heavy bout
of alcoholic intake, and reached maximum intensity over a period of two
hours. The pain is constant, radiates
straight through to the back and is accompanied by nausea, vomiting and
retching. He had a similar episode two
years ago, for which he required hospitalization.
What is it? - Acute pancreatitis.
How is it diagnosed? - Serum and urinary amylase and lipase
determinations. CT scan if the diagnosis
is unclear, or in a day or two if there is no improvement.
Management: NPO, NG suction, IV
fluids.
G.l.38. – A 43 year old obese
lady, mother of six children, has severe right upper quadrant abdominal pain
that began six hours ago. The pain was
colicky at first, radiated to the right shoulder and around towards the back,
and was accompanied by nausea and vomiting.
For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle
guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of
16,000. She has had similar episodes of
pain in the past, brought about by ingestion of fatty food, but they all had
been of brief duration and relented spontaneously or with anticholinergic
medications.
What is it? - Acute cholecystitis.
How is the diagnosis made? - Sonogram should be the first choice. If equivocal, an “HIDA” scan (radionuclide
excretion scan).
Medical management in most cases
will “cool down” the process. Surgery
will follow.
G.l.39. – A 52 year old man has
right flank colicky pain of sudden onset, that radiates to the inner thigh and
scrotum. There is microscopic hematuria.
What is it? - Ureteral colic ( included here for
differential diagnosis).
How is the diagnosis made? - Urological evaluation always begins with a
plain film of the abdomen (a “KUB”).
Nowadays sonogram often is the next step, but traditionally it has been
intravenous pyelogram (IVP).
G.l.40. – A 59 year old lady has
a history of three prior episodes of left lower quadrant abdominal pain for
which she was briefly hospitalized and treated with antibiotics. Now she has left lower quadrant pain, tenderness,
and a vaguely palpable mass. She has
fever and leukocytosis.
What is it? - Acute diverticulitis.
How is the diagnosis made? - CT scan.
Treatment is medical for the
acute attack (antibiotics, NPO) but elective sigmoid resection is advisable for
recurrent disease (like this lady is having).
Emergency surgery (resection or colostomy) may be needed if she gets
worse or does not respond to treatment.
G.l.41. – An 82 year old man
develops severe abdominal distension, nausea, vomiting and colicky abdominal
pain. He has not passes any gas or stool
for the past 12 hours. He has a
tympanitic abdomen with hyperactive bowel sounds. X-Ray shows distended loops of small and
large bowel, and a very large gas shadow that is located in the right upper
quadrant and tapers towards the left lower quadrant with the shape of a
parrot’s beak.
What is it? - Volvulus of the sigmoid.
Management: Proctosigmoidoscopy
should relieve the obstruction. Rectal
tube is another option. Eventually
surgery to prevent recurrences could be considered.
G.l.42. – A 79 year old man with
atrial fibrillation develops and acute abdomen.
He has a silent abdomen, with diffuse tenderness and mild rebound. There is a trace of blood in the rectal
exam. He has acidosis and looks quite
sick. X-Rays show distended small bowel
and distended colon up to the middle of the transverse colon.
What is it? - Acute abdomen in the elderly who has atrial
fibrillation, brings to mind embolic occlusion of the mesenteric vessels. Acidosis frequently ensues, and blood in the
stool is often seen. unfortunately not
much can be done, as the bowel is usually dead.
G.l.43. – A 53 year old man with
cirrhosis of the liver develops malaise, vague right upper quadrant abdominal
discomfort and 20 pound weight loss.
Physical exam shows a palpable mass that seems to arise from the left
lobe of the liver. Alpha feto protein is
significantly elevated.
What is it? - Probably liver cell carcinoma (hepatoma)
Next move? - CT scan.
If confined to one lobe, resection.
G.l.44. – A 53 year old man
develops vague right upper quadrant abdominal discomfort and a 20 pound weight
loss. Physical exam shows a palpable
liver with nodularity. Two years ago he
had a right hemicolectomy for cancer of the ascending colon. His carcinoembryogenic antigen (CEA) had been
within normal limits right after his hemicolectomy, is now ten times normal.
What is it? - Metastasis to the liver from colon cancer.
Next move? – CT scan to ascertain
extent. If mets are confined to one
lobe, resection may be done. Otherwise,
chemotherapy if he has not had it.
G.l.45. – A 24 year old lady
develops moderate, generalized abdominal pain of sudden onset, and shortly
thereafter faints. At the time of
evaluation in the ER he is pale, tachycardic, and hypotensive. The abdomen is mildly distended and tender,
and she has a hemogoblin of 7. There is
no history of trauma. On inquiring as to
whether she might be pregnant, she denies the possibility because she has been
on birth control pills since she was 14, and has never misses taking them.
What is it? - Bleeding from a ruptured hepatic adenoma,
secondary to birth control pills.
Management: It’s pretty clear
that she is bleeding into the belly, but
a CAT scan will confirm it and probably show the liver adenoma as
well. Surgery will follow.
G.l.46. – A 44 year old lady is
recovering from an episode of acute ascending cholangitis secondary to
choledocholithiasis. She develops fever
and leukocytosis and some tenderness in the right upper quadrant. A sonogram reveals a liver abscess.
Not much of a diagnostic
challenge here, but the issue is management, and it is included to contrast it
with the handling of the patient in the next vignette. This is a pyogenic abscess, it needs to be
drained (the radiologists will do it percutaneously).
G.l.47. – A 29 year old migrant
worker from Mexico develops fever and leukocytosis, as well as tenderness over
the liver when the area is percussed. He
has mild jaundice and an elevated alkaline phosphatase. Sonogram of the right upper abdominal area
shows a normal biliary tree, and an abscess in the liver.
What is it? - This one is an amebic abscess…very common
in Mexico.
Management: Alone among
abscesses, this one in most cases does not have to be drained, but can be
effectively treated with Metranidazole.
Get serology for amebic titers, but don’t wait for the report (it will
take 3 weeks). Start the patient on
Metranidazole. Prompt improvement will
tell you that you are on the right tract.
When the serologies come back the patient will be well and your
diagnosis will be confirmed. Don’t fall
for an option that suggests aspirating the pus and sending it for culture, you
can not grow the ameba from the pus.
H. Jaundice
G.l.48. – A 42 year old lady is
jaundiced. She has a total bilirubin of
6 and the laboratory reports that the
unconjugated, indirect bilirubin is 6 and the direct, conjugated bilirubin is
zero. She has no bile in the urine.
What is it? - The vignette in the exam will be adorned
with other evidence of hemolysis, but you do not need it to make the
diagnosis. This is hemolytic jaundice.
What do you do next? - Try to figure out what is chewing her red
cells.
G.l.49. – A 19 year old college
student returns from a trip to Cancun, and two weeks later develops malaise,
weakness and anorexia. A week later he
notices jaundice. When he presents for
evaluation his total bilirubin is 12, with 7 indirect and 5 direct. His alkaline phosphatase is mildly elevated,
while the SGOT and SGPT (transaminases) are very high.
What is it? - Hepatocellular jaundice.
Management: Get serologies to
confirm diagnosis and type of hepatitis.
G.l.50. – A patient with
progressive jaundice which has been present for four weeks is found to have a
total bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated
SGOT. The alkaline phosphatase was twice
normal value couple of weeks ago, and now is about six times the upper limit of
normal.
What is it? - A “generic” example of obstructive
jaundice.
Next move? - Sonogram, looking for dilated intrahepatic
ducts, possibly dilated extrahepatic ducts as well, and if we get lucky a
finding of gallstones.
G.l.51.- A 40 year old, obese
mother of five children presents with progressive jaundice which she first
noticed four weeks ago. She has a total
bilirubin of 22, with 16 direct and 6 indirect, and minimally elevated
SGOT. The alkaline phosphatase is about
six times the upper limit of normal. She
gives a history of multiple episodes of colicky right upper quadrant abdominal
pain, brought about by ingestion of fatty food.
What is it? - Again obstructive jaundice, with a good
chance of being due to stones.
What do you do next? - Start with the sonogram. If you need more tests after that, ERCP is
the next move, which could also be used to remove the stones from the common
duct.
Cholecystectomy will eventually
have to be done.
G.l.52. – A 66 year old man
presents with progressive jaundice which he first noticed six week ago. He has a total bilirubin of 22, with 16
direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times
the upper limit of normal. He has lost
10 pounds over the past two months, but is otherwise asymptomatic. A sonogram shows dilated intrahepatic ducts,
dilated extrahepatic ducts and av ery distended, thin walled gallbladder.
What is it? - Malignant obstructive jaundice. “Silent” obstructive jaundice is more likely
to be due to tumor. A distended
gallbladder is an ominous sign: when stones are the source of the problem, the
gallbladder is thick-walled, non-pliable.
What do you do next? - You already have the sonogram. Next move is CAT scan and ERCP.
G.l.53. – A 66 year old man
presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16
direct and 6 indirect, and minimally elevated SGOT. The alkaline phosphatase is about six times
the upper limit of normal. He is
otherwise asymptomatic. A sonogram shows
dilated intrahepatic ducts, dilated extrahepatic ducts and a very distended,
thin walled gallbladder. Except for the
dilated ducts, CT scan is unremarkable.
ERCP shows a narrow area in the distal common duct, and a normal pancreatic
duct.
What is it? - Malignant, but lucky: probably
cholangiocarcinoma at the lower end of the common duct. He could be cured with a
pancreatoduodenectomy (Whipple operation).
Next move: get brushings of the
common duct for cytological diagnosis.
G.l.54. – A 64 year old lady
presents with progressive jaundice which she first noticed two weeks ago. She has a total bilirubin of 12, with 8
direct and 4 indirect, and minimally elevated SGOT. The alkaline phosphatase is about ten times
the upper limit of normal. She is
otherwise asymptomatic, but is found to be slightly anemic and to have positive
occult blood in the stool. A sonogram
shows dilated intrahepatic ducts, dilated extrahepatic ducts and very distended, thin walled gallbladder.
What is it? - Again malignant, but also lucky. The coincidence of slowly bleeding into the
GI tract at the same time that she develops obstructive jaundice points to an
ampullary carcinoma, another malignancy that can be cured with radical surgery.
Next move: Endoscopy.
G.l.55. – A 56 year old man
presents with progressive jaundice which he first noticed six weeks ago. He has a total bilirubin of 22, with 16
direct and 6 indirect, and minimally elevated SGOT. He alkaline phosphatase is about eight times
the upper limit of normal. He has lost
20 pounds over the past two months, and has a persistent, nagging mild pain
deep into his epigastrium and in the upper back. His sister died at age 44 from a cancer of
the pancreas. A sonogram shows dilated
intrahepatic ducts, dilated extrahepatic ducts and a very distended, thin
walled gallbladder.
What is it? - Bad news.
Cancer of the had of the pancreas. Terrible prognosis.
How do clinch the diagnosis?: CAT
scan –which may show the mass in the head of the pancreas; then ERCP –which
will probably show obstruction of both common duct and pancreatic duct.
I. Biliary Tract
G.l.56. – A white, fat, female,
aged 40 and mother of five children gives a history of repeated episodes of
right upper quadrant abdominal pain brought about by the ingestion of fatty
foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right
shoulder and around to the back, and is accompanied by nausea and occasional
vomiting. Physical exam is unremarkable.
What is it? - Gallstones, with biliary colic.
Next move: Sonogram. Elective cholecystectomy will follow.
G.l.57. – A 43 year old obese
lady, mother of six children, has severe right upper quadrant abdominal pain
that began six hours ago. The pain was
colicky at first, radiated to the right shoulder and around towards the back,
and was accompanied by nausea and vomiting.
For the past 2 hours the pain has been constant. She has tenderness to deep palpation, muscle
guarding and rebound in the right upper quadrant. Her temperature is 101 and she has a WBC of 16,000. She has had similar episodes of pain in the
past, brought by ingestion of fatty food, but they all had been of brief
duration and relented spontaneously or with anticholinergic medications.
What is it? - If you are alert, you will recognize the picture
of acute cholecystitis…in fact this is vignette No. G.l.38, that had been
presented in the acute abdomen section.
It is repeated here to contrast it with the next one.
