lmcc review
DESCRIPTION
LMCC Review. General Surgery Dr. S. Tadros. Review Topics. Colo-rectal cancer/GI bleeding Diverticulitis/Appendicitis/IBD Peptic Ulcer Bowel Obstruction Breast Disease Hernias Thyroid disease Biliary Disease/Pancreatitis/Jaundice Trauma Peri-anal Disease. Colon Cancer. Risk Factors - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/1.jpg)
LMCC Review
General Surgery
Dr. S. Tadros
![Page 2: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/2.jpg)
Review TopicsColo-rectal cancer/GI bleedingDiverticulitis/Appendicitis/IBDPeptic UlcerBowel ObstructionBreast DiseaseHerniasThyroid diseaseBiliary Disease/Pancreatitis/JaundiceTraumaPeri-anal Disease
![Page 3: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/3.jpg)
Colon Cancer
Risk FactorsGenetics 6%PresentationInvestigationsTreatment
![Page 4: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/4.jpg)
Risk Factors
DietGeneticsAgeIBD’s
Presentations
• Anemia (R)
• Obstruction (L)
• RLQ Pain
• Change in Bowel Habits
• Rectal Bleeding
• Perforation
![Page 5: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/5.jpg)
Adenoma-Carcinoma SequenceSporadic -
>94%FAP - <1%HNPCC - 5%
![Page 6: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/6.jpg)
Investigations
FOBTDigital Rectal examBarium EnemaColonoscopyCT Scan / MRIU/S
![Page 7: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/7.jpg)
Screening
FOBT annuallyScreening Colonscopy:
Age > 50 q10 yrs.Exception: Family History History of polyps IBD
![Page 8: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/8.jpg)
Treatment (depends on presentation)
NothingChemo-radiation therapy (adjuvant & neo-adjuvant)Surgery, Surgery, Surgery Resection (anastomosis) Resection (stoma i.e.:Hartman’s Procedure)
Delayed reconstruction Palliative procedures
Intestinal by-pass
![Page 9: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/9.jpg)
Surgicalresections
![Page 10: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/10.jpg)
Diverticulitis
Pathophysiology
Increased luminal pressure
![Page 11: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/11.jpg)
Risk Factors
High FatGeographyGeneticsWeightLow Fiber (Not)
•
![Page 12: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/12.jpg)
Presentation
Diverticulitis Phlegmon (micro-perf)
Perforation Abscess (micro-perf) Free perforation (macro-perf)
BleedingObstruction Chronic disease (Sigmoid colon)
Fistulas to adjacent organs
![Page 13: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/13.jpg)
Epidemiology
>70% after age 80
30% recurrence after 1st attack
>50% recurrence after 2nd attack
Complications usually at first attack
![Page 14: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/14.jpg)
Diverticulitis
CT abd/pelvisAntibioticsAnalgesicsNon-operative treatmentBarium enema/Colonscopy 4-6 weeks post D/CSurgery after 2 or 3 attack
![Page 15: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/15.jpg)
Treatment
ABC’sFluidsAntibioticsResection (+/- stoma) Hartman’s (urgent) Primary anastamosis (elective)
Management of complications
![Page 16: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/16.jpg)
Appendicitis
Anatomical variation
Accounts for varied presentations and
degree of systemic illness
![Page 17: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/17.jpg)
Disease of the young
6% of populationMost common between 20-30 years of ageMost common cause of acute abdomenCaused by luminal obstruction Fecolith Peyer’s patch (distal ileum in the young)
![Page 18: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/18.jpg)
Presentation
Vague abdominal pain Peri-umbilical to localization RLQ
N/V & diminished appetiteFever / leukocytosis / tachycardiaProgressive symptomsPhlegmon / abscess / free perforation
![Page 19: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/19.jpg)
Investigations
CLINICAL DIAGNOSISU/S in females of child bearing ageBHCG importantCT (If you can’t take a good Hx/Px)Dx LaparoscopyObservation No antibiotics
![Page 20: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/20.jpg)
Treatment
SurgeryPerc drain abscess
Antibiotics alone (rarely) Indicated in delayed diagnosis
Interval appendectomy After percutaneous drain After antibiotics
