PESTANA VIGNETTES

1. Trauma
2. Orthopedics
3. Pre-op and Post-op Care
4. General Surgery
5. Pediatric Surgery
6. Cardiothoracic Surgery
7. Vascular surgery
8. Skin surgery
9. Ophthalmology
10. Otolaryngology
11. Neurosurgery
12. Urology
13. Organ Transplantation

1. Trauma

Initial survey
Airway
1. Conscious, voice normal = airway fine
2. Expanding hematoma in neck = airway threatened, intubation
3. Subcutaneous air in neck/upper chest = airway threatened, intubation, fiberoptic
bronchoscopy for visualization
4. Unconscious = intubation
5. Unconscious, had neck pain and LE paralysis before = airway first, fiberoptic
bronchoscope to protect C-spine.
6. Facial fractures, bleeding into airway = normal airway obscured, needs airway through
neck (cricothyroidotomy, paracutaneous tracheostomy)
Indications for intubation: expanding neck hematoma, air in tissues of lower neck, coma,
trauma to face. Remember to protect C-spine if needed.

Breathing
7. Spontaneous breathing, bilateral sounds, O2 sat fine = breathing is fine

Shock
8. Sweating, cold, hypotension, tachycardia in trauma patient = shock—hemorrhagic
(hypovolemic), pericardial tamponade, or tension pneumothorax.
Trauma patient in shock: chest involved? Neck veins distended/cvp high? If no, hemorrhagic.
If yes to both, pericardial tamponade or tension pneumo. Is breathing difficult? Then tension
 pneumo. Find bleeding (ex lap), stop bleeding, restore volume (ringer’s lactate + blood
products). Can restore volume first if surgery not necessary or bleeding not obvious.
9. Gunshot to abdomen, nearby trauma center = scoop and run (no IVs in field)
10. External bleeding = stop it, direct local pressure with sterile glove/dressing. Not
tourniquet or clamps.
11. Unconscious, low BP, tachycardia, H/N veins not distended, don’t know where he’s
bleeding from = Intubation, hemorrhagic shock, IV access first, then find bleeding
12. Child shot in arm, bleeding controlled, can’t start IVs = intraosseous cannulation in
proximal tibia
13. Man beat by bear, external bleeding controlled, still in shock, far from hospital = fluid
resuscitation in field
14. Gunshot to chest/abdomen, shock = need to know if neck veins distended, CVP
elevated.
15. Gunshot to chest/abdomen, shock, distended neck veins, breathing fine w b/l sounds
= pericardial tamponade. Pericardio- centesis, tube, or window. Then give fluids.
16. Stabbed in left chest, shock, distended neck veins, b/l breath sounds = pericardial
tamponade. Go to OR and perform median sternotomy to evacuate tamponade, repair
injury at same time.
17. Gunshot to chest/abdomen, shock, distended neck veins, respiratory distress, trachea
deviated, hyperresonance = Tension pneumothorax, big bore needle in 2nd intercostal
space.
18. CAR CRASH, coma w dilated pupils, shock = Shock cannot be only due to brain bleed.
Must be bleeding somewhere else.

Non-trauma shock
19. Old man w chest pain, dyspnea, shock, distended neck veins = cardiogenic shock. EKG,
troponins, coronary care.
20. Bee sting, shock, warm and flushed, low CVP
21. Penicillin injection, shock, warm and flushed, low CVP
22. High sensory block from spinal, shock, warm and flushed, low CVP = vasomotor shock,
loss of vascular tone. Give vasoconstrictors and replace volume.
Non-trauma shock: Pale, cold, clammy, low CVP = hemorrhagic; Pale, cold, clammy, high
CVP = intrinsic cardiogenic; Warm, flushed, low CVP = vasomotor

Review from head to toe: head, neck, spinal cord

Head trauma
1. Ax to head, awake, alert, hemodynamically stable = only remove foreign body in OR
2. Blunt head trauma, neuro intact, CT: linear fracture = Clean and close in ER
3. Blunt head trauma, neuro intact, CT: comminuted depressed fracture = Repair in OR
4. Hit by car, neuro intact now, unconscious before = Head CT
5. Hit by car, bruised eyes
6. Hit by car, clear fluid out nose
7. Hit by car, clear fluid out ear
 8. Hit by car, bruise behind ear = Basal skull fracture, CT of head and neck (neck at risk
too)
9. Child hit on head, loses consciousness, lucid interval, coma again, right pupil dilated,
contralateral hemiparesis = Epidural hematoma
10. Man in car crash, loses consciousness, regains briefly, deep coma, right pupil dilated,
contralateral hemiparesis = Subdural hematoma
Head trauma: Epidural if trivial trauma and normal when lucid. CT = lens. Evacuate with
craniotomy. Subdural if severe trauma and somnolent when lucid. CT = crescent. If midline
shift, evacuate, otherwise monitor ICP
11. Car crash, coma, no lateralizing signs, CT: crescent = Control ICP
12. Car crash, coma, dilated pupils, CT: gray-white interface blurred and punctate
hemorrhages, no hematoma = Diffuse axonal injury. Control ICP.
13. Old man becomes senile since falling from horse 4 weeks ago = Chronic subdural
hematoma (only in old age or alcoholics with brain shrinkage). CT and decompression,
good prognosis.
14. Car crash, coma, dilated pupils, shock = shock is not from brain bleed

Neck trauma
15. Shot in neck, BP deteriorating = Surgical exploration of neck
16. Shot near thyroid cartilage, spitting and coughing blood, expanding hematoma =
Surgical exploration (Zone II)
17. Shot above mandible = Difficult to access surgically, do angiography
18. Shot between clavicle and cricoid = Needs preop characterization of damage:
angiography, soluble-contrast esophagram, esophagoscopy, bronchoscopy
Surgical exploration of penetrating injuries to neck: Unstable, hematoma, spitting or
vomiting blood, gunshot to middle of neck
Alternative management: Above mandible, Below cricoid
19. Stabbed near sternomastoid, asymptomatic, stable = Observe
20. Car crash, blunt trauma to neck, tender neck, neuro intact = Neck CT for C-spine

Spinal Cord Injuries

21. Stabbed in back right of midline, ipsilateral paralysis and loss of proprioception,
contralateral loss of pain perception = Brown-Sequard
22. Car crash, burst fracture of vertebrae, bilateral loss of motor and pain, preserved
proprioception = Anterior cord injury
23. Old man, car crash, hyperextends neck, paralysis of arms, motor intact in legs = Central
cord syndrome
Management of spinal cord injury: High dose steroids, MRI

Review from head to toe: chest, abdominal

Chest trauma
Unlike rest of body, penetrating injury usually requires chest tube rather than surgery. Also,
less distinction between blunt and penetrating trauma because blunt trauma can drive ribs
into chest.
1. Old man falls, hits chest, rib fracture = Topical anesthetic to avoid compromise of
breathing, atelectasis, and pneumonia
2. Stabbed in right chest, stable, hyperresonance with no breath sounds on right = plain
pneumothorax. Unlike with tension, time to get a CXR. Then chest tube at 5 th intercostal
space, mid-axillary line.
3. Stabbed in right chest, stable, right base dull to percussion without breath sounds =
hemothorax. Bleeding usually from lung parenchyma, ie low pressure right ventricular
source. Still needs chest tube to prevent empyema.
4. Stabbed in right chest, stable, right base dull, CXR: hemothorax, tube drains 120 ml,
then 20 in next hour = bleeding from lung parenchyma has stopped
5. Stabbed in right chest, mildly unstable, right base dull, CXR: hemothorax, tube drains
1250 ml = bleeding from systemic vessel. Surgical ligation required.
6. Stabbed in right chest, stable, right base dull, CXR: hemothorax, tube drains 350 ml,
then 200 in next hour = systemic vessel
7. Stabbed in right chest, stable, right base dull, apex hyperresonant, CXR: one large air-
fluid level = Tubes to evacuate air and blood
8. Explosion with shrapnel, sucks air through flaplike wound with inspiration =
Threatened tension pneumo, vaseline gauze dressing in field with one-way flap to let air
out, chest tube and repair in hospital
9. Car crash with deceleration injury, bruises and point tenderness on chest, CXR: rib
fractures, segment of chest wall on left caves in with inhalation, bulges with
exhalation = paradoxical breathing, flail chest.
Management of deceleration injury: 3 components: 1) treat obvious lesion, 2) monitor for
48 hours for pulmonary contusion and myocardial contusion (CXRs, ABGs, EKGs, and cardiac
enzymes), 3) Look for traumatic transection of aorta with CXR (wide mediastinum) and
spiral CT. CT angio if discrepancy between CXR and spiral CT.
Fracture of first rib, scapula, or sternum = severe deceleration injury.
10. Car crash with deceleration injury, bruises and point tenderness on chest, CXR: rib
fractures, lungs clear and expanded, lungs “white out” on CXR 2 days later =
Pulmonary contusion. Fluid restriction, diuretics, if fluids needed use colloid or
crystalloid, respiratory support if ABGs deteriorate including PEEP if needed.
11. Car crash with deceleration injury, bruises and point tenderness on chest, CXR: rib
fractures, respiratory distress, shock, distended neck veins, left sided hyperresonance
= tension pneumothorax due to penetration from broken ribs. Chest tube.
12. Car crash with deceleration injury, bruises and point tenderness over sternum with
crepitus = Confirm sternal fracture with lateral CXR. High risk for myocardial contusion
or traumatic aortic rupture.
13. Car crash with deceleration injury, respiratory distress, absent breath sounds on left,
CXR: multiple air-fluid levels in left chest = Traumatic diaphragmatic rupture. Surgical
repair.
14. Motorcycle collision with wall, stable, first rib fracture on CXR, widened mediastinum
= Traumatic transection of aorta. Confirm with spiral CT. Emergency repair.
15. Car crash with deceleration injury, head and extremities injured, left pneumothorax,
subcutaneous emphysema over chest and neck = Thoracic subcutaneous emphysema
 (confirm with CXR). Caused by 1) Rupture of esophagus, 2) Tension pneumothorax, 3)
Transection of trachea or bronchus (confirm diagnosis and intubate with fiberoptic
bronchoscopy).
16. Large amount of air coming through chest tube placed for traumatic pneumothorax =
Major bronchial injury
17. Penetrating chest injury, intubated, chest tube placed, sudden cardiac arrest = air
embolism from injured bronchus to injured pulmonary vein. Cardiac massage and
thoracotomy needed.
18. Supraclavicular node biopsy, hissing sound, patient dies suddenly = air embolism from
damage to vessel. Should have prevented with trendelenberg.
19. Patient disconnects central venous line, dies suddenly = air embolism
20. Long bone fractures, petechial rash, respiratory distress, patchy infiltrates on CXR = fat
embolism. Respiratory support needed.
Pulmonary failure after trauma: fracture of first rib, scapula, or sternum = pulmonary
contusion, long bone fractures = fat embolism

Abdominal trauma
21. Shot in abdomen, stable = exploratory laparotomy. Prepare with foley, IV, abx.
22. Shot in abdomen, clean punched-out entrance and exit wounds in transverse colon =
Colostomy if gross fecal contamination, or primary repair if minimal contamination.
23. Shot two inches below left nipple = Treat any gunshot wound below nipples as if it
involves abdomen through dome of diaphragm. Ex lap.
24. Stabbed in abdomen, omentum protruding = peritoneal penetration took place, ex lap
needed
25. Obese patient stabbed in abdomen, stable, no peritoneal signs = peritoneal
penetration may not have occurred, confirm with digital exploration. If suspicious,
confirm with CT.
26. Car crash against wall, extremity fractures, hypotension, tachycardia, tender abdomen
with guarding and rebound = Acute abdomen (peritoneal irritation) with bleeding. Ex
lap needed.
27. Car crash against wall, extremity fractures, stable vital signs, tender abdomen with
guarding and rebound = Acute abdomen without bleeding. Ex lap needed.
28. Car crash, no obvious source of bleeding, hypotension, tachycardia, low CVP, normal
CXR = Unknown site of hemorrhage. Not brain (not enough room). Not neck (would be
obvious on exam). Not chest (normal CXR). Remaining possibilities: Abdomen, pelvis,
femur. Examine pelvis, femur. CT abdomen if stable. Sonogram or lavage if unstable. Ex
lap when abdominal bleeding confirmed.
29. Car crash, ribs fractured, shock, positive peritoneal lavage, ruptured spleen on ex lap =
Try to repair spleen. If splenectomy necessary, immunize with Pneumovax and against
HiB and meningococcus.
30. Massive transfusion in OR, blood oozing from IV sites, normal temp = Coagulopathy.
FFP and platelet packs.
31. Massive transfusion in OR, blood oozing from IV sites, low temp, refractory acidosis =
Temporarily pack surfaces and close abdomen.
 32. Massive transfusion and fluid resuscitation in OR, cannot approximate wound during
closure = Abdominal compartment syndrome: edema in operative area can lead to
pulmonary or renal failure through compression of diaphragm or IVC. Temporary
closure needed.
33. Postop day 1, tense and distended abdomen, retention sutures cutting through
abdominal wall, hypoxia and renal failure = Abdominal compartment syndrome.
Decompress abdomen and place temporary closure.

Review from head to toe: pelvic, urologic, extremity injuries

Pelvic fractures
34. Crushed by car, pelvic fracture, hypotension responsive to fluids, pelvic hematoma but
no intraabdominal bleeding on CT = Leave hematoma alone. Rule out injury to: rectum,
bladder, vagina (female) or urethra (male)
35. Crushed by car, pelvic fracture, refractory hypotension, no intraabdominal bleeding =
Pelvic venous bleeding probably not accessible via laparotomy or angiogram. External
fixation is best.