G.l.58. – A 43 year old obese
lady, mother of six children, has severe right upper quadrant abdominal pain
that began three days ago. The pain was
colicky at first, but has been constant for the past two and a half days. She has tenderness to deep palpation, muscle
guarding and rebound in the right upper quadrant. She has temperature spikes to 104 and 105,
with chills. Her WBC is 22, 000, with a
shift to the left. Her bilirubin is 5
and she has an alkaline phosphatase of 2,000 (about 20 times normal). She has had episodes of colicky pain in the
past, brought about by ingestion of fatty food, but they all had been of brief
duration and relented spontaneously or with anticholinergic medications.
What is it? - Acute ascending cholangitis.
Further test?: The diagnosis is
already clear. Sonogram might confirm
dilated ducts.
Management: This is an emergency
decompression of the biliary tract. To
achieve the latter ERCP is the first choice, but PTC (percutaneous transhepatic
cholangiogram) is another option.
G.l.59. – A white, fat, female,
aged 40 and mother of five children gives a history of repeated episodes of
right upper quadrant abdominal pain brougth about by the ingestions of fatty
foods, and relieved by the administration of anticholinergic medications. The pain is colicky, radiates to the right
shoulder and around to the back, and is accompanied by nausea and occasional
vomiting. This time she had a shaking
chill with the colicky pain, and the pain lasted longer than usual. She has mild tenderness to palpation in the
epigastrium and right upper quadrant.
Laboratory determinations show a bilirubin of 3.5, an alkaline
phosphatase 5 times normal and a serum amylase 3 times normal value.
What is it? - She passed a common duct stone and had a
transient episode of cholangitis (the shaking chill, the high phosphatase) and
a bit of biliary pancreatitis (the high amylase).
What does she need?: As in many
of these cases, start with sonogram. It
will confirm the diagnosis of gallstones.
If she continues to get well, elective cholecystectomy will follow. If she deteriorates, she may have the sone
still impacted at the Ampulla of Vater, and may need ERCP and sphincterotomy to
extract it.
J. Pancreas
G.l.60. – A 33 year old,
alcoholic male, shows up in the E.R. with epigastric and mid-abdominal pain
that began 12 hours ago shortly after the ingestion of a large meal. The pain is constant, very severe, and it
radiates straight through to the back.
He vomited twice early on, but since then has continued to have
retching. He has tenderness and some
muscle guarding in the upper abdomen, is afebrile and has mild
tachycardia. Serum amylase is 1200, and
his hematocrit is 52.
What is it? – Acute edematous
pancreatitis.
Management: put the pancreas at
rest: NPO, NG sution, IV fluids.
G.l.61. – A 56 year old alcoholic
male is admitted with a clinical picture of acute upper abdominal pain. The pain is constant, radiates straight
thorugh to the back, and is extremely severe.
He has a serum amylase of 800, WBC of 18,000 blood glucose of 150, serum
calcium of 6.5 and a hematocrit of 40. He is given IV fluids and kept NPO with NG
sution. By the next morning, his
hematocrit has dropped to 30 the serum calcium has remained below 7 in spite of
calcium administration, his BUN has gone up to 32 and he has developed
metabolic acidosis and a low arterial PO2.
What is it? – He has hemorrhagic
pancreatitis. In fact, he is in deep
trouble, with at least eight of Ranson’s criteria predicting 80 to 100%
mortality.
What do you do? Very intensive support will be needed, but
the common pathway to death from complication of hemorrhagic pancreatitis
frequently is by way of pancreatic abscesses that need to be drained as soon as
they appear. Thus serial CT scans will
be required.
G.l.62. – A 57 year old alcoholic
male is being treated for acute hemorrhagic pancreatis. He was in the intensive care unit fore one
week, required chest tubes for pleural effusion, and was on a respirator for
several days, but eventually improved enough to be transferred to the floor. Two weeks after the onset of the disease he
begins to spike fever and to demonstrate leukocytosis.
What is it? - Pancreatic abscess.
How do we confirm it? - CT scan.
What does he need? - Drainage.
G.l.63. – A 49 year old alcoholic
male presents with ill-defined upper abdominal discomfort and early
satiety. On physical exam he has a large
epigastric mass that is deep within the abdomen, and actually hard to
define. He was discharged from the
hospital 5 weeks ago, after successful treatment for acute pancreatitis.
What is it? - Pancreatic pseudocyst.
Management: You could diagnose it
on the cheap with a sonogram, but CT scan is probably the best choice. It will need to be drained, and the
radiologist will do it with CT guidance.
An older option was to operate and anastomose the pseudocyst to the GI
tract.
G.l.64. – A 55 year old lady
presents with vague upper abdominal discomfort, early satiety and a large but
ill-defined epigastric mass. Five weeks
ago she was involved in an automobile accident where she hit the upper abdomen
against the steering wheel.
What is it? - Again pancreatic pseudocyst, in this case
secondary to trauma rather than as a sequela of pancreatitis.
Management is the same as in the
previous case.
G.l.65. – A disheveled,
malnourished individual shows up in the emergency room requesting medication
for pain. He smells of alcohol and
complains bitterly of constant epigastric pain, radiating straight through to
the back that he says he has had for several years. He has diabetes, steatorrhea and
calcifications in the upper abdomen in a plain X-Ray.
What is it? - Chronic pancreatitis.
I hope they ask you to recognize
this vignette, but not to manage it.
There is precious little that can be done for these unfortunate
individuals. Stopping the alcoholic
intake is the first step (easier said than done). Replacement of pancreatic enzymes and control
of the diabetes are obvious needs, but the pain is most difficult to
eradicate. Various operations can be
done and those would be guided by the anatomy of the pancreatic ducts, thus if
forced to go further diagnostic test, pick ERCP.
K. Miscellaneous
G.l.67. – On the first
post-operative day after an open cholecystectomy, a patient has a temperature
of 101.
What is it? - Atelectasis.
Management: Listen to the chest,
chest X-Ray, encourage deep breathing and coughing.
G.l.68. – On the third
post-operative day after an open cholecystectomy, a patient develops a
temperature of 101.
What is it? - Urinary tract infection.
Management: Urinalysis, Urinary
culture, appropriate antibiotics.
G.l.69. – On the fourth
post-operative day after an open cholecystectomy, a patient develops a
temperature of 101. There is tenderness
to deep palpation in the calf, particularly when the foot is dorsiflexed.
What is it? - Deep venous thrombosis.
Management: Duplex ultrasound
(Doppler flow plus real time B-mode) to confirm diagnosis. Anticagulation to prevent thrombus
propagation.
G.l.70. – Seven days after an
inguinal hernia repair, a patient returns to the clinic because of fever. The wound is red, hot and tender.
What is it? - Wound infection.
Management: Open the wound, drain
the pus, pack it open.
G.l.71. – Two weeks after an open
cholecystectomy a patient develops fever and leukocytosis. The wound is healing well and does not appear
to be infected.
What is it? - A deep abscess. Two locations are prime suspects: subphrenic
or subhepatic. Had the operation been an
appendectomy, pelvic abscess would be the first pick.
Management: CT scan to find the
abscess and to guide the radiologist for the percutaneous drainage.
G.l.72. – On the fifth
post-operative day after a right hemicolectomy for cancer, the dressings
covering the midline abdominal incision are fund to be soaked with a clear,
pinkish, salmon-colored fluid.
What is it? - Wound dehiscence.
Management: Keep the patient in
bed, tape his belly together and schedule surgery for re-closure of the wound
if the patient can take the re-operation.
If too sick, the development of a ventral incisional hernia may have to
be accepted now and repaired later. On
the other hand, if following the discover of the copious, salmon colored,
pinkish clear fluid, the patient gets out of bed, or sneezes forcefully, you
may be confronted with a bucket-full of small bowel. Evisceration has taken place. In that case, keep the bowel covered and
moist with sterile dressings, and rush the patient to the OR for
re-closure.
6. ENDOCRINE
EN.1. – A 62 year old lady was
drinking her morning cup of coffee at the same time she was applying her makeup,
and she noticed in the mirror that there was a lump in the lower part of her
neck, visible when she swallowed. She
consult you for this and on physical exam you ascertain that she indeed has a
dominant, 2 cm. mass on the left lobe of her thyroid as well as two smaller
masses on the right lobe. They are all
soft and she has no palpable lymph nodes in the neck.
Management: Most thyroid nodules
are benign, and surgical removal to ascertain the diagnosis is a big
operation…thus surgery has to be reserved for selected cases. Worrisome features include: young, male,
single nodule, history of radiation to the neck, solid mass on sonogram and
cold nodule on scan. In center with
sufficient experience, the last tow tests are omitted in preference for fine
needle aspiration and cytology. This
case does not sound malignant, but you can not be sure. If given the option among the answers, go for
the FNA.
EN.2. – A 21 year old college
student is found on a routine physical examination to have a singe, 2 cm.
nodule in the thyroid gland. The young
man had radiation to his head and neck when he was thirteen years old because
of persistent acne. His thyroid function
tests are normal.
Management: This one will need
surgery, but if offered FNA is still your first answer.
EN.3. – A 44 year old lady has a
palpable mass in her thyroid gland. She
also describes losing weight in spite of a ravenous appetite, palpitations and
heat intolerance. She is a thin lady,
fidgety and constantly moving, with moist skin and a pulse rate of 105.
What is it? – A “hot” adenoma.
Management: confirm
hyperthyroidism by measuring free T4.
Confirm source of the excessive hormone with radioactive iodine
scan. Do surgery after Beta blocking.
EN.4. – A 22 year old male has a
2 cm. round firm mass in the lateral aspect of his neck, which has been present
for four months. Clinically this is
assumed to be an enlarged jugular lymph node and it is eventually removed
surgically. The pathologist reports that
the tissue removed is normal thyroid tissue.
What is it? - There is no such thing as “lateral aberrant
thyroid”. This is metastatic follicular
carcinoma from an occult primary in the thyroid gland.
Management: Look for the primary
with a thyroid scan. Eventually surgery.
EN.5. – An automated blood
chemistry panel done during the course of a routine medical examination
indicates that an asymptomatic patient has a serum calcium of 12.1 in a lab
where the upper limit of normal is 9.5.
Repeated determinations are consistently between 10.5 and 12.6. Serum phosphorus is low.
What is it? - Parathyroid adenoma.
How is the diagnosis made? - Had this question been written 20 years
ago, the vignette would have described a patient with a disease of “stones and
bones and abdominal groans”, and you would have cleverly asked for a serum
calcium as your first test. Nowadays
most parathyroid adenomas are identified when they are still asymptomatic,
because of the widespread use of automated blood chemistry panels. Across the board most cases of hypercalcemia
are due to metastatic cancer, but that would not be the case on asymptomatic
people. Your next move here is PTH
determination and sistimibi scan to localize the adenoma. Surgery will follow.
EN.6. – A 32 year old woman is
admitted to the psychiatry unit because of wild mood swings. She is found to be hypertensive and diabetic
and to have osteoporosis. (she had not
been aware of such diagnosis beforehand).
It is also ascertained that she has been amenorrheic and shaving for the
past couple of years. She has gross
centripetal obesity, with moon fascies and Buffalo hump, and thin, bruised
extremities. A picture from 3 years ago
shows a person of very different, more normal appearance.
What is it? - Cushings.
The appearance is so typical, that you will probably be given a
photograph on the test, with an accompanying brief vignette. The presenting symptom may be any one of
those listed.
How is the diagnosis made? - Start with AM and PM cortisol
determinations. Later she will get
dexamethasone suppression tests and MRI) of the head looking for the pituitary
microadenoma, which will eventually be removed by the trans-nasal,
trans-sphenoidal route.
EN.7. – A 28 year old lady has
virulent peptic ulcer disease. Extensive
medical management including eradication of H.Pylori fails to heal her
ulcers. She has several duodenal ulcers
in the first and second portions of the duodenum. She has watery diarrhea.
What is it? - Gastrinoma (Zollinger-Ellison).
How is the diagnosis made? - Start by measuring serum gastrin. Later CT scans (or MRI) of the pancreas
looking for the tumor, and surgery to remove it.
EN.8. – A second year medical
student is hospitalized for a neurological work-up for a seizure disorder of
recent onset. During one of his convulsions
it is determined that his blood sugar is extremely low. Further work-up shows that he has high levels
of insulin in the blood with low levels of C-peptide.
What is it? - Exogenous administration of insulin. If the C-peptide had been high along with the
insulin level, the diagnosis would have been insulinoma.
Management: In this case,
psychiatric evaluation and counseling (He is faking the disease to avoid taking
the USMLE). If it had been insulinoma,
CT scan or MRI looking for the tumor in the pancreas, to be subsequently
removed surgically.