![Page 21: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/21.jpg)
Acute Appendicitis
![Page 22: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/22.jpg)
Rectal Bleeding
Neoplasm…Benign Vs. MalignantDiverticular diseaseAngiodysplasiaIBDInfectiousTraumaticAno-rectal disorders
![Page 23: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/23.jpg)
![Page 24: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/24.jpg)
Upper GI Bleed
Esophageal VaricesMallory Wiese tearPeptic Ulcer/Benign or malignant/gastric or DuodenalGastritis
![Page 25: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/25.jpg)
Upper GI bleed
ResuscitationUpper Endoscopy/Diagnostic & therapeuticSurgery
![Page 26: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/26.jpg)
PUD
Gastric or DuodenalHypersecretion of acid and/or failure of protective mucosal defensesSymptoms include pain, vomiting, bleedingCancer associated with gastric ulcers in older patients
![Page 27: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/27.jpg)
Indications for surgery
Intractability (rarer than emergency indications)Obstruction (pyloric obstruction)Bleeding (post. duodenum)Perforation (ant. duodenum)NOTE: gastric perforations need to R/O cancer
![Page 28: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/28.jpg)
Medical Therapy
H2 blockersPPIH-Pylori therapyEndoscopy (Dx and Bx and R/O pre-malignant lesions)Reduce lifestyle risks (smoking / caffeine etc…)
![Page 29: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/29.jpg)
Perforated Ulcer
Most common location - anterior proximal duodenumGastric or duodenum Many be contained by surrounding
anatomy
Acute onset abd pain Sepsis often delayed up to 24 hours Chemical peritonitis - then bacterial
May present localized RLQ pain Follows right para-colic gutter
![Page 30: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/30.jpg)
Investigations
Upright AXR (best test) Decubitus Must be upright / decubitus for at least 10
minutes
Physical exam and history Diffuse peritonitis with discrete sudden
onset
Lab tests (non-specific)CT abd - most sensitive for free air Rules out other etiology
![Page 31: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/31.jpg)
AXR
Free Air
(Upright)
![Page 32: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/32.jpg)
Treatment
FluidsAntibioticsCorrection metabolic derangement'sCorrection of coagulation defectsSurgery, Surgery, SurgeryNon-operative treatment in very specific cases
![Page 33: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/33.jpg)
Surgical Therapy
Graham’s patch Omental patch
Serosal patch jejunum
Billroth I and Billroth IIBx for cancer & H.pylori Esp.. gastric for Ca
![Page 34: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/34.jpg)
Omental patch
![Page 35: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/35.jpg)
Bleeding
Ulcer
3 point vessel oversew
Gastroduodenal artery
Gastroepiploic artery
![Page 36: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/36.jpg)
Billroth I
![Page 37: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/37.jpg)
Billroth II
Duodenal stump stomach
Jejunum (loop)
Transverse colon
![Page 38: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/38.jpg)
Mesenteric Ischemia
The Great Pretender
![Page 39: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/39.jpg)
Risk Factors
Vascular disease Run of the mill type (CAD / PVD)
Embolic risk factors (a-fib etc…)Autoimmune diseases
(vasculitis)Prolonged obstruction
Trapped loopVolvulusDehydrationInotropes (iatrogenic)
![Page 40: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/40.jpg)
Presentation
Sub - acute or acute abdominal painPain vs physical findingsDiffuse non-localized abd painVolume contractedShocky / toxicSoft abdAcidosisAltered LOC
![Page 41: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/41.jpg)
Investigations
AXR pneumotosis, thumb printing
Lactate / CBC / CR / BUN / ABG’s Non-specific
ECG A-fib
CT abdAngiogram
![Page 42: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/42.jpg)
Pneumatosis
intestinalis
![Page 43: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/43.jpg)
TreatmentReverse underlying cause
Volume restoration Stop inotropes Embolectomy / thrombolysis
