worsening dyspnea; parasternal heave; pulmonic systolic ejection murmur; split s2; A fib, RVH, high rv o2 sat; ostium

secundum present in adulthood (fossa ovalis); eisenmenger syndrome; ostium prium (av valves, down syndrome; childhood failure) sinus venous (higher in septum anomalous pulmonary return) atrial septal defect females; common in adults; emboli, arrythmia, fight heart failure, phtn (primum) nosebleeds; latesystolic ejection in interscapular; weak lower extremity pulses, strong upper extremity; rib notching; children may have proximal to ligamentum and open PDA with no BP differences; HTN in adolescents, headaches; coarctation of aorta claudication, dyanosis; males, bicuspid aorta, turner, VSD syncopal episdoes; squatting relieves symptoms (decrfeases r->L shunt by increasing PVR) cyanotic blue spells; clubbing, systolic thrill (VSD) systolic murmur (pulm stenosis); high hb hct low o2; smalll heart pointed up, dimished tetralogy of fallot pulm vascularity; overrding large aorta; common neonate; aspiration, not feeding right; polyhydraminos; gas in stomach, barium into trachea/bronchi; usually esophageal atresia as well; radigraph shows tracheoesophageal esophageal pouch; methylene blue visualization during joint broncho and fistula endoscopy PERSISTENT COUGH due to the recurrent aspiration vomtting after meals; projectile a few weeks old, fine at first; olive like mass RUQ; metabolic alkalosis with hypochloremia; narrowing on enema; hypertrophy of pyloric muscle; NO metabolism possibly genetic/familial; scadinavian first born pyloric stenosis males; crampy pain, vomitting, distension, constipation/blockage, progression of pain, hx of abdominal surg, distended ab, dry, high pitched bowel; fluid sequester elevates hematocrit; intrinsic (ascaris) extrinsic (bowel ring) intraluminal leiomyooma; ischemia and necrosis due to impaired blood flow; adhesions, bulges, cancer, small bowel obstruction less air on imaging;

patch; cathertization; primu need mitral repair and sinus need prosthesis; contra in hemostable, pulhtn; eisenmenger (heart failure) HTN control, endocarditis abx (nafcilin) angio, resectin of stenosis oxygen, morphine, beta blockers; cath--> surg; vsd closure; shunt from pulm to subclavian/thoracic aorta; phtn has to be monitored infant warmer, head up , abx for aspiration, npo with suction; ablation of fistual and anastomosis as necessary

correct fluids/electrolytes; ramstedt pyloromyotomy

fluids, ng tube, foley, laparotomy fluids, abx, gastric decompression abdominal pain, nausea, vomitting, obstipation, distension; abdominal surgery hx; (colonoscopic) transverse/sigmoid distension visible on xray; colonc cancer, sigmoid diverticulitis, volvulus; bowel colonostomy, cecostomy, hartman large bowel obstruction edema/ischemia above obstruction--> perforation, death procedure facial flushing, severe headaches, episodic palpitations, perspiration, obstipation, phenoxybenzamine/prazosin with weight loss; htn, catecholamines elevated, clonidine fails, high glucose, salt to maintain volume; add beta to vanillylmandelic acid; chromafinncells; acth can be secreted; VHL, NF, MEN II; prevent arrythmia, resection; CHF, pheochromocytoma clonidine suppression fails mets, cardiomyopathy anterior portion of neck, painradiotherapyto neck hx, hard solitary mass; palpable thyroidectomy; radical neck if lymphnodes, normal TFT; FNA, psmamomma bodies, cold on scan; papillary lymphnodes involved, radioactive thyroid cancer most common (psmammoa bodies), iodine except Medullary abx (staph, strep,pseudo, alcoholism, chest pain, vomitting, tearing chest pain, SOB; tachy hyperten, subQ bacteroides); closure with drainage, crepitus, chest pain worse with flexion and swallowing; AST>ALT, wide post 24 hours ligation with j tube boerhaave mediastinum, subq air in neck, fluid level in pleural feedings difficulty swallowing solids and liquids, weight loss, regurgitation, slow progression, bad breath; low albumin, ANA neg, dilation of esophagus, LES nitrates/CCB, balloon dilation, hypertonic with high resting pressure, inadequate LES relaxation, beak on botulinum injection; heller swallow; impairment of inhibitin of auerbach with LES impariment; Cardiospasm cardiomyotomy (reflux ) risk of achalasia absence of peristaltic contractions cancer

