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Has a greater potential of being malignant b. More common in women c. Nodule is firm to palpation, can be accompanied by vocal cord paralysis; Utz shows solid mass with calcifications 4. Papillary CA a. Most common CA of thyroid b. Bilateral thyroid lobe spread is common e. Medullary CA a.

Has intermediate Px b. Secretes calcitonin; can Dx and follow dz with this blood assay 6. Follicular CA commonly results in blood-borne metastases to bone and lungs a. Multiple Endocrine Neoplasia Syndromes Table 1. Musculoskeletal A. Metabolic Bone Dz 1. Osteoporosis a. In adults the dz mimics osteoporosis d. Scurvy a. Nonneoplastic Bone Dz 1. Fibrous Dysplasia a. Osteomyelitis a.

Caused by bacterial infxn of bone; S. Pts with sickle cell dz get Salmonella; IV drug abusers get Pseudomonas c. Bone Tumors 1. Multiple myeloma a. Malignant clonal neoplasm of plasma cells producing whole Abs e. Bence-Jones proteinuria f. Urine dipsticks do NOT detect light chain protein; can use sulfosalicylic acid test in lieu of dipstick to screen g. Light-chain deposition causes renal amyloidosis i.

A radiograph of the skull shows numerous punched-out radiolucent areas. B Serum protein electrophoretic patterns. Abnormal serum protein electrophoretic patterns are contrasted with a nml pattern. In monoclonal gammopathy, which is characteristic of monoclonal gammopathy of unknown significance or plasma cell neoplasia, there is a narrow peak, or spike, because of the homogeneity of the immunoglobulin molecules secreted by a single clone of aberrant plasma cells. The hands of a pt with advanced arthritis show swelling of the metacarpophalangeal joints and the classic ulnar deviation of the fingers.

Less common is a boutonniere deformity i. C Rheumatoid nodule. A pt with rheumatoid arthritis has a mass on a digit. Tx 1 Radiation given for isolated lesions, chemotherapy for metastatic dz 2 Bone marrow transplantation BMT may prolong survival 3 Palliative care important for pain k.

Px poor despite Tx D. Arthropathies and Connective Tissue Disorders 1. Rheumatoid Arthritis RA a. Mnemonic for SLE diagnosis: Multisystem inflammatory disorder that chronically recurs b. Seronegative Spondyloarthropathy a.

Usually hard and painless, they affect the middleaged or elderly pts and often, although not always, are associated with arthritic changes in other joints.

Flexion and deviation deformities may develop. The metacarpophalangeal joints are spared. Color atlas of the eye in systemic disease. Inflammatory bowel dz can cause seronegative arthritis f. Disseminated gonococcal infxn can cause monoarticular arthritis 6. Skin tightening of face causing classic facial appearance Figure 1. Systemic sclerosis. Subcutaneous and periarticular calcium deposits may be extremely painful.

Medicine, 2nd Ed. Sarcoidosis a.

Idiopathic, diffuse dz presenting in 20s to 40s, African American pts are three times more likely to develop than Caucasian pts b. CXR has several stages of dz Figure 1. Dx is clinical; noncaseating granulomas on bx is very suggestive f. A Stage I. Bilateral hilar adenopathy and paratracheal adenopathy with nml lung fields. B Stage II. Bilateral hilar adenopathy with interstitial lung field involvement.

C Stage III.

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Lung field involvement only. D Stage IV.

Severely fibrotic lungs with volume loss and cyst formation. Commonly onsets in women in teens and 20s b. Gout a. Monoarticular arthritis because of urate crystal deposits in joint b. Most people with hyperuricemia never get gout d.

B Chronic tophaceous gout. Principles of ambulatory medicine, 4th Ed. Septic Arthritis a. Monoarticular arthritis in a sexually active pt usually because of Neisseria gonorrhea b. Otherwise, the most common cause is S. Synovial fluid microscopy under compensated polarized light showing the slender, needle-shaped, negatively birefringent urate crystals.