Correct coagulation defects Pre-op concern
Surgery (resection)Nothing
![Page 44: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/44.jpg)
Exam key points
Abdominal pain and physical finds do not correlate
Source of embolus or reason for thrombosis
May be acidotic (blood work)
![Page 45: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/45.jpg)
Small bowel Obstruction - Etiology
Adhesions- 60%Hernias - 10-15%Masses (benign and malignant) - 10-20%Volvulus - 3%Intususception - 1-2%Strictures (ischemic / IBD / other) - 5%FB - 2%Gall stone - 2-3%
![Page 46: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/46.jpg)
Symptoms
Vomiting / NauseaAbd distentionDecreased stool and flatusDehydrationAntecedent nausea and cramping
with mealsAbd pain (cramping)
Localized means advanced disease
![Page 47: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/47.jpg)
DiagnosisHistory and PhysicalAbXRCT abd/pelvisAntegrade small bowel enemaEnterosocopy
Small bowel scope seeking tumor Not indicated in complete obstruction
![Page 48: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/48.jpg)
![Page 49: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/49.jpg)
![Page 50: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/50.jpg)
![Page 51: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/51.jpg)
Pathophysiology of s.b. obst.
Increased intraluminal pressure leads to decreased capillary flow and causes ischemia
Mucosa secretes but does not absorbColon beyond obstruction hence no
absorptionBacterial proliferation secondary to stasis
(gut translocation)Vomiting leads to dehydration and alkalosis
![Page 52: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/52.jpg)
ManagementDrip and Suck (mainstay)
Fluids and NG decompression The sun should never set or rise on a
BO Serial Monitoring clinically,
Radiologically
Hernia reductionSurgery
Hernia / adhesions / masses / FB / gall stone / stricture / volvulus
Indications for Surgery: toxicity / peritonitis / Indications for Surgery: toxicity / peritonitis / failure to progress (Clinically/radiologically)failure to progress (Clinically/radiologically)
![Page 53: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/53.jpg)
Small bowel obstruction
70+% resolve with non-op treatment 50% will recur
30% require surgery 30% will return with SBO
![Page 54: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/54.jpg)
Large Bowel Volvulus
Sigmoid (80-85%)Cecal (10-15%)
Bascule (10% of cecal volvulus)
Transverse colon (5%)
Lack of fixation allows redundant colon to twist. Lack of fixation allows redundant colon to twist. Narrow mesenteric base.Narrow mesenteric base.
![Page 55: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/55.jpg)
EtiologySigmoid
Constipation (long history) & redundant colon
Cecal Intra-abdominal right colon Lack of peritonealization
Cecal Bascule adhesions
Transverse Colon redundancy
![Page 56: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/56.jpg)
Diagnosis
Exam and historyAXR
“Kidney bean”
Non-specific labsContrast enemasOscopy (rigid sig or colon)CT
![Page 57: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/57.jpg)
Sigmoid
Volvulus
![Page 58: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/58.jpg)
Cecal
Vovulus
![Page 59: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/59.jpg)
TreatmentsCecal Volvulus (Bascule)
Surgical reduction and resection Cecalpexy (not ideal)
Transverse Volvulus Surgical reduction and resection
Sigmoid Volvulus Rigid Sigmoidoscopy and de-torsion
(rectal tube) (40-50% recurrence) Surgery (Hartman’s or resection and
re-anastamosis)
![Page 60: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/60.jpg)
![Page 61: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/61.jpg)
![Page 62: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/62.jpg)
PBL 2007© General Surgery
40 year old woman complains of lump in right breast ?
![Page 63: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/63.jpg)
PBL 2007© General Surgery
What further history would you obtain to evaluate the breast lump?
![Page 64: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/64.jpg)
PBL 2007© General Surgery
What are the important elements of the physical exam for this patient.
