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Surgery Surgery Notes for the USMLE Step 3 Exam

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Surgery Notes for the USMLE Step 3 Exam

Complete rectal prolapse: A mucosal or full thickness layer of rectal tissue slides through the anal opening. Usually associated w/ conditions causing an increased intraabd P like constipation, BPH, and COPD. Presents w/ pain in anal area, rectal bleed, protruding rectal mass. If unctreated, strangulation and gangrene of the peolapsed mucosa is possible. This is a surgical emergency.

Painless testicular mass: always suspect malignancy. Should examine w/ scrotal US and measure serum tumor markers. A better procedure is a radical inguinal orchiectomy (can do histological analysis of the tumor).

MCC of oral lesions in elderly is trauma (esp dentures). Pt who wears dentures has a lesion in their mouth: try not wearing dentures for a couple weeks. If lesion persists, then consider malignancy (do a biopsy). Otherwise its ok.

Stress fractures: usually see in ppl with excessive running or training. There is pain w/ activity, which improves with rest. There is tenderness and swelling locally over the fracture site. Often, plain films are unrevealing for the first 2-4 weeks after the injury. MRI or technetium bone scans are very sensitive. Rx is generally w/ conservative treatment. Juts stop all activity for 4-6 weeks, and gradually return to activity.

Anal abscess: present w/ severe, constant pain with possible fever. Exam shows reythematous, indurated skin or a lfuctuant mass over the perianal or ischiorectal space. I and D is FSOM. In pt w/ DM, immunosuprpession, or extensive cellulitis, should also give abx. 50% of pt with anal abscess will go on to develop a fistula. Presents as a persistent abscess despite drainage. Fistulas usually need surgery.

Pancreatic cyst: Presence of it without any hx of pancreatitis should be considered malignant until proven otherwise. This is especially true if cyst is loculated in appearance on CT. Otherwise, it could just be a simple cyst. If loculated, should do surgical resection.

Silicone breast implant: Main complications are with capsular contracture which causes pain and shape distortion. Rupture is another common one, which could require removal of the implant. Otherwise, though, there is no evidence tosuggest an increased risk of any other disorder. Silicone also has no harmful effects on a developing fetus. It also doesnít increase any risk of anything with breast feeding. Babies can be breast fed as normal. Capsular contraction might interfere with mammogram, but in general silicone doesnít interfere with mammograms. Ppl with implants should still continue at regular intervals. Desmoid tumor: locally aggressive neoplasms aarising from muscle. Locally invasive, so only causes local complications. Present as minimally painful or painless, slow growing masses over a part of the body. Dx with tissue biopsy. Rx is surgical resection. There is a high rate of local recurrence, so look for old scars from previous removals.

Asymptomatic Gallstones: Most pt with these will never experience symptoms. Often, risks of therapy might exceed ebenfit. Can just observe. Ursodeoxycholic acid is indicated for pt with mild symptoms and small cholesterol stones. 50% efficacy, but can cause diarrhea.

Varicocele: dilation of pampiniform plexus (responsible for keeping testes cooler than rest of body). Presents as a mass (looks like worms in a bag), not tender, not fluctuant, and warm. Itís warm because the temperature within the testes has gone up. Thus, if you donít treat it, the temp will rise too high and cause the testicle to atrophy. R is with surgery.

Bilateral varicocele: if pt present w/ this, consider proceese that cause IVC obstruction (clot, tumor). CT abd would be good FSOM to look for mass obstruction. Also consider blockage in pt with varicocele which doesnít disappear in the supine position, or right varicocele (most varicocele are L sided).

Breast mass in pt < 35 yo: Most likely benign. Still, ned a full workup. Benign cysts are most prominent just before the start of a menstrual cycle, and regress after menstrual period is over. Other features suggestive of cyst include: smooth, soft, mobile, round. A diffuse nodularoity in the cyst is likely fibrocystic disease. FNA biopsy should be done with easily palpable cystic masses. If you get blood, send for cytology. If not, just reexamine in 1 month to see if mass regressed at all. Mass that goes away doesnít need further eval. US might be useful to distinguish cyst from solid mass. Also 2nd option if pt doesnít want FNA.

