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Direct hernias are groin hernias of adults that pass directly 1. Femoral hernias are groin hernias pass under the inguinal Question is: What type is it? Reducible is considered elective, incarcerated urgent. If the incarcerated hernia turns strangulated, with obvious peritoneal signs and an affected hernia, it becomes a surgical emergency Reducible Elective Elective requiring emergent Ex-Lap. Go straight to treatment surgery. If unsure, get a CT scan while preparing the OR. For the test, if the diagnosis is Periumbilical Pain obvious go straight to surgery. Carcinoid produces serotonin.

Intestinal serotonin is degraded by the liver. With mets to the and peritoneal signs liver, serotonin goes to the R heart causing fibrosis, flushing, Negative? wheezing, and diarrhea. The lungs degrade serotonin sparing Vague symptoms Physical the L heart, releasing 5-HIAA to be excreted into the urine; it is worrisome for Exam Inflammation used as a screening tool for the cancer. It must be staged and resected. A particular variant, consider an embolic or even thrombotic occlusion of the acute narrow angle glaucoma, is caused by fluid being trapped retinal artery. If you see cherry-red spots on the fovea, the in the anterior chamber. After a patient has spent a prolonged diagnosis is made. If available and within a limited period in low light situations i. a movie theater the iris dilates, timeframe, intra-arterial tPA is technically possible decreasing flow from the anterior chamber out of the eye.

This though difficult. To buy them time, or to get the clot further produces eye pain headache and an intensely rigid eyeball. down the arterial tree to spare some vision, you could try There may be halos or corneal clouding. The problem is that the hyperventilate rebreathed CO2 as in a paper bag to pupil dilated so pressure built up. While preparing an OR or getting the ophthalmologist, give smaller area of vision. things that will constrict the pupil and let the fluid out α- agonists, β-antagonists as well as diuretics to decrease Cataracts intraocular pressure acetazolamide. Drill a hole with a laser to Cataracts are caused by Age and diabetes.

This will present let out fluid. NEVER GIVE ATROPINE or atropine-like as a progressive and chronic vision loss. The person will products. needs immediate surgery and drainage. It cellulitis and treat like a regular cellulitis with antibiotics. will present with a chronic, progressive CENTAL vision loss peripheral vision is retained. To tell the difference Corneal Abrasions between wet and dry, simply to a retinal exam. Pain in the eye from toxic or traumatic exposure requires vigorous irrigation. Surgery may need to be done to repair lacerations. Wet can be treated with laser Dry is treated with supportive care Retinal Detachment This can occur spontaneously Marfan, HTN or following major trauma.

The patient will either complain of floaters indicating minor disease or of a veil or cloud on top of their visual picture indicating severe disease. Vision is compromised from there on, but without treatment they will lose all vision. The development of an AAA is dependent on Gender and Smoking. Often, these are found incidentally by getting images of the abdomen for something else. That is, they are asymptomatic in most cases. Screen by using an ultrasound in men who are over the age of 65 and have at least smoked at some point in their lifetime. Current smokers are at higher risk. A CT scan can be used to track changes and the AAA might show up on a CT scan obtained for something else abdominal pain, for example.

Size Comments Action The angiogram is the WRONG test and a great distractor. Otherwise, serial Ultrasound or CT scans are sufficient to track the AAA, while treating vascular disease BB, ACE, ASA, Statin. EVAR endovascular repair is the same as open surgery. Dissecting Hematoma Classic Elements of Dissection A dissection is caused by very elevated blood pressures, often Tearing chest pain radiating to the back seen in a career hypertensive someone who has had high blood Asymmetric blood pressures arm to arm pressure for a long time. There are three elements that define Widened Mediastinum Dissection. If there are 2, the diagnosis is essentially confirmed. Ascending To work up the dissection, first rule out coronary disease with an Normal EKG and Troponin. The X-ray will show the widened no false mediastinum.

The diagnostic test of choice is a CT angiogram that will demonstrate the false lumen. Other tests need to be considered, as the CTA is contraindicated in renal disease. Angiogram may be HARMFUL. Ascending dissections also called Type A can involve the great vessels and cause aortic regurgitation. These are fatal. They must undergo emergency surgery. An organic no anticoagulation needed echocardiogram shows the lesion. Surgical replacement is the sort of, definitely no bridge needed right answer. Balloon valvotomy is absolutely wrong. TAVR and TAVI may be attempted in poor surgical candidates. Mechanical Valves years duration Anticoagulation Mitral Regurgitation Warfarin, goal INR 2. Just like regurg, replace it when desired or treat with LV dilation. Aortic Insufficiency Aortic regurgitation is caused by infection, infarction, or in the case of aortic dissection. Other signs of chronic AI are widened pulse pressure, water-hammer pulses, pistol-shot pulses, and head bobbing.