![Page 65: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/65.jpg)
PBL 2007© General Surgery
Peau d’orange
![Page 66: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/66.jpg)
PBL 2007© General Surgery
Skin tethering
![Page 67: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/67.jpg)
PBL 2007© General Surgery
Enlarged right breast with nipple retraction
![Page 68: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/68.jpg)
Breast Cancer
![Page 69: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/69.jpg)
PBL 2007© General Surgery
What is the DDx of a Breast Lump ?
![Page 70: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/70.jpg)
Benign Breast Lumps
Breast CystFibroadenomaJuvenile/Giant FibroadenomaPhylloides tumorBreast abscessIntraductal papillomaSclerosing Adenosis & Radial scarFat Necrosis
![Page 71: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/71.jpg)
PBL 2007© General Surgery
What are your next steps in evaluation of the breast lump?
![Page 72: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/72.jpg)
Breast Disease
The Breast LumpHistory and PhysicalInvestigations: USS Mammography FNA/ stereotactic Bx. MRI
![Page 73: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/73.jpg)
PBL 2007© General Surgery
Ultrasonography
![Page 74: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/74.jpg)
PBL 2007© General Surgery
Diagnostic Mammography
![Page 75: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/75.jpg)
PBL 2007© General Surgery
palpable lump
Cystic
aspirate
solid
Core needle biopsy
mass
disappeared
watch
![Page 76: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/76.jpg)
PBL 2007© General Surgery
What is the treatment of breast carcinoma?
![Page 77: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/77.jpg)
Breast Cancer Treatment
Surgery: Lumpectomy Vs. Mastectomy
Axillary Sentinal Ln Vs. disect.
Radiation +/- Chemotherapy
![Page 78: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/78.jpg)
Inguinal Inguinal canalcanal
![Page 79: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/79.jpg)
Inguinal canal internal ringInguinal canal internal ring
Posterior (internal) view
Hesselbach’s triangle
![Page 80: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/80.jpg)
Inguinal herniaInguinal hernia
indirect direct
![Page 81: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/81.jpg)
Spigelian herniaSpigelian hernia
Present as mass in abd wall with little antecedent history.
Diagnosis often made at time of OR or by CT.
Treat with reduction and mesh.
![Page 82: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/82.jpg)
Umbilical epigastric
& incisional
hernia
![Page 83: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/83.jpg)
Solitary Thyroid Nodule
![Page 84: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/84.jpg)
35 years old female presents with a mass on the right side of the neck for 2 months. There is no pain and no other lumps
![Page 85: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/85.jpg)
What further history is needed?
![Page 86: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/86.jpg)
What is important in the physical examination?
![Page 87: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/87.jpg)
What is the DDx of a thyroid mass?
![Page 88: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/88.jpg)
What further investigations are needed?
![Page 89: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/89.jpg)
Solitary Thyroid Nodule FNA
FNA (Fine Needle Aspiration Cytology) Easy, safe, cost effective Negative predictive value 89%- 98% False Negative rate 6% False Positive rate 4%
FNA Cytodiagnosis Benign
Colloid adenoma, thyroiditis, cyst Malignant
Papillary (70%), follicular (15%), medullary (5%-10%), anaplastic(3%), lymphoma (3%), metastasis (rare)
Indeterminate Microfollicular, Hurthle cell, embryonal neoplasm
![Page 90: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/90.jpg)
Solitary Thyroid Nodule
FNAC Result
Benign Observe and repeat FNAC 1 year
Malignant Surgery
Indeterminate serum TSH normal SurgerySerum TSH low
Scintiscan
Inadequate Repeat FNA
![Page 91: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/91.jpg)
Pancreatitis & its Complications
Etiology Acute: Biliary 40% Ethanol 40% Idiopathic 10%
DrugsHigh lipidERCPPost-opTrauma
10%
infection
![Page 92: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/92.jpg)
Pancreatitis & its Complications
Biliary Pancreatitis Passage of Stone Edema of Sphincter of Odi Increase pressure in
Pancreatic ductEthanol Unknown