If you have a mass which is solid, too small, or cannot be felt, US is probably the best Dx to see if you ned a biopsy or not.

Cryptorchidism (undescended tests): Majority of cases resolve spontaneously by first several MONTHS of life. Risk of malignant transformation is increased, and remains so even after orchipexy (surgery). Orchipexy should be done before 2 years of age, and as early as 6 months. If untreated, complications of undescended testes include decreased fertility, increased risk of torsion, inguinal hernia, and malignant transformation. Orchipexy doesnít help w/ malignancy too much, but does help prevent torsion and infertility.

PSA: normal range is < 4. If > 4, should refer to urologist for a biopsy. PSA is ok for screening, but onlny biopsy can r/o cancer. 20% of pt with > 20 PSA have cancer. Cutoff value was reduced to 4 to increase sensitivity.

Transurethral Resection of the prostate: management of BPH. MC complication is retrograde ejaculation. Urinary incontinence and erectile dysfunction are complications of radical prostatectomy (used for Rx of early prostate cancer). These complications arenít problems with TURP.

If you do a TURP/biopsy/cytology and diagnose Prostate cancer, suprapubic resectionof the prostate is accepted therapy. Also do a lymph node resection.

Varicose Veins: visible, palpable veins of the legs. Usually asymptomatic, but might complain of cramping, heaviness, fatigue, and swelling. Symptoms worse w/ prolonged standing, and improve with leg elevation. FSOM is conservative: just leg elevation and compression stockings. Sclerotherapy is used for pt who have failed 3-6 months of conservative Rx. Youíre basically damagint (sclerosing) the vein, preventing further vein filling.

Peripheral Vascular Disease: Present w/ pain with walking. Relieved ith rest. Various CV risk factors probably present. Diminished distal pulses. Increased pallor w/ elevation of limb. Can Dx with ABI. Divide the lower extremity SBP by the brachial SBP. Normal ABI is 1-1.3 (At ankle, SBP should be higher than in the arm d/t gravity). ABI < 0.9 is a good cutoff for clinically significant PVD. ABI < 0.4 usually means there is ischemia. Besat conservative Rx for PVD is cliostazol (PDE inhibitor which inhibits platelet aggregation, also direct arterial vasodilator).Can be safely taken w/ aspirin and clopidogrel.

Complex Regional Pain Syndrome: criteria are presence of an initiating event or cause of immobilization, continuing pain, allodynia (pain w/ normally nonpainful stimulus), evidence of edema, or change in skin blood flow, and absence of other conditions. What happens is that after the initial event, the sympathetic system activates in order(normal). However, the sympathetic activity doesnít go away, and keeps going, eventually leading to vascular compromise (ischemia, atropht). Phenoxybenzamine (a-blocker) is good since it curtails sympathetic activity.

If some disease process causes LAD, and the LAD doesnít resolve along with the disease, then should be concerned about a lymphoma. Can be the first clinical sign of a lymphoma. Should get a biopsy.

Dumping syndrome: After gastrectomy, food and liquid passes through the stomach into the jejunum too fastr, laeidng to abd pain, diarrhea, N/V after eating. Dyspnea and dizziness might even happen. Usually change to a high protein diet w/ small frequent feedings will help.

Rectal cancer: the surgery always has a risk of messing up the spincter. Best type of cancer which will probably allow a sphincter sparing surgery is a proximal node + cancer. With these you can do a lower anterior resection (w/ chemo + radiation). Distal rectal cancers may be treated either with local resection (sphincter sparing) or abdomino-perineal resection (extensive radical operation). Location of the tumor is a big part of whether sphincter can be saved.