This will require emergent replacement. Mitral Stenosis Caused almost exclusively by rheumatic heart disease. This murmur can lead to CHF and Afib dilation of the left atrium. Options are a commissurotomy balloon dilation or simply replacement of the valve. That means EKG, IVF, and if needed, cardiac 1,2 Vessel Left Mainstem Angioplasty CABG indexing with cardiac wedge pressures. They still need BB, CATH PCI 3 Vessel Disease ACE-I, ASA, Statin like all CAD patients. Clopidogrel CABG © OnlineMedEd. However, in a euthyroid patient nodules can be cancer. FNA is the mainstem of management. If for cancer proceed to Thyroidectomy. Follicular cancer can be treated with radioactive iodine. Use the Sestamibi scan to find which one is enlarged. Take caution after resection for hypocalcemia perioral tingling, Chvostek Sign, Trousseau sign ; as the atrophied glands kick in they may not produce enough initially.

Cut it out. A CT scan locates the adenoma so it can be resected. Do a CT to find it, then try to resect it often, this fails. Now, they will have pain, can be anywhere from meningeal signs to coma, and may have a focal neurologic deficit. The diagnosis is made with a CT scan without contrast. It will show blood but outside the parenchyma and between the gyri separating it from other bleeds. The best radiographic test is to obtain a MR angiogram or CT angiogram. The arteriogram with the wire is reserved for intervention. ANEURYSM Clip Craniotomy Coil Endovascular Aneurysms are treated with coiling or clipping.

Coiling is an BLEEDING IV beta blockers to Prevent endovascular procedure. Clipping is a neurosurgical procedure. SEIZURES Any general antiepileptic All SAH need to have seizure prophylaxis with any of the standard VASO- CCB Prophylaxis general antiepileptics. To prevent vasospasm acute infarct after SAH the patient needs to be on calcium channel blockers. If vasospasm occurs, blood pressure actually must be INCREASED to maintain perfusion. This and seizures are the late complications. This occurs most often at the caudate and putamen. There are some herniation syndromes you could learn, but the yield is silly low.

The CT head will show blood in the parenchyma. The goal of management is to reduce ICP as above in SAH. Consider this the same as SAH — seizure prophylaxis, hydrocephalus, etc. but no need to worry to clip or coil. Follow up with CT scans track how rapidly the hematoma is expanding. If they survive, rehabilitation is key. Midline shift from an expanding hematoma © OnlineMedEd. Patients may have complaints of headaches that are Glioblastoma worse in the morning. Diagnose a lesion using an MRI. Definitive diagnosis is made by biopsy. A tumor can metastasize to the brain but NEVER from the brain die before it can get out. Resection is rarely curative. Posterior Fossa Tumor Pituitary Tumors Tumors in children are usually in the posterior fossa and in the Craniopharyngioma Medulloblastoma anterior fossa in adults.

T Acromegaly Adults Enlarging Bones Glucose 3 Acromegaly is a Growth Hormone secreting tumor that A HTN Suppression presents as enlarging non-long bones. There may also be HTN and DM. Diagnose with a CT E Deficits MRI scan showing a connection to the bone and a biopsy with R Oligodendrioma Adults Focal CT Scan psammoma bodies. Resect and the patient will improve. I Deficits MRI 5 Glioblastoma Multiforme is a highly aggressive, invasive, and O necrotic tumor with a dismal prognosis. CT scan shows a P Medulloblastoma Kids Obstructive CT Scan butterfly lesion that may cross the midline. O Hydrocephalus MRI S Ependymoma Kids Obstructive CT Scan 6 Ependymoma arises from the ependymal cells of the ventricles. Children are aware that if they curl into a ball R Hearing Loss MRI they relieve the obstruction and the symptoms. I 7 Medulloblastoma also arises in the 4th ventricle. Resection chemo AND radiation are required. Mets usually make it through the medium caliber vessels and get stuck as a single or multiple lesions at the grey-white border.

closed reduction with casting. Because the axillary nerve may be injured there may also be deltoid paresthesia. Diagnose - Axillary Nerve à Deltoid Paresthesia with an x-ray. Relocate and sling. If there was a - Seizures and Lightning Strikes seizure or electrical injury, treat those as well. It looks like a dinner fork two prongs sticking up - Dorsally displaced radius Diagnose with an X-ray and cast it. The ulna breaks while the radius - Upward block and a downward blow dislocates. An x-ray diagnoses it. In this wound the Galeazzi Fracture radius breaks gets hit first while the ulna dislocates. An x-ray - Downward block and a downward blow diagnoses it. Do casting or ORIF for the fracture. Initially, the x-ray will be normal. If bad enough that the damage is already seen X-ray - X-ray turns positive later do ORIF. Do an x-ray and cast it. This occurs in HUGE trauma in healthy people, but easily in Hip Fracture osteoporotic falls.

Ensure there is intact vascular and neural - Shortened Leg and Externally Rotated function distal to break. Because the femoral neck has a tenuous vascular - Head à Femoral Prosthesis supply, it requires femoral prosthesis for a fracture of the - Intertrochanteric à Plates ORIF femoral head. An intertrochanteric fx gets plates. If the shaft - Shaft à Rods was involved use a rod. Finally, if the fracture is open it - Open à Emergent washout constitutes an emergency for immediate cleaning. MRI is used for the knee. But - Hit from behind, Anterior draw sign ACL that takes time. Athletes get surgical repair while the obese get - Hit from front, Posterior draw sign PCL casting. The posterior draw sign indicates PCL tear. A valgus stress is from the lateral side and is more common because the Collateral Ligament Tear lateral side is exposed , rupturing the medial collateral ligament.

If only one ligament is ruptured do a hinge - One ligament à hinge cast cast, otherwise go to surgery also if they are an athlete. But, a healthy active athlete Meniscus Tear complaining of pain and a click on full extension is likely to have - Pain in the knee, click on full extension a torn meniscus. Use an MRI to confirm and arthroscopic repair - MRI to remove as little as possible to avoid resultant arthritis. Pushing a frail bone too Stress Fracture far can cause a fracture. This is seen in out-of-shape weekend - Weekend warrior or forced march warriors or in people on forced march. The patient will - Pinpoint tibia pain complain of pinpoint tibia pain. Like the scaphoid fracture, the - X-ray normal X-ray is normal for 2 weeks. Use a cast if severe and crutches - Cast anyway and watch the fracture unfold on repeat X-ray.

This requires direct trauma pedestrian - Adult pedestrian struck struck, adult. The deformity is usually obvious, confirmed by - X-ray x-ray, repaired by casting if closed, nailing if open with ORIF. They will all be swollen, tender, and - Running, Popping, Limping painful. You can be conservative casting cures in - ORIF or Cast months or aggressive surgery cures in weeks. Compartment Syndrome Compartment Syndrome After reperfusion to a previously ischemic extremity clot, - Reperfusion or Crush crush , the leg will swell. Confined by the fascial planes, the - Vascular compromise extremity becomes tense with an excruciating pain on passive - Excruciating pain on passive flexion flexion. Measure pressures. Release the tension with fasciotomy. The extension of the thumb mother cradling baby, guy lifting heavy median nerve innervates the plantar surface sensation and motor weights in the overhead position, anything where you have to of the first three digits.

This is seen in people who do repetitive push. The major presenting complaint is thumb inside a closed fist and performing an ulnar deviation. Pain gives way to paresthesias and weakness, ultimately Radial deviation, no pain. Ulnar deviation pain. With increased with thenar atrophy. This syndrome can be reproduced using the pain, the diagnosis is clear. Treat by splinting and NSAIDs. Surgical reattachment is median nerve. The diagnosis is clinical, so we start with possible but will not be the answer on the test. treatment first. It begins with Splinting and NSAIDs. Should that fail, intraarticular steroids can be attempted. But we see it often in to the OR, obtain an electromyography to confirm the diagnosis. alcoholic males with Scandinavian ancestry. The hand will be Carpal tunnel syndrome may be the presenting symptom of unable to extend because the fascia is contracted and balled up rheumatoid arthritis.

into palmar nodes. The fascia actually pulls the hand closed. Treat by typically following a penetrating injury. If that fails, use intraarticular injections. fascial plane so is exquisitely tender. There will also be a fever. See this as mini-compartment test. syndrome, in a really small facial plane at the tip of the finger. Treat with splinting and NSAIDs. Surgical reattachment is possible but will not be the answer on the test. Trigger Finger Inflammatory There is no sports injury but instead is a stenosing tenosynovitis. The patient is unable to extend finger caution confusing this for Mallet Finger. For pediatrics every disease has its own case you are studying surgery only unique presentation. Developmental Dysplasia of the hip nontraumatic The hip is insufficiently deep so the femur head constantly Septic Any Joint pain Aspirate Drain and Abx pops out. Confirm the diagnosis with an ultrasound at Transient Any Joint pain after History Supportive weeks as there can be physiologic laxity initially around Synovitis viral illness time of birth which may resolve.

Once diagnosed put the child in a harness to keep the femur approximated to the join as the joint grows out. Legg-Calve-Perthe Disease When a child is around six years old they can suffer from avascular necrosis of the hip. Diagnose by x-ray and then cast. Dx Patient Sxs Dx Tx iii. Slipped Capital Femoral Epiphysis Osgood- Teenage Knee pain with Clinical Support An orthopedic emergency, it can occur in adolescents who Schlatter athlete swelling are either obese or in a growth spurt. hip or knee pain of sudden onset.

Get a frog-leg position usually girl Rods x-ray to confirm. Surgery is required. It shows up in any age though Onion-skin usually a toddler during a febrile illness with complaints Fractures If a plate involved do open reduction and internal fixation of joint pain. Do an x-ray first then a joint aspiration with Gram stain and culture. It needs to be drained and antibiotics should be started. Transient Synovitis On the differential for septic hip. Treat supportively. The athlete has two options: stop exercising curative or play through it. If they work through, it there may be a palpable nodule. Otherwise, it causes no permanent sequelae but it does hurt.

Their thorax will tip to the side causing a cosmetic deformity. More severe disease can cause respiratory issues. Treat by bracing with the goal of slowing progression not curing. Surgery with rod placement is reserved for severe cases. Have two in mind: osteogenic sarcoma presents with a sunburst onion skin pattern typically at the distal femur. Resection is treatment in both cases. If the fracture involves the growth plate an ORIF is needed to ensure the plate is realigned. Otherwise the kid will grow up with one leg shorter than the other. That means murmurs. Each murmur has a characteristic sound, appearance, and association. Chest X-rays or EKGs may give clues, but all cardiac defects are diagnosed by Murmur or Sxs echocardiogram. Innocent CXR ECHO murmurs are always systolic murmurs and low grade difficult to hear.

They can represent any number of high flow states typical in kids. If they persist or no longer meet criteria for innocent they must be worked up Echo Gives Dx with CXR, EKG, and echo. This Right Ventricular Hypertrophy causes increased vascular markings on chest X-ray. Atrial Septal Defect Because the atria are low pressure, the consequences are small so this can be found at any age. Closure if needed is typically achieved via catheter-directed device closure. Ventricular Septal Defect This is the most common congenital heart disease. Depending on the type, some may close spontaneously and do not require intervention.

Children that have evidence of right-sided hypertrophy, increased right-sided pressures, failure to thrive, or heart failure need immediate repair. Patent Ductus Arteriosus A connection between the aorta and the pulmonary artery. The murmur may not be apparent on day one but may be noticed on the exit exam. In term infants, these usually are no big deal and most self-resolve within 7 days if they are going to. In preterm infants, these often need closed indomethacin or surgery as they can cause hemodynamic instability. Use prostaglandins if the PDA is needed for a critical heart lesion. This results in cyanosis blue baby and decreased Blue Baby Syndrome vascular markings on chest X-ray.

They present either with acute cyanosis or chronic effects such as clubbing. While there are others, these two are most commonly seen, discussed, and tested. During the Deoxygenated first 8 weeks of embryogenesis the heart forms and twists. survival Pregestational diabetes not gestational is a risk factor for this. Without a PDA this is fatal so give prostaglandins. It presents Pulm Artery on day 1 as a blue baby. Surgery must be done to correct it Aorta ASAP. LEFT Heart RIGHT Heart Tetralogy of Fallot The most common cyanotic defect of children because TGA babies die or get fixed. If severe, we get a blue baby and it requires immediate intervention. The tricky way of presenting is in a toddler with tet Spells cyanosis relieved by squatting. Squatting causes an increase in systemic vascular resistance, pushing more right ventricular blood into the lungs.

Look for a boot-shaped heart on chest X-ray. This is associated with Down and DiGeorge syndromes. Surgery is definitive therapy. The others are rare. Things like Truncus arteriosus, Tricuspid atresia, and Total anomalous pulmonary venous return TAPVR are almost never seen. Review Step 1 notes for clarity or to impress your attending. First, get blood pressures on arms and legs; there will be a large disparity. Do an echocardiogram to definitely diagnose. Surgically correct. The A nal imperforate most common type is type C. This is where the proximal esophagus is C ardiac Echo blind and the distal esophagus has an aberrant connection running from T racheal the trachea to the stomach.

These kids will vomit everything including E sophageal secretions from birth. Place a NG tube and obtain an x-ray. NG tube R enal ultrasound should coil up in the esophagus. There will be gas in the abdomen if the L imbs thumbs in particular distal esophagus is connected to either the proximal esophagus or to the trachea. Keep NG tube in, start parenteral nutrition, and call surgery. Look for other VACTERL anomalies - especially cardiac and renal. Do a cross table X-ray on the prone child with radiopaque perineal marking. This will give a relationship between gas bubble and anus. Low lesions closer to the anus can be corrected via dilation or a minor surgical procedure. There is also a higher chance of maintaining continence. High lesions away from the anus need a colostomy with future correction. All patients need evaluation for VACTERL and should undergo sacral ultrasound and X-ray, VCUG, NG tube passage, and echocardiogram.

These are from holes in the diaphragm. They are most commonly posterior Bochdalek most common but can be anterolateral Morgagni. Stabilize from a cardiac perspective before repairing surgically. Bilious Vomiting in Bilious Vomiting a Neonate A bilious vomit is indicative of an obstruction distal to the ampulla of vater. The first step in working up Babygram bilious vomiting is to get a babygram. What it returns is highly nonspecific, but there are clues. Multiple air-fluid levels are indicative of intestinal atresia a vascular accident in utero, i. mom used cocaine. The double-bubble sign is associated with duodenal atresia, Malrotation Annular Pancreas Intestinal annular pancreas, and malrotation. The chances are greater for or Atresia malrotation if there is a normal gas pattern distally gas had to get Duodenal Atresia Enema Surgically here before the obstruction arose. Confirmed Emergent repair before vascular supply dies © OnlineMedEd.

The amount of viscera on the outside usually determines the severity. Treatment of these conditions has significant overlap. Basically, cover viscera in a sterile bag and place saline-soaked gauze over extruded contents to prevent desiccation and infection. Place NG tube to keep the bowel decompressed. Fluid balance is important as there can be a lot of loss from the exposed areas. Gastroschisis is right of midline and without a membrane. It is typically not associated with chromosomal abnormalities but is more susceptible to twisting and infection. Omphalocele is in the midline and is covered with a membrane. It is more commonly associated with chromosomal abnormalities such as Beckwith-Wiedemann syndrome.

Keep covered with plastic barrier to prevent drying out. These are typically corrected surgically within 2 days to 2 weeks for best outcomes. One eye will be normal while the other eye will go blind. Attempt to treat by patching the dominant eye but the best way is to prevent the cause in the first place. Congenital esotropia should be corrected around 6 months. Later onset can often be treated with patching of dominant eye, glasses if caused by refraction , and surgery. Retinoblastoma In the nursery, instead of a red light reflex, a pure white retina can be seen in the back of the eye. The tumor needs to be resected. Observe the patient for future osteosarcoma - especially in the distal femur. Cataracts Congenital cataracts have a milky white appearance in the front of the eye.

Think of the TORCH infections, genetics if born with them, or a galactosemia if acquired early in life. Surgically correct it before amblyopia sets in. Retinopathy of Prematurity Premature neonates requiring high-flow O2 can get these growths on the retina. Using laser ablation can improve vision in life. Look also for intraventricular hemorrhage, bronchopulmonary dysplasia, and necrotizing enterocolitis in Type Timing Purulent Problems Treatment a preemie in the ICU. Chemical 24 hrs Varies Bilateral Caused by silver nitrate — stop it! Conjunctivitis in Newborns Gonorrhea Day Purulent Bilateral Ceftriaxone IM In a neonate born to a mother with cervicitis or PID, risk of erythromycin gtt infection by gonorrhea goes way up.

We should screen and treat Check for ppx mothers with either gonorrhea or Chlamydia to prevent systemic ophthalmologic infections. All infants should receive prophylaxis illness! at birth though this only works for gonorrhea ; silver nitrate Chlamydia Day Varies — Unilateral Erythromycin PO or erythromycin can be used. Chemical conjunctivitis occurs in watery then bilateral the first day of life think silver nitrate. If a baby has no then No topical conjunctivitis on day one but then subsequently develops it, purulent, Check for antibiotics!

consider bacterial conjunctivitis. The causes are vast, but bloody systemic gonorrhea and Chlamydia are at the top of the list. There are illness - can some physical features that separate the two, but because multiple turn into bugs can cause it get a culture or at least a PCR to know what pneumonia needs to be treated. The baby needs to go NPO immediately and get started on TPN and IV antibiotics. Meconium Ileus Usually seen in patients with cystic fibrosis, this is a collection This is cystic fibrosis until further notice of meconium that too thick and viscous to pass as a result of pancreatic insufficiency.

This can cause any combination of bilious vomiting or failure to pass meconium. X-ray can show an area of obstruction with a gas-filled plug. Perform water-soluble contrast enema to help breakdown the obstruction. Sometime surgical intervention is required. Complications include perforation which can lead to meconium peritonitis which is an emergency. This means no motility — the bowel unable to relax hence the increased rectal tone. muscles are unable to relax and contribute to peristalsis. There will be a history of overflow incontinence in the older child or a stool eruption after doing a digital examination in the nursery. Examination will show increased rectal tone the ganglions contribute to relaxation. If done, a KUB may show dilated colon actually the normal part and a normal distal colon the abnormal part.

The preferred initial test is a contrast enema which will show a transition zone. Suction biopsy is the next step to confirm diagnosis. Resect the affected area and connect pull-through procedure. Severe cases perforation, full colon involvement require colostomy. Intussusception When part of the bowel telescopes into another the blood supply Acute colicky pain with abrupt onset and resolution can be compromised. This causes an abrupt onset of colicky Can diagnose with ultrasound abdominal pain in an otherwise healthy baby. It occurs in kids 3 Air enema can be diagnostic and therapeutic months to 3 years. Kids will typically assume the knee- chest position and there may be some vomiting. Occasionally currant jelly diarrhea can be seen. A sausage-shaped mass can be felt in the abdomen. While a KUB may show evidence late in the disease, an air enema is sufficient to both diagnose and treat. An abdominal ultrasound is a non-invasive test that can increase pre-test probability.

Labs will show a direct HIDA after phenobarbital stimulation à hyperbilirubinemia. Ultrasound imaging may be helpful in Liver biopsy à Intraoperative cholangiogram both demonstrating absence of intrahepatic ducts and ruling out other structural causes masses, stones. Additional testing is done if still unsure. HIDA scan after days of phenobarbital stimulation can show lack of bile reaching duodenum. Intraoperative cholangiogram can be done if still uncertain. Differential includes autoimmune and metabolic disorders. Fatal without intervention, ultimately treat with Kasai procedure hepatoportoenterostomy. Physical exam will reveal an olive-shaped mass and visible peristaltic waves.

A CMP will reveal a hypochloremic, hypokalemic, metabolic alkalosis which should prompt immediate IVF for rehydration. They can occur individually or in combination. The cleft lip can be minimal and only involve superficial structures or it can run deeper down to the teeth and bone. It can be unilateral or bilateral. Cleft palate can involve the soft and hard palate. Exposure of the nasal cavities through the palate can occur when these two conditions occur together. Feeding is the biggest issue up front. Cleft lips are repaired by weeks and palates by months to preserve speech function. Complications can include frequent episodes of otitis media, feeding difficulties, possible hearing difficulties, and speech pathology if not repaired appropriately. Choanal Atresia This is an atretic or anatomically stenosed connection between the nose and mouth. It can be unilateral or bilateral which is an emergency. In severe cases the baby will be blue at rest as they are obligate nose breathers think breathing and breastfeeding simultaneously.

Surgery is required to open the atretic passage. It comes from sun-exposure. There are sun- - Number of times sunburned occupations sailor, farmer, construction , there are sun- - Severity of times sunburned locations hands, face, back, shoulders , and there are sun-people - Early-life burns worse than late-life burns those who easily burn — fair skinned, fair haired — and those who - Fair Skin, Fair Hair have burned — the worse the burn the higher the risk. The The tricks about treating Basal Cell Carcinoma diagnosis is made by excisional or incisional biopsy. Squamous Cell Carcinoma A malignancy of keratinocytes. The lesion is described as a well- The tricks about diagnosing Squamous Cell Carcinoma demarcated red papule in sun-exposed areas. For high-risk tumors, add radiation therapy to surgical resection. Unlike SCC of the lung, The tricks about treating Squamous Cell Carcinoma SCC of the skin has NO paraneoplastic syndromes. If you miss a melanoma, the patient will die.

The progression of melanoma is sporadic. It naturally waxes and wanes throughout its course of metastasis. The patient can live 10 years or 2 months. Melanoma is a cancer of melanocytes. Melanocytes have pigment in them. Thus, the cancer is going to be a pigmented lesion. The classic board picture is a jet black, smooth lesion on sun-exposed skin. The point of this is if the lesion is suspicious, get the biopsy. You need ANY 1 to suspect cancer If the lesion is large or the suspicion for melanoma is low, choose a punch biopsy. This captures good tissue next to cancer tissue. It spares the cosmetic deformity of excision. NEVER do a shave biopsy of melanoma. only Hope is on the horizon. Studies using immunotherapy This is not how melanoma is treated. If you work at an advanced academic center will get you the right idea. Do a CT scan to find the tumor, adrenal vein sampling to lateralize, and then resect. Secondary Hyperaldosteronism Renovascular Hypertension Secondary hyperaldo is caused either by bilateral renal artery stenosis old man, atherosclerotic disease, not amendable to surgery or fibromuscular dysplasia young woman, you should stent these ladies.

Diagnosis begins with aldo:renin ratio which shows that renin is driving the aldosterone approaches 1. But do the angiogram only when intervention is planned fibromuscular dysplasia and not RAS. Pheochromocytoma Paroxysms of Pressure HTN , Palpitations, Perspiration, Pain Pounding headache , and Pallor. Measure hr urinary metanephrines and catecholamines VMA is most sensitive. Clonidine suppression, serum catecholamines are also potentials, but will be the wrong thing on the test. If elevated, localize with imaging CT scan or MRI. Confirm laterality with an MIBG Scan or Adrenal Vein Sampling. and resect. Pretreat patients with α- blockade before β-blockers before surgery to prevent unopposed alpha stimulation. When faced with this condition, get a hr free cortisol level and confirm with 1mg Low Dose Dexamethasone Suppression test.

If extra-adrenal, perform a high dose dexamethasone suppression test to determine pituitary suppresses vs ectopic Ø suppression. Confirm pituitary Cushings with an MRI followed by transsphenoidal resection. There should be rib notching on the chest x-ray. The best test is an arteriogram, but CTA or MRA can be sufficient. Surgical correction is sufficient. See the difference between this and claudication in an old man who was a hypertensive, diabetic smoker who has PVD. It is NOT premalignant. DRE reveals a smooth, rubbery prostate and essentially rules out cancer.

Then, its medical therapy — no biopsies! Treat with α- blockers tamulosin for immediate symptom relief and a 5-α- reductase inhibitor finasteride for long term therapy. Transurethral resection of prostate is the surgical management, but should be avoided if able. NO BIOPSIES. NO PSA. Do this with nighttime tumescence to Nighttime determine if nocturnal erections occur. Organic causes of atherosclerosis or diabetes are usually Organic Resection gradual onset and can be treated with phosphodiesterase- Pumps and inhibitors. Other organic causes may include a spinal injury or Prosthesis an Arteriovenous malformation which will not be helped by Atherosclerosis PDE-i. Instead, he can try vacuum pumps, or as the last option, Sildenafil prosthetic devices. NO NITRATES WITH PDE-I. Control Diseases 3 Stones Kidney stones presents as colicky flank pain with hematuria. Septic Nephrostomy tube 4 Bacterial Prostatitis In a patient who has UTI symptoms but also fever, chills, and low back pain pyelo might be suspected.

Send him home on long term fluoroquinolones. On the other hand, a person with a tender prostate but no bacteria in the urine has a prostatitis noninfectious and just needs NSAIDs. The testis will be exquisitely tender with a horizontal lie. Elevation will cause Horizontal Lie Nontender Cord pain. Ultrasound with Doppler will show decreased blood flow. Physical Exam Torsion This is a urologic emergency and requires surgical intervention. If you untwist the testicle and it lives, do bilateral orchiopexy tac Surgery is down. If the testicle does, do orchiectomy. The Poor Blood Flow testicle is in normal lie and the cord is tender differentiating it Torsed Testicle from torsion. coli with Cipro. Local resection Contained disease Prostate cancer is an androgen-responsive malignancy that can GnRH Analogs First line for medication metastasize.