EN.9. – A 48 year old lady has
had severe, migratory necrolytic dermatitis for several years, unresponsive to
all kinds of “herbs and unguents”. She
is thin, has mild stomatitis and mild diabetes mellitus.
What is it? - Glucagonoma.
How is the diagnosis made? - Determine glucagon levels. Eventually CT scan or MRI looking for the
tumor in the pancreas. Surgery will follow. If inoperable, somatostatin can help
symptomatically and streptozocin is the indicated chemotherapeutic agent.
7. SURGICAL
HYPERTENSION
HT.1. – A 45 year old lady comes
to your office for a “regular checkup”.
On repeated determinations you confirm the fact that she is
hypertensive. When she was in your
office three years ago, her blood pressure was normal. Laboratory studies at this time show a serum
sodium of 144 mEq/L, a serum bicarbonate of 28 mEq/L, and a serum potassium
concentration of 2.1 mEq/L. The lady is
taking no medications of any kind.
What is it? - Hyperaldosteronism. Possibly adenoma.
How is the diagnosis made? - Start with determinations of aldosterone
and renin levels. If confirmatory (aldo
high, renin low) proceed with determinations lying down and sitting up, to
differentiate hyperplasia (not surgical) from adenoma (surgical). Treat the first with aldactone. Pursue the second with imaging studies (CT
scan or MRI) and surgery.
ET. 2. – A thin, hyperactive 38
year old lady is frustrated by the inability of her physicians to help
her. She has episodes of severe pounding
headache, with palpitations, profuse perspiration and pallor, but by the time
she gets to her doctor’s office she checks out normal in every respect.
What is it? – Suspect
pheochromocytoma.
How to diagnose it? - Start with 24 hr. urinary determination of metanephrine and VMA
(Vanillylmandelic acid). Follow with CT
scan of adrenal glands. Surgery will
eventually be done, with careful pharmacological preparation with
alpha-blockers.
HT.3. – A 17 year old man is
found t have a blood pressure of 190/115.
This is checked repeatedly in both arms and it is always found to be
elevated, but when checked in the legs it is found to be normal.
What is it? - Coarctation of the aorta.
Further testing; start with a
chest X-Ray, looking for scalloping of the ribs. Eventually aortogram and ultimately surgery.
HT.4. – A 23 year old lady has
had severe hypertension for two years, and she does not respond well to the
usual medical treatment for that condition.
A bruit can be faintly heard over her upper abdomen.
What is it? - Renovascular hypertension due to
fibromuscular dysplasia.
Management: I hope they only ask
you to identify this one in an extended matching set. How to proceed with the diagnosis is a can of
worms. There are a million tests, mostly
invasive and expensive, and none with clear-cut reliability. Eventually arteriogram will precede surgical
correction (or balloon dilatation).
HT.5. – A 72 year old man with
multiple manifestations of arteriosclerotic occlusive disease has hypertensin
of relatively recent onset, and refractory to the usual medical therapy. He has a fain bruit over the upper abdomen.
What is it? - Renovascular hypertension due to
arteriosclerotic plaque at the origin of the renal artery…or arteries (this is
usually bilateral). I hope you are not
asked to manage it. To the problems
outline above, add the difficult, equation of guessing which manifestation of
his arteriosclerotic disease is going to kill him first.
8. PEDIATRIC
SURGERY
A. At Birth – First 24 Hours
PD.1. – Within eight hours after
birth, it is noted that a baby has excessive salivation. A small, soft nasogastric tube is inserted
and the baby is taken to X-Ray to have a “babygram” done. The film shows the tube coiled back upon
itself in the upper chest. There is air
in the gastrointestinal tract.
What is it? – Tracheo-esophageal
fistula, the most common type with proximal blind esophageal pouch and distal
TE fistula.
Management: first, rule out the
associated anomalies (“VACTER”: vertebral, anal, cardiac, TE and
renal/radial). The vertebral and radial
will be seen in the same X-ray you already took, you need echo for the heart,
sonogram for the kidneys and physical exam for the anus. Then off to surgery.
PD.2. – A newborn baby is found
on physical exam to have an imperforate anus.
Management: This is part of the
“VACTER” group, so look for the others as mentioned above. For the imperforate anus, look for a fistula
nearby (to the vagina in little girls, to the perineum in little boys), which will
help determine the level of the blind pouch and the timing and type of surgery
(primary repair versus colostomy and repair later).
PD.3. – A newborn baby is noted
to be tachypneis, cyanotic and grunting.
The abdomen is scaphoid and there are bowel sounds heard over the left
chest. An X-Ray confirms that there is
bowel in the left thorax. Shortly
thereafter, the baby develops significant hypoxia and acidosis.
What is it? - Congenital diaphragmatic hernia.
Management: The main problem is
the hypoplastic lung. It is better to
wait 36 to 48 hours to do surgery to allow transition from fetal circulation to
newborn circulation. Meanwhile the trick
is to keep the kid alive with endotracheal intubation, hyperventilation
(careful not to blow up the other lung), sedation and NG suction.
PD.4. – At the time of birth it
is noted that a child has a large abdominal wall defect to the right of the
umbilicus. There is a normal cord, but
protruding from the defect there is a matted mass of angry looking, edematous
bowel loops.
What is it? - Gastroschisis.
Medial school professors love to
emphasize differential diagnosis of somewhat similar problems. The issue with abdominal wall defects, is
which one is the gastroschisis and which one is the omphalocele. Chances are all you’ll be expected t do is to
identify the correct one. Management is
intuitive: you got to get those chitlins back into the belly, and the technical
detail are best left to the pediatric surgeons.
They will be on the look-out for atresias, which these babies can have,
and they may need to use a silicon “silo” to gradually close the abdominal wall
defect.
PD.5. – A newborn baby is noted
to have a shiny, thin, membranous sac at the base of the umbilical cord. Inside the sac one can see part of the liver,
and loops of normal looking bowel.
What is it? - This one is the omphalocele.
Management: These kids can have a
host of other congenital defects. After
those are looked for, repair is as noted above.
PD.6. – A newborn is noted to
have a moist medallion of mucosae occupying the lower abdominal wall, above the
pubis and below the umbilicus. It is
clear that urine is constantly bathing this congential anomaly.
What is it? - Exstrophy of the urinary bladder.
What’s the point of the vignette? - These are very rare anomalies that only
very highly specialized centers can
repair. The problem is that unless the
repair is within the first 48 hours, it will not have a good chance to
succeed. It takes time to arrange for
transfer of a newborn baby to a distant city.
If a day or two are wasted before arrangements are made, it will be too
late.
PD.7. – Half an hour after the
first feed, a baby vomits greenish fluid.
The mother had polyhydramnius and the baby has Down’s syndrome. X-Ray shows a “double bubble sign”: a large
air fluid level in the stomach, and smaller one in the first portion of the
duodenum. There is no gas in the rest of
the bowel.
What is it? - It can be two things, but first some
general points. Kids vomit, bur and regurgitate
all the time (ask any parent), but the innocent vomit is clear-whitish. Green vomiting in the newborn is bad news. It means something serious. The two conditions that this could be are
duodenal atresia and annular pancreas
Management: with complete
obstruction, emergency surgery will be needed, but these kids have lots of
other congenital anomalies, look for them first.
PD.8. – Half an hour after the
first feed, a baby vomits greenish fluid.
X-Ray shows a double bubble sign”: a large air fluid level in the
stomach, and a smaller one in the first portion of the duodenum. There is air in the distal bowel, beyond the
duodenum, in loops that are not distended.
What is it? - Now you have three choices: it could be incomplete obstruction from duodenal
stenosis or annular pancreas, or it could be malrotation.
Management: If you are dealing
with incomplete obstruction you have time to do what’s needed, i.e. it is a
lesser emergency. But if it is
malrotation the bowel could twist and die, so that one is super-emergency. How can you tell? Do a contrast enema, and if not diagnostic
order a water-soluble 9gastrographin) upper GI study.
PD.9. – A newborn baby has
repeated green vomiting during the first day of life, and does not pass any
meconium. Except for abdominal
distention, the baby is otherwise normal.
X-Ray shows multiple air fluid levels and distended loops of bowel.
What is it? - Intestinal atresia.
Management: This one is due to a
vascular accident in uteru, thus there are no other congenital anomalies to
look for, but there may be multiple points of atresia.
B. A Few Days Out –Within First Month or
Two
PD.10. – A very premature baby
develops feeding intolerance, abdominal distention and a rapidly dropping
platelet count.. The baby is four days old, and was treated with indomethacin
for a paten ductus.
What is it? - Necrotizing enterocolitis.
Management: Stop all feedings,
broad spectrum antibiotics, IV fluids/nutrition. Surgical intervention if they develop
abdominal wall erythema, air in the biliary tree or pneumoperitoneum.
PD.11. – A three day old, full
term baby is brought in because of feeding intolerance and bilious
vomiting. X-Ray shows multiple dilated
loops of small bowel and a “ground glass” appearance in the lower abdomen. The mother has cystic fibrosis.
What is it? - Meconium ileus.
Management: Gastrografin enema my
be both diagnostic and therapeutic, so it is the obvious first choice. If unsuccessful, surgery may be needed. The kid has cystic fibrosis, and management
of the other manifestations of the disease will also be needed.
PD.12. – A three week old baby
has had “trouble feeding” and it is not quite growing well. he now has bilious vomiting and is brought in
for evaluation. X-Ray shows a classical
“double bubble”, along with normal looking gas pattern in the rest of the
bowel.
What is it? - Malrotation. The vignette is repeated here because not all
of them will show up on day one. They
can “twist” at any time later.
You know what to do: contrast
enema to verify the malrotation and emergency surgery.
PD.13. – A 3 week old first-born,
full term baby boy began to vomit three days ago. The vomiting is projectile, has no bile in
it, follows each feeding and the baby is hungry and eager to eat again after he
vomits. He looks somewhat dehydrated and
has visible gastric peristaltic waves and a palpable “olive size” mass in the
right upper quadrant.
What is it? Hypertrophic pyloric stenosis.
Management: Check electrolytes:
hypokalemic, hypochloremic metabolic alkalosis may have developed. Correct it, rehydrate and do Ramsted
Pyloromyotomy.
PD.14. – An 8 week old baby is
brought in because of persistent, progressively increasing jaundice. The bilirubin is significantly elevated and
about two thirds of it is conjugated, direct bilirubin. Ultrasound rules out extrahepatic masses,
serology is negative for hepatitis and sweat test is normal.
What is it? - Biliary atresia.
Management: HIDA scan,
percutaneous liver biopsy and exploratory laparotomy.
PD.15. – A two month old baby boy
is brought in because of chronic constipation.
The kid has abdominal distention, and plain X-Rays show gas in dilated
loops of bowel throughout the abdomen. Rectal exam is followed by expulsion of stool
and flatus, with remarkable improvement of the distention.
What is it? - Hirschsprungs’s disease (aganglionic
megacolon)
How do you diagnose it? - Barium enema will define the normal-looking
aganglionic distal colon and the abnormal-looking thickness biopsy of the
rectal mucosa.
C. Later in Infancy
PD.16. – A 9 month old, chubby, healthy looking little
boy has episodes of colicky abdominal pain that make him double up and
squat. The pain lasts for about one
minute, and the kid looks perfectly happy and normal until he gets another
colick. Physical exam shows a vague mass
on the right side of the abdomen, an “empty” right lower quadrant and currant
jelly stools.
What is it? - Intussusception.
Management: Barium enema is both
diagnostic and therapeutic in most cases.
It should be your first choice.
If reduction is not achieved radiologically, exploratory laparotomy and
manual reduction will be needed.
PD.17. – A one year old baby is
referred to the University Hospital for treatment of a subdural hematoma. In the admission examination it is noted that the baby has retinal hemorrhages.
PD.18. – A three year old girl is
brought in for treatment of a fractured humerus. The mother relates that the girl fell from
her crib. X-Rays show evidence of other
older fractures at various stages of healing in different bones.
PD.19. – A one year old child is
brought in with second degree burns of both buttocks. The stepfather relates that the child fell
into a hot tub.
What are these? - Classical vignettes of child abuse. Notify the proper authorities.
PD.20. – A 7 year old boy passes
a large bloody bowel movement.
What is it? - Meckel’s diverticulum.
Do a radioisotope scan looking
for gastric mucosa in the lower abdomen.