Porcelain gallbladder: Ca salts deposit in the wall of a chronically inflamed gallbladder. Usually gallstones are also present. See the Ca on a plain film, but CT is what is used to confirm the diagnosis. Ppl with porcelain gallbladder have higher risk of gallbladder cancer, so an elective cholecystectomy is recommended.

Subphrenic Abscess: usually develops 14-21 days aftrer abd surgery. Presents w/ swinging fever, leukocytosis (abscess). Cough and shoulder tip pain may also be present. Abd US is a good test for dx this.

Inguinal Hernias: These do not resolve with age, with high risk of potential compliations. Direct hernias are d/t musclear weakness of abd wall, and are rare in infants, more likely seen in elderly age group. Inguinial hernias in pediatric pt should be repaired ASAP.

Femoral Hernia: much higher risk of strangulation compared to inguinal hernia. Thus, should get surgery if you ever notice a femoral hernia.

Raloxifene: SERM (selective for bone) to improve bone mineral density. Increased risk of DVT and PE, so should be d/c 72 hours before surgery.

MCL injury: tenderness and pain along medial joint line. Usually involves valgus (abductor) stress to a partially flexed knee with fixed foot. There is pain with valgus stress of the knee. Injury happens with force from a leteral to medial direction.

ACL injury: Usually happens after a cutting movement, non-contact deceleration, or hyperextension. Poppig sound might be present. PE shows pain with doing a anterior drawer or Lachman maneuver.

PCL injury: little pain or alteration in ROM, but posterior drawer test is positive. Uncommon. D/t a posteriorly directed force on a flexed knee. Alternatively, can happen in a pt who falls on a flexed knee with the foot in plantar flexion. Knee doesnít appear quite as unstable as in ACL injuries.

Testicular cancer: suspect in any pt with hx of painless scrotal swelling. Key PE to do is transillumination. If mass illuminates, likely ot be a hydocele. FSOM is scrotal US to differentiate intra and extra testicular lesion. Cysts or fluid filled mases are unlikely to be cancerous. If you see something odd on US, do a CT of abd and pelvis. Measure afp and b-hcg. If test results make cancer likely, do a radical inguinal orchiectomy to get histological analysis. Testicular cancer has good prognosis if dx and treated early.Dont do a testicular biopsy/FNA since this might disseminate cancer cells.

Klinefelter syndrome (47 XXY) is associated w/ higher risk of breast cancer. In fact, this is the strongest known RF for male breast cancer (50x normal men). Some features include hypogonadism, low testosterone, and gynecomastia.

Retrosternal Goiter: can cause compressive symptoms. Iodine deficiency is a RF. Usually these are multinodular. Should do surgery to remove.

Bile salt induced diarrhea: commonly seen after cholecystectomy. Removal of gall bladder causes a shift to secondary bile acids, which are more likely to cause diarrhea. Cholestyramine is good Rx, as it can ind bile acids.

Epididymitis: can be associated with a unilateral hydrocle (confuse for testicular mass). With this infection, there is a testicular pain and tenderness. No voiding symptoms are present, and UA is normal. MCC is Chlamydia. Cremasteric reflex is intact. Prehnís sign (decrease in pain on testicular elevation) is usually positive. Do transillumination to see if an enlarging mass is hydrocele or malignancy.

Gastric bypass surgery (or equivalent bariatric) is recommende for pt w// BMI > 40, or serious co-exisitng medical problems or a markedly decreased quality of life.

Orchitis: presents as sudden onset of fever, severe scrotal pain, and swelling. Especially be on lookout for it in mumps pt.

Clavicle Fracture: Very common. Criteria for return to sactivity is a judgement call. Can do lower body excercises if no injuries there. When shoulder pain resolve, can do gentle pendulum excercises for shoulder motion. Generally, can return to activities is ok after pt has achieved the following. Painless, full, active ROM. Near normal strength. Evidence of bridging callus. Usually happens within 6 weeks in younger pt.

