Objective

 Bowel injury is a potential complication of laparoscopic surgery that may go unrecognized intraoperatively. Concerning postoperative findings include fever, leukocytosis, abdominal pain/guarding, and
ileus. Abdominal CT scan with oral contrast can help detect the site of leakage.
 Infusion of excess normal saline is a common cause of nonanion gap metabolic acidosis. The increase in intravascular chloride (Cl) drives intracellular shifting of bicarbonate (HCO3) to reduce serum
HCO3 and decrease blood pH.
 Meningiomas often occur at dural reflections and can cause headaches and progressive neurologic defects that localize to the brain area compressed by the mass.
 Pseudogynecomastia is characterized by chronic, excessive deposition of fat in the breast without a distinct margin, typically in patients with obesity. In true gynecomastia (i.e. enlargement of the
glandular breast tissue), the margin of firm glandular tissue is often palpable and the breast may be tender. The diagnosis is based on clinical findings. Management includes weight loss.
 Osteonecrosis of the femoral head presents with chronic groin pain and decreased hip range of motion. It is caused by disruption of perfusion due to vascular occlusion, endothelial dysfunction, or
increased intraosseous pressure. Excessive alcohol use is a major risk factor, with the risk proportionate to the amount and duration of use.
 The initial presentation of a biliary cyst may be acute cholangitis and should be suspected in a patient with fever, right upper quadrant pain, and obstructive jaundice, as well as a cystic bile duct mass.
Initial management of acute cholangitis is urgent biliary drainage (i.e. endoscopic sphincterotomy); complete surgical excision of the cyst should be performed later to reduce the risk of
cholangiocarcinoma.
 A negative fluid balance decreases the formation of pulmonary edema and accelerates recovery from acute respiratory distress syndrome.
 Wound dressings are an important element of the healing process. Wet-to-dry dressings are commonly used for wounds that are infected or have devitalized tissue or slough. Once healthy granulation
tissue appears, dressings are switched to nonadherent, moisture-retaining dressings to promote healing and epithelialization.
 Sensory, autonomic, and motor neuropathy can all contribute to plantar foot ulcer formation in patients with diabetic neuropathy. Motor neuropathy can cause intrinsic foot muscle atrophy, toe
clawing, and abnormal redistribution of pressure to the metatarsal heads.
 Ankylosing spondylitis is a rheumatologic inflammatory arthropathy that commonly involves chronic lower back pain, impaired spinal mobility, and enthesitis. Aortic regurgitation is a potential
complication of ankylosing spondylitis, resulting from chronic inflammation of the aortic root and valve cusps. Other cardiac valves are not affected.
 Inflammatory breast carcinoma (IBC) is an aggressive breast cancer that can present with unilateral breast rash, erythema, and edema. Metastatic disease (e.g. axillary lymphadenopathy) is common on
initial presentation. Patients require core needle breast biopsy and full-thickness skin punch biopsy for diagnosis.
 Type II error describes a study’s failure to detect an effect (e.g. difference between groups) when one truly exists. The probability of a type II error is affected by sample size, outcome variability, effect
size, and significance level.
 Anaphylaxis is a clinical diagnosis that can be difficult to recognize in surgical patients. Early recognition is dependent on thorough physical examination (e.g. inspecting skin under the surgical drapes).
 Anaphylaxis and anaphylaxis-like reactions can cause distributive shock due to the widespread release of inflammatory mediators (e.g. histamine) that incites massive peripheral vasodilation.
Arteriolar vasodilation decreases systemic vascular resistance to cause hypotension, and venular vasodilation decreases central venous pressure and pulmonary capillary wedge pressure.
 Transurethral resection of the prostate is an effective treatment for benign prostatic hyperplasia. However, this procedure does not preclude the prostate tissue from growing back and causing bladder
outlet obstruction. Other common complications of this procedure are urinary incontinence and urethral stricture.
 Subfalcine herniation, a type of brain herniation, occurs when the cingulate gyrus is displaced under the falx cerebri. This typically does not cause pupillary involvement but may cause ipsilateral
anterior cerebral artery compression that leads to contralateral leg weakness.
 Joint involvement in acromegaly is common and often involves both axial and appendicular skeleton. Excessive growth hormone causes hyperplasia of articular chondrocytes and synovial hypertrophy,
which may be visible on x-ray as widening of the joint space. However, in later stages, degeneration of the cartilage may lead to clinical and radiographic findings resembling osteoarthritis.
 High-pressure injection injury is a limb-threatening condition. The entrance wound may look deceptively benign, but the injected material can spread into the hand and forearm, leading to tissue
ischemia, necrosis, and compartment syndrome. Given the high risk of amputation, surgical debridement and fasciotomy should be performed immediately.
 Idiopathic pulmonary fibrosis is a disorder of epithelial injury that has been pathologically repaired by fibrotic responses. Antifibrotic drugs inhibit fibroblasts to slow the rate of lung function decline
and are first-line therapy.
 An avulsed permanent tooth should be reimplanted as soon as possible. The tooth can be briefly stored in cold milk or saliva and manually reimplanted after gentle rinsing of the tooth and socket with
normal saline.
 Blunt trauma to the ear can cause an auricular hematoma, which is a collection of blood between the perichondrium and cartilage of the outer ear. Prompt evacuation of the hematoma is required to
avoid complications of infection, avascular necrosis, and permanent cauliflower ear deformity.
 Heart failure is the leading cause of death in patients with infective endocarditis (IE). Surgical intervention is generally necessary for those with IE who have heart failure, local progression (e.g. abscess,
conduction abnormality), persistent bacteremia, large vegetations, and difficult-to-treat organisms.
 Malignant pericardial effusions are often large and prone to recurrence. In addition to acute management with pericardiocentesis, they often require prevention of reaccumulation, either via a
pericardial window or prolonged catheter drainage.
 Cardiac tamponade may be recognized by Beck triad (hypotension, jugular venous distension, distant heart sounds). Increasing pericardial pressure restricts diastolic filling of the right-sided heart
 chambers, leading to decreased cardiac output and obstructive shock. Right atrial pressure and pulmonary capillary wedge pressure (a reflection of left atrial pressure) are increased due to
compression.
 Purulent pericarditis is an acute, rapidly fatal infection most commonly caused by hematogenous spread of Staphylococcus aureus. Urgent echocardiography-guided pericardiocentesis is essential for
confirmation of the diagnosis and treatment.
 Malignancy (e.g. lung cancer) is a common cause of pericardial effusion, which may appear on chest x-ray as an enlarged cardiac silhouette with clear lungs. Echocardiography is used to confirm the
diagnosis, evaluate for signs of subacute tamponade, and guide pericardiocentesis.
 During a joint or bursal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as worsening pain several days following the procedure. Diagnostic
aspiration of the joint or bursa is necessary to assess for infection.
 Patients with intracerebral hemorrhage can have rapid clinical deterioration, especially when brain herniation is present. When a change in clinical status occurs, the ABCs (Airway, Breathing,
Circulation) should be reassessed because intubation and mechanical ventilation may be necessary (e.g. airway protection).
 Gout can cause acute bursal (e.g. prepatellar, olecranon) inflammation, chronic bursal swelling, or tophus deposition in the bursa. Tophus induces chronic inflammation in the surrounding soft tissue
and bones, which can result in erosions and overhanging edges of cortical bone on imaging.
 Distal radius fractures with neurovascular compromise (e.g. absent radial pulse, diminished median nerve sensation) should undergo immediate reduction.
 Septic prepatellar bursitis is characterized by acute erythema, warmth, and pain accompanying bursal swelling. It is usually caused by skin breakage that allows entry of skin floras (e.g. Staphylococcus).
Bursal fluid analysis is needed to confirm the diagnosis. Treatment includes systemic antibiotics.
 Aspiration pneumonia leading to translocation of anaerobic oral flora into the intrapleural space is likely the most common cause of empyema, commonly presenting insidiously (e.g. over 2-3 weeks)
with weight loss and similar signs and symptoms to uncomplicated pneumonia. Putrid or foul-smelling pleural fluid is diagnostic of anaerobic empyema.
 Complicated parapneumonic effusions involve bacterial invasion into the pleural space and require drainage in addition to antibiotic therapy. Positive pleural fluid Gram stain or culture is diagnostic of
a complicated effusion and is an indication for chest tube placement.
 Lung abscess is typically marked by subacute fever, putrid-smelling sputum, and a cavitary lung infiltrate with air-fluid level in a dependent portion of the lung. Patients often have history of swallowing
dysfunction or impaired consciousness. Sputum culture should be obtained but is rarely useful; empiric treatment with ampicillin-sulbactam or a carbapenem is recommended.
 Adenocarcinoma in the left side of the colon may obstruct the flow of stool, leading to altered bowel habits; visible hematochezia is common. In contrast, in the right side of the colon, obstructive
symptoms are uncommon, and any associated bleeding can be diluted by stool and is less likely to be visible; therefore, right-sided colon cancer often presents with occult bleeding and iron deficiency
anemia.
 The liver is the most common organ affected by metastatic colon adenocarcinoma. Surgical resection can be curative when metastatic colon cancer is confined to the liver. Regardless of stage, resection
of the primary tumor is recommended for patients with obstruction or threatened obstruction of the colonic lumen.
 Hyperplastic polyps are a non-neoplastic abnormality commonly found on screening colonoscopy. Small hyperplastic polyps do not increase the risk for colon cancer, and patients may continue
colorectal screening at the usual intervals (e.g. repeat colonoscopy in 10 years for individuals at otherwise average risk).
 Although most patients with localized (e.g. stage 1) colon adenocarcinoma are cured after surgical resection, some develop recurrent neoplastic lesions of the colon. Therefore, a colonoscopy should be
performed 1 year after surgical resection and every 3-5 years thereafter.
 Obesity and type 2 diabetes are associated with an increased risk of colorectal adenocarcinoma, likely due to hyperinsulinemia. Hyperinsulinemia results in increased circulating levels of insulin-like
growth factor-1, which inhibits colorectal epithelial cell apoptosis and promotes neoplastic progression.
 Patients with a Loxosceles reclusa (brown recluse) spider bite initially have a small, red papule that can progress to form a larger necrotic wound (loxoscelism). Most cases will resolve with the
application of cold packs and local wound care.
 Hip dislocation should be reduced within 6 hours of injury to minimize the risk of osteonecrosis of the femoral head. Dislocation without associated fracture is usually managed with closed (i.e.
nonoperative) reduction, whereas dislocation with fracture warrants open (i.e. operative) reduction.
 Blood products should be administered early in patients with signs of hemorrhagic shock. They should be administered in a ratio of 1:1:1 (fresh frozen plasma/packed red blood cells/platelets) to
reduce coagulopathy, a leading contributor to mortality in trauma patients.
 Large-volume crystalloid resuscitation increases coagulopathy, hypothermia, and mortality in trauma patients. Balanced resuscitation, which restricts crystalloid use and uses blood products to
maintain a blood pressure just sufficient for tissue perfusion (i.e. permissive hypotension) until hemorrhage is controlled, can decrease these adverse effects.
 Patients with seemingly minor blunt chest trauma (BCT) (e.g. clavicular fracture) can have serious intrathoracic injury (e.g. subclavian vessel injury). Abnormalities on screening tests (e.g. chest x-ray)
in stabilized patients with BCT should prompt additional studies (e.g. CT scan of the chest) to evaluate for intrathoracic injuries.
 The increased intra-abdominal and intrathoracic pressure seen in abdominal compartment syndrome can cause significant cardiovascular consequences, including venous compression with increased
central venous pressure, decreased venous return to the heart (decreased cardiac preload), and decreased cardiac output.
 Blood transfusion should be initiated early in patients with hemorrhagic shock. Group O, Rh D-negative blood (universal donor) should be transfused while waiting for type-specific blood to be
available.
 Adhesive capsulitis results from contracture of the glenohumeral joint capsule and presents with gradual onset shoulder pain and reduced active and passive range of motion. Treatment includes gentle
range of motion exercises; adjunctive measures include nonsteroidal anti-inflammatory drugs and corticosteroid injections.
 Femoral neck fractures are most common in elderly individuals, typically presenting with hip pain after a fall. Common x-ray findings include shortening of the femoral neck, disruption of the normal
cortical contour, and irregular lucency at the fracture plane. Femoral neck fractures have a significant risk of complications (e.g. secondary instability, malunion), and surgical repair is indicated for
most patients.
 Tarsal tunnel syndrome is caused by posterior tibial nerve compression beneath the flexor retinaculum in the medial ankle. It presents with burning pain or numbness in the posteromedial ankle, heel,
sole, and toes, which is elicited by tapping on the nerve (i.e. Tinel sign).
 Bronchial carcinoid tumors are the most common lung malignancy in young patients who do not smoke. They typically arise in the proximal airway and cause airway obstruction (e.g. dyspnea,
wheezing, pneumonia) or hemoptysis. CT scan with contrast usually reveals an avidly enhancing mass with an endobronchial component.
 Patients with blunt abdominal trauma and suspected intra-abdominal hemorrhage (e.g. free intraperitoneal fluid) on Focused Assessment with Sonography for Trauma examination are managed
according to their hemodynamic status. Hemodynamically stable patients can tolerate further imaging and should undergo contrast CT scan of the abdomen and pelvis.

 Dupuytren contracture results from progressive palmar fascia fibrosis, leading to puckering of the skin and fibrotic nodule and cord formation along the flexor tendons. Patients develop contractures
that limit extension at the metacarpophalangeal and proximal interphalangeal joints. The diagnosis is made clinically; no imaging is needed.
 Acromioclavicular (AC) joint sprain results from direct trauma to the superior or lateral shoulder. Examination shows maximal tenderness over the AC joint and pain with adduction of the arm across
the torso. X-rays can assess the degree of sprain and evaluate for concomitant clavicular or humeral fractures.
 Shoulder dislocation is commonly associated with rotator cuff injury (RCI), which presents as shoulder pain and difficulty with abduction. RCI can cause weakness but not sensory loss.

 Acute glenohumeral dislocation is often complicated by additional injuries, including axillary nerve injury, fracture, and rotator cuff tear. Humeral neck fractures are associated with an increased risk
for avascular necrosis, and closed reduction may lead to further displacement of the fracture. Therefore, dislocation associated with humeral neck fracture requires open surgical repair.

 Patients who experience shoulder dislocation are often at increased risk for recurrent dislocation due to labral tears (i.e. Bankart lesion), ligamentous laxity due to overuse, and underlying
multidirectional joint instability (i.e. excessive, symptomatic, and involuntary laxity of the joint capsule in > 1 direction).
 Severe acute pancreatitis (SAP) occurs in 15%-25% of patients with acute pancreatitis and causes failure of > 1 organ systems lasting > 48 hours. Predictors of SAP include signs of the systemic
inflammatory response syndrome and evidence (e.g. elevated blood urea nitrogen or hematocrit) of intravascular volume depletion. Patients with SAP have increased risk of morbidity and mortality
and usually require intensive monitoring.
 Infected pancreatic necrosis should be suspected in patients who develop worsening abdominal pain, unstable vital signs, or signs (e.g. fever, leukocytosis) of infection 7-10 days after onset of acute
necrotizing pancreatitis. CT scan of the abdomen demonstrating gas within the pancreatic necrotic collection is diagnostic.
 Patients with blunt chest trauma may be at risk for serious intrathoracic injury. Evaluation includes chest x-ray and ECG. Additional tests/interventions are based on the patient’s hemodynamic
stability, mechanism of injury, and initial test findings.
 Plantar fasciitis is a degenerative condition of the plantar aponeurosis at its insertion at the calcaneus caused by overuse. Pain is typically worsened by prolonged standing and is located at the
anteromedial heel. First-line treatments include activity modification, physical therapy (stretching), and padded heel inserts. Calcaneal spurs are incidental and do not require treatment.

 Myositis ossificans is characterized by the formation of lamellar bone in extraskeletal tissues (i.e. heterotopic ossification). It is triggered by severe or recurrent trauma and presents as a painful, firm,
mobile mass with local swelling. Alkaline phosphatase and inflammatory markers (e.g. erythrocyte sedimentation rate) may be elevated. X-ray may show calcification with radiolucent zones.

 Surgical evaluation is warranted for patients with Clostridioides (formerly Clostridium) difficile infection that progresses despite appropriate medical management, especially when abdominal
symptoms worsen or when megacolon or increased serum lactate is present. Peritonitis is a definitive indication for surgical exploration (e.g. laparotomy).
 Hereditary hemorrhagic telangiectasia involves arteriovenous malformations (AVMs) across multiple organ systems. Nasal telangiectasias lead to recurrent epistaxis, and pulmonary AVMs may cause
hemoptysis.
 Calcaneal stress fracture is caused by repetitive microtrauma to the calcaneus (e.g. abrupt increase in running). On examination, the pain is elicited by medial-lateral squeezing of the calcaneus, and the
diagnosis is confirmed with imaging (x-ray or MRI).
 Venomous snake bite should be managed with close observation and frequent coagulation studies and wound evaluations. Patients with mild envenomation and normal laboratory studies can be
 observed for 12-24 hours. Patients with abnormal laboratory results, progressing symptoms, or signs of systemic toxicity should receive antivenom.
 Errors in medication reconciliation (i.e. the process of reviewing and updating the patient’s prescription and over-the-counter medications) occur frequently during transfer of care (e.g. hospital
admission). Prevention includes increasing checkpoints (i.e. redundancy) by having at least 2 providers independently reconcile all medications, involving interprofessional staff (e.g. pharmacist
review), and repeating verification prior to continuing home medications.
 Ganglion cyst is a connective tissue outpouching arising from tendon sheaths and joint structures. It presents as a rubbery, mobile, transilluminating nodule, most commonly at the wrist. Most ganglion
cysts resolve spontaneously, and asymptomatic cysts can be observed.
 Psychological safety strengthens safety culture by enabling team members to express questions and concerns without fear and regardless of status. Team-based safety briefings, used by high-reliability
organizations (e.g. aviation), improve communication skills and psychological safety by encouraging collaborative discussion and monitoring.
 Poor teamwork (including miscommunication) is a leading root cause of retained foreign objects in surgical settings. Simulation training, adopted by high-reliability organizations, improves teamwork
and safety culture, promoting situational awareness, reduced hierarchical barriers, and closed-loop communication.
 Misreading look-alike drug vials is a leading cause of medication error in operative settings. Human factors engineering strategies can prevent such errors by designing systems that decrease human
effort and facilitate correct action. Examples include environmental design changes separating look-alike medications, standardizing and simplifying processes, and using visual cues.

 Most cases of priapism are idiopathic. However, it can be seen in hematologic disorders that cause altered blood viscosity or local microthrombi, leading to decreased outflow through the emissary
veins. Common disorders include sickle cell disease, hematologic malignancies (e.g. chronic myelogenous leukemia), thalassemia, and multiple myeloma.
 Priapism is a persistent, painful erection in the absence of ongoing sexual stimulation. Sickle cell disease is associated with an increased risk of priapism due to altered blood viscosity and resulting
venous obstruction. Initial management of priapism includes aspiration of blood from the corpora cavernosa, often followed by intracavernous injection of phenylephrine.

 Communication breakdown during signout (e.g. omitted information during handoff between providers) is a leading cause of transfer-of-care errors and can be prevented with standardized signout
processes (e.g. checklists, mnemonics) and redundancy (e.g. separate documentation of cross-coverage events).
 The diagnosis of acute Achilles tendon rupture can be easily missed and is best evaluated on physical examination with the calf squeeze test, which simulates gastrocnemius contraction. Absent foot
plantar flexion in response to calf squeeze is consistent with Achilles tendon rupture.
 Unilateral, spontaneous, bloody nipple discharge accompanied by a palpable breast mass is concerning for malignancy.
 Bile acid diarrhea is a common complication of cholecystectomy and occurs due to the overly rapid release of bile into the intestines, where it overwhelms the resorptive capacity of the terminal ileum
and spills into the colon, resulting in secretory (fasting) diarrhea. Bile-acid binding resins (e.g. cholestyramine, colestipol, colesevelam) are first-line therapy.
 The workup of a suspicious breast mass (e.g. unilateral, firm, fixed, causing nipple retraction) is the same in men as in women: imaging (e.g. mammography, ultrasound) is performed first, followed by
tissue sampling (e.g. core biopsy).
 Lymphatic drainage from the breast passes primarily to the axillary lymph nodes, with drainage traveling from lateral to medial, posterior to the pectoralis minor muscle. The pectoralis minor muscle is
the landmark for distinguishing the surgical levels of axillary lymph nodes during axillary lymph node dissection.
 Cocaine use can precipitate intracranial hemorrhage and should be suspected when stroke occurs in a subcortical location and/or in young patients with associated sympathetic activation or an
absence of typical risk factors.
 Cervical myelopathy often causes both spinal cord and spinal nerve root compression, resulting in myelopathic symptoms (e.g. upper motor neuron signs below the lesion) and radicular symptoms (e.g.
lower motor neuron signs, pain in a dermatomal/myotomal pattern). Lhermitte sign (electric shock-like pain with neck flexion) may occur.
 Cervical radiculopathies occur due to spinal nerve root compression and typically causes neck pain associated upper extremity sensorimotor deficits that follow a dermatomal/myotomal pattern.
Lateral flexion and rotation of the neck worsens compression of the nerve root, worsening pain and/or paresthesia.
 Cervical radiculopathy is due to nerve root compression and typically presents with neck or arm pain associated with sensorimotor deficits; radiation of pain with neck movement may occur. The
diagnosis is usually made clinically, and most patients improve with symptomatic treatment, including nonsteroidal anti-inflammatory drugs and avoidance of triggering activities.

 Management of hemorrhagic stroke focuses on preventing further bleeding (e.g. blood pressure control, anticoagulant reversal) and maintaining normal intracranial pressure. Hypertension is treated
with a reversible and titratable antihypertensive (e.g. intravenous nicardipine).
 Acute lung transplant rejection (ALTR) typically occurs within 6 months of transplant and may present with progressive dyspnea and cough accompanied by low-grade fever, hypoxemia, and chest x-
ray revealing perihilar opacities and interstitial edema. Because pulmonary infection can have a similar clinical presentation and the treatment for ALTR (i.e. high-dose glucocorticoids) could markedly
worsen an infection, bronchoalveolar lavage and lung biopsy should be performed in the diagnostic workup of ALTR.
 Breast conserving therapy typically consists of partial mastectomy and axillary sentinel lymph node biopsy, followed by whole breast radiation therapy. Adequate surgical excision of the cancer
requires negative margins.
 Bronchiolitis obliterans is the major manifestation of chronic lung transplant rejection and is common in lung transplant recipients > 5 years post-transplant. The diagnosis is usually made based on a
consistent clinical presentation (e.g. gradually progressive dyspnea and nonproductive cough) and pulmonary function testing showing an obstructive pattern.