diverticulitis

pseudocyst pancreas

pancreatitis

perforated ulcer

tension pneumo

portal htn

Peritonitis, IV fluids, NPO, abx (cipro + metro); colonoscopy; surgical abscess (if no drainage) LLQ pain, low fiber diet; tachy, fever, guarding, occult stool; bowel dilation; high peritonitis, fistula, obstruction, intraluminal pressure with bleeding, older, failure of med, recurrence let them grow to 6cm and mature 6 weeks; anastomosis to internal drainage; necrosis or abscess = immediate surg (percutaneous epigastric, fever, nausea, vomitting, hx of pancreatitis; immotile mass in epigastric drainage; less than 6cm usually area; leuko, elevated blood sugar, amylase, lipase, fluid mass on US; infection regress; internal septation or no cause abscess; trauma in children, surgery and alcohol; inflammation may be tumor NPO, ng tube, fluids; if necrotic improvement with fetal position, leaning forward; worse deep breathing; tender drainage, irrigation, distended abdomen some guarding ecchymoses; hypocalcemic signs; high pancreatectomy, peritoneal lavage, amylase and lipase; Ranson (age 55, ldh350, ast250; at 48 hours 10% hct drop, ; calcium gluconate; gallstones 5% increase in bun, calcium <8, hypoxemia 60, deficit >4, fluid sequester <6l) cholescystectomy, ; abscess drain pleural effusions, atelectasis, ileus, ascending gas, alcohol, gallstones, lipids, via tube or open and lavage every calcium, ascaris (parasites)CMV in HIV, campylo, azathio, mercapto, tetra, ercp 2 days gastric =gastrectomy vagotomy; duodenal closure w/omental patch if critical; ampicillin metronidazole and ceph, most cases resolve sudden onset severe epigastric pain, tahcy, hypotense, vomitting, stress, cofee, bleeding alone; h pylori 3 abx with alcohol, aspirin, radiating to back, diaphoresis, rigid abdomen, rebound pain, PPI; prostaglandin and sucralfate; occult blood; leukocytes, helicobacter, free subdiaphragmatic air; eroded fistula, ulcer, alkaline, blind loop, mucosum, acid (duodenal younger); blood group o, high carb low fat diet` dumping dont wait for xrays!! decompression creates open pneumothorax, enter mechanical ventialation; ards; intubated, tachy and hypotensive, cyanotic, right above rib edge, 2nd tracheal deviation. tympanic, dimished breath sounds, JVD, hypoxemic, intercostal,lateral to sternum 9kids) hypercapnic; hyperlucency with mediastinal shift; one way valve,dimished midclavicular adult; chest tube 5th ventilation; trauma and highpressure vent; clinical suspicion, dont wait for xrays!! intercostal midaxillary AMS with ammonia breath; chronic alcohol; hematemesis, hemmorhoids, varices; tachy hypotense; jaundiced, parotid enlarge; asterixis, spider angiomata, gynecomastia, palmar erythema, caput medusae, hard nodular liver, bulging hemodynamic stability; dullflanks, ascites, splenomegalt, testicular atrophy; anemia, ast alt; PT high, sclerotherapy transaminases,ggt, alk phos, low blood sugar, high ammonia; hypoalbuminemia; octrotide/vasopressin, balloon prehepatic, intra and post; collateral circulation with anastomses of left gastric to tamponade (blakemore tube); azygous (varices); superior __>inferior middle rectal hemmorhoids; surgical shunts, tranjugular paraumbilical--> inf gastric (caput); varices only ones that bleed for real intrahpeatic portosystemic shunt

acute choly

fat fair forty fertile; N/V, scapular pain, guarding, palpable, murphy sign; leukocytosis, alk phos and bilir elevated; thickened gallbladder, pericholecystic fluid, sonographic murphy; gallstones; ischemia, necrosis, perforation; brown infections; acalculous in severe burns parenteral nutrition;

anal fissure

tearing rectal pain straining and hard stool, constipation; spincter spasm, ulceration of mucosa, sentinel tag; hypertrophic papilla; minimal bleeding but intense pain

fissure

intermittent foul smelling purulent anal discharge; through opening in skin; anal crypt with communication to skin, usually secondary to abscess; posterior ones curve and anterior are straight

appendicitis rectal cancer

migrating pain from midline to RLQ. anrexia, tachy, mcburney point tender, rebound, psoas, obturator, rovsing, leuko, bhcg neg; ct and US;

surgery in frist 72 hours; ifnot npo ng tube, iv fluids abx with elective choly a month later; if perforation or empyema then emergent chole; ercp to remove just stones, cholecystomy in high risk candidates; gangrenous in elderly/diabetics appears benign; ascending cholangitis stool softeners, fiber, analgesics, sitz bath, suppository; refractory chronic lateral internspincterotomy; asses for chron or biopsy for cancer rectosigmoidoscopy, assess area; barium enema; fistulography delineates; surgery needed because of scarring; fistulotomy, fistulectomy, suture and fibrosis; IBD and HIV no surgery emergent surgery/ no abx analgesics; post op ampicillin, gentamicin, metornidazole; walled of abscess drain then appendectomy later

dislocated shoulder

falling backward sideways on hand, deformity of shoulder; loss of countour; depression under acromion (sulcus sign), palpate humerus underaxilla; limited ROM; check deltoid and hand for neurovascular; AP/oblique, axillary views; forced abduction/ex rotation; humeral fx (hill sachs) glenoid fx (bankart); posterior cannot ex rotate, coracoid is prominent, anterior is flat, shock and seizures; capsular tear recurrent

dupuytren

hip fx

osteosarcoma

osteomyelitis

radius fx

herniated disc

r/o fx, sooner reduction better; kocher (90 degress, external rotate traction and then adduct and internal rotate) xray to check; immobilize for 3 weeks, in younger physical therapy, night splinting, cant extend 5th fingers; alcoholism and cirrhosis; familial; thickened palmar fascia steroid shot, if no permananet with bands contracting fingers; can involve feet and penis; hydantoin, older changes surgery can help; alcoholics, diabetics, and post MI; earlier onset more severe recurrence in 15% best within 48 hours; nondisplaced stable impated may be medical if comorbidities; DVT prophylaxis; elderly fall, unable to bear weight on leg; pain in hip exaerbated with movement; retinacular vessels of capsule need leg ex rotate, shortened, adducted, positive logroll test, tenderness in groin; to be patent or avascular necrosis subcapital, transcervical an dextracapsular, intratrochanteric (intracapsular need arthroplasty) pain and swelling lower extremity; dull aching pain, worse at night; nontender fullness, no limits on ROM; ALK phos; sunburst knee with osteolytic metaphyseal lesion; sclerosis from periosteal rxn, codman triangle ( new bone piece); retinablastoma with radiation hx; pain can be in different areas than tumor; aggressive resection, radiation and teenagers, paget disease osteomyelitis chemo, pain, tender, inability to bear weight, fever, malaise, hx of open injury; leukocytosis, inflammatory markers, staphylococcus, pus in bone; staph aureus, nafcillin and aminoglycoside X6 pseudomonas, salmonella; hematogenous spread; suppuratino with bone death weeks, with fever and esr/crp pus and sinus formation; involucrum around sequestrum resolution, pus must be drained reduce and splint, cast a week later, intraarticular comminution, fall on outstretched hand, dinner fork deformity, radial styloid no longer higher thn failure to to align, complartment ulnar, r/o compartment syndrome, n/v checks; syndrome, severe acute back pain, radiation to but and worse with straining; heavy foot and numbness on side of leg; tenderness, normal spncter no saddle, weak toe, disk bed rest, analgesia, traction; herniatino on MRI, minor trauma, nerve compression, stenotic changes increased bladder bowel, muscle weakness, risk; s1/l5, vibrational stress smoking laminectomy or chemonucleolysis

Abdominal aortic aneurysm

sudden severe epigsatric pain; peripheral vascular disease hx, hypotension, tachy, pulsatile abdominal mass and bruit; intraluminal clot, free fluid and dilated aorta on US and CT; athlersclerosis, age smoking, MI, pseudoaneurysm. can lead to renal colic carotid bruit; diabetic, hypercholesteremia, possible neuro signs (mini strokes); MRA can confirm; proximal and bifurcation, fibromuscular dysplasia, arteritis, smoker, pain on walking, calf pain resolving with rest; diabetes, diminished pulses, femoral bruit; buerger test (foot pallor with elevation and red flush spreading) cool extremities, shiny skin, abi (0.4-.9); aortoiliac occlusive (leriche) buttock thigh claudication; angiogram can map

carotid stenosis

fluid resuscitation, osygen, blood, surgical reconstruction (ptfe dacron meshes) unruptured can undergo elective repair and symptomatic should as well. 5.5 cm asymptomatic too. 4-5.5 watch atleast once a year. beta blockers and stop smoking aspirin, risk factor, angioplasty/stenting; endarectomy> 70%; 100% cant do surgery

claudication

lung cancer

aortic disection

melanoma

necrotizing fascitis

right shoulder pain, worsening, facial flusing, sweating; fatigue, weight loss, smoking history; diminished sounds, COPD, eye ptosis, miosis, enophthalmos; nonsmall cell; superior vena cava syndrome hoarseness pancoast syndrome (wasting, arm pain, reduced pulse, jugular vein distension horner due to sympathetic invasion) tearing chest pain; radiation to back , voice hoarseness; htn, tachy, blood in false lumen (between intima and media) trauamtic deceleration; a ascending, b descending; mediastinal widending due to pooling of blood in false lumen; cocaine vascular disorders red hair, white, bleeding mole; color size shape changes; outdoor exposure; black blue, reticulated, flecked lesion ; satellite lesions; actinic keratoses on forehead; lymphadenopathy; bone scan for metastases; blistering sunburns, genes; back and leg in women; superficial spreading, lentigo malina (elderly) acral lentignous (hands) nodular worse because of invasion painful swollen erythematous extremity; febril tachy; laceration with rash; diabetes; dark purple lesionsblisters, pain; crepitus; leukocytosis, cpk, acidotic; rapid spread along fascial planes; polymicrboial type 1 after procuedres, immunocompormised, diabetc PVD; type II monocrobial GAS, MRSA anytime anywhere

percutanous transluminal angioplasty, bypass surger radiotherapy portal determines limited vs extensive; nsclc surgery mediastinocopy, lymph node brain work up; pneumonectomy, lobectomy, resections, vats; chemo and radio for adjuvant small cell and high risk type b medical (beta blockers); type a repair, stenting of occlusion, grafting excisions; lymphnode dissection for symptomatic SLN otherwise; chemo and radiation somewhat effective exploration and debridement; abx, hydration, reexplration; fournier gangrene in groin and perianal requiring cystoscopy, colostomy, orchiectomy

2* to stroke, ICH ASH, hydrocephalus; treat the cause; craniotomy, resection of tumor, csf severe headaches, nausea vomitting; present in morning or lying down; getting shunting, blood clot evacuation; worse; ICP >20; cn palsies, papilledema, periorbital bruising, cushing triad (pulse mannitol, steroids, hypervent, ICP pressure, brady, respiration) parinaud syndrome ( loss of upward gaze) barbituates early radiation; resection for painless hoarseness; tobacco/alcohol use; fiberoptic laryngoscopy erythematous progression; chemo; airway nodular; squamous cell from head and neck; hpv family hx, p53 mutation; males compromise (resection, head/neck cancer over 40 tracheostomy child running with food, coughing, choking, wheezing, decreased breath sunds; removal (bronchoscopy) abx for foreign body aspiration air trapping and decreased air movement postobstructive MRI; steroids (before dx); acute surgical decompression; fusion might be neecessary with laminectomy; posterior safer but possible instability; radiotherapy spinal cord cancer hx with severe back pain; extremity weakness; pain is excrucating, tender after or inthose with mild compression to percussion; vast difference in unaffected limbs; prostate, breast, lung, compression and no symptoms stab wound abdomen; hr tachy, hypotensive; cool clammy extremities; hb hct falling, FAST positive for free fluid; 25% of blood in young healthy individual before serious signs (tachycardia!!); airway, 16 gauge access, crystalloid/blood volume infusion; central line or venous cutdown if need be; response confrims dx hypotension perfusion loss and hypovolemic shock if not look for something else; vasoconstrictors are for bridging not cures death; silvadene, reconstructive surgery; very high fluid load 4ml X kg X % burned; heat lamps to avoid fire and smoke inhalation; blisters, erythema with pain; leathery skin can be cool , hyperthermia; circumferential burns carboxyhemoglobin; asensate 3rd degree, painful 2nd degress; skin can continue (surgical release/escarotomy to burns to necrose for 72 hours. alleviate swelling and occlusion) NEXUS (posterior midline tenderness, intoxication, alert, focal neuro, painful distracting injury: c spine series; collar until cleared; fall, headaches quadriparesis; RA weakness in all extremities; numbness in neck; atlantoaxial sublux in RA; higher c2 c6/7; c1/2 can be lethal, can also be unstable and compress; suspect in can cause ascneding sensory loss Cervical spine injury unconscious MVA and respiration impairment acute changes with neuro deficit needs emergent craniotomy AMS, intoxicated; nonreactive pupil; withdrawal and xtension with pain; crescent (unreactive pupil) only small subdural blood on brain ct; bridge veins collections can be conservative SOB, chest pain; MVA with wheel trauma; ecchymoses and flail chest; bony crepitus; paradoxical breathing; multiple rib fx; pneumo, hemothorax, lung contusions/laceration, cardac contusoin/tamponade, aortic dissectio, esophageal tear, bronchial tea diaphragmatic rupture; first rib thoracic spine sternum indicate chest trauma high impact;