Thyroglossal duct cyst: Presents w/ midline neck mas that moves w/ protrusion of tongue. Sometimes, the ectopic tissue on the cyst is the only functional tissue a pt has, so need to do imaging to look for a normal thyroid before surgery to make sure pt will still have thyroid function. CT scan is good. FNA usually not needed. These cysts have a high chance of being infected.

With elderly ppl, think about whther to take them to surgery or not: If there are no benefits from surgery, donít do it. Consider the ptís functional status and other comorbidities. If a pt is bedridden, benefit might be minimal. Pain alone is not a good indication for surgery, since you can manage pain w/ meds.

Acute arterial occlusion: Limb ischemia will have 5 Pís (pallor, pain, pulselessness, paresthesia, paralysis). Usually d/t embolus from distal source, trauma to artery, or acute thrombosis d/t previously diseased vessel. Sudden onset of symptoms in asymptomatic pt is likely embolus. Usually emboli are from the heart, but can also be from peripheries. FSOM is to do an embolectomy, then you should do histology on the embolus to find out where it came from. If it came from heart do an echo.

Atrial myxoma: most common primary cardiac tumor. Often in the LA. Can be friable, leading to embolization. Can also present with sudden onset of heart issues (heart failure, afib in a young pt). Might have some mitral valve signs (diastolic murmur) if big enough. Dx with echo. Rx is excise the mass ASAP to reduce risk of embolus.

Indication for surgery of shoulder fracture: compound fracture, distal comminuted fracture, multiple trauma, or severe displacement jeopardizing skin integrity. Otherwise, just a sling or figure of 8 brace is good enough.

Acute mesenteric ischemia: presents w/ acute onset of sever abd pain which has a PE that doesnít match the severity of of the pain. Metabolic acidosisis also present. This presentation is mesenteric ischemia until proven otherwise. Radiology might all be normal. MCC is superior mesenteric a. d/t thrombosis, embolus, or vasospasm. Must treat promptly. If untreated, bowle infarction, sepsis, and death could happen.

Osteoperosis can heppn in men too, especially male > 60 yo. Age is the single most important RF for osteoperosis and osteoporotic bone fracture. Steroid, anti-androgens, and anticonvulsants may also predispose pt to osteo.

Scaphoid fracture: classically, falling on an outstretched hand. The hyperextension and radial deviation of the wrist causes it. There is severe loss in ROM of the wrist, as well as severe pain and stiffness. Pt with a nondisplaced scaphoid fracture can have normal radiographs for up to 2 weeks after a traumatic incident. CT should benext step if you suspect it highly but plain filsm are negative. Rx for uncomplicated, undisplaced scaphoid fractures are immobilization in thumb cast w/ wrist in radial deviation. MC complication of scaphoid fractures is nonunion. Other one is avascular necrosis. Non union is more common.

Scrotal Trauma: US utility is controversial. Nromal US shouldnít preclude surgical exploration if there are obvious concerns on physical exam. Itís important to minimize chance that pt will need orchiectomy.

Parathyroidectomy: After surgery, serum Ca can fall, and symptoms of hypoCa could actually develop. These include perioral numbness, cramps, positive Chvostek sign (contraction of facial muscles on tapping the angel of the jaw) Whatever signs happen from this are bilaterally symmetrical. This effect is called hungry bone syndrome. The sudden drop in PTH causes all the Ca to shift from the serum into the bone, causing hypoCa symptoms. Usually develops 2-4 days postop.

Bellís Palsy: unilateral facial asymmetry. Usually recent URI. This is a lower motor neuron involvement of the facial nerve.

Acute compartment syndrome: ischemic tissue damage d/t elevated P in enclosed compartments of legs or forearm. In the LE, the cause is usually a traumatic event (tibial fracture). Any crush injury could also cause it. Presents as pain out of proportion to extent of injury. Pain with passive muscle flexion and tightness and weakness are other early signs. Sensory is usually affected earlier than motor. Decreased vibration sense, 2 pt discrimination, and numbness. If untreated, there is paralysis and absent pulses later on. Also leads to rhabdomyolysis which can lead to acute renal failure (life threatening). Dx it quickly by checking tissue pressure (> 30 is positive). This is a surgical emergency. Quickly rx with fasciotomy (surgical decompression).

