Escolar Documentos
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Cultura Documentos
Carlos Pestana, MD
Trauma Cases
Case #1:
A 19-year-old male is brought to the ER by ambulance after being shot in the abdomen 20
minutes earlier in a bar. On arrival, he is diaphoretic, pale, cold, shivering, anxious; he asks
for a blanket and water. Initial survey confirms the presence of an entry wound in the mid-
epigastrium, a blood pressure of 75/60, and a feeble pulse rate of 142.
Management:
Case #2:
A car accident victim arrives in the ER. Initial survey shows that he is fully conscious and
speaking with a normal tone of voice, but he is also pale, perspiring and shivering. He is
breathing well and his head and neck veins are not distended. Blood pressure is 85/62 and
there is a barely perceptible pulse at a rate of 115 per min.
• Unlike case 1 with penetrating injury, this patient sustained blunt trauma, perhaps to
the chest. Must r/o pericardial tamponade and tension pneumothorax.
• Normal JVD and breathing r/o both. Again, hemorrhagic shock is most likely
diagnosis.
Management:
• Remember ABC’s. Source of bleeding unknown; can’t use the “stop bleeding first,
replace volume later approach”
• Two large peripheral IV lines with a couple of liters of Ringer’s lactate (no sugar)
infused over 20-30 minutes
Management:
• Prompt and lasting stabilization of vital signs in response to fluid bolus would suggest
bleeding has spontaneously ceased Prompt and lasting stabilization of vital signs in
response to fluid bolus would suggest bleeding has spontaneously ceased
• If shock not reversed with volume replacement, more aggressive blood replacement
and surgery likely required
Case #3:
An ambulance arrives at the site where a car ran into a tree on a remote rural road. The lone
occupant of the vehicle is cold, pale, perspiring and shivering. His blood pressure is 80/60, his
pulse rate is 120, and he has no visible distended veins in his head and neck. The nearest
hospital is at least an hour away.
Management:
An innocent bystander is shot in the chest and abdomen during a botched bank robbery. On
arrival in the ER he is pale, diaphoretic, cold, shivering, anxious, and thirsty. He has bilateral
breath sounds and is breathing well, but he has large distended veins in his neck and
forehead. His blood pressure is 65/45, and his pulse rate is 150.
• Can r/o tension pneumothorax because he has normal breath sounds and is
breathing well
• By exclusion, correct diagnosis is pericardial tamponade
Management:
Management:
Case #5:
A 23-year-old gang member arrives at the ER with multiple gun shot wounds to the chest.
Breathing is labored, nostrils flared, and he has big distended veins in his neck and forehead.
He is pale, cold, sweating, shivering, and mumbles that he is going to die. Initial survey shows
a blood pressure of 60/40, barely perceptible pulse at a rate of 150, and a right hemithorax
that is hyperresonant to percussion and devoid of breath sounds. Palpation of the trachea
shows it to be deviated toward the left.
Management:
Case #6:
During a round of golf, a business executive is hit on the right side of his head with a golf ball.
He loses consciousness for a few minutes, but wakes up promptly and continues to play. 1
hour later he is found unconscious in the locker room. His right pupil is fixed and dilated, and
he has contralateral hemiparesis.
• Sequence of trauma, coma, lucid period, coma again, ipsilateral fixed dilated pupil
and contralateral hemiparesis suggests acute intracranial hematoma with
displacement of the midline structures.
• Epidural vs. subdural: subdural requires a much bigger trauma and presents with a
sicker patient.
• Blow to side of head where middle meningeal artery lies, as well as the very lucid
“lucid interval” suggests acute epidural bleed.
• In 90% of cases dilated pupil on same side as hematoma.
Management:
• CT scan of head to confirm location (right vs. left; epidural vs. subdural)
• Biconcave epidural hematoma on the right; deviation of midline structures to the left
• Cranionotomy and decompression
Case #7:
The front seat passenger of a car involved in a high-speed, head-on collision, arrives in the
ER in a deep coma. The EMTs report that he was unconscious at the site, woke up briefly in
the ambulance, and then lapsed into a coma again. His right pupil is fixed and dilated and he
has signs of contralateral hemiparesis with decerebrate posture.