The axis of slow vibration is from bottom left to top right. From Axford JS. B Calcium pyrophosphate dehydrate crystals extracted from synovial fluid , which are pleomorphic, rectangular, and weakly positively birefringent. Septic arthritis must be distinguished from gout and pseudogout, which can present similarly d. Joint fluid WBC count in pyogenic septic arthritis e. Polymyalgia Rheumatica a. Beware, often associated with temporal arteritis e. Tx is prednisone taper E.

Muscle Dz 1. General a. Dz of muscle are divided into two groups: X-linked lack of dystrophin b. Polymyositis and Dermatomyositis a.

A Neutrophil. B Eosinophil. C Basophile.

D Platelets. E Lymphocyte. F Monocyte. Myasthenia Gravis MG a. Autoantibodies block the postsynaptic acetylcholine receptor b. Most common in women in 20s to 30s or men in 50s to 60s c. Associated with thymomas, thyroid, and other autoimmune dz e. Hematology Figure 1. Anemia 1. From Anderson SC.

B Ringed sideroblasts on Prussian blue staining of iron in bone marrow. McClatchey KD. Clinical laboratory medicine, 2nd Ed. C Basophilic stippling of red cells on blood smear. Sickle cell anemia Figure 1. Normocytic Anemias a. Hypoproliferative Table 1. Hemolytic Table 1. Coagulation Disorders 1. Thrombocytopenia a. Causes Table 1. Lab values Table 1. Inherited Disorders a. Hypercoagulable Dz Table 1.

Myeloproliferative Dz Table 1. All can transform into acute leukemias 3. Thrombocytosis a. Leukemias 1. Acute Lymphoblastic Leukemia a. Peak age is 3 to 4 yr; most common neoplasm in children b. Most common leukemia in adults b. Chronic Myelogenous Leukemia a. Presents most commonly in the 50s but can be any age b. Chronic Lymphocytic Leukemia a. Mirrorimage, owl-eye nuclei contain large eosinophilic nucleoli. Lymphoma 1. Commonly seen in HIV, often in brain, teenagers get in head and neck b.

Occurs in a bimodal age distribution, young men and the elderly b. For community acquired infxns, pseudomonal coverage is not required, and ceftriaxone or cefotaxime are the preferred third-generation cephalosporins; for nosocomial infxns, pseudomonal coverage is required and ceftazidime or cefepime actually a fourth-generation cephalosporin are the preferred agents.

After identification of the actual causative organism, the initial empiric tx should always be narrowed as much as possible. Table 1. May be associated with muscle weakness and EKG abnormalities e. Predominantly occurs in pts with renal failure or muscle breakdown. Emergency Tx: It does not lower potassium. This will lower plasma potassium for several hrs 4—6 hrs. Longer-Term Tx Remove the cause. If the CO2 is higher than expected, there is an additional acidotic process occurring.

If the CO2 is lower than expected, there is an additional alkalotic process occurring. Mixed acidosis and alkalosis can cancel each other out, causing neutral pH. Perform the following steps to search for a mixed disorder. Note that this patient may also be vomiting and either tachypneic or bradypneic from obtundation. In this case, the disorders must be discriminated clinically or by changes in status in response to therapy.

Our thanks to Dr. The kidney resorbs extra bicarbonate from the tubules due to the loss of chloride anion tubules need a different anion to maintain electrical neutrality.

Administration of chloride anion in the form of normal saline will correct the alkalosis. When the hypercapnia is corrected e.

Until they adjust, the patient will have a posthypercapnic metabolic alkalosis. B , congestive heart failure, and hepatic cirrhosis.

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HCO3— increases by 1 for every 10 the CO2 increases. Acute respiratory acidosis: HCO3— decreases by 2 for every 10 the CO2 decreases. Acute respiratory alkalosis: HCO3— increases by 3. Chronic respiratory acidosis: Chronic respiratory alkalosis: HCO3— decreases by 5 for every 10 the CO2 decreases. Factitious hyponatremia is a true decrease in serum Na concentration but normal total body Na caused by glucose or mannitol osmotically drawing water into the serum. The gap is due to the presence of solutes detected by the lab but not accounted for in the osmolality calculation.

