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4 y/o M afebrile, nL labs, limited internal rot. and abduction of hip. Dx?
- Legg-Calve-Perthes disease, or idiopathic osteonecrosis of femoral head.
- 4-10, M predominance.
Benign bony growh located on midline suture of hard palate, secondary to both genetic and env. factors.
Common in young Fs, especially Asians.
What is an eschar
Eschar = Firm, necrotic tissue due to vascular limitation secondary to edema s/p burn.
Can cause compartment syndrome
S/p tonic-clonic seizure. Arm adducted and internally rotated. Inability to externally rotate.
Fat necrosis of the breast
- Risk factors include
- On biopsy shows macrophages and fat globules
Infection of submandibular and sublingual glands fron infected tooth. Can cause drooling and asphixiation. Fever, dysphagia, odynphagia, drooling.
SCC which arises within a burn wound. Can also occur from osteomyelitis, radiotherapy, venous ulcers.
1st and 2nd most common causes of hypotension with blunt abdominal trauma
- (1) Splenic laceration
- (2) Liver laceration
Bone pain, 10-20 y/o male,
- Alk phos is elevated
- Usuallye ffects areas of high growth.
- Pain worst at night.
- Pain typically begins after trauma.
- Usually ICU patient
- Probably due to cholestasis and gall bladder ischemia leading to infection.
- Gallbladder distention
- Gallbladder wall thickening
- Pericholecystic Fluid
How do you recogonize compartment syndrome
- Key words to look for:
- Ischemia-Reperfusion Syndrome
- Soft tissue swelling
Treatment for diverticulitis
Uncomplicated: Outpatient bowel rest, oral Abx (metronidazole, cipro), observation.
- Fluid collection < 3 cm = IV Abx, observation
- Fluid collection > 3 cm = CT-guided drainage, than surgical drainage and debridement if no improvement by day 5.
- Tetanus Immune globulin = Passive, temporary, immediate
- Tetanus-diphtheria toxoid = Active, prolonged, delayed
Toxoid for anyone with severe wound w/ last dose > 5 years ago.
Toxoid for any with clean minor wounds w/last dose > 10 years ago
TIG injection for anyone w/ less than 3 vaccines or unknown immune status.
Scaphoid fracture buzz words
- Pain on radial side of wrist
- Pain in anatomic snuffbox
- Decreased grip strength
- Repeat X-Ray if initially negative
Diffuse Axonal Injury
- Traumatic Deceleration Injury
- Vegetative State
- Occurs at gray white matter junctions where density difference is greatest.
- Minute punctate hemorrhages on CT
Acute Febrile Nonhemolytic Tranfusion Reaction
- Fever, rigors
- Immune mediated host antibodies that bind donor cells.
- Activates complement and inflammatory cytokines.
- Bilateral hip, thigh, buttock claudication
- Symmetric atrophy of bilateral LE 2/2 ischemia
Arterial occlusion at bifurcation of aorta into common carotids.
Labeled Erthrocyte Scintiography
tagged RBC scan used to identify source of bleed in case of occult lower GI bleed
When do you delay appendectomy?
- Syxs>5 days
- Usually have phlegmon w/walled off abscess.
- Give IV Abx, Bowel rest
- Delayed Appie a few weeks later.
What structures are at risk with a middle third clavicle fracture?
Brachial Plexus and Subclavian Artery
What to do with a scaphoid fracture?
- If displaced: Open reduction and internal fixation
- If no fracture shown, repeat in 10d.
- Somatostatin analog
- Acromegaly; gigantism
- Diarrhea from Carcinoid Tumor
- Bad dumping syndrome following gastrectomy
dx study for suspected esophageal perforation?
Meniscus vs. MCL or LCL vs. ACL/PCL injury
- Medial Meniscus (more commonly injured than lateral meniscus):
- Popping sound and severe pain after twisting injury.
- Positive McMurray's sign: Palpable or audible snap while slowly extending the knee w/ tibial torsion.
ACL: Forceful hyperextension or deceleration injury. Anterior drawer test
PCL: "Dashboard injury" Posterior-directed force on tibia with knee flexed at 90*
MCL/LCL: Valgus/Varus stree test. MCL = Abduction; LCL= Adduction is rarely injured.