Management:
• Head CT
• Semilunar, crescent-shaped hematoma on the right; deviation of the midline
structures to the left
• Deviation provides rationale for surgery; without displacement more conservative
approach with ICP management
• With major blunt trauma to the head, remember to check the C-spine
Case #8:
An 82-year-old alcoholic man is rummaging under the sink looking for his last bottle of cheap
wine. While doing so, he bumps his head against the counter, but suffers no apparent injury.
Over the next week, however, he gradually loses his mental capacities, and becomes
obtunded and disoriented.
Management:
Case #9:
A 18-year-old male is stabbed in the right chest. He presents moderately short of breath, but
his other vital signs are stable. Physical examination reveals an absence of breath sounds in
the right hemithorax, which sounds hyperresonant to percussion.
Diagnosis: Pneumothorax
Management:
Case #10:
A 20-year-old male is stabbed in the right chest. He is moderately short of breath, but his
other vital signs are stable. Physical exam reveals no breath sounds at the right base, and
faint, distant breath sounds at the right apex. Right side of his chest is dull to percussion. A
CXR shows blood in the right pleural space, and a chest tube is placed at the right pleural
base. The tube initially recovers 270 cc of blood, drains another 35 cc in the next hour, and 12
cc in the second hour.
Diagnosis: Hemothorax
• While bleeding will stop by itself, expectant therapy not advisable because
contaminated blood in the pleural space may produce empyema
Management:
Case #11:
A 19-year-old male is stabbed in the right chest. On arrival at the ER he is short of breath,
pale, with a pulse rate of 95 and a blood pressure of 90/70. His right hemithorax has no breath
sounds and is dull to percussion. CXR shows the entire pleural space to be filled with blood.
When a chest tube is inserted, 1600 cc of blood are recovered.
Case #12:
A 45-year-old woman involved in a car accident in which 3 other passengers died arrives at
the ER. She is moderately short of breath, but her other vital signs are stable. Initial survey
shows multiple bruises and minor lacerations, but the most impressive finding is the presence
of at least 8 rib fractures on the right side of her chest, and a very peculiar physical finding:
there is an area of the chest wall on the right that caves in whenever she inspires and bulges
out on expiration.
Diagnosis:
• Consider: severe trauma to the chest, deceleration injury
• Think of obvious injuries as well as hidden ones
• Broken ribs and flail chest are obvious
• Consider possibility of traumatic rupture of aorta
• Manage the obvious, uncover the hidden
Management:
Case #13:
A 23-year-old man crashes his car into a wall. When he arrives at the ER, a mirror image of
the word “Ford” can be seen imprinted as a bruise over his precordial region. He is exquisitely
tender at a point in the sternum, where palpation elicits a gritty feeling of bone grating on
bone.
• CXR will reveal sternal fracture and can check for widened mediastinum
• Diagnosis and management of myocardial contusion similar to MI; EKG more reliable
than enzymes
Case #14:
Two airplanes collide on runway and there are multiple casualties. One of the survivors is
found walking around in a daze, but otherwise seemingly unharmed. Over his objections, he
is taken to the hospital, where a CXR shows a wide mediastinum and a fractured left first rib.
• Intima and media may have cracked and be asymptomatic until adventitia gives way
Management:
• Aortogram
• Widened mediastinum on CXR not sufficient to rush to surgery; could be mediastinal
hematoma from other causes
A 22-year-old man has been shot in the abdomen with a 38 caliber revolver. He is
hemodynamically stable, but has moderate abdominal tenderness. There is an entrance
wound to the left of the umbilicus, and x-rays show the bullet lodged in the right paraspinal
muscles.
Management:
• Management of abdominal trauma straight forward in gun shot wounds and any
trauma that results in acute abdomen: exploratory laparotomy!
• Prep includes bladder catheter, big bore IV lines, broad-spectrum antibiotics
• Stab wounds more controversial
Case #16:
A 27-year-old man hits his abdomen against the steering wheel when his car collides with
another at an intersection. On arrival at the ER, his blood pressure is 95/75 and his pulse is
98. His abdomen is distended, tender in all four quadrants, with muscle guarding and rebound
tenderness.
Management:
Case #17:
A 32-year-old woman has been involved in an automobile accident. She has facial
lacerations, a broken arm, and bruises over her chest and abdomen. CXR is normal. Shortly
after arrival at the ER, she becomes progressively hypotensive, tachycardic and diaphoretic.
Her hematocrit is dropping and her central venous pressure is low.