Urologic injuries
36. Shot just above pubis, blood in urine = Bladder injury, surgical repair
37. Shot in flank, blood in urine = Kidney injury, surgical repair
38. Car crash, pelvic fracture, blood at meatus = with pelvic fracture, think bladder injury
or, in men, urethra injury. Needs retrograde urethrogram.
39. Male, car crash, pelvic fracture, blood at meatus, scrotal hematoma, can’t urinate,
high-riding prostate = posterior urethral injury. Retrograde urethrogram.
40. Male, car crash, pelvic fracture, blood at meatus, scrotal hematoma = anterior urethral
injury
41. Male, car crash, pelvic fracture, no blood at meatus, resistance met with foley = back
out, retrograde urethrogram.
42. Female, car crash, pelvic fracture, blood in urine = Likely source is bladder over urethra
since urethra is so short in women. Do retrograde cystogram. Once with full bladder to
see rupture at dome, once with nearly empty bladder to see rupture at trigone.
43. Car crash, gross hematuria, rib and abdominal injuries but no pelvic fracture = Likely
kidney injury. CT to confirm. Surgery not needed unless renal pedicle is avulsed.
44. Car crash, hematuria, rib and abdominal injuries but no pelvic fracture, retrograde
cystogram normal, renal injuries on CT don’t require surgery, dyspnea and flank bruit
develop 6 weeks later = AV fistula at renal pedicle causing CHF. Renal pedicle damage
could also present with renovascular hypertension due to stenosis.
45. 35 yo man, blunt trauma, microscopic hematuria = renal contusion, no intervention
necessary
46. 4 yo falls off tricycle, microscopic hematuria = suspect congenital anomaly
47. 14 yo slides down banister, smashes scrotum, large scrotal hematoma, able to urinate
normally, no hematuria = Sonogram to look for ruptured testicle
 48. Man slips in shower, injures penis, penile shaft hematoma, normal glans = Cover story
for fracture of tunica albuginea and corpora cavernosa during intercourse with woman
on top. Urologic emergency.
Blunt trauma and blood in urine: Lower rib fractures but no pelvic fracture? Renal injury—
CT. Pelvic fracture? Female: bladder; Male: urethra or bladder injury. In male: retrograde
urethrogram then cystogram.

Extremity injuries
1. Shot in anterolateral thigh, bullet lodged in muscles posterolateral to femur = bullet
tract is too lateral to damage femoral artery. Clean wound and give tetanus prophylaxis.
2. Shot in anteromedial thigh, exit wound in posterolateral thigh, normal distal pulses,
no hematoma, femur intact on X-ray = Anatomical proximity to femoral artery. Doppler
studies needed.
3. Shot in anteromedial thigh, exit wound in posterolateral thigh, expanding hematoma,
femur intact = Surgical exploration and repair.
4. Shot in medial arm, hematoma on inner arm, no distal pulses, radial nerve palsy,
shattered humerus = Vascular, nerve, and bone injuries. Fix bone first because it
requires rough handling, then approximate artery, then nerve. This delayed vascular
repair may cause compartment syndrome and require fasciotomy.
5. Shot in anterolateral thigh with high-velocity hunting rifle, exit wound posteromedial
thigh, femur is shattered = High-velocity bullets produce a cone of destruction.
Extensive debridement and repair needed.
6. Arm crushed in car crash, pulses normal, bones intact = What is crushed out of cells?
Hyperkalemia, myoglobinemia (and myoglobinuria, renal failure). Check serum
potassium, serum/urine myoglobin. Give fluids, osmotic diuretics, alkalinization of urine.
Compartment syndrome may require fasciotomy.

Burns
7. Girls spills Drano on herself = Chemical burn—massive irrigation needed
8. Man burned with high-tension electrical line = Electrical burn—always bigger than
expected, surgical debridement needed, also all muscles contract at same time, can
cause vertebral body compression, posterior dislocation of shoulder, cataracts,
demyelination, myoglobinemia/myoglobinuria. IV fluids, diuretics (mannitol),
alkalinization of urine.
9. Man rescued from burning building with soot in pharynx = Inhalation injury. Confirm
with bronchoscopy. f/u with ABG, may need respiratory support.
10. 3rd degree circumferential arm burns from barbecue = skin, thick and leathery, will not
yield to swelling. Check pulses with Doppler, capillary filling, may need escharatomy.
11. Child scalded on buttocks supposedly by spilling boiling water = Silver sulfadiazine and
call social services.
12. Extensive 2nd degree (moist, blisters, painful) and 3rd degree (white, leathery,
anesthetic) burns on body = 9% body surface area is a head, an arm, ½ a leg, ¼ of trunk
13. Extensive 3rd degree burns, what rate for fluid? = Ringer’s lactate at 1L/hr
 14. Extensive 3rd degree burns, what amount of fluid is needed? = 4ml per kg per
percentage burned area. One half in 1st 8 hrs, second half in next 16 hrs. Then one half
the total calculated amount on the 2nd day.
15. 70kg man on fluids with hourly urine output of 13, 22, 18 = Needs more fluid. UOP
should be 0.5-1 ml/kg/hr.
16. 70kg man on fluids with hourly urine output of 325, 240, 270 = Too much urine. Scale
back fluids.
17. 70 kg man on fluids with UOP of 45-110 ml/hr in 1st 48 hrs after burn, 270-350 ml/hr
on 3rd day after fluids stopped = Normal, fluids returns from burn area
18. Baby is burned = Head has two 9s, legs have three 9s in baby. Formula is 4-6*kg*%.
19. 65% burn, on fluids, management? = Tetanus ppx. Cleaning, and silver sulfadiazine.
Triple abx ointment near eyes. IV pain meds. Nutrition via gut after 1-2 days. Skin grafts
after 2-3 weeks.
20. Drops hot iron on lap = Small 3rd degree burn. Early excision and grafting.

Bites and Stings

21. Child bitten by dog while dog eating = Dog was provoked. Observe dog rather than start
rabies treatment (unless bite is on face near brain). Tetanus ppx.
22. Bitten by coyote, animal captured = kill animal and examine brain for signs of rabies
23. Bitten by bats = rabies ppx: Ig + vaccine
24. Bitten by rattlesnake = Observe 12hrs for signs of evenomation: local pain, swelling,
discoloration.
25. Bitten by rattlesnake with local edema, ecchymosis, and severe tenderness = Send labs
for type and cross, coags, renal/liver function. Give antivenin.
26. Young girl bitten by rattlesnake and envenomated = Doesn’t matter that she is small,
give antivenom based on estimated amount of venom injected.
27. Young girl stung repeatedly by bees, wheezing, hypotensive, urticarial rash =
Epinephrine. Remove stingers.
28. Black widow bite = IV calcium gluconate + muscle relaxants.
29. Spider bite causing ulcer with necrotic center = Brown recluse bite. Dapsone. Wait 1
week for excision and grafting.
30. Gang member has small deep sharp cut over knuckle “from screwdriver” = Human bite
from punching someone in mouth. Very dirty. Requires surgical exploration.

2. Orthopaedics

Disorders in children
Hip
1. Newborns hip can be easily posteriorly dislocated = developmental dysplasia
(congenital). Sonogram if any doubt about diagnosis (not calcified yet enough for X-ray).
Abduction splinting with Pavlik harness or double diapers.
 2. 6 yo boy with antalgic gait, limited hip motion, knee pain = Leff-Perthes (avascular
necrosis of capital femoral epiphysis). AP/lateral x-rays. Cast and crutches.
3. 13 yo obese boy with groin pain, limited hip motion, leg externally rotates when hip
extends = slipped capital femoral epiphysis. AP/lat x-rays. Pin femoral head in place.
4. Toddler with painful hip after flu, holds in abduction and external rotation = septic hip,
aspirate under anesthesia, open arthrotomy for drainage.
Diagnose hip problems based on age: Newborn: dev. dysplasia. Age 6: avascular necrosis.
Age 13: SCFE. Post febrile illness: Septic.

Other locations
5. Persistent, severe, localized bone pain after febrile illness = Acute hematogenous
osteomyelitis. X-ray won’t show for 2 weeks. Get MRI then abx.
6. 2 yo boy is bowlegged = Genu varum normal until 3. After then may be blount disease
(disturbance of medical proximal tibial growth plate).
7. 5 yo is knock-kneed = Genu valgus normal until 8
8. Boy injured playing football, pain and tenderness over tibial tubercle, no swelling =
Osteochondrosis of the tibial tubercle (Osgood-Schlatter). Immobilize knee for 4 weeks.
Remember: if intrinsic pathology, there will be swelling.
9. Baby boy with plantar flexion of ankle, inversion of foot, adduction of forefoot,
internal rotation of tibia = Talipes equinovarus (club foot). Serial plaster casts. Address
most distal deformity first. Operate after 6 months, before 2 years if needed.
10. 12 yo girl has thoracic spine curved to right, hump over right thorax when she bends
forward = Mostly girls during growth spurt. Needs bracing until skeletal maturity.
Skeletal maturity at 80% with menarche. Large deformity could limit pulmonary
function.

Fractures
Fractures in children have better outcomes than those in adults. Bones are more flexible.
They heal faster. They have tremendous remodeling capacity. Only downside is when
growth plate is damaged.
11. 4 yo fractures humerus, placed in cast, 2 days later AP/lat x-rays show significant
angulation = no problem. Will remodel.
12. 8 yo boy falls on hyperextended elbow, supracondylar fracture of humerus on x-ray =
Monitor vascular supply (pulse, Doppler) and compartment syndrome. Cast or traction.
13. Child fractures long bone involving epiphysis and growth plate, which are together in
one piece = Growth place in one piece. Closed reduction.
14. Child fractures long bone through epiphysis, growth plate, metaphysis = Growth plate
in fractured. Open reduction and internal fixation.

Tumors
Children and young adults
The main population that gets primary bone tumors
15. 16 yo with persistent pain in distal femur, sunburst on xray as tumor invades through
cortex = Osteogenic sarcoma. Most common.
 16. 10 yo with persistent in middle thigh, onion skinning on xray as tumor pushes cortex
out = Ewing sarcoma. Second most common. Younger children. In diaphyses.

Adults
17. 66 yo woman breaks arm picking up groceries = Pathological fracture. Osteolytic
metastatic tumor to bone (primary likely in breast, lung).
18. Pain at specific places on several bones, anemia, lytic lesions on xray = multiple
myeloma. Xrays + Bence-Jones in urine, SPEP for M spike. Tx with chemo or thalidomide.
19. Soft tissue tumor in thigh fixed to surrounding structures = Likely sarcoma. Get MRI.

General orthopaedics
Adult orthopaedic injuries
20. Fall from 2nd floor window, fractures femur, what xrays? = Two, 90º from each other,
including joints above and below, and other joints in same line of force (here lumbar
spine).
21. Clavicle fracture playing football, tenderness at junction of middle and distal third =
Sling or figure of 8 splint.
22. Falls, hurts shoulder, holds arm outward as if shaking hands, numbness over deltoid =
Anterior dislocation of shoulder, axillary nerve damage. AP/lat xrays, reduce.
23. Pain in shoulder after seizure, arm held close to body and not externally rotated =
Posterior dislocation of the shoulder (requires uncoordinated contraction of many
muscles). Xray with axillary or scapular lateral view.
24. Elderly woman falls on outstretched hand, deformed wrist like dinner fork, xray shows
dorsally displaced, dorsally angulated distal radius fracture with nondisplaced ulnar
stylus fracture = Colles fracture. Closed reduction and long arm cast.
25. Forearm hit with police nightstick, diaphyseal fracture of proximal ulna, anterior
dislocation of radial head = Monteggia fracture. Closed reduction of radial head,
possible ORIF of ulnar fracture.
26. Forearm hit with police nightstick, distal third radius fracture with dorsal dislocation
of distal radioulnar joint = ORIF for radius. Cast the dislocated join in supination.
Principle: If bone can be easily manipulated back into position, can do closed reduction. If
this is not possible, need open reduction and internal fixation.
27. Fall on outstretched hand, palpation over anatomic snuff-box, negative xrays =
Scaphoid fracture. Thumb spica cast. Repeat xray 3 weeks later.
28. Fall on outstretched hand, palpation over anatomic snuff-box, xrays show
displacement and angulation = Needs ORIF.
29. Punches wall, fracture of 4th and 5th metacarpal neck = If mild, closed reduction and
ulnar gutter splint. If severe, kirschner-wire or plate fixation.
30. Old man falls and breaks hip, affected leg is shortened and externally rotated,
displaced femoral neck fracture on xray = Blood supply to femoral head compromised.
Requires metal prosthesis.
31. Old man falls and breaks hip, affected leg is shortened and externally rotated,
intertrochanteric fracture = Less concern for AVN, open reduction and pinning
adequate. Add anticoagulation for postop immobilization.
Hip fracture – Displaced femoral neck: prosthesis; Intertrochanteric: ORIF, postop
anticoagulation

32. Unrestrained passenger in car crash, fracture of femoral shaft = Intramedullary rod
fixation
33. Unrestrained passenger in car crash, comminuted bilateral femoral fractures, shock,
low CVP, negative chest/pelvis/abdominal scans = hypovolemic shock from
comminuted fractures, fixation to reduce blood loss, fluids and blood to address shock
34. Unrestrained passenger in car crash, comminuted bilateral femoral fractures,
disorientation, fever, scleral petechiae, dyspnea, PO2 60 = fat embolism. Respiratory
support.
35. Knee injury playing football, pain and swelling on medial aspect, pain and laxity with
leg abduction while knee flexed to 30º
36. Knee injury playing football, pain and swelling on lateral aspect, pain and laxity with
leg adduction while knee flexed to 30º = Collateral ligament injury (the one with pain
on direct palpation)
37. Knee injury playing football, swollen and painful, leg can be pulled anteriorly with
knee at 90º = Anterior cruciate ligament injury
38. Knee injury playing basketball, swollen and painful, catching/locking sensation with
click during extension = Meniscal tear. MRI needed.
39. Localized tenderness on tibia after marching at boot camp, normal xray = Stress
fracture. Cast/non-weight bearing and repeat xray 2 weeks later.
40. Hit by car, angulation between knee and ankle = Tibia/fibula fracture. Cast those that
can be reduced. Intramedullary nailing if cannot be aligned.
41. Hit by car, angulation between knee and ankle, aligned and casted, but increasing
muscle pain over next 8 hours, especially with toe extension = Compartment
syndrome. Fasciotomy needed.
42. Pop in ankle playing tennis, swelling in back of lower leg = Achilles rupture. Cast in
equinus position or open surgical repair.
43. Old man twists ankle and falls on inverted foot while running = Fractures of both
malleoli. Get AP, lateral, mortise xrays. ORIF needed if fragments displaced.