9. OTOLARYNGOLOGY
A. Neck Masses - Congenital
OT.1. – A 15 year old girl has a
round, 1 cm. cystic mass in the midline of her neck at the level of the hyoid
bone. When the mass is palpated at the
same time that the tongue is pulled, there seems to be a connection between the
two. The mass has been present for at
least 10 years, but only recently bothered the patient because it got infected
and drained some pus.
What is it? - Thyroglossal duct cyst.
Management: - Sistrunk operation
(removal of the mass and the track to the base of the tongue, along with the medial
segment of the hyoid bone).
OT.2. – An 18 year old woman has
a 4c., fluctuant round mass on the side of her neck, just beneath and in front
of the sternomastoid. She reports that
is has been there at least 10 years, although she thinks that it has become
somewhat larger in the last year or two.
A CT scan shows the mass to be cystic.
What is it? - A branchial cleft cyst.
Management: Elective surgical
removal.
OT.3. – A 6 year old child has a
mushy, fluid filled mass at the base of the neck, that has been noted for
several years. The mass is about 6 cm.
in diameter, occupies most of the supraclavicular area and seems by physical
exam to go deeper into the neck and chest.
What is it? - Cystic hygroma.
Management: Get a CT scan to see
how deep this thing goes. They can
extend down into the chest and mediastinum.
Surgical removal will eventually be done.
B. Neck Masses – Inflammatory vs.
Neoplastic
OT.4.- A 22 year old lady notices
an enlarged lymph node in her neck. The
node is in the jugular can, measures about 1.5 cm, is not tender, and was
discovered by the patient yesterday. The
rest of the history and physical exam are unremarkable.
What is it? - It’s large lymph node…and that’s all we
know so far. These could be inflammatory
(the vast majority) or neoplastic (the rare ones that need something
done). So, how do we tell?
Management: before you spend a
ton of money doing a million tests, let time be your ally. Schedule the patient
to be rechecked in three weeks. If the
node has gone away by then, it was inflammatory and nothing further is
needed. If it’s still there, it could be
neoplastic and something needs to be done.
Three weeks of delay will not significantly impact the overall course
of a neoplastic process.
OT.5. – A 22 year old lady seeks
help regarding an enlarges lymph node in her neck. The node is in the jugular chain, measures
about 2cm, is firm, not tender, and was discovered by the patient six weeks
ago. There is a history of low grade
fever and night sweats for the past three weeks. Physical examination reveals enlarged lymph
nodes in both axillas and in the left groin.
What is it? - Lymphoma most likely.
Management: Tissue diagnosis will
be needed. You can start with FNA of the
available nodes, but eventual node biopsy will be needed to establish not only
the diagnosis but also the type of lymphoma.
OT.6. – A 72 year old man has 4
cm. hard mass in the left supraclavicular area.
The mass is movable, non tender and has been present for three
months. The patient has had a 20 pound
weight loss in the past two months, but is otherwise asymptomatic.
What is it? - Malignant mets to a supraclavicular node
from a primary tumor below theneck.
How do we make the
diagnosis? - Look for the obvious
primary tumors: lung, stomach, colon, pancreas, kidney. The node itself will eventually be biopsied.
OT.7. – A 69 year old man who
smokes and drinks and has rotten teeth has a hard, fixed, 4 cm. mass in his
neck. The mass is just medial and in
front of the sternomastoid muscle, at the level of the upper notch of the
Thyroid cartilage. It has been there for
at least six months, and it is growing.
What is it? – Metastatic squamous
cell carcinoma to a jugular chain node, from a primary in the mucosa of the
head and neck (oro-pharyngeal-laryngeal territory).
Management: Don’t biopsy the
node! FNA is OK, but the best answer is to do a triple endoscopy
(examination under anesthesia of the mouth, pharynx, larynx, esophagus and
tracheobronchial tree).
C. Squamous Cell Cancer – Other
Presentations
OT.8. – A 69 year old man who
smokes and drinks and has rotten teeth has hoarseness that has persisted for
six weeks in spite of antibiotic therapy.
OT.10. – A 69 year old man who
smokes and drinks and has rotten teeth has a painless ulcer in the floor of the
mouth that has been present for 6 weeks and has not healed.
OT.11. – A 69 year old man who
smokes and drinks and has rotten teeth has unilateral ear ache that has not
gone away in 6 weeks. Physical
examination shows serious otitis media on that side, but not on the other.
What is it? - These are all different ways for squamous
cell carcinoma of the mucosa of the head and neck to show up. They all need triple endoscopy to find and
biopsy the primary tumor and to look for synchronous second primaries.
D. Other Tumors – Adults
OT.12. – A 52 year old man
complains of hearing loss. When tested
he is found to have unilateral sensory hearing los on one side only. He hoes not engage in any activity (such as
sport shooting) that would subject that ear to noise that spares the other
side.
What is it? - Unilateral versions of common ENT problems
in the adult suggest malignancy. In this
case, acoustic nerve neuroma. Note that
if the hearing loss had been conductive, a cerumen plug would be the obvious
first diagnosis.
How is it diagnosed? MRI looking for the tumor.
OT.13. – A 56 year old man
develops slow, progressive paralysis of the facial nerve on one side. It took several weeks for the full blown
paralysis to become obvious, and it has been present now for three months. It affects both the forehead as well as the
lower face.
What is it? - Gradual, unilateral nerve paralysis
suggests a neoplastic process.
Work-up: Gadolinium enhanced MRI.
OT.14. – A 45 year old man
presents with a 2 cm. firm mass in front of the left ear, which has been
present for four months. The mass is
deep to the skin and it is painless. The
patient has normal function of the facial nerve.
What is it? - Pleomorphic adenoma (mixed tumor) of the
parotid gland.
How is it diagnoses? – FNA is
appropriate, but the point of the question will be to bring out the fact that
parotid masses are never biopsied in the office or under local anesthesia. Look for the option that offers referral to a
head and neck surgeon for formal superficial parotidectomy.
OT.15. – A 65 year old man
present with a 4 cm. hard mass in front of the left ear, which has been present
for six months. The mass is deep to the
skin and it is fixed. He has constant
pain in the area, and for the past two months has had gradual progression of
left facial nerve paralysis. He has
rock-hard lymph nodes in the left neck.
What is it? - Cancer of the parotid gland.
Management: same as above. Amateurs should not mess with parotid.
E. Pediatric ENT
OT.16. – A two year old by has
unilateral ear ache.
OT.17. – A two year old has
unilateral foul smelling purulent rhinorrhea.
OT.18. – A two year old has
unilateral wheezing and the lung on that side looks darker on X-Rays (more air)
than the other side.
What is it? - Unilateral versions of common bilateral ENT
conditions in toddlers suggest foreign body.
Appropriate X-Rays, physical
examination or endoscopies and extraction –typically under anesthesia.
F. Emergencies
and Miscellaneous
OT.19. – A 4 year old child is
brought by his mother to the emergency room because “she is sure that he must
have swallowed a marble”. The kid was
indeed playing with marbles and apparently completely healthy when he was put to
bed, but four hours later he had developed inspiratory stridor, a fever of 103
and obvious respiratory distress. The
kid is sitting up, leaning forward, drooling at the mouth and looking very sick
indeed.
What is it? – Acute epiglotitis.
Management: A real emergency
where expert help is needed! The
diagnosis is confirmed with lateral X-rays of the neck, but be sure experts go
with the kid to the X-Ray dept., ready to use bag and mask if needed. Then it’s off to the OR for nasotracheal
intubation. If bradychardia develops,
the kid is in real trouble: atropine will help, but hypoxia is the
problem. Along the way, start IV
antibiotics for H.Influenzae.
OT.20. – A 45 year old lady with
a history of a recent tooth infection shows up with a huge, hot, red, tender,
fluctuant mass occupying the left lower side of her face and upper neck,
including the underside of the mouth.
The mass pushes up the floor of the mouth on that side. She is febrile.
What is it? – Ludwigs’
Angina. (An abscess of the floor of the
mouth)
Management: Tracheostomy and incision
drainage of the abscess.
OT.21. – A 29 year old lady calls
your office at 10 AM with the history that she woke up that morning with one
side of her face paralyzed.
What is it? - Bell’s palsy.
Management: The latest trend is
to start these patients right away on anti-viral medication. Pick that answer if offered. If the question has been lingering in the
item pool for years, the correct choice will be that the process is idiopathic
and will resolve spontaneously in most cases.
OT.22. – A patient with multiple
trauma from a car accident is being attended to in the emergency room. As multiple invasive things are done to him,
he repeatedly grimaces with pain. The
next day it is noted that he has a facial nerve paralysis on one side.
What is it? – Trauma to the
temporal bone can certainly transect the facial nerve, but when that happens
the nerve is paralyzed right there and then.
Paralysis appearing late is from edema.
The point of the vignette is that nothing needs to be done.
OT.23. – Your office receives a
phone call from Mrs. Rodriguez. You know
this middle aged lady very well because you have repeatedly treated her in the
past for episodes of sinusitis. In fact,
six days ago you started her on decongestants and oral antibiotics for what you
diagnoses as frontal and ethmoid sinusitis.
Now she tells you over the phone that ever since she woke up this
morning, she has been seeing double.
What is it? - Cavernous sinus thrombosis, or orbital
cellulitis.
Management: This is a real
emergency. She needs immediate
hospitalization, high dose IV antibiotic treatment and surgical drainage of the
paranasal sinuses or the orbit. A CT
scan will be needed to guide the surgery, but I expect that the thrust of the
question will be directed at your recognition of the serous nature of this
problem, rather than the therapy.
OT.24. – A 10 year old girl has
epistaxis. Her mother says that she
picks her nose all the time.
What is it? - Bleeding from the anterior part of the
septum.
Management: Phenylephrine spray
and local pressure.
OT.25. – An 18 year old boy has
epistaxis. The patient denies picking
his nose. No source of anterior bleeding
can be seen by physical examination.
What is it? - Either septal perforation from cocaine
abuse, or posterior juvenile nasopharyngeal angiofibroma.
Management: Get your ENT friends
to take care of this one. You can not do
it.
OT.26. – A 72, hypertensive male,
on aspirin for arthritis, has a copious nosebleed. His blood pressure is 220/15 when seen in the
E.R. He says he began swallowing blood
before it began to come out through the front of his nose.
What is it? - Obviously epistaxis secondary to
hypertension.
Management: These are serious
problems that can end up with death.
Medical Rx. To lower the blood pressure is clearly needed, and may be
the option offered in the answers, but getting the ENT people right away should
also be part of the equation.
OT.27. – A 57 year old man seeks
help for “dizziness”. On further
questioning he explains that he gets light and work-up in that direction.
OT.28. – A 57 year old man seeks
help for “dizziness”. On further
questioning, he explains that the room spins around him.
What is it? - This one is in the vestibular
apparatus. I could not even begin to
tell you how to work it up, but seek the answers that look like either
symptomatic treatment (meclizine, phenergan, diazepam), or an ENT workup.
10. CARDIOTHORACIC
A. Congenital Heart
CT.1. – During a school physical
exam, a 12 year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognized that
she indeed has a pulmonary flow systolic murmur, but he also notices that she
has a fixed split second heart sound. A
history of frequent colds and upper respiratory infections is elicited.
What is it? - Atrial septal defect.
Management: Echocardiography to
establish the diagnosis. Surgical
closure of the defect. Closure by way of
catheterization is till experimental.
CT.2. – A three month old boy is
hospitalized for ‘failure to thrive”. He
has a loud, pansystolic heart murmur best heard at the left sternal
border. Chest X-Ray shows increased
pulmonary vascular markings.
What is it? - Ventricular septal defect.
Management: Echocardiography and
surgical correction.
CT.3. – A three day old premature
baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral
pulses and a continuous, machinery-like heart murmur.
What is it? - Patent ductus arteriosus.
Management: Echocardiography and
surgical closure or indomethacin.
CT.4. – A patient known to have a
congenital heart defect requires extensive dental work.
Pretty brief vignette, but the
point is that somewhere along the line, you might be expected to remember that
these patients need antibiotic prophylaxis for subacute bacterial endocarditis.
CT.5. – A 6 year old boy is
brought to the U.S. by his new adoptive parents, from an orphanage in Eastern
Europe. The kid is small for his age,
and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis
relieved with squatting. He has a
systolic ejection murmur in the left third intercostal space. Chest X-Ray shows a small heart, and
diminished pulmonary vascular markings.