• Head: No. Would have developed neuro signs . Hypovolemic shock can’t happen
from intracranial bleed.
• Chest: No. Pericardial sac not a possibility (low CVP in this patient); pleural spaces
could fill with blood but would have seen on CXR.
Where is the bleed?
• Pelvis or thighs: large enough spaces to hold that much blood, but vignette doesn’t
suggest these possibilities.
• Most likely: Abdomen
• Abdominal CT: will show the blood and source and will give idea of magnitude.
• Note: abdominal CT requires that patient be hemodynamically stable!
Case #18:
Management:
• Don’t attempt to pass a Foley!
• Retrograde urethrogram: anterior injuries repaired at the time; posterior ones delayed
• If urethrogram negative, pass a Foley and perform a cystogram. Look at post void film
Case #19:
A 55-year-old woman sustains multiple injuries in a car accident including fractures of the
lower ribs on both sides. There is no pelvic fracture. When a Foley catheter is inserted, gross
blood is recovered.
Management:
• Most penetrating renal injuries need surgery; most blunt ones do not
• Avulsion of renal pedicle example of exception
Case #20:
A 26-year-old man is shot in the leg with a 22-caliber gun. The entrance wound is in the
anteromedial aspect of his upper thigh, and the exit wound is lower down in the posterolateral
aspect of the thigh. He has normal distal pulses in that leg, and a small, non-expanding
hematoma under the entrance wound. The bone is intact.
Management:
Case #21:
A 14-year-old boy complains of pain in his right knee. His family notices that he has been
limping. He is sitting on the examination table with both feet dangling, and the right foot is
rotated towards the left. Physical examination is completely normal for the knee, but it shows
limited hip motion. When the hip is flexed, the leg goes into external rotation and it can not be
internally rotated.
Management:
• Orthopedic emergency
• After AP and lateral x-rays confirm diagnosis, femoral head will be pinned in place
Hip pathology:
In newborns: think developmental dysplasia (order sonogram; not CXRs); treat with
Pavlik harness
Painful hip in toddler after a febrile illness: think septic hip. Diagnosis established by
aspiration under general anesthesia. Emergency drainage required.
Hip pathology: By age group
Hip pain in early teens (boys): think slipped capital femoral epiphysis
Case #22:
A child complains of persistent, severe pain in his arm. He has a very tender area to palpation
at a very specific point in his radius, but he has no history of trauma to that area. For the past
several days he has had a febrile illness, for which he has received no treatment.
• A febrile illness in a toddler, followed by refusal to move the hip is a septic hip (an
emergency).
• A febrile illness in a child, followed by bone pain is osteomyelitis.
Management:
Case#23:
A 55-year-old homeless man comes to the ER complaining of extremely severe pain in his
right forearm. He has no history of trauma to that area, and relates that he was very drunk,
slept on a park bench, the next morning, the arm was numb, and began to hurt shortly
thereafter. The muscles in his forearm are very firm and tender to palpation . He has
excruciating pain when they are subjected to passive extension. Pulses at the wrist are
normal.
• Prolonged ischemia, followed by reperfusion, is the usual setting for the development
of compartment syndrome.
• Forearm and the lower leg are the two most common sites.
• Excruciating pain with passive extension is a classical finding.
• Presence of normal pulses does not rule out compartment syndrome.
Management:
• Emergency fasciotomy
• Permanent disability will ensue, if not promptly decompressed.
Case #24:
A 46-year-old man develops sudden excruciating pain, when attempting to lift heavy
object,“like an electrical shock,” in his lower back and down the posterior aspect of his right
leg. He suffered from very mild back pain for several months, which he attributed to “muscle
spasms.” At this time he is unable to ambulate, he keeps the right leg flexed, and says that the
pain becomes unbearable when he sneezes, coughs, or strains. Straight leg raising elicits
excruciating pain.
Management:
• MRI for diagnosis. Bed rest for several weeks, unless he develops progressive
neurological deterioration, or has sphincteric deficits.
• MRI is the best way to look at the cord and roots.
• Bed rest takes care of most herniated discs. Surgery is rarely needed.
Management:
• The cauda equina syndrome (distended bladder, flaccid rectal sphincter, perineal
saddle anesthesia) is a surgical emergency.