- Preschool children.
- Subluxation of head of radius at elbow. Arm held in pronation at chest.
Supinate forearm and flex elbow to reduce.
Bladder versus urethra traumatic injury? Sign and diagnostic study?
Bladder Injury: Gross hematuria, retrograde cystogram w/ post-void films.
Urethra injury: Blood at the meatus, get retrograte urethogram.
Who get's oxalate stones?
People with fat malabsoprtion (e.g. Crohn's disease) becasuse Ca+2, which usually binds oxalate and prevents it from being reabsorbed, is used up binding fat, so you get more oxalate in body.
Other causes of acute pancreatitis
- In addition to EtOH and cholelithiasis
PCWP, different values
- Low suggests hypovolemia
- nL 2-15
- High suggests alternative cause, such as myocardial contusion
What to do when you suspect PVD but have nL ABI
Try ABI pre/post exercise. Exercise can expose moderate ABI.
Contrast Aortic Injury/Rupture, Myocardial Contusion, Myocardial Rupture
- Myocardial rupture = Immediate death
- Myocardial contusion = Tachy with new arrthymias, sometimes sternal fracture
- Aortic Injury/Rupture = Widened mediastinum, L hemothorax.
Extremity arterial thrombosis vs. arterial occlusion
- Embolism = Acute pain, pulselessness, pallor
- Thrombosis = Slow, progressive narrowing with insidious onset.
- Caused by axial load (e.g. fall)
- Can lead to anterior cord syndrome with loss of pain and temp., motor control.
Central Cord Syndrome
- Greater motor loss in UE than LE
- Bladder dysfunction & urinary retention
- Variable sensory loss below level of injury.
- Freq caused by hyperextension injury in elderly.
Mallory-Weiss Tear vs. Esophageal Rupture
Esophageal Rupture/Boerhaave Syndrome -> Instrumentation in esophagus or vomiting (w/ resistance) causes pneumomediastinum
- In contrast,
- Mallory-Weiss tear = Incomplete tear at GEJ. Presents as self-limiting hematopoesis because rupture is incomplete.
Carboxyhemoglobin level indicating need for incubation in burn patient
Key notes on varicocele
- Will not transilluminate.
- More common on the L
- Dull or dragging discomfort.
What part of the bladder can cause leakage into peritoneum and pain on shoulder?
Nature of stress fractures
Do not result from discrete injuries such as falls/trauma. Instead secondary to repeated stress. Long distance runners most commonly effected, tibia and fibula most vulnerable.
Differentiating osteosarcoma and Ewing's Sarcoma
- Both in young males
- Osteosarcoma: Knee, sunburst pattern/Codman's triangle on X-ray. Risk factors: Paget's Disease; bone infarcts; radiation; familial retinoblastoma. No systemic features.
Ewing's Sarcoma: Anaplastic small blue cell malignant tumor. Onion-skin appearance on bone. Diaphysis of long bones. 11;22 translocation. Systemic features: fever; malaise; weight loss.
Paget's disease of Bone
- Disordered bone remodeling in old people.
- Increased osteoclast and osteoblast activity.
- Results in structurally inferior woven bone throughout the body (which is bigger)
- Frequently asymptomatic
- Bowing/fracture of long bones resulting in arthritis of hip, knee.
- Frontal Bossing/ Increased hat size.
- Hearing loss due to cochlear damage from enlargement of temporal bone.
- Increase in Alk Phos and Phosphorus levels.
- Recurrent skin infections around coccyx.
- Can form sinus tracts.
- Pilonidal cysts most common in young M, esp. w/lots of body hair.
Buzz word Nasopharyngeal Carcinoma
- Common in runners.
- Mechanically induced neuropathic degeneration
- Neuropathic pain radiating from 3rd and 4th toe metatarsal heads.
Intraductal papilloma of the breast
- Intermittent bloody discharge from one nipple,
- nL u/s and mammo bc mass is typically right under nipple.
Anterior vs. Posterior Shoulder Dislocation
- Anterior: Arm in Ext. rotation abducted (more common)
- Posterior: Arm in internal rotation adducted
What can be damaged in supracondylar fracture of the humerus in children?
What other infectious cause can mimic appendicitis