It will present either as bony mets or as BPH-like Leuprolide therapy of Prostate cancer symptoms. On physical exam Orchiectomy Refractory to medications if they give you the exam look for a firm, nodular prostate on Radiation Mets the rectal exam. In the presence of a suspicious finding and an elevated diagnostic PSA, the diagnosis is likely made. The Renal Cell Carcinoma preferred method of biopsy is a transrectal biopsy with multiple Presents with hematuria, flank pain, and a flank mass. Only samples taken. Staging is performed with a CT scan. Local disease of the Board patients will have it.

testosterone comes from the testicles, there are medication Nephrectomy is both diagnostic and therapeutic. Surgery is the options. GnRH analogs Leuprolide, the preferred first line shut treatment. Suspect this in a patient with hematuria without off the axis. Anti-androgens Flutamide is a backup. If urgency, frequency, and dysuria. refractory to medications, orchiectomy remove the source of androgen is an option. Track their progress with PSA — it should Testicular Cancer be negative. If there are mets, use radiation. for testicular cancer. The first test is trans-illumination which does not transilluminate. Since most tumors are malignant and Bladder Cancer FNA just spreads the tumor, a biopsy is done by orchiectomy. Risk increases with smoking and exposure to β-alanine dyes There are some tiny details about testicular cancers that need to dry cleaning. It may present with voiding symptoms but usually be known.

Luckily, Seminomas are exquisitely sensitive to has a painless hematuria. An ultrasound could be chosen if there chemo and radiation. Follow an endodermal sinus tumor with are obstructive symptoms, but the first and best test should be a AFP; follow Choriocarcinoma with β-HCG. Unlike in women, cystoscopy with biopsy. Since most bladder cancers are Teratomas are malignant in men. This recurs, so there must be surveillance for recurrence with cystoscopy. This is caused by redundant tissue within the urethra. Think of it as the pediatric equivalent to Kidneys bladder outlet obstruction from prostate hypertrophy in older Malignancy men. Perform a catheterization to relieve the pressure on the Hematuria glomerular bladder. Failure to do so will cause pressure within the bladder to rise leading to reflux up the ureters which can lead to hydronephrosis and renal dysfunction. There may be a history of oligohydramnios. Confirm the diagnosis with a VCUG.

Ureters Surgical intervention is typically needed. Hypospadias is hypo, on the bottom, and therefore the urethral opening is on the ventral surface of the penis. Epispadias is epi, on top of, and so the urethral opening is Bladder on top dorsal surface. This is clinical and cosmetic. You must Hematuria non-glomerular not do a circumcision; that skin is needed to rebuild the penis correctly. Repair is purely cosmetic; epispadias may present with incontinence. However, during a Epispadias high flow state such as diuresis from an alcohol binge the lumen is too narrow to handle the flow; the patient develops colicky pain. This resolves when the flow returns to normal. Diagnose with an ultrasound hydronephrosis without hydroureter. Infants should also have a VCUG to evaluate for contralateral reflux.

Males maintain continence as the ureter is implanted proximal to the external sphincter. Check with ultrasound, VCUG, and radionuclide scan to evaluate anatomy and renal function. Reimplant the bad one. The severity of ureter dilatation and distance of reflux determine the stage. The reflux can lead to recurrent urinary tract infections and renal scarring. Antibiotic prophylaxis can be used in mild stages but ultimately surgical correction may be needed. Diagnose with VCUG. Then the child voids which causes the VCUG Retrograde flow reflux bladder to contract. The dye should not go to the ureters. This is most commonly used in IV pyelogram Anatomy outdated study evaluating pediatric patients with urinary tract infections. Ultrasound looks at the tubes. It can see how large they are - not where they go or where they come from. That is, they can see hydronephrosis and hydroureter.

Hydro is caused by obstruction. Cystoscopy gets a camera into the bladder and the ureters. It's like a colonoscopy for the bladder instead of the colon. It allows direct visualization from inside the lumen. It also allows for biopsy of a mass and placement of stents. CT scan has a large radiation burden. Its use should be minimized in children. A contrasted scan shows the GU anatomy well, and includes the rest of the peritoneal contents. A NON-contrasted CT scan is required for kidney stones both are radio-opaque. Intravenous pyelogram is an injected material that moves into the kidneys and down into the GU system. Imaging is captured via X-ray. Isolated microscopic is usually benign and transient. Macroscopic has a broad differential ranging from infection to stones to pseudohematuria such as discoloration from medication. The morphology of the red blood cells can help points towards a cause.

Glomerular causes of bleeding typically have dysmorphic urinary RBCs, RBC casts, and cola-colored urine. History is important. If a child presents with true hematuria after a traumatic injury, further diagnostics with imaging CT scan should be obtained. With smoky-colored urine, eval for nephritic syndrome urinalysis with microscopy should happen. It can be given 6 months of age before considering Presence of RBC casts No casts present orchiopexy. Development will be normal 1 is enough , but these patients are at a 10x testicular cancer risk for life. Women are more likely to get PVD than men.

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