Case #25:
Diagnosis: Atelectasis
Diagnosis: Atelectasis
Day 1: atelectasis
Day 5: thrombophlebitis
Management:
Rule out other causes of fever by checking the wound, IV sites, and her urine; Document
extent of atelectasis with chest x-ray, improve ventilation with deep breathing and coughing,
postural drainage, incentive spirometry.
Case #26:
On the seventh post-operative day after pinning of a broken hip, a 72-year-old lady develops
sudden, sever chest pain and shortness of breath. The pain is accentuated by deep breathing.
She is anxious, diaphoretic and tachycardic, and she has prominent, visibly distended veins in
her neck and forehead.
Management:
• Confirm the diagnosis with blood gases (that will show hypoxemia and hypocapnia),
and ventilation-perfusion scan.
• Although pulmonary angio is the “gold standard,” ventilation-perfusion scan is more
commonly done.
• If PE’s recur while properly anticoagulated, place a Greenfield vena cava filter.
Case #27:
12 days after surgery for multiple gunshot wounds, a 27-year-old man becomes progressively
disoriented and unresponsive. He’s had multiple complications, including several
intraabdominal abscesses that have been percutaneously drained. He has bilateral pulmonary
infiltrates, and a PO2 of 65 while breathing 40% oxygen. Meticulous attention has been paid to
his fluid balance, and there is no evidence that he is in congestive heart failure.
Diagnosis: ARDS
Management:
• PEEP allowing enough hypercapnia to minimize pulmonary barotrauma. Continue the
search for other intraabdominal collections that may need to be drained.
Case #28:
Several hours after completion of surgery for multiple gunshot wounds to the abdomen, a 70
Kg., 52-year-old man is reported to have hourly urinary outputs of 17cc, 13cc, and 21cc, in
three consecutive hours. His blood pressure has hovered around 95 to 125 systolic during
that time.
Diagnosis:
Diagnosis:
• Look at his urinary sodium. It will be low (under 10 or 20 mEq/L) in the dehydrated
patient (give him more fluid), while it will exceed 40 in the case of renal failure (restrict
fluid).
Carlos Pestana, MD
GI/Abdomen Cases
A 62-year-old African-American man reports progressive dysphagia that started three months
ago with difficulty swallowing meat, and progressed to inability to swallow other solid foods,
then soft foods and now liquids. He has lost over 25 lbs. during that time. He has a history of
heavy smoking and drinking.
Management:
• Barium swallow first, then endoscopy and biopsies, eventually CT scan to determine
operability. Treatment will probably be palliative only.
• Although endoscopy and biopsy provides the diagnosis, the fear of perforation
prevents their use without a previous “road map” (provided by the barium swallow).
Management:
• Other esophageal tests, and when to do them:
o Questionable symptoms of reflux: pH monitoring
o Long standing clear picture of reflux: endoscopy and biopsies
o Dysphagia that is worse for liquids: manometry studies
o Hematemesis after prolonged vomiting: endoscopy
Case #30:
A 32-year-old man presents with a history of several days of protracted vomiting, progressive
abdominal distention, and colicky abdominal pain. He has not passed gas for the past 2 days.
On physical exam he’s found to have a distended, tympanitic abdomen with high pitched
bowel sounds that correspond to the colicky pain. X-rays show distended loops of small
bowel, with air-fluid levels, and no gas in the colon. 5 years ago he had an exploratory
laparotomy for a gunshot wound.
Management:
Management:
Case #31:
An 18-year-old college student develops anorexia, followed by vague periumilical pain, that a
few hours later localizes to the right lower quadrant and becomes sharp and consistent. On
physical exam he has tenderness to deep palpation, muscle guarding and rebound
tenderness, all of them localized to the right lower quadrant of the abdomen. His temperature
is 100.5 and his WBC is 13,000 with a shift to the left.
1. Anorexia
3. Sharp RLQ pain; plus the physical signs located rather than all over the
belly
Management:
• Emergency appendectomy
• For typical acute appendicitis, the management is still emergency appendectomy
(rather than a lot of diagnostic studies).
• In doubtful cases, the standard approach is Sonogram or CT scan. Sonogram is
cheaper but it is operator-dependent.
Case #32:
A 62-year-old man seeks medical attention at the insistence of his family, who have noticed
that he looks extremely pale. He admits to being tired and occasionally having fainting spells.
He is found to have a hemoglobin of 5, and 4+ occult blood in the stools.
