Usmle step 2 ck bible free download pdf

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1 The USMLE Step 2 CK BIBLE The Ultimate Step 2 CK Preparation Guide Jeffrey Anderson, M.D. The USMLE Step 2 CK BIBLE 2 nd Edition

2 The USMLE Step 2 CK BIBLE Copyright 2010 Jeffrey Anderson, M.D. All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of reprint in the context of reviews and personal education.

3 CONTENTS Chapter 1.. Surgery Chapter 2.. Obstetrics Chapter 3.. Gynecology Chapter 4.. Pediatrics Chapter 5.. Biostatistics Chapter 6.. Psychiatry Chapter 7.. Cardiovascular Chapter 8.. Endocrine Chapter 9.. Infectious Disease

4 Chapter 10 Allergies Chapter 11 Pulmonary Chapter 12 Gastroenterology Chapter 13 Nephrology Chapter 14 Hematology Chapter 15 Rheumatology Chapter 16 Neurology Chapter 17 Oncology Chapter 18 Dermatology Chapter 19 Preventative Med

5 FOREWORD The USMLE Step 2 CK BIBLE is the culmination of over four months of my own intense personal Step 2 CK preparation. This document contains and all of the notes I made, all of the charts, graphs, and images I put together to create the ultimate study guide, and I guarantee it is more than enough to help you pass, and if used properly can help you achieve a top score on the Clinical Knowledge exam. I used five different study guides as well as all of the notes I took from working in the wards to put together this in-depth study guide. This preparation guide contains the most up-to-date as well as the most commonly asked clinical information, which will help you score high on the Step 2 CK exam. When I put this preparation guide together, I did so with my own score in mind, and I made it so that I would have to study from one source, and that s exactly what you have here. If you study hard and use the CK BIBLE, you will not only pass, you will do very well. Best of luck on the Step 2 CK exam

6 Chapter 1 Surgery

7 TRAUMA Trauma patients are managed using the ABCDE s in the primary survey after a traumatic incident. A Airway Ensure patient is immobilized and maintain airway with jaw thrust If airway cannot be established, insert 2 large bore needles into the cricothyroid membrane Never perform tracheotomy in the field If patient is unconscious or you cannot establish an airway otherwise, intubate the patient. B Breathing Look for chest movement Listen for breathing sounds Observe the respiratory rate Look for life threatening injuries (tension pneumothorax, flail chest, open pneumothorax) C Circulation Placement of 2 large bore IV s in the upper extremities If patient is in shock, place a central line in the patient Keep blood on stand by in case of hemorrhage D Disability Assess the neurological status with the Glasgow coma scale Check all lab tests (blood, ETOH, electrolytes) Loss of consciousness A loss of consciousness can be assessed with the mnemonic AEIOU TIPS Alcohol, Epilepsy, Insulin, Overdose, Uremia, Trauma, Infection, Psychogenic, Stroke E Exposure Examine the skin (must remove all clothes)

8 In the secondary survey, perform the following: Check the Glasgow coma scale Check all orifices for trauma and/or injuries (bleeding) Perform checks using ultrasound, XRAY, CT Check for compartment syndrome GLASGOW COMA SCALE STATUS/FINDING Eye Opening Spontaneous 4 To Voice 3 To Stimulation 2 No Response 1 Verbal Response Oriented 5 Confused 4 Incoherent 3 Incomprehensible 2 No Response 1 Motor Response To Command 6 Localizes 5 Withdraws 4 Abnormal Flexion 3 Extension 2 No Response 1 A coma scale below 8 indicates severe neurologic injury POINTS

9 SHOCK The type of shock can be diagnosed by checking the cardiac output (CO), the pulmonary capillary wedge pressure (PCWP), and the peripheral vascular resistance (PVR). Differential Diagnosis of Shock HYPOVOLEMIC CARDIOGENIC SEPTIC CO PCWP PVR How to correct the different types of shock Problem Initial Treatment Hypovolemic Shock Decreased Preload 2 Large bore IV s, replace fluids Cardiogenic Shock Cardiac Failure 02, dopamine and/or NE Septic Shock Decreased PVR 02, NE, IV antibiotics Recognizing Shock In Chest trauma: The most common type of shock resulting from chest trauma is hypovolemic Patient will be pale, cold, and diaphoretic This patient is likely losing large amounts of blood, thus searching for source of bleeding is imperative Pericardial tamponade can be a result of thoracic trauma, look for distended neck veins In suspected pericardial tamponade, look for an enlarged heart on CXR, perform cardiocentesis, look for electrical alternans on EKG Management of shock: Control the site of bleeding Give fluids Prepare for an emergency laparotomy ** If a laparotomy isn t warranted, simply resuscitate with fluids

10 HEAD TRAUMA Epidural Hematoma There will be a history of trauma Sudden loss of consciousness followed by a lucid interval, then followed by rapid deterioration Most commonly bleed is from the middle meningeal artery Diagnosis: With a CT, looking for a lens shaped hematoma Management: Emergency craniotomy essential because this is a deadly case within a few hours

11 Subdural Hematoma Is a low pressure bleed coming from the bridging veins There is usually a history of head trauma with fluctuating consciousness Diagnosis: CT showing crescent shaped bleed Management: If there is midline displacement and signs of mass effect then do an emergency craniotomy If symptoms are less severe, conservative management includes steroids Diffuse Axonal Injury This type of injury occurs after an acceleration deceleration injury to the head Patient is usually unconscious There is a terrible prognosis associated with this injury Management: Lower ICP and prevent further injury

12 Basal Skull Fracture This presents with ecchymosis around eyes, behind the ears, or with CSF leak from the nose Diagnosis: CT scan of head and neck Management: CSF rhinorrhea will stop on its own If facial palsy is present, give steroids

13 BURNS 1 st degree and Second degree burns: Epidermis and superficial dermis Skin is painful, red, and blistered Treatment with ointments and/or pain relievers Third and Fourth degree burns: Affects all layers + subcutaneous tissues Painless, dry, charred, and cracked skin Burns affecting all layers of the skin require surgical intervention Depending on severity, resuscitate with fluids Removal of eschars Do a CXR to rule out lung injuries Topical antibiotics after eschar removal Burns that cover more than 20% of the body require admission to a burn center

14 SURGICAL ABDOMEN The following illustrates the differential diagnosis for abdominal pain in the right upper quadrant, right lower quadrant, left upper quadrant, left lower quadrant.