 Patients with suspected sepsis require early aggressive fluid resuscitation and broad-spectrum antibiotic therapy. Patients should receive rapid infusion of large volumes (e.g. 30 mL/kg) of crystalloid
fluid within the first 3 hours and broad-spectrum empiric antibiotics within 1 hour.
 Whiplash most commonly causes cervical strain without associated cervical spine fracture. Patients with cervical trauma should be evaluated using validated clinical decision rules (e.g. National
Emergency X-Radiography Utilization Study [NEXUS] low-risk criteria) to determine whether cervical spine imaging is needed.
 High-voltage electrical injuries frequently cause more severe damage to internal structures (e.g. muscle) than external structures (e.g. skin). Skeletal muscle necrosis is a frequent complication that can
result in acute compartment syndrome, rhabdomyolysis, and heme pigment-induced acute kidney injury.
 Superficial burns involve only the epidermis and are characterized by erythema, pain, intact capillary refill, and lack of blistering or weeping. They do not require debridement and can be managed with
simple wound care (e.g. cleansing, moisturization).
 Enteral nutrition is the optimal form of nutrition for patients with moderate to severe burn injuries. Early initiation helps offset the hypermetabolic response present after burn injury and has multiple
clinical benefits (e.g. maintenance of gut integrity, reduced rate of sepsis, decreased mortality).
 When invasive infection is suspected in patients with severe burn injuries, empiric antibiotic therapy is required, typically with coverage against both gram-positive skin flora (including methicillin-
resistant Staphylococcus aureus) and gram-negative organisms (including Pseudomonas aeruginosa). Piperacillin-tazobactam or a carbapenem, in combination with vancomycin, are common first-line
therapy.
 Patients with severe burn injuries are at high risk for sepsis. Acute enteral feeding intolerance may be an early sign of sepsis, indicating end-organ hypoperfusion and dysfunction.

 In patients with severe burn injuries, early excision of necrotic tissue and wound closure (e.g. skin grafting) reduces the risk of burn wound infections.
 Stress hyperglycemia is a transient elevation in blood glucose that occurs as a physiologic response to severe illness or injury. Mild elevations do not require treatment. Marked elevations (e.g. > 180-
200 mg/dL) are associated with increased mortality and should be corrected with short-acting insulin, with a target glucose of 140-180 mg/dL.
 Radiation proctitis (RP) is caused by mucosal damage associated with pelvic radiation therapy. Acute RP presents < 8 weeks postradiation with diarrhea, tenesmus, and mucus discharge, whereas
chronic RP occurs months to years after radiation, resulting in hematochezia, anemia, and possibly strictures. Colonoscopy demonstrates mucosal pallor, friability, and telangiectasias confined to the
rectum.
 Initial management of frostbite starts with rapid rewarming of affected tissues in a warm water bath. For patients with persistent signs of tissue ischemia (sensory loss, gray appearance, absent
capillary refill), studies such as angiography or technetium-99m scintigraphy can help identify those who would benefit from thrombolysis.
 Thrombosed external hemorrhoids usually appear as purple or blue anal bulges below the dentate line and may cause severe pain. Although conservative management (e.g. fiber, stool softeners, topical
anti-inflammatories and antispasmodics) is usually indicated, patients with severe pain should undergo hemorrhoidectomy under local anesthesia.
 Chronic radiation proctitis is characterized by obliterative endarteritis and submucosal fibrosis, which stiffens the rectum and impairs its compliance, resulting in urgency and fecal incontinence.
Chronic tissue hypoxia results in neovascularization and telangiectasia formation, which are prone to hemorrhage.
 Angiodysplasias in the gastrointestinal (GI) tract are a common source of GI bleeding. Bleeding from angiodysplasias may be triggered by underlying aortic stenosis, which is associated with low levels
of von Willebrand factor multimers; this glycoprotein is often destroyed when it passes through the damaged valve at high velocity.
 Patients who undergo splenectomy are at high risk for fulminant sepsis with encapsulated organisms. They should be prescribed amoxicillin-clavulanate to take immediately in the setting of fever and
then should be advised to proceed directly to the nearest emergency department.
 Life-saving procedures (e.g. intubation) may be performed without informed consent in emergencies, when obtaining consent is not possible. Informed refusal requires discussion of all the same
 elements (e.g. diagnosis, proposed procedure, risks/benefits, alternatives, risks of refusal) required for informed consent.
 An exception to the requirement of informed consent is extension of an authorized procedure if an unexpected complication arises that demands immediate treatment. However, this exception does not
cover procedures for unrelated issues that are not imminently life-threatening.
 Incapacitated patients may regain capacity as their condition improves. These patients should be reassessed for capacity before health care decisions are made.
 Essential elements discussed during the informed consent process include the patient’s diagnosis, the risks and benefits of both the proposed treatment and treatment alternatives, and the risks of
refusing treatment.
 A hyphema is a collection of blood in the anterior chamber of the eye that occurs typically following blunt or penetrating ocular trauma. Management involves preventing complications, such as
rebleeding and intraocular hypertension, which can result in optic nerve injury and permanent vision loss.
 Rectal prolapse is characterized by intermittent protrusion of the rectum through the anal canal; symptoms usually worsen with maneuvers that increase intra-abdominal pressure (e.g. defecation,
Valsalva). It is usually diagnosed in women age > 40 with risk factors that include multiparity, vaginal delivery, and chronic constipation. Symptomatic patients should be referred for surgical
intervention.
 Traumatic brain injury can cause damage to cortical areas responsible for inhibiting lower sympathetic centers. This disrupted inhibition may result in paroxysmal sympathetic hyperactivity, a
syndrome characterized by rapid-onset episodes of tachycardia, hypertension, and tachypnea often accompanied by fever and diaphoresis.
 Polyarteritis nodosa is marked by segmental, transmural inflammation of medium-sized arteries, which leads to luminal narrowing, thrombosis, and organ ischemia. The kidneys (e.g. renal infarction)
and gastrointestinal tract (e.g. mesenteric ischemia, bowel perforation) are often affected. Mesenteric angiography typically reveals multiple arteries with microaneurysms, irregular luminal narrowing,
and distal occlusions.
 Osmotic therapy (e.g. hypertonic saline, mannitol) is part of the initial treatment of elevated intracranial pressure in patients with traumatic brain injury. It creates an osmolar gradient that draws water
out of the edematous brain tissue, thereby reducing parenchymal volume and overall intracranial pressure.
 Acute traumatic coagulopathy, a state of hypocoagulability and hyperfibrinolysis, can complicate traumatic brain injury (TBI). Antifibrinolytic therapy (i.e. tranexamic acid) can improve outcomes for
patients with moderate TBI if administered within the first 3 hours after injury.
 Cataracts typically develop in patients age > 60 but may be seen in younger individuals due to HIV infection, diabetes mellitus, ocular trauma, glucocorticoid use, or external radiation exposure.
Treatment for cataracts includes surgical removal of the lens with implantation of a prosthetic lens.
 Cytomegalovirus (CMV) pneumonitis, an acute, febrile, and diffuse pneumonia, is a common opportunistic infection in the postacute period (> 1 month) after lung transplantation. It is usually due to
reactivation of latent CMV from the donor lung or the recipient leukocytes. Tissue injury caused by CMV pneumonitis leads to increased risk of graft rejection and decreased survival.

 The phrenic nerve can be injured during cardiac surgery. Patients can have dyspnea on exertion, orthopnea, and paradoxical breathing movement (i.e. abdomen moving inward on inspiration).

 Severe vomiting characteristically causes hypokalemic, hypochloremic metabolic alkalosis. The metabolic alkalosis is initiated by loss of gastric H, worsened by hypovolemia-induced activation of the
renin-angiotensin-aldosterone system, and perpetuated by profound total body Cl depletion leading to hypochloremia and impaired renal bicarbonate excretion. Urine Na and Cl are low due to total
body depletion and aldosterone-mediated renal tubular reabsorption. Repletion of volume and Cl with normal saline corrects the metabolic alkalosis (saline responsive).

 Nonanion gap metabolic acidosis (NAGMA) results from the loss of bicarbonate (HCO3). Because exocrine pancreatic secretions are high in HCO3, NAGMA is expected with large-volume fluid losses
from the pancreas (e.g. pancreatic duct leak) or small intestine (e.g. high ileostomy output, enterocutaneous fistula).
 Cecal volvulus occurs when the cecum and ascending colon twist on their mesentery, forming a closed-loop obstruction. Progressive abdominal pain and distension, along with nausea/vomiting, are
typical. Abdominal x-ray may reveal a large, dilated loop of colon.
 Sigmoid volvulus often presents as slowly progressive abdominal discomfort/distension in an elderly patient and a ‘coffee bean’-shaped dilated loop of colon on abdominal x-ray. Patients without
perforation or peritonitis can undergo flexible sigmoidoscopy to reduce the twisted segment and avoid emergency surgery.
 Patients who inject drugs into the femoral vein can develop iliofemoral deep venous thrombosis. This disorder is typically marked by unilateral leg edema, warmth, and erythema with evidence of
dilated superficial veins and increased calf/thigh diameter on examination.
 Primary sclerosing cholangitis is often diagnosed in asymptomatic individuals with high alkaline phosphatase and γ-glutamyl transpeptidase levels (cholestatic pattern). Magnetic resonance
 cholangiopancreatography findings of multifocal intrahepatic and extrahepatic biliary strictures with segmental dilations are diagnostic. A colonoscopy is recommended at the time of diagnosis because
many patients also have inflammatory bowel disease.
 Primary sclerosing cholangitis is characterized by fibrosis and stricturing of the medium and large intra- and extrahepatic bile ducts, promoting cholestasis and acute cholangitis. It occurs most
commonly in men and is strongly associated with ulcerative colitis.
 Occlusion of an anal crypt gland can lead to the formation of an anorectal abscess. Primary treatment is prompt incision and drainage. Systemic antibiotic therapy, which may decrease recurrence and
anorectal fistula formation, should be given to patients with high-risk features (e.g. systemic illness, diabetes) and considered for all patients.
 Topical glucocorticoid eyedrops and systemic glucocorticoids can raise intraocular pressure (IOP), leading to open-angle glaucoma (OAG). OAG is usually characterized by insidious loss of peripheral
vision, and some patients with steroid-induced OAG may develop central blurriness due to corneal edema. IOP can be measured with tonometry.
 The presence of a single vertebral fracture in a patient with blunt trauma is an indication to image the entire spine. CT scan is the screening modality of choice because of its sensitivity and accuracy.

 CT scan is the preferred test to screen for cervical spine injury. Indications include high-energy mechanism of injury or any of the following findings: neurologic deficit, spinal tenderness, altered mental
status, intoxication, or distracting injury.
 The administration of desmopressin, an analogue of antidiuretic hormone (ADH), can induce the syndrome of inappropriate ADH secretion. Urinary water excretion is impaired, leading to hypotonic
hyponatremia. Laboratory studies, including serum electrolytes, urine osmolality, and urine sodium, are the first step in establishing the diagnosis.
 The initial evaluation of thyroid nodules includes a serum TSH assay and thyroid ultrasound. Patients with a suppressed TSH should undergo thyroid scintigraphy. Small, hyperfunctioning nodules are
rarely malignant and do not usually require fine-needle aspiration.
 Subarachnoid hemorrhage typically presents with a sudden-onset, severe headache that may be accompanied by vomiting, neck stiffness, fever, and loss of consciousness. CT scan of the brain is the best
initial diagnostic step.
 Bisphosphonate-related osteonecrosis of the jaw is characterized by chronic swelling, mild pain, and exposed, necrotic bone. It is often triggered by tooth extractions or other invasive dental
procedures. The course can be intractable, and treatment is largely supportive with careful oral hygiene and antibacterial rinses.
 Puncture of the thin soft tissue overlying the hand metacarpophalangeal joints (e.g. clenched-fist punch to the human mouth) can result in septic arthritis, presenting with joint pain, erythema, swelling,
fluctuance, and painful range of motion. Treatment requires urgent surgical irrigation and debridement and antibiotic therapy.
 Barotrauma to the ear occurs most commonly after flying and can result in injury (e.g. ear pain, hearing loss) to the tympanic membrane (TM). Most barotraumatic TM injuries heal spontaneously
within a few weeks.
 Headaches, increased intracranial pressure, and an unprovoked first seizure are concerning for a brain tumor. Frontal lobe tumors may cause personality changes, abulia, and anhedonia.

 The expected hemodynamic alterations of mitral stenosis are elevated pulmonary artery pressures with normal left ventricular pressures. The pulmonary hypertension is primarily passive, resulting
from transmission of elevated left atrial pressure backward to the pulmonary circulation. There may also be a reactive component involving endothelin-mediated pulmonary arteriolar vasoconstriction
and remodeling.
 Catheter-related bloodstream infections occur approximately once per year in patients with tunneled hemodialysis catheters. Most cases present with systemic signs of infection (e.g. fever, malaise,
chills) without localizing symptoms. The catheter site frequently appears normal. Initial therapy usually includes antibiotics, fluid resuscitation, and removal of the dialysis catheter.

 Patients with long-standing chronic kidney disease often have hypocalcemia and hyperphosphatemia, which can lead to chronic parathyroid stimulation. Over time, this can cause parathyroid
hyperplasia and autonomous parathyroid hormone (PTH) secretion. The net effect, termed tertiary hyperparathyroidism, is characterized by hypercalcemia, hyperphosphatemia, and extremely high
serum PTH levels.
 Cervical facet dislocation typically occurs with forced flexion of the cervical spine (e.g. falling onto a flexed neck); a single facet is usually dislocated and results in radiculopathy of the corresponding
nerve root. The most commonly affected vertebral bodies are C5/C6, which lead to C6 radiculopathy, and C6/C7, which lead to C7 radiculopathy. Imaging demonstrates anterior subluxation of the
vertebral bodies.
 Pheochromocytoma commonly presents with episodic headaches and hypertension and can cause unexplained hyperglycemia. Measurement of urine or plasma metanephrines is the initial step in
diagnostic evaluation.
 Alarm features for constipation include acute onset at an older age, weight loss, and hematochezia. Ovarian cancer has nonspecific symptoms (e.g. lower abdominal pain, bloating, early satiety,
constipation). Therefore, older women (e.g. postmenopausal, age > 50) with new-onset abdominal pain and/or concerning gastrointestinal symptoms, ovarian cancer should be considered.

 Irritable bowel syndrome presents with recurrent abdominal pain related to defecation associated with episodes of diarrhea and/or constipation. Colonoscopy is required to rule out malignancy in
patients age > 50 with new-onset symptoms and in those with alarm features (e.g. gastrointestinal bleeding, iron deficiency anemia).
 The increase in blood volume and cardiac output associated with pregnancy can be poorly tolerated in the setting of valvular disease. Symptomatic mitral stenosis is among the highest-risk conditions
during pregnancy; therefore, surgical repair, preferably with percutaneous intervention, should be performed prior to pregnancy.
 Chronic pancreatitis occurs most commonly in patients with chronic alcohol use disorders and results in postprandial epigastric pain. Pancreatic ascites results from damage to the pancreatic duct with
leakage of pancreatic juice into the peritoneal space. Paracentesis findings include serosanguinous or yellow fluid with high amylase, high total protein, and low serum-ascites albumin gradient.

 Femoral neck and intertrochanteric fractures are the most common hip fractures in older adults and most typically occur due to mechanical falls. Examination findings include shortening and external
rotation of the leg compared with the contralateral side.
 Persistently bloody ascites after multiple diagnostic paracenteses is concerning for an underlying malignancy. Hepatocellular carcinoma is the most common cause, although bloody ascites can also
occur with peritoneal metastases from distant primary sites (e.g. ovaries, prostate). Cytologic analysis of the ascitic fluid can help identify the primary tumor.

 Hemobilia (bleeding into the biliary tract) is a rare cause of upper gastrointestinal bleeding that usually occurs as a complication of hepatic or biliopancreatic procedures. It presents with right upper
quadrant pain, jaundice, and upper gastrointestinal bleeding.
 Ascariasis typically affects patients with recent travel from endemic regions (e.g. Asia, Africa, South America). It is often asymptomatic but may cause pulmonary (e.g. cough, eosinophilic pneumonitis)
or intestinal (e.g. abdominal pain, nausea/vomiting, malnutrition) manifestations. Complications include obstruction of the small bowel or hepatobiliary tree (e.g. cholangitis, pancreatitis). Treatment
includes albendazole or mebendazole.
 Tracheoesophageal fistula with esophageal atresia presents shortly after birth with copious oral secretions and choking, coughing, and/or vomiting with feeding. Diagnosis can be confirmed by
inserting a nasogastric tube, which encounters resistance at the proximal esophageal pouch.
 Post-cardiac injury (Dressler) syndrome is a form of acute pericarditis that results from immune-complex deposition in the pericardium. It can occur following any event or intervention (e.g. myocardial
infarction, coronary artery bypass graft surgery, percutaneous coronary intervention) that exposes the immune system to cardiac antigens and typically has a latency period of several weeks to months.

 Posterior hip dislocation commonly occurs in head-on motor vehicle collisions in which the knee strikes the dashboard. The leg appears shortened and internally rotated. Complications include sciatic
nerve injury (e.g. impaired dorsiflexion) and arterial injury with avascular necrosis of the femoral head.
 Occult gastrointestinal bleeding usually presents with unexplained iron deficiency anemia and/or a positive fecal occult blood test. Initial workup includes colonoscopy and upper endoscopy; small
bowel evaluation (e.g. video capsule endoscopy, deep enteroscopy) may be required if initial tests are unrevealing. The presence of hemorrhoids should not preclude endoscopic evaluation.

 Initial treatment of septic arthritis includes intravenous antibiotics and adequate drainage of purulent material via needle aspiration, arthroscopic irrigation, or open surgical drainage. Serial
procedures are often required to completely clear the infection.
 Symptomatic simple breast cysts can be managed with fine-needle aspiration. Breast cysts that contain bloody fluid or that do not resolve with aspiration require core needle biopsy to evaluate for
breast cancer.
 Blunt trauma (e.g. direct blow to the flank) can cause renal injury. Concerning clinical findings (e.g. flank pain/ecchymosis) should prompt CT scan of the abdomen and pelvis, regardless of whether
hematuria is present.
 CT scan is the preferred test to screen for cervical spine injury. Indications include high-energy mechanism of injury or any of the following findings: neurologic deficit, spinal tenderness, altered mental
status, intoxication, or distracting injury.
 Neonatal circumcision is an elective procedure associated with several medical benefits, including reduced risk of urinary tract infections in the first year of life and penile phimosis, cancer, and
inflammatory disorders in adulthood. Circumcision also decreases the risk of acquiring some, but not all, sexually transmitted infections.
 Pseudomonas folliculitis is a self-limited cutaneous eruption that develops within hours or a few days following exposure to inadequately chlorinated pools or hot tubs. Patients generally have tender
papules, pustules, or nodules and low-grade fever. No treatment is usually necessary, but swimming in the contaminated water should be avoided.
 Blunt trauma to a full bladder can cause it to rupture at the weakest point, the dome. Diversion of urine from the urinary tract (e.g. inability to void) into the peritoneal cavity can cause urinary ascites
and increased blood urea nitrogen and creatinine from peritoneal reabsorption.
 Open globe laceration (OGL) is typically caused by small, high-velocity particles sent airborne by power tools, explosions, lawn mowers, or motor vehicle accidents. Large OGL may present with globe
deformity, extrusion of vitreous or iris, or a visible entry wound. Other manifestations include a peaked or teardrop pupil, asymmetric anterior chamber depth, loss of visual acuity or afferent pupillary
response, and reduced intraocular pressure.
 Pyogenic liver abscesses typically present with fever, right upper quadrant pain, hepatomegaly, leukocytosis, and elevated liver enzymes; an associated right-sided pleural effusion may occur. Diagnosis
requires abdominal imaging, and management includes blood cultures, antibiotics, and drainage.
 Pituitary apoplexy involves sudden hemorrhage into an enlarged pituitary adenoma. Patients typically have sudden onset of severe headache and visual disturbances. There is also loss of pituitary
function; because cortisol helps maintain vascular tone, the absence of ACTH-induced cortisol production can lead to adrenal crisis (acute adrenal insufficiency) with severe hypotension and
distributive shock.
 In patients with underlying chronic adrenal insufficiency, acute stressors (e.g. procedure, illness, trauma) can trigger adrenal crisis, which presents with hypoglycemia and severe hypotension often
refractory to initial volume resuscitation. Treatment requires rapid volume repletion and administration of hydrocortisone or dexamethasone.
 Atrial flutter is recognized by saw-toothed flutter waves on ECG; the rhythm can be regular or irregular depending on the variability of the ventricular response rate. Atrial flutter carries a similar risk of
arterial thromboembolization to atrial fibrillation and should be similarly managed with chronic anticoagulation.
 Prophylactic antibiotics reduce surgical site infections and are indicated when there is a high risk of infection or when infection would lead to significant morbidity/mortality. Patients undergoing clean
procedures (i.e. without infection or viscus entry) should receive coverage against gram-positive skin flora, ideally with a first- or second-generation cephalosporin (e.g. cefazolin) or, alternatively, with
vancomycin or clindamycin.
 Von Hippel-Lindau disease (VHL) is an inherited disorder caused by mutations in the VHL gene. It is associated with retinal and CNS hemangioblastomas, which are heavily vascular tumors that can lead
to hemorrhage or mass effect symptoms in the brain and spinal cord. Other manifestations include clear cell renal cell carcinoma, pancreatic neuroendocrine tumors, endolymphatic sac tumors of the
middle ear, and pheochromocytomas.
 Knee dislocation can cause limb-threatening injury to the popliteal artery. Meticulous vascular examination, including measurement of the ankle-brachial index, is necessary for ruling out vascular
injury.
 An arteriovenous fistula allows blood to bypass the high-resistance systemic capillaries, resulting in decreased systemic vascular resistance (afterload), increased venous return (preload), and
increased cardiac output. A large arteriovenous fistula can lead to high-output heart failure.
 Acute cellular rejection typically occurs within the first 3 months after liver transplant and can present with fevers, malaise, and a rise in aminotransferases, bilirubin, and alkaline phosphatase. Liver
biopsy is diagnostic, demonstrating mixed inflammatory infiltration of the portal tracts, interlobular bile duct destruction, and endotheliitis. Most patients can be treated successfully with high-dose
corticosteroids.
 Hemorrhagic shock is the most common type of shock in trauma patients. Areas where large amounts of blood can be lost (or hidden) are ‘the floor’ (external bleeding) ‘and 4 more’: chest, abdomen,
pelvis/retroperitoneum, and thigh.
 A septal hematoma presents after nasal trauma as fluctuant swelling of the nasal septum. It should be recognized and promptly drained to avoid complications of infection, septal perforation, and nasal
deformities.
 Impaired relaxation of the cricopharyngeus muscle during swallowing may lead to the formation of a Zenker diverticulum, which is seen on contrast swallow study as a pouch posterior to the
esophagus. Treatment is surgical with cricopharyngeal myotomy with or without diverticulectomy.
 Most cases of obstructive shock result from pre-pulmonary obstruction (e.g. due to massive pulmonary embolism or tension pneumothorax) with hemodynamic parameters showing high central
venous pressure (CVP), low pulmonary capillary wedge pressure (PCWP), and low cardiac output. Post-pulmonary obstructive shock (e.g. due to aortic dissection or severe aortic stenosis) leads to the
same findings as cardiogenic shock with high CVP, high PCWP, and low cardiac output.
 The ABCDE criteria can assist in evaluation of superficial spreading melanoma but are less sensitive for other types of melanoma (e.g. nodular, atypical). Nodular melanomas, the second most common
type of melanoma, usually grow vertically and have symmetric borders and a uniform, dark color. Suspicion should be raised when the lesion appears different from other lesions on the patient (‘ugly
 duckling sign’) or the lesion grows continuously, is elevated, or is firm.
 The assessment of pigmented skin lesions should include a predictive rule to estimate the risk of melanoma, such as the ABCDE (Asymmetry, Border irregularities, Color variation, Diameter, Evolving)
rule; lesions with > 1-2 of the ABCDE criteria warrant excisional biopsy. Biopsy is also recommended for lesions with inflammation; itching, crusting, or bleeding; or sensory changes and for lesions that
are significantly different in appearance from other pigmented spots on the same patient (ugly duckling sign).
 Rapid compression of the bowel during blunt abdominal trauma can cause a perforated viscus. When viscus perforation occurs within the retroperitoneum (e.g. duodenal tear), classic symptoms and
signs (e.g. fever, diffuse abdominal pain) may be delayed. Retroperitoneal free air may be present on abdominal imaging.
 Copper deficiency typically occurs in patients with a history of gastric surgery (e.g. bariatric), chronic malabsorption (e.g. inflammatory bowel disease), or excessive zinc ingestion. Symptoms include
slowly progressive myeloneuropathy similar to that of vitamin B12 deficiency (e.g. distal extremity paresthesia, numbness, sensory ataxia), anemia, hair fragility, skin depigmentation,
hepatosplenomegaly, edema, and osteoporosis.
 Clear, unilateral rhinorrhea that increases at times of relatively increased intracranial pressure (e.g. bending over, bowel movements) is suspicious for cerebrospinal fluid rhinorrhea, which is most
often caused by head trauma and can result in meningitis.
 An orbital floor fracture can result in entrapment of the inferior rectus muscle, which presents with vertical diplopia and restriction of upward eye movement.
 Sigmoidoscopy is an effective tool for evaluating lesions in the distal colon but does not visualize the right colon. Patients with left-sided adenomas or adenocarcinomas detected on sigmoidoscopy have
increased risk for synchronous neoplasia on the right side and require visualization of the entire colon with colonoscopy.
 Laparoscopic intra-abdominal surgery (e.g. cholecystectomy) requires insufflation of CO2 into the abdomen to create space for surgical maneuvering and visibility. The increased intra-abdominal
pressure stimulates stretch receptors on the peritoneum that respond by triggering an increase in vagal tone. Consequently, patients can develop severe bradycardia, atrioventricular block, and
sometimes asystole.
 Refeeding syndrome occurs after the reintroduction of nutrition in patients with chronic malnourishment. Clinical manifestations include hypophosphatemia and other electrolyte abnormalities,
muscle weakness, arrhythmias, and congestive heart failure.
 Surgical wounds proceed through 4 phases of wound healing: hemostasis, inflammation, proliferation, and maturation. Collagen production begins during the proliferation phase. Collagen remodeling
and cross-linking, which are most responsible for the wound’s final tensile strength, occur during the maturation phase.
 A diabetic foot ulcer is a common complication of long-standing diabetes mellitus and is particularly common in patients with neuropathy and peripheral vascular disease. Deep, long-standing, or large
ulcers require foot imaging (e.g. x-ray, MRI) to assess for underlying osteomyelitis, even when no signs or symptoms of soft tissue infection are present. Ulcers associated with elevated erythrocyte
sedimentation rate or C-reactive protein also require imaging.
 Vestibular schwannomas present with hearing loss and imbalance. Bilateral, hereditary schwannomas are most often associated with neurofibromatosis type II.
 Free perforation of the gastrointestinal tract in the setting of ongoing inflammation (e.g. diverticulitis) often causes a classic pain sequence: sudden, severe pain (perforation) followed by temporary
relief (decompression) and then generalized, constant pain (peritonitis). Abdominal imaging typically shows intraperitoneal free air.
 A dietary history to assess for anorexia nervosa should be obtained in any patient with a stress fracture, low body weight, and distress at having to limit physical activity. Patients with anorexia nervosa
are at risk for stress fractures due to decreased bone mineral density.
 Fluoroquinolones (e.g. levofloxacin) increase collagen degradation and are associated with adverse effects, including Achilles tendon rupture, retinal detachment, and aortic aneurysm rupture. When
possible, fluoroquinolone use should be avoided in patients with a known aortic aneurysm or substantial risk factors for aortic aneurysm.
 Severe burn injury often leads to a hypermetabolic response characterized by a hyperdynamic circulatory response, causing tachycardia and hypertension; increased gluconeogenesis and insulin
resistance; and increased protein and lipid catabolism, causing elevated basal body temperature.
 Most pancreatic cysts are benign and can be managed conservatively (e.g. surveillance imaging); however, some carry a risk for malignant transformation. Cysts with high-risk features (large size, solid
components or calcifications, main pancreatic duct involvement, thickened or irregular cyst wall) require further evaluation with endoscopic ultrasound-guided biopsy and possibly surgical resection.