![Page 93: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/93.jpg)
Pancreatitis & its Complications
Etiology Chronic: Ethanol 70-
80% High lipid High Ca Idiopathic Autoimmune
20%
![Page 94: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/94.jpg)
Acute pancreatitisAcute pancreatitis Etiology Pathogenesis
Gall stones 40 - 60%Alcohol 20 - 30%HypercalcemiaHyperlipidemiaDrugsFamilialEtc............Idiopathic 15%
Local activation of pancreatic enzymes
Tissue destructionEdema &
inflammationextensive
tissue destructionRelease of
cytokines
![Page 95: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/95.jpg)
Acute pancreatitisAcute pancreatitisPresentation Investigation
Acute onset abd. pain
N & VHistory of gall
stones or alcoholSymptoms vs
signs
Amylase serum urine
LipaseU/S
pancreas gall bladder
CT scan
![Page 96: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/96.jpg)
![Page 97: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/97.jpg)
![Page 98: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/98.jpg)
Admission Initial 48 Hours
Gallstone
Age >70 Hct Fall > 10
Wbc > 18,000 BUN elevation> 20
Glucose > 12 Ca <2
LDH >40 Base deficit > 5
AST > 250 Fluid Seq. > 4 L
Non-Gallstone
Age > 55 Hct fall > 10
Wbc > 16,000 BUN elevation>40
Glucose > 10 Ca < 2
LDH > 350 Base deficit > 4
AST > 250 Fluid seq. > 6 L
Ranson’sSigns
![Page 99: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/99.jpg)
Acute Acute pancreatitispancreatitisTreatment OutcomeNo specific RxHydrationN/G suctionPain controlSupportive
Oxygen, ventilator dialysis inotropes etc.
Common disease80 - 90%
transient10 - 20% severe
10 - 30% with severe will die
Complications(Ranson’s
criteria)
![Page 100: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/100.jpg)
Pancreatitis & its Complications
Local Complications : 1. Acute Fluid collection 2. Pancreatic Necrosis 3. Pancreatic Pseudocyst 4. Rupture of cyst 5. Pancreatic Abscess
![Page 101: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/101.jpg)
![Page 102: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/102.jpg)
![Page 103: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/103.jpg)
Pancreatitis & its Complications
Diagnosis: Contrast enhanced CT
scan FNA
![Page 104: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/104.jpg)
Pancreatitis & its Complications1. Fluid collection: Conservative2.Pancreatic Necrosis: Conservative
if Sterile Otherwise surgery3. Pancreatic psuedocyst:
Conservative vs. surgery 6X6 rule.4. Pancreatic abscess: Surgery
sterile
surgery
![Page 105: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/105.jpg)
![Page 106: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/106.jpg)
![Page 107: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/107.jpg)
![Page 108: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/108.jpg)
Gall stonesGall stones
Incidence increases with age
2:1 F:M10% in 40s (F)40% become
symptomatic2 - 4%
complicated disease
Acute colic acute abdominal
pain epigastric pain
moving to RUQ radiates to back.
scapula, shoulder N&V last 1 - 12 hrs
![Page 109: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/109.jpg)
Complications
CholecystitisBiliary colicCystic duct obstructionCholeduocholithiasisPancreatitisRupture Gall stone “ileus”Biliary cirrhosisCancer
![Page 110: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/110.jpg)
Gall Gall stonesstones
Cholecystitis empyema hydrops
Obstructive jaundice
CholangitisPancreatitisCancer(surgical
complications)
![Page 111: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/111.jpg)
Signs and symptoms
PainMurphy’s signCourvoisier gall bladder
![Page 112: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/112.jpg)
![Page 113: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/113.jpg)
Gall stonesGall stonessurgerysurgery
Indications symptoms complications (comorbidities)
Laparoscopic cholecystectomy (95%)
Open (5%)E.R.C.P. for
common duct stones
Cholecystostomy
![Page 114: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/114.jpg)
Principles of Trauma
Golden hourPrimary surveySecondary surveyTransfer to trauma center
Shortest out of hospital time
Pearls
![Page 115: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/115.jpg)
Primary Survey
A - irway (c-spine)B - reathingC - irculationD - eficitE - xposure of pt (undress
completely)
![Page 116: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/116.jpg)
Secondary Survey
F - arenheit (keep pt warm)G - et vitals (complete)H - ead to toe
With gloves, feel and move everything…everything!!!!