Orthopaedic emergencies
44. Man passes out drunk on forearm, muscles are firm and tender, pulses normal =
Compartment syndrome. Fasciotomy needed. Normal pulses does not preclude
damaged to muscle, which can occur with just 30 mmHg of pressure.
45. Persistent leg pain under cast applied 6 hours previously = Remove cast and examine.
46. Open fracture of right thigh after motorcycle accident = Orthopaedic emergency. Clean
and reduce within 6 hours to prevent osteomyelitis.
47. Hits dashboard with knees in car crash, right leg shortened, adducted, internally
rotated = Posterior dislocation of hip. Emergency reduction needed to avoid AVN.
48. Steps on rusty nail, 3 days later moribund, foot is swollen dusky and with gas
crepitation = Gas gangrene. IV penicillin. Surgical debridement. Hyperbaric oxygen.
Associated neurovascular injuries
49. Falls down stairs, oblique fracture of humerus, can’t dorsiflex wrist = Radial nerve
injured in spiral groove. Cast or splint or usually fine unless nerve became paralyzed
with the reduction indicating entrapment that will need surgical exploration.
50. Knee injury playing football, posterior dislocation of tibia = Check popliteal artery
(distal pulses, Doppler studies, CT angio). Prompt reduction.

Second hidden fracture

51. Fall from 3rd story, comminuted fractures of both calcanei = check thoracic/lumbar
spine
52. Unrestrained passenger in car crash strikes dashboard and windshield, suffers facial
lacerations, upper extremity fractures, blunt trauma to chest/abdomen = Check
femoral head
53. Unrestrained passenger in car crash has facial fractures, closed head injury = Check C-
spine: CT the neck.

Orthopaedic hand problems

54. Secretary has numbness/tingling in hand, especially over median nerve distribution
with percussion of carpal tunnel = Carpal tunnel syndrome. Do wrist x-rays and splint.
Do EMG to justify surgery if needed.
55. Wakes up at night with middle finger acutely flexed, can’t extend = Trigger finger.
Steroid injections. Surgery if needed.
56. Upon wrist flexion and thumb extension to carry baby, pain on medial side of wrist,
pain reproduced when fist is forced into ulnar deviation = De Quervain tenosynovitis.
Can splint and give NSAIDs, steroid injection best.
57. Old man of Norwegian ancestry with contracted hand and palmar fascial nodules =
Dupuytren contracture
58. Carpenter drives nail into pulp of index finger, 2 days later has throbbing pain, fever,
abscess in same location = Felon abscess. Urgent drainage required because pulp of the
finger is enclosed space that can have compartment syndrome.
59. Falls while skiing, jams thumb into snow, collateral laxity at MCP joint = Gamekeeper’s
thumb. Injury to ulnar collateral ligament. Requires casting to prevent dysfunction,
arthritis.
60. Holds shirt of fleeing thief, can’t flex distal phalanx = Jersey finger (flexor tendon
injury). Splint.
61. Middle finger injury playing volleyball, can’t extend distal phalanx = Mallet finger
(extensor tendon injury). Splint.
62. Man severs finger cleanly while bookbinding = Clean with saline, wrap in moistened
gauze, place in plastic bag, place bag on ice. Do not use antiseptic solutions or place
directly on ice.

Back pain
63. Old man has severe pain lifting heavy object, electric shock down leg, pain with
straining and straight leg raise = herniated disk, usually L4-5 or L5-S1, MRI for diagnosis.
 Shock by big toe = L4-5. Shock by little toe = L5-S1. Surgery if progressive weakness or
sphincteric deficits.
64. Old man has severe pain lifting heavy object, electric shooting down leg, pain with
straining and straight leg raise, distended bladder, flaccid rectal sphincter, perineal
saddle area anesthesia = Cauda equine syndrome, surgical emergency.
65. 34 yo with chronic back pain, morning stiffness, improves with activity, treated for
uveitis 2 years ago = ankylosing spondylitis. Bamboo spine. Give NSAIDS, PT.
66. Elderly, weight loss, back pain worse at night, unrelieved by rest or change in position
= Metastatic malignancy. MRI makes earlier diagnosis than xray.

Leg ulcers
67. Diabetic has unhealing foot ulcer = Usually at heel or head of first metatarsal. Control
diabetes, elevate leg, and keep ulcer clean. May have to amputate.
68. Smoker with hyperlipidemia and coronary artery disease has ulcer on toe, toe is blue
with no peripheral pulses = Ischemic ulcer due to atherosclerotic occlusion is usually
very distal. Doppler studies, angiogram. Revascularization.
69. Obese patient with varicose veins has unhealing ulcer above medial malleolus, skin
thick and hyperpigmented = Venous stasis ulcer. External support with stockings, boot.
Endoluminal ablation may be needed.
70. Dirty ulcer with heaped up edges near chronic draining sinus, history of osteomyelitis
= Squamous cell carcinoma
71. Dirty ulcer with heaped up edges near site of untreated severe burn, not healing =
Squamous cell carcinoma. Biopsy with wide local excision.
Ulcer location: Toe—Arteriosclerotic; Pressure point—Diabetes; Above medial malleolus—
venous stasis; Cycles of breaking down and healing—SCC

Foot pain
72. Sharp heel pain worse in morning, tender bone spur on heel = Plantar fasciitis.
Resolves spontaneously in 12-18 months. Requires symptomatic treatment.
73. Tenderness in third interspace of forefoot after prolonged use of high-heeled shoes, =
Morton neuroma, inflammation of common digital nerve. Change shoes, can excise.
74. Obese man with swelling, redness, exquisite pain at MTP joints in foot = gout. UA
crystals in joint fluid. Acutely indomethacin and colchicine. Long-term allopurinol or
probenecid.

3. Preop assessment

Cardiac risk
1. Scheduled sigmoid resection for diverticulosis, history of MI, radionuclide
ventriculography shows EF of 0.35 = Normal is >0.50. Here the incidence of
perioperative MI would be 75 to 85%. Should do medical therapy for diverticular
disease.
 2. Old, bedridden, scheduled for emergency cholecystectomy, recent MI, A-fib, PVCs,
jugular venous distension = Meets all Goldman criteria for operative cardiac risk.
Consider percutaneous cholecystostomy instead.
3. Old, scheduled sigmoid resection for diverticulosis, has JVD = CHF is worst Goldman
risk factor for perioperative cardiac complications. Give ACEi, beta-blockers, digitalis,
diuretics to treat CHF first.
4. Old, scheduled sigmoid resection for diverticulosis, transmural MI 2 months ago =
Recent MI (6 months) is second worst cardiac risk factor. Wait until 6 months. If surgery
is needed, admit to ICU to optimize cardiac parameters.
5. Old, scheduled abdominal aortic aneurysm repair, history of severe progressive angina
= might improve risk with coronary revascularization first
Pulmonary risk
6. Scheduled AAA repair, COPD with 60-pack yr history = Do PFTs. If FEV1 low, check gas.
If PCO2 high as well, then do respiratory intensive therapy before surgery (physical
therapy, expectorants, incentive spirometry, humidified air).
Hepatic risk
7. Cirrhotic needs surgery for duodenal ulcer, bili is 3.5, PT is 22, albumin is 2.5, has
ascites, encephalopathy = Don’t operate. Any of these alone causes mortality >40%. 4
or more causes at least 85% mortality. Do arteriographic embolization instead.
8. Cirrhotic with blood ammonia above 150 needs surgery = Don’t do it.
9. Cirrhotic with albumin below 2 needs surgery = Don’t do it.
10. Cirrhotic with bili above 4 needs surgery = If the bili is due to hepatic dysfunction, don’t
do it. Death occurs in all these scenarios with high-output cardiac failure.

Nutritional risk
11. Lost 20% weight over 2 months, albumin is 2.7, anergy to skin-test antigens,
transferrin is below 200 = Very high risk. Only 5-10 days of nutritional support
(preferably via gut) can mitigate this risk.

Metabolic risk
12. Diabetic is dehydrated, in coma, blood sugar of 950, severe acidosis, ketones
everywhere = Address DKA first.

Postoperative complications
Fever
13. Halothane and succinylcholine, 104º fever, acidosis, hypercalcemia, family member
with similar complication = Malignant hyperthermia. Give dantrolene. 100% O2.
Manage acidosis. Watch out for myoglobinemia/uria. Patient has hereditary lack of
enzyme to metabolize agents causing muscle contraction and generation of heat.
14. 45 min after cystoscopy, chills and fever to 104º = Bacteremia (septicemia). Cultures
times 3 + empiric abx.
Postop fever: Day 1: Wind (atelectasis), 3: Water (UTI), 5: Walking (DVT), 7: Wound, 10:
Wonder where (Deep abscess)
 15. Fever postop day 1 = Atelectasis. CXR; check wound, IV sites, UTI symptoms. Improve
ventilation with deep breathing, coughing, postural drainage, incentive spirometry.
16. Fever postop day 1, not compliant with atelectasis therapy, continued fever day 3 =
Pneumonic process in atelectatic segments. CXR, cultures, abx.
17. Abdominal surgery, afebrile days 1-2, fever day 3 = UTI. UA, cultures, abx.
18. Abdominal surgery, afebrile days 1-4, fever day 5 = DVT. Doppler studies, ambulation,
anticoagulants.
19. Abdominal surgery, afebrile days 1-6, fever day 7 = Wound infection. Physical
examination of wound needed.
20. Abdominal surgery, afebrile days 1-9, fever day 10 = Deep abscess (likely pelvic or
subphrenic). CT and drain percutaneously.
Chest pain after surgery = MI (within first day) or PE (after fifth day).
21. Severe retrosternal pain radiating to left arm postop day 2 = MI. EKG, troponins.
Cannot give tPA.
22. Unexpected bleeding during operation, hypotension for 1 hr, ST depression and T
wave flattening on EKG = Perioperative MI. Most often caused by prolonged
hypotension. Signs on EKG.
23. 7th postop day after hip repair, sudden pleuritic chest pain and dyspnea, tachycardic
with distended neck veins = PE. Hypoxemia with hypocapnia on ABGs. Get spiral CT. If
similar vignette, but venous pressure low, not a PE. Management: heparin, IVC filter.
24. Awake intubation in drunk combative man, he vomits and aspirates = Chemical injury
to tracheobronchial tree. Lavage with bronchoscopy.
25. Car crash with broken ribs, during surgery becomes difficult to bag him and BP
declines, CVP rises = Tension pneumothorax caused by puncture from broken ribs.
Intraoperative thoracic needle decompression.

Disorientation/Coma
26. Confusion 18 hrs postop = Do ABGs.
27. Confusion 2nd week postop, bilateral pulmonary infiltrates, PO2 65 on 40% O2, not in
CHF = ARDS, likely precipitated by sepsis. Low volume ventilation with PEEP.
28. Alcoholic confused, combative, hallucinating on 3rd postop day = Delirium tremens.
Benzos.
29. Confusion 12 hrs postop, followed by severe headache, seizure, coma, was mistakenly
put on too much fluid = Water intoxication. Confirm with serum sodium (likely will be
115). Give hypertonic saline.
30. Confusion 8 hrs after hypophysectomy followed by coma, UOP has been 600 ml/hr
despite fluids at 100 ml/hr = Diabetes insipidus. Hypernatremia. Confirm with serum
sodium. Give ¼ NS or D5W.
31. Cirrhotic comatose after portocaval shunt for bleeding esophageal varices = Hepatic
encephalopathy (hyperammonemia).

Urinary complications
32. Unable to void 6 hrs after abdominopelvic surgery = Inability to void common after
abdominopelvic surgery. Ambulate. In-and-out bladder catheterization.
 33. No urine output in foley after abdominopelvic surgery = Probably mechanical block,
catheter plugged or kinked.
34. Several hrs after surgery for blunt trauma, UOP is 12, 17, 9, not hypotensive = Needs
more fluids or renal failure. Measure urine sodium which would be < 20 if insufficient
fluid (FeNa<1).
35. No bowel sounds or flatus 4 days after small bowel surgery = Paralytic ileus. NPO and
NG suction until peristalsis resumes. Rule out obstruction with CT if not resolved by day
6. Also check serum potassium for hypokalemia.
36. Elderly patient, immobilized at baseline, abdominal distension on postop day 5,
distended colon on xray = Ogilvie syndrome (colonic dilatation). Correct
fluids/electrolytes. Neostigmine to improve motility. Colonoscopy.

Wound complications
37. 5th day after laparotomy, salmon-colored clear fluid soaks dressing = Wound
dehiscence. Repair in OR.
38. 5th day after laparotomy, salmon-colored clear fluid soaks dressing, patient gets up,
wound opens, bowel spills out = Evisceration. Cover bowel with large moist saline
dressing. Rush to OR for reclosure.
39. Febrile on 7th day after inguinal surgery, wound is red, hot, tender boggy = Wound
infection. Confirm abscess with sonogram if doubt as to the presence of pus (indicating
abscess over cellulitis).
40. 9th day after sigmoid resection, wound drains feces, no fever = Fecal fistula.
Inconvenient but not serious, fit with colostomy bag, not missing essential nutrients
from the lost feces
41. 8th day after hemigastrectomy and reanastomosis, wound leaks 2-3L of green fluid =
High fistula. Will need fluids, electrolytes, and elemental nutrients delivered to upper
jejunum by catheter. Abdominal wall has to be protected from digestion by leaking GI
fluids, which can be reduced by somatostatin or octreotide. “Let nature heal the fistula.”
Revise if still needed 3 weeks later.