Sometimes a cast can be causing a compartment syndrome. If so, split the cast.

Fat embolism: See after long bone or pelvic fractures. See a triad of hypoxemia, neuro abnormalities, and petechial rash. Early immobilization and operative fixation of fractures reduces the chances of fat embolism.

A pt who suffers a traumatic injury should be given narcotics for pain relief, even if they were previously addicted to pain meds.

Epidural Abscess: suspect in pt with fever as well as back pain. RF is spinal surgery, epidural injection, immunocompromised, and elderly. Dx with cenhanced MRI. CT myelogramis alternative. Then, get cultures to guide abx treatment. MCC is S. aureus. Surgery within 24 h is the most important Rx.

Pulmonary Contusion: MC lung injury in pt with blunt chest trauma. Present with varying degrees of dyspnea, tachypnea, hypoxemia, and hemoptysis. PE shows decreased breath sounds over affected areas. CXR can show homogenous opacification of the lung fields. Rx is supportive, and usually resolves within 3-5 days. There is a risk for late onset clinical deterioration, so should admit and minotor for 1-2 days. If there is significant injury, might have to provide mechanical ventilation until the lung injury heals.

Flail chest: Usually d/t 2 rib fractures in > 1 site. There is increased work of breathing d/t musclar pain and spasm. Often there is hypoxia. Present w/ tachypnea, shallow breathing, ant chest bruising, and peripheral cyanosis.

Cardiac contusion: may lead to hemodynamic instability, but resp changes should not be present.

If a pt has breathing problems after you intubate them, check that the tube isnít in the right main stem bronchus. There will be reduced lung expansion and hypoventilation on L side of chest. If you check the tube and pt still isnít breathing, then likely a tension pneumo. Besides resp stuff, there can be cardiac collapse too because the tension pneumo could compress the heart. Do a needle decompression.

Pregnant person w/ appendicitis: Complications depend on which trimester. In the first trimesters, there can be abortion. In the 2nd, there can be premature delivery. In the 3rd trimester, if rupture of the appendix happens, there could be peritonitis (leading to fetal death), abscess formation, and pylephlebitis (infectious thrombosis of the portal veins)

Renal stones: presents w/ sudden onset of pain and hematuria. Pain is usually colicky (wax and wane) and has a wide range. Upper stones cause flank pain, and lower stones cause groin pain. Start w/ conservative management (IV hydration and pain control). If < 5 mm, stone usually passes spontaneously. > 8-10 will need removal. Removal is indicated if pt goes into ARF, has signs of urosepsis, or is pain doesnít go away. 3 methods of removal: schokwave lithotripsy, flexible ureteroscopy, and percutaneous ureterolithotomy. Shockwave is prefereed for smaller stones < 10. If > 10, probablya need flexible ureteroscopy.

Amputaed body parts:while transporting, make sure to keep it wrapped in saline moistened sterile gauze, and put It in a sterile sealed plastic bag. No need for abx in the solution. Use Saline NOT LR. Once in the bag, put the bag on ice.

Increased ICP: triad of bradycardia, HTN, and resp depression. Early signs are headache, vomit, blurred vision. Later on there is dilation of pupil, altered consciousness decerebrate posturing, and hemiparesis d/t transtentorial herniatoin of brain tissue. Eventually there will be resp arrest. FSOM is to secure the airway incase of resp arrest. Note that hyperventilating to lower the ICP is contra in pt with a TBI as well as acute stroke.

Cardiac arrest d/t electrical injury: often in asystole. Epinephrine can be used to revert the asystole.

Meckelís Diverticulum: usually seen in kids < 2 yo, but can present in older ppl. Technetium scan will ID the diverticulum, usually in RLQ (near ileocecal valve). The technetium will concentrate in the parietal cells o fthe diverticulum. Presents with acute abd pain with rectal bleeding. Other causes are IBD and appy.