I - nspect back (log roll pt) Rectal if not done yet Spine precautions during roll
![Page 117: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/117.jpg)
Head to ToeRun hands through hairRemove c-collar with assistance and
palpate neck (ant & post)Feel all facial bones, manipulate jaw
and maxillaPassive ROM through all joints (not
obviously injured)Look in earsVaginal exam in females (if indicated)
Never assume vaginal blood is menses until proven
![Page 118: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/118.jpg)
Interventions
I.V. 2 large bore (one above and one below diaphragm)
Foley catheter (after rectal done)NG tube (if no basal skull fracture)Analgesia / sedationAntibioticsTetanus
![Page 119: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/119.jpg)
Investigations
CBC, diff, lytes, Cr, BUN, glucose, ETOH, INR/PTT, x-match x 6 units, drug screen, ABG’s
ECG (least important)CXR (most important x-ray),
Pelvis, c-spine (x-table lat)DPLU/S (FAST)CT scan (head/chest/abd/pelvis)MRI (not usually in first 24 hrs)
![Page 120: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/120.jpg)
Clearing the C-spine
NO distracting injuriesAlert and orientedNo drugs or narcotics on boardMust see to T1X-table lat / odontoid / AP views
(minimum)CT neck if incompleteMRIFlexion and extension views
![Page 121: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/121.jpg)
C-spineX-table lateral view
![Page 122: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/122.jpg)
C-spine
Flexion and extension view
![Page 123: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/123.jpg)
Chest X-ray
Tension Pneumothorax
![Page 124: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/124.jpg)
Chest X-ray
Hemothorax
![Page 125: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/125.jpg)
Chest X-ray Aortic Tear
![Page 126: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/126.jpg)
Indications for surgery in Thoracic trauma
Massive continued air leakHemothorax 1500cc + 250cc/hrX3Major Tracheal/
Bronchial/esophageal injuryCardiac tamponade or Great
vessel Injury
![Page 127: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/127.jpg)
PrioritizationAirwayBreathingCirculationDeficits (preserving brain)Restore vascular continuityRestore orthopedic continuityRestore intestinal continuityPrevent infectionMinimize cosmetic damageMinimize psychological
fallout
![Page 128: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/128.jpg)
Trends in Trauma Care
Non-operative management Spleen and Liver injuries Aggressive conservatism
Non-operative management Kidney injuries
Embolic hemorrhagic control Interventional radiology
![Page 129: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/129.jpg)
Hemorrhoids
External (thrombosed) or perianal hematoma AcutePain Sometimes bleed (small amount) Left lateral / right anterior / right
posteriorVast majority will resolve with medical therapy only. Then Vast majority will resolve with medical therapy only. Then
follow up with aggressive bowel routinefollow up with aggressive bowel routine.
Hemorrhoids can indicate more serious occult disease. If recurrent or other symptoms needs referral to surgeon.