 Small bowel obstruction can be complicated by bowel perforation. Free air on x-ray and clinical signs of peritonitis should prompt emergent surgical exploration.
 Sigmoid volvulus occurs when a segment of sigmoid colon twists on its mesentery, forming a closed-loop obstruction that often appears on abdominal x-ray as a dilated, inverted, U-shaped loop (‘coffee
bean’ sign). Chronic constipation and colonic dysmotility are risk factors.
 Spontaneous upper extremity deep venous thrombosis most often occurs in young, athletic men who lift weights or engage in activities that have repetitive overhead arm motions (e.g. pitching a
 baseball game). It is marked by acute arm swelling, heaviness, and pain. Treatment generally requires thrombolysis and/or 3 months of anticoagulation.
 Peripherally inserted central catheters increase the risk of upper extremity deep venous thrombosis. The risk is greatest in hospitalized patients, particularly those with malignancy or other
hypercoagulable state. Manifestations include arm swelling, erythema, and pain. The diagnosis is made with duplex ultrasonography. Treatment with 3 months of anticoagulation is required.

 Insufficient hemostasis is the most common cause of postoperative hematoma in patients with no personal or family history of easy bleeding or bruising.
 A conductive hearing loss (CHL) may show improved speech understanding in background noise. CHL in a young woman with a positive family history of hearing loss likely represents otosclerosis,
which is characterized by bony overgrowth of the stapes that causes stiffening of the ossicular chain.
 Greater trochanteric pain syndrome presents with lateral hip pain and tenderness over the greater trochanter during flexion. Initial treatment includes heat, activity modification, and nonsteroidal anti-
inflammatory drugs. Patients with persistent symptoms may benefit from local corticosteroid injection.
 Iliotibial (IT) band syndrome is characterized by poorly localized lateral knee pain. It is common in inexperienced runners starting a new or more strenuous training regimen. Examination shows
tenderness proximal to the joint line; pressure over the IT band just proximal to the lateral femoral epicondyle during flexion of the knee reproduces the pain.
 Venous air embolism (VAE) is suggested by sudden-onset respiratory distress following removal of a central venous catheter. Patients with suspected VAE should immediately be placed in the left
lateral decubitus position to trap air on the lateral right ventricular wall and help prevent right ventricular outflow tract obstruction and embolization of air into the pulmonary circulation. High-flow
oxygen is also important to encourage absorption of the air embolus.
 Venous air embolism results from the introduction of a large volume of air (e.g. > 50 mL) into the venous circulation; it can occur in the setting of trauma, certain surgeries (e.g. neurosurgical), central
venous catheter manipulation, or pulmonary barotrauma. The air can obstruct blood flow in the right ventricular outflow tract or pulmonary arterioles, leading to hypoxemia, obstructive shock, and
cardiac arrest.
 Positive-pressure ventilation can rapidly exacerbate tension pneumothorax (TP) and cause cardiovascular collapse. Therefore, decompression (e.g. needle thoracostomy) should be performed prior to
intubation for patients with TP who also need airway protection - an important exception to the typical order.
 Decreased urine output and high peak inspiratory pressures in the setting of a tensely distended abdomen are concerning for abdominal compartment syndrome (i.e. intra-abdominal hypertension
causing organ dysfunction). Bladder pressure measurement can estimate intra-abdominal pressure.
 Enteral nutrition, when feasible, is the optimal form of nutrition for critically ill patients and has multiple clinical benefits (e.g. reduction in infections, maintenance of gut integrity) when initiated early
(i.e. < 48 hr).
 Patients can develop respiratory alkalosis with a high respiratory rate and normal oxygen saturation due to inadequate pain control. Patients who take opioids chronically often develop tolerance and
require increased doses of opioids or multimodal strategies to appropriately control acute pain.
 Gastric outlet obstruction presents with intractable nausea and vomiting, early satiety, and weight loss. Most cases are caused by malignancy, most commonly from pancreatic adenocarcinoma with
gastric or duodenal invasion. Pancreatic adenocarcinoma can also cause unexplained hyperglycemia resulting from islet cell destruction.
 Carpal tunnel syndrome is the most common mononeuropathy in patients with end-stage renal disease on dialysis. It is characterized by pain and paresthesia in the lateral hand; symptoms typically
worsen during dialysis and are more severe in the arm with vascular access.
 Carpal tunnel syndrome is common in patients with hypothyroidism and is frequently bilateral. Hypothyroidism causes soft tissue thickening and mucinous infiltration, which can lead to compression
of the median nerve within the carpal tunnel.
 Prophylactic anticoagulation does not eliminate the risk of acute pulmonary embolism (PE), especially in high-risk patient populations (e.g. postoperative cancer resection). CT pulmonary angiography
is the initial diagnostic test of choice in patients with likely pretest probability of acute PE.
 Spinal epidural hematoma is a potential complication of neuraxial anesthesia (e.g. epidural block), lumbar puncture, or spinal surgery and is more common in older adults taking antithrombotic
medications. Manifestations include slowly progressive motor and sensory dysfunction and localized back pain; bowel and bladder dysfunction may occur. Management includes an urgent MRI and
neurosurgical decompression.
 Epidural hematomas occur due to tearing of the middle meningeal artery and typically occur with skull fracture. Although patients classically present with loss of consciousness followed by a lucid
interval, many initially remain alert. However, hematoma expansion results in neurologic decompensation with signs of elevated intracranial pressure (e.g. headache, nausea/vomiting, altered mental
status) within minutes to hours.
 Smoking is associated with an increased risk of surgical site infection and poor wound healing. Current smoking is associated with greater risk than past smoking, but patients who quit are still at
 increased risk. Smoking cessation is recommended prior to elective surgery, especially if cessation can be achieved at least 4-6 weeks before surgery.
 Patients with severe Crohn disease, especially those who have required intestinal surgery in the past, are at high risk for future complications and often need aggressive management with biologic
and/or immunomodulator therapy. Smoking is strongly associated with increased severity and progression of Crohn disease and should be avoided in these patients.

 Displaced fractures of ribs 9-12 can injure intra-abdominal organs, including the spleen. Bleeding that irritates the diaphragm may cause referred pain (e.g. to the left shoulder).
 Chronic disseminated intravascular coagulation is common in patients with mucin-producing tumors (e.g. pancreatic cancer) due to periodic release of tissue factor into the bloodstream, which triggers
low-grade coagulation and fibrinolysis. Patients frequently have normal platelet counts and coagulation times but are at increased risk for venous and arterial thrombosis and, to a lesser extent,
mucocutaneous bleeding.
 Severe trauma increases the risk of disseminated intravascular coagulation, a consumptive coagulopathy, due to the exposure of tissue factor and the release of procoagulant proteins and
phospholipids. Laboratory evaluation will reveal prolonged PT/PTT and thrombocytopenia. Patients usually develop signs of bleeding (e.g. oozing from venipuncture/surgical sites) and organ damage
(e.g. renal insufficiency).
 Ischemic hepatitis, characterized histologically by zone 3-predominant hepatocyte necrosis, occurs in the setting of global hypoperfusion and/or hypoxemia. Common causes include cardiac insults (e.g.
myocardial infarction, unstable arrhythmias), respiratory failure, hypovolemia, and septic shock. Patients immediately develop severe aminotransferase elevations with bilirubin levels remaining
unaffected or rising a few days later.
 A perilymphatic fistula can occur after head trauma and result in episodic vertigo triggered by sudden pressure changes (e.g. Valsalva maneuvers) or loud noises (Tullio phenomenon).

 Severe, uncontrolled inflammation in Crohn disease can lead to a fibrotic stricture of the small bowel with small bowel obstruction (SBO); smoking and young age (< 30) at diagnosis increase the risk of
such disease progression. Fibrotic stricture with SBO presents with bilious emesis, severe abdominal pain, and inability to pass flatus and/or stool. Treatment usually requires surgical removal of the
strictured portion of small bowel.
 Both Crohn disease and ulcerative colitis present with chronic diarrhea, abdominal pain, anemia, and elevated inflammatory markers. Colonoscopy with biopsies is the test of choice for diagnosis
because it can distinguish between characteristic findings of Crohn disease (e.g. cobblestone appearance, skip lesions, deep ulcerations, transmural inflammation, granulomas) and those of ulcerative
colitis (e.g. continuous, shallow ulcerations limited to the mucosa/submucosa, pseudopolyps).
 FEV1 and diffusion capacity of the lung for carbon monoxide (DLCO) are the best predictors of postoperative outcomes following lung resection surgery.
 Human papillomavirus can cause recurrent respiratory papillomatosis, which results in hoarseness due to wartlike growths on the true vocal cords.
 Adolescent idiopathic scoliosis is defined as lateral curvature of the spine without a known etiology in a child age > 10. Forward bend test reveals an asymmetric thoracic or lumbar prominence. The
first step in evaluation is x-ray of the spine to determine the degree of curvature and assess skeletal maturity.
 Sudden-onset, severe abdominal pain and anion gap metabolic acidosis should raise suspicion for acute mesenteric ischemia. Most cases arise in the setting of thromboembolism (e.g. atrial fibrillation).
Diagnosis is generally made with CT mesenteric angiography.
 Acute colonic pseudo-obstruction (Ogilvie syndrome) typically presents with severe abdominal distension, pain, vomiting, and obstipation. Common causes include electrolyte imbalance (e.g.
hypokalemia, hypomagnesemia) and factors that lead to autonomic disruption of the colon (e.g. major surgery, neurologic disease, anticholinergic medication). The diagnosis is made by CT scan
showing colonic dilation without anatomic obstruction, and treatment involves bowel rest and colonic decompression, sometimes aided by intravenous neostigmine.

 Persistent tachycardia and new arrhythmia (e.g. premature ventricular contractions) after blunt chest trauma are concerning for blunt cardiac injury. Patients with these findings are admitted for
continuous cardiac monitoring and echocardiography.
 Renal and perinephric abscesses manifest with insidious onset of flank pain and systemic symptoms (e.g. fever, weight loss), typically in patients with a history of urinary tract infection or extrarenal
infection (e.g. bacteremia) in the prior 1-2 months. In most cases, the urinalysis demonstrates pyuria, bacteriuria, and proteinuria, but it may remain normal if the abscess is not in contact with the
collecting ducts.
 Hypertension is one of the earliest clinical manifestations of autosomal dominant polycystic kidney disease. It likely results from cyst expansion leading to localized renal ischemia and consequent
increased renin production with activation of the renin-angiotensin-aldosterone system. Therefore, the hypertension is best treated with ACE inhibitors (e.g. lisinopril).
 Autosomal dominant polycystic kidney disease commonly presents with hypertension, hematuria, and recurrent flank pain in patients in their 30s or 40s. Treatment is mostly supportive, although
vasopressin-2 receptor antagonists (e.g. tolvaptan) may slow disease progression in some patients.
 Pelvic fractures, especially those with pelvic ring disruption, can cause life-threatening hemorrhage from vascular (e.g. venous plexus) injury. Pelvic binder application can decrease pelvic volume and
promote tamponade of bleeding.
 A Salter-Harris type III (juvenile Tillaux fracture) is characterized by fracture of the distal tibial epiphysis and lateral physis (i.e. growth plate) and most commonly occurs in adolescents when the
physis is partially fused. Injury to the growth plate can cause growth arrest and lead to persistent limb-length discrepancy.
 Buckle fractures are common in children and typically occur at the distal radius and/or ulna due to a fall onto an outstretched hand. X-ray is diagnostic and shows bulging of the bony cortex.

 Distal radius fracture with dorsal displacement can cause median nerve compression, resulting in acute carpal tunnel syndrome symptoms, including paresthesia of the lateral 3.5 digits and impaired
thumb abduction. In addition, if compression occurs proximal to the tunnel, the palmar cutaneous branch of the median nerve may be affected, leading to decreased sensation over the anterolateral
hand.
 Acute renal vein thrombosis presents with hematuria, renovascular congestion, and flank pain. The most common causes are nephrotic syndrome, malignancy, and trauma. Diagnosis can be confirmed
by CT or MR angiography or renal venography.
 Renal artery stenosis (RAS) can occur in the renal allograft, typically within 2 years of transplant. Like other forms of RAS, suggestive findings include persistently elevated blood pressure, decline in
renal function with the addition of ACE inhibitors, a lateralizing abdominal bruit, and recurrent flash pulmonary edema. The diagnosis is made with renal vascular imaging (e.g. renal Doppler
ultrasonography).
 Severe hypertension and recurrent flash pulmonary edema in the setting of diffuse atherosclerosis suggests renal artery stenosis. Associated findings can include chronic kidney disease and evidence of
secondary hyperaldosteronism (hypokalemia, elevated serum bicarbonate); urinalysis is typically bland. The diagnosis is confirmed with renal imaging (e.g. renal ultrasound with Doppler).

 Renal artery stenosis typically presents with uncontrolled hypertension. A lateralizing abdominal bruit is a highly specific examination finding; atrophy of the affected kidney may be seen on imaging.
Hypoperfusion of the post-stenotic kidney results in increased local renin secretion, leading to activation of the renin-angiotensin-aldosterone system and secondary hyperaldosteronism. Renin
secretion by the unaffected kidney is suppressed.
 Tracheobronchial injury should be considered in patients with thoracic trauma and extensive extrapulmonary air (e.g. chest tube with persistent large air leak). Bronchoscopy can confirm the diagnosis
prior to operative repair.
 Penetrating trauma accompanied by shock (e.g. severe hypotension) is attributed to hemorrhage until proven otherwise. Intrathoracic hemorrhage can cause massive hemothorax (> 1,500 mL), which
requires emergent thoracotomy to prevent exsanguination.
 Hypovolemic shock in the setting of blunt chest trauma is concerning for intrathoracic hemorrhage. Rib fractures (with intercostal vessel injury) are a common cause of hemothorax.

 Patients who undergo Roux-en-Y gastric bypass are at risk for multiple vitamin deficiencies. Fat-soluble vitamins and vitamin B12 deficiency are most common, but vitamin C deficiency can occur in the
setting of poor postoperative diet. Vitamin C deficiency is associated with ecchymosis, petechiae, poor wound healing, perifollicular hemorrhage, coiled hairs, and gingivitis; platelet count, prothrombin
time, and partial thromboplastin time will be normal.
 Thyroglobulin is produced only by thyroid tissue (either normally functioning or malignant). Serum thyroglobulin measurements are used as a tumor marker once the normally functioning thyroid
tissue is removed.
 Thyroid nodules that have suspicious sonographic features should undergo fine-needle aspiration biopsy, even if the patient is pregnant.
 Medullary thyroid cancer arises from the calcitonin-secreting parafollicular C cells. Serum calcitonin levels correlate with the risk of metastasis and recurrence, and are measured serially following
surgery.
 A postoperative neck hematoma should be recognized promptly and drained to avoid potentially lethal upper airway obstruction.
 Biliary atresia is a neonatal disorder in which extrahepatic bile ducts develop progressive fibrosis. Patients have jaundice, pale stools, and a small or absent gallbladder. Laboratory findings include
direct hyperbilirubinemia, normal reticulocyte count, and elevated γ-glutamyl transpeptidase.
 Cerebellar hemorrhage presents with progressive headache, nausea, and vomiting; in addition, vertigo, ipsilateral truncal (cerebellar vermis) or limb (cerebellar hemispheres) ataxia, dysarthria, and
 nystagmus may occur. CT scan demonstrates a posterior fossa hyperdensity. Urgent surgical decompression is indicated in patients with signs of neurologic deterioration or radiologic evidence of a
hemorrhage > 3 cm, brainstem compression, or obstructive hydrocephalus.
 Anastomotic leak is a serious postoperative complication that can present with fever, abdominal pain, tachypnea, and tachycardia, usually within the first week after bariatric surgery. The diagnosis is
best confirmed by oral contrast-enhanced imaging (either abdominal CT scan or upper gastrointestinal series), and treatment requires urgent surgical repair.

 Foreign body aspiration should be suspected in a child with abrupt-onset cough and wheeze (with or without a choking episode) that is unresponsive to albuterol. Supportive findings include a focal
lung examination (e.g. wheeze, decreased breath sounds, hyper-resonance) and/or unilateral lung hyperinflation with mediastinal shift on x-ray.
 Splenic abscess is a rare, life-threatening complication of bacteremia from a distant infection (e.g. infective endocarditis, cholecystitis). Manifestations generally include persistent high fever and tender
splenomegaly. Diagnosis is made with CT scan of the abdomen; antibiotic therapy and splenectomy are generally required.
 Atraumatic splenic rupture is an uncommon but life-threatening complication of hematologic malignancy, infection, and systemic inflammatory disease, and anticoagulation increases the risk. Patients
develop acute abdominal pain, shock, and anemia. Peritonitis and left shoulder pain may also be present.
 Von Hippel-Lindau disease is an autosomal dominant disorder resulting in benign and malignant multiorgan tumors. The most common tumors are hemangioblastomas of the central nervous system
and retina. Other common manifestations include renal cell carcinoma (often preceded by the formation of premalignant renal cysts) and pheochromocytoma.

 A pancreaticopleural fistula (between the pancreatic duct and the pleural space) resulting in an amylase-rich exudative pleural effusion occurs most commonly as a result of acute or chronic
pancreatitis. Management includes bowel rest to promote fistula closure; endoscopic retrograde cholangiopancreatography may be required.
 A laryngeal ulcer in a smoker is likely squamous cell carcinoma. Persistent hoarseness should always be evaluated by laryngoscopy to ensure no delay in diagnosis of possible cancer.