Penetrating injury to skull: Knife should be removed in the OR. Before doing this, get a PT/PPT/blood group and crossmatch to have spare blood ready. A couple reasons for this are that removing knife could cause bleeding in the venous sinuses. Also, before going to surgery, you want to make sure that the pt has no coagulopathies.

Consent for minors: Always need it, except for some exceptions. These include immediate care to prevent serious harm or death.

Rupture of Achilles tendon: sometimes occurs after abrupt calf muscle contraction. There might be an audible snap. Usually happens in ppl who donít perform exercise regularly. Presents w/ severe calf pain and inability to stand up on the toes. Thompson test is for Achilles rupture. Pt kneels on a chair or lies prone on exam table w/ feet hanging over the edge. When you squeeze calf muscle on normal side, foot will plantar flex. On affected side, no foot response. Rx with immediate immobilization of lower leg and surgical repair of tendon.

Aortic injury is the MCC of sudde death in sterring wheel injuries. Pt usually die at the scene. Rapid deceleration produces shearing force along aortic arch, and the aorta ruptures.

Acute cholecystitis: gallbladder inflammation w/ steady RUQ pain, fever, and leukocytosis. MCC is gallstones. Pain might radiate to the back or R shoulder. Murphy sign + (inspiratory arrest on palpation of gallbladder during deep inspiration). US is the best initial Dx. MC complication is gall bladder gangrene and perforation. Thus, all pt withi acute chlecystitis should be admitted and supported. Supportive includes NPO, analgesia, and IV antibiotics. Usually give amp + gent for broad coverage. This reduces risk of secondary infection.

Acalculus cholecystitis is seen I critically ill pt and elderly.

Neck trauma: airway must be secured with jaw lift to prevent further strain on the neck.

Tetanus prophylaxis: Immune globulin is indicated for contaminated wounds when immunization status is unknown or when pt has < 3 doses of tetanus antitoxin.

Only tetanus antitoxin is indicated if: pt has clean wound w/ unknown immunization status. Pt has clean wound and has > 3 doses of antitoxin with last dose > 10 eyars ago. If wound is contaminated byt pt has gotten >3 doses of antitoxin within last 5 years.

Thus if a pt has a dirty wound, the only way he doesnít get both the antitoxin and immune globulin is if he knows hes gotten >= 3 doses of antitoxin within last 5 years.

Pt who do hip replacement are at higher risk for VTE leading to PE. In pt getting this surgery, need ro get prophylactic LMWH. LMWH is shown to be better than warfarin or aspirin.

Morphine overdose post op: esp in opiate naÔve patients w/ renal insufficiency. Presents as lethargy, miosis, resp depression, apnea. FSOM is to secure the airway.Rx with naloxone.

Various nerve injuries may happen during carotid endarterectomy: hypoglossal nerve, which presents as tongue deviation. Facial nerve, presenting as asymmetric smile (d/t damage to the marginal mandibular branch). Ansa hypoglossus nerve, which innervates strap muscles of the neck. It can be sacrificed with impunity.

MCC sudden hyperglycemia is sepsis in pt getting surgery: Should look for source of infection (a line, pneumonia, wound). Another possibility is that IV infusion of TPN is going too fast. Note that during IV nutrition, bowel rest can happen, which leads to degenerative changes in small mucosa just after a few days.

Post obstructive acute renal failure: can present as sudden inability to void urine. Oone cause is BPH. In this case need to do bladder decompression quickly to alleviate pain and avoid further renal damage. Rx is with urethral catheter with a foley catheter.

Animal bite: important fact is wild animal or not (animal which has had shots). Need to observe animal for signs of rabies. Usually, you want ot close the laceration quickly. With hand bites, however, there is high risk of subsequent wound infection, so donít close those right away, and leave them open to drain and observe. Other bites which shouldnít be closed include: pucture wound, cat/human bites, pt presenting muich later after the bite. Cat/dog bites can be trested prophylatically with amox/clav.