Fluids and electrolytes

42. Patient comatose 8 hrs after hypophysectomy, UOP has averaged 600 ml/hr despite IV
fluids at 100 ml/hr, serum sodium is 152 = Hypernatremia developed rapidly. Every 3
mEq above 140 = 1L lost. Can reverse water deficit rapidly with 4L D5W.
43. Lost in desert, arrives in ED dehydrated, serum sodium 155 = Hypernatremia
developed slowly, correct 5L deficit with D5½NS to avoid too-rapid correction of
hypertonicity.
44. Confusion 12 hrs postop, followed by severe headache, seizure, coma, was mistakenly
put on too much fluid, serum sodium 122 = Hyponatremia due to retained water in
postoperative high-ADH state. Give 100ml hypertonic 3-5% saline and reassess.
45. Scheduled chemo for breast cancer, asymptomatic but serum sodium 122 = Brain has
adapted to this very slow loss. Water restriction.
 46. Incarcerated hernia, fecaloid vomiting for 5 days, serum sodium 118 = Initial loss of
isotonic fluid followed by thirst and pure water intake causes hyponatremia. Replace
with isotonic fluids.
High serum sodium: 1L water loss per 3 mEq above 140. Rapid change—replace with D5W.
Slow change—replace with D5½NS.
Low sodium: ADH is abnormally high. Rapid change—Hypertonic saline. Slow change—
Isotonic fluid. Very slow change—Water restriction.
47. DKA, dehydration, initial K 5.2, saline therapy, repeat K 2.9 = Cells dumped K to fix
acidosis, kidneys then dumped this K, causing profound hypokalemia. Start potassium as
soon as UOP is reestablished in DKA (as quickly as 20 mEq per hour).
48. Crush injury, shock, transfusion, acidosis, K is 6.1 = All these things cause hyperkalemia.
Give IV Ca to protect heart and insulin/dextrose to push K into cells.
49. Diabetic alcoholic in car crash, goes into shock, pH is 7.1, PCO2 is 36, sodium 138,
chloride 98, bicarbonate 15 = Anion gap metabolic acidosis due to lactic acidosis from
shock. Give ringer’s lactate.
50. Duodenal fistula develops after subtotal gastrectomy, drains green fluid, sodium 132,
chloride 104, bicarb 15, pH 7.2, PCO2 35 = Loosing bile and pancreatic juice, ie lots of
bicarb. In this case, give bicarb to correct metabolic acidosis.
51. Pyloric obstruction, vomiting of clear gastric contents, Na 134, Cl 82, K 2.9, HCO3 34 =
Hypochloremic, hypokalemic metabolic alkalosis. Give KCl 10 mEq/hr
Abnormal pH: Metabolic acidosis—treat cause; Metabolic alkalosis—give KCl.

4. General Surgery

Upper GI system
Esophagus
1. Substernal pain, gallbladder ultrasound, EKG, and cardiac enzymes negative,
sometimes consistent with reflux, sometimes not = Possible GERD. Do pH monitoring.
2. Substernal pain with bending over, wearing tight clothing, lying flat in bed, relieved by
antacids = GERD. Do endoscopy and biopsy.
3. Substernal pain with bending over, wearing tight clothing, lying flat in bed, relieved by
antacids but never formally treated, Barrett esophagus on endoscopy = Care of
gastroenterologist, PPIs.
4. Substernal pain with bending over, wearing tight clothing, lying flat in bed, but
progressing in spite of strict medial therapy with severe esophagitis on endoscopy =
Needs fundoplication.
5. Dysphagia to liquids more than solids, occasionally regurgitates undigested food =
Achalasia. Barium swallow. Dilation or surgical therapy.
6. Progressive dysphagia to solids then liquids, history of smoking and drinking, lost 30
lbs = Cancer. Likely squamous carcinoma. Barium swallow then endoscopy and biopsy.
CT to stage.
7. After drinking, repeated vomiting, becomes bloody = Mallory-Weiss tear
 8. After drinking, repeated vomiting, wrenching epigastric pain, diaphoresis, fever,
leukocytosis = Boerhaave syndrome. Gastrografin swallow to confirm.
Dysphagia: Liquids to solids = motility. Solids to liquids = cancer.
Dysphagia workup: Barium first. Motility problem: Manometry. Cancer: Endoscopy and
biopsy, CT scan.
Cancer: Smoking and drinking history = squamous cell. Barret’s = adenocarcinoma.
Esophagus in alcohol abuse: vomiting blood: Mallory Weiss: endoscopy. Boerhaave
syndrome: gastrograffin and repair promptly.
9. Retrosternal pain 6 hrs after endoscopy, diaphoresis, fever of 104º, respiratory rate of
30, subcutaneous emphysema = Instrumental perforation of esophagus. Gastrografin
swallow to locate and emergency repair.

Stomach
10. 3 months of weight loss, anorexia, vague epigastric discomfort = Suspect gastric
cancer. Upper endoscopy and biopsy. Surgery for cure or palliation.

Small bowel and appendix

11. Colicky pain and vomiting with no bowel movement for several days, loud bowel
sounds, distended loops with air-fluid levels on xray, ex lap 4 years ago = Mechanical
intestinal obstruction caused by adhesions. NG suction, IV fluids, careful observation.
12. Colicky pain and vomiting with no bowel movement for several days, loud bowel
sounds, distended loops with air-fluid levels on xray, develops fever, leukocytosis,
tenderness and rebound 6 hrs after hospitalization = Strangulated obstruction.
Emergency surgery.
13. Colicky pain and vomiting with no bowel movement for several days, loud bowel
sounds, distended loops with air-fluid levels on xray, groin mass that can no longer be
reduced = Mechanical intestinal obstruction caused incarcerated hernia. Emergency
surgery if acute abdomen, otherwise fluid replacement first then urgent surgery.
14. Protracted diarrhea, episodic facial flushing, expiratory wheezing, jugular venous
distension = Carcinoid syndrome. Carcinoid tumor from ileum metastasized to liver
releasing systemic serotonin. Damages right heart (tricuspid insufficiency). Confirm with
5-HIAA in 24-hr urine. CT liver. Resect mets to relieve symptoms.
15. Anorexia, vague periumbilical pain that becomes sharp in RLQ, tenderness, guarding
rebound, temp 99.6º, WBC 12500, neutrophilia = acute appendicitis. Emergency
appendectomy. If not clear cut, do CT.

Lower GI system
Colon
16. Fainting spells, pale, 4+ occult blood, hemoglobin of 5 = Cancer of right colon. Don’t
see obstruction or blood in stools when in the right colon. Presents as anemia.
Colonoscopy and biopsy, hemicolectomy.
17. Bloody BMs, constipation, stools of narrow caliber = Cancer of left colon.
Proctosigmoidoscopy first, then colonoscopy to rule out second primary.
18. On colonoscopy, villous adenoma in rectum, several adenomatous polyps in
descending colon = Which are malignant? Malignancy in descending order: familial
polyposis, familial multiple inflammatory polyps, villous adenoma, adenomatous polyp.
Benign: juvenile, Peutz-Jeghers, isolated, inflammatory, hyperplastic.
19. Chronic ulcerative colitis for 20 yrs with numerous hospital admissions, on high-dose
steroids, now has acute abdomen, gas in wall of colon on xray = Toxic megacolon.
Resect involved colon. Only do surgery for UC when quality of life is severely impacted.
20. Clindamycin for 7 days after appendectomy, watery diarrhea, crampy abdominal pain
= Pseudomembranous colitis from C. difficile. Diagnose with toxin in stool. Stop
clindamycin, use metronidazole or vancomycin.

Anorectal disease
*Always do physical exam*
21. Known hemorrhoids, bright red blood on toilet paper after evacuation = Internal
hemorrhoids–bleed but don’t hurt. Rule out cancer with exam/scope. Rubber band
ligation.
22. Known hemorrhoids, anal itching and discomfort toward end of day, perianal pain
when sitting = External hemorrhoids—hurt but don’t bleed. Rule out cancer with
exam/scope. Surgery.
23. Pain with defecation, blood on outside of stool, refuses anal examination fearing pain
= Anal fissure. Examine under anesthesia. Therapy to relax tight sphincter: botulin toxin,
diltiazem, internal sphincterotomy.
24. Multiple unhealing ulcers, fissures, and fistulas around anus with purulent discharge,
no masses = Rule out malignancy with biopsy. Medical management.
25. Exquisite perianal pain, painful BMs, hot tender red fluctuant mass between anus and
ischial tuberosity = Ischiorectal abscess. Examination under anesthesia and
incision/drainage. Close in-hospital follow-up if diabetic.
26. Fecal streaks in underwear, recently drained ischiorectal abscess, cordlike tract on
palpation = Anal fistula. Rule out cancer with proctosigmoidoscopy, then elective
fistulotomy.
27. Weight loss, fungating anal mass, hard and enlarged groin nodes = Squamous cell
carcinoma of anus. Biopsy. Chemo then surgery.

Gastrointestinal bleeding
GI bleeding: Most GI bleeding is upper (¾), and most of the remaining is lower GI bleeding
caused by diseases of the old: polyps, cancer, diverticulosis, angiodysplasia, hemorrhoids.
Young adult: Upper GI
Elderly adult: Anywhere in GI tract
Vomiting blood = Upper GI
28. Vomits bright red blood = Upper GI bleeding. Endoscopy to identify bleeding. Laser
ablation.
29. 33M, recent dark red bloody BMs, hypotensive = NG tube
30. 33M, recent dark red bloody BMs, hypotensive, NG tube returns bright red blood =
Upper GI bleeding. Do endoscopy.
31. 65M, recent dark red bloody BMs, hypotensive, NG tube returns clear green fluid =
Rule out hemorrhoids with anoscopy. If massive (1U every 4 hours), emergency
angiogram. Otherwise tagged-red cell study first.
32. 65M, remote dark red bloody BMs, NG tube returns clear green fluid = Bleeding has
stopped. Do upper and lower endoscopies.
Upper GI – esophageal varices, duodenal ulcer
Lower GI – diverticular disease, angiodysplasia
Bloody bowel movement: Black=upper, Bright Red=Lower, Dark Red=anywhere
Management: Bleeding now? Place NG tube and aspirate. Blood recovered? Upper GI
source, do endoscopy. Green fluid recovered? Upper GI ruled out, do tagged red cell study,
or estimate rate of bleeding—if bleeding is >2cc/min, do arteriogram. If bleeding is
particularly slow (<0.5 cc/min), wait and do colonoscopy once it has stopped.
White fluid on NG suction? Haven’t sampled duodenum. If young, do upper GI endoscopy.
If old, do tagged red cell study.
Not bleeding now? If young, do upper GI endoscopy. If old, do both upper and lower
endoscopies.
33. 7 yo boy passes large bloody BM = Meckel diverticulum, do radioactively labeled
technetium scan (identifies gastric mucosa).
34. In ICU with hemorrhagic pancreatitis s/p pancreatic abscess drainage, septic shock,
respiratory failure, vomits bright red blood = Stress ulcer. Prevent by keeping stomach
pH above 4 (H2 blockers and antacids). Diagnose with endoscopy. Treat with laser or
angiographic embolization of left gastric artery.

The Acute Abdomen

4 types of processes cause acute abdomen:
1) Sudden severe constant and generalized pain—Perforation. Rule out pneumonia with
CXR, MI with EKG, pancreatitis with lipase, then exploratory laparotomy.
2) Sudden colicky pain, localized, patient thrashing around—Obstruction. Often ureter or
biliary tract. If RUQ radiating to shoulder, sonogram of biliary tract. If flank radiating to
inner thigh, CT of ureter.
3) Gradual onset, constant pain, localized, often with fever and leukocytosis—
Inflammation. Use anatomic localization.
4) Blood in lumen plus pain— Ischemia.
35. Sudden generalized, constant abdominal pain, lies motionless, rigidity, guarding,
rebound tenderness = Perforation.
36. Cirrhotic with ascites, generalized abdominal pain started 12 hrs ago, moderate
tenderness, some guarding, equivocal rebound, mild fever = Not acute abdomen.
Peritonitis. Suspect in patients with ascites (ie. adult with cirrhosis or child with
nephrosis). Culture ascitic fluid, treat with appropriate antibiotics.
37. Excruciating sudden onset constant abdominal pain, rigidity, lies motionless, free air
under diaphragm on xray = Perforation. Ex Lap. (Perforated duodenal ulcer in most
cases).
 38. Alcoholic has severe epigastric pain after heavy alcohol consumption, constant pain
radiates to back with nausea, vomiting = Acute pancreatitis. Amylase and lipase. CT.
NPO, NG suction, IV fluids.
39. 43 yo obese mother of 6 children has severe RUQ pain, first colicky radiating to right
shoulder, then constant with tenderness, guarding, rebound in RUQ, fever and
leukocytosis = Acute cholecystitis. Sonogram, HIDA scan. Antibiotics, NPO, IV fluids.
40. Right flank colicky pain of sudden onset radiates to groin, microscopic hematuria =
Ureteral colic. CT-KUB.
41. Constant left lower quadrant pain, tenderness, palpable mass, fever, leukocytosis =
Acute diverticulitis = CT. Treat medically (abx, NPO) or elective sigmoid resection for
recurrent disease. Percutaneous drainage if abscess present. Colonoscopy 6 weeks later
to rule out perforated colon cancer.
42. 82 yo man, colicky abdominal pain, tympanitic distended abdomen, hyperactive bowel
sounds, distended loops on xray, tapering right-sided gas shadow like parrot’s beak =
Volvulus of sigmoid. Endoscopic intervention to relieve obstruction.
43. 79 yo man, atrial fibrillation, acute abdomen = Mesenteric ischemia. Emergency
angiogram and embolectomy if bowel not dead yet (acidosis implies dead bowel).
Acute abdomen: Ascities—primary peritonitis, Alcoholic—pancreatitis, Fat Fertile Female
Forties—Biliary tract disease; Very old—sigmoid volvulus or mesenteric ischemia; Atrial
fib—mesenteric ischemia