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16 Pneumonia Presence of pleuritic chest pain Perform a CXR, which will show pulmonary infiltrates Fitz Hugh Curtis Syndrome RUQ pain, fever There is going to be a history of salpingitis Caused by ascending Chlamydia or gonorrhea related salpingitis Perform an ultrasound which will show a normal gallbladder and biliary tree with fluid around the liver and gallbladder Right Lower Quadrant Conditions Differentiating Appendicitis Diffuse abdominal pain that localizes to the RLQ at McBurney s point (2/3 distance from umbilicus to ASIS) Fever and diarrhea often present Abdominal xray or CT to solidify diagnosis Decision to remove is based on clinical presentation Ectopic Pregnancy Presents with constant lower abdominal pain, crampy in nature Vaginal bleeding Tender adnexal mass Labs will show hcg Salpingitis Lower abdominal pain Purulent vaginal discharge Cervical motion tenderness Perform an ultrasound to detect the abscess, and a CT to rule out other conditions

17 Meckel s Diverticulitis Follows the rule 1% 2% prevalence 1 10cm in length cm proximal to ileocecal valve Presents with GI bleed, small bowel obstruction (SBO) Technetium pertechnetate scan to detect Yersinia Enterocolitis Presents similarly to appendicitis (fever, diarrhea, severe RLQ pain) XRAY will be negative Treat with aggressive antibiotic therapy Ovarian Torsion Patient develops an acute onset of severe, unilateral pain Pain changes with movement Presence of a tender adnexal mass Ultrasound is done first Confirm with a laparoscopy Pyelonephritis Classically presents with CVA tenderness, high fever, and shaking chills Best initial diagnostic test is a UA and Urine culture Intussusception Seen most commonly in infants between 5 and 10 months of age Presence of currant jelly stool (mix of blood and mucus) Vomiting, intense crying Infants will often pull legs into the abdomen to relieve some pain Barium enema is used for both diagnosis and treatment

18 Left Upper Quadrant Conditions Differentiating Myocardial Infarction Crushing chest pain that radiates to the jaw, neck, left arm Nausea, diaphoresis is present Diagnosed by EKG, cardiac enzymes (CKMB, trop I) Peptic Ulcer Presents as epigastric pain that is relieved by foods and/or antacids Perforations presents with acute and severe epigastric pain, may radiate to shoulders (Phrenic nerve involvement) Diagnose with an upper GI endoscopy Ruptured Spleen Usually a history of trauma Presence of Kehr s sign (LUQ pain that radiates to the left shoulder) Diagnose with an abdominal CT Left Lower Quadrant Conditions Differentiating Similar to the RLQ conditions are: Ovarian torsion, Ectopic pregnancy, and Salpingitis Diverticulitis Patient has LLQ pain, fever, and urinary urgency Diagnose with a CT scan, which shows thickening of the large intestine wall Sigmoid Volvulus Most commonly seen in an older patient Presents with constipation, distended abdomen, and abdominal pain

19 Contrast enema to diagnose, will see the classic bird s beak Pyelonephritis Classically presents with CVA tenderness, high fever, and shaking chills Differential Diagnoses for Midline Conditions GERD Epigastric/substernal burning pain Degree of pain changes with different positions (worse when patient is supine) Diagnosis made with either a barium swallow, ph testing, or upper GI endoscopy Abdominal Aortic Aneurysm Asymptomatic usually until it ruptures If rupture occurs, patient experiences abdominal pain + shock There is usually a palpable pulsatile periumbilical mass Ultrasound done first (least invasive), but can visualize with an xray or CT of the abdomen Pancreatitis Epigastric pain that radiates to the back Nausea and vomiting are usually present Patient often has a history of alcoholism Pancreatic Pseudocyst Is a result of pancreatitis Consider this if patient had pancreatitis that recurred and/or did not resolve Ultrasound will show a pseudocyst

20 Surgical Conditions of the Esophagus Achalasia A condition where the lower esophageal sphincter fails to relax Signs and Symptoms: Dysphagia to BOTH solid and liquid Regurgitation of food Diagnosis: Best initial test its the Barium Swallow, which demonstrates narrowing of the distal esophagus Most accurate test is esophageal manometry, which will demonstrate the lack of peristalsis The best initial therapy is pneumatic dilation If pneumatic dilation is not successful, surgery should be performed If patient does not want surgery, can attempt to relax the LES with injection of botulinum toxin Esophageal Diverticula (Zenker s diverticulum) Most common presentation is a patient with dyphagia that is accompanied by terrible breath Pathology is related to the posterior pharyngeal constrictor muscles with dilate, causing the diverticulum Signs and Symptoms: Dysphagia Halitosis Diagnosis: The best initial test is the barium swallow

21 Surgical resection of the diverticula is the best initial treatment option Cancer of the Esophagus There are Squamous Cell Carcinoma and Adenocarcinoma Common symptoms to both: Dysphagia to solids 1 st, then to liquids 2 nd Weight loss Heme (+) stool Anemia Hoarseness Squamous Cell Carcinoma Is the 2 nd MCC of esophageal cancer Related to chronic use of alcohol and tobacco Most commonly seen in the 6 th decade of life and later Adenocarcinoma Occurs in patients who have chronic GERD Chronic GERD leads to Barrett s esophagus, which then leads to Adenocarcinoma Diagnosing: The best initial diagnostic test is an endoscopy The best initial treatment is surgical resection as long as there is no metastasis Surgery should be followed with 5 FU