In digital injuries, tendons are more likely to beinjured than arteries, veins, or nerves.

Despite being on DVT prophylaxis, sometimes DVT can just happen anyways. If you suspect it, V/Q scan is the best initial test. D-dimer, although it has a high negative predictive value, is not very useful. It is almost always elevated in hospitalized patients (esp recent surgery). D dimmer would be more useful in a healthy pt who comes to ED with symptoms.

Cremasteric Reflex may be lost d/t diabetic neuropathy.

Femoral Nerve injury: uncommon. Present w/ weakness of the quad. Presents as unable to extend the knee against resistance. Sensory loss over ant aspect and medial thigh is common. Sensory loss also in medial shin and the arch of the fut. Knee jerk is decreased in amploitude or absent.

Subarachnoid hemorrhage: constellation of sudden onset headache, nausea, and nuchal rigidity. More specifically, a post. communicating artery aneurysm would also present w/ CN3 palsy (ptosis and anisocoria). PICA aneurysm would lead to ataxia and bulbar dysfunction.

Partial small bowel obstruction: can present with distended abd, increased bowel sounds, Air fluid levels on abd x ray, but there is still air in the distal colon. . (obstructive series). Also there might be repeated vomiting. Because itís only partial, can just observe and see if it resolves. If it doesnít resolve, sugery is indicated.

Inhalation Injury: Can happen if exposed to smoke. Leads to supraglottic damage. This leads to edema in surrounding soft tissues, which narrows the airway. Have a low threshold for intubation.

Patellar tendon tear: MCC is sudden quadriceps contraction while the foot is firmly planted. There is patellar tendon or rupture leading to pain, swelling, difficulty in bearing weight. Pt unable to perform active extension of the leg and cannot passively extend the knee against gravity by themselves. Should get surgery quickly, as waiting too long can lead to muscle atrophy and contracture formation.

Meniscal tear: MCC is twisting force with foot fixed on ground. Use McMurrayís maneuver to detect presence of tears. Pt is put in supine position with knee in maximum flexion. Then, externally roatte tibia, and extend knee. If there is audible click or pop then is a + test.

Tachycardia is the earliest sign of hypovolemia.

High risk factors for PE: previous hx of VTE, malignancy, orthopedic surgery, stroke, pt with MI.

Generally, LMWH is the prophylaxis of hoice. If pt has had previous MI, then give full dose therapeutic IV heparin.

Acute cholangitis: Triad of fever, RUQ and jaundice. Rx with hydration, VS monitoring, and immediate abx therapy. Shold get BC first, but a good empiric is amp + gent, or monotherapy with imipenem or levofloxacin. Afterwards, schedule for an ERCP. If pt doesnít improve, need to do biliary compression (done through ERCP). Watch out for sepsis. If pt also develops hypotension and confusion, pt has Reynoldís pentad, which has 50% mortality rate.

Abd gunshot wound: 95% of them need surgery. Presence of peritoneal signs is absolute indication for urgent laparotomy. Other absolute indications are hollow viscus perforation, hemodynamic compromise, hemo/pneumoperitoneum, diaphragmatic lesions, and spinal cord injury.

OíDonohueís unhappy triad: knee injury which includes ACL tear, M (tibial) CL injury, and medial meniscal injury. MAT

Differentiating btw aortic dissection and MI in the acute setting: very similar presentation, but some differenes in testing. CXR might show mediastinal widening on CXR. More accurately, a person having a MI who has active chest pain would likely have an abnormal EKG> Aortic dissection has a normal EKG.

Blunt cardiac injury: If mild, only associated with transient arrhythmias. More severe can lead to rupture of the valves, interventricular septum, or myocardium. EKG is a good first step. If EKG is normal in pt with mild/possible blunt cardiac injury, no further treatment is needed.

Best initial test to confirm pneumothorax diagnosis is an AP upright chest film.
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