Management:
Case #33:
A 34-year-old man has been passing large bloody bowel movements for the past 12 hours.
While in the office waiting to be seen, he has another very large evacuation of dark red blood.
On examination he looks pale and diaphoretic, has a blood pressure of 98 over 69, and a
pulse rate of 104.
• Three out of every four GI bleeders are bleeding from the upper GI
• Lower GI bleeding happens mostly to old people (polyps, cancer, diverticulosis or
angiodysplasia)
Diagnosis: Probably upper GI bleeding
• If patient is vomiting blood, the source is upper GI. If not vomiting (but presumed to be
actively bleeding at the time), the same information can be obtained by recovering
blood by NG tube.
Management:
• Start volume replacement. Pass nasogastric tube and aspirate. If blood is found in the
stomach, do upper GI endoscopy.
• The best diagnostic modality for upper GI bleeding is endoscopy (it allows treatment
also).
Management:
• If bleeding is not from the upper GI, and it exceeds 2 cc per minute (one unit of blood
every 4 hours), best diagnostic modality is emergency angiogram. Before you do it,
look for bleeding hemorrhoids!
Management:
Case #34:
A 63-year-old woman began to feel discomfort in the left lower quadrant of her abdomen
about 12 hrs. ago. The pain gradually built up in intensity and is now constant and moderately
severe. She has a vaguely palpable mass in her left lower quadrant, is tender to deep
palpation, w/mild muscle guarding and no rebound. She has fever and leukocytosis and
previously had 3 similar episodes requiring hospitalization.
Diagnosis: Acute diverticulitis
Management:
• CT scan will confirm the diagnosis. NPO, antibiotics and IV fluids should “cool it
down.” With three prior episodes, elective sigmoid resection should be considered.
Case #35:
A 47-year-old man develops extremely severe, colicky right flank pain of sudden onset, that
radiates to his inner thigh and scrotum. He also has mild nausea and some dysuria. When
seen in the ER, he is thrashing around on the stretcher, looking for a position of comfort. He
has microscopic hematuria.
• Abdominal pain from obstructive processes has sudden onset, is colicky , has specific
location and radiation patterns, and makes the patient move around seeking relief.
• Location and radiation patterns:
o Ureter: Flank, to inner thigh and scrotum or labia
o Biliary tract: RUQ, to back (as a belt) and right shoulder
o Pancreas: Epigastic, straight through to the back
Management:
• Start urological work up with sonogram, or plain film of the abdomen to be followed by
IVP.
Case #36:
A 57-year-old man is brought to the ER in the middle of the night. About one hr. before, he had
sudden onset of extremely severe abdominal pain, described as constant and involving his
entire abdomen. He lies motionless on the stretcher, guarding his abdomen with his hands,
perspiring, and obviously in great pain. His abdomen is rigid, very tender to palpation, with
muscle guarding and rebound in all quadrants.
• Abdominal pain from perforations has sudden onset, is constant and generalized, and
makes the patient lie still.
Management:
Case #37:
A 62-year-old man presents with progressive jaundice that began six weeks ago. For the past
two weeks he has had severe pruritus, and he also describes choluria and acholic stools. He
has total bilirubin of 24, with 14 direct (conjugated) and 10 indirect (unconjugated). His SGOT
(transaminase) is only mildly elevated, while his alkaline phosphatase is ten times the upper
limit of normal.
• Hemolytic jaundice has elevation of unconjugated bilirubin only, without bile in the
urine.
• Hepatocellular jaundice shows high levels of SGOT.
• Obstructive jaundice shows high levels of Alkaline phosphatase.
Management:
• Start with sonogram. It should confirm dilated ducts. If it shows gallstones as well,
continue with ERCP. If is shows thin walled, dilated gallbladder without stones,
continue with CT.
• A dilated gallbladder in a jaundiced patient suggests malignancy (Courvoisier-Terrier
sign).
Case #38:
A white, fat female, age 40 and mother of 5 children, has severe right upper quadrant pain
that began six weeks ago. The pain was colicky at first, radiated to the right shoulder and
around towards the back, and was accompanied by nausea and vomiting. The past 2 hours
the pain has been constant. She has tenderness to deep palpation, muscle guarding and
rebound in the right upper quadrant, a temperature of 101 and WBC of 12,000. Liver function
tests show a bilirubin of 2.5, and normal alkaline phosphatase.