EKG shows right ventricular hypertrophy.
What is it? - Tetralogy of Fallot. Cyanotic kids could have any of the 5
conditions that begin with the latter “T”: Tetralogy or Transportation of the
great vessels, which are common; or Truncus arteriosus, Total anomalous
pulmonary venous connection or Tricuspid atresia, which are rare. If the kid went home after birth, and later
was found to be cyanotic, bet on tetralogy.
If he was blue from the moment of birth, bet on transposition.
Management: Even if all you can
recognize in the vignette is that a child has cyanosis, start with an
Echocardiogram as a good diagnostic test.
The intricate details of surgical correction, and the need the surgeons
might have for cardiac catheterization prior to surgery are bound to b beyond
the level of knowledge expected of you in this examination.
B. Acquired Heart Disease
CT.6. – A 72 year old man has a
history of angina and exertional syncopal episodes. He has a harsh midsystolic heart murmur best
heard at the second intercostal space and along the left sternal border.
What is it? - Aortic stenosis.
Management: The diagnostic test
is echocardiogram. Surgical valvular
replacement is indicated if there is a gradient of more than 50 mm.Hg., or at
the first indication of congestive heart failure, angina or syncope.
CT.7. – A 72 year old man has ben
known for years to have a wide pulse pressure and a blowing, high-pitched,
diastolic heart murmur best heard at the second intercostal space and along the
left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in
the most recent one there is evidence of beginning left ventricular dilatation.
What is it? - Chronic aortic insufficiency.
Management: Aortic valve
replacement.
CT.8. – A 26 year old drug-addicted
man develops congestive heart failure over a short period of a few days. He has a loud, diastolic murmur at the right,
second intercostal space. A physical
exam done a few weeks ago, when he had attempted to enroll in a detoxification
program was completely normal.
What is it? - Acute aortic insufficiency due to
endocarditis.
Management: Emergency valve
replacement, and antibiotics for a long time.
CT.9. – A 35 year old lady has
dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and
hemoptisis. She has had these
progressive symptoms for about 5 years.
She looks thin and cachectic, has atrial fibrillation and a low-pitched,
rumbling distolic apical heart murmur.
At age 15 she had rheumatic fever.
What is it? - Mitral stenosis.
Management: Start with
echocardiogram. Eventually surgical
mitral valve repair.
CT.10. – A 55 year old lady has
been known for years to have mitral valve prolapse. She now has developed exertional dyspnea,
orthopnea and atrial fibrillation. She
has an apical, high pitched, holosystolic heart murmur that radiates to the
axilla and back.
What is it? - Mitral regurgitation.
Management: Start with the
echocardiogram, eventually surgical repair of the valve (annuloplasty), or
possibly valve replacement.
CT.11. – A 55 year old man has
progressive, unstable, disabling angina that does not respond to medical
management. His father and two older
brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a
sedentary life style, is a bit overweight, has type two diabetes mellitus and
has high cholesterol.
What is it? - It’s a heart attack waiting to happen…but
the point of this vignette is the management: this man needs a cardiac
catheterization to see if he is suitable
candidate for coronary revascularization.
CT.12. – A 55 year old man has
progressive, unstable, disabling angina that does not respond to medical
management. His father and two older
brother died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but
still has a sedentary life style, is a bit overweight, has type two diabetes
mellitus and has high cholesterol.
Cardiac catheterization demonstrates 70% occlusion of three coronary
arteries, with good distal vessels. His
left ventricular ejection fraction is 65%.
Management: He is lucky. He has good distal vessels (smokers and
diabetics often do not) and enough cardiac function left. He clearly needs coronary bypass, and with 3
vessel disease there should be no argument for angioplasty instead of surgery.
C. Lung
CT.13. – On a routine
pre-employment physical examination, a chest X-Ray is done on a 45 year old
chronic smoker. A “coin lesion” is found
in the upper lobe of the right lung.
What is it? - The concern of course, is cancer of the
lung. Next best thing to do: Find and
older chest X-Ray if one is available (from one or more years ago). The work up for cancer of the lung is
expensive and invasive. On the other
hand, cancer of the lung grows and kills in a predictable way, over a matter of
several months. If an older X-Ray has
the same unchanged lesion, it is not likely cancer. No further work up is needed now, but the lesion
should be followed with periodic X-Rays.
CT.14. – A 54 year old man with a
40 pack/year history of smoking gets a chest X-Ray because of persistent
cough. A peripheral, 2 cm. “coin lesion”
is found in the right lung. A chest
X-Ray taken two years ago had been normal.
CT scan shows no calcifications in the mass and no enlarged
peribronchial or peritracheal lymph nodes.
Bronchoscopy and percutaneous needle biopsy have not been able to
establish a diagnosis. The man has good
pulmonary function and is otherwise in good health.
What to do? - In dealing with cancer of the lung, there
is an interplay of three issues: establishing the diagnosis – which sometimes
requires very invasive steps; ascertaining if surgery can be done – i.e.: will
the patient still be functional after some lung tissue is removed?; and third,
does the surgery have a fair chance to cure him? Here is an example of a man who could stand
lung resection (peripheral lesion, good function) and who stands a good change
for cure (no node mets). Diagnosis steps
should be pushed to the limit. Start
with bronchoscopy and washings, if unrewarding go to percutaneous needle
biopsy, and if still unsuccessful go to open biopsy, i.e.: thoracotomy and
wedge resection.
CT.15. – A 72 year old chronic
smoker with sever COPD is found to have a central, hilar mass on chest X-Ray. Bronchoscopy and biopsy establish a diagnosis
of squamous cell carcinoma of the lung.
His FEV1 is 1100, and a ventilation/perfusion scan shows that 60% of his
pulmonary functions comes from the affected lung.
Management: It takes an FEV1 of
at least 800 to survive surgery and not be a pulmonary cripple afterwards. If this fellow got a pneumonectomy (which he
would need for a central tumor) he would be left with an FEV1 of 440. No way.
Don’t do any more tests. He is
not a surgical candidate. You already
have a diagnosis to pursue chemotherapy and radiation.
CT.16. – A 62 year old chronic
smoker has an episode of hemoptysis.
Chest X-ray shows a central hilar mass.
Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma
of the lung. His FEV1 is 2200, and a
ventilation/perfusion scan shows that 30% of his pulmonary function comes from
the affected lung.
Management: This fellow could
tolerate a pneumonectomy. CT scan and
mediastinoscopy are in order, to ascertain if surgery has a decent chance to
cure him.
CT.17. – A 33 year old lady is
undergoing a diagnostic work-up because she appears to have Cushing’s
syndrome. Chest X-Ray shows a central, 3
cm. round mass on the right lung. Bronchoscopy
and biopsy confirm a diagnosis of small cell carcinoma of the lung.
Management: Radiation and
chemotherapy. Small cell lung cancer is
not treated with surgery, and thus we have no need to determine FEV1 or nodal
status.
11. VASCULAR
CT.18. – A 54 year old right
handed laborer notices coldness and tingling in his left hand as well as pain
in the forearm when he does strenuous work.
What really concerned him, though, is that in the last few episodes he
also experienced transitory vertigo, blurred vision and difficulty articulating
his speech. Angiogram demonstrates
retrograde flow through the vertebral artery.
What is it? – Subclavian steal
syndrome. A combination of “claudication
of the arm” with posterior brain neurological symptoms is classical for this
rare, but fascinating (and thus favorite question condition.
Management: If you had been given
the vignette without the angiographic study, you would have asked for it. Now that you have it, you are ready for
vascular surgery.
CT.19. – A 62 year old man is
found on physical exam to have a 6 cm. pulsatile mass deep in the abdomen,
between the xiphoid and the umbilicus.
What is it? – Abdominal aortic
aneurysm.
Management: Needs elective
surgical repair.
CT.20. – A 62 year old man has
vague, poorly described epigastric and upper back discomfort. He has been found on physical exam to have a
6 cm. pulsatile mass deep in the abdomen, between the xiphoid and the
umbilicus. The mass is tender to
palpation.
What is it? - An abdominal aortic aneurysm that is
beginning to leak.
Management: Get a consultation
with the vascular surgeons today.
CT.21. – A 68 year old man is
brought to the ER with excruciating back pain that began suddenly 45 minutes
ago. He is diaphoretic and has a
systolic blood pressure of 90. There is
an 8 cm., pulsatile mass palpable deep in his abdomen, between the xiphoid and
the umbilicus.
What is it? - Abdominal aortic aneurysm, rupturing right
now.
What does he need? - Emergency surgery.
CT.22. A retired businessman has claudication when
walking more than 15 blocks.
Management: Vascular surgery, or
angioplasty and stenting are palliative procedures. They do not cure arteriosclerotic occlusive
disease. Claudication has an
unpredictable course, thus there is no advantage to an “early operation”. This man needs nothing. If he smokes, he should quit.
CT.23. – A 56 year old postman
describes severe pain in his right calf when he walks two or three blocks. The pain is relieved by resting 10 or 15
minutes, but recurs if he walks again the same distance. He can not do his job this way, and he does
not qualify yet for retirement, so he is most anxious to have this problem
resolved. He does not smoke.
Management: This fellow needs
help. Start with Doppler studies. If he has significant gradient, arteriogram
comes next, followed by bypass surgery or stenting.
CT.24. – A patient consults you
because he “can not sleep”. On
questioning it turns out that he has pain in the right calf, which keeps him
from falling asleep. He relates that the
pain goes away if he sits by the side of the bed and dangles the leg. His wife adds that she has watched him do
that, and she has noticed that the leg which was very pale when he was lying
down becomes deep purple several minutes after he is sitting up. On physical exam the skin of that leg is
shiny, there is no hair and there are no palpable peripheral pulses.
What is it? - Another version of the same problem. In this case rest pain. Definitively he needs the studies to see if
vascular surgery could help him.
CT.25. – A 45 year old man shows
up in the ER with a pale, cold, pulseless, paresthetic, painful and paralytic
lower extremity. The process began
suddenly two hours ago. Physical exam
shows no pulses anywhere in that lower extremity. Pulse at the wrist is 95 per minute, grossly
irregular.
What is it? - Embolization by the broken-off tail of a
clot from the left atrium.
What does he need? - Emergency surgery with use of Fogarty
catheters to retrieve the clot.
CT.26. – A 74 year old man has
sudden onset of extremely severe, tearing chest pain that radiates to the back
and migrates down shortly after it’s onset.
His blood pressure is 220/100, he has unequal pulses in the upper
extremities and he has a wide mediastinum on chest X-Ray. Electrocardiogram and cardiac enzymes show
that he does not have a myocardial infarction.
What is it? - Dissecting aneurysm of the thoracic aorta.
Management: Arteriogram first,
but the forces that dissected the vessel plus the force of the dye injection
could further shear the aorta, thus study is done with beta blockers or IV
nitrates to lower blood pressure. If the
aneurysm is in the ascending aorta, emergency surgery will be done. If it is in the descending, intensive therapy
(in the ICU) for the hypertension will be the preferable option.
12. NEUROSURGERY
A. Vascular - Occlusive
NS.1. – A 62 year old right
handed man has transient episodes of weakness in the right hand, blurred
vision, and difficulty expressing himself.
There is not associated headache, the episodes last about 5 or 10
minutes at the most, and they resolve spontaneously. Funduscopic examination reveals highly
refractile crystals in the left retinal artery.
What is it? – Transient ischemic
attacks in the territory of the left carotid artery (probably an ulcerated
plaque at the left carotid bifurcation).
How is the diagnosis
confirmed? - In spite of a constant
search for a non-invasive alternative, the gold standard is still angiogram.
Treatment: Carotid
endarterectomy.
NS.2. – A 61 year old man
presents with a one year history of episodes of vertigo, diplepia, blurred
vision, disarthria and instability of gait.
The episodes last several minutes, have no associated headache and leave
not neurological sequela.
What is it? - Another version of transient ischemic
attacks, but now the vertebrals may be involved.
Management: choose an arteriogram
that examines all the arteries going to the brain: i.e. an aortic arch
study. Vascular surgery will follow.
NS.3. – A 60 year old diabetic
male presents with abrupt onset of right third nerve paralysis and
contralateral hemiparesis. There was no
associated headache. The patient is
alert, but has the neurological deficits mentioned.
What is it? – Neurological
catastrophes that begin suddenly and have no associated headache are vascular
occlusive. The vernacular for this man’s
problem is “a stroke”.
