Adenocarcinoma of pancreas most commonly in head of pancreas 2. Nonmetastatic disease limited to head of pancreas may be resected with Whipple procedure i. Lesions in body or tail rarely amenable to surgery but can be resected via subtotal pancreatectomy if found early c. Adjuvant chemotherapy may be beneficial in resectable disease d. Enzyme deficiency treated with replacement therapy e. Stenting of pancreatic ducts, biliary ducts, or duodenum can be performed as palliative therapy in advanced disease 7.
Endocrine Pancreatic Cancers 1. Neoplasms involving glandular pancreatic tissue 2. Insulinoma a. Glucagonoma a. May present as refractory DM c. VIPoma a. Biliary Disorders A. Cholelithiasis 1. Gallstone formation in the gallbladder that can cause cystic duct obstruction 2.
Most stones are composed of cholesterol; others are calcium bilirubinate i. Acute Cholecystitis 1. Inflammation of gallbladder commonly caused by gallstone obstruction of cystic duct; acalculous cholecystitis can occur in patients on TPN or in those who are critically ill 2. Note the shadow caused by gallstones, which may be more apparent than the gallstones themselves in several cases.
From Kawamura, D. Cholangitis 1. Infection of bile ducts secondary to ductal obstruction 2. Quick HIT The addition of shock and altered mentation to the Charcot triad is also known as Reynolds pentad of ascending cholangitis. Gallbladder Cancer 1. Adenocarcinoma of gallbladder associated with cholelithiasis, chronic infection, and biliary tract disease; generally poor prognosis 2.
From Bickley, L. Autoimmune disease with intrahepatic bile duct destruction leading to accumulation of cholesterol, bile acids, and bilirubin 2. Progressive destruction of intra- and extrahepatic bile ducts leading to fibrosis and cirrhosis 2.
Disorders of Hepatic Bilirubin Transport 1. Normal bilirubin transport a. Unconjugated bilirubin from RBC hemolysis exists in venous circulation b. Unconjugated bilirubin enters hepatocytes and is conjugated by glucuronosyltransferase c. Conjugated bilirubin reenters venous circulation d. Gilbert disease a. Autosomal recessive or dominant disease with mild deficiency of glucuronosyltransferase b.
Crigler—Najjar syndrome type I a. Autosomal recessive disease with severe deficiency in glucuronosyltransferase b. Hepatic Disorders A. Alcohol-related Liver Disease 1. Progressive liver damage secondary to chronic alcohol abuse 2. Initially characterized by fatty deposits in liver; reversible with alcohol cessation 3.
Continued alcoholism causes hepatic inflammation and early necrosis 4. Progressive damage results in cirrhosis 5. Cirrhosis 1. Persistent liver damage leading to necrosis and fibrosis of hepatic parenchyma 2. Hemochromatosis 1. Autosomal recessive disease of iron absorption 2. Excess iron absorption causes iron deposition in liver, pancreas, heart, and pituitary, leading to eventual fibrosis 3. Rarely is result of chronic blood transfusions or alcoholism 4.
Wilson Disease 1. Autosomal recessive disorder of impaired copper secretion, primarily in young adults 2. Excess copper deposits in liver, brain, cornea 3. Most symptoms arise from emphysemic component of disease 3. Hepatic Neoplasms 1. Benign tumors e. Benign hepatic tumors found more commonly in women with history of oral contraceptive use b. Hepatocellular carcinoma hepatoma a.
Malignant tumor of hepatic parenchyma b. Quick HIT Biopsy of hepatic masses is usually contraindicated because of hypervascularity and risk of hemorrhage. Quick HIT Paraneoplastic syndromes associated with hepatoma include hypoglycemia, excessive RBC production, refractory watery diarrhea, hypercalcemia, and variable skin lesions.
A year-old woman with PMHx of DM walks into her primary care doctor complaining of progressive trouble swallowing solids and now liquids occasionally. Adenocarcinoma of proximal stomach B. Achalasia C. Scleroderma D. Esophageal cancer 2. The discomfort improves when he stands but worsens when he lies down.
His workup includes a normal ECG and chest x-ray. Esophageal spasm B. Myocardial infarction C. Gastroesophageal reflux disease D. Esophageal cancer 3.