 Evolving leukoplakia in the oral cavity requires biopsy (even if previously biopsied). Tobacco use is the most important risk factor for oral cavity squamous cell carcinoma.
 A tonsil ulcer in a smoker is likely due to squamous cell carcinoma.
 Approximately 25% of pancreatic cancer is heralded by a recent (< 2 years) diagnosis of diabetes mellitus. Although screening for pancreatic cancer is not recommended for patients with new-onset
diabetes mellitus, those who have symptoms (e.g. constant abdominal pain, weight loss) of pancreatic cancer should undergo abdominal CT scan.
 The most common symptom of pancreatic cancer is insidious, continuous midepigastric pain that often radiates to the flanks or back and is sometimes worse with eating and lying down. CT scan of the
abdomen is the first-line test for suspected pancreatic cancer.
 Rectal prolapse is characterized by intermittent protrusion of the rectum (i.e. erythematous mass with concentric rings) through the anal orifice. It is often associated with fecal incontinence,
constipation, and/or mucous discharge. Rectal prolapse is most common in women age > 40. Risk factors include multiparity, vaginal delivery, pelvic surgery, pelvic floor dysfunction, chronic
constipation or straining, dementia, and stroke.
 Lateral ankle sprains are typically caused by forceful inversion of the foot. The anterior talofibular ligament is most commonly injured. If there is tenderness only over the ligaments distal to the lateral
malleoli and the patient can bear weight, conservative management (e.g. compression bandage or brace, ice packs, crutches to reduce weightbearing) without imaging is appropriate.

 Ankle pain after trauma may be caused by a sprain or fracture. The Ottawa ankle rules are used to help determine which patients require imaging. X-ray of the ankle is indicated for patients with pain in
the malleolar region in association with either 1) bony tenderness at the posterior margin or tip of the lateral or medial malleolus or 2) inability to bear weight.

 An enlarged, ulcerated tonsil with ipsilateral cervical adenopathy is likely oropharyngeal (head and neck) squamous cell carcinoma. Human papillomavirus is the likely etiology in the absence of
traditional risk factors (smoking, alcohol).
 Esophageal dysphagia is characterized by a sensation of food ‘sticking’ in the esophagus; in older patients, esophageal malignancy is a common cause. Esophageal malignancy classically presents with
progressive solid-food dysphagia; retrosternal pain and weight loss are also common. Upper endoscopy is the test of choice to evaluate dysphagia.
 Eosinophilic esophagitis usually presents as intermittent solid food dysphagia and most commonly affects younger men with atopic conditions. Untreated disease can cause esophageal stricture and
food impaction. Management includes dietary therapy (e.g. allergen avoidance, elimination diet), proton-pump inhibitors, and topical glucocorticoids (e.g. fluticasone, budesonide).
 Blunt trauma that rapidly compresses the upper abdomen against the vertebral column can injure the pancreas. Pancreatic injury can be difficult to diagnose immediately following trauma; persistent
abdominal discomfort or nausea, increasing amylase, or peripancreatic fluid collection should raise suspicion for an undiagnosed injury.
 Rapid compression of the duodenum against the vertebral column during blunt abdominal trauma may result in a duodenal hematoma. Hematoma expansion can progressively obstruct the duodenal
lumen, causing a delayed (24-48 hr) presentation of worsening emesis. CT scan confirms the diagnosis.
 Effort rupture of the esophagus (Boerhaave syndrome) can occur with vomiting and may cause unilateral pleural effusion from leaked esophageal contents. Confirmation with esophagography or CT
scan using water-soluble contrast should prompt emergent surgical consultation.
 Blunt thoracic trauma can cause a sudden increase in intraesophageal pressure sufficient to rupture the esophagus. If gastrointestinal contents leak from the esophagus into the pleural space, pleural
effusion results, and fluid analysis typically reveals unusual color (e.g. green), low pH, and high amylase.
 Patients with rheumatoid arthritis are at risk for atlantoaxial instability; neck extension during intubation can result in subluxation with cord compression and cervical myelopathy. Symptoms of
cervical myelopathy include a slowly progressive, spastic paraparesis involving the upper and lower extremities, hyperreflexia, sensory changes, and a positive Babinski sign. Hoffman sign may also be
positive.
 Esophageal perforation is a life-threatening complication of esophageal instrumentation. Clinical presentation may include severe chest/back pain, fever, and a widened mediastinum on chest x-ray.
Water-soluble contrast esophagography can confirm the diagnosis.
 Acute cholangitis should be suspected in a patient with gallstone pancreatitis who also has fevers, right upper quadrant pain, jaundice, altered mental status, and hypotension. Endoscopic retrograde
cholangiopancreatography is required to relieve the biliary obstruction and prevent serious infectious complications.
 Ganglion cysts are mobile, nontender swellings that occur most commonly at the dorsal surface of the wrist. The diagnosis is usually obvious on inspection and can be confirmed on transillumination of
the mass. Most ganglion cysts resolve spontaneously and require no treatment.
 Acute pancreatitis is the most common complication after endoscopic retrograde cholangiopancreatography, and typically presents with abdominal pain with radiation to the back, nausea, and
vomiting. Lipase and amylase levels will rise several hours after symptom onset whereas CT scans can be normal for up to 48 hours.
 Acute graft-versus-host disease is a common complication of allogenic hematopoietic stem cell transplantation. It arises when donor T-lymphocytes recognize antigens on host epithelial cells as foreign
and initiate a strong inflammatory response. Patients usually manifest symptoms within 100 days of transplant, including a maculopapular rash; profuse, watery diarrhea; and signs of hepatobiliary
inflammation.
 Gastric cancer is common in those from Eastern Asia, Eastern Europe, and South America. It generally presents with progressive epigastric pain and weight loss. Friable tumor vessels can bleed into the
stomach lumen, leading to iron deficiency anemia. Metastasis to the liver can result in hepatomegaly and elevated transaminases and alkaline phosphatase.

 Gastric cancer is endemic to Eastern Asia, Eastern Europe, and the Andean portions of South America due to diets high in salt-preserved food and nitroso compounds. Manifestations typically include
weight loss and chronic mid-epigastric pain that worsens with eating. Esophagogastroduodenoscopy is the initial test of choice to establish the diagnosis.

 Biliary colic occurs when the gallbladder contracts against a gallstone that temporarily blocks the cystic duct. Classic symptoms include episodic postprandial right upper quadrant or epigastric pain,
nausea, and vomiting; however, vital signs, white blood cell count, and liver function studies remain normal. The diagnosis is confirmed with an abdominal ultrasound demonstrating the presence of
gallstones.
 Emphysematous cholecystitis is characterized by fever, right upper quadrant pain, and gas in the gallbladder wall, surrounding tissue, or hepatobiliary system. It occurs when gas-forming organisms
such as Clostridium infect damaged or ischemic tissue but, unlike uncomplicated acute cholecystitis, it is a surgical emergency and warrants immediate cholecystectomy.

 In a patient with risk factors for malignancy, ear pain with a normal ear examination may be referred from the base of the tongue or hypopharynx/larynx. Associated cervical adenopathy makes head
and neck squamous cell carcinoma the most likely diagnosis.
 Positive-pressure ventilation improves gas exchange but poses the risk of pulmonary barotrauma, leading to alveolar rupture and subsequent pneumothorax formation. Patients with a large
pneumothorax often demonstrate rapid-onset tachycardia, tachypnea, hypoxemia, and decreased or absent breath sounds on the affected side.
 Clostridioides (formerly Clostridium) difficile infections can occasionally be complicated by toxic megacolon, which usually presents with severe systemic symptoms (e.g. high fever, tachycardia),
leukocytosis, abdominal distension, and significant colonic distension on abdominal radiograph. Suspicion is often raised when a patient with C. difficile infection stops having diarrhea and symptoms
 clinically worsen.
 Acute diverticulitis is common in older individuals and typically presents with dull, left lower quadrant pain; nausea and vomiting; alteration in bowel habits; and (sometimes) irritative bladder
symptoms (e.g. dysuria, frequency) or sterile pyuria.
 Cholangiocarcinoma, a biliary tract epithelial malignancy, most often occurs in those who have fibropolycystic liver disease or primary sclerosing cholangitis due to underlying ulcerative colitis. Most
cases present with subacute right upper quadrant pain, weight loss, and signs of biliary obstruction such as jaundice, cholestatic liver enzyme pattern, and dilation of the intrahepatic or common bile
duct.
 Anorectal fistulas are most often due to rupture of a perianal abscess with formation of a persistent sinus tract. Symptoms include pain with defecation and chronic discharge. Management requires
surgical intervention.
 Thrombosis of an external hemorrhoid manifests as excruciating anorectal pain exacerbated by sitting. Examination demonstrates a bluish (or purplish) bulge at the anal verge. Initial management
includes sitz baths, stool softeners, and topical anesthetics.
 Acute spinal cord injury often manifests with loss of spinal cord function (e.g. areflexia, anesthesia, paralysis, distended bladder) below the level of the lesion. Lesions that arise above T1 also often
cause neurogenic shock due to interruption of the descending sympathetic fibers, which results in unopposed parasympathetic stimulation of the vessels (hypotension) and heart (bradycardia).
Hypothermia is also common due to a lack of peripheral vasoconstriction.
 Central cord syndrome is common after whiplash-type injuries in older adults with underlying cervical spondylosis. Damage to the central cervical spinal cord causes upper extremity motor, sensory,
and reflex abnormalities; sacral (e.g. bowel/bladder) and lower extremity function is generally preserved.
 Prolonged postoperative ileus, the delayed return of bowel function > 72 hours after surgery, is typically self-resolving; therefore, management is conservative with bowel rest and serial examinations.

 Patients with cirrhosis are often unaware of the condition until they develop complications. One major complication is hepatocellular carcinoma, a primary liver tumor that often presents with
decompensated liver failure, weight loss, and a palpable liver lesion. α-fetoprotein is elevated in ~50% of cases; therefore, it can be a useful diagnostic clue but cannot be used to rule out the disease.

 Hepatocellular carcinoma usually arises due to chronic liver inflammation from viral hepatitis, alcoholism, or environmental toxins. Incidence is greatest in regions that have high rates of hepatitis B
and C virus infection, such as Asia, Africa, and the Middle East. Approximately 50% of HCC cases are associated with dramatic elevations in α-fetoprotein.
 Hepatocellular carcinoma (HCC) is a common complication of cirrhosis, with a risk of 1%-8% per annum in this population. Therefore, screening with abdominal ultrasound every 6 months is
recommended. Because HCC often presents with liver decompensation (e.g. new-onset ascites, variceal bleeding), this condition should prompt abdominal ultrasound to evaluate for HCC.

 Young women on prolonged oral contraception are at greatest risk for hepatic adenoma. Although most lesions are benign and asymptomatic, life-threatening complications such as malignant
transformation or rupture can occur. Rupture should be suspected in the setting of sudden-onset, severe right upper quadrant pain and signs of hemorrhagic shock.

 Focal nodular hyperplasia is a benign liver lesion due to an aberrant congenital artery. It is usually found incidentally in young women and is marked by the presence of a stellate central scar and
radiating fibrous bands.
 Pyoderma gangrenosum is characterized by rapidly progressive, painful ulcers with a purulent base and violaceous border, often following local trauma (pathergy). Many patients have underlying
systemic inflammatory disorders (e.g. rheumatoid arthritis, inflammatory bowel disease). The diagnosis is made clinically after excluding other etiologies, usually with skin biopsy. Treatment is with
corticosteroids.
 Ventilator-associated pneumonia should be suspected when an intubated patient develops new pulmonary infiltrates on chest x-ray, worsened respiratory status (e.g. increased oxygen requirement,
increased secretions), and clinical signs of infection (e.g. fever, leukocytosis). Confirmation requires the identification of an organism in a lower respiratory tract sample.

 Ventilator-associated pneumonia is a hospital-acquired pneumonia that develops > 48 hours after endotracheal intubation. Most cases arise due to aspiration of oropharyngeal or gastric secretions.
Therefore, the risk is reduced by elevating the head of the bed to 30-45 degrees, suctioning subglottic secretions, limiting endotracheal tube movement, and avoiding gastric acid suppression, unless
patients are at high risk of stress ulcers.
 A branchial cleft cyst is a congenital neck mass that often presents in later childhood after an upper respiratory tract infection. It is typically located inferior to the mandible and anterior to the
 sternocleidomastoid muscle.
 Bladder cancer is common in older adults and often presents with hematuria, voiding symptoms (e.g. dysuria, frequency), and/or hydronephrosis with flank pain. Urgent cystoscopy is required to
visualize the bladder wall and to biopsy suspicious masses.
 Bladder cancer often presents with painless hematuria that lasts throughout micturition in an adult age > 40. Urinalysis should be performed to confirm hematuria (> 3 red blood cells/hpf) and to rule
out infection/glomerulonephritis. Those with no clear cause for hematuria require urgent evaluation with cystoscopy to visualize the bladder for lesions.
 Postoperative fever is generally mediated by cytokine release in response to tissue trauma, blood cell lysis, or infection. Immediate postsurgical fever occurs within hours of the operation and is usually
due to tissue trauma, mismatched blood products, or drug reactions. Acute (1-7 days postoperatively) and subacute (7-28 days postoperatively) fever is generally driven by infections.

 Polycythemia with high circulating erythropoietin (EPO) levels (secondary polycythemia) is usually due to tumors that produce EPO (e.g. renal cell carcinoma) or chronic hypoxia (e.g. cardiopulmonary
disease, obstructive sleep apnea). Individuals with secondary polycythemia and no evidence of hypoxia should undergo abdominal CT scan to evaluate for renal cell carcinoma.

 Renal cell carcinoma is common in older patients who smoke. It often presents with weight loss, hematuria, firm/nontender flank mass, and/or intermittent fever.
 Unilateral sensorineural hearing loss with imbalance (CN VIII dysfunction) and decreased facial sensation (CN V dysfunction) are concerning for a vestibular schwannoma, a benign tumor of CN VIII.

 Femoral hernias are more common in elderly women and are more likely than inguinal hernias to develop complications (e.g. incarceration, strangulation). Small bowel obstruction can occur and
typically presents with progressive abdominal pain, nausea/vomiting, high-pitched bowel sounds on examination, and distended loops of bowel with air-fluid levels on x-ray.

 Femoral hernias (hernia located below inguinal ligament) protrude through the femoral ring and usually present with a nontender, nonpulsatile bulge in the groin that grows in size with increased
abdominal pressure. Because the risk of incarceration with femoral hernias is high (due to narrow hernia orifice), patients with asymptomatic femoral hernias are referred for early elective hernia
repair. In contrast, asymptomatic inguinal hernias (hernia located above inguinal ligament) can usually be managed with watchful waiting because hernia contents pass through a wider orifice.

 Deep (fascial) wound dehiscences can result in exposure or herniation (i.e. evisceration) of intra-abdominal organs (e.g. bowel), resulting in possible strangulation. Therefore, patients with fascial
dehiscence require emergency surgery.
 Superficial wound dehiscence, separation of the epidermis and/or subcutaneous tissue with an intact fascia, is typically managed conservatively with regular dressing changes. In contrast, deep (fascial)
dehiscence involves the fascia and is a surgical emergency.
 Spinal cord injury above T6 can be complicated by autonomic dysreflexia, in which noxious stimuli below the injury level trigger an unregulated sympathetic response, leading to severe hypertension. A
compensatory parasympathetic response above the lesion typically causes bradycardia. Management includes removing noxious stimuli and treating the hypertension.

 Phantom limb pain is common following extremity amputation. The neuropathic pain, which is perceived in the absent portion of the limb, is best managed with a multimodal pain regimen consisting of
pharmacotherapy and adjuvant therapies.
 Post-traumatic neuromas are due to the transection of nerve fibers and form over several weeks to months following injury or amputation. They cause pain with local pressure that can complicate
fittings for amputational prosthetics. Injection of a local anesthetic can provide transient pain relief and confirm the diagnosis. Management typically involves excision of the neuroma.

 After initial stabilization, burn patients who require aggressive fluid resuscitation (e.g. due to burns covering a large total body surface area) should undergo urethral catheterization as soon as possible.

 Peyronie disease is an acquired disorder characterized by fibrosis of the tunica albuginea of the penis, which restricts tissue expansion and flexibility during erections. Manifestations often include
penile pain, curvature, and/or dorsal nodules/plaques; distortion of the normal erectile shape of the penis may make sexual intercourse difficult.
 The greatest risk factor for prostate cancer is advanced age; approximately 30%-80% of men age > 70 have histologic evidence of prostate cancer. Less-prominent risk factors include black ethnicity
and a diet high in meat and low in fruits and vegetables.
 Initial management of uncomplicated hemorrhoids includes increased intake of fluid and fiber, reduction of fat and alcohol intake, and regular exercise. Additional measures may include phlebotonics,
 topical hydrocortisone, astringents, and local anesthetics. Rubber band ligation and surgical hemorrhoidectomy are advised only for patients with refractory symptoms or prolapsed hemorrhoids that
cannot be reduced manually.
 Varicoceles typically present as a clustered scrotal mass above the testis. Men with a varicocele can have reduced fertility, possibly due to increased scrotal temperatures that can cause a reduced sperm
count and decreased motility.
 Unilateral cryptorchidism can be monitored until age 6 months, after which spontaneous descent is unlikely. In such a case, orchiopexy is indicated before age 1 to reduce the risk of testicular torsion,
infertility, and testicular malignancy.
 Acute infectious lymphangitis is marked by the formation of proximal, tender, erythematous streaks at the site of skin wound with regional lymphadenopathy and systemic symptoms (e.g. fever). Most
cases are caused by Streptococcus pyogenes or methicillin-sensitive Staphylococcus aureus; therefore, treatment with cephalexin is generally curative.

 Plantar fasciitis is characterized by inflammation and degeneration of the plantar aponeurosis (deep plantar fascia), a thick, fibrous band that extends from the calcaneus to the toes and supports the
longitudinal arch of the foot. It presents with chronic pain at the sole of the foot that is worse with weight bearing.
 Patients with epiglottitis who develop rapid-onset respiratory failure (e.g. tripod position, hypoxia, drooling, tachypnea) require urgent airway management. This includes bag-valve-mask ventilation
with 100% oxygen followed by endotracheal intubation with advanced equipment (e.g. video laryngoscope). A single failed attempt at video-assisted endotracheal intubation should prompt surgical
cricothyrotomy, which bypasses the epiglottal swelling and potential obstruction.
 Epiglottitis should be suspected in patients with sore throat, hoarseness, stridor, pooled oral secretions, and drooling. Risk factors include diabetes mellitus, obesity, and preceding upper respiratory
infection. The diagnosis can be confirmed (in those with stable respiratory status) using lateral neck radiograph.
 Benign prostatic hyperplasia can gradually compress the prostatic urethra, leading to incomplete bladder emptying and an increased risk for recurrent urinary tract infections.
 Normal pressure hydrocephalus (NPH) is characterized by ventriculomegaly with normal opening pressure on lumbar puncture. It classically presents with a triad of incontinence, cognitive
impairment, and gait abnormalities; however, all symptoms may not be present in early disease. NPH can be idiopathic or occur secondary to neurologic insults (e.g. subarachnoid hemorrhage, trauma,
meningitis) that result in scarring of the arachnoid granulations responsible for cerebrospinal fluid resorption.
 Chronic bacterial prostatitis often presents with symptoms of recurrent urinary tract infection, painful ejaculation, and/or prostatic tenderness in young or middle-aged men. Patients often have
transient improvement of symptoms with short courses of antibiotics. Six weeks of a fluoroquinolone is generally required for eradication.
 Acute bacterial prostatitis is characterized by fever, dysuria, and a swollen, tender prostate. Most cases are caused by coliform organisms (e.g. Escherichia coli) that have contaminated the urethra and
entered the prostate via intraprostatic urinary reflux. Urine culture is required to define the underlying pathogen, but 6 weeks of therapy with trimethoprim-sulfamethoxazole or a fluoroquinolone is
generally required to ensure eradication.
 Chronic bacterial prostatitis generally causes recurrent urinary tract infection symptoms and prostatic swelling and tenderness. Most cases arise when coliform pathogens enter the prostate from the
urethra; Escherichia coli is the leading pathogen.
 Pleural effusions occur in almost half of patients who undergo coronary artery bypass graft surgery. The majority of these effusions are small, asymptomatic, and benign. When the effusion is small to
moderate in size, begins within 1 or 2 days of surgery, and does not cause respiratory symptoms, it can be managed conservatively with observation.
 Mediastinitis is a complication of cardiovascular surgery characterized by infection of the deep tissues; it classically presents with systemic symptoms (e.g. fever, tachycardia), chest pain, chest wall
edema/crepitus, and purulent discharge; but it can also present atypically. Therefore, any patient with copious drainage from the sternal wound should undergo chest imaging. Radiographic findings
include fluid collections or pneumomediastinum.
 Sternal dehiscence is a complication of cardiac surgery characterized by separation of the bony edges of the sternum. Patients may report mild pain or sensation of chest wall instability and ‘clicking’
with chest movement. The diagnosis can be made radiographically (e.g. displaced sternal wire) or clinically; palpable rocking or clicking of the sternum confirms the diagnosis. Management involves
urgent surgical exploration and repair.
 A varicocele is a tortuous dilation of the pampiniform plexus surrounding the spermatic cord and testis. It presents as a soft, irregular mass that increases in size with standing and Valsalva. The
diagnosis is confirmed with ultrasound. Initial interventions include scrotal support and simple analgesics. Varicoceles are associated with increased risk for infertility; for patients with testicular
atrophy or changes in semen analysis, surgical venous ligation can improve fertility.
 Fournier gangrene is a life-threatening necrotizing fasciitis that typically affects perineal, scrotal, and lower abdominal skin. Patients generally have rapid-onset swelling, tenderness, and crepitus of the
affected region and significant systemic symptoms (e.g. hypotension, high fever). Rapid surgical intervention is required to prevent death and should not be delayed for imaging.

 Acute epididymitis is associated with posterior testicular pain/swelling, improvement of pain with testicular elevation, and normal cremasteric reflex. Most cases are caused by sexually transmitted
pathogens (e.g. Chlamydia, Neisseria) in patients age < 35 and by colonic pathogens (e.g. Escherichia coli) in those age > 35. Treatment with antibiotics is required.

 Testicular torsion can present with acute testicular pain and swelling after mild trauma. The diagnosis may be made clinically; however, in patients in whom the diagnosis is unclear, a Doppler
ultrasound of the scrotum can confirm the diagnosis and exclude other etiologies.
 Testicular torsion is caused by twisting of the spermatic cord and may result in testicular necrosis and nonviability. Patients have severe scrotal pain and swelling and may report prior episodes that
resolved without intervention. A reactive hydrocele may be visible on ultrasound; heterogeneous echotexture indicates testicular necrosis.
 Testicular torsion presents with abrupt onset of scrotal, inguinal, or abdominal pain, which classically does not resolve with elevation of the testicle. Torsion can occur after exercise, and patients may
have recurring, transient symptoms due to intermittent torsion.
 Urethral stricture is a fibrotic narrowing of the urethra. Common causes include urethral trauma, infection, and radiotherapy. Symptoms include weak or spraying urine flow and incomplete emptying.
Postvoid residual volume is increased. The diagnosis is confirmed on urethrography or cystourethroscopy; treatment includes urethral dilation or surgical urethroplasty.