Hepatobiliary
Liver
44. Cirrhotic develops RUQ discomfort, 20lb weight loss, palpable mass in left lobe, AFP
elevated = Primary hepatoma. Exclusively in cirrhotics. Resect if possible.
45. RUQ discomfort, 20lb weight loss, palpable liver with nodularity, history of colon
cancer, CEA was normal but is now 10x normal = Metastases to liver from colon.
Resection if no other mets and primary is slow growing.
46. 24 yo woman has sudden onset abdominal pain, shock, hemoglobin of 7, taking birth
control pills for 10 years = Ruptured hepatic adenoma. CT. Surgery.
47. Recovering acute ascending cholangitis, fever, leukocytosis, RUQ tenderness, liver
abscess on sonogram = Pyogenic abscess. Percutaneous drainage.
48. Migrant worker from Mexico, jaundice, fever, leukocytosis, RUQ tenderness, liver
abscess on sonogram = Amoebic abscess. Serology for amebic titers. Treat with
metronidazole. Don’t culture pus because the amoeba grows in the wall of the abscess.
Jaundice
49. Jaundice, total bili 6, indirect bili 6, no bile in urine = hemolytic jaundice
50. Jaundice and malaise after trip to Cancun, alk phos minimally elevated, transaminases
markedly elevated = Hepatocellular jaundice. Serologies.
51. 4 weeks progressive jaundice, alk phos markedly elevated, transaminases minimally
elevated = Obstructive jaundice. Sonogram to assess for dilated intrahepatic ducts.
52. Forty, fat, fertile female with progressive jaundice, alk phos markedly elevated,
history of colicky RUQ pain with fatty food = Stones. ERCP and eventual
cholecystectomy.
53. 6 weeks progressive jaundice, alk phos markedly elevated, transaminases minimally
elevated, 10lb weight loss, sonogram shows dilated ducts and distended thin-walled
gallbladder = Malignant obstructive jaundice (from cancer of pancreas, duct, or
ampulla). Next is CT and biopsy. Follow with ERCP if CT not diagnostic.
54. 6 weeks progressive jaundice, alk phos markedly elevated, transaminases minimally
elevated, sonogram shows dilated ducts and distended thin-walled gallbladder, CT
unremarkable, ERCP shows normal pancreatic duct but narrowed distal common duct
= Cholangiocarcinoma at lower end of common duct curable with
pancreatoduodenectomy (Whipple operation). Get brushings of duct for cytologic
diagnosis.
55. 6 weeks progressive jaundice, alk phos markedly elevated, transaminases minimally
elevated, sonogram shows dilated ducts and distended thin-walled gallbladder,
anemia, fecal occult blood = Bleeding implies ampullary carcinoma. Endoscopy.
56. 6 weeks progressive jaundice, alk phos markedly elevated, transaminases minimally
elevated, 20lb weight loss, sonogram shows dilated ducts and distended thin-walled
gallbladder, family history of pancreatic cancer = Cancer of the head of the pancreas.
Biopsy.
Jaundice: Isolated elevation in indirect bili? Hemolytic; Elevation of transaminases more
than alk phos? Hepatocellular jaundice; Elevation of alk phos more than transaminases?
Obstructive jaundice—Do sonogram. If stones, do ERCP to confirm and remove and
cholecystectomy later. If thin-walled, dilated, it’s a tumor. If tumor and no bleeding, do CT
and ERCP if needed. If tumor and bleeding, suspect ampullary carcinoma, do upper GI
endoscopy.

57. Fat Fertile Female in Forties has repeated colicky RUQ pain radiating to right shoulder
and triggered by fatty foods with nausea and vomiting = Gallstones with biliary colic.
Sonogram and elective cholecystectomy.
58. Fat Fertile Female in Forties has severe colicky RUQ pain with nausea, vomiting,
tenderness, guarding, rebound, fever, leukocytosis, normal LFTs = Acute cholecystitis.
Ultrasound shows gallstones, thickened wall, pericholecystic fluid. Confirm with HIDA
scan that shows tagged compounds avoiding the gallbladder. Abx, NPO, IV fluids.
Emergency cholecystectomy likely needed in male diabetic.
59. Elderly Fat Fertile Female has severe RUQ pain, colicky at first but now constant,
tenderness, guarding, rebound, high fever, marked leukocytosis, markedly elevated
alkaline phosphatase = Acute ascending cholangitis. IV abx and emergent
decompression by ERCP or percutaneous transhepatic cholangiogram.
60. Fat Fertile Female in Forties has repeated colicky RUQ pain radiating to right shoulder,
now with extended colicky pain and shaking chills, elevated alk phos and lipase =
Passed a common duct stone causing transient cholangitis and biliary pancreatitis. Start
with sonogram and conservative management followed by elective cholecsystectomy.
ERCP to remove stone if still impacted at ampulla.
Fat Fertile Female in Forties with RUQ pain = biliary disease. Do sonogram. If gallstones, but
otherwise asymptomatic, no surgery. If history of this colicky pain, do cholecystectomy.
If acute inflammatory process, check LFTS
 LFTs normal, but thickened gallbladder with fluid on US or HIDA scan shows no
radioactivity in gallbladder, then cholecystitis. Manage conservatively with NPO, IV
fluids, abx. Elective cholecystectomy or emergent if needed.
High alk phos in old sick patient: acute cholangitis. US shows dilated ducts, but no signs
of gallbladder inflammation. IV abx, ICU admission, ERCP to drain pus
High alk phos, amylase, lipase: biliary pancreatitis. US shows dilated ducts, but no signs
of gallbladder inflammation. NPO, IV fluids. If stone doesn’t pass, do ERCP with
sphincterotomy to remove. Eventual cholecystectomy will be needed.

Pancreas
61. Alcoholic with constant severe epigastric pain radiating to back after large meal,
vomiting, lipase 1200, hematocrit 52% = Acute edematous pancreatitis. Compared to
acute hemorrhagic pancreatitis, which will have low hematocrit. Put pancreas at rest:
NPO, NG suction, IV fluids.
62. Alcoholic with constant severe epigastric pain radiating to back, amylase of 800,
hematocrit of 40%, WBC 18000, glucose 150, Ca 6.5. Next morning after conservative
treatment, Hct 30%, Ca 7, BUN 32, metabolic acidosis, low arterial PO2 = Hemorrhagic
pancreatitis. Has 8 Ranson’s criteria predicting 80 to 100% mortality. Common pathway
to death is pancreatic abscess. Serial CT scans required.
Epigastric pain in alcoholic: Confirm pancreatitis with amylase/lipase (measure in serum
unless 48hrs later, in which case measure in urine). Hematocrit increased? Acute
edematous pancreatitis. Hematocrit decreased? Acute hemorrhagic pancreatitis. Admit to
ICU, daily CT scans, drain abscess promptly. Treat complications. Necrosectomy to remove
dead pancreatic tissue occasionally required.

63. 2 weeks after acute hemorrhagic pancreatitis, fever and leukocytosis = Pancreatic
abscess. CT, drainage, and antibiotics.
64. 5 weeks after successful treatment for acute pancreatitis, upper abdominal
discomfort, epigastric mass on exam = Pancreatic pseudocyst. Fluid in lesser sack.
65. 5 weeks after car crash hitting upper abdomen on steering wheel, upper abdominal
discomfort, epigastric mass on exam = Pancreatic pseudocyst.
Epigastric discomfort and mass with acute pancreatitis or upper abdominal trauma a few
weeks ago: US or CT. If less than 6cm or less than 6 weeks, observe. Otherwise, surgically
drain (cystogastrostomy), percutaneously drain, or endoscopically drain
66. Alcoholic requesting pain meds has constant epigastric pain radiating to back, has
diabetes, steatorrhea, and calcifications on xray = Chronic pancreatitis. Replace
enzymes, control diabetes. Do ERCP to check for obstruction. Many patients never get
satisfactory relief.

Evaluating hernias
67. 9 month old baby girl has umbilical hernia with 1 cm diameter defect, contents freely
reducible = May still close spontaneously if less than 5 years old.
 68. 18 yo man has inguinal hernia on routine physical exam, hernia bulge in his scotum
when he strains = Elective surgical repair. Repaired by open or laparoscopic approach
with a mesh.
69. 72 yo man has inguinal hernia on routine physical exam with bowel sounds in
scrotum, hernia has not been reducible for 10 years = Incarcerated hernia. Elective
repair. If irreducible state is new onset, this is an emergency.

Diseases of the Breast

Is it cancer? More likely in patients older than 30-40. Biopsy=radiologically-guided core biopsy
1. 18 yo with firm, mobile, rubbery breast mass = Fibroadenoma. Confirm with sonogram.
Excision is optional. Don’t do mammogram below 20 because breast is too dense.
2. 14 yo with firm, mobile, rubbery breast mass that has grown to 6 cm over past year =
Giant juvenile fibroadenoma. Do FNA. Recommend resection to avoid cosmetic
deformity.
3. 27 yo immigrant from Mexico has 12x10x7 cm firm, mobile, rubbery breast mass
present for 7 years, no palpable nodes = Cystosarcoma phyllodes. Benign, but can
undergo malignant transformation. Do margin-free resection.
4. 35 yo with cyclic breast tenderness and multiple lumps that come and go, now has
firm, round, 2cm mass for 6 weeks = Fibrocystic disease. Do mammogram to check for
nonpalpable lesions, then do aspiration. If bloody, send for cytology. If doesn’t go away
with aspiration, do core biopsy.
5. 34 yo with bloody nipple discharge without masses = Likely benign intraductal
papilloma. Rule out cancer with mammogram. Can resect for symptomatic relief.
6. 26 yo lactating mother with cracks in nipple has red, hot, tender breast mass, with
fever and leukocytosis = Unless lactating, breast abscess is cancer until proven
otherwise. On this patient, drain in OR and sample while draining to rule out cancer.
7. 49 yo has firm 2-cm mass in right breast present for 3 months = Mammogram and core
biopsies.
8. 34 yo woman in 5th month of pregnancy has 3cm, ill-defined breast mass present for 3
months = Mammogram while shielding uterus. Sonogram-guided biopsies.
9. 69 yo with 4cm fixed hard mass with ill-defined borders, skin like orange peel
appearance = Invasive adenocarcinoma. Mammographically guided core biopsy.
10. 69 yo with 4cm fixed hard mass with ill-defined borders, nipple retraction = Invasive
adenocarcinoma.
11. 69 yo with red swollen breast, skin like orange peel, mildly tender and hot =
Inflammatory breast cancer.
12. 69 yo with eczematoid lesion in areola present for 3 months not treatable with lotions
and oitments = Paget’s disease of breast. Suspicious skin lesions can be confirmed with
dermal punch biopsies.
13. 42 yo hits her breast with broom handle, noticed lump at that time = Still needs
mammographically-guided core biopsy.
14. 58 yo discovers hard movable 2cm mass in right axilla, exam of breast is negative =
Would be lymphoma in 28 yo, but more likely breast cancer in this age. Mammogram to
look for occult primary and biopsy the node.
15. 60 yo on routine screening mammogram has new area of increased density with
microcalcifications = Malignancy likely.
16. 2 cm mobile mass diagnosed as infiltrating ductal carcinoma, no palpable nodes and
no other lesions = Small tumor far from nipple. Do lumpectomy and axillary node
sampling followed by radiation
17. 4 cm hard mass under nipple in small breast diagnosed as infiltrating ductal
carcinoma, no palpable nodes and no other lesions = Cannot save breast, do total
mastectomy, and axillary node sampling.
18. 2 cm palpable mass, lobular cancer on biopsy = Higher incidence of bilaterally.
19. 2 cm palpable mass, inflammatory cancer on biopsy = Terrible prognosis.
20. Suspicious area on mammogram, ductal carcinoma in situ on biopsy = Lumpectomy
and radiation. Axillary sampling not necessary.
21. 32 yo in 7th month of pregnancy has 2cm breast mass, infiltrating ductal carcinoma on
biopsy = Lumpectomy. Only things to avoid in pregnancy: radiation and chemo during
first trimester.
22. Bleeding from the breast, huge, fungating, ulcerated mass firmly attached to chest
wall, present for 2 years = Neglected breast cancer. Chemo then radiation, with
operation for palliation.
23. 37 yo with lumpectomy and axillary sampling for infiltrating ductal carcinoma, clear
margins with cancer in the nodes, ER/PR positive = Chemo, radiation, then hormonal
therapy (tamoxifen in pre-menopausal, anastrozole in post-menopausal).
24. 66 yo has modified radical mastectomy for infiltrating ductal carcinoma measuring <1
cm, 1 of 2 nodes are positive, ER/PR positive = In this older patient, with a small
primary and only one positive node, we may forgo chemo and just do hormonal therapy
(Tamoxifen in pre-menopausal, anastrozole in post-menopausal).
Breast Cancer:
If operable, surgery first then chemo and hormonal.
If fixed to chest wall, ulcerated or inflammatory-type, chemo and radiation to shrink
tumor, then palliative surgery
If small tumor, large breast, tumor far from nipple, lumpectomy with sentinel biopsy
followed by radiation therapy
If large tumor, small breast, tumor near nipple, modified radical mastectomy with
sentinel biopsy
If node positive, need chemo
If ER/PR positive, need hormonal. Tamoxifen in premenopausal, Anastrozole in
postmenopausal.
If node positive, discuss chemo/hormonal therapy with patient

25. Severe headaches, mastectomy 2 years ago = Brain mets. Do MRI of the brain. Give
high-dose steroids and radiation.
 26. Constant back pain, tenderness to palpation on spine, completed chemo for breast
cancer 6 months ago = Bone metastases. MRI for diagnosis.