Diagnosis:
Management:
• Start with sonogram. It should show gallstones, thick walled gallbladder and
pericholecystic fluid. NPO and antibiotics should “cool down” the process.
Cholecystectomy will be eventually needed.
Carlos Pestana, MD
Breast Disease
Case #39:
A 42-year-old lady has a 2cm. firm mass in her right breast, which has been present for three
months, and is steadily growing.
Diagnosis:
Management:
• Start with mammogram to identify other lesions if present. Then, core biopsies.
• Mammogram should precede biopsies in women over 35, but it is done to identify
other potential lesions, not as a substitute for the biopsy (only the pathologist can
make the diagnosis).
Management:
• Do not order mammograms below age 20 (breast too dense – use sonogram if
needed) or in lactating women (will only see milk).
• Depending on the probability of cancer, a spectrum of progressively more aggressive
Tissue sampling is done: FNA, core biopsy, mammotome, ABBI, incisional biopsy or
excisional biopsy.
Case #40:
A 32-year-old lady has a solitary, 2cm., firm mass in the right lobe of her thyroid gland. The
mass has been present for at least three years, and is growing very slowly. Her thyroid
function tests are normal.
Diagnosis:
Management:
Even with good case selection, most resected thyroid nodules are benign. Highest
yield of malignancy when selected by FNA.
Case #41:
A 42-year-old lady has had hypertension for three years, and is not responding well to therapy
with blockers. She has a potassium of 2.5. She has not been on diuretics.
Diagnosis: Hyperaldosteronism
• thin, hyperactive lady with episodes of pounding headache, palpitations, pallor, and
perspiration: pheochromocytoma.
• Young person with high pressure in the arms, low pressure in the legs: coarctation of
the aorta.
• Either young woman or old arteriosclerotic man, with faint upper abdominal or flank
bruit: renovascular hypertension.
Management:
• Confirm diagnosis by finding high levels of aldosterone and low levels of renin. Verify
adenoma versus hyperplasia with lack of response to postural changes. Locate the
adenoma with MRI or CT.
Case # 42:
An 8-hr-old baby in the newborn nursery is noted to have “excessive salivation.” A small, soft
nasogastric tube is placed, and the baby is taken to x-ray to have a “babygram.” The film
shows the tube to be coiled back upon itself in the upper chest. There is normal gas pattern in
the abdomen.
• The most common type of TE fistula has a blind end of esophagus at the top, and a
fistula between the distal esophagus and the trachea (that is how air gets into the GI
tract).
• First rule out the other components of the VACTERL syndrome: look for an
imperforate anus by physical exam, look for vertebral or radial anomalies in the x-ray,
do sonogram for renal anomalies, do echocardiogram to rule out congenital cardiac
defects.
• Have a primary repair of the fistula, or if other problems delay it, a gastrostomy.
Case #43:
Half an hour after the first feed, a newborn baby vomits greenish fluid. X-ray shows a “double-
bubble,” i.e., a large air fluid level in the stomach, and a smaller air fluid level to the right of it,
originating from the first portion of the duodenum.
Management:
• Although surgical correction will eventually be needed for either of the above,
malrotation represents a more dire emergency. Look for it with contrast enema, or
upper GI study.
• The main risk in malrotation is torsion of the mesenteric vessels with ischemic
necrosis of the entire small bowel.
Case #44:
A 3-wk-old baby boy has been vomiting repeatedly for 3 days. The vomiting is projectile, has
no bile, and follows each feeding. After vomiting, the baby seems hungry and eager to eat. He
looks somewhat dehydrated, and has a scaphoid upper abdomen with visible gastric
persitaltic waves. A small, olive-sized mass is palpable in the right upper quadrant.
Diagnosis:
• Abdominal problems plus cystic fibrosis equals meconium ileus (do gastrographic
enema).
• Progressive jaundice at age 8 weeks, think biliary atresia. Rule out hepatitis, do HIDA
scan after one week on Phenobarbital.
Management:
• First correct the dehydration and the hypochloremic, hypokalemic metabolic alkalosis
likely to be present. Then do Ramsted Pyloromyotomy.
Case #45:
Diagnosis: Intussusception
• For some reason everyone who describes a child with intussusception calls the blood-
tinged stools “currant jelly stools.” If you see that description in the exam question,
they have given you the diagnosis on a silver platter.