 Indications for lower extremity amputation include nonrevascularizable limb ischemia, unsalvageable soft-tissue damage, and life-threatening infection (e.g. infected gangrene).
 Due to pre-existing collateral circulation, acute limb ischemia in the setting of chronic peripheral artery disease (PAD) often presents less dramatically than in patients without PAD. Emergency
intervention is still necessary.
 Turner syndrome is due to partial or complete loss of an X chromosome. Common manifestations include musculoskeletal (e.g. short stature, webbed neck), cardiovascular, renal, and ovarian (e.g.
infertility) disorders. Cardiovascular disease, including bicuspid aortic valve and aortic root dilation, places patients at an increased risk for aortic dissection; this risk is further increased during
pregnancy.
 Type A dissections involve the ascending aorta and present with sudden-onset chest or back pain that is severe and described as sharp or tearing. They may be complicated by syncope, stroke,
myocardial infarction, or heart failure and require immediate surgical intervention.
 Cocaine can cause rapid and transient hypertension and is associated with aortic dissection in young patients. There is typically sudden-onset, severe chest or back pain that is sharp or tearing, and
pleural effusion may occur due to hemothorax.
 Ehlers-Danlos syndrome is a collection of genetic connective tissue disorders. It is usually characterized by joint hypermobility/laxity, multiple joint dislocations, tissue fragility, poor wound healing,
and cigarette, paper-like scarring.
 Pain is the most common manifestation of abdominal aortic aneurysm (AAA), and it can vary according to aneurysm location. Proximal AAA tends to cause upper abdominal, flank, or back pain. In
symptomatic, hemodynamically stable patients, the diagnosis is best made by abdominal CT.
 Tricuspid regurgitation is usually secondary (functional), resulting from right ventricular cavity enlargement in the setting of chronic right-sided volume or pressure overload. A prominent V wave in
jugular venous pulsation is highly specific for tricuspid regurgitation.
 A regurgitant murmur over a prosthetic valve suggests prosthetic valve dysfunction (PVD) in the form of a paravalvular leak or transvalvular regurgitation. PVD can lead to serious complications (e.g.
heart failure) and should be promptly evaluated with echocardiography.
 Ludwig angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. Airway obstruction can occur due to displacement of the tongue posteriorly.
 Acute mitral regurgitation results in sudden-onset large-volume backflow of blood from the left ventricle to the left atrium. Neither chamber has time for compensatory dilation, leading to a rapid
increase in left ventricular end-diastolic pressure and left atrial pressure, resulting in pulmonary edema. Although forward blood flow is reduced, left ventricular ejection fraction is normal or
hyperdynamic due to a large amount of stroke volume flowing backward into the left atrium through the low-resistance regurgitant pathway.
 Timely surgical repair is the best treatment for chronic severe mitral regurgitation (MR) of primary etiology. The measured left ventricular ejection fraction (LVEF) significantly overestimates the
effective LVEF in patients with severe MR; therefore, surgery is indicated for both symptomatic and asymptomatic patients with LVEF < 60%.
 In patients with severe aortic stenosis, surgical aortic valve replacement is indicated in all symptomatic patients. It is also indicated in asymptomatic patients with left ventricular ejection fraction <
 50% and those undergoing other cardiac surgery.
 Pyogenic liver abscess typically presents with fevers, right upper quadrant pain, leukocytosis, and altered liver function tests. It can result from direct spread from the biliary tract or from
hematogenous seeding of distal infection, particularly those involving the portal system (e.g. diverticulitis). Diagnosis requires abdominal imaging, and management includes blood cultures, antibiotics,
aspiration, and drainage.
 Patients with a complete small bowel obstruction (e.g. obstipation, no air in the rectum on abdominal x-ray) require nasogastric tube insertion for gastric decompression plus emergency laparotomy
due to the high risk of life-threatening complications (e.g. bowel ischemia, perforation).
 Incisional hernias develop due to fascial closure breakdown and may have a delayed presentation (months-years). Patients typically have a slowly enlarging abdominal mass (i.e. protruding abdominal
contents) that is palpable while supine and enlarges with the Valsalva maneuver.
 Rectus sheath hematomas are characterized by acute abdominal pain with a palpable abdominal wall mass, often associated with anemia and leukocytosis. They usually occur due to rupture of the
inferior epigastric artery from blunt trauma or forceful abdominal contractions (e.g. severe coughing), particularly in those receiving anticoagulation therapy.
 Hiatal hernia is a common disorder that occurs when the contents of the abdominal cavity herniate through the diaphragm into the thoracic cavity at the esophageal hiatus. Plain radiography typically
reveals a retrocardiac opacity (often with an air/fluid level) within the thoracic cavity. Asymptomatic sliding hiatal hernias do not require further workup or intervention whereas patients with
gastroesophageal reflux disease should be medically managed.
 Paraesophageal hiatal hernias occur when the gastric fundus migrates into the thoracic cavity; large defects can result in herniation of the surrounding stomach and intra-abdominal organs.
Manifestations include nausea and vomiting, postprandial fullness, dysphagia, and epigastric and/or chest pain. Chest imaging typically reveals a retrocardiac air-fluid level within the thoracic cavity.

 Urologic consultation is advised for ureterolithiasis associated with urosepsis, anuria, acute kidney injury, or refractory pain. Consultation is also warranted for large kidney stones (> 10 mm in
diameter) that are unlikely to pass without additional intervention (e.g. lithotripsy). Most stones < 5 mm pass spontaneously, and α blockers (e.g. tamsulosin) can be used to facilitate passage (especially
for intermediate-sized stones 6-10 mm).
 Magnesium ammonium phosphate (struvite) causes large kidney stones in patients who have recurrent upper urinary tract infection with urease-producing organisms (e.g. Proteus, Klebsiella).
Antibiotics alone do not eliminate struvite stones, which can harbor bacteria, leading to further infection. Stone removal is usually required.
 Transfusion-related acute lung injury is a potentially fatal transfusion reaction, presenting with acute dyspnea and hypoxia, bilateral pulmonary infiltrates, and possible hypotension. Management
involves transfusion cessation and respiratory supportive care.
 Excess urinary excretion of uric acid and low urine pH can lead to supersaturation of urine and the formation of uric acid stones. Risk factors include gout, obesity, diabetes mellitus/metabolic
syndrome, chronic diarrhea (due to acidification of the urine), and increased systemic uric acid production. Alkalization of the urine with potassium citrate effectively dissolves the stones.

 Chronic osteomyelitis may lead to fracture nonunion. Common symptoms include intermittent pain and swelling and sinus tract formation. Open bone biopsy is recommended for microbiologic
assessment, and treatment requires surgical debridement of the infected and necrotic bone.
 Paget disease of bone is associated with increased bone remodeling, which dramatically increases the risk of osteosarcoma. Most cases present with pain, soft tissue swelling, and hallmark radiographic
findings (e.g. destructive bone lesion, sunburst periosteal reaction, Codman triangle).
 Osteosarcoma is a primary bone tumor that is often associated with inherited genetic mutations to the RB1 gene, which causes retinoblastoma, and the TP53 gene, which is linked to Li-Fraumeni
syndrome.
 Sudden, forceful contraction of the quadriceps muscle can cause rupture of the quadriceps-patellar tendon complex. Symptoms include an audible pop, rapid swelling, and inability to actively extend the
knee against gravity. In tears of the quadriceps tendon (proximal to the patella) the patella rides low, with a palpable defect above the patella.
 Fat embolism syndrome can occur following fracture of large, marrow-containing bones (e.g. femur, pelvis). Patients classically have the triad of respiratory distress, neurologic dysfunction, and a
petechial rash; however, the rash is present in less than half of cases.
 Compartment syndrome is caused by increased pressure within an enclosed fascial space that limits perfusion. Common causes include fracture, crush injury, severe burns, and arterial reperfusion
procedures; patients who are on anticoagulation or have a bleeding diathesis are at increased risk. Clinical features include pain, paresthesias, loss of sensation, and motor weakness. Diagnosis is
confirmed by measuring compartment pressures.
 Malignant hyperthermia is a genetic disorder associated with sudden-onset tachypnea, tachycardia, myoglobinuria, and masseter/generalized muscle rigidity following exposure to succinylcholine or a
 volatile anesthetic. Most cases arise during or shortly after induction, but symptoms are sometimes delayed until just after anesthesia cessation.
 Management of osteoarthritis of the knee should include weight loss, regular activity, and exercises to strengthen the quadriceps muscle. Simple analgesics may also be helpful. If conservative
management is inadequate, injectable glucocorticoids may relieve symptoms. Total knee arthroplasty is indicated for those who fail less aggressive measures.
 A keratoacanthoma presents as a rapidly growing nodule with ulceration and a central keratin plug. It frequently regresses and may resolve spontaneously over several months. Although
keratoacanthomas often have a benign course, some lesions may progress to invasive squamous cell carcinoma.
 Slipped capital femoral epiphysis is most common in obese adolescents and occurs when the proximal femur is displaced relative to the epiphysis along the growth plate. Knee pain may be the only
presenting symptom. Supportive examination findings include limited hip flexion and internal rotation.
 Slipped capital femoral epiphysis occurs when excessive shearing at the proximal femoral physis weakens the growth plate, causing displacement of the proximal femur diaphysis. Patients are
classically obese adolescents with chronic, dull pain along the thigh or knee that worsens with activity.
 Delirium tremens is a late manifestation of alcohol withdrawal that is characterized by delirium, hyperthermia, hypertension, and tachycardia 48-96 hours after the last drink. Delirium tremens is
associated with a mortality rate of 5% and requires aggressive intensive care unit-level supportive management in addition to benzodiazepine therapy.
 Pediatric acute osteomyelitis is most commonly caused by hematogenous spread of bacteria to the metaphysis of long bones. Patients have fever, refusal to bear weight, and point tenderness over the
affected bone.
 Transfusion-related acute lung injury typically occurs within minutes or a few hours of blood product transfusion. It manifests with acute hypoxemic respiratory failure and bilateral pulmonary
infiltrates. In contrast to patients with transfusion-associated circulatory overload, those with TRALI typically have normal brain natriuretic peptide and no jugular venous distension.

 Intracerebral hemorrhage (ICH) typically presents with progressive headache, nausea/vomiting, and altered mental status over a period of minutes to hours. ICH in young patients is commonly due to
arteriovenous malformation, which may also present with recurrent headache, seizure, or focal neurologic deficits.
 Basal cell carcinoma (BCC) rarely metastasizes but can be locally invasive. Nodular BCC on the trunk or extremities is typically managed with surgical excisional biopsy with narrow (3-5 mm) margins.
For the face and other delicate or cosmetically sensitive areas, Mohs micrographic surgery (sequential removal of thin skin layers with microscopic inspection) is more often performed.

 Burn victims frequently develop intravascular volume depletion and require aggressive resuscitation with crystalloid solutions. Lactated Ringer solution, a balanced fluid, is preferred because it
contains near-physiologic levels of electrolytes and includes a buffer that helps correct acidosis and maintain normal blood pH. Normal saline is associated with the development of hyperchloremic
metabolic acidosis.
 Initial management of osteoarthritis of the knee includes weight loss, regular moderate activity, and topical or oral nonsteroidal anti-inflammatory drugs. In addition, exercises to strengthen the
quadriceps muscles can reduce abnormal loading on the joint and protect the articular cartilage from further stress.
 Wound botulism occurs when Clostridium botulinum spores contaminate a puncture injury (e.g. intravenous needle), germinate, and generate neurotoxin in vivo. Manifestations include symmetric,
descending neurologic deficits (e.g. cranial nerve palsy), respiratory compromise, and autonomic dysfunction. In contrast to foodborne and infant botulism, fever and leukocytosis may be present.
Urgent treatment with equine botulinum antitoxin is required and should not be delayed for diagnostic evaluation.
 Mild ulcerative colitis (UC) is defined as < 4 bowel movements a day, intermittent hematochezia, normal inflammatory markers, and no anemia. First-line treatment is with 5-aminosalicylic acid
medications; suppositories or enemas are preferred in patients with UC limited to the rectosigmoid, whereas oral therapy is used for more extensive disease.
 Lung abscess is common in patients with periods of impaired consciousness (e.g. alcohol/drug abuse, seizure disorder) or swallowing dysfunction (e.g. Parkinson disease). It usually presents with
indolent systemic symptoms and cough productive of foul-smelling sputum. Chest x-ray usually reveals a cavitary infiltrate in a dependent portion of the lung.

 Osteoarthritis of the hip is characterized by chronic pain in the groin, buttock, or lateral hip that is worse with activity and weight bearing. Examination often shows decreased rotational range of
motion. X-ray reveals loss of the normal joint space, periarticular osteophytes, and sclerosis of the acetabular surface.
 Erythema nodosum presents with tender, nonpruritic, erythematous, or violaceous nodules measuring 2-3 cm and usually located on the shins. It has a strong association with inflammatory bowel
disease (IBD), especially Crohn disease, and its presence correlates with the degree of IBD activity.
 All pheochromocytomas should undergo surgical resection, which is a high-risk procedure due to the potential for intraoperative catecholamine surges and related complications. To reduce this risk,
patients should initiate preoperative α-adrenergic blockade 7-14 days prior to surgery, followed by β-adrenergic blockade 2-3 days prior to surgery. β-blocker therapy should never be given in the
 absence of α blockade due to the risk of precipitating hypertensive crisis.
 Plantar fasciitis presents with pain at the sole of the foot that is worse with prolonged weight bearing or with the first steps of the day. The pain may be reproduced by palpation of the insertion of the
aponeurosis on the calcaneus with dorsiflexion of the toes. X-ray may show calcifications in the proximal fascia (heel spurs), but this is neither sensitive nor specific.

 Patellar dislocation usually occurs after quick, lateral movements on a flexed knee. Lateral dislocation is most common. Risk factors include age < 20, joint laxity, lower extremity malalignment, and
patellar subluxation. Examination shows reduced range of motion and lateral displacement of the patella out of the trochlea.
 Management of hidradenitis suppurativa initially involves topical or oral antibiotics, depending on the severity. For severe or refractory disease, tumor necrosis factor-α inhibitors, oral retinoids, and
surgical excision may be warranted.
 Hidradenitis suppurativa is a chronic, relapsing condition characterized by inflamed nodules, subcutaneous abscesses, scarring, and sinus tract formation in intertriginous areas. Treatment includes a
prolonged course of topical or systemic antibiotics.
 The kidneys play a role in the compensation for primary metabolic acidosis via increased HCO3 reabsorption and H excretion. The increased HCO3 reabsorption leads to increased urinary chloride (Cl)
excretion. Most of the excreted H is in the form of ammonium (NH4) or the titratable acid, dihydrogen phosphate (H2PO4).
 Osteoporosis in a young or middle-aged man suggests a secondary cause. Bone loss is common in celiac disease due to malabsorption of vitamin D. Manifestations may include asymptomatic
osteopenia/osteoporosis or osteomalacia with bone pain, muscle weakness, and impaired ambulation.
 Benzodiazepine withdrawal may be characterized by agitation, tremors, perceptual changes, psychosis, elevated vital signs, delirium, and seizures.
 Scurvy (vitamin C deficiency) typically occurs in the setting of severe malnutrition due to alcoholism, drug abuse, or psychiatric illness. Common manifestations include prominent cutaneous findings
(e.g. follicular hyperkeratosis, perifollicular hemorrhage, ecchymosis, petechiae), gingivitis (e.g. recessed gums that bleed easily, dental caries), and impaired wound healing. Diagnosis is made with
plasma or leukocyte vitamin C levels.
 Hyponatremia can cause cellular swelling and cerebral edema. Symptoms reflect elevated intracranial pressure; mild/moderate symptoms include headache, nausea, and confusion, whereas severe
symptoms include seizure, coma, and respiratory arrest. Acute hyponatremia (< 48 hr duration) is poorly tolerated, and patients are at elevated risk of brain herniation; therefore, patients with any
symptoms should receive hypertonic 3% saline.
 Acquired methemoglobinemia results from the oxidization of iron in hemoglobin, which is most commonly due to topical anesthetic agents or dapsone. It presents with hypoxia, a characteristic pulse
oximetry reading of ~85%, and a large oxygen saturation gap.
 Cardiac catheterization in patients with cardiac tamponade typically reveals elevated and equilibrated intracardiac diastolic pressures. Urgent echocardiography should be performed in patients with
suspected cardiac tamponade for definitive diagnosis and management.
 Pulmonic valve stenosis usually occurs as a congenital defect and can often remain asymptomatic until adulthood. Cardiac auscultation reveals an ejection click, followed by a crescendo-decrescendo
systolic murmur over the left second intercostal space and widened splitting of S2.
 Angiosarcoma is a malignant tumor derived from the lining of blood vessels and lymphatics. Patients who have received localized radiation therapy for cancer treatment (e.g. breast cancer) are at risk
of developing secondary angiosarcoma of the skin. Breast cancer survivors with chronic lymphedema are also at risk.
 Transvenous lead placement through the tricuspid valve can cause severe tricuspid regurgitation due to direct valve leaflet damage or inadequate leaflet coaptation. This complication should be
suspected in patients presenting with right-sided heart failure following implantable pacemaker or cardioverter-defibrillator placement.
 Occlusion of an anal crypt gland can lead to a bacterial infection and perianal abscess formation. Perianal abscesses often present as tender, fluctuant, erythematous masses with fever and progressively
worsening pain. Anoreceptive intercourse and chronic constipation are among the risk factors for perianal abscess development.
 Patients who undergo renal transplantations are at risk for cytomegalovirus reactivation with viremia and/or end-organ disease. Gastrointestinal manifestations are common and include abdominal
pain, vomiting, bloody diarrhea, and endoscopic evidence of multiple, large, shallow ulcers. Biopsy is the gold standard for diagnosis of tissue-invasive disease.

 Patients who receive a laparoscopic appendectomy are at much greater risk for intra-abdominal abscess than those receiving laparotomy. Intra-abdominal abscess should be suspected when fever and
abdominal symptoms (e.g. pain, vomiting) return several days after an abdominal operation.
 Nasopharyngeal carcinoma is a tumor associated with Epstein-Barr virus reactivation that most commonly affects individuals living in southern China. Manifestations are due to nasopharyngeal
obstruction or invasion of adjacent tissues and include nasal congestion with epistaxis, headache, diplopia, cranial nerve deficits (e.g. facial numbness), and otitis media. Early metastasis to the cervical
 lymph nodes is common.
 Ventricular aneurysm occurs as a late complication (e.g. several months) following transmural myocardial infarction, and is suggested by ECG demonstrating persistent ST-segment elevation with deep
Q waves. Patients most commonly have progressive left ventricular enlargement and dyskinetic wall motion leading to heart failure.
 Testicular germ cell tumors are common in young men and manifest primarily with a painless testicular mass. However, a minority of patients may have symptoms of metastatic disease, including low
back pain (retroperitoneal lymphadenopathy) and dyspnea/cough (pulmonary nodules). Testicular examination showing a firm, ovoid testicular nodule should prompt a scrotal ultrasound and tumor
markers to support the diagnosis.
 Patients with perioperative myocardial infarction may lack chest pain and can develop cardiogenic shock due to left ventricular systolic dysfunction. Pulmonary artery catheterization reveals a low
cardiac index and elevated pulmonary capillary wedge pressure.
 An arteriovenous fistula can develop as a complication of vascular access during cardiac catheterization. Patients typically have mild localized pain and swelling and a continuous bruit accompanied by
a palpable thrill over the fistula site.
 The most common cause of cervical myelopathy in older adults is spondylosis, a degenerative spine disease that causes canal narrowing with spinal cord compression. Manifestations include
progressive gait instability and weakness in the extremities. Examination usually shows lower motor neuron signs at the level of the lesion (arms) and upper neuron signs below the level of the lesion
(legs).
 Cauda equina syndrome is most common following a large lumbosacral disc herniation. Suspicion should be raised in those with severe low back pain radiating into one or both legs with accompanying
saddle anesthesia (sensory change in the genitals/perineum) and/or bladder, bowel, or sexual dysfunction. An urgent lumbosacral spine MRI is required for diagnosis, followed by surgical
decompression.
 Delirium tremens is a severe manifestation of alcohol withdrawal usually presenting 48-96 hours after the last drink. It is defined by autonomic excitation, agitation, tremor, and altered sensorium.

 Vibrio vulnificus is a free-living marine bacterium that causes food-borne illness (through oysters) and wound infections. Wound infections may be mild, but some patients develop rapid-onset, severe,
necrotizing fasciitis with hemorrhagic bullous lesions and septic shock. Patients with liver disease such as cirrhosis, viral hepatitis, and hereditary hemochromatosis are at particularly high risk.

 Candidemia is common in patients hospitalized in the intensive care unit with intravascular catheters. Manifestations include fever, sepsis, and/or multiorgan failure. Blood cultures or biopsy are
usually required for diagnosis. A positive blood culture for Candida should never be considered a contaminant.
 A ruptured ovarian cyst can cause hemoperitoneum, which presents with abdominal rigidity, rebound, guarding, and referred shoulder pain. Hemodynamically unstable patients with peritoneal signs
require emergency surgery.
 Palpable breast masses in women age < 30 are initially evaluated with breast ultrasound due to increased density of breast tissue. Solid or complex-appearing masses on ultrasound may require
additional imaging (e.g. mammography) or biopsy to exclude malignancy.
 An isolated, firm, well circumscribed, and mobile breast mass in women age < 30 is commonly a benign fibroadenoma.
 Breast abscesses present with a unilateral fluctuant, tender, palpable breast mass with fever, surrounding erythema/pain, and associated axillary lymphadenopathy. Management includes drainage (e.g.
needle aspiration) and empiric antibiotics (e.g. dicloxacillin, cephalexin).
 Patellofemoral pain syndrome is a common cause of anterior knee pain in young women. It is usually due to chronic overuse or malalignment. The pain is provoked by maneuvers (e.g. squatting) that
involve contraction of the quadriceps with the knee in flexion. Initial management includes activity modification, nonsteroidal anti-inflammatory drugs, and stretching and strengthening exercises.

 The presence of an extra-axial well-circumscribed dural-based mass that is partially calcified on neuroimaging is strongly suggestive of a meningioma. Meningiomas are considered benign primary
brain tumors; however, they can present with headache, seizure, and focal neurologic deficits due to mass effect. In such cases, complete surgical resection is recommended.

 Prepatellar bursitis is characterized by anterior knee pain, tenderness, erythema, and localized swelling and is common in occupations requiring repetitive kneeling. Bursal fluid analysis should be
performed to exclude infection.
 Sialadenosis is a benign, noninflammatory enlargement of the salivary glands, often caused by chronic alcohol use.
 Lemierre syndrome (LS) is caused by an oropharyngeal infection, usually pharyngitis or tonsillitis, that leads to local invasion of the lateral pharyngeal wall and infection of the neurovascular bundle,
 especially the internal jugular vein. Thrombosis of this vein allows dissemination of septic emboli to distal sites. Fusobacterium necrophorum is the most frequent bacterial cause of LS.