Diseases of the Endocrine System

Is thyroid mass cancerous? If not functional, more likely
1. Prominent soft 2cm mass on thyroid = FNA and cytology.
2. 2cm thyroid nodule, TFTs normal, FNA indeterminate = Surgery.
3. Thyroid lobectomy for follicular neoplasm that was indeterminate on FNA, intra-op
frozen section diagnosis is follicular cancer = Total thyroidectomy.
Surgery:
Papillary – Not aggressive, any surgery
Follicular – Hematogenously metastasizes, total thyroidectomy, then radioactive iodine
ablation
Anaplastic
Medullary
4. During routine exam, hypercalcemia and hypophosphatemia = Parathyroid adenoma.
Measure PTH. If high, confirms adenoma. Sestamibi scan localizes adenoma.
5. Admitted to psychiatry because of mood swings, also has hypertension, diabetes,
osteoporosis, amenorrhea, shaves her face, centripetal obesity, moon facies, buffalo
hump, thin bruised extremities, normal appearance 3 years ago = Cushing syndrome. If
no suppression with low dose dexamethasone, Cushing disease. If no suppression at
higher dose, adrenal tumor, otherwise pituitary tumor.
6. Virulent peptic ulcer disease refractory to medical management including H. pylori
treatment, duodenal ulcers in first and second portions of duodenum, watery diarrhea
= Gastrinoma (Zollinger-Ellison). Measure serum gastrin. CT pancreas. Resect tumor.
7. Hospitalized for seizure disorder, hypoglycemic, hyperinsulinemic, low C-peptide =
Exogenous administration of insulin. Psychiatric evaluation. If it had been insulinoma, CT
scan.
8. Migratory necrolytic dermatitis, mild stomatitis, mild diabetes = Glucagonoma.
Determine glucagon levels. CT to localize tumor. Surgery or somatostatin if inoperable.

Surgical Hypertension
Is thyroid mass cancerous? If not functional, more likely
1. 45 yo woman who is hypertensive, sodium 144, potassium 2.1, no medications =
Hyperaldosteronism. Possibly adenoma. Check aldosterone to renin level. With
hyperplasia, there a normal response to postural changes. Treat with Aldactone.
Adenoma has no response. Image with CT/MRI then do surgery.
2. 36 yo thin woman with episodic pounding headache, palpitations, profuse
perspiration, pallor, paroxysmal hypertension = Pheochromocytoma. 24-urinary
metanephrine, VMA. CT adrenals. Alpha block before surgery.
3. 17 yo has BP 190/115 in arms, normal in legs = Coarctation of the aorta. Do CXR to look
for rib scalloping. Then CT angio, then surgery.
4. 23 yo woman with hypertension, bruit over abdomen = Fibromuscular dysplasia.
 5. 72 yo man with hypertension, bruit over abdomen = Renovascular hypertension 2º to
arteriosclerosis. Duplex scanning. CT angio. Angiographic balloon stenting. Only treat in
old man if it makes sense given his other comorbidities.

5. Pediatric Surgery

First 24 hours
1. Excessive salivation, NG tube inserted, coiled tube and air in GI tract on xray = TE
fistula, with proximal blind esophageal pouch and distal TE fistula. Rule out VACTER
anomalies (vertebral, anal, cardiac, TE, renal/radial). Xray can rule out vertebral and
radial. Echo for heart, sonogram for kidneys, physical exam for anus. Then surgery.
Gastrostomy tube to prevent aspiration if other defects need to be repaired first.
2. Newborn has imperforate anus on physical exam = VACTER anomaly. NG tube placed,
Xray. Echo for heart. US for kidney. If fistula, GI tract can drain there, not an emergency.
If no fistula, put metal marker on anal fistula during upside-down babygram to see how
close the blind ends are. If they are far apart, do colostomy, and repair at later date.
3. Newborn is tachypneic, cyanotic, and grunting. Abdomen scaphoid, bowel sounds
over left chest. Bowel in left thorax on xray = Diaphragmatic hernia. Main problem is
hypoplastic lung. Wait 36 hours for circulation to transition and keep baby alive with
intubation, low-pressure hyperventilation, sedation, NG suction.
4. Newborn has abdominal defect to right of umbilicus, with matted angry-looking bowel
loops protruding = gastroschisis. Look for atresias. IV nutrition since bowel will not
work. Put bowel in silo and gradually reduce over a week.
5. Newborn has membranous sac at base of umbilical cord with liver and bowel loops in
sac = omphalocele. Look for other defects. Put bowel in silo and gradually reduce over a
week.
6. Newborn has medallion of mucosae protruding from abdominal wall above pubis and
below umbilicus = Extrophy of urinary bladder. Must be repaired in first 48 hrs.
7. Newborn vomits greenish fluid, down syndrome, double-bubble on xray = Duodenal
atresia, annular pancreas, or malrotation. Barium studies to be sure.
8. Newborn vomits greenish fluid, double-bubble on xray, air in distal bowel =
Malrotation. Barium studies. Emergency surgery.
9. Newborn has repeated green vomiting, multiple air-fluid levels on xray with distended
bowel loops = Intestinal atresia. 2º to in utero vascular accident.
Key words in pediatric surgery: Excessive salivation = esophageal atresia (usually with TE
fistula); Trouble with first feeding = necrotizing enterocolitis; Bilious vomiting, ground glass
on xray, family history of cystic fibrosis = meconium ileus; 3-week-old with projectile
vomiting, olive mass = hypertrophic pyloric stenosis; 9-month-old with intermittent colicky
pain, “currant jelly” stools = intussesception
Green vomiting: Do babygram. Double bubble? Duodenal atresia, annular pancreas,
malrotation. Do barium studies.
First 2 months
10. Very premature baby, feeding intolerance, abdominal distension, dropping platelets,
treated with indomethacin = Necrotizing enterocolitis. Stop feedings, broad-spectrum
abx, IV fluids. Surgery is baby develops abdominal wall erythema, air in portal vein, or
pneumoperitoneum indicating dead bowel.
11. 3-day-old has feeding intolerance and bilious vomiting, dilated bowel and ground glass
appearance of lower abdomen on xray, mother has cystic fibrosis = Ground glass
appearance is inspissated meconium. Do gastrografin enema which is diagnostic and
therapeutic because of its hypertonicity (draws fluid into lumen). Then treat cystic
fibrosis.
12. 3-week-old not growing well, bilious vomiting, double bubble, but normal gas in rest
of bowel = Malrotation. Remember can show up at any time within first few weeks.
13. 3-week-old with projectile nonbilious vomiting, visible gastric peristaltic waves, olive
size mass in RUQ = Correct hypokalemic, hypochloremic metabolic alkalosis if present.
Then do pyloromyotomy or balloon dilatation.
14. 8-week-old has increasing jaundice, increased direct bili, serology negative for
hepatitis, sweat test normal = Biliary atresia. HIDA scan after 1 week of phenobarbital
(stimulates liver to put bile out). Operate if the scan shows that bile flow is blocked.
Transplant will be needed 2/3 of the time.
15. 2-month-old has chronic constipation, distention, dilated loops on xray, rectal exam
causes expulsion of stool = Hirschprung disease (aganglionic megacolon). Barium
enema shows distended proximal colon. Full-thickness biopsy of rectal mucosa confirms.

Later in infancy
16. 9-month-old has episodic colicky abdominal pain lasting 1 minute, mass in right
abdomen, empty right lower quadrant, currant jelly stools = Intussusception. Barium
enema diagnoses and treats because weight of barium pushes ileum back down. Surgery
only if refractory.
17. 1-year-old has subdural hematoma, retinal hemorrhages
18. 3-year-old has fractured humerus, xrays show older fractures in various stages of
healing
19. 1-year-old has burns on buttocks = All child abuse. Notify proper authorities.
20. 7-year-old has large bloody bowel movement = Meckel diverticulum. Radioisotope scan
reveals gastric mucosa in lower abdomen.

6. Cardiothoracic Surgery

Congenital Heart Problems

Child with noisy breathing: While exhaling = asthma, while inhaling = tracheomalacia, with
trouble swallowing = vascular ring (which compresses both trachea and esophagus)
1. 6-month-old has stridor, respiratory distress, crowing respiration, difficulty
swallowing = Barium swallow shows extrinsic compression. Bronchoscopy confirms
 segmental tracheal compression, rules out diffuse tracheomalacia. Surgical repair by
dividing the smaller of the two aortic arches.
2. Patient with prosthetic aortic and mitral valves needs dental work = Antibiotic
prophylaxis to protect from bacterial contamination.
3. 12-year-old has systolic murmur on routine physical, fixed split second heart sound,
history of frequent colds and upper respiratory infections = Atrial septal defect.
Echocardiography to confirm. Pulmonary congestion causes colds. Close by open
surgery.
4. 3-month-old has failure to thrive, loud pansystolic murmur at left sternal border, CXR
shows increased pulmonary vascular markings = Ventricular septal defect. Echo to
confirm. Surgical correction.
5. 3-month-old is asymptomatic but has small restrictive VSD low in the muscular
septum = Likely to close spontaneously in first 2 or 3 years.
6. 3-day-old premature baby has trouble feeding, pulmonary congestion, bounding
peripheral pulses, machinery-like murmur = Patent ductus arteriosus. Echo and surgical
closure since in heart failure.
7. Premature baby has mild pulmonary congestion, signs of increased pulmonary blood
flow on xray, wide pulse pressure, machinery-like murmur, not in congestive failure =
Less urgency than previous vignette. Candidate for indomethacin.
8. 6-year-old brought to US from orphanage in Eastern Europe, bluish lips and tips of
fingers, systolic ejection murmur, small heart, diminished pulmonary vascular
markings, EKG shows right ventricular hypertrophy = Tetrology of fallot. Echo. Surgical
repair. Next most common cyanotic anomaly is transposition of the great vessels, but
that baby would not survive to age 6.

Acquired Heart Disease

9. Angina, exertional syncope, midsystolic murmur = aortic stenosis. Echo. Indications for
surgery are pressure gradient >5, angina, syncope.
10. Wide pulse pressure, blowing diastolic heart murmur, left ventricular dilatation =
Chronic aortic insufficiency. Valve replacement (indication is the left ventricular
dilatation).
11. 26 yo drug addict develops CHF over few days, has loud diastolic murmur = Acute
aortic insuffiency due to subacute bacterial endocarditis. Needs emergency replacement
and long term antibiotics.
12. 35 yo has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough,
hemoptysis, atrial fibrillation, rumbling diastolic murmur = Mitral stenosis. Echo.
Eventually surgical mitral valve repair or balloon valvuloplasty.
13. 55-year-old has mitral valve prolapse, exertional dyspnea, orthopnea, atrial
fibrillation, holosystolic murmur = Mitral regurgitation. Echo. Surgical Repair
(annuloplasty—make annulus smaller to leaflets meet).
14. 55-year-old has unstable angina refractory to medical management, family history MI,
sedentary life style, overweight = Cardiac catheterization. Coronary revascularization if
good candidate.
 15. 55-year-old has unstable angina refractory to medical management, family history MI,
sedentary life style, overweight, cardiac catheterization demonstrates 70% occlusion
of 3 vessels with good distal vessels, LV ejection fraction 55% = Good candidate for
intervention. There must be 70% stenosis, good distal vessels, good ventricular function.
Angioplasty if 1-2 vessel stenosis. CABG for 3-vessel.
16. After open heart surgery, cardiac index is 1.7 L/min/m2, LV end diastolic pressure of 3
= Normal cardiac index is 3. Either ventricular function is compromised, or there is not
enough fluid. Here the pressure is low (normal is 10-12) so needs more volume.
17. After open heart surgery, cardiac output of 2.3, pulmonary wedge is 27mmHg = Now
ventricular function is compromised.