Patients with DI tend to be only mildly hypernatremic. Please see Acid-Base algorithms to determine acidbase status. F for a full description. The while cells take up potassium while they are sitting in the blood draw tube, creating spurious results. Heparin blocks aldosterone production, while cyclosporine blocks aldosterone activity.

Bactrim trimethoprim has K-sparing diuretic effect on tubules. Fluid and Electrolytes A. Physiology Figure 2. Total body water TBW is divided into extracellular one third and intracellular two thirds compartments 3.

Extracellular water a. Fluid Management 1. Thus, three to four times the vascular deficit should be administered if isotonic crystalloid solutions are used for resuscitation 2. Colloid solutions containing high-molecular-weight molecules; e. From Premkumar K. The massage connection anatomy and physiology. Hydration of Surgical Pts 1. Electrolytes should be replaced as necessary a. Common Electrolyte Disorders Table 2.

Blood Product Replacement A. Nml Hemostasis 1. Coagulation involves endothelium, platelets, and coagulation factors 2.

Endothelial damage allows platelets to bind to subendothelium, inducing platelet release of adenosine diphosphate ADP , 5-HT, and platelet-derived growth factor PDGF , which promote platelet aggregation 3.

Coagulation Cascades a. Extrinsic pathway 1 Tissue thromboplastin tissue factor activates factor VII, which then activates factor X 2 Measured in vitro by prothrombin time PT c.

Vitamin K is fat soluble, derived from leafy vegetables and colonic flora a. Deficiency caused by malabsorption, prolonged parenteral feeding, prolonged oral antibiotics, or ingestion of oral anticoagulants c. Preoperative Evaluation of Bleeding Disorders 1. Bleeding Time a. Evaluates platelet function b. Thrombin Time TT a. Measures the time to clot after the addition of thrombin, which is responsible for conversion of fibrinogen to fibrin b.

Transfusions 1. In trauma situations, type O negative blood is given while additional units are being typed and crossed O positive blood can be given to male pts and postmenopausal women if no O negative is available d. Transfusion ; Platelet Transfusions a. If pt is anticipated to experience severe blood loss intraoperatively or the pt is actively bleeding, transfuse to maintain even higher c.

Plasma Component Transfusion a. Plasma products do not require cross-matching, but donor and recipient should be ABO compatible b. Fresh-frozen plasma FFP 1 Contains all the coagulation factors 2 Used to correct all clotting factor deficiencies c. Perioperative Care A. Preoperative Care 1. Laboratory Tests a. CBC for pts undergoing procedure that may incur large blood loss b. Urinalysis UA in pts with urologic Sx or those having urologic procedures d.

PT and PTT in pts with bleeding diathesis or liver disease or who are undergoing neurosurgery or cardiac surgery e.

Liver function tests LFTs in pts with liver disease f. Perioperative Review of Systems 1. Neurologic—Cerebrovascular Disease a. Strokes usually occur postoperatively and are caused by hypotension or emboli from atrial fibrillation b.

Pts with a recent history of strokes should have their surgical procedure delayed 6 wk c. Anticoagulation should stop 2 wk prior to surgery, if possible 2. Cardiovascular a. Most postoperative complications are cardiac related b. Goldman cardiac risk index stratifies the operative risk of noncardiac surgery pts and helps in the decision of pursuing further Dx testing c.

See Table 2. Pulmonary a. Pulmonary complications rarely occur in healthy pts b. Chronic obstructive pulmonary disease COPD is the most important and significant risk factor to consider c. Obesity, abd, and intrathoracic procedures predispose pts to pulmonary complications in the postoperative period d. Renal a. Azotemia, sepsis, intraoperative hypotension, nephrotoxic drugs, and radiocontrast agents are risk factors for postoperative renal failure d. Preventive measures include expanding the intravascular volume with IV fluids and use of diuretics after administration of radiocontrast dye 5.

Infxn risk depends upon pt characteristics and surgery b. Surgical risk factors include GI surgery, prosthetic implantation, preoperative wound contamination, and duration of the operation d.

Prophylaxis 1 To prevent surgical wound infxns, antibiotics should be administered before the skin incision is made— stop prophylactic antibiotics within 24 hrs postoperatively 2 Appropriate choice of the antibiotics depends on the procedure 3 Give all pts with prosthetic heart valves antibiotic prophylaxis to prevent bacterial endocarditis 6.