 Aspiration pneumonitis is an acute lung injury secondary to a chemical burn from aspirated sterile gastric contents. In contrast, aspiration pneumonia is an infectious disease caused by aspiration of
infected oropharyngeal secretions.
 α1 receptor blockers such as tamsulosin act on the distal ureter, lowering muscle tone and reducing reflex ureteral spasm secondary to stone impaction. These agents facilitate stone passage and reduce
the need for analgesics.
 Acute type A aortic dissection can extend into the pericardial space, causing hemopericardium and rapidly progressing to cardiac tamponade and cardiogenic shock. CT angiography is the initial
diagnostic study of choice in hemodynamically stable patients and reveals an intimal flap separating the true and false lumens in the ascending or descending aorta.

 Thyroid storm is a life-threatening thyrotoxicosis often triggered by thyroid or non-thyroid surgery, trauma, infection, iodine contrast, or childbirth. It is characterized by tachycardia, hypertension,
cardiac arrhythmias, high fever, tremor, altered mentation, and lid lag.
 Epidermal inclusion cyst is a benign nodule containing squamous epithelium that produces keratin. It presents as a dome-shaped, firm, freely movable cyst or nodule with a small central punctum. The
lesion can remain stable or gradually increase in size but may produce a cheesy white discharge; it usually resolves spontaneously.
 Pyoderma gangrenosum causes a rapidly progressive and painful ulcer with a purulent base and violaceous border. Most patients have associated systemic disease (e.g. inflammatory bowel disease).
Diagnosis is made clinically after excluding other etiologies, usually with skin biopsy.
 Hidradenitis suppurativa is a chronic, relapsing condition characterized by inflammatory occlusion of folliculopilosebaceous units. It most commonly occurs in intertriginous skin areas and presents as
painful nodules that can progress to abscesses that open to the skin surface. Complications include sinus tracts, comedones, and scarring.
 Prosthetic joint infections can be acquired by perioperative contamination or by extension from an overlying wound infection. Infections due to virulent organisms (e.g. Staphylococcus aureus) present
within the first 3 months with acute pain, fever, and local signs of infection. Infections due to less virulent organisms (e.g. coagulase-negative staphylococci) have a delayed onset and present with
chronic pain, implant loosening, gait impairment, or sinus tract formation.
 Cystoscopy is recommended for patients with gross hematuria or with microscopic hematuria and other risk factors for bladder cancer. Risk factors for bladder cancer include cigarette smoking, certain
occupational exposures (e.g. painters, metal workers), chronic cystitis, iatrogenic causes (e.g. cyclophosphamide), and pelvic radiation exposure.
 Anterior cruciate ligament injuries are common in sports requiring rapid direction changes or twisting movements of the lower extremity. They usually present with rapid onset of pain and swelling
with hemarthrosis. Examination findings include laxity of anterior motion of the tibia relative to the femur.
 Hypoparathyroidism (parathyroid hormone deficiency) is characterized by low calcium and elevated phosphorus levels in the presence of normal renal function. Causes of hypoparathyroidism include
postsurgical, autoimmune parathyroid destruction, and defective calcium-sensing receptor. Hypocalcemia is the most common complication seen post thyroidectomy.

 Bariatric surgery is indicated for patients with a BMI > 40 kg/m2 or those with a BMI > 35 kg/m2 and additional weight-related comorbidity. Weight-loss medication is indicated for patients with a BMI
> 30 kg/m2 or those with a BMI 25-29.9 kg/m2 and weight-related complications. Medication failure is not required for patients to qualify for bariatric surgery; both interventions may be pursued
concurrently.
 Bacterial infection of a chronic diabetic foot ulcer may be minimally symptomatic and requires specific assessment. When the bone can be palpated with a probe, the risk of underlying osteomyelitis is
greatly increased. Biopsy and culture of affected bone is critical to confirming the diagnosis and guiding management.
 Heparin-induced thrombocytopenia (HIT) should be suspected in patients on heparin who develop thrombocytopenia or thrombotic complications. In patients receiving heparin subcutaneously (e.g.
enoxaparin), a classic thrombotic complication is skin necrosis at the abdominal injection site. HIT is treated by discontinuing all heparin products and initiating an alternate anticoagulant (e.g.
argatroban, fondaparinux).
 Initial management in hemoptysis involves establishing adequate patent airway, maintaining adequate ventilation and gas exchange, and ensuring hemodynamic stability. Patients should be placed
with the bleeding lung in the dependent position (lateral position). Bronchoscopy is the procedure of choice to identify the site and attempt early therapeutic intervention.

 Patients with hemoptysis and high clinical suspicion for pulmonary tuberculosis should be placed in respiratory isolation to prevent the spread of infection before further diagnostic evaluation and
treatment.
 Deep-breathing exercises and incentive spirometry can help prevent postoperative atelectasis. Adequate postoperative pain control can also help by minimizing pain-induced restriction of chest
expansion during respiration.
 Postoperative atelectasis is common and typically manifests 2-5 days following surgery. Hypoxemia results from localized intrapulmonary shunting and ventilation-perfusion mismatch, and
hyperventilation leads to primary respiratory alkalosis with low PaCO2 and high pH.
 Patients with blunt abdominal trauma should be assessed for intra-abdominal injury, beginning with Focused Assessment with Sonography for Trauma (FAST), a rapid, noninvasive examination that
can be performed at the bedside.
 Steatorrhea occurs due to fat malabsorption and generally presents with voluminous, greasy, and foul-smelling stools that are difficult to flush. It is commonly caused by pancreatic exocrine
insufficiency (loss of digestive enzymes) in patients with chronic alcoholic pancreatitis. Alcohol cessation and pancreatic enzyme supplementation can improve symptoms in such patients.

 Otosclerosis causes fixation of the stapes, which results in conductive hearing loss. It often presents in young women and may progress during pregnancy.
 Total parenteral nutrition causes gallbladder stasis and predisposes to gallstone formation and bile sludging, both of which may lead to cholecystitis.
 Neurogenic arthropathy (Charcot joint) is due to abnormal lower extremity sensation and proprioception, leading to altered weight bearing, mechanical stresses, and recurrent trauma. It is most
common in patients with diabetic neuropathy. It can cause impaired ambulation, but pain is typically mild. Examination shows deformity of the foot, and x-ray reveals bony destruction, osteophyte
formation, and loss of joint spaces.
 The management of small to moderately sized (i.e. 3 cm to 5.5 cm) abdominal aortic aneurysms (AAAs) involves lifestyle modification, with smoking cessation as the best intervention to minimize AAA
progression.
 Graves ophthalmopathy is characterized by ocular irritation, impaired extraocular motion, and proptosis. It is caused by T cell activation and stimulation of orbital fibroblasts by thyrotropin (TSH)
receptor autoantibodies, leading to expansion of orbital tissues.
 Splenic abscess usually presents with the classic triad of fever, leukocytosis, and left upper quadrant abdominal pain. Patients can also develop left-sided pleuritic chest pain, left pleural effusion, and
splenomegaly. Risk factors for splenic abscess include hematogenous spread, immunosuppression, intravenous drug use, trauma, and hemoglobinopathies. Infective endocarditis is most commonly
associated with splenic abscess.
 Patients with postoperative urinary retention often have suprapubic discomfort and fullness, along with hypertension and tachycardia (i.e. sympathetic stimulation); portable bladder ultrasound can
confirm the diagnosis.
 Syringomyelia is characterized by a fluid-filled cavity (syrinx) in the spinal cord that compresses the surrounding tissue. It is most commonly seen in patients with Arnold-Chiari type 1 malformations
or spinal cord injury. It typically affects the crossing fibers of the spinothalamic tract in the ventral white commissure (loss of pain and temperature sensation with preserved touch, vibration, and
proprioception) and may affect motor fibers in the ventral horns (flaccid paralysis). The diagnosis is confirmed by MRI, and management usually requires surgical intervention.

 Anticoagulation with warfarin places patients at risk for hemorrhage. Retroperitoneal hematoma may occur even without a supratherapeutic INR. Back pain and signs and symptoms of hemodynamic
compromise should raise suspicion for retroperitoneal hematoma.
 Patients with trauma from rapid deceleration are at risk for blunt thoracic aortic injury (BTAI). All patients with blunt chest trauma require a chest x-ray after initial trauma survey. Chest x-ray findings
concerning for BTAI include widened mediastinum, abnormal aortic contour, and/or left-sided effusion (hemothorax).
 Atelectasis is a common postoperative complication that results from shallow breathing and weak cough due to pain. It is most common on postoperative days 2 and 3 following abdominal or
thoracoabdominal surgery. Adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry decrease the incidence of postoperative atelectasis.

 Acute cholecystitis presents with right upper quadrant pain, fever, and leukocytosis. Patients with acute cholecystitis should be treated with laparoscopic cholecystectomy within 72 hours.

 Normal pressure hydrocephalus is characterized by abnormal gait, urinary incontinence, and cognitive impairment; however, only gait dysfunction is required for diagnosis. Neuroimaging
demonstrates ventriculomegaly out of proportion to cerebral atrophy. The diagnosis is confirmed with high-volume lumbar puncture demonstrating improvement of gait with cerebrospinal fluid
removal. Definitive treatment is ventricular shunt placement.
 Pilonidal disease most frequently affects males age 15-30, particularly obese individuals, those with sedentary lifestyles or occupations, and those with deep gluteal clefts. The most common presenting
 symptoms include a painful, fluctuant mass 4-5 cm cephalad to the anus in the intergluteal region with associated mucoid, purulent, or bloody drainage.

 Following splenectomy, patients are at increased risk for sepsis due to encapsulated organisms, including Streptococcus pneumoniae, Neissseria meningitidis, and Haemophilus influenzae. Vaccinations
against each of these organisms should be administered either > 14 days before scheduled splenectomy or > 14 days after splenectomy.
 Acute urinary retention (AUR) is common in elderly men, especially in the setting of underlying benign prostatic hyperplasia. The risk of AUR is further increased during the postoperative period.
Diagnosis is made using bladder ultrasound.
 Multiple liver masses are much more likely to be the result of metastatic disease than infectious causes or primary liver malignancy. Primary tumors of the gastrointestinal tract, lung, and breast are the
most common diseases causing liver metastases.
 Prolonged pressure over a bony prominence can cause ischemic necrosis of overlying tissues, leading to a pressure (decubitus) ulcer. Risk factors include impaired mobility, malnutrition, abnormal
mental status, decreased skin perfusion, and reduced sensation.
 Prolonged postoperative ileus is characterized by nausea, abdominal distension, obstipation, and hypoactive bowel sounds that persist postoperatively. Opiates compound this problem by decreasing
gastrointestinal motility.
 Ischemia-reperfusion syndrome is a form of compartment syndrome that occurs following reperfusion of an acutely ischemic limb. Symptoms include severe pain that is worsened on passive range of
motion, paresthesias, and sensory and motor deficits. The diagnosis is confirmed by measuring compartment pressures. Definitive management includes urgent fasciotomy.

 Intravascular volume depletion is a common cause of prerenal acute kidney injury (AKI). Patients typically have an elevated blood urea nitrogen/creatinine ratio (> 20:1), oliguria, and unremarkable
urine sediment. Administration of intravenous fluid restores renal perfusion and corrects the AKI.
 Rotator cuff tears cause pain and weakness at the shoulder. With the arm abducted over the head, the patient may be unable to lower the arm smoothly (drop arm test). An MRI scan can confirm the
diagnosis.
 Acute shoulder pain after forceful abduction and external rotation at the glenohumeral joint suggests an anterior shoulder dislocation, which may cause injury to the axillary nerve. The axillary nerve
innervates the teres minor and the deltoid, and injury can result in weakened shoulder abduction and decreased sensation over the lateral shoulder.
 Patients on warfarin who require urgent surgery with a high risk of bleeding, or those who are experiencing significant hemorrhage, should receive prothrombin complex concentrate (PCC) and
intravenous vitamin K. If PCC is unavailable, fresh frozen plasma can be given.
 Parotid masses are typically benign. Cranial nerve dysfunction (facial droop, facial numbness) increases concern for malignancy.
 In burn patients, clinical indicators of thermal inhalation injury to the upper airway and/or smoke inhalation injury to the lungs include burns on the face, singeing of the eyebrows, oropharyngeal
inflammation/blistering, oropharyngeal carbon deposits, carbonaceous sputum, stridor, carboxyhemoglobin level > 10%, or history of confinement in a burning building. The presence of > 1 of these
indicators warrants early intubation to prevent upper airway obstruction by edema.
 A popliteal (Baker) cyst is due to extrusion of synovial fluid from the knee joint into the gastrocnemius or semimembranosus bursa, and is most common in patients with underlying arthritis. Popliteal
cysts may present as a painless bulge in the popliteal space, but cyst rupture can cause acute pain in the calf.
 Bacterial pneumonia commonly causes a pleural effusion. Often the effusion is small, sterile, and resolves with antibiotics (uncomplicated). However, if bacteria persistently cross into the pleural space,
a complicated parapneumonic effusion or empyema can develop. Empyemas have frank pus or bacteria (by Gram stain) in the pleural space and require drainage (chest tube) in addition to prolonged
antibiotics.
 Osteonecrosis (avascular necrosis) of the femoral head is a common complication of glucocorticoid use. It is characterized by progressive hip pain, leading to reduced range of motion and joint
instability. X-rays will often be normal, and MRI is a more sensitive test.
 Fracture of > 3 contiguous ribs in > 2 locations can result in flail chest, with paradoxical movement of the fractured flail segment during respiration. Flail chest can cause hypoxia due to ineffective
ventilation, pulmonary contusion, and atelectasis.
 Flail chest should be suspected in patients with respiratory distress and multiple rib fractures. Flail chest increases work of breathing and may injure the underlying lung, often leading to respiratory
failure.
 Pancreatic cancer classically presents insidiously with a combination of constant and gnawing epigastric pain that is frequently worse at night, anorexia with weight loss, and jaundice due to
extrahepatic biliary obstruction. A peptic duodenal ulcer typically causes periodic epigastric pain relieved by meals.
 Blunt lower abdominal trauma can rupture the bladder at its weakest part (i.e. dome), spilling urine into the intraperitoneal cavity. Common clinical findings include hematuria, suprapubic tenderness,
difficulty voiding, and associated pelvic fracture.
 Acute cardiac tamponade is due to rapid accumulation of a small amount of fluid within a stiff pericardium, causing a sudden rise in intrapericardial pressure. Unlike subacute tamponade, the cardiac
silhouette can be normal on chest x-ray.
 Blunt abdominal trauma can cause gastrointestinal perforation in an acute or a delayed (e.g. progression of bowel contusion, mesenteric ischemia) fashion. Confirmation of perforation (e.g.
intraperitoneal free air on imaging) should prompt emergent surgical exploration.
 Patients with trauma following rapid deceleration are at risk for blunt thoracic aortic injury. Signs may include upper extremity hypertension with lower extremity hypotension (pseudocoarctation)
and/or a hoarse voice (left recurrent laryngeal nerve stretching).
 Rapid hematoma (e.g. epidural) expansion after head injury can abruptly increase intracranial pressure, compress the temporal lobe, and cause uncal herniation. The first sign is typically an ipsilateral
fixed and dilated pupil due to oculomotor nerve (CN III) compression. Contralateral hemiparesis is often seen due to direct compression of the ipsilateral cerebral peduncle.

 Positive-pressure mechanical ventilation causes an acute increase in intrathoracic pressure. In the setting of decreased central venous pressure (e.g. hypovolemic shock), initiation of mechanical
ventilation can cause acute loss of right ventricular preload, loss of cardiac output, and cardiac arrest.
 Severe burns are often complicated by wound infections and sepsis. Risk is increased with large burns (> 20% body surface area). Gram-positive organisms are common soon after injury; gram-
negative organisms and fungi are more common after 5 days. A change in burn wound appearance or the loss of skin graft is often the first sign of a burn wound infection.

 Greater trochanteric pain syndrome is an overuse syndrome involving the tendons of the gluteus medius and minimus at the greater trochanter. It presents with chronic lateral hip pain that is
worsened with repetitive hip flexion or lying on the affected side. Physical examination shows local tenderness over the greater trochanter.
 Postoperative pulmonary complications are common, particularly in patients with known risk factors. These risk factors include smoking, pre-existing pulmonary disease, age > 50, thoracic or
abdominal surgery, surgery lasting > 3 hours, and poor general health. Postoperative measures such as incentive spirometry and deep breathing exercises are used to prevent such complications and
improve outcomes by promoting lung expansion.
 Suppurative parotitis presents with exquisitely painful swelling of the parotid gland. This postoperative complication can be prevented with adequate fluid hydration and oral hygiene.

 Although shock in the trauma setting is initially assumed to be hypovolemic shock (from hemorrhage), elevated central venous pressure (CVP) is more consistent with obstructive or cardiogenic shock.
Blunt cardiac injury with myocardial dysfunction can cause cardiogenic shock with elevated CVP and refractory hypotension.
 Hypovolemic shock involves an initial decrease in preload and cardiac output followed by a compensatory increase in systemic vascular resistance, heart rate, and ejection fraction. Hypotension,
tachycardia, cold extremities, and evidence of hypovolemia (e.g. decreased jugular venous pressure) should be present.
 Hypovolemic shock in the setting of blunt trauma is concerning for hemorrhage. Decreased breath sounds and dullness to percussion, with contralateral tracheal deviation, is most likely due to a
massive hemothorax.
 Primary spontaneous pneumothorax (PSP) occurs in patients without a history of lung disease and is most common in tall, thin men in their early 20s. Management of small PSP in clinically stable
patients includes observation and supplemental oxygen, which enhances the speed of resorption.
 Blunt thoracic trauma can injure the underlying lung. The resulting alveolar hemorrhage and edema - often worsened by fluid resuscitation - can cause dyspnea, tachypnea, and hypoxemia. Irregular,
nonlobular infiltrates on chest x-ray or CT scan are classic for pulmonary contusion.
 Rapid deceleration can cause blunt thoracic aortic injury (BTAI). Widened mediastinum on chest x-ray should increase suspicion for BTAI and left-sided pleural effusion (hemothorax) may be present
from hemorrhage preceding containment (e.g. hematoma). Strict blood pressure control and emergent surgical intervention are necessary to prevent rebleeding and death.

 Febrile nonhemolytic transfusion reactions occur within 1-6 hours of transfusion initiation and can present in the immediate (within a few hours) postoperative period in patients who receive blood
products intraoperatively. Other causes of immediate postoperative fever include prior infection or trauma, inflammation due to surgery, malignant hyperthermia, and anesthetic medications.

 A varicocele is a dilation of the pampiniform plexus that presents as an irregular scrotal mass that increases in size with Valsalva maneuvers and does not transilluminate.
 Secondary spontaneous pneumothorax should be suspected in patients with underlying lung disease presenting with rapid worsening of respiratory symptoms. Rupture of alveolar blebs is the most
common cause in patients with chronic obstructive lung disease.
 Aortoiliac occlusion (Leriche syndrome) is characterized by the triad of bilateral hip, thigh, and buttock claudication; impotence; and absent or diminished femoral pulses (often with symmetric atrophy
of the bilateral lower extremities due to chronic ischemia).
 Sudden development of limb ischemia in a previously asymptomatic patient is most consistent with embolic arterial occlusion. Most arterial emboli are cardiac in origin.
 Retroperitoneal hematoma can occur as a local vascular complication of cardiac catheterization, and often presents with sudden hemodynamic instability and ipsilateral flank or back pain. Diagnosis is
confirmed with noncontrast CT scan of abdomen and pelvis or abdominal ultrasonography. Treatment is usually supportive with bed rest, intensive monitoring, and intravenous fluids and/or blood
transfusion.
 For patients with blunt abdominal trauma who are hemodynamically unstable, emergent laparotomy is indicated in the presence of peritonitis or intraperitoneal free fluid on Focused Assessment with
Sonography for Trauma (FAST) examination.
 The liver is one of the most commonly injured organs in blunt abdominal trauma. Patients with severe liver laceration causing intra-abdominal hemorrhage may have shock and intraperitoneal free
fluid on Focused Assessment with Sonography for Trauma.
 Ankle-brachial index is a noninvasive test that is highly sensitive and specific for peripheral arterial disease in symptomatic patients. It is the preferred first step to confirm the diagnosis in most cases.

 Major surgery is a significant risk factor for deep venous thrombosis (DVT). At least 3 months of anticoagulation is recommended for provoked DVT. Stable patients can be treated with anticoagulation
as early as 48-72 hours after surgery. Patients started on warfarin must be started on an additional anticoagulant (e.g. heparin) at the same time because warfarin temporarily causes a prothrombotic
state. Low molecular weight heparin is not recommended in end-stage renal disease.
 Gastric outlet obstruction can be caused by many disease processes and is characterized by early satiety, nausea, nonbilious vomiting, and weight loss. In a patient with a history of acid ingestion,
pyloric stricture is the most likely cause.
 Stress fractures of the metatarsals are associated with a sudden increase in activity and are common in athletes and military recruits; the second metatarsal is most commonly injured. Initial treatment
includes rest and simple analgesics. Stress fractures of the fifth metatarsal are at increased risk for nonunion and warrant more aggressive treatment.
 Peptic ulcer disease can be complicated by perforation, revealed as intraperitoneal free air. Emergent surgical exploration is indicated for patients with severe symptoms and a systemic inflammatory
response.
 A pericardial effusion appears as an enlarged, ‘water bottle’-shaped cardiac silhouette on chest x-ray. Physical examination findings of effusion without cardiac tamponade include diminished heart
sounds on auscultation and a maximal apical impulse that is difficult to palpate.
 Biliary colic occurs due to increased intra-gallbladder pressure that is created when the gallbladder contracts against an obstructed cystic duct. The pain is exacerbated by fatty meals, usually lasts less
than 6 hours, and resolves completely between episodes. There is no fever, abdominal tenderness on palpation, or leukocytosis.
 Drugs with anticholinergic properties can cause acute urinary retention by preventing detrusor muscle contraction and urinary sphincter relaxation. The treatment involves urinary catheterization and
discontinuing the medication.
 Succinylcholine is a depolarizing neuromuscular blocker that can cause life-threatening hyperkalemia in patients with a condition leading to upregulation of postsynaptic acetylcholine receptors (e.g.
skeletal muscle trauma, burn injury, stroke). Nondepolarizing neuromuscular blocking agents (e.g. vecuronium, rocuronium) should be used with these patients.