A previously healthy year-old male comes in today with worsening abdominal discomfort in RUQ and jaundice for about 5 days. The patient denies IV drug abuse, alcohol intake, or unprotected sex. He recently returned from travel in a cruise. Physical examination shows jaundice and scleral icterus. What is the most likely cause of his signs and symptoms?
Acute gastroenteritis B. Hepatitis C C. Hepatitis A D. Hepatitis D 4. A year-old woman with history of chronic urinary tract infections comes in to the emergency department with 1 week of non-resolving watery diarrhea that has occasional bloody streaks. The patient recently finished a course of antibiotics. On physical examination, she appears mildly dehydrated, and is tachycardic. Her abdominal exam is benign. She denies any recent travel or dietary changes.
What is the most likely organism responsible for her symptoms? Salmonella D. He has been taking over the counter pain medication for severe dental pain for about 1 week. He is a social alcohol drinker, but recently is not able to tolerate most drinks due to symptoms. His initial workup is within normal limits and physical examination is unremarkable, except for mild epigastric pain. Acute gastritis B. GERD C.
Hiatal hernia D. Viral gastroenteritis 6. A year-old male comes in with abdominal burning pain soon after eating. He denies chronic medications used, alcohol use, or change in diet. Physical examination is unremarkable. The patient tests positive on a urea breath test.
What is the most likely diagnosis and cause of symptoms? Gastric ulcer, H. Chronic gastritis D. Zollinger—Ellison syndrome 7. A year-old male presents with 4 months of abdominal cramps, weight loss, generalized joint aches, and watery diarrhea. Physical examination includes mild dehydration, oral ulcers, and a perianal fissure.
Initial workup shows a positive hemoccult test. Colonoscopy reveals cobblestoning, colonic ulcers, and skipped lesions. What is the most likely diagnosis? Crohn disease B. Ulcerative colitis C. Irritable bowel syndrome D. Ischemic colitis 8. A year-old female with history of constipation presents with abdominal pain and fever to the emergency department. Physical examination reveals LLQ tenderness to palpation with abdominal distention.
An abdominal plain film shows constipation, hemoccult is negative, blood work shows leukocytosis, and urine is unremarkable. The most likely cause of fever, distention, and pain is due to: A.
Ulcerative colitis B. Ischemic colitis C. Diverticulitis D. Lower GI bleed 9. A patient comes in with recurrent headaches, confusion, weakness, and diaphoresis. He has been found with persistent and recurrent hypoglycemia while fasting without any hypoglycemic medications given. This is most likely due to: A. Glucagonoma B. Zollinger—Ellison syndrome C. Pancreatic pseudocyst D. Insulinoma A year-old man with chronic alcoholism presents with severe sudden-onset epigastric abdominal pain with radiation to his back.
He is actively vomiting in the emergency room. Physical examination reveals a dehydrated male with signs of alcohol intoxication. Workup shows a normal ECG and chest x-ray. Pancreatitis B. Gastric ulcer C. Alcohol withdrawal D. Viral gastritis A year-old female comes in to the emergency department to get evaluated for nausea, vomiting, epigastric pain for 8 hours, and fever. On physical examination she has a positive Murphy sign.
She has had similar pains before, but never lasted this long. The next step is: A. Abdominal x-ray B. Abdominal and pelvic CT scan C. Endoscopic evaluation D. Abdominal ultrasound A year-old female with PMHx of HTN, high cholesterol, and gallstones is brought in by her son being to be evaluated for onset of RUQ abdominal pain, jaundice, fever, and changes in mental status since today.
This is a classic presentation of: A. Cholecystitis B. Porcelain gallbladder C. Ascending cholangitis D. Biliary cirrhosis A patient with chronic alcoholism is being evaluated by his PCP due to skin color changes.
Physical examination shows jaundice and abdominal distention with a fluid wave on palpation. He denies any IV drug abuse, recent illness, or travel. The patient takes no medications currently. This patient is most likely showing signs and symptoms of: A.
Cirrhosis B. Wilson disease C. Cholangitis D. Hepatic adenoma Upon evaluation, this patient shows a green-brown ring in his corneas, jaundice, and hepatomegaly. Portal hypertension B. Cirrhosis C. Hepatitis C D. Wilson disease A 9-day-old boy is brought in to a pediatric emergency room due to projectile vomiting after every feed.