22 Diffuse Esophageal Spasms Patient presents with severe chest pain Often times, they don t fit the criteria for an MI, but should get the cardiac enzymes and do EKG to rule out an MI Often comes after having a cold drink Diagnosis: Manometry is the most accurate diagnostic test Calcium channel blockers and nitrates are the treatment option of choice Mallory Weiss Tear Violent retching and/or vomiting causes sudden bleeding Most cases resolve spontaneously, if they don t though give epinephrine to constrict the blood vessels and stop the bleeding

23 Cancer of the Stomach Most cancers of the stomach are found to be malignant There is a link of stomach cancers to blood group A, which may indicate a genetic predisposition to the condition Linitis plastica is a diffuse cancer that is fatal within months, and is the most deadly form of gastric cancer Signs and Symptoms for all: GI discomfort and/or pain Weight loss Anemia Anorexia There is an risk when there is: Low fiber consumption Excess nitrosamines in the diet (due to smoked meats) Excess salt intake in the diet Chronic gastritis There are some classic findings in metastatic gastric cancer, they include: Virchow s node: Left supraclavicular node is hard Krukenberg Tumor: The metastasis of gastric cancer bilaterally to the ovaries Ovaries are palpable in this case They are signet ring cells

24 Sister Mary Joseph sign: Hard nodule at the umbilicus due to metastasis Indicative of a very poor prognosis Treatments: Surgery + chemotherapy Palliative care is often the only choice if too advanced

25 Hernias Inguinal Hernias Is the most common type of hernia Men > women Direct Inguinal Hernia: Protrudes directly through Hasselbach s triangle (inferior epigastric artery, rectus sheath, and inguinal ligament), medial to the inferior epigastric artery Indirect Inguinal Hernia: More common than the direct hernia, passes laterally to the inferior epigastric artery into the spermatic cord Signs and Symptoms: Groin mass (intermittent) that protrudes with valsalva type maneuvers Diagnosis: Must differentiate from a femoral hernia, which will herniated below the inguinal ligament Diagnosis is based on clinical examination Surgical repair

26 Femoral Hernias Women > Men Have a greater risk of incarceration due to the way they herniated Diagnose clinically Surgical correction (do not delay due to risk of incarceration and subsequent strangulation) Visceral Hernias This type of hernia causes intestinal obstruction Signs and Symptoms: Abdominal pain Obstipation (no flatulence) Diagnosis: XRAY will show air fluid levels, no gas in rectum Differentiate from adhesions Surgical repair

27 Surgical Conditions of the Gallbladder Gallstones (Cholelithiasis) Seen mostly in women with the 4 F s 1. Female 2. Fat 3. Forty 4. Fertile It isn t the presence of gallstones that warrants intervention, but the possible complications associated with them Ultrasound is the test of choice for identifying gallstones Asymptomatic gallstones require no intervention Chronic pain may require a cholecystectomy With an increased risk of cancer, such as in the case of a calcified gallbladder wall, cholecystectomy may be warranted Cholecystitis Is an infection of the gallbladder that is a result of an obstruction Common causes are: E. Coli, Enterobacter, Enterococcus, and Klebsiella Note the shadow from the impacted stone.

28 Signs and Symptoms: Acute onset of right upper quadrant pain that is non remitting (+) Murphy s sign arrest of inspiration upon palpation Diagnosis: Ultrasound to detect stones, a thickened wall, or fluid surrounding the GB Confirm with HIDA scan Labs show WBC s >20,000, Bilirubin, AST/ALT Keep patient NPO, give IV fluids, and give antibiotics to cover gram ( ) rods and anaerobes Do not give morphine for pain because it causes a spasm of the sphincter of oddi If improvements are not seen, cholecystectomy may be warranted Ascending Cholangitis Obstructed bile flow from an obstructed common bile duct leads to an infection Presence of Charcot s triad: RUQ, fever, jaundice is commonly seen Diagnosis: Ultrasound to detect dilation An ERCP can be used after the preliminary US diagnosis NPO IV fluids Gram ( ) antibiotics ERCP for decompression of the biliary tree and for removal of the stones

29 Choledocholithiasis An obstruction of the common bile duct Signs and Symptoms: Jaundice (obstructive) Alkaline phosphatase Conjugated bilirubin Diagnosis: Ultrasound to detect CBD obstruction Cholecystectomy Cancer of the GB Is a rare cancer that is associated with a history of gallstones Occurs later in life The MC primary tumor of the gallbladder is the adenocarcinoma Associated with Clonorchis sinensis infestation Has a grave prognosis, with most patients dying within 1yr of diagnosis Signs and Symptoms: Sharp, colicky pain Diagnosis: US or CT to detect the tumor Placement of bile duct stents Surgery as a palliative option, but is not curative

30 Surgical Conditions of the Pancreas Pancreatitis Autodigestion of the pancreas by it s own enzymes MCC is alcohol and gallstones Signs and Symptoms: Severe epigastric pain that radiates to the back Serum amylase and lipase Diagnosis: Clinical suspicion + abdominal CT There may be discoloration of the flank (Grey Turner s sign) and Cullen s sign (bluish discoloration of the periumbilicus) NPO, IV fluids, and Demerol for pain relief Be aware of the potential for alcohol withdrawal Complication: There is a risk for abscesses, renal failure, duodenal obstruction, and pancreatic pseudocysts

31 Pancreatic Pseudocyst Is a complication of chronic pancreatitis Results in a fluid collection within the pancreas that is encapsulated by a fibrous capsule Diagnosis: Ultrasound Abdominal CT Surgical drainage Creation of a fistula draining the cyst into the stomach Complications: Infection followed by rupture can cause peritonitis Endocrine Pancreas β cell hyperplasia causes an insulinoma α cell tumor causes hyperglucagonemia