Lung Cancer

18. 45-year-old chronic smoker has coin lesion in lung on routine CXR = Check older CXR
19. 65-year-old chronic smoker has coin lesion in lung on routine CXR, CXR 2 years ago
was normal = Sputum cytology and CT (including upper abdomen to detect liver mets).
Next biopsy the mass by bronchoscopy if central, percutaneously if peripheral.
20. 65-year-old chronic smoker has coin lesion in lung on routine CXR, CXR 2 years ago
was normal, CT shows no calcifications, liver mets, or enlarged
peribronchial/peritracheal nodes, sputum cytology and percutaneous needle biopsy
not diagnostic, has good pulmonary function = Thoracotomy or thoracoscopy and
wedge resection. 3 important issues: Establishing the diagnosis, is surgery appropriate?,
and does surgery have a good chance of cure?. Here we do the resection because of
high likelihood of cancer, high likelihood of cure with surgery.
21. 65-year-old chronic smoker has central hilar mass on CXR, sputum cytology establishes
squamous cell carcinoma, FEV1 is 1100, V/Q scan shows 60% of pulmonary function
from affected lung = Would have to have pneumonectomy because mass is central. His
post-surgical FEV1 would be 40% * 1100 or 440ml which is not adequate (needs at least
800ml). Not a surgical candidate. Do chemotherapy and radiation.
22. 65-year-old chronic smoker has hemoptysis, central hilar mass on CXR, squamous cell
carcinoma on bronchoscopy and biopsy, FEV1 is 2200, V/Q scan shows 30% of
pulmonary function from affected lung = Could tolerate pneumonectomy. But still need
to determine disease extent with CT. Might need PET, or endobronchial ultrasound to
investigate mediastinal nodes.
23. 33-year-old woman appears to have Cushing syndrome, CXR shows central 3cm lung
mass, bronchoscopy and biopsy confirm small cell carcinoma of lung = Radiation and
chemotherapy. Don’t need to determine FEV1 or nodal status.
Lung cancer: Typical presentation is elderly chronic smoker with coin lesion.
First find old CXR. Then do sputum cytology and CT of chest and upper abdomen.
If widespread disease (weight loss, palpable supraclavicular nodes, LFT abnormalities), CT is
very important.
If pulm function is limited (COPD, huffing and puffing), get PFTS first. If no limiting factors,
do bronchoscopy and biopsies for central lesion, transthoracic needle biopsy for peripheral
lesion.
 If this is not diagnostic, do thoracotomy and thoracoscopy and wedge resection for
diagnosis and treatment.
If small cell is diagnosed, do chemo and radiation.
If non-small cell is diagnosed, establish operability. Central lesion requiring pneumonectomy
+ presentation suggesting limited function requires checking the PFTs. Peripheral lesion
amenable to lobectomy, with function not an issue requires an evaluation of disease extent.
Evaluation of function requires FEV1 and V/Q scan to determine what FEV1 would be after
pneumonectomy.
Evaluation of disease extent requires CT of chest and upper abdomen. If status of
mediastinal nodes cannot be determined, add PET. If still unsure, do mediastinoscopy to
check carinal nodes.

7. Vascular Surgery

24. Coldness and tingling in left hand with exertion accompanied by vertigo, blurred
vision, dysarthria = Subclavian steal syndrome. Atherosclerotic plaque in subclavian
before vertebral leaves, which limits blood flow through vertebral when arm is being
used. Dupex will demonstrated retrograde flow through vertebral when patient
exercises arm. Need surgical bypass.
25. 62 yo man has 6cm pulsatile mass deep in abdomen above umbilicus = Abdominal
aortic aneurysm. 6cm is the cutoff for intervention. Need a CT.
26. 62 yo man has 6cm pulsatile mass deep in abdomen above umbilicus, mass is tender
to palpation, has epigastric and upper back discomfort = AAA threatening rupture;
needs consultation today.
27. 68 yo man has sudden excruciating back pain, diaphoresis, systolic BP of 90, 8cm
pulsatile mass deep in abdomen above umbilicus = Aneurysm is rupturing right now.
Needs immediate, emergency surgery.
28. Wealthy, retired man has claudication when walking more than 15 blocks = Would
benefit from exercise and cilostazol.
29. Postman has severe calf pain when walking 2-3 blocks, pain relieved by rest but
interferes with job, he does not smoke = Start with Doppler. If no significant gradient,
that means disease is due to small vessel disease not amenable to surgical intervention.
If there is a gradient, to arteriogram to find block and plan intervention (bypass or
stenting).
Claudication that interferes with lifestyle: Start with doppler studies (ankle-brachial index). If
no gradient, not surgical candidate, medical management is stop smoking, exercise
program, cilostazol. If there is a gradient, do arteriogram and choose surgical bypass or
stenting.

30. Pain in right calf prevents man from falling asleep, relieved with hanging leg off bed,
skin is shiny, no hair, no palpable peripheral pulses = Rest pain. Doppler studies for
pressure gradient, etc as above.
 31. 45 yo has sudden onset pale, pulseless, paresthetic, painful, paralytic lower extremity
with grossly irregular pulse = Embolization from atrial fibrillation. Embolectomy. May
need a fasciotomy to prevent compartment syndrome.
32. 74 yo has sudden onset severe tearing chest pain radiating to back, BP 220/110,
unequal upper extremity pulses, wide mediastinum on CXR, EKG and cardiac enzymes
negative for MI = Dissecting aneurysm of thoracic aorta. Spiral CT to confirm.
Emergency surgery for ascending aortic aneurysm, intensive hypertension therapy in
ICU for descending aortic aneurysm.

8. Skin Surgery

1. Farmer has indolent, raised, waxy, 1.2cm skin mass over bridge of nose slowly growing
over past 3 years = Basal cell carcinoma
2. Farmer has non-healing, indolent, punched out, clean-looking 2cm ulcer over left
temple slowly growing over past 3 years = Basal cell carcinoma. Grows more slowly,
metastasizes less, and is located more superior to squamous cell (above mouth). Do full-
thickness biopsy or complete excision.
3. Sailor has non-heling, indolent 1.5cm ulcer on lower lip slowly growing over 8 months
= Squamous cell carcinoma
4. Red-headed patient has 1.8cm skin lesion on shoulder: pigmented, asymmetrical,
irregular borders and colors = Dysplastic nevus. Excisional biopsy with narrow margin.
Wide local excision once diagnosis confirmed. Sentinel node biopsy for lesions 1-4mm.
(If depth > 4, probably will die no matter what).
5. Sailor has multiple nevi all over body, one has changed recently = Evolution. Think
melanoma. Manage as if dysplastic.
6. 44 yo man has liver mets, no primary tumor, missing toe removed at age 18 for black
tumor under toenail = Malignant melanoma, which can have very extended interval for
metastasis.
7. 32 yo has 3.4mm deep melanoma removed from back 3 years ago. Now has tumor in
in left ventricle/duodenum/ischiorectal area = Invasive melanoma metastasizes to
usual locations (lymph nodes, liver, lung, brain, bone) as well as unusual locations.
Aggressively resect metastasis.

9. Ophthalmology

Children
1. 1 yo has strabismus
2. 2 yo has congenital cataract = Can cause cortical blindness (amblyopia). Must surgically
correct.
3. 18-month-old has one pupil white and other black = Could be retinoblastoma or
cataract. Needs to see ophthalmologist today.
Adults
4. 53 yo has frontal headache and nausea after watching two movies, seeing halos,
pupils unreactive, corneas cloudy, eyes hard as rock = Acute angle-closure glaucoma.
Often after pupil has been dilated in dark for awhile. Treat with carbonic anhydrase
inhibitors, beta-blockers, alpha-2-selective adrenergic agonists.
5. 32 yo has swollen, red, hot, tender eyelids plus fever and leukocytosis, pupil dilated
and fixed, limited motion of eye = Orbital cellulitis (pus behind eye). CT and surgical
drainage.
6. 10 yo boy splashed Drano on face and is screaming in pain = Massive irrigation.
Remove solid matter. Recheck pH. Look under eyelid.
7. 59 yo with myopia, flashes of light when eyes closed, floaters during day, cloud at top
of visual field = Retinal detachment. Floaters are debris in eye. Cloud at top is
hemorrhage settling at bottom of eye. Ophthalmologic emergency. Laser to spot weld
retina.
8. 77 yo suddenly loses sight in right eye with no other neurological symptoms = Embolic
occlusion of retinal artery. Ophthalmologic emergency.
9. 55 yo with type 2 diabetes, has to squint to see TV after heavy dinner = Blurry vision
because of lens shrinking in response to hyperglycemia, but will need regular
ophthalmologic follow-up for retinal complications

10. Otolaryngology

Neck masses
Congenital – asymptomatic in kid
Midline, hyoid — thyroglossal duct cyst
In front of SCM – branchial cleft cyst
Mushy, in supraclavicular area – cystic hygroma
Inflammatory – recent onset
Neoplastic – several months of relentless, continued growth
Young, multiple nodes, fever, night sweats – lymphoma
Supraclavicular node – Mets from primary below clavicles
On side of neck in old man who smokes and drinks – Mets from SCC of mouth, pharynx,
larynx

Congenital
1. 15 yo has round 1cm mass at midline near hyoid bone, seems connected to tongue
when palpated, mass present for 10 years = Thyroglossal duct cyst. Do sistrunk
operation (remove mass to base of tongue along with medial segment of hyoid bone).
Can ascertain location of normal thyroid first with radioisotope scanning.
2. 18 yo woman has fluctuant mass in front of sternomastoid, CT shows that it is cystic =
Branchial cleft cyst. Do elective surgical removal.
 3. 6 yo has mushy fluid-filled mass at base of neck, occupied supraclavicular area and
goes deep into neck and chest = Cystic hygroma—congenital anomaly of lymphoid
tissue. CT to assess depth in chest and mediastinum, then surgical removal.
Inflammatory vs. neoplastic
4. 22 yo has enlarged nontender lymph node in neck discovered yesterday =
Inflammatory vs. neoplastic. Recheck in 3 weeks.
5. 22 yo has enlarged nontender lymph node in neck discovered 6 weeks ago, low-grade
fever and night sweats for 3 weeks, enlarged nodes in axilla and groin = Lymphoma.
FNA. Then excision.
6. 72 yo has hard mobile nontender mass in left supraclavicular area, 20lb weight loss =
Metastasis from below clavicles. Likely lung, stomach, colon, pancreas, kidney. Biopsy
the node.
7. 69 yo who smokes and drinks has hard fixed mass in neck in front of sternomastoid
muscle near thyroid cartilage, has been growing over 6 months = Metastatic squamous
cell carcinoma to jugular chain node from primary in head/neck mucosa. FNA, but don’t
biopsy. Do triple (pan) endoscopy of mouth, pharynx, larynx, esophagus,
tracheobronchial tree. Then do CT to stage. Radiation, platinum-based chemo, surgery.
Squamous cell cancer
8. 69 yo who smokes and drinks has had hoarseness for 6 weeks despite antibiotic
therapy = SCC in vocal cords.
9. 69 yo who smokes and drinks has had painless, non-healing mouth ulcer for 6 weeks =
SCC in mouth.
10. 23 yo with AIDS has had painless, non-healing mouth ulcer for 6 weeks = SCC in mouth.
11. 69 yo who smokes and drinks has had unilateral earache for 6 weeks with serous otitis
media on that side = SCC blocking Eustachian tube. Do triple endoscopy to find and
biopsy primary. Radiation, platinum-based chemo, surgery.

Other tumors
12. 52 yo man has unilateral sensory hearing loss, but no lifestyle cause such as shooting =
Acoustic nerve neuroma. If it had been conductive, think cerumen plug. Diagnose by
MRI.
13. 56 yo has slow progressive paralysis of facial nerve on one side, now present 3
months, affects both forehead and lower face = Neoplastic process. Gadolinium-
enhanced MRI.
14. 45 yo has 2cm firm painless mass in front of ear for 4 months, no interference with
facial nerve function = Pleomorphic adenoma (mixed tumor) of the parotid gland. FNA.
Parotid masses are never biopsied in the office or under local anesthesia. Needs
superficial parotidectomy.
15. 65 yo has 4 cm hard fixed mass in front of ear for 6 months, gradual facial nerve
paralysis, rock hard nodes in left neck = Parotid cancer. OHNS manages.

Pediatric ENT
16. 2 yo has unilateral earache
 17. 2 yo has unilateral foul-smelling purulent rhinorrhea
18. 2 yo has unilateral wheezing, lung looks darker on xray = Any ENT problem that would
normally be bilateral but is presenting unilateral suggests foreign body. Xrays, exam,
endoscopies, extraction; usually under anesthesia.

ENT emergencies and miscellaneous

19. Recent tooth infection, red hot fluctuant mass on lower face and upper neck, mass
pushes up on floor of mouth, fever = Ludwig angina (abscess of floor of mouth). Incision
and drainage while protecting airway.
20. Woke up with one side of face paralyzed = Bell palsy. Start right away on antiviral
medication and steroids.
21. Car crash, treatment in ER, facial nerve paralysis the next day = Paralysis appearing late
is from edema. No intervention required. If it had been immediate, would think of
transection in the trauma.
22. Repeated sinusitis in middle-aged woman, now has diplopia = Cavernous sinus
thrombosis or orbital cellulitis. Immediate IV abx and surgical drainage.
23. 10 yo has epistaxis, often picks nose = Bleeding from anterior part of septum.
Phenylephrine spray or local pressure.
24. 18 yo boy has epistaxis, no nose picking, no source of anterior bleeding on exam = In
this age group, think septal perforation from cocaine abuse (posterior packing) or
posterior juvenile nasopharyngeal angiofibroma (surgical removal required due to mass
effect).
25. 72 yo hypertensive man has copious nosebleed, BP 220/115 = Epistaxis 2º to HTN. Can
be serious. Control BP. Posterior packing. Emergency arterial ligation or angiographic
embolization may be required.
26. 57 yo man is “dizzy,” light-headed and unsteady, but room not spinning = Neurologic
pathology, probably vascular occlusive.
27. 57 yo man is “dizzy,” room is spinning = Vestibular pathology. meclizine, Phenergan,
diazepam or ENT workup.

11. Neurosurgery

Neurologic disease
Sudden onset=vascular. No headache—vascular occlusive. Headache—vasculo-
hemorrhagic.
Progressive Headache = tumor (headache worse in morning, eventual signs of increased
ICP) (See on MRI/PET)
Rapidly progressive headache with fever, leukocytosis with history of mastoiditis or
frontal sinusitis = brain abscess (CT)
Progressive neurological symptoms over years = degenerative process

Vascular Occlusive Disease

 1. 62 yo man has transient sudden-onset episodes of hand weakness, blurred vision, and
difficulty expressing himself that resolve spontaneously = Transient ischemic attacks
caused by carotid pathology (stenosis or ulcerated plaque at bifurcation). Do duplex. If
stenosis exceeds 70%, carotid endarterectomy.
2. 62 yo has transient sudden-onset episodes of vertigo, diplopia, blurred vision,
dysarthria, gait instability = TIA involving vertebrals. Duplex US.
3. 62 yo diabetic man has abrupt onset third nerve paralysis and contralateral
hemiparesis with no associated headache, deficits have not resolved = Vascular
occlusive stroke. CT and give tPA within 90 min.