Management: Vascular surgery in
the neck is designed to prevent strokes, not to treat them once they
happen. This fellow will get a CT scan
to assess the extent of the infarct, and supportive treatment with eventual
emphasis on rehabilitation.
B. Vascular - Hemorrhagic
NS.4. – A 64 year old black man
complains of a very severe headache of sudden onset and then lapses into a
coma. Past medical history reveals
untreated hypertension and examination reveals a stuporous man with profound
weakness in the left extremities.
What is it? - Neurological catastrophes of sudden onset, with
severe headache are vascular hemorrhagic.
This man has bled into his head.
In the vernacular, he has also suffered “a stroke”.
Management: Again supportive with
eventual rehabilitation efforts if he survives.
CT scan is the universal first choice to see blood inside the head (we
use it in trauma for the same purpose).
This man will get one, to see exactly where he bled, and how bad it is.
NS.5. – A 39 year old lady
presents to the ER with a history of a severe headache of sudden onset that she
says is different and worse than any headache she has ever had before. She is given pain medication and sent
home. She improves over the next few
days, but ten days after the initial visit she again gets a sudden, severe and
singular diffuse headache and she returns to the ER. This time she has some nuchal rigidity on
physical exam.
What is it? - This one is a classic: subarachnoid
bleeding from an intracraneal aneurysm.
The “sentinel bleed” that is not identified for what it is, is a common
feature. The “sudden, severe and
singular” nature of the pain, are classics.
And the nuchal rigidity betrays the presence of blood in the
subarachnoid space.
Diagnosis: We are looking for
blood inside the head, thus start with CT. Angiograms will eventually follow,
in preparation for surgery to clip the aneurysm.
C. Tumors
NS.6. – A 31 year old nursing student
developed persistent headaches that began approximately 4 months ago, have been
gradually increasing in intensity and are worse in the mornings. For the past three weeks, she has been having
projectile vomiting. Thinking that she
may need new glasses, she seeks help from her optometrist, who discovers that
she has bilateral papilledema.
What is it? - Brain tumor. Neurological processes that develop over a
period of a few months and lead to increased intracraneal pressure, spell out
tumor. Morning headaches are
typical. If the tumor is in a “silent”
area of the brain, there may be no other neurological deficits.
Management: If given the option,
pick MRI as your diagnostic test. If not
offered, settle for CT scan. Measures to
decrease intracraneal pressure while awaiting surgery, include mannitol,
hyperventilation, and high dose steroids (decadron).
NS.7. – A 42 year old right
handed man has a history of progressive speech difficulties and right
hemiparesis for five months. He has had
progressively severe headaches for the last two months. At the time of admission he is confused,
vomiting, has blurred vision, papilledema and diplopia. Shortly thereafter his blood pressure goes up
to 190 over 110, and he develops bradychardia.
What is it? - Again brain tumor, but now with two added
features: there are localizing signs (left hemisphere, parietal and temporal
area) and he manifests the Cushing’s reflux of extremely high intracraneal
pressure.
Management: is as above, but as
an emergency.
NS.8. – A 12 year old boy is
short for his age, has bitemporal hemianopsia and has a calcified lesion above
the sella in X-Rays of the head.
What is it? – Craniopharyngioma.
Management: Get the fancy MRI and
proceed with pituitary surgery.
NS.9. – A 23 year old nun
presents with a history of amenorrhea and galactorrhea of six months
duration. She is very concerned that
other may think that she is pregnant, and she vehemently denies such a
possibility.
What is it? - Prolactinoma.
Management: Every time you suspect
a functioning tumor of an endocrine gland, you measure the appropriate
hormone. So, here you want a prolactin
level. You are also going to do surgery
eventually, so you need to see the tumor.
The top choice for that is MRI.
The surgery will be trans-nasal, trans-sphenoidal. If inoperable, Bromocriptine will help.
NS.10. – A 44 year old man is
referred for treatment of hypertension.
His physical appearance is impressive: he has big, fat, sweaty hands;
large jaw and thick lips, large tongue
and huge feet. He is also found to have
a touch of diabetes. In further
questioning he admits to headaches and he produces pictures of himself taken
several years ago, where he looks strikingly different.
What is it? - Acromegaly.
Appearance is so striking that the vignette is likely to come with a
picture.
Management: Growth hormone
determination, MRI and eventually pituitary surgery.
NS.11. – A 15 year old girl has
gained weight and become “ugly”. She
shows a picture of herself a year ago, where she was a lovely young lady. Now she has a hairy, red, round face full of
pimples; her neck has a posterior hump and her supraclavicular areas are round
and convex. She has a fat trunk and thin
extremities. She has mild diabetes and
hypertension.
What is it? - Cushing’s.
this one will also come with a picture, rather than a description.
Management: AM and PM cortisol
levels, dexamethasone suppression test, MRI of the sella and eventually
trans-sphenoidal pituitary surgery.
NS.12. – A 27 year old lady presents
with a six month history of headaches, visual loss and amenorrhea. The day of admission to the hospital she
developed a severe headache, marked deterioration of remaining vision and
stupor. Besides the stupor, physical
exam is remarkable because her blood pressure is 75/45. Funduscopic examination reveals bilateral
pallor of the optic nerves.
NS.13. – A 55 year old lady is
involved in a minor traffic accident where her car was hit sideways by another
car that she “did not see” at an intersection. When she is tested further it is recognized
that she has bitemporal hemianopsia. Ten
years ago she had bilateral adrenalectomies for Cushing’s disease.
What is it? - Nelson’s syndrome. Years ago, before imaging studies could
identify pituitary microadenomas, patients with Cushing’s were treated with
bilateral adrenalectomy instead of pituitary surgery. In some of those patients the pituitary
microadenoma kept on growing and eventually gave pressure symptoms. That is Nelson’s syndrome.
Management: MRI will show the
tumor. Trans-nasal, trans-sphenoidal
surgery will remove it.
NS.14. – A 42 year old man has
been fired from his job because of inappropriate behavior. For the past two months he has gradually
developed very severe, “explosive” headaches that are located on the right
side, above the eye. Neurologic exam
shows optic nerve atrophy on the right, papilledema on the left and anosmia.
What is it? - Brain tumor in the right frontal lobe. A little knowledge of neuroanatomy can help
localize tumors. The frontal lobe has to
do with behavior and social graces, and is near the optic nerve and the
olphactory nerve. If you want the fancy
name, this is the Foster-Kennedy syndrome.
Management: MRI and neurosurgery.
NS.15. – A 32 year old man
complains of progressive, severe generalized headaches, that began three months
ago, are worse in the mornings and lately have been accompanied by projectile
vomiting. He has lost his upper gaze and
he exhibits the physical finding known as “sunset eyes”.
What is it? - Another classic. This tumor is in the pineal gland and if you
want the fancy name it is Parinaud’s syndrome.
What do you do?: MRI to
start. The neurosurgeons will take care
of the rest.
NS.16. – A six year old boy has
been stumbling around the house and complaining of severe morning headaches for
the past several months. While waiting
in the office to be seen, he assumes the knee-chest position as he holds his
head. Neurological exam demonstrates
truncal ataxia.
What is it? - Tumor of the posterior fosa. Most brain tumors in children are located
there, and cerebellar function is affected.
Management: MRI, neurosurgery.
NS.17. – A 23 year old man
develops severe headache, seizures and projectile vomiting over a period of two
weeks. He has low grade fever, and was
recently treated for acute otitis media and mastoiditis.
What is it? - Brain abscess. Signs and symptoms suggestive of brain tumor
that develop in a couple of weeks with fever and an obvious source on
infection, spell out abscess.
Management: These are seen in CT
as well as they would on MRI, and the CT is cheaper and easier to get...so pick
CT if offered. Then the abscess has to
be resected by the neurosurgeons.
D. Spinal Cord
NS.18. – An 18 year old street
fighter gets stabbed in the back, just to the right of the midline. He has paralysis and loss of proprioception
distal to the injury on the right side, and loss of pain perception distal to
the injury on the left side.
What is it? - Probably no one in real life will have such
a net clear-cut syndrome, but for purposes of examination vignettes this is a
classical spinal cord hemisection, better known as Brown-Sequard’s.
NS.19. – A patient involved in a
car accident sustains a burst fracture of the vertebral bodies. He develops loss of motor function and loss
of pain and temperature sensation on both sides distal to the injury, while
showing preservation of vibratory sense and position sense.
What is it? - Anterior cord syndrome.
NS.20. – An elderly man is
involved in a rear end automobile collision where he hyperextends his
neck. He develops paralysis and burning
pain of both upper extremities while maintaining good motor function in his
legs.
What is it? - Central cord syndrome.
Management for all three: I doubt
that the long and complicated management of spinal cord injuries will be tested
on the exam, but one item might show up: there is some suggestion that high
dose corticosteroids soon after a spinal cord injury may help minimize the
permanent damage. The medical evidence
is weak, but the legal consequences of not doing it could be devastating, thus
it has become an imperative to do it.
Pick that answer, if offered for the acute management.
NS.21. – A 52 year old lady has
constant, severe back pain for two weeks.
While working on her yard, she suddenly falls and can not get up
again. When brought to the hospital she
is paralyzed below the waist. Two years
ago she had a mastectomy for cancer of the breast,
What is it? - Most tumors affecting the spinal cord are
metastatic, extradural. In this case the
source is obvious, and the sudden onset of the paralysis suggests a fracture
with cord compression or transection.
Management: MRI is the best
imaging modality for the spinal cord.
The neurosurgeons may be able to help if the cord is compressed rather
than transected.
NS.22. – A 45 year old male gives
a history of aching back pin for several months. He has been told that he had muscle spasms,
and was given analgesics and muscle relaxants.
He comes in now because of the sudden onset of very severe back pain
that came on when he tried to lift a heavy object. The pain is “like an electrical shock that
shoots down his leg”, and it prevents him from ambulating. He keeps the affected leg flexed. Straight leg raising test gives excruciating
pain..
What is it? - Lumbar disk herniation. The peak age incidence is 45, and virtually
all of these are either L4-L5 or L5-S1.
Management: MRI for
diagnosis. Bed rest will take care of
most of these. Neurosurgical intervention
only if there is progressive weakness or sphincteric deficits.
NS.23. – A 79 year old man
complains of leg pain brought about by walking and relieved by rest. On further questioning it is ascertained that
he has to sit down or bend over for the pain to go away. Standing at rest will not do it. Furthermore, he can exercise for long periods
of time if he is “hunched over”, such as riding a bike or pushing a shopping cart. He has normal pulses in his legs.
What is it? - Neurogenic claudication.
Management: Get MRI. Eventually surgical decompression of this
cauda equina.
E. Pain Syndromes
NS.24. – A 60 year old man
complains of extremely severe, sharp, shooting, “like a bolt of lighting”, pain
in his face which is brought about by touching a specific area, and which lasts
about 60 seconds. His neurological exam
is normal, but it is noted that part of his face is unshaven, because he fears
to touch that area.
What is it? - Tic doloreaux (trigeminal neuralgia).
Management: Rule out organic lesions
with MRI. Treat with anticonvulsants.
NS.25. – Several months after
sustaining a crushing injury of his arm, a patient complains bitterly about
constant, burning, agonizing pain that does not respond to the usual analgesic
medications. The pain is aggravated by
the slightest stimulation of the area.
The arm is cold, cyanotic and moist.
What is it? - Causalgia (reflex sympathetic distrophy)
Management: A successful
sympathetic block is diagnostic, and surgical sympathectomy will be curative.
13. ORTHOPEDICS
A. Children
OR.1. – In the newborn nursery it
is noted that a child has uneven gluteal folds.
Physical exam of the hips reveals that one of them can be easily
dislocated posteriorly with a jerk and a “click”, and returned to normal position
with a “snapping”.
What is it? – Developmental
dysplasia of the hip
Management: Abduction splinting.
(Don’t order X-Rays in a newborn.
Calcification is still incomplete and you will not see anything).
OR.2. – A 6 year old boy has
insidious development of limping with decreased hip motion. He complains occasionally of knee pain on
that side. He walks into the office with
an antalgic gait. Passive motion of the
hip is guarded.
What is it? - In this age group, Legg-Perthes disease
(avascular necrosis of the capital femoral epiphysis). Remember that hip pathology can show up with
knee pain.
Management: AP and lateral X-Rays
for diagnosis. Contain the femoral head
within the acetabulum by casting and crutches.