![Page 130: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/130.jpg)
Internal Hemorrhoids (painless)Bleeding
Anoscope / sigmoidoscopy Medical therapy Banding Hemorrhoidectomy (emergent rare)
Prolapsed Reduction and planned elective therapy
Strangulated Reduction and possible emergent
hemorrhoidectomy
![Page 131: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/131.jpg)
HemorrhoIds
![Page 132: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/132.jpg)
Fissure in Ano
Is a linear ulcer of the lower half of the anal canal, usually found in the posterior midline (lateral fissures imply other disease)
Associated with anal tags or sentinel pileHigher than normal resting pressure in the
anal sphincter (internal)Cause and effect is not clearAssociated with constipation (stool
retention)
![Page 133: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/133.jpg)
Hypertrophied papilla
Fissure
Internal sphincter
• Sentinel pile
A
N
A
T
O
M
y
![Page 134: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/134.jpg)
Treatment
Good bowel routine (fruit / fluids etc…)
90% will heal with medical therapy (2-4 weeks)
Acute vs chronic Chronic more likely to require surgical
treatment
![Page 135: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/135.jpg)
Medical Treatment
Stool softenersDietary changesNitro pasteBotulism toxinNifedepineAnal dilatation (recurrence 10-30%
@ 1 year) Short term incontinence 40%
![Page 136: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/136.jpg)
Surgical Options
Lateral internal sphincterotomy (mainstay) Open (0-10% recurrence) Closed (0-10% recurrence)
Incontinence 5% average (closed less than open)
Most recurrence resolve with medical therapy
![Page 137: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/137.jpg)
Peri-Rectal/Anal Abscess
Arises from the anal crypts/glandsPainful / progressive30% associated with residual fistulaI & D definitive treatmentConsider underlying systemic
disease Especially if recurrent
![Page 138: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/138.jpg)
Etiology of abscess (non-cryptoglandular)
CarcinomaTraumaCrohn’sRadiationTuberculosisActinomycosi
sForeign bodyleukemia
![Page 139: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/139.jpg)
Perianal Abscess Types
Ischiorectal
![Page 140: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/140.jpg)
I & D PrinciplesAlways near the anodermal
junctionBreak up all pocketsLeave opening
Cruciate ellipse
Pack with wick X 1 daySitz with BM and 1-2 X dayFollow up in 1 weekRefer intersphincteric / ischiorectal
/ supralevator to surgeon
![Page 141: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/141.jpg)
Fistula-in-ano
Rarely heal spont.Present with recurrent abscessSurgical treatment is ideal
Seton Fistulotomy Fistulectomy
![Page 142: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/142.jpg)
Goodsall’s Rule
Establishes the
internal opening
![Page 143: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/143.jpg)
Colon cancer risk is increased in all except oneof the following:-
1) Juvenile polyps2) Familial polyposis3) Ulcerative colitis4) Previous colon cancer
Not all Polyps are created equal
FLASH QUIZ
![Page 144: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/144.jpg)
Case #1:
50 y.o. female with 24 hours of progressive abdominal pain. Associated with vomiting, fever, anorexia. No previous history. Some diarrhea now, 12 hours no stool. Decreased urine output. Pain localized to LLQ.
![Page 145: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/145.jpg)
What is the most likely diagnosis?
A.Colon CancerB.DiverticulitisC.AppendicitisD.Mesenteric
IschemiaE.Perforated Ulcer
![Page 146: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/146.jpg)
Which of the following do you consider to be a strong indication for laparotomy?
1) Localized pain
2) involuntary guarding
3) Crampy abdominal pain
4) Severe complaint of pain
5) Voluntary guarding
FLASH QUIZ
![Page 147: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/147.jpg)
Case #2
78 year old male with 24 hour hx of vomiting, no stool or gas for 18 hours, abd pain and cramping, abd distention ++. No fever. Decreased urine output. Anorexic. Nursing home patient. Previous history of similar symptoms 2 months ago (resolved spont..)
![Page 148: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/148.jpg)
What is the most likely diagnosis and how would you treat it?A Small bowel obstruction
Secondary to: adhesions / hernia / other
B Large bowel obstructionSecondary to: Cancer / diverticulitis /
volvulus / other
![Page 149: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/149.jpg)
What is the most likely diagnosis and how would you treat it?
A Small bowel obstructionSecondary to: adhesions / hernia /
other
B Large bowel obstructionSecondary to: Cancer / diverticulitis /
volvulus / other
![Page 150: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/150.jpg)
Case #3 (Trauma)
A 35 year old woman is involved as a right front seat passenger in a head-on automobile collision. In the emergency room, she has a tender abdomen and has the appearance shown here.