On evaluation, the child appears dehydrated and hungry; an olive-sized mass is found around the RUQ. The blood work shows hypochloremia and metabolic alkalosis. What diagnostic test would you perform? Abdominal ultrasound C. CT scan of abdomen D. Barium swallow A premature baby is brought back to the hospital due to poor feeding, abdominal distention, bloody stools, and bilious description of vomit. Blood work shows metabolic acidosis.
The child appears ill and dehydrated. X-ray shows bowel distention with air within bowel loops. This child is suffering from: A. Pyloric stenosis B. Intussusception C. Necrotizing enterocolitis D. Lactose intolerance 3 Hematology and Oncology I. Anemias A. RBCs serve to transport O2 from the alveoli to tissues via the bloodstream and CO2 from tissue to lungs. Alkalosis, decreased body temperature, and increased Hgb F fetal shift curve to the left.
Acidosis, increased body temperature, high altitude, and exercise shift curve to the right. Circulating RBCs, myeloid cells, and lymphoid cells all originate from the same pluripotent stem cells in bone marrow see Figure RBCs become enucleated during maturation in bone marrow and depend on glycolysis for survival. Quick HIT Carbon monoxide poisoning includes signs of mental status changes, cherry red lips, and hypoxia despite normal pulse oximetry readings.
From McConnell, T. Normal Hgb concentration and hematocrit Hct : a. Low Hgb and Hct i. Also require inpatient or transfer to burn center. Patients with significant smoke inhalation diagnosed by increased carboxyhemoglobin levels should receive highflow O2 and close monitoring for respiratory compromise requiring intubation. Cardiac and neurologic issues in electrical burns should be managed to decrease mortality.
Nasogastric tube should be placed when there is gastrointestinal GI involvement ileus will frequently develop. Antimicrobial agents e. Nonadherent bandaging or biologic dressings should be applied directly to severe burns; dressings should not be wrapped around affected areas because of potential swelling and constriction.
Surgical debridement and exploration should be performed to remove necrotic tissue and to determine extent of deeper tissue involvement; plastic reconstructive surgery with skin grafting may be needed. Complications a. Infection especially Pseudomonas, sepsis , stress ulcers Curling type , aspiration, dehydration, ileus, renal insufficiency caused by rhabdomyolysis , compartment syndrome, epithelial contractions may limit range of motion.
Electrical burns are associated with arrhythmias, seizures, bony injury, compartment syndrome, rhabdomyolysis, acute kidney injury. Drowning 1. Hypoxemia resulting from submersion in some type of fluid, usually water. Aspiration of any type of water causes pulmonary damage e. Fresh water: hypotonic fluid is absorbed from alveoli into vasculature, resulting in decreased electrolyte concentrations and red blood cell RBC lysis. Salt water: hypertonic fluid creates an osmotic gradient that draws fluid from pulmonary capillaries into alveoli and causes pulmonary edema and increased serum electrolyte concentrations.
Cardiovascular Emergencies This section discusses only emergent cardiovascular conditions that require resuscitation and immediate treatment—refer to Chapters 1 and 11 on Cardiovascular and Neurologic Disorders for additional information regarding MI, arrhythmias, and stroke. Cardiac Arrest 1. Cessation of cardiac function resulting in acutely insufficient cardiac output.
Requires immediate treatment to prevent systemic ischemic morbidity and death see Figure Treatment of Vfib and Vtach requires alternating attempts at electrical and pharmacologic cardioversion see Figure Pulseless electrical activity PEA consists of detectable cardiac electrical conduction with the absence of cardiac output see Figure Asystole is the absence of cardiac activity see Figure Quick HIT Do not resuscitate DNR status should be documented for any inpatient; documentation can be provided by a close relative or primary care provider to guide potential resuscitation attempts.
CPR, cardiopulmonary resuscitation. Initial workup differentiates between ischemic and hemorrhagic types. Appropriateness for thrombolysis, mechanical thrombectomy, or reversal of bleeding should be considered. Traumatology A.
Mechanisms of Injury 1. Acceleration—deceleration injuries a. Seen in falls, blunt trauma, and motor vehicle accidents b. Injury secondary to shearing forces in tissues and organs caused by sudden changes in momentum and sudden forces applied to tethered portions of organs e. Penetrating injuries a. Include gunshot wounds, stab wounds b. Missile damages tissue in path of trajectory and causes indirect damage from fragmented bone and external objects c.