 Cardiac tamponade can occur as a catastrophic complication of acute aortic dissection. It should be suspected in patients with hypotension, tachycardia, distended neck veins, and pulsus paradoxus who
have sudden onset of severe tearing chest pain radiating to the back.
 Acute vertebral compression fracture can be caused by twisting, lifting, or trauma and presents with back pain and vertebral point tenderness. It typically occurs in patients with osteoporosis or other
conditions associated with decreased bone mineral density.
 Tenderness to gentle percussion over the spinous process of the involved vertebra is the most reliable sign for spinal osteomyelitis. Pain is not relieved with rest. Fever and leukocytosis are unreliable
findings. The erythrocyte sedimentation rate is grossly elevated. MRI is the most sensitive diagnostic study. There should be a very high index of suspicion for vertebral osteomyelitis in patients with a
history of injection drug use or recent distant site infection (e.g. urinary tract infection).
 Complete small bowel obstruction usually presents with nausea, vomiting, abdominal bloating, and dilated loops of bowel on abdominal x-ray. Adhesions, typically postoperative, are the most common
 etiology.
 Effort rupture of the esophagus (Boerhaave syndrome) may occur during protracted vomiting. Chest x-ray may show leaked esophageal fluid collecting in the mediastinum (mediastinal widening) or
pleural space (pleural effusion). Pleural fluid analysis may show low pH and very high amylase (> 2500 IU/L). Confirmation with esophagography or CT scan using water-soluble contrast should
prompt emergent surgical consultation.
 Nontender, solitary cervical lymph nodes are concerning for mucosal head and neck squamous cell carcinoma, especially in an adult patient with a smoking history.
 Squamous cell carcinoma is the most common malignancy of the lower lip. Risk factors include sun exposure, fair skin, tobacco use, immunosuppression, and chronic inflammation. Biopsy is
characterized by invasive cords of squamous cells with keratin pearls.
 Cat bites are at high risk of infection due to inoculation of bacteria into deep puncture wounds. Amoxicillin with clavulanate has activity against Pasteurella multocida and oral anaerobes and is the first-
line agent for antibiotic prophylaxis.
 On clinical examination, features of a lesion that suggest melanoma include Asymmetry, Border irregularities, Color variation, Diameter > 6 mm, and Evolution in color, size, or shape.

 Hypercalcemia can occur in prolonged immobilization due to increased osteoclastic activity, especially in individuals with a high baseline rate of bone turnover. Bisphosphonates can reduce this
hypercalcemia and prevent bone loss.
 The femoral nerve is responsible for knee extension and hip flexion and provides sensation to the anterior thigh and medial leg. It is vulnerable to injury from pelvic fracture, hip dislocation, or iliacus
hematoma and can suffer iatrogenic injury during prolonged maintenance of the dorsal lithotomy position (e.g. hip/pelvic surgery, childbirth) or vascular procedures involving the femoral artery or
vein.
 Splenic injury, one of the most common intra-abdominal complications of blunt abdominal trauma (BAT), should be suspected in any patient with BAT and evidence of hemorrhage. Hemodynamically
stable patients with a negative ultrasound evaluation but high-risk features should undergo CT imaging.
 Most patients with acute, uncomplicated low back pain experience spontaneous resolution of their symptoms in the first few weeks. Patients should be advised to continue moderate activity.
Nonsteroidal anti-inflammatory drugs are preferred as initial management.
 Patients with plantar puncture wounds through footwear are at risk for Pseudomonas aeruginosa osteomyelitis.
 Solitary pulmonary nodules < 0.6 cm are unlikely to be malignant, whereas those > 0.8 cm require additional management or surveillance. Nodules that are intermediate or high probability for
malignancy (i.e. > 5% probability) based on clinical factors (e.g. nodule size, patient age, smoking history) should be biopsied or surgically excised.
 Patients who present with appendicitis > 5 days after the onset of symptoms have a high incidence of perforation with abscess formation. They often have a contained abscess. If the patients are
otherwise stable, they may be treated with intravenous hydration, antibiotics, bowel rest, and interval appendectomy.
 Acute knee pain associated with catching or reduced range of motion suggests a meniscal tear. Persistent symptoms in patients with suspected meniscal injury should be evaluated by MRI, and surgical
consultation is advised for significant tears.
 Peripheral artery aneurysm manifests as a pulsatile mass that can compress adjacent structures (nerves, veins), and can result in thrombosis and ischemia. Popliteal and femoral artery aneurysms are
the most common peripheral artery aneurysms. They are frequently associated with abdominal aortic aneurysms.
 Diaphragmatic rupture can have a delayed presentation after blunt thoracoabdominal trauma due to progressive enlargement of the diaphragmatic defect and herniation of abdominal organs into the
thoracic cavity. Chest x-ray may show elevation of the hemidiaphragm or abdominal organs (e.g. stomach) in the thorax.
 High-volume blood transfusion can cause symptomatic hypocalcemia due to chelation of ionized calcium by citrate in transfused blood. Patients with impaired hepatic function are at increased risk due
to decreased clearance of citrate by the liver.
 In patients with hemodynamic instability and signs and symptoms consistent with an abdominal aortic aneurysm (AAA) but without a known history, a focused bedside ultrasound should be
performed. A CT scan is helpful in symptomatic patients who are stable, while those who are unstable with a known history of AAA should undergo emergent repair.

 Thoracic aortic aneurysm repair can cause spinal cord ischemia, especially of the anterior cord. Anterior cord syndrome typically presents with distal, bilateral flaccid paralysis; loss of
pain/temperature and crude touch sensation; and urinary retention.
 Diminished relaxation of the cricopharyngeus muscle during swallowing results in increased intraluminal pressure in the hypopharynx. This may cause the mucosa to herniate, forming a Zenker
(pharyngoesophageal) diverticulum, which presents in patients age > 60 with dysphagia, halitosis, and regurgitation of undigested food.
 Simple renal cysts are almost always benign and do not require further evaluation. Features concerning for malignant renal mass include a multilocular mass, irregular walls, thickened septae, and
contrast enhancement.
 Diabetic foot infections are common in patients with poor glycemic control, neuropathy, and peripheral vascular disease. Most deep, long-standing diabetic wounds are polymicrobial with a mixture of
gram-positive, gram-negative, and anaerobic organisms. Underlying osteomyelitis is common due to contiguous spread from the wound.
 Clean intermittent catheterization is an effective measure for reducing the risk of catheter-associated urinary tract infection in patients with neurogenic bladder.
 In gastric adenocarcinoma, tumor stage at the time of diagnosis determines prognosis and treatment options. A CT scan is the initial staging modality.
 Subdural hematoma results from the rupture of bridging veins, most commonly from head trauma. Risk factors include advanced age and chronic alcoholism (due to brain atrophy), as well as
anticoagulant use. On noncontrast head CT scan, acute subdural hematoma appears as a crescent-shaped hyperdensity that crosses suture lines.
 Even without chest wall fracture, blunt thoracic trauma can cause pulmonary contusion. Tachypnea and hypoxemia are classic symptoms, and imaging often demonstrates patchy, irregular alveolar
infiltrates.
 Vitamin K deficiency is usually due to inadequate dietary intake, intestinal malabsorption, or hepatocellular disease. An acutely ill patient with underlying liver disease can become vitamin K deficient in
7-10 days. Laboratory studies usually show prolonged prothrombin time followed by prolonged partial thromboplastin time.
 Anal fissures present with pain and rectal bleeding on defecation. Treatment includes increased fiber and fluid intake, stool softeners, sitz baths, and topical anesthetics and vasodilators (e.g. nifedipine,
nitroglycerin).
 Zollinger-Ellison syndrome should be suspected in patients with multiple duodenal ulcers refractory to treatment or ulcers distal to the duodenum or associated with chronic diarrhea. In these patients,
inactivation of pancreatic enzymes by increased production of stomach acid may lead to malabsorption.
 Necrotizing surgical infection is characterized by intense pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. Early surgical exploration is
essential.
 Ischemic colitis is characterized by acute abdominal pain and lower gastrointestinal bleeding. It typically follows an episode of hypotension and most commonly affects arterial watershed areas at the
splenic flexure and rectosigmoid junction. CT scan may show a thickened bowel wall. Colonoscopy can confirm the diagnosis.
 Risk factors for Clostridioides (formerly Clostridium) difficile include recent hospitalization, advanced age, and recent antibiotic use. Manifestations can range from mild colitis (i.e. watery diarrhea, low-
grade fever, abdominal pain, leukocytosis) to fulminant colitis with toxic megacolon. Diagnosis is confirmed with stool studies for C. difficile toxin and glutamate dehydrogenase antigen and/or stool
assay for C. difficile exotoxin genes.
 Patients on chronic glucocorticoid therapy often have secondary adrenal insufficiency and can develop adrenal crisis when exposed to an acute stressor (e.g. surgery, illness, trauma). Adrenal crisis
primarily presents with hypotension and shock that is refractory to initial volume resuscitation. Treatment requires intravenous hydrocortisone or dexamethasone in addition to aggressive volume
repletion.
 Complicated parapneumonic effusions and empyemas often present with continued symptoms (fever, pleuritic pain) despite adequate antibiotic coverage for pneumonia. Chest x-ray usually shows
loculation, and thoracentesis reveals fluid that is exudative with low glucose (< 60 mg/dL) and low pH (< 7.2). Most complicated parapneumonic effusions and all empyemas require drainage (e.g. chest
tube) in addition to antibiotics.
 Ventilator-associated pneumonia occurs > 48 hours after intubation and usually presents with fever, purulent secretions, and abnormal chest x-ray. Patients should have lower respiratory tract
sampling (Gram stain and culture) and receive empiric antibiotics.
 Dumping syndrome is a common postgastrectomy complication characterized by gastrointestinal (e.g. nausea, diarrhea, abdominal cramps) and vasomotor (e.g. palpitations, diaphoresis) symptoms.
The symptoms can be controlled with dietary modification and usually diminish over time.
 Bronchogenic cysts are usually found in the middle mediastinum. Thymoma is usually found in the anterior mediastinum. All neurogenic tumors are located in the posterior mediastinum.

 Osteonecrosis (aseptic necrosis) of the femoral head is a common complication of sickle cell disease and presents with hip pain, reduced range of motion, and normal findings on initial x-rays. It is due
to occlusion of end arteries supplying the femoral head, leading to necrosis and collapse of the periarticular bone and cartilage.
 Squamous cell carcinoma (SCC) is the most common skin malignancy in patients on chronic immunosuppressive therapy for a history of organ transplant. SCC in immunosuppressed patients is more
aggressive, with an increased risk of local recurrence and regional metastasis.
 Venous insufficiency (valvular incompetence) is the most common cause of lower extremity edema. It classically worsens throughout the day and resolves overnight when the patient is recumbent.

 Sympathetic ophthalmia is characterized by damage of one eye (the sympathetic eye) after a penetrating injury to the other eye. It is due to an immunologic mechanism involving the recognition of
‘hidden’ antigens.
 High-velocity injury to the globe can lead to corneal abrasion or open globe laceration (OGL). Small injuries may not be visible on routine inspection, but further assessment can be obtained with
fluorescein instillation. In OGL, fluorescein may reveal extrusion of fluid through the laceration; in corneal abrasion, fluorescein stains the corneal defect and appears yellow.

 Spinal epidural abscess often presents with several days/weeks of fever, malaise, and the following progressive neurologic symptoms: focal back pain nerve root pain motor weakness, sensory changes,
and bowel/bladder dysregulation —9 paralysis. Suspected cases require urgent MRI spine; treatment generally includes surgical decompression and antibiotics. Epidural anesthesia is a common
triggering event (due to direct inoculation).
 Pheochromocytomas are catecholamine-producing tumors arising from chromaffin cells of the adrenal medulla. Paroxysms of severe hypertension in patients with pheochromocytoma can be
precipitated by surgical procedures, induction of anesthesia, and a number of medications.
 Lung abscess is usually due to the aspiration of oropharyngeal anaerobic bacteria. Patients with dysphagia or episodes of impaired consciousness (e.g. drug or alcohol abuse) are at high risk. Symptoms
include subacute fever, night sweats, weight loss, and cough with putrid sputum. X-ray reveals cavitary infiltrates, often with air-fluid levels.
 Ischemic colitis is a common complication of vascular surgery, as patients are often older and have extensive underlying atherosclerosis. CT imaging can show thickening of the bowel wall. Colonoscopy
shows cyanotic mucosa and hemorrhagic ulcerations.
 In adults, fibromuscular dysplasia most commonly affects women. Headaches due to internal carotid artery stenosis and secondary hypertension due to renal artery stenosis are common presentations.
Accompanying bruits may be found in the neck and abdomen.
 The modified Wells criteria can assess the pretest possibility of acute pulmonary embolism (PE). CT angiography is the test of choice in clinically stable patients in whom PE is likely. Empiric
anticoagulation in these patients is often appropriate, but clinical judgment is needed regarding clinical stability and contraindications.
 Rapid compression of the duodenum against the vertebral column during blunt abdominal trauma may result in a duodenal hematoma. Affected patients commonly have epigastric pain and emesis 24-
48 hours postinjury because the hematoma expands to obstruct the duodenal lumen. CT scan confirms the diagnosis.
 Patients with inflammatory bowel disease (IBD) are at highest risk of developing toxic megacolon (TM) early in the disease, sometimes at initial presentation. Patients with IBD-induced TM should
receive intravenous corticosteroids.
 Risk factors for trace mineral deficiency include malabsorption, bowel resection, poor nutritional intake, and dependence on parenteral nutrition. Clinical manifestations of zinc deficiency include
hypogonadism, impaired taste, impaired wound healing, alopecia, and skin rash with perioral involvement.
 Echinococcus granulosus is a dog tapeworm endemic to rural, developing countries. Humans are incidental hosts and usually acquire the infection through the consumption of food or water
contaminated with dog feces. Tapeworm eggs hatch in the small intestine and spread to the viscera (e.g. liver, lung), causing hydatid cysts. Symptoms are initially rare, but hepatic cysts may grow over
time, resulting in right upper quadrant pain, nausea, vomiting, and hepatomegaly. Imaging typically reveals a large, smooth cyst, often with internal septations.

 In patients with traumatic spinal cord injury, disruption of the autonomic tracts involved in bladder control can lead to urinary retention. Therefore, catheterization should be performed to prevent
bladder distension and possible injury.
 Germ cell tumors typically affect young patients and display aggressive biologic behavior. Nonseminomatous germ cell tumors typically produce both α-fetoprotein and human chorionic gonadotropin
tumor markers.
 Toxic shock syndrome due to Staphylococcus aureus is associated with menstruation (tampons), nasal packing, and post-surgery infections. Patients usually develop fever, myalgias, marked
hypotension, and diffuse erythematous macular rash (erythroderma) that can progress to multiorgan involvement.
 Mucus plugging can lead to large-volume atelectasis (lung collapse) due to airway obstruction. Chest x-ray demonstrates opacification of the affected lung area and mediastinal shifting toward the side
of atelectasis.
 Porcelain gallbladder is usually diagnosed on abdominal imaging showing a calcified rim in the gallbladder wall with a central bile-filled dark area. It is associated with an increased risk for gallbladder
adenocarcinoma and usually requires cholecystectomy.
 Diaphragmatic rupture should be suspected in patients with prior blunt thoracoabdominal trauma and abnormal chest x-ray findings (e.g. bowel loops in the thorax, mediastinal shift). Delayed
presentations can occur after progressive expansion of the diaphragmatic defect and abdominal organ herniation. CT scan of the chest and abdomen confirms the diagnosis.

 The typical CT/MRI findings in high-grade (e.g. grade IV) astrocytoma are heterogenous and serpiginous contrast enhancement. Glioblastoma (grade IV astrocytoma) has a classic butterfly appearance
with central necrosis on neuroimaging.
 Epidural spinal cord compression must be suspected in any patient with a history of malignancy who develops back pain with motor and sensory abnormalities. Bowel and bladder dysfunction are late
neurologic findings. Intravenous glucocorticoids should be given without delay. MRI is then recommended.
 Inferior vena cava filters are placed to prevent clinically significant pulmonary emboli in patients with contraindications to or complications from anticoagulation (e.g. active bleeding) and those who
have recurrent proximal deep venous thrombosis who failed anticoagulation.
 Small intestinal bacterial overgrowth (SIBO) is characterized by bloating, flatulence, and watery diarrhea; malabsorption and nutritional deficiencies may also occur. SIBO is a common complication of
gastric bypass procedures. Conditions that alter intestinal motility (e.g. systemic sclerosis, diabetes mellitus), anatomy (e.g. strictures), or gastric/pancreatic secretions (e.g. atrophic gastritis, chronic
pancreatitis) also predispose to SIBO.
 Leydig cell testicular tumors often cause feminization (e.g. gynecomastia) due to the production of estrogen by tumor cells. This frequently causes secondary inhibition of FSH and LH. Serum tumor
markers (e.g. β-hCG, AFP) are not usually elevated.
 Gastrinoma (Zollinger-Ellison syndrome) should be suspected in patients with multiple stomach ulcers and thickened gastric folds on endoscopy. The diagnosis is strongly suggested by a fasting serum
gastrin level > 1000 pg/mL. Patients with nondiagnostic serum gastrin levels should be evaluated with a secretin stimulation test.
 In cases of traumatic amputation, the amputated part should be transported by wrapping it in saline-moistened gauze, sealing it in a plastic bag, and placing the bag in a bath of ice water. Cooling of the
amputated part prolongs the window for replantation.
 De Quervain tendinopathy presents with lateral wrist pain over the tendons of the abductor pollicis longus and extensor pollicis brevis. It is most common in women age 30-50, with an increased
frequency during the postpartum period. Examination shows tenderness at the radial side of the wrist and a positive Finkelstein test (reproduction of pain on adduction of the wrist with the fingers
closed over the thumb).
 Tears of the medial meniscus often result from twisting injuries with the foot in a fixed position. Associated symptoms can include reduced extension, a sensation of instability, and a knee effusion.
Examination reveals palpable locking or catching when the joint is rotated or extended while under load. Diagnosis is confirmed with MRI or arthroscopy.
 Medial collateral ligament tear is caused by valgus stress or severe twisting injury and can be associated with injury to the medial meniscus. Findings include tenderness at the medial knee and valgus
laxity. MRI is the most sensitive test, and most patients are managed nonoperatively.
 Tibial stress fractures are caused by repeated tension or compression without adequate rest and occur most commonly in athletes or others who suddenly increase their activity. Findings include
subacute, localized, activity-related pain; swelling; and point tenderness on palpation. X-rays are frequently normal.
 Older patients with hip fracture should undergo definitive surgical correction as soon as reasonably possible. However, surgery may be delayed up to 72 hours to evaluate surgical risk and ensure
medical stability.
 Arterial supply to the scaphoid enters at the distal pole; fracture can disrupt flow to the proximal segment, leading to avascular necrosis and nonunion. Nondisplaced fractures may not be immediately
visible on x-ray. If initial x-rays are negative, CT scan or MRI is recommended, or the wrist should be immobilized and x-rays repeated after 7-10 days.
 Clavicle fracture can injure the underlying brachial plexus and subclavian artery. Hard signs of arterial injury (e.g. absent pulses, distal ischemia) require immediate surgical intervention. Soft signs of
vascular injury (e.g. unexplained hypotension, stable hematoma, reduced pulse) warrant CT angiography for further evaluation.
 Displaced supracondylar fractures of the humerus most commonly present after a fall onto an outstretched hand with posterior displacement of the distal humerus fragment. The anteriorly displaced
proximal humerus fragment can entrap the brachial artery and median nerve, which pass anterior to the humerus.
 Ruptured abdominal aortic aneurysm presents with the acute onset of severe abdominal or flank pain, sometimes accompanied by syncope, a pulsatile abdominal mass, and/or flank or umbilical
hematomas. The onset of hemodynamic instability can be abrupt or delayed.
 Ludwig angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. The source of infection is most commonly an infected mandibular molar. Early intervention with
intravenous antibiotics prevents airway compromise in most cases.
 Complications due to inappropriate central venous catheter placement are common. With the exception of select cases, appropriate catheter tip placement should be confirmed by chest x-ray prior to
 catheter use.
 Persistent pneumothorax and large air leak despite tube thoracostomy in the setting of blunt chest trauma suggest tracheobronchial rupture. Bronchoscopy can confirm the diagnosis prior to operative
repair.
 Nasopharyngeal carcinoma is associated with the reactivation of Epstein-Barr virus and occurs most commonly in those from Asia (particularly southern China) and parts of Africa and the Middle East.
Manifestations include nasal congestion with epistaxis, headaches, cranial nerve palsies, and otitis media. Early spread to the cervical lymph nodes is common.

 Surgical resection is the primary treatment modality for papillary thyroid carcinoma. Postoperative adjuvant therapies for patients at increased risk of recurrence include radioiodine ablation and
suppressive doses of thyroid hormone.
 Thyroid function tests are often abnormal in patients with severe, acute illness. The most common pattern is low T3 with normal T4 and TSH (i.e. euthyroid sick syndrome), which may represent an
adaptive response to severe illness. Thyroid hormone supplementation is not indicated for these patients, and follow-up testing should be delayed until the patient has returned to baseline health.

 Risk factors for pressure ulcers include decreased mobility, malnutrition, abnormal mental status, decreased skin perfusion, and reduced sensation. Interventions that can prevent pressure ulcers
include proper positioning for pressure redistribution, mobilization, careful skin care, moisture control, and maintenance of nutrition.
 Colovesical fistula is most commonly due to diverticular disease and presents with pneumaturia, fecaluria, or findings consistent with urinary tract infection. Abdominal CT scan with oral or rectal (not
intravenous) contrast can confirm the diagnosis by showing contrast material in the bladder with thickened colonic and vesicular walls.
 Coagulase-negative staphylococci are the most frequent cause of nosocomial bloodstream infection in patients with intravascular devices. Factors favoring infection over contamination include fever,
leukocytosis, hypotension, and blood culture growth in > 2 bottles (both aerobic and anaerobic) with the same organism and drug susceptibility.
 Patients with compartment syndrome have severe pain, pain with passive range of motion, and paresthesia. Sensory and motor deficits occur in later stages. Pallor and loss of limb pulses are
uncommon findings. Compartment pressures must be measured immediately if the index of suspicion is very high. Fasciotomy is the treatment of choice.
 Squamous cell carcinoma (SCC) is most often associated with ultraviolet (sun) exposure but may also arise in chronically wounded, scarred, or inflamed skin. SCC arising in chronic wounds tends to be
more aggressive.
 Neuropathic ulcers are caused by repeated pressure, friction, or trauma due to lack of sensation in the local tissues. They typically occur at weight-bearing sites on the sole of the foot. Diabetes mellitus
is the most common cause of neuropathic ulcers.
 Oxalate absorption is increased in Crohn disease and all other intestinal diseases causing fat malabsorption. Increased absorption is the most common cause of symptomatic hyperoxaluria and oxalate
stone formation.
 Initial management of angle-closure glaucoma is directed at rapidly lowering intraocular pressure. Combination therapy with multiple topical agents (e.g. timolol, pilocarpine, apraclonidine) is
recommended. In addition, acetazolamide rapidly reduces further production of aqueous humor. Subsequently, laser iridotomy can facilitate aqueous outflow and provide definitive management.

 If a patient develops a whistling noise during respiration following rhinoplasty, one should suspect nasal septal perforation likely resulting from a septal hematoma.
 Torus palatinus (TP) is a benign bony growth (exostosis) located on the midline suture of the hard palate. It can be congenital or develop later in life. TP is typically chronic and asymptomatic, and the
diagnosis is usually clinically evident. Surgery is indicated if the mass becomes symptomatic, interferes with speech or eating, or causes problems with the fitting of dentures.