OR.3. – A 13 year old boy
complains of pain in the groin ( it could be the knee) and is noted by the
family to be limping. He sits in the
office with the foot on the affected side rotated towards the other foot. Physical examination is normal for the knee,
but shows limited hip motion. As the hip
is flexed, the leg goes into external rotation and it can not be rotated
internally.
What is it? - Forget the details: a bad hip in this age
group is slipped capital femoral epiphysis, an orthopedic emergency.
Management: AP and lateral X-Rays
for diagnosis. The orthopedic surgeons
will pin the femoral head in place.
OR.4. – A little toddler has had
the flu for several days, but he was walking around fine until about two days
ago. He now absolutely refuses to move
one of his legs. He is in pain, holds
the leg with the hip flexed, in slight abduction and external rotation and you
can not examine that hip he will not let you move it. He has elevated sedimentation rate.
What is it? - Another orthopedic emergency: septic hip.
Management: Under general
anesthesia the hip is aspirated to confirm the diagnosis, and open arthrotomy
is done for drainage.
OR.5. – A child with a febrile
illness but no history of trauma has persistent, severe localized pain in a
bone.
What is it? - Acute hematogenous osteomyelitis
Management: don’t fall for the
X-Ray option. X-Ray will not show
anything for two weeks. Do bone scan.
OR.6. – A 12 year old girl is
referred by the school nurse because of potential scoliosis. The thoracic spine is curved toward the right,
and when the girl bends forward a “hump” is noted over her right thorax. The patient has not yet started to
menstruate.
Management: Too complicated for
our purposes, but the point is that scoliosis may progress until skeletal
maturity is reached. Baseline X-Rays are
needed to monitor progression. At the
onset of menses skeletal maturity is about 80%, so this patient still has a way
to go. Bracing may be needed to arrest
progression. Pulmonary function could be
limited if there is large deformity.
B. Tumors
OR.7. – A 16 year old boy
complains of low grade but constant pain in his distal femur present for
several months. He has local tenderness
in the area, but is otherwise asymptomatic.
X-Rays show a large bone tumor, with “sunburst” pattern and periosteal
“onion skinning”.
What is it? - Malignant bone tumor. Either osteogenic sarcoma or Ewing’s sarcoma.
Management: The point of the
vignette is that you do not mess with these.
Do not attempt biopsy. Referral
is needed, not just to an orthopedic surgeon (they see one of these every three
years), but to a specialist on bone tumors.
OR.8. – A 66 year old lady picks
up a bag of groceries and her arm snaps broken.
What is it? - A pathologic fracture (i.e: for trivial
reasons) means bone tumor, which in the vast majority of cases will be
metastatic. Get X-Rays to diagnose this
particular broken bone, whole body bone scans to identify other mets, and start
looking for the primary. In women,
breast. In men, prostate. In heavy smokers, lung…and so on.
OR.9. – A 58 year old lady has a soft tissue tumor in her
thigh. It has been growing steadily for
six months, it is located deep into the thigh, is firm, fixed to surrounding
structures and measures about 8 cm. in diameter.
What is it? - Soft tissue sarcoma is the concern.
Diagnosis: start with MRI. Leave biopsy and further management to the
experts.
C. General Orthopedics
OR.10. – A middle aged homeless
man is brought to the ER because of very severe pain in his forearm. The history is that he passes out after
drinking a bottle of cheap wine and he slept on a park bench for an
indeterminate time, probably more than 12 hours. There are no signs of trauma, but the muscles
in his forearm are very firm and tender to palpation, and passive motion of his
fingers and wrist elicit excruciating pain.
Pulses at the wrist are normal.
What is it? - Compartment syndrome.
Management; Emergency fasciotomy.
OR.11. – A patient presents to
the ER complaining of moderate but persistent pain in his leg under a long leg
plaster cast that was applied six hours earlier for an ankle fracture.
The point of this vignette is
that you never give pain medication and do nothing else for pain under a
cast. The cast has to come off right
away. It may be too tight, it may be
compromising blood supply, it may have rubbed off a piece of
skin…whatever. Your only acceptable
option here is to remove the cast.
OR.12. – A young man involved in a motorcycle
accident has an obvious open fracture of his right thigh. The femur is sticking out through a jagged
skin laceration.
The point of this one is that
open fractures are orthopedic emergencies.
This fellow may need to have other problems treated first (abdominal
bleeding, intracraneal hematomas, chest tubes, etc), but the open fracture
should be in the OR getting cleaned and reduced within six hours of the injury.
OR.13. – A 55 year old lady falls
in the shower and hurts her right shoulder.
She shows up in the ER with her arm held close to her body, but rotated
outwards as if she were going to shake hands.
She is in pain and will not move the arm from that position. There is numbness in a small area of her
shoulder, over the deltoid muscle.
What is it? - Anterior dislocation of the shoulder, with
axillary nerve damage.
Management: Get AP and
lateral X-Rays for diagnosis. Reduce.
OR.14. – After a grand mal
seizure, a 32 year old epileptic notices pain in her right shoulder and she can
not move it. She goes to the near-by
“Doc in a Box”, where she has X-Rays and is diagnosed as having a sprain and
given pain medication. The next day she
still has the same pain and inability to move the arm. She comes to the ER with the arm held close
to her body, in a “normal” (i.e., not externally rotated, but internally
rotated) position.
What is it? - Posterior dislocation of the shoulder. Very easy to miss on regular X-Rays.
Management: Get X-Rays again but
order axillary view or scapular lateral.
OR.15. – A front seat passenger
in a car that had a head-on collision relates that he hit the dashboard with
his knees, and complains of pain in the right hip. He lies in the stretcher in the ER with the
right extremity shortened, adducted, and internally rotated.
What is it? - Another orthopedic emergency: posterior
dislocation of the hip. The blood supply
of the femoral head is tenous, and delay in reduction could lead to avascular
necrosis.
Management: X-Rays and emergency
recuction.
OR.16. – A 77 year old man falls
in the nursing home and hurts his hip.
X-Rays show that he has a displaced femoral neck fracture.
The point of this vignette is
that blood supply to the femoral head is compromised in this setting and the
patient is better off with a metal prosthesis put in, rahter than an attempt at
fixing the bone. With intertrochanteric
fractures on the other hand, the broken bones can be pinned together and
expected to heal.
OR.17. A football player is hit
straight on his right leg and he suffers a posterior dislocation of his knee.
The point here is that posterior
dislocation of the knee can nail the popliteal artery.
Attention to integrity of pulses,
arteriogram and prompt reduction are the key issues.
OR.18. – A young recruit
complains of localized pain in his tibia after a forced march at boot
camp. He is tender to palpation over a
very specific point on the bone, but X-Rays are normal.
What is it? - Stress fracture.
The lesson here is that stress
fractures will not show up radiologically until 2 weeks later. Treat the guy as if he had a fracture (cast)
and repeat the X-Ray in 2 weeks.
OR.19. – A man who fell from a
second floor window has clinical evidence of fracture of his femur. The vignette gives you a choice of X-Rays to
order.
Here are the rules: Always
get X-Rays at 90°
to each other (for instance, AP and lateral), always include the joints
above and below, and if appropriate (this case is) check the other bones that
might be in the same line of force (here the lumbar spine).
OR.20. – A healthy 24 year old
man steps on a rusty nail at the stables where he works as a horse
breeder. Three days later he is brought
to the ER moribund, with a swollen, dusky foot, in which one can feel gas
crepitation.
What is it? - Gas gangrene.
What to do? - Tons of IV penicillin and immediate
surgical debridement of dead tissue, followed by a trip to the nearest
hyperbaric chamber for hyperbaric O2 treatment.
OR.21. – A 55 year old, obese man
suddenly develops swelling, redness and exquisite pain at the first
metatarsal-phalangeal joint.
What is it? - Gout.
Management: Diagnosis by serum
uric acid determination and identification of uric acid crystals in fluid from
the joint. Rx. with colchicine,
allopurinol or probenicid.
OR.22. – A 67 year old diabetic
has an indolent, unhealing ulcer at the heel of the foot.
What is it? - Ulcer at a pressure point in a diabetic is
due to neuropathy, but once it has happened it is unlikely to heal because the
microcirculation is poor also.
Management: control the diabetes,
keep the ulcer clean, keep the leg elevated..and be resigned to the thought
that you may end up amputating the foot.
OR.23. – A 67 year old smoker
with high cholesterol and coronary disease has an indolent, unhealing ulcer at
the tip of his toe. The toe is blue, and
he has no peripheral pulses in that extremity.
What is it? - Ischemic ulcers are at the farthest away
pint from where the blood comes.
Management: Doppler studies
looking for pressure gradient, arteriogram.
Revascularization may be possible, and then the ulcer may heal.
OR.24. – A 44 year old, obese woman
has an indolent, unhealing ulcer above her right maleolus. The skin around it is thick and
hyperpigmented. She has frequent
episodes of cellulitis, and has varicose veins.
What is it? – Venous stasis
ulcer.
Management: Unna boot. Support stocking. Varicose vein surgery.
14. UROLOGY
A. Urological Emergencies
GU.1. – A 14 year old boy
presents in the Emergency Room with very severe pain of sudden onset in his
right testicle. There is no fever,
pyuria or history of recent mumps. The testis
is swollen, exquisitely painful, “high riding”, and with a “horizontal
lie”. The cord is not tender.
What is it? - Testicular torsion, a urological emergency.
Management: Emergency surgery to
save the testicle.
GU.2. – A 24 year old man
presents in the emergency room with very severe pain of recent onset in his
right scrotal contents. There is fever
of 103 °
and pyuria. The testis is in the normal
position, and it appears to be swollen and exquisitely painful. The cord is also very tender.
What is it? - Acute epididimitis.
Management: This is the condition
that presents the differential diagnosis with testicular torsion. Torsion is a surgical emergency. Epididimitis is not. Don’t rush this guy to the OR, all he needs
is antibiotic therapy. If the vignette
is not clear-cut, i.e: and adolescent that looks like epidimitis, but could be
torsion, pick a sonogram to rule out torsion before you choose the non-surgical
option.
GU.3. – A 72 year old man is
being observed with a ureteral stone that is expected to pass
spontaneously. He develops chills, a
temperature spike to 104 and flank pain.
What is it? - Obstruction of the urinary tract alone is
bad. Infection of the urinary trac alone
is bad. But the combination of the two is
horrible: a true urological emergency.
That’s what this fellow has.
Management: Massive intravenous
antibiotic therapy, but the obstruction must also be relieved right now. In a septic patient stone extraction would be
hazardous, thus the option in addition to antibiotics would be decompression by
ureteral stent or percutaneous nephrostomy.
GU.4. – An adult female relates
that five days ago she began to notice frequent, painful urination, with small
volumes of cloudy and malodorous urine.
For the first three days she had no fever, but for the past two days she
has been having chills, high fever, nausea and vomiting. Also in the past two days she has had pain in the right flank. She has had no treatment whatsoever up to
this time.
What is it? - Pyelonephritis.
Management: Urinary tract
infections should not happen in men or in children, and thus they should
trigger a work-up looking for a cause.
Women of reproductive age on the other hand, get cystitis all the time
and they are treated with appropriate antibiotics without great fuss. However, when they get flank pain and septic
signs it’s another story. This lady
needs hospitalization, IV antibiotics and at least a sonogram to make sure that
there is no concomitant obstruction.
GU.5. – A 62 year old male
presents with chills, fever, dysuria, urinary frequency, diffuse low back pain and an exquisitely tender
prostate on rectal exam.
What is it? - Acute bacterial prostatitis.
Management: This vignette is
supposed to elicit from you what you would not do. The treatment for this man is intuitive: he
needs I.V. antibiotics…but what should not be done is any more rectal
exams or any vigorous prostatic massage.
Doing so could lead to septic shock.
GU.6. – You receive a call from a
patient at 3:00 AM. His regular
urologist retired five years ago, and he has not sought a replacement. At about 11:00 PM last night, the patient
injected himself with papaverine directly into the corpora, as he had been
instructed to do for his chronic, organic impotence. He achieved a satisfactory erection and had
intercourse, but the erection has not gone away and he still has it at this
time.
What is it? – Priapism is another
urological emergency. In the old days it
was very rarely seen, but now the iatrogenic form is common.
Management: Continued erection
beyond four hours begins to damage the corpora.
He needs emergency infection of an alpha agonist (phenylephrine,
epinephrine or terbutaline) into the corpora.