Management:
• Barium enema will show the pathology and reduce the intussusception. Surgery may
be needed to prevent recurrences.
Case #46:
A 15-month-old child is brought in with second degree burns on both buttocks. The stepfather
relates that the child is beginning to walk all around the house, and that he got into the kitchen
where he tipped a pot of boiling water.
Diagnosis: Child abuse
• All scaldings in babies should make you think of child abuse, but the pattern in both
buttocks is classic: the baby was held by arms and legs, and dipped into boiling water.
• Other classical presentations for child abuse:
Management:
• Silvadene cream for the burned areas, reporting to the proper authorities to protect
the child.
• After age 50, coin lesions have an 80% chance of being malignant. History of
smoking makes it more likely.
Management:
• Start by locating an older CXR if available. If the lesion was present and has
remained unchanged for a year or two, not cancer.
Management if this is a new lesion:
• Start with sputum cytology and CT scan (including upper abdomen to see liver).
• 2/3 of patients already inoperable when first seen. Thus the value of trying to
establish the diagnosis and extent in a non-invasive way (sputum cytology and CT
scan).
Management:
• Next steps to establish diagnosis (if needed): Biopsy via bronchoscopy for central
lesions, percutaneous for peripheral.
• Further diagnostic steps depends on potential for cure and ability to tolerate
pulmonary resection. Cure is not possible if there are mets at carinal nodes.
Resection is not possible if the residual FEV1 would be less than 800.
Management:
• Resectability is not an issue for small cell CA, which is treated with chemotherapy and
radiation.
Case #48:
A 72-year-old man is found on physical exam to have a 6cm. pulsatile mass in the abdomen,
located between the xiphoid and the umbilicus. The mass is not tender, and the patient is
otherwise completely asymptomatic.
Management:
• Size is the key-determining factor of the probability of rupture, and thus the need for
elective repair.
• Verify precise measurements with sonogram or CT scan. If indeed the aneurysm is 6
cm. in diameter, do elective surgical repair.
Management:
Management:
• Excruciating back pain in a patient with an abdominal aortic aneurysm means the
aneurysm is already rupturing (leaking retroperitoneally, and about to blow up into the
peritoneal cavity). Surgery has to be done as a super-emergency.
Case #49:
A 63-year-old car salesman is having difficulty doing his job. He works at a large, suburban
used-car lot which is about 3 blocks long. When he walks about 1/2 a block, he gets severe
cramping pain in his right calf, and must stop and rest for the pain to go away. As soon as he
has walked another 1/2 block, pain recurs. He is the sole supporter of his family and he is
about to be fired. He does not smoke.
Management:
Case #50:
A blond, blue-eyed, 71-year-old West Texan farmer of Scandinavian ancestry, has a non-
healing, indolent, punched-out, 2 cm. ulcer in the skin over his left temple, which has been
slowly growing over the past 3 years. He has no palpable lymph nodes in the head and neck,
but his skin has a “weather- beaten” appearance, with multiple areas of actinic keratosis.
• Skin cancer (basal cell, squamous cell, and melanoma) occur mostly in light-skinned
individuals with a lot of sun exposure.
• Most basal cell carcinomas are above a line drawn across the mouth, while most
squamous cell carcinomas are below that line.
• Melanomas occur in pigmented lesions that either have the ABCD mnemonic
(ASYMETRIC, irregular BORDERS, various different COLORS, and a DIAMETER
over 0.5 cm.); or else pigmented lesions that have recently changed (in any way).
Management:
• Full thickness biopsy at the edge of the lesion, including the bed of the ulcer and the
normal skin next to it. Resection with appropriate margins.
Case #51:
A 12-year-old boy has a round, 1 cm. cystic mass in the midline of his neck, at about the level
of the hyoid bone. The mass retracts when the tongue is pulled forward. Although the mass
has been present for at least 8 years, it had not bothered the patient until it got infected and
drained some pus a few weeks ago.
• Congenital masses in the neck are seen in young people, they typically have been
noticed for several years, but medical help is not sought until they become
symptomatic.
2. Up and down the anterior edge of the sternomastoid: Branchial cleft cysts
Management:
• Elective surgical resection, removing the mass, the middle segment of the hyoid bone
and a core of muscle from the tongue all the way back to the foramen cecum.