Intracranial bleeding
4. 64 yo hypertensive black man has sudden onset severe headache and profound
extremity weakness = Hemorrhagic stroke. CT. Then supportive therapy with eventual
rehab.
3 conditions causing brain bleed unrelated to trauma = HTN, AV malformation, Berry
aneurysm.
5. 39 yo woman with sudden severe singular headache on two separate occasions, the
second time accompanied by nuchal rigidity = Sentinel bleed followed by subarachnoid
hemorrhage. Do CT then angiogram in preparation for clipping or endovascular coiling.

Brain tumors
6. 31 yo has 4 months of persistent headaches, increasing in intensity, worse in morning,
recent projectile vomiting and bilateral papilledema = Brain tumor. Do MRI. Decrease
ICP with high-dose steroids (Decadron).
7. 42 yo has progressive speech difficulties, right hemiparesis, progressively severe
headaches with vomiting and papilledema, blood pressure increases to 190/110,
bradycardia = Brain tumor with signs localizing to left hemisphere. Cushing reflex from
increased ICP. Remember perfusion pressure decreases as ICP increases, so cushing
reflex is to increase arterial pressure to compensate.
8. Man has 2 months of severe explosive headaches, inappropriate behavior, optic nerve
atrophy, papilledema, anosmia = Brain tumor in frontal lobe (Foster-Kennedy
syndrome). MRI and neurosurgery.
9. 12 yo boy is short for age, has bitemporal hemianopsia, calcified lesion above sella =
Craniopharyngioma. MRI and craniotomy.
10. 23 yo woman has 6 months amenorrhea and galactorrhea, is not pregnant =
Prolactinoma. Check bHCG anyway and TSH (hypothyroidism). Check Prolactin level. MRI
to visualize tumor. Bromocriptine therapy or surgery.
11. 44 yo hypertensive man has big, fat, sweaty hands, a large jaw with thick lips, a large
tongue, huge feet, wedding ring no longer fits, mild diabetes = Acromegaly.
Somatomedin C determination, MRI, then pituitary surgery or radiation therapy.
12. 15 yo girl concerned that she has become ugly, has acne, posterior hump, fat trunk,
thin extremities, mild diabetes, hypertension = Cushing syndrome.
13. 27 woman with 6 months of morning headaches, loss of peripheral vision, and
amenorrhea has sudden severe headache, BP 75/45, bilateral optic nerve pallor =
 Pituitary apoplexy (bleed into pituitary adenoma). In shock due to adrenal insufficiency.
Steroid replacement urgently. Then MRI or CT and Surgery.
14. 32 yo man has 3 months of severe morning headaches with projectile vomiting, loss of
upward gaze, sunset eyes = Parinaud syndrome (tumor of pineal gland). MRI then
neurosurgery.
15. 6 yo boy has several months of severe morning headaches, truncal ataxia, patient on
hands and knees = Posterior fossa tumor. Likely ependymoma (which is on a pedicle
and therefore causes positional pain). MRI and neurosurgery.
16. 23 yo man has 2 weeks of severe headaches, seizures, projectile vomiting, low-grade
fever, recently treated for acute otitis media and mastoiditis = Brain abscess. CT then
resection.

Spinal Cord
17. 52 yo woman has 2 weeks constant severe back pain, sudden paralysis below waist,
history of mastectomy = Metastatic, extradural tumor with pathologic fracture of
weakened pedicles. CT to see tumor and fracture. MRI to assess cord damage.
Neurosurgery if cord compression.
18. 45 yo man has severe back pain with electric shock when he lifts heavy object, worse
with straining, positive straight leg-raising test = Lumbar disk herniation. If shooting
pain exits at big toe, L4-5. If pain exits little toe, it is L5-S1. MRI to diagnose. Rest and
pain control unless there is progressive weakness or sphincteric deficits, in which case
do neurosurgery.
19. 79 yo has leg pain with walking relieved by rest, has to sit down or bend over for pain
to disappear, can exercise if hunched over = Neurogenic claudication. Spinal stenosis.
MRI and refer to pain clinic. Steroid and analgesic injections under x-ray guidance.
20. T6 paraplegic is delayed several hours in doing his routing self-catheterization,
develops pounding headache, profuse perspiration, bradycardia, BP 220/120 =
Autonomic dysreflexia. Empty bladder. Give alpha blockers and CCBs (nifedipine) long
term.

Pain syndromes
21. 60 yo man has sharp shooting pain on face brought on by palpation, normal neuro
exam = Trigeminal neuralgia. Rule out organic lesions with MRI. Treat with
anticonvulsants (carbamazepine).
22. Constant burning pain in arm after crushing injury, aggravated by slight stimulation,
arm cold, cyanotic, and moist = Causalgia (reflex sympathetic dystrophy). Successful
sympathetic block confirms. Follow with surgical sympathectomy.

12. Urology

Urologic emergencies
 1. 14 yo boy with sudden severe pain in testicle, no fever, high riding and horizontal
testicle, cord not tender = Testicular torsion. Urological emergency to save testicle. Can
do doppler, but generally will rush to OR.
2. 24 yo man has severe pain in scrotum, fever, pyuria, testis in normal position, cord
tender = Acute epididymitis. Abx. Order sonogram to rule out testicular torsion.
3. 72 yo man being observed with small ureteral stone develops chills, temp of 104, flank
pain = Obstruction and infection of urinary tract—true urologic emergency. Massive IV
abx. Stone extraction.
4. Adult woman has dysuria with cloudy urine, develops high fever, nausea, vomiting,
flank pain 3 days later = Pyelonephritis. Hospitalization, IV abx, sonogram to confirm no
concomitant obstruction.
5. 62 yo man has chills, fever, dysuria, diffuse low back pain, tender prostate on rectal
exam = Acute bacterial prostatitis. IV antibiotics. No more prostate exam.
6. 33 yo man has dysuria with cloudy urine, fever, prostate not tender = Urinary cultures
and abx. UTIs in men are unusual so rule out urinary tract obstruction with sonogram.
UTI? Common—cystitis in young woman, prostatitis in old men. Just treat. Uncommon—
infection severe or in wrong kind of patient. Do sonogram to rule out obstruction.

Congenital urologic disease

7. Newborn has not urinated in first 24 hours, bladder is distended = Obstruction. Meatal
stenosis or posterior urethral valves. Catheterization. Voiding cystourethrogram to
diagnose, endoscopic fulguration or resection to treat.
8. Newborn boy has urethral opening on ventral side of penis = Hypospadias. Don’t
circumcise because foreskin may be needed for reconstruction later.

Not in notes: Child with hematuria after insignificant trauma = Need a sonogram.

9. Newborn boy has only one testicle in scrotum, other palpable in groin and can be
pulled to normal location but won’t stay there = Retractile testicle due to overactive
cremasteric reflex. Observe for now, may descend in first year or requires orchidopexy.
10. 9 yo boy has 3 days dysuria, flank pain, fever, chills = Congenital anomaly likely (reflux).
Abx, IV pyelogram, voiding cystogram. Patient may grow out of problem without
surgery.
11. 6 yo girl failed toilet training, she perceives sensation of having to void and voids at
normal intervals, but is incontinent of urine at other times = One ureter implanted
normally, one has low implantation into vagina. Do IVP and surgery.
12. 16 yo boy has colicky flank pain after first beer-drinking binge = Ureteropelvic junction
obstruction. Do sonogram and surgical correction.

Tumors
13. 62 yo man has gross, painless total hematuria (not initial or terminal hematuria) =
Blood could be coming from kidneys to bladder (not prostate or urethra). Infection vs.
tumor, so need to rule out cancer of kidney, ureter, or bladder with CT and cystoscopy.
 14. 70 yo man has hematuria, flank pain, flank mass plus hypercalcemia, erythrocytosis,
elevated liver enzymes = Renal cell carcinoma. CT. Has a tendency to grow into lumen
of renal vein. If tumor is broken when vein clamped, will cause pulmonary embolism. So
rule out this renal vein invasion on CT.
15. 55 yo chronic smoker has painless gross total hematuria, frequent irritative voiding
symptoms, no fever, negative UA = Bladder cancer. Do cystoscopy for diagnosis. Also
do CT to rule out tumor in ureter and collecting system.
Hematuria unrelated to trauma: Total: kidney, ureter, bladder. Initial: bladder, prostate,
urethra.
Total hematuria unrelated to trauma: IVP, sonogram or CT scan will reveal renal source.
Only cystoscopy will reveal early bladder tumors. Local injection of BCG can reduce bladder
cancer recurrence.
16. 59 yo black man has rock-hard, discrete nodule in prostate on exam
17. 59 yo black man has elevated PSA since last visit, no palpable prostate abnormalities =
Early cancer or prostate. Do transrectal needle biopsy of nodule (or sonogram to find
nodule). Eventual surgical resection or radiotherapy.
18. 62 yo man had radical prostatectomy 3 years ago, now has bone metastases =
Dramatic palliation can be achieved with orchiectomy. LHRH agonists and antiandrogens
(flutamide) are alternatives.
19. 78 yo man has checkup, PSA had been ordered 5 years prior but not done yet = Offer
selectively, even though we used to not offer after 75, because longevity and outcomes
have improved.
20. 25 yo man has painless hard testicular mass, not arising from epididymis = Do radical
orchiectomy without pathologic diagnosis. No benign tumors of testicle. Measure serum
AFP and betaHCG to before orchiectomy and follow-up after.
21. 25 yo man has pulmonary metastasis on routine CXR, weight loss, hard testicular mass
= Platinum-based chemotherapy may provide cure.

Retention and incontinence

22. 60 yo man can’t void for 12 hrs, bladder halfway between pubis and umbilicus, boggy
prostate on exam, taking antihistamines and nasal drops for cold = Acute urinary
retention with underlying benign prostatic hypertrophy. Precipitated by antihistamines
and alpha-agonist nasal drops. Catheterize to empty. Check post-void residual volume
with sonogram. Manage with alpha blockers.
23. Postop day 2 after bilateral inguinal hernia repair, urinary incontinence of few ml
every few min, palpable mass in pelvis = Overflow incontinence. Indwelling bladder
catheter for several days.
24. 42 yo G5P5 woman has urinary incontinence with laughing or getting up, no
incontinence at night = Stress incontinence after childbirth has caused pelvic floor to no
longer hold up neck of urethra. Recommend exercises to strengthen pelvic floor. Will
need surgery if cystocele present.

Stones
 25. 72 yo man passed 3 urinary stones in past, now has ureteral colic with 3mm stone just
proximal to ureterovesical junction = Small stone already passed through most of
ureter. Observe with fluids and pain medication. 70% chance of passing on its own.
26. 54 yo woman has sever ureteral colic, CT shows 7mm stone at ureteropelvic junction =
5% chance of passing on its own. Treat with shock-wave lithotripsy unless pregnancy,
bleeding diathesis, or stones several centimeters large are present.

Miscellaneous
27. 72 yo man has air bubbles coming out with urine = Fistula between bowel and bladder.
Commonly from sigmoid colon to dome of bladder, caused by diverticulitis. Cancer of
sigmoid also possible. Cystoscopy/sigmoidoscopy as well as contrast studies are often
unrevealing. Get a CT first. Can get sigmoidoscopy afterward to rule out cancer. Then do
surgery.
Impotence:
Trauma: Perineal trauma=Vascular injury. Amenable to repair., Pelvic Surgery=Erectile
plexus injury. Cannot repair.
Unrelated to trauma: Psychogenic=sudden onset, limited to circumstances that led to it
in first place; Organic=hypertensive diabetic older male, gradual onset

28. 32 yo man has sudden onset impotence after evening of heavy eating and drinking,
still gets nocturnal erections and can masturbate normally = Classic psychogenic
impotence: yound man, sudden onset, partner-specific. Curable with psychotherapy if
promptly done.
29. Young man impotent since crushing perineum in motocycle accident = Vascular injury
(ie pudendal artery). Arteriogram and vascular repair.
30. 52 yo man impotent since rectal cancer resection = Injury to erectile plexus. Prosthetic
devices can be offered.
31. 66 yo diabetic has gradual loss of erectile function, first short-lasting, then poor-
quality, then complete impotence, and no nocturnal erections = classic sequence for
organic impotence. Give sildanefil, tadalafil, vardenafil.

13. Organ Transplantation

1. 62 yo man in coma for several weeks after motorcycle accident, on respirator, on

vasopressors, no neurologic improvement, family inquires about possible organ
donation = All potential donors referred to local organ harvesting organization. Only
blanket exclusion is HIV positive patients.
Organ rejection
Hyperacute: within minutes, due to preformed antibodies, produces thrombosis,
prevented by proper matching
Acute: within weeks, most patients will get at some point, recognize deterioration of
organ function, diagnose with biopsy, treat with steroid bolus or anti-lymphocytic
 medication. Heart transplant requires routine biopsy due to lack of early clinical signs of
acute rejection. For liver, elevated LFTs suggest technical problems with the
anastomoses more than rejection because liver rejection is rare.
Chronic: Years later, poorly understood, irreversible. Do biopsy to rule out late acute
rejection.

2. GGT, alk phos, bilirubin levels increase 10 days after liver transplant, no ultrasound
evidence of biliary obstruction or Doppler evidence of vascular thrombosis = Acute
liver rejection. Do biopsy.
3. Clinical and laboratory signs of decreased renal function 3 weeks after closely
matched renal transplant = Acute rejection. Biopsy.
4. Fever, dyspnea, hypoxemia, decreased FEV1, interstitial infiltrate 2 weeks after lung
transplant = Acute rejection. Biopsy.
5. Loss of organ function (renal, hepatic, cardiac, pulmonary) several years after
successful transplantation = Chronic rejection. Biopsy to rule out late acute rejection
episode.