![Page 151: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/151.jpg)
A likely injury she may have sustained would be:
Perforated colonRuptured spleenMesenteric vascular
avulsionFractured pelvisPneumothorax
![Page 152: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/152.jpg)
FLASH QUIZ
How would you determine what was causing the following patient’s symptoms 2 minutes after arriving in the ER… hypotension, elevated JVP, tachycardia and dyspnea?A Chest -x-ray (upright)B CT chestC Chest x-ray (supine)D Needle thoracostomyE ECG
![Page 153: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/153.jpg)
FLASH QUIZWhat is Beck’s Triad?
A Diminished heart sounds, elevated JVP, tachycardia
B Diminished heart sounds, hypotension, tachycardia
C Elevated JVP, hypotension, diminished breath sounds
D Hypotension, diminished heart sounds, elevated JVP
![Page 154: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/154.jpg)
FLASH QUIZ
What does Beck’s Triad indicate?A Tension hemothoraxB Flail chestC Pericardial effusionD Disrupted tracheo-bronchial tree
![Page 155: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/155.jpg)
FLASH QUIZ
Where is the most common location of blunt aortic tears?A Aortic RootB Ascending aortaC Descending aorta at diaphragmD Ligamentum arteriosum
![Page 156: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/156.jpg)
FLASH QUIZ
Which of the following is an indication to take a patient with a spleen injury to the OR when managing non-operatively?A Age 68 yearsB Hypotension after transfusionC Sudden severe abd pain 3 days after
admissionD Hemoglobin of 70 3 days after admission (no
transfusion given)
![Page 157: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/157.jpg)
Case #4
A 35 y.o. male presents with a lump and pain in the right groin for 8 hours. It is hard and tender and above the inguinal ligament. What is the most likely diagnosis?A Femoral herniaB Indirect inguinal herniaC Direct inguinal herniaD Lymphoma
![Page 158: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/158.jpg)
Case #4
A 35 y.o. male presents with a lump and pain in the right groin for 8 hours. It is hard and tender and above the inguinal ligament. What is the most likely diagnosis?A Femoral herniaB Spegallian HerniaC Direct inguinal herniaD Lymphoma
![Page 159: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/159.jpg)
A 45yr old man comes into Emerg. with sudden severe abdominal pain. He is diagnosed as having acute pancreatitis. He does not drink, is on no meds. What is the most likely cause of his pancreatitis?
1) Idiopathic2) Hyperlipidemia3) Hypercalcemia4) Gall stones5) Scorpion bite
![Page 160: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/160.jpg)
A patient has an U/S for kidney disease and isfound to have gall stones. There is no history of symptoms. Which of the following are true?
1) Gall stones consist mostly of bile pigment2) Gall stones, left untreated, most will pass3) There is about a 40% chance the patient will become symptomatic4) There is a high incidence of gall bladder cancer with gall stones5) Gall stones are more often found in males
![Page 161: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/161.jpg)
FLASH QUIZ
What is Charcot’s Triad?A HypotensionB JaundiceC FeverD RUQ painE Altered LOC
![Page 162: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/162.jpg)
Sore BumCase #8: 28 y.o. male with 48 hours
progressive anal pain. +++ sitting and with BM’s. Very sore to touch. No drainage. No diarrhea. No previous symptoms or history. Girl friend states anal area is red and hot and swollen.
Case #7
What is the most likely diagnosis?
![Page 163: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/163.jpg)
Sore Bum
Case #8: 28 y.o. male with 48 hours progressive anal pain. +++ sitting and with BM’s. Very sore to touch. No drainage. No diarrhea. No previous symptoms or history. Girl friend states anal area is red and hot and swollen.
Perianal abscess
![Page 164: LMCC Review](https://reader035.vdocuments.site/reader035/viewer/2022081418/568150b7550346895dbed1a9/html5/thumbnails/164.jpg)
Differential diagnosis
Hemorrhoids (external or internal)
FistulaFissureRectal abscess
Peri-anal Intra-sphincteric Ischio-rectal Supra-levator