Hematologic a. Deep venous thrombosis DVT prevented by early ambulation and mechanical compression stockings b. Subcutaneous heparin may be substituted for compression stockings c. Pulmonary embolus should always be considered as a cause of postoperative acute-onset dyspnea 7.

Endocrinology a. If these measures are not taken, then adrenal crisis may occur. Fever 1. Intraoperative Fever a. Malignant hyperthermia 1 Triggered by several anesthetic agents; e. Postoperative Fever a.

Mnemonic for causes: Immediate postoperative fever includes atelectasis, Streptococcus and Clostridium wound infxns, and aspiration pneumonia c. Trauma A. General 1. If pt is likely to vomit, position them in a slightly lateral and head-down position to prevent aspiration d. If airway cannot be established, a large-bore gauge needle can be inserted into the cricothyroid membrane e.

Do not perform tracheotomy in the field or ambulance f. Assess chest expansion, breath sounds, respiratory rate, rib fractures, subQ emphysema, and penetrating wounds b.

Significant structures and the zones of the neck are illustrated. The clinical practice of emergency medicine, 3rd Ed. B Gunshot wound in Zone 1 of neck.

C Stab wound in Zone 1 of neck. Courtesy of Lewis J. Kaplan, MD. Neck injuries can be life threatening Figure 2. Structures at greatest risk in this zone are the great vessels, aortic arch, trachea, esophagus, lung apices, cervical spine, spinal cord, and cervical nerve roots b Zone II: Salivary and parotid glands, esophagus, trachea, cervical spine, carotid arteries, jugular veins, and major cranial nerves 2 Assessment: Esophageal injury: Gastrografin swallow or direct visualization e.

Two large-bore IVs placed in upper extremities if possible b. For severe shock, place a central venous line c. O-negative blood on standby for any suspected significant hemorrhage 4. Neurologic disability assessed by history, careful neurologic examination Glasgow coma scale , laboratory tests blood alcohol level, blood cultures, blood glucose, ammonia, electrolytes, and urinalysis [UA] , and skull x-rays b. Remove all clothes without moving pt cut off if necessary b.

Examine all skin surfaces and back for possible exit wounds c. Ensure pt not at risk for hypothermia small children C. Secondary Survey 1. Identify all injuries, examine all body orifices 2.

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Glasgow coma scale should be performed Table 2. Deaths from abd trauma usually result from sepsis because of hollow viscus perforation or hemorrhage if major vessels are penetrated 5. If pt stable, diagnostic peritoneal lavage, abd Utz, or CT scan b. If pt unstable, surgical laparotomy c.

If blood noted at urethra, perform retrograde urethrogram before placement of a bladder catheter; hematuria suggests significant retroperitoneal injury and requires CT scan for evaluation; take pt to OR for surgical exploration if unstable Table 2. Shock 1. DDx Table 2. Burns A. Partial Thickness 1. Infxn may convert to full-thickness burns B.

Full Thickness 1. All full-thickness burns require surgical treatment 5. Percentage of body surface area BSA affected Figure 2. Consider any facial burns or burning of nasal hairs as a potential candidate for acute respiratory distress syndrome ARDS and airway compromise b. CXR to rule out inhalation injury d. Excision of eschar to level of bleeding capillaries and splitthickness skin grafts i. From Nettina SM. The Lippincott manual of nursing practice, 7th Ed.

Table 2. Neck Mass Differential Table 2. Surgical Abdomen Figures 2. Midline Table 2. A Partial gastrectomy with Billroth I anastomosis. The ulcer and the ulcer-bearing portion of the stomach are resected. C Truncal vagotomy and pyloroplasty. The main nerves are divided to eliminate nervous stimulation of the stomach, reducing the acid secretory capacity, and gastric emptying is maintained with pyloroplasty. D Truncal vagotomy with gastrojejunostomy. The main nerves are divided and gastric emptying maintained with gastrojejunostomy.

E Highly selective vagotomy. Innervation of the acid-producing area of the stomach is interrupted, leaving the nerve supply to the antrum and pylorus intact. This does not affect gastric emptying, so a drainage procedure is not required.

IV antibiotics as needed 3. Surgery for hemostasis and life-threatening conditions, consult appropriate surgical service obstetric, pediatric surgery, etc. Esophagus A. Hiatal Hernia 1. Achalasia 1. Alternative is a myotomy with a modified fundoplication c. Surgical Tx may be used for palliation in pts with scleroderma, who may experience dysphagia or severe reflux C. Esophageal Tumors 1. Squamous Cell CA a.

Most commonly seen in men in the sixth decade of life 2. AdenoCA a. Gastric Tumors A. Linked to blood group A suggesting genetic predisposition , immunosuppression, and environmental factors D. Nitrosamines, excess salt intake, low fiber intake, H. Rarer Gastric Tumors 1. Lymphoma a. Associated with H. Linitis Plastica a. Infiltrating, diffuse adenoCA, invariably fatal within months b.

This is the deadliest form of gastric CA G. Several classic physical findings in metastatic gastric CA 1. Hernia Table 2. Inguinal Hernias Figure 2.

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Most common hernia; more common in men 2. Clinical oriented anatomy, 4th Ed. Indirect type is more common two thirds are indirect , pass lateral to inferior epigastric artery into spermatic cord covered by cremasteric muscle 4. Femoral Hernias Figure 2. More common in women 2. Visceral Hernias 1. Cause intestinal obstruction 2. Hepatic Tumors A. Benign Tumors 1. Malignant Tumors 1. Hemangiosarcoma a. Associated with toxic exposure to polyvinyl chloride, Thorotrast, and arsenic b. Gallbladder A.

Biliary Colic 1. Because of gallstone impaction in cystic or common bile duct CBD 2. May have multiple episodes that resolve, but eventually this condition leads to further complications, so surgical resection of the gallbladder is required 5. Cholecystitis 1. The EEEK! Escherichia coli, Enterobacter, Enterococcus, Klebsiella spp. Tx 1 NPO, IV hydration, and antibiotics to cover Gramnegative rods and anaerobes 2 Demerol better for pain as morphine causes spasm of the sphincter of Oddi 3 Surgical resection if unresponsive or worsening D.

Choledocholithiasis 1. Passage of stone through the cystic duct, can obstruct CBD 2. Ascending Cholangitis 1. This is a life-threatening emergency! Very rare, usually occurs in seventh decade of life 2. More commonly seen in females; gallstones are risk factors for developing CA 3.

Frequently seen in Far East, associated with Clonorchis sinensis liver fluke infestation 5. Passage of stone to CBD can cause acute pancreatitis if the ampulla of Vater is obstructed by the stone 5. Exocrine Pancreas A. Acute Pancreatitis 1. Other causes include infxn, trauma, radiation, drug thiazides, azidothymidine [AZT], protease inhibitors , hyperlipidemia, hypercalcemia, vascular events, tumors, scorpion sting 4.

Tx is aimed at decreasing stress to pancreas a. Demerol to control pain c. IV fluid resuscitation d. Alcohol withdrawal prophylaxis e.

May require ICU admission if severe 8. Repeated bouts of pancreatitis cause chronic pancreatitis, resulting in fibrosis and atrophy of the organ with early exocrine and later endocrine insufficiency Pancreatic Pseudocyst 1.

Collection of fluid in pancreas surrounded by a fibrous capsule, no communication with fibrous ducts 2. New cysts contain blood, necrotic debris, leukocytes; old cysts contain straw-colored fluid 7. Can become infected with purulent contents, causing peritonitis after rupture C. Pancreatic CA 1. More common in African Americans, cigarette smokers, and males; linked to chronic pancreatitis and diabetes mellitus 3.

Frequently invades duodenum, ampulla of Vater, and CBD; can also cause biliary obstruction 5. Site of CA and extent of disease at time of Dx determines Px: From Patel PR. Lecture notes on radiology. B Pancreatic tumors. Zollinger-Ellison syndrome a. Small Intestine A. Most common surgical condition of the small bowel 2. Surgical candidates receive antibiotics to include both anaerobic and Gram-negative coverage c.

Small-Bowel Neoplasms 1. Leiomyoma is most common benign tumor of the small bowel 2. Malignant neoplasms in order of decreasing incidence: Colon A.

Colonic Polyps: Most commonly adenomas and can be classified as tubular adenoma smallest malignant potential , tubulovillous adenoma, or villous adenoma greatest malignant potential b. Tx 1 Colonoscopic polypectomy or laparotomy 2 If invasive adenoCA is found, a colectomy is not mandatory if gross and microscopic margins are clear, if tissue is well differentiated without lymphatic or venous drainage, and polyp stalk does not invade 2.

Hyperplastic Polyps a. Most commonly benign, but can be associated with malignancy in hyperplastic polyposis syndrome c.

Familial Polyposis Syndromes a. Familial adenomatous polyposis FAP has autosomal dominant inheritance of APC gene; abundant polyps throughout the colon and rectum beginning at puberty b.

Peutz-Jeghers Syndrome Figure 2. Juvenile Polyposis Syndromes a. Examples include juvenile polyposis coli, generalized juvenile GI polyposis, and Cronkhite-Canada syndrome b. Diverticular Disease 1. True diverticula are rare, often found in cecum and ascending colon d. Diverticulosis a. Presence of multiple false acquired diverticula b. A Pigmented macules on the lips that cross the vermilion border. Courtesy of Jeffrey P. Callen, MD. B Buccal and perioral pigment spots are characteristic of this syndrome.

Atlas of gastroenterology, 3rd Ed. Diverticulitis a. Diverticular infxn and macroperforation resulting in inflammation b. Inflammation may be limited to the bowel, extend to pericolic tissues, form an abscess, or result in peritonitis c. Bright-red blood per rectum BRBPR usually points to bleeding in the distal small bowel or colon, although a proximal bleeding site must be considered 2. Massive lower GI hemorrhage usually is caused by diverticular disease, angiodysplasia, ulcerative colitis, ischemic colitis, or solitary ulcer Figure 2.

Chronic rectal bleed usually is because of hemorrhoids, fissures, CA, or polyps 4. Digital rectal exam DRE and visualization with an anoscope and sigmoidoscope to locate and Tx obvious bleeding site b. Endoscopy to evaluate for an upper GI bleed c.

Tagged RBC scan or barium enema if colonoscopy is non-Dx 5. IV fluids and transfusions as needed to maintain hemodynamic stability b. Large Intestine Obstruction 1. Other causes are fecal impaction, inflammatory disorders, foreign bodies, and other benign tumors 4. Presence of massive right-sided colon dilatation with no evidence of obstruction b. Volvulus 1. Rotation of the large intestine along its mesenteric axis— twisting can promote ischemic bowel, gangrene, and subsequent perforation 2.

Commonly occurs in elderly individuals 4. Sigmoidoscopy or colonoscopy for decompression b. If not successful, laparotomy with a two-stage resection and anastomosis is necessary c. Cecal volvulus is treated with cecopexy attachment of mobile cecum to peritoneal membrane or right hemicolectomy F. Colon CA 1. Second leading cause of CA deaths b. Genetic influences include tumor suppressor and protooncogenes c. Screening a. Pts with risk factors require more frequent and full colonoscopies 3.

Endoscopy or barium enema—biopsy not essential b. Follow-Up a. Hx, physical, and CEA level q3mo for 3 yr, then follow-up every 6 mo for 2 yr b. Colonoscopy at 6 mo, 12 mo, and yearly for 5 yr c. Rectum and Anus Figure 2.

Hemorrhoids 1. Varicosity in the lower rectum or anus caused by congestion in the veins of the hemorrhoidal plexus 2. Presence or absence of pain depends on the location of the hemorrhoid: Thrombosed External Hemorrhoid a. Not a true hemorrhoid, but subcutaneous external hemorrhoidal veins of the anal canal b. It is classically painful, tense, bluish elevation beneath the skin or anoderm 5.

Hemorrhoids are classified by degrees a. Fistula-in-Ano 1. Anal Fissure 1. Rectal CA 1. More common in males 2.

Anal CA 1. Most commonly squamous cell CA, others include transitional cell, adenoCA, melanoma, and mucoepidermal 2. Breast A. Mastalgia 1. Cyclical or noncyclical breast pain NOT because of lumps 2. Pain worse with respiration may be due to Tietze syndrome costochondritis 4.

Gynecomastia 1. Enlargement of male breast unilateral or bilateral 2. Lobules not found in male breast as in the female breast 3. Occurs as result of an imbalance in estrogen and androgen hormones usually occurring during puberty but can occur in old age 4. Can also be seen in hyperestrogen states, such as liver cirrhosis or drug use that inhibits liver breakdown of estrogen; e. Medication induces from cimetidine, spironolactone, antipsychotics, isoniazid, and digitalis 6.

CA Risks 1. Age number one factor in women c. CA occurs most frequently in upper outer quadrant tail of Spencer D. Breast Tumors 1. Fibroadenoma FA Figure 2.

A dominant mass arrows with smooth borders is the same density as nml breast tissue in a young woman. Tx NOT required, often will resorb within several weeks; reevaluation after 1 month is standard 2. Fibrocystic Disease Figure 2. A Mammogram showing oval, very well-defined mass without calcifications arrows.

B The mass was shown to be cystic on Utz. A Nml terminal lobular unit. B Nonproliferative fibrocystic change. C Proliferative fibrocystic change. Terminal duct dilation and intraductal epithelial hyperplasia are present. Cysts can arise overnight, of no clinical significance d. Parenchymal atrophy in premenopausal breast b. Multiple nodules will be present Intraductal Papilloma a. Will be solitary growth in perimenopause but can have multiple nodules if younger c.

Usually nonpalpable, seen as irregularly shaped ductal calcifications on mammography b. Unless comedonecrosis is present, not be visibly detectable c. This is a true premalignancy; will lead to invasive ductal CA e.

The terminal ducts are distended by CA in situ intraductal CA. The centers of the tumor masses are necrotic and display dystrophic calcification. Cannot be detected clinically or by gross examination; mammography is also a poor tool for diagnosing this disease b.

Most common breast CA, occurs commonly in mid 30s to late 50s, forms solid tumors b. Tumor size is the most important Px factor; node involvement is also an important Px factor c. Moderately differentiated IDC comes from cribriform or papillary intraductal originators d. Poorly differentiated IDC comes from intraductal comedo originator e.

Forms solid tumor; many subtypes of this tumor exist e. Reprinted with permission from Mitchell GW. The female breast and its disorders, 1st Ed. B Ductal CA. Invasive ductal CA. Irregular cords and nests of tumor cells, derived from the same cells that compose the intraductal component A , invade the stroma.

Many of the cells form ductlike structures. Invasive Lobular CA a. Exhibits single file growth pattern within a fibrous stroma Figure 2. Underlying ductal CA almost always present Inflammatory CA a. Breast has classic Sx of inflammation: Rapidly progressive breast CA, almost always widely metastatic at presentation c.

Px poor E. Mammography 1. Highly effective screening tool in all but young women 2. Urology A. Scrotal Emergencies 1. Testicular Torsion a. Usually peripubertal pt b. Epididymitis a. In contrast to invasive ductal CA, the cells of lobular CA tend to form single strands that invade between collagen fibers in a single pattern.

The tumor cells are similar to those seen in lobular CA in situ. Appendix Testis Torsion of Testicular Appendage a. Necrotizing fasciitis of the genital area b. Prostate CA 1. Bone scan helpful to detect bony metastases Figure 2. Modalities include finasteride, local irradiation, nerve sparing, or radical prostatectomy—risks of surgery include impotence and incontinence c. Clinical surgery.Renal Tubule Functional Disorders a.

Dz of muscle are divided into two groups: Adrenal Medulla a. This instability in ventricular response to atrial flutter is the reason why this rhythm is more dangerous than atrial fibrillation. See Table 2. Knee Injuries Table 2. We welcome any feedback you may have about Boards and Wards. Calculation of Statistical Values. If you continue to use this site we will assume that you are happy with it.