Shock wave from projectile impact and thermal effects can cause additional tissue damage particularly high-velocity projectiles NEXT STEP Count and pair all entrance and exit gunshot wounds to suggest a number of insulting bullets and to deduce a path for each bullet.
Trauma Assessment 1. Patient assessment is performed in an organized manner to detect all injuries and judge their severity. Initial assessment focuses on patient ABCs. Secure airway is established may require intubation , oxygenation is stabilized breathing , adequate circulation is confirmed, venous access is secured, and bleeding is controlled. Secondary assessment consists of a highly detailed examination to detect all wounds, fractures, signs of internal injury, and neurologic insult.
Do not proceed to the next step of the examination until the current segment has been addressed. Quick HIT The use of ultrasound in the assessment of trauma is reserved for the secondary survey and evaluated abdominal compartments and thoracic cavity for free fluid or pneumothorax. Quick HIT Loss of consciousness is considered to be caused by head trauma until ruled out. Head Trauma 1. Head trauma can result in cerebral or subarachnoid hemorrhage see Chapter 11, Neurologic Disorders 2.
Cerebral damage can be at the point of insult i. Neurologic injury in any segment of the spinal cord from trauma resulting from direct injury, compression, or inflammation 2. Neck Trauma 1. Neck is divided into zones based on anatomic site of injury; injury can involve trachea, esophagus, vascular structures, cervical spine, or spinal cord. Penetrating injuries violating the platysma should be further evaluated by contrast imaging or in the operating room see Figure 2.
Penetrating trauma with stable vital signs may be treated conservatively. Exploration of zones I and III is difficult and should be carried out only if vascular injury is suspected. Intubation is frequently required because of airway occlusion. Prophylactic antibiotics may be indicated because of increased risk of contamination by oropharyngeal flora.
Chest Trauma 1. Can result in injury to lungs, heart, or GI system 2. Aortic rupture caused by sudden acceleration and deceleration , tension pneumothorax, hemothorax, and cardiac tamponade are potentially fatal injuries 3. Radiology a. CXR and neck x-rays may show pneumothorax, hemothorax, cardiac hemorrhage, aortic injury, or rib fractures. Chest CT is important to assess for air leaks, hematoma formation, and pulmonary collapse. EGD and bronchoscopy are used to assess injury to esophagus and bronchi.
Angiography can detect vascular injury. Abdominal Trauma 1. Can cause injury to any abdominal organ or severe bleeding from the aorta, aortic branches, mesentery, spleen, or liver.
Penetrating trauma requires exploratory laparotomy; blunt trauma may be treated conservatively in the absence of signs of an acute abdomen. In cases where exploratory laparotomy is not automatically performed, examination must look for signs of abdominal bleeding e. Peritoneal lavage i. CT is sensitive for detecting abdominal fluid. Extended focused assessment with sonography in trauma e-FAST is a quick and sensitive means of determining the presence of free abdominal fluid, solid organ injury, and pneumothorax and has become the primary test performed for evaluation of blunt abdominal trauma at most trauma centers.
All penetrating abdominal trauma needs exploratory laparotomy. Diagnosed intra-abdominal bleeding or visceral damage from blunt trauma requires laparotomy for repair if the patient is hemodynamically unstable.
Retroperitoneal hematomas in the upper abdomen pancreas, kidneys require laparotomy for repair. Low retroperitoneal bleeding should be treated with angiography and embolization if caused by blunt trauma and laparotomy if from penetrating trauma.
Genitourinary and Pelvic Trauma 1. Injury can result from initial insult or indirectly from fracture of the pelvis. Examination should look for blood at the urethral meatus or hematuria indicative of urologic injury , or scrotal or penile hematoma.
Pelvic examination should be performed in women. Patients with a pelvis fracture should be given a thorough neurovascular examination. Intravenous pyelogram IVP can detect renal pelvis injury. Retrograde urethrogram or cystogram can detect urethral or bladder injury. X-ray can detect pelvis fracture. CT can detect renal damage and pelvic blood collections.
Penetrating injuries need surgical exploration. Urethral, intraperitoneal bladder, and renal pelvis injuries require cystoscopy and surgical repair; extraperitoneal bladder and renal parenchymal injuries may be treated nonoperatively.