Once the crisis is over, the patient has to be switched from papaverine
to Prostaglandin E1, which in now the agent of choice to achieve erection
because it is less likely to produce priapism.
B. Congenital
GU.7. – You are called to the
nursery to see an otherwise healthy looking newborn boy because he has not
urinated in the first 24 hours of life.
Physical exam shows a big distended urinary bladder.
What is it? - Kids are not born alive if they have not
kidneys (without kidneys, lungs do not develop). This represents some kind of obstruction. First look at the meatus, it could be simple
meatal stenosis. If it is not, posterior
urethral valves is the best bet.
Management: Drain the bladder
with a catheter (it will pass through the valves). Voiding cystourethrogram for diagnosis,
endoscopic fulguration or resection for treatment.
GU.8. – A bunch of newborn boys
are lined up in the nursery for you to do circumcisions.
You notice that one of them has
the urethral opening in the ventral side of his penis, about mid-way down the
shaft.
What is it? - Hypospadias.
The point of the vignette is that
you don’t do the circumcision. The
foreskin may be needed later for reconstruction when the hypospadias is
surgically corrected.
GU.9. – A 7 year old child falls
off a jungle gym and has minor abrasions and contusions. When checked by his pediatrician, a
urinalysis shows microhematuria.
What is it? - Hematuria from the trivial trauma in kids
means congenital anomaly of some sort.
Management: start with
sonogram. IVP may be needed later.
GU.10. – A 9 year old boy gives a
history of three days of burning on urination, with frequency, low abdominal
and perineal pain, left flank pain and fever and chills for the past two days.
What is it? - Little boys are not supposed to get urinary
tact infections. There is more than
meets the eye here. A congenital anomaly
has to be ruled out.
Management: treat the infection
of course, but also do sonogram right away to begin the work up.
GU.11. – A mother brings her
6-year-old girl to you because “ she has failed miserably to get proper toilet
training”. On questioning you find out
that the little girl perceives normally the sensation of having to void, voids
normally and at appropriate intervals, but also happens to be wet with urine
all the time.
What is it? - A classic vignette: low implantation of one
ureter. In little boys there would be no
symptoms, because low implantation in boys is still above the sphincter, but in
little girls the low ureter empties into the vagina and has no sphincter. The other ureter is normally implanted and
accounts for her normal voiding patter.
Management: If the vignette did
not include physical exam, that would be the next step, which might show the
abnormal ureteral opening. Often
physical exam does not reveal the anomaly, and imaging studies would be required
(start with IVP). Surgical repair will
follow.
GU.12. – A 16 year old boy sneaks
out with his older brother’s friends, and goes on a beer-drinking binge for the
first time in his life. He shortly
thereafter develops colicky flank pain.
What is it? - Another classic. Ureteropelvic junction obstruction.
Management: Start with ultrasound
(sonogram). Repair will follow.
C. Tumors
GU.13. – A 62 year old male known
to have normal renal function reports an episode of gross, painless
hematuria. Further questioning
determines that the patient has total hematuria rather than initial or terminal
hematuria.
What is it? - The blood is coming anywhere from the
kidneys to the bladder, rather than the prostate or the urethra. Either infection or tumor can produce
hematuria. In older patients without
signs of infection cancer is the main concern, and it could be either renal
cell carcinoma or transitional cell cancer of the bladder.
Management: The traditional “gold
standard-first study” in urology is IVP (Intravenous pyelogram, also known as excretory urogram). It’s main contraindication is poor renal
function. That is your first choice here. If normal, the next step is cystoscopy. Newer imaging studies have displaced the IVP
in some settings: sonogram is no the first step when the issue is potential
obstruction. CT scan is superb for renal
pathology, but is still not the first step in most cases. Some urologists will start the evaluation of
hematuria with cystoscopy (if there is no infection), but for the purposes of
the exam the best option remains IVP first, and cystoscopy next.
GU.14. – A 70 year old man is
referred for evaluation because of a triad hematuria, flank pain and a flank
mass. He also has hypercalcemia,
erythrocytosis and elevated liver enzymes.
What is it? - An examination vignette, that’s what this
is. No one in real life will present
with all the signs and symptoms of renal cell carcinoma (also known as
clear cell carcinoma, or hypernephroma) which this hypothetical patient has.
Management: IVP first and CT scan
next would be the standard sequence. In
real life, if a urologist saw a patient with a palpable flank mass, he or she
might go straight for the CT scan.
Hopefully they will offer you one or the other, and not force you to
choose between the two.
GU.15. – A 61 year old man
presents with a history of hematuria.
Intravenous pyelogram shows a renal mass, and sonogram shows it to be
solid rather than cystic. CT scan shows
a heterogenic, solid tumor.
What is it? - A better vignette if the objective is to
recognize renal cell carcinoma.
GU.16. – A 55 year old, chronic
smoker, reports three instances in the past two weeks when he has had painless,
gross, total hematuria. In the past two
months he has been treated twice for irritative voiding symptoms, but has not
been febrile and urinary cultures have been negative.
What is it? - Most likely bladder cancer.
Management: With this very
complete presentation some urologist would go for the cystoscopy first, but the
standard sequence of IVP first and cystoscopy next is the only correct answer
for an exam. An option both IVP and cystoscopy
would be OK.
GU.17. – A 59 year old black man
has a rock-hard, discrete, 1.5 cm. nodule felt in his prostate during a routine
physical examination.
What is it? - Cancer of the prostate.
Management: Trans-rectal needle
biopsy. Eventually surgical resection
after the extent of the disease has been established.
GU.18. – A 62 year old gentleman
had a radical prostatectomy for cancer of the prostate three years ago. He now presents with widespread bony
pain. Bone scans show metastasis
throughout the entire skeleton, including several that are very large and very
impressive.
What to do? - The point of this vignette is that
significant, often dramatic palliation cn be obtained with orchiectomy,
although it will not be long-lasting (one or two years only). An expensive alternative is luteinizing
hormone-releasing hormone agonists, and another option is antiandrogens
(flutamide).
GU.19. – An 82 year old gentleman
who has congestive heart failure and chronic obstructive pulmonary disease is
told by his primary care physician that his level of prostatic specific antigen
(PSA) is abnormally high. The gentleman
has seen ads in the paper for sonographic examinations of the prostate, and he
has one done. The examination reveals a
prostatic nodule, which on trans-rectal biopsy is proven to be carcinoma of the
prostate. The man is completely
asymptomatic as far as this cancer is concerned. He has not evidence of metastasis either.
What is it? - An example of technology running
amock. This man should have never had
the PSA in the first place, much less the sonogram and biopsy. After a certain age, most men get prostatic
cancer…but die of something else. As a
rule, asymptomatic prostatic cancer is not treated after age 75.
GU.20. – A 25 year old man
presents with a painless, hard testicular mass.
What is it? - Testicular cancer.
Management: This will sound
horrible, but here is a disease where we shoot to kill first…and ask questions
later. The diagnosis is made by
performing a radical orchiectomy by the inguinal route. That irreversible, drastic step is justified
because testicular tumors are almost never benign. Beware of the option to do a trans-scrotal
biopsy: that is a definitive no-no.
further treatment will include lymph node dissection in some cases (too
complicated a decision for you to know about) and platinum-based chemotherapy. Serum markers are useful for follow up:
alfa-fetoprotein and beta-HCG, and they have to be drawn before the
orchiectomy (but they do not determine the need for the diagnostic orchiectomy,
that still needs to be done).
GU.21. – A 25 year old man is
found on a pre-employment chest X-Ray to have what appears to be a pulmonary
metastasis from an unknown primary tumor.
Subsequent physical examination discloses a hard testicular mass, and
the patient indicates that for the past six months he has been losing weight
for no obvious reason.
What is it? - Obviously same as above…but with
metastasis. The point of this vignette
is that testicular cancer responds so well to chemotherapy, that treatment is
undertaken regardless of the extent of the disease when first diagnosed. Manage exactly as the previous case.
D. Retention - Incontinence
GU.22. – A 60 year old man shows
up in the ER because he has not been able to void for the past 12 hours. He wants to, bu can not. On physical exam his bladder is palpable half
way u between the pubis and the umbilicus, and he has a big, boggy prostate
gland without nodules. He gives a
history that for several years now, he has been getting up four or five times a
night to urinate. Because of a cold, two
days ago he began taking anthihystaminics, using “nasal drops”, and drinking
plenty of fluids.
What is it? - Acute urinary retention, with underlying
benign prostatic hypertrophy.
Management: Indwelling bladder catheter, to be left in
for at least 3 days. Long term therapy
includes many options, best are probably long-term alpha-blockers for
symptomatic relief, or some form of prostatic resection.
GU.23. – On the second
post-operative day after surgery for repair of bilateral inguinal hernias, the
patient reports that he “can not hold his urine”. Further questioning reveals that every few
minutes he urinates a few cc’s of urine.
On physical examination there is a large palpable mass arising from the
pelvis and reaching almost to the umbilicus.
What is it? - Acute urinary retention with overflow
incontinence.
Management: Indwelling bladder
catheter.
GU.24. – A 42 year old lady
consults you for urinary incontinence.
She is the mother of five children and ever since the birth of the last
one, seven years ago, she leaks a small amount of urine whenever she sneezes,
laughs, gets out of a chair or lifts any heavy objects. She relates that she can hold her urine all
through the night without any leaking whatsoever.
What is it? - Stress incontinence.
Management: Surgical repair of
the pelvic floor.
E. Stones
GU.25. – A 72 year old man who in
previous years has passed a total of three urinary stones is now again having
symptoms of ureteral colic. He has
relatively mild pain that began six hours ago, and does not have much in the
way of nausea and vomiting. X-Rays show
a 3mm. Ureteral stone just proximal to the ureterovesical junction.
Management: Urologists have a
bewildering array of options nowadays to treat stones, including laser beams,
shock waves, ultrasonic probes, baskets for extraction…etc, but there is still
a role for watching and waiting. This
man is a good example: small stone, almost at the bladder. Give him time, medication for pain, and
plenty of fluids, and h will probably pass it.
GU.26. – A 54 year old lady has a
severe ureteral colic. IVP shows a 7mm. Ureteral stone at the ureteropelvic junction.
Management: whereas a 3mm. Stone
has a 70% chance of passing, a 7mm. Stone only has a 5% probability of doing
so. This one will have to be smashed and
retrieved. Best option among answers
offered would be shock-wave-lithrotripsy).
F. Miscellaneous
GU.27. – A 33 year old man has
urgency, frequency, and burning pain with urination. The urine is cloudy and malodorous. He has mild fever. On physical exam the prostate is not warm,
boggy or tender.
The first part of this vignette
sounds like prostatitis, which would be common and not particularly
challenging; but if the prostate is normal on exam the ante is raised: The
point of the vignette becomes that men (particularly young ones) are not
supposed to get urinary tract infections.
This infection needs to be treated, so ask for urinary cultures and
start antibiotics…but also start a urological work-up. Do not start with cystoscopy (do not
instrument an infected bladder, you could trigger septic shock). Start with
either IVP (always a traditional way to begin a urological work-up), or
sonogram (which is also a pretty safe thing to do on anybody under any
circumstances).
GU.28. – A 72 year old man
consults you with a history for that for the past several days he has noticed
that bubbles of air come out along with the urine when he urinates. He also gives symptoms suggestive of mild
cystitis.
What is it? - Pneumaturia due to a fistula between the
bowel and the bladder. Most commonly
from sigmoid colon to dome of the bladder, due to diverticulitis. Cancer (also originating in the sigmoid) is
the second possibility.
Management: Intuitively you would
think that either cystoscopy or sigmoidoscopy would verify the diagnosis, but
real life does not work that way: they seldom show anything. Contrast studies (cystogram or barium enema)
are also typically unrewarding. The test
to get is CT scan. Because ruling out
cancer of the sigmoid is important, the sigmoidoscopic exam would be done at
some point, but not as the first test.
Eventually surgery will be needed.
GU.29. – A 32 year old man has
sudden onset of impotence. One month ago
he was unexpectedly unable to perform with his wife after an evening of heavy
eating and heavier drinking. Ever since
then he has not been able to achieve an erection when attempting to have
intercourse with his wife, but he still gets nocturnal erections and can
masturbate normally.
What is it? - Classical psychogenic impotence; young man,
sudden onset, partner-specific. Organic
impotence is typically older, of gradual onset and universal.
Management: Curable with
psychotherapy if promptly done.
(It will become irreversible after two years).