Case #52:
3 months ago, an 18-year-old woman noticed the presence of a 2 cm., firm, non-tender node
located in the left jugular chain, at the level of the hyoid bone. She thinks it is larger now than
when it first came to her attention. For the past 3 weeks she has had low grade fever and
night sweats. Physical exam confirms the presence of the node, and also shows 2 other
smaller nodes on that side of the neck, as well as enlarged nodes in both axillas.
Management:
• Start with FNA of the most accessible, largest node. Excisional biopsy will probably be
needed to establish specific tumor type.
• When dealing with a node that has just been discovered, a delay of a few weeks (two
or three) is appropriate before doing invasive, expensive studies. If the node was
inflammatory, it may go away during that time.
Case #53:
A 72-year-old man seeks help for a 4 cm., fixed, hard mass in the left jugular chain, at the
level of the upper edge of the thyroid cartilage. Patient says that he found it a week ago, but
his wife claims that it has been present for at least 6 months. The patient has a long-standing
history of alcohol and tobacco abuse, and he has terrible oral hygiene.
Management:
• Do not biopsy the mass! (FNA is OK, but do not take a piece of it.) Best way to
establish the diagnosis is with panedoscopy (“triple endoscopy”) looking for and doing
biopsy of the primary (or primaries). Then CT scan for determine operability. Platinum-
based chemotherapy and radiation therapy have central role in therapy.
Management:
• Another area where open biopsy is a no-no: Tumors of the parotid gland (anything in
front of the ear, or behind the angle of the mandible)
Carlos Pestana, MD
General Surgery Cases
Management:
• Duplex scanning of his carotid vessels, looking for stenosis of at least 70%, or
ulcerated carotid plaque, on the left. Carotid endarterectomy for either of the above.
• TIA’s are a predictor of strokes. Elective surgery is indicated if stenosis of at least
70%, or ulcerated plaques at the carotid bifurcation are found.
Case #55:
Diagnosis:
Subarachnoid bleeding from an intracranial aneurysm
• The sequence of an undiagnosed “sentinel bleed,” and a second bleed a few days
later is often seen.
• Prognosis depends on severity or neurological deficit at the time of presentation.
Identifying the “sentinel bleed” is crucial, because the next one may be devastating.
Diagnosis:
• Other conditions leading the intracranial bleeding include A-V malformations and
uncontrolled hypertension.
Management:
Case #56:
A 42-year-old right-handed man has a history of progressive speech difficulties and right
hemiparesis for five months. For the past two months he has had progressively severe
headaches, worse in the mornings. At the time of admission he is confused, has projectile
vomiting, blurred vision, papilledema and diplopia.
Diagnosis: Brain tumor, on the left side, affecting the motor strip
and the speech center, with signs of increased intracranial
pressure.
Diagnosis:
• Location nay not be obvious, if the tumor is pressing on a “silent area” of the brain,
but it may be clear if a particular function if affected.
• Some typical locations:
Management:
A 13-year-old boy presents with excruciating pain of sudden onset in his right testicle. No
fever, pyuria or history of recent mumps. The testis is swollen, very tender, located high in the
scrotum, and with its long axis in a horizontal position. Cord above the testis is not tender.
Management:
Case #58:
A 74-year-old man has a 3mm. ureteral stone lodged just above the ureterovesical junction.
He is receiving IV fluids and analgesics, with the expectation that the stone will pass. He
suddenly develops chills, his temperature shoots up to 104, and he complains of severe flank
pain.
• Urinary tract infections that are unexpected (i.e. on people who should not get them),
have to be worked up for possible unsuspected obstruction. Examples:
o Urinary tract infection in children
o Urinary tract infections in men
Management:
Case #59:
A 59-year-old man reports an episode of gross, painless hematuria, without any history of
trauma. He has normal renal function.
• Most cases of hematuria are from benign disease, but cancer has to be ruled out on
all of them.
Management:
Case #60:
During a routine physical, a 64-year-old black man is found on digital rectal exam to have a
rock-hard, discrete, 1.5 cm. nodule in his prostate.
• Except for very advanced cases, prostatic cancer is asymptomatic and has to be
actively sought.
• The two complementary screening exams are the digital rectal exam and the prostatic
specific antigen (PSA).
• The classical palpable tumor is a rock-hard discrete nodule.
Management: