UWorld Surgery Notes

C. diff infection:

• Watery diarrhea, can be followed by Toxic Megacolon – bowel loop dilation and abdominal distension.

Post-surgery/trauma nutrition:

• Start Enteral feeds as soon as possible – helps maintain gut wall integrity, lowers risk of sepsis, etc.
o Delay only if patient is hemodynamically unstable – i.e, inadequate perfusion to gut.
• Parenteral feeds (TPN) is needed only if patient is unable to tolerate enteral feeds or needs more than
enteral feeding can supply (hypermetabolic state).
o Otherwise, the risks of TPN are too high, and it has none of the benefits of Enteral feeding.

Euthyroid sick syndrome:

• Occurs in severe acute illness (high cytokine levels) or in patients on high-dose glucocorticoids.
• Glucocorticoids/cytokines suppress the peripheral conversion of T4 to T3 (thyroid hormone).
o i.e, Low T3, but normal T4 and TSH.

Acromegaly:

• Pituitary adenoma; can cause a variety of other symptoms.

• Low testosterone/erectile dysfunction – low ACTH; Polyuria – low ADH.
• GH increases blood sugar (causing polyuria) and increases metabolic rate (manifests as excess
sweating).
• Tissue overgrowth – synovial overgrowth causing widened joint spaces, and spaces between the teeth.
o Hemochromatosis presents with narrowed joint spaces.
o Amyloidosis also has widened joint spaces, but no sweating/teeth spacing.

Surgery can often be delayed!! Ex: Up to 72 hours, for femur neck fracture.

• If the patient has signs of some medical illness that may be more important, especially
cardiac/respiratory – patient must be stable before surgery.
o Ex: Atrial fibrillation, Pneumonia, Pleural effusion.
• So, treat the patient’s medical condition first, THEN go for surgery.

Bacterial/post-op endophthalmitis:

• Infection of aqueous or vitreous humor by conjunctival bacteria, usually in the process of cataract
surgery.
• A/w decreasing vision and ache in the eye.
• Emergency situation – diagnose clinically and treat with intravitreal injection of antibiotics.
Bloody ascites = Malignancy

• Ascitic fluid only appears bloody if RBC count > 50,000 /mm3.
• The malignancy disrupts and erodes nearby blood vessels.

Pheochromocytoma:

• A/w persistent HTN and hyperglycemia.

• Also apart of MEN – so often found with concurrent pituitary adenoma, causing symptoms by mass
effect.

Cryptorchidism:

• Wait for spontaneous descent until 6 months.

• Then, do Orchidopexy – before 1 year of age.

Priapism:

• Caused by hematologic disorders that alter blood viscosity.

• Ex: Sickle cell, Hematologic malignancy (CML, etc.), Thalassemia, Multiple myeloma.
o Associated hepatosplenomegaly is a sign of CML.
• CBC is the best initial test.

Splenic abscess:

• Happens after abdominal surgery; Left-sided abdominal pain with splenomegaly, sometimes radiating
to the back.
• Diagnose by CT scan; Treatment: Aspiration often fails – tiny occult abscesses reseed the spleen.
Splenectomy is usually needed.

Lemierre syndrome:

• Fusobacterium infection – initial pharyngitis, then local spread into neck, infecting the internal jugular
vein (pain along sternocleidomastoid).
o Then spreads hematogenously to other organs (septic emboli) – especially the lungs (Multiple
lung nodules).
Reason for Post-op Ileus:

• Splanchnic sympathetic nerve stimulation during surgery (sympathetic = decreased bowel motility).
• OR, Opioid analgesic use.
Thyroid nodule: If TSH is low, first do Radionuclide scan, then FNAC.

• ‘Cold’ nodules on scan need FNAC – high risk for cancer.

• ‘Hot’ nodules have low cancer risk – no need for FNAC.
• If the nodule has features of malignancy (irregular, calcified, etc.) then do FNAC directly.

Dumping syndrome:

• In gastric bypass patients, large amount of carbohydrate is ‘dumped’ into small bowel – leads to
osmotic fluid shift into bowel.
• This causes hypotension and sympathetic activation – tachycardia, sweating, etc.

Small intestine bacterial overgrowth:

• Usually a/w B12 deficiency and Macrocytic anemia.

• But also has increased Folic acid and Vitamin K (because of the bacteria).

Myxedema (hypothyroidism) Pathophysiology:

• Deposition of a mucinous material composed of glycosaminoglycans, hyaluronans and

mucopolysaccharides.
o Ex: Infiltration of median nerve, it’s nerve sheath, and the surrounding carpal tunnel can cause
carpal tunnel syndrome.

Circumcision benefits:

• Decreased risk of UTI early in life/some STDs/Penile cancer later in life.

Liver stores 30 days of Vitamin K – easily depleted in malnourished patients.

Fibroadenoma is sensitive to estrogen (grows bigger after OC pills).

Breast mass:

• Fibroadenoma-like in adolescent – review after next menstrual cycles.

• Adults age <30:
o USG first; if suspicious for malignancy, core biopsy (may use mammogram as additional test).
• Adults age >30:
o Mammogram first. Core biopsy if features of malignancy.
Methemoglobinemia can be caused by anesthesia!!

• Topical anesthetics, like benzocaine, specifically.

• Also, Dapsone and Nitrates can do the same.
• SpO2 is fixed at around 85% (because of the pigment of methemoglobin).
• ABG O2 sat will be falsely elevated, because that is calculated off pO2 (which is normal), not the actual
oxygen bound to hemoglobin.

Aneurysm repair involves clamping of the aorta and grafting that can shear off some small branches – can
cause ischemic symptoms (infarction) of other organs.

• Ex: Spinal cord infarction – anterior half of spinal cord, which is supplied by small segmental branches
of the aorta that can be sheared off during graft repair.
o The posterior half is supplied from the vertebral/posterior inferior cerebellar arteries –
branches of carotid circulation, which are supplied before the site of clamping/repair.

Risks of Succinylcholine:

• It binds to acetylcholine receptors, triggering sodium influx and potassium efflux.

• In certain conditions, the Ach receptors are upregulated – so succinylcholine causes massive potassium
efflux, leading to hyperkalemia → Cardiac arrythmia.
o Ex: Skeletal crush injury, Burn injury, muscle atrophy, denervation (GBS, stroke, neuropathy,
etc.)
• Crush injury already predisposes to hyperkalemia (release from crushed cells), increasing the risk.

Symptomatic pancreatic pseudocyst:

• Treat with endoscopic drainage, and IV antibiotics if infected (fever, leukocytosis).

Slipped capital femoral epiphysis:

• Occurs in obese adolescents, but does not have fever. Also, is a chronic pain with hip deformity.

Pacemaker implantation = high risk of tricuspid regurgitation!!

• Because the pacemaker lead has to pass through the valve – can be damaged while placing.
• Tricuspid regurgitation = holosystolic murmur at left sternal border.
o VSD also has the same murmur, but may also have a palpable thrill.
o Also, VSD is not a/w pacemaker implantation.
Squamous cell carcinoma:

• Most common cause – sun exposure (in sun-exposed areas).

• Can also occur at sites of chronic wound (venous stasis ulcers) and scars (burn wounds).

Prosthetic joint infections:

• < 3 months post-op → virulent organisms like Staph aureus and Pseudomonas.
o A/w fever, leukocytosis, synovial WBC > 50000.
• 3-12 months post-op → less virulent, like CONS (Staph epidermidis) or Propionibacterium.
o Synovial WBC > 1000, but <50000.
o Unlikely to have fever, erythema, etc. Mostly just a mild join ache.

Abdominal compartment syndrome:

• Massive third spacing of fluid into the abdomen in inflammatory settings – patient goes into
hypovolemic shock as all fluid moves into the abdomen.
• Abdomen is tense and distended; pushes up the diaphragm causing difficulty breathing (bibasilar
atelectasis on x-ray).
o This extrinsic pressure causes increased central venous pressure (CVP), adding to the decreased
preload (venous return).

Partial biopsy (Punch/Deep shave)

• Usually not done, since the whole lesion should be inspected (may miss something by only examining a
small part).
• Can be done for very large lesions, or those on the face/ear (where full excision is
difficult/problematic).

Fatigue can be a symptom of Graves disease.

Overuse syndromes (tendon sheath inflammation):

• Rx: Initial rest/heat/NSAIDs; local corticosteroid injection if those fail.

Hemorrhoid treatment:

• Surgical hemorrhoidectomy for external hemorrhoids.

• Coagulation/Rubber band ligation/Sclerotherapy for internal hemorrhoids.
o These are NOT used for External hemorrhoids since they are innervated with pain sensation.
Primary adrenal insufficiency:

• Suspect in patients with low sodium/high potassium (low glucose may also be an indicator).
• Autoimmune destruction of all layers of adrenal cortex.
• Sudden stress, like surgery/endoscopy/anesthesia will precipitate adrenal crisis.
o Due to low mineralocorticoid (hypoaldosteronism).
o Severe hypotension and tachycardia, refractory to volume resuscitation and vasopressors like
epinephrine (since cortisol is needed to ‘permit’ epinephrine to act).
• So, Rx: Volume resuscitation + Glucocorticoid.
o Dexamethasone is preferred (doesn’t alter plasma cortisol levels, which are important for
diagnosis.
o Mineralocorticoid replacement takes several days to show its effects (still done, just after
resuscitation).

Aortic dissection:

• Can cause pleural effusion (direct extension – hemothorax, or inflammatory reaction of blood irritating
the pleural lining).
• And may have elevated d-dimer.

Bowel ischemia – watershed areas:

• Ischemia is more common at the splenic flexure and rectosigmoid junction – not the hepatic flexure.
• Small bowel is usually involved in embolic/thrombotic episodes – not due to hypotension.

Expanding neck hematoma (post-surgery):

• Requires EMERGENCY decompression (by opening the incision again – surgical exploration).
• Emergency because it can cause airway compromise, or compress the neck vessels.

Abdominal Aortic Aneurysm screening:

• In Men age 65-75, with h/o smoking ONLY.

Back pain that is worse at night and unrelieved by rest = Metastatic cancer.

Prevention of post-op pneumonia:

• Most effective – incentive spirometry.

• Other options – CPAP, deep breathing exercises, positive pressure breathing.
o CPAP is 2nd choice, since it has a higher risk of complications (use if incentive spirometry fails).
Types of cranial bleeds and their characteristics (Subdural, Epidural, Subarachnoid, etc.)

• Epidural – in young adults; tear of middle meningeal artery at the pterion (frontotemporal region).
o Classically LOC f/b lucid interval, but that only happens in 20-50%.
o May instead remain alert, but quickly decompensate due to the expanding hematoma
compressing the brain.
o Due to trauma.
• Subdural – tear of the bridging veins, usually in old/on blood thinners patients.
o Coma from onset, no lucid interval.
o Due to trauma.
• Subarachnoid hemorrhage – thunderclap heachache a/w LOC; NOT due to trauma (usually aneurysmal
rupture).

Deep diabetic wound/ulcer infections: Almost always polymicrobial, with contiguous spread to bone.

Pericardial effusion in Chronic hemodialysis patient:

• Highly likely to be infected (dialysis predisposes to infection), which makes it an emergency.

• Immediate pericardiocentesis (diagnostic and therapeutic) is a must.

Ibuprofen/Colchicine – Rx for idiopathic/viral pericarditis (would only have small pericardial effusion).

Charcot arthropathy – destruction of the ankle joint because of lack of sensation/proprioception in diabetics.

• Patient does not automatically adjust to avoid/minimize normal wear and tear, thus heavily damaging
the joint.

Acalculous cholecystitis:

• Commonly seen in patients who are critically ill, or post-surgery.

• A/w RUQ pain and fever/WBC increase and may or may not have abnormal LFT.
o Normal LFT does NOT exclude the disease.

Patient with rib fracture:

• Has a high risk for pneumonia & atelectasis – due to shallow breathing and not coughing because of
the pain.
• So, to prevent pneumonia, PAIN CONTROL (analgesia) is important.
o Will ensure adequate breathing and cough.
o NSAIDs or Opioids can be used – respiratory depression of opioids is outweighed by the
benefits of adequate pain control.
Blunt abdominal trauma with intraperitoneal bleeding = Splenic laceration.

Basal cell carcinoma:

• Excision biopsy, then 4 mm margin excision if positive.

Colonic pseudo obstruction: a.k.a Ogilvie syndrome

• Colonic motility is lost due to several causes – Ex: Electrolyte abnormalities – causing autonomic
derangement.
o A/w severe trauma, massive diarrhea, major surgery, neurologic disorders, etc.
• Patient presents with severe intestinal obstruction.

Antibiotics after splenic rupture/splenectomy:

• Targeting encapsulated organisms, we use amoxicillin-clavulanic acid!! For those with penicillin
allergy, use Levofloxacin.

Eggshell calcifications (in a liver mass/cyst) = Hydatid cyst.

Upper limb DVT:

• Can be due to repetitive motions (like pitching a baseball), weightlifting, central venous catheters, and
malignancy.
• Manifests as acute arm edema with erythema; risk of PE is present.
Lymphedema is chronic, not acute.
Superficial thrombophlebitis is pain and erythema along the vein, not the whole arm.

Occlusion of the aortoiliac junction: Leriche syndrome

Papillary thyroid cancer: Surgery is the 1st choice; radioactive iodine is an adjunct, if needed/recurrence
occurs.

Rotator cuff tendinopathy:

• Overuse injury – ex: painting high ceilings all day.

• Pain, but the active movement is still possible – Positive impingement tests (ex: Neer’s empty can test).
• Chronic – increases risk of rotator cuff tear.
o Tear → Active movement is no longer possible; only passive.

Rectal bleeding:

• Do a colonoscopy for colon cancer screening only if:

o Age > 50, OR age >40 with family history of colon cancer at age <60.
o Profuse rectal bleeding (mild bleeding into stools doesn’t count).

Acute limb ischemia:

• Immediate anticoagulants like Heparin (fast acting).

• Then consider thrombolysis or surgical thrombectomy.

Signs of open globe (eye) injury:

• ‘Fixed teardrop’ pupil – iris lacerated by the foreign body; or decreased anterior chamber
depth/intraocular pressure (as fluid leaks out).
• Rx: Eye shield and Emergent surgical opthal consult.
Hypopyon will eventually form, but that is a chronic finding.
Acute corneal opacification is a sign of angle closure glaucoma.

Diabetics might not have Fever in Septic shock!!!

• Hyperglycemia affects leukocyte function, so the cytokine production is impaired.

• So, diabetic patient with signs of septic shock (hypotension, non-healing ulcer, etc.) – assume it is
septic shock even without fever.
o Rx: Aggressive IV hydration and IV antibiotics.
o As volume is restored and tissue perfusion improves, the acidosis with fade (lactic acidosis from
hypoperfusion).
Stress hyperglycemia:

• Blood glucose shoots up in stressful conditions, ex: trauma, sepsis due to release of cortisol and
catecholamines.
• Identified by normal HbA1c – NO TREATMENT needed!

Acute flank pain:

• Could be kidney (pyelonephritis, etc) but could also be Abdominal aortic aneurysm rupture!!
• Marked hypotension without fever → AAA.

Pheochromocytoma: HTN episodes

• Can be triggered by:

o Positional changes
o Changes in intra-abdominal pressure, like palpating the tumor
o Surgery
o Anesthetics.
• Thyroid storm could cause similar symptoms, but patient usually has fever as well.

Acromio-clavicular joint sprain:

• Diagnosed by adduction of the shoulder across the body (compresses the AC joint) causing pain.
• Occurs when the shoulder hits the ground in a lateral angle.
• Mild sprain → Normal x-rays.

Sudden onset chest pain and difficulty breathing

• Consider Pneumothorax – bleb rupture in COPD patients.

o This is a secondary pneumothorax – tracheal deviation is rare compared to spontanoues
pneumothorax.
o And breath sounds are only diminished, not absent entirely.

Diverticulitis + Abscess (fluid collection with a ring-enhancing rim):

• < 3 cm → IV antibiotics and observation.

• >3 cm → Percutaneous drainage and antibiotics.
o If STILL not treated – surgery and debridement. Not colectomy.

Prevent post-op pneumonia – Incentive spirometry (CPAP only if it fails and pneumonia develops).
Diaphragmatic hernia: Look for the nasogastric tube circling back up – causes breathlessness despite chest
tubes.

• After blunt chest/abdominal trauma (ex: car crash).

Hypocalcemia might occur after massive blood transfusions (ex: major trauma surgery).

• The citrate in the transfused blood binds ionized calcium.

• Does NOT occur normally, because citrate is rapidly metabolized by the liver.
o It occurs only in patients with liver dysfunction – ex: liver laceration or chronic liver disease.
• Hypocalcemia == Paresthesia (numbness), Chvostek/Trousseau signs, and hyperreflexia.
Evaluation of Thyroid nodule:

Prosthetic valve aortic regurgitation:

• Murmur is best heard at the LEFT sternal border (unlike Right for normal AR).
 • May be a leak through the valve (transvalvular) or around the valve (paravalvular).

Risk for Prostate cancer:

• Advancing age (<40 never get prostate cancer)

• Black ethnicity
• Diet high in animal fat (mild increase).
• 5-alpha reductase inhibitors (finasteride) reduce the risk.

Fothergill sign:

• Abdominal mass that does not cross the midline and does not move with movement of the lower
limbs.
o It is a sign of rectus sheath hematoma.
• The sign helps differentiate between an abdominal wall mass and an intra-abdominal mass – positive
sign → abdominal wall mass.
Rectus sheath hematoma is a/w severe coughing, and has a +ve Fothergill sign.

Liver abscess – hypodense on contrast CT.

Leydig cell tumor can produce BOTH testosterone (expected) and estrogen.

• So, may present with acne or gynecomastia.

DIC also causes hypotension.
Atrial flutter also needs anticoagulation, like atrial fibrillation.

• Definitive Rx: ablation of the atrial reentrant circuit, which is the cause of the flutter.
• But that is only needed if patient is severely symptomatic.

Horner syndrome + Arm pain → Suspect Pancoast tumor (chest X-ray).

Autonomic dysreflexia:

• Occurs in spinal cord injury.

• Stimulus below the level of injury sets of the normal response (ex: sympathetic), but this stimulus
doesn’t reach above the level of the injury.
o So, for example, pain = sympathetic vasoconstriction below the injury.
o Vasoconstriction = HTN → the baroreceptors act to decrease BP by Bradycardia.
▪ Compensatory parasympathetic response (flushing, vasodilation, etc.) above the lesion.
• Can be fatal.
Ehlers-Danlos syndrome is a/w fragile tissues (easy bruising, organ rupture) and poor wound healing (wide,
atrophic scars).

• In addition to join hyperextensibility and skin laxity.

• Genes COL5A1 and COL5A2.

Large pericardial effusion (or cardiac tamponade) → Inability to palpate cardiac apex (point fo maximal
impulse).

Types of brain herniation:

• Subfalcine → Lower extremity weakness due to anterior cerebral artery occlusion (remember it as the
motor homunculus having the lower limbs towards the middle).
• Uncal/Transtentorial → Ipsilateral fixed and dilated pupil – compression of the ipsilateral oculomotor
nerve and the associated parasympathetic fibers.
• Tonsillar → Fixed, mid-position pupils (both sympathetic and parasympathetic supply are disrupted).

Mild ulcerative colitis:

• Superficial ulcers in the rectum/colon with normal inflammatory markers (ESR/CRP).

• Rx: Mesalamine enema (5-ASA inhibitors) if confined to anorectum; oral if spread further.
Intranasal Desmopressin (for von Willebrand’s disease) can cause SIADH!!!

• Hypotonic hyponatremia due to a. Water retention and b. Natriuretic peptide-mediated urine sodium
excretion (because of high volume from water retention).
• Present with non-specific nausea/fatigue.
• So, patient on Desmopressin → Check electrolytes.

IVC Filter for DVT:

• Placed if patient has contraindication to anticoagulation OR has developed complications (ex: bleeding)
from anticoagulation.
• Usually placed temporarily to avoid complications from dislodged filter.

Risk factors for Colon cancer:

• Note that coffee/tea are actually slightly protective for colon cancer, probably due to antioxidant
effects.
Pediatric neck masses:

• Rx: Surgical resection.

Infected wound + Cranial nerve palsy/Muscle weakness:

• Think of Botulism infection – botulinum toxin can cause weakness and palsies.
o Descending motor paresis, beginning with the cranial nerves; sensory innervation is usually
normal.
o A/w Respiratory acidosis – respiratory muscle (diaphragm) weakness.
o Autonomic dysfunction – ileus, urinary retention, etc. is also possible.

Aortic regurgitation is a potential complication of ankylosing spondylitis.

• Because of chronic inflammation of the aortic root/cusps.

• Associated symptoms of Ankylosing spondylitis - ↓ spinal mobility, limited chest expansion, enthesitis
(heel pain).
(Mitral and Tricuspid valves are not involved in ankylosing spondylitis).

Tophaceous gout may present without the usual signs of acute inflammation.

• Usually radiolucent, but calcium may precipitate in it.

• Associated chronic inflammation causes bony erosions of the joint it is in, with ‘overhanging edges’.
 • Usually a/w urate nephropathy – worsening CKD from urate deposition in the kidney.

Osteonecrosis of the jaw:

• In patients taking bisphosphonates (ex: zoledronic acid) – high doses for cancer or osteoporosis.
• Usually seen after tooth extraction – failed wound healing, swelling/erythema, and exposed bone.
• Rx: Mostly supportive, good oral hygiene and antibacterial rinses.
o Antibiotics/debridement only in severe cases (when needed).

Atraumatic splenic rupture – high risk in patients with hematologic malignancy.

Polycystic kidney disease:

• Frequent episodes of flank pain and hematuria – mild discomfort rather than pain.
• A/w mild nephrogenic diabetes insipidus, likely from tubular dysfunction – serum vasopressin levels
are increased.
o Vasopressin agonists decrease cyst formation – ex: Tolvaptan.
• A/w HTN due to localized renal ischemia (from the cysts) → high renin → HTN.

Long-standing diabetic foot ulcer:

• Always check for osteomyelitis – even if the bone is not exposed and there are no signs of infection.
• Hyperbaric oxygen is a late treatment option for non-healing ulcers, but osteomyelitis diagnosis and
antibiotics are more urgent.

Dural-based/Extra-axial mass – Meningioma (well-circumscribed).

Inter-gluteal tender fluctuant mass - Pilonidal disease.

• A/w mucoid discharge that may turn bloody.

Bladder rupture – intraperitoneal free fluid is seen, but no peritonitis (because urine is typically sterile).

• The rupture is at the dome, the weakest part of the bladder (usually).
• Do a Retrograde cystography with a water-soluble contrast (to avoid causing peritonitis with the
contrast leaking).
Testicular torsion – usually scrotal pain, some patients present with lower abdominal pain.

• Might be intermittent, self-resolving and recurring; pain intensifies with lifting of the scrotum.
• Rx: Surgical detorsion and fixation (+ checking the contralateral testes); manual detorsion if surgery not
available.
• May occur spontaneously, or after mild trauma.

Solitary liver nodule/mass + Long-term OC pills = Hepatic adenoma

• Well-circumscribed mass, hyperechoic on USG; may compress the bile tract – elevated ALP/GGT.
• Do NOT biopsy – high risk of bleeding. If necessary (ex: severe bile obstruction), do surgical excision.
• May rupture and send the patient into hemorrhagic shock.

Normal post-anesthetic delirium – agitation or confusion up to 45 minutes after anesthesia.

• Just need reassurance and observation, unless other abnormalities (hypotension, hypercapnia, etc.)
are present.
o It is usually seen in adults with existing psychiatric history (ex: PTSD).
• Don’t jump immediately to withdrawal.

Carpal tunnel syndrome is highly associated with Hemodialysis.

• Due to beta-2 amyloid deposition in the carpal tunnel – inflammation from dialysis increases amyloid
deposition.
• Symptoms worsen during dialysis due to increased venous pressure. And vascular steal from the fistula
causing relative ischemia of the hand (ischemic neuropathy).
o Symptoms are more severe in the hand that has the vascular access.

Carbonic anhydrase inhibitors – increase HCO3- reabsorption at the PCT.

Pelvic fracture: separation of pubic symphysis, lower limb adducted, flexed and internally rotated.

• = High risk of posterior urethral injury – blood at the meatus, high-riding prostate.
• Diagnosis – retrograde urethrography.
o NOT cystography – cystography uses a Foley in the bladder to fill it with dye; in urethral injury,
catheterization is contraindicated.
Patellofemoral pain syndrome: Overuse(?) type pain under the patella.

• Provoked by flexion movements at the knee, which press the patella into the trochlear groove of the
femur. A/w buckling/give-way sensation – a very nonspecific finding of ANY ligament/muscle injury.
• Rx: Decreased activity, NSAIDs, and strengthening of quadriceps/abductors to stabilize the joint.
Strategies to minimize preventable errors:

Hypocalcemia: Hyperreflexia is also a symptom.

Stress fractures in the foot:

• Normal occurrence in the metatarsals – heavy stress while running.

• 2nd, 3rd, 4th metatarsals – no need for splinting/cast/fixation, since the adjacent metatarsals act like
splints. Risk of non-union or malunion is minimal.
o Only need splinting if there is severe pain, displacement, etc. that suggests non-union.
• 5th metatarsal fracture requires splinting/internal fixation – free on one side, so risk of non-union is
higher.
(Stress fractures are normal in people undergoing heavy training – no need for a Bone scan).

Sensory and/or motor loss in Upper limb with Lower limb sparing:

• Syringomyelia, OR traumatic central cord syndrome.

o The fibers for the Upper limbs are towards the center of the spinal cord.
o Syringomyelia is also a type of central cord syndrome.
• First affects spinothalamic (sensory) tracts; if large lesion, can reach the corticospinal (motor) tracts as
well – preferentially the upper limbs since they’re closer to the center.
Traumatic cause – Hyperextension injury (whiplash, impacting an airbag) in patients with existing degenerative
spinal disease (spondylosis, RA, etc.).
Sites of Paget disease (damaged bone) are susceptible to malignant transformation to Osteosarcoma:

• Lytic bone lesion, with periosteal elevation (Codman’s triangle)/Sunburst pattern on X-ray.
o Concentric layers of reactive bone == ‘Sunburst’

o
• Associated with severe pain that is worse at night (unable to sleep) and refractory to NSAIDs.

Insect bite (while putting clothes on) f/b small ulcer at the site:

• == Brown recluse spider!!

• Patient will eventually develop necrosis and eschar at the site of the ulcer.
Black widow spider bite – no ulcer; develops muscle rigidity/cramps, including abdominal rigidity (mistaken
for peritonitis/surgical emergency.
Lyme disease – Tick must be attached for >48 hours, and symptoms (arthralgia, arrythmia, rash) take months
to appear. No ulcer – the rash is the 1st symptom.
Snakebites – Hemoglobinuria and muscle paralysis. Hemorrhage/bleeding in some.
Bariatric surgery:

• Perform the surgery in unison with the usual lifestyle modifications – hence why readiness to change is
important.
• So long as the criteria are fulfilled, bariatric surgery is done immediately.
o Do NOT need to wait for failure of lifestyle modifications/drugs.
o Usually, pharmacological methods are used while evaluating and prepping the patient for
surgery.

Alcohol withdrawal vs. Schizophrenia episode:

• Patients with schizophrenia episodes are not disoriented – their time, place and person is intact.
• Also, schizophrenia does NOT cause tachycardia/HTN.
Opioid withdrawal – Heroin has a half-life of 12 hours (alcohol – 2 days). Symptoms are also more GI and
myalgia – only mild elevation of heart rates is seen.

Long-standing CKD == Decreased Vitamin D (= Low calcium) and Increased phosphate (less excretion).

• Low calcium and high phosphate → trigger for PTH secretion.

• Chronic CKD → Chronic ↑ PTH → Hyperplasia of the glands.
o Along with which there is downregulation of the calcium-sensing receptors, so feedback
inhibition of PTH is lost → Drastically elevated PTH even once calcium is normal/high.
• This is Tertiary hyperparathyroidism.
Chronic varicocele:

• = Risk of infertility and testicular atrophy – due to the slightly elevated temperatures.
• Diagnosis – USG.
• So, in older men → no need for intervention; reproductive age/pre-pubertal boys → surgical
correction (IF patient starts to exhibit low fertility on semen analysis – periodic monitoring is essential).
Avascular necrosis: Risk factors

• Excess alcohol use is a major risk factor. Corticosteroids – only with long, chronic use.

• X-ray:

Autoimmune arthritis = Rheumatoid arthritis.

Excess load on the joint = Osteoarthritis.
HLA B-27 = Ankylosing spondylitis/Psoriatic arthritis.

Eastern Asia/Europe/South America:

• High prevalence of salt-preserved food (damages stomach lining) and nitroso compounds
(carcinogenic).
• Predispose to gastric carcinoma – epigastric tenderness and weight loss.
• Diagnosis – UGI endoscopy.
General advice for muscle injuries – maintain normal physical activity (walking, moving around, etc.) – just
avoid stressful/provocative movements.

• Strict bedrest should be avoided.

Post-op Atelectasis: Decreased breath sounds at the lung base.

• Cause: Due to pain/muscle weakness post-op, patient takes shallow breaths and has a weak cough
reflex.
o I.e, alveoli collapse as the inspired air isn’t enough, and mucus plugs form since the cough is too
weak to dislodge them == Atelectasis.
• So, Rx: Pain control, Deep breathing exercises, Directed coughing, Incentive spirometry.

Acute pancreatitis:

• CT findings can be normal for up to 48 hours. So it is NOT used for diagnosis.

• Serum lipase/amylase can be detected earlier.
• Post-ERCP pancreatitis is a thing – occurs in 10% of ERCP patients.

Fungating laryngeal (vocal cord) mass +/- bleeding:

• Squamous cell carcinoma – smoking is the greatest risk factor.

Hemodynamically unstable – Systolic BP < 90 mm Hg.

Nodular malignant melanoma – grows vertically, so doesn’t have the usual signs of a melanoma.

• Looks like a simple nevus – smooth, well-circumscribed.

• Growth on sun-exposed areas is a warning sign.
• ‘Unnoticed until now’ – a prominent nevus would usually have been noticed in childhood. “Unnoticed”
means ‘recently grew big enough to notice’ == Growing lesion.
Smoking is the greatest risk factor for AAA.

• Diabetes is NOT a risk factor at all for aneurysm – only for atherosclerosis/CAD.

Pancreaticopleural fistula:

• Pleural effusion with amylase-rich fluid.

• Rx: Bowel rest to avid pancreatic stimulation, so the fistula can close.
o ERCP + stent to improve drainage through the ampulla of Vater instead of the fistula.
o Percutaneous drainage/Surgery for refractory cases.

Otosclerosis:

• Imbalance of bone deposition and resorption that finally ends with fixation of the stapes – i.e,
dampening of air conduction of sounds (i.e, conductive hearing loss).
• High likelihood of progression during pregnancy – so symptoms appear towards the end/after
pregnancy.

Intra-cranial hemorrhage in Young people without the typical risk factors:

• I.e, Young, no chronic HTN.

• Think of Cocaine use – increases risk of sub-cortical bleeds (ex: Thalamus).
o A/w acute HTN and tachycardia (sympathetic activation), and dilated pupils.
o Diagnosis – urine toxicology screen.

Ulcerated tonsillar lesion + Neck lymph nodes

• = Squamous cell carcinoma, probably due to oral HPV (HPV-16).

o A/w painful swallowing, and halitosis.
o Can be oropharyngeal or tonsillar.
• Multiple sex partners is a risk factor.

Normal-pressure hydrocephalus:

• Ventriculomegaly on MRI.
• Complaint of gait instability and magnetic gait – feeling as though the feet are ‘stuck’ to the ground.
UMN lesions symptoms may also be seen.
• Diagnosis – symptoms improving after large volume LP.
• Rx: Ventriculo-peritoneal shunt.
Ludwig angina – infection of submandibular space.

• Usually from teeth roots – polymicrobial infection.

• Rx: Ampicillin-sulbactam, Clindamycin. (Rarely need drainage – minimal pus).
o Mechanical airway if swelling compromises the airway.

Patient with hemoptysis and an upper lobe mass → High suspicion for TB (especially if patient is from an
endemic area).

• 1st place the patient is respiratory isolation!!! Keep them in isolation until he tests negative for TB.
• Next, sputum analysis (bronchoscopy only if sputum is indeterminate or patient is in active hemoptysis
to control bleeding).

Suspected appendicitis: ALWAYS confirm with imaging before surgery.

•
• CT scan (contrast) for adults; USG +/- MRI for children and pregnant women.
• Note Rx options for Nonperforated and Perforated appendix in the algorithm

Mitral regurgitation treatment:

• For Primary MR (i.e, pathology of the valve itself) Valve repair if LV Ejection fraction is 30%-60% (i.e,
<60% = surgical repair).
 o Regardless of symptoms! Even if asymptomatic.
• If Secondary MR (i.e, valve is normal but ventricle is dilated, causing MR – like Dilated
cardiomyopathy), use ACE inhibitors or Beta-blockers.

Chronic radiation proctitis:

• Mucosal pallor/friability + Multiple telangiectasias.

•
• Angiodysplasia also occurs in elderly and presents as telangiectasias, but mucosal pallor/friability and
the history of radiation point to Radiation proctitis.

Flail chest:

•
 • The paradoxical motion of the flail segment compromises the respiratory effort – i.e, lower tidal
volume and increased work of breathing.
o Also, the force a/w flail injury causes pulmonary contusion → decreased oxygen diffusion →
further increased work of breathing.
• With time, the patient becomes fatigued due to the increased work of breathing and starts to
deteriorate into respiratory failure.

Fat embolism:

• Occludes the capillaries, so there is no visible filling defect on CT Angiography (capillaries are too small
to be visualized).
o B/L ground-glass opacities are seen – pulmonary edema mimicking ARDS.
• A/w tachypnea/hypoxia, confusion, and a petechial rash (50% of cases).

Unilateral bloody nipple discharge:

• No mass = Intraductal papilloma (too small to be palpated).

• Irregular mass +/- skin retraction = Invasive ductal carcinoma.

Diaphragmatic rupture:

• A/w blunt thoracoabdominal trauma – sudden increase in pressure tears the diaphragm.
• Left is more susceptible – congenital weakness, and Right has the liver as protection.
• May be asymptomatic for months/years – symptoms usually of lung compression/incarcerated bowel.
Wound infection in Burn injuries:

• The eschar (necrotic tissue) is an excellent substrate for bacterial growth.

o So, excision of eschar and skin grafting is the best way to minimize wound infections – done
within 5 days of burns.
o Usually done in stages over the body, since the procedure involves a large amount of blood loss
(excising the eschar until capillary bleeding is encountered, then grafting).

Auricular hematoma (i.e, of the pinna):

• Surgical evacuation is a must.

• It is highly prone to infection; also, it can compress and cause avascular necrosis of the auricular
cartilage (since the cartilage has no direct blood supply – only diffusion).
o Fibrocartilage overgrowth after necrosis can cause ‘Cauliflower Ear’.

Scalp trauma + Progressive contralateral weakness/paresis = Epidural hematoma.

• Neurological symptoms due to rapid expansion and uncal herniation – contralateral hemiparesis from
compression of the midbrain by the herniated part, and ipsilateral oculomotor nerve palsy
(compression against the tentorium cerebelli).
• Also contralateral homonymous hemianopia with macular sparing (PICA compression – occipital lobe).

Nasopharyngeal carcinoma → Epstein-Barr virus.

• Endemic to Southern China (and parts of East Asia/South America) – due to cured/salted foods with
nitroso compounds.
• EBV DNA is found in the tumor cells.
• Symptoms – Nasal congestion, recurrent epistaxis, cervical lymphadenopathy.

Empyema (pleural effusion) is often a/w weight loss.

• i.,e not cancer, but a parapneumonic effusion (i.e, underlying pneumonia).

• In Elderly/Alzheimer’s patients – Aspiration pneumonia and infection with oral anaerobes can cause
Empyema.

Duodenal/Splenic laceration – fluid is retroperitoneal, not intraperitoneal.

• Also, the blood is contained in the capsule/membranes and tamponades itself – so they usually
respond well to volume resuscitation.
Liver laceration is Intraperitoneal – blood is not contained, so patient does NOT respond to volume
resuscitation (ex: no improvement with 2 L fluid bolus).
Abdominal aortic laceration/rupture – usually exsanguinates before reaching hospital.

• If they don’t, it is because the blood was contained retroperitoneally – so no intraperitoneal fluid.

Thyroid nodule evaluation:

• TSH, then USG.

o If >1 cm with features concerning for malignancy (irregular border, microcalcifications, etc.), do
FNAC.
o If >2 cm, do FNAC for all.
• Normally, an RAI is also done to check for hot vs. cold nodule (Cold is more risky) – done before FNAC.
• In pregnant women – don’t do RAI (risk of radiation to fetus – congenital hypothyroidism by destroying
the fetal thyroid).
o Go directly to FNAC.
o Usually, thyroidectomy (if required) can wait until delivery – but if it is a very rapidly aggressive
cancer, then 2nd trimester surgery may be needed.

Biliary atresia – symptoms (jaundice and hepatomegaly) appear at 2-8 weeks. Baby is normal at birth.

Ulcerated lesion → Squamous cell carcinoma.

• Usually friable (bleeds on touch) and a/w history of smoking or immunocompromised status.
• HPV is a major risk factor (especially for Oral SCC).

Liver abscess – diagnose with CT Abdomen/USG. Then drain it.

Hypocalcemia can cause QT-prolongation.

Succinylcholine – major side effect is cardiac arrythmia.

• It is a depolarizing blocker – it causes sodium influx and potassium efflux, setting the membrane into a
refractory period, and thus, paralysis.
• Therefore, it causes severe hyperkalemia → cardiac arrythmia.

Fat Embolism: Microvascular occlusions, no visible filling defects on CT Angio.

• Microvascular emboli slip past pulmonary circulation and cause systemic infarction – ex: brain
(confusion, agitation), dermal capillaries (skin rash).
• The fat emboli can also cause inflammation, worsening the occlusion.
• Develop pulmonary edema (ground-glass opacity) and thrombocytopenia (sometimes).
Spinal cord compression: Immediate glucocorticoids 1st.

• Bone scan/Skeletal survey can identify bone metastasis, but the immediate concern here is the
neurological symptoms – need an MRI to visualize.

C. diff can also cause Toxic megacolon – Rx: Bowel rest, nasogastric tube (to relieve distension) and aggressive
antibiotics against C.diff. Also, discontinue anti-motility drugs (like opioids/anticholinergics/loperamide).
Hidradenitis suppurativa:

• Follicle occlusion by keratinocyte proliferation → eventual rupture due to friction causing

inflammation; releases proinflammatory factors causing further occlusion.
• Smoking is a major risk factor – nicotine/other tobacco substances promote follicular occlusion and
are also pro-inflammatory.
o Metabolic syndromes (obesity, diabetes) are also risk factors.

• (See Rx).

Internal hemorrhage after cardiac catheterization:

• = Retroperitoneal hematoma from the femoral access site.

o A/w back pain/discomfort.
• Diagnose with non-contrast CT – since it is a hematoma, not active bleeding.
o Not active bleeding → Symptomatic improvement with IV fluids.

Pseudo gynecomastia (due to fat):

• No distinct borders, no palpable glandular tissue/nodules.

• Rx: Weight loss – no need for imaging/lab tests (USG only for nodules/asymmetric mass).

Bloody Ascitic fluid:

• Grossly bloody fluid → RBC Count > 50,000 /mm3.

• Single tap bloody → blood from the paracentesis trauma.
• Multiple taps bloody → Underlying malignancy.
o Portal vein thrombosis does not cause ascites (obstruction proximal to liver).
o Hepatic vein thrombosis (Budd-Chiari) can cause ascites, but non-bloody.
Blunt chest trauma – ECG to screen for blunt cardiac injury (in addition to Chest x-ray/CT and FAST).

• BCI can cause clinically silent tamponade or wall rupture – abnormal ECG → 24 hour monitoring with
cardiac enzymes and echocardiography.

Perianal abscess – Rx: Incision and drainage

• Followed by systemic antibiotics if patient has 1. Systemic disease/infection, or 2. Immunosuppression

(ex: diabetes).
o Prevents recurrence of the abscess.

Bisphosphonate-induced Osteonecrosis of the jaw:

• Erythema and gingival inflammation with exposed bone – usually after a dental extraction.
• Rx: Supportive – antibacterial rinses and oral hygiene.
o Antibiotics/Debridement only when needed.
• Periodontal abscess is usually more acute, with localized swelling and lymph node involvement (and
fever) – doesn’t expose the bone.

Fecal elastase – low levels are a marker of chronic pancreatitis (not acute).

Acute pancreatitis → Gallstones, or Alcohol.

• Gallstone pancreatitis is diagnosed with RUG ultrasound.

• CT is NOT AS SENSITIVE as Ultrasound for gallstones.

Pain on the plantar surface of the heel: Plantar fasciitis.

• Pain worse on weight-bearing, especially immediately after rest.

• Pain reproduced by pressure over the plantar surface of the heel.
Achilles tendinopathy → Pain over posterior heel, reproduced by ankle dorsiflexion.
Calcaneal stress fractures (overuse injury) → Pain reproduced by squeezing the sides of the heel.

CT Cervical spine is the preferred test for emergent C-spine injury (or any spinal injury).

• Way more sensitive that Plain X-ray – but x-ray is still used for Chest/Pelvis.
• C-spine imaging is particularly important in high-energy collisions and in patients with neurological
deficits/distracting injuries.
Presence of a single vertebral fracture → CT Image the entire spine!! Risk of a 2nd, non-contiguous fracture is
as high as 20%. Also done generally for high-energy injuries. (CT is more sensitive than plain X-ray).
Nerve conduction study – to determine the site of block in peripheral neuropathy (ex: carpal tunnel).

Eythema nodosum: Painful erythematous nodules on the shins, usually 2-3 cm in size.

• A symptom of inflammatory bowel disease – a delayed hypersensitivity reaction.

o Biopsy → septal panniculitis without vasculitis.
• Weight loss is also a symptom of IBD – not just cancer.

Aspiration pneumonia = Oral streptococci and anaerobic bacteria.

Empyema Rx: Antibiotics + Chest tube + Intrapleural fibrinolytics (tPA/DNase) to improve drainage.

Renal Abscess:
Infection/Sepsis in Diabetics:

• Often do NOT exhibit the usual local or systemic signs of infection, because of impaired leukocyte
function (immunosuppression).
• Even fever may be absent.

Hypothyroidism – Myxedema → Mucinous material (mucopolysaccharides).

Testicular trauma:

• Why not hematoma?

o This is a minor trauma, and the scrotum is not swollen/increasing in size, which would be the
case with hematoma.
• Torsion is more likely with minor trauma like this – hence the USG.

Primary sclerosing cholangitis:

• Multiple strictures and dilations of the intra- and extra-hepatic bile ducts.
o ALP and GGT elevated.
• >90% associated with Inflammatory bowel disease – so, always do a colonoscopy to check.
o Annual colonoscopy for Colon cancer – increased risk in both PSC and IBD.
Fibroadenoma:

• In adolescents – no further management/imaging needed.

• In adults (>20 years) – imaging (USG/mammogram).
o To rule out malignancy – physical exam alone isn’t enough in adults.

Porcelain gallbladder: Increased risk for Adenocarcinoma of the gallbladder.

•
• Calcified rim = Porcelain gallbladder, NOT Hydatid cyst (image below).

o
Sialadenosis: Benign, non-inflammatory swelling (bilateral) of parotid glands.

• A/w chronic alcoholism, malnutrition, or bulimia.

• Pleomorphic adenoma – unilateral (commonly); Sjogren syndrome – more in women, and a/w dry
mouth.
• Salivary stone – pain and swelling only during eating, when saliva flow is stimulated.

Solitary pulmonary nodule:

• Mass >0.8 cm in size with any other risk factors → Biopsy/Surgical excision.

• (Include ‘irregular borders’ as a risk).

Ogilvie syndrome:

• Acute pseudo-obstruction of the colon, due to electrolyte abnormalities – autonomic disruption.

o Ex: From large-volume diarrhea/vomiting.
• Colonic dilation (tympanic abdomen), but normal small bowel.
• Rx: NPO & NG tube decompression; Neostigmine if no improvement in 48 hours.

Mild UC can have normal CRP/ESR.

Hemodynamically stable patient with hemoptysis:

• Immediate respiratory isolation – suspected TB.

• If patient is in active hemoptysis – Bronchoscopy to control the site of bleeding (for large-volume -
>600 ml/day or 100 ml/hour).
o Thoracotomy if patient continues bleeding despite Bronchoscopy and/or Pulmonary artery
embolization.
Peyronie disease:

• Fibrous plaque on the penile surface – due to trauma during sexual intercourse and aberrant wound
healing.
• Causes pain and abnormal curvature of the penis, leading to erectile dysfunction or difficulty
penetrating the vagina.
• Rx: Pentoxifylline for fibrosis, or collagenase (local injection). Surgery for refractory cases.
Tertiary syphilis can cause plaques (gumma) but they are painless and usually ulcerate.
Penile cancer is also usually painless and may/may not ulcerate.

Ulcerated tonsil with/without cervical lymph nodes

= Squamous cell carcinoma → Oral HPV infection is a common underlying cause (in sexually active people).

Food getting ‘stuck’ in the esophagus: a.k.a Food impaction

• Eosinophilic esophagitis (a/w asthma or allergies).

• Starts off as intermittent; progressive inflammation can form strictures and lead to further impaction.
• Diagnosis: Endoscopy – ‘trachealization’ of the esophagus (multiple ring-like indentations in the
esophagus). Biopsy - >15 eosinophils/hpf.
• Rx: Topical (inhaled) glucocorticoids and allergen avoidance.
Achalasia and Esophageal cancer cause progressive – not intermittent – dysphagia.
And Pill esophagitis (can be caused by NSAIDs) has severe odynophagia – can’t even swallow saliva.

Avascular necrosis/Osteonecrosis – chronic alcohol use is a risk factor.

Acoustic neuroma/Vestibular schwannoma:

• Involves cranial nerves 8, 5 and 7.

• Diagnosis – Audiogram, MRI.