32 Cancer of the Pancreas More common in African Americans/males/smokers May be more common in diabetics 90% are adenocarcinomas 60% arise from the head of the pancreas Signs and Symptoms: Weight loss Painless jaundice Diagnosis: bilirubin, alkaline phosphatase, CA19 9 CT scan Although usually a terminal diagnosis, can do a resection of the pancreas, or Whipple s procedure The 5yr survival rate is only 5%

33 Surgical Conditions of the Small Bowel Small Bowel Obstruction SBO can be caused by a number of conditions Causes: Peritoneal adhesions Hernias Crohn s disease Meckel s Gallstone ileus Abdominal inflammation Signs and Symptoms: Nausea/vomiting Abdominal pain Abdominal cramps Tenderness/distention Hyperactive and high pitched bowel sounds Diagnosis: Abdominal xray Air fluid levels on upright film Small Bowel Obstruction (Supine View)

34 Small Bowel Obstruction (Upright View) NG tube decompression NPO IV fluids If only partially obstructed may be able to treat without surgery If surgery is required, must remove both obstruction and dead bowel Neoplasm of the Small Bowel Most commonly is a leiomyoma, second MC is a carcinoid tumor (benign types) Most common malignant types are: adenocarcinoma, carcinoid, lymphoma, and sarcoma Biopsy required for diagnosis Treatment involves surgical resection along with LN s and metastases

35 Surgical Conditions of the Large Bowel Polyps Are neoplastic, hamartomas, or inflammatory Neoplastic polyps are MC adenomas Adenomas can be classified as: Tubular (these have the smallest potential for malignancy) Tubulovillous Villous (these have the highest risk of malignancy) Signs and Symptoms: MC presents with intermittent rectal bleeding Diagnosis: Colonoscopy or sigmoidoscopy Polypectomy Diverticular Disease General Information: Up to half of the population has diverticula The risk increases after 50yr of age Only 1/10 people are symptomatic when diverticula are present A TRUE diverticula is rare, and includes full bowel wall herniation A FALSE diverticula is most common, and involves only a herniation of the mucosa The MCC is a low fiber diet which causes an increased intramural pressure (this is hypothesis)

36 Diverticulosis This is the presence of multiple false diverticula Signs and Symptoms: Most people are asymptomatic, with diverticula found only on colonoscopy or other visual procedures May have recurrent bouts of LLQ abdominal pain Changes in bowel habits is common Rarely, patient may present with lower GI hemorrhage Diagnosis: Colonoscopy Barium enema can also be used for diagnosis If patient is asymptomatic, the only therapy should be to increase fiber and decrease fat in the diet If patient has GI hemorrhage, circulatory therapy is warranted (IV fluids, maintenance of hemodynamic stability) Diverticulitis Inflammation of the diverticula due to infection There are many possible complications, such as abscess, extension into other tissues, or peritonitis Signs and Symptoms: LLQ pain Constipation OR diarrhea Bleeding Fever Anorexia

37 Diagnosis: CT demonstrating edema of the large intestine DO NOT perform a colonoscopy or barium enema in an acute case, this might aggravate the problem Complications: Perforation Abscesses Fistula formation Obstructions If there is an abscess, percutaneous drainage is required Most patients are managed well with fluids and antibiotics For perforation or obstruction, surgery is required Obstruction of the Large Intestine Most common site of colon obstruction is the sigmoid colon Common causes include: Adhesions Adenocarcinoma Volvulus Fecal impaction Signs and Symptoms: Nausea/vomiting Abdominal pain with cramps Abdominal distention Diagnosis: XRAY showing a distended proximal colon, air fluid levels, and an absence of gas in the rectum If there is severe pain, sepsis, free air, or signs of peritonitis there must be an urgent laparotomy

38 Laparotomy if cecal diameter is >12cm Volvulus Twisting and rotation of the large intestine Can cause ischemia, gangrene, perforation The MC site is the sigmoid colon Occurs most commonly in older patients Signs and Symptoms: High pitched bowel sounds Distention Tympany Diagnosis: XRAY kidney bean appearance (ie. Dilated loops of bowel with loss of haustra) Barium enema showing a bird s beak appearance points to the site of rotation of the bowel Sigmoidoscopy or colonoscopy acts as diagnosis and treatment If this doesn t work, laparotomy is warranted Cancer of the Colon Colon cancer is the 2 nd MCC of cancer deaths Believed that a low fiber, high fat diet increases the risk There are many genetic factors that contribute to colon cancer, such as Lynch syndrome and HNPCC Lynch Syndrome: LS 1 is an autosomal dominant predisposition to colon cancer that is usually right sided LS2 is the same as LS 1 with the addition of cancers outside the colon, such as in the endometrium, stomach, pancreas, small bowel, and ovaries

39 Screening: Screening should start at 40yr in people with no risk factors If a family member has had cancer of the colon, screening should start 10yr prior to when they were diagnosed (assuming this is less than 40yr) Should have yearly stool occult tests Colonoscopy every 10yr And a sigmoidoscopy every 3 5yrs Diagnosis: Obtain preoperative CEA (allows you to follow the progression or recession of the disease) Endoscopy + barium enema Surgical resection + LN dissection If disease is metastatic, add 5 FU to the post operative regimen Follow up: CEA levels every 3 months for 3 years Perform a colonoscopy at 6 and 12 months, then yearly for 5 years If a recurrence is suspected, a CT should be performed

40 Surgical Conditions of the Rectum and Anus Hemorrhoids Varicosities of the hemorrhoidal plexus Often related to strenuous bowel movements Signs and Symptoms: Bright red blood per rectum Itching Burning Palpable anal mass Internal hemorrhoids are NOT painful, while external hemorrhoids ARE painful Usually self limiting Sitz bath Hemorrhoidal cream Stool softeners to relieve pain Thrombosed Hemorrhoids These are not a true hemorrhoid, but are external hemorrhoidal veins of the anal canal They are a painful bluish elevation that lie beneath the skin Classifications: 1 hemorrhoids involve no prolapse 2 hemorrhoids classically prolapse with defecation but return without manual reduction 3 hemorrhoids prolapse with either straining or defecation and require manual reduction 4 hemorrhoids are not capable of being reduced Conservative therapies Sclerotherapy, rubber band ligation, and surgical hemorrhoidectomy

41 Anal Fissure A crack or tear in the anal canal Usually occurs after the passage of diarrhea or constipation Signs and Symptoms: The most common presentation is the passage of a painful bowel movement that is accompanied by bright red blood Diagnosis: Perform an anoscopy to diagnose Bulking agents and stool softeners are usually all that is needed If fissures persist despite conservative measurements, a lateral internal sphincterotomy may be required Anal and Rectal Cancer Anal Cancer: The most common form is squamous cell carcinoma Signs and Symptoms: Anal bleeding, pain, and mucus upon evacuation Diagnose: Biopsy Chemotherapy + Radiation Rectal Cancer: Seen in males > females Signs and Symptoms: Rectal bleeding, altered bowel habits, tenesmus, obstruction

42 Diagnosis: Colonoscopy Surgery that spares the sphincter If metastasis involved, addition of 5 FU chemotherapy + radiation

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44 Medulloblastoma: Common in children Found in the cerebellum/4 th ventricle Prolactinoma: Is the MC pituitary tumor Presents with many endocrine disturbances such as amenorrhea, impotence, galactorrhea, and gynecomastia. The MC presenting symptoms is visual disturbance (bitemporal hemianopsia) Lymphoma: MC CNS tumor in AIDS patients An MRI shows a ring enhanced lesion Often confused with toxoplasmosis Schwannoma: A tumor that affects the 8 th cranial nerve Presents with tinnitus, loss of hearing, and increased intracranial pressure Hydrocephalus An increase in CSF causes an enlargement of the ventricles Signs and Symptoms: ICP, cognition Headache Focal neurological deficits Diagnosis: A CT or MRI can show the dilation of ventricles A lumbar puncture can help determine the type of hydrocephalus If ICP is normal, it is a communicating hydrocephalus (presents with urinary incontinence, dementia, and ataxia) If ICP is, it may be either communicating or non communicating (Pseudotumor cerebri, congenital)

45 If possible, treat the underlying cause If not possible, a shunt should be placed (usually drained into peritoneum)

46 Surgical Conditions of the Vascular System Aneurysms Is a dilatation of an artery to greater than two times its normal diameter True aneurysms involve all 3 layers of the vessel, and are caused most commonly by atherosclerosis and congenital disorders False aneurysms are covered only by the adventitia of the vessel, and are most commonly caused by trauma Signs and Symptoms: Gastric/epigastric discomfort Back pain Commonly in the abdomen (abdominal aorta aneurysms) Also commonly in the peripheral vessels Complications: A rupture of an abdominal aneurysm is an emergency Presents with abdominal pain, a pulsatile abdominal mass, and severe hypotension Diagnosis: Ultrasound can help detect aneurysms CT is the best test to determine size The most accurate test is the aortogram Control blood pressure Reduce risk factors Surgery recommended if aneurysms are >5cm

47 Peripheral Vascular Disease (PVD) Due to atherosclerosis Signs and Symptoms: Presents with claudication Patient may have smooth and shiny skin with a loss of hair in the affected area Diagnosis: Ankle:Brachial Index (ABI) is the best initial test normal test is 0.9 The most accurate test is an angiography Lifestyle modifications such as cessation of smoking and incorporation of exercise Control lipids with an LDL <100 Control blood pressure Daily aspirin Surgery is required if there is pain at rest, necrosis, intractable claudication, and/or a non healing infection

48 Aortic Dissection Is a dissection of the thoracic aorta Presents with intense tearing pain that radiates to the back There is a difference in blood pressures between the right and left arm Diagnosis: The best initial test is a CXR showing a widening of the mediastinum The most accurate test is the CT angiography Urgent blood pressure control with β blockers followed by nitroprusside to maintain a decreased blood pressure Urgent EKG and CXR Then get a TEE or CT Surgical correction is necessary, otherwise this is rapidly fatal.

49 Subclavian Steal Syndrome An occlusion of the subclavian artery leads to a decreased blood flow distal to the obstruction The vertebral artery steals the blood due to retrograde flow Patient experiences claudication of the arm, nausea, syncope, and supraclavicular bruit Diagnose: Angiography Doppler ultrasound MRI Carotid subclavian bypass Carotid Vascular Disease Is an atherosclerotic plaque in the carotid arteries Signs and Symptoms: Patient may present with a TIA Amaurosis fugax (blindness in one eye) Carotid bruit Diagnosis: Angiography Decrease the modifiable risk factors Aspirin Other anticoagulation medications Surgery is warranted if there is stenosis >70%, if patient has recurring TIA s, or if they have suffered from a previous cerebrovascular accident

50 Surgical Conditions of the Urinary System Testicular Torsion Usually occurs in a younger patient Acute edema and severe testicular pain Patient usually experiences nausea and vomiting due to the degree of the pain ABSENCE of the cremasteric reflex Presence of scrotal swelling Testicle may have a horizontal lie Diagnosis: Ultrasound to assess arterial patency Upon elevation of the teste, the pain is not alleviated 1 st step is to secure the circulation 2 nd step is to evaluate the need for excision of the testicle if it is dead Epididymitis Unilateral pain of the testicle Dysuria Painful and swollen epididymus Less common in prepubertal children as opposed to torsion Diagnosis: Swab for Chlamydia and Gonorrhea NSAIDs and antibiotics Prostate Cancer Obstructive symptoms Rock hard nodule in the prostate Diagnosis: PSA

51 Serum phosphatase Azotemia Transrectal ultrasound The only surgical requirement is a radical prostatectomy in very severe cases risk of incontinence and/or impotence

52 Orthopedic conditions requiring surgery Knee Injuries Include: Anterior cruciate ligament tears Posterior cruciate ligament tears Collateral ligament tears Meniscus tears Anterior Cruciate Ligament tears: Injury history usually reveals a pop sound during the trauma The Lachman test (anterior drawer test) is used in the field to make a diagnosis MRI is the test of choice to determine the severity of the injury Treatment is either with conservative measures, or if severe with arthroscopic repair Tear of the ACL with associated joint effusion Posterior Cruciate Ligament tears: Injury usually occurs when the knee is flexed Posterior dresser drawer sign MRI is the test of choice to determine severity of the injury

53 Treatment is either with conservative measures, or if severe with arthroscopic repair Tear of the PCL Collateral Ligament tears: The MCL is the most commonly injured ligament Seen with a direct blow to the lateral knee Is commonly injured in conjunction with the injury to the ACL or PCL MRI to determine severity of the injury Knee brace Tear of the MCL Meniscus tears: Often seen in older patients and is due to degeneration Injury is most commonly seen in the medial meniscus and is much more common in men

54 Diagnose with McMurray s test MRI to determine the severity of the injury Treatment is usually rest alone, if severe can treat with arthroscopic surgery Medial meniscus tear Shoulder Injuries Rotator Cuff Injury Can range from mild tendonitis to severe tears Involve the Supraspinatus, Infraspinatus, Teres Minor, Subscapularis Signs and Symptoms: Pain and tenderness of the deltoid with movement Pain over the anterior aspect of the humeral head Neer s sign (+) pain elicited when the arm is forcefully elevated forward Diagnosis: Clinical suspicion MRI is used for confirmation NSAIDs Steroids injections

55 For severe diseases that are not successfully treated with steroids, arthroscopic surgery is helpful Dislocation of the Shoulder Is most commonly an anterior dislocation Posterior dislocation seen when patient is electrocuted and/or experiences a status epilepticus seizure Signs and Symptoms: Immobility Extreme pain Anterior dislocation of the humerus Traction countertraction techniques to put the bone back in the socket Immobilization period (2 6 weeks)

56 Hip and Thigh Injuries Dislocations Dislocations require emergency reduction under sedation Risk of injury to sciatic nerve Avascular necrosis is a severe complication Femoral Neck Fracture Requires significant force for injury Produces severe pain of the hip/groin that is exacerbated with movement Leg is classically externally rotated Diagnose with xray Requires surgical reduction and internal fixation Fracture of the left femoral neck Wrist Injuries Colles Fracture: This is a fracture to the distal radius Occurs after falling on an outstretched hand Diagnose with H & P and xray Treat with cast immobilization for 2 4 wk

57 Colles fracture Scaphoid Fracture: Almost always secondary to a fall Most commonly misdiagnosed as a sprained wrist Diagnosis is classically made when there is pain in the anatomic snuff box Manage with a thumb splint for 10 weeks Complication is avascular necrosis Scaphoid Fracture

58 Carpal Tunnel Syndrome Presents with pain, numbness, tingling of the hands along the distribution of the median nerve Diagnosis: Pathognomonic sign is Tinel s Sign, where tapping over the palmar aspect of the wrist elicits shooting pains Phalen s test is also diagnostic Wrist Splints: Holds the wrist Treat by avoidance of aggravating activity, use in a position of wrist splints which hold the wrist in slight slight extension extension Severe cases should first be managed with steroid injection in the carpal tunnel, if no treatment surgery is performed

59 The Breast Workup of a Breast Mass Algorithm (AAFP)

60 Cancer Risks The #1 risk factor for breast cancer is gender (Female >>> Male) In women, age is the #1 factor for breast cancer risk Late menopause increases the risk of breast cancer (after 50yr) If less than 11yr at menarche, the risk of breast cancer is increased If >30yr at first pregnancy, the risk for breast cancer increases History of Fibroadenoma and/or Fibrocystic disease does not increase the risk of getting breast cancer Family History and Breast Cancer: Only 5% of breast cancers are familial With a 1 st degree relative being affected, the risk of cancer increases Autosomal dominant conditions with increased risk: BRCA 1, BRCA 2, Li Fraumeni syndrome, Cowden s disease, Peutz Jeghers

61 Tumors of the Breast Mammogram All women >40yr (controversial as to age to start) should have yearly mammograms Not effective in young patients because the breast tissue is too dense Fibroadenoma The classic presentation is a firm, non tender, mobile breast nodule Most commonly seen in teens and younger women When to perform certain tests pertaining to breast masses: A palpable mass that feels cystic always requires an ultrasound first. A palpable mass that doesn t feel cystic requires a FNA (after an US or instead of an US). Any FNA that reveals bloody fluid requires cytology. Always do a mammogram in patients >40yr who present with almost all pathologies of the breast. Diagnosis: Breast exam FNA Follow up clinical breast exam in 6 weeks Not required as this condition is not a cancer precursor and often disappears on its own A biopsy is required when a cyst recurs more than 2 times within 4 weeks, when there is bloody fluid, when there are signs of inflammatory breast disease, and when a mass does not disappear with FNA.

62 Fibrocystic Disease This presents with multiple/bilateral painful lumps in the breast that vary in pain with the menstrual cycle Is the most commonly seen breast tumor in women between 35 50yr of age Diagnosis: Fine needle aspiration to drain fluid, and it will collapse after the FNA OCP s can help prevent this from occurring Pre Invasive Breast Cancers Include Ductal Carcinoma In Situ and Lobular Carcinoma In Situ Ductal Carcinoma In Situ (DCIS) It s presence increases the risk of invasive breast cancers Usually non palpable and seen on mammogram as irregularly shaped ductal calcifications Will lead to invasive ductal carcinoma

63 Diagnosis: Histology shows puched out areas in ducts and haphazard cells along the papillae Surgical excision ensuring clean margins Post operative radiation is recommended to decrease the risk of recurrence (Can give Tamoxifen in addition to radiation or instead of radiation) Lobular Carcinoma In Situ (LCIS) In contrast to DCIS, this is not precancerous, it does however increase the risk of future invasive ductal carcinoma Diagnosis: Hard to diagnose with mammogram Cannot be detected clinically The histology shows mucinous cells in the classic saw tooth pattern Tamoxifen alone is used for treatment

64 Invasive Breast Cancers Treatment for all invasive cancers: 1. If lump is <5cm, Lumpectomy + radiation, may add chemo and adjuvant therapy. 2. Perform sentinel node biopsy (preferred over an axillary node biopsy) 3. Test for estrogen/progesterone receptors and the HER2 protein 4. If tumor is >5cm, the treatment involves systemic therapy Invasive Ductal Carcinoma Is the most common form of breast cancer, seen in almost 85% of all cases Is unilateral Metastasizes to the brain, liver, and bone Important prognosis factors are size of the tumor and the lymph node involvement Paget s Disease of the Breast Presents with an erythematous and scaly lesion of the nipple that is pruritic. Nipple may be inverted Nipple discharge common Inflammatory Breast Cancer Less common Rapid growth/progression Early metastasis Red, swollen, pitted, and warm breast (peau d orange) Lobular Carcinoma Multifocal and within the same breast (usually) 20% of cases present as bilateral multifocal lesions BRCA1 and BRCA2 Testing for these genes should be performed if there is a history of the following: Family history of early onset breast cancer

65 Family history of male breast cancer Past history of breast and/or ovarian cancer in that patient Ashkenazi Jewish heritage

66 Chapter 2 Obstetrics

67 Terminologies Gravidty = total number of pregnancies Parity = number of births with a gestational age >24 weeks Term delivery = delivery after 37 weeks of gestation Premature delivery = delivery of infant between 20 and 37 weeks The Uncomplicated Pregnancy Diagnosing Pregnancy The presence of amenorrhea and + urinary ß hcg suggests pregnancy. Confirm pregnancy with the following: Presence of gestational sac [seen with transvaginal US at 4 5 weeks. ß hcg level approx 1500mIU/ml.] Fetal heart motion [seen by US between 5 6 weeks.] Fetal heart sounds [heard with Doppler US at 8 10 weeks.] Fetal movement [on examination after 20 weeks.] Estimating date of confinement (EDC) Use Nagele s rule = Last Menstrual Period (LMP) + 7 days 3 months + 1yr. *Calculation accuracy depends on regular 28 day cycles. DRUG CATEGORIES DURING PREGNANCY Category A B C D Description Medication has not shown an increase in risk for birth defects in human studies. Animal studies have not demonstrated a risk, and there are no adequate studies in humans, OR animal studies have shown a risk, but the risk has not been seen in humans. Animal studies have shown adverse effects, but no studies are available in humans, OR studies in humans and animals are not available. Medications are associated with birth defects in humans; however,

68 X potential benefits in rare cases may outweigh their known risks. Medications are contraindicated in human pregnancy because of known fetal abnormalities that have been demonstrated in both human and animal studies. COMMON TERATOGENS IN PREGNANCY Drug Lithium Carbamazepine, Valproate Retinoid Acid ACE Inhibitors Oral hypoglycemics Warfarin NSAIDs Birth Defect Ebstein s anomaly (single chambered right side of heart). Neural tube defects. CNS defects, craniofacial defects, cardiovascular defects. Decreased skull ossification, renal tubule dysgenesis, renal failure in neonate. Neonatal hypoglycemia CNS & Skeletal defects Necrotizing enterocolitis, constriction of ductus arteriosis. At first visit upon discover of pregnancy Perform the following: Complete physical exam with pelvic and Pap smear. Culture for gonorrhea and Chlamydia Labs include the following: CBC Blood type with Rh status UA with culture RPR for syphilis Rubella titer TB skin test Offer HIV test Additional testing: Genetic testing if history indicates the need If pt not immune to rubella, DO NOT immunize (live virus).

69 Recommend: Folic acid Iron Multi vitamin lb weight gain during pregnancy What to do during each trimester 1 st trimester: Should see patient every 4 weeks. Assess: Weight gain/loss Blood pressure Edema Fundal height Urine for glucose and protein Estimation of gestational age by uterine size 2 nd trimester: Continue to see the patient every 4 weeks Assess: At 12 weeks use Doppler US to evaluate fetal heart beat (each visit) Offer triple marker screen (ß hcg, estriol, α fetoprotein(afp)) at weeks, [AFP decreased in Down s syndrome], [AFP increased in multiple gestation, neural tube defects, and duodenal atresia]. Document quickening (fetal movement) at weeks and beyond. Amniocentesis if mother is >35yr or if history indicates (hx of miscarriages, previous child with deficits, abnormal triple marker screen). Glucose screening at 24wk Repeat hematocrit at 25 28wk MS AFP: Neural tube defect (NTD), ventral wall defect, twin pregnancy, placental bleeding, renal disease, sacrococcygeal teratoma. * The most common cause of inaccurate lab results is dating error. MS AFP: Trisomy 21, Trisomy 18

70 SECOND TRIMESTER ROUTINE TESTS Screening Test Diagnostic Significance Diabetes 1hr 50g OGTT Abn if (24 28 wks) >140mg/dL Anemia CBC measured Hb <10g/dL = between anemia weeks. Atypical antibodies GBS screening Indirect Coombs test Vaginal and rectal culture for group B strep at weeks. Performed in Rh( ) women looking for antibodies (anti D Ab) before giving RhoGAM (+) GBS is a high risk for sepsis in newborns. [treat with intrapartum IV antibiotics]. Next Step in Mgmt If +, perform 3hr 100g OGTT Iron supplementation RhoGAM not indicated in Rh ( ) women who have developed anti D antibodies IV: Pen G Clindamycin Erythromycin in PCN allergic patient. 3 rd trimester: See patient every 4 weeks until week 32, every 2 weeks from week 32 36, then every week until delivery. Assess: Inquire about preterm labor [vaginal bleeds, contractions, rupture of membranes]. Inquire about pregnancy induced hypertension. Screen for group B streptococcus at weeks. Give RhoGAM at weeks if indicated The confirmatory test for diabetes in pregnancy is the 3hr 100g oral glucose tolerance test (OGTT). Plasma glucose >125mg/dL at beginning of test = DM Abnormal plasma glucose is >140mg/dL at 1hr, >155mg/dL at 2hr, and >180mg/dL at 3hr. If 1 post glucose load measurement is abnormal, impaired glucose tolerance is the diagnosis. If 2 or more post glucose load measurements are abnormal, gestational diabetes is the diagnosis.

71 The following antiemetics are safe to use during pregnancy: Doxylamine Metoclopramide Ondansetron Promethazine Pyridoxine

72 The Complicated Pregnancy Bleeding after 20 weeks (late pregnancy) Most common causes of late pregnancy vaginal bleeding are: 1. Abruptio placenta 2. Placenta previa 3. Vasa previa 4. Uterine rupture * Never perform a digital or speculum exam in any patient with late vaginal bleeding until a vaginal ultrasound has ruled out placenta previa ABRUPTIO PLACENTA Sudden onset of severely painful vaginal bleeding in patient with history of hypertension or trauma. Bleeding may be concealed, in which case there will be severe, constant pain without the presence of blood. DIC is a feared complication Management: Emergent C section if patient or fetus is deteriorating Admit and observe if bleeding has stopped, vitals and HR are stable, or fetus is <34 weeks. PLACENTA PREVIA Sudden onset of painless bleeding that occurs at rest or during activity without warning. May include history of trauma, sexual activity, or pelvic exam before onset. Occurs when the placenta is implanted in lower uterine segment Best management is emergency C section. 3 forms of placenta previa: 1. Accreta does not penetrate entire thickness of endometrium

73 2. Increta extends further into the myometrium 3. Percreta placenta penetrates entire myometrium to uterine serosa VASA PREVIA A condition life threatening to the fetus. Occurs when vilamentous cord insertion results in umbilical vessels crossing the placental membranes over the cervix. Membrane rupture causes tearing of the fetal vessels, and blood loss is from the fetal circulation. Fetal bleeding and death occur rapidly. Management: Immediate C section. Classic triad of vasa previa: 1. Rupture of membranes 2. Painless vaginal bleeding 3. Fetal bradycardia Emergency C section is always the first step in management UTERINE RUPTURE Occurs when there s a history of uterine scar with sudden onset of abdominal pain and vaginal bleeding. Associated with a loss of electronic fetal HR, uterine contractions, and recession of the fetal head. Management: Immediate surgery and delivery

74 Comparing Placenta Previa and Placental Abruption Abnormality Epidemiology Placenta Previa Placenta implanted over internal cervical os (completely or partially) Risk grand multiparas and prior C section Placental Abruption Premature separation of normally implanted placenta from decidua Risk preeclampsia, previous history of abruption, ROM in a pt with hydramnios, cocaine use, cigarette smoking, and trauma. Time of onset weeks Any time after 20 weeks Signs & Symptoms Sudden, painless bleeding Painful bleeding, can be heavy and painful, with frequent uterine contractions Diagnosis Treatment Complications US Placenta in abnormal location Hemodynamic support, expectant management, delivery by C section when fetus is mature enough Associated with a two fold increase in congenital malformations so evaluations for fetal anomalies should be undertaken at diagnosis Clinical, based on presentation of painful vaginal bleeding, frequent contractions, and fetal distress. Hemodynamic support, urgent C section or vaginal induction if patient is stable and fetus is not in distress Risk of fetal hypoxia and/or death, DIC may occur as a result of intravascular and retroplacental coagulation.

75 Hypertension in Pregnancy Hypertension in pregnancy predisposes both the mother and fetus to serious conditions. A BP of 140/90 during pregnancy can be classified as chronic hypertension or gestational hypertension. Hypertension accompanied by signs and symptoms of end organ damage or neurological sequelae is diagnosed as preeclampsia, eclampsia, or HELLP syndrome. Sustained hypertension may cause fetal growth restriction and hypoxia, and increase the risk of abruptio placenta. Diagnosis: Elevated pregnancy before pregnancy or before 20 weeks gestation = chronic hypertension Development of hypertension after 20 weeks gestation that returns to normal baseline by 6 weeks post partum = gestational hypertension Presence of proteinuria and/or presence of warning signs = preeclampsia Warning Signs of Preeclampsia: Hallmark symptoms include: Signs: Labs: Headache Epigastric pain Visual changes/disturbances Pulmonary edema Oliguria Thrombocytopenia Elevated liver enzymes

76 Disease Characteristics Preeclampsia HTN (>140/90 or systolic BP >30 mmhg or diastolic BP >15 mmhg compared to previous BP). New onset proteinuria and/or edema. Commonly around week 20 Severe Preeclampsia SBP >160 mmhg or DBP >110 mmhg. Significant proteinuria (>1g/24hr urine collection or >1+ on dip) CNS disturbances such as headache or visual disturbance Pulmonary edema RUQ pain Eclampsia CONVULSIONS 25% occur before labor, 50% during labor, 25% in first 72hr post partum Primiparas are at greatest risk for eclampsia. Chronic hypertension with superimposed preeclampsia is diagnosed when there is chronic hypertension with increasingly severe hypertension, proteinuria, and/or warning signs. Eclampsia is the diagnosis when there is unexplained grand mal seizures in a hypertensive and/or proteinuric in a woman in the last half of pregnancy. Seizures are due to severe diffuse cerebral vasospasm, which cause cerebral perfusion deficits and edema HELLP syndrome is diagnosis when there is Hemolysis, Elevated Liver enzymes, and Low Platelets. BP goal is mmhg (systole) and mmhg (diastole). Don t treat unless BP is >160/100 mmhg Maintenance Therapy: First line therapy Methyldopa Second line therapy β blockers such as labetalol