 Patients with penetrating abdominal trauma and hemodynamic instability, peritonitis, evisceration, or impalement should undergo immediate exploratory laparotomy.
 Displaced scaphoid fractures should be considered for surgical intervention. Wrist immobilization with a cast can be considered for nondisplaced fractures, but patients should be monitored with serial
x-ray to rule out osteonecrosis of the proximal segment and nonunion of the fracture.
 Midshaft humeral fractures occur due to direct blows to the arm and can cause pain, swelling, deformity, and shortening. Associated radial nerve neurapraxia is common and often resolves with
appropriate management of the fracture. Many midshaft humeral fractures can be treated nonsurgically. Indications for open reduction and surgical exploration include open fractures, neurovascular
compromise, and significant displacement.
 Brown recluse spider bites can cause a deep necrotic ulcer at the bite site. The ulcer can progress over days to an eschar.
 Circumferential, full-thickness (third degree) burns can result in eschar formation that restricts venous and lymphatic drainage, leading to acute compartment syndrome.
 Blunt trauma can cause renal injury. Concerning clinical findings include flank pain and ecchymosis, costovertebral area tenderness, and hematuria. These findings, or a concerning mechanism of injury,
should prompt CT scan of the abdomen and pelvis.
 Hard signs of vascular injury include pulsatile bleeding, bruits or thrills over the injury, an expanding hematoma, and signs of distal ischemia (e.g. absent pulses, cool extremities). In the presence of a
penetrating injury, such signs are almost universally predictive of the need for urgent surgical repair.
 Penile fracture is most commonly caused by blunt trauma (e.g. sexual intercourse) to an erect penis. Although penile fracture is a urologic emergency that requires urgent operative repair, patients with
evidence of urethral injury (e.g. blood at the meatus, dysuria, urinary retention) should undergo retrograde urethrography prior to surgery.
 Pelvic fractures in men may be complicated by posterior urethral injury. Patients with suspected urethral injury (e.g. blood at the urethral meatus, high-riding prostate) should undergo retrograde
urethrography.
 Suprapubic pain and gross hematuria with associated pelvic fracture are concerning for bladder injury. Because of urine containment within adjacent tissues, extraperitoneal bladder rupture typically
causes localized (vs diffuse abdominal) symptoms and a negative examination with Focused Assessment with Sonography for Trauma.
 Bladder cancer often causes hematuria, voiding symptoms (e.g. dysuria, urgency, frequency), and/or suprapubic pain. Patients who have no clear source (e.g. cystitis) for these symptoms require urgent
workup with cystoscopy.
 Fat embolism syndrome can occur following the fracture of large, marrow-rich bones (e.g. the femur). Microvascular obstruction in the pulmonary circulation can lead to respiratory distress;
obstruction in the cerebral circulation may cause neurologic dysfunction, including confusion and focal deficits.
 Patients with cervical spine injuries are at risk of respiratory compromise. Orotracheal intubation with manual stabilization of the cervical spine is recommended for initial airway management.

 Short-term hyperventilation helps lower increased intracranial pressure by causing cerebral washout of CO2, leading to vasoconstriction and decreased cerebral blood flow.
 Delayed emergence from anesthesia is defined as the failure to return to consciousness within the expected window of the last administration of an anesthetic or adjuvant agent (typically 30-60
minutes). The etiology is often multifactorial, however; the presence of respiratory failure (e.g. low pH, elevated pCO2, low pO2), bradypnea, and bradycardia suggests prolonged medication effect
resulting in hypoventilation.
 Any penetrating wound below the fourth thoracic dermatome (i.e. nipple level) can involve the intra-abdominal organs. Patients with penetrating abdominal trauma and any of the following indications
- hemodynamic instability, peritonitis, evisceration - should undergo immediate exploratory laparotomy.
 Adequate pain control is the mainstay of rib fracture management to prevent the associated complications of atelectasis and pneumonia.
 Tension pneumothorax is a life-threatening condition caused by air within the pleural space that displaces mediastinal structures and compromises cardiopulmonary function. It is characterized by
rapid-onset dyspnea, tachycardia, tachypnea, hypotension, and distension of the neck veins. Treatment should be initiated immediately with needle thoracostomy.

 All trauma patients should be triaged using the Glasgow coma scale (GCS), which can predict the severity and prognosis of coma, during the primary survey. The GCS assesses the patient’s ability to
open his/her eyes, motor response, and verbal response.
 CT-guided percutaneous drainage is recommended for complicated diverticulitis with abscess formation. Surgical drainage can be attempted if percutaneous drainage fails.
 Psoas abscess commonly presents subacutely with fever and lower abdominal or flank pain radiating to the groin. The ‘psoas sign’, abdominal pain with hip extension, can often be detected on
examination. CT scans are required to confirm the diagnosis, and drainage with antibiotics is the mainstay of therapy.
 Ileus is commonly due to abdominal surgery but can also be seen in retroperitoneal/abdominal hemorrhage, intra-abdominal inflammation (e.g. pancreatitis), intestinal ischemia, and electrolyte
abnormalities. Signs and symptoms include nausea, vomiting, abdominal distension, obstipation, and hypoactive or absent bowel sounds. Abdominal radiography classically reveals uniformly
distended, gas-filled loops of both the small and the large intestines.
 Sudden-onset, severe abdominal pain with peritonitis and subdiaphragmatic free air on upright chest x-ray is a classic presentation of perforated viscus (e.g. perforated peptic ulcer).

 Rotator cuff tears occur most commonly in patients age > 40, often after a fall on an outstretched arm. These injuries are characterized by pain and weakness with abduction and external rotation of the
humerus. MRI can confirm the diagnosis.
 Rotator cuff tendinopathy (RCT) is most common in patients who perform repetitive arm movement above shoulder height. It presents with subacute pain on abduction. Impingement syndrome refers
to compression of soft tissue structures between the humeral head and acromion and is a characteristic feature of RCT.
 Chemical burns to the eye are vision-threatening emergencies. The most important and urgent step in management is copious irrigation to normalize the pH.
 Hyperextension injury, especially in elderly patients with cervical spine degenerative changes (i.e. cervical spondylosis), can cause central cord syndrome. This classically causes loss of pain and
temperature sensation in the upper extremities and disproportionate upper extremity weakness.
 The evaluation of patients with suspected appendicitis (e.g. modified Alvarado score > 4) now includes imaging, which can visualize the appendix (e.g. normal vs nonperforated or perforated
appendicitis) and direct management. CT scan of the abdomen and pelvis is the recommended imaging study in nonpregnant adults.
 Human bite wounds often result in polymicrobial infections with aerobic and anaerobic oral organisms. Empiric treatment with amoxicillin-clavulanate provides adequate coverage for the majority of
virulent oral bacteria.
 Gilbert syndrome, the most common inherited disorder of bilirubin glucuronidation, is characterized by recurrent episodes of mild jaundice precipitated by stressors (e.g. infection, fasting, vigorous
exercise, surgery). With the exception of elevated unconjugated bilirubin, liver function test results and complete blood counts are normal.
 Sphincter of Oddi dysfunction is a functional biliary disorder due to dyskinesia or stenosis of the sphincter of Oddi. Patients experience recurrent, episodic pain in the right upper quadrant or epigastric
region, with corresponding elevations in aminotransferases and alkaline phosphatase. Opioid analgesics (e.g. morphine) may cause sphincter contraction and precipitate symptoms.

 In humans, hepatic hydatid cysts are due to infection with Echinococcus granulosus. Dogs are the definitive host. A cystic hepatic lesion with eggshell calcification is highly suggestive of infection with
this organism.
 Entamoeba histolytica is a protozoan that can cause colitis or extraintestinal (liver, pleura, brain) illness in patients who live in or travel to developing countries. Amebic liver abscess is characterized by
right upper quadrant pain, fever, and (usually) a single subcapsular lesion in the right lobe. Diagnosis is made with serology; needle aspiration is usually unnecessary.

 Pancreatic cancer can be due to hereditary (e.g. first-degree relative with pancreatic cancer, hereditary pancreatitis) or environmental (e.g. cigarette smoking, obesity) risk factors. Cigarette smoking is
the most consistent reversible risk factor for pancreatic cancer.
 Pancreatic cancer in the body or tail of the organ may present with constant, progressive back pain that is worse at night and when supine. Because this is a referred pain, back/neurologic examinations
and radiographic imaging are generally normal. An abdominal CT scan is usually diagnostic.
 The most common malignancy of the liver is metastasis from another primary source.
 Acute acalculous cholecystitis is an acute inflammation of the gallbladder in the absence of gallstones that is most commonly seen in hospitalized and critically ill patients.
 Postcholecystectomy syndrome is persistent abdominal pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystectomy. Etiologies include biliary (e.g. retained common
bile duct, cystic duct stone) or extra-biliary (e.g. pancreatitis, peptic ulcer disease) causes. Abdominal imaging (e.g. ultrasound) followed by direct visualization (e.g. endoscopic retrograde
cholangiopancreatography, magnetic resonance cholangiopancreatography) can establish the diagnosis and guide therapy toward the causative factor.

 Emphysematous cholecystitis is a life-threatening form of acute cholecystitis that occurs more commonly in patients with immunosuppression (e.g. diabetes) or vascular disease. It arises due to
infection of the gallbladder wall with gas-forming bacteria and requires emergency cholecystectomy.
 The presentation of pancreatic cancer is dependent on tumor location; tumors in the pancreatic head often present with painless obstructive jaundice, whereas those in the body or tail often cause
abdominal pain without jaundice. Although ultrasound is the imaging test of choice to evaluate a jaundiced patient, a CT scan of the abdomen is indicated for those with a nondiagnostic ultrasound or to
evaluate for suspected malignancy in a nonjaundiced patient.
 Gallstone pancreatitis should be suspected in patients who have evidence of pancreatitis with alanine aminotransferase levels > 150 U/L. Early cholecystectomy is indicated in all patients with gallstone
pancreatitis who are medically stable enough to undergo surgery.
 Hepatic adenoma is a benign tumor most often seen in young and middle-age women who take oral contraceptives. Possible long-term complications include progressive growth, rupture, and
malignant transformation.
 Asymptomatic gallstones should not be treated. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease.
 Gallstones and chronic alcohol abuse are the most common causes of acute pancreatitis. Abdominal ultrasound is the most sensitive and specific imaging study to detect gallstones and should be
performed in all patients with suspected gallstone-induced pancreatitis.
 The first step in the treatment of acute upper gastrointestinal bleeding is to establish vascular access with 2 large-bore intravenous catheters to initiate resuscitation with intravenous fluids.

 Acute cholecystitis usually presents with sudden onset of right upper quadrant abdominal pain, fever, vomiting, and leukocytosis. The primary inciting event is a gallstone obstructing the cystic duct
with subsequent inflammation and infection.
 Gallstone ileus results from small bowel obstruction due to a gallstone that has passed through a biliary-enteric fistula. As the stone advances it may cause ‘tumbling’ obstruction before ultimately
causing complete obstruction. Treatment involves surgical removal of the stone and cholecystectomy.
 Pancreatic pseudocyst is an encapsulated area (comprised of enzyme-rich fluid, tissue, and debris) that causes an inflammatory response. Diagnosis is confirmed by abdominal imaging. Expectant
management is preferred initially in patients with minimal or no symptoms and without complications. Endoscopic drainage is typically reserved for patients with significant symptoms (e.g. abdominal
pain, vomiting), infected pseudocyst, or evidence of pseudoaneurysm.
 Postoperative endophthalmitis is the most common form of endophthalmitis. It usually occurs within 6 weeks of surgery. Patients usually present with pain and decreased visual acuity. Examination
reveals swollen eyelids and conjunctiva, hypopyon, corneal edema and infection.
 A cataract is a vision-impairing opacification of the lens. Patients usually have painless blurred vision, glare, and often halos around lights. Treatment with lens extraction and artificial lens implantation
is indicated when loss of vision impairs activities of daily living.
 Retropharyngeal abscess presents with neck pain, odynophagia, and fever following penetrating trauma to the posterior pharynx. Infection within the retropharyngeal space can drain into the superior
mediastinum. Extension through the alar fascia into the ‘danger space’ can transmit infection into the posterior mediastinum and result in acute necrotizing mediastinitis.

 Acute mesenteric ischemia is commonly due to abrupt arterial occlusion from cardiac embolic events (e.g. ventricular thromboembolism). If ischemia is prolonged, patients may develop more focal
findings due to infarction, perforation, or peritonitis. Laboratory studies typically show leukocytosis, elevated hemoglobin, elevated amylase, and metabolic acidosis.

 Patients with septic shock first require aggressive volume resuscitation with intravenous 0.9% saline prior to the initiation of vasopressors to restore adequate tissue perfusion.
 Hypoxemia can be caused by reduced inspired oxygen tension, hypoventilation, diffusion limitation, shunt, and V/Q mismatch. Hypoventilation is associated with a normal A-a gradient and respiratory
acidosis.
 A mole may represent melanoma if it appears substantially different from others (‘ugly duckling sign’), itches or bleeds, or develops nodularity. If melanoma is suspected, an excisional biopsy should be
obtained.
 Necrotizing fasciitis presents with erythema and swelling, severe pain out of proportion to the physical examination, and signs of tissue necrosis such as crepitus, purulent drainage, or radiographic
evidence of gas in the deep tissues. When skin or soft-tissue infection is suspected, rapid progression of physical examination findings or severe systemic signs such as hypotension should raise
suspicion for necrotizing fasciitis.
 Myxomas are the most common primary cardiac neoplasm and usually arise in the left atrium. Fragments of the tumor can dislodge and lead to systemic embolization (e.g. stroke, acute limb ischemia).
The tumors may also cause position-dependent obstruction of the mitral valve, leading to a mid-diastolic murmur and symptoms of decreased cardiac output (e.g. dyspnea, syncope). Constitutional
symptoms (e.g. fever, weight loss) may also be present.
 As soon as acute limb ischemia is clinically diagnosed (e.g. pallor, pulselessness), anticoagulation (e.g. intravenous heparin infusion) should be initiated. This prevents thrombus propagation and distal
thrombosis while the patient undergoes further diagnostic procedures or awaits surgical intervention.
 Squamous cell carcinoma of the lung usually arises in the central tracheobronchial tree (e.g. hilar mass) and is often associated with cough, hemoptysis, dyspnea, and hypercalcemia (due to parathyroid
hormone-related protein release). In contrast, small cell carcinoma of the lung causes other paraneoplastic syndromes (e.g. ACTH production, syndrome of inappropriate antidiuretic hormone
secretion), and adenocarcinoma of the lung typically causes peripheral lung lesions.
 Painless jaundice in a patient with conjugated hyperbilirubinemia and markedly elevated alkaline phosphatase should raise concern for biliary obstruction due to pancreatic or biliary cancer. Other
common causes of biliary obstruction include choledocholithiasis and benign biliary strictures.
 Trousseau syndrome is a hypercoagulability disorder presenting with recurrent and migratory superficial thrombophlebitis at unusual sites (e.g. arm, chest area). It is usually associated with an occult
visceral malignancy such as pancreatic (most common), stomach, lung, or prostate carcinoma.
 Giant cell tumor of bone is a benign but locally destructive neoplasm that is most common at the epiphysis of long bones in young adults. Most patients have local manifestations (e.g. pain, swelling), but
 pulmonary metastasis and malignant transformation may occur. X-ray shows an eccentric lytic lesion, often resembling soap bubbles. The diagnosis is confirmed with biopsy, and surgery is first-line
treatment.
 Squamous cell carcinoma in a cervical lymph node, especially in a smoker, likely has a mucosal head and neck primary site and requires examination of the laryngopharyngeal mucosa.

 A nonhealing, painless, bleeding skin ulcer associated with a chronic scar suggests squamous cell carcinoma (SCC). SCC arising within a scar or chronic wound carries an increased risk of metastasis.
The diagnosis should be confirmed with biopsy.
 Nodular basal cell carcinoma has low metastatic potential but should be removed with either electrodessication and curettage or surgical excision. Mohs micrographic surgery, in which thin layers are
removed and inspected microscopically to ensure clear margins, is used for high-risk lesions in delicate or cosmetically sensitive areas.
 Superior pulmonary sulcus tumors are malignant lung neoplasms that arise in the superior portion of the lung. They most commonly present with shoulder pain, Horner syndrome, arm pain, and/or
hand weakness.
 Diagnosis of esophageal cancer requires esophageal endoscopy with biopsy. Young, low-risk patients with undetermined esophageal symptoms may start with barium esophagram, but those who are
age > 50 or with alarm symptoms (e.g. weight loss, gross or occult bleeding, early satiety) should proceed directly to endoscopy.
 The differential diagnosis for an anterior mediastinal mass includes the ‘4 T’s’: thymoma, teratoma (and other germ cell tumors), thyroid neoplasm, and terrible lymphoma. Seminomas may cause an
elevated β-hCG, but the AFP is essentially always normal. Nonseminomatous germ cell tumors often have an elevated AFP, with a considerable number also having an elevated β-hCG.

 A solid, firm, nontender testicular mass should be considered testicular cancer until proven otherwise. A diagnostic workup generally includes bilateral scrotal ultrasound, serum tumor markers, and
radical inguinal orchiectomy.
 A congenital umbilical hernia is typically soft and reducible and does not require intervention. These hernias usually close spontaneously by age 5.
 Violent muscle contractions (e.g. seizure, electrocution injury) can cause posterior shoulder dislocation. On examination, the arm is held in adduction and internal rotation, with flattening of the anterior
aspect of the shoulder. X-rays show loss of the normal relation between the humeral head and glenoid and internal rotation of the humeral head. Most posterior dislocations are managed with closed
reduction.
 Bowel ischemia and infarction are possible early complications of operation on the abdominal aorta, such as AAA repair.
 Effort rupture of the esophagus (Boerhaave syndrome) can occur with vomiting. Leakage of esophageal air through the full-thickness perforation may cause pneumomediastinum, evidenced by
suprasternal crepitus on examination. Confirmation with esophagography or CT scan using water-soluble contrast should prompt emergent surgical consultation.

 Fat necrosis of the breast is a benign condition with clinical and radiographic findings similar to breast cancer, including skin or nipple retraction and calcifications on mammography. Biopsy will reveal
fat globules and foamy histiocytes in fat necrosis. No further workup is indicated for excised lesions.
 Mammography is the first-line imaging study for assessing a palpable breast mass in women age > 30. Ultrasound may be added for better characterization of the mass. Tissue biopsy is required to
confirm the diagnosis.
 Acute mediastinitis can occur following cardiac surgery and present with fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray. It is a serious condition that requires drainage, surgical
debridement, and prolonged antibiotic therapy.
 Esophageal perforation is a life-threatening complication of endoscopy. Clinical presentation may include severe chest/back pain, systemic inflammatory response, and pleural effusion from leaked
esophageal contents. Contrast esophagography is the best test to confirm the diagnosis.
 Salivary stones occur most often in the submandibular glands and can present with recurrent sialadenitis due to obstruction of the duct.
 The spleen is one of the most commonly injured organs in blunt abdominal trauma. Patients with severe splenic laceration causing intra-abdominal hemorrhage may have shock and intraperitoneal free
fluid on Focused Assessment with Sonography for Trauma.
 Immediate surgical intervention is indicated for patients with intestinal obstruction who develop clinical or hemodynamic instability, fail to improve after initial conservative measures, and/or develop
symptoms or signs of ischemia or necrosis.
 Pulmonary edema causes hypoxemia due to right-to-left intrapulmonary shunting, an extreme ventilation/perfusion (V/Q) mismatch. When the edema is diffuse, alveolar ventilation is zero throughout
much of the lungs and the hypoxemia does not correct with supplemental O2. As with any type of V/Q mismatch, pulmonary edema leads to an increase in the alveolar-arterial O2 gradient. It also causes
stiffening of the lungs and decreased lung compliance.
 Suspected heparin-induced thrombocytopenia requires immediate cessation of all forms of heparin and initiation of anticoagulation with an alternate agent (e.g. argatroban, fondaparinux). Once the
platelet count is > 150,000/mm3, most patients can be switched safely to warfarin.
 Acalculous cholecystitis occurs in critically ill patients. The clinical presentation may be similar to calculous cholecystitis, though assessment may be difficult due to the underlying illness. Imaging
studies show gallbladder wall thickening and distension and pericholecystic fluid. The emergency treatment of choice is antibiotics and percutaneous cholecystostomy, followed by cholecystectomy
when the medical condition stabilizes.
 Most ureteral stones < 5 mm in diameter pass spontaneously; increased oral fluid intake is recommended to ensure adequate flow of dilute urine. α blockers can be used to facilitate passage of larger
stones (6-10 mm). Urologic consultation is recommended for stones > 10 mm and for refractory pain, anuria, acute kidney injury, or signs of urosepsis.

 Recurrent pneumonia in an elderly patient with dysphagia and regurgitation of undigested food raises concern for a Zenker diverticulum, which may occasionally present with a palpable mass. A
swallow study with contrast esophagography can be used to confirm the diagnosis.
 Tumors in the head of the pancreas can present with weight loss, jaundice, and a nontender, distended gallbladder (e.g. Courvoisier sign) on examination. Imaging can demonstrate dilation of both the
intra- and extrahepatic bile ducts as well as the pancreatic duct (i.e. double duct sign).
 Diagnosis of toxic megacolon requires radiographic evidence (e.g. abdominal CT scan) of colonic dilation > 6 cm, along with manifestations of systemic toxicity (e.g. fever, leukocytosis, hemodynamic
instability).
 Abdominal CT scan is the best diagnostic test for diagnosing acute diverticulitis and differentiating it from other causes of abdominal pain.
 Mallory-Weiss tear occurs due to a sudden increase in intra-abdominal pressure (e.g. retching), leading to a mucosal tear and hematemesis. The diagnosis can be confirmed on endoscopy. Bleeding
stops spontaneously in most patients, but those with ongoing bleeding can be treated endoscopically.
 A muffled voice should make one consider a diagnosis other than uncomplicated pharyngitis or tonsillitis. A peritonsillar abscess is a potential complication of tonsillitis and requires both intravenous
antibiotic therapy and urgent drainage of the abscess. Deviation of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a peritonsillar abscess from epiglottitis.

 The most common presentation of primary hyperparathyroidism is asymptomatic hypercalcemia with an elevated parathyroid hormone level. Parathyroidectomy is recommended for patients with
symptomatic hypercalcemia and those with complications (e.g. nephrolithiasis) or at increased risk for complications. Younger patients (age < 50) are likely to have complications during their lifetime
and should be offered surgery.
 Papillary muscle rupture leading to acute mitral regurgitation and cardiogenic shock is a mechanical complication of acute myocardial infarction and usually occurs 3-5 days after the infarct.

 Massive pulmonary embolism is likely in a postoperative patient with hypotension, jugular venous distension, and new-onset right bundle branch block.
 Acute mesenteric ischemia classically presents with acute-onset, severe, midabdominal pain out of proportion to physical examination findings. Progression to bowel infarction causes focal pain,
peritoneal signs, rectal bleeding and sepsis.

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