Pelvic fractures may be treated nonoperatively if stable and with open reduction and internal fixation when unstable. NEXT STEP Perform a fasciotomy in any patient with a combined bone and neurovascular extremity injury because of the high risk of compartment syndrome.
Extremity Trauma 1. Injury can involve bones, vasculature, soft tissues, or nerves in extremities. Superficial or soft tissue wounds require irrigation and approximation e. Bone injury alone is treated with immobilization, if stable and internal, or external fixation, if unstable. Combined bone, vessel, and nerve injuries are treated by fracture repair followed by vascular and neurologic repair. Large wounds frequently require debridement or amputation. NEXT STEP Serial neurovascular examinations should be performed following any type of treatment for an extremity to detect an evolving or iatrogenic neurologic injury.
Trauma During Pregnancy 1. Leading cause of nonobstetric maternal death 2. Anatomic differences a. Inferior vena cava IVC compression by the uterus makes pregnant women more susceptible to poor cardiac output following injury b. Decreased risk of GI injury from lower abdominal trauma because of superior displacement of bowel by the uterus but greater risk of GI injury from upper abdominal or chest trauma 3. Low risk of fetal death with minor injuries high risk in life-threatening injuries 4.
Trauma increases the risk of placental abruption 5. Abuse and Sexual Assault A. Abuse 1. Most frequently seen in children, spouses or partners especially women , and the elderly 2. Abuse can be physical, emotional, sexual, or exploitative; neglect 3.
Child abuse a. Neglect, the most prevalent form of child abuse, constitutes the failure to provide the physical, emotional, educational, and medical needs of a child b. Suspected cases should be well documented 4. Spousal or partner abuse a. Patient should be interviewed without partner present c.
Elder abuse a. Quick HIT A physician who has reason to suspect child abuse but does not report it or act to protect the child may be held liable for subsequent injury or mortality. Quick HIT Most women in an abusive relationship who are killed by their abuser are killed when trying to leave their abuser. Sexual Assault 1. Nonconsensual sexual activity with physical contact; forced intercourse is rape. Victims can be children or adults. Detailed history must be collected and thoroughly documented in cases where patient reports assault.
Examination should focus on the entire body, with particular attention to genitals, anus, and mouth to look for signs of assault. Patients who have not admitted to being assaulted may appear depressed or very uncomfortable with examination.
Labs a. Collect oral, vaginal, and penile cultures to test for sexually transmitted diseases. In cases of rape, all injuries must be well documented and vaginal fluid and pubic hair should be collected for evidence i. Pregnancy testing should be performed to look for incidental conception occurring during assault.
Quick HIT Another health care worker chaperone must be present when a sexual examination is performed, and the patient should be made to feel as comfortable as possible with the history and physical examination. Issues in the Intensive Care Unit A. Provides intensive nursing care for critically ill patients 2.
Patients may require intubation, ventilation, invasive monitoring, vasoactive and antiarrhythmic medications, and close nursing supervision B. Pulmonary Concerns 1.
Intubation and ventilation required when a patient is at risk for airway obstruction or needs support in breathing. Ventilator support is required in patients to maintain respiratory effort or in poor-oxygenation states see Chapter 6, Pulmonary Disorders. Quick HIT The left subclavian and right internal jugular veins provide the easiest access for Swan—Ganz catheter insertion.
Invasive Monitoring 1. Arterial line A-line a. Placed in either radial, femoral, axillary, brachial, or dorsalis pedis artery b.
Used to record more accurate blood pressure than blood pressure cuff 2. Pulmonary artery catheter Swan—Ganz catheter a. Catheter inserted through subclavian or jugular vein; runs through heart to pulmonary artery b. Measures pressures in right atrium and pulmonary artery; balloon can be inflated at catheter tip to fill pulmonary artery lumen and measure wedge pressure equivalent to left atrium pressure c. Also, may measure cardiac output, mixed venous O2 saturation, systemic vascular resistance II.
Transfusions 1. Infusion of blood products to treat insufficient supply of a given blood component see Table 2. ABO blood groups a. Blood is defined by A and B antigens and antibodies to absent antigens.
Blood with both antigens will not have antibodies to either antigen in plasma i. Blood with neither antigen will have antibodies to both antigens in plasma i. Rh blood groups a. In order to ensure that user-safety is not compromised and you enjoy faster downloads, we have used trusted 3rd-party repository links that are not hosted on our website.
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